Book reviews 67

The place of these important tools formedical practice, education and re-search and as aids to the enlighten-ment of patients is well explained andfully expressedThe authors have carried out an

excellent, timely and scholarly reviewof iatrogenic illness. It is my hope thatthey will examine in a subsequentbook such topics as commerciogenicmedical harm (marketing of medi-cines and infant formula) mediogenicmedical harm (premature proclama-tion of "breakthroughs" and unbal-anced scare stories) political medicalharm (subordination of health care toweaponry, and medical involvementwith torture), and ideological medicalharm (denial of medical care towomen, sanctity of life, abortion,euthanasia, terminal care).

THOMAS E OPPEEmeritus Professor of Paediatrics

Ethical Issues inMental Illness

Caroline Dunn, Aldershot, AshgatePublishing, 1998, 201 pages, £39.95.

Caroline Dunn's book places au-tonomy at the centre of ethical debatesabout mental illness and its treatment.Her account differs from some othersinsofar as she is keen to make sure thatthe "voice" of mentally ill patients andtheir families is heard throughout herbook; and she suggests subtly (andsometimes not so subtly) that mentalhealth care professionals frequentlyfail both patients and families.Dunn takes the view that mental ill-

ness is a valid concept, that mental ill-ness is an illness, and therefore doesnot engage with questions of the valid-ity of the concept. Rather, she goes onto explore how autonomy may beaffected by mental illness. She per-ceives the autonomy of the mentally illto be restricted insofar as the mentallyill lack rationality, and she spendssome time discussing what rationality,or more obviously what irrationality,might mean. For Dunn, "the ability toreason" is a crucial aspect of au-tonomy. It is this lack of the ability toreason which makes the mentally illpatient less autonomous.Dunn then goes on to discuss the

treatment of the mentally ill and ishighly critical of traditional psychiatriccare. She uses excerpts from the writ-ing of Antonia White and Jimmy Lang(who was institutionalised from a veryearly age for many years in different

types of institutions including penalones), and, finally, documents writtenby the mother of a person with schizo-phrenia who later died of a drug over-dose. She suggests that patients aretreated badly by traditional mentalhealth care systems because they arevoiceless; and that the voicelessness isone aspect of the denial of autonomyby virtue of patients' perceived irra-tionality. However, she is also criticalof the opposite view, in which the realdisabilities of the mentally ill are notproperly recognised and respect forpatients' autonomy is privileged aboveother interests; what she calls "benignneglect".

I have no doubt that Dunn is rightto address the ethical dilemmas inher-ent in the assessment and treatment ofpatients with mental illnesses in termsof autonomy and restrictions on au-tonomy. However, I was sorry not tosee in Dunn's account of autonomyany mention of the importance ofemotions as being an important aspectof full rationality. Although traditionalaccounts of reason, and the ability toreason have always excluded experi-ence of feeling and its expression,more sophisticated contemporary ac-counts of rationality concede that per-sons who have either too little or toomuch emotion are also not fullyrational. This argument was hinted atby Carol Gilligan,' and developedmore fully by Justin Oakley.2 Stimulat-ing accounts have come from neuro-scientists such as Anthony Damasio'who have described cases of peoplewith decreased capacity for emotion asa result of their brain damage, whoalso appear to have significant deficitsin their capacity to reason. This ofcourse is highly significant given thatmood disorders (especially depres-sion) are probably the commonestmental illness suffered by the generalpopulation of the mentally ill, includ-ing those with psychotic illness.Dunn's account of autonomy does

not go on to explore how differenttypes of mental illness might impairautonomy and the ability to reason.She seems to rely heavily on accountsof patients with psychotic illnesses.However, these are only a very smallproportion of patients with mental ill-ness: similarly, she addresses (briefly)the question of compulsory detentionfor the protection of others, not men-tioning that detained patients are verymuch the minority of those who aretreated by mental health care profes-sionals. The question of how andwhen it is justifiable to detain peopleon the grounds of mental illness for

the protection of others is an enor-mously important question of course;but it is perhaps not the only issue inrelation to mental illness.Dunn raises an important concern

when she questions the nature of therelationship between mental healthcare professionals and the relatives ofpatients with severe and chronic men-tal illness. In particular she raises thequestion of what duties mental healthcare professionals might have to suchrelatives. I was surprised not to see anymention of resources in her discus-sions; Dunn seems to suggest thatmost of the limitations of the mentalhealth care system are a function ofthe attitudes of the professionalsinvolved. Although this is true to someextent, it must be relevant to the pro-vision of care that the number of inpa-tient beds available to mental healthservices has fallen by a half in urbanareas like Central London. It is alsowell known that there is a lack of con-sultant psychiatrists and experiencednurses, so that many mental healthservices not only do not have theresources, but do not have the staff tooffer a proper service either. It seemsto me the other aspect of voiceless-ness, which Dunn rightly emphasises,is that the mentally ill are not votewinners and their needs are easilyignored.

This might seem like special plead-ing by a reviewer who is a psychiatristand a psychotherapist. But I think it ismisleading to present deficiencies inmental health care simply as a ques-tion of professional attitudes. There isundoubtedly much more to do in theeducation and training of all mentalhealth care professionals; in particularI would argue that education inphilosophy and ethical reasoning iscrucial because there are so very manyethical and conceptual dilemmas indaily clinical practice. I had a sensethat Dunn's heart was in the rightplace, but found her account of thesemost important issues somewhat cur-sory. I think there is probably room fora book which addresses itself solely tothe question of the nature of au-tonomy and how mental illness im-pinges upon it, but this is not it. Ifound this a rather tantalising bookwith a broad base using broad argu-ments. It had for me a somewhatempty quality insofar as there wasnothing in the book about the encoun-ter between two people, which is thebedrock of the professional-patientrelationship in mental health care. IfDunn is seriously concerned about theattitudes of mental health care profes-

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68 Book reviews

sions, then it might have been interest-ing for her to find out more about thefeelings and thoughts of those profes-sionals in relation to their patients; totry and understand how it is that theycome to have these attitudes which failtheir patients. Otherwise one is forcedinto a somewhat adversarial position,which as Dunn rightly suggests is not away to address a complex dilemma.

