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State Intervention

In the past years, the state of the Netherlands has massively intervened in mental health care as well as health care in general. This involvement is so far-reaching, that it cannot be ignored. I am using the Netherlands as an example, although similar state intervention has been on the upsurge in many countries in recent years.

The purpose of state intervention is control. The state is strongly preoccupied with financing health care and dealing with the rising costs. It does so first of all by managing a social medical insurance system regarding heavy medical risks, such as long-term or permanent hospitalization. Furthermore, the Ministry of Health determines the fees for various medical treatments, and it determines hospital budgets. The single most important issue in health care policy during the past two decades has been keeping costs down.

These attempts at controlling costs have led to a number of successive financing systems, which were all sooner or later replaced because they didn’t work well. Understanding and implementing these systems requires medical institutions to develop increasing specific economic expertise. At one time a psychiatric institution was managed by a psychiatrist-director. Through the years it became necessary to add a financial director. This financial director became continually more important and powerful. The emphasis on the organization of care and the demand for more efficiency gave rise to the development of a professional management, which increasingly determines work protocols and the organization of treatment. At the same time, there is a great deal of reorganizing, and in particular merging of various institutions. A common complaint that was and still is heard, is that mental health care is fragmented and a confusing jungle. Mergers are supposed to provide more clarity. These mergers generated regional, practically monopolistic institutions. Health care has been heavily bureaucratized..

The state’s influence is not limited to determining financial/economic and organizational frameworks. Legislation has affected the practice of medicine in several major ways. Examples are standards of quality which stipulate which conditions institutions must meet to be eligible for state licensing and funding. Another law stipulates specific quality criteria for various medical professionals.

Even more intrusive is the law regulating physician-patient relations. The state considers this relationship contractual, yet determines most of the conditions of the contract. One of those conditions is that physicians must inform patients about what is wrong with them, which different types of treatment are available, and the advantages and disadvantages of each treatment. The final decision is made by the patient.

This law was a nail in the coffin of the medical profession’s so valued principle of paternalism, which dictates that the doctor determines what is good for the patient. The law’s influence on the physician-patient relationship is far-reaching. Although physicians find it difficult to break the habit of a paternalistic attitude, and increasingly raise their voices to call for reinstating the honor of traditional paternalism, gradually a lot is changing in this aspect. Patients have become more assertive, or as we call it in Dutch, “mouthy.” They play an active role in determining aspects of their treatment.

Consequences for the therapy are far-reaching. In recent years many more complaints are heard about this law than the initial enthusiasm would have led one to expect. It seems that the law does not reduce costs as was expected, because the patient often chooses the more costly therapy, even when the physician does not consider it necessary. Terminal patients often choose a last-hope treatment, even when the side-effects are so serious, that one would wish to spare the patient from them. The use of placebos has become virtually impossible, as it violates the information obligation. Nonetheless this law has clearly improved the position of patients in the sense that their wishes are taken more seriously than before.

State intervention has resulted in little being left of physician-patient confidentiality. Psychiatrists are more and more turning into civil servants whose work is greatly influenced and determined by a large number of regulators: the state, medical insurers, complaint arbiters, and local government. All of these regulators claim to represent the interests of patients. This means that on the one hand, the power of individual psychiatrists regarding their patients has been drastically reduced, and on the other hand, all sorts of institutions are increasingly bearing responsibility for people’s mental health care.

Szasz’s views on this are unambiguous. They are described in Chapter III. He has continued to write about them during the last two decades as well. He holds the libertarian view that the state should limit its intervention to defense and criminal justice. In books as Our Right to Drugs (1992) and Pharmacracy (2001) he discusses the problem that the state has in his view gained much too much influence over daily health care, and has through legislation imposed prohibitions, for instance, regarding the use of medical as well as recreational drugs. In Cruel Compassion (1994) Szasz sketches a lively image of the consequences of in his view undesirable state intervention in the lives of all sorts of helpless and powerless people. He condemns all state assistance to the weak, because this will weaken them even more.

I cannot share this view, as too many obviously powerless people would become victims of this ideology. This raises the question where the line should be drawn, and how far the state should go in this. An illustration of this problem, which was also discussed in Chapter VI, is the law providing attractive benefits for people who are declared unemployable due to illness. In recent years the benefits had to be constantly made less attractive, as such massive advantage was being taken of the law that a million people (on a population of 16 million) were receiving benefits under this law. The challenge is to find the mean between the Scylla of unjustly abandoning the needy and the Charybdis of excessively attractive benefits for people who cannot hold their own in society.

Indirectly, state influence on the conceptualizing of psychiatric disorders is expressed in many ways. For instance, dealing with addicted people used to be a function of the criminal justice system, but was later assigned to health care. In the past, the psychopathological nature of disorders related to substance abuse were considered less important than the criminogenic effects such use often has. A similar problem is the question of what should be counted a psychiatric disorder, and what as a psychosocial problem, so what belongs in health care and what belongs in welfare. This is not the place to suggest an answer to these questions, only to point out how they influence work in the field in all sorts of ways.

As posited above the state also exercises far-reaching and determinate influence on medical ethical issues through legislation. The law regulating physician-patient relations has far-reaching consequences for daily contacts between doctors and their patients. Laws regarding areas as abortion and euthanasia compels physicians to act according to legal directives. Massive state intervention regarding coercion in psychiatry will be discussed in the next section.

I wish to limit my discussion to this survey of examples of state intervention in health care, which are only a fraction of the total. The examples mentioned are the ones which are relevant to the theme of this book.
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