Not if, but when and how: Considerations for the euthanasia debate | Christian Colombo, Joanna Onions

Unlike abortion, polls have been showing that the majority of Maltese have been consistently in favour of euthanasia since at least 2016. According to recent surveys, opposition to assisted dying amongst the population of Malta has shrunk to around 18%, albeit with differences between the generations.

The generally accepted moral idea seems to follow the principle that as long as the person is not coerced into making the choice, incurably suffering individuals should be allowed to end their lives.

We welcome this news, as we believe in individual autonomy, human dignity, and quality – rather than quantity – of life, and ask for the right to choose, for those relatively few who want it. To be clear, we are talking here about what is often termed as voluntary assisted dying (VAD) – presupposing the patient’s consent, including both voluntary active euthanasia and physician-assisted suicide.

As argued by so many who have faced the prospect of their own lingering death, a terminally ill person seeking VAD is not choosing between living and dying, but between two different ways of dying; either drawn-out and undignified, with all quality gone, or peacefully and when they are ready.

Justice and compassion require the ending of suffering if that is what a patient decides; and an individual’s right to choose must not be hampered by those who wouldn’t make that choice for themselves or others.

A general prohibition on VAD binds all, patients and medical professionals alike, to one view. Legalisation, for those who want it, would enable people, and the medical profession, to act on their own conscience, and would be a recognition of both the limits of current medical capabilities, and the nature of palliative care, however much it might be capable of improvement in the future.

We welcome the recent acknowledgment by bioethics Professor Pierre Mallia that palliative care might not be enough to ensure a dignified death in up to 20% of cases. This seems to be echoed by Health Minister Jo Etienne Abela, who recently said he supports doctor-assisted dying for the terminally ill, in extreme pain, where palliative care is unsuccessful.

More and more it feels that it is no longer a question of if, but when and how, VAD will be introduced. It is therefore crucial that a serious debate tackles important questions surrounding the principle. The debate must be about the practical implications; how to formulate a regime which permits VAD for those whose personal circumstances and beliefs warrant it, while safeguarding against abuse of those unable to freely decide for themselves. Here we propose some of the salient questions:

What should be the eligibility criteria?

Should VAD be strictly limited to those who are suffering without any hope of relief? Would patients with a terminal illness, even if not in unendurable pain, also be allowed to choose VAD?

And should the definition of suffering be restricted to physical pain?

Internationally, 370 million have access to some form of VAD legislation, and the great majority of legally assisted deaths worldwide are, understandably, related to cancer. According to a UK parliamentary enquiry, published in February, there are 17 legal jurisdictions (not necessarily countries) where VAD is legal only on the basis of terminal diagnosis; nine where VAD is legal on the basis of wider criteria such as intolerable suffering (physical or mental); and four where VAD is not illegal, but unregulated.

How do we ensure no coercion of the vulnerable, by greedy relatives, or a health-care system under pressure in the financing of long-term cases? What safeguards are necessary to ensure requests for VAD are freely made, when mentally competent, considered, and sustained over time?

On coercion, evidence, for example from the UK enquiry, suggests it is extremely rare, and that, with proper regulation, it can be prevented - as far as any crime can be.

Mental capacity can be tested, but any doubt should halt the process. Truly independent witnesses, and trained experts, can be called. Regulatory bodies can be established. Should those of demonstrably sound mind, but in anguish, be left to suffer because of a hypothetical risk, which can be controlled, to the few?

How do we reconcile religious beliefs with those who don’t share them? How should conscientious objection to VAD by medical professionals be addressed in a legal regime?

For some, VAD is against their religious beliefs, but the sanctity of life for those who believe in it, and want to live as long as possible, is not in question. VAD cannot, by definition, legally be imposed on patients who disagree with it. Conscientious objection by doctors in Malta (bound, if Catholic, by State Regulation to follow the church’s doctrine) must be addressed, and balanced, carefully.

Other parliaments are currently moving towards VAD: the French government has recently introduced a bill to legalise it; a parliamentary committee in Ireland is recommending legalisation; and private member’s bills in the Isle of Man and Scotland have strong local support.

At the European level, a group of 28 NGOs, including Humanists Malta, has launched a petition to the EU parliament seeking to establish the principle of the right to VAD via the EU Charter of Fundamental Rights (although legislation would remain within the competence of individual member states). It can be found here: https://eumans.eu/voluntary-assisted-dying-fundamental-human-right.

This is never going to be an easy subject, but it cannot be beyond the skills of legislators to construct a regime which caters for those with a clear and proven freedom of choice, no hope of relief, no dignity, no quality of life, and a documented wish (including, for example, by the registration of a legally-binding Living Will) to die on their own terms.

A regime which must include carefully scrutinised safeguards, and strict rules which both guide and protect patients, medical professionals, and families.