Assisted dying - for and against

The classical liberal case on either side of the debate.

Photo by Jametlene Reskp on Unsplash

FOR

By Head of Lifestyle Economics, Chris Snowdon

We have been hearing a lot about the slippery slope recently. Although slippery slope arguments are technically a fallacy, the domino effect of regulation (or, less commonly, deregulation) can often be observed. You start off with a seemingly reasonable idea and before you know it, it has been pushed to lunatic extremes. Take the concept of hate speech, for example, or goal line technology. Mario Rizzo and Glen Whitman have done some fine work explaining the logic and mechanics of the slippery slope. In my own area of research - ‘nanny state’ paternalism - there are constant pressures to apply policies that were introduced to combat the supposedly unique problem of smoking to food, alcohol and gambling.

If, instead of using the term ‘slippery slope’, we say ‘setting a precedent’ or ‘crossing the Rubicon’, the cold logic becomes obvious. In the case of assisted dying, once we accept one premise - that the state can kill people if they request it - the danger is that we open the door to a range of possibilities that were previously unthinkable. It clearly makes it more likely that the NHS will kill people who are depressed if we allow the NHS to kill people who have terminal cancer, just as the legalisation of suicide in 1961 made it politically feasible to introduce assisted dying today.

Nevertheless, it is a fallacy to assume that such slippery slopes are inevitable. The legalisation of same-sex marriages has not led to the legalisation of polygamy or inter-species marriages, as some opponents claimed at the time. In the UK at least, the legalisation of abortion has not led to the legalisation of full-term abortions, let alone to infanticide (on the contrary, the abortion limit has been lowered from 28 weeks to 24 weeks since 1967). The legalisation of cannabis in several countries has not led to the legalisation of heroin or cocaine.

The premise behind assisted dying is an extremely important one and deserves more parliamentary time than has been afforded Kim Leadbeater’s private members bill. It should, in my view, have been a manifesto commitment rather than a favour to Esther Rantzen. But leaving aside the politics of it, I am in favour of the principle: if the patient wills it, doctors should be allowed to put them out of their misery. They used to do it with generous doses of morphine and some still do, but in the wake of Harold Shipman, it became more than their job was worth.

Concerns about the slippery slope should not be dismissed, but they should be only one argument among many. The debate about assisted dying is unusual in that fears about the slippery slope are more or less the only argument that opponents have. This, I suspect, is because they find it very difficult to argue that people who are trapped in their own body with motor neurone disease, or a similar condition, and face a slow, painful and undignified death should be prevented from ending their own lives.

These are the people that Leadbeater’s law is designed to help, and the law, as written, would go no further than that. It explicitly rules out mental health problems and disability as justifications for assisted dying and requires two doctors to conclude that the individual has less than six months to live. If parliament wants to relax these conditions in the future, that is its prerogative, but any such change would be fundamental and would arouse a public debate similar to the one we have seen in recent weeks. Personally, I am comfortable with the slope of assisted dying being quite slippy. I see no reason, in principle, why someone who wishes to die should not be able to pay a professional to do the job properly, rather than take their chances jumping in front of a train (at great inconvenience to commuters). But this puts me on the libertarian fringe. Opponents of assisted dying can be confident that my voice will be ignored, as usual.

The point is that the proposed legislation draws a firm line that makes sense to most people and that any change would be a major upheaval. There is nothing remotely inevitable about sliding from what is in the Leadbeater bill to some form of involuntary euthanasia. There has been no slippery slope in most of the countries that have assisted dying and while the Canadians have not helped the cause by expanding the scope significantly, that was the result of judicial activism rather than direct political action. It has been claimed that something similar could happen in the UK as a result of the European Court of Human Rights. This is doubtful but even if it were true it would be just another reason to leave the ECHR.

The other argument against assisted dying - albeit one that relies on the slippery slope argument for its force - is that people will feel pressured by family members to end their own lives when they would otherwise take palliative care. This strikes me as an argument that liberals of any stripe should have no time for. We trust people to make rational decisions in their own interest throughout their adult life, so why treat them differently in their last six months? I can only echo Nick Boles in suggesting that if you do not want to die you should not say ‘yes' when a doctor asks if you’re interested in assisted dying.

By and large, people want to see their parents and spouse live for as long as possible. If they are having the conversation about assisted dying, it is probably because they want them to avoid unnecessary suffering rather than because they want to get them out of the way. It cannot be denied that there are sometimes economic considerations, but since when did classical liberals think that economic considerations should play no part in people’s decisions? Matthew Parris was roundly abused for making this point in The Times earlier this year, but it is perfectly reasonable for terminally ill people to not want to be a burden and for them to want to have some money left to give to their children when they die.

There is nothing noble in suffering and there is nothing inherently wrong with suicide. It is inhumane to prevent people who cannot physically end their own lives from getting assistance to do so. These are the hard cases but we should not assume that they will make bad law.

