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

We would like to respond to the article "

 Their article in turn addresses an earlier essay on 

Strouse et al place forms of actively hastening death under the rubric of medical aid in dying (MAID), noting that 10 states and the District of Columbia have now legalized MAID, and that “all current state laws explicitly stipulate that such deaths are not suicide.” Their letter argued for a distinction between decisions to “directly hasten one’s own death” in the context of terminal illness, and what they called “conventional suicides.” Citing work including a statement from the American Association of Suicidology (AAS), Strouse et al argued that suicide is not the same as physician aid in dying, and that—allowing for some overlap—the 2 acts differ on the level of psychopathology. They further suggested clinicians distinguish between conventional suicide and MAID, so that they may “work skillfully and humanely with cancer patients, especially those who are expressing doubts about proposed treatment, or articulating a preference for hastened death.”

We respect Strouse and his colleagues’ clinical experience and humane intentions. However, as psychiatrists, medical ethicists and a palliative care physician (Dr Geppert), we find this thesis deeply troubling. In particular, the focus on state laws ignores the central ethical question of whether physicians’ helping patients kill themselves is ever justified in the context of terminal illness or in any other circumstance.

The notion that 22% of the US population live in a state where MAID is legal is a demographic fact, not a value claim. As Daniel P. Sulmasy, MD, has observed, “data cannot tell a society or a profession what ought to be done” and neither can legislation. This is a consequence of what philosophers call the 

. Sulmasy has said, “Whether just 1 person or 100,000 persons legally avail themselves of lethal prescriptions cannot tell us whether the practice is right or wrong.”

The mere fact that some state legislatures have passed statutes redefining suicide, such that MAID is not suicide, does not prove that this redefinition is conceptually or ethically justified; in fact, several judicial decisions have held this opinion. In 2017, the New York Court of Appeals held that “suicide has long been understood as ‘the act or an instance of taking one’s own life voluntarily and intentionally’ ... Aid-in-dying falls squarely within the ordinary meaning of the statutory prohibition on assisting a suicide.”

 Similarly, in 2016, the New Mexico Supreme Court held that the prohibition against assisted suicide unambiguously covered self-induced death in situations such as those described by Strouse et al.

 (521 US 702, 1997), the US Supreme Court permitted laws prohibiting assisted suicide because of the states’ compelling interest in suicide prevention, effectively equating assisted suicide with suicide.

While redefining suicide averts legal liability for physicians providing MAID, it does not change the essentially unethical nature of the act itself. The term 

 fundamentally means helping patients kill themselves. This is why the American College of Physicians rejects the term and explicitly endorses the term 

 Perhaps even more significant, following a comprehensive evaluation by the Council on Ethical and Judicial Affairs, the American Medical Association (AMA) House of Delegates rejected the term 

 Indeed, the process typically described as MAID in no sense aids dying; on the contrary, it rapidly converts an ill individual into a dead one. This is substantively different than the withdrawal of heroic but nonbeneficial or inappropriate measures, such as the use of ventilators that merely prolong the dying process in the final stages of a terminal illness.

Finally, statutorily declaring that self-induced death via a physician’s assistance is not suicide may soothe the consciences of legislators and allow payouts on life insurance policies; but, perversely, it may also incentivize some terminally ill patients to kill themselves. Furthermore, as Sulmasy

 notes, preliminary reports suggest increased rates of suicide in the general population of states that have legalized PAS. Specifically, “legalizing PAS has been associated with an increased rate of total suicides relative to other [non-PAS] states, and no decrease in non-assisted suicides.”

 Similarly, suicide rates in the Netherlands (where medical euthanasia is legal) have accelerated, compared to neighboring countries that have not legalized medical euthanasia.

Redefining suicide to exclude PAS in the context of terminal illness represents a radical linguistic maneuver that flies in the face of ordinary language, expressed over thousands of years. The Latin 

from which the English word suicide is derived—means the act of killing oneself intentionally or voluntarily. To be clear: we do not deny that there are often psychological and motivational differences between those with terminal illnesses who take their own lives and those who do so in the context of severe psychiatric illness, as the AAS statement details. But in both instances, the act is that of suicide

[A] s a philosopher, I feel an obligation to point out that, as a conceptual matter, there is nothing inaccurate or false about stating that a person who takes a drug, knowing that it will cause her death, and takes it because it will cause her death, is committing suicide on any reasonable conceptual analysis of what suicide is.

