The letter by Gert and colleagues begins inauspiciously. They claim mistakenly that we categorized as immoral their position that physicians should notify dying patients who request physician-assisted suicide that, as an alternative, they may stop eating and drinking. We made no such claim. As is abundantly clear from our article, we advanced a much more modest claim: that if a patient's voluntary refusal of food and fluids were equivalent to suicide, and if a clinician were to believe that this patient's suicide would be immoral, then it would be wrong for a clinician to inform the patient that he or she had a legal right to stop eating and drinking. This is part of the moral complexity that we claimed proponents of the practice of voluntary refusal of hydration and nutrition have failed to address. Gert and colleagues attempt to address this complexity by invoking the concept of moral paternalism. While we welcome careful discussion about the nature and limits of paternalism in medicine, their proposal that a physician should not withhold information if it is not universally agreed that withholding such information would be morally correct is unhelpful. If a clinician were to inform a seriously depressed but otherwise healthy patient that he has a legal right to refuse food and fluids as a means to committing suicide, then the clinician's conduct clearly would be wrong. This would remain true even if there were, as there no doubt are, some persons who think otherwise.

The real issue concerns what a patient has a moral right to know. The voluntary refusal of foods and fluids by patients who are capable of eating and drinking is not currently the standard of care in palliative medicine. For this reason, clinicians who oppose this practice do not deny their patients information they are entitled to have when they do not inform them of this option. Failure to grasp this point may have led Gert and colleagues to claim falsely that patient refusal of hydration and nutrition is a practice that avoids moral controversy altogether.