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Introduction

Officially, bioethics in Malta can be said to have started immediately after the 1987 general elections when, following 16 years of socialist administration, a more conservative Nationalist Party administration was elected. Setting up a “National Dialogue on Bioethics” was described by the then Minister of Social Policy, Dr. L. Galea, as one of his Ministry’s “keynote acts.” This was followed by a public conference to which Professor Laurence J. O’Connell from St. Louis University was invited. These two facts already quite simply dictate the path that bioethics was to take: the taking on of bioethical issues by a conservative government concerned with traditional moral values, which the country embraced as they were felt to have been abandoned over the past years (Galea, 1989), and the invitation of a professor from a Catholic university in the United States.

The proceedings from that meeting (Cortis, 1989) remain a historical document, having laid the scene for the next years. In this book, the important role that the Church was to play was confirmed in various papers and reflected upon in one of the talks (Grima, 1989). An issue which was discussed by the Prime Minister was “Bioethics and Future Generations” (Fenech Adami, 1989). Following the recent contribution Malta had made at the United Nations in the context of proposals of a new Law of the Sea, and general rules governing “common heritage,” the Prime Minister spoke about the relevance of genetics and its impact on future generations. At the time, the University of Malta also had a “Future Generations Programme” which dealt not only with bioethical issues but which also took a broader view upon future generations. Several years later, an international meeting on genetics was hosted by this program, the proceedings of which were published by Kluwer (Agius & Busuttil, 1998). Genetics however never really took on major debate in Malta, probably because there was never a successful attempt at genetic technology.

Many of the papers of the above public meeting however focused on reproductive technology, in particular, in vitro fertilization. This was already being practiced, and indeed people were starting to question not only the morality of the technology but also the lack of a legal framework within it was working (Grech, 1989). Grech pointed out that the Catholic Church sympathizes with couples who cannot conceive but that its position was that getting children is not a right. It can be said that this debate continues to this very day within the context of assisted procreation. The main question posed is that if we say that childless couples have a right to have children, it would be conveying a message of children being a property or a commodity. The Catholic Church has held this position in Donum Vitae (Ratzinger, 1987). Obviously in this context other issues, such as the respect for the embryo, embryo freezing and when human life begins, were brought up as well (Grech, 1989; Tabone, 1989).

The major concerns over time have been various but central to all these remained the issue of in vitro fertilization, with the government at times feeling paralyzed to move forward. A key contention was how to go about not freezing embryos while not putting the mother through undue and unnecessary procedures. With the recent developments of cryopreservation of ova, this seems to have been solved, but many remain skeptical as to whether this can be used for the masses (Mallia, 2010). Perhaps what kept legislation back was the lack of initiative of the relevant committees to start with agreeing on principles within the conflicts that existed. Clearly, there were conflicts of value about whether IVF should be used at all. An agreement to move forward on agreed principles between the government and the Church would probably have saved a considerable amount of time. At one point when all seemed to be ready for legislation, Archbishop Mercieca made a statement that IVF remained illicit and that it involved the killing of human life. Following this, then President of the Republic, Dr. Fenech Adami, stated that he will not give his signature of approval on any legislation put forward by parliament unless the Church is in agreement (Mallia, 2010b).

It is pertinent here to point out that Malta is a southern European and Mediterranean country and as such influenced by the deontological approach to bioethics in these areas (Gracia, 1993). Malta has always been under European influence, with the exception of a several hundred years in the first millennium, after the fall of the Roman Empire. During that time, it was under Arab rule, which in turn influenced the language. This Maltese has a Semitic background, although it is Latin in writing and influence.

Other than that, Malta has always been European and thus besides Mediterranean, southern European. It was part of the Kingdom of the Two Sicilies, during which period it was transferred from one nobility to another during the fiefdom period, until it was finally given to the Knights of St. John, from whence they obtained the name of the Sovereign Military Order of Malta. During this time, the Catholic Church was always very influential, and more recently the book by Montserrat, The Kapillan of Malta, clearly shows the social role priests play on the island. In bioethical debate, most Maltese people look to the Church for advice. This is not necessarily a disadvantage as the population has strategically placed individuals who are also easily accessible to guide them on what largely remain Catholic normative values.

