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Abstract
Eating disorders are mental illnesses that can have a significant and persistent physical impact, especially for those who are not treated early in their disease trajectory. Although many persons with eating disorders may make a full recovery, some may not; this is especially the case when it comes to persons with severe and enduring anorexia nervosa (SEAN), namely, those who have had anorexia for between 6 and 12 years or more. Given that persons with SEAN are less likely to make a full recovery, a different treatment philosophy might be ethically warranted. One potential yet scarcely considered way to treat persons with SEAN is that of a harm reduction approach. A harm reduction philosophy is deemed widely defensible in certain contexts (e.g. in the substance use and addictions domain), and in this paper we argue that it may be similarly ethically defensible for treating persons with SEAN in some circumstances.
ACKNOWLEDGEMENTS
The authors would like to thank Daniel Buchman and Ruby Shanker for sharing valuable perspectives on the ethics of harm reduction and eating disorders during the development of this paper.
DISCLOSURE STATEMENT
Andria Bianchi and Katherine Stanley are employed by the University Health Network. The opinions expressed are their own, and not necessarily those of their employer. Kalam Sutandar has acted as a consultant for Sunovion Pharmaceuticals.
Notes
1 Throughout this paper we will be using the term “person(s)” to describe persons with eating disorders. Thanks to our colleague, Ruby Shanker, for highlighting that the term “people” can denote homogeneity and a group agency, whereas the term ‘persons’ retains agency for individuals.
2 However, some persons with SEAN may significantly improve with certain treatment approaches, as was demonstrated in a study on cognitive behavioural therapy for persons with SEAN (Calugi, El Ghoch, and Dalle Grave Citation2017).
3 Although a harm reduction approach is deemed defensible in some circumstances and by some organizations/individuals, it is not an approach that is endorsed by all. For instance, Alcoholics Anonymous endorses an abstinence-only approach to alcoholism. Thanks to an anonymous referee for offering this example.
4 It is important to highlight that a fine and important line exists between trying to encourage or convince someone to change their mind about a treatment plan versus coercing them to do so.
5 While supervised injection sites are a recent example of a harm reduction initiative, the practice of harm reduction has a much longer history. The concept of harm reduction originated in England in the 1980s in response to growing rates of Human Immunodeficiency Virus (HIV) amongst people who use drugs (Bridgeman, Fish, and Mackinnon Citation2017). In order to respond to the increase of HIV (and, correspondingly, Hepatitis C), needle exchanges and other harm reduction initiatives were introduced. Harm reduction initiatives were primarily started and supported by public activists and were only later implemented by some mainstream governmental and healthcare systems (Des Jarlais Citation2017).
6 In addition to being separate diagnostic categories, SUDs and SEAN are distinct when it comes to thinking about how they are stigmatized and why a harm reduction methodology may be helpful. People with SUDs may experience particular harms from drugs (e.g. overdoses, HIV, Hepatitis C) at least in part because of the stigmatizing and prohibitive laws and policies that exist, which often result in people using drugs in an unsafe manner (e.g. without sanitary injecting equipment). Although people with SEAN may also be stigmatized such that society may fail to comprehend and/or sympathize with those who are diagnosed, the nature of the stigma is different. The harms that people with SEAN experience are not caused by stigmatizing and prohibitive laws/policies in relation to their eating disorder behaviors, whereas the harms that people with SUDs experience are often related to this kind of stigmatization.
7 In the substance use domain, harm reduction occurs on a spectrum that ranges from abstinence to no changes in one’s using.
8 Because harm reduction is a different type of treatment approach, it may influence conflicting individual perspectives on clinical teams. Exploring the complex team dynamics that may result from implementing a harm reduction approach is outside the scope of this paper, but we would suggest as a starting point that all team members have an opportunity to voice their perspectives and concerns in a safe environment. Consulting external services (e.g. bioethics, mediation services, etc.) may also be beneficial when it comes to exploring and/or making changes to the way that a unit operates.
9 While it is typically argued that the autonomous decisions made by capable individuals ought to be respected, it should also be noted that capacity and autonomy are not synonymous. Because of this, it may also be the case that people who are deemed ‘incapable’ may be able to make autonomous decisions, and, if so, then these decisions would also need to be considered from the perspective of autonomy.
10 As stated by Geller et al., “the values of patient autonomy and the right to refuse treatment come in conflict with care provider nonmaleficence and the intent to avoid harm to the patient.” We recognize that this same conflict may arise even when a patient decides to pursue a harm reduction approach since some types of harm will inevitably occur.