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Bioethics Forum Essay

Should Doctors Treat Family Members?

Many privileges come with having a doctor in the family: appointments squeezed into busy schedules as personal favors, a conspicuous lack of financial strain, an ability to comprehend both treatment plans and health care systems. But familial and professional roles often clash in a health crisis.

“It’s impressive,” an x-ray technician said to Dr. David Alfandre as they gazed together at an image of Alfandre’s young son’s lung, opaque with pneumonia. The technician’s interested tone came from a place of collegiality—he interacted with Dr. Alfandre as he would a physician, rather than an overwhelmed father. Soon, Dr. Alfandre found his professional and parental roles incompatible: “I wanted to just be my son’s dad, and have the doctors explain things to me like I had no medical knowledge.” He adopted a persona of “deliberate ignorance,” shedding his physician rhetoric in order to get the “support, education, and patient explanations” he needed.

Dr. Alfandre’s story is included in “Doctor in the Family: Stories and Dilemmas Surrounding Illness in Relatives, a collection of essays in the current issue of Narrative Inquiry in Bioethics.

Physicians are not supposed to treat family members, as specified in the AMA Code of Medical Ethics, but the essays reveal a more nuanced reality. In some cases, a physician is a family member’s primary caregiver. In other cases, a physician abdicates his or her professional role completely to fulfill a familial one. In most of the narratives, however, physicians are something in between: advisors, translators, interpreters, a door-openers, and decision-makers for family members.

Dr. Jessica Turnbull found it impossible to abdicate either the role of physician or family member. She didn’t want to overstep her bounds when her beloved uncle became ill with throat cancer, but she wanted to make sure he was prepared for any outcome. She found it difficult to know how to go about this, asking if it “was it right to use my aunt as a conduit for my ideas to Uncle Dan’s doctor? Or, would it be okay to call Uncle Dan’s doctor myself and suggest, as professionally as possible, that it seemed involvement of a palliative care team would now be very prudent?” She felt she was half-committed to each identity, that of niece and that of doctor, and not performing either well. When Uncle Dan died, Dr. Turnbull felt regret and grief over both half-walked paths: her reluctance to take charge of his care, which she felt was insufficient, and her inability to spend simple family time with a loved one at the end of his life.

By the time he was faced with his own tough choice, Dr. Joseph J. Fins had performed thousands of ethics consults. His 93-year-old father regained his heartbeat after a code, something Dr. Fins had only witnessed a handful of times, and never in an older person. It was a miracle. His dad had seemed healthy until the day before, when doctors had discovered an abdominal aortic aneurysm, which Dr. Fins and his siblings urged their father to have repaired. He had a cardiac arrest in the ambulance on the way to the hospital.

After the miraculous rebound, Dr. Fins, who is a Hastings Center Fellow and board member, needed to make a decision about his father’s care. Should he allow the vascular surgeon to perform the planned surgery in his dad’s vulnerable state, suspending his “Do Not Resuscitate” order? On the one hand, his dad had been reluctant to have the surgery, preferring instead to let nature take its course. On the other, he had just recovered from the brink of death and had been healthy and happy only the day before. Was now the time to let him go?

Over the course of the day, Dr. Fins “sought refuge in the hemodynamics of aortic flow to obscure hard choices.” In other words, in an exercise he often taught his own students, he evaded making value judgments by filling his mind with technical language. “If after thousands of ethics consults, I could fall prey to the power of filial love,” he writes, “we should be more tolerant of families as they confront their own tragedies. It is never as simple as the philosophers would have us believe.” Read the full text of his essay here.

Dr. Fins’s essay is perhaps the only one in the collection that directly addresses a bioethical issue, his urge to ignore a DNR because of his attachment to his father. The others circle around a kind of ethics that commentator Arthur W. Frank calls rightness. “Recent work in cognitive science suggests—some would say proves—that ethical decisions are made quickly and pre-consciously,” Frank writes. “Reasons are invoked post hoc to make those decisions accountable to others and to oneself.” He argues that the doctors’ stories reinforce this theory. Each doctor decides, intuitively, the right level of involvement in their family member’s care without deference to the AMA guidelines or formal codes of ethics. “Then they describe circumstances in ways that justify that decision,” Frank writes.

The issues at stake are sticky and human. Several of the authors encountered the pitfalls of treating a family member that justify the AMA guideline: they were unable to be objective, tolerate a loved one’s pain, or keep medical decisions separate from family dynamics. At the same time, each of the authors was in possession of knowledge, opinions, and connections that could help their loved one facing a health crisis, and withholding these resources may have seemed impossible. As a result, most of the stories do not focus on the author’s decision to treat (or assist in treating) their loved one, but rather reflect on their efforts to negotiate the tricky blessing of being the doctor in the family.

Mary Click is the communications coordinator for Narrative Inquiry in Bioethics.

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