Revisiting the Euthanasia Debate: Why the Slippery Slope Argument Doesn’t Stack Up

euthanasia and the slippery slope argument

Nazi-style euthanasia was an infamous form of euthanasia carried out by physicians in Nazi Germany. It involved the death of some 90,000 individuals and began with the killing of infants and children. These 90,000 victims were killed because of their physical and mental infirmities, which, according to Nazi doctors, made them unworthy of life.

In order to assess whether we – or any other country – is on an inevitable path towards this kind of euthanasia, I will examine the historical, legal, and ethical contexts surrounding the debate regarding physician-assisted dying. It is crucial to ask whether we are on a slippery slope towards Nazi-style euthanasia since this style of euthanasia was justified on grounds very similar to the kind which supported the Holocaust. The main argument was that Jewish people, like disabled patients, had lives not worth living. In fact, the psychiatrist Robert Jay Lifton argued in 1986 that Nazi-style euthanasia was a rehearsal for the eventual “mass killing…of Jews, in the extermination camps themselves.”

The aim of this discussion is to discredit the claim that physician-assisted dying is becoming unavoidably similar to Nazi-style euthanasia. The menacing prospect of a second Holocaust is, therefore, not likely. Furthermore, the very nature of Nazi-style euthanasia should emphasise why this style of euthanasia is atypical in the recent history of physician-assisted dying.

Euthanasia in Nazi Germany and Late 19th Century Britain

Robert Proctor, in his revealing book Racial Hygiene, posits that the German doctor Gustav Boeters, a proponent of eugenics, heavily influenced Nazi-style euthanasia and the justification for its use. Boeters joined the Nazi party in 1930 and his influence was underlined in 1939 when Adolf Hitler ordered doctors to give physically and impaired patients a mercy death.

The notion of a ‘mercy death’ can be traced back to the literal meaning of ‘euthanasia’; which, from its Greek etymology translates into ‘happy death’. However, Hitler seems to have distorted the original meaning of euthanasia (which implies a desire to die) in order to support his overarching goal of eugenics. In order to illustrate this point, it’s worth recalling that Hitler ordered physicians to kill physically disabled and mentally ill patients, as opposed to giving physicians or patients a choice in the matter. In this way, there was nothing merciful about Nazi-style euthanasia, since clearly in most cases, the patients did not want to die.

We can contrast the compulsory and forceful nature of Nazi-style euthanasia with the kind of euthanasia practised in Britain in the 1870s. According to British law at the time, euthanasia was permissible so long as it was done passively and received voluntarily. Now, it is certainly true that there was a thriving eugenics movement in Britain that began around the same time, which was catalysed by the works of Francis Galton (who coined the term eugenics), in books such as Hereditary Genius. Nonetheless, the movement did not materialise in the horrific fashion that it did in Nazi Germany.

The stark difference between how Britain and Germany practised euthanasia can be explained if we compare the motivations of Nazi doctors to those of British doctors in the 19th century. To begin with, Hitler authorised physicians to conduct euthanasia in a way which discriminated against the disabled, because his concerns were economical, rather than ethical. Hitler was influenced by Boeters’ view that citizens with disabilities were costly to maintain in society, and so, Nazi physicians treated their patients as parasites, rather than as autonomous humans with dignity and interests.

British doctors, on the other hand, were not motivated to serve a political ideology, but instead worked to serve the interests of the patient. This is exemplified by the utilitarian-based arguments put forward by Samuel D. Williams, published in The Saturday Review in 1870. Williams argued that when patients were hopelessly ill and seriously suffering, it is humane for doctors to administer chloroform and end their life quickly and painlessly. Williams was referring exclusively to patients who were in the throes of a terminal illness, unlike the kind of patients that Nazi doctors killed, who most certainly were not afflicted in this way.

