When (If Ever) Is Enough Enough?

Those who treat patients with severe and enduring anorexia nervosa sometimes find themselves facing the following sort of treatment dilemma. The patient’s behavior has brought her to a point of real bodily danger: her weight is so low that she is in serious danger of dying from various complications. From the standpoint of survival, she really needs to regain weight. However, the patient refuses either to alter her behavior or to voluntarily admit herself to a hospital for monitored feeding. The patient has already been through years of treatment, but this has not produced any improvement. Statistically speaking, the odds of recovery for such patients, though not zero, are extremely low. Given that the patient passionately wishes not to gain weight or to be hospitalized, and given the low probability that hospitalization and monitored feeding will do any good, might it make sense to say enough is enough? Might it make sense to accept the patient’s wishes, even though doing so means accepting that the patient may die?

The dilemma assumes slightly different forms in different contexts. For example, sometimes it would be possible to involuntarily admit the patient to a hospital or treatment center. However, just because we can do something, doesn’t mean we should. In such cases, the question for the therapist becomes whether it makes sense to exercise this option given its high costs for the patient. Coercive intervention is a drastic measure in the best of circumstances. Is it worth it in a case like this, if it is so unlikely to help the patient in the long run?

In other cases, because the patient is deemed to have decision-making capacity, there is no option of involuntary treatment. But even here, if the therapist believes that the patient is in serious danger, the question remains: how hard should he or she push the patient in the direction of accepting treatment? How much effort should go into trying to get the patient to voluntarily admit herself? Again, in some cases, it may not seem worth it. But again, giving up on persuasion is to accept the very likely outcome of death. Moreover, we should not underestimate the difficulty (for everyone involved) of accepting death in a patient who is not terminally ill and who, in some sense of “could,” could live a long and productive life, if only she could overcome her self-destructive behavior.