JUDGMENT NO. 204
YEAR 2025
ITALIAN REPUBLIC
IN THE NAME OF THE ITALIAN PEOPLE
THE CONSTITUTIONAL COURT
composed of:
President: Giovanni AMOROSO;
Judges: Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI, Massimo LUCIANI, Maria Alessandra SANDULLI, Roberto Nicola CASSINELLI, Francesco Saverio MARINI,
has delivered the following
JUDGMENT
in the constitutional legitimacy review proceedings of the Law of the Tuscany Region of March 14, 2025, n. 16 (Organizational Modalities for the Implementation of Constitutional Court Judgments 242/2019 and 135/2024), initiated by the President of the Council of Ministers with an appeal served on May 14, 2025, filed with the Registry on the subsequent May 16, registered under no. 20 of the appeals registry 2025 and published in the Official Gazette of the Republic no. 22, first special series, of the year 2025.
Having seen the deed of constitution of the Tuscany Region;
Having heard, in the public hearing of November 4, 2025, the Reporting Judges Francesco VIGANÒ and Luca ANTONINI;
Having heard the State Lawyers Giancarlo Caselli and Gianna Galluzzo for the President of the Council of Ministers and the Lawyer Fabio Ciari for the Tuscany Region;
Deliberated in the council chamber on November 4, 2025.
Facts Considered
1.– By an appeal served on May 14, 2025, filed with the Registry on the subsequent May 16, and registered under no. 20 of the appeals registry 2025, the President of the Council of Ministers, represented and defended by the State Attorney General’s Office, challenged the entirety of the Tuscany Region Law of March 14, 2025, n. 16 (Organizational Modalities for the Implementation of Constitutional Court Judgments 242/2019 and 135/2024), as well as its articles 1 to 6, and art. 7, paragraph 2, in reference, overall, to art. 117, second paragraph, letters l) and m), and third paragraph, of the Constitution.
The appeal summarizes the contents of the provisions of the challenged regional law, whose art. 1 states the purpose of regulating – in the exercise of the regional competences «in matters of health protection», as declared in point 6 of the preamble – «the organizational modalities for the implementation of the provisions of Constitutional Court Judgments of September 25, 2019, no. 242 and of July 1, 2024, no. 135, concerning medically assisted suicide». Pursuant to the subsequent art. 2, «[u]ntil the entry into force of the State legislation,» persons possessing the requirements indicated by the aforementioned judgments may access the procedures relating to the latter, with the modalities provided for by articles 1 and 2 of Law no. 219 of December 22, 2017 (Provisions on informed consent and advance health directives).
Art. 3, paragraph 1, establishes that the local health units «shall establish a permanent multidisciplinary Commission [...] for verifying the existence of the requirements for access to medically assisted suicide as well as for verifying or defining the related implementation modalities», while, in the subsequent paragraphs, it regulates the professional composition of the commission, providing that regional health service personnel, identified on a voluntary basis, shall be part thereof, and that the activity performed therein shall be considered institutional, not entailing the payment of any fee for office or attendance.
Pursuant to paragraph 1 of art. 4 (Modalities of access to medically assisted suicide), «[t]he interested person, or their delegate, shall submit an application to the local health unit competent for the territory for the verification of the requirements for access to medically assisted suicide as well as for the approval or definition of the related implementation modalities». The subsequent paragraph 2 requires that the application be accompanied by the available health documentation, as well as, if applicable, «the indication of a trusted physician and the protocol» containing the modalities for implementing medically assisted suicide; the application and related documentation are promptly forwarded, under paragraph 3 of the same provision, to the aforementioned commission and to the Ethics Committee operating within the unit pursuant to art. 99 of the Tuscany Region Law of February 24, 2005, n. 40 (Regulation of the Regional Health Service).
Art. 5, concerning the «[v]erification of requirements», provides that:
«1. The procedure for verifying the requirements referred to in Article 2, paragraph 1, shall conclude within twenty days of receipt of the application by means of the communication referred to in paragraph 6. The deadline may be suspended once only, for a period not exceeding five days, for clinical-diagnostic assessments.
2. The Commission shall preliminarily verify that the applicant has received clear and adequate information on the possibility of accessing palliative care. The applicant shall also be informed of their right to refuse or revoke consent to any medical treatment, including life-sustaining treatment, and of the possibility of resorting to continuous palliative deep sedation pursuant to Law no. 219/2017.
3. If the applicant confirms the will to access medically assisted suicide, the Commission shall proceed to verify the requirements. To this end, the Commission shall examine the produced documentation and carry out the necessary assessments, including with the support of the regional health service structures, ensuring personal and direct interaction with the interested person, after hearing the trusted physician, if indicated by the person. Consent to medically assisted suicide must be expressed freely and knowingly pursuant to Article 1, paragraph 4, of Law no. 219/2017.
4. The Commission shall request the opinion of the Committee on the ethical aspects of the case under examination, transmitting to it the documentation concerning the interaction and the assessments carried out. The Committee shall express its opinion within seven days of receipt of the documentation.
5. The Commission shall be required to request the Committee’s opinion in sufficient time for the deadline referred to in paragraph 4 to be compatible with compliance with the overall deadline provided for the conclusion of the verification procedure referred to in paragraph 1.
6. The Commission shall draw up the final report certifying the results of the requirements verification. The local health unit shall communicate the verification results to the interested person».
Art. 6, which according to the appellant concerns «the introduction of an atypical health obligation», provides as follows:
«1. In the event of a positive outcome of the requirements verification, the Commission shall proceed, pursuant to paragraphs 2 and 3, for the purpose of approving or defining the modalities for implementing medically assisted suicide. The procedure shall conclude within ten days of the communication referred to in Article 5, paragraph 6, with the communication of the results provided for in paragraph 7.
2. The interested person may request the Commission to approve a protocol drawn up by the trusted physician and containing the modalities for implementing medically assisted suicide.
3. The interested person may also request the Commission to define, in agreement with the person, the modalities for implementing medically assisted suicide by drawing up a specific protocol. In the absence of an agreement, the request shall not proceed.
4. The implementation modalities must provide for the assistance of a physician and must be such as to avoid abuse to the detriment of vulnerable persons, to guarantee the dignity of the patient, and to avoid suffering to the patient.
5. The Commission shall request the opinion of the Committee on the adequacy of the protocol referred to in paragraphs 2 and 3. The Committee shall express its opinion within five days of receipt of the documentation transmitted by the Commission.
6. The Commission shall be required to request the Committee’s opinion in sufficient time for the deadline referred to in paragraph 5 to be compatible with compliance with the overall deadline provided for the conclusion of the procedure referred to in paragraph 1.
7. The Commission shall draw up the final report relating to the results of the request referred to in paragraphs 2 and 3. The local health unit shall communicate the results of the procedure to the applicant».
Art. 7 is dedicated to supporting the implementation of the medically assisted suicide procedure, according to which:
«1. Within seven days of the communication referred to in Article 6, paragraph 7, the local health unit shall ensure, in the forms provided for by the protocol approved by the Commission or defined by the latter in agreement with the interested person, the technical and pharmaceutical support as well as the health assistance for the preparation for self-administration of the authorized drug. The assistance shall be provided by health personnel on a voluntary basis and shall be considered as institutional activity to be carried out during working hours.
2. The services and treatments regulated by this law constitute a level of health assistance superior to the essential levels of assistance. The Region shall cover with its own resources the financial effects connected to these services and treatments, in accordance with the provisions of Article 13 of Legislative Decree no. 502 of December 30, 1992 (Reorganization of the discipline on health matters, pursuant to Article 1 of Law no. 421 of October 23, 1992).
3. The person in possession of the requirements authorized to access medically assisted suicide may decide at any time to suspend or cancel the provision of the treatment.
4. In any case, the local health units shall bring the procedures regulated by this law into conformity with the State legislation».
Finally, art. 8 establishes the free provision of services and treatments «performed by the regional health service within the scope of the therapeutic-assistance path of medically assisted suicide», while art. 9 provides for the estimation and coverage of financial burdens for the implementation of the regional law.
1.1.– The first ground of appeal asserts that the entire Tuscany Regional Law no. 16 of 2025 and its art. 1, by «claiming to give "implementation” to Constitutional Court Judgments no. 242/2019 and 135/2024», violate, firstly and absorbingly, art. 117, second paragraph, letter l), of the Constitution, relating to the matter of «civil and criminal law», and, alternatively, art. 117, third paragraph, of the Constitution, with reference to the matter of «health protection».
In the appellant's view, the regulation of medically assisted suicide falls under the matter referred to in the aforementioned second paragraph, letter l), of art. 117 of the Constitution, reserved to the exclusive legislative competence of the State, as it affects «personal rights, including that of life, a prerequisite for all rights, and physical integrity» of the individual. Since it is «a legal institution that, on the one hand, innovates civil law and, on the other hand, finds direct application within the scope of criminal law», it should be the State law that dictates the regulation, leaving the intervention of the regional legislator prohibited in areas of extreme delicacy «such as criminal liability (Articles 579 and 580 of the Criminal Code), the duty to protect human life, the principles of self-determination, protection of consent and refusal of medical treatments, inferable from Articles 2, 13 and 32 of the Constitution and art. 5 of the Civil Code».
