Ethical considerations in collaborative care in severe and enduring anorexia: an application of an ethical decision-making model

Severe and enduring anorexia nervosa (SE-AN) is a mental illness with a high morbidity and mortality rate. It can profoundly affect a person's quality of life and relationships due to frequent periods of relapses and remissions. Many people become critically unwell and refuse treatment because they fear gaining weight, and they become resistant when subjected to coercion. Psychiatric advance directives (PADs) can reduce treatment refusal and enhance collaboration between health professionals and patients. SE-AN is an ethical concern for health practitioners, families and ethicists. Few qualitative studies have explored the ethical debate of whether to impose forced treatment or respect a person's right to refuse medical care. This thesis critiques both arguments and explores the ethical considerations. It uses a constructivist-interpretivist grounded theory method guided by a symbolic interactionist approach to inductively build an ethical decision-making model framed under the auspices of PADs. A purposeful homogenous sample of five women with SE-AN and eight clinicians participated in semi-structured interviews and focus groups. All participants were recruited from a hospital in Melbourne, Australia. The results confirmed that coercion is a moral and ethical problem when treating people with SE-AN. The central concern was that they lacked control over the illness, specifically in relation to provision of care, decision-making process, living with the debilitating effects of anorexia and absence of knowledge regarding PADs. The model addresses these concerns by enabling people with SE-AN to collaborate with their healthcare providers regarding their treatment preferences if they lose their ability to make decisions. In clinical practice, if patients' rights and treatment preferences are not respected, this may result in further acts of coercion, which may damage the therapeutic relationship and leave the patient feeling powerless and not in control of their illness. The sample size limited the generalisation of the findings. Future researchers should empirically test and modify the model for other clinical settings and patient groups to enhance the transferability of findings.