The Medical Slope of Assisted Death: From "Who May" to "Who Should"

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It has been argued¹ that no slippery slope of assisted death (AD) exists in America. In particular, it has been remarked that the principal eligibility criterion of “terminal condition” has remained constant over time.

Eligibility, however, is not the most important factor in predicting the scale of AD use. As shown in Table 1, Canada has 580% of the incidence of AD observed in Oregon (when expressed as a fraction of all deaths). Although Canada has no terminal illness requirement, only 4.1% of Canadian euthanasia is practiced outside that category. Clearly, the quantitative difference between Oregon and Canada cannot be explained in that manner. The true cause, I suggest, lies in the explicit Canadian definition of euthanasia as medical care.² The true movement, now observable on the American slope, lies in an incremental adoption of that definition in law and in practice.

Table 1. Comparison of AD incidence in Oregon and Canada

Although individuals may be supportive of a hypothetical right to die conceived as a sovereign personal liberty to choose the time and manner of one’s death, they likely also desire assurance that resulting deaths will be objectively justified. Many believe that placing AD under the mantle of medicine might provide the desired certainty. Indeed, there is a general expectation that medical science (and the clinician's wisdom) would serve to balance the dangers of unrestrained choice.

As we shall see, however, quite the opposite is true.

Conflating Political Compromise With Objective Standards

In medical ethics, the principles of autonomy (ie, subjective patient self-determination) and beneficence (ie, what is believed to be objectively in the patient’s best interest) always exist in dynamic balance. One principle may be emphasized but cannot ever exclude its counterpart. Considering who should be allowed to choose AD thus also raises the question of which patients are objectively indicated for such death.

It is here that we meet the central failure of claiming medical legitimacy for the practice of AD. For crudely stated: there is no scientifically objective standard for the provision of assisted death.⁷ All we have are eligibility criteria born of political compromise. To confound one with the other, most unfortunately, is to conclude that all patients medically eligible to choose AD are objectively designated for that death (whether they wish to avail themselves of that privilege or not). In other words, we are inviting physicians to behave as though patients who may partake in this activity actually should.

Clearly then, conceptualizing AD as benevolent medical care does not lessen the dangers of choice. On the contrary, such medical thinking encourages theorists and practitioners of AD to expand its application far beyond the exceptional cohort of patients originally considered.

Post-Oregon Legislation Has Progressively Reinforced the Medical Interpretation of AD

What’s in a name? At the time of Oregon's Death with Dignity Act (DWDA), AD was commonly understood as physician assisted suicide (PAS), being a sovereign personal act (albeit assisted by a complicit physician prescribing lethal drugs).

And yet, there was great uneasiness concerning negative associations of the word suicide, not only in relation to life insurance and contract law but also as a fundamental principle. For that reason, the term PAS does not occur in the DWDA. In fact, no name at all (ie, no defined term) was then given to denote the technical act of AD.⁸ And the same observation applies to post-Oregon legislation in other states.^9,10

The States of New Mexico and Colorado have resolved this ambiguity by adopting the internationally established term medical assistance in dying (MAID), defined as "the medical practice of...".^11,12

This formulation suggests a complete conceptual about-face: from the maximal expression of active patient self-determination (as postulated in Oregon) to a fundamentally passive vision of AD, as medical treatment, under the responsibility of attending professionals.

Societal obligations and mandates. Health care conceived as a human right creates extensive social obligations.¹³ Under this paradigm, AD is not merely permitted, but actively promoted by the state, transformed from a liberty of permission to an entitlement right.

Oregon, again, provides a case in point. Although the original DWDA contained no mandates or entitlements, loose medical assumptions have since been used to justify both AD for non-state residents,¹⁴ and the use of state funds to ensure access.¹⁵

Furthermore, mandates designed to maximize AD access have become a staple of legislation from other states. Such initiatives typically presume the willing participation of both institutions and professionals. Refusal is available to individuals and private institutions, but not to institutions run by the state, and is always subject to critical limitations.¹¹

Therefore, contrary to claims that AD will change nothing for typical patients, access to AD is systematically prioritized over access to non-participating professionals and institutions. Hence, the desires of a small patient minority are prioritized over those of a much larger majority.

