The four principles of biomedical ethics in anorexia nervosa

The four principles of biomedical ethics, respect for autonomy, beneficence, non-maleficence, and justice, were first systematically articulated by Beauchamp and Childress in their seminal work, Principles of Biomedical Ethics (Reference Beauchamp and Childress1979). This ethical framework emerged in the wake of post-WWII research scandals and medical paternalism, offering clinicians a systematised way to navigate moral dilemmas in medicine.

1. Autonomy: respecting patient choice vs. impaired decision-making

Respect for autonomy, the right of patients to make informed decisions about their care, is a cornerstone of medical ethics. While the four principles continue to be given equal weight by Beauchamp and Childress (Reference Beauchamp and Childress2019), some would argue that respect for autonomy should be seen as ‘first among equals’ (Gillon Reference Gillon2003). This primacy of autonomy underpins a general presumption in favour of respecting patients’ treatment refusal, even when this conflicts with medical advice. In the case of AN, there is reason to challenge this normative strength of autonomy. Anorexia is characterised by overevaluation of weight and shape concerns, the core psychopathology that maintains the cognitions and behaviours of the illness (Forrest et al. Reference Forrest, Jones, Ortiz and Smith2018). These overvalued ideas can pervasively distort an individual’s evaluative outlook, placing significance on thinness and control beyond their ordinary value. A person’s entire personal identity can become inextricably intertwined with anorexia; it may become an inherent part of their personality (Tan et al. Reference Tan, Hope and Stewart2003). Further, some patients with anorexia may view death and disability as relatively unimportant compared with maintaining their eating disorder, while others may struggle to believe they could be harmed by their eating disorder (Tan et al. Reference Tan, Hope and Stewart2003). The paramount importance of being thin, as well as the valued functions anorexia can serve, such as giving a feeling of control, avoiding growing up, or helping increase popularity are all personal values that may have become distorted by the illness (Tan et al. Reference Tan, Hope, Stewart and Fitzpatrick2006). While clinicians should not dictate which personal values are ‘correct’, it is important to distinguish whether values arise from the individual or from the disorder (Tan et al. Reference Tan, Hope, Stewart and Fitzpatrick2006). If it can be clearly determined that values arise from the mental disorder as opposed to the person, these values cannot be seen to be authentic, thus undermining the individual’s capacity for autonomous choice. The situation has been likened to how suicidal thoughts may be a defining feature in depression; certain desires may be thought of as ‘intrinsically pathological’ (Jefferson Reference Jefferson2024).

Capacity is foundational for autonomy and needed in order for a person to exercise their autonomy meaningfully. Without the capacity to fully understand and evaluate the consequences of a decision, autonomy cannot be fully realised (Donnelly Reference Donnelly2008). There are convincing biological reasons to question decision-making capacity in AN, given the effects of starvation on the brain. Anorexia is associated with structural alterations in the brain, with smaller brain volumes and a decrease in cortical thickening (Walton et al. Reference Walton, Bernardoni, Batury, Bahnsen, Larivière, Abbate-Daga, Andres-Perpiña, Bang, Bischoff-Grethe, Brooks, Campbell, Cascino, Castro-Fornieles, Collantoni, D’Agata, Dahmen, Danner, Favaro, Feusner, Frank and Ehrlich2022). This brain volume loss is also correlated with illness duration, with worsening effects on the brain with more chronic illness (Fonville et al. Reference Fonville, Giampietro, Williams, Simmons and Tchanturia2014). Decision-making ability has been found to be impaired in AN (Tchanturia et al. Reference Tchanturia, Liao, Uher, Lawrence, Treasure and Campbell2007); cognitive flexibility can also be affected, with reduced ability to set-shift (Steinglass et al. Reference Steinglass, Walsh and Stern2006). Impaired mental capacity has been found in around one-third of patients with severe anorexia (Elzakkers et al. Reference Elzakkers, Danner, Hoek and van Elburg2016), though determinations of capacity in this cohort are complex and nuanced (Jefferson Reference Jefferson2024). These potential issues around capacity, along with the aforementioned pathological influence on personal values may represent significant impairments of autonomy. Thus, respecting treatment refusal at face value in these circumstances may risk conflating pathology with agency, elevating the illness voice above the patient’s own authentic preferences (Hope et al. Reference Hope, Tan, Stewart and Fitzpatrick2011).

