At this point in time, Malta does not have the legal, clinical, or institutional structures required to safely and ethically implement such a law, The Maltese Association of Psychiatry (MAP) said in a position statement it issued on the proposed introduction of assisted voluntary euthanasia legislation.

It is opposing the law's introduction until certain conditions are met.

"As psychiatrists and physicians, we are deeply aware of the profound emotional, ethical, and human dimensions of this national discussion. We have stood beside individuals and families facing unbearable suffering due to terminal illness, profound frailty, and existential despair, and we acknowledge the depth of pain that can accompany the end of life. Our position is rooted in both empathy and responsibility. While we recognize the intention to offer dignity and relief in moments of intense vulnerability, we must express our serious concerns," it said

"At this point in time, Malta does not have the legal, clinical, or institutional structures required to safely and ethically implement such a law. Introducing assisted dying legislation under the current framework risks exposing vulnerable individuals to harm, placing undue strain on clinicians, and bypassing the robust safeguards seen in countries with more developed systems."

It highlighted its concerns on a number of points.

Legal Framework for Mental Capacity is Inadequate for Assisted Dying

It said that Malta currently lacks formalised legislation on Mental Capacity with only the Mental Health Act (2012), existing in statutory form, giving provisions on capacity assessments which are brief and underdeveloped.

"It lacks codified standards for how capacity assessments should be conducted, recorded, contested, or reviewed-especially in high-stakes decisions such as assisted dying. In contrast, the UK's Mental Capacity Act (2005) and the Dutch euthanasia review committees include detailed protocols, multidisciplinary input, and procedural safeguards to ensure robust and repeatable decision-making in such cases. A 2023 systematic review published in Age and Ageing concluded that implementation of mental capacity legislation requires not only statutory clarity but also institutional training, professional accountability, and clear procedural pathways (Carver et al., 2023). These elements are absent in Malta. Capacity cannot be reliably assessed when professionals lack consistent guidance, legal protection, and ethical oversight-especially in cases involving fluctuating cognition, suicidal ideation, or mental illness. The introduction of assisted dying legislation would elevate capacity assessment from a background task to a legally determinative gatekeeping function. The current legal framework is not equipped to support such a shift."

Absence of a Functional Medical Council Undermines Clinical Governance

MAP said that the lack of a fully operational Medical Council in Malta poses a fundamental barrier to safe implementation.

"In every jurisdiction that has introduced assisted dying-whether Canada, Belgium, the Netherlands, or parts of the United States-national medical regulatory bodies are central to the framework. They define eligibility criteria, oversee clinical protocols, license providers, and respond to ethical concerns."

"Without such a council, clinicians will be forced to interpret ethically fraught decisions without recourse to regulatory support or peer guidance. This exposes them to legal liability and moral injury and renders any model of assisted dying in Malta ethically ungovernable."

Palliative Care Must Precede Any Legalization of Assisted Dying

The availability and quality of palliative care are prerequisites-not accessories-to any ethically defensible assisted dying framework, MAP said. "Currently, palliative care in Malta is patchy, under- resourced, and inequitably distributed."

"According to a 2024 Guardian investigation, even in countries with advanced systems like the UK, more than 20 individuals die each day in unrelieved pain due to gaps in palliative access (The Guardian, 2024). If suffering persists in such systems, one must question whether Malta's far less developed infrastructure can ethically offer death as an 'option' when pain, fear, and isolation remain inadequately addressed."

People with Mental Illness: Exclusion is Discriminatory, Inclusion is Dangerous

The position of MAP is that people with mental health conditions are uniquely vulnerable in the context of assisted dying legislation-and that neither exclusion nor unregulated inclusion offers a safe or ethical solution.

"On the one hand, blanket exclusion of individuals with mental illness (as has been proposed in Malta's early white paper discussions) is discriminatory and violates international legal norms. The Convention on the Rights of Persons with Disabilities (CRPD) prohibits the categorical exclusion of persons with psychosocial disabilities from legal processes available to others. Recent European case law (e.g. Mortier v. Belgium, ECtHR, 2022) affirms that if assisted dying is to be permitted, it cannot exclude psychiatric conditions per se. On the other hand, inclusion without ironclad safeguards places individuals at extreme risk. Psychiatric disorders can impair insight, judgment, and temporal stability. A 2022 study in Frontiers in Psychiatry showed that patients who express a desire to die during depressive episodes often change their minds after receiving adequate psychiatric care. In such contexts, assisted dying may function as a permanent solution to a transient, treatable state. This paradox-where exclusion is discriminatory but inclusion is dangerous-demands a comprehensive psychiatric governance framework, including mandatory assessments, independent review panels, and evidence-based screening tools. Malta currently lacks all of these."

