This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter “AN: the diagnosis”) several ethical issues are revealed. Firstly, “AN: the diagnosis” influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, “AN: the diagnosis” impacts on how treatment and treatment efficacy (...) are defined and the ethical justifiability of paternalism. Thirdly, “AN: the diagnosis” can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. “AN: the diagnosis” can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty. (shrink)

This article will explore whether the law should allow people with anorexia nervosa to refuse nutrition and hydration with special reference to the English decision in Re E (Medical Treatment: Anorexia). It argues that the judge in that case made the correct decision in holding that the patient, who suffered from severe anorexia nervosa, lacked capacity to make valid advance directives under the Mental Capacity Act 2005 of the United Kingdom, and that medical procedures that (...) are apparently against her wishes should be carried out for the sake of preserving her life. The law should generally not permit patients with anorexia nervosa to decline nutrition and hydration, precisely because their autonomous ability to make such decisions has been substantially circumscribed by this psychiatric condition. (shrink)

Anorexia nervosa remains an enigma among Western cultures. Various causal explanations have been offered, encompassing biological, psychological, and sociocultural models. These explanations, however, focus on the immediate or proximal mechanisms of causation. A more thorough understanding of anorexia nervosa can be achieved by understanding the relationship between these factors and ultimate causation, the level of explanation which deals with individual reproductive fitness. This paper reviews the biological, psychological, sociocultural, and evolutionary models and indicates a necessary synthesis (...) between proximate and ultimate levels of causation in examining the anorexia nervosa puzzle. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we (...) argue that conceptualizing anorexia nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

This is a preprint draft. Please cite published version (DOI: 10.1111/mila.12385). The aim of this paper is to provide a novel analysis of anorexia nervosa (AN) in the context of the sense of agency literature. I first show that two accounts of anorexia nervosa that we ought to take seriously— i.e., the first personal reports of those who have experienced it firsthand as well as the research that seeks to explain anorexic behavior from an empirical perspective— (...) appear to be thoroughly in tension with one another in their descriptions of anorexic actions. Rather than proceeding at this point by way of disregarding anorexic testimony as meaningless or insincere, I instead offer a positive account of the sense of agency in anorexia nervosa that renders these two depictions compatible. The resultant picture of anorexic behavior is one that accommodates current empirical findings while also providing valuable insight into how it is that anorexics can sincerely report feeling fully in control over their food restriction. (shrink)

Body dissatisfaction has long been considered an integral component of and driving force behind anorexia nervosa. In this paper, I characterise body dissatisfaction in terms of problematic beliefs about body size and the value of thinness. I suggest two methods for understanding these beliefs. Regarding body size beliefs, I suggest focusing on certain forms of misleading phenomenal evidence that sufferers of anorexia nervosa are exposed to. Regarding beliefs about the value of thinness, I suggest focusing on (...) the benefits of such beliefs. (shrink)

The principles that usually direct ethical decision making are not easily or straightforwardly applicable to the care and treatment of anorexia nervosa, particularly the care and treatment of severe and enduring anorexia nervosa, where the sufferer seems to be recalcitrant to treatment and where the condition has become life-threatening.There are exceptional circumstances that characterize this puzzling and still scarcely understood condition; I suggest that these exceptional circumstances provide moral reasons for partial derogation from the usual principles (...) of ethical decision making.In what follows I argue... (shrink)

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then the (...) decision to refuse therapy may be on a par with other decisions to refuse life‐prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result. (shrink)

This is a book that attempts to propose itself as a new trigger in the wide world of anorexia nervosa. The originality of its proposal consists in approaching anorexia nervosa, not only by endocrinological and psychological perspectives, but also by anthropological, philosophical and ethical point of view. In this way it's not only an update of specific literature, but also an integration with a new method to study this condition. The purpose of the book is to (...) approach anorexia nervosa from different points of view, to reach a new interpretation which involves notions from biological and human sciences interpreted in a unique model and which could allow a new method of treatment. (shrink)

In this insightful and well-argued article, Osler aims to provide a more fine-grained, phenomenological account of anorectic bodily experience. She notes that although anorexia nervosa often is understood in terms of a distorted body image, this approach does not exhaustively or accurately reflect many subjects' bodily experiences, and also unduly privileges a third-person perspective over first-person accounts. In addition, focusing primarily on body image gives rise to the impression that AN is a form of radical dieting gone wrong (...) as a result of misperceiving or misjudging one's body size or shape. Osler emphasizes that AN is not a static disorder, but rather involves numerous stages. To account for the... (shrink)

