Rationing Sanity: Ethical Issues in Managed Mental Health Care

Rationing Sanity: Ethical Issues in Managed Mental Health Care

Rationing Sanity: Ethical Issues in Managed Mental Health Care

Rationing Sanity: Ethical Issues in Managed Mental Health Care


Mental illness is the poor, and somehow "damaged," cousin to physical ailments in the eyes of too many in our society. Compare the difference in how people would respond to someone who had fallen and broken their leg on the street, to how most react to those mentally ill among us, on those same streets, who spend their winters on steam grates and forage for food in dumpsters. Rationing Sanity is a provocative analysis of the mental health care system in the United States, dealing with issues of justice and access to mental health care.

How should a decent society, affluent but facing many serious calls on its resources, best care for citizens afflicted with severe and persistent mental illnesses? James Lindemann Nelson brings together, for the first time, scholars of the ethics of mental health care and top managed care policy analysts to address this crucial problem. Rationing Sanity integrates those perspectives with the thoughtful practice-based experience of physicians well versed in the actual care of people with emotional and behavioral problems. Over a period of years, the contributors met face-to-face to engage each other on the ethics of managed mental health care -- the result is a unique, collaborative effort that provides a wealth of important new insights on not only how Americans can readjust their attitudes toward the mentally ill -- but also how we may find more just and humane treatment for those afflicted.


James Lindemann Nelson

Although suffering from any kind of serious illness brings with it risks of stigma and (at least in countries such as the United States) impoverishment, people ill with a psychological or behavioral disorder suffer under a particularly dark cloud. To be—or to have been—mentally ill is still seen in many social contexts as essentially damaged, as defective in those features of cognition or agency that we tend to prize as distinctive to and definitive of human personhood. To face mental illness is to face problems that have been resistant to standard medical intervention and thus to rely on forms of care that may be either largely custodial in nature or on the fringe of the kind of substantiated scientific knowledge that (as many of us fondly imagine) characterizes health care generally considered. Even when what seem to be highly promising or effective therapies do appear—for example, in the case of depression or anxiety—by a curious inversion of the logic of stigmatization, even being cured can seem vaguely unsatisfactory. Shedding anxiety or depression under the influence of Paxil or Prozac strikes some as short-circuiting the “right” way for people to recover their psychological equilibrium: not by the exercise of will and thus as an expression of character, but rather via “merely” causal mechanisms.

These accompaniments of psychological illnesses—with the exception, perhaps, of scruples about how one is cured—have had a troublesome impact on the character of mental health insurance. Health care policies have traditionally made stark distinctions between the kind of underwriting they supply for “physical” ailments and that provided for mental illness, much to the disadvantage of the latter. From the perspective of publicly supported mental health care, deinstitutionalization, coupled with a lack of support for community-based mental health initiatives, has had highly visible consequences for many people suffering from severe and persistent psychological and behavioral problems.

Recently, debates about “parity” have been prominent, with Congress and the White House studying, considering, but—as of this writing—not enacting legislation that would mandate no invidious distinction between support for mental or physical health care by insurers. Yet an even more significant issue has been less a matter of media attention and public concern—the shift to using the tech-

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