Is Suffering a Useless Concept?

"Suffering" is a central concept within bioethics and often a crucial consideration in medical decision making. As used in practice, however, the concept risks being uninformative, ambiguous, or even misleading. In this paper, we consider a series of cases in which "suffering" is invoked and analyze them in light of prominent theories of suffering. We then outline ethical hazards that arise as a result of imprecise usage of the concept and offer practical recommendations for avoiding them. Appeals to suffering are often getting at something ethically important. But this is where the work of ethics begins, not where it ends.

Developing an Ethics and Policy Framework for Psychedelic Clinical Care: A Consensus Statement.

Importance: As government agencies around the globe contemplate approval of the first psychedelic medicines, many questions remain about their ethical integration into mainstream medical practice. Objective: To identify key ethics and policy issues related to the eventual integration of psychedelic therapies into clinical practice. Evidence Review: From June 9 to 12, 2023, 27 individuals representing the perspectives of clinicians, researchers, Indigenous groups, industry, philanthropy, veterans, retreat facilitators, training programs, and bioethicists convened at the Banbury Center at Cold Spring Harbor Laboratory. Prior to the meeting, attendees submitted key ethics and policy issues for psychedelic medicine. Responses were categorized into 6 broad topics: research ethics issues; managing expectations and informed consent; therapeutic ethics; training, education, and licensure of practitioners; equity and access; and appropriate role of gatekeeping. Attendees with relevant expertise presented on each topic, followed by group discussion. Meeting organizers (A.L.M., I.G.C., D.S.) drafted a summary of the discussion and recommendations, noting points of consensus and disagreement, which were discussed and revised as a group. Findings: This consensus statement reports 20 points of consensus across 5 ethical issues (reparations and reciprocity, equity, and respect; informed consent; professional boundaries and physical touch; personal experience; and gatekeeping), with corresponding relevant actors who will be responsible for implementation. Areas for further research and deliberation are also identified. Conclusions and Relevance: This consensus statement focuses on the future of government-approved medical use of psychedelic medicines in the US and abroad. This is an incredibly exciting and hopeful moment, but it is critical that policymakers take seriously the challenges ahead.

Absence of nonfatal suicidal behavior preceding suicide death reveals differences in clinical risks.

Nonfatal suicidality is the most robust predictor of suicide death. However, only ~10% of those who survive an attempt go on to die by suicide. Moreover, ~50% of suicide deaths occur in the absence of prior known attempts, suggesting risks other than nonfatal suicide attempt need to be identified. We studied data from 4,000 population-ascertained suicide deaths and 26,191 population controls to improve understanding of risks leading to suicide death. This study included 2,253 suicide deaths and 3,375 controls with evidence of nonfatal suicidality (SUI_SI/SB and CTL_SI/SB) from diagnostic codes and natural language processing of electronic health records notes. Characteristics of these groups were compared to 1,669 suicides with no prior nonfatal SI/SB (SUI_None) and 22,816 controls with no lifetime suicidality (CTL_None). The SUI_None and CTL_None groups had fewer diagnoses and were older than SUI_SI/SB and CTL_SI/SB. Mental health diagnoses were far less common in both the SUI_None and CTL_None groups; mental health problems were less associated with suicide death than with presence of SI/SB. Physical health diagnoses were conversely more often associated with risk of suicide death than with presence of SI/SB. Pending replication, results indicate highly significant clinical differences among suicide deaths with versus without prior nonfatal SI/SB.

Conceptual competence in psychiatric training: building a culture of conceptual inquiry.

Building a culture of conceptual inquiry in psychiatric training requires the development of conceptual competence: the ability to identify and examine assumptions that constitute the philosophical foundations of clinical care and scientific investigation in psychiatry. In this article, we argue for the importance of such competence and illustrate approaches to instilling it through examples drawn from our collective experiences as psychiatric educators.

Are Psychedelic Experiences Transformative? Can We Consent to Them?

