Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

The Bible tells us to lay hands on the sick and they shall recover and will continue to do that without the fear of the spread of any virus. —Pastor Tony Spell, Life Tabernacle Church, Baton Rouge, LA

Can prayer on behalf of those with serious illness be of benefit to a cohort of anonymous recipients? We recently became aware of a randomized, controlled study aimed at answering precisely this question for a population of patients with COVID-19 in the intensive care unit.

 Whatever one’s religious or spiritual beliefs—or lack thereof—this study raises profound questions and concerns for psychiatrists. For example, what is the effect on patients and their families if their prayers for ailing loved ones are not answered? What is the potential for religious and spiritual interventions to relieve—or to exacerbate—the stress of the COVID-19 pandemic? In this article, we explore the double-edged sword of religious and spiritual responses to the pandemic.

The upside of religion and spirituality during the pandemic

 sponsored by the American Psychiatric Association highlighted the adverse psychological effects of the current pandemic and the prominent place of religious faith in addressing these effects.

 The survey results indicate that nearly half of Americans (48%) are anxious about the possibility of contracting coronavirus; about 40% are anxious about becoming seriously ill or dying from coronavirus; and even more Americans (62%) are anxious about the possibility of family and loved ones getting coronavirus. The APA survey is cited in a new 

(DHHS) resource for faith-based leaders assisting their communities to manage the challenges COVID-19 presents to their faith and lives. Importantly for our topic, DHHS cites research that “one in four people who seek help for mental health concerns turn to faith leaders before they seek help from clinical professionals.”

Indeed, there is a long philosophical and historical relationship between religion, spirituality, and healing, as well as a modern body of solid empirical evidence showing the beneficial effects that traditional religion and more contemporary spirituality have on physical and mental health.

 Although there is valid criticism of the methodological limits of some studies—including, for example, the difficulty in establishing causality—most health care practitioners, including mental health professionals, have seen these benefits for many patients under their care.

"One in four people who seek help for mental health concerns turn to faith leaders before they seek help from clinical professionals.”

For example, a rigorous 16-year follow-up study showed that women (N = 74,534) who attended religious services more than once per week experienced 33% lower all-cause mortality, including cancer and heart disease, compared with women who had never attended religious services.

 Li and colleagues noted that, “There may be many pathways from attendance at religious services to health” and that effects on depressive symptoms, smoking, social support, and optimism were potentially important mediators. No single mediator explained more than about 25% of the effect.

Even more pertinent to psychiatry findings from a study published in the 

suggest that persons who endorsed religion and spirituality as being of “high importance” in their lives had only one-tenth the risk for depression (especially recurrent depression), compared with those for whom religion was of less or no importance—no matter the nature of the religious or spiritual beliefs.

This association held true even more strongly if an individual had a depressed parent.

We might just say, all well and good: religion and spirituality, through 1 or more mechanisms, can have a positive impact on heart disease and depression. But how could religious belief and spiritual practice be helpful in the worldwide COVID-19 pandemic when we do not even have a vaccine? Intuitively, it might seem more likely that, in the context of such a devastating plague, certain religious beliefs would only worsen fear and despair—perhaps conjuring up images of apocalyptic plagues and divine punishment for sin, or leading people to feel that God had abandoned them and then to reject religion and spirituality completely.

Although scientific research on this issue is not yet available, news stories and public opinion polls suggest that the picture is actually more ambiguous, and that there is both an up- and a downside to religion and spirituality in COVID-19, as we will discuss in the remainder of this article.

Many mainstream churches, synagogues, mosques, and temples—faced almost overnight with the need to promote public health restrictions and cancel the services that are the heart of much communal worship—

 that reduced isolation and offered solidarity in prayer, medication, and religious reading.

Moreover, a recent Gallup Poll—again belying the scenario that COVID-19 will lead to a loss of faith or negative expressions of religiosity—has found that the COVID-19 crisis has enhanced spirituality and religion for many Americans. During the period when the pandemic was rapidly spreading to many parts of the US (March 28-April 1), 19% of those interviewed felt their faith or spirituality had “gotten better” during the crisis. Commenting on this finding, Gallup senior scientist Frank Newport, PhD,

that “One of the traditional roles of religious individuals and religious entities has been to serve a positive, integrative, pro-social, charitable function in crisis situations.”

