#A man in his 60s, identified as A, collapsed from cardiac arrest at home and was admitted to the intensive care unit. Due to repeated cardiac arrests and hypoxic brain injury, the attending medical team determined that he was in the "dying process." In the advance directives he had completed, he indicated that he did not want life-sustaining treatment. But his family said they didn't know that and asked to continue treatment.
President Lee Jae-myung mentioned granting incentives, such as premium discounts, to patients who choose to stop life-sustaining treatment to reduce the financial burden on the national health insurance, but the medical community says there are limits to approaching life-sustaining treatment as a matter of finances.
Experts say the core of life-sustaining treatment policy is not to create incentives to receive less, but to build a structure that allows patients to make choices after fully considering their wishes, and that when such a structure is in place, ethical controversy will decrease and medical cost savings can naturally follow.
The Health Ministry is also cautious. A key official at the ministry said, "Issues of life-sustaining treatment should first be reviewed from the ethical and moral perspective of 'a dignified death.'" Another official said, "We will consider various ways to reduce the National Health Insurance's financial burden related to life-sustaining treatment, but it is unlikely to be realized in the form of incentives."
◇Why life-sustaining treatment isn't reduced to "a money issue"
The financial burden surrounding life-sustaining treatment is clear in the numbers. According to a Bank of Korea report, if about 70% of elderly decedents continue to receive life-sustaining treatment as they do now, health insurance expenditure on life-sustaining treatment is projected to increase from 3 trillion won in 2030 to 16.9 trillion won in 2070. If the share of elderly decedents receiving life-sustaining treatment falls to around 15%, the 2070 cost of life-sustaining treatment would drop to 3.6 trillion won.
However, it is difficult to view this simply as an area where finances can be cut. A decision on life-sustaining treatment does not end with a single choice but goes through several hurdles from the assessment stage to implementation.
First, determining whether a patient is in the "dying process" is not easy medically. Not a few patients experience repeated cycles of deterioration and improvement even after an end-of-life diagnosis. For this reason, there is growing support for expanding the point at which stopping life-sustaining treatment is allowed from the current "dying process" to the "terminal stage." In a study conducted last year by the Yonsei University Industry-Academic Cooperation Foundation at the request of the Health Ministry, 22 of 27 related medical societies (81.5%) supported moving up the timing for stopping life-sustaining treatment. A bill with the same intent was also submitted to the National Assembly last year, led by Rep. Nam In-soon of the Democratic Party of Korea.
Even if the medical team confirms an irreversible dying process and verifies the patient's wishes, the decision is not immediately carried out. In the field, life-sustaining treatment often continues due to family opposition. The United States even has a term for this: "Daughter from California Syndrome," referring to a situation where a child with little contact shows up late and demands every possible treatment for a parent. Such conflicts often lead to lawsuits against medical staff.
◇"Rather than policies to reduce care, enable patients to choose"
Experts say the problem lies in a structure where life-sustaining treatment continues by inertia without sufficient information and deliberation, regardless of the patient's right to self-determination.
Yoo Shin-hye, a professor at Seoul National University Hospital's Palliative Care and Clinical Ethics Center, said, "Repeated cardiopulmonary resuscitation or intensive care unit treatment even after sufficient treatment has already been provided is a medical practice with low clinical utility and is close to a waste of medical resources," and added, "Under the current legal system, it is institutionally difficult to rein in people who want to continue life-sustaining treatment, and this is exactly where the National Health Insurance's financial burden grows."
Yoo said that tying incentives to stopping life-sustaining treatment could risk pushing decisions in a particular direction rather than helping patient self-determination. Yoo said, "Even now, many patients choose to stop life-sustaining treatment out of concern about burdening their families, and if economic incentives are added, secondary factors like expense and burden could take precedence over reflection on life."
Yoo added, "Considering that many patients contemplating life-sustaining treatment are elderly, there is also a risk that people will be driven to the conclusion that 'it is better for everyone if I die' in Korean society, where elderly poverty and elderly suicide are serious problems."
There are also concerns that incentives will not substantially improve quality of life at the end of life. Yoo said, "Although no specific design has been proposed yet, premium discounts would not be much different from 'consumption coupons' in effect," adding, "Since the timing of deciding to stop life-sustaining treatment often does not coincide with the actual time of death, what patients want in the interim is not cost savings but services like single rooms or caregiving support." Yoo said, "If money is to be spent, it would be more meaningful to use it to fill that gap."
There is not enough domestic palliative care infrastructure to support this. According to the 2024 National Hospice and Palliative Care Annual Report by the National Hospice Center, there are 1,815 hospice beds nationwide, or 28 per 1 million people. That is about half the European Association for Palliative Care (EAPC) recommendation of 50 per 1 million.
Eligible conditions are also limited. The current Act on Decisions on Life-Sustaining Treatment for Patients in Hospice, Palliative Care, or the Dying Process defines hospice eligibility as cancer, chronic respiratory failure, chronic liver cirrhosis, acquired immunodeficiency syndrome (AIDS), and chronic obstructive pulmonary disease, among others.
◇When patients decide, medical costs fall and hospice use rises
Statistics also show how a structure that respects patient choice changes actual medical use and costs. Lim Min-kyung, a researcher at the National Health Insurance Service's Health Insurance Research Institute, recently said that a comparison between cases where patients completed advance directives or life-sustaining treatment plans and cases where families decided on their behalf showed clear differences in end-of-life medical costs and patterns of medical use.
The analysis used the 2023 National Health Information DB to examine the relationship between decisions to stop or withhold life-sustaining treatment and end-of-life medical costs, divided into patient-decision and family-decision groups. Among those who died that year, about 19.9% used the life-sustaining treatment decision system.
The analysis found that medical costs in the month before death were highest in the family-decision group at 12.11 million won. Costs were lower when patients completed advance directives (10.23 million won) and lower still when they completed life-sustaining treatment plans (8.57 million won). The share of life-sustaining treatment costs in total medical costs was also highest in the family-decision group at 9.4%, compared with 7.4% for the advance directives group and 4.9% for the life-sustaining treatment plan group. ICU and emergency room utilization rates were also highest in the family-decision group at 36% and 71.6%, respectively.
By contrast, hospice use was significantly higher when patients directly expressed their wishes. Hospice utilization was 44.5% for patients who completed advance directives and 23.9% for those who completed life-sustaining treatment plans, showing a clear gap with the family-decision group (9.1%).
Lim said, "Each additional type of prescribed life-sustaining treatment increases end-of-life medical costs by an average of 32.9%," adding, "The prescription rates for major life-sustaining treatments such as cardiopulmonary resuscitation and hemodialysis were also lower in the patient-decision group." Lim explained, "The clearer the patient's wishes, the lower the treatment intensity and the greater the likelihood of shifting to palliative care centered on quality of life."