The complexities and dgering targets of accountability can pose conflicting ethical dilemmasfor the administrator of public mental health programs, but this situation need not discourage those embarked on such a career.
Can the Public Psychiatric Administrator Be Ethical? Roger Peele Can the public psychiatric administrator be ethical? In addressing this question, I will be reviewing the values that have led to deinstitutionalization of the psychiatrically ill, especially the homeless psychiatrically ill. There are at least twice as many psychiatrically ill in this nation’s public streets as in the public psychiatric hospitals, and they are in the streets because of a change in the values of public psychiatric administrators. I will review the sources of these values, touch on their impact, and address the choices for psychiatric administrators today in answering the question of whether administrators can be ethical.
Sources of Values A number of government agencies, whose values are evident in regulations and guidelines, influence the care of the psychiatrically ill. The values of third-party payers (such as Medicaid and insurance companies) also affect the care of the psychiatrically ill, through even more rules and regulations for reimbursement. State agencies, with their licensing authorities, safety codes, and health standards, affect what psychiatric administrators can and cannot do. The values of the courts, the legislatures, and the media also influence the actions of psychiatric administrators. Finally, medical This chapter is adapted from a lecture given to the 142nd annual scientific meeting of the American Psychiatric Association, May 11, 1989, San Francisco. Ms. Donna Ondrish contributed to what clarity this chapter possesses, and Miriam Woodall Roland, M.D., made over one hundred editorial improvements. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES. no. 49, Spring 1991 OJossey-BassInc.. Publishers
41
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professionals and their respective accrediting bodies also influence the actions of psychiatric administrators. In this chapter, I will focus on only four major systems whose values impinge on public psychiatric administrators: the legislative branches of government, the executive branches, the judiciary, and medicine itself. It is crucial that the public psychiatric administrator function as a buffer, preserving and protecting medicine’s unique values from the influence of the political system, the bureaucracy, and the judiciary. Let us compare these values, as perceived by those of us who act as buffers.
Values of the Political System As one moves from participating in a treatment-planning conference to meeting with political leaders, or to testifymg before a legislative committee,
one immediately perceives a difference in values. While both systems are interested in doing good, the political system is interested in doing good for many, whereas medicine’s focus is on doing well for a single patient. Whereas the political system expresses society’s prejudices about the undesirability of the psychiatrically ill, medicine’s values are captured in Maimonides’ prayer for physicians: that we will fully serve the undesirable. Whereas the political system reflects the desire to tax as little as possible (and thus provide the minimal service required for the psychiatrically ill), medicine expects to provide all that might well serve the patient. Thus, with an exception or two, resource limitation has characterized American public psychiatric programs throughout their history of more than a century and a half. To counteract this limitation, public psychiatric administrators have found themselves in an uncomfortable position. The public psychiatric administrator who maintains that he or she has always told the truth has probably never testified on behalf of the executive branch before a legislative budget committee. To minimize resource limitation and enhance public support, we are required to sell programs and policies without the cautions and uncertainties expected of a discipline that is scientifically based. We claim that we are technocrats, not Republicans or Democrats, but this stance can be retained only so long as we are answering questions from political leaders. When we want to initiate public programs or policies, the need to sell arises. Thousands of bills are thrown into the hopper each legislative session, but only a few will survive, and the cautious scientific style is often a nonsurvivor. For example, the major political initiative in public psychiatric administration in our time has been community psychiatry. In advocating community psychiatry, we presented none of the cautions, doubts, and questions characteristic of a scientific statement. While one can question the ethics of selling, avoidance of selling can be fatal in the legislative process. Therefore, the public psychiatric administrator often ends up being respon-
CANTHE PUBLICPSYCHIATRIC ADMINISTRATOR BE ETHICAL?
43
sible for programs with high expectations and low funding. Just to compare the words patient and constituent points to a difference in values.
Values of the Executive Branch
As we move from the treatment-planning conferences of the clinical world
to meetings with executive-branch agency chiefs, we perceive a shared interest in competence and expertise, but we also often perceive a tilt toward accountability as opposed to responsibility, a tilt toward efficiency as opposed to efficaciousness,loyalty to the hierarchy as opposed to loyalty to the patients, neutrality toward those being served as opposed to advocacy for patients. While there are clearly overlaps, responsibility and specialization (the values of medicine) are less restrictive, more ambitious, than accountability and departmentalization. Saying an agent is accountable for a person is less comprehensive than to say one is responsible for a patient. While both departmentalization and specialization are seen as guilty of not focusing on the whole person, departmentalization unequivocally restricts the focus, whereas medical specialties are constantly reminded to treat the patient with as broad an approach as possible for the patient’s welfare. Throughout the history of public psychiatry in the United States, the specific executive branches with which we have worked have changed. Public responsibility began locally in the early nineteenth century. Then, from the mid nineteenth to the mid twentieth century, it became primarily the state’s responsibility. In the 1960s, the federal government became more involved, the state effort was conceptualized as suspect, and local control, even separate from city and county, was championed. In 1981, however, the federal government suddenly withdrew its interest in the state public sector, leaving some confusion about who was responsible. The results have been split levels of authority and a multitude of separate agencies for community care, rather than public hospitals, which used to provide health care, social and vocational education, board, and housing (often, unhappily, at abysmal levels). Thus, since the 1950s, there has been a shift from one authority to multiple authorities for the psychiatrically ill. The move of patients from hospitals to communities decreased psychiatric administrators’accountability and authority, requiring us to work with many others to meet patients’ needs and leading to our decreased sense of special identity and responsibility. To counter this diffusion, there is a need for greater assertiveness, advocacy, and negotiation on the part of clinicians and their supervisors. Assertiveness, advocacy, and negotiation, while very important to those of us in psychiatric administration today, are not covered in the typical administrative psychiatry books. Advocating and negotiating within the bureaucracy can be disheartening and discouraging to those trying to assume full responsibility for patients and their needs. This is one of the
44
ADMINISTRATIVE ISSUES
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PUBLIC MENTALHEALTH
reasons that many prized psychiatric programs are outside the bureaucratic system, paid by contract. Too often, the public psychiatric administrator’s buffer has failed in the face of bureaucratic values, leading to patients’ and physicians’ disillusionment and frustration with available treatment. When the buffer is too weak, physicians may narrow their treatment to medication. For some patients, however, medication has little or no impact.
