There are many more statements in the professional medical literature in the period 1975-1982 related to limiting life-prolonging medical treatment; we have only presented a small selection from that much more extensive literature, a literature whose history deserves a much fuller analysis. But we have seen that Deciding to Forego Life-Sustaining Treatment goes beyond what was already in the professional literature primarily by emphasizing the point that the organizing theme for all policies and decisions to limit care should be the decisions of the patient or those who speak on behalf of the patient, because the patient has the right to refuse life prolonging therapy. Even that theme was present in some of the professional literature, but none of that literature made it the organizing theme. In this way, Deciding to Forego Life-Sustaining Treatment is an application of the general principles about decision making enunciated in Making Health Care Decisions.

We turn from the medical literature to legal developments. I want to emphasize at least two developments, the development of natural death statutes and the development of right-to-die decisions in the courts. We shall see in that material ample evidence of the acceptance of most of the elements of the current consensus.

California passed the first natural death statute in 1976. It was followed in 1977 by Arkansas, Idaho, Nevada, North Carolina, Oregon, and Texas.9 By the time the Commission report came out, 14 states and the District of Columbia had passed such statutes. This is not the place to offer a full analysis of all of them. We shall only focus on the extent to which the first seven, which antedated by several years the work of the President's Commission, incorporated the elements of the current consensus.

The full force of principle (a) of the current consensus, that life-prolonging care can be withheld because the patient has a right to refuse it, is the whole point of all of these natural death statutes. But it is worth noting that several of them (Arkansas, California, Idaho, and North Carolina) begin with an explicit statement of that right. I note, parenthetically, that Arkansas defines it as both the right to refuse such therapy and the right to request it and that North Carolina defines it as the right to a peaceful and natural death. It is also worth noting that while most of them (California, Idaho, Nevada, Oregon, and Texas) confine their provisions to patient refusals in certain cases, thereby seeming to limit the recognition of patient rights, all who do so make it clear that the statute does not limit any more general right to refuse treatment. Principle (b), that the right extends to incompetent as well as competent patients, is once more the whole point of these statutes, but it is worth noting that two of the statutes (Arkansas and North Carolina) add more provisions which provide for surrogate decision making on behalf of incompetent patients. As all of the statutes allow attending physicians to rely upon directives without the authorization of a



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