Anorexia Nervosa (AN), also known as anorexia, is classified as a mental illness and restrictive eating disorder in the DSM-5. The illness is characterized by “restriction of energy intake relative to requirements, leading to a significant low body weight in the context of age, sex, developmental trajectory, and physical health” [1]. In addition to an abnormally low body weight, an intense fear of gaining weight and a distorted perception of body size is also common [2].
In a survey of 9,282 English-speaking adults in the U.S., lifetime prevalence estimates for DSM-IV anorexia nervosa were around 0.9% for females and around 0.3% for males [3]. Patients with anorexia often go to such extremes to maintain a low body weight that other health complications occur, such as fatigue, bone loss, anemia, and kidney or heart problems. These complications affect the individual’s daily functioning, can have long lasting health effects, and can cause sudden death, even if the individual is not severely underweight [4].
In extreme cases, severe and enduring anorexia nervosa (SE-AN) is diagnosed in patients who have had anorexia for 6 years or more [2]. Patients with anorexia also have the “highest death rate of any mental health disorder; the mortality rate for AN is 5.6% per decade of illness (i.e. the risk of death increases the longer one has been ill)” [2]. The low recovery rates and high mortality rates make anorexia one of the most challenging and lethal mental health disorders, further emphasizing the need for a comprehensive and compassionate treatment plan.
While treating anorexia and SE-AN, clinicians must weigh a variety of ethical concerns to determine the most appropriate form of medical intervention. Treating anorexia often introduces the ethical and medical question of whether the use of force is justified in the clinical setting. In the modern clinical setting and general Western society, personal autonomy is highly valued, which the use of forced care violates. The use of force may also cause additional trauma to the patient leading to long-term health complications and mistrust of medical caregivers.
These ethical considerations are especially important when treating SE-AN given that this version of anorexia makes patients even less likely to make a full recovery. The long term nature of anorexia suggests that a different treatment philosophy that avoids the use of force may be necessary to care for the patient and ensure their quality of life [2].
One potential method to treat anorexia and SE-AN is a harm reduction approach, which is defined as “a philosophy and an approach to policy, programs, and practices that aims to reduce health, social, and economic harms” [5]. A harm reduction approach to chronic anorexia would primarily emphasize the improvement of quality of life. For example, a harm reduction model would allow patients to maintain an agreed upon weight that may not be clinically recommended, but would allow the patient to have quality of life [2].
Harm reduction is already implemented in the treatment of substance use disorders (SUDs) and applying this methodology to anorexia is not the typical standard of care. When taking a harm reduction approach to instances of SUD, individuals who use drugs are not reprimanded, but instead provided with supervised injection centers and taught safer methods to use drugs [2]. The goal is to lessen the stigma around SUD while reducing the possibility and severity of harm. Harm reduction is inexpensive, easy to implement, and has a high positive impact on individuals and the overall community [4].
Another example of harm reduction in the clinical setting is adjusting a diabetes patient’s diet when a clinician recognizes that the patient is unlikely to completely abstain from certain foods [2]. Suggesting that a patient reduce the consumption of certain foods can bridge the gap between the patient’s and clinician’s goals, fostering rapport, mitigating harm to the patient, and protecting the patient-clinician relationship in the long-term.
While implementing a harm reduction treatment plan appears promising for the treatment of anorexia, any harm reduction treatment plans must consider the inherent ethical challenges of treating anorexia and work to mitigate them. A typical concern about harm reduction is that this method of treatment normalizes the behavior and does not do enough to discourage restrictive eating, suggesting a more forceful approach to care is more clinically and ethically appropriate. This ethical concern is not unique to harm reduction and undergirds all forms of anorexic treatment. Respecting patient autonomy is a central principle in the United States; however, anorexia is a form of mental illness characterized by disordered thinking. In addition to this, the physical effects on the body from starvation can alter the patient’s ability to think clearly, potentially perpetuating restrictive eating behaviors [4].
Harm reduction does, though, encourage dialogue between the patient and the members of their care team. If clinicians took a more forceful approach to treating anorexia, which is the more common treatment, not only would clinicians cause the patient distress, but they would also damage any future possibility of having an open, trusting, and collaborative clinician-patient relationship. A relational approach to autonomy would better serve the treatment of anorexia than an individualistic approach. Relational autonomy is a concept of autonomy that assumes that individual decisions will inevitably be influenced by our social circles [2]. A harm reduction treatment plan implements a relational approach to autonomy by opening dialogue and showing compassion and respect for the patient, enabling the patient to have a support network they can trust. By prioritizing compassion, trust, and collaboration clinicians create an environment where the patient can be exposed to ethical and social norms that encourage a healthy relationship with food [2].
Perhaps the greatest challenge, though, to treating anorexia is not the effects that the disease has on the patient, but the effects the disease has on the family and care team. A harm reduction approach can help mitigate the strain on support and care team members by providing a framework to protect the patient’s autonomy while minimizing harm. A harm reduction approach is not giving up on the patient, but a way to acknowledge the inherent long-term nature of anorexia nervosa. Forced care can be distressing for patients and family members, so implementing a harm reduction treatment plan minimizes the potential long-term negative consequences to the patient and their support network.
Given that anorexia is a long-term illness with a low full recovery rate, any attempts to treat the disease should be guided by compassion and view treatment from a long-term perspective. Treating anorexia from a long-term perspective challenges the necessity of forced care. Forced clinical interventions may be ethically and clinically justified when a patient’s decision-making capacity is impaired, or when the risk of death or serious morbidity is high, and the likelihood of benefits outweighs the risk of harm [7]. Forced clinical interventions should, however, remain as a last resort in the treatment of anorexia given the long-term nature of the disease. Anorexia comes with a variety of psychological comorbidities and results from disordered thinking, so a secure patient-clinician relationship is essential to making any steps towards recovery. In implementing a harm reduction approach, clinicians are better able to guide a patient towards a healthier weight and attitude towards food.
Works Cited
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Mayo Foundation for Medical Education and Research. (2018, February 20). Anorexia nervosa. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591
Buchman, D. Z., & Lynch, M.-J. (2018). An ethical bone to PICC: Considering a harm reduction approach for a second valve replacement for a person who uses drugs. The American Journal of Bioethics, 18(1), 79–81. https://doi.org/10.1080/15265161.2017.1401159
Home. Harm Reduction International. (2023, March 22). Retrieved March 22, 2023, from https://hri.global/
Lavoie, M., &; Guarda, A. S. (2021). How should compassion be expressed as a primary clinical and ethical value in anorexia nervosa intervention? AMA Journal of Ethics, 23(4). https://doi.org/10.1001/amajethics.2021.298