The Hearing of Octomom’s Doctor and the Medical Ethics Debate
She’s the news story that will never end — Nadya Sulemnan, otherwise known as Octomum, is back on CNN. Well, more accurately, her doctor, Michael Kamrava, is in the news, though it’s impossible to discuss one without the other. Currently, he is taking part in a hearing that will determine whether or not he should lose his medical license. He has already lost his membership to the non-profit group, ASRM (American Society for Reproductive Medicine).
On one hand, it seems like a no-brainer. Beyond the Suleman case, there are other reasons Kamrava is having this hearing. With Suleman, guidelines state that doctors should transfer “no more than two embryos for women under 35 years old and no more than five for women over 40.” He clearly violated the guidelines, and in doing so, put a patient’s life in grave danger as well as the lives of her unborn children. Just because the story has a happy ending (is it a happy ending?) doesn’t mean that the medical board should forget the statistically much more likely ending which could have included maternal death or neonatal death due to premature birth.
An expert witness inadvertently stated the heart of the matter. Dr. Victor Fujimoto was asked by the deputy attorney about Suleman’s request to transfer 12 embryos.
When Alvarado asked him if it is not a doctor’s responsibility to protect a patient from themselves, he answered “Sometimes.”
There are clearly times when we’d fight just as hard for the right to not accept a doctor’s protection. We can point to plenty of cases where we want the patient’s voice to be heard, even when they are taking a risk with their life. Can we have it both ways?
For instance, VBAC (vaginal birth after cesarean) is a popular hot topic. The decision for a VBAC should be solely between the patient and doctor since only these two individuals have the woman’s medical information. Yet what about women who rest in that grey zone for VBAC, neither clearly safe to attempt it, nor high risk for a uterine rupture? Is it the doctor’s responsibility to protect the patient from herself and make the call, or is it the patient’s right to decide once they’ve weighed the risks?
Moving up to an even greyer area, the case of Virginia v. Cherrix. Abraham Starchild Cherrix (also called Wolf) refused to continue chemotherapy in order to combat Hodgkin’s disease. In refusing treatment, is the doctor allowing a patient to put themselves in harm’s way, and is it that doctor’s job to protect that patient from themselves?
Clearly, doing something to the body is quite different than withholding something from the body, though the end result may be the same. Still, this is a discussion we need to have because the meeting of religion and medicine could lead to more Suleman-like situations down the road (and for the record, Suleman is not the first person to have 12 embryos transferred. She is simply the first person who had 8 embryos implant and carried and delivered all 8 babies. People never hear about other cases because either none or a lower amount of the embryos implant).
Some religions have made clear statements against the freezing of embryos. But in a medical procedure that is just as much art as science, it is impossible to control how many viable embryos are created in the end. Doctors need to encourage the production of multiple embryos in order to give patients a chance of having one or two viable embryos for transfer. But what about the lucky few who create many viable embryos in a cycle? If they are against freezing embryos or destroying embryos, are religious organizations encouraging them to transfer too many embryos (legally sharing the embryos in this situation becomes almost impossible without freezing the remaining embryos)?
Please remember in thinking about this case, while Dr. Kamvara was negligent, he is not the first doctor to transfer more embryos than the human body can safely carry. While some people who have multiple embryo transfers (MET) end up with twins or higher order multiples, many patients who have a MET end up with a singleton. And while single embryo transfers (SET) would obviously be the ideal, what stops most people from electively opting for a SET is the high cost of IVF, which is often not covered by insurance. Medical ethical dilemmas may seem to have a clear solution until you consider the other pieces of the puzzle.
Fertility procedures have been keeping medical ethicists busy, but the question of whether a doctor should follow the request of a patient isn’t unique to the fertility world. Do you believe a doctor should follow the wishes of his patient if that wish has the potential to harm them?
Cross-posted with BlogHer.
29 comments
It’s such a hard question, but yes, I think it needs to be up to the individual to make decisions about their care when given all options and risks explained. In addition, I think doctors need to follow their own judgement and what they can take responsibility for. Together they should be able to come to a reasonable compromise.
I think doctors can refuse to do what is not safe … patients can always go see a third or fourth physician, who might not be as ethical or scrupluous. But I think there’s a reason that doctors get the training they do … as much as I am a Dr. Google patient myself, I hope I can trust that my doctors know more than I do about the practice of medicine.
