Bioethics Forum Essay
New York’s Involuntary Psychiatric Treatment Initiative: Positive Signs and a Path Forward
Recent policies by New York State Governor Kathy Hochul and New York City Mayor Eric Adams to identify homeless mentally ill people and remove them from the streets for involuntary treatment have raised many ethical concerns. But there is encouraging news–some individuals brought in under these policies to hospitals that provide longer-term treatment have benefited, ending up in supportive housing.
We praise the expansion of voluntary extended stay units at Bellevue and Kings County Hospitals and in other systems. They offer individuals intensive support. They include longer stays, medication management, rehabilitative activities, and counseling before people re-enter the community (often in supportive housing). This level of care should be the rule, rather than the exception.
Currently, homeless mentally ill individuals are stuck in the revolving doors of trauma, and the indignity of forcible removal and commitment. It perpetuates the cycling of homelessness and incarceration, mostly for people of color.
The issues of homelessness and mental illnesses are complex and illustrate centuries of systemic racism and the marginalization of people of color, the poor, and those with significant mental illness. In the 2010’s, New York State further limited the care of people with mental illness under Medicaid, as part of efforts to curtail health care costs. This Medicaid reform limited psychiatric hospitalizations to 12 days, and significantly reduced reimbursement for any additional days of care.
In a Hastings Bioethics Forum essay, Aashna Lal made the case that psychiatric treatment over an individual’s objection is an ethical imperative in limited situations. We agree that providing care to those truly without the ability to care for themselves is moral and ethical. The core ethical issue is that there is a continuum from individual autonomy to provider beneficence. As Lal mentions, Hastings Center cofounder Willard Gaylin and senior advisor and fellow Bruce Jennings state in their book, The Perversion of Autonomy: The Proper Uses of Coercion and Constraints in a Liberal Society, that it is morally dangerous to place too much value on individual autonomy and too little on care and support for people in need. Ethical support requires treatment over the full continuum of care, not simply removing the unsightly homeless individuals from public spaces.
Jonathan Wolf, in his book, The Human Right to Health, asks, “How can there be a human right to health if the resources are just not there to satisfy it?” People with mental illness have been systemically and continuously deprived of that right by the lack of resources and investment in their well-being and housing. Homeless individuals are often people of color who grew up in communities that have been redlined by the banks. This stigma and the bias against homelessness create further social isolation. Hence, policies that point to “handling the homeless” and “cleaning the streets” perpetuate epistemic injustice, even among well-trained health care professionals.
We advocate for a more communal and integrated approach for health care professionals involved with homeless people experiencing mental health concerns. Clinicians, not police, must be the ones to determine whether the homeless individuals suffer from serious mental illness requiring treatment in an ER. Distressed people in distressed communities deserve more immediate and more lasting solutions. States have achieved decades-long savings by closing psychiatric hospitals and denying support to many communities. A positive outcome will demand a re-investment of these resources in care and services.
Individuals with mental illness should receive robust and adequate treatment as determined by the members of their clinical teams before they are discharged from the hospital or transferred to state facilities. The length of stays and discharge decisions should be made by the health care team, rather than insurance companies or regulators.
Stays should also not be longer than necessary, a problem that results when people with mental illness must wait a long time for authorization of post-discharge supports. The legal process to obtain assertive community treatment, assisted outpatient treatment, and other forms of support can take months. The process must be streamlined, so that people are neither discharged prematurely nor given unnecessarily extended stays.
The New York City and State governments’ focus on the needs of homeless individuals with serious mental illnesses seems genuine and worthy. But indiscriminate involuntary removal and evaluation of homeless individuals should be just one tiny facet of care. The allure of an easy fix should be resisted. The care of this population is complex and demands a holistic approach that integrates preventative, corrective, and rehabilitative measures along the entirety of the care continuum. All efforts must be supported by investments of money and resources that improve our safety net hospitals, celebrate human dignity, and truly prioritize the least advantaged members of our society. There is early evidence that providing extensive comprehensive care is working. To do otherwise would be a tragic farce that is doomed to fail, once again.
The authors are members of the Empire State Bioethics Consortium. This essay reflects discussions during the meetings.
Richard A. Siegel, LCSW-R, is an adjunct professor at the Silberman School of Social Work at Hunter College. He recently retired as the director of Social Work at NYC H+H/Metropolitan and as the co-chair of the H+H Ethics Council.
Leora Botnick, LCSW, is co-chair of the New York City Health + Hospitals Bioethics Council and of the Ethics Committee at NYC H+H/Jacobi and is a social work supervisor in the Department of Social Work at NYC H+H/Jacobi.
Kara Simpson, LCSW-R, is the director of social work for behavioral health services at NYC H+H/Jacobi. She is also a masters of bioethics student at the Center for Bioethics at Harvard Medical School.
Louis Voigt, MD, MBE, is chair of the Memorial Sloan Kettering ethics committee and an attending physician in the departments of medicine and of anesthesiology, pain, and critical care medicine. He is an associate professor of medicine in clinical anesthesiology and of clinical medicine in medicine at Weill Cornell Medical College.
Robert Klitzman, MD, is a professor of psychiatry in the Vagelos College of Physicians & Surgeons and the Mailman School of Public Health and the director of the masters of bioethics program at Columbia University. He is a Hastings Center fellow. @RobertKlitzman
Benita Zahn, DPS, MS, NBC-HWC, is a journalist and certified health and wellness coach working with cardiac patients.
Nancy Dubler, LLB, is an attorney and the consultant for ethics at the Health and Hospitals Corporation, and a Hastings Center fellow. She is the author of books and articles detailing how to use mediation in clinical ethics consultation.
