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by Donna Dickenson and Bill Fulford
Oxford University Press, 2000
Review by Christian Perring, Ph.D. on Nov 19th 2002

In Two Minds

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 adoption.

·        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 psychotherapist’s 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 Alzheimer’s disease who refuses help from social services but is a burden to her neighbors.

·        15-year-old boy requests genetic testing for Huntington’s disease.

·        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 outpatient follow-up.

·        79-year-old man with Alzheimer’s 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 patient’s “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 don’t 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 philosophically richer.) 

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, it’s 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.

Christian Perring, 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 general public.