Marshall B. Kapp

Residents of State Mental Institutions and their Money (Or, the State Giveth and the State Taketh Away)

This article explores the legal, ethical, and policy considerations raised by the economic relationship between the state and residents of the states institutions for the mentally ill and mentally retarded. The focus is upon two interrelated aspects of this relationship: (1) compensation for labor performed by residents within the institution, (2) the residents obligation to reimburse the state for care and treatment received. Each of these issues is traced historically; current state practice is surveyed; and alternatives to present practice are suggested.

Book Review: Mental Health and Law: Research, Policy and ServicesMental Health and Law: Research, Policy and Services, edited by SalesBruce D. and ShahSaleem A. (Durham, NC: Carolina Academic Press, 1996), 371 pp.,

Legislation, regulation, and judicial decisions pertaining to mental health and the mentally ill are based upon a series of factual assumptions about the world and how it operates. These assumptions of lawmakers are usually derived from personal and/or well-publicized individual anecdotes-the human face of the law. The problem is that the most influential of these anecdotes about mental health and the mentally ill may fail to illuminate the larger picture accurately. Indeed, many of the factual assumptions upon which the present mental health system and its legal parameters are built are probably no sounder than a house of cards. As Mark Twain is reputed to have mused in a more general context, It aint what people dont know thats so bad. Its what they know that just aint so.

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Professional ethics are approached today from a number of different, but generally complementary, directions. Principalism emphasizes the intellectual process of applying several (sometimes competing) fundamental values. In the health arena, for example, such prominent values as autonomy, beneficence, nonmaleficence, and social justice are applied to the particular facts of problems facing the professional. To the extent that virtue is identified with ethics, the primary appeal is to the inherent good character of a practitioner: to his choice to do the right thing.? In casuistry, reasoning usually begins with the practical realities of specific cases and works progressively toward the discovery of relevant general principles.

Book Review: Codes of Professional ResponsibilityCodes of Professional Responsibility, third edition, edited by GorlinRena A. (Washington, DC: Bureau of National Affairs, 1994), 816 pp.,

When reading The Lost Lawyer, I was reminded of a recent Wall Street Journal cartoon depicting a mystical guru perched on a mountaintop with a sign at his feet reading: Only wisdom dispensed here. For legal advice, consult your attorney. In this book, Anthony T. Kronman, the Edward J. Phelps Professor of Law at Yale, laments a past in which he claims the relationship between wisdom and law was seamless instead of sharply distinct. For Kronman, the legal profession today is in the midst of a serious identity crisis about what it means to live a life in the law, because few attorneys find their professional life intrinsically satisfying any longer-that is, rewarding beyond the material benefits that one may earn with a law degree.

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A host of books intended to introduce physicians and medical students to fundamental principles of medical ethics compete in the marketplace for the attention of teachers and practitioners. Medical Ethics for Physicians-in-Training, written by a philosopher who teaches medical ethics at New York University and affiliated health care institutions, joins the crowd. Though the authors respect for patient autonomy and dignity is laudable (and I have no doubt that he is an excellent teacher), he tries to accomplish too much in this small volume and ends up gently breezing through a panoply of issues without ever really pulling them together in a coherent, helpful fashion.

Book Review: The Lost Lawyer: Failing Ideals of the Legal ProfessionThe Lost Lawyer: Failing Ideals of the Legal Profession, by KronmanAnthony T. (Cambridge, MA: Harvard University Press, 1993), 422 pp.,

Toward the end (p. 437) of Psychiatric Disability: Clinical, Legal and Administrative Dimensions, one set of contributors mentions the relatively recent development of several specialized professional journals (presumably including the one in which this review appears) as illustrating the growing interaction between the law and psychiatric disability. The current constellation of public programs designed to provide medical, rehabilitative, and income support to the mentally disabled forms a bewildering labyrinth for legal and medical professionals, and certainly for the intended beneficiaries. The main disability programs-Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Workers Compensation, and Veterans Administration (VA) service-connected and non-service-connected benefits-originate from disparate and often uncoordinated statutory and regulatory schemes, which in turn have received disparate and often uncoordinated judicial interpretations. The specific definitions and coverages reflect a variety of different and sometimes inconsistent policy perspectives, and they operate through distinct, complex procedures and bureaucratic structures.

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During his 1988 election campaign, George Bush declared that mental illness was the principal cause of homelessness in the United States. Though some persons have disagreed with the scope of this assessment, the most credible of current studies estimate that at least one-third of the homeless do have a serious chronic mental disability. The reason that so many mentally ill persons are subsisting on the streets instead of in adequate public facilities or private housing arrangements, so the argument goes, is the abject failure of the mental health deinstitutionalization movement of the 1960sand 1970sand the accompanying related debacle of the • community mental health center foray in the 1970s and 1980s.

Book Review: Medical Ethics for Physicians-in-TrainingMedical Ethics for Physicians-in-Training, by KantorJay E. (New York:Plenum Medical Book Company, 1989), 226 pp.,

The legal representation of actual or alleged mentally disabled persons or of persons or institutions concerned with the actual or alleged mentally disabled, raises a panoply of interesting and difficult ethical questions for the practitioner. In a civil commitment or guardianship proceeding, who should be regarded as the real client? Should the attorney act as a zealous advocate for his clients spoken choices, or in accordance with the persons best interests as judged by the attorney? Should the issue of competency to stand trial, or of criminal insanity, be pursued even over the clients objections?

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The field of geropsychiatry has been defined as the psychiatry of late life, encompassing the behavioral sciences, psychodynamic concepts, and psychiatric practice with reference to the aging personality and the mental disorders of late life. (p. 207) The term psychogeriatrics has been defined to mean that branch of psychiatry which is concerned with the whole range of psychological disorders developing in the senium (i.e., after the age of 65). (p. 208) This text is an effort to merge concepts within geriatric psychiatry (a term chosen by the editors for the title) with principles and practices found within the more established discipline of forensic psychiatry.

Book Review: Psychiatric Disability: Clinical, Legal, and Administrative DimensionsPsychiatric Disability: Clinical, Legal, and Administrative Dimensions, edited by MeyersonArthur T. and FineTheodora (Washington, DC: American Psychiatric Press, Inc., 1987), 461 pp.,

This volume is a mixed collection of unrelated articles contributed by American and Canadian experts in law, sociology, psychiatry, and psychology. Editor Weisstub is Professor of Law at Osgoode Hall Law School of York University, Ontario, and has a distinguished background in international mental health law. Because there is no common thread among the various pieces (other than some obvious connection to mental health and the law), each contribution must be evaluated on its own.