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Definitely worth a larger discussion! Good post.
First I think it might be helpful to quote my full original comment:
I advocate for staying within a framework where we draw the line at imminent or near-certain death cases. I'm fine with assisted suicide there. I'm not fine with anything more flexible than that, and the direction I believe most societies that relax suicide legalization will end up going is a bad one. There are essentially two competing rationales here. If you draw your justification from the idea that "adult decision-making fundamentally should include suicide" that's one idea, but the one I like better is "if someone's going to die, you might as well grant them control over the method". Those are not interchangeable, and should not be conflated. Let's call the first a suicide right and the second a terminal death right for clarity.
My argument, to be clear, is that as a practical matter whatever the philosophical truth of the suicide right, not only is it controversial, implementing it is very vulnerable to abuse, to a degree that the terminal death right is not; therefore, we should not implement anything beyond a terminal death right. Some people still disagree with a terminal death right, but the scope of abuse is inherently limited. The major concern is that the diagnosis is wrong. If the suicide is done too early, frankly they were going to die anyways, so while there might still be harm to the family or others, they were going to have to cope with it at some point (and as we all know, the normal method of death is often worse for them). I think the evidence is clear enough on that point we can just all agree. So we're just left with the concern about misdiagnosis, and we can discuss that if someone objects, but structurally the incentives mostly run the other way: people don't like to be told their death is certain, the medical system both doctor and insurer prefers to keep them alive (and paying bills), etc. Of course, the government does not, they'd rather do whatever is least costly overall, and the individual doesn't have enough say on policy to matter, even if theoretically affected by the premium increase. Ironically despite 2010 opposition to an ACA addition for Medicare coverage of voluntary end-of-life consultations and decision-making (so-called "death panels"), we ended up with something slightly worse, where we ended up with coverage but the decisions are usually made ad-hoc, last minute, and influenced by hidden coverage decisions by bureaucratic panels. Still, despite the imperfection, I don't think people who could have lived longer but were misdiagnosed is a large group, and I am not worried about that group growing too big over time.
By contrast, a suicide right has a much larger scope of potential harm. The most notable one being that you might getter 'better' in some way. So a death cuts off that entire potential. After all, that's one of the main and more general moral objections to death, is that is robs an individual of potential. Because of this scope enlargement, some issues that were previously irrelevant suddenly become very relevant. Because of this scope enlargement, the potential pool of people expands by an order of magnitude at least. Some examples include the mentally ill, those in chronic pain, those with "bad quality of life", and also the elderly themselves as a whole category. Even, potentially, people who aren't mentally ill in a traditional sense but find low overall "meaning" in life. In addition to the possibility that you might exit one of these groups (get 'better' in the relevant way), there's also the possibility that one or more of these groups shouldn't philosophically deserve a death right at all. We might call that last opinion, where you like some but not all of those groups, a limited suicide right for clarity of language.
Now again I want to say that I'm agnostic or even slightly in favor of a broad suicide right (for example on the autonomy grounds you mentioned). I simply don't trust the incentives to align in a way where that right, insofar as it exists, is meaningfully and rigorously defined and enforced. In other words, I don't want to give it the full legal status as a "right" because of side effects. Does that mean I don't actually believe in a suicide right as an traditional right? I leave that to the philosophers, but I feel similarly about the death penalty, if it's relevant. I think a death penalty is highly natural, even desirable, but practically the legal fight and bills and guilt certainty and political controversy and all that isn't worth bothering over, so if the "right" goes unimplemented, I'm not too bothered.
So let's talk evidence. As you say, my argument can be disproved or disputed seemingly simply based on the evidence (is abuse so common as to become inevitable). I agree that it is sensible to do so, and hopefully we have enough data. However, I think it's telling that despite agreeing here you then spend most of your post in speculation mode despite the stated intention to spend it in evidentiary mode. I don't mean that as any kind of attack and enjoyed your post quite a bit as a thought experiment, but think you settled the evidence too quickly and glossed over the details of the system as it currently works abroad. Yes, that does mean we get plenty of good elucidation of your ideas on the subject more broadly, which is neat, but I don't find it a satisfying response to my actual original claim, and that's what I'm going to focus on in my response here. With that said, it's possible I'm wrong about this and you are admittedly in a slightly better spot to asses it (?) than I am. I also want to caveat this with the point where I notice that all the examples are by definition foreign examples. America has a unique health care system, very infamously set up differently than how almost everyone does it, and so it's probably true that the American risks take on a slightly different form than those abroad! I'm American and admittedly American-centric in most of my comments here (sorry).