In other words, «[a]ll the arguments affected and the principles underlying the issue in question» should be traced back to the aforesaid exclusive legislative competence of the State, also to ensure the need for uniformity of regulation throughout the national territory.
Moreover, by citing this Court’s Judgment no. 50 of 2022 – regarding the inadmissibility of the request for a abrogative referendum on art. 579 of the Criminal Code – the State Attorney General’s Office excludes that the norms protecting life have a constitutionally binding content, thus leaving the determination of the minimum level of protection required by the constitutional references to which they are linked necessarily to the legislator’s evaluation.
To confirm the impact of the challenged provisions on the criminal system, the State Attorney General’s Office observes that the purpose of the regional intervention stated in art. 1 of Tuscany Regional Law no. 16 of 2025, which is to regulate the organizational modalities for the implementation of this Court’s Judgments no. 242 of 2019 and no. 135 of 2024, results, in practice, in «providing and setting up the operational tools» for the application of the ground for non-punishability introduced by the cited judgments, whose limited operation in one part of the national territory would also determine an intolerable disparity of treatment in the criminal system.
1.1.1.– According to the Attorney General’s Office, pending the decisions taken by the State legislator, the regions cannot be assigned «a "substitute” role», given the principles expressed by this Court’s Judgment no. 262 of 2016, which, by declaring the constitutional illegitimacy of two regional laws setting out provisions on advance health directives (AHDs), deemed uniformity of regulation throughout the national territory necessary in this area.
This is because the absence of specific State legislation «in no way justifies the interference of regional legislation in a matter entrusted exclusively to the competence of the State».
This Court’s Judgment no. 5 of 2018 is also relevant in a similar vein, which, in the matter of vaccination obligations, emphasized that the right of the person to be effectively treated and to have their physical and psychological integrity respected must be guaranteed «in conditions of equality throughout the country, through general State legislation».
In the appellant’s view, furthermore, the regulation of cases in which the legal system decriminalizes assistance in suicide cannot pertain to the matter of «health protection», referred to in art. 117, third paragraph, of the Constitution, cited in the preamble to Tuscany Regional Law no. 16 of 2025, since, on the one hand, the serious impairment of health, considered by constitutional jurisprudence, would only be a «concrete antecedent fact that decriminalizes [...] behaviors otherwise criminally sanctioned»; on the other hand, the medical verification of the prerequisites for accessing medically assisted suicide would only be the «assessment method» thereof.
In any case, even if it were held, hypothetically, that some aspects relating to the exemption fall within the said matter, regional intervention would be precluded if it disregarded the prior determination of fundamental principles, which art. 117, third paragraph, of the Constitution reserves «to State legislation»; this is both because such principles would follow from the structure given to the institution in the civil and criminal legal system, and because, otherwise, the institution itself would be inadmissibly recognized in a divergent manner across the national territory (reference is made to this Court’s Judgment no. 438 of 2008).
Moreover, the Attorney General’s Office continues, the wish expressed by this Court for a «prompt and complete regulation by the legislator» in the matter of end-of-life care could only refer to the State legislator. Consequently, the introduction of «any regional regulation on assisted suicide procedures», before at least the fundamental principles of this delicate sector are outlined, «would affect the regulatory prerogatives of the State», potentially «compromising the complex balance between the principles of law reconstructed by constitutional jurisprudence».
1.1.2.– Symptomatic of the violation of the exclusive State legislative competence in the matter of «civil law» would be, in the opinion of the Attorney General’s Office, the provision in art. 4, paragraph 1, of the challenged regional law, which delegates the activation of the procedure to an «"unspecified delegate” in terms of its legitimacy characteristics», despite this being «certainly a [...] deeply personal act», and does not regulate the content and form of the application to be submitted, leaving the relationship with the much more precise forms dictated by Law no. 219 of 2017 on consent to medical treatment, whose application is expressly indicated by constitutional jurisprudence, uncertain.
Furthermore, the fact that the right of the interested party to «suspend or cancel the provision of treatment», specified by art. 7, paragraph 3, of Tuscany Regional Law no. 16 of 2025, has not been regulated in content and form, and that it has not been provided, before its execution, that «it must be positively ascertained that the interested party does not intend to suspend or cancel it», would be «doubtful».
1.2.– The second ground of appeal denounces the violation, by the entirety of Tuscany Regional Law no. 16 of 2025 and its articles 2 and 7, paragraph 2, of art. 117, second paragraph, letter m), and third paragraph, of the Constitution, with reference, respectively, to the exclusive State legislative competence in determining the essential levels of services concerning civil and social rights and the concurrent competence in the matter of health protection.
The invoked exclusive competence, the appeal maintains, cannot be «eluded» by the qualification, made by the cited art. 7, paragraph 2, of the services regulated by the regional law as a level of assistance superior to the essential levels, given that the legal institutions involved, affecting «the foremost civil right» guaranteed by the Constitution, namely the right to life, can only find regulation in a State law.
Furthermore, constitutional jurisprudence itself, besides not having affirmed «the existence of a "right” to suicide, as a service guaranteed by legislation», rather establishing the cases in which assistance in suicide must be deemed decriminalized, has considered legislative intervention in this delicate matter on several occasions, but «addressing it only and solely to the national legislator». It would therefore be precluded to the regions to «modify, limit or condition the essential levels of services concerning the right to life [...] and, specifically, to regulate cases and procedures in which the right to life is disposed of».
1.2.1.– In any case, even if medically assisted suicide were qualified «as a "service” concerning civil rights», it should be held that, in the absence of a minimum level of service established by the State legislator, on the one hand, the «prerequisite for issuing superior regional legislation» would be lacking and, on the other hand, such intervention would conflict «with the indispensable homogeneity at the national level of end-of-life regulation».
Nor could the aforementioned minimum level be derived from this Court’s Judgments no. 242 of 2019 and no. 135 of 2024, which actually concern «[a] precise and limited scope of the legal system, different from establishing legislation on essential levels of services pertaining to civil and social rights».
In conclusion, it should be excluded that the structural and organizational interventions necessary for the health service to carry out the verification activities identified by the cited judgments can be carried out by regional law, because all the determinations made in this regard imply choices that are not organizational, but rather directly affect the right to life, and must therefore fall under the exclusive competence of the State legislator.
1.2.2.– The State Attorney General’s Office points out that, to admit regional regulation of the end-of-life, it would be irrelevant to invoke «the application of the principle of "inverted subsidiarity” [...] in the face of State legislative inertia», since, according to the jurisprudence of this Court, regulatory subsidiarity may be provided by the regions in matters within their legislative competence, without the provision of the clause allowing them to intervene on aspects pertaining to the exclusive competence of the State legislator (reference is made to this Court’s Judgment no. 1 of 2019).
Moreover, the State defense observes that a regional law is not necessary to make the precepts established by this Court's decisions immediately operational, as confirmed by the fact that, «in some cases already, these precepts have received application».
The arguments outlined would highlight the violation of art. 117, second paragraph, letter m), of the Constitution, not only by the entire regional law, but also, specifically, by art. 2, when, in the appellant’s view, it «establishes» the procedures to which persons possessing the indicated requirements may have access, and by art. 7, paragraph 2, where it specifies that the services and treatments regulated by the regional law constitute a level of health assistance superior to the essential levels of assistance (ELAs).
1.3.– Alternatively to the previous two grounds, the appeal specifically challenges articles 3, 4, 5, and 6 of Tuscany Regional Law no. 16 of 2025 for violation of art. 117, second paragraph, letters l) and m), of the Constitution, in relation to art. 1, paragraphs 556, 557, and 558, of Law no. 208 of December 28, 2015, concerning «Provisions for the formation of the annual and multi-year State budget (2016 Stability Law)», and to art. 2, paragraph 7, of Law no. 3 of January 11, 2018 (Delegation to the Government in matters of clinical trials of medicinal products as well as provisions for the reorganization of health professions and the health management of the Ministry of Health).
The aforementioned regional provisions would establish the «permanent multidisciplinary commissions» within the Tuscan local health units (LHUs) and regulate their tasks and functions in such a way that they would «overlap with the competences [...] reserved by State law to the various "local ethics committees”», regulated, most recently, by the Decrees of the Minister of Health of January 26, 2023 (Identification of forty local ethics committees) and January 30, 2023 (Definition of criteria for the composition and operation of local ethics committees), in implementation of art. 2 of Law no. 3 of 2018, and, previously, by the Decree of the Minister of Health of February 8, 2013, in implementation of art. 12, paragraph 10, of Decree-Law no. 158 of September 13, 2012 (Urgent provisions to promote the development of the Country through a higher level of health protection), converted, with modifications, into Law no. 189 of November 8, 2012.
Constitutional Court Judgment no. 242 of 2019 referred to these committees, the appeal maintains, «as the sole competent bodies» to issue opinions on the conditions of patients suffering from an irreversible pathology, source of physical or psychological suffering.
The commission established by art. 3 of Tuscany Regional Law no. 16 of 2025, as a body exclusively of regional origin, cannot be classified among the ethics committees identified by the State legislation currently in force, so it must be excluded that the assessment requested by this Court for the purpose of decriminalization from criminal liability can be entrusted «to bodies created from time to time, with autonomous rules, by each region».
