In some cases of severe and persistent mental illness (SPMI), the pursuit of clinical remission entails an unacceptable benefit-to-burden ratio, rendering it qualitatively futile. Consequently, this approach should be forgone on the principle of non-maleficence. Additionally, some treatment refusals are autonomous and thus should be respected. Importantly, this does not relieve mental health professionals of the obligation to provide care following from the principle of beneficence. The ensuing predicament can be resolved by reprioritizing the goals of care. Palliative psychiatry prioritizes harm reduction, relief of suffering, and best-possible quality of life rather than clinical remission. This includes end-of-life care for those dying from SPMI but goes beyond it, encompassing all approaches that prioritize quality of life. Understood in this broader sense, some already established programs for individuals with SPMI can be characterized as palliative, such as supervised injectable heroin treatment. From a perspective of justice, the current lack of palliative approaches in psychiatry can be interpreted as structural discrimination against individuals with SPMI and as perpetuating their stigmatization. It follows that advances in palliative psychiatry are likely to facilitate more equitable access to care.