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Euthanasia is a truly complex problem: it has legal, social, medical, anthropological, moral, economic and even religious elements. Its study admits multiple points of view, each one with its pros and cons. Currently in Spain there is a desire that the laws enshrine the will of a subject to end one's own life with medical assistance. With these notes I intend, in a modest way, to address some main guidelines in each aspect highlighted: the role of the laws, the role of the subject's will, the role entrusted to physicians. I offer them to those who may find them useful.

These lines can be used to reflect and argue about this problem, or serve as the basis for a briefing or a debate. I deliberately leave aside, in these notes, other considerations: whether the professional institutions and civil society have been listened to, whether a social debate has been allowed to open on the issue, whether such a law was opportune at this time of pandemic, whether there was a political or economic interest behind it, the proposal of palliative care, etc.

The outline that these notes will follow is as follows:

1. The reasons in favor of euthanasia.
2. The law on euthanasia passed in the Spanish Parliament.
3. About the patient's will.
4. About the role that the law assigns to physicians.
5. The Catholic position on euthanasia.

1. The reasons in favor of euthanasia

Sometimes the reasons given by those in favor of euthanasia can be caricatured with a certain levity. Or they are labeled as "ideological", forgetting that we find people in favor of euthanasia throughout the social and political spectrum, from the most liberal to the most conservative, rich or poor, intellectual or not, in our society. It is not a waste of time to know in some detail their positions, because to value those who are different or think differently is an attitude that denotes inner freedom and open-mindedness.

Why is it held that laws should recognize as a right the will of someone to end his or her life, receiving medical help to do so?

In the first place, it is pointed out, because it gives the possibility of ending pain and suffering, both to the patient and to their families. People have the right to decide about their lives; everyone must be free to decide what they want to do with their lives and when to end it. And this law allows people to decide for themselves. To let people be free is not to force them to submit to one's own criteria. To keep someone suffering, to deny them peace, is like torture and an incomprehensible, irrational, unjust act of cruelty.

If the demands of patients, of society, and even of many physicians, have undergone a change of sensitivity towards the voluntary request to die, it is necessary to have laws that regulate it with guarantees. This is a requirement of pluralism. Where a need arises, a right arises. Those who support this law are in favor of dignity and freedom. This law makes us advance in our freedom and will offer sufficient guarantees so that the procedure respects that individual freedom. It would benefit all those who request it, and it would not obligate anyone to anything. Not even doctors, since the law itself includes the right to conscientious objection.

Of course, I hope that no one has to make these decisions. But the reality is that there are hundreds of people who do want to make them: they have been living for years with intolerable suffering or in situations of irreversible deterioration of their lives. And we cannot impose our beliefs or our decisions on others, but must respect individual convictions about the best time to end one's life. Those who want to continue living in distressing situations will be able to continue to do so as they have been doing up to now. But those who freely wish, in these situations, to put an end to their suffering, will be able to do so thanks to this law. No one loses rights, and we all advance a little in our freedom.

2. The law on euthanasia passed in the Spanish Parliament.

It is an unfair law for at least two reasons:

a) because it legislates against the protection of a fundamental right, the right to life. This technical expression ("fundamental right") is used to refer to the basic goods that must be respected in every human being by the mere fact of being "human". They are not "dispositive" rights. Other fundamental rights are, for example, the right to education, to physical integrity, to private life, to freedom of thought, etc. They are not the creation of a legal or political system: they are basic goods essential to the development of each person. They are usually described with some characteristic notes: they are universal, absolute rights (i.e., "without conditions" of sex, age, etc.), inalienable (they cannot be sold or transferred to a third party), unrenounceable (particularly clear in the right to life, the first of all fundamental rights since it is the generator of any other possible right).

b) because it allows serious injustices to be committed under the protection of the law itself. Many jurists, including supporters of euthanasia, have pointed out that, technically speaking, the present law opens the door to committing greater injustices than those it seeks to prevent: murder for the sake of interest, falsification of the advance directives document, application of death against the subject's will, elimination of the judicial guarantee in the procedure, etc. At bottom, the problem basically lies in the fact that it is not the patient who decides. The mechanisms established by this law are legally insufficient to avoid abuses, and there is room for unjust applications. This injustice is particularly serious because it is impossible to repair, since the death that has occurred is irreversible: life cannot be restored to someone who has been killed "by mistake" or in bad faith.