Also, the argument given by Williams stresses that particular methods of killing are more ethical than others – a fact which British doctors were aware of in the 1870s since the advancement of anaesthetics, such as ether. Conversely, the methods of killing used in Nazi-style euthanasia were particularly inhumane. If Nazi doctors had published accounts of these methods in respected medical journals, they would have surely been stigmatised by the medical community.

Yet, these cruel methods could be carried out in secrecy because Nazi physicians were not subject to a code of ethics or euthanasia laws like British doctors were subject to in the 19th century. Additionally, it could be said that Nazi doctors completely ignored their patients’ welfare because their loyalty to Hitler and his ideologies were so fervent. And, arguably, it was this loyalty that enabled Nazi doctors to conclude that the Jewish problem was a medical problem – a conclusion which surely fuelled the Holocaust. Nonetheless, since British doctors did not – and do not – practise their profession under a tyranny like Nazi Germany, it is unfair to say that we are on a slippery slope towards Nazi-style euthanasia. If we look at the role played by ethics and the law in the current debate regarding physician-assisted dying, this points seems uncontroversial.

Physician-Assisted Dying in a Modern Context

In developed countries such as the US, Germany, and the UK, the practice of active and involuntary euthanasia, like the kind practised in Nazi Germany, is illegal. In modern-day Germany, for example, the prevailing medical opinion is that doctors should have no role in causing death, and this view, some claim, arises from Germany’s regrettable history of Nazism. Whilst Nazi-style euthanasia is unlikely to be adopted again in Germany for this very reason, the law does permit the practice of euthanasia if carried out passively and with a patient’s consent. Likewise, in the US and UK, active euthanasia is emphatically illegal, but the practice of passive euthanasia, which involves withholding or withdrawing treatment, is not. This is because in cases concerning terminally ill patients, such as those at the end stages of cancer, it would be inhumane to keep them alive artificially.

Admittedly, passive euthanasia does lead to a patient’s death; however, performing the procedure does not make a doctor morally culpable in the same way Nazi physicians were. First of all, doctors in the US swear by the Hippocratic Oath never to administer a lethal drug to any patient. Secondly, withdrawing treatment can be justified on utilitarian principles which doctors generally ascribe to – namely that suffering should be reduced for the sake of an individual’s well-being. Moreover, if a doctor were to turn off a life support machine, the actual cause of the patient’s death would be their terminal illness, which is out of the doctor’s control. Obviously, this differs from Nazi-style euthanasia where doctors did administer lethal drugs to patients, and to patients who were not suffering from an illness which would otherwise kill them. Therefore, the evidence suggests that countries like the US and the UK are not on a slippery slope towards Nazi-style euthanasia.

Even in places where active euthanasia or assisted suicide is legal, such as the Netherlands and certain US states (e.g. Oregon) respectively, certain medical guidelines prevent the practice from becoming unpleasant in the way Nazi-style euthanasia was. In the Netherlands, specific court decisions mean that the physician who performs the procedure is protected from prosecution, provided that they meet a rigorous set of guidelines. It appears that the two most important rules the physician must abide by are, firstly, that the patient’s request for assisted death must be voluntary (judged by whether they are of sound mind) and, secondly, that the patient must be undergoing intolerable suffering (usually due to a terminal illness).

Furthermore, the patient judges the intolerable nature of the suffering, rather than the physician. This strict respect for a patient’s autonomy, plus a utilitarian concern for preventing pain, characterises the Dutch practice of euthanasia. In contrast, Nazi-style euthanasia involved ignoring the patient’s autonomy, as well as their general well-being. And perhaps this is what turned Nazi doctors into killers, rather than healers.

We can see why Nazi doctors can be thought of as killers rather than healers simply by examining the number of people who perished under Nazi-style euthanasia compared to those who request to die under Holland’s more liberal style of euthanasia. For example, Germany’s concentration camps had a program which worked to destroy inmates who were no longer capable of work. As a result of this program, millions died, including Jews, Gypsies, gay people, and communists. Then we have Dutch doctors who do not assist patients in dying for economic reasons, but because euthanasia is a form of treatment which in rare cases can truly help the patient. This is revealed by the fact that in the Netherlands, only 4% of all deaths happen as a result of physician-assisted dying.

