Monday, March 12, 2012

Informed Consent

I'm in an uncomfortable position with one of my clients (at the eating disorders partial hospital program) where there is a mismatch between what she wants and what the program requires - specifically, she is already in what can be considered a healthy weight range, but the program "requires" weight gain up to a BMI of 21. Disagreements over this requirement are not an uncommon occurrence, given that individuals with eating disorders are often highly ambivalent, and have highly distorted thinking. However, it does raise some interesting clinical and ethical questions.

I'd like to frame the issue in terms of two ethical concepts. First, all healthcare providers are required to obtain informed consent for all treatment services. That means clients have the right to be fully informed about the suggested treatment, along with its possible risks and benefits; have the right to accept or decline, with possible consequences of both choices outlined; and have the right to withdraw their consent at any time. Informed consent assumes that individuals are legally competent to make decisions for themselves - i.e., adults with sufficient cognitive functioning to fully understand and weigh the risks and benefits, and make treatment decisions accordingly.

Second, informed consent is closely related to another core ethical standard for social work practice (as outlined in the NASW Code of Ethics): self-determination. Self-determination is the freedom to make decisions for oneself, without coercive influences. It means that clients have the right to decide their own goals and values, whether or not we agree with them. This is the basis for a push toward more collaborative treatment planning, with client-identified goals. The only exception recognized by the Code is when a client's choices present a "serious, foreseeable, and imminent risk to themselves or others;" that is usually interpreted to mean suicidal or homicidal intent. According to Miley, O'Melia & DuBois, in all other circumstances, "When social workers impose solutions, give direct advice, assume the role of expert, treat clients as subordinates, or in other ways control decisions, they thwart client self-determination."

So back to my dilemma. When clients are severely malnourished, it causes cognitive impairments, and may prevent someone from providing truly informed consent. In those cases, it is easily justified for the treatment team to require weight restoration as part of responsible treatment. Even so, it is very difficult (though not unheard of) to get a court order to treat a client against her will - they usually have to consent to be admitted to treatment, though as with all psychiatric admissions the legal status is "conditional voluntary," meaning that their ability to make informed treatment decisions may be impaired.

However, when someone is no longer malnourished, but we're still pushing them to gain weight against their will, that seems to violate the principle of self-determination. Yes, a client's unwillingness to weigh more than ___ lbs may be a "symptom," but over a certain point, it's not a risk issue, so they should be free to make their own choice (of course, this begs the question of what that point is). It seems like our role would be to give the information needed for them to make an informed decision - the physical and mental reasons why we recommend weight gain, along with the possible outcomes of gaining or not gaining. If it's more important to someone to feel comfortable with her weight and still somewhat preoccupied with food, vs. less preoccupation but more body image issues, that's a legitimate decision. Hopefully therapy can begin to shift the centrality of weight and body image in self-worth, which may then lead to willingness to gain additional weight.

An additional issue with consent is that we don't talk with clients about weight gain protocols at the beginning of treatment. It would definitely scare a lot more people off, but it would also be more in keeping with informed consent to tell people that they will be put on a weight restoration meal plan until they reach a BMI of 21. Without that information, it seems a little like a bait and switch - people get involved with treatment, connect to the group and team, and delve into underlying issues, and then find out that, in order to keep those positives, they have to do something they aren't willing to do.

I think that forced weight gain beyond clients' level of consent is a significant reason for relapse. If someone isn't on board and willing to be that weight, they're going to try to get back into their comfort zone as soon as they leave treatment, and getting back into the comfort zone is going to trigger the behaviors that rapidly become compulsive. We might better help clients with long-term recovery by taking things more slowly. But that's just my opinion.

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