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Chapter 104

Behavioral Consequences of Force-feeding Malgorzata Starzomska and Marek Smulczyk

Motto The Good Samaritan deserves sympathetic support, officious intermeddling must be discouraged (Anon. 1974).

Abbreviation DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

104.1 Introduction Food refusal may occur for a variety of reasons. For example, it may be used as a method of exercising control over others (either at family or society level), as a method of self-harm, or even as a way of committing suicide. It is sometimes a symptom of mental illness. Thus, management of self-starvation depends on the motivation behind it, and consequently, on specification of the extent to which incompetence influences the decision to refuse food. Forcible feeding is the most frequent behavioral intervention in the case of severely emaciated individuals but is it the only way in which they can be helped? Clearly, each case is very specific but it is important to try to analyze the unique character of food refusal and the difficulties involved in forcible feeding of emaciated individuals, at least on several examples. The author has chosen hunger strikes and anorexia nervosa to illustrate, among other things, the consequences of forcible feeding and the practical implications for therapy.

M. Starzomska (*) The Maria Grzegorzewska Academy of Special Education, Institute of Applied Psychology, 40 Szczesliwicka Street, 02-353 Warsaw, Poland e-mail: [email protected] V.R. Preedy et al. (eds.), Handbook of Behavior, Food and Nutrition, DOI 10.1007/978-0-387-92271-3_104, © Springer Science+Business Media, LLC 2011

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104.2 F orcible Feeding Under Existing Regulations of the Mental Health Act Force-feeding can take the form of either oral refeeding, by which it is understood that the patient is effectively pressurized into feeding himself or herself, or tube feeding (Draper 2000). Some clinicians also apply nocturnal nasogastric refeeding (inserting a plastic tube through the nostril to the stomach to feed anorexics with a fluid diet) (Robb et al. 2002). Each forced treatment is a difficult situation for the patient, the patient’s family, and the hospital staff; however, it is sometimes essential if a patient’s life is to be saved (Melamed et al. 2003). Such intervention is usually undertaken within compulsory treatment. It must be underlined that any patient assessed for compulsory, and in the case of food refusal, forcible feeding, must be diagnosed not only with a mental disorder per se but also with a mental disorder with symptoms that support involuntary intervention (Brockman 1999). The key question in this case is testifying to the patient’s competence (capacity), namely his or her ability to make informed decisions. Capacity (which is the equivalent of competence) (Tan et al. 2003a) is a very important issue with respect to treatment consent and refusal; it derives from the premise that the ability to decide about one’s medical condition, irrespective of how imperfect or inaccurate that judgment might be, constitutes a fundamental human and legal right. Similarly, administering treatment against a patient’s conscious and direct will is ethically dubious, even if not legally (Tan et al. 2003b). Nowadays, the capacity-centered approach is common in legal systems (Tan et al. 2003b). Therefore, a patient who is competent to make decisions may not be treated – and this includes artificial feeding – against his or her will (Dyer 2000).1 It is important to remember that presence of a mental disorder does not always imply incompetence. The criteria for compulsory treatment are defined in the Review of the Mental Health Act (1999) and are shown in Table 104.1.

Table 104.1 The criteria for compulsory treatment According to Review of the Mental Health Act 1983 “5.95. Before confirming a compulsory order the tribunal would have to be satisfied as to the following: i. the presence of mental disorder which is of such seriousness that the patient requires care and treatment under the supervision of specialist mental health services; and ii. that the care and treatment proposed for, and consequent upon, the mental disorder is the least restrictive and invasive alternative available consistent with safe and effective care; and iii. that the proposed care and treatment is in the patient’s best interests; and, either iv. that, in the case of a patient who lacks capacity to consent to care and treatment for mental disorder, it is necessary for the health or safety of the patient or for the protection of others from serious harm or for the protection of the patient from serious exploitation that s/he be subject to such care and treatment, and that such care and treatment cannot be implemented unless s/he is compelled under this section; or v. that, in the case of a patient who has capacity to consent to the proposed care and treatment for her/his mental disorder, there is a substantial risk of serious harm to the health or safety of the patient or to the safety of other persons if s/he remains untreated, and there are positive clinical measures included within the proposed care and treatment, which are likely to prevent deterioration or to secure an improvement in the patient’s mental condition” (p. 70–71). Reprinted from Review of the Mental Health Act 1983 (Report of the Expert Committee) 1999. [Online]. Available at: http://www.dh.gov.uk/assetRoot/04/06/26/14/04062614.pdf [Accessed 30 May 2009], with permission.

With the exception of patients covered by the 1983 Mental Health Act who may be treated against their will even if they are competent, but only if the treatment is for their mental disorder (Dyer 2000).

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104 Behavioral Consequences of Force-feeding

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104.3 Hunger Strikes 104.3.1 Definition of hunger strikes The Declaration on Hunger Strikers (Declaration of Malta) (1991, http://www.wma.net/e/policy/ h31.htm) defines a hunger striker as a mentally sound person who has voluntarily initiated a hunger strike and does not accept food and/or fluids over a considerable time. Oguz and Miles (2005) define a hunger strike as an action based on nourishment refusal, performed by an individual (possibly imprisoned) whose decision-making capacity is not impaired, with the aim of obtaining fulfilment of a specific demand. Most hunger strikes include the ingestion of some water and other liquids, salt, sugar, and vitamin B1 for a certain time without asserting intent to fast to death (Oguz and Miles 2005). Hunger strikes have a rich political history (Oguz and Miles 2005), starting with the suffragettes through the IRA in Britain or the Doukhobors in Canada (Lewey 1977) and ending with the famous case of Guantanamo Bay hunger strikers (e.g., Nicholl et al. 2006; Wilks 2006).

