South Korea's 3.2 Million Treatment Refusals Test the Promise of a Dignified Death

Millions Have Recorded Their Wishes, but Timing Still Matters

More than 3.2 million South Koreans have registered their wish to forgo life-sustaining treatment, according to figures released by the National Agency for Management of Life-Sustaining Treatment. Yet the law allows doctors to withhold or withdraw that treatment only when a patient is in the dying process, with death imminent and no possibility of recovery.

That narrow window sits at the heart of a growing national debate. People can record their preferences in advance, but putting those preferences into practice depends on medical assessments, access to documents and, frequently, decisions made by relatives when patients can no longer speak.

Women account for nearly two-thirds of registrations, with 2.13 million women and 1.07 million men having recorded their wishes. People aged 65 or older make up more than two-thirds of the total. Nearly one in four women in that age group has filed an advance directive, a document setting out preferences for future treatment.

The figures show how widely planning for death has spread since the system began in February 2018. They also place pressure on a framework whose practical limits have become increasingly visible: treatment decisions often arrive shortly before death, access to hospice remains restricted, and a disruption to the national information system can prevent hospitals from checking what patients wanted.

As of January 22, 2026, proposed changes seek to allow treatment to be stopped earlier in an irreversible illness. The central issue is how to turn a recorded choice into care that respects the patient while maintaining legal safeguards for the protection of life.

How Registration Grew From 86,000 to More Than Three Million

South Korea recorded approximately 86,000 registrations in the first year of the system. Participation then rose steadily, passing one million in August 2021, two million in October 2023 and three million in August 2025.

The milestones trace the spread of a formal way for people to express preferences that might otherwise remain an informal conversation with their family:

• February 2018: The system for decisions on life-sustaining treatment began operating.
• First year: Approximately 86,000 people registered.
• August 2021: Registrations reached one million.
• October 2023: Registrations reached two million.
• August 2025: The total exceeded three million.
• By January 22, 2026: The National Agency for Management of Life-Sustaining Treatment reported more than 3.2 million registrations.

The latest total is more than three times the one million recorded in August 2021. The gender figures also show women registering at roughly twice the rate of men: 2.13 million compared with 1.07 million.

Older people account for most registrations, making the system particularly relevant to an aging population. Their choices reflect growing attention to personal comfort, control over medical decisions and the burdens that treatment can place on families.

What South Koreans Want From the End of Life

A survey by the Korea Institute for Health and Social Affairs found that an overwhelming majority of respondents placed priority on reducing physical pain and easing the financial burden on their families. Its findings describe a changing understanding of a good death, with comfort and avoiding unnecessary suffering becoming more prominent.

The study described the change in these words:

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,

Survey findings also indicate that 91.9 percent of South Koreans would stop treatment intended to prolong life if they became terminally ill. That level of support reaches beyond those who have already completed a formal registration.

Patients face choices shaped by chronic disease and increasingly advanced medical intervention. Treatment may prolong life while also bringing discomfort or costs. The growing interest in a dignified death places the patient's wishes at the centre of decisions about whether such interventions should continue.

South Korea's shift toward personal choice also changes medical ethics and family relationships. Recording a preference gives people a way to make their voice heard before illness leaves them unable to take part in decisions.

Two Court Cases Changed the Legal Debate

The legal framework developed through years of ethical debate, including the Boramae Hospital case in 1998 and the Severance Hospital case in 2009. Both forced courts and doctors to confront the question of who can authorize the end of treatment and under what circumstances.

In the Boramae Hospital case, surgeons discharged a patient at his wife's request because of financial burdens. The doctors were found guilty, and the Supreme Court ruled that they had acted as accomplices to murder. The wife's request was treated as an unauthorized decision made on the patient's behalf.

The verdict created fear of criminal liability within the medical profession. Doctors felt compelled to continue prolonging life to avoid the risk of prosecution, even as difficult questions about patients' wishes remained unresolved.

