REVIEWED BY CAROL A. TAUER, PhD
What Price Mental Health? The Ethics and Politics of Setting Priorities
Phillip J. Boyle and Daniel Callahan, eds.
Georgetown University Press, Washington, DC
1995, 243 pp., $45 (hardcover)
This book is the outcome of a two-year project on Priorities in Mental Health Services undertaken by the Hastings Center, Briarcliff Manor, NY. Funded by the MacArthur Foundation, the project brought together an interdisciplinary group of clinicians, scholars, and public health services. As Gerald Grob's essay on the history of mental health services shows, our country has expressed its changing attitudes toward mental health and mental illness through a series of contrasting approaches to treatment. This book, edited by Philip J. Boyle and Daniel Callahan, attempts to make sense of the variety of approaches and to propose recommendations that might guide public policymakers today.
The book's overall focus is provided by Boyle and Callahan, codirectors of the project, who summarize project conclusions in the preface. This summary, which consists of 12 brief statements, identifies the book's specific overarching themes. These themes are drawn out more fully in the coeditors' chapter, "Minds and Hearts: Priorities in Mental Health Services." Curiously, however, we are told in the preface that "the report and its conclusions. . . are solely those of the project's codirectors" (p.vii). To this extent, the project seems to have been unsuccessful in reaching consensus even among the project participants--not a good sign for an enterprise that seeks eventual consensus within society as a whole.
The book consists of a series of essays loosely held together by the framework provided by the codirectors. These essays range from pure history to analysis of public policy to philosophical discussion of theories of equity and justice. All the authors appear to share several general assumptions: that healthcare resources are limited, that current distribution of resources involves covert priority setting, and that it would be better (whether medically, politically, or ethically) if priority setting were conducted more rationally and openly.
Given these assumptions, the essays address how priorities should be set. Some authors focus on the processes a local community or state might use to develop coherent and publicly acceptable priorities for allocating treatment resources. Other authors tackle difficult conceptual, philosophical, and ethical questions: Should the focus be on treating mental illness or on promoting mental health? How should treatment effectiveness be assessed, particularly in comparing acute conditions with chronic illnesses? Is it better to focus public resources on treating a small number of severely ill persons or a larger number who are less seriously affected?
The book consistently supports the position that mental health is inextricably linked with physical health. As a result, authors advocate that priorities be set simultaneously for the treatment of physical and mental health conditions, that they be established by similar criteria and procedural mechanisms, and that they be viewed equally when distributing public resources. At the time the project group was meeting, the Clinton plan for a national healthcare program was under discussion. The book commends the Clinton plan for its mandate on mental healthcare coverage, but criticizes the president's plan for setting more stringent limits on the treatment of mental health problems than on the treatment of physical conditions.
The chapter that describes the development of the Oregon Health Plan, particularly its incorporation of mental health services, is superb. This chapter provides a concrete example of public processes and philosophical debates that are presented more abstractly in other chapters. Its authors, all involved in the public policy process in Oregon, show that it is possible to integrate the expertise of professionals and the values of the community, to balance the acute needs of a few with the less acute needs of many, to identify publicly acceptable measures of effectiveness, and to consider costs without disrespecting human values. The success of the citizens of Oregon in reaching public consensus on the allocation of public resources is impressive and encouraging.
Readers who are neither public policy buffs nor philosophers will find much of this book rather difficult reading. At various points authors assume that readers are familiar with John Rawls's work, with other theories of justice, and with philosophical debates on the allocation of resources. Even the nonphilosophical essays are conceptually dense and overwhelmingly abstract.
The book as a whole could have benefited from the inclusion of case studies involving specific mental health conditions or patients. Such scenarios would have illuminated the abstract questions posed by various authors, and making the issues more compelling. Note, for example, a series of excellent case studies that illustrate the difficulty of defining "medically necessary treatment" in psychiatry, published in the Hastings Center Report at about the same time this book was in production (James E. Sabin and Norman Daniels, "Determining Medical Necessity' in Mental Health Practice," vol. 24, no. 6, pp. 5-13).
This book is a good first step toward an essential but elusive goal: establishing and implementing publicly shared priorities for treating mental health conditions. But it is only a first step. Others who can accept its assumptions and its broad but well-argued conclusions must carry the discussion further if the project on Priorities in Mental Health Services is to bear fruit.
Carol A. Tauer
Professor of Philosophy
College of St. Catherine
St. Paul, MN
Copyright © 1997 by the Catholic Health Association of the United States
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