Category: Health Care

He Cares So You Don’t Have To

I suspect that President Obama’s selection of Dr. Thomas R. Frieden for director of the Centers for Disease Control and Prevention will be sold as a limited need to scale up to the needs of the nation from his current position as New York City health commissioner. It’s more likely because Dr. Frieden is inclined to further the state’s intrusion into personal choices:

Dr. Alfred Sommer, emeritus dean of the Johns Hopkins Bloomberg School of Public Health, who was on the team that recommended Dr. Frieden as New York’s health chief in 2002, recalled interviewing him shortly after the Sept. 11 attacks. Dr. Frieden had flown to New York from India, where he was living and working on tuberculosis control.

Before he left India, he was asked about his top priority, Dr. Sommer said. “Oh, well, that’s easy, Al,” Dr. Sommer recalled him replying. “Tobacco. Tobacco is killing more people, and that’s my top priority.”

“Tom, I don’t disagree that tobacco is a real scourge, but have you heard of 9/11?” Dr. Sommer said he countered.

“Of course I know about that, but bioterrorists are not going to kill more New Yorkers than tobacco is,” Dr. Frieden said.

Dr. Frieden’s efforts to ban smoking and trans fats in restaurants, to require calorie counts on menus and to restrict sodium don’t offer much hope that he’ll fill the role responsibly, with respect for the voluntary choices of individuals.

Previous entries on Dr. Frieden here and here.

Has the free market failed?

Andrew Sullivan posted this letter from a reader about problems with the private market for health insurance.

I’m one of the 40+ million Americas that the market has efficiently removed from health care rolls. I was laid off from a corporate job and make ends meet with freelance work while I job hunt in this rather difficult job market.

I bought a private policy — because COBRA was twice as expensive — a year or so ago from the company that held my employer-sponsored plan (rhymes with Clue Loss / Rue Field). I figured this would make continuity of prescriptions and care pretty straightforward, and instead found, when I went to the pharmacy, that those carry-over prescriptions were no longer covered, because my seasonal allergies were now a pre-existing condition. Yes, it’s true that leaving health care in private hands reduces political corruption, but there’s one thing that I’ve seen happen with long term political corruption: indictments. You don’t see that too much with corporate corruption, do you?

I see the point that there’s a problem, but this is an issue of distorted incentives. The government started the process by taxing income to the point where employer-subsidized health insurance became a rational perk. This has lingered to the current day. If insurance had remained an individual decision, would the market produce this result? Assuming the individual could still afford the premiums upon losing a job, a separate issue, it’s logical to assume that there would be no reason to change insurance plans when losing a job. The tax/regulatory structure created by generations of politicians produced a system weaker than it would otherwise be. Why should anyone believe that further government intervention would solve the problem better than government retreat?

The solution to the problem is (A) or (A).

On the general subject of taxation, Matt Yglesias
defends sustained and increasing progressivity (emphasis added):

As Ed says, the argument is that “we can’t have progressives taxes because somebody’s rich uncle might not have the wherewithal to subsidize somebody’s business start-up.”

I’m not going to dignify this with a response. I’ll just note that Schramm is president and CEO of the Kauffman Foundation and I believe he was in the room when I first heard the “rich uncle” argument, so I may have been present at the creation of this particular talking point. Meanwhile, the crippling long-term budget deficits that will result from refusing to raise new revenues are not going to be doing any wonders for entrepreneurs. And perhaps more directly to the point, the lack of a guarantee of affordable health coverage is a major impediment to entrepreneurship in the United States. The status quo systematically discourages talented, skilled people form leaving jobs at existing firms in order to strike out on their own, and this is one of the things the administration is trying to address in its budget proposals.

It’s very useful to frame problems with the solution in mind.

Long-term budget deficits occur because Congress does not match spending to tax revenue. (They are crippling because Congress believes that politics is more important than either economics or accounting.) There are at least two solutions. Congress can raise new revenue, as Yglesias suggests. Within that solution, it can raise taxes on high-income Americans or lower-income Americans. Fairness and equality in treatment suggest that everyone should share the burden, if we are to raise taxes. That’s beyond my point here, so I’ll back up and reiterate: Congress can raise new revenue. Congress can also reduce spending. Is that not an acceptable option? Ignoring it reeks of a preference for social engineering over responsibility.

