THE FAMILY AND BIOETHICS

The concept of the family is an important one that cuts across many common bioethical issues. In most developed countries 'the family' is perceived to be under threat, due to such factors as divorce, increasing mobility within society, and legal changes affecting marriage. However, family is significant as the view we take of it impacts many common bioethical questions, while conversely developments in bioethics may impact families.

The philosopher Brenda Almond opens her book The Fragmenting Family with: 'What is the family? There are many ways of answering this question, but I take as my starting point here G K Chesterton's striking metaphor of family as "this frail cord, flung from the forgotten hills of yesterday to the invisible mountains of tomorrow". In more prosaic terms, it is the chain of personal connections that gives meaning to our human notions of past, present and future - a mysterious genetic entity that binds us in our short span of individual existence to our ancestors and to our successors. But for many people, these familiar domestic foundations, taken for granted by previous generations, have begun to crumble.' (1)

We might ask what has this to do with the issues of bioethics? The view we take of the family is important for two reasons. Firstly, it will have an impact on the answers we give to many common bioethical questions. Secondly, the answers we give to bioethical questions may, directly or indirectly, have an impact on families, especially regarding reproductive technologies.

Our view of the family is thus relevant to abortion, reproductive technologies like infertility treatments and saviour siblings, euthanasia and physician assisted suicide, the allocation of healthcare resources (especially for the elderly), sex education, and contraception for teenagers. This File will not address these issues themselves, but rather consider how they intersect with our view of the family.

How are families changing?

In recent decades, changes in law and social policy have played a role in the changing concept of the family, as have technologies that allow us to control conception and reproduction. Yet these developments have not occurred in an ideological vacuum, but have generally paralleled philosophical trends:

Autonomy

An important modern focus for moral and political philosophy is the individual and his personal autonomy to live his life as he wishes. Having personal autonomy is good in that it allows us to live our lives free from the interference of others, but we should not think of our autonomy as being without limits.

Equality

In an attempt to ensure equality, governments and policy makers have accepted that a variety of relationships and domestic situations are equal to marriage, and should therefore be afforded similar status to marriage and the traditional family.

Rights

These ideals of autonomy and equality have been given impetus by a 'rights-based' culture, seeking to ground rights to autonomy and equality not just within a moral framework, but legally. These changes in the way the family has come to be viewed are not, however, without consequences, albeit that these may be unforeseen and unintended. So, for example, a commitment to individual autonomy and equality tends to focus on the wishes of adults. Brenda Almond notes that there is then a failure 'to address one important question: what are the implications of these philosophical views for the least powerful individuals who make up the family - the children?' (2)

Similarly, the philosopher Roger Scruton suggests that focusing on the rights of adults places little emphasis on the welfare of children: 'Instead of regarding the family as the present generation's way of sacrificing itself for the next, we are being asked to create families in which the next generation is sacrificed for the pleasure of the present one'. (3) Such an approach is likely to decrease the permanency of relationships, as autonomy and rights replace community and responsibility as ideals.

Scruton's point emphasises the importance of the intergenerational ties that are central to the proper functioning of families. These ties necessarily involve an element of sacrifice, as one generation invests something of itself in the upbringing of the next. Further, the proper functioning of families may also require an element of sacrifice when those in the prime of life care for earlier generations in the frailty of old age.

What does the Bible say?

Much thinking therefore seems to start from the perspective that the individual is supreme. How may I achieve my own goals? How may I be free? What rights do I have? How might I experience happiness? However, reflecting on relevant biblical principles suggests that the starting point for thinking about the family is not my goals, my freedom, my rights and my experiences. Rather, the starting point for the idea of the family is the place that marriage occupies in the created order.

