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Jamieson SK, Tan J, Piekunka K, Calvert S, Anderson S. Navigating the ethical complexities of severe and enduring (longstanding) eating disorders: tools for critically reflective practice and collaborative decision-making. J Eat Disord 2024; 12:134. [PMID: 39243050 PMCID: PMC11378593 DOI: 10.1186/s40337-024-01082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 08/09/2024] [Indexed: 09/09/2024] Open
Abstract
Decisions about the treatment of eating disorders do not occur in a socio-political vacuum. They are shaped by power relations that produce categories of risk and determine who is worthy of care. This impacts who gets access to care and recognition of rights in mental health services. Globally, there are calls for more human rights-based approaches in mental health services to reduce coercion, improve collaborative decision making and enhance community care. Treating individuals with longstanding, Severe and Enduring Eating Disorders (SEED) or Severe and Enduring Anorexia Nervosa (SE-AN) can be particularly problematic when it involves highly controversial issues such as treatment withdrawal and end-of-life decisions and, where legally permissible, medically assisted dying. In this article, we argue that the socio-political context in which clinical decision making occurs must be accounted for in these ethical considerations. This encompasses considerations of how power and resources are distributed, who controls these decisions, who benefits and who is harmed by these decisions, who is excluded from services, and who is marginalised in decision making processes. The article also presents tools for critically reflective practice and collaborative decision-making that can support clinicians in considering power factors in their practice and assisting individuals with longstanding eating disorders, SEED and SE-AN to attain their rights in mental health services.
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Affiliation(s)
| | - Jacinta Tan
- Imperial College London and My Lighthouse Ltd, London, UK.
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2
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Abstract
LEARNING OBJECTIVES After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. ABSTRACT Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.
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Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2022; 51:261-271. [PMID: 36379875 DOI: 10.1016/j.rcpeng.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 11/25/2020] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Anorexia nervosa poses an important bioethical dilemma, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. METHODS Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. RESULTS The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. CONCLUSIONS It is concluded that the difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.
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Duarte Madeira L, Costa Santos J. Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature. F1000Res 2022; 11:219. [PMID: 36329795 PMCID: PMC9617066 DOI: 10.12688/f1000research.109555.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/01/2023] Open
Abstract
The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.
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Affiliation(s)
- Luis Duarte Madeira
- Instituto de Medicina Preventiva, Faculdade de Medicina - Universidade de Lisboa, Lisboa, Lisboa, 1649-035, Portugal
- Psiquiatria, CUF Descobertas, Lisboa, 1998-018, Portugal
| | - Jorge Costa Santos
- Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Portugal
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Duarte Madeira L, Costa Santos J. Reconsidering the ethics of compulsive treatment under the light of clinical psychiatry. F1000Res 2022; 11:219. [PMID: 36329795 PMCID: PMC9617066 DOI: 10.12688/f1000research.109555.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2022] [Indexed: 11/01/2023] Open
Abstract
The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It focuses on how patients experience CT and its impact on their mental health and treatment programs, the reasons for the use of CT versus voluntary treatment and what efforts have been made to reduce, replace and refine the presence of CT in psychiatry.
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Affiliation(s)
- Luis Duarte Madeira
- Instituto de Medicina Preventiva, Faculdade de Medicina - Universidade de Lisboa, Lisboa, Lisboa, 1649-035, Portugal
- Psiquiatria, CUF Descobertas, Lisboa, 1998-018, Portugal
| | - Jorge Costa Santos
- Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Portugal
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Duarte Madeira L, Costa Santos J. Reconsidering the ethics of compulsive treatment in light of clinical psychiatry: A selective review of literature. F1000Res 2022; 11:219. [PMID: 36329795 PMCID: PMC9617066 DOI: 10.12688/f1000research.109555.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/01/2023] Open
Abstract
The ethics of compulsive treatment (CT) is a medical, social and legal discussion that reemerged after the ratification by 181 countries of the 2007 United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). The optional protocol of the UN-CRPD was ratified by 86 countries aiming to promote, protect and ensure the full and equal enjoyment of all human rights. It also determined the need to review mental health laws as under this light treatment of persons with disabilities, particularly those with mental disorders, cannot accept the use of CT. This selective review of literature aims to clarify inputs from clinical psychiatry adding evidence to the multi-disciplinary discussion. It provides contradictory evidence on how patients experience CT and its impact on their mental health and treatment programs, also which are main reasons for the use of CT and what efforts in psychiatry have been made to reduce, replace and refine it.
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Affiliation(s)
- Luis Duarte Madeira
- Instituto de Medicina Preventiva, Faculdade de Medicina - Universidade de Lisboa, Lisboa, Lisboa, 1649-035, Portugal
- Psiquiatria, CUF Descobertas, Lisboa, 1998-018, Portugal
| | - Jorge Costa Santos
- Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Portugal
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Westmoreland P, Parks L, Lohse K, Mehler P. Severe and Enduring Anorexia Nervosa and Futility: A Time for Every Purpose? Psychiatr Clin North Am 2021; 44:603-611. [PMID: 34763793 DOI: 10.1016/j.psc.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The concept of futility in the treatment of individuals with severe and enduring anorexia nervosa remains controversial and has significant legal and ethical considerations. For those who have been unremittingly ill for 8 to 12 years, full recovery, although possible, is unlikely, and alternatives to traditional, active treatment must be explored. The harm reduction model, palliative care, and end-of-life care are explored as meaningful and reasonable treatments for this population. Landmark cases demonstrating the legal and ethical controversy of such treatment are explored.
