The issues surrounding mandatory treatments have become a topic for debate considering COVID-19 vaccine mandates for healthcare workers. The message to healthcare professionals in some settings and facilities was clear; comply with mandatory vaccination or face possible termination. Many healthcare professionals followed the vaccination mandate regarding it as part of their responsibility to protect society. Ethically, it was a decision to put the welfare of others above their self-interests. In this context, many healthcare workers who were dubious about the efficiency of the vaccine still decided to get it (Myers et al., 2023).
However, the validity and effectiveness of mandatory COVID-19 vaccines have been questioned. Some saw mandatory vaccine policies to be scientifically problematic. Arguments supporting this position included diminishing efficacy against infection and transmission at 12-16 weeks post-vaccination. Data also supported that once infected, vaccinated and unvaccinated persons transmitted the virus to others at comparable rates. It was also posited that a blanket mandate policy did not consider the significant risk variance across populations. The underlying concern was that vaccine mandates would infringe on human rights, erode public trust in the healthcare system, and negatively impact vaccine confidence (Bardosh et al., 2022).
Another area where ethical questions arise is compulsory treatments for mental health disorders. Compulsory outpatient treatment in mental health (COT), also called community treatment order, poses substantial ethical questions. It occurs globally in more than 75 jurisdictions; however, the evidence regarding COT's effectiveness is unclear (Martinho et al., 2022).
In the United States, many cities have created new policies to combat homelessness, serious mental illnesses, and substance use disorders. A proposal central to most of these policies is involuntary treatment. In November 2022, the mayor of New York City announced a proposal to employ mental health regulations to enable involuntary treatment when individuals are incapable of caring for themselves or when their behaviors pose a danger to others. Similar proposals have been approved in California and Oregon. Court-mandated treatments can incorporate therapeutic interventions, medication management either in a facility or on an outpatient basis, assistance from social workers, and housing referrals (Drabaik, 2023).
In Portland, Oregon, the base cause of homelessness is the high cost of accommodation and financial difficulties. Only one in three persons who are homeless in Portland state that they have a psychiatric illness, substance use disorder, or both. However, combining one or both of these disorders and homelessness has resulted in numerous public tragedies. Examples of these include persons with schizophrenia freezing to death on city streets. Homeless persons have given birth to premature infants that do not survive the ordeal. Research findings show that homeless people in Portland die thirty years earlier than the average adult in this country.
Civil commitment is not a new concept; it has existed for decades. But it has recently gained attention as a means of tackling the juncture of homelessness, psychiatric illness, and substance use disorder. Two theories are invoked as the foundation for laws that permit civil commitment. The first is the principle of 'parens patriare,' a Latin expression that translates as 'parent of the nation'; this principle asserts that states have a legal and ethical duty to step forward and assist vulnerable persons who cannot care for themselves. The second legal premise used is that states have an obligation to enact and apply laws to maintain public health and safety, which can be adversely impacted by homelessness (Drabaik, 2023)
States differ in the content of their civil commitment laws. Since these laws provide a civil process for courts to supervise treating persons with serious mental illness or substance use disorders, they do not criminalize homelessness or employ punitive measures. While 'homelessness' is an all-inclusive descriptor, this population includes several sub-groups with varying needs. But the most noticed group is the chronically homeless lacking shelter, with the highest incidence of untreated mental illness and serious substance use disorders. A study conducted in California that looked at 64,000 persons within fifteen states who were homeless discovered that 78% of unsheltered homeless persons had a mental illness, and 75% suffered from a substance use disorder. 50% of those surveyed had both diagnoses. Healthcare providers know that psychiatric illness and substance use disorders play a role in homelessness and worsen the problem. The impetus for changing the civil commitment law in Oregon is to give physicians more flexibility in requiring treatment for patients who are too ill to recognize their need for care. The case put forward is that persons left without treatment for psychiatric illness and substance use disorders are caught in an endless cycle between life on the streets, county jails, and state mental hospitals (Drabaik, 2023).
50% of the United States homeless population is reported to live in California. While only around one-third to a quarter of this population suffers from severe psychiatric illnesses, they are the homeless people that residents in California's major cities are most likely to confront. The mayors of these cities, for example, San Francisco, San Jose, and San Diego, have voiced their exasperation that the ceiling set for mental health intervention is too high. With mayoral support, lawmakers in California have introduced new laws that would assist in bringing more people into treatment, even if it contradicts their preferences.
While the objectives of civil commitment are to improve the health and safety of people and communities, it does introduce difficult ethical questions, especially around the issue of autonomy- the core belief that people have the right to make decisions for themselves. There is also the question of beneficence, which guarantees that interventions put in place are more beneficial than harmful. Some in authority oppose civil commitment laws and advocate that states should instead depend on voluntary services. They argue that voluntary treatment is equally effective as civil commitment while at the same time preserving the individual's autonomy and freedom to choose or reject treatment. Another argument is that civil commitment infringes on the principle of beneficence since it can stigmatize homeless persons with serious psychiatric illnesses and substance use disorders by suggesting they do not belong in society. There are still others who consider civil commitment as being cruel and intimidating (Drabaik, 2023).
Opponents of civil commitment in California object to the courts having the right to deprive people of their freedom and privacy. They advocate that the state should invest in improved voluntary psychiatric health services. Some of their major concerns center around race. African Americans form disproportionately high numbers of the homeless population and have been historically over-diagnosed with Schizophrenia (Kennedy, 2022). According to many against civil commitment, these more stringent processes will excessively pursue this group.
Those who support civil commitment believe that it successfully connects people with the help they need and satisfies a moral requirement that stops people from experiencing illness and hardship on the streets. Most healthcare professionals assume that individuals can make their own medical decisions in accordance with their values and requirements. But it must be kept in mind that those with serious psychiatric illness or substance use disorder can suffer from diminished ability to consider what is in their best interests and make effective decisions. In actuality, the person's state negates their autonomy. In these situations, it can be argued that involuntary commitment is a positive intervention that enables people to redeem their autonomy. Regardless of how they got there, they are now in an environment that stabilizes their condition and puts them on the road to recovery (Drabaik, 2023). However, there are limitations to this approach; for example, in California and Oregon, current laws do not include substance use disorders as justification for commitment.
Another factor that poses challenges is the inadequate capacity to provide needed treatments. In Oregon, there are long waiting lists with reports that the statewide capacity to provide services for prevention, treatment, and recovery is around 50% of what is required. Overall, in this country, there is a shortage of trained professionals who can provide mental health care; this includes psychiatrists, psychologists, social workers, and mental health and substance use disorder therapists. Data reveals that more than 50% of counties in the United States have no psychiatrists. One of the essential remedies for this problem is to create more residency openings. A positive finding is that more people are attracted to careers in mental health services. In 2022, there were almost twice as many applicants for psychiatric residency as available places (Weiner, 2022).
