Abstract
The traditional family—a husband and wife, together with their biological children—provides young children, adolescents, and adults with well-documented social, economic and adaptive advantages. Yet, in the West, this form of the family is in decline. A growing percentage of men and women choose not to be bound by the moral and social expectations of marriage and traditional family life and an ever more significant number of children are being born to single mothers. More than 40% of all births in the United States in 2011 were to unmarried women. Such demographic shifts are associated with important changes in underlying taken-for-granted social and sexual mores. They also reflect public policies that instantiate a hermeneutic of suspicion against the traditional family. For example, the individualistic character of the social-democratic egalitarian ideology that underlies current dominant approaches to health care policy and medical decision-making in Western Europe and North America is associated with a decline in family stability. Individually directed informed consent, for example, accents an unqualified affirmation of persons as the source of authority over themselves. This practice of informed consent tends to present persons outside of any social context in general and outside of their families in particular. The burden of proof is placed on the family to demonstrate that it acts with legitimate authority and in the best interests of individual members.
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- 1.
That the family is normative and central to human flourishing does not imply that family-based duties do not need to be carefully explicated. As Ilhak Lee notes: “filial duty has been (mis)understood as an unconditional, unlimited commitment and sacrifice, meaning children should do what, in the opinion of ‘others,’ is best for their parents, not what the parents prefer. It seems in this case children have little chance of demonstrating obedience, which is the proper understanding of filial duty. They also seem to have little chance for a discussion with their parents about the treatment they prefer, or what the parent would want” (2014).
- 2.
Julianne Holt-Lunstad, Timothy Smith and J. Bradley Layton, in a meta-analytic review across 148 studies with some 308,849 participants documented that strong traditional social relationships, such as the family, indicate a 50 % or greater increased likelihood of survival across a wide range of causes of death. “Cumulative empirical evidence across 148 independent studies indicates that individuals’ experiences within social relationships significantly predict mortality. The overall effect size corresponds with a 50 % increase in odds of survival as a function of social relationships. Multidimensional assessments of social integration yielded an even stronger association: a 91 % increase in odds of survival…Results also remained consistent across a number of factors, including age, sex, initial health status, follow-up period, and cause of death, suggesting that the association between social relationships and mortality may be generalized” (Holt-Lunstad et al. 2010, p. 9. See also House et al. 1988; Norval et al. 2009).
- 3.
As Ana Iltis notes: “Families have particular interests both because they are stakeholders in family members’ well-being and because they ordinarily want to protect the interests of individuals in the family (and of the family over all)” (2014). On this point see also Bishop (2014).
- 4.
“Children raised in single-parent households are, on average, more likely to be poor, to have health problems and psychological disorders, to commit crimes and exhibit other conduct disorders, have somewhat poorer relationships with both family and peers, and as adults eventually get fewer years of education and enjoy less stable marriages and lower occupational statuses than children whose parents got and stayed married” (Gallagher and Waite 2000, p. 125).
- 5.
“How an adolescent fares during the transition to adulthood has long-term repercussions. Earning a college degree leads to a higher-paying and more prestigious job, while early parenthood, unsuccessful marriage at a young age, and involvement in crime or problematic substance use all foretell difficulties in finances, family relationships, and beyond” (Osgood et al. 2010, p. 210).
- 6.
Richard Settersten and Barbara Ray note, for example, that “both in the United States and in many European countries, the process of becoming an adult is more gradual and varied today than it was half a century ago. Social timetables that were widely observed in that era no longer seem relevant, and young people are taking longer to achieve economic and psychological autonomy than their counterparts did then” (Settersten and Ray 2010, p. 20).
- 7.
“Even if the transition to adulthood had not become so demanding, members of these vulnerable groups [children raised in foster care or in a group care setting] would face exceptional challenges finding employment, attending college, and marrying and starting a family. Many struggle with emotional or behavioral problems; many have histories of problems in school and the community. Often their families are unable or unwilling to provide the support that most families provide to their children during this transition—funding for college, child care that permits work or schooling for young parents, a place to live when times are hard” (Osgood et al. 2010, p. 211).
- 8.
“Current evidence also indicates that the quantity and/or quality of social relationships in industrialized societies are decreasing. For instance, trends reveal reduced intergenerational living, greater social mobility, delayed marriage, dual-career families, increased single-residence households, and increased age-related disabilities. More specifically, over the last two decades there has been a three-fold increase in the number of Americans who report having no confidant—now the modal response. Such findings suggest that despite increases in technology and globalization that would presumably foster social connections, people are becoming increasingly more socially isolated” (Holt-Lunstad et al. 2010, p. 2; see also McPherson and Smith-Lovin 2006; Putnam 2000).
- 9.
