Contemplating suitable circumstances and justifications for the involuntary treatment of severe and enduring anorexia nervosa (SE-AN) presents numerous challenges. While there is considerable support for resorting to civil committal powers to coerce selected SE-AN patients into treatment (Bowers, 2014), there is on-going debate about the characteristics of the group for whom this is justified and about when a patient should be permitted to decline treatment where refusal is likely to result in their death (Gans and Gunn, 2013; Giordano, 2010; Lopez, Yager and Feinstein, 2010).
International approaches to span a wide range of clinical, ethical and legal positions (Carney, et al., 2006). In federations such as the United States, Canada or Australia, legal and clinical responses can vary from one part of the country to another due both to policy choices by clinicians about the use of the law, and because the constitutional authority to make laws lies with the States or Provinces, rather than the central government, enabling quite different approaches to be taken from one jurisdiction to the next. In Australia for instance some jurisdictions (such as Victoria) rely on mental health (civil commitment) laws alone, while in the neighbouring jurisdiction of New South Wales the more ‘empowering’ philosophy of adult guardianship (with its interposition of a guardian between patient and clinician) is open to be used as an alternative to mental health laws (and even child protection laws have also been utilised) (Carney, Tait, Saunders, Touyz, and Beumont, 2003). Mental health laws also differ amongst themselves (some favour empowering clinicians to invoke coercion subject to later review, others insist on prior approval of a legal body: Carney, Tait, Perry, Vernon and Beaupert, 2011) and differ between countries in whether courts (as in the US and much of Canada) or multi-disciplinary tribunals authorize or review the exercise of coercive powers (as is the case in Britain and Australia), as well as in whether involuntary detention grants authority to impose treatments such as medications (as in Australia), or requires separate legal authorization.
This chapter explores the often vexed and complex dilemmas confronting the clinician when having to decide upon the involuntary treatment of a patient with severe and enduring AN (SE-AN). It explores the literature beyond the evidence-base. It then provides some considered wisdom, extracted from the published literature, to guide the clinician through what often can become an emotionally charged encounter with an oppositional patient. Clear decision making based upon sound clinical principles can often pave the way for a more successful outcome without what many would consider a ‘bruising battle’ of wills. Finally, the road ahead is addressed looking at compulsory treatment from an international perspective and briefly touching upon the urgent need for research to determine whether such patients do have the mental capacity to make such potentially life-saving decisions.