Anorexia Nervosa (AN) is an eating disorder defined as severe, self- inflicted starvation leading to body weight at least 15% below that expected for the individual’s sex and height and age. According to the 10th edition of the International Classification of Diseases (ICD-10) of the World Health Organization (WHO) AN is a mental illness. It should not be confused with Bulimia nervosa (cycles of bingeing and vomiting or other compensatory behaviour) although these mental disorders have a lot in common and may occur in the same person both sequentially or concurrently. Body image disturbance is a symptom of AN. AN is much more common in teenage girls and young women compared to male individuals and in other age groups, affecting up to 1% of female adolescents in industrialized countries (with money to spend on epidemiological field studies to acquire such knowledge about a- regarding the whole population - rather rare disorder). However, it is a serious disorder with a high mortality between 5% and 18%, and especially considering the young age of those afflicted. Unrealistically slim media portrayals of the female body may increase the risk of developing AN. . Patients who are dangerously thin are sometimes force-fed using a naso-gastric (through the nose) or transdermal duodenal tube (PEG). Normally, medical treatment cannot be administered without the consent of the patient. However, mentally ill patients may not have the mental capacity to make a choice. Despite this, medical ethics, pragmatics and human rights call the treatment into question.
Life is more important than dignity, many medical treatments are unpleasant or painful but they are necessary to preserve life. Without force feeding the anorectic patient will often die. In Australia about 80 per cent of all anorexic children required hospital admission (from 101 cases), and of those, 50 per cent required tube feeding as a life-saving measure to manage starvation. When a patient requires emergency treatment doctors should do what is necessary to save the patient’s life. Psychological problems can only be treated if the person is alive. Treatment for the psychological problem should be considered to go hand in hand with saving the patient’s life as in the B vs. Croydon Health Authority where force feeding was ruled to be complemented the use of other methods to treat her psychiatric problems.
McLean T., Half of anorexic kids need force feeding, 2008, http://news.theage.com.au/national/half-of-anorexic-kids-need-force-feeding-20080528-2itg.html, accessed 07/22/2011
 Keywood K., B v Croydon Health Authority 1994, CA: Force-Feeding the Hunger-Striker under the Mental Health Act 1983., University of Liverpool, http://www.ncl.ac.uk/~nlawwww/articles3/keywood3.html, accessed 07/22/2011
Life is more important than dignity. None the less there is a significant difference between someone who is in an emergency condition being treated without their consent and someone who has previously refused treatment being forced to have treatment. Patients are allowed to make decisions doctors believe are unwise.
 Patients.co.uk, ‘Consent To Treatment (Mental Capacity and Mental Helth Legislation)’ 2009, http://www.patient.co.uk/doctor/Consent-To-Treatment-%28Mental-Capacity-...
Anorectic patients are typically treated under mental health legislation (e.g. the UK 1983 Act). They do not make a free choice because they are not rationally able to weigh up decisions and consequences, they ‘feel’ fat when they obviously are not and are irrational as they are willing to starve themselves to the point of death when suicide is not their intent. The patient is not “capable of forming unimpaired and rational judgements concerning the consequences” (British Medical Association 1992). There have been court cases that have confirmed that force feeding should be allowed when a patient is considered mentally ill. For example the case of “B vs. Croydon Health Authority” in 1994 it was judged, that B (a borderline personality disorder patient, which involves suffering from an irresistible desire to inflict-self-harm) can be force fed, even though she did not give consent to the treatment.
The court explained that because she was not aware of the seriousness of her condition and she had found it difficult to break out of the cycle of self-punishment, she was deemed unfit to make decisions about her nutrition.
 Fedyszyn & Sullivan, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa’, 2007, http://leedsmet.academia.edu/GavinSullivan/Papers/255145/Ethical_Re-Evaluation_of_Contemporary_Treatments_for_Anorexia_Nervosa_Is_An_Aspirational_Stance_Possible_In_Practice, p.202
 Keywood K., B v Croydon Health Authority 1994, CA: Force-Feeding the Hunger-Striker under the Mental Health Act 1983., University of Liverpool, http://webjcli.ncl.ac.uk/articles3/keywood3.html, accessed 07/22/2011
Force feeding is undignified. The World Medical Association considers “Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment.” This is treatment which the European Convention on Human Rights prohibits in Article 3 on the prohibition of torture. The patient’s right to refuse treatment should be respected even if they are mentally ill. (N.B. Anorexia is not recognised as a mental illness in every country).
