A right at the end: Dignity, autonomy, and the case for assisted voluntary euthanasia | Andrew Sciberras

The government’s public consultation on Voluntary Assisted Euthanasia (VAE) has prompted passionate and polarised responses. That is understandable. The subject touches on life, death, suffering, autonomy, and the moral fabric of our society. But if ever there were a moment to speak honestly and listen humbly, it is now.

The current proposal invites public feedback on the legalisation of assisted dying for competent adults who are terminally ill and have six months or less to live. Furthermore, it would apply only to individuals who have been continuously residing in Malta for not less than 12 months. It also makes clear that VAE would not be extended to persons living with disabilities, chronic conditions, or mental health disorders such as dementia. The scope is narrowly defined, applying only to those already in the final stages of terminal illness.

Some argue that discussing assisted dying is premature or even dangerous. Others insist that Malta must first build a world-class palliative care system before considering VAE. I respectfully disagree.

Let us begin with what unites us: the belief that no one should face their final days in agony or abandonment. I think we all agree that Malta’s palliative care framework does require further investment and accessibility. We rely too heavily on the charitable services of exceptional NGOs like Hospice Malta, Dar Bjorn, and Dar tal-Providenza. The state must step up, and step in. Encouragingly, important steps have already been taken: the government continues to support Hospice Malta through long-standing service agreements and has co-funded the newly inaugurated St Michael Hospice in Santa Venera.

And yet, even with the best intentions, palliative care alone cannot meet every need. To suggest it is a substitute for VAE is, in my view, both ethically and practically flawed. Even in countries with the highest standards of end-of-life care, there are limits to what can be achieved. We needn’t look very far: Malta’s oncology system was recently lauded by the European Commission as a European best practice - yet even this best of care that we provide cannot eliminate all suffering. Some suffering cannot be alleviated by morphine or sedation. Some patients, lucid and competent, do not wish to be sedated into oblivion. Others, like my late mother Rose who endured the agony of a terminal illness, simply want to die on their own terms, in their own space, without tubes, monitors, or institutional walls. They wish for peace, not prolongation.

For those who are morally opposed to assisted dying, that view must be respected. No doctor or healthcare professional should ever be compelled to participate. But in a pluralist, democratic society, no single moral or religious viewpoint should determine the legal rights of all.

This brings us to the heart of the matter: dignity through autonomy. In the advanced stages of terminal illness, when death is no longer a question of if, but when, the question becomes how. Autonomy means recognising that competent adults should have the legal right to decide how they face their final hours. It does not mean compelling anyone to choose death. It means giving each person the dignity of choice.

Regrettably, this distinction between coercion and self-determination, is often lost in the moral debate. VAE is not killing, nor is it suicide in the traditional sense. Killing is a violation of another’s will and is always wrong. Suicide is often rooted in mental illness or despair. VAE, by contrast, is a conscious and deliberate decision made by a competent person who is already in death’s embrace. It is not about ending life for its own sake. It is about release when death is already at the door.

That distinction was acknowledged in a landmark 2019 ruling (Judgment No. 242/2019) by Italy’s Constitutional Court, which held that assisting a person in ending their life should not be considered a crime when that person is irreversibly suffering, fully competent, and reliant on life-sustaining treatment. The judgement affirmed that the law must give way to dignity and free will when death is near and suffering beyond relief.

VAE, therefore, is not a rejection of life. It is an affirmation that when life becomes prolonged suffering, it should not be preserved at all costs, especially against the wishes of the person living it. Indeed, we already allow patients to refuse life-sustaining treatment. We already acknowledge the right to a passive death. The potential legalisation of VAE would simply recognise that, in rare and tightly regulated cases, an active, peaceful, medically assisted death is a compassionate and dignified alternative.

Yes, any potential law must protect the vulnerable. But it must also respect the will of the competent and suffering. Safeguards must be in place. But they should not be so burdensome as to deny the very relief they are meant to protect.

For those who are morally opposed to assisted dying, that view must be respected. No doctor or healthcare professional should ever be compelled to participate. But in a pluralist, democratic society, no single moral or religious viewpoint should determine the legal rights of all.

And let me also be clear on this point: VAE is not something that can be imposed. It is a deeply personal decision, and it must originate from the patient and the patient alone. Not from the family, not from the doctor, not from the state. Any future legislation must ensure that no suggestion, pressure, or influence is exerted. Any form of coercion will not only invalidate the process but will constitute a criminal offence.

This consultation is not about glorifying death. It is about recognising that in the face of irremediable suffering and imminent death, a peaceful end should not be illegal.

Dignity is not a luxury. It is a right. And it must be protected not only in life, but in death too.