The hijacking of ordinary language is becoming increasingly common, such that comforting euphemisms like 

 have replaced the more troubling ordinary language term 

 Accordingly, one might reasonably wonder if the insistence that MAID not be described as suicide betrays some cognitive dissonance regarding the practice, especially on the part of psychiatrists whose duty is to prevent suffering patients from taking their own lives. The 

of many physicians who carry out MAID has been well-documented.

Cognitive Distortions, but No Mandated Treatment

Furthermore, most MAID laws do not require treatment for serious medical conditions, even when it is available to the patient. For example, a patient whose metastatic cancer stands a reasonably good chance of remission with aggressive treatment, but who nevertheless 

, is not required by state laws to undergo the treatment.

 Choosing assisted suicide in such a scenario may superficially appear to be a rational choice; but may instead represent a decision grounded in certain cognitive distortions that also characterize so-called conventional suicide. Importantly, this may be so, even in the absence of a diagnosed psychiatric disorder.

For example, Tomer T. Levin, MD, and Allison J. Applebaum, PhD, noted that some cancer patients may make erroneous assumptions, like, “No one can help me” or “No one understands what I am going through.”

 Such cognitive distortions may respond favorably to cognitive behavioral interventions and potentially avert or abort a request for PAS. Indeed, it has been found that “Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided.”

Unfortunately, in almost every US jurisdiction where PAS is allowed, no attempt to offer treatment by a mental health professional is required by law; and the psychiatrist’s role is typically relegated to ruling out mental illness and 

The Issue Is Not Intractable Pain and Suffering

As Daniel P. Sulmasy, MD, PhD, noted, “Despite public arguments that PAS is needed to avoid excruciating pain and other symptoms, the reasons attributed to patients who seek PAS are not uncontrolled symptoms but lost autonomy, independence, and control.”

 These are forms of psychological distress which, in our view, are best managed with supportive and empathic counseling and/or cognitive behavioral interventions, provided to patients and their families—not by prescribing lethal drugs. Indeed, as Levin and Applebaum pointed out

[T]he root of many patients’ desire for a hastened death may reside in dysfunctional thoughts such as, ‘I get claustrophobic in small spaces like coffins’ and ‘I deserve to die.’ Exploring such cognitions by asking, ‘What are your biggest fears about death and dying?’ will allow the cognitive therapist to reframe dysfunctional thoughts. For example, if the patient worries that death is always painful based his perception of his grandfather’s death in 1975, the therapist might explore how good pain management can facilitate a more peaceful death and contrast the state of palliative care in 1975 versus the advances of the present day.

Even the AAS acknowledges that there is an “undetermined amount of overlap” between the 2 categories of physician aid in dying and conventional suicide.

 Accordingly, we believe that the same precautionary principle that governs public health ought to apply to MAID requests.

This means erring on the side of caution and treating MAID requests from patients with terminal illnesses with the same degree of psychiatric scrutiny and concern that we would bring to any patient’s expressed wish to die. However, in most states, psychiatric assessment is not mandated in the MAID process and does not occur unless specifically requested by the evaluating physician who has initiated the MAID process.. This rarely happens. For example, in Oregon in 2020, only 0.8% of patients who were 

 were referred for psychiatric evaluation.

Moreover, the fairly subtle cognitive distortions described by Levin and Applebaum are unlikely to be detected in a superficial assessment of mental competence. It is no contradiction or paradox to argue, as we have, that pronouncing a patient qualified or competent for MAID is a violation of psychiatric ethics, since this unethically colludes with the process of aiding a patient’s suicide. Psychiatric involvement in end-of-life care is indeed essential, but it should remain well outside the procedures and processes involved in MAID deliberations.