Resources

Legislation in bioethics continues to be evasive. Malta is close to legislating on reproductive technology, but some issues with cryopreservation remain. Other legislation which challenged normative values, such as that of the introduction of divorce, and the periodic sermons by bishops which attack assisted procreation creating wide media response may have played a role in setting back legislation. The issue of IVF therefore was sidetracked a number of times (Op. Cit. Mallia, 2010b) due to the other consequential questions it raises: to whom to offer it (legally married couples, cohabiting couples, single parents, same sex couples, etc.), issues with freezing of embryos, and, when the issue became hot on a European level, what to do with frozen embryos and stem cell research. Conversely, there is general agreement about abortion (even the Green party, Alternattiva Demokratika, has taken a stand against it), that embryos have a right to life and not to remain frozen, and that IVF should be offered only to heterosexual couples who can offer a traditional family environment.

While legislation remains elusive, however, there are at the country’s disposal a number of structures which have been set up. The main platform is the Bioethics Consultative Committee. Also, teaching programs within various degree courses at the University of Malta have been set up. The media plays a major role as many bioethical issues create a lot of sensation. This was seen especially with regard to IVF, stem cell research, and cases of removal of nutrition and hydration of people in a persistent vegetative state (namely, the Terri Schiavo and the Eluana Englaro cases). Moreover, some scholars commit themselves to public education on bioethical issues on newspaper columns and radio programs. These scholars and commentators are frequently invited on the more popular television debate programs. There is therefore a considerable amount of public debate, which unfortunately, on a small island, can even taint the reputation of some who take more liberal stands, and abuse verging on subtle defamation has not been absent.

Infrastructure

Teaching of Bioethics

The main teaching of bioethics occurs under the aegis of the University of Malta. Both Faculties of Theology and of Medicine and Surgery have their own programs. Recently, the Faculty of Theology has started a Master’s program in Bioethics. This will be followed shortly by a Master’s program in Clinical Ethics and Law in the Faculty of Medicine and Surgery, within its Bioethics Research Program. This second degree is necessary because it is felt that while the MA degree offered by the Faculty of Theology offers a substantial humanities approach to bioethical issues, it does not prepare students for professional carriers such as clinical ethicists.

The Faculty of Medicine and Surgery’s Bioethics Research Program falls directly under the Dean of the Medical School. This program is intended to be a platform for research in ethics by encouraging students to choose bioethical topics for their theses and by participating in local and international research projects, especially those related to the European Community Framework Program. In addition, it promotes the understanding of bioethical issues by the general public through media such as daily newspapers and television and radio program. The author, who is the coordinator of the program, has a regular column on The Malta Independent on Wednesdays and is a weekly guest on the morning program Bongu (meaning “good morning”), for example. These media are used to speak mostly about current affairs in bioethics when they arise and also to promote understanding of mainstream areas of bioethics including patients’ rights issues.

The author occupies the only academic post in bioethics (with a special focus on patients’ rights) in Faculty of Medicine and Surgery but has an agreement with the university administration to teach in the Faculties of Laws, Sciences, Health Sciences (including nursing school, laboratory technicians, and nursing Master’s programs such as Mental Health), Education (in conjunction with Sciences), and Dentistry. He also participates in the Master’s degree offered by the Faculty of Theology.

Bioethics Consultative Committee

This committee is non-statutory; members are not paid and are self-selected by the Minister of Health. It is a consultatory committee, as the name suggests, to the minister of health. In the past, it has also been under the Ministry for Social Policy. Thus, it has oscillated between these two ministries. It has taken on a quasi-official role as being the “national” bioethics committee, and therefore it is members from this committee who participate in the CDBI meetings of the Council of Europe. For several years, it has been organizing a yearly seminar on a topic which is relevant to the country at the time. In the past, proceedings of these conferences were published along with any document the committee may have released. Such was the case when the committee worked on the Reproductive Technology Document and the Organ Transplantation Document (Cauchi, 2000).

