The family in medical decisionmaking.

Should the authority to make treatment decisions be extended to the competent patient's family? Neither arguments from fairness nor communitarian concerns justify such an infringement on patient autonomy. Families have traditionally exercised, and continue to exercise, considerable control over medical treatment of minor children. In both law and morality, families (or more specifically, parents) are regarded not just as interested parties whose views should be solicited and taken into consideration, but rather as rightful surrogate decisionmakers to whose judgment the physician normally ought to defer. When the patient is an incompetent adult, physicians often consult with family members (that is, children or siblings of the patient, parents, spouse, etc.) about specific medical interventions and even about continuation of treatment, and many physicians are guided by the family's decision if it is not obviously unreasonable and if it does not contradict any previously expressed wishes of the patient. Family involvement is also sought when the patient is a competent adult, not, of course, because the family is given the authority to decide for the patient, but because it is thought that patients may need the emotional support of family members during times of crisis. The role of the family in treatment decisions for young children has been extensively discussed in the bioethics literature; I will not rehearse the familiar arguments for this general parental authority nor the reasons for preferring families as proxies for noncompetent adults. I want instead to turn to the case of competent adult patients and critically examine the current system of medical decisionmaking and its legitimating ethos in the light of the fact that patients are often cared for in the context of the family. I want to ask whether, in view of certain features of the relationship between patients and their families, the principle of patient self-determination at the core of contemporary medical ethics is in need of some serious rethinking. Might it be that family members, by virtue of their closeness to the patient, should not only have some special authority to speak on behalf of patients who are incompetent, but should also share decisional authority with patients who are competent? A recent proposal that speaks to the family's role in medical decisionmaking has been advanced by John Hardwig. In his provocative essay, "What about the Family?"[1] he contemplates far-reaching changes in medical practice based on a critique of our prevailing patient-centered ethos. My discussion of his proposal is chiefly designed to pave the way for what I call a communitarian account of the role of the family in acute care decisionmaking. This account--which, I hasten to add, I do not endorse--has not to my knowledge been taken seriously as a theoretical possibility in the bioethics literature. Since the label "communitarian" is liable to be misunderstood, I should note at the outset that I am not interested in communitarianism as a political theory. Rather, I want to focus on the family as communitarian political writers sometimes think of it, namely, as a model for their conception of the larger society, and on the basis of this understanding of the family, to mount a challenge to the dominant patient-centered ethos that parallels the communitarian critique of liberal political philosophy. This communitarian position resembles Hardwig's proposal in that it does not regard the competent patient as the ultimate decisionmaker, but takes it as morally significant for the attribution of decisional authority that his or her life is intimately intertwined with the lives of close others. However, as we will see, the communitarian account is philosophically more radical than Hardwig's challenge to the dominant patient-centered medical ethos. My own position is that the locus of decisional authority should remain the individual patient, but I also argue that family members, by virtue of their closeness to and intimate knowledge of the patient are often uniquely well qualified to shore up the patient's vulnerable autonomy and assist him or her in the exercise of autonomous decisionmaking. …