Christiane Burmeister¹, Sarah Kayser², Florian Funer¹

¹ Institute for Ethics and History of Medicine, University of Tübingen

^{2 Department of General} Psychiatry and Psychotherapy with Outpatient Clinic, University Hospital Tübingen

The approach to the care of people with severe and persistent mental illness (SPMI), discussed under the term ‘palliative psychiatry’, is based on far-reaching ontological, epistemological and normative assumptions. Central to this is the application of a distinction, familiar from somatic medicine, between curative and palliative forms of therapy to psychiatric treatment strategies. The assumption is that certain patients, due to the severity, chronicity and treatment-resistance of their condition, can realistically no longer be considered curable. In such cases, the statistical evidence of increased mortality and suicide rates is interpreted as the functional equivalent of a fatal somatic diagnosis. Consequently, a primarily palliative treatment approach – focused on symptom relief, reducing suffering and improving quality of life – is said to be preferable to a curative approach.

However, this line of argument raises fundamental questions about the understanding of illness and prognosis in psychiatry, particularly with regard to the specific temporal structure of mental illnesses. Unlike many somatic illnesses, the course of psychiatric disorders is often characterised by non-linearity and long-term uncertainty, which can only be reflected to a limited extent in statistical prognoses. Equating statistical increases in risk with individual ‘fatalism’ risks normatively closing off this temporal openness. Furthermore, the particular performative effect of classification as ‘palliative’ and its influence on therapeutic dynamics must be examined.

The aim of this lecture is to systematically bring together the often fragmented strands of discussion on ‘palliative psychiatry’ and to make explicit their ontological, epistemological and normative premises. The objections raised are not intended to reject palliative psychiatry concepts, but rather to critically examine their plausibility, scope and risks. On this basis, the aim is to explore under what conditions the distinction between curative and palliative approaches in psychiatry can serve as an ethically sound, time-sensitive and therapeutically responsible guiding principle.