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In today’s society the topic of if individuals with anorexia nervosa should be able to withdraw from life sustaining treatment is still an ongoing debate. On one side you have to weigh the option of how much the patient’s autonomy and competence play into their decisions of being able to assess their quality of life. When an individual is deemed competent the clinicians and doctors much respect their autonomy and let them withdraw from life sustaining treatment is they see it is the best decisions for themselves. On the other hand, you have to think about the severity of Anorexia Nervosa and how it affects their ability to make rational decisions regarding their quality of life. No one suffering from Anorexia Nervosa is in the right head space to be able to make any decisions regarding their nutrition and feeding. With that being said it is smart to either have involuntary treatment done such as compulsory therapy. The clinicians and doctors have a duty to protect their patients from dying and doing mandatory treatment might be the best option for the greatest success of the patient. Overall there is evidence to support both sides of the argument about the legal and ethical aspects of individuals with Anorexia Nervosa withdrawing life sustaining treatment and if it should be allowed.
Anorexia Nervosa, AN, is defined as “ a serious psychiatric disorder characterized by body image distortion, an intense fear of weight gain, and self-induced weight loss leading to physical and mental abnormalities” (Douzenis & Michopoulos, 2015). According to the diagnostic criteria for Anorexia Nervosa set forth by the DSM-IV, there are four points to determine one qualifies for the diagnosis of Anorexia Nervosa. They include; refusal to maintain body weight or above a minimally normal weight for their age and height, intense fear of gaining weight or becoming fat, disturbances in the way in which one’s body weight or shape is experienced, and in postmenarchal females, amenorrhea, the absence of at least three consecutive cycles (Tan, 2016).
Individuals who are suffering from Anorexia Nervosa are characterized as ego-syntonic self-starvation, denial of illness, and ambivalence towards treatment (Guarda,2008). When it comes to treatment for those suffering most patients point towards wanting to change, but they don’t wish to gain weight and would rather end treatment then gain weight. When it comes to the idea of individuals having the right to end life sustaining treatment, many issues arise about who can ultimately make that call. Some believe that individuals with anorexia nervosa are competent and should be allowed to make the decision to stop treatment, even if death results from this decision. While others believe that Anorexia Nervosa doesn’t allow one to be able to make such a life alternating decisions such as ending treatment. Since they are in no mindset to make decisions regarding their feeding and nutrition, the physicians have the duty to protect their patients, which sometimes means using compulsory treatment. The ethical question remains, should individuals suffering from Anorexia Nervosa be able to refuse life-sustaining treatment (Werth,2003).
There are two sides of the debate about yes individuals should be allowed to refuse treatment or no individuals should not be allowed to refuse life sustaining treatment. There are positives and negatives to both sides, and each side has various points as to why their viewpoint is the right answer to this ongoing debate.
Looking at it from the point of view of those in favor of allowing individuals with Anorexia Nervosa to refuse life sustaining treatment, there are two points that push for this to be the precedent. First, some suffers of Anorexia Nervosa may be competent to refuse, and in those cases it would be wrong and unlawful to force them to undergo therapy that they competently refused (Harper,2000). The legal codes most places have in place are that individuals have the right to refuse medical treatment even if that refusal would result in or hasten an individual’s death (Goldner&Smye, 1997). With that being said a patient must be deemed competent in order to make these decisions, if a patient is deemed incompetent due to a mental disorder the right to refuse treatment will be denied and the legal decision making will be shifted to others. Additionally, minors are likely to be denied the right to refuse treatment, their parents would be their final decision makers, unless they fall under the criteria to be an emancipated minor (Goldner &Smye, 1997).
