MOTION #67: THIS HOUSE WOULD FORCE
FEED SUFFERERS OF ANOREXIA NERVOSA
Anorexia Nervosa (AN) is an eating disorder defined as severe, self-
inflicted starvation leading to body weight at least 15% below that expected
for the individual’s sex and height and age. According to the 10th edition of
the International Classification of Diseases (ICD-10) of the World Health
Organization (WHO) AN is a mental illness. It should not be confused with
Bulimia nervosa (cycles of bingeing and vomiting or other compensatory
behaviour) although these mental disorders have a lot in common and may occur
in the same person both sequentially or concurrently. Body image disturbance is
a symptom of AN. AN is much more common in teenage girls and young women
compared to male individuals and in other age groups, affecting up to 1% of
female adolescents in industrialized countries (with money to spend on
epidemiological field studies to acquire such knowledge about a- regarding the
whole population - rather rare disorder). However, it is a serious disorder
with a high mortality between 5% and 18%, and especially considering the young
age of those afflicted. Unrealistically slim media portrayals of the female
body may increase the risk of developing AN. . Patients who are dangerously
thin are sometimes force-fed using a naso-gastric (through the nose) or
transdermal duodenal tube (PEG). Normally, medical treatment cannot be
administered without the consent of the patient. However, mentally ill patients
may not have the mental capacity to make a choice. Despite this, medical
ethics, pragmatics and human rights call the treatment into question.
Pros
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Cons
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Life is more important than dignity. Life is more important than dignity, many medical
treatments are unpleasant or painful but they are necessary to preserve life.
Without force feeding the anorectic patient will often die. In Australia
about 80 per cent of all anorexic children required hospital admission (from
101 cases), and of those, 50 per cent required tube feeding as a life-saving
measure to manage starvation. When a patient requires emergency treatment
doctors should do what is necessary to save the patient’s life. Psychological
problems can only be treated if the person is alive. Treatment for the
psychological problem should be considered to go hand in hand with saving the
patient’s life as in the B vs. Croydon Health Authority where force feeding
was ruled to be complemented the use of other methods to treat her
psychiatric problems.
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Life is more important than dignity. None the less
there is a significant difference between someone who is in an emergency
condition being treated without their consent and someone who has previously
refused treatment being forced to have treatment. Patients are allowed to
make decisions doctors believe are unwise.
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Anorectic patients are not able to make the decision
for themselves. Anorectic patients
are typically treated under mental health legislation (e.g. the UK 1983 Act).
They do not make a free choice because they are not rationally able to weigh
up decisions and consequences, they ‘feel’ fat when they obviously are not
and are irrational as they are willing to starve themselves to the point of
death when suicide is not their intent. The patient is not “capable of
forming unimpaired and rational judgements concerning the consequences”
(British Medical Association 1992). There have been court cases that have
confirmed that force feeding should be allowed when a patient is considered
mentally ill. For example the case of “B vs.
Croydon Health Authority” in 1994 it was judged, that B (a borderline
personality disorder patient, which involves suffering from an irresistible
desire to inflict-self-harm) can be force fed, even though she did not give
consent to the treatment.
The court explained that because she was not aware of
the seriousness of her condition and she had found it difficult to break out
of the cycle of self-punishment, she was deemed unfit to make decisions about
her nutrition.
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Force feeding is undignified. The World Medical
Association considers “Even if intended to benefit, feeding accompanied by
threats, coercion, force or use of physical restraints is a form of inhuman
and degrading treatment.” This is treatment which the European Convention on
Human Rights prohibits in Article 3 on the prohibition of torture. The
patient’s right to refuse treatment should be respected even if they are
mentally ill. (N.B. Anorexia is not recognised as a mental illness in every country).
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Force feeding can help psychologically. A healthier body weight is necessary to be able to
treat the patient’s psychological problems. Studies in Minnesota show that
when normal volunteers were starved, they began to development anorectic
patterns. They over-estimated the sizes of their own faces by approximately
50%. This shows the impact of starvation on the brain.
