Month: November 2022

On “Involuntarily Removing Mentally Ill People from Streets”.

Post author By Maria Yang, MD
Post date November 30, 2022

There’s been buzz about the report of New York City to Involuntarily Remove Mentally Ill People From Streets. The comments section of the article as well as letters to the editor articulate the complexities around this issue. I also appreciate that the New York Times solicited perspectives from people experiencing homelessness themselves.

In trying to think through this myself, I turn to two mental models: First, what problem are “we” trying to solve? Second, can health care ethics provide guidance here?

What problem are “we” trying to solve? This requires reading the mind of New York City Mayor Eric Adams, which I cannot do. He has argued that The Royal We have a “moral obligation” to solve the problem of “assist[ing] those who are suffering from mental illness”. If we take him at his word, then we can fold his argument within the framework of medical ethics.

If, however, Mayor Adams is trying to solve a different problem (e.g., make homelessness invisible; reduce the number of complaints from the public about people exhibiting unusual or dangerous behaviors; demonstrate that he is “doing something” about homelessness, etc.), then the framework of medical ethics may not apply. If he is trying to solve a different problem, then instead of assisting those who suffer from mental illness, he is using those who suffer from mental illness to assist him and his actual agenda.

Of course, he may be trying to solve multiple problems through the guise of only one.

Can health care (or medical) ethics provide guidance here? One model used in medical ethics is called the four box model. Of note, the four boxes focuses on individual patients, not on populations of people.

Medical Indications (Beneficence and Nonmaleficence)	Patient Preferences (Respect for Autonomy)
Quality of Life (Beneficence, Nonmaleficence, and Respect for Autonomy)	Contextual Features (Justice and Fairness)

Medical indications asks what benefits and harms the patient might experience from interventions. Would involuntary psychiatric hospitalization help people with mental illness who are homeless? Some of them, yes. Would it help all of them? Maybe, maybe not. Could involuntary psychiatric hospitalization cause harm? That is not the intention, but sometimes it does. For reasons valid and invalid, it might discourage people from engaging in psychiatric services ever again. Anything involuntary always involves some degree of coercion, which people generally dislike.

Just because people are behaving in unusual ways and are living outside does not mean that psychiatric hospitalization is guaranteed to “fix” them. I do not mean to diminish the care people receive in psychiatric hospitals. People often need more than involuntary psychiatric hospitalization to get and stay well. Sometimes there is no medical indication for psychiatric hospitalization (involuntary or otherwise) for people with mental illness who are experiencing homelessness. Sometimes they just need a stable place to live.

Patient preferences refers to the dignity and choices people should have in living their lives. Some people would rather take pills by mouth every day than receive a monthly injection of medicine. Some people would prefer not to take any medicine at all. Patient preferences matter.

Some people who are living outside and behaving in unusual ways may not want to be in a hospital. Or maybe they are willing to be in a hospital, but not at that moment—maybe they have other things to take care of that day. Or maybe they are only willing to go to certain hospitals on their own, not at the behest of law enforcement. By definition, involuntary removal of people from the streets disregards patient preferences. Options other than psychiatric hospitalization, such as crisis centers, partial hospital programs, or day programs, can help preserve patient preferences and hence their dignity.

Quality of life describes the patient’s quality of life. Interventions should provide benefit, minimize harm, and maximize the dignity and choices of patients. This does not refer to the quality of life of the general public. If involuntary removal and psychiatric hospitalization are the means to the end of improved quality of life, how can these improvements be sustained following hospitalization?

It is absolutely true that psychiatric hospitalization can be life-saving and life-improving. However, people need and benefit from ongoing care and services following hospitalization. Mayor Adams’s target population also need places to live to maintain their gains. If you’ve ever been hospitalized for any reason, can you imagine the course of your recovery if you had no place to go upon leaving the hospital? How are you supposed to rest when you don’t know where you will sleep that night? Quality of life requires planning and sustained care; acute interventions alone rarely produce improvements in quality of life.

