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Force-feeding anorexic patient curbs freedom of choice

Force-feeding or starving to death? Emotive terms for an appalling choice. But this choice – whether to restrain and force-feed a young woman against her will or let her die of starvation – was recently…

An English court has ordered that a young anorexic woman be force fed. DoD /Wikimedia Commons

Force-feeding or starving to death? Emotive terms for an appalling choice. But this choice – whether to restrain and force-feed a young woman against her will or let her die of starvation – was recently considered by an English court.

The term force-feeding has a lot of baggage, especially in England, where hunger-striking suffragettes were force-fed (in a brutal and punitive manner, according to contemporary accounts) as were, more recently, imprisoned IRA hunger strikers.

Voluntarily starving to death has links with the rational suicide debate, and attracts largely disapproving attention from ethical, legal and religious sources. The court was between a rock and a hard place indeed.

The case

In brief, the facts of the recent case are:

  • “E” is a 32-year-old woman who has refused food to a point where she is clearly dying. Indeed, she has been admitted to a community hospital as a palliative patient.

  • E has indicated, in writing and repeatedly, that she does not want to be kept alive by attempts to feed her, or to be resuscitated in the event of cardiac arrest.

  • Her parents had reluctantly accepted this, given that E had suffered from anorexia nervosa for decades, and the prognosis for recovery was grim.

  • The local authority wanted to know if E should be protected from this fate, and took the matter to court.

  • E, while described as “intelligent”, “articulate” and even “charming” is deeply troubled, abusing alcohol and opiates, and suffering from a personality disorder.

A suffragette on hunger strike being forcibly fed with a nasal tube (1911). Wikimedia Commons

The judge ruled that E should be restrained, physically or chemically, for a year and force-fed, recognizing that it would cost over half a million dollars to achieve this – and that it was likely that she would not change her view.

He declared that all E’s stated wishes, despite their consistency over time, were not valid as she lacked the capacity to make decisions about her care and lifestyle. The main cause of this lack of capacity was her weight loss and low BMI – based on the idea that a BMI of 17 is needed to ensure that E has an adequately functioning brain. E’s BMI is currently around 11.

Autonomy, capacity and volition

Decision-making capacity is the cornerstone of autonomy – all accounts of autonomy from JS Mill onwards acknowledge this. The bigger the decision (that is, the graver its consequences), the more capacity is required. Mill famously offered no suggestions as to what capacity is, or how to test it, so this task has fallen to others, and many have taken on the challenge.

Put most simply, capacity requires the ability to value and the ability to act. By “act” we would normally mean to communicate a choice. “To value” is more complex: it is a composite of understanding, appreciating, reasoning and having a set of values and goals as a reference point.

In Australia, these goals and values can be irrational – it’s not necessary for others to be able to agree with, or even understand these values for the person to be considered competent (to possess adequate decision-making capacity).

A caricature of John Stuart Mill on the cover of Vanity Fair (1873). Leslie Ward via Wikimedia Commons

In this case, the judge didn’t explicitly state which of the elements of capacity E lacks, and has lacked for some years. She can communicate, and her intelligence is favourably commented on – E having been for several years a medical student. Her written and verbal comments make it clear that she can appreciate her situation, and is aware of the consequences of her actions.

The failure must then lie in her reasoning, influenced by the detrimental cerebral effects of severe malnutrition and the widely-held view that sufferers from anorexia have a distorted body image that renders them incapable of a reasoned approach to their own care.

The bigger dilemma

The problem is this: what if E is subjected to the course of treatment mandated by the court (however impractical that seems), regains weight to the target BMI of 17, writes the same advance directive and stops eating again? Do we wait for her BMI to fall below 11, then pronounce her incompetent and start again?

Would it not be better to acknowledge that the real problem here is E’s values – she values not eating above all else, including her own life. This is a value system that most of us find not only baffling but also deeply hurtful and offensive.

To wish to die of starvation in a society of plenty is uncanny, unsettling and scary. E may well have the capacity to decide, as many experts testified, but the court found her decision unacceptable. While this is a parentalistic attitude that most clinicians would find abhorrent, there’s a long-standing jurisdiction (parens patriae) that allows courts in England and Australia to make such a judgement.

Unsurprisingly, the judgement has proved deeply divisive. I personally find it worrying for this reason: what is to stop courts from using their jurisdiction to curtail our freedom to make bad decisions? Our dignity as humans resides in our ability to make our own decisions – good or bad.

Join the conversation

15 Comments sorted by

  1. Tim Mazzarol

    Winthrop Professor, Entrepreneurship, Innovation, Marketing and Strategy at University of Western Australia

    The Judge must decide with reference to the often imperfect legal frameworks that are available to them. So the dilemma of waiting until "E" reaches a BMI of 17 then letting her free to repeat her death wish - however troubling - is probably a result of the limitations of the law.

    Yet let's flip this around. If a person is eating so much that they are placing themselves at risk of an early death and they have a BMI of say 40+ would it be appropriate for the court to demand that they be restrained and placed on a weight loss program?

    For that matter would the court's have a similar view of someone who is drinking or smoking to a level that is placing their life at serious risk?

    Perhaps we need to consider the power of the state to intervene in people's lives and whether there might be too much interference.

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  2. Anna Renwick

    Research ecologist at University of Queensland

    I agree that this is a difficult one but I have seen over and over again many beautiful but starved individuals (male and females) having no desire to live, refusing to eat and clearly stating their desire to not eat over and above their own life. However, with careful inpatient treatment with caring staff these same individuals having gradually regained their desire for life. I am not saying that once the reached a miracle weight that everything was fine but they were willing to fight and experienced what happiness was - even if this was just for random, brief moments in the first instance. There are numerous studies of the effect of starvation on the brain and the ability to think rationally is only but one. From my own experience I am glad nobody gave up on me and am determined to fight on.