Psychedelic substances have great promise for the treatment of many conditions, and they are the subject of intensive research. As with other medical treatments, both research and clinical use of psychedelics depend on our ability to ensure informed consent by patients and research participants. However, some have argued that informed consent for psychedelic use may be impossible, because psychedelic experiences can be transformative in the sense articulated by L. A. Paul (2014). For Paul, transformative experiences involve either the acquisition of knowledge that cannot be obtained in any other way or changes in the self. Either of these characteristics may appear to undermine informed consent. This article argues, however, that there is limited evidence that psychedelic experiences are transformative in Paul's sense, and that they may not differ in their transformative features from other common medical experiences for which informed consent is clearly possible. Further, even if psychedelic experiences can be transformative, informed consent is still possible. Because psychedelic experiences are importantly different in several respects from other medical experiences, this article closes with recommendations for how these differences should be reflected in informed consent processes.

What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness?

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.

A Focus Group Study of the Views of Persons with a History of Psychiatric Illness about Psychiatric Medical Aid in Dying.

BACKGROUND: Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with persons with lived experience of mental illness. METHODS: We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team. RESULTS: A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide. CONCLUSIONS: Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk.

Hard Choices: How Does Injustice Affect the Ethics of Medical Aid in Dying?

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of "hard choice," in that death is prima facie bad for the individual and only promotes that person's interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person's life go better. I consider the implications of this view for law and policy regarding MAID.

AI as a Mental Health Therapist for Adolescents.

This Viewpoint discusses benefits and risks of using conversational artificial intelligence platforms to deliver psychotherapy to adolescents.

Does It Matter Whether a Psychiatric Intervention Is "Palliative"?

Palliative interventions are intended to alleviate suffering and improve quality, not quantity, of life and are not intended to cure illness. In psychiatry, uncertainty about which interventions count as palliative stems from the fact that psychiatry generally prioritizes symptom management irrespective of diagnosis or specific pathophysiology of illness. This commentary on a case considers how distinctions between palliative and other psychiatric interventions might not be all that helpful in resolving clinical and ethical questions about which interventions are-and when they are-appropriate.

Medical Assistance in Dying in Neurology.

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

A machine learning approach to identifying suicide risk among text-based crisis counseling encounters.

Introduction: With the increasing utilization of text-based suicide crisis counseling, new means of identifying at risk clients must be explored. Natural language processing (NLP) holds promise for evaluating the content of crisis counseling; here we use a data-driven approach to evaluate NLP methods in identifying client suicide risk. Methods: De-identified crisis counseling data from a regional text-based crisis encounter and mobile tipline application were used to evaluate two modeling approaches in classifying client suicide risk levels. A manual evaluation of model errors and system behavior was conducted. Results: The neural model outperformed a term frequency-inverse document frequency (tf-idf) model in the false-negative rate. While 75% of the neural model's false negative encounters had some discussion of suicidality, 62.5% saw a resolution of the client's initial concerns. Similarly, the neural model detected signals of suicidality in 60.6% of false-positive encounters. Discussion: The neural model demonstrated greater sensitivity in the detection of client suicide risk. A manual assessment of errors and model performance reflected these same findings, detecting higher levels of risk in many of the false-positive encounters and lower levels of risk in many of the false negatives. NLP-based models can detect the suicide risk of text-based crisis encounters from the encounter's content.

Public mental health during and after the SARS-CoV-2 pandemic: Opportunities for intervention via emotional self-efficacy and resilience.

