At this moment of profound moral reflection, Malta stands on the cusp of redefining how we confront the end of life. Although the government’s White Paper on Assisted Voluntary Euthanasia promises robust safeguards, beyond the mechanics of dual medical opinions, psychiatric assessment and legal oversight lies a far more urgent question: What will this decision mean for Maltese society in the long term?

Across Europe, only five nations allow doctors to administer life-ending medication under tightly defined conditions of unbearable suffering and a prognosis of six months or less. The Netherlands and Belgium led the charge in 2002, followed by Luxembourg in 2009, Spain in 2021 and Portugal in 2023.

A second group of countries decriminalise assisted suicide, allowing individuals to self-administer prescribed lethal drugs. In Switzerland, helping someone end their life with prescribed drugs is legal as long as the helper has no selfish motives. Germany adopted a similar law in 2020 and Austria followed in 2021. In Italy, the regions of Tuscany, Apulia and Emilia-Romagna have quietly introduced local protocols allowing self-administration, despite Italy’s national ban.

The United Kingdom remains a patchwork. England and Wales passed the Terminally Ill Adults (End of Life) Act in 2024, though services are not expected before around 2029 as safeguards are bedded in; Scotland’s equivalent bill is still under parliamentary scrutiny; and Northern Ireland retains a formal ban on assisted dying, albeit one rarely enforced when compassion is clearly evident.

France stands alone in maintaining a strict prohibition and instead permits continuous deep sedation under its 2016 Claeys-Léonetti law.

Meanwhile, the vast majority of European countries continue to offer palliative care and uphold patients’ absolute right to refuse treatment rather than any form of assisted dying.

Set against this context and informed by Europe’s diverse experience, Malta’s proposal on Assisted Voluntary Euthanasia outlines a fortress of safeguards: any resident aged 18 or over, with at least 12 months’ residence and a terminal illness giving no more than six months to live, may request assisted euthanasia once fully briefed on palliative-care options.

Eligibility depends on certification by a specialist and two further assessments – one by a psychiatrist. The process will be overseen by a board, which must meet the patient after a one-week reflection period and decide within 14 days. If approved, the patient may self-administer government-supplied medication at home or in a designated government hospital area, under medical supervision. The right to withdraw remains absolute and coercion is a criminal offence. Patients with curable diseases, mental health conditions, disabilities or age-related impairments such as dementia are excluded.

Yet, despite these layers of protection, Malta’s blueprint faces the same perils observed abroad.

In Belgium, what began as a tightly controlled system in 2002 quietly extended eligibility from 2014 to minors under exceptional circumstances.

Last year, the Federal Commission for the Control and Evaluation of Euthanasia reported that euthanasia accounted for more than 3% of all deaths in Belgium, roughly one in every 32 deaths.

In the Netherlands, a similarly cautious regime has slipped to the point where euthanasia now makes up 5.4% of fatalities (about one in every 18 deaths), with all the Dutch Regional Euthanasia Review Committees noting a growing share of psychiatric and non-terminal cases.

Across Europe, only five nations allow doctors to administer life-ending medication- Ivan Cauchi

In contrast, Denmark has resolutely bucked the trend. In January 2024, the Danish National Council on Ethics voted 16–1 against legalising assisted dying, arguing that scarce resources would be better spent on palliative care and advance-directive frameworks. That caution reflects deep professional unease: a 2016 survey of Danish geriatricians in the Danish Medical Journal found that 56% considered euthanasia ethically unacceptable and 64% opposed physician-assisted suicide.

Since then, Copenhagen has committed millions to expand hospice services, train home-care teams and bolster specialist support, resolutely keeping its legal and moral boundaries intact.

Such caution seems all the more justified when one considers a more fundamental challenge than the risk of ‘scope creep’: Can doctors reliably predict a six-month life expectancy? A landmark BMJ study led by Dr Geoffrey Glare in 2003 found that only 25% of oncologists’ six-month survival estimates for terminal cancer patients were accurate within a week.

A systematic review by Dr Rachel White and colleagues in 2016 echoed that prognosis-accuracy ranges wildly, from 23% to 78%, and as Emeritus Professor Paddy Stone and Research Fellow Nicola White cautioned in the Financial Times in December 2024, six-month prognoses can resemble weather forecasts – at times accurate but often misleading.

Clinicians’ predictions are further skewed by personal biases. A 2016 study led by psychologist Colin Zestcott found that doctors’ predictions were often skewed by a patient’s age, disability, race or social background. In 2017, researchers Chloë FitzGerald and Samia Hurst warned in BMC Medical Ethics that entrusting life-and-death decisions to fallible, subjective judgements risks embedding discrimination within law.

Framed in this way, legalising assisted dying in Malta is more than a legislative milestone. It is a crucible in which our compassion, prudence and collective courage are being tested. We now stand at a crossroads: to summon the discipline of oversight or to slip, almost imperceptibly, into widening criteria that undermine the very dignity we seek to protect.

To head off this slow drift, Malta would do well to hardwire safeguards into law from the outset:

Enact a sunset clause, requiring parliamentary renewal every five years to compel lawmakers to revisit outcomes and revise safeguards in light of fresh data.

Ring-fence a substantial palliative-care budget, to train specialist teams, expand hospice capacity and bolster home-care networks, to ensure that relief through care remains the first recourse.

Establish an independent oversight commission to publish annual case-by-case reports, broken down by age, diagnosis and socioeconomic background, to sound the alarm at any widening of eligibility.

By embedding these safeguards from the outset, Malta can ensure that its laws, when called upon, embody our fullest humanity.

It will foster a culture of compassion, prioritising care and vigilance over the expedience of a hasty end.

Ivan Cauchi is a freelance researcher and lecturer in economics and public policy. He also serves on the Justice and Peace Commission within the Archdiocese of Malta and is actively involved in the lay community of the Missionary Society of St Paul (MSSP).

A longer version of this article is available here.