End of Life: "Mario", Italy's first case of assisted suicide, died. Marco Cappato: "We had to step in for the State. And we'll continue to do so

“Mario” is 44-year-old Federico Carboni of Senigallia: “Life is wonderful, but the suffering is too much. I am proud to have written a piece of history.” 

Marco Cappato, Treasurer of Associazione Luca Coscioni and Co-president of EUMANS: “We had to step in for the State. And we'll continue to do so”

June 16, 2022 - 44-year-old Federico Carboni of Senigallia, known until now as “Mario,” died this morning. He is the first in Italy to have successfully sought access to medically assisted suicide, which was legalized by Constitutional Court ruling no. 242/2019 on the Cappato-Antoniani case. 

“Mario” had asked for his true identity to be revealed upon his death. Federico Carboni died at home after self-administering a lethal pharmaceutical using a special machine. The approximate cost of €5,000 was entirely at the patient's expense and paid for through a fundraiser set up by the Luca Coscioni Association. 

The procedure was supervised by Dr. Mario Riccio, anesthetist of Piergiorgio Welby and an advisor to Federico during the legal process. At Federico's side were his family and friends, as well as Marco Cappato, Filomena Gallo, and part of his legal team.*

The final green light for this medically assisted suicide came on February 9 with a decision on the drug to be used and the means of “execution,” nearly two years after Federico's initial request to the regional health authority and a lengthy legal battle that he fought together with the Luca Coscioni Association. 

Here are his last words: “I can't deny that I'm sorry to go. I'd be a liar if I said otherwise, because life is wonderful and we only get one. But unfortunately, this is how it ends. I did everything I could to live the best possible life and try to overcome my disability, but I've reached the end of my rope, mentally and physically. I have no autonomy in everyday life, I'm at the mercy of events, I depend on others for everything, I'm like a boat adrift in the ocean. Well aware of my physical state and future prospects, I am entirely at peace with what I'm about to do. Together with the Luca Coscioni Association we have played defense by attacking and offense by defending; we have earned a place in Italy’s law books and created a piece of the country’s history, and I am proud and honored to have been by your side. I am finally free to fly where I want.” 

Filomena Gallo and Marco Cappato, national secretary and treasurer of the Associazione Luca Coscioni, have released the following statement: “On behalf of our entire association, we are grateful to Federico for his faith in us over the last two years, ever since he decided not to die in Switzerland and chose to assert his rights here in Italy. Our hearts go out to Federico's mother and friends and to all who loved him. Through remarkable determination, he not only achieved his own aim but paved the way for others in his condition. For Federico, the Luca Coscioni Association had to step in for the State to defend his rights. We will continue to fight for those who ask for our help. At this point, A law like the one currently being debated by the Italian Parliament has proved once again to be inadequate. 

* Federico's entire legal team consists of attorneys Filomena Gallo, Massimo Clara, Angelo Calandrini, Cinzia Ammirati, Francesca Re, Rocco Berardo, Giordano Gagliardini, and Francesco Di Paola. 

For information (Italian and English): Stefania Cicco +39 328 314 6032 - stefania.cicco@associazionelucacoscioni.it 



***ADDITIONAL INFORMATION***


END OF-LIFE DECISIONS -  FROM ITALY TO EUROPE 


Marco Cappato, co-president of EUMANS is as well the Treasurer of Associazione Luca Coscioni and nonviolent leader and political activist engaged in civil disobediences, direct actions, and participatory democracy initiatives for improving the laws on end of life decisions in Italy. 
During the EUMANS Congress in Warsaw together with Marco Cappato we presented the first draft of a proposal for an initiative on the European Living Will. 
Following this link, you can read everything about the initiatives of Associazione Luca Coscioni, Marco Cappato, and the citizens who are activating instruments of participation on End of Life Decisions initiatives and the proposal for a European Living Will.


EUTHANASIA IN EUROPE
 
At the moment, four European countries have legalized euthanasia: the Netherlands, Belgium, Luxembourg, and Spain.
Other countries allow one or more other forms of medically assisted death such as terminating treatment, or “assisted suicide” in which the patient, with a doctor in attendance, directly administers a dose of pharmaceuticals to end his or her life.

The situation is quite varied and there are also “strict” countries that punish any form of suicide assistance: Ireland, for example, provides for sentences of up to 14 years and Greece and Romania of up to 7 years in prison.
 
Belgium.

Belgium passed an end-of-life law in 2002. The country has what is likely the most progressive law in Europe, and was the first in the world (2014) to permit euthanasia for minors, with no age limit, under certain conditions. According to Belgian law, end-of-life decisions are governed by the principle of individual self-determination. Euthanasia can be (i) active: the doctor administers a substance that causes or accelerates the patient's death; or (ii) passive: the doctor refrains from giving treatment or provides the patient with a substance to take autonomously. This latter form (medically assisted suicide) is not expressly mentioned in Belgian law, neither to equate it with euthanasia nor to exclude it. The prevailing interpretation, therefore, is that assisted suicide is subject to the same conditions set by law for euthanasia: the doctor is required to assist the patient until the final moment of life.
 
