In short, there are tragic situations where healthcare professionals’ routine goals of restoring health or preserving life are unattainable, and indeed inappropriate, and times when assistance with dying may indeed constitute desirable and appropriate care.
Certainly, those who assist with dying, should this practice be decriminalised, should have the right to opt out of participating in such practices if they clash with their conscience, as is the case with termination of pregnancy (abortion) in South Africa.
Slippery Slope
A significant argument against assistance with dying is that practising it would have ethically undesirable or unacceptable consequences, such that it would be better to refrain from it altogether.
Proponents of this argument predict a variety of undesirable consequences. For example, it is claimed that some healthcare professionals would abuse their social standing and power to exert undue influence over vulnerable patients to end their lives, thus embarking upon a slippery slope towards non-voluntary or even involuntary euthanasia.
This would undermine the trust people have in healthcare professionals and in the professions themselves. Others hold that hospice care, pain relief and comfort care would be undermined.
This argument is not about assistance with dying being morally wrong in itself, or intrinsically wrong, but about its possible or probable effects.
Presumably, then, if predicted bad consequences fail to materialise, assistance with dying as such would be ethically acceptable.
Any responsible practice of assistance with dying would need to put in place strict guidelines and effective safeguards to prevent undesirable consequences, accompanied by monitoring, reporting and oversight.
Predicted bad consequences remain just that – predictions that are not inevitable, but may turn out to be alarmist and false. Although the slippery-slope argument has intuitive appeal, both its logical and empirical versions are questionable.
First, according to the logical version, the justification used for assisted dying would also justify other forms of killing that are clearly wrong. It does, however, not follow, on logical grounds, that the reasons justifying assisted dying, namely respect for autonomy and mercy, would also justify killings that are neither respectful of autonomy nor merciful.
People routinely make a clear distinction between ethical and unethical practices, even if they are closely related in other respects, including justified and unjustified forms of killing, for example in self-defence or war.
Moreover, there is no logical reason why medical practitioners, even (improbably) assuming they might sometimes wish their patients dead, will slide down a slippery slope only in respect of one subset of end-of-life decisions, namely, assisted dying.
It seems perfectly reasonable to assume that what is true of withholding or withdrawal of potentially life-sustaining treatment, or terminal sedation, is prima facie also true of assisted dying. Logically speaking, slippery-slope dangers would be equally existent or nonexistent in either case.
Second, the empirical version of the slippery-slope argument holds that assistance with dying will, as a matter of fact, lead to unjustified forms of killing, such as involuntary euthanasia.
If this were in fact true, one would expect there to be evidence of all kinds of other slippery slopes in end-of-life decision-making, for example, that the accepted medical practice of refusal of life-sustaining treatment would also put one on a slippery slope towards assisted dying.
On the contrary, available evidence does not bear this out. A comparative study of limitation (rationing) of life support in intensive care units (ICUs) in the United Kingdom and South Africa, shows no significant differences across the developed/developing world “divide”.
Where physician-assisted suicide is legal, for example, in the states of Oregon and Washington in the United States, there is no evidence of a slippery slope to voluntary active euthanasia.
More generally, proponents of the slippery-slope argument need to produce credible evidence that withholding or withdrawal of life-sustaining treatment lead to abuse of vulnerable patients. Lack of such evidence is not surprising, since decision making in this context involves loving family members and caring, professional healthcare professionals.
Nor is there credible evidence that legalising assisted suicide in, for example, the states of Oregon or Washington, has led, or would lead, to voluntary euthanasia.
Having said that, such decriminalised practices should be closely monitored, for example, to assure proper informed consent. Interestingly, a significant percentage of patients who opt for physician-assisted suicide in Oregon eventually die of natural causes, but they have the assurance that if their suffering became unbearable they would be assisted with dying.
Abuse is possible in all human activities and practices. It follows that opponents of assisted dying have a moral responsibility to factor in the possible abuse of patients at the end of life who are denied assistance with dying.
So, the claim that assisted dying is somehow unique or different from other end-of-life decisions – since it alone would make society or medical practice slide down a slippery slope towards unintended forms of killing, thus eroding our respect for human life – lacks evidence.
Still, the Nazi’s “euthanasia” programme before and during the Second World War is often cited as proof that legalising assistance with dying would place society on a slippery slope to something equally bad.
Before the war, Nazi Germany indeed embarked upon a programme of non-voluntary “euthanasia” of defective infants. The programme expanded to non-voluntary and involuntary euthanasia of adults with mental and physical disorders.
It was embedded in an ideology of the superiority of the Volk, and the motive was racial purity. It was state-sanctioned mass murder, not euthanasia where death is voluntarily requested and is in the interest of the person who dies. It was an abuse of the term “euthanasia”. Significantly, holocaust survivors do not see any link between the Nazi “euthanasia” programme and voluntary active euthanasia in a caring healthcare setting.
Since unintended – foreseen and unforeseen – bad consequences are risks that attach to virtually any human activities and practices, the constant challenge is to put in place the policies, structures and practices to address those risks as best we can.
In sum, possible bad consequences need to be managed through effective strategies and their implementation. And we