You basically present the following pieces of evidence:
"The countries that have legalized assisted dying are not, generally speaking, ruthless capitalist hellscapes where human life is valued purely in economic terms"
Netherlands, Belgium, Switzerland, and Canada have all had assisted dying for 1-2 decades and do not "pressure vulnerable populations into premature death" and serve as good evidence.
There are rigorous oversight systems and multiple safeguards, and furthermore these have neither decayed/weakened nor been peeled back in scope or rigor
The absolute numbers remain "low"
The families of those killed have "better outcomes"
There is "no significant evidence of systemic coercion"
People like the policy overall
(I find the last point irrelevant. Sometimes people like bad policies. That doesn't make them good policies, and doesn't make them good for society either. This is a common fallacy and I don't think it merits inclusion, my belief in the wisdom of the masses notwithstanding.)
Before I go further, let me clarify a few things. A suicide right, remember, can be applied to the mentally ill, those in chronic pain, those with "bad quality of life", and also the elderly, not just terminally ill people. Some of the common failure modes to a suicide right that I had in mind:
Government pressure to kill yourself early/without sufficient cause, saving money
Misdiagnosis risks for non-terminal categories
Family pressure to kill yourself early/without sufficient cause, saving them trouble or money
Self-pressure to kill yourself early/without sufficient cause. The reasons are myriad but might prominently include three: fearing being a burden, making a poorly reasoned/rushed decision, or finally a subjective claim that your life lacks sufficient function and/or meaning [implied: which might be inaccurate or morally objectionable].
Well meaning doctors pressure you to kill yourself early/without sufficient cause, but use poor judgement in doing so
Insurers pressure you indirectly to kill yourself early/without sufficient cause to save money
"Society" provides a background pressure to kill yourself early/without sufficient cause, and this distorts all of the above in more subtle ways
Safeguards become lax, toothless, ineffective, confusing, or counterproductive
To be clear, I will acknowledge as true that safeguards, waiting periods, and smart policy might potentially mitigate many of these worries simultaneously without needing to address root causes, and that might be fine. This admittedly makes evidentiary examination a little tricky to tease out, but also potentially easier, as in theory we can simply examine end-states instead of going point by point. However, examining end states is not an exhaustive reply to all of my concerns.
I have a few doubts about your evidentiary claims here more specifically.
A lot of the studies you cite (and performed) are about terminally ill patients. This completely misunderstands my original point, as I hope is clear above. Terminally ill patients don't give us near the same information about the slippery slope that I worry about, they aren't the problem. You cite a study about cancer patients who were terminally ill. Then you cite a study about Canada's first two years of MAID, which is a mixed-methods examination of medical end providers and families but seems to my eyes to be more an examination of how the implementation was rather than an examination of the process itself (e.g. the survey questions and methods all baked in an assumption of patient autonomy, i.e. a suicide right, as a good thing, and some moral objections as a bad thing, things like that). Furthermore, as I'll detail, the Canadian process in the first two years is much different than it is today.
You bring up the Dutch report, and I'd say on the whole the Netherlands offers moderate evidence against a slippery slope. This study summation from 2009, though dated, states there is no slippery slope almost word for word, though in the decade and a half since rates have doubled again (the trend overall is definitely not exponential and has reversed itself at times). A few more words about the Netherlands: The Dutch report refutes point 7, yes, finding that notable instances of protocol noncompliance are rare. In a sense, point 7 and point 2 are pretty similar, and maybe not justified. Maybe it bears on points 1, 5, 6, or 7, but what about the others? Anyways, it appears the Dutch protocol is designed to confirm that the to be due care, a request was "voluntary and well considered", suffering was "unbearable with no prospect of improvement", well-informed, with "no reasonable alternative", an independent physician's confirmatory opinion (including psychiatric expertise if relevant), and a well-executed death. It does seem like a legitimate system overall, with reasonable stability, and no significant evidence against, although I'm interested in what the next 10 years will have in store.
