Between Safeguard and Constraint: Navigating Patient Autonomy in Protective Laws for Medical Assistance in Dying

There has been an increase in the number of jurisdictions legalizing or decriminalizing Medical Assistance in Dying (MAiD). Legal frameworks worldwide strive to balance respect for autonomy with regulatory safeguards that both operationalize voluntary choice and prevent access to MAiD in cases of remediable despair or coerced decision-making. However, the implementation of such an equilibrium diverges. Some legal systems prioritize personal autonomy and informed consent as the main criterion to access MAiD (e.g., US jurisdictions), while others also add the alleviation of suffering (e.g., The Netherlands). Using the lens of relational autonomy and focusing on Spain's MAiD legislation as a case study, this article poses the question of what notion of autonomy is implied in this system, and whether the imposition of certain safeguards might inadvertently undermine or restrict autonomy, in some specific cases. To that aim, we first analyze its stringent requirements for assessing the so-called "euthanasic context" which establishes eligibility conditions to access MAiD; then, we highlight how some of its assessments can interfere with the person's autonomy. The analysis highlights how protective measures (e.g., three external assessments before the request is either granted or denied) may imply forms of pathogenic vulnerability, in which safeguards meant to protect autonomy could paradoxically heighten an individual's vulnerability while diminishing autonomy through forms of epistemic injustice. We conclude that these highly protective laws might fall into the "trap of protection," illustrating the tension between safeguarding autonomy and respecting individuals' capacity for self-determination in the context of MAiD.