Comparative legal and bioethical perspectives on euthanasia and assisted suicide: a systematic review of european frameworks

Abstract

Background

Euthanasia and assisted suicide remain legally and ethically contested practices across Europe. National frameworks differ in eligibility criteria, procedural safeguards, and oversight mechanisms, reflecting diverse cultural, religious, and bioethical perspectives. The recent approval of Spain’s Organic Law 3/2021 regulating euthanasia provides a relevant context for comparative analysis. This review addresses the following research question: To what extent do differences in European legislation on euthanasia and assisted suicide impact the application of core bioethical principles—autonomy, dignity, beneficence, non-maleficence, and distributive justice—in patients with severe, incurable, or terminal conditions experiencing intolerable suffering?

Methods

A systematic review was conducted following PRISMA guidelines. Searches were performed in PubMed, Scopus, and Web of Science, as well as official sources from health ministries and regulatory bodies in the Netherlands, Belgium, Luxembourg, Austria, Germany, Portugal, and Spain.

Results

Twenty-four studies met the inclusion criteria. The Netherlands (2002), Belgium (2002), and Luxembourg (2009) were the first to legislate comprehensive euthanasia and assisted suicide frameworks, followed by Spain (2021), Portugal (2023), and Austria (2021). Switzerland (1937) and Germany (2020) decriminalized assisted suicide without enacting specific laws. Spain, Portugal, Luxembourg, and the Netherlands allow both euthanasia and assisted suicide, while Belgium limits access to euthanasia, and Austria, Germany, and Switzerland regulate only assisted suicide. Terminal illness is not required under older laws (Netherlands, Belgium, Luxembourg), but recent legislation in Spain, Portugal, and Austria mandates a prognosis of limited life expectancy. Regarding minors, Belgium permits euthanasia at any age under strict conditions, the Netherlands allows access from age 12 with parental consent, while Spain, Portugal, Austria, and Luxembourg restrict access to adults. Oversight mechanisms differ, ranging from retrospective review (Netherlands, Belgium, Luxembourg) to mandatory prior approval (Spain, Portugal). Procedural timelines also vary, from 30–40 days in Spain to a minimum 12-week reflection period in Austria.

Religious frameworks shape additional divergences: Christianity and Islam largely prohibit euthanasia and assisted suicide, whereas Hinduism and Buddhism offer limited acceptance of compassionate death. Bioethical analysis highlights the centrality of autonomy, beneficence, non-maleficence, justice, and dignity, underscoring persistent tensions regarding vulnerability, conscientious objection, and equitable access.

Conclusions

Euthanasia and assisted suicide legislation across Europe remains heterogeneous, with significant consequences for the application of core bioethical principles. Although secularization has strengthened patient autonomy, religious values and institutional conscientious objection continue to influence access and implementation. These findings underscore the need for balanced regulation that safeguards autonomy while ensuring equitable access, procedural integrity, and ethical protection for vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-026-01410-w.

Definitions

Assisted dying refers to a set of legally regulated end-of-life practices in which a healthcare professional provides medical support to enable a patient to intentionally end their life.

Euthanasia: A clinician directly administers life-ending medication.

Assisted suicide: A clinician prescribes or supplies the means for the patient to self-administer the substance

Background

On March 24, 2021, Spain enacted Organic Law 3/2021 on the Regulation of Euthanasia, incorporating assisted dying into the national health system's portfolio of services. With this legislation, Spain became the fourth country in Europe—and the seventh worldwide—alongside the Netherlands, Belgium, Luxembourg, Colombia, Canada, and New Zealand, to legally recognize euthanasia. End of life care remains a highly debated topic that continues to raise ethical dilemmas in the medical, legal, and social domains, particularly regarding its moral and ethical implications.

Euthanasia, assisted suicide, assisted death, and dignified death are different terms used to refer to assistance in dying, etymologically understood as a "good death." This concept has been addressed culturally through religious, ethnic, political, and moral lenses throughout history [1], aiming to regulate the act through written or tacit norms, as a reflection of the prevailing philosophical currents of each era.

Conceptually, euthanasia refers to the deliberate act of ending a patient’s life, performed by a healthcare professional through the administration of medication following the individual's formal and uncoerced request [1, 2]. According to the definition provided by the World Medical Association, the applicant must be competent, adequately informed, and suffering from an incurable disease [3].

Over more than two decades of ethical and legal debate in the twenty-first century, various concerns have been raised regarding the purpose, intentionality, voluntariness, terminal nature of the underlying disease, consciousness, and suffering—elements that require clear conceptualization [3].

The most common dilemma surrounding the act of euthanasia lies in the dichotomous connotation of killing versus letting die. Killing involves an active intervention, whereas letting die refers to an omission within the framework of limiting therapeutic efforts—for example, issuing a "do not resuscitate" order, withdrawing ventilatory or dialysis support, or suspending artificial hydration or nutrition. This duality reflects the distinction between what is termed “active euthanasia” and “passive euthanasia”: the former involving the administration of drugs to intentionally end a person's life, and the latter referring to the withholding of life-sustaining treatment, thereby allowing death from natural causes to occur. These concepts, however, are increasingly falling into disuse today.

The primary purpose of euthanasia is to alleviate suffering; therefore, in the clinical and ethical assessment of such cases, it must be provided exclusively to patients who are experiencing suffering, as an act of compassion [3]. In the absence of suffering, there is no justification for considering euthanasia in the first place. The presence or absence of suffering within the context of euthanasia is particularly significant, as the bioethical principles of non-maleficence and beneficence are intrinsically linked to the imperative of not causing harm and the obligation to relieve suffering, respectively.

This creates the complex challenge of qualitatively assessing physical, psychological, and existential suffering along the spectrum of tolerability (from tolerable to intolerable) and relief (from partial to complete). Conceptualizations of suffering vary and may encompass experiences such as loss of dignity, loss of personal integrity, dependency on care, loss of meaning or purpose, and fear of a future devoid of objectives [3, 4].

Assisted Suicide vs. Euthanasia

Within the concept of euthanasia—understood as a "good death"—the terms assisted suicide and assisted dying (understood commonly as euthanasia) are encompassed. In assisted suicide, a third party provides the necessary information and means for the patient to self-administer the intervention with the intent of ending their own life [3]. In contrast, in assisted dying – over the article we refer to this as euthanasia-, it is the healthcare professional who administers the pharmacological agents to end the patient’s life.

A sine qua non condition for both forms—assisted suicide and assisted dying/euthanasia—is that the provider of the means must act with the explicit intention of enabling the patient’s death, whether through passive means (assisted suicide) or active intervention (euthanasia), with the primary purpose of alleviating suffering that is deemed unbearable—whether current or anticipated [1, 3].

