In his paper in Current Oncology, and in the CTV W5 program on assisted dying, Dr. José Pereira claimed that permitting assisted dying will produce slippery slopes. He calls it “the illusion of safeguards and controls.” But slippery slopes should actually be slippery, shouldn’t they? That means, once you’re on the slope there’s no way of stopping yourself until you get to the bottom. The whole slope should be like a sheet of ice at an angle.

This is what he thinks he shows in his article, which is based on other people’s research. This is important. Pereira does no original research of his own. He takes research papers written by others and says that they provide give evidence of slippery slopes in in places where euthanasia and assisted suicide have been legalised. There are two serious problems with his approach to the issue. First, Pereira himself speaks with some regularity to Roman Catholic “pro-life” groups. His next big appearance will be at a “Priests for Life” symposium for clergy with the title, “Euthanasia — False Compassion.”

He already spoke on the same subject to another such symposium in August of this year, so it is apparently part of a continuing dog and pony show. And this brings us to the second serious problem with Pereira’s approach to the issue. It would be one thing if he were to take a reasoned position on the issue, but once religion enters the picture, unfortunately reason makes a quick get-away. The real reasons for the Roman Catholic Church’s opposition to assistance in dying is that life is sacred, and taking life, or enabling it to be taken (by the dying or suffering person), is, according to the church, anyway, contrary to natural law. And natural law, of course, is established, in the beginning, by God himself. The nature of being human, or the essence of being human, distinguishes accurately, for this way of thinking, between what is morally right and ought to be done, and what is morally wrong and ought not, under any circumstances, to be done.

This means that, when José Pereira gets up on his hind feet and objects to assisted dying, because, as he claims, safeguards and controls give us only the illusion of control with illusory safeguards, what he is claiming is that, in the very nature of the case, once God’s law (that is the natural moral law) is broken, there can no longer be any controls, even if people imagine that they have established parameters within which assisted dying can be safely practiced. It’s important for everyone to see what people like Pereira are doing, because most people don’t realise how genuinely underhanded it really is. Of course, Pereira won’t see it as underhanded, because he doubtless believes the Roman Catholic moral position, which, to my mind, is simply propaganda, since it is based solely on questionable religious beliefs, that, once a natural moral law is broken, there is nothing that anyone can do to stop the disaster that will inevitably impend.

I think I’ve quoted this before, but it’s worthwhile recalling it here, because it’s such a classic example of how Roman Catholic morality works. The natural moral law, for the Roman Catholic, is a finely woven network; pull one thread and the whole thing begins to unravel. Of course, they don’t usually argue in public this way. Their public arguments are, in general, seem fairly straightforwardly purely secular, but because each moral law is related in complex ways to every other moral law, the implicit assumption is that breaking one moral law inevitably leads to breaking all the rest, and moral chaos will be the result — which is the classic definition of a slippery slope. So slippery slope arguments are intrinsic to the essence of natural law morality. With those preliminary remarks, consider the following from Cahal Cardinal Daly’s book Morals, Law and Life:

A sexual revolution involves a new philosophy of man and the world, of time and of human destiny, of sickness and health, of life and death. The Family Planning experts in India and Puerto Rico, for example, are finding that they can make no appreciable ’progress’ because the whole philosophy of life in these societies is opposed to neo-Malthusianism: the experts must begin by effecting a total “change in those attitudes which determine … the cultural pattern.” The works of the scientific humanists are there to prove that man’s attitude to contraception determines whether he will think it wrong or right for a mother to kill her defective child, or for a doctor “gently and humanely to extinguish his patient’s life. [45]

Now that’s pretty clear. Pull one thread, and the whole fabric of morality simply unravels.  Or, in the more familiar “slippery slope” language, put one foot on the slippery slope and there’s nothing to stop the slide until you get to the bottom!

That’s what Pereira is claiming in the article in Current Oncology, and because it appears in a peer-reviewed journal — this point was made strongly by the journalist Victor Malarek (of W5) when he referred to it — it seems to have greater weight and authority than it would have, had it been written, say, by me, since I don’t have Pereira’s expertise. But Pereira has no more expertise than I do in bioethics, and may indeed have less. He’s a palliative care physician, and professor of palliative care at the University of Ottawa, but he is not an ethicist, and has done no extensive bioethics research. The biggest problem with Pereira’s claim that safeguards and controls are mere illusions is that the people whose research he uses for support do not themselves believe this.

