International comparison of physicians' attitudes toward refusal of treatment by patients with anorexia nervosa: a case-based vignette study

Plain English summary This study aimed to investigate the attitudes of physicians in Japan, the UK, and the US toward refusal of treatment for anorexia nervosa. Physicians in all three countries received an anonymous questionnaire comprising four fictitious cases for which they had to respond whether they would choose compulsory inpatient treatment or not. The study revealed that in all three countries, compulsory treatment tended to be the prevalent choice in cases of life-threatening malnutrition, regardless of the patient's age or duration of illness. Moreover, in all the three countries, treatment tended to be forced if a family member requested treatment, and this trend was particularly strong in Japan. The influence of family request was stronger for acute AN in the U.K. and the U.S., and for SE-AN in Japan. Background This study investigated the attitudes of physicians in Japan, the United Kingdom (UK), and the United States (US) toward refusal of treatment for anorexia nervosa. Methods A questionnaire survey was administered to physicians treating patients with eating disorder (Japan, n = 55; UK, n = 84; US, n = 82) to evaluate their treatment strategies for fictitious cases of refusal of treatment for anorexia nervosa. Results For acute patients, 53 (96.3%) physicians in Japan, 65 (77.4%) in the UK, and 54 (65.9%) in the US chose compulsory treatment if the patient's family requested treatment, while 46 (83.6%) physicians in Japan, 53 (63.1%) in the UK, and 47 (57.3%) in the US chose compulsory treatment if the family left the decision to the patient. For severe and enduring anorexia nervosa, 53 (96.3%) physicians in Japan, 62 (73.8%) in the UK, and 57 (69.5%) in the US chose compulsory treatment if the patient's family requested treatment, while 38 (69.1%) physicians in Japan, 56 (66.7%) in the UK, and 55 (67.1%) in the US chose compulsory treatment if the family left the decision to the patient. Conclusions Physicians in all three countries tended to choose compulsory treatment irrespective of disease duration or whether the patient's family requested treatment or not. This may indicate that medical practitioners value the ethical obligation of beneficence, giving priority to the protection of life. Attitudes toward refusal of treatment during a life crisis tend to vary among medical professionals, particularly if the patient's family does not request treatment.