SPAIN 
One year with an Assisted Dying Law: lessons from Spain’s first steps

Guest article by Borja Robert, press officer, Derecho a Morir Dignamente (DMD), Spain

The country's voluntary assisted dying legislation reached the one-year mark on June 25th, 2022. Despite some regional hurdles and a limited number of total cases, the wide range of conditions permitted to make use of the law points to a hopeful future.

The first assisted death under Spain’s Euthanasia Law happened exactly four weeks after it came into effect. Eskarne, a basque 86-year-old woman, couldn’t speak or recognize her loved ones when she received help to die. She suffered severe dementia and had lost her ability to make decisions. It was her decision, though: ten years earlier, while still lucid, she had explicitly asked for assisted dying in her living will.

“It would be against my values and beliefs to live without enough autonomy to carry out the basic activities of daily life. Living in such circumstances would cause me unbearable suffering I wouldn’t want to endure. If that were the case, I want to be actively helped to die, fast and peacefully, by euthanasia”, she wrote, as published by the Spanish newspaper El País, which spoke to her family.

Spain’s Assisted Dying Law came into effect on June 25th, 2021, after 18 months of parliamentary debate and more than a dozen failed attempts since the 1990s. The law passed with 203 votes for it and 140 against. It grants citizens a new right and undid a decades-long democratic anomaly: whilst at least 72% of Spanish citizens supported the legalization of assisted dying according to all surveys on the matter, it remained a criminal offense, punished with prison.

Eskarne’s assisted death was the first of around 180 that were carried out in the following twelve months. It’s a small number. Spain has a population of 47 million people and around 420,000 deaths yearly – disregarding the coronavirus pandemic, which pushed the figure above 490,000 in 2020. Assisted dying, therefore, accounted for around 0.04% of all deaths. By comparison, in Canada, with a smaller population, 1,015 persons made use of medical assistance in dying (MAID) in 2016, the first year it was legal (0.3% of all deceases).

The first months of Spain’s Assisted Dying Law were difficult. The 17 Spanish Autonomous Communities, in charge of their own healthcare systems, had to implement the new right to die. Not all took the endeavour equally seriously. While some, like Basque Country and Catalonia, were ready by June 25th, others delayed it for months. Madrid and Andalucía – with about one third of Spain’s population – dragged their feet until October and November, respectively. For months, their citizens had the right to an assisted death but no way to exercise it.

Also, some regions neglected the training of healthcare workers. Many did (and still do) not know how to act when they receive a request for an assisted death. It causes bewilderment in professionals and extra suffering in those who ask for an assisted death. At least three “do-it-yourself” suicides, two of them violent, were caused by delays in the process or lack of protocols for dealing with conscientious objection – requests must be accepted and forwarded to the manager by law. Only once, the negligent behaviour had consequences for the professionals involved.

Fortunately, things have improved with time. Every new safely conducted case dispels prejudice amongst healthcare workers, helps iron out unforeseen rough edges, and builds up institutional experience.

Spain’s Assisted Dying Law is somewhere in between the most restrictive legislations – e.g. Victoria (Australia) – and the more progressive ones – e.g. Belgium. It allows a medically assisted death for the terminally ill, with no limit regarding life expectancy, and for those with an irreversible condition that severely impacts their physical autonomy. As mentioned earlier, it can be requested in a living will. It excludes minors, even those allowed to make other critical medical decisions, and persons who haven’t lived in Spain for at least a year. It also adds extra safeguards and cumbersome steps to the application process. A regional committee of lawyers and healthcare workers must authorize all assisted deaths, after the review and agreement of two doctors, before the assisted death can proceed.

Despite the low number of cases, a wide range of conditions has been considered valid under the new law. There have been reports of assisted deaths for patients with terminal cancer, ALS, multiple sclerosis, tetraplegia, organ failure, comorbidities related to old age, the already mentioned severe dementia, fibromyalgia, and at least one case in which a mental disorder coexisted with other severe physical ailments.

The split between regions where the right to die works and those where it doesn’t isn’t clear-cut, but one strategy appears to have the biggest effect: some regional governments have set up a cadre of experts on assisted dying, entrusted with helping fellow healthcare workers who deal with their first patient’s request. Anecdotal evidence from this first year points to them being a key figure for the right to die to be effective. Only one thing has proven more important: the political will of the regional governments to make it work.

Newsletter 2022-3-1-e