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The Youth in Asia Aren't Sliding: An Empirical Look at Slippery Slopes
In the thread fathered by Cjet, @EverythingIsFine raised the classic concern about assisted suicide: sure, it sounds compassionate in principle, but won't we inevitably slide from "dignified death for the terminally ill" to "economic pressure on grandma to stop being a burden"? This is the kind of argument that is very hard to adjudicate one way or the other without, in the end, appealing to observed reality.
After all, some slopes are slippery. Some slopes are sticky. Some are icy for five feet then turn into sand. The real question isn’t “is there a slope?” but “what kind of slope is this, and can we put friction on it?”
Fortunately, in 2025, which is well past its best-by, we can look at said reality in the many countries where a form of euthanasia is legal, and see how that's panned out. I think that settles the question far better than arguing over philosophy (I started the argument by arguing about philosophy). The best way to overcome Xeno’s paradox is to show that yet, things move.
The Welfare State Reality Check
Let's start with a basic empirical observation: the countries that have legalized assisted dying are not, generally speaking, ruthless capitalist hellscapes where human life is valued purely in economic terms.
The UK, where I currently work in healthcare, is hemorrhaging money on welfare policies that would make American progressives weep with joy. I can personally attest that a substantial number of people drawing unemployment or disability benefits aren't, if we're being honest, actually incapable of productive work. We have an influx of immigrants who aren't economically productive but receive extensive support anyway. As the public (or at least British Twitter) has realized, we spend gobs of money on Motability cars for people who look suspiciously able to jog for the bus (I can't make a strong claim on how widespread said fraud is, but several instances seemed highly questionable to me).
This is not a society poised to start pressuring vulnerable people into death chambers to save a few pounds. Our doctors are, if anything, a meek and bullied bunch who err on the side of aggressive treatment even when it's clearly futile. I regularly see resources poured into advanced dementia patients who have no quality of life and no prospect of improvement. The NHS is many things, but “relentlessly utilitarian” is not one of them.
If I had a dollar for every dementia patient who has straight up asked me to kill the, well, I wouldn't quite retire (and I'd ask why I'm being given dollars), but it would be enough for a decent meal. Enough for a fancy French dinner, were I to include family pleading on their behalf. And I think those people have a point. Most of these claims arise in the rare periods of lucidity that bless/curse the severely demented. You get a few good minutes or hours to realize how your brain is rotting, often before your body has, and you realize how awful things have become. Then you slide back into the vague half-life of semi-consciousness, and I hope your mind is choosing to devote its last dregs of cognition to happier memories, instead of the living hell you currently dwell in. Meanwhile, your loved ones have no such recourse. All the memories of good times are unavoidably tarnished by seeing the people you love shit themselves and not even care.
Even the supposedly heartless United States has far more social safety nets than people give it credit for. Reddit memes about medical bankruptcy notwithstanding, it still spends around 6-8% of GDP on public healthcare and another roughly 5% on Social Security. I'm not sure how to tease apart Medicare, Medicaid, Social Security Disability, food stamps, housing assistance. That doesn't exactly look like a Darwinian free-for-all.
In other words, both countries already have welfare states that leak money in every direction except the one we’re worried about. So the empirical track record is: we’re bad at saying no. If we legalised assisted suicide tomorrow, I expect the dominant failure mode would still be “keep Grandma alive at enormous cost,” not “shove Grandma off the cliff.”
The Empirical Record
But let's not rely on anecdotes or gut feelings. We have actual data from places that have implemented assisted dying:
The Netherlands legalized euthanasia in 2002. Belgium in 2002. Switzerland has allowed assisted suicide since 1941. Canada introduced Medical Assistance in Dying (MAiD) in 2016. If the slippery slope argument were correct, we should see clear evidence of these societies pressuring vulnerable populations into premature death.
Instead, what we see is:
In the Netherlands, for example, support for euthanasia remains at ~90% in both 1997 and 2017 in the general populace. I lifted said figure from this study
I would consider it rather suspicious if it was 95% in a country where 5% of people get offed annually by MAID. Fortunately, that's not the case.
(Yes, I know that it's 5% of all deaths, not 5% of the total population. I couldn't resist the joke, sue me)
The most common criticisms of these systems aren't "too many people are being pressured to die" but rather "the bureaucratic requirements are too onerous" and "some people who clearly qualify are being denied."
Designing Better Incentives
That said, EverythingIsFine's concerns aren't completely unfounded. Any system can be corrupted by perverse incentives. The question is whether we can design safeguards that are robust enough to prevent abuse while still allowing genuinely autonomous choice. I spend an ungodly amount of time juggling hypotheticals, so I have Opinions™.
Here are some mechanisms that could work:
Competing Advocates System
Structure the tribunals with explicitly competing incentive structures. Pay psychiatrists or social workers bonuses for every person they successfully talk out of euthanasia after demonstrating that their suffering can be meaningfully ameliorated. Simultaneously, have patient advocates who are rewarded for ensuring that people with genuinely hopeless situations aren't forced to endure unnecessary suffering.
This creates a natural tension where both sides have skin in the game, but in opposite directions. The "life preservation" team has incentives to find creative solutions, provide better pain management, connect people with resources they didn't know existed. The "autonomy" team ensures that paternalistic gatekeeping doesn't trap people in unbearable situations.
Red Team Testing
Implement systematic "penetration testing" for the oversight system. Create fictional cases of people who clearly should not qualify for assisted dying - someone with treatable depression, a person under subtle family pressure, an elderly individual who just needs better social support. Have trained actors present these cases to euthanasia panels. (E.g., 25-year-old grieving a break-up, fully treatable depression, no physical illness)
A modest proposal for the composition of such a panel:
7 people, randomly selected for each case):
2 psychiatrists, paid only if the panel declines the request.
2 social-workers/advocates, paid only if the group approves the request.
1 “neutral” physician (salary fixed).
2 lay jurors, paid a flat fee.
The psychiatrists and advocates must publish a short written justification (≤500 words). The neutral physician and lay jurors read both sides and vote. Majority rules. The adversarial structure means the psychiatrists have skin in the game if they rubber-stamp a case that later looks fishy, and the advocates have skin in the game if they brow-beat a clearly salvageable patient. The lay jurors are there to keep the professionals honest.
(Alternative models might be splitting the psychiatrists and advocates across both teams)
Any panel that approves inappropriate cases faces serious consequences. This creates strong incentives for rigorous evaluation while identifying systemic weaknesses before they cause real harm.
We already use similar approaches in other domains. Government agencies test whether stores are properly checking ID for alcohol sales. Tax authorities use mystery shoppers to verify compliance. Financial regulators use stress tests to identify institutional weaknesses.
Temporal Safeguards
Build in meaningful waiting periods with multiple check-ins. Not the perfunctory "wait two weeks" that can be gamed, but structured reassessment over months. Require people to demonstrate that their decision remains stable across different contexts - good days and bad days, when surrounded by family and when alone, after various treatment interventions have been attempted. At any time the patient can unilaterally revoke the request (one phone call suffices), at which point the whole timeline resets. Finally, lethal medication is dispensed only on the day of the procedure, and only if the patient re-asserts consent on camera, without the advocate or psychiatrist in the room.
This serves multiple purposes: it prevents impulsive decisions, allows time for circumstances to change, and creates multiple opportunities to identify and address external pressures.
More Watching of the Watchers
All decisions (with names redacted) are published in a searchable database. Independent academics can run regressions on approval rates vs. patient age, diagnosis, postcode, etc. Outlier panels get flagged automatically. (If Panel #7 approves 90% of 25-year-olds with psoriasis, maybe look into that). The tribunal system becomes a public good: researchers learn what actually predicts irrevocable suffering, and policy can adjust.
Economic Firewalls
Perhaps most importantly, create strong institutional barriers between economic interests and euthanasia decisions. Healthcare systems, insurance companies, and family members should have no financial incentive for someone to choose death over continued treatment.
This might mean that euthanasia decisions are handled by completely separate institutions from those bearing the costs of care. Or it might mean generous death benefits that make someone more economically valuable alive than dead. Or mandatory cooling-off periods after any discussion of treatment costs.
EverythingIsFine’s deepest worry is emotional pressure: Grandma feels like a burden even if no one explicitly says so. The adversarial tribunal can’t eliminate that feeling, but it can reduce the plausibility of the belief. If Grandma knows that two professionals will lose money unless they are convinced she is beyond help, the thought “my family would be better off without me” loses some of its sting. The process itself becomes a costly signal that society is not eager to see her go.
The Comparative Harm Analysis
But here's what I think clinches the argument: we need to compare the risks of legalized assisted dying against the status quo.
Right now, people who want to end unbearable suffering have several options, all of them worse:
Each of these approaches involves more suffering, more uncertainty, and more potential for things to go wrong than a well-designed assisted dying system.
Meanwhile, the people we're supposedly protecting by prohibiting euthanasia - those who might be pressured into unwanted death - are already vulnerable to abuse in countless other ways. Family members can pressure elderly relatives to sign over property, refuse beneficial medical treatment, or accept substandard care. Healthcare systems already make implicit rationing decisions based on cost considerations (but this is a necessary tradeoff for any system that doesn't have literally infinite amounts of money. The Pope doesn't spend all of the Church’s budget on a single drowning orphan)
Creating a transparent, regulated system for end-of-life decisions doesn't create these pressures - it makes them visible and addressable.
The Autonomy Principle
Ultimately, this comes back to the fundamental question of autonomy that cjet79 raised in the original post. If we don't trust competent adults to make informed decisions about their own deaths, even with appropriate safeguards and cooling-off periods, then we don't really trust them to be autonomous agents at all.
We let people make all sorts of life-altering decisions with far less oversight: whom to marry, whether to have children, what career to pursue, whether to undergo risky medical procedures, whether to engage in dangerous recreational activities. Many of these decisions are statistically more likely to cause regret than a carefully considered choice to end unbearable suffering.
The paternalistic argument essentially says: "We know better than you do whether your life is worth living." That's a pretty extraordinary claim that requires extraordinary justification.
Conclusion
Legalising assisted suicide beyond the “imminent death” cases does open a channel for pressure and abuse. But the same could be said of every other high-stakes civil right: police shootings, child custody, involuntary commitment, even driving licences. The solution has never been “ban the activity”; it has been “create adversarial oversight with transparent metrics and random audits.”
If we can audit restaurants for rat droppings and banks for money-laundering, we can audit tribunals for premature death. The price of liberty is eternal paperwork (woe is me, I do more than my fair share already) but at least the paperwork can be designed by people who actually want the patient to live if there’s any reasonable chance of recovery.
I'm not arguing for euthanasia-on-demand or a system with minimal safeguards. I'm arguing for thoughtfully designed institutions that balance individual autonomy against the genuine risks of coercion and abuse.
(To put an unavoidable personal spin on it, I've been severely depressed, I've had suicidal ideation. I would have a very easy time indulging in that feeling, and I refrained not just from thanatophobia, but from a genuine understanding that my brain is/was broken. My advocacy for the right for people to make this choice is informed by a deeply personal understanding of what being there is like. Don't worry, I'm mostly better.)
The slippery slope argument assumes that any movement toward assisted dying will inevitably lead to systematic devaluation of vulnerable lives. But this treats policy design as if it's governed by some inexorable natural law rather than conscious human choices about how to structure institutions.
We can choose to create robust safeguards. We can choose to separate economic interests from end-of-life decisions. We can choose to err on the side of caution while still respecting individual autonomy.
The question isn't whether a poorly designed system could be abused - of course it could. The question is whether we're capable of designing better systems than the brutal status quo of forcing people to suffer without recourse or resort to violent, traumatic methods of ending their lives.
I think we are. And I think the evidence from jurisdictions that have tried suggests that the slippery slope, while worth watching for, isn't nearly as slippery as critics claim.
Regarding the UK, do you remember the furore over the Liverpool Care Pathway? Allegations that elderly patients were being ushered out instead of patched up and sent home, on the rationale that they would only get sick and end right back up in hospital again, putting more strain on the over-stretched NHS, and thus it was better all round (and more compassionate) to just let them die - or if they annoyingly didn't show signs of dying just yet, to help them along the way.
Some lurid stories of people visiting sick relatives and noticing another patient begging for water, claiming to be thirsty, and being ignored by nurses, and when the visitors asked about it, they were told this person was 'nil by mouth', they were unresponsive, they were DNR, and it was none of the strangers' business, and so (it was claimed) they were being let die of dehydration by stealth.
Things like that are why euthanasia in hospitals has a very tough opposition to overcome: people are legitimately afraid they, or their loved ones, will be checked off a list by some faceless bureaucrat on the grounds of 'too expensive to keep them alive', and not because of expensive experimental end-of-life treatment, but literally "well they got pneumonia, they may come back in next winter with it again, just let them die this year and save the bother".
