Philip Rule KC provides an analysis of the most recent decision in this field.

On 13 June 2024 the Chamber decision of the European Court of Human Rights in Daniel Karsai v Hungary (app. 32312/23) was delivered. The Strasbourg Court has, in particular, rejected a claim that there is a right under Article 8 of the Convention (right to respect for private and family life) to a physician-assisted death for a man who suffers a terminal illness. An Article 14 (prohibition on discrimination) challenge also failed.

This case is really a follow up to an earlier decision in a case brought against the UK itself in Pretty v UK (2002) 35 E.H.R.R. 1. In that case there was an unsuccessful challenge to the compatibility of the prohibition on encouraging or assisting suicide in section 2 of the Suicide Act 1961 with Articles 2 (the right to life), 3 (prohibition on inhuman or degrading treatment), 8, 9 (freedom of thought, conscience and religion) and 14. The more recent decision will likewise be of interest to those with a concern over the availability of assisted dying in Europe.

Mr Karsai suffers advanced amyotrophic lateral sclerosis (ALS), a type of motor neurone disease with no known cure. It consists in the gradual loss of motor neurone function, and of the voluntary control of muscles. Patients generally maintain their intellectual functions and consciousness throughout the progression of the disease. Speech and unaided breathing and swallowing become very difficult and ultimately impossible. Typically, death due to respiratory paralysis occurs within three to five years.

Mr Karsai would like to be allowed to have help in ending his life before his suffering becomes too much to bear. He would like that to happen in Hungary or, if that is not possible, abroad. However, it is a criminal offence in Hungary to help somebody to end his or her own life, and anyone assisting him at home or abroad (even if he died in a country which allowed physician-assisted dying) could face criminal prosecution by the Hungarian authorities.

It was not disputed that he has full mental capacity and has formed a genuine wish to have access to assisted dying if his suffering becomes unbearable [147]. He brought his complaint that he is not able to end his life with the help of others and of discrimination compared to terminally ill patients on life-sustaining treatment who are able to ask for their treatment to be withdrawn. He argued this was a violation of Article 8 alone and/or Article 8 in conjunction with Article 14 which prohibits discrimination in the enjoyment of his private life.

The Strasbourg Court refused to dismiss the complaint on the basis, as Hungary contended, that the impugned criminal law provisions applied to those who would seek to assist him in suicide, rather than to him directly [86].

Furthermore, the Court accepted that the fact that anyone in Hungary who would assist the applicant in committing suicide could be prosecuted was effectively equivalent to denying him the possibility to end his life on his own terms, at home or abroad, thereby interfering with his right to respect for his private life.

Furthermore, in view of the fact that physician-assisted death would necessarily involve a positive provision of access to medical intervention, such as access to life-ending drugs, his complaint engaged both the negative obligations (not to interfere with private life unjustifiably) and positive obligations (to take all reasonable steps to ensure respect for private life) upon states under Article 8, which were intertwined [136].

However by six votes to one the Court has ultimately dismissed the complaints. The criminal ban on assisted suicide complied with the requirement of lawfulness and pursued the legitimate aims of, amongst other things, protecting the lives of vulnerable individuals at risk of abuse, maintaining the medical profession’s ethical integrity and protecting the morals of society with regard to the meaning and value of human life.

Accordingly, Mr Karsai, suffering from an incurable progressive neurodegenerative terminal disease, failed to establish that the blanket prohibition in the law on his being assisted in dying in his homeland or even extraterritorially was unlawful.

The essential reasoning as to why that blanket ban in Hungary on physician-assisted death is lawful was expressed to be:

i.  There were potentially broad social implications and risks of error and abuse involved in the provision of physician-assisted dying [152]. There were questions over the challenges to put in place resources for ensuring any decision was free from external influence and not underpinned by concerns that could be met in other ways, or susceptible to changes of views over time.

ii.  Despite a growing trend towards its legalisation, the majority of the member States of the Council of Europe continue to prohibit both medically assisted suicide and euthanasia. The subject continued to be one that raised extremely sensitive moral and ethical questions and was one on which opinions in democratic countries often profoundly differed. Each State therefore has a wide discretion [141]-[144].

iii.  The Hungarian authorities had not failed to strike a fair balance between the competing interests at stake and had not overstepped that discretion. For example, whilst the suffering may be a genuine and severe anguish there was high-quality palliative care, including access to effective pain management, available to ensure a dignified end of life in Hungary [154]. The use of palliative sedation was generally able to provide relief to patients in the applicant’s situation and allow them to die peacefully. It was open to Mr Karsai to decline life-sustaining assistance with his breathing or request withdrawal of treatment, when the time came.

iv.  The refusal or withdrawal of treatment in end-of-life situations was intrinsically linked to the right to free and informed consent, rather than to a right to be helped to die, and was widely recognised and endorsed by the medical profession, and refusal or withdrawal of life-support was allowed by the majority of the member States. The Court therefore considered that the alleged difference in treatment of the two categories was objectively and reasonably justified.