A "good death" should be regarded as a means of improving the patient's condition, understood as the relief of suffering, and grounded in a fundamental respect for the patient’s autonomy in their decision to die.

Legal frameworks for assisted dying in Europe

Currently, several European countries have legalized euthanasia under specific legal and medical frameworks, including the Netherlands, Belgium, Luxembourg, Spain, Germany, Austria, and Portugal. Despite a shared recognition of the right to assisted dying, the regulatory approaches vary considerably across jurisdictions. These models can be classified into three categories:

• Those authorizing physician-administered euthanasia,

• Those allowing patient self-administration of lethal medication,

• Those permitting both modalities.

Spain

On June 25, 2021, Spain’s Organic Law 3/2021, of March 24, on the regulation of euthanasia (LORE), came into force, marking a legal and ethical milestone in end-of-life care. This legislation formally recognizes the right of individuals to request and receive medical assistance in dying under specific conditions of intolerable physical or psychological suffering resulting from a serious and incurable illness or a chronic, severe, and disabling condition [5–8]. The law represents a substantial shift in medical practice, incorporating euthanasia as a benefit provided through the National Health System.

Under LORE, euthanasia is defined as a deliberate act carried out by a medical professional who, following a legally established safeguard process, causes the death of a patient upon the patient’s explicit and repeated request [5–9]. The patient must be fully informed about their diagnosis, prognosis, available therapeutic alternatives—including palliative care—and the euthanasia process itself [5–9].

The law establishes two modalities for the provision of aid in dying: direct administration of a lethal substance by a physician, and prescription or supply of such a substance for patient self-administration [6, 7]. Both forms are subject to a strict procedural protocol that ensures patient autonomy and adherence to the bioethical principles of non-maleficence, beneficence, and justice [7, 8].

The process requires a voluntary and repeated request by the patient, who must be an adult, conscious, and fully competent, and who must hold Spanish nationality or legal residency [6, 7]. The request must be made in writing on two separate occasions, at least 15 calendar days apart. The attending physician, who must have specific training in the relevant medical conditions, is responsible for verifying compliance with the legal requirements and for engaging in a deliberative dialogue with the patient [6, 7]. An independent consulting physician, with no affiliation to the attending physician’s team and with similar expertise, must also provide a written opinion on the case [6, 7].

Following the consultant’s favorable opinion, the case is submitted to the regional Guarantees and Evaluation Committee, a collegiate body responsible for verifying compliance with all legal criteria [6–8]. The committee assigns a physician and a legal expert to evaluate the case. If the outcome is favorable, the procedure may proceed, with provisions allowing the patient to postpone (for up to six months) or revoke their request at any time before the administration of the substance [6–8]. Revocation nullifies the existing process, requiring a new request to initiate the procedure again.

Article 3 of LORE explicitly recognizes the right to conscientious objection for healthcare professionals directly involved in the procedure [5–10]. It requires that objection be declared in advance and in writing, with objectors registered in an official database to ensure proper coordination of healthcare services [5].

The Netherlands

The Netherlands was the first country globally to establish a statutory framework legalizing both euthanasia and assisted suicide [11, 12]. The "Termination of Life on Request and Assisted Suicide Act" (Law No. 26691/2001), effective since April 2002, regulates the conditions under which these practices may occur [11, 12].

Under the Dutch Penal Code, murder is defined as the intentional and premeditated ending of another person’s life [2]. It further establishes that any individual who ends another person’s life at that person’s explicit and serious request is guilty of homicide [2, 12]. However, the same article (Article 293 of the Dutch Penal Code) specifies that such an act is not considered a criminal offence when performed by a physician who meets the due-care criteria outlined in the Termination of Life on Request and Assisted Suicide Act. This provision safeguards physicians acting with appropriate clinical judgment and solely in the patient’s best interests, provided they assist the patient and supply the means for the act, and subsequently fulfil their duty to report the case to the Investigating Magistrate.

The law requires that the physician be convinced that the patient’s request is voluntary and well-considered, that the patient is experiencing unbearable suffering with no prospect of improvement, and that the patient is fully informed about their current condition and future outlook [2, 12]. In addition, Dutch law mandates consultation with an independent physician, who must also examine the patient and issue a written opinion confirming that all legal requirements have been met.

Importantly, Euthanasia is not a patient right under Dutch law; healthcare professionals are not legally obliged to comply with a request and may refuse on grounds of conscience [12].

The law does not restrict suffering to somatic conditions. Psychiatric suffering, under certain criteria, may also constitute grounds for euthanasia, a provision that has generated considerable ethical, legal and clinical debate [11, 12].

Assisted dying (euthanasia and assisted suicide) is also permitted for minors aged 12 and older, provided they demonstrate sufficient capacity to understand and assess their situation [5, 12]. Parental consent is required for patients aged 12 to 15 [5, 12]. For those aged 16 and 17, parents must be involved in the decision-making process, though their consent is not mandatory [5, 12].

For newborn and children aged 1 to 12 years, a different legal framework applies [13]. Since February 2024, the Netherlands has implemented a dedicated regulatory scheme for life termination in this age group, which does not fall under the Termination of Life on Request and Assisted Suicide Act: Regulation on the Review Committee for Late-Term Pregnancy Termination and Life Termination in Newborns and Children Aged 1–12 Years¹³. In contrast to minors aged 12 and older, children aged 0–12 cannot request assisted dying themselves, as the initiative arises from the treating physicians in situations of exceptional and medically irremediable suffering [13]. Life termination is considered only when the child experiences unbearable and untreatable suffering, no reasonable therapeutic or palliative alternatives exist, and the intervention is judged to be the only means to alleviate such suffering [13]. Parental informed consent is mandatory, and the child must be involved in the process to the extent that their developmental level allows [13]. All cases must be reported to a national review committee, which assesses whether the strict due-care requirements of the regulation have been met. This framework is grounded not in patient autonomy but in the doctrine of medical necessity (overmacht) under Dutch criminal law, and remains reserved for a very small number of exceptional cases.

Euthanasia and assisted suicide are legally distinct but equally regulated under the Act, which conceptualizes both as intentional acts of assisted dying. Assisted suicide is formally classified as a specific form of suicide under Dutch criminal law [2].

Oversight is conducted by regional review committees (Regionale Toetsingscommissies Euthanasie), which retrospectively evaluate all reported cases. These bodies verify compliance with legal criteria and publish annual reports detailing all notified instances of euthanasia and assisted suicide [2, 5, 12]. Cases found to deviate from legal standards are referred to the Public Prosecution Service and the Health Inspectorate for further review [2, 5, 12].

