With opinion sharply divided we wonder whether it is possible to address the issue of assisted suicide without a charge of bias, and for this reason we thought it was better to be explicit about our position in relation to a change in the law. No editorial limited to 1500 words will satisfy our correspondents’ criticisms that other evidence was overlooked. Matthew Hotopf was indeed involved with the Royal College of Psychiatrist's response to Lord Joffe's Bill.

We agree with Professor Graham that terminology is important. However, we do not think the distinction between assisted suicide and assisted dying is clear. The use of ‘assisted dying’ is problematic, we suggest, as it may be confused with the work of palliative care, a system of care specifically designed to assist people at the end of their lives, to do all to maintain dignity in dying and not to ‘strive officiously to keep alive’.

Any change in the law is likely to involve drawing a distinction where assisting suicide is lawful as opposed to one where it is not. If one sets aside the legitimate moral question as to whether a doctor should ever assist in suicide, the issue comes down to devising a set of safeguards. Most, we think, would agree that freedom from coercion is important, although there may be debate about how to define this. Psychiatry may have only a limited role to play in such an assessment. The other main safeguards which tend to be proposed relate to the presence of suffering, mental capacity and consistency of wishes, and are areas we think psychiatrists bring expertise and might be expected to be agents in a new legislation.

The proponents of a change in the law might argue that a specific group can be defined in whom a law could safely be applied, whose request is valid and whose suffering is authentic. In terms of suffering, in an era where the voices and views of patients with psychiatric disorder are, thankfully, increasingly given due weight, we do not think it is tenable to suggest that patients with psychiatric disorder can so readily be distinguished from the rest of the population. If one makes ‘unbearable suffering’ a condition of assistance, but does not think that people with chronic mental disorders should have access to such assistance, then we suggest one has to answer the ‘why not?’ question. The suffering of patients with chronic mental disorders may be quite as unbearable or more so than that of a patient with cancer. As Dr Curtice's letter points out, ^{Reference Curtice1} this is a live issue.

The issues of mental capacity in relation to suicidal behaviour are complex, as the case of Kerry Woolterton (a woman with an emotionally unstable personality disorder whose death by suicide was not prevented on the basis that she had mental capacity) indicates. ^{Reference David, Hotopf, Moran, Owen, Szmukler and Richardson2} The complexity is added to by the high frequency of depression ^{Reference Rayner, Lee, Price, Monroe, Sykes and Hansford3} and cognitive impairments ^{Reference Lawlor, Gagnon, Mancini, Pereira, Hanson and Suarez-Almazor4} in patients with advanced disease. We suspect that mental capacity assessments in this context are unlikely to be value neutral.

Our clinical experience of working with patients with advanced disease suggests to us that there is considerable commonality between the patients we see in emergency departments who have harmed themselves and patients receiving palliative care who have persistent suicidal ideas. No matter how apparently understandable their desires, in our experience there is nearly always a high degree of ambivalence, and we have seen many patients whose strong suicidal ideas have reversed with support provided by palliative care services.

In Oregon, the Death with Dignity Act became law before psychiatrists had had an opportunity to fully consider the implications of their role in the process. In a time when assisted suicide is being discussed in depth but not practised we have this opportunity. We hoped our article would encourage psychiatrists to grapple with the complexity of the arguments and consider how they might respond personally and professionally to the patient who asks for assistance to end their life.