Anorexia and autonomy, continued.

[Updated below].

[Update 2: Do scroll to the comments for further arguments, and contribute if you have any thoughts].

Thanks to The Dish, I’ve had some push-back against my post last week.

John Magruder writes:

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.

Bensix adds:

[S]omeone 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.

‘MacGuffin’ is blunt:

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.

My emphases.

So I had previously defined autonomy very broadly as being about ‘letting those able to make decisions, make decisions’, where being able amounted to being a mentally developed adult.

Now, by ‘mentally developed’ I didn’t mean anything fancy, picking out an IQ threshold that people had to pass or a certain proportion of true beliefs. I really did mean nothing more than: not a child. And the objection that runs through the three comments above is that, yes, autonomy requires the ability to make decisions which requires mental development, but that in turn requires a sound mind, absent of delusion, capable of rational thought. So what to make of this?

First, we can note immediately another definitional problem. Autonomy itself was a sufficiently elusive concept, but now it is being tied up with rationality, making the picture even murkier. What is meant by rationality? I take it that none of the commenters mean something simple and Humean like ‘an ability to pick out the appropriate means towards one’s ends’. The anorexic woman has an end – not to experience pain – and she resists force-feeding treatment accordingly. If that’s all rationality was, she’s got it. So presumably by labelling her irrational, what is supposed to be conveyed is that her end, which entails death, is irrational. Maybe she fails to see the value of life because her mind is so clouded by physiological problems? To which I would say two things:

First; how, exactly, is this irrational? What conception are we working with here?

And second, if this counts as irrational, where does this leave our attitude to euthanasia? Here, by definition, a person wills to end their life because they judge it to no longer be worth living. So if you define rationality as appreciating the value of life irrespective of pain and you insist that autonomy requires rationality, then if someone denies this and thereby expresses irrationality, they cannot be autonomous. And this leaves us in a situation where those seeking euthanasia can never be judged to have made an autonomous decision. Why? Because it would, allegedly, be necessarily irrational.

If I mischaracterise what ‘rationality’ is meant to mean here, please correct me. But if I don’t, consider one more implication:

This type of argument is quick to infer that if someone is irrational and thereby not autonomous, intervention is justified. But do we really think that? Would we really want external force blocking a person’s choices to be, in principle, legitimate whenever their logic falls short of Einsteinian standards? Who sets those standards? And how is anybody going to meet them?

Which returns me to my recommended rule: the state will do best to respect the wishes of its citizens, where their wishes are exactly what they say they wish.

As always, comments would be much appreciated.

[Update] I just realised there is a simple and obvious way in which the woman could be labelled irrational: she is simply inconsistent. An interesting scenario indeed, but not the one at hand. Allow me to refer back to Foster’s original post:

If she is not admitted against her will to hospital, detained there for not less than a year, and forcibly fed under physical or chemical restraint, she will die. She understands this perfectly well. She doesn’t actively seek death, but doesn’t want to be force fed.

This doesn’t look inconsistent to me. I take this to mean that if she could live without being force-fed, she wouldn’t go out of her way to finish herself off by committing suicide. But, given this is the inevitable consequence of refusing force-feeding, she’d accept it. It seems highly contentious to claim there’s anything obviously contradictory here that justifies the overruling of another person. In fact, it looks like an accidental, quasi-employment of the widely-backed Doctrine of Double Effect.

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5 thoughts on “Anorexia and autonomy, continued.

  1. John Magruder raised a pertinent example that you didn’t really address directly – what if you were standing next to someone on the edge of a cliff and he or she was acting erratically and saying that they have the power of flight, you wouldn’t try to stop them from leaping? Even physically stopping them?

    Let’s take another example – someone is standing on the subway tracks with a train coming, clearly wanting to commit suicide. You wouldn’t pull the emergency stop lever to prevent the train from running him or her down?

    Perhaps your moral system values individual choice more highly than anything else, but I would feel a moral obligation, let alone a right, to prevent the deaths of the individuals above.

    Unless you feel that individuals have that right, but not the state? Or that anorexia is somehow different?

    • Apologies for not getting around to that example. Thanks for pulling me up on it.

