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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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