When homelessness and mental illness overlap, is compulsory treatment compassionate?
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A homeless encampment along a street in Skid Row on Dec. 14, 2022 in Los Angeles, California. Two days earlier, LA Mayor Karen Bass declared a state of emergency regarding homelessness in the city, where an estimated 40,000 residents are unhoused.
Many of Portland's least fortunate live in tents pitched on sidewalks or in aging campers parked in small convoys behind grocery stores.
High housing costs and financial adversity are the primary root causes behind the burgeoning population on the streets; only about one in three people who are homeless in Portland report having a mental illness or a substance use disorder, or both.
But the combination of homelessness with substance use or untreated mental illnesses has led to a lot of very public tragedies.
People with schizophrenia, for example, have died of hypothermia on the city's streets. Residents have given birth out in the open, to premature infants who did not survive. Methamphetamine, cheaper and more harmful than it used to be, is creating a heightened risk of overdose and psychosis.
Mental illness can be part of the story of how a person ends up homeless or part of the price of survival on the streets, where sleep and safety are scarce. Unsheltered residents in Portland die thirty years earlier than the average American, according to county data.
These grim realities have ratched up the pressure on politicians to
do
something.
In Oregon, some politicians, including Portland mayor Ted Wheeler, have proposed changing civil commitment law, so doctors have more leeway in compelling treatment for patients who are too sick to know they need care.
Without such changes, they argue, people with untreated addictions or mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.
"I think we can do better by people than allowing them to flounder," says Janelle Bynum, a state legislator who represents suburbs east of Portland.
Bynum was the sole Democrat to sign on to a pair of bills, introduced by Republicans earlier this year, that would expand the criteria for involuntary commitment in Oregon. "My intention was to signal how cruel I think our current system is," she says.
As multiple crises spill into streets, calls for change
Half of the country's unsheltered
people live in California, and though only about a quarter or third of them are estimated to have a serious mental illness, they are the ones residents are most likely to encounter in California's cities. Mayors from San Francisco, San Jose, and San Diego have all expressed frustration that the threshold for psychiatric intervention is too high.
"When I'm often asked, 'Mayor, why aren't you doing something about this person who is screaming at the top of their lungs on the street corner? And I said, 'Well, they're not a threat to themselves or to others,' that rings hollow," says Todd Gloria, mayor of San Diego.
Now, state lawmakers in Sacramento, backed by mayors, have introduced new laws and bills that would help bring more people into treatment, even if it's against their will.
Last year, legislators approved a new system of CARE Courts, where judges issue treatment plans. That program begins on a pilot basis this fall in eight counties, including Los Angeles and San Francisco counties, with the rest of the state expected to join next year.
This year, a bill moving through the legislature would expand who qualifies for a yearlong conservatorship, or involuntary psychiatric hold.
The bill is gathering support and sponsors are optimistic that Gov. Gavin Newsom would sign it if passed. But it's been controversial: opponents fear a return to bygone policies of locking people up just for being sick.
Half a century ago, California policymakers shuttered state psychiatric institutions, denouncing them as inhumane. Involuntary commitment was deemphasized and state laws ensured that it only be used as a last resort. The thinking was that the patient should have autonomy and participate in their care.
But progressive leaders across California are now reconsidering involuntary commitments. They argue that
not
helping people who are seriously ill, and living in squalor on the streets, is inhumane. Psychiatrists who support the bill say it would constitute a modest update to a 56-year-old law.
The shift is dividing liberals over the very meaning of compassion and which rights should take precedence: civil rights like freedom of movement and medical consent? Or the right to appropriate medical care in a crisis?
"The status quo has forced too many of our loved ones to die with their rights on," says Teresa Pasquini, an activist with the National Alliance on Mental Illness. Her son has schizophrenia and has spent the past 20 years being "failed, jailed, treated, and streeted" by what she calls a broken public health system.
"We are doctors who have to watch these people die," says Dr. Emily Wood of the California State Association of Psychiatrists, a sponsor of the conservatorship bill,
. "We have to talk to their families who know that they need that care, and we have to say we don't have any legal basis to bring them into the hospital right now."
/ Mario Tama/Getty Images
Under current state law
, a person can be held in the hospital involuntarily if they are a danger to themselves or others, or if they are unable to seek food, clothing, or shelter, as a result of mental illness or alcoholism. Doctors want to add other substance use disorders to the criteria, and include a person's inability to look out for one's own safety and medical care.
(The state law defines what is known as "mental health conservatorship," which is separate from the probate conservatorship that Brittney Spears was held under.)
Dr. Wood, who practices in Los Angeles, gives two examples of people she and her colleagues have tried to care for, but who slip through the cracks under the current rules. One is a man who doesn't take his diabetes medication because he's not taking his schizophrenia medication, and doesn't understand the consequences of not managing either condition.
Wood explains that even if he repeatedly ends up in the ER with dangerously high blood sugar, no one can compel him to take either medication under current law, because poorly managing one's health is not a trigger for conservatorship.
Clash over 'compassion' fuels conservatorship controversy
Another man Dr. Wood describes has a developmental disability that was never treated in childhood. He developed an addiction to methamphetamine in his twenties. Wood says the man is now regularly found sleeping in a park and acting inappropriately in public. His family members have begged doctors to treat him, but they can't because substance use disorder is not a trigger for conservatorship.
To Dr. Wood, treating these people, even when they're unable to consent, is the compassionate, moral thing to do.
"
It's essential that we respect all the rights of our patients, including the right to receive care from us," she
Friday, March 31, 2023 at 9:01 am