104.3.2 Causes of Hunger Strikes Among Prisoners According to Brockman (1999), hunger strikes among prisoners may be motivated by a variety of factors. For example, sentenced young prisoners (particularly in the case of a first lengthy sentence) use self-starvation (which may be treated as a variant of self-harm) as a method of reducing tension or an attempt to precipitate change. Only a few prisoners choose to commit suicide (which may be chosen as a method of escaping punishment, a means of exercising autonomy or a method of self-killing secondary to grief or guilt) by starvation as they are prevented from killing themselves by other physical means. On the other hand, the main motivation behind hunger strikes of remanded prisoners is unfair – in their opinion – charge or refusal of application for bail. Finally, asylum seekers at an early stage of imprisonment communicate distress and their desire to change detention status through food refusal. Later, when it becomes apparent that they will be repatriated against their will, food refusal can be motivated by the desire to die rather than accept this tragic fate. Illegal immigrants most often use hunger strikes to express their outrage at having been treated as criminals when they do not perceive themselves as such. Although it is claimed from time to time that the main motivation behind hunger strikes is to draw media attention to the striker’s problem (e.g., Lewey 1977, p. 416), most authors would generally agree that an unarmed individual has very few methods left to resort to if he or she wants to make a life or death decision (Oguz and Miles 2005). Thus, they think that the choice to refuse food in the case of hunger strikes in prisons can be an authentic, albeit lethal, expression of values that may end the person’s life (Oguz and Miles 2005), although it cannot be excluded that prisoners sometimes seem to play with the system in undertaking their hunger strike, as Dryer suggests (2000) (Table 104.2).

104.3.3 C ompetence Testifying and Its Effect on Force-feeding of Hunger Strikers in Prisons It is very important to say that the majority of cases in which prisoners refused nutrition were inspired by numerous reasons other than mental disorder (Brockman 1999) and hunger strikes are very rarely unjustified. It is therefore not surprising that society and the law now acknowledge that a competent prisoner, even with suicidal tendencies, may choose to self-starve. A prisoner’s decision, regardless of

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Table 104.2 Motivations behind food refusal among hunger strikers in prisons and anorexics Motivation behind food refusal Hunger strikes among prisoners Anorexics Distorted body image. Sentenced young particularly in the case of a first lengthy sentence prisoners – self-starvation (which may be treated as a variant of self-harm) is used as a method of reducing tension or an attempt to precipitate change. An intense fear of weight gain, self-starvation as a form of a suicide (which may even when they are bordering on be chosen as a method of escaping punishphysical collapse. ment, a means to exercise autonomy, or a method of self-killing secondary to grief or guilt), because they are prevented from killing themselves by other physical means. Efforts to exert control over their Remanded prisoners self-starvation as a form of protest against unfair eating behavior. – in their opinion – charge or refusal of their application for bail. Egosyntonicity of anorexia nervosa, Asylum seekers At an early stage of imprisonment – food refusal namely this condition is often as communication of distress and the desire to highly valued by anorexics. This change detention status. phenomenon refers to the sense, which many patients experience, of anorexia nervosa being part of themselves or of their identity. Communication of distress (usually a Later, when it becomes apparent to the asylum person is not fully aware of it) seeker that he will be repatriated against his concerning adulthood, body, and will, food refusal can be motivated by the especially, sexuality and the desire desire to die rather than accept this tragic fate. to manage it. Through hunger strikes illegal immigrants most often express outrage for being treated as criminals when they do not perceive themselves as such. Although from time to time opinions are published suggesting that the main motivation behind hunger strikes is to draw media attention to their problem. Sometimes prisoners seem to be playing with the system in undertaking their hunger strike. There are various motivations behind food refusal among hunger strikers in prisons and anorexics, including the desire to inflict self-harm, change one’s detention status or die, escape punishment, communicate distress or play with the system (in prisoners); distorted body image, intense fear of weight gain, an effort to exert control overeating behavior, egosyntonicity, and communication of distress (in anorexics)

whether it appears to be foolish, cannot be overruled unless the individual is incompetent (Brockman 1999). When a prisoner refuses nourishment and is considered by the doctor to be capable of forming an unimpaired and rational judgment concerning the consequences of such voluntary refusal, he or she shall not be fed artificially (Kenny et al. 2004). The above attitude is further reinforced by the question of whether death by hunger strike is suicide, or simply exercising the right to self-determination (Williams 2001). Studies have shown that prisoners who go on hunger strikes have a high prevalence of depression or post-traumatic stress disorder but are not especially likely to be suicidal or incapable of making the decision to go on hunger strike (Oguz and Miles 2005, p. 170). Wynia (2007) underlines that suicide as a medical term has no place in discussing hunger strikes. Hunger strikers are not generally clinically depressed and would prefer not to die; the strikers are not suicidal, even if they are willing to die to achieve their political aims. Hernan Reyes of the International Committee of the Red Cross said that true hunger strikers do not want to die any more than soldiers charging a hill want to die (Table 104.3).


