The Prime Minister has promised to open the public dialogue on euthanasia. Of course, this should not be taken for granted that he is actually condoning euthanasia. A structured form of public debate, run by an independent source, is something which is strongly needed in Malta. The only debates, which seem to occur are those organised through NGOs or university and through the media, which is more often than not an arena for opposing sides to launch attacks at each other.

The Council of Europe has published a recommendation on public debate. The French also have a good model on public debate which they have used successfully and which is published as a document. The important thing is to be able to reach all sections of society and to have a structured way of collecting information which is not misguided, as vox pops usually are. People have to feel free and protected because often people fear to state things in public lest they be jeered at or molested. Disagreements are welcome but the idea that might is right should not come into any public debate, nor should those conducting the debate be directive in their questions, which is why pilot studies are important.

Secondly, the aim of the debate should be to guide people to the right questions and correct misplaced ideas. Vox pops have actually played a strong role in bringing out these misplaced ideas. Typically, when someone says that they agree with euthanasia and then are asked why, they would state something like “why should one die in pain?” or “why should one suffer?” Of course, these are not reasons for euthanasia because there are moral and legal structures to allow for this. That some people still die in pain is a fact. Many have experienced this with their relatives. My wife’s aunt, a nun, was continuously in agony in the Palliative Care Unit, of all places, and it was only when my wife would tell the nurses that she was in agony that they would give her more morphine. This lasted for days on end. No one to blame of course – nurses have to handle a lot of patients and there may be unclear or no protocols. Also, I am given to understand that the patient remains under the original consultant and not transferred under the care of a Palliative Care consultant. If we really want good palliative care, we have to have good protocols in place.

It goes without saying that this is not the general state of affairs, but it is certainly common enough to merit looking into. It is very unfortunate therefore that people pass through the experience of seeing a relative or friend die in pain and suffering giving rise to an increased cry for euthanasia.

Secondly, it should be noted that in the UK, the argument for euthanasia started off as well with palliative care, but over the years it went on to suffering, including existential suffering, and then simply to a “right” to choose one’s death. One therefore can have a right to die “with dignity” if one develops dementia. A right to die however, even if given by the state (and the state has to decide whether it is in its interest to do so) does not automatically translate into a right to have someone assist you with the suicide. Let us make it clear that it is an assisted suicide. Assisted dying is what ought to happen – pain relief, removal of disproportionate treatment, respect for the patient’s right to refuse life-prolonging treatment, and so on. It is unfortunate that lobbies are confusing (intentionally or unwittingly) these two terms. Doctors do assist patients with pain and suffering – this does not mean they are deliberately terminating the lives of their patients.

Morally, at the end of life, we distinguish between killing and allowing a person to die a natural death. The latter does not mean however allowing them to die in agony. Giving pain relief, even if it hastens death by a few days, which studies have shown is not in fact the case, is morally accepted. People also can refuse extraordinary, disproportionate or burdensome treatment.

It is also important to note that doctors cannot treat without the patient’s (or a proxy’s) consent. This is also true for life-prolonging treatment. There are many who refuse chemotherapy. But one can refuse being put on a respirator, say, for advance Motor neuron disease, even if it will prolong the life by a few years. They will be sedated and allowed to die a natural death.

Given our cultural context it is important to note that all this is found in the Catholic Catechism. But unfortunately, many get so caught up in the debate that instead of teaching what can be done we often only hear what cannot be done. I would urge priests to help people understand their rights and that morphine is there as a “charitable” (yes, from Catechism) thing towards the patient even if it may hasten death. It is foreseen, indirect and unintentional.

Finally, even if a right is given to patients to receive euthanasia, this is still a far cry from it to be one of the goals of medicine. Sometimes people are left with severe disability, such as total paralysis, from an accident or disease and they usually plead for euthanasia. But it is rather contradictory to save a patient’s life and then take it away later because the person has lost meaning. Now this is easy to say for me. But we have good models, like Bjorn, who have found meaning in their suffering. I have seen people find meaning because through their disease they are indirectly teaching and sending humbling messages to their carers and family.

So before we enter a public debate, we must put all cards on the table and enter into a public educational process of what is already allowed and what is lacking. Certainly, doctors will need the comfort of a more detailed law allowing what is already considered moral to become legal with impunity, once the proper protocols of planning ahead with patients and family are followed.

Euthanasia is a deliberate intention to kill, actively or passively; pain relief, removal or refusal of treatment is not killing; any harm is indirect and unintended. Nature is allowed to take its course. For the rest we need to continue to search for more meaning at all stages in our lives. The slippery slope is that people whose lives are miserable for any reason, even old age, depression or drug addiction etc., will ask for the right to die.

Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches at the University of Malta. He chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee.

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