Ken Kipnis Those of us who teach medical ethics in philosophy departments can find ourselves intellectually positioned between two areas of inquir y. At one end, some of our colleagues are investigating novel problems of philosophical interest that have emerged from health care. Much of the estimable work of Frances Kamm and Jeff McMahon has that character: except for the types of problems they take on, the concepts and methodologies they employ are ones that are familiar to philosophers. John Harris’s anthology Bioethics¹ includes work of this type. These materials are characteristically addressed to philosophers and often support results that are not readily incorporated into the practices of health care professionals who must respond to other imperatives. At the other end of the spectrum are philosophers like Haavi Morreim and Jeff Spike, who work in medical schools and are very good at conversing with physicians, hospital administrators, researchers, and so on. These "practitioners" publish, consult, and lecture broadly; but despite a foundational philosophical training that is evident in their work, they are not primarily participants in philosophy’s conversations. Their audiences include novices and professionals in health care who need practical advice on the management of immediate and concrete ethical problems. The spectrum is not unique to medical ethics. Philosophy of law has exponents who look to their philosophical colleagues and others who work with and write for legal professionals. Philosophy of science can also be done in ways that require an understanding of the history and content of science, as well as in ways that do not. There is, accordingly, a decision that philosophy professors have to make when they take on an undergraduate course in medical ethics. One approach focuses on the conceptual puzzles that fascinate us and can yield to the intellectual tools we have developed to engage them. This is a familiar path. A second approach works through the nettlesome dilemmas that can challenge the ethical judgment and compromise the integrity of health care professionals. It is arguably a preferred route where most students aspire to careers in health care and philosophy majors are a comparative rarity. It demands that instructors know something about clinical practice, how physicians think and approach their work, how hospitals are organized, and so on. Much can be learned from service on hospital ethics committees and Internal Review Boards, and sociological studies like Charles Bosk’s Forgive and Remember² are surprisingly useful depictions of the moral ambience of hospitals. I expect most specialists in ethics are comfortable with the first type of course. Here are six educational objectives that might be considered for courses of the second type. We must help our students make room for the probability that the moral principles that have served them and their families well over the years may be inadequate to the task of providing twenty-first century physicians with sound ethical guidance. The personal values and moralities that well-intentioned students bring with them into the classroom may support unprofessional choices in clinical practice or provide insufficient guidance. Vexing ethical dilemmas are effective in getting students’ attention. And that attention is the most dramatic evidence that students accept that they have something to learn. We must expose students systematically to the main elements of the profession’s current sense of its ethical responsibility. Here, professional codes, consensus statements, and the literature of clinical ethics are useful materials. Ideally, students should be able to distinguish between cutting-edge issues (e.g., medical "futility" for example) and consensus issues (e.g., refusals of blood by adult Jehovah’s Witnesses). A third objective is to help students grasp the essential relationship between the privileged status that the consensus principles should enjoy and the soundness of the arguments given in support of them. Here we are on our home turf. I am not suggesting that these consensus positions are ethical commandments: they are "in play" and subject to criticism and revision. We know something about how this should be done. A fourth objective is to nurture the development of practical ethical skill. An ethically competent physician does not merely have an open mind, a grasp of the profession’s conventional ethical wisdom, and a sense of the debates that give rise to that consensus. Ethical competence also includes research skills, mastery of effective clinical communication strategies, writing ability, and so on. A fifth objective involves, not individual students, but the class as a whole. Ethics education succeeds most impressively when a class can model within itself the character of an ethically competent profession. Medicine is one of civilization’s great traditions and, as Alasdair MacIntyre has famously urged, to remain vital a tradition must sustain ongoing and vigorous debate about the nature of its distinctive goods and how these are to be realized in the course of practice. While one cannot and should not avoid student-centered teaching, the fifth educational objective calls upon teachers to promote the creation of what can be called an ethically competent profession. Each of the preceding objectives is a prerequisite for this larger one. For unless medicine enjoys a critical mass of what we might call "statespersons," it will be unable to participate coherently in the social organization of health care, unable to chart its own course, unable to shape its distinctive dedication. The student body needs to grasp what it is to play a role in a profession’s ethical governance. A sixth and final objective takes us to a broader level. For the medical profession exists to serve—centrally—the health needs of its community. The relationship between the two expresses something of a social contract: Benefits and resources flow directly and indirectly to members of the profession as its distinctive services are rendered to its community. A community is in good order when both parties are reasonably satisfied with the balance between the goods they receive and the burdens they are obligated to shoulder. Questions of justice, social values, ethical obligation, and public policy pervade aspects of that transaction and, ironically, physicians will almost inevitably find themselves on both sides of the bargaining table, as providers and, on occasion, as patients. If, in one context, the ultimate student in a medical ethics course is the medical profession, in another the professor’s ultimate client is the community. For a central collective task of the profession is to reach a stable and just accommodation with its community. This has never been easy, in part because of the tendency to act out of personal interest rather than out of professional values: The boundary between professional associations and trade associations is often blurred. Accordingly, those who teach professional ethics in health care must consider the proper place of medical care in a just society, to pay attention to the standards that should inform "the deal." As bioethicists, we have been fairly successful in moving out of the classroom and into the public sphere, making contributions that can potentially reach broad audiences even as they address pressing social concerns. We can show how health care professionals can help craft the social setting within which medicine is practiced even as we equip practitioners to work responsibly within that context.

David Benatar University of Cape Town

Dan Brock National Institutes of Health The confidentiality of medical information has received new challenges in recent decades. In the Tarasoff case in 1976, the court held that a health care professional has a legal duty to breach confidentiality when necessary to prevent a serious harm being caused by his or her patient to a third party. The court held that the health care professional is obliged to make a judgment about the seriousness of the potential harm, its probability, and what steps are reasonably available to the health care professional to prevent the harm. An important feature of the so-called Tarasoff rule is that it does not only permit the health care professional to breach confidentiality to protect someone who would be otherwise harmed by his patient, but it also places a legal duty on him to do so and holds him civilly liable for damages in the case of failure to do so. Subsequently, the AIDS epidemic focused attention on the risk of infection of others with the HIV virus, unaware that the sexual or drug sharing behavior of infected individuals puts them at that risk. Here too, the law in most states now recognizes that physicians are at the least permitted to breach confidentiality in order to warn others of this risk from their patient, and many physicians now accept that they have a duty to do so when the patient is unwilling to change his behavior and/or warn others at risk. Now with rapid advances in genetics and genetic testing, information is increasingly available to patients about their likelihood of developing a variety of medical conditions and diseases at some point in their lives, as well as their risk of transmitting those diseases, or the risks of those diseases, to their future children in reproductive contexts. This information can have important consequences for spouses, especially concerning reproductive choices, where both parties may wish to understand their reproductive risks and to make choices about how to deal with them. Because of the way genetic risks and conditions are inherited within families, this kind of genetic information about one individual commonly has implications for other family members of the individual, most obviously siblings but sometimes others as well, whether for their own health or for reproductive choices. Other family members can often take steps to reduce their risks of genetically transmitted harm. For example, women who learn that they are at increased risk of breast cancer because they have inherited the BRCA 1 or 2 genes can increase mammography and other screening measures, or can even undergo more extreme preventive measures like radical mastectomy. Or they may wish to alter their reproductive choices, perhaps by not reproducing at all, or by using preconception or pre-natal testing for the particular genetic risks in question. Now, of course, in most cases individual patients will feel a responsibility to provide this genetic information to other affected family members and will willingly do so. But for a variety of reasons, such