

Monday, January 5, 2009

Force Feeding and Respecting Values

Is it morally right to force-feed anorexic patients? To interfere with a suicide attempt? I think the better question is not whether it is always acceptable or always unacceptable. Better that we ask, when is it morally correct to intervene in the potentially lethal action of another?

Zarathustra at Mental Nurse wrote a piece in September about using degrading, humiliating, coercive means to force patients with eating disorders to eat. He is extremely candid about the reality of force feeding, detailing the force-feeding protocol:
The protocol for serving a meal to an eating disorder patient is a no-holds-barred affair. She’s made to come to the table with her hair tied back and wearing short sleeves, wearing no watches or jewellery, so that there’s nowhere to secretly stash food. She’s then made to eat everything - everything - on the plate with a nurse watching her like a hawk. No excuses are tolerated. No “that’s got a bit of gristle on it” or “but that’s just a crumb”. The plate has to be completely cleared. Afterwards she’s made to sit resting for a full hour so she can’t go off and purge or exercise.

If she fails to complete the meal, or doesn’t complete the rest period, then she’s ordered to drink a nutritional supplement milkshake. If she refuses to do that, then she’s restrained while a nasogastric tube is passed up her nose and into her stomach to force-feed her. Nasogastric feeding is so unpleasant that few of the girls have to have it done more than once. As coercive psychiatry goes, you don’t get much more coercive than this. [Emphasis mine.]
At the end of this litany of horrors, though, Zarathustra wonders - if it saves the girl's life, what's so wrong with that?

The short answer is that, for many people, there are things that are more important than life.

I have written in the past that it is sometimes permissible to save a person's life against his will. I propose two criteria for this:
  1. Because of a condition that clearly destroys the person's ability to act in his own genuine interests, such as an acute confusional state in a person who is otherwise lucid, the person is not acting in his own interests (note that I mean his own interests, according to his own values, not his "best interests" as defined by others); and
  2. there is substantial evidence that the person, in his lucid state, values his life more than he values being free from the kind of intrusion that would save his life.
I think it was Dr. Maurice Bernstein of the Bioethics Discussion Blog who said that, faced with an anorexic patient who was refusing to eat and would die without intervention, but still said she wanted to live, he would opt to force-feed. This actually accords well with my model of a time when it is appropriate to intervene: when it accords with the patient's ascertainable values. (I am not sure my first prong is met - anorexia nervosa seems to be more of a life-long condition rather than a sudden-onset break with reality. This is the hardest prong to define and apply[1].)

But if an anorexic patient values her bodily inviolability, her dignity, more than she values her life - then it is morally wrong, and damaging to her as a human being, to stick a nasogastric tube down her throat. There are some things that are more important - to her - than her life. How can it be right to ignore her values and humiliate her in furtherance of protecting her life from damage she herself may do to it?

A similar model may be helpful in determining when it is appropriate to interfere with a suicide. Some people who attempt suicide really want to die, and coercive suicide prevention is a horror that they would rather die than accept (Group 1). Some people who attempt suicide genuinely want to die but fail to be in a lucid state when they make the attempt; they are forcibly "rescued" and treated, and when more lucid are grateful for the indignity of forced treatment (Group 2). And some people who attempt suicide do not really want to die at all - they have bought into what I have termed the dangerous fantasy of rescue, and count on being saved from their suicide attempts through coercive means (Group 3). (In "Attempted Suicide as a Signal," I have articulated the way in which a policy of always interfering with suicides actually harms people who don't wish to die - because it sets up an incentive structure that rewards them for engaging in lethal behavior.)

In my view, it is permissible to interfere with the second group's suicide attempts if the two prongs of my test above are met - the person is experiencing an acute state of mental confusion or delusion (I don't think DSM-IV depression qualifies here), and according to the person's own value system (when lucid), remaining alive is more important than the humiliation and suffering involved in the proposed coercive intervention.

Group 3, suicide attempters who clearly lack a sincere intent to die, seem to me to present the easiest case. Under our current system, rescuing them - following through with the fantasy they have been fed - is the morally correct option. However, as I mentioned above, it would actually be better for them if there were a well-known public policy of not interfering with suicide attempts, because under such a system, they would have no incentive to make a potentially harmful, insincere attempt in the first place.