While anorexia has the potential to profoundly undermine capacity and autonomy, it would be an oversimplification to generalise this to all persons with the illness. Determining a person’s authentic preferences is a tricky endeavour, and risks prioritising the assessor’s assumptions of what authentic choices should be over what they actually are (Hope et al. Reference Hope, Tan, Stewart and Fitzpatrick2011). Indeed, there may be a certain amount of paternalism in enforcing treatment against the patient’s expressed wishes in order to vindicate what is thought to be the person’s authentic preferences (Jefferson Reference Jefferson2024). Moreover, in patients with severe and enduring anorexia who have been ill for many years, how would one even start to determine where the illness ends and the authentic self begins? The recent reforms introduced by the Assisted Decision-Making (Capacity) Act 2015, which move the focus from acting in a person’s ‘best interests’ to respecting their ‘will and preferences’, require both clinicians and the judiciary to carefully consider what ‘preferences’ mean for this population.

Respecting autonomy in patients with anorexia who refuse treatment is complicated; involuntary treatment has the potential to constrain autonomy in a manner that may be deemed paternalistic but may also treat the illness that is impairing a person’s capacity to make autonomous choices, thereby allowing them to recover their authentic selves. In order to determine whether involuntary treatment is the morally correct choice, we must also consider the other ethical principles of beneficence, non-maleficence, and justice which will be explored below.

2. Beneficence: the ethical duty to promote wellbeing and recovery

The principle of beneficence refers to the positive obligation of clinicians to contribute to the welfare of patients, taking steps to attend to help patients and not merely refraining from harmful acts (Beauchamp and Childress Reference Beauchamp and Childress2019). When considering the ethics of controversial practices such as involuntary treatment for anorexia, the principle of beneficence demands that we consider the potential benefits that could be gained from such treatment. There have been developments in the evidence base for anorexia treatment in recent years, particularly in relation to early intervention programmes such as ‘First Episode Rapid Early Intervention for Eating Disorders’ (Fukutomi et al. Reference Fukutomi, Austin, McClelland, Brown, Glennon, Mountford, Grant, Allen and Schmidt2020). Psychological treatments such as cognitive behavioural therapy enhanced (CBT-E), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), and Specialist Supportive Clinical Management have a strong evidence base and are recommended by NICE guidelines (Byrne et al. Reference Byrne, Wade, Hay, Touyz, Fairburn, Treasure, Schmidt, McIntosh, Allen, Fursland and Crosby2017; NICE 2017). Research suggests that around half of patients will achieve a healthy weight with these treatments within 12 months, with one-third reaching remission (Byrne et al. Reference Byrne, Wade, Hay, Touyz, Fairburn, Treasure, Schmidt, McIntosh, Allen, Fursland and Crosby2017); treatment needs regular review and potential escalation in intensity in order to avoid a chronic course of illness (Himmerich et al. Reference Himmerich, Keeler, Tchanturia and Treasure2024). Family-based treatment (FBT) has shown good efficacy in weight restoration in adolescents (Lock and Le Grange Reference Lock and Le Grange2019), whilst daycare treatment following brief inpatient admission was shown to have a similar outcome to full inpatient treatment (Herpertz-Dahlmann et al. Reference Herpertz-Dahlmann, Schwarte, Krei, Egberts, Warnke, Wewetzer, Pfeiffer, Fleischhaker, Scherag, Holtkamp, Hagenah, Bühren, Konrad, Schmidt, Schade-Brittinger, Timmesfeld and Dempfle2014). While these advances in evidence-based treatment are promising, they focus predominately on individuals in the earlier stages of illness who are voluntarily engaging with treatment. The evidence for involuntary treatment, as well as for treatment of SE-AN in general, is more limited.

