Any claims by psychiatrists1 to be able to improve people morally should be extremely modest. It is helpful to be reminded that psychiatrists have attempted to do this and still do so, nowadays usually unconsciously or implicitly. In fact where therapeutic approach embodies moral positions, as clarified for the psychoanalytic tradition by Edward Harcourt2, it is important for these to be made explicit so that they can be scrutinised.
People coming to see a psychiatrist are often in a personal crisis, whatever its cause (which may include the effects of mental disorder as well as factors in their lives contributing to that disorder). They may as a result may be driven to re-evaluate their lives, their choices and their relationships (there are parallels with the impact of serious physical illness and confrontation with disability and mortality). In fact any serious illness or intimation of mortality may generate the same kind of self-questioning. Such people are clearly faced with moral questions, whether that be regarding specific decisions, balancing their own needs with those of others, making hard choices or making amends. How they address these things will form part of their recovery and shape it. An important difference between physical and mental illness is that people living through the latter are more likely to be lonely, relatively unbefriended, isolated and short of support from family, friends or other social circles, or indeed alienated from them. They are thus at once more vulnerable and more likely to seek guidance from a mental health worker, and mental health workers may be more tempted to give it.
In my view psychiatrists should be wary of seeking directly to improve people morally in such situations, and concentrate on treating their mental disorder. Improvements in someone’s moral condition should be seen as a bonus rather than the goal. Psychiatrists, psychoanalysts and psychotherapists do not have a plausible claim to be more moral than anyone else, and most people are fortunate enough to find people elsewhere in their lives who act as some kind of moral touchstone, be they a parent, another relative, a friend, a teacher, a mentor, a work colleague, a priest, someone else who shows them kindness or indeed a public figure with whom they can strongly identify. Again, these sources of help may be less available to people to people with mental disorders
One way in which a psychiatrist or anyone offering a therapeutic alliance may contribute to someone’s moral understanding is through their own behaviour, for example by being honest, trustworthy and reliable, and concerned. In this way some rudiments of a model for other relationships may be seen. Beyond this, the psychiatrist job is usually to help people to break out of social isolation so that they do break out of their isolation and so find a wider range of non-professional people who can act as their sounding boards.
(It is interesting that some people who are very dismissive of the judgments made of their behaviour by others, have quite high expectations of doctors and therapists, in terms of confidentiality, punctuality and access to certain goods and services).
A further consideration which should encourage humility in any psychiatrist inclined to guide their patients morally is that their patients most often will be in a less favourable socioeconomic position than they are. This does not mean that they have no choices, but the range of choices open to them is likely to be narrower. This will have implications for the morality or otherwise of, for example, benefit fraud, or sex work, or breach of Covid-19 restrictions, or indeed of abortion.
Drug treatments in psychiatry may restore people’s level of concern for and awareness of the needs of others, but this is no different from the effects eg of analgesics in relieving somatic pain, which also makes people withdraw into themselves. In a wider sense, it could be said that morals depend on morale, in that relative freedom from pain, optimism of the will and a sense that change is possible are likely to be associated with a more generous and courageous spirit.
With respect to drugs given specifically to enhance moral behaviour, the studies in this area are limited by the way they measure moral decision-making, and the lack of a demonstrable link between the answers given to questionnaires and any sustained difference in behaviour3. In addition, when people use alcohol or another drug to give themselves the courage to say or do something difficult, or to seek a spiritual experience, there does have to be first the wish to take that challenge or make that decision. This applies to some studies of psychedelic drugs.
There is a more general point here. As Kant noted, changing in a desirable direction this or that quality in a person is no guarantee of moral behaviour:
Moderation in the affections and passions, self-control, and calm deliberation are not only good in many respects, but even seem to constitute part of the intrinsic worth of the person; but they are far from deserving to be called good without qualification, although they have been so unconditionally praised by the ancients. For without the principles of a good will, they may become extremely bad, and the coolness of a villain not only makes him far more dangerous, but also directly makes him more abominable in our eyes than he would have been without it.4
In the forensic arena, improvements in moral awareness and behaviour are again likely to arise as a bonus effect of treatment broadly understood, which includes physical restrictions for periods of time. It is important here to consider how constraints of certain kinds – prison, probation – may themselves play a part in moral improvement, for example by creating a space for enforced reflection, or by giving someone what may be the novel experience of being held to account for their behaviour. Such benefits should probably not be exaggerated.
When attempts have been made specifically to change the mental and moral set and behaviour of people with severe antisocial personality disorder, the results have not been encouraging5. A different approach, used with prisoners identified as having PTSD arising from their violent offending, appeared to be more promising as a way to open up a route to reflection and consideration of the impact on victims6. However this depended on the prisoners being willing to enter the treatment programme in this first place, which recalls the maxim that for someone to be open to arguments for acting in a good way they have first of all to recognise a distinction between acting in a good way and acting in a bad way.
An important influence on moral growth not mentioned in the article is that of the group. Most obviously this can be seen at work in settings such as AA, but also in group therapy more generally, which traditionally is supposed to make people more mature, rather than less neurotic as with individual therapy. Since morality is about interpersonal behaviour, it is not surprising that it is transmitted largely through groups, starting with parents then extended family then school, then social clubs, workplaces, sport and so on. Clearly the kind of lessons learned vary widely depending on the nature of these groups in practice, but they are likely to be much more influential than individual instruction.
For nine years I ran a weekly group for patients on a mixed-gender acute admission ward in a very ethnically and socially diverse town. This had a number of benefits, one important one being a continuing effort to develop at least a minimum morality for co-existence on the ward, through a mixture of discussion and, where it could be tolerated, group feedback to participants about their behaviour. The basic principles modelled were modest but important: the right to have your say, the right to be listened to and basic courtesy. Expressions of care and concern in this setting could be powerful and moving.
A more ambitious and articulated use of group therapy in an inpatient setting was described by Bion and Rickman in a military hospital in World War ll7
The effect of this approach to the problem of neurosis was considerable. There was a readiness, and sometimes an eagerness, to discuss both in public and private the social implications of personality problems. The neurotic is commonly regarded as being self-centred and averse from cooperative endeavour; but perhaps because he is seldom put in an environment in which every member is on the same footing as regards interpersonal relationships.