1.3.1.– The provisions under review would thus be in conflict, «considered per se», with the exclusive State legislative competence in the matter of «civil and criminal law» under art. 117, second paragraph, letter l), of the Constitution, as well as with art. 117, second paragraph, letter m), of the Constitution, in relation to both art. 1, paragraphs 556, 557, and 558, of Law no. 208 of 2015 – which regulates the modalities necessarily shared between the State and the regions for defining and updating health assistance levels – and to art. 2, paragraph 7, of Law no. 3 of 2018, which delegates the identification of local ethics committees to a specific Decree of the Minister of Health.
In this case, the establishment of the exclusively regional commission would «override» the requirement that the determination of any further levels of health assistance and the modalities by which they may or must be implemented be carried out not autonomously by individual regions, «but with the necessary involvement of the State, also in order to ensure uniformity of treatment at the national level».
Similar considerations – and related challenges of constitutional illegitimacy – would apply with reference to the «ethics committees in clinical practice», already operating within the Tuscan LHUs under art. 99 of Tuscany Regional Law no. 40 of 2005, to which the challenged provisions assign advisory tasks «on the ethical aspects of the case» in the requirements verification phase (art. 5, paragraph 4), as well as on the adequacy of the implementation protocol (art. 6, paragraph 5), so that the role of these committees too «would illegitimately overlap with that of the "local ethics committees”» referred to in Judgment no. 242 of 2019.
2.– With a document filed on June 17, 2025, the Tuscany Region constituted itself in the proceedings, requesting that the constitutional legitimacy challenges raised by the Government be declared unfounded.
2.1.– As for the first ground of appeal, the exclusive State legislative competence in the matter of civil and criminal law would not be violated because, at the time of the regional legislative intervention, this Court, with Judgments no. 242 of 2019 and no. 135 of 2024, had fully established both the conditions that legitimize access to medically assisted suicide and the principles «underlying the procedure for verifying these conditions and choosing the implementation modalities».
These pronouncements, together with the subsequent Judgment of this Court no. 66 of 2025, should therefore be recognized as having «an additive and innovative scope for the legal system, as well as self-applicable and binding force for the principle and the related substantial and procedural conditions subject to the addition».
From this perspective, the challenged regional law differs from those, in the matter of AHDs, declared constitutionally illegitimate by Judgment no. 262 of 2016. Those laws directly and substantially regulated aspects relating to the conditions legitimizing the advance declaration of medical treatment. In the present case, however, the Tuscan legislator would have started from this Court’s judgments and legitimately implemented them, assuming certain services for the Regional Health Service and regulating their organizational aspects.
As for Judgment no. 50 of 2022, concerning the admissibility of the abrogative referendum of art. 579 of the Criminal Code, it actually underlines the profound differences between the factual situation examined therein and the other one subject to Judgment no. 242 of 2019.
Judgment no. 5 of 2018, on vaccination obligations, is moreover irrelevant in any way, given that Tuscany Regional Law no. 16 of 2025 limits itself to implementing, strictly organizationally for the regional health units, the conditions for medically assisted suicide, provided by this Court, «uniform and valid for the entire national territory».
2.1.1.– The Tuscany Region also deems the challenges raised against art. 4, paragraph 1, and art. 7, paragraph 3, of the challenged regional law to be unfounded, in order to demonstrate the alleged intrusion into the exclusive legislative competence of the State in the matter of «civil law».
The first of these provisions does not regulate the activation of the procedure «in deviation from the dictates» of this Court, limiting itself to allowing the actual submission of the application also by a delegate, while remaining true that the manifestation of the will to access medically assisted suicide must result as «necessarily and expressly referable to the patient». Furthermore, the challenge alleging that the regional law provided for a generic application, not regulated in content and form, is unfounded, as it is evident from the «organic reading» of Tuscany Regional Law no. 16 of 2025 that the regional legislator has referred, in this regard, to this Court’s judgments and Law no. 219 of 2017.
Similar considerations would also apply to art. 7, paragraph 3, which, in conformity with this Court’s rulings, ensures the interested person the possibility of modifying their will: which, moreover, in the case of assistance in suicide, is inherent in the fact that they retain control over the final act that triggers the lethal process.
2.1.2.– Tuscany Regional Law no. 16 of 2025 has thus limited itself to providing for detailed rules falling within the concurrent competence of health protection, referred to in art. 117, third paragraph, of the Constitution, of which health organization is «an integral part» (reference is made to this Court’s Judgment no. 202 of 2024).
Specifically, the contents of the regional law under review have in no way interfered with the exclusive competences invoked by the State defense, being solely aimed, instead, at ensuring certain timeframes and organizational uniformity in the Tuscan regional territory regarding medically assisted suicide, in full compliance with the regulation dictated by Law no. 219 of 2017 on informed consent.
Furthermore, according to the Region, on the one hand, the so-called inverted subsidiarity, wrongly cited by the State defense, is not relevant in this case, since Tuscany Regional Law no. 16 of 2025 duly implemented the «minimum constitutional principles» established by this Court in the matter under review, from an organizational point of view. On the other hand, however, this Court’s jurisprudence on so-called inverted subsidiarity is nevertheless invoked by the Region, to justify precisely the term «subsidiarity» used in point 8 of the preamble to the challenged regional law, in order to argue that, in regulations where State and regional competences intersect (such as the present one), «Regions can intervene and provisionally regulate the matter, in the event of State inaction, until the adoption of the prescribed State acts».
2.2.– The regional defense deems the second ground of appeal, which laments the violation of art. 117, second paragraph, letter m), and third paragraph, of the Constitution by the entirety of Tuscany Regional Law no. 16 of 2025 and its articles 2 and 7, paragraph 2, also unfounded.
Indeed, the regional law does not determine any level of service, limiting itself to intervening on organizational and management aspects of a regulation that entered the legal system following this Court’s judgments, and in any case, regions, within the scope of their competences, may guarantee levels further than the essential levels of assistance, so-called extra-ELAs (references are made to Judgments no. 297 of 2012, no. 207 of 2010, and no. 248 of 2006); in this case, the Tuscan regional legislator has made the «health service provision» as defined in Judgment no. 242 of 2019 homogeneously implementable in reference to its LHUs.
Furthermore, with regard to heterologous medically assisted procreation, in the period between its recognition following this Court’s Judgment no. 162 of 2014 and its inclusion in the ELAs, administrative jurisprudence affirmed that regions not subject to a recovery plan may recognize additional health services beyond the ELAs in order to facilitate access to this practice (reference is made to the Council of State, Third Section, Judgment of July 20, 2016, no. 3297). More recently, constitutional jurisprudence, in examining provisions of a regional law concerning health services, has not stopped at the «mere "formalistic” criterion» for defining ELAs, adopting a substantial definition thereof, also considering the failure of the State to update the relevant list (reference is made to Judgment no. 201 of 2024).
Moreover, since the Tuscany Region is not subject to a health recovery plan, the reference to extra-ELAs, made by art. 7, paragraph 2, of the challenged regional law would be legitimate and should be understood as limited to the assumption, by the regional, non-health budget, of the economic burden arising from the services and treatments provided by the regional LHUs, as would emerge from subsequent articles 8 and 9.
2.3.– The third ground of appeal would also be unfounded, as it is based on a «misinterpretation of the regional legislation», which does not reveal any undue overlap between the role of the multidisciplinary commission referred to in art. 3 of the challenged regional law and that of the ethics committees referred to in Judgment no. 242 of 2019, currently regulated by the aforementioned Decrees of the Minister of Health of January 26 and 30, 2023.
The regional legislator, by providing for the establishment of the multidisciplinary commission, would in fact have limited itself to providing a specific organizational module, within the health units, for carrying out the operational role entrusted by this Court to the public structures of the national health service in verifying the requirements and implementation modalities of medically assisted suicide: a role distinct from the advisory role instead entrusted to the ethics committees.
Likewise unfounded would be the further challenge, concerning the lack of identity between the local ethics committees referred to by this Court and the ethics committees in clinical practice to which the Tuscan law refers.
In essence, the current State legislation referred to in the ministerial decrees, resulting from the agreement reached in the Permanent Conference for Relations between the State, the Regions, and the Autonomous Provinces of Trento and Bolzano, allows the regions to maintain the advisory function with reference to medically assisted suicide in the hands of the ethics committees to which it was attributed at the territorial level and, therefore, in this case, to the ethics committees in clinical practice, already established pursuant to art. 99 of Tuscany Regional Law no. 40 of 2005.
3.– Eight amicus curiae briefs were filed, pursuant to art. 6 of the Supplementary Rules for proceedings before the Constitutional Court, admitted by presidential decree of September 24, 2025.
In particular, the Luca Coscioni Association for the Freedom of Scientific Research APS, the Liberididecidere association, the Leo Foundation ASSL, the Italian Matrimonial Lawyers Association for the Protection of Persons, Minors, and the Family - AMI, and the Consulta di bioetica ONLUS filed opinions with arguments supporting the non-foundedness of the raised constitutional legitimacy issues.
Conversely, the Family Day Association - Let's Defend Our Children APS, the Committee for a Subsidiary and Shared Public Agenda "Say it on the Rooftops (Mt 10.27)" - PASC, the Vera lex? Parliamentary Activity Observatory, the Siena Bioethics Observatory - ETS, the Nonni 2.0. association, the "Rosario Livatino" Study Center, the "Science & Life" Study Center, and the Italian Catholic Jurists Union (UGCI) filed opinions to the contrary.