Imposing artificial feeding on people with anorexia nervosa may be unethical. This seems to be Heather Draper's suggestion in her article, ‘Anorexia Nervosa and Respecting a Refusal of Life‐Prolonging Therapy: A Limited Justification.’ Although this is an important point, I shall show that the arguments supporting this point are flawed. Draper should have made a brave claim: she should have claimed that people with anorexia nervosa, who competently decide not to be artificially fed, should (...) be respected because everybody is entitled to exercise their autonomy, not only ‘in the middle’ of their life, but also at the end of it, or when their own life is at stake, because autonomy also extends to the most difficult moments of our life, and, ultimately, ‘stretches [.*T*.*T*.] far out into the distance’ at the end of it. I explain why Draper should have made the brave claim, and why she has not made it. I conclude that a defence of people's entitlement to competently refuse artificial feeding cannot rest upon the arguments developed by Draper. Whether or not we should respect competent refusal of artificial feeding depends on the normative strength that we are ready to ascribe to the principle of autonomy, to the moral relevance that we ascribe to the circumstances in which a person's autonomy is exercised, and, perhaps, eventually, on our sense of compassion. (shrink)

Anorexia nervosa involves seemingly irrational beliefs about body size and the value of thinness. Historically, researchers and clinicians have avoided referring to such beliefs as delusions, instead opting for the label ‘overvalued ideas’. I discuss the relationship between the beliefs associated with anorexia nervosa and the distinction between delusions and overvalued ideas, as it is conceived in both European and American psychiatric traditions. In doing so, I question the benefit of applying the concepts of delusion and (...) overvalued idea to anorexia nervosa and raise some issues with contemporary use of the Brown Assessment of Beliefs scale for assessing the level of delusionality associated with the disorder. (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came (...) to the concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

Anorexia nervosa is a psychiatric disorder that seems to be closely related to the identity of the person suffering from it. This is referred to in the vast literature on anorexia nervosa by specifying the quality of symptoms as ‘egosyntonic’ (e.g., Vitousek, Watson, and Wilson 1998). The pursuit of excessive thinness is part of a search for identity in which the control of the body—its size and needs—becomes central (Gillett 2009). This need for control seems to (...) be triggered by a state of bodily alienation in which the body is perceived to be foreign and horrifying to its bearer. However, the relentless dieting and excessive exercise pursued by the anorexic person eventually lead to a state of starvation in which .. (shrink)

There is preliminary evidence, from case reports and investigational studies, to suggest that Deep Brain Stimulation could be used to treat some patients with Anorexia Nervosa. Although this research is at an early stage, the invasive nature of the intervention and the vulnerability of the potential patients are such that anticipatory ethical analysis is warranted. In this paper, we first show how different treatment mechanisms raise different philosophical and ethical questions. We distinguish three potential mechanisms alluded to in (...) the neuroscientific literature, relating to desire, control, and emotion, respectively. We explain why the precise nature of the mechanism has important implications for the patient’s autonomy and personal identity. In the second part of the paper, we consider practical dimensions of offering DBS to patients with AN in certain cases. We first discuss some limited circumstances where the mere offering of the intervention might be perceived as exerting a degree of coercive pressure that could serve to undermine the validity of the patient’s consent. Finally, we consider the implications of potential effects of DBS for the authenticity of the patient’s choice to continue using stimulation to ameliorate their condition. (shrink)

In this paper anorexia nervosa is examined through three lenses to determine its possible causes. This paper contains a clinical analysis of the anorexic personality, a psychoanalytic/religious interpretation of the demands of society, and· a feminist reinterpretationof the effects of those demands on the female body. The societal demands to renounce instincts, when examined through a feminist lens, reveals that these demands, in concert with the detrimental effects of feminine socialization and characteristics of the anorexic personality, may lead (...) some women to view their needs as not important, and cause a detachment from and turning against the body in the form of anorexia nervosa. It is concluded that anorexia is not just women taking a diet “too far.” There are other psychological, philosophical, and social factors leading to a prevalence of anorexia nervosa in Western culture. (shrink)

