Severe and persistent mental illness (SPMI) is defined as a mental disorder that is resistant to evidence-based interventions and impairs psychosocial functioning (1). Recent years have seen increasing calls for non-curative approaches in mental health care (MHC) for individuals with SPMI, such as assisted dying and palliative psychiatry (2-4). Palliative psychiatry explicitly prioritizes the current quality of life of individuals with SPMI over the traditional goal of MHC, the reduction of core symptoms of the mental disorder. For example, palliative psychiatry might promote providing heroin to individuals with severe opioid dependence to relief suffering from craving and withdrawal (prioritizing this over the reduction of dependence). Another example is letting individuals die from severe anorexia nervosa rather than cause further suffering by coerced feeding.
Palliative psychiatry is justified by the acknowledgment that in some cases of SPMI, there is an inacceptable benefit/burden ratio of further interventions aimed at reducing core symptoms. Prolonged symptom duration, recurring symptom relapse, and unsuccessful treatment attempts all decrease the likelihood of achieving substantial symptom reduction with future attempts, while increasing the likelihood of side effects (5). In cases where MHC professionals expect little improvement with further intervention, especially in the face of very probable harms of treatment, there is often a resulting moral intuition to not proceed with the intervention. Avoiding treatment, however, conflicts with many MHC providers’ sense of obligation to intervene, resulting in significant moral distress and calls for alternative approaches such as palliative psychiatry.
The ethical concept underlying these considerations is futility, which was coined in the wake of rapid advances in life-sustaining measures in Anglo-American critical care medicine (6). Pope (7) distinguishes between physiological futility (no chance of producing the desired biological effect), quantitative futility (very low probability of success), and qualitative futility (lack of benefit to quality of life). While the debate around futility continues in somatic medicine (8), in MHC, it has not even begun.
Despite its demonstrated clinical relevance (9), futility has rarely been explicitly addressed in MHC. This research gap contributes to moral distress in MHC professionals, and increases the vulnerability of individuals with SPMI within health care systems, as they are at risk of both undertreatment (e.g., withheld interventions out of mistaken assumptions of futility) and overly aggressive care (e.g., coerced interventions with inacceptable benefit/burden ratio out of oversight of their futility). This workshop will bring together the necessary stakeholders to begin the discussions necessary to address important ethical questions related to whether and how the concept of futility can be used in MHC.