3.1.– More specifically, the former generally consider that Tuscany Regional Law no. 16 of 2025 acted within the framework of the rules for the medicalized procedure dictated by Judgment no. 242 of 2019, making this procedure more precise with detailed rules on health protection; as for the provision to charge the Regional Health Service with the services introduced, they emphasize that regions not subject to the deficit recovery plan could arrange for expenses beyond the ELAs.
They also note that the Tuscan law duly organized a system that avoids recourse to the courts by the patient to obtain the provision of the medically assisted suicide service within reasonable and compatible time limits.
Finally, they assert that, in the absence of intervention by the State legislator, there is room for «operational» regulation at the regional level, which in this case would have restored legal certainty to the health authorities regarding the specific perimeter within which they are authorized to operate.
3.2.– The opposing opinions, overall, exclude that the regional legislator can intervene in the end-of-life field, since this regulation pertains to the exercise of private autonomy and disposal of one's own body, falling within the sphere of exclusive State legislative competence. In particular, this Court’s Judgment no. 262 of 2016 is valued, where it refers to «imperative reasons of equality» and clarifies that the lack of national legislation «in no way justifies the interference of regional legislation» in matters of exclusive State legislative competence.
It is also noted, on the one hand, that Tuscany Regional Law no. 16 of 2025 is based on the erroneous assumption that this Court has affirmed a true right to the provision of medically assisted suicide services and treatments; on the other hand, that these procedures cannot be traced back to the matter of health protection, since this would imply the possibility of deducing the fundamental principles of this matter from a judgment of this Court pertaining, in reality, to criminal law.
4.– In proximity to the public hearing, the Tuscany Region filed a supplementary memorandum, reiterating that the challenged regional law limits itself to duly implementing, from the organizational aspect of its territory's health authorities, the dictates of this Court’s judgments, which have defined both the conditions that legitimize access to assisted suicide and «the fundamental principles underlying the verification procedure of these conditions and the choice of implementation modalities».
The memorandum then signals the recent Judgment no. 132 of 2025, in which this Court, by valuing the role of the National Health Service, would have confirmed the traceability of the end-of-life issue also to the matter of health protection.
This would legitimize the intervention of the regional legislator, taking into account the principle of organizational pluralism that underlies the NHS; the Tuscany Region would have adhered to this criterion with the challenged regional law.
In Law Considered
1.– With the appeal indicated in the heading (appeal reg. no. 20 of 2025), the President of the Council of Ministers challenged the entirety of Tuscany Regional Law no. 16 of 2025, and more specifically a series of its provisions, assuming their overall conflict with art. 117, second paragraph, letters l) and m), of the Constitution, as well as the third paragraph thereof, the latter with reference to the matter of health protection.
The challenged regional law, whose contents are analytically illustrated in the Facts Considered, is entitled «Organizational Modalities for the Implementation of Constitutional Court Judgments 242/2019 and 135/2024». According to the appellant:
– firstly, the regional law as a whole, and specifically its art. 1, encroach upon the exclusive legislative competence of the State in the matter of civil and criminal law under art. 117, second paragraph, letter l), of the Constitution, and in any case – alternatively – the concurrent legislative competence of the State in the matter of health protection under art. 117, third paragraph, of the Constitution, since regions are precluded from intervening by law in this matter where State law has not determined the fundamental principles;
– secondly, the regional law as a whole, and specifically its articles 2 and 7, paragraph 2 – which respectively regulate procedures in matters of medically assisted suicide and establish that the services and treatments «constitute a level of health assistance superior to the essential levels of assistance» – encroach upon the exclusive legislative competence of the State in determining the essential levels of services under art. 117, second paragraph, letter m), of the Constitution, as well as the concurrent legislative competence of the State in health protection under art. 117, third paragraph, of the Constitution;
– finally, and alternatively, articles 3, 4, 5, and 6 of the regional law, in so far as they establish and regulate the permanent multidisciplinary Commission and provide for the advisory role of the Ethics Committee in clinical practice, encroach upon the exclusive legislative competence of the State in matters of civil law under art. 117, second paragraph, letter l), of the Constitution in relation to the interposed parameter represented by art. 2, paragraph 7, of Law no. 3 of 2018, which dictates the regulation of ethics committees; as well as the exclusive legislative competence of the State in determining the essential levels of services under art. 117, second paragraph, letter m), of the Constitution, in relation to the interposed parameter under art. 1, paragraphs 556, 557, and 558, of Law no. 208 of 2015; the latter provisions, which regulate «the modalities necessarily shared between the State and the Regions for defining and updating the essential levels of health assistance».
2.– On the merits, the first two grounds of appeal, by which the President of the Council of Ministers challenges the entire regional law, primarily asserting the invasion of the State’s exclusive legislative competence in the matters of «civil and criminal law» (first ground) and «determination of essential levels of services» (second ground), as well as, alternatively, the State’s concurrent legislative competence in health protection, since the Region intervened by law in an area where State law has not yet determined the fundamental principles of the matter (first ground), may first be examined together.
The examination of these grounds requires a general premise.
2.1.– The challenged regional law defines its purposes in art. 1, stating its intention to regulate «the organizational modalities for the implementation of the provisions of Constitutional Court Judgments no. 242 of 2019 and no. 135 of 2024», relating to medically assisted suicide.
This purpose is further clarified in the preamble, at points 6 and 7, where it is declared that the Region intends to lay down, «in the exercise of its competences in the matter of health protection, and in implementation of an immediately enforceable judgment, [...] organizational and procedural rules, to uniformly regulate on its territory the exercise of the functions that constitutional jurisprudence attributes to health authorities in the matter in question» (point 6), further observing that the introduction of regional legislation «serves to define the timeframes and modalities concerning the procedure indicated by the Constitutional Court and, therefore, to eliminate any residual uncertainty and issues regarding the provision of a health service divided into multiple phases, from the verification of conditions to the verification of the modalities for self-administration of the drug that can ensure a quick, painless, and dignified death» (point 7).
The express intention of the regional legislator is, therefore, to lay down rules of a merely organizational and procedural nature, in order to uniformly regulate the assistance provided by the regional health service to persons who – being in the conditions established by this Court in Judgment no. 242 of 2019, as further specified in Judgment no. 135 of 2024 – request assistance in dying. In this way, the regional law intends in fact to regulate the services that the regional public administration, and specifically the individual regional local health units, are required to provide on the basis of the principles enunciated by the jurisprudence of this Court.
By regulating the activity of the Tuscan local health units, the challenged regional law pertains, prima facie, to the matter of health protection, the object of concurrent legislative competence pursuant to art. 117, third paragraph, of the Constitution.
2.2.– Contrary to what is asserted in the State’s appeal, the exercise of this competence by the regional legislator cannot be considered precluded by the fact that the State has not yet provided, despite numerous invitations from this Court, for the approval of a law that comprehensively regulates, throughout the national territory, access to the medicalized procedure for assisted suicide.
In fact, according to the constant jurisprudence of this Court, «Regions, in order to exercise their concurrent legislative powers, must not wait for the possible determination of fundamental principles by the State» (Judgment no. 94 of 2003, point 4.1. of the Facts Considered; in the same sense, Judgments no. 120 of 2005, point 4 of the Facts Considered, no. 359 of 2003, point 3 of the Facts Considered, no. 196 of 2003, point 4 of the Facts Considered, as well as, more recently, Judgment no. 166 of 2021, point 3.2. of the Facts Considered), as the fundamental principles of the matter can be derived not only from State laws expressly aimed at this purpose, but also from the complex of existing State laws (Judgments no. 424 of 2005, point 2.3. of the Facts Considered, no. 319 of 2005, point 2.2. of the Facts Considered, no. 120 of 2005, point 4 of the Facts Considered, no. 359 of 2003, point 3 of the Facts Considered, no. 353 of 2003, point 2 of the Facts Considered, no. 201 of 2003, point 4 of the Facts Considered, no. 196 of 2003, point 4 of the Facts Considered, no. 94 of 2003, point 4.1. of the Facts Considered, no. 533 of 2002, point 8 of the Facts Considered, no. 282 of 2002, point 4 of the Facts Considered).
This principle was also confirmed, at the level of ordinary legislation, in art. 1, paragraph 3, of Law no. 131 of June 5, 2003 (Provisions for the adaptation of the Republic's legal system to Constitutional Law no. 3 of October 18, 2001), according to which «[i]n matters belonging to concurrent legislation, Regions exercise legislative power within the scope of fundamental principles expressly determined by the State or, in their absence, as inferred from existing State laws».
In the case under examination, the fundamental principles of the matter relating to the regulation of access procedures to medically assisted suicide can be inferred from the existing State legislation, read in light of the judgments of this Court.
