I believe that adults have the right to decide freely whether they want to live or die, and to have that decision respected. The critical – and difficult – part is that word “freely”. Imagine that you have a friend in an abusive relationship. She is so miserable that she openly says she will let her abuser kill her; she has no intention or will to leave him. In that case, the decision to die may be perfectly rational, but it isn’t taken “freely” at all. Another person has destroyed your friend’s ability to value her survival, and rather than leave her to the death she says she accepts, you will maybe feel that she should be forcibly removed from the influence of her abuser before she can be seen as competent to make life-or-death decisions.
Now, what if instead of another person being the source of self-destructive tendencies, it was a mental illness? A high court judge has ruled that a 32-year-old woman with severe anorexia can be force fed, against her wishes and the wishes of her parents. Named as “E” by the court, she is described as “intelligent”; she’s a former medical student. She would be a perfect example of competence when it comes to choices about her own body and life, except that she has a disease that makes her morbidly afraid of eating: in other words, the treatment she is refusing is food, and because anorexia is a disease that makes the sufferer fearful of eating, the anorexic is by definition not competent to make that decision.
The detail that tips me away from thinking the court should respect her wishes is the judge’s comment that, “She does not seek death, but above all she does not want to eat or be fed.” It’s not completely fanciful to think of anorexia as something like abuser exerting control over the victim. In this post at Vagenda, writer Emer describes how the disease “tried to pay me an unwelcome visit”. She relates a dialogue with the disease as though it’s something outside herself, a hostile presence to be stalled and rejected – and she has successfully pushed it out of her life. Not every sufferer can do that though, and the detail that tips me in favour of thinking the court should accept E’s wishes is that she seems to be one of those whose condition is incurable.
The NHS says that 20-30% of those with anorexia do not respond to treatment; one in 20 will die of malnutrition. At 32 and with two decades of affliction, E is certainly in that first category, and only medical compulsion is keeping her out of the second. She is in all likelihood going to die, and force feeding will only be an extra interval of unpleasantness before death. The moment of questioning her competency has possibly passed: after 20 years, it seems likely that all interventions have been attempted and all have failed. She still does not want to eat or be fed. The disease isn’t external to E, it is in her and of her, and if she seems to speak with the voice of anorexia, that is her voice too and should be listened to.