It is never morally permissible to coerce people in the first group to remain alive.

But, on the bridge or in the ER or on the bathroom floor of the apartment, how do you tell the difference? How can you tell whether the person belongs to Group 1 or Group 2 or Group 3? How do you know whether the bleeding, half-conscious person's values allow for interference with his suicide attempt?

Many people fail to ask this question at all. They assume without question (a) that anyone who would attempt suicide is in a state of mental confusion sufficient to render his actions and judgment valueless, and (b) that everyone places his own life above all other values - that any humiliation or insult to dignity or loss of liberty is worth it if it saves one's life.

I think it is true that many people hold the belief in (b), but I don't think it's controversial to say that not everyone values his own life over all else. If it were true, I think our race would be a race of cowards. But it is not: people are willing to die for their political and religious beliefs, and for other people, demonstrating that one's own life is not the supreme value for everyone. And for some of us, dignity and bodily inviolability are values we hold above even life itself.

But we can, and ethically must distinguish between the two groups (Group 1 above - those who value dignity over life - and Groups 2 and 3, who want to live despite any indignities that might entail). I have previously articulated a proposal for distinguishing between these groups, with two options, as follows:

  • Radical option: Cease automatic interference with suicide attempters, and publicize this policy, to destroy the dangerous "fantasy of rescue" that might cause many people who do not genuinely want to die to make a suicide attempt, and
  • set up a procedure for medically assisted suicide (a prescription for a lethal dose of, say, barbiturates to a competent adult requester) that would be unlikely to be used by anyone not extremely serious about suicide, and
  • allow people who value their lives over any possible indignities to enter contracts while lucid to allow them to be "rescued" or forcibly treated should they become suicidal, refuse to eat, etc., as with medical advance directives;
  • Minimal option: or, as an alternative, at a minimum, establish an "opt-out" policy that would allow a competent person to execute a legally enforceable document, revocable only by the person it concerns, that would exempt him from coercive suicide prevention "treatment" and from medical "rescue" in the case of his suicide
Regardless of whether the radical or the minimal option is enacted, the following criteria would apply:
  • the suicide procedure (or execution of the opt-out document) could have a waiting period, like gun purchases or marriage or divorce, and even require multiple requests
  • requesters, to be competent, must understand the nature of death and be able to articulate a non-delusional reason for wanting to die
  • a DSM-IV diagnosis of Major Depressive Disorder would not suffice to render someone incompetent to request suicide assistance
Some things are more important than life. But life is important to many - for some, it is the most important thing. A policy like the one I have outlined would respect everyone's values.

Thanks to mysterious, modest commenter failed poet for inspiring probably the only thinking I've done in weeks, which thinking led to this post.

1. If my neighbor wants to lose weight, and values losing weight, but doesn't have the will power and determination to achieve it, would it be morally right for me to kidnap my neighbor, feed him only health food, and make him run on a treadmill two hours a day? Of course not - unless, perhaps, his values were such that the humiliation of being kidnapped and forced to run on a treadmill was nothing compared to the value of losing weight. He may hate it in the moment - people sometimes feel this way about their hired trainers or physical therapists - but if his deepest, truest value is losing weight, then I think the action is permissible, and he would probably agree. In this way, it all comes down to value - no mental illness/acute mental confusion prong is even necessary. (The only problem comes in judging which of several "selves" is speaking one's true values. And it is tempting for a listener to assume that the "self" that articulates values close to one's own is the true self.)


  1. I have been thinking about phrasing the issue with Group 2 in terms of personal identity, and it seems to fit well with your position.

    Grant the establishment that John, who is severely depressive, is indeed under several false impressions about, say, his prospects for the future and others' attitude towards him, and that things don't look so dire after all. However, these false beliefs are nevertheless genuine beliefs of his, and based on these and his preferences, he has a long-standing desire to die. All these things have been incorporated into his identity, and he refuses to undergo a therapy because he thinks that that would put him in a delusional state of mind, putting rosy glasses before his eyes, which he feels would make someone else of him - destroy his identity ins a long, painful process, which he doesn't want. Furthermore, he has an additional reason for not becoming someone else in this way: Other people might not think that they then have another person before them, and so this other person may be loved by others as him, which would leave a totally untruthful memory of him, and he values that those dear to him should have a correct picture of him.