as fear of adverse consequences when the information is known by others, fear of embarrassment or stigmatization, estrangement from other family members, or fear of criticism from others about how one is or is not using the information, an individual may be reluctant or unwilling to share the information with affected family members. In the United States at least there is a strong tradition among genetic counselors of so-called nondirective counseling; information is given to patients, but counselors do not pressure or in many cases even urge patients to share that information with other family members who have an interest in it, much less themselves breach the confidentiality of their patients to do so. One issue for public policy is whether individuals should be entitled to have this information treated confidentially by health care professionals when they are unwilling to share it with affected family members. If health care professionals are prepared in some cases to breach confidentiality when necessary to inform family members of their patients about genetic risks, patients should be apprised beforehand of the limits to the confidentiality they will receive. Some psychiatrists, for example, make a point at the outset of therapeutic work with a patient of explicitly informing her of the limits to the confidentiality of information about the patients that the psychiatrist will be able to observe, and the kinds of circumstances in which it may be breached. Failure to warn patients of the limits to the confidentiality that they can expect is to participate in deception of the patient. But should that confidentiality be limited? To answer that question, we need to address what moral reasons underlie the medical practice of confidentiality. Before doing that I want to underline that the argument I shall address below is not based on any special obligation a patient may be said to have to other family members. Others in this session will focus on that issue. But I think it is interesting that even in the absence of any claim about such special obligations, we can make a case for important limits on confidentiality of genetic information in the case of family members. It is worthwhile noting that in many social circumstances there is no presumption or expectation of confidentiality—if a waiter or a patron at the next table overhears your conversation in a restaurant, they are under no obligation to keep what they hear confidential. So there must be special reasons for the confidentiality of medical information imposed on health care professionals. The most obvious and commonly cited justification for the practice of confidentiality is a consequentialist one—it produces good consequences and avoids bad ones. For example, it is important for optimal diagnosis and treatment of patients that they provide their treating health care professionals with all potentially relevant information without withholding some because of embarrassment or fear that it might be passed on to others. Maintaining confidentiality also avoids potential unjust discriminatory use of that information—for example to deny health insurance or employment. This is obviously a special concern in the case of genetic information because of the predictive power it often has of future health problems which an employer or insurer will often want to avoid if possible. While some states have laws prohibiting the use of genetic information in insurance or employment, individuals’ fears that those laws will not always be effective are often reasonable. Further, in some cultural contexts some genetic information will be stigmatizing for those it is about. While it is an assumption in many developed country contexts that increased capacity for genetic testing in the reproductive context increases women’s reproductive freedom and control, in other contexts it can have the opposite effect. In the context of practices of arranged marriages, the presence of some genetic conditions can make women unmarriageable. In highly patriarchal societies, new genetic information can reduce women’s reproductive freedom when it leads to new choices that are coerced by their husbands or other family members. There is a second moral reason for why confidentiality should usually be maintained: patients have been promised that their medical information will be confidential. Sometimes that promise is explicit, as when health care professionals explicitly reassure patients that their medical information will be confidential. But even in the absence of any explicit discussion or reassurance about confidentiality, the health professions hold out to patients that their medical information will be kept confidential, and there are widely known legal requirements that they do so. These explicit or implicit promises of confidentiality create prima facie moral obligations to respect confidentiality. But these obligations will not be decisive in all cases—obligations to keep promises are in general prima facie. They can be overridden in circumstances in which they conflict with more weighty obligations or when breaking them is necessary to prevent serious harm to others. And of course in the circumstances of concern here, breaching confidentiality to materially affected family members can sometimes be necessary to prevent such harms. But there are at least two complications to whether any obligation based in a promise of confidentiality does or need apply. First, as I noted at the outset, in recent decades limits to the confidentiality that patients can expect have been established in most state laws. To the extent that the promise of confidentiality is based on these professional and legal practices, then that promise has limits to it. Moreover, since the limits are typically framed not in terms of specific kinds of medical information, such as HIV status, but rather in terms of whether disclosing the information is necessary to prevent serious harms, these limitations arguably cover the cases of genetic information important to the health or reproductive choices of family members. The second complication of a promise as the basis of confidentiality is that even apart from the point just made about whether the promise now applies to the cases of concern here, the policy question for the future is whether any promise should be made that covers the cases of concern here. Just as many psychiatrists now do with their patients at the outset of treatment, health professionals too could explicitly warn their patients that genetic information important for family members’ health or reproductive choices would not be kept confidential from those family members. So any appeal to a promise of confidentiality has little weight with regard to what practice should be for these cases. There is a third moral reason supporting the practice of confidentiality. It appeals to two ideas—that medical information is typically only obtained with the consent and cooperation of the patient and that because that information is primarily about the patient, the patient should control who has access to it. The first of these two ideas can, I believe, does little work in establishing confidentiality of information in the cases here in question. That is because patients could be told at the outset of any genetic testing that information would not be kept confidential from seriously affected family members. If patients then proceed to give consent and cooperate in the genetic testing, they would have no moral complaint if the information is subsequently shared with those family members. So I believe that what must do the work in this idea is that the information primarily concerns the patient and so the patient should control who has access to it. But of course it is precisely this which is not true in the genetics cases of concern here. The information typically is equally about family members and may be just as vital to those family members’ well being as it is to the patient. So this third moral reason does not support keeping genetic information confidential from seriously affected family members. I think the upshot of this brief tour of the moral reasons in support of the practice of medical confidentiality is that in the case of genetic information seriously affecting family members, only the first reason which appeals to the good consequences of the practice appears relevant. But in these cases, breaching confidentiality when the patient is unwilling to share the information with affected family members is necessary to prevent serious harms to their family members or their offspring. It is hard to see how the harms to the patient of breaching his or her confidentiality are, except in very unusual cases, plausibly thought to be more serious than those prevented for the family member. Now, of course, in assessing the consequences of a policy for these cases, it is necessar y to look beyond the consequences in an individual case to the affects on the practice over time. For example, it might be argued that making clear that confidentiality would not be maintained in these types of cases would discourage people from seeking genetic information and, in turn, from using it to protect their own health or to make wise reproductive choices. A similar argument was made in the early stages of the AIDS epidemic that any limits to the confidentiality of patients HIV status would discourage persons at risk from coming into the health care system. They would lose the benefits of information about protecting their own health and of counseling to protect others; the consequences, all things considered, might be worse from breaching confidentiality to warn persons at risk of infection. Just as in the case of HIV, there is no good data to assess this argument in genetics’ context, but it does pose a speculative harm against an often more direct and probable harm. Any assessment of consequences of practice in this area is obviously fraught with uncertainty. I believe the task for public policy is to carefully frame the circumstances in which genetic information will not be kept confidential from seriously affected family members, and to specify how and by whom it will be shared. Health professionals should in most cases be permitted, but not required, to share the information to enable them to take account of the specific circumstances of a particular case. Moreover, weakening the practice of confidentiality of genetic information in the case of family members provides no basis whatsoever for weakening it for other third parties such as employers and insurers. But in the family context, we must rethink the practice of confidentiality of genetic information.