Contextual features are the intersections of a patient’s care with the rest of the world. There are a multitude of contextual features in Mayor Adams’s plan (and it makes me wonder if the mayor consulted with any partners prior to making his announcement). Here are a smattering of contextual features that come to my mind:

How will first responders decide if someone has a mental illness? What if they think someone has an “attitude problem” and instead refers them to jail? How severe do psychiatric symptoms have to be? Will only those who attract the attention of law enforcement be involuntarily removed? (What about the elderly woman who keeps to herself and has been homeless for decades and won’t move indoors because the voices tell her that she will die if she does?)
How will hospital psychiatrists react to people who, in their professional opinion, do not need hospital-level care, though the law argues otherwise? Will psychiatrists become agents of social control on behalf of the jurisdiction? There are some parallels here to the overturning of Roe v. Wade: Some gynecologists are not performing abortions, even though there are medical indications to do so, because of the law. Here, psychiatrists may proceed with involuntary treatment even though there are no medical indications to do so… because of the law.
Let’s say someone experiencing homelessness is involuntarily removed from the street and is psychiatrically hospitalized. Where will they go upon discharge? What if they prefer returning to the street instead of a shelter? What if they have no sources of income and there is insufficient affordable housing? (This is not actually a “what if” question.)
What about all the people who are homeless, but do not demonstrate symptoms of mental illness? Are there any opportunities to prevent or reduce the chances of mental illness in this population? (Yes, by increasing access to stable housing.)
What about all the people with severe mental illness who are not homeless? Are there any opportunities to prevent or reduce the chances of homelessness in this population? (Yes, by increasing access to and flexibility of psychiatric services.)

The four box model here highlights some ethical problems with Mayor Adams’s plan, though there are solutions to increase beneficence, autonomy, and justice while reducing non-maleficence. My hope is that Mayor Adams and leaders of other jurisdictions with similar ideas will take heed.

Blogosphere Reading Systems

Peanuts, Egg Drops, and PKM.

Post author By Maria Yang, MD
Post date November 26, 2022

Happy 100th Birthday Charles M. “Sparky” Schulz! Charles Schulz was the creator of the world-renowned Peanuts comic strip. In honor of the centennial of his birth, many cartoonists created a comic strip for this weekend. You can view the tributes here. (Some side comments: As most people read newspapers online now, are there far fewer readers of newspaper comic strips now? I used to read the Sunday funnies throughout my youth; I recognize few of the cartoonists on that tribute page. My favorite strips included Peanuts, Calvin and Hobbes, Non Sequitur, and The Boondocks. For anyone who has even a mild interest in Peanuts, I highly recommend a visit to the Charles M. Schulz Museum in Santa Rosa, California. There are fun exhibits, thousands of comic strips on display, and interesting history about Mr. Schulz.)

Egg Drop from Space. I am one of the millions of subscribers to Mark Rober’s YouTube channel. His most recent video, Egg Drop from Space, is compelling because he shares his major failures in this project. Perhaps he knew that this would make for great storytelling, though he did not have to be this honest and share so many vulnerabilities. (I also completely missed that he was, in essence, trying to design a guided missile.) This isn’t the first time he has brought up failure in his videos, though the extents of his failures make him relatable and his resulting persistence is inspiring. I continue to hope that people will be willing to share their failures, since we’ve all experienced them and will continue to do so. (In that vein, in 2016 I shared a post about My CV of Failures. The formatting is weird because I am unable to use a WordPress footnotes plugin now that I was able to use then.)

“Personal Knowledge Management.” Though I’ve had an interest in technology for much of my life, I would not describe myself as someone who is technologically savvy. There are technologies I routinely use, though I have not uncovered their (or my) full potential. One tool that I have used for several months now is Logseq, which has the accurate description of being a “privacy-first, open-source knowledge base”. (I had dabbled in Obsidian—which I learned about as a loyal Dynalist user for several years—for a while, though personally find Logseq to be more powerful and flexible. As I get older, my appreciation for open-source projects has also grown… though I understand essentially nothing about or in Github.) I’ve not used Notion or Roam Research, but have used Notational Velocity and Tiddlywiki, which are similar “knowledge bases”. If you have used these programs in the past (or even if you haven’t), consider trying Logseq (not a paid endorsement, just someone who is at or near the peak of Mt. Stupid).