Values of the Judiciary Moving from the treatment-planning conference to meetings with attorneys or to the courtroom, one perceives another shift in values. When we compare the values of the judiciary and medicine, it seems that we share the value of careful and full focus on the individual (except in class-action suits), but there are values and related procedures that seem incompatible. Whereas the judiciary assumes an inherent conflict between parties in striving for justice, medicine assumes no inherent conflict between parties in striving to restore health. Whereas the judiciary pursues its factual determinations formally, adversarily, and with rules of evidence, medicine pursues its factual determinations informally, cooperatively, and scientifically. Whereas the judiciary’s fact determinations are made by laypersons, medicine’s fact determinations are made by expertise. Judicial decisions represent the end point and are fixed and final. Medical decisions come early, are flexible, and are subject to change. Whereas the judiciary’s focus in review is on process and is scholastically based, medicine’s focus in review is on results and is empirically based. Whereas the judiciary’s concern about error is expressed in the idea that it is better for ten guilty persons to go free than for one innocent person to be punished, medicine’s concern about error is expressed in the statement that it is better for ten persons to be hospitalized unnecessarily than for one person not to be hospitalized and die. Whereas the judiciary’s adopted legal theories become permanent, medicine’s theories are tentative and subject to empirical tests. Whereas the judiciary has to assume free will, to preserve the sense of culpability, medicine has to assume deterministic models, to achieve therapeutic predictability. This is the value that lawyers seem to have trouble grasping. One has to point out to them that every therapeutic act involves a prediction of what the act will produce, whether the act is to give a medication or to offer interpretation in therapy. That prediction may be based on empirical evidence, or it may be based on a concept about the illness. Principles of treatment cannot contain free will at any syllogistic junctions, because that would remove predictability, rendering the concept clinically useless. Another important difference is that the strength of the judiciary lies in providing decisions directed toward resolving conflicts, while medicine’s strength lies in providing actions directed toward solving problems.
CANTHE PUBLICPSYCHIATRIC ADMINISTRATOR BE ETHICAL?
45
Whereas the judiciary is especially potent in prohibiting action (enjoining), medicine is especially potent in providing action (treating), These judicial values-reliance on conflict, factual determination by laypersons, formality of decisions, review that focuses on process only, the finality of decisions, a concern about incarceration versus a concern about life, the assumption of free will, and a focus on making decisions rather than on solving problems-have increasingly been imposed on public psychiatry through court decisions and through regulations written from the judicial perspective. Beginning in the 1960s, a series of federal judicial decisions affected public psychiatry, moving us in conflicting directions. First we had decisions that directed us to intervene only minimally with patients. Other decisions enhanced the entitlement of patients to therapeutic intervention. One decision said that psychiatrists in the public sector could be liable for retaining people in a public institution, even though thirty courts had ruled in favor of such retention. We have also had a number of right-to-refuse-treatment decisions, which forced us directly into the adversarialjudicial arena. The overall effect of these decisions has been to discourage us from assuming responsibility for the psychiatrically ill. The imposition of the judiciary’s values and procedures over the past twenty-five years has decreased our authority for the psychiatrically ill, added an element of conflict to the patient-psychiatrist relationship, and increased the cost of service. Furthermore, public administrators are subject to judicially written regulations, whose ponderous style feels especially stifling when we are responsible for chronic, difficult patients, in cases where initiative, individuality, and parentalism are indicated.