Leonard M. Fleck Michigan State University The title of this paper might be a puzzle to many. Is there a problem with sharing genetic information within a family? Empirically, the answer is that such information is generally shared within families, though there may be some practical psychological problems in figuring out how best to do that. But our question is this: What if an individual refuses to share such information with a sibling, and that failure to share might cause irreparable harm to that sibling? Is that sibling with the genetic information then open to moral criticism for failing to share? If so, what are the relevant moral norms that have been violated and that serve as a reasonable basis for that moral criticism? As we shall see, there is a problem here that it is harder to get a handle on than what might first appear. We need to give our ethically problematic sibling a name. Gene will do very well. Gene asserts that he has a right to privacy. He has the right to control medical information about himself, which means he can deny that information to anyone and everyone. We point out to Gene that his withholding this information might cause serious but preventable harm. Further, we are talking about his brother, not some stranger. But Gene, having been philosophically trained at MIT, points out that the fact that someone has a need, even a very urgent need, does not generate a right against him to meet that need, even if he is well positioned to meet that need. Someone may be faced with premature death unless they receive a kidney transplant or a bone marrow transplant. Gene may be a perfect match for that person. There might be other matches somewhere in the world, but there is no guarantee that they will be found soon enough. Still, it seems Gene is correct in his philosophic belief that the individual does not have any right to his kidney or to his bone marrow. He concludes that he is not open to any justified moral criticism for his refusal to donate in such a case. However, this is his brother; this is family. Does not this fact by itself have both moral relevance and moral weight, perhaps decisive moral weight? Further, he is not being asked by his brother to give up either a kidney or bone marrow. He is not being asked to undergo major surgery or even endure some significant pain. It is just simple painless medical information that he is being asked to share with his brother in order to prevent serious harm to his brother. Still, Gene might well insist that his brother has no right in this regard, and consequently, he has no duty to provide the needed information. This might well be a correct moral conclusion. For the sake of discussion, I will take it as such. Nevertheless, that leaves us in a morally uncomfortable position. I am inclined to think that Gene’s choice in this matter is open to justified moral criticism. I am reminded of Judith Jarvis Thomson’s "minimally decent Samaritan." My intuition is that this might be morally helpful in this context in understanding why Gene’s behavior seems morally criticizable. Thomson provides us with several illustrations of what minimally decent Samaritanism is all about. The one I will call to the reader’s attention is the story of herself and Henry Fonda. Thomson imagines herself in the hospital on the East Coast with a dangerously high fever that will result in her death shortly unless the fever is broken. The only thing which can accomplish that is the "cool touch of Henry Fonda’s hand on her fevered brow." The only problem is that Fonda is on the West Coast. If he is apprised of her circumstances, she being a complete stranger to him, does he have any moral obligation to fly from the West Coast to save her life. Nothing else can save her life. Still, Thomson is certain that she has no moral right to expect this of him, nor does he have a moral duty to provide this aid. But if Fonda did get on a plane and fly to her side to save her life, then he would be described as the proverbial "Good Samaritan" of the Gospels. By way of contrast, if by some chance he were visiting a friend across the hall in the hospital where Thomson was, and if Thomson’s plight were brought to his attention, and if refused to walk across the hall for a minute or two and just place his cool hand on her fevered brow, then Thomson concludes he would be open to legitimate moral criticism for failing to act as a "minimally decent Samaritan." He would not have violated her rights, nor would he have failed to carry out a strict moral duty. Nevertheless, his failure to respond would warrant legitimate moral criticism because he fell below a minimal level of human decency. What I want to explore is whether a similar sort of standard might exist within a family among siblings, for example, and whether such a standard can elucidate some of these genetic information issues. I Though it may not be obvious at the moment, I believe that the issues raised here are much more contextually complicated and require more contextually sensitive moral judgment than the generic case scenario raised in my Introduction might elicit. So I am going to offer three more concrete scenarios which might elicit those more refined moral judgments. Scenario 1. Imagine that Al has been given a serious medical diagnosis. He will die in several years as a result of a cancer to which he is genetically susceptible. Nothing can be done to alter his fate in this regard. However, if his younger brother is alerted as to his own risk, and if his brother Bob gets that test and the test is positive, then Bob will have medical options that would likely be able to forestall a terminal outcome for twenty years. (To be clear, it could turn out that Bob does not have the gene that would result in this cancer risk, which would mean he would have a normal life expectancy, all other things being equal.) Al and Bob have never been on very good terms, going all the way back to childhood. Outsiders would just judge that there was a basic personality incompatibility. One complicating factor is that Bob did defraud Al of ten thousand dollars several years ago. Bob did pay back what he had unjustly taken, but this still resulted in increased alienation between the two. Question: In spite of this family history, is it still the case that Al ought to share with Bob the genetic information he has acquired about himself? And should he do this because this is what a minimally decent sibling ought to do in these circumstances? Scenario 2. Charles has been given a cancer diagnosis with the same medical consequences as in our first scenario. He has the option of saving his younger brother Dan from this fate by informing him of the genetic risk to which he might be vulnerable. Charles and Dan have always been on good terms and genuinely care about one another. However, they do have very different religious commitments. Charles is a very devout and very conservative Roman Catholic. His brother is a liberal Catholic, the sort who believes that if he cheers vigorously for Notre Dame on a football Saturday he is excused from Sunday Mass. Charles would be happy to share his genetic information with Dan if he were certain that Dan would only use this information for his own personal benefit. But he knows that Dan is planning to start a family soon. If Dan were positive for the same genetic mutation as Charles, then Charles fears that Dan would use this information in making family planning decisions as well. Specifically, he is concerned that Dan would either have future fetuses prenatally tested for the mutation or take advantage of pre-implantation genetic diagnosis. In either case Charles sees here the possibility of, to him, the absolutely impermissible destruction of either fetal or embryonic life; and consequently, he is unwilling to share his genetic information with Dan. Question: Is it morally permissible for Charles to invoke both his right to privacy and his deep religious beliefs to justify not revealing this genetic information to his brother? Or must a minimally decent sibling share such information in this situation, no matter what their religious beliefs? Scenario 3. Ed and Frank are brothers. Their father had been a sperm donor several years ago. A child that resulted from one of these donations, Grant, has sought out and now found his father and his two half-brothers. Both brothers have recently had the above referenced genetic test. Ed is the older brother who is now faced with a terminal prognosis. Frank, as it turns out, had a negative genetic test. The question has arisen as to whether or not Grant ought to be apprised of these genetic test results so that he could decide whether or not he wished to pursue testing. Ed is opposed to saying anything to Grant. He has no brotherly sense of attachment to him, as he does with Frank, whom he informed within a week of receiving his test results. Grant is mostly a stranger to him. Ed might have some diffuse negative feelings toward Grant, linked perhaps to the circumstances of his birth and his "intruding" into their lives just now, though he would deny such feelings if asked. Question: Could Ed argue that the "minimally decent sibling" norm is irrelevant as far as Grant is concerned, and consequently, he is not open to any moral criticism? Ed does accept the legitimacy of the norm; it is not a phony philosophic invention. But he emphasizes that he met the requirement of the norm when he informed Frank about the genetic test results. Another wrinkle can be added to this scenario, Scenario 3b. Frank has warmed up to Grant and sees him as a good and decent person. He is ver y comfortable with the idea of accepting him as a brother. He personally feels that Grant ought to be told about the genetic test so that he could make his own decisions, but he is also sensitive to Ed’s feelings. Consequently, he has refrained so far from saying anything to Grant. Question: Is Frank open to justified moral criticism for failing to meet the requirements of the minimally decent sibling norm? After all, the relevant genetic information does not just "belong to Ed." Or is it morally salient that Frank only possesses this information now because Ed motivated him to obtain it by getting the relevant genetic test? II We said at the beginning of this essay that the problem here is more complex than might first appear. It would be helpful to tease out some of that complexity. Part of our initial moral problem clearly is linked to the fact that we are talking about "family." There is an assumption, often warranted, that we have more in the way of moral obligations to family members than we have to others who are just strangers to us. Before we consider what such obligations might look like, we need to take a closer look at this notion of family. We tend to think of the defining features of family in biological terms: parents, children, aunts and uncles, cousins, and so on. But if we reflect carefully, those biological connections probably carry very little in the way of moral weight in and of themselves. For example, Osama bin Laden is supposed to have nine wives and fifty children. Do we imagine that all fifty of those children have special moral relationships to one another, just by virtue of the fact that they have Osama as their father? Or should we judge instead that there are really nine families here? What sorts of considerations should push our judgment one way rather than the other? Because of divorce and re-marriage in the United States what are called "blended families" would be a very common phenomenon. Some of these families are "blended" in only the most attenuated sense. That is, there is very little in the way of a shared life or shared affection among the children who have different parents. From a psychological perspective they are