Why not allow people to make their own decisions in the market for mental health services, just as they do in other markets? One argument is that the normal presumptions about consumer sovereignty break down here. This argument could also be called the argument from mental impairment. It amounts to saying that society should exercise some control over the care for the mentally ill precisely because they are mentally ill (and therefore cannot recognize their own need for treatment or properly act on that recognition.)

The main premise of this argument is that mental illness is an impairment that prevents accurate self-diagnosis or self-treatment. Several studies have shown, for example, that over 50 percent of all patients with a serious mental illness are not aware of their illness. Of those who recognize that they are sick, about 60 percent either think that they can solve their problems on their own or that the problem will simply go away by itself. Left to their own devices, these mentally ill people would either choose not to be treated, or would seek improper treatment. Left untreated, they could endanger themselves and others, and generate substantial social costs (e.g., the paranoid-schizophrenic who hears voices that lead him to assault people.)

• Unlike the previous two arguments, this is not an argument for redistributing from some to others; instead it is an argument for collective control of funds people would otherwise spend on themselves. This collective control might be exercised through private or public health insurance programs.

• The argument from incapacity could be used to argue that people should be forced to pay premiums to an insurance plan that provides mental health services to its enrollees. Or, one could argue that people who purchase insurance for other health needs should not be free to exclude mental health services from their health plan.

• The argument is strongest where incapacity is greatest, e.g., serious mental illness; the argument is much weaker for mild forms of mental illness, e.g., mild depression.

It does not follow from the fact that A is more knowledgeable than B that A is entitled to make decisions for B or control his life. Similarly for A being saner than B. Ordinarily, we need a court hearing and due process before a person must forgo his right to make his own decisions about how to spend his resources. Why throw out that principle wholesale?

Further, medical decisions about treatment for the mentally ill are rarely made by individuals; they are made by families. So even if the patient's mental faculties are impaired, the consuming unit (the family) may be able to make rational decisions.

As with the previous two arguments, the argument from ignorance violates principle of individual rights. People should not have to give up their right to make choices simply because they make unwise decisions.

The argument carried to an extreme leads to absurd conclusions: I am ignorant about lots of products in lots of markets. In fact, in every market in which I am a consumer, there is undoubtedly an expert who knows more than I do and could make a more informed choice. Does this mean that other people should make all my decisions for me?

Links: