Deputy Minister of Public Health, Tania Margarita Hernández Cruz, presented at a meeting of the Council of Ministers on October 2, 2023, a draft public health law to be debated and approved by the National Assembly in December 2023.
In his speech, Hernández assured that the bill contains statements about the right of patients to die with dignity. In particular, palliative care and care for patients with incurable, agonizing illnesses or with intractable suffering and exceptional or disproportionate interventions in connection with prospects of recovery and life-ending therapies.
Several users have written asking for clarification on this matter, interpreting that in the absence of medicines and resources, the Cuban authorities are determined to end the lives of thousands of people, describing them as candidates for “dying with dignity.” ”
The deputy minister’s intervention and the debate that arose about it on social networks require clarification.
The project is not new
The project to which the deputy minister refers is not new. According to the official Cuban press, Portal Miranda, Minister of Public Health, presented the preliminary draft to deputies of the National Assembly of People’s Power in December 2022.
From that moment on, the head of the Ministry of Health (Minsap) announced the possibility of including the legalization of euthanasia in the country in the final project. What has happened now is a formality that is part of the law approval process. The Minsap presented the finished project to the Council of Ministers so that it could in turn present it to the ANPP and be discussed and approved by the Cuban parliamentarians.
In any case, it appears from the intervention broadcast on national television that the inclusion of the right to a “death with dignity” and the ways to implement it remain a priority or aspiration of the health authorities.
What does a “death with dignity” mean?
The term “dying with dignity” is widely recognized and used worldwide to describe the process of dying peacefully without unnecessary interference; but also to the process that is offered in some countries to people who want and ask for help in dying (euthanasia).
Those who use the term “dignified death” do so because they believe it to be the only way to end or avoid the lives of people who survive in “dignified” conditions due to the suffering or torment that they entail, are classified as patient.
Euthanasia, understood as active assistance to someone who decides to die, is only legalized in seven countries in the world: Canada, Colombia, the Netherlands, Belgium, Luxembourg, New Zealand and Spain. There are also corresponding initiatives in other countries (Switzerland, Austria, Germany, Italy and some US states). The small number of countries authorizing the procedure shows the lack of general consensus and global ethical, religious and legal discussion on the issue.
Concepts to consider
Although it is not the first time that euthanasia has been discussed in Cuba, the deputy minister’s intervention provided some elements that provide additional assessments to those carried out so far.
According to the official, recognition of the right to a dignified death of patients “with painful or incurable diseases with incurable suffering” appears to be under consideration. The technical terms used are recognized by theorists and scientists in the field of medicine.
Some research suggests that “agony” is the state that characterizes the complete exhaustion of physiological reserves and irreversibly leads to death. The word agony (derived from the Greek agon, meaning fight) also refers to the torment a person experiences when on the verge of death.
On the other hand, “intractable suffering” is a subjective medical term used in some laws regulating euthanasia. “Unbearable suffering” describes the perception of some patients who would rather not continue living due to their reduced quality of life. In determining this condition, healthcare professionals face a major challenge due to the lack of a precise definition and the specific variables that constitute it or the way in which they should be measured are not known with certainty. Its interpretation has led to legal problems, particularly in Belgium and the Netherlands, and more and more patients with mental illness or dementia are demanding justice.
Therefore, the use of the terms in future laws on dying with dignity in Cuba would emulate those of other legal systems that have regulated the procedure.
The deputy minister also mentioned the possibility of including in future legislation a regulation on “extraordinary or disproportionate procedures with a view to prospects for improvement”. This is another internationally recognized medical term that does not always have to do with euthanasia, but with the patient’s right to consent or not to medical treatments that prolong their life without much prospect.
For example, Argentina’s penal code punishes anyone who incites another to commit suicide or assists him or her in committing suicide. However, Law 26.742 (known as the “Patient Rights, Medical History and Informed Consent Law”) states in Article 5, subsection g that patients have the right to refuse surgery, hydration, nutrition, artificial resuscitation, or withdrawal of life-sustaining measures Measures if they are “extraordinary or disproportionate to the prospects for improvement” or if they cause “disproportionate suffering”. They also have the right to refuse hydration and feeding if these will only prolong the incurable, irreversible and incurable condition in which they find themselves.
The refusal of such treatments is recognized as part of people’s right to die with dignity and is even permitted by the Catholic Church, although it is one of the main opponents of euthanasia on doctrinal grounds.
In 2017, Pope Francis declared that euthanasia is “always illegal” but acknowledged that “it is morally legitimate to refrain from or suspend the use of therapeutic means” when they are ethically disproportionate.
The issue of exceptional or disproportionate procedures is closely related to two other concepts mentioned by the Deputy Minister: “therapeutic rigor” and “limitation of therapeutic effort”.
The first, also called “therapeutic persistence” or “therapeutic stubbornness”, involves excessive persistence in applying exceptional therapeutic measures. Something that can be beneficial for some patients, but is useless for others for whom it has no real benefit.
From a biomedical perspective, it is therefore crucial in any case to evaluate the cost-benefit ratio of the procedures and medications used and to use only what is absolutely necessary and the usual measures of palliative medicine, the focus of which is on alleviating pain and discomfort lies. instead of insisting on the implementation of all procedures available thanks to science and technology and on the use of all available medications.
On the other hand, “limiting therapeutic effort” involves a considered decision not to perform or discontinue medical therapies if it is determined that they do not provide a significant benefit to the patient.
In addition to the previous aspects that can be considered as the approach of medical staff in the face of death, the deputy minister also mentioned a much broader concept that appears to be addressed in the new legislation. He called them “life-ending therapies.”
Although the details are sparse and limited to the fragment broadcast on national television and previous official statements, it is not unreasonable to assume that it is the inclusion in the new law of procedures and methods aimed at preserving the life of the Patients directly and not just stopping treatments to avoid or withhold if death occurs naturally.
Valid concerns in the Cuban context
The interpretations of many Cubans to the Vice Minister’s words are understandable, considering that the Cuban State has not allowed a public debate on this issue, which includes reaching a consensus on the possibility, necessity and advisability of carrying out euthanasia in Cuba.
On the contrary, citizens have received only brief reports from those in power on how and under what conditions they intend to implement a mechanism that requires resources – which are scarce in the current Cuban reality – and requires the preparation of qualified personnel to carry out decide the applications and decide to implement policies.
Citizens had no access to the project and were not informed about the mechanisms for implementing the law. The lack of information is an excellent breeding ground for free interpretation. It is the responsibility of the state to inform about this.
Likewise, citizens question not only the ethical, religious and legal issues behind the regulation, but also the existing capacity in the country to apply procedures that have largely been implemented by highly developed countries and have not been spared from conflict.
In the subconscious of the population there is the idea that the Cuban government is unable to guarantee the gloves and essential materials for general medical procedures, as well as the resources that make the lives of incurable or dying patients more bearable. When Cubans first hear about the regulation of euthanasia in such a context, it is normal to doubt and question whether, in a country where almost nothing works, the implementation of a mechanism requires more than good will or humanism to be viable .
Conversations about euthanasia and the right to a “death with dignity” are clouded, especially at this time, because many Cubans believe that before talking about the possibility of dying with dignity, one should think about how to live in Cuba can survive less humiliation.
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