Photo by Jametlene Reskp on Unsplash

AGAINST

By Daniel Freeman, Managing Editor

Liberals should think twice before supporting assisted suicide bill currently going through Parliament for three main reasons.

Firstly, as in other countries which have embraced assisted suicide the scope and application is likely to expand with time and possibly quite dramatically.

Though the slippery slope argument is often derided as a logical fallacy when it comes to policy making it’s an empirical fact. To take just one example smoking was banned in offices before pubs, and when it was banned in pubs the supporters of the ban mocked the idea that this would eventually lead to a ban on adults smoking which is just what we’re getting with the generational smoking ban.

When it comes to assisted suicide I would expect the slope to be extremely slippery both because of what it’s supporters are already advocating but also because the experience of other countries would suggest it. Even in Oregon which Kim Leadbeater holds up as a model, now Canada’s MAiD programme has become a dark meme, the list of conditions eligible for assisted death have steadily expanded through court cases and administrative decisions (without any change in the legislation) to include mental health conditions like depression and anorexia.

Such severe mental illness is a difficult area for liberals in the sense that allowing people to act out there wishes under such circumstances may not be conducive to their long-term interests or liberty. Restraining someone in a state of psychosis from cutting off their leg, is in some narrow sense restraint on choice but is not something that liberals are bound to oppose (though I acknowledge that opinions differ on this topic). Equally I would argue that giving someone with severe depression the means to kill themselves is not an expansion of liberty but allowing a disease to extinguish it.

Secondly, Leadbeater’s bill is not proposing to simply remove a piece of state restriction but requires taxpayer money be used to provide suicide as a service on the NHS. Though individuals in large bureaucracies like the NHS are as well intentioned as the rest of us there is a strong institutional interest in encouraging people towards cheaper treatment. As the cocktail of drugs which kill in a few hours will always be cheaper than caring for someone with a long-term condition it should not surprise us if patients and doctors come under insidious pressure in this direction.

This is not some dystopian vision of the future it has already occurred with numerous scandals surrounding the Liverpool Care Pathway and the use of Do Not Resuscitate orders without proper consent from patients. Assisted suicide will simply offer another angle from which institutional interests of the NHS can take precedence over caring for patients.

There will also be substantial social pressures driving people in the same direction. It’s a cliché that ‘Our NHS’ is the closest thing the UK has to a state religion but like most cliches it contains a hefty grain of truth. If anthropologist were to observe the weekly clap for the NHS ritual of the pandemic years or the £20bn per year ‘birthday present’ of extra funding given it by the government in 2018 – it’s not hard to see that they would see something cultish about the nation’s relationship with the state health bureaucracy. In this context it won’t take a ‘Kill yourself to save the NHS’ campaign for the idea to be lodged in the back of many minds.

But even leaving aside our bizarre parasocial relationship with the NHS there is a more fundamental point that should give liberals pause when considering Leadbeater’s bill.

That is that while choice is important, the purpose of liberalism is not simply to reduce to zero the number of choices that are restrained by law. At an obvious level we can think of actions which directly affect others – restricting my right to burn my neighbour’s house, shoot his dog, or trade in slaves does reduce the number of choices I can make but a society that has laws against this is not less liberal than one that does not.

But classical liberals have also long acknowledged that in a few cases even activities that do not directly affect others should be restrained because the very nature of the choice destroys freedom.

John Stuart Mill’s harm principle is sometimes invoked by advocates of assisted suicide. Yet in On Liberty Mill argues that there are circumstances in which choice which can be constrained even when others will not be affected. For example, he argues that a contract to sell yourself into slavery would be illegitimate as it would eliminate all future choice,

“Not only persons are not held to engagements which violate the rights of third parties, but it is sometimes considered a sufficient reason for releasing them from an engagement, that it is injurious to themselves. In this and most other civilised countries, for example, an engagement by which a person should sell himself, or allow himself to be sold, as a slave, would be null and void; neither enforced by law nor by opinion… by selling himself for a slave, he abdicates his liberty; he foregoes any future use of it, beyond that single act… The principle of freedom cannot require that he should be free not to be free. It is not freedom, to be allowed to alienate his freedom.”

Few would argue that liberals would be bound support a bill introducing slavery contracts, even if some people genuinely wished to be enslaved. But if so, the same argument applies with even more force for entering into an agreement to have the state kill you. I say it is more forceful because even on becoming a slave you retain some freedom of action – you may choose to run away even if your chances of escape are slim, your master might have a fit of conscience and free you from the contract, on a practical level even if you do remain a slave forever some rudimentary choice will still be available to you (your master cannot command you what to think or remember). In death all choice is eliminated far more comprehensively and irretrievably than by even slavery.

Choice is of course hugely important, but the word should not act as a prophylaxis against thought. Choosing death is not equivalent to the choice of which party we vote for or whether we go to the pub after work and liberals need to give serious consideration to both the practical and philosophical implications of the bill.