Assisted suicide for anorexia nervosa expands assisted suicide from terminal to chronic conditions.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In January I wrote an article about assisted suicide for anorexia nervosa. In the article I quoted from a case report published by the ACAMAID, an organization of assisted suicide practitioners who approved assisted suicide for anorexia nervosa by defining the condition as being "terminal." 

An article by Jennifer Brown that was published in the Colorado Sun on March 14 reports on Dr. Jennifer Gaudiani, an internal medicine doctor who specializes in eating disorders and who published a paper on her experience with prescribing assisted suicide for three people with anorexia nervosa.

Gaudiani defines anorexia as a terminally illness. Colorado's assisted suicide law does not permit assisted suicide for chronic or mental illnesses. Gaudiani considers anorexia to be a terminal condition because of the high rate of death among those who struggle with the condition. Brown writes:

In the paper, published in February in the Journal of Eating Disorders, Gaudiani ... writes that, although anorexia doesn’t have delineated levels of severity like cancer, which has stages of progression and a terminal phase, it can be brutally lethal. It is widely believed to have the second-highest mortality rate of all mental illnesses, behind only substance use disorders.

Based on the fact that anorexia has the second-highest mortality rate of all mental illnesses, second to substance use disorder, does that mean that people with substance use disorder also qualify for assisted suicide?

Is anorexia nervosa a terminal or a chronic condition?

A study by Kamryn Eddy et al., published in the Journal of Clinical Psychiatry in February 2017 titled: Recovery from Anorexia Nervosa and Bulimia Nervosa at 22 year Follow-Up recognizes that some people with Anorexia Nervosa die from the condition, but the study considers anorexia nervosa to be a chronic condition, not a terminal condition. The study is based on a 22 year follow-up and it concludes that for many people recovery is slow but nearly two-thirds of the participants fully recovered by year 22.

The study by Eddy is significant as it began in 1987 and followed up the participants at regular intervals including the 9 year interval and the 22 year interval. The study found:

Results:
At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa but not in bulimia nervosa.

Conclusion:
At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.

There are several significant findings in this study:

1. Recovery from anorexia nervosa was slower than bulimia nervosa. Whereas 31.4% of the participants with anorexia nervosa were fully recovered by year 9 and 62.8% were fully recovered by year 22, with bulimia nervosa 68.2% were fully recovered by year 9 and 68.2% were fully recovered by year 22.

In both anorexia nervosa and bulimia nervosa, some of the participants who had fully recovered by year 9 were no longer fully recovered by year 22, but that also suggests that these are chronic conditions. Anorexia nervosa often requires a longer term treatment commitment to achieve full recovery which also indicates that anorexia nervosa is a chronic condition andnot a terminal condition.

2. The data in the study indicates that of the 246 study participants 18 people were known to have died by the 20 - 25 year interval. There is some missing data since researchers lost contact with 15 of the participants, and 37 participants decided not to continue participating in the study, nonetheless, if anorexia nervosa were a terminal condition the death rate by the 20 - 25 year interval would be much higher. The study does not indicate if all of the 18 participants who were known ot have died, died from the chronic condition or if some died from another cause.

Eddy refers to a study by Hay and colleages who suggested that:

“both the clinician and [chronically ill] patient often share the experience of hopelessness and despair about the likelihood of meaningful change.”

I suggest that feelings of hopelessness and despair are leading assisted suicide clinicians to redefine anorexia nervosa as a terminal illness and thus prescribe death as a treatment.

The recent Oregon 2021 assisted suicide report also listed anorexia as a reason for assisted suicide.

 My earlier comments that assisted suicide for anorexia nervosa is abandonment is supported by the conclusion of the study which states:

Our data indicate that the majority will recover from anorexia nervosa and bulimia nervosa over time. Yet 2 decades of illness represents considerably meaningful life lost, and our findings emphasize the importance of developing interventions to reduce the duration of illness. Our findings that recovery remains possible even after long-term illness argue for active treatment rather than palliative care for most patients. Increased research attention to identifying early predictors, mediators, and moderators of recovery in naturalistic and controlled treatment trials is needed to guide treatment disposition recommendations.

By prescribing lethal drugs for assisted suicide or lethally injecting a person (euthanasia) the clinician is abandoning the patient rather than helping the patient find hope with the potential of long-term recovery.