A systematic review identified at least 60 cases of assisted death among patients with eating disorders between 2012 and 2024, including in jurisdictions that restricted the practice to terminal conditions.

In the study, published in Frontiers in Psychiatry, the investigators revealed significant gaps in the reporting of assisted death cases involving psychiatric conditions. The investigators conducted a systematic search of peer-reviewed literature and government reports from jurisdictions where assisted dying was legal for psychiatric conditions. They identified 10 peer-reviewed articles and 20 government reports describing cases of assisted death in patients with eating disorders. A content analysis was performed to identify clinical rationales used to justify assisted death, which were categorized into three domains based on common legal criteria: terminality, irremediability, and voluntary request.

The investigators identified at least 60 patients with eating disorders who underwent assisted dying across multiple countries. All of the identified cases involved female patients. Further, 61% and 22% of the patients had more than three and four comorbid psychiatric disorders, respectively; 68% of them were described as severely underweight or malnourished when their requests were granted; 58% of them were characterized as chronically suicidal, with 37% of them having made multiple past suicide attempts; and 89% and 63% of them exhibited depressive symptoms and anxiety symptoms, respectively, and 32% of them engaged in self-injury.

Among the 19 cases with detailed summaries:

• 32% were under the age of 30 years, 37% were aged 30 to 50 years, and 31% were aged over 50 years.
• 61% had been diagnosed with anorexia nervosa specifically.
• 52% had a comorbid depressive disorder, 37% had post-traumatic stress disorder, 32% had obsessive-compulsive disorder, and 16% had autism spectrum disorder.
• 48% had at least one personality disorder, with 26% specifically diagnosed with borderline personality disorder.

The investigators found that clinical rationales often relied on certain concepts, including severe and enduring eating disorder and severe and enduring anorexia, treatment resistance, illness duration as a predictor of prognosis, and treatment futility.

Irremediability Domain:

• 95% of the cases cited the length of time the patient had been ill as a rationale for assisted death.
• 89% emphasized poor prognosis and failure of past treatments.
• 89% stated there were no realistic treatment options remaining.
• 47% used terms like "chronic eating disorders" or "severe and enduring anorexia."
• 42% described patients' conditions as "treatment resistant."

Terminality Domain:

• Terminality was cited exclusively in U.S. cases, where it was a legal criterion for medical aid in dying.

Voluntary Request Domain:

• 95% of the cases asserted that patients had decision-making capacity to end their life.
• 100% emphasized the consistency of the patient's request.
• 53% highlighted the autonomous nature of the patient's decision.
• In 26% of cases, patient intelligence was explicitly mentioned as evidence of capacity.

The review identified several points. Among the 27 jurisdictions where assisted dying was legal, only 16 of them regularly published reports. Just two jurisdictions reported the number of patients referred for psychiatric evaluation, and none of them provided information about psychiatric diagnoses in their reports. Patients with eating disorders appeared in a notable proportion of cases receiving assisted death for psychiatric reasons. Additionally, the study noted challenges in assessing decision-making capacity in patients with eating disorders, particularly given the cognitive effects of malnutrition. The review examined whether requests for assisted death may have reflected eating disorder symptoms rather than autonomous desires.

The investigators emphasized the need for more detailed reporting in public health records to enable further research. They called for the development of an empirically informed framework to guide care for patients with eating disorders expressing a wish to die. The study underscored the importance of examining the legal and ethical basis for assisted death in patients with this condition. It also highlighted a need for improved treatment approaches for patients with severe and chronic eating disorders.

In conducting this systematic review, the investigators provided a comprehensive examination of assisted death in patients with eating disorders, offering crucial data for clinicians, researchers, and policymakers in the fields of psychiatry and bioethics.