Philosophy, Psychiatry, & Psychology

Most (but not all) adult persons with anorexia satisfy the existing criteria widely used to assess decision-making capacity, meaning that incapacity typically cannot be used to justify coercive intervention. After rejecting two other approaches to justification, Professor Radden concludes that it is most likely not possible to justify coercive medical intervention for persons with anorexia in liberal terms, though she leaves it open whether some other framework might succeed. I shall assume here that the standard approach to assessing decisionmaking capacity is adequate.¹ The question then is whether (contra Radden) we can justify—within a liberal framework—coercive intervention with the decision of a competent adult for the sake of that adult's welfare.²

I believe we can justify a limited amount of paternalism in liberal terms.³ Of course, much turns on what "liberal" means. I take "liberal" to describe a moral/political framework that focuses primarily on individuals: their choices and their welfare as subjectively conceived. It accords great weight to individual rights, particularly freedoms. And it views competent individuals as moral equals who are generally able to run their own lives, who are "self-rulers."

Though a limited justification is possible, I wish to emphasize that coercive intervention with the choices of persons with anorexia is only rarely justified. This is extremely important, because I do not wish to provide arguments for those who might misuse coercive power. Coercive intervention is only rarely justified in anorexia because it is only rarely plausible to think that it would be in the overall best interests of such patients. Liberalism can sometimes justify paternalistic intervention, but only if genuine benefits are likely.

Persons with anorexia jeopardize their lives by restricting food intake to the point where their starved bodies are prone to various types of malfunction. If, having reached such a point, they continue to restrict they will die. And it is worth remembering that a significant number of patients do, in fact, die of this illness.⁴ Coercive intervention in the form of forced weight gain therefore looks most appealing to third parties (family members, therapists, judges) when a patient is dangerously underweight and death is an imminent possibility. [End Page 155]

However, mere continued biological life is not necessarily in the best interests of persons with anorexia.⁵ Coercive intervention is justified therefore only if it is plausible that the patient could, if restored to a safer weight, overcome anorexia and go on to live a life free of the distresses and misery characteristic of chronic anorexia. Given the complexities of prediction, the requirement is best stated negatively: one should not coercively intervene if one has reason to think full recovery unlikely. Research reveals that the longer a person has anorexia, the less likely she is to fully recover (Treasure & Russell, 2011; Treasure, Stein, & Maguire, 2015; Von Holle et al., 2008). Moreover, given that coercive intervention itself tends to reduce the effectiveness of other modes of therapy, which are the only means of full recovery (Schreyer et al., 2016), it should always be a last resort.⁶

It is against this backdrop that we must consider the liberal case for limited paternalism. To properly explain the justification, I begin by presenting several key assumptions often neglected in the bioethics literature.⁷ First, I assume welfare is real, meaning there are objective facts (whether or not we know them) about which choices are better or worse for people. There are better and worse ways for a life to go. Second, such a claim is entirely compatible with a sophisticated form of subjectivism about welfare, according to which something cannot be good for someone at a time unless at that time she either (a) enjoys it, or (b) sees value in it.⁸ This view holds, however, that when a person wants something but does not yet "have" it, we cannot know for certain whether it would be good for her to get it. Whether it would or not depends on what her own response to it would be once it is "in" her life.

This brings me to the third...