The downside of religion and spirituality

In our view, the best available evidence points to a predominantly positive effect of spirituality/religion on mental health and coping, especially during times of crisis. However, as Mosqueiro and colleagues

 observe, “there is also a downside to this relationship . . . [as] religion can be a major source of stress for many people.”

 have described what they call a spiritual struggle in some individuals, defined as “any dysfunctional religious or spiritual belief that is capable of generating or exacerbating suffering.” This is also called negative religious coping and may include religious guilt, the belief that God is malicious, and the fear of [divine] retribution.

In the context of the coronavirus pandemic, clinicians may need to consider the following questions: What happens to religiously oriented people when things go badly, despite their faith and prayer, when for example, a loved one dies of COVID-19 despite the prayers and faith in God of family members? Might the family think that they did not pray hard enough or were not cheerful and positive enough? Or that their loved one was somehow unworthy of being saved? Consider how people of faith—especially someone with a psychiatric disorder, such as major depression, obsessive-compulsive disorder, or posttraumatic stress disorder—would feel if a priest, rabbi, or other religious leader assured them that if they attend a large religious gathering, God will protect them from COVID-19; and later, the individual becomes ill and learns that other members of the congregation—including, the leader himself—have died of COVID-19. This is exactly what befell a respected Virginia pastor who had promised his congregation that “God is larger than this dreaded virus.”

 Not only may the members of that congregation experience an exacerbation of their underlying mental health condition, they may also lose trust in the very community and beliefs that were providing support and purpose.

We are not aware of any systematic research that has examined these questions with respect to the COVID-19 pandemic, which is still at a relatively early stage. However, studying these issues may have important implications for psychiatry and mental health treatment. For example, Rosmarin and colleagues

 found that spiritual struggle (negative religious coping) was a strong predictor of greater symptoms of both depression and mania and appears to be a common and important risk factor for depressive symptoms. However, religious affiliation, belief in God, and frequency of religious service attendance were all unrelated to affective symptoms. These findings suggest that it is not religious belief or religiously oriented behavior per se that negatively affects mood; but rather, the dimension of spiritual struggle and its accompanying cognitions (eg, “God must be punishing me,” “I must be unworthy of being saved”).

Negative religious coping may be more common among faiths and congregations that encourage the belief that people can will themselves into remission from some disease through prayer—and that continued disease is a sure sign that the person has failed in some respect. Thus, Christina Puchalski, MD, MS, FACP, FAAHPM, Director of the 

George Washington University Institute for Spirituality and Health

, reports “I’ve had very religious patients who told me that ‘my church group said I didn’t pray hard enough, because otherwise my diabetes would have been cured.’”

We wonder how such a self-blaming belief may be playing out in very religious patients who are suffering prolonged and severe bouts of COVID-19—but again, we are not aware of research in this area, at this stage of the pandemic. Nevertheless, we note with concern CNN reporter Miguel Marquez’s observation at a recent protest against restrictions imposed in the wake of the COVID-19 pandemic.

 Marquez caught sight of a truck that bore the message, “

 As clinicians, we wonder what happens to people of strong religious faith when the “Jesus vaccine” does not work for them or their families.

Healthy religious and spiritual expression has almost always offered solace in disaster, consolation in bereavement, hope in sickness, and peace in death, for millions of human beings over the millennia. These are powerful reasons why, despite Freud’s prediction in 

 nearly 100 years ago, that religion was a mass delusion that reason would soon banish—religious and spiritual expression has retained its vital significance in human life. Until quite recently, Freud’s view captured the ambivalent, if not frankly adversarial, relationship psychiatry has had, historically, with religious belief. In our view, such animus is not in the best interest of our religiously oriented patients. Fortunately, as Professor of Medical Humanities, Farr Curlin, MD,

 has noted, “This historical antagonism appears to be waning.”