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Affiliation(s)
- Patricia Westmoreland
- Women's Unit, The Medical Center of Aurora and Consultant, ACUTE Center for Eating Disorders at Denver Health, Denver, CO 80204, USA.
| | - Libby Parks
- Clinical Social Work, ACUTE Center for Eating Disorders at Denver Health, Denver, CO 80204, USA
| | - Kristen Lohse
- ACUTE Center for Eating Disorders at Denver Health, Denver, CO 80204, USA
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Fernández-Hernández JL, Herranz-Hernández P, Segovia-Torres L. Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2021; 51:S0034-7450(20)30126-8. [PMID: 33735003 DOI: 10.1016/j.rcp.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/03/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Anorexia nervosa poses an important bioethical quandary, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. METHODS Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. RESULTS The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. CONCLUSIONS The difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.
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9
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Clausen L. Perspectives on Involuntary Treatment of Anorexia Nervosa. Front Psychiatry 2020; 11:533288. [PMID: 33192651 PMCID: PMC7641604 DOI: 10.3389/fpsyt.2020.533288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/16/2020] [Indexed: 01/12/2023] Open
Abstract
Involuntary treatment of anorexia nervosa is an option in cases in which the patient's life or other people's lives are at risk or, in some countries, to prevent the deterioration of the illness. Involuntary treatment is often regarded as controversial and has been intensely debated, although typically with few references to documented knowledge. This paper provides a research perspective of the topic by examine data in the field of the involuntary treatment of anorexia nervosa to pinpoint present knowledge as well as areas demanding clinical action or research attention. The prevalence of involuntary treatment in general as well as specific measures is described and possible early markers of patients at risk of involuntary treatment are discussed. Studies including patients' perspectives of involuntary treatment show the complexity of this treatment, its initiation, and its consequences. To qualify future discussions, improve current practice, and minimize involuntary treatment in general as well as on an individual level, at least four areas need attention: (i) the present specific symptoms of anorexia nervosa and their imminent consequences, (ii) illness history, (iii) overall psychiatric symptoms and general functioning, and (iv) contextual sphere of the patient. In particular, the last two require attention from both clinicians and researchers. Furthermore, critical evaluation of the attitudes of both patients and health care professionals toward each other and the treatment is recommended.
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Affiliation(s)
- Loa Clausen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Psychiatry, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Maslen H, Pugh J, Savulescu J. The Ethics of Deep Brain Stimulation for the Treatment of Anorexia Nervosa. NEUROETHICS-NETH 2015; 8:215-230. [PMID: 26594256 PMCID: PMC4643100 DOI: 10.1007/s12152-015-9240-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/10/2015] [Indexed: 11/09/2022]
Abstract
There is preliminary evidence, from case reports and investigational studies, to suggest that Deep Brain Stimulation (DBS) could be used to treat some patients with Anorexia Nervosa (AN). Although this research is at an early stage, the invasive nature of the intervention and the vulnerability of the potential patients are such that anticipatory ethical analysis is warranted. In this paper, we first show how different treatment mechanisms raise different philosophical and ethical questions. We distinguish three potential mechanisms alluded to in the neuroscientific literature, relating to desire, control, and emotion, respectively. We explain why the precise nature of the mechanism has important implications for the patient's autonomy and personal identity. In the second part of the paper, we consider practical dimensions of offering DBS to patients with AN in certain cases. We first discuss some limited circumstances where the mere offering of the intervention might be perceived as exerting a degree of coercive pressure that could serve to undermine the validity of the patient's consent. Finally, we consider the implications of potential effects of DBS for the authenticity of the patient's choice to continue using stimulation to ameliorate their condition.
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Affiliation(s)
- Hannah Maslen
- The Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House 16/17 St Ebbe’s Street, Oxford, OX1 1PT UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House 16/17 St Ebbe’s Street, Oxford, OX1 1PT UK
| | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House 16/17 St Ebbe’s Street, Oxford, OX1 1PT UK
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McKinney C. Is Resistance (N)ever Futile? A Response to "Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come" by Cynthia Geppert. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:53-54. [PMID: 26147268 DOI: 10.1080/15265161.2015.1042991] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Ashby MA, Rich LE. Two deaths and a birth: reminiscing and rehashing principles in biomedical ethics. JOURNAL OF BIOETHICAL INQUIRY 2014; 11:1-4. [PMID: 24647806 DOI: 10.1007/s11673-014-9509-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/05/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Michael A Ashby
- Palliative Care Service, Royal Hobart Hospital, Southern Tasmania Area Health Service, and School of Medicine, Faculty of Health Sciences, University of Tasmania, 1st Floor, Peacock Building, Repatriation Centre, 90 Davey Street, Hobart, TAS, 7000, Australia,
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Carney T. The incredible complexity of being? Degrees of influence, coercion, and control of the "autonomy" of severe and enduring anorexia nervosa patients. Commentary on "Anorexia nervosa: the diagnosis: a postmodern ethics contribution to the bioethics debate on involuntary treatment for anorexia nervosa" by Sacha Kendall. JOURNAL OF BIOETHICAL INQUIRY 2014; 11:41-42. [PMID: 24390618 DOI: 10.1007/s11673-013-9506-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Terry Carney
- Faculty of Law, Eastern Avenue, The University of Sydney, Sydney, NSW, Australia, 2006,
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Ryan CJ, Callaghan S. Treatment refusal in anorexia nervosa: the hardest of cases. Commentary on "Anorexia nervosa: the diagnosis: a postmodern ethics contribution to the bioethics debate on involuntary treatment for anorexia nervosa" by Sacha Kendall. JOURNAL OF BIOETHICAL INQUIRY 2014; 11:43-45. [PMID: 24415127 DOI: 10.1007/s11673-013-9498-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/15/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Christopher James Ryan
- Discipline of Psychiatry and the Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia,
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