Involuntary Hospitalization During the COVID-19 Pandemic

In early 2020, coronavirus disease 2019 (COVID-19), which is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a global pandemic. Health professionals and government officials have mobilized health care systems, including outpatient clinics, emergency departments, inpatient medical and surgical floors, and intensive care units, to meet the demands introduced by this novel coronavirus. By cancelling elective surgeries, delaying nonessential outpatient appointments, and shifting to telehealth services, among other measures, clinicians have sought to free up health care resources and to keep patients out of hospitals when possible. Within this context, the COVID-19 pandemic creates new questions regarding involuntary psychiatric hospitalization. In particular, how do the ethics of involuntary psychiatric hospitalization change during a pandemic?

Shifting the Balance of Ethical Principles

Health professionals often use a framework of four principles—autonomy, nonmaleficence, beneficence, and justice—when faced with ethical dilemmas in clinical decision making (1), and a pandemic disrupts the balance of ethical principles for involuntary psychiatric hospitalization.

First, the principle of autonomy emphasizes respecting patients’ abilities to make decisions for themselves. By overriding patients’ decision making regarding inpatient psychiatric care, involuntary hospitalization entails considerable restrictions on patient autonomy. In many countries, civil commitment statutes authorize involuntary psychiatric hospitalization under specific circumstances, usually when patients pose a danger to themselves or others because of mental illness. Safeguards to protect patient autonomy include time limits for involuntary care, requirements for judicial review, and restrictions on use of restraints, seclusion, and medication over objection. However, certain infringements on autonomy, such as taking away patients’ abilities to avoid health care facilities (which may be focal points of infectious disease transmission), to maintain physical distance from others, to remain with family, and to manage finances, can become more harmful for patients during a pandemic. To reduce SARS-CoV-2 transmission, staff may also institute policies, such as restrictions on visitors or in-person legal proceedings, that can undermine patients’ autonomy.

Second, the principle of nonmaleficence emphasizes avoiding harm. During involuntary hospitalization, patients risk not only acquiring COVID-19 in health care settings but also infecting others. Hospitals can institute measures, such as screening, testing, and isolation, to decrease inpatient SARS-CoV-2 transmission. Nevertheless, reports suggest that SARS-CoV-2 may be spread by infected individuals with few or no symptoms, and patients and staff might unknowingly spread the virus despite these measures. Not knowing who might be infected on an inpatient unit may be terrifying for a patient who did not consent to hospitalization. Further, inpatient psychiatry units are structured in ways that may increase SARS-CoV-2 transmission. Patients and staff intermingle in patient rooms, hallways, day rooms, dining areas, and other common spaces. Group therapy is a mainstay of treatment on inpatient psychiatry units. Staff on these units may not have extensive training in infection control and may lack access to adequate personal protective equipment. Patients with psychiatric symptoms might have impaired ability to follow infection control protocols and limited access to hand sanitizer because of unit policies. In April, news media had already documented the spread of SARS-CoV-2 within mental health facilities in 23 U.S. states, as well as in a number of other countries (2). One mental health facility in South Korea attracted international attention after more than 100 patients contracted SARS-CoV-2 and at least seven died (3).

Third, the principle of beneficence focuses on promoting patients’ welfare. By providing a safe environment for patients with acute psychiatric needs—an environment where mental health professionals can evaluate patients, provide treatment, and plan for transitional care—involuntary hospitalization can bring many benefits to patients and the public. Many patients with serious mental illness already face risks related to unstable housing, unemployment, criminal justice involvement, substance use, and stigma. During a pandemic, patients may encounter new difficulties accessing shelter, food, hygiene products, and psychiatric care, and inpatient psychiatry units can help patients meet these needs. However, changes to inpatient policies geared toward mitigating viral transmission may reduce the effectiveness of involuntary care. Suspending in-person activities, such as team visits with patients, group therapy, and family meetings, may reduce SARS-CoV-2 transmission but may also impede efforts to promote patients’ recovery. Testing newly admitted patients for SARS-CoV-2 may identify infections and limit viral spread, but isolating patients with acute psychiatric needs in their rooms for prolonged periods while awaiting test results could exacerbate their symptoms. Wearing personal protective equipment, such as masks, face shields, and gloves, may protect staff from infection, but these measures might disrupt therapeutic alliances and cause anxiety for patients who may already be grappling with psychosis, mania, obsessions, or other acute psychiatric symptoms.

