Jacinta Tan

Competence to Make Treatment Decisions in Anorexia Nervosa: Thinking Processes and Values

Abstract: This paper explores the ethical and conceptual implications of the findings from an empirical study (reported elsewhere) of decision-making capacity in anorexia nervosa. In the study, ten female patients aged thirteen to twenty-one years with a diagnosis of anorexia nervosa, and eight sets of parents, took part in semistructured interviews. The purpose of the interviews was to identify aspects of thinking that might be relevant to the issue of competence to refuse treatment. All the patient-participants were also tested using the MacArthur Competence Assessment Tool—Treatment test of competence. This is a formalized, structured, interviewer-administered test of competence, which is a widely accepted clinical tool for determining capacity. The young women also completed five brief, self-administered questionnaires to assess their levels of psychopathology. The issues identified from the interviews are described under two headings: difficulties with thought processing and changes in values. The results suggest that competence to refuse treatment may be compromised in people with anorexia nervosa in ways that are not captured by traditional legal approaches.

Anorexia nervosa and personal identity: The accounts of patients and their parents.

Jacinta O.A. Tan*, Tony Hope, Anne Stewart Research Fellow, Oxford Centre for Ethics and Communication in Health Care Practice (Ethox Centre), Department of Public Health, University of Oxford, Oxfordshire, UK Professor of Medical Ethics, Oxford Centre for Ethics and Communication in Health Care Practice, University of Oxford, Oxfordshire, UK Consultant Adolescent Psychiatrist, Oxfordshire Mental Healthcare, NHS Trust, Oxfordshire, UK

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion

Background The compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that patients are often subject to compulsion and coercion even without formal compulsory treatment orders. Research also suggests that patients suffering from anorexia nervosa can change their minds in retrospect about compulsion. Methods Qualitative interviewing methods were used to explore the views of 29 young women concerning compulsion and coercion in the treatment of anorexia nervosa. The participants were aged between 15 to 26 years old, and were suffering or had recently suffered from anorexia nervosa at the time of interview. Results Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals. Conclusions People with anorexia nervosa appear to agree with the necessity of compulsory treatment in order to save life. The perception of coercion is complex and not necessarily related to the degree of restriction of freedom.

Capacity and Competence in Child and Adolescent Psychiatry

Capacity and competence in the field of child and adolescent psychiatry are complex issues, because of the many different influences that are involved in how children and adolescents make treatment decisions within the setting of mental health. This article will examine some of the influences which must be considered, namely: developmental aspects, the paradoxical relationship between the need for autonomy and participation and the capacity of children, family psychiatry, and the duty of care towards children and adolescents. The legal frameworks relevant to consideration of consent and competence will be briefly considered, as well as some studies of childrens consent, participation and competence. A case vignette will be used as a focus to consider the complexity of the issue of competence in child and adolescent psychiatry, in the particular mental disorder of anorexia nervosa.

Agency, ambivalence and authenticity: the many ways in which anorexia nervosa can affect autonomy

On the basis of detailed interviews of females aged between fifteen and twenty-six years with a diagnosis of anorexia nervosa we argue that the autonomy of people with this condition may be severely compromised in four ways, particularly in relation to eating and weight. First there are problems with agency. Second, affective components, particularly anxiety, can dominate beliefs such that the grounds for making a decision may differ from the reasons given in justification. Third, the interactions between the affective components and the objective evidence lead to substantial inner conflicts with resulting lack of stability in preferences and beliefs. Fourth, this lack of stability leads to concerns around identity and authenticity. We argue that some of the ways in which autonomy is compromised reduce competence to decide on treatment. We suggest that these results may be relevant to other mental disorders and have clinical and policy implications.

