Palliative Psychiatry and Assisted Suicide for Mental Illness: Not 1 and the Same

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We read with great interest Karandeep Sonu Gaind, MD's commentary, “‘Palliative Psychiatry’ and Assisted Suicide: Compassion? Abandonment? Or Something Far Worse?” However, we take issue with Gaind’s mischaracterization of palliative psychiatry. Specifically, we are troubled by his unsubstantiated claim that “palliative psychiatry takes a dangerous turn when discussions invariably lead to advocacy for assisted suicide policies for mental illness.”¹ We assert that palliative psychiatry does not invariably lead to advocacy for assisted dying for mental illness (ie, medical assistance in dying for mental illness as the sole underlying medical condition [MAID-MI SUMC]). To our knowledge, there is no scholarly literature where palliative psychiatry is used to advocate for MAID-MI SUMC policy. More importantly, we object to Gaind’s conflation of palliative psychiatry with MAID-MI SUMC. We believe that mischaracterizing palliative psychiatry as reflected in Gaind’s commentary is likely to perpetuate stigma about the intentions of palliation, confuse palliative psychiatry with end-of-life care exclusively, and lead to barriers in developing a patient-centered, compassionate approach that could offer a potential alternative care pathway for individuals suffering intolerably from mental illness—one that is neither care as usual nor MAID-MI SUMC.

We hope to clarify the aims and scope of palliative psychiatry, rather than to comment on the ethics of MAID-MI SUMC specifically or wade into the debate as to whether MAID should fall under the umbrella of palliative care. We argue that there is nothing about palliative psychiatry that specifically advocates for MAID-MI SUMC and provide evidence defending the rejection of Gaind’s claim.

Palliative psychiatry applies the holistic principles of palliative care to individuals living with severe and persistent mental illnesses (SPMI), such as treatment-refractory symptoms of schizophrenia, severe and enduring anorexia nervosa, or certain affective disorders.^2-4 Palliative psychiatry specifically focuses on quality of life (QOL) by examining how suffering can be alleviated even without reducing symptoms, accepting that symptoms must sometimes be allowed to progress unfettered as treatment is worse than the experience of illness, or both.² This contrasts with general psychiatry, which focuses primarily on symptom reduction for cure or disease modification with improvement in QOL as a byproduct of successfully achieving these goals of care.⁵ Palliative psychiatry is distinct from psychiatry in palliative care, which has been well documented elsewhere.^6,7 Much like palliative care in physical health care, palliative psychiatry intends neither to hasten nor postpone death and is life-affirming.⁸ The congruence between palliative psychiatry and personal recovery is just 1 example of how this care approach takes a life-affirming perspective.⁹

We believe part of the confusion regarding palliative psychiatry and MAID-MI SUMC is because of a narrow and outdated characterization among the lay public and health professionals of palliative care being synonymous with end-of-life care.^10,11 Specifically, individuals tend to incorrectly associate palliative care with abandonment, giving up, lack of hope, and imminent death.¹⁰ Palliative care clinicians, investigators, and organizations have gone to great lengths to dispel this persistent and stigmatizing misperception because the evidence demonstrates repeatedly that these false ideas are a major barrier to access.^11,12 A growing body of evidence suggests that high-quality early palliative intervention for patients with advanced cancer can extend the quantity of life and improve QOL.^14-16 Within mental health care, it is possible that a palliative psychiatry approach—with its explicit directive to reduce suffering—could engage individuals experiencing severe mental illness who would have otherwise rejected care.

There is some qualitative evidence that supports acknowledging and discussing suffering earlier in the course of a mental disorder (a practice consistent with early integration palliative care principles), as it could ultimately prevent patients from considering MAID.¹⁷ Additionally, the Oyster Care Model from Belgium—currently the best operationalized specialized care model exemplifying palliative psychiatry—was created in part because some questioned whether a palliative response to intolerable psychological suffering could be an alternative to euthanasia for individuals with severe mental illness.¹⁸ Evaluations of Oyster Care have shown that patients can feel better with palliative psychiatry intervention, specifically because they experience belonging and not being abandoned.¹⁸ These studies dispute the claim that palliative psychiatry invariably leads to advocacy for MAID-MI SUMC. They highlight the importance of distinguishing palliative psychiatry as a treatment approach much broader than solely providing MAID-MI-SUMC.

Palliative psychiatry models are still developing. The ethical underpinnings of palliative psychiatry must be evaluated in their own right (eg, by interrogating concepts such as futility in mental health care, treatment resistance, and capacity to consent to this plan of treatment), and must not be assumed to converge with those concerning MAID-MI SUMC. As the evidence base for palliative psychiatry grows and further expands into a meaningful, patient-centered, and compassionate alternative approach to care-as-usual or MAID-MI-SUMC, we encourage wider public and health care professional education on knowledge about palliative psychiatry and what it represents.^2,10 A more widespread and better understanding of palliative psychiatry can help counter misleading claims, especially as Canada prepares for MAID-MI SUMC legalization in March 2027. While a palliative psychiatry approach may not be appropriate for all individuals experiencing SPMI, assuming palliative psychiatry invariably leads to MAID-MI-SUMC distracts from developing an innovative care model for individuals who are suffering intolerably from psychiatric symptoms.

Acknowledgements

The authors wish to thank Kathleen Sheehan, MD, DPhil, for helpful comments on an earlier version of the commentary. Both Buchman and Levitt wish to acknowledge the generous support from the Canadian Institutes of Health Research project grant PJT – 195849.

Dr Buchman is a bioethicist and scientist at the Centre for Addiction and Mental Health and an associate professor in the Dalla Lana School of Public Health at the University of Toronto. Dr Levitt is a staff psychiatrist and an assistant professor at the University Health Network and Department of Psychiatry in the Temerty Faculty of Medicine at the University of Toronto.

References

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