Continuing my series of responses to the New York Timesâ€™, The Ethicist, without imposing values, here is my take on todayâ€™s post, â€œCan Dad Bring His Second Wife to Momâ€™s Funeral?”
My question is whether itâ€™s appropriate for Woman B, who broke up Woman Aâ€™s marriage, to attend Woman Aâ€™s funeral.
My dad planned to bring his second wife, with whom he had an affair before he left my mother (after 35 years of marriage), to my momâ€™s funeral. I thought it was inappropriate for her to be there; my mother disliked and resented Woman B for the rest of her life, even though my mother eventually remarried. To me, it seemed wrong that Woman B be among the many people at the service honoring my mom.
When I told my dad as much, he passed it on. Apparently Woman B felt â€œhurt and confused,â€ to the point that my dad didnâ€™t attend the funeral, either, even though he and my mother had established a cordial relationship over time. My dad has called me just once since the funeral to ask me to explain my reasons again so that he could help Woman B understand. The rift between us has grown to the point that he and Woman B canceled Christmas dinner with my brothers and me and our children.
I actually feel sympathy for my father, because I think Woman B is making him choose between her and us. I believe she should have understood the sensitivities of the occasion and let Dad be with his children to honor their mother and his first wife. We have tried to have a good relationship with Dad and Woman B over the years, but this was one occasion when I felt she just didnâ€™t belong.
Itâ€™s uncomfortable having my dad be unhappy with me, but I have held my ground, because I think I did the right thing by my mother. As her second husband said, she wouldnâ€™t have wanted Woman B there, and that was good enough for me. Was I right or wrong? Name Withheld
My response: At the top level you ask about appropriateness and right and wrong. B and your father thought it appropriate and right, or at least not wrong. You thought it inappropriate and wrong. The opinion of a newspaper columnist won’t change that you’re asking opinions and that there is no absolute measure.
You say B broke up the marriage, but your father left your mother, not B. Do you consider B responsible for his behavior? If you feel one person can be responsible for another’s behavior, what role did your mother have in his leaving? Or if not, why not hold your father responsible for leaving your mother? Was he powerless to resist B’s control? Is it possible you didn’t understand the dynamics of the various relationships?
In any case, I suggest that instead of labeling a past you can’t change with abstract philosophical concepts, you focus on things you can do, like improving your social skills to improve the relationships among the living and improving your self-awareness and other emotional skills so you can tell what “improve” means for your relationships, and so you can handle your emotions.
Can you accept that people with different values can differ on what they consider right and wrong and still have mutually rewarding relationships? Can you do so in this case? Or do you prefer to cut ties? Either way, can you keep yourself happy? Can you understand other people’s perspectives without imposing your values on them?
In short, I would focus on what you can do today, and developing relevant social and emotional skills, than imposing your judgment of the past on others.
The New York Times response:
Funerals are not occasions at which people are at their rational best. You felt that your mother wouldnâ€™t have wanted your stepmother at the funeral, and you said so. Did your stepmother not know that your mother continued to resent her? Or that, as your letter suggests, you do, too? If so, I can see why she might have been upset to discover this. You might consider the possibility that you were not at your rational best, either. I wonder if you had quite come to terms with your fatherâ€™s new life, and whether you weighed his feelings enough when you spoke up. Still, once your stepmother discovered that she was unwelcome, I agree that she should have encouraged your father to go alone. Even if she thought it unkind or unwarranted to ask her to stay away, the feelings of the bereaved deserve respect.
She might have been hurt not just by your having made it clear that she wasnâ€™t welcome but also by your fatherâ€™s desire to go. She may still feel guilty too about her role in the breakup of your parentsâ€™ marriage, which makes your resentment to some degree justified. I would ask your father to convey to her that you hope sheâ€™ll come around and that you can understand why she was hurt by the decision to ask her to stay away. If she cares about him, sheâ€™ll probably come to see that she shouldnâ€™t stop him from interacting with his children.
