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Irish newspapers regularly feature reports of High Court rulings on anorexic patients. The story in nearly all cases goes like this: The patient’s doctors (psychiatrists and physicians) inform the Court that she is in imminent danger of dying and lacks capacity to make decisions about treatment. Invariably, the Court grants permission to proceed with involuntary treatment, including force-feeding. I have been involved in the care of several anorexic patients over the years, but thankfully I have never been asked to force-feed a patient. I have often thought about how I would respond to such a request.
Patients with severe anorexia are assumed to lack capacity, on the grounds that malnutrition impairs cognitive function, including the ability to make rational decisions about treatment. The sparse literature on the subject doesn’t really support this view. Dr Jacinta Tan, a psychiatrist and ethicist, has written several papers on capacity in anorexia. In a 2006 study based on interviews with 10 adolescent anorexic girls, she found that they performed well on standard tests of competence. A more recent 2016 study from the Netherlands investigated capacity in 70 adult women with “severe” anorexia, and found that mental capacity was “diminished” in a third, but was preserved in two-thirds. Many legal academics, such as Ms Beverley Clough of the University of Leeds, argue that the current binary approach to capacity in anorexia is crude and simplistic and may lead to violations of human rights.
I could find no data in the medical literature on outcome in anorexic patients who have been force-fed. There are occasional newspaper reports of cases returning to the High Court where doctors outline progress since the initial court order. I suspect — although I have no evidence — that some patients may indeed gain weight after force-feeding, but after discharge, revert to previous eating patterns and lose the weight briefly gained by force. Force-feeding doesn’t exactly foster a trusting relationship between patient and doctor either. Prof Penney Lewis, Professor of Law at King’s College London, wrote: “As her trust has been violated, she may be less likely to seek help for her anorexia or for any other medical problem. The gain has been short-term, rather than long-term. The immediate crisis has been averted, but long-term damage has been done.”
As a gastroenterologist, I have concerns about the insertion and maintenance of a nasogastric tube in a patient who doesn’t want to have it. Again, the literature has remarkably little to say on the subject. The only — very brief — discussion of the matter I could find was in the Royal College of Psychiatrists 2014 MARSIPAN Report: “Insertion of a nasogastric tube against the patient’s will usually require the presence of mental health nurses trained in safe control and restraint techniques, and psychiatric advice should be sought before embarking on this procedure.” Presumably, these tubes are kept in place with a nasal bridle, but a determined patient can dislodge both bridle and tube. I have often wondered who actually carries out the nasogastric tube insertion in these unwilling, and (presumably) sometimes actively-resisting, patients: The physician involved in the High Court application, or a junior member of the medical team? If the latter, do they have the right to refuse? Are the patients sedated? How exactly are they restrained? How is the patient then prevented from sabotaging the tube and the bridle?
Although the medical literature is conspicuously quiet on the subject, details on the mechanics of force-feeding can be gleaned from press reports on the US detention centre in Guantánamo Bay, where hunger-striking prisoners have been regularly force-fed. The procedure is complicated and much can go wrong. Navy doctors insert nasogastric tubes while the prisoners are immobilised in a specially-designed ‘restraint chair’. Although the head is immobilised with padding and a strap, even slight movements can cause pain, damage to the nose (bleeding and occasionally fracture), and it carries the risk of tube misplacement into the lungs. The prisoners are often held in these chairs for several hours while feeding is administered and then moved to a ‘dry room’, where they are given antiemetics and monitored to ensure they do not induce vomiting.
The physician or gastroenterologist generally becomes involved in the care of an anorexic patient at a moment of crisis. In an ideal world, the physician would be part of a multidisciplinary specialist eating disorders unit, but this is seldom the case in Ireland. Patients are often transferred as an emergency from a psychiatric facility to an acute general hospital when the BMI drops below 13.5, or there is metabolic or haemodynamic instability; the physician takes on the patient for the simple reason that they happen to be on-call. Earlier this year, the HSE launched the long-overdue National Clinical Programme for Eating Disorders. Hopefully, this will lead to the establishment of specialist units where physicians with training in nutrition can develop an expertise in eating disorders.
I have sympathy for psychiatrists treating gravely-ill anorexic patients. The mortality in this young population is significant and families commonly exert extreme pressure on doctors to ‘do something’. I’m just not convinced that force-feeding is the answer.
Prof Seamus O’Mahony is the author of ‘The Way We Die Now’.