Why I decided to provide assisted dying: it is truly patient centred careBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l412 (Published 30 January 2019) Cite this as: BMJ 2019;364:l412
All rapid responses
I read with interest the thoughtful essay by Dr Sandy Buchman, explaining why accepting patient’s autonomy led him to provide lethal injection. His questions have been mine. What are the goals and values of medicine? What does it mean to truly respect patient autonomy?
Consent to treatment is fundamental to the integrity of the doctor-patient relationship. Its ethical basis is the respect for the autonomy of the individual. The respect for autonomy has enormous value as a principle, derived from a high opinion of the patient’s value and worth and should grace each interaction with a patient. However, should autonomy be the pinnacle of modern medical ethics? I do what I want for me. I choose for me. What about the effects on my friend, my neighbour, my doctor if I always do what I want? Is unrestrained individual autonomy good for society? Is not society the very expression of the inter-dependent relationships we have with each other? I stop at the red light because waiting for you to go first makes sense for us both.
What limitations then, if any, should be placed on autonomy?
The problem with ‘The Four Principles’ of Beauchamp and Childress in Medical Ethics is the pre-eminent principle. Is it ‘do no harm’ or justice or beneficence or autonomy? And what trumps what? Does autonomy trump justice if a terminally ill patient wants the last ICU bed? Does patient autonomy trump doctor autonomy if a dying patient wants CPR? What if these are not the most important principles at all? What about compassion or human dignity or the inherent value of human life?
Does the introduction of euthanasia affect more than those concerned? Dr Buchman is right that it represents ‘a fundamental shift in the medical profession’s role.’ The shift from preserving life to taking life is enormous and should not be minimised. The prohibition of taking life is present in almost all civilised societies due to a high view of the worth of human life. Everyone has a right to life under Article 1 of The Human Rights Act 1998 such that no one should be deprived of that life intentionally. This is in accordance with the UN Universal Declaration of Human Rights which affirms, ‘the inherent dignity and the equal and inalienable rights of all members of the human family.’ For the state to sanction the taking an individual’s life is a solemn and significant action. It reverberates across the values and shakes the very basis of our society.
Far from one person’s decision affecting no one but himself, it affects us all. Some patients may never consider assisted suicide unless it was suggested to them. The terrible irony is that legislation introduced with the intention of enhancing individual autonomy may diminish the autonomy of the most vulnerable.
Dr Buchman described the case of Professor Froggatt whose suffering was undeniable. We must face such suffering squarely- as physicians we cannot make everything better. How do we move forward? Beauchamp and Walters conclude that moral dilemmas are “a need to balance rival claims in untidy circumstances”. Do we need a different matrix for analysis? Or simply to strengthen the matrix to involve more dimensions to each claim? We need to consider the intrinsic nature of the act of state sanctioned-taking of life by a doctor. We must outline the unintended consequences of diminishing the autonomy of others. We must consider that the underlying principle of inherent human dignity is core to both these values- is it compromised more by the state permitting the intentional taking of life or by restraint on individual autonomy?
We must stop to reflect because some patient suffering is terrible, but human value and worth restrain us from taking life. Responsibility to the vulnerable is the very stuff of friendship and family, of society, of the doctor-patient relationship itself.
I do not want to take patients’ lives. Even if they ask me to.
1.Beauchamp TL, Childress J. Principles of biomedical ethics. 1st ed. New York: Oxford University Press, 1979; 5th ed, 2001
4. Beauchamp and Walters Contemporary Issues In Bioethics, 6th Ed. (New York: Wadsworth, 2003).
Competing interests: I am a Christian.
There is no neutral stance on the ethics of euthanasia: A response to Drs Buchman and Blackmer.*
The BMJ has recently published two articles, one by Dr Buchman, a palliative care physician and the incoming president of the Canadian Medical Association (1), the other by Dr Blackmer, a physician and vice president of international health at CMA (2) presenting a very positive and benign picture of the implementation of legalized euthanasia in Canada, euphemistically called “Medical Aid in Dying” (MAiD). As an academic medical ethicist at McGill University in Montreal for nearly four decades and now living and working in Australia, I am concerned that Australian legislatures, which are currently considering whether to legalize euthanasia, might accept the picture presented in these articles, without identifying their deficiencies.
