Anorexia nervosa and refusal of naso-gastric treatment: A response to Heather Draper

Bioethics

Volumn 17, Issue 3, 2003, Pages 261-278

  Giordano, Simona ^a  

^a UNIVERSITY OF MANCHESTER   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANOREXIA NERVOSA; ARTIFICIAL FEEDING; HUMAN; INDEPENDENCE; MEDICAL DECISION MAKING; MEDICAL ETHICS; MORALITY; NOSE FEEDING; PATIENT COMPLIANCE; PATIENT RIGHT; REVIEW;

EID: 0038185138     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/1467-8519.00340     Document Type: Review

References (62)

1. H. Draper. Anorexia Nervosa and Respecting a Refusal of Life-Prolonging Therapy: A Limited Justification. Bioethics 2000; 14: 120-133.
2. M. Kundera. 1991. Immortality. London. Faber and Faber: 73.
3. 'Crossing the border of humanity/We met before time the carrion/Which kills all desires and dreams/ Don't disdain pity.' F. De André. 1969. Corale. Milano. BMG Ricordi. Copyright 1990 Casa Ricordi.
4. H. Draper, op. cit. note 1, p. 120.
5. H. Draper. Treating Anorexics Without Consent: Some Reservations. JME 1998; 24: 5-7.
6. H. Draper, op. cit. note 1, p. 120. My emphasis.
7. I am referring to the English law, to which Draper also refers. Gillick v West Norfolk Wisbech AHA [1985] 3 ALL ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman; see also Estate of Park [1959] P 112; Re C (adult: refusal of medical treatment) [1994] 1 All ER 819, (1993) 15 BMLR 77; J. Harris. 1992. The Value of Life. London. Routledge: 200ff.
8. I am referring to the English law, to which Draper also refers. Gillick v West Norfolk Wisbech AHA [1985] 3 ALL ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman; see also Estate of Park [1959] P 112; Re C (adult: refusal of medical treatment) [1994] 1 All ER 819, (1993) 15 BMLR 77; J. Harris. 1992. The Value of Life. London. Routledge: 200ff.
9. I am referring to the English law, to which Draper also refers. Gillick v West Norfolk Wisbech AHA [1985] 3 ALL ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman; see also Estate of Park [1959] P 112; Re C (adult: refusal of medical treatment) [1994] 1 All ER 819, (1993) 15 BMLR 77; J. Harris. 1992. The Value of Life. London. Routledge: 200ff.
10. I am referring to the English law, to which Draper also refers. Gillick v West Norfolk Wisbech AHA [1985] 3 ALL ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman; see also Estate of Park [1959] P 112; Re C (adult: refusal of medical treatment) [1994] 1 All ER 819, (1993) 15 BMLR 77; J. Harris. 1992. The Value of Life. London. Routledge: 200ff.
11. M. Brazier. 1992. Medicine, Patients and the Law. London. Penguin: chapters 2, 4, 5.
12. St George's Healthcare Trust v S R v Collins and others, ex part S [1998] 3 All ER 673.
13. Lane v Candura [1978] 376 NE 2d 1232 Appeal Court of Massachusetts.
14. Hopp v Lepp [1979] 98 DLR (3d) 464 at 470 per J. Prowse.
15. Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital [1985] 1 All ER 643 at 509 b per Lord Templeman; see also R v Blame [1975] 3 All ER 446.
16. Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital [1985] 1 All ER 643 at 509 b per Lord Templeman; see also R v Blame [1975] 3 All ER 446.
17. F v West Berkshire Health Authority [1989] 2 All ER 545; see also State of Tennessee v Northern [1978] 563 SW 2 d 197; All ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman.
18. F v West Berkshire Health Authority [1989] 2 All ER 545; see also State of Tennessee v Northern [1978] 563 SW 2 d 197; All ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman.
19. F v West Berkshire Health Authority [1989] 2 All ER 545; see also State of Tennessee v Northern [1978] 563 SW 2 d 197; All ER 402 at 409 e-h per Lord Fraser and at 422 g-j per Lord Scarman.
20. H. Draper, op. cit. note 1, p. 129. See also the Law Commission Report on Mental Incapacity, No. 231, 1995; Who decides? Making Decisions of Behalf of Mentally Incapacitated Adults. A Consultation paper issued by the Lord Chancellor's Department, December 1997; April Mental Health Act Review Expert Group. April 1999. Draft Proposals for the New Mental Health Act. http://www.hyperguide.co.uk/mha/rev-prop.htm
21. H. Draper, op. cit. note 1, p. 129. See also the Law Commission Report on Mental Incapacity, No. 231, 1995; Who decides? Making Decisions of Behalf of Mentally Incapacitated Adults. A Consultation paper issued by the Lord Chancellor's Department, December 1997; Mental Health Act Review Expert Group. April 1999. Draft Proposals for the New Mental Health Act. http://www.hyperguide.co.uk/mha/rev-prop.htm
22. H. Draper, op. cit. note 1, p. 129. See also the Law Commission Report on Mental Incapacity, No. 231, 1995; Who decides? Making Decisions of Behalf of Mentally Incapacitated Adults. A Consultation paper issued by the Lord Chancellor's Department, December 1997; Mental Health Act Review Expert Group. April 1999. Draft Proposals for the New Mental Health Act. http://www.hyperguide.co.uk/mha/rev-prop.htm