    Surely Jones is a pattern example of a member of Group 1.

    Why is it wrong to forcibly treat John? For the same reason why it is wrong to brain-wash people, or to slowly and painfully kill them.

    Now suppose John has a problem: He just can't get himself to actually commit suicide. He doesn't have the courage, because the only method available to him is extremely violent. However, one day John's girlfriend terminates their relationship, which puts John in a state of such distress that he would now be able to overcome his inhibitions and jump off the bridge.

    Of course, it is still wrong to prevent him. Why? Because what he would do perfectly accords with his identity. After all, he has been willing to die all the time, only couldn't.

    Compare this with Mary. Mary is an irritable and unstable person, but at times she is very joyous and generally is glad to be alive. But she is struck by the same calamity as John: Her boyfriend deserts her. And this has the impact of making her feel that her life is over, that there is nothing pleasant to come, she feels hopeless and wants to die.
    If she is prevented from killing her self, she will be calmer the next day and determined to overcome her grief and go on living, she has taken on new hopes and is happy to be still alive.

    She belongs to Group 2, so it's permissible, possibly even mandatory, to seize her off the bridge.

    What is the crucial difference? The Mary on the day after the incident doesn't identify with her desire to die anymore. She feels herself to be in contiuity with herself before that terrible day, but this one day seems to her like a lapse, it isn't quite incorporated into her identity.
    Also, on that day, the being that wanted to die didn't have any considered preferences about what should become of her, she only wanted to escape the suffering and the prospect of its continuing.

    We could therefore say that giving the Mary on the fatal day a sedative is actually tantamout to killing that person, after which the old Mary comes forth again. (This, I think, resembles Peter Singer (and others)'s treatment of sleeping persons.)

    What is yet to be explored, of course, is the exact implications of this approach...

      And how are these "not so dire" (digression: that's a reason to live?) things likely to happen if he is that depressed? Further, who gets to make this determination. The optimism bias is well established in human psychology.

      And John is the only one who knows how he feels.
    2. If she is prevented from killing her self, she will be calmer the next day...

      Your examples have a lot of presumptive, absolute knowledge about the future.

      What makes you think you can make better predictions about my future than I can?
    3. Most systems of morality consider things other than identity important. Hell, killing someone destroys that identity; by this logic we may as well brainwash him and get a functional member of society, since this identity will be lost anyway.
  2. Thank you, your examples elucidate just what I was saying.

    The hard problem, of course, is figuring out what a given individual's true values are - is the "real" individual the suicidal one, or the happy one, or some hypothetical future happy one?

    I think my proposals for a change in background policy and/or opt-outs get at this with a wide brush - better for people to tell us what their deepest values are, while lucid (whatever that means, maybe that's just as hard) - as with a medical advance directive - and for us to trust them, than for third parties to try to guess.
  3. I think the notion of a "real" individual is precisely what I would like to avoid. The two Maries in my example are equally real.

    One further problem that arises is: Why can't the suicidal Mary not have it her way? (Or even: Why isn't she entitled to have it her way? If we're strong anti-paternalists...) My tentative argument seems to be that that would violate the latent non-suicidal Mary's rights.

    With regard to policy, the question arises how long you have to be suicidal in order to be considered the only self... Is this an empirical psychological question? How long a temporal gap in their identity can persons accomodate? If that turns out to be rather long, do you really have to wait all the time?

    And aren't such latent persons exceedingly dubious entities? Could contractualism help us suspend such metaphysical questions?

    If this doesn't work, what should we do?

    Either we take each state of a person as a separate person (defined by the preference set this state has). Then we're going to have an extremely hard time justifying any interference, because the present state is likely to prevail over past states. (That future versions can't be anything but irrelevant seems quite obvious in this case.)

    Or we define the person over the whole life. But then, what counts as such a person's preference? I have no idea about this.