In focusing only on respect for the autonomy and relief of the suffering, of an individual, personally identified, educated, mentally competent patient who requests and gives informed consent to MAiD, Dr Buchman makes the strongest case possible for the ethical acceptability of euthanasia and its legalisation. But, apart from other concerns, generalizing even these justifications beyond Dr Buchman’s patient and his specific characteristics and circumstances raises problems. In reality, how many people requesting euthanasia or assisted suicide (MAID) will have the intensive attention, medical and family support Dr Buchman describes, or be as informed, articulate and highly educated as this patient, who himself was a doctor?
Respect for individual autonomy is used, as Dr Buchman does, by pro euthanasia advocates as a justification for legalizing MAID. But it is far from the only consideration which needs to be taken into account, even if one does not object to MAID on the most fundamental basis that we should not authorise anyone, let alone doctors, to intentionally inflict death on other human beings.
Dr Buchman makes no mention of any such considerations, in particular, risks and harms to the “common good” and society. These include breaches of the value of respect for human life at both the individual and societal levels, and serious physical and existential risks and harms to vulnerable people, especially those who are disabled and fragile elderly people.
Whether we agree or disagree with MAID, we can all agree with Dr Buchman’s goal of relief of suffering, but we must kill the pain and suffering, not the person with the pain and suffering.
Dr Blackmer’s article raises a wide range of important issues, which he does not identify. They include: Is MAID medical treatment? It can be argued that it is not (3). Likewise, MAID is not, as its promoters argue, just a legitimate incremental extension of “good palliative care”. The informing philosophies of MAID and palliative care are in conflict. Palliative care is based on a commitment to help people to live as fully as possible until they die a natural death. The informing principle of MAID is that it is ethical to intentionally inflict death to relieve suffering or even the fear of future suffering.
Whether to legalize MAID is a societal and political decision, not primarily a medical one and it’s suggested that if a society wants it to be available and legalizes it, for many reasons, it should be kept out of medicine (4). I call this “taking the white coat off euthanasia”.
By embracing euthanasia and assisted suicide as medical treatment the CMA made physician participation an expectation and refusing to provide them became an exception requiring justification. Despite assurances from the CMA leadership, Canadian doctors who object to participation in “therapeutic homicide”(5) now risk discipline and even expulsion from the medical profession. (6).
Euthanasia has been rapidly normalized and routinized in Canada at a rate that even one of its strongest advocates, Dr Yves Robert, registrar of the College of Physicians of Quebec has found alarming, in that it has quickly become just another choice of how to die. (7)
Not everything that is legal is ethical. So, the Canadian Medical Association could have maintained its long-established stance - which reflects almost 2,500 years of medical ethics wisdom - that it is unethical for physicians to participate in MAID, even though it is now legal in Canada. When the cloak of medical approval is absent, the public are much more likely to question the wisdom of legalizing it.
Finally, while the CMA might be neutral with respect to who may be a member, in that it accepts as members both physicians who are pro-MAID and those who are anti-MAID, there is not, as Dr Blackmer claims, any “neutral stance” on the ethical acceptability of MAID. In not continuing to oppose physicians’ involvement in it as unethical, the CMA is unavoidably supporting it in some or other form, which is not a neutral position. In fact, we can see precisely that outcome in the use of CMA statements by Canadian courts, legislatures and regulators in promulgating and implementing the law legalizing MAID in Canada.
In short, there is no neutral stance on the ethics of MAID but a clear choice to be made as to whether one is for or against it, as the present conflict among Canadian physicians so clearly demonstrates, despite the CMA’s and Dr Blackmer’s desire to whitewash the situation.
* Margaret Somerville AM, FRSC, A.u.A (pharm.), LL.B. (hons),
D.C.L., LL.D. (hons. caus.), D.Sc.(hons. caus.), D.Hum.Let.(hons. caus.).
Emerita Samuel Gale Professor of Law; Emerita Professor, Faculty of Medicine;
Emerita Founding Director, Centre for Medicine, Ethics and Law, McGill University,
Professor of Bioethics, School of Medicine (Sydney campus), Affiliate of the Institute for Ethics and Society, The University of Notre Dame Australia,
1. Buchman S. Why I decided to provide assisted dying: it is truly patient centred care. BMJ. 2019 Jan 30;364:l412.
2. Blackmer J. Commentary: How the Canadian Medical Association found a third way to support all its members on assisted dying. BMJ. 2019 Jan 30;364:l415.