Nonfiction Seattle

Blue of the Sky.

Post author By Maria Yang, MD
Post date November 16, 2022

The bus stop is at 145th Street and Aurora Avenue. There was a city bus there; if I run the two blocks fast enough, I thought, maybe I can catch it.

Then I noticed the two law enforcement vehicles, sturdy vans with red and blue lights flashing from the windows. One was parked directly in front of the bus; the other was in the driveway of a nearby storefront.

The bus remained at the stop as a third law enforcement vehicle made an assertive U-turn in the middle of the street to join the other two.

I stopped walking. I took a few steps forward, then stopped again.

“No, this doesn’t seem right… I can catch the bus at the next stop,” I muttered out loud.

It was a few minutes after 11am on Tuesday, November 8th, in the year of our Lord 2022.

There is essentially no sidewalk on the west side of Aurora Avenue. I reached the bus stop at 135th Street on Aurora; no bus was coming. I kept walking, squeezing myself between the parked cars and the businesses along the street. I had faith that a sidewalk would soon appear.

I heard the rumbling first. A bulky black box with thick treads on its large wheels approached. A man wearing a helmet and sunglasses inside the armored vehicle glanced out the open window. The red and blue lights in the front and on top of the vehicle were not on. The white “SWAT” lettering on its side gleamed in the late morning sunlight.

A few minutes later, a second armored SWAT vehicle rumbled past.

“What is happening?” I asked.

A photo of the 14-year-old was distributed to all Seattle police and an officer located the two teens on a Metro bus at North 145th Street and Aurora Avenue North at 11:02 a.m., the charges say.
Seattle Times: What prosecutors say happened at Ingraham High before the fatal shooting

I had to cut through a car dealership on Aurora because there still wasn’t a sidewalk. Despite the sun floating in the blue of the sky, I put the black beanie back on my head. Underneath my black wool winter coat was a black puffer jacket; a grey scarf was knotted around my neck. I continued to look for a sidewalk. I was apparently unwilling to cross the street.

The young women already knew that there is no sidewalk on Aurora, so they stood in the street. Their hands, adorned with colorful fingernails, tossed their shiny, long hair over their shoulders. Their shorts and skirts stopped just past the curvature of their hips, exposing the bare skin of their legs to the gaze of drivers and the cold morning air. The cropped jackets covered their arms, but not their cleavage. Their eyelashes looked like small, dark butterflies on their cheeks. Shades of red, pink, and purple were on their lips.

They weren’t yet waving at cars passing by.

One of them waved at me as I approached and called, “Hey!”

We made eye contact; she grinned. “What do you call those big cats that live in the hills?”

I reflexively smiled back at her, though did not stop walking. “Mountain lions?” I guessed.

Her rosy lips bloomed into a satisfied smile. She nodded, pointed at me, and said, “I like that.”

I shrugged and kept walking. I wished she and her peers weren’t standing out there. I wondered what their circumstances were. I prayed for their health and safety. I thought about why she asked me this peculiar question. (I only learned about REST, real escape from sex trafficking, after this conversation.)

I continued to look for a sidewalk.

About a week later, I boarded the light rail at the most northern stop. It was another sunny and cold day.

Many young people were on the train. Some of them had signs. I couldn’t read all of them; I spied one that was upside down that included the word “GUNS”.

They poured out of the train at Pioneer Square. Many of them had traveled over 130 blocks to join other students at Seattle City Hall to

[call] for better mental health support, more restrictions on gun access and more training for security staff in the wake of a shooting Tuesday at Ingraham High that left one student dead.
Seattle Times: At rally, Seattle students demand more mental health resources, gun safety measures

I looked up, shielded my eyes from the sun, and squinted at the blue of the sky, white of the snow, and grey of the mountains.