Moreover, if we consider what is happening in the Netherlands, for example, we will see that, not only do safeguards work, they may in fact prevent people who should qualify for assisted dying from receiving the assistance they need. In an article published in Netherlands Radio Worldwide we are told:

Abortion, the suicide pill and euthanasia. In the Netherlands, life and death are both individual choices. That may be the image the Netherlands has abroad but euthanasia is not, in practice, carried out on any major scale. Dutch doctors are often reticent. [bolding in original]

In other words, what we have in the Netherlands is not a slippery slope, but a sticky one. It’s so sticky, in fact, that in 2010 only a third of requests for assistance in dying were approved. One physician, Petra De Jong, who supports the Netherlands euthanasia legislation,

… is pleased with the Dutch euthanasia act, since it has allowed more openness about the subject. However, she complains that — for many doctors — unbearable suffering always means physical suffering. People with severe depression or dementia are often excluded.

And of course those with depression and dementia are not the only ones excluded. Since doctors express some reticence about assisted dying, and since some are absolutely opposed to it on religious grounds, it can sometimes be difficult for a suffering patient to get access to assisted dying at all.

The title of the symposium which Dr. Pereira will address next year is taken straight from the Roman Catholic playbook. It is a section heading in the United States Conference of Catholic Bishops’ Statement on Physician-Assisted Suicide, To Live Each Day With Dignity (which you can download as a pdf file from this site). According to this statement physician-assisted suicide is false compassion. Here’s a quotation from the statement:

The idea that assisting a suicide shows compassion and eliminates suffering is equally misguided. It eliminates the person, and results in suffering for those left behind – grieving families and friends, and other vulnerable people who may be influenced by this event to see death as an escape.

The sufferings cause by chronic or terminal illnesses are often severe. They cry out for our compassion, a word whose root meaning is to ”suffer with” another person. True compassion alleviates suffering while maintaining solidarity with those who suffer. It does not put lethal drugs in their hands and abandon them to their suicidal impulses, or to the self-serving motives of others who may want them dead. It helps vulnerable people with their problems instead of treating them as the problem. [4]

This is very cleverly worded. When someone is helped, at their request, to die, they are not being treated “as a problem”; they are being treated as adults who have the power to choose. It doesn’t abandon people to ”their suicidal impulses.” It takes people seriously as those who have thought about their situation, and recognises that bringing life to an end may be a reasonable decision, and is not always merely a matter of sheer impulse. Yes, some people, in moments of despair, may take their lives, acting impulsively and self-harmingly, and any law which legalises assistance in dying must be aware of the possibility that a person’s decision to die is sometimes not carefully thought through. But death is not always a harm. Sometimes, it can reasonably be thought to be better than remaining alive. The statement says that “[t]rue compassion alleviates suffering while maintaining solidarity with those who suffer.” And of course, the result of someone’s death “is suffering for those left behind,” but in the case of those who are assisted to die, this is not because of such assistance, but simply because the loss of a loved one is the source of much grief for those who are still alive.

However, it is not true that suffering can always be alleviated, and refusing the decision of a person in such circumstances to die, is not maintaining solidarity with that person, but denying their right to decide for themselves when life has reached the stage when suffering has become intolerable. Calling the acceptance of a person’s decision to die “false compassion” is a deliberate misrepresentation of a decision that may indeed be not only fully thought through, but may be a thoroughly reasonable decision in the circumstances. What the American bishops are saying is that it can never be reasonable to decide to bring one’s life to an end; and there is absolutely no reason to hold that this is true.

In evidence presented to the Commission on Assisted Dyingin England, Dr. Elisabeth Macdonald sets out ”to contest the assertion that all symptoms at the end of life can be successfully managed by modern western techniques of palliative care leaving each person comfortable and at peace to die.” In her report Dr. Macdonald provides the following disturbing evidence:

It has been reported however that in the UK up to 50% of patients dying in hospital and up to 20% of patients dying in a hospice have uncontrolled symptoms at the time of their death.