Changing Values in Psychiatry Despite all the forces outside psychiatry, our own values have contributed immensely to community psychiatry-or to the negative side of the same coin, deinstitutionalization. American public psychiatric administration began in the early nineteenth century with the hypothesis that people suffered from psychiatric illnesses because they had been exposed to immoral conditions in the community. Thus, treatment required the removal of patients from the community and their placement in moral settings-asylums-where they would be cured. In the first half of the nineteenth century, psychiatric administrators claimed many cures. In the second half of the century, for various reasons (including the hypothesis that people suffering from psychiatric illnesses had brain dysfunctions), institutions became the final community for many. Over time, conditions in the institutions were often found to be inhumane, and periodic calls for reform were common from the 1870s up to the 1950s. In the 1950s, the call for reform became a call for abolition of the institutions, strengthened by the evolution of the
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IN
PUBLICMENTALHEALTH
social hypothesis that patients suffered not from their illnesses but from institutionalism, and that the more the institution structured a patient’s life, the more likely institutionalism would be as a result. Most unfortunately, some important public psychiatric administrators even adopted the position that public psychiatric hospitals were inherently harmful. Thus, some of medicine’s own key public psychiatric administrators reversed the position of our founding fathers: the concept that psychiatrically ill patients suffered from corrupting community influences and needed placement in moral settings was replaced by the concept that the psychiatrically ill suffered from the institutional environment, and the new cure was supposed to be placement in the warm bosom of the community. In the 1950s, there was also the development of medications that facilitated deinstitutionalization. These medications were subjected to controlled studies before their adoption. The social hypotheses associated with community psychiatry, however, were not tested. Therefore, tested medications allowed the carrying out of untested social hypotheses.
Deinstitut ionalization The values of political, bureaucratic, judicial, and professional thinking all came together and spoke with one voice on the need to deinstitutionalize patients. The results of deinstitutionalization are well known to most. Since 1955’s peak of 550,000 inpatients, there was a drop to 150,000 by 1980, and today the number is between 110,000 and 120,000. Where have the psychiatrically ill gone? Three years ago, the director of the National Institute of Mental Health (NIMH) told a congressional inquiry that 6 percent of adults with schizophrenia were in state mental hospitals, 5 percent were in nursing homes, 14 percent were in acute inpatient settings, 17 percent were known to be in outpatient settings, and 58 percent, nearly one million, had been lost to NIMH. Where have these missing people gone? Studies of shelters find that roughly two-thirds of homeless people have psychiatric illnesses, and half of this group are substance abusers. The abandonment of responsibility for the psychiatrically ill is not due to a shortage of psychiatrists. In 1900, we had 450 APA members, fewer than half the number of psychiatrists available today in the District of Columbia alone. In 1950, we had 6,000 members; in 1983, we had 29,000. Since 1983, we have been averaging a gain of about 1,000 members per year, and membership now stands at 36,000.
Exclusiveness There appear to be no ethical guidelines for the degree to which one should increase the effectiveness of a program through exclusion of patients. Some administrators are saddled with responsibility for establishing good programs
CANTHE PUBLICPSYCHIATRIC ADMINISTRATOR BE ETHICAL?
47
by admitting only “good patients, and many programs require such limitations in order to survive. How many patients with both schizophrenia and substance abuse should a substance-abuse program admit? Should it be allowed to exclude all of them? How many such dual-diagnosis patients should a program treating schizophrenic patients be expected to take? Some of these questions can be answered programmatically, but deliberations often eventually reach the ethical level with respect to the degree of exclusiveness that is morally acceptable. Again, the psychiatric administrator may be very exclusive and yet feel ethically correct from a bureaucratic point of view; but there are questions to be asked about the clinical and public ethics of exclusiveness.
Transinstitutionalit ion Transinstitutionalization, the moving of a patient from one institution to
another, has been a major development in American psychiatry. While we do not know the exact number of public psychiatric patients who have been transinstitutionalized, there are probably hundreds of thousands. It is estimated that 700,000 patients in nursing homes have primary psychiatric problems. Prisons are estimated to have from 5 percent to 20 percent who are psychiatrically ill. Boarding homes constitute another form of transinstitutionalization, since many do not represent a real return to the community. Transinstitutionalization is attractive to psychiatric administrators because it reduces the number of patients. Moreover, the patients removed are often not making good use of our resources-that is, they are not getting well. Furthermore, transfer from a public psychiatric hospital to a nursing home means that the patient is transferred from a Medicare-ineligible system to a Medicare-eligible one. Such transfers reduce costs for the state because nursing homes are usually less expensive than hospitals in the first place, and the state can be reimbursed for about 50 percent of the cost of a patient’s nursing-home stay through Medicare. A number of ethical questions arise in the transinstitutionalization of patients. The move may be an improvement in the patient’s living conditions, but often it is not. Is it ever right to move a patient to an institution that offers less comfortable conditions, less freedom, and less psychiatric support? Can that move be justified when it will help to free resources that will help other patients? Can it be justified on the basis of improving staff morale and the climate for therapeutic effectiveness by removing a patient for whom treatment tends to be futile? Can it be justified when there is a court decision that the public psychiatric institution in question is the most restrictive setting? (That is, can it be justified because the court says it must be done, even though we know that the patient will be less active, less free, and less well served psychiatrically?) Moving “old trees” can be lethal, as demonstrated by studies of patients who have been moved from
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ADM~N~STRAT~VE ISSUES IN PUSUC MENTALHEALTH
state hospitals to nursing homes. Can transinstitutionalization be justified politically as reducing costs to state taxpayers? Transinstitutionalization to nursing homes pleases state politicians, state bureaucrats, the judiciary, and, in some settings, clinicians. Thus, we can become heroes in the eyes of the public and the bureaucracy. But is transinstitutionalization ethical when patients are poorly served? In the 1960s and 1970s, deinstitutionalization often involved the transfer of the patient from an institution to his or her family. If family members found this troublesome, we offered them guilt and family therapy. The ethos has changed in the past decade, but we need to ask ourselves why we needed pressure from an external group of patient advocates to force a more humane approach.
