Slippery slopes and safeguards

Where do we draw the line? A slide from my thesis presentation.

My thesis is done! I’m not going to post it anywhere until I’ve graduated in a few weeks, but in the meantime, here is a summary (which I adapted from the abstract).

Physician-Assisted Suicide: Slippery Slopes and Safeguards

Although physician-assisted suicide (PAS) is legal in several jurisdictions around the world, debate about its merits and implementation is far from settled. This debate has special, timely significance in Canada, as new PAS legislation is imminent. (Controversial recommendations from the Joint Special Committee on Physician-Assisted Dying include PAS for mature minors, PAS in advance directives, and PAS for people with mental illness.)

Slippery slope concerns are often at the centre of this debate—opponents worry that legalizing PAS in any form, however acceptable now, will inevitably lead to practices that are unacceptable. Concerns include risk of abuse and mistake, expansion of criteria, and an unobstructed path to euthanasia. Opponents also observe that those who support PAS on the basis of autonomy and suffering (common foundational arguments) are logically, on principle, committed to its expansion.

As the literature reveals, the slippery slope debate is confusing and often misunderstood. This essay seeks to achieve clarity by investigating the two types of slippery slope arguments—empirical and logical. The validity of each slippery slope argument is considered, with the following results. Empirical slippery slope concerns have not been validated. Recent data from Oregon and Europe neither support nor disprove slippery slope claims conclusively. Low numbers of usage of PAS, particularly in Oregon, reduce fears. Logical slippery slope concerns, while theoretically compelling, can be assuaged by drawing a bright line between what is acceptable and what is unacceptable. Consistency of principle need not be the highest value if other compelling reasons exist to make this distinction. Generally, slippery slope arguments are addressed (by proponents of PAS) by pointing to qualifying thresholds or criteria, also known as safeguards.

Two particular safeguards are then examined—determinations of capacity and suffering, respectively. Some questions addressed include:

• On what basis are physicians expected to assess capacity?
• On what basis are physicians expected to assess suffering, especially if terminal illness is not a criterion?
• To what extent can physicians make these determinations without also judging the patient’s quality of life?

In exploring answers to these questions, significant doubt is raised as to the extent to which these criteria function as safeguards against slippery slope concerns. Physicians are faced with the near-impossible task of assessing capacity and determining suffering without inserting their personal judgment of whether the person really ought to die, and in this way. In addition, they must do so without meaningful guidelines to assist in making these determinations with fairness and consistency. Other than in obvious cases of incapacity, why would a physician ever say no? More importantly, how could a physician ever say no without risk of accusation of inappropriately judging another’s suffering? Indeed, even if a physician denies a request a more agreeable physician may be found.

I conclude that, with the legalization of PAS in any form–particularly the form proposed in Canada –the promise of safeguards as protections proves illusory.

The thesis was submitted in partial fulfillment of the Master of Science degree requirements at The Bioethics Program, Union Graduate College/Icahn School of Medicine at Mount Sinai. Supervised by Bonnie Steinbock, Professor of Philosophy at University of Albany.