Eating disorders (EDs), while horrific and sometimes life-threatening, are usually treatable. Killing someone with an ED, on the other hand, is not. And as the legal boundaries for assisted suicide expand, patients with EDs are increasingly being killed rather than treated, a new study has found.
Published July 30 in Frontiers in Psychiatry, it claims to be “the first study to systematically review all known cases of assisted dying in patients with eating disorders across both peer-reviewed studies and official government reports.”
Diagnosis Murder
That turned out to be a daunting task because there are “considerable gaps in the reporting of assisted death in patients with psychiatric conditions, posing substantial concerns about oversight and public safety,” wrote Chelsea Roff, executive director of the ED recovery-support organization Eat Breathe Thrive, and Catherine Cook-Cottone, a professor at the University at Buffalo who treats patients with EDs.
“In many cases,” they continued, “the clinical rationales that were used to affirm patients with EDs were eligible for assisted death lack validity and do not cohere with empirical understanding.”
At least 30 jurisdictions worldwide — including in the United States — allow assisted suicide. Most require the patient to have a terminal illness, although “legislation rarely provides a comprehensive, clinically applicable explanation of how determinations of terminality should be made,” contended the authors. Others have even laxer requirements, though they usually mandate that the patient have “an irremediable condition causing unbearable suffering.” Physicians thus enjoy a great deal of latitude in determining whether a patient is eligible for assisted suicide.
Doctors being human, however, their determinations are necessarily imperfect, reflecting the doctors’ knowledge, biases, personal beliefs, and perhaps even weariness with attempting unsuccessfully to treat a patient. Doctors tend to be pessimistic about patients’ chances of recovery — all the more so when the patient suffers from a psychiatric, rather than physical, condition such as an ED.
Anorexic Reporting
Roff and Cook-Cottone did their best to make sense of the assisted-suicide documents they were able to obtain, but were hampered by the “dearth” of ED-related studies in peer-reviewed literature and the inconsistent, sketchy reports provided by governments that “rarely include detailed information (e.g. psychiatric diagnoses) about the characteristics of patients who underwent assisted death.” Still, they managed to identify “10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024.”
Only 19 of these cases “included descriptive case summaries with information about the patients and the clinical rationales that were used to justify assisted death,” reads the study. Every one of those patients was a woman, the vast majority of them 50 years old or younger.
The authors further found:
All but one person described in the case reports had multiple comorbid psychiatric diagnoses. Rates of comorbidity were high; 95% had more than one psychiatric disorder, 61% had more than three, and nearly a quarter had four or more comorbid conditions.
Patients also suffered from high rates of depression, chronic suicidality, “poor social functioning,” and self-injury.
Starving for Treatment — Not Death
Between physicians’ limitations and ED patients’ psychiatric disorders, determining that an ED patient cannot be cured, has the capacity to choose death, and has voluntarily done so presents serious ethical problems.
In a Joint Statement Against Assisted Suicide for Eating Disorders, Eat Breathe Thrive declares:
Eating disorders are treatable conditions that require timely and comprehensive treatment. The notion that they are incurable or terminal is scientifically unsupported and dangerously misleading.
Even patients who have suffered from EDs for years can recover, though it may take a long time for evidence of recovery to manifest itself.
In the United States, euthanized ED patients were invariably described as terminal because state assisted-suicide laws require such a diagnosis. To get away with this, the notion of “terminal anorexia” — when a patient simply gives up on further treatment and accepts death as inevitable — was invented. However, noted the study, “this conception of terminality deviates from medical definitions of a terminal condition, by describing reversible cognitive behaviors … as indicators of a terminal illness…. Unlike cancer or Alzheimer’s disease, most medical complications associated with anorexia can be treated with adequate nutritional intake and weight restoration, even in severely emaciated patients.”
ED patients’ numerous psychiatric disorders — not to mention malnutrition — naturally affect their thought processes, calling into question their supposedly voluntary choices. The authors pointed out that ED patients frequently cannot “appreciate the consequences of their decisions,” “lack insight into their disorder and its life-threatening risks,” and have impaired “ability to discern and communicate their true wishes, raising questions about the authenticity of the voluntariness of their decision to die.”
“Ascribing autonomy to the expression of symptoms of a treatable mental disorder in order to grant a request for assisted dying reflects a fundamental misunderstanding of the nature of EDs and their associated psychopathology and an obfuscation of a physician’s duty to prevent harm,” asserted Roff and Cook-Cottone.
Compassion or Cruelty?
“We categorically reject the argument that assisted suicide is a form of compassionate care for individuals with eating disorders,” says Eat Breathe Thrive. “Compassionate care involves consistent, effective treatment — not facilitating suicide.”
Unfortunately, euthanizing people with EDs was inevitable from the moment death-by-doctor became legal. As Wesley Smith observed:
Once the legalization train leaves the station, it is no longer containable or controllable. Or, to put it another way, once a society decides that killing is an acceptable answer to human suffering, the category of “killables” never stops expanding.