Mental Health Services: II. Ethical Issues

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II. ETHICAL ISSUES

At the beginning of the twenty-first century, American society is engaged in a continuing critical reexamination of fundamental issues in health matters. As healthcare reforms progress through the social and political process, the opportunity exists to remedy past failures in the management of health resources, to renew fundamental values and commitments to individual and public health, and to shape new priorities for a system of healthcare that is both fiscally sound and ethically justified. The most pressing challenge is to allocate health resources to those in need of them without unfairly compromising other cherished social goods such as education and defense, or other ideals such as economic prosperity and self-determination. This challenge is made even more complex by the relentless growth in technological and scientific achievements, and an ever-widening public concern about their responsible use and distribution in society.

Of increasing concern to many in American society is the system of goods and services to provide care to the mentally ill. The mental health system of the 2000s is a complex web of intersecting and often competing factors that reflect changing ideas regarding mental illness and the resources that are needed to deal with it. The mental health field is characterized by a stunning diversity of problems that reflect the complex shifts in society over the past several decades. Whether these problems are considered in terms of diagnosis, level of dysfunction or disorder, duration of symptoms or disease, or social attitudes regarding concepts of deviancy and dangerousness, mental illness is a problem of enormous complexity and heterogeneous characteristics. The ethical issues are no less complex, and raise some of the deepest philosophical questions regarding mind and body, the nature of suffering, the range of human potentialities, and the conflicts between individual and societal needs.

Although ethical considerations are implicit in nearly every aspect of mental healthcare, the emphasis in this article is on ethical aspects of the mental health service system. The most dominant issue is the problem of justice and the derivative question of how to strike a fair and equitable balance between the requirement that society protect its citizens from harm and its simultaneous duty to protect and promote the moral, legal, and civil rights of each individual. Answers to this particular question continue to be reflected in various mental health directives and policies that define the field of mental health services. In various ways, these directives and policies document the extent to which the problems of mental illness are valued or disvalued by society, the eligibility criteria of those persons who may receive society's goods and those who will not, and the perceived importance of mental health to the vitality and character of the nation.

This article addresses the issues of equity, parity, and fragmentation in relation to considerations of justice, and supports the argument that mental health concerns should be given higher priority in the healthcare system of the future.

The Mental Health Service System

Mental illness affects people throughout the entire life cycle, including all age groups and socioeconomic strata (Regier, Narrow, Rae, et al.; U.S. Surgeon General). According to one estimate, approximately one-third of Americans will experience some form of a mental disorder at some point in their lives; of the 28 to 30 percent of all adults who experience mental disorders in a year, 2.6 percent have chronic, severely disabling conditions such as schizophrenia (Kessler, Berglund, Zhao, et al.). Psychiatric patients are more likely than the general population to have substance abuse disorders as well. Furthermore, although 28.1 percent of the population received diagnosis of mental or addictive disorders in one year, only about 15 percent received any mental health services in that time frame (Regier, et al.; U.S. Surgeon General). In 1990, the annual direct cost of mental and substance-abuse services in the United States was estimated to be $99 billion. Indirect costs, such as lost days of work, has added another $79 billion (Rice and Miller; U.S. Surgeon General).

Many mental and substance abuse disorders are severe and chronic, and thus often produce emotional and financial burdens for patients and families that last a lifetime. Although 28 to 30 percent of all adults experience mental disorders in a year, only one third of this population receives mental healthcare (U.S. Surgeon General). Similarly, despite the fact that 7.5 million children in the United States under the age of eighteen suffer from an emotional problem severe enough to require treatment, as many as 70 to 80 percent do not receive the services they need (U.S. Office of Technology Assessment). Finally, Americans over sixty-five years of age are at high risk of developing mental disorders because of reputed stressors associated with aging, including concomitant physical illness, increasing isolation, and diminished social supports. Studies demonstrate, however, that just over half of older adults with mental disorders are provided services through the mental health sector (U.S. Surgeon General). The rest, often referred by physicians—whose poor abilities to recognize the psychological symptoms of older adult patients have been documented—obtain services from the general health sector. Consequently, many older adults with mental health problems may not receive the services they need from qualified mental health professionals (Gatz and Smyer).