In a searching analysis, Radden elucidates key problems in justifying coercive treatment in anorexia nervosa despite a common intuition that it should have a place. Indeed, AN, perhaps more than any other condition, challenges the validity of a test purporting to provide a justification. Our generally accepted model for involuntary treatment is based on impaired decision-making capacity and "best interests." A treatment refusal by a person with "capacity" is to be respected, regardless of the consequences. (I exclude here (...) the criteria under conventional mental health law—a diagnosis of a "mental disorder" coupled with a risk of harm to self or to others—because they discriminate against people with a... (shrink)

We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, (...) and the compelling parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts... (shrink)

HARDIN PK. Nursing Inquiry 2003; 10: 209–217 Shape-shifting discourses of anorexia nervosa: reconstituting psychopathologyThis article explores how the circuitous relationship between individuals, the media, and discursive systems replicate and reinforce the act of self-starvation in young women. Using a feminist poststructuralist methodology, the focus of this article is on how discourses and institutional practices operate to position young women who take up the subject position of wanting to be diagnosed as anorexic. Utilizing data from online accounts and individual (...) interviews, I attend to the ways in which young women are institutionally positioned as ‘anorexics’ and the effects that those positions have on their behaviors, in addition to reinforcing institutional practices that construct anorexia nervosa. Questions addressed through this inquiry are: How do institutional practices create and continue to constitute ‘anorexia nervosa’? How do discourses operate to position young women such that they are either included and/or excluded into the category of ‘anorexia nervosa’? What are the effects and consequences that emanate from these positionings? (shrink)

In my article "Controlling the noise," I present a phenomenological investigation of bodily experience in anorexia nervosa. Turning to descriptions of those who have suffered from AN, which repeatedly detail the experience of finding their bodies threatening, out of control and noisy, I suggest that the phenomenological conceptions of body-as-object, body-as-subject and visceral body can help us unpack the complex bodily experience of AN throughout its various stages. My claim is that self-starvation is enacted by a bodily-subject who (...) wishes to quell or reassert authority over a visceral body whose demands and needs she finds threatening to her autonomy.The relationship between body-as-object and... (shrink)

Self-illness ambiguity is a difficulty to distinguish the ‘self’ or ‘who one is’ from one's mental disorder or diagnosis. Although self-illness ambiguity in a psychiatric context is often deemed to be a negative phenomenon, it may occasionally have a positive role too. This paper investigates whether and in what sense self-illness ambiguity could have a positive role in the process of recovery and self-development in some psychiatric contexts by focusing on a specific case of mental disorder – anorexia (...) class='Hi'>nervosa. (shrink)

Existing phenomenological accounts of anorexia nervosa suggest that various forms of bodily alienation and distorted bodily self-consciousness are common among subjects with this condition. Subjects often experience a sense of distance or estrangement from their body and its needs and demands. What is more, first-person reports and existing qualitative research reveal struggles with authenticity and a search for identity. Is there a connection between the two? I argue that to gain a fuller understanding of anorexia nervosa, (...) how it is experienced by subjects, and why many of them express concerns about authenticity, we need to look more closely at their experiences of bodily alienation and the ways in which they encounter a diminished sense of bodily ownership. After presenting a general overview of the various sorts of bodily alienation that appear to be characteristic of anorexia nervosa, I outline three conceptions of authenticity and introduce some empirical evidence indicating that many subjects with this condition have concerns about identity and authenticity. Then, I examine how different sorts of bodily alienation have the potential to compromise authenticity at various stages of the disorder. Throughout, I draw from several first-person accounts of anorexia nervosa to illustrate and support my claims. (shrink)

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa. A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations (...) of capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile. (shrink)

Anorexia Nervosa (AN) is a complex disorder characterised by self-starvation, an act of self-destruction. It is often described as a disorder marked by paradoxes and, despite extensive research attention, is still not well understood. Much AN research focuses upon the distorted body image that individuals with AN supposedly experience. However, based upon reports from individuals describing their own experience of AN, I argue that their bodily experience is much more complex than this focus might lead us to believe. (...) Such research often presents an overly cognitive understanding of bodily experience in AN, underplaying the affective, felt experience of individuals with AN, as well as descriptions of empowerment, strength and control reported in the early stages of AN. This paper seeks to enrich our understanding of bodily experience in AN as it progresses throughout the various stages of the disorder. I show how the classical phenomenological distinction between the body-as-subject and the body-as-object, as well as Leder’s conception of the visceral body, can inform our understanding of bodily experience in AN. I suggest that the project of self-starvation is an attempt to overcome the noisy demands of the visceral body, which are experienced as threatening the body-as-subject, through a process of objectifying the body-as-object. By cashing out AN as a project of radical bodily control that, tragically, comes to control the individual, we can capture important aspects of the bodily experience of AN and the temporal progression of the disorder. -/- . (shrink)