In particular, the following are relevant here:
– articles 1 and 2 of Law no. 219 of 2017, which regulate the mode of refusal and interruption of life-sustaining treatments, and which were used by this Court’s Judgment no. 242 of 2019 as reference points already present in the legislation in force for the configuration of the medicalized procedure for assessing the request for assisted suicide, pending the expected intervention of the State legislator;
– Law no. 38 of March 15, 2010 (Provisions to guarantee access to palliative care and pain therapy), which protects and guarantees access to palliative care and pain therapy for the patient by including them among the essential levels of assistance, and which was also referred to by the aforementioned Judgment no. 242 of 2019 and subsequent Judgments no. 135 of 2024 and no. 66 of 2025 to emphasize the mandatory and effective availability of these services;
– art. 14, third paragraph, letter q), of Law no. 833 of December 23, 1978 (Establishment of the National Health Service), according to which local health units provide, among other things, «the assessments, certifications, and any other medico-legal service incumbent on the national health service»: assessments, prescriptions, and services which include those necessary, according to the judgments of this Court, within the scope of the medicalized procedure for assisted suicide.
2.3.– The prima facie traceability of the challenged regional law to the matter of concurrent legislative competence «health protection», within the scope of the fundamental principles derivable from the provisions just mentioned, does not, however, exclude that individual provisions of this law may, at the same time, illegitimately encroach upon spheres of competence reserved to State legislation, in violation of art. 117, second paragraph, of the Constitution.
2.4.– It is appropriate, in this regard, to immediately dismiss the challenge raised against the entirety of Tuscany Regional Law no. 16 of 2025 for violation of the exclusive State legislative competence in matters of criminal law. This challenge is, in fact, unfounded.
According to the constant jurisprudence of this Court, «a regional norm is deemed invasive of the exclusive State competence in matters of criminal law [...] when it affects criminal definitions, modifies the prerequisites for their application or introduces new grounds for exemption from criminal liability», or «when it produces "further sanctioning effects consequent to the commission of a crime” (Judgment no. 172 of 2017)» (Judgment no. 248 of 2019, point 3 of the Facts Considered) or when it realizes an impermissible novation of the source.
The challenged regional law, as a whole, except as stated below (point 4), does not produce any of these effects. The scope of non-punishability of conduct abstractly classifiable as the criminal offense of instigation or assistance in suicide under art. 580 of the Criminal Code remains, in fact, that determined by the cited Judgment no. 242 of 2019, which in its operative part identified six requirements – four substantial and two procedural – in the presence of which the application of the criminal norm would produce a result incompatible with the Constitution. The challenged regional law in no way modifies the four substantial requirements, entrusting their verification to the same Regional Health Service, which is also given the task of establishing the modalities for implementing assisted suicide, after obtaining the opinion of the committee on ethical aspects (a committee that, as will be discussed below, performs in Tuscany the functions of the ethics committees in the general territory of the nation): in conformity, therefore, also with the two procedural requirements identified by Judgment no. 242 of 2019 («provided that such conditions and implementation modalities have been verified by a public structure of the national health service, following the opinion of the competent territorial ethics committee»).
Nor, as the State Attorney General’s Office complains, does the challenged regional law create, in itself, an unjustified disparity in the national territory by making a ground for non-punishability for a crime regulated by the Criminal Code operational only in the Tuscan territory. The scope of non-punishability is, in fact, that identified throughout the national territory by Judgment no. 242 of 2019, which entrusts the health service and ethics committees with verifying in the concrete case the four substantial requirements for access to the medicalized procedure for assisted suicide: thereby directly burdening the health service itself and the ethics committees, throughout the national territory, with the related tasks, the fulfillment of which is necessary for the protection of the constitutional rights of which the person – in the presence of the four substantial requirements identified – is the holder, irrespective of whether the activity of the regional health services and the ethics committees operating therein has been regulated in detail by law (whether State or regional).
2.5.– The assessment of the alleged violation of the exclusive State legislative competence in matters of civil law is, however, more complex.
The State Attorney General’s Office argues that the challenged regional law, far from exclusively regulating organizational and procedural aspects related to the assistance that regional health authorities must provide to patients in the conditions indicated by Judgment no. 242 of 2019, actually affects the concrete scope of their personal rights, including life and physical integrity, thereby innovating in the matter of civil law, which must be uniformly regulated throughout the national territory.
The State defense particularly invokes the precedent represented by Judgment no. 262 of 2016, in which this Court declared constitutionally illegitimate two laws of the Friuli-Venezia Giulia Region that provided for the establishment of a regional register for the collection of advance health directives and for the donation of organs and tissues post-mortem, also determining the form, object, and recipients of these directives, as well as the modalities for their collection and conservation in specific databases at the local health units.
Similarly, it must be considered that in Judgment no. 253 of 2006, this Court declared constitutionally illegitimate two provisions of a Tuscan regional law that regulated the possibility of delegating to third parties the expression of consent to medical treatments and the characteristics of consent to gender reassignment treatments.
In both cases, however, the regional provisions annulled had regulated rights not yet recognized in State legislation at the time, which they intended to introduce ex novo, or (in the case of one of the Tuscan provisions annulled by Judgment no. 253 of 2006) had unduly modified the modalities for exercising the rights provided for by the corresponding State legislation.
The regional law under challenge in this proceeding, however, does not operate in a situation of similar «legal vacuum». In fact, State law already precisely regulates the possibility and modalities for the patient to renounce or refuse medical treatments necessary for survival (articles 1 and 2 of Law no. 219 of 2017); and precisely this regulation was extended by this Court, in Judgment no. 242 of 2019, to the medicalized procedure for assisted suicide, in order to avoid unreasonable and rights-violating results for a person who is already entitled to refuse life-sustaining treatments, and who nevertheless deems it more consistent with their notion of dignity to depart from life more quickly, without being «forced to undergo a slower and more painful process for those dear to them» (point 2.3. of the Facts Considered), such as that which would result from the interruption of treatments.
The challenged regional law does not intend, therefore, to recognize in the Tuscany Region a right that is not recognized in other regions, as had instead occurred as a result of the provisions of the regional laws annulled by Judgments no. 253 of 2006 and no. 262 of 2016, but declares its intention to regulate in detail the modalities for the implementation of guarantees and procedures, the essential features of which – uniform throughout the national territory – are already found, as argued above, in the legal system in force in light of this Court’s Judgments no. 242 of 2019 and no. 135 of 2024.
As will be further discussed, however, in laying down this procedural regulation, in some cases the provisions of the challenged regional law end up improperly reproducing or even indirectly affecting the concrete scope of the rights at stake.
This requires an analytical, provision by provision examination of the challenged regional law, in order to ascertain whether the regional regulation incurs the signaled defects.
2.6.– Mutatis mutandis, analogous considerations must be made regarding the further challenge of violation of the exclusive State legislative competence in determining the essential levels of services.
The challenged regional law, as a whole, regulates the activity that the regional health service is required to carry out according to the existing legal system, as shaped by the regulatory principles enunciated by the aforementioned judgments of this Court. From this point of view, it therefore does not introduce any new essential level of assistance, nor does it modify the corresponding State regulation.
What, however, must be precluded to regional legislation is to establish itself what falls within and what does not fall within the essential levels of health assistance, this being evidently a matter reserved to the exclusive legislative competence of the State pursuant to art. 117, second paragraph, letter m), of the Constitution.
2.7.– From yet another perspective, the challenged regional law would prove constitutionally illegitimate if – while remaining within the scope of the matter of «health protection» – it did not limit itself to laying down detailed regulations, but presumed to unduly overlap with, or even modify, the fundamental principles of health protection established by State legislation, in violation – this time – of the third paragraph of art. 117 of the Constitution.
2.8.– In conclusion, the first two grounds of appeal cannot be upheld insofar as they are directed against the entirety of the regional law.
The individual challenges contained therein must instead be evaluated in relation to each provision of the law (infra, 3-10).
3.– Taking then as a starting point art. 1, this Court finds that it is exempt from all challenges formulated by the appellant. In fact, this provision limits itself to declaring the purpose of Tuscany Regional Law no. 16 of 2025 to regulate the «organizational modalities for the implementation of the provisions of Constitutional Court Judgments of September 25, 2019, no. 242 and of July 1, 2024, no. 135», relating to medically assisted suicide. It therefore simply states the purpose of providing – through a law attributable to the concurrent legislative competence in health protection – operational details to the Regional Health Service to ensure assistance to persons in the conditions indicated by Judgment no. 242 of 2019, as specified in the subsequent Judgment no. 135 of 2024.
4.– Opposite conclusions must be reached for art. 2 of the challenged regional law, which directly identifies, «[u]ntil the entry into force of State legislation», the requirements for access to medically assisted suicide, expressly referring to Judgments no. 242 of 2019 and no. 135 of 2024, and to the modalities provided by articles 1 and 2 of Law no. 219 of 2017.
The provision violates art. 117, second paragraph, letter l), of the Constitution in reference to the exclusive State legislative competence in matters of civil and criminal law.
On the one hand, Judgments no. 242 of 2019 and no. 135 of 2024, by defining the scope of application of the ground for non-punishability of assistance in suicide and enunciating the access requirements, innovated civil and criminal law.
On the other hand, in the challenged provision, the reference to the aforementioned judgments realizes a novation of the regulatory principles contained therein, which results in the effect of defining in regional legislation, rigidifying them, the requirements for access to assisted suicide and, indirectly, the contours of the exemption under art. 580 of the Criminal Code as identified by this Court’s judgments.
According to established constitutional jurisprudence, the novation of sources in civil matters (among others, Judgment no. 69 of 2024) and criminal matters (among others, Judgment no. 35 of 2011) is not permitted to the regional legislator and results in a violation of State competences under art. 117, second paragraph, letter l), of the Constitution.
