To Treat or Not to Treat: legal and ethical issues in the compulsory treatment of anorexia

Abstract

Treatment resistance is a characteristic feature of anorexia nervosa, and is usually regarded as a symptom of the illness. In the case of some chronic anorexics, however, rejection of therapeutic intervention may be the result of reasoned decision making. Some patients ('end-stage' anorexics) may feel their quality of life so poor and the prospects of recovery so slight that they would prefer to be allowed to die. For others ('identity' anorexics), their illness may have become so integrated into their sense of self that they reject attempts to ‘cure’ them, despite being aware of the risks this poses to their health. Under New Zealand law, there is the possibility that such patients could be considered legally competent under the Protection of Personal and Property Rights Act (PPPRA), but mentally disordered under the Mental Health (Compulsory Assessment and Treatment) Act (MHA). Whether compulsory treatment is lawful would thus depend on the piece of legislation used when assessing the need for a treatment order. A principlist analysis of the ethics of compulsion suggests that enforced treatment is justified in the case of identity anorexia (providing effective treatment is available), but not in end-stage anorexia. I conclude that current legislation needs to be amended to ensure that the PPPRA and the MHA can be applied to anorexic patients in a legally consistent and ethically appropriate manner.