‘Lethal discrimination’, ideology and social justice

Perhaps the journal risks accusations of hyperbole by adopting the slogan of ‘lethal discrimination’ in relation to the shockingly high standardised mortality ratios (SMRs) of people with severe mental illness (SMI). Other serious illnesses (cancer, etc.) have high SMRs but to suggest that this is due to lethal discrimination would attract criticism.

Taggart & Bailey ¹ are right to draw attention to the high SMRs in people with SMI. This is consistent with accepted tenets of moral philosophy, particularly liberal political philosophy. Central to this are principles that citizens enjoy maximum liberty (subject to respect for the liberty of others) and, second, that social arrangements permit social inequality only to the degree that this improves the well-being of the least advantaged. ² People with SMI are among the most disadvantaged.

Table 1 of the editorial indicates that those with SMI in contact with services fare better in the USA than in the UK. This will not surprise those who have expressed dismay about developments in mental health services in the UK. ³ However, the important question is whether the way US mental health services are funded, commissioned and managed may be better. Psychiatrists need to remain open minded about what systems deliver best results, if we are to achieve our aims effectively. ⁴

International comparisons are notoriously difficult to make. A host of health and social indicators however suggest worse outcomes in more unequal societies. Because the USA is a more unequal society, Table 1 is counterintuitive. Perhaps Table 1 is misleading. Taggart & Bailey do not tell us whether the US data include outcomes of individuals with SMI receiving care in prison. In the past 40 years the proportion of people with SMI who are compulsorily detained in the USA has remained the same. However, whereas 40 years ago 75% were in mental hospitals and 25% in penal institutions, now the proportions are 5% and 95% respectively. ⁵ Table 1 will have validity only if the outcomes of imprisoned individuals with SMI are included.

Should further research confirm US superiority, another issue might arise: does more restrictive treatment (in prison) achieve better outcomes? If so, psychiatrists will have to face deeply uncomfortable questions. Could it be that enhanced incarceration leads to lesser freedom but a lower SMR? Would lower a SMR be the effect of more intensive psychopharmacological treatment or is there less psychopharmacological intervention in prison and the higher UK SMR is due to more psychopharmacological treatment in the community? What kind of societies lead to best outcomes for people with SMI?

Health outcomes do not depend only on healthcare. To participate constructively in debate and action aimed at reducing SMRs in those with SMI, psychiatrists need to become familiar with the complex issues addressed by political philosophy ² as well as public mental health. They also need to be aware that although they may master evidence and political ethical reasoning, social ideology will sometimes prevail as to what happens on the ground. ⁶ Perhaps it is anxiety secondary to this that impelled invention of the concept of lethal discrimination in people with SMI.