>From: Jeremy Frank Shearmur >Date: Fri, 27 Sep 1996 09:54:10 +1000 (EST) >Subject: euthanasia & liberty There is currently a lot of controversy in Australia, as the Northern Territory has enacted legislation which allows (under highly restrictive conditions) for voluntary euthansia; there are attempts (primarily by those with religious inspiration, along with those sectors of the medical profession who resent the idea that they should be considered our agents) to overturn it at a Federal level, and we have just had the first case of someone who has taken advantage of it, and has penned a passionate public defence of its importance, as his last public act. In my personal view, I would put the right to choose when and how one should die as perhaps the most important right that an individual can have; yet I am struck by what seems to me an odd silence about it, with respect to those in the classical liberal tradition. (Indeed, I found it interesting that, when I published on this topic with a broadly classical liberal institute here ["The Individual: A Suitable Case for Denationalization", Policy, 11, no. 2, Winter 1995, pp. 31-5], the idea of my doing something on this topic was, to say the least, not welcomed with universal enthusiasm.) I also find it odd that people can wax eloquent about government not taxing people too much, about restrictions on hand guns, and so on, but not really seem to care that what in my view are the most important decisions about people's lives are coopted by the state. I'd welcome information about how this issue relates to the history of, and current defences of, classical liberalism; not least because - at least here in Australia - this seems to me an issue in which the main enemies of liberty are inspired by religious concerns (notably the Catholic Church, the role of which in Australian politics is in danger of re-kindling, in my personal reaction to political matters, the anti-Catholic paranoia which, historically, has played a role in British political culture!), which may highlight some tensions between the religious inspiration of many classical liberals in the U.S. and the consequences that others, elsewhere, draw from those same religious views... Jeremy Shearmur, Political Science, Faculties, ANU, Canberra ACT 0200, Australia ============================================================================= >Date: 27 Sep 1996 08:21:02 -0500 >From: "Robert Sade" RE>euthanasia & liberty 9/27/96 Jeremy Shearmur says: *I'd welcome information about how this issue relates to the history of, and current defences of, classical liberalism* There is, of course, a lot of controversy about euthanasia in the US as well. The best liberal defense of legalizing euthanasia I have seen is Tris Engelhardt's, in his book, Foundations of Bioethics (second edition recently published). He argues, in essence, that euthanasia should not be made illegal because the state has no moral authority to do so. Interestingly, he personally is a committed Catholic, but makes a clear separation between personal morality (euthanasia, abortion, etc., are wrong) and the very thin morality (protecting freedom from coercion) permissible for the state. The American Medical Association has taken a stand against legalization of physician assisted suicide and euthanasia, but has been (officially) silent on the general question of assisted suicide. Myown view on this is that assisted suicide and euthanasia should not be prohibited, as a matter of public policy and law. I also believe, though, that AS-E should not be restricted by law to physicians (which I understand the Australian law does, as well as the Oregon law). It is dangerous to assume that physicians will do what patients want, because there is a considerable weight of published evidence that physicians do not know what their patients want at the end of life, but think they do, so often do things to and for patients that are unwanted. Paternalism remains widespread in medicine, despite advances in public discussion and acceptance of patients' autonomy, informed consent, etc. in the last 30 years. I have a short piece on the subject in the most recent number of Perspectives in Medicine and Biology, arguing that AS-E should not be illegal, but that someone other than physicians ought to do it. (As a matter of private morality, in my view, physicians ought not to participate in AS-E, because it is inconsistent with the healing role of physicians, and it requires no specialized knowledge to put someone to death). Best regards. --Bob ============================================================================= >From: "Eleftheria Maratos-Flier" >Date: Fri, 27 Sep 1996 11:19:18 EST Robert Sade writes: (As a matter of private morality, in my view, physicians ought not to participate in AS-E, because it is inconsistent with the healing role of physicians, and it requires no specialized knowledge to put someone to death). I wonder if you can clarify this point -- it requires no specialized knowledge but the best drugs --barbituates or opiates -- are only available via prescription. Are you against prescribing medications, ostensibly for sleep or pain relief, that you suspect may be used for either assisted suicide or euthanasia? What if the patient asks for a prescription and is explicity about his intended use? Granted this would be different is all medications were available as over the counter, but they aren't. Eleftheria Maratos-Flier ============================================================================= >Date: Fri, 27 Sep 1996 08:27:11 -0700 >From: arhu032@uabdpo.dpo.uab.edu (Scott Arnold) Four comments: 1) Regarding euthanasia and the classical liberal tradition: As I am sure Jeremy knows, one of the founders of classical liberalism--Locke--believed that we have no right to take our own lives because we do not really own ourselves. We are, on Locke's view, owned by God because He created us. So, if we were to "quit our station" (to use that wonderful British phrase), we would be destroying God's property (literally). Locke does not seem to have considered the possibility that God might give us permission in some cases to destroy his property. The following story, which I sometimes tell students when I teach stuff on euthanasia, illustrates the point. A farmer's land is about to be inundated by a rising river. The sheriff comes by in his Jeep and tells the farmer he will be swept away in the flood, and it is time to leave. Clutching his Bible, the farmer responds that God has told him he will be saved. The sheriff leaves. A little while later the river breaches the levee and inundates the farmer's land. He has to climb up on his roof to avoid the flood. The sheriff returns, this time in a powerboat to tell the farmer it is time to leave. Once again the farmer replies that God has told him he will be saved so he doesn't leave. The floodwaters continue to rise, and eventually the farmer is standing on top of his chimney, still clutching his Bible. Rescuers once again appear, this time in a helicopter. As before, the farmer refuses help, unshaken in his faith that God will save him. The floodwaters continue to rise, the farmer is swept away, and drowns. He appears before St. Peter at the Pearly Gates and says, "There must be some mistake. I wasn't supposed to die. God was supposed to save me." St. Peter checks for his name on his roster and says, "Indeed, there must be some mistake. It says here we were supposed to send a jeep, a powerboat, and a helicopter to save you." 2) One of the most famous treatments of the topic of euthanasia is an article (later expanded into a book) by one of my colleagues, James Rachels. The article is variously titled (since it originally appeared as a letter to the editor of the NEW ENGLAND JOURNAL OF MEDICINE), though the usual title is "Active and Passive Euthanasia." In it, he argues for the moral equivalence of active and passive euthanasia. (Essentially, the idea is that if it is OK to let someone die, then it is OK to kill him). This article has been expanded into a book, THE END OF LIFE, published in 1986 by Oxford Univ. Press). Though one can find things to disagree with in this book, it is a level-headed and interesting discussion of the topic. 3) I found Bob Sade's remarks on physicians interesting. Holland, of course, has effectively decriminalized euthanasia. Carlos Gomez has studied how this has actually worked in practice and reports that physicians have remarkable latitude in deciding on euthanasia and exercise their discretion in highly paternalistic ways. His account is found in REGULATING DEATH: EUTHANASIA AND THE CASE OF THE NETHERLANDS (New York: The Free Press, 1991). [I don't know if Gomez wrote this book or if he or someone else edited it.] 4) For what it's worth, I suspect euthanasia/physician-assisted suicide will never be effectively legalized in the United States. Even if the appropriate laws were passed, any guidelines that are written into the law would be endlessly litigated, both in general and in particular cases, to the point where victims will die of whatever it is that led them to consider euthanasia in the first place. Scott Arnold Professor of Philosophy University of Alabama at Birmingham ============================================================================= >From: "Aeon Skoble" >Date: Fri, 27 Sep 1996 10:44:45 +0000 > physicians ought not to participate in AS-E, because it is inconsistent with > the healing role of physicians Depends on how you construe "healing." It doesn't seem too unreasonable to include "alleviating suffering" as part of the definition. A terminal patient can't actually be "healed" anyway, the only thing one can do is relieve or exacerbate pain, and prolong or quickly end existence. But let's combine two moral principles: (1) if I have a right to my own life, I have a right end my own life. (2) if it's permissible for me to do x, then it's permissible for me to seek assistance doing x when I can't do x by myself. If (1) and (2) are correct, then what's wrong with physician-assisted suicide? (Of course, if the state didn't prohibit self-medication, this wouldn't be an issue.) ============================================================================= >From: "Aeon Skoble" >Date: Fri, 27 Sep 1996 10:51:05 +0000 OK, let me follow up on what was at first an afterthought to my last post. Physician-assisted suicide is only an issue because the state dictates that the rest of us must jump through various hoops to get medication. If all drugs were legally available at the pharmacy, then I could ask any friend or family member to get my pain pills or whatever, and could commit suicide without involving physicians. If MDs see this issue as a moral dilemma and want to get out of this situation, they should support legalization of all drugs. ============================================================================= >From: Jeremy Frank Shearmur >Date: Sat, 28 Sep 1996 08:04:23 +1000 (EST) >Subject: Euthanasia and liberty Many thanks for the various responses to my earlier posting. I did, indeed, know about Locke's views, and about the general academic literature on these matters (although thanks for specific suggestions). What I was interested in was slightly different, and I clearly did not formulate my query as well as I had intended. My concern is this: why does the issue of Euthanasia not - as far as I can tell - figure particularly prominently in the concerns of modern libertarians or classical liberals? I ask this just because the issue looks to me of real theoretical and practical significance (in Locke, God was ones residual owner; today, it seems, it is the state; but Locke, after all, thought that God was our maker...). Prima facie, it would seem to me strange that people would care more about thether the state could tax you, than its arrogating to itself decisions on these matters! In practical terms, it seems to me that there is every reason that these matters will be in the hands of physicians; not only because there are *surely* problems about the completely free sale of substances that can kill easily (here it seems to me that Nozick's line of argument about behaving dangerously towards others is very much to the point; which is, for example, one reason why I don't see the issue of gun ownership as a simple issue of liberty; but I don't want to get into this one here!!), but also because of the phenomenon of clinical depression and, more generally, of individuals not being well-informed about how the current state of medical knowledge relates to their situation. In the short article to which I referred, I suggested that one might deal with this issue, by way of a re-development of the institution of the general practitioner - someone with whom one could build up a relationship, and could select on the basis also of their sympathy with your values. Such people could then discuss with you your attitude towards medical issues prior to your being seriously ill, could get a standard witnessed statement about your views, and would then act as your agent if you were, say, to enter hospital, with legal arrangements in place such that the hospital etc would *have* to act, with regard to issues of whether or not you would be treated in certain circumstances, and euthanasia, on the instructions of your agent. This, it would seem to me, might overcome some of the existing problems of living wills (e.g. that they are disregarded); and also, because what is involved is both a document (on the basis of which, say, your family could take action against your agent, if it seemed as if he or she was going flagrently against your wishes as expressed there) and a personal relationship with someone who is well-informed about your views, and is capable of understanding medical argument (e.g. along the lines that your earlier decision, as recordsed in the document, was made on the basis of now-superceded medical ideas), they would be in a good position to act on your behalf. The suggestion is, of course, more complex than I can indicate here (even though the article is short), but it seems to me better than the arrangements that, say, we have in place here; not least as it does not restrict euthanasia to cases in which someone is in pain or is about to die (personally, the onset of Altzheimer's disease is something for which I would wish to make provision!); and it undercuts completely any argument about a 'slippery slope', as the arrangement is linked to the judgement of the individual, as explicated in discussion