Information on the current situation
In collaboration with LovinMalta, the Malta Humanist Association created this video to explain the Humanist view on assisted dying.
Assisted Dying in Malta
The term ‘Assisted Dying’ covers both active euthanasia and assisted suicide:
- active euthanasia is the administration of a lethal drug to a patient by a doctor because the patient is terminally ill or incurably suffering. Voluntary active euthanasia requires the patient’s consent;
- assisted suicide is the intentional provision to a person, at their request, of the knowledge, means, or both, required to commit suicide. Physician-assisted suicide involves such actions by a doctor. (We have found no jurisdictions where assisted suicide by other than a doctor is legal when physician-assisted suicide is not.)
By contrast, withholding or withdrawal of medical treatment, and palliative sedation (even if relieving a patient’s distress might indirectly shorten their life), sometimes collectively called passive euthanasia, are not generally viewed as Assisted Dying, but as ways to make a patient as comfortable as possible, avoiding fruitless interventions and suffering, and allowing them to die peacefully, rather than causing them to.
What is the current legal situation in Malta?
- active euthanasia is illegal, and assisting a suicide is a crime punishable by up to 12 years in prison;
- PM Robert Abela announced November 2022 that the government will take a decision on the legalisation of voluntary euthanasia by the end of the current legislature (2027);
- 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
- euthanasia, assisted suicide, and legally enforceable living wills are not considered human rights under international treaties, nor by the European Court of Human Rights. But 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 & interests”;
- international human rights legislation recognises the right to life, but that does not imply a duty to live under any circumstances.
How does society feel about it?
- According to a 2021 study, a small majority in Malta (52.6%) support the right to legally end one’s life if terminally ill and suffering, reflecting a shift in public opinion over recent years, as found in earlier polls. The study also found that 88% believe the subject should be discussed nationally.
Amongst Maltese youth, including law and medicine students, euthanasia is becoming more acceptable than among older generations. 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).
How do doctors feel about it?
- In a 2016 survey of 350 doctors, over 90% said they were against euthanasia, but 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”.
Where do political parties in Malta stand?
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.
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.
Of course, as was the case in the divorce debate, and currently in the abortion debate, there are those who do not follow the stand taken by the political party they belong to or usually vote for.
A Humanist View
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. Justice and compassion require the ending of suffering if that is what a patient wants. Humanists Malta supports bodily autonomy, meaning that people should have the right to choose the manner and timing of their own death – although strict monitoring, regulation and safeguards are necessary to avoid any abuse or uncertainty.
A general prohibition on Assisted Dying binds all, patients and medical professionals alike, to one view. Legalisation, for those who want 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 so far been little evidence of significant abuse in countries where 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 Assisted Dying with or without regulation.
And 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, quality of life, and dignity, regardless of their level, or lack of, of pain.
Finally, there must be clear legislative provisions on conscientious objection to Assisted Dying. We do not agree that a doctor should make moral judgements on behalf of a patient, but on the other hand recognise that medical professionals have their own human rights.
Assisted Dying in the rest of the world (at January 2023)
Legislation, and criteria, vary, but forms of Assisted Dying are legal in a number of countries:
- Physician Assisted Suicide: Parts of Australia; Austria; Belgium; Canada; Colombia; Germany; Italy [but with no legislative framework]; Luxembourg; The Netherlands; New Zealand; Spain; and Switzerland;
- Voluntary Active Euthanasia: Austria; Belgium; Canada; Colombia; Germany, Luxembourg; New Zealand; the Netherlands; and Spain.
Assisted Dying is under discussion in France, Scotland, the Isle of Man and Ireland; under public consultation in Jersey; and expected to be the subject of a parliamentary inquiry I 2023 in relation to England and Wales.
Safeguards against abuse
These vary between jurisdictions, including whether available only to the terminally ill; to those ‘only’ unbearably suffering; and to those suffering from mental, rather than physical, disorders. They include:
- a request for 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 before proceeding with an assisted death. 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, Assisted Dying available only to residents;
- cases of 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.
It should not be beyond the skills of legislators and medical ethics experts in Malta to draft safeguards which adequately protect all.
Figures from around the world are hard to find and to collate, but some are available:
- more than 350 million people around the world have a legal right to die (source);
- 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);
- the most common illness of patients turning to physician-assisted suicide is cancer, often followed by ALS (eg in Oregon 77% of those electing assisted suicide 1998-2016 had cancer, 8% ALS). Similar cancer rates among patients deciding on assisted suicide were Belgium 69%; Canada 63%; Netherlands 71%; & US states of California 68%; Colorado 64%; Vermont 83%; & Washington 72% (source);
- 2018, in countries where either is legal, they were responsible for only between 0.3% & 4.6% of deaths, over 70% of which related to cancer (source);
- figures from Switzerland show those living in the country who underwent assisted suicide rose from 187 2003 to 965 2015 (source), and in 2019, 1,196 people overall died with assistance there; (source)
- according to Dignitas, 221 travelled there for assisted suicide in 2018: 87 from Germany, 31 France & 24 UK (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.
Investigations on the impact of Assisted Dying
- 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.’
Assisted Dying services in the EU for Maltese residents (at January 2023)
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.