When it comes to looking at if it is right for a competent patient, who is suffering from Anorexia Nervosa to make the decision to refuse treatment, we need to look at the distinction between passive euthanasia and competent refusal of life-prolonging therapy. On the hand of passive euthanasia, some view it as wrong, or down right murder in a sense. In a way there is one core difference between passive euthanasia and competent refusal of therapy and that is who makes the final decision. With passive euthanasia happens when one person gives some a drug or medicine to another person with the intention that the person will die as a result of taking said drug or medicine. While on the other hand competent refusal of therapy or withdrawing therapy is when one person makes that decision for or to oneself. With that being said autonomy is a key word in that clinicians need to respect the wishes of their patients, when they are deemed to be competent and are making a decision for themselves, and one they see as the best decision. The example can be used that while clinicians have the moto of “do no harm” they must understand when they partake in euthanasia, it is almost the same as when a patient withdraws from therapy, both would result or mostly likely lead to one’s death. (Draper,2000). One thing that many tend to overlook is that when the individual wishes to forgo treatment it is likely because they are in extreme suffering and there is no other therapy, treatment, or forced eating that would help (Giordano, 2010).
A second point that should be made is that doctors and clinicians should respect individuals’ autonomy when deciding if they want to forgo their life sustaining treatment. A doctor or clinician should be able to accept and respect the patient’s wishes and know that they are responsible for the consequences of withdrawing their treatment (Draper,2000). As mentioned previously, competence is a main component when talking about refusal of treatment. Competence goes hand and hand with autonomy, the terms can in some cases be used interchangeably. For instance, we already mentioned that an individual deemed competent should be allowed to make the decisions regarding ending their treatment if they feel that is the best option for them. With that said the doctors need to respect their autonomy when they make these competent decisions.
Autonomy is the one thing that should never be taken away from and individual, but when it is, it’s like taking away one’s freedom. One makes an autonomous decision when they are a competent individual and can use rational deliberation (Wright &Matusek, 2010). When one is trying to make the ultimate decision to withdraw treatment, they are considering the hard facts and burden of knowing if they request to stop treatment they will be the sole one in charge of bringing upon their death (McKinney, 2010). The inviduals dealing with end-stage Anorexia have already dealt with trying numerous treatments that didn’t work and have been through enough suffering that they feel nothing would help them get to a sustainable weight, that they would be to live a happy life afterword’s.
Heather Draper has given the following guidelines for decision of a competent patient to decide to end their treatment. First the patient has been refusing or not on board with treatment beyond the natural cycle of the disorder, usually between one to eight years. Second they have already tried or have been forced feed prior to the decision to withdraw treatment. Lastly the patient has been previously deemed competent and able to make this decision regarding the quality of her life (Draper,2000). When it comes to respecting the wishes of a patient, clinicians must understand that sometimes an individual dealing with anorexia may be competent and deciding to withdraw treatment and that, “there is a difference between saving the life of a sufferer and curing them of their anorexia” (Draper, 2000). While there have been the approaches of forced feeding that some believe to work, we must understand that not everyone can be cured of anorexia and that sometimes the best option for the patient if competent to make the decision about their quality of life, is to withdraw treatment.
On the other side of this debate is the people who believe that there are no way individuals who are suffering from anorexia nervosa should be able to make the decisions to withdraw life sustaining treatment. One of the counterpoints is that individuals who are suffering from anorexia can be said to have “thought disturbances” and those disturbances can lead to one not being competent to make a decision about food intake and their overall wellbeing (Werth, 2003). While there is little information about how cognitive functioning can impair one while suffering from Anorexia Nervosa, it has been found that “self-starvation can interfere conceptualization, perceptions, and decision making” (Werth, 2003). The sole judgment about withdrawing life sustaining treatment is if the individuals feeling the treatments will not help them, which is ironic due to the fact that an individual with Anorexia Nervosa has no desire to gain weight, so the questions remains how could they make such a life altering decision.
When it comes to talking about the severity of Anorexia it can be very devastating, and even at times look like a terminal illness, but it can in no way be classified as a terminal illness. With that being said Anorexia is reversible, so the idea that we float around that we should allow individual with Anorexia to withdraw treatment is in a way crime like because they are basically killing themselves. To go into detail about the reversibility of Anorexia it means that the starvation can be cured, with eating or forced eating, and the psychological effects that may come with the disease can be changed to enhance one’s quality and outlook on life (Giordano, 2010). With this information there seems no plausible evidence that would support one ending their care, if it is recognized that most individuals with eating disorders can recover since it is known to be reversible (Giordano, 2010).
