only performed sporadically. The increase of PAD of PPD in certain jurisdictions offers an opportunity to further study this practice. Indeed, a few empirical studies have been performed (table 1), but they have methodological shortcomings, mentioned by the authors in the discussion paragraphs. The opportunity for thorough empirical studies on PAD of PPD is here now and should be used. When performing these empirical studies, researchers should not focus on ‘the psychiatric patient’ as a single group, but pay attention to differences between individual psychiatric disorders. A strength of this review is that we performed a comprehensive and systematic study of the literature on irremediability in the context of PAD of PPD. A weakness is that the included studies were highly divergent and that the included empirical studies were of low quality. Therefore, a critical appraisal of the evidence was of no added value and the numbers mentioned should be carefully considered when used elsewhere. CONCLUSION Irremediability of suffering is an important aspect of any justification for physicianassisted death. Whether psychiatric suffering can and should be classified as irremediable has been an issue of debate for over 20 years. This systematic review showed that arguments about irremediability evolve around three main themes and provides suggestions for empirical research and normative deliberation. The first theme is uncertainty about irremediability. This calls for empirical research in order to diminish the level of uncertainty about irremediability, as well as deliberation on what level of certainty is necessary for PAD of PDD to be acceptable. The second theme is hope. This calls for more research on the relationship between the option of PAD of PDD and the phenomenon of hope in patients, and the need for deliberation in individual patient cases. The third theme concerns treatment refusal. This calls for further empirical investigation into which treatments are being refused, and why, and normative deliberation on the justification of decisions to forego treatment in the context of the physician-patient relationship. Finally, this review showed the lack of thorough empirical studies, and basic epidemiological data on patients with a psychiatric disorder who request and receive PAD. 70 | PART II - CHAPTER 4 4
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