Taking Families Seriously

Medical decisionmaking would be a messier but better thing if it honored what is morally valuable about patients' families. The concerns of intimates have a legitimate call upon us even when we are ill. It has become commonplace to remark that advances in reproductive medicine do more than simply expand the available options for forming families - allegations that they put pressure on such basic concepts as |mother' and |child,' and threaten to distort fundamental features of our most intimate ties, are widespread. For example, surrogate motherhood is criticized on the grounds that it illicitly substitutes a contractual model of obligation for duties that should be seen as flowing "naturally" from the biological fact of parenthood, or because it cuts a child off from natural kinship relations and hence imperils the sense of belonging that seems so important to children and other family members.[1] Prenatal diagnostic techniques are faulted for their contribution to the development of a "quality control - consumer choice" orientation toward infants; quite apart from whatever social harm might be involved in terminating pregnances on grounds of, for example, cleft palates or femaleness, the attitudes underlying such practices seem out of keeping with the spirit of loving acceptance that we like to associate with families, and that may in fact be key to some of the important psychological work done within them.[2] These arguments may seem unpersuasive, vitiated by their reliance on what may appear an unrealistically romantic view of families, by the vagueness of their causal claims, and by a lack of clarity concerning just what practical response they demand. (Are we supposed to abolish the offending practices, or simply modify them so that they become more "family friendly"?) There is justice in all these concerns; yet without endorsing every claim made in its name, I am broadly sympathetic to what might be styled a family-sensitive line of critique. In my view, in fact, the full critical potential of taking families seriously has not yet been tapped. The interactions between medicine and families are deeper than those forged in an infertility clinic or a surrogacy brokerage; families and medicine interact not just when reproduction is a problem, but continually. Characteristically, the two systems appeal to each other at just the points of each others' greatest vulnerability. Families turn to medicine when domestic ability to provide appropriate care for sick members is strained or exhausted, when new members join at birth, and when members leave at death. Medicine, for its part, typically turns to families when its own store of expertise reaches its limit, when it is time to determine not simply what can be done for a patient, but what, finally, ought to be done. But despite this multifaceted and familiar pattern of inter-action between the two institutions, relatively little careful attention has been devoted to its ethical dimensions.[3] Here, I attend particularly to how families are affected, not by reproductive technologies, but by day-to-day patterns of medical practice, decisionmaking in particular. Succinctly stated, what I find is this: standard accounts of medical ethics obscure what is particularly morally significant about families. Medical practice, influenced by those accounts as well as by its own traditions, can dishonor, sometimes possibly erode, those morally important features. What I will propose in response is a modification of the received view of how medical decisionmaking ought to occur that is sensitive both to the important values featured by current practice, and to values arising out of intimate relationships that current practice neglects. But the concerns I raise do have implications for reproduction, confidentiality, indeed for the whole way in which we tend to think about the role of families in healing. Moral deliberation about families is more than usually difficult. …