mere acquaintances of one another. Other "blended families" may achieve extraordinar y degrees of intimacy among themselves. And, of course, there will be lots of degrees in between. What seems to be most morally salient is that individuals have heightened responsibilities for the well being of one another when they have shared in complex and intimate ways long stretches of their lives in the course of which complex relationships and expectations of mutual dependency would naturally emerge. This is not a very precise description, but my judgment is that the matter may not allow more fine-grained precision. If my brother needs help building a deck for his summer home, then he should feel comfortable asking me for help and expecting that I will respond positively, unless I have some serious conflicting obligation (my employer expects me to work overtime). Morally speaking, this is in the domain of bringing aid. Lots of other people may be building decks, but none of them may legitimately expect that I volunteer to help. If my brother carelessly failed to send me a Christmas card last year, which I found to be very annoying, that would not be sufficient reason for my refusing to assist him in building that deck. He would not have "a right" to my help, nor would I have "a duty" to provide that help. Still, given a background of good sibling relations with the normal ups and downs of such relationships, I "ought" to provide that help, which is to suggest that this is the sort of thing a "minimally decent sibling ought to do." There are lots of reasonable excusing reasons that would dissipate potential for any moral criticism connected to my not being available to help. However, my annoyance with being overlooked for a Christmas card would not seem to be one of those excusing reasons. I want to be clear that the comments above do not imply that there are no moral rights or moral obligations within a family. There are. Family members, for example, have privacy rights. They have the right to withhold from other family members information about themselves that they judge to be too personal or too intimate for a very wide range of reasons. Also, there are legitimate expectations of confidentiality within the family. Some analogies exist between the doctor-patient relationship and relationships within the family. Certainly our birth families require our living within close proximity of one another, which means in practice that some very intimate details of our lives will be known to other family members either because there is no practical way to prevent their knowing those details or because we choose to share those details with them in order to elicit emotional support or advice on ver y sensitive matters. Those matters requiring confidentiality can be pretty sharply delineated in the context of the doctor-patient relationship; the boundaries of those moral expectations are much fuzzier in the context of the family. For the most part (outside strict explicit requests for confidentiality within the family) we must rely upon keen moral sensitivity. With these introductor y remarks as background, let us turn to our first scenario. Al and Bob do not have amicable brotherly relationships with one another. If Bob were going to build a deck on his summer home, he would have no reasonable basis for thinking that Al, as a minimally decent sibling, ought to help him. Does that same logic yield the conclusion that Al does not have to reveal certain genetic facts about himself to Bob as a minimally decent sibling, even though the consequences of his failing to reveal that information would be the loss of many possible years of life for Bob? Al appeals to his right to privacy as the primary source of moral justification for his decision. But this does not seem to be sufficient for this justificatory task. There are numerous sorts of things related to myself that I might justifiably protect from discovery by others through invoking my right to privacy. I might be ashamed as a philosopher if anyone were to discover that I had received a grade of "C" in a college logic course. This might appear silly and trivial to most people but I would have a strong privacy right in this matter. Recognition of this right is easy because no countervailing moral harms to others can be readily imagined as a result of protecting this right. However, this is precisely what is not the case in our Al and Bob scenario. Bob is at risk of losing many possible years of life if this information is not divulged to him. If this were the whole story, this might not be sufficient to overcome Al’s presumptive right to privacy. However, it is morally significant in this case that there is no moral substance to Al’s right to privacy. That is, what he is asserting is a "bare right," a right that is essentially content-less in this context. Al cannot tell a story of personal humiliation if he reveals these genetic facts about himself, nor is he at risk for serious financial losses or loss of a job or health insurance or anything else comparable to those theoretically possible losses. Al has nothing at all comparable in the way of emotional fear to what I have with regard to someone discovering I received a "C" in that logic course. To be sure, some emotional feelings attach to that information for Al, but these feelings may be very problematic from a moral point of view. These feelings may have to do with revenge; Al may actively hope that Bob suffers the same fate that he is doomed to endure. In effect, Al is using his moral right to bring about potential harm to Bob. Al will argue, of course, that he is not harming Bob. If any harm comes to Bob, the harm will come from Bob’s own genetic constitution. Al had nothing to do with imposing that on him; that is just a natural fact about Bob. Instead, Al will say that he is simply failing to aid Bob, which he has no duty to do. This is where Al will argue the analogy exists with his unwillingness to assist Bob in building that deck. However, the moral dis-analogies seem glaring in that case. Al is not a unique source of free labor when it comes to building the deck. Bob can have other friends help him achieve that goal. Maybe Bob has not been very good at building a network of friends because most people do not trust him. That is regrettable, but nothing of moral consequence attaches to whether or not that deck gets built. The loss of possible life years for Bob is clearly something of moral consequence. Further, no one else is available as a source of this information. Al is uniquely positioned in this regard, even though that unique position came about entirely by chance. This now looks very much like an "easy rescue" situation. Al is not responsible for Bob’s risk to his future health, but he is uniquely positioned to prevent those risks of harm from being actualized. Further, no additional risks or harms accrue to Al in revealing certain genetic facts about himself. Moreover, this situation is not one that will repeat itself again and again in the future so that there is some aggregate burden that would be generated that might serve as an excuse. (If I give a panhandler a dollar so that he can eat, am I then morally obligated to give the next 10,000 panhandlers in the same situation a dollar each until I am reduced to being a panhandler?) This is just a one-time rescue effort. The fact that Bob defrauded him of $10,000 in the past (and made restitution) does not have any moral salience in the overall situation. The easy rescue is what matters. If Bob were drowning in seven feet of water and Al were the only one around who could rescue him, and Al was an excellent swimmer, then Al would not be excused from making the rescue because Bob had earlier defrauded him of $10,000. One thing that might not be very clear in this case is whether Al ought to rescue Bob "as a minimally decent sibling." We return to our Fonda story. Henry Fonda would be less than a minimally decent person if he refused to go across the hospital corridor to rescue Thomson by merely putting his cool hand on her fevered brow. She does not have SARS. She poses no risk to him. But we can imagine this other scenario. If Thomson were his sister, and if Fonda had to drive 100 miles to rescue her from death by putting his cool hand on her fevered brow, then he would be open to moral criticism for failing to be a minimally decent sibling, though my judgment is that he would not be open to moral criticism for failing to be a minimally decent person. So, in our actual scenario with Al and Bob it is not clear that sharing that genetic information is a matter of being a minimally decent sibling. It seems to be mostly a matter of easy rescue, what would be required of any minimally decent person. However we can say this much confidently I believe. If something is required of someone as a minimally decent person, then at least that much will be required of him as a minimally decent sibling. III We turn now to our second scenario. Charles and Dan are on very good terms with one another as brothers. But they have very different religious perspectives. What gives this scenario its distinctive character is that Charles has primarily religious reasons for not wanting to share his genetic test results with his brother. These are not the morally tainted reasons that seemed to be motivating Al. Still, the fact is that Dan is at risk for a serious harm that is preventable. Charles is the only one who is uniquely positioned to prevent that harm from occurring. What ought Charles do as a minimally decent sibling? There are several scenario variations we can consider. We can argue that Charles does not have the option of literally doing nothing, letting nature take its course and hoping for the best. That would not allow him justifiably to think of himself as a minimally decent sibling. He does care about his brother’s future health. He could explain to his brother in very nonspecific terms the moral dilemma that he sees himself faced with. He could tell his brother that he would reveal to him the very specific genetic information that he needs to know, but Dan would have to promise him one of two things. He would have to promise that he would have no children (or no more children). Or, alternately, he would have to promise that he would use neither prenatal genetic testing nor pre-implantation genetic diagnosis to avoid having a child who might have the same genetic defect. He would emphasize to his brother how important his religious/moral beliefs are in this matter. He would emphasize that he was seeking from him a sacred and irrevocable promise, since that is the only way in which he could be confident that he had not compromised his fundamental religious commitments. A case could be made that there is something morally illegitimate about trying to extract a promise of this sort. Prima facie, this looks like an unjust restriction of what would otherwise be Dan’s procreative liberty. Further, such a promise, made under something that looks like duress, might not be a "real promise," one that Dan would be morally obligated to follow through with. Charles could question Dan closely on this matter. He could explain to him that as a brother he would not expect him to use the tricks of casuistry to avoid following through on the promise. Further, the promise would continue to hold even after Charles had died. I need to put aside some of the moral issues that might be raised about this sort of promise since they would distract us from the main line of argument. Dan might think about this very carefully, knowing there might be serious risks to his own health for failing to agree to this promise. But we will assume that he refuses. If Charles has done this much, then I believe Charles would not have failed the norm of being a