3. Boudreau, J. Donald and Margaret A. Somerville, “Euthanasia is not medical treatment”, British Medical Bulletin 2013; 106: 45–66,
4. Ruijs, Cees, Margaret Somerville, Henk ten Have, Joz Welie forthcoming publication.
5. Flegel K, Fletcher J. Choosing when and how to die: are we ready to perform therapeutic homicide? CMAJ. 2012 Aug 7;184(11):122
6. Kelsall D. Physicians are not solely responsible for ensuring access to medical assistance in dying. CMAJ. 2018 Feb 20;190(7): E181
7. Yves Robert, Vers la morte a la carte, http://www.cmq.org/nouvelle/fr/vers-la-mort-a-la-carte.aspx (accessed 12 February 2019)
Competing interests: No competing interests
As an ordinary Canadian family physician, I have seen a different side of the new ‘Medical Aid in Dying’ regime Dr. Sandy Buchman glowingly describes. The scheme was sold to us and the public as a rare matter of assisting the suicide of extreme terminal illness cases. By a year into it, hundreds (now thousands) had died and over 99% of the deaths were not by self-administration, but intravenously by doctors and nurses. The Canadian euthanasia death rate has continued to escalate, while funding for palliative care services has fallen in several provinces.
The wide eligibility criteria do not require any estimate of prognosis. Yet there is already intense social pressure to widen them further to include euthanasia of children, the healthy disabled, cognitively impaired, and mentally ill.
Ending life has been re-defined as ‘part of care’. An Ontario court ruling has confirmed that doctors who want nothing to do with euthanasia have to get involved by making an “effective referral”.
Few Canada doctors foresaw that “going neutral” would guarantee the arrival of euthanasia, or that promises of a shot in the arm for palliative care would be forgotten. Even fewer realised they would have no option but cooperate with providing death on demand.
It has become all too easy to end patients’ lives. Learn from our mistakes.
Competing interests: No competing interests
Agree or not with the concept of assisted dying, it’s clear that the account of Dr Sandy Buchman is heartfelt, and that the sincere intention was to lessen pain & suffering. It’s also clear that pain and anguish are not limited to the patient alone. Sometimes however, big questions can overshadow seemingly trivial details - like the choice of drugs to enable that dreamt-for but dreamless sleep.
Intravenous propofol given to induce anaesthesia not infrequently results in the patient complaining of discomfort or pain as the drug enters the vein. This can be reduced by the admixture of lidocaine. Rocuronium also sometimes results in arm withdrawal or flinching, in those already given a ‘sleep’ dose of propofol. Other equally effective muscle relaxants do not cause this pain response.
We have little doubt that the end-of-life described was as painless and peaceful as it appeared, but know that patients we anaesthetise with these drugs do sometimes ‘drift off’ experiencing short-lived pain that our drugs have caused. Of no lasting consequence for the dying perhaps, but potentially unsettling & upsetting for those doing the assisting. Forever wondering whether last thoughts were interrupted by pain from the procedure: never able to ask, explain or apologise.
Personal views on the big question clearly differ but no-one seeks to add to the suffering of those involved. Whatever our views, we need to talk.
Competing interests: No competing interests
I am deeply troubled that the BMJ should print a 3 page essay on a one sided opinion on Assisted dying and once again allows advertising from a pro Assisted Dying lobby group with full endorsement in it from senior BMA figures and yet claims to be representing the membership of British doctors. The BMA has not agreed to support this motion and should it ever do so I will leave immediately.
I believe in the sanctity of life. I have an aged relative and many similar patients who are blind, almost deaf and suffer from medical ailments, not wishing to burden their family as they can no longer be useful. They would fit the criteria for Assisted Dying with intolerable suffering but far from a lethal injection they need to be told of their intrinsic worth as a human being and assured of people who care to travel this journey with them. Palliative Care may not be good enough in many ways but we fail our patients most of all when we give up trying to alleviate suffering and Assisted Dying is the most feeble and pathetic of excuses for this.
I hear the argument of personal autonomy. Which of us chooses our cancer, our dementia, our degenerative diseases? Nor do we choose the time of our death but this one alone will surely come.
Competing interests: No competing interests
In June 2016, Canadian legislation came into effect with Bill C-14 that legalized Medical Assistance in Dying (MAiD), a euphemism for euthanasia and physician-assisted suicide. In Canada, most cases of MAiD are via euthanasia, where patients’ lives are ended through a lethal injection of drugs administered by a physician or a nurse practitioner. Many palliative care experts object to the term ‘assistance in dying’ because that is what palliative care physicians already do by helping people to die well, without hastening or causing death. Nevertheless, the term was formally adopted by the government, and continues to contribute to confusion regarding palliative care and MAiD.
