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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst Moral ResponsibilityAgency and AnswerabilityAgency and ResponsibilityAgency, Freedom, and Moral ResponsibilityAging, 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How Much?Why Some Things Should Not Be for SaleWisdom, Intuition and EthicsWithout ConscienceWomen and Borderline Personality DisorderWomen and MadnessWondergenesWould You Kill the Fat Man?Wrestling with Behavioral GeneticsWriting About PatientsYou Must Be DreamingYour Genetic DestinyYour Inner FishYouth Offending and Youth Justice Yuck!
Judging from the number of books in the
Psychology/Self-Help sections of bookstores, the general public has a strong
interest in issues to do with mental health and clinical psychology. Academics in the fields of Philosophy and
Biomedical Ethics have, however, largely neglected the metaphysical,
conceptual, ethical and political issues to do with psychopathology that so
fascinate others. Philosophers have had
some well-publicized debates about the scientific status of psychoanalytic
theory, but these have been of merely academic or theoretical interest, since
in psychiatric practice psychoanalysis faded out decades ago. There has been a change of intellectual
climate in the last five or so years that philosophers and ethicists have
started to investigate clinical psychology as it is actually practiced. It is helpful to compare this book by
Jennifer Radden with one by Carl Elliott; both are important landmarks in the
development of the new field of philosophy of psychiatry.
Both books deal primarily with issues of the moral
rights and moral responsibilities of people with mental illnesses. But they have quite different styles. Raddens Divided Minds and Successive
Selves is aimed at an audience with philosophical training. It is academic in its approach, and pays
careful attention to detail. The actual
writing style is quite typical of modern academic philosophy, i.e., dry and
sometimes hard to read. Radden is prone
to clunky prose style, and her book would have benefited from more careful
attention from an editor. I even wonder
whether the font (Bembo) in which the book is printed is hard on the eyes: something
about the physical appearances of the pages makes the writing look
unapproachable to me. Elliott is a
better writer, and since The Rules of
Insanity is a slim 124 pages of text, it is a comparatively quick
read. His claims are easy to understand
and his arguments are straightforward.
The scope of the book is relatively narrow. In contrast, Raddens book is ambitious, covering a wide variety
of issues and fields of study. There is
no overall simple thesis for which she argues, and her book defies quick
While the subtitle of Raddens book is Ethical
Issues in Disorders of Identity and Personality, the book actually devotes
more space to discussing metaphysical issues, which are then used in arriving
at ethical conclusions. There are four
parts to the book, the first of which is devoted to setting out the basic
issues to do with understanding the differences between the unity of mind in
normal people and the disunity of mind in the various forms of
psychopathology. Radden is quite ready
to agree that these differences are real: she is not sympathetic to some of the
radical views of critics of psychiatry, who have claimed that there is no real
difference between sanity and insanity, or madness is just a label that society
uses to control deviancy. Although she
does say some things which might go against some psychiatric practices, she is
happy to stay within the mainstream.
Radden emphasizes that we need to be careful in our
characterization of normal minds. They
are not as unified as we might think.
However, there are still striking differences between the normal and the
pathological. The clearest case of
multiplicity within a mind is in dissociative identity disorder (DID),
popularly called multiple personalities.
Here there are different selves coexisting within one body. Radden does not go so far as to say that the
different selves are different people, but they collectively have significantly
more diversity among them than a normal person does in him or herself. Each self is a separate agent, with a
distinct personality, which persists over time (even though the self may not be
present all the time), and the subject (i.e. the collection of selves) appears
to experience unusual amnesia.
Armed with these criteria, she moves on to examine
other clinical phenomena, such as mood disorders and schizophrenia, in order to
determine the extent to which they also exhibit multiplicity. She points out that these illnesses do not,
as a rule, lead to profound personality changes. The personality change associated with mania can last for weeks
or months, and while there is no significant loss of memory, there is memory
distortion and selectivity. But
Radden's discussion of these cases is disappointingly short. Despite the fantastic array of real clinical
phenomena, she only considers in this part of the book one real life example of
schizophrenia. She concludes that it can make sense to say that during a acute
phase of the illness, we are dealing with a different self from the normal self
that previously existed, and will return when the illness is controlled.
Contexts of Responsibility
Part II of the book is the longest of the four, at
over 100 pages, divided into six chapters.
