these three studies we can conclude that establishing IPS in the context of PAD is a morally relevant and challenging issue. The main challenges concerning establishing irremediability The second question of this dissertation is: what are the main challenges in establishing IPS in the context of PAD? Chapter 4 presents a scoping review that synthesizes the insights of 50 articles that address IPS in the context of PAD. The majority of the articles are conceptual and normative, but there are also eight empirical studies that address irremediability. Three core issues were discerned in the debate, which spans over three decades. First, we found that uncertainty about irremediability is a recurrent theme in the debate. Due to the nature of psychiatric disorders and psychiatric treatment, uncertainty about irremediability is seen by most as unavoidable. The challenge lies in the fact that dissensus continues to exist about how much certainty is necessary before irremediability can be established. The second recurrent theme is hope. The assumption of different authors is that the possibility of PAD will lead to hopelessness. They suspect that this will be a relevant clinical challenge in jurisdictions that allow PAD for PPD. Other conceptual commentators disagree with this and argue that it is the experience of irremediability that causes hopelessness and that the option of PAD can actually help. A final theme throughout the literature is treatment refusal. Empirical studies show that PPD who request PAD have regularly refused certain treatments. How to respond to these refusals and what this means for the assessment of irremediability of the suffering in the context of PAD is seen as an important challenge. The insights gained in the scoping review formed the basis for the qualitative study in chapter 5. For this study eleven psychiatrists with experience in assessing IPS in the context of PAD were interviewed. Remarkably, they did not especially struggle with the possible effect of PAD on hope or hopelessness. In their clinical experience PAD sometimes induced hopelessness and sometimes resolved it. Introduction of PAD for PPD may have societal effects, but did not lead to specific clinical challenges during the assessment procedure of individual patients. The participants did however recognize the challenge of uncertainty and many of them reported struggling while deciding over irremediability. Various participants argued that the complicated nature of psychiatric suffering makes meaningful prognostic claims challenging and maybe impossible. A way the psychiatrists addressed this challenge was by focusing on retrospective elements when establishing IPS. More specifically this means that psychiatrists focus on past attempts to reduce the suffering that have been tried and failed. This retrospective assessment of irremediability is frustrated when a patient has refused certain treatments, which various psychiatrists therefore recognized as a relevant challenge when establishing IPS. Some psychiatrists suggest that ‘treatment fatigue’ is an important reason for treatment refusal. This concept is new to psychiatry GENERAL DISCUSSION | 119 7