Special obligations of parents are legitimately limited

In the simplest scenario, an individual parent holds special obligations to an individual child. A parent is charged with protecting and nurturing the child's well-being as well as with fostering the child's growth. The parent's devotion, commitment and attention are selective and weighted heavily to her child, not all children.

Yet, a parent's special obligations are not limitless. Parents slow down, delay and forego attention to many of their own needs and desires in the fulfilment of their special obligations to their children. But parents have a right to not neglect indefinitely their own emotional, physical and developmental needs. There are times when a parent choosing to spend time and money on her own career development and workforce re-entry instead of, for instance, investing more time, energy and money into an advanced, more intensive music training programme for a child could be praiseworthy. Parents also have other legitimate obligations to professional colleagues, the community, or one's own parents that may limit devotion to a child's needs.

Children can benefit when their parents exercise other obligations at the expense of the child's non-urgent concerns. A child learns he is one node in his parent's matrix of moral relationships—a close and especially connected node—but just one.

A parent's limited time, devotion and energy must account for the strong and weighty obligations to her child for sure, but at least the time and energy are limited and thus require discernment to meet a child's needs. Of course the opposite is true too. Too limited time, attention and devotion can hurt children and can be cause for us to ascribe blame to parents for neglecting them. If a parent's attention is diverted from his child for frivolous or destructive behaviour, he could be blamed for not fulfilling his special obligations. But parents having other needs and obligations outside of a parenting role per se need not undermine the existence of fundamental special parenting obligations.

Needs are different than wants and other goods

Special obligations of parents pertain to taking responsibility for meeting the basic needs essential for a child's development.ⁱ Parents may need to sacrifice a considerable amount of time, finances and energy to ensure true needs are met. How that plays out may vary from culture to culture, but many basic features persist across cultures.

What a child wants and what is good for a child are different, subtler matters. If a child does not get their favourite meal tonight, they are not harmed, and parents are not negligent, so long as the child's basic biological, economic, emotional and spiritual needs are being attended to. Similarly, it might be good for a child to have their teeth straightened; that is neither a need nor a want per se, but it is still good. Moreover, the long-term developmental interests of children are better served when parents refrain from satisfying all ‘wants’ of a child. Doing so can create space for that child to develop his own capacity to fulfil the want independently.

Parents may not be required to give up as much for a child's wants compared with a true need. However, a child's wants are important and should not be ignored. Part of good parenting involves providing opportunities for that child to flourish through exploring and fostering preferences, aptitudes and interests. Thus, a parent must make a lot of judgement calls about the merits of a ‘want’ in deciding whether or how to satisfy it. A child who delights in making things with his hands, but never is allowed to explore crafts or Legos may not flourish. Other wants may not merit any attention or resources at all. Thus, great parenting is a dance that incorporates wants, but does not necessarily cater to them at every moment.

Moreover, distinguishing needs from wants or other goods in particular circumstances may not be easy. For instance, one of us has a 12-year-old child who at the age of 10 years declared herself a vegetarian. By our lights, parents are not strictly obliged to provide a perfect vegetarian menu for their children who choose to be vegetarian. However, systematically withholding viable plant-based protein sources when financial resources are not a constraint probably disrespects who that child sees herself to be. Respecting that child's considered and sustained preference while strictly not a ‘need’ represents more than a spurious ‘want’ and seems to take on some features of need, want and good.

Sufficient satisfaction of special obligations is a function of resources and context

Appropriate exercise of parental special obligations is also a function of the resources, culture and context. In a particular country routine secondary education may not be a basic need for children. In other settings, it might be. Likewise, what constitutes an acceptable risk—good hygiene, enough oversight and ‘adequate’ provision of care—are embedded in social expectations and conditions of one's social context at a given point in time. Behaviours that might be grounds for a parental neglect claim in North America in 2015 may look quite different in the developing world (or North American in 1950), and rightly so.

When others of one's own children are involved, parents must factor in their special obligations to each of the individual children

The obligations of a parent often involve multiple children. When children join a family, a parents' capacity to love may grow, but their capacity to exercise their special obligations to each of the individual children in a timely manner may be limited by competing obligations. Urgency of needs, prospect of benefit, commitment to fairness and existence of alternative options for meeting a need may influence how parents discharge their special obligations. In addition, competing legitimate non-parental role obligations may influence how parents discharge their special obligations. If a diaper needs to be changed for Suzie, snack can wait for Charlie. How much a child stands to benefit from a parent's time and attention in a given instance bears consideration as well. And asking prudential questions like ‘will the satisfying of this need require a lot or a little parental energy?’ is important too. Similarly, if a child has a need, but that parent does not have the resources to address the need, the parent may need to ‘triage’ and focus on those who can be benefited at a given moment. Wise parents will assess how their attention is spread across children over time, asking “am I giving each child their due attention and devotion suitable to their developmental stage and in a way that avoids perception of favoritism?” Parents may also delegate care to another parent or family member to meet their full range of obligations to children and others. Even if the specific parenting maxims suggested here are not shared by all parents, they are reasonable maxims and, for the sake of argument, establish the plausibility of distributed special obligations in parenting.