The Severance Hospital case brought a different judgment in 2009. The family of a woman in a persistent vegetative state sought a court order to discontinue treatment. The Supreme Court recognized that withdrawal could be permissible when a patient had reached an irreversible stage of death and it reflected the patient's presumed intent.

The court grounded that decision in constitutional rights to human dignity, the pursuit of happiness and self-determination, meaning a person's right to make decisions about their own life. The two cases helped establish the judicial foundation for legislation passed in 2016 and put into effect in 2018.

Why the Law Separates Terminal Illness From Imminent Death

The Act on Decisions on Life-Sustaining Treatment distinguishes between the terminal stage of disease and the dying process. The terminal stage describes a condition expected to cause death within months despite treatment. The dying process means death is imminent and recovery is no longer possible.

Under the current framework, withholding or withdrawing treatment is permitted only during the dying process. A person may therefore be terminally ill and have recorded a refusal, while still being outside the legal period in which doctors can act on it.

The restriction is designed to balance the patient's right to decide with the protection of life. In practice, it puts considerable weight on determining when a patient has moved from terminal illness into imminent death.

The legislation created Advance Statements for Life-Sustaining Treatment (ASLST) and Physician Orders for Life-Sustaining Treatment (POLST) as formal mechanisms for recording decisions. It also established oversight through the National Agency for Management of Life-Sustaining Treatment and Institutional Ethics Committees.

Those arrangements give patients and medical staff a legal process to follow. The difficult part is applying that process at a moment when an illness may be changing quickly and a patient's ability to communicate may already be fading.

Families Remain Central as Personal Choice Grows

Confucian traditions have long shaped medical decisions in South Korea. Filial piety places a duty on children to care for their parents and prolong their lives. Decisions about treatment have historically been collective family matters, rather than choices made by an individual alone.

Discussions about death were often considered taboo. Families sometimes shielded patients from the truth about their prognosis to prevent despair. A legal framework built around individual choice therefore operates within a culture where relatives have traditionally taken substantial responsibility for care.

The registration figures show growing participation in personal planning, especially among women. Their higher rate of registration may reflect changing roles in managing health or a greater willingness to confront mortality. The figures do not give a reason for the gender difference.

Family members still have a formal role under the law. They may act as surrogate decision makers when a patient cannot make decisions and no prior intent can be confirmed. A surrogate is someone who makes a decision on another person's behalf.

Disagreement between relatives and a patient's previously expressed wishes can complicate care. Estrangement creates another difficulty, particularly when relatives are expected to help establish preferences or authorize decisions. Growing support for individual autonomy therefore sits alongside continued reliance on families in the hospital.

Treatment Decisions Often Come in the Final Days

A study published in BMC Medical Ethics examined electronic medical records and surveyed health professionals. It found that decisions to withhold life-sustaining treatment were frequently made just one to two days before death.

By that point, patients may be too ill to participate meaningfully. Planning ahead loses much of its practical value when the formal discussion begins only after a person can no longer explain what matters to them.

The study also found that family members made the decision in 81.5 percent of cases. That pattern contrasted with the view expressed by patients and families that the patient should be the person deciding.

The study authors described when most doctors and nurses thought discussions should take place:

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,

Doctors face uncertainty about how an illness will progress and when death becomes imminent. The law requires a patient to be in the dying process before treatment can be withdrawn, but identifying that point is clinically difficult.

Fear of legal liability and uncertainty about the medical criteria can delay conversations until the patient is unconscious. Aggressive treatment may then continue until death is imminent, even when the patient would have preferred an earlier focus on comfort.

Hospice Access Leaves Many Illnesses Outside the Rules

The 2018 Act was intended to promote hospice care alongside decisions to forgo life-sustaining treatment. Hospice and palliative care focus on comfort and relief from suffering, providing support when serious illness brings pain and other difficult symptoms.

Government mandated hospice services are restricted to five conditions: cancer, HIV, chronic obstructive pulmonary disease, chronic liver failure and chronic respiratory failure. Patients with other serious illnesses, including cardiovascular disease or dementia, fall outside that legal access to specialized palliative care.