Netherlands.

The first law legalizing euthanasia was passed in April 2001 in the Netherlands, which became the first country in the world to permit euthanasia and assisted suicide under certain conditions. In 2020, the Groningen Protocol extended the right to euthanasia to terminally ill children from birth to age 12.  
 
Luxembourg.

The law came into force in March 2009. The patient's right to self-determination is construed as both the right to refuse treatment (under a law dating back to August 28, 1998) and the right to euthanasia and assisted suicide (law of March 16, 2009). A doctor who “responds to a request for euthanasia or assisted suicide” cannot be criminally charged or sued for damages.
 
Switzerland.

The law allows suicide assistance if provided without selfish motives (Article 115 of the Swiss penal code). Foreign nationals can also seek assisted suicide from authorized clinics.      
 
Spain.

Spain's euthanasia law is Europe's most recent, passed in 2021. Provided the decision is autonomous and based on informed consent, the law allows patients to request and receive assistance to end their life. The law makes a distinction between active euthanasia, passive euthanasia (refusal of treatment) and indirect euthanasia (palliative care), and in its preamble mentions reasons for the growing demand in Spanish society (increased life expectancy, scientific and technological advancements, secularization, and appreciation of personal autonomy) and the need to find a balance between opposing interests, such as the right to life and individual freedom.
 
Germany.

On February 20, 2020 the German Constitutional Court struck down Article 217 of the country's criminal code, which set prison sentences of up to three years for aiding and abetting suicide “for profit” and banned commercial assisted suicide organizations. The Court expressly cited the “right to suicide” and its justification in the principle of human dignity. The ruling also stated that “the right to end one's life, which pertains to the innermost sphere of self-determination, is not restricted to serious or terminal diseases or to specific phases of life or of a disease.” Therefore, to request assisted suicide, it is no longer necessary to be a terminal patient or to be in great suffering on life support.
 
Other European countries. Sweden's national authority ruled in favor of passive euthanasia (interruption/omission of treatment) in 2010. Active euthanasia is banned. Denmark permits living wills, including the right to end treatment if the patient expressly demands it. In France, since 2015, the law has allowed patients to request continuous deep sedation with medicines that can shorten life.

 

THE "MARIO'S BATTLE - POINT BY POINT  

This is a description and timeline of the case of "Mario," a quadriplegic patient from the Italian region of the Marche. After the Constitutional Court ruled on the Cappato case, Mario asked his local health authority to acknowledge that he met the conditions set in that ruling for medically-assisted suicide in Italy.

Who is Mario?
Mario (not his real name) was born in 1978 and lives in a small town in the Marche region of Italy. An automobile accident in 2010 left him with a fractured spine, and because of the damage to his spinal cord he is fully paralyzed (quadriplegic) and suffers from other serious health problems. His condition is irreversible. Mario has pursued every possible chance to improve his health, to no avail.

Mario’s request
In 2020 Mario wrote to Marco Cappato, treasurer of the Luca Coscioni Association and President of EUMANS, asking for information on assisted suicide in Switzerland. He learned that he could start refusing treatment and go into palliative care and deep sedation; that he could have a living will drawn up to make sure his wishes were respected even if he could no longer communicate. He also learned that the Constitutional Court, ruling in the Cappato case, had made assisted suicide legal in Italy too under certain conditions. So Mario had his living will drawn up and on August 27, 2020 wrote to his regional health authority to assert his rights under the Constitutional Court ruling, so he would not have to go to Switzerland to end his life. In short, he asked the health authority to confirm that he met the conditions for assisted suicide established by the Court.

Initial reply from the Marche health authority
On October 1, 2020 the regional health authority denied Mario's request and ignored its duty of assessment under the Constitutional Court ruling: following laws already in force in the Italian legal system, a public facility working under the national healthcare system must follow up on a patient’s request for assisted suicide by assessing four conditions (the patient is on life support, has an irreversible pathology that causes intolerable suffering, and is fully capable of making free and conscious decisions) further to an opinion issued by the local ethics committee. 

Taking the case to court
After receiving the health authority's reply, Mario asked for legal assistance from the Luca Coscioni Association so he could sue the health authority and obtain an injunction requiring it to comply with the Constitutional Court ruling.


Counseled by lawyers from the Luca Coscioni Association's Comitato dei Giuristi per le Libertà (a legal team made up of Filomena Gallo, Massimo Clara, Angelo Calandrini, Cinzia Ammirati, Francesca Re, Rocco Berardo, and Giordano Gagliardini), he petitioned the court to order the Marche’s regional health authority to assess his condition and determine how he could proceed – pending approval from the ethics committee – with having a lethal drug prescribed in order to end his suffering through assisted suicide.



Ruling by the court of Ancona
With a decision handed down in late March 2021, the court of Ancona denied Mario access to medically assisted death in Italy.