In non-urgent situations where no basic needs are at stake, great parenting will require allowing kids to experience and grow from their strengths through the undivided attention of the parent, which may require a sibling to wait in the fulfilment of their own wants. That attention may require periods of focused energy on a particular child that make equity of time and attention difficult to achieve.

When multiple parents are involved other factors come into play

When multiple parents are involved, decisions of how to apportion time, energy and attention between the parents are negotiated based on parental and child wishes, legitimate competing parental demands, child developmental phase, parental life goals/trajectory/fulfilment, household income earning considerations, as well as the skills/aptitudes of respective parents, and desire for continuity. Such determinations are dynamic—together discerning what is best to meet the needs of children at various developmental phases. At one phase in a child's life, one parent in a two-parent relationship may spend a larger amount of time with that child. Sometimes parents negotiate to have the ‘less competent’ parent assume responsibility for the children so the ‘more competent’ parent can have a break or pursue other noble goals as discussed above (even if the children would prefer the more competent caregiver). A child's ‘want’ for one parent must be considered in light of all the factors discussed. Distributing and redistributing the time and attention entailed by special obligations across parents is normal and healthy for caregivers and those being cared for. Such sharing can be done with integrity that does not compromise a parent's special obligations.

Some might question our analogy based on the incongruences between clinical and familial relationships. Admittedly much more would need to be worked through to determine at what point the analogy breaks down. Nonetheless the analogy of parenting can be instructive to help in thinking about distribution of physician special obligations.

Special obligations of physicians are legitimately limited

To fulfil their special obligations to patients, physicians need not have their patient care obligations be all encompassing. In fact, physicians might be better physicians if their career obligations were not all encompassing. Physicians with no avocational passions– who never, fish, run, read, play—may exhibit less than fully human (or humane) attributes in their work. It is good that physicians have interests and goals outside of their patient care role. It is right that they attend to institutional, civic, familial and collegial obligations beyond direct patient care. While this may seem obvious, the articulation of this reality in the traditional ethic in the 20th century was largely absent.

Needs are different than wants

We might also note that just as for children, distinguishing patient wants from patient needs may be crucial to discharging a physician's special obligations. Patients may want things that are less beneficial or are even harmful, or they may feel entitled to technology or services that they are not entitled to. Physicians who help patients live within limits that are in their own best interests are taking their special obligations seriously. Deprivation of wants does not violate special obligations per se. Nevertheless, patient preferences are important. This problem is particularly difficult when the patient needs to be treated for a problem but wants for various reasons a suboptimal treatment. We do not deny that how and under what circumstances to accommodate a patient preference for suboptimal treatment may be a difficult problem. The same basic struggles and complexity hold in parenting. Ought a parent to allow a 14-year-old to waste $200 of his hard-earned money on a seemingly frivolous purchase? When patients want what appears, from a medical perspective, to be suboptimal care, when can/should a physician accommodate that?

Several factors may weigh into a parent's or clinician's determination of whether to accommodate such a preference: Risk of irreversible harm (both magnitude and probability), coherence with previously stated wishes and the robustness of the value set on which the preference is based (eg, Does the patient's whole worldview line up with this preference such that not allowing it would be an affront to his/her way of life?) seem like reasonable candidates.

We also acknowledge it is difficult to always and consistently draw the needs versus wants distinction clearly both in parenting and in practice because in reality children and patients experience wants as needs. For this and other reasons, making the application of this distinction may seem sometimes arbitrary. If a want is so closely aligned with how the patient or the child sees himself or herself while the physician/parent still regards it as a want, friction, misunderstanding or conflict could ensue. That reality holds equally for both parenting and medicine. The fact that the distinction may seem arbitrary in some particular circumstance does not negate the legitimacy and relevance of the general intuition.

Navigating the wants versus the needs of patients can be challenging. Part of being a professional involves doing what is right for the patient regardless of the incentives. A patient may ‘want’ arthroscopy for her arthritis, but that does not necessarily mean she needs it, since the data supporting it are questionable.17 However, ignoring uncontrolled arthritis pain and the patient's desire to do something about it would not be right either.