Reducing Stigma vs Shifting it to the Other

Strouse et al emphasized that, “Most importantly, they [MAID laws] are intended by lawmakers to help avoid the stigma of suicide.” we agree that there is societal stigma associated with suicide, as the AAS recognizes. This, the AAS asserts, is in contrast to attitudes surrounding physician aid in dying

: “Death by suicide is often associated with substantial social stigma... [whereas] where it is legal, PAD is typically well accepted within the community and society at large.”

We infer from their commentary that Strouse et al would agree with the AAS claim (and co-author Margaret Battin, PhD, is a signatory to the AAS statement). Although well-intentioned, the AAS position and that of Strouse et al may have the unintended effect of increasing stigma directed toward those who attempt or complete a non-MAID suicide. In our view, creating a binary distinction between MAID and conventional suicide tends to marginalize individuals in the conventional group as “the Other.” This position may suggest to the general public that suicidal individuals with mental illness value their lives less than those with terminal physical illnesses—a claim we reject.

Indeed, as numerous suicide prevention websites 

: “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.”

 We would suggest that the same may be said of at least some individuals with cancer who seek MAID. Whenever complex ethical dilemmas are formulated as black-and-white categories, the many grey instances are often misclassified, with tragic consequences.

In short, the AAS position may have the perverse effect of merely shifting societal stigma from one group—those with terminal medical conditions—to those whose suicidal behavior occurs in the context of psychiatric disorders. We do not need such a 2-tiered classification, in which there are good and bad methods of taking one’s own life.

Moreover, we believe that such a dichotomy would likely magnify disparities in end-of-life care in resource-poor areas, where MAID would be far less expensive than sustaining palliative care. The AAS position may also weaken the motivation and rationale for suicide prevention, during a period when suicide rates have been rising in the US.

 We believe that efforts to promote MAID would be better directed toward destigmatizing the mental illnesses that underlie the majority of suicides and toward bolstering the availability of state-of-the-art palliative care.

The American College of Physicians has said

Physician-assisted suicide is neither a therapy nor a solution to difficult questions raised at the end of life. On the basis of substantive ethics, clinical practice, policy, and other concerns, the ACP does not support legalization of physician-assisted suicide. … However, through high-quality care, effective communication, compassionate support, and the right resources, physicians can help patients control many aspects of how they live out life's last chapter.

Like the ACP, we reject the implication that merely legalizing MAID somehow means that it is consistent with ethical medical practice. Quite the contrary. As physician and ethicist 

, MD, has pointedly cautioned: “We must care for the dying, not make them dead.”

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and Editor in Chief emeritus of 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland; a clinical assistant professor of psychiatry at the University of Maryland; and a member of the teaching faculty at Tulane University in New Orleans, Louisiana. 

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College, and serves as the Ethics Editor for 

is Director, Forensic Psychiatry Fellowship, University of Maryland, Baltimore, MD.

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. June 11, 2021. Accessed June 20, 2021. 

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8. Jones DA, Paton D. How does legalization of physician-assisted suicide affect rates of suicide? 

9. Boer T. Does euthanasia have a dampening effect on suicide rates? Recent experiences from The Netherlands. 

10. Dworkin G. Suicide, strictly speaking. 3 Quarks Daily. July 22, 2019. Accessed June 23, 2021. 

11. Koch T. The ethicist as language czar, or cop: "end of life" v. "ending life". 

12. Pies RW. How does assisting with suicide affect physicians? 

. January 7, 2018. Accessed June 20, 2021. 

13. To live each day with dignity: a statement on physician-assisted suicide. United States Conference of Catholic Bishops. June 16, 2011. Accessed June 23, 2021. 

14. Levin TT, Applebaum AJ. Acute cancer cognitive therapy. 

15. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2019 Data Summary. February 25, 2020. Accessed June 23, 2021. 

16. Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. 

17. Cerel J, Battin MP. Statement of the American Association of Suicidology: “Suicide” is not the same as “physician aid in dying.” American Association of Suicidology. October 30, 2017.

18. Martuzzi M, Bertollini R. The precautionary principle, science and human health protection. 

19. Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act: 2020 Data Summary. February 26, 2021. Accessed June 23, 2021.

20. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. 

21. Macomb County Suicide Prevention Coalition. Holding onto life toolkit. Accessed June 23, 2021. 

22. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999-2018. 

