Friday, June 15, 2012

When is it OK to force feed anorexic patient.

A High Court judge has ruled that a 32yr old Welsh woman suffering from severe anorexia should be force fed. It is reported that the woman is intelligent, articulate, wishes to make her own decisions, and that her carers and family oppose force feeding. They also believe she should be allowed to die with respect. Its also reported that she has been on a course of palliative treatment for a long time, not having eaten for many months. What is one to make of this decision. Must admit that I find it quite shocking.

I accept that force feeding of anorexic sufferers is not always wrong. Its an awful condition, and if a judgement is made that the patient is not competent to make a decision, and there is a good chance of recovery if force feeding takes place, it may be reasonable to force feed. But we' re told that this woman is 'intelligent and articulate" and "wants to make her own decisions". We're also told of the long term nature of her condition and the conclusion of her carers, and those who know her best believe she should be allowed to die with dignity.

My first instinct was that this is a quite awful decision, where the 'state' has decided to take ownership of a 'competent' person's body, and to take an unreasonable action to extend life. I accept that its easier to take a view not knowing who the patient is. Even after thinking about it, I still consider it to be a bad decision. But I do want to discuss it with those to whom I look for discussion about the ethics of these sort of issues - Lord Carlile of Berriew, Lady Finley of Llandaff and Robert Preston of LDW. Already I am a strong opponent of 'assisted suicide' and of 'presumed consent'. Is this to be another cause to persue?


Anonymous said...

I don't think you can take the middle ground with these issues. If you are against 'legal suicide' you should also be against this. You cannot allow the state to decide on some things but not on others (It is for this reason why I am against judges deciding on when life support should be 'switched off').

I disagree with you on presumed consent as the ex citizen (or his family) will always have the option to stop the state from removing the organs. So I am all for it. On the other hand, if doctors could somehow appeal to judges to 'get the organs' from those who have not consented, THIS is what I would disagree with.

But as you say Glyn, it is really difficult to discuss this unless you know the person and although I've said the above. I know full well if I was a 'cabbage' and I could see it was a nuisance to my family, I would want the right to have 'assisted suicide'.

Big issue this, and I don't think anyone has the right answer.

bonetired said...

I don't want to answer this directly except to say that this is a mental illness and the brain behaves differently during the grip of this illness. I don't know whether this lady has been sectioned or not but having known a person who has had this illness, it holds the person in a vice-like grip that is almost impossible to shake off. The person appears to be lucid and rational but there is always the illness ....

Anonymous said...

My concern with your view, and indeed that of her carers it would seem, that she should be allowed to "die with dignity" is that it doesn't hold true and fast when someone's in the grip of a mental illness. The mere fact that someone with anorexia has allowed themselves to waste away is unatural and not something that a right thinking person would do. Therefore, how is that person in a competent state to decide upon his or her own welfare?

I've been there myself with severe depression. I spent 6 years in a constant suicidal state. That is an unatural state of mind to be in. If someone with anorexia wants to die and is allowed to do so, then it would open the flood gates. The courts would be obliged to allow severely depressed people to seek the same on the basis of their immense mental suffering.

I am reminded of Dr Jack Kevorkian. A documentary about his work showed him assisting in the deaths of several terminally ill people. With that, I have some sympathy, as those people had poor quality of life and the outlook was even bleaker. They were mentally competent to make decisions about their treatment and the manner of their deaths.

But then he made a massive error of judgement in my book and assisted in the suicide of a mother who had developed depression after losing both her sons. She was clearly not capable of making a rational decision. Treatment was available and this current case is similar in nature.

Democritus said...

It is worth reading the judgement in full before drawing conclusions.

For what it's worth though I think Glyn's initial call on this is correct. Moreover I think that the ruling that E lacked mental capacity is pretty ropey ..

Anne Marie said...

Here is the full court judgement. It was obviously a very difficult decision. It seems at the time she certainly lacked capacity to make a decision, but what was in doubt was whether it was in her best interests to receive treatment. Eventually the judge decided it was.

Anonymous said...

I had anorexia at 22yrs old, I was a successful career girl, I have no idea why I went down the path of starving mysel, almost to death! I has pneumonia, under 5stones but I somehow lived.for years I starved myself, well, I'm 56yrs old now and I'm paying the price for it, so much organ damage ! Looking back, YES I wish they had force fed me, I wouldn't be chronically I'll, bedridden now if they had tube fed me. To everyone I was smart, knew my own mind, could make my own decisions! NO I couldn't ! I was clever, dare I say very clever I could make people believe what I was doing was right, but it wasn't, it was very wrong! Anorexia is such a sneaky illness, you are always one step ahead.

James Lee said...

