Political parties, the Church and government should keep away from the serious discussion that is needed on euthanasia, medical ethics Professor Pierre Mallia told The Malta Independent on Sunday.
Asked whether he sees Malta introducing euthanasia as a right in the near future, he said that the most important thing before that happens is for there to be a serious public discussion without the interference of political parties, the Church and government.
One of the dangers of our political system is that if someone were to present euthanasia as a private member’s bill in Parliament, it would lead to a rushed referendum like what happened in 2011 with divorce.
Conversely, a serious public debate needs the funding of the government and has to listen to all voices, including the less popular and emarginated, and not only the powerful voices – political parties, religious organisations and NGOs.
He added that unless values, morals and ethics become simply a matter of statistics, we cannot simply follow our leaders because a majority want it, having understood only superficially what they are voting for. Ethics is not only a feeling but needs rational thought.
Before the last general election, Prime Minister Robert Abela had said that Malta needs to start a discussion on euthanasia.
The Malta Independent on Sunday met Professor Mallia who in the last legislature was chairperson of the Bioethics Committee.
Professor Mallia said that euthanasia is defined as the deliberate and intentional killing of an individual, who in most cases would be done because of health reasons. He added other things such as the refusal to give treatment which is futile at the end of life is not considered as passive euthanasia, “unlike many people think”.
Prof. Mallia said that when many people are asked about the subject, they say that the right should be introduced because they don’t want to die in pain. “These are not valid reasons because we already give, or should be giving more, morphine and sedation at the end of life… increasing the dosage until we can.”
He said that giving morphine and sedation at the end to relieve pain is allowed even if it shortens life by a few days, as it is not clearly defined by law. Prof. Mallia said that even the Catholic catechism, when referring to pain relief at the end of life, in its teachings describes it as being a charitable act.
“At this stage patients need not be on extraordinary care and ought to be able to refuse treatment, such as a hydration drip, especially at the end of life in order to avoid unnecessary pain or discomfort with repeated search for veins which start to get clogged,” he said.
Adding to the list of misconceptions that people have on the delicate subject, Mallia said that some believe that if a patient dies just after 10 minutes of receiving a dosage of morphine, then it was that treatment that killed them.
He said that unless the dosage of morphine given is not breaching the standard of care established by doctors universally and hence recognised under law, then doctors and nurses should not be afraid of relatives threatening to sue them in such cases. “It is a matter of communication ahead of time.”
“The most important thing at one’s end of life is to keep the person comfortable, even if that means sedating the person,” Mallia said.
The doctor explained that there are two different types of euthanasia: active and passive. He said that active euthanasia is when a dose of a lethal substance is given to immediately stop the heart, while passive euthanasia is when, for example, a cancer patient who is not at the end of his life has a chest infection and instead of treating it the doctor decides that nature should be left to take its course. Conversely patients do have a right to refuse treatment and the onus here is not on the doctor who cannot treat without consent.
Apart from these two there is also physician-assisted suicide, which in Mallia’s opinion is a misnomer, “because if I give you a gun for you to shoot yourself, I am still an accomplice. It is as active as it gets”.
Speaking about euthanasia in general he said that the medical profession was always against it but that has started to change in recent years.
Referring to a European project on end-of-life care, which he coordinated, he said that Malta’s end of life care is not optimal as it ought to be from surveys done. The workshops were attended by healthcare professionals, including consultants and there was a request to hold more.
Mallia said that he together with other medical professionals, had teamed up and created a protocol on end of life#. Apart from that he edited a consensus document between the faculties of laws, medicine and theology and also devised a curriculum for courses on the ethical, legal, social and spiritual aspect.
“Every doctor and nurse needs training in palliative care, as during their university years, end of life care is very slightly touched upon,” he said. Not all patients actually die in the palliative care unit. Having said that, many specialities, such as respiratory medicine, oncology, gastroenterology and others, lend themselves well to end of life care.
