DISCUSSION This systematic review synthesized literature addressing irremediability in the debate about physician-assisted death for patients with psychiatric disorders. The review shows that irremediability has been a central and recurring issue in this debate for over 20 years and that the arguments addressing it evolve around three main themes. First, whether uncertainty about irremediability can be sufficiently eliminated and how this influences the acceptability of PAD. Second, whether access to PAD introduces hopelessness in psychiatric patients and thereby contributes to irremediability. Third, whether patients who refuse certain treatments can be considered to be suffering irremediably. Uncertainty Absolute certainty about the prognosis of any psychiatric disorder is unreachable; psychiatry does not differ in this aspect from other medical fields. Although absolute certainty is impossible, knowledge about treatment options for individual patients can be improved. Precision psychiatry is promising in this respect. Machine learning algorithms, based on both clinical information and biomarkers, are increasingly capable of predicting treatment outcome. (Chekroud et al., 2016) These relatively new researchmethods can be used to quantify the recovery chances for an individual patient with a seemingly irremediable psychiatric disorder. This will help patients and psychiatrists to make informed decisions about PAD. It might also foster the development of new palliative psychiatric approaches, which may prevent PAD. The development of new methods to reduce uncertainty will, however, not solve the issue completely. Even if knowledge of possible treatment options increases, a certain level of uncertainty will remain. Unless the proposition is a total ban of PAD, it seems reasonable to direct attention to the level of uncertainty that is morally admissible and the due diligence procedures needed to establish this level. Various safeguards might be explored, such as mandatory second opinions by psychiatrists specialized in the patient’s disorder or mandatory time between the request and performance of PAD. Qualitative research among psychiatrists with experience in PAD can provide insights and suggestions for safeguards. Hope It has both been claimed that PAD can induce hopelessness and that it can resolve hopelessness. A reason to doubt that PAD always induces hopelessness is the finding that psychotherapists do not induce suicidal thoughts by discussing suicide with a patient. Even more so, openly discussing suicidal ideation leads to better disease outcomes. (Dazzi et al., 2014) One might argue that the option of PAD can have the same function: by discussing PAD openly, recovery may become possible. The effect 68 | PART II - CHAPTER 4 4