Bioethics

Addressing the false dichotomy between autonomy and preservation of life: Clinical, legal, and ethical considerations in severe and longstanding anorexia nervosa
Agnes Ayton, Ali Ibrahim, Marco Solmi, Cynthia M Bulik, Eric F van Furth, Philip S Mehler, Maryrose Bauschka, Angela S Guarda

Abstract:

Anorexia nervosa (AN) is a serious metabo-psychiatric disorder. Despite a mortality rate approximately five times higher than that of age-matched controls, most deaths result from delayed recognition, fragmented care, and limited access to integrated, evidence-based treatment. Refusal of life-sustaining nutrition in severe or longstanding AN presents profound ethical and legal dilemmas, challenging the balance between autonomy, protection, and the duty to preserve life. This paper provides a critical narrative and normative review of how clinical uncertainty, systemic failure, and legal interpretation influence decision-making in treatment refusal. It examines capacity, futility, and best-interests determinations within mental health and capacity law in England and Wales, with comparative reference to other high-income countries. The review finds that unvalidated constructs such as "severe and enduring" and end-of-life framing of AN lack empirical and legal foundation. Their adoption risks normalising treatment withdrawal and assisted dying in a treatable psychiatric disorder that predominantly affects women. Ethical analysis grounded in autonomy, beneficence, non-maleficence, and justice demonstrates that autonomy should be supported rather than presumed absolute when reasoning is impaired by malnutrition or psychopathology. The paper concludes that aligning clinical and legal practice with the Convention on the Rights of Persons with Disabilities would strengthen supported decision-making, safeguard the right to life, and promote parity between psychiatric and physical healthcare. A shift toward the prevention of avoidable deaths, rather than acceptance of inevitability, is urgently required.

Annotation

The finding: This article is a narrative review of clinical and legal publications related to treatment of severe anorexia nervosa with the core argument that current discussions create a false dichotomy between coercive futility and end-of-life care. First, the authors note that the use of terminology such as “treatment-resistant,” “severe and enduring anorexia nervosa” and “terminal” is subjective and lacks evidence, preventing access to treatment for individuals who could potentially benefit. Legal precedents in Europe, the US, Canada, and Australia all support involuntary treatment; however, legal decisions may be constrained by non-evidence-based terminology and pessimistic views about treatment that do not reflect published clinical outcomes. The authors argue that the preservation of life is a core duty and that treatment, especially when delivered skillfully and compassionately, is not coercion. Finally, the case is made that lack of access to treatment is the core cause of premature deaths in eating disorders; the authors note that by failing to recommend evidence-based treatment that physicians may further contribute to limiting access to treatment and, as a result, preventable deaths.

Strength and weaknesses: This article attempts to reframe the discussion around severe eating disorders, summarizing the evidence that eating disorders are treatable, even when long-standing.  It demonstrates that across Western countries involuntary treatment of eating disorders has been both clinically and legally supported. One key limitation of this study is that it is a narrative, not a systematic review, and the authors may not have presented studies that contradict their core arguments (particularly around the success of treatment).

Relevance: Over the last decade there has been fierce debate over the involuntary treatment of patients with severe anorexia nervosa, and CL psychiatrists are practicing at the confluence of these differing opinions. When patients with medical complications of eating disorders are admitted to medical services, CL psychiatrists are asked to assess capacity, make recommendations for treatment, and potentially initiate treatment over objection.  It is critical that CL psychiatrists treating these patients understand the evidence for eating disorders treatment and ethical arguments for and against treatment over objection, both to ground their own clinical decision-making and to be able to communicate the rationale to patients, colleagues, and families. 

Treatment over Objection Versus Withdrawal of Dialysis in Cases of Severe Mental Illness
Nicholas S Kowalczyk, Andrea Landi, Liliana Osadchuk

Abstract:

Patients with severe mental illness are more likely to develop kidney disease and its complications compared to patients without severe mental illness. Once patients with mental illness develop end-stage kidney disease, supporting adherence is important but can be difficult in moments of acute psychosis when the patient objects to dialysis, particularly when considering the lack of dialysis-compatible psychiatric hospitals. In this case, a woman with a history of bipolar disease and end-stage kidney disease has a manic episode after discontinuing her antipsychotic medications and refuses dialysis owing to paranoid delusions. We argue that, due to the potential imminent harm to the patient in refusing dialysis when incapacitated due to severe mental illness, it is reasonable to pursue treatment over objection while waiting for return to capacity unless the surrogate decision maker does not believe it would be in line with the patient's values and beliefs. If there is no return to capacity after an agreed trial period and dialysis cannot be safely pursued outside of the hospital, the provider may ethically withdraw dialysis even contrary to the surrogate decision maker when continuing treatment may be limited by resources and overshadowed by harm to the patient. In this article, we will discuss how Rubin and Prager's criteria in deciding to treat over patient objection were used and their limitations in being able to quantifiably weigh each principle, as well as the ethical justifiability of withdrawal of dialysis should the patient continue to be decapacitated and unwilling to cooperate with dialysis.

Annotation

The finding: The authors present the case of an 84-year-old woman with bipolar disorder who is dialysis dependent and stopped both her antipsychotic medications and dialysis. She was found to lack capacity to decline both due to paranoid delusions causing her refusal and dialysis was done over objection with consent provided by a surrogate decision maker. Logistically this involved ICU admission for that purpose, sedation, physical restraints, antipsychotic medications provided, and interdisciplinary meetings among multiple specialties and nursing to come to consensus about the plan. The authors recommend in cases of patients with severe mental illness (SMI) and end stage kidney disease to assess if the lack of capacity may potentially be reversible through psychiatric treatment. If so, then they recommend the consideration of a time-limited trial for dialysis over objection with chemical and physical restraints being used.

