Assisted Suicide and Slippery Slopes: Reflections on Oregon

Abstract

Slippery slope argumentation features prominently in debates over assisted suicide. The jurisdiction of Oregon features prominently too, especially as regards parliamentary scrutiny of assisted suicide proposals. This paper examines Oregon’s public data (including certain official pronouncements) on assisted suicide in light of the two basic versions of the slippery slope argument, the empirical and moral-logical versions. Oregon’s data evidences some normatively interesting shifts in its assisted suicide practice which in turn prompts consideration of two elements of moral-logical slippage that are not widely discussed. One is slippage from an initial autonomy-based public justification for assisted suicide which does not include burden-based concerns within its operative account of voluntariness to an evolved public justification that does. The other is an expansion of a terminal illness ground to include chronic illnesses effectively rendered terminal via a refusal of treatment.

KEYWORDS:

• Assisted suicide
• slippery slope
• Oregon
• euthanasia
• terminal illness
• chronic illness

Acknowledgements

This paper has been improved by comments from Prof. John Keown and the journal's two anonymous reviewers.

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No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Notes

1 Though assisted suicide differs materially from voluntary euthanasia, for argument’s sake I include the latter under the former (unless otherwise stated). This paper understands both to centrally involve deliberate medical co-operation in a competent person’s autonomous choice to end their own life.

2 An absence largely due to the self-regarding nature of voluntary decisions to proceed with assisted suicide.

3 USA (Oregon will be used as the most important state example in this paper), Netherlands, Belgium, Switzerland, Luxembourg, Colombia, and Canada.

4 Oregon: see below; Netherlands: Houses of the Oireachtas Joint Committee on Assisted Dying (2023b); Belgium: Michas (2023); Switzerland: Montanga et al. (2023); Luxembourg: RTL (2019a, 2019b); Colombia: Cook (2023); Canada: Government of Canada (2023) and BMJ News (2022b).

5 Switzerland has not legislated for assisted suicide and therefore has no grounds to expand or contravene.

6 Luxembourg has witnessed neither a de jure nor a de facto widening of grounds, though the legislative grounds – enacted in 2009 – were wide and subjective to begin with and include provision for advance euthanasia directives; Oregon: see below for reasons to think that a de facto expansion of grounds is there occurring; Netherlands: BBC News (2019) and The Guardian (2023); Belgium: Raus et al. (2021); Colombia: World Federation of Right to Die Societies (2022) and BMJ News (2022a); Canada: Coelho et al. (2023).

7 Providing figures for the first three years corrects against backlog bias.

8 New Zealand’s End of Life Choice Act 2019, based on Oregon’s Act, offers an interesting comparison. The first full-year official report into New Zealand’s assisted suicide figures indicates 328 deaths between April 2022 and March 2023 (Government of New Zealand 2023). In the first year of the operation of Oregon’s Act there were 16 deaths (Oregon’s population in 1998 was c. 3.28m compared with New Zealand’s current population of c. 5.2m).

9 An autonomy-based justification for assisted suicide is distinct from the legal permission established by the justification – a legal permission established by a particular justification may have a side-effect of giving immunity to practices or reasons not intended by, or even not consonant with, its establishing justification.

10 Which is not to suggest that it is morally unimportant. Unless one assumes a simple, unvariegated, absolutist account of autonomy’s significance, such that all expressions of self-regarding autonomy are morally equivalent regardless of variations in underpinning reasons and wider motivations, the normative underpinnings of voluntary choices ought to matter for moral analyses of a dedicated legal facilitation of those voluntary choices.

11 As Dr. Jeanne also pointed out, in Oregon patients can cite numerous concerns motivating a choice for assisted suicide. The top two concerns are loss of autonomy and loss of ability to enjoy life.

12 De jure expansion of the Oregon law has also occurred but not as regards expansion of the terminal illness ground. These expansions, well summarized by Jones (2023), are left aside for present purposes since they are not as morally important as the expansion of the ground(s) for access to assisted suicide.

13 Part of the issue is the difficulty in making accurate prognoses as much as six months out from the limit timepoint. See White et al. (2017). Yet a safeguarding issue also arises because there is an inherent difficulty in safeguarding against potential abuses of a terminal prognosis ground when the ground gives access to an intervention that works to shield the prognosis from scrutiny.

14 One might be tempted to think that Covid explains part of the increase from a longest duration average of 536 days for 1998–2018 to an average of 1384 days for 2019–2022. But the two longest durations were for the years 2019 and 2022, i.e. the two least affected by Covid.

15 The official report for 2022 ceased outlining illnesses that fall under the heading ‘other illnesses’.

16 From this condition to the last condition mentioned in this sentence the combined average numbers of assisted suicide deaths per annum across 2020–2021 was 8.

17 Prior reports included other conditions which qualified for assisted suicide and which are difficult to reconcile as predictably terminal, e.g. the reports for 2014–2016 included under ‘other illnesses’ Parkinson’s and Huntington’s diseases.

18 Citing a statement of Prof. Linda Ganzini, School of Medicine, Oregon Health and Science University made on March 16, 2017. Prof. Ganzini has published widely on Oregon’s assisted suicide practices.

19 Citing the responses of Mr. Craig New, a Research Analyst at the Oregon Health Authority with responsibility for, inter alia, ‘Death with Dignity statistics’.

20 Citing a different official source from within the Oregon Health Authority.

21 In practice there appears to be sufficient medical privacy to allow for treatment refusal of this sort to happen in a way that would not preclude access to assisted suicide. According to Dr. Jeanne (Houses of the Oireachtas Joint Committee on Assisted Dying 2023b), ‘Determinations related to disease treatment and, if appropriate, end-of-life care options are made between the patient and the physician. The law does not include any medical oversight or regulation distinct from what is done for other medical care … . The OHA [Oregon Health Authority] does not investigate whether patients met the Act’s criteria, nor how their diagnoses, prognoses, and treatment options were determined’. This (startling) admission suggests at least the potential for slippage concerning what is permitted by the overall regulatory regime in Oregon.

22 Further illustration of the question’s real-world relevance is provided by the recent development of the concept ‘terminal anorexia’. See Riddle et al. (2022).

23 I do not think that the right to refuse medical treatment is exclusively a function of patient autonomy, especially autonomy understood merely as doing-what-one-wills. Other considerations also seem to inform the right, e.g. the intrinsic personhood of the human body, the more qualified duty to positively help compared to the absolute duty to avoid intentional infliction of harm, practical feasibility and limited medical resources, etc.

24 Perhaps only up to a point, for an untreated chronic illness may produce a terminal condition. This scenario would be impossible to exclude from a terminal illness ground and illustrates a practical difficulty in excluding chronic illnesses from considerations of terminality.

25 Beneficence-based approaches to assisted suicide would logically seem to require moving towards non-voluntary euthanasia. Hence some in favor of medicalized killing proceed via a joint view: autonomy plus beneficence grounds assisted suicide. The argument here leaves all this aside. To the extent that it can be shown that the beneficence-based approach to assisted suicide has reason to think it dubious to restrict the qualifying grounds to ‘direct’ terminal illness only, then the reason(s) applies a fortiori to any joint view.

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Notes on contributors

Thomas Finegan

Thomas Finegan is the Chair of the Governing Board at the Anscombe Bioethics Centre. His previous publications have appeared in Bioethics, Journal of Medical Ethics, Medical Law International, among other journals.