Many European nations, more so those from the north, place a great deal of importance on the value of autonomy and the right of every patient to have the final say on matters relating to terminal treatment. Some (including Belgium, Luxembourg, the Netherlands, Sweden and Switzerland) have legalised euthanasia, while others (including Denmark, Finland and Norway) do not seem to have definitive legislation prohibiting it.
Most other countries worldwide, perhaps the more conservative nations including Malta, have argued that nobody, and in particular no patient, has the right to terminate his or her life, irrespective of the pain and misery they may be suffering. Moreover, it is a criminal offence for anyone to aid and abet another person to commit suicide. This includes the doctor who is the person most likely to facilitate such an event.
In a popular discussion programme on the ABC TV (Australian Broadcasting Corporation), a sort of high-powered Xarabank where experts as well as patients took part, this issue was examined in considerable depth.
One might argue that the difference between palliation – which is universally accepted as a humane method of controlling terminal pain, and euthanasia is a question of speed of action rather than substance.
In palliative care, strong drugs are given in doses just sufficient to control the pain, though the actual dose is often under the control of the patients themselves. The result is that terminal patients are kept in a semi-comatose state until they slowly fade away. On the other hand, euthanasia involves the administration of lethal doses of painkillers (like nembutal) whose action is instantaneous and irreversible.
However, it has to be emphasised that intention plays a pivotal role in determining the legality of such actions. The aim of palliation is not to kill the patient, while the aim or euthanasia invariably is. And even if the end result is eventually the same, there is an enormous intentional gulf separating one from the other.
In an article in Malta Today (August 17) relating to a survey of medical practitioners in Malta, it was stated that while the majority of general practitioners oppose euthanasia, “over 14 per cent of them received requests for euthanasia from their ailing patients”. Moreover, it stated that “a relative majority of respondents (45 per cent) agreed that patients had a right to decide whether to hasten their end or not.”
These findings further indicated that there exists “some misunderstanding with respect to the role of sedation at the end of life”.
In a more comprehensive survey of European and American medical practitioners (Medscape Ethics Report 2014) ), 41 per cent of European doctors, (and 54 per cent of American doctors) stated that physician-assisted suicide should be allowed.
It is obviously the case that attitudes towards medically-assisted termination of life are changing worldwide. The deeply religious ideas that used to inform our ethical life are being eroded in Malta as elsewhere in the developed world. It is therefore all the more important to ensure that the public is well aware of what facilities are available to deal with end-of-life issues and clear distinctions made between the various modalities of treatment.
In Malta, in addition to these ethical issues, we have the further problem of rampant paternalism affecting members of the family who, with the best of intentions, tend to rob the patient of their autonomy and, as often as not, believe they have the right to decide on their behalf. It is often the case that family members act as the go-between, protecting their loved one from the bad news that comes from health professionals.
I believe it is high time that this kind of benign protective paternalism should come to an end, and patients encouraged to think for themselves and take responsibility for their decisions. In a situation where informed consent is the most critical requirement for decision-making, it is crucial that patients are clear what they are requesting. No patient is free to choose if all decisions are taken by proxy, through the administrations of well-wishing family members.
It is also beneficial to the general community to participate in programmes such as the one mentioned, to ensure that important societal issues are discussed and aired in public, particularly for the benefit of others, including health practitioners and those responsible for political decision-making.
[First published in the Sunday Times of Malta on 29 Nov 2015]
Prof. Maurice N. Cauchi 