with a well-informed person, not to others' views about the quality of ones life etc. I would stress again, though, that my concern is not to get into a discussion of the details of such arrangements (to say nothing of issues about the control of sales of drugs or guns!!) but to ask whether others shared my view that it is strange that libertarians should be more concerned about taxation, say, than the removal by the state of control over key decisions about life and death - and if not, why not. Jeremy Shearmur, Political Science, Faculties, ANU, Canberra ACT 0200, Australia ============================================================================= >Date: 27 Sep 1996 21:41:30 -0500 >From: "Robert Sade" RE>(Fwd) Re: euthanasia & liberty 9/27/96 Eleftheria Maratos-Flier writes: *Robert Sade writes: (As a matter of private morality, in my view, physicians ought not to participate in AS-E, because it is inconsistent with the healing role of physicians, and it requires no specialized knowledge to put someone to death). I wonder if you can clarify this point -- it requires no specialized knowledge but the best drugs --barbituates or opiates -- are only available via prescription. Are you against prescribing medications, ostensibly for sleep or pain relief, that you suspect may be used for either assisted suicide or euthanasia? What if the patient asks for a prescription and is explicity about his intended use? Granted this would be different is all medications were available as over the counter, but they aren't.* To treat pneumonia, a physician needs to know bacterial sensitivities, antibiotic dosage schedules, drug interactions, patient allergy history, toxicity levels, etc. To kill someone, you need to know none of that, only the lethal dose of drug x or y. This could easily be taught to almost anyone with a grade school education. A euthanatist certification process could be used to assure this minimal level of knowledge, prescription writing power assigned on the basis of certification, and you don't need a doctor. (Alternatively, you could do away with laws controlling prescription drugs.) Of course, a myriad social and legal problems would need to be dealt with, but, in the end, you don't need a doctor to do away with people, without or with drugs. You are right, though, that without changes in the current system of laws and regulation, a humane physician might be justified in using prescription power to help a severely suffering patient. With appropriate palliative care (antidepressants, pain medication, etc.), this should rarely be necessary. Best regards. --Bob ============================================================================= >Date: 27 Sep 1996 22:26:46 -0500 >From: "Robert Sade" RE>>euthanasia & liberty 9/27/96 Aeon Skoble says: * > physicians ought not to participate in AS-E, because it is inconsistent with > the healing role of physicians Depends on how you construe "healing." It doesn't seem too unreasonable to include "alleviating suffering" as part of the definition. A terminal patient can't actually be "healed" anyway, the only thing one can do is relieve or exacerbate pain, and prolong or quickly end existence. * Alleviating suffering IS part of healing, in my view. The aspect of the 'healing role' I was referring to is the fundamental importance of trust of the physician by the patient for healing to be effective. If you combine the power to euthanatize without risk of punishment with the currently rapidly increasing public awareness of the extent to which doctors ignore advance directives (living wills, donor cards, and the like), trust in doctors is likely to become of historic interest only. *But let's combine two moral principles: (1) if I have a right to my own life, I have a right end my own life. (2) if it's permissible for me to do x, then it's permissible for me to seek assistance doing x when I can't do x by myself. If (1) and (2) are correct, then what's wrong with physician-assisted suicide?* Your logic is correct, for the patient. What's wrong with physician-assisted suicide is not the assisted suicide, but is the participation of the physician. I'm not saying that it should be illegal for physicians to assist in suicide; the law should be mute on this subject. I am saying that physicians, as a profession, should not participate in assisted suicide and euthanasia for the same reason they should not participate in (perfectly legal) executions of criminals. Purposefully ending life must not be done by doctors if they are to be trusted, and trust is at the core of what it means to be an effective healer. This is especially true in the era of managed care, when physicians are (lamentably) acting more and more for the financial benefit of the company that is paying the bills than for the best interest of patients. Would you trust the doctor who stands to increase his income by reducing intensive care stays of his patients to decide when to pull the plug on your ventilator? I don't mean to be melodramatic, but this is increasingly reality in the last decade of the millenium. Best regards. --Bob __________________________________________________ Robert M. Sade, M.D. Department of Surgery Medical University of South Carolina Charleston, SC 29425 sader@musc.edu ============================================================================= >Date: 27 Sep 1996 22:26:14 -0500 >From: "Robert Sade" RE>>Euthanasia and liberty 9/27/96 Aeon Skoble says: * OK, let me follow up on what was at first an afterthought to my last post. Physician-assisted suicide is only an issue because the state dictates that the rest of us must jump through various hoops to get medication. If all drugs were legally available at the pharmacy, then I could ask any friend or family member to get my pain pills or whatever, and could commit suicide without involving physicians. If MDs see this issue as a moral dilemma and want to get out of this situation, they should support legalization of all drugs. * BINGO! See my note earlier this evening to E M-F. Best regards. --Bob ============================================================================= >Date: Fri, 27 Sep 96 23:53:30 EDT >From: Eleftheria Maratos-Flier Jeremy Shearmur writes: >>In practical terms, it seems to me that there is every reason that these matters will be in the hands of physicians; not only because there are *surely* problems about the completely free sale of substances that can kill easily << There is very deadly stuff that is sold quite freely. For example rat poison is a very effective, it's just very unpleasant. Also acetaminophen (tylenol) which can be readily purchased at the supermarket is deadly, the lethal dose is about 30 grams +/- The problem is that once one has taken it takes about a week to die of acute liver failure. For anyone who knows botany, there is a lot of deadly stuff in the perennial garden and should you live in Florida, where Bufo Marinus (horned toad) has become a pest well the stuff that oozes out of it's poison glands is very bad. The prohibition of free sale of opiates and barbituates isn't based on deadliness, it's based on the state's perceived potential for abuse. >>In the short article to which I referred, I suggested that one might deal with this issue, by way of a re-development of the institution of the general practitioner - someone with whom one could build up a relationship, and could select on the basis also of their sympathy with your values. Such people could then discuss with you your attitude towards medical issues prior to your being seriously ill, could get a standard witnessed statement about your views, and would then act as your agent if you were, say, to enter hospital, with legal arrangements in place such that the hospital etc would *have* to act, with regard to issues of whether or not you would be treated in certain circumstances, and euthanasia, on the instructions of your agent.