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. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came to the (...) concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

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. (shrink)

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, (...) is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet “mutually enriching paradigms” despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Decision-Making as a Broader ConceptJacinta O. A. Tan (bio), Anne Stewart (bio), and Tony Hope (bio)KeywordsCompetence, decision-making, capacity, anorexia nervosa, autonomy, values, identityWe 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.The Current Criteria for DMCWhiting argues that the current criteria for DMC are correct and that an additional criterion along the lines of absence of pathological values should not be added. This argument assumes that there is a clear and agreed understanding of the current criteria. We believe this is not the case for three reasons.(i) Whiting begins his account of DMC by saying that it is normally taken to include: "(1) [End Page 345] understanding (and appreciation)" (2009, 341). Already there is an area of dispute, and the use of parentheses reflects this. The concept of 'appreciation' was developed by Grisso and Applebaum (Grisso, Appelbaum, and Hill-Fotouhi 1997). It is not included in either English common law development, for example (ReC), nor in the criteria specified in the Mental Capacity Act 2005. More important, Grisso and Appelbaum in their comment on our original paper (2006) argue that our work advances thinking about 'appreciation' rather than requiring that we add new elements. The implication is that they believe that what we have called pathological values are relevant to the assessment of capacity and are already included in an account of capacity that incorporates the criterion of 'appreciation.' In our response, we argued that pathological values are not entirely captured within the account of appreciation that Grisso and Appelbaum had previously given. We do not want to revisit that issue here, but the point of relevance is that on one view (that of Grisso and Appelbaum) pathological values are already included in the current criteria for DMC as part of the concept of appreciation, whereas on Whiting's view they are not.(ii) Even if there were agreement over the wording and concepts relevant to DMC there is a further important issue: how are those concepts... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Studying Penguins to Understand BirdsJacinta O. A. Tan (bio), Anne Stewart (bio), Ray Fitzpatrick (bio), and Tony Hope (bio)Keywordsanorexia nervosa, treatment decision-making, competence, valuesWe are grateful to Grisso, Appelbaum, Charland, and Vollmann for their thoughtful commentaries on our paper. We would like to respond by picking up on some of the points they make, although we do not address all the issues raised.Our general aims in the paper are (...) less immediately pragmatic than are the central concerns of Grisso and Appelbaum. Our interest is primarily in a number of ethical, and related conceptual, issues that arise from empirical data. In the long run, of course, we believe that these ethical and conceptual issues are important to the care of people with mental disorders, but our focus is philosophical.Our central interest is what justifies overriding treatment refusal. We are unhappy with a "status" approach according to which, for example, the mere fact that a person suffers a mental disorder provides grounds for overriding her wishes. Such an approach, it seems to us, fails to identify reasons, and discriminates against those with mental disorder, a view shared by the Law Commission (The Law Commission 1995). We are, on the other hand, attracted by the approach that grounds any overriding of treatment refusal on lack of capacity (or competence) to make treatment decisions. The concept of capacity has been well developed through legal cases and conceptual analysis, not least by Grisso and Appelbaum themselves. We were struck, however, first through clinical experience, and subsequently from the pilot study reported in our paper, that many patients with anorexia nervosa who refuse treatment do not necessarily lack capacity, using the current criteria, and yet show features or give reasons that raise serious doubts as to whether it is right to respect their refusal of treatment.To avoid reliance on a "status" approach, the issue with which we are grappling is whether the concept of capacity (and therefore lack of capacity) can be developed to encompass some of our findings, and whether it is ethically right to do so. Charland makes the important point that the concept of competence, or capacity, has both a descriptive and a prescriptive component. It is for this reason that the question of whether, for example, we should extend the criteria for capacity is part of the question of when it is morally right to override treatment refusal.Grisso and Appelbaum suggest that our work advances "our thinking about appreciation, rather than requiring that we add new elements" (2006, 297). From our perspective, and at this stage, it is a secondary issue whether we are suggesting a development of appreciation, or a new element (e.g., "pathological values"). 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 [End Page 299] such a way as to avoid the ever-present danger of simply overriding autonomy in a patient's best interests.We chose to study anorexia nervosa for various reasons, but we expect that the issues raised have a more general relevance (such as to substance abuse and impulse control disorders as Grisso and Appelbaum and Charland suggest). We do not expect the results to be relevant to all, or even most, mental disorders. Our main interest is not the specific management of people with anorexia, but how the data challenge, and help to develop, the concept of capacity, and the ethical analysis of overriding patient refusal of treatment. Our paper aims to address what we understand Charland to be referring to by the "pretheoretical desiderata" (2006, 283) of the concept of capacity. One reason why we chose anorexia as the focus of this work is because it is different from many mental disorders in the issues that it raises. In this it is, perhaps, rather like studying penguins to better understand the concept of bird just because penguins, although clearly birds, have unusual features.We agree, therefore, with Grisso and Appelbaum's caution that it would be unwise to jump in and change the MacCAT-T on the basis of the results... (shrink)

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 children's 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. (shrink)

We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, and the compelling (...) parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts... (shrink)