It is estimated that 13–44% of inpatient admissions for anorexia occur on an involuntary basis, with a higher complexity of illness noted in involuntary cohorts (Clausen and Jones Reference Clausen and Jones2014). While involuntary patients tend to have lower BMIs on admission, indicating increased severity of illness, BMI on discharge tends to be similar compared with voluntary patients, albeit with a longer admission duration (Atti et al. Reference Atti, Mastellari, Valente, Speciani, Panariello and De Ronchi2021). There are few long-term follow up studies on outcomes for those with anorexia who have been involuntarily treated, though the few studies available seem to suggest no significant difference in mortality compared with voluntary patients (Atti et al. Reference Atti, Mastellari, Valente, Speciani, Panariello and De Ronchi2021). While involuntary treatment can often treat the physiological aspects of the illness, this is not necessarily a guarantee; one study mentions a patient receiving involuntary treatment, including physical restraint, for 178 days and only gaining 1.11 kg (Thiels Reference Thiels2008). While involuntary treatment to medically stabilise critically ill adults can be lifesaving, even the coercive nature of treatment does not guarantee success in all cases, and the evidence base for the practice remains limited. Beneficence thus becomes ethically fraught when patients resist treatment and where treatment outcomes do not necessarily confer significant benefit in the longer term. The current evidence suggests that some patients can certainly benefit, but identifying this subset of patients remains a challenge.

Contemporary paradigms recognise the multidimensional nature of recovery, transcending BMI (McDonald et al. Reference McDonald, Williams, Barr, McNamara and Marriott2021). A patients’ view of recovery may not align with that of the clinicians; some favour the removal of physiological parameters, such as BMI, from recovery criteria entirely (McDonald et al. Reference McDonald, Williams, Barr, McNamara and Marriott2021). Should a clinician’s concept of recovery be the determining factor in enforcing the treatments offered, even if this overrides the patient’s view and risks causing psychological distress?

This divergence forces clinicians to grapple with a fundamental conflict: whether to override refusal to prevent death (aligning with traditional paternalism) or to respect a patient’s expressed wishes when they perceive ongoing treatment attempts as a worse outcome than death. Some patients retrospectively acknowledge the need for involuntary treatment, with one study noting that half of the participants changed their perspective over time (Rienecke et al. Reference Rienecke, Dimitropoulos, Duffy, Le Grange, Manwaring, Nieder, Sauerwein, Singh, Watters, Westmoreland and Mehler2023). One former patient described it as ‘horrible to have part of my free will stripped away’, but later recognised that without it, she would not have survived (Fuller et al. Reference Fuller, Chapman, Cave, Druce-Perkins, Daniels and Tan2023).

While damage to the therapeutic relationship is frequently a concern when considering involuntary treatment, there is some emerging evidence that coercive pressure to begin treatment does not necessarily undermine the therapeutic relationship (Guarda et al. Reference Guarda, Pinto, Coughlin, Hussain, Haug and Heinberg2007, Schreyer et al. Reference Schreyer, Coughlin, Makhzoumi, Redgrave, Hansen and Guarda2016). Involuntary treatment in this cohort has potential benefits, but for a subset of patients may add little to their journey toward recovery and cause further distress, exposing the limits of beneficence in a condition where ‘doing good’ lacks consensus. Westmoreland and colleagues (2024) highlight this inherent challenge for clinicians in anticipating which patients are likely to benefit from coercive intervention. Predicting treatment response in AN remains imprecise, and the ethical calculus is complicated by this uncertainty. When involuntary treatment results in measurable improvement, such as reductions in eating psychopathology, patients and families often retrospectively view the intervention as necessary or even lifesaving (Rienecke et al. Reference Rienecke, Dimitropoulos, Duffy, Le Grange, Manwaring, Nieder, Sauerwein, Singh, Watters, Westmoreland and Mehler2023). However, when coercive measures fail to yield clinical benefit, the psychological and relational consequences can be profound, often leaving patients feeling traumatised and alienated from future care. For this subset of individuals, repeated exposure to coercive or unsuccessful interventions risks perpetuating cycles of therapeutic harm, ultimately tipping the balance from beneficence toward maleficence. In such cases, Westmoreland and colleagues suggest, that the harm associated with involuntary treatment overrides the slim chance of recovery. (Westmoreland et al Reference Westmoreland, Yager, Treem and Mehler2024).

