Portugal President Marcelo Rebelo de Sousa vetoed Tuesday a bill permitting physician assisted death. This was the second time that Sousa vetoed the bill, which sought to amend Portugal’s Criminal Code to allow doctors to assist terminally ill patients with ending their lives.

Upon rejecting the bill, Sousa sent a letter to the President of Portugal’s Assembly. In this letter, he included several points. In one of these points, Sousa highlighted two paths for expanding medically assisted death. According to Sousa, one path could follow the European legal system, which allows assisted death for patients who do not suffer from a fatal disease. The other could follow the American system, where some states decriminalize assisted death only for patients suffering from terminal illness.

Sousa also made two requests involving issues within the bill. First, Sousa noted the bill included contradictory language, providing that a person qualifying for assisted death must have a “fatal disease.” However, the bill also provides that a person with an “incurable disease” or “serious disease” may qualify for assisted death. Hence, Sousa asked Portugal’s Assembly to state what type of disease (fatal, incurable, or serious) the bill requires.

Second, Sousa stated that if a fatal disease is no longer required, then he requests that the Assembly re-evaluate the requirements. Sousa also opined that the different disease requirements correspond to the value of life and free self-determination in Portuguese society.

Portugal’s Assembly first approved the bill in January, passing the bill in a 136–78 vote. However, the bill ultimately failed to become law. The bill would require two or three intervening doctors to assess the patient’s wishes. Additionally, the assisted death option would only be available for citizens and legal residents of Portugal who were 18 or older. Sousa received the bill and had 20 days to approve or deny.

Sousa chose to refer the bill to Portugal’s Constitutional Court, seeking an advisory opinion on the bill’s constitutionality. The court held that the physician assisted death bill was unconstitutional. The court’s opinion found that permitting assisted death for a “definitive injury of extreme severity according to scientific consensus” was unconstitutional. Subsequently, the Assembly amended the bill. The Assembly will likely need to amend the bill again to receive Sousa’s approval.