<< I don't think most doctors are comfortable with active participation in euthanasia -- well the one's I know aren't and I worry a lot about those that are. I think a more intimate relationship than the doctor-patient one is called for. >>shared my view that it is strange that libertarians should be more concerned about taxation, say, than the removal by the state of control over key decisions about life and death - and if not, why not.<< Probably because it's more fun to talk about taxes than to talk about death? Eleftheria Maratos-Flier, M.D. ============================================================================= >Date: 28 Sep 1996 09:05:42 -0500 >From: "Robert Sade" RE>Euthanasia and liberty 9/28/96 Jeremy Shearmur says: * . . . one might deal with this issue, by way of a re-development of the institution of the general practitioner - someone with whom one could build up a relationship, and could select on the basis also of their sympathy with your values. * It's unlikely most people could find such a soul-mate physician. Values and attitudes of doctors are not those of the masses, but those of the elite (see, eg, the recent thread on the Bell Curve). A sympathetic physician is not necessarily a non-paternalistic one. There are a few of the sort you describe, but most people don't know how to find one. (That's why Kevorkian is still in business.) * Such people could then discuss with you your attitude towards medical issues prior to your being seriously ill, could get a standard witnessed statement about your views, and would then act as your agent if you were, say, to enter hospital, with legal arrangements in place such that the hospital etc would *have* to act, with regard to issues of whether or not you would be treated in certain circumstances, and euthanasia, on the instructions of your agent.* This is exactly what's supposed to be happening in the US now. Doctors and hospitals now 'have' to act on the basis of legally binding advance directives, but either they don't look for them or ignore them when they are available (see the report by SUPPORT investigators in JAMA in November, 1995). Thirty years of work on changing paternalistic attitudes of physicians has made some important changes, but there is still a large reservoir of doctor-knows-best out there. At the root of the euthanasia debate is an unspoken truth: people simply don't want to take responsiblity for themselves, either for their lives or for their deaths. If they truly want to die, there are plenty of easily available vehicles for it: poisons, natural gas stoves, ten story buildings, knives, guns, automobiles-concrete walls, and many others of varying levels of comfort (if comfort is an issue) that are detailed in popular market books like Derek Humphrey's Final Exit. The current euthanasia debate is an effort to medicalize and to sanitize death. Medicine has little to do with it. There are plenty of ways to kill yourself if you really want to do it; it's an abdication of personal responsiblity to ask someone else to do it for you. For those who are physically unable to kill themselves and need help, far better to get a spouse or a trusted friend to do it for you than a physician who has a waiting room full of patients or a managed care company on his back. Very few doctors have the time or energy to become a friend and confidante to their patients in the same way a close friend or a husband is. If you don't have a relative or friend you can trust, what does that say about the kind of life you have lived? You also * ask whether others shared my view that it is strange that libertarians should be more concerned about taxation, say, than the removal by the state of control over key decisions about life and death - and if not, why not.* I do share your view, and ask where have the libertarians been in this debate. Perhaps mixed in with the pro-euthanasia lobbyists? Best regards. --Bob ============================================================================= >From: MaryRuwart@aol.com >Date: Sat, 28 Sep 1996 10:31:03 -0400 You wondered what the classical libertarian position was on suicide and why you haven't heard more about it. My younger sister, Martie, elected physician-assisted suicide with Dr. Kevorkian in February of 1993. I took care of her during her last few months, as she struggled with pancreatic cancer. I have been speaking, writing, and doing TV/radio shows on the topic ever since. I have tapes of some of the more popular programs (Rolanda, Larry King, Morton Downey, Jr.). If you have specific questions, I'd be happy to share what I know. The only thing I've put on the Web is from my monthly column at http://www.lightworks.com/MonthlyAspectarian/1996/June13-0696.html I certainly agree that without the right to take your own life, you can hardly be considered to have any self-ownership. ============================================================================= >From: "Aeon Skoble" >Date: Mon, 30 Sep 1996 08:16:36 +0000 > the fundamental importance of trust of > the physician by the patient for healing to be effective. My trust for physicians would increase, not decrease, if I found out there was an greater incidence of respecting the autonomy of competent adults. > I'm not saying that it should be illegal for > physicians to assist in suicide; the law should be mute on this subject. I can agree with you there. > Purposefully ending life must not be done by doctors if they are to be trusted > and trust is at the core of what it means to be an effective healer. If non-physicians could have access to the drugs, I'd be willing to countenance this stance. But right now, _only_ MDs can help. If MDs want to be off the hook for unpleasant exercise of their prescription powers, they ought to support an end to their monopoly on prescribing drugs. > Would you trust the doctor who stands to increase his income by reducing > intensive care stays of his patients to decide when to pull the plug on your > ventilator? Point well-taken. But I was more concerned with cases where the patients wishes are known, but the patient is physically unable to enact them. ============================================================================= >Date: Mon, 30 Sep 1996 08:44:17 -0500 (CDT) >From: Tibor R Machan Suppose a new category of physician - not doctor - were to evolve, along Kavorkian's lines of work. This would not involve healing but helping in matters involving physical problems, problems related to the disposition of one's health, etc. There need not be some rigid designation of what a physician ought to do for others - in light of the long lives people