Economics and ethics in mental health care: traditions and trade-offs

Background: Both economic and ethical perspectives are exerting increasing influence at all levels of mental health policy and practice; yet there is little consensus on how these two different perspectives are to be reconciled or explicitly incorporated into decision-making.

Aim: This review article is directed towards a fuller understanding of the complex trade-offs and compromises that are or may be made by clinicians, managers and policy-makers alike in the context of mental health care planning and delivery.

Method: We briefly outline a number of key principles of health care economics and ethics, and then focus on the particular incentives and trade-offs that are raised by these principles at three levels of the mental health system: government and society; purchasers and providers; and users and carers.

Results: At the level of government and society, we find (economically influenced) attempts to reform mental health care offset by concerns revolving around access to care: whether society is prepared to forgo economic benefits in exchange for improved equity depends to a considerable extent on the prevailing ethical paradigm. The implementation of these reforms at the level of purchasers and providers has helped to focus attention on evaluation and prioritization, but has also introduced ‘perverse incentives’ such as cost-shifting and cream-skimming, which can impede access to or continuity of appropriate care for mentally ill people. Finally, we detect opportunities for moral hazard and other forms of strategic behaviour that are thrown up by the nature of the carer:user relationship in mental health care.

Conclusion: We conclude by highlighting the need to move towards a more open, accountable and evidence-based mental health care system. Acknowledgement of and progress towards these three requirements will not deliver ideal levels of efficiency or equity, but will foster a greater understanding of the relevance of ethical considerations to mental health policies and strategies that are often influenced strongly or solely by economic arguments, whilst also demonstrating that equity must come at a price. © 1998 John Wiley & Sons, Ltd.