Various forms of the slippery slope argument

If we change the law and accept voluntary euthanasia, we will not be able to keep it under control.

• Proponents of euthanasia say: Euthanasia would never be legalised without proper regulation and control mechanisms in place

Doctors may soon start killing people without bothering with their permission.

• Proponents say: There is a huge difference between killing people who ask for death under appropriate circumstances, and killing people without their permission

• Very few people are so lacking in moral understanding that they would ignore this distinction

• Very few people are so lacking in intellect that they can't make the distinction above

• Any doctor who would ignore this distinction probably wouldn't worry about the law anyway

Health care costs will lead to doctors killing patients to save money or free up beds:

• Proponents say: The main reason some doctors support voluntary euthanasia is because they believe that they should respect their patients' right to be treated as autonomous human beings

• That is, when doctors are in favour of euthanasia it's because they want to respect the wishes of their patients

• So doctors are unlikely to kill people without their permission because that contradicts the whole motivation for allowing voluntary euthanasia

• But cost-conscious doctors are more likely to honour their patients' requests for death

• A 1998 study found that doctors who are cost-conscious and 'practice resource-conserving medicine' are significantly more likely to write a lethal prescription for terminally-ill patients [Arch. Intern. Med., 5/11/98, p. 974]

• This suggests that medical costs do influence doctors' opinions in this area of medical ethics

The Nazis engaged in massive programmes of involuntary euthanasia, so we shouldn't place our trust in the good moral sense of doctors.

• Proponents say: The Nazis are not a useful moral example, because their actions are almost universally regarded as both criminal and morally wrong

• The Nazis embarked on invountary euthanasia as a deliberate political act - they didn't slip into it from voluntary euthanasia (although at first they did pretend it was for the benefit of the patient)

• What the Nazis did wasn't euthanasia by even the widest definition, it was the use of murder to get rid of people they disapproved of

• The universal horror at Nazi euthanasia demonstrates that almost everyone can make the distinction between voluntary and involuntary euthanasia

• The example of the Nazis has made people more sensitive to the dangers of involuntary euthanasia

Allowing voluntary euthanasia makes it easier to commit murder, since the perpetrators can disguise it as active voluntary euthanasia.

• Proponents say: The law is able to deal with the possibility of self-defence or suicide being used as disguises for murder. It will thus be able to deal with this case equally well

• To dress murder up as euthanasia will involve medical co-operation. The need for a conspiracy will make it an unattractive option

Many are needlessly condemned to suffering by the chief anti-euthanasia argument: that murder might lurk under the cloak of kindness.

A C Grayling, Guardian 2001

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Devalues some lives

Some people fear that allowing euthanasia sends the message, "it's better to be dead than sick or disabled".

The subtext is that some lives are not worth living. Not only does this put the sick or disabled at risk, it also downgrades their status as human beings while they are alive.

The disabled person's perspective

Part of the problem is that able-bodied people look at things from their own perspective and see life with a disability as a disaster, filled with suffering and frustration.

Some societies have regarded people with disabilities as inferior, or as a burden on society. Those in favour of eugenics go further, and say that society should prevent 'defective' people from having children. Others go further still and say that those who are a burden on society should be eliminated.

People with disabilities don't agree. They say:

• All people should have equal rights and opportunities to live good lives

• Many individuals with disabilities enjoy living

• Many individuals without disabilities don't enjoy living, and no-one is threatening them

• The proper approach to people with disabilities is to provide them with appropriate support, not to kill them

• The quality of a person's life should not be assessed by other people

• The quality of life of a person with disabilities should not be assessed without providing proper support first

Opposition to this argument

Supporters of euthanasia would respond that this argument includes a number of completely misleading suggestions, and refute them:

• Dying is not the same as never having been born

• The debate is nothing to do with preventing disabled babies being born, or preventing people with disabilities from becoming parents

• Nobody is asking for patients to be killed against their wishes - whether or not those patients are disabled

• The euthanasia procedure is intended for use by patients who are dying, or in a condition that will get worse - most disabilities don't come under that category

• The normal procedure for euthanasia would have to be initiated at the patient's request

• Disabled people who are not mentally impaired are just as capable as able-bodied people of deciding what they want

• Protections will be in place for patients who are mentally impaired, whether through disability or some other reason

• It is possible that someone who has just become disabled may feel depressed enough to ask for death, which is why any proposed system of euthanasia must include psychological support and assessment before the patient's wish is granted

• All people should have equal rights and opportunities to live, or to choose not to go on living

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Patient's best interests

A serious problem for supporters of euthanasia are the number of cases in which a patient may ask for euthanasia, or feel obliged to ask for it, when it isn't in their best interest. Some examples are listed below:

• the diagnosis is wrong and the patient is not terminally ill

• the prognosis (the doctor's prediction as to how the disease will progress) is wrong and the patient is not going to die soon

• the patient is getting bad medical care and their suffering could be relieved by other means

• the doctor is unaware of all the non-fatal options that could be offered to the patient