Belgium

In May 2002, Belgium enacted comprehensive national legislation regulating euthanasia but not assisted suicide [5, 14]. The Belgian Parliament did not amend the Penal Code to decriminalize assisted dying; rather, it enacted dedicated legislation that defines euthanasia as a deliberate act carried out by a third party—specifically a physician—intended to end a patient’s life at the patient’s explicit request [2, 14].

The Belgian legislation establishes that, to be eligible for euthanasia, the applicant must possess legal decision-making capacity, be of legal age, and suffer from a serious and incurable medical condition that causes unbearable physical or psychological suffering with no prospect of relief or recovery [13]. The law further specifies that the request must be voluntary, repeated, and free from any external coercion [5, 14].

Physicians are required to inform the patient about their medical condition and prognosis and to play a guiding and mediating role in the shared decision-making process. In cases where the request is made by a non-terminal patient, the attending physician must consult either a psychiatrist or a specialist in the patient’s condition, who is responsible for confirming the presence of intolerable and irreversible suffering [2, 5, 14].

Physicians are not required to comply with requests, but if they decline, they must inform the patient or their representative and transfer the medical record to another willing provider [5].

In February 2014, legislation was amended to include minors [5, 14]. No minimum age limit is specified; however, the patient must be competent, aware of the implications, in a terminal condition, and have parental approval.

Euthanasia cases are reviewed by the Federal Control and Evaluation Commission, in collaboration with the Belgian Medical Council [2, 14]. The committee is composed of physicians, legal experts, and representatives from civic volunteer organizations involved in the care of terminally ill patients. From both a legislative and medical oversight perspective, it is understood that the physician is expected to accompany the patient until death occurs. A clear distinction is emphasized between euthanasia and terminal sedation: while euthanasia involves the intentional act of ending a person’s life, terminal sedation aims solely to alleviate suffering in the final phase of life, without the primary intention of causing death [2, 14].

All euthanasia procedures must be reported to the Federal Commission [5, 14]. Failure to do so may result in the act being classified as homicide, and assisted suicide may be interpreted as death by poisoning [2]. The Commission publishes a biannual report summarizing its findings.

Luxembourg

Euthanasia and assisted suicide were legalized in 2009, modeling legislation after the Netherlands and Belgium [5, 15], and complemented by a palliative care law [2].

Luxembourg’s legal framework defines euthanasia as an act carried out by a physician with the explicit intention of ending the life of a person who has made a voluntary and uncoerced request [2, 15]. Assisted suicide is defined as the act in which a physician provides assistance or the necessary means for an individual to end their own life, within the context of an express and voluntary request [2, 15].

Eligibility criteria closely align with those of other jurisdictions that permit assisted dying. The patient must be suffering from a condition that is incurable or irreversible and offers no therapeutic alternatives, resulting in significant physical or psychological suffering [2, 5, 15]. The request must be voluntary, consistent, and repeated, and must be verified by an independent consulting physician [5, 15]. The law applies to both euthanasia and assisted suicide, including cases in which patients have completed advance directives or equivalent documents. No provisions are established for minors under Luxembourgish law [5, 15].

The attending physician is responsible for verifying that the patient meets all legal requirements. Following the procedure, the physician must submit an official declaration identifying all individuals involved and outlining the patient’s clinical situation. Compliance is monitored by a National Commission for the Control and Evaluation of the Law’s Application, which must issue a determination within two months regarding adherence to the statutory conditions [2, 5, 15].

Physicians have the right to conscientious objection and must, in such cases, transfer the patient's medical records to another physician designated by the patient or their representatives [2, 5, 15]. A legal exception was introduced to decriminalize assistance in dying; however, the Criminal Code continues to include offenses such as homicide and poisoning. Assisted suicide is formally classified as a type of suicide.

Switzerland

In Switzerland, assisted suicide is legally permitted, whereas euthanasia—defined as the direct administration of lethal drugs by a healthcare professional—is explicitly prohibited [2, 5, 11, 16]. According to the Swiss Penal Code, assisted suicide is not considered a criminal offense provided that it is not motivated by selfish or financial interests [2, 5, 16]. The act must be altruistically motivated. Although euthanasia is prohibited, it carries a lesser penalty than involuntary manslaughter [2, 16].

The Swiss approach differs markedly from other jurisdictions in that it does not require the individual to have a terminal illness or to be experiencing severe medical suffering. Assisted suicide may be accessed by any competent individual, regardless of medical condition, and can be facilitated by non-medical personnel. However, the prescription of the lethal substance must be issued by a licensed physician in accordance with the Federal Act on Medicinal Products and Medical Devices [2]. In practice, the process is typically managed by specialized non-profit organizations.

Cases of assisted suicide are recorded as suicides and reported by these organizations. The legal basis for the practice is not derived from statutory legislation but rather from rulings by the Swiss Federal Supreme Court, which has held that access to assisted suicide does not violate constitutional principles [16].

Decriminalization resulted from constitutional court rulings recognizing the right to assistance in dying [11, 16].

Germany

Until 2020, euthanasia was illegal. However, indirect active euthanasia (assisted suicide) is no longer punishable unless the patient is incapacitated or the provider has financial interests [9, 17]. Physicians prescribing life-ending medication are exempt from prosecution.

The Federal Constitutional Court recognized assisted suicide as part of the constitutional right to self-determination, allowing individuals to seek help from third parties [9, 11, 17]. Assisted suicide must be voluntary and altruistic; profiteering private companies are prohibited [5, 17].

Access is not limited to patients with incurable illnesses or by age: any competent adult may request it for any reason. Assisted suicide is decriminalized based on the constitutional right to self-determination and is intended as an occasional, altruistic act, commonly within family or close relationships [9].

Portugal

In Portugal, the euthanasia bill was approved by Parliament on four occasions since 2021 but was repeatedly returned for constitutional review due to opposition from the President of the Republic [5]. In 2023, a comprehensive legal and medical regulatory framework was finally enacted, authorizing both euthanasia and assisted suicide [8, 18]. The Constitutional Court framed these practices within the context of the right to life, recognizing the legitimacy of aiding an individual in ending their suffering, and linked the provision to the broader constitutional right to personal autonomy.

The distinction between euthanasia and assisted suicide in Portuguese law is based on the patient’s physical condition. Active euthanasia may only be carried out when assisted suicide is not feasible due to the patient’s physical incapacity [9, 18].

Access to the procedure requires a diagnosis of a serious and incurable illness. The involvement of third parties has been decriminalized and is recognized as a legal liberty, allowing both public and private healthcare professionals to participate. The legal framework ensures that the request is voluntary, free from external coercion, consistent over time, and compliant with health-related criteria defined by law [18].