Some of the most notable objections that jurists have made to this law are:

1) In the present law, the judge (the judicial guarantee and protection) does not appear at any time, anywhere. The "controls" that the law establishes are merely administrative, in a matter of capital importance because it is a fundamental right (just think that the inviolability of the home, the removal of the corpse, the body search, the non-voluntary admission in a psychiatric institution, etc., are situations that require judicial action).

2) With respect to the capacity to act of the patient requesting euthanasia (the legal capacity of a person, in full use of his or her mental faculties, to act voluntarily), the law introduces a worrying novelty, by establishing as "Situation of de facto incapacity": situation in which the patient lacks sufficient understanding and will to govern himself/herself autonomously, fully and effectively, regardless of the existence or adoption of support measures for the exercise of his/her legal capacity. (see Article 3, paragraph h). According to this, a representative of the patient or a physician, i.e. a third party, may request death if he or she considers, without any judicial guardianship, that he or she is incapable.

3) The law provides that the provision of assistance in dying may be carried out according to two modalities. One of them is "the direct administration of a substance to the patient by the competent health care professional"(see Article 3, paragraph g-1). This is a decriminalization of homicide, contrary to the Penal Code. Between the moment of requesting euthanasia and its application, a period of time elapses during which the subject may wish to revoke this decision, or postpone it for a while. Although the law includes the patient's right to revoke the decision or postpone it (see art. 6.3), it must be taken into account that if the physician, or a third party, considers that at that moment the patient is no longer "fully conscious" or is "de facto incapable" of expressing his or her contrary will, or simply that the patient has lost the physical capacity to communicate, euthanasia could be applied against his or her will. Who certifies that, at the moment when death is to be administered, that person wants it to be administered: there is no judicial vigilance for the protection of the patient.

4) Art. 5.1 establishes the requirements for receiving the aid in dying benefit. What is worrisome is that in the next line (Art. 5.2) the law states that "the provisions of letters b), c) and e) of the previous paragraph shall not apply in those cases in which the responsible physician certifies that the patient is not in the full use of his or her faculties nor can give free, voluntary and conscious consent to make the requests, complies with the provisions of paragraph 1.d), and has previously signed a document of advance directives, living will, advance directives or legally recognized equivalent documents, in which case the provision of assistance in dying may be provided in accordance with the provisions of said document.". The same article specifies that the assessment of the situation of de facto incapacity will be made by the physician responsible for the patient. In the incapacitation procedure, to consider whether or not a person is capable of deciding about his or her own life, the judge is nowhere to be found.

5) Among the requirements for receiving the death assistance benefit, it is determined (see art. 5.1.c) that "if the responsible physician considers that the loss of the applicant's capacity to give informed consent is imminent, he/she may accept any lesser period he/she considers appropriate (it has been previously mentioned that there must be 2 written requests for euthanasia separated by a period of 15 days). according to the concurrent clinical circumstances, which should be recorded in the medical record.". Pay attention to several things:

• that the criterion of capacity is established by the physician. In a matter as serious as legal capacity, a physician is given that power;
• that if the physician considers that the procedure of the two previous requests should be skipped, for example based on the criterion that in a few days the patient will lose his/her capacity to act, he/she may skip the protocol.

6) In establishing the requirements to be met by the application for aid in dying, it is stated (see art. 6.4) that, once the de facto incapacity has been determined, "...".the request for the provision of assistance in dying may be submitted to the responsible physician by another person of legal age and fully capable, accompanied by the advance directive, living will, advance directives or legally recognized equivalent documents previously signed by the patient. If there is no person who can submit the request on behalf of the patient, the physician treating the patient may submit the request for euthanasia.". It is not only that the family may be left out of the decision, but as it is later pointed out (see art. 9) the physician "is obliged to implement the provisions of the advance directive or equivalent document"The document can reach the physician (perhaps falsified) at any time during the clinical evolution, once the patient is deemed "de facto incapable".

