Long-term experience on assisted suicide in Switzerland: dementia, mental disorders, age-related polymorbidity and the slippery slope argument.

OBJECTIVES: According to the Swiss medico-ethical guidelines valid between 2004 and 2018, the key criterion for assisted suicide (AS) was that the patients who wished to die suffered with a disease leading to death in the foreseeable future. Critics of AS fears that broadening of the medical indications will lead to an uncontrolled expansion to persons who are not terminally ill (slippery slope argument). We evaluated to what extent this broadening took place in practice over time. STUDY DESIGN: Retrospective national cohort study. METHODS: By using data of the Swiss Federal Statistical Office, we analyzed the long-term development of AS in Switzerland over a 20-year period (1999-2018; n = 8738 cases). We classified the cases into one of three categories regarding the aforementioned key criterion for AS. RESULTS: In 43.6% of AS cases, the criterion 'end of life is near' was met. In 5.3% of cases, this criterion was not met (4.7%: mental disorders; 0.6%: dementia). In 51.1% of cases, the reason underlying AS comprised several, mostly age-related diseases and/or functional impairments; the aforementioned key criterion, however, was probably not met in most of the cases. Over time, the number of cases doubled over each 5-year period; this increase occurred similarly for the three categories. CONCLUSION: The fact that many AS cases took place outside the valid medico-ethical guidelines might be interpreted as a development in the idea of the slippery slope argument. The fact that the percentage distribution of these cases remained unchanged over time argues against it.

Saúde mental e abortamento voluntário na audiência pública da ADPF442/STF / Mental health and voluntary abortion in the public hearing of ADPF442/STF / Salud mental y aborto voluntario en la audiencia pública del ADPF442/STF

O estudo teve como objetivo identificar os argumentos da estratégia de persuasão dos discursos apresentados na audiência pública sobre a Arguição de Descumprimento de Preceito Fundamental-ADPF 442, realizada em 2018, cujo propósito era discutir sobre a interrupção voluntária da gravidez até a 12ª semana. Para tal, foi realizada uma pesquisa de abordagem qualitativa, analítico-descritiva e documental. O objeto de análise foi o registro da audiência, apresentado em vídeo, disponibilizado na plataforma digital YouTube, e em ata lavrada pelo STF, ambos de acesso público. A partir de uma análise do discurso, identificou-se os argumentos utilizados na estratégia de persuasão, que foram sistematizados em quatro categorias de argumentos para cada um dos dois grupos identificados: o grupo pró e o grupo contra a descriminalização do aborto. As três primeiras categorias, Saúde mental, Direito e Saúde pública, mesmo com diferenças na forma de apresentar o argumento, se repetem nos dois grupos. Todavia, a quarta categoria, Pressupostos, se diferenciou. No grupo pró descriminalização do aborto, apresentou-se como Pressupostos filosóficos e científicos, e no grupo contra, como Pressupostos morais. Por fim, a defesa da saúde mental das mulheres foi o principal argumento numa forma de humanizar o sofrimento vivido pelas que desejam abortar e não encontram o suporte do Estado para assegurar sua dignidade, cidadania e efetiva igualdade, garantidas constitucionalmente.(AU)

The study aimed to identify the arguments of the persuasion strategy of the speeches presented at the public hearing on the Action Against the Violation of Constitutional Fundamental Rights -ADPF 442, held in 2018, whose purpose was to discuss the voluntary interruption of pregnancy until the 12th week. To this end, a qualitative, analytical-descriptive, and documentary research was carried out. The object of analysis was the video recording of the hearing available on the YouTube platform, and in minutes drawn up by the STF, both of which are public. Based on a discourse analysis, the arguments used in the persuasion strategy were identified, which were systematized into four categories of arguments for each of the two identified groups: the group for and the group against the decriminalization of abortion. The first three categories, Mental Health, Law and Public Health, even with differences in the way of presenting the argument, are repeated in both groups. However, the fourth category, Assumptions, differed. In the group for the decriminalization of abortion, it was presented as Philosophical and Scientific Assumptions, whereas the group against, as Moral Assumptions. Finally, the defense of women's mental health was the main argument in a way of humanizing the suffering experienced by those who wish to have an abortion and do not find the support of the State to guarantee their dignity, citizenship, and effective equality, constitutionally guaranteed.(AU)

