Anorexia Nervosa: A Case for Exceptionalism in Ethical Decision Making

Coercive treatment for anorexia nervosa raises acute ethical, legal and clinical issues: it is sometimes the only way to prevent death, but it represents a serious form of bodily intrusion and a violation of the stated wishes of patients who are often intelligent and well articulated. The purpose of this article is to clarify the philosophical and ethical issues involved in the treatment of anorexia nervosa and to propose applicable principles of ethical decision making. Anorexia nervosa raises acute ethical issues: can it ever be ethical to impose treatment despite sufferers' apparently intact intellectual capacity? In cases of severe and enduring anorexia, where patients seem to be recalcitrant to therapy and where the condition is life-threatening, can it ever be ethical to discontinue lifesaving treatment? This article discusses cases that appeared before the courts of England and Wales from 2012 to 2016. It offers a philosophical analysis of the notions and concepts used (particularly capacity, best interests and futility), and evaluates the ethical principles underpinning these decisions through the classical methods of philosophical investigation. The usual principles of ethical decision making (respect for autonomy, respect for capacitous refusals, discontinuation of futile treatment) are not straightforwardly applicable to the treatment of anorexia nervosa. The exceptional circumstances which characterize anorexia nervosa provide moral reasons for partial derogation from the usual principles of ethical decision making. Alternative principles of ethical decision making are proposed. It is suggested that coercive treatment in patients with late stage anorexia can be justified, but in a limited number of circumstances and when there is concrete possibility of recovery and significant improvement of the quality of life of the sufferer. Early paternalistic intervention may be more justifiable, ethically, than later coercive intervention.