Population aging is taking place very rapidly in South Korea; the proportion of the elderly population (aged 65 years or older) has already exceeded 14% of the total population, and South Korea has become an aged society. According to Statistics Korea data in 2021, the proportion will exceed 20% in 2025, making South Korea a super-aged society [1]. Rapid population aging means an increase in people who need end-of-life care. The number of yearly deaths is steadily increasing, and it is estimated that more than 400,000 people will die in 2030 [2]. End-of-life care is recognized as one of the major social issues that our society faces, and several legal and institutional changes related to decisions such as withdrawal of life-sustaining treatment also reflect this atmosphere. However, caring for dying patients is an issue with very complicated social and cultural aspects, and multi-layered conflicts are inherent. High-quality end-of-life care does not mean simply responding to people’s needs, but instead relates to human dignity and is a subject that should be discussed from a philosophical and value-oriented perspective.

On February 3, 2016, the Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life (hereafter referred to as the Act on Decisions on Life-Sustaining Treatment) was enacted. The purposes of this act were to ensure the best benefits for patients and to protect human dignity and values by esteeming self-determination. The enactment of this law was achieved through social discussions triggered by two crucial events. The so-called Boramae Hospital case restricted a physician’s decision to determine cases in which the likelihood of recovery is low despite active treatment (Seoul High Court sentenced on February 7, 2002. Judgement 98NO1310). The Grandmother Kim case showed that withdrawal of life-sustaining treatment can be permitted when it is recognized that a patient who has reached the stage of irreversible death exercises the right to self-determination (Supreme Court of Korea sentenced on May 21, 2009. Judgement 2009DA17417). Although the Act on Decisions on Life-Sustaining Treatment still has problems to be solved, such as the accuracy of terminology and problems involving unrelated people [3], it may have a tremendous impact on social changes as the only legal and institutional agreement on end-of-life medical decision-making in South Korea.

Currently in South Korea, physician-assisted suicide (PAS), in which a patient ends his or her life with the help of a physician, is illegal. The Act on Decisions on Life-Sustaining Treatment only permits the withdrawal of life-sustaining treatment including cardiopulmonary resuscitation, the use of a ventilator, and hemodialysis after two physicians determine that a patient is in the dying process [4]. Recently, a partial amendment to the Act on Decisions on Life-Sustaining Treatment permitting PAS was proposed at the National Assembly of South Korea (representative proposal by Assembly Member Gyubaek Ahn, June 15, 2022), and the reason for proposing the amendment was explained by citing a public opinion poll according to which nearly 80% of adults favored euthanasia [5]. According to the study by Professor Young Ho Yun’s research team at Seoul National University Hospital cited as the basis of law proposal [6], 76.3% of respondents among 1,000 Korean citizens aged 19 or older favored euthanasia and PAS, reflecting a near-doubling in 5 years compared to the proportion of people in favor in 2016. Moreover, a survey of 1,000 Korean adults by Hankook Research from July 1 to 4, after the law proposal [7] showed that 82% favored legalization of assisted death with dignity. The proportion of those who were “strongly in favor” reached 20%.

There is a risk of distorting public opinion if opinions on the legalization of euthanasia are judged on the basis of just a few questions, without information on the systems and services currently implemented in South Korea, their problems, and future prospects. Therefore, the Korean Society for Hospice and Palliative Care (KSHPC) conducted a structured nationwide opinion poll to investigate people’s comprehensive awareness and attitudes toward end-of-life care issues, including PAS.

The survey was conducted by Research View Co., Ltd., a specialized institution for opinion polls, and was commissioned by the KSHPC. A randomized mobile phone survey was conducted among adults aged 18 years or older nationwide for a total of 10 days from July 27 to August 5, 2022. The weighting for randomization was conducted according to gender, age, and region, based on data from June 2022. Calls were tried to a total of 10,657 people, and 1,007 people (response rate: 9.5%) completed responses. The sampling error was ±3.1%p at a 95% confidence level, and the characteristics of participants are shown in the Supplementary Table 1.