In the case of multiple embryo transfer, it isnt just the mother/patient and the doctor; the child/ren should also be viewed as patients. Even if a parent wants to run the risk of multiples in their quest for a single pregnancy, someone has to think of the children involved. Even twin pregnancies come with risks (which I know all too well, and IVF was not how we got pregnant), so the more babies, the more issues. Someone has to speak for the babies, and, if not the doctors, then who? So, yes, in the case of reproductive medicine, I do think the doctors have an obligation to think outside the box and do what is best for themselves AND the babies, as I hope the parents are also looking at what is best for themselves AND their children.
When you have a single woman who consistently comes back again and again for fertility treatments, always transferring 4-7 embryos (or more as in the last pregnancy she had) there is obviously something wrong. Yes, there are probably cases out there where women have transferred multiple embryos, as many as 12, but don’t those women have a hard time conceiving with the usual number of embryos? And wasn’t Nadya Suleman successful FIVE TIMES prior to the cycle where they transferred 12? Her doctor should have been able to see that there was a more serious underlying issue there. As far as a person refusing chemo, that’s a choice they are making with their own body. But being irresponsible and transferring 12 embryos and ending up with 8 babies puts 8 other people’s lives at risk, 8 babies who had no say in the matter. That is what I don’t agree with. Nadya lied to the public multiple times about the real situation: she claimed they only transferred 6 embryos when in fact they transferred 12. She also said they were her last 6 frozen embryos and she wanted to give them all a chance at life when she actually did FRESH cycles every time and now has 29 frozen embryos left!!!! When does it end? The sad part is that she can legally use those embryos and try for even more children, which I wouldn’t be surprised if she does. Sorry for the rant but I’ve been reading so many articles about her lately and it makes me so mad!!
There are so many things wrong about the Octomom situation, I wouldn’t even know where to begin. . . .
But to answer your question “Do you believe a doctor should follow the wishes of his patient if that wish has the potential to harm them?”. . . . my answer is no. In a situation like this, where a decision is being made which will not only affect the patient herself but also other people (the resulting children), I do not think the doctor can simply follow the patient’s wishes. Doing so allows the patient to substitute her (non-medically-educated) judgment for the physician’s professional judgment.
And the fact that this doctor violated clear ASRM guidelines, in a patient who already had SIX living children from ART, makes his actions all the more egregious, IMO. We’re not talking about someone’s last ditch attempt at parenthood here; we’re talking about someone who had previously had documented success with ART.
To answer your question, I say no, a doctor should not always follow the wishes of his/her patient. I think that like many other situations, people let their ethics and motives guide their decisions. Dr. Kamrava was obviously hoping to garner some fame, business and spotlight by doing this procedure. Well, it worked.
Isn’t the doctor’s motto, “First, do no harm”?? With the odds so great of harm to the mother, the baby(s) or both in such an extreme transfer situation, I would say no, he should not have followed her wishes.
Yeah, it does bring into question that first part of the hippocratic oath. It’s funny; I think he should have his medical license revoked, but not for the reason that he listened to the patient. Because it becomes a slippery slope.
Okay, here’s what I think. The reason we are hearing about this woman and this doctor and not the ones who transferred twelve in the past is because this is the first doctor to have done so in such a flagrant manner. Now, you can’t really say this because hindsight is 20/20, but the other times when there have been ridiculously large numbers of embryos transferred, they were right because they didn’t result in eight children. But those doctors weren’t making a stupid decision and the result proves their case. I don’t think we should necessarily go after every doctor who allows for such a ridiculous number of embryos, but in this case, where you want to smack yourself in the head and yell “what was he thinking?”, this guy ought to lose his license. I guess my point is that it should be considered on an individual basis, but doctors who were are so obviously stupid shouldn’t be allowed to continue being so stupid.
I don’t think that all came out exactly as I meant it to.
And no, I don’t think a doctor who knows better ought to follow a patient’s wishes. For example, if I decided that I had cancer, and went to the doctor who declared that I did not have cancer, I would expect them to not permit me to be treated for cancer. They shouldn’t give me chemotherapy just because I demand it. (Now, in that case, they ought to give me a psych evaluation, but that is a different story.)
Does anyone else remember a story that appeared in 17 magazine or Sassy back in the late 80s about a person (Boy? Girl?) who wanted to find a doctor to cut off his/her toes because the toes were constantly berating the person. And they couldn’t find a doctor who would remove their healthy toes because they didn’t believe the toes spoke to the person and drove them crazy?
Take away his license.
He didn’t transfer a FEW extra, 6, 8, 9, even. He transferred TWELVE embryos into a PREVIOUSLY rather EASILY pregnant woman. Twelve. I mean really, just sit with that for a second. Twelve. Embryos.
