Anorexia and the capacity to make decisions about nutritional intake

By Ty Glover, 14^th July 2024

Back in 2007, a spate of television programs focused on “size 0” and “super skinny” bodies with the focus being on the then (and now) fashionable trend for size 0 models. Although I did not watch all of those programs, I recall one in which Louise Redknapp, wife of former footballer and current TV pundit Jamie Redknapp, presented “The Truth about Size Zero“. In that program Louise vividly articulated the misery and difficulty of achieving the goal of dropping two dress sizes and reaching size 0 for which the program was designed. Her physical, emotional, and psychological distress at achieving that goal, despite support from expert nutritionists, was clearly described.

At that time I was a relatively inexperienced Consultant in Eating Disorders, but I had already witnessed such suffering, and this programme had a significant impact on my thinking. Given that, after oxygen requirements, fluid intake, and excretion, food intake can be considered as one of a human’s most fundamental needs, it became clear, both due to my early experience and Louise Redknapp’s articulate description, that avoidance of appropriate calorific intake was profoundly aversive and to continue in such a pattern of behaviour would require a psychological force of immense proportions.

My experience since then has only confirmed that belief. Anorexia Nervosa is a profoundly powerful condition. It is classified as a Mental Illness (ICD-11 6B80) and recognised as an impairment of the mind with respect to the Mental Capacity Act 2005. Its ability to derail the life path of articulate and intelligent people, usually young women, has to be seen to be believed. Their inability to simply accept sufficient calories to maintain weight is extremely difficult to overcome. The lengths to which such patients will go to avoid calorific intake and weight gain is remarkable. The misery and depression which goes alongside this behaviour is consistently reported by patients and their families as well as clinical observers.

It is only by understanding the profoundly aggressive nature of anorexia nervosa that one can begin to understand the disparity between otherwise cognitively intact young woman and their intrinsically harmful thinking and behaviour.

It was, therefore, no surprise to receive Celia Kitzinger’s request for me to explain how such articulate and intelligent young women could possibly be deemed to lack capacity to make decisions when they appear, on the surface, to be so coherent and insightful. Her request was prompted (she said) by a recent case before Mr Justice Hayden at which public observers watched “Pam” gave powerful and eloquent evidence to the court about her wish to be discharged from treatment (see Anorexic woman gets to make her own (incapacitous) decisions, says Hayden J).  Despite her articulate and intelligent self-presentation, none of the parties (including the Official Solicitor who was acting for “Pam”),  argued that “Pam” had capacity to make decisions about her nutritional intake for herself.  The judge and all the parties (except “Pam” herself) accepted that the presumption of capacity in the domain of nutritional intake had been rebutted.  This was queried by one of the observers in a comment on the  blog post:  “I think the main surprise for me on the day was the difficulties the psychiatrists had with demonstrating why Pam lacked capacity to make decisions about her treatment. It felt like it was assumed that because the illness itself and decisions about being fed are so intertwined, NO patient with anorexia can be deemed as having capacity to make decisions regarding treatment? This was in contrast with how eloquently Pam put her case across – surely if anybody was going to be deemed as having capacity it was this lady?” (Nat Davies).

It is only by understanding the profoundly intrusive nature of anorexia nervosa on an individual’s thinking in regard to nutritional intake, weight gain, whilst also understanding the limits of this impact with relative preservation of thinking in other domains (e.g., financial, emotional and medication decisions etc.)  that one can realistically comprehend how such a disparity can occur.

Although an individual with anorexia may be unable to decide between an apple and Mars bar despite their “life depending” on the acceptance of a Mars bar, they may articulately, coherently, and capacitously make decisions about finance, relationships and medication without any cause for concern.

This highlights the specific and time related nature of capacity decisions. It is clear to me that patients with severe “active” anorexia almost always lack capacity to make decisions about nutritional intake whilst under the influence their anorexic condition. The overwhelming nature of the anorexic cognitions endured by patients with anorexia in relation to weight gain, or in anticipation of weight gain, mean that they will almost always, under the influence of that condition, make decisions regarding nutrition which are almost certainly lacking in capacity. It is in the domain of weighing matters in the balance that this lack of capacity should be understood.

The overwhelming impact of anorexia nervosa on an individual’s ability to weigh matters in the balance is, in my opinion, incontestable. The avoidance of weight gain and the restriction of dietary intake (or the urge towards compensatory behaviour) is such that I have no doubt that most patients, if not all, who are enduring an anorexic condition lack capacity to make decisions about the nutritional intake which is most appropriate for their overall well-being.

There is also a clear, though not universal, impact on a patient’s ability to understand the nature of nutrition and their body weight. Many patients erroneously believe that they are of normal (or above normal) weight, and they also believe, in a similarly erroneous way, that normal dietary intake will have a profound effect on their weight with massive weight gain anticipated. These errors of comprehension are directly attributable to their anorexic condition.

It is not possible, given the construction of the Mental Capacity Act 2005, to believe that such patients retain capacity to make decisions related to calorific intake in the face of such an overwhelming psychological impairment.

There is, however, no doubt that these individuals retain capacity in most, if not all, other domains of cognition. There may well be an impact from their condition on their relationships, emotional state, and motivation, including some suicidal thinking. That does not, however, mean that capacity in these other domains is necessarily impaired. It is my practice to assume that most patients with anorexia nervosa lack capacity only in the domain of nutritional intake. For example, I rarely, if ever, insist that patients take medication against their will as there is, as yet, insufficient evidence to take such an authoritarian position.

There is no doubt, in my mind, that these individuals almost always retain capacity to make decisions about finances, relationships, and about with whom they should associate. There is also little doubt that they retain capacity to make decisions about residence and their own living circumstances. Given that they also remain articulate and often insightful with regards to nutrition, it is unsurprising that such patients might appear to many observers in the Court of Protection to be expressing capacitious views about their own anorexia. That appearance is misleading. As explained above, anorexia has such a profound effect on an individual’s ability to weigh matters in the balance and often also on the ability to correctly comprehend  one’s own circumstances, that, in most cases, the presumption of capacity is rebutted.

Only by understanding both the severity of anorexic cognitions, the profound impact of those cognitions on the ability to both understand and weigh the relevant information in the balance and the restricted nature of this psychological impairment can one reconcile the determination that patients lack capacity in relation to nutritional intake with their capacity to make decisions in most, if not all, other domains and their apparently coherent and insightful ability to articulate their own position.

Ty Glover is a Consultant in Eating Disorders Psychiatry and an Independent Medicolegal Expert with experience of the Court of Protection, whose knowledge of this field draws from his experience over the last 12 years as an expert witness in numerous complex cases of serious medical treatment involving eating disorders in the broadest and narrowest sense of that term – as well as further experience as an expert witness in the Court of Protection in relation to mental health problems unrelated to disordered eating.