The paradox of euthanasia and palliative care

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 palliative care as a key component of the country’s healthcare system, with an emphasis on primary healthcare as well as community 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 ultimate 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 euthanasia. Through an expansion and improvement 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 answers to these two questions show an interesting 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 elderly patients’ anxieties about death, may have chosen to give them false hopes and treatments that actually shortened lives instead of improving them.

Older persons are among the most vulnerable 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 families have become increasingly independent of them and the scope of references to the future has progressively narrowed.

Paradoxically, humankind is still discussing 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 towards 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 burdensome or experimental treatments that may have a very low success rate. If people insist that everything be done, they are likely to die in the medically confronting environment of an intensive care unit, possibly prolonging the process of dying itself.

Good palliative care helps patients and families avoid both overtreatment and neglect of treatment. It enhances patient autonomy and decision-making capacity by improving symptom control and empowering 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 present, receive the best possible relief of symptoms and, on rare occasions, deliberate palliative sedation, not terminal sedation.

They can also refuse to prolong the dying process. Ideally, this should be readily 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 emphasise the patient’s autonomy, but with euthanasia, the patient’s dying is not assisted. Rather, a doctor is required to kill the patient 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 consider euthanasia legislation before ensuring there is universal access to palliative care.