The euthanasia physician-assisted suicide and euthanasia (PAS-E) debate involves a conflict between respect for individual autonomy and respect for human life. Pro-PAS advocates give priority to autonomy, anti-PAS-E adherents to respect for life.
Pro PAS-E argue PAS-E are medical treatments, just extensions of palliative care. Anti PAS-E disagree seeing doctors killing patients or helping them to kill themselves as a seismic disruption of our foundational societal values and a radical change in the ethos of medicine.
Many pro PAS-E people argue PAS-E concerns only the individual. Anti PAS-E point out that legalising euthanasia raises wide-ranging major issues for medicine and law, for practitioners of these two professions, and for all of us as families, communities and a society.
Pro PAS-E deny there are slippery slopes, but once euthanasia becomes normalised slippery slopes are unavoidable. Where PAS-E is legal, the logical slippery slope, expanding the situations where euthanasia is allowed, is constantly increasing. Instances of the practical slippery slope – euthanasia not in compliance with the law – are legion.
Here, I’ll briefly discuss two very recent striking examples of the logical slippery slope, one in the Netherlands the other in Quebec, which should make those who deny slippery slopes think again and be a warning to Australian legislators.
Psychiatrist Dr Boudewijn Chabot, a very prominent pro PAS-E advocate in the Netherlands who’s been called the “patron saint of euthanasia”, expresses horror at what is happening in his country.
Writing in a leading Dutch newspaper, Chabot says that “legal safeguards for euthanasia are slowly eroding away and that the law no longer protects people with psychiatric conditions and dementia.” He is not anti-euthanasia (he’s prepared to “accept tens of thousands of euthanasia cases”) but aghast at the rapid rise in the number of people with psychiatric illness or dementia who have been euthanized. He recognizes “we are dealing with a morally problematic act: how do you kill someone who does not understand that he will be killed?”. And he concludes bitterly, “I don’t see how we can get the genie back in the bottle. It would already mean a lot if we’d acknowledge he’s out.”
We should think of this in relation to vulnerable Australians, for example, those who are elderly and fragile, especially those with dementia.
The Australian Law Reform Commission has just warned that 4 to 14 percent of elderly Australians are abused. Financial abuse takes the form of “early inheritance syndrome” – the old person lets another person, often their child, handle their financial assets and they use it for themselves. Imagine “early death syndrome” added to this.
And governments or industries might have conflicts. Canadian healthcare economists estimate euthanasia could save Medicare (the Canadian healthcare scheme) $138 (C) million annually. American healthcare insurance companies are refusing to pay for expensive life-extending drugs, but will pay for physician-assisted suicide because it’s “available at a reasonable cost”.
An extreme example of the logical slippery slope is also just unfolding in Quebec.
Dr. Yves Robert the Registrar of the College of Physicians and Surgeons of Quebec (the medical licensing authority) was a main instigator of the movement to legalise euthanasia. He routinely rejected claims that effective safeguards could not be put in place to regulate it.
He also rejected arguments that euthanasia was not a medical act and that if legalised it must be kept out of medicine. Dr Robert regarded it as good palliative care appropriate for doctors to provide – his constant reference was to a continuum of good end-of-life care which included euthanasia.
My suggestion that if euthanasia were to be legalised a specially trained group of technicians, who could be called thanatologists, should administer it, was rejected.
As in the Australian debate, pro-euthanasia advocates claimed it would be rarely used and estimated about 100 cases a year in the Quebec. In the first year, there were over 400 cases in Quebec and almost 1500 in Canada as a whole. Some Quebec cases breached the legal requirements: in one the patient probably had just a urinary infection.
But none of this seemed to raise any questions for the College or, I assume, Dr Robert, about whether legalising euthanasia had been a good idea.
Here’s what has done so for him.
There are now calls and possibly the launching of a court case to have “death on demand” declared a constitutional right.
The argument is that no one else has the right to tell me what I should do with my life or body and if I want to be dead that’s my right and having to fulfil certain conditions to access euthanasia breaches my right and is legally actionable discrimination.
This claim of a right to “death on demand” is consistent with the arguments for legalising euthanasia: people have a right to autonomy and self-determination concerning their own bodies and lives.
This expansion is, however, where Dr Robert is parting company with some fellow pro euthanasia advocates. He’s released a letter from the College entitled “Death a la carte”; that is, there’s a menu of options for choosing how one wants to die.
He first notes that opinion leaders and the media have denounced, as cruel and discrimination, cases where people, who do not fulfil the conditions for access to euthanasia in Quebec, have been refused it.
Dr Robert points out the paradoxical discourse that calls for safeguards to avoid abuse of “medical aid in dying” (the euphemism for euthanasia) which are meant to limit its availability, while asking doctors to act as if there were no restrictions.
He continues that if euthanasia is an unfettered right, then it’s not within the scope of “medical aid to die”, but simply “assisting dying” and, he says, society must consider other options than involving the medical profession in this. That’s because it is to transform “medical aid in dying” to “legally authorized aid in dying”, a form of assisted suicide which, he says, could be provided by private enterprise as in Switzerland.
Dr Robert describes the law as “une ouverture majeure” (a major opening) to euthanasia, and expresses surprise at how quickly public opinion seems to have judged the opening insufficient, when testing the law is still in the “apprenticeship phase and the application and consequences of its provisions are not fully assimilated.”
In short, euthanasia has become normalised with astonishing rapidity – just one year - and that has caused calls for access to it to be expanded, indeed, calls to have no restrictions at all on access.
Dr Robert concludes: “Prenons le temps de bien reflechir avant d’aller plus loin. Il n’y a pas d’urgence a mourir.” (Let us take the time to reflect deeply before going any further. There is no urgency to die.) I totally agree but, to use a common saying, “it’s too late to lock the barn door after the horse has bolted.”
This example shows, as British moral philosopher, Dame Mary Warnock, has put it, “you cannot successfully block a slippery slope except by a fixed and invariable obstacle”, in the case of PAS-E that obstacle is the rule that we must not intentionally kill.
Why did so many doctors and lawyers of goodwill and professional integrity, such as Dr Robert, so adamantly deny that such expansions could occur – although none of us expected an expansion to this degree?
I believe it was a total failure of individual and professional collective memory and imagination. A failure to look back to the past and take into account the cautionary tales history provides, and a failure to look to the future through imagination and ask ourselves “How do we not want our great great grandchildren to die?” And what kind of world will we have left them?
Margaret Somerville is Professor of Bioethics at University of Notre Dame Australia. This address was given at the “End of Life Choices” conversation of The University of Divinity Centre for Research in Religion and Social Policy (www.centrerasp.org) on 29 June 2017. A reduced version of this address was published by the Herald Sun on 5 July 2017.