• Active euthanasia is illegal.
• Suicide itself is not a criminal offence.
• Assisting a suicide is a crime punishable by up to 12 years in prison. As far as we are aware, there is no guidance or case law in Malta on when prosecution would not be in the public interest. For example, would simply being present when a suicide died, or accompanying them to an institution abroad, in both cases at their clear request, be worthy of prosecution? Such guidance is available in the UK.
• Palliative sedation and withdrawal of treatment is legal.
• Patients have the right to refuse treatment, but must be conscious to do so.
• There is no law regulating “living wills” (or “advance directives”), which would enable people to state their wishes to be respected if, for example, they are no longer able to communicate or make decisions about treatment. Read more here.
• Voluntary Assisted Dying, and legally enforceable living wills, are not considered human rights under international treaties, nor by the European Court of Human Rights. As early as 2005, UNESCO’s Universal Declaration on Bioethics and Human Rights included (Article 5) “The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests”.
• International human rights legislation recognises the right to life, but that does not imply a duty to live under any circumstances.

• According to two surveys by The Times of Malta and MaltaToday in April 2024, 61% or 62% agree euthanasia should be legal under certain conditions, with 19% or 28% opposed, albeit with differences between the generations.
• This is a marked change from previous findings. According to a 2021 study only a small majority (52.6%) supported the right to legally end one’s life if terminally ill and suffering.
• As early as 2016, euthanasia was becoming more acceptable to Maltese youth. A 2016 Għaqda Studenti tal-Liġi (Law Students Malta) survey showed approval for euthanasia among law students at 69%. Another poll the same year showed that 65.1% of those aged 18-34 agreed the state should allow terminally ill people the right to end their life (only 35.2% above the age of 55 agreed).

• In March 2024, bioethics Professor Pierre Mallia, who has written in opposition to euthanasia, acknowledged that palliative care might not be enough to ensure a dignified death in up to 20% of cases.
• However, the only wider information we have found on doctors’ views dates back to a 2016 survey of 350 doctors in which over 90% said they were against euthanasia. (Just over 50% agreed with intensifying analgesia with the possibility of hastening death, and 32.1% had withdrawn or withheld treatment to terminally ill patients). 11.9% had faced requests for euthanasia. The survey concluded that “doctors need more guidelines, both legal and moral about this subject. In the absence of this, religion and life philosophy were being used as a guide in this difficult aspect of practicing their profession”. Such calls for more guidance and legal certainty for the medical profession have continued.
• There was a difference in perspective between doctors polled in 2016, and doctors then in the making. The Malta Health Student Association said in the same year “the health care system. . .start to seriously consider the legalisation of Euthanasia as it is undoubtedly an answer to some of our critically-ill patients”.
  • Catholic doctors in Malta are bound by State Regulation to follow the doctrine of the Roman Catholic church.

• We can find no definitive statements on main parties’ agreed positions, but it seems that, so far, the only party supporting legalisation of any form of Assisted Dying is VOLT.
• Labour Party
  • In March 2024 Health Minister Joe Etienne Abela supported ‘doctor-assisted dying’ for the terminally ill, in extreme pain, where palliative care is unsuccessful.
  • In November 2022 PM Robert Abela said the government will take a decision on the legalisation of voluntary euthanasia by the end of the current legislature (2027).
  • In 2020, PL deputy leader Daniel Micallef said he would be campaigning for the legalisation of euthanasia. And according to a non-exhaustive report 2020, some individual PL MPs would support it.
  • In 2017, PL youth branch Forum Żgħazagħ Laburisti said it favoured legalisation of euthanasia.
• Nationalist Party
  • In 2022 PN party leader Bernard Grech said he was against it becoming an electoral issue, but it merited discussion.
  • In 2017 the PN opposed legalisation of euthanasia.

Humanists generally agree that our lives are our own, not a gift from, nor owing anything to, a higher power, and we should be free to decide our own destiny and life-experience, provided that does not result in harm to others.

Humanists Malta supports people’s right to choose the manner and timing of their own death if circumstances warrant it. But strict monitoring, regulation and safeguards are necessary to avoid any abuse or uncertainty.

A general prohibition on Voluntary Assisted Dying binds all, patients and medical professionals alike, to one view. Legalisation, for those relatively few who need it, would enable people, and the medical profession, to act on their own conscience. Voluntary Assisted Dying cannot, by definition, legally be imposed on patients who disagree with it; the sanctity of life for those who believe in it and want to live must not be in question.

There has been little evidence of significant abuse in countries where Voluntary Assisted Dying is legal (see dedicated point below), although some cases have arisen, including in relation to a patient’s mental capacity to choose, and failure of monitoring, which only underlines the crucial need for careful legislation and strict enforcement, especially to protect vulnerable groups such as the elderly, poor, and disabled.

