Despite the apparent prevalence of family matters in the practice of medicine (as well as, of course, the reverse—the prevalence of medical matters in the practice of family), an understanding of the goods and goals of family is conspicuously absent from most bioethics texts. Where bioethics intersects with sexuality or gender studies, “the family” has, perhaps, become a topic of interest. Whether narrated as a breakdown in traditional family structures or as a liberating openness to alternative expressions of family, the increase in same-sex domestic partnerships, for example, has called attention to theological, political, and philosophical differences in understanding the meaning and experience of family. Assisted reproductive technologies have further added to the ways in which families might (re)configure themselves, prompting some bioethicists to probe the relationship between biology and theology: should biological limits be considered normative? Is biological (genetic) kinship more important than voluntary association? To take another example, abortion is generally, and tediously, construed as a competition between the rights of the woman and the unborn child, but groups such as Feminists For Life have called for greater attention to dynamics between society and families (especially non-traditional families), setting the individual choice of abortion in its context of societal choices regarding maternity and family leave, child care, education, and fair employment.
In most bioethics discussions, however, “the family” is incidental to the ostensible problem at hand. The family is simply the backdrop in front of which the drama of competing goods (or evils) is played out. The ethicist must decide, for instance, which family member may rightly serve as proxy for an incompetent patient, or whether one family member’s right to test for a genetic disease inappropriately impinges on another family member’s right not to know, or whether a clinician’s will should trump a parent’s in disputes over the care of a minor child.
Rarely does the family in these discussions function as anything other than a loose collection of individuals, sometimes with a common interest, all asserting and protecting their rights, even against each other. Take, for example, the genetic testing issue mentioned above. A woman whose mother is a breast cancer survivor decides to test for the so-called breast cancer genes—BRCA1 and BRCA2. The mother has declined to be tested, preferring not to know whether her cancer is likely to recur. The daughter’s test, if it reveals the cancer-causing mutations, will expose information about the mother’s genetic code, violating both her medical privacy and her autonomous decision not to know this information. Cast this way, the issue revolves around the conflict between the mother’s desire not to know her genetic status and the daughter’s desire to discover her own. The relationship between mother and daughter is reductively narrated: it is a genetic association only. Mother and daughter do not function here as a family; they are individuals with competing interests, forced into a problematic situation because of their (merely) genetic relationship—a relationship that seems artificial and external.
Reproductive genetics—the intentional genetic selection or manipulation of offspring by the parent(s)—seems to be an issue where deeper questions about the meaning of family beg to be asked and addressed. Yet even here, the topic is often cast in terms of the rights of the individuals in question (the rights of the child to be free from disease or to be unconstrained by parents’ wishes, or the rights of the parents to make use of available technology or to parent as they see fit) rather than in terms of the meaning and experience of childrearing, of family relationships, or of bearing with a loved one’s illness.
Although A. MacIntyre’s work Dependent Rational Animals is not an explicit engagement with the bioethics of family life, his emphasis on what he calls the “virtues of acknowledged dependence” ([Carus, 1999] 119) challenges the unrelenting individualism in which bioethics generally operates. He insists that the process of becoming a moral agent is ineluctably communal: one begins to acquire the intellectual and moral virtues through one’s participation in communities willing to accept the burden of such care and formation. Taking his cue from the patterns of interdependence operative in healthy families (e.g., childrearing, caring for aging parents, gracious receptivity to care), he suggests that the local community must learn to structure itself in ways that assume the validity and importance of such bonds of interdependence. It will then find the political will to include the interests of both “independent practical reasoners” (his term for those who have achieved moral maturity) and those who are not capable of full moral, physical, or economic independence. “What I am trying to envisage then,” he explains, “is a form of political society in which it is taken for granted that disability and dependence on others are something that all of us experience at certain times in our lives and this to unpredictable degrees” (130). The needs of the disabled (or otherwise dependent) are seen not in light of our own (relative) independence, but in light of the relationships of profound dependence that are required for all humans to flourish. Their interests are not, then, “a special interest, the interest of one particular group rather than of others, but rather the interest of the whole political society” (130).