It is possible that psychiatrists could benefit from training in normative moral theories, but the effect of such training might be to make them less rather than more enthusiastic about direct effects to influence their patients’ moral development.

1. McConnell and colleagues refer to ‘psychiatry’, but these matters are relevant to all mental health professionals
2. Harcourt E 2015 The Place of Psychoanalysis in the History of Ethics Journal of Moral Philosophy
3. Crockett MJ et al 2010 Serotonin selectively influences moral judgment and behavior through effects on harm aversion https://www.pnas.org/doi/10.1073/pnas.1009396107
4. Kant E 1785 Groundwork of the Metaphysics of Morals
5. Tyrer P et al 2015 The lessons and legacy of the programme for dangerous and severe personality disorders Personality and Mental Health 9:96-106
6. Evans C et al 2007 Intrusive Memories and Ruminations Related to Violent Crime Among Young Offenders: Phenomenological Characteristics Journal of Traumatic Stress 20:183-196
7. Bion WR, Rickman J 1943 Intra-group tensions in the therapy: their study as the task of the group Lancet 242: 678-682

As a retired palliative care physician, I am puzzled by several aspects of this article. First, authors’ choice of terminology: ‘terminal sedation’ and ‘expanded terminal sedation’. It is more than 20 years since the use of the former began to be discouraged because of perceived ambiguity, and replaced by ‘palliative sedation’ (PS)[1] – as reflected in current professional guidelines.[2] And despite dissenting voices,[3] most clinicians would probably consider ‘expanded terminal sedation’ to be ‘slow euthanasia’.
PS was used to describe a deliberate switch from escalation of symptom management to a deliberate reduction in a patient’s level of consciousness in order to ease otherwise intolerable refractory suffering in ‘imminently dying’ patients. The sedation varied from light to deep depending on individual need. Some guidelines refer to ‘intermittent’ as well as ‘continuous’ sedation. Recently, because of the lack of clarity in many reports, there’s been a trend towards limiting discussion to ‘deep continuous sedation until death’ (CDSUD) – the most contentious aspect of sedation near the end of life.
Second, it may be correct that ‘the Doctrine of Double Effect (DDE) continues to shape much of the ethical and legal literature concerning end-of-life care’ (EOLC), but what about the medical literature? Would it surprise the authors if I say that, when a practicing clinician, I never agonized about ‘double effect’? As they noted, DDE was originally formulated to exonerate someone who, when acting in self-defence, injured an assailant. The principle is universally applicable, not limited to medicine or EOLC. The practice of medicine would be impossible without it: all treatment has an inherent risk and, inevitably, sometimes things will go wrong and result in unintentional harm to a patient. However, to say that DDE can ‘justify’ a specific treatment is incorrect. Treatment is justified by necessity (not by DDE) and, accordingly, should always be proportionate to need – but this does mean it must always be ‘gradual’ and never ‘rapid’.
Doctors are committed to sustaining life when feasible and always seeking to relieve suffering. We cannot stand by and do nothing. Even so, we must work within the broad medical principles of ‘do good; avoid or minimize harm’ (beneficence and non-maleficence) [4]. Thus, I strongly agree with the authors when they say that the relief of suffering is a fundamental goal of EOLC. However, I disagree that some dying patients continue to suffer ‘despite the technical knowledge and ability to pharmacologically relieve suffering’ (my italics). The relief of suffering demands an holistic approach by health carers – embracing the physical, psychological, existential and social dimensions of personhood. Particularly in relation to existential suffering, skilled personalized psychological support is essential [5]. Drugs play only an ancillary role.
