The euthanasia law that the Congress of Deputies approved on March 18 must enter into force three months after it is published in the Official State Gazette (BOE). The new standard, which has taken years to achieve, makes Spain the fifth country in the world to regulate it after the Netherlands, Belgium, Luxembourg and Canada. But, once voted, the most difficult thing remains: putting it into operation with guarantees. And both supporters and detractors agree that the wording of the rule leaves many aspects up in the air. The federal president of the Right to Die with Dignity (DMD) association, Javier Velasco, a supporter of the law, openly admits: “It is a very demanding deadline, but that is better than leaving it for two years.” Manuel Martínez-Sellés, president of the Madrid Medical Association andContrary to the initiative, he agrees: “Three months is a very short time to do and clarify a lot of things. All the legal procedures have been accelerated and the times specified are also short ”.
Juan José Rodríguez Sendín, president of the Ethics Commission of the Collegiate Medical Organization (WTO), believes that, precisely, the first of the imbalances is in the deadlines: although the law enters into force in three months, it gives another three for autonomous evaluation commissions are set up, which will control the process. “What happens if someone asks for euthanasia in between?” That is why he believes that it would be better for this work to be started in parallel so that the commissions, protocols and all procedures are ready when the law becomes effective.
The only homogenizing mechanism provided by law is an annual meeting between the chairmen of the commissions and representatives of the Ministry of Health (in turn responsible for management in Ceuta and Melilla). Javier Velasco believes that “it would be good if the Interterritorial Council gave common guidelines.”
For DMD it will be essential to have annual reports on the work of these commissions and the decisions it makes in each community. Velasco believes that it is essential that there be digitized forms for requests, so that the responsible doctor will find it easier to process it, and also so that it is possible to compare what is happening in each place, what has been allowed and what has been rejected. And this supposes a joint development of the 17 autonomous communities and Ingesa (the body on which the care in the autonomous communities depends), which experience says is not easy (achieving interoperability of health cards has taken more than 15 years ).
Who is the responsible doctor
Another aspect that the law does not clarify is who is the doctor responsible for the patient. Velasco affirms that “in an oncological patient it seems clear, but euthanasia does not necessarily have to be requested by an admitted patient.” “In that case we advocate for him to be the family doctor,” he adds. Martínez-Sellés agrees, and reaches another controversial point, that of the objection of the health workers. “Indeed, the law speaks of a responsible team and a responsible doctor, but it does not say what happens if the doctor makes an objection. I think it is appropriate to remember that the Code of Medical Deontology that we have in Spain and which is recent [is less than 10 years old] says: ‘The doctor will never intentionally cause the death of any patient, not even in the case of an express request by this’.
However, this last statement is questioned by Velasco, who believes that there is a lot of noise from the management of medical colleges, but that later the professionals will not be so willing to refuse. In fact, the only surveys that have been carried out in medical schools recently ( Bizkaia, Madrid, Tarragona and Las Palmas) give support above 67% to help end the suffering of a patient in this way. In addition, the president of DMD estimates that, due to what has happened in the Netherlands and Belgium, requests for euthanasia will be relatively few, around 1% of deaths, which are about 400,000 a year in Spain. Even so, he admits that in Belgium “very few doctors dared”.
Whether they are many or few, the law establishes that a registry of professionals who object to applying or participating in euthanasia will be created. The president of the Madrilenian doctors affirms that it seems to him “very controversial to force to pronounce on convictions and appear in registers that can have an intimidating character and repercussions at the labor level”. “I think that such registration may even go against the data protection law,” he adds. He agrees on this with the PP Health spokesman in Congress, José Ignacio Echániz, who stated in the rostrum that appearing in that registry may have the consequence that this professional is not hired or denied a promotion. Velasco points to another nuance: “It may not be right to object to everything; there are doctors who can refuse euthanasia but not assisted suicide ”.
Rodríguez Sendín is against a registry of objectors. “It may happen that someone changes their mind, or that in a specific case modifies it,” he says. The deontology commission, therefore, defends that the objectors communicate it in writing to their immediate bosses so that they know it when organizing the service. In addition, he points to a risk that he believes must be avoided, and that is to happen as with the regulation of abortion: there were so many objectors that the benefit was referred to private centers. “You have to avoid specific facilities for euthanasia,” he says.
The text does not name assisted suicide
Actually, the law does not make that difference formally. The word suicide does not appear, as Martínez-Sellés criticizes, but it is explained that the patient can be given a medication so that he can self-administer it and cause death. Of course, during the process, he asks that there be a toilet with him. “What happens if, in the end, the patient decides not to take it? In Oregon, where assisted suicide is decriminalized, but not euthanasia, 35% of patients eventually do not take it. Maintaining close face-to-face surveillance can be interpreted as coercion ”, criticizes the president of the Madrid doctors, since the law does not set a period from when the authorization to receive aid to die is received until the process is completed, either through euthanasia itself (someone from the healthcare team, not specified either,
Martínez-Selles points to other aspects that are difficult to fulfill. The law gives the doctor two days from when the patient tells him that he wants euthanasia to inform him of his alternatives both with respect to his illness and the aid he can receive for palliative care or dependency law. “It is a very short time to offer a plan. In such a short time it is almost impossible to consult palliative care, social work, and other services involved, “he says.
Although it does not affect both the procedure and the substance of the matter, the president of the Madrid doctors considers the most serious thing that the law gives the possibility of skipping the previous controls in cases of death or imminent loss of capacity. “It can be a dangerous shortcut that gives a single uncontrolled medic unlimited power. It seems particularly absurd that this should be raised in cases of imminent death. Why isn’t palliative sedation done? ”He wonders. The difference between this —administering the necessary drugs to control symptoms such as pain or anguish, even knowing that this will cause the death of the patient— and euthanasia is that the former seeks to “end the suffering”, and the latter , “End the sufferer,” he says.
The difference, explains DMD, is that with the euthanasia law the patient can decide when to request these medications and there is a whole procedure in place to ensure that their wishes are taken care of without having to wait for a palliative team to decide if they suffer. enough to sedate you. It was what happened four years ago with Luis de Marcos, affected by advanced multiple sclerosis, who was refused sedation in a specialized palliative center in Madrid despite the fact that he asked for it due to the pain he suffered, which forced him to change hospitals to be treated. In fact, in its opinion on euthanasia, one of the ideas pointed out by the Spanish Biology Committeeis that greater flexibility and ease of access to sedation would avoid requests for euthanasia.
Rodríguez Sendín explains it like this: “All doctors defend life. Another thing is what we consider to be life. This is a debate of subjectivities, of assessing whether the patient has intolerable suffering or not. That is why you have to be careful and flexible ”.