One helpful way of approaching the bioethics of family life, then, is to understand the family itself as a model for the sorts of relationships that can and should characterize political and social life (including that political and social institution called medicine). Each of us begins life radically dependent on the care of a parent; as we mature, our relationships (with parents, siblings, children, extended family) involve both dependence and mutuality. The incapacities of old age do not represent a return to the dependence we had left behind with childhood; they are rather an intensification of the interdependence that has characterized all of our lives. Naming dependence, rather than autonomy, as a normative condition for human life forces a shift in the way bioethical problems are described, particularly where it is tempting to narrate dependence as, itself, one of the problems.
Sondra Wheeler’s essay, “Contingency, Tragedy, and the Virtues of Parenting,” is a thoughtful example of this sort of approach. She approaches the issue of reproductive cloning by wondering about the normal experience of parenting: “If it were not so commonplace, we would think it was madness” (Beyond Cloning [ed. R.C. Turner; Trinity, 2001] 117). The madness she probes includes the parents’ precipitous commitment “sight unseen” to a complete stranger—“a being who will reliably cost them enormous time, money, labor, anxiety, and grief for a mixed and unreliable long-range return” (118). Insofar as reproductive cloning represents an almost pathological desire to control those contingencies that make parenting what it is, that define its virtues and its goods, she argues, it imperils what it seeks to achieve: a healthy family.
Another way of approaching the bioethics of family life is found in the work of A.L. Hall (cf. Conceiving Parenthood [Eerdmans, 2007]). Her work explores the intersection of medicine and family life not where medical quandaries incidentally involve familial relationships, but instead where medical concerns exercise broad, yet barely perceptible, influence over the practice of family life. Using cultural artifacts such as religious and secular parenting magazines, advertisements, and sermons, Hall traces the history of American Protestantism’s appropriation of medical rhetoric to describe its understanding of domestic and church family life. The same cultural artifacts testify to a mirroring appropriation of religious metaphors and warrants for medical interventions into domestic life.
The practice of family life changed over the course of the twentieth century, Hall finds, due to an increasing emphasis on the professional, scientific, quantifiable, and productive. The emphasis on these virtues came in concert both with genuine advances in medical knowledge and skill and with national emphases on the importance of industrial progress. Thus, discriminating mothers began keeping “scientific” and “modern” records of their children, protecting them with hygienic products that bespoke their “constant,” “devoted” care, seeking expert guidance on which strained peas to buy, and guarding against social and medical disaster (“They called him sissy!! But he was just too frail to keep up!” warns an ad pictured on p. 175) with the various educational and nutritional accoutrements without which one’s parenting seemed so negligent as to court charges of abuse.
The consumers of these goods surely believed themselves to be exercising due care for the health of their beloved offspring, just as the nation was beginning to exercise due care for public health. Where Hall finds these trends suspect—rather than a simple and appropriate adoption of practices consistent with new medical knowledge or genuine societal progress—is in their subtle (and sometimes frighteningly overt) deployment of racial and socio-economic markers as measures of health and productivity. From what was the “discriminating mother” to distinguish her family? Precisely from those families who were marked by racial or socio-economic inferiority. Just as illness could infect a healthy body through contact with pathogens so the healthy family could be “infected” with moral or social disability through contact with those marked as impure. “Due care” came, more and more, to require the performance and pursuit of class distinctions, and the products necessary to sustain personal health were virtually indistinguishable from those acquired to proclaim social respectability. One Life article Hall quotes determines that “health and decency” require—positively require—“in addition to a pleasant roof over [one’s] head, a vacuum cleaner, washing machine, stove, electric iron, refrigerator, telephone, electric toaster and such miscellaneous household supplies as matching dishes, silverware, cooking utensils, tools, cleaning materials, stationery and postage stamps” (346).
Healthy and decency (note the moral freight in this formulation) are narrated here in distinctly industrial terms: a society oriented toward the health of families must organize its production and consumption such that even the poorest of its citizens can have this “bare minimum.” It is on the one hand a laudable emphasis on extending the benefits of progress to all, and on the other, an intensification of the divide between rich and poor. Basic food and shelter are renarrated as unhealthy and indecent, in comparison with the luxuries the American economy can provide. The economy, in its turn, is judged in terms of its ability to provide these luxuries, rather than its propensity to sustain work worth laboring for and compensation for those labors.
We are obviously beyond the purview of standard bioethics here. Yet Hall’s work, in probing the unstated and unreflective commitments that underlie our bioethical decision-making, calls us to a different kind of bioethics, a different kind of family life. She calls us to be attentive to how the values according to which we live, knowingly or not, conform to the values by which Christians are called to live.