Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice
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Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment. The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice. In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m 2 and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.
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Literature suggests that capacity impairments can be subtle in eating disorders.
“While clinical rationales asserted that patients were capable of making a life-ending decision and that their desire to die was not influenced by symptoms of mental illness, literature suggests that capacity impairments can be subtle in EDs (42, 150).”
From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [42]
Clinician assessments may not catch subtly diminished capacity in individuals with complex psychiatric conditions.
“clinician assessments may not catch subtly diminished capacity in individuals with complex psychiatric conditions (42, 43).”
From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [42]
Between 2011 and 2014, at least 68% of psychiatric patients who received assistance in dying had psychiatric histories of over 11 years.
“Between 2011 and 2014, at least 68% of psychiatric patients that received assistance in dying had psychiatric histories of over 11 years.”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [12]
Standardized tests of competence fail to identify many individuals with anorexia nervosa whose capacity is impaired.
“standardized tests of competence fail to identify many individuals with AN whose capacity is impaired [22, 23]”
From Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined (2022) · cites this paper as [22]
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d’Ussel, M., Sacco, E., Moreau, N., Nizard, J., & Durand, G. (2024) · BMC Medical Ethics · doi:10.1186/s12910-024-01096-y · Cited by 10 · see citing works
Ethical Challenges in the Treatment of Patients With Severe Anorexia Nervosa
Westmoreland, P., Yager, J., Treem, J., & Mehler, P. S. (2024) · FOCUS The Journal of Lifelong Learning in Psychiatry · doi:10.1176/appi.focus.20230035 · Cited by 7 · see citing works
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A Bitter Pill: The Ethics of Involuntary Treatment of Adolescents With Severe Eating Disorders
Riss, V., Hartman-Munick, S. M., Shubkin, C. D., & Lahey, T. (2025) · Hospital Pediatrics · doi:10.1542/hpeds.2024-007921 · Cited by 5 · see citing works
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Anorexia nervosa and the law: Legal mechanisms for involuntary treatment in Ireland
Dunne, E. (2023) · Medico-Legal Journal · doi:10.1177/00258172221149539 · Cited by 3 · see citing works
Capacity to consent to treatment in severe eating disorders
Parmigiani, G., Tarsitani, L., Grassi, F., Mandarelli, G., & Ferracuti, S. (2024) · International Review of Psychiatry · doi:10.1080/09540261.2023.2300781 · Cited by 3 · see citing works
What are the arguments for and against recognizing ‘terminal’ anorexia nervosa? A narrative review
Connor, C., Kim, S., & Taylor, H. (2026) · International Review of Psychiatry · doi:10.1080/09540261.2026.2687524 · Cited by 1 · see citing works
Takimoto, Y. (2022) · Research Square · doi:10.21203/rs.3.rs-1561951/v1
Takimoto, Y. (2022) · Research Square · doi:10.21203/rs.3.rs-1772418/v1
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Decision-Making in Civil Matters
Nason, J. A., & Drogin, E. Y. (2024) · Cambridge University Press eBooks · doi:10.1017/9781009119375.043
- Authors
- Elzakkers, I. F. F. M., Danner, U. N., Grisso, T., Hoek, H. W., & van Elburg, A. A.
- Affiliations
- Altrecht GGZ (NL)
- Utrecht University (NL)
- University of Massachusetts Chan Medical School (US)
- University Medical Center Groningen (NL)
- Venue
- International Journal of Law and Psychiatry
- Publisher
- Elsevier BV
- Published
- 2018-05
- Volume
- 58
- Pages
- 27-35
- ISSN
- 0160-2527 (ISSN-L)
- OpenAlex
- W2792046331
- Cited by
- 30
- References
- 87
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 9 · 2023: 4 · 2022: 7 · 2021: 1 · 2020: 3 · 2019: 2
- FWCI
- 1.77
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- International Journal of Law and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Utrecht University Repository (Utrecht University) (submittedVersion)
- Funders
- Nuts Ohra Foundation (1104-017)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Keywords
- anorexia nervosa, decision-making capacity, informed consent, clinical judgment, inter-rater reliability, treatment refusal, severe eating disorders
- MeSH terms
- Adult, Anorexia Nervosa, Female, Humans, Informed Consent, Judgment, Patient Acceptance of Health Care, Surveys and Questionnaires, Mental Competency, Young Adult
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