The process is overseen by the national Verification and Evaluation Committee, which holds regulatory authority and is responsible for publishing an annual report. The procedure mandates the involvement of a primary physician and a consulting physician. A third physician, specialized in psychiatry, must also participate if there are concerns regarding the patient's capacity to make a serious and autonomous decision or if a mental disorder is suspected. This psychiatric consultation is mandatory unless the patient explicitly refuses it [9]. The minimum duration for completing the process is set at two months, serving also as a period for reflection [9].

Administratively, the procedure is structured as an authorisation process involving multiple formal steps. The applicant must express their intention in writing up to six times, thereby demonstrating the persistence and seriousness of their decision [9].

According to the law, the service is integrated into the public healthcare system, and must therefore be performed by qualified health professionals. The right to conscientious objection is protected and includes the possibility of a late declaration of objection at any point in the process, not only at the outset [9]. Ongoing political developments have delayed the full implementation of the regulatory framework.

Austria

The Austrian Penal Code permits assisted suicide but continues to prohibit euthanasia. While assisted suicide was previously punishable as participation in another person's suicide, it is now legally recognized under both criminal and civil law [9, 19].

In 2020, the Austrian Constitutional Court ruled that the criminalization of assisted suicide was partially unconstitutional, concluding that it violated the individual's right to self-determination. In response, legislation was introduced in 2021 to decriminalize assistance in suicide, grounded in the constitutional rights to personal autonomy, privacy, and the freedom to make decisions about one's own death [9, 19].

As part of this legal framework, Parliament established a formal process for declaring the intention to die, similar to an advance directive. This declaration must originate from a freely made and self-determined decision, and assistance may only be provided to Austrian nationals or habitual residents over the age of 18 who are legally competent at the time of both the declaration and its execution, within the context of an incurable and fatal illness [19].

The declaration is revocable at any time and must be signed in separate stages by two physicians—one of whom must specialize in palliative care—a notary (or authorized patient representative), and a pharmacist, who dispenses the lethal substance [9]. These professionals are required to confirm that the patient meets all legal criteria, including voluntariness free from coercion, decision-making capacity, adequate information, and the presence of a medically confirmed incurable condition [9, 19].

A mandatory 12-week reflection period is established by law to ensure the persistence of the individual’s decision. Following this period, the "declaration of intention to die" is formally signed before a notary [9, 19]. The law also stipulates that no prior declaration or prescription for the same purpose may exist, in order to prevent the unauthorized use of life-ending substances by individuals not eligible for the procedure [9, 19].

Responsibility for reporting the administration of assisted suicide lies with both the notary and the dispensing pharmacies [9]. The law also recognizes the right to conscientious objection. In conjunction with the law’s enactment, the Austrian Chamber of Pharmacists compiled a list of pharmacies willing to dispense medications for assisted suicide.

Methods

Study objectives

The aim of this study is to examine access to requests for medical assistance in dying in European countries that legally recognize the right to medical assistance in dying.

The specific objectives are:

- Compare the legal frameworks governing access to medical assistance in dying in European countries where such practices are permitted.

- Identify key bioethical considerations related to end-of-life decision-making in the context of euthanasia.

Design of the study

This study is a systematic review. It was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the aim of compiling the available evidence from multiple databases to address the proposed objectives for the period between January 1, 2020, and July 2024.

Research question and PICO framework

The research question was structured using the PICO format:

• P (Population): Adult patients with severe, incurable, or terminal illness experiencing intolerable suffering in European countries.

• I (Intervention): Access to euthanasia or assisted suicide under current national legal frameworks.

• C (Comparison): Countries without explicit legislation or with more restrictive frameworks European legislation on access to euthanasia compared to Spanish legislation.

• O (Outcomes): Differences in patient eligibility, safeguarding mechanisms, respect for autonomy, and equity in access to end-of-life care. Bioethical implications regarding the principles of autonomy, dignity, beneficence, non-maleficence, and distributive justice.

Based on this framework, the research question is as follows: To what extent do differences in European legislation on euthanasia and assisted suicide impact the application of core bioethical principles—autonomy, dignity, beneficence, non-maleficence, and distributive justice—in patients with severe, incurable, or terminal conditions experiencing intolerable suffering?

The working hypothesis is: Countries with comprehensive legislation and prior oversight mechanisms on euthanasia and assisted suicide provide stronger safeguards for ethical consistency.

Search strategy

A systematic literature review was conducted using the following databases: Medline/PubMed, Scopus, and Web of Science. The search included articles published in English and Spanish, and was limited to studies involving human subjects. Keywords were selected using the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH) thesauri.

The primary search terms included: euthanasia, assisted suicide, bioethics, law, Europe, Belgium, Luxembourg, Portugal, Germany, and Spain. Search strategies were adapted to the indexing and structure of each database, combining keywords using Boolean operators AND and OR. The detailed bibliographic search strategy is outlined in Table 1.

Table 1.

Databases and search strategy

Databases	Descriptors and search strategy
Medline/Pubmed	euthanasia[Title/Abstract]) OR (assisted suicide[Title/Abstract])) OR (law)) OR (bioethics)) OR (spain)) OR (germany)) OR (portugal)) OR (austria)) OR (netherlands)) OR (belgium)) OR (luxembourg)) OR (switzerland) OR Europe
Scopus	TITLE (euthanasia) OR ALL (law) OR ALL (bioethics) OR ALL (Spain) OR ALL (Portugal) OR ALL (Germany) OR ALL (Austria) OR ALL (Netherlands) OR ALL (Belgium) OR ALL (Luxembourg) OR ALL (Switzerland))
Web of science	euthanasia (Title) OR assisted suicide (Title) OR bioethics (All Fields) OR law (All Fields) OR spain (All Fields) OR belgium (All Fields) OR netherlands (All Fields) OR luxembourg (All Fields) OR germany (All Fields) OR portugal (All Fields) OR switzerland (All Fields) OR austria (All Fields)

Study selection

The eligibility criteria for study inclusion were as follows: publications dated between January 1, 2020, and July 31, 2024; articles addressing euthanasia or assisted suicide; texts published in either Spanish or English; open access publications; books or book chapters; studies involving human subjects; and content within the medical, social, or ethical domains. In addition, studies were required to score at least 7 points on the QARI (Qualitative Assessment and Review Instrument) (available in supplementary material). methodological quality scale.

The exclusion criteria included: publications prior to January 1, 2020; articles not addressing euthanasia and/or assisted suicide; restricted-access articles; editorials or letters to the editor; studies involving animal subjects, due to their fundamentally different approach to euthanasia; plant-related research; and studies in the field of cellular biology, which does not address the human being as a whole and therefore lacks applicability to the holistic context of end-of-life care.

Studies involving dementia or psychiatric disorders were also excluded due to widespread ethical and legal controversy and the limitation of decision-making capacity often present in these patient populations. Psychiatric disorders were excluded in particular due to their non-terminal classification in most legislative frameworks.

