An interdisciplinary group of academics from the University of Malta and senior clinical staff at Mater Dei Hospital is recommending the inclusion of a durable power of attorney for healthcare in Malta’s proposed Advance Medical Directives Act, warning that its omission causes a significant ethical and clinical gap.
In a position paper, the group says that a trusted healthcare proxy provides a more flexible and ethically robust safeguard than a static written directive.
A proxy, they note, can interpret a patient’s wishes in light of unforeseen medical circumstances, which a document drafted years in advance may not adequately anticipate.
Drawing on expertise spanning medicine, ethics, theology, philosophy, law and jurisprudence, the authors welcome the intent behind the proposed legislation but caution that its effectiveness depends on the strength of the framework underpinning it.
They emphasise that advance medical directives are a vital tool for safeguarding patient dignity at the end of life, supporting families navigating complex decisions, and offering legal clarity to healthcare professionals. However, they also stress that such directives must be applied within a broader ethical context.
“Decisions at the end of life cannot be reduced to a legalistic application of written instructions,” the paper states. “Advance directives must be interpreted within a broader ethical framework grounded in prudence, proportionality of treatment, and respect for human dignity.”
The paper also examines the clinical and ethical complexities surrounding artificial nutrition and hydration (ANH), highlighting that different medical contexts – including reversible conditions, chronic illness and the final stages of dying – require distinct ethical assessments rather than a uniform rule.
Among its recommendations, the group calls for stronger safeguards to protect vulnerable individuals, particularly the elderly, from subtle coercion when drafting directives.
It also advocates the introduction of clinical ethics consultation services, enhanced palliative care infrastructure, the inclusion of a conscience clause for healthcare professionals, and clearer procedures for assessing mental capacity.
The authors say that advance medical directives can serve as compassionate and ethically responsible instruments for end-of-life care, but only when supported by a legislative framework that prioritises dignity, solidarity and sound clinical judgement.
The position paper has been submitted to all Members of Parliament and relevant stakeholders.
