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End-of-Life Decision Making across Cultures

Article  in  The Journal of Law Medicine & Ethics · June 2011

DOI: 10.1111/j.1748-720X.2011.00589.x · Source: PubMed

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End-of-Life A
s is evident from the other articles in this spe-
cial issue, end-of-life treatment has engen-
dered a vigorous dialogue in the United States
Decision Making over the past few decades because decision making at
the end of life raises broad and difficult ethical issues

across Cultures that touch on health professionals, patients, and their

families. This concern is exacerbated by the high cost
related to the end of life in the U.S. Moreover, in light
of demographic patterns, progressively scarce health
Robert H. Blank care resources, and an expanding array of life-saving
technologies, decisions at the end of life are becom-
ing problematic matters of public and, thus, scholarly
concern in most countries. Issues at the end of life are
central not only to bioethics but also raise important
ancillary policy dimensions.
Until recent decades, death and the dying process
were largely the matter of private decisions made
within specific religious and cultural frameworks.
Increasingly, however, questions of how we make deci-
sions at the end of life have become a matter of pub-
lic policy and of ethical debate. Advances in medicine
have the capacity to extend life indefinitely, but often
with poor quality and escalating dependence on medi-
cal technologies. Demographically, the aging popula-
tions in most developed countries and the increasing
incidence of AIDS and other chronic diseases in devel-
oping countries promise to complicate end-of-life
decision making in the coming decades. As a greater
proportion of societal resources are expended at the
end of life, the ethical and policy issues are bound to
intensify. Thus, the more we can understand, deliber-
ate, and frame the issues now, the better the chance
we will have to deal with their mounting consequences
that face us.
The literature on treatment of terminal patients,
euthanasia, brain death, and other issues related
to dying has expanded significantly in the recent
decades.1 There remains, however, a scarcity of pub-
lications on how these issues are handled in different
cultural settings across countries. Furthermore, a lim-
itation with many comparative studies in health policy
and bioethics is that they tend to compare only a few,
primarily western, countries, thus giving a skewed
picture of the problems and context.2 As a result, the
debates over end-of-life issues have become largely
framed by western practices and values. This failure to
adequately include the context of end-of-life decisions
in other countries has led to a situation where much
of bioethics and health policy is parochial to western
nations, predominantly the U.S. As a result, we are
missing richness of other cultures in designing poli-

Robert H. Blank, Ph.D., is a Professor of Political Science at

the University of Canterbury in Christchurch, New Zealand.

cost and end-of-life care • summer 2011 201

S Y MPO SIUM

cies. Moreover, this scholarly focus on the U.S. risks
losing relevance and credibility abroad and produces
the uncomfortable assumption that only western val-
ues are acceptable and should serve as the norm.
This article first summarizes the broad range of
issues surrounding end-of-life decision making since
often articles and books focus on one aspect to the
exclusion of others. It then discusses the need for more
Physicians it should include control of pain and other
symptoms, psychosocial support for both the patient
and family, medical services commensurate with the
needs of the patient, and specially trained personnel
with expertise in care of the dying and their families.3
What types of hospices operate, and what level of pal-
liative care and pain management are accessible to the
dying patient in each country?

In light of demographic patterns, progressively scarce health care resources,

and an expanding array of life-saving technologies, decisions at the end of
life are becoming problematic matters of public and, thus, scholarly concern in
most countries. Issues at the end of life are central not only to bioethics
but also raise important ancillary policy dimensions.

comparative country research on death and dying and
summarizes the debate over policy convergence. Atten-
tion then shifts to the importance of culture and how
cultural differences shape end-of-life decisions both
within and across countries. Finally, it examines the
implications of a study of end-of-life policies across 12
disparate countries for a much broader range of issues
surrounding death and dying.
The Issues Surrounding End-of-Life
Decision Making
There are numerous overlapping issues that together
define the context of decision making at the end of life.
Although most attention in the West has focused on
the elderly or on cancer patients, in some countries
the focal point is on younger adult AIDS patients or
on children dying from malnutrition or infectious dis-
eases. In each of these categories, the responses to the
problems they present can vary significantly across
countries. Basic questions relate to what institutional
services exist for care of the critically or terminally ill;
how, where, and by whom these patients are treated;
how aggressive and costly the treatment regime is
(e.g., what availability of intensive care units); who
makes the final decisions as to the level of care given;
and who pays the escalating costs of dying?
More specific questions regarding the end of life
relate to availability of medical specialists and ade-
quate pain management, palliative care, and hospice
services. Hospice care may be provided either in a facil-
ity or in the home, but the basic concept of hospice is
one of comprehensive care for the dying. Although the
physical facilities may be very extensive or quite mini-
mal, according to the American Academy of Family
Conversely, what, if any, boundaries or cut-off
points exist for aggressive treatment of a particu-
lar category of patient, whether an end-stage cancer,
AIDS or Alzheimer’s patient, or a terminally ill elderly
patient? Under what circumstances are cardiopulmo-
nary resuscitation and artificial hydration and nutri-
tion used? Are they even available? For instance, with
few exceptions, artificial feeding is most prevalent in
the U.S. and hardly used in most countries, even some
European ones. “Curiously, many cultures see stop-
ping eating as a sign of dying and not its cause. They
never even consider the use of a feeding tube.”4 Also,
do individuals generally die in intensive care units,
hospital wards, nursing homes, hospices, or at home?
Moreover, how is such care funded, and who ulti-
mately makes the life-ending decision in cases where
the patient is unable to do so: doctors, the family, eth-
ics committees, the government, or some or all of the
above?
Accompanying the medical dimensions of policy
making at the end of life are the social and legal aspects.
In some western countries, considerable emphasis in
recent decades has been directed toward empower-
ment of the patient or patient autonomy. Obviously,
truth telling is an important aspect of this dimension.
A wide variety of legal mechanisms have been created
toward this end in some countries, but by no means
most. The stated goal of advance directives, whether
living wills or powers of attorney, is to return to the
individual the ability to control the dying process, pri-
marily by refusing life-extending interventions, but
this is far from universally accepted. There are con-
flicting views on their effectiveness, and cultural back-
grounds in various countries have resulted in different

