Case Study

Pam is an eighteen-year-old with a history of depression. She has been hospitalized for the past six months for severe weight loss and dehydration. When admitted, she was diagnosed with acute inflammation of the pancreas and gall bladder, but it became clear that these issues were secondary to a diagnosis of anorexia nervosa. Her weight upon admission was seventy-six pounds. Pam refuses to accept this diagnosis and will not cooperate with any provider who refers to “anorexia” or attempts to discuss her eating disorder.

As a pragmatic strategy for providing care, the medical team has largely avoided referring to anorexia or eating disorders when treating her. But Pam is not the only problem. Pam’s mother, the only family member directly involved in her care, also refuses to acknowledge her daughter’s anorexia and has supported Pam’s extremely restrictive requests to control her hospital meals as she regains her ability to eat by mouth. Prior to admission, Pam was living at home with her mother. She has no contact with her father.

Now that Pam’s acute condition has improved, the medical team worries that any further complicity in her denial of her anorexia will hinder attempts to begin eating disorder treatment protocols. Consultants from adolescent medicine and psychiatry tried having a frank discussion with Pam and her mother about Pam’s underlying eating disorder. This conversation only succeeded in making them both angry. Her mother ultimately threatened to “fire” these physicians.

The medical team and hospital decide to pursue involuntary commitment to treat Pam’s anorexia if she does not agree to treatment. Yet when a consulting surgeon recommends that Pam’s gallbladder be removed, Pam is allowed to consent to surgery. Soon thereafter she is evaluated by a mental health professional, who decides that Pam does not meet criteria for involuntary commitment. Pam insists she be discharged.

Her primary nurse couldn’t help but wonder: does Pam have the capacity to make medical decisions, or doesn’t she?

• Commentary
• Douglas J. Opel

The distorted body image and unrealistic perceptions that give rise to denial in anorexia pose an interesting ethical issue: how does this distortion and denial affect the patient’s capacity to make treatment decisions? It could be argued that Pam’s refusal to acknowledge her disorder represents a lack of the insight and comprehension required to make decisions about treatment. This, in turn, could call into question her decisional capacity and provide justification for involuntary commitment. The clinicians in Pam’s case seem to be making this claim. But their other actions— such as obtaining Pam’s consent to remove her gallbladder—seem to imply the opposite. How can we declare that a person both retains and lacks decisional capacity at the same time?

The answer to this question might simply be that assessments of capacity should be specific to the decision in question, rather than a global assessment. Therefore, even though we might think Pam lacks capacity to make decisions about her feeding regimen, we may still consider it appropriate to respect her autonomy in other decisions, such as whether to remove her gallbladder. But herein lies the rub: where does anorexia begin and end? Can treatment decisions in this case really be separated into “anorexia-specific” and “other”?

When it is difficult to discern which decisions are adversely affected by the patient’s underlying disease, there are two possible ethical approaches: (1) err on the side of respecting autonomy and allow the patient to make some decisions that perhaps she does not have the capacity to make, or (2) err on the side of protecting the patient by narrowing the scope of decision-making authority, thus failing to fully respect the patient’s autonomy. Option one has practical appeal in this case because of the need to engage the patient in her recovery with a disease that is centrally about control. However, option two seems to have equal appeal for anorexia and other mental illnesses because of the difficulty in determining the effect the disease has on any decision.

Even though the standard model of decision-making capacity is not a global assessment and option one is...