Foreigners and the unclaimed left without end-of-life choices, denied dignified death

When a critically ill patient at the National Medical Center in Seoul recently entered the final stage of life, doctors were ready to shift to palliative care. The patient’s spouse and children had agreed to forgo resuscitation and other life-sustaining treatment, signing a formal consent document.

But then came a problem: medical staff learned that the patient’s elderly parents were still alive.

Under South Korean law, the decision to halt life-sustaining treatment requires full consent from all immediate family members, including the spouse, adult children and parents, if the patient has not previously made their wishes clear.

In this case, the patient’s family had intentionally withheld the news from the parents, fearing it would be too much for them to bear. As a result, the patient was kept on life-sustaining treatment longer than the family desired.

This is one of many cases that illustrate how the noble intent behind Korea’s 2018 law on dignified death, designed to allow patients to make end-of-life decisions, can be undermined by rigid procedures that fail to reflect the diversity of modern families, and worse, exclude the most vulnerable from a peaceful death.

Delayed goodbyes due to family discord

In February, a 92-year-old woman remained on life support for two additional years because her daughters could not agree on whether to let her go.

One daughter opposed life-prolonging treatment but her sisters insisted their mother might recover. The youngest eventually gave up on convincing them, fearing irreparable damage to family relationships. “What good would come from fighting over this?” she said.

Doctors say the legal requirement for full familial consensus places an unreasonable burden on both families and health care providers.

"Tracking down all family members and obtaining agreement is not only emotionally fraught, but also logistically exhausting,” said Lee Ju-sun, a nurse at Chungnam National University Hospital.

She recalled making repeated calls to local offices and institutions in search of unreachable relatives. In one case, a necessary family member was incarcerated, making communication virtually impossible.

Legal gaps for nontraditional families

The law also overlooks the reality of varied family structures. Common-law spouses, for example, are excluded from end-of-life decision-making unless they are legally registered.

“We see many elderly patients whose primary caregivers are de facto second spouses,” said Yang Jin-won, head nurse at Jeju National University Hospital. “They are the ones who know the patient best, but they have no legal say.”

Even close friends or longtime caretakers who intimately know a patient’s wishes are powerless if they are not immediate family. One patient at Seoul National University Hospital had been estranged from their legal family for years but had a close friend who testified that the patient did not want to be resuscitated.

Legally, that testimony was irrelevant. Medical staff were required to seek consent from the patient’s estranged family.

In some cases, family members actively refuse to participate. “We’ve heard responses like, ‘I want nothing to do with that person anymore,’ or ‘I don’t want to be held responsible for the medical bills,’” said Kim Ye-jin, a social worker with Seoul National University Hospital's palliative care center.

The forgotten: unregistered, undocumented

Those most disadvantaged by the law are people with no verifiable next of kin, such as undocumented foreigners or the elderly living alone. For these individuals, discontinuing life-sustaining treatment is often impossible, even when the patient is clearly beyond recovery.

At Inha University Hospital last September, a Sri Lankan patient was admitted unconscious with advanced hydrocephalus. Doctors determined the patient was dying.

His brother, acting as guardian, wanted to stop artificial ventilation. The patient's parents, living in Sri Lanka, sent a letter confirming their consent.

Still, the hospital could not act. Because there was no official family registry, the patient’s marital status remained unclear. If he had a spouse, the parents’ consent alone would not be enough.

Despite efforts to work with the embassy, the situation could not be resolved. The patient remained on life support until he died during resuscitation.

“In most countries, there’s no equivalent to Korea’s family registry that lists all relatives in one document,” said Inha University Hospital’s Kim Ah-jin. “We’re relying on a uniquely Korean administrative system to manage life-and-death situations for a highly internationalized population.”

When guardianship is compromised

End-of-life decisions for minors present another legal gray area. Parents or legal guardians can decide to stop life support for children — but what happens when those parents are abusive?

In 2023, a mother convicted of child abuse in Daejeon signed off on withdrawing life support from her comatose child, who had no chance of recovery. The hospital held two ethics committee meetings before approving the withdrawal.

Although legally sound, the decision sparked public backlash once the mother’s criminal record came to light.

Moon Jae-young, a professor at Sejong Chungnam National University Hospital, said there needs to be a mechanism for local governments or legal representatives to act when parents are disqualified or unfit.

“Hospitals should not be alone in making these difficult calls. We need a system that includes legal, ethical and public oversight,” Moon said.

Time to rethink ‘consensus’

Experts agree that while the law was designed to prevent abuse and ensure dignity, its rigid demand for “unanimous consent” often results in prolonged suffering, particularly for the marginalized.

“The assumption is that family structures are stable and supportive,” said Kim Ah-jin. “That’s increasingly not the case.”

They urge reforms that better reflect diverse life circumstances — including the expansion of advance directive use, better documentation systems for foreigners, and broader recognition of non-traditional caregivers.

Until then, many in Korea — especially those without the “right” kind of family — will continue to endure delayed, medicalized deaths that defy the law’s original intent: to let people die on their own terms.

This article from the Hankook Ilbo, the sister publication of The Korea Times, is translated by a generative AI and edited by The Korea Times.