The debate on the ethics of involuntary treatment for Anorexia Nervosa (AN) is dominated by biomedical ethics approaches to the issues. In keeping with the biomedical ethics emphasis on objectively balancing ethical principles, the debate centres on how to respect the autonomy of persons with AN who refuse treatment whilst protecting these persons from harm. Commentators discuss this at a normative ethics level. Thus, the debate does not address the moral relevance of how knowledge is constructed in the practice environment (...) and the impact this has on how professional values are applied during treatment decision making. Social work ethics highlights the need for professionals to account for the authority of professional knowledge and for patients to participate in treatment decisions. However, in the practice environment, questioning medical hegemony and supporting patient participation, empowerment and self-determination (core social work values) is complicated by a lack of treatment efficacy, the high level of risk that patients present to themselves and uncertainty around the autonomy and competence of the patient to refuse treatment. This paper argues that postmodern ethics can support practitioners in managing these issues. In doing so, this paper makes a social work contribution to the debate. (shrink)

In the UK, current policies and services for people with mental disorders, including those with intellectual disabilities (ID), presume that these men and women can, do, and should, make decisions for themselves. The new Mental Capacity Act (England and Wales) 2005 (MCA) sets this presumption into statute, and codifies how decisions relating to health and welfare should be made for those adults judged unable to make one or more such decisions autonomously. The MCA uses a procedural checklist to guide this (...) process of substitute decision-making. The personal experiences of providing direct support to seven men and women with ID living in residential care, however, showed that substitute decision-making took two forms, depending on the type of decision to be made. The first process, ‘strategic substitute decision-making’, paralleled the MCA’s legal and ethical framework, whilst the second process, ‘relational substitute decision-making’, was markedly different from these statutory procedures. In this setting, ‘relational substitute decision-making’ underpinned everyday personal and social interventions connected with residents’ daily living, and was situated within a framework of interpersonal and interdependent care relationships. The implications of these findings for residential services and the implementation of the MCA are discussed. (shrink)