Anorexia Nervosa - Springer Link

Bioethical Inquiry (2014) 11:31–40 DOI 10.1007/s11673-013-9496-x

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Anorexia Nervosa: The Diagnosis A Postmodern Ethics Contribution to the Bioethics Debate on Involuntary Treatment for Anorexia Nervosa Sacha Kendall

Received: 3 February 2013 / Accepted: 5 December 2013 / Published online: 24 December 2013 # Springer Science+Business Media Dordrecht 2013

Abstract This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter “AN: the diagnosis”) several ethical issues are revealed. Firstly, “AN: the diagnosis” influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, “AN: the diagnosis” impacts on how treatment and treatment efficacy are defined and the ethical justifiability of paternalism. Thirdly, “AN: the diagnosis” can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. “AN: the diagnosis” can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty. Keywords Anorexia nervosa . Coercion . Involuntary treatment . Postmodern ethics . Professional ethics S. Kendall (*) UNSW Medicine, University of New South Wales, School of Women’s and Children’s Health, UNSW Randwick Hospital Campus, Level 2 McNevin Dickson Building, Randwick, NSW 2031, Australia e-mail: [email protected]

Introduction In Western contexts, the dominant definitions of anorexia nervosa (AN) applied in treatment environments are those contained in the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (American Psychiatric Association 2013), and the International Classification of Diseases-10 (World Health Organization 2007). These classification systems are recognised as the primary diagnostic tools for all mental illnesses and disorders in these settings (Robertson and Walter 2007; Sadler 2004). At the same time, critical and post-structuralist discourse analyses of anorexia nervosa highlight that AN is known and understood through disciplines like psychiatry that are themselves discourses that systematise and discover realities (Surgenor, Plumridge, and Horn 2003, 23; see also Gremillion 1992). Psychiatric discourses constitute and regulate mental illness and specific categories of diagnosis (Malson et al. 2004, 476; see also Hepworth 1999; Malson 1998). These arguments are relevant for the debate on the ethics of involuntary treatment for AN (the debate), indicating that the hegemony of medical knowledge can undermine alternative perspectives of illness and inherently justify paternalism. However, they need to be balanced with consideration of the ethical tensions that professionals face in the clinical contexts where involuntary treatment for AN is provided. Persons with AN for whom involuntary treatment is considered usually present with acute and severe physical symptoms of the illness that place them at immediate risk of death or

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permanent injury. Moreover, as Sadler (2004) illustrates, “diagnosis” is a multidimensional phenomenon with many functions and meanings. Critiques of psychiatric discourse should therefore go beyond analysis of the reductionist capacity of diagnoses and explore the ontological, epistemological, axiological, and sociopolitical complexities of “diagnosis” and how illness is conceptualised. This is particularly relevant in jurisdictions (such as in the Australian state of New South Wales, the context of this research) where involuntary treatment orders are made by magistrates or Mental Health Tribunals on the basis of the recommendations of the treating team regarding the patient’s need for “care, treatment and control” (see the New South Wales Mental Health Act, New South Wales Government 2007) rather than assessments of patient competence. The current debate on the ethics of involuntary treatment for AN is dominated by biomedical approaches to the issues. Biomedical ethics positions professionals as experts who can balance ethical principles (“respect for autonomy,” “beneficence,” “nonmaleficence,” and “justice”) in the best interests of patients (Beauchamp and Childress 2001). This “principles-based” approach is the prevailing ethics paradigm in Western psychiatric ethics ( R o b e r t s o n , Ry a n , a n d Wa l t e r 2 0 0 7 , 2 8 1 ) . Consequently, the debate has not addressed how the authority of professional knowledge and values impacts on the way that the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. This paper makes such a contribution by taking a postmodern ethics approach.

