Manuel Martínez-Sellés D’Oliveira Soares is one of the most prestigious medical doctors in Spain. Deeply concerned about the present state of medical treatment, he is nevertheless “much more concerned about the future.”
Currently head of cardiology at Gregorio Marañon Hospital, a public research hospital in Madrid, and president of the Madrid College of Doctors, an elected position he won by campaigning as a protector of human dignity, Martínez-Selles’ curriculum vitae also includes award-winning research, teaching, and several post-graduate degrees, including one in pastoral theology from the Pontifical Lateran University. In 2019, he authored Eutanasia: un análisis a la luz de la ciencia y la antropología (Euthanasia, an Analysis in the Light of Science and Anthropology).
Sadly, euthanasia became legal in Spain last year. The law, which came into force in June 2021, permits legal injections in cases not only of “grave and incurable illness” but also in the face of “grave, chronic, or crippling suffering,” opening the possibility of euthanising the disabled. It enshrines euthanasia both as a service to be provided in the country’s public health system and as an “individual right.”
The law was passed by a Left majority in parliament that eschewed public debate. The Spanish Bioethics Committee, an independent consultative organ, was not formally consulted but, on its own initiative, submitted a 94-page analysis of the law that roundly rejected it as unethical. Supporters of euthanasia blocked expert testimony before parliament.
According to a recent article in the Spanish newspaper ABC, approximately 2,000 doctors have registered as conscientious objectors to euthanasia. Does this figure reflect the wide opposition of doctors to euthanasia?
Regarding the disagreement of doctors with euthanasia, I think it is important to remember that euthanasia is prohibited in the Hippocratic Oath, is condemned by the World Medical Association, and is not recommended by the Spanish Bioethics Committee or the Spanish Code of Medical Ethics. That code, in its article 36.3, says: “The doctor will never intentionally cause the death of any patient, not even in the event of an express request by the latter.” A doctor who is against euthanasia is supported, not only by his right to conscientious objection, but also by his code of ethics.
Are there doctors who do not want to participate in euthanasia but have not registered as objectors for whatever the reason may be?
Of course, yes, I would say the vast majority. That is, for example, my case. Conscientious objection is a fundamental right recognized in the European Charter of Human Rights and guaranteed in our Constitution. No regulation can regulate it, much less limit it. And the exercise of this right must be free and confidential. Likewise, it can be applied unexpectedly, “ad casum,” in the circumstances, place, and time of the specific case that arises. It is not necessary to make an “a priori” conscientious objection. In fact, the [Spanish] Constitutional Court has declared that conscientious objection does not require specific legal regulation in order to be recognized. Our Code of Ethics also states in its article 32 that the recognition of the conscientious objection of the doctor is an essential presupposition to guarantee the freedom and independence of his professional practice.
How is the introduction of euthanasia in medicine affecting health care staff morally?
It affects us a lot, even more so in a country like ours where palliative care is underdeveloped. It should be remembered that in the latest European Atlas of Palliative Care, two palliative care [beds] are recommended for every 100, 000 inhabitants. We have 0.6 [palliative care beds available], that is, we are not even halfway there. We are between Georgia and Moldova [in the ranking of countries level of palliative care]. With this situation, so deficient in palliative care, it seems that the only alternative that is being given to many patients with advanced diseases is euthanasia. I think it is important to remember the WHO definition of Palliative Care: “an approach that improves the quality of life of patients and families facing the problems associated with advanced diseases, through the prevention and relief of suffering through early identification and evaluation and treatment of pain and other problems, physical, psychological, and spiritual.” It’s basically the opposite of euthanasia, taking care of those who suffer, not killing them.
The law was promoted to provide strong safeguards against abuse. Is it working like this in practice?
The first case in Spain was performed on an 86-year-old patient with cognitive impairment. For me, this data point already answers that question. Our law gives very short deadlines and does not even require a psychiatric evaluation for patients. In this regard, I strongly recommend reading the recently published Position Paper on Physician Assisted Suicide and Euthanasia from the College of Psychiatrists of Ireland.
What problems are doctors encountering when a relative or a patient asks for euthanasia?
First, confusion. Even the law itself avoids the term euthanasia and speaks of “providing assistance in dying.” Euthanasia is confused with palliative care, it is called “dignified death” and it is assumed to be a medical act, when it is not. The confusion goes further and reaches deception when the law requires that deaths by euthanasia be considered natural deaths from a legal point of view. Something that, in addition to not being true, makes it difficult to control.
Do doctors see that there is a social demand, as those who supported the law claimed?
No. What we have a great social demand for is palliative care, comprehensive care, aid for dependency, specific policies for an increasingly aging country. Faced with this, the government has opted for a path that has made us the exception of Europe (euthanasia is only legal in the Benelux).
Is the conscientious objection of doctors being respected?
As far as I know, yes, but we already have statements from some ministers talking about the need to limit it. Conscientious objection is an ethical and constitutional requirement that does not depend on the thinking of a minister. Conscientious objection allows someone to refuse to carry out acts seriously contrary to one’s own conscience. Acknowledging this primacy is also recognizing that justice is much more than laws and that there are fundamental rights that any rule must always respect. Putting obstacles to conscientious objection is to muzzle those who think differently, compromising the freedom of the professional, and is a frontal attack on the relationship of respect and trust between doctor and patient. We cannot tolerate an illegitimate interference in the practice of medicine.
In Spain, to be able to practice medicine, you have to pass a national exam (MIR). Last year, in this exam, a clinical case was presented with four possible answers, three were types of euthanasia and the other was assisted suicide. It is not understood how, if these practices are condemned by the World Medical Association, by the Bioethics Committee, by the Hippocratic Oath, and by our Code of Ethics, doctors are obliged to indicate one of them as correct. I am concerned about the present, but I am much more concerned about the future.