One of my patients, K, arrived in the United States in florid psychosis. Back in China, she worked as a housekeeper and lived independently. She took her medications reluctantly but consistently, forced upon her by her parents. After her parents passed away, she stopped her medications. She became convinced her life was being controlled by the Chinese government. In terror, she booked a ticket to the land of freedom, America. She quietly walked around New York City in exile. She sometimes got sick enough to be hospitalized. In the inpatient unit, she would soon become “stable.” She was not violent nor suicidal, which makes her not a “harm to self or others.” So we discharged her. Like that, she cycled through the city’s mental health system for the past three years she has been here: emergency room (ER), admission, street, shelter, and ER again.
During one admission, we ran into an interpreter who had met her years earlier. He asked us a strange question: “Did she have a brain injury recently?” We were befuddled. He said her English, once fluent, had noticeably deteriorated since he last saw her. Over years of cycling between untreated psychosis, brief stabilization, and return to the streets, her brain must have taken a toll. With her English, her brain was eroding away in this land of freedom.
Coming from Korea, my first few years of training as a psychiatrist in New York were marked by profound ethical disorientation. In South Korea, beneficence, the physician’s ethical obligation to act in the patient’s best interest, often supersedes patient autonomy. Medicine is full of moments where these ethical principles collide. What do we do when a patient refuses a life-saving blood transfusion for religious reasons? When a patient declines cancer treatment out of fear of becoming a financial burden to their family? People do not always make the best decisions for themselves. Therefore, at times, it is a doctor’s responsibility to intervene, even at the cost of autonomy. Or at least, that is what I had learned in Korea. Mental health is a discipline where these conflicts are especially stark.
Training as a psychiatrist in New York, I was taught a different set of priorities: autonomy over beneficence. One psychiatric ER shift, I was told: “Patients have the freedom to roam around the city in peaceful psychosis.” I was aghast. At the cost of what? Why would we allow people to remain homeless and delusional when treatment could help them not to be, even if that meant temporarily limiting their freedom? The answer was simple: Because in America, patients have the freedom to choose that life.
Mental health laws faithfully reflect this ethical stance. To hospitalize a patient against their will, physicians must apply for involuntary admission. In New York, that requires meeting a narrow set of legal criteria. A patient must be deemed an “imminent danger to themselves or others,” within the next 24 hours. There is another standard, “inability to care for oneself.” But the bar is extraordinarily high. The impairment must be so severe that death or serious harm appears imminent. The result is a large group of people who fall into the space in between: not about to die, not actively violent, but clearly unable to sustain a humane life. They struggle to secure stable shelter, maintain basic hygiene, preserve relationships, or hold a job. Yet, they are not sick enough to qualify for care.
I am not trying to ignite a political debate about mass institutionalization. This is not the question of “locking people up” versus “protecting the rights of the unhoused.” I am talking about a clash between two ethical values, autonomy and beneficence. In the United States, autonomy is held so highly that we sometimes fail to see what is being sacrificed in its name. Part of this may stem from the historical guilt that American psychiatry still carries. For decades, people with mental illness were institutionalized indefinitely, hidden away and forgotten. The movement toward deinstitutionalization, championed in the 1960s under John F. Kennedy, was meant as a moral correction. The promise was freedom. However, we forget that freedom was only half the promise.
The other half was community care: housing, case management, education and employment opportunities, and clinics capable of meeting people where they are. That infrastructure was never fully built. So people like K were sent back to the streets without homes to return to, wallets to buy food, jobs to provide meaningful roles, and people to catch them when they are falling. Today, we speak boldly about patients’ rights to free will. And that is a good thing. But this spotlight sometimes shades on other things: the right to a humane life, the right to care and protection. In that sense, for people like K, free will without support does not become autonomy. It becomes abandonment.
Wonyun Lee is a psychiatrist.
