A few days ago I watched a film called La Grazia, directed by Paolo Sorrentino. Among the many things it addresses, the film raises the possibility of the Italian president signing the euthanasia law at the end of his term. On one side stands the Catholic jurist — mature, firm, and uncompromising. On the other, a young jurist full of ideas, who asks a question that stayed with me for days: to whom do our days belong? That question led me to write about this topic. As you know, this site does not take sides. Our goal is to present the facts and the most recent findings in the medical literature. Enjoy the reading.

In 1991, a doctor at Tokai University in Japan administered potassium chloride to an irreversibly comatose patient, at the family-s request. He was convicted of murder and sentenced to two years in prison with probation. Thirty years later, that verdict still reflects the standard across most of Asia. The lesson is precise: where you are born, what culture you carry, and what faith you hold determines how you die — and who decides.

Euthanasia — from the Greek eu (good) and thanatos (death) — is one of the most contested topics in contemporary bioethics. There is no global consensus. Instead, there are cultural traditions, religious doctrines, legal codes, and family dynamics that produce radically different answers to the same question: who has the right to decide the end of a suffering life?

This article examines the differences between Western culture — Catholic, Protestant, Latin, and Saxon — and Asian culture, with focus on Islam, Hinduism, Buddhism, Confucianism, China, Japan, and India. All sources are peer-reviewed articles from PubMed, Frontiers in Psychology, Journal of Religion and Health, SAGE Journals, and Archives of Public Health.

Active Euthanasia, Passive Euthanasia, and Assisted Suicide: The Terms That Matter

Before comparing cultures, the terminology must be precise. Confusion between these terms produces errors in both ethics and law.

Active euthanasia occurs when a physician administers a lethal substance directly to the patient, at the patient-s explicit request. It is legal in the Netherlands (since 2002), Belgium, Spain, Colombia, and Canada. Passive euthanasia is different: treatments that prolong life are withdrawn or not started. This form is far more widely tolerated, including in religious contexts. Physician-assisted suicide (PAS) means the physician prescribes the lethal drug but the patient self-administers it. This is permitted in Switzerland, Austria, and several US states.

A meta-analysis by Grove, Lovell, and Best in the Journal of Religion and Health (2022) identified 44 academic articles on euthanasia and religion: 25 on Christianity, 9 on Islam, 7 on Judaism, 5 on Hinduism, and 4 on Buddhism. That distribution is not random. It reflects where the debate has been most intense and where religious traditions have carried the most political weight.

As of 2025, the European Parliament reports 26 jurisdictions worldwide with some form of legalized assisted dying: six Australian states, Belgium, Canada, Colombia, Ecuador, Luxembourg, the Netherlands, New Zealand, Spain, Switzerland, and 10 US states. The Netherlands was the first country to legalize euthanasia in 2002. No Asian country has legalized active euthanasia.

The Divided West: Catholics and Protestants

The Catholic Church-s position is clear. The document Samaritanus bonus, issued by the Congregation for the Doctrine of the Faith on September 22, 2020, states that every form of active euthanasia is incompatible with the dignity of the human person. Life is a gift from God; only God is its author. At the same time — and this is often overlooked — the same document teaches that life must not be preserved at any cost. Aggressive life-prolongation is condemned just as strongly as euthanasia. The goal is to accompany the sick person through compassionate care, not to prolong agony artificially.

A 2024 study in SAGE Journals by Kozakowski described this position as a “middle ground”: neither active euthanasia nor aggressive intervention, but intensive palliative care and whole-person accompaniment. This framework directly influences healthcare systems in Catholic-majority countries: Italy, Portugal, Poland, and Latin America consistently invest more in palliative infrastructure relative to the euthanasia debate.

Italy has no comprehensive law on assisted suicide. The Constitutional Court has intervened multiple times, declaring criminalization unconstitutional in specific circumstances, but Parliament has not produced comprehensive legislation. A 2024 analysis on PubMed (PMC12027273) describes the current Italian regulatory framework as “inconsistent” and recommends adopting the Spanish or Portuguese model.

Spain is the most instructive case: a historically Catholic country, it legalized euthanasia in 2021 and became the fourth European country to do so. In Europe in 2025, four EU countries allow physician-administered euthanasia: Belgium, Spain, Luxembourg, and the Netherlands. Germany, Italy, and Austria allow only assisted suicide under specific conditions.