minimally decent sibling. He made a conscientious effort to compromise in order to prevent this future possible harm to his brother. But then we return to the "easy rescue" analogy. We might imagine this alternate scenario. Charles and Dan are brothers, Charles being the very conservative Catholic, Dan being very liberal. Dan is very vocal about his liberal ideas. He has insisted that today no one can be morally responsible in reproductive matters unless they have themselves genetically tested and then make appropriate decisions about the genetic endowment of their future possible children. That is, if they knew they were at risk of passing to their children a serious genetic disorder, then they should use pre-implantation genetic diagnosis to make certain that did not happen. Dan now finds himself very close to drowning. The only person available to save him is Charles, for whom the rescue would be easy and risk-free. But Charles will refuse to save Dan unless Dan promises that, if he has children, he will have them with whatever their genetic endowment happens to be. He must promise Charles that he will not destroy any fetal or embryonic lives in order to assure a better genetic endowment for his future possible children. My judgment in this case is that Charles would be open to serious moral criticism if Dan refused to make this promise and Charles simply allowed him to drown. This is an easy rescue. He has no right to extract a promise of that sort under these circumstances, even though it would seem that Charles’ religious commitments are at risk. But if this is so, then why does not this same logic apply in the prior scenario? The short answer I would suggest is that the "easy rescue" scenario is not as obviously true in both cases. Dan is genuinely at risk in the earlier scenario. There is, we will say, a 50% chance that he has the genetic mutation that would put him at risk for the same cancer. But even if he has the gene, it is, like BRCA1, a susceptibility gene. There must be other factors that would be necessary to achieve that causal result. Dan could be lucky, have the genetic mutation, but those other causal factors might never come together to yield a cancerous process. In other words, in our first scenario Dan is not correctly described as being imminently in need of rescue. Six months from now he could change his mind about making that promise and then be "rescued" by Charles. In the drowning scenario the need for rescue is as imminent as we could possibly imagine, and the promise would be extracted under obvious duress. Another variation we might briefly mention is this. We could imagine that Dan already has two children, but plans to have one or two more. The promise Charles wants to extract from Dan is that he will not reveal to those children that they might be at risk for these genetic disorders as well, unless they promise to have their children without any effort to alter their genetic endowment (if such alterations required the loss of either fetal or embryonic life). Here it seems to me that our moral intuitions are fairly clear. Dan does not have the right to make such promises on behalf of those whose lives could be affected in such a fundamental way, nor, for the same reason does Charles have the right to request that such a promise be made. Finally, there is an interesting possible twist we can make to our original second scenario. Pretend as if it is the case that Dan, the liberal Catholic, is the one who has the genetic mutation and is now likely to be faced with a premature death. Further, pretend as if both Dan and Charles are philosophically inclined. They like to argue with one another over matters of health care ethics. They in fact imagined the first version of this scenario. In the course of that discussion Charles asserted with all seriousness exactly what we described above. That is, he would extract this promise from Dan or he would deny him the information that might be necessary to save him from a premature death. This was just a philosophic conversation about a hypothetical scenario. As Dan reflects on it now, however, he is certain that this is precisely how Charles would react were the situation real. Having this thought, he now concludes that he will not inform Charles of the genetic risks to which he might be vulnerable as well. To justify this conclusion he reasons that morality is fundamentally about reciprocity, and he is morally certain that Charles would do exactly what he said he would do were the situation reversed. Dan sees this as a violation of reciprocity, and therefore he concludes that he is not open to moral criticism for failing to inform Charles of these genetic risks. Is this a correct conclusion? Or does this represent a violation of the minimally decent sibling norm? My own intuitions are that this would represent a violation of this minimally decent sibling norm. It is not as obvious as Dan believes that the reciprocity condition would be violated in this scenario. After all, Charles would be making an effort based in brotherly concern to save Dan’s life should he prove to be a bearer of this mutation. But he is doing that in a way that would preserve the integrity of his religious commitments. Dan has nothing morally comparable to those religious commitments that would justify his denying this genetic information to Charles. Instead he has as motivating factors for his refusal of something that is morally akin to what motivated Al in our first scenario. Al had suffered actual harm from Bob who had defrauded him of $10,000. Dan has suffered nothing comparable to that. Strictly speaking, Dan has suffered nothing more than hypothetical harm because Charles has explained to him what choices he would make in the course of a philosophic conversation. One could understand why Dan might be annoyed, hearing that from a brother about whom he had always cared. But even in that hypothetical conversation Charles had respectable reasons for his judgment. Dan has nothing more morally worthy than annoyance with his brother for his refusal to share. So that looks like it would fail the minimally decent sibling test. Further, this reversal of circumstances does not look like an actual violation of the reciprocity condition in our moral practices. The situations of Dan and Charles are not just reverse images of one another. IV We turn now to our third scenario (after we consider a prefatory scenario). The scenarios I have discussed so far are very simple two-person scenarios. This does not reflect the real world very well wherein there are ver y often multiple siblings and a significant number of other potentially affected family members. Consider, for example, a family in which there are six siblings. Steve is the affected individual with the genetic mutation, which will result in his premature death. He is the oldest in the family. He has very mixed relations with his other siblings. He has had very good relations with half of them and very unsatisfying relations with the other half. He decides he will inform his favored siblings of the genetic risks to which they might also be vulnerable, but he will not inform the siblings who, for various reasons, have incurred his disfavor. He has also extracted a promise from his favored siblings that they will not reveal what they have learned from Steve to the siblings that he disfavors. Is Steve open to justified moral criticism for failing as a minimally decent sibling? My judgment is that he would be open to such criticism. We can imagine many possible reasons for those siblings being in a disfavored position, everything from having annoying personality traits to perpetrating fraud against Steve, as Bob had done in our first scenario. But none of those sorts of considerations seem morally sufficient to excuse Steve from doing what he needs to do as a minimally decent sibling. Essentially the same analysis would apply to Steve that applied to Al in the first scenario. The feature that is added to the Steve scenario is that there are these favored and disfavored siblings. All, however, have grown up together and shared a common family history. Siblings may favor or disfavor one another more or less. This is a common phenomenon. It might be reflected in who gets a birthday present and who does not. There is nothing especially morally problematic about that because there is nothing of significant moral substance at stake in those matters. But this is not true in our scenario with the genetic risks. There is the possibility for the loss of many life years that do not have to be lost. Given this, Steve cannot play favorites with this genetic information without being open to justified moral criticism for failing as a minimally decent sibling. Our next question is how morally similar or dissimilar the Ed/ Frank/Grant scenario is to the Steve scenario. Grant is a half-brother who has only entered the family circle within the past year. Ed is the one who has the genetic mutation that will result in his premature death. He has informed Frank of these facts so that Frank can pursue genetic testing and find out what his own health situation is. But he is unwilling to inform Grant because he has no sense of brotherly attachment to him. Frank, however, has connected with Grant and feels a sense of attachment to him. How seriously should we take Ed’s argument that Grant is not a real sibling, and consequently, not entitled to any special moral treatment? My own intuitions are that we can dodge the issue of sibling status for purposes of determining what is the right thing to do. This looks very much like a matter of easy rescue, something that is rightly expected of any of us as minimally decent persons. Ed might insist on a right to privacy, as Al attempted to do in our first scenario. But this will be, as a practical matter and as a moral matter, a substantively empty right in this context. Ed has nothing to lose in revealing these facts about himself. There are no psychological losses, no financial losses, no morally significant losses whatsoever. But the information could potentially make a very large difference in Grant’s life. That Ed does not have any feelings of brotherly attachment to Grant is insufficient to excuse his failing to make this information available to Grant. This is what a minimally decent person should do. For the sake of argument, I ask the reader to accept this last conclusion. Where does Frank fit into this picture? He genuinely likes Grant. He does not want any unnecessary harm to befall him. He knows that Ed has indicated he has no intention of revealing this genetic information to Grant. Frank feels intuitively that he himself ought to inform Grant. After all, he rightfully has the information now. Further, it is not as if Ed is the "owner" of the family genome. Still, Frank respects Ed. They have had a long and loving relationship with one another. Ed has even bailed him out of a couple very difficult financial situations that could have had disastrous results. How could a minimally decent sibling go against what he knows to be the clear wishes of his brother in this situation? We might be tempted to think about this from the perspective of legitimate breaches of confidentiality. But my judgment is that this will not take us very far toward a satisfactory resolution. If we think about the Tarasoff case and its lessons, then the first requirement is that there be a risk of harm that is serious, imminent, and irreversible. It is not obvious in this situation that this condition would be met. The harm, if it materializes is serious (we will grant), but we cannot conclude that the harm is imminent. Further, the harm may prove to be reversible. That, of course, will depend upon the relevant facts, as they are revealed. Frank wants to be a minimally decent sibling to both Ed and Grant. If he were in Ed’s position, then he would be rightly expected to reveal this information to Grant as a minimally decent sibling. Does that all by itself warrant Frank in divulging that information to Grant? I think there is another alternative, which must be tried first. Frank needs to try to make a case with Ed to reveal this information to Grant. This might take several conversations and it might take a prolonged period of time. This seems to be congruent with being a minimally decent sibling. Ed does not have some exclusive right to this information. Hence, Frank would not be violating any of Ed’s rights if he simply revealed this information to Grant. But he should not do that straight out, as a minimally decent sibling. If it becomes clear to Frank that Ed is totally immovable in this matter, then the right thing to do is to reveal this information to Grant since Frank is now the one positioned to effect the easy rescue. In concluding this I am also concluding that Frank does not have the option of silence. That is, he cannot offer as an excuse for not informing Grant that this was contrary to Ed’s wishes since Ed’s wishes are morally flawed. Let me add one final tweak. If Ed had discussed this matter with Harry, a friend who otherwise does not know Grant, then Harry too should try to persuade Ed to see things differently. But if he failed, and if Frank is out of the picture for whatever reason, then I am less confident that Harry ought to reveal this information to Grant (and would be open to justified moral criticism if he failed to do so). That is (and this is all I mean to say), Harry is not in the position where he is rightly expected to meet the standard of a minimally decent sibling.