As stated above, the members of this committee are selected by the minister. This has not always been ideal as it very much depends on the importance that the minister gives to the committee. Thus, although members from various sectors which are deemed to have a stake in bioethics are chosen, such as clergy, media, and lay representation, many members are also political appointments. In 1999, the committee contained no less than 50 % of its members who had contested the general elections for the same party. However, these situations were rare. But it has to be mentioned that the chair of this committee has been for several years a member of parliament who remains a politician. Nevertheless, he has a strong interest in bioethics, but one can argue that the opinion of the chair may be biased.

Health Ethics Committee

“Following EU Accession, Malta has to adopt EU Directives as part of its own legislation. Three such directives concern the conduct of clinical trials in European countries – 2001/20/EC, 2003/94/EC and 2005/28/EC. These directives, and the respective guidelines explaining their implementation, have considerably changed the way clinical trials are conducted.”

Maltese researchers and hospital consultants have long participated in international trials, especially at phase three levels. It is envisaged that with the forthcoming construction of a science park near the University of Malta, which in turn has the Medical School at Mater Dei Hospital on adjacent grounds, phase 1 and phase 2 trials may also be feasible, where before they were not because there was no appropriate setup. At first, the introduction of the HEC was frowned upon as something interfering and impeding progress in research, but time has convinced researchers that it is indeed in their interest and protection that such a committee exists. According to protocol, the HEC must give an answer to an application within a stipulated time frame of 2 months. If that time is exceeded, it can legitimately be taken that the research has been accepted. On average, the HEC handles about five to ten international research applications annually (usually from local consultant who have been asked by drug companies to participate in a phase three trial). There is a separate scientific committee at the Medicines Authority. The HEC has to give its ethics approval. This usually concerns issues such as informed consent processes and data protection. There is still some concern on the informed consent process as the application forms do not address this appropriately.

The HEC follows guidelines which were transposed into Maltese legislation (Clinical Trials Regulations, 2004 (LN490 of 2004); Cauchi, Aquilina, & Ellul, 2006) from the relevant EU directives (above). The Medicines Authority and the HEC have not stipulated any further requirements than what is laid by the directives. The HEC has, however, to take into consideration all kinds of research, even research carried out by private family doctors in small private clinics. These would usually be questionnaires and may not pose large problems as clinical trials. However, there have been instances where family doctors were recruited by drug companies to participate in phase three or four trials.

Other Research Ethics Committees

There are several research ethics committees, all at the University of Malta. Both the Faculties of Medicine and Surgery and that of Health Sciences have their own REC for research done by students, graduates, and health professionals working in the NHS hospitals. The latter, being teaching hospitals, have at their disposal the service of these committees, which are chaired by professionals working within the same structure.

The RECs look into scientific validity and methodology of the study and ethical issues relating to informed consent, safety, and data protection. They are composed of professionals, ethicists, and lay representation.

The University of Malta also has a central REC – the University Research Ethics Committee (UREC) – which overlooks also research done in the humanities, especially psychology, which involves human interviews or studies, and animal research done in the Faculty of Science. It also overlooks the other two RECs mentioned above. Relating to research on animals, there have been ongoing tensions, as Malta has yet to implement EU directives with regard to research on animals, which is mostly done on mice in the department of neuropharmacology. The UREC therefore has to deal with this research, and it is being considered to establish a subcommittee to deal with animal welfare.

Research and Public Debate

Research in bioethics takes the form of theses and of participation in local and EU-funded projects. As stated above, the Bioethics Research Program has been developed specifically to aid such initiatives. The program has as yet no funds but has already conducted research in areas of palliative care (Abela & Mallia, 2010) and participated in several FP-EU-funded projects. The coordinator of the program (author) is also the ethics advisor to the Medical Council of Malta, the chair of the above-mentioned Health Ethics Committee, the Dean’s delegate for ethical, social and public relations to the faculty of Medicine and Surgery, and also holds the academic post of the above-mentioned patients’ rights and bioethics.

Public debate has been mentioned already, but only in the context of public seminars. It is important to note however that the media plays an important role in bioethical debate, with popular prime-time evening programs which choose different topics each week giving a major contribution. Cases which create sensation are usually debated and offer an opportunity not only for academicians and stakeholders to either explain the background and theory or to have their position stated but give a significant opportunity for the general public to participate. Issues which were significantly discussed were the reproductive rights, including the right to IVF, abortion, status of the embryo, and right to life, as well as the Elauna Englaro and Terri Schiavo cases, in which issues of hydration and nutrition and the meaning of a “natural death” were widely debated. Another significant case was the Maltese Siamese Twins debate, which followed the case of the separation of “Mary and Jody” in the children’s hospital of Manchester which was resolved in the UK Courts of Justice (Kaveny, 2002).

