Personal encounters with terminally-ill people in extreme pain have led surgeon and newly-appointed health minister Jo Etienne Abela to believe that doctor-assisted dying is justified in extreme cases.

Speaking in an interview with Times of Malta, Abela said he opposes euthanasia in its broader forms and is planning to invest in more facilities and resources for palliative care, but lethal illnesses can become unbearably painful beyond the reach of any medical remedy.

“We will offer palliative care to patients, of course, but sometimes even the best palliative care leaves the patient in a lot of pain with no hope of surviving. In those circumstances I believe doctor-assisted suicide is suitable and justified,” he said.

After the interview he clarified that he meant to use the more appropriate term ‘doctor-assisted dying’.

“I have sometimes seen terminal illnesses advance beyond any hope of cure or survival. I dealt with the worst forms of lethal cancers in my career, and I have seen and lived with people who were at a point where they had no way out. And that suffering disturbs me,” he said, silently breaking down in tears.

He stopped the interview briefly, apologising for getting emotional and explaining the subject reminds him of a friend who is going through such a situation.

“This is why the government wants to have this discussion at some point,” he continued.

“I understand it will inevitably bring up ethical and moral arguments, and that’s fine, but we must have the discussion.”

In its electoral manifesto before the 2022 general election, Labour promised to start a national discussion on the matter. The party’s deputy leader Daniel Micallef also voiced support for a discussion in the past, after his own father had lost the battle with a fatal illness.

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Interview with Health Minister Jo Etienne Abela

MLZ: You’ve cancelled a mental health hospital Chris Fearne had planned, you want to expand the emergency department, you will be building a new hospital at St Luke’s, you’re re-introducing helipads at Gozo and Mater Dei hospitals and you’re buying new MRI and CT scan machines. Was Fearne doing it all wrong?

JEA: Chris Fearne did absolutely nothing wrong during his tenure. I worked as a surgeon at Mater Dei during that time and I could see progress first-hand. Our health system is robust and resilient and it’s thanks to him. But we’re two different individuals, with different ideas.

MLZ: Why have you ditched plans to build the long-promised mental health hospital? Don’t we need it now more than ever?

JEA: Experts have repeatedly advised us that it would be more beneficial to build an acute mental health unit within Mater Dei.

If we want to reduce mental health stigma, we must treat it like all other health issues and what better way to do that than integrating the unit within the hospital? A standalone hospital would have only segregated mental health once again.

MLZ: So, when your government planned to build a standalone hospital, it was doing it wrong.

JEA: Absolutely not. There was a shift in ideas and there’s nothing wrong with changing ideas when faced with new evidence or advice. We will also offer some services at a new outpatients’ psychiatric clinic at St Luke’s. Patients with chronic issues will still be treated at Mount Carmel, which is being renovated as we speak.

MLZ: When will the Mater Dei mental health unit be ready?

JEA: The Foundation for Medical Services (FMS) has already begun work on it and on the expansion of the emergency unit, which will grow to double the number of beds.

MLZ: By when will these be operational? Because you just boasted about our ‘robust’ health system while there are people at the emergency unit as we speak who have been waiting there for 12 hours.

JEA: It’s the same situation in emergency units abroad. It’s normal for patients to wait long hours.

MLZ: But is that right?

JEA: Of course not. If I thought it was right, I wouldn’t be expanding the unit to double its size, and if there’s a patient waiting in our hospital corridor, it makes no sense to tell them to be patient because patients in the UK are also waiting. We are aware of the problem and that’s why we’re increasing infrastructure and resources. But there’s also a challenge with human resources – not just to find the people but to retain them.

MLZ: Why are medical professionals leaving?

JEA: It would be too simplistic to say salaries are the problem. I was in Greece recently and they pay their medical professionals far less than we do. It’s the same in Italy. Our salaries are at par with the UK. We pay some professions even more. Of course, there are countries that pay more than we do – like the US, Australia and Norway – and salaries should continue to increase by time. But salaries in Malta are not bad and they’re not the only issue.

I think we should focus more on offering professionals more career progression and opportunities for training, research and fellowships abroad.