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Table 104.3 Mental disability, capacity, and attitudes toward suicide among hunger strikers in prisons and anorexics Mental disability, capacity, and attitudes toward suicide In hunger strikers in prisons In anorexics According to the 1990 Mental Health Act Mental disability Generally prisoners who go on hunger strikes anorexia nervosa does not meet the and capacity are not incapable of making a decision to criteria of psychosis under the Act (so go on a hunger strike; food refusal by anorexics are generally competent) but prisoners may be motivated by a variety of this current legal conception of factors, most of which are not related to capacity, which is based on understandmental disorder. ing and reasoning, does not capture the difficulty that arises from the impact of anorexia nervosa on the sense of personal identity, especially resulting in egosyntonicity. Suicide prisoners who go on hunger strikes have a high Anorexics are genuinely terrified of the prospect of being overweight and prevalence of depression or post-traumatic some state openly that they would stress disorder but are not especially likely rather be dead than fat; in contrast to be suicidal, suicide as a medical term, to suicidal patients they do not has no place in discussing hunger strikes; explicitly discuss a desire to end hunger strikers are not generally clinically their lives but their actions lead in depressed and would prefer not to die; they that direction. are not suicidal, even if they are willing to die to achieve their political aims. Generally, neither prisoners nor anorexics are incapable of making the decision to go on hunger strike but the current legal conception of capacity, which is based on understanding and reasoning, is completely inadequate for anorexia nervosa

104.3.4 Hunger Strikers’ General Attitudes Toward Food Refusal According to a blogger commenting on the situation of the Guantanamo prisoners who go on hunger strike, force-feeding not only violates US domestic and international laws but is also undisputedly perceived as cruel practice against human life and dignity (blog of rights, http://blog.aclu. org/2009/01/09/end-the-inhumane-force-feeding-of-guantanamo-prisoners/). In this vein, The World Medical Association Declaration of Malta concludes that forced feeding, unlike refusal to eat, is always accompanied by some form of physical or mental abuse and must therefore be perceived as degrading and inhuman (Wynia 2007). Most medical organizations advocate respect for a freely chosen decision to strike. Their disposition is mainly based on the concept of freedom of expression introduced by the International Covenant on Civil and Political Rights (Oguz and Miles 2005).

104.3.5 T he Dilemma of the Physician Who Tries to Help a Hunger Striker in Prison Although generally a doctor will not be neglecting his duty if he refrains from feeding a prisoner against his will, each time prisoners refuse food their doctors face a dilemma (Wynia 2007). Each case of hunger strike triggers the debate on legality and morality of force-feeding, which has continued through most of the history of prison medicine (Lewey 1977). Cases of force-feeding of prisoners (especially asylum seekers) by doctors result in great concern. When coming into contact with a prisoner on hunger strike, doctors should be aware of their professional, legal, and ethical obligations (Kenny et al. 2004). There are legal and social interests, reflecting profound ethical values, which militate against the prisoner’s absolute right to die by means of hunger strike but it has been debated

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whether a doctor may provide medical treatment once a hunger striker has reached the point where he is no longer capable of rational thought (Strauss 1991). Allowing the striker to die ratifies the charge that the authorities do not value the personhood of prisoners. Force-feeding to save life draws attention to the way the diminished quality of life has inspired the protest (Oguz and Miles 2005). Thus, the physicians find themselves between the rock and the hard place, where either decision is burdened with guilt (Lewey 1977). Any response by the state, including neglect, negotiation, and force-feeding, is a question of dialogue with the strikers and, consequently, is very problematic and difficult (Oguz and Miles 2005). Clearly, a physician who either respects the choice to hunger strike or force-feeds the striker is very often inevitably engaged in a political act (Oguz and Miles 2005). According to Oguz and Miles, such physicians ought to stay politically neutral and refrain from commenting in any way (positive or negative) on the striker’s motifs as well as being respectful of the striker’s right to exercise such a protest, by supplying him or her with essential updates on his or her condition without forcing them to terminate the protest (Oguz and Miles 2005). They should also be willing to take proactive action and provide information in advance so as to plan for loss of decision-making capacity, thus helping to delay death and reduce the risk of irreversible disabilities (Oguz and Miles 2005). Additionally, they should refrain from advocacy or criticism of the political aspirations of individuals under their care (Oguz and Miles 2005).