Karen Kovach Mercer University School of Medicine If one person may be said to have a moral duty to undergo genetic testing for the sake of another, or if she may be said to have a duty to reveal genetic information to another, such a duty would be a positive moral duty. It would also be what we might call an informational duty. A person may have a duty to seek information whether or not she wishes to possess it or she may have a duty to reveal information whether or not she wishes it to be possessed by others. One important difference between positive and negative duties—between duties to perform and duties to refrain from performing certain acts—is that whether or not a person may be said to have a particular positive moral duty—a duty to aid another in a particular way—depends on how difficult it would be for her to aid in that way. The standard illustration of this difference is a contrast case of two moral agents, one of whom pushes a small child into a river, another who fails to pull the child out. The person who has pushed the child in surely had a negative duty not to endanger the child’s life. What we are to say about the positive duties of passersby is famously less clear. Surely the fit swimmer seeing the child in a calm river has a moral duty to attempt a rescue. Just as surely an individual who is unlikely to succeed at the rescue and likely to lose his own life in the attempt has no duty to try to help in this way. But drawing the line between those who do and those who do not have a duty to jump in cannot be a simple matter. In the context of genetic testing, the "difficulty " would be that involved in possessing or releasing a particular piece of information. How difficult it would be for one individual to possess or to provide the information that would be useful to another will depend on the nature of the information and on the relevant beliefs, desires, and fears of the individual. Some people prefer not to know, for instance, whether they are likely to develop a particular disease; they prefer to live lives in which the state of their future health is epistemically open. Of those who already know significant facts about their own genetic makeup, some prefer to keep this information to themselves. We typically determine whether or not a moral agent has a particular duty to aid by looking at both the degree of difficulty for the agent and the importance of the aid to the potential recipient. (I will be assuming that the act at issue would indeed benefit the recipient, or, at least, that it would be reasonable for the potential agent to believe it would.) In some circumstances in which we might wonder whether one sibling may be said to have a duty to another based on their shared DNA, the difficulty of providing the needed information would seem to be minimal and the importance of the aid tremendous. Dora and Tina are sisters. Both plan to have children in the near future. Because Dora’s partner knows that he is a carrier for cystic fibrosis, Dora undergoes genetic testing to determine her carrier status. She learns that she too is a carrier. Tina is unaware of the increased risk that she is a CF carrier and will remain in the dark if she is not informed of Dora’s carrier status. Should Dora share this information with Tina? Without further details that would make sense of some extraordinary difficulty Dora would face in doing so, the answer would seem to be, of course. Dora would surely wrong Tina if she did not share information so clearly pertinent to Tina’s decision-making and potentially so significant for the well being of a future person. In a case such as this, we need not wonder whether siblings have special duties to each other—duties they have to each other by virtue of their relationship. The imbalance of burden and benefit together with the fact that Dora is uniquely placed to help Tina would seem sufficient grounds for us to say that Dora has an obligation to inform Tina. Strangers owe each other more when they are uniquely placed to provide assistance and we might think that they owe each other at least the very little that would meet a pressing need when that need can be met very cheaply. Because biological siblings share genes, they are uniquely placed to share needed information, and so we can account for many of the duties that siblings have to each other strictly in terms of ordinary moral duties. When, however, the potential benefit to one sibling is less important, or the difficulty for the other is greater, the question arises whether siblings have special moral duties based on their special relationship. I wish to explore the idea that siblings have special duties to each other and to begin with Aristotle’s account of relationships among friends and within families. While Aristotle surely did not have the expansive ideas that we may have of what constitutes a family, the fact that he locates his remarks on familial duties within his discussion of friendship tells us that he has in mind what is essentially a social and not a biological relationship. Of course, these often go together. We are often raised with those with whom we "share blood." But what is morally significant, according to Aristotle, is not the blood we share but the social relationship that is formed by people who develop socially and morally together. The Aristotelian account of friendship—a relationship formed through a lengthy process of shared thought and action, shared appreciations and deliberations that ideally arrives at and continues as a condition of perfect deliberative and evaluative agreement so thoroughgoing that it permits us to consider the friend an "other self "—provides, I wish to suggest, one way of understanding the moral significance of siblinghood. Aristotle thought that siblings were particularly likely to instantiate this kind of relationship. This is a bit surprising perhaps since sibling relationships, unlike most close friendships, are not voluntar y. Part of what explains the possibility of close friendships is the fact that friends choose each other. Not just any two people can reach a substantial amount of agreement on practical matters by thinking and acting together. When two people are too dissimilar to reach significant agreement on how to live, they may well see little point in continuing to share their lives. Reaching deliberative concord would seem to presuppose some likeness to begin with, so that the sharing of thought and action might begin in earnest. The relationship between siblings, while not voluntary, is one that develops as the moral personalities of the two individuals develop. Of course, siblings often develop in a very similar context—taught by the same parents, in largely overlapping periods of time, in the same social environment. They also, however, develop within the context of their shared relationship. They are often talking, planning, and acting together as they figure out what is involved in living well and as they begin to take responsibility for their own choices and actions. It is, I think, fair to say that to the extent that a sibling relationship fits this description, the siblings have reason to be grateful to each other. Each may be said to have a special duty to take an interest in the interests of the other and, in particular, a duty to support the other’s ability to make good choices. Admittedly, not all sibling relationships fit this description to any significant extent. Siblings who are raised together may not develop close, mutually concerned relationships. Some biological siblings hardly know each other or have never met. When siblings are raised together but do not form an Aristotelian friendship, it is possible all the same that a related debt of gratitude is incurred when children develop socially and morally, at least in part, by acting on each other. Children develop morally by making choices, acting on the choices they make, and witnessing the results of their actions. Since it is typically those nearest who are affected by these actions undertaken by the morally immature, it is frequently siblings who serve as the tools of our moral training. Because our siblings are typically only children themselves at the time of our moral development and because sibling relationships are constant and permanent, the consequences for them of our moral successes and failures can be enormous. In all cases of biological siblinghood, including those in which the siblings have never met, there is a sharing of at least one parent. This is not the place for an extended discussion of filial obligation, but insofar as we have duties to take into account the interests of our parents and insofar as it is reasonable to suppose that our parents take an interest in the well being of their other children, we have reason to take an interest in the interests of our siblings. I have suggested three reasons for thinking that siblings may have special moral duties to each other. In one or both of two ways, our siblings often play a significant role in our becoming who we are. Further, they are typically objects of concern for those to whom we are, it is widely thought, less controversially indebted. Of course, these characteristics may not all be found in every sibling relationship. Discord may as well as concord characterize a particular sibling relationship, and some individuals have little reason to be grateful for sibling contributions to their moral personalities. What follows from all of this is that when we ask, in any particular case, whether one sibling has a moral duty to obtain genetic information for the sake of another or a duty to provide genetic information to another, it may be necessar y to ask all of the following questions:

How significant would be the benefit for the recipient of learning this information? How difficult would it be for the agent to possess or provide it? Is the agent uniquely placed to aid her sibling in this

way? And, finally, • What is the nature of their relationship and how much more can we therefore expect each to do for the other?