Methodology The postmodern ethics approach taken here draws on the work of Foucault and Bauman. Foucault, in his approach to ethics, argues that all concepts of good and right are socially constructed, and therefore ethics has historically influenced and in turn been influenced by dominant discourses. Thus, language and power are morally relevant, as it is through language that meaning is constructed (Foucault 1980). Further, discourse and practice are connected to “techniques” that humans use to understand and govern themselves (Foucault 1997, 224–225). In this way the self is central to ethics. Bauman’s approach to ethics is concerned with the relationship between self and other. For Bauman, moral responsibility constitutes unconditional responsibility

Bioethical Inquiry (2014) 11:31–40

for the other (Bauman 1993). In professional contexts, this equates to recognising how professional roles can constrain moral agency and responsibility for the other (Bauman 1994). Professionals must recognise the fallibility of professional knowledge and embrace the moral uncertainty that comes with this. Accountability for professional knowledge and power is the process through which it is possible to respond to the needs of the other (Bauman 2001). Consistent with these approaches, this paper examines power, values, and the conceptualisation of AN in relation to the debate on the ethics of involuntary treatment. For this reason, I refer to AN as a construct/ discourse called “AN: the diagnosis.” The purpose of examining this discourse is to highlight the moral relevance of the hegemony and diversity of professional knowledge and values, not to devalue psychiatric or other professional knowledge and values.1 Nihilistic and relativistic approaches to the ethics of involuntary treatment are of no use to professionals and are potentially harmful to patients. Moreover, this discussion is not intended to diminish the value of patients’ lives or suggest that professionals should not intervene to prevent the death of patients with AN. The relevance of this discussion lies in the space of considering professional discourse and how it impacts on the everyday practice and moral decision-making undertaken in treatment contexts. Many patients with AN for whom involuntary treatment is considered (in emergency situations and otherwise) have long-standing AN, years of treatment intervention that have failed to produce a recovery from the illness, and long-term therapeutic relationships with their treatment providers who, in turn, are able to understand the patient’s experience of living with AN over time, conceptualise the patient’s competence at particular points in time, elicit the patient’s perception of his or her quality of life with AN, and discuss with the patient (and the patient’s families and/or carers) the circumstances where future involuntary treatment may or may not be in the patient’s best interests. In cases such as these, polemic approaches to the ethics of involuntary treatment for AN with “collusion with the illness” at one extreme and “duty of care” at the other can be equally unhelpful as nihilistic and 1 This is consistent with Foucault’s genealogical approach for examining the “disciplinary power” of psychiatry. This approach is not “anti-psychiatry.” Rather, the purpose of applying this approach is to reveal and understand the operation of disciplinary power (Foucault 2008, 39-40).


relativistic approaches. The reality of decision-making in these cases is more complex, and “duty of care” must incorporate consideration of how the knowledge and values of the treating professionals influence the decisions that are made and the extent to which the knowledge and values of patients and their families and/or carers contribute to these decisions. In order to unpack the existing debate and make a postmodern ethics contribution, this paper will be separated into two parts: “treatment refusal” and “coercion.”

Treatment Refusal The key issue underpinning the debate is how to balance respect for individual autonomy with the responsibility to treat an illness that poses a threat to the person (Carney 2009; Carney et al. 2005; Carney et al. 2006). “Competence” is central to this balance as commentators identify, formulate, and address the ethical questions relevant to the use of involuntary treatment for AN using a biomedical ethics framework. Within this framework, ethical principles have prima facie value contingent on the competence of the person (Beauchamp and Childress 2001, 65). Further, AN is well established as a psychiatric syndrome, defined as a set of symptoms and behaviours that are consistently associated with each other in a common course of illness and which respond to a common form of treatment (Beumont and Carney 2003, 2004; Carney 2009). Thus, AN is associated with the identification of psychiatric abnormality that can impair decision-making competence. Contributors to the debate agree that AN can seriously impair treatment decision-making competence. The issue at the centre of the debate is whether treatment refusals by persons diagnosed with AN should ever be accepted and under what circumstances. This is a contested area due to a number of factors. Assessing Patient Competence Assessing the competence of persons diagnosed with AN can be fraught with difficulty, as these persons are usually competent to make decisions about all aspects of their lives—except in relation to their body weight— and score good results on standardised competence tests (Carney et al. 2006; Melamed et al. 2003; Tan, Hope, and Stewart 2003a, b; Tan et al. 2006). Thus, it is not always clear if persons diagnosed with AN possess the

