The Patient Self-Determination Act (PSDA) took effect December 1, 1991. As a direct result of the Nancy Cruzan case, this Act is intended to promote awareness and discussion of health-care issues in preparation for medical decisions at the end of life. The mechanism is the federal requirement that any health-care institution which expects to receive Medicare or Medicaid funds must inform patients upon admission of state laws governing self-determination issues. Any discussion among patients, families and their physicians stimulated by the PSDA is healthy. Physicians must be prepared for new questioning by patients about self-determination issues and must be knowledgeable of state laws. They must also defend against bureaucratization of medical decision-making by taking a leadership role in the patient autonomy movement, injecting into the movement an awareness of the rational capacity of medical technology.