Nor would I write that the lack of a guarantee of affordable1 health coverage is the impediment implied. If person X quits her job to start a business, she loses her medical coverage after a certain period of (more expensive) COBRA coverage. Tying health insurance to an employer is the problem. If her business becomes successful, then her employees will be burdened as she was if they want to leave. The system is flawed and needs to be fixed because it limits individual choices. We should begin our search for a solution from that starting point. Changing our treatment of health insurance to resemble other decisions individuals make for themselves independent of how they earn income is a possible solution Mr. Yglesias ignores.

The general theme within Mr. Yglesias’ framing appears to be a push for equality of outcome rather than equality of treatment. Equality of outcome will never happen in practice for precisely the reasons that his proposed solutions are possible in America. The political atmosphere makes it possible to treat others “more equal” by pitting one group against another, with the politicians conveniently acting as final arbiter. Endorsing that system is at least an implicit statement that control is fine as long as you are the one in control. It’s either that, or the person proposing such a statement is ignorant. I don’t think Mr. Yglesias is ignorant.

1 I will ignore the issue of affordability here. Such a subjective word requires a much deeper analysis, including the trade-offs, that I’m not interested in addressing in this post. Let it suffice that Mr. Yglesias and I probably agree very little on the matter.

Check Your Premises

From England:

It took a death threat to stop Abdi’s wife from circumcising their two daughters, aged 2 and 4. She called him from Somalia while on holiday to say she wanted to carry out the procedure.

Abdi, a London-based Somali, said that his wife’s eagerness to circumcise their daughters was fuelled by a combination of religious, cultural and tribal pressures placed on her after she took the girls to Somalia for a brief summer break last year.

But he refused to be swayed, despite his wife’s argument that the girls would improve their chances of attracting a good husband because they would be perceived as being more traditional and pure.

First, notice the third paragraph. I can’t and won’t begin a detailed analysis because it would be speculation, but the information there suggests that this reasoning is at most a difference of degree between this and what Western parents often choose for their sons. The focus is on how to make the child more attractive to a future partner, not what the child needs. Attempt to build a defense of infant male circumcision on the grounds of potential benefits, but ultimately this reasoning must make no distinction between those alleged-but-not-really medical reasons and the nonsense that what the child’s future sexual partners might want is relevant to what to do to his genitals. The whole notion is absurd.

Second, this one example proves nothing. However, it demonstrates that those who perpetuate the belief that female genital cutting is exclusively perpetuated by men are mistaken. At some point we have to lay down our agenda of blame and figure out how to stop these violations. I suspect the desire to blame is responsible for much of the inability to see the similarities between male and female genital cutting. Medically unnecessary genital cutting on a non-consenting person is unethical. That is a statement of principle free from the ramifications of gender-specific reasoning and outcomes. It considers only the victim. That’s what matters.

Linkfest

LINK: From the April issue of reason, Matt Welch addresses the ongoing topic of “liberalterianism” and how it’s doomed. The heart of his argument, which I agree with completely:

It is certainly no surprise that any party, let alone the Democrats, would want to use that fancy government once it held the awesome reins of power. Unified Republican governance this decade should disabuse even the most gullible from the notion that either of our two major parties is ever going to enact a small-government agenda, especially during a perceived crisis. But already during Obama’s first 100 days we’ve seen how quickly liberals will turn against libertarians once they’re no longer swinging at the same piñata.

Small-l libertarians will never find sufficient common ground with anyone interested in maintaining partisanship at the expense of ideas.

LINK: Also from reason Ronald Bailey discusses a free market approach to health care coverage proposed by University of Chicago economist John Cochrane.

So how does health-status insurance work? As Cochrane explains, “Market-based lifetime health insurance has two components: medical insurance and health-status insurance. Medical insurance covers your medical expenses in the current year, minus deductibles and copayments. Health-status insurance covers the risk that your medical premiums will rise.” Cochrane offers the example of a 25-year-old who will likely incur $2,000 in medical expenses in a year. His medical policy component would thus cost about $2,000 per year, plus administrative fees and profit. For purposes of illustration, Cochrane then assumes the 25-year-old has a 1 percent risk of developing a chronic medical condition that would increase his average medical expenses to $10,000 per year. In that case, he would be able to buy medical insurance for $10,000 per year—which is a big financial hit. That’s where health-status insurance comes in: It insures that you can be insured in the future.

