Letting Anorexics Die, or Not

The New York Times has offered us a long, detailed and fair article about an important question for psychiatry. It’s author, Katie Engelhart has done an excellent job of framing the issues, in all of their maddening complexity.

Should physicians allow anorexic patients to die? Should they stop all treatments and merely provide hospice care, to make them comfortable while they starve themselves to death? 

At a time when Canada, O Canada seems to have discovered that assisted suicide is a good way to save health care dollars, the question of  assisted suicide-- or its variant, depriving patients of care-- looms over the profession.

The obvious answer is: never. We should never give up on an individual. And we should not traffic in specious analogies between anorexia and terminal cancer. The terminal cancer patient is surely going to die, sooner or later. The anorectic patient can be treated, even cured, by-- food. 

Engelhart reports on those physicians who want to let anorexics die and on those who are horrified by the notion that we should give up on them. Rightly so.

If we imagine that these patients are suffering from an underlying depression-- which ought to be distinguished from bipolar disorder-- then surely a physician’s pessimism will contribute-- either a lot or a little-- to their wish to stop the suffering and to end it all. 

Patients read physicians’ attitudes, to discern how ill they really are. If a physician communicates that there is no chance for remission or cure, the anorexic patient will draw the logical conclusion.

One should understand that some treatments work. The situation is not hopeless. And yet, many treatments are less than effective. Many patients insist that they have had enough therapy and that they just want to die. Would they feel the same way if they had had better treatments?

On the other side, doling out too much hope is not helpful either.

Yager could see that some of his patients benefited from his cheerleading. Others, though, were propelled into unwanted treatment by somebody else’s hope for them — and then left to feel defeated when it didn’t work. So couldn’t it also be argued that a doctor had a moral obligation not to provide hope that was unjustified, and maybe even to expose false hope where it lay? “We thus find ourselves in a paradox,” wrote Justine Dembo, a psychiatrist and assistant professor at the University of Toronto, “in which hope is vital for recovery but may also lengthen lives of unbearable mental anguish. What is an ethical therapist to do?”

The Times presents the case of Naomi. As one reads of her case one suspects that she will, by the end of the story, have succeeded in killing herself. But, such is not the case. She renounces most forms of therapy-- even forms that have worked for others-- and starts recovering by finding purposeful activity-- caring for her parents.

And yet, she rejects all the therapies she has tried:

After their initial meeting, Naomi was told that she could set the rules. Point 1: no more residential programs, ever. “It only accelerates the suffering,” she said. “And I refuse to encounter it ever again.” Point 2: no involuntary heroic measures from her doctors, no mandatory weigh-ins, no behavioral therapy. Naomi was willing to play around with new psychiatric medications — because, she said, a better drug might make her remaining days more tolerable — but she no longer wanted to analyze the root causes of anything. She was tired of telling her life story, tired of trying to interpret things.

As the physicians point out, starving yourself makes it all the more difficult to think clearly. At that point, how can a physician rely on the patient’s wish to get better or even her wish to die?

Some physicians had doubts about the premise — core to Yager’s thinking — that patients who were very sick could still have the mental capacity to make decisions as grave as the one to stop recovery-oriented care. A typical anorexic patient had cognitive distortions and pathological values. She was intransigent, fearful, cognitively inflexible. She could be emotionally anesthetized too, so apathetic that she didn’t care very much what happened to her. Her brain was literally starving. How could such a patient be taken at her word when she said she was prepared to die — that it was what she “wanted”? Any experienced physician should know that what the anorexic patient “wanted” was perverted by her disease. He should see through the ruse — even if, like many people with anorexia, his patient spoke well and dressed well, was not in the depths of psychosis and could clearly articulate the potential medical benefits and drawbacks of various treatments. This was not mental lucidity, but instead a pantomime of reasoned thought.

Such observations have led to involuntary commitment and forced feeding. And, in some cases these are effectivel.

And yet, anorexia seems to be a battle of wills. The willpower of a girl who refuses to eat or who tries to starve herself is arrayed against the willpower of parents and physicians, people who are more than happy to force her to do something she insists she does not want to do.

I will not ignore the implications of forcing a girl to put things in her body against her will. But I will not be more explicit about them either.

Allow me a couple of reflections on the cultural side of chronic anorexia. Surely, these young women are strong and empowered. They are defiant and highly resistant to authority. Does that sound familiar?

And then, there also seems to be a spiritual dimension. Self-starvation seems to produce mental states that feel like spiritual transcendence. In the Middle Ages, anorexia was practiced by women who wanted to be more saintly. See Rudolph Bell’s book, Holy Anorexia.

And then there is the sexual angle. Anorexics often make themselves so unattractive that sex seems no longer an issue. Since we live in a culture where, as Heather Mac Donald wrote, the default for young women is Yes, not No, a girl who does not want to explore her sexuality during adolescence might very well try to suppress it, by starving herself. Or else, she may see forced feeding as akin to sexual assault, and reject it in the name of virtue.

And then there is the obvious-- consuming food is a social ritual. Therapy notwithstanding, the issue is not about appetite or even your desires. Could it be that family dinners are a good basis for developing normal eating habits?

Often anorexics begin their journey by dieting. They claim that they diet because they want to be slim. They are often supported by other women who feel that looking more skeletal is more attractive. Or else, they are dieting in order to punish their bodies for being female.

But then, dieting becomes anorexia when it becomes a bad habit. This suggests that we ought not to consider it to be a meaningful experience, one whose deeper meaning is hidden from consciousness. Discovering the deeper meaning of the condition does not change the condition.

But then, how do we deal with a bad habit? Force feeding might be necessary, even involuntary force feeding. And yet, one errs when one considers that we ought to try to break bad habits. Those who try to break bad habits often end up breaking the patient.

So, we turn to Aristotle-- who was not a physician. He said that rather than try to control or suppress bad habits, we should replace them with good habits. On an obvious level, we can simply follow the advice offered in 12 Step programs. Rather than go from work to the local bar, participants are encouraged to attend AA meetings.