7) Once euthanasia has been performed, the responsible physician must submit certain documents to a supervisory committee. The wording of the regulation opens up the possibility that, even if the patient has not requested euthanasia in writing, someone "on behalf of the patient" may request it (see art. 12, paragraph a-4: "If the applicant had an advance directive or equivalent document and it identified a representative, the full name of the representative. Otherwise, full name of the person who submitted the application on behalf of the patient with de facto incapacity.").

8) Finally, it is of great concern that the First additional provision. On the legal consideration of deathstate that "Death as a consequence of the provision of aid in dying will be legally considered a natural death for all purposes, regardless of the coding performed on the death.". That is to say, when a judge or a relative receives the death certificate, he will read natural deathThe company's management has also been able to prevent a lawsuit from being filed on the suspicion that, for example, not all guarantees have been complied with.

When faced with any law, legal scholars often ask themselves what is the most important one, and what is the most important one? the intention of the law itself. Many fear that the underlying intention is rather economic, as another means of securing the welfare state (sustainability of pensions, etc.). And that the law of a dignified death is actually disguising, under that name, a procedure to terminate what is considered to be a useless life.

3. About the patient's will

Many legal and medical scholars have pointed out that assessing the true autonomy of someone who expresses his or her will to die is one of the most difficult questions.

The law points out that the free and voluntary consent of the subject can easily be vitiated: it can be coerced by the family, caregivers, the physician, by persons interested in collecting life insurance, or by the Administration (in the case of a patient who is under the care of the health administration alone), etc. When the situation of the sick person involves a significant family burden, objective or subjective, the option of choosing euthanasia becomes a moral coercion on the conscience of the person who feels that he or she is a hindrance.

In medicine, specialists (psychiatrists, palliativists, intensivists, neurologists, etc.) have raised important objections to the patient's freedom when he/she expresses his/her "will to die". Let us see some of them:

• Only from freedom can decisions be made in accordance with one's own way of thinking and way of living. The disorders that influence it will cause, to a greater or lesser extent, a decision taken from the pathology, in which it lacks a fundamental element: freedom. But it is precisely when mental disorders are present, freedom is seriously compromised, This is an essential element (the freedom or autonomy of the patient's will to express his or her express will to die) in order to respond or not to the request for assistance in dying.
• Some pathologies can compromise the essential psychic functions (consciousness, thinking, sensory perception, experience of the self or affectivity) for making relevant decisions. The integrity of these functions is a condition sine qua non to assume that a decision is freely made and conforms to the true will of the person and not to the pathologically determined will. Therefore, people suffering from psychopathological decompensation at the time of making decisions that affect their future should be supported beforehand in order to restore their freedom and, ultimately, their ability to make decisions. Especially if these decisions are against their own interests and are irreversible.
• The most severe mental disorders in themselves place these patients in situations of particular vulnerability, as they are associated with problems of life expectancy, access to housing, employment, specialized health care, etc.: it is important to ensure that these remediable shortcomings do not contribute to the desire to die.
• It is well known that the desire to die is part of the usual symptomatology of several mental disorders, especially depressive disorders, but also schizophrenia, addictions and severe personality disorders, among others. In fact, suicide is a global public health concern - the incidence of completed suicides in patients with mental disorders is very high, being one of the leading causes of death in people aged 15 to 34 years. Scientific opinion is unanimous in linking the majority of completed suicides to the presence of mental illness, even accepting that the desire to die does not always result from the manifestation of a mental illness.
• The presence of depression is a particular concern in euthanasia requests because it can affect patients' competence, particularly in the relative weighting they give to the positive and negative aspects of their situation and possible future outcomes. Depression is a disease for which treatments exist and is potentially reversible. Patients with depression may be considered a vulnerable population in this context, as their request for death may be due to the presence of depression; and the correct response is treatment of depression, rather than assistance in dying.
• There is no doubt that some mental disorders cause enormous suffering and the degree of affectation they generate is easily inferred, both from social and professional experience with psychiatric patients, as well as from the suicide figures attributable to psychiatric disorders. The similarity of hopelessness and the desire to die with the symptomatology of depression and with the clinical context of suicide cannot be overlooked. Vulnerability should not be used to discriminate against access to aid in dying or to any other legal right, but the presence of elements outside the person in the decision making process cannot be ignored, even more so when it is an irreversible event. In societies in which suicide prevention is considered a global responsibility, and the reduction of the annual figures a common objective, the incongruity of proposing aid in dying for people suffering from disorders whose symptoms include suicidal ideation and the desire to die as part of the pathology cannot be avoided.
• There are numerous studies on the "wish to die" presented by oncological or terminally ill patients at some point in their clinical evolution. Research has shown that this state of mind has a very different meaning to that of an "effective desire to be killed".

