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Complexity, uncertainty and potentiality in the euthanasia debate

Complexity, uncertainty and potentiality in the euthanasia debate

by Margaret Somerville | October 23, 2017

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A journalist once asked me what I thought would be the major issues for ethics in the future. I responded, spontaneously, with three words: “complexity; uncertainty; potentiality”. My statement surprised me, as I had no idea where it came from or even what it might mean in relation to ethical analysis. Since then, I’ve pondered the latter.

I believe that when engaging in ethical decision making, if we expressly search for and find complexity, uncertainty and potentiality, these are warning flags that identify situations in which we are facing difficult ethical issues. Situations that have any one of the characteristics need a high level of ethical sensitivity. Situations that have all of them need an extremely high level. Deciding whether to legalize physician-assisted suicide and euthanasia is such a situation. (I will use the word euthanasia to include physician-assisted suicide.)

Uncertainty

First, in ethical decision making, we need to be conscious of the dangers of false certainty. To avoid this, we have to incorporate into our decision-making structures an ethics of uncertainty, that is, an ethics of how to deal ethically with uncertainty.

Many ethical mistakes are made because the decision makers, especially professionals, politicians or advocates for a cause or ideology, are often extremely uncomfortable with uncertainty. They see admitting to it as necessarily harming them, for instance, by losing them votes or support for their cause.

They try to eliminate the unavoidable uncertainty by converting it to certainty, but it’s a false certainty. For example, pro-euthanasia advocates’ claim that there is no abuse of euthanasia in the Benelux countries is at best a false certainty (and at worst a falsehood), as is their claim that its risks and harms can be controlled through “safeguard” regulations. That these claims are wrong is ethically relevant beyond just their inaccuracy, because good facts are necessary for good ethics, and good ethics for good law.

The “do something” syndrome, the belief that doing something is always preferable to doing nothing, is also often operative in situations of uncertainty, especially when those situations also involve fear and anxiety as dying and death often do. In particular, politicians are seen as weak and ineffective if they do nothing, as compared with strong and effective when they act, even if doing nothing is the ethically indicated approach.

So, we hear many heartbreaking stories from pro-euthanasia advocates, who include politicians, of the terrible suffering endured by some people’s loved ones at the end of their lives, their feelings of helplessness to remedy this situation and pleas to “do something”, namely legalize euthanasia and provide it. The preferable alternative of making sure everyone who needs it has access to high quality palliative care, so as to make euthanasia unnecessary, is ignored.

Pro-euthanasia advocates are very reluctant to admit that euthanasia has resulted in “slippery slopes” – the extension of access to euthanasia or its abuse if legalized – in the Netherlands and Belgium, but proclaim their certainty, if that is correct, it will not occur in Australia, because “we are different”. They are almost certainly wrong as recent reports from those countries and now Canada, after just over a year of legalization in the latter country, show. Indeed, as Australian advocates themselves have admitted in their more candid moments, at first they hope just to open the door to euthanasia a crack in order to be able to open it far more widely later.

“Safeguards” for euthanasia being proposed in the Victorian bill include that the person is likely to die within the next 12 months, but life-expectancy predictions are notoriously inaccurate. Consequently, an important issue in deciding about legalizing euthanasia, is whether this uncertainty can be quantified and effectively communicated, and what is ethically required in this regard.

Considerations include whether accurate descriptions of such uncertainty can be conveyed to those who will be the decision makers about legalization and, if legalization occurs, to patients, families and healthcare professionals in making decisions about euthanasia. We must also be aware of the danger that language can be deliberately chosen in order to conceal such uncertainty.

A major uncertainty for some people – perhaps a majority – in the context of dying and death is what happens to us after we die. Many people of faith are certain that there is an afterlife which they will experience. Atheists, by definition, are certain there is nothing, that death is the end of their existence. Many people are agnostic, that is, not certain. Such uncertainty can elicit intense fear and free-floating anxiety. Is offering the person a way to end their life an appropriate and ethical treatment for that?

Complexity

In deciding whether to legalize assisted suicide or euthanasia, we need as well to be conscious of the dangers of being simplistic; in other words, we must also build into our decision-making structures an ethics of complexity,  that is, an ethics of how to deal ethically with complexity.

As our ancestors were much more aware than we seem to be, dying is not a simple, straightforward or easy experience or process. They responded with “ars moriendi”, the art of dying, which reflected a belief that we could prepare for death and learn to die well. In contrast, euthanasia strips death of any mystery, converts it to a problem and presents a technological solution, a lethal injection.

Dealing appropriately with complexity and uncertainty are related, in that when we are reasonably comfortable living with unavoidable uncertainty, we are much more at ease in recognizing complexity and behaving accordingly.

It also merits noting that some decision-making processes are designed with a specific goal of allowing us to deal as well as possible with ethical complexity and can allow us to do so better than we otherwise could. Some of these aids in decision making are quantitative and more objective and others qualitative and more subjective, but none of them give “perfect” ethical answers and there is a danger in assuming that they do.

Potentiality

In deciding about legalizing euthanasia, we must also be conscious of the dangers of not considering the impact our decisions will have in the future and on future generations. That requires us to also build into our decision-making structures an ethics of potentiality, that is, an ethics of how to deal ethically with potentiality.

We must ask questions such as: What do we owe to future generations? What must we hold in trust for them? If we legalize physician-assisted suicide or euthanasia now, in one hundred years’ time, how will our descendants be treated and what will their society look like, especially its values, political climate, institutions and “ethical tone”?

As I’ve written elsewhere, traditional wisdom tells us to respond to questions like these, among other ways, by looking back seven generations – examining human history, better called “human memory” - and employing what we learn from this to look forward seven generations using our human imaginations. I believe that if we do this open-mindedly, honestly and with integrity, we will decide legalization of euthanasia would be a cataclysmic mistake.

Margaret Somerville is professor of bioethics in the school of medicine at the University of Notre Dame Australia. 

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