Social Darwinism for the mentally ill

David Hill suffered from a mental illness that his family struggled to manage.Suzanne Kreiter/Globe staff

David Hill’s problem wasn’t just that he had suicidal thoughts. The 23-year-old Eastham resident also needed more support than his family could wrangle for him in a state where mental health care hospital beds are hard to come by.

Hill’s case figures prominently in the Globe Spotlight Team’s latest investigation, which shows how, as Massachusetts dismantled its psychiatric hospital system over a half-century, patients and their loved ones were left without adequate treatment options. Families like the Hills face a creeping new social Darwinism. Mentally ill citizens and their long-suffering relatives have to fend for themselves.

And if they can’t? Whatever — the cops can sort it out, for it’s often law enforcement that fills the void. Believing Hill was on a suicide mission, family members called police for help one night in October 2006 — a fateful choice. In the end, he was shot to death by an officer in the woods.

A previous installment of the Spotlight series last month zeroed in on people who, authorities believe, were murdered by loved ones with a history or clear symptoms of serious mental illness. Cases like these are tragic on their own terms. They also represent cracks in the very idea of a commonwealth, symptoms of how government has given up on some of the responsibility it once took for the well-being of its citizens.

Yet long after it has abandoned patients’ bedsides, government ends up intervening in their troubled lives one way or another. So either we make room — in our politics, budgets, and treatment protocols — for the idea that society needs to take explicit responsibility for vulnerable people up front, or we just accept the idea that someone like David Hill is on his own until he gets in a fatal confrontation with a cop.

It’s an ironic predicament for a liberal state to back itself into.

One bleeding-heart explanation of problems like those described by the Spotlight Team is that Massachusetts isn’t investing, or even raising, enough money to meet the varied and complex needs of its residents.

There’s some truth to that, if this strange budget season on Beacon Hill is any indication. Years into an economic recovery, with construction cranes filling the Boston skyline, you’d think the state could build up its rainy-day reserves and figure out which new initiatives to move off the wish list and into reality. Instead, the Legislature and the governor have been scrambling to adjust as tax collections come in below expectations.

Rather than rethink its tax system for a dawning age of the Internet and yawning inequality, the state cut taxes on dividends, interest, and ordinary income during the dot-com era. Noah Berger, executive director of the left-leaning Massachusetts Budget and Policy Center, says cuts like those add up to $3 billion in lost revenue a year.

Still, there’s more to the story. The money that does come in is locked into programs whose expenses the state can’t easily control in the short term. According to the business-funded Massachusetts Taxpayers Foundation, 54 percent of the state budget consisted of nondiscretionary items in fiscal 2008; in 2017, it’ll be about 61 percent. The cost of public employee pensions and debt service have risen. By far the biggest increase has been in MassHealth — a result of an entirely warranted effort to expand access to basic insurance coverage, but also of the state’s high health care costs overall.

There’s a squeeze on. In real dollars, spending on mental health has been flat at best; as a portion of GDP, it’s shrunk. Without some new revenue, a revolution in controlling health care costs, and more restraint by public employee unions and other interest groups, Massachusetts will have more and more trouble providing a range of social and physical infrastructure to people who need it.

The other barrier to a more comprehensive mental health system is philosophical. Across the political spectrum, most of us are wary of letting government meddle in individual patients’ lives to the degree that it did half a century ago — and to the degree that some patients clearly need. The large psychiatric institutions of yesteryear were both expensive and coercive, and neither doctors nor public agencies have proved themselves infallible in the intervening decades. Many of today’s drugs and therapeutic techniques may well seem clumsy or ineffective someday.

Still, even in less restrictive community settings, effective treatment requires some deference to doctors — and judges, if necessary — when patients fall out of compliance with treatment or deliberately refuse it. Massachusetts is one of four states where courts lack a straightforward way of compelling troubled patients to undergo treatment. Our lack of trust in the professional judgment of private psychiatric units extends, as STAT reported this past week, to the point of micromanaging, via legislative and regulatory fiat, how much fresh air their patients should receive.

Far more momentous decisions about mentally ill patients’ fate sometimes fall to our social workers of last resort — police officers, who never asked for the role but are summoned in moments of crisis.

Our public policies need redirection, but budgetary and political constraints have knocked the steering system out of alignment. Agents of government are still making momentous choices about mentally ill citizens and their loved ones. Those decisions just get made by the wrong people in the wrong place at the wrong time — by police officers, not by doctors; in random locations, not in clinical settings; and on the spur of the moment, not soon enough to save people who’ve been left to survive on their own.