In fact, «[t]he intrusion into the State legislative competence is noted simply by the presence of a novation of sources (recently, Judgment no. 239 of 2022 and, in the matter of "civil law”, Judgments no. 153 of 2021 and no. 234 of 2017), which are susceptible to modifications and integrations over time» (Judgment no. 69 of 2024, point 6.2.1. of the Facts Considered).
From this premise, it must also be inferred that the region is precluded from crystallizing in its provisions regulatory principles affirmed by this Court at a specific historical moment – which are, moreover, abstractly susceptible to modification – and moreover in the declared expectation of an intervention by the State legislator.
Indeed, Judgment no. 135 of 2024, cited by the challenged provision, took care to specify that «the task of this Court is not to substitute itself for the legislator in identifying the most appropriate abstract balance point between each individual’s right to self-determination over their own existence and the opposing demands for the protection of human life, their own and that of third parties; but only to fix the minimum limit, constitutionally required in light of the legislative framework under review, for the protection of each of these principles, while remaining open to the legislator the possibility of identifying solutions that ensure more intense protection for one or the other [...]. This being without prejudice, in any case, to the Republic's duty – pursuant to Articles 2, 3, second paragraph, and 32 of the Constitution, as well as art. 2 of the ECHR – to ensure all appropriate therapies to these patients, including those necessary to eliminate or, at least, reduce the suffering caused by their pathologies to tolerable proportions; and together with the duty to ensure them all support of an assistance, economic, social, psychological nature» (point 7.2. of the Facts Considered).
Regional legislation, therefore, with reference to these delicate balances, which essentially pertain to the matter of civil and criminal law, cannot claim to act as a substitute for State legislation, not even temporarily, by so to speak "taking possession” of the regulatory principles identified by this Court.
Article 2 of the challenged regional law must, therefore, be declared constitutionally illegitimate for violation of art. 117, second paragraph, letter l), of the Constitution, with absorption of the remaining challenges.
5.– As for art. 3 of the challenged regional law, it remains immune from all challenges raised.
The provision provides for the establishment, within the local health units, of permanent commissions, responsible for examining the existence of the requirements for access to medically assisted suicide and for verifying or defining the related implementation modalities.
These are multidisciplinary commissions, intended to be integrated from time to time by a specialist physician for the pathology from which the person requesting medically assisted suicide suffers.
In these terms, the challenged provisions do not pertain to the exclusive State competences invoked by the appellant, but are configured as organizational provisions, attributable to detailed regulation in matters of health protection, therefore within regional competence as implementing fundamental principles that, even in light of this Court’s Judgments no. 242 of 2019 and no. 135 of 2024, the Region could infer from various State laws regulating specific assessment activities.
These include art. 14, third paragraph, letter q), of Law no. 833 of 1978, according to which local health units provide, among other things, «the assessments, certifications, and any other medico-legal service incumbent on the national health service».
It must also be noted that art. 3, paragraph 4, of the challenged regional law provides for voluntary participation in the commission, also in consistency with what was affirmed by this Court, according to which there is no obligation for physicians to proceed with assisted suicide, leaving it to «the conscience of the individual physician to choose whether or not to comply with the patient's request» (Judgment no. 242 of 2019, point 6 of the Facts Considered).
6.– As for art. 4, it is also exempt from all challenges by the referring judge, except for the phrase – contained in paragraph 1 – «, or their delegate,», which invades the exclusive State legislative competence in matters of civil law.
This provision regulates the modalities of access to medically assisted suicide, in particular by regulating the procedure for submitting the application for verification of the related requirements as well as for the approval or definition of the related implementation modalities.
This regulation as a whole does not exceed the limits of detailed legislation in matters of health protection, within the limits set by the fundamental principles derivable from State law, as specified above; it does not establish new rights of the person nor unduly overlap with the corresponding State regulation; nor does it overlap with the determination of essential levels of services by State law.
However, the State’s challenges hit the mark when they complain about the provision allowing the application to be submitted by a delegate of the patient, rather than the patient themselves.
This provision visibly derogates from the regulatory framework established by Law no. 219 of 2017, in which the medicalized procedure for assisted suicide was placed by this Court’s jurisprudence. Art. 1, paragraph 4, of Law no. 219 of 2017 establishes that the patient’s will is acquired «in the ways and with the instruments most suited to the patient’s conditions» and documented «in written form or through video recordings or, for persons with disabilities, through devices that allow them to communicate». This provision refers, in fact, textually to the patient’s «informed consent» to the interruption of treatment; but Judgment no. 242 of 2019 expressly refers to it, as a solution existing in the legislation to regulate the different hypothesis of the request for assistance in suicide by the person in the conditions that legitimize such request, based on the same judgment.
Now, art. 1, paragraph 4, of Law no. 219 of 2017 unequivocally presupposes that the will to interrupt care (or, following Judgment no. 242 of 2019, to access assisted suicide) is expressed personally – with the modalities indicated therein, which ensure the possibility of expressing will even to persons with communication disabilities – and not through a delegate, as provided by the challenged Tuscan law. This, moreover, appears consistent with the need to ensure that the decision to depart from life is made directly by the person, who must have the full capacity to make free and conscious decisions, with the possibility, as specified in paragraph 5 of the same art. 1, of modifying their choice at any time.
The constitutional illegitimacy of art. 4, paragraph 1, limited to the phrase «, or their delegate,», results from this, for conflict with art. 117, second paragraph, letter l), of the Constitution, with absorption of the remaining challenges.
Consequently, the regional health service must enable the interested party to personally formulate their application, possibly with the modalities provided for by art. 1, paragraph 4, of Law no. 219 of 2017.
7.– At this point, articles 5 and 6 of the challenged regional law, which respectively regulate the procedures for verifying the requirements for access to assisted suicide and for determining the related implementation modalities, may be examined jointly.
7.1.– The multiple regulatory fragments that, in these provisions, establish the duration of these procedures deserve careful analysis first.
In particular, paragraphs 1, 4, second period, and 5 of art. 5 provide for strict deadlines for verifying the requirements for access to medically assisted suicide; this is also provided for by art. 6, paragraphs 1, second period, 5, second period, and 6, with regard to the «approval or definition» of the modalities for implementing medically assisted suicide.
More specifically, the cited provisions of art. 5 provide that: a) the conclusion of the entire procedure for verifying the requirements for access to medically assisted suicide shall take place within twenty days of receipt of the application, specifying that the deadline is suspendible once only, for no more than five days, for clinical-diagnostic assessments; b) the Committee’s opinion on the ethical aspects shall be expressed within seven days of receipt of the documentation; c) the request for an opinion to this Committee by the Commission shall be made in sufficient time to ensure compliance with the overall deadline of twenty days for the conclusion of the verification procedure.
Those of art. 6 establish that: a) the Commission shall conclude the procedure for approving or defining the modalities for implementing medically assisted suicide within ten days of the communication to the interested party of the existence of the requirements for accessing it; b) the Ethics Committee in clinical practice shall express its opinion on the adequacy of the protocol on the implementation modalities, drawn up by the trusted physician of the interested person or defined by the Commission in agreement with the person, within five days of receipt of the documentation transmitted by the Commission; c) the Commission shall request the opinion of this Committee in sufficient time for the procedure to conclude within the overall deadline of ten days.
The questions are well-founded with regard to the normative fragments just cited, for violation of the exclusive State legislative competence in matters of civil law under art. 117, second paragraph, letter l), of the Constitution and of the concurrent State competence relating to the determination of fundamental principles in matters of health protection under art. 117, third paragraph, of the Constitution.
As for the first profile, it should be noted that these sequences of terms, marking the entire procedure and its delicate phases, relate to the «balance between the duty to protect human life, deriving from art. 2 of the Constitution, and the principle of the patient’s "autonomy” in decisions involving their own body, which is in turn an aspect of the more general right to the free development of one’s person» (Judgment no. 66 of 2025, point 6.2. of the Facts Considered).
From this point of view, in connection with the principle of self-determination, the challenged provisions violate, firstly, art. 117, second paragraph, letter l), of the Constitution, as they involve choices that require «uniformity of treatment throughout the national territory, for imperative reasons of equality, the ultimate rationale for the reservation to the State of the exclusive legislative competence in matters of "civil law”, provided for by the Constitution» (Judgment no. 262 of 2016, point 5.4. of the Facts Considered).
Furthermore, the same provisions disregard the fact that accompanying requests for access to medically assisted suicide necessarily requires an accurate medical assessment of the existence of the relevant requirements, both under the profile of the health condition of the interested party, and under that of the formation of the will in a free and autonomous manner.
While the need for prompt handling of the applicant's request remains, the possibility of carrying out all those clinical and diagnostic in-depth analyses that the multidisciplinary Commission, involving different skills (including psychiatric, palliative, psychological, medico-legal, etc.), deems appropriate, even possibly adopting interlocutory decisions, which may require verification times incompatible with the stringent deadlines set by the challenged provisions, must therefore always be allowed (on the principle of autonomy and responsibility of the physician, in general, Judgment no. 282 of 2002, point 4 of the Facts Considered, as well as, in the same sense, Judgments no. 162 of 2014, point 7 of the Facts Considered, and no. 151 of 2009, point 6.1. of the Facts Considered).
