SUMMARY In the Netherlands, physician assisted death (PAD) is possible for patients who are competent in their death wish and who suffer from a medical condition that is unbearable and irremediable. These criteria, which are codified in the 2002 law on euthanasia, are the outcome of a long societal debate that started in the 1970s, when physicians emphasized the tension between the duty to alleviate suffering and the duty to preserve life. They argued that in certain cases actively assisting in the death of a patient was the only merciful option. Although the debate mainly focused on patients suffering from somatic suffering, PAD is legally allowed for psychiatric suffering since the 1990s. Only a very limited number of cases have been reported until 2011. From then on, there has been a rise in assisted deaths for patients with a psychiatric disorder. Chapter 1 discusses he historical, legal and epidemiological background of psychiatric PAD. The increasing clinical experience accompanying the rise in PAD-requests made it clear that psychiatrists struggle with establishing irremediability. This dissertation therefore examines the concept of irremediable psychiatric suffering (IPS) in the context of PAD. We do this in three steps. First, we establish the moral relevance of IPS in the context of PAD. Secondly, we identify the main challenges clinicians face while establishing IPS in the context of PAD. And finally, we establish criteria for IPS in the context of PAD. To illustrate the moral relevance of irremediability in the context of PAD for patients with a psychiatric disorder (PPD), Chapter 2 presents a case-report. It describes a patient, diagnosed with schizophrenia, who suffers unbearably from hearing nursery songs. Substantial treatment has been tried and failed for 18 years and the patient turned to the Expertise Centre for Euthanasia requesting PAD. As part of the due diligence procedure the patient is referred to a psychiatrist specialized in psychotic disorders. His complaints are reinterpreted as compulsive thoughts and treatment is changed accordingly. After several weeks of treatment with an antidepressant and cognitive behavioral therapy, the patient recovers and retracts his PAD-request. This case highlights the complexity of psychiatric diagnosis and the establishment of irremediability. On the one hand the patient was not far from receiving assisted death while a relatively simple treatment was still possible, on the other hand if the patient had not requested PAD, he would not have been referred to the specialist and would likely not have recovered. This case also highlights the importance of a comprehensive due diligence procedure including a second opinion. The moral relevance of studying IPS in the context of PAD is further elucidated in chapter 3. It describes an analysis of 35 casefile summaries of PPD receiving PAD. The 136 | APPENDICES A
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