202 journal of law, medicine & ethics


views on what role they should play and on their use
even where legal. At this moment in time, however,
the possibilities of developing a global approach on
advance directives extend no further than comparing
different cultures and in this way trying to nurture
the debate and clarify the thinking about end-of-life
decisions.5
Related to advance directives are various policy ini-
tiatives and debates over the concept of euthanasia,
itself loaded with complex and varied meanings both
within and across cultures and countries. Some com-
mentators distinguish between passive and active, vol-
untary and involuntary, and other categories of eutha-
nasia, thus allowing for support of some but not other
types. Others argue that such distinctions are artificial
and that all forms of euthanasia are morally wrong and
must thus be outlawed. Still others argue that the dis-
tinctions are of little help and that individuals should
not be precluded by law or moral codes to make their
own choice as to how and when to die. Although the
most vehement opposition to euthanasia tends to cen-
ter on those cases where active assistance of a third
party is required, the debate over doctor-assisted sui-
cide frequently is deliberately linked with cases involv-
ing the withholding or withdrawing of treatment, thus
again clouding the lines between passive and active
types of euthanasia. The question remains as to how
different countries define and deal with withholding
or withdrawing particular types of intervention or
with more direct forms of termination.
Another exigent issue is how we define the death
of a human being. In response to the development of
life-sustaining technologies and the need for organs
for transplantation, some countries have accepted a
legal definition of brain death. There are two critical
dimensions to this issue. The first is the conceptual
interpretation of what death means in the context of
medical technology, since the traditional understand-
ing of death as the irreversible cessation of cardio-
pulmonary functions has been confounded by tech-
nological means of prolonging these functions. The
second dimension centers on the appropriate clini-
cal tests to be used to determine that a patient is in
fact dead, especially when the patient’s life has been
protracted by technological means. Because technolo-
gies in both of these areas are advancing rapidly (in
the first instance life-sustaining technologies and in
the second diagnostic imaging technologies that indi-
cate the presence or absence of characteristic types of
activity in specific regions of the brain), and because
of the linkage of brain death to organ transplantation,
the definition of death has become a contentious issue,
and one that varies from country to country.
cost and end-of-life care • summer 2011 203
Robert H. Blank
A broad array of end-of-life issues, therefore, from
how and where the dying are treated, to who makes the
decision to withhold or withdraw treatment or allow
physician-assisted suicide, and to how we define and
measure death elicit considerable public and profes-
sional debate. This is not surprising because decision
making at the end of life is among the most intensely
emotional and ethically charged issue areas. Critical
to understanding these issues in a broad sense is the
extent to which they are common across nations and
cultures or, contrarily, vary from one country to the
next. As noted in the International Bioethics Commit-
tee’s Report on the Possibility of Elaborating a Univer-
sal Instrument on Bioethics, the meaning and signifi-
cance of life and death are inextricably tied to culture
and tradition.6
The Need for Comparative Country Research
In spite of the difficulty of comparing health care
across countries, comparison is an appealing strategy
for social enquiry. It adds complexity and nuances to
ethical principles and policies. Cross-country compar-
ison is not only interesting but also provides a basis
for identifying the variety of options that exist in fram-
ing biomedical issues. Comparative studies also give
us insights as to what works or does not work within
a wide variety of institutional and value contexts and
illuminate the commonalities of problems and vari-
ables across countries. Given the complexity of end-
of-life issues, only with a thorough knowledge of what
occurs across many countries can we generate the evi-
dence necessary to consider the full array of available
options.
In recent years, there has been considerable theo-
rizing over the concept of policy convergence that
contends that as countries industrialize they will
converge towards the same policy mix.7 For instance,
some scholars argue that there are global trends in
the formation of health policies, and that the objec-
tives and activities of health systems internationally
are becoming more alike.8 Convergence is bolstered by
globalization and by the development of an interna-
tional health forum through the internet where people
from all countries can comparison shop. In addition,
explicit efforts by international organizations such as
the OECD, WHO, and the EU help prepare the foun-
dation for what Harrison et al. refer to as “ideational
convergence.”9 Convergence is intuitively attractive
because similar problems potentially make for simi-
lar solutions. This assumption is also supported by the
fact that ultimately there are only a limited number
of policy instruments available to address a particu-
lar problem, thus suggesting that function rather than
S Y MPO SIUM

politics informed by historical legacy or culture shapes
policies.
In contrast, critics of convergence argue that it
oversimplifies the process of development and under-
estimates significant divergence across countries.10
Convergence, they contend, downplays the impor-
tance of country-specific factors other than economic
development and neglects the fact that most studies
finding evidence of convergence do not find it appli-
cable across the board, thus allowing for divergence in
vention. Not surprisingly, the economic wealth and
cultural heritage of the country are most important
determinants of where people die. More broadly, in
their study Cox et al. conclude that there are signifi-
cant cultural differences regarding advance care plan-
ning and end-of-life decision making that represent
major challenges for health care providers. Moreover,
“advance directives, which are generally accepted in
western civilization, hold little or no relevance in other
cultures.”13 Similarly, for the most part it is only in the

Comparative studies also give us insights as to what works or does not work
within a wide variety of institutional and value contexts and illuminate
the commonalities of problems and variables across countries. Given the
complexity of end-of-life issues, only with a thorough knowledge of what
occurs across many countries can we generate the evidence necessary to
consider the full array of available options.

other areas. For instance, a cross-national study of the
health systems of nine developed nations found some
convergence of ideas but considerable variation in
policy.11 Countries continue to adopt diverse and often
culture-bound strategies to deal with the similar prob-
lems facing them. Therefore, while one can selectively
find evidence of convergence, it is by no means cer-
tain, inclusive, or consistent and has not necessarily
translated into similar values, policies, or even policy
directions across countries.
The concept of convergence, however, is important
for end-of-life decision making because if it is viewed
as inevitable, there will be accompanying pressures
to converge in areas that might be counterproductive
to the unique needs and value systems of particular
countries. Likewise, there is a danger of making the
assumption that ethical frameworks will converge to
a western model despite continued evidence of a wide
divergence across countries in bioethical perspectives.
As argued by Macer and others, bioethics has had a
distinct western bias and focuses on concepts that may
have little relevance to other countries.12 Three-quar-
ters of the world’s population is not linked to concepts
such as individual autonomy and truth telling that are
assumed by the conventional western bioethics com-
munity as critical in medicine.
Importance of Culture and Religion
Despite the heavy emphasis in the West on intensive
care and medical interventions, most people around
the world die at home without any medical inter-
U.S. that we even consider artificially feeding patients
with end-stage Alzheimer’s disease or other dementias
or feel that we are starving a patient to death by with-
holding artificial feeding machines.14
In their study of India and Germany, Chattopadhyay
and Simon contend that culture is crucial because it
creates the context within which individuals experi-
ence life and comprehend moral meaning of illness,
suffering, and death. “The ways the patient, family
and the physician communicate and make decisions
in the end-of-life care are profoundly influenced by
culture.”15 For instance in India, where illness is more
a shared family affair than an individual incident, a
physician is likely to respect the family’s wishes and
withhold the truth about the diagnosis of a fatal dis-
ease to the patient while in Germany a physician is
legally required to inform the patient about the dis-
ease. Similarly, while advance directives are virtually
non-existent in India, in Germany they are regarded
as mandatory and health care is covered by insurance.
Chattopadhyay and Simon conclude that the explora-
tion of finding a common ground of morality across
different cultures while acknowledging and respecting
cultural diversity remains a “formidable challenge for
the bioethicists.”16
Another study found that Japanese medical resi-
dents were more likely than U.S. residents to include
the family when disclosing diagnosis and prognoses
of terminal illnesses — an act which is speculatively
credited to the Japanese culture of making decisions
as a group.17 Moreover, in a comparative study of Ger-

