Everyone dies. Some patients, however, are lengthening their lives with pain, even though they do not want to. To get rid of pain of such patients, there are increasing numbers of countries where ‘death with dignity’ is legalized. In recent times, there are also laws in Korea that legitimize death with dignity. Let’s check the laws from other countries and compare with the laws of our country and find out what we need to improve.

What is ‘death with dignity’?

The meaning of death with dignity is, when patients reach the unrecoverable stage (point of death, in other words), even though medical treatment is done to the best of its ability, stopping life-long treatment, which makes patients maintaining current condition, and make the patients be able to ' die with dignity.' The problem of death with dignity is still controversial from the past to the present. However, it is becoming a national issue as Korean government announced that death with dignity law (in other words, the law of well-dying) will be implemented from February 4, 2018 in earnest. In addition, in Italy, which has a strong Catholic tradition that is opposed to deal with life artificially, in spite of the opposition of the church, the law allowing the death with dignity for the people was passed in December 2017.

Current state of affairs

Around the world, 20% of all deaths in 2016 died in pain due to cardiopulmonary resuscitation or administration of anticancer drugs, so their families suffer from mental and economic pain. In California, where death with dignity was legalized in 2016, 111 people chose the death with dignity for six months from June to December 2016. As well in Oregon, the United States, 37 out of every 10,000 people select the death with dignity. And in 2016, it is known that 133 people in Oregon chose the death with dignity. In Belgium, 2,223 cases of death with dignity went into effect in 2016, it means that it was more than twice as many as in 2012. 
Let’s talk about Korea. In 2015, KOREA INSTITUTE FOR HEALTH AND SOCIAL AFFAIRS(KIHASA) had announced that 9 out of 10 elderly people who were aged more than 65 are against to lifetime treatment. In a survey conducted by the Ministry of Health and Welfare in 2012, 72.3% of Koreans chose for 'no meaningful lifesaving treatment.’ And In 2011, 90% of Seoul National University Hospital's patients who were diagnosed with terminal cancer refused to life saving treatment. In this wise, the voice of self-determination over death is getting higher and higher.

As interest in death with dignity is growing globally, policies of death with dignity are also increasing.

 

United States of America

 

There are six states in the United States that have implemented death with dignity law. Oregon was the first state to enforce the law of death with dignity in 1997, Washington, Vermont, California and so on are in operation, too. Among them, there was an incident that made the state of California to allow death with dignity. Britany Maynard, a 29-year-old female terminal cancer patient, moved to Oregon where death with dignity is allowed and died on her own in 2014 with the help of a doctor. She left a video calling up on the state to allow death with dignity before she was dead, and this video was even shown when the State Council of California discussed a bill of allowing death with dignity in early 2015. The State Council passed the bill of death with dignity with 23 in favor and 14 against. In the end, ‘the Death with Dignity Acts’ went into effect in earnest starting from June 2016. This act allows terminally ill patients to be prescribed medicines from a doctor and die from it. The patients, however, must have 6 months or less of expected survival period, be able to make mentally sound judgments and make decisions about taking medicine on their own. As well, people over the age of 18 in California can be prescribed drugs, and the death with dignity act has exception that patients can refuse treatment or prescriptions associated with death with dignity.

 

Italy

 

In Italy, the campaign which introducing death with dignity began from 2009. But the death with dignity was not legalized because of strong resistance from the nation due to religious reasons. However, the argument was brought up again when the incident about the death with dignity was known to the nation in February 2017. Fabiano Antoniano, a popular music DJ, lost his sight from the car accident and he was found to have been paralyzed for three years. He killed himself with the help of the campaign of death with dignity by moving to Switzerland where death with dignity was allowed. This case made Italy start to discuss about creating a death with dignity system. After that, ANSA News Agency reported on December 14, 2017 that the Senate of Italy passed the death-selectable bill by 180 in favor and 71 against. This bill provides if he or she later falls into an accident or illness, patients can stop treatment with recognizing the effect of their will which patients wrote before they got serious illness.

 

Switzerland

 

Switzerland legally allows both death with dignity and euthanasia. In particular, Switzerland has ‘Dignitas’, a group of people who claim their rights about their death and get help from doctors and nurses to die. This is a non-profit institution, also referred to as the ' suicide clinic ', allowing not only locals but also foreigners to die with dignity and it is the only thing in the world. For the group of people, doctors or nurses do not inject medicine but assist patients who are suffering from terminal cancer to take or inject medicine themselves. According to a report released in January 2017, the number of people who applied for Dignitas from 2012 to 2017 was 7,764 from 96 countries around the world. Germany had the highest number of applicants of 3,223, 1,139 of British, 730 of French, 684 of Swiss, 392 of Italians and 453 of Americans. And in Asia, 18 of Koreans,17 of Japanese, 10 of Thai and 7 of Chinese is the following number of applicants.

 

While the number of countries where death with dignity is legalized is on the increase, the death with dignity has always been a subject of controversy. Some people claim that death with dignity is the right to be " human, " but others argue that the death with dignity is the choice of death which against ‘the right of life’.

 

A hasty judgment

 

There is representative case of patients’ death due to hasty judgment by family protector. Six-year-old Australian boy, Kisco, underwent surgery at a hospital after he was diagnosed with brain cancer in late 2015. Doctors told his parents that when the boy receives treatment combined with chemotherapy and radiation, the survival rate would be more than 30 percent. But his parents refused, saying that the child's pain could be too severe and have serious side effects, such as permanent intellectual disorder. Because of the parents’ opposition, the doctors filed a suit with the Western Australia Court to order mandatory treatment and at last in March 2016, the court ruled that the child should get chemotherapy and radiation. But Kisco’s parents still refused, so the lawsuit continued. However, Kisco's condition had already worsened a lot, so it was concluded that it is better to get only pain relief care rather than to get intensive care. In the end, in September 2016, the court ruled in favor of the parents and Kisco died in December 2016.