El estudio tuvo como objetivo identificar los argumentos de la estrategia de persuasión de los discursos presentados en la audiencia pública sobre el Argumento por Incumplimiento de un Percepto Fundamental -ADPF 442, realizada en 2018, con el objetivo de discutir la interrupción voluntaria del embarazo hasta la 12.ª semana. Para ello, se llevó a cabo una investigación cualitativa, analítico-descriptiva y documental. El objeto de análisis fue la grabación de la audiencia, que está disponible en la plataforma digital YouTube, y actas levantadas por el Supremo Tribunal Federal -STF, ambas de acceso público. A partir de un análisis del discurso se identificaron los argumentos utilizados en la estrategia de persuasión, los cuales se sistematizaron en cuatro categorías de argumentos para cada uno de los dos grupos identificados: el grupo pro y el grupo en contra de la despenalización del aborto. Las tres primeras categorías ("salud mental", "derecho" y "salud pública") aún con diferencias en la forma de presentar el argumento se repiten en ambos grupos. Pero difiere la cuarta categoría "supuestos". En el grupo a favor de la despenalización del aborto se presentó como "supuestos filosóficos y científicos", y en el grupo en contra, como "supuestos morales". Finalmente, la defensa de la salud mental de las mujeres fue el principal argumento en un intento por humanizar el sufrimiento que viven aquellas que desean abortar y no encuentran el apoyo del Estado para garantizar su dignidad, ciudadanía e igualdad efectiva, preconizadas por la Constitución.(AU)

[An analysis of the "slippery slope" of assisted death]. / Pendiente resbaladiza de la muerte asistida en los Países Bajos, Bélgica y Colombia.

The study analyzes the phenomenon of the "slippery slope" of assisted death in The Netherlands, Belgium, and Colombia after the depenalization or legalization of this practice. Data analysis was performed reviewing the evidence published in scientific journals and in the governments' official reports. We verified a progressive broadening of the limits initially established by the law for the practice of assisted death in these three countries. This confirms the occurrence of the "slippery slope". Also, the exponential increase in the number of assisted deaths in these three countries after the legalization indirectly suggests the presence of the "slippery slope". An analysis of the anthropological and ethical implications of assisted death highlights that its moral assessment should not be exclusively based on consequentialist arguments. Also, a prudential interpretation of the slippery slope argument in the legal debate about assisted death should be incorporated. We conclude that the moral evaluation of assisted death cannot be exclusively grounded on its negative social consequences, but rather on the lack of respect for basic human values such as life and the intrinsic dignity of a person. The verification of the "slippery slope" in these three countries should be regarded as an alarm for an eventual legalization of euthanasia in Chile.

Pendiente resbaladiza de la muerte asistida en los Países Bajos, Bélgica y Colombia / An analysis of the "slippery slope" of assisted death

The study analyzes the phenomenon of the "slippery slope" of assisted death in The Netherlands, Belgium, and Colombia after the depenalization or legalization of this practice. Data analysis was performed reviewing the evidence published in scientific journals and in the governments' official reports. We verified a progressive broadening of the limits initially established by the law for the practice of assisted death in these three countries. This confirms the occurrence of the "slippery slope". Also, the exponential increase in the number of assisted deaths in these three countries after the legalization indirectly suggests the presence of the "slippery slope". An analysis of the anthropological and ethical implications of assisted death highlights that its moral assessment should not be exclusively based on consequentialist arguments. Also, a prudential interpretation of the slippery slope argument in the legal debate about assisted death should be incorporated. We conclude that the moral evaluation of assisted death cannot be exclusively grounded on its negative social consequences, but rather on the lack of respect for basic human values such as life and the intrinsic dignity of a person. The verification of the "slippery slope" in these three countries should be regarded as an alarm for an eventual legalization of euthanasia in Chile.

Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia.

The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 15 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been refuted in this context.

Slipping on slippery slope arguments.

Slippery slope arguments (SSAs) are used in a wide range of philosophical debates, but are often dismissed as empirically ill-founded and logically fallacious. In particular, leading authors put forward a meta-SSA which points to instances of empirically ill-founded and logically fallacious SSAs and to the alleged existence of a slippery slope leading to such SSAs to demonstrate that people should avoid using SSAs altogether. In this paper, I examine these prominent calls against using SSAs and argue that such calls do not withstand scrutiny. I then identify several types of mechanisms leading to slippery slopes in real-life contexts to demonstrate that both the strength of SSAs and the justifiability of using SSAs are best assessed on a case-by-case basis. This result does not exempt the proponents of SSAs from the task of vindicating their use of SSAs. However, if correct, it undermines the often-made claim that people should avoid using SSAs altogether.