      Why is Mary allowed to have sex? She could get pregnant or an STD or her heart broken or miss an episode of her favorite TV show, all for some disappointing sex; and she'll regret it.
  4. This is the core thing I'm trying to figure out.
  5. Mulling over this business of the "true self," I can't help but think of that scene in Young Frankenstein where the good doctor, just before entering the cell with the Monster, pleads with his minions:


    And then, moments later:

    Let me out. Let me out of here. Get me the hell out of here. What's the matter with you people? I was joking! Don't you know a joke when you hear one? HA-HA-HA-HA. Jesus Christ, get me out of here! Open this goddamn door or I'll kick your rotten heads in! Mommy!

    When you dispense with ethics proper and get down to the brass tacks of Legal, I think the true voice is the one that's speaking, whenever. Call it a simplistic Rothbardian default, but it narrows the slippery slope. After all, it's not as though those "truer" selves are clamoring somewhere. Is it?

    I like the pro-anna sites. They bleed sincerity. Anorexics are the niggers of the world.
  6. So I have this new invention called a wheel.

    No really. Actually I have been avoiding getting into substantive discussions over the idea of successive selves/single selves/future selves etc. and its implications for suicide rights, because there exists a large somewhat intimidating literature on this very concept.

    In the interest of not re-inventing the wheel, I am trying to at least scratch the surface of this literature, starting with Parfit (Reasons and Persons), and if anyone wants to join me, let me know. Perhaps we can go from there to a working understanding of the problem of successive selves and their possible duties to each other. Worse case, we read through Parfit. Who is in? (feel free to email too.)

    Chip, your proposition about "which is the true voice?" (it's the one speaking) is temptingly cheap and tasty. It would be awesome if that were what I ended up with after schlogging through Parfit and beyond.

      This may come as a shock, but decisions are actually made *in the present*.
  7. True voice? Seems to me we're just localized transitory states in more or less constant flux. Oh, there's some pattern cohesion, I suppose; enough to make us recognizable, at any rate. But trying to find the 'real you' is like photographing a whirlwind, and believing you have something more than a static representation of dust. (I purposely ran into the middle of one of those things, btw. It didn't pick me up, but stung like a motherfucker).

    Sorry, Kung Fu moment there. I guess if there was a point in that nonsense to be made, it's that trying to find a 'true self' is a metaphysical endeavor, and not a naturalistic one. That being so, we approach each case with sympathy, and with an eye for granting as much autonomy to the other's decisions as we can bear, realizing that mindstates flow, and flow is what we are, not mindstates. And maybe we try to keep our eye on the ball of intention i.e. whose wishes are we trying to serve...the other's, or ourselves.


    Again, in my opinion personality is an automatic dance inchoate matter is performing. Suffering is an aspect of that, but one I'm not particularly fond of. I want it to go away. Or perhaps it's the universe in me that wants it to go away. *shrug* Anyhow, I support what you're trying to do here, Curator. Cheers, and peace.

    Yikes, what a ramble! Perhaps another Mickeys.
  8. Well, it's true that the "identity" theorist of "personal identity" speak of is not the usual identity predicate. It doesn't have the expected properties, e.g. it is not transitive, nor is it reflexive! This is why Parfit ends up calling it not identitiy but relation R. The crucial thing is, however, that for practical purposes, it's supposed to play the role of identity.

    Unfortunately, I'm afraid, I won't find the time to finally read Parfit before next summer...
  9. "...and be able to articulate a non-delusional reason for wanting to die"

    How about: "None of your fucking business"?
    1. How about: "None of your fucking business"?

      DAMN right.
  10. I can't help but notice this article seems to treat naive preference utiliarianism as identical with morality. While I'm inclined towards at least incorporating preference utiitarianism, I wouldn't consider it trivially true; is it defended elsewhere on this site, or simply assumed?
    1. It's one of the big questions I deal with constantly. Are there things that are important other than mental states of aware beings? Are "value" important except to the extent that they make people happy or sad? Experience machine y/n?
  11. Hello, I would love to be able to use your piece for my higher english project. I would be using it along with several others that have the same key ideas, if this would be alright for me to use I would like if I could know your full name to give credit as I can only use it if I know the writers full name, thank you.

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  3. Fear of death is not love of life.

  4. @Ian_HT completely my own fault of course







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  12. @bswud thanks!

  13. @realmattforney you're too real the rest of the time






  19. how are those belmont "marriages" going lol 

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