Amanda Evans (University of Pittsburgh), "Medical paternalism, anorexia nervosa, and the problem of pathological values"
Synthese, 2025
Anorexia and Paternalism: Why Values-Based Medicine Can’t Save Us
By Amanda Evans
Anorexia nervosa (AN) has the highest mortality rate of any mental disorder (Meczekalski et al. 2013). It is also a condition that makes many bioethically-minded researchers particularly uneasy when it comes to its treatment, and rightfully so. Among the myriad of reasons to be squeamish about treating AN are the following:
i. The AN population is overwhelmingly made up of women (the most common figure cited is 90%) as well as gender and sexual minorities (Smink et al. 2012, Nagata et al. 2021).
ii. For many anorexics[1], AN is an egosyntonic disorder (which is to say that the symptoms which make up AN are reflectively endorsed and in keeping with the agent’s goals and values). In other words, many anorexics do not want to be treated for their anorexia (Gregertsen et al. 2017, see also Evans 2023).
iii. Given (i.) and (ii.), the modern conceptualization of AN has been compared to the Victorian conception of female hysteria (Bordo 1993, see Radden 2022 for a related discussion).
iv. Given (i.-iii.), we ought to consider whether it would be deemed bioethically acceptable (as it is in our current system) to subject anorexics to forced hospitalization and involuntary tube feeding if the demographic makeup of the AN population were otherwise.
Factors such as these, when taken together with the considerably high mortality rate of AN, make for an incredibly thorny bioethical dilemma. We don’t want to be guilty of the sort of vicious paternalism that the Victorians helped themselves to when “treating” female hysterics, but we equally don’t want to shirk the bioethical responsibility of helping those who appear to be suffering, often viscerally so. What, then, are we to do?
According to one solution that many have found appealing, the way we can avoid engaging in problematic medical paternalism is by listening to the unique values and perspectives of AN patients and then incorporating these findings into the aims of AN treatment itself. This is the solution suggested by values-based medicine (VBM), which was popularized by philosophers such as Bill Fulford and Giovanni Stanghellini and has been touted as being particularly applicable to psychiatric conditions such as AN (Stanghellini and Mancini 2017, Fulford 2020, Stanghellini and Fulford 2020, Stanghellini et al. 2021). As you have probably gathered from the title of this post, I am not so optimistic about the prospects of this proposal. In this entry, I will provide a brief overview of how I arrive at this conclusion, though interested readers should also refer to my full paper here (for the official version) and here (for the non-paywalled preprint version). At the end, I will return to the troubling bioethical picture sketched above with some further context and reflections that will help to situate this largely negative piece in the context of my broader thoughts on the matter.
To start, let’s return to (ii.) above. From here on out, it is important to clarify that I am primarily speaking of individuals with chronic and severe anorexia nervosa, since it is this patient population that is most relevant when we are discussing medical paternalism and compulsory treatment. The fact that anorexic patients (particularly within this patient population) tend to experience their disorder egosyntonically increases the risk of unjustified paternalism in AN treatment, given that the clinical aims of treating a given mental disorder will necessarily be at odds with the persistence of the disorder’s core symptoms. The way I choose to frame this point in the paper is by arguing that AN is a condition that is partially constituted by pathological (or, more accurately, pathologized) values, which follows similar claims made by philosophers such as Jennifer Radden, Simona Giordano, and Louis Charland. For ease of reference, I will be referring to these as “anorexic values”.
You may be wondering, at this point, why we need to worry about these anorexic values in the first place. Can’t we just disregard them on the basis of their being pathological? Although a thorough response to this worry would take us beyond the present scope, it is important to note that the labeling of anorexic values as “pathological” is itself a product of the psychiatric structure that is currently being interrogated on paternalist grounds. To assert that anorexic values can be disregarded simply because they are pathological thus risks circularity.
The idea that AN develops and is maintained by the presence of (purportedly) pathological values makes it an intriguing candidate for something like VBM. Although I agree that VBM is capable of effectively navigating relatively shallow value conflicts, I argue in the paper that it cannot adequately address the sort of conflict that is currently on the table. Take, for instance, Fulford and Stanghellini’s case study of Diane, a bipolar patient who disagreed with her doctor about medication strategies for treating her mania. In this sort of case, both patient and clinicians agree that the condition itself ought to be treated in some way or other. This makes it fundamentally disanalogous to the AN case. Despite this, Fulford and Stanghellini have argued that VBM is particularly well suited to be applied to AN treatment on numerous occasions (Stanghellini and Mancini 2017, Fulford and Stanghellini 2018, Fulford 2020, Stanghellini and Fulford 2020). In order to more concretely assess the merits of applying VBM to AN treatment, I label this VBM-based solution to patient-clinician value conflict the “Value Incorporation Proposal” or VIP. This is because the (admittedly vague) suggestions as to how VBM could be applied to AN treatment all boil down to a directive to “incorporate” AN patients’ values into the goals of treatment in some way or other.