4. On the role that the law assigns to physicians

First of all, it is necessary to refer to the official declarations written by various medical corporations. They are unanimous in their categorical rejection of the perverse collaboration requested of physicians in causing the death of a patient. According to the professional deontology of the physician, euthanasia and medical aid to suicide are incompatible with medical ethics.

• The World Medical Association, in October 2019, issues a Statement in which it expresses its "firm opposition to euthanasia and physician-assisted suicide; no physician should be compelled to engage in euthanasia or physician-assisted suicide, nor should any physician be compelled to refer a patient for this purpose.".
• The Consejo General de Colegios oficiales de Médicos en España (the Organización Médica Colegial), made public in May 2018 its "Posicionamiento ante la eutanasia y el suicidio asistido", where it states, in coherence with the Código de Deontología Médica, that. a physician shall never intentionally cause the death of a patient, even at the patient's express request..
• And more recently, the Spanish Bioethics Committee (a consulting body under the Ministry of Health) released its Report, published in October 2020, in chapter 6 of which (entitled Euthanasia and medical professionalism) pointed out that "from a strictly medical point of view [...] euthanasia involves a transformation that must be highlighted. By describing it as a right exercised in the context of medical activity, it is the medical activity itself that is transformed, since in certain cases described by the law, medical homicide becomes a protocolized action.. [...] With euthanasia, the medical professional acquires a new power, albeit unintended. He possesses a power of death over the patient, which certainly opens up according to the patient's will and the circumstances provided for by law. The change that occurs is the intentional homicide by the physician as a legal obligation that will transcend the lex artis.".
• Also of special interest are the Declarations published by the Spanish Society of Psychiatry, the Spanish Society of Palliative Care, and the official joint Declaration of the Madrid Associations of Pharmacists, Dentists and Physicians.

What does it mean for Medicine that the physician must provoke the death or collaborate in the suicide of his patient, if the latter asks him to do so? In short, it could be said that it brings about the degeneration of Medicine, because it turns Medicine into something else:

• The perversion of the doctor-patient relationship. Suicide assistance is not a task that arises from a physician's professional responsibility, as it is important that seriously ill patients can regard their physician as a trustworthy person, with whom they can talk, even if they are struggling with the desire for premature death. Within the protected space of the patient-physician relationship, each patient should be able to rely on a fair discussion of suicidal thoughts and intentions, and on life-oriented advice and support from the physician. Refusing to assist suicide allows physicians to preserve the ethical deontological significance of their profession and allows patients to maintain a stronger trust in their physicians.
• The abolition of the ethos It destroys the medical vocation, the basic qualities of the profession: care and accompaniment of the patient to the end, prevention of suffering, fidelity to the patient, respect for his or her dignity, professional fellowship, equal justice for all. The physician is the person in whom one trusts at the very moment when illness and suffering sap one's spiritual and bodily strength and endanger life. A physician cannot be asked to judge or to decide who should live and who should die. The trust that the patient places in him is based on the assumption both of his professionalism and of the unequivocal pro-life attitude expected of him.
• A fair view of reality reveals that the physician, as a moral agent, is not a "superior being". He is a human being, with virtues and weaknesses, ideals and defects. He may at times be too tired, annoyed by his failures, or too moved by the suffering of his patients. Out of emotional fatigue or thoughtless compassion, the physician may be tempted to anticipate a patient's death, especially when the patient asks him to do so. If he were then to yield, he would commit homicide. The absolute prohibition of killing patients, present since Hippocrates in professional ethics, has been the moral driving force and the human salvation of physicians and medicine.
• The physician sets himself up as the proxy of the incapable patients. The physician who accepts the euthanasic "solution" for some of his patients becomes, for reasons of moral coherence, the owner of the lives of the chronically incapable (profoundly deficient, permanently comatose, senile insane, etc.).
• Experiences in Belgium and the Netherlands are showing that the limits initially set by the law are soon erased by the practice of physicians. When euthanasia acquires the status of something morally acceptable or even good in the consciences of individuals or societies, euthanasia becomes widespread and, in fact, legally uncontrollable.
• One more reason, worthy of attention, is that euthanasia profoundly harms biomedical research, particularly those aimed at treating advanced and terminal disease. But also to that which seeks a solution to diseases currently considered incurable, especially if researchers do not discover promising prospects for rapid advances. Sweet death" can steal incentives from research into the mechanisms of brain aging, the rehabilitation of dementia, advanced cancer, the correction of multiple malformations, and many serious genetic diseases. Those who argue that euthanasia will impoverish the work and science of physicians are quite right.

