Optimum Use of Artificial Nutrition and Hydration Near the End of Life: Ethics, Advance Directives, Public Deliberation, and Reform of Korea’s Life-Sustaining Treatment Act

This commentary examines the ethical implications of the mandatory provision of artificial nutrition and hydration (ANH) under Korea’s Act on Decisions on Life-Sustaining Treatment. Building upon a target article derived from a policy research report, we focus on the proposal to incorporate ANH into advance directives and argue that the current legal framework creates serious clinical ethical problems. Although ANH is widely recognized as a medical intervention requiring individualized proportional judgment, the Act effectively mandates its provision even during the end-of-life process. We argue that this rigid approach violates the principles of nonmaleficence, justice, and respect for autonomy by prolonging suffering, producing unequal end-of-life options across institutional settings and according to the type of intervention sustaining patients’ lives, and undermining trust between patients and clinicians. Accordingly, ANH should not be treated as a universal obligation but as a medical intervention subject to proportionality, patient preferences, and clinical judgment. Finally, we argue that active public deliberation is necessary for the ethical and legal incorporation of ANH into advance directives.