The President-Elect of the Canadian Medical Association (CMA), Dr. Sandy Buchman, a palliative care physician and euthanasia provider, has exacerbated this confusion further. In his recent invited BMJ essay (2), Dr. Buchman describes providing euthanasia as the most patient- centered way to relieve suffering. Dr. Buchman’s views are not consistent with the official policy of the CMA regarding palliative care (3), or the position of the Canadian Society of Palliative Care Physicians (CSPCP) and the majority of palliative care physicians in Canada who do not view euthanasia as part of palliative care. In a recent survey, CSPCP members strongly agreed that euthanasia is not part of the provision of palliative care. The vast majority (92% of 213 respondents) do not provide euthanasia (4). The CSPCP position that palliative care strives to reduce suffering, not to end life (5), is consistent with international standards for palliative care, such as the World Health Organization definition (6). CMA Policy on Palliative Care also recognizes that palliative care and MAiD are distinct (3).
Dr. Buchman romanticizes euthanasia. He calls it “the most patient-centered service I could offer,” leading to “the most peaceful death I had ever witnessed.” Peer reviewed, published evidence demonstrates that most requests for euthanasia are motivated by a desire for control, or a fear of dying, not by uncontrolled symptoms such as pain or shortness of breath (7). The patient Dr. Buchman refers to in his essay illustrates the existential, not symptom-based, risk factors involved. These existential issues include fear of loss of control, questioning the meaning, purpose and value of life, fear of what comes after death, demoralization, and fear of being a burden to others (8). None of these issues are properly addressed by euthanasia, and hastening the death of a patient removes any further therapeutic opportunities. Simply bowing to “patient autonomy” and ending a life without working hard to alleviate the deeper total pain is hardly “patient centered” in the most robust sense of that term. As Chochinov and Mount beautifully express, “…to be clear, palliative care is not a panacea that can eliminate every instance and every facet of end-of life suffering. However, the physician-patient relationship is complex and profound. Preserving dignity for patients at the end of life is comprised of a steadfast commitment to non-abandonment and a tone of care marked by respect, kindness, and an unwavering affirmation of patient worth.” (9).
The other group of citizens ignored in Buchman’s account are those whose lives are made even more vulnerable by the very existence of euthanasia, including those with disabilities, mental illness, dementia, children, seniors, and those who lack resources including financial, social supports, or access to palliative care. The Vulnerable Persons Standard (VPS) has been developed to provide standards for safeguards needed in Canada to protect those who are most vulnerable to coercion, or who feel that they have no other option than to choose to have their lives ended (10). Sadly, these very practical, broadly supported and meticulously documented recommendations for true “patient-centered care” have been dismissed and ignored by supporters of euthanasia and all levels of government. The few regulations that have been implemented, such as the requirement for capacity – both at the time of request and at the time of delivery of euthanasia, and a ten day waiting period between formal request and death, have no standard system of oversight to ensure compliance, and enforcement is essentially non-existent. There are no standardized training requirements for capacity assessment or psychiatric consultation for MAiD. Individual physicians or nurse practitioners are solely responsible to determine eligibility and whether or not to waive the ten day interval. The assessments for receiving government supported workers’ compensation or home oxygen are often more lengthy and stringent than those done in preparation for MAiD!
Drs. Blackmer and Buchman assert that the CMA supports physicians who refuse to participate in euthanasia (1,2). They fail to note that some provincial medical regulators, including the largest one in Canada with over 40,000 physician members, demand strict physician participation through “effective referral” (11), and that physicians who refuse such participation could be forced to withdraw from practice or lose their licences altogether. Some of these physicians are fighting a lengthy and expensive court battle to resist this coercion (12). A number of medical groups have supported these physicians by requesting intervener status in the case. The CMA has not.
Two and a half years after its legalization in Canada, strong lobbies are intensifying their push for euthanasia as a response to mental illness, physical disability, cognitively incapacitated patients through advance directives, and children. In Toronto, the Hospital for Sick Children has already drafted policy on providing euthanasia to mature minors (children felt to be capable of making their own medical decisions, despite not yet reaching the age of majority), anticipating a change in legislation later this year that would make euthanasia permissible for these children (13).