204 journal of law, medicine & ethics


many and Israel, religion was found to be a powerful
explanatory factor in divergent end-of-life policies as
enunciated by national commissions.18 In relation to
the acceptance of euthanasia, because of seculariza-
tion, religious people in the Netherlands tend to be
more liberal and progressive as compared to coun-
tries where there is still a more conservative religious
climate like Italy, although Christian people in the
Netherlands are still more likely to be against assisted
suicide when compared to their non-believing fellow-
countrymen.19
Likewise, Searight and Gafford argue that the U.S.
model of health care that values autonomy in medical
decision making is not easily applied to some racial
and ethnic groups. “Cultural factors strongly influence
patients’ reactions to serious illness and decisions
about end-of-life care.”20 There remain major differ-
ences across cultures regarding communication of
“bad news,” the locus of decisions and attitudes toward
advance directives, and end-of-life care. Even within
U.S. there are differences by race. One recent study
concluded that a large majority of seriously ill older
Latinos favored family-centered decisions and limited
patient autonomy.21 Despite preferring less aggressive,
comfort-focused end-of-life care, few had documented
or communicated this preference, thus placing them
at risk of receiving high intensity care inconsistent
with their preferences. Similarly, another study found
that hospice use is low among Latinos and that cul-
tural values of denial, secrecy about prognosis and a
collective, family-centered system influenced hospice
decisions in Latinos but not non-Latinos. This results
in a significant dilemma: how to discuss hospice with
a patient and family who prefer not to discuss a termi-
nal prognosis.22
In many Asian cultures, it is perceived as unnec-
essarily cruel to directly inform the patient of a can-
cer diagnosis.23 Thus, in contrast to the emphasis on
truth telling in the U.S., health care professionals in
other countries frequently conceal critical diagnoses
from patients out of deference to respect or potential
harm to the patient. Furthermore, the U.S. emphasis
on patient autonomy might conflict with filial piety,
an orientation of the extended family where illness
is considered a family event not an individual occur-
rence.24 It is common practice in Asian cultures for
health care providers not to disclose the complete
truth of the illness, especially to a patient with ter-
minal cancer. The responsibility of telling the truth is
left to the family, but mutual silence prevails between
patients and families when discussing medical issues
and poor communication persists. In Taiwan, for
example, the public is reluctant to talk or think about
death, preferring not to consider death until it occurs.
cost and end-of-life care • summer 2011 205
Robert H. Blank
Thoughts or conversations about a premature death
are ill favored and in that sense a taboo.25 Moreover,
the Confucius culture emphasizes that the family is
the original source of everything and thus family val-
ues are placed above the individual. Although families
in many countries often insist in very aggressive care
that represents a net harm to the dying patient, in
Asian countries disagreements between a patient and
his or her family about end-of-life care may result in
medical professionals who too often follow the opin-
ions of the family members rather than those of the
patient.26
Although the Asian cultures might diverge most
from western values, there is considerable variation
within the West as well. In a major study of decisions
by patients, families, and health care providers about
medical care at the end of life in 37 European ICUs,
culture was found to have a major impact on end-of-
life decisions across the regions of Europe. End-of-life
decisions regarding cardiopulmonary resuscitation,
brain death, withholding or withdrawing treatment,
and active shortening of the dying process all reflected
statistically significant differences among regions that
could be attributed largely to cultural factors.27 Another
study, drawn from the same data set, examined the
influence of religious affiliation and culture on end-of-
life decisions in intensive care units. They found that
withholding occurred more often than withdrawing if
the physician was Jewish, Greek Orthodox, or Muslim,
while withdrawing occurred more often for physicians
who were Catholic, Protestant, or had no religious
affiliation. Thus, “significant differences associated
with religious affiliation and culture were observed for
the type of end of life decision, the times to treatment
limitation and death, and the discussion of decisions
with patient families.”28
An increasing number of studies, then, have dem-
onstrated that the way health care professionals, the
patient and his/her family communicate, interact
and make decisions in health care setting can be pro-
foundly influenced by the interplay of the meaning of
health and illness, existing social norms, moral val-
ues, and a culture-specific sense of professional duty
toward patient care.29 Cultural variation particularly
across countries has been recognized as a key factor
in providing care at the end of life.30 In many cultures,
filial duties and sense of responsibility in interper-
sonal relationships may form the principal basis for
non-disclosure. For example, in Italy, disclosing a
diagnosis of cancer is believed to disrupt the seren-
ity of the terminally ill.31 For individuals of Hispanic
and Asian origin, disclosure of a terminal prognosis
removes all hope and may be harmful to the patient.
African American patients generally are more desir-
S Y MPO SIUM
ous for life-sustaining treatment than comparable
whites; they are less likely to decline life-sustaining
treatment irrespective of illness severity and largely
reject assisted death.32
Notwithstanding its important influence on end-
of-life decisions, cultural diversity is often marginal-
ized in discussions in medicine and bioethical issues.33
Also, while the literature on bioethical issues related
to the treatment of terminal patients and other issues
related to death and dying has expanded consider-
ably in the recent past and there are many single-
nation studies, the few genuine cross-national studies
on end-of-life care that have been published include
principally western countries. Thus, it appears there
remains a gap in understanding of the end-of-life care
and decision-making processes from an East-West
cross-cultural perspective.
End-of-Life Context in Twelve Countries
This section is a summary of the findings of a book34
that brought together ethical and policy experts from
a range of countries in order to examine how end-of-
life policies vary across these countries, what country-
specific factors influence them, and how terminally ill
patients are treated by the respective health care sys-
tems. As noted above, few works previously examined
a full range of these issues across more than several
nations. Even the broader literature on comparative
health policy has tended to include only industrialized,
primarily western, countries, thus giving a skewed
picture of the problems and context. As a result, the
conceptual debates over various health policy issues,
including end-of-life decision making, have become
largely framed by western practices and values. The
objective of the book, therefore, was to expand the pre-
vailing boundaries of comparative study by including
countries that represent a broader range of cultural,
economic, and ideological dimensions.
The findings make it clear that ethical issues as
framed in affluent countries dominated by a liberal/
capitalist value system cannot easily be extrapolated
to countries with less individualistic cultures or those
that lack the economic resources necessary to achieve
such ends. Although there is considerable variation
across western nations (and in many cases within
them, as noted above) regarding end-of-life policies,
these differences are even starker in this wider sample
of countries.
In order to provide a starting point for coverage and
facilitate comparative data, contributors were asked
where possible to address these questions and issues:
1. What are the estimated costs of dying, per per-
son and aggregate?
206 journal of law, medicine & ethics
2. What proportion of health care costs are
expended in last three months of life? The last
six months of life?
3. What proportion of population dies in inten-
sive care units, hospital, hospice, home?
4. What proportion dies with some form of
advance directive? What forms of advance
directives are available? Are they binding?
5. What is the level of availability to pain
management?
6. What is the mix of high technology and pallia-
tive care?
7. What are cut off points for aggressive care?
Who decides? What is legal definition of
death?
8. What government policies, if any, are operative
in end-of-life decisions?
9. What policies, if any, are there for assisted
suicide/euthanasia?
10. What agents are most responsible for mak-
ing these decisions (a government agency, the
medical community, ethics committees, the
family)?
11. What role does age play, if any, in decision
making at end of life?
12. What factors unique to the country (cultural,
social, religious, economic, etc.) are critical for
understanding end of life decision making in
that country?
In the end, emphasis given each topic varied widely
across the chapters. The fact that many authors were
unable to uncover even rough data on many of these
factors, especially on the first four questions, is itself
important in demonstrating the variation in the state
of end-of-life policy across these countries.
In order to provide a meaningful range of case stud-
ies, 12 countries were selected representing a mix
of economic, religious, and cultural contexts about
equally from the West and non-West. They range in
size from six million in Israel to India and China with
over one billion each. There is also substantial varia-
tion along economic lines. While European countries,
Japan, and the U.S. all have a per capita GDP well
over $30,000, India and Kenya have only a fraction
of that. In terms of health, two variables that serve as
very rough indicators of the health status of a popula-
tion are life expectancy at birth and infant mortality
rates. Life expectancy is 82 years in Japan and over 80
in Israel, but only about 66 years in India and 58 years
in Kenya. Likewise, infant mortality rates vary widely
from 2.8/1000 births in Japan to over 50/1000 in
India and Kenya. Moreover, it might be expected that
countries with rapidly aging populations face pres-
 Robert H. Blank

Table 1
Variation by Country on Selected Variables

a b c d e f
Brazil 199 10,100 26.7 6.4 72.0 22.6
China 1339 6,600 19.8 8.1 73.5 20.3
Germany 82 34,100 13.7 20.3 79.3 4.0
Israel 7 28,400 27.9 9.9 80.7 4.2
India 1157 3,100 30.5 5.2 66.1 50.3
Japan 127 32,700 13.5 22.2 82.1 2.8
Kenya 39 1,600 42.3 2.6 57.9 54.7
Netherlands 17 39,500 17.4 14.9 79.4 4.7
Taiwan 23 32,000 16.7 10.7 78.0 5.3
Turkey 79 11,400 27.2 6.1 71.9 25.8
U.K. 61 34,800 16.7 16.2 79.0 4.8
U.S. 307 46,400 20.2 12.8 78.1 6.2

a. Population in millions (2010) d. Population over 65 (2010 est.)

b. Gross Domestic Product per person, in U.S. dollars (2010 est.) e. Life expectancy at birth (2010 est.)
c. Population under age 15 (2010 est.) f. Infant mortality rate, deaths per 1000 births (2010 est.)
Source: Data from World Factbook, 2010.

sures different than those with relatively young pop-
ulations. Among these countries there again is wide
variation: counties such as Brazil, Turkey, India, and
especially Kenya have high proportions under age 15,
while countries such as Germany, the U.K., and Japan
are dealing with large older populations.
Likewise, cultural factors and social values vary
across countries and in some cases were found to be
most crucial for end-of-life decision making. This
study reiterated that, despite what much of the bio-
ethics literature assumes, values dominant in the
West such as individual rights, lifestyle choice, and the
heavy dependence on medical fixes, are not universals
but rather exceptions.35 Moreover, as discussed above,
given increased cultural diversity within western
nations, there can be strong cultural and value divi-
sions within a country that are important in defining
end-of-life policies. Religious factors are particularly
critical dimensions for death-related policies, and the
single most important influence in some countries.
Moreover, social structures, particularly the impor-
tance of the family and the role of women, can be
central to care of the terminally ill and in setting the
boundaries of such care. In many countries extended
families and communities still have a vital role to play,
while in other countries even the nuclear family seems
to play a limited role in care giving. Overall, then the
countries represented here offer a wide range of con-
texts for studying end-of-life decisions.
The trends and patterns emerging from these case
studies in terms of the wide disparities in attention
and debate given end-of-life issues in these countries
are enlightening, although not surprising. In some
cases, these studies mark the first time this subject has
been discussed in an English language publication,
and in several cases in any publication. The cases on
Brazil, China, India, Israel, Japan, Kenya, Taiwan, and
Turkey, especially, provide valuable insights into the
importance of culture and religion, and demonstrate
how narrowly this subject has been framed in the pre-
dominant literature. These findings reaffirm the view
that conventional western-based bioethics must make
clear its unique culture foundations and, thus, its lim-
its. Even in western countries, however, these chap-
ters illustrate how historical and cultural factors have
created significant differences concerning end-of-life
policy, and explain, for instance, why the Netherlands
might embrace assisted suicide while neighboring
Germany has not.
The analysis here demonstrates that end-of-life poli-
cies across nations vary both in terms of substance and
refinement. Although all countries were found to be
addressing some of the issues surrounding end-of-life
decisions, the importance of culture and economics
cannot be overestimated when dealing with the pro-
foundly emotional subject of death. “Death policy” is
not an area that most medical professionals and politi-
cians care to emphasize. For modern medicine, which
is designed primarily to forestall it, death is often seen
as failure. Similarly, politicians are not anxious to risk
their careers on what are often no-win, highly sensi-
tive and inflammatory issues with heavy moral dimen-
sions. Despite this reluctance to set end-of-life policy,
a multitude of factors have combined to place at least

cost and end-of-life care • summer 2011 207

S Y MPO SIUM

some of these issues on the political agendas of all the
countries examined here. However, as vividly illus-
trated by the authors of the case studies, the framing
of the issues varies significantly. Policies and concepts
that in some countries enjoy widespread support are
taboo elsewhere and not even open for discussion.
Data on Dying: Costs and Place of Death
One of the first findings of most of the chapter authors
was that systematic, accurate data on dying in their
countries was not available. As a result, many of the
Some authors were better able to provide data on
the proportion of people who die in various medical
and non-medical settings, although in most countries
it is based more on conjecture or rough estimates than
hard figures. The economic wealth and cultural heri-
tage of the country appear to be important determi-
nants of where people die. A key social factor is the
strength of the extended family structure and the duty
of family members to care for the dying person. In
most of the world and in a majority of our countries,
most people die at home. In Turkey, for instance, a res-

The analysis here demonstrates that end-of-life policies across nations vary
both in terms of substance and refinement. Although all countries were found
to be addressing some of the issues surrounding end-of-life decisions, the
importance of culture and economics cannot be overestimated when dealing
with the profoundly emotional subject of death.