3. Non-maleficence: avoiding harm in treatment

Non-maleficence refers to the ethical duty of clinicians to avoid causing harm to patients, emphasising that medical interventions should not inflict suffering (Beauchamp and Childress Reference Beauchamp and Childress2019). Although non-maleficence underscores the ethical obligation to ‘do no harm’, interventions in this patient cohort necessitate a careful weighing of potential risks and benefits. Involuntary treatment, including involuntary detention, nasogastric feeding under restraint, and involuntary administration of psychotropic medication, can lead patients to feel trapped, and augment their suffering (Mac Donald et al. Reference Mac Donald, Gustafsson, Bulik and Clausen2023). It may also lead to conditioned food avoidance in the long term (Batsell et al. Reference Batsell, Brown, Ansfield and Paschall2002). There are physical risks to involuntary measures such as nasogastric feeding, including nasal irritation, epistaxis, electrolyte disturbance, and refeeding syndrome (Hindley et al. Reference Hindley, Fenton and McIntosh2021); while there is a theoretical risk of serious complications like aspiration pneumonia with nasogastric feeding, this does not commonly appear in the literature relating to its use in anorexia. There are concerns that involuntary treatment may damage therapeutic rapport, though there is limited evidence to support this widespread concern (Schreyer et al. Reference Schreyer, Coughlin, Makhzoumi, Redgrave, Hansen and Guarda2016; Rienecke et al. Reference Rienecke, Dimitropoulos, Duffy, Le Grange, Manwaring, Nieder, Sauerwein, Singh, Watters, Westmoreland and Mehler2023). Using coercive interventions can also place an emotional strain on staff, who may feel morally distressed about their role in the treatment (Kodua et al. Reference Kodua, Mackenzie and Smyth2020). The psychological impact of coercion remains a serious consideration, however, not intervening may be associated with illness progression, irreversible medical harm or death.

Ethical justifications for compulsory interventions may also differ according to the stage of illness. In early-stage AN, beneficence may justify limited, short-term coercive measures to prevent irreversible medical harm and chronicity. In contrast, in long-standing or treatment-resistant cases, the ethical balance between beneficence and autonomy becomes increasingly complex, as ongoing coercion may undermine dignity, therapeutic trust, and overall quality of life.

For SE-AN, a harm-reduction approach, frequently used in other chronic conditions such as substance use disorders, may offer some compromise and has been increasingly discussed (Carney et al. Reference Carney, Yager, Maguire and Touyz2019). This means shifting focus from weight restoration to improving quality of life, stabilising physical health at a lower weight, and supporting nutritional intake without coercion. This approach acknowledges that rigid weight-based treatment goals may not be attainable for all individuals and that treatment refusal should not automatically equate to withdrawal of care. This differs from a palliative care approach to care, as while quality of life remains the priority, ‘it may also involve modifying one’s disease in order to ensure that one survives and/or achieves the quality of life that one wants’ (Bianchi et al. Reference Bianchi, Stanley and Sutandar2020). There is also no need to determine that treatment is ‘futile’ before implementing this approach, thereby bypassing some of the problematic associations inherent in discussions around futility in anorexia.