“The differences begin in infancy, when most of the cohabiting couples are still living together and the child has a two-parent family. Stacey Aronson and Aletha Huston used data from a study of early child care conducted by the National Institute of Child Health and Human Development to assess the mother-infant relationship and the home environment for children at ages 6 months and 15 months. On both measures and at both ages, the children of married couples did significantly better than the children of cohabiting parents, who in turn had scores that were only fractionally higher than the children of single mothers. … The disadvantages of being born to cohabiting parents extend into childhood and adolescence, even when the cohabiting couple still consists of the two biological parents. Susan Brown used the 1999 cohort for the National Survey of America’s Families to examine behavioral and emotional problems and school engagement among six- to eleven year-olds and twelve to seventeen-year-olds. Same story: Having two unmarried biological parents was associated with worse outcomes than having two married biological parents, and the outcomes were rarely better than those for children living with a single parent or in a ‘cohabiting stepparent family’” (Murray 2012, pp. 164–165, citing Aronson and Huston 2004; Brown 2004).
- 10.
The prevalence of sexually transmitted disease has also increased. Roughly 16 % of Americans between the ages of 14 and 49, for example, are infected with genital herpes, one of the most common sexually transmitted diseases. The infection rates are worst for African-American women (about 48 %) and African-Americans generally (about 39 %); for women (about 21 %), than for men (about 11.5 %). According to the Centers for Disease Control, treating sexually transmitted diseases costs the United States healthcare system some $ 16 billion annually (see Allen 2010). The World Health Organization issued an alert in June 2012 expressing their concerns regarding new forms of antibiotic resistant gonorrhea (Shepherd 2012).
- 11.
Perhaps, as Wenqing Zhao (2014), argues, it would be beneficial to turn to the family as a whole to help assure proper medical decision-making. Moreover, as Yaning Yang (2014), argues, family-based accounts of advanced directives would likely benefit the elderly. For insights into the situation in Taiwan see Lee (2014b, pp. 125–136), who notes that the goal in family-based decision making at the end of life in Taiwan is family consensus: “in actual practice, family consensus is the target. It is usually upheld by medical professionals. In many cases, the presentation of all the relevant family members, for example, in the decision for parent’s medical treatment, the decisions of all brothers and sisters are usually requested. Even the spouse and elders were present, medical professionals would insist that other known family members be present before the final decision is made. In cases of not a matter of urgency, medical professionals usually ask the family members to hold meetings to arrive at a consensus decision before taking any further action.”
- 12.
“It was the contribution of the women’s movement to attempt such a synthesis by placing the family in the center of social analysis. Feminists identified the family as a crucial institution in the reproduction of social relationships generally, and decisive for women’s subordination. Hence, in theory and practice, the women’s movement adopted a critical stance toward family life” (Breines et al. 1978, p. 43).
- 13.
Engelhardt continues: “… consider the contrast between those who favor autonomous individualism and those who would give moral priority to family life. Those who regard autonomous individualism as the presumptively appropriate relation among persons would require any deviations to be established by explicit statement and agreement. For example, patients would be presumptively treated as autonomous individuals willing and committed to choosing on their own, unless they explicitly demanded to be regarded and treated within a traditional family structure…On the other hand, if one considered life within a traditional family structure as the presumptively appropriate relation among persons, the burden of proof shifts. Persons are approached as nested within the thick expectations of traditional family structures, unless they explicitly state that they wish to be regarded and treated as isolated individuals” (Engelhardt 2002, pp. 24–25).
- 14.
For a detailed account of autonomy and family-based autonomy in the Korean medical context see Kyungsuk Choi who argues that “The individual (the self) and the family (a community) should be balanced. The family can be considered a community in a basic sense. From a traditional Eastern perspective, the family, rather than the individual, has been the basic unit for society and the state. However, it was not long before Korean society began to recognize an individual as having autonomy. We cannot disvalue modernity. In this regard, the value of autonomy should continue to be emphasized, but it must be balanced with other traditional values” (2014).
- 15.
See, e.g., Rawls 1999. Rawls urges that parents should not be appreciated as possessing moral status or moral authority in themselves, but only insofar as parents and the family function as the preferred social institution for raising children in a well-ordered and just society. “I shall assume that the basic structure of a well-ordered society includes the family in some form, and therefore that children are at first subject to the legitimate authority of their parents. Of course, in a broader inquiry the institution of the family might be questioned, and other arrangements might indeed prove to be preferable” (1999, p. 405). Left to itself, Rawls argues, the family makes it impossible “…in practice to secure equal chances of achievement and culture for those similarly endowed,” which implies that for reasons of justice, “… we may want to adopt a principle which recognizes this fact and also mitigates the arbitrary effects of the natural lottery itself” (1999, p. 64). Insofar as families are the most appropriate social institution to integrate children, as they gradually acquire the proper sense of liberty, equality, and social justice, into a well-order society, so much the better; if not, then either the family ought to be regulated and reorganized or other more preferable arrangements found to raise children to become free and equal members of society.
- 16.
For example, Unguru et al. (2010) argue that more should be done to educate children so that they can give meaningful assent to participate in oncology research. “Tools to assist investigators ascertain that children understand what they are agreeing to when they assent to research and to determine their preferences for inclusion in research may help make assent more meaningful” (e876; see also Unguru et al. 2010). Sinclair argues that adolescents should be permitted a significant role in deciding whether to undergo a life saving heart transplant, perhaps even permitting them to refuse a life saving transplant (Sinclair 2009).
