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In Two Minds: A Casebook of Psychiatric Ethics
  1. S Louw

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    D Dickenson, Bill (KWM) Fulford. Oxford University Press, 2000, £27.50, pp 382. ISBN 0–19–26–28–58–5

    Although the title describes this as a “casebook”, it is much more than that. The casebook format entices the reader into a series of readily accessible discussions of increasing complexity and erudition until a vast landscape of medical ethics is evoked and in many instances the very bedrock of morality exposed. The authors seem effortlessly to introduce complex philosophical ideas, including sections on the philosophy of science and the philosophy of mind (rationality, meaning, agency, identity etc). The centrepiece of the book is undoubtedly a series of well-chosen cases (thematically progressing from diagnosis to management and prognosis), each followed by an extensive analysis of the ethical issues, including contrasting arguments from different vantage points. There then follows a commentary by a practitioner with relevant experience—in some cases this reflects a practical, no-nonsense approach, while other commentators develop points or themes made by the authors. Each section is rounded off with an extensively annotated bibliography. Considerable space is also devoted to legal issues: an appendix provides a four page glossary of key legal cases.

    The book is extraordinarily innovative in many respects. Not only is the case history and analysis format interesting and methodologically robust, but the case material is so challenging and the ethical analyses so wide ranging and scholarly that it is difficult to put this book down! One discovers how different analytical strategies lead to progressively deeper levels of understanding of the ethical issues, thus exposing “the heart of the matter”; along the way one is referred to books, chapters, and articles for further reading. As might be expected, Fulford’s notion that an explicit analysis of values is helpful in defining diagnostic concepts in all areas of medicine is a recurring theme. Dickenson’s interest in informed consent (also in children), “moral luck”, and her feminist reconstruction of rationality, are drawn upon in several sections.

    Several of the clinical cases are “grey area” cases—cases that do not easily fit into clear diagnostic slots, where clinicians disagree about the precise diagnosis and may start doubting their own judgment. For example, the question of the differential diagnosis of a man who appears to have a religious delusion, yet leads a very successful professional life turns “not on the facts about his experiences and behaviour, but on a series of value judgements”. The authors point out that the diagnosis of schizophrenia in the DSM-IV (a widely used diagnostic classification system) requires the criterion of “social/occupational dysfunction … below the level achieved prior to the onset”. Here a paradox is demonstrated: the evaluation of “social dysfunction” depends on values, yet the authors of the DSM-IV claim that the system was “grounded in empirical evidence”! The reader is challenged to come to terms with the value related elements of the diagnosis of schizophrenia and related diagnoses. As with several other cases, the importance of a team approach is emphasised, bringing to bear, as it should, a variety of perspectives that may include elements of cultural formulation and the patient’s values.

    Other chapters address teamwork and service organisation, and research ethics; a section on wider perspectives gives an international view; in an interesting chapter Fulford describes the basis for his belief that psychiatry can take the lead in bioethics, “providing lessons for medicine as a whole”. There is also a useful sample teaching seminar, showing how theory is put into practice.

    This book will appeal to any reader who wishes to escape from the well-worn path of “four principles plus”. It is likely to be enriching to psychiatrists who feel that the DSM-IV and ICD-10 are constrained not so much by limitations of their science, but of their humanities. It provides thoughtful material for those interested in finding a way of resolving the tensions between physical medicine, psychiatry, and ethics. The book is a treasure trove of annotated bibliographies and very enjoyable to read.