Illusion of choice? Implicit coercion and assisted dying in clinical practice.

Abstract

In this article, we argue that the narrow focus on explicit coercion in assisted dying obscures more pervasive forms of implicit coercion operating at interpersonal and institutional levels. Drawing on complex adaptive systems theory, we conceptualise healthcare systems as environments in which coercive dynamics emerge non-linearly and cannot be adequately mitigated through linear procedural safeguards.We look at the potential for implicit coercion within the unique context of terminal illness and consider how end-of-life emotional distress and attachment style shape individuals' responses to vulnerability, dependency and care, influencing how choices are expressed. We also examine the erosion of personal identity in terminal illness, arguing that beyond decision-making capacity and voluntariness, the authenticity of decision-making should be an important consideration in requests for assisted dying.We then turn to structural and institutional coercion, focusing on the influence of social roles, norms and professional authority. We examine how structural constraints and choice architecture affect freedom of choice. The Mental Health Act in England and Wales is used as a case study to illustrate how institutional coercion can emerge in practice despite the presence of statutory safeguards.Finally, we argue that assisted dying legal frameworks fail to adequately address implicit coercion and offer mitigation strategies to reduce the risk of it arising in complex healthcare systems.