The intersection of ethics, psychiatry, and palliative medicine—reflections on a complex relationship

Introduction

The care of patients facing life-limiting illnesses is marked by profound ethical, existential, and psychological challenges. The complexity of the patients’ needs is substantially aggravated in patients who are suffering from pre-existing severe and persistent mental illness (SPMI), particularly when ethical dilemmas are present. Therefore, with this series, we aim to bring together the views and expertise from the field of palliative medicine, psychiatry, and medical ethics to discuss aspects of existential suffering, patient autonomy, and care for patients with complex needs and burdens from different perspectives. With this, we aim to foster a critical dialogue at the intersection of our disciplines, where clinical practice meets ethical reflection and psychiatric expertise.

Palliative psychiatry

In their article, Sarah Levitt and a Canadian-Swiss author team (1) present a fundamental expert consensus on how to define palliative psychiatry and proceed in the clinical, scientific, and educational development of this field. They convey that, obviously, in palliative care and psychiatry, we often share a common central goal of care—to increase quality of life (QoL)—and a holistic, patient-centered approach and attitude. Furthermore, they refer to recent works of the same working group under the leadership of Manuel Trachsel (2,3) that clearly show that SPMI may, in some cases, be understood as a terminal illness. We strongly recommend reading the article for further, intriguing elaborations about the concept of people with lived experience (PWLE), controversies arising from discussions of futility and many other interesting thoughts.

Existential suffering and sedation

Christoph Gabl and the working group from the Austrian Association of Palliative Medicine (4) share a critical review of the ethical controversies around sedation as a potential means of alleviating existential suffering. Depending on the diverging moral background (“personal ethics”) of different health-care professionals, discussions and decisions about whether sedation is indicated for such patients, suffering, for example, from spiritual distress, can lead to profound conflicts and moral distress within multi-professional palliative care teams. Besides careful and detailed ethical and philosophical considerations, the authors discuss clinical uncertainties arising from a simplified understanding of so-called “unconsciousness” under sedation, which has potential practical implications for the questions discussed (i.e., “unresponsiveness is not equal to unawareness”).

Assisted suicide for patients with mental disorders

May assisted suicide be a legitimate choice for patients with mental disorders? This question, which is often perceived as taboo or a last resort, is discussed by Georg Marckmann and Thomas Pollmächer from Germany (5). The authors manage to abstain from black-and-white thinking but approach the topic with the necessary academic clarity, while sustaining a sensitive attitude in their writing. They convey that one of the key questions in the discussions around the wish for hastened death in patients with mental disorders is whether one can claim that these persons are unable to make a free, autonomous decision and to judge the degree of their own suffering and the consequences of death.

Anorexia nervosa in a palliative context

Anna Westermair and co-authors (6) present a structured review about end-of-life care issues in so-called “terminal” anorexia nervosa. The findings illustrate the controversies about what clinicians and ethicists around the world consider “terminal” stages of the disease and whether specific therapeutic measures may be considered “futile”. In their review, they explain that, just as in the article of Georg Marckmann and Thomas Pollmächer (5), the question of whether the decision-making capacity of these patients can be impaired at some stage of the disease is subject to intensive debate and not yet universally answered. In practice, this means that patients with severe anorexia nervosa may not be granted complete patient autonomy by some clinicians and teams, even though this is a fundamental pillar of medical ethics and patient rights. Obviously, this deserves a cautious and meticulous dialectical discussion.

Case report: death from catatonia in refractory schizophrenia?

Finally, Junona Elgudin and her colleagues from the US and Switzerland (7) share their practical experiences with a specific patient whose case touches many of the aspects discussed in the theoretical papers described so far. Here, the patient journey of a 49-year-old man with treatment-refractory psychosis is described who finally died after the decision to withholding life-sustaining treatments during phases of severe malignant catatonia. The latter was decided after a long process of mindful and cautious proxy involvement (parents) and interdisciplinary discussions (psychiatry, palliative medicine, intensive care, and ethics). Reading the case, it becomes evident how closely the disciplines of palliative care, psychiatry, and ethics are interconnected in the care of such patients.

Conclusions

Rather than offering definitive, easy answers, this series seeks to illuminate grey zones and foster thoughtful engagement with contested questions in practice and research. We hope it encourages reflection, dialogue, and awareness among different healthcare professionals in palliative care, psychiatry, medical ethics, and scholars from philosophy and public health. At best, this special series will contribute to the development of more patient-centered care for the affected patients and their significant others, and reduce the severity of conflicts and moral distress among teams caring for these patients.

Jan Gaertner

Manuel Trachsel

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine for the series “Ethics and Psychiatry Meet Palliative Medicine”. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-25-74/coif). The series “Ethics and Psychiatry Meet Palliative Medicine” was commissioned by the editorial office without any funding or sponsorship. J.G. serves as an unpaid Associate Editor of Annals of Palliative Medicine from February 2024 to January 2026 and served as an unpaid Guest Editor of the series. M.T. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Levitt S, Cooper RB, Gupta M, et al. Palliative psychiatry: research, clinical, and educational priorities. Ann Palliat Med 2024;13:542-57. [Crossref] [PubMed]
2. Trachsel M, Hodel MA, Irwin SA, et al. Acceptability of palliative care approaches for patients with severe and persistent mental illness: a survey of psychiatrists in Switzerland. BMC Psychiatry 2019;19:111. [Crossref] [PubMed]
3. Gloeckler S, Trachsel M. Nurses' views on palliative care for those diagnosed with severe persistent mental illness: A Pilot Survey Study in Switzerland. J Psychiatr Ment Health Nurs 2022;29:67-74. [Crossref] [PubMed]
4. Gabl C, Feichtner A, Weixler D. Sedation indicated?-rethinking existential suffering: a narrative review. Ann Palliat Med 2024;13:397-414. [Crossref] [PubMed]
5. Marckmann G, Pollmächer T. Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations. Ann Palliat Med 2024;13:708-18. [Crossref] [PubMed]
6. Westermair AL, Weber S, Westmoreland P, et al. Scoping review of end-of-life care for persons with anorexia nervosa. Ann Palliat Med 2024;13:685-707. [Crossref] [PubMed]
7. Elgudin J, Johnsen C, Westermair AL, et al. Palliative psychiatry for a patient with treatment-refractory schizophrenia and severe chronic malignant catatonia: case report. Ann Palliat Med 2024;13:433-9. [Crossref] [PubMed]