What’s the Difference Between Anorexia Nervosa and Hunger Strike?

My last post presented the debate over force feeding hunger striking prisoners in Israel. This post will discuss another group subjected to the dramatic means of force feeding in extreme circumstances, Anorexia Nervosa patients (AN).

Although ethical justifications for force-feeding are similar for both Anorexics and Hunger strikers (save life), the legal framework is completely different in each context. Whereas hunger striking prisoners were dealt with via ad-hoc legislation meant to answer national security threats, AN patients are handled within the framework of mental health law.  In the U.S., compulsory hospitalization of mental patients occurs through the state’s Civil Commitment Laws, which require dangerousness resulting from a mental illness to be evaluated by a psychiatrist.

Is the different legal attitude justified? How is it that the same act performed by prisoners is viewed as a political assertion but when done predominantly by adolescent middle-upper class girls, it is considered mental illness?

These questions were approached by a stream in feminist scholarship that supports the notion of AN being a social phenomenon rather than a pathology. Their stand refers to the critical literature on women and madness, which examines the casting of women’s behaviors in terms of madness by medical men. Accordingly, some feminist scholars argue that AN is a form of political expression defying against patriarchy. Their fasting is portrayed as disruptive to the family and society as they disobey norms and distort beauty ideals.

One of the voices of this approach in the legal setting is Rebecca Dresser, a law professor who argued in the Wisconsin Law Review[1] that committing Anorexic patients to compulsory treatment via civil commitment laws should be more restrictive, and retain the AN patient’s right to refuse treatment, even in lifesaving conditions. She builds her argument with reliance on the socio-cultural model of AN, which challenges the belief that other factors (biomedical or psychological) play a significant role. She stretches a line between early 20th century hunger strikers and AN girls, making their fast an exercise of free will.

Despite its attractiveness, this analogy is problematic to say the least. Joan Jacobs Brumberg, the author of Fasting Girls,[2] a book that explores the phenomena of fasting girls along a historical continuum casts this analysis as counterproductive, failing to take into account the history and complexity of AN in different stage of the disease, for example, when fasting becomes involuntary and the girls are unable to consume food despite their willingness to. Brumberg rejects the comparison to political hunger strikers, stressing that unlike the suffragists who had a specific political goal after which the fasting could stop, AN patients’ alleged protest is not really clear and most likely could not be stopped by simple command.

Modern manifestations of the cultural model can be found in perceptions of AN as an important part of identity among patients.[3] A worrisome recent trend is the Pro-Ana group which presents AN as a desired lifestyle. This understanding is advocated through websites and closed forums meant to encourage and share experiences of weight loss in a nonjudgmental atmosphere; some were taken down by Yahoo.

AN is a paradoxical disease in which patients can be simultaneously located on either side of the scale, as incompetent mentally ill victims, or as symbols for self-control, a parody of body discipline, social protests and rebelling patients and daughters. Different measures are available to better acknowledge the autonomy and competency of AN patients in medical decision making,[4] but one should be careful when choosing one model and sticking to it completely when becoming an advocate. The tension between the cultural and biomedical models of AN might become clear in the event a Pro-Ana group raised a legal objection against the banning of its websites, in which case a court would have to rule if the Pro-Ana websites are a harmful dangerous inducement.

[1] Rebecca Dresser, Feeding the Hunger Artists: Legal Issues in Treating Anorexia Nervosa, 1984 Wis. L. Rev. 297 (1984).

[2] Brumberg, Joan Jacobs, Fasting Girls: The History of Anorexia Nervosa, (New York: Vintage Books, 2000).

[3] Tan, J. O., Hope, T., & Stewart, A., Anorexia Nervosa and Personal Identity: The Accounts of Patients and Their Parents, 26(5) International Journal of Law and Psychiatry, 533 (2003).

[4] Jacinta Tan, Tony Hope, Anne Stewart, Competence to refuse treatment in anorexia nervosa, 26 International Journal of Law and Psychiatry, 697 (2003).

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