Medicine

Families have played a most important role in the history of medicine, tending the sick when doctors were unavailable or unavailing. Medicine and the family, the two ancient and in some respects rival systems of care for the very vulnerable, are each in part shaped by the other and rely upon the other for certain kinds of help. When illness or injury exhausts a family's capacity for care, the family looks to professional medicine for the necessary facilities and expertise; in turn, technological advances in medicine have driven the healthcare system to depend on families for what can be enormous sacrifices of time, money, caring labor, and even spare body parts on behalf of its patients. Recent developments in medicine have not only expanded the options for forming families—for example, through in vitro fertilization and contract pregnancy—but they have also had an impact on familial demographics: artificial means of birth control have helped reduce family size, while improvements in healthcare have extended longevity, though they have not eradicated the ills of old age.

Yet the most profound impact of contemporary medicine on the family may not be so much a function of new technologies as of new social practices. A characteristic of the social arrangement of healthcare in the twentieth century was the professionalization of care and the concomitant migration of care provision from home to hospital. If trends in the 1990s hold true, however, the twenty-first century may see a reversal of that process, with greater amounts of care—requiring greater skill, and more intensive investment of time, energy, and emotion—moving back into family contexts.

Bioethics has a rather checkered record of engagement with moral issues that arise where families and medicine meet. While new reproductive technologies have been the focus of bioethical attention from the start, the proper role of family interests in healthcare decision making has been addressed only by relatively few workers in the area, and bioethics has, as of yet, taken little notice of the moral questions involved in the "hospital to home" shift. The lack of attention to issues apart from those suggested by reproductive technologies is curious, both because of the practical exigencies involved (family members, for example, are and will continue to be much more influential than formal advance directives in making healthcare choices for the incompetent), and because the conceptual and moral questions involved in understanding the special character of these intimate associations are very challenging. What constitutes a family? How do various forms of family relationship translate into moral duties and prerogatives? What does "justice" mean in such contexts, and how should justice within families relate to broader concerns about justice in the allocation of healthcare resources in society?

With the turn of the twenty-first century, however, bioethicists have shown a greater willingness to take up these questions, and to consider in particular that the role of family members in the care of ill relatives may be morally more complex than simply that of serving as conduits of information about the treatment preferences of patients too ill to express them on their own. The pioneering work of scholars such as John Hardwig has helped to instigate broader bioethical reflection on how healthcare choices can affect the well being of other family members, and has pressed in particular the question whether the impact of patient care on families gives them a legitimate stake in the treatment decision-making process. While the notion that the interests of families should be considered along with patient interests in choosing among treatment options remains highly controversial among bioethicists, there is some evidence that healthcare providers are more receptive to this idea than are theorists. A 2003 study by Hardart and Truog reports that many physicians regard the interests of family members as pertinent to healthcare decision making, even in the absence of specific patient acknowledgement of those interests. A sizable minority went further, regarding family interests as of equal significance to those of patients. If these results are representative, then bioethicists will have a strong incentive to consider the role of families more carefully then they have yet done, and to address in particular the burdens on families that do not emerge primarily from clinical decision making, but rather from policies on the part of hospitals and insurers that send patients home "quicker and sicker."

There is other evidence that healthcare providers have been more sympathetic than bioethicists to the role that families play in the lives of so many patients. Family medicine or family practice is a distinct primary care specialty within medicine, but there is no comparably entrenched specialty within bioethics and little bioethical attention has been paid to family medicine's particular focus and problems. In addition to its treatment of the family from perspectives pertinent to bioethics, then, this entry also contains a brief discussion of the ethical dimensions of family medicine.

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