Family Covenant: Considerations of Trust

Doukas and Berg (2001) serve a useful function in beginning a dialogue on the important issue of family communication in the area of genetic testing. Initially, my concern was that in the current healthcare environment, physicians would simply not have the time necessary to devote to this sensitive topic, especially when several persons will be involved and numerous family and individual meetings are necessary. Specifically, under the current fiscal reimbursement scheme, the nonbillable hours necessary to adequately perform the task are prohibitive. However, while healthcare reform via changes in benefit plans or legislative mandates entail massive efforts, they are not, given enough time and public demand, insurmountable (Morriem 1991).

Indeed, the proactive nature of the communication between patient and physician influences the development of a trusting relationship. However, as proposed, the family covenant introduces several uncontrollable variables that may actually place the maintenance of a physician-patient trust relationship at risk. The literature on trust delineates that the first variable in its development is for Patient A to reliably predict that the behavior of Professional Y is consistent with his or her stated intentions (Rempel, Holmes, and Zanna 1985).Three issues that may jeopardize the development and maintenance of that trust are briefly listed below for consideration.

1. Non-operationalization of the term "family unit"

While not specified, Doukas and Berg appear to assume the functioning of a traditional, nuclear family structure in which all parties have only the best intentions toward the other members in their family. They state that "The covenant applies only to the extent that the physician (and patient) must consider the impact of genetic test results on other family members to that extent agreed upon a priori by the family." My question is: Which family and how can they all agree a priori? Is the stepson who visits his father only once per year included or excluded in the dialogue; how are adoptive families, who may, by law, be unable to have contact with the biological parents, to engage in this dialogue; how do couples utilizing sperm banks or artificial insemination convene their "family"? This issue might be addressed by simply limiting the "family" to those members present during the dialogue. However, if the intention is to include all interested parties, it is difficult to imagine the exclusion of a family member who may be affected by the decisions of those involved in the covenant.

2. Lack of comprehensive training in family systems

While current training in internal medicine and family practice generally address issues related to family systems, physicians are trained in medicine and most training is geared toward the one-to-one dialogue between a single patient and physician. The vast majority of physicians do not have in-depth training in family systems or in interventions geared towards families with longstanding patterns of dysfunctional, interpersonal relationships. While some families pull together under times of stress, it is at least as probable that when under stress systems will exhibit increased dysfunctional behavior. When a family has one or more members with a DSM-IV Axis II diagnosis, the physician may find himself or herself needing to spend an unacceptable amount of time on that single family unit and coming to a resolution that is not ideal for any of the parties involved. While primary care physicians must be involved in all stages of the process, I suggest that the actual ongoing dialogue be conducted via specialists in the areas of genetic and/or behavioral science.

3. Potential increased legal liability and placement of the privilege in jeopardy

In a society that increasingly relies on legal recourse for problem solving, having physicians not specifically trained in this area may increase their risk of liability. I doubt whether many physicians are prepared for formal family systems intervention, and if cases become too complex and referrals are made, might a physician be accused of abandonment during a particularly difficult period in the life of a family? While not an attorney, I would also question [End Page...