The palliative care approach, which prioritises relief of suffering, dignity, and symptom control in the management of terminal illness (WHO 2020), may be relevant for a small subset of patients with severe, longstanding illness (Westermair et al. Reference Westermair, Weber, Westmoreland, Mehler, Elsner and Trachsel2024). While there is emerging literature around palliation in anorexia, there remains significant uncertainty around the practice (Westermair et al. Reference Westermair, Weber, Westmoreland, Mehler, Elsner and Trachsel2024). It raises a difficult ethical question for clinicians around whether anorexia should ever be considered a ‘terminal’ illness and at what point palliative approaches should be considered over repeated forced interventions. These considerations raise the concept of ‘medical futility’ of care, and in the case of anorexia, that prolonged, coercive interventions in chronically ill patients with no sustained recovery may prolong suffering rather than meaningfully restore health (Schneiderman et al. Reference Schneiderman, Jecker and Jonsen1990; Yager Reference Yager2020). However, acknowledgement of anorexia as a ‘terminal illness’ and of treatments as ‘futile’, may carry the adverse risks of treatment and condition nihilism, as well as withdrawal of care. Further, while the chances of sustained recovery may be low, most medical complications can nonetheless be reversed with refeeding, therefore it is difficult to argue that treatment is ‘futile’ from a physiological standpoint. Unlike a late-stage cancer diagnosis, where treatment futility means that there is no hope of cure even with intensive treatment, futility in anorexia is ‘the result of rejecting or giving up on treatment’ (Jefferson Reference Jefferson2024). These questions around futility were examined by Gaudiani et al. in their (Reference Gaudiani, Bogetz and Yager2022) paper which proposed criteria for the concept of ‘terminal anorexia nervosa’. The authors proposed that patients above the age of 30 with anorexia, who have decision-making capacity and continue to have severe illness despite prior persistent engagement in high-quality, multidisciplinary eating disorder care could be considered to have ‘terminal’ illness. There was significant backlash from both clinicians and those with lived experience of anorexia following publication, eventually culminating in the authors retracting the label ‘terminal’ entirely (Gaudiani Reference Gaudiani2025). As will be discussed further below, even the most controversial definitions of futility require that a person have had trials of high-quality care prior to considering the illness to be ‘terminal’; In jurisdictions with unequal access to specialist eating disorder care such as Ireland, this is far from the norm for many patients (Cahill Reference Cahill2025).

The classification of AN as a potentially terminal illness brings with it profound ethical and clinical implications, most notably, the possibility that individuals with eating disorders could meet eligibility criteria for assisted dying (Roff and Cook-Cottone Reference Roff and Cook-Cottone2024). If the concept of AN as a ‘terminal illness’ becomes commonplace, this could risk a shift toward assisted dying as a solution in the longer term. This complex and nuanced issue warrants careful examination that goes beyond the scope of the present article and is likely to become increasingly salient in the coming years given legislative advances toward legislation in some jurisdictions.

The ethical question for clinicians is when is it appropriate to consider a harm reduction approach; should it be made explicit earlier in the treatment journey for those struggling to engage with recovery, or only in the context of severe and enduring illness with the recognition that some patients may never fully recover? And when, if ever, should discussions of palliative care enter the fray? Evidence suggests that some patients continue to recover years into their illness, with follow up after 22 years showing twice the amount had recovered compared to after 9 years (Eddy et al. Reference Eddy, Tabri, Thomas, Murray, Keshaviah, Hastings, Edkins, Krishna, Herzog, Keel and Franko2017). There is therefore a risk that entering into discussions around palliative care too soon may stymie a patient’s chance for recovery; yet delaying these conversations indefinitely risks prolonging suffering, highlighting the ethical tension between hope for recovery and the imperative to alleviate harm.