      I think I agree, yes, that it seems absurd to refuse to stop anyone from trying to ‘fly’ on the grounds that their autonomy must be respected. But I wonder if the reason for that undermines my general position. The thought we have here, perhaps(?), is that we are not violating a person’s autonomy in preventing them from ‘flying’ because autonomy is about doing something that is possible, and this is a wish that is, by natural necessity, impossible. Is that not the crux of our intuition here?

      On your other example, though, I’m definitely not on board. In fact, I think you’ve so constructed it that unless you deny the right to suicide, you have to let the person die. You wrote that they ‘clearly want to’ die. If you know this, I don’t see the grounds for stopping the death at all.

  2. Thank you for the thoughtful (and swift!) response.

    To respond to your counterexample : while I would argue that it is morally permissible to prevent an anorexic from starving himself/herself, you suggest that the mere desire for or acceptance of one’s death does not preclude rationality, and cite the example of euthanasia.

    I would point out that the difference between these two situations lies not in the outcome or risk of death, but in the veracity and flexibility of the underlying beliefs. The person seeking euthanasia is using their rational capacities to act on (ideally) true beliefs. The anorexic is using her rational capacities to act on the fixed, false belief that she is fat, even though she is objectively emaciated. There is no standard of rationality to apply, because anorexia is a fixed, false belief – a delusion. One can be very intelligent and still be anorexic, and in fact, many anorexics are intelligent and driven people who use their intelligence and drive in service of their delusion.

    So, we agree that in these situations, it is morally impermissible to prevent a rational person from acting on true beliefs, even if the result of that action is self-harm or death. But in order to argue that an anorexic has the right to refuse refeeding, you must argue that a person has an inalienable right to act on a fixed, false belief, even if that will cause them harm or death.

    I must insist on a false belief that is fixed – IE, one that persists despite objective evidence and reasonable discourse. This is because it is morally permissible to correct false beliefs in order to prevent harm. Consider a rational man who is misinformed: he has good reason to believe his food is poisoned, but it is not. If he does not eat, he can be said to be acting on a false belief but not necessarily one that is fixed, as if you prove to him that his food is not poisoned, the false belief disappears, he will eat, and he will no longer starve. If you saw this man starving and could prove that his food was safe, you would (at the very least) be in the moral right to do so.

    Now, compare him to the anorexic. The distinction is that the misinformed rational man’s false belief is not fixed, but the anorexic’s false belief is fixed. With the misinformed rational man, it is unquestionably permissible to prevent his starvation by correcting his false belief. With the anorexic, is it, as you suggest, morally wrong to prevent her starvation because her false belief is fixed? In which case, it is morally permissible to intervene on behalf of the mentally sound, but not on behalf of the mentally ill. This would seem to be a logical conclusion from that line of reasoning.

    I appreciate this discussion and especially your very thoughtful response to mine and others’ objections, and it is indeed important to look at this decision from every angle. Philosophy is indispensible in situations such as these. However, philosophy is helpful only insofar as it interacts with the realities of human life – if it is divorced from the realities of human life, its power is to mislead and obfuscate. Thus, it is absolutely critical that we allow an understanding of the true nature of this disease to underpin our discussion.

    With that in mind, I would correct a misconception in your post here : the aim of the anorexic is not to avoid pain. Her aim is to keep from consuming calories, so she can become ever more thin, despite pain. Starvation is very painful. Broken bones due to osteoporosis are very painful. Isolation from friends and family is very painful. Frequent vomiting is painful. Hair loss and dry, scaly skin are painful. Gastroparesis and chronic constipation are painful. She chooses the painful route because she has the fixed, false belief that she is morbidly obese and can only become beautiful by starving herself.

    • Thanks again, John. I’m understanding your perspective a lot better now. Your key point seemed to be summed up nicely here:

      “The anorexic is using her rational capacities to act on the fixed, false belief that she is fat, even though she is objectively emaciated… In order to argue that an anorexic has the right to refuse refeeding, you must argue that a person has an inalienable right to act on a fixed, false belief, even if that will cause them harm or death.”