quantitative questions posed could not be answered.
In some countries, no reliable data exists, even on the
number of deaths. In Brazil, for instance, there remains
a “cultural silence around death” and few statistics are
available.36 Turkey has no national statistics on dying
and no data on the costs of dying. Likewise, India has
no systematic data on the causes and costs of death.
In Kenya, the context of a “highly paternalistic medi-
cal profession” has worked counter to the collection of
national statistics surrounding death.37 Li et al. found
that the only way to study end-of-life policy in China
was to focus on one province or city, in part because of
the lack of even crude national data.38
Israel, too, has few statistics and little research on
death and dying, and, “no laws and little consensus.”39
Even in legalistic Germany there is little empirical
data on dying. Of all these countries, only Japan, Tai-
wan, the U.K., and the U.S. systematically collect data
on the causes, costs, and numbers of deaths nationally.
Moreover, except for Britain and the U.S., it was not
possible to even estimate the costs of dying, either by
disease category or in the aggregate. Even in the U.K.,
where substantial records on death are kept, they
are fragmented and of questionable reliability when
it comes to estimating the cost of dying.40 This is not
surprising in that the cost of dying is not readily iden-
tifiable in “health” statistics. As noted above, death is
not what traditional medicine is about, even though it
will be the ultimate result for all patients.
olute duty of children to look after their parents, com-
bined with limited access to life-support technologies,
means that the vast majority of terminal patients die
at home.41 Kenya, too, has a strong extended family
support system, a severely under funded and stressed
health care system and very few available life support
systems.42 Therefore, like Turkey, most deaths occur
at home.
In India, another country with a poor medical infra-
structure and a strong notion of family responsibility,
outside of urban areas, most people die at home.43 In
urban areas, the middle and upper classes might go
to hospitals or nursing homes, but since there are few
intensive care units, the proportion that die there is
insignificant. China, likewise, demonstrates a clear
distinction between urban and rural areas. Although
reliable estimates again were not available, the norm is
for rural residents to die at home and urban residents
in hospital.44 Even though dying at home has a special
cultural meaning both for Chinese patients and their
families and even though most cancer patients prefer
to receive terminal care and die at home, in Taiwan,
an increasing number of terminal patients are dying
in hospitals, especially in the urban areas where tra-
ditional culture has been diluted by western values.45
However, even there, 2000 data still show that 58 per-
cent die at home (80 percent in rural areas, 20 percent
in urban) and only 35 percent in hospital.
Only when we move to western countries, do we
find majorities that die in hospital. Simon estimates

208 journal of law, medicine & ethics


that about half the deaths in Germany occur in hospi-
tals. Although national data on the deaths outside of
hospitals is poor, a 1997 study from Rhineland found
the following breakdown: 44 percent in hospital; 13
percent in nursing home; 40 percent at home; and
3 percent elsewhere.46 Similarly, despite its strongly
rooted family tradition, in Japan a majority die in hos-
pital, although it must be noted that most “hospitals”
in Japan are not large acute care medical centers, but
smaller long-term facilities along the lines of western
nursing homes.47
Not surprisingly, the U.K. and U.S. have the high-
est rates of in-hospital deaths. Relatively weak fam-
ily support structures and the ready availability of
life-support facilities have increased this prevalence
over past decades. While most individuals in the U.S.
express a desire to die at home, most do not. National
estimates of deaths are: 55 percent in hospital; 25 per-
cent at home; 9 percent in nursing home; 9 percent
in hospice; and 1 percent elsewhere. As evidenced by
the extensive Dartmouth Atlas study, however, there is
considerable variation across the U.S. Moreover, this
study found that the single best indicator of where a
person dies is the availability of acute care in a spe-
cific locale: if acute care is available, it is used.48 Of
all the countries examined here, the U.K., with its
national health service, appears to have the highest
rates of death in a hospital setting. Based on his sta-
tistical analysis of hospital records, Ashcroft estimates
that 65 percent of deaths occur in hospital, 20 percent
at home, 4 percent in hospice, and 8 percent in other
communal establishments.49
Palliative Care and Hospices
Closely linked to the question of where people die
are the use of palliative care and hospices, where a
preponderance of palliative care takes place in some
countries and virtually none in others. Palliative care
is quite limited and a relatively recent addition in most
countries, although it appears to be expanding. In
Brazil, for instance, a national association for pallia-
tive care was first founded in 1997, and there are pres-
ently only 29 palliative care centers spread across the
entire population. Part of the reason for the paucity of
work in pain management is a cultural view that one
must suffer as part of life.50 In China, too, palliative
care is a recent activity but dedicated wards have been
added in recent years. Taiwan has a relatively recent
(1990) but active hospice movement and has seen a
relatively rapid expansion of inpatient and home-care
programs particularly in the urban areas. Pain man-
agement in Taiwan, however, remains inadequate, in
part because of a cultural emphasis on Stoicism under
which patients often refuse pain medicine or cut
cost and end-of-life care • summer 2011 209
Robert H. Blank
ordered dosages.51 Moreover, altering the traditional
value that views sending a dying loved one to hospice
as abandonment and a dereliction of filial responsibil-
ity is one of the keys to facilitating acceptance of pal-
liative care and has led to a recent shift in hospice care
from hospital to home in both Taiwan and Japan.52
With severely limited health care resources, pallia-
tive care is almost non-existent in Turkey. Pain man-
agement is inadequate, although recently some medi-
cal centers have established dedicated departments.
Moreover, a culture that sees it as a duty of children to
look after their dying parents means most people die
at home and that hospices do not exist except in a few
nursing home settings.53 Similarly, Kenya exhibits an
absence of pain management/palliative care services,
although a charitable hospice movement has begun.54
In India there are a few charitable palliative care cen-
ters, but outside urban areas most people die at home
without palliative resources.55
In Germany there is a system of small, independent
hospices as well as integrated palliative care centers,
but they were relatively late in coming. Home care
offers pain therapy and symptom control but, as noted
by Simon, since they are not covered by health insur-
ance, hospice services are mostly volunteer-based.56
According to ten Have, the relatively primitive state of
palliative services in the Netherlands is partly a reflec-
tion of diminished options due to the heavy emphasis
on euthanasia. However, specialized centers in pain
control and management have been established in the
last decade and interest in palliative care is on the rise
in the Netherlands.57 Although Japan has had dedi-
cated palliative care units since 1980, a cultural reluc-
tance to use them means that less than one percent of
deaths overall occur in a hospice, and pain manage-
ment in Japan remains inadequate.58
In contrast, other counties have more extensive pal-
liative care facilities and services. Israel has a well-
established institutional and home care hospice system.
The U.K. was the birthplace of the hospice movement
although it remains overwhelmingly charitable and,
thus, a low priority for the NHS. The U.S. also has a
well-established hospice system that emerged for can-
cer patients in the 1960s and was expanded to AIDS
patients in the 1980s, although overall their use has
been relatively low in spite of expanded Medicare
funding over the past two decades. As elsewhere, pain
management and palliative care continue to be under
funded in the U.S.59
Advance Directives
The legal status of advance directives, too, varies widely
across these countries, but even in those countries that
formally allow them, use rates remain low. Indian law
S Y MPO SIUM

