years, the patient was unsuccessfully treated with antipsychotics, including clozapine. Hearing these songs became increasingly unbearable for the patient and eventually resulted in a request for physician-assisted death. He contacted the ECE. After an assessment period of 1 year, the ECE referred him to an academic hospital for an obligatory second opinion. During admission, the patient’s symptoms were carefully analyzed, and the songs were recognized as intrusive thoughts and not psychotic phenomena. Treatment started with 20 mg of citalopram, which within 3 weeks led to a decrease of the songs the patient heard—a significant clinical improvement. Afterward, cognitive-behavioral therapy was added to the pharmacological treatment, and a few weeks later the patient reached full remission, which continued through the day of this article’s submission, 9 months later. As of this writing, the patient has withdrawn his request for physician-assisted death. DISCUSSION This case highlights the complexity of physician-assisted death for psychiatric patients. The patient’s recovery, of course, was a relief for all parties involved. Yet, an obvious question presents itself: what should clinicians think of the fact that this patient might have died if the diagnosis had not been revisited and no new treatment was started? Two opposing answers can be given. On one hand, this near miss may be used as an argument for banning psychiatric patients from physician-assisted death. On the other hand, it may be concluded that the procedure worked: in the end, the patient was properly diagnosed and adequately treated, after which he withdrew his request. Moreover, if he had not sought the help of the ECE, he may not have been referred for a second opinion, and his suffering might have continued. These arguments provoke several ethical questions, two of which will be discussed here. First, how does one reach a justified conclusion on the irremediability of a patient’s suffering, given the uncertainty about diagnosis and prognosis? Second, what conditions are required for physician-assisted death due to psychiatric suffering? Dealing with uncertainty. Because of the variety of explanatory models and the unclear biological basis of psychiatric disorders, there is always room for uncertainty. Some authors argue that this uncertainty makes physician-assisted death morally inadmissible for psychiatric patients. (Appelbaum, 2018; Schoevers, Asmus, & Van Tilburg, 1998) Others argue that absolute certainty about a prognosis is epistemologically impossible and therefore unreasonable. (Rooney, Schuklenk, & van de Vathorst, 2017) Schuklenk and van de Vathorst mention that uncertainty should be discussed with the patient. (Schuklenk & van de Vathorst, 2015) If he or she understands this uncertainty after adequate 32 | PART I - CHAPTER 2 2
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