REFLECTIONS This dissertation found that irremediable psychiatric suffering is a relevant concept in the context of physician assisted death. We also found that, although several challenges remain, experts agree that certain criteria are essential when establishing IPS. But what to make of these findings? When regarding the work described in this dissertation the following reflections are in place. First, we will consider who is in the best position to decide on IPS. Secondly, we will reflect on the used research methodologies. And finally, we will regard the findings from a virtue ethics perspective. Who decides on irremediable psychiatric suffering? A fundamental question that keeps returning throughout this dissertation is who is best suited to decide on the irremediability of psychiatric suffering in the context of PAD. Four different approaches to this challenge can be discerned: 1) the objective approach, 2) the expert-centered approach, 3) the patient-centered approach and 4) the shared approach. The objective approach reduces the decision about IPS to a calculation about one’s chances of recovery. This method needs a prognostic tool that is able to predict the individuals’ chances of recovery using a predetermined set of clinical parameters. This means that when adhering to this approach the main question is not who decides on irremediability, but what decides. What chance of recovery is accepted while still speaking of irremediability is not defined absolutely, but 5% has been mentioned in this context. (Schneiderman, 2011) This approach largely places the decision about irremediability outside of the persons involved, for - in a sense - the algorithm underlying this prediction establishes irremediability. This view on irremediability, within reasonable limits, underlies decision making based on staging in cancer. (Greene & Sobin, 2008) The main advantage of this objective approach is that it is independent of the subjective experience. However, important weaknesses are that these predictions are only as strong as the science supporting them and the different stages will almost certainly not do justice to the complexity of individual patients, especially in psychiatry. Also, if this objective view of irremediability is applied too rigidly, it can hamper the freedom of choice of individual patients who may want to continue treatment, even though their chances of success are below the predetermined threshold. (Khatcheressian et al., 2008) The second approach is that the psychiatrist, or another relevant expert, decides on irremediability. The difference between these first two viewpoints is that here the physician not merely follows a predictive model, but integrates all information available and forms an expert opinion about the irremediability of the suffering. Leaving the 122 | CHAPTER 7 7