A leading eating disorder specialist has proposed that patients with anorexia nervosa should be allowed access to assisted suicide. Dr Jennifer Gaudiani, a Denver-based physician, contends in the Journal of Eating Disorders that:
“… patients with terminal AN [anorexia nervosa] who are severely physiologically compromised, and whose end-of life suffering results from both psychological and physical pain, should be afforded access to medical aid in dying in locations where such assistance has been legalized—just like other patients with terminal conditions.“
Assisted suicide is legal in Colorado, where Dr Gaudiani practices.
There can be no doubt that anorexia nervosa (AN) is extremely dangerous. It has the second highest mortality rate of any psychiatric disorder after opioid use — the singer Karen Carpenter is probably its most famous victim. But normally it is treatable.
However, Dr Gaudiani believes that there are AN patients who are suffering from a heightened form of the disorder, which she calls “severe and enduring anorexia nervosa” (SE-AN). These people are over 30; all previous treatment has failed to help them; and they are capable of making an autonomous choice to stop prolonging their lives.
In her article, she narrates the stories of three of her patients who gave up fighting their disease and chose to die.
Her stories are meant to be heart-rending – and they are. One was even written by a posthumous co-author of the article. Dr Gaudiani tries to demonstrate that the effort involved in getting them to eat properly was effectively burdensome treatment. In her judgement their psychiatric disorder was intractable. Therefore, SE-AN patients should have the option of physician assisted suicide, or medical aid in dying (MAiD), as she prefers to call it.
The narratives, however, do not offer overwhelming evidence for this. In the first, Aaron, a 33-year-old man, refused treatment. He did not even ask for MAiD. Jessica, a 36-year-old woman, did take a lethal prescription and died surrounded by her family. And the co-author, Alyssa, a 36-year-old woman who had struggled with AN for 15 years, received a lethal prescription, but died in hospice without actually taking it.
Dr Gaudiani is pleading for her colleagues acknowledge that there is such a thing as SE-AN and that assisted suicide is appropriate end-of-life care for patients who suffer from it.
However, her reasons are more emotional than logical. As Australian psychiatrist John Buchanan observed to MercatorNet, anorexia is a very complex disease. Medication is only one piece of the puzzle. Sufferers need psychotherapy and behaviour modification therapy – and they may take years to succeed.
“The distress that anyone experiences with an illness is proportional to the quality and extent of the treatment and management,” says Dr Buchanan. “There’s a lot of poor quality psychiatric treatment being done.”
Therapy may be needed as well for families to help them to be resolute in supporting their loved one. This adds an extra layer of complexity to treatment. As Dr Buchanan points out, “The psychological reality is that family members often have very ambivalent feelings about a person who is seriously ill. The notion that all families are caring and benign is regrettably false. Many would prefer the ill person ‘got on with it’.” What if the anorexia patient fails to recover because their family is simply not committed to the necessary level of care? In such a case, recourse to MAiD would be putting the patient out of the family’s misery.
Dr Gaudiani insists that physician assisted suicide is not suicide: “MAID is offered to individuals whose death is inevitable within six months from an underlying disease process; it provides patients a choice in how they die, not whether they die. It is not a means of suicide.”
This, however, is sheer sophistry. Choosing a place, a method, and a time to end one’s own life is suicide. Besides no doctor can predict with certainty how long a patient will live. Treating MAiD as a natural end to life for anorexia sufferers is effectively medical neglect. If doctors persevere with patients who suffer from cancer or heart disease or diabetes for years, why not with anorexia?
Bioethics writer Wesley J. Smith, writing in the National Review, recently slated this approach as “abandonment”.
“Then why not allow an intentional, lethal opioid overdose as a “treatment” for opioid use disorder? Once you open the door for one by redefining it as “terminal,” you won’t be able to keep others out. When psychiatrists give up on their mentally ill patients — and indeed, are allowed to help them commit suicide — who will defend the value and continued importance of their lives? How will these very unhappy people be kept among us during their darkest days?“
As Dr Buchanan points out, permitting assisted suicide for anorexia nervosa would sweep away barriers to this solution for other people suffering from psychiatric illness.
“Many of them are suicidal at some point of their management. Most are recoverable and afterwards are thankful that action was not taken on their suicidal thought. It is absolutely simplistic and naive to act on the suicidal thought of people with psychiatric illness when they are obviously mostly quite treatable. The obvious ones are depressive illness, bipolar disorder, but many other conditions have an element of depression marked by suicidal thought!”
Anorexia patients may be very intelligent, but they are in the grip of a fantasy that they are overweight. The responsibility of their families and their physicians is to support reality not delusions.
International helplines can be found at www.befrienders.org. In the US, the National Suicide Prevention Lifeline is at 800-273-8255 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counsellor. In the UK and Ireland, Samaritans can be contacted on 116 123 or email firstname.lastname@example.org or email@example.com. In Australia, the crisis support service Lifeline is 13 11 14.