Written by Julian Savulescu
A version of this article has been published by The Conversation
Epicurus wrote: “Death does not concern us, because as long as we exist, death is not here. And when it does come, we no longer exist. ”
We are in the midst of two great ethical debates: marriage equality and assistance in dying. The great plebescite is ongoing and the Victorian parliament is debating a new law to allow assistance in dying in the last year of life.
A search of Victorian paper “The Age” reveals about 2400 results for “marriage equality” and only about 1700 for assisted dying related terms. But even more striking is the difference in the strength of the feelings they have embodied: despite the fact that one of these topics is literally a life and death matter, the same-sex marriage debate has been far more polarizing.
Beyond the Veil, Beyond the Pale
Public ethical debates are fuelled by emotion and psychological biases on both sides. In the case of assisted dying, most of us are not like Epicurus: we fear death. We hate talking about it:
“Most parents would prefer to talk with adolescents about drugs, sexual behavior and HIV than about dying (Sagall, 1991),” http://www.tandfonline.com/doi/pdf/10.1080/07481180490476489?needAccess=true
Despite the fact that polls show that 73% of Australians favour Euthanasia, https://www.theguardian.com/society/2017/sep/01/voluntary-assisted-dying-supported-by-73-of-australians-poll-finds it is not clear whether it will pass: 40 out of 87 MPS in the legislative assembly told the Herald Sun they would vote yes http://www.heraldsun.com.au/news/victoria/deputy-premier-james-merlino-to-seek-to-halt-assisted-death-push/news-story/2e2cff2f10c1e0a75e3df9392e6daa41. Australian history is littered with failed bills.
So there should be an enormous impetus to show MPs the level of public support. But it has been rather muted. Perhaps for similar reasons we post photos of weddings on Facebook, but not funerals: both are important, but only one makes good dinner party conversation.
Terror Management Theory, Evolution and Social Signalling
In fact, our fear of death might even be linked to our love of marriage according to the so-called terror-management theory (TMT).
” when we’re faced with the idea of death, people defensively turn to things they believe will shield them from death, literal or otherwise. Thinking about death also motivates people to indiscriminately uphold and defend their cultural worldviews, whatever those may be.”
Dr. Claudia Aguirre
https://www.headspace.com/blog/2016/03/24/why-dont-we-talk-about-death/
TMT has been linked to our development of regulation and rituals around sex http://journals.sagepub.com/doi/10.1207/S15327957PSPR0403_1
A foundational commitment to marriage being between a man and a woman may be more of an immoveable foundation upon which group membership is grounded against our shared fear of death than an ethical position that can be defended or rebutted on rational grounds.
While fear suppresses talk about dying, marriage equality involves sex. People crave to talk about love and sex. And sex has been more important than death in evolutionary terms. As evolved animals, we were only here to survive long enough to reproduce. Reproduction is evolution’s goal, and so practices around its rituals and norms are hugely important in evolutionary and religious terms. Religions and societies seek to control reproduction. For the Judeochristian tradition, sex was to occur within marriage between one man and one woman.
Death at an old age is of much less evolutionary significance.
We are social animals, motivated to support our in-group and reject out-group members. Tribalism can help explain our devotion to football teams for example. We have developed social signalling to show our group which side we are on and maintain trust. Add to that a status quo bias, and public debates where the topic in question is seen to express something foundational about ourselves can become little more than cheering for our own team.
Anchoring
Anchoring is a psychological bias that means we evaluate how good or bad something is relative to anchor of existing examples. In the UK, 2013 same-sex marriage legislation was fairly uncontroversial. One reason could be that Civil Partnerships–same-sex marriage in all but name– were created back in 2004. Each step in the UK’s progress towards marriage equality was a short step from the previous state of being.
In contrast, the Australian anti-same sex marriage campaign portrays the choice as a paradigm shift in our culture, extending far beyond marriage. Tony Abbott linked the debate to political correctness, gender fluidity and even the date of Australia day, later saying “This isn’t just about marriage…there are lots and lots of implications here and we’ve got to think them through before we take this big leap into … the dark.”
