most patients were diagnosed with multiple psychiatric disorders (71-79%). Common diagnoses were depression (46%-74%), personality disorders and personality problems (52%-54%), anxiety disorders (11-23%), and PTSD (20%-23%). Both studies were limited by the relatively low number of publicly available cases and the fact that they only concerned patients receiving PAD, not patients requesting PAD. This limitation does not apply to a report by the ECE that was presented at the beginning of 2020. (Kammeraat & Kölling, 2020) For this report, 1308 files of patients who requested PAD for psychiatric suffering were analyzed. The report, that has not been peer reviewed, shows that patients requesting PAD often had severe and long-standing psychiatric complaints, 60% had a treatment history of more than 10 years. The mean age of applicants was 50 years. 60% of the applicants were women, 70% were single, 76% had a low or secondary education level and 88% were receiving benefits. 70% of the applicants had more than one psychiatric diagnosis. The most common main diagnosis was depression (35%). When comorbidity is taken into account, common diagnoses were depression (50%), cluster B personality disorder (22%) and trauma- and stressorrelated disorders (20%). 90% of the PAD requests due to psychiatric suffering did not end in PAD, 20% withdrew the request, 68% were rejected. Patients with a cluster B personality disorder as the main diagnosis were relatively often rejected. The study also mentions 8 patients who died by suicide after their request for PAD was rejected. Most patients whose PAD request was granted were between the ages of 50 and 60, 28% had a diagnosis of major depressive disorder and 13% a trauma- or stressorrelated disorder. The challenge of irremediability As mentioned above, the irremediability of suffering serves as an important justification for PAD. This justification is also known as the conflict of duties; a physician has both the duty to relief suffering and to protect life. Usually these duties coincide, but there are situations where the only way to relief the suffering of patients is to help them to die. In these cases, when the suffering is irremediable and there are no subsidiary means of relieving it, the duty to relieve suffering may transcend the duty to protect life and therefore PAD may be justified. However, when we apply this reasoning to psychiatric suffering, several challenges concerning the concept of irremediability arise. To further illustrate this we will first discuss the ongoing conceptual debate and secondly we will discuss the scarce empirical evidence on the topic. Over the past four decades, conceptual papers on the topic of PAD for PPD continuously identify irremediable psychiatric suffering (IPS) as an important ethical challenge. (Berghmans, Widdershoven, & Widdershoven-Heerding, 2013; Blikshavn, Husum, & Magelssen, 2017; Schoevers et al., 1998; van Ree, 1983) Several aspects of psychiatric suffering appear to contribute to the complexity of this topic. First, INTRODUCTION | 19 1
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