4. Justice: fair allocation of resources and access to care

The ethical principle of justice demands fair and equitable access to treatment, yet stark disparities persist in availability of eating disorder treatment. In Ireland, there have been no comprehensive epidemiological studies to determine the prevalence of eating disorders. Figures extrapolated from international rates estimate that 188,895 Irish people will experience an eating disorder in their lifetime, though these figures are likely an underestimation given recent population growth (HSE 2018). In Ireland, access to specialist care remains a postcode lottery, with protracted waits for services as the National Clinical Program for Eating Disorders is being developed (Cahill Reference Cahill2025). Despite significant investment in eating disorder services, only three inpatient public beds are available for adults in the entire country (Cahill Reference Cahill2025). While progress has been made with regard to the provision of community-based eating disorder treatment, many areas of the country continue to lack specialist eating disorder teams (Cahill Reference Cahill2025). This means that patients must rely on a patchwork of non-specialist mental health teams, private treatment providers, and treatment overseas (McGlynn Reference McGlynn2025). This systemic inequity raises an ethical paradox: how can treatment refusal be deemed ‘informed’ when patients may never have accessed high quality, evidence-based care? If recovery-oriented therapies such as CBT-E and MANTRA are unavailable to the patient, the very concept of ‘futility’ becomes suspect (Wonderlich et al. Reference Wonderlich, Bulik, Schmidt, Steiger and Hoek2020). Yet resource-intensive, involuntary treatment, risks being deployed asymmetrically – prioritising those with acute medical crises over those denied early, effective intervention due to resource constraints (Ayton et al. Reference Ayton, Viljoen, Ryan, Tutisani, Gardner, Collins and Ibrahim2019). There are also distributive justice dilemmas inherent in the provision of psychological treatments to patients with SE-AN; there is limited evidence to suggest that this group of patients benefits from available treatment, leading to the question of whether resources should be diverted away from patients earlier in their illness who have more hope of recovery (Touyz et al Reference Touyz, Le Grange, Lacey, Hay, Smith, Maguire, Bamford, Pike and Crosby2013). Such rationing forces clinicians into impossible cost–benefit calculations, balancing a justice imperative with the fiscal and manpower realities of limited health resources.

Laws governing involuntary care for anorexia nervosa in Ireland

In Ireland, involuntary treatment for adults with anorexia operates within a fractured legal landscape. The doctrine of necessity allows for emergency medical treatment when patients are unable to consent, should immediate intervention be necessary to protect life (Law Reform Commission 2006). Prior to the full commencement in 2023 of the Assisted Decision Making (Capacity) Act (2015), Wardship was the main route for involuntary treatment of adults with anorexia outside of these emergency situations (Dunne Reference Dunne2023). As Wardship is no longer a legal option, treatment orders may now be sought under the inherent jurisdiction of the High Court for adults who lack capacity. While anorexia meets the definition of a mental disorder under the Mental Health Act (2001) and patients may therefore be involuntarily detained under the 2001 Act, there has long been uncertainty as to whether interventions such as nasogastric feeding under restraint would also be covered by the legislation. This matter was ultimately examined in HSE v HH(2024), a case which determined that the Mental Health Act (2001) had inadequate legal safeguards for the oversight of nasogastric feeding, including with restraint. This leaves clinicians reliant on the High Court’s inherent jurisdiction to authorise treatment for patients with anorexia, a significant divergence from how the law authorises treatment for other mental illnesses. Patients may be subject to two different legal processes simultaneously: the MHA 2001 to provide for involuntary detention, and Inherent Jurisdiction to allow for NG feeding. It also differs from mental health law in jurisdictions such as England and Wales, where the Mental Health Act (1983) covers both detention and treatment such as nasogastric feeding (Dunne Reference Dunne2023). Recent Irish capacity legislation, the Assisted Decision Making (Capacity) Act 2015, emphasises the principle of respecting an individual’s will and preferences rather than relying solely on substituted decision-making. This development represents a shift toward supported autonomy, even in cases where decision-making capacity may be impaired, and has significant implications for ethical and legal considerations in the treatment of anorexia.