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Far from helping solve the patient’s psychological
problems force feeding is just as likely to exacerbate the problems and make
them much less willing to seek out treatment, something that they are often
already unwilling to do. While it may be the case that when starved people
over-estimate their own size those who are anorexic in the developed world
did not start out starved so there must have been a different initial cause
of the anorexia that will need to be found and solved, there are numerous
different types of psychological treatment that can help do this.
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In the first instance, doctors should always act to
keep a patient alive. Medical ethics say
that a doctor has a responsibility to keep the patient alive to administer
treatment. In the UK Diana Pretty was denied the right to die by the House of
Lords even though she consistently requested it. The Israeli Courts ordered
the force- feeding of political hunger strikers arguing that in a conflict
between life and dignity, life wins. India prosecuted a physician who allowed
a hunger striker to die. The medical profession take their responsibility for
life very seriously on a global level.
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When it comes to hunger strikes the World Medical
Association says that “Forcible feeding is never ethically acceptable.” While
there are obviously differences in terms of the objective when it comes to
the consent of the patient there is no difference. In both cases the patient
does not want to be force fed and understand what the consequences may be.
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Short term
success is all that is necessary to save a life. Once the anorectic patient
is out of danger then more long term treatments can be explored. This means
working out how to reduce the fear of food and of weight and if the patient has become worried about going
to hospital then at least there is time to sort that out as well. While
emergency force feeding has to be within a hospital not all treatment has to
take place in such an environment and ongoing psychological treatment can
take place elsewhere.
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Compulsory treatment is not a long term solution.
Compulsory treatment may only be successful in the short term. In the long
term it does nothing to reduce the fear of food, weight and hospital felt by
the patient and is a barrier to treatment. Hospital admission often has a
worse outcome for the patient; there are increased mortality rates which are
then even higher for those who are admitted against their will. Suicide
accounts for 27% of anorexia deaths. Compulsory treatment may make the
patient more depressed and at greater risk from harm.
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In 1997 the Mental Health Act Commission opened the
door to allowing force feeding of anorexic patients in the UK by allowing the
compulsory admission of anorexics to hospital. This change of policy did not
reduce the number of patients being admitted for treatment which has gone up
from 419 in 1996-7 to 620 in 2005-6.
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Anorexics need to be able to trust their doctors. The most successful policies are where anorectic
patients feel safe and trust their doctors so are willing to go to clinics
voluntarily as they feel that they are in control of the situation.
Conversely an anorectic patient’s fear of weight gain, especially forced
weight gain in hospital is an obstacle to treatment. If an anorexia nervosa
sufferer thinks that they will be force- fed they may be less likely to seek
treatment or advice.
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Yes there will be negative consequences to such a step
as force feeding however this is only done when it is absolutely necessary
and the negative consequences of not doing so are much worse. Doctors will
only force feed if they are convinced that doing so is for the good of the
patient, indeed they are prohibited from taking such a step if it is not
absolutely necessary.
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Force feeding
strategies may cause. Force-feeding has
negative consequences. If the patient is dangerously thin and is then
force-fed, it can led to Hypophosphataemia (reduction of phosphates in the
blood) which causes heart failure. Anorexics are characterised by self-denial
and often do not come forward voluntarily. Indeed it according to Dr Sacker
anorexia is often not even about food rather "By stopping food from
going into the body, what they really feel is they can be in control of their
body.” This desire is actively harmed by force feeding as a result they are
even less likely to come forward voluntarily if they are faced with the
possibility of force- feeding.
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Palliative care is defeatist and does not attempt to
cure the problem. Recovery is always a possibility and that is what doctors
should be striving for “In a 10 year follow up of 76 severely ill women with
anorexia, Eckert et al found that 18 (24%) had fully recovered, about half had
a benign outcome, and only five (7%) had died.” Doctors do not often have to
deal with severe or chronic anorexia. Just because it is a very long
treatment schedule that can be harrowing for a doctor, this not a reason to
settle for palliative care. Better support structures ought to be put in
place to enable the doctor to fulfil their obligation to the patient.
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The focus should be
on palliative care. Some doctors advocate focusing on
palliative care (relief of pain but not treatment of cause) due to the low
full recovery rates of anorexia sufferers. Research Studies show that over 10
years only approximately 20% of patients recover. Those patients who are
sufferers for more than 12 years are unlikely to ever recover.
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