I’m not fully convinced that this would work, but I’m not unconvinced, either. I don’t know enough. However, the idea seems to be based in personal responsibility. Life is unfair, so some of us get sick. There are costs involved. It’s unfortunate if medical costs cause financial distress. We should mitigate that, but provide individuals the options to do that for themselves. That is the right approach.

Mr. Cochrane also discusses how his plan would help separate health insurance from employer provision. That will be a feature of any responsible health care reform. (Transferring the incentive from employer to government does not qualify as that type of responsible reform.)

LINK: Harold Meyerson is an incurious propagandist:

But in the United States, conservatives have never bashed socialism because its specter was actually stalking America. Rather, they’ve wielded the cudgel against such progressive reforms as free universal education, the minimum wage or tighter financial regulations. Their signal success is to have kept the United States free from the taint of universal health care. The result: We have the world’s highest health-care costs, borne by businesses and employees that cannot afford them; nearly 50 million Americans have no coverage; infant mortality rates are higher than those in 41 nations — but at least (phew!) we don’t have socialized medicine.

Universal education is not “free”. The minimum wage costs jobs. Financial regulations overlooked obvious warnings of Bernie Madoff. “Nearly 50 million” uninsured is not true. Infant mortality is more complex than a quick comparison can demonstrate.

He also wrote this, so it’s clear that he’s interested in his narrative more than facts.

Take it from a democratic socialist: Laissez-faire American capitalism is about to be supplanted not by socialism but by a more regulated, viable capitalism. And the reason isn’t that the woods are full of secret socialists who are only now outing themselves.

We do not have laissez-faire capitalism. No amount of stating preferred explanations will make them true.

LINK: Steven Pearlstein defends President Obama’s budget in a way I don’t fully understand.

In the meantime, the federal government is one of the few entities that is still able to borrow in the current environment, and given the perceived safety of buying government bonds, the cost of that borrowing is about as low as it has ever been. From a purely cash-flow point of view, substituting 18 percent credit card debt with 3 percent Treasury bond debt is a positive development for the grandchildren.

The 18 percent credit card debt makes no sense here. Government borrowing isn’t replacing that. And my hypothetical grandchildren do not have any debt right now. Adding more, even at 3 percent, is hardly a positive development for them. The administration intends to grow the debt, not refinance it.

Refinancing costs are relevant, too. If the so-called positive development of new debt at 3 percent interest helps us, what will this new debt look like at 4, 5, or more percent when interest rates rise, as they will? Maintaining the apparently-permanent interest payments is a cost.

He continues with a bit about how infrastructure creates lasting economic value without defending it. Would the Bridge to Nowhere have justified its cost? Doesn’t matter, it seems. He reassures:

Strange as it may sound, there are times when it’s necessary to make things worse in order to make them better. Fighting a war to achieve a lasting peace. Making a patient sick to cure his cancer with radiation or chemotherapy. And, yes, taking on more debt to help get the country out of a debt-induced recession.

Unlike chemotherapy, where doctors eventually stop dosing a patient, what evidence do we have that politicians will ever believe we’ve reached the “ideal time for the government to deleverage and put its financial house in order”? The new deficit spending is permanent. The only open question once the budget passes is who will pay for it. Right now, the answer is “the rich” and the Chinese. Eventually, it will be the middle class, including all of our grandchildren.

LINK: Wanting an iPhone does not mean a consumer is entitled to an iPhone with the carrier of his choice.

The Consumers Union, the New America Foundation, and the Electronic Frontier Foundation, as well as software provider Mozilla and small wireless carriers MetroPCS (PCS) and Leap Wireless International (LEAP), are lining up in opposition not only to the Apple-AT&T partnership, but to all manner of arrangements whereby mobile phones are tethered exclusively to a single wireless service provider.

Apparently a voluntary contract between two parties means nothing if it means a consumer has to then make a choice that she doesn’t like. I want an iPhone with Sprint, but I can’t get it. My response is to decide which has more value and act accordingly, not whine to the government.

More Consumers Union nonsense here and here.

Individual Incentives Can Be Skewed

When I wrote about comparative effectiveness research, I focused on the merits of including funding in the deficit spending bill as a path to more socialized health care. I haven’t changed my opinion on that, but it’s worth noting that the idea behind this research is reasonable. Do our interventions produce results?

