Anorexia and autonomy.

Image: IMAGEZOO / SuperStock

The following, we are told, has happened: a woman has suffered from anorexia to such an extent that the only way she stands any chance of surviving is to be force fed in hospital for a year. She does not consent to this option, but if it does not go ahead then she will certainly die. The judge ruled that she is to be force fed.

On the face of it, this is a battle between the value of life and autonomy and the latter has lost. But the judge denied this. He argued that autonomy was not violated by disregarding the woman’s wishes because she was not in a state in which she possessed autonomy. So she could not, presumably, be judged to be thinking clearly. We cannot attribute rational decision to her. And thus, on the contrary, by imposing physiological alterations upon her we do not remove her autonomy. We resurrect it by putting her through more undesired pain for the sake of potentially achieving a situation in which she is fit and healthy and able to live well again.

I’ve been playing around with the issues at stake here for some time now, and I’m still in no place to offer a firm conclusion. But perhaps I can tentatively map out the relevant questions and arguments and consider what route we might want to go down.

I think it is clear that if an agent is autonomous, medical action should only proceed if they consent. We don’t like the idea of a hospital that operates upon the principle that it will round up sick people while they are sleeping precisely because we think patients should agree to how their bodies are treated.

Now there are caveats here. Paramedics must work on people incapable of giving them the go ahead. And here it seems to me that it would be perfectly fine to assume the person would agree to treatment, if the context is a car crash or something else of that accidental variety. If the person has just waved farewell to a loved one and carried out euthanasia, however, they should obviously be left alone. Either way, what the autonomous agent would say once awake again is the decisive factor.

This, though, is obvious and easy. The real question is clearly what autonomy is. That is up for dispute. If the anorexic woman has it, my principle can be applied to get the conclusion that she is not to be force fed, regardless of the consequences. But if she doesn’t, as the judge claimed, then the dilemma gets significantly murkier.

And I must admit that it seems to me that in cases where autonomy is lacking, acting under the presumption that life is to be preserved and the expressed wishes of the agent ignored seems hugely reasonable. But I think I wish to conceive of autonomy so broadly that any paternalistic overtones here need not worry us, and this is where things must get a little more technical.

Photo: The Economist.

One major job the philosopher has is to define concepts clearly, but that’s not always easy to do. Some of the most important ideas we employ in daily discourse are notoriously hard to pin down with a thorough analysis. Take knowledge – after over two millennia of thought, we still have no satisfactory definition of it. The alternative, then, is to ‘define’ roughly, by example. And it’s perhaps tempting to do that with a word as crucial but elusive as ‘autonomy’.

I take it as fairly clear that I – a twenty year old in good health – am autonomous. I am perfectly capable of making decisions about how to conduct my own life, and should be left to do so. Conversely, a non-negotiable candidate for not having autonomy is a four year old child. If one refuses vaccination, only madmen would think this a good reason not to overrule their choice and do what’s best for them. And these examples hint at an analysis of autonomy according to which it is about letting those able to make decisions, make decisions. Kids can’t be expected to. I can. Why? Because autonomy comes with age and mental development; age, presumably, only mattering insofar as it is necessary to foster the mind.

This is why issues surrounding parental authority and teenagers are always so sensitive. Teens face a period in which they are well on their way to adulthood, but still haven’t quite been brought up to it. And so conflicting intuitions about to what extent they should be nudged in the ‘right’ direction are inevitable.

And yet, this in turn seems to suggest why the anorexia case, after some reflection, can be deemed quite disturbing. On what grounds is the judge to decide the woman lacks autonomy? Clearly not that she is too young. Nor that she is mentally undeveloped. Rather, he has decided that for some reason she is too deluded to be able to make decisions about her own welfare, despite admitting the following:

[T]he patient’s wishes and feelings ‘are not the slightest bit less real or felt merely because she does not have decision-making capacity… particular respect is due to the wishes and feelings of someone who, although lacking capacity, is as fully and articulately engaged as [the patient].’