The current system of mental healthcare in the United States is enormously complex and has the following characteristics that differentiate it from the more general system (Phelen, Link, Stueve, et al.; U.S. Surgeon General):

Mental health services are dependent upon public funding and are frequently subject to a high degree of government regulation.
Mental health services are provided by an increasingly diverse set of professionals, including psychiatrists, social workers, psychiatric nurses, and mental health counselors. Increasingly, these services are offered in a variety of settings, including state and mental hospitals; general, private, and government hospitals with psychiatric units; community mental health centers; nursing homes; and specialized alcohol, drug, and addiction disorder treatment units.
These diverse settings may alter the transaction between a patient and therapist, and create threats to the often private and intimate character of the therapeutic relationship.
The chronically mentally ill and other severely disordered persons constitute a highly dependent population that presents extraordinary challenges for administrators and providers attempting to maintain a responsive, accountable, and humane program.
Disputes regarding the diagnosis and etiology of mental health disorders and the efficacy of their treatments persist and make it difficult to evaluate the utility of treatment programs.
The boundaries of mental health services are difficult to define, and create diverse sets of expectations and conflicts regarding medical and social models of disease.
Mental health services are generally perceived as having a poor public image and as valuable for only a small group in society who have aberrant emotional or behavioral conditions.

These characteristics provide a clear portrait of the complex issues faced by mental health practitioners and policymakers. They may explain some of the reasons why mental healthcare has a low position on the American agenda.

Vulnerability

Illness of any kind, but especially mental illness, exacerbates the need to depend on others for help and to trust that this dependence will not be exploited or manipulated. Many severely mentally ill persons remain dependent on the healthcare and mental health services systems to provide necessities of life. The human tragedies generated by severe mental disorders are considerable; often not only the health and well-being of individuals but also that of their families and communities are destroyed. Persons with chronic mental illness such as schizophrenia, bipolar illness, and psychoses that impair or distort decision-making abilities may be particularly vulnerable to possibly unjustified paternalistic interventions in their lives. Although the stigma attached to the use of mental health services may be diminishing, it still endures in some forms, thus increasing the vulnerability of the mentally ill to negative social judgments. These vulnerabilities create moral obligations on the part of society and its institutions to provide the resources to meet basic human needs and promote policies that include strategies to avoid discrimination, stigmatization, and the exploitation of dependence. These obligations are grounded in moral beliefs regarding society's duty to help those who are weak or vulnerable, and on the moral principles of care and trust that form the basis of the therapeutic relationship between patient and provider (Carter).

Historical Features of Mental Health Services

Although mental healthcare represents a significant part of the overall healthcare system, it has been separated from the mainstream of healthcare by historical, institutional, and conceptual barriers. Historically, mental healthcare was linked to social welfare policies; mentally ill persons incapable of living in society were separated from it not so much because they were sick as because they were viewed as disruptive to society. They were cared for in local or state asylums. These institutions, and the cycles of reform they mirror, have been the subject of well-documented historical works (Deutsch; Foucault; Grob, 1991). Of relevance in this article are the underlying moral and social reasons that justified the various services provided within these institutions. For instance, in the early 1800s social reformers and physicians began to lobby against a shared responsibility by the state and local governments for providing services to the mentally ill. As a result, many mentally ill persons become wards of the state (Boyle and Callahan). In the institutions of the mid-nineteenth century, treatment consisted of providing a calm, humane, and disciplined environment. The ethical justification for these services was that the state could meet its responsibilities to the individual, family, and community by providing medical treatment for acute problems and humane, custodial care for those with chronic problems. Furthermore, the health of the general public could be served by protecting society from the threat of disease or dependency (Grob, 1992).