Falácia dilemática nas discussões da bioética / False dilemma in bioethics discussions / Falacia dilemática en las discusiones de bioética

Resumo O artigo objetiva explicitar o sentido e a presença da falácia dilemática na discussão bioética, quando a argumentação se reduz a duas posições antagônicas, não permitindo o debate ao eliminar soluções intermediárias. A falácia acontece na deliberação dos comitês de ética clínica ou investigativa quando os membros confundem a argumentação retórica com a demonstração lógica, desconsiderando que a solução é sempre contingente. Ela também está presente nos debates públicos da sociedade sobre desafios éticos quando os participantes não assumem perspectiva pragmática, mas defendem posição ideológica que dificulta o diálogo e a discussão de soluções consensuais, sempre passíveis de revisão. A falta de certeza e a possibilidade de rever as propostas, que dependem da referência ética necessária aos contextos, são condições hermenêuticas da racionalidade prática, retórica e pragmática, bases para uma bioética crítica.

Abstract The article aims to explain the meaning and the presence of the false dilemma in the bioethics discussion, when the argumentation is reduced to two antagonistic positions, not allowing the debate because it eliminates intermediary solutions. The fallacy occurs in the deliberation of clinical or investigative ethics committees when members confuse rhetorical argumentation with logical demonstration, not taking into account that the solution is always contingent. It is also present in society's public debates on current ethical challenges, when participants do not take a pragmatic perspective, but advocate an ideological position that hinders dialogue and discussion of consensual solutions, which can always be reviewed. The lack of absolute certainty to the contexts, with is the hermeneutical condition required by practical, rhetorical and pragmatic rationality and the basis for a critical bioethics.

Resumen El artículo tiene el objetivo de explicitar el sentido y la presencia de la falacia dilemática en la discusión bioética, cuando la argumentación se reduce a dos posiciones antagónicas, no permitiendo el debate, ya que elimina las soluciones intermedias. La falacia tiene lugar en la deliberación de los comités de ética clínica o investigativa, cuando los miembros confunden la argumentación retórica con la demostración lógica, sin tomar en consideración que la solución es siempre contingente. Ésta también está presente en los debates públicos de la sociedad sobre los desafíos éticos actuales, cuando los participantes no asumen una perspectiva pragmática, sino que defienden una posición ideológica que dificulta el diálogo y la discusión de soluciones consensuales, siempre pasibles de revisión. La falta de certeza absoluta y la posibilidad de revisión de las propuestas, que dependen de la necesaria referencia ética a los contextos, condición hermenéutica exigida por la racionalidad práctica, retórica y pragmática, bases para una bioética crítica.

The psychological slippery slope from physician-assisted death to active euthanasia: a paragon of fallacious reasoning.

In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common logical argument regularly employed against these practices is the "slippery slope argument." One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a "slippery slope" into acceptance of active euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that warp a society's values and moral perspective of a practice over an extended period of time. This formulation is known as the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that practice physician-assisted death and/or euthanasia, the paper argues that (1) employing the psychological slippery slope argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice, and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death.

When slippery slope arguments miss the mark: a lesson from one against physician-assisted death.

In 1989, Susan Wolf convincingly warned of a troublesome consequence that should discourage any movement in American society towards physician-assisted death-a legal backlash against the gains made for limiting life-sustaining treatment. The authors demonstrate that this dire consequence did not come to pass. As physician-assisted suicide gains a foothold in USA and elsewhere, many other slippery slope arguments are being put forward. Although many of these speculations should be taken seriously, they do not justify halting the new practice. Instead, our courts, regulatory agencies, journalists, professional organisations and researchers should carefully monitor and study it as it unfolds, allowing continuous improvement just as our society has done in implementing the practice of limiting life-sustaining treatment.

Support for Voluntary Euthanasia with No Logical Slippery Slope to Non-Voluntary Euthanasia.

This paper demonstrates that acceptance of voluntary euthanasia does not generate commitment to either non-voluntary euthanasia or euthanasia on request. This is accomplished through analysis of John Keown's and David Jones's slippery slope arguments, and rejection of their view that voluntary euthanasia requires physicians to judge patients as better off dead. Instead, voluntary euthanasia merely requires physicians to judge patients as within boundaries of appropriate deference. This paper develops two ways of understanding and defending voluntary euthanasia on this model, one focused on the independent value of patients' autonomy and the other on the evidence of well-being provided by patients' requests. Both avoid the purported slippery slopes and both are independently supported by an analogy to uncontroversial elements of medical practice. Moreover, the proposed analyses of voluntary euthanasia suggest parameters for the design of euthanasia legislation, both supporting and challenging elements of existing laws in Oregon and the Netherlands.

