The Mentally Ill Poor: Rethinking Ethics

To the Editor: I am one of many community psychiatrists who believe that caring for the mentally ill poor population is an ethical obligation rather than a charitable option. I am just not sure anymore how to explain the basis of this moral responsibility. Recent contributions to Psychiatric Services, such as those in the special section on caring for the least well off in the May 1999 issue, have attempted to address this issue by providing both historical and ethical arguments for allocating care to the least well off in our communities (1,2).

Appeals to conventional moral rules and principles of resource allocation, however, may no longer suffice. Just as market forces are changing the way in which mental health care is being allocated, so too are they changing the way in which we think about applied medical ethics. I agree with Daniel Callahan (3), who argues for alternative approaches to developing a moral justification for allocating resources to those who frequently walk in the shadows of the public mental health care system. For example, the ethical principles of beneficence, autonomy, and justice have traditionally centered rather narrowly on the physician-patient relationship to the exclusion of examining organizational values and commitments.

The same can be said for professional codes of ethics. Ezekiel Emmanuel (4), acknowledging the influence managed care has had on health care delivery, noted, "The advent and explosive growth of managed care has dramatically and irreversibly changed the nature of medical practice, and therefore the context in which ethical issues arise. … Interactions occur within organizations in which the practitioner or a small group of colleagues no longer control the rules of engagement. The context of medical ethics can no longer be cases, but institutional structures." Hence, when articulating community psychiatry's moral responsibility to the least well off in society, I would argue that the moral analysis should be expanded to include an examination of the ethical values of the mental health organizations in which we practice.

Three values understood to be moral commitments that define the practices and policies of a particular organization have long been embedded within a compassionate community mental health tradition of providing care to the poor: humaneness, fairness, and social responsibility. Identifying and invoking these values on an organizational level broadens the grounding of a moral obligation to treat the most vulnerable members of society.

Humaneness as an institutional value directs policies and practices that promote a sense of benevolence to people in general as well as compassion for people in need. For example, an evaluation of the moral acceptability of the managed care contract of a community mental health center (CMHC) would take into account the impact of such arrangements on those with the greatest need and the fewest resources.

Fairness on an institutional level would require a CMHC to critically evaluate how it distributes its limited resources. Financial considerations in setting allocation priorities at the beginning of every fiscal year would be tempered with concerns about need, opportunity, and therapeutic benefit for those on the margins of inclusion.

Social responsibility is a central value to the organizational tradition of CMHCs. A CMHC that values social responsibility will inform its practices with a respect for its obligations to the social community in which it exists. Caring for a community's mentally ill poor population would be an exceptionally high priority, and setting such a priority would likely put a brake on socially irresponsible referrals to free clinics, primary care practices, or other resource-limited agencies that are less capable of meeting the needs of this population.

Who will care for the mentally ill poor population? The ethical basis for a community psychiatrist's commitment to serve marginalized persons ought to go beyond principle-based ethics directing individual choice and find roots within organizational values and structures. Indeed, the lives of those without a voice or resources depend on these institutional commitments.