Traditionally, philosophers of mind have been guided by a brainbound approach: the mind, whatever it turns out to be, will be related to or identical with the brain. The body, under this approach, plays a merely instrumental role — it is what keeps the brain alive and healthy. Over the past few decades there has been increasing resistance to the brainbound approach, and a strongly supported push for taking a non-brainbound approach: the body is not merely instrumental, but in many (...) ways constitutive of the mind — the mind, whatever it turns out to be, is bodily in many fundamental respects. Thus, in explaining the mind, we must consider not only brain states, but also wider bodily processes. What those wider bodily processes are, and how they constitute certain mental states, are the key questions that we now face as non-brainbound philosophers of mind. -/- One avenue of investigation that many have taken in view to answering these two questions has been to look at bodily awareness and its relation to our sense of self. How does our body, and our awareness of our body more specifically, constitute our sense of self and our subjective experience of the world. A clear way of investigating this last question is to turn to pathological cases of body awareness, e.g. body dysmorphic disorder and anorexia nervosa. Anorexia nervosa is an interesting case. The DSM-5 distinguishes anorexia nervosa from body dysmorphic disorder — the former is classified as an eating disorder, while the latter is classified as a mental disorder. As I will explore in this chapter, this very manner of distinguishing among such pathologies admits of a traditional brainbound approach to separating the mind/brain from the body. Here I shall consider how a non-brainbound approach might give us different, and perhaps even better insight into cases such as anorexia nervosa, and I shall, conversely, consider how such body awareness disorders might serve to further strengthen the view that the right approach to understanding the mind is the non-brainbound approach. (shrink)

Body checking, characterized by the repeated visual or physical inspection of particular parts of one’s own body (e.g. thighs, waist, or upper arms) is one of the most prominent behaviors associated with eating disorders, particularly Anorexia Nervosa (AN). In this paper, we explore the explanatory potential of the Recalcitrant Fear Model of AN (RFM) in relation to body checking. We argue that RFM, when combined with certain plausible auxiliary hypotheses about the cognitive and epistemic roles of emotions, is (...) able to explain key characteristics of body checking, including how body checking behavior becomes habitual and compulsive. (shrink)

Müller and colleagues (2015) address a range of ethical considerations associated with neurosurgical interventions for the treatment of anorexia nervosa (AN), arguing for several protective measures to safeguard clinical research and practice. This is an important article, which provides a thorough review of current neurosurgical research and presents key insights into challenges associated with compromised decision-making capacities in the context of AN and the early average age of onset. However, it is somewhat striking that they neither use nor (...) examine the concept of authenticity. We describe the way this concept features in discussions of AN, and suggest that a deeper understanding of authenticity reveals further ethical problems that Müller and colleagues do not consider. (shrink)

New neural models for anorexia nervosa are emerging as a result of increased research on the neurobiology of AN, and these offer a rationale for the development of new treatment technologies such as neuromodulation. The emergence of such treatment technologies raises new ethical questions; however these have been little discussed for AN. In this article, I take an empirical approach and explore how young women who suffer from AN perceive treatment technologies in light of the concept of authenticity. (...) Interview data showed that participants in this study did not seem to unconditionally adhere to treatment modalities that only imply laborious self-work, such as therapy. The data also showed that they were willing to accept new treatment possibilities such as pharmacological or brain-directed treatment strategies, which they view as having potential instrumental value in coping with certain symptoms of the illness. However, such modalities can pose threats to patients’ authenticity, especially with regard to self-discovery. I argue that, in a context where there is an increased interest in brain-directed treatment strategies for AN, studies should continue to explore the ethical and psychological impact of such treatment technologies on individuals. (shrink)

The DSM‐5 highlights two essential psychological features of anorexia nervosa (AN): recalcitrant fear of gaining weight and body image disturbance. Prominent accounts grant false beliefs about body weight and shape a central role in the explanation of AN behavior. In this article, we propose a stronger emphasis on recalcitrant fear. We show that such fear can explain AN behavior without the intermediary of a false belief, and thus without the associated explanatory burdens and conceptual difficulties. We illustrate how (...) shifting the emphasis from false belief to recalcitrant fear can supplement a number of different non‐doxastic models of AN. (shrink)

