Compulsory Treatment of Anorexia Nervosa
Mitrany, Edith, Melamed, Yuval, The Israel Journal of Psychiatry and Related Sciences
Abstract: Compulsory treatment in anorexia is a controversial subject brought to the fore of public awareness with each new case reported in the media. The attitudes towards involuntary hospitalization for anorexia swing like a pendulum from recognizing the necessity for compulsory treatment in life-threatening situations to advocating the patient's rights for autonomy over his/her body and thus the right to refuse treatment. In view of the fact that the existing legislation in Israel (Law of Patients Rights, 1996; Law of Guardianship 1962; and the Law for the Treatment of the Mentally Ill, 1991) does not provide an adequate solution to emergency situations in which anorexia is life threatening, the authors suggest that the Law for the Treatment of the Mentally Ill (1996), which enables compulsory treatment, can be interpreted to include life-endangering conditions.
The increasing number of adults referred to treatment for anorexia in the past two decades is evidence that anorexia is no longer an illness exclusive to the younger population. Specialized eating disorders units have been opened in response to the request for treatment settings aside from those in the traditional psychiatric framework. The presentation of Anorexia Nervosa can be full or part syndromal, restrictive, bulimic, mixed-Eating Disorder Not Otherwise Specified (1).
Anorexia is one of the few medical conditions in which there is no community of interests and goals between the patient and the caregiver. The classic anorectic refuses to recognize the presence of an illness and implicitly the necessity for a curative intervention. Anorectic patients often oppose change and if they do adhere to a recommended treatment program it is generally under protest. The problem is especially difficult for severe anorexia patients whose lives are threatened by the seriousness of the illness.
From a medico-legal perspective it is not the incidence of severe anorexia, but its characteristics and consequences, which distinguish it from other DSMIV(TR) eating disorders. Experienced by up to one per cent of young women (2), anorexia nervosa differs precisely because it is such a serious, life-threatening condition (3). This feature tests the ethical limits of medicine, the State and the law in deciding whether to coerce patients into treatment (4).
It is possible that death rates could be reduced by early diagnosis and by long-term specialist care (5).
Anorexia is not an incurable disease and treatment has been proven effective in most cases (6). As such, should compulsory treatment be imposed upon a life endangered patient who still chooses to exercise free will and refuse treatment (7)? Some therapists believe that involuntary treatment is not an option, since quite often even involuntary treatment does not lead to recovery. Patients who are compulsorily hospitalized tend to be readmitted, sometimes in a more critical condition. Coercion may undermine the patients trust in the caregivers, and particularly in the therapeutic relationship. However, others endorse this decision, in extreme cases, for lack of any other option, in order to save patients' lives. Moderates contend that compulsory treatment should be invoked only by the courts.
The legal standpoint varies in different countries. In Israel a number of laws deal with this issue (8-10).
This paper will focus on the question of involuntary hospitalization of anorectic patients and the related clinical, ethical and legal implications.
Emergence of the Illness and Choice of Treatment Setting
Anorexia does not have a high prevalence in the general population (estimated prevalence: 0.3% to 3.7%) (11, 12). Outcome studies show that about 20% remain chronically ill despite treatment (13). The reported mortality rates is as high as 6% per decade (14), and 16% in a 21-year follow-up or 20% in the long term (15).
A patient who exhibits a reasonable degree of motivation and compliance can be treated in a community-based outpatient clinic by a multidisciplinary team. …