Ethical challenges in managing children and adolescents

The ethical landscape is also complex when anorexia occurs in children and adolescents, where Ireland has not yet endorsed mature minor doctrine, and children are generally not presumed to have legal autonomy (Lyons and Donnelly Reference Lyons and Donnelly2024). Treatment decisions rely on parental permission, with prioritisation of parental rights and the role of the family in Irish Law (Law Reform Commission 2011). While the HSE National Policy on Consent encourages involvement of children in decision-making and respect for their views, the Irish Courts have not recognised a right to give valid consent for children under 16 years (HSE 2024, Lyons and Donnelly Reference Lyons and Donnelly2024). To add further complexity, while young people aged 16 and up can consent to medical and surgical treatment, the case for psychiatric treatment is less clear, with the Mental Health Act (2001) defining a child as under 18 (Law Reform Commission 2011). This means that, in Ireland, a 17-year-old is treated for medical reasons in an adult hospital, but receives psychiatry care in a child and adolescent psychiatry unit. Additionally, while 16- and 17-year-olds may consent to medical and surgical treatment, refusal of treatment is more complicated; cases involving the refusal of life-saving treatment in this cohort are brought before the High Court in order to determine what is in the best interests of the young person (Law Reform Commission 2011). It is not clear to what extent they can refuse psychiatry care, if at all.

Clinicians must weigh up the views of both parents and children, which can diverge significantly. Parents may advocate for intensive refeeding (prioritising health) which the young person may refuse (prioritising avoidance of psychological distress). Parents may also seek specific treatment settings such as inpatient care, whereas the child may indicate a preference for outpatient treatment. Autonomy thus operates in a contested space, where the young person’s right to self-determination intersects with parental responsibility and clinicians’ duty of care. A further complication may arise if parents are not aligned in their decision, where the clinician is required to address family dynamics while holding the child’s best interests central. Clinicians therefore are required to consider whose version of ‘wellbeing’ prevails. Where agreement between the relevant parties cannot be reached, legal intervention by the Courts is often necessary, which may risk traumatising families and alienating the patient (Ferguson and Rayner Reference Ferguson and Rayner2023). In the case of minors, some Irish inpatient psychiatric units request court orders for child admissions, even in the presence of parental consent, to pre-emptively override potential treatment refusal, a practice that raises significant ethical concerns about justice, autonomy and the presumption of incapacity in paediatric anorexia.

These issues expose the limits of the rigid, age-defined capacity thresholds existing in Ireland and urge us to consider a more nuanced and graded approach to autonomy, including endorsing principles of Gillick competence as exists in other jurisdictions (Lyons and Donnelly Reference Lyons and Donnelly2024).

While discussions around management of patients with severe and enduring anorexia generally concern adults, recent literature suggests that a small subset of adolescents may share similar features to those with SE-AN (Tsiandoulas et al. Reference Tsiandoulas, McSheffrey, Fleming, Rawal, Fadel, Katzman and McCradden2023). These adolescents have a poor quality of life, limited treatment response, medical instability, and severe symptoms, which has been coined ‘AN-PLUS’ (Tsiandoulas et al. Reference Tsiandoulas, McSheffrey, Fleming, Rawal, Fadel, Katzman and McCradden2023). It has been suggested that a harm reduction approach may sometimes be in the best interests of these patients when intensive treatment options have not been beneficial; the authors are also clear in distinguishing this from the palliative care model, and that it does not preclude intensive intervention should life-saving treatment be needed (Tsiandoulas et al. Reference Tsiandoulas, McSheffrey, Fleming, Rawal, Fadel, Katzman and McCradden2023).

Striking an ethical balance

The treatment of anorexia exists in an ethical grey zone where medical necessity, patient rights, and long-term wellbeing must be carefully balanced. While involuntary treatment may be essential in some cases, it should not be regarded as the default solution; it is a delicate balance where ‘patients should not die with their rights on; but they should not live with their rights off, either’ (Hoffman Reference Hoffman1977).

For patients with severe and enduring illness, a more nuanced, individualised approach is needed. Harm reduction strategies and palliative care models may provide alternative paths in some cases for those who do not respond to standard treatments. However, these approaches must be carefully considered to ensure they are not prematurely applied in a way that enables the eating disorder rather than supports the patient.