Euthanasia isn't a slippery slope

Should euthanasia be legalized?

euthanasia

Calls for assisted dying, euthanasia, to be legalised are on the rise. While many do not think it is morally wrong for a dying person to voluntarily end their life, concerns about the knock-on consequences of legalisation often stand in the way of changing the law. The slippery slope argument stands in the way of assisted dying. Such arguments are often a rhetorical device, that use suffering patients as a means to an end and not as ends in themselves, writes Emily Jackson.

 

Slippery slope arguments are generally employed in order to argue against doing something, on the grounds that even if doing the thing itself might be unproblematic, doing it is likely to have unintended and undesirable consequences. A slippery slope claim is not concerned with whether a particular activity is right or wrong, but with whether it is in practice impossible to confine ourselves to that activity only.

There are two different reasons why a slope might be slippery. In a logical slippery slope argument, the claim is that that once we allow activity A, there is no non-arbitrary reason to stop there, and so we are logically committed to also allow activity B. An empirical slippery slope argument suggests that once activity A becomes familiar and routine, taking further steps towards activity B will begin to seem less problematic, and we will eventually find ourselves accepting activities B, C and D.

Euth Rationalising Suicide Read more Because the essence of a slippery slope claim is that once we have stepped onto the slope, we will not be able to stop ourselves from descending, an obvious response would be to advocate regulation that permits the innocuous thing at the top of slope, while prohibiting the undesirable things that lie towards the bottom the slope. At the heart of a slippery slope claim, therefore, is pessimism about our capacity to regulate effectively, and to locate and police boundaries between acceptable and unacceptable conduct.

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At the heart of a slippery slope claim, therefore, is pessimism about our capacity to regulate effectively, and to locate and police boundaries between acceptable and unacceptable conduct.

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Slippery slopes and assisted dying

Slippery slope arguments against assisted dying are not concerned with whether it would be legitimate for doctors to help their patients to die. Someone who invokes a slippery slope argument against assisted dying is making the consequentialist claim that even if there might be circumstances in which it would be acceptable for a doctor to help a patient to die – perhaps because she is in intolerable agony that cannot be relieved in any other way – legalising assisted dying would be dangerous because we would be unable to confine it to patients like this. Having taken that first step onto the slope, we would inevitably slide down it, and soon vulnerable patients’ lives would be being brought to an end when their depression is treatable, or because their beneficiaries have persuaded them that death is preferable to expensive residential care.

A slippery slope argument against assisted dying does not involve the claim that there is something wrong with doctors helping their patients to die. In practice, people who use slippery slope arguments against assisted dying often also believe that it is intrinsically wrong, but this is not the claim that they are making when they invoke the slippery slope. Rather, the slippery slope claim is that, even if we were to accept that doctors might sometimes act reasonably when they comply with a patient’s request for assisted dying, we should nevertheless prohibit it because, if assisted dying were to be legalised, it would be impossible to prevent abuse.

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In practice, despite being essentially empirical claims about the likelihood that doing A makes doing B more likely, slippery slope arguments are seldom proved or disproved by the evidence.

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Slippery slope claims have been made in other areas of medical practice, to which the response has been regulation rather than complete prohibition. Take preimplantation testing (PGT) for monogenic disorders, for example. A slippery slope argument against PGT might involve saying that if we allow would-be parents to test their embryos for a fatal condition such as Tay-Sachs disease, we will be unable to prevent other would-be parents from using PGT to select beautiful, sporty and intelligent children. Aside from the fact that this is scientifically impossible, preimplantation genetic testing can be regulated, as it is in the UK, so that it is lawful to test embryos only if there is a significant risk that the child would be born with a serious genetic condition.

The question of whether legalising assisted dying makes involuntary killing or abuse of the elderly more likely could be said to be a straightforward empirical claim, which we could attempt to answer by looking at the experience of jurisdictions which have legalised assisted dying. Indeed, some opponents of assisted dying have sought to do this by pointing to evidence that the number of people opting for an assisted death tends to increase in the years following legalisation. This does not prove the existence of abuse, however, because the number of assisted deaths in the first year after legalisation does not necessarily represent the total number of eligible patients, so that any increase must mean that assisted deaths are taking place in more dubious circumstances. Instead, it is possible that the number of assisted deaths immediately after legalisation will be unusually low, given that fewer patients may be aware of it as an option.

Opponents of legalisation also commonly cite data collected by the Dutch which appear to show that, in a small number of cases, patients’ lives are ended in the absence of an explicit request. On its own, evidence that 0.2 per cent of deaths in the Netherlands involve a patient’s life being ended in the absence of an explicit request does not prove that that percentage is higher than it was before legalisation. It might be, but in order to establish this, we would need evidence (which is unavailable) of the causes of deaths in the Netherlands before legalisation. We also do not know what percentage of patients’ lives are ended in the absence of an explicit request in countries where assisted dying is unlawful: this might be less than 0.2 per cent, or it might be more, and without this data, it is impossible to say that legalisation makes this practice more common.