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competence to consent to/refuse treatment and therefore whether involuntary treatment is respectful of patient autonomy. Contributors to the debate offer various perspectives on how to manage this situation. For example, Kluge argues that persons with AN should be understood as globally incompetent to make decisions on issues such as body image, eating, and food and that therefore involuntary treatment is justifiable for lengths of time until their competence status is permanently changed (Kluge 1991, 1124). Alternatively, it may be best to focus on the behaviour of persons with AN when judging whether to uphold decisions to refuse treatment, as their intentions and/or thought content are not usually impaired (Appelbaum and Rumpf 1998; Melamed et al. 2003). Yet, judging consent on the basis of behaviour raises new issues, as it can then be argued that competence to consent to treatment is essentially equivalent to compliance with treatment plans (see Rathner 1998, 183–185). Tan et al. (2006) argue that there are multiple factors that influence the competence of persons diagnosed with AN. Beliefs and values in relation to the meaning of “fatness,” low self-esteem, the importance of being thin, and the positive gains that could be taken from AN impact on decisions to consent to and refuse treatment. However, the difficulty with assessing competence on the basis of beliefs and values is that, in the case of salient belief, there are countless examples of this in ordinary life where persons engage in risky behaviour without intervention from others. In terms of values, there is a danger in associating values with competence as this can lead to the pathologising of and discrimination against individuals who hold values that are different from those of professionals or the mainstream of society (Tan et al. 2006, 277–278). Tan et al. propose checking the authenticity of beliefs and values by looking at whether they arise from the person or AN. Further, engaging patients in discussion about these issues may work toward unravelling the complexity of competence and determining how to act as well as fostering competent decision-making (Tan et al. 2006, 279). Treatment Efficacy There is a lack of treatment efficacy for involuntary treatment and no clinical trial evidence (Tan et al. 2006, 268). The literature shows a general agreement

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that involuntary treatment should be used only as a last resort. The primary reasons given for the necessity of involuntary treatment are to save the patient’s life and to counteract the effects of starvation that impact on the patient’s ability to make treatment decisions (Griffiths and Russell 1998, 130). Commentators argue that, as treatment of severe AN appears to have only limited success, the ethical justification for overriding patient autonomy on the basis of “best interests” is limited (Carney et al. 2006, 27; see also Draper 2000). Alternatively, Carney (2009) asserts that the higher the level of coercion proposed the more solid should be the evidence required to justify it. Commentators have also raised the issue of whether treatment efficacy alone justifies overriding treatment refusals. It may be ethically justifiable to uphold particular patient decisions to refuse treatment or to withdraw treatment from some patients even when there is evidence for treatment efficacy (Carney et al. 2006, 21). This issue is particularly contentious when the patient has “chronic” AN and there is imminent risk of death without professional intervention. For example, Draper (1998, 2000) has argued that “chronic anorexics” may not be able to make competent decisions about food intake but still be able to make competent decisions regarding their quality of life with AN. Draper asserts that it is important to make this distinction for ethical reasons because “chronic anorexics” are in a “strong position to judge what life with AN is like and therefore are also in a position to determine whether prolonging treatment is worth the accompanying burdens” (Draper 1998, 6). Alternatively, Giordano (2003) asserts that AN cannot be compared with debilitating, chronic, or terminal illness, as for persons with AN the condition is reversible and death is avoidable. Therefore, if competent decisions made by persons with AN to refuse treatment are to be upheld, this cannot be on the basis of illness chronicity. Rather, these decisions can only be upheld on the basis of respect for the autonomy of the person; people with AN who competently decide to refuse treatment should be respected because everyone is entitled to exercise his or her autonomy (Giordano 2003, 271). Yet, Giordano also questions whether the normative strength of “respect for autonomy” is weakened in the case of persons with AN refusing treatment because the condition is reversible and death avoidable (Giordano 2003, 275). Draper (2003) thus challenges Giordano for, on the one hand, urging “respect for autonomy” but, on the