We believe that mental health and religious professionals must work together to help persons of faith toward an authentic understanding of spiritual practice and religious devotion. Furthermore, we believe that certain religiously based misconceptions can actually work against the interests of the patient. For example, a purely instrumental view of prayer can inhibit what we would call the experience of relational openness to God. In this regard, Daniel Sulmasy, MD, PhD,

 a former Franciscan monk and philosopher – physician, has pointed to the danger of “trying to control or manipulate God’s power, even for a good purpose, such as healing . . . .” Dr Sulmasy specifically relates this to the matter we raised at the beginning of this article—that of the “unanswered prayer.” He writes:

Is one to suppose that God is absent from those that are not healed? Should one question the purity, intensity, sincerity, quantity, or duration of these patients’ prayers or of those who prayed for them? From the point of view of true faith, God is never absent from persons who seek him with a sincere heart. Persons whose prayers for healing are not answered with healing should not be made to feel guilty; they must find a way to understand [God’s] mysteries. . .

One approach to these mysteries—especially in some Asian religions and in existential psychotherapy—is to shift the focus of prayer from the narrowness of one’s ego to a wider vision of the self that encompasses empathy for the suffering of others. Religious leaders have urged the faithful to see the immense human anguish and economic dislocation the pandemic has wrought as an invitation to spiritual transformation. Thus, the Abbott of Wat Pasukato—a Buddhist monastery in Thailand, the Venerable Phra Paisal Visalo,

This situation has great potential to help each of us to reduce our selfish behaviors and attitudes and increase our generosity in support of each other. We need to stay connected and encourage people to express their goodness from within, which ultimately helps others.

Like any intervention with the power to effect emotional change, religious and spiritual approaches to serious illness have risks and benefits. As psychiatrists, we need to understand both the positive and negative interactions of religion and spirituality with the particular patient’s physical and emotional needs—and this will likely differ considerably from patient to patient. We can address maladaptive responses stemming from religious guilt and fear, while supporting beliefs and practices that foster hope and resilience. Finally, we believe that psychiatry can play a useful role in re-framing the distressing aspects of the current pandemic in the altruistic and prosocial terms so eloquently expressed by Phra Paisal Visalo.

is Professor, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston, MA; he is Editor in Chief Emeritus of 

 is Professor, Department of Psychiatry and Internal Medicine, and Director of Ethics Education, University of New Mexico School of Medicine in Albuquerque, NM; she is also Health Care Ethicist, Ethics Consultation Service, VA National Center for Ethics in Health Care. She is also an Editorial Board Member of 

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Worshippers go online, those at services keep at distance

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Handbook of Spirituality, Religion and Mental Health. 

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revised ed. New York, NY: HarperCollins; 2005.

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https://twitter.com/miguelmarquez/status/1252262768591491072?lang=en

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The Rebirth of the Clinic: And Introduction to Spirituality in Health Care. 

Washington, DC: Georgetown University Press; 2006.

Senior Thai Monk Offers a Buddhist Perspective on Dealing with COVID-19

Articles

Clinicians may need to consider what happens to religiously oriented people when things go badly, despite their faith and prayer.

The Upside and Downside of Religion, Spirituality, and Health

There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure, say the authors in this rejoinder to Drs Kious and Battin’s "

Response to Physician Aid-in-Dying and the Proper Role of Physicians.

" Also see the original article by Ronald W. Pies, MD; Annette L. Hanson, MD; Mark S. Komrad, MD; and Cynthia M.A. Geppert, MD, MPH: 

PAS Versus Involuntary Commitment: Is There a Moral Dilemma?

for the opportunity to provide a rejoinder to their response." In their 

, Drs Kious and Battin argue that the long-established practice of psychiatrists to make every effort to prevent suicide including the use of involuntary commitment and the relatively new availability of physician aid-in-dying (PAD) create a moral dilemma. Their proposed resolution of the dilemma is to permit psychiatric patients, as well as those with medical illnesses, to access PAD when their suffering is severe and irremediable. Our commentary rejects the fundamental presumption that any physicians, much less psychiatrists, should be involved of the work of killing rather than the calling of healing, among other criticisms.

In this rejoinder, we first dispute some of the practical claims Drs Kious and Battin suggest in their response and then refute their challenges to the philosophical foundations of our position We would favor the term physician-assisted suicide, “PAS,” when referring to our 

 position as more clearly conveying that the practice is incompatible with the professional ethos of medicine.

