Consult-Liaison Homelessness Public health psychiatry Systems

On “Involuntarily Removing Mentally Ill People from Streets”.

Photo by Mart Production

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.