Sometimes a patient's need may be met by not using the medical system to achieve that need. The temptation to commit the equivalent of ‘hover parenting’ in medicine and thereby make a medical issue out of every aspect of a patient's life, wellness and self-care is a real challenge. Discharging special obligations may at times mean not intervening and instead cultivating the capacity of the patient to meet their own needs.

Sufficient satisfaction of special obligations is a function of resources and context

What constitutes the basic needs of a patient is a function of the resources and context. Basic postmyocardial infarction care may look quite different in Houston than it does in Havana. Thus, what it means to be an attentive caregiver is a function of the circumstances of caring. Physicians can no more escape this than parents can. Systems, insurance and documentation all play into how care responsibilities of the physician are met.

When others of one's own patients are involved, physicians must factor in their special obligations to each individual patient

When a physician takes on multiple care relationships, each with its special obligations, the time and attention required to discharge those obligations will need to be distributed across individuals. Acuity of need, commitment to fairness, likelihood of benefit and ability to fulfil the service, all factor into how time and attention are apportioned with patients. This fact may weaken but does not obliterate the idea of special obligations. For generations physicians have managed these limitations implicitly, and doing so wisely is not easy, but can be done. For most patients, most of the time, this distribution is manifest by having to wait to see the doctor. Doctors are often late, sometimes to the point of disrespecting scheduled patients. That lateness is in part justifiable to the extent that the delays were not foreseeable and the other patients delaying the physician were deserving of and benefiting from that attention. These realities imply a real distributional constraint on how physicians meet their individual obligations to members of a group that did not begin with bundle payments or population health nor do they spell the end of special obligations.

When physicians practise in groups, responsibilities can be shared and negotiated

Thankfully, medicine is not practised alone. The time, care and attention needed to meet a physician's special obligations can and often must be distributed across different responsible caregivers. Different clinicians on a team can share responsibility for a patient or multiple patients. Those roles are not always intuitive. For sharing to be constructive, roles need to be negotiated. Contractual obligations, schedules, expertise, patient comfort level, degree of prior bond with the patient may all factor into how special obligations are operationalised across team members. Who ‘owns’ the patient's care can vary over time. When should the patient with chronic respiratory disease be transferred back to the medicine service after elective knee replacement? These are not easy questions that must be negotiated among colleagues, but all speak to the implied reality that operationalising special obligations spreads time and attention for patients across multiple caregivers.

In these circumstances patient preferences are important but not absolute. A patient may prefer one cardiologist to another, but schedules may make seeing the preferred cardiologist more difficult. While systems should not dictate whom the patient sees, they should account for patient preference and promote continuity, especially in non-urgent situations. Having the continuity of a relationship to rapidly incorporate patient preferences is crucial to humanising systems that distribute care responsibilities.

While there may be a risk of physicians who practise in ACOs misreading the performance incentives and reflexively medicating an individual patient against her wishes to ‘help his numbers’, those same bundled payment plans could provide a more patient-centred, holistic team approach to empowering the patient's daily life. Arguably, rather than medicating marginally elevated blood pressure to try to achieve a short-term performance target, systems and teams that support chronic disease self-management (as many ACOs do) could offer programmes that promote diet and lifestyle counselling first that over time could increase self-care capacity and thereby effect a much greater impact on a patient's long-term health outcomes. Conversely, if Shared Savings Programmes turn out to create their own perverse incentives for physicians to overtreat or disrespect individual patients, physicians would have an obligation to resist those incentives and instead advocate for necessary changes in ACO evaluation metrics, even if it meant not meeting performance targets. Such advocacy would rightly derive from and would find its support in the enduring special obligations physicians feel is a part of their job even in imperfect systems.

There will be challenges in upholding physician special obligations in the midst of incredible system change. Is it possible to salvage what was good from the individual model of care to cultivate a sense of ‘taking ownership’ for a patient's management when so many aspects of a patient's care are spread across so many team members? Can we still image medicine as a profession of self-sacrifice when physicians increasingly feel less control and less emotional investment in the future of their practice? Will physicians be able to believe and convey a sense of the unique needs of each patient when they are encouraged to standardise care and manage populations? Will the benefits of relationship continuity succumb to the burgeoning bureaucratic need for ‘throughput’? These questions are not trivial and speak of the hard challenges ahead for the profession. These and other legitimate challenges can be faced with a realistic and robust commitment to special obligations of healthcare professionals as our doubly distributed account outlines.