Another counterpoint is that experts believe individuals dealing with Anorexia are not competent to make decisions and when they recover they become grateful for medical intervention in the end (Werth, 2003). With this being said the patient might be grateful when treatment is over and there at home recovering but we must consider the effect the treatment has. For example, consume evidence has shown that more progress has been made for patients who are committed involuntary instead of who voluntary comply with treatment. The hardest thing for those struggling with the disease is that they are not willing to eat first due to the guilt and shame. While when eating is enforced by the doctors or clinicians in treatment they feel less guilty and more willing to comply (Wright &Matusek, 2010).
On must also consider that the clinicians and doctors have a duty to protect their patient and took an oath that they would do no harm to their patients. So in this sense it can be understood that clinicians see involuntary treatment as a good thing because it will allow the patient to be in an environment where they can get the help and treatment they need. Without any medical intervention it can be inferred that a patient will die from Anorexia that is why clinicians sometimes push for involuntary treatment because they are not competent and educated enough about what will happen if they ask to withdraw treatment. Sometimes individuals with Anorexia don’t know what they want or if treatment will help them but, “the goal of treatment is to slow progression of symptoms until the client is able to develop healthy coping mechanisms” (Werth, 2003). Individuals with Anorexia Nervosa may not be suicidal or even look to be underweight, but that does not mean clinicians and doctors have a right and duty to protect them from harm. It is better for clinicians and doctors to be proactive with a treatment so one will not want to withdrawal treatment seeing as it is not ethical or okay.
The topic of if individuals suffering from Anorexia Nervosa should be allowed to withdraw from life sustaining treatment is still a topic of discussion today. There are many points as to why it should or should not be allowed. Many people have different views based on their religion, values, and ethics. There is overwhelming evidence to support both sides of this argument therefor, it should be a matter that is left up for the patient, family, and physician to decided together as a group.
References
- Douzenis, A., & Michopoulos, I. (2015). Involuntary admission: The case of anorexia nervosa. International Journal of Law & Psychiatry, 39, 31–35. https://doi-org.ezproxy.sju.edu/10.1016/j.ijlp.2015.01.018
- Giordano, Simona. “Anorexia and Refusal of Life-Saving Treatment: The Moral Place of Competence, Suffering, and the Family.” Philosophy, Psychiatry, & Psychology, Johns Hopkins University Press, 22 July 2010, muse.jhu.edu/article/388720/pdf.
- Wright, Margaret O’Dougherty, and Jill Anne Matusek. Ethical Dilemmas in Treating Clients with Eating Disorders: A Review and Application of an Integrative Ethical Decision-Making Model. Department of Psychology, Miami University, OH, USA, 30 July 2010, www.marshall.edu/psych/files/2012/06/Eating-Disorders.pdf.
- Tan, Jacinta, et al. “Competence to Make Treatment Decisions in Anorexia Nervosa: Thinking Processes and Values.” National Institute of Health, Dec. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC2121578/pdf/nihms5623.pdf.
- Guarda, Angela S. “Treatment of Anorexia Nervosa: Insights and Obstacles.” Physiology & Behavior, vol. 94, no. 1, 2008, pp. 113–120., doi:10.1016/j.physbeh.2007.11.020.
- Goldner, Elliot M, and Victoria Smye. “Addressing Treatment Refusal in Anorexia Nervosa: Clinical, Ethical, and Legal Considerations .” Handbook of Treatment for Eating Disorders , edited by C. Laird Birmingham, 2nd ed., The Guilford Press , 1997, pp. 450–460.
- Draper, Heather. “Anorexia Nervosa and Respecting a Refusal of Life-Prolonging Therapy: a Limited Justification.” Bioethics, U.S. National Library of Medicine, 1 Apr. 2000, www.ncbi.nlm.nih.gov/pubmed/11765761.
- Werth, James L., et al. “When Does the ‘Duty to Protect’ Apply with a Client Who Has Anorexia Nervosa?” The Counseling Psychologist, vol. 31, no. 4, 2003, pp. 427–450., doi:10.1177/0011000003031004006.
- McKinney, Cushla. To Treat or Not to Treat: Legal and Ethical Issues in the Compulsory Treatment of Anorexia. 31 Mar. 2010, ourarchive.otago.ac.nz/bitstream/handle/10523/5541/McKinneyCushla2010MBHL.pdf;sequence=1.
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