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new-logo25By author/contributor Marilyn M.  Singleton, M.D., J.D. a board-certified  anesthesiologist and Association of American Physicians and Surgeons (AAPS)  member


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. 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 ObamacareHurtwithdraw medical  treatment—even against a patient’s wishes. 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. (See, for example, California Probate Code section  4701).

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, 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 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.

The UHCDA provides that a physician or institution that  has decided to withdraw care against the patient’s wishes must make “reasonable  efforts” to transfer the patient to a provider willing to comply with the  patient’s wishes and provide continuing care until a transfer is made or a  transfer is found to be impossible. This leaves much room for defining  “reasonable” efforts, and there may be no options available in areas where  medical facilities are scarce. Of course, hospital policies caution physicians  that decisions should not be governed by age, race, creed, or economic status.  However, if a patient cannot afford skilled nursing care or home health aides,  ability to pay determines the outcome.

In  treatment withdrawal cases, physicians must continue pain relief and “palliative  care.” Stanford’s policy defines palliative care as any treatment that  concentrates on reducing the severity of symptoms of a disease or condition,  rather than providing a cure. Taken literally, this definition would include  anti-hypertensives for high blood pressure and insulin for  diabetes.

Is  treatment withdrawal about compassion and preventing suffering, or pragmatism  and saving money? Medicare spends an average of $24,000 for beneficiaries in  their last year of life versus an average of $4,000 for all other beneficiaries.  However, a recent federally funded study concluded that decedents’ average “cost  of dying” is only modestly higher than yearly costs for individuals with  similarly complex medical needs, e.g., dementia, cancer, stroke, or chronic  obstructive lung disease.

Over the last 20 years, one-fourth of Medicare dollars  has been spent on services for the five percent of beneficiaries in their last  year of life, even with the growth of hospice. Predictions, such as those from  the American Heart Association that heart failure treatment costs will soar over  the next 20 years, may compel the government to formulate rigid, bright-line  rules and policies that promote a culture of rationing and “letting Grandma go  to a better place.”

Making peace with death is a complex personal process.  Many would choose to forgo treatment rather than spending every dollar on care  they perceive to be of low value.

But most Americans are forced to depend on a system that  will increasingly push Grandma onto a pathway to death well before her natural  lifespan has run its course—at the whim of elite decision-makers in the name of  the benefit of the collective.


Marilyn M. Singleton, MD, JD is a board-certified  anesthesiologist and Association of American Physicians and Surgeons (AAPS)  member. Despite being told, “they don’t take Negroes at Stanford”, she graduated  from Stanford and earned her MD at UCSF Medical School. Dr. Singleton completed  2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s  Beth Israel Hospital. She was an instructor, then Assistant Professor of  Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in  Baltimore, Maryland before returning to California for private practice. While  still working in the operating room, she attended UC Berkeley Law School,  focusing on constitutional law and administrative law. She interned at the  National Health Law Project and practiced insurance and health law. She teaches  classes in the recognition of elder abuse and constitutional law for  non-lawyers. Dr. Singleton recently returned from El Salvador where she  conducted make-shift medical clinics in two rural villages. Her latest  presentation to physicians was at the AAPS annual meeting about challenging the  political elite.

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