live, their deaths would change, as well, and some professionalism in helping with this death could well develop and be perfectly respectable. Tibor Machan ============================================================================= >Date: 30 Sep 1996 10:06:49 -0500 >From: "Robert Sade" Reply to: RE>>euthanasia & liberty Aeon Skoble says: *My trust for physicians would increase, not decrease, if I found out there was an greater incidence of respecting the autonomy of competent adults. * Respecting autonomy and participating in causing death are two different things. If I thought abortion were wrong, and would not do one, I might easily and without contradiction respect your (wife's) right to have one. If you were Dutch, would your trust in physicians increase or decrease when you learn that more than half the cases of euthanasia in Holland are involuntary (the patient never consented to it, but it seemed like a good idea to the physician), in clear violation of the official guidelines that permit only voluntary euthanasia (see R Fenigsen, The report of the Dutch governmental committee on euthanasia. Issues in Law and Medicine 7:339-46, 1991), as well as Carlos Gomez' book that Scott Arnold referred to a few days ago. *If non-physicians could have access to the drugs, I'd be willing to countenance this stance. But right now, _only_ MDs can help. If MDs want to be off the hook for unpleasant exercise of their prescription powers, they ought to support an end to their monopoly on prescribing drugs.* You are right on that one. But keep in mind that prescription drugs are not the only way to be killed. Best regards. --Bob ============================================================================= >From: "Aeon Skoble" >Date: Mon, 30 Sep 1996 09:55:41 +0000 > If you were Dutch, would your trust in physicians increase or decrease when > you learn that more than half the cases of euthanasia in Holland are > involuntary (the patient never consented to it, but it seemed like a good idea > to the physician), I'm most supportive of the permissibility of voluntary euthanasia, cases where it's clear that the patient wishes to die but cannot realize this wish. It's a slippery slope to suggest that we should not allow voluntary euthanasia because it could lead to involuntary euthanasia. But even having said that, I'd also say that there are cases where non-voluntary euthanasia would be best for everybody also, but I'd like some strict guidelines about when this should be permitted. Best, Aeon ============================================================================= >Date: Mon, 30 Sep 1996 10:37:05 -0500 (CDT) >From: Tibor R Machan When someone kills another, one needs to demonstrate that this is justified - the killer has the burden of proof (sometimes in demand after the fact, of course, as in self-defensive killings). I think this is what ought to be the policy vis-a-vis non-voluntary euthanasia. That burden is, of course, not easy to meet. Tibor R. Machan ============================================================================= >Date: Mon, 30 Sep 1996 12:42:01 -0400 (EDT) >From: "Daniel Shapiro" >Subject: Slippery slope arguments and euthanasia Aeon suggested, in his reply to Robert Sade, that it would be a slippery slope argument to suggest that vol. active euthanasia shouldn't be legalized because it leds to many cases of nonvoluntary euthanasia. I would like some clarification on this, please. Admittedly, many versions of slippery slope arguments are fallacious. But not all. Suppose one thought that if voluntary active euthanasia was legalized, this would lead to many caes of euthanasia that were rights violations. Why wouldn't that be a legitimate basis to argue against legalizing voluntary active euthanasia? Now Bob Sade didn't say that the nonvoluntary cases violated individual rights. But it's not wildly implausible to suggest that they might have, in which case we have a genuine worry for libertarians, I think. Anyway, I'd like to know what Aeon or others think about this. Danny Shapiro ============================================================================= >From: "Aeon Skoble" >Date: Mon, 30 Sep 1996 13:05:20 +0000 > Admittedly, many versions of slippery slope argumetns are fallacious. > But not all. Agreed. What distinguishes the valid form from the fallacious form is whether there is some non-arbitrary line to draw. Regarding the slippery slope from voluntary to nonvoluntary euthanasia, we have such a line available: if the patient's wishes are known. If I want to die, but physically cannot kill myself, so someone else does it for me at my request, there's no rights-violation. If I'd prefer not to die, but, my wishes being unknown, someone kills me, then my rights are being violated. But we can draw a line here which eliminates slippery-slope type problems. Slippery slope fallacies occur when "where do you draw the line" questions are posed in a situation where there is a line to be drawn. The argument "if we permit voluntary euthanasia, that will lead to nonvoluntary euthanasia" is thus a fallacious slippery slope. (BTW, Danny, I get that article - thanks, I'll let you know after I've read it.) Best, Aeon ============================================================================= >Date: Tue, 1 Oct 1996 10:51:03 -0400 (EDT) >From: "Daniel Shapiro" >Subject: Two kinds of slippery slope arguments Aeon--You are right that if one says "Where can one draw the line" and there is a line to be drawn, then a slippery slope argument is fallacious. BUT--as Feinberg points out in Offense to Others--there is another kind of slippery slope argument. One might argue that while there is a line to be drawn, IN FACT the line will not be drawn. Feinberg calls this the empirical form of the slippery slope argument (as opposed to the logical form, which is what you were concerned with.) This is not a fallacious argument at all. For what one is saying is that the way the political system or legal sytem works, we will in fact slide down the slope (ie, move from acceptable to unacceptable actions) even though we didn't HAVE to do that (ie, it was not logically required.) I don't know if this is what Bob Sade had in mind--[feel free to jump in here Bob!] but he might have. And it seems a perfectly legitimate argument and a perfectly legitmate worry about legalizing vol. active euthanasia, at least where one can predict that doctors will be the ones doing the euthanisizing, so to speak. I hope this is reasonably clear. Danny ============================================================================= >Date: Tue, 1 Oct 1996 07:57:50 -0700 >From: arhu032@uabdpo.dpo.uab.edu (Scott Arnold) >Subject: Euthanasia and Slippery Slopes I don't think Aeon has quite answered Danny's challenge. There are at least two versions of the slippery slope argument, what we might call a logical version and an empirical version. The logical version is a simple Modus Tollens argument of the following form: If practice A is morally acceptable, then so is practice B Practice B is not morally acceptable. Therefore, Practice A is not morally acceptable. To defeat the 1st premise, all one needs is a morally relevant distinction between the two practices, which Aeon claims to find (viz., explicit consent). But