There were also some allegations about euthanasia in the Netherlands, one I remember from years back was a doctor deciding on behalf of a sick nun that he'd give her euthanasia because he knew her religion would prevent her asking. That's the kind of fear of "god-complex" doctors that people have. It may be unfounded, but one rotten apple ruins the whole barrel.
There is currently a case where a family here in Ireland claim a Swiss clinic provided "assisted dying" to their mother without their knowledge or consent (but the clinic counter-claim they got permission from the family) and only learned she was dead via a Whatsapp message.
I suppose that my view is "it depends". Sometimes letting someone go without resorting to extreme measures is the right thing to do. Actively intervening to cause death? Yeah, that's difficult for me.
My own experience of this is with my late father. He suddenly, in his mid-70s, collapsed one day with what turned out to be total kidney failure. While in hospital, he had to be resuscitated three times. The hospital asked us (after the first resuscitation) would we want them to try again, should it happen (with the very strong hint that we should say "no"). My mother and siblings insisted that no, we wanted him given every chance.
When they did let him out, it was clearly evident from their behaviour that they considered they were just sending him home to die. He was very weak and very ill, but my mother and I nursed him through it and he got another ten years of life, and good years too - not miserable, confined to bed years. In fact, he bounced back so well that the consultant used to call him his "miracle man" (and we smiled wryly and muttered under our breaths 'no thanks to you bastards, if we left it up to you, he'd be dead').
Come forward to when he's in his early 80s and my mother died of lung cancer the year before. This time, he was gradually failing. Nothing big, but you could tell he was fading. I said to my sister that this would probably be his last year, or if not, then next year. He got a stroke due to DVT clot, and this time when the hospital said that efforts to prolong life would just be futile, we agreed. He was ready to die, and it was his time. Any extreme measures would just have meant waiting for the next stroke, and the next. So, letting him go while keeping him comfortable was a peaceful, and even natural, death.
My point? The first time would have been wrong to let him die. The second time would have been wrong to try and keep him alive. And both times, the hospital was trying to nudge us towards the death side of the equation. That's the lack of trust in medical experts that is at the heart of the debate.
The LCP seems to be well before my time. I wasn't even in med school when the program officially wrapped up. And I've only been in the UK for almost exactly a year now.
The most obvious of the critiques that stands out to me is that paying the local trusts for adherence to the policy is potentially misguided. It is standard practice to award funds on the basis of performance. Paying local trusts for adherence to an end-of-life protocol sounds like ordinary KPI management. We pay for sepsis bundles, maternal mortality reductions, time-to-thrombolysis, all the usual dashboards.
But the object-level signal here is different. If your target is “percent of palliative patients on Pathway X,” you create a reward for moving people onto Pathway X. In stroke or obstetrics, the KPI rewards rescuing people. In end-of-life care, a superficially similar metric can look like a reward for getting to the end faster. Most clinicians will ignore that perverse reading. Some will not. Families will presume the worst when outcomes are bad. This is not a moral condemnation. It is a predictable human response to incentives that look ugly from the outside.
I find this hard to believe. In the hospital I worked at, it was often the case that palliative patients were put NBM, but usually because they simply couldn't tolerate it. They presented severe choking risks, leave aside complications like aspiration pneumonia. More common was simply attempting to feed them as much as they could manage, usually manually and by means of thickened fluids. A lot of these palliative patients simply can't eat enough to keep them alive, and options like NG tubes or parenteral nutrition were decided against: dying patients often can't tolerate them, and they provide maybe a few days or weeks of life at the cost of reducing QOL even further.
NBM does not mean “no comfort.” People receive subcutaneous or intravenous fluids when appropriate. They get oral care, ice chips, and we do our best to ameliorate the sensation of dryness, which is different from actual dehydration. From the corridor, it can look like neglect. From the notes, it is usually a documented risk-benefit tradeoff made by clinicians who do not enjoy saying no to water.
I'm glad your father survived the initial hospitalization and gained many years of healthy life. However, I think both your family and the doctors did the right thing. We're not omniscient, patients who seem unlikely to die can pass away overnight, and in rare cases, those we judge to be on death's door might just not answer when the Reaper rings. We try our best to make hard decisions with limited information.
I've mentioned elsewhere a patient of mine from not long ago. Physically healthy as an ox, we thought, even if his brain was riddled with holes from the dementia. Then it turned out the previous hospital was negligent, he'd had a hemorrhage in his cranium, and deteriorated overnight. We even did the palliative paperwork, and were ready to provide end of life care as seemed inevitable.
I went away to India for a few weeks, and genuinely thought he was a goner. I came back, and found out that he was back on his feet, and as chipper as ever. The nurses seemed happier about that than they were about my return. I'd call this truly unexpected, as every single one of the doctors at the hospital genuinely expected him to die. It's a shame that he didn't get the benefit of such a reprieve from death while his brain was still healthy, but he might live another year or two yet.
Yet, he is the exception. In 9/10 cases, a patient like that will die regardless of what we resort to. The process of resorting to everything (including escalation to an ICU) is normally worse than keeping them comfortable till the end. Escalation to ICU can mean delirium in a bright room, tubes in places you do not want tubes, and no family at the bedside. Even the young and hearty do not enjoy their stay there, let alone the aged, frail and dying.
The lurid anecdotes make sense if you only see the sip denied. They look different if you see the swallow test, the chest x-ray, and the conversation the team had with the family yesterday. Perverse incentives make suspicion easier, which is why tying money to a pathway box is a bad idea even if it probably helps more than it hurts.
As you say, you came along long after all this row. So any improvements that occurred before you started working in the UK are invisible to you. I don't know if the lurid accusations were true but they were certainly made:
That is part of the problem: something is done to excess, it gets fixed, the people who come along later have no idea of the history and go "well everything is fine as it stands today, what is the problem?"
The problem is, we've seen the days when it wasn't okay, and there's little reason to think that there will not be new and improved ways of going off the rails in future.
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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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This is, naturally, not a very strong argument for assisted suicide, which creates an obligation on other individuals or the state to end your life.
I say the question is moot. It is not that hard to kill yourself, if you are able-bodied and motivated. The only places in the planet where it becomes nigh-impossible are strict prisons, or an in-patient suicide unit.
The terminally ill usually aren't able bodied, and lack the option of taking the quick way out most of the time.
Even without a positive right to demand that others kill you, there is room for a negative right to stop people from preventing you from seeking assistance in that regard.
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In principle, you can let doctors, Catholic hospitals, etc opt out of any obligation to provide assisted suicide, even if it's "medically necessary" under some rubric. Even if you're extending the concept of coercion to taxpayers being forced to fund assisted suicide, you can block government funds from being used for it.
In practice, I recognize the slippery slope here.
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As someone with chronic health issues that knows the inside of the hospital fairly well, any communication from a health care provider that isn't explicitly from someone in scheduling or providing test results is assumed to be a new mystery bill you were never informed of verbally or in writing at any point, and 95% of the time that assumption is accurate. Sending the survey as a text message or email will have better hit rates. Also, this seems like it shouldn't need to be said but really, really does, make sure the survey actually works. I actually try to complete these when I get them (probably 8-12 a year) and fully half of them are dead links or malfunction in some other way. The institutional work ethic of an organization free from market forces and able to obfuscate its billing practices without consequence, imo, spills over into absolutely everything they do and encourages mediocrity at best.
Did you take that seriously? I would hope not, because the joke was that it's hard to get responses from participants in euthanasia because they're dead. If it's meant to be an educational aside, I appreciate it.
You might assume they only try to interview patients who survived the procedure. Though that also would imply the procedure was botched extremely badly.
You've given me the idea for a very good medical comedy about a critical care doctor who either disagrees with the concept of euthanasia, or bumbles around never quite being told which patients are involved.
He, or she, holds the record for most lives saved or resuscitations performed. In a very British manner, the actual doctors responsible for euthanasia are very vexed by his tendency to immediately save their patients, and they're in a cat and mouse game of taking turns murdering and unmurdering any given patient.
The hospital brass are desperate to figure out a way to not award him excellence awards, because it's just plain old embarrassing at this point.
I can foresee potential to change the plot to get more demographic appeal. The life saving male doctor versus the ice queen no-nonsense German euthanasia dom. Or getting Rowan Atkinson to play the male lead.
It might be delightfully British. We can fabricate end of season drama by having them come to blows, and then have them either start to fuck over a corpse that comes alive (because their thrusting counts as CPR), or when they realize that they can game both metrics if they cooperate to keep the bodies clinically dead for long enough to fool the coroner.
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I sometimes think that our approach to euthanasia is stymied by fundamental incompatibilities and contradictions with post-enlightenment principles. We highly prize autonomy and regard as foundational the need for consent. But the ones most in need of euthanasia are those who have declined to the point they no longer meaningfully can consent. And I find it somewhat cruel to imagine a person struggling with a terminal illness or other severe mental or physical suffering, being additionally burdened with having to take the sole decision of if and when to end their life. What a huge question to have to grapple with at the lowest point in your life.
I think there is a serious and tragic problem here; but we lack a suitable cultural programming to adequately solve it. Our focus on preservation of life to the exclusion of all else creates outcomes where people spend months or years existing, suffering, without hope of recovery. An insistence on the inviolable importance of consent means many of those who arguably need it most cannot access euthanasia under any system we could invent. And a belief that any such avenue must be systematized and accountable will create a system overloaded with bureaucracy, hoops to jump through and people covering their asses at every turn in case they go to jail. None of it will be the best interests of the patient.
Both of my father's parents had signed and notarized DNR (do not resuscitate) orders drafted, with copies kept with their lawyer and stuck to the fridge with a magnet, since they were in their early 70s. And they established power of attorney in their children with very clear instructions that when in doubt, pull the plug. It's not exactly euthanasia, but there are steps you can take to pre-establish consent if you're proactive.
It's morbid, but it's never too early to set your affairs in order. Don't trust your fate to the decision-making skills of a dementia-ridden potato and your grieving children.
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For once, the Brits are better about this. Living wills and Anticipatory Care Plans are quite common and actively encouraged. You get to have people make these decisions before they become infirm or lose decision-making capacity. Then the family and doctors do their best to follow along.
One set of my grandparents had living wills and the other did not. I can attest that setting up a living will is an incredible gift to your loved ones. It's much easier to make difficult choices when you already have iron-clad proof of someone's wishes back when they were sound of mind.
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Every time I see arguments speaking for Euthanasia, I recall reading the comic Transmetropolitan, by Warren Ellis.
The first story in said comic series involves a gonzo journalist by the name of Spider Jerusalem in the far future hunting for a story, stumbling across a break-away group being lead by an old companion of his. Said group has taken to utilizing radical body-mods to effectively partially transform themselves into half-human, half-alien hybrids. They're effectively throwing a political hissyfit/riot to get recognized as some sort of special group by the City, so they can acquire benefits and whatnot. Of cource, there's the slight issue that said radical body-modding tech they're utilizing was a failure from the start, hence the hybrid part, as it should have been a perfect transformation, but whatever...
Anyways, the story ends with Spider effectively shaming everyone into calming down and not bashing all the hybrids brains out on the sidewalk, and ends writing a column about the entire circumstance.
One line in said column always stuck out at me, roughly paraphrased from memory, as I lack said comic in front of me to quote verbatim. 'If we were a civilized society, we'd give these damaged people a playground sandbox, a pat on the head, and let them do their own thing in peace'.
If we were a civilized society.
Civilized.
That word, I've always felt, did alot of heavy lifting. Loading bearing, you could call it. If we were civilized. If we lived in a society where a sizable chunk of people that wouldn't take advantage of such a fail-state, that wouldn't abuse the system, that wouldn't twist it for their own ends. If we were mature. Adult. Civilized. If things were only civilized, we could do so many things.
I'm a big believer in personal responsibility. I feel that if people want to do something, that doesn't harm others, they should at least have that option. Suicide included. If you want to check out, well, I personally don't agree with it, and it's not my thing personally, but I can at least understand why some people would want to do so. My odd life has put me in close contact with a wide spread of people, including some older individuals that refuse to change their behavior and have basically decided that if they're going to go out, they're going to go out living life on their terms.
However.
I'll be the first person to play the devil's advocate and note we don't live in a perfect world, that perverse incentives are the quiet ruler that dictates more than I wish, and the road to hell is paved with good intentions. While personal responsibility and choices is one thing, it's entirely another to give authority to the state.
Do I trust individuals to make good, well-informed decisions that have the best outcome for their future? No. But the thing about believing in personal responsibility is that this also includes the fail state to fuck up in a cataclysmic fashion.
