• electronic correspondence
• law and medical ethics
• physician assisted suicide

At the time of writing there appear to have been no electronic submissions to the Journal of Medical Ethics. It seems appropriate, therefore, to begin electronic correspondence with a consideration of some of the ethical implications of this new form of ethical dialogue.

I have posted this response to Kenneth Boyd’s editorial on Mrs Pretty and Ms B¹ as this article may provoke debate far beyond the medical and ethical establishment. This issue may be of tremendous concern to patients or their carers who are presently suffering in circumstances similar to those described.

The electronic response forum of the BMJ has been in operation for over four years.² An editorial in the BMJ on physician assisted suicide³ has attracted 125 responses at the time of writing. An important feature of electronic responses, particularly on items that generate a lot of debate, is that the contributions often refer to each other. These responses range from the scholarly and meticulously argued to distressing personal accounts of suffering. As both an avid reader of rapid responses to the BMJ, and a physician, I consider both sorts of contributions to be valuable, but increasingly feel uncertain about what my written response to them should be when I wish to enter into dialogue with the author. I feel on sure ground when considering the scholarly submission that is clearly intended as a contribution to a peer reviewed journal, and have no qualms at drawing up a response to point out its weaknesses. Equally, as a family doctor, I hope that I am able to approach distressing accounts of suffering with a degree of empathy. It is sometimes the case, however, that submissions clearly showing distress also contain dubious argument that any peer review process would deal with severely.⁴ Where accounts of suffering alongside dubious arguments are posted from patients I personally feel squeamish about responding, finding myself caught between the roles of vituperative reviewer and empathic listener. As an editorial in the BMJ on the subject of electronic responses has noted: “We’ve begun to capture the opinions and experience of patients … and publish just about anything that isn’t libellous or doesn’t breach patient confidentiality”.² Inevitably, such a broad range of responses will produce many that deserve to be challenged. Merely to ignore dubious argument implies that such opinions are correct. Furthermore, it is astonishingly easy to post an electronic response, and the process contains no warning that opinions expressed may be severely challenged. We should consider what the rules of debate on this Journal of Medical Ethics web site should be.

To prevent any misunderstanding, I wish to state that this response does not issue out of intense personal suffering, and that I am prepared for the most stringent peer review of its contents. Say anything in response, but please don’t ignore me.