other, imposing limits on the autonomy of persons diagnosed with AN because the condition is potentially reversible. Commentators’ perspectives on how to balance “respect for autonomy” with “beneficence” and “nonmaleficence” therefore vary depending on how patient competence to refuse treatment is understood and whether poor treatment efficacy is seen as a reason to justify or limit the use of involuntary treatment. Further, whether AN can be considered a chronic illness is a crucial issue in these evaluations, making it possible to argue that when a patient is incompetent to make decisions about his or her nutritional intake, the patient might still be able to provide informed consent to withdraw from treatment based on his or her history of treatment and quality of life with and without further treatment intervention. In turn, it is possible to recognise the difficulty in accepting patients’ decisions to withdraw from treatment (due to the uncertainty around treatment efficacy), whilst also making the judgement to uphold these decisions. Giordano (2010) revisits these issues, arguing that patients’ right to refuse treatment (when this will inevitably lead to their death and can therefore be understood as the “right to die”) should be upheld on the basis of respect for patient competence and to relieve the patient of the suffering caused by the illness. This requires consideration of the futility of treatment and distinctions must be made between “treatable” and “untreatable” patients. In cases where the patient is “untreatable,” patient suffering is arguably equally morally relevant as patient autonomy. Patient suffering may even be more morally relevant because the competence of extremely ill or dying persons is always questionable. Further, no person, regardless of competence status, should be forced to receive futile treatment (Giordano 2010, 150). This position is described as the “legitimate use of prudence, recognition of the value of life and common sense: if there is a fairly good chance that the patient will thank you for rescuing her, then you should rescue her” (Giordano 2010, 147). Yet, whilst it is clear that Giordano is concerned to respect the welfare and dignity of persons diagnosed with AN (Giordano 2010), the argument Giordano presents is also a value statement made in the context of moral, political, professional, and social discourses. Further, Giordano’s approach requires interpretation of the patient’s wishes. If this interpretive element of treatment decision-making is not accounted for by professionals when they make judgements about


a patient’s best interests, the wishes of patients who hold values that conflict with professional values may not be upheld. Conceptualising Patient Autonomy It is unclear whether it is “colluding with the illness” to allow patients to refuse or withdraw from treatment (Draper 1998, 5, 2003, 279). Whilst it can be argued that “respect for autonomy” requires respecting decisions made by autonomous persons at any stage of illness, this issue is complicated in the case of persons diagnosed with AN because it is unclear whether decisions to refuse treatment are made autonomously. Tan, Hope, and Stewart (2003a) assert that the difficulty in assessing the autonomy of persons diagnosed with AN is that patients conceptualise AN as intrinsic to their identity. Personal identity is recognised as an important factor in medical decision-making, because when a person’s identity is altered as a result of illness it is difficult to know whether the treatment decisions he or she makes are valid, if his or her competence is compromised by the alteration in identity, or if the patient’s priorities, attitudes to the disorder, and values are consequently changed (Tan, Hope, and Stewart 2003a, 537–538). In this way, the autonomy and competence of persons diagnosed with AN are understood as interconnected. This is problematic because the meaning of “respect for autonomy” and what is in the “best interests” of another person is a matter of values (Rathner 1998, 192) and therefore open to interpretation (Sadler 2004). It has been argued that the medical profession (alone) does not have the right to determine when it has a duty to provide (futile) treatment or what is in the best interests of patients; this must be decided in concert with patients and society (Kluge 1991, 1123). However, arguably persons diagnosed with AN are systematically disadvantaged in terms of contributing to this decisionmaking process because their identity and values are understood as enmeshed in the pathology of their illness. AN can be diagnosed by the presence of the following criteria: “restriction of energy intake relative to requirements, leading to significantly low body weight in the context of what is minimally expected for age, sex, developmental trajectory and physical health (significantly low weight is defined as weight that is less than minimally normal or, for children and adolescents, less than that minimally expected),” plus

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“intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significant low weight,” and combined with “disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight” (American Psychiatric Association 2013, under “Anorexia Nervosa”). In this way, the physical symptoms that might justify the use of involuntary treatment are related to patients’ experiences and perceptions of self, and professionals’ judgements about the extent that body shape and weight should influence our selfevaluations will impact on their assessments of patient competence and need for intervention. Patient and professional knowledge and values cannot be separated from these experiences, evaluations, and judgements. As Tan et al. (2006) have similarly argued, whilst the pathologisation of values is ethically problematic because they are connected to the identity of the person, recognising the extent to which values and identity are enmeshed requires consideration of how these could impact on patient competence. Likewise, it is important for treatment providers to consider how their professional identity and values impact on their assessments of patient competence and need for treatment intervention. Again, this is not to advocate for nonintervention on the part of professionals but to highlight the role that professionals might play in contributing to patients’ self-perceptions over time via the patient–professional relationship and how the patient understands himself or herself as a person with AN via professional knowledge (Sadler 2004). “AN: the diagnosis” can thus preclude persons diagnosed with AN from being understood as competent to refuse treatment and, in turn, inherently justify involuntary treatment. This may be perpetuated by the point that AN can be conceptualised (and experienced) as intrinsic to the person’s identity; in this way, the values and autonomy of persons diagnosed with AN cannot be understood in isolation from their diagnosis. Further, even when commentators agree that persons with AN can be competent to refuse treatment, decisions about the ethical justifiability of involuntary treatment vary depending on how “respect for autonomy” is defined and balanced with other ethical principles. These definitions are mediated by understandings of patient competence to refuse treatment and professional perspectives on the limits of treatment (and therefore professional responsibility) in light of poor

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treatment efficacy. This will also be affected by the discourses around “professionalism” that dominate in the treatment decision-making context.