23. Secretary of State for the Home Department v Robb [1995] 1 All ER 677.
24. Re C [1994] 1 FLR 31, Re MB [1997] 8 Medical Law Report 217; Banks v Goodfellow [1870] LR.5 QB 549 at p. 569 per lord C.J. Cockburn.
25. Re C [1994] 1 FLR 31, Re MB [1997] 8 Medical Law Report 217; Banks v Goodfellow [1870] LR.5 QB 549 at p. 569 per lord C.J. Cockburn.
26. See: the Mental Health Act Review Expert Group, op. cit. note 14, para. 152.
27. E. Faccio. 1999. Il disturbo alimentare, modelli ricerche e terapie. Roma. Carocci: 83.
28. M. Selvini Palazzoni. 1998. Anoressia mentale, dalla terapia individuale alla terapia familiare. Milano. Feltrinelli: 70.
29. H. Bruch. 1974. Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. London. Routledge: 384.
30. Law Commission. 1993. Consultation Paper No. 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. - Para. 2.18 from Re W [1992] 3 WLR 758, HMSO; in particular para. 2.3.2. The legitimacy of forcefeeding is a highly controversial issue. Anorexia nervosa is considered a mental illness, and therefore patients can be compulsorily detained and treated under sections 2 and 3 of the Mental Health Act 1983. According to s.63 of the Act, consent to treatment for the mental disorder will not be required to sectioned patients, and polemics arose as to whether naso-gastric feeding should be considered as a treatment for the mental disorder and could therefore be legally imposed under s.63, or should instead be considered as a treatment for the physical conditions, for which consent must be obtained. Despite the cases of Re KB (adult) (mental patient: medical treatment) [1994] 19 BMLR 144, Riverside Health NHS Trust v. Fox [1994] 1 FLR 614, B. v. Croydon District Health Authority [1995] 1 All ER 683, where the Court decided that artificial feeding could be imposed, debate on the legitimacy of force-feeding is ongoing. In April 1999, the Mental Health Act Review Expert Group suggested that feeding contrary to the will of the patient should be included among treatment that should deserve special safeguards. See: Mental Health Act Review Expert Group, op. cit. note 14, para. 19.
31. Law Commission. 1993. Consultation Paper No. 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. - Para. 2.18 from Re W [1992] 3 WLR 758, HMSO; in particular para. 2.3.2. The legitimacy of forcefeeding is a highly controversial issue. Anorexia nervosa is considered a mental illness, and therefore patients can be compulsorily detained and treated under sections 2 and 3 of the Mental Health Act 1983. According to s.63 of the Act, consent to treatment for the mental disorder will not be required to sectioned patients, and polemics arose as to whether naso-gastric feeding should be considered as a treatment for the mental disorder and could therefore be legally imposed under s.63, or should instead be considered as a treatment for the physical conditions, for which consent must be obtained. Despite the cases of Re KB (adult) (mental patient: medical treatment) [1994] 19 BMLR 144, Riverside Health NHS Trust v. Fox [1994] 1 FLR 614, B. v. Croydon District Health Authority [1995] 1 All ER 683, where the Court decided that artificial feeding could be imposed, debate on the legitimacy of force-feeding is ongoing. In April 1999, the Mental Health Act Review Expert Group suggested that feeding contrary to the will of the patient should be included among treatment that should deserve special safeguards. See: Mental Health Act Review Expert Group, op. cit. note 14, para. 19.
32. Law Commission. 1993. Consultation Paper No. 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. - Para. 2.18 from Re W [1992] 3 WLR 758, HMSO; in particular para. 2.3.2. The legitimacy of forcefeeding is a highly controversial issue. Anorexia nervosa is considered a mental illness, and therefore patients can be compulsorily detained and treated under sections 2 and 3 of the Mental Health Act 1983. According to s.63 of the Act, consent to treatment for the mental disorder will not be required to sectioned patients, and polemics arose as to whether naso-gastric feeding should be considered as a treatment for the mental disorder and could therefore be legally imposed under s.63, or should instead be considered as a treatment for the physical conditions, for which consent must be obtained. Despite the cases of Re KB (adult) (mental patient: medical treatment) [1994] 19 BMLR 144, Riverside Health NHS Trust v. Fox [1994] 1 FLR 614, B. v. Croydon District Health Authority [1995] 1 All ER 683, where the Court decided that artificial feeding could be imposed, debate on the legitimacy of force-feeding is ongoing. In April 1999, the Mental Health Act Review Expert Group suggested that feeding contrary to the will of the patient should be included among treatment that should deserve special safeguards. See: Mental Health Act Review Expert Group, op. cit. note 14, para. 19.