So, what’s the matter with utilizing values-based medicine and embracing the VIP? It is important to remember, first, that the VIP cannot simply be a call for clinicians to genuinely listen to what their patients have to say regarding their AN diagnosis. While there are undoubtedly clinicians who would benefit from this sort of reminder, the VIP is a much more significant ask—it is a directive to fundamentally change the structure and nature of the doctor-patient relationship. So, we must take the “incorporation” bit of the VIP seriously if we are to properly assess its potential.
What we are considering, then, are those instances in which there is a bona fide conflict between the patient’s considered goals and values and the considered goals and values of AN treatment. For ease of exposition, I will refer to a hypothetical AN patient, “A”, and her clinician, “C”. It seems to me that there are two ways in which C might heed the directive of the VIP in treating A when faced with a genuine therapeutic value conflict:
Option 1: C interprets the VIP as a therapeutic emphasis on discussing A’s anorexic values with an eye toward changing said values. Thus, C treats A with the goal of altering either the contents of A’s values and/or the relative prioritization of A’s anorexic values in relation to her other values.
Option 2: C interprets the VIP as a therapeutic emphasis on discussing A’s anorexic values without the goal of altering the contents of A’s anorexic values or of changing A’s relative value prioritizations.
Once the available options have been laid out more clearly, it is easier to see that Option 1 amounts to the intentional manipulation of values from a position of power on the part of the clinician. Although one can try to debate the circumstances under which clinicians can justifiably engage in this form of manipulation, recall that the VIP is advertised as an antidote to paternalism—not a means of substituting one form of paternalism for another. Furthermore, any account of the ethics of paternalist manipulation ought to be especially squeamish when it is the patient’s sincerely held, longstanding values that are being manipulated.
If you were already partial to the spirit of values-based medicine and the VIP, however, it’s likely that you found Option 2 more appealing. Unfortunately, committing to Option 2 is in many ways more radical than it might initially seem. Clinicians are, after all, bound by a duty of care— they must “do no harm”, which is something that is explicitly pointed out as a limitation in this context by Jaiprakash et al. (2024). According to the most common interpretations of the clinician’s duty of case, then, Option 2 is functionally off the table. Allowing a Jehovah’s Witness to refuse a blood transfusion, to use one prominent bioethical stock example, is one thing. Actively engaging in the therapeutic process when some subset of the goals and values espoused by this process are contrary to the patient’s physical wellbeing is another thing altogether. At the end of this entry, I will suggest that there may be some potential for a version of Option 2, if it were possible to actually implement it. For now, however, it will suffice to note that the proponents of values-based medicine certainly do not appear to have this radical a vision in mind when they describe how VBM can be applied to AN treatment.
At this point, you may find yourself frustrated by my framing of the available therapeutic options. You might want to object, for instance, that C’s intention can simply be to practice good and thorough therapy in a way that inquires into A’s values. With the right sort of therapeutic relationship and enough time, surely A will come to see that her overarching values of the good life are incompatible with her anorexic values—right? In the paper I dub this objection the Teleological Objection, since it relies on the assumption (reminiscent of sort of psychological teleology) that, with sufficient therapeutic intervention, all (or all but the most severely ill) individuals will ultimately move away from what is psychopathological and toward relative non-pathology or wellness.
Unfortunately for the optimists hoping to leverage the Teleological Objection, I think it is ill-founded. This is because it seems to presuppose (quite incorrectly, given what we know about AN) that anorexic values are sufficiently malleable in such a way that this strategy could be reasonably expected to lead to the desired outcome in some clinically significant number of cases. This is an empirical question that certainly cannot be assumed on a sort of faith or optimism in the natural tendencies of human psychology. Furthermore, what we do know empirically suggests that the opposite of this teleological assumption is the case—especially in chronic and severe AN patients (Charland et al. 2013, Radden 2021 and 2022, Hay et al. 2012).
I go on to suggest that by continuing to unpack the Teleological Objection we can come to see the paternalistically manipulative undercurrent running through both it as well as the VIP itself. That is, although the VIP purports to be committed to a form of value pluralism, I suspect that many VIP advocates would be less committed to the idea of value incorporation if it did not in fact lead to any changes in either the contents or the relative value orderings of patients with anorexic values.
For more on that, you’ll need to check out full article. Zooming out, however, I’d like to take stock of where we are at with respect to the bioethical dilemma outlined at the beginning of this post, particularly given the fact that the work I’ve outlined here is almost entirely negative. Toward the end of the paper, I tease the idea that the desire to avoid paternalism may simply be irreconcilable with the treatment of egosyntonic mental disorders, at least within the confines of psychiatry as it is currently practiced. It must be stressed, however, that this is not equivalent to me saying that anorexia nervosa should not be treated in some way or other, or that I am not concerned about the wellbeing of those currently suffering from AN. Indeed, it is because of my own experiences as a former anorexic who underwent intensive inpatient treatment functionally against my own will that I am so deeply wary of this style of superficially inclusive solution.