104.3.6 C onsequences of Forcible Feeding Among Prisoners Who Undertake Hunger Strikes Very little has been written about the consequences of forcible feeding in the case of hunger strikes in prisons. There are some reports of inquests where death was accelerated by force-feeding (due to pneumonia or syncope). Force-feeding can also lead to major infections, collapsed lungs, and other devastating health consequences, including serious digestive and pancreatic problems. Unfortunately, reports on the behavioral consequences of such forcible feeding are lacking. Evaluation of such consequences implies adopting a clear stance on values because, as was mentioned above, the strikers are not mentally disturbed, even if they are willing to die to achieve their political goals. Therefore, the physician must answer the following difficult questions: Is one individual’s freedom of choice to be limited by another individual’s moral obligations to benevolence? Or in this case, does freedom seem to be the highest human value? Those who value freedom of self-determination above all, even life itself, advocate noninterference. Others feel that when the choice leads to death, the human moral obligation to benevolence impels one to intervene – in a medical context, the physician must attempt to save life and preserve health (Lewey 1977). In such situations, the doctor has to apply a lesser evil to prevent a greater one. But what he shall consider to be a lesser evil is his arbitrary decision. It is difficult to say precisely what a forcibly fed prisoner feels but there is no doubt that such intervention does not bring relief. On the one hand, forcible feeding saves life but on the other hand, as Oguz and Miles argue, for prisoners who, by and large, are deprived of means of exercising their political rights, hunger strikes convey a powerful and independent political message (Oguz and Miles 2005). Hence, forcible feeding seems to narrow their already diminished freedom.2 Nowadays it is very difficult to bypass the dilemma with the so called “Cat and Mouse Act” under which hunger strikers were released from prison and then re-detained once they were fit again (Lewey 1977) because there were a lot of unintended consequences of the act. For example, the authorities experienced much more difficulty than anticipated in re-arresting the released hunger-strikers.

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Table 104.4 Medical and behavioral implications of forcible feeding among hunger strikers in prisons and anorexics Medical and behavioral implications of forcible feeding In hunger strikers in prisons In anorexics Pneumonia and over-hydration. Medical Pneumonia, syncope, major infections, collapsed lungs, serious digestive and pancreatic problems. Feeding alone is thought to be ineffective, and even Behavioral For prisoners, conventional means of counterproductive and antitherapeutic, and may be political expression, such as defined as mistreatment. Because the fundamental voting, donating to political therapeutic aim in working with anorexia nervosa organizations, publishing, or patients should be to facilitate the development of a national organizing are greatly secure, separate sense of self and minimize egosyntodiminished. They are obstructed, nicity of the condition, such behavioral treatment impracticable, or illegal. Under programs for anorexic patients are indeed paradoxical. these circumstances, a hunger Force-fed anorexics evidence no differences in strike asserting bodily integrity is recovery from anorexia’s psychological aspects, one of the few tools for strong satisfaction with treatment, or medical complication political expression, thus forcible frequency compared with those who received oral feeding seems to narrow already kilocalories alone. In addition, such intervention diminished freedom. Such clearly destroys the relationship of trust between intervention does not solve the patient and practitioner and jeopardizes the patient’s problem of the hunger striker, for prospects of long-term recovery. Force-fed patients example it cannot change with anorexia nervosa tended to perceive their figure detention status of an asylum and femininity more negatively than before hospitalseeker, so not only does forceization. Paradoxically, force-feeding may be connected feeding not minimize his distress, with greater risk of death. it intensifies it. There are various negative biological and behavioral consequences of force-feeding among hunger strikers in prisons and anorexics, pneumonia being the most familiar biological consequence and failure to reduce distress being the most familiar behavioral consequence. Not only does force-feeding fail to reduce distress in prisoners, it actually exacerbates it. In anorexics, force-feeding leads to mental deterioration and may be connected with greater risk of death

Such intervention does not solve the problem of the hunger striker. For example, it cannot change the detention status of the asylum seeker and therefore force-feeding not only does not minimize his distress, it intensifies it even further (Table 104.4).

104.4 Anorexia Nervosa 104.4.1 Definition and Causes of Food Refusal in Anorexia Nervosa It is common knowledge that anorexia nervosa is a serious psychiatric disorder characterized by distorted body image, which triggers intensive self-starvation (a person eats very small amounts of low caloric food) and – as a consequence – significantly diminished body weight. The very essence of this eating disorder is the staunch refusal to change (to gain weight) in conjunction with profound denial of illness (Harris et al. 2001). These patients often do not perceive themselves as sick (Gans and Gunn 2003). They do not want to eat and they typically manifest an intense fear of weight gain, even when they are bordering on physical collapse from malnutrition (MacDonald 2002) (Table 104.2). Clinicians working with patients suffering from anorexia nervosa must face not only the chronic but also the life-threatening (Patton 1988) nature of the illness and this is probably the most difficult aspect of their work. Although Beumont and Carney (2004) claim that patients express authentic terror at the thought of being overweight, with some of them going so far

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as to claim they would rather be seen dead than fat, in contrast to suicidal patients, they do not explicitly discuss a desire to end their lives, yet their actions lead in that direction (Melamed et al. 2003, p. 622). Refusal of treatment that could look suicidal in another patient may, for the anorexic, be an affirmation of the only life she can conceive of living (e.g., Gans and Gunn 2003). Although anorexia nervosa is sometimes described as suicide in refractive or refracted (Lemma-Wright 1994; Malan 1997), the desire to assert autonomy and self-control is what eliminates the likelihood of suicide, replacing it with a process of starvation that is stretched over time (Lemma-Wright 1994). Anorexia is a paradoxical disorder in which the choice to starve is experienced existentially as the choice to be and every anorexic girl derives her fundamental meaning and satisfaction, her reason to live, from her efforts to become thin (Gans and Gunn 2003). Very often the anorexic person is unaware that her illness is a cry for help in the face of acute distress concerning adulthood, the body, and especially sexuality.