The main point of this part is to investigate the responsibility of the
successive selves we find in abnormal psychology for the actions of the person
they constitute. Radden says that there
is no simple rule with which we can judge the responsibility of a person with a
mental illness. Instead, we need to
specify the context in which we are concerned with responsibility. The approach used in psychotherapy, for
instance, will be quite different from that used in a court of law. In therapy, the different selves of a person
with DID will consider themselves quite separate from each other, and not
responsible for each others actions.
However, in a court of law, it is not practical to make such fine
distinctions, because there the bottom line is whether the defendant should be
found innocent, or found guilty and punished.
It is not feasible to find one self innocent and other guilty, even
supposing that we could be sure that the defendant was not faking multiple
Radden considers whether people with DID who have
committed crimes should be found not guilty on grounds on insanity, diminished
capacity, or other possible defenses linked to the disorder. She concludes that no such defense is
justifiable, although there might be good reason to reduce the punishment. Currently this is an issue of mainly
theoretical interest, since there have been very few cases of defendants trying
to avoid punishment on the grounds of having multiple personalities. It might become an issue of greater public
concern if such a defense becomes more common, but this seems unlikely given
the current public hostility to any insanity defenses, and the particular worry
that it is easy to fake the dissociation of identity.
A topic of more public concern is when it is morally
permissible to force a mentally ill person to undergo psychiatric
treatment. The law generally permits us
to hospitalize a person if she has a major mental illness and is a serious
danger to herself or to others. But
there are many more times when a person does not meet such stringent criteria,
and yet her family or friends are concerned enough to try to convince her to
seek treatment. When rational or
emotional persuasion fails, there is not much that people can do, since, at
least in America, so much emphasis is put on the right of citizens to be free
from interference. Can a moral case be
made for overriding this right in the case of people who are not dangerous but
whose lives are going severely awry because of their untreated mental illness?
Radden argues against various philosophers who have
tried to make such a case. It is hard to say that the mentally ill are
incompetent to run their own lives, because we have no clear criteria of
competence. If we force treatment on
one person on the grounds of incompetence, for making a disastrous life
decision, where can we draw the line?
Clearly there is a danger that government or the medical establishment
would start to have too much power over peoples lives.
Other proposals for justifying forced treatment are
that it is in the patients best interest, or that it is what the patient would
have wanted. Radden does an impressive
job in showing the problems that arise for these approaches. Neither does it work to argue that, by
making the patient take drugs or involuntarily hospitalizing her, we are
actually returning her to her true self, and so, despite appearances,
increasing her freedom. There are
enough difficulties with this idea that it fails to pass the crucial test of
being a solid argument. Radden insists
that if there are lingering questions about the soundness of the arguments, we
should stay on the side of liberty.
Sometimes it is not just the
family and friends of an ill person who wish she could get treatment. Sometimes she herself, before and after the
illness, wishes that she would get treatment when ill. In such cases, she might write instructions
ahead of time, while healthy, saying that she permits, or even demands, to be
forced to accept treatment. These have
been called Ulysses contracts.
Presumably they are a legal minefield, but Radden is not interested in
the legal aspects. She is concerned
about the moral legitimacy of these directives, and argues that unless the ill
person is actually self-destructive, we should not honor her previous request
to force treatment.
Her argument is subtle. We can view the situation in one of two ways. Either the contract-writing healthy self
counts as a different individual as the later irrational ill-self, or they are
the same. If they are different, then
what we have is one individual forcing another to get treatment, and this is
unfair. If, on the other hand, they are
the same individual, then that individual has the right to change her mind
about whether she wants treatment, and she should be able to refuse it. We think people have the right to make bad
choices, and the mentally ill should be no exception to this, no matter what
they previously instructed.
It is a standard liberal view that we can override a
persons wishes just when those wishes are likely to harm another. In a person with recurrent major mental
illness, understood on a successive-self analysis, when the ill-self threatens
suicide, this also threatens the healthy-self, who would re-emerge if the
illness was treated. We can interfere
with suicidal wishes when a person is mentally incompetent, but incompetence is
difficult to establish even in the suicidal.
