Friday, April 8, 2016

Euthanasia and the Slippery Slope

Some of the arguments for and against what is now being called "Physician Assisted Death" (PAD)  rest on core ethical beliefs and are intractable. But the "slippery slope" argument that legalizing PAD in limited and arguably ethically acceptable circumstances, as with the Oregon "Death with Dignity Act," will inevitably lead to ethically unacceptable actions, is testable.

PAD became legal in Oregon in 1997. In the intervening 19 years there has been no significant public pressure to legalize PAD for persons who are not terminally ill, and no evidence suggesting that PAD is victimizing vulnerable populations such as the poor, ethnic minorities, or frail elderly. PAD is a relatively infrequent event, accounting for 0.4% of deaths in 2015. Further, PAD has not undermined good end-of-life-care, another slippery slope fear. In actual fact, Oregon is among the national leaders in providing good palliative and hospice care.

But although Oregon proves that the slippery slope argument against laws modeled on the Death with Dignity Act is invalid, reports from Belgium and the Netherlands are worrisome. In those countries PAD and active euthanasia occur at 10 times the rate in Oregon. What I find most disturbing is the way Belgium and the Netherlands have extended the practice beyond the terminally ill to include people described as "tired of living" and to others suffering from otherwise non-terminal psychiatric ailments.

If you're interested in PAD and the potential validity of the slippery slope concern, please read Rachel Aviv's brilliant New Yorker article from last year - "The Death Treatment," in which she tells the story of Godelieva De Troyer:

Godelieva De Troyer

At 64, De Troyer had recently been abandoned by a boyfriend and was feeling distant from her son. She sought out Dr. Wim Distelmans, an oncologist and professor of palliative medicine (!). Distelmans, who is apparently revered in Belgium for his support for euthanasia, cuts a handsome and charismatic figure:

Wim Distelmans

De Troyer had lived a roller coaster life. Her emotional states ranged from ebullience when her relationships were fulfilling to painful despair when her important attachments were disrupted. But given the clear history of relatedness during her adult life, I would wager that virtually all experienced psychiatrists in the U.S. would have seen De Troyer's wish for death when she met with Distelmans as a transient symptom, not an autonomous choice.

Rachel Aviv was able to interview Distelmans. Here's a crucial paragraph from her article:
Distelmans told me that he had no doubts about the way he handled Godelieva’s case. He explained that she was “a very nice person, a very warm person,” and that she had “wanted to do one decent thing in her life, and that is to die in a decent way, because the rest of her life was such a horrible mess.” When I asked if he worried about transference—perhaps she had idolized him or depended too much on his opinion—he laughed and said, “I’ve never met a patient who is willing to die to please someone else.”
I'd make the further wager that most experienced therapists in the U.S. would share Aviv's speculation that a "transference" was at work. And Distelmans's statement that no one is willing to die to please someone else is sheer nonsense. If we needed more proof than "psychological autopsies" conducted after suicides provide, just think of the suicide bombers who blow themselves up with heroic martyrdom as one of their motives.

Washington (2009), Vermont (2009) and California (2016), the three additional states that have passed "Death with Dignity" laws, all follow Oregon by limiting the procedure to patients with terminal conditions from which they are expected to die within 6 months. The slippery slope argument holds no water against that approach. But advocates for similar laws in other states should recognize that there appear to be real slippery slopes across the Atlantic, and must explain clearly the difference between Belgium and the Netherlands and what Oregon, Washington, Vermont and California have done.

(I've never met Rachel Aviv, but I've written about her superb work here and here.) 


Anonymous said...

Dear Dr. Sabin,

I hope that you will reconsider your opinion of the “slippery slope” argument in light of supervening events in Canada, a nation very similar to the USA in many respects. After the Canadian Supreme Court effectively ordered Parliament to write legislation enabling “Medical Aid in Dying” or “MAiD” (the Canadian euphemism for physician assisted suicide (PAS) and euthanasia), the government commissioned ethics panels which concluded that no meaningful distinction could be made between PAS and euthanasia and that both would have to be legalized as MAiD.

Less than one year later, over 1500 Canadians have had their lives medically terminated, the vast majority by euthanasia by lethal injection. The rate at which euthanasia has been accepted by the Canadian medical profession and the public is shocking. The New England Journal of Medicine even published the protocol used by Toronto hospitals to select patients for MAiD euthanasia in the May 25, 2017 edition

It is difficult to understand how one can accept the principle of PAS for patients capable of swallowing 100 secobarbital pills but reject euthanasia by lethal injection for even sicker patients who are unable to. This is why every jurisdiction outside of the USA which has legalized PAS has also legalized euthanasia. Canada is already discussing euthanasia of children and allowing euthanasia by advanced directive.

For the record, Oregon has also introduced a bill that would legalize euthanasia, although it did not pass in this session.

Once doctors accept the fallacy that killing is compassionate medical care, and a humane response to suffering, then there is no potential limit to the medical killing.

That is why maintaining the Hippocratic red line is so important. It protects the medical profession from being asked to do things that we should not want to do and should not do.

“Neither will I administer a deadly drug to anybody when asked to do so, nor will I suggest such a course. . .”

Joseph E. Marine, MD, MBA
Johns Hopkins University School of Medicine

Jim Sabin said...

Dear Dr. Marine

Thank you for your very thoughtful and important comment!

Canada appears to have followed Belgium and the Netherlands in passing a very expansive assisted suicide/medical aid in dying law.

The "slippery slope" fear leads many who would otherwise support the limited scope of the Oregon Death with Dignity Act and the similar laws in Washington, Vermont, California, Colorado, Montana (not a law, but a court decision) and District of Columbia to take exactly the view that you take. They are ethically comfortable with "medical aid in dying" for those who are terminally ill, decisionally competent, under no external pressure, and consistent in their request, but would not accept the kind of extension you describe in Canada.

If you haven't read the New Yorker article to which I give a link in this post I recommend reading it. I found it a horrifying example.

As you say, in 2015 State Representative Mitch Greenlick in Oregon proposed extending the criteria of the Death with Dignity Act. The legislature did not support his proposal, but I agree that legislatures or courts could extend patient eligibility. It hasn't happened in the 20 years since the DWDA act was implemented, but it definitely could happen.

I've discussed the "slippery slope" concerns with colleagues in Oregon, Washington and California. They acknowledge that legislatures or courts could change the eligibility criteria beyond those seen as having a terminal illness and capable of self administration of medication. Most of them favor retaining the Oregon criteria as ethical guidance even if the legal situation changed.

Again, THANK YOU for the very important issues you raise.