As Malta holds its first national discussions on voluntary assisted euthanasia, Parliamentary Secretary for Reforms and Equality Rebecca Buttigieg said that even with the best possible palliative care, some patients, who are terminally ill and have six months to live, still want the right to choose how their life ends.
In an interview with The Malta Independent on Sunday, Buttigieg said that the government's current role is to listen and explained why autonomy is at the centre of the reform.
In early May, the government launched a two-month public consultation on its proposed principles and safeguards for Voluntary Assisted Euthanasia. Under the proposed guidelines, only individuals with an incurable, irreversible terminal illness expected to result in death within six months would be eligible to request it.
The patient must be at least 18 years old, have been a resident of the country for a minimum of 12 months, and the patient must be evaluated by three medical professionals, including a specialist in the relevant condition, a psychiatrist and a verifying doctor.
The request would then go to a board of medical professionals which is responsible for deciding on requests for voluntary assisted euthanasia, mandated to make a final decision within two weeks of a patient's request. Once approved, the final procedure for voluntary assisted euthanasia follows.
Buttigieg said the government is currently consulting the public on the sensitive subject of voluntary assisted euthanasia, with the public consultation being opened until 2 July. The government is holding three community meetings on the matter, in Fgura, Mosta and Gozo.
In an interview with The Malta Independent last Sunday, Hospice Malta expressed concern that the country's palliative care system must be improved before any such law is introduced.
Responding to Hospice Malta's concerns, Buttigieg acknowledged that investing in palliative care is certainly important, but stressed that end-of-life care and euthanasia are entirely separate matters.
"There are still those people, despite the best palliative care in the world, who still want that option," she said.
The public consultation is meant to explore opinions, parameters and possible safeguards, should Malta pursue legislation, she said.
Buttigieg said that more than 260 written submissions were received in the first three weeks of the consultation exercise, alongside a high turnout at the public consultation meetings.
"We are having very mature discussions based on respect. This is not about political division, or a fight between those in favour or those against," Buttigieg said.
Principle of conscientious objection
Asked whether the government has faced resistance, especially from the medical community, Buttigieg said that the principle of conscientious objection is embedded in the proposal.
"Just as how we do not want the patient to be forced or coerced to make this decision, we also believe that the medical professional must have the choice on whether or not to participate, according to what they believe and according to the individual," Buttigieg said.
She said that the government has spoken with several associations, such as the Medical Association of Malta (MAM), the Malta Union of Midwives and Nurses (MUMN), as well as with psychiatrists, pharmacists and psychologists.
"The feedback has always been valid, and we are discussing the need to continue investing in palliative care," Buttigieg said, adding that the Health Minister and the Prime Minister were both clear in their plans to continue investing in palliative care.
Buttigieg mentioned that she also took note of the public statements made by these social partners regarding the issue of voluntary assisted euthanasia, where the MUMN clearly said in a statement that nobody can judge the decisions of those patients who have arrived at the end of their life.
"We are talking about people who have gone through great suffering, and are at the most vulnerable time of theirs, and their families' lives, and we must understand that it is a difficult decision to arrive to," Buttigieg said.
The draft framework includes a crucial safeguard: "it must be the patient themselves that carries out the final procedure that leads to the end of their life."
Patients' decision
The government is calling the proposal assisted voluntary euthanasia, however, many, as well as Archbishop Charles Scicluna, believe that what is really being proposed is assisted suicide.
In response, Buttigieg said the word "voluntary" is crucial in this.
"We are proposing a system where the patient decides for themselves, and the patient themselves administer the dose at the last stage of this process," she said.
Buttigieg pushed back against the characterisation of the proposal as "assisted suicide" insisting that the focus is on autonomy for terminally ill patients.
"They know they will die. The question is: can they have the right to a choice, always if they decide for themselves? I do not believe this is a situation where we are talking about suicide," Buttigieg said.
Palliative care professionals had also warned that the current debate is causing distress among patients, who fear they will inevitably suffer because their condition is incurable.
Buttigieg was asked how the government is ensuring that the public discussion around assisted dying does not unintentionally create fear or stigma around terminal illness and end-of-life care.
She said she could not understand what was so wrong about the country discussing such a subject.
"Is it wrong that the country is in a dialogue on such a sensitive matter? I believe it is an important process we should have, a process which even resulted into more awareness on palliative care," Buttigieg said.
She added that these discussions have also raised public awareness around palliative care.
"If you had to ask people in general, maybe there is not enough awareness on what palliative care means. I am pleased that this debate has brought the matter to light," Buttigieg said.
Asked about a possible referendum on voluntary assisted euthanasia, Buttigieg said the consultation process is still ongoing and the government has not put a deadline.
She said she has seen interpretations on social media that when this eight-week period of consultation closes, then the government will be presenting a legislative bill.
"That is not the case; our mandate is based on public consultation, and we are listening, and there have been submissions on how people believe it should be introduced, if it should be introduced in the first place," Buttigieg said.
Cannabis use among youths did not increase after reform
Police Commissioner Angelo Gafà has recently described the law regarding cannabis odour in public as "practically unenforceable".
The new law imposes a €235 fine on people causing a nuisance with cannabis odour, with Gafà saying that police officers will have difficulty identifying smells and determining the difference between cannabis, a cigar or a vape, and urged legislators to pass laws that can be enforced effectively.