Assisted dying legislators have taken the opposite tack, anchoring the current bill at the bottom of the international spectrum:
“This will be … the most conservative model in the world, with many safeguards…This is the most cautious, the safest, scheme for assisted dying anywhere in the world.”
Daniel Andrews, Victorian Premier
A better approach
Take the debate on assisted dying. For this to be an appropriate activity for medicine, we should show that death can be an appropriate therapeutic end, and in a patient’s best interests. That is, that their life is no longer worth living. That is an incredibly difficult thing to show and I haven’t seen any good arguments for how to evaluate that. Why wouldn’t be just go on what a competent person says? If they say they’re better off dead, they are probably right.
But here is another way to think about it. The Victorian legislation will only provide assistance to those in the last year of life from a physical illness. They are effectively in the process of dying. Shortening of life has always been possible in law near the end of life, provided the intention was to relieve suffering. People died days or weeks earlier than they could have died with maximal medical assistance. This law will extend that principle from days to weeks, to a year and allow death to be the intended aim.
One major objection to the assisted dying Bill is that we don’t need it because good palliative care is sufficient. Relief of suffering is incredibly important and more should surely be spent on end of life planning and palliative care.
But this objection is complicated for several reasons. If palliative care is so good, people won’t request assistance in dying. So there is no need to ban it.
More importantly, while palliative care may be able to control pain and suffering, it is not a panacea. It can’t do everything. Together with colleagues in Oxford and Barwon Health, we surveyed 382 lay people from the general population and 100 attendees at an Advance Care Planning (ACP) clinic. We didn’t ask them about assistance in dying but we did ask them to rank 4 factors at the end of life: pain relief, dignity, independence and living as long as possible, [http://spcare.bmj.com/content/early/2017/08/08/bmjspcare-2016-001177]
The relief of pain and suffering was ranked as the most important value by the highest proportion of both groups, followed by maintaining dignity and remaining independent. Living as long as possible was ranked as most important by the lowest proportion of participants, top for only 4% of ACP and 2.6% of the general population (and 30–35% regarded this as either not important or not very important)
People care not only about pain relief but dignity and independence at the end of life. These are much more subjective and less amenable to control by palliative care. So while palliative care can address part of what people care about, it may not be able to address all their values.
There is one sense in which the palliative care objection is right: we don’t need assistance in dying. People can already shorten their lives, by more than a year, for any medical condition, or no medical condition at all, by refusing to eat and drink by mouth. It takes around 10 days to die of thirst. Such people could be given palliative care to relieve their suffering during this period of suicide [http://eprints.qut.edu.au/79897/]. But surely the Victorian law is a better way to die than this form of suicide? As with the palliative care, this kind of death does not provide the dignified death, or the independence, that people value.
Like many other people, I thought the plebescite was a waste of money. But on reflection, this idea maybe misplaced. When the views of one part of the community are deemed politically incorrect and suppressed, they foment, then erupt in a Brexit or a Trump. Debate is vitally important to democracy. There are deep philosophical issues involved in both of these debates. What we should hope is that people engage in these debates with their heads, not their hearts. It will take considerable effort on both sides to overcome the psychological obstacles to finding the most fair and reasonable policy.
As Epicurus also said, ” The art of living well and the art of dying well are one.”
Even the language of physician-assisted suicide is misleading. The most important part of the physician’s “assistance” merely consists in writing a prescription for the deadly medication, and that is only necessary because the law enforces artificial scarcity in what a person can buy.
If every person could simply buy a deadly dose of nembutal and metoclopramid for personal at a drug store, there would be no need for a physician’s assistance at all. It strikes me as absurd that having studied medicine gives one a morally legitimate god-like power to decide when and how other people are allowed to die. That decision should firmly rest with that person, and that person alone.
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