Attitudes Toward Compulsory Treatment for Anorexia Nervosa

Patients with anorexia nervosa (AN) may refuse treatment, and one of the ethical issues that arise when a patient refuses treatment is whether the patient is competent or can make his or her own treatment decisions. The question of whether to override a patient with AN’s refusal of treatment is a difficult one. Results of a recent survey of psychiatrists in the United Kingdom revealed different attitudes toward compulsory treatment among different psychiatric specialists (Child Adolesc Psychiatry Ment Health 2008; 2:40. [Epub ahead of print]

Most clinicians agree that patients who are competent to make treatment decisions should be allowed to make their own choices about treatment, even if these choices seem foolish or unwise. In the United Kingdom, the legal test of competence, or capacity, focuses on the ability to understand, retain, and weigh treatment information, to come to a decision, and to express a choice (Mental Capacity Act 2005).

A questionnaire was sent to three specialties

To explore attitudes about compulsory treatment for AN patients, Dr. Jacinta Tan and colleagues sent a self-administered questionnaire to general adult psychiatrists, child and adolescent psychiatrists, and psychiatrists with an interest in eating disorders. The researchers also sought to explore factors clinicians thought were relevant to considering compulsory treatment for these patients, and to see how the psychiatrists used concepts such as competence, and patients’ recognition of their own best interests.

Slightly more than half of the 1,300-plus psychiatrists surveyed returned questionnaires, and 686 individuals completed the survey. Most of the respondents were consulting psychiatrists, and 64% had worked in the field for more than 10 years. A small percentage (5.7%) of those responding reported working in settings where they only treated eating disorders’ patients, and another 10% reported working in settings with a special interest in eating disorders. Sixty-two clinicians (9.7%) said they were eating disorders specialists.

Most respondents had treated between 1 and 10 patients with AN in an outpatient setting in the previous year; most had not seen any inpatients with AN. However, about 20% said they had looked after patients with AN in a compulsory inpatient setting who had never before been on compulsory treatment.

Different attitudes emerged

Dr. Tan and colleagues reported that in general, the respondents tended to support the use of compulsory treatment to protect the health of patients at risk and also to protect the patients’ best interests.  In particular, eating disorder specialists supported the compulsory treatment of patients with AN independently of viewed about their capacity to make decisions, while child and adolescent psychiatrists tend to support the treatment of patients with AN “in their best interests,” when the patients’ decision-making ability is impaired.

Patients with “mild” AN were generally viewed as having significantly more control over their behavior and decision-making ability than were those with “severe” AN. Eating disorders experts were less likely than other psychiatrists to think that patients with “mild” AN were choosing to lose weight or able to control their weight loss behaviors. According to Dr. Tan and colleagues, eating disorders experts may be more prepared to act to protect the health of patients who are not yet severely ill, and may act earlier to protect these patients. More than half (56%) of the respondents moderately or strongly agreed that AN compromises the competence of an adolescent to make treatment decisions. Nearly 75% agreed with the statement that treatment refusal is due to the effects of the disease and does not fully reflect the patient’s true wishes or personality. Child and adolescent psychiatrists tended to support the treatment of patients with AN “in the patient’s best interests” when the AN patient’s decision-making ability was impaired.