As Malta continues a national discussion on assisted voluntary euthanasia, one message is echoing loudly from medical professionals and civil society: before we consider ending life, we must ensure we have done everything possible to support it with dignity. The debate on euthanasia has swiftly taken centre stage in public discourse, but organisations opposing the measure insist that the country must first address the glaring gaps in palliative care.

The government's decision to launch a national palliative care strategy in April, only a month before introducing its euthanasia proposal, appeared to some as a calculated move to soften public reaction. However, the rapid momentum of the euthanasia debate has largely eclipsed the palliative care strategy, raising concerns that the government is more intent on legalising euthanasia than ensuring end-of-life comfort and care.

The Medical Association of Malta (MAM) has strongly reinforced the need for proper palliative care as the foundation for any ethical discussion about assisted dying. Dr Patrick Sammut, MAM's president, pointed out that Malta's palliative care infrastructure is alarmingly underdeveloped. The country has only two officially appointed palliative care specialists - one consultant and one resident doctor. This is a fraction of the 12 full-time specialists recommended by the World Health Organization (WHO) for a country with Malta's population.

Sammut stressed that the WHO's Essential Medicines List for Palliative Care, which identifies 22 key medications, represents a baseline for lower-income countries. Malta should be aiming far higher, not just in terms of what medications are stocked, but in how accessible they are.

The issue, as MAM outlines, is not simply about which drugs are available - it's about who can access them, and where.

First, palliative care in Malta is overwhelmingly cancer-focused, despite cancer making up only around 25% of palliative care needs. Sammut pointed out conditions such as advanced heart failure, chronic obstructive pulmonary disease (COPD), end-stage liver disease, ALS, and severe dementia often involve prolonged suffering that palliative care is specifically designed to address. Patients with these diagnoses frequently fall through the cracks.

Second, location matters. Many palliative medicines can only be accessed in hospitals or hospices, cutting off those who wish to remain in their homes. A patient-centred approach would ensure that essential medications and specialist care are available at the community level, through home care teams and local pharmacies.

Third, there is a critical shortage of trained professionals, Sammut said. Palliative care is more than prescribing drugs. It requires holistic, ongoing assessment of a patient's physical, emotional, and spiritual suffering. Without enough specialists to provide this level of nuanced care, family doctors and hospital staff - often without adequate training - are left to fill the gap. This compromises the quality of end-of-life care and increases the risk of unnecessary suffering.

The MAM has not limited itself to pointing out flaws. It has proposed clear solutions and a roadmap for progress, calling on policy-makers to collaborate with medical professionals to bring Malta's palliative care system in line with international standards.

If euthanasia is to be seriously debated, it must come only after every effort has been made to relieve suffering through existing medical means. As Sammut aptly stated, "To truly honour the dignity of every person at the end of life, we must be able to look them in the eye and say: we have done everything modern medicine can offer to relieve your suffering."