Anorexia Nervosa, Lack of "Coherence" with Deeply Held Beliefs and Values, and Involuntary Treatment
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In a searching analysis, Radden (2021) elucidates key problems in justifying coercive treatment in anorexia nervosa (AN) despite a common intuition that it should have a place. Indeed, AN, perhaps more than any other condition, challenges the validity of a test purporting to provide a justification. Our generally accepted model for involuntary treatment is based on impaired decision-making capacity and "best interests." A treatment refusal by a person with "capacity" is to be respected, regardless of the consequences. (I exclude here the criteria under conventional mental health law—a diagnosis of a "mental disorder" coupled with a risk of harm to self or to others—because they discriminate against people with a mental disorder. [Dawson and Szmukler, 2006; Szmukler, 2018])
If a capacity–best interests schema fails in AN, then we resign ourselves either to no involuntary treatment, or to some form of exceptionalism, such as "hard" paternalism based on some notion of "best interests" but divorced from impaired decision-making capacity. The difficulties are clearly set out by Radden. Furthermore, such ex ceptionalism may threaten to expand the State's reach into the lives of others with unusual values.
I defend the applicability of a modified capacity–best interests test in AN. I restrict myself to adult patients, though the approach may be helpful in adolescents who may have achieved certain capabilities.
Decision-Making Capacity
I agree with Radden, as with Tan, Hope, and Stewart (2006), on the shortcomings of a "procedural," ostensibly "value-free" test of capacity based on formal "cognitive" functions. It fails to take into account the role of values.
A relentless pursuit of thinness in AN, at the expense of physical well-being (or life itself), key relationships, and important personal life projects, seems to be a bizarre yet powerful value, one that demands examination. But how can we examine the patient's values free of an imposition of the assessor's values?
"Using," "weighing," "appreciating," or "reasoning" abilities, commonly required in a [End Page 151] "capacity" test, occur in the context of a person's reasonably stable, deeply held beliefs, values, commitments or conception of the good. (I shall refer, as a shorthand, to these as "authentic" values). I suggest that more important than the nature and constricted internal coherence of the values in AN, is how the affected person has come to hold them; that is, how coherent they are with the person's "authentic" values.
Davidson's idea of "radical interpretation," how we attempt to understand a "radically different speaker" offers a useful approach (Banner & Szmukler, 2014). In "interpreting" the person, we start by assuming what the speaker says is by and large "coherent" within their holistic system of related beliefs and values and has a reasonable "correspondence" to the real world. This "Principle of Charity" offers an important direction for engaging a person who expresses unusual beliefs or values. An apparently bizarre belief may on further discussion turn out to be coherent with the person's "authentic" values. There is a resemblance to Jaspers's notion of "understanding," involving a process of empathy as we learn about the individual's personality, history and circumstances. On Jaspers's account, when the person becomes un-understandable, we resort to another kind of sense-making, one that invokes "explanation," for example, seeking law-like natural causes (such as brain pathologies).
I suggest that the AN values are rarely, if ever, coherent with the person's "authentic" values. Despite a thorough exploration of the person's beliefs and values—with the person as well as those who know the person well—we are very likely to conclude that their "authentic" values have been supplanted in a non-understandable way. AN usually starts with unremarkable dieting, but then seems to develop a "life of its own." Relatives may say the person no longer seems to be "herself" or "himself." The AN values, "out of joint" with the person's "authentic" values, may undermine decision-making. Refusal of treatment may result. I imagine that rarely, if ever, do young persons, not yet engaged in serious...