Do I want to give that sort of power to the State and Authority as a whole? Fuck no. I could go off on a long rant here about how I feel some laws and societal allowances have a gargantuan knock-on effect on societal development as a whole in a very bad way, but I won't belabor the point, and it would be distracting, anyways.
Am I being cruel, here? Evil, one could argue? Dooming people whom suffer, physically and mentally, in a state of agony that last as long as they live? Perhaps. Is this fair? I don't know. I wish we had better options. I honestly, really do.
If we were just civilized...
But what I do know is that maybe, just maybe, we want to keep that genie in the bottle for a very good reason.
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Am I severely miscalibrated? Over 5% of total deaths sounds like a massive amount to me.
If anything, it seems low to me. From my understanding of the actuaries table here, it seems that the median age of death is around 79--84.
That is certainly what I would call old age. Assume that half of the people dying above that age have a terminal condition which qualifies for MAID, such as cancer, and that half of the ones who qualify actually opt for it. That would give us 1/8th of the deaths (12.5%).
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I would say that in my own life, 5% of deaths "could have been timed better" sounds about right. Not necessarily a case of some exotic terminal illness, but cascading old age concerns. There's a clear point of no return, I could see someone pulling the trigger on it.
Especially these days when the medical apparatus is increasingly good at keeping people alive when they probably shouldn't be
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It sound tiny to me. The median lifespan is like 83, presumably some percent of these people want help dying at the end.
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I thought the same FWIW.
It was sold as ‘if you have a terminal illness, you are going to die in a few weeks, you are in terrible agony and there is no way of alleviating your pain or saving you’ which I would expect to be 0.1% max. Hence calling it ‘assisted dying’.
I think that this was never the intended use case and that those politicians who advocated for it on these terms were being dishonest.
Far more illnesses become terminal when you're old and frail. A flu you might walk off becomes fatal pneumonia. A mild UTI or stomach upset in the young becomes the cause of septic shock. A scratch becomes cellulitis and gangrene, becoming too weak to toss and turn becomes suppurating bed sores.
Children are often nigh-unkillable. The elderly are the exact opposite, it's a goddamn miracle life expectancies are where they're at.
Maybe something around 0.1% is your intuition for how many people are in such a state right now. It is closer, in terms of magnitude. The issue is when you lack firm intuitions for how that stacks up over the longterm, at least over a year. I probably tend to overestimate the figure that dies miserable deaths, because the peaceful desths at home don't come to me. I am, however, aware of that bias and try to account for it. It remains to be seen how successful that is, but I see 5% as fine.
"...and believe me, folks, I've tried." :P
I take your point. My intuitions could be wrong. But I think also 'assisted dying' was marketed as being for much more specific freak cases where people have an absolutely certain and very short life expectancy, and were in horrible pain that could not be alleviated through even strong pain medication. I would be willing to bet that if you raised the figure of "5% of all deaths" before this stuff was legalised you would be dismissed as a scaremonger if anti- and if pro- you would be taken aside and given a stern talk about staying on-message.
Look dude, you're the one who said that whatever's disclosed while sobbing in that 'Spoons stays in the Spoons.
At any rate, I wasn't around when the PR push you're talking about for euthanize took off (which jurisdiction are we talking about?) It's not legal in the UK, and I am part, albeit only at a very junior level, of the bodies putting forth policy proposals and considering whether to make it legal. I can tell you that we use simultaneously more careful, and more broad, language. It is definitely not being sold as something for those who are in maximal agony and only at the very last minute.
Ha. In all seriousness, though, you're aware that a bill was put forward at the end of last year to legalise it in the UK, right? And that it was basically bounced through the Commons as a private, unscheduled bill with no preparation and is now waiting for approval from the House of Lords, after which it will become law?
And I do remember that the first few times 'assisted dying' was floated it was about really quite specific scenarios, and that even now a lot of the 'pro' polls about it are still quite specific. For example
https://www.theguardian.com/society/2024/oct/16/england-and-wales-assisted-dying-bill-formally-launched-in-house-of-commons
And yet when it comes to the actual law:
whereas if you look at actual public opinion you see support for a much narrower version, with:
https://www.ipsos.com/en-uk/two-thirds-uk-public-continue-think-assisted-dying-should-be-legal-provided-certain-conditions-are
and
https://www.salvationarmy.org.uk/news/survey-reveals-publics-fears-about-assisted-dying-bill (yes, biased, but the poll was carried out by YouGov)
I've thought a lot about this issue for the last ten years, as many have, and it's hard to escape the feeling that public consent has been laundered by keeping the spotlight firmly on rare, sympathetic cases while the intent of campaigners has always been significantly more far-reaching. Even the chosen term is very obviously a marketing gambit - 'assisted dying' where in reality they aren't dying in any sense other than the philosophical and the point is to legalise deliberately injecting them with something that will kill them. My memory is that these words were originally justified twenty years ago by limiting discussion to the near-death cases I describe, though I admit I can't back that up.
I'm not trying to lay this on you, you're honest about your opinions. But the way the whole thing has been handled leaves a nasty taste in my mouth.
My extreme scepticism around these kinds of bills comes from abortion legislation (elsewhere and here in Ireland). The activists pushing for it run the most extreme cases, swear up down and sideways only a very teeny-tiny few will ever need to avail of this if made legal, and then work their socks off behind the scenes to have the language in the legislation as vague as possible (so it can be challenged in court if necessary) and that a way of gaming the system (e.g. having two doctors sign off on abortion in the UK became 'this is only rote rubber stamping') can be introduced to get what they want.
"Intolerable suffering from incurable condition" means what, exactly? If I'm thirty years old and claim that my depression means I have no boyfriend or no career (instead of a dull job) and I see no change on the horizon, am I not intolerably suffering?
There's a lot of wiggle room between "let everyone assume we mean people dying in horrible pain from mortal cancer" and "in practice, just tell the doctor this script with this exact wording to get it".
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This...seems like a fully generalizable description of basically all political activism in WEIRD democracies??
Yeah, I guess. I hate it. But in particular I feel like I was around for most of this one and so I feel more jerked around by it.
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Yeah people massively underestimate how good modern medicine is at prolonging that last 6 months to a year now. My father who's in good shape for mid seventies now had successfully-treated skin cancer a few years ago and some of the people he and I saw clinging to life whilst visiting oncology were medical miracles.
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What do you think the intended use case was?
Broadly that described by @self_made_human. Total autonomy (as least for educated people) over their own life and death in all cases, Roman-style, which in practice means breaking the social/religious and legal taboo over suicide. The 'assisted dying for the terminally ill' case was introduced as the thin end of the wedge where those objections were not very sensible, with advocates knowing that they would be able to push the ball significantly down the slope once the Schelling fence was overcome.
I think that the 'we will euthanise the elderly to save NHS money' people aren't wrong at the edge but this happens to some extent anyway with Do Not Resuscitate; I expect some scandals but not widescale abuse. I am more worried about the elderly pressuring themselves into suicide, and about those with long-standing but irrational suicidal tendencies. I differ from @self_made_human in thinking that suicidal depression is an absolute indicator that a given person cannot be trusted with this particular form of autonomy as their judgement in this area is compromised.
Personally, I would rather have legalised voluntary assisted suicide specifically for dementia patients, requiring two time-spaced diagnoses of clinical dementia from two different doctors and a voluntary statement from the patient taken when compos mentis (to the extent that this is practical). I think this addresses the real, secret fear that is propelling normie support for these political movements and is limited enough to be stable. Alas I don't think that 'culling the mentally-feeble' would make it past the journalists and I don't think it would satisfy the campaigners, but I think it would take the wind out of the issue.
I think being depressed is very good reason not to agree to people's pleas to die right away! It is a mental illness which twists your cognition. It should be difficult to kill yourself on the grounds of depression.
I do not think it's an absolute indicator to ignore someone, if used in the literal sense. You have to keep in mind that the BATNA for these patients is jumping in front of a train. That makes absolutist stances less than actionable, in the pragmatic sense. If you want to achieve this in the real world, you need to lock some people up for the rest of their lives on those grounds alone, and I think letting them kill themselves might well kinder in some cases.
Holding out for a miracle cure is a gambit at the best of times, but still - I think "how likely is it that we'll have unprecedentedly effective antidepressants by, say, 2050" has to be considered. There is a difference between locking people up for life as the stated goal, and locking them up indefinitely until we help them better. If you think there's a decent chance of a cure being developed within the patient's lifespan, I think it's worth the chance.
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Who am I to tell you what's massive or not? When you see how the elderly, who make up a very large chunk of all deaths these days, actually go out, it really doesn't surprise me. I would start raising eyebrows past 20%, and be alarmed past 30. This is implying business as usual, not something like the Culture's post-scarcity, where people almost never die natural deaths, and euthanize themselves when they're bored. We'll figure that out if/when we get there.
The person using the number as part of an argument that there's no cause for concern?
That's pretty wild numbers, imo, and reduces my ability to take your general judgement of risk, safety, acceptibility, etc on this topic as particularly calibrated toward anything persuasive. I think burying your own calibration in a p.s. is kind of dishonest when you are trying to lay out a defense of something.
Yeah but the medical doctor who's likely spending significantly more time in the company of the hospiced and hospice-adjacent probably has a better bead on this than a layperson.
Can't remember the Scottpost but the stats on medical professionals opting out of end of life interventional care at a highly elevated rate are likely relevant here.
From 2011 (not Scott)
https://www.zocalopublicsquare.org/how-doctors-die/
Scott linked it in one of his golden era posts, who by very slow decay
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Yep that's the one I was thinking of, thank you. Afaik Scott linked it in one of his articles?
Realistically, that's probably where I found it lol
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Really? Okay? What if I say 5% is massive, or not massive? You can make the same fuss either way. There are people who are categorically against the euthanasia of even a single person, and people who think that every human should be euthanized. What do you have to say to them?
Do you have an intuitive or even an intellectual understanding of how miserable the average death is? Did you remind yourself that euthanasia is meant to replace that inevitable, often painful and undignified death, with one that doesn't draw out the inevitable and lets people go out on their own terms?
Please, if you accuse me of being miscalibrated, then produce your own ISO calibrated standards. I remain in earnest anticipation, and until then, this is probably the queerest objection in the thread.
Reading iprayiam's post, I was originally in agreement with him, but now, I am not sure. If euthanasia was legalized, I would expect a spike as all the olds with terminal illnesses and low quality of life euthanized themselves, and then a stabilizing as the rate of them would be the rate of people entering those low quality of life stages of their life for the first time. Are there really 5% of people right now with terminal illnesses and low quality of life? I hadn't really ever thought about it.
A major issue:
Terminal illness is not strictly defined, and neither is low quality of life. It's more of a know it when you see it kinda deal.
If you're willing to settle for proxies -
How many people will need palliative care in 2040? Past trends, future projections and implications for services
My quick trawl of the literature suggests that ~95% of all deaths in the Anglosphere are due to illness and not external factors. I mean, if a disease kills you, I'd certainly call it terminal at some point. Most of these patients have some combination of cardiovascular disease, respiratory disease, cancer and so on.
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2023#leading-causes-of-death
This is illustrative. I manually added all the leading causes:
4.2+4.8+5.1+5.5+10+11.6 (the big 6) add up to 41.2%. That leaves every other thing that kills people.
Note that is not exhaustive, and this kind of data is a pain to collate. I hope that even just going by the biggest causes makes it clear that a 5% MAID rate is nothing to write home about. @iprayiam3 is, to out it bluntly, terribly miscalibrated. People can just say things, and be wrong on the internet, while bringing no facts to the table themselves.
My own figures of 20-30% are hardly perfect, but they're certainly closer to plausible figures for people undergoing rather unseemly and painful deaths. They came from a strong hunch, and it's clear that working in medicine makes that gut feeling more accurate.
Now that I know more accurate values, I can see a plausible case for much higher rates.
Forgive the aside, but what is the meaning of the word 'disease' in medical parlance? I suppose in the back of my mind I was aware of 'heart disease' but I would normally think of 'disease' as synonymous with 'infection'.
Disease is defined somewhat tautologically, since we usually define health (or the WHO does) as:
Google tells me that they haven't bothered to define disease. Well, a disease is anything that impacts you negatively and isn't something like a car crash or a bullet to the head.
Wikipedia goes for:
This has plenty of room for arguments, even if I find some deeply stupid or misguided. Some deaf and autistic people claim that trying to cure their conditions, or that of their children, is medicalizing a "normal" or equally valid state of being, and tantamount to genocide.
I have no sympathy for such a position, sure, mild autism isn't that bad, but if they're non-verbal and low-functioning, almost everyone wants them cured. At best, I support individual autonomy enough that if a deaf person insisted that they wished to remain deaf, they have the right to refuse treatment. I begrudgingly concede that they should have the right to make that decision for their children, even if I think it's a really dumb one.