Decision-Making as a Broader Concept

We thank Demian Whiting for the thoughtful critique of aspects of our paper (Tan et al. 2006a). A primary aim of our research was to provide empirical grounds on which to stimulate discussion about the nature of decision-making capacity (DMC). Whiting criticizes in particular the concept of ‘pathological values’ that we suggested might be relevant in the assessment of DMC and in the related issue of deciding when a patient’s refusal of beneficial treatment should be overridden. Whiting’s central concern is with DMC. Whiting argues that the absence of pathological values should not be a criterion for DMC. We are unclear whether he is also arguing that pathological values do not provide a reason of any kind for overriding treatment refusal. At the end of the paper he writes: “we cannot justify compulsory treatment of patients who have pathological values . . . on the grounds that these patients lack DMC” (2009, XX). This seems to leave open the possibility that we may be able to justify compulsory treatment of patients who have pathological values on grounds other than that they lack DMC. As we wrote in our response to the discussants of our original paper, “The primary issue for us is whether the reasons for refusal to which we draw attention provide grounds for overriding refusal, and if they do how they can be characterized in such a way as to avoid the ever-present danger of simply overriding autonomy in a patient’s best interests” (Tan et al. 2006b, 300). In deciding on whether to use compulsory treatment, there are other relevant factors that may need to be considered, such as the seriousness of the decision, which determines the threshold for competence. However, in this response we consider three issues. First, we argue that the current concept of DMC is by no means so clear cut or generally agreed upon as Whiting implies, and that some of the lack of clarity relates to pathological values. Second, that the concept of DMC is itself dependent on accounts of autonomy, and that it is plausible that pathological values can affect autonomy. Third, we directly consider the question of whether a coherent account of pathological values might be given based on a concept of authenticity.

Anorexia Nervosa as a Passion

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that conceptualizing anorexia nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals.

Consent and confidentiality in clinical work with young people

Consent and confidentiality are increasingly important in clinical practice. However, the dilemmas faced by mental health practitioners can be highly complex and difficult to resolve. This difficulty is compounded by the fact that consent and confidentiality are subject to several different types of legislation based on different principles, and many of the policies which are formulated for general medical practice may not fit well with the mental healthcare context. The ethical principles, evidence base, legal context, developmental considerations and clinical context relevant to each situation must all be integrated, in consultation with children and adolescents and their parents, in order to arrive at a treatment plan which is sensitive to the views of all, developmentally appropriate for the children and adolescents, and responsive to changes in the situation or attitudes. We offer some practical approaches, including clinical practice algorithms, to consider the issues of consent and confidentiality in the child and adolescent mental healthcare setting.

Investigating eating disorders in elite gymnasts: Conceptual, ethical and methodological issues

Abstract Elite gymnastics, and other sports where athletes and coaches are particularly concerned with aesthetic considerations, weight and shape, are fields within which the risk of eating disorders may be unusually high. Adolescent gymnasts, developing their own sense of self, at a time of life where body image concerns are common, often compete at the very top of the sport with a need to maintain a body shape and weight optimal for elite performance. Research into this field should address the range of sociological and ethical aspects of eating disorders in elite sport, their prevalence as well as the ethos of the sport itself. This paper addresses a range of conceptual, ethical and methodological issues relevant to conducting research in this sensitive yet important field.

Deep Brain Stimulation in Anorexia Nervosa: Hope for the Hopeless or Exploitation of the Vulnerable? The Oxford Neuroethics Gold Standard Framework.

Neurosurgical interventions for psychiatric disorders have a long and troubled history (1, 2) but have become much more refined in the last few decades due to the rapid development of neuroimaging and robotic technologies (2). These advances have enabled the design of less invasive techniques, which are more focused, such as deep brain stimulation (DBS) (3). DBS involves electrode insertion into specific neural targets implicated in pathological behavior, which are then repeatedly stimulated at adjustable frequencies. DBS has been used for Parkinson’s disease and movement disorders since the 1960s (4–6) and over the last decade has been applied to treatment-refractory psychiatric disorders, with some evidence of benefit in obsessive–compulsive disorder (OCD), major depressive disorder, and addictions (7). Recent consensus guidelines on best practice in psychiatric neurosurgery (8) stress, however, that DBS for psychiatric disorders remains at an experimental and exploratory stage. The ethics of DBS—in particular for psychiatric conditions—is debated (1, 8–10). Much of this discourse surrounds the philosophical implications of competence, authenticity, personality, or identity change following neurosurgical interventions, but there is a paucity of applied guidance on neuroethical best practice in psychiatric DBS, and health-care professionals have expressed that they require more (11). This paper aims to redress this balance by providing a practical, applied neuroethical gold standard framework to guide research ethics committees, researchers, and institutional sponsors. We will describe this as applied to our protocol for a particular research trial of DBS in severe and enduring anorexia nervosa (SE-AN) (https://clinicaltrials.gov/ct2/show/NCT01924598, unique identifier NCT01924598), but believe it may have wider application to DBS in other psychiatric disorders.