      I see why this is so salient now. I appreciate that the reason this issue is so baffling is that, where we would hope the simple solution should be available of *talking* to the person in question so that they *see* they should eat, rational discourse indeed does not persuade.

      But I still hesitate in accepting the inference that therefore, she should be force-fed. And I guess that’s because regardless of whether her situation is a result of a false belief that she is fat, it is still the case that she holds the true belief that coercion will cause pain and she does not want it, and that just seems to matter most of all. I’ve purposely grown cautious in my language now, because I’m feeling unsure again.

      Another euthanasia example to try to explain my reluctance: if I experienced so much pain that I thought life was no longer worth living, and the only way to end that pain was to force me through a painful operation, which would secure decades of healthy life in the future – if I rejected this necessary evil for a long term gain, would we want to overrule me? I agree my choice seems irrational. But that seems beside the point. The same goes, doesn’t it, for the person refusing chemotherapy even though it could well cure their cancer? If they insisted on dying naturally even after we explain why treatment is worthwhile and rational – even if they based their choice on a false belief that the treatment is doomed to fail – I presume we don’t have the same desire to overrule them here. So I’m trying to figure out why anorexia feels different?

      One more thing – you wrote:

      “The aim of the anorexic is not to avoid pain. Her aim is to keep from consuming calories, so she can become ever more thin, despite pain.”

      I took that claim from the original post on the Practical Ethics blog, which whilst not always true of anorexics, is at least true in this case:

      ‘She doesn’t actively seek death, but doesn’t want to be force fed. As well as the anorexic’s usual horror of calories, the forcible medical administration of nutrition reminds her horribly of the sexual abuse she suffered as a child.’

      So she does have personal reasons, anorexia aside, for wanting to resist treatment that aren’t based on delusions at all.

      I address your previous example in the other comment, by the way, if you want to check it out.

      • Thanks, Jacob – I’m really enjoying this exploration of medical autonomy.

        A bias I will admit is that I am a pediatric neurology doctor-in-training, and have been trained in general pediatrics. The odd truth therein is that as a pediatric doctor you have to be willing (to some extent) to inflict pain on unwilling children if you want to care for them. Think about a four year old child who needs to be vaccinated – they have the true belief that the shot will make them suffer and that they do not want it, and yet we vaccinate them anyway. So, I may have less tendency and/or ability to hesitate regarding these sorts of decisions.

        Regarding your other examples (deferring a painful but life-saving operation, deferring chemotherapy,) I would actually say that those choices aren’t irrational – in fact, yesterday a patient’s family was faced with the latter situation and opted to defer chemotherapy, which we respected. Every decision is a balance of risk and benefit, and if a person feels the benefit of a medical therapy is not worth its risks, then it is their right to refuse it. The physician’s duty is to inform them as fully as possible. At some point, though, the decision is theirs to make – and autonomy includes the freedom to make a bad or incorrect decision.

        A delusion such as anorexia, though, is different from a patient’s unique appreciation of the balance between risk and benefit, and the decision not to eat is not simply a bad decision. Unlike the cancer patient who weighs the known harmful effects of treatment with the likelihood of meaningful benefit, an anorexic believes that food itself is the disease, and her refusal to eat is itself her illness. That would be as if a cancer patient was offered chemotherapy, but refused it because they wanted to have cancer, even if it would eventually kill them.

        So what I see as the heart of the discussion is : do we treat the mentally ill against their wishes, when their wishes are the direct manifestation of their illness? We could also compare the anorexic refusing to eat because she believes she is fat with the schizophrenic refusing to eat because he believes his food is poisoned. Both are acting on a delusion, both believe food is harmful, and both know that forced feeding would be painful and that they do not want it. I presume that you would have less hesitation to feed the schizophrenic, but it is only a presumption.

        I do agree that anorexia does feel different, intuitively – maybe because it is presented by the anorexic as a reasoned decision not to eat. (It is a thorny issue, and if you want to see how thorny, look up so-called “pro-ana” websites, which exist as forums for anorexic girls to support each others’ decision not to eat and trade techniques for not eating and for deceiving or resisting people who would have them eat.) I also agree that this girl’s particular case is different in that forced feeding reminds her of prior abuses, and that her case needs to be approached with much more trepidation.

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