Cultural and Ethical Issues in the Treatment of Eating Disorders in Singapore

The ethical issues involved in the treatment of eating disorders have received considerable discussion in the literature, with debates chiefly focusing on the issue of compulsion (Ayton et al. 2009; Giordano 2003; Dresser 1985; Draper 2000; Rathner 1998; Vandereycken and Beumont 1998; Tiller et al. 1993; Carney et al. 2005). Some empirical ethics research has also been conducted with patients, parents and mental health professionals concerning issues such as the ethics of compulsion and the impact of having an eating disorder on decision-making (Serpell et al. 2004; Tan et al. 2008; Tan et al. 2010; Tan 2006; Newton et al. 2005; Serpell and Treasure 2002; Serpell et al. 1999). Most of these discussions and research studies, however, have taken place in Europe, Australasia and the United States, mirroring the fact that most eating disorder research is also based in Europe, Australasia and the United States.

The Singapore Context

Singapore is a small island state with a population of 5,312,400 (Department of Statistics Singapore 2012). The population is largely composed of different ethnic groups: Chinese 74.2%, Malays 13.3%, Indians 9.2% and Others 3.3% (Department of Statistics Singapore 2012), but there is also a sizeable number of foreign nationals resident in the country. It is a multi-religious, multi-lingual country. Singapore has a highly-educated and affluent population but the population is ageing and there is a widening income gap (Rajan and Thangavelu 2009).

The prevalence of eating disorders in Singapore is unknown. What is known is that the number of patients with eating disorders presenting to mental health services in Singapore is rising, and that this is congruent with patterns in other Oriental countries such as Japan (Miller and Pumariega 2001). Although there have been suggestions that eating disorders can be different in non-Western cultures, and that Chinese sufferers may lack a fear of fatness (Lee et al. 2001), the clinical presentation of anorexia nervosa in Singapore has been found to be similar to that seen in other countries internationally (Lee et al. 2005). Treatment of eating disorders in Singapore is based on clinically-proven treatment models developed in Europe, Canada and the United States. There is one specialist eating disorder treatment centre in Singapore, which accepts patients aged 13 years and above. It is based in a general hospital and works closely with the departments of endocrinology and gastroenterology and is the only such specialist centre in the whole of Southeast Asia. When faced with ethical issues in the treatment of eating disorders, many mental health professionals refer to the Singapore Medical Council’s ethical code of conduct as a guide. The code is similar to, but less detailed than, the General Medical Council’s medical practice guidelines in the United Kingdom (Singapore Medical Council 2006; General Medical Council 2009; General Medical Council 2008).

Methods

A focus group was run in Singapore, to which health professionals working with patients with eating disorders were invited. The aim of the focus group was to explore the ethical issues that arise for mental health professionals treating eating disorders in the Singapore context.

Ethical issues in the treatment of eating disorders were discussed within the focus group, which lasted 90 minutes and had two facilitators. The direction of the discussion was largely driven by the participants themselves, although a brief topic guide was used to help direct the discussion (see below).

Focus group discussion topic guide:

1. 1. What is involved in treatment in eating disorders?

2. 2. What are the problematic issues you encounter in this work that may have ethical aspects?

3. 3. How does the Singapore context affect these?

The focus group session was video-recorded with all participants’ knowledge and consent. No patients were named during the discussion. The focus group was conducted using a flexible approach with the facilitators helping the participants to co-construct their views regarding ethical issues, which they may not have thought about themselves (Tan and Hope 2008). The...