Further exclusions included research related to critical care, where the prioritization of therapeutic limitation and the immediacy of clinical decisions make the formal legislative process underlying euthanasia implementation impractical. Studies focused on nursing care were excluded, as this field primarily concerns the administration of medication following medical orders, rather than direct participation in end-of-life decision-making. Lastly, articles scoring below 7 on the QARI methodological quality scale were excluded from the review (Fig. 1).

Fig. 1.

Item selection diagram

Methodological quality assessment

Following the acquisition of evidence in accordance with the PICO framework and the predefined inclusion and exclusion criteria, a methodological quality assessment was conducted. This was carried out using a metasynthesis approach, consistent with a qualitative systematic review design, as proposed by the Joanna Briggs Institute for synthesizing qualitative evidence.

The evaluation employed the Qualitative Appraisal and Review Instrument (QARI) (Annex 2), a critical appraisal tool consisting of 10 closed-ended questions. Each item is rated using a four-point response scale: yes, no, unclear, or not applicable. A response of yes is scored as one point, while all other responses are scored as zero. The total score ranges from 0 to 10.

After applying the inclusion and exclusion criteria and removing duplicate studies, only those articles, outlined in Table 2, scoring a minimum of 7 points on the QARI scale were included. This threshold was established to ensure a minimum standard of methodological quality in the evidence reviewed.

Table 2.

QARI criteria of included articles

	Articles	Criteria 1	Criteria 2	Criteria 3	Criteria 4	Criteria 5	Criteria 6	Criteria 7	Criteria 8	Criteria 9	Criteria 10	Note
1	Mroz S, Dierickx S et al 2021 [1]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	9
2	Downie J, Gupta M, et al 2022 [2]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	9
3	Riisfeldt TD 2023 [3]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	9
4	Kale B, Jaiswal P 2024 [4]	Yes	Yes	Yes	Doubtful	Yes	No	Yes	NA	Yes	Yes	7
5	Martínez-León M, Feijoo VelazJ, et al 2022 [5]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
6	Velasco Sanz TR, Pintor Pastor P, et al 2023 [8]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	9
7	Sánchez Barroso, B 2023 [9]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	9
8	Kono M, Arai N, et al 2023. [10]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
9	Velasco Bernal, C, Trejo-Gabriel Galan J.M 2022 [11]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
10	Picón-Jaimes YA et al 2022 [20]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
11	Grove G, Lovell M, et al 2022 [21]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
12	Boichenko NM, Fialko NA 2023 [22]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
13	Svenaeus F 2020 [23]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
14	Busquet-Duran X, Martínez Losada EJ et al 2024 [24]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
15	Borges PJ, Hernández-Marrero P, et al 2024 [25]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
16	Ruíz-Rico C 2023 [26]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	9
17	Mavropoulos A 2024. [27]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA	Yes	Yes	9
18	Mousavi S 2024 [28]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
19	Javadly G 2024 [29]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
20	Pérez-Capellades RM, et al 2024 [30]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
21	Doomen J 2023 [31]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8
22	Guevara B AM, Taboada R P 2022 [32]	Yes	Yes	Yes	Yes	Yes	Yes	No	NA	Yes	Yes	8

Results

Comparative Summary of euthanasia and assisted suicide legislation in Europe: an analysis from the Spanish perspective

The comparative analysis of European legislation on euthanasia and assisted suicide, summarized in Table 3, reveals significant differences and similarities across six key dimensions: year of legal adoption, type of procedure permitted (euthanasia and/or assisted suicide), requirement of terminal illness, mandatory consultation with an independent physician, existence and function of a regulatory committee, and eligibility of minors to access the procedure.

Table 3.

Comparative analysis of the characteristics of current European laws on euthanasia

Country	Year of approval	Procedure	Waiting period	Oversight committee	Minors	Restricted to terminal patients	Independent physician consultation	Post-procedure report
Netherlands	2002	E/AS	Not specified; variable	Post facto	Yes, from age 12 **	Not specified	Yes	Yes
Belgium	2002	E	1 month between request and procedure	Post facto	Yes, all ages (since 2014)	Not specified	Yes	Yes
Luxembourg	2009	E/AS	Not specified; variable	Post facto	No	Not specified	Yes	Yes
Switzerland	1937	AS	Not specified; variable	Managed by associations	Not specified	No	No	Yes
Germany	2020	AS	Not specified	Not specified	No	No	No	Yes
Austria	2021	AS	Not specified; variable (12-week reflection period)	No (regulated by pharmaceutical association)	No	Yes	Yes	Yes
Portugal	2023	E/AS*	Not specified; variable	During the process	No	Yes	Yes	Yes
Spain	2021	E/AS	30–40 days between request and procedure	During the process; mandatory prior approval	No	Yes	Yes	Yes

^**Since February 2024, the Netherlands has implemented a dedicated regulatory scheme for life termination in this age group, which does not fall under the Termination of Life on Request and Assisted Suicide Act: Regulation on the Review Committee for Late-Term Pregnancy Termination and Life Termination in Newborns and Children Aged 0–12 Years* In Portugal, euthanasia may only be carried out when assisted suicide is not feasible due to the patient’s physical incapacity

Among the countries with explicit legislative frameworks, the Netherlands (2002) was the first to adopt a law permitting both euthanasia and assisted suicide [2, 5], followed by Belgium (2002) and Luxembourg (2009). More recently, Spain (2021), Portugal (2023), and Austria (2021) have joined this group, although Austria has only decriminalized assisted suicide. In Switzerland, assisted suicide has been decriminalized since 1937 without a specific legislative act [2, 5], while Germany decriminalized the practice in 2020.

With respect to the type of practice authorized, Spain, Portugal, Luxembourg, and the Netherlands permit both euthanasia and assisted suicide. Belgium and Luxembourg allow only euthanasia. In contrast, Switzerland, Germany, and Austria authorize assisted suicide exclusively and do not permit direct involvement of healthcare professionals in administering lethal substances [2, 5, 11].

Regarding the requirement of terminal illness, earlier laws in the Netherlands, Belgium, and Luxembourg do not mandate that the patient be terminally ill, focusing instead on the presence of intolerable and irreversible suffering [5–9, 11]. In contrast, more recent legislation in Spain, Portugal, and Austria requires that the applicant have a medical condition with a limited life expectancy [8]. This terminal illness criterion has become more prevalent in laws adopted from 2021 onward.

