Whatever their views about the use of compulsion in anorexia nervosa in general, or on issues of competence and capacity, all participants thought that it is right to impose treatment in order to save life. No participant supported the view that it is right to allow a person with anorexia nervosa to die as a result of respecting their refusal of treatment.
A concept that is receiving increasing research attention is that of ‘perceived coercion’ (Bindman et al., 2005; Guarda et al., 2007
). This is the idea that psychiatric patients often experience coercion whether or not formal legal means are used. Such coercion includes ‘leverage’ when a patient may be ‘encouraged’ to behave in a certain way through a threat of the use of more formal coercion or the loss of some benefit (Appelbaum & Redlich, 2006
). The participants in this study described such perceived coercion. Indeed their experience of formal legal compulsion was much less frequent than that of other forms of compulsion.
The participants' frequent accounts of experiences of lack of choice and the use of leverage are ethically problematic when contrasted with the relative infrequency of legal compulsion they experienced. On the one hand, the use of leverage can be an effective and flexible way of enabling acceptance of treatment while avoiding the stigmatizing and potentially traumatic experience of formal legal compulsion, and may not be experienced negatively; on the other hand, the use of leverage and other non-legal forms of coercion leave already vulnerable patients at risk of unethical treatment and loss of autonomy and rights without the protection of legal procedure, advocacy and right of appeal that formal legal compulsion brings. It has been argued that it is unethical and discriminatory towards those with mental disorders to use any form of coercion or act in a patient's best interests without consent unless he or she clearly lacks capacity (Szmukler, 2001
); and furthermore, that coercion is counterproductive in anorexia nervosa (Rathner, 1998
). Studies suggest that patient perception of ‘coercion’ or experience of formal legal compulsion is not subsequently associated with a poorer engagement with treatment or poorer therapeutic relationship with mental health professionals (Ayton et al., 2009; Bindman et al., 2005; Greenberg, Mazar, Brom, & Barer, 2005
). The limited research also does not clearly show that formal compulsory treatment is associated with poorer short or longer term clinical outcome (Ayton et al., 2009; Carney et al., 2008; Ramsay et al., 1999; Watson et al., 2000
). Even if there is no clinical harm, however, the issue of compulsion in treatment for anorexia nervosa is still ethically problematic. From the ethical point of view, a traditional stance is that patient autonomy should be respected even if unwise or foolish decisions are made, and the justification for acting in a patient's best interests instead of according to his or her wishes is the pivotal issue of capacity (Buchanan & Brock, 1989
What is striking from this study is that the issue of capacity was not the central one for participants in the context of compulsory treatment. It is true that many participants did view treatment refusal by people with anorexia nervosa as problematic because the anorexia compromises decision-making. But this was not the main issue in their consideration of the rights and wrongs of compulsion. The main issues centred on their relationships with those involved in the treatment: health professionals and sometimes parents. The participants did not appear to resent leverage or ‘informal’ compulsion if it is carried out in the context of a trusting relationship and perceived as care and help, and may not even experience it as coercive.
These results have implications for the ethical analysis of compulsory treatment in the context of anorexia. One approach, we suggest, is that, on the accounts of those with anorexia, the central issue is not the question of whether and when a person lacks capacity to consent to, or refuse, treatment. Instead the central issue concerns the context and relationships involved in good and compassionate psychiatric care. A greater objective restriction of choice may be experienced as less negative, and indeed ultimately as good care, if conducted within a trusting and supportive relationship and environment. Such an approach might be seen as a ‘virtue ethics approach’ in which the focus is on how carers can act with compassion. It is also consistent with recent trends in bioethics that highlight the importance of trust in decision-making (O'Neill, 2002
An alternative response to the accounts reported here is to retain the emphasis on autonomy and capacity in thinking about the ethics of compulsion but to suggest that more subtle and broader difficulties in making treatment decisions may need to be considered (Charland, 1998
). Key questions are: when and why a patient may fail to make autonomous decisions because of the influence of the mental disorder, and whether help and even coercion to engage in treatment might increase autonomy (Charland, 2002; Tan & Hope, 2006; Tan et al., 2006
). Conversely, a patient may technically lack capacity, for example being impaired in his or her ability to retain information, but broader factors such as an ability to express underlying values may enable him or her to continue to make valid choices with the appropriate support (Department of Constitutional Affairs, 2007; Tan et al., 2006
These two approaches are not mutually exclusive, as poor relationships and difficult or hostile settings tend to disempower patients with respect to whether they feel able to make decisions for themselves and can also cause them to resist or refuse help; while strong, trusting relationships and supportive treatment settings tend to facilitate patients in making their own decisions and help them to feel more actively involved in their care. Indeed, the ethical justifications voiced in these results suggest that it is a complex mix of a virtue ethics and nuanced capacity approach that is used by patients in thinking of their experiences of, and attitudes to, compulsory treatment and coercion. The analysis of this study and results of a previous study suggest that in anorexia nervosa issues of control and choice can have a strong influence on whether patients are able to make decisions. This is because patients suffering from anorexia nervosa often struggle to remain in control of themselves and their lives and, as a result, resist help, while at the same time feeling out of control with respect to their eating behaviour and wishing to have help (Tan et al., 2003c
In conclusion, in this qualitative interview study, patients with anorexia nervosa reported considerable experience of compulsion and restriction of choice despite a relative lack of the use of formal compulsory treatment. Nevertheless, there is strong consensus that compulsory treatment should be used if needed to save life in anorexia nervosa. There was less consensus concerning the use of compulsory measures for the treatment of anorexia nervosa in the absence of immediate risk to life. A striking result was that what mattered most to participants was not whether they were compelled to have treatment but the nature of their relationships with parents and mental health professionals. Indeed, within a trusting relationship compulsion may be experienced as care.