This adds up to a distressingly large number of patients. According to the Office for National Statistics for England and Wales, there were 491,348 registered deaths in England and Wales in 2009 (page 3). Some, of course, will have died at home or in accidents, but even allowing for those deaths, an extraordinarily large number of patients have uncontrolled symptoms at the time of their death. By any measure this is a moral catastrophe.

At the present time in the UK very little can be done to relieve the distress that dying causes for so many.

At the end of life people may have a variety of intensely personal reasons for concluding that their quality of life is such that they do not wish to survive any longer. Many of these relate to loss of personal dignity and a deep desire not to be a burden to others, — altruistic motives to be respected provided there is certainty that no coercion is involved.

When death is imminent many patients and their families take a fatalistic view and accept their fate with all the suffering that this may entail. Some regard their end as being in ‘God’s hands’ and prefer to be stoical and not to question their fate or interfere with the time and circumstances of their passing. Others however, faced with a ghastly death, will seek an escape route and feel that personal freedom should permit them to avoid where possible the worst tortures of uncontrolled symptoms and to die sooner rather than suffer a slow agonising demise. Several ‘escape routes’ are recognised: namely suicide, self-denial of food and water, assisted dying, euthanasia, and, in a different category, palliative sedation. Of these escape routes only suicide, self-denial of food and water and palliative sedation currently lie within the law. Doctors are explicitly forbidden by the Director of Public Prosecutions from practicing assisted dying or euthanasia or in fact even discussing these possibilities with their patients. [all italics mine]

While palliative sedation may be used as a solution to distress at the end of life, it is subject to the same concerns as euthanasia or physician-assisted suicide, raises the same sorts of questions of moral legitimacy as euthanasia, and is simply not available to people who may have many years left to live in a state of pain and paralysis, as with patients suffering from ALS (motor neurone disease) or MS. As Macdonald points out, the safe use of palliative sedation at the end of life depends upon the integrity of the health-care team, but “[i]t is … still ill-defined and variable as a practice and could be open to misuse or even abuse if not routinely scrutinised and regulated in a controlled and structured way.”

My point is not to provide an adequate answer to the problem of intolerable suffering, or how best provisions for assisted dying might be safely inscribed in law. It is merely to point out that the position of the Roman Catholic Church (as well as many other churches who simply hang on to the Roman Catholic Church’s coattails) is not adequate to answer the needs of those who are dying, or who are suffering from long-term degenerative conditions, and who are in such great distress that death would be preferable to staying alive.

I would go further and suggest that, if there are slippery slope issues here, it is not up to the person suffering to solve them. It cannot be said that a person suffering intolerable distress should not receive assistance in dying because this might put others — those who are not suffering from intolerable distress — at risk. Rights do not function in this way. A person should not be forced to suffer because, in the opinion of some, others will be put at risk. If it is possible to identify those who will be put at risk, then it is possible to so frame a law that these persons will not be placed at risk. It is simply unacceptable to force people to die in misery on the basis of a vague claim that some undefined class of persons will be placed at risk; but this, in fact, is precisely what, by raising the question of such risks, opponents of assisted dying do. The risk factor, however, as we have seen, is not the real reason for religious opposition to assisted dying. The real reason lies in those tell-tale words about “solidarity with those who suffer,” — the Anglican Church of Canada speaks about assisted dying in terms of “a failure of community,” which comes to the same thing – for it is not because people will be put at risk that the Roman Catholic Church (and other churches and religious groups) oppose assisted dying.  Their opposition to assisted dying is absolute, and it is based on religious grounds. Thus the supposed threat to life is left vague and undefined. After all, on this religious view, it applies to everyone. If no one has the right to assisted dying, because every case is a failure of solidarity or community with the suffering, then the legalisation of assisted dying puts everyone at risk. This, however, is a rhetorical trick, the same one that is played when assisted dying is called false compassion. But this misunderstands the basis of support for assisted dying. It is not just a matter of compassion; more importantly, it recognises that people have a right to die when living has become an unrelievable torment to them. The refusal to recognise this right is not only cruel; it is a moral offence against the person whose life-choice regarding the time and manner of their dying is being denied, and the opportunity to act as independent persons is being withheld.