A Bitter Pill: The Ethics of Involuntary Treatment of Adolescents With Severe Eating Disorders

Severe eating disorders (EDs) are a common and increasing threat to normal adolescent health and development. Major clinical challenges include longstanding malnutrition potentially complicated by emergent electrolyte disorders and cardiac dysfunction. The care of adolescents with severe EDs can lead to challenging decisions regarding the initiation of involuntary feeding with restraints. After describing a representative case, we present pertinent ethical challenges involved in the use of involuntary feeding with restraints in adolescents with severe EDs. These include the following: (1) the relationship of involuntary feeding with restraints to evolving adolescent autonomy; (2) why weak efficacy evidence should prompt individualization of involuntary treatment decisions; and (3) how unequal access to ED care complicates decision-making regarding involuntary feeding with restraints. To help clinicians characterize whether involuntary feeding with restraints is ethically permissible in a specific adolescent with severe anorexia nervosa (AN), we propose a 3-step decision-making guide that weighs case features such as magnitude of health threats, whether less invasive treatment options have been tried, patient decision-making capacity, prior response to similar therapies, caregiver support for the plan, and the availability of subsequent steps in expert ED care. Decisions to undertake involuntary feeding with restraints in adolescents with severe AN are intrinsically fraught, but this 3-step decision-making guide can help clinicians identify and weigh pertinent ethical tensions effectively and with transparency.