The Medical Association of Malta said the legalisation of Assisted Voluntary Euthanasia (AVE) is premature, as the health ecosystem in Malta is not ready for it.
MAM issued a position paper days after the government launched a public consultation exercise on its proposed principles and safeguards on Assisted Voluntary Euthanasia, with only those who meet the criteria of having an incurable, irreversible terminal illness expected to cause death within six months to be eligible under the proposed safeguards.
In a statement on Saturday, MAM said AVE is a sensitive, multifaceted, and deeply emotive issue. “While we appreciate the inclusion of certain safeguards and the Government’s stated commitment to dignity and patient autonomy, we have serious reservations regarding the document’s lack of clarity, insufficient readiness, and the profound implications it may have for both patients and the medical profession,” MAM said.
MAM said it has a duty to ensure that any legislation on end-of-life decisions is underpinned by rigorous clinical, ethical, and professional standards. As it stands, the proposal remains vague on multiple critical fronts and risks undermining patient safety and public trust in the medical profession, MAM said.
Doctors are bound by internationally accepted ethical frameworks, including the Declaration of Geneva and World Medical Association (WMA) guidelines, which enshrine the principles of preserving life and alleviating suffering. AVE introduces a significant ethical tension with these values, MAM said.
Any legislative shift in this direction must safeguard the professional conscience of clinicians, as well as be assessed not only for its intended outcomes, but for its potential to erode public trust in the profession.
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, the association said..
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.
Stakeholder engagement must go beyond the immediate AVE debate. A national strategy must involve palliative care professionals, oncologists, geriatricians, pharmacists, community-based clinicians, social workers, family medicine specialists, nurses, bioethicists, hospice services and should draw from international best practices.
Evidence from other jurisdictions is concerning. Countries that legalised AVE have experienced subsequent declines in palliative care rankings: · Canada dropped from 11th place in 2015 to 22nd in 2022; · Belgium from 5th to 26th; · New Zealand from 3rd to 12th.
This pattern suggests AVE may shift policy and funding focus away from holistic end-of-life care-a trend we cannot afford to replicate. While we support the formalisation of advanced care directives and ceilings of treatment, the reality in Malta is stark. Community palliative care remains under-resourced, MAM said.
Without universal access to effective symptom management, psychological support, and well-staffed, empowered hospice care, patients may be left with no meaningful alternative-rendering AVE a decision driven by lack rather than autonomy.
Although the draft mentions the right to conscientious objection, its provisions remain insufficiently detailed. Clarifications are needed on: · Whether doctors can decline participation in referral pathways. · Legal safeguards against professional or institutional liability. · Mechanisms for institutional objections. A clear, enforceable legal framework is essential to protect healthcare professionals who opt not to participate in AVE under ethical or moral grounds, MAM added.
The draft lacks key operational definitions and protocols. In addition, vague language like “assisted dying” is open to misinterpretation. Clear, unambiguous definitions must be introduced, accompanied by national public education efforts to mitigate misunderstanding. Furthermore, the draft fails to outline: What constitutes undue pressure, and how coercion will be investigated; How certification, training, and physician support will be delivered; The documentation, audit mechanisms, and appeals process for rejected applications. In Malta’s close-knit, often politicised society, enforceable and transparent safeguards are not optional – they are essential.
Legalising AVE in its current form is premature, MAM said. The current healthcare ecosystem is not ready.
Before considering such irreversible policy, the following conditions must be met: A full national audit of palliative care needs and access; A strategic investment plan for expanding community-based palliative care with 24/7 availability; Creation of an independent ethical review panel involving palliative physicians, geriatricians, pharmacists, bioethicists, social workers, family doctors, mental health professionals, and international advisors; Legal protections for conscientious objectors, including those unwilling to refer; Establish robust legal frameworks for clinicians to navigate complex end-of-life decisions-ranging from DNAR to treatment withdrawal and palliative sedation; Abandon the six-month prognosis criterion, which is clinically unreliable. Studies show prediction accuracy to be as low as 23%, regardless of specialty; Guard against coercion. In Washington State, 59% of AVE candidates cited feeling like a burden; 10% cited financial distress. These are not valid clinical indications-they reflect gaps in psychosocial care.
MAM recommended immediate expansion of palliative medication access and streamlined prescribing. It also called for fast-track access to social services, home aids, and psychological care, mandatory education for healthcare professionals, patients, families, and caregivers on palliative options, national guidelines for ethical and clinical end-of-life care. A
s the professional body representing Malta’s medical workforce, MAM said it remains committed to policies that honour compassion, autonomy, and dignity. But reforms must be built on a foundation of readiness-not rushed to meet political timelines. We urge the Government to prioritise palliative care as a national health emergency before opening the door to assisted dying. The system, as it stands, is not ethically, clinically, or operationally equipped for such a step. Let us first ensure that no one chooses to die because we failed to help them live with dignity, MAM said.