Note those requirements. While technically more expansive than strictly terminal cases, in practice it seems pretty similar. Physicians are instructed not to encourage it, only to permit it, trust is high, and the requirement that it is "unbearable with no prospect of improvement" and "no reasonable alternative" is pretty strong. No prospect of improvement and unbearable! This is not the language of an elective suicide right. Also, "the general structure of the Dutch health care system is unique. The Dutch general practitioner is the pivot of primary care in the Netherlands", so we have the generalizability issue, and I'd furthermore call out of some language from the foreword: "As in previous years, 2024 saw a significant rise in the number of euthanasia cases" and "I am therefore pleased to see the public debate on euthanasia for young people with a psychiatric disorder... debate leads to reaffirmation or adaptation of social norms... [it] helps prevent euthanasia for being taken for granted". Now, the report conflates assisted dying with terminal death care, but there is some cause of worry: institutions declaring it a right without distinction, that anyone disagreeing is against that right rather than a reasonable moral viewpoint, and explicitly stating that social change is happening. It's moral regulatory capture of a sort? Though yes, absolute numbers are in a certain sense downstream from the pressures, so if we aren't seeing supermassive increases maybe it's decent evidence against. That's however the extent of your evidence as presented.
Implied to be similar are the cases of Belgium and Switzerland. This basically also agrees against slippery slopes in Belgium despite modest increases year on year. However we should also note increasing references to a suicidal right in legislation proposed, which was on initial adoption (via decriminalization without mandatory reporting, notably, so there's reason to distrust their official numbers) explicitly said not to be a right at all. Belgium also expanded the law to cover minors, though I don't think this is a big deal by itself. Belgium also displays something interesting: an increasingly large group with a "polypathology" justification: a combinations of conditions that are not sufficient on their own but combined are bad enough to qualify. That's something to keep an eye on. And yes, the numbers we have also continue to rise, albeit slowly, and in part due to demographic changes, and mostly as that link says due to more "complex" health conditions, not psychiatric stuff, and remains mostly terminal case stuff. Overall I'd consider Belgium moderate evidence in your favor.
Switzerland is weird. It's basically self-administration only, legally unbanned with the only requirement being that it's "nonselfish"... but in practice it's administered by nonprofits or by doctor discretion which do their own gatekeeping and there's a parallel medical system that takes care of it. Frankly I think this is fertile ground for investigation, especially socially, but my post is feeling too long so I'm going to ignore it for now because those effects seem pretty unique and difficult to tease apart to my satisfaction.
Finally, but more relevantly, the Canadian example could hardly be more different than the Netherlands. Notably the best comparison for the US in particular, we see a dramatic expansion of terminal suicide rights to outright suicide rights, in all sorts of areas which trigger nearly every one of my concerns. Initially the issue is forced due to a court case that I'm not qualified to explain. It's framed in 2016 as terminal care: adults, consent-capable, "end of life", "serious and incurable illness" (in legislation softened to add "or disability"), "advanced state of irreversible decline", and "constant or unbearable physical or psychological suffering with cannot be relieved in a manner the patient deems tolerable" (in legislation softened from tolerable to "acceptable"). Seems mostly in line already, but see some cracks? The patient deems what is a tolerable remedy, and the end of life assessment is if it's "reasonably foreseeable". It's implemented, but the next development is a 2019 court case strikes the end of life bit, though, citing the Canadian modern bill of rights equivalent (!) and requests some vague changes.
The new ensuing legislative response (after some delay, in 2021) is startling. We get almost a wholesale shift from terminal-right adjacent claims to suicide-right language. More specifically, there's an expansion from terminal to "grievous and irremediable" only (though non-terminal get their own set of different requirements), the patient's own judgement remains enshrined, they expand to "mature minors", they allow limited "advance" consent, they even allow an eventual automatic time-gated clause to expand to purely mental conditions (currently on pause, it was extended). Terminal patients are given their own track, but even the existing safeguards are notably weakened, with fewer witnesses required, a removal of the waiting period, etc. The non-terminal patients admittedly get a nominally more strict set of requirements, like a 90-day reflection period. But critically, the patient must be informed about other options, but is not even required to attempt such! The witnesses need only agree that the person "given serious consideration" to the alternatives presented.
It's my understanding that this was partly based on an assertion stemming from the court cases in the early 2010s outside Quebec that suicide is in many cases itself ethically valid, and thus the physician might as well participate. I will say overall "bioethicists" come off quite poorly: see for example this impassioned and personalized narrative of the situation dressed up as a formal paper, and with a clear and controversial agenda accompanied by a disdain for any who disagree (outright abuse of credentialism, false consensus, and laundering of opinions as fact, normally things I am skeptical of when accusations are made, are pretty notable and pervasive here).
Some reporting on this issue may lead to you think that Canada, even once it allows purely mental health cases, will only be up to par with the Netherland model. I can't emphasize enough how this seems not at all to be the case. The latter model basically requires all avenues to be exhausted or likely not to work; the former only makes vague gestures at such, and although to some extent all judgements about assisted suicide have an element of subjectivity to them, Canada's model takes this way too far and almost leapfrogs terminal death rights to arrive at something pretty close to full suicide rights almost cold turkey. The narrative and impetus is driven by court cases rather than a normal bottom-up democratic process.