does not recognize advance directives of any type. In essary in each case and as a result few people bother
Kenya they are seldom used, and in some African cul- to have one. In Taiwan, the process for obtaining an
tures they are rejected because they are seen as invit- advance directive was formalized by the Natural
ing death. Turkish law allows advance directives, but Death Act of 2000. According to the Act, terminally ill
they are not binding and often ignored. In contrast, patients have the right to make a living will or appoint
DNR orders are illegal in Turkey, but they are prac- a durable power of attorney that can be executed after
ticed. Likewise, advance directives are rare in China, two doctors certify that the patient suffers from a ter-
and in Israel, advance directives have unclear status minal illness. Despite the Act, actual use in Taiwan
and are seldom used. remains very low.60 Moreover, Confucianism regards
Although Japanese statutes allow living wills, they “Hsiao” or filial piety as one of the key values neces-
are rare and less than one percent of patients die with sary to maintaining social stability and family mem-
some form of advance directive. While German law bers who sign DNR might be viewed as abandoning
recognizes advance directives, court approval is nec- the loved one.61 The Netherlands has a special proce-
dure through which a patient can request euthana-
Table 2 sia in advance of becoming incompetent. Although a
Advance Directives variety of advance directives are legal in the U.K., their
use is not widespread. Of all the countries examined
Brazil Limited use here, the U.S. stands alone in terms of attention paid
China No legal basis to advance directives, perhaps due to the emphasis
Germany Court approval in each case required, on individual rights and highly litigant system, but
few have them
even in the U.S. advance directives are utilized in a
India Law does not recognize, not used
very small proportion of deaths, contrary to what one
Israel Unclear status, seldom used
Japan Living wills legal but uncommon use, <1 might believe given all the media attention.
percent
Kenya Rarely used, seen by some African cultures as Euthanasia: Withholding, Withdrawing, or
inviting death Assisting Death
Netherlands Advance requests for euthanasia, seldom used As noted earlier, euthanasia is a multi-faceted and
Taiwan Recent law, low use, two doctors must certify culture laden term (see Table 3). It can range from
terminal case the omission of (withholding or withdrawing) life-
Turkey No legal basis, not binding, little used extending care that might include antibiotics, artifi-
U.K. Legal but low use cial hydration and nutrition, or life-support systems
U.S. Legal but low use
on the one hand, to actions taken to induce death on
the other. Moreover, any of these measures can be
voluntary on the part of the
patient, speculative when
Table 3
the patient is unable to con-
Categories of Euthanasia78
sent, or involuntary. For this
reason, many cultures reject
Passive Active use of the term itself. Thus,
omission of measures to direct inducement of there remains considerable
prolong life death confusion over even the defi-
Voluntary Passive Voluntary – Active Voluntary – nition of euthanasia in many
With patient’s express and Conscious and rational pa- Conscious and rational countries and as a concept it
informed consent tient refuses life-prolonging patient requests and is is considerably less compre-
treatment given lethal injection hensible than some western
Speculative Passive Speculative – Active Speculative – observers assume. Although
Without express and informed Cessation of life-prolonging Lethal injection adminis- assisted suicide remains ille-
consent (i.e., comatose patient, treatment for patient unable tered to patient unable gal in most jurisdictions, tech-
infant, dementia patient) to give informed consent to give informed consent nically even the Netherlands,
Involuntary Passive Involuntary – Active Involuntary –
in many countries there has
Against the express directions Cessation of life-prolonging Lethal injections adminis- been a trend towards accep-
of the patient treatment to rational per- tered to rational patient tance or at least tolerance of
son against her will against his will other forms of euthanasia,
particularly the withholding

210 journal of law, medicine & ethics


Table 4
Euthanasia
Passive Active
Brazil Unsettled, new concept Illegal
China No clear standards Illegal
Germany Yes, voluntary WH-WD Illegal
India Against law in any form (LLS) Illegal
Israel Varies, no law or rules Illegal
Japan Yes, WH-WD Illegal*
Kenya Against law (LLS) Illegal**
Netherlands Yes, WH-WD Illegal***
Taiwan Yes, WH-WD Illegal
Turkey Against law (LLS) Illegal
UK Legal, WH-WD Illegal*
USA Legal, WH-WD Illegal***
* Leniency given, especially for family members
** AIDS changing this
*** Official Dutch view, but technical only
*** Leniency/exception Oregon and Washington
WH—withhold
WD—withdraw
LLS—lack of life-support systems in country
of medical technologies when a competent patient so
decides (voluntary category). Again, culture and the
sophistication and availability of medical technologies
in a country appear to be major influences.
In Kenya, for example, there are few facilities for
life support and euthanasia is illegal. However, there
recently has been a surge in requests for assisted sui-
cide because of the AIDS epidemic.62 Similarly, in
Turkey euthanasia of any form is unlawful. Although
Turkey is a secular state, its 95 percent Muslim popu-
lation guarantees that the Islamic prohibition against
euthanasia is embedded in criminal law.63 Like Kenya
and Turkey, euthanasia in India is against the law
under all circumstances. Moreover, there has been
little public debate over a right to die. In all three of
these countries, the lack of available life-sustaining
intensive care facilities at the end of life means that
passive euthanasia as defined in the West is a near
meaningless concept since there is nothing to with-
draw or withhold.
Israel is an interesting case in that there is neither
written law nor obligatory unwritten rules regarding
euthanasia. The result is that end-of-life policy varies
from one medical center to the next and often from
one ward to another in the same center. Although
it is unclear if a patient has the right to refuse life-
sustaining treatment, there is increasing openness to
withholding (but not withdrawing) such treatment,
although it remains a minority opinion. The authors
note that any form of active euthanasia is unlikely to
cost and end-of-life care • summer 2011 211
Robert H. Blank
ever be acceptable in Israel, although high doses of
morphine that result in death might be given for pain
relief.64
In Japan, a medical treatment used to remove or
reduce pain that might also cause premature death
is lawful but only if the patient suffers from incur-
able disease, the pain is unbearable, and the patient
consents. Anyone assisting death is liable to be pun-
ished under law, but the courts have shown leni-
ency, especially for family members who do so.65 A
strong conviction of absolute respect for human life
in Brazil has meant that even with a change in the
code in 1988 to include quality-of-life considerations,