What does it mean for Medicine that the doctor must provoke the death or collaborate in the suicide of his patient, if he asks him to do so? The degeneration of medicine, because it turns medicine into something else.

Juan Carlos García Vicente

5. The Catholic position on euthanasia

In all of the above, no reference has been made to religious convictions. But certainly the idea that a believer receives from one's own religious convictions about the origin and destiny of man leads him to react with uneasiness to any attempt to legalize this practice. The believer receives with a sense of security and relief the persuasion that only the God of life is the Lord who masters death. The coming to this life and the end of this life are events too important and mysterious for any human authority to meddle with.

The main official documents of the Catholic Church on euthanasia are the Declaration on Euthanasia, the Declaration on Euthanasia and the Declaration on Euthanasia. Iura et bonaand the Charter Samaritanus bonusboth published by the Congregation for the Doctrine of the Faith in 1980 and 2020 respectively. To these documents must be added the rejection of euthanasia formulated by Saint John Paul II in his Encyclical Evangelium vitae n. 65, with particularly solemn words: "In accordance with the Magisterium of my predecessors and in communion with the bishops of the Catholic Church, I confirm that euthanasia is a grave violation of the Law of God, insofar as it is the deliberate, morally unacceptable elimination of a human person.".

Both documents, although 40 years apart, contain a brief compendium of Catholic morals on sickness and death. Their reading shows that the magisterium was aware of the ongoing evolution of things, both with regard to euthanasia and to the new therapies that made it possible to save lives or prolong them almost indefinitely.

In the statement Iura et bona The two anthropological postulates on which voluntary euthanasia and assisted suicide are based are taken into account and refuted: on the one hand, the idea that, in some circumstances, dying is a good and living an evil; on the other hand, the claim that man has the right to choose to procure or procure the death of others. This document, moreover, denies that pain is an absolute evil to be avoided at all costs: it is an obligatory act of charity to do what is possible to alleviate the suffering of the sick, but without forgetting the positive meaning of suffering voluntarily accepted and sustained by faith in Jesus Christ.

Mercy and beneficence have a thousand ways of expressing themselves. But among them there is no place for the murder of a dying brother. Catholic doctrine affirms that life is a marvelous gift and a duty entrusted by God to man. And that, precisely because it is a gift and a mission received from the Lord, it must be administered and lived to the full, always entrusting ourselves with confidence to the designs of divine love, especially in moments of greatest difficulty. Therefore, Catholic morality sees in euthanasia and assisted suicide an evil that is opposed, not to abstract dogmatic principles, but to the very good of man, because it contradicts his innermost being and his vocation to happiness.

When one is sick, entrusting oneself to divine providence does not eliminate the personal duty to take care of oneself and to be taken care of, nor does it impose the obligation to have recourse to all possible remedies. Concretely, this declaration points out these precisions:

• in the absence of other remedies, it is lawful to resort, with the consent of the patient, to the means provided by the most advanced medicine, even if they are still at an experimental stage and are not free of some risks;
• It is also lawful to discontinue the application of these means when the results do not correspond to the expectations placed in them;
• it is always lawful to be content with the normal means that medicine can offer;
• When faced with the imminence of inevitable death, in spite of the means employed, it is licit to renounce treatments that would only mean a precarious and painful prolongation of life, but without interrupting the normal care that should be given to any patient in these cases.

