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Agency, ambivalence and authenticity: the many ways in which anorexia nervosa can affect autonomy1

  • Tony Hope (a1), Jacinta Tan (a2), Anne Stewart (a3) and John McMillan (a4)

On the basis of detailed interviews of females aged between fifteen and twenty-six years with a diagnosis of anorexia nervosa we argue that the autonomy of people with this condition may be severely compromised in four ways, particularly in relation to eating and weight. First there are problems with agency. Second, affective components, particularly anxiety, can dominate beliefs such that the grounds for making a decision may differ from the reasons given in justification. Third, the interactions between the affective components and the objective evidence lead to substantial inner conflicts with resulting lack of stability in preferences and beliefs. Fourth, this lack of stability leads to concerns around identity and authenticity. We argue that some of the ways in which autonomy is compromised reduce competence to decide on treatment. We suggest that these results may be relevant to other mental disorders and have clinical and policy implications.

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We would like to thank all the participants in the study described in this article for their time and willingness to share their experiences; and Chris Fairburn for advice concerning the study. Ray Fitzpatrick provided invaluable support and supervision throughout the designing and carrying out of the empirical study. To him we are particularly grateful. TH would like to thank The Fondation Brocher [], the Hastings Center [] and the Uehiro Foundation and Centre, for support during his times as a visiting researcher at these institutions. Finally we would like to thank the Wellcome Trust for funding much of this research including the collection of data.

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American Psychiatric Association (1996) Diagnostic and Statistical Manual, 4th edn.Washington, DC: American Psychiatric Association.
Beauchamp, T.L. and Childress, J. F. (2009) Principles of Biomedical Ethics, 6th edn.New York: Oxford University Press.
Bruch, H. (1962) ‘Perceptual and Conceptual Disturbances in Anorexia Nervosa’, Psychosomatic Medicine 24: 187–94.
Buchanan, A. E. and Brock, D. W. (1989) Deciding for Others. Cambridge: Cambridge University Press.
Charland, L. (1998) ‘Is Mr Spock Mentally Competent? Competence to Consent and Emotion’, Philosophy, Psychiatry, and Psychology 5: 6781.
Charland, L. (2002) ‘Cynthia's Dilemma: Consenting to Heroin Prescription’, American Journal of Bioethics 2: 3747.
Craigie, J. (2009) ‘Competence, Practical Rationality and What a Patient Values’, Bioethics 25(6): 326–33.
David, A. J., Hotopf, M., Moran, P., Szmukler, G. and Richardson, G. (2010) ‘Mentally Disordered or Lacking Capacity? Lessons for Management of Serious Deliberate Self-harm. BMJ 341: 587–89; online 341:c4489.
Dworkin, G. (1988) The Theory and Practice of Autonomy. Cambridge: Cambridge University Press.
Feinberg, J. (1986) The Moral Limits of the Criminal Law. Vol. 3, Harm to Self. New York: Oxford University Press.
Frankfurt, H. G. (1971) ‘Freedom of the Will and the Concept of a Person’, Journal of Philosophy 68: 520.
Garner, D. M., Garfinkel, P. E., Stancer, H. C. and Moldofsky, H. (1976) ‘Body Image Disturbances in Anorexia Nervosa and Obesity’, Psychosomatic Medicine 38: 327–36.
Goldberg, E. (2009) The New Executive Brain: Frontal Lobes in a Complex World. New York: Oxford University Press.
Grisso, T. and Applebaum, P. S. (1998) Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press.
Hope, T., Tan, J., Stewart, A. and Fitzpatrick, R. (2011) ‘Anorexia Nervosa and the Language of Authenticity’, Hastings Center Report 41(6): 1929.
Loewenstein, G. F., Weber, E. U., Hsee, C. K. and Welch, N. (2001) ‘Risk as Feelings’, Psychological Medicine 127: 267–86.
Serpell, L., Treasure, J., Teasdale, J. and Sullivan, V. (1999) ‘Anorexia Nervosa: Friend or Foe?’, International Journal of Eating Disorders 25: 177–86.
Spriggs, M. (2005) Autonomy and Patients' Decisions Lanham, MD: Lexington Books.
Tan, J. (2006) Competence and Treatment Decision-making in Anorexia Nervosa. Unpublished DPhil thesis, University of Oxford.
Tan, J., Doll, H., Fitzpatrick, R., Stewart, A. and Hope, T. (2008). Psychiatrists' Attitudes Towards Autonomy, Best Interests and Compulsory Treatment in Anorexia Nervosa: A Questionnaire Survey. Child and Adolescent Psychiatry and Mental Health 2:40. Available at: doi:10.1186/1753-2000-2-40.
Tan, J. and Hope, T. (2008) ‘Treatment Refusal in Anorexia Nervosa: A Challenge to Current Concepts of Capacity’ in Widdershoven, G., MacMillan, J., Hope, T. and Van Der Scheer, L. (eds), Empirical Ethics in Psychiatry. Oxford: Oxford University Press, 187210.
Tan, J., Hope, T. and Stewart, A. (2003a) ‘Anorexia Nervosa and Personal Identity: The Accounts of Patients and their Parents’, International Journal of Law and Psychiatry 26: 533–48.
Tan, J., Hope, T. and Stewart, A. (2003b) Competence to Refuse Treatment in Anorexia Nervosa. International Journal of Law and Psychiatry 26: 697707.
Tan, J., Hope, T., Stewart, A. and Fitzpatrick, R. (2006a) ‘Competence to Make Treatment Decisions in Anorexia Nervosa: Thinking Processes and Values’, Philosophy, Psychology and Psychiatry 13: 267–82.
Tan, J., Hope, T., Stewart, A. and Fitzpatrick, R. (2006b) ‘Studying Penguins to Understand Birds: Response to Commentaries’, Philosophy, Psychology and Psychiatry 13: 299301.
Tan, J., Stewart, A., Fitzpatrick, R. and Hope, T. (2010) Attitudes of Patients with Anorexia Nervosa to Compulsory Treatment and Coercion. International Journal of Law and Psychiatry 33: 1319.
Tan, J., Stewart, A. and Hope, T. (2009). ‘Response to Critique: A Broader Concept of Competence’, Philosophy, Psychology and Psychiatry 16, 345–49.
Teasdale, J. (1997) ‘The Relationship Between Cognition and Emotion: The Mind-in-place in Mood Disorders’, in Clark, D. and Fairburn, C. (eds), Science and Practice of Cognitive Behaviour Therapy. Oxford: Oxford University Press, 6793.
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International Journal of Law in Context
  • ISSN: 1744-5523
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