In the early twentieth century, the United States began to embrace the view that the individual is responsible for meeting the basic needs of life. Society, in the form of federal or state government institutions, would intervene only when an illness placed excessive burdens on the afflicted individual or family, when the disease posed a danger or threat to the community, or when the individual lacked the necessary resources to deal with it. Vulnerable people, such as those with tuberculosis, mental illness, or mental retardation, could obtain needed services such as those provided in the mental institutions of the day. There was no broad right of access to healthcare services; rather, the dominant social policy focused on the value of serving only those with special needs. Mental health policy in the 1940s was based on the assumption that society had an obligation to provide a severely and chronically ill person with both care and treatment in public mental hospitals. Gradually, in response to economic and cultural shifts, these mental hospitals became increasingly custodial and bureaucratic (Grob, 1992).

In the years following World War II, radical transformations shook American culture, and new ideas regarding individual and societal rights emerged. The social activism and political unrest of the 1960s provided the backdrop for a number of shifts in thinking about the nation as a whole. States began to reconsider their policies regarding the mentally ill, and people who had been cared for in mental hospitals were moved to newly created community alternatives. In the 1960s, the movement to deinstitutionalize the mentally ill was partly based on the idea that the chronically mentally ill could receive support in the community without infringement of their civil rights. The other assumption that fueled policies of deinstitutionalization was derived from intellectual and scientific disputes within the practice of psychiatry. Disagreements about the definition of mental illness, diverse explanations of its causes, and skepticism about treatment efficacy generated controversy and ambiguity. These disagreements in turn affected the nature of the services available to those with mental disorders.

Monumental revolutions in ideas regarding individual, civil, women's, and fetal rights provoked fundamental questions about the role of the state in a free democracy, and the power of technology to alter constructs such as life and death. As these social and intellectual events converged, new attitudes regarding the nature of medical care, research on human subjects, and the value components of therapeutic relationships began to be reflected in legal decisions, social policy, and ethical discourse. In the field of mental health, ethical concepts of autonomy, informed consent, and paternalism began to appear in the literature. Psychiatrists, social workers, psychologists, and other mental health providers began to critically examine their relationships with patients, colleagues, society, and the state. They were confronted with new puzzles, such as how to respect the recently enhanced rights to autonomy and individual freedoms, and yet protect society from the potentially harmful actions of a mentally ill person. Ethical values were often in conflict with other values, thereby dividing professional loyalties and obligations (Reiser, Bursztajn, Appelbaum, et al.).

In response to shifts in public values and attitudes, the federal government began to endorse social welfare programs aimed at prevention; new programs attempted to ameliorate the social problems that were said to foster mental illness. Mental health policy increasingly began to rely on federal government programs to administer, manage, fund, and reimburse for these services. The passage of the Omnibus Reconciliation Act of 1981 effectively eliminated previous policies that had emphasized community care outside the mental hospital (Kiesler). Federally-sponsored programs such as Medicare and Medicaid initiated cost-based reimbursement strategies that fueled the evolving rhetoric of the right to healthcare, and fed the expectation that such a right would be funded. Congressional passage of the Tax Equity and Fiscal Responsibility Act of 1982 and the Medicare Prospective Payment System (PPS) in 1982 altered this expectation by restricting future payments for inpatient hospital services.

These events, and many others detailed elsewhere, foreshadowed the current public debate regarding the existence and scope of this right to healthcare and its numerous philosophical, conceptual, economic, political, and social ramifications.

All of these transformations in ideology influenced policy directions and contributed to the evolution of a diffuse, heterogeneous system of services that provided a diverse set of services to assist the adjustment of the mentally ill to life outside the mental hospital. For instance, in the 1960s the view that mental illness did not require psychodynamic intervention, and that those experiencing problems in living could find the support they needed in the community, led to the policy of deinstitutionalization. This policy of transferring patients from public mental hospitals to community-based mental health centers, coupled with the emergence of psychotropic agents to control their symptoms, profoundly altered the mental health system.

