We thank the authors for their interest and offer some necessary clarifications. Assisted dying is an emotive and complex issue, and the aim of our Editorial^{Reference Bhui and Malhi1} was to anchor the debate within a framework of sophisticated discourse. Some issues raised by our colleagues seem to lack reason and are somewhat speculative as they are based on assumptions of premises that are unlikely to be realised.

The inconsistencies in reporting current practice in end-of-life care are inevitable given the lack of guidance or standard reporting frameworks in most jurisdictions, and this is a prevalent problem worldwide. We concur that legislation may bring more oversight of end-of life decisions, yet it is not obvious that this would suffice, and significant concerns remain where legislation for assisted dying has been passed. For example, in jurisdictions such as Belgium and The Netherlands, where assisted dying is already available and seemingly extensive safeguards are in place, there are ongoing complaints voiced by relatives of patients and advocacy groups that are submitted to governing bodies with the responsibility of legal and professional oversight. These complaints question the validity of the decisions made by physicians and procedures used to consult family and friends.

We disagree also with the point made that ‘perhaps it is unnecessary to single out assisted dying as a novel problem for the specialty’, given that putatively psychiatry already has a role in the management of such requests made by patients suffering from terminal illnesses. There is no global or even national agreement as to what psychiatric care should be made available to those receiving end-of-life care. Consenting to assisted dying solely on the basis of suffering from a physical illness ignores the important psychological impact of a terminal physical ailment such as cancer. Having in addition a mental illness not only adds to the suffering but invariably complicates the evaluation of quality of life, as it may impair the individual's reasoning. Further, the comorbid mental illness may not be optimally treated, especially if the suffering is considered to be inevitable. Thus, the development of a mental illness or its existence concurrently generates a whole new and separate set of implications where psychiatrists must be centre stage. New proposed legislation also suggests that capacity should be assessed more comprehensively, in particular if there are complications; in these instances, psychiatrists might be engaged precisely for such purposes, rather than for the overall assessment of optimal care for mental illness and the ability to weigh up decisions in the absence of suffering.

We are also somewhat puzzled by the challenge to our claim that ‘patients may be coerced’. We state quite clearly that this is a possibility that is evidenced in the original drafts of the proposed legislation. Coercion may come from all quarters, including in particular family and those that may have a conflict of interest. Procedures set up to monitor assisted dying in The Netherlands and Belgium, for example, which focus largely on the role of physicians, have regularly found procedural irregularities, with doctors often not following the stipulated steps. The insinuation in some of these instances is that physicians have a conflict of interest and are perhaps overly keen to facilitate the assisted dying pathway. We haven't commented on this specifically but have simply raised the concern that families and friends may also succumb to questionable practices. Again, this seems possible and needs safeguards, especially in those that are vulnerable such as the disabled, elderly, poor, and chronically and/or mentally ill.^{Reference Battin, van der Heide, Ganzini, van der Wal and Onwuteaka-Philipsen2} These concerns are borne out by research. For example, studies in 2010 in Oregon and Washington (states within the USA that permit physician-assisted dying) have shown that nearly a quarter of those ingesting lethal drugs did so because they no longer wanted to be a burden on their family.³ Furthermore, insurance companies were reported to favour funding for assisted dying rather than more intensive treatment.^{Reference Berger4}

Therefore, it is perhaps better to examine practices in jurisdictions where legislation and procedures are already in place and construct a pathway that allows for close monitoring and measurement of any provisions made for assisted death. However, trials of ‘denying’ end-of-life care are highly implausible both where the legislation for assisted death is already in place and, similarly, where the legislation does not permit end-of-life care – as is the situation in the UK at present. Suggesting that it is unjust to not pass legislation, by invoking the false premise that if assisted death is not permitted then care is being denied, does not advance a moral or logical argument.

In the UK, and where legislation is not in force, we assert that the necessary preconditions for legislation are not yet in place. Better-funded end-of-life care generally and standards of care that apply to people with severe mental illness may achieve much, if not all, of what legislation might achieve. In addition, we need further research and trials with appropriate monitoring of processes and procedures – all under the umbrella of close careful legal scrutiny. Thus, our emphasis is on a much more considered approach that allows for further investigation while maintaining choice and dignity for those involved.