for psychiatrists to admit hopelessness through participating in PAD. (Blikshavn et al., 2017; Kissane & Kelly, 2000; Simpson, 2018) This is expressed in the following quote by Simpson et al: “we must always seek the possibility of finding ways to help people with their suffering and help them see their ongoing life as valuable and vital, for themselves and for others who know them and love them.” (Simpson, 2018) It is argued that the option of PAD entails a self-fulfilling prophecy: it will diminish hope in a patient, which further diminishes their motivation for treatment, which adds to the irremediability. (Blikshavn et al., 2017) Furthermore, opening the door to PAD is seen as a dangerous message to all psychiatric patients, indicating that there indeed are hopeless conditions. (Appelbaum, 2018; Blikshavn et al., 2017) It is, however, also argued that hopelessness is already present in patients requesting PAD and is not introduced into a therapeutic relationship by discussing it. (Rooney et al., 2017) Other authors argue that the possibility of PAD could give patients hope that there is an end to their suffering, thereby motivating them to pursue treatment. (Vandenberghe, 2011) One study found that 8 out of 48 psychiatric patients that were granted PAD in the end did not need it because “simply having this option gave them enough peace of mind to continue living”. (Thienpont et al., 2015) Furthermore, it has been argued that giving false hope to patients contemplating death might lead to distancing from the therapist and therefore an increase in suicidality. (Vandenberghe, 2011) False hope may be harmful, as is expressed in the following quote: “Although patients then may get support, attention, and care from others, the existential despair which is expressed in the request for PAS is not being seriously addressed”. (Berghmans et al., 2013) Also, authors worry that a psychiatrist that harbors false hope might resort to invasive and useless treatment that might significantly detract from the patients quality of life and lead to loss of dignity. (Hodel & Trachsel, 2016; Reel et al., 2017) Arguments concerning treatment refusal A further theme concerns the role of treatment refusal in PAD of PPD. Treatment refusal is not only a theoretical issue; as early as 1997, in a questionnaire study among 204 Dutch psychiatrists who had experience with patients requesting PAD, it was shown that 64% of the patients who requested PAD refused a form of treatment. (Groenewoud et al., 1997) More recently, in a 2016 study of 66 case-summaries of Dutch patients who received PAD due to psychiatric suffering between 2011 and 2014, it was found that 56% of the patients had refused at least one treatment, ranging from psychotherapy to medication or ECT. Reasons for refusal were lacking motivation in 29% of all cases, concern about adverse effects or risks of harm in 18% and doubts about efficacy in 15%. It was also reported that personality disorders play a common role in treatment refusal. (Kim et al., 2016) Another study from 2019 on the casesummaries of patients with personality disorders found that 51% refused some form of treatment, suggesting that treatment refusal might actually be slightly lower in this subgroup. (Nicolini, Peteet, Donovan, & Kim, 2019) 60 | PART II - CHAPTER 4 4