In November 2022 New York City Mayor
Eric Adams announced a proposal to increase
the city’s involuntarily hospitalization of
people with serious mental illnesses such as
schizophrenia and bipolar disorder when they
were found to be dangerous to themselves.
Adams touted his proposal as fulfilling a
“moral obligation […] to assist those who
are suffering from mental illness” and to
reduce the city’s homelessness and crime.1
Nevertheless, pushback to Adams’s proposal
was swift and varied, with concerns about the
plan’s feasibility, the city’s lack of structural
and systemic support, high rates of burnout
among first responders, and exacerbating police
violence, especially against Black men.2
Adams’s proposal was met with a still more
difficult challenge: the conviction that
involuntary hospitalization is unethical
precisely because it is done against the will
of the person with serious mental illness. As
City Councilwoman Tiffany Cabán tweeted
shortly after the announcement of Adams’s
proposal, “Consent is key […].”3
Cabán’s tweet
helpfully clarifies that debates about Adams’s
proposal are at least as much about ethical questions such as the meaning and purpose
of human rights as they are about psychiatric
or social questions about, for example, proper
medication and homelessness.
The objection that involuntary care violates the
rights of people with serious mental illness fears
– sometimes with strong justification – that
even the most well-intended interventions can
be harmful and that justifying any intervention
at all makes it easier to legitimize harmful ones.
Invoking human rights would seem to protect
people with serious mental illness from harms
that are too often and too easily inflicted when
consent is rendered unnecessary, but doing
so would tie the city’s hands and, thus, to
perpetuate homelessness and crime.
I believe that thinking more carefully about the
meaning and purpose of rights can provide a
way forward from this impasse. Cabán’s defense
of consent reflects one way to understand rights,
but it does not necessarily reflect the only or
the best way to think about these issues. Her
understanding of rights reflects that of classical
liberalism, according to which the solitary,
rational individual is prior to the community
or the state, and rights exist to protect the
individual’s life, liberty, and property from interference by others.
A classically liberal assessment of the case at
hand yields the conclusions that the individual
with mental illness is necessarily the primary
unit of moral concern and that the city of New
York and the needs of its other residents are of
secondary value; that that person with serious
mental illness has a right to live life as he or she
sees fit, even if those life-plans are not good
for themselves (e.g. because they are devised
under hallucinations, delusions, or manic or
depressive episodes); that those life-plans ought
not be interfered with by the city’s police or
workers, especially when that person does not
consent to hospitalization; and that, therefore,
involuntary hospitalization is unethical. If
liberalism is presumed, Cabán’s defense
becomes intelligible and even persuasive.
And yet, questions arise. Should liberalism
be presumed? How viable or compelling, in
fact, are its presuppositions? How helpful
is its assessment of this case? Even granting
liberalism’s long history of shaping social
thought in the United States, it is not, in fact,
the only resource that Americans have drawn
from to think about public life throughout
history. As sociologist Robert Bellah and his coauthors famously argued in Habits of the Heart:
Individualism and Commitment in American
Public Life, individualism might be Americans’
“first language,” but they have also turned to
the less individualistic and more communally-centered resources of civic republicanism and
biblical religion (including, of course, the
Catholic tradition). Liberalism, then, is not our
only option for evaluating Adams’s proposal.
Nor should it necessarily be, as there are good
reasons to challenge liberal presuppositions. A wide array of resources ranging from the
Catholic tradition to Aristotelian philosophy to
evolutionary biology to contemporary studies
about human loneliness to human experiences
such as friendship, marriage, and parenthood
cast serious doubt upon liberalism’s claim
that humans are first and foremost individuals
disconnected from one another rather than
intrinsically relational creatures.
Furthermore, as philosopher Martha Nussbaum
argues in Frontiers of Justice: Disability,
Nationality, Species Membership, liberalism’s
requiring rationality casts people with serious
mental illness as sub-human. Protecting people
with serious mental illness from interference is
not entirely meritless, but it also risks cutting
them off from loving and being loved in the
concrete – precisely the type of relationships
and care privileged by the Catholic tradition
and its healthcare organizations. By uncritically
and necessarily prioritizing the wants of the
individual over the needs of the community,
liberalism risks justifying the perpetuation of
homelessness, crime, and other problems that
imperil people with serious mental illness.
The Catholic rights tradition as developed
through papal encyclicals like Pacem in Terris
(1963) and the work of Catholic social ethicist
David Hollenbach offers a more helpful way
to think about rights for evaluating Adams’s
proposal. Unlike liberalism’s individualistic,
rationalistic anthropology, this tradition
maintains that humans are intrinsically
dignified and relational creatures because
they are created in the image and likeness of a
relational, trinitarian God. This anthropology
suggests that having serious mental illness
does not erase one’s humanity and commends
balance between the wants (and needs) of the individual and the needs of the wider
society. This balance suggests that simply
invoking one’s “right” to be left alone is not
necessarily the trump card that liberalism
believes it to be, because people with serious
mental illness – like all humans, for that matter
– can be mistaken or misled about what is, in
fact, good for them. This is especially the case
when their illness affects the areas of the brain
responsible for recognizing mental illness itself,
as this unawareness often leads to medication
noncompliance. Rights, therefore, do not so
much protect freedom from interference as they
do the freedom of each person to participate
as fully as possible in the life of the society.
Participation includes (but is not limited to)
access to psychiatric healthcare as well as the
responsibility to contribute as best one can to
the common good.
The Catholic rights tradition does not entirely
reject the importance of consent, but it can
helpfully complicate a singular privileging of
consent over other worthwhile ethical issues
and resources. It can help us to appreciate more
carefully the good that Adams’s proposal might
enact (while not precluding necessary caution
about how well it can and will be implemented
on the ground). It can invite us to critically
assess the presuppositions upon which our
positions depend. And it can remind us that
concerns such as Cabán’s, though certainly not
unimportant, are not the only ones that deserve
a fair hearing in our conversations about how
best to care for people with serious mental
illness, because, ultimately, “do not interfere
with your neighbor” falls woefully short of
loving one’s neighbor as oneself (Matthew
22:34-40).
PETER K. FAY, M.T.S
Doctoral Candidate in Theological Ethics
Boston College
Chestnut Hill, Massachusetts
[email protected]
ENDNOTES
- Andy Newman and Emma G. Fitzsimmons, “New York
City to Involuntarily Remove Mentally Ill People From
Streets,” The New York Times, November 29, 2022,
- For example, see Emma G. Fitzsimmons and Andy
Newman, “New York’s Plan to Address Crisis of Mentally
Ill Faces High Hurdles,”The New York Times, November
30, 2022, sec. New York, Anthony Almojera, “I’m an
N.Y.C. Paramedic. I’ve Never Witnessed a Mental Health
Crisis Like This One.,”The New York Times, December
7, 2022,;Giulia Heyward, “NYC Mayor Adams Faces
Backlash for Move to Involuntarily Hospitalize Homeless
People,” National Public Radio, November 30, 2022, For
support of Adams's proposal from a leading psychiatrist
who specializes in the marginalization of people with
serious mental illness, see Ellen Barry, “Behind New York
City’s Shift on Mental Health, a Solitary Quest,” The New
York Times, December 11, 2022
- https://twitter.com/tiffany_caban/
status/159763875832492032