Massachusetts law is clear that before a person can be committed to a mental health facility, including sections of general hospitals set apart for the treatment of the mentally ill, he or she must be found beyond a reasonable doubt to be a danger to self or others.  In the case of a man I’ll call John, no such hearing had ever been held; no finding of dangerousness had been made.  His case caught the attention of a public interest law group that focused on helping people with disabilities.  They argued that John was being unlawfully confined in violation of his constitutional rights and that he should be released.

“Judge,” his advocate argued, “John loves his freedom. He hates confinement. This is why he has a history of leaving the facilities he is placed in. He heads for the trains. He loves to ride the rails. He is the last hobo in America.”

John was a likable fellow with a good sense of humor who had been homeless for a number of years.  It was easy to imagine him perched in a box car, free and uncooped, wind ruffling his hair as the train whipped along.  But as so often happens, it soon became clear that there was much more to his story.

A few years earlier, John had been found incompetent to manage his own affairs because of dementia due to chronic alcohol abuse.  The dementia impaired his memory and his judgment. He also had severe chronic pulmonary disease which caused frequent episodes of extreme shortness of breath that required immediate intervention.  Although John was prescribed several medications in inhalers to control and stabilize his condition, when on his own he could not refrain from drinking alcohol and he could not remember to take his medication.

Since there were no family members available to serve as John’s guardian, the court had appointed an attorney to serve in this role.  The guardian initially placed John in a nursing home which was at that time within her power as a guardian.  She also authorized the administration of any necessary ordinary medical treatment.    

The nursing home had alarms on the doors but few security guards.  During his three months at that home, John showed just how much he loved his freedom.  He escaped twelve times.  Each time, he ended up in an emergency room because of intoxication and respiratory distress.  Since the nursing home could not adequately care for him, he was sent to a detoxification center.  After just a few days, he escaped again. Over the next 30 days, he was treated in the emergency rooms of four different Boston area hospitals on eight separate occasions. On one of those occasions, he was admitted into intensive care unit where he stayed for ten days.  Another time, he was admitted and treated for pneumonia. 

Since these first two facilities were no match for John’s penchant for freedom, the guardian placed John in a state hospital operated by the Department of Public Health.  Patients in the section of the hospital where John stayed wore ankle bracelets that would trigger an alarm if they passed through an external door and there were a sufficient number of security guards present to escort wayward patients back to their units. 

“Your Honor, this amounts to unlawful confinement,” John’s advocate argued.  “This has lasted for more than three years.  The situation is shocking!”  They went on to argue that all of this had happened without due process and without the required commitment hearing. 

The guardian argued persuasively that the facility came under the jurisdiction of the Department of Public Health, not the Department of Mental Health, and that the section of the hospital where John was placed was not set aside for the treatment of mental illness.

John himself was present at the trial, slightly bemused by all the fuss and casting long glances out the window, probably wondering if he could manage one more escape to freedom.  When his turn came to speak, he readily acknowledged that he liked being treated daily with medication for his pulmonary disease but he still wanted out of the hospital.  However, his testimony also made it plain that his dementia rendered him unable to remember to take his medication.      

While John hated to be confined, the “last hobo in America” had lost his ability to survive life on the streets and on the rails.  With his alcohol induced dementia and chronic pulmonary disease, he no longer ran toward the freedom of “the road”, he ran smack into medical crises.

At the end of the trial, I ruled for the guardian finding that John’s love of freedom was better served by granting him the freedom to catch his breath rather than the freedom to catch a train.