vices of excess and deficiency. The exact position of the right middle, also known as the golden mean, is always context dependent. A well-known example is that of courage, being the golden mean between cowardice and rashness. When psychiatrists have to decide on irremediability, the virtue of courage is relevant, but carefulness can be regarded as the most important virtue in this context. Carefulness can be seen as the golden mean between carelessness and overcautiousness. Judging that a patient’s suffering is beyond remedy too quickly would be careless, but potentially harming the patient by insisting on further treatment that yield negligible chances of recovery can be seen as overcautious. From the perspective of Aristotle both these extremes are wrong and therefore blame is appropriate, however, if psychiatrists are successful in balancing these opposing vices, they deserve praise for they have acted carefully and therefore virtuously. Following this reasoning, the set of criteria in chapter 6, can be used to support the process of finding the golden mean between carelessness and overcautiousness when establishing irremediability in the context of PAD. STRENGTHS AND LIMITATIONS Strengths A first strength of this dissertation is that by employing various empirical ethical research methods we added important insights to the ethical debate about IPS in the context of PAD. The review in chapter 4 shows that the debate on IPS in the context of PAD spans over three decades and shows repetition of opposing viewpoints and arguments. By approaching the problem of psychiatric irremediability empirically and by using the lived moral experience of experts in chapters 5 and 6, we showed that new viewpoints were possible when regarding irremediability. For instance, by identifying that experts mainly deal with the morally complex issue of irremediability by employing a retrospective view or by showing that intersubjective consensus is possible. The second strength is that we used structured and transparent methods. The studies in chapters 4, 5 and 6 were preregistered at the open science framework and when applicable relevant reporting guidelines were used. Also, in the qualitative empirical ethical studies we were transparent about, and continuously, reflected on the presuppositions in the group. Finally, a strength is that, especially in the Delphi study, we were able to convert the insights gained by empirical ethical research to clinically applicable criteria. GENERAL DISCUSSION | 127 7
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