There are no signs, then, that the Netherlands is on a slippery slope towards Nazi-style euthanasia. Nevertheless, since I have only compared a handful of countries, it would be rash to conclude that we will never be on a path towards Nazi-style euthanasia. In fact, one could argue that some classic cases of physician-assisted dying demonstrate how we may be on such a path.

Classic Cases in Physician-Assisted Dying and the Slippery Slope 

On 4 June 1990, Jack Kevorkian, a doctor from Michigan, assisted Janet Adkins in ending her life through painless intravenous injections. Adkins suffered from Alzheimer’s disease, but at her time of death, she was in the initial stages of the disease and so was not experiencing any unbearable pain. According to Holland’s criteria for physician-assisted dying, Adkin’s condition would probably not warrant a doctor to assist her in dying. In addition, in 1989, Kevorkian explicitly stated that his interest in assisting patients in dying did not stem from compassion, but instead from his desire to “secure more organs for transplantation.”

After scrutinising this case, the bioethicist Daniel Callahan remarked that there was no “single way to defend him [Kevorkian]” and that, if euthanasia were legalised, it would surely open the way to abuse.” This is a conceptual slippery slope argument. Callahan is arguing that, for the sake of logical consistency, many other physicians can be justified in behaving the way Kevorkian did. Although, even if this is true, there is still no justification for the further claim that rare, publicised cases like the Kevorkian one must lead to the horrors of Nazi-style euthanasia. In fact, other cases involving physician-assisted dying are very dissimilar from the case of Kevorkian.

For instance, in 1990, the physician Timothy Quill agreed to assist ‘Diane’, a patient suffering from cervical cancer, in dying. This case differed from the one with Kevorkian because Quill knew Diane well, offered her alternative treatments, preserved her anonymity, and also published an honest account of her death in a well-known medical journal. Thus, it is unreasonable to say that a few cases involving misconduct must trigger an unstoppable chain of events resulting in many doctors behaving unethically. Ultimately, the case of Timothy Quill highlights that Callahan’s conceptual slippery slope argument is quite flawed.

Other than conceptual slippery slope arguments, empirical ones can be made, too, which state that a big change, such as a move towards Nazi-style euthanasia, is the inevitable outcome of much smaller changes, such as the legalisation of physician-assisted dying in Oregon, Holland, Belgium, and Switzerland. The American psychiatrist Leo Alexander, for example, makes such a claim. He contends that “destructive concepts”, like those fostered by physicians in Oregon and Holland, “cannot remain limited…but must inevitably…be directed against one’s entire surrounding world.” However, an empirical slippery slope argument like this can be refuted by pointing out that in Oregon, only a small minority of doctors are actually involved in assisted dying. This illustrates that the legalisation of physician-assisted dying does not entail a trend towards Nazi-style euthanasia.

Both conceptual and empirical slippery slope arguments make unjustified and extreme conclusions based on very limited data and examples. Contrary to the grave predictions made by slippery slope claims, physician-assisted dying around the world is based on the utilitarian goal of maximising happiness and minimising pain. Furthermore, in cases of legally sanctioned assisted death, the patient’s autonomy is always respected, and their death can be achieved painlessly, with dignity, and in the comforting presence of family and friends.

We can easily juxtapose these benign cases with the cruelty of Nazi-style euthanasia, where parents were forced to hand over their impaired children to Nazi physicians. Whilst this contrast does hold, one should still remember that, because slippery slope arguments refer to the distant future, we cannot say for certain that physician-assisted dying will never be like Nazi-style euthanasia. But be that as it may, the historical, legal, and ethical perspectives which I have looked at suggest that we are probably not on a slippery slope towards Nazi-style euthanasia.

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