suffering should be present for several years. This criterion reflects the notion that persistence of suffering is not only time dependent but also treatment dependent. (Demyttenaere and Van Duppen, 2018) Implementation of this criterion as a due diligence requirement might provide clarity for patients and regulators about the high threshold of irremediability in the context of PAD for PPD. It may also be relevant for distinguishing PAD-requests from impulsive suicidality. (Pronk, Willems and van de Vathorst, 2020) The results also show that experts take both biological and psychological treatments, and social interventions, into account when establishing IPS. This is in line with the biopsychosocial model of psychiatric suffering and treatment, which was introduced by George Engel in 1977, and is still highly influential in contemporary psychiatry. (Engel, 1977) In the context of PAD it can serve as a helpful framework to assess individual treatment criteria. Regarding the biological treatments, there is consensus that medication and ECT should have been tried, but not psychosurgery. Based on the comments, two main reasons for dissensus emerge: participants find psychosurgery too experimental, too invasive, or both. This shows that effectiveness and proportionality should be taken into account when deciding on treatment criteria. Participants also agree that appropriate psychotherapeutic treatments must have failed before IPS can be established. Psychiatrists especially supported repetition of psychotherapy if there are indications that earlier therapy was ‘performed inadequately’. This criterion should be used with caution, as it is difficult to reliably evaluate the quality of earlier psychotherapy, and knowledge about the efficacy of repeated psychotherapy for therapy-resistant psychiatric complaints is lacking. (van Bronswijk et al., 2019; van Veen et al., 2020) There was no consensus regarding the criterion that acceptance-based therapy should be attempted. This is at odds with the suggestion that working towards acceptance of suffering can be seen as a subsidiary option to psychiatric PAD. (van Veen, Ruissen and Widdershoven, 2020) The participants consider social interventions, including recovery-oriented approaches, important in the context of PAD. Also, if necessary, substantial efforts should be made to improve the patient’s social situation. This may be read as support for the often used argument against PAD stating that when a patient with a psychiatric disorder wants to die, we should improve their situation, not offer PAD. (Vulnerable persons standard, 2016) But the criterion also implies that when there is no need for improving social support or if proper support does not reduce suffering, IPS may still be established and PAD may still be justified. 110 | PART III - CHAPTER 6 6