Following that, here’s an interesting analysis of comparative effectiveness research that focuses on the relevant issues (link via Kevin, M.D.). The analysis contains useful examples, and is worth reading. I don’t think we’ll get what we expect from the newly-funded research unless we expect more decision-making power handed to bureaucrats. Still, the idea behind comparative effectiveness research is reasonable.

But the more useful, immediate discussion is this:

Here’s where things get dicey. A chief medical officer I know was once discussing unnecessary procedures in his healthcare system. In a rare moment of unvarnished truthtelling, one of his procedural specialists told him, “I make my living off unnecessary procedures.” Even if we stick to the correct side of the ethical fault line, doctors and companies inevitably believe in their technologies and products, making it tricky to get them to willingly lay down their arms. …

You can probably figure out that I’m going to discuss this in the context of infant circumcision. First, let me make this clear, in case anyone’s missed me saying it previously: I do not believe there is a conspiracy to circumcise infant males. It is a common, actively-pursued goal, but it does not fit the nefarious intent behind a conspiracy.

That does not mean that individual doctors are immune to the undeniable point that genital surgery is not indicated for most infant males. The ethical claim is impregnable to excuses based in cultural and moral relativism. What incentive does a doctor like Dr. Neil Pollock have to begin deferring to his patients’ needs rather than his own?

Dr. Neil Pollock, who performs about 2,500 infant circumcisions annually in Metro Vancouver, travelled to Rwanda in December to teach his circumcision method to local surgeons.
…

Pollock is hopeful that the painless [ed. note: Even if true, the ethical claim must win out.] nature of his technique, which takes less than a minute to perform, will persuade many Rwandan parents to consider circumcision for their infants.

Once again: When public health officials discuss the potential reduction in HIV risk from voluntary, adult male circumcision, they always forget voluntary and adult. Always.

Looking at comparative effectiveness research, Dr. Pollock is based in Vancouver, British Columbia, outside the realm of the deficit spending bill’s reach. He’s good anecdotal evidence, though, because he shows what it means to be uninterested in placing your patient’s needs and rights first. He’s built a practice around performing more than 12 infant circumcisions per business day. Will he readily give that up, since he’s so clearly invested in continuing the involuntary procedure?

Of course, the conclusion on infant circumcision is already in. Here’s what the Canadian Pediatric Society says about routine infant circumcision:

Recommendation: Circumcision of newborns should not be routinely performed.

I see no reason to believe there will be any difference in the US. Most American doctors already ignore the ethical case for protecting the rights of infant males. There are people invested in perpetuating the imposition of unnecessary genital cutting. No government study is going to change that.

Searching for a Solution’s Problem

John Cole writes about the direction of health care in America (in response to an entry by Andrew Sullivan).

… Only a fool can not see the writing on the wall- we are going to have to move to single-payer at some point, because businesses can not compete and the largest problem for Detroit is… their health care obligations and other retiree benefits. Likewise, we spend an enormous amount of our GDP on health care yet have rankings that look third world on issues like infant mortality. Something has to give.

I don’t want to play the fool here, because I see that we’re moving to single-payer at some point. That’s the obvious political outcome driven by our unthinking, economically-illiterate public debate. This is a Bad Idea because of the problems everyone is glossing over, particularly those involving rationing.

But that’s not my quibble here. We do not have to move to single-payer. If part of the problem for American business is the cost of health care, the proper step is to separate health care from employment. Single-payer is one route to attempt that, but it is not the only route.

Do we have a national automobile insurance crisis because our employers do not provide subsidized auto insurance? The comparison is weak, as I’m happy to admit. The absurdity is intentional. But it points out that options exist beyond Employer or Government. The incentive system involved in employer-provided health insurance is flawed. We need to move beyond our limited mindset that if someone doesn’t take care of us, we’re all going to die a horrible, uninsured death.

Mr. Cole is more cautious about the possibility of success from that outcome than most, but he uses emotional justifications to support the national undertaking. For example, infant mortality is more complex than just reciting statistics. As the link shows, there are ways to look at the complexities that don’t prove that U.S. infant mortality rates are meaningless as a comparison. But this issue is too big and the outcomes too loaded with consequences to disregard the nuances and uncertainty in favor of a pre-determined solution.