Against the pro-euthanasia culture, Christianity denounces the contradictions and weaknesses of positions that do not realize the drama of those who, ill and perhaps marginalized by all, can no longer endure life. The desire to die is often the result of an inhuman and unjust situation, or of a pathological condition that has been neglected or even ignored. It cannot be denied that prolonged pain is unbearable, and other reasons of a psychological nature can cloud the mind to the point of leading someone to think that he can legitimately ask for death or procure it for others. But, nevertheless, murdering a sick person is inadmissible.

The request to die is hardly the result of a real choice. He who finds himself in such circumstances has only the experience of despair or of actual loneliness, but no experience of death: death can only be imagined, but it cannot be measured, let alone counted. It is the only human affair that leaves no possibility of going back. Paradoxically, there is no moment in life in which it is so fundamental to rekindle hope as when one is close to death: it is the instant in which the history lived until then reaches its full meaning only if the possibility of a future remains open.

The Charter Samaritanus bonus reflects all the same sentiments. But it broadens the focus of attention, taking into account the last 40 years of medical development. Just reading the table of contents of this document gives an idea of the new fields of health and therapies in which Catholic morality can shed important light.

In a very summarized way, we can enucleate two guidelines that appear in this document:

• A key concept that has been reiterated is that of the care (when it is not possible to cureit is always possible care) and the accompaniment to the chronically ill patient with no hope of cure, or in the terminal phase of his illness. Continuity of care is a duty of the physician, as a peculiar way of solidarity with those who suffer.
• Particular attention is paid to the physician's duty to adapt therapies to the real possibilities of improvement of the patient, pointing out therapeutic futility as a practice that is not only medically but ethically unacceptable. And the recognition of the lawfulness of sedation in the final stage of life: "To reduce the pain of the patient, analgesic therapy uses drugs that can cause the suppression of consciousness (sedation). [The Church affirms the licitness of sedation as part of the care offered to the patient, so that the end of life may take place with the greatest possible peace and in the best possible interior conditions. This is true also in the case of treatments that anticipate the moment of death (deep palliative sedation in the terminal phase), always, as far as possible, with the informed consent of the patient." (Samaritanus bonus, n. 7).

Sources used for this work, as references for interested readers:

1) A sample button of the position of euthanasia supporters can be seen:

2) The current law on euthanasia in Spain can be read at: https://www.boe.es/buscar/pdf/2021/BOE-A-2021-4628-consolidado.pdf

3) The following readings are proposed to shed light on why it is an unjust law. Although it does not refer to the Spanish law that is being processed, but in general, the analysis of the European Court of Human Rights, of August 31, 2020, is excellent. It can be seen in: https://www.echr.coe.int/Documents/Guide_Art_2_ENG.pdf. The pages devoted to a legal analysis of euthanasia in the Report of the Spanish Bioethics Committee (a consulting body under the Ministry of Health) are also of extraordinary interest: http://assets.comitedebioetica.es/files/documentacion/Informe%20CBE%20final%20vida%20y%20la%20atencion%20en%20el%20proceso%20de%20morir.pdf.

4) There are various studies on the technical limitations of the current euthanasia law, from the legal point of view. To cite a more detailed study, among many others, concerning the legal technique, see: R. Gisbert, El gran peligro de la ley de eutanasia

(https://www.youtube.com/watch?v=21vp0TXhlaQ; durac. 37 min). This author handles the text of the bill passed in Congress, prior to its passage through the Senate and the drafting of the law currently in force. However, the amendments made to the current law do not affect the substance of R. Gisbert's analyses, which are still relevant. Other quality studies, now shorter, can be found in R. Navarro-Valls, La encrucijada sangrienta del derecho (La encrucijada sangrienta del derecho) (https://blogs.elconfidencial.com/espana/tribuna/2020-10-20/encrucijada-sangrienta-derecho_2796332/); or J.M. Torralba, Dignidad humana y autonomía personal en la nueva ley de eutanasia (https://www.elespanol.com/opinion/tribunas/20201017/dignidad-humana-autonomia-personal-nueva-ley-eutanasia/528817119_12.html).