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  3. Marlon Perera

    -

    Sorry if this sounds harsh, but I say let her die... the freedom of choice to die and mark bad decisions as stated is one thing, but spending half a million dollars to force feed a woman stupid (or crazy) enough to value not eating more than her own life, when there are hundreds of thousands of starving people in other countries that could be fed with the same amount is frankly, appalling..

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    1. Marlon Perera

      -

      In reply to Anna Renwick

      Didn't mean any offence Anna and perhaps my comment was worded strongly, but I stand by my point. I'm genuinely interested in what you think the right course of action would be, because you havent provided one, simply proposed that I have no idea what I'm talking about. To me it just seems that spending half a million dollars to keep alive a woman who a) wants to starve to death and b) will probably repeat this action again if we did force feed her, seems like a colossal waste of money when half a million dollars donated to a charitable cause can help so many more people who are starving because they have no choice BUT to starve..

      Also, not sure what you mean by 'you clearly don't understand the consequences of starvation', educate me then.. I've seen people actually starving in the country that I come from, perhaps that's why I have a lack of pity on people who have plenty yet impose starvation on themselves

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    2. Marlon Perera

      -

      In reply to Anna Renwick

      Also, to clarify I'm not saying that people with eating disorders deserve no help or deserve to starve to death (I realise it might have come across that way but that's not what I think at all... all human beings need help when they are in trouble), but in THIS case, I'm arguing that the significant resources could be better spent.

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Marlon Perera

      Marlon Perera - I have some sympathy for what you say, but are we ready to draw the line?

      What do we do about cancer treatment for lifestyle-induced cancers? Liver transplants for alcoholics? Intensive Care for the end of life in old age?

      Then, what about outside medicine? SHould we shift health care expenditure to youth support services, or pre-school education. Not an easy dilemma.

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  4. Aden Date

    Student of Clinical Psychology

    The debate is reminds me of motorcycle helmet laws in the United States. In many U.S. states, it is not legally required that motorcyclists wear a helmet, and efforts to change these laws are often met with vicious attack. Behind biker rhetoric is the central argument that a person of sound mind should be allowed to pursue their values, provided the pursuit of those values does not harm others.

    The interesting parallel with both cases is that it draws to light the ugly side of our decision to…

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  5. Joel Mayes

    Bicycle Mechanic

    The closing paragraph in the article is fine example of the slippery slope fallacy.

    We have plenty of law which restrict choice, and generally, this is a good thing.

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  6. Anthony Muscio

    Systems Analysist and Designer

    What do we think would happen if the person was offered euthanasia ? Perhaps some psychological problems are so unbearable people must be free to die. If however this person is keen to die of starvation could it then be classified as a manageable disorder and thus intervention permissible ?

    Could there be something else interfering such as a desire to die yet avoid suicide due to religious beliefs ?

    What ever the answers and best value judgments on this it needs to be done with a very detailed…

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  7. Robert Tony Brklje
    Robert Tony Brklje is a Friend of The Conversation.

    retired

    Does 'E' have a choice or is she just a more vulnerable victim of modern psychologically targeted saturation marketing. Marketing vetted by doctorate in psychology to ensure maximum choice altering impact.
    Should the force be applied to victims of marketing or should the force be applied to those who create and distribute that marketing by every possible venue, force to restrict their activities and to establish controls upon the nature of marketing.
    The force has already applied to 'E' the force of peer pressure, the force of conforming, the force of being ostracised for failure, the force of what is not just expected but demanded.
    This is not a story about what harm must be done against 'E' to cure them but the forgotten harm of what was done against 'E' driven by nothing but greed.

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  8. Andrew McGee

    Lecturer, Faculty of Law at Queensland University of Technology

    I think it's a dangerous thing to say that the case undermines the freedom to make a bad choice Peter.

    The law has always been clear that it will not interfere to reverse 'bad' or 'irrational' decisions because that would be an unacceptable interference with autonomy. There is no reason to think that this case has changed the law in any way in that regard.

    When you say that 'the court found her decision unacceptable' I just think you are in danger of running together the issue of whether the…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Andrew McGee

      Isn't the discourse here about the issue of capacity?

      In acute situations in health care, we make evaluations of the person's capacity to make rational decisions - based on the influence of illness, drugs and other toxins, dementia etc.

      The judgement is not about the validity of the person's choices, but about their ability to make a decision with an unclouded mind. IF I understand correctly, returning "E" to a level of nutrition that allows her mind to function would be the equivalent of reversing a toxic drug or treating an infection, to return the person to a state where they are competent to make an autonomous decision.

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  9. Gil Hardwick

    anthropologist, historian, novelist, editor and publisher at eBooks West

    Further, Peter, courts under the Westminster adversarial system do not carry out investigations, or launch their own prosecutions. I think you badly misapprehend the role of the court in Common Law, not least here in what I gather was a civil action rather than criminal.

    Your question, "What is to stop courts from using their jurisdiction to curtail our freedom to make bad decisions?" is misplaced. The relevant question is rather, "What is to stop a prosecutor from filing an application to curtail…

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  10. Scott Parkes

    Physician, Specialist in Intensive Care

    John, thank you for such a measured and dispassionate description of this decision. For me a (clinician and non-lawyer) the decision fails firstly as being practically impossible to implement, and perhaps more particularly at the ethical hurdle of distributive justice. In Tasmania, where I have worked for over 20 years in total, a decision such as this would deny effective health care to many. The decisions of our courts surely must be practical and just to be respected.

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