Goodman J. The ethics of mental hospitals. HPHR. 2022;62. 10.54111/0001/JJJ8
I shall be obliged to speak with great plainness, and to reveal many things revolting to the taste…. But truth is the highest consideration. I tell what I have seen—painful and as shocking as the details often are—that from them you may feel more deeply the imperative obligation which lies upon you to prevent the possibility of a repetition or continuance of such outrages upon humanity. If I inflict pain upon you, and move you to horror, it is to acquaint you with suffering which you have the power to alleviate….
Excerpt from Dorothea Dix’s Memorial to the Legislature of Massachusetts (1843)i
After studying the treatment of the mentally ill in England during the 1830s, Dorothea Dix returned to the United States where she conducted a series of investigative studies and reports on the care for the mentally ill, which she presented as “memorials” to state legislatures—first in Massachusetts (1843), followed by New Jersey (1845), Illinois (1847), North Carolina (1848), and Pennsylvania (1853).ii Her remarkable efforts ultimately lead to passage by Congress of the “Bill for the Benefit of the Indigent Insane” in 1854, which would have funded construction and maintenance of asylums for the mentally ill across the United States from sale of federal land.
If this bill had been adopted and implemented, our federal government’s ultimate responsibility for the care of the mentally ill would have become an integral part of the American experience starting in the mid-19th century. Unfortunately, President Franklin Pierce vetoed the bill, arguing that social welfare was the responsibility of the states. Subsequently, Dorothea Dix was appointed the Superintendent of Army Nurses by the Union Army during the Civil War.
I propose today in 2022 that the federal government assume the responsibility of caring for the “indigent insane” that Dorothea Dix first proposed, and Congress first approved, in 1854.
In her “History of Psychiatric Hospitals,iii Professor Patricia D’Antonio, Mental Health Nursing Chair at the University of Pennsylvania School of Nursing, describes the transition from almshouses and private hospitals in the 18th century to the development in the 19th century of public and charitable asylums that adopted a “moral treatment” program for the mentally ill first developed in Europe. This moral treatment discontinued use of harsh restraints and long periods of isolation. It relied upon construction of mental hospitals in secluded, country settings that provided opportunities for work and recreation. Privileges and rewards were granted for the exhibition of rational behaviors, and less painful restraints were adopted for short periods.
An early example of this system was built by Philadelphia’s Quaker community in 1814, the Friends Asylum. Similar mental hospitals that adopted the moral treatment program included the McLean Hospital built by Massachusetts General Hospital in 1811, the Bloomingdale Insane Asylum built by New York Hospital in 1816, and later the Institute of the Pennsylvania Hospital in 1841 (the Institute). Thomas Kirkbride was the first superintendent of the Institute, and he designed what became known as the “Kirkbride Plan,” which was the prototype for many subsequent mental hospitals built in the United States. Almost all states funded one or more of these institutions during the latter part of the 19th century.
In the 1890s, as life expectancies increased, local and municipal governments started to shift the cost of caring for the elderly by redefining the concept of senility into a psychiatric problem, and then transferring many elderly patients to state funded mental hospitals. The resulting increase of patients in state mental hospitals forced doctors and nurses to confront the limitations of trying to provide psychiatric treatment to large numbers of elderly patients suffering from dementia.
Many of these state mental hospitals have now closed due to the deinstitutionalization process described below, but I note that both my parents who are now deceased (Dr. Melvin Goodman and Shirley Goodman, M.S.W.) worked at two of the remaining Texas state mental hospitals (North Texas State Hospital in Vernon and Rusk State Hospital). They also worked at two of Texas’ community mental health facilities (in Temple, TX, and Odessa, TX). Nothing in this article should be considered as a criticism of the noble men and women like my parents who dedicated their lives to caring for the least among us, often working in the harshest of circumstances, and this article is dedicated to their memory.
Professor D’Antonio concludes her survey of U.S. mental hospitals with the following thoughts:
Today, only a small number of the historic public and private psychiatric hospitals exist. Psychiatric care and treatment are now delivered through a web of services…. The quality and availability of these outpatient services vary widely, leading some historians and policy experts to wonder if “asylums,” in the true sense of the word, might be still needed for the most vulnerable individuals who need supportive living environments.
Overcrowding and deteriorating conditions in state-run mental hospitals was exacerbated by the economic depression of the 1930’s followed by the widespread reallocation of medical personnel caused by World War II. In partial response to these problems, the Mental Hygiene Movement arose during the early 20th century iv that proposed creating more outpatient clinics (like the MHMRs mentioned above) to provide mental health treatment away from the traditional confines of mental hospitals. Also, during the 1930s and 1940s, psychiatrists began experimenting with new types of therapies (some of which were later criticized and discontinued) including insulin and electric shock, psychosurgery, and different medications.
Despite these problems and worsening conditions, the United States reached its peak number of mental hospital beds in 1955, almost all of which were in state-run facilities. At that time, there were over 500,000 available psychiatric beds (compared with just over 50,000 as of 2014 — a ninety percent reduction during this six-decade period).v
The 1950’s brought major pharmacological changes to the field of psychiatry with development of chlorpromazine and other anti-psychotic medicines, which offered the hope of treating some of the most severe and debilitating psychiatric problems like psychosis and schizophrenia (i.e., the serious or severe mental illnesses or SMI). Though some members of the SMI population responded positively to these new medicines, many continued to need long term custodial care.