I think ASRM’s guidelines are good. I am fine that they believe I shouldn’t transfer over 2 embryos unless it’s a special circumstance. Maybe in a special circumstance (Fail Fail Fail anyone, cause been there, done that) I woudl do 3. MAYBE someone would choose to do 4, even 5, MAYBE EVEN 6 if you’re older. MAYBE. But what situation, on God’s green earth, calls for more than 6 embryos?? REALLY?
On the flip side, they can’t really take his license without hoopla because it IS legal to transfer 12 embryos. Ethical? Not in my opinion. Legal, yes. So in the end, my opinion is that there NEEDS to be SOME broad guideline for legality for the safety of the patient and the PROTECTION of the doctor. Even if it was 8 embryos, I can’t see the POSSIBLE reason for doing that many even, let alone more.
You would not believe how timely this post is for me.
I have just suffered my third failed transfer of my (frozen) adopted embryo. Each time we’ve transferred two and none have become a pregnancy. We’ve also lost one in the thaw for my second transfer.
I am thirty-five and these are “healty egg-donor embryos” which is why my doctor has erred on the side of caution thus far. BUT, in my EXPERIENCE, transferring two has not worked. I have more embryos awaiting transfer. I am ready to try transferring three this time. My doctor seems to be leaning towards transferring two again but will do as I wish. Given my failed transfers, I have a hard time believing that all three will likely implant and become babies.
Would anyone care to respectfully throw their two cents my way? This is something that I am carefully considering. I am ready to be aggressive. We’ve all been in my shoes. I’ve just had another good cry because every year for the past SEVEN years I’ve thought, “This will be the last Christmas that I won’t have a baby to love!” Yet, hear I am. Again. I am pretty sure that transferring three is what I’d like to do, but this is an experienced group of women, so, I’d like to hear what you have to say.
Also, my regular doc is out of the office until next Monday, and I talked to someone different today. He suggested that transferring three was using an “all or nothing approach, like Octomom did.” I was more than a little offended at the implication. We are talking three, for a woman who is thirty-five who has had no success. Methinks this situation is a little different.
The hippocratic oath really does cover this situation. Doctors should NOT put their patients wishes ahead of what they know to be safe.
Thanks to my consultations with Dr. Google, I often get grandiose ideas that I try to convince my RE to consider. I completely trust him, though, to talk to me sensibly and accurately and only do the things that are safe. That is his #1 job and even though I wish we could get faster and better results, I am glad he is doing his job well and I am unharmed.
And PS – for those of us who are still waiting for any form of IVF to work, this entire octomom story is insulting!!
Well, first of all, what made him think it was a great idea to transfer 12 embryos when the woman already had 5 kids? Perhaps, some counsellingpsych evaluation might have been in order? I seem to recall going through a homestudy, being fingerprinted, interviewed ad nauseum so I could adopt one child. People, including doctor and patients, should take responsibility for their actions.
Interesting post and I appreciate your thoughts. With regard to “are religious organizations encouraging them to transfer too many embryos? ” I can tell you in the case of the Catholic church, this is one reason they are against in vitro to begin with. It becomes a slippery slope and you get to the point where there are no good choices…
I agree with Jen, in other cases where high numbers of embryos were transferred, the result was NOT high order multiples of this magnitude. I have a friend in her 40s who stimmed like a 30 year old, but never got pregnant. She was at a top clinic, and at a certain point in her IVF journey they transferred everything they got. Still, BFN. They assessed her chances before transferring so many. (Happily, my friend is expecting a baby girl in Feb. via DE and GC.) This doctor did not. We still don’t know all the possible problems these eight children may have. They were teeny tiny. 12 FRESH embryos from a 33 year old? Criminal. He should lose his license.
Also, I can’t help it, in my head I’m shouting, “I KNEW IT! I KNEW IT!” I knew that at her age, and with allegedly frozen embryos, there was now f#@&ing way 6 were transferred and 2 split.
Dora — I agree with you. I knew it, too. They never really talked about the two that supposedly split. Two sets of identical twins: that in and of itself would’ve been newsworthy. That woman is really, really troubled. And for those of us who are up to our eyeballs in fertility debt after a couple rounds of IVF–I have to wonder–how did she pay for so many fresh cycles? How would she pay for ONE fresh cycle with six kids at home? How can she afford to keep 29 embryos on ice (when she’s selling her bras to make her mortgage)? It is beyond comprehension how the doctor could agree to work with her, much less transer 12 embryos. She has 14 kids… who couldn’t possibly be getting the love and support they deserve from a woman so troubled. And sadly she is the reason that assisted reproduction will surely get a whole host of limitations/regulations that will make it even harder for the average infertile to have a baby.