These developments, and the ongoing jeopardy faced by objecting physicians in Canada, contradict the optimistic, rosy assessment offered by Drs. Blackmer and Buchman. Other jurisdictions need to take a hard look at the reality of the Canadian context before holding Canada up as an example to be emulated.
Dr. Leonie Herx, Division Chair & Associate Professor of Palliative Medicine, Connell Chair in Palliative Medicine, Queen's University, Kingston, Ontario, Canada
Dr. Srini Chary, Associate Professor, Division of Palliative Medicine, University of Calgary, Calgary, Alberta Canada
Dr. Ed Dubland, Palliative Medicine Consultant, Burnaby, British Columbia, Canada
Dr. Robin Fainsinger, Professor, Division of Palliative Care Medicine Medicine, Edmonton, Alberta, Canada
Dr. David Henderson Palliative Medicine Consultant, Truro, Nova Scotia, Canada
Dr. Bernard Lapointe, Associate Professor, Departments of Oncology & Family Medicine, Director of Palliative Care, McGill University, Montreal, Quebec, Canada
Dr. Valerie Schulz, Professor, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
1. Blackmer J. Commentary: How the Canadian Medical Association found a third way to support all its members on assisted dying. BMJ. 2019 Jan 30;364:l415.
2. Buchman S. Why I decided to provide assisted dying: it is truly patient centred care. BMJ. 2019 Jan 30;364:l412.
3. Palliative Care (Policy). Canadian Medical Association. 2016. Accessed on February 6, 2019: https://www.cma.ca/sites/default/files/2018-11/cma-policy-palliative-car...
4. Medical Assistance in Dying Member Survey (October 2017). Canadian Society of Palliative Care Physicians (CSPCP) 2018 February. Accessed on February 6, 2019: https://www.cspcp.ca/wp-content/uploads/2018/02/CSPCP-MAID-survey-report...
5. Key Messages: Physician-Hastened Death. Canadian Society of Palliative Care Physicians (CSPCP) 2015, October. Accessed on February 6, 2019: http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf
6. WHO Definition of Palliative Care. Accessed on February 6, 2019: https://www.who.int/cancer/palliative/definition/en/
7. Palliative Care (Policy). Canadian Medical Association. 2016. Accessed on February 6, 2019: https://www.cma.ca/sites/default/files/2018-11/cma-policy-palliative-car...
8. Rodríguez-Prat A et al. Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography. BMJ Open. 2017 Sep 29;7(9):e016659. Accessed on February 6, 2019: https://bmjopen.bmj.com/content/7/9/e016659.long
9. Chochinov, H. Dying, Dignity, and New Horizons in Palliative End‐of‐Life Care. CA: A Cancer Journal for Clinicians. 2006; 56: 84-103. doi:10.3322/canjclin.56.2.84
10. Chochinov H, Mount B. Physician Hastened Death: Awaiting a Verdict. CMAJ Blog. 2014 October, 14. Accessed on February 6, 2019: https://cmajblogs.com/physician-hastened-death-awaiting-a-verdict/
11. Vulnerable Persons Standard. Accessed on February 6, 2019: http://www.vps-npv.ca/
12. Medical Assistance in Dying (Policy). College of Physicians and Surgeon of Ontario. 2016 Accessed on February 6, 2019: https://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-i...
13. Leiva, R et al. Euthanasia in Canada: a cautionary tale. World Medical Journal. 2018 64(3):17 Accessed on February 6, 2019: https://www.wma.net/wp-content/uploads/2019/01/wmj_4_2018_WEB.pdf
14. DeMichelis C, Zlotnik Shaul R, Rapoport A. Medical Assistance in Dying at a paediatric hospital. J Med Ethics. 2019 Jan;45(1):60-67.
Competing interests: No competing interests
Re: Why I decided to provide assisted dying: it is truly patient centred care; response to Regnard et al (Feb 5th)
Can six senior Palliative Care (PC) consultants  really have ignored the main thrust of my letter? Several senior Belgian PC physicians were prominent advocates of legalising Medical Aid in Dying (MAID); Dr Buchman's account of his conversion to pro-MAID is only the latest of numerous similar accounts from PC physicians. Where it is legal, many PC physicians have felt able to involve themselves, whether simply agreeing to refer patients or actually administering lethal medication. Some did so easily, others after much heart-searching; others still refused. The Australian survey I referenced is the most recent evidence that in most Western countries except Britain, PC physicians have a wide range of views about MAID and feel free to express them. Among mainly Arab and Muslim physicians, a similar spectrum of views exists, though even passive euthanasia (something British PC physicians carry out every day) is a step too far for some. I asked not whether but why similar diversity is seemingly absent in British PC. Regnard et al did not answer.