Data is a little sparse especially for the newer non-terminal track patients, but the numbers are much more potentially exponential looking overall than we saw in either European nation we looked at, see here for an example. Although in those cases we saw increases in the earlier years of the program, Canada has seen continual tweaking and also what appears to me to be steeper increases. We've also started to see some abuse. Non-compliance is plainly very rarely reported, see here for an example, allegedly up to a quarter of all total MAID cases, and requiring legwork the government did not even attempt to do. This examination flatly concludes that "The Canadian MAiD regime is lacking the safeguards, data collection, and oversight necessary to protect Canadians against premature death." A Wikipedia page relates several examples of exactly the kinds of pressures I worried about: doctors telling patients not applying for MAID is selfish, considering homelessness an inherently valid reason for suicide, offering MAID as a suicide intake risk assessment tool, offering MAID as an alternative to installing a wheelchair ramp, etc. to name a few. There are MAID teams at pretty much every major hospital in Canada, and my understanding is that they sometimes advocate their services under the guise of awareness, rather than keep shop open for last-resort style care.
I speculate that the Canadian method of implementation makes it uniquely vulnerable to these pressures, and I further speculate that if implemented in the United States, it would be a disaster. Maybe there's a cultural element to it as well. And before you say it, Oregon and similar states are also terminal illness only models. The US system especially has already quite a problem and unique situation with insurers and other layers in the medical system that make the incentive structure go crazy.
So hopefully you see my point. Terminal suicide rights are fine. An independent individualized suicide right based purely on conceptions of autonomy is a different ball game. I furthermore think that when considering suicide rights as such, the European examples aren't actually of nearly the same utility as they first present themselves to be (they are mostly presented in the language of terminal rights despite technically being more broad). And yes, wording and systems matter. I ran out of steam here so apologies if this didn't fully address the points that you made, but as I see it the actual evidence that I see is pretty weak for a right to suicide rooted purely in principles of autonomy. The only nation to most closely attempt such has shown very worrying signs that should be red lights for all advocates, and I predict these issues will only worsen. It's quite possible that better-designed legislation can prevent or mitigate these issues sufficiently, but that's mostly untested.
There's also concern around organ donation. I've seen some reports online about adopting new guidelines around brain death so that (to put it crudely) they can start getting the organs as fresh as possible.
I think that, too, causes unease: some eager-beaver surgeon pushing for declaration of death while the patient is literally still breathing in order to get the organs as fast as possible.
There's a lot of ways this could go wrong, and I'm too cynical to accept "but that would never happen! slippery slope is a fallacy!" arguments since the slopes have been greased with butter in every other instance of big social changes. Right now the fears around euthanasia may not have manifested, but I think that is largely due to the brakes from social lack of acceptance being put on. Remove the brakes, and what will happen?
EDIT: To clarify that last, I don't mean simply making it legal. Where it's legal, but there is high social opposition to it, that keeps the brakes on. But push for mainstreaming it, run publicity campaigns with the hardest cases (the way activists fighting abortion bans always pick the "pregnant by incestuous rape ten year old" victim when the vast majority of abortions are for economic reasons), and weaken that opposition, and then what happens?
Canadian style MAID where disabled veterans are told "we can't afford to pay for the supports for you to live in your own home, but if you want to kill yourself we can sign you right up"? If a twelve year old wants assisted suicide, then providing a psychiatrist rubber-stamps that they are mature enough to make the decision, it can go ahead? Once again like the bad old days before antibiotics, the danger is not from the illness but from going into hospital, because you're less likely to come out alive?
When you take the brakes off, there's only so long the inertia holds. Then the new normal sets in, and then all the edge cases and "that will never happen" start happening.
Probably prompted by the op-ed a week or two ago, Donor Organs Are Too Rare. We Need a New Definition of Death?
The author made a very good case that some utilitarians aren't nearly wise enough to try their hand at maximizing expected utility and should just be deontologists instead.
Not intentionally, of course.
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I understand this is a common fear and I'm supposed to identify the doctor as some kind of monster for being insufficiently respectful of the likely dead. But, like, they're not chomping at the bit for those organs because they want to turn a profit, they need them to save other people's lives. I definitely do want safeguards put in place and to ensure the false positive rate is very very low and am in no way saying we should take healthy people's organs in some kind of utilitarian maximizing nightmare world. But sometimes the cynicism in this type of post rubs me the wrong way. We should all want the same thing here.