23. Snyder Sulmasy L, Mueller PS, Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians Position Paper. 

A comparison of physician-assisted/Death-with-Dignity death and suicide patterns in older adult women and men

Are physicians who assist in suicide betraying their professional values?

. June 15, 2021. Accessed June 23, 2021. 

Pies RW, Hanson A. Twelve myths about physician assisted suicide and medical aid in dying. 

https://www.hcplive.com/view/twelve-myths-concerning-medical-aid-in-dying-or-physicianassisted-suicide

Articles

Should psychiatrists help patients end their own lives, even if it is technically legal? 

Against Assisted Suicide 

The fairest rules are those to which everyone would agree if they did not know how much power they would have. – John Rawls

When the welcome news of effective vaccines for COVID-19 arrived in December 2020, the country shared a collective sigh of relief. Yet, the hard work was still in front of us. One fact always remains true in medicine: We have limited resources (ie, manpower, medications, hospital beds, organs, etc) with which to treat the population. In this instance, the overriding question was how would we, as a society, determine who gets the first shots?

Three primary ethical frameworks have guided COVID-19 

 and prioritization in the United States: those formulated by the Centers for Disease Control and Prevention (CDC),

 and Johns Hopkins University’s Center for Health Security.

Unfortunately, a review of the frameworks reveals a relative 

 with serious mental illness (SMI) and the practitioners who treat them.

 This raises many important questions: How is it that, yet again, patients with SMI and substance use disorders (SUD) have been marginalized, in this instance from vaccine allocation protocols? What are the clinical and ethical imperatives to ensure there is equity in access? And how can mental health professionals promote a true community of immunity?

The 3 frameworks’ prioritization schemes are summarized in 

, and a quick study of the interrelated epidemiological and ethical grounds upon which they are based makes it even more surprising that there is no explicit inclusion of patients with SMI and SUD. Phase 1b of the National Academy of Sciences framework prioritizes adults with comorbid conditions that place them at significantly higher risk of illness and death from COVID-19, as does phase 1c of the CDC guidance. Johns Hopkins also places in tier 1 those at greatest risk of severe illness and death, and their caregivers. Results of high-quality research conducted before the pandemic have repeatedly identified that patients with SMI have life expectancies 25 years lower than those of the general population, mostly due to rates of medical comorbidities that are 2 to 3 times higher than average.

Table 1. Empirical Facts and Ethical Reasoning Supporting Prioritization of SMI for COVID-19 Vaccination

A study of more than 25,000 patients showed that even in the integrated Kaiser health care system, patients with SMI were 1.5 times more likely to have a number of serious and chronic health conditions, including obesity, diabetes, and cardiovascular disease.

 Many of these same conditions are associated with a higher risk of 

 Indeed, data from China indicate that the SMI cohort is at higher risk of contracting the virus, developing severe cases of COVID-19, being hospitalized, and dying.

 Individuals with SUD, especially opioids, are also at elevated risk of serious illness and death both from COVID-19 and overdoses related to pandemic-induced isolation and stress. Yet so far, in terms of SUD, states have prioritized only those with tobacco use disorder.

Phase 2 of the National Academy of Sciences prioritization scheme does specifically list and include individuals in homeless shelters and group homes; those with disability and mental illness; and those in prisons and jails. These populations are often overlapping: The percentage of 

patients with serious mental illness who are homeless

 and the prevalence of mental illness among those incarcerated in jails and prisons is between 15% and 20%.

 When the first wave of the virus hit New York, the strongest factor associated with case fatality rates, after age, was schizophrenia spectrum disorders.

These figures alone would support giving individuals with mental illness prioritization for vaccination. Vaccination of the significant population of individuals with SMI who live in various congregate settings is often the most feasible, and hence ethically compelling, means of protecting residents and caregivers from the virus. Many patients with SMI may find it extremely difficult to adhere to strict infection control protocols, and limited access to mental health care may lead to worsening of symptoms that then magnify risk of infection.

