Euthanasia: time for mature debate

For too long now, the word ‘euthanasia’ has been bundled alongside ‘abortion’ as a by-word for a dystopian future that is best avoided. A good example of this was the recent divorce referendum, which threw up the same old argument that divorce would pave the way to ‘abortion’ and ‘euthanasia’… as if this were enough to end the discussion altogether.

This is not conducive to a healthy debate on any subject, still less a medical issue that has serious consequences for people caught up in ordinary, everyday circumstances. This week, 56-year-old Joe Magro made an impassioned plea for a discussion on euthanasia, after being diagnosed with ALS, a deadly neurodegenerative disease that affects nerve cells in the brain and the spinal cord.

ALS is the same disease that sparked the ‘ice bucket challenge’ last summer. People responded well to this well-meaning initiative aimed at raising money for research into this little-known condition; it would appear, however, that beyond the fun and games, we are reluctant to come to grips with the longer-term ramifications.

When dealing with terminal, degenerative conditions such as ALS – and there are many others – Malta has traditionally avoided discussing whether our legal framework covers all eventualities. Euthanasia and assisted suicide are not contemplated in Maltese law; and while many might argue – not without good reason – that the status quo should be retained, it is clear that the issue is complex and warrants debate on a national level. 

Above all, the debate is needed in the face of increasing demand for such interventions. A study published in the Malta Medical Journal in 2015, carried out by Dr Jurgen Abela from the University of Malta’s department of family medicine, revealed that 14.4% of general practitioners said they had received requests for euthanasia in the course of their professional careers. 

An overwhelming majority, 89.1%, said they would never consider euthanasia. The study further reveals that most doctors are guided by religious values when dealing with end-of-life issues: with 89.8% of respondents stating that their own respective religion or philosophy of life was “important” or “very important” in guiding their end-of-life decisions.

Most (82.3%) family doctors identified Roman Catholicism as their religion. Further to this response, the doctors were asked to rate how important their religion or philosophy was in taking end-of-life decisions. 53% replied ‘very important’ while 37% replied ‘important’.

In an age when religion is increasingly viewed as a private matter of opinion, it is debatable whether this approach gives due weight to the opinions of the patient. Surely the religious beliefs (or lack thereof) of the patient must also be taken into consideration in such a delicate situation. 

Moreover, Malta’s legal infrastructure does not address the central question raised by Mr Magro, and others in his predicament. We talk of the value of life as a principle unto itself; but do we pay enough attention to the quality of life in such circumstances? Do we attach enough importance to end of life ethics, and the dilemma of giving dying patients a dignified death?

The 160 GPs interviewed in that study revealed that they were believers in preserving life and would only consider intensifying painkillers to alleviate the pain of the dying. While they would not consider euthanasia, many do not shun the intensification of painkillers and analgesia at patients’ end of life.

Just under half the 160 doctors surveyed had intensified analgesia at end of life, even if only 7.5% had sedated patients. This indicates that, even if religious or private opinions preclude euthanasia as a response, doctors are nonetheless acutely aware that the prerogative to end suffering can often conflict with the stated mission of preserving life.

Interestingly, a relative majority of respondents (45.3%) agreed that patients had a right to decide whether to hasten their end or not. But there was significant agreement that physicians should always aim to preserve life, with just 17.7% disagreeing with such an aim. 

What also emerges from the study is a need for clearer definitions of ‘euthanasia’ and ‘assisted suicide’. There is a difference between a treatment which actively terminates the patient’s life, and the cessation of treatment that prolongs life. The majority of GPs (58.1%) agree with the process of withdrawing or withholding various forms of treatment at the end of life. This response might seem to contradict the strong sense of preserving life. But the study notes that withdrawing or withholding treatment is not necessarily done with the aim or consequence of hastening death.

The study concludes that in general GPs believe in preserving life as a guiding principle at the end of life, but do not shun intensification of analgesia at the end of life. But it also shows that there exists “some misunderstanding with respect to the role of sedation at the end of life” and calls for guidance for GPs in dealing with the legal aspect and ethics of end-of-life decisions. In the absence of such guidance, the doctors’ “religion and philosophy of life are used to guide them in this rather difficult area of practice”.

Clearly, there is room for healthy, mature debate on improving Malta’s legal-medical framework for people in Mr Magro’s predicament.