the expected benefits of a treatment do not outweigh the burdens. Building on the earlier studies we designed a two-round Delphi study in order to establish criteria for IPS in the context of PAD. This study is described in chapter 6. We asked 67 psychiatrists from the Netherlands and Belgium with experience to provide a definition of IPS and to explain it further in a comment section. Also, we formulated various criteria and asked them if they agreed or disagreed using a 5-point Likert scale. The results of round one formed the basis for discussions in the project-group and a second round with adjusted and new criteria was drafted. In the end, thirteen criteria reached consensus. In general, the participants agree that a carefully posed diagnosis, confirmed by an independent psychiatrist, is necessary. Regarding treatment, there is consensus that indicated psychopharmacological, psychotherapeutic, recoveryoriented and electroconvulsion treatments must have been tried and failed. Also, substantial efforts should have been made to improve the patient’s social situation. The participants also agree that the suffering must be present for several years so that all relevant treatments can be tried, but should also be limits to the number of diagnostic procedures and treatments a patient has to undergo before IPS can be established. In Chapter 7 we discuss the findings and give recommendations for clinical practice and research. First, we answer the question who is in the best position to decide on IPS in the context of PAD. We propose that shared-decision making is the best strategy. A meaningful dialogue between patient and expert is best suited to mitigate the challenges of uncertainty and treatment refusal, because it utilizes all relevant knowledge sources and applies it meaningfully to the patient’s unique situation. Second, we suggest that the use of consultative and dialogical empirical ethical approaches in this study have led to meaningful normative conclusions. It should be taken into account that these conclusions only apply to the current Dutch and Belgian context. Thirdly, we suggest that it is helpful to regard the findings from a virtue ethics perspective. The Dutch and Belgian PAD practice rely heavily on the virtuous behavior of the physician. We suggest that the most important virtue when establishing IPS in the context of PAD is carefulness, which can be seen as the right middle between carelessness and overcautiousness. A strength of this dissertation is that by applying an array of methodologies we were able to get more insight in the complex and relevant topic of IPS in the context of PAD. We also employed structured and transparent methods and were able to translate the insights to clinically applicable criteria. Yet, there are also limitations. The database used for the study reported in chapter 3 is prone to selection-biases. Also, the relatively small number of psychiatrists involved in the study presented in chapter 4 raises 138 | APPENDICES A