July 4, 2022

Should patients with anorexia be force fed?

Yes, says a Hong Kong lawyer

Anorexia nervosa is a serious and chronic mental illness – and the one with the highest mortality rate, about 20% in 20 years. Force-feeding as a treatment is ethically fraught as many patients adamantly refuse to eat and waste away. Death from physical causes is 5 times higher and death by suicide is 32 times higher.

The ethics of treatment for anorexia, which is classed as a type of body dysmorphia, has become a hotter topic with the sharp increase in gender dysphoria. Opponents of allowing young people to transition to a different gender often use anorexia as a counter-example. If it is ethically acceptable to refuse to respect the autonomy of anorexic patients, why is it wrong to do so in for gender dysphoric patients?

Although he does not refer to the transgender debate, a recent article in the journal Bioethics by a legal scholar at the University of Hong Kong, Eric Ip, makes a case for forcing anorexic patients to accept treatment.

The law should generally not permit patients with anorexia nervosa to decline nutrition and hydration, precisely because their autonomous ability to make such decisions has been substantially circumscribed by this psychiatric condition.

Patients with anorexia often make advance directives indicating that they should not be force fed if their condition deteriorates. However, Ip contends that “patients suffering from anorexia nervosa have only compromised autonomy at best, and at worse no autonomy at all to make meaningful advance directives about life‐and‐death scenarios”. He goes on to state:

Respect for autonomy on the part of medical professionals and even courts does not automatically obligate them to act on any and every request of a patient. Chronic malnutrition precipitates deficiencies in macronutrients such as carbohydrates and in protein and micronutrients such as vitamins and minerals. Consequently, declining hydration and nutrition by medical professionals in some ways amounts to starving the patient to death. The validity of advance directives by those hindered by anorexia nervosa to discontinue hydration and nutrition should be subjected to more intense scrutiny by the courts … Even an apparently autonomous decision to take one's own life should be treated with great caution, for if autonomy is genuinely valuable, it seems extremely irrational to choose to exercise it in order to destroy autonomy itself, even autonomously; instead, autonomy should be preserved.

Michael Cook is editor of BioEdge

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