104.4.2 E gosyntonicity as the Main Feature of Anorexia Nervosa and Inadequacy of the Current Model of Capacity Serpell et al. (2004) raise the issue of the egosyntonic nature of anorexia nervosa, which prompts people affected by the disorder to perceive it as a value (in contrast to bulimia nervosa, Serpell and Treasure 2002). Although egosyntonicity seems to be very important for the assessment of anorexic patients’ capacity, its impact is still unaccounted for in the legal definition of capacity (Tan et al. 2003c). The authors (Tan et al. 2003c) suggest that personal identity should be considered a relevant factor in the assessment of competence to consent to, or refuse, treatment in anorexia nervosa, depending on how it affects an individual’s sense of personal identity and her ability to make decisions. It is very important to say that the application of capacity in consideration of treatment refusal in anorexia nervosa can be problematic, especially because anorexic patients’ difficulties concerning their ability to make treatment decisions, described above, are poorly captured by the concept of capacity currently in use that is based on understanding and reasoning (Tan et al. 2003a, b). The legal criteria of capacity are largely intellectual ones, based on the ability to believe and understand treatment information and to reason about it and they seem to be inadequate in the case of anorexia nervosa because anorexia affects patients’ values rather than understanding and reasoning (Tan et al. 2003c). In this light, it is very controversial that, according to the 1990 Mental Health Act, anorexia nervosa does not fulfill the criteria of psychosis under the Act and therefore anorexic patients are generally competent and cannot be compulsorily hospitalized (if anorexic patients are temporarily disturbed or pose a risk to themselves, the Act allows them to be detained to facilitate emergency treatment as mentally disordered persons for a maximum of 3 days) (Lemma-Wright 1994; Griffiths et al. 1997) (Table 104.3).

104.4.3 General Attitudes Toward Forcible Feeding of Anorexic Patients The deep existential motivation behind self-starvation in anorexia nervosa does not always seem to affect attitudes toward treatment of this condition because forcible feeding is still the main method of “helping” them in some hospitals. The strong conviction that many medical and highly dangerous complications of self-starvation may remit after re-nutrition (Corcos et al. 2003; Holtkamp et al. 2003) still lingers among some clinicians. According to MacDonald (2002), the main reason given


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for rejecting the full implications of patient autonomy (for example in the case of forcible feeding) in the case of anorexia nervosa is that treatment promises both physical and psychological benefits. Many clinicians are convinced that if the treatment succeeds in inducing weight gain, the patient will be healthier physically (for example, she will have less risk of heart attack) and mentally (she will have less starvation-induced cognitive impairment). Thus the anorexic person, once admitted to hospital, very frequently may be subjected to a variety of treatment programs whose principal aim is to restore the anorexic to a normal weight (Lemma-Wright 1994). Such interventions should be deemed fundamentally improper.

104.4.4 Consequences of Forcible Feeding of Anorexic Patients According to Draper (2000), feeding, unless administered to physically enable the patient to participate in therapy, is ineffective. Forcible feeding as a method of treating patients with anorexia nervosa may be counterproductive and antitherapeutic (Tan et al. 2003a). Thus, strict behavioral interventions (demanding, for example, that a patient eat 100% of her/his meal or be forcibly fed) may be defined as mistreatment in the case of anorexia nervosa (Treasure and Ramsay 2002), especially because of the surprising results reported by Finfgeld (2002) and Castro et al. (2004): nutritional abnormalities in adolescent anorexia nervosa persist after short-time recovery and both nonweight restored and some weight-restored individuals with anorexia nervosa experience chronic problems. Because treating patients with anorexia nervosa should be fundamentally aimed at rebuilding their stable, independent identity (Levens 1995), such behavioral treatment programs for anorexic patients are indeed paradoxical (Lemma-Wright 1994). This paradox is well exemplified by many very negative consequences of force-feeding in patients with anorexia nervosa. For example, involuntary nasogastric tube feeding (described earlier) of patients with anorexia nervosa is particularly problematic. Although according to Zuercher et al. (2003), patients who had received voluntary tube feeding gained significantly more weight per treatment week than those who received oral refeeding alone3 and patients who had received tube feeding evidenced no differences in recovery from anorexia’s psychological aspects, satisfaction with treatment, or medical complication frequency than those who received oral kilocalories alone, the effectiveness of (even voluntary) tube feeding in the treatment of anorexia nervosa is highly problematic. Such compulsory tube feeding destroys the relationship of trust between patient and practitioner and jeopardizes the patient’s prospects of long-term recovery (Dresser 1984). Also literally forcing food into the mouths of sufferers decreases the chances of long-term recovery and is hardly in patients’ best interest (Draper 2000, p. 121). A study conducted by Robb et al. (2002) showed that nasogastric feeding was a more effective alternative to less subtle forcible feeding as it resulted in faster and more substantial weight gain when applied over a similar period of time. A study by Mehran et al. (1999) into the perception of femininity, figure, diet, and clothing conducted before and after 3-month hospitalization also revealed a negative link between forcible feeding and patients’ self-esteem: the force-fed patients evaluated both their femininity and figure in a more rejecting and unfavorable manner than before hospital admission (Figs. 104.1–104.4). Gowers et al. (2000) find hospitalization unsupported by psychological help responsible for deterioration in patients’ condition or even premature death while Draper argues that forcible feeding,

Patients who received tube feeding for at least half of their length of stay gained 1 kg/week versus 0.77 kg/week for patients receiving oral re-feeding alone.