MLZ: When will the Mater Dei mental health unit, the new St Luke’s hospital and the Mount Carmel renovation project be ready? Because we’ve been promised a proper Mount Carmel renovation for ages and it hasn’t happened yet.

JEA: Works at Mount Carmel are ongoing. Are they fast enough? I don’t think so.

 

MLZ: But why? The buck stops with you now, it’s your responsibility to make things happen.

JEA: OK, allow me to comment on the tendering process. I don’t expect the health sector to get preferential treatment when it comes to procurement but we need to understand that health-related issues involve an element of urgency.

We have the money but we often can’t buy the equipment or build facilities because tendering processes sometimes take years. The system is essential for the sake of transparency, but if we want a patient-centred health system, we must find a way to make it more efficient.

Two years ago, I tried to get a CT scanner at St Vincent De Paul to ease the pressure on Mater Dei. We have the money for it. But, to this day, I haven’t managed to do a single CT scan there because the process has been going through a series of appeals.

So I can’t tell you when I’ll have all these projects up and running because it depends on how long the tendering process takes. When it flows, it does so very effectively. We recently opened a community care clinic in Għargħur. Work on it started just last December. In Gozo, we renovated a multi-disciplinary clinic in just four or five months. But we must understand there is an element of urgency here because we’re dealing with sick people, not buildings or bridges.

What I can tell you is that, by May, I will have presented a master plan and issued tenders for St Luke’s. New units will be built, some old units will be demolished and built anew and others will be renovated. The entire health sector’s administration will be housed in modern offices there, along with units which offer services to medical and nursing schools, a national outpatients unit that will significantly ease the pressure of Mater Dei and an entire ambulatory care hospital, which will be transferred there to absorb all day surgeries.

By the end of the year, we will have a new Child Development Assessment Unit (CDAU) and a child psychiatry unit up and running at St Luke’s.

MLZ: Drug-related emergencies have doubled and it seems cocaine is making its way everywhere. People who went to the emergency department suffering from issues related to cannabis intake quadrupled after the government passed the law on recreational cannabis. In hindsight, was that law a mistake?

JEA: As a doctor, I will never advise anyone to smoke cannabis.

MLZ: So, was it a mistake?

JEA: Was it? Was it not? I’m not...

MLZ: OK, maybe the law wasn’t the ideal thing to do?

JEA: I will tell you this categorically. I will never advise anyone to smoke cannabis. My advice will always be “don’t do it”, for several reasons. The law sought to regularise and sanitise cannabis use.

The government wanted to have a clean and safe source for it and that aim was good. Nobody in government ever urged people to smoke cannabis.

MLZ: We also have the highest rate of syphilis in Europe. You can’t tell me other countries also have this problem because statistics show we’re worse than all of them.

JEA: Our genito-urinary clinics have seen a spike in visits, which doubled to more than 7,000. This is why the government is also working on a sexual health policy.

MLZ: That’s been promised for 14 years.

JEA: It will be out for sure in the coming weeks.

MLZ: Will it be out before summer at least?

JEA: Yes, I think it will be ready before summer. It will have to go through cabinet, then launched for public consultation and then updated and published.

But this strategy alone will not solve all problems. It must be accompanied by marketing and PR campaigns on contraceptive use.

MLZ: Do you plan to revise the abortion law in any way?

JEA: It’s not in my plans. I believe the government achieved its aim with the amendment passed last year, to safeguard pregnant women’s health in bad circumstances.

MLZ: And what do you say to pro-choice activists and women who feel they’re being denied their reproductive rights?

JEA: I listen to everyone. But your question was about my intentions and I don’t intend to change it.

MLZ: Do you exclude that it could be changed by the next election?

JEA: I don’t exclude anything. This is a modern and fluid country and I can’t exclude anything. I don’t see anything wrong with a discussion on a revision of the law. If the government wants to discuss that, I will not be a spoke in the wheel. But you’re asking a very hypothetical question.

MLZ: Do you draw the line somewhere? If the prime minister comes to you with a proposal to amend the law to allow abortion up to 12 weeks, for instance, would you support that?

JEA: My own family members are divided on this issue.

MLZ: But none of your family members are the health minister. You are the health minister.

JEA: But my family reflects the society’s sentiments.

