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Commentary.

Familiar modes of ethical argumentation involve a way of reading a text that can obscure or mute morally rich and relevant features. One way of making moral sense of a story is to read it shrewdly, fleshing out ethically significant details that not only make it more intelligible but also permit ethical justification of a seemingly dubious action. Such a reading can provide the proper context for resisting the conclusion that Dr. H and the cardiologist have acted wrongly.

A crucial detail in this story is that Dr. H is not Mr. G's physician but his brother-in-law. Moreover, the two men have been intimate friends for most of their lives. They are bound closely by ties of affection, marriage, proximity (until very recently), and a long shared history--ties that bind their families as well. This detail has moral implications: people who live in loving intimacy have claims on one another that go beyond the claims of friends, casual acquaintances, or strangers. One's right to one's own money is tempered, for instance, by one's spouse's and children's claims on it. So too one's right to privacy is tempered. We would think it very odd indeed if, for example, Mrs. G were to go out of town on business but said nothing about it to her husband; we would think that their marriage was no longer intimate.

It might be objected that although intimacy is an important feature of the story, so is the fact that Dr. H is a doctor. He is bidden to obey a special set of rules, imposed by the profession for the excellent reason that they preserve trust between doctor and patient. But an analysis governed solely by rules of confidentiality fails to see that Mr. G is not Dr. H's patient, nor are they merely relatives: Mr. G called his brother-in-law, not to consult him professionally, but because Dr. H could translate into lay terms what Mr. G's illness means for him.

What does it mean? To see the illness properly we must go back four years, to the time when Mr. G had a serious heart attack. When we flesh out the details of that episode we see that for the first time in his life, perhaps, and so suddenly that it left him unprepared, he had no choice but to confront the fact of his mortality. We may also suppose that, like many men of his generation, he found it difficult to talk about his fears. So he put a smooth face on them, and when he got better he carefully avoided the subject of his health. He is not the sort of man to ask for help from his wife and children, but his brother-in-law the doctor can reassure and comfort him. Dr. H, who always was a talker anyway, will tell the kids without needing to be asked and will help them deal with their own fears--this is simply his role in the family story.

Understanding the cardiologist's role in all this can also help us to see Dr. H in a different light--and to resist too facile a condemnation of either physician on grounds of broken confidentiality. Two salient points require attention. First, a number of recent studies indicate that heart patients do much better if they have familial support. We may reasonably suppose that the cardiologist knows this and thinks it a part of her job to keep families in the picture. Second, we know that while few families designate their spokesperson in a formal way, if there's a doctor, nurse, nurse's aide, or social worker in the family, that person is often the one the rest of the family turns to for help in understanding what the illness means. The cardiologist treats Dr. H as what he in fact is: the informal spokesman for the family on such matters.

But, some will object, all this is sheerest make-believe. Once one begins reading things into the story that aren't there, one can come to any conclusion at all. This objection overlooks morally important features of the story that were actually given. We were told that the family is a loving one. We were told that Mr. G looked up to his brother-in-law. We were told about the previous heart attack. What was required, then, was a sophisticated way of seeing this story that allowed us to make moral sense of these facts, which were present in the story all along.

This sophisticated seeing, which must remain faithful to the facts, will not tell us what is true but what we may plausibly believe. Insofar as it does, we are able to make sense of the peculiar tension in the story, which speaks of intimacy but ignores its moral implications, and so pushes us toward the kind of conclusion too easily arrived at by familiar modes of argument.

A well-nuanced reading also offers its own conclusion: what counts as morally unacceptable behavior among physicians isn't necessarily so among intimates, or when the fullness of a story is told.

[Hilde L. Nelson is associate editor of the Hastings Center Report.]
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Title Annotation:Case Study: The Voluble Brother-in-Law; confidential communications between doctor and patient
Author:Nelson, Hilde L.
Publication:The Hastings Center Report
Date:Jan 1, 1993
Words:848
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