The treatment outcome for adults with anorexia who are hospitalized involuntarily is similar to that of individuals with the eating disorder who enter an inpatient program voluntarily. This, according to a study conducted by the University of Haifa in partnership with Sheba Medical Center, Tel Hashomer and Haifa’s Rambam Medical Center.
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Researchers examined the hospitalization, treatment and recovery process over the course of a decade for patients with severe anorexia, some of whom were hospitalized willingly and some whose hospitalization was forced on them. They found similar treatment outcomes for both groups, a finding that invites new debate over the ethics of involuntary hospitalization of people with anorexia. Under current Israeli law, any such forced hospitalization requires a court order.
The study was conducted by Prof. Yael Latzer of the University of Haifa’s Faculty of Social Welfare and Health Studies, the director of Rambam’s Eating Disorders Clinic, together with graduate student Adit Zohar-Beja and Dr. Eitan Gur, director of Sheba’s Eating Disorders Department.
The study examined 79 female patients between the ages of 18 and 38 over the last 10 years, 28 of whom were forcibly hospitalized by the courts while the remaining 51 were willingly hospitalized. Each patient had similar clinical data upon entering the hospital, including Body Mass Index, blood pressure, pulse and other relevant characteristics.
“The study included all the cases in the last 10 years of forced hospitalization by court order – there aren’t many. We also collected data on a group of patients who agreed to be hospitalized, who had similar clinical characteristics,” explains Zohar-Beja.
“We’re talking about a group of patients in a dire, life-threatening situation, which forced the courts to order them forcibly hospitalized – they weighed 30 kilograms or less, with a 13 or 14 BMI and very low heart rate, around 20 beats per minute.”
Investigators examined numerous parameters in both groups. Aside from their intake data, patients’ socioeconomic and demographic backgrounds were recorded. Their level of cooperation was also recorded, taking into account whether they attempted to leave the hospital during treatment and if they participated in psychotherapy, as well as their nutrition plans and pace of weight gain. In addition, the researchers recorded the patients’ conditions after hospitalization, including mortality rates, as well as possible psychological treatment outside the hospital.
“We found that forced treatment does not hinder success rates, as such patients had similar results to patients who agreed to treatment,” says Zohar-Beja. “We also found a similar number of patients from both groups continued, of their own volition, into continuing treatment programs. In any case it’s important to remember that when the patients are extremely sick – whether forcibly hospitalized or not – the rates of reaching a healthy weight, even after treatment, are low.”
Regardless, the group of forcibly hospitalized patients was characterized by more difficult psychopathology. “It’s true that there weren’t many clinical differences between the patients in both groups, but the women who were forcibly hospitalized were in worse shape in terms of comorbid sickness, and some of them had histories of abuse,” says Latzer. “It’s not without reason that this group did not want to cooperate. They are characterized by difficult life stories and lack of trust in the system.”
Forced hospitalization of anorexia patients is at the center of medical ethics discourse in many places around the world, as it pits notions of personal freedom and autonomy against the responsibility to save lives. In February 2012, the Israeli government supported a bill initiated by then-MK Rachel Adatto that would allow forced hospitalization of anorexia patients in order to save their lives. The bill passed its initial reading, but the government was subsequently dissolved and the bill has since been neglected.
“There’s a widespread medical ethics debate on forced hospitalization of anorexia patients,” says Latzer. “There is a clinical and ethical argument about the patient’s judgment and possible psychosis, and specific mental health criteria as to when it’s possible to hospitalize a person against his or her will in order to preserve his liberty.
“Seeing as how I have much experience with women like this, there are many patients who cannot be forcibly hospitalized. They walk the streets and die, their families are desperate because they don’t want treatment.
“I think that it’s injustice not to allow forced hospitalization. Forbidding it allows them to choose not to be healthy. In their clinical situation they have very weak powers of judgment. We must figure out how to allow it without harming them physically or humiliating them – that’s our duty as a society. Our findings support that this is indeed life-saving – even if it started with compulsion, the process ends with the patients being extremely grateful.”
There is only one hospital ward in Israel equipped to deal with eating disorders in adults, at the Sheba Medical Center, though there are also a few beds preserved for this purpose at the psychiatric ward at Hadassah University Hospital in Ein Karem, Jerusalem.
Gur described the situation in stark terms. “There are more than a few patients in serious condition who refuse treatment and are never hospitalized. Not every patient who refuses treatment ends up being forcibly hospitalized. It depends on the family. If the family lets her stay at home, it could lead to her death.”