Online Beeb has an interesting article on the debate over euthanasia in the UK. They quote Len Doyal as coming out in favor of active euthanasia, which their headline bills as some sort of shocker (readers of medical ethics literature will know this is not a new or even especially rare position to take – it has just been backburnered in the public debate on end-of-life care). The real point of interest to me was the breadth of opinion now being openly bandied about. Another interesting point is my recognition that some parts of that range of opinion are new, at least on the public stage, and some people or organizations that uphold what were once radical positions have been forced into opposing others who are now going further than those so-called radicals feel comfortable with.

All of which is by way of saying that there may be something to this slippery-slope business after all.

First, let’s take a look at what’s going on:

Len Doyal, ex-member of the British Medical Association’s ethics committee, said doctor-assisted deaths did take place and should be better regulated. . . .

Professor Doyal said that when doctors withdraw life-sustaining treatment from severely incompetent patients, such as those in a permanent vegetative state, it was effectively euthanasia, the Clinical Ethics journal reported.

“Doctors may not want to admit this and couch their decision in terms such as ‘alleviating suffering’ but withdrawal of life sustaining treatment from severely incompetent patients is morally equivalent to active euthanasia,” he stated.

“If doctors can already choose not to keep uncomprehending patients alive because they believe that life is of no further benefit to them, why should their death be needlessly prolonged?”

Again, those familiar with the subject will recognize this as the very old, and very familiar, “killing vs. letting-die” debate – one long since resolved by a consensus that sees no moral difference between the two (assuming an equal responsibility for, and ability to carry out, the decision to do one or the other). But, even more obviously, this is a consensus that has seen very little practical implementation in terms of policy. Kevorkian took that moral conclusion seriously, and was given a life sentence. Halting steps in the same direction have been made in the Netherlands, but elsewhere, the euthanasia debate has settled largely on “physician-assisted suicide” – or what would have been called, back when we still actually used the word “euthanasia” – “voluntary indirect active euthanasia”. Essentially, Doyal is advocating biting the bullet and finding the most effective, and (by way of efficiency) most compassionate, way to achieve what it has already been decided is permissible in some cases. Doyal also makes reference to withdrawal of treatment from non-consenting patients, thus invoking “non-voluntary direct passive euthanasia”, presumably under the rubric of “medical futility”. (My, how our jargon does grow apace!) In fact, he makes this explicit with some impolitically clear language:

“Proponents of voluntary euthanasia should support non-voluntary euthanasia under appropriate circumstances and with proper regulation,” he concluded.

Here again, he advocates taking a central concept of bioethics – quality of life – seriously enough to apply it to all patients.

As previously commented, none of these are new ideas. What is new about them is the suggestion that their time has come, policy-wise – or at least that that time is clearly-enough foreseeable that these suggestions can no longer be dismissed from the policy debate. The reactions are interesting.

[O]ther experts said patients should make a living will if they do not want to be resuscitated. . . .

Deborah Annetts, Chief Executive of Dignity in Dying, said: . . . “People who may later lack capacity to make decisions for themselves can choose to enforce their wishes by making a living will (or advance directive) and we do not agree with Professor Doyal that the law needs to be changed for non-competent patients.”

Dr Nigel Sykes, consultant in palliative medicine at St Christopher’s Hospice, London, said: “Doctors have always seen it as part of their duty to assist their patients to die comfortably. “This does not mean that doctors are causing those patients’ deaths.

I would argue that it is the illness that brings about death, and not the withdrawal of treatment.

“Where I would agree with Professor Doyal is in the suggestion that euthanasia, once legalised, would lead to non-voluntary euthanasia at some point, and this would affect an increasing number of people who are among the most vulnerable in our society.”

The British Medical Association dropped its long-held opposition to assisted dying in July last year, voting at its annual conference to adopt a neutral stance on the issue.