Treating the Census In overcrowded public psychiatric wards, there is a need to reduce the census, so that the remaining patients will have some hope of obtaining adequate attention and treatment. In addition to the goal of having a manageable number of patients, there are pressures from the hierarchy and from the ward staff to “discharge four patients today.” In large urban public programs, there are some units with no discretion about the number of their patients (these are usually admission units). These units are the ones that feel the most pressure to treat the census rather than the patients, and so patients are discharged before they are ready or before arrangements are made for the necessary community support. In addition to direct discharges, other, more subtle means are used to reduce the census. If psychiatrists are sluggish in discharging patients, the staff may allow patients to elope or may set up situations that lead to patients’ being released against medical advice. Some public systems are not overburdened and do not have these phenomena, but it is probably fair to say that all public psychiatric services in large urban centers have some severe overcrowding that leads to premature discharging, and those discharged make up a proportion of the psychiatrically ill people in the streets. Treating the census instead of patients clearly raises ethical questions. Which ethos should apply-medicine’s tradition of treatment based on each patient’s need, or an organization’s tradition of considering all its resources and limits? Patients or others may be harmed if they are discharged too soon, but wards that are overcrowded are also dangerous. Should we be loyal to a given patient or to an organization? Should we insist on keeping patients until their illnesses have diminished and can be treated within the community, and should we use overcrowding itself to attain more resources (use our patients to change policy)? Sometimes this approach is successful, but the additional resources obtained in this fashion may be taken from another program, just as needy but less “squeaky.”
CANTHE PUBUC PSYCHIATRIC ADMINISTRATOR BE ETHICAL?
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The Buffer Function It is the role of the public psychiatric administrator to work with as many
as possible of the values of the systems in which he or she operates, and to pass on as few as possible that conflict with clinical needs. In absorbing the incongruities and inconsistencies among all the values of the four systems discussed in this chapter, we allow each system to maintain its own values, but we must also protect our medical values. Which way out? One solution would be for psychiatric administrators to adopt only one of the major value systems. Most of us would choose to adhere to medicine’s values, but this choice is usually perceived as an honorable route to being fired (which partly explains why a state commissioner’s life expectancy is two years and seven months). A second solution could involve changing the values of one of the other systems with which we interact, but should we try to do that? Probably not: our problems are not so significant to the political system, the bureaucracies, or the judiciary that any adjustment would dissolve our discomfort. A third solution could be for public psychiatric administrators to develop ethical standards that would address our own priorities, provide us with our own stamp of approval, and provide us some comfort. Nevertheless, it is difficult to see how this solution would really help the patients. A fourth solution could be for psychiatric administrators to advocate medical-practices laws, government policies, and court decisions that would provide full rights for the psychiatrically ill, rights that, when fully achieved, would eliminate the need for the public psychiatric services as we know them today. There are three distinct rights that we want to champion: 1. The right to independence, meaning the maximum practical freedom from illness and the consequences of illness 2. The right of equality, meaning that the psychiatrically ill have the same opportunities for access to treatment and services in our community that the nonpsychiamcally ill have, totally without discrimination 3. The right of entitlement, meaning that, just as blind people need access to materials in Braille and deaf people need access to hand-signing interpreters, chronically disabled psychiatrically ill people need access to educational, occupational, and social support to be part of society.
In advocating entitlements, especially the more expensive ones, we owe the public empirical evidence that a specific entitlement achieves its purpose. Too often, we have been able only to offer rationales. Each entitlement needs to be approached in the same way we approach treatment modalities-specifymg the indications, contraindications, cautions, and conditions for each. We need to express public psychiatric policy in med-
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ADM~NISTRATIVE ISSUES IN PUBLIC MENTALHEALTH
ical terms, moving from dogma and debate to data, and clarifymg what an entitlement will achieve, for whom and at what cost. The ethical solution for the psychiatric administrator is to work progressively for the rights of the psychiatrically ill. While full attainment of these rights over time is likely to abolish much of the need for the public psychiatric program, we do not want our goals stated in negative terms (such as “abolition of public programs”). Negative goals (such as the unfortunate term deinstitutionalization) pave the road to neglect. Should the day ever dawn when psychiatrically ill people have full access to private psychiatric service systems, one fears that the private sector will have taken on many of the characteristics that today mark the public sector as unethical. The managed-care part of the private sector seems headed in the direction of limited services, departmentalization, and treating the census. We in public psychiatric administration would say that it is not too early for those in private psychiatric administration to ask themselves whether they are ethical. As public psychiatric administrators, we are inevitably unethical in the eyes of all the major systems with which we interact. The ethical solution is to be constantly working for the full rights of the psychiatrically ill, so that we are always in the position of striving to achieve autonomy, nondiscrimination, and entitlements that allow psychiatrically ill people full access to private choices and opportunities, with no need for public psychiatric programs. To say that we are a focal point of the inconsistencies and conflicts of this nation’s major institutions is not to say that being the focal point is not fun. To be inconsistent, incongruent, irrational, and in conflict is to be human, and this condition contributes to the attractiveness of public psychiatric administration.
