Executive Director, Euthanasia Prevention Coalition
Physician-assisted suicide (PAS)—commonly but misleadingly called “medical aid in dying” (1) —is now legal in 11 jurisdictions in the US. PAS remains an area of great controversy among physicians, medical ethicists, and various patient advocacy groups, as evidenced by numerous opinion pieces in Psychiatric Times. (2,3) While we recognize that individuals of good conscience may differ on the ethics of PAS, we have consistently maintained—as the American Medical Association has opined—that (4):“Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”This position has also been consistently taken by the World Medical Association. (5) Despite such clear statements, we and others have called attention to the ever-expanding eligibility criteria for PAS/euthanasia (PAS/E), particularly in Canada, Belgium, and the Netherlands. In essence, every one of these foreign jurisdictions that has legalized PAS/E has eventually expanded them—a phenomenon often referred to as “the slippery slope.” (6)
Komrad et al explain that assisted suicide laws are legalized based on restrictions related to terminal illness and then it expands.
The expansion typically begins with the “low-hanging fruit” of end-stage or terminal illness and gradually broadens to “chronic, nonterminal, or treatment-refractory illness,” as one of us (M.S.K.) has shown. (7)Komrad et al, then explain how the slippery slope exists in the US.
Whenever a line is drawn to limit eligibility criteria, those just outside the line protest, based on understandable (if misplaced) ethical principles of justice, fairness, and parity. Consequently, the boundaries of eligibility for PAS/E have been greatly stretched—in practice, in law, and in guidelines issued by professional organizations. (8)
As opponents of PAS/E, we often hear proponents claim that the slippery slope argument is merely hypothetical—an alarmist bogeyman used to scare away supporters of PAS/E.9 We also hear that, even if the slippery slope metaphor applies in foreign countries, “it would never happen here” in the US. We respectfully disagree. Although the angle of the slope is considerably greater in Canada and the Benelux countries (Belgium, the Netherlands, and Luxembourg) than in the US, we find troubling signs of slippage here at home.
In this piece, we critically examine 2 such examples: (1) the introduction of California Senate Bill 1196, along with expanded PAS criteria in several other states; and (2) 3 cases of PAS in Colorado, in which patients with anorexia nervosa died from lethal prescribed drugs.
California Senate Bill 1196, the End of Life Option Act, was introduced by Senator Catherine Blakespear and represented a radical departure from existing California law.10 SB 1196 proposed several changes (Table).11 Additionally, it contained language that would have turned these practices into a quasi-research protocol by requiring the prescribing physician to report the type of lethal medications prescribed, the time from drug ingestion/administration to death, and any observed complications.
This radical bill was “a bridge too far” even for some groups that have long supported PAS. For example, the group Compassion & Choices stated, “Compassion & Choices and the Compassion & Choices Action Network respectfully oppose SB1196…” which the group viewed as posing “…significant risks to the current medical aid-in-dying law, potentially undermining its purpose and availability.”12
Ultimately—and fortunately—Blakespear withdrew this extreme proposal, and California dodged the proverbial bullet. However, in our view, the mere fact that SB 1196 was proposed is cause for great concern and a sign of the slippage we have witnessed in other countries.
In March of 2022, the Colorado Sun ran the following headline: “Denver doctor helped patients with severe anorexia obtain aid-in-dying medication, spurring national ethics debate.”(17)Komrad et al explain why assisted suicide for anorexia was so wrong.