Lacie — follow your gut. You have to consider the possible outcomes and if you’re prepared to handle them: if all three should take–can you financially/emotionally take care of three babies? Would you consider selective reduction? Three also ups your odds of twins–is that OK? Are 2-3 okay with your partner? Do you have family to help if you needed it? And if you transfer three, how many remain? Would transferring three deplete your stash and would that be a stressful concept? As long as you know the answers and can live with them (and those closest to you can too, which helps protect you from irrational ideas)–do your thing.
I think doctors should be open to listening to their patients. We are beyond the age where patients take the doctor’s word as the final opinion. What with the internet and second opinions, listening to the wishes/fears/research of the patient is the doctor’s responsibility. That does not mean that the doctor is bound by the patient’s wishes. The doctor should use his/her knowledge to make an informed decision regarding whether or not to treat a person who is demanding something unreasonable. And if the doctor makes the decision to not treat the patient, he/she should explain why they are making that choice. I don’t think doctors are used to having their opinions called into question.
I testify in court as an expert witness. As the general public becomes more “informed” (usually via CSI/NCIS/Forensic Files), I have to explain more about my decision making process. Old school scientists who opt to say “Based on my training and experience, I made this decision” rather than describing how they performed an analysis and reached a conclusion are finding themselves the subject of criminal appeals. And convictions are being overturned.
Similarly, as people become more informed about medicine, doctors’ decisions are being called into question. I don’t think it’s a bad thing – doctors need to think critically rather than simply going by rote.
Regarding Dr. Kamrava…I think his license should be revoked for violating medical ethics. He clearly lied about the circumstances of Suleman’s procedures. Regardless of his violation of standards and questionable methods, and dangerous transfers resulting in damage and death to fetuses and children…aside from all that…he lied about what he did. To me, that indicates that he was aware that he was doing something that was not ethically correct. For that, he should not be allowed to practice medicine.
Doctors aren’t mechanics. They aren’t there to simply tell you your options and then let you pick the “basic, preferred, or premium” package. While it is her body- she needed medical intervention to get this procedure and the doctor doing it should have handled this far better than he did. I mean, I want Metformin but my doc won’t give it because she claims I dont need it. I disagree- but she’s a doctor and she says so and I have to abide by it. Like I said. Doctor does not equal mechanic.
And Lacie- I’m so sorry you had to be compared to Octo-Mom for what you are considering doing. This is the WORST part of the whole situation- that she has somehow become the “symbol” for ART. Sickening.
If the hippocratic oath covered anything at all, we would not be having these debates. Doctors harm patients all the time, hopefully for their own good in the long run (but it can be very hard to work out the risks vs benefits sometimes). Chemo or surgery are prime examples, and don’t let’s get started on end-of-life decisions or the concept of “futile care”. Uh, ok… this is going to have to be done in parts…
To be continued…
Bea
Whew, impressed with the sheer number of comments.
I think patients should be allowed to refuse treatment, but should not be given treatment that endangers them. Right of refusal on the patient’s behalf and on the doctor’s behalf when the treatment being demanded is not safe (in their eyes).
A doctor crosses the line when he prescribes something that is very clearly unethical (in this case) or when things that are prescribed are not clearly discussed with the patient. E.g. my friend’s father was given an extremely high dose of chemo a week after being diagnosed with aggressive lung cancer, and died a week later, almost certainly from the chemo. No warning was given to the family that this could happen.
Bottom line – bedside manner is everything!
Right.
The religion vs ethics debate is an interesting angle in some ways, but not, I think, something that particularly points to religion being on the wrong track. The answer to a lot of it is a) insurance and b) more research. If you could freeze embryos without damage (the improvements over the last ten years are phenomenal) or, if that’s not enough, freeze eggs or perform low-stim cycles resulting in only one or two good embryos without undue financial burden or work out how to screen eggs and sperm in order to increase the rate of embryo viability or any one of a number of alternatives a lot of these ethical dilemmas disappear. There’s a lot of win-win solutions, both in the short and long term, if people are willing, and I don’t think misgivings against embryo “mistreatment” need to be tossed aside as unethical in themselves (although I would encourage people to be clear-headed when they come to balancing those concerns against other concerns, such as for maternal and neonatal death – I don’t see how transferring lots and lots of embryos is a morally superior solution, and most patients I know of who feel strongly about embryos have chosen to limit the number of embryos created in the first place despite the fact that this might lower their chances, or forgo treatment altogether, because most people are sensible and can make tough tradeoffs and rank solutions in order of ethical viability).
