Perspectives in Biology and Medicine

Mental illness affects every aspect of life and society, from relationships between individuals and within families, to small communities and entire polities. People with serious mental illness die decades before those without. Mentally ill people suffer daily as they struggle to function in societies that are unforgiving and uninterested in their pain. Those with serious mental illness may be incarcerated because of their sickness, they may be passed over or fired from jobs, subjected to ridicule and mockery, given little treatment or safe shelter, and violently victimized. As a result, persons with mental illness are some of the most vulnerable people in our society. And while the world is focused on the COVID-19 pandemic, it is important to remember that these facts have not changed and, in fact, the burden of mental illness continues to increase, claiming the lives of thousands of people each day who die from suicide, drug overdose, or comorbidity caused or exacerbated by psychiatric illnesses. This issue of Perspectives in Biology and Medicine offers an interdisciplinary sampling of new scholarship describing the conceptual, ethical, and policy challenges presented by the harsh reality of mental illness.

We begin with Steven Hyman's discussion of the nature of mental illness and how it is diagnosed. The stakes of this most fundamental question—"What is mental disorder?"—are high. How one answers this question will be predictive and determinative of ethical and policy choices related to caring for mentally ill [End Page 1] people. Those who view mental illnesses strictly as natural kinds will emphasize the need for technologies to identify and correct biological mechanisms implicated in psychiatric conditions. They will plumb the depths of molecular and cell biology searching for biomarkers predictive of schizophrenia, for example, and develop pharmaceuticals to target and arrest the progression of symptoms. The implicit but misplaced belief that objectivity and validity may only be found in the reduction of complex human phenomena to diagnostic categories is made apparent in the ways psychiatric research and treatment interventions are prioritized or given the imprimatur of "evidence-based." Hyman describes how categorical nosologies of the past, and in particular DSM-III, operationalized this view, which, in his view, ultimately impeded clinical research by imposing artificial definitions at a time when critical data were unavailable. During the decades of reliance on DSM-III and its successors, the field has largely failed to identify reliably effective treatments, much less cures, for serious mental disorders.

The new psychiatric sciences, now armed with massive troves of genetic data and immense computational power, have shown that our current categories of mental disorders are ersatz cutouts of the real things. The maladies we find in the DSM are in actuality highly variable patterns visible across a complex tapestry of genetic predisposition, neurobiological function and dysfunction, and environmental triggers. Hyman's paper reminds us that confusion about etiologies, misapplied categorization schemata, and other conceptual limitations in psychiatry do not undermine the basic fact that mental illnesses are real. Hyman's pragmatism offers a kind of pluralistic realism that allows for various nosologies to coexist, each suited for and directed toward a particular purpose. New models of psychiatric diagnosis offer the promise of more effective interventions and treatments. Most importantly, they presage a time when psychiatric conditions may be finally recognized as simply "illness," a movement toward equity that would advance the rights and protections for those who live with and die because of extreme mental pain.

What of those who live with such severe psychological suffering they wish to die with medical assistance? This is the topic of two essays in this issue. The first, by Scott Kim, reconsiders the ways euthanasia and medical assistance in dying (MAID) for psychiatric illnesses have been discussed and debated. Kim lays out the broad contours of the debate that has embroiled professional psychiatry since the legalization of MAID in the United States and Canada, and the permissiveness of MAID for psychiatric conditions in parts of Continental Europe. Kim offers a compelling set of objections to the possibility of expanding euthanasia and assisted suicide to include psychiatric conditions, in part because...