33. Law Commission. 1993. Consultation Paper No. 129. Mentally Incapacitated Adults and Decision-Making. Medical Treatment and Research. - Para. 2.18 from Re W [1992] 3 WLR 758, HMSO; in particular para. 2.3.2. The legitimacy of forcefeeding is a highly controversial issue. Anorexia nervosa is considered a mental illness, and therefore patients can be compulsorily detained and treated under sections 2 and 3 of the Mental Health Act 1983. According to s.63 of the Act, consent to treatment for the mental disorder will not be required to sectioned patients, and polemics arose as to whether naso-gastric feeding should be considered as a treatment for the mental disorder and could therefore be legally imposed under s.63, or should instead be considered as a treatment for the physical conditions, for which consent must be obtained. Despite the cases of Re KB (adult) (mental patient: medical treatment) [1994] 19 BMLR 144, Riverside Health NHS Trust v. Fox [1994] 1 FLR 614, B. v. Croydon District Health Authority [1995] 1 All ER 683, where the Court decided that artificial feeding could be imposed, debate on the legitimacy of force-feeding is ongoing. In April 1999, the Mental Health Act Review Expert Group suggested that feeding contrary to the will of the patient should be included among treatment that should deserve special safeguards. See: Mental Health Act Review Expert Group, op. cit. note 14, para. 19.
34. H. Draper, op. cit. note 1, pp. 132-133. My emphasis.
35. Ibid. p. 131.
36. For easiness, given that the majority of sufferers are women, I shall follow Draper in the choice of female pronouns. However, it should be reminded that eating disorders also affect the male population. See: H.G. Pope, H.G. Pope Jr., J.I. Hudson, D. Yurgelun-Todd & M.S. Hudson. Prevalence of Anorexia Nervosa and Bulimia in Three Student Populations. IJED 1984; 3: 33-51; see also the Eating Disorders Association reports at www.edauk.com, section 'Men's Issues.'
37. For easiness, given that the majority of sufferers are women, I shall follow Draper in the choice of female pronouns. However, it should be reminded that eating disorders also affect the male population. See: H.G. Pope, H.G. Pope Jr., J.I. Hudson, D. Yurgelun-Todd & M.S. Hudson. Prevalence of Anorexia Nervosa and Bulimia in Three Student Populations. IJED 1984; 3: 33-51; see also the Eating Disorders Association reports at www.edauk.com, section 'Men's Issues.'
38. H. Draper, op. cit. note 1, p. 122.
39. This apparent inability to control eating often leads to the thinking of anorexia as a form of addiction. Besides generic similarities between the two conditions, however, they present crucial differences that make the comparison improper, even at a logical level. See: S. Giordano. Addicted to Eating Disorders? Eating Disorders and Substance Use Disorders, Differences and Fallacies. IJPBS 2001; 11: 73-77.
40. H. Draper, op. cit. note 1, p. 133.
41. Ibid. p. 122.
42. Ibid. p. 123.
43. Ibid. p. 124. My emphasis.
44. I b i d.
45. It should also be noticed that, in order to defend people's entitlement to make decisions relating to their life, we do not need to demonstrate that their decisions have nothing to do with 'euthanasia.' Draper assumes that 'euthanasia is unethical', and therefore tries to define 'euthanasia' in a way in which refusal of artificial feeding appears to be something different from a request for 'euthanasia.' However, a defence of people's entitlement to make decisions relating to their life would be more consistent and persuasive if we openly claim that sometimes morality demands respect for a person's decision, even if that decision results in the person's death. Rather than saying that respect for refusal of artificial feeding may be legitimate because it has nothing to do with 'euthanasia', we should rather say that we should sometimes respect the request for omission or suspension of life-saving treatment, even if this involves some kind of 'euthanasia.' What should be demonstrated, in other words, is not that a decision does not fall under the category of 'euthanasia', but rather that some decisions, although involving the death of the person who competently makes those decisions, should be respected, and that it is unethical to violate the person's competent wishes about her own life, even if someone may call this 'euthanasia.'
46. H. Draper, op. cit. note 1, p. 123. My emphasis.
47. Janet L. Treasure. 1998. Anorexia and Bulimia Nervosa. In Seminars in General Adult Psychiatry. G. Stein & G. Wilkinson, eds. London. Royal College of Psychiatrists: 858-902.
48. A.S. Kaplan & E.P. Garfinkel. 1988. The Neuroendocrinology of Anorexia Nervosa. In Clinical Neuroendocrinology. R. Cullu, G.M. Brown & R. Van Loon, eds. London. Blackwell: 105-22.
