Unhoused or Hospitalized: The Ethics of Forcing Psychiatric Care on New York City’s Unhoused Population with Mental Illness

Mayor Eric Adams of New York City issued a plan in 2022 that allows unhoused individuals who are exhibiting symptoms of mental illness and who do not appear to be able to meet their basic needs (food, shelter, etc.) to be forcibly removed from the streets by police officers and evaluated for psychiatric treatment. Additionally, Mayor Adams pushed for 50 additional beds for psychiatric units, because the mental health care systems in New York City are extremely congested and unable to serve many patients in need of beds. According to Adams, the goal of this new practice is for the city of New York to fulfill a “moral obligation” to help unhoused people who the City deems to be in desperate need of mental health care. In my Bioethics Project, I will explore the intersections of the principle of respect for autonomy and the value of safety, and consider the ethical framework of utilitarianism. I will use the bioethical principle of justice to address the lack of access to mental health care in the Medical Industrial Complex for unhoused patients, a concept which will be later described in the paper. This Bioethics Project will explore the ethical implications of forced psychiatric care for unhoused individuals exhibiting mental illness symptoms, specifically in New York City, by asking the question: Is it ethical for New York City to forcibly remove unhoused individuals from the streets for psychiatric care evaluations, and possibly treatment, if they are exhibiting signs of mental illness and portraying signs that they are unable to meet their basic needs? 

Table of Contents

• Abstract 

• Case Study

• Background

• Consequentialism

• Utilitarianism

• Respect for Autonomy

• Justice

• Responsibility

• Safety

• Conclusion

Case Study

Imagine you are waiting for a subway in New York City, and all of the sudden, a group of police approach a person who is poorly groomed and surrounded by bags of belongings. This person is alone and quietly mumbling to themself, and seems to be posing no immediate threat to themself or others. The police share with the person that they need to come outside to an ambulance, which will take them to a psychiatric facility to be evaluated for a mental health disorder and perhaps treatment. Imagine that the person resists going with the police by kicking and screaming in an effort to get away from the police intervention, however the police forcibly and physically remove the person and put them into an ambulance for potential treatment, surrounded by spectating individuals on the street. This scenario encompasses some of the potential problems of the implementation of a plan of Mayor Adams.

Background

In order to best understand and take a stance on Mayor Adams’s approach to provide mental health care services to people thought to be unhoused and unable to meet their basic needs, it is crucial to understand the psychiatric care practices through the 20th century. WWII had a strong impact on the rise of psychiatric institutions in the U.S. After the War, many veterans struggled with post traumatic stress disorder (PTSD) and other mental health disorders, leading them to voluntarily enter or be involuntarily admitted into psychiatric institutions. Other factors that contributed to the rise of psychiatric institutions, specifically in the 1950s, were new governmental agencies and laws surrounding mental health. One was the establishment of the National Institute of Mental Health in 1949, and following this was the passage of President Kennedy’s Community Mental Health Act in 1963. The public focus on mental health in these efforts aided funding to mental health services across the nation. Contrary to standard institutional care practices of this time, President Kennedy’s Community Mental Health Act worked to provide care to people outside of a restrictive environment, and instead in the comfort of their own homes and comfortable spaces. In 1955, there were about 559,000 patients in psychiatric institutions, however, due to the internal abuse and harsh treatment of patients within these facilities, most of these institutions shut down prior to the early 2000s, creating a significant deinstitutionalization, which is the transition of mental health patients to care and housing within communities, rather than specific medical facilities. By 2003, the number of institutionalized psychiatric patients had dropped to around 47,000 (Gerald N. Grob’s Mental Illness and American Society). Today, mental health facilities are even less populated, however there is still a mental health crisis, as one out of four American adults suffer from mental illness. (Johns Hopkins’ Medical Center) Over 1.6 million residents of New York City struggle with mental illness, a number that has only risen as a result of the lasting social impacts of COVID-19. Since COVID-19 in 2020, a significant amount of mental illness across New York City was left untreated, people lost jobs due to the pandemic, and isolation left many people in need of psychological and psychiatric care. (New York City Department of Health and Mental Hygiene) With all of this considered, New York City Mental Health facilities continue to be understaffed, underfunded, and congested with patients, creating barriers for allowing new patients into care, specifically those without the means to pay for care. The psychiatric system is facing demand far beyond what it can supply today.

