End of life issues: setting the record straight

In August, this newspaper reported the experience of a family who lost Paul, their husband and father, after he suffered a cardiac arrest and spent three years in “a state of unresponsive wakefulness”. The family shared their story to advocate for the introduction of euthanasia, suggesting that their father might have benefitted from such a procedure if the criteria proposed by the government earlier this year were broader.

Before anything else, we wish to express our admiration for Paul’s relatives, who continued to provide him with all the love and commitment throughout all these years despite not seeing any improvement.

However, the article makes a number of claims regarding end-of-life care that are inaccurate and which we would like to clarify. Without entering into the specifics of the case, we would like to point out some common misunderstandings related to euthanasia and the care of patients in states of minimal consciousness.

First, it was reported that Paul was placed on life support 20 minutes after the onset of cardiac arrest. It is a well-established fact that the higher centres of the brain suffer irreversible damage within minutes once blood flow and oxygen supply cease. As his son rightly noted, that was the critical moment, at which a decision needed to be made about whether to accept the reality of death or to begin life support, knowing that normal brain function could never be restored.

Second, Paul’s family continued to show care and affection even though they could not know whether he was aware of their presence. Their care is admirable. So long as a person is not brain dead, that person retains full human dignity and must be treated with respect. Consequently, the direct and intentional termination of life of a person who is minimally conscious but not brain dead can never be ethically or legally justified.

Third, the family’s statement that Paul would have opted for euthanasia if it were available is understandable, as many people make similar remarks when imagining extreme suffering or hopelessness. However, what such statements often express is a desire not to have treatment prolonged unnecessarily when there is no reasonable hope of recovery.

Administering euthanasia to someone who cannot consent amounts to involuntary euthanasia, which is, effectively, homicide

Here we must recall the risk of therapeutic obstinacy, the administration of futile treatment that simply prolongs life even when there is no realistic hope of improvement.

The line between the administration of futile treatment and normal basic care at the end of life is sometimes a fine one and often becomes blurred. For this reason, regular reassessment and constant discussion between the medical professional staff and the relatives, as well as clinical prudence, is imperative. Ethically and morally, there is no obligation to pursue aggressive means when these are futile or excessively burdensome.

Finally, the family suggested that euthanasia laws should be expanded to include cases in which a person cannot give consent. This proposal would cross an ethical red line.

Administering euthanasia to someone who cannot consent amounts to involuntary euthanasia, which is, effectively, homicide. It would undermine the very safeguards meant to prevent abuse and would endanger vulnerable persons. This is why, even where euthanasia is legal, governments have insisted that it must remain voluntary.

True compassion does not lie in ending life but in accompanying it faithfully, even through suffering. It is an act of care rooted in respect for both life and human dignity.

Fr Carlo Calleja lectures in applied ethics at the University of Malta. Mark Anthony Vassallo is a geriatrician. Fr Emmanuel Agius is professor of moral theology at the University of Malta.