Pathologizing Values: When Should Patients Be Treated Against Their Will?

Many sufferers of anorexia nervosa — and similar eating disorders — intensely value thinness. They believe that thinness is of the utmost importance, more so than school, work, personal relationships, and their own physical health. Valuing thinness so strongly is harmful not only because of the malnutrition that follows but also because of how it undermines treatment. Treatment for anorexia leads (one way or another) to weight gain. Just as valuing thinness causes people with anorexia to lose weight, it can also cause them to refuse treatment that leads to weight gain.

How should clinicians respond when their patients refuse treatment? One possibility is to treat them against their will. In the case of anorexia, this involves detainment in in-patient facilities, which enforce strict protocols around feeding. In severe cases, it can also involve force-feeding through a tube. But is this ethical? On the one hand, such treatments can help sufferers to improve and prolong their lives. On the other hand, clinicians have a duty to respect their patients’ decision-making autonomy. This means respecting their decisions about what (if any) treatment they will receive — even decisions that seem irrational or harmful.

An illustrative example of the principle of decisional autonomy involves religion. Jehovah’s Witnesses often refuse blood transfusions due to their religious beliefs. That can result in death and could seem unreasonable from the perspective of those outside their faith. Nevertheless, such decisions are generally respected.

To exercise their decision-making autonomy, patients must be able to understand and appreciate the relevant medical facts. Many conditions, like psychosis or dementia, undermine this capacity. In such cases, patients are judged to lack decision-making competence, and coercive treatment is generally seen as warranted. Anorexia is a particularly perplexing case because those who suffer from the disorder often maintain their ability to understand and comprehend their treatment options. They are simply opposed to treatments that undermine their desire to be thin.

The philosopher and clinician Dr. Jacinta Tan advocates for one approach to justifying coercive treatment in the context of anorexia. She argues that the thinness values associated with anorexia are pathological — they belong to the disorder, not the individual. Because they are pathological, they can (and should) be distinguished from the agent’s authentic values, i.e. those that are genuinely her own. So, while someone with anorexia may be able to weigh their options and understand the relevant medical facts, they cannot freely decide on treatment because these (inauthentic) values get in the way.

The history of psychiatry suggests that we should tread carefully when it comes to pathologizing values. In the 1800s, drapetomonia was a supposed mental illness afflicting enslaved Africans. The central symptom was a strong desire to escape from captivity, leading to escape attempts. In trying to escape, these slaves were pursuing something they valued: freedom. But this value (according to certain psychiatrists from the Southern states) was pathological. The case of drapetomania illustrates an important principle: labeling values as pathological has serious consequences. We ought to, therefore, have a strong justification for the label.

Tan and her colleagues suggest basing such judgments on the co-occurrence between mental disorders and values. In the case of anorexia, intense thinness values occur (almost exclusively) in those diagnosed with the disorder, aren’t held before the disorder or after recovery, and their strength correlates with the strength of the disorder. According to Tan and colleagues, this strong co-occurrence between values and disorder justifies attributing thinness values to the disorder, not the person.

The cause of drapetomania illustrates the risk of this approach to pathologizing values. Escaping slaves who risked their lives to escape captivity did so because of their values — they valued freedom over a continued life in captivity, even one that brought (comparable) safety. However, having such a value system (and engaging in the escape behavior that follows from it) is precisely what attracted the ‘drapetomania’ label. Those values occur with drapetomania because having them is partly what it means to have drapetomania.

The same problem applies to anorexia. Intensely valuing thinness (and the resulting weight loss behavior) is deeply intertwined with diagnosis. Anyone who valued thinness with the intensity that anorexia sufferers do would engage in the same weight loss behaviors, therefore meeting the criteria for diagnosis. Co-occurrence tells us something about diagnostic categories but nothing about the authenticity of someone’s values. To dismiss thinness values as inauthentic, we cannot rely on co-occurrence alone.

One way to make progress on this issue is by better understanding the psychological factors that drive thinness values and how such factors relate to decision-making competence. Alternatively, ethicists might turn their attention to a different factor associated with anorexia.

Many sufferers of anorexia hold false beliefs about their body size. Experiments requiring patients to indicate their current size show that they consistently indicate body sizes much larger than their own. Indeed, sufferers of anorexia are often convinced that their bodies are larger than clinicians, family members, and friends insist.

Research suggests that these false beliefs are caused by misleading experiences of body size. Sufferers of anorexia genuinely perceive their bodies as larger than reality due to disturbances in the way their brain represents their body size. Their false beliefs are a natural response to these misleading experiences.

These false beliefs can, in some cases, undermine patients’ decisional competence. Consider an excerpt from an interview with a patient, recorded by Tan and colleagues:

Has the risk of death been mentioned? “Yeah.”

Do you believe these things you’ve been told? “No.”

About the risk of death, do you think it could happen? “Not to me.”

That’s the opinion of doctors, and I wonder why you don’t think it can happen to you. “Because you have to be really thin to die, and I’m fat, so it won’t happen to me.”

In this excerpt, the interviewee cannot understand that the relevant risks apply to them because of their beliefs about their own body size. This relates to an integral feature of decision-making competence. It isn’t enough that patients understand the relevant medical facts; they must also be able to appreciate how those facts apply to them. Some sufferers of anorexia are unable to do so because they don’t believe they are thin.

This illustrates how false beliefs about body size can undermine patients’ ability to reason about treatment, through a different route than what was proposed for thinness values. Tan and colleagues suggested that because thinness values are inauthentic, any treatment decisions that follow from them are similarly inauthentic. Body size beliefs, however, undermine decision-making competence not because they are inauthentic but because they distort sufferers’ reality. In doing so, they rob patients of the capacity to appreciate how medical risks apply to their situation.

It remains to be seen whether the thinness values associated with anorexia undermine sufferers’ decision-making competence and, if so, why. To solve that puzzle, we must understand more about the psychological factors that drive those values. But an equally important feature of anorexia related to decision-making competence is the body size beliefs involved. Such beliefs do not necessarily forfeit a patient’s right to choose their treatment. A clinician would need to probe the extent to which the beliefs are resistant to change and whether they are driving their patient’s treatment refusal. There is still much work needed to understand the relationship between body size beliefs and decision-making competence, but it represents a fruitful topic for future research.