Legislation

Although as discussed there is no specific legislation in bioethics, there are other laws which are worth mentioning that govern bioethical issues. Reference here is made to Cauchi et al. (2006).

Human dignity, rights, and freedoms are protected under the Press Act, the Code of Organization and Civil Procedure, and the Criminal Code which address the dignity of the victim. The Commissioner for Children Act set up a commissioner to oversee the dignity, respect, and fairness in the treatment of children. Also, the Constitution of Malta guarantees against discrimination and protects rights and freedoms.

Furthermore, especially in relation to bioethics, the Data Protection Act protects privacy and has generated considerable consideration in the area especially with regard to research. The Criminal Code distinguishes between intimate and non-intimate samples taken from a person (Cauchi et al. (2006)). Article 350 defines intimate samples as blood samples, semen or any other tissue fluid, pubic hair, and any swab taken from any orifice of the body other than the mouth. Non-intimate are defined as a sample of hair (other than pubic hair), samples of nail or from under the nail, swabs taken from mouth or other areas of body excluding other body orifices, urine, saliva, footprint, or other impression other than a part of hand. Magistrates are given the authority to authorize the taking of samples from intimate areas or to take intimate photographs.

The Civil Code describes the procedure for informed consent and where this is not valid (e.g., where it has been given by error or extorted by violence or fraud. Conversely, the Prevention of Disease ordinance requests doctors to notify the health authorities of communicable diseases, which are listed in the ordinance. The Health Care Professions Act regulates the medical professions and includes section on ethical Codes of Conduct. The Medical Council of Malta has requested from its ethics advisor a suggestion for an update on this part of the law. Suggestions have been made with regard to (1) obtaining consent, (2) research on human subjects, (3) confidentiality, (4) dual responsibilities of doctors, and (5) advertisements. To date, these recommendations have not yet been entrenched into the law. They adapt the UK General Medical Council guidelines for the local scenario.

Malta also respects directives issued by the European Union. To date it has not signed or ratified the Council of Europe’s Convention on Human Rights and Biomedicine due to some controversial areas of bioethics, such as abortion, which are still being studied, but it is expected to do so.

Finally, there is a Mental Health Act, which has recently been updated and which describes the rights of the mentally ill and the procedures necessary to admit patients into psychiatric wards without their consent. The law does not refer to research on mentally ill patients. Although this can easily fall under the general rules of research, the fact that mental patients as a vulnerable group had not been discussed with bioethicists during the drafting of the law shows the insufficient awareness of the field of clinical and bioethics when it comes to legislation.

Major Bioethics Issues and Discussions

Malta is largely a conservative society which is highly influenced by tradition, culture, and religion. This is slowly changing and more liberal ideas than those proposed by Catholic tradition are influencing secular society. The latter may defend issues like abortion and euthanasia, but by and large this does not mean that Maltese society has made substantial shifts to decrease ecclesiastical influence on legislation. For the purposes of this chapter, three selected areas, which have given rise to public debate, are discussed.

In Vitro Fertilization

Malta has been trying to regulate the use of in vitro fertilization since the beginning of bioethics debate on the island. In vitro fertilization poses problems in several areas. First of all, according to the Catholic Church, it does not follow natural law, as interpreted through divine law. The Catholic document Donum Vitae (literal translation: the gift of life) categorically states that IVF is “illicit” because it bypasses the conjugal act. Many often think that the Catholic Church has reservations on IVF merely because it results in the freezing of embryos. While this is also true, the whole nature of the matter, and therefore the debate, has been on whether IVF is licit or not. Although many priests in pastoral care have encouraged married couples to use the technology, once the issue came into public debate it was quite clear that the Church had the final say which halted the whole process (Mallia, 2010a). Part of the problem was that the true conflict – the nature of IVF itself – apart from other consequential issues like protection of the embryo and the family unit had not been discussed at high levels of government and curia. Had agreement on this been reached, then it would have been difficult for the curia to issue statements at the eleventh hour.

