What do we do about treatment refusal, and when is compulsory treatment ethically justified?
We found that contexts and relationships are very important to people's views of whether compelling people to have treatment is ethically justified.
Compulsion is a perception of other people's behaviour, which makes it quite complex. For example, a person might be given little choice about having treatment but perceive it as support and care, whereas another person might be given the same lack of choice and perceive it as coercion.
What we found was that free choice was less important to people with anorexia nervosa than how they were treated, that is, whether they were treated as individuals and given respect and their views heard, even if they were not given many choices. If they did not feel understood or respected, or feel that they were being treated out of a textbook rather than with regard to what their particular issues are, they were likely to feel coerced. It was crucial that professionals always listen to people's views.
Another issue was that people with anorexia nervosa felt that they need to be able to trust professionals first, before they can be made to have treatment. If they did trust their professionals, then compulsion can be perceived as supportive. Some people with anorexia nervosa said they even wished to be compelled, and felt relieved when this was done in a way that understood their needs and wishes.
| I mean trust was definitely the key issue with me. Because if you don't trust your doctors or you don't trust your parents to be doing what they think is best, then you're not going to do it. So yeah, I think that I had good doctors, because they really understood. And they all, it was always sort of, from my, it didn't feel like they were all ganging against me, it felt like they were coming from my point of view. Which made it much easier to trust them. And, yeah, I feel, I feel that it's been done well. 14P |
We found that there was a range of attitudes to compulsory treatment for anorexia nervosa. Although the medical ethics position is that people should only be treated without their consent when they lack the competence to make their own treatment decisions, competence or capacity were not much used by people as the main ethical justification for making people have treatment. Instead, it was a universal view that if life was in danger, then people with anorexia nervosa should be made to have treatment. The rationale in life-threatening cases was that any treatable mental disorders should be treated, and anorexia nervosa is treatable. People felt that health professionals should save people to fight / struggle another day, and that anorexia nervosa is not worth dying for. People also felt that at extreme low weights, competence IS actually impaired anyway, which made it even more sensible to treat them if they were at risk of dying.
| I think other people should be made to have treatment because you do get to the point where you don't know what's right for you. I know last year when I was ill there was no way I would have let anybody do anything to treat me, like for my own choice I would have just carried on losing weight, I know I would have done until I didn't live anymore, but now I hate to think that just because I said “no” I would have been left. 30P |
Unlike the issue of giving treatment to save life, which all people agreed about, there was much less agreement about whether people who have anorexia nervosa should be made to have treatment in other situations. Many people felt that the decision to get better is one that only the individual with it can make, because without cooperation treatment will fail. Other people felt that they had to be made to have treatment initially, and that later on they got well enough to want to get better themselves.
| I think if somebody's life is in danger and is threatened and they have to go into hospital then yes it's very important to obviously re-feed them and to get them to a stage where they're not, where they're medically stable, but you can't enter anybody into treatment if they're not willing to. 36P |