Although many writers have analyzed the mixed impact on mental health services brought about by this policy (Mechanic and Rochefort), others underscore its abject failures in helping the seriously ill or reducing the number of inpatient services (Geller; Lamb and Bachrach). Other writers have argued that the community mental health policies not only overlooked the social and human needs of the severely ill, but also bifurcated therapeutic or treatment services from care and support services. The former were identified more with, and included in, the medical healthcare system, whereas the latter were affiliated with the welfare or social system. This bifurcation inadvertently distorted priorities, with more focus applied to providing therapeutic services in outpatient settings for a broadly defined population (Grob, 1992). Still others have argued that with the closure of state mental hospitals and related services, many chronically and severely ill individuals found themselves with nowhere to go for needed services and help (Lamb and Bachrach). Transformations in mental health laws to protect the mentally ill and promote their rights began to dominate intellectual discourse. New laws demonstrated the evolutions in understanding of the concepts of confinement, commitment, access to services, and the scope of individual autonomy in treatment decisions (La Fond). In the last decades of the twentieth century, mental health law became an able instrument of advocacy and protection of the civil, legal, and ethical rights of the mentally ill (Perlin; La Fond).

Access

Changes in the way mental health services are defined, distributed, delivered, and financed have produced a number of ethical concerns related to justice and other ethical principles. One of these is the problem of access to services. In the United States, healthcare is ordinarily covered by private or public insurance. Insurance reimbursement policies were originally constructed to shield both patient and provider against the worry about costs once an illness actually occurred. Reimbursements were quite generous and uncontested, with third parties acting as silent partners in the negotiation between physician and patient for needed services. The result of this is now obvious: a highly inflationary system with rapidly accelerating healthcare expenditures (Fuchs), which has in turn led to the growing managed care system.

Obviously, the 16 percent of the U.S. population currently estimated to be without public or private health insurance will also be without financial insurance against psychiatric or addictive disorders (Bureau of the Census). Yet even where insurance is provided, mental health insurance benefits are not on par with those in the general medical sector (U.S. Surgeon General). Moreover, Medicare and Medicaid place restrictions on the amount and setting of services for psychiatric and addictive disorders, thus further restricting the access and availability of needed resources for the mentally ill. While opportunities for mental health services increasingly exist under Medicare, only 5 percent of Medicare funding at present goes for mental health (U.S. Surgeon General). Finally, office-based care by psychiatrists, and often by other mental health providers, is generally covered by insurance firms but is rarely equivalent to other office-based physician care (Frank, Goldman, and McGuire, 1992).

Thus, although policies have been aimed at treating mental illness on an outpatient basis, all the incentives in insurance programs send the signal that inpatient treatment is what will be reimbursed. Of all mental health expenditures, an estimated 70 percent are designated for inpatient care. Many health insurance policies will reimburse fully for hospitalized care, but only partially cover outpatient care, and pay even less for prevention services. Nursing homes have not been integrated into any mental health system, although the Nursing Home Reform Act of 1987 mandates "active treatment." The predictable mental health needs of an aging population have not been factored into health policies, thus widening the gap between perceived need and access to service for a substantial segment of the population (Gatz and Smyer).

Moreover, simply being labeled as receiving treatment for a mental disorder can affect an individual's access to the general healthcare system. This occurs through the practice of medical underwriting, a process that denies individuals health insurance because of a medical disorder for which they received care in the past (Boyle and Callahan). These forms of discrimination not only impair the individual's access to services that are otherwise standard, but also further the antiquated idea of the dualism between mind and body.

These restrictions on the access and availability of services through insurance and financing mechanisms create inequities in many parts of the system. First, many Americans, especially the poor and underinsured, cannot afford the cost of needed mental healthcare. Second, many uninsured people at risk for major mental and/or addictive disorders will be denied appropriate prevention services and be inadequately protected against the possibility of catastrophic financial harm. Third, failure to provide meaningful access to services within the mental health system results in inappropriate and excessive use of the general resources of healthcare, creating further inequities for individual consumers and providers, and increasing the economic burden on the general medical economy as a whole. These inequalities of access to needed care are unacceptable to a decent and humane society (U.S. President's Commission; U.S. Surgeon General). Some of them may be explained by historical accounts of the various ideological, political, and societal events that helped produce them, but they are not justified from an ethical point of view. Any society concerned with the well-being of its citizens cannot promote the importance of healthcare in achieving well-being while allowing people to suffer because of arbitrary barriers to healthcare.

