The Thin End of the Wedge?: The Moral Puzzle of Anorexia Nervosa

The practice of force-feeding dangerously malnourished patients with anorexia nervosa (AN) raises a puzzle for clinical ethics. Force-feeding AN patients may seem justified to save their lives and to help them recover from a debilitating pathological condition. Yet, clinical ethics seems committed to a robust anti-paternalism principle, on which it is normally wrong to force treatment on decisionally capacitated patients for their own good. Some AN patients do retain decisional capacity, at least by standard criteria. Thus, routinely force-feeding AN patients seems to constitute an unjustifiable exception to a well-established principle of clinical decision-making. Call this the moral puzzle of AN. I examine three attempts to solve the puzzle and argue that, individually or taken together, they cannot justify force-feeding those AN patients for whom this intervention would be potentially effective at enabling recovery. I conclude that no such justification is currently available. A solution to the moral puzzle of AN may come from a reevaluation of the anti-paternalism principle, a deeper clinical understanding of the psychology of AN, or even a novel reconceptualization of decisional capacity.