Informal-curriculum Medicine Reading Systems

Recent Readings.

Post author By Maria Yang, MD
Post date November 2, 2022

Stack of read newspapers. — Photo by brotiN biswaS

On medicine being agents of social control. These three news articles highlight the misuse of authority within the context of medicine:

Delta ‘weaponized’ mental health rules against a pilot. She fought back. In short, a woman named Karlene Petitt was (and remains) a pilot for Delta airlines. In response to a general exhortation from Delta leadership to speak up about safety issues, she submitted reports that did just that. In return, Delta leadership sought to silence her and initiated a process to deem her “too mentally unstable” to be a pilot. Delta recruited a psychiatrist who provided a diagnosis to support this argument. (The psychiatrist apparently diagnosed her with bipolar disorder because of her many accomplishments—“well beyond what any woman [he’s] ever met could do”.) She contested this and took legal action. She won.

How a Chinese Doctor Who Warned of Covid-19 Spent His Final Days. This 16-minute video investigation includes remarks from a physician who provided care to Dr. Li Wenliang, the ophthalmologist in China who tried to alert the public about Covid-19 before he died from the infection himself. Around minute 11 of the video, both the narrator and the physician comment that hospital administrators wanted the health care team to provide an intervention (ECMO) that was not clinically indicated. However, it would buy the hospital administrators time and allow the hospital to report that the health care team “did everything”. The physician states that using ECMO would have been both a violation of medical care and medical ethics. This is an example of “reputation management” superseding clinical judgment.

Woman’s legal quest illuminates the rights of hospital patients who want to leave. Here, a woman voluntarily agreed to enter a psychiatric hospital for care, but was not permitted to leave upon request. Available documentation suggests that she was not at risk of harming herself or others at the time of her request to leave. Under these circumstances, that means the hospital was essentially holding her captive. (This is reminiscent of “On Being Sane in Insane Places“, where context affects how we evaluate situations.) Even worse:

“All patients admitted to the facility,” the manager said, meet the criteria to be involuntarily committed, “even voluntarily admitted patients.”

The manager told DOH investigators that staff “do not orally notify voluntary patients” of their right to be released immediately, despite a state law requiring this disclosure. If they did, he said, “Everybody would be asking to leave.”

Those two short paragraphs reflect poorly on the hospital in question.

On the death penalty. The first two articles present opposing perspectives on the death penalty. The third article provides a first-person account of being in prison, which adds context to the first two articles.

If Not the Parkland Shooter, Who Is the Death Penalty For? Here, the author describes justifications for punishment:

Society embraces four major justifications for punishment: deterrence, rehabilitation, incapacitation and retribution.

I’ve not seen it described this way and appreciate the framework. This might be a red herring: The author also argues that the Parkland shooter’s “human dignity requires his just punishment [with the death penalty] as an end in itself”. I struggled to wrap my head around this one: We usually cite people’s humanity and dignity as reasons to keep them alive, not to kill them.

I Wish the Jury Had Not Sentenced My Family’s Killer to Death. In contrast, the author here argues how the death penalty, while maybe just, doesn’t actually solve any problems. It instead only prolongs suffering for the families of victims. Also, “death by incarceration” is still death. (I also appreciated her firm recommendations about how to support people who experience unspeakable tragedies.) While the author of the previous pro-death penalty piece focuses more on theory and logic, the author here focuses more on practicalities and emotions. Both models have value. Both articles made me consider my own stance on the death penalty.

Prisoners Like Me Are Being Held Hostage to Price Hikes. The author of this piece is currently in prison. Though I have never worked in prison, I have worked in jail. His descriptions about commissaries, food items, and access to various items seem similar to what I have observed in jail settings. (It also continues to baffle me how businesses are allowed to make money off of people in jail—including medical care!!!) Nobody is spared from inflation and price hikes.

To end this on a lighter note: This artwork from Andy J. Pizza made me feel a variety of invisible things: