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An interdisciplinary look at the deinstitutionalization of the mentally ill.

Randall G. Krieg [*]

Abstract

Deinstitutionalization of the mentally ill has had an enormous impact on the mentally ill, the community, family members and taxpayers. This paper assesses the impact of deinstitutionalization on each of these groups. The approach is interdisciplinary in nature, using schools of thought found in the fields of political and economic thought in analyzing the effect of deinstitutionalization on each stakeholder group. Although assessments vary by stakeholder group, some overall observations can be made. Ironically, both libertarian and utilitarian arguments favor deinstitutionalization, although for different reasons. A deontological view, however, finds deinstitutionalization lacking. [C] 2001 Elsevier Science Inc. All rights reserved.

1. Introduction

Deinstitutionalization refers to a shift in the care of mentally ill persons from long-term psychiatric hospitalization to more independent living environments. A number of factors led to this shift in care. The widespread use of new drugs beginning with Thorazine in 1955 served as a catalyst for the release of many patients from psychiatric hospitals. Patients that could not previously function well in society could, with the use of newer drugs, live independently in society. This transition was also aided by a number of court decisions. What has become known as the "least restrictive alternative" allows involuntary admission to psychiatric hospitals only if there are no other feasible means of treatment that would allow more freedom to patients (Shelton v. Tucker 1960). In the 1975 case O'Connor V. Donaldson, the U.S. Supreme Court ruled that nondangerous mental patients that are institutionalized against their will, have the right to be treated or discharged. The process of deinstitutionalization was grea tly accelerated by the enactment of federal Medicaid and Medicare programs, which enable many patients to sustain themselves financially in the community.

Deinstitutionalization has also meant a shift in the role of government. State and county governments have largely funded long-term hospital care. Independent living must be funded privately, with some federal support, largely in the form of Social Security Disability Income and Supplemental Security Income.

Deinstitutionalization was instituted with the best of intentions. However, there have been unintended consequences accruing to many in society, due to an absence of sufficient planning for alternative care with adequate resources. While most consumers of care benefit from the increased freedom associated with deinstitutionalization, many of the more severely ill have been neglected. In addition, other members of society have been adversely affected by deinstitutionalization.

This policy shift has had an enormous impact on the mentally ill, their families, community members, psychiatric professionals, social workers, taxpayers, and the criminal justice system. The process of deinstitutionalization has been examined from the perspective of mental health professionals, social workers, sociologists and historians. Unlike these previous efforts, this study is interdisciplinary. It is my hope that the gains from the comprehensiveness of this tapestry approach will outweigh any lack of specialization.

My approach follows a line of analysis sometimes used in business ethics known as "stakeholder" analysis. Evan and Freeman (1988) define stakeholders as those who have a stake or claim on a firm and are vital to its success including suppliers, customers, employees, stockholders, and the community. Here, the stakeholders in deinstitutionalization will consist of patients/consumers, the community, families of patients, and taxpayers. These groups have the same rights to participate in the policy-making process that will ultimately affect their well being.

The appropriateness of deinstitutionalization for stakeholders is discussed from different perspectives including: (1) utilitarianism, which is concerned with how the consequences of the policy affect social welfare, (2) deontological thought, which is based on principles of duty, and (3) libertarianism, which stresses individual rights. This paper assesses deinstitutionalization from the perspectives of consumers, the community, taxpayers, and the families of patients in Sections 2-5 respectively. Section 6 presents some final thoughts.

2. Consumers of mental health care

2.1. Rights versus paternalism

The debate over deinstitutionalization is often framed as liberty versus paternalism. Libertarian thought as espoused by Locke construes individuals as naturally free to live their lives as they see fit. Deinstitutionalization has extended this to the mentally ill, the consumers of care, who have become more free to make their own decisions.

Libertarians cite the rights of all people to what Maslow (1943) refers to as self-determination. Self-determination dictates that people have unimpeded access to what life has to offer. Although self-determination is not explicitly enumerated in the United States Constitution, there is some basis for it in common law. In a number of equal protection cases, due process cases, and privacy cases, the Supreme Court has established that self determination is a fundamental right under the Ninth and Fourteenth Amendments.

The "least restrictive alternative" doctrine as originally put forth in Shelton v. Tucker (1960), making involuntary commitment more difficult, is based on the assumption that this is what is best for the patient, not what is best for the community. Similarly, in O'Connor v. Donaldson (1975) the Supreme Court stated that the right of people in the community not to be bothered is important, but not as important as the right of the bothersome to be free.

