When Nadya Suleman, 33, had her eight children at a Kaiser Permanente hospital in Bellflower, Calif., one medical guideline had already been broken. The American Society for Reproductive Medicine, a leading organization in the field of reproductive medicine, recommends that a woman under the age of 35 should have no more than two embryos implanted by way of in vitro fertilization (IVF). That limit was chosen, says Sean Tipton, director of public affairs for the society, in order to avoid multiple births through IVF that would expose both mother and offspring to significant health risks. This is merely one of several ethical, financial, psychological and medical issues that have arisen from the stunning news of the Suleman octuplets, who join the single mom's existing brood of six children living with her parents in Whittier, about 18 miles southeast of downtown Los Angeles. Did Suleman know she was having so many kids? Did anyone counsel her? How did she afford this? What is her psychological profile?
This much seems certain. According to her mother Angela Suleman, all 14 of Nadya's children were conceived through IVF with the same sperm donor. Nadya confirmed in a TV interview that six were implanted, with two resulting in twins. The sperm donor remains unidentified; one person ruled out was Nadya's ex-husband Marcos Gutierrez (their divorce was finalized last year). Angela told the Associated Press that her daughter opted for IVF treatment because her Fallopian tubes were "plugged up" and that she decided to have more children so the frozen embryos left over from her previous fertilizations wouldn't be destroyed. In her television interview, Nadya said she wanted lots of children because she had grown up an only child in a dysfunctional family.
How could doctors let her bring so many babies to term? Though it makes recommendations, the American Society for Reproductive Medicine does not have the legal power to enforce guidelines. It can only oust unethical members from its ranks. The Medical Board of California, however, does have the ability to investigate claims filed against physicians and impose sanctions. The board will be looking into whether the as-yet-unnamed physician or clinic that treated Suleman violated the standard of care for the profession. Candis Cohen, spokeswoman for the medical board, says it is at the beginning of the inquiry, which could take several months. If found guilty of misconduct, the medical practitioner involved could face punishment ranging from a letter of reprimand to the revocation of his or her medical license.
The unusual situation has prompted some experts in the bioethics and reproductive-technology fields to re-examine the need for more regulation of IVF treatments. "The right to reproduce isn't unlimited. You can't put children at risk. The field of reproductive medicine and fertility treatment has an absolute responsibility to look out for the children it is creating in new ways. And in this case it seems to have failed," says Arthur Caplan, chair of the department of medical ethics at the University of Pennsylvania, arguing for a need for professional regulations. "[The process] should look more like adoption, requiring some evaluation of the patient, requiring some assessment of their psychological, emotional and physical abilities to raise children and some control over not trying to have too many children created all at once."
Politicians may enter the debate as well. California state senator Sam Aanestad, a Republican, says the legislature should not be in the business of setting the standard of care in medicine, preferring that it be left to the doctors with legislative oversight unless taxpayers' money is involved. "If it's all private funding, then that's between the mother and her doctor and whoever is paying for it," says Aanestad. "But if we find that taxpayer dollars have been used or are going to be used in the medical care of these kids, not just the eight now but the previous six, over the course of their lifetime, then it is the role of government to make sure something like this does not happen again. That's not fair to the taxpayers, the people of California, who've got their own families to try to take care of."
Some experts argue, however, that these huge multiple births occur precisely because U.S. health-care programs and insurance do not cover such treatments, allowing them to be defined by the free market of patient choice. In countries like those in the U.K., where national health insurance covers three cycles of IVF treatment, the incidence of multiple births is 1 in 4 cases, compared with 1 in 3 in the U.S. "Fertility doctors often report feeling pressured by their patients to exceed the guidelines," says Judith Daar, associate dean for academic affairs at Whittier Law School and clinical professor of medicine at UCI College of Medicine in Irvine, Calif. "Because IVF is largely not covered by insurance in most states, if a couple mortgages their home to have a single cycle, it's understandable that they'd want to maximize their opportunities for a successful outcome. There is a tension in the field between what the patients' wishes are and what the clinical guidelines suggest."
Indeed, in her first television interview, Nadya Suleman told NBC's Ann Curry on the Today show that it was her decision to have all the embryos implanted despite being told what the recommendations were. "All I wanted was children," she said. "It turned out imperfectly." She also explained that six embryos were implanted in each of the IVF procedures that resulted in her previous six children. This time, apparently, all of them took, and she decided to bring them all to term. Asked how she was going to care for such an enormous family, Suleman said she was returning to school to get a master's degree in counseling. She had been attending California State University when she became pregnant with the octuplets. "I'm providing myself to my children," she told Curry. "I'll stop my life for them."
Given the enormous cost and general lack of health-care coverage for IVF one cycle can cost $10,000 or more questions have arisen about how Suleman, who previously worked as a psychiatric technician at Metropolitan State Hospital in Norwalk, Calif., earning just $625 a week, could afford such a procedure. At the time of her IVF treatments, it does not appear that Suleman was working, owing to an injury sustained on the job.
Records obtained from the California Department of Industrial Relations show that Suleman received $167,908 in disability payments for a back injury suffered during a riot on Sept. 18, 1999, at the hospital where she worked. The payments were made between 2002 and 2008, during which time Suleman gave birth to most of her first six children, even though she was separated from her husband during part of this time. Psychiatric evaluations of Suleman portray a well-mannered but very depressed and anxious woman who reported severe lower-back pain, which limited her ability to pick up her 15-lb. baby without first sitting down. She also had difficulty sleeping. Wrote one doctor: "Since the birth of her baby, she has become very fearful that he will be kidnapped, injured, etc. She is anxious both for herself and for him, particularly in public places to the extent that 'somebody, my husband or my mother, has to take me almost everywhere.' " (The evaluation was performed when Suleman and her husband were attempting a reconciliation, which lasted for about one month.)
The documents paint a very different picture from the one put forth in the media following Suleman's hiring a public-relations agent less than a week after the octuplets' birth. Joann Killeen, president of the Killeen Furtney Group, was hired to field book, movie and TV offers for her client. During an interview on Larry King Live on Feb. 3, Killeen portrayed Suleman as a "wonderful woman." "She's smart, she's bright, she's articulate, she's well educated. She is just a delight. And I can't wait for the media to get to meet her," Killeen said. "She's a very balanced woman. She's got perspective. She really wants to tell her story."
Killeen also countered published reports that Suleman was trying to negotiate becoming a broadcast-TV child-care expert (NBC denied it paid for its interview with Suleman, the full version of which was scheduled to air on Feb. 9). She did confirm, however, that it is Suleman's desire to pursue paying projects about the birth of the octuplets. "It's not true that she is being paid multiple millions of dollars for going on the media," Killeen told King. "She's not on welfare, has no plans on being a welfare mom and really wants to look at every opportunity that she can to make sure that she can provide financially for the 14 children that she's responsible for now."