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The slippery slope

The slippery slope argument is dismissed out of hand by most in the end-of-life movement.  It simply doesn't hold water, they say.  It is illogical to argue that something as affirming of individual autonomy as assisted suicide can ever lead to the abuses of individuals by society. And if, in reply, one tries to describe to them how it already has happened in recent memory, they tend to become horribly indignant and shut off all conversation.  "If we can't discuss this without you calling me a Nazi, then we have nothing to talk about."

People in the end-of-life movement are not Nazis.  The vast majority are good, compassionate, well-meaning people who have the best interests of dying patients at heart. But if you examine the facts coldly and logically, and if you factor in the depth of our increasing economic crisis in healthcare, the slippery slope argument, I believe, becomes compelling.

Let's deal first with the Nazis.  The Nazis were obsessed with the purity of race, with removing all "imperfect" humans from the breeding pool. That was their ideology, and we don't have that ideology.

Yet, the evolution of the arguments advanced by the Germans to justify their actions sound eerily familiar.  Long before the Nazis came to power, German scholars were calling for legal euthanasia as a means of promoting mercy and personal choice in the face of intractable suffering, using language identical to the language we are hearing today.  This movement steadily gained steam, and during the economic crisis of post-World-War-I Germany it came to be advanced as a way of controlling spending on individuals who were seen as burdens to society.  The "science" of eugenics nicely added the imprimatur of the scientific community to the humanitarian and economic arguments made by proponents of euthanasia.  By the time the Nazis came to power, the groundwork had been laid for their handiwork.  It had been laid not by fiends, but by generally well-intentioned scientists, doctors, lawyers, and economists. To dismiss those events, out of hand, as irrelevant to our culture is just foolish.  

Also relevant to the slippery slope argument is the Dutch experience with euthanasia.  The Dutch have not actually legalized euthanasia, but have developed an official policy under which the laws forbidding euthanasia will not be enforced as long as certain guidelines are adhered to. These guidelines require intolerable suffering on the part of the patient that causes them to persistently request to be allowed to die; the patient must have a good understanding of what he or she is requesting; no other reasonable solutions can be apparent; and at least two physicians must concur that euthanasia is the only good choice.  

Recent reports on the Dutch experience have been mixed.  American proponents of assisted suicide see a shining example of the societal benefits of permitting end-of-life autonomy of choice.  Opponents see a series of terrible abuses (noting, specifically, an utter disregard of the prescribed guidelines).  To me, the most striking feature of the Dutch experience, and the most relevant to the slippery slope argument, is that thousands of cases of "active involuntary euthanasia" are reported to be occurring each year.  In other words, patients are being killed at the hands of their doctors and without their permission.  All, it is said, are leading insufferable existences, and all are being euthanized solely for humane reasons.

What do medical ethicists say about such a thing?  Not all agree, of course, but it turns out that it is fairly easy to derive an ethical argument in support of involuntary active euthanasia from the starting point of upholding individual autonomy.  It goes like this: the principle of autonomy demands that patients be allowed to refuse therapy; refusal of therapy is the ethical equivalent of voluntary euthanasia (as we have seen); since voluntary euthanasia is a right of individuals with intractable suffering, it follows that it would be unethical to withhold euthanasia from suffering individuals just because they are incapacitated and unable to give their permission. Hence, involuntary euthanasia is ethical for suffering patients who are unable to give their permission.  

Where this leaves us is at a place where others can decide for an individual what constitutes intractable suffering, and when that individual is incompetent to make such a determination for him or herself.  Where these "others" end up drawing the line on whether a person's existence is of value or whether a person is competent, of course, can be influenced by all sorts of external factors.

In Nazi Germany, those external factors included a belief in the purity of the Arian race, and that belief led to horrible excesses.  Again, we don't have that belief here.  

What we do have is an imperative to ration healthcare, which means that potentially beneficial care is going to have to be withheld from somebody, somewhere.  Can we be sure that, once we start down the road of allowing patients to choose death, we will be able to withstand our external influences, and stay our hands from ending the suffering of some who might not be so sure of their choice or who are incapable of making a choice - especially when, by so doing, we will make more healthcare available to others who could actually benefit from it?

I believe the slippery slope argument holds a lot of water.  

Erosion of the doctor-patient relationship

I don't need to say too much more about this.  A short vignette will suffice.

Vignette: Why is that doctor smiling?

Imagine yourself at age 75 in a hospital bed with a serious illness, but one that is potentially treatable with a lot of effort. Your doctor walks in, smiling.

If physician-assisted suicide and euthanasia are not available, you can be reasonably sure he's smiling with confidence. He thinks he can cure you, and his smile tells you so. You relax. You feel better already.

But what if assisted suicide and euthanasia are legal?  What would his smile mean then? He still might be smiling with confidence, of course.  But maybe he's smiling for another reason. Maybe it's that sheepish, somewhat sympathetic, ain't-life-a-pisser smile that can herald bad news. Maybe he's about to pull up a chair, slowly let his smile fade, and say, "Well, you know, things don't look so good this time, Charlie."  He'll pause, then let the smile return, "But the good news is, we can make it all pretty easy on you."

Or worse, he might not say anything.  He might offer some vague opinions, like "Well, Charlie, we're sitting on some pretty nasty blockages here.  But I've seen worse."  That smile again. "I'm real certain things are going to work out just fine. And all that pain and windedness?  Well, that's going away. Promise." Then he leaves.  And he leaves you guessing. Just how hard is he going to work to make you well, before he decides the other way is better?  

You've even heard - well, you've heard they don't always tell you beforehand.

It's hard to imagine anything more destructive to the trust between a doctor and a patient than knowing that your doctor, at some point, may shift from trying to cure you to trying to usher you into the next life as cheaply and painlessly as possible (by encouraging suicide, by offering euthanasia, or by simply doing the euthanasia because you're so incompetent you can't see it's the only thing to do).

If people want to commit suicide, and if the ethicists agree that assisted suicide is entirely okay, then let the ethicists do the assisting. I have relatively little to say against ethicist-assisted suicide. But leave the doctors out of it.