there is another form of the slippery slop argument. This version says that whatever the real distinctions between two practices, those distinctions will not in fact be observed. If the morally unobjectionable practice is permitted to occur, that will in fact lead to the occurrence of the morally objectionable practice. This is the general point of Danny's objection. Now I think that this is in fact a legitimate worry in the case of euthanasia. Voluntary euthanasia, in the abstract, is morally unobjectionable. (I could argue for that, but I won't). But it may lead to a morally objectionable practice. That practice may not be non-voluntary euthanasia (where a patient has no expressed wishes) but INVOLUNTARY euthanasia (euthanasia against a person's wishes). Here is where Bob Sade's worries about the paternalism of physicians and the effects of managed care are legitimate and serious. If there is a conflict between, on the one hand, what the patient really wants (which is sometimes hard to determine), and on the other hand, what the doctor and the insurance company think is best for the patient, I have no confidence in the outcome. Though I have some confidence in my own doctor, I believe the people at my insurance company were all hired away from the Department of Motor Vehicles. But, as I said before, I think this is essentially an academic issue, at least in the US. Any decision to legalize euthanasia would invite lawyers into the process--even worse, lawyers for the managed care insurance companies!! --Scott Arnold Professor of Philosophy University of Alabama at Birmingham ============================================================================= >Date: Tue, 01 Oct 1996 08:20:29 -0800 >From: Jim Chesher >Subject: Slip slope Daniel Shapiro observed of the "empirical slippery slope" that "it seems a perfectly legitimate argument and a perfectly legitmate worry about legalizing vol. active euthanasia, at least where one can predict that doctors will be the ones doing the euthanisizing, so to speak." I think that the worry here is reasonable, but why should it count against legalizing active euthanasia IF it is agreed that (at least under certain specifiable conditions) a person has a Right to it? Wouldn't it be unjust to deny someone that to which he/she has a right on the grounds that doing so will (likely) lead to abuse? (Especially when the abuse will not come from the one exercising his/her rights). --Jim Chesher ============================================================================= >From: "Aeon Skoble" >Date: Tue, 1 Oct 1996 12:12:12 +0000 > If there is a conflict between, on the one > hand, what the patient really wants (which is sometimes hard to determine), > and on the other hand, what the doctor and the insurance company think is > best for the patient, I have no confidence in the outcome. Though I have > some confidence in my own doctor, I believe the people at my insurance > company were all hired away from the Department of Motor Vehicles. Perhaps this raises a problem for proponents of non-voluntary euth., but I don't see how this is a problem for proponents of voluntary euth. Also, again, this concern wouldn't arise if we all had access to drugs. ============================================================================= >From: "Aeon Skoble" >Date: Tue, 1 Oct 1996 12:12:12 +0000 > there is another kind of slippery slope argument. One might argue that while > there is a line to be drawn, IN FACT the line will not be drawn. I'm not sure how different this really is though. If the line is there, it can be drawn as a matter of ethical theory or public policy. The pieces I've seen on euthanasia argue that if voluntary euth. is declared morally permissible, it will erode respect for life, etc., and we will then find ourselves in the undesirable situation of having doctors terminating patients against their will, or even killing patients with non-terminal illnesses, or killing the retarded or diabetic or whatever. That's fallacious reasoning no matter how you slice it. To argue that my physician should not be permitted to assist me in carrying out my wishes on the grounds that "it would lead to" mad-scientist types killing diabetics is absurd. (I'm not accusing anyone on this list of this reasoning, but it appears frequently in applied-ethics texts.) ============================================================================= >Date: Tue, 1 Oct 1996 13:24:48 -0400 >From: jnarveso@watarts.UWaterloo.ca (Jan Narveson) >Subject: More on Slippery Slopes The distinction between the "logical" version of slippery slope, which is plainly invalid, and the "empirical" versions ("psychological", as they are sometimes called) is obviously of extreme importance in the domains where they are used. In the empirical case, one escapes from the outright invalidity of the logical version by arguing that if A is permitted, it might "lead" to B, regardless of he absence of any logically compelling reason why it must do so. But there is a good deal of loose talk about "leading". If you allow people to do x, it is said, then they will in fact start doing y. But if y is well-defined, is made illegal, and is understood to be immoral, why should we suppose that it will? For example, James Rachels has long argued that if euthanasia is hedged in by procedures making it about as certain as it is readily possible to imagine that it was indeed voluntary, there is nothing to worry about. On the contrary, as he points out, the real worry is that euthanasia will remain illegal in its good forms as well, with the result that human misery will be perpetuated for no good reason. Let's remember that although theft and murder are illegal, lots of people do both. Thieves and murderers do not hedge with legal fine points and depend on subtle marginal increments of meaning - they just go ahead and steal and kill people. Making something illegal won't stop it happening. That is the other side of my coin, which is that making the thing next door legal won't assure that the bad things which the former prohibitions were supposedly designed to prevent will cease happening, indeed - BUT making them legal will also not, so far as it goes, bring about massive increments in what everybody knows to be wrong, either. The empirical use of slippery slope demands evidence, and in fact that is where the discussion ought to be focussing: just how much and what sort of evidence is needed in order to show that permitting something was a mistake, on the ground that what was no intended to be permitted is now happening anyway? 