Legally Forced Treatment of Patients with Eating Disorders: Pros and Cons

The law has a long and varied history with respect to mental health treatment, especially involuntary hospitalization of the mentally ill. The pendulum has swung from patient rights to public safety many times, balancing the personal liberty of the mentally ill against the danger these people may pose to the public.

The latest significant swing of these rights was the eviction  of tens of thousands of patients from state hospitals after most of these institutions closed in the 1980's. There were clear pros such as greater personal liberty and cons, many of these people ending up in the prison system.

The continued effect on patient safety and well-being is that it has become harder to hold patients in a hospital if they are deemed a danger to themselves or others and very difficult for the most ill patients to go to longer term state hospitals, a treatment option that can provide considerable safety, stability and long-term benefit.

Recent decades opened new debates about the role of the court in the treatment of patients with life threatening eating disorders. These laws were created for patients with illnesses that threaten both their well-being and those around them, typically psychiatric episodes that include losing touch with reality. However, people with eating disorders don't lose touch with reality and don't cause any harm to the public. The overarching question is how far should the state safety net reach in eating disorder treatment?

Some states allow involuntary treatment of these patients due to the severe medical consequences, including death, of their illness while other states don't. A requirement for the court to grant a legal order to hold someone against their will is that the patient be at risk for severe immediate harm and not understand the condition and ramifications of their illness, legally termed competence. 

It's easier to make this legal case for patients with schizophrenia or a severe bipolar episode since the symptoms of the illness show a clear break with reality. No one will question the competence of a patent who believes the FBI planted a chip in their head. It's also likely that medications will at least mitigate the psychiatric symptoms quickly and effectively enough to avoid immediate danger. Indeed these laws were intended to address this type of psychiatric emergency.

But many of the sickest eating disorder patients understand the severity of their illness, even at the most dire moments, and still cannot eat. Unlike a patient with schizophrenia, someone with an eating disorder is typically much more aware that the state is mandating treatment against their will and demonstrate competence by comprehending and being able to repeat back their predicament. In addition, a few weeks of nutrition is unlikely to alter the course of a severe eating disorder, so the potential benefit of the legal decision is much more cloudy. The process used for other psychiatric situations doesn't apply as directly or effectively for patients with eating disorders.

The purpose of a court-ordered involuntary treatment is twofold: protecting the patient from immediate harm from the illness and protecting the public from the patient. In the case of eating disorders, the first has questionable effect and the latter is not relevant, but there is a third, more subtle component to the decision. The concept of dying from not eating is anathema to most of the public, and this loophole allows a legal, immediate resolution. 

The act of publicly forcing a patient to eat is a paternalistic approach to a perturbing, stubborn, growing public health problem in modern society. There's no evidence that forced treatment will do more than improve nutrition and health for a few weeks, but the act of involving the court allows hospital staff and administration to believe everything has been done to help this patient. In fact, any forced eating typically triggers more anger and self-punishment for the patient which leads that person back to worsening eating disorder symptoms. 

Eating disorders are serious medical illnesses as much as psychological ones. Although the psychological symptoms must be addressed for full recovery, all the physical symptoms are a result of poor nutrition and starvation, which affect all of the body's organ systems, including the brain. First and foremost, recovery involves restoring adequate nutrition. Without that step, the patient can make progress but can't step into full recovery. 

That being said, eating disorders are also lethal illnesses. Other psychiatric illnesses cause so much suffering that they can lead to suicide. That happens to patients with eating disorders as well, but eating disorders themselves also kill people. Any clinician treating these patients must accept this fact. Short-term forced treatment is a mere blip in the course of a longstanding eating disorder, and often a harmful one at that. Using the legal system to force feed a patient can engender a deep loss of trust in clinicians, including ones not involved in the decision, and in fact derail long-term recovery.

There are instances when court-ordered treatment has a place for patients with eating disorders, but I think these circumstances apply only when the patient cannot comprehend the severity of her condition, the more rare instances when they are not competent. That will limit the utility of the legal avenue to the type of patients the law intends to help and will diminish the negative effect of enforced treatment on a patient's recovery.