MLZ: Society is split on everything. Some people in society are Labourites and some are Nationalists. But that doesn’t matter because you are the minister. What would you do?

JEA: It would be very simplistic for me to just give you an answer on the spot. It’s a very complicated issue – it has ethical and moral implications and we must respect the will of the people who elected us. I did not expect you would ask me about this, although it’s a legitimate question. But I’m being honest. I haven’t thought about it and it’s not in my plans.

MLZ: Where do you personally stand on abortion?

JEA: I’m against it. But I can engage in a mature discussion and I can listen to all sides.

I definitely agree with a cigarette ban

MLZ: Are you in favour of any form of euthanasia or assisted suicide?

JEA: Yes. I oppose broad forms of euthanasia but, as a doctor, I’ve seen terminal illnesses advance beyond any hope of cure or survival. I dealt with the worst forms of lethal cancers in my career. I have seen and lived with people who were at a point where they had no way out. And that suffering disturbs me.

[The minister becomes emotional as he explains that a close friend went through a similar situation.]

Sometimes, even the best palliative care leaves patients in a lot of pain, with no hope of living. In those circumstances, I believe doctor-assisted suicide is justified.

We would like to discuss this at some point. I understand it will inevitably bring up ethical and moral arguments and that’s fine but we must have the discussion.

MLZ: Many people are going to Turkey for major weight-loss surgeries. Does this trend worry you?

JEA: I worry because I’m not sure they are sufficiently informed about the surgeons performing those operations. They are very safe surgeries but, like all surgeries, they can go wrong in a number of ways. If it were me, I would have a surgery like that in Malta, where we have a better health framework and know who the specialists are.

MLZ: So you don’t see a problem with the surgery itself but with doing it abroad.

JEA: It’s a very safe operation.

MLZ: Some people say that, after the surgery, they feel full after two bites of a sandwich or a spoonful of soup. Do you think that’s healthy?

JEA: That’s the point of the surgery.

MLZ: To stop eating altogether?

JEA: Our hunter-gatherer body probably evolved eating two or three times a week, at most. The operation has risks  but it is safe overall. And it does not just make you lose weight and feel better about yourself – it also helps heal conditions like high blood pressure, heart attacks, kidney failures, diabetes, arthritis, obstructive sleep apnoea and other conditions.

The same goes for the medications your paper wrote about this week. I often prescribed injections like those as a surgeon, given the person was really overweight and did not suffer from conditions that precluded their intake. These remedies work and this branch of pharmaceuticals will only grow in the future but we can’t fight obesity with just surgery injections either.

MLZ: So, maybe, we should push its tourism aspect. So that people start coming to Malta, instead of going to Turkey.

JEA: I’ve been thinking about that for as long as I’ve worked in Malta. I agree. But first we need to increase services to cater for the people in our country, then we can expand to attracting that kind of tourism.

MLZ: Will you introduce a cigarette ban?

JEA: I definitely agree with it and I’m talking to government backbenchers who have already started working on it.

MLZ: Is new FMS head Robert Xuereb being paid as much as his predecessor, Carmen Ciantar? She earned €163,000 per year.

JEA: He’s not being paid as much.

MLZ: How much is he being paid?

JEA: I don’t know how much but less than that for sure.

MLZ: Two judgments in the Vitals and Steward case found that taxpayers were not just defrauded by the deal – government officials were also complicit. Essentially, your government defrauded the country. Don’t you feel you or someone in government should at least apologise to the people?

JEA: The government never opposed any of those judgments, which shows we want to move forward. There’s an ongoing international arbitration process and I cannot comment further but our lawyers are doing everything they can...

MLZ: I’m not asking about the arbitration though. That’s about the €100 million clause. I’m asking why none of you feel compelled to at least apologise for what was done.

JEA: The government’s aim to deliver the medical services it promised was not achieved and I have no problem apologising for that. I wasn’t even in politics at that time and, as a medical professional, I could feel the need for an MRI scanner in Gozo, for instance. Now, thanks to the government, we got that. I have no problem apologising but I’m more concerned about how to move forward.

The interview has been edited for clarity and brevity.

Watch the interview online on Times of Malta.