A medical journal analysis published in 2024 found that only around 10 percent of patients with terminal illnesses received palliative care in 2022. Use remained heavily concentrated among people with cancer, although heart disease and dementia are also leading causes of death in South Korea.

That gap affects what choices feel possible to patients and families. Without access to care centred on comfort, some patients may feel compelled to continue aggressive treatment to make sure they receive medical support at all.

The World Health Organization recommends palliative care for all patients with serious suffering related to their health. South Korea's legislation has yet to fully align with that approach. Efforts to expand the list of eligible diseases have moved slowly, leaving many families without the support intended to accompany decisions about stopping treatment.

A Data Centre Fire Disrupted Access to Patients' Wishes

A fire at a data centre in September 2025 disrupted the National Information Resources Service and exposed the risks of relying on a central digital registry. The Life-Sustaining Treatment Information Processing System went down, preventing hospitals from verifying advance directives.

Doctors could not check whether unconscious patients had already refused treatment intended to prolong life. Without verifiable documents, decisions reverted to family members. Patients who lived alone or had cut ties with relatives faced the risk that their recorded wishes would not guide their care.

One affected patient was a man in his 60s with terminal stomach cancer. He had signed a refusal months earlier, but the hospital could not verify it when he was transferred for emergency surgery. Medical staff had to persuade him and his family to complete a new document during the crisis.

The case showed how a technical failure could disrupt preparations made well before an emergency. Patients and relatives were left dealing with paperwork at the same time as urgent medical decisions.

The National Agency subsequently encouraged conscious patients to carry physical registration cards and sign documents directly at hospitals as a workaround. Those measures depend on a patient being able to participate. The outage highlighted the need for backup arrangements that also protect people who cannot speak for themselves.

Proposed Changes Would Allow Earlier Decisions

Representative Nam In-soon of the ruling Democratic Party of Korea proposed a revision in 2025 to broaden eligibility beyond the immediate dying process. Her proposal would include patients who are "approaching a likely death," allowing treatment to be forgone earlier during an irreversible illness.

The change would bring the decision period closer to the terminal stage, when death is expected within months but is not yet imminent. Its purpose is to give patients more room to decide before they lose consciousness or undergo interventions offering little benefit.

Welfare Minister Jeong Eun-kyeong has also supported widening the scope. She acknowledged that restrictions on when treatment decisions can take effect limit patients' right to self-determination.

The government's Second Comprehensive Plan on Hospice and Life-Sustaining Treatment, covering 2024 to 2028, includes proposals to bring forward the timing of treatment withdrawal. The legislative expansion remains a proposal as of January 22, 2026, rather than an enacted change.

Reform must address ethical boundaries and the meaning of futile treatment, or treatment that offers little benefit in an irreversible illness. The current narrow window was designed to protect life, while proposals for an earlier window seek to give patients greater control over the care they receive.

More than 3.2 million registrations demonstrate the scale of public participation. Making those decisions work in practice also depends on timely conversations, access to care focused on comfort and reliable ways for hospitals to retrieve patients' wishes.

The Essentials

• More than 3.2 million South Koreans have registered to forgo life-sustaining treatment, including 2.13 million women and 1.07 million men.
• People aged 65 or older account for more than two-thirds of registrations.
• The system began in February 2018, after legislation passed in 2016 and major court cases in 1998 and 2009.
• Current law permits withholding or withdrawing treatment only during the dying process, when death is imminent and recovery is impossible.
• A clinical study found decisions were frequently made one to two days before death, with families deciding in 81.5 percent of cases.
• Government mandated hospice access covers five conditions, while around 10 percent of patients with terminal illnesses received palliative care in 2022.
• A September 2025 data centre fire prevented hospitals from verifying advance directives.
• Proposals seek to allow earlier treatment decisions, with the government's comprehensive plan covering 2024 to 2028.