by Zain Khalid
October 10th marked the first anniversary of California’s Senate Bill 43 (SB 43), a major revision of the landmark Lanterman-Petris-Short Act of 1967, a de-institutionalization era law designed to “end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders.” The law loosened eligibility standards for civil commitment by expanding the existing “grave disability” criterion, making it easier to detain and hospitalize persons with mental illness against their will.
New York City’s mayor, Eric Adams, enacted a similar initiative in November 2022, the same year 40-year-old Michelle Alyssa Go, was tragically killed after being shoved onto the subway by an unhoused man with a long history of mental illness and patchy treatment. New York’s plan authorized emergency medical workers and police officers to involuntarily remove people with severe mental illness from the streets to be evaluated for hospitalization. Mayor Adams framed his plan in terms of the city’s “moral obligation” to help mentally ill citizens and California Governor Gavin Newsom spoke of a “life-and-death urgency” in advocating for SB 43.
These controversial initiatives are among the highest profile of a growing national trend toward expanding civil commitment laws: Ohio, DC, Tennessee, Alabama and Florida have introduced similar legislation in just the past year. Across the U.S., this turn toward civil commitment is driven by a triple whammy of unmitigated housing crises, an increasingly visible unhoused mentally ill population, and rising violent crime. But is civil commitment a defensible strategy in tackling this Gordian knot of intersecting social crises? Or does it merely serve to keep unseemly realities away from the public eye? To understand the role of civil commitment in addressing these challenges, we must begin by looking at how we got here.
Looking Back: A romp through three centuries of mental healthcare in the US
The 19th century asylum movement spearheaded by Dorothea Dix was a compassionate response to the neglect persons with mental illness faced in prisons and almshouses at the time. Over the next century, however, the asylums it spawned fell into disrepair, becoming overcrowded and understaffed, exemplifying the very neglect they were meant to alleviate. In response, the civil rights movement, coincident with the advent of the antipsychotic chlorpromazine motivated the Community Mental Health Act of 1963, which marked a shift away from “distant custodial institutions” to “community-centered agencies.” Asylums were emptied, and inpatient bed numbers shrank. Landmark judicial decisions in Lake v. Cameron and O’Conner v. Donaldson established patients’ rights to the “least restrictive treatment. Olmstead v. L. C, applied the Americans with Disabilities Act’s “integration mandate,” which requires that states “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”
These mandates, however, never materialized, and community-based services remained woefully underfunded and inaccessible, placing formerly institutionalized persons at the mercy of shrinking social safety nets, and harmful criminal justice policies. Several hundred thousand of them are now unhoused or incarcerated. The recent history of mental health treatment in the US reads on this account, as a series of well-meaning paroxysmal reforms that seem to all have perished at the altars of political neglect or administrative failure.
Understanding the present: the complicated ethics of civil commitment
These failures significantly complicate the ethics of civil commitment. Critics arguing for individual autonomy and legal protections for the mentally ill warn against reversing decades of civil rights progress for the sake of what is essentially public convenience. But autonomy is not an absolute ideal and must be balanced against competing values such as public safety. Persons with mental illness may admit that obligations to community rightly circumscribe or even constitute their sense of self and autonomy. The state under its parens patrea (“parent of the country”) powers has a legitimate interest in protecting its vulnerable citizens from the preventable harms resulting from mental illness.
But this ethical framework fails when individuals with mental illness who are unable to obtain timely, voluntary care in the community are subjected to civil commitment as their illness deteriorates to the point of dangerousness. The lack of dignified, community-based alternatives, in this way, compels an over-reliance on involuntary confinement, which in turn, reproduces experiences of structural discrimination for the mentally ill, and alienates them from care. The strongest ethical challenges to expansion of civil commitment laws then derive not from infringements upon individual autonomy or liberty interests per se, but from an indefensible excess of such infringement when autonomy-preserving alternatives in voluntary community care could be made available, and their absence causally contributes to the need for coercion.
Charting an ethical path forward
Ethical remedies for such coercive excess can be found in a return to the Olmstead decision’s “integration mandate” based in the ADA. There is good evidence that the mandate works. Even when involuntary, as through New York’s Assisted Outpatient Treatment (AOT) law, community-based care has effectively reduced hospitalizations, arrests and incarceration rates, and housing instability. Governor Newsom’s Community Assistance, Recovery, and Empowerment (CARE) courts, introduced alongside SB 43, offer an analogous model.
Community-based care works even better when available voluntarily. The Certified Community Behavioral Health Clinic (CCBHC) model, authorized by the Excellence in Mental Health and Addiction Treatment Act of 2021, offers a promising approach to revitalizing neglected community-based mental health services. This model funds round-the-clock crisis care, emphasizes evidence-based practices, drastically reduces wait times, and improves access by promoting workforce expansion, training, and services. In eight states where it has been adopted, the results are already impressive: there is a 72% reduction in hospitalization rates, a 40% reduction in homelessness, and a 60% reduction in incarceration rates among the population it serves. A third of CCBHCs allow same-day access to care, and 87% provide care within 10 days of referral. The national average is 48 days.
These results speak to the promise of community-based, noncoercive care in realizing the ambitions of the deinstitutionalization movement inaugurated by the Community Mental Health Act. They represent a more empirically defensible and ethically desirable path forward than a regressive policy emphasis on expansion of civil commitment. If the State is to retain its moral standing as a “parent” and make ethical use of civil commitment, it must do more to protect its most vulnerable citizens. Timely psychiatric care should not require sacrificing freedom, dignity or community participation.
Zain Khalid is Assistant Professor at Brown University’s Department of Psychiatry and Human Behavior and a master’s candidate at Harvard Medical School’s Center for Bioethics (M.B.E 2025). He is board certified in adult and forensic psychiatry and practices as a psychiatric intensivist.