The debate continues to move forward, and the Prime Minister recently made a statement that all problems seemed to have been resolved with the possibility of cryopreservation of ova. A proposal was made by a parliamentary committee that the government should consider the possibility of a limited amount of embryo freezing, however, with the possibility of donating these embryos should the parents, for some reason or other, not use them within a stipulated time. But many remained uncomfortable with freezing and also with donating embryos. Certainly legislation would have to be put in place for the government to be able to take custody of these embryos, something which would need considerable legislative thought.

The issue of IVF brought on a persistent debate about the freezing of embryos. One possibility was to freeze an egg which has been fertilized before the two pronuclei have met – as is done in Germany. Again there was some debate on whether life should be considered to begin when fertilization is complete or when fertilization begins. Part of the problem was that debates went directly into the public realm, and there was no serious academic effort to provide proper information to the government and educate the public at the same time. Therefore, issues such as differentiating between a zygote and an embryo were very difficult to discuss on the media which continuously insisted with academics invited to participate on programs to speak in language which everybody can understand. Although the media contributed considerably to the debate, one cannot resolve the issues here. Although many priests did take part in the discussion, the Curia avoided debate completely and even when invited to comment on a report issued by the Bioethics Consultative Committee as early as 2000, it simply said that the priests that were on the committee were sufficient. And yet, when the bioethics committee held its annual seminar on the topic and the media reported on the issue, an angry archbishop called the minister who in turn called the then secretary of the committee for an explanation (Mallia, 2002).

The issue, according to many, has changed with the introduction of divorce, many feeling that the Church has lost its power. In this author’s opinion this is not correct, losing on an issue (and divorce has been considered as a civil right in the mind of many) does not mean that the Church still does not enjoy ecclesiastical authority in matters of morality.

The government is committed, however, to move forward on legislation. This has been stated by the Minister of Health and the Prime Minister on several occasions. While it is recognized that the Church sees IVF as illicit, it is also recognized that the responsibility of the state is to legislate within good standards and that state law cannot be according to canon law. There is general agreement that there should be protection of embryos and of family values. However, an ongoing debate had been whether to offer IVF only to married couples or also to cohabiting couples. If the former, it meant that since most legally married couples marry within the Church, paradoxically, IVF will be offered only to these couples (Mallia, 2002). There were, however, strong arguments also to offer the service to cohabiting couples. Certainly since until this year divorce was not possible, people from broken marriages (legal separations) would have settled with another partner, and some of these would invariably be infertile. Since they could not legally marry again, the argument was whether it would be an insult to the institution of the family if they were offered IVF. One compromise was to offer it to those people who had separated at an early stage and were awaiting annulment. In fact, it was often said that the problem with divorce took on a lot of force because of the considerable number of separated couples who either waited too long (sometimes up to 8 years or more) for a church annulment, or those who lost hope in ever obtaining such an annulment. State annulments took much less, on average 2 years, and this raises the issue whether it is licit. However, many young people still feel that the church annulment is the proper annulment to take. This raised the question that if the Church was more efficient, the question of divorce may not have gained momentum.

Divorce now will make IVF possible to many more couples and resolved the issue of offering the service to legally married couples. Naturally, for the Church, it is presumed that only the first marriage counts, but this does not seem to be an issue which impedes IVF; the stronger issue is the problem of freezing of embryos. Here, the government seems reluctant even to follow the advice of the parliamentary committee for social affairs which made a recommendation for a limited amount of freezing – as it is quite impossible to impose the technical fertilization of one ovum at a time. It is not clear whether the advent of cryopreservation of ova resolves this issue. In practice, one still has to see as this method was not introduced in any way to treat whole populations. Although it was a method for those who had problems with freezing of embryos, one has to ask whether it will be feasible for whole populations. Certainly one would need to employ an embryologist as freezing of ova is not without its problems. In the first instance, you lose much more ova than you lose embryos when you thaw them. Moreover, due to changes that occur in the outer lining of the ovum, one would have to use intracytoplasmic injection of sperm (ICSI) to fertilize eggs on each occasion. This method is more expensive and requires more time than current practices.

