David Pollack

The authors describe the ethical considerations underlying the inclusion of mental health services into a prioritized health care system. The Oregon Health Plan is a process for defining and delivering basic health services to an entire state. As the plan was developed, the mental health community needed to decide whether or not to participate in the process and, if so, how. Lengthy discussions among mental health consumers, family members, and providers led to a strategy that emphasized the integration of mental health and chemical dependency services into a comprehensive and universal health care program. This approach appears to have achieved relative parity for mental health

Pharmaceutical industry research and marketing methods and relationships with prescribing providers pose numerous ethical challenges. The authors review the impact pharmaceutical treatments and their costs play in the overall health care system. Several problematic prescribing practices are described along with a discussion of how the pharmaceutical industry has contributed to these practices. The Food and Drug Administration and the legislation that guides it bear much responsibility for how the pharmaceutical industry performs, but is signii cantly impaired in its ability to sui ciently monitor and regulate some pharmaceutical industry practices. Although the pharmaceutical industry has made major contributions to the improvement of health through the introduction of newer and better therapeutic agents and through its support of physician education and patient access to some medications, it is nonetheless driven in part by its proi t motivation, which may undermine some of its more noble goals. In particular the marketing methods utilized by the industry, including the use of pharmaceutical sales representatives, direct-to-consumer advertising, biased or misleading professional journal advertisements, and biased professional educational events, make it very dii cult for prescribing providers to make rational and ef ective treatment decisions. The authors review how conl icts of interest can be avoided and how evidence-based decision-making may be accomplished. Many useful and less biased resources on drugs and evidence-based prescribing are provided