alternative solutions have to be discussed and all options acceptable for the person requesting PAD have to be tried. In 2018, a new guideline was introduced removing the requirement that death must be reasonably foreseeable, which enables PAD for psychiatric suffering. The new guideline does prescribe a mandatory consultation by a psychiatrist when the death wish stems from psychiatric suffering, this consultation is used, in part, to assess irremediability. (van de Wier, 2021) At the time of writing, no official numbers are available, but PAD for psychiatric suffering appears to remain rare in Switzerland. In July 2021 Spain passed a law which is similar to that of the Netherlands and Belgium, it allows PAD for people who ‘suffer from a serious and incurable disease or suffering from a serious, chronic and disabling disease’, leaving room for PAD for psychiatric suffering. In March 2021, the Canadian parliament voted in favor of removing the demand that death has to be reasonably foreseeable from their PAD law. This means that PAD for psychiatric suffering will become possible in Canada. A two-year sunset clause is installed, so that a due diligence procedure can be drafted. The debate is ongoing, and it is unclear what this procedure will look like exactly at the time of writing. It is possible that irremediability will be interpreted more leniently in Canada as compared to the Netherlands, Belgium and Luxembourg. Canadian law states that only the treatments that are acceptable to the patient have to be tried, meaning that in theory a patient with a psychiatric disorder could refuse all treatment and still be eligible for PAD. (Gaind, 2020) The Dutch practice in numbers Although the Supreme Court ruled in 1994 that psychiatric suffering can also be a reason for PAD, for almost two decades, it remained rare. Since 2011, however, there was a remarkable increase in the number of patients that receive PAD due to psychiatric suffering (Figure 1). (Dutch Regional Euthanasia Review Committees - Annual Report 2020, n.d.) The number of requests based on psychiatric suffering is many times higher than the number that is actually performed. It is estimated that 56% of all psychiatrists have had a request for euthanasia during their career, and that about 95% of all requests were rejected. (Kammeraat & Kölling, 2020; Onwuteaka-Philipsen et al., 2017) Detailed quantitative empirical research into PAD for PPD, until recently, remained scarce. For a few years, the only available source for research were the case summaries that were published on the website of the Dutch Regional Euthanasia Review Committees. Kim et al. studied 67 summaries of patients with a psychiatric disorder that received PAD between 2011 and 2014. (Kim, de Vries, & Peteet, 2016) Chapter three of this dissertation describes a study that followed up on this research using the summaries that were published between 2015 and 2017. Both studies found that 18 | CHAPTER 1 1
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