One particular feature of the Court’s decision is the specific argument considered about not allowing another person’s assistance to Mr Karsai so he could go abroad to where it is legal to have a physician-assisted death [93]. Mr Karsai was concerned that anyone assisting him could be prosecuted – anyone in Hungary who would assist him in committing suicide, including by helping him to travel or make arrangements for physician-assisted death to be carried out abroad (for example at Dignitas in Switzerland), could be prosecuted [135]. The Court considered the complaint that the prohibition prevented him from seeking assisted death abroad to concern an essentially negative obligation, that is, the obligation to refrain from interfering with his Article 8 rights [159]. In that connection the Court noted that physician-assisted death continued to be punishable under criminal law in the majority of the Council of Europe’s member States. It found that the criminal prohibition on assisted suicide was intended to deter life‑endangering acts and to protect interests arising from considerations of a moral and ethical nature [160]. As the comparative-law research covering forty‑two Council of Europe member States confirmed, there was nothing unusual or excessive in the fact that the State’s prohibition applied also when the act of suicide was ultimately carried out abroad, especially if the victim of the crime and/or the perpetrator were both nationals of that State [160]. Ensuring that his wish to use a service abroad was not penalised in Hungary would in effect require it to create an exception in the operation of its criminal law. That would be contrary to the coherency of the domestic criminal-law system and the collective moral and ethical considerations underpinning the prohibition of assistance in suicide [161]. Those considerations provided reasonable grounds for the Hungarian authorities’ reluctance to introduce the type of exception sought. The ban on assisting the death abroad was found not to be disproportionate.


Proponents of the right to an assisted dignified death in cases of intolerable suffering may not find in the Court’s recent judgment any tangible advancement of the law in the two decades since Pretty v UK.  Absent any reversal by the Grand Chamber, the matter once again seems to rest in the legislative sphere of each member state. It is perhaps both the continued divergence between the approach different states take, and the need for any permitted system to be resourced and designed to ensure the respect for life that requires safeguards against abuse or pressure placed upon a vulnerable group of persons, that stands behind the court’s reluctance to find criminalisation to be disproportionate per se.

Fortunately for those in England and Wales there is at least a public interest decision that rests with the Director of Public Prosecutions, to be exercised according to the considerations in particular set out in the Suicide: Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide (published in February 2010, and last updated in October 2014) (available at That means there is at least individual consideration required, rather than a requirement anyone assisting a loved one must be prosecuted in any and every circumstance.

There is a possibility that one Crown Dependency jurisdiction may become the first jurisdiction around the British Isles to change the law to allow physician-assisted death: see the Second Report of the 2023-2024 session of the House of Commons’ Health and Social Care Committee on Assisted Dying/Assisted Suicide (published 29 February 2024). If that does occur it may prompt further governmental recognition of the need to revisit this issue.

The government’s response on 29 April 2024 was that “The long-held position of successive UK governments is that any change to the law of England and Wales in this area is a matter for Parliament and an issue of conscience for individual parliamentarians rather than one for government policy. It would be for the UK Parliament to develop a specific proposal on AD/AS reform, not the Government, because this is a matter of conscience”. It remains to be seen if, after the forthcoming elections, there is any change to this position or any new legislative consideration by Parliament.

Scotland notably has no direct equivalent to the Suicide Act 1961 (and Northern Ireland law) rendering assisting or encouraging suicide an offence in the rest of the UK.

At the time of the CPS guidance being brought in the then DPP, later the Rt Hon Sir Keir Starmer MP, wrote in the national press that he was “unlikely to prosecute those motivated by compassion who help a relative or close friend” with a “clear, settled and informed” wish to die.  At the time that the guidelines were issued, the BBC reported that Lord Carlile QC, the then chairman of the campaign group Care Not Killing which opposed assisted death, had stated that the revised guidelines “greatly reduce the risk of undermining existing law.” ( What is clear is that no certainty presently exists for families or those who seek their own physician-assisted death. Perhaps it will resurface in the legislative agenda for debate, but of course any delay to any change in the law may be regarded as too long by those who suffer terminal degenerative disease and seek greater certainty so as to pursue their intention.

The judgment is available at{%22itemid%22:[%22001-234151%22]}

The Parliamentary materials mentioned above are available at


Philip Rule KC of No5 Chambers is a specialist in human rights issues and provides expert legal advice and representation in cases before the UK courts and internationally, including proceedings before the European Court of Human Rights.