In this paper, I discuss what I call the oversized experiences that anorexic patients suffer from. It has been known for some time that anorexic patients mentally picture their bodies as larger than reality. While this constitutes one kind of oversized experience, I claim there is another, less explored kind. This is an experience of the body as oversized in relation to the affordances of its environment. I discuss recent evidence suggesting anorexic patients exhibit distorted affordance perception. I then discuss (...) how this distorted affordance perception also constitutes an oversized experience of the body. Along with sociocultural influences, I claim oversized experiences ground negative propositional attitudes regarding body size. (shrink)

Anorexia nervosa is an eating disorder characterized by intense fear of gaining weight and a distorted body image which usually leads to low caloric intake and hyperactivity. The underlying mechanism and pathogenesis of anorexia nervosa is still poorly understood. In order to learn more about the underlying pathophysiology of anorexia nervosa and to find further possible treatment options, several animal models mimicking anorexia nervosa have been developed. The aim of this review is (...) to systematically search different databases and provide an overview of existing animal models and to discuss the current knowledge gained from animal models of anorexia nervosa. For the systematic data search, the Pubmed—Medline database, Embase database, and Web of Science database were searched. After removal of duplicates and the systematic process of selection, 108 original research papers were included in this systematic review. One hundred and six studies were performed with rodents and 2 on monkeys. Eighteen different animal models for anorexia nervosa were used in these studies. Parameters assessed in many studies were body weight, food intake, physical activity, cessation of the estrous cycle in female animals, behavioral changes, metabolic and hormonal alterations. The most commonly used animal model is the activity-based anorexia model in which typically young rodents are exposed to time-reduced access to food with unrestricted access to a running wheel. Of the genetic animal models, one that is of particular interest is the anx/anx mice model. Animal models have so far contributed many findings to the understanding of mechanisms of hunger and satiety, physical activity and cognition in an underweight state and other mechanisms relevant for anorexia nervosa in humans. (shrink)

Reduced Environmental Stimulation Therapy (REST) alters the balance of sensory input to the nervous system by systematically attenuating sensory signals from visual, auditory, thermal, tactile, vestibular, and proprioceptive channels. Previous research from our group has shown that REST via floatation acutely reduces anxiety and blood pressure while simultaneously heightening interoceptive awareness in clinically anxious populations. Anorexia nervosa (AN) is an eating disorder characterized by elevated anxiety, distorted body representation, and abnormal interoception, raising the question of whether REST might (...) positively impact these symptoms. However, this approach has never been studied in eating disorders and it is unknown whether exposure to REST might worsen AN symptoms. To examine these possibilities we conducted an open-label study to investigate the safety and tolerability of REST in AN. We also explored the impact of REST on affective symptoms, body image disturbance, and interoception. Twenty-one partially weight-restored AN outpatients completed a protocol involving four sequential sessions of REST: reclining in a zero-gravity chair, floating in an open pool, and two sessions of floating in an enclosed pool. All sessions were 90 minutes, approximately one week apart. We measured orthostatic blood pressure before and immediately after each session (primary outcome), in addition to collecting blood pressure readings every 10 minutes during the session using a wireless waterproof system as a secondary outcome measure. Each participant's affective state, awareness of interoceptive sensations, and body image was assessed before and after every session (exploratory outcomes). There was no evidence of orthostatic hypotension following floating, and no adverse events (primary outcome). Secondary analyses revealed that REST induced statistically significant reductions in blood pressure, anxiety and negative affect, heightened awareness of cardiorespiratory but not gastrointestinal sensations, and reduced body image dissatisfaction. The findings from this initial trial suggest that individuals with AN can safely tolerate the physical effects of REST via floatation. Future randomized controlled trials will need to investigate whether these initial observations of improved anxiety, interoception, and body image disturbance can be effectively extended to acutely ill AN populations. (shrink)

