Four years later, in 1998, the first guideline regarding PAD for PPD was published by the Dutch Psychiatry Association. It already contained an elaboration of many of the due diligence requirements that are still important today, including irremediability. In the guideline, suffering was seen as irremediable when there is no prospect of relieving, alleviating or removing it. It also stated that ‘absolute irremediability’ is virtually non-existent in psychiatry, unless the psychiatric disorder is based, for example, on demonstrably irreversible brain damage. For this reason, the guideline committee chose to speak of irremediability if “no realistic treatment perspective” was present. Three requirements were set for a realistic treatment perspective: (a) according to current medical insight, with adequate treatment, there is prospect of improvement, (b) within a foreseeable period, (c) and with a reasonable ratio between the expected results and the burden on the patient. The guideline further stated that a psychiatrist may conclude that there is no prospect of improvement when all relevant biological, psychotherapeutic and social intervention options have been exhausted. Finally, the guideline stated that, in principle, suffering cannot be irremediable if a realistic alternative to alleviate suffering is rejected by the person seeking help. In 2001, the Dutch parliament voted in favor of the ‘Termination of Life on Request and Assisted Suicide Act’ that firmly established and clarified the due diligence procedures for PAD that had developed over the previous years. These legal requirements will be discussed in greater detail below. The Act became law in 2002 and at the time, the Dutch Minister of Health, Els Borst, emphasized that psychiatric suffering could also be grounds for PAD. This historic legislative change was followed by a mostly quiet decade in the field of PAD for PPD. The number of reported cases remained very low and the debate appeared dormant. The guideline underwent minor revisions by the Dutch Psychiatry Association in both 2004 and 2009, mainly regarding procedural demands. This relatively uneventful period ended when, in 2011, the number of reported cases started rising. This rise coincided with the foundation of The End-of-Life Clinic; a special facility specifically aimed at patients who wanted PAD but did not find help from their own physician. The End-of-Life Clinic has quickly become the center of psychiatric PAD in the Netherlands. In the years following its establishment, an increasing portion of all reported PAD’s for PPD have been performed by physicians and psychiatrists working in The End-of-Life Clinic (figure 1). The End-of-Life clinic saw this as a problem and, in 2019, renamed themselves as the Expertise Centre Euthanasia (ECE) and started focusing more on supporting regular psychiatrists in performing PAD themselves. With the rising number of cases, the societal attention and the academic interest returned. This led to a major revision of the PAD-guideline in 2018, which we will further discuss below. This renewed interest and the new guideline in particular provided the motivation for this dissertation. 14 | CHAPTER 1 1