In 2023 in New York City alone, 763,000 adults who needed psychiatric care did not receive care due to financial challenges, a prime example of how mental health care remains inaccessible and expensive, nonetheless desperately needed. (National Alliance on Mental Illness) Viewing New York City’s homeless population in 2023, there were 91,271 unhoused individuals, and of this group, 1 in 6 struggle with severe mental illness (Coalition for the Homeless). Mental illness disproportionately impacts homeless people in NYC, as mental illness can greatly impact a person’s ability to hold jobs or other means of stable income, and there are also significant disparities regarding accessible care. These inequalities are prevalent due to lack of insurance, the fact that psychiatric care is 10 times more likely out-of-network care and most unhoused people are not insured through their jobs, if they have jobs. Additionally, there are small numbers of unhoused people on Medicare and Medicaid, even when they are eligible. Not only is this care financially inaccessible, the psychiatric care branch of the New York City healthcare system is extremely underfunded and understaffed, making it even more difficult for patients to receive care. The mental health care system in New York City has a shortage of beds leaving over 15,000 patients in need of in-patient mental health treatment unable to secure hospital placement. Knowing of this shortage, Mayor Adams has pushed for 50 additional patient beds in psychiatric institutions.

As previously mentioned, Adams's policy is to forcibly remove unhoused individuals from the streets and bring them to hospitals or other medical institutions where they are evaluated for psychiatric care. Adams's goals for this initiative are to support unhoused people and fulfill a “moral obligation”, founded in safety and beneficence, to the city of New York, including unhoused residents. Adams also puts effort in optimizing public safety and providing underserved people care with the implementation of this plan. This raises the ethical questions: How do we define and ground this moral obligation? Should Adams be making this decision surrounding the “moral obligation” he, and the government as a whole, have, or should decisions regarding this concern be addressed with input from residents in New York City?  

With 22 years of experience in the NYPD, Mayor Adams has seen the crisis of homelessness firsthand, thus he is implementing a policy for police intervention in the care of unhoused individuals. However, the NYPD may not well understand the actual needs of and best way to support the homeless population. According to the National Library of Medicine, 9% of unhoused individuals have experienced some form of police brutality. There is distrust between the homeless community and the police force, that many worry may contribute to reluctance of unhoused individuals to comply with this plan, because unhoused people may not understand that the police are intending to help them, and not hurt them. Additionally, a motivation of Adams's plan is to optimize public safety and avoid incidents of violence on the streets of New York City. For example, in January of 2022, a woman was pushed to her death on the subway tracks by an unhoused individual, who was unprovoked by the woman.

(New York Times) It is crucial to address that this unhoused individual cycled through homeless shelters, prisons, and psychiatric care facilities, yet still remained on the streets with severe mental illness. Adams's policy aims to prevent similar events from occurring similar events occuring, and takes the following steps to prevent this: When police encounter an unhoused individual who is exhibiting signs of mental illness and appears to not be able to meet their basic needs, the police must take measures to remove the unhoused person off the streets. Typically, an EMS team is called and transports this patient via ambulance to the nearest hospital. The patient then undergoes a psychiatric exam (New York City Government). There is very little information available regarding the later steps taken by the care providers. 

In other places across the United States, similar policies aimed to support unhoused people are being implemented. For example, structures have been emplaced throughout Portland and Wisconsin to help home unhoused people with mental illness before providing treatment. In these plans, potential patients are first met by mental health care professionals, which is not seen in Adams’s Plan. However, like the situation in New York City, there is a shortage of beds to care for these individuals in need (NPR). The commonalities amongst these policies are the limited supply of resources and the continued mental health crisis for this vulnerable population, homeless people. 

