«Anabel, Artemisa, 41 years old: My father died three years ago, months before COVID-19 started. He had metastatic throat cancer. Because it was impossible for him to speak, he wrote me on a note that he wanted to end everything immediately so that we (his family) would not spend even more money on travel, food or bad nights in the hospital. I understood what he was trying to say, but my brothers didn’t. Very painful”.
The draft Public Health Law was the focus of debate in some sections of social media after its presentation on December 11, 2022 before the Cuban Parliament. One of the newest and most controversial aspects of the as yet unpublished document is the recognition of the right to a dignified death through euthanasia.
In general, the World Health Organization (WHO) and the World Medical Association (WMA) define euthanasia as “the procedure which the patient or his/her relatives voluntarily accept when the former could not decide for themselves and is carried out by a physician which hastens the death of a patient to avoid unnecessary suffering and pain.
In recent history, several paradigmatic cases have exposed the human dimension of the conflict and encouraged legislative change. For example, in the Netherlands in 1973, a doctor was convicted for having encouraged her mother’s death at her request. The case caused a great deal of excitement, and although the verdict was upheld, the court ruling established criteria by which a doctor is not required to keep a patient alive against their will. As a result, the Dutch courts have issued a protocol that allows doctors to use the procedure when the person is in the terminal stages.
A notable case in Spain is that of Ramón Sampedro, a Galician navigator and writer. Sampedro committed suicide in 1998 with the help of his girlfriend Ramona Maneiro. The writer became paraplegic after an accident. For several years he asked to be allowed to die legally, but was always turned down. His story sparked legal and ethical debates in the European country about the dignity of life and whether death is part of the right to a dignified life. After many years of debate, in June 2021 Spain passed an organic law regulating euthanasia.
However, the topic is still controversial even among health experts. The World Medical Association Declaration on Euthanasia (adopted by the 38th World Medical Assembly in Madrid in October 1987 and reaffirmed by the 170th Session of the Council in Divonne les Bains, France in May 2005, repeated and adopted in Georgia in October 1987). 2019) provides the following:
“Euthanasia, that is, the intentional killing of a patient’s life, even if it is done voluntarily or at the request of family members, is unethical. This does not prevent the doctor from respecting the patient’s wish to let the natural process of death take its course in the final stages of his illness. The World Medical Association reiterates its firm belief that euthanasia is contrary to the fundamental ethical principles of medical practice and urges all national medical associations and physicians not to engage in euthanasia, even when permitted by law or decriminalized under certain conditions.
Each case (whether the person faces an agonizing death, is in a vegetative state, or their circumstances do not allow them to fulfill their ideal of dignity) presents new conflicts, although a constant in the debate is respect for the individual will and will appear to be minimum quality of life standards. The fact that currently the world organizations leading the debates do not have positions confirms the diversity and complexity of the ethical, medical and legal debate.
Regulation, decriminalization and other international experiences
Euthanasia as a medical aid is not recognized in most countries. The Netherlands implemented it as a variant in 2001, Belgium in 2002, Luxembourg in 2008 and Canada in 2016. In Colombia, the only Latin American country with such a provision, it has been a constitutional right since 1998, although implementation only started as of 2015.
Other countries have opted for alternatives that involve civil society more directly and require less intervention from healthcare institutions. This is the case in Switzerland, where assisting in suicide is not a crime unless there are selfish motives. Assisted suicide — not to be confused with euthanasia — is carried out by right-to-die associations, and some serve citizens of other countries. This leads to the informal existence of so-called suicide tourism in the Alpine country.
In the case of euthanasia, the medical staff is the one who administers the drugs that cause death and it is the medical institution that must control the process and give guarantees of compliance with law and ethics. With assisted suicide, on the other hand, the person self-administers the medication provided.
Several territories in Australia and New Zealand have regulated euthanasia. In 2017, the Parliament of the state of Victoria – in south-eastern Australia – passed a new legislative measure allowing the terminally ill to request euthanasia through the use of drugs.
In the United States, at least ten states allow assisted suicide if the person’s medically determined survivability does not exceed six months.
Austria passed a law on euthanasia in December 2021 following a ruling by its constitutional court. This and Spain, through the Organic Law Regulating Euthanasia, are the latest countries to have implemented laws for a dignified death.
In countries like Chile, Portugal, France or Ireland there are initiatives to promote the decriminalization of euthanasia.
In addition, the Council of Europe, which has been dealing with the subject since 1976, has made various recommendations on euthanasia.
Among these, Recommendation 1418 (1999), adopted on 25 June 1999 by the Parliamentary Assembly of the Council of Europe, stands out. The Assembly calls on Member States to incorporate in their domestic laws the necessary legal and social protections against threats and fears. that the terminally ill or dying faces:
I. Dying with unbearable symptoms (e.g. pain, suffocation, etc.).
II. The prolongation of the dying process against the will of the terminally ill.
III. Dying in social isolation and degeneration.
IV. Dying from fear of being a social burden.
V. Restrictions on life support for economic reasons.
SEEN. The lack of funds and material resources to provide adequate care for the terminally ill or dying.