Standard professional obligations. In many cases, even nonparticipating physicians cannot entirely shield their patients from the invasive presence of death-as-care. For when conceived as a standard medical procedure, AD demands that physicians apply well established protocols. Colorado, Vermont, and New Mexico, for example, require that all medically qualified patients be informed of their eligibility. Sometimes termed the right to know,¹¹ this practice is allegedly justified under accepted medical standards of informed consent, whereby any therapeutic discussion must include consideration of all available alternatives.

Proactively providing information regarding AD is thus prioritized over protecting patients from the suggestion of suicide.

The Impact of Normalizing AD in Medical Practice

Regrettably, the pressure exerted on patients to accept medical AD is not limited to passive suggestion, as doctors do not simply inform patients of different options. On the contrary! It is the primary duty of physicians to propose optimal medical care, with the full force of professional authority (subject only to patient consent).

In the end, encouraging doctors to speculate on the objective benefit of AD potentially exposes every eligible patient to the overbearing weight of such proposal. And since (as previously noted) there are no objective standards for the clinical indication of AD, all this professionally tendered lethal suggestion is justified only by the subjective prejudice of individual doctors.¹⁶

The medical conception of AD also emboldens other individuals (eg, professionals, family, friends, and casual acquaintances) to voice their opinions, since the alleged objective nature of these questions invites the free expression of all.

In consequence, although it was once assumed that any assisted death regime must include strict measures to protect patients from external influence, conceptualizing AD as medical treatment brings precisely the opposite effect.

At worst, people are literally badgered to consent, in the same way that uncooperative patients are badgered to take their insulin. For that is the strict logical consequence of representing AD as benevolent medical care.^17-19

Rejected by Both Doctors and Patients; a Democratic Bait and Switch

Of course, slopes, slippery or not, are only harmful when they lead us where we do not want to go. There are 3 powerful indicators that impugn the social legitimacy of medical AD:

1) Professional opinion²⁰ has been trumped by political decree. A majority of doctors may pragmatically support the freedom of colleagues to provide AD where it is legal but tellingly refuse to participate themselves.

2) There is—at most—a marginal demand for AD²¹ among the intended clientele: never more than 9-10% in any patient category, as observed in Canada and the Netherlands (Table 2).

3) Democratic support has been almost entirely enlisted around the ideal of patient-requested death-as-choice, not that of physician-proposed death-as-care. Indeed, there has been no focused public discussion concerning the implications of medically justified AD.²² On the contrary, those implications have been essentially ignored in the validation of autonomous choice.

Table 2. Maximim AD Consent Rate: Terminal Cancer

Concluding Thoughts

This presents all the characteristics of a true slippery slope: a virtually inevitable slide from A to B, resulting not from deliberate policy decision, but from conflating subjective suicidal desire with objective medical determination, and thus conflating may with should. In the US, this medical model is emerging piecemeal through a mosaic of legislation in multiple states, where new laws in any one state may likely affect attitudes and practices elsewhere. In this progression, it is not eligibility criteria or administration methods that are immediately crucial, for the expansion of those 2 factors is logically found downstream from the medical definition of AD.

Nor may we discount future AD beyond the consent barrier, since reputedly appropriate care cannot be ethically withheld from the incapable.^26-29 Ideas have consequences. The slope is real—and slippery beyond even what many opponents of AD have yet imagined.

Gordon Friesen is a disabled individual who has followed the assisted death question closely since the early 1990s, and is currently President of the Euthanasia Prevention Coalition.