We could also invoke a different sort of slippery slope claim to see why evidence that practice X occurs in a jurisdiction which has legalised assisted dying does not establish that legalisation has caused practice X to occur. Let us say that there is evidence that palliative care provision in Oregon improved after the legalisation of assisted suicide. This does not establish that legalisation caused palliative care provision to improve. We could use this evidence to show that there has not been a decline in the provision of palliative care after legalisation, but we could not use it to establish a causal relationship between lawful assisted dying and better palliative care.

Slippery slope claims as rhetorical devices

In practice, despite being essentially empirical claims about the likelihood that doing A makes doing B more likely, slippery slope arguments are seldom proved or disproved by the evidence. The principal concern of people who make slippery slope arguments against assisted dying is generally not the effectiveness of regulation, but the intrinsic wrongness of assisted dying. Slippery slope arguments are in fact often a smokescreen, invoked by people who are fundamentally opposed to legalisation, in order to appeal to people who are not, but who do have concerns about the possibility of abuse.

Slippery slope arguments thus shift the focus of debate away from cases at the top of the slope – the person with full capacity, whose suffering is intolerable and cannot be relieved in any other way, who has made a voluntary decision to die – towards cases on which opinion is much more divided. Instead of arguing, on principled grounds, that it would be morally wrong to give the suffering patient access to the relief she seeks, the slippery slope proponent does not dispute that her case may be compelling, but instead argues that if we allow assisted dying in her case, we will inevitably end up with doctors euthanasing children and people with disabilities, and greedy families pressurising their frail, elderly relatives to choose death over inheritance-consuming care.

Slippery slope arguments are powerful rhetorical devices because no system of regulation is perfect. Their purpose is to foster and stoke doubts about whether any set of checks and balances could be guaranteed to prevent every single possible case of abuse. Just like the ‘precautionary principle’, slippery slope arguments tend to favour the status quo as the ‘safest’ option, when we cannot prove that taking a step into the unknown will be 100 per cent safe. What is missed by a slippery slope argument, therefore, is the cost of doing nothing, not only for patients who want an assisted death in order to relieve their unbearable suffering, but also for the wider group of patients who would be reassured and comforted by the knowledge that assisted dying would be an option, should their suffering become unbearable in the future.

Those who oppose assisted dying in all circumstances, on principal, are in a minority. Public opinion surveys consistently indicate that a majority of the population believes that there are circumstances in which assisted dying should be lawful. Faced with an articulate patient who is seeking an assisted death in order to relieve her intolerable and unrelievable suffering, opponents of legalisation are not going to get very far by saying that giving her what she wants would be morally wrong. A more effective strategy is to sow doubts about whether we could ever be certain that a system of legalised assisted dying would be 100 per cent effective in preventing doctors from helping patients to die in more questionable circumstances.

I do not mean to suggest the use of slippery slope arguments is always entirely cynical: people who oppose assisted dying in principle are often also genuinely concerned about the risk of abuse. But if someone’s opposition to assisted dying is rooted in their belief that it is always morally wrong, there are no safeguards that could ever persuade them that it would be safe enough.

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A blanket ban on assisted dying in order to protect the vulnerable involves disregarding the rights and interests of non-vulnerable patients.

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People who invoke slippery slopes are generally not interested in trying to craft a regulatory system which would enable patients whose circumstances lie at the top of the slope to have access to assisted dying. Rather, their point is that the only way to protect the vulnerable is to have a blanket ban on assisted dying, for non-vulnerable patients as well as for those who are genuinely vulnerable. We do not do this in other contexts – we do not prevent adult patients with capacity from refusing blood transfusions because we are worried about vulnerable patients being pressurised into making similar decisions against their wishes. Instead, we have a system in place in which a patient’s capacity can be assessed, and if there is any doubt about their capacity, or whether their apparent decision reflects their wishes, applications can be made to the courts to resolve the matter.

A blanket ban on assisted dying in order to protect the vulnerable involves disregarding the rights and interests of non-vulnerable patients. If we think we can protect the vulnerable – while also respecting the autonomy of non-vulnerable patients – in the context of refusals of life-prolonging treatment, it seems implausible to claim that it would be impossible to protect the vulnerable when it comes to assisted dying.

To say to someone who is suffering intolerably, with no prospect of relief, that she must be denied access to the assisted death she is seeking – not for her own good, but in order to protect other hypothetical vulnerable patients – is to treat her as a means to an end, rather than as an end in herself. If we accept (a) that there could be suffering so intolerable that assisted dying would be a legitimate response, and (b) that there is a risk of abuse, we owe it to the people who are suffering intolerably to at least try to devise a regulatory system capable of distinguishing between eligible and ineligible patients. Without proof that this is, in fact, impossible, slippery slope proponents are forcing identifiable individuals to endure unnecessary suffering in order to protect someone else.

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Ron Spackman 30 January 2022

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