Background: Type 1 Diabetes Mellitus (T1DM) is increasingly prevalent and requires consistent insulin therapy to prevent life-threatening complications such as ketoacidosis.. During puberty, therapy adherence is challenging. While some risk-taking is developmentally typical, persistent insulin omission raises ethical concerns – especially when minors refuse psychiatric evaluation. We present two cases discussing the ethical dilemma between patients’ autonomy and best interest, particularly whether incompliance in T1DM justifies involuntary hospitalization.Case Reports: Patient A, a 15-year-old boy using an insulin pump, experienced recurrent ketoacidosis and was diagnosed with an attachment disorder and suspected borderline personality disorder. The caregivers applied for psychiatric admission due to presumed suicidality.Patient B, also 15, received intensified conventional therapy and presented with persistent hyperglycemia due to insulin omission, though without acute metabolic decompensation. He was diagnosed with a conduct disorder including delinquency, drug use, but denied suicidal intent.Material & methods: The four key principles proposed by Beauchamp and Childress were used to structure the ethical discussion.Results: Respect for Autonomy: Both patients denied psychiatric care and demonstrated sufficient understanding of their illness and (long-term) consequences of insulin omission. For both patients, the short-term perceived benefits of their behaviour outweighed the potential long-term harm. Respecting an adolescent’s autonomy when decision-making capacity seems to be preserved may implicate accepting some degree of self-endangerment – especially in the absence of acute suicidality.Beneficence vs. non-maleficence: Psychiatric assessment may help exclude suicidality and may improve adherence to medical treatment. However, it is questionable whether involuntary psychiatric hospitalization may seem warranted in these cases. It may undermine an adolescent’s trust in medical care. In cases of self-induced acute health risk (as seen in patient A), it seems clearer that a compulsory intervention may be in the patient's best interest than in those cases in which only a potential future acute health risk is recognizable.Justice: Societal tolerance for health-endangering behaviours among adolescents appears inconsistent as, for instance, substance use rarely results in involuntary hospitalization and motivational approaches are preferred. It is possible that the risk to life associated with diabetes treatment errors contributes (professional) discomfort with an acceptant attitude towards non-compliance. Additionally, psychiatric resources are limited. Prioritizing involuntary care for patients without clear acute psychiatric pathology may divert care resources from those who actively seek help.Conclusion: The ethical dilemma lies in balancing the protection of minors with the respect for their autonomy. Involuntary hospitalizations in adolescents with T1DM should be restricted to acute, life-threatening situations when less autonomy-undermining options have failed. Ethical justification for the latter requires an individual risk evaluation, assessment of decision-making capacity, prior engagement efforts, and the adolescent’s best interests. In cases of preserved capacity and persistent but non-acute risk, involuntary admission rarely appears warranted. Autonomy must not be overridden unless adequate justification. While Patient A may meet such criteria, Patient B likely does not.In summary, to improve ethical clinical decision-making in such complex constellation systematic data analysis through (inter-)national registers for coercive measures may help to understand non-compliance and develop proportionate interventions.