Serious mental illness (SMI) is defined by the NIMH as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI.
One of the researchers into these new drug treatments was Dr. Nathan S. Kline,vi a professional colleague of my late father Dr. Melvin Goodman. In 1952, Dr. Kline created a research unit at Rockland State Hospital in New York, where he investigated the use of reserpine as a possible treatment for schizophrenia. He also promoted the use of iproniazid, an anti-depressant for the treatment of severe depression. (As a child, I accompanied my family on a vacation to Haiti where we visited the Mars and Kline Psychiatric Institute, which was co-founded by Dr. Kline.)
All these changes led to the deinstitutionalization movement that started in the 1960s. Within the judiciary, courts responded to real civil rights concerns by creating increasingly stringent rules for making commitments into mental hospitals starting with the case of Lake v. Cameron,vii which introduced the concept of “least restrictive setting.” In 1975, the U.S. Supreme Court found in O’Connor v. Donaldsonviii that a person had to be a danger to him- or herself or to others for confinement in a mental hospital to be constitutional. Finally, in 1999 the U.S. Supreme Court in Olmstead v. L.C.ix determined that mental illness was a disability under the Americans with Disabilities Act,x and as such “reasonable accommodations” had to be made to move people from mental hospitals into community-based treatment facilities.
As noted by Dr. Daniel Yohanna, Chair of the Department of Psychiatry at the University of Chicago Pritzker School of Medicine, in his 2013 comprehensive review of these events in the AMA Journal of Ethics,xi these judicial constraints on the commitment process were instituted at about the same time that Congress passed the “Community Mental Health Construction Act,” in 1963, which made federal grants available to states for establishing local community health centers in anticipation of closing the state-run mental hospitals.
But the most significant change in federal law was the introduction of Medicaid, which shifted funding for people with SMI from a state-run program into a shared partnership with the federal government. This created a perverse incentive for states to close the facilities that they funded on their own (i.e., the state mental hospitals) and move those patients into community mental health facilities and nursing homes partially paid for by the federal government through Medicaid.
The deinstitutionalization process continued in 1981 with the “Omnibus Budget Reconciliation Act,”xii which ended federal funding for community-based nursing homes that primarily treated patients with mental health problems and required states to return to funding non-nursing homes (many of which were private and for-profit) for the long-term care of people with SMI within the community.
The resulting confusion and disruption caused by these well intentioned judicial and legislative initiatives, and their unintended consequences, are apparent in every city around the United States. The resulting plague of unhoused and unsheltered individuals living on our city streets suffering from SMI and, even more distressingly, the use of jails and prisons as default long-term residential facilities for some individuals with SMI are outrageous. And yet, as Dorothea Dix observed so many years ago, we have the power to alleviate this suffering.
A reviewer of this article commented, and I agree, that society must begin to move the needle away from the moral/eugenics model for mental health (which we still apply, yet which is most often absent from general physical medical care) – creating a double standard between mental and medical ethics in the USA that we can no longer afford given the known negative public health outcomes.
The Marine Hospital Service was established by Congress in 1798 through passage of “An Act for the Relief of Sick and Disabled Seamen.” xiii It was the first federal public health law, and it led to creation of a wide network of hospitals along the U.S. coasts and inland waterways.xiv In 1902, the Marine Hospital Service was renamed the Public Health and Marine-Hospital Service, and in 1912 it was again renamed the Public Health Service (Division of Hospitals). This system of federal hospitals reached a peak of 30 hospitals in 1943, and then began to decline through a series of closures—first during the period 1944-1953 and another series of closures in 1965-1970. The system’s remaining eight general hospitals, including the one I visited with a family friend on Staten Island in the 1970’s, were finally closed or transferred to other groups in 1981.
There are also several federal hospital facilities specifically dedicated to mental health care including St. Elizabeth’s Hospital in Washington, D.C., which is now administered by the District of Columbia Department of Mental Health, and two Federal Medical Center facilities (FMC Devens in Massachusetts and FMC Lexington in Kentucky) that are now operated by the Federal Bureau of Prisons.
Congress should consider taking the following steps:
Dr. Yohanna found in 2013 that there were approximately 378,00 incarcerated individuals with SMI and many times that number of individuals suffering from SMI who were not incarcerated, including a significant portion of the unhoused and the unsheltered living on our city streets. The new and re-purposed Marine Hospital Service should aim to establish and maintain a minimum of 300,000 safe and sanitary psychiatric beds located in every state throughout the U.S., and to offer scientific and compassionate treatment to all individuals suffering from SMI.xv
Justice Gordon Goodman was elected to the First Texas Court of Appeals in 2018. He is a member of the Texas State Bar, Pennsylvania Bar, and Energy Bar Associations. Before serving on the bench, he started his career with the Whittenburg Law Firm in Amarillo, TX, where he focused on civil trials, appellate work, oil & gas law, banking law, and general practice. He subsequently served in senior positions for the Howell Corporation; E.I. DuPont de Nemours & Co.; Conoco, Inc.; Occidental Petroleum Corporation; and most recently with NRG Energy. He earned his BA degree Magna Cum Laude from the University of Pennsylvania and his JD degree from the University of Pennsylvania Law School both in Philadelphia. He received his high school degree from the Horace Mann School in the Bronx, NY.