Coercion The problems outlined above in relation to understanding and respecting the autonomy and competence of persons diagnosed with AN are just as ethically relevant when there is no imminent risk of death and the person is consenting to treatment. If involuntary treatment is justifiable on the grounds that it is respectful of autonomy because persons with AN lack the competence to make treatment decisions, then it must be questioned why involuntary treatment is rarely used and only as a last resort in life-saving circumstances. Contributors to the debate have not addressed the issue of whether there should be a limit on the use of voluntary treatment. Moreover, the conditions that must be met in order for a person to be treated as a “voluntary” patient and the relevance this might have for the debate on the ethics of involuntary treatment remain unexplored. This section addresses these limitations by examining the literature on the use of coercion. Ramsay et al.’s (1999) study (conducted in Britain) found that most involuntary patients originally entered treatment services on a voluntary basis. Involuntary patients were not more severely ill than their voluntary counterparts, but their condition was more intractable and more commonly associated with psychiatric comorbidity. It was also found that involuntary status was statistically associated with prior episodes of admission. In the United States, Watson, Bowers, and Anderson (2000, 2001) similarly found that involuntary patients had been ill for significantly longer and had more previous hospital admissions. These authors conclude that the only difference in short-term outcomes between involuntary and voluntary patients is that the involuntary patients would have otherwise been “lost” to treatment. Likewise, Carney et al.’s (2005) Australian study reports that involuntary treatment was more likely to be used for patients with more chronic histories, with other psychiatric diagnoses, and with lower weights. Further, involuntary treatment “was invoked to preserve life rather than to achieve significant clinical advantages” (Carney et al. 2005, 4). Thus, patients who have been ill for a long time and had several previous admissions are more likely to be


treated without their consent under an involuntary treatment order. That involuntary treatment is used primarily as a last resort and when patients are at risk of death explains this. However, these findings contrast sharply with the arguments outlined in the previous section that persons who have been ill for a long time are less likely to benefit from involuntary treatment and are more likely to be able to make a competent decision to refuse treatment based on their quality of life and that prolonging the life of persons with chronic AN is disrespectful of autonomy because of the suffering caused by ongoing treatment. Moreover, Giordano (2005) observes that many of the patient behaviours that are used to warrant interventions are not so clearly harmful or of such immediacy and gravity that they justify the use of involuntary treatment. This suggests that there are issues associated with treating AN in the clinical environment that impact on decisions to use involuntary treatment in practice. These issues are divided here into two categories: “resistance” and “control.” Resistance Resistance to treatment is common in persons diagnosed with AN, and coercion (rather than involuntary treatment under a legal order) is regularly used by treating teams as part of the treatment of voluntary patients (MacDonald 2002; see also Surgenor, Plumridge, and Horn 2003). Carney et al. highlight the “fluidity and the hybrid character of the pattern of management of anorexia nervosa” (2006, 13) and discuss the various uses of informal coercion to encourage treatment compliance as a means for balancing biomedical principles. These may take the form of “contracts” outlining the mutual obligations of the clinician–patient relationship or “strategic use of the law” to foreshadow or threaten the use of formal measures (Carney et al. 2006). “Libertarian paternalism” approaches may also be used, controlling the “choice-frame” within which persons can exercise their autonomy. This might involve behavioural/incentivebased programs where the patient receives “rewards” contingent on behaviour or outcomes specified by the clinician (Carney et al. 2006, 19–20; Carney, Ingvarson, and Tait 2006). The use of these types of strategies indicates that persons with AN are paradoxically understood as possessing the competence to make decisions to comply with treatment but not to refuse it. In this way, competence and consent might only be questioned when


