restricted access Anorexia, Authenticity, and the Expert Perspective
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Anorexia, Authenticity, and the Expert Perspective

In this issue of the Hastings Center Report, Tony Hope, Jacinta Tan, Anne Stewart, and Ray Fitzpatrick, reporting on twenty-nine interviews they conducted with women with so-called anorexia nervosa, note that the participants recurrently raised issues of authenticity. The paper reflects on the way their behaviors, experiences, and choices can be considered authentic (parts of their “real selves”), or inauthentic (parts of their anorexia). The authors also pose a question about the normative implications of their analysis—if some choices are inauthentic, then is it ethical to override them? For example, they suggest that “showing respect” for the sufferer “does not necessarily mean simply acceding to the person’s requests to decline help or treatment.”

The paper is rich in suggestions and hypotheses and raises a number of questions, some methodological and others more “substantial.” I will discuss only a couple of issues.

On the methodological front, the authors’ assumptions about anorexia are never made explicit, and this can bias the respondents’ answers. The authors ask, for instance, “What is your understanding of what anorexia nervosa is?” “How has anorexia nervosa changed you”? and “Do you think anorexia is an illness?” In doing so, they assume that anorexia is a thing with the power to change people or cause behaviors. Thus rather than just ask a question, they provide an answer. One wonders whether the respondents’ stress on authenticity is a function of the interviewers’ perspective. What would the respondents have answered had they been asked questions such as, “How and when have you changed (if you have changed)?” rather than, “How has anorexia changed you?” “What is your understanding of your values, fears . . . ?” rather than, “What is your understanding of anorexia?”

Of course, the interviewers cannot be expected to approach a subject without preconceptions and opinions about it. But it is important that these are spelled out clearly, especially because the relationship between researcher and participant is not on a par; the researcher is “the expert,” and the sufferer, as the vulnerable party, may not be in the position to detect and critically evaluate the interviewer’s hidden assumptions. Therefore, if, as the authors emphasize, it is important to remember the value of self-knowledge, as the Oracle of Delphi they cite advised, then it is perhaps even more important to remember Pyrrho’s lesson, on the importance of skepticism and of suspending judgment as a means to attain knowledge.

On a more substantial point, the authors (rightly) stress the importance of self-knowledge, but knowing and understanding are different: I may know that fat terrifies me and yet have no understanding of why. I may even predict that Sally will make herself sick after dinner, and still fail to understand why. Knowledge and ability to predict may be mistaken for understanding and for the ability to explain, and the authors seem to make such a mistake. They suggest that some behaviors or experiences may not be authentically a part of the sufferers’ self, but rather caused by the anorexic side. In fact, they note that a recurrent theme in interviews is the “power struggle” between these different parts. This perspective may be reassuring (I am not doing this to myself, something is doing this to me), but it can be dangerous. “Pro-Ana” websites exist thanks to such reification: anorexia becomes “the best friend” or the worthwhile goal. Moreover, this approach may disempower some sufferers: if anorexia is something that happens to me, what can I do about it? And if the therapists themselves consider anorexia as an inauthentic and self-destructive force, then how can they propose to truly understand the sufferer’s experiences?

The sufferers are those with the real expertise: they are in the position to tell us why thinness and lightness are so important to them, what they symbolize, and why fat is dangerous. Values such as self-control, perfectionism, mastery of the body, and will-power have already been identified in the literature as among the core features that may explain the terror of fat and the relentless search for thinness. In Western morality, corpulence has traditionally symbolized vices such as indolence...