That’s quite a range of opinion, and quite an interesting example of ongoing changes in opinion on these subjects. The BMA has softened its stance, some doctors are talking about non-voluntary euthanasia, some are talking about active euthanasia, and voluntary passive euthanasia has become the conservative position. That would have been hard to predict even a few years ago (though as we see above, euphemism and evasion still abounds). I want to ignore the question of the advisability of any of these policies, for now, and address this question of changing consensus. What appears to be a clear trend in professional opinion, reaching even to what had, a generation or two ago, been seen as unutterable heresies, is a striking sight. In particular, it evokes the hoary, lame specter of the “slippery slope”.

I have always regarded slippery slope arguments as the last refuge of the timid or reactionary (and the particularly dumb among them, at that). The obvious answer to such arguments, it seemed to me, was simply to say “Don’t do that”. If you’re afraid a certain policy goes too far – don’t adopt that policy. Why should there be any trouble in not adopting a policy to do something you think you shouldn’t do in the first place?

I have never understood the imaginary metaphysics of the “slippery slope”, whereby merely doing one thing requires you to do some other thing entirely irrespective of your desire or intention to do so. Saying people do one thing and then choose to do another makes perfect sense, but it also raises no particular dangers. Again, if you oppose one or the other of those things, simply argue on the merits that people ought not do to it – or pass a law, if you have to. If you can convince people to follow your policy, you’re home free; if not, perhaps the policy is not well-advised, or at the worst you have an enforcement problem, but there’s nothing puzzling about either one.

The slippery slope, though – that one’s a puzzler. The argument implicitly claims that people tend to do bad things not because they choose to, but because they previously did good things and then just couldn’t help themselves. It’s never explained why, and it never seems to make any sense. (I brush my teeth every day, but I never brush my eyeballs. Every time I think of brushing my eyeballs, I simply say to myself “That’s a stupid idea. Don’t do it!”, and it never seems to be a problem. I don’t even seem to have any creeping tendency to scrape upwards on my face in a way that would eventually result in my brushing my eyeballs. The slippery slope seems very easily avoidable, in that case at least.)

One could offer psychological explanations, such as that a certain kind of action “desensitizes” one to similar actions, even if they are morally worse, or that the widespread acceptance of one kind of behavior removes any barrier it might have posed to acceptance of another, somewhat more extreme, behavior. And there may be something to that (though those explanations are much more often “Just So Stories” than real psychology or sociology, I suspect). But I don’t think those claims, even if true, prove that there is a “slippery slope”. They only prove that, once people change their opinions about something, they are much more likely to adopt the behaviors associated with it – and more likely to change their opinion on, and thus adopt, still other behaviors that are similar. This is not being the victim of some sort of moral reasoning sinkhole – it’s merely making different decisions in the light of increased experience and changed values, which in general is a good thing.

However, whether the metaphysical slippery slope is real or not, there has certainly been a progression – and I would argue a largely healthy one – in how the public perceives these issues, and how professionals handle them. There is considerable public interest in end-of-life topics, and, aside from the excesses of partisans involved, the media have helped educate the public about them and allowed the public’s voice to be heard on them in real-time (in large part due to the success of blogs). The greater boldness of professionals in discussing radical policies I suspect is not evidence of their own slide down the slippery slope, but rather of the public’s greater knowledge of the issues and the emergence of a range of public opinion and a spectrum of disagreement on them. As policy-making has become a spectator – and to some degree public-participation – sport, the full range of opinion on issues has surfaced, not forcing the public down some kind of slope but allowing them to evaluate – often very badly, sometimes with sophistication – the different positions on offer, and the manipulations that are being practiced upon them to influence their preferences.

Seeing it in that light, the “slippery slope” seems no more real than before, but the emergence of a broad range of opinion and policy alternatives, including ones formerly taboo, is evidence of a matured public consciousness on these issues. That’s not to say the debates are conducted very well or very effectively (Terri Schiavo is a still-raw case in point), but the public is getting involved in seeing how its own values are wrapped up in policy-making, and that trend seems like a positive one.

UPDATE: Fixed some typos and bad HTML.