Protestant churches are not a unified bloc. Conservative evangelical churches — theologically close to Catholic positions — oppose any form of active euthanasia. Liberal Protestant denominations tend to prioritize individual patient autonomy. A study of 614 Catholic and Protestant clergy in the Cleveland area (PubMed, PMID: 12337911) produced a counter-intuitive finding: conservative Protestants opposed passive euthanasia even more strongly than Catholics. The division within Protestantism is therefore more clinically relevant than simple denominational membership.

The Netherlands and Belgium — both with strong Protestant and secular traditions — were the global pioneers. A narrative review in Frontiers in Psychiatry (2022) by Marijnissen, Chambaere, and Oude Voshaar (DOI: 10.3389/fpsyt.2022.857131) documents 20 years of euthanasia practice in dementia, including the ethical dilemmas in patients with reduced decision-making capacity.

Islam: Life as an Inviolable Trust from God

In Islam, life is an amanah — a trust that Allah has placed in the human being. It does not belong to the person living it. This theological principle has direct and concrete consequences: no Muslim has the right to end their own life, and no physician has the authority to end it for them.

A 2020 narrative review in Medicine, Science and the Law (SAGE Journals, DOI: 10.1177/0025802420934241) by Madadin et al. consulted the Quran, hadith literature, and legal codes of multiple Islamic countries. The conclusion is unambiguous: both active euthanasia and physician-assisted suicide are forbidden under Islamic law. In all Muslim-majority countries, active euthanasia is illegal. A physician who participates faces criminal prosecution, though the patient-s explicit repeated consent can reduce the sentence from capital punishment to imprisonment and medical license revocation.

There are distinctions between Islamic schools. Sunni and Shia traditions agree on the illegality of active euthanasia but diverge on passive forms. Some Shia interpretations allow the withdrawal of treatments considered futile when death is inevitable — a position that converges with Catholic teaching against aggressive life-prolongation.

A growing population of Muslim patients in Western countries with euthanasia laws has created practical clinical tensions. A 2024 systematic review in the Journal of Pain and Symptom Management examined the experiences of Muslim patients and caregivers in non-Muslim majority nations. The review found communication difficulties with healthcare providers and a strong preference for intensive palliative care over assisted dying. For physicians working in European healthcare systems, this difference is not peripheral. It changes how prognosis conversations should be structured.

Hinduism, Buddhism, and Karma as a Guide to Death

In India, the euthanasia debate is inseparable from ahimsa — non-violence toward every living being — which is the central principle of Hinduism, Buddhism, and Jainism. Intentionally ending a life, even out of compassion, is understood as interference in the natural process of karma.

Karma is the principle that every action has consequences in future existences. A premature death could interrupt a necessary process of spiritual maturation. This does not mean suffering is ignored. Buddhism has developed an elaborate philosophy of suffering (dukkha) and its transcendence. But transcendence is achieved through spiritual practice, not through induced death.

Grove et al.-s 2022 review (Journal of Religion and Health, PMC9569313) analyzed primary texts from both traditions and concluded that both Hinduism and Buddhism oppose EPAS while leaving room for compassionate interpretations in extreme cases. Hinduism does allow religiously motivated suicide — such as prayopavesa, a ritual fast unto death for spiritual reasons — but this is fundamentally different from medical euthanasia.

India-s Supreme Court clarified the legal position in 2018: passive euthanasia is permitted under specific conditions (permanent vegetative state, documented informed consent). Active euthanasia remains illegal. An article in the International Journal of Social Science Research and Review (2024) documented that Indian cultural tradition strongly values family involvement in end-of-life decisions: patients of Indian origin, even when living in the United States, consistently prefer family participation in terminal medical choices.

China and Japan: Confucianism, Family, and Legal Ambiguity

China and Japan share a Confucian cultural substrate that places family at the center of every major decision, including death. Confucianism emphasizes human relationships and filial piety: children have a duty to care for elderly parents. In this context, withdrawing care from a parent is often perceived as abandonment, not as respect for their wishes.

In China, euthanasia is illegal in all its forms. There is no specific statute explicitly prohibiting it — but there is none permitting it either. A 2024 analysis in Frontiers in Psychology (Liu & Liu, PMC10863618) documented that Chinese families verbally accept care withdrawal but frequently refuse to sign written consent, fearing social repercussions. A family that allows an elderly parent to die risks accusations of violating filial piety. Physicians fear accusations of malpractice or murder. The result is a system where preferences exist but cannot be formally acted upon.

