Structurally conditioned autonomy and assisted dying: health equity, vulnerability, and end-of-life decision-making

Abstract

Assisted dying is frequently justified through appeals to individual autonomy and self-determination. However, contemporary end-of-life decision-making occurs within broader social, economic, and institutional conditions that may significantly shape experiences of suffering and the range of available choices. This paper presents an interdisciplinary normative analysis situated at the intersection of bioethics and public health ethics, examining how structural inequalities may influence assisted-dying decision-making. Drawing on scholarship in bioethics, relational autonomy, structural vulnerability, public health ethics, and global health equity, the paper develops the concept of structurally conditioned autonomy. The concept describes forms of autonomy shaped not only by individual preferences and interpersonal relationships but also by unequal access to healthcare, socioeconomic vulnerability, social isolation, disability-related inequities, and disparities in palliative care and long-term care systems. Unlike related frameworks, structurally conditioned autonomy focuses specifically on how structural conditions shape the substantive circumstances under which end-of-life choices are formed, interpreted, and ethically evaluated. The analysis examines ethical debates surrounding assisted dying in jurisdictions including Canada, the Netherlands, Belgium, and Switzerland, while also considering inequalities affecting vulnerable populations and under-resourced healthcare systems. Rather than arguing that assisted-dying requests are reducible to failures of care, the paper contends that structural inequities may influence, constrain, or intensify end-of-life preferences in ethically significant ways. It further proposes an illustrative framework for incorporating structural determinants into ethical evaluation of assisted-dying requests without undermining patient agency or introducing paternalistic restrictions. The paper concludes that ethically robust assisted-dying frameworks require not only procedural safeguards related to decisional capacity, voluntariness, and informed consent, but also greater attention to healthcare equity, structural vulnerability, and the social conditions under which autonomous choices are exercised. Structurally conditioned autonomy is presented as a complementary framework capable of integrating individual self-determination with broader commitments to healthcare justice and social responsibility.