Euthanasia: tackling a 'wicked' policy problem

Medicine and law are the main social institutions at the heart of the euthanasia debate. Where euthanasia is legalised, doctors have the problematic gate-keeping role as the arbiters of terminal illness, deciding how terminal it is, administering pain relief and treatment and ultimately, depending on the version of euthanasia legislation adopted, prescribing or delivering terminal medication. Medicine shares this gate-keeping role with the law, which serves a regulating and restraining function, providing safeguards for both doctors and individuals. The many safeguards required in most versions of euthanasia legislation, covering issues such as the meaning of terminal illness and suffering, the patient's decision-making capacity, the interpretation of intention and coercion, the availability of alternative relief, the responsibilities of medical professionals and provision for scrutiny of doctors' decisions, underline the complexity of the issue.

A strong view put forward by anti-euthanasia advocates is that "the very soul of medicine" is placed on trial by euthanasia and that doing harm to medicine would also harm society. This argument is based on the position of trust doctors have in our society. Allowing doctors to intentionally inflict death is regarded as fundamentally undermining that trust.

A distinguishing characteristic of euthanasia as a public policy problem is its moral dimension. It goes to the fundamental principles on which society is based and challenges long-established, previously widely shared societal values. In the absence of institutionalised religion and in the face of the diversity of views in a pluralist, secular society, policymakers and politicians need to search for an ethical base and confront conflicting values.

One of the most commonly raised objections to changing the law to allow euthanasia is the slippery slope argument, a concern with potential abuse, the difficulty of setting secure limits and unintended adverse consequences. The slippery slope argument suggests that legalisation of assisted suicide will lead inexorably to acceptance of other kinds of non-voluntary deaths. This was a major concern for the British House of Lords Select Committee on Medical Ethics in 1994 which concluded that it was impossible to set secure limits on voluntary euthanasia:

to create an exception to the general prohibition of intentional killing would inevitably open the way to its further erosion whether by design, by inadvertence, or by the human tendency to test the limits of any regulation.

While some argue that the law can provide safeguards against the slippery slope effect, others are doubtful and advocate the adoption of the "precautionary principle," an established principle in environmental policy, which has two main elements: the need to anticipate harm before it occurs; and an obligation, if the level of harm is high, for cautious action.

This year in the UK after an extensive process of public debate and exchange of views, the Falconer Commission on Assisted Dying came to a different conclusion from the House of Lords inquiry, supporting a new safeguarded framework to permit terminally ill people to end their own life, finding this preferable to the uncertainties of the current "inadequate and incoherent" legal framework.

Tackling 'wicked' policy problems in Australia

How does a pluralist society like Australia where many policy issues get too easily categorised into partisan political camps before we even have a debate, deal with euthanasia? Should we just act on popular sentiment as fuelled by questionable opinion polling? After all, Australia has done well in the past in managing considerable policy change such as reorientating our economy and having a sustainable welfare system, so why cannot we also tackle euthanasia effectively?

There are three basic requirements for dealing with 'wicked' policy problems like euthanasia.

First, there needs to be time to engage the public in open, depoliticised, iterative discussion of the many dimensions of the problem. This is an absolute necessity for complex social issues with a strong moral dimension like euthanasia, in order to make different perspectives understood and create a shared understanding of the issue to address.

Second, there needs to be reliable evidence and data so as to inform the debate and avoid distortion of the facts, but this alone it is not sufficient when conflicting values and perspectives are at stake. Euthanasia is not an issue where 'evidence' based policy development alone can resolve the matter, but we certainly need to clarify the 'evidence.'

Third, it is essential to have appropriate mechanisms (more than one) for public engagement in informed debate, to explore the range of arguments and to encourage the consideration of wider social implications if an agreed policy solution for the common good is to emerge.

Engaging the public in this kind of policy process would be a welcome new feature in the Australian political process. In recent years, that process has been characterised by: rushed policy development and demands for 'instant' policy solutions; flawed policy processes; trivialisation and politicisation of national policy discourse; and a high degree of distrust of politicians and key institutions. Complex policy problems defy simplistic and populist solutions and call for thorough and extensive public discussion and 'cool' debate. Providing the opportunity for people to think more fully and seriously about important public issues, to be part of a meaningful dialogue and deliberation that acknowledges different values and beliefs, is more likely to lead to a sound and lasting policy solution than an adversarial approach or the 'tyranny of the majority.'