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

backgroundEuthanasia 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?

methodsA 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.

resultsTwenty-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.

conclusionsEuthanasia 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.