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Book Forum: The Patient’s Perspective   |    
Who Qualifies for Rights? Homelessness, Mental Illness, and Civil Commitment
H. RICHARD LAMB, M.D.
Am J Psychiatry 2003;160:1533-1533. doi:10.1176/appi.ajp.160.8.1533
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By Judith Lynn Failer. Ithaca, N.Y., Cornell University Press, 2002, 200 pp., $29.95.

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Why are people with severe mental illness homeless and living on the streets? In my opinion, this book provides some answers.

The author provides an exposition of the logic and language of rights of people with severe mental illness, the theory behind civil commitment, basic assumptions about who does, and who should, qualify for constitutional rights, and the arguments for and against civil commitment. The well-known case of Joyce Brown and her attempted commitment in 1987 while she was living on the streets of New York City is used throughout the book to illustrate the issues and arguments about rights.

If all the complexities of this analysis of rights were taken into account with regard to every case in clinical settings, would civil commitment of persons with severe mental illness ever happen? Obviously it would, but the frequency would be considerably decreased if those trying to decide were obsessing about all the points raised in this book. As I followed all the twists and turns of the discussion, I found myself wishing that Alexander the Great were here to confront this huge knot of arguments and slice it through as he did so long ago with the Gordian Knot.

In practice, are the criteria of danger to others, danger to self, and grave disability so difficult to apply appropriately in a clinical setting? Not in my experience. And when there is a disagreement, a decision can be taken to court, where a judge weighs in with still another perspective.

Unfortunately, obsessively debating issues of rights, as is done in this book, is more than just an intellectual exercise. There are real-life consequences to decreasing the frequency of involuntary treatment. The result is that people with severe mental illness who need treatment do not receive it. For those who are homeless, homelessness continues, and this is not a benign thing. The quality of life on the streets is poor and can be abysmal—being outdoors in dangerously low temperatures, eating out of garbage cans, and having little access to treatment of medical disorders such as cardiac disease, diabetes, hypertension, tuberculosis, and infestations of scabies and lice. Life on the streets is dangerous. Rape is common, and one can be severely beaten or killed for one’s meager possessions. Where is the morality in letting severely mentally ill people be subjected to such a life because their illness prevents them from knowing what they need while we are obsessing about their rights?

Many homeless, severely mentally ill people find their way into the criminal justice system for offenses that stem from their illness. One has considerably fewer rights in a jail than in a hospital. If the person is released from jail and placed in an outpatient program under the jurisdiction of the criminal justice system, that person is in a system far more coercive than anything proposed in outpatient civil commitment. After all, the criminal justice system by its very nature must be concerned with the public safety and the person’s potential threat of harm.

The homeless, severely mentally ill person whose access to civil commitment is reduced and, as a consequence, remains on the streets or is arrested may well suffer a significant loss of rights. In my opinion, the right that should have received far more emphasis in this book is the right to treatment of people with severe mental illness.

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