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• MAID, social determinants, and the slippery slope.
  Thomas Koch
  Published on: 22 September 2021

• Published on: 22 September 2021

  MAID, social determinants, and the slippery slope.

  • Thomas Koch, medical ethicist and geographer. University of British Columbia (Vancouver); Alton Medical Centre (Toronto).

  In their recent article, Jocelyn Downie and Udo Schuklenk conclude, first, that the Canadian experience denies the existence of a 'slippery slope' expanding medical termination from a limited to a broader medical constituency. Second, they argue a faiure to provide social constituents of health and support is a significant factor in the increased requests for 'medical aide in dying.' (1) It is hard to credit their conclusions on either point.
  As they note, 2016 legislation legalized 'medical assistance in dying" in cases of serious and incurable illness, disease or disability in an advanced state of decline with death an inevitable and foreseeable conclusion. But as they note (pg. 3-4) new legislation has broadened those criteria to include those with 'disabilities' whose death is not reasonably foreseeable as well as others with chronic, non-progressive disorders including mental illness. Indeed, enui seems to now be an acceptable rational for termination among even those without serious chronic illnesses or disorders. (2)
  That is precisely the definition of the slippery slope, a narrow framework of action is broadened to include ever larger classes of peoples.
  Similarly, they give short-shirt to the issues of the social constituents of health, ignoring the complex of predicate failures that may lead one to seek a rapid death. These include the limited availability of expert palliative care, the shortage...

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  In their recent article, Jocelyn Downie and Udo Schuklenk conclude, first, that the Canadian experience denies the existence of a 'slippery slope' expanding medical termination from a limited to a broader medical constituency. Second, they argue a faiure to provide social constituents of health and support is a significant factor in the increased requests for 'medical aide in dying.' (1) It is hard to credit their conclusions on either point.
  As they note, 2016 legislation legalized 'medical assistance in dying" in cases of serious and incurable illness, disease or disability in an advanced state of decline with death an inevitable and foreseeable conclusion. But as they note (pg. 3-4) new legislation has broadened those criteria to include those with 'disabilities' whose death is not reasonably foreseeable as well as others with chronic, non-progressive disorders including mental illness. Indeed, enui seems to now be an acceptable rational for termination among even those without serious chronic illnesses or disorders. (2)
  That is precisely the definition of the slippery slope, a narrow framework of action is broadened to include ever larger classes of peoples.
  Similarly, they give short-shirt to the issues of the social constituents of health, ignoring the complex of predicate failures that may lead one to seek a rapid death. These include the limited availability of expert palliative care, the shortage of hospices across Canada's provinces, and in each provincial health system the limited availability of those resources and the rehabilitative, psychological and social facilities that may make a life lived with chronic conditions meaningful and sustainable.
  As a Canadian long engaged in this debate--legal and social--as well as in the care of those with chronic conditions I thus find their arguments incomplete and their conclusions inaccurate. I would, of course, be more than willing to debate their argument in person or in this, or another journal.

  Tom Koch
  The University of British Columbia, VAncouver, BC, Canada.
  Alton Medical Centre, Toronto, ON, Canada.

  1. Downie J. and Schudklienk U. Social determinants of health and slippery slopes in
  assisted dying debates: lessons from Canada. J Med Ethics 2021. doi:10.1136/medethics-2021-107493.
  2. Koch T. Old age alone shouldn’t be considered a justification for physician-assisted death. Globe and Mail 2018 (April 18). https://www.theglobeandmail.com/opinion/article-old-age-alone-shouldnt-b....

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  Conflict of Interest:
  None declared.

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