Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada; Health Science Research Program, University of Toronto, Toronto, ON, Canada.
Department of Pediatrics, Scarborough Health Network, Toronto, ON, Canada; Child, Youth, Family Services, Centre for Addiction and Mental Health, Toronto, ON, Canada.
Lancet Child Adolesc Health. 2023 Jan;7(1):69-76. doi: 10.1016/S2352-4642(22)00236-X. Epub 2022 Oct 4.
Treatment of anorexia nervosa poses a moral quandary for clinicians, particularly in paediatrics. The challenges of appropriately individualising treatment while balancing prospective benefits against concomitant harms are best highlighted through exploration and discussion of the ethical issues. The purpose of this Viewpoint is to explore the ethical tensions in treating young patients (around ages 10-18 years) with severe anorexia nervosa who are not capable of making treatment-based decisions and describe how harm reduction can reasonably be applied. We propose the term AN-PLUS to refer to the subset of patients with a particularly concerning clinical presentation-poor quality of life, lack of treatment response, medically severe and unstable, and severe symptomatology-who might benefit from a harm reduction approach. From ethics literature, qualitative studies, and our clinical experience, we identify three core ethical themes in making treatment decisions for young people with AN-PLUS: capacity and autonomy, best interests, and person-centred care. Finally, we consider how a harm reduction approach can provide direction for developing a personalised treatment plan that retains a focus on best interests while attempting to mitigate the harms of involuntary treatment. We conclude with recommendations to operationalise a harm reduction approach in young people with AN-PLUS.
治疗神经性厌食症对临床医生来说是一个道德难题，尤其是在儿科领域。在平衡潜在益处与伴随危害的基础上，对治疗进行个体化的挑战，最好通过探讨和讨论伦理问题来突出。本观点旨在探讨在治疗不具备治疗决策能力的患有严重神经性厌食症的年轻患者（10-18 岁左右）时的伦理紧张问题，并描述如何合理应用减少伤害。我们提出 AN-PLUS 的概念，用于指具有特别令人关注的临床表现的患者亚组，包括生活质量差、治疗反应不佳、病情严重且不稳定、以及严重症状，这些患者可能受益于减少伤害的方法。我们从伦理文献、定性研究和我们的临床经验中确定了为患有 AN-PLUS 的年轻人做出治疗决策时的三个核心伦理主题：能力和自主权、最佳利益以及以患者为中心的护理。最后，我们考虑如何通过减少伤害的方法为制定个性化治疗计划提供方向，该计划在关注最佳利益的同时，试图减轻非自愿治疗的危害。我们最后提出了针对患有 AN-PLUS 的年轻人实施减少伤害方法的建议。