Fortunately, the sufferers of most diseases seek cures. There's no movement to redefine psoriasis, fungal feet infections or heart attacks as a manifestation of the human condition that shouldn't be eliminated. Doctors just nod at the dumb stuff, and keep doing what seems sensible. Or at least I do.
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When i was young i occasionally worked as a home care assistant. I would travel around and help infirm elderly people with daily activities like showers, cooking, cleaning, giving them meds etc. Due to where this happened almost all our patients were relatively well off and most had contact with their families. They weren't bed bound and could do some things on their own.
Despite all of this about 1/5 of the patients regularly asked me to help kill them. They were in more or less constant pain despite pain management, increasingly felt that the help the got was degrading and their minds were rapidly slipping.
I didn't mind much when people passed away but being begged on a daily basis to kill the people you're interacting with wasn't fun.
Is 1/5 an exaggeration or (to quote black hawk down) a no-bullshit exception?
My mind immediately goes to "this is another reason why you should never, ever let anyone disarm you." Horrifying.
To be more accurate, a lot of patients talked about wanting to die, some asked me at some point if I could help out (I'm not sure how serious those requests were) and one lady pleaded with me to kill her every time I was there, which was almost every day. 1/5 was an approximation on my part. I was regularly asked by patients to "help them die", but I wasn't really regularly asked by the same person except by the one patient. Some other people phrased things like that "it would have been good if I was allowed to help them die", which isn't really asking but is kind of in the same neighborhood.
Most of these people could probably have killed themselves if they had really wanted to, and for all I know some might have. They could have overdosed on the medications they already had in their homes. Perhaps this was too complex and scary for them though, I don't know. I imagine people want a solution that is painless and guaranteed to work, possibly under the supervision of a medical professional, not something where they can fail and die alone painfully over a longer period of time.
These things dont necessarily correlate with how poorly someone is either. My grandfather for instance who died last year at 100 desperately wanted to live even at the end when he was in horrific pain, had terrifying hallucinations and had not been able to move from his bed for months. The last thing he said to my mother was to ask her when he was going to get better again.
His wife (my grandmother), who died 40 years prior from ALS, wanted to be killed and started refusing food etc almost as soon as she became hospital bound in order to speed things up.
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I'm lucky. By the time they end up in the dementia wards (autocorrect really wanted to make that dementia wars, which is a colorful turn of phrase), they're too far gone to beg. Most of the time. I assume if I had spent a year in your shoes, I actually could retire.
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I want to be killed if I get Dementia. If there was a waiver I could sign I would sign it. I have seen my relatives waste away. Not only is it no life, it’s an awful life, and an awful life that colors the memory of you among your descendants, other family and friends who outlive you and remember you primarily as a giant, violent, aggressive, awful, stupid, shitting baby requiring constant care.
Arguments about ‘abuse’ are unconvincing. If “the government” or “the powers that be” want to kill me, they can and they will. If there is a 1% chance that the chair of the death panel hates me, bankers, Jews, people with brown hair, whatever, and condemns an innocent person to an early grave, so be it (there are relatively objective tests doctors like you use, anyway, and I mostly trust them).
I have watched a great aunt beg for death (as you say) in her lucid moments. My own parents have said they want to die if they get it. Legal implications aside, I don’t think I have it in me to do it.
This is part of my discomfort with it TBH -- if you don't have it in you, do we really want a government health service that does? Like, shoot your own dog, man.
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The main problem isn't that someone in the government wants you dead. It's that incentives will lead to bad decisions that end up with you dead. Nobody has to specifically want you dead as a terminal goal (no pun intended) for incentives to have an effect.
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Seconded. My father got Alzheimer around retirement age. Initially it was not too bad, but in a decade it reduced him to the cognitive level of a new-born. The end came when he finally could no longer swallow. Dying from a lack of fluids and food is not a good death. For an elderly person who is not already weakened by cancer, it also takes fucking forever. Three days without water might kill a healthy adult, but for someone who was just laying in bed before it can be two weeks. To my knowledge I have never killed a mammal in my life, but I would have gladly injected him with pentobarbital. Instead, we played by the restrictive German laws and waited for nature to take its course, never knowing if what was left of him was in pain (despite the opiates he got). 0/10 as far as ways to die go.
The trouble with dementia is that nobody will respect your living will. MAID for lucid cancer patients is one thing, MAID for someone who is no longer lucid is something entirely different. So you basically have to off yourself while your quality of life is still positive.
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Absolutely seconded. Mental coherency is, fundamentally, what makes a person a person, what makes one oneself. Getting out while the getting is good and you are still you is right and honorable.
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I understand. The only reason I don't fear dementia more is because of a genuine confidence that it will be a solved problem by the time I'm old enough to be at risk. This almost certainly holds true for you too, modulo all the assumptions that lead me to have that belief in the first place. A mere example would be the recent discovery that semaglutide reduces the relative risk of developing Alzheimer's by 50%.
I have seen so many people utterly hollowed out by the illness. It is an unavoidable perk of the psychiatry of old age. The lucky are those who are far gone, they are past all but the most primal of pain or pleasure. The prick of a needle, as I pull blood like an anorexic vampire, the recognition that a smile means friendliness. Their inner world seems to have shrunk to a point. It is often better for them, and certainly for everyone else, when they are physically frail. A robust body attached to a shattered mind is a uniquely challenging combination.
We had a gentleman who was 95, and as strong as an ox. He broke two noses on the ward before nearly dying of a stroke. I went on vacation and had every confidence he wouldn't be around when I came back. Nope, he shrugged it off, and everyone was happy to have him back even if it came at the cost of their facial features. It takes a certain kind to work in that field in the long-term, I'm not cut out for it.
My own grandpa, who I love dearly, is at the same age. Covid killed him, if not physically, then the enforced idleness killed the man he was. More man than me, mostly gone now. It was the clinic and regular interaction with his patients that kept him truly alive, and the decline was obvious when it stopped. It's enough to make me cry, and I try not to think about it if I can help it. When he sees me, all he remembers is that I'm back from the UK, and his only concern is when I'll visit again. This loops every five minutes. It is enough that he can do this, and I get to hold his hands one more time. They're very similar, those hands. His and mine. He had a good run, almost 92 years of putting others to shame. 3 where the survivors finally lapped him. Outlived his enemies (the very few he had), most of his very many friends, but not his family. He has the comfort of his two daughters these days, if not the grandson he loves the most. He was the kindest man I know, he used to feed honey to the bees by the window sill, and the angriest I've ever seen him was when he tried to do the same to a wasp and it stung him for his kindness. God, I wish things were different. The universe is cruel, and physician heal thyself? Fucking hell, I can't heal the people I actually love. What good are these hands after all?
I digress. It is easier to talk about the problems of others. It helps me pretend to have a degree of clinical detachment, and gives time for the tears to dry.
The worst-off are those who know, or even suspect. The disappointment on their faces when the diagnosis is disclosed, the scans finally in. The furtive glances at their loved ones, the attempts to put on a brave front. Some sob. Some smile and talk about the weather. None really withstand the blow, but most come to terms with it. Then the dread sets in.
Putting myself in their shoes, it is the present, horrifying knowledge of what they are and what they are becoming, a slow-motion unraveling they are forced to witness from the inside. They are passengers in a vehicle that is slowly, but unstoppably, falling apart around them. Is it any surprise that many come to terms with the inevitable, and seek to go out on their own by wresting the wheel into the nearest tree? Can't blame them, poor bastards, even if it's my job to stop them. I wish it wasn't my job, and I wish my job allowed me to let them exercise the last bit of agency they have left.
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I mostly agree with you, but the trajectory of the things like the dissolution of marriage certainly makes me worried. If you looked 10 years after any one legal or social change, it would have looked like the conservatives were unnecessarily worried, but nevertheless when I nowadays bluntly state that modern marriage is entirely meaningless in varied company, most people agree with me (after an initial slightly scandalized look). This is a category change compared to the past, when marriage was both considered sacred and had a clear purpose (the creation of family). While most still say it was worth it for individual liberty, few disagree that we have lost something that we won't get back. And I suspect that there is at least some social desirability bias in what people say, but that part is obviously hard to prove.
These changes can take multiple generations to fully take effects. The first generation grew up under the old system and will often replicate it through simple inertia, especially if the change was explicitly sold as a emergency measure only reserved for extreme cases and there is a clear moral framework on why it should be so. The second already grows up with the measure existing, albeit rare enough that not everyone has had direct contact with it, and they will often extend the application of the measure in incremental ways for what they think is personal benefit (which they aren't always correct on). By the time of the third generation it is fully normalized so that it can be extended to large swathes of the population.
For this reason, I'd like a strict criterion of using MAID exclusively for cases where death is foreseeable in the near future (called Track 1 in Canada). It's still somewhat slippery - what is "foreseeable"? what is "near future"? - but it's imo much less slippery than estimating some nebulous quality of life cutoff that is sufficient for the state to help you kill yourself. I know Track 2 is still only a small percentage, but that needn't stay so.
It has been a generation! In some cases, multiple:
If this a slippery slope, then at the current rate of progress we might have Dyson Swarms before the Netherlands breaks double digits for proportion of deaths conducted by MAID.
Switzerland has octogenarians
runninghobbling around who don't remember a regime before euthanasia. It also has a rather high proportion of the elderly, which suggests they're not being culled when inconvenient.Can I make guarantees that societal norms won't change, and in a direction either you or I will disapprove of? Who can? The legalization of gay marriage hasn't, as far as I'm aware, causally produced a legalization of pedophilia or beastiality as some feared. I consider my claims very strong evidence, it's harder to get stronger.
You can't launch many rockets if your standard for rocketry is that we must perfect the design before putting a single nozzle on the pad. You will not enact any social change at all, out of an overabundance of caution. I consider this regrettable.
I mean it’s been generations in Europe. Like everything else context matters. American healthcare is not anything like European healthcare— ours is a private, for-profit system designed to cut the costs of healthcare and to ensure profits for hospitals and insurance companies. In a taxpayer funded system like NIH, I’d agree that the slippery isn’t that steep, it’s probably a little steep depending on who’s caring for the patient, how difficult that care is, and the ability of the family to either provide it or pay someone to do so. In America, everything is mediated through health insurance, and as for-profit companies, those companies have every incentive to not cover treating elderly patients who might not live long anyway. Treating cancer is expensive: hospital stays, chemotherapy, pain management, in home care between visits, blood work. Giving an elderly cancer patient an overdose of morphine is cheap. Few extended families in the US can afford to pay out of pocket for cancer treatment, it’s simply too expensive, so if the insurance company refuses to cover it because the cancer treatment is expensive, there aren’t any options, either the extended family spends themselves into poverty to pay for granny’s chemotherapy, or they let her get her OD of morphine and convince themselves that she — and they — chose “death with dignity.”
Oh no. You're taking the claims about the American healthcare system at face value.
I'm going to dial @Throwaway05 for backup/moral reassurance. I'd say *page */bleep but the US is a more enlightened regime:
The American healthcare system is incredibly socialist. Is there a better word for a regime where you can walk into any hospital clutching your gut, and they legally must treat you, even if you look and smell like a hobo and throw feces at them? Where the hospital isn't allowed to throw you out, or means test you for such trifling things as the ability to pay for care? Where hospitals, and by extension, actual paying customers, must subsidize/swallow losses in case their patient wanders out and says fuck you to collections? Assuming you even got an address or ID to send those?
Buddy, that's socialism masquerading as capitalism, with only the polite and respectable actually going through the whole charade. You should see what happens in India, where we're not quite so keyed into the kayfabe - despite having both entirely free public care as well as a booming private sector. We'd laugh at the softness. They'd kick your ass to the curb, and the cops would come and laugh.
The government, and by extension, the humble net tax-payer, faces the same dilemma in the UK. We do not kill people just to save money. To the extent that mere prioritization of finite funds kills people, it's in the name of saving more lives than we let die. My bosses do not get a raise or a cut of the savings. To murder anyone would take the collusion of, at minimum, the nurses and resident doctors on the ward. Worst case you rope in the family and pharmacy. It takes working here to truly grok how ridiculous such a proposition is, the nurses will throw you under the bus for looking at the patient wrong, let alone killing them.
Yeah, OP has bit (and I cannot blame him given the amount of poor reporting and understanding out there) on a lot of the popular misconceptions about U.S. healthcare.
Your mention of EMTALA and how the ED works is super instructive. Supposedly during the recent strikes in South Korea hospitals would just post up guards outside the ED and not let people in and they would wander off to another hospital, get better on their own, or just die on the street. Not an option here and EMTALA violations are one of the few ways a physician can get truly screwed.
But yes the U.S. isn't really a private system, it's not really for-profit (or non-profit - it's a mix of both in surprising ways). It is super complicated but is part of where the confusion comes from a lot of time.
