Consequences for PAD of PPD In the light of the uncertainty about diagnosis and prognosis on the one hand, and treatment on the other hand, authors reach different conclusions about the acceptability of PAD of PPD. Many authors want to restrict access to PAD for psychiatric patients. (Brown, Elliott, & Paine, 2013; Cowley, 2015; Kelly, 2017; Kissane & Kelly, 2000; Schoevers et al., 1998) In their view, the harm of assisting in the death of a patient who might recover justifies a ban on PAD for all psychiatric patients. As Cowley et al. put it: “if in any sort of doubt, a psychiatrist should avoid any irreversible decisions, and should err on the side of keeping her alive.” (Cowley, 2013) Proponents of PAD of PPD disagree with this assessment and argue that uncertainties are not a good enough reason to infringe on patient autonomy and continue unbearable suffering. (Dembo et al., 2018; Steinbock, 2017) When a competent patient understands that it is uncertain whether their suffering is truly irremediable, it is up to the patient to decide whether or not to continue living with those chances. (Appel, 2007) Other proponents of PAD argue that the harm of letting a majority of truly irremediable patients suffer could be greater than the voluntary death of a minority that might recover spontaneously or benefit from future treatment. (Pienaar, 2016; Rooney et al., 2017; Schuklenk & Vathorst, 2015) Also, the non-lethality argument is disputed altogether, as patients may die through suicide, which may be regarded as worse than dying through PAD. (Rooney et al., 2017) A third viewpoint balances these two positions, arguing for decision-making on the basis of a reasonable amount of certainty. (Berghmans, Widdershoven, & Widdershoven-Heerding, 2013; de Boer & Oei, 2011) What counts as reasonable depends on the situation, and has to be determined through dialogue between doctor and patient. This approach has a long tradition in the Netherlands. (Tholen et al., 1999) It is embedded in the Dutch euthanasia-law as well as in different guidelines addressing the subject of PAD of PPD. (Nederlandse Vereniging voor Psychiatrie, 2018; RTE, 2018) However, worries about the Dutch system have been uttered, as it is said to be based on ‘inherently vague’ criteria. (Kim & Lemmens, 2016) Arguments concerning hope Hope is an often-discussed factor in the debate about PAD of PPD. Sometimes hopelessness is simply used as a synonymfor an absent chance of recovery. (Cowley, 2015; Groenewoud et al., 1997) But more often hopelessness is seen as a state of mind, both for the patient and the doctor, not necessarily related to the actual prognosis. (Blikshavn et al., 2017; Kissane & Kelly, 2000; Simpson, 2018; Vandenberghe, 2011) A qualitative analysis of testimonies by psychiatric patients shows that feelings of hopelessness are an important and recurring reason for requesting PAD. (Verhofstadt et al., 2017) Remaining hopeful is seen as a basic therapeutic tool for the psychiatrist and as a basic condition for recovery of the patient. Opponents of PAD of PPD argue that it is unethical IRREMEDIABLE PSYCHIATRIC SUFFERING IN THE CONTEXT OF PHYSICIAN ASSISTED DEATH | 59 4