Does the hormone "endogenous ouabain" exist in the human circulation?

Studies in the early 1990s suggested that a hormone identical to ouabain or an isomer of ouabain is secreted by the adrenal glands into the circulation and plays a role in the regulation of arterial pressure and cardiac and renal function. This hormone, known as endogenous ouabain (EO), was claimed to contribute to the pathophysiology of a number of disorders including heart failure, renal failure, pregnancy-induced, and essential hypertension. However, some research groups have been unable to confirm the presence of EO in the human circulation and the issue remains in dispute. In that the implications are of considerable importance to clinicians who, like the authors, lack biochemical expertise, it would be useful if the dispute could be addressed by disinterested scientists with long-standing and acknowledged expertise in analytical chemistry who could opine as to whether the evidence is, or is not, sufficient to state categorically that EO does (or does not) exist in the circulation in man. This brief review does not present new data but, rather, recommends that adjudication is needed regarding this important issue. © 2018 BioFactors, 44(3):219-221, 2018.

Perícia ou imperícia: laudos da justiça do trabalho sobre LER/Dort / Expertise or malpractice in Labour Justice on RSI

Introdução: O Código de Processo Civil determina que nos processos judiciais em que a matéria depender de conhecimento técnico ou científico, o juiz será assistido por perito, que produzirá um laudo. Foram analisados 83 laudos de processos judiciais do Tribunal Regional do Trabalho da 2ª Região (TRT-2), referentes a reclamantes com Lesões por Esforços Repetitivos ou Distúrbios Osteomusculares Relacionados ao Trabalho (LER/Dort), que abrangem afecções crônicas do sistema musculoesquelético de origem ocupacional e são decorrentes, dentre outros motivos, da execução de movimentos repetitivos por tempo prolongado e sobrecarga estática, sem que haja tempo para uma recuperação fisiológica. Deveriam abordar os vários aspectos do adoecimento para auxiliar a decisão judicial quanto à existência de agravo à saúde relacionado ao trabalho, assim como sua extensão e repercussões sobre a vida e capacidade laboral do trabalhador. Objetivos: Identificar e analisar, nos laudos, conceitos sobre adoecimento ocupacional e incapacidade laboral, bem como as principais linhas de argumentação, para a descaracterização do nexo causal nos casos em que havia nexo causal presumido pelo critério epidemiológico. Material e método: O material de estudo (83 laudos) foi buscado dentre os processos arquivados no período de 2012 a 2016 na Coordenadoria de Gestão de Arquivo do TRT-2, que abrange 30 municípios da região metropolitana de São Paulo e Baixada Santista. Atributos associados aos grandes temas da pesquisa foram codificados com o objetivo de melhor sistematização para uma análise de conteúdo. Resultados: Os laudos periciais foram elaborados, na sua quase totalidade por médicos, dentre os quais 56 (67,47%) médicos do trabalho, 13 (15,66%) médicos sem especificação de especialidade, 9 (10,84%) médicos com especialização em perícia ou legistas e 4 ortopedistas (4,82%). Um deles (1,21%) foi elaborado por fisioterapeuta. Do total de laudos, 25 (30,12%) não tinham quaisquer informações sobre o processo de adoecimento e apenas 23 (27,71%) contemplaram uma história clínica abrangente. Em 34 (40,96%) não havia qualquer informação sobre as características da atividade de trabalho e em 30 (36,15%) havia a citação de alguns aspectos biomecânicos. Apenas 19 (22,89%) apresentaram uma análise da atividade de trabalho, incluindo aspectos biomecânicos e organizacionais. Nenhum laudo continha uma análise da incapacidade para o trabalho de forma ampla, sendo que em 50 laudos (60,24%), o perito considerou apenas o diagnóstico para se pronunciar sobre a incapacidade. Do total dos laudos, apenas 13 (15,66%) utilizaram o conceito de multicausalidade e 12 (14,46%) o de concausalidade. Dos 15 laudos com nexo causal presumido pelo critério epidemiológico, descaracterizados no caráter ocupacional na perícia, nenhum continha uma análise da atividade de trabalho, embora 9 deles tenham utilizado argumentos biomecânicos, 8 tenham utilizado o argumento de que se tratava de doença degenerativa e 3 de que o quadro era de fibromialgia não ocupacional. Foram discutidos conceitos de adoecimento ocupacional, nexo causal e incapacidade, além da relação de desigualdade, presenteísmo, individualização do adoecimento e culpabilização. Conclusão: A maioria dos laudos periciais peca pela falta de consistência conceitual, metodológica e argumentos fundamentados, deixando lacunas na área clínica, na análise da atividade de trabalho e na avaliação de incapacidade

