• Active euthanasia is illegal.
• Suicide itself is not a criminal offence.
• Assisting a suicide is a crime punishable by up to 12 years in prison. As far as we are aware, what constitutes ‘assistance’ in a completed suicide is undefined. For example:
  – would simply being present when a suicide died, or accompanying them to an institution abroad, in both cases at their clear request, be worthy of prosecution?
  – would supplying information on organisations offering assisted suicide be viewed as ‘assistance’?
  – would a ‘Dying Declaration’ before a notary, including confirmation that the suicide’s decision is well-considered, autonomous (and possibly against the wishes of, or at least not influenced by, the ‘assistant’) be likely to be a successful defence for the ‘assistant’?
  We would like to see guidance on when prosecution would not be in the public interest in Malta. Such guidance is available in the UK.
• Palliative sedation and withdrawal of treatment is legal.
• Patients have the right to refuse treatment, but must be conscious to do so.
• There is no law regulating “living wills” (or “advance directives”), which would enable people to state their wishes to be respected if, for example, they are no longer able to communicate or make decisions about treatment. Read more here.
• Voluntary Assisted Dying, and legally enforceable living wills, are not considered human rights under international treaties, nor by the European Court of Human Rights. However, as early as 2005, UNESCO’s Universal Declaration on Bioethics and Human Rights included (Article 5) “The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests”.
• International human rights legislation recognises the right to life, but that does not imply a duty to live under any circumstances.

• According to two surveys (by The Times of Malta and MaltaToday) in April 2024, 61% or 62% agree euthanasia should be legal under certain conditions, with 19% or 28% opposed, albeit with differences between the generations.
• This is a marked change from previous findings. According to a 2021 study only a small majority (52.6%) supported the right to legally end one’s life if terminally ill and suffering.
• As early as 2016, euthanasia was becoming more acceptable to Maltese youth. A 2016 Għaqda Studenti tal-Liġi (Law Students Malta) survey showed approval for euthanasia among law students at 69%. Another poll the same year showed that 65.1% of those aged 18-34 agreed the state should allow terminally ill people the right to end their life (only 35.2% above the age of 55 agreed).

• In March 2024, bioethics Professor Pierre Mallia, who has written in opposition to euthanasia, acknowledged that palliative care might not be enough to ensure a dignified death in up to 20% of cases.
• However, the only wider information we have found on doctors’ views dates back to a 2016 survey of 350 doctors in which over 90% said they were against euthanasia. (Just over 50% agreed with intensifying analgesia with the possibility of hastening death, and 32.1% had withdrawn or withheld treatment to terminally ill patients). 11.9% had faced requests for euthanasia. The survey concluded that “doctors need more guidelines, both legal and moral about this subject. In the absence of this, religion and life philosophy were being used as a guide in this difficult aspect of practicing their profession”. Such calls for more guidance and legal certainty for the medical profession have continued.
• There was a difference in perspective between doctors polled in 2016, and doctors then in the making. The Malta Health Student Association said in the same year “the health care system. . .start to seriously consider the legalisation of Euthanasia as it is undoubtedly an answer to some of our critically-ill patients”.
  • Catholic doctors in Malta are bound by State Regulation to follow the doctrine of the Roman Catholic church. What exactly constitutes a ‘catholic member of the profession’ is not defined.

• We can find no definitive statements on main parties’ agreed positions, but it seems that, so far, the only party supporting legalisation of any form of Assisted Dying is VOLT.
• Labour Party
  • In November 2022 PM Robert Abela said the government will take a decision on the legalisation of voluntary euthanasia by the end of the current legislature (2027).
    In December 2024 Parliamentary Secretary Rebecca Buttigieg announced she would release a consultation paper on ‘euthanasia’ in 2025.
  • In March 2024 Health Minister Joe Etienne Abela supported ‘doctor-assisted dying’ for the terminally ill, in extreme pain, where palliative care is unsuccessful. He reiterated this position in December 2024 “. . .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.”
  • In 2020, PL deputy leader Daniel Micallef said he would be campaigning for the legalisation of euthanasia. And according to a non-exhaustive report 2020, some individual PL MPs would support it.
  • In 2017, PL youth branch Forum Żgħazagħ Laburisti said it favoured legalisation of euthanasia.
• Nationalist Party
  • In 2022 PN party leader Bernard Grech said he was against it becoming an electoral issue, but it merited discussion.
  • In 2017 the PN opposed legalisation of euthanasia.

Humanists generally agree that our lives are our own, not a gift from, nor owing anything to, a higher power, and we should be free to decide our own destiny and life-experience, provided that does not result in harm to others.