I completely agree that there are limits to autonomy and I don’t object to forcibly removing people from living on the streets. However, many people call for forcible treatment of those with addictions and/or mental illness. My question is, is there any data on how successful forced treatment for addiction (and mental illness generally) is? This isn’t a question about whether it’s ethical to treat people against their will or over their objections, but whether it works.
The sentence “But indiscriminate involuntary removal and evaluation of homeless individuals should be just one tiny facet of care” suggests the authors do not understand the US Constitution and its important protections. Additionally, the assertion that “The core ethical issue is that there is a continuum from individual autonomy to provider beneficence.” This is generally not seen as a continuum at all – although clearly some uses of beneficence in the bioethical literature sit in tension with autonomy. While the authors are sincere and well-meaning in their views and I have much respect for them, a human rights approach would comport with WHO, the UN, and the US Constitution more squarely. For disclosure, I was part of the ESBC working group but withdrew when the direction of the paper became continuum of care as opposed to human rights protections. I think it may be important to note that ESBC has many members (perhaps 150?) and hopefully many individual views.
The growing population of homeless mentally ill adults reflects the inadequate mental health care options in our communities at all levels of care. Locating a provider who is accepting new patients is the first hurdle. My young adult son was struggling with depression after a series of setbacks in his personal life. He didn’t have the capacity to call around for help. He hasn’t formed any kind of a relationship with a primary care doctor. He felt embarrassed he wasn’t copying well. After some months, and so much encouraging and listening, he agreed to see a counselor. I spent a day calling every doctor and social worker on the provider list given by our insurance. Most were not accepting new patients. Those that were had up to a six month wait time for the first initial appointment. I narrowed the list and gave the numbers to my son because I was not allowed to make an appointment on his behalf. He called and set an appointment four months away. The day that appointment arrived, he was struggling to keep a new job and was afraid to ask for the time off so he blew it off. In the meanwhile his condition worsened and he was living six hours away from family, completely isolated. Another month or two went by and he drove himself to a local ER. They discharged him a few hours later with a list of providers that required he make phone calls and go through yet another screening process that would start a month later. It was too much for him. He lost his job. A few months after that, behind on his rent, he finally agreed to move home. Now home, he rarely leaves his room and doesn’t want help. He is incapable of holding a job, having lost 3 over the past two months.He refuses to make an appointment with a counselor because he is too anxious. Recently, he was unable to get out of bed and start his new job, a job he interviewed for online, and was very enthusiastic about just the day before. When that fell apart, he finally agreed to be seen for an evaluation and to get some help and here we go again. I called an adult mental health clinic and got an answering machine that told me to leave my name and number and I’d get a call back within 48 hours–to set an appointment. I called a hospital that provides mental health inpatient services and was told to bring him to an ER–again, to wait for hours in a quasi-public space and share his very personal struggles with a tapped out ER nurse who may or may not be well trained, but knows there are no beds except in the most extreme cases, only to be sent home as non urgent, find a doctor to treat you, here is another list. He refused to go to the ER. He made an appointment with a counselor who can see him in October. We are back at square one. The window for him has closed again. He was ready and willing to get help two days ago. It’s debatable if he will show up at his October appointment. I expect our experience has a great deal to do with the growing populations of homeless/mentally ill adults.
Local, accessible mental health care is so woefully inadequate. We need 24/7 walk-in clinics that can provide high level care in an appropriate setting at the hour of need. People would be outraged if this is how we treated broken bones. But broken brains? There is no urgent care available for emerging issues, or for people who are not in immediate danger to themselves or others. Isn’t this an equity issue? And an ethical issue?
And my son comes from a supportive family who has been trying earnestly to get him into care for about a year now. We have great insurance coverage….but he will be ineligible due to his age in a few months….then what?
The real problem is that we have a mental illness epidemic in the U.S. because conventional psych drugs aren’t designed to cure anyone. They’re designed to work as chemical straight jackets until patients eventually die. We could end almost all cases of mental illness by providing people with treatment proven to restore mental health but these approaches are out of favor, shall we say, with those at the helm of America’s mental health care system. When my loved one was psychotic, all the psychiatrists told me “Mental illness is incurable,” and that he would need to live in a “home” for the rest of his life. Instead, I did my own research, found an approach called “orthomolecular medicine” which seemed sensible and safe. It took me four months to slowly taper him off of THREE daily antipsychotic drugs while I simultaneously gave him the “nutraceuticals” his brain needed. He completely recovered, safely and with no side effects. He has no need for psychiatrists or their miserable drugs. I have three videos about this approach on Youtube about it at Linda Van Zandt’s Mental Health Recovery Channel. Mental illnesses have been curable for over a century, just not with high-tech chemicals, aka “psych meds.” All Americans need to know there is no federal law that provides even a morsel of oversight over which treatment approach is used by those at the helm of our mental health care system. They’re free to use any approach they like so, gee, no surprise, they have chosen the approach that brings in a lot of profit —but cures no one. Please watch for my upcoming FB group, “Curing Our Mentally Ill Loved Ones.” The bottom line is that we have an enormous, gaping federal loophole that is allowing people with a mental illness to never be given treatment proven to restore mental health. It’s sickening.
If I may make another statement, I’d like to say that, according to the NIH, 21% of all cases of schizophrenia in the U.S. are caused by an infection of Toxoplasma gondii. These protozoa create cysts and if they grow in the brain they cause psychosis or schizophrenia. The NIH also says a natural plant derivative, Artemisinin, kills these protozoa. You might assume psychiatrists naturally carry out a trial of Artemisinin on each and every patient with psychosis or schizophrenia just to see if they get better —but they don’t. They only match up a person’s symptoms to a patented, synthetic drug to be taken for life. Suppressing symptoms instead of curing patients isn’t even against the law because, again, there is no law to break.