Concerning eligibility for minors, Belgium permits euthanasia without a minimum age threshold since 2014, provided strict criteria regarding unbearable suffering are met [2, 5, 11]. The Netherlands allows access starting at age 12 with parental consent [2, 5, 11], and under other legal framework based on “exception” at physician petition, it is allowed for children between 0 to 12 [13]. Spain, Portugal, Austria, and Luxembourg restrict access to legal adults [2, 5, 11]. Germany and Switzerland do not specify a minimum age, leaving this aspect open to interpretation [9].

Institutional oversight is a consistent feature across all countries with formal legislation. In earlier models such as those in the Netherlands, Belgium, and Luxembourg, regulatory committees conduct retrospective reviews after the procedure has been performed. In contrast, Spain and Portugal assign a proactive and binding role to their oversight bodies, which must authorize the procedure before it is carried out [5–9]. Both countries also require post-procedure notification to formally close the clinical file [5, 6].

Consultation with an independent physician is a mandatory requirement in all legislated systems [2, 5–9, 11], except in Switzerland [2, 5], where it is only recommended, and in Germany, where it is not required [9].

Procedural timelines between the initial request and the performance of the intervention also vary. Spain mandates a regulated period of 30 to 40 days [2, 5–7, 11], Belgium requires a minimum waiting period of one month2,5, and Austria enforces a reflection period of at least 12 weeks [9]. Other countries do not define specific timeframes, offering greater procedural flexibility [5–7, 11].

Identifying bioethical considerations in end-of-life decision-making related to euthanasia

Euthanasia has historically been the subject of significant social, moral, and ethical debate. The term itself has, at times, been distorted—most notoriously during World War II, when it was misused to justify the extermination of individuals considered to have a "less dignified" life [20]. The original concept of a “good death,” understood as the ideal set of circumstances under which an individual would wish to die, has evolved across time [20], shaped by prevailing societal norms, religious beliefs, and dominant philosophical perspectives.

In ancient Greco-Roman culture, early references to euthanasia can be found in the writings of Socrates and Plato, who considered death a plausible response to suffering caused by severe illness. Plato’s Republic notably presents death as an escape from prolonged agony [20]. In contrast, Hippocrates—through the Hippocratic Oath—alongside Pythagoreans, Aristotelians, and Epicureans, condemned euthanasia, a stance that suggests the practice may have been relatively widespread at the time [20].

During the Roman Empire, suicide was generally accepted as a means of ending suffering in the absence of medical remedies [20, 21]. However, this acceptance shifted with the rise of Catholicism, which forbade burial for those who took their own lives, viewing suicide as a violation of divine will. In the Middle Ages, the dominance of Catholic doctrine reinforced an ideology of suffering as a path to glory [20, 21]. Nonetheless, on the battlefield, ending the life of mortally wounded enemies was commonly practiced under the notion of compassionate death [20, 21].

The Renaissance, marked by the resurgence of arts and sciences, revived the original understanding of euthanasia as death without suffering in cases of incurable illness. Thomas More notably shaped the modern conception of euthanasia by emphasizing the importance of patient acceptance and official—often clerical—approval. Still, other perspectives emerged advocating the right of terminally ill individuals to continue living with support and compassion [20].

In the twentieth century, opioid derivatives were documented for pain relief and chloroform-based substances were used to reduce consciousness and hasten death, as noted by S. Williams [20]. However, this period also saw the rise of utilitarian ideologies and social Darwinism, which distorted the concept of euthanasia into a tool for eliminating those deemed "unfit" or weak [20, 22, 23]. This misuse culminated in Nazi Germany’s eugenic programs, where lists of "undesirable" conditions were developed, and healthcare professionals were required to report affected individuals—including neonates and adults—for termination through starvation or lethal injection, all within a state-sanctioned system that allowed no room for conscientious objection [20].

The notion of conscientious objection gained prominence in response to these atrocities and was formally recognized in the development of bioethical principles for human biomedical research [20]. Later in the twentieth century, movements such as the Hospice movement emerged, focusing on patient-centered care, companionship, and respect for suffering—laying the foundation for modern palliative care.

Palliative care today is strongly linked to the alleviation of suffering, which remains the central motivation behind many patients’ desire to hasten death [20, 24]. This desire often arises in response to existential, intolerable suffering, perceived as inescapable, leaving death as the only viable option [25]. However, this should be distinguished from the natural acceptance of death or the wish to die naturally [24, 25], which is typically associated with finding meaning in suffering or lack of awareness about palliative options.

Unbearable suffering comprises physical, emotional, spiritual, and psychosocial dimensions [23–25]. It represents a form of existential distress involving the loss of meaning, identity, and purpose [23]. Expressing a wish to hasten death can be a way for patients to regain a sense of control and relieve psychological and spiritual distress [24, 25]. Autonomy in this context is closely linked to rejecting prolonged agony and asserting control over the timing of death [25]—often in response to disrupted life plans and a fractured personal narrative. As such, suffering is deeply individual and shaped by personal values [24].

The wish to hasten death is intertwined with the four fundamental bioethical principles—autonomy, beneficence, non-maleficence, and justice—as well as with dignity and vulnerability [22, 23, 25–27]. These principles guide ethical reflection on euthanasia. As summarized in Table 4, an ethical approach to euthanasia must uphold patient autonomy by recognizing their right to choose and request euthanasia. This decision must aim to alleviate suffering (beneficence) while avoiding disproportionate harm (non-maleficence). Given the patient's vulnerable condition, support must be provided alongside the assurance of dignity, which entails respecting their values and wishes. Furthermore, distributive justice requires equal access to the service regardless of the individual's location or socioeconomic status.

Table 4.

Bioethical principles related to euthanasia and their implications [22–27]

Ethical principle	Definition	Ethical implications
Autonomy	Right to make free decisions Self-determination	The reduction of autonomy to the sole context of death/euthanasia/the wish to hasten death may lead to neglect in other biomedical decisions It may also result in patients being forced to make decisions due to external pressures
Beneficence	Pursuit of the patient’s benefit Protection of their rights	Ensures the patient’s maximum benefit by aiming to reduce suffering and maintain or improve quality of life until death, whether assisted or not Refers to proportionality in clinical action
Non-maleficence	Prohibition of killing, causing harm, or inflicting suffering	Euthanasia appears to violate this principle However, euthanasia, compared to prolonged suffering and the dying process accompanied by pre-agonic states, may be considered less harmful Refers to proportionality
Justice	Promotes equity in healthcare provision, without distinction or conflicts of interest	Geographic location entails differences in access, treatment, and available resources In the context of euthanasia, access may be limited in certain areas—whether due to individual or institutional conscientious objection, or restrictive legislation
Dignity	Intrinsic value Respect for every human being by virtue of their existence, regardless of circumstances, age, gender, ethnicity, or socioeconomic status Closely linked to the degree of dependence and the loss of physical and moral integrity	Implies that the individual must be treated with compassion and that emotional, physical, and psychosocial well-being should be ensured The wish to hasten death or to request euthanasia in these patients is often related to the desire to preserve dignity and integrity until the end, enabling them to maintain control over their process and avoid dying in conditions that conflict with their moral values
Vulnerability	Condition of being susceptible to harm Fragility Reduced capacity to express autonomy Related to the degree of dependence and the loss of physical and moral integrity Inherent to the situation, setting, and context of end-of-life care	The presence of illness—particularly those compromising autonomy—constitutes a threatening circumstance that may create additional barriers to treatment and decision-making In palliative care, a third party may sometimes need to make decisions on behalf of the patient, potentially conflicting with the patient’s values In relation to euthanasia, this may imply that decisions are not always proportional to the patient’s needs The principle of double effect is relevant in the context of vulnerability: an intended “good” outcome, such as prolonging life, may inadvertently produce the “bad” outcome of prolonging suffering