While with the freezing of ova one presumably needs less hormonal stimulation of women to obtain such embryos, one still has to use hormonal stimulation to emulate a pregnancy when introducing fertilized eggs. Again, a pertinent question remained: How many fertilized eggs are you going to introduce in one attempt? If you introduce more than one then you will still have to go through the process of ICSI several times. Practically, it is difficult to imagine embryologists working on populations fertilizing only one egg at a time, without risking waiting list and mistakes, such as (albeit on rare occasions) mixing accidentally ova and sperm of different people. The government has not yet tackled the numbers: up till now, only those who could afford went for IVF; once everyone would be entitled on the National Health Service (and therefore free of charge), it remains to be seen whether one would be able to cope with the demand. Certainly this mistake was done in the construction of the new main hospital. Besides, for some unknown reason, having fewer beds available, the planning team did not envisage that many would now want to go to the state-of-the-art hospital, whose hotel services were even better than those offered by private hospitals. The result was a considerable rise in waiting lists. Can infertile couples afford to wait weeks or months before the embryologist/s have time to fertilize another ovum and have it introduced in the uterus due to the larger demand?

Another problem is that many seem to think that there is no moral weight with ova. Indeed, throwing away an ovum is not as problematic as discarding an embryo. But gametes do have moral weight attached to them for the simple reason that they are gametes. Unlike males, females have a limited amount of ova. Many may be uncomfortable with having them thrown away once they have conceived. Property rights have not yet been considered in this regard. What if someone refuses to have her ova discarded? Can she legitimately ask the court that they be preserved? In such an event, can she legally be made to pay for their preservation? What if she cannot afford this?

In the meantime, the issue of legislating IVF continues to elude at the time of writing of this chapter.

Hydration and Nutrition

The problem with hydration and nutrition was put in evidence following the Terri Schiavo case (in the USA) and later the Elauna Englaro case (in Italy) which were portrayed as euthanasia by conservative Catholics.

It was quite clear from the onset of the debate of Terry Schiavo that the moral theologians and ethicists in Malta were of the opinion that extraordinary treatment need not be given. When the case of Eluana Englaro surfaced a few years later, however, the public outcry in Italy (Italy being very close to Malta) and the fact that a bishop spoke to Prime Minister Silvio Berlusconi to prevent the removal of artificial feeding and nutrition created a situation where many erroneously believed, or started to believe, that removal of water and nutrition is always passive euthanasia. This was reinforced by the allocution of Pope John Paul II (2004) who had said that they should always be considered basic care.

Yet several statements were made on the media by ethicists at the time. The allocution of Pope Pius XII (1957a) that doctors cannot treat (even force-feed) without the consent of the patient was referred to. For all intents and purposes, this still holds. Secondly, patients need not accept extraordinary treatment but are morally obliged to accept ordinary treatment. What many people, including health-care professionals, often do not understand is that it is the patient who decides what is ordinary and extraordinary for himself. The allocution clearly states that extraordinary has nothing do to with the state-of-the-art of the treatment or care being provided. Rather it has to do with disproportionate care, with discomfort, and with respecting that people do die and that this is in itself not a bad thing.

Pius XII (1957b) also had explained the concept of double effect in the provision of pain relief – that death brought about unintended while giving pain relief, even if foreseen, is allowable. Standards of care have to be followed, but since a considerable amount of health-care provision in Malta is given at home, for many GPs who have to use limited resources, following specific protocols is not always feasible. Indeed, it would be extraordinary care to bring all resources available in hospital to the bedside at home as this would require a disproportionate expense on the part of the patient. Doctors therefore can use their clinical training as a means of titrating proper doses of pain relief. A study done recently (Abela & Mallia, 2010) shows that GPs appreciate vocational training in this regard, for example, on the use of syringe drivers and other therapeutic issues in giving palliative care at home.

The point which was shown to the public was that not all that seems like euthanasia is indeed euthanasia and the frustration was that many Catholics seemed to believe so. The problem is made more complex by some theologians who seem to have a definition of artificial nutrition and hydration as being always ordinary treatment and who also seem to omit what the Catholic Church says also in regard to burden on the family (and not only therefore on the patient). Admittedly, the allocution of John Paul II on hydration make things more difficult to explain to the public especially in cases of persistent vegetative state which has lasted several years.