In their response to our article, Drs Kious and Battin, repeat their claim that involuntary psychiatric commitment for suicide prevention (IPCSP) can in some situations constitute a value judgment about the severity or remediability of a person’s suffering. We believe their description of the relationship of suffering to IPCSP is based on a legal and ethical misunderstanding of the legal and ethical grounds for IPCSP. The warrant for IPCSP is solely contingent upon a person’s 

under the well-established legal doctrines of 

 and the police powers of the state-and is not contingent on any 

 or clinical judgment regarding how “severe and irremediable” a person’s “suffering may be.” In our combined 128 years of clinical practice, we have never seen a case in which a psychiatrist failed to pursue IPCSP, based on the judgment that a mentally competent patient’s suffering was so severe and irremediable as to justify suicide. That is, we don’t say, as clinicians, “Oh, we made a big mistake hospitalizing this patient, because it turns out his suffering is really, really bad and his choice to die is reasonable!”

We agree with Drs Kious and Battin that, like abortion, PAD in contemporary American society may generate irreconcilable differences of opinion. However, we note that abortion does not represent the risk to public health that a suicide contagion poses. Thus, IPCSP can provide protection beyond the effect on the individual patient. Physicians also have a duty to promote and protect the health of the public-not just treat and protect the vulnerable patient. In any case, irreconcilable differences do not warrant abandoning a critical examination of the opposing arguments, given such a momentous departure from traditional medical praxis. For example, we fundamentally disagree with our two colleagues that public opinion is an ethically appropriate means of informing public policy decisions or even more crucially, determining professional norms of physicians.

Polls have not just moral but also methodological problems. Response rates are often low, and typically it is those with the strongest feelings about the issue who respond. Responses are also highly sensitive to the ways questions are worded (eg, “assisted suicide” vs. “aid in dying.”

) The most robust and proper way to explore ethical questions-especially radical shifts proposed in such an enduring and venerable professional ethos as this one-is not by simply doing a “gut check,” and quickly answering a poll. It is by a process of deep examination, study and consultation with a variety of professional experts in philosophy, medical ethics, and sociology, as well as our patients. Medical ethics is not so much about finding the one “right answer” as it is about pursuing the right process.

This “deep dive” is precisely the process that was brought to bear by the 

 (WMA) in their recent reexaminations of their ethical opposition to these practices.

 several times at the request of PAS proponents, and each time, though acknowledging the caring intentions on both sides of the issues, these organizations kept coming to the same conclusion-that these practices are “firmly opposed.” Similarly, for the second largest medical organization in the US-the American College of Physicians

-and even for the organization that works professionally in the “end-zone” of life-the International Association for Hospice and Palliative Care

-these and other articulations, are not mere polls. They are robust deliberations by organizations representing physicians and others, whom society is asking to do the killing. Moreover, no medical organization in the US has actually endorsed PAS as a laudable practice so far. At most, those organizations not opposed to PAS have expressed official “neutrality” on this issue.

Drs Kious and Battin may well be right that general polls of the public do show an increasing trend toward acceptance of PAD. However, the same cannot be said of the professional organizations which are the guardians of the core values of the medical ethics. They are overwhelmingly opposed to PAD precisely because they hold it is antithetical to the ethical identity of physicians as healers. In their response, Drs Kious and Battin incorrectly assume that this conception implies we would “have no role in a how a patient’s death goes.” This is a classic strawman argument. Physicians have an ancient place, standing at the bedside of the dying, palliating pain and offering compassion for suffering-the very meaning of “compassion” is “to suffer alongside.” Where we contend physicians should not stand is where Drs Kious and Battin would have them stand: in the position of bringing about the death of any human being. Palliative care physicians are experts in the relief of the discomfort of dying. That expertise does not require PAD and can successfully manage the very symptoms that are the rationale for PAD.

It is an argument of accident rather than substance to say that physicians have prescribing powers; hence, they must be the ones to administer PAD. States are already authorizing pharmacists to prescribe some medications and can as easily add lethal medications to that list. Our prescriptive privileges have no bearing on our ethical duties when the latter conflict with the purpose for which those medications are prescribed.

