views on irremediability of patients with a psychiatric disorder and a request for PAD would be a good place to start. But practice shows that there are also other important stakeholders, such as friends and relatives of the patient, general practitioners, clinical psychologists, nurses and chaplains. Studying the views of all these groups will likely lead to valuable new insights. Secondly, chapter 4 of this dissertation uses publicly available casefile summaries of patients who received PAD. If legally possible and taking into account privacy issues, we recommend that the full database of the Regional Euthanasia Review committees should be made accessible for scientific enquiry. This would give excellent possibilities for research, because the database contains all psychiatric PAD cases that have ever been reported. Thirdly, as the experts that were included in our studies were exclusively from the Netherlands and Belgium, it would be useful to study the views of the abovementioned stakeholders from other countries and cultures. PAD is an ethical theme that evokes a great diversity of viewpoints around the world and it is possible and maybe even expected that experts from other countries will have different views based on specific conditions and historical context. Finally, the suggestion that treatment fatigue is an important reason why patients request PAD and refuse further treatment, merits further study. If new studies confirm treatment fatigue as a relevant causal factor for requesting PAD this will help to understand these requests better and it may be a potential target for psychosocial interventions. If treatment fatigue is recognized and discussed in time, the patient and psychiatrist may choose to stop treatment, waive certain steps or postpone it until the patient is ready to try again. CONCLUSION This dissertation studied the moral relevance and challenges of establishing irremediability in the context of physician assisted death for patients with psychiatric disorders. We showed that establishing irremediability has already been the topic of a decade long ethical debate and a relevant clinical issue in the Netherlands. The most important clinical challenges for psychiatrists are the uncertainty they face when establishing irremediability and how to handle treatment refusal. In the end, expert psychiatrists can agree on criteria for irremediable psychiatric suffering in the context of PAD. In their view, a carefully constructed diagnosis is necessary and substantial, but not limitless, biopsychosocial treatment has to be tried without 130 | CHAPTER 7 7
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