As indeed happens after every invitation to speak on a talk-show, some reflective practice after the episode is bound to happen both about what has been said by the other and about my responses. Holding these discussions within parameters of respect is not easy, especially when you get to know the person and when you perceive that there is not enough knowledge going around to make people think thoroughly through their wishes - which may seem simple enough to many. For, example, my esteemed friend (as I may rightly so call him now) made parameters explaining that certain conditions ought to be given rights for euthanasia, but others he did not accept. Even after the show the host asked me, "but don't you think that the law can at least make a list of conditions for which euthanasia can apply?" We would be very naïve to think that there will be no bargaining in the process. What one feels ought not to be included, another will strongly feel the opposite. Politicians will find themselves in a quagmire and what we do not want is some sort of "right" that then can be applied to anyone, such as what happened in a European country where a person serving a life sentence for multiple murder and rape was allowed to have euthanasia because he was depressed and did not want to spend the rest of his life in prison.

To make an effective public debate we have to first legislate what can actually be done according to traditional moral law - something which our law has yet to clear and which indeed was reflected to me by the Deputy Prime Minister and Minister for Health, Dr Chris Fearne, when I presented my EndCare projects. What counts, at the end of the day, is whether a doctor can still be taken to court if he or she does something which someone's whim thinks is murder - such as giving pain relief which indirectly shortens life (a practice accepted by the doctrine of double effect). The law must, therefore, immediately clarify and stipulate at least the following:

1.      There is a difference between killing and allowing someone to die - in the latter one has a duty to keep the person comfortable, by morphine, say, and even inducing sedative palliation

2.      We cannot treat patients without their consent

3.      Patients have a right to refuse treatment, including life-prolonging treatment such as chemotherapy and ventilators

4.      Only a doctor can make the sole (pharmacological or technological) decision of what is futile treatment. By futile we are not meaning disproportionate or extraordinary, but something which is not going to accomplish anything within the circumstances. Of course, this should always be explained to the patient or family, for example, "I am not going to attempt this because at this stage it will not only not accomplish anything, but will even cause discomfort"

5.      There is a difference between ordinary and extraordinary treatment. In this, it is not the doctor or nursing staff who decide what is extraordinary, but the patient, and short of that, a discussion with close relatives

6.      What many consider ordinary (such as Artificial Nutrition and Hydration) can indeed become extraordinary or indeed futile. The patient and/or family, when they are proxy, can decide that this may send a relative into a vegetative state - something which if done deliberately is immoral in itself. Medicine is not there to keep someone alive at all costs, even if it means that they lead a meaningless life in twilight

These have all been acknowledged through the end care project, which involved the faculties of Medicine & Surgery, Laws, and indeed Theology (besides universities from the UK, Ireland, Italy and France). Having the points explicit in the law, as articles where it is stated that any physicians who contributes to euthanasia can be accused of murder and given up to 11 years in jail, will accomplish a great deal and reduce suffering considerably. What is morally accepted practice ought also to be explicitly explained by social institutions such as the local Church, as there are still people going around saying that it was that last dose of morphine which took away their loved one. It was not, period. The public has to know what is and what is not euthanasia. Surveys are not giving us a good evaluation of what people really think when they give reasons such as "why should one die in pain".

But here, doctors have to make an examination of conscience and take responsibility for our field which, in good faith, keeps people alive with many conditions and finally some people just have had enough. It is ironic that some would want us to keep relatives on machines for evermore while others would want to die. But that is life. Before medicine contemplates killing people, it should acknowledge that we have failed at the courage to provide proper pain management and palliation because of lack of comfort of the law and lack of funds. Patient advocacy is about shouting at those responsible to provide us with what we need; to do our job and provide a good death. At what stage should we start discussing advanced care planning with people?

There is a sly expression going around, exchange the term physicians-assisted euthanasia for physician-assisted dying. They are not the same and it would be a disaster if the wolf had to dress up as a sheep. Let us call a spade a spade - we already assist people when they are dying - by pain relief, palliative care instead of further treatment, etc. But we assist them when they are dying or when they decide they do not want to accept further life-prolonging treatment. I once had a Japanese patient who had lung cancer and was here in Malta receiving no chemotherapy because she did not want it. She was only on morphine. She was doing very well and died peacefully a couple of years later. We should not shy away from Medical Cannaboids. Assisted dying is not about killing, it is about allowing someone to die. This is true dignity. There is a lot of overlap out there between what can be done and what people still believe to be euthanasia. Before we go to any referendum or even a public debate for that matter, these things should be clear so that there will be no confusion.

I call out to our politicians on both sides of the House to draw their attention to the above clarifications in the law. I am sure that they understand that any clarifications we can give to our doctors will benefit everyone. It would indeed be at the least ironic and at the most disastrous if we were to even attempt to introduce euthanasia without understanding what it does not constitute and what it does and without providing the legislative background to provide proper end-of-life care. There may be quandaries. Moral teaching says that hydration, for example, should always be considered ordinary care. But for some it may also be burdensome or disproportionate. While there are areas for contention, we must respect the prime moral duty of not treating people without consent. Be that as it may, this should not prevent us from legislating what is morally accepted and agreed upon but does not find comfort in legislation.

Introducing euthanasia, without due consideration to what can already be done, would not only mean missing out on values towards the end of life but it would spell out a failure in our health care system when it comes to providing what we all want - a good and pain-free death. After all, if one looks at a 100-year-old dictionary, one finds that euthanasia originally meant "dying in one's sleep" and not a deliberate termination.

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. Email: [email protected]

This article is his personal opinion and does not represent the opinion of any committee or Board he serves on.