Importance: During the pandemic, the number of United States adults reporting clinically significant symptoms of anxiety and depression sky-rocketed, up from 11% in 2020 to more than 40% in 2021. Our current mental healthcare system cannot adequately accommodate the current crisis; it is therefore important to identify opportunities for public mental health interventions. Objective: Assess whether modifiable emotional factors may offer a point of intervention for the mental health crisis. Design setting and participants: From January 13 to 15, 2022, adults living in the United States were recruited via Amazon Mechanical Turk to complete an anonymous survey. Main outcomes and measures: Linear regressions tested whether the primary outcomes during the SARS-CoV-2 pandemic (depressive and anxiety symptoms, burnout) were associated with hypothesized modifiable risk factors (loneliness and need for closure) and hypothesized modifiable protective factors (the ability to perceive emotions and connect with others emotionally; emotion-regulation efficacy; and resilience, or the ability to "bounce back" after negative events). Results: The sample included 1,323 adults (mean [SD] age 41.42 [12.52] years; 636 women [48%]), almost half of whom reported clinically significant depressive (29%) and/or anxiety (15%) symptoms. Approximately 90% of participants indicated feeling burned out at least once a year and nearly half of participants (45%) felt burned out once a week or more. In separate analyses, depressive symptoms (Model A), anxiety symptoms (Model B), and burnout (Model C) were statistically significantly associated with loneliness (ßModel A, 0.38; 95% CI, 0.33-0.43; ßModel B, 0.30; 95% CI, 0.26-0.36; ßModel C, 0.34; 95% CI, 0.28-0.41), need for closure (ßModel A, 0.09; 95% CI, 1.03-1.06; ßModel B, 0.13; 95% CI, 0.97-0.17; ßModel C, 0.11; 95% CI, 0.07-0.16), recent stressful life events (ßModel A, 0.14; 95% CI, 0.10-0.17; ßModel B, 0.14; 95% CI, 0.11-0.18; ßModel C, 0.10; 95% CI, 0.06-0.15), and resilience (ßModel A, -0.10; 95% CI, -0.15 to -0.05; ßModel B, -0.18; 95% CI, -0.23 to -0.13; ßModel C, -0.11; 95% CI, -0.17 to -0.05). In addition, depressive and anxiety symptoms were associated with emotional self-efficacy (ßModel A, -0.17; 95% CI, -0.22 to -0.12; ßModel B, -0.11; 95% CI, -0.17 to -0.06), and beliefs about the malleability of emotions (ßModel A, -0.08; 95% CI, -0.12 to -0.03; ßModel B, -0.09; 95% CI, -0.13 to -0.04). Associations between loneliness and symptoms were weaker among those with more emotional self-efficacy, more endorsement of emotion malleability beliefs, and greater resilience, in separate models. Analyses controlled for recent stressful life events, optimism, and social desirability. Conclusion and relevance: Public mental health interventions that teach resilience in response to negative events, emotional self-efficacy, and emotion-regulation efficacy may protect against the development of depressive symptoms, anxiety, and burnout, particularly in the context of a collective trauma. Emotional self-efficacy and regulation efficacy may mitigate the association between loneliness and mental health, but loneliness prevention research is also needed to address the current mental health crisis.

Suffering and the dilemmas of pediatric care: a response to Tyler Tate.

In a recent article, Tyler Tate argues that the suffering of children - especially children with severe cognitive impairments - should be regarded as the antithesis of flourishing, where flourishing is relative to one's individual characteristics and essentially involves receiving care from others. Although initially persuasive, Tate's theory is ambiguous in several ways, leading to significant conceptual problems. By identifying flourishing with receiving care, Tate raises questions about the importance of care that he does not address, giving rise to a bootstrapping problem. By making flourishing relative to an individual's circumstances, Tate is forced to confront questions about exactly how relative it can be, suggesting the possibility that, on his view, to flourish is simply to be however one is. In an attempt to surmount these problems, I offer a revision and restatement of Tate's view that defines the relationship between individualized flourishing and the more conventional, species-relative concept, and describe more clearly the role that care should play with respect to flourishing - one that is instrumental and not merely constitutive. Even this restated view, however, fails to answer difficult questions about how one should respond to the medical needs of some children, highlighting the fact that a conceptual analysis of suffering may do little, in the end, to untangle ethical dilemmas in the care of severely ill children.

Epistemic injustice and the psychiatrist.

BACKGROUND: Psychiatrists depend on their patients for clinical information and are obligated to regard them as trustworthy, except in special circumstances. Nevertheless, some critics of psychiatry have argued that psychiatrists frequently perpetrate epistemic injustice against patients. Epistemic injustice is a moral wrong that involves unfairly discriminating against a person with respect to their ability to know things because of personal characteristics like gender or psychiatric diagnosis. METHODS: We review the concept of epistemic injustice and several claims that psychiatric practice is epistemically unjust. RESULTS: While acknowledging the risk of epistemic injustice in psychiatry and other medical fields, we argue that most concerns that psychiatric practice is epistemically unjust are unfounded. CONCLUSIONS: The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.

