DISCUSSION This study provides an exploration of how psychiatrists define IPS in the context of PAD and what challenges they encounter while establishing IPS. Although IPS is seen as a prospective concept, participants mostly refer to retrospective dimensions and more specifically to the failure of past treatments, when defining IPS. This appears logical, for various studies have shown that failed past treatments are a predictive factor for chronicity in psychiatry. (Breier, Schreiber, Dyer, & Pickar, 1991; Denys, Burger, van Megen, de Geus, & Westenberg, 2003; Sinyor, Schaffer, & Levitt, 2010) The main opportunity of explicitly adopting a retrospective view on IPS is that it absolves the psychiatrist from the unreasonable task to make highly accurate prognostic claims. It also corresponds with the feeling of ‘treatment fatigue’ that often appears to underly the PAD request of patients with a psychiatric disorder. (Pronk, Willems, & van de Vathorst, 2021) Furthermore, a retrospective view on irremediability justifies the intuitive uneasiness various psychiatrists reported with performing PAD on patients who refuse treatment. Because the patient’s history is central to establishing irremediability, treatment refusal can seriously hamper the psychiatrist’s ability to make a meaningful claim about irremediability. In other words, physicians cannot compel patients to try therapies, but patients cannot compel physicians to conclude that a condition is irremediable if they are not willing to try a sufficient number of therapies. The retrospective view on irremediability therefore also justifies a stricter stance on treatment refusal in psychiatry than in other, somatic, specialties that can use a more prospective view on irremediability due to biological parameters that lead to a meaningful prognosis. Similar reasoning can be applied to young people requesting PAD, which happens often in the Netherlands and is seen as a moral challenge. (Kammeraat & Kölling, 2020) If treatment history forms the basis of the decision on irremediability, but relatively little treatment has been possible due to the fact that the patient has not had symptoms for that long, it is reasonable to postpone judgment on irremediability. This study also confirms earlier findings that psychiatrists struggle with uncertainty as a distinctive element of the definition of IPS. In the conceptual debate about IPS in the context of PAD, much attention is given to uncertainty, and it is often used as an argument against PAD for PPD. (Gaind, 2020; van Veen et al., 2020) Both the nature of psychiatric suffering and the lack of a biological substrate are seen as elements that add to the uncertainty surrounding IPS. Yet, most participants feel that refusing PAD due to uncertainty alone does not do justice to the individual patient’s request for PAD. We have to acknowledge that absolute certainty about the prognosis of any type of suffering is epistemologically impossible. We should therefore also aim to find a reasonable balance between the need for certainty and the need to assist 86 | PART II - CHAPTER 5 5