References1 Gilligan C. In a different voice. Cam-

bridge, Mass and London: HarvardUniversity Press, 1984.

2 Oakley J. Morality and the emotions.London: Routledge, 1992.

3 Damasio A. Descartes' error: emotion,reasons and the human brain. New York.G P Putnam and Sons, 1994.

DR GWEN ADSHEADConsultant/Honorary Senior Lecturer in

Forensic Psychotherapy,Broadmoor Hospital, Crowthorne, Berkshire

RG45 7EG

A Question of Choice.Bioethical Reflectionson a SpiritualResponse to theTechnologicalImperative

Pam McGrath, Aldershot, Ashgate,1997, 242 pages, £40.

This book reports a study set withinthe discipline of bioethics which ex-plored one Australian hospice's re-sponse to death and dying, using thepost-modern notions of discourse andpower.

Although at first sight the title is atrifle unwieldy and there is somerepetition in parts of the text, the bookoffers a refreshing and timely chal-lenge to the predominance of themedical model in care of the dying inour Westernised society.The researcher takes up the chal-

lenge of combining post-moderntheory with applied research. Mc-Grath challenges the traditional bio-medical model of palliative care withits physiological, technologised, re-ductionist approach to death anddying and resultant bioethical dilem-mas. She explores an alternative wayof responding to the dying in the formof the Karuna Hospice Service(KHS), a Buddhist community-basedhospice organisation situated in Wind-sor, Brisbane, Australia.

Through non-directive open-endedinterviews with 15 subjects who are orhave been involved with KHS she firstof all describes the different approachto terminal care offered by KHS, withits emphasis on patient and familychoice, acceptance of difference, Tao-ist response to power, "will to care"and holism.She describes how a spiritual dis-

course emerged as one of the mostimportant differences between theKHS and mainstream medicine. Thisdiscourse was central to KHS's differ-ence and became the main focus of theresearch. In sharp contrast to the bio-medical discourse with its emphasison power, status, profit and income,the spiritual discourse or "gentle spir-ituality" was described as providing"the discursive space and a subjectiv-ity which creates, supports and at-tracts spiritual ways of seeing and act-ing which can offer some resistance tothe dehumanising aspects of biomedi-cine's demands" (page 164). McGrathdescribes how this spiritual discoursenot only accounted for the KHS's dif-ference but allowed it to: maintain itsvision and values in spite of pressurefrom external organisations; be effec-tive in attracting like-minded individu-als, and resist mainstream bureaucra-tisation and professionalism both atorganisational level and at the grassroots level of patient care.The author acknowledges that the

findings of the study are not generalis-able and that the service provided byKHS is not suited to everyone. Shesimply offers KHS as an alternativeapproach to caring for the dying.The researcher goes on to explore

the implications of her research forbioethics. She addresses two mainbioethical issues: the question of howto respond to increasing bioethicaldilemmas arising from medicalised"high-tech" responses to death anddying; and rationalism and how thisinfluences our perception of end-of-life issues and bioethical debate.McGrath holds that bioethical di-

lemmas, such as the right to refusetreatment and when to cease artificiallife support, arise directly from amedicalised technologised response tocare of the dying. She challenges theassumption that biomedicine is theonly way to respond to death anddying, offering the KHS response as arefreshing alternative.She criticises the discipline of prin-

ciplism (ie "disciplined reflection onmoral intuitions and moral choices"),'as too theoretical and unrealistic andfor ignoring issues ofhuman emotions

and power. She takes this criticismfurther, choosing to explore otherways of arriving at ethical insightsusing post-modern notions of dis-course, power and subjectivity. Shesteps out of the biomedical discoursecompletely and into KHS holisticspiritual discourse, which she presentsas one example of an alternativeresponse to the dying, and which, sheclaims, avoids many of the problemsthat biomedical reflection tries toaddress. Instead of applying principlesto ethical dilemmas, the KHS re-sponds at a deeper level, choosing to:empower individuals and their lovedones by encouraging autonomouschoice; engage ethically with the indi-vidual; serve others, and accept andsupport the individual in a non-judgmental manner.

In the final chapter the authorpoints out the dearth of research onspirituality in health care. She ac-knowledges the difficulty in investigat-ing this topic and holds that to do sousing scientific epistemologies whichare based in the physical sciences isinadequate. She expresses the need foran "expanded science" and presentsthe post-modern approach sheadopted as one example of an "ex-panded science".2The book will be more easily

digested by those with a knowledgeand understanding of post-moderntheory, although for those with a lessdetailed knowledge an adequate de-scription is given, with useful summa-ries, in most chapters. The book is forall those with an interest in and/orinvolved in caring for the dying. Itshould especially be welcomed byprofessionals working in hospices. Inparticular the book should be read byprofessionals caring for the dying inhospitals or nursing homes, for whomit should present a special challenge.

References1 Veatch R. Medical ethics. Boston: Jonesand Bartlett, 1989: 6.

2 Fahlberg L, Fahlberg L. Exploringspirituality and consciousness with anexpanded science: beyond the ego withempiricism, phenomenology, and con-templation. American Journal of HealthPromotion 1991; 5, 4: 273-81.

LINDA A ROSS

School of Nursing and Midwifery,University of Glamorgan

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