DOCTORS have been issued with controversial new guidelines which spell out for the first time when they are legally allowed to force-feed anorexic patients close to death.
The rules state that if two doctors believe an anorexic patient is mentally ill and in danger of dying, the patient can be sedated and tube-fed against their will.
The new Scottish guidelines, issued by the Mental Welfare Commission, also allow dangerously underweight children to be force-fed against the wishes of their parents.
Anorexia affects a growing number of Scots and there has been severe criticism of the lack of specialist services. Scotland on Sunday can reveal that each year around 30 patients are already tube-fed without consent north of the Border.
The practice is allowed under existing mental health laws, but until now there has been no specific guidance on when and how anorexic patients should be force-fed, leaving medics vulnerable to compensation claims.
Patients' groups last night expressed concern about the guidelines because they fear doctors will be more likely to resort to force-feeding rather than trying to persuade patients to consent to treatment.
But Dr Flora Sinclair, medical officer for the Mental Welfare Commission, said they wanted to ensure the practice was only carried out as a last resort and under strict criteria.
Patients who become extremely ill as a result of their eating disorder need to be kept alive by artificial means, such as a tube inserted into the nose or stomach which gives the body vital nutrients.
However, many people with anorexia are so ill they do not want any kind of sustenance. In such cases, they must be sedated and treated against their will because they are often so frail that it is too dangerous to try to hold them down.
Sinclair said: "Doctors would only be able to resort to something like this without the patient's consent if there were very serious concerns that they may die. It's not just if they are refusing food and getting thinner, it's where there's a real physical risk that they may collapse and die. It's basically to save their life."
She added: "We thought it was important to have practice guidelines for people thinking about giving artificial nutrition without patient's consent. We are trying to ensure that if people are going to use these provisions they are going to do it properly. This makes it clearer and introduces specific safeguards that have to be put in place. This is not to make it more attractive as a treatment option."
Sinclair said doctors could also forcibly treat children under the age of 16 who were refusing food, even against their parents' wishes.
She said: "By far the best thing is to come to a negotiated compromise, but there may be times when clinical teams have to treat against the will of both parents and children."
The guidance also warns that doctors must take legal advice if they are considering stopping treatment in line with a patient's wishes, a decision that would lead to the death of the patient, because of the legal and ethical considerations of withdrawing life-sustaining treatment.
Scotland had 217 people diagnosed with anorexia, bulimia and other eating disorders last year, 35% more than the 161 patients in 1999. Experts estimate that the true number of undiagnosed cases is far higher and it is thought that 83,000 Scots have some form of eating disorder.
Yet there are few NHS services for such patients, and doctors have to refer the most extreme cases to two private centres, Huntercombe Edinburgh Hospital in Uphall, West Lothian and the Priory in Glasgow.
Mark Reilly, head of services for the eating disorders support group B-eat, said: "This is a sensitive issue as treatment against a patient's will is not always successful. Eating disorders are most successfully treated when the problem is addressed early on.
"Where there is this dilemma it may be helpful to have guidelines, but it does raise the debate about whether it promotes the practice."
Anorexia is a complex mental illness in which sufferers starve themselves even when they are dangerously thin. Refusing to eat is a way of coping with their emotions and problems and keeping in control. Experts believe 20% of those seriously affected will die as a result, from associated conditions such as heart failure which may occur years later.
Experts fear the size zero craze led by models with a waist measurement of just 22 inches is triggering more eating disorders among women.
Fiona Campbell, who is recovering from anorexia after suffering from the condition for 20 years, said she believes the guidance will save lives.
She said: "When people's weight drops with an eating disorder their ability to make rational decisions becomes more difficult and their obsessive tendencies become more pronounced. It is very important that there is something in place that can help."
Scottish Conservative health spokeswoman Nanette Milne said: "If people are this ill they need to be treated and this is a life-saving measure. But it then has to be followed up with proper psychiatric treatment and there are serious concerns about the lack of facilities for these patients, and it's crucially important that they are given the proper treatment because this is a serious illness."
SNP health spokeswoman Shona Robison said: "The idea of force-feding is something that makes me feel very uneasy and I would want to meet with the Commission to talk about this. Obviously this would be used only in extremis, but then not eating is only a symptom of what is really mainly a mental illness. The key difficulty is a lack of available mental health services, and that is what needs to be addressed."
Disorder leads to disease and death
ANOREXIA nervosa is an eating disorder mainly affecting adolescent girls, but boys can also suffer from the condition.
Its cause is unknown, however biological and social factors are believed to contribute. Puberty, bullying, peer pressure to lose weight and other life stresses are often catalysts.
Health practitioners usually diagnose anorexia when someone's body weight is at least 15% below their expected weight.
Symptoms include depression, cessation of periods, delayed development in puberty and loss of interest in socialising.
There are many medical risks associated with anorexia, including irregular heartbeat, mineral loss, reduced fertility and osteoporosis. Sufferers are encouraged to seek help from their GP.
Hospitalisation can be required when body weight drops 20 to 25% below normal weight. Treatments include talking therapies and medication.
Severe anorexia can prove fatal. Lena Zavaroni, the Scottish child prodigy, developed severe anorexia and depression.
Despite spending two years in a Canadian clinic for eating disorders, the singer, from Rothesay on the Isle of Bute, died of pneumonia aged 36 weighing less than five stone.
Brazilian model Ana Carolina Reston died from anorexia-related complications last year, aged 21.