A Shift in National Consciousness
More than 3.2 million South Koreans have formally registered to forgo life-sustaining treatment in the event of an incurable illness. This figure, released by the National Agency for Management of Life-Sustaining Treatment, highlights a profound shift in how the nation approaches the end of life. The data reveals that women comprise nearly two-thirds of the registrants, with 2.13 million women and 1.07 million men having made their wishes known. People aged 65 or older account for more than two-thirds of the total, indicating that aging populations are actively planning for their final chapters.
The steady rise in participation since the system launch in February 2018 suggests that the concept of a “dignified death” is gaining traction. From approximately 86,000 registrants in the first year, the numbers surged to one million by August 2021 and reached two million by October 2023. By August 2025, the total had exceeded three million. This rapid adoption reflects changing social attitudes toward death, autonomy, and the medicalization of dying.
Recent studies support this trend. A survey conducted by the Korea Institute for Health and Social Affairs found that an overwhelming majority of respondents prioritize minimizing physical pain and easing the financial burden on their families. The research indicates that for many Koreans, a “good death” is defined less by traditional family-centered rituals and more by personal comfort and the avoidance of unnecessary suffering.
“A growing number of Koreans now see a ‘good death’ less as a family-centered moment and more as one free of pain and financial strain,” the study noted, highlighting a significant departure from historical norms.
This pragmatic approach to end-of-life care is reshaping the landscape of medical ethics and family dynamics in South Korea. As the population ages and medical technology advances, the ability to refuse aggressive interventions has become a critical component of patient rights.
The Evolution of Legal Frameworks
The current legal infrastructure did not appear overnight. It is the result of years of ethical debate and landmark legal cases that forced South Korean society to confront difficult questions about dying. The path to the 2018 Act on Decisions on Life-Sustaining Treatment was paved by two pivotal court cases: the Boramae Hospital case in 1998 and the Severance Hospital case in 2009.
In the 1998 Boramae Hospital case, surgeons were found guilty after discharging a patient at his wife’s request due to financial burdens. The Supreme Court ruled that the doctors had acted as accomplices to murder, treating the wife’s request as an unauthorized proxy decision. This verdict sent shockwaves through the medical community, creating an atmosphere of fear where doctors felt compelled to prolong life at all costs to avoid criminal liability.
The legal landscape shifted a decade later with the Severance Hospital case. Here, the family of a woman in a persistent vegetative state sued to discontinue treatment. The Supreme Court ruled that if a patient has reached an irreversible stage of death, they have a constitutional right to self-densation. The court recognized that withdrawing life-sustaining treatment could be permissible if it aligned with the patient’s presumed intent, grounded in the constitutional rights to human dignity and the pursuit of happiness.
These cases provided the judicial foundation for the legislation passed in 2016 and enacted in 2018. The Act established a clear distinction between the “terminal stage” of a disease and the “dying process.” The terminal stage refers to a condition expected to result in death within months despite treatment, while the dying process refers to a state of imminent death with no possibility of recovery. Crucially, the law only permits the withholding or withdrawal of treatment during the “dying process,” a narrow window designed to balance patient autonomy with the protection of life.
The legislation created specific mechanisms for decision-making, including Advance Statements for Life-Sustaining Treatment (ASLST) and Physician Orders for Life-Sustaining Treatment (POLST). It also established governing bodies like the National Agency for Management of Life-Sustaining Treatment and Institutional Ethics Committees to oversee the process.
Confucian Values versus Modern Autonomy
Implementing Western-style legal frameworks within a traditionally Confucian society presents unique challenges. In South Korea, Confucian values emphasize filial piety, where children are duty-bound to care for their parents and prolong their lives. Historically, medical decisions were collective family matters rather than individual choices. Discussions about death were often considered taboo, and patients were frequently shielded from the truth of their prognosis to prevent despair.
Despite these cultural undercurrents, the data shows a clear move toward individual autonomy. The fact that women are registering at twice the rate of men may suggest shifting gender roles in health management or a greater willingness among women to confront mortality. Furthermore, nearly one in four elderly women aged 65 or older has filed an advance directive.
This shift does not eliminate the role of the family. The law still permits family members to act as surrogate decision-makers if the patient is incapacitated and no prior intent can be confirmed. However, this creates potential conflicts. If a family disagrees with a patient’s previously stated wishes, or if the family is estranged, the patient’s autonomy can be compromised.
The Korea JoongAng Daily reported on the growing movement, noting that support for dignified death extends beyond just the legal opt-out. Surveys indicate that 91.9 percent of South Koreans would stop life-prolonging treatment if they became terminally ill. This high level of public support suggests that while cultural traditions persist, they are adapting to modern realities of chronic disease and high-tech medical intervention.
Gaps Between Law and Clinical Reality
While the legal framework exists, research indicates significant gaps between the law’s intent and clinical practice. A study published in BMC Medical Ethics analyzed electronic medical records and surveyed health professionals, revealing that decisions to forgo treatment are often made extremely late in the disease trajectory.
The study found that decisions to withhold life-sustaining treatment were frequently made just one to two days before death. This eleventh-hour timing undermines the concept of advance planning, as patients are often too ill to participate meaningfully by the time the legal process is initiated. Furthermore, the study highlighted a discrepancy in who makes these decisions. While patients and their families believe the patient should decide, clinical data shows that family members make the decision in 81.5 percent of cases.