Marriage is part of God's created order

Marriage is not merely a social or legal institution developed as a convenient way of ordering human relationships. Rather, it has been part of the created order since the beginning of human history. (4) From Genesis 2:24 John Stott has defined marriage biblically: 'Marriage is an exclusive heterosexual covenant between one man and one woman, ordained and sealed by God, preceded by a public leaving of parents, consummated in sexual union, issuing in a permanent mutually supportive partnership, and normally crowned by the gift of children'. (5) He thus summarises four key characteristics of marriage: its exclusivity, its public acknowledgement, its permanence, and its consummation by sexual intercourse. (6) In the New Testament, Jesus confirms that marriage is part of the created order. (7)

Children are a precious gift from God

Although marriage and procreation are part of the created order, there is no biblical sense in which there is a right to have children. Quite the opposite. Psalms 127 and 128 convey the idea that children are a blessing from God. Moreover, several Bible passages emphasise the pain of infertility. (8)

Ideas of identity and family heritage are important biblical themes (9)

Although in no sense unique to ancient Israelite society, the idea of kinship and family identity is a key Old Testament theme. For example, there was for the ancient Israelites the 'strength of the bonds of kinship and the obligation felt towards them' and also the 'sacredness of the family land'. (10) Further, numerous Bible passages set out genealogies. (11)

We may be tempted to skip these passages because they apparently have little to say to us. Nevertheless, their presence implies an important biblical idea: families and the heritage of successive family generations have been crucial to the Living God's plan of salvation for mankind. Matthew 1 and Luke 3 set out in detail the heritage of Jesus' human family.

Adoption

However, while genetic parentage and family lines are important biblically, the idea of adoption is also a significant theme. In the context of the New Testament, the Christian is one who has been adopted into God's family. (12)

The 'nuclear family' is biblical

Chris Wright has pointed out that in Leviticus chapters 18 and 20 we find 'the internal boundaries of legitimate and illegitimate sexual relationships within the close-knit kinship framework were carefully defined in a way that protected very carefully the integrity of the constituent nuclear families'. (13) This importance of sexual faithfulness within marriage is emphasised repeatedly in the New Testament.

The family as the context for religious and moral instruction

In Deuteronomy 6:6-7, Moses says to the Israelites: 'These commandments that I give you today are to be upon your hearts. Impress them on your children. Talk about them when you sit at home and when you walk along the road, when you lie down and when you get up.' In short, the context for the religious and moral instruction of children is primarily the family and the main responsibility lies with parents. Further, verses such as Proverbs 19:18 and Proverbs 23:13 indicate the importance of children learning discipline within the family.

Honouring parents is a biblical command

One of the Ten Commandments is 'Honour your father and your mother'. (14) It is worth noting that this is the only Commandment that came with a promise: if the Israelites honoured their parents, then they would live long lives in the land that God was giving to them. While the Christian cannot necessarily expect material prosperity to flow directly from obeying God's Word, those who honour their parents will nevertheless experience God's blessing in the richness of family relationships as one generation succeeds another.

While the lifestyles and cultures of the 21st century are very different from those of Bible times, the biblical principles set out above are still as relevant today. We might be correct to conclude that some of the family laws contained in Old Testament books such as Leviticus and Deuteronomy have no direct application in modern Britain. (15) Nevertheless, a careful and sensitive reading does reveal a paradigm for the family in a secular society today. (16)

However, we should not be tempted to adopt 'an attitude that loads the family with great expectations and responsibilities, and is quick to blame families, especially parents, for the many ills and troubles of society at large'. (17) For we need to understand family within the context of God's created order and his plan of redemption for a fallen world.

Bioethical issues from a family perspective

Some bioethical issues at the beginning of life and at the end of life highlight the impact that a biblical view of the family might have on bioethics. It is at the beginning and end of life that we are often most vulnerable and dependent on others, so it is here that our view of the family is likely to be most relevant.

Beginning of life

Technological advances that allow us to control or assist conception and reproduction have given rise to a plethora of ethical issues. The aim of this File is not to consider the moral rightness or wrongness of these issues in themselves. Indeed a number of them have been addressed in previous CMF Files. (18) The aim is rather to stand back a little and try to place these issues in the broader context of a biblical understanding of the family.

