In Two Minds is an excellent
casebook of tough ethical problems in mental health. It aims to provide a thorough discussion of a number of
perspectives on a variety of cases.
There are fourteen main cases discussed, with several other shorter
examples scattered through the book.
The first section, consisting of two chapters, sets out the tools of
the trade, explaining some of the basics of philosophy and the particular
approach the authors take. Their
central claim is that issues of value are pervasive in psychiatry, and thus
psychiatric ethics has a broader scope than more traditional medical ethics. They organize their cases around the stages
of the clinical process: the proper scope of psychiatry, diagnosis, etiology,
treatment, prognosis, and teamwork and the organization of services. The final chapters look at teaching and
research ethics. The book includes some
comical cartoons to illustrate some of the main points, and there is a reading
guide to the literature at the end of each chapter. Each case has a commentary
by a practitioner as well as its own list of articles and books referred to in
its discussion. The authors emphasize
the importance of understanding the point of view of patients, and steer
between the extremes of a rigid medical model and a radical
antipsychiatry. They do not insist on
any particular methodology, but rather are inclined to use whatever approach
might be helpful in a given situation.
They often argue that conceptual analysis can be a helpful tool in
understanding the issues at hand.
Given that this is really the only
book of cases in psychiatric ethics that is currently in print, it has no
serious competition. It sets a high
standard for any future competitors, in its broad ranging discussion of the
philosophical issues raised by clinical experience. It is worth listing the cases:
35-year-old solicitor with a ten-month-old baby who
previously had postnatal depression and now wants to put her baby up for
53-year-old man with a learning disability with fecal
impaction due to chronic self-neglect.
42-year-old man with hallucinations, delusions and
strong suicidal feelings who says he has nothing to live for.
35-year-old woman with a history of repeated hospital admissions
who makes it very difficult for people to help her.
Middle-aged African-American lawyer whose religious
experience may be interpreted as psychosis.
42-year-old woman who is depressed and suicidal but
refuses admission to hospital.
27-year-old woman with genetic disorder who acquires an
odd belief about her psychotherapists sexual attitudes towards her.
38-year-old man with history of inveterate drug and
alcohol abuse becomes the principal carer for his three daughters.
69-year-old woman with Alzheimers disease who refuses
help from social services but is a burden to her neighbors.
15-year-old boy requests genetic testing for
54-year-old man who is depressed and suicidal is due to
be released from hospital but he may be a danger to his sons.
Man in his early forties with paranoid schizophrenia
and a history of indecent assaults who is reluctant to continue with his
79-year-old man with Alzheimers disease; should he be
allowed to return home after being hit by a car?
15-year-old boy suffers repeated psychotic breakdowns
but his father refuses treatment for him.
The cases are described in good detail for a page or two and
then the subsequent discussion takes several more pages. Naturally, one of the central themes is the
competency and autonomy of an individual and the rights of psychiatrists to
impose treatment. They raise a wealth
of important considerations, including the definition of mental disorder, the
responsibility of agents for their actions, the criteria for rationality, the
scientific basis of psychiatry, the rights of patients, the notion of the
patients true wishes, the dangers in predicting dangerous behavior, and the
responsibilities of research scientists towards their subjects. The authors bring in not only ethical
theory, but also philosophy of mind, personal identity, methodological
considerations, and epistemology.
Strangely, there is almost no discussion of the nature of freedom of the
will and the question of whether alcoholics and drug users are responsible for
their actions. This is a missed
opportunity, and is especially odd given that Fulford has elsewhere argued that
the best way to understand mental illness is a failure of action, and one of
his central examples concerns addiction.
Nevertheless, through their sustained argument throughout the book, the
authors succeed in their aim to show that psychiatric ethics as they practice
it is philosophically richer and more challenging than traditional medical
ethics, although they dont give any reason to suppose that medical ethics
could not be more philosophically interesting.
(Indeed, since the authors are also co-editors of Healthcare Ethics
and Human Values: An Introductory Text with Readings and Case Studies
(2002), it is likely they believe that medical ethics can become
There are however, some significant
limitations to this text. Most
obviously, it is very much devoted to a British context. The authors are British and all the
practitioner commentaries are by British clinicians. When legal issues are raised, the only law
covered, with a couple of exceptions, is British. This makes the book far less useful to a wider international
readership, and it all but rules it out as a possible textbook for teaching
psychiatric ethics in North America or the rest of the world. It also means that it does not deal with
some of the problems that are specific to the US. It is striking that the book includes no cases that concern the
ethical quandaries faced by psychiatrists when trying to get the best care for
patients with no or inadequate coverage from health insurance or managed care
providers. Indeed, with only fourteen
main cases covered, the book leaves many kinds of difficult cases
undiscussed. There are no cases of
children with depression, attention deficit hyperactivity disorder, or conduct
disorders with schools or parents demanding that they be placed on medication,
or refusing to allow them to be treated.
Neither does the book include sustained discussion of patients
threatening their doctors with violence, nor of doctors becoming sexually or
romantically involved with their patients.
While some of the cases are of parents who may be unable to carry out
their parental responsibilities or may even be a threat to their children, none
of them includes sexual abuse.
Another limitation of the book is
that while it provides excellent discussion of its cases covering both the
philosophical issues and the practical details, its less clear whether readers
will find it easy to use the book as a manual to help find the correct answer
to difficult cases. Of course, this may
be asking too much of a casebook. As
much as readers may wish for an algorithm for deciding the right course of
action given any ethical dilemma, this is simply not possible in most
cases. The philosophical issues are
simply too complex and our ethical knowledge is too uncertain for simple
answers to be available. Nevertheless,
the authors could have provided more in the way of a decision-making framework
to help clinicians work through difficult cases. Furthermore, it would be helpful to not only discuss the
philosophical complexities, but the difficulty of acting in the face of the uncertainty
of philosophical knowledge and the contingency of philosophical beliefs. One of the central problems in real life
cases is how to proceed when those responsible for decision-making consider the
facts with great care, deliberate long and hard about what to do, and yet still
disagree amongst themselves about what is best.
Even with these limitations, In
Two Minds is still an excellent resource for those interested in
psychiatric ethics. It is the natural
choice for a textbook for courses on this topic in Britain, and it could be
used for similar courses in the US and other countries if it were supplemented
by other readings or information relevant to the country in question. Highly recommended.
2002 Christian Perring. All rights reserved.
Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island.
He is editor of Metapsychology Online Review. His main research is on
philosophical issues in psychiatry. He is especially interested in exploring
how philosophers can play a greater role in public life, and he is keen to help
foster communication between philosophers, mental health professionals, and the