Promoting Client Welfare and Preserving Autonomy: Ethical Treatment of Eating Disorders

Eating disorders (EDs) are complex and often life threatening conditions. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (American Psychiatric Association, 2013), EDs are generally characterized by disturbances in eating behavior. EDs are classified into one of several specific categories: anorexia nervosa, bulimia nervosa, binge eating disorder, and feeding or eating disorder not elsewhere classified. Anorexia nervosa (AN) is characterized by restriction of food intake, refusal to maintain minimally appropriate body weight, intense and irrational fear of weight-gain, and distorted body image. Bulimia nervosa (BN) is marked by the consumption of a large amount of food in a short period of time; individuals with bulimia often report feeling out of control during consumption and appear to possess a selfimage that is disproportionately influenced by body image. Binge eating disorder (BED) is defined as frequent episodes of eating significantly more food in a short period of time than the average person would eat under similar circumstances. Individuals with BED often experience feeling out of control and may eat too quickly, even when not hungry. Episodes may be accompanied by feelings of guilt or shame, thus individuals with BED may hide binge-eating behavior. BED is associated with marked distress and typically occurs at least once a week over at least three months. The category feeding and eating disorders not elsewhere classified includes eating disorders that do not meet the diagnostic criteria for AN, BN, or BED, including, atypical AN, sub-threshold BN, subthreshold BED, and purging disorder. The subtypes of EDs share commonalities such as fear of weight gain, body image dissatisfaction, and preoccupation with food. EDs have a significant personal, familial, societal, and health impact. Individuals with eating disorders often develop medical complications. As reported by Stice, Marti, and Rohde (2013), the lifetime prevalence of AN in American women is approximately 0.8%, for BN, it is 2.6%, for BED it is 3.0%, and for FEDEC, it is 11.5%. The total lifetime prevalence for all EDs is 13.1%. College-age women are at a greater risk for eating disorders than the general population (Schoen et al., 2012). EDs have the highest mortality rate of any mental disorder and are more lethal for women aged 15-24 than any other condition (Sullivan, 2002). Crow et al. (2009) reported the approximate mortality rates for individuals with EDs as 4% for those with AN, 3.9% for those with BN, and 5.2% for those with other eating disorders, including BED. Additionally, individuals with EDs also have an elevated risk of suicide (Apter et al., 1995; Bulik, Sullivan & Joyce, 1999; Pompili et al., 2004; Preti, Rocchi, Sisti, Camboni, & Miotto, 2011), and co-morbid mental health disorders including various types of mood, anxiety, personality, and substance use disorders (American Psychological Association, 2009). Many individuals with eating disorders die of starvation related illnesses and, for individuals with AN, the rate of suicide is up to fifty-seven times higher than that of the general population. The lifetime frequency of suicide attempts in individuals with BN has been estimated to be between 15% and 40% (Bulik et al., 1999; Corcos et al., 2002; Favaro & Santonastaso, 1997; Preti et al., 2011) and in individuals with AN to be between 5% and 22.9% (Favaro et al., 1997; Preti et al., 2011, Pryor et al., 1995). Sullivan (1995) noted that the second most common cause of death in AN sufferers was completed suicide, which accounted for 27% of fatalities. Clearly, EDs are potentially lethal disorders that may require intensive intervention by counselors. In many cases, individuals with EDs have no intention of changing their behavior and are often either unaware of or unwilling to accept the physical dangers of their conditions. The purpose of this article is to describe ways in which people with EDs may experience cognitive and decision -making impairments, to highlight the ethical dilemmas that may arise with clients who are unwilling to seek additional treatment, and to provide a case example demonstrating the application of Welfel's (2010) ethical decision-making model as a way to manage and balance ethical issues that may arise during counseling with eating disordered clients. …