On Raddens view, however, we dont need to resort to declaring the
ill-self incompetent, since her self-destruction can be prevented on other
grounds, i.e., the protection of the healthy-self. Here she is assuming that the healthy-self and the ill-self are
different individuals. The ill-self
might have the right to destroy itself, but it does not have the right to
destroy the healthy-self.
There are several problems with this argument, but I
will just mention one here. It proves
too much. For it would follow from this
analysis that the healthy-self does not have the right to destroy the ill-self. Of course, the healthy-self is not suicidal,
but in a sense, it wants to destroy the ill-self. The healthy-self has a right to exist, but the ill-self has equal
moral status, and so cannot be intentionally destroyed. A person who was successfully treated by
medication, for instance, would seem to have a responsibility to go off it
periodically in order to allow the ill-self some more time to exist. This conclusion is so absurd that it casts
doubt on Raddens successive-self analysis.
For the third part of the book, Radden obliquely
opposes postmodernists who advocate a multiplicity of self. She argues that being unified is generally
better than being disunified. This is
also relevant to therapists treating patients with DID: should they aim to
bring all the personalities together into one, or is it reasonable to allow
them to continue to coexist? Radden
favors the merger of the different personalities into one.
In making her argument over four chapters, Radden
goes into interesting details and thoughtful discussion. She tends not to take
strong stands in this part. But she
does argue that it makes sense to say a person is responsible for her past
actions, at least in some ways, even when she has gone through such severe
personality change that she is not the same self as she was previously. She concedes that in cases of extreme flux
and discontinuity, as found in DID, it hardly makes sense to use our normal
language to describe peoples lives.
But she thinks that in more moderate cases, it is at least possible to
apply the concepts to some degree. For example, we find no problem in saying a
person was trustworthy for some period of her life, but not during another
period. Radden points out that one can
have integrity through dramatic changes in oneself, if there is a continuity of
self-monitoring. Indeed, this is what
often goes on in therapy.
Metaphysics of Possession
In the fourth and final part of the book, Radden
delves into philosophy of mind and turns to the ways that minds can be divided
at one time. She starts off considering
whether there can be more than one center of awareness within a body at one
instant. Much of the supposed
behavioral evidence for this phenomenon is not conclusive, both in people with
DID and in hypnotic states, and in people who have had operations to sever most
of the neural connections joining their two brain hemispheres. She says it is possible to explain these
phenomena without recourse to hypothesizing a divided consciousness. She also examines a variety of other
psychological phenomena, such as thought insertion, depersonalization,
derealization, possession states, and out-of-body experiences as other possible
sources of evidence for divided consciousness.
Radden argues that they are cases of division, but this does not mean
that there are two separate independent centers of awareness. Rather, they involve a duality of experience
happening to one center of consciousness.
Finally, Radden considers the ways in which we can
see some parts of our minds as not really part of us at all. This is to do with the distinction between I
and not-I. For instance, schizophrenics
sometimes experience auditory hallucinations, where they hear voices as if they
are coming from someone next to them.
The voice sounds as if it is not their own, but belongs to someone else. In these cases, the hallucinators think that
it does really belong to someone else.
Radden says this strange phenomenon is not a matter of people failing to
realize who is having the experience, but rather a failure to realize that they
are the actual originators of the experience.
In this kind of work, Radden is doing a form of conceptual tidying of
our metaphysical understanding of the mind.
It is worthy work, although it is hard to make it exciting to those who
are not predisposed to be interested in such fine detail.
Falling Between Several
Divided Minds and Successive
impressive for its relevance to current philosophical debates and shows how
much the philosophers writing about subjectivity and consciousness are missing
when they neglect issues arising from the study of psychopathology. But philosophers will criticize the book for
not doing into enough detail, and its overly brief discussions of the ideas of
other philosophers. The book may be
interesting to philosophically-minded psychologists and psychiatrists who are
interested in gaining a clearer conceptual understanding of the phenomena they
deal with in their everyday practices.
But unfortunately it is unlikely to appeal to a general audience. Apart from the stylistic problems and the
use of philosophical jargon, the issues it deals with tend to be abstruse, and
Radden shies away from dealing the implications of her ideas for current social
issues. This is a pity, because the
work she has done is actually original and important, and deserves to gain wide
attention. I hope that she will in the
next few years write a sequel to Divided Minds and Successive Selves,
which would be aimed at a wider audience, and would engage more in the debates
that rage over social and legal policy.