The Case for Medical Aid in Dying: Part 3

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COMMENTARY

In parts 1 and 2 of this series,^1,2 I examined arguments by opponents of MAID based on beliefs that the practice is categorically wrong, followed by arguments asserting unacceptably harmful consequences that might follow MAID. In both cases, I maintained that these arguments are unpersuasive. In this final article, I will examine a type of argument that has played a prominent role in this debate: the slippery slope.^3-5

The Slippery Slope

The basic form of the argument is that even if A is not so bad, if allowed, it will inexorably lead to B, which is even worse, then to C, which is worse still, and on to some catastrophic state of affairs. How should we look at these kinds of arguments? Bernard Williams, widely regarded as one of the most astute and nuanced ethicists and philosophers of the late 20th century, wrote an insightful article entitled “Which slopes are slippery?”⁶ In it, he points out that there are 2 assumptions behind a slippery slope argument. The first is that what is at the bottom of the slope is something we all see as horrible, even if the first step may seem acceptable and even positive to at least some of us. He points out that frequently, the advocates of this sort of argument actually think the first step is wrong as well, but are not sure they can persuade others. If I think A is wrong but you do not, I may get you to agree to oppose A if I can convince you that it inevitably leads to B, then C, and so forth, until we reach some point that we all agree is wrong.

The second assumption is that the slide down the slope, once begun, is unstoppable. This sometimes involves the notion that the advocates for A will then advocate for B, then for C, and so on. But if we believe A and B are desirable, but C and D are not, is it not logical to support A and B but oppose C and D? The usual response here is that each step is so incremental and essentially indistinguishable from the immediately prior step that drawing a line at any point on the continuum is simply arbitrary and hence hard to defend. One could argue, for instance, that wherever one draws the line of eligibility for MAID procedures, those just outside that line can understandably argue that it is unfair that they are being excluded. Why those with a prognosis limited to 6 months? Why not 7 months or 8 months? In cases of protracted suffering, why not extend MAID to those whose deaths are not imminent? If it is acceptable for age 18, why not 17, 16, and children? If MAID is legal, why not permit euthanasia for those who cannot self-administer a lethal drug? Surely the incompetent suffer as much as the competent, so why not allow a competent person to leave instructions to authorize euthanasia once they reach some future condition that they feel is unacceptable to them at a time they are no longer judged competent? And on and on.

Williams makes the point that this is not a valid type of argument, noting that “indistinguishable from is not a transitive relationship: from the fact that A is indistinguishable from B, and that B is indistinguishable from C, it does not follow that A is indistinguishable from C.” Around most matters, even if it is difficult to draw a precise line between acceptable and unacceptable, it is likely that agreement can be had as to a large portion of the behaviors at issue that some are not acceptable and others are.

In matters of public policy, we nonetheless need to draw some explicit line in the sand between acceptable and unacceptable at a practical level. Williams argues that in such cases, it is a long-established societal practice to draw an arbitrary line as a reasonable and practical approximation to our sense of what is the conceptual breakpoint between acceptable and unacceptable. We draw arbitrary lines all the time, and these can be pragmatic solutions that work quite well even if we cannot logically defend why the line is drawn precisely where it is as opposed to somewhere else. Speed limits on roads are an example. If the speed limit is 55, we cannot logically defend that 54 is categorically safer than driving at 56. The age for consent to marriage, the age at which one may buy alcohol, the blood-alcohol level that defines intoxication, and the age at which we are deemed mature enough to vote are other examples. As a society, we are free to draw arbitrary demarcations in the continuum of behaviors when they have practical utility. We are not doomed to keep sliding down the slope.

Pushing the Agenda

But what about the concern that advocates of MAID do not want to stop at A? Their agenda is to push for more and more permissive laws expanding the pool of individuals who are eligible as well as easing access to the process. Opponents cite changes that have in fact occurred in other states and countries that have permitted MAID. It is indeed true that some advocates believe in much broader applications than imminent terminal illnesses and/or support euthanasia as well. But just because there is a push in this direction does not automatically make it a bad thing. We must judge the merits of each step and decide whether we find it acceptable.

Frankly, I personally find a lot of the subsequent developments cited as if they are obviously horrific to be positive. I think it is totally reasonable to allow MAID for intractable suffering even in the absence of imminently terminal illness. It seems to me quite reasonable to allow a competent individual to state in advance that they wish to be euthanized once they reach a defined level of physical or mental deterioration, even if they are not judged competent at that later point. To me, one of the greatest tragedies of not allowing euthanasia in such circumstances is that an individual who has an illness that is likely to reach a point at which they are no longer physically and/or mentally capable of ending their own life must make and implement the decision to terminate their life while they are still able, when by their own standards some period of satisfying life remains. I am not suggesting that everyone should agree with me around each of these issues. I am only saying that the pressure to move to a next step is not automatically a bad thing. The case needs to be made for each new change as to whether it is desirable or undesirable. The fact that there is pressure to move in and of itself is morally neutral.