1. To start with, there must be a real increment in the marginal rate of the bad thing (in this case, murder masquerading as euthanasia): that is, cases that would not have happened anyway crop up, and do so in a way attributable to the legalization in question. My guess is that the net marginal increment in real murder due to legalizing euthanasia will be Zero; but the point is, hard information is required. But that's not all. We also need 2. A rate of substitution for the incremental factor of the bad thing against the marginal increment of desirable cases, that is, cases where, say, euthanasia occurs in cases where it is clearly desirable (and desired), and which would not otherwise have happened. For one thing is clear about laws: it affects the behavior of the law-abiding, who are numerous. There are various reasons why people are law-abiding when they are. While fear of apprehension and punishment is, of course, prominent among them, it is by no means the only factor. Plenty of people obey laws because they are laws, thinking that that is their duty or, perhaps even more likely, just not thinking at all. We may be sure that much euthanasia is prevented by its previously illegal status. Were it legalized, a fair number of these cases would result in the desired death that we who think euthanasia, when suitably desired by the subject, to be a good thing and even a right, would applaud. How do we get the right rate? There is a tendency to suppose that no number of good cases can outweigh even one bad case. This kind of thinking is the number one enemy of liberty in all domains, it should be noted. Liberty ALWAYS entails risks; there will ALWAYS be people who misuse it when it is granted. Of course we do not want to be murdered, and therefore want to reduce the risk of murder. Bu also, we do not want to suffer extremely in old age when we are unable to do anything about it ourselves. To make it illegal for others to do it even at our request is to foreclose our liberty to secure a good. That is just as bad when done by the law as when done by a private murderer or thief. There is no option but to make a sort of intuitive computation of the value to you of having the liberty to secure your own demise when life is no longer worth living, as far as you're concerned, and there is no way to secure it by your own unaided devices, versus the value to you of the life that you would lose if murdered by an unscrupulous so-called euthanasiast. This, as we all know, can only be done by talking expected utility talk. The probability of being in the situation that legalizing euthanasia is designed to enable is decidedly nontrivial, if not enormous. The probability, so far as we have any reason to know, of being what amounts to a murder victim at the hands of someone who would not have acted were it not that euthanasia has been made legal, is extremely low. The probability of dying in an automobile accident is, I would guess, a great deal higher than the latter, but one does not see argument that driving cars should therefore be made illegal. All this is empirical work for someone, but that work will be wasted if the wrong moral assumptions are made. There is, so far as I can see, no reasonable substitute for the ones I have sketched above - though there are plenty of unreasonable ones. __________________________________________________________________________ Jan Narveson (Professor) Department of Philosophy, University of Waterloo; Waterloo, Ontario, Canada, N2L 3G1 (519) 888-4567-1-2780# (from touch-tone); or 885-1211, ext. 2780 (via switchboard); FAX (519) 746-3097 Home: (519) 886-1673 (answering machine) e-mail: jnarveso@watarts.UWaterloo.ca ============================================================================= >Date: Tue, 1 Oct 1996 12:51:50 -0500 (CDT) >From: Tibor R Machan The slippery slope threat is nearly universal - wherever distinctions need to be made but there are (a) some borderline cases and (b) some folks embark upon fudging them. Jan is right - what is needed is vigilance, not giving up making distinctions. As I noted before, resting the burden of proof with those who kill is one way to discourage abuse. Tibor Machan ============================================================================= >Date: Tue, 1 Oct 1996 14:42:16 -0400 (EDT) >From: "Daniel Shapiro" >Subject: Slippery slopes and evidence I am in agreement with most of what Jan says in his recent post on slippery slopes, particularly about the point about evidence. But I thought Bob Sade's post was about such evidence that (a) doctors are paternalistic and often act against their patients wishes and (b) that in Holland, 50% of the cases were not voluntary euthanasia. IF a lot of the latter were indeed murder, then libertarians who favor legalizing vol. active euthanasia would have something to do worry about. I don't know how many, or if anyone knows how many, of (b) were tantamount to murder. [Again--an opening here for Bob Sade, if he'd like to take it.I don] 't mean to bug you Bob!]But I would think that looking at Holland and how doctors in fact behave would be the kind of evidence that is relevant to the assessment of the soundness of the empirical slippery slope argument against legalizing voluntary active euthanasia (where doctors are in in control of the euthanisizing.) Danny ============================================================================= >Date: Tue, 1 Oct 1996 12:04:56 -0700 (PDT) >From: Fred Foldvary On Tue, 1 Oct 1996, Daniel Shapiro wrote: > in Holland, 50% of the cases were not voluntary euthanasia. IF a lot of > the latter were indeed murder, then libertarians who favor legalizing > vol. active euthanasia would have something to do worry about. We already have living wills and signed instructions on whether to extend life when the patient is terminally unconscious. These can be slippery; doctors don't always follow them. Perhaps what is needed in all theses is clearer and more effective enforcement. What are the penalties for doctors who ignore written requests? Fred Foldvary ============================================================================= >Date: 1 Oct 1996 20:54:28 -0500 >From: "Robert Sade" RE>>Slippery slopes and evidence 10/1/96 Fred Foldvary says: *We already have living wills and signed instructions on whether to extend life when the patient is terminally unconscious. These can be slippery; doctors don't always follow them. Perhaps what is needed in all theses is clearer and more effective enforcement. What are the penalties for doctors who ignore written requests?* In effect, there are no penalties. Each state with living will laws has different civil or criminal penalties associated with ignoring advance directives, but they are not enforced. There seem to be a lot of reasons for this, including the fact that the one who was harmed is now dead (or terminally unconscious), so is no threat to anyone. The family is grieving, laden with guilt, and simply in no condition or position to take action, even if they would otherwise be inclined to. Because of the elevated status of physicians, I doubt that 'clearer and more effective enforcement' is likely to happen. Sheriff's departments don't generally cruise hospitals, and few are willing to call them. There are some peculiar cultural aspects to respecting the wishes of dead persons that go beyond terminal illness itself. For example, a signed organ donor card, properly witnessed, is legally valid and cannot, under the law (in the US), be ignored or overridden by family. Yet, after any death, the family is always asked whether they want to donate organs of the deceased, regardless of the presence of a donor card or other advance directive specifying that organs are to be donated. It is often said that the reason for this is that the dead person cannot sue doctors for failing to act on an advance directive, but families sure can if the doctor does something they do not approve of. So, always ask