A Dark History

The history of involuntary institutionalization should give pause to anyone eager to hospitalize people against their will. Mental institutions, as they were once called, were infamously overcrowded, unsanitary, and abusive. The buildings were rodent-infested, and disease spread throughout them unchecked. Patients were punched, kicked, and beaten, both by staff and by other residents. Unproven, ineffective, and harmful treatments (like lobotomies and electric-shock therapy) were administered. Extraordinary levels of surveillance and control were the norm.

With those on the Left advocating local community mental health centers as a compassionate alternative, and those on the Right decrying involuntary hospitalization as a threat to civil liberties (and an expensive one at that), the mid-1960s to mid-’80s saw a wave of deinstitutionalization that attracted support from across the ideological spectrum.

Contemporary advocates of involuntary hospitalization typically acknowledge the failure of the traditional mental institution, promising in its place something more effective and humane. But there’s plenty of reason for skepticism on that front. While there exist some excellent modern psychiatric facilities, the reality is that at present, most institutions struggle to hire and retain qualified employees.

Jobs in mental health care often pay poorly and have a high burnout rate. With underqualified and overwhelmed staff, life in the psychiatric hospital becomes rife with instability and violence, traumatizing patients already in crisis. To expect these overcrowded and underfunded institutions to absorb tens of thousands of new patients is to court genuine disaster.

It is thus reasonable to worry that involuntary hospitalization — characterized by its proponents as a humane act of care — is in reality an act of callous abandonment at best, and a cruel denial of basic freedom at worst. This is where advocates for the homeless, including many progressives, are wont to reach for libertarian arguments. They say that rather than be forcibly locked away, those struggling on the streets should be left to move about freely. Rather than have every daily choice dictated by some superior, they should be left to make their own decisions. As the National Law Center on Homelessness and Poverty puts it, “Homeless people are the experts of their own condition.” So long as they are not harming anyone, they should be left alone to live their lives.

The problem, though, is that for many of the homeless individuals in question, leaving them alone to live their lives doesn’t secure for them the sort of autonomy worth having. The libertarian right — which has had more influence on liberal and progressive thought than many like to admit — often ends up advocating a hollowed-out version of freedom that just amounts to a person making whatever choices they want. It’s an understanding of freedom modeled on consumer choice — one that caters to people’s preferences, whatever they happen to be. But in the most extreme cases at least, protecting freedom of this sort does precious little to enhance a troubled or mentally ill individual’s autonomy in any real sense.

Consider the case of Karen Batts. Homeless and schizophrenic, she’d previously been hospitalized in Portland after police found her drinking bottles of hand sanitizer — she needed to clean her mouth, she said. After she was released in 2016, her family tried to nudge her back into treatment but discovered that their legal options were minimal. So she was left alone to live her life, and before long she froze to death in a parking garage.

Or consider another unhoused woman from Oregon who gave birth on the street on a frigid January night. A passerby discovered her shoeless, pants at her ankles, holding a baby that she’d let die of hypothermia rather than seek help. The child, she claimed, was the result of an immaculate conception.

While there is perhaps some sense in which Batts chose to drink hand sanitizer, and perhaps some sense in which the other woman chose to give birth on the street, to suggest that either were self-governing or autonomous individuals would strain credulity. These choices, such as they are, were determined more by mental illness, substance dependency, and economic destitution than by these individuals themselves. They were the results of delusion, confusion, fear, and lack of support.

This is a point that strikes many people as blindingly obvious, and it’s one that the Left would do well to acknowledge. Prior to the libertarian and neoliberal identification of freedom with consumer choice, the left-liberal tradition identified autonomy with a person’s capacity to evaluate and adopt the values that are to govern their life.

John Rawls, for instance, argued not that individuals’ choices should be respected simply because they are chosen, but that they should be respected because they are chosen by beings capable of contemplating what values constitute a worthwhile life, and capable of pursuing life plans that accord with those values. It’s a person’s capacity to value Christianity, a medical career, or community involvement and to live according to these values — rather than a mere preference for Pepsi over Coke, say — that makes their choice worth protecting in the first place.

Likewise, Marxists and other left-wing radicals have long disputed the idea that individual choice per se is a manifestation of autonomy under all circumstances. The choice that a worker makes to take a low-wage job at Amazon or Walmart rather than starve hardly represents the kind of freedom worth caring about — rather, it is a reflection of the deep unfreedom imposed by economic deprivation and capitalist property relations, which socialists seek to eliminate by transforming the social context in which people make their choices.

When someone is drinking hand sanitizer or giving birth on the street in January, it’s not as if they are making decisions that we find disagreeable but that are nevertheless expressions of their values — as we might if someone adopted an eccentric diet or birthing plan. These are cases in which people are straightforwardly prevented by their sickness and circumstances from being able to weigh values, to fully understand the implications of their actions, and to act in ways that accord with what they care about. In other words, they are cases in which their mental illness and material circumstances undermine their autonomy. Leaving them alone might be a way to respect bare-bones libertarian freedom. But if it’s meaningful autonomy we care about, it’s entirely insufficient.