Given the «"personalistic nature” of health care», the legislative provisions, therefore, cannot «preclude the physician from the possibility of evaluating, based on the most up-to-date and accredited technical-scientific knowledge, the individual case» (Judgment no. 169 of 2017, point 8 of the Facts Considered) submitted to their attention.
This is also confirmed by the fundamental principles derivable from Law no. 219 of 2017 itself, which values and promotes the so-called therapeutic alliance, or «the care and trust relationship between patient and physician based on informed consent in which the patient's decision-making autonomy and the physician's competence, professional autonomy, and responsibility meet» (art. 1, paragraph 2).
The determination of deadlines by a regional law in relation to a medicalized procedure that assumes a completely peculiar character, in no way comparable to common administrative procedures given the extremely delicate evaluations involved in ending a human life, certainly «directly and necessarily involves the fundamental principles of the matter, being located "at the intersection of two fundamental rights of the sick person”» (Judgment no. 338 of 2003, point 5.1. of the Facts Considered), and more precisely between the protection of their self-determination and their right to be effectively treated, according to the canons of medical science and art, also through the concrete availability of effective palliative care.
It must, therefore, be reiterated once again the «need to adopt appropriate precautions so that "the option of administering drugs capable of causing the patient’s death within a short time does not involve the risk of any premature renunciation, by the health structures, to always offer the patient concrete possibilities of accessing palliative care other than continuous deep sedation, where appropriate to eliminate their suffering [...] in line with the commitment undertaken by the State with the aforementioned Law no. 38 of 2010”. Involvement in a palliative care pathway must, in fact, constitute "a prerequisite for the choice, subsequently, of any alternative pathway by the patient” (as already envisaged by Ordinance no. 207 of 2018)» (Judgment no. 242 of 2019, point 2.4. of the Facts Considered).
Moreover, «contact with healthcare professionals and a structure effectively capable of ensuring the timely activation of palliative therapies can guarantee patients the right to receive complete information on their care pathway and allow each person the opportunity to confront the illness and the final stage of life in a dignified and suffering-free manner, also with a view to preventing and significantly reducing the demand for assisted suicide» (Judgment no. 66 of 2025, point 7.1. of the Facts Considered).
Art. 5, paragraphs 1, 4, second period, and 5, and art. 6, paragraphs 1, second period, 5, second period, and 6 must therefore be declared constitutionally illegitimate for violation of art. 117, second paragraph, letter l), of the Constitution, with reference to the matter of «civil law» and of art. 117, third paragraph, of the Constitution, with reference to the matter of «health protection».
7.2.– The remaining provisions of articles 5 and 6 of the challenged regional law, which regulate in detail the verification of the requirements for access to medically assisted suicide and the determination of the related implementation modalities, ensuring in particular direct personal interaction with the interested person, are instead exempt from the State’s challenges, remaining within the scope of detailed regulation in matters of health protection, within the limits set by the fundamental principles derivable from State law, as specified above. This regulation, moreover, does not establish new rights of the person, nor does it unduly overlap with the State regulation concerning the determination of essential levels of services.
8.– Art. 7 of the challenged regional law must now be examined.
8.1.– Paragraph 1 of this provision, by regulating the «[s]upport for the implementation of the medically assisted suicide procedure», commits the local health units to ensure, in the forms provided for by the protocol, the technical and pharmaceutical support as well as the health assistance for the preparation for self-administration of the authorized drug, also specifying that the assistance is provided by health personnel on a voluntary basis and is considered institutional activity to be carried out during working hours.
This provision is constitutionally illegitimate because it invades the State’s reservation for setting the fundamental principles in matters of health protection, all further grounds of challenge being absorbed.
In fact, it is not set as a detailed implementation of pre-existing fundamental principles found in State legislation, but as an illegitimate determination of the same by regional legislation.
It is true that the person with respect to whom the existence of all the conditions indicated by this Court has been positively verified, in the due procedural forms, is the holder of a «subjective situation protected, as a consequential projection of their freedom of self-determination, and specifically has the right to be accompanied by the National Health Service in the procedure of medically assisted suicide, a right that, according to the principles governing the service, includes the procurement of suitable devices, where available, and assistance in their use» (Judgment no. 132 of 2025, point 4.2. of the Facts Considered).
However, the challenged regional provision, by establishing the mandatory involvement of local health units in the execution of medically assisted suicide, does not certainly lay down detailed rules, in the sense of a simple «adaptation of regional legislation to fundamental principles» (Judgment no. 66 of 2017, point 3.3. of the Facts Considered), but has a regulatory scope that demonstrates a true, impermissible, "regionalization” of the same principles.
Not having «limited itself to setting a detailed regulation» (Judgment no. 438 of 2008, point 4 of the Facts Considered), the Region has in reality appropriated the fundamental principles, determining a breach of the reservation, established by art. 117, third paragraph, of the Constitution, to State legislation for their determination.
In any case, it must be specified that the declaration of constitutional illegitimacy of art. 7, paragraph 1, of Tuscany Regional Law no. 16 of 2025 leaves intact the right of the person, in relation to whom the conditions for access to medically assisted suicide have been positively verified, to obtain from the regional health service units the drug, any devices necessary for self-administration, as well as health assistance during the execution of this procedure, as stated, moreover, in the aforementioned Judgment no. 132 of 2025, which is self-applicable from this point of view.
It remains, however, established that healthcare personnel, faced with the irreversibility of the consequences of the suicidal act, must take special care to verify the persistence of the full and conscious will of the person to end their life and the absence of undue conditioning at the time of execution, since it is «precisely the protection of the freedom of self-determination that justifies, primarily to ensure it is genuine and responsible, its balance with the State’s duty to protect life» (Judgment no. 66 of 2025); with the consequent opportunity that the healthcare personnel involved – also to avoid possible criminal liability – attest to the implementation modalities of the procedure and its outcome.
If it is true, in fact, that assisted suicide, on the one hand, «expands the spaces recognized to the autonomy of the person in freely deciding on their destiny», it «simultaneously creates risks that the legal system has a duty to avoid, in fulfillment of the duty to protect human life which, also, derives from art. 2 of the Constitution» (Judgment no. 66 of 2025, point 7 of the Facts Considered, and in the same terms Judgment no. 135 of 2024, point 7.2. of the Facts Considered), with every measure that proves necessary with the aim of protecting, in particular, the most fragile and vulnerable persons, who might be induced to depart from life prematurely.
8.2.– As for paragraph 2 of art. 7, its first period – according to which «[t]he services and treatments regulated by the regional law constitute a level of health assistance superior to the essential levels of assistance» – invades the exclusive State legislative competence in matters of determination of essential levels of services, and is therefore constitutionally illegitimate due to conflict with art. 117, second paragraph, letter m), of the Constitution, with absorption of the further challenges.
The objection raised by the respondent to specify, on the one hand, that in the present case the regional law does not determine any level of service, limiting itself to intervening on organizational and management aspects of this regulation and, on the other hand, that constitutional jurisprudence has always allowed regions, not in a recovery plan, within the scope of their competences, to guarantee further levels of protection (citing this Court’s Judgments no. 297 of 2012, no. 207 of 2010, and no. 248 of 2006) is not decisive.
The reference made by the regional defense to administrative jurisprudence (Council of State, Third Section, Judgment of July 20, 2016, no. 3297) concerning heterologous medically assisted procreation, which, in the period between the recognition of its lawfulness, following this Court’s Judgment no. 162 of 2014, and its subsequent inclusion in the essential levels of assistance, would have affirmed the possibility for regions not subject to a recovery plan to recognize health services additional to the ELAs, is also irrelevant.
It is, in fact, not a question here of the possibility for the Region to admit, in its constitutional autonomy, the provision of a specific service where it has available financial resources for this purpose, as provided for, moreover, by the second period of paragraph 2 of the challenged art. 7, moreover referring to resources that fall outside the perimeter of the region's health budget and pertain to that relating to social services (in this case, falling under Mission 12, relating to «Social rights, social policies and family»).
Rather, the legislative definition made by the challenged provision is relevant, which, by explicitly referring to a superior level of health assistance, still illegitimately invokes, from the point of view of the constitutional distribution of competences, the category of «essential levels of assistance».
This Court has repeatedly emphasized that «the attribution to the State of exclusive and transversal competence» under art. 117, second paragraph, letter m), of the Constitution, «refers to the determination of the structural and qualitative standards of services that, concerning the satisfaction of civil and social rights, must be guaranteed, generally, to all entitled persons» (Judgments no. 168 and no. 50 of 2008, points 3.2.3. and 4 of the Facts Considered respectively, and, in the same sense, Judgment no. 387 of 2007, point 5.1. of the Facts Considered). Such title of legitimacy for State intervention is invoked «in relation to specific services for which State legislation defines the essential level of provision» (ex multis, Judgments no. 273 and no. 247 of 2020, points 4.1. and 13 of the Facts Considered respectively) and with it was attributed «to the State legislator a fundamental instrument to guarantee the maintenance of adequate uniformity of treatment regarding the rights of all subjects, even in a system characterized by a decidedly increased level of regional and local autonomy» (Judgments no. 125 of 2015 and no. 111 of 2014, points 4.1. and 7.3. of the Facts Considered respectively).