Morse (1982), a modern libertarian, argues that all involved would be better off without involuntary commitment. He sees involuntary commitment as an unneeded exercise of police power and paternalism of the state, arguing that many normal people are incompetent and most mentally ill persons are not. Morse (1982) contends that healing should be the overriding issue and that paternalistic arguments constitute social control, protecting society at the individual's expense.

Liberty is not the only argument used by those pushing for further deinstitutionalization. Time spent in psychiatric hospitals may increase one's proclivity to be homeless. Long stays in hospitals may result in: (1) dependency or a pathological adaptation to a hospital environment, (2) lack of meaningful relationships, (3) lack of privacy, and (4) lack of personal identity and fulfillment (Litvinenko, 1992).

What is considered a right is a matter of debate. Lamb and Mills (1986) argue that when the mentally ill are a "serious threat" to themselves or to others they have a "right" to involuntary treatment. Those who favor less deinstitutionalization argue that using the criteria "danger to self or others" as the only requirement for involuntary treatment ignores those who are in great need of treatment but aren't dangerous.

Moreover, many mentally ill people may well be living in the community, in a state of misery and degradation. Many severely mentally ill people may need restrictive treatment not only to maintain their mental health, but to survive. One can degrade people by taking care of them and by failing to take care of them.

Many arguments in favor of lessening deinstitutionalization may be viewed as examples of impure paternalism as put forth by Dworkin (1971, p. 365). Dworkin defines paternalism as "interference with a person's liberty for his own good." Impure paternalism exists when the group whose good is at issue is not the same as the group whose freedom is restricted. In the case of deinstitutionalization the restricted group is the mentally ill, while those who may receive the benefit (or incur the cost) are all stakeholders including the mentally ill patients.

The paternalistic view sees involuntary commitment as being in the best interest of a patient's mental health. Of course what is considered paternalistic is somewhat subjective. In some cases, even treatment of deinstitutionalized patients may at times be seen as paternalistic, for example, patients are often moved from one place to another without regard for their wishes. However, some patients may not have realistic visions about what housing is appropriate for them. Moreover, residential services, to a large

extent, are provided by paraprofessionals who have not been trained in traditional mental health care (Randolph, Ridgway & Carling, 1991).

Other problems encountered by the deinstitutionalized include poor decisions concerning their lifestyles, affecting themselves and others, without being subject to involuntary hospitalization. It is unclear whether they are rational agents capable of making decisions that are in their best interests. It is in our inherent nature to wish to be free of restrictions even when at times it is not in our best interest. While this nature is inhibited somewhat by our rationality, in the case of the mentally ill (who may be less rational) such inhibitions may not be sufficient to do what is in their best interest, that is, receive needed care.

2.2. Deontological perspective

Deontological thought judges a decision based on how it conforms to a relevant principal or duty, not based solely on its consequence. Accordingly, O'Neill (1985 p. 253) states that:

..... an adequate understanding of what is to treat others as persons must view them not abstractly as possible consenting adults, but as particular men and women with limited and determinate capacities to understand or to consent to proposals form action. Unless we take one another's limitations seriously, we risk acting in ways that would be enough to treat "ideal" rational beings as persons, but are not enough for treating finitely rational, human beings as persons.

She argues that in order to further the ends of others, we must take their particular capacities for rationality into account. Deontological arguments concerning deinstitutionalization must consider how mental illness may influence this capacity.

Though Kant (a pioneer of deontology) predated this issue, some of his writing adds insight to this discussion. In Metaphysics of Morals, Kant states "I cannot do good to anyone according to my concept of happiness (except to young children and the insane), but only according to that of the one I intend to benefit (1996, p. 203)." Thus, as with children, we may use our own judgment of "happiness" (what is best for the mentally ill) when considering the appropriate care for the mentally ill. The good of the patient becomes the determinant of the appropriateness of deinstitutionalization, not necessarily the preference of the patient. Although deontological arguments cannot be directly incorporated into consequentialist (e.g., utilitarian) analysis, they can be used as benchmarks in maximizing social welfare.

2.3. Utilitarian perspective

Utilitarians contend that policy should be promoted if it results in good consequences to society. Such consequences include satisfaction of consumer preferences, as well as costs to society.