Consequentialism

Looking at Adam’s policy, the plan may be beneficial to unhoused individuals who may not otherwise have been able to receive care. The plan could also prevent these patients from experiencing long-term negative health impacts. For example, long term psychosis, when left untreated, can cause more severe mental illness and brain damage, therefore providing people with help as soon as possible may have important long-term consequences. (NIMH) The policy is intended to improve the healthcare system, long term care plans, and homeless shelters for New York City’s homeless community, which may aid in ending the crisis of homelessness.  

Although there are clear benefits to this plan, there are also many potential concerns, making it appropriate to evaluate the plan through the ethical framework of consequentialism. Firstly, these one time evaluations may not well encompass and provide a complete picture of a person’s entire mental illness and/or history of mental illness, especially if they have bipolar disorder or schizophrenia, and their disorders cause more episodic behaviors. This may lead to inaccurate diagnoses and/or early discharges for those who are still in need of care. The discharges are dependent on the state of each patient, therefore the care team would evaluate patients to understand if they are equipped for outpatient treatment or if they must remain in inpatient care.  It may be challenging for unhoused persons to follow up with appointments, therapies, etc., which begs the question: Are unhoused people even set up to successfully follow care plans? Adams's administration should address this barrier by providing support to unhoused people through adequate access to technology, stable shelter, and transportation. The potential psychiatric treatments may be associated with severe side effects such as increased suicidal thoughts, heart palpitations, and in rare cases, comas. (National Health Service, United Kingdom) The care is intended to help patients, and therefore the benefits of treatment should outweigh all potential risks. Additionally, if unhoused individuals with mental illness are forcefully removed from the streets, however they don't need care, they are being put in potentially unnecessary negative, violent and unsafe situations with the NYPD which could perpetuate the chronic distrust between unhoused people and police. The possibility of negative consequences as a result of the Mayor’s plan should be outweighed by the considerable benefits and support that the plan may be able to provide.

Utilitarianism

Utilitarianism is also a framework that I used to better understand the ethical implications of Mayor Adams's plan. Utilitarianism is a form of consequentialism that identifies the right action as the one that produces the greatest good for the greatest number of people. The stakeholders include: unhoused individuals, the government,  police, mental healthcare providers, and patients currently within the New York psychiatric care systems. Firstly, placing unhoused individuals into forced care may be the City’s way of removing them from the public to improve the appearance of New York City, sheltering New Yorkers from a real crisis of justice for the unhoused community. This would be using psychiatric care to remove a number of unhoused people from the streets to optimize the appearance, at a minimum, of New York City and keep them away from New York city residents to provide the greatest good to the majority. The small scale of Mayor Adams's plan also does not allow for every unhoused person to be put into treatment, therefore the greatest number of unhoused people may not be cared for adequately. This begs the question: who should be prioritized for mental health care if not everyone can receive it? The framework of utilitarianism can help to best address the way that housed society shapes the care that is provided to - some might say “forced upon” - unhoused people.

Respect for Autonomy

The first bioethical principle that is unequivocally relevant to address is the principle of respect for autonomy. The forced care component of this situation raises concerns surrounding autonomy, specifically the breach of autonomy for unhoused individuals. Exercising respect for autonomy requires a person to hold decision making capabilities. Although people under this plan may be able to make decisions in some areas, they may not be able to make decisions regarding their mental health care. This is where Mayor Adams’s plan arises and the police exercise control in making decisions about introducing these unhoused people to care. However, these potentially violent and very public removals may make unhoused people even more reluctant to accept care. 

It is crucial that this group of patients actively chooses to want care, as they may likely not comply with treatment plans otherwise. Unhoused individuals may not take medications, follow up with doctors, engage in therapies and other care if not actively supported by those around them. They also may not have privacy, or an ideal and realistic living situation to pursue their care, making it even more difficult for them to get the care they need. On the other hand, Adams’s plan may introduce potential patients to treatment that they would not otherwise have had access to, or did not know existed. The implementation of this plan could benefit the persons affected by this policy who may not be aware of care and are in need of it, therefore Adams’s plan is ethical because it may help some patients. For example, if an unhoused patient was unaware they could receive care, and was struggling on the street until being taken into care through this policy, they may be introduced to necessary care and their quality of life could greatly improve. Although there are barriers that may present challenges for unhoused people to follow this plan, there are great benefits to the introduction of treatment this policy provides. 