 World Medical Association, ‘WMA Declaration of Malta on Hunger Strikers’, 2006
 European Court of Human Rights, Convention for the Protection of Human Rights and Fundamental Freedoms’, 2010, P.4
A healthier body weight is necessary to be able to treat the patient’s psychological problems. Studies in Minnesota show that when normal volunteers were starved, they began to development anorectic patterns. They over-estimated the sizes of their own faces by approximately 50%. This shows the impact of starvation on the brain.
 Fedyszyn & Sullivan, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa’, 2007, http://leedsmet.academia.edu/GavinSullivan/Papers/255145/Ethical_Re-Evaluation_of_Contemporary_Treatments_for_Anorexia_Nervosa_Is_An_Aspirational_Stance_Possible_In_Practice, P.202
Far from helping solve the patient’s psychological problems force feeding is just as likely to exacerbate the problems and make them much less willing to seek out treatment, something that they are often already unwilling to do. While it may be the case that when starved people over-estimate their own size those who are anorexic in the developed world did not start out starved so there must have been a different initial cause of the anorexia that will need to be found and solved, there are numerous different types of psychological treatment that can help do this.
 Jimerson, Shane R. et al., ‘Eating Disorders: Treatment’, 2002, http://education.ucsb.edu/jimerson/eatingdisorders.html
 NHS Choices, ‘Treating anorexia’, 2010, http://www.nhs.uk/Conditions/Anorexia-nervosa/Pages/Treatment.aspx
Medical ethics say that a doctor has a responsibility to keep the patient alive to administer treatment. In the UK Diana Pretty was denied the right to die by the House of Lords even though she consistently requested it. The Israeli Courts ordered the force- feeding of political hunger strikers arguing that in a conflict between life and dignity, life wins. India prosecuted a physician who allowed a hunger striker to die. The medical profession take their responsibility for life very seriously on a global level.
When it comes to hunger strikes the World Medical Association says that “Forcible feeding is never ethically acceptable.” While there are obviously differences in terms of the objective when it comes to the consent of the patient there is no difference. In both cases the patient does not want to be force fed and understand what the consequences may be.
 World Medical Association, ‘WMA Declaration of Malta on Hunger Strikers’, 2006
Compulsory treatment may only be successful in the short term. In the long term it does nothing to reduce the fear of food, weight and hospital felt by the patient and is a barrier to treatment. Hospital admission often has a worse outcome for the patient; there are increased mortality rates which are then even higher for those who are admitted against their will. Suicide accounts for 27% of anorexia deaths. Compulsory treatment may make the patient more depressed and at greater risk from harm.
 Fedyszyn & Sullivan, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa’, 2007, http://leedsmet.academia.edu/GavinSullivan/Papers/255145/Ethical_Re-Evaluation_of_Contemporary_Treatments_for_Anorexia_Nervosa_Is_An_Aspirational_Stance_Possible_In_Practice, p.201
Short term success is all that is necessary to save a life. Once the anorectic patient is out of danger then more long term treatments can be explored. This means working out how to reduce the fear of food and of weight and if the patient has become worried about going to hospital then at least there is time to sort that out as well. While emergency force feeding has to be within a hospital not all treatment has to take place in such an environment and ongoing psychological treatment can take place elsewhere.
The most successful policies are where anorectic patients feel safe and trust their doctors so are willing to go to clinics voluntarily as they feel that they are in control of the situation. Conversely an anorectic patient’s fear of weight gain, especially forced weight gain in hospital is an obstacle to treatment. If an anorexia nervosa sufferer thinks that they will be force- fed they may be less likely to seek treatment or advice.
 Susic, Paul, ‘Anorexia Treatment and the Unwilling Patient’, http://www.psychtreatment.com/anorexia_treatment.htm, accessed 07/21/2011
In 1997 the Mental Health Act Commission opened the door to allowing force feeding of anorexic patients in the UK by allowing the compulsory admission of anorexics to hospital. This change of policy did not reduce the number of patients being admitted for treatment which has gone up from 419 in 1996-7 to 620 in 2005-6.
 Disordered eating, Anorexia Nervosa Statistics (Uk), http://www.disordered-eating.co.uk/eating-disorders-statistics/anorexia-nervosa-statistics-uk.html, accessed 07/22/2011
Force-feeding has negative consequences. If the patient is dangerously thin and is then force-fed, it can led to Hypophosphataemia (reduction of phosphates in the blood) which causes heart failure. Anorexics are characterised by self-denial and often do not come forward voluntarily. Indeed it according to Dr Sacker anorexia is often not even about food rather "By stopping food from going into the body, what they really feel is they can be in control of their body.”  This desire is actively harmed by force feeding as a result they are even less likely to come forward voluntarily if they are faced with the possibility of force- feeding.