2.3.1. Consumer preference

A number of studies of deinstitutionalization have dealt with the preferences of consumers of mental health services (see Davidson, Hoge, Godleski, Rakfeldt & Griffith, [1996] for a review of this literature). Studies show that consumers generally prefer to live on their own and prefer care by outreach staff on call as opposed to living with staff (Ford, Young, Perez, Obermeyer & Rohner, 1992; Jones & Golightley, 1986; Lehman, Possidente & Hawker, 1986; Allen, Baigent, Kent & Bolton, 1993; Okin & Pearsall, 1993; Okin, Borus, Baer & Jones, 1995; Wills & Leff 1996). Ridgway and Zipple (1990) argue that consumers want housing, jobs, a good income, relationships and a place in the community. Concerning housing they contend "having a home in the community is a right for persons with severe disabilities, and that a stable home is a prerequisite for effective treatment and psychosocial rehabilitation (p. 16)." Tanzman (1993) summarized the results of 26 studies, finding that patients prefer to live independently or with a spouse or significant other, and not with other mentally ill patients.

2.3.2. Costs of increased deinstitutionalization to consumers

Although deinstitutionalization can be seen as a utilitarian policy, the needs of many patients may not be met. Costs to consumers of independent living include high suicide rates, accidents, and untreated illness. Torrey (1997 p. 8) discusses this unintended consequence, bringing the efficacy of deinstitutionalization into question:

The lifetime suicide rate among those with schizophrenia is 10 to 13% and among those with manic-depressive illness 15 to 17%, as opposed to about 1% among the general population. In addition to suicide, many people with severe mental illnesses die prematurely because of accidents and untreated physical illnesses. We don't know how many of them would be alive today if they had received adequate treatment, but almost certainly hundreds of thousands have paid with their lives for an illness that need not have been fatal.

This is particularly disheartening considering that 8 in 10 people suffering from mental illness can return to normal productive lives with proper treatment, yet only about half the people with schizophrenia seek treatment (APA, 1998).

Homelessness is often cited as an unintended consequence of increased deinstitutionalization (Susnick & Belcher, 1995; Bachrach, 1992; Belcher, 199 1). Empirical studies indicate that deinstitutionalization has added substantially to the number of homeless. In a study of former hospital patients, Belcher (1989) found that thirty-six percentage of his sample became homeless in a period of 6 months. He contends that the great majority of those who became homeless were severely mentally ill, which prevented them from effectively participating in the community.

Studies suggest that approximately 30-50% of the homeless are mentally ill (Lamb, 1984). For example, Arce, Tadlock, Vergare & Shapiro (1983) find that 43% of those living in homeless shelters in Philadelphia were mentally ill, and Bassuk et al. (1984) find similar results for Boston (38%). Loneliness and isolation of those living alone may exacerbate their problems. In a Washington D.C. survey Susnick and Belcher (1995) find that the primary response given for one's homelessness is physical or mental illness. Half of the homeless surveyed said that they have had nervous breakdowns or similar problems with nervousness. They also find that only 4% of the homeless population receive entitlements, although 35% are eligible.

Mental health providers have additional concerns. In a recent study of mental health providers Davidson, Hoge, Godleski, Rakfeldt & Griffith (1995) find that care providers are concerned that the severely mentally ill who leave hospital settings may face problems of prostitution, drug abuse, and unsafe sexual practices.

3. The community

3.1. Rights and community interests

Community members are legitimate stakeholders in deinstitutionalization since any community needs order, and therefore has a right to civilized behavior in public spaces. John Stuart Mill in his defense of individual liberty states:

Acts, of whatever kind, which, without justifiable cause, do harm to other, may be, and in the more important cases absolutely require to be, controlled by the unfavorable sentiments, and, when needful, by the active interference of mankind. The liberty of the individual must be thus far limited; he must not make himself a nuisance to other people (On Liberty, p. 53).

Concentration of the mentally ill in a community may cause NIMBY (not in my backyard) syndrome. Torrey (1997) studied the impact of deinstitutionalization on a number of communities with a large number of mentally ill including Long Beach New York, Ocean Grove New Jersey, and New York City. In describing the effects on a neighborhood in Ocean Grove he mentions heavy littering, frequent public urination and defecation, indecent exposure, obscene gestures, increased shoplifting, decreased tourism, increased prostitution, suicide and threatened suicide, and lack of physical health care.