Introduction: The Civil Code Procedure determines that in judicial proceedings in which the matter depends on technical or scientific knowledge, the judge will be assisted by experts, who will produce a forensic report. A total of 83 reports, from the Regional Labor Court of the 2nd Region (TRT-2), were analysed, concerning claimants suffering from Repetitive Strain Injury or Work-Related Musculoskeletal Disorders (RSI/WRMD), which include occupational chronic conditions of the musculoskeletal system, that are due, among other reason to the execution of repetitive movements for a prolonged time and static overload without pause foa a physiological recoevery. They should address the various aspects of illness in order to assist the judge in his decision regarding the existence of as aggravated health related to work, as well as its extent and repercussions on the life and work capacity of the worker. Objectives: To identify and analyse concepts about occupational illness and disability to work, expressed in the reports, as well as the main lines of argument, for the de-characterization of the causal nexus in cases where there was causal nexus presumed by the epidemiological criterion. Material and method: The study material was searched from the archived processes from 2012 to 2016 in the File Management Coordination of TRT-2, which covers 30 municipalities in the metropolitan region of São Paulo and Baixada Santista. Attributes associated with the major themes of the research were codified with the aim of better systematization for a content analysis. Results: The expert reports were elaborated almost entirely by physicians, among them 56 (67.47%) occupational physicians, 13 (15.66%) doctors without a declared specialty, 9 (10.84%), forensic doctors, 4 orthopedists (4,82%). One of the reports (1.21%) was elaborated by a physiotherapist. Of the total reports, 25 (30.12%) did not have information about the illness process and only 23 (27.71%) contemplated a comprehensive medical history. In 34 (40.96%) there was no information about the characteristics of the work activity and in 30 (36.15%) there were citation of some biomechanical aspects. Only 19 (22.89%) presented an analysis of the work activity, including biomechanical and organizational aspects. No report contained an embrancing analysis of disability to work comprehensively, and in 60.24% of them, the expert considered only the diagnosis to pronounce on the disability. Of the total reports, only 13 (15.66%) used the concept of multicausality and 12 (14.46%) the concept of concausality. Of the 15 reports with a presumed causal nexus by the epidemiological criterion, which were not characterized in the occupational character, none contained an analysis of the work activity, although 9 of the 15 reports used biomechanical arguments to de-characterize the occupational character, 8 used the argument that it was degenerative disease and 3 that the condition was non-occupational fibromyalgia. Concepts of occupational illness, causal nexus and disability were discussed, as well as the relationship of inequality, presenteism, individualization of illness and blame. Conclusions: Most of the expert reports are lacking in conceptual, methodological and reasoned arguments, leaving relevant gaps in the clinical area, in the analysis of the work activities and in the assessment of disability

Argumentos para la necesaria regulación de la gestación por sustitución / Arguments for the need to regulate surrogacy

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The Slippery Slope Argument in the Ethical Debate on Genetic Engineering of Humans.

This article applies tools from argumentation theory to slippery slope arguments used in current ethical debates on genetic engineering. Among the tools used are argumentation schemes, value-based argumentation, critical questions, and burden of proof. It is argued that so-called drivers such as social acceptance and rapid technological development are also important factors that need to be taken into account alongside the argumentation scheme. It is shown that the slippery slope argument is basically a reasonable (but defeasible) form of argument, but is often flawed when used in ethical debates because of failures to meet the requirements of its scheme.

Value-impregnated factual claims and slippery-slope arguments.

Slippery-slope arguments typically question a course of action by estimating that it will end in misery once the first unfortunate step is taken. Previous studies indicate that estimations of the long-term consequences of certain debated actions, such as legalizing physician-assisted suicide, may be strongly influenced by tacit personal values. In this paper, we suggest that to the extent that slippery-slope arguments rest on estimations of future events, they may be mere rationalizations of personal values. This might explain why there are proponents even for strikingly poor slippery-slope arguments.