One of the most frequent arguments used to oppose Medical Aid in Dying (MAID) laws and the right to die generally is the “slippery slope” argument. It is usually expressed something like the following from James Rachels, in an essay titled “Euthanasia”:
Once a certain practice is accepted, from a logical point of view we are committed to accepting certain other practices as well, since there are no good reasons for not going on to accept the additional practices once we have taken the all-important first step. But, the argument continues, the additional practices are plainly unacceptable; therefore, the first step had better not be taken.
The argument is made also, as Rachels explains, in an emotional or psychological form:
[O]nce certain practices are accepted, people shall in fact go on to accept other more questionable practices.
This argument is not a claim about a logical action, as Rachels explains.
[T]his form of the argument says that if we start off by killing people to put them out of extreme agony, we shall in fact end up killing them for other reasons, regardless of logic and nice distinctions. Therefore, if we want to avoid the latter, we had better avoid the former.
Of course, with MAID no one is “killing” another. Sick and dying people decide for themselves that it is time to die and do so by their own action.
The “slippery slope” argument often continues with something like,
Once the practice of MAID is accepted, expanding it further will be impossible to resist. It will force itself on us. Thus, voluntary hastening of death will become compulsory. We can’t allow any of it because, like dominoes stood on edge and lined up in a row, once the first topples, all the rest will fall one by one.
This argument, of course, is logical nonsense. There is no law, norm, or facet of human nature that requires one course of conduct to lead inevitably to another. Voluntarily deciding to die is no more of a gateway to involuntary euthanasia than obtaining a driver license is the cause of vehicular homicide.
Another voluntary euthanasia writer, Joseph Sullivan, 70 years ago described the process this way:
If voluntary euthanasia were legalized, there is good reason to believe that at a later date another bill for compulsory euthanasia would be legalized. Once the respect for human life is so low that an innocent person may be killed directly even at his own request, compulsory euthanasia will necessarily be very near. This could lead easily to killing all incurable charity patients, the aged who are a public care, wounded soldiers, captured enemy soldiers, all deformed children, the mentally afflicted, etc. Before long the danger would be at the door of every citizen.
A voluntary decision
Such thinking denies rationality, moral precepts, and legal principles. While it is true that some philosophers and bioethicists debate the involuntary ending of human life, few of us who believe in a right to die go beyond the formulation of this right as a voluntary decision of one person about that person’s life. The view that no one has the right to take from us the liberty to make such decisions to end our lives except ourselves appears to be the norm in this society for those who are near the end of their lives because of disease or condition. Voluntariness is inextricably bound up with the decision to die to escape suffering near the end of life.
In discussing this issue from a voluntariness perspective and rejecting the “slippery slope” argument, I am not suggesting that the legal systems now in place should remain unchanged. Indeed, the impediments to voluntary death found in all existing MAID laws deny us the liberty to decide when our lives should end. Changing those laws to make them better accommodate the voluntary needs and decisions of citizens is not a slippery slope to involuntary euthanasia, but an essential improvement to move toward the equal protection of MAID laws for everyone, not just those with six months or less to live.
Medical Aid in Dying: Six variations among U.S. State Laws
Thaddeus Pope, the most recognized authority in the US with respect to MAID legal issues, as well as medical futility cases, recently lectured about six variations currently in MAID laws. Ten jurisdictions in the US permit MAID. All but Montana (which permits MAID by judicial decision) follow the Oregon model, but there are some variations.
In most MAID states, two mental capacity assessments are mandatory. A third capacity assessment could occur, done by a clinician, LCSW, or psychologist, but this rarely happens. Only Hawaii always requires three capacity assessments.
All MAID laws require a set time (usually 15 days) to pass between two separate oral requests for MAID. Many, if not most, patients die during the waiting period.
Hawaii requires a 20-day waiting period. Oregon now allows a waiver of the waiting period if the patient is likely to die during that period.
Most jurisdictions with a MAID law require a written request, with the lethal prescription in six states to be provided only after 48 hours after the written request. California and Colorado do not have a written request waiting period. In Vermont, the 48-hour wait occurs after the second oral request, followed by the written request, which results in a 17-day waiting period. During this entire time, many dying people are suffering, a factor that makes this process unconscionable for those who don’t believe such suffering serves any useful purpose.
Then there is the problem of whether the patient must ingest the drug or take the drug. Some patients can’t swallow, or have poor absorption, or an obstruction, or uncontrolled vomiting. The intent is that the patient must take the final overt act that leads to death. Oregon changed the verb “ingest” to “take” or self-administer. Washington, Oregon, California, and Maine allow ingestion by mouth, feeding tube (patient presses a plunger), or rectal tube (patient presses a plunger). The verb “take” can also permit IV administration with the patient taking the final overt act. Colorado, Vermont, New Jersey, District of Columbia, Hawaii, and Montana allow IV administration by means of the final act by the patient.
If a patient’s clinician opts out of participation in MAID for a conscience-based objection, there is no duty to participate, inform, or refer, though clinicians must send patient records elsewhere if requested. Only Vermont requires that a patient be informed about options or referred if the clinician opts out.