Our colleagues are correct that in our initial article, we may not have clearly stated that Drs Kious and Battin do not consider 

 suffering, as potentially justifying PAD, although we feel this does not change the strength of our argument. Nor do we disagree with the claim that, in theory, there is suffering so severe and irremediable that it might legitimate a person’s seeking assistance to die. The vendor of death could be a clergyman or a cousin-or even a cadre of trained “thanatologists” who are not in the house of medicine. Our main argument is simply that 

cannot ethically comply or collude with even the most desperate of requests to end-a patient’s life by suicide.

We now turn to Drs Kious and Battins’ critique of our philosophical position as “essentialism” and “historicism.” If by “essentialism,” they mean that we hold certain medical ethical truths to be constant, enduring, and not “will-o-the-wisp” notions dependent on polls and plebiscites, then, yes-we are guilty of “essentialism.” While we would acknowledge that “evolving social expectations” do have some influence on “what is permissible for physicians,” we would deny that such expectations are infinitely elastic and 

 vis-Ã -vis what is ethically permissible. Would the authors change their 

 position favoring “assisted dying” if new polls showed that most physicians oppose the practice? Or do they base their position in favor of PAS on their own view of what is “essential” to the role of physicians? If we make medical ethics dependent upon polls, we are opening the field to a kind of post-modern relativism that undercuts the very concept of a “profession.” Medical ethics are not a kind of weather vane, changeable with each new poll that comes out! We would argue that PAS is really an outgrowth of, and is contemporaneous with, the consumer movement of the past 50 to 60 years and is therefore an 

It is not the literal wording of the Hippocratic Oath, but the subsequent development of those values that has provided a moral compass for the medical profession. That growth, intellectually and experientially, resembles, for example, the development of religious values, not confined to, but inspired by the esteemed teachers and holy books of the world’s great religious traditions. These are evolving and venerable moral compasses for covenantal communities. The current Tree of Medicine is rooted in its Hippocratic soil. It has ramified branches of thoughts and values yet embodies a core ethos that has persisted through the rise and fall of many societies.

Our colleagues should not so easily dismiss the lessons of history as mere “historicism.” We believe very much in Santayana’s famous wisdom: “Those who cannot remember the past are condemned to repeat it.” Changing social mores and highly popular notions, championed by celebrities, intellectuals, and policy makers, have swept physicians off their ethical moorings in the past. Consider the historic example of Soviet psychiatry. Civil commitment was used to isolate dissidents, and the doctors went along with it. Physicians, especially psychiatrists, participated with relish in eugenics-inspired forced sterilization programs of the mentally ill in the US.

 There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure. Public health policy should not be contingent upon popularity. Many popular ideas were proved both wrong and harmful (eg. conversion therapy for homosexuals).

a physician friend about the social pressure on physicians to kill in the name of mercy, observing that:

The followers of Hippocrates were dedicated completely to life under all circumstances, regardless of rank, age, or intellect-the life of a slave, emperor, foreign man, defective child . . . This is a priceless legacy which we cannot afford to tarnish. But society has repeatedly attempted to make the physician into the killer . . . It is the duty of society to protect the physician from such requests.

Dr Geppert is Professor of Psychiatry and Medicine, and Director of Ethics Education, University of New Mexico School of Medicine; and Ethics Section Editor of 

Dr Komrad is on the psychiatry faculty of Johns Hopkins, University of Maryland, and Tulane University. Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of 

2007-2010). Dr Hanson is Director of the Forensic Psychiatry Fellowship at the University of Maryland.

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

2. Magelssen M, Supphellen M, Nortvedt P, Materstvedt LJ. Attitudes towards assisted dying are influenced by question wording and order: a survey experiment. 

3. Dany L, Baumstarck K, Dudoit E, et al. Determinants of favourable opinions about euthanasia in a sample of French physicians. 

