Academic journal article The Hastings Center Report

What about the Family?

Academic journal article The Hastings Center Report

What about the Family?

Article excerpt

We are beginning to recognize that the prevalent ethic of patient autonomy simply will not do. Since demands for health care are virtually unlimited, giving autonomous patients the care they want will bankrupt our health care system. We can no longer simply buy our way out of difficult questions of justice by expanding the health care pie until there is enough to satisfy the wants and needs of everyone. The requirements of justice and the needs of other patients must temper the claims of autonomous patients.

But if the legitimate claims of other patients and other non-medical) interests of society are beginning to be recognized, another question is still largely ignored: To what extent can the patient's family legitimately be asked or required to sacrifice their interests so that the patient can have the treatment he or she wants? This question is not only almost universally ignored, it is generally implicitly dismissed, silenced before it can even be raised. This tacit dismissal results from a fundamental assumption of medical ethics: medical treatment ought always to serve the interests of the patient. This, of course, implies that the interests of family members should be irrelevant to medical treatment decisions or at least ought never to take precedence over the interests of the patient. All questions about fairness to the interests of family members are thus precluded, regardless of the merit or importance of the interests that will have to be sacrificed if the patient is to receive optimal treatment. Yet there is a whole range of cases in which important interests of family members are dramatically affected by decisions about the patient's treatment; medical decisions often should be made with those interests in mind. Indeed, in many cases family members have a greater interest than the patient in which treatment option is exercised. In such cases, the interests of family members often ought to override those of the patient.

The problem of family interests cannot be resolved by considering other members of the family as patients," thereby redefining the problem as one of conflicting interests among patients. Other members of the family are not always ill, and even if ill, they still may not be patients. Nor will it do to define the whole family as one patient. Granted, the slogan "the patient is the family" was coined partly to draw attention to precisely the issues I wish to raise, but the idea that the whole family is one patient is too monolithic. The conflicts of interests, beliefs, and values among family members are often too real and run too deep to treat all members as "the patient." Thus, if I am correct, it is sometimes the moral thing to do for a physician to sacrifice the interests of her patient to those of nonpatients-specifically, to those of the other members of the patient's family.

But what is the "family"? As I will use it here, it will mean roughly "those who are close to the patient." "Family" so defined will often include close friends and companions. it may also exclude some with blood or marriage ties to the patient. "Closeness" does not, however, always mean care and abiding affection, nor need it be a positive experience-one can hate, resent fear, or despise a mother or brother with an intensity not often directed toward strangers, acquaintances, or associates. But there are cases where even a hateful or resentful family members interests ought to be considered.

This use of "family" gives rise to very sensitive ethical-and legal issues in the case of legal relatives with no emotional ties to the patient that I cannot pursue here. I can only say that I do not mean to suggest that the interests of legal relatives who are not emotionally close to the patient are always to be ignored- They Will sometimes have an important financial interest in the treatment even if they are not emotionally close to the patient. But blood and marriage ties can become so thin that they become merely legal relationships. …

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