People in Malta often go to bishops to inquire about end-of-life issues when a relative is on life support. Bishops always explain that allowing nature to take its course is an option, which means that if there is no reasonable hope, then people, even if not brain-dead, can be removed from advanced life support as it is extraordinary. One had to extrapolate this argument to show that if this is allowable in people on advanced life support who are not brain-dead, then it should be allowable also to people in PVS. PVS is a state which is brought about by modern medicine, and when speaking on disproportionate efforts to keep people alive, Pope Paul VI made the point that it was immoral to push people into PVS. PVS was described in the early 1970s as something brought about by advanced care and in a letter to the International Federation of Catholic Doctors, Cardinal Villot, on behalf of Pope Paul VI, stated that it would be a useless torture to impose a “vegetative reanimation” (Petrini, 2011). So once this vegetative state occurs, the question is why cannot one alleviate any perceived suffering and terminate artificial means of keeping the person alive?

Moreover, it often has to be explained that hydration and nutrition in PVS is not ordinary feeding. In the first instance, it requires expertise to maintain the tubes and to provide the physiological solutions. Secondly, when infections do arise they are often treated and that therefore it is doubtful how only nutrition and hydration is being provided. Thirdly, people are not getting any sensation of feeding – a former relative explained on the media how his mother would crave for some tea when in hospital even though the nurse would have just poured the tea through her nasogastric tube. There was no sensation of “drinking” tea. Fourth and most important, but one which people tend to comprehend least, is the fact that in a true PVS, only the brain stem is alive. This is a transition zone between the upper brain (basal ganglia and cortex), which gives experience and consciousness, and the spinal cord. Even dead people continue to have reflexes of the spinal cord for some time. Therefore, it is understandable that the brain stem may continue to function. This does not mean that the person is experiencing anything. Therefore, it does not make sense to “starve” a PVS patient, as starvation is a sensation. Nevertheless, the facial reflexes and the continued beating heart and respiration can often deceive people that there is conscious life. But is this situation not the same one we declare people on life support brain-dead but whose relatives, seeing a body which is still warm and monitors showing a beating heart, refuse to accept that the person has died? Are not these advanced life support taking the place of the brain stem?

PVS creates an illusion of the possibility of conscious life. While there certainly is life, one has to return to the basics of whether basic ANH is ordinary or extraordinary. What is more, health-care professionals should accept that it is not their choice but that of the patient, and when the patient cannot make that choice, the family’s wish should be taken into consideration. One has to accept that many will say that they opt to remain in that state if they ever find themselves in that position; others will not. Also many families can accept their loved ones in that state; others may want them to die peacefully. This is certainly an area where greater Catholic dialogue would illuminate Catholic countries like Malta.

Abortion

One would think that in a country where most people are against abortion and all political parties have declared themselves to be pro-life as well, that abortion would not be an issue of debate. Yet debate occurred on several instances. Three will be mentioned here: in the instance of emergency contraception, in the instance of the Dutch ship which visits countries providing abortion (Women on Waves), and in the instance of the Constitution of Malta.

Emergency contraception and some other contraceptive measures such as the coil have been known to provide a risk of aborting a fertilized egg. Traditionally, therefore, they have never been allowed into Maltese health care. It was only for a short while during a socialist administration and until awareness was raised that insertion of the coil was allowed in government health services. Coil insertion is still, however, done privately. Moreover, abortion is a criminal act, and so is assisting an abortion in any way. Legally, a pregnancy is defined as “woman carrying child.” Yet it is clearly evident that in a Catholic country, to “carry” does not mean implantation – as decided by the UK courts of law in the case of the Society for the Protection of the Unborn Child (SPUC) challenging the provision of the morning-after pill (Levonelle) through pharmacies across the UK, claiming that these were abortifacient and therefore a criminal offense. Mr. Justice Munby held that since a woman is not yet carrying a baby, she cannot be said to miscarry. Maltese morality follows the Catholic teaching that life has to be protected from conception.