Indeed, the fictitious case history suggests that the authors – none of whom is a palliative care specialist – are unaware of the full range of possibilities available to clinicians when caring for a patient with severe unrelenting existential distress. Palliative care doctors generally are reluctant to offer CDSUD for existential suffering alone because (a) it is impossible to be sure that the suffering is refractory (generally it is responsive to holistic treatment [5]), and (b) the estimated prognosis tends to be months rather than days.
However, such patients may well benefit from respite sedation. Thus, for a young woman with end-stage cancer who was finding life intolerable (very similar to the case history in the article), I suggested that, because of her much reduced physical stamina and the stress of her illness, being awake for 16 hours a day was too long to cope with, and recommended that she had an extra dose of ‘night sedation’ immediately after lunch (in her case given as an injection of midazolam). This enabled her to sleep for 3-4 hours and wake refreshed, and able to enjoy her visitors in the evening. However, it was not just the pharmacological intervention which eased her distress: I listened to her and acknowledged her distress, and together with individually tailored psychological support, life was no longer intolerable.
Other centres have used time-limited deep sedation for up to 48 hours (often called ‘intermittent PS’) to provide a prolonged period of sleep and relaxation.[6] Such treatment is not conditional on being ‘imminently dying’ but on need. It is best considered as an optional component of standard symptom management for existential distress.
According to the authors, another reason for failing to relieve suffering at the end of life is that a dying patient may be ineligible for CDSUD because their estimated prognosis was several months. As noted above, it was originally suggested that it should be limited to the ‘imminently dying’. Giving the inevitable uncertainties of clinical practice, this was a necessarily vague term. However, with the introduction of more detailed professional guidelines, the limit was variously set at a few hours to a few days, to 1–2 weeks,[2] and sometimes unspecified (just terminally ill with a limited prognosis in Norway). In the Netherlands, when the Royal Dutch Medical Association produced guidelines with a prognostic limit of two weeks, these were ratified by the Department of Health and became a de facto legal time limit, thereby rigidly restricting clinical practice.
Over the last century, as the ability to cure has increased, medical training has become increasingly ‘biomedical’ (cure-oriented) and less ‘holistic’ (comfort-oriented). The modern standard medical paradigm – evaluate, diagnose, fix – has its limitations. Some problems cannot be fixed. This can lead to feelings of failure and an inclination to withdraw, and death may be seen as the only way to deal with the suffering. Thus, doctors who cannot, when appropriate, switch from a cure to a comfort modus operandi will tend to have an unconscious bias towards CDSUD. Certainly, many (possibly most) doctors find caring for dying patients extremely difficult [7]. As a psychiatrist observed many years ago:
‘Patients tend to be sedated when the carers have reached the limit of their resources and are no longer able to stand the patient’s problems without anxiety, impatience, guilt, anger or despair. Perhaps many of the desperate treatments in medicine can be justified by expediency, but history has the awkward habit of judging some as fashions, more helpful to the therapist than to the patient [8].