3.2. Costs of deinstitutionalization to society

Risk of violence posed to others is a major cost to society. A number of studies have found a positive association between persistent violence and neurological impairment (Krakowski & Czobor, 1994; Lewis, 1976). Recent empirical studies have found a number of factors that interact with severe mental illness (Swartz, Swanson, Hiday, Borum, Wagner & Burns, 1998; Swanson et al. 1997; Borum, Swanson, Swartz & Hiday, 1997; Bartels, Drake, Wallach & Freeman, 1991; Smith, 1989). Swanson et al. (1990) find that the mentally ill who are prone to drug or alcohol use are twice as likely to engage in violent behavior.

According to Swanson et al. (1997), schizophrenics as a group, tend to be relatively more violent than the average person, while manic-depressives have a lower propensity toward violence than those with other disorders but often engage in threatening behavior. Schizophrenics are four times more likely to engage in violent behavior in a given year (8%) than the average person (2%). This difference widens, however, when combined with substance abuse. There is a higher rate of violence for those with multiple diagnoses.

Lamb and Shaner (1993) argue that those who need care and fail to receive it may become even more ill and avoid treatment making them vulnerable to homelessness and incarceration. Many are discharged into the streets without adequate placement and follow-up care. Many become homeless because they run out of money.

Rural/urban status plays a role in the effectiveness of deinstitutionalization in the community. Rural patients are less likely to receive community mental health services (probably due to lack of availability of opportunities for psychosocial rehabilitation) and more likely to become involved with the criminal justice system (Sullivan, Jackson & Spritzer, 1996).

A number of studies have been done on the impact of deinstitutionalization on the criminal justice system (see Miller, 1992). Studies indicate increases in the number of the mentally ill in prison (Bonovitz, Caldwell & Bonovitz, 1981), as well as increases in the incidence of mentally ill incarcerated (Whitmer, 1980).

A substantial number of those incarcerated suffer from severe mental illness. James, Gregory, Jone & Rundell (1980), found that 10% of his sample of Oklahoma prisoners were severely disturbed. Guy, Platt, Zwerlin & Bulloch (1985), using 96 randomly selected admissions to a Philadelphia jail found that 14.6% had schizophrenia or manic-depressive illness. Interviewing 3,332 inmates in New York, Steadman, Fabisiak, Dvoskin & Holohean (1987) found that 8% have substantial psychiatric and functional disabilities that clearly warrant treatment. In a Chicago study, Teplin (1990) interviewed 728 jail admissions and found that the observed jail rates of schizophrenia, major depression, and mania were two to three times higher than in the general population. A more comprehensive survey by the National Alliance for the Mentally ill found that 7.2% of inmates appeared to have a serious mental illness Torrey et al. (1992).

Although libertarians may argue that everyone should have the right to fail as well as succeed, from the perspective of the criminal justice system it is difficult to find a bright side to deinstitutionalization. Although they are not readily measurable, costs due to crime caused by deinstitutionalized mentally ill may outweigh psychiatric hospitalization costs. More protective care of those with a propensity to commit crimes is warranted, since the problem can only get worse in the long-run as mentally ill inmates fail to receive adequate care.

3.3. Community attitudes

Attitudes that the mentally ill confront in the community affect the extent to which deinstitutionalization promotes freedom and liberty. In order for deinstitutionalization to be successful, it must have community support. If members of the community equate mental illness with deviance it will be hard for further deinstitutionalization to succeed. According to the National Association of Private Psychiatric Hospitals "One quarter of a population recently surveyed would not want people who have had mental health problems as neighbors, while 60% would not want them as tenants." In a 1991 survey done in West Sussex, 71% had heard of local mental hospital closings, but only 18% were in favor of such closings. The community wanted to be sure that the mentally ill were not on their own (Loam & Egan, 1990). Such a divergence between policy makers and public opinion brings the policy choice into question.

Huxley 1993 finds that 33% of those surveyed had knowledge of their local mental health facility. This is slightly higher than numbers found in previous studies by Heinemann (30%) in 1974, Morrison and Lebow (29%) in 1977, Rabkin (23%) in 1985, and Taylor (21%) in 1988. This could be interpreted as an indicator that the facility meshes in naturally with the community helping to lessen negative attitudes toward the mentally ill in the community. Murphy et al. (1993) find that those surveyed show a low level of fear and a high level of sympathy towards the mentally ill.

4. Taxpayers

4.1. Taxpayer obligation

Libertarians often argue that to the degree that taxpayers are autonomous agents, their freedom to keep the income they earn must be considered. Moreover, libertarian thought holds that it is nice to help others, but never an obligation (unless contractually established). This is at odds with the Kantian view.