there are no national laws that protect withholding
of treatment or DNR orders.66 Despite this, in 1999
Sao Paulo State enacted a law that gives individuals
a right to refuse painful or extraordinary attempts to
prolong life.
As in these other countries, active euthanasia is ille-
gal in China and forbidden in clinical practice. China
has no formal euthanasia law and there are no clear
standards or indicators for withdrawing therapy.
Moreover, while there has been some discussion in
government, to date there has been no formal law on
passive euthanasia. Although active euthanasia also
remains illegal in Taiwan, some argued for it during
the six-year debate over the drafting of the Natural
Death Act of 2002. The Act did formalize procedures
for withdrawal of life support systems, although as
Chiu points out, implementation of the law has not
been without difficulty.67
In Germany, the courts have ruled that there is no
obligation to sustain life and that life-support treat-
ment can be withheld or withdrawn if the will of the
patient is known. Moreover, the prescription of drugs
for the purpose of reducing pain is allowed even if it
leads to death. Active euthanasia in Germany is pro-
hibited by criminal law, although the status of assisted
suicide policy is more complicated. A physician can-
not be punished for assisting in the suicide of a patient
by supplying drugs as long as the death does not occur
in his presence. For Simon this “absurd legal situa-
tion makes assisted suicide a humanly difficult option
as it forces the person administering euthanasia to
leave the dying person at the end in order to escape
prosecution.”68
In the U.K., voluntary passive euthanasia is widely
accepted and practiced. In contrast, as borne out by
highly publicized court cases, active euthanasia in any
form remains a criminal offence. Despite the legal sta-
tus, however, in practice it is not clear-cut and there
have been few prosecutions for assisted suicide.69 In
these cases, the verdicts have been especially lenient
for family members convicted of killing a loved one.
S Y MPO SIUM
Table 5
Brain Death
Brazil Increased acceptance, presumed consent law repealed
China No recognition of brain death
India Defined by law but virtually all patients wait until cardiovascular death
Israel General refusal to accept, very low organ transplant rates
Japan Unsettled despite much debate over brain death and organ transplantation
Kenya No recognition of brain death, no harvesting of organs for transplantation
Turkey No recognition of brain death
U.K. Legal definition but some family refusal to accept
U.S. Legal definition but some family refusal to accept
As usual, there has been considerable variation across
the U.S. states. However, a series of high profile court
rulings and an active right-to-die movement has
resulted in the legalization of voluntary passive eutha-
nasia through the withholding or withdrawal of life-
sustaining technologies.70 Physician-assisted suicide is
illegal in all but two of the 50 states, but like the U.K.
in practice prosecution has been limited in most states
jurisdictions and there is little evidence of a national
policy initiative. In 2008, Washington State became
the second state to legalize physician-assisted suicide
following Oregon, which operates under very strict
controls, with an annual number of assisted deaths
reported less than 50.71
Much attention has been centered on the euthana-
sia policy of the Netherlands, but it remains contro-
versial and is still not an established, normal prac-
tice.72 Although the Termination of Life on Request
and Assisted Suicide Act does legalize such actions
performed by a physician, the Dutch government
insists that the law does not legalize active euthanasia,
but merely provides a punishment exclusion assuring
that physicians will not be prosecuted. So even in what
some international observers see as an unambigu-
ous case of active euthanasia, the situation remains
unsettled.
Overall, these countries present a wide range of
responses to the broad issue of euthanasia. As many
of the authors point out, this is an area where there
is substantial inconsistency between the formal law
and actual practice, particularly as related to the with-
holding and withdrawal of treatment and the use of
pain-killing drugs to relieve suffering. Even in those
countries with strong cultural objections to eutha-
nasia and with Stoic traditions, there are indications
that clinical practice, particularly related to the use of
drugs to relieve suffering, often does not correspond
with either law or culture.
Definition of Death
For American observers, brain death as a concept is
widely accepted and frequently assumed to be the
212 journal of law, medicine & ethics
universal definition of death. The review
of these countries, however, demonstrates
that the debate over brain death and its
connections and implications for organ
transplantation has been at best muted
elsewhere. Of those countries where it has
been an issue, only in the U.K. and U.S. is
brain death widely supported and prac-
ticed as the basis for organ transplanta-
tion. In Kenya, there is no recognition of
brain death and organs cannot be trans-
planted.73 Similarly, in Israel there is a
general refusal to accept the concept of brain death
and, thus, a very low rate of organ transplantation.74
Although death is defined as brain death by law in
India, most families refuse to accept it and choose to
wait for cardiovascular death to occur so it is very rarely
practiced. However, there is strong support for organ
removal after cardiovascular death since under the
Hindu/Buddhist traditions the body means nothing
at death. In Japan there has been a heated debate over
brain death and organ transplantation, and although
the laws are slowly changing, there remains little pub-
lic acceptance of brain death and very few transplants
are performed.75 Brazil, on the other hand, has seen
increased acceptance of brain death and a transplant
number second only to the U.S., even though a law
to require presumed consent designed to increase
organ donation rates was repealed after strong public
opposition.76
Policy Arenas and the Question
of Convergence
In addition to major differences in many substantive
areas surrounding the end of life, the analyses here
demonstrate considerable variation in the role of gov-
ernments in end-of-life decisions. There is also wide
divergence among these countries over the stage of
debate on specific death issues as well as where this
debate takes place: among government policymakers,
the medical profession, commissions or committees,
academics, or a public forum. Moreover, while a few
governments like the Netherlands and Taiwan have
passed specific legislation, in most others end-of-life
decisions have largely been left to the medical profes-
sion or, as in the U.K. and U.S., handled through court
decisions on a case-by-case approach. In a few coun-
tries, ethics committees are active in the decision pro-
cess, but overall the western emphasis on such mecha-
nisms has seen limited applicability elsewhere.77
Although economic pressures and the motivation
to reduce pain and suffering appear to be breaking
down some past restrictions, particularly as related
to pain management and the withholding or with-

