Anorexia nervosa is a complex eating disorder characterized by severe food restriction, leading to a dangerously low body weight. Individuals with anorexia nervosa often experience an intense fear of gaining weight, a distorted body image, and may not fully recognize the significant health risks associated with the condition.

In cases where individuals have undergone years of unsuccessful treatments, repeated hospitalizations, and significant cognitive and physical decline, the continued use of involuntary medical interventions has been increasingly debated. Critics argue that individuals should have the right to make decisions about their own end-of-life care, including the option to die on their own terms. 

Medical Assistance in Dying (MAID) has been extended to psychiatric disorders with high-mortality risk  including anorexia nervosa, in countries like the United States, Belgium, and the Netherlands. In Canada, discussions about expanding MAID eligibility to include psychiatric conditions are ongoing, though legislative decisions have been postponed. This important issue was further explored in a podcast interview with Anita Federici, a recognized clinical psychologist and fellow of the Academy for Eating Disorders. 

In 2022, physician Jennifer Gaudiani published a polarizing paper introducing the notion of “terminal anorexia nervosa” for patients with chronic, treatment-resistant cases of severe and enduring anorexia. Drawing on a sample of three individuals, the paper argued for the eligibility of MAID for patients who met four specific criteria: a diagnosis of anorexia nervosa with a life expectancy of six months or less, being 30 years or older with a prolonged history of illness, repeated treatment failures resulting with no symptom improvement, and the patient’s ability to provide informed consent.

Federici raises concerns about the potential harms of these criteria, emphasizing that many physicians, including psychiatrists, receive little to no training in eating disorders. She also highlights that the paper does not adequately consider the diversity of eating disorder experiences and doesn’t incorporate perspectives from individuals with lived experience, caregivers, and other researchers and clinicians.

A 2024 publication by Chelsea Roff and Catherine Cook-Cottone examined cases of MAID involving individuals with eating disorders, particularly those with severe and enduring anorexia nervosa. Analyzing over 60 MAID cases for eating disorders between 2012 and 2024 across multiple American states, the Netherlands, Belgium and Switzerland, the study identified inconsistencies in clinical justifications for assisted dying. Many MAID applications were approved despite coexisting psychiatric comorbidities, unclear eligibility criteria, and variable mental health assessments. 

Labelling individuals with severe and enduring anorexia as “treatment-resistant” is also a point of contention, as it can overlook the systemic gaps of existing care models. Standard weight-centric treatments frequently fail to address the diverse needs of patients, contributing to higher dropout rates and relapses. 

When treatment is appropriately adapted, recovery outcomes can improve significantly. However, research suggests that many individuals seeking MAID were not offered care tailored to their specific needs. As Federici states, “You put people into treatments that were never built for them, they don’t respond adequately. Then people say they’re chronic, and now they’re terminal because there never really was the right treatment for them.”

Closeup of patient mother writing medical information on document discussing sickness symptoms with african american doctor during clinical appointment in hospital office. Health care service

While some argue that individuals with severe anorexia nervosa should have the same rights to MAID as those with other chronic conditions, others caution that anorexia nervosa can significantly impair decision-making. Long-term malnutrition can induce neurological changes that distort a patient’s ability to accurately assess their condition and prognosis. Roff and Cook-Cottone’s study found that 68% of eating disorder patients approved for MAID were medically underweight and malnourished, raising concerns about their capacity to provide informed consent.

A key issue in advocating for MAID eligibility for individuals with anorexia nervosa is the assumption that some patients are beyond recovery. However, research suggests that even for those who have struggled for a long time, recovery is possible with appropriate, individualized care.

Federici has observed how patients’ perceptions of their future can shift over time: “Suicidality is part of many people’s experiences with eating disorders and while important not to invalidate the suffering, at one point or another most of my patients would qualify for MAID. I’ve worked with people in their 30’s and 40’s who recover and have great qualities of life, so it’s dangerous to have the criteria for assessing physician-assisted death so loosely defined. I’ve had too many people that are on the other side of it saying ‘I’m so glad I didn’t have those options.’” 

Unlike terminal illnesses such as cancer or ALS (Lou Gehrig’s disease), anorexia nervosa does not have a definitive threshold for irreversibility. As alternative therapies, including somatic healing and psychedelic treatments, continue to develop, classifying anorexia nervosa as a terminal illness risks denying individuals the opportunity for meaningful recovery. 

Federici underscores the importance of maintaining hope in the recovery process, “Hope is one of the most important tenets of recovery, you lose that by giving someone the prospect of a death sentence. I don’t want to take away choice from people, but I want to protect people too.” 

She advocates for reforming treatment models to provide more accessible, innovative, and individualized care. Ultimately, the direction of this debate will depend on the collaboration of policymakers, clinicians, and individuals with lived experience to balance compassionate care with the potential for recovery. 

– Ruby Kagan, Contributing Writer

Image Credits:

Feature: pvproduction on FreePik, Creative Commons

Body Image 1: Annie Spratt on Unsplash, Creative Commons

Body Image 2: DC Studio on FreePik, Creative Commons