This blog comment concerns me, and seems to miss important points about the treatment of anorexia nervosa. Firstly, it is a life-threatening disease - like pneumonia, myocardial infarction and meningitis - and needs to be treated as such. The disease manifests as an irrational fear of gaining weight and a distorted body image, such that patients often consider themselves overweight despite severe malnutrition. Unfortunately, the nature of the disease is that the sufferers are usually "articulate" and "intelligent", and often express that they would rather die than be treated (especially as this may inevitably involve being fed). It is critical to realise that this is the manifestation of the disease, and should not be mistaken for the wishes of a "competent" individual.

The idea that feeding in this context is some sort of breach of human rights or imposition by the state is misguided. Patients with AN can be treated successfully and returned to health. Such treatment might include compulsory feeding to address the physical complications of anorexia nervosa, insofar as this is a necessary precondition to the treatment of the underlying mental disorder.

The alternative here would be to allow individuals with mental illness - manifesting as a deluded perception of their body image - to die from the self-inflicted starvation that is driven by the disease. The issue of "competency" or capacity - in medical terms - is appropriately raised, although it has been recognised that while patients with anorexia nervosa – who might otherwise retain the capacity to understand the nature, purpose and likely effect of treatment – may not possess the capacity to give valid consent as this is compromised by fears of obesity or by denial of the
consequences of their actions.

Before publically criticising the decision and contemplating "persue"-ing [sic] it, please discuss this with some psychiatrists in your constituency, who regularly treat AN, so that they can explain in more detail why feeding under the mental health act is a necessary and life-saving component of therapy for some patients with AN.

Anonymous said...

GD - I think you have jumped to a very emotive position without maybe doing a bit of background research into the mental illnesses and disorder this unfortunate girl is suffering.

Im a doctor in psychiatry and have dealt with those suffering similar difficulties (though not with the same level of experience and aptitude as the doctor involved in this case). The issue of capacity is complex at the best of times, and specific to the question being asked - you cannot simply have capacity to make decisions or otherwise. This is certainly true of those with other illnesses such as affective disorders such as depression, psychosis, or dementia.

This lady also suffers from borderline personality disorder, which leads to "black and white" thinking and impulsive thinking, to put it crudely.

Also "wanting to make her own decisions" is not the same as actually being able to.

Anorexia is a mental illness, not like, say cancer, where people may have the faculties to make a decision on their own life and choose not to be treated. Anorexia can easily affect the decision making abilities of a person, despite its treatability.

I am not privy to this case, to I rely on the expertise on all involved, and trust their decision. This type of decision is *never* taken flippantly, given its potential consequences, and to simply soundbite it by saying that the state has taken ownership of such a situation is dissapointing.

I agree that it may be worthwhile to talk to senior psychiatrists regarding this issue for further insight into capacity and mental illness.

Michael Fitzgerald said...

Are you ok for teenagers to starving themselves due to what they see on TV or in the newspapers, you're ok for them to travel down an anorexic route, a bulimia route, to the extent that they starve themselves to death? What you should realise is that they are not in the right state of mind, both to make decisions for others and most importantly themselves, the thought disorder is along the same line of depression and suicide, you should really think about this before you jump to sides and see the full picture here!

Anonymous said...

After suffering from severe anorexia for a number of years I ended up in hospital and was force fed. I wanted to die and could make perfectly articulated arguments as to why I should be allowed to do so. However, as others have said you can appear completely rational and have capacity in some areas, but when it comes to this area because of the nature of the illness and its hold on you, you cannot. As the judge rightly said, although you say you want to die, it is really you do not want to eat. I am impressed at the judge's grasp of the complexities of the illness, which is a great deal more than a good number of psychiatrists I had the misfortune to encounter which contributed to me ending up being force fed.

I cannot speak for this lady, but I can for myself and a large number of other sufferers from anorexia who I have met and that it is summed up in the words of the judge "E is a special person, whose life is of value. She does not see it that way now, but she may in future." I believed that I was worthless and that there was no point to my life and had I been given the opportunity to die I would have done. Even though I have continued to battle anorexia, I have managed to get it under control and have a life and see that there is a value to my life. I returned to my studies, completed a PhD, traveled, now work full-time, have a long-term relationship and live independently.

With the right help and support anorexia is not incurable. If politicians spent less time criticizing judges, who in this case showed remarkable insight and cutting back services for people with mental health problems be cut back and more time investing in services and effective treatment (which is lengthly and requires extensive follow-up)then perhaps other sufferers with anorexia could come to see their personal value and discover a meaning and purpose to life.

Anonymous said...

From a person who is both involved with the medical profession and has been through psychiatric treatments in the past for mental illness before, I think this needs to be stated; No matter how articulate and intelligent you may appear to be, mental illness significantly alters your judgements .

Whilst I accept that this particular case may have been difficult to judge, and the nuances blur the lines somewhat, the views that Glyn Davies has expressed here on such an open public forum make him appear to be ignorant and arrogant in that he presumes to know more about mental illness and the laws surrounding it than a judge who has been professionally trained to rule on such decisions, and medical staff who deal with anorexia nervosa on a daily basis.