Should we be leery of being Leary? Concerns about psychedelic use by psychedelic researchers.

Psychedelic research is proceeding rapidly, despite ongoing legal and regulatory barriers and lingering questions about study design, such as the difficulty of ensuring adequate blinding, the relative overrepresentation in studies of participants who have previously used psychedelics, and the importance of personal experience with psychedelics for those who provide psychedelic-assisted therapy. Here we wish to explore a distinct concern: whether personal use of psychedelics by researchers could threaten the objectivity and ethical conduct of psychedelic research itself. In 2020, Anderson et al. suggested that psychedelic use could lead even "conservative individuals to become wildly enthusiastic about the potentials of psychedelics to heal and transform". Recent popular press criticisms of psychedelic science, in particular critiques of the MAPS Phase II and Phase III MDMA-Assisted Therapy trials for PTSD, have also raised questions about whether personal use of psychedelic drugs by psychedelic therapists could compromise scientific objectivity, lead to the exploitation of research subjects, or promote biased reporting of results. Here, we elaborate on and attempt to delimit these concerns, with the goal of informing policy related to psychedelic research and the eventual clinical use of psychedelics. In particular, we explore whether the possibility that psychedelic use can directly and positively affect investigators' enthusiasm about psychedelics themselves raises concerns about bias and scientific integrity. We then discuss several practical strategies to reduce perceived conflict of interest.

Burdening Others.

Many people are afraid they will, as they age or fall ill, become burdens to others. Some who fear this say they would be willing to hasten their own deaths-engaging in self-sacrifice through suicide, assisted suicide, or euthanasia-to avoid it. Still, some bioethicists and other critics of medical aid in dying reject the idea that fear of being a burden can be a good reason for self-sacrifice. They argue that dependency is nearly universal, emphasize that caregiving is a valuable pursuit, and raise concerns about the impact of aid-in-dying policies on vulnerable groups. After defining what it is to be a burden, articulating why being a burden is morally significant, and, crucially, distinguishing burdensomeness from what I call "mere dependency," I defend the intuition that self-sacrifice can be justified by the desire to avoid being a burden and by the concern for the well-being of one's caregivers that this choice implies.

Moral Distress and Involuntary COVID-19 Vaccination of a Mature Minor Receiving Inpatient Psychiatric Treatment.

Mandatory vaccination against COVID-19 is a highly controversial issue, and many members of the public oppose it on the grounds that they should be free to determine what happens to their own body. Opinion has generally favored parental authority with respect to vaccination of children, but less attention has been paid to the ethical complexities of how to respond when mature minors refuse vaccination that is requested by their parents. We present a case in which an mature minor, who was psychiatrically hospitalized, refused vaccination that had been requested by her parents, which lead to significant moral distress for her caregivers.

Three kinds of suffering and their relative moral significance.

Suffering is widely assumed to have particular moral significance, and is of special relevance in medicine. There are, however, many theories about the nature of suffering that seem mutually incompatible. I suggest that there are three overall kinds of view about what suffering is: value-based theories, including the theory famously expounded by Eric Cassell, which as a group suggest that suffering is something like a state of distress related to threats to things that a person cares about; feeling-based theories, which equate suffering with aversive feelings or sensations like pain; and objective theories, which suggest that suffering is the absence of objective flourishing. Rather than argue that one or another of these kinds of theory most accurately captures the nature of suffering, I allow that the term is ambiguous and thus that it may have at least three different kinds. I further argue, however, that when we think about suffering as potentially justifying end-of-life interventions, especially for cognitively typical adults, we are interested mainly in value-based suffering. This is because the moral significance of value-based suffering for persons with decision-making capacity generally outweighs that of the other types; those other types of suffering achieve overriding moral significance only if they also constitute, or contribute to, value-based suffering.