Ethical issues related to restrictive practices for anorexia nervosa in young people

Anorexia nervosa (AN) is an eating disorder affecting many young people. In severe AN, complications associated with profound weight loss and malnutrition can arise, and restrictive measures (e.g., manual force, devices, or medications) may be employed to ensure treatment of patients at imminent risk of harm. This narrative review explores the ethical issues in restrictive practices or coercive treatment for young people with AN.

345 papers were initially retrieved from online databases Ovid Medline, PsycINFO, Embase and PubMed. 247 papers were systematically screened according to established inclusion and exclusion criteria, before being assessed for relevance. 40 papers remained after screening and were included in the review.

Only three empirical studies were identified, with the remainder of the papers in the review being non-empirical. Significant arguments supporting restrictive or coercive practices include preservation of life; cognitive immaturity; altered capacity; alleviation of pressure or guilt regarding treatment decisions (particularly for parents or guardians); and retrospective gratitude. Pertinent counterarguments include patient distress; unjust violation of autonomy; harm to others; damage to parent-child relationships; and impacts on the therapeutic alliance. Despite there being widespread agreement on the ethical issues raised, the literature lacks guidance on how to proceed in these situations. Although restrictive or coercive treatment may be considered essential, last-resort management for young people with severe AN, the literature prompts clinicians to consider the associated harms. Future empirical research should be conducted to better understand the benefits and harms of such practices from patient, parent, and clinician perspectives.