"There's more to recovery than just weight gain": Ethical challenges for justice and respect in adjudication of capacity for patients with anorexia nervosa.

Anorexia nervosa (AN) is a complex psychiatric illness with a high mortality rate. When patients with AN refuse medical treatment, it may be ethically justifiable to provide treatment in their best interests if they are found incapable to make the decision themselves. In Ontario, Canada, any person deemed incapable has the right to challenge that decision at the Consent and Capacity Board (CCB), an independent tribunal that adjudicates hearings under six Acts, including the Health Care Consent Act. Recognising both the complexity of capacity assessment in the context of AN and widespread stigma experienced by persons with eating disorders, this study uses qualitative methodology to analyse the ethical quality of capacity adjudication for patients with AN at the CCB. A search conducted via the Canadian Legal Information Institute (CanLII), a public online database, identified 29 Reasons for Decision related to capacity in persons with AN over a ten-year period. Line-by-line coding of these decisions revealed four main themes: (i) barriers to procedural fairness, (ii) divergent perceptions of people with AN, (iii) suspicion, distrust and disbelief, and (iv) a disconnect between patient values and medical priorities in AN treatment. Thematic analysis through a procedural justice lens suggests that patients with AN face multiple barriers to procedural fairness and may experience stigma and epistemic injustice at CCB hearings. Our recommendations focus on promoting a more procedurally just, patient-centred, and recovery-oriented approach for patients with AN who appear before the CCB.