In order to characterize the current status of end-of-life care in South Korea, a group of five experts who have worked for over 10 years in hospice-specialized institutions, including specialists who were executive directors of KSHPC and social workers, selected the items for the final questionnaire through 5 meetings. In the survey, it was explained that “hospice and palliative care” 1) is provided by experts to alleviate symptoms in terminally ill patients and their families by active control and to help psychological and social difficulties, 2) involves hospitalization with treatment and care alleviating symptoms in a designated ward or home visits by healthcare providers, and 3) is currently limited to diseases including terminal cancer. It was also explained that the available specialized institutions are insufficient, to the degree that only about 20% of terminally ill patients who die every year receive hospice and palliative care. The survey protocol was approved by the Gachon Gil Medical Center institutional review board (approval no.: GFIRB2022-225).

In response to the question on the current social (government and local government) support system for terminally ill patients and their families, 61.1% responded that the system is insufficient. Furthermore, 60.0% of respondents did not recognize the term “hospice and palliative care” for patients in terminal stage and dying process (Table 1). Younger age, better current health status, and higher educational level were associated with a lower awareness of hospice and palliative care.

Table 1 . Survey Questions and Responses (Dichotomized)..

Question	Response (%)
Q1. Do you think the current social support system for terminally ill patients and their families in Korea is sufficient?	Very insufficient	Insufficient	Neither	Sufficient	Very sufficient	Insufficient	Sufficient
	18.9	42.2	34.0	3.8	1.1	61.1	4.9
Q2. How would you rate your recognition of the term “hospice and palliative care”?	Very poor	Poor	Fair	Good	Excellent	Unrecognized	Recognized
	31.0	29.1	12.9	24.4	2.6	60.0	27.1
Age group (yr)
18~29	57.3	18.4	10.7	13.1	0.4	75.7	13.5
30~39	57.1	22.1	6.3	11.7	2.9	79.2	14.6
40~49	33.9	34.0	11.4	19.8	0.9	67.9	20.7
50~59	16.1	32.2	16.7	31.7	3.3	48.3	35.0
≥60	10.6	33.6	15.9	35.5	4.3	44.3	39.9
Current health status
Bad	24.0	28.4	14.9	29.9	2.8	52.4	32.7
Neither bad nor good	25.8	30.2	14.4	26.3	3.3	56.0	29.6
Good	34.4	28.5	11.9	22.9	2.2	63.0	25.1
Educational level
Middle school or lower	20.0	33.6	12.5	32.2	1.8	53.6	33.9
High school	25.4	31.6	14.4	25.4	3.2	57.0	28.6
College or higher	35.3	27.1	12.2	22.9	2.5	62.4	25.4
Q3. If there is no possibility of recovery, would you like to receive life-sustaining treatment?	Strongly disagree	Disagree	Neither	Agree	Strongly agree	Disagree	Agree
	45.0	36.7	11.3	4.9	2.1	81.7	7.0
Economic status
High	56.2	29.2	10.1	2.9	1.6	85.4	4.5
Average	44.3	38.8	10.2	5.5	1.3	83.1	6.7
Low	45.6	33.4	12.4	4.2	4.4	79.0	8.6
Q4. If you are diagnosed with a terminal illness, would you like to receive hospice and palliative care?	Strongly disagree	Disagree	Neither	Agree	Strongly agree	Agree	Disagree
	8.7	13.7	19.1	41.3	17.1	58.4	22.5
Familial support
Low	15.9	22.4	15.6	28.2	17.8	38.4	46.0
Average	8.7	12.3	28.9	37.4	12.7	21.0	50.1
High	7.6	12.8	16.5	44.6	18.4	20.4	63.1
Educational level
Middle school or lower	18.7	19.3	14.4	33.2	14.4	38.0	47.6
High school	11.3	17.2	23.1	35.5	12.9	28.5	48.4
College or higher	6.1	11.2	17.9	45.1	19.6	17.3	64.8
Q5. What should the government and the National Assembly do first in order to achieve dignified death?	Legalization of physician-assisted suicide	Economic support including reduction of medical expenses	Prepare a support system to reduce the burden of care	Expansion of hospice palliative and care services	Others
	13.6	26.7	28.6	25.4	5.7
Q6. What do you think about the view that the expansion of hospice and palliative care should precede the legalization of physician-assisted suicide for a dignified death?	Strongly disagree	Disagree	Neither	Agree	Strongly agree	Agree	Disagree
	2.7	6.9	32.1	41.4	16.9	58.3	9.6
Educational level
Middle school or lower	9.0	8.0	33.4	35.7	14.0	16.9	49.7
High school	3.0	8.8	34.6	41.1	12.5	11.7	53.6
College or higher	1.6	6.0	30.5	42.6	19.3	7.6	61.9