Kant (1996) refers to "perfect" obligations as those concerned with obeying the law and obtaining one's own moral end, and he refers to "imperfect" obligations as those concerning duties of beneficence and the development of oneself as a means to future ends. Prior to deinstitutionalization, psychiatric hospitals accepted the perfect (legal) duty to care for patients. Subsequently, the imperfect duty of this care has been passed on to society. This does not mean that there is any less need, or that there is not a general, nonspecific responsibility to care for the mentally ill. In a Kantian framework, imperfect duties are duties in every sense, not simply supererogatory niceties that people might decide to do. Kantians would argue that this imperfect duty needs to be accepted by society. To the extent that voluntary efforts fall short, the responsibility falls on taxpayers.

Moreover, it could be argued that citizens have an obligation to help and develop the opportunity of others to enjoy what life has to offer. In cases where corresponding rights or entitlements exist, O'Neill (1988) argues that taxpayers have a perfect obligation. Even when such entitlements do not exist, O'Neill contends that such duties may be imperfect obligations resting on society. O'Neill' s argument could be applied to corresponding entitlements for the mentally ill to better care, especially for the more severely mentally ill.

4.2. Pecuniary costs

4.2.1. Cost-effectiveness

Deinstitutionalization has been touted as an economical way to care for the mentally ill. Promises of cost-effectiveness were major factors in the legislative support of deinstitutionalization. Using data from the Mental Health Center of Dane County, Madison, Wisconsin, Wolff et al. (1995) estimate societal costs to be $23,061 for 1988 ($30,586 in 1996 dollars). More than half of the government funding was financed through state and local governments. One-third of the costs were financed by the federal government through Medicare and its share of Medicaid.

Murphy and Datel (1976) compared community versus institutional living. They estimated an average net savings of $20,000 per patient over a ten-year period ($66,197 in 1996 dollars). Of course, dollar values cannot be assigned to all variables that are affected by deinstitutionalization. In a study of cost-effectiveness, Coursey, Ward-Alexander & Katz (1990) estimate that halfway houses save insurers 59% of their hospitalization costs. They also note that in past studies, costs of alternative care have never exceeded that of inpatient care.

However, deinstitutionalization is not a clear windfall for taxpayers. For example, to effectively treat the mentally ill, community programs need flexible hours, walk-in services and outreach capabilities. In addition, from a taxpayer perspective, the indirect transfer of patients from hospital care to the criminal justice system is an inefficient use of funds. As a by-product of deinstitutionalization, there have been increases in the number of mentally ill in prison (Bonovitz & Bonovitz, 1981).

4.3. Funding community living

Deinstitutionalization means a shift of the tax burden from the state and local level to federal taxpayers through Social Security Disability Income, Supplemental Security Income, and Veterans Administration disability income. When patients are transferred from a state psychiatric hospital (where the state pays the majority of the costs) to a nursing home or some other type of outpatient care, they receive federal transfer payments. Torrey (1997) estimates that 1963 state and local sources of revenue covered 98% of the support for persons with mental illness, but only 38% in 1994. This time period spans the bulk of deinstitutionalization.

Some of the original motivation for increased deinstitutionalization was the belief that care would be maintained at a lower cost to taxpayers. It does not appear that such savings have been passed on from hospital funding to community funding.

From a policy perspective we must look at all consequences of transfer payments including enhanced utility which the patients receive from the increase freedom of choice, including the freedom to purchase whatever they see fit. This includes freedom to buy necessities, proper medication as well as illegal drugs and alcohol. This is especially relevant in light of the fact that those mentally ill who use drugs or alcohol are much more likely to engage in violent behavior, another cost to taxpayers.

5. Family members

With the advent of deinstitutionalization, fewer patients are admitted to psychiatric hospitals, and those that are stay for much shorter periods. This leads to a larger role played by families in the care of patients and makes family members important direct stakeholders in deinstitutionalization. Goldman (1982) estimates that 65% of patients discharged return to their families. In a more recent study, Steinwachs, Kasper & Skinner (1992) found that 42% of those with mental illness lived with relatives, 31% lived independently, and only 14% lived in supervised residential settings.

From the perspective of family members, the major issues include care for the patients' welfare, a sense of familial obligation or duty, the desire to be close to the patient, and the costs involved in family care. The satisfaction received from proximity to mentally ill family members must be weighed against the pecuniary, time and psychic (e.g., stress) costs incurred by families.

