Spain, at the European forefront of the right to die: how euthanasia is regulated in the rest of the countries

The euthanasia of Noelia Castillo is not only a personal and judicially complex case: it is also a stress test for Organic Law 3/2021 on the regulation of euthanasia and a mirror in which is reflected the degree of development of this right in Spain compared to the rest of Europe.

After nearly two years of litigation, appeals, and family confrontations, the young woman has managed to unblock a procedure that had been validated from the beginning by the medical bodies. Her case has gone through practically all judicial instances, becoming one of the most paradigmatic since the entry into force of the norm in June 2021.

The day Noelia Castillo will see her wish to access euthanasia fulfilled, the issue has also once again been a protagonist in Congress, dialectically confronting deputies from the groups that voted against the law with those who managed to make it prosper. Specifically, the Vox spokesperson in the Congress's Constitutional Committee, Carlos Flores, has called the young woman's euthanasia an “execution”, to which Sumar's spokesperson for Justice and Interior, Enrique Santiago, has responded by recalling that euthanasia is a right endorsed by the Lower House and that Vox is not "to question Noelia's decision," whose suffering, he has denounced, "they have already prolonged for two years, sadistically, with infinite resources."

When the law faces reality

The trajectory of Noelia Castillo's case evidences both the strength and the limitations of the system. On the one hand, all technical bodies —medical and administrative— endorsed from the beginning that she met the legal requirements in force in Spain. On the other, her father's opposition opened a judicial battle that has delayed for months the effective application of an already recognized right. The core of the conflict has been the patient's decision-making capacity. While her father maintained that there were mental health problems that invalidated her will, the courts have repeatedly concluded that Noelia retains said capacity and that her decision is free and conscious.

This point is key because it sets a criterion: the patient's will prevails over the opposition of third parties when legal guarantees are met.

Spain, among the few countries of the EU with legal euthanasia

Spain is part of a very small group within the European Union that expressly and regulatedly allows euthanasia. Along with the Netherlands, Belgium and Luxembourg, it is one of the only countries where a healthcare professional can directly administer the provision of aid-in-dying within the public system.

This fact is not minor. The majority of European countries still do not recognize this right or, in the best of cases, have opted for more limited models based on assisted suicide.

In the Spanish case, the law not only decriminalizes the practice, but also integrates it as a healthcare service with guarantees, controls, and public supervision. That is, it goes from being a penal exception to becoming a recognized and regulated right.

What makes Spanish law different

The main singularity of Spanish legislation is its breadth and its guaranteeing approach. Organic Law 3/2021 on the regulation of euthanasia allows access to the service in two main scenarios: serious and incurable illness or serious, chronic, and disabling suffering. This second scenario is key and explains why cases like Noelia Castillo's fit within the legal framework. It is not required, therefore, that the patient be in a terminal phase. It is enough that the suffering is considered intolerable and that there is an irreversible situation, always with full decision-making capacity.

In addition, the procedure incorporates multiple filters: double application, evaluation by two doctors, verification by an autonomous commission and possibility of conscientious objection on the part of healthcare professionals.

Europe, a fragmented map between prohibition and partial advances

Compared to the Spanish model, Europe presents a deeply unequal landscape. As we have pointed out previously, only four EU countries allow active euthanasia in similar terms. Other States, such as Germany, Austria or Italy, have opened the door to assisted suicide, but without going so far as to allow a doctor to directly administer the substance.

In countries like France or Portugal, the debate is advanced, but the laws are not fully operational or continue to face political and constitutional obstacles.

The case of Switzerland is presented as the most singular. For decades, assisted suicide has been tolerated or permitted as long as there are no selfish motives. It is not a model of active euthanasia comparable to the Spanish one and has given rise to a phenomenon that has been described as “assisted suicide tourism”, with citizens from other countries traveling to the country in search of help to die.

For its part, United Kingdom still does not have a general law in force, although the debate is very much alive. In England and Wales, the Terminally Ill Adults (End of Life) Bill is still undergoing parliamentary processing.

The rest of European States, however, maintains the prohibition or lacks a clear regulation, which evidences that consensus is far from being reached.

What is happening in the rest of the Western world?

Beyond the EU, euthanasia is contemplated in a very different way in the Western world.

Canada has developed one of the broadest systems of medical assistance in dying, with a growing number of cases each year. Australia and New Zealand have also legalized the practice, although with differences in its scope.

United States, for its part, presents a decentralized model: several states allow assisted suicide, but generally limited to terminally ill patients and without contemplating active euthanasia as in Spain.

This places the Spanish model in an intermediate-high position in terms of rights recognition: broader than the American in some aspects, but within a global trend of regulated expansion.