July 23--When Nadya Suleman, an unemployed and unmarried California woman who came to be known as "Octomom," delivered eight premature babies after in vitro fertilization (IVF) with multiple embryos, ethicists, doctors and taxpayers howled.
Possibly they were thinking about the medical costs of caring for preemies, which at the neonatal intensive-care unit at Seattle Children's hospital can go up as high as $20,000 a day.
Some people said, "There oughta be a law!"
But should there be?
And if there's a law setting limits on IVF, should there also be one curbing smoking and drinking while pregnant, say? Otherwise, isn't it discriminating against those with fertility problems?
These and other thorny questions -- such as when parents and doctors should stop trying to save an extremely premature baby -- will be discussed and debated at a sold-out Seattle conference Friday and Saturday.
Medical caregivers
"Tiny Babies, Large Questions: Ethical Issues in Prenatal and Neonatal Care" at Bell Harbor International Conference Center will be webcast live at www.seattlechildrens.org/bioethics/ beginning at 8:30 a.m. Friday.
About 250 medical caregivers, some from as far away as Australia, are expected to attend.
Limits on IVF and other pre-birth issues will share the spotlight with other post-birth dilemmas, such as the ethical issues involved in prenatal surgery and the decisions to start -- or stop -- resuscitation of a premature baby.
"How early does a baby have to be born before we say we shouldn't do anything?" asks Dr. Doug Diekema, education director for the Seattle Children's Treuman Katz Center for Pediatric Bioethics, sponsor of the conference. "This is what clinicians are talking about: What should be the limits of our technology?"
In these topics, the matrix of considerations includes cost, which in this country often skews health-care decisions.
The case of Suleman illustrates how upside-down incentives and economics can lead to multiple births.
When women have to pay for the procedure themselves, they're more likely to implant multiple embryos in hopes of having at least one baby, notes conference speaker Dr. Annie Janvier, a Quebec medical-ethics researcher and neonatologist.
Janvier said fertility clinics, charging $10,000 to $15,000 per try, have an incentive to implant multiple embryos to ensure a better chance of producing babies -- and attract more clients.
The downside: a higher risk of multiples and premature births. Next month, the provincial government of Quebec will begin covering the costs of IVF -- to save money.
The government will pay for three tries, but limit the number of implanted embryos. By cutting down on multiple births, proponents say, the program will save twice as much as it spends.
Major changes
In the "tiny baby" field, there have been huge changes over the past several decades, says Dr. Norm Fost, director of the Program in Medical Ethics at the University of Wisconsin and a conference speaker.
Until the mid-20th century, babies born with various handicaps were routinely allowed to die, Fost said -- a "terrible injustice that went on for years, and turned around on a dime" with the efforts of bioethicists such as himself and political support by former President Reagan.
Now, the debate centers on how much -- if any -- treatment to provide extremely early preemies, generally babies born at 24 weeks or less of gestation.
Janvier has documented bias against treating those newborns.
In a series of studies, she asked medical providers to rank how likely they were to give emergency care to several hypothetical patients.
She found that they were far less likely to give emergency care to a very premature infant than almost any other type of patient, even when the baby was more likely to survive without problems than the other patients.
In 2005, Janvier -- pregnant for only 23 weeks and three days -- suddenly realized she was about to deliver.
Various interventions delayed the birth by nine days, still a gestational age many in the medical field believe is too early to survive.
"Violette had a rocky course," Janvier wrote in The Journal of Clinical Ethics about two years later.
Soon after birth, the baby's condition was dire. Janvier and her husband, with great angst, decided to take out Violette's tubes and let her die in peace.
But as the parents readied for their child's death, Violette began to suck on her pacifier. Janvier's husband, also a neonatologist, saw it as a sign she would be OK -- irrationally, Janvier believed.
Angrily, she noted that sucking is a primitive reflex even of babies who have no brain.
Still, she listened to her husband, "... because I love him, because we had to be on the same side, and because I couldn't fight for my daughter's death."
The baby survived. Violette spent four months in the Neonatal Intensive Care Unit (the NICU), and eventually went home.
Janvier argues that facts and rationality aren't enough when it comes to making decisions in this realm.
Hers was a fully informed, rational decision. Her husband's was irrational and emotional, she says.
Now, at age 5, Violette is a "beautiful tiny little flower," small but mostly healthy, Janvier said.
"Emotion saved her life."
Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com
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