The intrinsic symptomology of SMI and substance use—such as paranoia, apathy, depression, and disorganization, as well as the psychosocial context that existed even before the pandemic, such as isolation, poor self-care, unemployment, and fear of the medical establishment—makes this population meet almost every definition of vulnerability.

 opined that the adverse social determinants of health for the SMI population are so entrenched and significant that, ethically, they should constitute a distinct category of health care disparity. If such a designation were formally recognized, it would obviously require vaccine and other potential therapeutic allocation frameworks to rethink the prioritization of SMI.

In the past, thought leaders as diverse as Pope John Paul II and President Harry Truman stated, in essence, that “a society will be judged on how it treats its weakest members.” Prioritizing 

 for individuals with SMI and SUDs, people who have long borne a stigma in American health care, promotes the “equal concern” principle of the National Academies. This principle encompasses the idea that every individual has intrinsic worth, dignity, and value, and such prioritization would answer the CDC’s call to remove unfair and avoidable barriers to vaccination as a matter of justice. Even when the scenario is viewed from a classic public health ethics perspective—as De Hert has persuasively argued—protecting the health of the public requires reducing exposure among those cohorts with high probability of exposing others, and among those least likely to take steps to prevent transmission of the virus.

Given these formidable scientific and ethical arguments for the vaccination of those with SMI and SUD, their comparative neglect in major allocation frameworks likely reflects long-standing systemic social determinants of mental health treatment. These determinants have resulted from lack of economic parity, intrinsic social stigmatization, cultural bias, absence of legal representation, and political disenfranchisement, among many other complex and unjust causes.

The ethical impetus to ensure COVID-19 vaccinations for individuals with SMI and SUD becomes even more urgent when the external and internal obstacles to vaccination among this population are considered. These obstacles are far more formidable than those facing other cohorts who are ranked higher in the allocation protocols. There is a disturbing dearth of research on routine preventive vaccination in the SMI and SUD population, although it is known that the cohort has very low rates of routine vaccination relative to the general population. More encouragingly, results of a recent pilot quality improvement project, involving a collaboration with the local public health department, increased preventive vaccination rates in a community outpatient mental health clinic.

 Recent articles offer recommendations for overcoming systems- and individual-level barriers to COVID-19 vaccination for individuals with SMI and SUD, respectively (

Table 2. Obstacles to Vaccination (and how to overcome them)

Individuals with SMI and SUD lacked parity in health care before the pandemic, and COVID-19 has massively exacerbated existing inequalities. These individuals often do not have access to the primary means of health care delivery and of arranging vaccine appointments in the pandemic: electronic communication technology. Patients with SMI often lack the knowledge, skill, and infrastructure to utilize it even when it is available. Internal obstacles only compound these external barriers. These include mistrust of the health care system (due to past histories of abuses), low health literacy about COVID-19, and lack of information about the vaccine. A recent set of interviews with individuals with SUDs assessed vaccine readiness and identified significant mistrust among respondents.

 In 2020, the Addiction Policy Forum interviewed 87 individuals about their readiness to receive the COVID-19 vaccine; all were either using substances, in treatment for substance use, or recovering from substance use disorders. Just 45% said they were ready immediately; of the rest, 8% said they would be ready after a delay, 23% were uncertain, and 25% were unwilling to take the vaccine. The reasons participants offered to explain their 

 included concerns about the rapid development of the vaccine, potential adverse effects, potential interactions with current medical problems, doubt that they were at serious risk for developing COVID-19, and mistrust of the government.

Not only patients with psychiatric disorders but also the practitioners who treat them have reason to fear being in the back of the vaccination queue. Health care workers are in phase 1a of the CDC guidance, high-risk health workers are in phase 1a of the National Academies of Science allocation protocol, and Johns Hopkins includes in tier 1 those most essential to sustaining the ongoing COVID-19 response. While most readers of 

 would likely assume that psychiatrists and other mental health practitioners would be included in all of these phases/tiers, this assumption was not widely shared outside of circles of mental health professionals.

In December, right after the United States Food and Drug Administration’s emergency use authorization of the Pfizer vaccine, Forbes reported that mental health workers feared they would be left out of vaccine protocols.

