End-of-life care: Europe is moving forward in a disorganised manner – from euthanasia in Spain to the Italian conundrum

It is precisely this layering of regional rulings and regulations that makes the Italian case unique. Euthanasia is not legalised, nor is there a national law on assisted suicide, but there is a scope of non-punishability defined by the Constitutional Court. The same request may therefore be subject to different procedures depending on the region in which it is submitted.

The debate in Parliament remains ongoing. Among the main points of contention are the eligibility criteria, conscientious objection and, above all, the role of the National Health Service: some political groups argue that the procedure should be included among the services guaranteed by the public health system, whilst others are calling for it to be excluded.

Spain is now one of the most progressive examples of end-of-life regulation in Europe. Through Organic Law 3/2021, it has legalised both euthanasia and medically assisted suicide, recognising the right to request and receive assistance in dying within the public healthcare system.

Access is subject to a detailed procedure. The patient must be of legal age, capable of making independent decisions, and suffering from a serious and incurable illness or a condition of permanent suffering deemed unbearable. Subsequent checks are carried out by doctors and oversight committees to verify that the decision is made freely and in full knowledge of the facts.

The law is the result of a debate that has lasted for decades and has been marked by landmark cases such as that of Ramón Sampedro, the Galician sailor who was left quadriplegic following an accident and became the face of the campaign for the right to die. His story inspired the film *The Sea Inside*, which won an Oscar in 2005.

Even after legalisation, however, the disputes have not gone away. The case of Noelia Castillo from Catalonia, at the centre of a long-running legal dispute between her wishes and her father’s opposition, reignited the debate in 2026 on the limits of self-determination and the role of family members in end-of-life decisions.

France occupies a middle ground. The Claeys-Leonetti Act of 2016 permits the withholding of treatment and deep, continuous sedation until death in the cases provided for by the legislation. However, it does not authorise either active euthanasia or assisted suicide.

In recent years, the issue has returned to the forefront of French politics. Following the Citizens’ Convention on end-of-life care convened by Emmanuel Macron, Parliament debated a reform introducing a right to ‘assisted dying’ for patients suffering from serious and incurable conditions that cause suffering deemed unbearable. The bill has deeply divided political parties, doctors and religious organisations.

France is therefore seeking its own path, distinct from both the Spanish and Italian models: greater openness than in the past, but within a highly regulated framework and accompanied by a strengthening of palliative care.

In Austria, too, the turning point came from the courts. In 2020, the Constitutional Court ruled that the blanket ban on assisted suicide was unlawful, deeming it incompatible with the right to self-determination. Since January 2022, assisted suicide has therefore been permitted under certain conditions.

The Austrian system is one of the strictest in Europe. Only adults suffering from a terminal illness or a serious chronic condition are eligible for the procedure. Independent medical opinions are required, one of which must be from a palliative care specialist, in addition to mandatory reflection periods and further procedural safeguards. Euthanasia, however, remains prohibited.

Moving eastwards, the picture changes significantly. In Lithuania, Bulgaria, Greece, Hungary and the Czech Republic, euthanasia remains prohibited and there are no procedures comparable to those in place in Spain or Austria.

In many of these countries, the debate is influenced by the weight of religious traditions and the belief that the priority should be to strengthen palliative care rather than to legalise assisted dying. In Bulgaria, for example, an attempt to introduce a law on euthanasia was unanimously rejected by Parliament in 2011, and since then the issue has remained on the fringes of national politics.

In Hungary, the case of the constitutional lawyer Dániel Karsai, who suffers from ALS, has reignited public debate, whilst in Greece, civil society groups and secular organisations have been calling for reform for years, facing strong opposition from the Orthodox Church.

*This article is part of the European collaborative journalism project ‘Pulse’ and was produced in collaboration with Lola García-Ajofrín (El Confidencial, Spain), Francesca Barca (Voxeurop, France), Jakob Pflügl (Der Standard, Austria), Ieva Kniukštienė (Delfi, Lithuania), Martina Bozukova (Mediapool.bg, Bulgaria), Matěj Moravanský (Deník Referendum, Czech Republic), Sarolta Kuglics (HVG/EUrologus, Hungary) and Dimitris Angelidis (EfSyn, Greece)