How Neuroscience is Influencing the Bioethical Debate About Compulsory Treatment for Anorectics

Anorexia nervosa is a psychiatric disorder characterized by excessive preoccupation with body size and weight as well as self-deceptive attitudes toward the nature of thinness and emaciation. Treating anorexia is replete with challenges. First of all, treatment is often unsuccessful. Less than 50% of anorectics recover within ten years of the onset of the disorder. About 25% of cases develop into chronicity. Oftentimes, anorexic behavior is replaced by bulimic behavior.

Anorexia is a classic case where the tension between preservation of liberty of the patient and the imperative to treat a severe illness becomes quite acute. In most cases of anorexia nervosa, a well-structured therapeutic program, administered by a multidisciplinary staff experienced in treating eating disorders, is adequate. Even with the best of treatment options, however, avoiding treatment is part of the condition of anorexia. Anorexia is characterized with the obsessive pursuit of thinness and treatment is always aimed at thwarting this goal. The refusal may not be total: many patients accept psychotherapy or family therapy, but may refuse components of treatment likely to increase food intake, reduce physical activity and induce weight gain. In severe cases where anorectic patients categorically deny all treatment oriented toward weight gain, compulsory treatment is usually pursued.

A patient who refuses nutrition despite severe emaciation is generally thought to be behaving without autonomy and is deemed incompetent to consent to treatment. The Mental Health Act Commission allows, “that in certain situations, patients with severe anorexia nervosa whose health is seriously threatened by food refusal may be subject to detention in hospital and further that there are occasions when it is necessary to treat the self-imposed starvation with measures such as involuntary naso-gastric feeding to ensure the proper care of the patient.”

As a rule, most treatment programs resort to compulsory treatment only as a last resort. Compulsory treatment seems to be justified only by immediate mortal danger to the patient, but may also be pursued based on motives of beneficence within the health care system. Nevertheless, the ethics of compulsory treatment of anorectics is hotly contested issue.

Compulsory treatment for anorexia as well as other conditions assumes that the doctor is right about what is in the patient’s best interest. However, in medicine, prognostic ability is a far cry from an exact science, despite the fact that prognoses are usually given in percentages. Moreover, the prognostic difficulties are complicated in psychiatry, with psychiatrists very often incorrect in their identification of danger to the patient.
Moreover, the pursuit of compulsory treatment usually implies that treating the patient against her wishes will help her. A general principle of compulsory treatment is that one must be reasonably confident that the treatment is going to bring about some beneficial effect. In the case of anorexia, the ethics of compulsory treatment are complicated by the fact that the patient must at some point submit to either treatment or resuming somewhat normal eating patterns. An anorectic cannot spend the rest of her life in a psychiatric ward or on a feeding tube involuntarily. At some point, she must cooperate with therapeutic efforts if she is to recover. Compulsory treatment must both aim for, and have a reasonable likelihood of success achieving a state of voluntary cooperation with the anorectic.

New developments in neuroscience are changing our understanding of the role of the brain in mental illness, as scientists rapidly discover minimally invasive and benign techniques for exploring and altering the brain. Brain mapping technologies like positron emission tomography (PET scans) and functional magnetic resonance imaging (fMRIs) serve to identify the brain areas involved in certain behaviors like self- starvation or performing a given task like consenting or refusing to consent to medical and psychiatric treatment.

Neurotechnology offers more advanced scientific data related to specific cognitive deficits relevant to consent, which has a direct impact on psychiatric diagnostic criteria, providing objective bases, derived from the structure and processes of the brain, for classifying a brain as “abnormal.” Standards for determining competence right now in the clinic are unreliable and based on what is called the “reasonable person standard.” With new neurotechnologies, it may become clearer both clinically and legally what constitutes a reasonable person.

Neuroscientific data is also leading toward a richer understanding of the nature of consent which is based on the idea of “degrees” of competence, rather than a simple threshold. Basically, neuroscience is pointing away from a model of consent that views the capacity to consent as an “all or nothing” sort of thing, and towards a model that accepts more or less capacity. That is, capacity to consent lies on a continuum. On a degree notion of competence, patients are never said to be either fully competent or totally incompetent, but rather, as displaying various and changing degrees of competence to consent at various different times.

Most contemporary models and tests for mental competence do not make adequate provisions for the positive influence of emotions in the determination of competence. Recent advances in the neuroscience of emotion provide compelling evidence that the decision-making process, including the act of giving consent, is not exclusively cognitive, nor can decisional capacity be assessed by purely cognitive means such as the Mac Arthur Competence Assessment Tool (MacCAT-T). Integrating more neuroscience studies on the complexity of the consent process is leading to a “multifactorial and qualitiative account of the components of capacity” which could lead to clinical developments that enhance the necessary components to improve decision-making. For example, fear and anxiety may impair an anorectic’s ability to consent to treatment, which may be enhanced by introducing a known and trusted confidant to the consent process who can engage the patient more successfully on an emotional level.

Although the issue of compulsory treatment, including forced-feeding, for anorectics has been greatly debated on the theoretical in bioethical circles, as Simona Giordano rightly identifies in her book Understanding Eating Disorders, the question of compulsory treatment is also, and perhaps primarily, an “empirical” problem:

People with eating disorders are typically intelligent, and are not at all the stereotypical ‘insane’ person, detached from reality. People with eating disorders are generally skilled, intelligent, and able to run their life in many important ways, like everybody else. It is hard to believe that all of them, when they refuse treatment, are incompetent. Given that we are dealing with intelligent and generally competent people, it seems that one cannot assume a priori that every time a person with eating disorders refuses treatment, she is incompetent. It seems that their incompetence should be assessed, not presumed (193).


1 comment so far

  1. Mike on

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