If an institution or facility where a clinician works opts out of participation in MAID, traditionally the clinician may participate when off-duty. However, the Centura Health Corporation, a Catholic organization in Colorado, prohibits a physician, even if off-duty and acting outside the purview of the institution, from participating in MAID (see Barbara Morris, MD v. Centura Health Corporation, now under litigation).
Equal protection concerns
One flaw that is clear about all current MAID laws, no matter the variations among them, is that they deny equal protection to most people–those who are dying but do not have a six-month prognosis because of the nature of their illness. The Oregon model works reasonably well for those with some form of cancer, but not so well for many other dying patients.
Many people who must wait until they have a six-month terminal prognosis to use a MAID law lose the physical ability to end their own lives or become mentally incompetent during the wait. Examples of such conditions include or may include ALS, Huntington’s, Parkinson’s, Lewy Body dementia, Alzheimer’s, other dementias, Marfan Syndrome, muscular sclerosis, and progressive pulmonary and cardiovascular disease.
Such patients routinely are denied access to MAID. To advocate that they be permitted the same choice available to those with six months to live is not putting our society on a slippery slope to death on demand, or to suicide on demand. Such characterizations are slurs and exaggerations used against the expansion of MAID to people who are suffering or will suffer as much as cancer patients, for example, before death from their disease.
In every such case, the choice belongs to the patient; it is a voluntary decision. The line between access and no access to MAID should be based on whether it is a voluntary decision of a patient with a terminal disease. A decision to end a person’s life made by another person violates the liberty, privacy, and due process rights that make all of us equal before the law. Any law that treats some suffering, terminally ill individuals differently from others similarly situated denies the equal protection of the laws, to which we are all entitled.
The voluntariness of the decision by a suffering, dying person assures that we are not on a slippery slope. Until we have laws that treat all such people fairly, the Final Exit Network stands ready to educate and train these people in how they may carry out their own decisions to hasten their own deaths.
Lamar,
I find this latest topic fascinating. It was not mentioned there but in Germany in 1939 the T4 (Tiergartenstrasse Four) program was enacted in Germany. It REQUIRED that no German citizen be allowed to suffer for any reason: physical, mental, social, financial or criminal). It lasted until 1941 when the Roman Catholic Church protested to all their congregations on a weekly basis that Christ and “life” require people to suffer. Their example, of course, was that Jesus suffered terribly on the Cross before He was allowed to die.
Actually, the T4 program did do great wonders. NO ONE from babies to old folks with dementia were allowed to voice or show they were suffering. I see nothing wrong with that. Some people do suffer from all varieties of problems. No one can judge who deserves release of not. I believe under Hinduism self death is allowed. In India they used to have a practice whereby the wives of the dead would throw themselves into the funeral fire and die with their own husbands when they were dead. The practice was called “Sutti” and the British stopped it from happening over time when they ruled India.
I had one friend whose wife bore a child requiring a breathing tube his entire life. The infant lived in great pain and breathing difficulty and the cost was huge to maintain a life like that. I don’t know how long that went on. It was years ago.
The danger, of course, in the T4 program was that after it was stopped, the German government then used the same T4 personnel to apply it to the murder of the Jews since their government had decided just being a Jew was too much suffering for the individual and for the nation at large. Of course, that was a terrible crime but it did come out of the T4 program.
That is why today most governments are very careful about letting such practices get out of hand. In Switzerland after every use of Nembutal to allow people an assisted death the Police are summoned to review the video and talk to family members and the doctors.
In my case I am dying from medical abuse of the elderly by two doctors who maimed my feet. Thus, my case would probably NOT be suitable for a Swiss exit since the performing doctors could be accused of complicity in a homicide. They do allow folks to go like a 104 year old Australian who had no illnesses or pain and was allowed an Assisted Voluntary Death in Switzerland last year.
I forgot to add this link to my prior comment. It shows how the “slippery slope” really did happen with the T4 program in Germany:
https://sanodox.blogspot.com/2011/03/t4-euthanasia-program-in-legal-history.html
From the link you provided:
The Nuremberg Trials found evidence that German and Austrian physicians continued the extermination of patients after October 1941 and evidence that about 275,000 people were killed under T4. More recent research based on files that were recovered after 1990 gives a figure of at least 200,000 physically or mentally handicapped people that were killed by medication, starvation, or in the gas chambers between 1939 and 1945.
What follows is not from the article in the link, but my own research: The T4 program was suspended for a time due to vehement opposition of the Catholic Church, but the Nazis found more devious ways to continue this program. It expanded to adults with mental illnesses as well. There is credible evidence from people who witnessed or were unwilling participants (like nurses) in these deaths that some of the higher functioning developmentally disabled children and mentally ill adults eventually figured out what was going on and tried to escape or fought back on their way to the gas vans or buses to take them to the gas chambers. And some families knew that their children or mentally ill family members were killed, too, and tried not to have them sent away. Why? When someone they knew received a letter that Johann or Mathilde had died due to a measles outbreak in the facility and he or she had already had the measles, they smelled a rat.