Parity

A related ethical issue has to do with whether funding of treatment for mental health conditions should be equal to that of the general health sector. Many commentators have noted a lack of parity both between the two healthcare systems and within the mental health system itself. The latter can be expressed as both the disparity of treatment between kinds of mental illness, and the disparity of treatment between different degrees of mental illness severity.

Despite several major legislative efforts in the 1990s and early 2000s, there is little evidence that any significant change in mental health parity has occurred. Aside from failing to be passed by Congress, these bills failed to greatly affect parity for many reasons, including: covering only a subset of the population; covering only selected illnesses, often based on an archaic and fictional division of the mental and the biological; only covering certain severities of illness, often based on diagnosis of a specific illness or by level of debilitation; exemptions for small businesses, or for large cost increases; unequal limits on annual costs, lifetime costs, outpatient visits, days of inpatient care, per visit co-payments, or annual deductibles; and a variety of nearly nonquantifiable disparities in the quality of care provided (Rochefort, 1996; National Advisory Mental Health Council, 1998, 2000; Geller; U.S. Surgeon General's Report).

One such piece of federal legislation passed into law in 1996 was the Mental Health Parity Act (MHPA) (Domenici/Wellstone), which required all group health plans already covering mental healthcare to have equal cost restrictions on yearly and lifetime benefits as traditional medical and surgical services. The MHPA had little effect on parity due to provisions within the act that allowed for exemptions for small businesses and for businesses that experienced an increase in cost because of the act. Moreover, 87 percent of employers' plans that complied with the MHPA had one or more methods of restricting mental health benefits more than traditional medical or surgical services. Congress allowed the MHPA to expire in 2001 and failed to pass the proposed 2001 Mental Health Equitable Treatment Act (S.543), which attempted to address most of the problems with the 1996 MHPA (Gitterman, et al.; Barry and Frank; Geller; General Accounting Office).

The greater focus on mental health parity by the federal government spread to the state legislatures with similarly ineffective results. As of 2001, thirty-one states had adopted mental health parity requirements for employee health insurance, with all but five doing so after the passage of the 1996 MHPA. However, the 1974 Employee Retirement Income Security Act prevents states from regulating self-insured plans, thus limiting the affected population to those in group health plans (Gitterman, et al.; General Accounting Office; National Advisory Mental Health Council, 1998, 2000).

Two possible successes for parity have occurred, though their future is unclear. First, President Clinton announced at the First White House Conference on Mental Health in 1999 that health plans for all federal employees must cover mental health at full parity (though the durability of this order was unclear with the change in administration in 2000). Second, the Americans with Disabilities Act (1990) provides some hope for protection for people with severe mental disabilities to receive basic mental health services and protection from discrimination, but the constitutionality, and thus the future, of the ADA is questioned by some (Geller).

In general, parity legislation has thus far had only a small effect on parity itself. Parity legislation appears to encourage the presence of managed care, which results in lower or stable costs for mental healthcare. In general, these lower costs seem to come from a combination of increased efficiency and lower quality and accessibility (National Advisory Mental Health Council, 1998, 2000; General Accounting Office; U.S. Surgeon General).

For decades, U.S. health policy has been centered on the short-term, acute-care general hospital, despite the fact that this does not match the population's health needs; this continued focus points to the problems of parity of mental health services between different groups within the population. Preventive services have until recently been largely neglected, as have the needs of chronically ill elderly, children, and youth. While healthcare in the acute-care hospital in the United States is arguably the best in the world, in mental health, care outside a hospital is demonstrated to be better and less expensive than care in the hospital (Kiesler). This raises the caveat that simply mimicking the flawed policies of the general health system may not necessarily prove to be the best strategy for mental health policymakers of the future, even though it may lead to greater parity between the two systems (Kiesler; U.S. Surgeon General). Arbitrary limits on outpatient services, inpatient hospitalizations, community-based health services, and higher co-payments for mental health services reflect the way mental health is disvalued in society, and its inferior status compared with physical health. Whenever a society establishes a priority system for the kinds of goods and services it makes available to its members, questions of fairness are evoked. If a society assigns insufficient or inadequate resources to a segment of the population at risk for or suffering from mental and addictive disorders without appropriate justifications, it violates ethical commitments to social beneficence, liberty, compassion, and justice.

