Records found through database search (N = 159) Medline: 58 Embase: 67 Psycinfo: 34 Full text articles excluded (N = 56) Reasons for exclusion: - No mention of irremediability: 21 - Briefly mentions irremediability: 23 - Non-psychiatric suffering: 12 Exclusion of duplicated records (N = 54) Records excluded (N = 142) Additional records from other sources (N = 143) Unique records from database searches (N = 105) Records screened on title and abstract (N = 248) Full text records reviewed (N = 106) Records included in review (N = 50) FIGURE 1. Flow diagram of the systematic search and study selection process. Arguments concerning uncertainty of diagnosis and prognosis Uncertainty of diagnosis and prognosis is a recurring theme in the debate about PAD of PPD. Empirical studies from the Netherlands show that there is disagreement about irremediability between psychiatrists in 11-20% of the physician-assisted deaths due to psychiatric suffering. (Kim et al., 2016; van Veen, Weerheim, Mostert, & van Delden, 2018) Several authors cite clinical studies that show that some psychiatric patients will never recover. (Dembo, Schuklenk, & Reggler, 2018; Downie & Dembo, 2016; Pienaar, 2016) But whether these ‘truly irremediable’ patients can be identified is subject of debate. Rooney et al. argue that irremediability can be predicted for individual depressed patients with help of staging models. (Rooney, Schuklenk, & van de Vathorst, 2017) A questionnaire in 2016 among 248 Dutch psychiatrists found that 70% disagreed with the statement that it is impossible to assess whether a psychiatric patient suffers irremediably and unbearably, 12% agreed with this statement and 17% was neutral. (Onwuteaka-Philipsen et al., 2017) In the ethical debate, however, many authors argue that it is impossible to reliably differentiate between patients that have IRREMEDIABLE PSYCHIATRIC SUFFERING IN THE CONTEXT OF PHYSICIAN ASSISTED DEATH | 57 4