Where the Slope Slips

Arthur Caplan

Two main ethical concerns are ad­vanced against the legalization of physician-assisted suicide. The first is that it is not our place to decide the time of our death; only God can decide when our time on this planet is over. That argument might persuade some, but it is not a good reason for outlawing physician-assisted suicide. It rests firmly on a foundation of religious belief, which is not a sound basis for public policy. Worse, it runs roughshod over the right to individual self-determination. Furthermore, it is not coherent. When medicine can do no more to prevent death, then it makes no sense to argue that treatment must not stop because only God can decide when it is time for us to die. Whatever role God plays in determining who lives and who dies, surely a deity does not need a ventilator, dialysis, or blood pressure medicine to keep us going if it is not yet time for us to die.

The other argument is that legalization of assisted suicide, by doctors or any other third party for that matter, will lead inevitably to a slippery slope. If it is made legal to help the terminally ill die, then pressure will quickly grow to extend that right to others who are not terminally ill, raising the specter of horrific abuse.

I rarely find slippery-slope arguments persuasive. If the slope is slippery, then build some handrails or stairs. That is what is needed as, in fact, pressure begins to build to extend the right to assistance in dying beyond the terminally ill.

Belgium has begun considering whether to extend the right to assistance in dying to newborns and children. Clearly children cannot be autonomous. Critics who earlier raised the slippery-slope concern are busy polishing their “I told you so” editorials.

Belgium is not alone. Derek Humphry, the author of Final Exit and a pioneer in the movement to legalize assisted suicide, has recently argued in favor of permitting assisted suicide for those suffering from incurable mental illness. The idea, he said, came from people with mental illness increasingly approaching him seeking help in killing themselves: “From their point of view, the suffering is as great as a person dying of a physical illness,” he wrote in an announcement of a lecture in Tucson, Arizona.

Three U.S. states—Oregon, Washing­ton, and, most recently, Vermont—have legalized physician-assisted suicide for the terminally ill. One state (Massachusetts) defeated an attempt at legalization, while in another (Montana), a ruling by the state’s Supreme Court would seem to permit physician-assisted suicide. In all of the states where assisted suicide is legal, the core rationale is that the competent terminally ill patient should be able to request assistance in dying. Self-determination—personal autonomy—is the key value that trumps all other concerns and objections.

Belgium has long permitted assisted suicide for anyone over the age of eighteen. The country legalized the practice in 2002. In the last decade, the number of reported cases per year has risen from 235 deaths in 2003 to 1,432 in 2012. Doc­tors typically give patients a powerful sedative before injecting another drug to stop their hearts. While this occurs rarely, a person does not have to be terminally ill to request assistance in dying.

A bill has been proposed in the Belgian parliament that would expand the right of euthanasia to children and those suffering from dementia. Dr. Gerlant van Ber­laer, a pediatric oncologist at the Uni­versitair Ziekenhuis Brussels Hospital, says the proposed change would legalize what is already happening informally. He said cases of euthanasia in children are rare. He estimates about ten to one hundred cases in Belgium every year might qualify.

“Children have different ways of asking for things, but they face the same questions as adults when they’re terminally sick,” van Berlaer said. “Sometimes it’s a sister who tells us her brother doesn’t want to go back to the hospital and is asking for a solution,” he said. “Today if these families find themselves [in that situation], we’re not able to help them, except in dark and questionable ways.”

In the past year, several cases have been reported of Belgians who weren’t terminally ill but were euthanized. One involved a pair of deaf forty-three-year-old twins who were going blind. Another case saw physicians assist a patient to die after a botched sex-change operation.

The slippery slope is much in evidence in the Belgian cases that involve disability, not terminal illness. It is also present both in Belgium and among supporters of Humphry’s proposals to expand assisted suicide to the mentally ill.

The key ethical shift in all of these is moving away from self-determination. In arguing for opening the door to legalizing assisted suicide for children, the disabled, or the mentally ill, the moral standard is shifting from autonomy to the “best-interest” of the patient.

Certainly individuals endure huge amounts of suffering as a result of many diseases, injuries, and even life problems. But no one, including doctors, is in a position to determine whether helping someone die is the only response to suffering. Honoring self-determination by a competent adult who is terminally ill is a bright line. Honoring claims of suffering advanced on behalf of the mentally ill or a child is not.

The former provides a way to terrace the slippery slope. The latter does not. Ethically, it is not possible to slide from respecting self-determination to making judgments about the degree of suffering that merits death without making the slope to euthanasia awfully slippery.

Arthur Caplan

Arthur Caplan is director of the University of Pennsylvania’s Center for Bioethics and a nationally prominent voice in the debates over cloning and other bioethical concerns.


Two main ethical concerns are advanced against the legalization of physician-assisted suicide.

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