As new psychiatrists in an inner-city clinic, we face an ethical struggle. Insurance companies require â€œprior authorizationsâ€ with lengthy forms absurdly accepted only by fax, or endless phone calls, or they wonâ€™t pay for newer, costlier medications.
We spend hours campaigning against discriminatory insurance practices, hours that could be better used to provide psychiatric care to patients who canâ€™t access it elsewhere because of critical shortages. After 25 years in practice, our supervisor, Dr. Claudia Baldassano, feels ill equipped to guide us in practicing in an increasingly adversarial and resource-starved system.
Prior authorizations create perverse incentives for doctors to change their prescription choices to avoid wasting hours on paperwork. Should we prescribe cheap medications with bad side effects or less effective medications to avoid prior authorizations so we can see more patients? Or should we push for the best medications for fewer patients and leave others without care? Drs. Claudia Baldassano, Behdad Bozorgnia, Lisa Jacobs, Katherine Riva, Puneet Sahota, Elyse Smolcic and Ashley Un, The Bipolar Disorders Clinic, Department of Psychiatry, University of Pennsylvania School of Medicine
My response: No absolute right answer exists or you wouldn’t have written. You describe a system you didn’t create. Since we don’t live in an Eden or have manna falling from the sky when necessary, limited resources mean that life involves situations where values conflict and you have to choose among them.
Within the system you describe, you can choose a policy of choosing case-by-case, by a blanket policy, a mix, or some other method. Case-by-case may optimize for each case but take more time relative to a blanket policy. Such are the challenges of operations. Your business is no different from others in this regard. Labeling your choices as ethical doesn’t change that you have the same decision-making challenges of anyone else with finite resources.
You can also look at the system or outside it to see how you can influence it. Here you may find more solutions, though I doubt you’ll be able to get all the medications you want for all patients. I suspect, instead, that you’ll reach the same dilemma eventually, though being able to help more patients.
Since your question was what you should do in such a situation, I won’t help create options to expand the pie, even though I consider that effort will help more people. I believe that you’re not asking questions that will help you most, but I’ll simply state my belief that you’ll never get away from having to find ways to distribute limited resources. I’d work on changing the system and improving my skills to do so. Also, to manage my emotions to maximize my effectiveness and happiness.
The New York Times response:
The choice that the insurance companies are confronting you with is indeed unenviable. On one hand, you can give each patient what you think is best for him or her. On the other hand, you can treat more patients but not do whatâ€™s best for them. Unenviable, though, does not mean irresolvable. The fundamental obligation of a doctor is to the patient he or she is dealing with at the time. Thatâ€™s what patients are entitled to. Only the first option is acceptable. Imagine how you would feel as a patient if your doctor said to you, in effect, â€œIâ€™m going to give you a drug with bad side effects, rather than one without, so that I can see another patient.â€
You might object that Iâ€™ve just enunciated a principle that rules out the practice of triage in the emergency room. There you donâ€™t get the best treatment you could get, in some sense, which is immediate treatment, because the doctor is going to attend first to a patient who is worse off than you are. In triage, though, what happens is delayed treatment, not treatment that is otherwise inferior. Of course, sometimes delay is bad treatment: with an accident victim, say. But if youâ€™re one of two such victims, the doctor may say, â€œIâ€™m going to give you the treatment you require, but first I have to attend to someone whose need is greater.â€ You wouldnâ€™t be happy to hear it, but youâ€™d understand.
Thereâ€™s a division of labor here between the perspective of the individual doctor, loyal to each patient, and the public-health perspective, which can trade off between the interests of individuals to maximize the aggregate welfare of the whole population. Itâ€™s outrageous from a public-health point of view that we donâ€™t have the clinical resources to meet the legitimate needs of all patients. You and your professional colleagues, given everything you know, should press your concerns with public officials and political representatives. But ultimately itâ€™s our problem â€” societyâ€™s problem â€” to deal with, not just yours.
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