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HEALTH

One year since Spain’s euthanasia law was passed, what has changed?

A year since Spain's euthanasia law was passed, there have been over 150 assisted deaths in the country but still many objectors from within the medical sphere. Here's what the data reveals about Spain's approach to this highly divisive practice.

One year since Spain's euthanasia law was passed, what has changed?
Supporters of Spain's euthanasia law hold signs saying: "To choose to die without suffering" and "I decide when and how to die" during a March 2021 demonstration in Madrid. Photo: JAVIER SORIANO/ AFP

Spain’s historic euthanasia law was passed a year ago on June 25th, 2021.

Since that day at least 171 people have ended their lives through the assisted dying procedure, although the statistics to date are both regional and provisional. That number could, in reality, be higher.

The figure is based on figures from Spanish newspaper El Mundo, although it must be said that it doesn’t include the regions of Asturias and La Rioja, where the data is not yet available.

Before the landmark legislation, assisting somebody who wanted to die was punishable by up to ten years in prison, and the law, which made Spain the fourth country in Europe to allow people to end their own life, following the Netherlands, Belgium and Luxembourg, was as controversial as it was groundbreaking.

Pedro Sánchez’s PSOE-led coalition government had to rely on the congressional support of minor left-wing parties to pass the bill, and although it was celebrated by right-to-die campaigners in Spanish society -described as creating a “a more humane and fair society,” by Health Minister Carolina Darias – it outraged many conservative and religious groups.

 
The law

Although widely known as Spain’s euthanasia law, in reality the legislation prescribes two forms of dying: euthanasia and assisted suicide.

Euthanasia is the procedure of prematurely ending a life to relieve suffering or pain – via lethal injection administered by a doctor, for example.

Assisted suicide, however, is undertaken by the person themselves with help.

Both euthanasia and assisted suicide can be carried out on consenting patients suffering from chronic and debilitating conditions, incurable illness, or conditions that cause immense suffering.

You must be an adult Spanish national or have legal residency in Spain, and be “fully aware and conscious” when you make the request, which must submitted twice in writing, two weeks apart.

But that doesn’t mean that applying, or having your application accepted, is easy.

The Local had delved into the realities of Spain’s historic euthanasia legislation one year on.

Regional variations

Although there are still no officially collected and aggregated statistics on a national level, and even some slight variation on the figures within Spanish media outlets, using provisional regional data it is possible to gage how the law has been implemented in its first year.

Nationally speaking, it seems at least 336 Spaniards requested euthanasia procedures in the first year of legal euthanasia, of which 171 were performed, 18 applications rejected, and 43 still pending decisions. 

But data from the first year of euthanasia procedures paints an interesting regional picture. Euthanasia and assisted dying have so far been, it seems, concentrated in certain regions of Spain.

Catalonia, for example, has performed 60 in the first year alone, while Andalusia, with one million more inhabitants than Catalonia, just 11.

In Andalusia, just 19 applications were made, of which 11 were accepted, six rejected and two still pending. In Catalonia that figure was 137.

After Catalonia, Basque Country had the second most euthanasia procedures, with 25 of 75 applications accepted. Third was Madrid, with 19, and fourth the Valencian Community, where 13 procedures have already been completed out of 23 applications made. 

On the Balearic Islands, eight were carried out of the 17 applications, whereas in the Canary Islands seven applications were made with four still awaiting a decision.

In Castilla-La Mancha eight applied, with four approved. But in Galicia, it seems the Galician government have a lower threshold for accepting euthanasia applications: of the 19 applications it received this year, just four were accepted. 

Similarly, in Castile y Leon, just two of the seven applications were accepted, and it is believed that the process became so drawn out that some patients even died before receiving a verdict.

In Murcia, on the other hand, four of the five total applications have already been carried out. In Cantabria, 12 procedures were requested, five completed, two rejected, and one still pending decision, 

Across the rest of Spain’s autonomous communities, none have completed more than five procedures.

How quickly is euthanasia approved in Spain?

Judging from the raw numbers, it seems that Catalonia and the Basque Country are the most willing to grant euthanasia procedures, but are also the fastest bureaucratically speaking: it takes patients, on average, 41 days from application to procedure in the two northern regions.

In Andalusia and Madrid, however, the process is much slower. In Andalusia, for example, the regional government took five months to even implement the law, and it is believed that they have kept applications waiting as long as three months due to a convoluted bureaucratic process that passes the application between different doctors with no streamlined system, which leads to a lag in processing.

Other regions, however, have already set up systems to deal with the applications.

In Catalonia, Navarre, the Basque Country and the Canary Islands, applications are dealt with by specially created teams made up of at least one doctor and a nurse who have studied and specialise in the implementation of the law. 

Medical objections

While the issue of euthanasia has long been politically and religiously controversial, the law has also divided doctors. In just the six regions alone where data is available, it is believed 4,500 doctors have objected to the procedures, either refusing to carry it out or withdrawing from the process altogether. 

Madrid has had the most objections from doctors, with almost 3,000 in the first year alone, while in Andalusia over 500 have objected.

Interestingly, even in a region with very few applications such as Castille y León, where only seven patients requested the procedure, over 400 doctors have ruled themselves out of the euthanasia process. That is more than Catalonia (167) where the most applications and procedures were recorded.

However many believe, the figures, admittedly provisional and very patchy at a national level, for now, could be hiding greater numbers of doctors who are uncomfortable with Spain’s new euthanasia law. 