But the possibility of abuse of a legal right does not justify withholding that right for all; for example, adults’ rights to drive are open to abuse (by recklessness, or under the influence of alcohol or drugs) are not withheld until they commit such abuse.

It is unlikely that covert forms of Assisted Dying will not occur where they are illegal. And abuse will almost certainly happen in any event; the choice is between Voluntary Assisted Dying with or without regulation.

Voluntary Assisted Dying is not inconsistent with palliative care. But, while any future improvements in palliative care are to be welcomed, and palliative care has a crucial role at the end of life, it is not the answer for those terminally ill or incurably suffering who have a clear and positive wish (rather than a momentary response to an unbearable situation) that their body should not be kept functioning when they are without independence, hope of relief, quality of life, and dignity.

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 proven decision (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.

• A UK House Of Commons Committee Report in February 2024 identified:
  • 17 jurisdictions (not necessarily countries) where Voluntary Assisted Dying is legal only on the basis of a terminal diagnosis. These include, for Physician Assisted Suicide, parts of Australia; Austria; Belgium; Canada; Colombia; Germany; Luxembourg; The Netherlands; New Zealand; Spain; and Switzerland. And for Voluntary Active Euthanasia, Austria; Belgium; Canada; Colombia; Germany, Luxembourg; New Zealand; the Netherlands; and Spain. In these jurisdictions:
    • 2 medical professionals must agree that the applicant fulfils eligibility criteria, including that they are expected to die within a specific time (all within 12 months of the request) from a terminal illness.
    • Voluntary Assisted Dying is not available to under 18s, and there are no grounds of mental illness or disability.
    • There is a range of safeguards, including a requirement for the applicant to make repeated requests, multiple assessments over time, and a cooling-off period between the request and its fulfilment.
  • Nine jurisdictions where Voluntary Assisted Dying is legal on the basis of much wider of criteria, such as intolerable suffering (physical or mental).
  • Four jurisdictions where Voluntary Assisted Dying is not illegal, or there is ongoing case law.

• At May 2024, other parliaments are currently moving towards Voluntary Assisted Dying: 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 Voluntary Assisted Dying via the EU Charter of Fundamental Rights (although legislation would remain within the competence of individual member states). It can be found here.

These vary between jurisdictions, but include:

• a request for Voluntary Assisted Dying must be expressed, not implied, voluntary, well-considered, informed, persistent over time (eg at least a month between initial and further requests), and revokable at any time, in any manner;
• requesting persons who had previously told their family of their wishes, but had not formalised them, are not covered;
• if there are any doubts amongst the doctors involved about a patient’s emotional or psychological capacity to make an informed, clear choice, a psychiatrist must confirm such capacity;
• tightly-policed protocols requiring 2 independent witnesses able to confirm the request was made willingly and free of coercion. Neither witnesses nor health professionals involved may have any legal, financial or other interest in the outcome;
• two doctors, independent of each other (eg not one working for the other; from different medical teams) and trained in medical ethics, must separately give written agreement the patient has an incurable, grievous and irremediable condition;
• there should be agreement by at least a second (if not third) doctor that all criteria have been met. The second and/or third doctor must be independent (not involved with the care of the patient) and trained to ensure the patient is informed of all options, including the benefits of palliative care;
• an age limit, often not below 18 years;
• to prevent ‘suicide tourism’, Voluntary Assisted Dying available only to residents;
• cases of Voluntary Assisted Dying must be reported to a central body following the procedure;
• health professionals have the right to conscientious objection to any involvement in Assisted Dying.

Serious debate is required about all the practical implications of a legal regime; how to formulate a structure which permits Voluntary Assisted Dying for those whose personal circumstances and beliefs warrant it, while safeguarding against abuse of those unable to freely decide for themselves. Some of the salient questions:

• Eligibility Should Voluntary Assisted Dying 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 able to choose Voluntary Assisted Dying? And should the definition of suffering be restricted to physical pain?
• How to ensure no coercion of the vulnerable (eg 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 Voluntary Assisted Dying are freely made, when mentally competent, considered, & sustained over time? On coercion, evidence, for example from the UK enquiry mentioned above 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 by professional experts should halt the process. Truly independent witnesses, and trained experts, can be called. Regulatory bodies can be established. Should those of demonstrably sound and independent 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? For some, Voluntary Assisted Dying 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; Voluntary Assisted Dying cannot, by definition, legally be imposed on patients who disagree with it. But a patient’s right to choose must not be hampered by those who would not make that choice for themselves or others.
• How should conscientious objection to Voluntary Assisted Dying be addressed? We do not agree that a health professional should make moral judgements on behalf of a patient, but of course recognise that such professionals have their own human rights. Legislative provisions on conscientious objection to Voluntary Assisted Dying by health professionals in Malta must be clear, carefully balanced, and supported by comprehensive subsidiary guidance, for example on a duty to refer to a non-objecting doctor.

