[Column] The direction of a comfortable death

I received a question from a Hong Kong lawyer about what Korea's 'Advance Medical Directive' system is like. It is said that you are researching the institutionalization of Hong Kong's advance medical directive system. This involves preparing related decisions in advance in case a patient is unable to make medical decisions, and includes the intention to discontinue life-sustaining treatment. In other words, it is a system for discontinuing life-sustaining treatment and is a type of euthanasia.

Euthanasia is broadly divided into four types. On one axis are active and passive, and on the other axis are others and oneself. In other words, death is actively chosen by others, actively by oneself, passively by others, and passively by oneself.

In Korea, the 'Life Sustaining Treatment Decision Act' was implemented for the first time in 2017, and a legal system for discontinuing life sustaining treatment is in place, but only 'passive euthanasia by others' is allowed and the scope is very limited.

According to the Life Sustaining Treatment Decision Act, it is permitted to discontinue measures such as CPR, artificial respiration, hemodialysis, etc. that only meaninglessly prolong the period of the dying process only for patients who are in the dying process and are in a state of imminent death with no medical possibility of recovery. In this case, either the patient must register an advance directive for life-sustaining treatment (i.e., the same as the advance medical directive above) with the responsible agency in advance, or the patient's family must go through strict procedures and prepare a life-sustaining treatment plan. It is difficult to meet all of these requirements, and there are many ambiguous areas in which it is difficult to determine whether the requirements are met. For example, in reality, the decision as to whether a patient is in the process of dying or simply a 'terminal patient' can become an issue.

However, in a 2022 survey of 1,000 people conducted by Seoul National University Hospital, 76.3% of the public said that they were in favor of ‘euthanasia.’ Specific reasons for approval were 'meaninglessness of remaining life' at 30.8%, 'right to a dignified death' at 26.0%, 'reduction of pain' at 20.6%, 'family pain and burden' at 14.8%, and 'social burden due to medical expenses and care' at 4.6%. In addition, as a result of a 2023 opinion poll of 1,000 people conducted by the Seoul Shinmun and the Korea Public Opinion Research Institute, 81% responded that they were in favor of introducing 'physician-assisted dying', while only 6.7% were opposed. The reasons for approval were 'guaranteeing the right to self-determination' at 29.0%, 'reducing pain due to illness' at 27.7%, 'comfortable death' at 23.1%, 'reducing the mental and economic burden on the family' at 18.0%, and 'reducing social burden' at 2.1%.

According to surveys like this one, public opinion is currently positive about euthanasia. Of course, the actual public opinion may differ from this depending on the sample and reliability of the survey, and such public opinion may be the result of not carefully considering the 'right to self-determination regarding death', which is the essence of the euthanasia discussion, as the reason for the approval of Seoul National University Hospital's survey is that 'the meaninglessness of remaining life' is higher than the right to self-determination. Nevertheless, it cannot be denied that our society is currently becoming increasingly interested in the decision to die comfortably.

In fact, a total of 924,271 advance directives for life-sustaining treatment have already been registered from 2018, when the life-sustaining treatment decision system was introduced, to May 2022, showing that public awareness and recognition of the life-sustaining treatment decision system is increasing.

Ultimately, our society is moving in the direction of expanding the scope of euthanasia, and ultimately, that will happen. It's just a matter of limitations and timing. Last July, the ‘Assisted Death with Dignity Act’ (enactment) was proposed. The law includes provisions that allow terminally ill patients to choose their own time of death. This is an attempt to expand patients' options regarding death compared to the existing system for discontinuing life-sustaining treatment.

Of course, there are still many problems to be solved in institutionalizing euthanasia or death with dignity, whether passively or actively. There are still many problems that remain, such as the possibility that it may not be their true intention, that they may choose euthanasia due to financial or psychological pressure due to lack of medical expenses or the perception of their family, and that the system may be abused or misused. Now, the discussion on whether euthanasia is acceptable will be a process of resolving that problem.

No one is born by their own choice. However, in this society where the individual's right to choose to live his or her own life is respected, shouldn't the choice to complete one's life also be respected? Take time to think about what that ‘respect’ means.

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