Things in the U.S. are more expensive than the rest of the world but part of that is cost of living part of that is poor health of the population part of that is the fact that the U.S. can actually afford it and subsidizes everyone else...
Usually expensive cancer treatments in the U.S. end up discounted, or insurance will cover them (but not fast enough), and they might not be available at all in other countries or it takes too long to get an appointment to get delivered them.
You know, now that I think about it, I think 50% of this was going off the memory of an AAQC of yours. Had to be you.
I suppose that means I remembered enough of it not to bring dishonor upon your name. And thank you for being polite enough not to point that out first.
Lol, well "no actually it is quite a bit more complicated than that and the popular presentation and imagining is grossly inadequate" is like the central lesson of The Motte. Internalizing that and putting it to use is YOUR credit.
For the issue at hand - it's worth noting that most Americans can be signed up for Medicare or Medicaid and hospitals will do that in an attempt to deal with some of the cost of mandatory care.
Illegals become more problematic and can easily end up sucking up hospital level resources for a year and a half while waiting for a charity care dialysis placement or something like that.
Incidentally I write with - transitions all the time. Is that materially different than that em-dash thing all the kids are complaining about? Do I look like an AI??????
You write far fewer long-form essays than I do, thought they are almost always a treat to read. I'm sure if you keep it up, someone will come get your ass too.
See, it's a if she floats/if she sinks situation. If it sits still, it's probably an AI. If you see 'em make a dash for it, then it's definitely an AI. Or so the logic goes.
(People think that someone who can come up with that pun, while dying of heatstroke and quasi-manic from sleep deprivation on a bus, needs AI? Hardly. The AI is lucky to have me. This post is only 90% a joke)
The most cynical will, like in my case, assume that - transitions are a search-and-replace. That is despite me swearing on Scout's honor that I never put one em-dashes put in, or had to take one out at any point (and I actually was a Scout). It is trivially easy to launder AI written content. If I was making an intentional effort to disguise entire tracts of the stuff, I promise nobody would ever tell.
On a more general note, em-dashes are noteworthy because very few people used them before ChatGPT did. Think journalists, researchers (or their editor), pretentious literary types etc. They were often difficult to type on most devices, leaving aside most people didn't really conceptualize them as a separate thing from normal dashes, let alone finer considerations like the en-dash vs en-dash.
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Human or LLM: Yes—no—maybe (em dashes)
Lazy human: Yes--no--maybe (pairs of hyphens as ersatz em dashes)
Idiosyncratic human: Yes – no – maybe (en dashes plus spaces)
Lazy and idiosyncratic human: Yes - no - maybe (hyphens as ersatz en dashes, plus spaces)
Insane human: Yes- no- maybe
Insane human: Yes — no — maybe (em dashes plus spaces)
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I'll grant you Switzerland. Netherlands and Belgium are still too recent imo. Marriage developments also took decades, as well as multiple specific law changes, to fully take effect.
And as I said, it's not that I want to outlaw it; But I just want to make the slope a little bit less slippery. It's notable that in Switzerland, it's merely legal by omission, it's illegal for organizations or people to earn any money or get any other benefits through it, and the substance can only be provided, but it has to be administered by the person themselves. All of these seem like sensible limitations to me. And there have been almost no changes to either practice or law since then. Contrast Canada, where it has only become legal recently, is explicitly legalized as a service by the health care industry, it already got extended significantly only a few years in, and is in the process of getting extended yet again. At least to me, it seems like it's reasonable to worry about a slippery slope being possible if it's done the wrong way; That doesn't mean it's impossible to find a correct way, though.
I will note that this is a concern I have intentionally and prominently addressed. I am personally okay with euthanasia as a cost-saving measure, keeping someone on the verge of brain death in the ICU is both expensive and futile. Doubly so if the savings are used to extend more lives on net.
As it stands, I am willing to compromise on my fantasy of euthanasia booths next to children's parks if that's the cost of making it available in more jurisdictions. What I proposed is a version specifically designed to appease the squeamish, while still being something I am content with myself. This involves removing or minimizing financial incentive to individuals or even most parts of the system.
To the extent that this calls for amendments in places with legal euthanasia, well, it does do that. It's just not as pressing as elsewhere.
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I'm not sure about the Netherlands.
E.g. they killed a 29 year old woman even though she was perfectly healthy. Did they try any of the bleeding edge treatments of depression? E.g. a week long sleep deprivation fixes treatment resistant depression ?
You could actually find out how much of depression is genetic, and how much is learned. We are reasonably sure memory can be erased, so why dispose of valuable, healthy human resources through euthanasia? Maybe it could be a way of rehabilitating criminal sociopaths..
How is that surprising? The world's most enlightened and civilized people, Europeans, are against free expression because they correctly recognized the famous, reviled but unquestionably true in principle american dictum:
If they did not believe that people are sheep, easily led astray, they'd not be restricting the internet, free expression, suppressing holocaust denial, banning Russian TV and so on.
I am getting deja vu, and not just because of sleep deprivation.
As a matter of fact, I have previously addressed the exact same case. In short, I think the doctors did the right thing.
https://www.themotte.org/post/1701/culture-war-roundup-for-the-week/302719?context=8#context
...
"The doctors did the right thing in helping a 29 year old woman with depression kill herself" is quite literally the slippery slope. That's what we're talking about when we call something a slippery slope, that social norms will change so radically, and people will just be all "actually, that's a good thing we changed that!"
Hang on, please explain to me, ideally without referencing slippery slopes at all, what is the precise issue with this 29 year old woman with depression being offered euthanasia?
I try not to brow-beat people with my credentials any more than I can help, but I have experience in both psychiatry and being severely depressed. It would take far worse to make me seek euthanasia, but my depression wasn't as bad as it can truly get. Some forms of dysfunction and agony can truly be hard to discern from a distance. You see a pretty young woman in the prime of her life being consigned to death by uncaring doctors.
I see a tortured soul, who has consented to her doctors trying everything they can feasibly try. If you don't believe me, you can look at the article. Her every day is utter misery, we have no idea how to fix her, at present. And we've tried, tried oh so hard, with no results. I had reasons to cling to life even when my brain screamed it was pointless to get out of bed, I do not care to dictate beyond a very limited extent, how much others should really tolerate.
She is an exception. 99.9% or more of depressed people are not recommended euthanasia. She went through all the loops and hoops, she didn't change her mind. Her very right to do so was challenged, and when I initially engaged with the article, being adjudicated in a court of law. The rules are being followed.
This is a very critical point. By saying "MAID is in principle on the table for depression", you create some incentive to engage with the medical system.
If instead you take the firm stand that suicide is bad and that you will gladly lock up patients who talk about suicidal ideation until they learn to credibly deny having such thoughts, that is sending a very different signal.
As others have pointed out here, anyone who is not bedbound has a BATNA, which is to kill themselves against the wishes of broader society. Unilateral suicides impose great costs on broader society. You can not let your loved ones know lest they call the cops on you -- unless you trust them to approve your defection. While medically, killing a person in a way which is both painless and also not highly disturbing to onlookers is a solved problem, the situation for the average person is very different, and they may well prefer an option which is good at delivering a quick death but traumatizing for the onlookers. Jumping in front of trains has massive externalities, for example.
Knowing that your loved one is opting for MAID for depression is terrible, but what is worse is coming home and finding them dangling from a rope -- without you ever having had a chance to talk to them about it or say goodbye to them. If offering MAID for depression turns 10 suicides into 7 suicides (who do not want to jump through the hoops) plus 1 medically assisted death and two patients who can be treated to a level where their life is positive-sum for them, that seems like a clear win.
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If she wants to kill herself that's one thing. She didn't need assistance. She was young and healthy and could've just hung herself, or jumped off a tall building, or
in front of a trainin some other way that doesn't involve someone else, please. The fact that she couldn't muster up the will to do this, honestly makes me question how suicidal she really was in the first place. After all, thousands of people in the Netherlands do this every year. But unlike the bedridden elderly people that are usually taken as an example in these cases, she certainly always had the option.What I really think we shouldn't be doing as a society is validating or normalizing such a decision. That is not about the details her specific case, but about the example that's set for others. It doesn't even matter if her mental suffering truly were unbearable in some manner. Ultimately only she knows her inner mental state. To an outside observer, she was young and healthy, and she had people who cared about her. (We should all be so lucky!) And we're going to just kill her on request? That shouldn't be normal. It's what's observed from the outside that sets the norm.
Are you seriously suggesting that society prefer depressed people commit suicide by train?
That feels like the most outlandish thing I have read on the internet all week.
Suicides by train are only topped by intentionally driving on a highway in the wrong direction as far as damage to broader society goes.
Suppose you are a train conductor without psychopathy. You go through your routine job of driving the train, listening to music perhaps when suddenly a person steps on the track 50m ahead of you. You sound the whistle and slam the brakes. You have more than a second to contemplate what is about to happen, but no way to stop it. You hear the impact over the sound of the brakes. After the trains comes to a halt, you grab a first aid kit and run back the person you have just hit. If you are lucky you only need a glance to confirm that they are dead, cut apart by your vehicle. Or you might spent the next ten minutes giving CPR to a corpse until the ambulance arrives, hoping for a miracle which is unlikely to happen.
Intellectually, you know that you did not kill the person, they killed themselves. Still, it was your train. You know that it is not feasible to slow trains down to speeds where they will no longer be used as a method of suicide. If you had reacted a tenth of a second faster, it would not have made any difference. But still, you wonder while you lay sleepless in bed, held awake by the images and sounds which have burned themselves into your memory.
Driving trains is your job, a profession you spent years to learn. It is high responsibility, but also very routine. Before you had hit that person, it was not very stressful, most of the time. But now your brain anticipates that any second, another person might step on the track in front of you, and you would be just as helpless to do anything about it as the first time.
Personally, I would take the life of a physician who assists a suicide of a depression patient after all the process is done a ten times over the life of that train driver.
Okay, not a train. That's an asshole thing to do. If you're going to commit suicide, don't involve other people.
I included it because it's the stereotypical thing to do (at least around here), but thinking a bit further, it's probably that way because when someone does it, everyone in the train knows. Probably most people have been on a train that's been delayed because of a train suicide. Other methods of suicide don't get that attention.
I do absolutely think we shouldn't be offering assisted suicide to people who are physically capable of unassisted suicide.
This is surprisingly hard to do. Someone needs to find the body and unless you plan carefully this can easily be a random bystander or group of random bystanders (and planning carefully is hard when you are suicidal).
Usually EMS and healthcare get involved and seeing someone who has committed suicide can be deeply harmful (especially if it's gruesome like a gunshot to the head). Often they'll have to run a code on the body even if it's clearly dead which is....awful.
Then you have to think about the family and friends of the deceased. Having a close contact or family commit suicide is a risk factor for suicide it hurts people around you in a way that just dying doesn't.
Yes, suicide is bad. Ideally there would be no suicide at all. This is part of my point.
When we do something in an official manner, we thereby give it a stamp of approval. We should not approve bad things if we can avoid it. Because by doing so, we are saying that the bad thing shouldn't be considered as all that bad. We are shifting the norms and encouraging more of it. We can't always avoid this, but we should at least always try.
If someone's dying anyway, say with terminal cancer, and we artificially keep him alive at that point (which we've gotten quite good at), we are merely prolonging his suffering. At that point, sure, just end it humanely.
But this person (and see my other comment, there are more) was not actually dying. She was in fact physically healthy. There is no argument to be made that we are prolonging her suffering. We are not actively doing anything. There is no argument to be made about freedom either. If you are physically capable of killing yourself, you always have this option.
She could've ended her own life herself at any time. And that would still be bad, even if it truly is the least bad option it's still bad, but we would at least have avoided giving the act an official stamp of approval. And maybe she never would've killed herself, and then there would've been one less suicide. This is the point that I was trying to make.
And it does seem to be accelerating. I looked up the statistics (see my other comment for the sources). There were 14 euthanizations for purely psychiatric reasons in 2014. By 2024, this had grown to 219. In the same year, there were 1819 traditional suicides. So by now, for every ten suicides we're adding an eleventh.
Sorry I don't really have a dog in this fight I just wanted to make that point specifically.
In truth I remain somewhat undetermined about how to handle this specific issue which is awkward given the possibility of it appearing in my clinical practice, however my plan is to just follow legal, regulatory, and hospital frameworks and stay out of the ethical side of this thing.
That said it is worth dialing in just how miserable certain classes of patients are. Again I'm not convinced we should assist them in dying but certain patients have a lived experience that is comparable or worse than the more typical examples (dying of chronic disease, intractably bad life experiences, significant chronic pain*).