Physicians face their own set of difficulties. Medical professionals often struggle to determine the “right time” to discuss life-sustaining treatment due to prognostic uncertainty. The law requires that the patient be in the “dying process” before treatment can be withdrawn, but pinpointing this moment is clinically difficult.
“Most doctors and nurses suggested that the appropriate timing to discuss the discontinuation of life-sustaining treatments should be when the patients are critical but conscious,” the study authors observed.
However, in practice, the fear of legal liability and the ambiguity of medical criteria often delay these conversations until the patient is no longer conscious. Consequently, the default position often remains aggressive treatment until death is imminent, contrary to the wishes of many patients who might have preferred comfort care earlier.
Unequal Access to Palliative Care
Another critical issue is the disparity in access to hospice and palliative care. The 2018 Act was designed to promote hospice care alongside decisions to forego life-sustaining treatment. However, current regulations restrict access to government-mandated hospice services to patients with only five specific conditions: cancer, HIV, chronic obstructive pulmonary disease, chronic liver failure, and chronic respiratory failure.
This exclusion leaves a vast number of patients with serious illnesses, such as cardiovascular disease or dementia, without legal access to specialized palliative care. A 2024 analysis published in a medical journal noted that only around 10 percent of patients with terminal illnesses received palliative care in 2022. The utilization remains heavily skewed toward cancer patients, despite the fact that heart disease and dementia are leading causes of death in South Korea.
Without access to palliative care, patients may feel forced to continue aggressive life-sustaining treatments simply to ensure they receive some form of medical support. The World Health Organization recommends palliative care for all patients with serious health-related suffering, but South Korea’s legislation has not yet fully aligned with this global standard. Efforts to expand the list of covered diseases have been slow, leaving many families to navigate the end of life without the necessary support systems.
Systemic Risks and Technological Dependence
The reliance on a centralized digital system to manage advance directives, while efficient, introduces systemic risks. A recent incident in September 2025 exposed these vulnerabilities when a fire at a data center disrupted the National Information Resources Service. The government’s Life-Sustaining Treatment Information Processing System went down, preventing hospitals from verifying whether patients had signed advance directives.
This outage caused immediate chaos in medical centers across the country. Doctors were unable to confirm if unconscious patients had refused life-prolonging care. In the absence of verifiable documents, decision-making authority reverted to family members. For patients who had cut ties with their relatives or lived alone, this posed a grave risk that their wishes would be ignored.
One case involved a man in his 60s with terminal stomach cancer. He had signed a refusal of life-sustaining treatment months prior, but when he was transferred for emergency surgery, the hospital could not verify his document due to the system outage. Medical staff were forced to persuade the patient and his family to draft a new document in a moment of crisis. The incident highlighted the fragility of the system and the distress caused to patients when their carefully laid plans are derailed by technical failures.
The National Agency has since encouraged conscious patients to carry physical registration cards and sign documents directly at hospitals as a workaround. However, the event underscored the need for backup systems to protect the autonomy of those who cannot speak for themselves.
Proposals for Legislative Expansion
Recognizing these limitations, lawmakers and health officials are pushing for reforms to expand the scope of the law. Representative Nam In-soon of the ruling Democratic Party of Korea proposed a revision in 2025 that would broaden eligibility to include patients who are “approaching a likely death,” not just those in the immediate “dying process.”
Under current law, patients must be imminently dying before treatment can be stopped. This narrow definition restricts the window for decision-making and can force patients to endure interventions that offer little benefit. The proposed amendment aims to allow patients to forgo life-sustaining treatment earlier in the course of an irreversible illness. This would align the legal framework more closely with the concept of the “terminal stage,” where death is expected within months but is not yet imminent.
Welfare Minister Jeong Eun-kyeong has also expressed support for widening the scope. She acknowledged that limiting decisions to the terminal stage restricts patients’ right to self-determination. The government’s Second Comprehensive Plan on Hospice and Life-Sustaining Treatment (2024-2028) includes proposals to advance the timing of treatment withdrawal, reflecting a growing consensus that the law must evolve to better serve the population it was designed to protect.
These proposed changes face challenges, particularly regarding ethical boundaries and the definition of futility. However, the sheer number of South Koreans opting out of treatment suggests that the public is ready for a more flexible and humane approach to end-of-life care.
The Essentials
- Over 3.2 million South Koreans have formally opted out of life-sustaining treatment, with women comprising roughly two-thirds of registrants.
- The Act on Decisions on Life-Sustaining Treatment was enacted in 2018, following landmark court cases that established the right to refuse futile care.
- Research indicates a shift from traditional family-centered decision-making toward individual autonomy driven by desires to minimize pain and financial burden.
- A 2025 data center fire exposed systemic risks, causing chaos when hospitals could not verify advance directives for unconscious patients.
Access to palliative care remains limited, legally covering only five specific diseases, which excludes many patients with cardiovascular conditions or dementia.
Lawmakers have proposed revisions to expand eligibility for stopping treatment to the “end stage” of illness, allowing decisions to be made earlier in the disease process.