The metaphor gets in the way here. If we are on a slippery descending incline and we do not want to end up at the bottom, then any movement we feel is ominous. If it is slippery enough, the only safe thing to do is not get on the slope at all. I think a much more apt analogy in these kinds of situations is a hill rather than a slope. This is in keeping with the Aristotelian notion of the golden mean—namely that the desirable position, the point of virtue, is somewhere between 2 extremes, both of which are morally bad.⁷ When an advocate of a position wants to continue moving in a particular direction, the question we need to answer is whether the advocate is pushing us uphill and closer to the optimal position, or downhill toward one of the extremes.

Consider the following slippery-slope argument: “It was a mistake to give women the right to vote. After all, once they had it, they were not satisfied. Advocates then were pushing for equal employment opportunities, equal pay, protection from on-the-job sexual harassment, and increasing numbers of women in management. Where will it end? Before you know it, they will want women’s salaries to be double that of men and all supervisors to be women. This is a slippery slope indeed, and it all started with giving them the right to vote.” I suspect very few of us would find this argument compelling, because most of us see women’s rights as still on the ascending slope of the hill and further pressure to advance them as justified. Furthermore, I suspect we all feel that the movement could and would be stopped long before it reached the projected end of a woman-dominated society. Yet the logical structure of this argument is exactly the same as the ones made regarding MAID and its alleged slippery consequences. The mere fact that there has been pressure to move the line of what is permissible is not in and of itself ominous. We need to assess each proposed step on its own merits, and then decide whether to support it or argue to draw the line there.

The Disability Community

There is one instance of the slippery-slope argument that, because of its importance, merits specific comment. Spokespersons for the disability community have raised concerns that if MAID were extended to individuals based on pain, suffering, or dignity-depriving dysfunction, it could lead to a judgment that individuals with disabilities have lives not worth living and result in pressure for those individuals to request MAID.⁶ This would seem a highly unlikely consequence of MAID legislation as currently conceived, even where it has been broadened to individuals without imminently terminal illnesses. Safeguards against undue influence on the individual choosing MAID by persons who stand to benefit from hastening the individual’s death have been accepted as important for everyone, not just those with disabilities. Any future attempt to unduly pressure individuals with disabilities should be vigorously opposed by us all. But it is not a reason to reject MAID as currently construed.

Spokespersons for the disability community sometimes go further to argue that even if an individual with significant functional limitations freely opts for MAID, this is an afront to all disabled individuals because it is an assertion that living with significant functional impairments is not a life worth living. I think this is an unfair conclusion. When an individual chooses MAID, they are not making a judgment as to the worth of the lives of a group of people who happen to share their medical condition or limitations. They are not even saying that their particular life is in some abstract sense not worth living. Rather, they are saying that after considering and weighing all the unique components of their situation, they are deciding that they would prefer not to go on living.

Every significant decision we make should consider all the unique circumstances of our lives in light of our own values and preferences. Such a decision should not be seen as a judgment on the lives of others who happened to share some features with our lives, or on the decisions they choose to make in light of their unique circumstances. This is true of all our important life decisions, such as whether to marry, whether to have children, whether to divorce, what career you choose, and where to live. We should not be condemned to having every one of our choices be viewed as a judgment we are passing on others.

Concluding Thoughts

In this series of articles, I have argued that the burden is on opponents of MAID to demonstrate why we should be deprived of this particular exercise of our freedom and autonomy. I have considered in turn what I view as the primary categories of these arguments. I believe they fail to make the case. These discussions have focused on MAID for terminal illnesses, and although I personally support broader applications in cases of intractable suffering or loss of dignity, that merits fuller discussion at another time.

Dr Heinrichs is a psychiatrist in Ellicott City, Maryland.

The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times™.

What are your thoughts on MAID? Share your questions, concerns, and potential solutions via PTEditor@mmhgroup.com.

References

1. Heinrichs D. The case for medical assistance in dying: part 1. Psychiatric Times. https://www.psychiatrictimes.com/view/the-case-for-medical-aid-in-dying-part-1

2. Heinrichs D. The case for medical assistance in dying: part 2. Psychiatric Times. https://www.psychiatrictimes.com/view/the-case-for-medical-aid-in-dying-part-2

3. Komrad MS. First, do no harm: new Canadian law allows for assisted suicide for patients with psychiatric disorders. Psychiatric Times. 2021;38(6).

4. Pies R. Will the AMA heed its own ethics council regarding assisted suicide? Psychiatric Times. 2018;35(7).

5. Pies R. Physician-assisted dying for adolescents with intractable mental illness? Psychiatric Times. 2016;33(5).

6. Williams B. Which slopes are slippery? Making Sense of Humanity and Other Philosophical Papers. Cambridge University Press; 1995:213-223.

7. Aristotle. Nicomachean Ethics, 2nd Edition. Translated: Irwin T. Hacket Publishing; 1999:27-30.