drawing of life-support systems, overall convergence
in end-of-life policy appears very limited. Even in
those areas that western observers might see as more
straightforward, such as encouraging hospice/pallia-
tive care, brain death, and advance directives, there is
little evidence of convergence across these countries.
On euthanasia, especially, there is unlikely to ever
be convergence. Death-related issues are too intense
and culturally sensitive to expect a convergence to the
western, largely U.S. driven, norms despite the dif-
ficult resource allocation questions surrounding the
end-of-life and aging populations that cross national
boundaries.
Even more so than in other areas of medicine, issues
at the end of life elucidate the importance of religion
and culture, as well as the role the family and social
structure. In most countries examined here, even the
western ones, there is still fervent opposition to change
on these issues among sizeable segments of the popu-
lation and the health care professions. The accounts
of these 12 countries demonstrate how controversial
these issues are. In many countries, there remains
the feeling that death is a highly personal matter, not
something to be publicly discussed, much less made a
matter of public policy. As discussed here, however, in
all countries the ethical issues are beginning to be dis-
cussed and are finding their way to the public policy
agenda and, as such, will increasingly become con-
tentious and unremitting political issues for the 21st
century.
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with US-Born White, Non-Latino Cancer Caregivers,” Pallia-
tive Medicine 24, no. 4 (2010): 427-434. Also see, J. C. Hey-
man and I. A. Gutheil, “Older Latinos’ Attitudes toward and
Comfort with End-of-Life Planning,” Health & Social Work 35,
no. 1 (2010): 17-25.
23. See Searight and Gafford, supra note 20, at 517.
24. Id., at 518.
25. W. Y. Hu, T. Y. Chiu, R. B. Chuang, and C. Y. Chen, “Solving
Family-Related Barriers to Truthfulness in Cases of Terminal
Cancer in Taiwan: A Professional Perspective,” Cancer Nursing
25, no. 6 (2002): 486-492.
26. S. T. Tang, T. W. Liu, M. S. Lai, L. N. Liu, and C. H. Chen,
“Concordance of Preferences for End-of-Life Care between
Terminally Ill Cancer Patients and Their Family Caregivers in
 S Y MPO SIUM
Taiwan,” Journal of Pain Symptom Management 30 (2005):
510-518.
27. F. D. Ganz, J. Benbenishty, M. Hersch, A. Fischer, G. Gurman,
and C. L. Sprung, “The Impact of Regional Culture on Inten-
sive Care End of Life Decision Making: An Israeli Perspec-
tive from The ETHICUS Study,” Journal of Medical Ethics 32
(2006): 196-199. See also S. Cohen, C. Sprung, P. Sjokvist, and
A. Lippert et al., ‘Communication of End-of-Life Decisions in
European Intensive Care Units,” Intensive Care Medicine 31,
no. 9 (2005): 1215-1221.
28. C. L. Sprung, P. Maia, H-H. Bulow, and B. Ricou et al., “The
Importance of Religious Affiliation and Culture on End-of-Life
Decisions in European Intensive Care Units,” Intensive Care
Medicine 33, no. 10 (2007): 1732-1739.
29. J. T. Berger, “Culture and Ethnicity in Clinical Care,” Archives
of Internal Medicine 158 (1998): 2085-2090; N. D. Thomas,
“The Importance of Culture throughout all of Life and
Beyond,” Holistic Nursing Practice 15 (2001): 40-46; C. Seale,
“Characteristics of End-of-Life Decisions: Survey of UK Medi-
cal Practitioners,” Palliative Medicine 20 (2006): 653-659; C.
J. Wiedermann and C. Druml, “End-of-life Decisions in Aus-
tria’s Intensive Care Units,” Intensive Care Medicine 34, no. 6
(2008): 1142-1144; A. Yaguchi, R. D. Truog, J. R. Curtiss, J. M.
Luce, M. M. Levy, C. Melot,  and V. L. Vincent, “International
Differences in End-of-Life Attitudes in the Intensive Care
Unit,” Archives of Internal Medicine 165 (2005): 1970-1975.
30. See Searight and Gafford, supra note 20.
31. See Berger, supra note 29; G. Bertolini, S. Boffelli, and P. Mal-
acarne et al., “End-of-Life Decision-Making and Quality of
ICU Performance: An Observational Study in 84 Italian Units,”
Intensive Care Medicine 36, no. 9 (2010): 1495-1504; G. Ser-
villo and P. Striano, “End-of-Life: Still an Italian Dilemma,”
Intensive Care Medicine 34, no. 7 (2008): 1333-1335.
32. W. H. Shrank, J. S. Kutner, and T. Richardson et al., “Focus
Group Findings about the Influences of Communication Pref-
erences in End-of-Life Care,” Journal of General Internal Med-
icine 20, no. 8 (2005): 703-709.
33. L. Turner, “Medical Ethics in a Multicultural Society,” Journal
of the Royal Society of Medicine 94 (2001): 592-594; L. Turner,
“Bioethics in Pluralistic Societies,” Medicine, Health Care and
Philosophy 7 (2004): 201-208.
34. R. H. Blank and J. Merrick, eds., End-of-Life Decision Mak-
ing: A Cross-National Study (Cambridge: MIT Press, 2005).
Although the data from this study are six years old, where pos-
sible I contacted the authors of the chapters (and searched the
literature for other evidence) to ascertain if there have been
any major changes in their countries that would alter their
original conclusions. With only a few exceptions, which are
raised in the discussion below, the description of these coun-
tries remains accurate.
35. A. T. Alora and J. M. Lumitao, Beyond Western Bioethics:
Voices from the Developing World (Washington, D.C.: George-
town University Press, 2001).
36. L. Pessini, “Ethical Questions Related to End of Life Decisions:
The Brazilian Reality,” in Blank and Merrick, eds., supra note
34, at 13-32.
37. A. Wasunna, “End of Life Decision Making in Kenya,” in Blank
and Merrick, eds., supra note 34, at 131-46.
38. Y. Li, O. Doering, L. Fang, F. Li, and S. Baoqi, “End of Life
Decision Making in China: A View from Beijing,” in Blank and
Merrick, eds., supra note 34, at 33-60.
39. T. Amidror and F. J. Leavitt, “End of Life Decision Making in
Israel,” in Blank and Merrick, eds., supra note 34, at 97-108.
40. R. Ashcroft, “Death Policy in the United Kingdom,” in Blank
and Merrick, eds., supra note 34, at 197-218.
214 journal of law, medicine & ethics
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41. S. Aksoy, “End of Life Decision Making in Turkey,” in Blank
and Merrick, eds., supra note 34, at 183-96.
42. See Wasunna, supra note 37.
43. S. K. Pandya, “End of Life Decision Making in India,” in
Blank and Merrick, eds., supra note 34, at 79-96; R. K. Mani,
“End-of-Life Care in India,” Intensive Care Medicine 32, no. 4
(2006): 1066-1068.
44. See Li et al., supra note 38.
45. S. T. Tang, “Meanings of Dying at Home for Chinese Patients
in Taiwan with Terminal Cancer: A Literature Review,” Cancer
Nursing 23 (2000): 367-370; T.-Y. Chiu, “End of Life Decision
Making in Taiwan,” in Blank and Merrick, eds., supra note 34,
at 169-82.
46. A. Simon, “End of Life Decision Making in Germany,” in Blank
and Merrick, eds., supra note 34, at 61-78.
47. D. Macer, “End of Life Care in Japan,” in Blank and Merrick,
eds., supra note 34, at 109-130.
48. Dartmouth Institute for Health Policy and Clinical Practice,
Quality of End-of-Life Cancer Care for Medicare Beneficiaries
(Hanover, NH: Center for Health Policy Research, 2010).
49. See Ashcroft, supra note 40.
50. See Pessini, supra note 36.
51. See Chui, supra note 45.
52. A. P. Glass, L. K. Chen, E. Hwang, Y. Ono, and L. Nahapetyan,
“A Cross-Cultural Comparison of Hospice Development in
Japan, South Korea, and Taiwan,” Journal of Cross Cultural
Gerontology 25, no. 1 (2010): 1-19.
53. See Aksoy, supra note 41.
54. See Wasunna, supra note 37.
55. See Pandya, supra note 43.
56. See Simon, supra note 46.
57. H. ten Have, “End of Life Decision Making in Netherlands,” in
in Blank and Merrick, eds., supra note 34, at 147-68. Also see
J.-L. Vincent, “End-of-Life Practice in Belgium and the New
Euthanasia Law,” Intensive Care Medicine 32, no. 11 (2006):
1908-1911.
58. See Macer, supra note 47.
59. J. Merrick, “Death and Dying: The American Experience,” in
Blank and Merrick, eds., supra note 34, at 219-242.
60. See Chui, supra note 45.
61. C. H. Huang, W. Y. Hu, T. Y. Chiu, and C. Y. Chen, “The Prac-
ticalities of Terminally Ill Patients Signing Their Own DNR
Orders: A Study in Taiwan,” Journal of Medical Ethics 34
(2008): 336-340.
62. See Wasunna, supra note 37.
63. See Aksoy, supra note 41.
64. See Amidror and Leavitt, supra note 39.
65. See Macer, supra note 47.
66. See Pessini, supra note 36.
67. See Chui, supra note 45.
68. See Simon, supra note 46.
69. See Ashcroft, supra note 40.
70. See Merrick, supra note 48.
71. R. Steinbrook, “Physician-Assisted Death: From Oregon to
Washington State,” New England Journal of Medicine 359
(2008): 2513-2515.
72. See ten Have, supra note 57.
73. See Wasunna, supra note 37.
74. See Amidor and Leavitt, supra note 39.
75. See Macer, supra note 47.
76. See Pessini, supra note 36.
77. See Chattopadhyay and Simon, supra note 15.
78. See R. H. Blank, Biomedical Policy (Chicago: Nelson-Hall,
1995): at 163.