Public Policymakers Need to Use Data on Homelessness

A new policy announced by New York City Mayor Eric Adams to force people with mental illness into hospitals even if they pose no imminent threat to others has sparked debate about its legality and ethics. New York State law allows police and other emergency personnel to take people to hospital emergency rooms against their will if, because of mental illness, they pose an imminent threat to themselves or others. In practice, that usually has meant if the individual is about to commit a violent act, although courts have generally interpreted risk of harm to self as including not being able to take care of one’s basic needs, like obtaining food and shelter.

In many cities throughout the U.S., the impression that more people with mental illness are living on the streets and that they are increasingly dangerous has led to calls to remove them, forcibly if necessary. In fact, data are sparse on just how many of the approximately 55,000 homeless people in New York City actually have mental illness and how many of them would benefit from psychiatric hospitalization. It is estimated that only about 1,000 people in New York City need a drastic intervention, like forcible removal from the streets to a hospital emergency room. That would thus be a small percentage of the total number of homeless people, but hospital emergency rooms and inpatient psychiatric wards are overcrowded in New York City and many other U.S. cities to the point that even an extra 1,000 patients could overwhelm the system.

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The New York City plan announced by Mayor Adams includes holding people who are deemed to be unable to care for themselves in hospital emergency rooms until a suitable long-term care plan can be arranged. That is a tall order: it is unclear how mental healthcare systems that are already overloaded and underfunded would handle an influx of people who might not even want care. The prospect of hundreds of people being transported to emergency rooms and then held there indefinitely is unrealistic given the shortcomings of the psychiatric healthcare system in New York City and throughout the country.

In a moving op-ed piece in the New York Times, a New York City paramedic noted other problems with the proposed plan. “For one thing,” wrote Anthony Almojera, “the mayor is shifting more responsibility for a systematic crisis to an overworked medical corps burned out from years of low pay and the strain of the pandemic.” Almojera fears that emergency medical responders are not equipped to deal with “standoffs” with people refusing to go to the hospital, while police “are not keen to intervene with the mentally ill.”

A Policy Without Data

Is it legal to force people who are not in imminent danger of violence to go to the hospital? Is it ethical? We can leave these critical questions to legal and ethics experts, but remember that we are considering forcing someone to go to the hospital against their will when they do not pose an actual, immediate threat of harming themselves or anyone else. Rather, there is the concern that due to mental illness they will ultimately come to harm because they are unable or unwilling to care for themselves. Obviously, we do not want to allow people to starve on the streets or to succumb to frostbite or heatstroke. So the legal and ethical issues here are clearly not straightforward.

Our concern is that there is insufficient data to know whether such a policy is warranted and no articulated plan to evaluate whether it is successful. This appears to be a not uncommon instance in which an important piece of public policymaking is formulated without asking the fundamental question about whether we have any data that tell us whether it is needed or will work. It seems to us that much of the motivation for Mayor Adams’ plan stems from the discomfort people have with seeing homeless people in their midst and not with a genuine concern about the fate of homeless people. Before forcing homeless people to go to the emergency room against their will, we might first consider whether we are actually doing them any good.

The first thing to figure out is the extent of the problem and whether the mental healthcare system has the capacity to even deal with it. How many people living on the streets right now in New York City, or any other U.S. city, are suffering with mental illness that impairs that ability to care for their basic needs, puts them at risk for serious adverse outcomes, and therefore even approaches the justification for forcing them to give up their basic rights? We have not yet seen that anyone has collected those data.

Once we have those data, we next have to ask is for how many of the people at risk would emergency rooms, inpatient psychiatric wards, and outpatient psychiatric treatment centers actually be able to accommodate and provide meaningful care. Would homeless people being committed to the hospital merely wind up in emergency rooms for days, or even longer, waiting for a mental healthcare system well-known to be inadequate to find space for them? Is it absolutely clear that people forced into hospital emergency rooms will be better off than if they figured out some other approach to helping themselves?

Are There Any Data Already Collected To Help Us?

We would imagine that plenty of homeless people with mental illness who are having difficulty caring for themselves have agreed to go to the hospital willingly. What happened to them? Do we have any data to suggest that even those who go willingly to the hospital wind up in meaningful mental healthcare and are ultimately able to better care for themselves? We should have been collecting data like these for some time to help inform the new policy. Our hypothesis is that the results of such an inquiry would not indicate that hospital intervention has much impact on the ultimate fate of people with serious mental illness who are homeless and that this would be a warning that the new policy would thus be unlikely to work. But without real data, ours is simply a hypothesis.

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Finally, does Mayor Adams’ plan include any provision for evaluating whether it actually works? If people are forced to go to the hospital even without posing an imminent safety threat, will they simply wind up back on the streets after a few days, or will some meaningful psychiatric care result that improves their lives and benefits society as a whole? Was a pilot project even considered in which careful tracking of outcomes is made to learn what might really work to help homeless people with mental illness?

Data are only one part of policymaking decisions. Even with all of these data, legal and ethics experts might still deem forcible removal to the hospital to be wrong. Yet, it seems absolutely necessary that policymakers have data at hand when they propose new policies that have significant legal and ethical challenges. It might be considered on balance reasonable to force someone who might succumb to starvation or other adverse outcomes into the hospital against their will if, in fact it, helps them. But without any indication that this is the case, we wonder whether all the legal and ethical deliberations about the issue are missing the point.

Emergency medical responders may be reluctant to get involved with forcing people to go to hospitals against their will. Hospital emergency rooms in big cities tend to be overcrowded, sometimes to the point of chaos. The mental healthcare systems in big cities are also challenged. It is very hard for us to imagine that an influx of homeless people into hospitals will benefit them. At the very least, we should try to get some answers to the questions we have posed. The goal here is not to remove homeless people from the streets so we don’t have to see them. Rather, the goal must be to provide help for people in desperate situations who could die if not provided with proper care.