A False Choice

But the dilemma of forcible institutionalization versus laissez-faire presents a false choice. A third way — more noble and humane — is to take positive measures to enhance people’s autonomy. In many cases — or more than I suspect most people realize — this will involve no coercion at all. Brown, for instance, was by most accounts aware of the significance of her choices and her reasons for making them. An offer of more material resources like decent housing and better health care would have given her more life options, but locking her up seemed both unnecessary and destructive of her freedom.

But cases like hers should not encourage us to fetishize a lack of coercion. Coercion, after all, can also be autonomy-enhancing. Consider the way children are subject to a kind of coercion by both parents and educators. A parent gives their teenager a curfew not just with the hope of keeping them safe in the moment, but with an eye to teaching them to resist their most immediate impulses so that they’ll be able to pursue what really matters to them as an adult.

Teachers require that students read and understand books not just with the hope of transmitting information, but with an eye to their growing into adults who are able to evaluate and embrace values of their own. (Indeed, this is the theme of Jean-Jacques Rousseau’s Enlightenment-era masterpiece, Emile, which tells the story of a boy subject to significant coercion at the hands of his tutor, all for the sake of molding him into an adult capable of thinking and acting for himself.) Paradoxical as it may seem, autonomy sometimes requires coercion.

Most homeless individuals are not children, of course, and what they need is something quite different from parenting and education. But the point is that coercion can serve to enhance autonomy, and that we are familiar with examples of this. The real moral danger here is not coercion per se. It is that we’ll opt for the most aggressive, dramatic, and punitive acts of coercion, which simply do not aim at autonomy at all.

Much talk about coercing unhoused individuals betrays an objectionable aim to control others, or maybe just to move them out of the way. It betrays, in other words, the aims of discipling and manipulating; it is a kind of coercion undertaken for the sake of the coercers rather than concern for the coerced. For instance, when we talk about coercing homeless individuals, what comes to mind is likely armed police officers arriving to aggressively dismantle encampments or hauling off people who have been reported for being disruptive before locking them away for a long time.

But there are alternatives to these cruel displays of force besides simply leaving people alone to suffer. Trained outreach professionals can arrive once a tent goes up on a sidewalk and then return repeatedly to advocate aggressively for mental health treatment and to offer some provision of social services, ideally including permanent shelter and housing options. Such soft coercion might be backed up by an implicit threat of eventual hard coercion — such as a warning that they will eventually be removed from the public space (and then perhaps be held for evaluation for seventy-two hours, or put through drug court rather than be committed to an institution).

Family members might be allowed to petition the government to perform an intervention, placing moderate pressure on a homeless loved one to accept a temporary supervised outpatient treatment program — again, perhaps with an implied warning that they might eventually end up with a nonvoluntary legal guardianship if they reject all forms of help.

Furthermore, sometimes options simply need to be taken away from a person — access to hand sanitizer should be denied if there’s reason to think someone will drink it, and the option of sleeping outside should be revoked if a person is in danger of freezing to death. To allow someone to make tragic choices that are driven by their mental illness or addiction does nothing to respect their autonomy and indeed can simply make it less likely that they’ll be able to live autonomously in the future.

Many will undoubtedly object that coerced treatment does not work. Indeed, its failures are well documented. But the case against it can be overstated. For ethical reasons, it’s difficult to conduct randomized controls, and so the evidence is not as robust as we might hope. The arguments for coercion’s ineffectiveness are often overly broad in scope and too sweeping in their conclusions — after all, there are many different methods of coercion, along with great diversity among people struggling with mental illness and substance use disorder, and so sweeping conclusions can encourage us to overlook instances of success. However, when we don’t overlook such cases, we find that there is sometimes more reason for optimism than we might have imagined.

Many opponents of coercion are likely erring on the side of caution, hesitant to coerce in light of the moral danger in doing so. My point is that this overlooks moral danger on the other side. The Left should understand coercion as one among many tools available when addressing those who are addicted or mentally ill. But it’s a tool that should be used sparingly, carefully, and — above all — with an eye to enhancing people’s autonomy. The goal should not be to remove homeless people from public life for the convenience of others, nor force them to live according to a narrow set of values that they don’t endorse. The goal should be to invest resources into efforts that will allow them to live what they themselves recognize as a good life.

All of this, of course, requires a commitment to the sorts of social democratic institutions and programs that would allow us to pursue genuinely autonomy-enhancing measures: better mental health care, more social insurance, affordable housing, and so on. Thoughtful coercion administered with such conditions in place need not be despotic; it can be progressive and decent. But without such an ambitious social democratic buildout, the options too often are either to institutionalize people against their will or to leave them suffering on the streets — two different ways of abandoning the most vulnerable.