Humanists Malta supports people’s right to choose the manner and timing of their own death if circumstances warrant it. A person facing the end of life cannot choose between living and dying, but should be able to choose between two different ways of dying. Of course, strict monitoring, regulation and safeguards are necessary to avoid any abuse or uncertainty (see dedicated point below).

A general prohibition on Voluntary Assisted Dying binds all, patients and medical professionals alike, to one view. Legalisation, for those relatively few who need it, would enable everyone, including the medical profession (if freed from the legal requirement to adhere to Roman Catholic doctrine), to act on their own conscience. Voluntary Assisted Dying cannot, by definition, legally be imposed on patients who disagree with it; the sanctity of life for those who believe in it and want to live as long as possible must not be in question.

There has been little evidence of significant abuse in countries where Voluntary Assisted Dying is legal (see dedicated point below), although some cases have arisen, including in relation to a patient’s mental capacity to choose, and failure of monitoring, which only underlines the crucial need for careful legislation and strict enforcement, especially to protect vulnerable groups such as the elderly, poor, and disabled.

But the possibility of abuse by others in the exercise of a legal right does not justify withholding that right for all, especially those demonstrably not subject to such abuse. It is unlikely that covert forms of Assisted Dying will not occur where they are illegal. And abuse will almost certainly happen in any event; the existence of a law does not guarantee it will not be broken. The choice is between Assisted Dying with or without regulation.

Voluntary Assisted Dying is not inconsistent with palliative care, nor have we seen any evidence of Voluntary Assisted Dying negatively impacting palliative care. Both should be part of an integrated, holistic, approach to end-of-life care which supports patients’ choices, provided they understand all the options. While any future improvements in palliative care are to be welcomed, it is not the answer for those suffering now, who have a clear, positive, and demonstrably sustained wish that their body should not be kept functioning when they are without independence, hope of relief, quality of life, and dignity.

This is never going to be an easy subject, but it cannot be beyond the skills of legislators to construct a regime which caters for those with a proven decision (including, for example, by the registration of a legally-binding Living Will) to die on their own terms. A regime which must include carefully scrutinised safeguards, and strict rules which guide and protect patients, medical professionals, and families.

• A UK House Of Commons Committee Report in February 2024 identified:
  • 17 jurisdictions (not necessarily countries) where forms of Voluntary Assisted Dying are legal only on the basis of a terminal diagnosis: 
    Voluntary Active Euthanasia in New Zealand, Western Australia, South Australia, Tasmania (Australia), Queensland (Australia), New South Wales (Australia), and Victoria (Australia);
    Physician Assisted Suicide in New Zealand, Western Australia, South Australia, Tasmania (Australia); Queensland (Australia), New South Wales (Australia) Victoria (Australia), New Mexico (USA), Hawaii (USA), District of Columbia (USA), New Jersey (USA), Vermont (USA), and Maine (USA).
  • 9 countries where Voluntary Assisted Dying is legal on the basis of ‘intolerable suffering’, allowing both Voluntary Active Euthanasia and Physician Assisted Suicide: Canada, Portugal, Spain, Luxembourg, Belgium, The Netherlands, Switzerland, and Austria.
  • 4 jurisdictions where Voluntary Assisted Dying is not necessarily illegal, but there is no formal process: Germany, Colombia, Montana (USA), and Italy (in February 2025 Tuscany became the first Italian region to approve a bill regulating Physician Assisted Suicide).

• • A bill on Assisted Dying for England and Wales is currently under discussion in the UK parliament. Another bill is being discussed in the Scottish parliament, and another is in its final stages in the UK Crown dependency of the Isle of Man.
• In April 2024 the French government introduced a bill to legalise Voluntary Assisted Dying, but it has yet to pass into law.

These vary between jurisdictions, but may include:

• A request for Voluntary Assisted Dying must be expressed, not implied, voluntary, well-considered, informed, persistent over time (eg at least a month between initial and further requests), and revokable at any time, in any manner;
• Requesting persons who had previously told their family of their wishes, but had not formalised them, are not covered;
• if there are any doubts amongst the doctors involved about a patient’s emotional or psychological capacity to make an informed, clear choice, a psychiatrist must confirm such capacity;
• tightly-policed protocols requiring 2 independent witnesses able to confirm the request was made willingly and free of coercion. Neither witnesses nor health professionals involved may have any legal, financial or other interest in the outcome;
• two doctors, independent of each other (eg not one working for the other; from different medical teams) and trained in medical ethics, must separately give written agreement the patient has an incurable, grievous and irremediable condition;
• there should be agreement by at least a second (if not third) doctor that all criteria have been met. The second and/or third doctor must be independent (not involved with the care of the patient) and trained to ensure the patient is informed of all options, including the benefits of palliative care;
• an age limit, often not below 18 years;
• to prevent ‘suicide tourism’, Voluntary Assisted Dying is available only to residents;
• cases of Voluntary Assisted Dying must be reported to a central body following the procedure;
• health professionals have the right to conscientious objection to any involvement in Assisted Dying.

