Trusting families: Responding to Mary Ann Meeker, "Responsive care management: family decision makers in advanced cancer"

Mary Ann Meeker's article admirably reminds readers that family members are involved in--or "responsively manage"--the care of relatives with severe illness in ways that run considerably beyond the stereotypes at play in many bioethical discussions of advance directives. Her observations thus make thinking about the role of families in healthcare provision more adequate to the facts, and this is an important contribution. There's reason to be worried, however, that one explicit aim of the article--to ease the standing anxieties that many clinicians and ethicists have about the reliability of family members as proxy decision makers--will be frustrated by its very success. Those already inclined to suspicion may tend to think that the more intricate and pervasive the ways in which families influence the healthcare decision making of their sick, the more chances they have for altering the connection between patients' interests and the actions of professional providers. To determine whether and when such alterations are something to be concerned about, we'll need to supplement a better grasp of the pertinent facts with a deeper sense of how human agency works and why we value it. We may also need some reminders about the defensibility of diverse moral understandings. Although both professionals and family members may profess an ethic that sets patients' interests above those of non-patients--as Meeker's own results suggest--any strict allegiance to such a framework may be more notional than normative--as her findings also hint. The actual working norms (among professionals, as well as within families) will likely be more complex, but not necessarily any the less defensible for that.