Understanding the “end-of-life” debateSeptember 9, 2014
Understanding the issues in end of life care (Revised)October 9, 2014
In the last paragraphs of the CMA’s position paper on Euthanasia and Assisted Suicide (http://policybase.cma.ca/dbtw-wpd/Policypdf/PD14-06.pdf ) (Updated in 2014) the authors warn that if euthanasia or assisted suicide were permitted in Canada what could follow would be a “slippery slope…” That is, if you permit capable adults the right to some form of medical assistance in dying then the next step would lead you tumbling down a precipice (the slippery slope) to leave you helpless in a place you really do not want to be.
Slippery slope arguments work by suggesting that if you permit, or accept “this” (for instance euthanasia or medical aid in dying for capable, terminally ill-adults) then inevitably, by a series of small and perhaps seemingly innocuous steps, you will end up somewhere everyone would accept is very bad. The conclusion is therefore not to permit “this” in the first place. Slippery slope arguments are not always fallacious, but they do always rely on a chain of either causal, or conceptual reasoning connecting the dots between the “this” which might be acceptable and the “that” which manifestly is not. So, in the debate about euthanasia, or medical aid in dying it will be very important to look carefully at the possible defences against the slippery slope. Can we, should we, build fences and guardrails?
But before we look at fences, let’s look at the slope (or rather slopes) instead, let’s examine the territory that is so slippery. I think, that in this debate there are two quite different slopes, and two quite different forces at play to push us onto those slopes. This is because there are two quite different sets of arguments that get presented to support changing the law to permit some sort of physician aid in dying.
The argument from “autonomy”
The first is a straightforward argument from personal autonomy or freedom or independence. I ought to be as free as possible to live my life, as far as possible, as I wish to live it. The basic limitation on this personal freedom is that I cannot be free to perform acts that harm others. (This goes back to Bentham and Mill, and, of course there is much more we could say about this.) A version of autonomy is a prevalent principle in health care. The doctrine of “consent” to treatment is founded on the idea that I should not have things done to me (for instance, medical treatment) without my agreement. The Ontario Health Care Consent Act (1996) describes itself as an act to promote autonomy. (You can probably see there are two versions of “autonomy” or “freedom” being used here – one is positive, a “freedom to” do something, the other is negative, a “freedom from” something. These two senses are too often confused in health care. I am certainly entitled to refuse treatments – I can withhold my consent and exercise my “freedom from,” but I do not have a corresponding right to demand a treatment, a “freedom to…”)
In the end of life debate, the concept of autonomy (freedom from) gives rise to patient refusals of treatment, or resuscitation, or feeding, and the patient-prompted removals of treatments that have already been started, such as ventilator support, pacemakers, dialysis and so on. In each of these cases it is recognized that these decisions are within the authority of a capable patient, and even if those refusals of treatment result in death occurring earlier than it otherwise would – those refusals must be honoured. This is accepted as legal, respectful of persons, and good medical practice. (The CMA position paper on Euthanasia and Assisted Suicide makes exactly this point in its preamble.)
The autonomy argument for euthanasia or medical aid in dying goes on to say I ought to be able to make the decisions in my life that most affect me. That must include the time and means of my death if I so choose, and it must include the ability to enlist assistance if I can find a willing participant. Hence, if we are to be respectful of persons and individual autonomy we should permit people to seek and accept medical aid in dying. (You could think of this as the “boomer” argument – around my dinner table amongst my middle-aged, wine-drinking friends this is the position you would hear most commonly articulated.)
The slippery slope for the boomer (autonomy) argument.
If euthanasia or medical aid in dying is permitted on the grounds of autonomy for capable patients with incurable illness and intractable pain it is easy to see where the next steps will come. Refusals of treatment grounded in a patient’s autonomy are already permitted for a non-capable patient through advance directives (written or given when the patient was capable) or through the decisions of a substitute decision-maker (again authorized when the patient was capable.) What argument could there be for not extending the same right to medical aid in dying? If medical aid in dying is permitted why cannot I authorize that assistance now, while I am capable, to take effect at some time in the future when pre-specified conditions are met and when I am no longer capable? This would be morally no different and would have no different effect from an advance directive that stated that I should not be resuscitated or intubated under a specified set of conditions, and that is standard practice and relatively uncontroversial now.
The other shove down the slope from the autonomy argument concerns the conditions I must meet in order to qualify for medical aid in dying. Most such legislation would include language concerning terminal illness, incurable disease and intractable pain. But who gets to define what counts as my pain? And all life is terminal. If I am free to make the decisions that most affect me then I must be free to define the conditions under which I take my life to be worth living. And if medical aid in dying is available, on the grounds of autonomy, to anyone how can it be denied to me if that is what I want?
The relief of suffering argument
The second argument for permitting euthanasia or medical aid in dying is that it is sometimes the only viable way of relieving intractable pain or suffering. We would not leave an animal to suffer in this way – we would “put it out of its misery” how can we deny that same boon to our fellow suffering humans? It is cruel to leave people to suffer and if the only way of relieving that suffering is to end that person’s life then we have a moral duty to do so. This argument puts medical aid in dying as part of the range of options that should be available to the palliative care specialist. It should, of course, be pointed out that one of the basic premises for this argument (that the only way of relieving suffering is to kill the patient is highly contested. Many palliative care specialists would argue that it is never necessary for a patient to suffer while dying. However, this is, in effect, the approach of Bill 56 in Quebec, which makes medical aid in dying part of the toolkit for palliative care.) The basic position, however, does have a great deal of emotional and persuasive power. It is cruel to leave a person to suffer.
The slippery slope for the relief of suffering argument
Proposals for permitting euthanasia or medical aid in dying usually contain a range of conditions – terminal illness, intractable suffering and capable patient for example. The push down the slippery slope that comes from the relief of suffering argument concerns “capacity.” If it is cruel to let a human being suffer it is cruel to let that person suffer regardless of his her capacity and regardless of whether that person has ever been capable of making any form of decision for him or herself. This is precisely the position articulated by Robert Latimer in his defence against the charge of murdering his daughter Tracy and it is precisely the argument presented by the Dutch authors of the “Groningen protocol” which lays out the conditions under which they believe it is acceptable to euthanize an infant.
In the debate on euthanasia and medical aid in dying fears of a “slippery slope” are often used as a form of argument against permitting any liberalization of the law. To assess the effectiveness of those arguments it helps to understand the nature of the slippery slopes we should be worried about. And, understanding those slopes may give us a better chance of building the fences we might need.