'Is involuntary (compulsory) treatment ever justified in patients with SE-AN: An international perspective’ by
Joel Yager, Terry Carney and Stephen Touyz in Touyz, Le Grange, Lacey and Hay (eds)
Managing Severe and Enduring Anorexia Nervosa (Routledge, 2016)
comments
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.
