Antoaneta’s refusal to accept counseling for her anorexia nervosa from anyone but me created the most challenging ethical dilemma I ever faced involving one of my own patients. Fortunately I served for many years as Ethics Director for my hospital and for my medical group and I had learned when faced with two bad options, to try to find a third way.
I offered Antoaneta a deal. I agreed to help her but insisted that if her weight fell below 100 lbs (45.5 kg) or if she missed a menstrual period (which would indicate poor nutrition) that she must then agree to regular visits with a mental health professional. (Her weight that day was 110 lbs (50 kg). After a few moment’s consideration she agreed to my offer and agreed to be truthful about her periods but she refused to be weighed at future visits. Looking for that third option again, I proposed that we weigh with her back to the scale so she couldn’t see the result. I promised not to reveal her weight unless it dropped below 100 lbs (45.5 kg). With that, we reached agreement.
My hope that she would respond to counseling was based on several aspects of her situation:
- She had mentally and physically improved in response to my counseling for irritable bowel syndrome in the past and made clear her strong belief I could help her again.
- Her nutritional status was still reasonably good.
- She was managing a part-time job as a music teacher, two children (ages 10 & 13), her husband and her household.
- She had symptoms of depression but none of anxiety or post-traumatic stress.
- She had no addictions or substance abuse problems.
- She had no suicidal or homicidal thoughts, no hallucinations and no history of self-mutilation.
- With the deal we agreed to, if my counseling failed then psychiatric help would begin with her in better nutritional status than would be the case if I refused treatment and waited for the inevitable complications.
In the next post, treatment begins.
Tags: anorexia, childhood stress