Recommendation 1418 also urges that the dignity of the terminally ill or dying be protected and preserved in all aspects; affirms and protects the right to comprehensive palliative care, protects the right to self-determination and supports the prohibition of the deliberate termination of life of the terminally ill and dying.
According to the European Council’s Guide to the decision-making process for medical treatment at the end of life, respect for autonomy begins with the recognition of the legitimate right and capacity of individuals to make personal choices. The principle of autonomy is essentially realized through the exercise of free consent (without restrictions or undue pressure) and informed consent (after providing the appropriate information according to the proposed action). The individual can change their mind about consent at any time.
Cuba, how would it be settled?
«Rodolfo, Artemisa, 79 years old: I live alone, I have been a widower for more than 15 years and my only daughter has been living in Italy for a long time. If I find myself in such a critical health situation, the best thing would be to leave this world calmly and without bothering anyone. I was lucky and have nothing on my conscience. I lived the way I wanted, so if I could put it in writing, I’ll put it. I want to be even less of a burden to my brothers who live in the province and who are the same age as me and to my daughter».
If passed by Parliament, the Cuban Public Health Law must include the recognition of euthanasia. However, the implementation of the new code requires a higher-ranking legal regulation. That is, another specific norm that regulates the cases and the procedure to be followed.
According to José Ángel Portal Miranda, Minister of Public Health, euthanasia is recognized as the right to a dignified death and as a form of welfare and health care.
Passing a law recognizing euthanasia in Cuba opens up opportunities that have never been publicly addressed or discussed. In the first place the possibility that man decides the course of his life up to his end. Each person could live (and die) according to their beliefs, at least in terms of bodily autonomy.
The procedure can also be analyzed as a variant for eliminating or minimizing the so-called therapeutic cruelty in the palliative care phase. Palliative care is a medical specialty that focuses on terminally ill patients, not only in the health process, but also in psychological support, occupational therapy, etc.
However, not everything that is technically possible is always advantageous for the patient. Dysthanasia (extending a patient’s life near death and with no hope of recovery), stubbornness, or therapeutic cruelty is an ethical error and a lack of competence. With this in mind, those who advocate euthanasia question the moral legitimacy of using futile treatments.
From the law, the clarifications that define the legal position related to the concept of euthanasia are linked to the crime of assisted suicide provided for in Article 353 of the Penal Code in force on the island. So far, the possibility of recognizing euthanasia in Cuba has been viewed and discussed mainly from the perspective of bioethics, not as a legal category that requires a deeper study of the topic.
The possible approval requires significant changes in the judicial procedures and draws distances between criminal and non-criminal behavior, between freedom and prison, between justice and injustice.
The social media debate
“Carlos, 62 years old, Havana: My mother had been recovering for almost a year and was getting worse every day. I would have preferred to have a happy memory of her since she was conscious and sane, but it was impossible. Alzheimer’s is a complex disease that devastates both the mind and body of those affected, and I wish I could have made decisions about how to end their suffering and, by extension, that of their loved ones.
The debate on the legislation comes at a time of deep economic crisis that is directly affecting both care and the healthcare system. Many people then ask, is it wise or realistic to recognize the right to a dignified death when quality standards of attention and care cannot be guaranteed?
Professor Alina Bárbara López Hernández, PhD in Philosophical Sciences, shared on her Facebook wall (December 12, 2022) when some of the draft law’s proposals were published: “A dignified death should be the culmination of a dignified life. They want to guarantee one without us enjoying the other!”
As a result of the publication, a debate arose. User Leydi Suarez shared: “With all due respect. It seems to me that this country is modern with the laws, and that’s a good thing! But the most pressing problems in our society are postponed every day. It would be necessary to prioritize and examine, for example, the quality of health services, let alone other issues, before starting to think about euthanasia. Please!”
For his part, Ramonin Muro argued: “Every philosophical, religious conception and every culture has its way of understanding life and death. I personally defend euthanasia and respect for human free will.
For Tico Sánchez Pérez, approving the law could have other connotations: “If something like euthanasia is approved in Cuba, it means giving these benefits, at a price of solidarity, to the “foreign brothers” who will pay what they are Value. And they will make death an exportable line because they are so good at it… ».
The debate is complex and is just beginning, as Jorge Álvarez Santiesteban understands it: «Basically, I do not question the right for someone to end their life if they are in an incurable state of health. I don’t support it because I view euthanasia as assisted suicide, but at the same time I appreciate the emotional and mental anguish it causes for a person who is in terminal stages of health to know that there is no cure or cures, that will save life in the short term. Which is quite questionable, because when you put a patient to sleep and after a few months the cure appears… in short, it’s a topic that deserves a lot of analysis and national debate. I do not believe that assent to this right is confined to the narrow confines of our National Assembly. What I question is the moment that attempts are made to debate this law.
The social conversation will be complex and it is important that it is informed. For this, more clarity about the proposed law is essential, as is a communication strategy that encompasses all possible edges of the debate: bioethics, medicine, sociology, religion and law.
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