Fourth, the principle of justice tasks clinicians with distributing health care resources and treating patients equitably. However, scarcity of health care resources during a pandemic raises complicated questions about involuntary care. If psychiatric beds become difficult to access, should mental health professionals prioritize patients who require involuntary hospitalization and may have greater psychiatric needs, or should patients who voluntarily seek services and might also benefit from care be given priority? How might clinicians weigh various risk factors related to COVID-19, such as old age or respiratory status, against patients’ needs for psychiatric admission? If hospital resources across services become stretched thin, how should clinicians allocate resources between specialties—for example, deciding between admitting a patient with COVID-19 and declining respiratory status who wants care versus a patient with psychotic symptoms who does not want care?

Navigating These Dilemmas

During the COVID-19 pandemic, clinicians and policy makers might consider these ethical principles when navigating dilemmas related to involuntary psychiatric hospitalization. Reconsidering criteria for admissions and discharges may be necessary given the unique risks of infectious disease transmission in psychiatric facilities; for example, during the early stages of the pandemic, some mental health systems in the United States announced temporary suspensions of civil commitment admissions and discharges for specific patients (4). Prioritizing patients with the greatest psychiatric needs for admission and discharging patients as soon as can safely be done may be one approach to achieving justice if beds become less accessible. Admitting patients with confirmed or suspected COVID-19 to dedicated units or care teams might promote nonmaleficence and reduce inpatient transmission risks. Adopting higher admission thresholds for patients who are vulnerable to COVID-19 (e.g., elderly patients and those with preexisting medical comorbidities) might be another way to balance the principles of beneficence and nonmaleficence. In addition, health professionals should consider the public risks of contagion when discharging patients from psychiatric care and take steps to mitigate these risks—for example, by testing patients when possible; connecting patients with follow-up care; providing patients with essential supplies, such as masks; and counseling patients about prevention of viral transmission.

Beyond adjusting procedures for admissions and discharges, clinicians can take other steps to maintain the benefits of involuntary hospitalization while mitigating the risks of COVID-19. Staff can develop policies that promote nonmaleficence without compromising care, including regularly screening staff and patients for COVID-19 symptoms, expanding surveillance testing for staff and patients, increasing checks of vital signs of admitted patients, moving from communal dining to meals in patient rooms, sanitizing commonly used surfaces, increasing access to masks and other personal protective equipment, and encouraging handwashing. Admitting patients to single rooms might decrease risks of infectious disease transmission but may also reduce access to psychiatric beds. Increasing patient access to phones, mobile devices, or the Internet when clinically appropriate might offset the effects of visitor restrictions on patients’ autonomy. Similarly, using tele- or videoconferencing for legal proceedings may preserve frameworks for protecting patients’ autonomy while limiting SARS-CoV-2 transmission risks from in-person legal hearings. Replacing in-person team visits, family meetings, and group therapy with virtual visits whenever possible can help maintain beneficence associated with involuntary hospitalization. Although some of these policies may be temporary and reversible, clinicians should study the effectiveness of pandemic-related changes to involuntary care and consider which ones, such as enhanced access to videoconferencing, might be beneficial to patients more broadly moving forward.

Future Directions

The degree to which the COVID-19 pandemic will change involuntary psychiatric care remains unclear. For example, although research suggests associations between influenza infection and psychosis during the 1918 influenza pandemic, at least one study from the Netherlands indicated that the incidence of acute compulsory psychiatric admissions did not vary during that period (5, 6). Patients and staff on inpatient psychiatry units now face many uncertainties amid the evolving COVID-19 pandemic—the risks of becoming infected or infecting others, changing protocols for inpatient care, the availability of clinicians, and their futures outside the hospital. Meanwhile, the broader mental health effects of SARS-CoV-2 infections, mass quarantine, strained health systems, and economic disruption around the world remain to be seen. As inpatient psychiatry continues to adapt to this pandemic, clinicians and policy makers should remain mindful of the shifting ethics of involuntary psychiatric hospitalization.

Key Points/Clinical Pearls