While acknowledging that the patient met the conditions set by Constitutional Court Ruling no. 242/19, the Ancona court argued that "there are no...reasons to maintain that, under the conditions in which assisted suicide may be deemed legal, the Court has also established the patient's right, where such conditions are met, to obtain the collaboration of medical personnel in implementing the decision to end his own life; nor can it be argued that the recognition of such a right is the direct consequence of the newly established exemption from criminal charges, given the poly-functional nature of non-punishability that is not always instrumental to the exercise of a right."


However, after a grievance was filed against the Ancona court's decision, a panel of judges from the same court overturned that decision and issued this injunction ordering the Marche’s regional healthcare authority to assess whether Mario satisfied the conditions for assisted suicide and to determine whether the chosen procedure, method, and drug were suitable for ensuring the most rapid, painless, and dignified death possible. In short, the Ancona court’s judiciary panel ordered the health authority to act in accordance with the Constitutional Court's ruling (no. 242/2019) in the Cappato/Antoniani case.

First formal warning to the Marche health authority
After a month had passed from the Ancona court's ruling with no action by the Marche health authority, on July 12, 2021 Mario's lawyers sent the authority a warning letter. Thirty days later, in the face of continued inaction, the legal team coordinated by Filomena Gallo took a number of legal and out-of-court actions to assert Mario's rights.

 
On August 27, 2021, in a formal notice to the Italian Government, Mario petitioned the government to use the full extent of its powers to ensure his right to legally access assisted suicide as established by Constitutional Court ruling 242/2019. 

On September 1, 2021, the Marche health authority contacted Mario to schedule a series of appointments: throughout the month of September he would meet with psychologists, palliative care specialists, and neurologists to complete the preliminary reviews required by the Marche region's ethics committee before it would issue its opinion. With these reviews performed scrupulously by the interdisciplinary team, on October 14, 2021 Mario was informed that the team's written report had been submitted to the appropriate department serving the ethics committee.



Second warning and delivery of the ethics committee opinion 
Met with still more delays and no communication at all about the ethics committee opinion or how his case was proceeding, on November 15, 2021 Mario sent another warning letter to force some action.


On November 23, 2021, Mario received the ethics committee opinion, which confirmed he met the four conditions established by the Constitutional Court, while declining to express an opinion on the lethal drug as there had been no reviews of method, dosage, or means of administration. For the first time, a patient in Italy had received confirmation that he met the conditions set by the Constitutional Court ruling that had legalized medically assisted suicide.

Impasse over lethal drug and third warning letter
At Mario's instruction, the legal team sent yet another warning letter to force the regional health authority to review the assisted suicide protocol as ordered by the court of Ancona. The health authority had not assessed the protocol, nor had the ethics committee mentioned this crucial part of its assignment, which was not only mandatory under the court order but required by the Constitutional Court ruling. In the warning letter, the legal team included the opinion of its own advisor, Dr. Mario Riccio, who had been Piergiorgio Welby's physician. Dr. Riccio laid out the protocol for self-administration of the drug he considered appropriate on the basis of Mario’s condition. His opinion was included solely to facilitate the procedure, seeing as the Constitutional Court ruling only puts the national health service facility in charge of reviewing such a protocol once approved by the local ethics committee.

 
Charges of torture and government negligence
On December 17, 2021 Mario's legal team filed a criminal complaint against the ethics committee and the Marche regional health authority for the crime of torture and government negligence as well as all possible related offenses caused by their continued obstructionism and inaction, specifically for failing to review the choice of lethal drug and its means of administration.

The final go-ahead
On February 9, 2022, Mario received a certified email containing the interdisciplinary team's report on the chosen procedure, method, and drug. After lengthy discussion the commission, made up of two department directors (anesthesia/resuscitation and legal medicine), two unit directors (palliative care and pharmacy), one pharmacology specialist, and one health authority executive, had come up with a unanimous, precise and detailed reply. Regarding Mario's preferred procedure, method, and lethal drug: “Sodium thiopental appears suitable for ensuring painless, rapid death (in minutes) at a dosage of no less than 3-5 grams for an adult weighing 70 kg. The means of administration is self-administration by intravenous infusion.”

The choice of lethal drug and procedure were the final missing links after the go-ahead from the ethics committee. Validation of the drug and the means of self-administration has finally created a precedent that will allow those in situations like Mario's to receive help, if they wish, in voluntarily ending their lives. 


Since February 9, 2022, "Mario" has been free to decide when he will end his suffering – in Italy, with his loved ones by his side – and those who assist him are no longer punishable under Criminal Code Article 580 in light of Constitutional Court Ruling 242/19.


Constitutional Court Ruling 242/2019
With the "Cappato Decision" in the trial of Marco Cappato for having assisted the suicide of  Fabiano Antoniani, better known as DJ Fabo, the Constitutional Court struck down Criminal Code Article 580 on assisted suicide where it does not exclude culpability for providing such assistance to a person on life support, whose condition is irreversible and causes intolerable suffering, and who is fully capable of making free and conscious decisions, provided those conditions and the assisted suicide protocol have been verified by a public facility of the national health service on the basis of an opinion from the local ethics committee.