Hilde Lindemann Nelson Michigan State University Many of the ethical issues surrounding the recent advances in genetic medicine are matters for public policy or involve general duties of physicians to patients. I am not going to talk about those. Instead, my contribution to this panel is to discuss the ethics that govern the interpersonal relations between brothers and sisters. I am going to offer a strategy for recognizing or assigning responsibilities that attach to sibling relationships, and then suggest ways to assess the credibility of that strategy. As our connections to our brothers and sisters are paradigmatically connections we haven’t chosen, they fall outside the scope of moral theories, whose purpose is to secure for individuals the greatest amount of liberty that is compatible with the rights or interests of others. Given medical ethicists’ long reliance on those theories to set informed consent at the ethical heart of the doctor-patient relationship, it is perhaps understandable that they have paid relatively little attention to the moral pull exerted by relationships that are indifferent to informed consent. But that attention must now be paid, not only because developments in genetic medicine increasingly give rise to ethical issues involving siblings, but also because of other medical advances, such as living donor organ transplantation, that put pressure on family members to make previously unthinkable sacrifices for one another. Just what responsibilities siblings have to or for one another depends, as it does in other contexts as well, on the nature of the relationship in which the responsibilities are situated. I do not mean anything very complicated by this: if you are my student I am supposed to teach you, rather than, say, to feed you; if you are my literary agent, you are supposed to find me a publisher rather than sell me a house. As these examples indicate, the responsibilities inhering in many relationships are perfectly straightforward and widely understood, for the roles that constitute the relationship bear socially shared meanings, while the norms that govern those roles are likewise socially shared. Consensus is useful, where it exists, because it shows us what we are expected to do and how we can expect others to treat us—it allows us to make sense of how we live in moral community with others. Responsibilities are perhaps most clearly understood in relationships that can be entered and exited freely, where contracts can be drawn up that spell out who is responsible for what, to whom, and that stipulate the penalties to be incurred for nonperformance. Matters are not quite so straightforward, however, for nonconsensual relationships, except in the case of parents and their dependent children. There is growing moral agreement in many segments of society that fathers should support their offspring whether or not they consented to the child’s existence, while the norms governing mothers range over everything from what they must or may not ingest during pregnancy to how clean they must keep their houses when their children are half-grown. But when we move from the domain of diapers and hockey practice to that of adult children with elderly parents, there are sharp differences of opinion in the ethics literature as to whether any responsibilities exist, and by the time we arrive at adult sisters and brothers, the philosophical conversation consists mostly of long silences. There is, to be sure, a shared sense that our siblings have a greater claim on us than strangers do. The fact that the person in trouble is your brother is a reason for you to help him. But just what that help should consist of is indeterminate—there does not seem to be any settled social understanding about how much help is enough, or how long it should be provided. As the standing moral theories cannot offer much guidance here, I argue that the best way to make sense of our moral responsibilities to our brothers and sisters is via a detailed description of our relationship to them. The description of that relationship is best understood as a narrative description, because it selectively represents morally relevant acts, incidents, and other features of the siblings’ shared history, weighting the features according to their relative importance and tracing temporal and causal connections among them. The story’s accuracy rests on its following the moral shape that the relationship actually has, and it is the persuasiveness of the story that justifies, or fails to justify, whatever action the sibling now proposes to take.¹ The fact that you and I are children of the same parent might make it reasonable for you to depend on me for something and reasonable for me to believe that you do in fact depend on me for that thing. It is then morally important for me to acknowledge our history, the present state of the relationship, and our possible or probable future together, because the relationship shows me what I owe you, why I owe it, and whether I have any latitude in how or when I discharge my obligation.² The backward-looking stories of my relationship to you can show me not only what I owe you but also how we got into this situation where something is owed. Sideways-looking stories can show me who else has responsibilities here, who will be affected by what I do, and the nature of the context in which I do it. And forward-looking stories display the possibilities for how, or perhaps whether, you, I, and others will go on in the future, and what that going on will mean for all of us. Let me show you what I mean by telling you a true story. I have a half-sister, whose existence I knew nothing about until I was eighteen years old. At that time, my father told me that he had been married before—to a woman he met, courted, and wed one summer when he was doing philological research in Austria in the late 1930s. The woman spoke no English, so when he brought her home to the United States that autumn he invited his mother, a German-speaking immigrant, to share their household with them and provide companionship for his wife. Soon afterward, he returned home from work to find that his wife had thrown a plate at his mother in the course of a violent quarrel with her. Mother and son talked it over and concluded that the young wife’s behavior was becoming increasingly erratic—so erratic that my father began to make inquiries among his wife’s friends in Austria. From them he learned that her father had died of drink and her mother was confined to an institution for the mentally ill, and when he taxed his wife with this she confessed that she had not told him for fear that he would refuse to marry her. Believing that her family was tainted with hereditary insanity and determined to keep his own lineage pure, he divorced her forthwith and sent her back to Austria. She was pregnant at the time. I do not know whether my half-sister survived the war, or if she is still living. But now let’s suppose something that is not true: that the genetic tests available now were available in the 1960s, when she and I were of childbearing age. Let us imagine that after I suffered several miscarriages, testing revealed that I have a balanced translocation—a condition in which the correct number of chromosomes are present, but two pieces of chromosomal material have switched places. This means that while I looked and felt perfectly healthy, there was a good chance that I might start a baby with an egg that had a normal chromosome and a translocated chromosome—an unbalanced translocation. Because there is then an extra portion of one chromosome and a missing portion of the other one, the fetus would have had extra or missing genetic information, and this could have led to severe birth defects, including serious mental deficiency. That ironic predicament would, of course, have put paid to my father’s efforts to keep his lineage pure. But my concern here is for my half-sister. Knowing that she might also be in danger of giving birth to a catastrophically impaired child, would I have had a duty to find her and warn her? The question cannot, I think, be answered by simple appeal to a principle such as beneficence or even by invoking the Tarasoff criteria. Too many other considerations are morally salient—especially the ones that have to do with my relationship to her. I have already told you the backward-looking stor y of that relationship, which picks out a number of considerations against seeking her out and letting her know. I was not sure she was alive, or where in Austria to start looking for her. She would in any case have been a few years older than I, so she might already have borne a seriously impaired child. Or perhaps her own translocation was unbalanced, and she herself was severely affected. Then too, there is the story of who I was, which would have twined around and through the story of my relationship to my sister. My story would, for example, have included the fact that I had little money to finance such a quest and that my father would almost certainly have refused to help me. But these stories do not yet, by themselves, reveal the full moral shape of the situation. To see that shape clearly, we have to add the sideways-looking story of my relationship to my father. When he