Roger Peele, M.D., is chair of the Department of Psychiutry, Saint Elizabeth’s Hospital, Fort Washington, Maryland.
Can the Public Psychiatric Administrator Be Ethical? Roger Peele Can the public psychiatric administrator be ethical? In addressing this question, I will be reviewing the values that have led to deinstitutionalization of the psychiatrically ill, especially the homeless psychiatrically ill. There are at least twice as many psychiatrically ill in this nation’s public streets as in the public psychiatric hospitals, and they are in the streets because of a change in the values of public psychiatric administrators. I will review the sources of these values, touch on their impact, and address the choices for psychiatric administrators today in answering the question of whether administrators can be ethical.
Sources of Values A number of government agencies, whose values are evident in regulations and guidelines, influence the care of the psychiatrically ill. The values of third-party payers (such as Medicaid and insurance companies) also affect the care of the psychiatrically ill, through even more rules and regulations for reimbursement. State agencies, with their licensing authorities, safety codes, and health standards, affect what psychiatric administrators can and cannot do. The values of the courts, the legislatures, and the media also influence the actions of psychiatric administrators. Finally, medical This chapter is adapted from a lecture given to the 142nd annual scientific meeting of the American Psychiatric Association, May 11, 1989, San Francisco. Ms. Donna Ondrish contributed to what clarity this chapter possesses, and Miriam Woodall Roland, M.D., made over one hundred editorial improvements. NEW DIRECTIONS FOR MENTAL HEALTH SERVICES. no. 49, Spring 1991 OJossey-BassInc.. Publishers
41
42
ADMINISTRATIVE ISSUES
IN
PUBUCMENTALHEALTH
professionals and their respective accrediting bodies also influence the actions of psychiatric administrators. In this chapter, I will focus on only four major systems whose values impinge on public psychiatric administrators: the legislative branches of government, the executive branches, the judiciary, and medicine itself. It is crucial that the public psychiatric administrator function as a buffer, preserving and protecting medicine’s unique values from the influence of the political system, the bureaucracy, and the judiciary. Let us compare these values, as perceived by those of us who act as buffers.
Values of the Political System As one moves from participating in a treatment-planning conference to meeting with political leaders, or to testifymg before a legislative committee,
one immediately perceives a difference in values. While both systems are interested in doing good, the political system is interested in doing good for many, whereas medicine’s focus is on doing well for a single patient. Whereas the political system expresses society’s prejudices about the undesirability of the psychiatrically ill, medicine’s values are captured in Maimonides’ prayer for physicians: that we will fully serve the undesirable. Whereas the political system reflects the desire to tax as little as possible (and thus provide the minimal service required for the psychiatrically ill), medicine expects to provide all that might well serve the patient. Thus, with an exception or two, resource limitation has characterized American public psychiatric programs throughout their history of more than a century and a half. To counteract this limitation, public psychiatric administrators have found themselves in an uncomfortable position. The public psychiatric administrator who maintains that he or she has always told the truth has probably never testified on behalf of the executive branch before a legislative budget committee. To minimize resource limitation and enhance public support, we are required to sell programs and policies without the cautions and uncertainties expected of a discipline that is scientifically based. We claim that we are technocrats, not Republicans or Democrats, but this stance can be retained only so long as we are answering questions from political leaders. When we want to initiate public programs or policies, the need to sell arises. Thousands of bills are thrown into the hopper each legislative session, but only a few will survive, and the cautious scientific style is often a nonsurvivor. For example, the major political initiative in public psychiatric administration in our time has been community psychiatry. In advocating community psychiatry, we presented none of the cautions, doubts, and questions characteristic of a scientific statement. While one can question the ethics of selling, avoidance of selling can be fatal in the legislative process. Therefore, the public psychiatric administrator often ends up being respon-
CANTHE PUBLICPSYCHIATRIC ADMINISTRATOR BE ETHICAL?
43
sible for programs with high expectations and low funding. Just to compare the words patient and constituent points to a difference in values.