To avoid such a wrong choice, it is necessary to have a definite system standard for deciding what is right.

 

Problems with cost

 

As death with dignity is legalized, patient’s life and death are a matter of choice, but there are some cases that some insurance companies intervened in one of the criteria of choice, cost. In Oregon, the state of the United States, where the death with dignity law was actually carried out, insurers urged terminally ill patients to choose to die with dignity. The patient charged the insurance company for medical expenses to receive treatment to prolong his life, but the insurance company refused to provide insurance. The insurance company said that there is no possibility of life extension even if he is prescribed medicine, so instead the insurance company would pay the expenses incurred after choosing death instead of medicine. This position causes controversy. After that, there was also similar case in the state of California, where death with dignity was allowed. The insurance company said that the company could not pay for chemotherapy for the patients who had very little chance for recovery. Like this, there are some cases that insurance companies force patients and his or her family to decide death with dignity which the companies want to.

 

Then what about the death of the dignity of our country? Let's see our country's death with dignity law.

 

The beginning of death with dignity

 

Kim is the first person in Korea who brought up a conversation topic to nation of death with dignity. On February 18, 2008, she was hospitalized to Severance Hospital for taking a lung biopsy because of cancer and she went into a vegetative state due to brain damage from excessive bleeding. Her family members asked the hospital to stop the meaningless life prolonging treatment and allow her to die with dignity, but the hospital refused. Her family took legal action for it. On May 21, 2009, the Supreme Court's final ruling said that if patients are deemed to exercise their own right (on the basis of one's dignity, values, and the right to pursue happiness) after reaching an unrecoverable level, they can be allowed to stop their life prolonging treatment. After the judgement, the hospital removed her respirator on June 23, 2009 and she died on January 10, 2010.

 

The law of well-dying

 

The Ministry of Health and Welfare announced that demonstration project of ‘the law of well-dying’ would be carried out by 10 medical institutions from October 23, 2017 to January 15, 2018, and the law of well-dying would go into full force beginning on February 4, 2018. The law of well-dying enables patients to stop the medical care of the patients based on their will. Patients who are subject to death with dignity are quite beyond recovery, in spite of treatment, and are in dying process. However, patients in terminal stage and continuous vegetative state are not the subject of the death with dignity, so there is a continuous discussion about it. Right now, two doctors, including one of the patients ' doctor in charge, determine whether or not the patient can get well, and the doctors decide whether to die with dignity or not. The medical care for life prolonging includes medical procedures such as cardiopulmonary resuscitation, hemodialysis, injecting anticancer drug administration, and artificial ventilator treatment, and can be stopped based on patient's judgment. However, basic care of pain relief such as nutrition, moisture and oxygen supply, keeping the body warm, assistance of evacuation and urination, administration of pain reliever, and so on, cannot be stopped even they choose death with dignity. According to the law of well-dying, patients over 19 years old cannot express his or her opinion and if there is no way to confirm patients’ intent, patient's opinion is respected based on statements made by the patient's family. The family's statement is made by two or more patients ' families and this statement should same as doctors’ opinion. Until January 3, 2018, the number of people who submitted ‘the program of medical care for life prolongation( saying that they will not get the lifesustaining care)’ which can be written by critically ill patients was about 60, and the number of people who submitted  ‘the advance declaration of Intent of medical care for life prolongation’ which can be written by ordinary person was over 7,200.

 

Weakness

Vague criteria of patients’ deathbed

 

The medical community explains that there is currently no clear standard in the law of well-dying about the time of patients’ last. In fact, ' a handbook of the law of well-dying ' published by The Ministry of Health and Welfare and the Korean National Institute for Bioethics Policy in December 2017 says that, patients who are medically judged as being on their deathbed can make their own decision to implement or stop the medical care for life prolongation. However, the clear criteria of patients’ deathbed are not specified in the handbook. Some people point out that the unclear ‘criteria of patients’ deathbed’ could make doctors judge the criteria differently from other doctors, also even doctors may not know when to discontinue patient's life support treatment. As for this, the persons concerned with The Ministry of Health and Welfare said, “The government cannot interfere in its efforts to judge the period of the patients’ deathbed because it is up to experts, “adding, “there may be some confusion after enforcing the law, but I expects it to stabilize after time.”

 

Death with dignity for person in a vegetative state

 

Patients in a vegetative state were reported to be unable to stop the medical care for life prolongation in Korea. The reason is that people in a vegetative state can sometimes survive. In practice, 'Current Biology journal reports' reported on September 26, 2017 that a 35-year-old man has been in a vegetative state for 15 years due to a car accident and has been shown to have recovered partial consciousness after an experimental treatment by continuously implanting a nerve stimulator in the chest. In Korea, if the patients’ doctor in charge and one of the medical specialists of relevant field make a judgment that the patient is " dying, " he or she can become the subject of death with dignity. In Britain, however, patients who have no hope of revival may refuse the treatment, also patients can choose 'living will' to deny treatment to prepare for the case which their lives are in danger or unable to express their opinions. It is generally admitted for people in vegetative state to die with dignity in the United Kingdom after the judge has handed down a verdict that patients who had been in a vegetative state for more than three years were acceptable to die with dignity in 1993.

 If you think about the meaning of the human dignity, which means we may be valued for being human and respected for our character, we should question whether treating patients who are close to death is really an act of respecting them as human beings. I think it is necessary for anyone to think seriously about how to face the end of their life. Therefore, the nation needs a better policy to respect the wishes of the patients.

 

 

황희원  sso03134@naver.com

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