Press Release: An Instrument of Distortion

I loosely follow a rule in my blogging that I don’t bother with press releases. They’re skewed to push the angle of whoever is paying the bill. It might be worth picking out the propaganda from a press release to find the facts, but I can usually achieve that with less effort by going to news sources to make a point. (Of course, most news sources reporting on circumcision are filled with propaganda, too.) Generally a press release is only good for demonstrating propaganda. This recent press release is a good example:

Hospitals in states where Medicaid does not pay for routine male circumcision are only about half as likely to perform the procedure, and this disparity could lead to an increased risk of HIV infection among lower-income children later in life, according to a UCLA AIDS Institute study.

The first half is fact. The second half is conjecture. News, then propaganda. The HIV-circumcision studies researched the effect of voluntary, adult male circumcision in reducing the risk of female-to-male HIV transmission from heterosexual intercourse. It is inaccurate to draw the conclusion that the foreskin puts men at higher risk of HIV. Unprotected sex with HIV-infected partners increases an individual’s risk of HIV infection. The male must first engage in that specific activity to become infected. Focusing on the foreskin distracts from efforts to reduce such behavior.

But that doesn’t sell the way fear sells.

But recent clinical trials in South Africa, Kenya and Uganda have revealed that male circumcision can reduce a man’s risk of becoming infected with HIV from a female partner by 55 to 76 percent. In June 2007, the AAP began reviewing its stance on the procedure.

By now you know what was left out of that summary, right? When public health officials talk about voluntary, adult male circumcision, they never mean voluntary, adult. Never.

As the press release so helpfully theorizes in its opening line:

Lack of coverage puts low-income children at higher risk of HIV infection

Think of the (poor) children. That’s not very original. It has the added bonus of being inaccurate. Are these children sexually active? Specifically for the age of the children discussed in this press release, the answer is no for 100% of them. They are not at risk of (female-to-male) sexually-transmitted HIV infection. But those necessary, contradictory details must be ignored. Think of the (poor) children.

That is how propaganda is done.

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Not to let an opportunity go to push for a collective response to an individual problem, the Family Planning Cooperative Purchasing Program helpfully regurgitates this press release, with the necessary bits of speculation helpfully emphasized in bold. An example:

In addition to the overall lower circumcision rates, the researchers found that the more Hispanics a hospital served, the fewer circumcisions the hospital performed. For Hispanic parents, the circumcision decision was about more than simply cost, since male Hispanic infants were unlikely to receive the procedure even in states in which it was fully covered by Medicaid.

What point is FPCPP trying to make with that emphasis, given the sentence that follows it? The only justification I infer is an implicit suggestion that we need to encourage Hispanics to “Americanize”. That wouldn’t surprise me because it’s the typical, mindless support for non-therapeutic genital mutilation in America. And FPCPP files this under “Public Policy”, among other categories. See above re: voluntary and adult. If it’s not that, I’m stumped.

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You and I, through a grant from the National Institute of Mental Health, paid for this research. Mental Health? With mission creep like that, who could possibly worry about government-run health care?

However, this raises the question of national health care and the future of routine infant male circumcision in America. I’ve long held that the former would not end the latter. The political environment for defending non-therapeutic circumcision is too strong, as evidenced by studies like the one leading to the above press release. No politician is going to say that parents can’t circumcise, despite the clear constitutional flaw in our status quo.

Ending public funding isn’t sufficient. The state should not pay for mutilation, but fails to end the practice. Poor parents pay for the surgery out-of-pocket. They complain about it, citing the potential benefits as an excuse for why Someone Else should pay, but they pay the cost anyway. Their sons are not protected by their state’s lack of Medicaid reimbursement. And ending government reimbursement doesn’t always end government reimbursement, as Minnesota’s politically-motivated solution showed.

Still, I need to have a think on my position. I won’t suddenly support government-run health care, but I should explore the nuances further.

How to Require Extra Rules for Opponents

Steven Pearlstein began his Friday Washington Post column with this line:

To most Americans, the language on Page 52 of the report of the House Committee on Appropriations would have seemed perfectly sensible.

He’s picking a fight, but he intends to pretend that he’s not fighting because only the other side is fighting what is supposed to be “perfectly sensible”. Given that President Obama uses this tactic repeatedly to push the deficit spending bill, Pearlstein is not alone.

