The debate on medically assisted suicide now occupies a central position in the public, legal and healthcare discourse in our country, in light of the developments in case law that have taken place in recent years, beginning with Judgment 242/2019 and subsequent rulings. In this context, it is imperative that the SICP – the only Italian scientific society specifically dedicated to the culture, clinical practice and development of palliative care – adopt a clear, well-reasoned and institutionally responsible stance: it is essential to avoid partisan exploitation and divisive debates that stray from the genuine protection of the rights and dignity of the sick person.
The relationship between palliative care and medically assisted suicide constitutes one of the most sensitive areas, where issues relating to the protection of human dignity, the principle of self-determination, professional responsibility, the protection of the vulnerable, and the very mission of medicine and care converge.
To address such a controversial issue, the Italian Society for Palliative Care has established a Committee on Ethical Issues (COMETE), comprising 25 professionals including doctors, nurses, bioethicists, psychologists, legal experts and philosophers.
The diverse ethical, cultural and professional perspectives within the Committee were not an obstacle, but rather the essential methodological foundation for drafting a document capable of reflecting the true complexity of the issue and, through reasoned dialogue, identifying solid and widely accepted points of convergence.
The outcome of this discussion, guided by the search for a shared bioethical framework, is a Position Paper that provides an ethical and organisational framework for the relationship between the right to palliative care and requests for SMA.
Palliative care and SMA represent two profoundly different approaches to end-of-life care, as they address radically different human, clinical and ethical questions.
The request for palliative care is expressed in the question: “Help me to live out my life to the end in a way that is dignified for me, with bearable suffering and a renewed sense of purpose amidst my illness”.
‘Help me to end my life in a way that is dignified for me, because my suffering has become unbearable and meaningless’, is, by contrast, the request for SMA.
Palliative care has its roots in a form of medicine focused on care and support. According to the World Health Organisation’s (WHO) definition, it “affirms life and regards dying as a natural process; it is not intended to hasten or delay death” (1990). Its aim is to alleviate suffering, support the individual, uphold quality of life, prevent neglect, and preserve dignity and relationships until the natural end of life (due to the progression of the disease).
Medically Assisted Suicide (MAS) belongs to a different paradigm, in which death that is intentionally brought forward and self-induced is considered, under certain conditions, a possible response to suffering deemed intolerable by the person experiencing it
The fundamental ethical distinction concerns intentionality: in palliative care, the shared intention is to treat and alleviate suffering until the natural end of life (due to the progression of the disease); in medically assisted suicide, the intention is to bring about one’s own death in order to eliminate the suffering that makes life intolerable.
Palliative care is neither complementary nor an alternative to medically assisted suicide: it is distinct because it addresses different clinical and ethical issues.
The Position Paper emphasises the importance of palliative care teams being involved in the information and assessment phases of requests for medically assisted suicide. Palliative care teams possess specific expertise in active listening, the therapeutic relationship, and the assessment of overall suffering, refractory symptoms, psychological vulnerability, existential suffering, relational and spiritual needs, and fears of abandonment or of being perceived as a burden to loved ones.
The palliative care team can assess whether the person has genuinely had the opportunity for timely access to high-quality palliative care, or whether the request for SMA is determined or influenced by inadequate care that could potentially be improved.
In this sense, palliative care plays an essential role in safeguarding the genuine freedom of the patient, aimed at ensuring that this freedom does not stem from avoidable suffering, poor communication, therapeutic neglect or a lack of comprehensive care; such care can therefore be proposed and, if accepted, implemented.
The issue of direct participation in the implementation phase of SMA is, however, a separate matter. Individual professionals belonging to palliative care teams may, according to their conscience and in a personal capacity, choose to participate in SMA. However, whilst recognising this individual freedom, it remains essential to maintain a clear distinction between the identity of palliative care and the specific aims of SMA, and to preserve the specific mission of palliative care and palliative medicine.
This distinction does not stem from an ideological stance, but from the need to protect public trust in palliative care, clarity of communication and freedom of access to palliative care for vulnerable people who do not require the SMA.
There are several reasons for this separation: the need to avoid confusing roles and objectives; the risk of creating (at this moment in history) a misleading link between palliative care and its provision, which is mistakenly perceived as being limited to end-of-life care; the uncertainty that this might compromise the free choice to seek palliative care precisely on the part of those who actually need it, so that full freedom of choice can be guaranteed to those who require palliative care but do not request SMA.
Recognising this distinction does not mean denying the ethical pluralism present in contemporary societies, nor does it mean disregarding the importance of SMA being regulated and governed. On the contrary, it is precisely in a pluralist society that it becomes essential to maintain a clear distinction between palliative care and SMA, so that every person may exercise, in accordance with their own needs and their deepest values and convictions, a genuine freedom of choice that is truly informed and free from misunderstandings.
Above all, this distinction protects the most vulnerable people – those who require palliative care but do not wish to undergo SMA – so that they may freely access care without fear, ambiguity or culturally misleading misunderstandings.
Confusing the two areas would entail a serious restriction of genuine freedom: “Authentic freedom,” the Position Paper emphasises, “does not consist merely in the abstract recognition of a right, but in the concrete possibility of choosing without fear, without ambiguity and without implicit conditioning”.
The Position Paper is available on the SICP website at this link: https://www.sicp.it/doc/position-paper-rapporto-CP-richiesta-SMA.pdf
