Abstract
Malcolm Parker, Senior Lecturer in Ethics & Professional Development, School of Medicine, University of Queensland, Australia:
The following response by Malcolm Parker to Ranier Dziewas and Henning Henningsen (‘Medicine, psychiatry and euthanasia: an argument against mandatory psychiatric review’ 36:266–267) should have accompanied their letter in the same issue.
Dziewas and Henningsen accept my arguments that show that there is no justification for requiring mandatory psychiatric review of requests by patients for active assistance to die, but not for requests for treatment withdrawal. Those arguments explained why the distinction has traditionally been supported, by linking considerations of institutionalized medicine's appropriation of the rules of dying and its flawed intuitions about causing death; psychiatry's understandable prejudices concerning the possibility of rational suicide; and the lack of conceptual clarity concerning depression and decisionmaking competence.
However, my arguments are said to be incomplete, in the sense of not accounting for the psychological version of the slippery slope defence of the status quo, that proposes that while there may be no logical distinction to be made between killing and allowing to die through withdrawal of treatment, the removal of impediments to an additional category of killing may in fact lead to nonvoluntary or even involuntary euthanasia.
My focus was on mandatory psychiatric review, not euthanasia per se, and even though the acts/omissions distinction informs both areas of debate, my paper assumed the institutionalization of euthanasia in some form, as do those who argue for mandatory psychiatric review. However, I will address my correspondents’ slippery slope challenges.
I suggest that the separation of logical and psychosocial versions of the slippery slope argument is not as easily maintained as my correspondents, like many others, assume; their ‘concrete points’ may be used to demonstrate this:
‘Physicians… might start seeing euthanasia as another therapeutic option and to influence patients in that direction’: Well, the apparently self-evident badness of such a situation surely trades on presupposing that the acts/omission doctrine is morally significant, whereas the move to legalized euthanasia presupposes the moral irrelevance of the doctrine, at least in certain cases. In that context, doctors would fail in their duty of care to certain patients if they failed to disclose the availability of euthanasia. Further, what do we (not) know of the extent to which physicians influence patients to seek treatment withdrawal? Dziewas and Henningsen suggest that reductions in sympathy and compassion could be induced by allowing active euthanasia, and that palliative measures may be confined. The first fear appears to be based on how one defines sympathy and compassion, which in turn will depend on one's basic position vis a vis acts and omissions. Again, a particular view is presupposed which is inconsistent with that which, in theory, is approved. Second, the prediction that palliative measures may be restricted depends on conceiving euthanasia and palliative care as alternatives. Not only is there is no evidence for the prediction, there is no basis for the conception.
Dziewas and Henningsen agree that the psychosocial versions of the slippery slope argument are poorly supported. As I stated in the paper, insisting on psychiatric review would be pointless if you did not accept that there were morally acceptable cases of active assistance to die, since review must be aimed at distinguishing acceptable from unacceptable requests. While Dziewas and Henningsen rightly suggest that the prohibition of euthanasia cannot rest firmly on slippery slope arguments, they assert that they are strong enough to suggest that mandatory review is required to secure patient autonomy and to avoid coercion. If they have no logical objections to my thesis, why do they not extend the review requirement to cases of treatment withdrawal, in order to secure the same certainties?
Of course, my thesis goes further than this equivalence. I support the third of three possible positions on mandatory psychiatric review of end-of-life decisions:
Mandatory psychiatric review of requests for treatment withdrawal and for active assistance to die. Mandatory psychiatric review of active requests but not for treatment withdrawals. Mandatory psychiatric review of neither active requests nor treatment withdrawal requests.
The third position follows from holding both that, ceteris paribus, the acts/omissions distinction does not mark a morally significant boundary, and that freedom is threatened in all end-of-life decisions by mandatory psychiatric review.