He continues:

The report spelled out the committee’s rationale for including $1.1 billion for something called “comparative effectiveness research” in the massive economic stimulus bill. For those of not steeped in the argot of health policy, that’s research done by doctors and statisticians who troll through large number of patient records to determine, for any particular disease, which treatments work best.

“By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those [treatments] that are most effective . . . will be utilized, while those that are found to be less effective and in some cases more expensive will no longer be prescribed.”

Those of us Pearlstein attempts to discredit are those who will ask the important question. It doesn’t matter that comparative effectiveness research already occurs. Who will make those decisions? Stating without support that “nearly all experts agree [the effort] is a necessary first step to reforming a broken health-care system” does not dismiss the question.

After describing the opposition as a right-wing brushfire, he continues:

It’s not that these various groups have no reason for concern. If comparative effectiveness research is done badly, or if the results are used simply as an excuse to deny insurance coverage for all expensive treatments, then there would be plenty of reason to get out the pitchforks and storm Capitol Hill. And there are surely examples from Britain and other countries of people being denied access to the latest drugs and procedures, including some that are significantly more effective than other treatments.

So, we’re in agreement, right? What were we arguing about?

What the critics don’t have, however, is any shred of evidence that the professionals who do this research are incompetent or have any but the best intentions in trying to figure out what treatments are the most effective for patients. …

This is a bait-and-switch. We’re not arguing about the ability or integrity of the researchers. No one said anything about that. The issue is who will make decisions resulting from the research. Pearlstein’s desire to obfuscate the issue suggests he has an intention he doesn’t want fully known. It’s obvious since he spoke of experts he did not quote, but he gives it away as the paragraph continues:

… There is no reason to believe that once this clinical research is completed, it cannot be used in a disciplined, scientific way by physicians, economists and medical ethicists to determine whether there are drugs, tests, surgical procedures or devices that simply don’t deliver enough benefit to justify their cost. …

Physicians? Sure. Many could use a lesson about cost-benefit mixed with ethics. It’s easy to fall into a pattern of inertia, despite evidence. But where do economists come into this? Again, who is making the decision? I don’t think he means economists at insurance companies or parents as economic actors. As Pearlstein continues:

… And there is no reason we cannot set up reasonable procedures, overseen by independent health professionals, to protect patients who can demonstrate a special need for a treatment that is not normally cost-effective.

We finally get there. Patients need procedures to demonstrate a special need for “not normally cost-effective treatments”. When not trying to pretend that is enlightened, it’s called rationing. Regardless of an individual’s willingness to pay, someone else must decide if it’s cost-effective rather than first asking if the treatment is effective, followed by the question of how much it costs? That’s government-run health care, despite Pearlstein’s pretense that it is not.

Remember: Good, cheap, and universal. We can only have two. Yet, we actually try for three, despite Pearlstein reciting the tired lies that America denies “vital medical services to the 40 million Americans without health insurance”. Lies, plural, because we do not deny care to the poor in the manner Pearlstein implies, nor are there 40 million Americans without insurance because of it’s cost. He’s advocating services without visible sacrifice. Why would anyone think the goal of this is government-run health care?

Irrational Requests as Ethical Dilemma

Is it ethical to use fertility treatment when the mother already has six children?

How in the world does a woman with six children get a fertility doctor to help her have more _ eight more?

An ethical debate erupted Friday after it was learned that the Southern California woman who gave birth to octuplets this week had six children already.

Large multiple births “are presented on TV shows as a `Brady Bunch’ moment. They’re not,” fumed Arthur Caplan, bioethics chairman at the University of Pennsylvania. He noted the serious and sometimes lethal complications and crushing medical costs that often come with high-multiple births.

So I don’t use this solely to leapfrog to my concern, I’ll say no, it’s not ethical, although I won’t go so far as to say it should be prohibited. But if the facts are as they’re being speculated in the media, the doctor who administered these fertility treatments acted unethically.

Okay, so to jump to my question. We’re talking about whether this is ethical, but not enough people would realize the ethical dilemma this presents for the law. This woman can legally alter the genitals of six of her newborns, for whatever reason or no reason, while her other two newborns are legally protected from unnecessary genital surgery. The general consensus in the American medical and legal community is that this is ethical. No one should be surprised that a ridiculous case of fertility treatment for a woman with six kids can occur.