Why shouldn’t ‘examined emotions’ have a role to play in bioethics?

With the enactment of Voluntary Assisted Dying (VAD) legislation in the Australian Capital Territory (ACT), euthanasia has now been legalised across Australia, except for the Northern Territory, where it is pending. If we believe that euthanasia is unethical and a very unwise idea, what might we be able to do to reduce its use to the minimum possible?

The primary requirement is to have fully funded, excellent quality, readily accessible palliative care, which is offered and available to all who need and want it. Reprehensibly, Australia, like some other countries, is falling far short of this goal.

Might there, however, be other, not so obvious, approaches we can take? I suggest teaching a comprehensive, in-depth bioethics program to medical students is one such way.

Together with colleagues, I am teaching bioethics to 165 first year medical students at the National School of Medicine of the University of Notre Dame Australia, Sydney campus. A recent teaching experience reinforced my long held belief that in “doing ethics in practice”, especially medical practice, our choice of words matters, and what I call “examined emotions”, in contrast to mere emotionalism, is an important “human way of knowing”, especially about ethics, and that these two elements of ethics decision-making – word choice and examining our emotions – are connected.

Here are the stories that precipitated this article

Monday afternoon: Bright-eyed, bushy-tailed first year medical students sitting in a large lecture theatre are asked to comment, via an app on their iPhones, on their classes in bioethics:

Many students are concerned about the way some sessions are conducted: Use of emotionally loaded language … [for] example… ‘Lonely, Abandoned Human Embryos’ title in Bioethics Workshop 5

This “emotionally loaded language” to which the students strongly objected, is the title of a short, solicited article I published and a lecture I gave to them on ethical issues in IVF and human embryo research, which included what ethics should guide our treatment of so-called “left over or spare” frozen embryos from IVF treatments. It was intended to remind us that human embryos are living human beings and that we are all ex-embryos, in order to elicit a feeling of personal connection to the embryos in making decisions about their fate. Paradoxically, the student complaint shows that the title was effective in achieving this outcome.

The students – and remember these are future doctors – express similar objections to describing euthanasia as “doctors inflicting death” or, even more so, “doctors killing their patients”. Reality regarding VAD is not always welcome in the context of the ethics of end-of-life decision-making and euphemisms are very common and diverse. A doctor or nurse practitioner administering a lethal injection or providing a patient with the means to commit suicide is referred to as delivering “a merciful act of good clinical care”. Who could object to that?

A related issue is the use of definitions to sanitise euthanasia, in particular, characterising it as “medical treatment”, which, in my opinion, it is not. Putting the white coat on euthanasia by having doctors provide it confuses people as to its fundamental nature.

Moreover, arguments against the need to respect objecting doctors’ rights to freedom of conscience on the grounds that they must provide all legal medical treatments including VAD, or that patients have a right to all legal treatments, flow from this characterisation, as do claims that all healthcare institutions must provide VAD. Note arguing VAD is not medical treatment does not, in itself, mean it is unethical.

Prohibiting doctors from listing VAD as the cause of death on a Medical Cause of Death Certificate, as in the Western Australian VAD legislation, is an obfuscation of the use of VAD that raises a host of ethical issues. But might it show a discomfort with the ethical acceptability of a doctor intentionally inflicting death on a patient? Or, likewise, does it reflect families feeling conflicted about their loved one dying by VAD and not wanting others to know this?

Words matter in ethics because, depending on which we choose to use, different emotions can be elicited and that can affect our decisions as to what is and is not ethical.

 

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We ignore our feelings at our ethical peril  

Tuesday morning: I listen to a live interview on ABC Radio National with an Australian surgeon just returned from providing medical aid in Rafah.

He describes the unspeakable horror of a 12-year-old boy hit in the abdomen by a large piece of shrapnel, his penis, bladder and rectum blown off, his intestines spilling out and, despite surgery, dying with nothing to relieve his extreme pain except Panadol.

I had great difficulty continuing to listen to this doctor’s horrific story but forced myself to do so. It is important that we face reality, especially when decisions about ethics are involved, as they are in all wars.