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Fig. 104.1 Changes in perception of femininity in restricting-type anorexics (RAs) and bulimic-type anorexics (Bas) (Reprinted from Mehran et al. 1999. With permission)

Fig. 104.2 Changes in perception of figure in restricting-type anorexics (RAs) and bulimic-type anorexics (Bas) (Reprinted from Mehran et al. 1999. With permission)

albeit life-saving, does not address the underlying condition. Coupled with physical side effects of tube feeding such as pneumonia and over-hydration as well as a possible link between hospitalization and higher mortality, the reasons for forcible feeding as a form of treating anorexia nervosa do seem controversial for anorexia nervosa patients. These words sound especially tragic in the light of intriguing considerations of Zerbe (1993) and Levens (1995) that even clinicians’ words are perceived by these patients as threatening; according to Zerbe (1993), they need “homeopathic” doses of therapy. Using cybernetic terms to portray the reciprocal relationship between forcible feeding and improvement of the anorexic patient’s condition, one may say that the more food is given to patients compulsorily, the worse they feel (Table 104.4).


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Fig. 104.3 Changes in perception of diet in restricting-type anorexics (RAs) and bulimic-type anorexics (Bas) (Reprinted from Mehran et al. 1999. With permission)

Fig. 104.4 Changes in perception of clothing in restricting-type anorexics (RAs) and bulimic-type anorexics (Bas) (Reprinted from Mehran et al. 1999. With permission)

104.4.5 The Right to Die in the Case of Anorexia Nervosa? In the context of deliberations on the chronicity of anorexia and illness-related suffering, the following question is inevitable: what is the sense of treatment and can treatment be replaced with palliative care? Draper (2000) is one researcher who has thoroughly examined the palliative care option for some anorexic patients. She maintains that abandoning treatment, however disturbing or gruesome in the case of an illness that seems easily curable, may be the only alternative for a person who refuses to be treated but cannot live without the illness either. Tan et al. (2003b) emphasize that some

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patients, especially those who have been battling against anorexia for years, and some mothers, are of the opinion that if anorexia becomes chronic and does not respond to treatment, and if the sufferer exceeds a certain critical point, she should be allowed to leave. According to Manley and Leichner (2003), it is typical for a patient to experience, at one point in therapy or another, exhaustion and lack of strength to endure the struggle with the illness. As Draper (2000) says, such difficult cases are not typical, yet it should be noted that some people will never recover from anorexia or even maintain body weight stable (if low) enough to lead a normal life. Undoubtedly, when a person suffering from anorexia chooses death, this creates a serious ethical dilemma for the family and people involved in the treatment. Draper (2000) suggests that the palliative approach should be applied to patients who have been ill for a very long time (for longer than 1–8 years, i.e., the natural cycle of the illness), who have already been force-fed, are critical about making decisions concerning their own lives, are able to see the impact of anorexia on certain aspects of their lives, and whose lives are not at direct risk. According to the researcher, in such cases refusal of therapy is analogous to abandoning life-prolonging therapy in the case of patients with disabling, chronic or acute terminal illnesses in favor of palliative treatment. When patients in full possession of their mental faculties refuse treatment, whether they are terminally ill or just choose to die, a doctor should accept the refusal (2000). An undoubtedly suggestive statement is the comparison proposed by Gans and Gunn (2003), referring to the difference between a 20-year-old woman that is secretly starving herself and a 50-year-old woman with chronic anorexia, exhausted by hospital and clinic stays and various medical appointments. Gans and Gunn (2003) wonder whether there is a point when clinicians abandon hope that the patient will change her attitude and come to the conclusion that they are unable to continue in their treatment attempts that have always proved a failure? They may think this way: if no method of fully curing anorexia has been found so far, why should they hope that the next attempt is going to be successful? (Gans and Gunn 2003). Obviously, we can consider sending the patient to a better, private treatment center yet the question arises: who is going to pay for it? On the other hand, treatment of the long-term disability of anorexic patients is also expensive (Su and Birmingham 2003). Such questions seem to be highly problematic. Can we really resign from saving lives only because we feel discouraged or cannot always afford high-level therapy? Should we always do whatever is possible to save somebody’s life? Some researchers openly criticize the concept of palliative care of anorexic patients. Melamed et al. (2003) have no doubt that anorexia is a curable illness; frequently, therapy is only aimed at partial recovery and one must take recurrences into account, especially in chronic cases, but this is actually the reason why clinicians should focus on saving the lives of anorexic patients in the first place. The palliative care option is also considered disputable by Griffiths et al. (1997). They argue that in spite of the extreme difficulties of anorexia treatment, those who survive are deeply grateful to the doctors who have helped them. Gans and Gunn (2003) take an even more definitive stand on the issue, by saying that if an anorexic person dies, there will be no chance for recovery whatsoever.

104.4.6 Other Cases of Forcible Feeding Forcible feeding is sometimes applied in the terminal phase of various illnesses, for example Alzheimer’s disease (e.g., Sheldon 1997) or cancer (e.g., Higginson and Bruera 1996). Such patients may consistently refuse food and drink for both psychological and physical reasons. Sometimes doctors argue that patients who are terminally ill should be allowed to starve rather than be artificially fed. It is argued that force-feeding needlessly extends the dying phase, while starvation can offer a dignified death.