patients object to particular treatment plans, and clinical decisions regarding whether a person is treated “voluntarily” or “involuntarily” may be more so based on levels of compliance than competence to provide informed consent to treatment (see Rathner 1998, 192– 193). Moreover, “strategic use of the law” to threaten involuntary treatment highlights that “voluntary” consent may be provided by patients simply in order to avoid receiving treatment as an involuntary patient. This devalues the consent provided by persons with AN and complicates the issue of how to understand “voluntariness.” Further, because AN is defined by “deliberate weight loss, induced and sustained by the patient” (World Health Organization 2007, F50.0), or “persistent behavior that interferes with weight gain” (American Psychiatric Association 2013, under “Anorexia Nervosa”), biomedical conceptualisations of AN can be interpreted such that resistance to treatment is understood as inherent to the illness, which in turn implies that recovery requires compliance. This presumed need for compliance suggests that persons diagnosed with AN who resist treatment are incompetent to make treatment decisions and require intervention and supervision. This is ethically problematic, as compliance is thus embedded in competence assessments and used to decide how to balance “best interests” with “respect for autonomy.” In this way, compliance with the goals of the treating team results in patients being defined as rational and in “recovery” (Moulding 2006, 797–798; see also Gremillion 1992, 2003). Alternatively, patient attempts to exercise autonomy or make decisions about treatment that deviate from the treatment plan can be reframed as evidence that the patient is controlled by AN and unable to autonomously and competently make treatment decisions, which in turn justifies paternalism. Practitioners need to account for these power dynamics as part of their treatment decision-making. Control Ethical evaluations about the use of coercion are also complicated by the point that the need for control is understood as part of the core pathology of AN and the primary factor that causes patients to struggle to engage in treatment programs. The use of coercion can therefore be seen as either counterproductive/anti-therapeutic because it provokes increased resistance to treatment or in the best interests of patients because they are not in

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control of their lives (Tan et al. 2003, 630; see also Moulding 2006). Tan et al. (2003) argue that decision-making regarding whether to use involuntary treatment must take into account that the actions of persons diagnosed with AN may not reflect their actual competence or capacity but their need to maintain a sense of control in their lives. Further, because of the need to maintain a sense of control, clinical attempts to exert control over patients may lead only to resistance against them. Moreover, the experience of feeling controlled by clinicians may diminish patients’ ability to make balanced, autonomous treatment decisions (Tan et al. 2003, 642). The medicalisation of control thus pathologises patient resistance to professional knowledge. Professional justifications for the use of coercion must therefore account for how patient experiences of contact with treatment professionals might impact on their decisions about treatment and how they perform during competence assessments. This is supported by Carney et al. (2006), who examine how, over time, patients may behave in accordance with their perceived role as a person diagnosed with AN receiving treatment in hospital. As a patient becomes more accepting of treatment intervention, this is usually seen as progress and a lessening of the “web of control.” However, the point that the patient has become more “managed” and accepting of the authority of his or her clinicians could equally explain this (Carney et al. 2006). Patients may do this for the preservation of their relationships with their caregivers and family or to preserve their reputation as a “good patient” (Carney, Ingvarson, and Tait 2006, 55). Further, the treatment environment may promote this behaviour (Carney, Ingvarson, and Tait 2006, 57). Carney, Ingvarson, and Tait 2006 conclude that the role of “power” in the treatment of AN explains why involuntary treatment is so rarely used; the disciplinary practices of the treatment environment act as a substitute for the law. These practices include the daily routines of behaviour, surveillance, and measuring and all other rituals of institutional living. These practices target identities via role-playing as an “anorexic patient” and may lead to displaying signs of “recovery” (Carney, Ingvarson, and Tait 2006, 56–57). This demonstrates the particular relevance of Foucault’s (1997) approach to ethics, which makes a connection between technologies of self and power with