And my thought, I guess, is that it’s really not clear what it means to say an agent lacks autonomy in such situations. She feels unbearable pain and does not wish to be held down against her will. She has convictions on this question as strong as our own. But someone else decides that they count for nothing, and so she is to be treated like a child. I think force-feeding her is, ultimately, wrong.

Which hints at a rule of thumb: whenever the wishes of a grown adult are departed from and contradicted with force by others, our alarm bells should ring. Some exceptions are clear: what a man says when temporarily drunk should not count as final. But are we to view any and all psychological states that accrue from an imperfect BMI with suspicion? Is the anorexic woman really like the bladdered man on a Friday night? Try to convince me otherwise, but my instinct is to respect precisely what it is that she says. To argue the opposite, someone needs to explain what they think autonomy is and how, exactly, anorexia can be seen to undermine it.

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10 thoughts on “Anorexia and autonomy.

  1. I’m with you on most of this. The only thing that’s perplexing me is precisely why they’ve deemed her non-capacitous. If it is simply because she’s anorexic then that’s terrible, but I think they suggest there’s more to it, and that right now in particular her physical health has deteriorated such that she isn’t fully lucid. We can speculate on this, but really we need clarification on the medical detail of the case.

    • Definitely. No doubt the judgement has the backing of psychologists, in the same way practisers of that discipline get to decide if, say, Anders Breivik is ‘insane’. Maybe we’re being naive about the nature and powers of the subject, but I’m deeply, deeply suspicious of it and any such professional opinions. We should at least know what definitions they’re working with.

    • The author mentions the philosopher’s obligation to define terms properly.

      With that in mind : anorexia is not a mere conviction as the author suggests, it is a delusion. It is a false belief that is impervious to rational discussion. That is why the anorexic in question does not have autonomy : if allowed to starve herself, she would be acting on a delusion in such a way that it would end her life. There is no need for medical clarification, because the nature of her illness is a self-destructive delusion.

      Imagine, instead, that her delusion was that she could fly. If a person is standing on the edge of a cliff about to leap to their death because they believe they can fly, is it paternalistic to prevent them from jumping? Or do we hesitate to give them the help they need because their “conviction” is so strong?

      • Thanks for your comment, John. I think I’ll tackle this in a new post soon, so do keep an eye out.

      • This is not a question on which my views are fully-formed but I’d like to echo John Magruder’s point that someone who’s in the firm grip of anorexia nervosa is unlikely to have “convictions” in the sense that most people do. Extreme food restriction is a cause of irrational thought as well as a consequence of it: Ancel Keys’ Minnesota Starvation Experiment, for example, produced depression, hysteria, a preoccupation with food and its consumption and even apparent episodes of self harm among its previously normal testees. Once they underwent refeeding they began to recover from the emotional problems.

        http://jn.nutrition.org/content/135/6/1347.full

  2. Pingback: Anorexia and Autonomy (a reply) « Jon Robinson

  3. Maybe time to re-read Melville’s Bartleby? Or perhaps the great essay on that short story in Adam Phillip’s Promises, Promises (‘On eating, and preferring not to’)?

    It doesn’t matter how you define autonomy, all people, even most animals, know when they are being abused. Certainly it sometimes is the case that – and especially with psychic and emotional abuse – that knowledge is only at a deep, non-articulable level, perhaps consciously unknown by the victim herself, which is why rational argument can merely compound the symptom.

    Mostly though, she knows consciously as well.

    Force-feeding aggressively takes the side of the abuser and compounds the abuse to which not-eating is a last, forlorn resistance. It is internally rational though frustratingly irrational to an outsider.

    I do take bensix’s point though that, bio-chemically, not-eating eventually reaches a threshold in which mental and physical responses become negatively self-reinforcing.

    So maybe the question should be, should we abuse to protect the abused . . .

    It’s a tough one, but, and heart-breakingly, a case can be made for it. I’d get the parents right out of the picture however before I started on that ‘remedy’ . . .

  4. For goodness sake, is this question really so difficult? Anorexia is the manifestation of a mental illness that undermines autonomy. The woman is not in a condition to make sound judgements.

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