Responses to the killing of Jordan Neely on a New York City subway train split along predictable partisan lines: The left framed Neely’s death as a racially motivated murder, while the right defended Daniel Penny as a Good Samaritan trying to protect straphangers from a man with a history of violent assaults. But regardless of their views on Penny’s culpability, liberals and conservatives broadly concurred that Neely’s untreated mental illness was a crucial factor. If only Neely had had access to adequate mental-health services—or if only the state had been authorized to institutionalize and medicate him against his will—his downward spiral and death might have been avoided.
While such discussions acknowledge the complex social factors that shape mental illness—in Neely’s case, a traumatic childhood, drug use, and a precarious existence—they nonetheless take for granted that mental illness is not fundamentally different from any other illness. Specifically, the prevailing assumption is that mental illness can, in principle, be treated or at least managed by effective medical intervention. Accordingly, it is a truism that access to mental-health services—voluntary or otherwise—is good policy. But the evidence for this assumption is tenuous at best.
For more than a century, the United States has led the way in the treatment of mental illness, pioneering many of the therapeutic and pharmacological methods now deployed worldwide. But despite this head start, the country continues to suffer from the highest prevalence of mental illness among developed countries. The National Institutes of Health report that “1 in 5 US adults live with a mental illness” of varying severity, with adults under 49 reporting the highest rate.
Perhaps the problem is that the treatments aren’t getting to those who most need them. In the wake of Neely’s death, many on the left decried a lack of public funding for mental-health services. The reality, however, is that the United States does expend considerable resources on the problem. While Republicans remain more squeamish than Democrats about funding mental-health services, there is, again, a bipartisan consensus that mental-health issues are real, that a medical response to them is needed, and that at least some public funding is necessary. In 2020, the federal government spent $280 billion to address mental health, up from $171.7 billion a decade earlier. Expenditures have ballooned every year since 1986, with nearly 60 percent of all behavioral-health services paid for by Medicare and Medicaid.
Despite the resources poured into these services, the rate of mental illness also seems to have slightly increased to 15.7 percent today, up from 14.5 percent in 1990. Other estimates suggest that a quarter of people deal with mental-health issues. Looking at post-pandemic trends, it would seem that mental-health issues are on a steady, linear upward trajectory in younger age groups.
It seems likely that if ever more resources had been dedicated to the treatment of any other disease, yet the incidence of that disease continued to increase, some might begin to ask whether the treatments in question are actually effective. But the failure of mental-health services to reduce the incidence of mental illness over the decades hasn’t dampened the conviction that expanding access to them is the only conceivable response to the problem.
It may well be that the overarching approach isn’t merely ineffective, but harmful. Many well-intentioned public-health approaches have proved to be damaging in the past—for instance, the isolation of elderly people in nursing homes during the pandemic. But the problem may also be foundational: that we have misunderstood the nature of mental health, and all our responses to it are therefore destined to fail. Perhaps, that is, we are assigning to the medical profession problems it has no real hope of addressing—whether it is the anxiety, depression, and anomie afflicting people living in an increasingly atomized society, or the thorny question of how society should deal with individuals whose impairments predispose them to seriously antisocial behavior.
The category of “mental illness” encompasses a broad range of dissimilar conditions, from commonplace depression and anxiety to the much more severe state Jordan Neely was in prior to his fatal encounter on the subway. Lumping these conditions together has serious policy implications. Expanding access to mental-health services, despite weak evidence of efficacy for both therapy and commonly used antidepressants, might offer some relief to those with the motivation to seek out treatment. But the severely mentally ill, as Neely’s history reveals, often refuse treatment when it is offered. According to the National Alliance on Mental Illness, 20 percent of those with bipolar disorder and 30 percent of those with schizophrenia “experienced ‘severe’ lack of awareness of their diagnosis.” This is part of why involuntary confinement of the severely mentally ill was a widespread practice until relatively recently. The efficacy and legitimacy of this practice are fundamentally a political question, not a medical one.
Mental-health professionals’ ostensible role is to heal diseased individuals, but they are also charged with protecting society at large from those who fall under their care. In liberal democracies, this has always created tension. There is a widely held discomfort with forcing care on autonomous individuals—particularly if that care involves confining them against their will.
One way of resolving this dilemma is to understand mental illness as a loss of autonomy in itself. If people afflicted with psychosis and related conditions can’t be held responsible for their own actions, involuntary institutionalization might be justified. Yet many still balk at this idea—not unreasonably, given the foundational principle in Anglo-American law that persons forcibly restrained must be charged with a crime. Those with serious mental-health issues are mired in legal confusion: They can be deemed a danger without having committed a crime, but when they have committed one, they may be deemed not responsible for their actions. Which is it?
“The category of ‘mental health’ attempts to turn political questions into medical ones.”
This confusion arises in part because the category of “mental health” attempts to turn social and political questions into medical ones. Psychiatry stands out among medical specialities for the impressionistic vagueness of its diagnostic procedures and categories. There are no purely physical signs of mental illness, and a psychiatrist can’t perform an objective test to assess an individual’s mental state. Instead, this must be inferred from the individual’s statements and acts, and the degree to which these are seen as aberrant or pathological will depend on what is regarded as normal in a given context.
It was easy enough to ridicule progressive proposals to replace police with mental-health professionals, but such proposals capture a truth: The reality is that mental-health services are tasked less with treating and curing illnesses in a normal medical sense than with enforcing social norms. In milder cases, therapy and antidepressants promise to help individuals continue to function as normal, productive members of society; in more severe cases, mental-health services are, in theory, supposed to keep individuals out of serious trouble.
The debate around expanding—or mandating—access to mental-health services obscures deeper questions around normative standards of behavior that should be allowed in public life. There is no scientific or medical answer to the question of how society should accommodate individuals like Jordan Neely. The question is political and philosophical. It touches on the limits of individual autonomy and to what responsibility we have, collectively, in shaping and restraining the behaviors of our fellow citizens, and what level of force is justifiable as a means to this end.
The paramount value we place on individual rights makes it difficult for any coherent conversation to be had on this subject, since a shared vision for what kind of society we want no longer exists. So instead, we take refuge in the supposedly objective pronouncements of medical science to find some basis for a shared discussion. But the compounding failures of this approach are becoming difficult to ignore. If faith in science dissipates, what will we have left?