The integration of these ethical principles aligns with the notion of a “good death,” understood as death in accordance with an individual's values, sense of dignity, and personal beliefs [24]. Religious faiths often inform these beliefs, shaping attitudes toward death and the desire to hasten it [21]. Religion, as a social construct, fosters belonging and cultural identity, and its influence on society stems from moral frameworks rooted in reverence for deities. These frameworks inform behavioral norms related to life, death, and everyday living [21, 28].

Table 5 Summarizes the bioethical implications of euthanasia, the desire to hasten death, and end-of-life decision-making as interpreted by the world’s four major religions.

Table 5.

Major religions worldwide and their stance on euthanasia [20, 21, 27–29]

Religion	Scriptural Message	Ethical implication
Christianity (Bible) Monotheistic	Creation: God as the sole creator and giver of life, and sustainer of universe	Human limitation regarding life and death Everything is under divine control
	Human value: Humans as part of creation, made in the image and likeness of God	Only God has authority to decide on an individual’s death
	Suffering: A consequence of sin and disobedience to God’s commandments	God Responds to human suffering through the figure of Jesus Provides an explanation for individual suffering
	Death: after death, there is hope for eternal life free of suffering. Death is understood as the pathway to immortal life	Living according to God’s commandments assures eternal life without suffering
Islam. (Qur’an) Monotheistic	Creation: Allah holds exclusive authority over life and death	Human life is sacred
	Human value: Life is inherently sacred	Connected to the ability to profess faith
	Death: Belongs solely to Allah or may occur through the exercise of justice	Accepts natural death or death as a consequence of justice
	Suffering: Endurance of illness is encouraged	Through perseverance in suffering, one may attain paradise. Provides comfort and hope in resurrection
Hinduism Polytheistic	Life and death: Humans are composed of a mortal body and an immortal soul. Death applies only to the physical body; the soul reincarnates. Life is understood as cyclical and in balance	Death does not imply the end of existence, but the continuation of the cycle of rebirth
	Dharma: The moral force that orders the universe Karma: The moral dimension of daily conduct	Suffering is attributed to the law of Karma. If destined, it must be endured in this life; otherwise, it will manifest in the next
	Ahimsa: Non-violence and prohibition of taking life	Killing is forbidden by the law of Karma
Budism Non-theistic	Life: Considered cyclical
	Suffering: Governed by the law of balance and justice through reincarnation	Can be overcome through enlightenment by following the Noble Eightfold Path
	Death does not represent liberation, given the endless cycle of existence	Rejects euthanasia, since desires must be extinguished rather than pursued

^*Noble Eightfold Path of Righteousness: moral vision, intentions and conduct, words, way of life, effort, mindfulness, concentration

Christianity regards life and death as domains governed solely by God, leading to a general prohibition of euthanasia and assisted suicide [21]. Both Eastern Orthodox and Evangelical Protestant traditions uphold the sanctity of life, viewing any intentional termination as morally unacceptable [20, 21, 27, 28].

In Islam, suicide and euthanasia are explicitly forbidden unless justified by divine law [21, 28, 29]. Both Sunni and Shia branches consider life sacred, regardless of suffering, and prioritize legal and theological judgment when addressing end-of-life acts [21, 29].

Hinduism, lacking a single doctrine or deity, approaches euthanasia through the lens of karma and reincarnation [21, 29]. Suffering is seen as part of a spiritual journey, but some schools allow for compassionate death, viewing it as a lesser sin than prolonged suffering—although modern Hindu legal and cultural norms reject assisted dying [21, 28].

Buddhism condemns killing and suicide due to their karmic consequences and the central aim of eliminating desire [21, 28]. Yet in rare cases, where a person has achieved full detachment, death may be seen as a natural transition to Nirvana [21].

Overall, opposition to euthanasia in Abrahamic religions is rooted in divine authority and the moral value of enduring suffering. In Eastern traditions, it is linked to karmic cycles and spiritual development. Despite these doctrines, secularization and rising individual autonomy have led to evolving moral frameworks that increasingly center on personal choice rather than religious mandates [21, 28].

Despite increasing secularization, many individuals continue to identify deeply with religious values [21]. This creates tension between personal beliefs, societal norms, and evolving legal frameworks—particularly when medical professionals are faced with requests for euthanasia. Conscientious objection, defined as a refusal by a healthcare provider to participate in a procedure based on religious or ethical convictions [21, 22, 30], must be justified within a professional ethical framework and can serve to protect the practitioner’s moral integrity and mental well-being while respecting religious pluralism [21, 29].

However, conscientious objection raises questions about distributive justice and equitable access to care [30]. When exercised at the institutional level—where an entire healthcare facility objects—it may deny patients lawful services based on the institution’s values [21, 30]. This institutional objection, though permissible under certain conditions (e.g., ensuring alternative referral mechanisms), may conflict with obligations to provide all services included in national healthcare provisions [25, 30]. In the context of euthanasia, delays or denial driven by conscientious objection can exacerbate suffering and undermine the principles of beneficence, non-maleficence, dignity, and justice.

Moreover, autonomy may be constrained for vulnerable groups such as minors, persons with disabilities, individuals with mental illness, and patients with dementia [26]. In jurisdictions like Spain, these populations are excluded from access to euthanasia unless strict criteria—such as prior documented capacity—are met [26]. Contrastingly, in countries with longstanding euthanasia laws, some debate extends eligibility to those experiencing existential suffering or "completed life," including proposals for adults over 75 [31].

