Public reasoning about voluntary assisted dying: What we found when we analysed submissions to the Queensland Parliamentary Inquiry

What are the reasons, forms of reasoning, and rhetoric that people use in their support for or opposition to physician-assisted suicide and euthanasia, and the introduction of “voluntary assisted dying” (VAD) legislation that would legalise these practices? While numerous polls estimate public attitudes to such practices and legislation, there is little interrogation of why people think the way they do.

There are many reasons that may be valid, but not all reasons are strong reasons. Moreover, some reasons may conflict with other reasons. Understanding public reasoning about VAD can help to shape better policy grounded on coherent reasoning.

In November 2018, the Queensland Parliamentary Inquiry in Aged Care, End-of-Life and Palliative Care, and Voluntary Assisted Dying invited submissions from the public on why they support or oppose VAD. We analysed 1,119 of the submissions made by individuals of the over 4,500 submissions made to the inquiry. We focused on individuals, not organisations, so that we could illuminate the rhetoric, reasons, and reasoning of the general public.

Using a combination of digital humanities techniques and more traditional qualitative research methods, our research identified the terms most frequently used by those both in favour and opposed to VAD. We then analysed the words most closely and distinctively associated with these terms in the submissions. This enabled us to identify clusters of related terms that characterise different themes of rhetoric, reasons, and reasoning by those in favour and opposed to VAD.

We found evidence of the four recurring themes in the VAD debate that were identified nearly a decade ago by Maggie Hendry and her colleagues: the importance of personal witness of unbearable suffering; concerns about poor quality of life; desire for a good death; and worries about the potential abuse of the practice. But, as we have indicated, our analysis also identified additional themes used by supporters and opponents of VAD. For those who support VAD, personal witness or direct experience of suffering a terminal illness, a concern about the supposed indignity of suffering and poor quality of life, and respect for individual choice and rights are important themes in their reasoning. For those who oppose it, VAD is an intrinsically immoral practice akin to suicide and murder; it violates the intrinsic value of life, undermines the principles and authority of modern medicine, jeopardises the provision of high‐quality palliative care as the medically and socially appropriate response to suffering, and is against the public interest by permitting state‐sanctioned killing that puts vulnerable groups at risk.

We thus identified ten themes that relate to the rhetorical strategies, reasons, and arguments that people use to justify their position on VAD:

Pro-VAD themes:

• personal witness or direct experience of suffering a terminal illness (Theme A);

• a concern about the supposed indignity of suffering and poor quality of life (Theme C);

• respect for individual choice and rights (Theme B); and

• the status of Advance Health Directives (Theme J).

Anti-VAD themes:

• VAD is an intrinsically immoral practice akin to suicide and murder (Theme F);

• VAD violates the intrinsic value of life (Theme I);

• VAD undermines the principles and authority of modern medicine (Theme E);

• VAD jeopardises the provision of high‐quality palliative care as the medically and socially appropriate response to suffering (Theme D);

• VAD is against the public interest by permitting state‐sanctioned killing (Theme G); and

• VAD puts vulnerable groups at risk (Theme H).

Pathos versus ethos as rhetorical styles

Different rhetorical strategies — that is, styles or techniques of persuasion as distinct from reasoning per se — seem to be favoured by each side. For the proponents of VAD, narrative accounts of suffering (Theme A) set the context for and function as a bridge to other arguments, such as demands to die with dignity (Theme C), or to respect choice or a right to die (Theme B). The appeal is to the emotions of the reader to persuade them that VAD will prevent such horrible situations.

By contrast, the opponents of VAD tend to employ ethos‐based rhetorical strategies by appealing to the credibility of modern palliative care practice (Theme D) or the authority of professional medical bodies such as the World Medical Association (Theme E). Here the perceived authority or credibility of such organisations is the persuasive power.

Individual versus communal ethical frames

The debate about VAD is an example of the classic tension between individual interests and communal values. While both those in favour and opposed are concerned about suffering, those in favour tend to focus on the suffering of those closest to them (pathos), and consequently tend to adopt reasons that are more strongly associated with the rational self-interest of individuals. In other words, they don’t want their loved ones to suffer, and, more importantly, they want to have the power themselves to prevent their own suffering.

Those who oppose VAD tend to consider the community as a whole and the meaning of such legislation for those who are more vulnerable to unjust systems and power structures. If the state’s job is to protect the vulnerable, then those opposed to VAD view the legalisation as a failure of the state to protect the common good or public interest.

Normative moral reasoning: deontology and consequentialism

Deontologically, the proponents of VAD employ the following principles:

(1) Unnecessary suffering is evil and should be avoided (Theme A).

(2) Human freedom should be respected when there is no substantial harm to others (Theme B).

(3) Dignity — understood as self‐worth or freedom from humiliation — should be protected and not violated by “forcing” someone to “endure” “horrible” suffering (Theme C).

(4) Human beings have a “right to die” (Theme B).

(5) Compassion demands that we should end suffering by euthanasia, as we already do in the case of animals (Theme C).

If principles (2) and (3) are used independently, there are consequences for how assisted dying is understood. If respect for human freedom is a non‐negotiable principle, then assisted dying can only ever be “voluntary.” In contrast, dignity, understood as self‐respect or freedom from humiliation, could be used alone to justify non‐voluntary assistance in dying on the basis of preserving a person from the “indignity” of suffering or loss of quality of life. It is not clear from our research whether this distinction and its implications are well understood in public reasoning.