4. World Medical Association. WMA Declaration on Euthanasia and Physician-Assisted Suicide. 

https://www.wma.net/policies-post/declaration-on-euthanasia-and-physician-assisted-suicide

5. Snyder L, Sulmasy DP, Ethics, Human Rights Committee ACoP-ASoIM. Physician-assisted suicide. 

6. De Lima L, Woodruff R, Pettus K, et al. International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide. 

7. Pies RW. Physician-Assisted Suicide and the Rise of the Consumer Movement. 

https://www.psychiatrictimes.com/couch-crisis/physician-assisted-suicide-and-rise-consumer-movement

Keepin America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940.

 New York: Cornell University Press; 2003.

9. Mead M. The Hippocratic Registry of Physicians. 

The current Tree of Medicine is rooted in its Hippocratic soil. There are moral absolutes that our profession should stand up for, in spite of legislative or popular pressure, say the authors.

Psychiatrists Must Prevent Suicide, Not Provide It

Physician-assisted suicide (PAS) violates the norms of Hippocratic medical ethics. Involuntary hospitalization to prevent suicide affirms those norms, according to the authors.

Editor's note: Read the response to this article by Drs Kious and Battin here: 

Physician Aid-in-Dying and the Proper Role of Physicians

, psychiatrist-ethicist Brent M. Kious, MD, PhD, and philosopher-ethicist Margaret P. Battin, PhD,

 present what they see as a “moral dilemma.” Specifically, the authors argue that

Involuntary psychiatric commitment for suicide prevention [IPCSP] and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from non-terminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD.

We wish to challenge this thesis and argue that the supposed “moral dilemma” Kious and Battin suggest is purely factitious. Indeed, it is easily disposed of once the underlying rationale for “physician aid-in-dying”-a 

-is exposed as inconsistent with the values of Hippocratic medicine.

Moral dilemmas typically arise in medicine when two courses of action represent competing goods of roughly equal “weight,” or of commensurate risks and benefits. For example, when only one kidney is available for transplant, and there are two equally appropriate recipients in urgent need of the organ, transplant physicians face a classic moral dilemma.

We do not believe that the seeming conflict between PAS and IPCSP represents such a moral dilemma, because, in our view, PAS does not represent a “moral good” of any kind. That the legislative intent behind the laws underlying these two procedures may be contradictory-or in 

conflict with one another-does not perforce create a “moral dilemma” for anyone, especially physicians. Law and ethics are not necessarily congruent domains. Indeed, Oxford University law professor Charles Foster

 rightly observes that Kious and Battin conflate “. . . the different functions of law and ethics.”

, PAS is ethically impermissible there is no 

 succinctly puts it, “The dissonance stops (and the [Kious and Battin] article’s main complaint is resolved) as soon as PAD is taken off the statute book.”

The putative intent of physician-assisted suicide-to reduce suffering and respect the patient’s autonomy-does not salvage the practice, when viewed through the lens of medical ethics. While reducing suffering and honoring the patient’s autonomy are laudable moral ends, PAS is not an ethical means to these ends. Furthermore, there are alternative means for reducing suffering, which do not entail the moral problems of PAS; eg, state-of-the-art palliative and hospice care, and-in extreme cases-voluntary stopping of eating and drinking (VSED) and palliative sedation.

 We do not accept the moral theory, implicit in the ideology of PAS, that eliminating suffering human beings is an ethically acceptable path to eliminating human suffering. Indeed, once we strip away the anodyne euphemisms of the PAS movement-such as “medical aid in dying”-its philosophy is reduced to the claim that the patient’s self-determination takes precedence over all other moral goods. In our view, this apotheosis of autonomy represents a radical distortion of Hippocratic values.

Assisted suicide and involuntary hospitalization are ethically and legally distinct

We believe that the moral issue regarding PAS is quite clear, consistent with the position of the American Medical Association; the American Psychiatric Association; the American College of Physicians; and the World Medical Association: 

PAS is incompatible with the ethical principles underlying Hippocratic Medicine.

the case with respect to involuntary psychiatric commitment for suicide prevention (IPCSP)-an entirely separate ethical issue from assisted suicide. IPCSP has long been upheld as an ethical means of protecting the lives and well-being of suicidal patients, as the American Psychiatric Association has affirmed.

 Importantly, ethically-based IPCSP is used only when the patient’s life and well-being cannot be secured through less restrictive means. In a move of surpassing perversity, the advocates of PAS turn this ethos on its head by enabling vulnerable individuals to 

 their lives-ostensibly for the sake of their well-being!