The president of the Ethics Commission of the Andalusian Council of Medical Associations, Dr. Ángel Hernández Gil, said that “there are a very large number of doctors who are conscientious objectors” but are not recorded in the official statistics “because they are only registering as conscientious objectors when the request arrives. In the event that the application does not arrive, people will not register,” he explained in the Spanish press this week.

Speaking as a representative of the medical profession in Spain’s most populous region, Hernández Gil suggested so many doctors are against euthanasia because they believe “is not within the purpose of medicine.”

“Our position has nothing to do with any kind of political ideology, religious principle or moral principles,” he added.

“We understand that euthanasia is not a medical act.”

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HEALTH

What is Spain’s trouble-ridden Dependency Law?

The landmark legislation introduced in 2006 was supposed to widen the safety net for dependent people, but a person on the waiting list for services offered by Spain's Dependency Law died every 13 minutes in 2023.

What is Spain's trouble-ridden Dependency Law?

What is Spain’s Ley de Dependencia?

Spain’s Dependency Law (Ley de Dependencia) was passed in 2006 under the Zapatero government.

It was essentially put together in order to try and construct a social, psychological and financial framework of support for dependent people. In the words of the law itself, the aim was to: “to regulate the basic conditions that guarantee equality in the exercise of the subjective right of citizenship to the promotion of personal autonomy and care for dependent persons.”

To do this, it created the System for Autonomy and Care for Dependency (SAAD), and the benefits and services offered were put in place to give dependent people not only more support but dignity.

READ ALSO: What’s life in Spain like for people with physical disabilities?

However, the law (and system) has been dogged by backlogs and delays ever since. In 2021 the Spanish government injected hundreds of millions into the system to try and improve performance, but recent reports in the Spanish media suggest that things have barely improved — as of December 31st 2023 there were 296,431 people still on the waiting list.

How does the Dependency Law work?

The support available depends on the level of dependency, something which is examined by a medical expert and then graded on a scale. In theory, the dependency level can be changed depending on how the recipient’s needs develop over time.

The law outlines the Basic Activities of Daily Living (ABVD) that the SAAD is designed to assist with: “the most basic tasks… which allow them to function with a minimum of autonomy and independence, such as: personal care, basic domestic activities, essential mobility, recognising people and objects, finding their way around, understanding and carrying out simple orders or tasks.”

The three degrees of dependency are as follows:

  • Moderate dependency (1st degree) – someone who needs help once a day to complete basic activities.
  • Severe dependency (2nd degree) – someone who needs help 2/3 times a day to complete basic activities.
  • Great dependency (3rd degree): someone who needs ongoing, permanent assistance to manage their basic needs and activities.

What are the different types of dependency?

Dependencies can be wide-ranging and often have crossovers. The law defines dependency as “the permanent state of people who, for reasons of age, illness or disability, and linked to the lack or loss of physical, mental, intellectual or sensory autonomy, require the care of another person or persons or substantial help to carry out basic activities of daily living or, in the case of persons with intellectual disabilities or mental illness, other support for their personal autonomy.”

So the four main dependency categories are physical, mental, sensory, and mixed.

  • Physical – disability or mobility issues due to age, injury or illness, that makes someone dependent on another for physical support.
  • Mental – when a mental condition (such as dementia, for example) means a person is no longer capable of making decisions or problem solving and rely on someone else to do it for them.
  • Sensory – a loss of a sense, such as blindness, makes someone dependent on another for help.
  • Mixed – someone who suffers from two or more types of dependency

What does the law offer to dependent people?

Essentially care, whether in the home or at a residency centre, or financial assistance for people caring for loved ones.

The degree of dependency is tied to the care coverage:

1st degree: 10-20 hours/month
2nd degree: 21-45 hours/month
3rd degree: 46-70 hours/month

The average amount of home help is 33.8 hours per month, which rises to 57.9 hours for 3rd degree dependencies.

The financial benefit received by those who care for a dependent relative at home is €240.17 — €369.6 in the case of 3rd degree decencies.

The average amount of state benefit linked to a residential place for 3rd degree dependents is €575: less than a third of the real cost of these services.

READ ALSO: Can I claim UK Personal Independence Payments (PIP) in Spain?

Why is the law trouble-ridden?

However, as progressive as the legislation is on paper, in reality things haven’t worked out like that.

In 2023 alone, 40,447 people died while waiting to be assessed or cared for. This works out to 111 people dying a day in Spain while on the Dependency Law waiting list.

As of 31 December 2023 there were 296,431 people still on the waiting list. The time it takes to even process a dependency application and arrange care intervention takes almost a year (324 days).

But these failures aren’t for a lack of trying (or more specifically, money) by the government. In 2021, Spain’s Ministry of Social Rights approved a shock plan that increased state funding for the SAAD to the tune of €600 million. This money was mainly used to try and resolve the backlog in case applications and widen the coverage of benefits offered.

However, the plan hasn’t really worked as anticipated.

This seems to be for two main reasons: firstly, the complexity of the procedures taking a patient from application to dependency diagnosis and finally to care — in other words, slow bureaucratic processes getting in the way.

Secondly, the cutting of funding at a regional level has made an already overwhelmed system even more stretched.

Much of the money for the Dependency Law comes from regional authorities, and in 2023 nine regions reduced their funding for dependency services, including Catalonia (by 57.3 million), Andalusia (51.6 million), Valencia (40.6), Madrid (15 million), Extremadura (11), Asturias (10.8), Cantabria (8.7), Castilla y León (7.4) and Murcia (1).

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