Objection 1 -- There is always the possibility of an incorrect diagnosis or the discovery of a treatment that will permit either survival or recovery.

Reply -- While these things cannot be ruled out as absolutely impossible, they can often be ruled out as impossible for all practical purposes. It is frequently beyond all reasonable doubt that the diagnosis is mistaken or some cure will not be discovered in time to help, and it is not clear why this should not be sufficient. The law has never taken a "pigs might fly" attitude towards the risks attendant on any activity. We only need to establish "guilt beyond reasonable doubt" to send a person to prison or even to his execution, and it is not possible to require more without making the enforcement of the law impossible. Why a more stringent standard should be demanded in the cases of voluntary euthanasia needs to be explained.

Moreover, when the likelihood of being restored to what one would regard as a worthwhile life is small, and that of enormous pain and degradation relievable only by death is great, no one can plausibly say that the decision to die is an unreasonable one. But if so, respect for the autonomy of the individual requires that we not prohibit him from authorizing others to help put it into effect.

Objection 2 -- We can never be absolutely sure that we have voluntary and informed consent. If the request is made prior to patients' coming to be in a desperately bad way -- say in the form of a living will -- it cannot be considered binding because it is insufficiently informed. On the other hand, if the request is made when patients are in a bad way, then the pain and drugs prevent them from making a fully rational decision. In either case, it is not possible to secure a death-request that would justify the deed.

Reply --- For reasons given in the reply to Objection 1, the demand for absolute certainty with which this objection begins is too strong. But even if the complaint of that feature were purged, it is still not good. It is indeed true that prior request ought to not always be considered binding. Certainly it should not be if individuals subsequently renounce their decisions. Again, if individuals alternately reaffirm and renounce their decisions we may be in a quandary about what to do. But it cannot reasonably be claimed that a prior request can never be binding because it is always insufficiently informed. If individuals reaffirm their decisions under pain, after the first shock of it has passed, we have very good grounds for claiming to know their fixed and settled desires.

Again, if individuals fall into a state which does not permit them to either reaffirm or renounce their decisions, and are not expected to recover from that state, then we have the same reason to act on their prior death-requests as we would subsequently have to distribute their estates in accordance with their wills. In both cases, such decisions are momentous, irrevocable, and ones that might not have been made if the persons could have foreseen their futures. But to deny the bindingness of such requests is to say that persons should not be permitted to make such decisions, and that is surely unacceptable.

Where the individuals make the death-requests in pain and under the influence of narcotics, it must be admitted that they are not in the best condition to make a fully rational decision. But it must also be granted that they are in an excellent position to say whether or not they wants to continue living in such a state.

It may also be that such an existence is the best they can expect, and there will come a time when it is quite unreasonable to tell patients that they will adjust to their condition, and a time when it is unreasonable to hold out any hope for any improvement. It is hard to see why the appropriate facts of this sort, conjoined with the patients' judgment that their present state is intolerable, should not yield a request for death that is sufficient to justify action.

Objection 3 --- The chronically and terminally ill are often vulnerable and feel themselves to be (and often are) a burden to others. Many of the ill, however, are not tired of life and do not want to die. But if voluntary euthanasia were readily available, they might feel obligated to opt for death, and relatives or others in whose care they are, who often would just as soon be rid of the burden, may consciously or unconsciously exert pressures, in a way difficult to detect and avoid, to request assistance in voluntary euthanasia.

Reply ---- It is unrealistic to suppose that some such tragedies will not occur. But that should not be taken as a decisive objection to the practices in question. Society allows policemen to carry guns and young people to choose their marriage partners, and tragedies result from these too. But we accept such tragedies, however regretfully, as a part of the price of policies that are on the whole beneficial and a similar line is plausible in the case of voluntary euthanasia.

It is a mistake to think that if we do not liberalize the law no tragedies will occur. The pain and degradation which euthanasia laws address will continue; the sick will continue occasionally to attempt suicide in ways which are neither painless to themselves or others nor always successful; friends and relatives will be faced with the terrible choice of either standing by and watching the suffering and disintegration of a loved one, or acting in a way which is contrary to law and for which they have no expertise.

Objection 4 --- Legalizing voluntary euthanasia today will lead to active nonvoluntary euthanasia tomorrow, and that will lead to active involuntary euthanasia the day after: the antisocial, the ethnically unattractive, the politically deviant, the aged, etc., will all become potential victims. Thus if we do not draw the line where it is, we will not be able to prevent substantial harm to others. This is the famous "Slippery Slope" or "Wedge" or "Camel's Nose" argument.

Reply --- This argument is singularly implausible if one who makes it means that there is a logical connection between the killings in question such that one who endorses the first cannot without inconsistency refuse to endorse the last. The fact that in one case a person is killed in his own interest because he requests it, whereas in the other a person is killed in the interest of others without (or contrary to) his consent, is surely a morally relevant difference. Since this is so, the question "How can we draw the line?" should not perplex one for long. No one thinks that making killing in self-defense an exception to criminal homicide starts one on a slippery slope that logically must end in the abolition of the crime of murder; no one should think the same about legalizing voluntary euthanasia.