Fragmentation

One of the most difficult ethical problems confronting the current mental health service system is the striking lack of coordination and collaboration among other human service agencies. The current mental health system is remarkable for a pronounced variation in the use of institutional and community-based services, admission rates, lengths of stay and services, and multiple funding sources and patterns.

Fragmentation in services is a consequence of developments in the larger healthcare system, as well as of the lack of integration in legal, social, economic, and scientific aspects of health policy. These problems stem from a cluster of ambiguities that prevail in the field of mental health: the diversity of beliefs regarding the concept of mental disease or disorder (Wakefield; U.S. Surgeon General); deeply-rooted cultural beliefs regarding behavior that seems inexplicable, bizarre, or threatening; and disagreement about which social policies to adopt in regard to persons whose autonomy is impaired by mental disorder, especially when this impairment may lead to the possibility of harm to self or others. Serious conceptual and normative questions regarding the definition of mental illness have led to practical disagreements about when and how to intervene. As of the mid-1990s, models of mental illness ranged from the purely medical model and its psychotherapeutic or psychoanalytical interventions, to a model that emphasizes the unity of biological, psychological, social, and personal factors in health and illness. Different mental health therapists subscribe to a variety of different theories on the nature of mental health. Specialists disagree, for example, about the boundary between mental illness and other forms of deviancy, and about the relative contributions of individual, family, environmental, and social variables in producing mental disorders (Rochefort, 1989). It has also been noted that a significant portion of the fragmentation and lack of coordination within the mental health system may be due to idiosyncratic factors related to politics, prejudice, and professional or civic self interest (Rochefort, 1989).

The lack of precise criteria to define and classify mental illness apparently has the following result: Both the person with catatonic schizophrenia, incapable of functioning in social life, and the person with an obsessive-compulsive neurosis, whose behavior is simply bothersome, are labeled as mentally ill. Both may be in need of some treatment to reduce distressing symptoms, but these services may be quite distinct from one another, and they raise significantly different concerns regarding what should count as a mental health service and what should not.

Thus, despite great expansion of mental health services, the system is remarkably fragmented. Without a centralized organization or locus of responsibility, quality of and accountability for services remain fragmented (U.S. Surgeon General). On the systemic level, the problem of fragmentation seems to have produced the following: under-treatment of the seriously and chronically ill; undervaluing of prevention services, rehabilitation, and long-term care; diminished access to available services for those with or at risk of mental and addictive disorders; restrictive barriers to insurance entitlement; and a generally lower position on the national healthcare agenda, despite data that demonstrate the efficacy of treatment for many forms of mental disorder.

These ambiguities exert a profound influence on normative and value questions, and can have a direct effect on the kind of mental health policy that is developed and the priorities it has in the overall healthcare agenda (Rochefort, 1989; Mowbray, Grazier, and Holter). Ultimately society's norms and values determine what kinds of services and resources will be made available, to whom they will be targeted, where they will be provided, and how they will be financed. Disparities of access and status provoke dilemmas of choice regarding principles of justice, on the one hand, and principles of cost-effectiveness on the other. They also expose the genuine difficulty of deciding which values should govern the policymaking process, when not all values can be equally promoted. For example, if society decides to purchase mental health services because of underlying commitments to humanitarian goals, then policy should probably be directed toward those individuals who have the most serious conditions and greatest needs. However, if society purchases mental health services because of commitments to principles of social or economic utility, then policy efforts would need to be driven by cost-benefit analyses and outcomes. In this instance, priority might be given to those individuals with depression, anxiety disorders, and alcohol addiction, because of the likelihood they would recover sufficiently to return to productive society (Klerman, Olfson, Leon, et al.). The principle of favoring the least well-off would have to be balanced against other considerations of justice that might be based on utilitarian assessments of what might provide the greatest benefits to the greatest number of people.