 This is because state governments exercise considerable independence in how closely they follow national recommendations for allocation. Public health officials and those in the media may not appreciate that, from the beginning of the pandemic to this day, psychiatrists and other mental health professionals have been 

 of intensive care units and emergency departments treating patients, often doing so without adequate personal protective equipment.

 Many other mental health practitioners were repeatedly exposed to high-risk patients whose disorders made them unable or unwilling to follow infection-control practices or to take advantage of telehealth options, necessitating in-person visits at community outpatient clinics, inpatient psychiatric units, residential care facilities, and substance use treatment programs.

In response to this neglect of the mental health workforce in vaccine allocation schemas, the National Association of State Mental Health Program Directors, the National Council of Behavioral Health, and the National Mental Health Corporations of America wrote to Robert R. Redfield Jr, MD, then the CDC director, prior to the Advisory Committee on Immunization Practices issuance of its allocation framework. The mental health organizations 

 that mental health practitioners “should be categorized as frontline providers, therefore making them eligible to receive COVID-19 vaccine in its earliest phase of distribution.”

 In May 2020, Elinore McCance-Katz, MD, PhD, who at the time was assistant secretary for Mental Health and Substance Use, had already 

 “that the services provided in mental and substance use disorder treatment programs across the country are essential medical services.”

The American Psychiatric Association (APA) has joined these organizations in calling upon its members to actively promote equity in COVID-19 vaccine allocation, issuing a 

 The document affirms that “psychiatrists are uniquely positioned to address many of the public health challenges” that prevent the ideal of equitable vaccine distribution from becoming a reality. The APA lays out practical advice to help psychiatrists educate and counsel their patients about vaccination, including information on how to locate and obtain vaccination in various states.

Psychiatrists know better than almost anyone that an efficacious vaccination campaign directed toward patients with SUD and SMI is necessary but not sufficient to ensure shots in arms. What is most crucial to overcoming vaccine hesitancy and encouraging motivation in these populations is to build on the strength of the therapeutic alliance. Patients trust the recommendation of their psychiatrists or other mental health professionals about vaccination.

 There is a compelling obligation for mental health professionals to talk to their patients at every possible opportunity about the benefits of COVID-19 vaccination using a technique I call “The 4 Es” (

Psychiatrists who work in integrated care settings, hospitals, and public health clinics are ideally placed to educate medical colleagues and public health officials about the ethics of COVID-19 vaccination for persons with SMI and SUD. Similarly, local departments of psychiatry and professional societies can provide information explaining that these 2 groups are at elevated risk of COVID-19, and that many individuals within these cohorts—with appropriate facilitation—will accept the vaccination and should have it offered to them, along with other marginalized populations.

As the momentum for mandatory vaccination gathers, psychiatrists have an ethical duty to uphold the values of informed consent and autonomous decision-making among individuals with SUD and SMI, who may be at elevated risk of coercion.

 For example, generally speaking, vaccination should not be required for voluntary admission to a psychiatric hospital or residential treatment program. Instead, staff should work collaboratively with the patient to persuade them to understand how vaccination meets their own treatment goals and also protects their fellow patients and caregivers.

The national vaccine rollout is showing signs of success, even while premature abandonment of public health measures and the growing dominance of variants threatens a 

 Our advocacy on behalf of our patients and our profession can significantly shift the direction of the pandemic, and even further, set a precedent for the infectious disease outbreaks that are unfortunately inevitable in the future. Securing equity for our patients and ourselves in COVID-19 vaccination is also a critical step in the long and vital walk toward the larger goals of destigmatization and justice in psychiatric care. For patients with SMI and SUD and those who care for and about them, COVID-19 may fulfill both meanings of a crisis: It is a challenge and an opportunity. The pandemic can serve as professional impetus and ethical rationale to redouble our efforts to achieve equity, so that when the next public health emergency strikes, we are all encompassed in the community of immunity.

is a professor in the Department of Psychiatry and Internal Medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is also a health care ethicist with the Ethics Consultation Service of the Veterans Administration National Center for Ethics in Health Care, and an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College.

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How can mental health professionals promote a true community of immunity?

What About Us? The Marginalization of Serious Mental Health and Substance Use

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.

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

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

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