Psychiatric Darwinism = Survival of the Fittest + Extinction of the Unfit

By Cosman, Madeleine Pelner | Issues in Law & Medicine, Summer 2001 | Go to article overview

Psychiatric Darwinism = Survival of the Fittest + Extinction of the Unfit


Cosman, Madeleine Pelner, Issues in Law & Medicine


ABSTRACT: This article is a critical analysis of the American Health Security Act of 1993. Although AHSA was soundly defeated when first proposed, parts of it have been enacted into law in 1996, with the prospect of further piece-meal enactments in the future. It includes matters of fundamental importance to American mental health practitioners, to vulnerable citizens with psychiatric disorders, to their families, and to their few champions in medicine and law. Utilitarianism is the unstated philosophical substructure of AHSA and its legislative progeny, i.e., whatever cuts medical costs and saves money is good.

The author delineates AHSA's mental health entitlements and limitations of in-patient, out-patient, and other patient care. She enumerates a dozen major imperfections and dangers of this mental health law, especially its medical utilitarianism emphasizing outcomes and quality of life. Dr. Cosman argues that medical cost, outcome, quality of life, and managed competition threaten the essential liberties and the lives of older persons, persons who are chronically ill, fatally ill, and most particularly those who are mentally impaired. She concludes that if limited money, medicine and time are invested only in inevitable medical success, then America's medicine by its medical law will be Medical Darwinism encouraging survival of the fittest by requiring extinction of the unfit.

When was the last time you read the failed Clinton Health Plan of 1993 called The American Health Security Act (AHSA)?(1) AHSA's 1,364 pages of legislation include sections of critical importance to American mental health practitioners, to the vulnerable citizenry with psychiatric disorders, to their families, and to their few champions in medicine and in law. Everyone concerned with America's mental health care should read AHSA. It is astonishing psychiatric cultural history. Analysis of AHSA, however, is more important for providing context for medical legislation directly derived from it and already law of the land.(2) Furthermore, studying AHSA now provides warnings of other AHSA sections proposed for forthcoming medical laws. Utilitarianism is the unstated philosophical substructure of AHSA and its legislative progeny. What is good for the state is good for the patient. Whatever cuts medical costs and saves medical money is good. A patient under capitation payments is simply one head among many hungry heads. Individualism, integrity, and autonomy are out-worn ideas no longer valid for modern America where medical costs are stratospheric, and chronically ill patients live expensively long lives with poor medical "outcomes," and dismal "quality of life." Every American must have equal access to medicine. Those who get too little must get more. Those who get too much must get much less.

Many powerful people lamented AHSA's failure to become American law, especially its mental health provisions. Some politicians still bemoan it as a lost necessity.(3) Other legislators are determined to implement AHSA slowly, surreptitiously, and part by part. Whole sections of the Clinton health plan already have been incorporated essentially unchanged in legislation Congress passed into law in 1996. For instance, the Health Insurance Portability and Accountability Act (HIPAA, familiarly called Kennedy-Kassebaum) contains approximately one hundred pages directly from AHSA of criminal penalties for doctors who minimally, even unintentionally, violate the law.(4) Other AHSA restrictions governing Medicare patients were interpolated into Section 4507 of the Balanced Budget Act of 1997.(5) Moreover, Senator Hillary Rodham Clinton and her adherents know that AHSA is not dead but hibernating, ready for vigorous reawakening, hungry and rapacious, whenever the political season warms and time converges with her opportunity

Dangers to liberty, restrictions of choice, and noxious naivete of AHSA are most dramatic in section 1115 defining Mental Health and Substance Abuse Services. …

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