One of the biggest issues concerning euthanasia as a right arises mostly when people who are still young get to know through genetic testing that in the future, they are going to suffer from autoimmune diseases such as Huntington disease which, more often than not, triggers dementia. Prof. Mallia said that the first thing that such people say is that they want euthanasia as a right as they do not want to live with the condition.
He said that medical professionals are not inherently there to assist people in killing themselves.
“Many of us will get dementia. We simply do not know what it feels like. Ought it to be medical ethos to terminate lives if people do not want to live with a condition?” he said.
He added that some people do not understand that although dementia makes those affected forget things, they are sometimes lucid. Despite this, Mallia said that such patients demand more dignified care.
Mentioning another example, he said that even when someone becomes paralysed and becomes dependent on other people and they might think that euthanasia is their answer, Mallia still believes that it is totally preventable. In this situation he added that it is not the first time that such people find the needed support and attention from their family and thus are able to lead a fulfilling life. Moreover, we should be re-thinking the saving-at-all-cost argument without acceding to the patients’ wishes to live the kind of life being offered. He said that if at any stage the patients refuse further treatment we should, following assessment and consultation, accede to their wishes.
Speaking about countries who have introduced euthanasia as a right, Mallia said that if Malta were to follow their example it would be going down “a slippery slope” as although patients to be considered for the procedure would at first most likely be those who are terminally ill, it would only be a matter of time until it would also be presented as an option to those suffering from, say, chronic depression. “You cannot have a universal law for the exceptional case," he said.
Mallia predicts that such a right would be abused of if it were not restricted to certain circumstances and conditions. In further explaining what he meant by abuse, he said that people would be more willing to “end it” rather than deal with the health problems they might have and find ways to make their lives better. Although the medical argument in favour of euthanasia as a right embraces the autonomy of the individual and their right to decide for themselves, Mallia said that “rights are something given and accepted by a society… they are not something that just falls from the sky. There needs to be a social agreement as it is society that gives rights, and, surveys have clearly shown that 85% of society requires more information, including those who are in favour of such a move”.
In conclusion Prof. Mallia noted that when someone dies by suicide everyone questions why they were not receiving help but when it comes to euthanasia, nobody does as euthanasia is more “socially acceptable” and that patients are assisted by physicians.
What they think
The Malta Independent on Sunday, has in recent past weeks interviewed several people who work closely with those affected by cancer and those given a terminal diagnosis.
In these interviews, they were also asked to share their views on euthanasia based on their experience.
Oncology charge nurse Ronnie Frendo said that in his personal opinion he believes that if euthanasia were to ever be introduced in Malta as a right it should be limited to certain cases only, where a patient would have exhausted all treatment options.
Although being a person with a strong Catholic faith, Ronnie said that he feels deeply for those who are in pain and that personally, if he was ever in that position, would not want to spend his last few days in pain.
He added that some of these patients end up being bed bound with severe skin abrasions, despite nurses and doctors doing their utmost to avoid them.
He said that in his opinion he would choose euthanasia if he would have exhausted all treatment options and failed and been given an ultimatum by the doctors, especially if he would have a long way ahead before he passes away such as six months to a year.
“I wouldn’t want my relatives to see me in that state,” he said.
Another nurse who works in the palliative care section and decided to remain anonymous for various reasons said that he would not consider euthanasia if they were to ever be given a terminal diagnosis by doctors and having already explored all options.
“I don’t agree with euthanasia as there are many ethical issues,” he said.
The palliative care nurse said that he would personally not want to choose his date and time of death, but let nature take its course as “I don’t think it is ethically right, as it also goes against the scope of palliative care, which is to make the terminally ill patient comfortable”.
Mentioning some of the reasons why he disagrees with euthanasia he said that in some cases terminally ill patients might be more inclined to go for euthanasia because they don’t want to cause unnecessary suffering to their relatives “even if they would not be in pain”.
Bella Mifsud, whose husband died of cancer, said that Jesmond was given a terminal diagnosis but he never considered euthanasia “as he was a man with a strong Catholic faith”.