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May 1992

Implementation of Advance Directives: For Physicians, a Legal Dilemma Becomes an Ethical Imperative

Author Affiliations

Department of Medicine Harvard Medical School Boston, MA 02115

Arch Intern Med. 1992;152(5):925-929. doi:10.1001/archinte.1992.00400170015004

When the Patient Self-Determination Act (PSDA) went into effect on December 1, 1991, a new right was bestowed uniformly on all Americans, the right to determine the kinds of care that they will accept and the kinds of care that they will not accept should they become incompetent. The right of the competent patient to refuse care is rooted in the common law and has been recognized for generations in the United States.1 The courts in the United States have struggled for 15 years, since the Quinlan case brought the question dramatically into public view, to find a way by which the right of the competent individual to refuse care could be made available equally to the incompetent patient.2,3 Physicians struggled over those years to make decisions regarding life-prolonging care for incompetent patients but, despite even the most conscientious efforts, decisions were sometimes driven as much by fear