Detailed debate is required about all the practical implications of a legal regime; how to formulate a structure which permits Voluntary Assisted Dying for those whose personal circumstances and beliefs warrant it, while safeguarding against abuse of those unable to freely decide for themselves, and protecting medical professionals:

• • Eligibility
    Should Voluntary Assisted Dying be limited to the terminally ill who are suffering without any hope of relief? Should patients with a terminal illness, even if not in unendurable pain, be able to choose Voluntary Assisted Dying? Should patients without a terminal diagnosis, but unable to endure their suffering, be able to opt for Voluntary Assisted Dying? And should the definition of suffering be restricted to physical pain? Different regimes have differing approaches, from limiting availability to those expected to live no more than 6 months, to allowing access for the non-terminally who are suffering, either physically or mentally, and even for minors.
  • Coercion
    Concerns are often expressed about the danger of coercion of the vulnerable (eg by greedy relatives, a health-care system under pressure in the financing of long-term cases, or perceived pressure not to be a burden). What safeguards are necessary to ensure requests for Voluntary Assisted Dying are freely made, when mentally competent, fully informed, considered, and sustained over time?
    • evidence, for example from the UK enquiry mentioned above,  suggests coercion to agree to Voluntary Assisted Dying is rare, and that, with a stringent regime and the involvement of trained professionals, it can be prevented, as far as any crime can be. Two US doctors recently testified that they have not seen coercion in that sense, but have seen it the other way round; the patient wants to let go, but the family is not willing;
    • mental capacity can be assessed by appropriately trained professionals, under guidelines established by law, but any doubt by professional experts should halt the process;
    • truly independent witnesses can be required.

    Should those of demonstrably sound and independent mind, but in anguish, be left to suffer because of a hypothetical risk, which can be controlled, to the few?

  • Abuse of the law
    Some reports, especially in relation to Belgium and Canada, suggest that adherence to safeguards is relaxed over time, or not properly monitored or enforced. Are these failures of the legislative system, rather than a negation of the principle? A regulatory body, properly constituted, must be given robust legal duties and powers to oversee the regime.
  • The ‘Slippery Slope’
    Some worry, citing Canada, the Netherlands, and Belgium, that legal amendments after the initial legislation will inevitably widen eligibility criteria and reduce safeguards. This does not have to be the case unless, after experience of the initial regime, public opinion calls for it. For example, it has not happened in Oregon, New Zealand, Australia or Switzerland or Luxembourg.
    Reasons for the increase in deaths by Voluntary Assisted Dying (see Some Numbers, below), where legal, are unclear, but are not necessarily indicative of a ‘slippery slope’; it is more likely that there has always been a demand, but it is now increasingly available and visible for those who would choose it.
  • Religious beliefs
    For some, Voluntary Assisted Dying is against their religious beliefs. The sanctity of life for those who believe in it, and want to live as long as possible, cannot be in question. But not everyone holds such beliefs; should an individual’s right to choose be denied by those who would not make that choice for themselves or others?
  • Conscientious Objection
    Should legislation include a right to conscientious objection? We do not agree that a health professional should make moral or religious judgements on behalf of a patient, but such professionals have their own human rights. Legislative provisions on conscientious objection to Voluntary Assisted Dying by health professionals in Malta must be clear, carefully balanced, and supported by comprehensive subsidiary guidance, for example on a duty to refer to a non-objecting doctor.

Figures from around the world are hard to find and analyse, but some are available. For example:

