Before euthanasia, can we first talk about the introduction of a living will?

England and Wales have just passed a Bill which will make assisted dying legal.

The historic vote in Parliament saw the Bill passing by 314 to 291 votes. It will legalise the procedure for terminally ill people. It will give those with less than six months to live in England and Wales the right to an assisted death, after approval from two doctors and a panel including a psychiatrist, a social worker and a senior lawyer.

There will be safeguards and protections and criminal action will be taken against any family member found to be coercing someone to choose to hasten their own death.

The very close result indicates just how divided MPs were on this very sensitive issue. One Labour MP, who was initially against it because of his Christian beliefs, eventually changed his mind. “I believe in choice and while I believe assisted dying is not for me, it should be a choice for others,” he said.

Locally, this result will be viewed with interest as the discussion on whether to introduce a similar law to allow assisted dying (which is being called assisted voluntary euthanasia), has been no less emotional and fraught with personal appeals from both sides of the debate. Public consultation on this delicate topic is open until 2 July 2025.

This is one of those topics about which I find myself torn, and I cannot decide whether I would vote for or against. Like everyone else, I have had relatives with a terminal illness in both my immediate as well as extended family. Was it easy watching them deteriorate month by month (and sometimes even years), seeing the anguish in their eyes, knowing that they are aware of their own imminent mortality, and witnessing their silent plea to be rid of the pain and suffering? Of course not. In some cases, they even verbalised their wish: “This is not living, I am just existing, and if I cannot be cured, I don’t want to live like this anymore.”

The deep melancholy and sense of despair which sets in when one is facing endless treatments to alleviate the pain cannot be explained and I can understand that feeling of wanting it to be all over, rather than to linger for who knows how long, without any hope, losing one’s dignity and one’s independence.

And yet, I am sure we also know of people who were told they would not survive an illness, and yet they did, for many years after the initial diagnosis. They face their prognosis with determination and keep fighting. Those additional years were precious gifts, and had they chosen assisted dying, both they and their families would have been deprived of more invaluable memories. Should we be the ones to ‘play God’ and decide our own fate, or should we let nature take its course, as has always happened, for better or worse?

It’s a thorny, ethical dilemma which, unsurprisingly, arouses very passionate reactions. Yet, I feel we are jumping the gun in so many ways. Before discussing euthanasia, would it not make more sense to discuss living wills first? There is no provision at law that make living wills possible.

According to the definition adopted by the Mayo clinic: “Living wills and other advance directives include written, legal instructions that state the treatment you want for medical conditions when you’re unable to make decisions for yourself. Advance directives guide choices for healthcare professionals and caregivers in certain situations. For example, a medical team may use advance directives when you’re unable to talk and are terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.”

The importance of advance directives is that they are not only for older adults. Anyone at any age can have an unexpected accident or illness which leaves them incapacitated. Putting a living will in place is crucial in these circumstances as well.

When sudden illness or accidents hinder a person’s ability to speak up for themselves, the decision-making falls on the family and other caregivers. If these scenarios have never been discussed (and let’s face it, people rarely do talk about ‘what if something should happen?’) it can be very difficult in times of crisis to know whether one is doing the right thing and whether the wishes of the person concerned are being respected.

Even more problematic is when there are a number of relatives involved—usually the children of the patient—and they cannot agree on the way forward. Does the patient want to go to a care home for long-term care, or would they prefer a live-in carer to remain in their own home?  Sometimes, these wishes would have been verbalised over the years, but think how much better it would be if there were clear written instructions, which no one could dispute. Ideally, there should also be funds specifically set aside for this purpose with a power of attorney already in place so that relatives do not have to grapple with this legal issue at a time when they are also dealing with the health concerns of their loved one.

Living wills in other countries also cover medical decisions such as what type of palliative treatment you would like, whether you prefer to die at home and how you wish to manage your pain. They then go into the more ethical aspects such as whether to be put on a mechanical ventilator, and more definitive instructions such as Do Not Resuscitate (DNR), and Do not Intubate. The list of advance directives which one can put into place is long and covers a wide range of healthcare situations so they are impossible to reproduce here. For now, none of these are possible here, of course, unless the assisted dying law is passed.

If one wants to really take it further, one can also go into more specifics, such as what type of funeral one wants, or whether one prefers cremation. I’m being morbid, I know, but being in close proximity to illness makes one hyper aware of these things, and inevitably you realise how important it is to prepare for the unexpected. No one wants to think about these things, of course; in fact, most people push the prospect of their own mortality, or of being unable to make their own decisions, to the back of their minds and think, I’ll get round to it, but not just yet, there’s still time.

Unfortunately, losing one’s independence and being rendered frail and vulnerable is not something any of us wish to contemplate, especially when we have seen with our own eyes what the ravages of time and illness have done to our own elderly relatives. And, also unfortunately, while living wills and directives can ensure that our wishes when it comes to our healthcare are adhered to, these directives cannot force anyone to do what they are not willing to do.

This was brought home to me recently in a comment made on Facebook, in which it was pointed out that patients who are living in care homes are frequently being accompanied to their hospital appointments, not by their loved ones, but by carers. Apart from the fact that this depletes the staff available for the rest of the care home, since one could spend as much as three hours or more at the hospital—I found it appalling that the elderly have been abandoned to such an extent. Yes, they are in a care home, because sometimes that is the best solution, but to not even go with your elderly parent to the hospital and shirk one’s responsibility “because there is a carer” is just shocking to me. I was also told that the reason this is happening so often is that the reasoning by the relatives is “that is what the carer is being paid for, it is part of their duties” (even in cases when the carer is living at home with the patient).

Again, this callous attitude is beyond the pale. Whatever happened to love and respect towards the elderly? Whatever happened to being their solace and a source of comfort in their twilight years, not out of a sense of duty or forced obligation, but simply because, they are your parents. On second thoughts, maybe I should not be so surprised, as I have seen with my own eyes the social cases abandoned at Mater Dei and Karin Grech—patients who never, ever have any visitors. They are there, at the mercy of long waiting lists, until a place opens up at a government care home.

Frankly, it is a terrible indictment that a country which used to be so caring towards its parents and grandparents, willing to care for them until the end, now just dumps them, turns away and never looks back.