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In this well-written and thoughtful book, Carol Austad argues that the current mental health care system is unfair. Those in great need, who could benefit greatly from mental health care, often get none, while those with little need, the worried well, can consume a great deal of resources with no measurable result. The old fee-for-service method of providing of health care simply perpetuates this state of affairs. Much of current managed care is bureaucratic and mismanaged. Austad's solution is to have better-run managed care making more rational decisions. In times of limited financial resources, we cannot afford luxuries like long-term psychotherapy for the worried well, and we should do away with it. All treatment should be portioned out in ways that accord with our empirical knowledge of what helps, rather be held back by traditional practices and the profit motives of large businesses. This help us become a more just society. There will be much resistance from the mental health profession towards such change, because it will require new methods of working and maybe less income. But it is not possible to keep on as we have been going, so since we must change, we should change for the better.

Before reading this book, I had not expected to like it. Like most people I know, I have had plenty of difficulties with both a health insurance company and an HMO. Having spent eight years at universities in the northeastern US, where it seemed unusual for someone to have not ever been in therapy, I tend to be unsympathetic to people who want to do away with it. Although the title of the book is phrased as a question, it seemed that Austad was going to defend HMOs and criticize long-term therapy. Which she does. But she does so with subtlety, stating her case very clearly, and addressing the main objections to her view.

What I found especially hard to argue with was her emphasis on social justice. I grew up in the United Kingdom, and my background obviously influences my views as an ethicist; I see health care as a right as basic as education, so I am shocked at the number of people in the US who have no or inadequate health insurance, and also at the profiteering and commercialism involved in so much of medicine. At the same time, I have personally experienced mostly good and efficient health care here in the US, and I am shocked at the stories of long waiting lists and bad health care I sometimes hear from friends and family in the UK. Austad argues for a just and efficient system of health care provision, which promise the best of both worlds. The question we are left with is how feasible are her proposals? She is realistic about the financial constraints on health care, but is she realistic about what can be achieved in the US? It is admirable to give us an ideal to aim at, but there are also dangers. We may end up with a worse state of affairs than we started out with if we don't have realistic goals. I'm unsure how much public will there is to work for a new health care system in the US, despite the frustration of the millions of people who are not well served by the current health system. When I teach health care ethics at the University of Kentucky and we discuss what happens to people who do not have health insurance, or the disparities in health care between rich and poor, almost no students express outrage or indignation about the current system, even when they know the relevant facts and can see how costly and inefficient the US system is compared to other countries. They seem to have deep seated suspicion of trying to make the US more like other countries. This is true not just for the "college age" students, but also for the many non-traditional students in my classes. My students are by no means the privileged few -- a large proportion of them work 20 - 40 hours a week at the same time as taking a full set of classes. Yet when I taught at Princeton University as a graduate student, I had more students expressing anger at social injustice than I do now.

I see my individual experience reflected in the way that health care revision seems to have been completely dropped from the national political agenda. It is still a topic of debate at the state level, and there are increasing attempts to regulate HMOs in many states. But this tinkering with the system at the state level looks unlikely to effect any major systematic changes. Maybe through books such as Is Long-Term Psychotherapy Unethical? a more coherent vision of how to improve health care in the US will emerge, and this will eventually help to guide the health care policy of the future. Even though I have my doubts, I hope that Austad's book will be influential.