Reconsidering Korea’s Life-Sustaining Treatment Decision System Through the Epistemology of Preferences

South Korea's life-sustaining treatment decision-making system, despite institutional expansion following legislative reform, continues to face friction in translating patient preferences into clinical reality. Three assumptions underlying the current system warrant reexamination. First, insights from the advance care planning outcomes debate, affective forecasting, and the disability paradox reveal that patient preferences are not stable, predefined objects, but rather an evolving process of formation, reformation, and translation. Second, within Korea's relational decision-making culture, family consensus operates not merely as an external constraint on autonomy but as a medium through which autonomy is shaped; critiques of family-unanimity provisions should therefore focus on the quality of dialogue rather than on the minimization of family involvement. Third, in cases of progressive cognitive decline such as dementia, the temporal authority of precedent autonomy reaches its limit, calling for approaches that accommodate patients’ fluctuating capacity. Advance directives should therefore be redesigned from static, one-time documents into iterative, relational dialogues anchored in clinical ethics committees and integrated community care.