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Familiar? Yes. Flawed? Not Necessarily.

Over the past few weeks, I’ve found myself puzzling over Hilde Lindemann’s essay “Sound Familiar?” published on Bioethics Forum on June 18. Lindemann gives us this interesting case, which a “group of bioethicists” she knows has recently discussed: The parents of a severely cognitively disabled 20-year old woman want to use their daughter’s eggs to have another child. They have “cultural and personal reasons” for not wanting the family line to end with them. A sperm donor would be the biological father, and a contractual gestational mother would bring the baby to term. The parents, in addition to caring for their disabled daughter, would also raise their grandchild.

It isn’t Lindemann’s case study that had me mulling, but her reasons for recounting the case. Lindemann describes her frustration as she listens to her colleagues’ discussion. All of them object to the procedure in question, and all use what Lindemann considers “standard grist for the bioethical mill” to defend their stance: one objects to the procedure on the ground that it is not in the daughter’s best interest – she would derive no benefits but be subject to risks. Another is worried that the attention required by a new baby would deprive the disabled daughter of appropriate care. A third and fourth argue that, because the patient does not have the capacity to consent to the procedure, and because the surrogate decision-makers (her parents) have a vested interest in their daughter having the procedure, the procedure cannot ethically go forward. Somebody even wonders whether, given this conflict of interest, a court should intervene by appointing the daughter a different surrogate.

Lindemann is exasperated. It’s typical bioethics reasoning, she laments: it fails to account for the rich interrelatedness of the individuals whose dilemma it is. She reminds her readers that the mother, father, and daughter in the case are not “Hobbesean strangers,” each fighting against the other and for their own good, but family members – parents and child – whose love and interests are deep, complex, and necessarily intertwined. To fail to appreciate the situatedness of these individuals is to miss “the ongoing and enduring relationships of intimacy that bind their interests together.”  Having reminded us of this important point, Lindemann does not accept that the parents in this case (who, after all, have spent 20 years devoted to the care of their daughter) would be exploiting or abusing their daughter by using her eggs to have another child. Part of what it means to be in a family, she holds, is to accept that one “must sometimes give way to the interests of others.” In this case, the daughter’s interests must now give way to those of her parents.

Over the years, Lindemann and others have made extraordinary contributions to bioethics and related fields by insisting that individuals be seen as more than autonomous, self-contained beings. They have shown the necessity of considering family and relational contexts, demonstrating that such considerations can sometimes change the ethical decisions we make. But why, in the case Lindemann presents, should family considerations ultimately dictate the conclusion we come to? Accounting for the situatedness and interrelatedness of individuals, while important, does not automatically override considerations of autonomy, respect for persons, and the best interests of the patient. In this case, Lindemann is mistaken in letting them do so. Here’s why.

First, Lindemann’s point that a mother loves her child “deeply if not perfectly” is perplexing, since love alone does not prevent mothers (or fathers) from doing things that harm their children. On the contrary, many parents do harmful things in the name of love. In this case, the fact that the parents love their daughter deeply, and have spent many years caring for her, does not legitimize their desire to use her body for their own ends. While it is reassuring to know that these parents love their daughter, claims about love don’t go very far in providing a rationale for why this particular procedure should be allowed.

Lindemann’s next point, that a family member “must sometimes give way to the interests of others,” is well taken. Few of us would claim that parents must always, regardless of circumstances, put their child’s interests before their own. Accepting that this is sometimes appropriate, however, does not mean that it is appropriate this time. Recognizing, as Lindemann does, that these parents have a real and valid interest in perpetuating their family line is surely important. It would be simplistic to dismiss their desire as frivolous. But admitting that their reason for wanting another child is valid, genuine, and even compelling, doesn’t mean they can use their already existing, severely cognitively impaired daughter to reach their goal. Reasons can be good without being good enough.

Finally, for all the emphasis Lindemann places on family relationships and the parent-child bond, she neglects to account for the interests and relationality of one family member entirely: the baby who would result from this process.  The grandparent-grandchild bond is an undeniably special one, particularly when the grandparents are the child’s primary caregivers. But it is not the same as the parent-child bond, and grandparents who raise their grandchildren usually do it out of necessity, not choice. The fact remains that this baby, if born, will knowingly be denied a relationship with both of her parents. Her mother will be severely cognitively impaired, and her father an unknown sperm donor. And while her grandparents might live well into her adulthood, the chances are that they will not. For Lindemann’s colleagues to have asked who will care for the child and her mother once the grandparents are infirm or dead is a sensible question, and one that attends to family functioning in a way Lindemann doesn’t recognize.

Sometimes, accounting for familial relationships changes the way we think about ethical dilemmas and influences the conclusions we come to. But not always. Giving interrelatedness the weight that Lindemann gives it here is no better than always favoring autonomy or always favoring the patient’s best interest. Lindemann is right to point out that we must consider this family’s unique situation and set of relationships. She is wrong, however, in assuming that such considerations will necessarily settle an ethical dilemma.  In this case, allowing these parents to subject their daughter to the risks and invasiveness of egg stimulation and procurement, for the purpose of having another child (for the ultimate purpose of extending their family line), is wrong – even if the parents love their child, and even if their interests are valid.

Good ethical deliberation requires weighing the many competing values in any difficult ethical dilemma. Weighing values doesn’t mean pitting them against one another, but considering their contextual and relational heft in a given case. In this case, once we’ve given values like autonomy, the patient’s best interest, and family relationality our considered thought, we see that certain values outweigh others. Here, the parents’ desire for another child may be legitimate, but it does not trump their vulnerable daughter’s right to protection from harm. She would be subject to risks without benefits, unable to consent, and for what? To satisfy her parents’ wish that the family line continue. The reason is not compelling enough to justify the procedure, and it is even less compelling when it results in a child being born without parents. At the end of her piece, Lindemann reasserts the importance of accounting for family dynamics, and to anyone who disagrees, she says, “go ask your mother.” What will she say to the child who, born from the procedure she allows, asks, “What mother?”

Published on: July 8, 2009
Published in: Bioethics

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