Treating anorexia nervosa

Humbling for doctors

“None of these cases, however exhausted, are really hopeless as long as life exists,” commented William Gull about anorexia nervosa in 1873.1 Doctors have up to now been exhorted never to give up in the attempt to induce anorectic patients to eat and restore weight even if, as Gull also said, this might entail the need to “fight for every mouthful.” Two personal views in this week's journal2 3 and a recent paper on treating anorexia nervosa as a terminal disease4 raise disturbing questions for those who battle with this common and tragic illness.

Treatment of patients with anorexia nervosa must be constantly reviewed to ascertain that it accords with the five ethical principles of beneficence, autonomy, non-maleficence, justice, and utility. All of these, however, are open to interpretation, and our patients' interpretations often differ greatly from our own. Because we know the effects of starvation on the brain, is it ever ethical to act in accordance with a severely emaciated patient's decision to reject active treatment?5 6 Yet are some patients truly incurable, and is palliative care then more appropriate? Conversely, given that many of our patients are both contrary and ambivalent, can the clinician's acceptance of palliation as a treatment goal even have the paradoxical effect of motivating recovery?

We must also question exactly whom we are treating and whether we are colluding with the denial of the nihilism of the patient, her family, or the funding authority. Are we being moved to inappropriate action or excessive restraint by the impotence and guilt that anorexia nervosa can so powerfully engender? Although draconian inpatient regimens achieve weight gain, lenient treatment works as well for most patients.7 But what do we do with a patient who repeatedly rejects or fails in our user friendly refeeding programme? Even if we do not believe everything our patients tell us, we must be sensitive to the trauma described in the published accounts and mindful of the potential sequelae, particularly in a condition in which abusive antecedents may have occurred.8

Improving a patient's nutrition by whatever means might result in a change of mind, even to the point of accepting weight gain and eventual return to normal life. Even when restoration of weight is only partial or intermittent the quality of life might still be deemed acceptable, and who are we to argue? Doctors never cease to be surprised by patients with seemingly chronic anorexia nervosa who recover after 10 years or more.9 After all, in a condition in which the average duration of illness is around five years9 10 what should we regard as chronic disease? Like the patient whose personal view appears on p 635,3 recovered or recovering patients often extol the virtues of a particular clinician's psychotherapy or a treatment programme in which their individuality was respected and they at last felt safe to be themselves. If at the deepest level anorexia nervosa signifies that the sufferer is having difficulty achieving a secure sense of self11 12 we as clinicians must take care that our treatment is a help, not a destructive hindrance in this process.

None the less, our patients often feel desperately out of control, and our firm limits would seem to be the only effective antidote. Most of us can recall a patient treated coercively who made a full recovery and later sincerely thanked us for doing what was experienced at the time as totally reprehensible.6 Unfortunately, not all our patients do as well or are as happy with their treatment. Anorexia nervosa is a humbling condition, and it behoves ethical clinicians not only to accept this with good grace but to appreciate just how fine is the line they walk.