5) We propose a reading, because of its enormous interest for knowing the limitations of the will of the subject who expresses his wish to die, of the position of the Spanish Society of Psychiatry, which can be found in: http://www.sepsiq.org/file/Grupos%20de%20trabajo/SEP-Posicionamiento%20Eutanasia%20y%20enfermedad%20mental-2021-02-03(1).pdf

6) For the interested reader, especially physicians and health personnel, some more recent research on the "wish to die" expressed by some patients is noted:

- Bellido-Pérez M, Monforte-Royo C, Tomás-Sábado J, Porta-Sales J, Balaguer A. Assessment of the wish to hasten death in patients with advanced disease: A systematic review of measurement instruments. Palliat Med. 2017 Jun;31(6):510-525. doi: 10.1177/0269216316669867. Epub 2016 Oct 22. PMID: 28124578; PMCID: PMC5405817. The article can be read at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5405817/

- Rodriguez-Prat A, van Leeuwen E. Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies. Med Health Care Philos. 2018 Mar;21(1):63-75. doi: 10.1007/s11019-017-9785-y. PMID: 28669129. An abstract of the abstract can be found at: https://pubmed.ncbi.nlm.nih.gov/28669129/

- Belar, Alazne & Arantzamendi, Maria & Santesteban, Yolanda & López-Fidalgo, Jesús & Martínez García, Marina & Gay, Marcos & Rullan, Maria & Olza, Inés & Breeze, Ruth & Centeno, Carlos (2020). Cross-sectional survey of the wish to die among palliative patients in Spain: one phenomenon, different experiences. BMJ Supportive & Palliative Care. bmjspcare-2020. 10.1136/bmjspcare-2020-002234. The article can be downloaded at: https://www.researchgate.net/publication/342429857_Cross-sectional_survey_of_the_wish_to_die_among_palliative_patients_in_Spain_one_phenomenon_different_experiences

- Arantzamendi M, García-Rueda N, Carvajal A, Robinson CA. People With Advanced Cancer: The Process of Living Well With Awareness of Dying. Qual Health Res. 2020 Jul;30(8):1143-1155. doi: 10.1177/1049732318816298. Epub 2018 Dec 12. PMID: 30539681; PMCID: PMC7307002. The article can be read at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307002/

7) The October 2019 World Medical Association Statement can be viewed at: https://www.wma.net/es/policies-post/declaracion-sobre-la-eutanasia-y-suicidio-con-ayuda-medica/

8) The May 2018 Statement of the General Council of Official Colleges of Physicians in Spain (the Organización Médica Colegial) can be found at: https://www.cgcom.es/sites/default/files/u183/np_eutanasia_21_05_18.pdf. A new Declaration of this Agency was necessary after the approval of the law in Congress, pointing out that The regulation of euthanasia in Spain means endorsing by law that euthanasia is a "medical act". This is contrary to our Code of Medical Ethics and contradicts the positions of the World Medical Association. Further on, it warns that the CGCOM will activate all the necessary mechanisms in defense of the medical profession, the practice of medicine, the values of medical professionalism and the doctor-patient relationship.. It can be found at: https://www.cgcom.es/sites/default/files/u183/np_ley_eutanasia_cgcom_18_12_2020.pdf

9) The Report of the CBI (Spanish Bioethics Committee) can be read at: http://assets.comitedebioetica.es/files/documentacion/Informe%20CBE%20final%20vida%20y%20la%20atencion%20en%20el%20proceso%20de%20morir.pdf.

10) The Declaration of the Spanish Society of Psychiatry can be read at: http://www.sepsiq.org/file/Grupos%20de%20trabajo/SEP-Posicionamiento%20Eutanasia%20y%20enfermedad%20mental-2021-02-03(1).pdf

11) The very forceful declarations of the Spanish Society of Care can be found, to cite only the two most recent ones, in: 

– https://aecpal.secpal.com/Sobre-la-eutanasia-y-la-dignidad-al-final-de-la-vida

– https://www.secpal.com/Comunicado-de-SECPAL-y-AECPAL-sobre-la-Proposicion-de-Ley-Organica-de-Regulacion-de-la-Eutanasia.

