Conundrums and controversies in mental health and illness.

journal of law, medicine & ethics M. Carmela Epright, Ph.D., is an Associate Professor of Philosophy at Furman University, in Greenville, South Carolina. She serves as a clinical bioethicist and ethics consultant to numerous hospitals and medical associations and has published articles in bioethics, moral theory, political philosophy, and psychiatry. Her current research focuses upon the legal and moral implications of psychiatric diagnosis and treatment. Robert M. Sade, M.D., is a Professor of Surgery and Director of the Institute of Human Values in Health Care at the Medical University of South Carolina in Charleston. He chairs the Planning Committee of the Thomas A. Pitts Memorial Lectureship in Medical Ethics. He currently serves as the Associate Editor (Ethics) of the Annals of Thoracic Surgery, as Chair of the Ethics Committee of the American Association for Thoracic Surgery, and as Chair of the Standards and Ethics Committee of the Society of Thoracic Surgeons. There are many good reasons for dedicating a symposium to issues in mental health and illness, but the main motivation for this one was first and foremost concern for the well-being of psychiatric patients in a health care system that is illequipped to meet their needs. The conference from which this symposium is derived took place in South Carolina, which, in company with many other states, has drastically reduced funding for mental health services in recent years. The state hospital has eliminated approximately a third of its beds, patients experience increasingly lengthy waits for mental health services, and emergency rooms have become the primary source of acute treatment for many psychiatric patients. The criminal justice system is similarly overburdened by competing demands with regard to the mentally ill — prisons contend with ever increasing numbers of mentally ill inmates and face complicated questions regarding how to establish a proper balance between treatment and punishment. In light of these challenges, both the health care system and society at large must consider anew old questions about the mentally ill — what constitutes a mental illness, how such illnesses should be treated, whether psychiatric diagnoses should be considered mitigating factors with respect to criminal behaviors, and whether, how, and under what circumstances respect for autonomy of psychiatric patients should be waived.