And while we have pointedly distinguished legal from ethical issues, it is notable that IPSCP is legal, subject to various limitations and conditions, in 

 US states. IPSCP laws are grounded in the two principles of 

(the authority of the state to protect persons legally unable to act on their own behalf) and the “police power” of the state.

 There is no such broad legal acceptance of PAS in this country, which has legal status in only nine US states and the District of Columbia.

Indeed, almost all states criminalize assisted suicide, and six states specifically outlaw assistance of suicide by physicians.

 Furthermore, in the last ten years, at least nine US states have strengthened their laws against assisted suicide/euthanasia.

 In addition, in the Assisted Suicide Funding Restriction Act of 1997, the US Congress prohibited the use of federal funds to facilitate the practice of PAS;

 and, in 2017, the US House of Representatives introduced a resolution condemning PAS.

 Finally, it is notable that legislative initiatives to legalize PAS have failed more than 125 times in 50 states since 1995.

This is not to say that the matter of IPSCP is ethically uncontroversial, or that it is not subject to misuse or abuse; but its ethical (and legal) status is far different in the US than that of PAS. It is also important to distinguish brief, emergency “holds” or emergency hospitalization (usually 48 to 72 hours) for purposes of psychiatric evaluation from 

. Physicians from any specialty; police officers; social workers; and others with legal standing may initiate an emergency hospitalization, whereas only a judge or magistrate may institute the long-term civil commitment of a patient.

 immediately create conceptual problems for themselves by positing that PAS is “permissible.” We deny that premise, in any 

sense of the term “permissible.” We understand that PAS is 

 in several US states, but we deny that it is morally or ethically permissible 

based on long-standing principles of Hippocratic medicine.

 This immediately renders moot the supposed “moral dilemma” the authors have posited. There may indeed be conflicts that arise as a matter of 

-ie, difficulties reconciling the legislative rationales underlying PAS and IPSCP-but no such conflicts arise within the purview of medical ethics. Indeed, we would take the authors conditional statement (“If PAD in terminal illness is permissible, [then] it should also be permissible for some who suffer from non-terminal psychiatric illness”) and counter with the claim, “If PAS is 

 morally permissible for any patients, then it is not morally permissible for those who suffer from non-terminal psychiatric illness.” This is consistent with the line of reasoning pursued by Prof Foster.

, and there is no “moral crisis” for physicians. Genuine ethical dilemmas present a choice between two equally “right” or good options. Unlike the involuntary hospitalization of suicidal patients, PAS, in our view, is manifestly wrong. In short, there is no “moral equivalence” between PAS and IPSCP; and hence, no “moral dilemma” arises for physicians who oppose PAS but support IPSCP.

Indeed, we have argued that it is morally incumbent upon physicians to oppose PAS.

That a state can legalize physician-assisted suicide, as Oregon has done, highlights the difference between what is legal and what is ethical; what the state allows [state] residents to do and what members of a given profession, in this case medicine, believe they ought to do.

Indeed, in our view, the American Medical Association’s third principle of medical ethics makes it incumbent upon physicians to oppose PAS laws: “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”

“Self-killing” is not the same as physician-assisted suicide

We also take issue with the way Kious and Battin

 have framed the matter of “self-killing.” They argue that, “. . . the implicit rationale for laws allowing PAD in the US is that suffering can be an adequate reason for self-killing; but this implies . . . that suffering due to mental illnesses should at least sometimes be an adequate justification for self-killing, too.”

We certainly acknowledge that psychiatric illness is often a cause of significant suffering, though we would take issue with the very broad claim that either mental or physical suffering “. . . can be an adequate reason for self-killing.” (Is 

 such suffering, even for a day or a week, adequate reason for self-killing? Is suffering that can be substantially relieved with appropriate treatment adequate reason for self-killing?). However, even if it were true that “. . . suffering due to mental illnesses should at least sometimes be an adequate justification for self-killing . . .” it would hardly follow that physicians are acting ethically when they 

in a patient’s self-killing (suicide). Rather, it is our calling as physicians to do all in our power to offer help and give hope to distressed and suffering patients who seek to end their lives.

