Addressing the false dichotomy between autonomy and preservation of life: Clinical, legal, and ethical considerations in severe and longstanding anorexia nervosa
Bibliographic record
Abstract
Anorexia nervosa (AN) is a serious metabo-psychiatric disorder. Despite a mortality rate approximately five times higher than that of age-matched controls, most deaths result from delayed recognition, fragmented care, and limited access to integrated, evidence-based treatment. Refusal of life-sustaining nutrition in severe or longstanding AN presents profound ethical and legal dilemmas, challenging the balance between autonomy, protection, and the duty to preserve life. This paper provides a critical narrative and normative review of how clinical uncertainty, systemic failure, and legal interpretation influence decision-making in treatment refusal. It examines capacity, futility, and best-interests determinations within mental health and capacity law in England and Wales, with comparative reference to other high-income countries. The review finds that unvalidated constructs such as "severe and enduring" and end-of-life framing of AN lack empirical and legal foundation. Their adoption risks normalising treatment withdrawal and assisted dying in a treatable psychiatric disorder that predominantly affects women. Ethical analysis grounded in autonomy, beneficence, non-maleficence, and justice demonstrates that autonomy should be supported rather than presumed absolute when reasoning is impaired by malnutrition or psychopathology. The paper concludes that aligning clinical and legal practice with the Convention on the Rights of Persons with Disabilities would strengthen supported decision-making, safeguard the right to life, and promote parity between psychiatric and physical healthcare. A shift toward the prevention of avoidable deaths, rather than acceptance of inevitability, is urgently required.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.033 | 0.066 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.008 | 0.047 |
| Scholarly communication | 0.007 | 0.006 |
| Open science | 0.003 | 0.008 |
| Research integrity | 0.013 | 0.025 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".