The United States may be at the brink of an important turning point in the way the nation cares for those with mental disabilities.
This week, the US Supreme Court takes up a case that could force state governments to stop using state mental hospitals as what critics say are little more than human warehouses for the mentally retarded.
Advocates for the disabled say the case may be the most important in a century in helping to integrate those with mental disabilities into American society. And it could go a long way in finally closing the door on the nation's well-documented history of ill-treatment of those diagnosed with mental retardation or mental illness.
"It's about freedom. It's about society recognizing one's capacity and one's entitlement to lead the same kind of life that everyone else leads," says Ira Burnim, legal director of the Bazelon Center for Mental Health Law in Washington.
The case, argued April 21, involves two women diagnosed as mentally retarded who were being housed at a mental hospital in Georgia, even though care professionals determined they would most benefit from a community-based program.
Georgia does not dispute that its own professionals determined that the women, Lois Curtis and Elaine Wilson, could live safe and productive lives outside the hospital. But lawyers for the state argue that Georgia must retain the discretion to decide when to move individuals out of a hospital and into locally run programs.
Whichever way the court decides, legal analysts say, it will be a significant decision. "If the court agrees with Georgia, it will make the Americans with Disabilities Act a dead letter, at least in the public-services area," says Steven Caley, one of the Atlanta Legal Aid lawyers to file suit on behalf of Ms. Curtis and Ms. Wilson.
Other analysts say that if Georgia loses, it could trigger a massive shutdown of mental institutions across the country and force states to set up community-based programs costing hundreds of millions of dollars.
Limiting state benefits
In the Georgia case, the two women were on a waiting list for community placement and were asked to wait their turn. "It is a hallmark of everyday citizenship, not a mark of disability, to be eligible for some benefits when they become available," writes Beverly Patricia Downing, senior assistant attorney general of Georgia in her legal brief to the court. "No civil rights statute of which we are aware has ever barred such an approach to allocating limited government benefits."
Lawyers for Curtis and Wilson counter that the Americans with Disabilities Act of 1990 requires state governments to immediately transfer mental hospital residents to community-based programs when care professionals determine it would be beneficial.
Such community programs include assisted group-living arrangements and small-scale treatment, counseling, and education. Most experts believe community-based programs foster an atmosphere that is more conducive to the happiness and progress of citizens diagnosed as being mentally retarded.
Advocates say that in addition to being more humane and effective, community-based programs are also cheaper to run. The annual per patient cost of a bed in a Georgia mental hospital ranges from $80,000 to $180,000, according to legal briefs. In contrast, the yearly per person cost of the program where the women were transferred is $20,000.
The case is being compared to one of the most important civil rights decisions of the Supreme Court, Brown v. Board of Education, which in 1954 outlawed the separate but equal doctrine.
"This is no different than how black people were treated for hundreds of years," says Mr. Caley. "Segregating black people in education was justified because it was said to be better for them and better for society." By failing to offer community-based treatment options, Caley says, states are forcing the mentally retarded into an isolated and segregated existence. That, he says, is a form of discrimination.
Lawyers for Georgia counter that the Americans with Disabilities Act is aimed at ensuring that programs and services available to the non-disabled are also available to the disabled. But the law does not dictate to states how and where mentally retarded persons must receive benefits.
There is no constitutional right to receive such benefits, legal analysts say. But there is a constitutional right that any benefits provided by a state be distributed according to the law, including civil rights laws, they say.
Until the late 1960s, the only way for someone diagnosed as mentally retarded to receive government assistance was to become a resident at a state mental hospital. By 1969, there were roughly 200,000 people in mental hospitals. Since then, most mental health professionals have found that the vast majority of mentally retarded residents in mental hospitals do better in smaller, community-based treatment facilities.
Thus, the trend has been away from using mental hospitals as long-term care facilities and, instead, transferring residents to community-based programs.
But some states, like Georgia, have resisted this trend. Nationwide, there are still more than 60,000 individuals diagnosed with mental retardation being housed in mental hospitals.
"What we have is the failure of government to put in place services and supports for people with mental retardation in order for them to survive in their communities," says Paul Marchand of The Arc, a national advocacy group for the mentally disabled.
Mr. Marchand says the 60,000 current residents of state mental hospitals are just the tip of the iceberg. He says there may be as many as 250,000 others who are being cared for by parents to protect them from what is perceived as the prospect of an inhumane life at a mental hospital.
He says there is a waiting-list crisis among those seeking the limited spots in community-based programs. "The worst crisis is where [an elderly mom or dad] is still taking care of an adult son or daughter with mental retardation."