I wrote that I ‘suspected’ that pressure from senior clinicians explained the total absence of pro-MAID expressions in British PC (Prof Ahmedzai’s brief, unrepeated excursion excepted). In reality I am almost certain of it, because My Death, My Decision knows of junior clinicians in PC who have been told that if they join MDMD or publicly express support for MAID, their careers will be at risk. That is why medical and nursing professionals will soon be able to both join MDMD and take part in the debate anonymously.
When abortion was debated in the mid-1960s, many gynaecologists opposed decriminalisation but many also argued for it. When the law changed, the dangerous complications of back-street abortion disappeared from casualty departments almost overnight. Few gynaecologists (or politicians) now argue for repeal, even if there is still debate about time-limits (as there is with MAID).
Finally, Regnard et al selectively quoted what Michael Irwin and I wrote about British PC physicians. We did indeed write that they were “in some very important respects, unfit—or at any rate, much less than ideal -” but the sentence continued: “- for a medical specialty that deals every day with human beings holding diverse views on one of the most important stages of our life.” No MAID campaigner doubts the value and importance of good PC, or the dedication and sincerity of its practitioners, any more than abortion campaigners doubted the need for good obstetric care. Successful campaigning for MAID has mostly happened in legislations that already had good PC facilities. When it legalized MAID in 2002, Belgium already had excellent PC. British PC physicians are unique in their anti-MAID conformity. Either it is enforced or it genuinely reflects a uniform world-view that is held by all British PC clinicians. Both explanations are surely worrying.They have not always “been too quiet [or] respectful and considerate of the views of others”, particularly of those ‘others’ who are their patients.
1. Regnard C, Davis C, George R, Oliver D, Anthony-Pillai R, Proffitt A. Rapid Responses to Buchman S. Why I decided to provide assisted dying: it is truly patient centred care, Feb 5th.
2. Brewer C. Rapid responses to Buchman S. Why I decided to provide assisted dying: it is truly patient centred care Feb 4th
3. Abohaimed S.S. Matar B. Al-Shimali H. Al-Thalji K. Al-Othman O. Zurba Y. Shah N. Attitudes of Physicians Towards Different Types of Euthanasia in Kuwait. Medical Principles and Practice. 2019. DOI: 10.1159/000497377
Competing interests: I have been active in the right-to-die movement for over 40 years and am Director of Campaigning (medical) for My Death, My Decision, a pro-choice organisation.
Quite a coincidence though, huh?
Competing interests: No competing interests
I was surprised at the publication bias of the BMJ in relation to its decision to print a 3 page pro-euthanasia article before the forthcoming RCP (Royal College of Physicians) poll on assisted dying, without any corresponding article from the opposite viewpoint in the print version. I couldn’t find a conflict of interest statement from the BMJ to accompany the article either, so that it is open and transparent to readers that the BMJ has previously declared as a journal that it is in favour of assisted dying.
I previously highlighted this publication bias and its impact on creditability of the BMJ as an independent and peer reviewed journal:
and you published a response of reassurance:
I’m disasppointed that you have not followed the reassurances you gave.
Competing interests: No competing interests
Thanks to Nicola S Wright (https://www.bmj.com/content/364/bmj.l412/rr-8) and David J Jones (https://www.bmj.com/content/364/bmj.l412/rr-9) for asking about an insert advertising the pressure group Healthcare Professionals for Assisted Dying (HPAD) that was distributed with the 2 February 2018 print issue of The BMJ.
The BMJ depends on paid-for advertising revenue, but the advertising and editorial departments operate independently, without any day-to-day knowledge of the content each other is putting in any print journal.
We accept only legal adverts that meet Advertising Standards Authority rules and The BMJ’s policy. See https://www.bmj.com/about-bmj/resources-advertisers-and-sponsors
The BMJ has distributed paid-for inserts from HPAD many times before, and we welcome advertising from all sides of the assisted dying debate.
The BMJ strives to present all views on assisted suicide. In addition to last week's Essay by Sandy Buchman we published several pieces online that expressed varied opinions, as stated in the Essay in print. We will publish further articles this week in print and online, expressing different views.
Competing interests: No competing interests