For instance someone with severe borderline personality disorder may find themselves zigzagging from being too happy to wanting to kill themselves to burning down their relationships to getting fired to whatever on a regular basis. With associated involuntary suicidal ideation it can approach a point where the life experience is almost abhuman, miserable, and devoid of the traditional pleasures of existence.
That's a reasonably good case, especially since some people like this may struggle to successfully kill themselves because the system does a good job of preventing it and because the problem isn't pure depressive misery, therefore it becomes challenging to overcome the routine desire to live.
Again not necessarily advocating here just pointing out if you had chance to interact with one of these people you might go....oh yeah, I get it, holy shit (or might not).
*Although best we can tell this is somewhat linked to psychic distress.
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The pilot of Germanwings flight 9525 would like to have a word with you.
I knew when I wrote this that someone would come up with another exotic counterexample. I will not try to argue that flying a plane into a mountain is a special case of going the wrong way on a highway either.
Fine. I retract my claim and say that they are the second most harmful commonly occurring suicides, and patiently wait for someone to explain to me why that is still wrong.
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Severely depressed people are famously known for being well motivated and agentic.
You might have heard, most likely as a semi-serious observation, that the side effect profile of most antidepressants includes increased risk of suicide.
Ever wonder why? It is because depression affects multiple part of the brain, and antidepressants can start fixing some parts before the other. In other words, you accidentally fix someone's motivation and agency before restoring their mood, and you suddenly have someone who is very energetically motivated to kill themselves.
People often do not know their inner mental state. If you care to criticize this, then just about nothing in psychiatry remains standing. There is nothing, in principle, stopping a sane person from talking into thin air, and gibbering about the CIA watching him. Yet this is a reliable metric for psychotic illness. In a similar manner, what do you think the usual stereotypes are of how a depressed person looks and behaves?
The reason that psychiatry is not purely stamp-collecting is because said stamps allow us to mail cheques we can often cash. A diagnosis of depression usually leads to a treatment of depression. It's not perfect, in very rare circumstances, such as hers, literally nothing worked. If she wants to lie after all of that (and there is a lot of "all of that"), then she's earned the right to kill herself.
She's always had it, and never lost it. This was part of my point. It's the official approval that I disapprove of.
This is not the way in which I meant it. By outsiders I meant the general public, society as a whole, not her psychiatrists, who I'm sure knew what they were doing and tried their best. Because even if I grant that this was the right decision in this particular individual case, I still oppose it because of the example that it sets.
The picture that is shown is of a (physically at least) healthy 29-year-old, who has people who care about her. When someone like that commits suicide, it should not get a societal stamp of approval. Let alone that we should do it for her. This will cause the societal norm around suicide to shift.
I think that we shouldn't be giving the general public the idea that society approves of just stepping out of life if you're not feeling it. I grant you that that's not actually what happened in this case. But that is what it looks like. You know what the fancy words mean, but remember that to a layman, "depression" means "not feeling it".
And in fact, I've just found another depressed 29 year old woman who was euthanized. I forgot the name of the first one, googled "euthanized depressed 29 year old" and immediately found another. This made me go and look up the statistics. Here they are, in Dutch, but summarizing: in 2014 there were 14 cases of euthanasia for purely psychiatric reasons. This is the first year for which there is data, so presumably the first year this was even done. By 2024 this had grown to 219. Line go up fairly quickly.
Meanwhile, there were 1819 "traditional" suicides in 2024. So by now, for every ten suicides we're adding an eleventh. More than that.
This really looks to me like official approval causing the social norms to shift, in turn causing the psychiatrists too (who are after all also part of society) to be more free in granting approvals, causing the norm to shift further.
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I'm not necessarily pro suicide, but I think the idea that pursuing bureaucratic rather than kinetic means to suicide indicates a lack of seriousness is backwards.
One can jump off a bridge instantly on a whim, and of the people who have done it and survived many said they regretted it instantly.
Where euthanasia has a 100% success rate, and requires serious intent over an extended period of time.
Interesting idea for an RCT: Some portion of euthanasia subjects are head faked, put under anesthesia, then when they wake up you ask them if they regretted their decision. If they still want to die you kill them on the second try.
Probably because jumping off a bridge is awesome; it's the largest adrenaline rush I've had bar none including skydiving. Seems likely to (at least temporarily) break a suicidal mindset right there. I doubt the APA would approve bungi jumping even as an experimental therapy though.
Is it inexcusably awful that I think we should be utilizing the "wants to and is approved to die" demographic for experiments like that?
Fuck it, harness them up and toss them off a bridge. Let them drive dangerous car races, or play airsoft with live ammunition. See if it alters their feelings about death.
Russian Roulette as therapy? Mind you, I think that was the original purpose.
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So life sucked for her. Life sucks for a lot of people. Giving people who see no point in living (a surprising amount of people, most of whom are too anaesthetised to realise it) a societally sanctioned way of killing herself (this is clearly what she was after) is a pretty slippery slope. We'll see how slippery pretty soon after AGI, I think.
The manner of someone's death matters not as much as the fact of the premature death. One could theorize some nightmarish ways to go that could traumatize the bereaved but generally, it doesn't matter.
I stubbed my toe this morning. That puts me in the same category as people screaming from the agony of testicular torsion, childbirth, or a subarachnoid hemorrhage. It is helpful to deny them painkillers because I've walked it off.
I do not understand how you fail to see that the degree of sucking matters. If your mother complains of a mild headache, you pop down to the chemist for some Tylenol. If she is screaming with an arrow in her guts in the middle of the Amazon, you would be very kind to give her the opportunity to extend her life for a few minutes or hours, at least an opportunity to let her demonstrate moral character in the face of adversity.
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Canada's MAID is the usual poster child for assisted suicide abuse, having been accused of suggesting it for people who are unhappy with the conventional medical care provided, or for political reasons, or for people who cost the system too much.
(and just because you filtered out the em-dashes doesn't mean I don't see what you did there)
As always, there's a relevant XKCD (even if it came out after the comment was posted).
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I looked at the new, improved GPT5 free content I got today, and, lol, there are 18 in a single response. But then it generated a .docx of basically the same content, and lo and behold, the em dashes are gone, and now there are a lot of colons instead. Also, it's formatted nicely with headings. Huh.
I have custom instructions that specifically tell ChatGPT not to use em-dashes in conversation with me. As the screenshots attest, it doesn't give a single fuck regardless of the model. In a way, it's actually gotten worse, because when I first put that there it usually listened.
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If you have any evidence of systematic failures of the Canadian system, as opposed to anecdotes, then I would be happy to see them. Any large system would have failures, and eye-catching, condemnation worthy failures to boot.
Is this a claim that this essay was mostly, or even substantially AI generated? If so, that would be false.
I have no qualms about stating that I use AI, but for the purposes of proof-reading, stylistic suggestions/polish, critique, or research. In fact, I've been an open advocate for doing so. What do you think this post suggests?
I'm happy to provide affirmative evidence. I've uploaded an album of screenshots. You can see the embryo of my original draft, further refinements and conversations with o3 where I did my due diligence. As a matter of fact, I spent at least an hour tracking down sources, and groaning as I realized that the model was hallucinating. If this essay is LLM-slop, then please, explain.
In fact, I can go further:
https://www.themotte.org/post/1701/culture-war-roundup-for-the-week/302888?context=8#context
https://www.themotte.org/post/1701/culture-war-roundup-for-the-week/302842?context=8#context
https://www.themotte.org/post/1701/culture-war-roundup-for-the-week/302567?context=8#context
Or one can simply look up everything I've ever said about euthanasia on this forum:
https://www.themotte.org/search/comments/?sort=new&q=author%3Aself_made_human%20euthanasia&t=all
You will find what I hope is extremely strong evidence of me formulating and discussing similar views months/years back, often with identical wording. Short of video-taping myself while writing each and every comment, there can be no stronger proof.
It reads as LLM output to me as well -- more importantly failing the everpresent tl;dr criterion.
So while I'm not sure how posting a bunch of screenshots of you chatting with an LLM is supposed to make people think that you didn't generate the post using an LLM, if it's the case that you take so much input from the LLM that your post sets off people's LLM alarms, even though you typed it all out using your own fleshy hands -- maybe you are just working a little to hard on this, and it would be better to simply give us the straight slop?
Since I couldn't read your post (my AI detector involves reading normally, which for me means a lot of skimming -- and when I start to skim after two lines and... just don't stop, I figure LLMs are involved somehow and am almost always right) my comments on the actual content will be sadly limited -- however from the perspective of an actual Canadian who knows a couple of elderly & sickish people who did choose assisted suicide I can say this:
While I'm in favour of people being "allowed" to do more or less anything they want (direct and deliberate harm to others aside), in practice the whole thing feels... not good, in the pit of my stomach -- mostly I don't like the "assisted" part all that much, nor the moral preening that seems to go along with it. Could be that people just don't know how to do this thing correctly yet, but I'm not sure that's all there is too it.
The motte is a cancer riddled 96 year-old in constant pain, marking the minutes and waiting for the sure-enwinding arms of cool-enfolding death -- the IRL bailey (IME) often seems to be rather different from that.
This is intended to be shared elsewhere, in the near future. Attention spans are fickle, and the use of a conclusionary section is 100% an intentional measure for a dense piece. Don't tell me LLMs have a monopoly on writing conclusions or TLDRs. I have written both before GPT-2 was a twinkle in a
twink'sAltman's eye.That's the best evidence I have. As explained somewhere nearby in this thread, this essay began as a reply to EverythingIsFine that quickly ended up becoming so large that I decided to take it elsewhere. By that point, 80% of the work or more was done, I just needed to make sure I was done tidying up citations. You can see me double checking for anything I missed, and it turns out there wasn't much written on the exact metrics of patient satisfaction. I still had those tabs right at hand, and I made sure to show how I was going about this.
I tried to demonstrate that:
The bulk of the essay was written my me. LLM usage was used to help me consider areas to rephrase or re-arrange for clarity. In situations where that was warranted, I saw nothing wrong with copying short snippets of their output (which was a remix of my work!).
The essay recapsulates things I have personally said on this very forum. I wasn't looking at those comments at the time I was writing this, but anyone can see the exceedingly similar phrasing and argumentation. That is strong evidence that this is my own work. As a matter of fact, half of what I've written in responses to different queries also are things I've said before, in some capacity. There isn't much new under the sun, or on the Motte. We rehash a lot of the same points.
There is clear evidence of me writing the essay at a very particular time, and once again, letting EIF that I saw his original reply, and that I was almost done writing a substantial message as a standalone essay. That represents 3+ hours I was writing said essay. This can't be faked without implausible levels of foresight or conspiracy.
Further:
Accusations of use of AI are nigh-unfalsifiable. Someone down below said that people suspected that their essay on Reddit was AI, until that person noticed it was written around 2020. It is rather exhausting to defend against, at best, and I do not even see my actions as objectionable. It's >80% my writing. I fact checked everything, from my own recollections to suggestions from the LLMs I asked for advice, which took over an hour. I write top-level posts where I advocate for more people learning to use LLMs in a productive capacity, and explain how to do it when it comes to writing. I have nothing to hide.
And most importantly of all:
Why do many people object to LLM usage? Why do even I draw a distinction between good usage of chatbots, and bad/value-negative behavior?
It can be a substitute for independent thought. It can be used to gish-gallop and stonewall. It can have hallucinations or outright distortions of truth. It can be boring to read.
I ask you to show any of the above. As far as I'm concerned, there's none.
Some people have developed an innate distaste for any text with even minor signs of AI usage, let alone when the user is admitting he used them in some capacity. This is not entirely irrational, because there's a lot of slop out there and memetic antibodies are inevitable. I think this is an over correction in the opposite direction. I'm annoyed by the fact that I had to waste time dealing with this and defending myself. Because of the implication if nothing else.
You might be surprised to hear that I have been doing this for the past 24 hours. Barring @Rov_Scam specifically asking me to resume an experiment we had discussed weeks back, I intentionally refrained from even touching an LLM while using the Motte. This was mostly for the sake of proving to myself that I have no issues doing so, and why would I have issues? LLMs weren't good enough for this kind of work for ages, and I was a regular here well before then.
To a degree, this is also confounded by me being extremely sleep deprived, including at present. I guess doctors are just used to having to operate under such conditions. I also started as annoyed by what I perceive as unfair accusations or, the very least, smearing by association. To be charitable, this might not have been intentional by the people who pointed out that I had made use of LLMs (once again, something I've literally never denied, and have pro-actively declared).
I can do my work/leisure unaided. After the experiment, I am just as firmly of the opinion that 90% self_made_human and 10% a potpourrie of LLMs is better than either one by itself. That is a personal opinion. I have demonstrated effort in the past, I do so now, and I do not think I've made a mistake.
