AMA Journal of Ethics^®

Case

Psychiatrist Lisa Feinberg had been working with Suzanne Martin for 2 years. Miss Martin was referred to Dr. Feinberg by her primary care physician who suspected that Suzanne's extreme low weight was indicative of anorexia nervosa (AN). Dr. Feinberg agreed with the diagnosis of AN and began meeting with Suzanne weekly. Suzanne Martin, a 19-year-old sophomore at the state university, was an excellent student and fine musician. She managed course work, a 3-hour per day practice schedule, and a regular exercise routine with little sleep and little food. Suzanne Martin made light of what others called her "illness." She met with Dr. Feinberg mostly to keep her parents "off her back." She chatted easily with Dr. Feinberg, but the psychiatrist found it difficult to get Suzanne beyond superficial chatter, on the one hand, and deep theoretical discussions of her studies and her music, on the other hand. Suzanne avoided talking about her illness and the behaviors that must be necessary to maintain her dangerously low weight. She managed to remain just above a level of physical exhaustion and weakness that would have necessitated hospitalization.

One night Suzanne collapsed and was brought to the ER by friends over her protestations. She had received glucose and was gaining enough strength to demand to go home when her parents arrived. Her physician had been called, and he was present also. Suzanne's parents appealed to the physician to say that Suzanne was endangering her life—for all practical purposes, she was suicidal, they said—and hence should be declared incompetent to make medical decisions. Suzanne's physician had been reluctant make the declaration and had summoned to the hospital to confer about involuntary admission and artificial nutrition.

By the normally applied standards, Suzanne Martin was not incompetent to make medical decisions. She could understand the information she was given; she could analyze and measure the consequences of her refusal of treatment against an internal set of values and goals; and she could give back her decision in a coherent and consistent way. Dr. Feinberg figured that Suzanne's finely calibrated system had slipped out of control that day—a bit too much exercise or too little food. She was like a diabetic who takes too much sugar or too little insulin on a given day. One wouldn't hospitalize the diabetic against her will once physiologic balance had been restored. Dr. Feinberg feared that if Suzanne were hospitalized against her wishes and refused to eat all the food that was given her, she would be fed through a nasogastric tube. Lisa Feinberg knew Suzanne well enough to know that Suzanne would consider this a grave and obscene violation. She thought that hospitalization and the treatment Suzanne would receive if declared incompetent would set her work with Suzanne back seriously. Suzanne might even consider Dr. Feinberg's role in the commitment so serious a betrayal of trust that she would discontinue coming for therapy.

Commentary 2

Dr. Feinberg was not taking a sufficiently active and assertive role in the treatment of Suzanne. Suzanne should be hospitalized. Suzanne is not at all like a diabetic who slips out of control 1 day. Suzanne is more like a diabetic who denies having diabetes than like a typical diabetic who gets a bit sloppy. Suzanne was not really analyzing and measuring the consequences of her refusal of treatment against an internal set of values and goals. There is no indication that she understood the precarious medical situation she was in, that she could have died, that she was undoubtedly doing severe harm to her body and brain, or even that she had an illness. She may well be delusional about her weight and believe that her weight is in the normal range.

Dr. Feinberg was reportedly concerned that hospitalizing her would lead to nasogastric feedings and damage to the therapeutic work. There are problems with this assessment. First, hospitalization would not necessarily lead to nasogastric feeding. Nasogastric feeding against Suzanne's will would require an evaluation of her competence to refuse. Similarly, patients who are admitted to the hospital for medical or psychiatric problems have the right to refuse treatment. To override their refusal a forensic evaluation is needed.

In addition, Suzanne was not making progress in therapy. Suzanne did not appreciate the nature of her illness despite 2 years of therapy. She went to therapy but had not really engaged and does not appear to be on a path in which she would be able to really appreciate and work on her illness. There was not much work to be set back. Moreover, patients with anorexia nervosa often do not make progress in therapy until refeeding has begun and the clouding of their thinking from malnutrition subsides.

Even though Suzanne is no longer a minor, given her precarious condition and the reasonableness of hospitalizing her, the wish of her closest relatives (her parents) that she be hospitalized is material.

As a side issue, there is no indication that Dr. Feinberg obtained a consultation to help with this case. She needs assistance since it is going poorly. There is also no indication that she has experience and training in this area. If she is not highly trained in this area her need for consultation is that much greater.