Asked about the enforcement difficulties of new cannabis odour laws, Buttigieg defended the amendments that were part of a legislative package to strengthen the reform for the responsible use of cannabis.
She said that it was never about promoting use but rather eliminating criminalisation and targeting the black market.
"We changed the policy around responsible use," she said, adding that it has been three years since the reform was passed in 2021.
"We went from a country which looked more at punishing people who used cannabis, and looked at them as criminals. That was the story in our country. This courageous reform benefited many people as for the first time, adult persons who make conscious use of cannabis are not being seen as criminals," Buttigieg said.
She said that for the first time, they are being given legal and safe access to a cannabis product.
"We did this in the interest of public health at the end of the day. We wanted the black market to take a big hit, and it did. This is shown through the many Cannabis Harm Reduction Associations that today have a licence to operate and distribute cannabis to their adult members," Buttigieg said.
She said that many were initially against the reform, arguing that the law will incentivise cannabis consumption, but "scientific and academic" studies have shown that through the reform, the use of cannabis did not increase among youths, primarily.
"That is witness to our intention as a government, and the law is working properly," Buttigieg said.
She said that this amendment about odours was one of many amendments the government made to strengthen the reform, but it was the one which caught the most attention.
Through the recent amendments, the Authority for the Responsible Use of Cannabis (ARUC) was granted broader enforcement powers.
The new rules also require that Cannabis Harm Reduction Associations must be located at least 250 metres away from schools, youth centres and now, sports facilities. Buttigieg also mentioned the introduction of stricter penalties for associations that admit minors, including a fine of €10,000.
"We did this to send a strong message that minors cannot be members of these associations," she said.
On cannabis odour, she clarified that the complaints received often relate to the cultivation process, not just simply smoking a joint, as the reform allows for the cultivation of up to four plants in their residence.
"There were people who could not enjoy their gardens or rooms because of the very strong smell, during the drying process," she said, adding that carbon filters, as well as other measures, can be used as a mitigation method.
"We wanted to create a balance, to remove nothing from people's rights, but also protect others' rights to enjoy their own property," Buttigieg said.
Buttigieg also said that the definition of what counts as cannabis was clarified, which includes both THC and CBD, and non-psychoactive cannabinoids with less than 0.2% THC will be excluded, so that there is no ambiguity on what a cannabis product means.
She continued that synthetic cannabis has also been classified as a narcotic drug.
"The criticism, which sometimes occurs, I would say unjustly, that this government is lacking in the war against drugs, is not true, and these amendments clearly show our commitment to fight the irresponsible use of drugs," Buttigieg said.
She also said that anonymous complaints will not be accepted by the authority, and said that the chairperson of ARUC, Joey Vella, was also very clear about this.
"We do not, in any way, want a police state or that we go around knocking on people's homes to check on them," Buttigieg said.
She appealed for responsibility to ensure that one person's right does not impose on that of another's.
Pressed on whether there were any discussions between the authority and the police on the way forward on the odour matter, Buttigieg said that ARUC has the primary role in this, while keeping constant communication with the police.
"I again appeal for responsibility, we do not want to end up in a position where we send the police to people. That is not the intention," Buttigieg said.
'There has been a shift in mentality towards LGBTQ+ persons,' Buttigieg
Malta often boasts about topping LGBTQ+ equality rankings, but many trans and non-binary people still struggle to access healthcare, employment and basic respect.
She was asked whether she acknowledges that Malta still has a long way to go beyond just implementing laws, and what steps the government is taking to address this.
Buttigieg said that she was pleased to say that for 10 consecutive years, Malta has remained at the top of the index when it comes to LGBTQ+ rights.
Despite being only 31 years of age, Buttigieg noted that the situation for LGBTQ+ individuals was significantly different during her childhood compared to how it is today.
She said that LGBTQ+ people who were in relationships used to feel the need to hide that part of their identity, in fear of getting bullied.
"Fast-forward to a change in government and the revolutionary which happened around civil rights. Who would have thought that a country, which only legalised divorce in 2011, would, by 2025 have achieved full civil rights?" Buttigieg said, adding that this is a great achievement not just for the government, but all of society.
She noted the change in mentality and mentioned a recent incident where a couple had decided to withdraw their children from a government primary school after they discovered their teacher was gay, because he had a rainbow flag on his bag.
"When you look at the backlash from society, it was directed towards the parent's mentality, and not the teacher because of his identity. There, one can see the huge stride forward we have made," Buttigieg said.
Had that episode occurred 20 years ago, matters would have been different, Buttigieg said.
"I will never say that we have arrived, as there is more to be done. This is a change in mentality, and we will continue legislating and amending," Buttigieg said.
The country prohibited the practice of conversion therapy for LGBTQ+ persons under the Labour government, she said, and under her direction, the promotion of conversion therapy practices was also prohibited, ensuring legislation remains relevant for today's society.
She said that the government also has a strategy for the next five years for the rights of LGBTQ+ persons.
Buttigieg said she was worried about the events occurring around the world with regards to trans persons, whose rights are being attacked and taken away from them.
"Malta must always be vigilant, continue to affirm its commitment in favour of equality for all, but particularly for these people," Buttigieg said.
For non-binary people, Buttigieg said that last year, the government introduced legislation allowing non-binary individuals to represent their identity on public and official documents using the mark X.