- 17.
As the Ethics Working Group of the Confederation of European Specialists in Paediatrics argued: “Firstly, seeking a person’s consent/assent respects their basic right to self-determination (autonomy). Individuals are best placed to determine what is in their best interests and the only justification for infringing this right is to prevent harm to others. Secondly, obtaining consent/assent involves treating others in a way in which we would expect to be treated ourselves. The universal need to obtain consent/assent also involves treating people justly. Thirdly, obtaining consent/assent protects patients from the physical and psychological harms which may occur as a result of illness or its treatment. Fourthly, obtaining consent/assent confers benefit by encouraging active participation of individuals in investigation and treatments which are intended to restore their health” (Levy et al. 2003, p. 630).
- 18.
Similarly, current California law requires neither parental consent nor simple parental notification for a child to obtain an abortion. See Planned Parenthood Parental Consent and Notification Laws. Available: www.plannedparenthood.org/teen-talk/teen-pregnancy/parental-consent-notification-laws-25268.htm. See also California Health and Safety Code, Sect. 123420–123450. “Do I have to get my parent’s permission to get an abortion? No. You do not need anyone’s permission, and the law protects your privacy. No one else has the right to know or do anything about it—not your parents, your boyfriend or partner, or your husband. Even if you are married or under 18, the decision is up to you.” ACLU, “Your Health; Your Rights” [On-line.] Available: www.teensource.org.
- 19.
Dickens and Cook argue that: “There is usually no chronological ‘age of consent’ for medical care, but a condition of consent, meaning capacity for understanding” (Dickens and Cook 2005, p. 179).
- 20.
“Debates surrounding the rights of adolescents to receive confidential and private reproductive health services have centered around the potentiality conflicting interests of parents and their children. The desire of parents to guide and direct their children’s health and development and make health-care decisions for their children is easily understandable. However, the health threat faced by adolescents exposes the tension between public or societal interests in maintaining a healthy population and private or parental interests in maintaining control over their children” (Ringheim 2007, p. 245).
- 21.
For example, in his detailed Roman Catholic casuistry of parental decision making on behalf of their children, Edwin Healy (1956), argues that parents should and must make decisions regarding ordinary vs. extraordinary care on behalf of their children, including even determining when treatment is too expensive to be obligatory (Healy 1956, pp. 81–89, see especially page 82).
- 22.
Consider, for example, Susan Moller Okin who argues, “The liberal state … should not only not give special rights or exemptions to cultural and religious groups that discriminate against or oppress women. It should also enforce individual rights against such groups when the opportunity arises and encourage all groups within its borders to cease such practices” (Okin 2002, pp. 229–230). Moreover, education policies, it is argued, should carefully restrict religiously-based education that might encourage children towards traditional sex roles. “If parents are permitted to educate their children in sheltered settings in which they are taught, by example, doctrine, and the content of their curriculum, that it is the will of an omnipotent and punitive God that women’s proper role in life is to be an obedient wife and a full-time mother, how can the girls be said to be ‘aware of … alternatives’ in any meaningful way, to be able to ‘assess these alternatives’ (or even to think it desirable to do so), or to be able to ‘participate effectively’ in other roles or ways of life?” (Okin 2002, p. 226) Children, it is asserted, should be educated in the public virtues of justice, equality and tolerance.
Amy Gutmann opines similarly: “Some kinds of social diversity … are anathema to political liberalism. Civic education should educate all children to appreciate the public value of toleration” (1995, p. 559). Gutmann continues: “The basic principles of liberalism, those necessary to protect every person’s basic liberties and opportunities, place substantial limits on social diversity. … The limits on racial and gender discrimination, for example, enable many people to pursue ways of life that would otherwise be closed to them by discriminatory practices at the same time as they undermine or at least impede some traditional ways of life” (Gutmann 1995, p. 559).
- 23.
The Supreme Court has reasoned that, on balance, the available scientific evidence, including neuroimaging studies of the relative immaturity of the adolescent brain, does not support the conclusion that adolescents possess adult capacities for personal agency and rational mature choice. See Roper v. Simmons p. 541 US 551 (2005); Graham v. Florida p. 560 US (2010); and Miller v. Alabama p. 567 US (2012).
- 24.
“‘Less marriage means less income and more poverty” (Sawhill 2011, p. 42). reckons Isabel Sawhill, a senior fellow at the Brookings Institution. She and other researchers have linked as much as half of the income inequality in America to changes in family composition: single-parent families (mostly those with a high-school degree or less) are getting poorer while married couples (with educations and dual incomes) are increasingly well-off.
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Cherry, M. (2015). Individually Directed Informed Consent and the Decline of the Family in the West. In: Fan, R. (eds) Family-Oriented Informed Consent. Philosophy and Medicine(), vol 121. Springer, Cham. https://doi.org/10.1007/978-3-319-12120-8_3
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