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.