Social Inequity and Structural Coercion

Social context shapes choice, it added. "Individuals facing economic deprivation, inadequate care, or social isolation are more likely to view assisted dying not as a free act of autonomy, but as a means of alleviating burdens placed upon their families."

It said that this is particularly concerning in Malta, where multigenerational caregiving is common, and the elderly or chronically ill may perceive themselves as burdens. "If palliative and social support systems are not strengthened first, assisted dying could become a covert mechanism of economic triage."

The Psychological Aftermath for Families and Caregivers

It said that evidence from international literature shows that the emotional aftermath of assisted dying is complex and enduring. "Families often experience unresolved grief, guilt, or relational trauma- particularly when they felt conflicted about the process or ill-equipped to understand it. Malta's cultural fabric, grounded in close family ties and religious values, may amplify these effects. Without structured bereavement services, psychological follow-up, or community rituals of closure, families may carry these wounds silently and indefinitely."

Prognostic Uncertainty and Informed Consent

Medical prognoses, particularly in non-cancer diagnoses such as heart failure or neurodegeneration, are often inaccurate, it said. "A landmark study by Glare et al. (2003) and numerous follow-ups-including more recent work-have shown that physician estimates of survival are frequently incorrect, even among specialists. Relying on terminal prognoses as eligibility criteria without acknowledging this uncertainty risks premature death based on flawed assumptions. More troubling still is Malta's cultural pattern of withholding prognostic information."

The Role of Clinicians in Assisted Dying

Assisted Dying poses profound ethical, legal, and professional dilemmas for clinicians with the medical profession remaining deeply divided on the issue, it said.

It said that the role of clinicians in assisted dying remains contentious. "The core of the opposition lies in the view that doctors are trained to treat illness and relieve suffering-not to actively end life."

Body and Legal Mechanisms providing Assisted Dying

Medicine is fundamentally oriented toward healing, alleviating suffering, and preserving life, MAP said. "Embedding assisted dying within health services may compromise this mission and alter the perception of clinicians as healers."

"Moreover, studies show that many doctors experience significant moral and emotional conflict when asked to participate in assisted dying, even in legal settings. Should assisted dying be implemented in Malta, establishing a separate body or legal mechanism outside the mainstream healthcare system to oversee assisted dying could preserve the integrity of medical care while respecting the legal rights of patients. This separation can reduce the ethical burden on individual clinicians and protect the therapeutic trust between doctor and patient."

Availability of Resources

At present in Malta "we still have a lack of specialists in Psychiatry and other multidisciplinary mental health professionals who are able to cover existing clinical services including adequate mental health support for patients in palliative care. Introduction of new demands will place further pressure on an already under resourced speciality, diverting away from people with acute mental health needs."

The Malta Association of Psychiatry affirms that assisted dying is not merely a matter of legislation-it is a system-wide intervention that affects medical ethics, legal interpretation, family dynamics, and public trust.

Premature and dangerous

"To introduce such legislation in a country where capacity law is underdeveloped, the Medical Council is inactive, palliative care is under-resourced, psychiatric governance is absent and cultural norms impede full disclosure, would be premature and dangerous."

It urged government to: 1. Reform the Mental Capacity Act with enforceable, reviewable, and clinically informed procedures. 2. Activate and empower the Medical Council to oversee professional standards and patient protection. 3. Expand national palliative care infrastructure and access as a moral prerequisite. 4. Create psychiatric oversight mechanisms, especially for requests involving mental health conditions. 5. Conduct structured, population-based research into public needs, attitudes, and fears around dying.

"Until these conditions are met, MAP stands opposed to any legislative attempt to legalize assisted dying in Malta."

It said that should Assisted Dying be introduced at any stage once safeguards are in place MAP recommends the following: 1. Professionals who come in contact with end-of-life situations should have the right to Conscientiously Object to participating in Assisted Dying at all stages. 2. Planning, procedural development and implementation of services should involve ALL stakeholders including patient representatives, carer representatives and professional representatives throughout the process. 3. Assisted Dying services should not be implemented or delivered through mainstream healthcare services but through a separate entity. 4. It must be ensured that there are adequate multidisciplinary mental health resources used to provide this service and that these are not diverted from mainstream healthcare services. 5. The role of the Psychiatrist in Assisted Dying procedures merits more in depth discussion.