This is not to say that there are no advocates of abortion. Yearly data are published of Maltese women who have gone to the UK for an abortion. Although abortion is illegal in the UK, it is provided for health reasons (health being defined in the broader term of including not only biological reasons, as in Ireland where they provide abortion for medical reasons but also psychological and social).

Emergency contraception falls therefore in an area of difficulty. The Catholic tradition speaks of emergency contraception in instances of rape – it cannot allow EC in marriage and for extramarital sexual activity. It is clear, following the British Episcopal Conference statement that a girl who is raped has a right to defend herself from pregnancy. She can only do so, however, if she is not ovulating. Therefore, ovulation tests may be used. There is an element of coercion here as the woman will not be provided with EC unless she accepts this test. There is ongoing debate in this area in which the author is involved, and hopefully it will be resolved in the future. There has been an argument (Mallia, 2005) to show that it can fall under double effect. Moreover, recently Sulmacy (2006) argues that testing for pregnancy should be morally equivalent to testing for ovulation, which of course is more acceptable – the test is more directly implying a pregnancy or not.

Women on Waves (WOW) had created some public debate with advocates of abortion coming forward in the media. In general, they are still small in numbers. It is interesting to note however that democracy can tie or untie moral values. Although morality is never a statistic, as one experienced with the divorce debate, numbers do count. It may be the case that some politicians will privately speak in favor of abortion, but they and their parties will know that this will be a cause for condemnation by the religious community and can thus cause a loss of votes. WOW also sends abortifacient medication to women by post. There are no statistics to show whether this service is being used and how many women use it. There do not seem to be any restrictions by the post either as when one sends for medicine, one only has to state that they are not for commercial use.

However, the visit by WOW and the ensuing debate created a movement of people to protect the unborn child and which even advocated, at one stage, that there should be a law which not only prohibits women to travel abroad for an abortion and that the partner may actually impede a pregnant woman from traveling as well if he suspects her intent. Moreover, they argued that the state should protect the unborn child also from women who abuse alcohol, drugs, etc. Of course these proposals did not find any support as they were largely based on emotion and ignorance. Although good in intent, they ignored the freedom of the woman and basic human rights that a pregnant woman should enjoy other than prohibiting direct abortion. This triggered discussion on whether we should have a “protection of the embryo act.”

This “embryology act” was proposed in 2005 by the Vice Prime Minister following pressure from pro-life groups to prevent abortion, freezing of embryos, and the use of embryos for research. It made considerable debate at the time but never actually reached implementation as existent law already prohibits abortion and that any new reproductive technology law will legislate against freezing irresponsibly anyway.

This was followed by a push to insert an antiabortion law into the Maltese constitution. This move was motivated primarily to make a statement, especially in view of Malta’s entry into the European Union. Amendment to the constitution requires a two-third majority in parliament and not a simple majority vote which can be passed by a presiding party. The idea was to protect that law and enshrine it into the constitution. The Church even invited speakers to encourage this move. Although there would not have been anything wrong with this, it was not really necessary as abortion is not seen as a problem in Malta: it is already illegal, and all political parties have stated they will never legalize abortion. The idea was therefore shelved as it is understandable that with so much work facing parliament, one cannot use up valuable time to pass unnecessary laws.

Conclusion

This overview has shown that Malta remains largely a country with Catholic normative values, but social change is occurring over time and people are challenged to object to some of the Church’s teaching when it comes to medical treatment. Although there are no great debates on abortion and euthanasia, when it comes to reproductive technology and end-of-life issues, legislation is showing a change in trend of these normative values. However, people often find solace in seeking advice from Catholic authorities.

This is not to say that there are disadvantages to this. Many priests in pastoral care would not hesitate to help people to make an ethical choice to have IVF. Moreover, the application of natural law also means application of allowing a natural death, which in turn translates into helping people and families with loved ones at the end of life, not to feel pressured to allow extraordinary measures to be taken. Conversely controversy at the beginning of life is more difficult to tackle as it challenges the very concept of when life begins and the protection of that life from the beginning. This does not mean that dialogue in areas such as emergency contraception and IVF is still not possible. Recent developments of Trinitarian ontology within the Catholic Church and how this may be applied to social problems such as bioethics provide a hopeful window for a better understanding while maintaining one’s fundamental position in favor of life.