• There are more than 62 million deaths in the world each year. More than 720,000 are suicides. Doctor-assisted deaths in 2023 were just over 30,000.
• It is reported that, internationally, some 300 million have legal access to some form of Voluntary Assisted Dying.
• In 2018, it was reported that the proportion of global annual deaths reported as physician-assisted suicide were relatively low, typically less than ½%.
• A lengthy and comprehensive report by the Swedish National Council on Medical Ethics in 2024 discussed regimes around the world, including in Spain, Belgium, Luxembourg, Colombia, Switzerland, the USA, Canada, Latin America, Germany, Italy, France, Ireland, the UK, Denmark and Finland. For example, it said that:
  • In Australia, which has seen 1,667 deaths from VAD 2019-23, cancer dominates as an underlying condition in 58%-78% of patients. Neurodegenerative diseases and a variety of respiratory illnesses are the reason in 10–15% of cases. About 80% are receiving palliative care, about 15% of whom have been receiving palliative care for over a year. About half of patients who request Voluntary Assisted Dying are aged 65–81 years. The median age varies 72-76 years. The proportion of all deaths through voluntary assisted dying is highest in Western Australia, where Voluntary Assisted Dying accounted for 1.4%.
  • In New Zealand in the year 2022/3 807 people formally requested assisted dying. As in Australia, Benelux, Canada and the USA, various forms of cancer were the most common diagnosis. More than 75% of patients were over 65 years of age and more than 18% over 85. More than three-quarters were receiving palliative care at the time of applying for Voluntary Assisted Dying.
  • In 2022, 8,720 people died by Voluntary Assisted Dying in the Netherlands, 5.1% of all deaths in the country that year. Over 97% died through practitioner-administered assisted dying. Just under 90% who died through Voluntary Assisted Dying had either cancer (58%), neurodegenerative conditions (7%), cardiovascular disease (4%), respiratory diseases (3%) or a combination thereof (16%). 115 patients with a mental illness were granted Voluntary Assisted Dying (1.3% of all Voluntary Assisted Dying deaths). In the 20 years since Dutch assisted dying legislation was introduced, there have been 91,565 documented cases. In 133, a review has shown deviations from the criteria for proper care. In one case, this led to a criminal investigation.
  • Spain accepts advance directives in which an approved request for assisted dying may remain in force even if the patient’s decision-making capacity has subsequently declined. Of the 528 applicants in 2022, 14 had an advance directive, all with a legal representative previously appointed by the patient.
  • Dignitas in Switzerland assists around 200 non-Swiss citizens to die each year. Since its inception in 1999, 1,449 Germans, 531 Britons, 499 French citizens and 36 Swedes have died by self-administered assisted dying at Dignitas.
• Assisted Dying accounts for 4% of deaths in Canada, where the vast majority have an assisted death because they are less able to engage in enjoyable life activities (82.1%), are in severe pain (56.4%), or worried about loss of dignity (53.3%).
• In Oregon, on average a third of those approved for assisted deaths don’t take their life-ending medication. In most cases, because having the security of knowing they can end their suffering if it ever became too much to bear is enough.

Voluntary Assisted Dying is undoubtedly on the increase where it has been legalised. It is reported that cases have increased in every jurisdiction where it is legal (and where there is a requirement to publish reports) (see Slippery Slope, above).

• A 2007 investigation by Professor Battin et al later discussed in detail by Professor Battin focused on the impact of Assisted Dying in Oregon 1998-2006 and the Netherlands 1990-2005, and concluded that in both countries, apart from a very few suffering from AIDS, people from vulnerable groups were voluntarily accessing assisted deaths free from risk or coercion: ‘found no evidence to justify the grave and important concern often expressed about the potential for abuse—namely, the fear that legalised physician-Assisted Dying will target the vulnerable or pose the greatest risk to people in vulnerable groups [and] there is no current factual support for so-called slippery-slope concerns about the risks of legalisation of Assisted Dying – concerns that death in this way would be practised more frequently on persons in vulnerable groups.’ Battin et al, ‘Legal physician-Assisted Dying in Oregon and the Netherlands: evidence concerning the impact on patients in ‘‘vulnerable’’ groups”’
• A 2020 study on Canada’s Assisted Dying regime (MAiD – Medical Assistance in Dying) by Dr James Downar et al, current head of palliative care at the University of Ottawa, found: ‘Another common concern about the legalization of MAiD is the potential for people who face social or economic vulnerabilities to be pressured into MAiD. However, our data indicate that people from traditionally vulnerable demographic groups (from an economic, linguistic, geographic or residential perspective) were far less likely to receive MAiD, consistent with findings from the US and Europe.’ ‘…The practice of MAiD in Ontario is most common among elderly, community-residing patients with cancer, neurodegenerative disease or end-stage organ failure who are in the final months of life. Our findings that Ontario residents who received MAiD were frequently already followed by palliative care providers suggests that MAiD requests are unlikely to be the consequence of inadequate access to palliative care in Ontario. Recipients of MAiD in Ontario were younger, wealthier, more likely to be married and substantially less likely to live in an institution than the general population of decedents, suggesting that MAiD is unlikely to be driven by social or economic vulnerability.’

We have not found any EU jurisdictions where any form of Assisted Dying is effectively available to non-residents. This is why we would support the establishment of bilateral agreements with other countries to enable Maltese residents to make use of Assisted Dying clinics abroad, as a partial alternative until suitable legislation is established here.

Dignitas.