I do not like the idea of killing people. That's usually the opposite of what a doctor seeks to do. I think that in some circumstances, it aligns with the wishes of those involved, and is a kindness. I would prefer everyone sit tight and try to wait it out till we cure most or all disease, including aging itself. That aspiration (which I consider pretty plausible) is of little utility when a 90 year old woman is dying in agony and asking to go out on her own terms. The Bailey, which I am willing to defend, includes far less obvious cases, but that's informed by my firm opinions and professional knowledge, and once again, I would prefer to cure rather than kill. But if cures aren't on the cards, I think society should allow death with dignity, and I would take on that onerous task.
Boring to read, ineffective at getting your points across, way too long -- the AI is making your writing worse.
Nobody cares how hard you worked (well, some people might, but I don't) -- the clarity of communication in your post was very bad, even though the chosen topic is interesting. I think you are high on Sam's supply, and should probably consider that if you are getting negative feedback on your writing methods, your self-assessment may be flawed.
There's the motte, yes...
Society should allow it yes -- but should it provide it?
The person this essay was initially written to address, @EverythingIsFine, said he approved. At the end of the day, it's a morbid and difficult topic, and I am not fully satisfied with it in its current state. I also think that a lot of the negative feedback (which really isn't that much in absolute terms) is heavily colored by people jumping on the anti-AI bandwagon, rather than assessing the work as it stands. I already intend to rewrite it, add a whole bunch of additional data points and a deeper examination of MAID systems.
Hard disagree there. The structure was chosen precisely to improve clarity, and that is what set people off in the first place. It appears perfectly clear to me, but then again, I wrote it. I invite you to find another comment claiming that it lacked clarity; none of the people raising issues with it other than you have said so.
"Society" allows buses and trains. It occasionally also provides buses and trains. The same holds here, since I have made the case that access to euthanasia is a net public good.
Ironically it could probably be greatly improved by asking the LLM (or better yet, a skilled human editor) to edit it for brevity -- I am confident that you could communicate everything you set out to while reducing the length by a good 60-80%.
That is unlikely to make it better -- if you are going to do that, the first step would be to cut the current piece to the bone or deeper. It is bloated.
"It reads like AI and I don't like it" is equivalent -- I'm trying to be more constructive than that, but you don't want to hear it.
Unlike 'MAID', busses and trains do not usually homicide their users (in spite of notable exceptions on the "trains" department) -- additional scrutiny seems warranted?
You have not -- as practice for your next draft, can you explain this in four sentences or less, such that your thesis is clearly distinguishable from those of Messrs. Scrooge and Swift?
I'm not made out of money! The day I can expect to make more than pocket change from my Substack is not clear, and it only just crossed the hundred-subscriber threshold. But I would use an LLM to help me figure out what to trim and keep, so I was planning to do that myself.
I appreciate that, thank you, but I still genuinely disagree. We will have to chalk that down to a difference of opinion.
"Some deaths appear imminent and inevitable, and involve a great deal of suffering before they bury you. In the event that we can't actually resolve the problem, it is laudable to make the end quick and painless. Most people die complicated and protracted deaths (as will be illustrated downstream), and hence, among many other recommendations, I say it is in your best interest to support euthanasia, and will aim to reassure you regarding some common concerns. I think this is a public good, but even if the government doesn't enter the business itself, it should, like in Switzerland, hurry up and get out of the way."
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A few problems with this statement:
I can only address this if you link to the specific instance(s) of this happening.
This is, as far as I can tell, a fully generalized counter-argument against having a government at all. Or at least an argument for inventing mind reading devices and strapping them to every politician and bureaucrat. Once they're invented, we can re-examine this, and with my mild approval.
Why is cost-cutting inherently a bad thing? If drug X comes out that roughly does the same thing as drug Y, why would it be bad for a healthcare system to preference one over the other? Money matters (citation not needed), money saved somewhere can, at least theoretically, be spent elsewhere. If we're not spending tens of thousands of $currency on keeping someone who is going to die in a few days or months alive for the sake of it, then that money is available for other tasks.
For the sake of pragmatism, I don't care very nearly as much about why things are done, as I do about how they're done or their outcomes.
What. I think it's a tad-bit much to expect me to do that. You can Google that yourself, I fail to see what I can add since I live and work in jurisdictions where euthanasia is yet to be legalized.
But, in short:
Is patient sad/in pain? And not just a stubbed toe, to the point they're asking for the release of death. Or don't have the cognition left to ask.
Can we do something about that?
Have we tried? Anything left to try?
Consider euthanasia based on previous points.
Talk to them, their family, and a few lawyers before proceeding.
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It's certainly pushing the boundary in terms of what is and isn't AI slop, and I'm sure it doesn't violate the rules (for obvious reasons).
But even though it doesn't trigger obvious alarm bells, my eyes did glaze over when you started the AI slop listicle format and started delving into details that nobody really gives a darn about.
At the very least I'm pretty sure your listicle headers are straight from the mouth of a computer, not a human.
I seriously seriously doubt these words were typed by human fingers.
Aaaand even if somehow those words were typed by human fingers, you would never have written anything nearly close to this essay if it weren't for the corrupting influence of AI. Talking to robots has corrupted and twisted your mind, away from a natural human pattern of thought into producing this meandering and listless form that somehow traces the inhuman shape of AI generated text. It lacks the spark of humanity that even the most schizo posters have: the thread of original thought that traces through the essay and evolves along with the reader.
I checked, and yes, at some point in the half a dozen loops of iteration, my initial bullet points turned into a listicle. That bit is, in closer inspection, sloppy. At the very least, those additional (explanations) in brackets doesn't add to the essay. Mea culpa. I would normally remove them when I do edit passes, but I feel that it would dishonest for me to make changes, it would, even if not ended to be, come across as an attempted cover-up.
A critique I have consistently received is using run-on sentences and too many commas. I make an intentional effort to replace it with dashes (and even I've got an allery to em-dashes), semicolons, colons or parentheses.
I tried to use our search function to find comments by me which include "-", because I expect that it would demonstrate a gradual and natural increase in my usage over the years. Sadly it doesn't seem to work, perhaps because the system doesn't index individual characters.
... I obviously disagree. One man's "twisting of a natural mind" is another man's polish and increase to readability.
On more neutral terms: prolonged exposure to a tool also moulds the user. I have been using LLMs since the GPT-3 days, and some aspects of their writing have been consciously or accidentally adopted. What of it? I hadn't really noticed em-dashes before ChatGPT made them notorious, and by then even I felt nauseated by them. Bullet points and lists have their advantages, and I will die on the hill that they deserve to exist.
At the end of the day, this is a debate I'm not particularly interested in. I'm on record advocating for looser restrictions on the usage of LLMs, and I enforce the rules (which are, at this point mostly a consensus on the part of the mods, and not on the sidebar). I am not, in fact, above reproach, and I am answerable to the other mods for personal wrongdoing. I deny that said wrongdoing happened.
I invite you to look closely at all the examples I linked above. None of this is new - at worst, I self-plagiarized by finally collecting years of scattered posting into one place.
Speaking not as a mod, I don't think we should (or realistically could) ban "AI-assisted" writing. (Something that was obviously mostly or entirely generated by AI, OTOH...) That said, I was starting to be impressed by your essays, then I realized that a substantial portion of them are AI written, and now I tend to skim over them.
IMO, using ChatGPT to do light editing and maybe make some suggestions here and there is one thing (just advanced grammar and spellchecking, really), but actually letting it generate text for you is ... not actually writing. We can debate whether GPT can "write well" by itself, but it's definitely not you writing it just because you gave it a prompt, and I would even say that "collaboration" is stretching it.
But I don't just give it a prompt! 80% of the text is mine, at the absolute bare minimum. I'd say 90% is closer to the average. That is me attempting to estimate raw words, the bulk of the 10% is alternative phrasing.
My usual practice is to write a draft, which I would normally consider feature complete. I feed it into several models at the same time, and ask them to act as an editor.
(If this was Pre-LLM era, I would probably be continously updating the post for hours. I still do, but the need to fix typos and grammatical inconsistencies is decreased by me being a better writer in general, and of course, the LLMs. All I'm doing is frontloading the work)
I also, simultaneously, feed them into a more powerful reasoning model such as o3 or Gemini 2.5 Pro for the purposes of noting any flaws in reasoning. They are very good at finding reasoning flaws, less so at catching errors in citations. Still worth using.
I then carefully compare the differences between my raw output and what they suggest. Is there a particular angle they consider insightful? I might elaborate on that. Would this turn of phrase be an improvement over what I originally wrote?
Those are targeted, bounded changes. They are minimal changes. They don't even save me any time, in fact, the whole process probably takes more time than just letting it rip. If I was just uncriticially ripping off an LLM, the it would be a miracle if every link in the previous post worked, let alone said what I claim they said.
Does this dilute my authorial voice? To a degree, yes, but I personally prefer (90% SMH and 10% half a dozen different LLMs) to pure SMH, and certainly better than any individual LLM.
I consider this a very different kettle of fish to people who simply type in a claim into ChatGPT and ask it to justify it to save themselves the hassle of having to write or think. self_made_human is the real value add. The LLMs are a team of very cheap but absent-minded editors and research interns who occasionally have something of minor interest to add.
Why do you think I bothered to show that I have independently come up with all the thoughts and opinions expressed in this essay? I literally did all of that years ago, and in some cases, I forgot I had done the exact same thing. I could have easily just copied most of that and gotten the bulk of the essay out of it.
At the end of the day, my anger is mostly directed at the lazy slobs who shovel out actual slop and ruin the reputation of a perfectly good tool. At the end of the day, it is your perogative to downweight my effort-posts because a coterie of LLMs helped me dissect and polish them. I am disappointed, but I suppose I understand.
Edit: The present >80 and the average ~90% only applies for specific comments. I can only stress that the majority of all commentary by my digital pen is entirely human written.
But isn't that the point of posting here?
"This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases"
If you're testing your reasoning against an LLM first then you're kind of skipping part of the entire point of this space no? We should pointing out flaws in your reasoning. You're making an arguably better individual post/point, at the expense of other readers engagement and back and forth. Every time the LLM points out flaws in your reasoning you are reducing the need for us, your poor only human interlocuters. You're replacing us with robots! You monster! Ahem.
If the LLM's at any point are able to completely correct your argument then why post it here at all? We 're supposed to argue to understand, so if the LLM gets you to understanding then literally the reason for the existence of this forum vanishes. It's just a blog post at best.
It's like turning up for sex half way to climax from a vibrating fleshlight then getting off quickly with your partner. If your goal is just having a baby (getting a perfect argument) then it's certainly more efficient. But it kind of takes away something from the whole experience of back and forth (so to speak) with your partner I would suggest.
Now it's not as bad as just ejaculating in a cup and doing it with a turkey baster, start to finish, but it's still a little less...(self_made_)human?
Not saying it should be banned (even if it could be reliably) but I'd probably want to be careful as to how much my argument is refined by AI. A perfectly argued and buttressed position would probably not get much discussion engagement because what is there to say? You may be far from that point right now, but maybe just keep it in mind.
I don't see how this implies that any user must submit the literal first draft they write.
Consider the following:
You write a comment or essay.
You do an edit pass and proof read it. Corrections happen.
You might ask your buddy to take a look. They raise some valid points, and you make corrections.
You post. Then people come up with all kinds of responses. Some thoughtful and raising valid concerns. Some of them that make you wonder what the fuck is going on. (You must be, to some degree, a rather masochistic individual to be an active Mottizen)
You either edit your essay to incorporate corrections, clarifications, or start digging into topics in sub-threads.
The place where LLMs come in is stage 2/3, at least for me. I ask them if I am genuinely steelmanning the argument I'm making, if I haven't misrepresented my sources or twisted the interpretation. If you do not objection to having a friend look at something you've written, I do not understand why you would have concerns about someone asking an LLM. The real issue, is, as far as I'm concerned, people simply using the ease of LLM issue to spam or to trivially stonewall faster than a normal person can write, or to simply not even bother to engage with the argument in the first place. I think I've framed my stance as "I don't mind if you use ChatGPT in a conversation with me, as long as your arguments are your own and you are willing to endorse anything you borrow from what it says."
As evidence I've shared suggests, all arguments are my own. I have made sure to carefully double check anything new LLMs might have to add.
Is that how it works? Nobody told me!
On a more serious note: Do you actually think that writing a well-reasoned, thoughtful and insightful essay is a guarantee that nobody here will come and argue with you?
I wish that were true. At the bare minimum, the population of the Motte is extremely heterogeneous, and someone will find a way to critique you from their own idiosyncratic perspective.
That is the point. That is why I come here, to polish my wits and engage in verbal spars with gentleman rules at play.
