ArticleBMC medical ethics2026
When advance directives clash with family consent: designing an operational framework for end-of-life decision-making in China and Korea.
Article in BMC medical ethics, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundEnd-of-life decisions in East Asia often juxtapose written advance directives (ADs) with family-centered consent, generating recurrent conflicts at the bedside. While scholarship richly describes cultural rationales, the operational translation of legal-ethical principles into implementable hospital procedures remains underdeveloped. This study addresses that gap by proposing a comparative, workflow-ready blueprint that integrates priority rules, a duty-to-search protocol, and clinician safe-harbor protections across China (PRC; mainland China) and the Republic of Korea (South Korea) frameworks.
methodsWe conducted systematic doctrinal analysis of Chinese and Korean legal frameworks, followed by normative design of operational tools. Framework coherence was evaluated through structured scenario analysis of 12 literature-derived cases using established walkthrough methodology—a non-empirical validation approach standard in policy design.
resultsWe present three integrated tools: (1) the Autonomy-Prioritized Decision Model (APDM; the “3 + 1” structure—three decision tiers plus one execution step) establishing decision hierarchy (Layer 1: Verifiable AD; Layer 2: Appointed Proxy; Layer 3: Default Kin; +1: Order Execution); (2) an auditable “Duty-to-Search” (DtS) protocol converting vague obligations into time-bound, documentable actions with mandatory EHR fields; and (3) dual-model Safe-Harbor clauses linking procedural compliance to liability protection. Scenario-based walkthroughs across 12 conflict types achieved 100% decision-path convergence after iterative refinement (initial convergence: 83%), with 75% appropriately triggering ethics consultation, demonstrating logical coherence and operability across three legal environments (Korea, CN-Local, CN-No-Rule) via jurisdiction settings.
conclusionsBy converting autonomy and relational concerns into operational law, the blueprint supplies regulators and hospitals with actionable design patterns to reconcile ADs with family practices in China and Korea. It is portable to other East Asian jurisdictions, supports incremental adoption through local bylaws and hospital policies, and delineates measurable compliance tools for quality assurance. This approach provides a basis for future mixed-methods evaluation.
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