A more common and plausible way of understanding the objection is to take it as alleging an empirical connection between the killings in question. If, however, the claim is an empirical one, it stands in need of evidence. What is the evidence that a policy of allowing death on request, begun in good faith and motivated by compassion, will lead to unwanted killings?

Two items of evidence are commonly alleged. The first is the Nazi experience. However, there is no parity between the cases; all they have in common is the name "euthanasia". In these cases, the name stands for quite different policies. The Nazi program of "euthanasia" was neither voluntary nor based on compassion; it was, rather, motivated by the desire to remove "useless eaters" and preserve the purity of the Volk, and hence was the result of a vicious and racist ideology already firmly in place, not the unwanted and unexpected upshot of an intrinsically desirable social reform.

The second, which is currently attracting the most attention, is the Netherlands experience. In the Netherlands we have a living laboratory in which the euthanasia experiment in being conducted, and it is claimed that active nonvoluntary and involuntary euthanasia are openly practiced there, exactly as predicted by the slippery slope argument.

The claim of the open and common practice of involuntary euthanasia has been often repeated, but has never been substantiated, and indeed has been repeatedly challenged.

There is, however, firm evidence of a significant incidence of nonvoluntary euthanasia. The Remmelink Commission (1991) reports that of Holland's 130,000 deaths in 1990, 0.8% (1000 cases) were as a result of active nonvoluntary euthanasia, and there is no reason to doubt that this is a minimum figure. But we cannot immediately infer that a slippery slope has taken place, or that it was a mistake (which we should not repeat in the U.S.) to legalize voluntary euthanasia.

To begin with, to say that a slippery slope has taken place is to make a causal claim to the effect that legalizing voluntary euthanasia caused an increase in the incidence of active nonvoluntary euthanasia. But a high incidence rate does not, in itself, establish causation.

Nor can one argue for causation on the ground that legalizing voluntary euthanasia was followed by an increase in active nonvoluntary euthanasia. For even if there were evidence for this (which there is not), that would commit a fallacy. It would be like arguing that the growth of teeth in infants is caused by the growth of hair, because the former follows the latter. To establish causation, it is necessary to show that if voluntary euthanasia were not legalized, then there would not have been an increase in incidence of active nonvoluntary euthanasia. However, there is no evidence to support this, and hence no evidence for a slippery slope having taken place in Holland.

Moreover, even if a slippery slope were demonstrated, the wrongness of legalizing voluntary euthanasia would not follow without considerable further argument. Two defenses are open to defenders of legalization.

First, one can argue that the occurrence of that incidence of active nonvoluntary euthanasia is a regrettable but acceptable consequence of an on-balance beneficial policy. This is the argument invoked in the Reply to Objection 3, which accepts the downside alleged, but contends that there is a countervailing up side.

Second, one can take the line that the incidence of active nonvoluntary euthanasia is acceptable and not regrettable. The cases of active nonvoluntary euthanasia which comprise the bulk of those which occurred in Holland involved severely defective newborns or debilitated elders (many of whom had made a prior request for euthanasia, but not in a way which satisfied the stringent consent requirements laid down in Dutch law). Furthermore, some Dutch physicians argue that active nonvoluntary euthanasia is more humane and dignified for all concerned than the alternatives of keeping the patient alive or letting nature take its course.

Suppose that all the above is mistaken. Suppose, that is, that a slippery slope has taken place in Holland, and that this is unacceptable. The question still remains whether this provides compelling evidence that a slippery slope would certainly or likely occur if voluntary euthanasia were legalized in the U.S.

There is a difference between the two cultures, which makes that inference problematic. There also may be ways of making legal space for those practices -- say with greater safeguards or stiffer penalties -- which will prevent unacceptable results. Even if Holland's way of legalizing voluntary euthanasia led to active nonvoluntary euthanasia there, that provides no evidence for saying that other means of legalizing those practices will lead to that consequence elsewhere.

The upshot of the above is that we do not have convincing evidence that legalizing voluntary euthanasia will certainly or probably lead to unacceptable consequences. Thus the empirical version of the slippery slope argument fares no better than the logical version.

There is one final version of the slippery slope argument to be considered. It is sometimes argued that while there is no evidence for a slippery slope taking place, it is something which everyone must admit is possible, and do we want to take that chance?

This argument assumes that things are just fine now. The problem with the argument is that the assumption is false. There are people in this world whose autonomy is violated and suffering is unmitigated; as indicated in the Reply to Objection 3, one should not think that there is no downside to maintaining the status quo. We know that legalizing voluntary euthanasia will help. We do not have any evidence that bad consequences will ensue. Put this way, which we submit is the accurate way, the gamble seems eminently reasonable.

Objection 5 ---- The proposed legislation would make it easier to commit malevolent homicide. Many people want, and badly want, to be rid of others, and the deaths of those persons could be brought about under the cover of voluntary euthanasia.

Reply ---- This objection applies with equal force to allowing killing in self-defense as non-criminal homicide. So, insofar as it is not used to advocate the repeal of that classification, its application to the case of voluntary euthanasia is unsound and discriminatory.