Values of the Executive Branch
As we move from the treatment-planning conferences of the clinical world
to meetings with executive-branch agency chiefs, we perceive a shared interest in competence and expertise, but we also often perceive a tilt toward accountability as opposed to responsibility, a tilt toward efficiency as opposed to efficaciousness,loyalty to the hierarchy as opposed to loyalty to the patients, neutrality toward those being served as opposed to advocacy for patients. While there are clearly overlaps, responsibility and specialization (the values of medicine) are less restrictive, more ambitious, than accountability and departmentalization. Saying an agent is accountable for a person is less comprehensive than to say one is responsible for a patient. While both departmentalization and specialization are seen as guilty of not focusing on the whole person, departmentalization unequivocally restricts the focus, whereas medical specialties are constantly reminded to treat the patient with as broad an approach as possible for the patient’s welfare. Throughout the history of public psychiatry in the United States, the specific executive branches with which we have worked have changed. Public responsibility began locally in the early nineteenth century. Then, from the mid nineteenth to the mid twentieth century, it became primarily the state’s responsibility. In the 1960s, the federal government became more involved, the state effort was conceptualized as suspect, and local control, even separate from city and county, was championed. In 1981, however, the federal government suddenly withdrew its interest in the state public sector, leaving some confusion about who was responsible. The results have been split levels of authority and a multitude of separate agencies for community care, rather than public hospitals, which used to provide health care, social and vocational education, board, and housing (often, unhappily, at abysmal levels). Thus, since the 1950s, there has been a shift from one authority to multiple authorities for the psychiatrically ill. The move of patients from hospitals to communities decreased psychiatric administrators’accountability and authority, requiring us to work with many others to meet patients’ needs and leading to our decreased sense of special identity and responsibility. To counter this diffusion, there is a need for greater assertiveness, advocacy, and negotiation on the part of clinicians and their supervisors. Assertiveness, advocacy, and negotiation, while very important to those of us in psychiatric administration today, are not covered in the typical administrative psychiatry books. Advocating and negotiating within the bureaucracy can be disheartening and discouraging to those trying to assume full responsibility for patients and their needs. This is one of the
44
ADMINISTRATIVE ISSUES
IN
PUBLIC MENTALHEALTH
reasons that many prized psychiatric programs are outside the bureaucratic system, paid by contract. Too often, the public psychiatric administrator’s buffer has failed in the face of bureaucratic values, leading to patients’ and physicians’ disillusionment and frustration with available treatment. When the buffer is too weak, physicians may narrow their treatment to medication. For some patients, however, medication has little or no impact.
Values of the Judiciary Moving from the treatment-planning conference to meetings with attorneys or to the courtroom, one perceives another shift in values. When we compare the values of the judiciary and medicine, it seems that we share the value of careful and full focus on the individual (except in class-action suits), but there are values and related procedures that seem incompatible. Whereas the judiciary assumes an inherent conflict between parties in striving for justice, medicine assumes no inherent conflict between parties in striving to restore health. Whereas the judiciary pursues its factual determinations formally, adversarily, and with rules of evidence, medicine pursues its factual determinations informally, cooperatively, and scientifically. Whereas the judiciary’s fact determinations are made by laypersons, medicine’s fact determinations are made by expertise. Judicial decisions represent the end point and are fixed and final. Medical decisions come early, are flexible, and are subject to change. Whereas the judiciary’s focus in review is on process and is scholastically based, medicine’s focus in review is on results and is empirically based. Whereas the judiciary’s concern about error is expressed in the idea that it is better for ten guilty persons to go free than for one innocent person to be punished, medicine’s concern about error is expressed in the statement that it is better for ten persons to be hospitalized unnecessarily than for one person not to be hospitalized and die. Whereas the judiciary’s adopted legal theories become permanent, medicine’s theories are tentative and subject to empirical tests. Whereas the judiciary has to assume free will, to preserve the sense of culpability, medicine has to assume deterministic models, to achieve therapeutic predictability. This is the value that lawyers seem to have trouble grasping. One has to point out to them that every therapeutic act involves a prediction of what the act will produce, whether the act is to give a medication or to offer interpretation in therapy. That prediction may be based on empirical evidence, or it may be based on a concept about the illness. Principles of treatment cannot contain free will at any syllogistic junctions, because that would remove predictability, rendering the concept clinically useless. Another important difference is that the strength of the judiciary lies in providing decisions directed toward resolving conflicts, while medicine’s strength lies in providing actions directed toward solving problems.
CANTHE PUBLICPSYCHIATRIC ADMINISTRATOR BE ETHICAL?
45
Whereas the judiciary is especially potent in prohibiting action (enjoining), medicine is especially potent in providing action (treating), These judicial values-reliance on conflict, factual determination by laypersons, formality of decisions, review that focuses on process only, the finality of decisions, a concern about incarceration versus a concern about life, the assumption of free will, and a focus on making decisions rather than on solving problems-have increasingly been imposed on public psychiatry through court decisions and through regulations written from the judicial perspective. Beginning in the 1960s, a series of federal judicial decisions affected public psychiatry, moving us in conflicting directions. First we had decisions that directed us to intervene only minimally with patients. Other decisions enhanced the entitlement of patients to therapeutic intervention. One decision said that psychiatrists in the public sector could be liable for retaining people in a public institution, even though thirty courts had ruled in favor of such retention. We have also had a number of right-to-refuse-treatment decisions, which forced us directly into the adversarialjudicial arena. The overall effect of these decisions has been to discourage us from assuming responsibility for the psychiatrically ill. The imposition of the judiciary’s values and procedures over the past twenty-five years has decreased our authority for the psychiatrically ill, added an element of conflict to the patient-psychiatrist relationship, and increased the cost of service. Furthermore, public administrators are subject to judicially written regulations, whose ponderous style feels especially stifling when we are responsible for chronic, difficult patients, in cases where initiative, individuality, and parentalism are indicated.