Currently, the Act on Decisions on Life-Sustaining Treatment has been implemented, and a patient with irreversible diseases such as terminal cancer can legally refuse or withdraw life-sustaining treatment in the dying process. In response to the question on the intention to receive life-sustaining treatment only for life prolongation without a likelihood of recovery, most respondents (81.7%) did not want to receive life-sustaining treatment, and this trend was prominent among people with higher income (85.4%).

In response to the question about intention of receiving hospice and palliative care if hospice and palliative care expands in the future and a respondent is diagnosed with a terminal disease, 58.4% responded that they would like to receive hospice and palliative care. The intention of receiving hospice and palliative care was higher among people with higher familial support (63.1%) and higher educational level (64.8%).

The respondents stated that the most important matters that the government and National Assembly should consider for death with dignity were preparing a support system to reduce burden of care (28.6%), economic support including reduction of medical expenses (26.7%), and expansion of hospice and palliative care services (25.4%). Legalization of PAS reached only 13.6%. In addition, 58.3% favored the view that proactive expansion of hospice and palliative care should precede the legalization of euthanasia or PAS in order for high-quality end-of-life care. This trend was prominent among people with a higher educational level (61.9%).

The main results of this survey are as follows. First, as of 2022, members of the Korean public think that the social support system for end-of-life care is insufficient. Second, people are not well aware of hospice and palliative care implemented for end-of-life care, although they are willing to use the system if they are in the corresponding situation. Lastly, people do not want life-sustaining treatment only for life prolongation, and other efforts including the expansion of hospice and palliative care should precede the legalization of PAS. Compared to the two recent opinion polls on PAS [6,7], this survey focused on systemic priorities. In a previous study, 80% of the public favored investment of insurance finances into the expansion of hospice and life-sustaining treatment and support of well-dying in a broader sense [7]. However, when legalization of PAS was included as one of the options in this survey, the public clarified what was more urgent at this point.

The results of two recent online polls [6,7] that many people favored PAS reflect the suffering of terminally ill patients and their families that the South Korean public is experiencing. The Act on Decisions on Life-Sustaining Treatment has been revised several times to broaden the range and depth of its application, and the number of terminal cancer patients who died after receiving hospice and palliative care more than doubled compared to 10 years ago [8]. However, the low awareness rate (27.1%) of hospice and palliative care in this survey indicates that the government and KSHPC still face a large task. In the absence of proactive promotion and financial investment to expand facilities and human infrastructure in the future, the public’s demand for euthanasia (e.g., PAS) will continue to grow.

In August 2022, two debates were held at the National Assembly of South Korea [9,10]. The reasons supporting the legalization of assisted death with dignity were ensuring the right to self-determination, the right to a dignified death, and the suffering and burden of families, whereas respect for life, risk of abuse, and violation of the right to self-determination were reasons for opposition. Our society’s perceptions of human dignity are changing rapidly. It is hoped that a social consensus with sufficient support from public opinion will be achieved in order to ensure people’s dignified death and high-quality end-of-life care.

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2022.25.4.198.

No potential conflict of interest relevant to this article was reported.

Conception or design of the work: all authors. Data collection: all authors. Data analysis and interpretation: all authors. Drafting the article: ICH, DKK, KHL. Critical revision of the article: all authors. Final approval of the version to be published: all authors.