Difficult decisions in the Treatment of Anorexia nervosa: Navigating Capacity, Coercion and Assisted Suicide

Guarda A.S, Westmoreland P., Hanson, A. and McKinney, C
International Conference on Eating Disorders, June 2021

This workshop will examine some of the most challenging decisions facing clinicians treating severe anorexia nervosa. Amongst psychiatric conditions, anorexia nervosa is second only to opioid use in lethality, yet experienced clinicians have all seen patients who have failed multiple treatment attempts, been ill for decades and labelled as treatment resistant — make full recoveries. Ambivalence towards behavioral treatment aimed at weight restoration is a hallmark of the disorder, anxiety about behavior change is very high, and the disorder is often intertwined with identity. Restriction and exercise become increasingly overvalued behaviors, that remain inexplicably rewarding despite incremental and extreme personal costs. When the disorder is life threatening and the patient declines recommended treatment, how can we best assess capacity to refuse treatment? What, if any, is the role of coercive interventions? Is there ever a place for assisted suicide in cases of extreme anorexia nervosa, and what are the dangers?
Using case examples presenters will review ethical dilemmas presented by treatment refusal in extreme anorexia nervosa and discuss ethical, legal and practical concerns drawing on the relevant extant literature and published studies. Dr Guarda will review both formal and informal methods of coercion in the treatment of anorexia nervosa and their threat to the therapeutic alliance. Dr. Hanson will present on the current status of physician-assisted suicide in the U.S. and internationally including its risks and implications for severe and enduring eating disorders. Dr Westmoreland will review guardianship and data on civil commitment, and Dr McKinney will discuss the challenging issue of the assessment of capacity and competence to refuse treatment in anorexia nervosa from the perspective of both a bioethicist and an individual with lived experience and recovery from severe and enduring anorexia nervosa.