‘Let’s first ensure that no one chooses to die because we failed to help them live with dignity’ – MAM

The Medical Association of Malta (MAM) has raised serious concerns over the government’s draft proposal on Assisted Voluntary Euthanasia (AVE), warning that the country lacks the clinical, ethical, and operational infrastructure to support such legislation.

In a formal response, MAM acknowledged the government’s decision to launch a public consultation on the matter, but criticised the document for vagueness and insufficient detail. It warned that the proposal risks undermining patient safety and public trust in the medical profession.

Citing international ethical standards, including the Declaration of Geneva and World Medical Association guidelines, MAM stated that AVE presents a fundamental ethical conflict with the principle of preserving life. It said that any legal shift must include clear protections for the professional conscience of clinicians and safeguard public confidence in the healthcare system.

Malta’s palliative care services were identified as a critical shortfall. MAM noted a lack of infrastructure, personnel, and access to essential medications. It argued that patients should not consider assisted dying simply because they lack adequate symptom control or support.

Dignity and quality of life, it said, cannot be maintained without accessible, comprehensive palliative care.

The association called for wider stakeholder involvement, including palliative care specialists, oncologists, geriatricians, pharmacists, social workers, family doctors, and bioethicists. It recommended drawing on international best practices to inform policy development.

Citing international data, MAM pointed to a decline in palliative care standards in countries that legalised AVE. Canada fell from 11th place in global rankings in 2015 to 22nd in 2022, Belgium from 5th to 26th, and New Zealand from 3rd to 12th.

The association warned that AVE could divert attention and funding away from holistic end-of-life care, a risk Malta should not take.

It expressed support for formalised care directives and treatment ceilings but noted that community-based palliative care in Malta remains under-resourced. Without adequate psychological support and well-staffed hospices, it said, patients may be left with no meaningful alternative to assisted dying.

The association also criticised the draft’s treatment of conscientious objection. While the document references the right to object, MAM said it fails to define whether doctors can decline participation in referral processes or whether institutions can opt out. It called for enforceable legal protections for professionals who choose not to take part on ethical grounds.

MAM highlighted the use of vague terminology in the draft, such as “assisted dying,” and said clearer definitions and public education are needed to prevent misunderstanding.

It also flagged the absence of protocols around coercion safeguards, professional training, certification, documentation, and appeals.

The association concluded that legalising AVE under current conditions would be premature. It called for a national audit of palliative care needs, investment in 24/7 community services, and the creation of an independent ethical review panel. It recommended removing the six-month prognosis requirement, citing evidence that clinical predictions are often inaccurate.

MAM also referenced figures from Washington State, where 59% of AVE applicants cited feeling like a burden and 10% cited financial distress—indicators, it said, of unmet psychosocial needs rather than valid medical grounds.

It called for immediate steps to improve palliative care, including wider access to medication, faster support from social and psychological services, and national education campaigns on end-of-life care. National guidelines should also be established for ethical and clinical decision-making.

Representing Malta’s medical workforce, MAM urged the government to treat palliative care as a national health priority before considering assisted dying legislation. It warned that the current system is not prepared to support such a policy shift.