I don’t remember the toes story, but clearly the patient did not have a problem with the toes, but with his psychiatric health. As such, taking off the toes would have been really wrong. Like a doctor agreeing to cut out someone’s appendix and leave it at that because the patient had googled appendicitis and become convinced, when in fact they had a bowl cancer and the doctor knew it. So. Not the same thing. Unless you’re going to make the argument that NS had a psychiatric disorder rather than a fertility problem and the doctor should have known it, which seems possible (as previous commenters have said) but more of a stretch because, didn’t she also have a fertility problem of sorts, at the end of the day? Whereas in the toes example, the toes were obviously healthy and a toe specialist would have been able to confirm this, leaving only one possibility on the table. The fertility specialist is not a trained psychiatrist, after all, and getting all fertility patients to sit routine psyche evaluations is this whole other debate, so there is going to be some leeway for the fertility specialist to miss relevant mental health issues (although this case may still fall into the “far too obvious” category, my point is it’s not clear-cut like the toes).
I don’t think it’s a doctor’s job to blindly follow patient instruction. Someone said “garage mechanic” – that’s pretty much it. People are not cars, babies who require protection and cannot make or communicate decisions for themselves, especially, are not cars. We all have more moral responsibility towards people than cars, those who are in a position of care for people, doubly so. (That said, I would expect a mechanic to refuse to do illegal or unsafe work as well, so there are a few standards even there, mostly aimed at the protection of people rather than the car itself.)
There is also a distinction between action and inaction (not forcing potentially helpful chemo or other treatments on competent, adult human beings vs actively performing a harmful treatment at patient request) as you have said.
Bottom line: doctors should take patient wishes into account even if the patient wants to follow a potentially harmful course of action (in fact, the actions doctors *recommend* tend to be potentially harmful). However, when the balance of risks and benefits passes a “certain” point, the doctor is within his/her rights – in fact, duty – to refuse to get involved in or actively support/enable the patient’s decisions. Of course there’s a lot of grey area.
Sorry, jumbled, written in many parts.
Bea
I think there should be clear guidelines for doctors to follow, based on scientific evidence for the safety concerns, and that final decisions should be made between the individual and her doctor.
curious what else the expert said — he was not my doc but in my practice. I agree it’s not all black and white — the answer is often “it depends.” I’m all for patients’ rights and want my wishes honored. but that comes at a limit — of ethics and moral conduct, of safety to mother and child (yes, do no harm).
in this case though it was more than just *potential* to harm, there was a*high likelihood* of harm. any health practictioner should know why professional guidelines exist. to blatantly disregard them because a patient asks you to is not only unprofessional but as you said, medical negligence.
A physician must bear the responsibility for their actions, and their profession, like most professions, whether you be a nurse, lawyer, social worker, or psychotherapist, has certain parameters you must reside within when it comes to decision-making. Medical decisions should be based on research and not whims, and that includes the whims of the patient. I’ve had behavioral health patients who believed they had maggots crawling out of their arms and therefore tried to burn them out with an iron. Do they have a “right” to harm themselves thus? No. Does a woman who has a prior history of successful transfers have the “right” to have 12 put back at once. No. And the physician who she requests this from has the professional obligation to grow a pair and say no.
So much has been covered already…so I won’t rehash (though I did plenty of nodding at the discussions of doctors using their well-formed brains for a bit of common-sense and balance when a patient seems to be lacking just that.
One thing that I’ve thought about a lot since my IVF (which resulted in a complicated twin pregnancy and the late-term loss of a twin) is that the success rate of fresh transfers is going up MARKEDLY with the advent of such standard techniques as ICSI. A good majority of the ladies in my IVF cycle became pregnant with twins as a result of ICSI combined with a two-embryo transfer. It makes me think more and more that transferring one embryo should become standard practice.
Ah, if only insurace would help.
But that is a whole ‘nother topic altogether.
Thanks for such stimulating convo, Mel.
This is such an interesting post. In my experience as a psychologist, I have been asked many times to support a plan that was clearly not in the patient’s best interests. In my field, to do so is considered colluding with the patient–which if not unethical is at the very least bad clinical care. It’s clear that the Octomom’s RE did not consider all of the psychological factors at play in her decision.
Thanks for such a wonderful blog, and for bringing so many people together in the IF community!
Lisa Rouff, Ph.D.
http://www.theinfertilitytherapist.blogspot.com