CBS, ‘A very thin line’, 02/11/2009, http://www.cbsnews.com/stories/1999/05/20/48hours/main47832.shtml, accessed 07/22/2011
Yes there will be negative consequences to such a step as force feeding however this is only done when it is absolutely necessary and the negative consequences of not doing so are much worse. Doctors will only force feed if they are convinced that doing so is for the good of the patient, indeed they are prohibited from taking such a step if it is not absolutely necessary.
Some doctors advocate focusing on palliative care (relief of pain but not treatment of cause) due to the low full recovery rates of anorexia sufferers. Research Studies show that over 10 years only approximately 20% of patients recover. Those patients who are sufferers for more than 12 years are unlikely to ever recover.
Palliative care is defeatist and does not attempt to cure the problem. Recovery is always a possibility and that is what doctors should be striving for “In a 10 year follow up of 76 severely ill women with anorexia, Eckert et al found that 18 (24%) had fully recovered, about half had a benign outcome, and only five (7%) had died.” Doctors do not often have to deal with severe or chronic anorexia. Just because it is a very long treatment schedule that can be harrowing for a doctor, this not a reason to settle for palliative care. Better support structures ought to be put in place to enable the doctor to fulfil their obligation to the patient.
 Williams, Christopher J. et al., ‘We should strive to keep patients alive’, 1998, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113542/
BBC News, ‘Compulsory treatment ‘helps anorexics’’, 31 July 1999 http://news.bbc.co.uk/1/hi/health/408362.stm
CBS, ‘A very thin line’, 11 February 2009, http://www.cbsnews.com/stories/1999/05/20/48hours/main47832.shtml
Disordered eating, Anorexia Nervosa Statistics (Uk), http://www.disordered-eating.co.uk/eating-disorders-statistics/anorexia-nervosa-statistics-uk.html, accessed 07/22/2011
European Court of Human Rights, ‘Convention for the Protection of Human Rights and Fundamental Freedoms’, June 2010, http://www.echr.coe.int/NR/rdonlyres/D5CC24A7-DC13-4318-B457-5C9014916D7A/0/ENG_CONV.pdf
Fedyszyn, Izabela Ewa, & Sullivan, Gavin Brent, ‘Ethical re-evaluation of contemporary treatments for anorexia nervosa: Is an aspirational stance possible in practice?’, Australian Psychologist, Vol 42, No. 3, September 2007, pp.198-211 http://leedsmet.academia.edu/GavinSullivan/Papers/255145/Ethical_Re-Evaluation_of_Contemporary_Treatments_for_Anorexia_Nervosa_Is_An_Aspirational_Stance_Possible_In_Practice
Keywood K., B v Croydon Health Authority 1994, CA: Force-Feeding the Hunger-Striker under the Mental Health Act 1983., University of Liverpool, http://webjcli.ncl.ac.uk/articles3/keywood3.html
Jimerson, Shane R. et al., ‘Eating Disorders: Treatment’, 11 January 2002, http://education.ucsb.edu/jimerson/eatingdisorders.html
McLean T., Half of anorexic kids need force feeding, The Age, 28 May 2008, http://news.theage.com.au/national/half-of-anorexic-kids-need-force-feeding-20080528-2itg.html, accessed 07/22/2011
NHS Choices, ‘Treating anorexia’, 7 May 2010, http://www.nhs.uk/Conditions/Anorexia-nervosa/Pages/Treatment.aspx
Patients.co.uk, ‘Consent To Treatment (Mental Capacity and Mental Helth Legislation)’, 18 April 2009, http://www.patient.co.uk/doctor/Consent-To-Treatment-%28Mental-Capacity-and-Mental-Health-Legislation%29.htm#ref2
Susic, Paul, ‘Anorexia Treatment and the Unwilling Patient’, St. Louis Psychologists and Counseling Information and Referral, http://www.psychtreatment.com/anorexia_treatment.htm, accessed 07/21/2011
Williams, Christopher J. et al., ‘We should strive to keep patients alive’, British Medical Journal, Vol. 317(7152), 18 July 1998, pp.195-197, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113542/
World Medical Association, ‘WMA Declaration of Malta on Hunger Strikers’, October 2006, http://www.wma.net/en/30publications/10policies/h31/