I genuinely think that is impossible in practice. There's a reason for that saying about every modus tollens having a modus ponens. Someone will come in and challenge your beliefs here, even if the topic is what anime you like. There is a lot of fundamental difference in both opinion and normative, epistemic and moral frameworks here!
In the limit, values are orthogonal to intelligence. If I was relying on some ASI to craft the perfect essay about how fans of Tokyo Ghoul should seppuku, then what's stopping someone from coming in and using their ASI to argue the opposite?
We do not have ASI. An LLM cannot replace me today. The day has yet to come when shooting the shit with internet strangers is made obsolete for my purposes. I would be sad if that day actually comes, but I think it's a good while off.
In the meantime, I'm here to dance.
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Should be 100%. But that's just my opinion.
I don't hate AI. In fact I like it a lot (while having some concerns about long term implications). I use it for art, and I have artist friends who are furious about that. I do use it to write tedious stuff, like rough drafts for letters of recommendation, which I then clean up and edit.
But on an art forum, I would not post AI, or even post-worked AI, unless there was a section specifically for that. On a writers' forum I would not want to see AI writing unless there is a section for that. And I don't want to start wondering how much help AAQCs are getting from AI.
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I didn't mean to suggest any preferential treatment, just that as someone who participated in the process of creating them you would have a clearer idea of what line is and write well within it.
I also agree that the majority of the text in your essay did pass through human fingers, but there are some elements that are suspiciously suspicious.
Also I hope I'm not coming off wrong here in my comments, I don't mean anything to be negative towards you, I think you are cool, I'm just a huge huge AI hater.
You'll just have to take my word for it, I'm afraid.
As far as I'm concerned, the most compelling reason to not worry too much about anything but the most-blatant usage of LLMs is that it is almost impossible to tell. There are obviously hints, but they are noisy ones. Anyone who opts to be careful can get away with it easily. About 70% of our effort-posts, if posted on Reddit, would immediately face accusations of being AI. Even things written in, say, 2020.
I am deeply annoyed by implicit accusations of cheating by generating even a substantial portion of my work with AI, or worse, trying to disguise and launder LLM-usage. I consider even the weaker claims that I use LLMs to help me write to be as farcical as accusing SS of being an anti-semite. For once in my life, like him, I'd go "yeah? And?".
(This is not a personal attack on you, I know we have probably irreconcilable differences of opinion, but you're one of the "LLM-skeptics" here who is open to alternative arguments and willing to engage in proper debate. My blood pressure doesn't rise when talking to you, and I'm grateful for that)
I've already shared screenshots. I would even share the very first draft, which I was writing in the text box as a response here. This post is from 4 hours back, and about an hour before I submitted the final essay. I think that's a sufficient amount of time to write said essay from scratch. I can't fake the time stamps without a time machine, and even GPT-5 can't build those yet. I think it's the version in one of the Gemini 2.5 screenshots, but god only knows at this point. I'm not kidding about staying up still almost 7 am.
If after that much time and hard work, I face such concerns, then what can I even say? I bother now both because I'm definitely not getting any sleep, and so I have something to link to if this happens again.
I actually had this happen to me!
I made a detailed comment about a particular video game strategy in the game's subreddit, probably around 2020, long before writing it with AI would have been plausible.
This year someone responded with "if this wasn't written when it was I would think it was AI"
I guess given the context that's a compliment?
I've cried myself hoarse trying to reason with people who reflexively think LLM=bad. They're tools, tools that have serious flaws, but which are so useful it makes you wonder how you managed before. It's like trying to navigate the internet before Google.
I suspect that if Scott, Gwern, or any of the other big names were obscure today, and broke containment, they'd go nuts trying to fend off accusations of being AI. There is good reason why the LLMs were taught, intentionally or inadvertently, to mimic such a style. Nearly formatted essays with proper markdown are not the sole domain of AI. They make things more pleasant, at the cost of a very small amount of individuality. I promise you that every one of my essays screams self_made_human regardless of how many models I ask for advice. You should take it as a compliment, in this particular scenario.
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What's the acceptable rate of systemic murder?
For me it's 0 so I don't think any case can be dismissed as anecdote.
If we're allowed to use the "any system can fail and that's okay" I ask then what your position is on capital punishment and collateral damage in the pursuit of legitimate military targets.
With most things, there are trade-offs. Like Scott, I stand beside the snakes and traders.
Cops have a non-zero systemic murder rate. This tells us fuck-all if they are net positive or not. Perhaps they are basically a criminal gang running a protection racket and kill everyone who does not pay up. Or perhaps they are mostly good once per 50 years two crooked cops will use their uniform to cover up a 2nd degree murder committed by one of them by planting a gun on the victim.
Or consider organizations with regard to systemic child abuse. Any organization whose members will have contact with kids will have a nonzero systemic child abuse rate, because you can sink any amount of resources into reducing the risk and organizations generally run on finite resources. However, there is a vast difference between "we should have considered the fact that the kid was waving at their teacher as evidence that they were in an abusive relationship and started an investigation" and "once we got too many complaints about the priest touching kids, we simply transferred them to another church".
Likewise with collateral damage. Either claiming that no civilian casualties are acceptable or that any are okay is foolish. Killing one civilian for every 50 killed enemies would in most wars be a conduct noble beyond belief, while killing 50 civilians per killed enemy would be excessively brutal.
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That just reduces the question to an argument about the meaning of the word "systemic". The acceptable rate of men killing their wives is clearly greater than zero, given that it's a sizeable chunk of the overall murder rate and we don't spend a lot of resources trying to prevent it. It isn't obvious why this changes if the men are talking their wives into in appropriate MAID.
I think the argument is worth having.
I don't want the state killing people. I don't care if people suffer or even die to make sure that power is very securely under control. Because I've seen what happens when it is not.
I'm willing to eat some murders happening because we don't execute murderers even though they deserve it. All because it should be a Big Deal when institutions take a life. I don't see how this is any different.
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There's a rationalist shibboleth that I am very fond of: "The optimal amount of X is not zero"
This isn't a call for nihilism or a license for carelessness. It's a recognition that we live in a universe of trade-offs, and that clinging to a perfect "zero" in one narrow domain can inadvertently cause immense harm in others.
For some very high stakes activities, it really ought to be extremely zero over human timescales. For example, if there is an automated system that is responsible for initiating a response to a nuclear strike, I sincerely hope that the failure rate is 0.0... per annum, for several zeroes. Stanislav Petrov was responsible for preventing an accidental nuclear war because he correctly diagnosed that the Soviet early-warning system was malfunctioning.
The lower the stakes, the more the leeway for failure or unpleasant outcomes. If you truly wanted a government that never "systematically" murders someone (and we're assuming that murder is definitionally objectionable), then your best bet is to get rid of government altogether. I suspect that doing so will just lead to an increase in the number of murders overall.
Consider medicine, my home turf? What is the acceptable rate of iatrogenic death, i.e patients killed by the treatment meant to save them? We know for a fact that surgery has a non-zero mortality rate. Anesthesia can kill. Drugs have unexpected, fatal side effects. We could reduce iatrogenic deaths to absolute zero tomorrow by simply banning all surgery, all anesthesia, and all prescription medication. The number of people who would then die from otherwise treatable conditions would be rather large. We accept a small, managed risk of systemic medical error because the alternative is a certainty of systemic medical neglect. That is the only sensible way of going about such things without, as I've said before, literally infinite money/resources.
(This is why deontology is insane. The Pope might not want any orphans to starve in Africa, but he doesn't pawn off the Pope Mobile to pay for it. At least adopt something more sensible like Rule Utilitarianism/Consequential ism or even Virtue Ethics. It is easy to say that the optimal number of starving orphans is zero, far harder to make it happen without sacrificing more important concerns)
Even the legal system, in your own example, abides by Blackstone's ratio. A certain number of the innocent will accompany the guilty, be it to the gallows, a short stint in prison, or in paying fines. To reduce the rate of wrongful conviction to literal zero would be to dispense with a legal system. Guess what that does to crime statistics?
If I had to put a number on the "acceptable" rate of systematic murder, the most obvious way to peg it is by calculating the number of non-systematic murders that would occur. I think I can slightly bias the conversion ratio, but in both directions. I am quite unlike to be either systematically or unsystematically murdered myself, but I guess I'd prefer the latter for the sake of fairness, should Rawls drape a veil over me.
That's still deontology. How did you decide who gets to do the "managing"? You think that's based on raw numbers of successes and failures, or assetions of authority deciding to crush your supposedly beloved principle of autonomy under it's boot? If the system worked the way you describe, we'd be living in ancap insurance-ocracy, not what we have today.
I didn't decide to do anything at all. I'm talking about an existing system, which was created over decades by people with far more degrees and alphabets after their name. Give me ten years, maybe 20,before I get there.
It is obvious to me that even attempting to frame the system-as-it-exists as exclusively deontological or utilitarian/consequentialist is at least partially a category error. There are a lot of sticky fingers in that pie.
What I am advocating for is a better system overall. I think the existing system is okay. Not great, not terrible. Hence the critique.
Would it surprise you to find out that I would actually prefer to live there? One of the many reasons I dream of moving State-side is because it's the closest any country has ever come to embodying those aspirations.
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You should provide evidence for your claims. I'll start.
In 2023, 15,343 people received MAID in Canada, with 95.9% (14,721) falling under Track 1 (those whose natural death was reasonably foreseeable) and 4.1% (622) under Track 2 (those whose death was not reasonably foreseeable).
Average age track 1: 77.7
Average age track 2: 75.0
Does this seem like a lot to you? Because to me it kind of does...
I don't even know how to respond to that
Define "a lot"
I guess you could contrast it with other causes of death in Canada?
But like how much is too much MAID, is 10% too much? Is 50% too much? Define what your limit is.
Does the amount of death attributed to MAID even matter? If 96% of MAID recipients have a terminal illness, why do you care?
600 people per year being deliberately killed in a population the size of Canada seems significant to me, regardless of how many other terminally ill people are killed. (which I'm also uneasy about, although if they want to DIY it that seems fine, and certainly there are some cases where it seems like a mercy)
Typically there are 6-700 murders per year in Canada; these are normally considered undesirable and kind of a big deal. So you need to do some work to convince me that this new category of homicide is totally cool and no problem.
Why is homicide specifically worse when it's another person doing it?
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*Voluntarily killed
How is a ~77 year old terminal cancer patient going to DIY suicide, and how is that better for literally anyone? Sucks for them to DIY it, sucks for them even more if they fuck up DIYing it and survive with a crippling injury, sucks if they just can't, and have to die of their terminal disease slowly, sucks for whoever has to find their DIY remains (likely, a family member).
It's not homicide, it's literally voluntary. The average age is 75 for track 2.
Further, given it's VOLUNTARY, it won't happen to you, so why are you so tilted other people are doing it?
I feel like you should convince me why terminal or near terminal old people shouldn't be able to go out peacefully and painlessly. I think everyone has a right to a dignified and painless end, justify why they should be stopped if they consent.
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You know how everyone was freaking out over that dude that got sent to El Salvador? It's this times 622.
I struggle to imagine what kind of view of doctors you have if a voluntary
anesthesiaeuthanasia program being approved for someone who, just maybe, wasn't about to die on their own, is comparable to being bagged by ICE.Hopefully I haven't made a wrong turn somewhere, and we're still talking about euthanasia, rather than anesthesia.
It's true that my view of doctors is rather mixed, but your argument leaves my scratching my head. I imagine most of them don't perform such procedures.
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In terms of the slope slipperiness, Canada is expanding MAID to people suffering solely from a mental health condition. This is legally required due to a court case they lost challenging the MAID law's exclusion of the mentally ill. They have temporarily delayed this through new legislation, but eventually they will either implement it, or be taken back to court and forced to implement it. The people newly eligible will all fall under track 2.
https://www.canada.ca/en/health-canada/news/2024/02/the-government-of-canada-introduces-legislation-to-delay-medical-assistance-in-dying-expansion-by-3-years.html
So MAID is the "poster child for assisted suicide abuse" because the government, who lost a court case forcing their hand, is doing what they can do delay expanding eligibility to it?
Seems very abusive lol
The courts aren't part of the government?
Have you heard of three branches of government:
They teach that factoid in the US, the UK, and even in India. Some parts of the government exist to exert checks and balances on the others. The judiciary doesn't cease to be part of a functional government because that's rhetorically convenient.
I did, that's my point.
That strikes me as nothing more than fiction. The idea relies on there being some objective standard the judiciary judges the other branches of the government on, without it, it's still government just wanting to do something. Look no further than no right to euthanasia existing for the majority of the existence of Canada, only to magically appear now.
My bad.
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This is akin to going to a waterslide at a theme park and complaining the slope is slippery. You do not know how bad mental illness can get if you think "mental illness" is some privileged form of disease. I'd take many forms of cancer over schizophrenia.
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