Doctors' Reform Society of Australia

Euthanasia: Slippery Slopes and Pendulums

26 Feb 1997
The euthanasia debate continues to be topical. At the time of writing, three patients have used the Northern Territory (N.T.) voluntary euthanasia legislation, and the Andrews Bill which seeks to overturn it is to be debated in the Senate. Interestingly, voluntary euthanasia legislation warrants a conscience vote for politicians, but reductions in health funding causing involuntary euthanasia from resource restrictions do not.

Supporters of the N.T. bill are usually responding to two major arguments. One is that the legislation is compassionate and the other that the legislation supports personal autonomy (more power for patients and less for doctors). This has resulted in some unusual alliances between the political left and libertarian right.

There are also two major groups of argument against the N.T. legislation. One is based on beliefs it is always wrong to kill, and the other on invocation of a "slippery slope".

The arguments that it is always wrong to kill ignore the fact that virtually no-one truly holds this belief. Even a pacifist might commit voluntary euthanasia by killing a mortally wounded soldier who begged them to do so. These arguments against voluntary euthanasia appear to be based on "authority", often a religious one. Religious interpretation of euthanasia as immoral does seem to underlie most of the vehement opposition to the N.T. legislation.

Slippery slope arguments claim that an apparently innocuous small step can act as the thin edge of the wedge to bring about undesirable major changes further in that direction. Our society is more interested in secular than religious arguments, so slippery slope arguments are prominent in euthanasia debates.

Slippery slopes create slippery arguments suitable for use against almost any proposal for change. Indeed, supporters of the N.T. bill also bolster their case with a slippery slope, by stating that overturning the legislation with the Andrews Bill will inevitably lead to increasing interference in state and territory rights. Opponents of the N.T. bill propose that even permitting limited active euthanasia must eventually lead to more killing outside this context than already occurs.

The "Dutch experience" is often said to confirm a slippery slope, and it is claimed that huge numbers of people are now being killed against their will. Examination of the statistics does not appear to support this interpretation however.

For instance, the 1990 Netherlands study is discussed in Peter Singer's book "Rethinking Life and Death" (1994). He notes that roughly 48,700 deaths were associated with end of life medical decisions. Of these, about 22,500 were decisions to withdraw or withhold treatment, and 22,500 involved the use of symptom relieving drugs which may have hastened death but were not used with this intention.

Of the remaining 3,700 cases, 2,700 were cases of voluntary active euthanasia or medically assisted suicide, and in three-quarters of these cases life was judged to have been shortened by less than four weeks. The 1,000 remaining cases are those in which a doctor prescribed, supplied or administered a drug with the intent of hastening death, but without a current explicit request from the patient to do so.

Singer goes on to explain why these 1,000 cases should not be trumpeted as evidence that the slippery slope is alive and well and living in the Netherlands.

First, none of these were cases of involuntary euthanasia of unwilling patients. They were cases of active nonvoluntary euthanasia of suffering patients who were near death and no longer mentally competent (therefore euthanasia was nonvoluntary rather than involuntary). In 71%, it was felt life was shortened by less than one week. In 60%, euthanasia had been discussed but clinical deterioration occurred prior to an explicit request being made, and in all but two of the remaining cases a permanently reduced state of consciousness had precluded discussion.

Second, it is not known how many deaths like this occurred before euthanasia became available. In addition, if actions once felt not to be euthanasia are gradually reinterpreted as being euthanasia, or if doctors become more comfortable reporting euthanasia, then notifications will increase with no change in behaviour.

Active nonvoluntary euthanasia also occurs in Australia, with or without legislation.

For instance, the common practice of giving papaveretum and hyoscine injections to comatose, terminal patients with a death rattle may often be active nonvoluntary euthanasia. It seems irrational to claim the intent is to treat the patient, who is presumably unaware and already toxic from drugs as their liver and kidneys fail. This is using life-shortening drugs to suit relatives distressed by their loved one's condition.

The dangers of slippery slopes are overstated, and they become particularly improbable when a clear distinction can be made between the desired and undesired behaviour. A legislative distinction between asking to be killed and not asking to be killed is obvious.

In addition, if slippery slopes exist then one might expect civilisations to gradually slip into extreme policies on every social issue as the centuries pass. Instead, human societies reiterate the same controversies and arguments.

Voluntary euthanasia was debated in ancient Greece with Hippocrates against, and Aristotle, Plato and Pythagorus supporting it. There are also reported to be past cultures which permitted limited nonvoluntary euthanasia without ever descending further down a slippery slope. Nazi euthanasia programs were not preceded by voluntary euthanasia legislation, and were never motivated by respect for personal autonomy.

Social policy does not slip down slopes, but it may swing on pendulums. Legalisation of voluntary euthanasia might precede that of nonvoluntary euthanasia requested by a living will, but it is difficult to see the pendulum swinging further than this.

Nonetheless, there is a need to carefully draft safeguards into legislation and maintain surveillance for abuses. Well-drafted legislation will be more likely to prevent abuse than create it.

The Australian community appears broadly supportive of moves toward allowing voluntary euthanasia. Religious and Hippocratic dogma, exaggerated talk about slippery slopes, and poorly substantiated claims that hard cases make bad laws, currently appear inadequate reasons to deny this democratic will.

Killing patients sounds unappealing, but our social role as doctors regularly requires us to perform the unpleasant. The Doctors Reform Society supports the introduction of carefully-drafted voluntary euthanasia legislation, and believes that the Northern Territory bill provides a reasonable model to work from.

Andrew Gunn  DRS Qld
26 Feb 1997

An edited version of this article was published as "Euthanasia: levelling the slope" in Australian Doctor 14 March 1997.