told me that he had cut off all ties with his child, he showed no remorse, nor did I ever have any sense that he was ashamed of what he had done. Indeed, his sole reason for telling me about his former wife was to teach me that I must never to marry in haste. But that is not the lesson I learned. I learned instead that a wrong is compounded when its perpetrator refuses to acknowledge having done anything wrong. And that knowledge made me feel doubly responsible to my sister. I thought then, as I do now, that the fact of my being my father’s daughter is a reason for me to do what I can to make amends for what he did to her. It is a reason I have never acted on. Too many other responsibilities, too little information, never enough money to embark on the search. But had I had a balanced translocation I do not think, in the face of what my father had already done to her, that I could sit idly by without warning her of the danger to herself. The question that now arises is whether my version of the story is the one that should have guided my actions toward my sister. If my father, for example, were to tender his version of the story, surely it would differ from mine in many crucial respects. When stories conflict, which one should we believe? How can we judge whether a given stor y has accurately captured the moral dimensions of a particular relationship? Stories are, after all, selective in what they depict. They leave out certain details while emphasizing the importance of others, so there can be serious disagreements about whether they accurately represent an actual state of affairs. I think, though, that narrative descriptions of a moral situation can be assessed for their accuracy in the same way that we assess other descriptions, using the ordinary standards that competent people employ. If, for example, I am an architect and I describe a building to another architect, she can assess my description by looking at the building herself. Then, if we disagree about what we see, she can point out certain features I have overlooked, I can argue that she has missed something important about the overall shape of the building, and so on, until our corrected and augmented joint description satisfies us both. Or, if it does not satisfy us, we at least have a better understanding of what the other finds important that we do not. Because moral perception is no more mysterious or exalted than other kinds of perception, I submit that when morally competent people disagree about the shape of a moral situation, they too have to look at it again and describe it narratively until each understands what the other is seeing. My story is an unusual one, and it could be argued that its exceptional character is not a good model for thinking about what siblings ordinarily owe one another. But this objection misses the point. In the absence of any determinate social consensus regarding the content of, and limits to, sibling responsibilities, we must look to the particularities that inform the relationship—the respective ages, social circumstances, whether and how the siblings were reared together, and the nature of the personal relationship. A detailed and nuanced narrative depiction of those particulars can serve as a reliable guide to action when brothers and sisters need to sort out their conduct toward each other.

Felicia Nimue Ackerman Brown University When Peggy read psychology articles in magazines, what struck her was how little the authors seemed to know about human nature, or at least about hers. Envy, for instance, was treated as a sign of insecurity, a problem to be solved. No one suggested that envying someone who succeeded where you failed was as reasonable and appropriate as shielding your eyes from the sun. At first, she had only disliked Natalie. Natalie was sharp-tongued, sharp-witted, and alarmingly intense about philosophy. Her ideas rushed out as though escaping from jail, and she would glare impatiently at anyone who took too long to respond. All her thought processes seemed instantaneous. "She probably even sleeps fast. She probably never daydreams," Peggy had told Dwight, and they ’d spent the afternoon speculating about all their friends’ fantasies. Then Dwight became Natalie’s thesis director. Peggy flunked out of the program. Natalie took to calling Dwight at home about her work, and one evening at dinner he told Peggy the philosophy department might be offering Natalie a job. Peggy’s mind began to slip around, as it was apt to under pressure. (This was one reason she had disliked taking examinations.) Now she was considering yellows: the bright chrysanthemum centerpiece she had picked from the garden, the paler yellow kitchen walls, the rich yellow-brown of Natalie’s hair. Natalie wore it in a great bun at the nape of her neck, pulled straight back from a face that seemed almost ethereal and romantic until she opened her mouth. "You mean she’ll be calling all the time for the rest of our lives?" Peggy said. Dwight pushed back the hair that had fallen across his forehead: thick, shiny hair, black as a cat’s. "I can tell her to stop phoning here if you want," he said. His voice, as always, was soft and measured. "I wish you would," said Peggy, and cut herself an extra-large slice of chocolate chiffon pie. Magazine articles also said anxiety made you want to overeat, but Peggy always wanted to, anxious or not. Dwight had laughed when she told him about one piece she’d read on the causes of obesity—the author hadn’t even mentioned that fattening foods tasted good. "You really want her to get the job, don’t you?" she asked, thinking: what a stupid question, before it was halfway out. Dwight was always saying that when it came to philosophical discussion, Natalie was practically the best person he knew. "Sure," said Dwight, "for her sake and for ours." "Our . . . oh, you mean the department’s." "She’s so original, not everyone sees how good her work is," Dwight continued, "so I’m afraid she’ll end up at a second-rate place that won’t give her much time for research, and we’ll end up compromising and hiring someone safe. Don’t worry; I’ll tell her to stop calling," he added after a moment. "You come first, of course." His eyes were heavy-lidded, remote, almost as if he were avoiding Peggy, but that was just how his eyes naturally looked. He had the longest lashes she’d ever seen on a man, a high-school girl’s dream. *** The next day, when Peggy awakened, over half the morning was gone and so was Dwight. Ten-thirty, said the blue enamel clock on the night table. That was her compensation for not working or being in school. She could get up when she wanted, do what she felt like, read anything she pleased, and not get graded on her ideas about it. Today she was going to finish Vanity Fair (no time for books like that last year), then drive to the beach at Santa Cruz. Or maybe reverse the order, finish the book on the beach. She looked out the window at the gleaming day, and got out of bed to run the water for her bath. An hour later, she was eating a tootsie-roll pop and pulling out of the driveway in her red Stingray, the most unacademic used car she’d been able to find the month after her career ended; let them think she’d chosen not to be one of them. Now the car embarrassed her a little, but it was exciting to drive and she wouldn’t consider trading it in. She switched on the radio, and a thick male voice slithered into the air. "Do it for yourself and for the loved ones in your life." Just taking it for granted that you and your loved ones wanted the same thing. The song turned out to be a part of a message about blood-pressure pills. As if doing it for yourself wouldn’t be reason enough; you’re nobody till somebody loves you? Unless you were a big success, of course, the way she once thought she might be. The way Natalie was going to be, maybe, if she got the job. She’d started the graduate program five years ago along with Peggy, and now she might be on the faculty soon. Did she ever wonder what Peggy was doing these days? Maybe tonight at the Kramers, Natalie would ask, —And what have you been up to, Peggy, since you, er, left school? —Well, let’s see. I drive around in my beat-up old Stingray. I take my cat to cat shows where she never wins any prizes. I lie on the beach and read nineteenth-century novels, not to mention piles of mysteries and magazines. I make chocolate chiffon pies and double the whipped cream; you should like that, Natalie. Want a piece? Impressed? I changed the recipe all by myself. And that, of course, was the catch to no school and no job: most people considered you pretty useless, most people including yourself. Sometimes Peggy wished she were back in Salt Lake City, where not being a Mormon had been enough to make her count as accomplished, intellectual, sophisticated, and daring. But Utah had no ocean. And if she hadn’t come to Stanford, she never would have met Dwight. Would he move to Utah now if she wanted, do it for her? He could get a job at the state university, she was sure, and he once told her he’d be willing. But he must have known he was safe, because she didn’t really want to go back. She wanted to stay in California, where she could go to the mountains and the sea on the same day, in the perpetual spring. ***