Physician-ethicist Dr Leon Kass advocates “the wisdom of repugnance”, we must probe our “Yuk Factor “emotional responses, overcome our “I cannot bear to know that” reaction, for the ethical wisdom they can carry and communicate.

“Examined emotions” are an important “human way of knowing”, especially in ethics decision-making in medical practice. They are humanising instruments: we see the suffering other as a fellow human and ourselves in their shoes – that is, with compassion. Pro-VAD advocates and doctors who provide VAD genuinely believe they are acting compassionately and ethically to relieve suffering, but as a wise palliative care physician once explained to me, “There is a vast distance ethically between wishing that someone would die and making them dead”.

“Examined emotions” are safeguards against “malignant normalisation” – unethical conduct metastasizing – spreading - and becoming seen as ethically acceptable through familiarisation. And they are safeguards against “malevolent normalisation” – we knowingly accept unethical conduct as ethical to achieve certain goals.

An example in the healthcare context is some American private medical insurance companies have refused payment for expensive cancer treatments, but instead offered payment for physician-assisted suicide at a fraction of the cost.

Governments are also concerned about future costs of public healthcare insurance schemes, in particular, with an aging population. On average, people use 50 percent of their lifetime healthcare costs in the last six months of their life. Might VAD present a temptation to eliminate this period? Canadian academics have calculated a saving of at least C$140 million dollars a year for Medicare, the government funded Canadian healthcare scheme, from the legalisation of MAiD.

The pro-VAD case is littered with euphemisms, which, I suggest, shows the ethical discomfort of its advocates with what they are promoting. But they suppress that discomfort or override it by rationalising that the patient wanted to die, is no longer suffering, and is deeply grateful to the doctor, who feels he or she has done a worthy, compassionate act.

In contrast, there are Canadian doctors who signed up to provide euthanasia, did it once, and then removed their name, saying they could never do it again. Might the reality of what they were doing and their emotional response to that, have made them question the ethics of it?

This raises the issue of how the doctors who specialise in euthanasia and do many hundreds of cases  (indeed, some do no other medical procedures), cope with their emotions? Do they suppress them or respond by emphasizing that they are relieving suffering? I was consulted in a Canadian case by a distraught family member who said that the doctor who euthanised his mother, “acted mechanically”. He was saying that what was for him a momentous event, for the doctor was just another routine medical procedure.

Despite their complaints, I will continue to try to teach medical students to examine their emotions in searching for ethics and to be aware of how choice of language can affect these. Perhaps the old saying, “There are none as blind as those who cannot see”, could be reworded as, “There are none as blind to ethical issues as those who cannot or do not honestly examine their emotions”.  


What do you think about the notion of "the wisdom of repugnance"? 


Margaret Somerville is Professor of Bioethics in the School of Medicine at the University of Notre Dame Australia. 

This article was originally published in Catholic Voice

Image credit: Bigstock 


 

Showing 3 reactions

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  • Maryse Usher
    commented 2024-07-02 21:11:31 +1000
    Unfortunately, the prolific and exaggerated use of emotional language in reporting today, as well as the fact both sides of ethics use emotional expressions to emphasise their feelings about things, discredits this view.

    I think it is far more effective, honest and truthful to simply state facts and use the words which mean what they say. Leave people to have their emotions in the privacy of their own hearts.

    For example; abortion using surgery or chemical substances is the deliberate killing of an unborn child.
    Suicide, whether committed alone or with the requested assistance of another person, is the deliberate killing of yourself.
    If those on the right side of ethics simply refuse to use any other words but those which state the truth, it goes a long way to making the point without the manipulative use of adjectives or emotional language.
    News reports are infested with exaggerated, unnecessary and inflammatory descriptions which would never have survived a subeditor’s blue pencil 30 years ago and which ultimately reduce the reader to yawning indifference; one defence against others trying to make you have a bad case of the feels about nearly everything.
  • Maryse Usher
    followed this page 2024-07-02 20:46:10 +1000
  • Margaret Somerville
    published this page in The Latest 2024-06-30 15:39:09 +1000