With certain safeguards, it would also be difficult to pass off murder as euthanasia. Certainly that would be no easier -- and probably a good deal harder -- to do than to pass of murder as self-defense or suicide. Since this is so, it is unlikely that legalizing voluntary euthanasia will cause an increase in the incidence of murder or of undetected murder.

Objection 6 ---- Patients seeking voluntary euthanasia clearly do not wish to prolong their agony, but seeks a quick end to their suffering. Yet any proposal for the legalization of these practices must necessarily include some process of ensuring that their decision is voluntary and informed. Any such procedures would have to be carefully followed and the results painstakingly confirmed. All this would demand time, and by wrapping the decision-making process in red tape, create the very delays that those who advocate the practices seek to avoid.

Reply --- To ensure that voluntary euthanasia is not misapplied, time-consuming procedures must be followed. But to conclude from this that these practices should not be legalized is like arguing that no one should get a driver's license or unemployment benefits, because it would be irresponsible to hand them out without verifying the information, and that means that people cannot get them as speedily as they wish.

The unavoidable necessity of delaying voluntary euthanasia is no reason for denying them altogether. We must also not exaggerate the time and red tape that need be involved in following procedures that are reasonable safeguards against misuse and abuse.

Objection 7 --- The medical profession exists to provide important professional services, and neither wants to be nor should be involved in the kind of bureaucratic activity involved in responsibly administering the delivery of voluntary euthanasia.

Reply --- This objection begs the question by assuming that voluntary euthanasia are not "important professional services." But that is false. It is important to most people to die painlessly and with dignity, and engineering such a death by way of voluntary euthanasia is a matter calling for medical expertise. Grant this, and the objection that we should not legalize the practices because of the paperwork involved -- which could not be any greater than that involved in determinations of competency -- is embarrassingly lame.

Objection 8 --- The extraordinary development of palliative care and pain control in recent years is a more positive and safer response to the problems than voluntary euthanasia.

Reply ---- The hospice movement and advances in pain-control are certainly welcome developments that do something to reduce the need for legalizing voluntary euthanasia. But they do not remove it altogether, and we should not view these things as alternatives.

There are indeed drugs that, if properly administered, can control pain. Nonetheless, insofar as the patient remains conscious, there are other forms of distress such as the terror of breathlessness, uncontrollable vomiting, paralysis, incontinence, and inability to swallow and sheer weakness and helplessness that cannot always be adequately controlled. We must also remember that it is often difficult to arrive at and maintain the correct dosage of drugs under the most conscientious surveillance of patients, and the practical realities of contemporary medical care mean the patients often get less than this.

However, even if pain and distress were not a problem, there is frequently a strong fear on the part of patients of the abject dependency and degradation involved in the loss of bodily and mental functions which often accompany the dying process, and no amount of care services can remove these.

Objection 9 ----The legalization of voluntary euthanasia will discourage the search for new cures and treatments for the terminally ill patient.

Reply --- There is no difficulty in showing any policy to work ill if we conjoin idiocy with it; and if we suppose that people will accept voluntary euthanasia as substitutes for treatments and cures, there is no difficulty in showing a serious problem with their legalization. But if one is to look askance at these practices for this reason, one must do so at a host of other things as well, such as improvements in palliative care, fire and theft insurance, and airbags in automobiles.

But this is surely absurd. There is no reason to think these mitigating measures have that effect, and it remains to be shown why we should think that legalizing voluntary euthanasia would have it either.

Objection 10 --- Patients who struggle to recover have better recovery rates than those who have given up hope. The availability of voluntary euthanasia will encourage patients to give up, and so significantly decrease their chances for recovery.

Reply --- On the face of it, this argument applies with equal force against allowing people to divorce, drop out of college, or refuse medical treatment, for removing those options would likewise make people struggle with sometimes a good effect. But even if we limit the scope of the argument to voluntary euthanasia, it is not a good one.

One cannot argue that the struggle would be beneficial in all cases. Nor could one realistically argue that medical prognoses are so fallible that it may be valuable in any given case. The prohibition must therefore be based on the claim that it would be beneficial on the whole. There is, however, no evidence to suppose that this is so. But even if there were, criminalizing the conduct for this reason relies on a questionable theory of interference.

Certainly, society may interfere to prevent individuals from harming others. It is more problematical, but also arguable, that it may interfere to prevent unencumbered individuals from harming themselves. This argument, however, depends on the still more controversial view that society can prevent some unencumbered individuals from acting in their interest in order to prevent other unencumbered individuals from acting to their detriment, and this principle seems impossibly strong.

In summary, two things are evident: the arguments against these practices are very weak, and each applies with equal force against some other well-entrenched practice or practices, most notably passive voluntary euthanasia (all except Objection 5) and killing in self-defense (Objections 4 and 5). Given the latter, if we do not allow the arguments to rule out those practices, we should not let them rule out voluntary euthanasia. And, given the former, we should not allow the arguments to rule out those practices. Thus we have failed to find any objection sufficient to cancel the case in favor of voluntary euthanasia. Unless some such objection is produced, legal provision should be made for those practices.

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