The idiomatic expression on placing the cart before the horse signifies the reversal of the proper order of things. This is what the consultation document published by government on Assisted Voluntary Euthanasia for terminally-ill patients does.
The proposal for public consultation is paved with a multitude of good intentions. Many empathise with friends and close relatives who suffer greatly as a result of their terminal illness, in particular when excessive pain is manifestly associated. This encapsulates the proposal on the need to ensure that it is possible to die in dignity, thereby avoiding long drawn-up pain.
While this is a natural reaction, it however ignores that the provision of adequate palliative care could address the issue, even if realistically this would not be applicable across the board. As a result, by factoring in palliative care as a central element in the public consultation, this would transform the process from a negative exercise (to die in dignity) to a positive one (to live in dignity).
This is also the basic message of the Medical Association of Malta (MAM) who, in their response to the public consultation document, specifically emphasise this point. Palliative care capacity, states MAM, should be a precondition, not an afterthought.
MAM's response, in fact, further states the following: "Malta's deficiencies in palliative care extend far beyond infrastructure, training, and personnel. There is a systemic lack of access to essential end-of-life medications. Dignity and quality of life-core ethical priorities-cannot be upheld without comprehensive, equitable, and timely access to high-quality palliative care. No patient should be placed in a position where AVE feels like the only option due to inadequate symptom control or lack of support."
The state in Malta, unfortunately, provides a bare minimum of palliative care, which undoubtedly can be substantially improved upon. In fact, it was only some weeks ago that a ten-year Palliative Care Strategy for Malta was launched. Would it not be much better if the implementation of this strategy is emphasised as a positive contribution to the consultation exercise?
Discussing assisted suicide, or as the document describes it, Assisted Voluntary Euthanasia (AVE), in the absence of proper palliative care poses serious ethical risks. Other countries have been through this path, MAM emphasises. Countries that have legalised assisted suicide have experienced subsequent declines in palliative care. Consequently, when, as in Malta, palliative care in the public health sector is still in its infancy, it will not be allowed to develop: its growth will be stunted.
It was thus a shrewd move when Archbishop Charles J. Scicluna took the initiative to assist Hospice Malta in its mission through providing the premises for St Michael's Hospice in Santa Venera at the former Adelaide Cini Institute. This was an initiative taken seven years ago, in 2018, and it materialised earlier this year when the facility was inaugurated. The Scicluna initiative anticipated today's debate on assisted suicide and as a result pointed out the alternative serious option.
Government made a substantial financial contribution in order that this Hospice Malta project materialises, directly as well as through access to EU funds and funds derived from the (now) illegal sale of citizenship. This is definitely not enough commitment from the national health service!
Hospice Malta, an NGO, has been providing palliative care for a long time, supplementing the basics provided by the national health service. Charity has been supplementing the welfare state for far too long, not just in palliative care.
Government has made a political choice in favour of assisted suicide by placing this matter up for public consultation. The proposal for assisted suicide is definitely a political issue, and should be dealt with through a serious political debate.
Until such time that we have a robust system of palliative care in place, this whole debate is however premature. It places the cart before the horse. The prioritisation of palliative care should be the main issue, even though there is a limit as to what palliative care can actually achieve.
We should also discuss and improve patients' rights: including the right of patients to refuse futile life-prolonging treatment. This can be done through what is known as a living will, which ADPD-The Green Party has proposed in its electoral manifestos.
Only after the provision of adequate palliative care has been seriously addressed should the debate on assisted suicide proceed further. To do otherwise will inevitably push policy and funding towards assisted suicide and away from palliative care. The priority should be quality palliative care, not assisted suicide. This public discussion, unfortunately, is leading to the inevitable (wrong) conclusion that assisted suicide is the only practical (and preferred) solution to alleviate pain. Nothing could be further from the truth.
We expect better from our health authorities. Government should positively prioritise the right to live in a dignified manner. Acting otherwise is a political failure of the first degree.
The consultation must transform the debate from the negative start to a positive finish. From one emphasising a dignified death to one ensuring that our patients are not faced with a Hobson's choice but ensured that with proper palliative care they will be able to look forward to a dignified life, even in their last days.
An architect and civil engineer, the author is a former Chairperson of ADPD-The Green Party in Malta. [email protected] , http://carmelcacopardo.wordpress.com