So, for example, we might consider emergency contraception and conclude it is morally wrong because it can lead to the demise of an embryo. Similarly, we might argue that abortion is wrong because it is wrong to kill a fetus. However, if this is our only focus where abortion or contraception are concerned, then we may miss another important aspect. For it seems that our approach to abortion and contraception draws heavily on the views we have of sexual intercourse and reproduction. Perhaps many, especially teenagers and those in their twenties, see sex as essentially a recreational activity to be enjoyed without recognising its connection with marriage and family. The desire to uncouple sexuality from reproduction lies behind the view many have of contraception and abortion. (19) Yet this is obviously at odds with the biblical created order that establishes a clear link between marriage, sexual intercourse, reproduction and family life. Similarly, if we view children as a precious gift from God, then again it is likely to set the problem of abortion within a very different context, whether the abortion is for 'social' reasons or fetal disability.

Since 1978 when Louise Brown, the first 'test tube baby', was born, IVF and other assisted reproduction technologies have come a long way. IVF was initially developed to assist infertile couples with conception, and we are now at a point where the demand outstrips what the National Health Service can reasonably offer. This is against the backdrop of increasing infertility, as for a variety of reasons more women delay childbearing, and as increasing numbers of women are rendered infertile through sexually transmitted diseases.

Much IVF demand is therefore a consequence of the ability to control the link between sexuality and reproduction. Further, although it was initially developed for infertility it has, in conjunction with gamete donation, allowed single mothers and same-sex couples to have children. For many of these children this has led to a division of the different aspects of parenthood - genetic, social and legal. Yet, as an end-1980s report on reproductive ethics noted: 'The normal state for a child is to have one parent of each sex. It is surely right to be very cautious about tampering with something so fundamental.' (20) Recently it has also become possible to create a 'saviour sibling' with a particular genetic make-up who can donate blood or tissue to an existing sibling suffering from a serious disease.

Reproductive technologies therefore allow people:

• to control fertility
• to find solutions to infertility
• to have children in circumstances where they would previously have been unable to do so
• where there is a genetic disorder in the family, to a certain extent to decide what sort of children they want to have.

Interestingly, this increase in reproductive choice afforded to women has been paralleled by a significant decrease in the number of children adopted since the 1970s. In 1971, 21,495 adoptions were included in the Adopted Children Register in England and Wales. In 2007, the number had fallen to a mere 4,725, (21) with adoptions of babies being very rare. Most adopted children are aged over three and come from broken families. By comparison, in 2007 the number of abortions in England and Wales was reported as 198,500, with the abortion rate highest among women aged 19. (22)

Space prevents more discussion, yet the point is made that biblical principles about the family can provide the basis for a broader understanding of such issues. This is not to deny that these issues are complex, or that they are painful for those who face them. However, when we bear in mind that the biblical account of the created order treats marriage, sexual intercourse and reproduction as inextricably linked and also that every child is a precious and unique gift from God, then we have a distinctive starting point from which to approach bioethical issues arising at the beginning of life.

End of life

There are a number of debates in this area. In the UK there have been calls for the law to be changed to decriminalise physician-assisted suicide. In 2006, Lord Joffe's Assisted Dying for the Terminally Ill Bill was defeated in Parliament. Claims for a change to the law in relation to assisted suicide are often presented on the basis that, just as there is a moral and legal right to life, so there is also a 'right to die'. It has also been argued that preventing a terminally ill patient (who may be dependent on others and suffering greatly) from ending his life at a time of his choosing is an affront to human dignity.

As people in the developed world live longer, we also find that other debates come to the fore. There is in general a very real issue concerning the provision of resources for the care of the elderly. More specifically, we are beginning to see a significant increase in the numbers with dementia, requiring particularly intense levels of care. How will we meet this challenge? Is the care of the elderly primarily the responsibility of the state, or is it the case that families must assume a significant role? If euthanasia or assisted suicide become lawful, is it likely that at least some of the elderly would feel pressure from families to end their lives? Similarly, might the family of someone with dementia who no longer has the capacity to make their own decisions think it kinder to let their elderly relative die rather than continue to live in an 'undignified' way? Is it always the case that when a terminally ill patient says they want help to die that they really do want to die, or is it a cry for help to resolve some other life issue?