My advice to Glyn Davies would be to be extremely careful about making such statements in the future, as it appears hypocritical alongside views against assisted suicide. I would also advise that he discusses these issues with psychiatrists and psychiatric nursing staff to gain a greater understanding of these issues; provocative statements like "shameful decision" are not going to win Glyn any support from people who deal with these kinds of things day-in day-out.

Within the current information age when such statements are available to a global community, more balanced statements that are less based on knee-jerk reactions should be considered, especially from people who represent the community.

Anonymous said...

You can dress this issue up however you wish, anorexia is an illness of the mind, and therefore treatment should be given to assist in curing the illness.

Anyone in a healthy state of mind and I qualify this comment by adding unless they are facing a painful or slow death because of terminal illness, would not choose to end there life prematurely, therefore if this women in question is asking to be allowed to die, it supports the argument that she is not of fit mind and needs protecting from herself. The issue is a complex and not one to be tossed around by two bit MP's

My real concern is that so called MP's who are looking to grab the headlines for there own benefit, make headline grabbing comments via social media websites, who are you to question a qualified Judge, without all the facts and the mental capacity to deal with such an emotional issue.
Maybe his efforts should be directed towards saving lives around this country and the wider world. The question really should be, What value does this MP bring to justify his position and cost to the local tax payer.

Im not allied to any political party, the political system is corrupt and broken, we need to get back to local representation on a national basis, not undemocratic political parties.

Anonymous said...

Anorexia Nervosa is a psychological illness. A person may be intelligent and articulate, but not be competent to make a decision due to the nature of their psychological illness, while still being perfectly capable of making other decisions in her life.

For example, this woman may be perfectly competent to decide on a medical issue unrelated to the anorexia, but where the problem is linked to her anorexia, she has not been deemed to be competent to decide on the best course of action.

I am sure that neither you nor I can assess her competence based on the fact that we have never met her. However the doctors and the judge that have met her and assessed her have decided that she is not competent to refuse treatment in this particular case.

Anonymous said...

MCA 2005 roughly states "mental capacity is time and decision specific" i.e a person may have mental capacity that morning, may lack mental capacity late eveving. The comment within the section Recovery of Capacity "On the evidence I have heard, it is not likely that she will recover
capacity within a year" seems to dismiss this important fact and purely as an observer it seems to me that this will neatly allow treatment to continue for a 12 month period.

Anonymous said...

Ann Marie comments "at the time i've no doubt she lacked mental capacity", I agree, however I am concerned regarding the statement relating to E's advance decision which states " I am clear that E lacked capacity to make an advance decision on 3
July 2011.To an extent, this is confirmed by her subsequent attempt to
put herself in a position to make an advance decision that would be
accepted as valid.

Am I missing something here? Could this be a mentally capacitated person ensuring that her wishes are legally respected. Is there another "catch 22 here??".

Roy Norris said...

It seems to me that you have placed yourself in a position which argues that a person whose capacity is in doubt should be allowed to die, whereas those whose capacity is not (apparently) so challenged are to continue to be denied the opportunity to end their lives with (or without) dignity. I really do not see how you can argue both positions.

I am the more surprised at the position you have adopted over this because your conviction and fairly expressed views over the assisted suicide debate caused me to rethink my previous belief that assisted suicide should be permitted without much ado.

On the issue of the state telling us what to do with our bodies that argument was lost when the Vaccination Act was passed in the 1860s. Indeed in the Middle Ages people where not allowed to be Witches or Warlocks, so perhaps it was never more than a straw man proposition.

On a practical point, I can see the headlines in Murdoch's papers:- 'Medics allowed mentally ill girl to starve to death while they watched Euro 2012'. Is it reasonable to expect medical professionals to just sit back when a person is mentally ill and seeks to harm themselves? It must be difficult enough when a court order is given to have to switch off a life support machine.

So on this one you have not been able to convince me that your position is tenable.

Alison said...

Just because someone is intelligent, does not make them immune from mental health issues. The anorexia is obviously part of mental illness.

If you take the line that this person should be allowed to die, then logically you need to take the line: people should be allowed to commit suicide "because they are intelligent". No state intervention.

The problem with that approach is twofold (a) you don't separate mental illness from the rest of the person, (b) that there is society duty of care towards vulnerable people.

Judges do not intervene because they want to be control freaks. They're working with longstanding legal principles. In this case, capacity.

JohnJ said...

'Intelligent woman'
He (the judge) acknowledged that her parents were in an "impossible" position and that "does not merely entail bodily intrusion of the most intimate kind, but the overbearing of E's will in a way that she experiences as abusive".

In all this we must not forget "E's" Parents who must have experienced many year's of desperation for their precious daughter.
We would pray to our Heavenly Father for them all.