Further, there seems to be an increasing tendency for CDSUD to be regarded as a ‘one size fits all’ solution for seemingly intractable distress. In stark contrast is the testimony of one palliative care doctor:
‘Throughout a 40 year career in palliative care, I have never ordered ‘palliative sedation’… The very concept fails to capture my clinical reasoning. I do not manage delirium, shortness of breath and pain with standard treatments and then designate a symptom ‘intractable’, turning to ‘last resort’ therapy for severe cases. I do not shift my clinical goal from symptom relief to ‘sedation’, nor do I pre-determine that unconsciousness is the only means by which symptoms can be relieved [9].’
I can echo these words, as can many other holistic palliative care doctors. Inevitably, some patients become sedated as a secondary effect from the escalation of specific symptom control measures, no doubt deeply at times. However, a deliberate abrupt switch from symptom management to CDSUD is extremely rare in my experience, and almost always relates to uncontrollable hyperactive delirium in someone close to death, not to existential suffering.

In conclusion, I would suggest that there is an urgent need to investigate why, in national studies of all non-sudden deaths at home and in care homes and hospitals, the incidence of CDSUD ranges up to 25%, i.e. 10 or more times higher than that reported by several palliative care services [10]. The results should enable more focused training about EOLC, and lead to a considerable reduction in unrelieved suffering at the end of life.
Robert Twycross, MA, DM, FRCP, FRCR
Emeritus Clinical Reader in Palliative Medicine, University of Oxford
Oxford, UK
Email: rob.twycross@spc.ox.ac.uk

References
1. Broeckaert B, Nunez Olarte JM. Sedation in palliative care: facts and concepts. In: ten Have H, Clarke D, eds. The Ethics of Palliative Care. European Perspectives. Buckingham, UK: Open University Press 2002.166-180.
2. Gurschick L, Mayer DK, Hanson LC. Palliative sedation: an analysis of international guidelines and position statements. Am J Hosp Palliat Care 2015;32:660-71.
3. Cellarius V. ’Early terminal sedation’ is a distinct entity. Bioethics 2011;25(1):46–54.
4. Beauchamp T, Childress J. Principles of Biomedical Ethics (7th edition). New York:: Oxford University Press 2013.
5. Canadian Association of Psychosocial Oncology. Position Statement: Role of Psychosocial Oncology in Medical Assistance in Dying (MAID). Toronto:: CAPO 2017.
6. Morita T. Palliative sedation to relieve psycho-existential suffering of terminally ill cancer patients. J Pain Symptom Manag 2004;28:445–50.
7. Hicks MHR. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for doctors. BMC Fam Pract 2006;7:39. doi:10.1186/1471-2296-7-39
8. Main T. The ailment. Brit J Med Psychol 1957;30:129-45.
9. Scott JF. The case against clinical guidelines for palliative sedation. In: Taboada P, ed. Sedation at the end-of-life: an interdisciplinary approach. Heidelberg:: Springer 2015. 143-59.
10. Vivat B, Twycross R. CSD Continuous Sedation until death; a response to changing practices in the use of continuous sedation at the end of life: a systematic review of the literature (Heijltjes et al., 2020.) J Pain Symptom Manag 63;1:e139-42.

While the continuing discussion on vaccine mandates is most welcome, one thing that struck me as needing more attention being dedicate to is how do we cater to workers vaccine preferences and what are the corresponding duties of employers to provide such vaccines. As I have argued elsewhere (https://www.tandfonline.com/doi/full/10.1080/20502877.2021.1959789) there is a part of the population that is not in principle opposed to vaccination in general, but might have objections to specific vaccines. Whether or not we accept vaccine mandates as ethical perhaps we need to discuss what employers should be doing to promote vaccination. While some of the authors of this paper have argued elsewhere (https://academic.oup.com/phe/article/14/3/242/6324053?login=true) that the only thing that matters is that the vaccine given is effective, particularly when a vaccine mandate is being put in place there seems to be an obligation to reduce the burden of that mandate on the workers. What I would wish to see is more debate on the obligations of employers (and the wider health service) to provide vaccines that staff deem personally acceptable. Even if there are no mandates, this might increase vaccination uptake. To return to the article at hand, it would be good if we had alternatives to influenza vaccines that were not made in hen's eggs so as to cater to vegan staff and it would be good to have vaccines not developed with HEK293 (or other similar cell lines) for whatever disease will come next to cater for staff who believe the use of such cell lines to be morally dubious.