Changing Values in Psychiatry Despite all the forces outside psychiatry, our own values have contributed immensely to community psychiatry-or to the negative side of the same coin, deinstitutionalization. American public psychiatric administration began in the early nineteenth century with the hypothesis that people suffered from psychiatric illnesses because they had been exposed to immoral conditions in the community. Thus, treatment required the removal of patients from the community and their placement in moral settings-asylums-where they would be cured. In the first half of the nineteenth century, psychiatric administrators claimed many cures. In the second half of the century, for various reasons (including the hypothesis that people suffering from psychiatric illnesses had brain dysfunctions), institutions became the final community for many. Over time, conditions in the institutions were often found to be inhumane, and periodic calls for reform were common from the 1870s up to the 1950s. In the 1950s, the call for reform became a call for abolition of the institutions, strengthened by the evolution of the
46
ADMINISTRATIVE ISSUES
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social hypothesis that patients suffered not from their illnesses but from institutionalism, and that the more the institution structured a patient’s life, the more likely institutionalism would be as a result. Most unfortunately, some important public psychiatric administrators even adopted the position that public psychiatric hospitals were inherently harmful. Thus, some of medicine’s own key public psychiatric administrators reversed the position of our founding fathers: the concept that psychiatrically ill patients suffered from corrupting community influences and needed placement in moral settings was replaced by the concept that the psychiatrically ill suffered from the institutional environment, and the new cure was supposed to be placement in the warm bosom of the community. In the 1950s, there was also the development of medications that facilitated deinstitutionalization. These medications were subjected to controlled studies before their adoption. The social hypotheses associated with community psychiatry, however, were not tested. Therefore, tested medications allowed the carrying out of untested social hypotheses.
Deinstitut ionalization The values of political, bureaucratic, judicial, and professional thinking all came together and spoke with one voice on the need to deinstitutionalize patients. The results of deinstitutionalization are well known to most. Since 1955’s peak of 550,000 inpatients, there was a drop to 150,000 by 1980, and today the number is between 110,000 and 120,000. Where have the psychiatrically ill gone? Three years ago, the director of the National Institute of Mental Health (NIMH) told a congressional inquiry that 6 percent of adults with schizophrenia were in state mental hospitals, 5 percent were in nursing homes, 14 percent were in acute inpatient settings, 17 percent were known to be in outpatient settings, and 58 percent, nearly one million, had been lost to NIMH. Where have these missing people gone? Studies of shelters find that roughly two-thirds of homeless people have psychiatric illnesses, and half of this group are substance abusers. The abandonment of responsibility for the psychiatrically ill is not due to a shortage of psychiatrists. In 1900, we had 450 APA members, fewer than half the number of psychiatrists available today in the District of Columbia alone. In 1950, we had 6,000 members; in 1983, we had 29,000. Since 1983, we have been averaging a gain of about 1,000 members per year, and membership now stands at 36,000.
Exclusiveness There appear to be no ethical guidelines for the degree to which one should increase the effectiveness of a program through exclusion of patients. Some administrators are saddled with responsibility for establishing good programs
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by admitting only “good patients, and many programs require such limitations in order to survive. How many patients with both schizophrenia and substance abuse should a substance-abuse program admit? Should it be allowed to exclude all of them? How many such dual-diagnosis patients should a program treating schizophrenic patients be expected to take? Some of these questions can be answered programmatically, but deliberations often eventually reach the ethical level with respect to the degree of exclusiveness that is morally acceptable. Again, the psychiatric administrator may be very exclusive and yet feel ethically correct from a bureaucratic point of view; but there are questions to be asked about the clinical and public ethics of exclusiveness.
Transinstitutionalit ion Transinstitutionalization, the moving of a patient from one institution to
another, has been a major development in American psychiatry. While we do not know the exact number of public psychiatric patients who have been transinstitutionalized, there are probably hundreds of thousands. It is estimated that 700,000 patients in nursing homes have primary psychiatric problems. Prisons are estimated to have from 5 percent to 20 percent who are psychiatrically ill. Boarding homes constitute another form of transinstitutionalization, since many do not represent a real return to the community. Transinstitutionalization is attractive to psychiatric administrators because it reduces the number of patients. Moreover, the patients removed are often not making good use of our resources-that is, they are not getting well. Furthermore, transfer from a public psychiatric hospital to a nursing home means that the patient is transferred from a Medicare-ineligible system to a Medicare-eligible one. Such transfers reduce costs for the state because nursing homes are usually less expensive than hospitals in the first place, and the state can be reimbursed for about 50 percent of the cost of a patient’s nursing-home stay through Medicare. A number of ethical questions arise in the transinstitutionalization of patients. The move may be an improvement in the patient’s living conditions, but often it is not. Is it ever right to move a patient to an institution that offers less comfortable conditions, less freedom, and less psychiatric support? Can that move be justified when it will help to free resources that will help other patients? Can it be justified on the basis of improving staff morale and the climate for therapeutic effectiveness by removing a patient for whom treatment tends to be futile? Can it be justified when there is a court decision that the public psychiatric institution in question is the most restrictive setting? (That is, can it be justified because the court says it must be done, even though we know that the patient will be less active, less free, and less well served psychiatrically?) Moving “old trees” can be lethal, as demonstrated by studies of patients who have been moved from
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state hospitals to nursing homes. Can transinstitutionalization be justified politically as reducing costs to state taxpayers? Transinstitutionalization to nursing homes pleases state politicians, state bureaucrats, the judiciary, and, in some settings, clinicians. Thus, we can become heroes in the eyes of the public and the bureaucracy. But is transinstitutionalization ethical when patients are poorly served? In the 1960s and 1970s, deinstitutionalization often involved the transfer of the patient from an institution to his or her family. If family members found this troublesome, we offered them guilt and family therapy. The ethos has changed in the past decade, but we need to ask ourselves why we needed pressure from an external group of patient advocates to force a more humane approach.
