ROME – Just days before the 11th anniversary of the death of an Italian man whose battle to be allowed to die stimulated wide debate in the country over euthanasia, the Italian senate on Thursday approved a “living wills” measure strongly backed by right-to-die advocates.

For the Catholic Church here, the vote marks a third major political setback in the last two years, coming on the heels of its failures to block adoption of civil unions in 2016, which the Church saw as a step toward gay marriage, and to push through a ius soli law granting immigrant children citizenship by birth, which came with Pope Francis’s personal blessing.

In many ways, Thursday’s result caps a political movement in Italy that began in 2006, when poet and painter Piergiorgio Welby publicly declared his wish to die as a result of the muscular dystrophy that had plagued him since he was a teen. The case generated wide controversy, which continued after his death on Dec. 20, 2006 – in part, because Welby was denied a church burial.

Under the new law, a “living will” is a written or video declaration of a person’s preferences regarding future medical treatment should he or she not be able to express informed consent. The proposal formally was brought before the Italian Senate on April 21, and adopted Thursday with 180 votes in favor.

The push for the law was led by the Italian Radical Party and the Associazione Luca Coscioni, of which Welby was co-president. The new legislation reflects a large portion of the Italian population’s views, with recent polls showing between 70 and 80 percent in favor.

Where things stand

The new law, along with its 3,000 amendments, is an effort to walk a fine line between the more permissive legislation in some European countries, and a more restrictive focus on the intention of the patient and individual.

Importantly, it does not allow physician-assisted suicide, where the patient is administered a drug to put an end to his or her life, as is the case in Switzerland. The law also does not allow euthanasia, where a doctor intervenes to bring about the death of a patient.

At the heart of the legislation is the notion of informed consent, recognizing the right of every individual to know their medical situation and the consequences of every cure or intervention – or, the decision to refuse treatment. Italians will now have an option to fill out a module expressing their preferences in case they might not be able to express it in the future.

The will of the patient may change at any time, according to the law.

Patients will also be able to identify another person, either a family member or trusted individual, who will take charge and speak to doctors if the patient is incapacitated.

In the case of minors and people with disabilities, the law provides that a parent or guardian may give that consent, although it specifies that the patient must be able to freely express his or her will.

The new law recognizes artificial nutrition and hydration as “medical treatments,” in light of the fact that they are prescribed by a doctor. This means that in a living will, individuals may refuse them and they can be suspended.

Finally, legislators agreed that doctors “must abstain from every unreasonable obstinacy in the administering of cures, and from resorting to disproportionate and useless treatments.” Physicians are still required to relieve the pain of their patients, even if she or he refuses medical care, placing a special focus on palliative care.

Senator and doctor Maria Rizzotti, of the conservative party Forza Italia, expressed her opposition to the law by calling it “a veiled form of euthanasia,” while biologist and pharmacologist Elena Cattaneo, a senator of the Italian Democratic Party, said “the law reinforces the fundamental rights of everyone, the unstoppable need for freedom that we express in the self determination of end of life choices.”

The stand of the Catholic Church

On the whole, most Catholic leaders in Italy took the stance that end-of-life patients should not be unduly burdened with unnecessary treatments, but also expressed alarm over the living wills law as a potential step towards euthanasia.

In a November message sent to European representatives of the World Medical Association who were meeting at the Vatican to discuss end-of -life issues, Pope Francis called physicians to avoid overzealous treatment. The pope drew on a 1957 speech to anesthesiologists and intensive care specialists by Pius XII, which stated that it is not necessary for doctors to resort to every single remedy, and that in some cases it is wiser to refrain from their use.

“It thus makes possible a decision that is morally qualified as withdrawal of ‘overzealous treatment’,” Francis said, adding that “such a decision responsibly acknowledges the limitations of our mortality, once it becomes clear that opposition to it is futile.”

He underlined how this understanding promotes a focus on the accompaniment of the dying, and while it means ethically avoiding excessive treatments, “it is completely different from euthanasia, which is always wrong, in that the intent of euthanasia is to end life and cause death.”

Francis acknowledged that many cases and situations can be “difficult to evaluate,” and that there is no one-size-fits-all rule that can be adopted. “There needs to be a careful discernment of the moral object, the attending circumstances, and the intentions of those involved,” he wrote.

Cardinal Gualtiero Bassetti, president of the Italian bishops’ conference (CEI), commented on the pope’s speech at the time, stating that it’s not always simple to identify “a clear line distinguishing overzealous treatment and euthanasia,” and for this reason it’s essential to “identify who makes the decisions in such dramatic situations,” keeping in mind the will of the patient and the conscience of the doctor.

In this aspect the former secretary of CEI, Cardinal Giuseppe Betori of Florence, said in a speech Dec. 8 that the law “is very problematic on some points.”

According to Betori, the new legislation does not guarantee conscientious objection on the part of doctors and hospitals involved. For this reason, the cardinal called for “more reflection and circumspection, in order to avoid opening doors that would introduce euthanasia and assisted suicide in our society.”

Catholic Doctors stand by the patients

According to a parliamentary study, on average 70 percent of doctors in Italy are conscientious objectors and in eight regions that percentage rises sharply. These numbers refer to doctors who will not perform abortions, but it offers insight into the number of doctors in Italy who might refuse to comply with the wishes expressed in a legal will.

Massimo Antonelli, director of the Institute of Anesthesia and Reanimation of the Catholic University in Rome, warned that the recent legislation raises concerns for doctors and might hinder their relationship with patients.

“A potential risk could be presented by a doctor strictly following the dispositions of the law and the will expressed by the patient, giving up on opening a dialogue inspired by a therapeutic alliance, cornerstone of the doctor-patient relation,” Antonelli told Italian newspaper Corriere della Sera.

The Catholic physician also expressed his concern with the figure chosen by the patient to promote his wishes, stating that if that individual and the doctor don’t see eye to eye in the interpretation of the living will, then they would have to go before a judge.

“Decisions should be made at the patient’s bedside, and not in a courtroom,” he said.

“Beyond the dispositions of the law, the position of Catholic doctors is clear: the doctor must be close to the patient as his ally,” Antonelli added. “A sick person must be assisted until the last moments without ever being abandoned.”