Again, this is no attempt to deny the complexity of these issues, or to deny that they are painful and demanding for those involved. What is suggested, however, is that these issues may be about more than simply the 'right to die' or how we should allocate resources. They are in a large part issues about what we value, what kind of a society we want, and how we regard the frail and the vulnerable within our families.

One of the key themes in a biblical perspective of the family is the importance of honouring one's parents. We might ask then to what extent this will impact our approach to bioethical questions at the end of life? If we are committed to honouring our parents in their advancing years, and presumably by implication other elderly members of our families, then their quality of life and their need of care and support will require our serious attention.

A Christian response

This File has sought a different 'take' on some common bioethical issues. It has not sought to explain why particular practices are wrong in themselves; rather that a biblical understanding of the family provides the context in which we can address issues.

Understanding the influence of a biblical view of the family on bioethics is about more than simply advancing arguments in support of the family. These biblical principles, if we accept them as true, are to be lived out. The relevance of the family to bioethical issues, therefore, is not only about the arguments we develop and the policies we propose. It is about how we live, how we choose to order our family circumstances, and how we can best honour, value and care for the vulnerable and the frail in our families. The Christian church has a role to play here in the way that it supports families in its midst, models the importance of family to those outside the church, and cares for those who may have little or no family of their own.

Philosophical thinking and changes in policy and legal developments in recent times may have tended to emphasise the supreme importance of the individual and their choices. Yet, to paraphrase John Stott, true freedom (the freedom that can be found in the Christian life) is not freedom to do as we wish, it is freedom to love and serve. (23) When we work this out in our family life, the questions raised by some of the common bioethical issues are no longer primarily questions about autonomy, equality, and rights. They are questions about love and service.

Mark Campbell trained in medicine, and having retrained in law, is currently a visiting tutor in the School of Law, King's College London and a PhD candidate in the Centre of Medical Law and Ethics, King's College London

References

• Almond B.The Fragmenting Family.
  Oxford: OUP, 2006. p1
• Op cit 55
• Scruton R. This 'right' for gays is an injustice for children.
  The Sunday Telegraph, 28 January 2007
• Genesis 2:21-25
• Stott J. Issues Facing Christians Today.
  London: Marshall Pickering, 1990. p289
• Ibid
• Matthew 19:4-6;
  Mark 10:6-9
• Genesis 30:1;
  1 Samuel 1
• An in-depth discussion of this point is clearly beyond the scope of this paper, but for a detailed account of the family in ancient Israel, see
  Wright C.
  Old Testament Ethics for the People of God.
  Leicester: IVP, 2004. Chapter 10
• Op cit 338
• See, for example: Genesis 10;
  Matthew 1;
  Luke 3
• See, for example: Romans 8:15,23;
  Galatians 4:5;
  Ephesians 1:5
• Wright Op cit 355
• Exodus 20:12;
  Deuteronomy 5:16
• See, for example, Leviticus 25:49 which provides that a relative may redeem someone who has been forced to sell himself into slavery because of financial hardship
• Wright Op cit chapter 10 (especially pp354-356)
• Ibid
• See, for example: File 21 (2003) 'Sex Selection';
  File 23 (2003) 'Abortion';
  File 28 (2005) 'Saviour Siblings';
  File 35 (2007) 'Consequences of Abortion'
• That is not to deny that particular forms of contraception may be appropriate as a method of family planning within the context of marriage
• Glover J et al.
  Fertility and The Family: The Glover Report on Reproductive Technologies To the European Commission.
  London: Fourth Estate, 1989
  cited in Almond Op cit 111
• See the Office for National Statistics website: (accessed 8 March 2009)
• See the Department of Health website: (accessed 8 March 2009)
• Stott J.
  The Message of Thessalonians.
  Leicester: IVP, 1991. p91