I have been invited to take part in this debate. Anorexia and other mental health conditions are being considered in the context of assisted dying laws. Should someone with anorexia be allowed to ask to have an assisted death?
This is a deeply complex and controversial question that touches on ethical, medical, spiritual and legal considerations. Our answer may depend on how we weigh up the concepts of autonomy (freedom to choose) capacity (being sane) and the nature of anorexia as a severe and enduring mental health problem that creates intense suffering, with no known treatment guaranteed to work.
That doesn’t mean we stop trying.
Many people get better, and I know there is usually a turning point sooner or later. This turning point has been studied so I won’t go into it now. But it can happen with or without therapy. Sometimes people get sick and tired of being sick and tired and then fight their own way out of the starvation phase.
All the same, some people don’t get better despite years of treatment. I have known more than a few people very ill who tell me with conviction that they don’t have anorexia but they have depression. One long-term patient told me that she wanted to pull her skin off her body. I write this not to shock you but to illustrate that anorexia is often complicated by other things and can cause profound suffering.
I can think of reasons for refusing permission to die.
The main one is that anorexia distorts thinking and mental decision making because of neurological changes associated with starvation. The prefrontal cortex in anorexia shrinks to 6.4% of its healthy volume (Maudsley 2024) – a factor that interferes with effective therapy. This is what makes it hard to decide whether someone has the capacity to make such a decision.
Also, the mental component of anorexia includes a drive for self-destruction that complicates whether the person has autonomy in the same way as an adult suffering from cancer or a degenerative disease.
While anorexia is severe and sometimes enduring, recovery or partial recovery is possible even in cases that seem hopeless, given compassionate treatment and support. If we grant access to assisted dying for people with anorexia, we create a slippery slope where the lives of other people with mental problems are undervalued.
Last and not least, healthcare providers have an ethical duty to preserve life, especially in people who lack judgement. We should not abandon people who, at one point in time, have lost all hope of a meaningful life.
I can think of reasons for allowing it
One is that having gone through years of unsuccessful treatment and who continue to experience unbearable suffering, IF palliative care still doesn’t help, assisted dying might be seen as a compassionate option. This has been allowed in other countries such as in Sweden and in Canada.
Deciding whether someone with anorexia has capacity requires rigorous psychiatric and medical evaluation. I don’t think we have explored who would do it and how it would be done. We shouldn’t leave one person to carry responsibility for someone’s life and death.
The bottom line must be NO, or NOT YET
If we extend assisted dying to people with mental health problems it will add to the stigma people with anorexia already have and there is a real risk of pushing people toward this option rather than putting effort into their recovery.
This question is serious and pertinent. Most experts will argue that our priority is improving access to treatment and ensuring that people with anorexia receive compassionate care, either with a treatment service or, if all fails, with palliative care. People can use the space of palliative care to gather the strength to change. We must acknowledge the interplay between the complexity of anorexia, mental capacity and the potential for recovery. Before deciding.
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