The challenged provision therefore uses a relational concept – that of a level of health assistance superior to the ELAs – without the State legislator having yet determined the essential level. Therefore, in this case, qualifying a specific service as a superior level is equivalent to interfering with the very definition of essential level – moreover creating disparities between citizens depending on whether the region is in a recovery plan or not – which is reserved to the State legislator.
8.3.– The second period of paragraph 2 of art. 7, where it is provided in particular that «[t]he Region shall cover with its own resources the financial effects connected to these services and treatments», remains immune from censure. This provision does not interfere with the State regulation on ELAs, nor does it otherwise encroach upon the matter of civil law or violate the fundamental principles of health protection established by State law.
8.4.– Conversely, the entire paragraph 3 of art. 7, according to which «[t]he person in possession of the requirements authorized to access medically assisted suicide may decide at any time to suspend or cancel the provision of the treatment», must be declared constitutionally illegitimate, for conflict with the fundamental principles of health protection as resulting from the existing State legislation, interpreted in light of the constitutional jurisprudence.
This provision appears, in fact, completely inconsistent with the very structure of medically assisted suicide, the logic of which requires that the patient themselves self-administer the drug, possibly availing themselves of technical instruments prepared for this purpose if they are unable to move their limbs or swallow (on this point, Judgment 132 of 2025, point 5 of the Facts Considered). Thus, in the case of medically assisted suicide, there is properly no "provision” of a treatment that can be suspended or canceled (as instead in the hypotheses of active euthanasia, classifiable in the Italian legal system as the offense of consensual homicide), but rather an assistance by healthcare professionals to a person who must perform by themselves the final act that directly causes their death.
8.5.– Finally, paragraph 4 of art. 7, which merely establishes the obvious principle that the «local health units shall bring the procedures regulated by this law into conformity with State legislation», must be considered exempt from censure.
8.6.– In conclusion, art. 7 must be declared constitutionally illegitimate: a) in its paragraph 1, for conflict with art. 117, third paragraph, of the Constitution; b) in its paragraph 2, first period, for conflict with art. 117, second paragraph, letter m), of the Constitution; c) in its paragraph 3, for conflict with art. 117, third paragraph, of the Constitution.
9.– As for art. 8 of the challenged regional law, it is exempt from the appellant’s challenges.
The provision establishes the free provision of «services and treatments performed by the regional health service within the scope of the therapeutic-assistance path of medically assisted suicide». This choice by the regional legislator does not appear, evidently, in conflict with any of the parameters invoked by the State appeal.
10.– Art. 9, finally, is a financial provision merely accessory to the preceding one, establishing the financial coverage of the burdens arising from the law. In this case too, it does not appear in conflict with any of the parameters invoked by the State appeal.
11.– The third ground of appeal by the President of the Council of Ministers remains to be examined, which is specifically directed against articles 3, 4, 5, and 6 of the challenged regional law, assuming their conflict with art. 117, second paragraph, letter l), of the Constitution in relation to art. 2, paragraph 7, of Law no. 3 of 2018, and with art. 117, second paragraph, letter m), of the Constitution, in relation to art. 1, paragraphs 556, 557, and 558 of Law no. 208 of 2015.
11.1.– The first question is unfounded.
The State appeal assumes that the challenged provisions conflict with art. 2, paragraph 7, of Law no. 3 of 2018, which delegates to a decree of the Minister of Health, to be adopted following an agreement in the State-Regions Permanent Conference, the identification of local ethics committees, in fact regulated by Ministerial Decrees of January 26 and 30, 2023.
In reality, however, the attribution – in the Tuscany Region – to the clinical ethics committee of the advisory function in the procedure for access to medically assisted suicide does not conflict with the invoked State sources, since the Ministerial Decree of January 26, 2023 (Identification of forty local ethics committees), implementing Law no. 3 of 2018, art. 1, paragraph 4, allows the regions «to keep operational the ethics committees existing in their territory of competence, but not included in the list» of local ethics committees of which the decree is comprised, provided that these committees «operate for functions other than those exclusively attributed» to the local ethics committees.
As emerges from the agreement of the Permanent Conference for Relations between the State, the Regions, and the Autonomous Provinces of Trento and Bolzano acquired on the text of the decree, and referred to in the premises (agreement of January 11, 2023, Rep. CSR Acts/3), this provision incorporates, with a general formulation, the position of the regions and autonomous provinces, which expressed their agreement subordinately, among other things, «to the confirmation that, pending the adoption of a dedicated provision, the opinions required with reference to medically assisted suicide continue to be the competence of the Ethics Committees, to which this function was attributed at the territorial level».
In the case of the Tuscany Region, the attribution of these opinions is the responsibility, pursuant to the resolution of the Tuscan Regional Council no. 383 of March 23, 2020 (Tuscany Regional Law 40/2005, art. 99 - Approval of essential elements for the organization of Clinical Ethics Committees - Revocation of Regional Council Resolution 552/2005 and 949/2009) to the clinical ethics committees, regulated by art. 99 of Tuscany Regional Law no. 40 of 2005, as replaced by art. 24, paragraph 1, by Tuscany Regional Law no. 36 of July 25, 2017 (Provisions regarding the new organizational structure of regional clinical governance functions, the Regional Bioethics Commission and the Ethics Committees of Tuscany), and subsequently amended by art. 74, paragraph 1, of Tuscany Regional Law no. 29 of July 20, 2023 (General law for the maintenance of the regional order 2023).
Nor is the challenge by the State Attorney General’s Office shareable, according to which the role attributed by the challenged regional law to the multidisciplinary commission would overlap with that of the ethics committees referred to by Judgment no. 242 of 2019, currently regulated by the aforementioned Ministerial Decrees of January 26 and 30, 2023, based on what is provided for by the cited art. 2, paragraph 7, of Law no. 3 of 2018.
The role of the multidisciplinary commissions is, in fact, that of verifying the compliance of the specific pathological conditions of the person requesting assistance in suicide with the requirements set by Judgments no. 242 of 2019 and no. 135 of 2024, as well as their full capacity to make free and conscious decisions, and ultimately – the very existence of the intention to end one’s life. The commissions are also entrusted with the task of determining the modalities for implementing assistance in suicide. This role does not overlap with that of the local ethics committees (in the terminology of Tuscan legislation: committees for the ethical aspects of the case), to which the same Judgment no. 242 of 2019 entrusted – «[p]ending the intervention of the legislator» – the task of «guaranteeing the protection of situations of particular vulnerability», expressing an opinion on the case. These are different functions, with respect to which the challenged regional law – contrary to what is asserted by the State appeal – does not determine any undue overlap.
11.2.– Likewise unfounded are the State challenges which assume the conflict of articles 3, 4, 5, and 6 of the regional law with art. 117, second paragraph, letter m), of the Constitution, in relation to art. 1, paragraphs 556, 557, and 558 of Law no. 208 of 2015.
The latter provisions stipulate that the National Commission for the update of ELAs and the promotion of appropriateness in the National Health Service, established at the Ministry of Health, carries out, among others, the activities of: a) systematic evaluation of the services included in the ELAs, to evaluate their maintenance or to define conditions for provision or appropriateness indications; b) acquisition and evaluation of proposals for the inclusion of new services, activities, and provisions in the ELAs; c) evaluation of the economic impact of changes to the ELAs. Based on the activities thus outlined, the Commission annually formulates a proposal for updating the ELAs.
However, the provisions of the regional law challenged here do not provide – nor could they provide, as argued above – for an essential level of assistance, limiting themselves to regulating organizational aspects of the regional health structures; nor could they in any way affect or influence the autonomous determinations of the State Commission on the matter.
11.3.– Hence the overall non-foundedness of the challenges raised in the third and final ground of appeal.
for these reasons
THE CONSTITUTIONAL COURT
1) declares the constitutional illegitimacy of articles 2; 4, paragraph 1, limited to the words «, or their delegate,»; 5, paragraphs 1, 4, second period, and 5; 6, paragraphs 1, second period, 5, second period, and 6; 7, paragraphs 1, 2, first period, and 3, of the Law of the Tuscany Region of March 14, 2025, n. 16 (Organizational Modalities for the Implementation of Constitutional Court Judgments 242/2019 and 135/2024);
2) declares the constitutional legitimacy challenges of the entire Tuscany Regional Law no. 16 of 2025, as well as art. 1 of the same regional law, initiated with reference to art. 117, second paragraph, letter l), and third paragraph, of the Constitution, by the President of the Council of Ministers with the appeal indicated in the heading, to be unfounded;
3) declares the constitutional legitimacy challenges of the entire Tuscany Regional Law no. 16 of 2025, as well as art. 7, paragraph 2, second period, of the same regional law, initiated with reference to art. 117, second paragraph, letter m), of the Constitution, by the President of the Council of Ministers with the appeal indicated in the heading, to be unfounded;
4) declares the constitutional legitimacy challenges of articles 3, 4, 5, and 6 of Tuscany Regional Law no. 16 of 2025, initiated by the President of the Council of Ministers with the appeal indicated in the heading, with reference to art. 117, second paragraph, letters l) and m), of the Constitution, to be unfounded.
Decided thus in Rome, at the seat of the Constitutional Court, Palazzo della Consulta, on November 4, 2025.
Signed:
Giovanni AMOROSO, President
Francesco VIGANÒ, Rapporteur
Luca ANTONINI, Rapporteur
Igor DI BERNARDINI, Chancellor
Filed in the Registry on December 29, 2025