The largest national study ever conducted in China on this topic — published in Archives of Public Health (Springer Nature, 2025) with 31,449 questionnaires — found that psychosocial factors predict end-of-life choices more powerfully than somatic disease severity. Fear of becoming a burden on the family and loss of personal dignity were the dominant predictors. This challenges the common clinical assumption that physical suffering drives end-of-life decisions. In China, the relational context matters more.

Japan-s situation is structurally similar. The 1991 Tokai University case created a precedent that keeps Japanese physicians extremely cautious. A 2025 study (PMC11748524), approved by the Ethics Committee of the University of Tokyo, compared physician and public attitudes. Japanese physicians oppose euthanasia more strongly than their Western counterparts, while roughly one third of the Japanese public supports some form of it. The explanation lies in Confucian influence: decision-making is structured around family relationships and respect for elders, not individual autonomy.

South Korea represents an outlier: euthanasia is illegal, but roughly 80% of citizens support some form of assisted dying. In 2024, the first bill to legalize physician-assisted death was introduced. Psychiatric Times (2026) attributes South Korea-s opening to its greater degree of Westernization compared to the rest of Asia and the declining influence of Buddhism there.

The Role of the Family: An Invisible Cultural Boundary

The deepest contrast between Western and Asian cultures on euthanasia concerns who has the right to decide. In the individualist Western model — especially in Saxon countries like the Netherlands, Belgium, Germany, and the United States — the decision belongs to the patient. Written advance directives are legally recognized instruments. The physician is legally obligated to respect the patient-s wishes, even against family preferences.

In the collectivist Asian model — China, Japan, India, Korea — the family is the primary decision-maker. In many cases, the patient is not even told the terminal diagnosis: the family receives the information and decides. A study cited in EthnoMed (2024) found that Korean and Mexican-American patients are more likely to consider the family as the decision-maker for withholding aggressive treatment, rather than the patient individually.

Buddhism, Confucianism, and Asian Christianity all reinforce filial piety: children must prevent parents from being “abandoned” by medicine. This creates difficult clinical situations in intensive care units. A review on PMC (PMC4057346) documented that in China, even when families and patients both want care withdrawn, the inability to sign formal written documentation leaves physicians in permanent uncertainty.

Even in Latin Catholic culture — Italy, Spain, Latin America — the family carries significant weight in end-of-life decisions, though differently from the Asian model. In Latin cultures, family suffering is experienced as solidarity, not as violation of a structural obligation. This distinction explains why Spain, a Catholic country, could legalize euthanasia in 2021: individual patient autonomy was framed as part of respecting dignity, not as breaking a family bond.

Cultural Background Is a Clinical Tool

The question of who has the right to end a suffering life has no universal answer. It has cultural answers — answers that shift depending on where you were born, what you believe, and who you love.

In Catholic countries, life is a sacred gift that should not be artificially prolonged beyond all limits. In liberal Protestant countries, individual autonomy is the supreme value and assisted dying is a choice of dignity. In Islam, life belongs to God. In Hindu and Buddhist traditions, karma and ahimsa make induced death a disruption of a necessary spiritual process. In China and Japan, the family decides, and deciding to let a loved one die carries social risk.

These are not merely philosophical positions. They are systems that produce laws, train physicians, and guide families through the most difficult moments of their lives.

For any physician working with elderly patients who carry chronic pain or terminal diagnoses, this cultural map is an essential clinical instrument. Knowing a patient-s cultural framework changes how prognosis is communicated, how family is involved, and which options are presented. A Chinese patient who refuses to sign advance directives is not uninformed. They are following a relational logic different from the Western model. A Muslim patient who declines sedative palliative care is not being irrational. They are protecting a theological principle that is foundational to their identity.

End-of-life care is never purely medical. It is always also cultural. The first step toward improving it is recognizing that difference without judging it.

For further reading on the science of aging and cultural factors in longevity, see the aging theories article and the research on spirituality and healthy aging published on this site.

References

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2. Guzowski A, Filon J, Krajewska-Kulak E. Strength of religious faith and attitude towards euthanasia among medical professionals. J Relig Health. 2024;63:1075–1090. doi:10.1007/s10943-023-01860-1

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