• the patient's request for euthanasia is actually a 'cry for help', implying that life is not worth living now but could be worth living if various symptoms or fears were managed

• the patient is depressed and so believes things are much worse than they are

• the patient is confused and unable to make sensible judgements

• the patient has an unrealistic fear of the pain and suffering that lies ahead

• the patient is feeling vulnerable

• the patient feels that they are a worthless burden on others

• the patient feels that their sickness is causing unbearable anguish to their family

• the patient is under pressure from other people to feel that they are a burden

• the patient is under pressure because of a shortage of resources to care for them

• the patient requests euthanasia because of a passing phase of their disease, but is likely to feel much better in a while

Supporters of euthanasia say these are good reasons to make sure the euthanasia process will not be rushed, and agree that a well-designed system for euthanasia will have to take all these points into account. They say that most of these problems can be identified by assessing the patient properly, and, if necessary, the system should discriminate against the opinions of people who are particularly vulnerable.

Chochinov and colleagues found that fleeting or occasional thoughts of a desire for death were common in a study of people who were terminally ill, but few patients expressed a genuine desire for death. (Chochinov HM, Tataryn D, Clinch JJ, Dudgeon D. Will to live in the terminally ill. Lancet 1999; 354: 816-819)

They also found that the will to live fluctuates substantially in dying patients, particularly in relation to depression, anxiety, shortness of breath, and their sense of wellbeing.

Other people have rights too

Euthanasia is usually viewed from the viewpoint of the person who wants to die, but it affects other people too, and their rights should be considered.

• family and friends

• medical and other carers

• other people in a similar situation who may feel pressured by the decision of this patient

• society in general

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Proper palliative care

Palliative care is physical, emotional and spiritual care for a dying person when cure is not possible. It includes compassion and support for family and friends.

Competent palliative care may well be enough to prevent a person feeling any need to contemplate euthanasia.

You matter because you are you. You matter to the last moment of your life and we will do all we can to help you die peacefully, but also to live until you die.

Dame Cicely Saunders, founder of the modern hospice movement

The key to successful palliative care is to treat the patient as a person, not as a set of symptoms, or medical problems.

The World Health Organisation states that palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death; it provides relief from pain and suffering; it integrates the psychological and spiritual aspects of the patient.

Making things better for patient, family and friends

The patient's family and friends will need care too. Palliative care aims to enhance the quality of life for the family as well as the patient.

Effective palliative care gives the patient and their loved ones a chance to spend quality time together, with as much distress removed as possible. They can (if they want to) use this time to bring any unfinished business in their lives to a proper closure and to say their last goodbyes.

Palliative care should aim to make it easier and more attractive for family and friends to visit the dying person. A survey (USA 2001) showed that terminally ill patients actually spent the vast majority of their time on their own, with few visits from medical personnel or family members.

Spiritual care

Spiritual care may be important even for non-religious people. Spiritual care should be interpreted in a very wide sense, since patients and families facing death often want to search for the meaning of their lives in their own way.

Palliative care and euthanasia

Good palliative care is the alternative to euthanasia. If it was available to every patient, it would certainly reduce the desire for death to be brought about sooner.

But providing palliative care can be very hard work, both physically and psychologically. Ending a patient's life by injection is quicker and easier and cheaper. This may tempt people away from palliative care.

Legalising euthanasia may reduce the availability of palliative care

Some fear that the introduction of euthanasia will reduce the availability of palliative care in the community, because health systems will want to choose the most cost effective ways of dealing with dying patients.

Medical decision-makers already face difficult moral dilemmas in choosing between competing demands for their limited funds. So making euthanasia easier could exacerbate the slippery slope, pushing people towards euthanasia who may not otherwise choose it.

When palliative care is not enough

Palliative care will not always be an adequate solution:

• Pain: Some doctors estimate that about 5% of patients don't have their pain properly relieved during the terminal phase of their illness, despite good palliative and hospice care

• Dependency: Some patients may prefer death to dependency, because they hate relying on other people for all their bodily functions, and the consequent loss of privacy and dignity

• Lack of home care: Other patients will not wish to have palliative care if that means that they have to die in a hospital and not at home

• Loss of alertness: Some people would prefer to die while they are fully alert and and able to say goodbye to their family; they fear that palliative care would involve a level of pain-killing drugs that would leave them semi-anaesthetised

• Not in the final stages: Other people are grateful for palliative care to a certain point in their disease, but after that would prefer to die rather than live in a state of helplessness and distress, regardless of what is available in terms of pain-killing and comfort.

There should be no law or morality that would limit a clinical team or doctor from administering the frequent dosages of pain medication that are necessary to free people's minds from pain that shrivels the spirit and leaves no time for speaking when, at times, there are very few hours or days left for such communication.

Dr. David Roy, Director of the Centre for Bioethics, Clinical Research Institute of Montreal

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Fears about regulation

Euthanasia opponents don't believe that it is possible to create aregulatory system for euthanasia that will prevent the abuse of euthanasia.

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