Figures from around the world are hard to find and to collate, but some are available:

• It is reported that, internationally, some 400 million have access to some form of Voluntary Assisted Dying legislation.
• By far the most common illness of patients turning to physician-assisted suicide is cancer.
• Assisted Dying accounts for 1.12% of deaths in Canada, where the vast majority have an assisted death because they’re less able to engage in enjoyable life activities (82.1%), are in severe pain (56.4%), or worried about loss of dignity (53.3%) (source);
• In Oregon, on average a third of people approved for assisted deaths don’t take their life-ending medication. In most cases, because having the security of knowing they can end their suffering if it ever became too much to bear is enough (source);
• Nearly 800,000 commit suicide every year (approximately 1.4% of deaths worldwide); physician-assisted suicide is typically less than ½% of all deaths (source).

Euthanasia and assisted suicide are undoubtedly on the increase where they have been legalised.

• Netherlands: a gradual increase starting in 2007 saw the number of Assisted Dying cases climb to 6,585 cases in 2017, 4.38% of total deaths (about 96% of cases involved euthanasia, with less than 4% assisted suicide) (source);
• Belgium: federal data shows 2,655 cases reported in 2019, an increase from 2,357 cases recorded in 2018, 2.1% of all deaths (source)
• Oregon (where a requirement is a maximum life expectancy of 6 months): frequency of assisted deaths is increasing at a much lower rate than in the Netherlands, currently less than 10% of Dutch numbers (source);
• Switzerland (where assisted suicide is tolerated without legal safeguards or monitoring): the rate of increase in assisted suicides is similar to Belgium and the Netherlands, with a frequency approaching that of Belgium (source);
• Canada (which legalised euthanasia 2016): euthanasia already represented almost 1% of all deaths in Canada in 2017 (source);
• California (which regulates assisted suicide as in Oregon): only 0.14% of deaths were by assisted suicide (source);

These figures suggest that legalising only assisted suicide, with stringent rules excluding patients not terminally ill, as in Oregon, limits the number of assisted deaths and their increase with time. The reasons for the greater increase in deaths by euthanasia, where legal, are unclear, but are not necessarily an indication of a ‘slippery slope’; it is more likely that there has always been a demand for Assisted Dying, but now it is increasingly available and visible.

• A 2007 investigation by Professor Battin et al later discussed in detail by Professor Battin focused on the impact of Assisted Dying in Oregon 1998-2006 and the Netherlands 1990-2005, and concluded that in both countries, apart from a very few suffering from AIDS, people from vulnerable groups were voluntarily accessing assisted deaths free from risk or coercion: ‘found no evidence to justify the grave and important concern often expressed about the potential for abuse—namely, the fear that legalised physician-Assisted Dying will target the vulnerable or pose the greatest risk to people in vulnerable groups [and] there is no current factual support for so-called slippery-slope concerns about the risks of legalisation of Assisted Dying – concerns that death in this way would be practised more frequently on persons in vulnerable groups.’ Battin et al, ‘Legal physician-Assisted Dying in Oregon and the Netherlands: evidence concerning the impact on patients in ‘‘vulnerable’’ groups”’
• A 2020 study on Canada’s Assisted Dying regime (MAiD – Medical Assistance in Dying) by Dr James Downar et al, current head of palliative care at the University of Ottawa, found: ‘Another common concern about the legalization of MAiD is the potential for people who face social or economic vulnerabilities to be pressured into MAiD. However, our data indicate that people from traditionally vulnerable demographic groups (from an economic, linguistic, geographic or residential perspective) were far less likely to receive MAiD, consistent with findings from the US and Europe.’ ‘…The practice of MAiD in Ontario is most common among elderly, community-residing patients with cancer, neurodegenerative disease or end-stage organ failure who are in the final months of life. Our findings that Ontario residents who received MAiD were frequently already followed by palliative care providers suggests that MAiD requests are unlikely to be the consequence of inadequate access to palliative care in Ontario. Recipients of MAiD in Ontario were younger, wealthier, more likely to be married and substantially less likely to live in an institution than the general population of decedents, suggesting that MAiD is unlikely to be driven by social or economic vulnerability.’

We have not found any EU jurisdictions where any form of Assisted Dying is effectively available to non-residents. This is why we would support the establishment of bilateral agreements with other countries to enable Maltese residents to make use of Assisted Dying clinics abroad, as a partial alternative until suitable legislation is established here.

Dignitas.