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Table 104.5 Current knowledge on consequences of forcible feeding and its applications to other areas of health and disease Current knowledge about consequences of forcible feeding Its applications to other areas Hunger strikes, especially among prisoners Alzheimer’s disease Anorexia nervosa Cancer cachexia-anorexia Widespread self-destructive behavior such as alcohol abuse The behavioral implications of force-feeding in prisoners and hunger strikers may be helpful in the event of force-feeding of individuals who cannot eat for mental or bodily reasons, in the terminal phase of their disease, e.g. Alzheimer’s disease or cancer cachexia-anorexia, and widespread self-destructive behavior such as alcohol abuse

Table 104.6 Key points concerning causes, problems, and consequences of forcible feeding 1. Food refusal may occur for a variety of reasons, for example it may be used as a method of exercising control over others (either at family or society level), a method of self-harm, and even committing suicide, only sometimes is it a symptom of mental illness. 2. Force-feeding always creates a difficult situation for the patient, the patient’s family, as well as the hospital staff, especially physicians; however, it is sometimes essential to save a patient’s life. 3. Although force-feeding, contrary to informed and voluntary refusal, is never ethically acceptable, and especially feeding accompanied by threats, coercion, force, or use of physical restraints is a form of inhuman and degrading treatment. Although previously force-fed patients, especially ones who have recovered from anorexia nervosa, are sometimes deeply grateful to the doctors who helped them, it must be underlined that using forcible feeding alone as a method of help either anorexics or self-starving prisoners may be counterproductive and may result in paradoxical effects (e.g. Brockman 1999; Draper 2000). Food refusal may occur for a variety of reasons and it always creates a difficult situation for the patient and the social environment. In spite of the advantages of force-feeding, using it alone as a method of helping self-starving individuals may be counterproductive and may result in paradoxical effects.

104.5 Applications to Other Areas of Health and Disease The attitude presented above may be helpful in situations described briefly in this chapter, namely in the event of force-feeding of persons, who cannot eat for mental or bodily reasons, in the terminal phase of their disease. If even in mentally and bodily healthy prisoners and generally healthy (except for the consequences of malnutrition) persons suffering from anorexia, forcible feeding may exacerbate the disease symptoms through organ damage and deepening of depression, this may also occur, but with greater intensity, in the event of patients suffering from terminal diseases. In addition, such undoubtedly self-destructive behavior as self-starvation, highlights other destructive behaviors, even those which are commonly recognized and do not qualify as mental disturbance, such as excessive alcohol consumption or nicotinism. It is worth considering whether and why only radical interventions aimed at the person’s good are admissible here (Table 104.5).

104.6 Conclusion Food refusal provokes many questions and proposed solutions. If doctors want to succeed in these difficult circumstances they should try to apply the golden mean in every situation. Both forcible feeding and such entirely different solutions as palliative care for people with anorexia or consent for a prisoner’s death of malnutrition are highly inhuman; decisions in case of severe diseases such as Alzheimer’s or neoplastic diseases seem to be even more difficult. In this situation, it is necessary to

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clearly determine competence status in cases of anorexia whereas in prisoners, if mental disturbance is not suspected, detailed examination of mental status and exclusion of manipulation are essential in order to fulfill the requirements. Often, particularly in prisons, for example in the famous Guantanamo Bay case, force-feeding becomes one more repression or even torture technique. Of course it is not recommended to see such torture in every force-feeding event, although the prison metaphor is frequently used in existential approaches to anorexia (e.g., by Lemma-Wright 1994), but one should always carefully examine the deep-set motives underlying each case of deliberate food refusal because this is always an important message, which very rarely means a death-wish. The fact that, in spite of the extreme difficulties involved in the compulsory treatment of anorexia, survivors are very grateful to the doctors who helped them, should act as an additional incentive to undertake such efforts. This is why we should be very cautious when examining the possibility of palliative care for patients with anorexia, which in practice means permission to leave them alone. Obviously, we cannot always expect patients with anorexia, and especially prisoners, to be grateful for saving their life or to view doctors as Good Samaritans but it is always worth risking such action, knowing that we only have one life.

Summary Points • Food refusal provokes many questions and solutions. • Force-feeding seems to be a highly inhuman solution but is consenting to the death of another person as result of starvation not equally inhuman? • A basic recommendation for people dealing with patients refusing food is thorough examination of their competence, which seems particularly difficult in anorexia nervosa because the capacity criteria prevailing in psychiatry are completely inadequate in case of this disease. • You should remember that often, particularly in prisons, as for example in the famous case of Guantanamo Bay, force-feeding does not follow from the wish to help the prisoner but is yet another repression technique, sometimes a political one. • The fact that people who refuse food are often very grateful to their doctors for saving their life (through forcible feeding among other things) should motivate us to seek the golden mean when dealing with people who refuse to eat. In this context, you should carefully examine the proposal of palliative care for people with anorexia, which practically permits us to leave them alone.

