Volume 1, Issue 10 - December 1998

Privatization of Care for the Mentally Ill - A Special Case

You've heard people say they feel like they've been to hell and back. At Brainstorm Fundamentals inc. this is not a clich?this is reality. Through personal, family, and professional experiences with mental illness, my business partner and I have been to hell. Over and over again, sometimes. We eventually rallied and upon critical analysis decided that the existing system of health care services for the mentally ill was less than ideal.

So we checked out the political structure, organized some of the devils, planned and executed a revolution, won some, lost some, attempted to overthrow Satan, and watched for the dust or should I say, the embers, to settle. And along the way we got burnt. You see, that's what it feels like to deal with mental illness and the mental health industry. It's an ordeal difficult to explain to someone who hasn't been impacted by mental illness. But it's unforgettable, and in our experience it became the motivator for creating a new business designed to help people who, because of mental illness, feel that they are isolated in a burning hell without recourse. The most difficult ethical challenge that faces private health care service providers such as ourselves is the charge that private business unfairly discriminates against the poor. It is this charge that I wish to address in this article.

The argument against private, for-profit health care facilities is that access is unjustifiably denied to those who cannot pay for services. For, on the one hand, illness can strike anyone at any time. And on the other, we all need a certain degree of health for wellbeing, regardless of such arbitrary concerns as our respective economic or social status. Therefore, health care services ought to be available to all who need them, regardless of an individual's ability to pay for these services directly. Thus, to charge individuals for health care services - and therefore to limit access to those who cannot pay - is ethically unjustified. While we recognize the value of equity that this argument esteems, we believe there are good reasons to accept a necessary compromise - at least in the context of mental illness.

From my experience in the public mental health system, access to services is limited to those who can maneuver the system, luck-in at getting a compatible doctor or service, and who have an intimate support network. The more severe and persistent mental illness one has, the more challenges one faces. This implicitly limits access to services based on one's ability to negotiate the system. The first benefit of private services is that it is made explicit at the outset how services are to be rationed.

Access is limited to those who can maneuver through the system

Critical to care for mental illness is responsiveness to the unique needs of individual sufferers. People need treatment in their communities, close to their families and loved ones. Prevention, early intervention, and support at home through teaching, educating, influencing and guiding, are the strategies to use in addressing mental illness in the nineties - for all mental health care consumers. The real advantage of private mental health services is that it is part of a consumer-run system. Therefore, it is highly responsive to the needs of consumers and families. Direct payment for service results in mutual accountability. Private health care provider agencies are 100% accountable to the families and individuals they serve.

The public sector has had many years to provide a responsive, effective, appropriate mental health system. But it hasn't met this requirement. And we suggest that while private health care may limit access, its efficiency and effectiveness in providing care is so significant, it far outweighs the harm of limiting access. Thus, we argue a private system is no more ethically offensive than our current system.

We recognize the entitlement of the poor and the disadvantaged to good care. And we feel that were the public health system able to meet the needs of the mentally ill appropriately, this would be the way to go. However, recent history and personal experience have made it clear that the current health system is not able to meet these needs - change needs to take place. And there is nothing wrong with starting this change by supporting the mentally ill who can afford to pay for services. Through this we can develop intervention strategies, lay down the foundations for an inclusionary outreach mental illness service, and in effect lead the way out of this darkness. The skills, knowledge and abilities of individuals and families served by the private sector will have a ripple out effect on the greater community.

We should also keep in mind that those more economically well-off are as disadvantaged by their mental illness as the poor. The wealthy also have a legitimate claim to good care. But this care is denied to all - it does not discriminate by economic status. The quality of service presently being offered has been woefully inadequate to mental health consumers from all economic backgrounds. Today individuals and families are educating themselves and looking for the best care available. This sets the scene for a competitive market.