the family is the rule, even though the law prohibits it. It's not that simple, though. In countries where litigation is minimal, families are still almost always asked for permission to take organs, even when the patient had a valid advance directive, and, more surprisingly, even in countries where presumed consent is the law (the patient is always presumed to have consented to donation unless he has specifically opted out) --in all those circumstances, the family is nearly always asked for permission, though it is inappropriate and illegal. In effect, one has control (through an advance directive) over the disposition of one's own body after death only if the doctor and the family choose to honor the directive, regardless of what the law requires. It's a peculiar world out there. Best regards. --Bob ============================================================================= >Date: 1 Oct 1996 21:45:55 -0500 >From: "Robert Sade" RE>Slippery slopes and evidence 10/1/96 Daniel Shapiro says: *I am in agreement with most of what Jan says in his recent post on slippery slopes, particularly about the point about evidence. But I thought Bob Sade's post was about such evidence that (a) doctors are paternalistic and often act against their patients wishes and (b) that in Holland, 50% of the cases were not voluntary euthanasia. IF a lot of the latter were indeed murder, then libertarians who favor legalizing vol. active euthanasia would have something to do worry about.* There is indeed a lot of evidence from the American medical literature that doctors act against their patient's wishes (usually because they don't know, but think they do, what the patient's wishes are), and that in Holland most euthanasia is involuntary (and therefore against the law). However, I did not frame those facts as a slippery-slope argument, because, as Jan Narveson suggests, some critical evidence is missing: there are no studies to show what the rate of euthanasia was before euthanasia was made administratively acceptable in Holland (it has always been illegal). Therefore, we cannot know whether the rate of voluntary and involuntary euthanasia has increased, decreased or stayed the same after euthanasia was exempted from criminal liability. The point I was making was that, whatever the effect of legalizing or decriminalizing euthanasia, doctors are not reliable agents of their patients, and do not follow guidelines. If euthanasia is to be made legal, it should be made legal for husbands, wives, friends, or professional euthanatists on the same basis as doctors. We physicians, I am sad to say, occupy no special high moral ground when it comes to carrying out patients' wishes. Tibor was quite right when he said that the burden of proof that the killing was not murder should be on the euthanatist. It will require changing the law in most states to make euthanasia a form of justifiable killing (along with self-defense, legal execution, and the like). In practice, however, no doctors and few relatives who have helped severely ill patients who desired to die, with benevolent motivation, have been found guilty of a crime. Prosecutors, judges, and juries are very reluctant to penalize benevolent acts. Best regards. --Bob ============================================================================= >Date: Wed, 2 Oct 1996 08:38:48 -0400 (EDT) >From: Wayne Dymacek Those who argue for voluntary euthanasia are naive if they believe that the decisions will remain with doctors, patients, and insurance companies. Health care in the US has too much government in it. Euthanasia will therefore also have government involvement and this will lead to the government making the decisions. Of course, euthanasia is wrong because our death is God's decision, not our own. Wayne M. Dymacek Washington and Lee University phone: (540) 463-8805 (office) Mathematics Department (540) 463-6981 (home) Lexington, Virginia 24450 fax: (540) 463-8945 e-mail: wdymacek@liberty.uc.wlu.edu ============================================================================= >Date: Wed, 2 Oct 1996 07:49:32 -0500 (CDT) >From: Tibor R Machan On Wed, 2 Oct 1996, Wayne Dymacek wrote: > Of course, euthanasia is wrong because our death is God's decision, not > our own. IF euthanasia is wrong, it isn't because our death is God's decision (whatever ON EARTH that would mean). God, at most, would have decided for his making the decision as to our death because that is right. God, if there is one, just happens to be very good at knowing what's right and wrong - he or she or it isn't inventing what's right and wrong. (Jan made this point very well before.) So we mere mortals human beings still need to figure out what's right and wrong. Now if what is right is difficult to secure among us because institutions we may cook up to do this do not function, is it our business to see to it that better institutions are available to us or should be just give up on securing what's right? If we ban euthanasia because, well, it is difficult to tell who is doing it legit and who is merely faking it but committing murder, does this not pretty much destroy any effort to secure the legal protection of what's (politically) right? Such difficulties face us EVERYWHERE. Child molestation versus child discipline, sex versus violence, rape versus seduction, self-defense versus vengence - I could go on interminably. Tibor Machan ============================================================================= >From: MaryRuwart@aol.com >Date: Fri, 4 Oct 1996 08:05:01 -0400 I suggest that in discussing assisted suicide that we make a distinction between it and euthanasia. Euthanasia is "mercy killing," done for or to someone by someone else. Assisted suicide is just that--the doctor provides the means, but the patient does his or her own execution. For example, in my sister's case, Dr. Kevorkian provided Martie with a mask which had a tube leading to a carbon monoxide cylinder. A clip on the tube prevented the gas from flowing until Martie pulled it off. With assisted sucide, the patients wishes are known. The decision of when, where, and how is the patient's, not the doctor's. The only decision for the doctor is whether or not he or she wants to be the assistant. Assisted suicide should be legalized; no slippery slopes here. Allowing individuals to purchase medications to take their own life could take the doctor out of the loop. However, for patients that could no longer keep things in their stomach, like my sister, some sort of IV medication might be necessary. IVs might be difficult for a sick person to self-administer, but a family member might assist (preferably in front of witnesses, so that their would be no questions of the patient's true wishes). If the patient has a living will giving a doctor permission to terminate life under certain circumstances, then the doctor could, from a rights standpoint, perform euthanasia (i.e., the doctor pulls the plug, not the patient). Things get messy only when someone other than the patient is pulling the plug. The solution is to legalize assisted suicide to take care of those who can self-administer it and put the burden of proof on whoever pulls the plug in other cases. =============================================================================