Concerns over medical paternalism are especially salient when there exists a conflict of values between patient and clinician. This is particularly relevant for psychiatry, the field of medicine for which the phenomenon of conflicting values is most present and for which the specter of medical paternalism looms large. Few cases are as glaring as that of anorexia nervosa (AN), a disorder that is considered to be egosyntonic (meaning its symptoms are reflectively endorsed by the patient) and maintained by (...) the presence of pathological values. One might think, given this, that an approach to medicine that foregrounds the role of values in clinical encounters would be particularly well suited to address the problem of medical paternalism in treating AN. As it happens, this is precisely the goal of values-based medicine, an approach to medicine that prioritizes the integration of patients’ unique values into the aims of treatment and that has been touted as being particularly applicable to psychiatric conditions such as AN. Although this strategy may initially appear promising, in this paper I will argue that the directive to incorporate patient values (as dictated by values-based medicine) cannot do the work of mitigating medical paternalism in the treatment of egosyntonic disorders such as AN. Rather than chalking this up as a failure due to AN being a particularly challenging case, I will instead conclude that the failure of values-based medicine in this context cuts to the heart of the limitations of rectifying medical paternalism within psychiatry as it currently exists. (shrink)

Empiricist models explain delusional beliefs by identifying the abnormal experiences which ground them. Recently, this strategy has been adopted to explain the false body size beliefs of anorexia nervosa patients. As such, a number of abnormal experiences of body size which patients suffer from have been identified. These oversized experiences convey false information regarding the patients’ own bodies, indicating that they are larger than reality. However, in addition to these oversized experiences, patients are also exposed to significant evidence (...) suggesting their bodies are in fact thin. This situation poses a conundrum: why do patients appear strongly influenced by the former kinds of evidence while the latter has little effect? To solve this conundrum, I suggest a two-factor account. First, I discuss research on the biases patients exhibit in how they gather, attend to and interpret evidence related to their own body size. Such biases in evidence treatment, I suggest, cause oversized experiences to be sought out, attended to and accepted, while veridical body size experiences are ignored or explained away. These biases constitute the second factor for this empiricist model, accounting for the unwarranted conviction with which these beliefs are held. Finally, in line with recent research into self-deception, I propose that, paradoxically, these biases in evidence treatment arise from patients’ own desires. (shrink)

The practice of force-feeding dangerously malnourished patients with anorexia nervosa (AN) raises a puzzle for clinical ethics. Force-feeding AN patients may seem justified to save their lives and to help them recover from a debilitating pathological condition. Yet clinical ethics seems committed to a robust anti-paternalism principle, on which it is normally wrong to force treatment on decisionally capacitated patients for their own good. And some AN patients do retain decisional capacity, at least by standard criteria. Thus, routinely (...) force-feeding AN patients seems to constitute an unjustifiable exception to a well-established principle of clinical decision-making. Call this the moral puzzle of AN. I examine three attempts to solve the puzzle and argue that, individually or taken together, they cannot justify force-feeding those AN patients for whom this intervention would be potentially effective at enabling recovery. I conclude that no such justification is currently available. A solution to the moral puzzle of AN may come from a reevaluation of the anti-paternalism principle, a deeper clinical understanding of the psychology of AN, or even a novel reconceptualization of decisional capacity. (shrink)

Anorexia nervosa is a very serious condition because of the suffering and loss of life that it causes. However, the wishes of the people directly involved can be strongly opposed. The person with severe AN may not want treatment, yet her family beseeches professionals to unilaterally intervene and clinical teams are divided over the defensibility of involuntary hospitalization and treatment. The metaphor of a crucible is used in this paper to help identify how much is at stake and (...) how much is in conflict when someone has AN. Frank cautions against ethical analyses that rely mostly on substantive principles or rules and institutional conflict resolution procedures. This paper applies his heuristic concepts of “ethics-as-substance” and “ethics-as-process” to a prototypical AN case to illustrate how process activities can expand understanding of, and responsiveness to, those who are living with this dire condition or those who are obligated to help. (shrink)

Anorexia Nervosa (AN) is a psychiatric illness that presents a complex variety of perceptual alterations and somatic sensations. These alterations occur at the level of (1) bodily representations and (2) bodily experiences. The alterations are widespread, and they involve multiple cognitive functions. We reviewed the current literature linking the psychiatric literature on AN with the philosophical debate on the Cognitive Penetrability of Perception (CPP). We describe the alterations in perception, starting from the most widespread and studied, i.e., those (...) concerning distortions in the estimation of the dimensions of one's body (“dysmorphophobia” or “body image disturbance”) to then describe those of more recent analysis involving alterations in bodily experiences. Body image disturbances in AN have been linked to alexithymia, emotional dysregulation, and altered interoceptive awareness, highlighting the complex interaction between emotion, cognition, and perception in AN. We show how the recent debate on CPP can benefit from the empirical investigations in AN, and can, in turn, serve to outline new lines of research. (shrink)