Sue,
Personally, I think the T4 program in Germany had good intentions. The real flaw is that it was not voluntary. I think we should allow VOLUNTARY euthanasia for any adult whether mentally competent or not down to age 13. Below that age parents consent should be required. For infants parents should make the decision. I believe Nembutal should be the drug of choice supplied by physicians.
By the way, those “gas chambers” were very efficient. A few thousand could die in the space of just five to ten minutes. However, they should only be used on a voluntary basis for those requesting a mercy death. There should be strict safeguards to prevent abuse.
However, before anyone gets an Exit, they should be required to try to live with their suffering for at least 3 months. Many may learn how to do that as I have. Suffering is rarely 24/7. It occurs usually just for a few hours possibly on a daily basis. The rest of the day may well be worth living.l
This blog post has been clearly thought out and written to inform readers of information to which they may not have had prior access. I especially profited by the distinctions in certain MAID states which allow the patient/client to “self-administer” lethal medications when they may no longer be able to swallow. I thank Lamar Hankins for this valuable information!
The T4 program did not have benign intent. It was to save money on care and treatment of disabled and mentally ill adults, “useless eaters” in Nazi thinking. It was primarily based on the 1920 book by Karl Binding and Alfred Hoche, “Allowing the Destruction of Life Unworthy of Life”. And yes, sadly, the eugenics movement in the US also added fuel to the fire as well and had some influence on Hitler. Far too many involuntary sterilzations took place in the US (and Canada) during the 1920s and for far too long afterwards. The infamous Carrie Buck case was one notable example.
If the safeguards mentioned
(from various state right-to-die laws)
do not prove sufficient,
then some additional safeguards can be added
—either to existing laws
or to new laws as they are enacted.
Here is another presentation of the
possible problem of the slippery-slope
with regard to the right-to-die
and a comprehensive list of safeguard-procedures
to put sand on the sidewalk
to prevent anyone from slipping:
https://s3.amazonaws.com/aws-website-jamesleonardpark—freelibrary-3puxk/SG-SLOPE.html
Personally, after reading all the comments above and the related links, I think everyone should be allowed to SELF exit with material like Nembutal to be available on a doctor’s prescription. The doctor and patient together should make the decision. Suffering minor children should be allowed to have an exit if the parents and the attending doctors agree. The parents should be able to decide with a doctor for suffering infants who cannot communicate. However, I do not think the State should be allowed to force these exits at all.
As a counter choice everyone going down this road should be encouraged to learn how to live with their suffering first. I have lived that way now for five years and even, if many times suffering is intolerable, the next day suffering is reduced in the natural cycle of how it occurs. Thus, suffering is never present 24/7. There are good times and bad times.
In the end EVERYONE dies whether a self exit was allowed or not. Thus, suffering has its own solution.
I have CKD 3B, by 2029/2030 according to the prognosis by the kidney doctor, I will need dialysis. He agreed that dialysis for older people is “very rough”. I will then be around 90. Following Dutch custom, I will ask the help of the local FEN Exit Guides to help me ending my life, unless an artificial kidney is available then. A Dutch laboratory is working on this, but the use of it opens to more questions than answers. However, what fun may it be to be alive at that age, specifically when you realize that my wife died three months ago.
Cornelis, from your post it appears you are age 80 now and worried about what happens when you get to age 90. I am age 85 now and dying now from two doctors assaulting my feet which could be adjudged as a homicide after I die when the police order an autopsy. I thought the Netherlands allowed one to Exit if seriously ill. Here in America in my state all they have is a Living Will and Advanced Directives. Implementing that involves refusal of all treatment including food and water. It takes 10 to 20 days of extreme torture 24/7 to die that way.
You will probably never reach age 90. From age 80 onwards the population numbers plunge rapidly. Thus, you really have no worries. The best bet for you and I is to learn to live with the suffering and await the usual conclusion: breathing or heart stoppages. My breathing has already stopped about four times. You will probably go that way long before you even get to age 90. FEN has turned me down twice in the past several years so their medical committee must have felt the same: just live each day to the fullest as if it was our last since it well may be our LAST !
Voluntarily stopping eating and drinking (VSED) does not have to be torture in any form or fashion if the protocols for VSED are followed. Please search this blog using the acronym VSED to find resources that are available and learn how to accomplish VSED following established protocols.
Lamar, if I use VSED, then the homicide possibility from the autopsy after my death would be ruled out. I have to die from the effects of assault and battery only. Thus, in my case I am locked in unless some other natural terminal illness hits me first.
So sorry for the loss of your wife. It must be very difficult for you right now, especially while living with a long-term illness like CKD 3B. What I do know is that most people recover from the death of a spouse or long-time partner. It can take up to a year or more to find a “new normal” as a widower or widow. Give yourself time. Maybe consider a grief support group if you haven’t already done so. If you have tried one and didn’t like it, try another one.