Mmmm. That's a bit too much like the thought experiment about the surgeon kidnapping people and killing them for their organs - is he wrong or is he in the right? And there does seem to be some financial inducements involved, or at least alleged.
I think people are uncomfortable with revising definitions of death to be "this person isn't dying fast enough so we can break them down for parts, let's say that if they're not up and about dancing flamenco, they're toast and we can start cutting".
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If you want to read more about this some discussion is here: https://old.reddit.com/r/medicine/comments/1mf2rv4/donor_organs_are_too_rare_we_need_a_new/
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Thank you for taking the time to write such a thoughtful reply. An AAQC report is the least I can do.
I agree that we disagree on some fundamental values. The policy I've envisioned is a compromised one, a version that is sanded down to increase its political palatability. I have more extreme views, I believe we should allow anyone who is of sane mind to opt for euthanasia (with massive caveats that they need to demonstrate their sanity and show that they aren't making that decision on a whim). However, I must hasten to point out that my policy recommendation isn't meant to be disingenuous, rather, it is a system I would genuinely be content with. If we had it in place, I wouldn't immediately switch to lobbying for suicide booths next to every bus stop.
We're all going to die! I might be a transhumanist, one that considers living for a quadrillion years as software running on the carefully rationed Hawking radiation from a black hole in the post-stelliferous era to be a nice retirement, but even I don't think we can live for literally forever. Heat Death is likely to be a bitch.
Putting those aspirational stretch goals aside, we are really all going to die. The terminal stage of illness just makes that expiry date more... obvious. It becomes less of a hypothetical end to the story of your life, and more of a realization that the novel is about to end, there aren't many pages to flip.
As I've noted elsewhere, Switzerland has had assisted dying since 1941. All but nonagerians don't remember a time before some form of legal euthanasia. That is multiple generations, and they are a functional and wealthy society where the elderly seem quite content.
I consider this to be a very strong existence proof that a society can stably accept euthanasia without devolving in the directions many fear.
I was recently challenged by iprayiam to prove that 5% of all deaths being MAID is an acceptable state of affairs. Interrogating it , I found out I was wrong, but wrong in the direction of underestimating the potential proportion of deaths that would likely be unproblematic candidates. And I mean going by your stricter definition, restricting ourselves to the terminally ill.
Humans have got a good thing going. Most of the usual causes of death in human history are largely irrelevant in the West. Heart attacks used to be nigh universally fatal, half the kids used to die in childhood. Now, we've dealt with that, but still have to deal with chronic disease which stubbornly resists our best efforts.
I will have to look into it, but this gives me the strong impression that their system is quite similar to the British one. I can only hope their GPs are paid better and work fewer hours.
I disagree with this framing. All regulators tend to have some degree of moral consensus (or at least a majority vote). This fact only comes to conscious awareness when you face the fact that the regulators disagree with your own opinions, and then desire representation. I would expect that the final report is likely the outcome of internal deliberation, and usually internal dissent is squashed (bad) or consensus achieved. We don't know, there might be true euthanasia maximalist in there who are annoyed that they didn't get their way. I doubt most systems are like the US Supreme Court, in the sense that dissenting opinions are prominently featured in the final output, it not the verdict.
I don't see a cause for concern? It seems quite clear to me that a person with, say, moderate dementia + moderate COPD + moderate arthritis can have a quality of life that's as awful as someone with a really bad case of any of the above. Multiple factors can work together to reduce QALY/DALY. When you get old enough, just about everything starts breaking down, it's a race to see which one kills you. Even the young can draw the short straw.
[I will pause here since I'm traveling right now, but I would ask that you hold off on replying since I intend to add a lot more to my reply. Unless you really want to, in which case don't let me stop you!]
@EverythingIsFine I'm getting hammered in a gay bar (no, not that way), so if you do wrote back, I'll check in when I'm sober
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On the other hand, Swiss clinics do have a reputation for dodginess around "if you can pay for it, we'll do it" plus the famous Swiss discretion regarding "it's none of our business where the money comes from: Nazi gold, drug money, African dictators robbing the treasury, we'll give you a bank account".
See the claim here about a Swiss clinic, Pegasos, that provides assisted dying. I don't know what the truth is here, but I wouldn't be surprised if there is "one law for the Swiss citizen, another for the foreign national coming over here to our discreet and legal clinic where what they do is none of our business (so long as they're not doing it to any Swiss)".
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