The distinction between respect for choice and (2) a “right” to die (4) is important, because the two have different philosophical and legal implications. If one recognises a right, then it follows that a society has an obligation to ensure that the right is met. Most jurisdictions do not recognise a right to die, but rather the idea that when certain criteria are met (such as doctors’ assessments, and so on), a patient is permitted to request to have their life ended. VAD is understood as a justifiable exception to the commitment of governments to protect life. It is not clear from our research whether this distinction and its consequences are well understood by the public or whether there is generally a conflation of the two principles.

The idea that compassion demands euthanasia, as we do for animals (5), is interesting because it is arguably at odds with (2) and (3): animals do not have a choice in the matter. Animals are euthanised because there is no instrumental or existential value in their suffering. This is, however, not the case for human beings, for whom free choice and the desire to be treated with respect and not to be humiliated are both integral to existential meaning‐making. Permitting (5) as the sole reason for VAD may undermine the claims of free choice or respect for dignity and open the door to legitimising non‐voluntary or even involuntary euthanasia. It is not clear that those who invoke this example are aware of such implications.

From a consequentialist standpoint, the pro‐VAD position is relatively simple: allowing VAD will reduce unnecessary suffering. Yet, how suffering is understood is associated with the principles employed. While physical pain is one kind of suffering (in line with the rhetoric of pathos), the principles of respect for choice and protection of dignity as self‐respect and freedom from humiliation imply that the consequence of permitting VAD would be more respect for human freedom and fewer violations of dignity. These consequences are associated with reduced existential suffering and not necessarily with pain. If the premise is accepted that reducing existential suffering arising from perceived lack of control or fear of humiliation is legitimate as the sole reason for VAD, even in the absence of physical pain, then this potentially broadens the range of circumstances in which VAD would be permissible — including, for example, people experiencing psychological distress.

For those against VAD, deontological principles include the following:

(a) Unnecessary suffering is evil and should be avoided.

(b) The sanctity or intrinsic value of human life must be respected (Theme I).

(c) Intentional killing, like suicide and murder, is morally wrong (Theme F).

(d) Medicine must cure or comfort, and never intentionally kill (Theme E).

(e) Government has a duty to preserve the common good (Theme G); and

(f) to protect the vulnerable (Theme H).

Like proponents of VAD, opponents believe that there is a duty to prevent unnecessary suffering, be it physical, psychological or existential (a). They are also likely to agree with the principles of respect for freedom and protection from humiliation — that is, (2) and (3) above. For opponents of VAD, however, the latter cannot be applied in ways that violate (b)–(e).

There are fewer conflicts between principles (a)–(e) than the possible conflicts between (1)–(5). One notable possible problem is if (b) is overemphasised as an absolute rule, such that life should be preserved at all costs regardless of whether there is a proportionate benefit or burden in doing so. It is possible that some members of the public hold this view. Similarly, some proponents of VAD may believe that this rule is the cause of the suffering they wish to end. Neither of these is consistent with mainstream religious or professional medical views, or the current law in Queensland, which allows a person to refuse or withdraw from their own treatment.

From a consequentialist standpoint, opponents appeal to the empirical credibility of the effectiveness of high‐quality palliative care (Theme D) to address the problem of suffering adequately while not violating (b)–(e). Against VAD, they argue that ignoring (b)–(e) will result in the abuse of vulnerable people (Theme H), in state‐sanctioned killing undermining the public interest or common good (Theme G), in worsening or at least not helping the suicide problem (Theme F), and in undermining the core values of the medical profession, thereby reducing public trust in the healthcare system that is already under pressure to deliver high‐quality healthcare to all Queenslanders.

Religion less important

In contrast to previous findings regarding the importance of religion in opposing VAD, our research suggests that the religion factor is less important than other factors in the debate in Queensland — at least as far as public reasons go. “God” is the only religious terminology that made it into the keyword list (with an appearance of 84 times, or a rank of 30 among the top 100 most frequently used words in the “No” document; versus 42 times, or a rank of 360 in the “Yes” document).

This may reflect the increasing secularisation of Australian society and the trend toward the medicalisation of end‐of‐life matters over the past decade. But it could also be the case that theological values or arguments may have greater resonance if they are packaged in secular terms. We suggest that further research be conducted to clarify this important issue.

The need for caution

Our research does not exhaust the possible reasons, arguments or rhetorical strategies used by the public in supporting or opposing VAD. It does, however, help to characterise the main approaches of the two sides: Individualist Pathos versus Communal Ethos. Importantly, it underscores the complexity of reasons and reasoning, and that it is not clear whether this complexity is understood by the public.

In particular, in the case of those supporting VAD we see potentially contradictory principles invoked, which, when applied, could have quite different implications for what the resulting “assisted dying regime” might look like. This reiterates the need for caution in relying on surveys of public opinion to make laws concerning VAD. Sound normative reasoning remains vital.

David Kirchhoffer is the Director of the Queensland Bioethics Centre at Australian Catholic University. His research focuses on the relevance of human dignity in contemporary ethics, and its application to bioethical issues, especially the limitations of respect for autonomy in human research ethics.

Chi‐Wai Lui is a research associate at the Queensland Bioethics Centre at Australian Catholic University. His research focuses on end‐of‐life care, social determinants of health, ageing, and experiences of living with chronic illness.