“Self-killing” (suicide), of course, has occurred in many forms for all of recorded human history. In contrast, physician-assisted suicide is a relative newcomer to medical ethical discourse and is largely contemporaneous with the “

 Self-killing per se has nothing fundamentally to do with the ethics of 

 self-killing. On the contrary: a core ethos of psychiatry is to help people find a path to a better future; mobilize their support systems; and provide other resources to fortify hope. Psychiatry can also play a unique role in helping patients requesting PAS find meaning in their suffering.

 Unfortunately, most PAS laws do not require mental health professionals as part of the initial evaluation process; hence, the unique skill set of psychiatrists is rarely deployed in behalf of the suicidal patient.

For similar reasons, the issue of the patient's “autonomy” raised by Kious and Battin

 proves to be a red herring. For example, they write that, “. . . respect for autonomy is an important part of the justification for the [PAS] laws in Hawaii and other states. . .” But once again, we must distinguish between what underlies 

. Furthermore, even if some notion of “autonomy” led to the conclusion that mentally competent patients ought to be 

 to end their own lives-for example, via VSED

-it would by no means follow that physicians ought to be involved in prescribing lethal drugs to patients who want to end their lives. Nor would such a notion of unimpeded personal liberty amount to a “right” to assisted suicide at the hands of physicians-a right the US Supreme Court (USSC) has said does not exist (eg, in 

, 80 F.3d 716 [2d Cir. 1996]). As the USSC pointedly noted, “The distinction between 

. . . it is clear that the justification for PAD laws in the US, as elsewhere, depends in large part on the recognition that suffering-whether due to painful sensations or to the loss of dignity, self, or independence-can sometimes be an adequate reason to end one’s own life, and that persons who suffer severely because of a terminal physical illness and who retain decision making capacity 

This line of argument radically mistakes the ethical question 

. It is not a question of whether suffering patients “should be allowed to pursue” physician-assisted suicide; clearly, a few states (Oregon, California, etc.) have ruled that they should be. (That PAS is legal in these states does not mean that it is ethically sound or good social policy). Rather, the question is whether physicians are ethically justified 

, the patient’s pursuit of assisted suicide. We say the answer is no, consistent with the numerous professional medical organizations cited above. As Dr Leon Kass

The legalization of physician-assisted suicide [perverts] the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic . . . has held as an inviolable rule, ‘Doctors must not kill.’ The venerable Hippocratic Oath clearly rules out physician-assisted suicide. Without this taboo, medicine ceases to be a trustworthy and ethical profession . . .

Indeed, we would go further and argue that there is very little 

 difference between handing the patient a lethal prescription and handing him or her a loaded gun. (The differences are mainly instrumental and esthetic). Neither action comports with the ethics of Hippocratic medicine. Both shred the fabric of medical ethics beyond repair. Both constitute what Foster

 rightly calls “a distortion of the doctor-patient relationship.”

 suicide-we do not provide it. In the words of Dr Leon Kass,

 “We must care for the dying, not make them dead.”

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor-in-Chief Emeritus of 

). Dr Hanson is Director of the Forensic Psychiatry Fellowship at the University of Maryland. Dr Komrad is on the psychiatry faculty of Johns Hopkins, University of Maryland, and Tulane University. Dr Geppert is Professor of Psychiatry and Medicine, and Director of Ethics Education, University of New Mexico School of Medicine; and Ethics Section Editor of 

The Danger of Assisted Suicide Laws. Part of the Bioethics and Disability Series. National Council on Disability. October 9, 2019. 

Response to Open Peer Commentaries on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry.”

2. Pies RW. Brittany Maynard and the loose language of suicide. 

https://www.medscape.com/viewarticle/835014

3. Pies R. Assisting Suicide is Not Assisting Nature. 

https://pro.psychcentral.com/assisting-suicide-is-not-assisting-nature

Physician-assisted suicide violates the norms of Hippocratic medical ethics. Involuntary hospitalization to prevent suicide affirms those norms, according to the authors.

Cynthia M.A. Geppert, MD, MA, MPH, MSBE, DPS

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