It is also appropriate to address autonomy in regards to utilitarianism. This raises the question: Should the autonomy of unhoused individuals who appear to be unable to meet their basic needs be respected at the expense of their or someone else’s safety? Should unhoused individuals have autonomy, or should the mental assurance and public safety considerations of New Yorkers override their cause of starting care? In simpler terms, why do we want to care for these individuals? If Adams's intentions are to solely care for unhoused people, this would result in the same outcome for these patients if Adams provided care to remove these unhoused individuals from the streets to make New Yorker’s more comfortable: in both situations unhoused people would be cared for. It is interesting to note that the same outcome of care will occur in both situations: whether to honor Mayor Adam’s desire for care for unhoused people with mental illness, or other New Yorker’s desire for these people to be treated. However, it is important to acknowledge that unhoused people should get care to help themselves and their situations, even if they are not putting others in harm's way, as it is fundamentally a duty of the City to help these individuals by removing them from the streets and into care facilities, even when deemed to be rather restrictive of these persons’ autonomy. I choose to look at the bioethical principle of autonomy to help come to the conclusion that the autonomy of unhoused people should be overridden when conflicting with the safety of themselves and others. Safety is the value that is of utmost importance in this situation, as all members of society should be safe and get the care they need and deserve.

Justice 

Due to the inaccessible, understaffed, and underfunded mental health facilities across the city of New York, the bioethical principle of justice is pertinent when addressing Adams's plan to address the homeless mentally ill. Mental healthcare in New York City is scarce and strongly needed, however the supply of care is not meeting the demand, as mental healthcare is an under-resourced sector of the medical system. If an unhoused individual is admitted into a care facility, yet they don’t want or need care, this may result in restricting another person who may not be able to afford care but is still in need of it.  Justice looks at treating two situated individuals similarly, but these two patients are not in the same situation because one of them is housed and the other person is unhoused. This creates a complexity for healthcare teams because these extremely limited resources can not be optimally utilized by unhoused patients who are unable to attend treatments and therapies, take medication, etc, despite their desire for treatment. The principle of justice also pertains to using limited resources most efficiently. Another significant barrier for many patients needing care is the financial burden of treatment, especially for uninsured patients. A great percent of the homeless community in New York City is uninsured, mostly due to the lack of employment opportunities for unhoused individuals, especially those struggling with mental health issues, therefore insurance cannot be achieved through the workforce. (Coalition for the Homeless) This is an underlying problem that is a flaw of the government, since healthcare insurance is tied to employment. Although many unhoused people are eligible for Medicaid and Medicare, very few actually have it, and many of the common behavioral struggles of unhoused people are not addressed under these services. (Forbes) Therefore, many of these patients can not afford mental health care, making it inaccessible in the event they want it.This leads to the question: How do police prioritize who is in need of care if the majority of eligible unhoused persons under this plan are in similar situations? Although justice partially drives decisions regarding which patients are most in need of care, the short and often stressful police interactions with unhoused people are perhaps random, creating inequalities amongst which unhoused individuals in need of care are actually brought to it. The Adams’s Administration should allocate more resources to mental health care to widen this plan and allow more patients to receive care. 

Responsibility

The question of responsibility emerges when considering the Adams Administration, or government in general, interfering with the daily lives of individuals. Does the government have a responsibility to interfere with the lives of its people when they are unable to meet their basic needs and have mental illness? Grasping the New York City homelessness crisis at its core means understanding the City’s failure to provide its people with affordable housing, employment opportunities, accessible support, and safe homeless shelters, amongst other disparities. Although Mayor Adams has stated his intentions to “fulfill a moral obligation”  it is hard to believe there is not already an obligation to house and care for the homeless in other ways, such as creating accessible and more affordable housing and giving people an opportunity to get on their feet through job opportunities and attainable healthcare. Although Adams and other organizations are working to allocate more resources to homeless shelters at this time, there continue to be other ways in which unhoused people are underserved and unable to thrive. Additionally, psychiatric care may not be the first care option for unhoused individuals who are not able to meet their basic needs, and suffer from mental illness. The systemic challenges in regards to lacking affordable housing, expensive and inaccessible healthcare, unsafe homeless shelters, amongst other reasons as well contribute to the homelessness crisis, and in turn, the New York City government is both solving and failing to address homelessness simultaneously.  

