of PAD of PPD on hope requires further empirical research. This can be performed through surveys using hopelessness scales or through qualitative interviews among psychiatric patients who request PAD or, in jurisdictions that do not allow PAD, among psychiatric patients who appear to suffer irremediably. (Beck et al., 1974) Also interviewing patients who found a physician willing to assist them in dying, but eventually choose against it, would be helpful in this respect. Such studies might help to better understand the phenomenon of hope in the context of discussing PAD with psychiatric patients. This may help psychiatrist to deal with expectations and experiences of patients. Yet, in individual cases, a clinical assessment of the reaction of the patient will be needed, and the psychiatrist might require a second opinion and further deliberation with colleagues in order to come to a well-considered conclusion concerning the role of hope. Treatment refusal Treatment refusal is a relevant issue in PAD of PPD, since empirical research shows that in a considerable number of cases in which PAD was performed in PPD, the patient refused one or more treatment options. This raises questions concerning the relationship between refusal of treatment and irremediability of suffering. On the one hand, it can be argued that as long as treatment options exist, suffering is not irremediable. On the other hand, one can argue that demanding a patient to undergo different treatments for which he is not motivated may be ineffective and harmful, as motivation is an important determinant of treatment efficacy, especially when it concerns psychotherapy. (Ryan et al., 2011) Further empirical research on reasons underlying treatment refusal is needed. Also, the efficacy of treatments that psychiatric patients who request PAD have to ‘undergo’ in order to satisfy the requirement of irremediable suffering should be studied. This review shows that different jurisdictions allowing PAD have different ways of handling treatment refusal; the question underlying these policies is: who has agency to decide whether enough treatments have been tried before PAD is justified? If this decision is left entirely to the patient, based on the respect for their autonomous choice, patients may choose to refuse all treatment in order to candidate for PAD. Alternatively, the decision can be left to the psychiatrist, which can be seen as unduly paternalistic. A third approach is to find a balance between these options through shared decision-making; this approach is laid down in the Dutch euthanasia law. Policymaking concerning how to deal with treatment refusal in the context of PAD of PDD will require both empirical information on effectiveness of treatments and reasons for refusal, and normative considerations concerning the physician-patient relationship. (Emanuel, 1992) Our review shows that there is little empirical research available on psychiatric patients who request PAD. Until fairly recent, PAD of PPDwas largely a theoretical issue, for it was IRREMEDIABLE PSYCHIATRIC SUFFERING IN THE CONTEXT OF PHYSICIAN ASSISTED DEATH | 69 4