Despite the wide and daunting array of cross-cultural obstacles that the formulation of a global policy on advance directives will clearly pose, the need is equally evident. Specifically, the expansion of medical services driven by medical tourism, just to name one important example, makes this issue urgently relevant. While ensuring consistency across national borders, a global policy will have the additional and perhaps even more important effect of increasing the use of advance directives in clinical settings and enhancing their effectiveness within each country, regardless of where that country's state of the law currently stands. One cross-cultural issue that may represent a major obstacle in formulating, let alone applying, a global policy is whether patient autonomy as the underlying principle for the use of advance directives is a universal norm or a construct of western traditions that must be reconciled with alternative value systems that may place lesser significance on individual choice. A global policy, at a minimum, must emphasize respect for patient autonomy, provision of medical information, limits to the obligations for physicians, and portability. And though the development of a global policy will be no easy task, active engagement in close collaboration with the World Health Organization can make it possible.

A generally accepted consensus of end-of-life (EOL) care decision-making did not appear in Korean medical society until the year 2009. To enhance physician's ethical perception of EOL care, consensus guidelines to withdrawing life-sustaining therapies endorsed by Korean Medical Association, Korean Academy of Medical Science, and Korean Hospital Association, were published on October 13, 2009. In this article, the characteristics and issues with the guidelines are presented to improve understanding by physicians who interact with EOL patients. According to the guidelines, physicians should identify, document, respect, and act on hospitals inpatients' needs, priorities, and preferences for EOL care. The guidelines advocate that competent patients express their right of self-determination in EOL care decisions through advance directives. However, there are barriers to adopting advance directives as a legitimate tool of EOL decision-making in our current society. The guidelines stressed the importance of open communication between care-givers and patients or their surrogates. Through communication, physicians can create a plan regarding how to manage EOL until the patients' last day of life. Concerted actions among the general public, professionals, other stake-holders for EOL care, and governmental organizations to improve EOL care in our society are also stipulated. Physicians, who know the clinical meaning of the treatments available to EOL patients, should play a central role based on the consensus guidelines to help patients and their families make informed decisions about EOL care.

BackgroundLittle is known about the effects of socio-environmental factors on dental caries in different demographic situations in Asian populations. We investigated whether the nature of the association between regional socio-economic context and dental caries experience differed according to gender and age groups in Korean adults.MethodsWe obtained a linked data set containing individual information from the 2000 Korean National Oral Health Survey and regional information from the “Major statistical indices of Si-Gun-Gu” (city-county-ward), published by the Korean Statistical Office. We stratified participants into women and men and into four 10-year-interval age groups (19–34, 35–44, 45–54, and 55–64 years) and analysed the linked data using a multilevel analysis. In total, 5,259 individuals were included in the final study population.ResultsRegional socio-economic context was significantly associated with dental caries experience in men, but not in women. The patterns of the association between regional contextual variables and dental caries experience differed among age groups. People 35–44 years of age living in areas less dependent on the manufacturing industry and those 45–54 years of age living in areas where local government was relatively poor were more prone to have caries experience.ConclusionsThe results of this study indicated that socio-economic factors affecting residents’ dental health status may operate through different mechanisms or degrees according to geographic location, suggesting that some gender- and age-defined subgroups may be likely to benefit from different types of intervention, including the development of specific health policies.

J Korean Med Assoc 2009; 52(9): 848 -855 T his year on May 21st, the full panel of the Supreme Court in Korea had first made a judgment on 'withdrawal of life-sustaining management'. In this case, where a 76 -year-old patient was represented by her children, while being in a persistent vegetative status, the Supreme Court ruled that if a patient is in an irreversible condition with imminent death and the discontinuation of treatment can be approved as the patient's self -determination, while such action will not be allowed in any other special circumstances. This judgement presented the general criteria and process of withdrawal of life -sustaining management in Korea for the first time. The Supreme Court also brought about the specific requirements of advance directives and decided that in case where legal proceedings are not taken, the hospital ethic committee constiting of medical specialists should decide whether the patient is in an irreversible condition. However, the judgment vaguely defined the concept of 'irreversible death-imminent condition' and did not clearly examine the relations between the patient's right on self-determination and the duty of the national government to protect the life of the people, and the discretionary power of the doctor.Keywords: Life-sustaining management; Advance directives; Hospital ethics committee; Death with dignity; Euthanasia Abstract

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