Homelessness, Mental Health and Civil Commitment: Ethical Considerations
Officials Pursuing Compulsory Treatment for Homelessness, Mental Health Issues, and Substance Abuse
In the past year, cities across the US have announced plans to tackle homelessness, driven by concerns about health and crime. One strategy involves civil commitment, or involuntary treatment, for people with severe mental illness or substance use disorders.
Take, for example, New York City, where Mayor Eric Adams recently proposed using mental health laws to facilitate involuntary treatment for individuals unable to care for themselves or pose a threat to others. This plan involves therapy, social workers, housing referrals, medication, and other interventions—either in hospitals or on an outpatient basis.
California and Portland, Oregon, have also approved similar plans, drawing on laws that date back decades. These laws have been rekindled as a tool to address the intersections of homelessness, mental health issues, and substance abuse.
As a health law and medical ethics professor, it's essential to examine these measures and the ethical challenges they present.
How Civil Commitment Works
States have enacted civil commitment laws based on two principles: the doctrine of parens patriae and public health law's concept of police power. The former empowers states to step in and help vulnerable individuals who can't act in their own best interest, while the latter obliges states to protect community health and safety.
The laws vary by state, but they can allow courts to oversee treatment plans for individuals with severe mental illnesses or substance use disorders that meet specific criteria. A court might decide on treatment following testimony and evidence from clinicians that a person's condition warrants intervention to avoid dangerous situations, such as freezing to death on the streets.
Civil commitment does not "criminalize" homelessness. Treatment occurs in a hospital setting, focusing on stabilization and recovery. Laws mandate using the least restrictive plan possible. Due process, including a fair procedure for individuals to participate, object, and receive legal counsel, is also required.
The Face of Chronic Homelessness
When we talk about homelessness, we're referring to multiple groups with varying needs. Most visible are the chronically homeless—those living on city streets—who have high rates of untreated severe mental illnesses and substance abuse disorders. However, estimates vary for this population.
For instance, the University of California's California Policy Lab studied 64,000 homeless individuals across 15 states and found that 78% of unsheltered homeless individuals suffered from mental illness, while 75% dealt with substance abuse issues. About half experienced both.
Mental illness and substance abuse can exacerbate homelessness, as well as stem from it.
Ethical Dilemmas
Civil commitment aims to improve individuals' and communities' well-being. However, several ethical questions arise, such as autonomy—people's right to make their own medical decisions—and beneficence, or ensuring the chosen interventions create more benefits than harm.
Some experts argue against using civil commitment laws, suggesting states should rely on voluntary services instead. They argue that voluntary treatment is equally effective at addressing the issue, while preserving autonomy and freedom of choice.
On the other hand, proponents of initiatives like New York City's plan argue that civil commitment laws can help connect people with care and fulfill a moral obligation to save our city's most vulnerable residents from enduring unnecessary suffering.
Balancing autonomy and beneficence is crucial. People with severe mental illnesses or substance abuse disorders may experience impairments that compromise their autonomy, even as involuntary treatment violates it. By stabilizing and aiding in recovery, involuntary treatment might eventually help individuals regain their capacity for self-determination.
Many clinicians and outreach workers also argue that ignoring the impact of untreated mental illness and substance abuse disorders violates the principle of beneficence, potentially leading to increased health risks.
Broader Impacts
Ethics debates must consider the impact of treatment on surrounding communities, such as safety. San Diego District Attorney's Office data shows homeless individuals are disproportionately both victims and perpetrators of crime[1]. Though most homeless individuals live peacefully, some studies suggest that those with severe mental health issues are three to four times more likely to engage in violent behavior.
Evidence indicates that civil commitment can increase follow-through with treatment, reduce acute hospitalization, and decrease violent behavior[6]. Proponents argue that—despite its coercive nature—civil commitment offers a stepping stone toward health restoration for each individual and society as a whole.
Originally published by The Conversation, February 3, 2023, under the terms of a Creative Commons Attribution/No derivatives license.
Additional Insights:
- Some ethical concerns raised about civil commitment include violations of civil rights, lack of community-based services, stigma and discrimination, unequal access to care, due process concerns and long-term consequences.
- Expanding community-based mental health services, implementing collaborative models, and legislative reforms can address these issues and provide more effective and compassionate solutions to tackle homelessness and mental health concerns.
- The use of civil commitment for individuals with severe mental illness or substance use disorders raises questions about autonomy and beneficence in health and wellness.
- Therapies and treatments for mental health conditions, such as those proposed by New York City's plan, may improve both the individuals' well-being and community safety.
- Policy and legislation regarding chronic diseases, neurological disorders, and mental health must consider the broader impact on general news, including public safety, stigma, civil rights, and due process.
- In the realm of health and wellness, the ethical debate on civil commitment involves balancing the right to self-determination with ensuring interventions are beneficial and reduce harm, particularly for those suffering from chronic diseases and homelessness.
- Addressing homelessness, mental health issues, and substance abuse requires not only therapeutic interventions but also policy changes, such as expanding community-based services, implementing collaborative models, and reforming legislations to ensure compassionate and effective solutions.