The backstory, as told in the Colorado Sun article, was this(17):The third patient—Alyssa B—was actually a coauthor of the paper with Gaudiani. According to the published paper, “Dr G prescribed the [medical aid in dying] medications about 6 weeks after Alyssa entered hospice care.”18The Gaudiani et al paper is notable in acknowledging that:“Dr Jennifer Gaudiani, an internal medicine doctor who specializes in eating disorders, published a paper in which she describes the deaths of [3] patients with anorexia nervosa [AN]. One 36-year-old woman died after ingesting the lethal doses prescribed by another doctor, with Gaudiani serving as consulting physician. Another 36-year-old woman died of severe malnutrition on the same day she planned to take aid-in-dying medication prescribed by Gaudiani.”“Alyssa had not completed a full residential eating disorder program; never fully restored weight; never tried newer psychedelic options such as ketamine, psilocybin, or MDMA; and hadn’t had a feeding tube. Dr G acknowledged that all but the feeding tube might ordinarily be undertaken prior to someone’s seeking end-of-life care for AN. Yet, [Alyssa] had been suffering for so long, and despite many conversations about all these treatment possibilities, Alyssa would not consent to any of them. Therefore, given her clarity of understanding around these issues and her sense that she could not fight anymore, everyone had to accept that they weren’t meaningful options.”
Not surprisingly, the published paper and its rationale were vociferously criticized by many in the psychiatric community. For example, Angela Guarda, MD—the director of the eating disorders program at Johns Hopkins Hospital in Baltimore, Maryland—is quoted as saying that using aid-in-dying medication for anorexia patients is “alarming” and “fraught with problems.” This is partly because “…it is impossible to disentangle this request [for PAS] from the effects of the disorder on reasoning, and especially so in the chronically ill, demoralized patient who is likely to feel a failure.”(17)Komrad et al conclude that California Bill SB 1196 and the cases of assisted suicide for anorexia are proof that a slippery slope exists with assisted suicide in America. They write:
We strongly agree with Guarda and regard the 3 cases as exemplifying the slippery slope of eligibility for PAS/E in the US. One of us [C.M.A.G.] has argued that the concept of futility in the treatment of anorexia nervosa is not supported by current evidence and should not serve as the basis for decision-making in this condition. (19),(20)
In our view, the phenomenon of the slippery slope is, in large part, the expectable consequence of “normalizing” or naturalizing the physician’s direct or indirect killing of the patient via euthanasia or PAS, respectively. The more widely these acts are performed, the easier it becomes to mischaracterize them as forms of “medical care.” This is epitomized in the obfuscating euphemism medical aid in dying. As the American College of Physicians has stated (21):“Terms for physician-assisted suicide, such as aid in dying, medical aid in dying, physician-assisted death, and hastened death, lump categories of action together, obscuring the ethics of what is at stake and making meaningful debate difficult.”In truth, assisted suicide does not aid the dying process—it terminates dying by terminating the patient.
By the same token, the more PAS/E are viewed as medical care, the easier it becomes to broaden the eligibility criteria to encompass almost anyone who feels they are “suffering.” Then the slide down the slope can accelerate, from terminal conditions to chronic conditions (such as mental illness), as is happening in our culturally and geographically adjacent neighbor, Canada. That opens the path for the next drift in the evolving ethos—transforming one’s opportunity to seek these lethal procedures into the virtue of relieving loved ones from the burden of their condition.
Finally, we believe it essential that the American Psychiatric Association (APA) maintain its ethical opposition to PAS/E, consistent with the American Medical Association (AMA) Code of Ethics. (4) Doing otherwise will create a schism between the APA and the AMA. Indeed, we hope that as our colleagues consider these issues, they bear in mind the teaching from medical ethicist Leon Kass, MD: “We must care for the dying, not make them dead.” (22)
Link to the original article for references (Original article link).
Dr Hanson is director of the forensic psychiatry fellowship at the University of Maryland in Baltimore.
Dr Geppert is a professor in the Departments of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is the lead ethicist for the Western region and director of education at the Veterans Health Administration National Center for Ethics in Health Care in Washington, DC, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College in New York. She serves as the ethics editor for Psychiatric Times.
Dr Ronald Pies is a professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York; a clinical professor of psychiatry emeritus at Tufts University School of Medicine in Boston, Massachusetts; and editor in chief emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.