In California, a physician who is unwilling to comply with a terminally ill patient's wish to be allowed to die must transfer the patient. Failure to do so constitutes unprofessional conduct.
In Florida, a physician unwilling to comply with a patient's declared intent must make only a "reasonable effort" to transfer the patient.
In Alaska, however, an attending physician who fails to comply with a patient's properly declared wish not to have his or her life artificially prolonged has no right to be paid for services after the point at which those wishes should have been honored. The physician can also be subject to a civil penalty of up to $1,000 for failing to comply with a patient's declaration.
These differences in state laws are examples of the many nuances that govern Americans' rights to refuse or withdraw life-prolonging medical treatment. Keeping up with these variations can be a full-time job.
Fortunately, the legal staff of the Society for the Right to Die has undertaken that task by publishing "Refusal of Treatment Legislation: A State-by-State Compilation of Enacted and Model Statutes."
It takes a 3-inch ring binder to compile the results of their research and analysis.
The reason for the ring binder, rather than the traditional book binding, is obvious: Since March, when this project went to press, eight states have passed new legislation, adopting or updating statutes regarding living wills or the durable power of attorney for health-care matters. Moreover, new legislation has been pending in six other states -- all of which means that the society is already publishing an update consisting of more than 100 pages of new legislation.
When the Supreme Court's 1990 decision in the Nancy Cruzan case brought the national spotlight to the issue of futile prolongation of life, the importance of these state laws came into clearer focus.
The court ruled that Missouri had a constitutional right to require strict standards of proof that Nancy Cruzan, then in a persistent vegetative state, would have wanted to be removed from life-prolonging medical support. But the ruling left states free to set their own standards.
There are many variations in the ways states treat such issues as a physician's obligation to follow a patient's declared wishes, the ability of surrogates to make decisions for the patient or the definition of the imminence of death.
For example, some states retain a restrictive definition of a "terminal" condition that would exclude advanced Alzheimer's patients or, in some cases, those in persistent vegetative states. In other words, these conditions would not be enough for living wills or other forms of advanced directives to take effect and, thus, life-prolonging treatments would continue.
These variations can produce complications for people who find themselves in hospitals in other states, or for people who spend substantial amounts of time in states away from their primary residence.
"Refusal of Treatment Legislation" may provide more information than the average person needs on this subject. But it is an invaluable tool for lawyers, libraries and groups that work with terminally ill people. It is available from the Society for the Right to Die for $45 for members, $55 for non-members. The 1991 update is available to members for $15, $20 for non-members.
Membership in the society costs $15 per year and includes a newsletter and discounts on publications. Contact the Society for the Right to Die, 250 W. 57th St., New York, N.Y. 10107; (212) 246-6973.
Send your comments and questions about death and dying to = Sara Engram, Mortal Matters, The Evening Sun, P.O. Box 1377, = Baltimore, Md. 21278.