Safety

Adams's administration should focus on tackling homelessness in addition to providing unhoused people with potential care and police interactions. Not all unhoused people have mental illness, however many people in the unhoused community struggle with attaining resources, public services and other means of financial support. The role of the government is to provide its citizens with safe and adequate living conditions, as well as maintain safety and security in the daily lives of its people. In a study conducted by the National Health Care for the Homeless Council, suicide rates amongst unhoused individuals were 10 times higher than those of their non-homeless counterparts. Unhoused people commonly live in unsanitary and unsafe conditions.  They are a key stakeholder in the City’s duty to uphold safety for its people. Other stakeholders are residents inhabiting New York City, as they want to be assured they are safe around unhoused individuals who may be perceived as dangerous. Lastly, another stakeholder in the realms of safety are mental healthcare workers, as they are working on the frontlines with patients who may behave in an unsafe manner. The conflict of autonomy vs. safety is heavily present in Adams's plan. Safety should be prioritized at the forefront of Adams's decision, and honored over the autonomy of unhoused patients when deciding if they do not want care. Safety is of highest value because the health and wellbeing of people should be prioritized over all other aspects of life.

Conclusion

Looking out one year since implementation of Adams's plan, about 137 unhoused individuals are forcibly being put into mental health care facilities each week (New York Pix 11 Local News). Additionally, the Adams administration is collecting data on the results of unhoused people receiving care to optimize and improve the police and healthcare providers’ practices. The Adams administration is continuing to work alongside first responders, as well as composing stronger plans to house people to tackle the systemic challenges of homelessness. Hospitals are also working to implement telehealth into their psychiatric care practices, however this may not be helpful to unhoused patients without internet access, privacy, and these patients may be behaviorally unequipped for virtual appointments. 

Considering the values and principles of autonomy, justice, and safety,  I believe this is a step forward for helping the over 90,000 unhoused people in New York City, as there are some unhoused people who are in desperate need of care and may not otherwise receive it. However, it is important to acknowledge this may be a partial solution to a serious systemic problem in New York City.  I believe the Adams Plan is going to positively impact more unhoused people than it will do harm, therefore it is ethical to be in place. Additionally, New Yorkers are lacking the appropriate skills to identify when or if unhoused people are putting others in danger, therefore more should be done on behalf of the government to educate New Yorkers when to seek police intervention in situations. At the end of the day, the unhoused community is composed of human beings in need of care and support, thus New Yorker’s need to know how to properly address these individuals. This concern is ongoing and will take time, however greater societal involvement is a crucial step to bettering the lives of unhoused people across the city. Adams’s intervention continues to be a first step to helping these people, that also requires voluntary and social support of others in society such as rides to doctor appointments, reminders of medical care appointments, medication pickups, and more. Today, changes are already being made by Adams's administration to help police officers when evaluating unhoused people on the streets, such as allowing them to contact mental health care professionals through online and video chats. As we look forward to the future, justice is unequivocally necessary to navigate not only the challenges of the unhoused mentally ill, but also tackle homelessness as a whole. 

If I had additional time to research this topic, I would have liked to address the structures utilized by previous New York City mayors to help treat unhoused individuals with mental illness, and the ways in which those procedures compare and contrast with that of Adams. Additionally, due to the recent nature of this plan, few patients have spoken out about their firsthand experiences of Adams’s plan; hearing the perspectives and experiences of persons who have been committed to psychiatric evaluation under the Adams plan would be very beneficial.

Lastly, I hope to further research the models of care outside of New York City for unhoused individuals with psychiatric illness that appear in various other cities, states, and countries. In addition, I would like to research the ways in which the U.S. healthcare system adds disadvantages to the care of these vulnerable populations beyond what is seen in other countries. 

Works Cited