The general strategy of purporting to involve the patient in a way that materially amounts to mere lip service was something that was already present in the AN treatment I was subjected to in the early-to-mid 2010s. Adding in a new treatment methodology that boiled down to the VIP would have essentially been more of the same in a shiny new package. As a patient, I often found AN treatment to be degrading, infantilizing, and endlessly self-contradictory. Indeed, witnessing the self-contradictory nature of the way we treat AN was what prompted me to pursue a career in philosophy in the first place, particularly after the life-altering experience of reading Bordo’s Unbearable Weight in the wake of my first experiences with treatment.
This is the first time I have disclosed the personal significance of my research in print, as I figured this relatively more casual venue was as good a place as any to do so. Although standpoint theory for the mentally ill is relatively underdeveloped, I think it is worth mentioning the added context I have when evaluating the potential effectiveness of something like values-based medicine in treating anorexia. Suffice it to say I am fairly confident that this “solution” to the inherent ethical tensions of AN treatment would not have helped, at least not for anorexics like me. If there is any way forward past the bioethical dilemma described throughout, it is to be found in something far more radical, perhaps in the form of making it structurally (and legally) possible for clinicians to embrace a genuine version of Option 2 above. For more on that, though, you’ll need to stay tuned for future work.
References
Bordo, S. (1993). Unbearable weight: Feminism, Western culture, and the body. University of California Press.
Charland, L., Hope, T., Stewart, A., & Tan, J. (2013). “Is anorexia nervosa a passion?” Philosophy, Psychiatry & Psychology, 20(4), 33–365.
Evans, A. (2023). “Anorexia nervosa: Illusion in the sense of agency”. Mind & Language, 38(2), 480-494.
Fulford, K.W.M. and Stanghellini, G. (2018). “Values and Values-based Practice”, in Stanghellini et al. (eds.), The Oxford Handbook of Phenomenological Psychopathology. Oxford University Press.
Fulford, K.W.M. (2020). “The State of the Art in Philosophy and Psychiatry: an international open society of ideas supporting best practice in shared decision-making as the basis of contemporary person-centred clinical care”. Phenomenology and Mind, 18, 16-36.
Gregertsen, E. C., Mandy, W. & Serpell, L. (2017). “The egosyntonic nature of anorexia: An impediment to recovery in anorexia nervosa treatment”. Frontiers in Psychology, 8, 2273.
Hay, P., Touyz, S., & Sud, R. “Treatment for severe and enduring anorexia nervosa: A review”. Australian and New Zealand Journal of Psychiatry, 46(12), 1136-1144.
Jaiprakash et al. (2024). “Valuing patient perspectives in the context of eating disorders”. Eating and Weight Disorders: Studies on Anorexia, Bulimia, and Obesity, 29(1), 12.
Meczekalski, B., Podfigurna-Stopa, A., and Katulski, K. (2013). “Long-term consequences of anorexia nervosa”. Maturitas, 75(3): 215-220.
Nagata, J., Ganson, K., and Bryn Austin, S. (2020). “Emerging Trends in Eating Disorders among Sexual and Gender Minorities”. Current Opinion in Psychiatry, 33(6): 562-567.
Radden, J. (2021). “Food Refusal, Anorexia and Soft Paternalism: What’s at Stake?”. Philosophy, Psychiatry & Psychology, 28(2), 141-150.
Radden, J. (2022). “Starving to death and the anorexic frame of mind”. Transcultural psychiatry, 1-10.
Smink, F., van Hoeken, D., and Hoek, H. (2012). “Epidemiology of Eating Disorders: Incidence, Prevalence, and Mortality Rates”. Current Psychiatry Reports, 14(4): 406-414.
Stanghellini, G. and Mancini, M. (2017). The therapeutic interview in mental health: A values-based and person-centered approach. Cambridge University Press.
Stanghellini, G. and K.W.F. Fulford (2020). “Values and Values-based Practice in Psychopathology: Combining Analytic and Phenomenological Approaches”, in Daly et al. (eds.), Perception and the Inhuman Gaze: Perspectives from Philosophy, Phenomenology, and the Sciences. New York: Routledge.
Stanghellini, G., Abbate Daga, G., & Ricca, V. (2021). “From the patients’ perspective: what it is like to suffer from eating disorders”. Eating and Weight Disorders—Studies on Anorexia, Bulimia, and Obesity, 26(7), 751-755.
[1] Note that I am choosing to use the term “anorexic” in addition to “AN patient”, “individuals with anorexia”, etc. Although there may be some benefit to using person-centered language in certain contexts, there are theoretical as well as practical reasons for my continued use of “anorexic”, particularly when discussing individuals for whom AN is experienced egosyntonically. And, for what it’s worth, I always found the attempts by my treatment providers to get me to stop referring to myself as “anorexic” (as opposed to a person with anorexia) to be maddeningly patronizing. More on my personal run-ins with this subject matter below.