These priority decisions ultimately reflect political and social value judgments about how much society is willing to invest in caring for its mentally ill citizens. Although disagreements persist on a number of conceptual, scientific, and professional issues, there does seem to be consensus on one essential point: Mental health must have a higher status in the healthcare system. Furthermore, setting priorities regarding the relative value of mental health services will require a decision process based on principles of fairness, non-abandonment of those in need, public accountability, and objectivity (Boyle and Callahan; U.S. Surgeon General).

Ethical Values in Contemporary Mental Health Policy

Since the publication of the influential Flexner Report in 1910, the U.S. healthcare system has been based on a medical model firmly anchored to the concepts of scientific, physical medicine and notions of medical treatment and cure. Ideas of prevention, health, and public health were relegated to the "back porch" (Smith). American society has structured its health policies, programs, professions, and institutions on this model for many decades, as though there were little relationship between mental and physical health. However, there is a growing body of empirical knowledge that documents the role of mental state in the maintenance and deterioration of good physical health, and in the treatment and recovery from physical illness (Praeger and Scallet).

Contemporary mental health policy, whether developed in terms of prevention, accessibility to needed services, rehabilitation, or maintenance of persons most greatly in need, is in a process of change. These changes reflect shifting concepts of mental illness, new etiological formulations of mental disease, treatment interventions, epidemiological trends, past program successes and failures, and the broader social, political, and economic currents (Rochefort, 1989; Rochefort, 1996). Ultimately, policies represent society's effort to deal with one of the most difficult and persistent human problems: how to balance the classic conflict between the power of the state to act for the good of society, and the responsibility of society to ensure the full expression of individual rights and freedoms. Questions concerning who has the legitimate power to control the lives of the mentally ill continue to provoke philosophical debate. In contemplating the public and scholarly discourse in the mental health field over the past several decades, several difficult questions regarding past policies must be confronted before new ones are generated. For instance, what ethical values, if any, were promoted by policies of deinstitutionalization? Has the goal of returning the mentally ill and disabled to the community for care enhanced the rights of individuals, or has it produced in them, or their communities, some greater harm? How will mental health policy of the future balance the competing claims of liberty, equality, and social beneficence?

Such questions represent difficult value choices, made more complex by a climate of increasing public distrust (Jellinek) and scarcity of fiscal resources (Morreim). Past assumptions of political liberalism and economic expansion are no longer valid. Instead, policies of allocation are becoming more explicitly value-directed, not simply regarding cost-containment or efficiency but on principles of equity, justice, and compassion (Jennings). Allocation policies, insofar as they are regarded as socially legitimate and politically acceptable, may then be understood to be a mechanism by which society seeks to define and to express its sense of self, its values, and its integrity (Childress). In a time of great transition and transformation of the healthcare system at large, American society is at a crossroad in its attempt to understand the health of the human mind and of all the forces that seek to promote and sustain it (Praeger and Scallet). It is a time of constructive chaos, in which the very mission and telos of healthcare are being redefined. Along with this redefinition, the opportunity exists to raise the status of the mental health services field from the "poor stepchild of the health care delivery system" (Boyle and Callahan, p. 53) to a level that conjoins mental and physical well-being and integrates biomedical and behavioral knowledge regarding health parameters. To accomplish this, it will be necessary to pay close attention to issues of equity in the access, availability, and efficacy of all health-related services, and to avoid arbitrary demarcations between mental and physical well-being (U.S. Surgeon General; Mowbray, et al.).

At the beginning of the twenty-first century, there is clear and urgent need for serious ethical reflection on which values and priorities should govern the mental health policies of the future. What is needed is an integrated, comprehensive, and equitable strategy that builds on knowledge and research in mental and physical health, and links these to appropriate and beneficial services for those in need of them. Problems of individual and social justice penetrate all areas of society, but are especially powerful in relation to the needs of the mentally ill, and to the communities in which they live. Undoubtedly, care and treatment of the mentally ill pose a range of ethical concerns that will continue to challenge society well into this century.

michele a. carter (1995)

revised by author

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Encyclopedia of Bioethics