Strength and weaknesses: The authors use a systematic approach to outlining an ethical process for weighing dialysis over objection for people with severe mental illness. Specifically they apply guiding principles from Rubin and Prager (2018) on deciding whether to perform a medical intervention over objection in an individual without capacity: (1) Likely severity of harm without intervention; (2) How imminent that harm is; (3) efficacy of the intervention; (4) risks of the intervention; (5) likely emotional effect of performing the intervention over objection on the patient; (6) patient’ reason for refusal and whether that can be addressed; and (7) the logistics of treating over objection. The authors proposed approach does not however cite more than one case, and a case series or larger sample size would have been helpful in assessing how feasible or generalizable their recommended approach is.

Relevance: C-L psychiatrists are frequently asked to conduct capacity evaluations when patients are declining interventions. The criteria for how to conduct those capacity evaluations are well-established in the literature. The article summarized here goes beyond that to also give C-L psychiatrists a framework for advising primary teams on whether to proceed with doing a medical intervention over a patient’s objection when severe mental illness is present, particularly in the case of dialysis.

Reference:                                                                                         

9. Rubin and K.M. Prager, “Guide to Considering Nonpsychiatric Medical Intervention over Objection for the Patient Without Decisional Capacity,” Mayo Clinic Proceedings 93, no. 7 (July 2018): 826–9.

Suicide, Capacity, and End-of-Life Decisions: Ethical Considerations in Withdrawing Care
Tyler J Thompson, Victoria Garcia, Arlen Gaba, Katelyn Li, Sahil Munjal

Abstract:

We present a case of an incarcerated patient who attempted suicide while in police custody for less than 24 hours. He sustained a C1 vertebra fracture resulting in quadriplegia, poor prognosis, and little chance of neurologic recovery. The patient's urine drug screen was positive for multiple substances, indicating likely intoxication at the time of the attempt. While in the intensive care unit he was only able to communicate through eye movements and blinking. He consistently expressed a wish to withdraw life-sustaining care. This case highlights the ethical challenges involved in assessing decision-making capacity after a suicide attempt in an incarcerated individual, the impact of substance use on capacity, the complexities and potential biases in surrogate decision-making, and the emotional and moral burden of end-of-life care decisions on healthcare providers. We used a deliberate approach involving time for information gathering and deliberation, identification of surrogate decision makers, and engagement of multidisciplinary teams to reach a consensus that upheld ethical principles and protected clinicians from moral injury.

Annotation

The finding: This case report examines the ethical complexity of withdrawing life-sustaining treatment after a suicide attempt in an incarcerated patient with devastating spinal cord injury, suspected recent intoxication, limited communication ability, and an initially uncertain surrogate decision-making structure. The patient consistently expressed a desire to withdraw care after his attempt, but psychiatry determined that he lacked decision-making capacity for end-of-life decisions in the immediate aftermath of the suicide attempt, given the difficulty assessing the rational manipulation component of capacity amid acute suicidality, likely substance involvement, severe distress, and profound communication limitations.

The authors argue that the ethically defensible path in such a case is neither reflexive honoring of the patient’s request nor indefinite paternalistic prolongation of treatment, but rather a deliberate period of multidisciplinary deliberation. In this case, roughly 72 hours allowed clinicians to gather collateral, identify a surrogate, clarify the patient’s values, treat possible withdrawal and anxiety, and engage psychiatry, ethics, palliative care, surgery, chaplaincy, and critical care before reaching consensus for compassionate extubation.

The paper’s central contribution is its effort to hold several tensions together at once: that suicidal behavior does not automatically negate all autonomy, that recent suicide attempts may still appropriately raise concern about decisional capacity for irreversible life-ending choices, that surrogate decision-making is vulnerable to bias especially when relationships are estranged, and that incarcerated status introduces additional risks of injustice and dehumanization in end-of-life decision-making.

Strength and weaknesses: A major strength is that the article addresses a clinically recognizable but under-discussed problem at the intersection of consultation-liaison psychiatry, critical care, palliative care, and correctional medicine. Rather than presenting the case as straightforward, the authors show how familiar frameworks such as capacity assessment, substituted judgment, and the principles of autonomy, beneficence, nonmaleficence, and justice become strained after a catastrophic suicide attempt.

Another strength is its practical orientation. The paper focuses less on abstract debates about rational suicide and more on how clinicians can proceed when facts are incomplete, communication is limited, and the emotional burden on staff is high. Its emphasis on time-limited deliberation, collateral gathering, and shared responsibility across disciplines is especially useful.

The main limitation is that, as a single case report, it cannot resolve the broader question of when a recent suicide attempt should alter the threshold for honoring a request to withdraw life-sustaining treatment. The paper also suggests that a person immediately after a suicide attempt lacks full capacity, a claim that may not generalize across jurisdictions and risks sounding more categorical than the case itself supports.

Relevance: For consultation-liaison psychiatrists, this article addresses core issues in C-L work including capacity, suicidality, surrogate decision-making, end-of-life ethics, and diagnostic uncertainty in medically complex patients. It is particularly useful because these cases often provoke polarized reactions, with some clinicians viewing withdrawal as assisting suicide and others seeing continued treatment as prolonging suffering. The article offers a more disciplined middle path.

The paper is also valuable because it shows how structural vulnerability can distort ethical reasoning. Incarceration, estrangement, substance use, and impaired communication all increase the risk that clinicians will substitute their own values for the patient’s. For that reason, the article has clear teaching value for psychiatrists working with ICU, trauma, and palliative care teams in cases where capacity is difficult to assess and suffering is profound.