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understandings of good and right. Arguably, persons with AN in treatment environments are taught to selfgovern in such a way that affirms professional knowledge and practice. This is not to cast persons diagnosed with AN as “docile bodies”2 (Foucault 1977) or their behaviour as determined by the dominant discourse. Rather, persons with AN recognise that particular behaviour and knowledge are valued in the treatment environment and respond to these conditions. The following authors add further to this discussion. Gremillion (2003) argues that, whilst patients actively resist the identity constructions that treating teams impose on them (for example, reducing their identity to a set of numbers), the treatment environment also encourages patients to learn to attribute their difficulties with treatment compliance to “a deficiency of ‘self,’” a deficiency that had led to adopting anorexia as a “superficial identity” or a “false sense of self” (Gremillion 2003, 62). Further, this study demonstrated that, whilst there was often disagreement between members of the treating team about the treatment goals that should be set, team members always presented treatment goals as “unified, expert opinion” that attributed difficulties in treatment to the pathology of the patient, leaving no room for patient contestation if he or she wanted continued support from the team (Gremillion 2003, 64–66). This is problematic as, on the one hand, patients are asked to submit to the authority of the team and, on the other hand, display “self-control” and “choose” the path to recovery. This produces a paradoxical identity for patients as both dependent and autonomous (Gremillion 2003, 65). In this context, when patients internalise the knowledge that they are responsible for the (failed) self-control of their bodies, patients can perceive that the only way to resist this professional knowledge is through AN (Gremillion 2003, 67). Malson et al. (2004) show that patient resistance to treatment cannot be explained in terms of a unitary cause; patients take up multiple, shifting, ambiguous, and contradictory perspectives in relation to their diagnosis, to the prospect of change, and to their treatment (Malson et al. 2004, 480). Further, their study demonstrated that, in the treatment environment, patients were understood only in terms of a particular construct of Foucault examines “docile bodies” in his genealogy Discipline and Punish (1977). The “docile body” refers to the 18th-century conceptualisation of the body as an object that could be used, transformed, and improved. This understanding of the body made it a target for manipulation and power (Foucault 1977, 136).

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“eating disordered patient” whereby everything they did was understood as “anorexic” (Malson et al. 2004; see also Moulding 2006). This construction of the “eating disordered patient” renders patients powerless because there is no space from which patients can express a valid view (see also Carney et al. 2006, 126–128, and Rich 2006). It must therefore be considered that “resistance to treatment” may actually be resistance to this disempowering “eating disordered patient” role, rather than evidence that the person is in denial of his or her eating disorder or is incompetent (Malson et al. 2004, 482–485). It is noteworthy, however, that patients also apply the construct of being “100 percent anorexic” to themselves. For example, patients in Malson et al.’s (2004) study stated that anorexia is their identity. The construct of the “eating disordered patient” is thus problematic, because when it is imposed by health care workers it is experienced as depersonalised and disempowering; when it is imposed by patients onto themselves it appears to close off the possibility of recovery (Malson et al. 2004, 483). Reviewing the literature on coercion through a postmodern professional ethics approach reveals how “AN: the diagnosis” can promote the notion that recovery is contingent on patients taking responsibility for decisions that impact on their bodies, but requires of patients that they are responsible to their clinicians and that they comply with the goals of clinicians set out in treatment plans. In this way, professional knowledge and values are inherently affirmed by the disciplinary practices of the treatment environment and clinicians can justify involuntary treatment (or any kind of treatment) based on their authority in the clinical context. Further, these conditions are ethically problematic because the self-governing practices of persons diagnosed with AN make it impossible to understand the degree of autonomy and competence with which a person with AN acts and therefore the extent to which paternalism might be justifiable.

Conclusion: Implications for the Ethics of Involuntary Treatment for AN Moulding (2006) highlights that some treatment providers see “resistance” as a product of the controlling forms of psychiatric intervention and not wholly attributable to the nature of AN. These treatment providers reported making changes to their practice so that it is less rigid and weight-focused and more responsive to


patient wishes (Moulding 2006, 802). Acknowledging how treatment and professional knowledge can be harmful is potentially one way that professionals can foster more trusting relationships with patients, which in turn may result in less use of coercion, less perceived coercion from patients, patients having more autonomy and power in decision-making processes, and more beneficial treatment experiences. Recognising the fallibility of professional knowledge and values could result in the upholding of biomedical principles in a way that patients feel that they have been respected and heard, protected from harm, and benefited by treatment because professional interpretations of what these principles look like have been informed by the patient relationship. This is crucial, as patient accounts of their treatment experiences indicate that involuntary treatment may be experienced as beneficial when their relationships with professionals are caring and supportive (Tan et al. 2010, 18). Further, acknowledging that”resistance” and “control” might be products of the treatment environment and psychiatric intervention means that professionals must take responsibility for the conditions produced by “expert knowledge” and how it can warrant involuntary treatment and be counterproductive.

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