One of the central issues to consider when thinking about non-treatment decisions for anorexia patients is the issue of decision-making capacity (or as some people refer to it, competence). Contemporary medical practice in the western world is predicated on the ethical idea of informed consent, the idea that the patient decides what treatment to accept or refuse. But only patients deemed to have decision-making capacity are allowed to exercise such choice.

The question of whether or not patients with anorexia have decision-making capacity is a vexed one. If we apply the standard framework for determining capacity, an anorexia patient will most likely have capacity at certain points during the course of her illness when her weight is higher, but then lack it at other times when her weight is extremely low and her cognitive functions are impaired. But the standard framework itself can be troubling in the context of a disease like anorexia, and a number of people have challenged the idea that all patients who satisfy these criteria really do have capacity. Finally, the fact that capacity assessment always leaves a fair bit of room for interpretation and judgment on the part of the assessing psychiatrist means that it is often incredibly difficult to predict ahead of time whether particular anorexia patients will be found to have capacity.

All of this matters because capacity is typically assumed to be the determining factor when one considers whether or not to honor a treatment refusal. If the patient has capacity and wishes to refuse treatment she can. If she lacks capacity, it is often simply assumed that this settles the matter in favor of treatment. But in other areas of medical practice, non-treatment decisions do not always, of necessity, require decision-making capacity. Perhaps some of these other rationales might apply in the case of psychiatric illness as well. For example, if (on independent grounds) treatment could be deemed futile or if it could be deemed to be against the best interests of the patient, it might be possible to justify non-treatment in anorexia patients even when they are found to lack capacity. How such a justification might go, and who would make such a determination, are two of the important topics to be discussed in this session.