Critics argue that such proposals risk devaluing human life by shifting the justification for assisted dying away from medically grounded criteria and toward subjective or socially mediated assessments of life quality [31, 32]. This trend raises substantial concerns regarding a potential slippery slope, whereby the boundaries of eligibility gradually expand to include individuals whose motivations may stem not from medically intractable suffering, but from social isolation, economic hardship, lack of adequate caregiving, or profound “life fatigue” [31]. This emerging discourse intensifies ethical alarm, as it suggests a transition from euthanasia as a last resort in the context of severe and incurable illness to a broader societal mechanism for alleviating suffering that is, in many cases, preventable through social and healthcare interventions.

The worry is that social pressure may emerge—particularly on marginalized groups—to seek death in lieu of insufficient medical or palliative support [31]. This may, in turn, exert undue influence on clinicians to approve requests, thereby eroding core bioethical safeguards [32]—particularly autonomy, beneficence, non-maleficence, and justice—by allowing external socioeconomic factors to shape end-of-life decision-making.

Discussion

The comparative analysis of euthanasia and assisted suicide legislation in Europe reveals a heterogeneous landscape regarding eligibility criteria, clinical requirements, and regulatory frameworks. Early adopters such as the Netherlands, Belgium, and Luxembourg did not require terminal illness, focusing instead on intolerable and irreversible suffering, whereas more recent laws in Spain, Portugal, and Austria emphasize terminality as a condition for access. This shift suggests an evolution in which safeguarding and procedural control have become increasingly prioritized.

A central dimension concerns the role of regulatory committees. While retrospective oversight (post facto) characterizes the early models (Netherland, Luxembourg, Belgium), Spain and Portugal have introduced a proactive and binding mechanism, reinforcing legal certainty for both patients and healthcare professionals. This mechanism prevents the act from being classified as homicide, as may plausibly occur in jurisdictions where review takes place only post facto. However, this more stringent oversight may prolong procedural timelines, potentially delaying effective access.

It is important to note that the consulting physician—mandated in all jurisdictions with formal legislation—does not form part of either the prospective or retrospective oversight structures. Instead, their role constitutes an essential safeguard, providing an independent clinical verification that supports and reinforces the assessment made by the attending physician.

The inclusion or exclusion of minors and vulnerable populations highlights profound ethical divergences. Belgium and the Netherlands allow access under strict conditions, whereas other jurisdictions restrict the procedure to legally competent adults. This raises a persistent tension between autonomy and protection, particularly in cases involving disability, mental illness, or cognitive decline. The ongoing debate on “completed life” or “existential fatigue” further underscores the risk of a slippery slope, where non-medical motives such as social or economic pressures could displace the original medical rationale, thereby undermining the inherent value of human life.

From a bioethical perspective, euthanasia remains a field of tension between the principles of autonomy and beneficence on the one hand, and the duty to protect vulnerable groups and ensure distributive justice on the other. Autonomy manifests in the individual’s right to decide on end-of-life matters, yet this choice must be supported by strong palliative care systems to ensure that the decision is not driven by unmet healthcare needs. Similarly, conscientious objection, though legitimate as a safeguard of professional moral integrity, becomes problematic when exercised institutionally, as it may restrict access to a legally recognized right and contribute to inequities in service provision.

Religious traditions continue to exert significant influence. Abrahamic religions strongly oppose euthanasia, grounded in the sanctity of life, whereas Eastern traditions adopt more nuanced positions linked to karmic cycles and compassion. Nevertheless, the progressive secularization of European societies has shifted the ethical focus toward individual autonomy, granting personal values increasing primacy over religious doctrines.

This review offers a timely and comprehensive examination of euthanasia and assisted suicide legislation across all European jurisdictions in which these practices are either formally regulated or decriminalized. To date, no previous study has systematically integrated both regulatory frameworks (e.g., the Netherlands, Belgium, Luxembourg, Spain, Portugal) and decriminalization-based models (Germany, Switzerland, Austria) into a unified comparative analysis. By consolidating these heterogeneous legal approaches, the study provides an overarching synthesis not previously available in the literature.

Incorporating recent legislative developments—such as Spain’s Organic Law 3/2021, Portugal’s 2023 regulatory framework, and Austria’s 2021 decriminalization—the review establishes an updated reference point for scholars and policymakers. Through its comparative approach, it elucidates how different jurisdictions operationalize core bioethical principles and delineates structural divergences in eligibility criteria, procedural safeguards, and oversight mechanisms. In doing so, the study bridges health law and bioethics, offering a foundational framework for understanding the normative tensions that shape assisted-dying policy across contemporary Europe.

Limitations

This study presents limitations that should be acknowledged. Articles addressing euthanasia or assisted suicide in the context of psychiatric disorders or dementia were excluded. This decision was based on the substantial ethical controversy surrounding such cases and, importantly, because these conditions involve complex questions about decisional capacity and its assessment—issues that fall outside the scope of the present research. Consequently, the exclusion of these populations limits the generalizability of findings to jurisdictions where euthanasia for psychiatric illness or dementia is permitted.

Conclusions

The comparative review of European euthanasia and assisted suicide legislation demonstrates that, although autonomy, dignity, and relief of suffering constitute shared underlying principles, legal and bioethical frameworks differ substantially across jurisdictions. This diversity reflects the enduring influence of cultural and religious traditions as well as political priorities concerning the balance between life protection and individual freedom.

The principal difference identified in the analysis of European jurisdictions regulating assisted dying lies in the timing of case evaluation by the oversight committee. Spain and Portugal, the most recent countries to enact legislation, are the only jurisdictions that mandate review prior to the procedure. This approach ensures compliance with the legal requirements while also providing safeguards for the principles of vulnerability, autonomy, beneficence, and justice.

For euthanasia to be ethically and socially acceptable, legal frameworks must ensure a balance between autonomy and protection, while avoiding inequities and guaranteeing universal access to palliative care. The expansion of eligibility criteria to non-medical grounds requires cautious deliberation, given the risk of devaluing human life and generating undue pressure on vulnerable populations.

Ultimately, the European debate on euthanasia transcends the dichotomy between individual liberty and the sanctity of life. It must instead be framed as a question of social justice, ensuring that end-of-life decisions are made freely, with dignity, and within health systems capable of providing equitable and compassionate support.

Abbreviations

NA

Not applicable

E

Euthanasia

AS

Assisted suicide

PRISMA

Preferred Reporting Items for Systematic reviews and Meta-Analyses

Authors’ contributions

Conception: L. Francés Vañó, A. Sanchís-López, C. Arce-Recatalá; design of the work: L. Francés Vañó; acquisition, analysis and interpretation of data: L. Francés Vañó; draft the work: L. Francés Vañó; revised the work: L. Francés Vañó, A. Sanchís-López, C. Arce-Recatalá.

Authors’information

Lucía Francés Vañó, MD, Specialist in Family and Community Medicine, currently working primarily in palliative care within a Hospital at Home unit. Member of the Bioethics Committee at Hospital General Universitario de Elche.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.