12) The official joint declaration of the Madrid Associations of Pharmacists, Dentists and Doctors can be read at: https://www.icomem.es/comunicacion/noticias/3640/Declaracion-oficial-contra-el-Proyecto-de-Ley-de-Eutanasia-de-los-Colegios-de-Farmaceuticos-Odontologos-y-Medicos-de-Madrid

13) There are hundreds of interviews, books and articles written by physicians on the meaning for medicine of a physician having to provoke the death or collaborate in the suicide of his patient, if the latter asks him to do so. To cite a study by a physician, addressed to physicians, particularly valuable for its conciseness, clarity, and the qualifications of its author, read G. Herranz, Los médicos y la eutanasia, which can be found at: http://www.muertedigna.org/textos/euta29.html

14) Regarding the Catholic position on euthanasia, it is important not to forget that the Spanish Episcopal Conference (and many bishops in their ordinary magisterium) has published several strong statements on the subject. They can be found in:

– https://www.conferenciaepiscopal.es/podcast/la-vida-es-un-don-la-eutanasia-un-fracaso/or its text version under the title Life is a giftwhich can be read at: https://www.conferenciaepiscopal.es/interesa/eutanasia/iglesia-frente-eutanasia/

– https://www.conferenciaepiscopal.es/podcast/sobre-la-aprobacion-de-la-ley-de-eutanasia-palabras-de-mons-arguello/

15) As is well known, the main official documents of the Catholic Church on euthanasia, issued by the Congregation for the Doctrine of the Faith, are the statement Iura et bonaand the Charter Samaritanus bonuswhich can be read at:

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_sp.html

https://press.vatican.va/content/salastampa/es/bollettino/pubblico/2020/09/22/carta.html

16) To give a reference of the universal and solemn magisterium on euthanasia, it is necessary to mention the text of St. John Paul II from the Encyclical Evangelium vitae, n. 65.

17) Readers will find in the Letter Samaritanus bonusV, ten sections on ethical decision making in very diverse clinical situations (pediatric contexts, vegetative state, withdrawal of therapies, etc.). It will be of particular interest to physicians.

18) In order to facilitate the work of consultation, some text of the Charter is provided below. Samaritanus bonusChapter V: Even when cure is impossible or improbable, medical and nursing support (care of the essential functions of the body), psychological and spiritual, is an unavoidable duty, because otherwise it would constitute an inhuman abandonment of the sick person. (.../...) Recognizing the impossibility of cure in the near eventuality of death does not mean, however, the end of medical and nursing work. Exercising responsibility towards the sick person means assuring care until the end: "to cure if possible, always to care". This intention to always care for the sick person offers the criterion for evaluating the various actions to be carried out in the situation of "incurable" illness; incurable, in fact, is never synonymous with "incurable". The contemplative gaze invites us to broaden the notion of care.

19) The moral permissibility of sedation is well known from the Charter of the United Nations. Samaritanus bonusV, n. 7.

20) The following is suggested as additional general bibliography:

I. Carrasco de Paula, voice Euthanasiain Pontifical Council for the Family, Lexicon (Ambiguous and disputed terms on family, life and ethical issues)Palabra 2004, pp. 359-366.

M. Martínez-Selles, Euthanasia. An analysis in the light of science and anthropology., Rialp, Madrid 2019, 98 pages.

C. Centeno, Euthanasia, by law, in Spain: is everything clear?in https://theconversation.com/eutanasia-por-ley-en-espana-esta-todo-claro-152908

C. Centeno, I want a society that protects the weak and soothes the sickin https://eldebatedehoy.es/noticia/entrevista/08/02/2021/carlos-centeno-eutanasia/#:~:text=Quiero%20una%20sociedad%20en%20la,enfermo%20se%20le%20ofrezca%20alivio.&text=Estoy%20a%20favor%20de%20la,que%20viven%20todos%20los%20dem%C3%A1s.

AA.VV., Giving life at the end of life: 20 reflective papersin Cuadernos de Bioética (can be downloaded at: http://aebioetica.org/eutanasia-y-etica.html)

Aceprensa, UN experts: disability is not a ground for euthanasiain https://www.aceprensa.com/el-observatorio/expertos-de-la-onu-la-discapacidad-no-es-motivo-para-aplicar-la-eutanasia/

E. García Sánchez, Patient autonomy as a moral justification for euthanasia. Analysis of its instrumentalization and perversionin: https://www.bioeticaweb.com/wp-content/uploads/eutanasia_vs_autonomia.pdf

R. Sánchez Barragán, Conscientious objection to euthanasia: a biolegal analysis.,in: http://revistas.usat.edu.pe/index.php/apuntes/article/view/398/843

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