Forced Feeding for Anorexia: Soft or Hard Paternalism?

My thanks to Professors Hawkins and Szmukler for their thoughtful commentaries; I am particularly glad to see these scholars' valuable expertise directed toward what raises pressing issues not only for psychiatry but for contemporary society.

Prof. Hawkins reasons that the use of forced feeding with some anorexia is justified, while emphasizing that this will occur rarely. She and I are in agreement that a mere handful of cases may be affected by our debate, since anecdotal evidence from clinical settings as well as the studies Hawkins cites suggest that forced feeding will often be contraindicated. Still, the matter can equally well be cast hypothetically, as I implied in my earlier discussion. If forced feeding were an effective method to achieve treatment goals, would it be justified? My concern with Hawkins's modest version of liberalism is that it offers too little resistance to the suggestion that it would.

Hawkins's position is that even a liberal can justify limited paternalistic intervention with rare cases of anorexia. The modest form of liberalism that she defends comprises valuing free choice highly; placing individualism at the center of focus, and generally construing welfare in terms dictated by the subject, so that people can live lives "largely" shaped by their own decisions.

Explaining these tenets (whether of weak liberalism or hard—or soft—paternalism, I leave the reader to decide), Hawkins stakes out her qualified stance: a person's welfare describes a state of affairs that is consequent on choices that are better or worse, and an objective fact about which the individual, like those around her, may be mistaken. The rare case where this "prudential mistake" is made by the person about her own interests occurs where the decision's consequences are both dire and irreversible, and in these cases, paternalism is tempting, as Hawkins puts it. But, as I tried to illustrate in my earlier discussion of Dworkin's criteria of far-reaching, potentially dangerous and irreversible risk, both the dire and the irreversible outcomes of decisions seem hard to maintain for decisions over food intake. This is because judgments of direness and irreversibility are interrelated: although a dire and foreseeable outcome, the future risk of death is all too readily able to be discounted (the way it often is by the anorexic). Its apparent reversibility, achieved merely by eating, and evident in cases that seem to remit without medical help, leaves the outcome less immediately dire. This is not a quirk of anorexic reasoning but a feature of everyday calculation; we discount remote risks we believe it is in our power to avoid. Again, although this seemingly voluntary picture of the anorexic's decision may be misleading, more is required to show why.

Like Hawkins, Prof. Szmukler also finds room for best interests in reasoning about anorexia. Defining "authentic values" as those that are "reasonably stable, deeply held beliefs, values, commitments or conception of the good" (p. 152) he allows that when some incapacity or impairment leads to a decision that might violate the person's authentic values understood as a reflection of the person's best interests, there may be justification for intervention in their name. It is certainly an imaginable circumstance: beset by psychosis, a person may refrain from eating out of a suddenly formed delusional belief that all food is contaminated, or that God commands it. Combined with a radical departure from any previously ascertained authentic values, this may be a plausible case for intervention, Szmukler implies, and I would agree. In this hypothetical case, however, two separable elements converge, the delusional beliefs are the result of recognized, multiply incapacitating and demonstrated disorder, and they conflict with the person's more characteristic and enduring ("authentic") values. When either of these occurs separately—self-starvation brought about by longentrenched delusions might be one case, or by an abrupt but apparently voluntary change of mind, another—it will be harder to judge. Clinical lore has almost always maintained that the anorexic is not delusional.¹ Nor, contrary to Szmukler's generalization here, is the combination of will and preferences making up what can be...