49. Draper points out that in some cases, people with eating disorders accept to live only on the condition that they maintain abnormally low weight. In these cases, physical complications are typical, and the concern toward thinness fills the person's mind and grossly reduces the quality of their life. This shows the problematic nature of the notion of 'recovery.' We should also admit that some people never get better. As we have seen above (cf. note 34), a high number of those who have eating disorders die. The majority dies because they commit suicide. No doubt, many people who have eating disorders feel unbearably unhappy. However, we should also consider that, according to the same estimates reported by Draper, the majority of those who develop an eating disorder recover (according to Lang, The Harvard Medical Letter, recovery rate is between 50-70% over ten years. E.D. Eckert et al. Ten-Year Follow-up of Anorexia Nervosa: Clinical Course and Outcome. Psychological Medicine 1995; 25: 143-56. They report 24% full recovery andjust under 50% benign outcome. Quotation in: H. Draper, op. cit. note 1. In this note, Draper concludes that, 'taken together these sources suggest a failure rate of between 25-50% over ten years.' Obviously, this means that the recovery rate, over ten years, is about 50-75%). Moreover, there is empirical evidence of considerable improvement when the appropriate approach is adopted. See, for example, results reported by: M. Selvini Palazzoli, S. Cirillo, M. Selvini, A.M. Sorrentino. 1998. Ragazze anoressiche e bulimiche, la terapia familiare. Milano. Raffaello Cortina Editore. Perhaps, it should also be considered that 50% of those who have been force-fed declare, with the insight of the 'afterward', that this was a good thing for them. See the Eating Disorders Association at the website: www.edauk.com.
50. Draper points out that in some cases, people with eating disorders accept to live only on the condition that they maintain abnormally low weight. In these cases, physical complications are typical, and the concern toward thinness fills the person's mind and grossly reduces the quality of their life. This shows the problematic nature of the notion of 'recovery.' We should also admit that some people never get better. As we have seen above (cf. note 34), a high number of those who have eating disorders die. The majority dies because they commit suicide. No doubt, many people who have eating disorders feel unbearably unhappy. However, we should also consider that, according to the same estimates reported by Draper, the majority of those who develop an eating disorder recover (according to Lang, The Harvard Medical Letter, recovery rate is between 50-70% over ten years. E.D. Eckert et al. Ten-Year Follow-up of Anorexia Nervosa: Clinical Course and Outcome. Psychological Medicine 1995; 25: 143-56. They report 24% full recovery andjust under 50% benign outcome. Quotation in: H. Draper, op. cit. note 1. In this note, Draper concludes that, 'taken together these sources suggest a failure rate of between 25-50% over ten years.' Obviously, this means that the recovery rate, over ten years, is about 50-75%). Moreover, there is empirical evidence of considerable improvement when the appropriate approach is adopted. See, for example, results reported by: M. Selvini Palazzoli, S. Cirillo, M. Selvini, A.M. Sorrentino. 1998. Ragazze anoressiche e bulimiche, la terapia familiare. Milano. Raffaello Cortina Editore. Perhaps, it should also be considered that 50% of those who have been force-fed declare, with the insight of the 'afterward', that this was a good thing for them. See the Eating Disorders Association at the website: www.edauk.com.
51. Several conventions and declarations of human rights stress the importance and fundamental value of individual autonomy (General Assembly of the United Nations, Universal Declaration of Human Rights, 10 December 1948; Council of Europe, Convention on Human Rights and Biomedicine, Oviedo, 4 April 1997). In coherence with this principle, in most European countries the law generally recognises individuals' right to consent to medical treatment or to refuse it. See for example: M. Brazier. op. cit. note 8, chapters 2 and 5.
52. M. Kundera, op. cit. note 2, p. 73.
53. H. Draper, op. cit. note 1, p. 122.
54. Ibid. pp. 125-26.
55. Ibid. p. 126.
56. Ibid. pp. 122-23.
57. Ibid. p. 122.
58. Ibid. pp. 122-23.
59. A real-story-based novel well expresses the paradox of accepting misery and death, while longing for happiness and life. D. Hautzig. 1982. Second Star to the Right. London. Fontana Lions.
60. See: M. Selvini Palazzoli et al., op. cit. note 36, pp. 115-18.
61. H. Draper, op. cit. note 1, p. 124.
62. See for example, the recent case of Ms B., a woman who is paralysed from the neck downward, and who has been acknowledged by the High Court the right to have her life support machine turned off. See BBC news, Friday 22 March 2002, at the website www.bbc.co.uk