Putting choice at the heart of our care | Daniel Schembri

Daniel Schembri is a physiotherapist working in the public service

Malta is at another ethical crossroads. Fundamentally, the assisted voluntary eutha-nasia (AVE) debate boils down to whether or not we should allow individuals, who are terminally ill and suffering, the right to face their pain and death on their own terms.

As expected, the emotionally-charged debate has reignited the old fears of social col-lapse in the face of change.

The main concern voiced by the anti-choice group is that giving autonomy to an indi-vidual by legalising AVE could somehow compromise the common good.

But legalising AVE is not just about empowering the individual to have a choice. It is also about providing a legal framework that protects vulnerable people from coer-cion.

Doctors are already allowed to stop intervention, declare a patient as not being a candidate for CPR, or put a patient on a morphine pump.

Can these powers conferred to medical professionals be used abusively against vul-nerable people? Of course. Yet such practices are well established and generally un-questioned.

In light of all this, and the fact that competent adults are already allowed to refuse life-saving treatments, why can’t requesting a medically assisted death be accepta-ble? After all, patient autonomy is a cornerstone in medical ethics.

While the doctors’ oath not to cause harm is often used as justification to discredit assisted voluntary euthanasia as a form of healthcare, such a statement, devoid of context, is an unjust oversimplification of the issue at hand.

A good medical professional is not one who prolongs life at all costs, but one who takes a balanced approach that takes into account longevity, quality of life and above all, respect for the patient’s wishes. The common good is served not by denying pa-tients their right to choose, but by respecting human dignity and upholding the pa-tient’s choice, while still ensuring effective support systems, informed consent, and using all the legal tools to prevent coercion.

Another concern of the anti-choice group is that legalising AVE will impact invest-ment in palliative care. A number of medical professionals who oppose choice have also raised the issue that current palliative care in Malta is inadequate and that it is too early to legalise AVE. I am sure that whoever is against AVE because of some moral conviction, will remain against it even if the best palliative care is available.

Still, just like any other health service, there is much room for improvement when it comes to palliative care, and just as the state is duty-bound to offer a sound legal framework with effective safeguards when it comes to AVE, it is also obliged to pro-vide the best palliative care possible. Palliative care and euthanasia are not exclusive of each other, but rather work in tandem for the patient to have a full spectrum of options to choose from.

An article published in the Journal of Medical Ethics in 2015 entitled Does Legal Phy-sician-assisted Dying Impede Development Of Palliative Care? states that the Neth-erlands and Belgium invested more in palliative care after legalising euthanasia.  Sim-ilarly, the Third Annual Report on Medical Assistance in Dying in Canada, 2021, found that 81% of patients who chose euthanasia did so after going through palliative care, and 39% of patients who were considering euthanasia, opted out as palliative care was enough.

These studies not only show that legalising euthanasia has had a positive impact on palliative care, but they are evidence that AVE and palliative care can coexist and support each other. There is no valid reason why Malta cannot achieve this goal.

The fear of introducing slippery slopes that might lead to social fallout has always characterised the debates preceding reforms. Yet, in spite of the fears expressed by those opposed to women’s suffrage in 1947, social benefits in the 1950s, divorce in 2011 and same-sex marriage in 2017, we now have a progressive society with more respect towards people’s autonomy and marginalised groups. We have an opportuni-ty to make history again.

Legalising AVE is not about choosing death over life. It is about choosing autonomy and dignity over enforced suffering. It is about putting the patient at the centre of our care by offering all possible services, instead of forcing anyone to live in agony against their will.