It is easy to see the expected benefits of increased deinstitutionalization for family members. First, deinstitutionalization helps maintain closeness with a family member.

Second, families may care for mentally ill members themselves, lessening the pecuniary costs of care.

Economic costs of families could be measured in terms of extra time and money spent by the family to provide care for the member who has mental illness. The value of money spent by families is self-evident. The value of members' extra time can be measured in a variety of ways. One option is to use the wage rate of family members, that is, the cost of staying home from work. Another is the cost that would be incurred by hiring workers to perform tasks otherwise done by family members.

Psychic costs are borne by families as well. Extra needed attention by mentally ill family members means less time available to other family members. This could add stress to familial relations, including contributing to separation or divorce. Brothers and sisters may become resentful if inordinate amount of the parents' time is devoted to a mentally ill sibling (Kelly, 1992).

In some cases psychic cost to families includes violence. In a study of patients admitted to psychiatric hospitals, Tardiff (1984) found that 65% of the sample had attacked a family member. Of family members caring for a mentally ill patient, the major care provider, usually a spouse or mother, is at the greatest risk of violence. Negative consequences of such care may often be unexpected. There is the risk of violence or unforeseen disruption of family relationships that may result over time. Unfortunately, even experts cannot accurately predict these consequences.

Hatfield (1993) contends that families are concerned that mental health systems do not provide adequate housing, and residences are scattered throughout the community with no guarantee that tenants will become integrated into community life. Adding to the problem are family concerns that loneliness and a lack of social relationships are among the greatest problems faced by consumers. Another concern of families is the aging of family caregivers. Steinwachs et al. (1992) found that more than half of the family caregivers were over 65 years old, and a fifth were over 70. Thus, not only is this a burden on senior citizens, but family care opportunities will diminish over time for consumers of mental health care.

6. Some final thoughts

The use of stakeholder analysis in this study of deinstitutionalization is important from the perspectives of each school of thought considered here. Libertarians are concerned with the rights not of one, but of all stakeholders, including consumers and taxpayers. Utilitarians must consider the greater good for society, that is, all groups in society who are in any way affected, not only those directly involved. Similarly, deontological study of deinstitutionalization should also consider the rights and duties of all involved or in any way influenced by this policy.

Although libertarian thought is often at odds with utilitarianism, both schools of thought have reason to favor deinstitutionalization. Libertarianism which sees individuals as basically good in essence and naturally free, is pitted against government or societal influence which is more centralized and constraining. Utilitarians may also find reason to support deinstitutionalization. While the more severely mentally ill may lose, becoming homeless or incarcerated, the majority of consumers seem to prefer the increased freedom that comes with deinstitutionalization (Tanzman, 1993). In addition, the financial cost of mental health care decreases as care becomes less structured and more patients live independently as cited above. Although the apparent cost savings of the provision of mental health care must be balanced against the increase in costs due to increased homelessness and imprisonment.

Our current policy of deinstitutionalization is utilitarian in nature, and is built for those who, for the most part, can look after themselves. This paper has questioned its appropriateness from a number of fronts. Possibly the most persuasive argument comes from the Kantian perspective. During the period of institutionalization, state and local governments generally accepted the "perfect" duty or legal responsibility for the mentally ill. Since deinstitutionalization began, government support has been tenuous, leaving the "imperfect duty" to others with the aid of federal transfer payments. This duty, or responsibility, needs to be accepted by someone.

Deinstitutionalization has meant great cost savings for state and local governments. It may be appropriate for policy makers to take more responsibility for the most severe cases of the mentally ill. It is not good policy to sacrifice adequate care in an effort to decrease costs. Savings could be passed from hospital funding of programs prior to deinstitutionalization to community funding of programs today. Programs such as halfway houses need to be established with continued stability. It seems that the limited existing programs along with federal transfer payments do not provide sufficient care, particularly in cases of the most needy. Ultimately policy-makers must decide whether legal entitlements exist, and the corresponding nature of citizen obligation.

Randall G. Krieg is Professor of Economics at The University of Mary, Office of Academic Affairs, Bismarck, North Dakota. He has published extensively in the field of Labor Economics. His current research agenda is in the area of applied ethics.

(*.) Tel.: + 1-319-273-2412.

E-mail address: rkrieg@umary.edu (R.G. Krieg).

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Author:Krieg, Randall G.
Publication:The Social Science Journal
Geographic Code:1USA
Date:Jul 1, 2001
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