Encouraging privatization to provide competition and choice is a legitimate way to bring about change in the health system - at least for mental health services. We believe it can lead the way by teaching the current system a better way to operate. Private service, as an adjunct to public service, is a viable necessity. Privatization is not the only answer. The ideal situation would be a collaborative cooperation between private, public, and non- profit sectors. I'm tired of working in the system with my hands tied and hearing the hollow promises of a better tomorrow and worse yet, the weak reassurances that ours is indeed the best health care system that we can expect. We've had more than enough time to see some results.

Pia welcomes responses at (403) 730 - 6339 (tel), (403) 730 - 6388 (fax), or by e-mail at bsfinc@cadvision.com.

1999 PHEN Membership Renewal

Members of PHEN are reminded that December 31, 1998 marks the expirations of membership with the Network. In order to avoid a lapse in subscription to IN TOUCH , those members interested in renewing their memberships are encouraged to do so before the year's end. Membership dues remain as last year at $10.00 for individual members and $25.00 for institutional members.

Along with a subscription to IN TOUCH , other benefits of the membership include:

• User Fund Access: Members are eligible to apply for a grant up to $500.00 to attend a health ethics conference/educational event of their choice;

• Subscription to Health Ethics Today : A quarterly newsletter of incisive articles on ethical issues in health care in Alberta, published in conjunction with the John Dossetor Health Ethics Centre;

• Special Publications: Members receive a complimentary copy of certain booklets and brochures produced by the Network, such as Health Ethics Resource Directory for Alberta ;

• Health Ethics Resources: Members receive a 25% discount on most resource items available for purchase through the Network;

• Health Ethics Workshops: Institutional members of the Network receive a 20% reduction in the cost of booking a health ethics workshop for their staff/clients;

• Joining a Group of Like-Minded Albertans: The Network represents a collection of individuals and organizations interested in ethical issues in health and health care. As one of those individuals, your membership supports the work of an organization dedicated to providing resources and education on health ethics and to incorporating ethical considerations into all aspects of health system deliberation and decision-making. Despite being the least tangible benefit of membership, it may be the most important.

Announcements

• PHEN sponsored a teleconference of Health Ethics Network representatives in North America in October. In addition to Alberta, Health Ethics Networks of Florida, Maryland, Vermont, Los Angeles, Manitoba and Ontario took part or submitted information for sharing. The meeting revealed many similarities in the roles of and struggles faced by such organizations. Common goals of the Networks included providing resources to, and forums for interaction between, ethics committees, care providers and in some cases members of the general public. The groups' primary funding sources ranged from none to government, membership fees, and private foundations. Most participants felt that the Networks complemented and could be differentiated from academic bioethics centres by their focus on linking ethics resources to practitioners in the field and in raising awareness amongst a broader audience. General challenges identified for such networks included human and material resources incommensurate with the demand for services, engaging physicians in activities, and achieving a balance between effecting change and maintaining neutrality as facilitators of discussion.

• PHEN is working closely with a number of Alberta organizations including the John Dossetor Health Ethics Centre and St. Joseph's College Ethics Centre to host the 1999 Canadian Bioethics Society Annual Conference and General Meeting. This promises to be an especially exciting opportunity as the conference will be preceded by a one day workshop featuring Board members of the International Association of Bioethics. The theme of the conference will be Expanding the Boundaries of Health Ethics. Stay tuned for more news of this exciting event!

• Since our last report in October, staff of the Network have been busy doing a number of different workshops and seminars. These have included presentations in the Capital, Calgary, David Thompson, Headwaters, Mistahia, Northern Lights, Peace, Palliser, and WestView Health Regions. Upcoming module presentations will be hosted by various programs within the Aspen, Capital, Chinook, and David Thompson Health Regions.

• The final session in the series of discussion forums on Personal Directives: A Retrospective on Year One, co-hosted by PHEN and the Office of the Public Guardian, will take place in Red Deer on January 12, 1999 from 9:30AM to 12:00PM. To register please contact 1-888-343-4553.

• PHEN Board and Staff Notes
  • PHEN is pleased to announce that Susan Cox has joined the Network as a part-time administrative assistant working several hours a week in the Calgary office. We're very pleased to have Susan with us and welcome her on board!

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.