References

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2. An act respecting end of life care, Quebec bill 52, § 3.3, 3.6, 4 (2014). Accessed November 20, 2024. https://www.legisquebec.gouv.qc.ca/en/document/cs/s-32.0001

3. Oregon Health Authority, Public Health Division, Center for Health Statistics. Oregon death with dignity act 2023 data summary. Oregon.gov. Accessed November 30, 2024. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year26.pdf

4. Health Canada. Fifth annual report on medical assistance in dying in Canada 2023. Accessed December 24, 2024. https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2023.html#a2

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8. The Oregon death with dignity act Oregon revised statutes 127.800 – 127.995. 1995. Accessed January 2, 2025. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/statute.pdf

9. The Washington death with dignity act. Washington State Legislature. 2009. Accessed November 3, 2023. https://app.leg.wa.gov/rcw/default.aspx

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13. Constitution of world health organization. 1946. Accessed November 30, 2024. https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1

14. Relating to Death with dignity; and declaring an emergency. Oregon HB 2279. 2023. Accessed November 30, 2024. https://olis.oregonlegislature.gov/liz/2023R1/Measures/Overview/HB2279

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16. Stefan S. Medical aid in dying: not a medical choice, but a personal one. Psychiatric Times. December 8, 2022. https://www.psychiatrictimes.com/view/medical-aid-in-dying-not-a-medical-choice-but-a-personal-one

17. Kaplan M. Canadian doctors accused of pushing medically assisted death on patients: ‘They make you feel less than human.’New York Post. July 25, 2024. Accessed January 2, 2024. https://nypost.com/2024/07/25/world-news/canadian-doctors-accused-of-pushing-euthanasia-on-patients/

18. Schadenberg A. Canadian cancer patient was ‘offered’ euthanasia in the operating room. Euthanasia Prevention Coalition. October 15, 2024. Accessed January 2, 2024. https://alexschadenberg.blogspot.com/2024/10/canadian-cancer-patient-was-offered.html

19. Bartlett G. Mother says doctor brought up assisted suicide option as sick daughter was within earshot. CBC News. July 24, 2017. Accessed November 30, 2024. https://www.cbc.ca/news/canada/newfoundland-labrador/doctor-suggested-assisted-suicide-daughter-mother-elson-1.4218669

20. Chochinov HM, Fins JJ. Is medical assistance in dying part of palliative care? JAMA. 2024;332(14):1137-1138.

21. Friesen G. The harms of assisted death are not just a ‘disabled thing’. Psychiatric Times. December 19, 2022. https://www.psychiatrictimes.com/view/the-harms-of-assisted-death-are-not-just-a-disabled-thing

22. Marchand M. L’aide médicale à la mort : réflexions et débats en cours au Québec. Frontières. 2011-2012;24(1-2).

23. Canadian Cancer Statistics Advisory Committee. Canadian cancer statistics. Canadian Cancer Society, Statistics Canada, Public Health Agency of Canada. 2023. Accessed November 30, 2024. https://cdn.cancer.ca/-/media/files/cancer-information/resources/publications/canadian-cancer-statistics-2023/2023pdfen.pdf?rev=43c8cc8f34b547d4ad227000bd8df9dc&hash=68C12E2EE9AA7308C14C3065BDFED5B0

24. Global cancer mortality: both sexes. World Cancer Research Fund. Accessed November 30, 2024. https://www.wcrf.org/preventing-cancer/cancer-statistics/global-cancer-data-by-country/

25. Regional Euthanasia Review Committee. Annual report 2023. 2023. Accessed January 2, 2024. https://english.euthanasiecommissie.nl/the-committees/documents/publications/annual-reports/2002/annual-reports/annual-reports

26. Lévesque C. Quebec college of physicians slammed for suggesting MAID for severely ill newborns. National Post. October 11, 2022. Accessed November 30, 2024. https://nationalpost.com/news/quebec-college-of-physicians-slammed-for-suggesting-maid-for-severely-ill-newborns 

27. An act to amend the criminal code (medical assistance in dying). 43rd Parliament (2021). Accessed November 30, 2024. https://www.parl.ca/DocumentViewer/en/43-2/bill/C-7/royal-assent

28. Komrad M. Oh, Canada! Your new law will provide, not prevent, suicide for some psychiatric patients. Psychiatric Times. June 1, 2021. https://www.psychiatrictimes.com/view/canada-law-provide-not-prevent-suicide

29. Act respecting end-of-life care. LegisQuebec. Updated October 1, 2024. Accessed January 2, 2024. https://www.legisquebec.gouv.qc.ca/en/document/cs/s-32.0001