Eating disorders: use of involuntary treatments and the issue of consent
Eating disorders are a debilitating form of mental illness that affect approximately 4% of the Australian population at any one time.
The severity and impact of these disorders cannot be understated. Individuals suffering from eating disorders have mortality rates almost twice as high as the general population – with this figure rising to 5.86 times higher for individuals with anorexia.
Anorexia nervosa is characterised as an emotional disorder resulting in an obsessive desire to lose weight by refusing to eat. This compulsion, combined with the physical effects of starvation can impact upon an individual’s capacity to make decisions in their best interests. As a result, it may become necessary for medical practitioners to employ coercive or involuntary means of treatment as a life-saving measure.
The difficulties faced by practitioners in treating anorexia are significantly magnified with minors. In treating minors, practitioners must consider whether consent can be obtained from the sufferer and if not, whether involuntary treatment can be provided.
What is the current position in Australia?
In Australia, minors are capable of giving consent about their medical treatment provided they have sufficient intelligence to understand what has been proposed.
For young children, a parent’s right to decide a child’s medical treatment is absolute. However as that child grows and matures they acquire greater autonomy and are later able to make decisions about their own medical treatment.
The highest incidences of anorexia sufferers lie between the ages of 15 to 19 years of age. These individuals are young adults who would ordinarily be capable of providing their informed consent. Unfortunately, some minors can become medically compromised due to the severity of anorexia nervosa and may not be able to act in their own best interests.
So how should medical practitioners proceed in instances where a minor suffering anorexia nervosa is refusing life-saving treatment? Particularly in instances where that minor may be cognitively impaired due to their condition?
These questions and more were addressed in the recent decision of Fletcher (an minor by her litigation guardian Rylands) v Northern Territory of Australia  NTSC 62.
What were the facts?
The minor (whose identity was protected during proceedings) suffered from a severe form of anorexia nervosa. She began exhibiting anorexic behaviours in mid-2015 and was formally diagnosed in February 2016. By March 2016, the minor’s weight had dropped to just 43 kilograms and she was in dire need of medical attention.
The minor was admitted to the Flinders Medical Centre (‘the Centre’) and placed on an urgent treatment plan for rapid weight restoration. This plan included utilising nasogastric feeding following a failure to eat or complete a meal. After a successful weight increase, she was discharged from the program.
Unfortunately, following her discharge the minor began again exhibiting anorexic tendencies and was re-admitted. During the course of this admission, she was diagnosed as suffering from a severe form of anorexia. The severity of her illness meant she no longer had the capacity to make decisions about nutrition that would be in her best interests.
The Centre then sought to implement a treatment plan involving involuntary nasogastric feeding as an early intervention strategy. The Defendant’s Acting Medical Director refused this on the basis that the minor could make her own decisions regarding her healthcare.
The minor’s litigation guardian then applied to the Court seeking that:
- The Defendant be authorised to feed the minor nasogastrically if necessary by force and against her will.
The Defendant must not unreasonably refuse to feed the minor nasogastrically after she arrives at hospital and at the request of one of her parents.
What were the findings?
The Court upheld the common law position in Australia that the autonomy held by minors does not typically give them a right to refuse treatment that is in their best interests. It was reinforced that a Court can intervene in circumstances where a minor refuses treatment that may result in their death or severe permanent impairment.
Here, it was held that the severity of the minor’s condition meant that she did not have the capacity to refuse treatment in her best interests.
The Court also considered that the purpose of the involuntary feeding was therapeutic and a failure to implement treatment could result in grave consequences.
However, it was held that the Court’s authorisation would not have been necessary but for the refusal of the Director to implement the treatment plan.
Further, even if the minor was deemed competent, utilising involuntary nasogastric feeding would be justified on the grounds that a refusal to eat would result in an unacceptable risk of permanent injury.
So how do the Court’s findings affect the treatment of eating disorders?
The Court found that, dependent upon the severity of the condition, individuals suffering from anorexia nervosa may not be capable of providing their consent for treatment. That is, their judgment may be so clouded by the illness that they are unable to act in their best interests.
Anorexia nervosa has the highest mortality rate of any psychiatric disorder so it is imperative that effective treatment is provided as quickly as possible. A multi-disciplinary approach taking into account all viable options, including coercive or involuntary treatments, must be considered in treating this debilitating condition.
This case serves as a reminder that involuntary, life-saving treatment can be provided to minors quickly, and without the Court’s authorisation, in circumstances where there is a grave risk of permanent injury.