Definitions and Explanations of Key Terms Anorexia nervosa: is a serious psychiatric disorder characterized by distorted body image, which triggers intensive self-starvation and – as a consequence – significantly diminished body weight. The very essence of this eating disorder is categorical refusal to change in conjunction with profound denial of illness. Competence (capacity): – in psychiatry, ability to make rational decisions. Egosyntonicity: – a phenomenon appearing in very few disorders, whose the main feature is that the afflicted person derives his or her sense of identity from the disorder. Force-feeding: is the practice of feeding a person or an animal against their will. Hunger strike: is a method of nonviolent resistance or pressure in which participants fast as an act of political protest, or to provoke feelings of guilt in others, usually with the objective to achieve a specific goal, such as a policy change.


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Acknowledgments Malgorzata Starzomska and Marek Smulczyk are very grateful to professor Helena Yanet Grzegolowska-Klarkowska for her invaluable assistance.

References Anon. BMJ. 1974;2:737–8. Beumont P, Carney T. Aust N Z J Psychiatry. 2004;38:819–32. Blog of Rights. Available at http://blog.aclu.org/2009/01/09/end-the-inhumane-force-feeding-of-guantanamo-prisoners/ Accessed 29 May 2009. Brockman B. J Med Ethics. 1999;25:451–6. Castro J, Deulofeu R, Gila A, Puig J, Toro J. Int Eat J Disord. 2004;35:169–78. Corcos M, Guilbaud O, Paterniti S, Chambry J, Chaouat G, Consoli SM, Jeammet P. Psychoneuroendocrinology. 2003;28:229–49. Draper H. Bioetics. 2000;14:120–33. Dresser R. Wis L Rev. 1984;2:297–374. Dyer C. BMJ. 2000;320:731. Finfgeld DL. Arch Psychiatr Nurs. 2002;16:176–86. Gans M, Gunn WB. Int J Law Psychiatry. 2003;26:677–95. Gowers SG, Weetman JSA, Hossain F, Elvins R. Br J Psychiatry. 2000;176:138–41. Griffiths RA, Beumont PJV, Russell J. Aust N Z J Psychiatry. 1997;31:525–31. Harris, WA, Wiseman, CV, Wagner, S, Halmi, KA. In: Dewan MJ, Pies RW, editors. The difficult-to-treat psychiatric patient. Washington: American Psychiatric Publishing, Inc.; 2001. p. 243–271. Higginson I, Bruera E (ed). Cachexia-anorexia in cancer patients. Oxford: Oxford University Press; 1996. Holtkamp K, Hebeband J, Mika C, Grzella I, Heer M, Heussen N, Herpertz-Dahlmann B. J Psychiatr Res. 2003;37:165–9. Kenny M, Silove D, Steel Z. Med J Aust. 2004;180:237–40. Lemma-Wright AL. Starving to live. The paradox of anorexia nervosa. London: Central Book Publishing; 1994. Levens M. Eating disorders and magical control of the body. Treatment through art therapy. London: Routledge; 1995. Lewey L. Can Med Assoc J. 1977;116:416–9. MacDonald C. Can J Psychiatry. 2002;47:267–70. Malan D. Anorexia, murder, and suicide. What can be learned from the stories of three remarkable patients. Oxford: Butterworth Heinemann; 1997. Manley RS, Leichner P. Crisis. 2003;24:32–6. Mehran F, Leonard T, Samuel-Lajeunesse B. Eur Eat Disord Rev. 1999;7:111–20. Melamed Y, Mester R, Margolin J, Kalian M. Int J Law Psychiatry. 2003;26:617–26. Nicholl DJ, Atkinson HG, Kal J, Hopkins W, Elias E, Siddiqui A, Cranford RE, Sacks O. Lancet. 2006;367:811. Oguz NY, Miles SH. J Med Ethics. 2005;31:169–72. Patton GC. Psychol Med. 1988;18:947–51. Review of the Mental Health Act 1983 (Report of the Expert Committee). 1999. Available at: http://www.dh.gov.uk/ assetRoot/04/06/26/14/04062614.pdf Accessed 30 May 2009. Robb AS, Silber TJ, Orrell-Valente JK, Valadez-Meltzer A, Ellis N, Dadson MJ, Chatoor I. Am J Psychiatry. 2002;159:1347–53. Serpell L, Treasure J. Int J Eat Disord. 2002;32:164–70. Serpell L, Teasdale JD, Troop NA, Treasure J. Int J Eat Disord. 2004;36:416–33. Sheldon T. BMJ. 1997;315:327–32. Strauss SA. ML. 1991;10:211–18. Su JC, Birmingham CL. Eat Weight Disord. 2003;8:76–9. Tan J, Hope T, Steward A. Int J Law Psychiatry. 2003a;26:697–707. Tan J, Hope T, Steward A, Fitzpatrick R. Int J Law Psychiatry. 2003b;26:627–45. Tan J, Hope T, Steward A. Int J Law Psychiatry. 2003c;26:533–48. The Declaration on Hunger Strikers (Declaration of Malta). 1991. Available at: http://www.wma.net/e/policy/h31.htm Accessed 29 May 2009. Treasure J, Ramsay R. Maudsley Discussion Papers. 2002;3:1–20. Wilks M. BMJ. 2006;332:560–1.

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Williams Y. MYCY. 2001;40:285–96. Wynia MK. MGM. 2007;9:5. Zerbe KJ. Bull Menninger Clin. 1993;57:161–77. Zuercher JN, Cumella EJ, Woods BK, Eberly M, Carr JK. J Parenter J Enteral Nutr. 2003;27:268–76.