Involuntary treatment of eating disorders: legal, scientific and ethical dimensions

Abstract

Background The aim of this work is to evaluate whether patients affected by severe eating disorders (ED) should be submitted to coercive treatment or not. Methods Relevant international studies, identified by means of a medline-search, were examined, reviewed and integrated with our experience in Palazzo Francisci. APA guidelines and international legislation were consulted too. Results Among the DSM-IV-disorders, ED show the highest mortality rate after drug addictions. The mortality rate is even higher for anorexia nervosa because the frequent refusal of treatment delays diagnosis and treatment and influences prognosis. The American guidelines for ED treatment (2000) tackle the problem in two or three passages "Legal interventions, including involuntary hospitalization and legal guardianship, may be necessary to ensure the safety of treatment of reluctant patients whose general medical conditions are life-threatening"; "On these rare occasions staff have to take over the responsibilities for providing life-preserving care. Naso-gastric feedings are preferable to intravenous feedings...total parenteral feeding is required only very rarely and in life-threatening situations"; "In situations where involuntary forced feeding is considered, careful thought should be given to clinical circumstances, family opinion, and relevant legal and ethical dimensions of the patient's treatment". In Italian legislation, compulsory medical treatment is specified for mental illnesses but there are no specific indications. Phenomena such as anorexia nervosa do not have their own position in the legislation. Conclusion The bibliographic review showed that there are no agreed guidelines on the use of compulsory medical treatment. In our experience too, CBT-type interventions in patients without severe psychiatric co-morbidities appear to drastically reduce or even eliminate any recourse to such an extreme measure seen as aggressive, intrusive and linked to a lack of value of the patients.