Treating the Census In overcrowded public psychiatric wards, there is a need to reduce the census, so that the remaining patients will have some hope of obtaining adequate attention and treatment. In addition to the goal of having a manageable number of patients, there are pressures from the hierarchy and from the ward staff to “discharge four patients today.” In large urban public programs, there are some units with no discretion about the number of their patients (these are usually admission units). These units are the ones that feel the most pressure to treat the census rather than the patients, and so patients are discharged before they are ready or before arrangements are made for the necessary community support. In addition to direct discharges, other, more subtle means are used to reduce the census. If psychiatrists are sluggish in discharging patients, the staff may allow patients to elope or may set up situations that lead to patients’ being released against medical advice. Some public systems are not overburdened and do not have these phenomena, but it is probably fair to say that all public psychiatric services in large urban centers have some severe overcrowding that leads to premature discharging, and those discharged make up a proportion of the psychiatrically ill people in the streets. Treating the census instead of patients clearly raises ethical questions. Which ethos should apply-medicine’s tradition of treatment based on each patient’s need, or an organization’s tradition of considering all its resources and limits? Patients or others may be harmed if they are discharged too soon, but wards that are overcrowded are also dangerous. Should we be loyal to a given patient or to an organization? Should we insist on keeping patients until their illnesses have diminished and can be treated within the community, and should we use overcrowding itself to attain more resources (use our patients to change policy)? Sometimes this approach is successful, but the additional resources obtained in this fashion may be taken from another program, just as needy but less “squeaky.”
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The Buffer Function It is the role of the public psychiatric administrator to work with as many
as possible of the values of the systems in which he or she operates, and to pass on as few as possible that conflict with clinical needs. In absorbing the incongruities and inconsistencies among all the values of the four systems discussed in this chapter, we allow each system to maintain its own values, but we must also protect our medical values. Which way out? One solution would be for psychiatric administrators to adopt only one of the major value systems. Most of us would choose to adhere to medicine’s values, but this choice is usually perceived as an honorable route to being fired (which partly explains why a state commissioner’s life expectancy is two years and seven months). A second solution could involve changing the values of one of the other systems with which we interact, but should we try to do that? Probably not: our problems are not so significant to the political system, the bureaucracies, or the judiciary that any adjustment would dissolve our discomfort. A third solution could be for public psychiatric administrators to develop ethical standards that would address our own priorities, provide us with our own stamp of approval, and provide us some comfort. Nevertheless, it is difficult to see how this solution would really help the patients. A fourth solution could be for psychiatric administrators to advocate medical-practices laws, government policies, and court decisions that would provide full rights for the psychiatrically ill, rights that, when fully achieved, would eliminate the need for the public psychiatric services as we know them today. There are three distinct rights that we want to champion: 1. The right to independence, meaning the maximum practical freedom from illness and the consequences of illness 2. The right of equality, meaning that the psychiatrically ill have the same opportunities for access to treatment and services in our community that the nonpsychiamcally ill have, totally without discrimination 3. The right of entitlement, meaning that, just as blind people need access to materials in Braille and deaf people need access to hand-signing interpreters, chronically disabled psychiatrically ill people need access to educational, occupational, and social support to be part of society.
In advocating entitlements, especially the more expensive ones, we owe the public empirical evidence that a specific entitlement achieves its purpose. Too often, we have been able only to offer rationales. Each entitlement needs to be approached in the same way we approach treatment modalities-specifymg the indications, contraindications, cautions, and conditions for each. We need to express public psychiatric policy in med-
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ical terms, moving from dogma and debate to data, and clarifymg what an entitlement will achieve, for whom and at what cost. The ethical solution for the psychiatric administrator is to work progressively for the rights of the psychiatrically ill. While full attainment of these rights over time is likely to abolish much of the need for the public psychiatric program, we do not want our goals stated in negative terms (such as “abolition of public programs”). Negative goals (such as the unfortunate term deinstitutionalization) pave the road to neglect. Should the day ever dawn when psychiatrically ill people have full access to private psychiatric service systems, one fears that the private sector will have taken on many of the characteristics that today mark the public sector as unethical. The managed-care part of the private sector seems headed in the direction of limited services, departmentalization, and treating the census. We in public psychiatric administration would say that it is not too early for those in private psychiatric administration to ask themselves whether they are ethical. As public psychiatric administrators, we are inevitably unethical in the eyes of all the major systems with which we interact. The ethical solution is to be constantly working for the full rights of the psychiatrically ill, so that we are always in the position of striving to achieve autonomy, nondiscrimination, and entitlements that allow psychiatrically ill people full access to private choices and opportunities, with no need for public psychiatric programs. To say that we are a focal point of the inconsistencies and conflicts of this nation’s major institutions is not to say that being the focal point is not fun. To be inconsistent, incongruent, irrational, and in conflict is to be human, and this condition contributes to the attractiveness of public psychiatric administration.
Roger Peele, M.D., is chair of the Department of Psychiutry, Saint Elizabeth’s Hospital, Fort Washington, Maryland.
