A Delicate Balance: Treating the Resistant AN Patient
Reprinted from Eating Disorders Review
November/December 2003 Volume 13, Number 6
©2002 Gürze Books
Treatment for anorexia nervosa (AN) usually combines nutritional therapy to increase body weight and psychiatric therapy or family therapy, or both. Patients with AN, however, do not want to gain weight, and typically show an intense fear of doing so, even when they are near collapse from malnutrition.
According to Dr. Chris MacDonald, of Dalhousie University, Halifax, Nova Scotia, when patients resist rather than refuse treatment, clinicians are faced with the ethical challenge of deciding whether particular interventions will be infringements upon patient autonomy (Can J Psychiatry 2002;47:267).
A great deal of attention has been paid to treatment refusal, according to Dr. MacDonald, and much less to treatment resistance. Clinicians who are faced with a patient who resists being treated may find themselves using coercion, persuasion, and manipulation in an attempt to get patients to eat. Even patients who are voluntarily hospitalized will have their actions limited or modified in a range of ways, for example:
Restricted movement within the hospital (for example, the patient will be ordered to stay in her room or on the ward); demanding that an inpatient eat 100% of her meals; and cajoling the patient into doing volunteer work in the hope that forging such social connections will benefit the patient.
Respect for patient autonomy is a cornerstone tenet of modern medical ethics, writes Dr. MacDonald. Autonomy is defined as the ability to direct one's own life to make one's own decisions. It usually has two parts: control of one's actions (absence of constraint) and the capacity for rational thought. First, individuals with severe AN have diminished capacity in each category. Secondly, individuals suffering from AN typically lack the capacity to rationally think about the effects of their caloric intake. Thus, such patients may lack both of the characteristics needed for autonomous action in regard to food and exercise.
Infringing upon a patient's autonomy is always ethically worrisome, according to the author, but it is particularly so in certain situations. First, there is a notorious power imbalance between clinicians and their patients. Second, infringement of autonomy is of particular concern for those whose autonomy is already seriously compromised.
When is interference warranted?
According to Dr. MacDonald, in some cases treating a patient despite resistance might be justified on the basis of consent. Most patients in eating disorders programs are there more or less voluntarily; that is, they want clinical intervention even though they may disagree with their clinician over the specific goals of the intervention (for example, weight gain vs. palliation, or body fat increase vs. electrolyte rebalance). He adds that when a patient has voluntarily entered a program and knows what treatment will follow, she is in effect consenting to a certain amount of infringement upon her autonomy. This will also depend upon the freedom with which consent was given—was the patient under undue pressure from her family, or has she been threatened with civil commitment if she doesn't enter treatment? Also, treating a resistant patient may also be justified simply on the basis of the good of the patient.
The author notes that because of the primacy of respect for autonomy in modern health care ethics, the simple fact that a proposed treatment will help the patient is not sufficient to justify imposing that treatment. Instead, the desire to do good must be balanced against the need to respect patient autonomy.
Finally, Dr. MacDonald notes that every action that infringes upon another person's autonomy is ethically significant, though not always ethically wrong. He adds that the treatment of AN merely constitutes a particularly clear example of what is in fact a general part of clinical practice: Ethical decision-making pervades all clinical practice.