Issue link: https://maltatoday.uberflip.com/i/1536441
mt SURVEY maltatoday | SUNDAY • 15 JUNE 2025 11 LAST April, the health ministry launched the National Palliative Care Strategy 2025- 2035. The main objective of the strategy is to continue strengthening access to pallia- tive care as a key component of the coun- try's healthcare system, with an emphasis on primary healthcare as well as commu- nity and home care services. All persons who are in the last phase of life due to chronic conditions will now be offered a dignified service where their symptoms are totally controlled. The ulti- mate goal is for every person to live with dignity, even in this phase of life. Although not expressly stated, one of the aims of the strategy is the prevention of eu- thanasia. Through an expansion and im- provement of palliative care facilities, the strategy is trying to rule out the possibility that future requests for euthanasia might be brought about through insufficient and inadequate palliative care. The euthanasia debate is now coming to the fore. A well-considered policy about euthanasia can only be developed based on a well-developed system of palliative care. Concerning the issue of the prevention of euthanasia through palliative care, two questions need to be distinguished: Can palliative care prevent euthanasia? Should palliative care prevent euthanasia? The an- swers to these two questions show an in- teresting relationship of dependency. The National Palliative Care Strategy is implicitly enforcing the right to life and dignity in old age. Older persons have sometimes been treated like cadavers even when they were, clinically and biologically, still alive. This occurred especially in cases where they were dying or suffering from terminal illnesses, although they did not necessarily have to be in this predicament to receive degrading treatment. There was often a predisposition to treat older persons as if they were dying, regardless of how serious or irreversible their condition actually was. Doctors, uncomfortable dealing with el- derly patients' anxieties about death, may have chosen to give them false hopes and treatments that actually shortened lives in- stead of improving them. Older persons are among the most vul- nerable to death. Their position in the age structure of society becomes, almost by default, a predictor of their demise. This social construction of old age prompts a particular way of treating the elderly. The social structures in which older persons are involved are orientated to the fact of their forthcoming death when their fami- lies have become increasingly independent of them and the scope of references to the future has progressively narrowed. Paradoxically, humankind is still discuss- ing what to do about ensuring a dignified death. There is a debate about what should be protected—the conditions of death or the ability to choose when to die? I am afraid that, here in Malta, we are dangerously and recklessly moving to- wards a gradual integration of palliative care, euthanasia and physician-assisted suicide. This supposed common ground is both a contradiction in terms and perhaps even contrary to sound medical practice. Despite its inevitability, dying is not a popular topic for discussion. Death is not a medical or pharmacological event. It remains instead a profound mystery and the natural end of the complex journey of life. It is universal yet unique, personal but communal. It affects us all. Dying can be traumatic, terrifying and painful for the patient and challenging for the grieving family. In the face of inevitable death, some patients are willing to explore improbable alternative therapies or bur- densome or experimental treatments that may have a very low success rate. If peo- ple insist that everything be done, they are likely to die in the medically confronting environment of an intensive care unit, pos- sibly prolonging the process of dying itself. Good palliative care helps patients and families avoid both overtreatment and ne- glect of treatment. It enhances patient au- tonomy and decision-making capacity by improving symptom control and empow- ering patients to participate in their care. It affirms the patients' right to choose their therapy, decline futile therapy, choose the place of dying, choose who should be pres- ent, receive the best possible relief of symp- toms and, on rare occasions, deliberate pal- liative sedation, not terminal sedation. They can also refuse to prolong the dy- ing process. Ideally, this should be readi- ly available for all those with life-limiting illnesses. Legally defining euthanasia as "voluntary assisted dying" in any future law conceals the true nature of what will be proposed. The word "voluntary" attempts to empha- sise the patient's autonomy, but with eu- thanasia, the patient's dying is not assisted. Rather, a doctor is required to kill the pa- tient or to help the patient commit suicide. A person's desire for hastened death changes over time and reduces when care is good. It is illogical and immoral to even consid- er euthanasia legislation before ensuring there is universal access to palliative care. THE right to medically assisted termi- nation of life raises a number of legal and ethical issues that are controversial. It is intended to allow terminally ill patients who are enduring unbearable pain and suffering, the right to die with dignity. In the European Union this right is recognised in the Netherlands, Belgium, Luxembourg, Spain, Portugal, Germa- ny and Austria. France is currently dis- cussing a similar bill and this in a highly politically charged environment due to harsh opposition from the far right. The Terminally Ill Adults [End of Life] Bill is being currently debated in Westminster for England and Wales, whilst in Scot- land a similar bill has already received general approval from MPs. Countries which do not recognise the right, some- times have policies against the com- mencement of prosecutions in particu- larly pitiful human circumstances. The issue of euthanasia has been brewing on the back burner in Malta for some time. In 2021, I had discussions with then president of the Labour Par- ty and friend, Daniel Micallef, who is a firm believer in such a law, to push the issue forward. The matter, however, had not been mentioned as a commitment in the 2017 Labour Party electoral man- ifesto and we were practically on the eve of a general election. Subsequently, the Labour Party made a commitment in its 2022 electoral manifesto to launch a public consultation on the introduction of assisted voluntary euthanasia. The PL has kept its commitment and I thank my colleague Rebecca Buttigieg for involving me in the drafting of the White Paper. I commend her for the mature and organised way the public consultation process is being conduct- ed. I am in favour of a law that gives a per- son the choice to obtain medical assis- tance to die. The proposal is to make this available to adults who are in a terminal stage of a serious and incurable medical condition, which is inflicting physical suffering the patient cannot bear. How- ever, any law, must take a strict and reg- ulated approach and provide effective checks and balances. I am not surprised with the position taken by the Catholic Church. Its posi- tion is in accordance with its consistent teachings and doctrine. However, it is the obligation of government and legis- lators to legislate for all and make avail- able such a right to anyone of age who wants to avail themselves of it. The request for euthanasia will be ex- amined by three medical practitioners one of whom will have to be a special- ist in the treatment of the medical con- dition to which the patient is subject. These shall enquire whether the pa- tient's request is clear, informed, persis- tent and well considered. The national health system will offer the patient any palliative care as may be available, if the patient so desires. The existence of such a law does not mean that government is not to keep investing in palliative care. Government invests tens of millions of euros in palliative care and should maintain the momen- tum, more so if such a law is introduced. The medical practitioners shall draw up a report on the patient's state of health. If, from that report, it results that the patient cannot be cured; the physical suffering cannot be controlled; the patient considers such suffering unbearable; the request of the patient was made freely, clear and made in an informed manner and was properly re- flected upon; the demand of the patient is persistent; they shall send their report to a commission to be established by the law. I believe the commission should be composed of three persons—a former member of the judiciary as chairperson, a medical practitioner of good standing and a person who specialises in moral philosophy and/or medical ethics. The commission shall within a number of days accept or refuse the report. Where the commission finds that those re- quirements are satisfied and accepts the medical practitioners' report, no crimi- nal or disciplinary proceedings may be taken against any person providing such assistance. Finally, an important aspect of any proposed law should be that the patient may at any time withdraw the said re- quest, even in a verbal manner. Medical practitioners and members of the health care professions shall be free to refuse assisting someone to die but will be obliged to refer the request to another medical practitioner likely to accept to consider the request. A medically assisted death shall be considered a natural death for all intents and purposes of law and of contract. I support the introduction of a law in- tended to allow terminally ill patients who are enduring unbearable suffering to be granted the right to die with dig- nity. Edward Zammit Lewis Mark Said Edward Zammit Lewis is a lawyer and Labour MP Mark Said is a veteran lawyer The paradox of euthanasia and palliative care The right to let go with dignity