Death panels already at a hospital near you.

• Position: Life Span

When advance health care directives ("living wills") were popularized, the guiding principle was to allow patients to choose to "die with dignity:' but one man's dignity is another man's poison, cautions anesthesiologist Marilyn M. Single ton, a member of the Association of American Physicians and Surgeons, Tucson, Ariz.

Surveys suggest that half of those with a serious chronic illness prefer to die at home. The other half prefer treatment in hospitals. Advance directive legislation has evolved from a means to ensure patient autonomy to a license for health providers to withdraw medical treatment--even against a patient's wishes, Singleton charges. Statutory advance directives provide that individuals "have the right to give instructions about their own health care," but they fail to mention that such instructions may not be carried out if individuals have chosen life.

The Uniform Health Care Decisions Act (UHCDA), model legislation developed in 1994, has been adopted in whole or in part by several states. It provides that health care providers--without legal consequences--may decline to comply with an individual's health care decision that "requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution."

Not surprisingly, Singleton points out, the key term, "medically ineffective" is not defined. Any attempts at specificity would force an open debate on the morality of rationing and "playing God."

Patients must be informed of the rules before the final seconds of the game. Under state laws, circumstances under which wishes can be denied range from a terminal condition or permanent unconsciousness (Alabama) to being permanently unconscious or "an incurable or irreversible condition" that will cause death "within a relatively short time" (Maine).

Unbeknownst to patients, many hospitals have policies that flesh out treatment withdrawal standards. For example, Stanford (Calif.) Hospital's "Policy for Medically Ineffective (Futile) Treatment" states: "Medically ineffective refers to treatment that would not offer the patient any significant benefit. If an attending physician believes treatment is not medically ineffective and assumes care of the patient, treatment is not medically ineffective." This tortured clarification anoints the physician as the final arbiter, explains Singleton.

UHCDA provides that a physician or institution that has...