The importance of ‘Examined Emotions’ in decisions about ethics

From the Classroom to the War in Gaza

VAD – euthanasia – has been legalised in the ACT. If we believe that it is unethical and a very bad 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.

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. With colleagues, I am teaching bioethics to one hundred and sixty-five 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. 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 not¹. 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’ right 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.

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.

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.

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.

We ignore our feelings at our ethical peril.

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.

The average person uses fifty percent of their lifetime healthcare costs in the last six months of their life. Might VAD present a temptation to eliminate this period?

Governments are also concerned about future healthcare costs of public insurance schemes, in particular, with an aging population. The average person uses fifty 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 one hundred and forty 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 show 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 they have done a worthy, compassionate act. In contrast, there are Canadian doctors who signed up to provide euthanasia, did it once 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 emphasising that they are relieving suffering? I was consulted in a Canadian case by a distraught family member who said 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”.

¹(J. Donald Boudreau and Margaret A. Somerville, “Euthanasia is not medical treatment”, British Medical Bulletin 2013; 106: 45–66, DOI:10.1093/bmb/ldt010 http://bmb.oxfordjournals.org/content/early/2013/03/26/bmb.ldt010.full?keytype=ref&ijkey=IKP7zm8pfcR3lNH)

• Margaret Somerville AM FRSC is a Catholic philosopher and professor of bioethics at the University of Notre Dame Australia. She was previously Samuel Gale Professor of Law at McGill University