The development of living wills in China started relatively late and has been characterized mainly by two transitions: first, at the institutional level, a shift from spontaneous advocacy by civic associations to official exploration of legislative practice. In 2006, drawing on the experience of the United States, the concept of the “living will” was introduced into mainland China for the first time through the website Choice and Dignity. In 2013, the first living will promotion association in mainland China was established in Beijing; building on the US. living will template Five Wishes and taking into account China's national context, the association introduced a living will document entitled My Five Wishes for use by mainland residents, which, in the form of a questionnaire, guides individuals in arranging end-of-life medical measures in accordance with their wishes and treatment preferences. In 2015, the China Association for Life Care released the China Living Will Promotion Plan, marking the entry of living wills in mainland China into a phase of substantive promotion. Beijing, Shanghai, Guangdong, Jiangsu, Zhejiang and other provinces have since carried out practical explorations of living wills. Second, at the societal level, attitudes have shifted from passive observation to active acceptance. Three surveys conducted by the Beijing Living Will Promotion Association between 2006 and 2015 indicate that public awareness of, and willingness to complete, living wills have risen year by year (9), and by 2022 a total of 57,187 people in China had registered their living wills (10). Since the Shenzhen Regulations incorporated living wills into legislation, related practice has expanded rapidly. Attorney Du Qin executed a living will for herself at the Shenzhen Notary Office, which became the first notarized living will in Shenzhen after the law was enacted (11). As of March 2024, the Shenzhen living will registry had recorded 33,084 entries by March 2024, with registrants displaying a pronounced trend toward younger age groups, and related topics have sparked extensive discussion across the country (12).

These developments indicate that, over the past two decades, China's living will system has undergone a gradual yet substantive transition from grassroots advocacy to institutional practice, accompanied by a steady rise in societal awareness and acceptance of autonomy at the end of life. Nevertheless, against the backdrop of China's increasingly acute population aging, a pronounced mismatch persists between the existing institutional supply of living wills and the practical needs of an aging society. The wave of population aging has not only exacerbated the imbalance between the supply of and demand for medical resources, but has also generated an urgent need among large numbers of functionally dependent and partially dependent older adults for support in end-of-life medical decision-making. Owing to illness, many such older adults may experience impaired consciousness or lose the capacity to communicate; in the absence of an advance specification of their treatment preferences through a living will, they risk being caught in a dilemma between “overtreatment” and “undertreatment,” while simultaneously placing substantial caregiving burdens and ethical decision-making pressures on their families. Driven by this practical context, the evolution of China's living will system is no longer confined to latent, spontaneously expressed demands at the societal level, but has increasingly taken the form of an explicit, time-sensitive claim for legal safeguards at the national level. Only the legislative establishment of a unified, clearly articulated and practicable institutional framework can move living wills from being a discretionary option for a limited group of individuals to a mainstream mechanism for protecting the rights of the majority.

China has long relied on an incremental legislative model characterized by “pilot projects first, then scaling up”, and the legislative evolution of the living will system is no exception. The development of China's living will system can be divided into three stages (Supplementary Table 1).

The first is the stage led by policy documents and legislative initiatives. In this stage, the State Council's issuance of dedicated opinions, together with legislative proposals submitted by deputies to the National People's Congress (NPC) and members of the Chinese People's Political Consultative Conference (CPPCC), have served as the main vehicles for clarifying the direction of reform and the need for legislation, thereby providing a value basis and policy foundation for subsequent law-making. In 2013, the State Council issued the Several Opinions on Promoting the Development of the Health Service Industry, which encouraged the development of and improvement in the quality of palliative care services, thus supplying policy support for the promotion of the living will system (13). As a key practical vehicle for living wills, palliative care centers on respecting patients' end-of-life medical preferences and safeguarding life dignity, and therefore closely corresponds to the core meaning of living wills—namely, the ex-ante specification of end-of-life treatment choices. In the same year, many CPPCC members and NPC deputies submitted proposals advocating the promotion of a living will system. Thereafter, proposals concerning living will legislation have been submitted by NPC deputies or CPPCC members almost every year (14). Article 8 of the 2017 expert draft of the Personality Rights Book of the Civil Code asserted that natural persons have the right autonomously to decide to forgo medical treatment, thereby directly embodying the core connotation of living wills. Although the final text of the Civil Code did not directly adopt this opinion, Article 1,002 on the “right to life” explicitly provides that “the safety and dignity of the life of a natural person are protected by law,” thereby incorporating “life dignity” into the catalog of statutory rights. Some scholars have observed that “the core of life dignity lies in dignity in death” (15), and that dignity in death depends to a considerable extent on the quality of life in the terminal phase. Living wills, as a concrete institutional arrangement for specifying end-of-life medical preferences in advance and enhancing the quality of life at the end of life so as to safeguard life dignity, therefore find their principal doctrinal basis in Article 1,002 of the Civil Code. In 2019, the National Health Commission, together with other departments, jointly issued the Guiding Opinions on Establishing and Improving the Health Service System for the Older adults, which further provided policy support for the practical implementation of the living will system in terms of service standards, model design and public education (16).

The second is the stage of local legislative exploration. Guided by the national policy framework, certain provinces or special economic zones have undertaken legislative experiments on living wills through local regulations, thereby accumulating practical experience for national-level legislation. On 1 January 2023, the revised Shenzhen Regulations entered into force. Article 78 of these Regulations, for the first time in China, conferred legal effect on living wills: under this provision, decisions regarding emergency resuscitation at the end of life are no longer made by family members but by patients themselves (17). In addition, the Regulations specify the conditions for effectiveness, core content and forms of execution of living wills. With respect to the conditions for effectiveness, the Regulations expressly limit them to circumstances in which “the patient is in the terminal stage of an incurable injury or illness or at the end of life.” As to content, a person making a living will may choose among three categories of medical measures that are expressly recognized in the legislation: invasive resuscitation measures, life-support systems, and continuing treatment measures for the primary disease. At the same time, the inclusion of the term “etc.” leaves room for expanding the scope of medical measures in future legislation. Regarding the form of execution, the Regulations provide three modes for making a living will, namely a notarization mode, a witnessed-execution mode and an audio–video recording mode. They also impose a special restriction on witnesses: “medical and health personnel involved in the patient's treatment” are excluded from serving as witnesses, and only third parties with the capacity to act as witnesses may do so. As a breakthrough in local legislation, these Regulations directly transformed “living wills” from a policy concept into a legal norm, thereby making Shenzhen the first city in mainland China to enact specific legislation on living wills. The institutional design of the Shenzhen Regulations offers a practical model for the nationwide promotion and legislation of living wills. Following the entry into force of these Regulations, other provinces likewise initiated legislative efforts concerning living wills. Members of local political advisory bodies submitted proposals for enacting local regulations on living wills, recommending that Shenzhen's legislative experience be taken as a reference (18). Some provinces have already incorporated living wills into the legislative plans of their provincial people's congresses (19).

The third is the stage of systematic national legislation, which aims to distill the institutionally mature arrangements tested in local practice and elevate them into laws or administrative regulations of uniform application nationwide. At present, the development of the living will system in China has not yet progressed to this stage. However, in light of both the internal logic of institutional evolution and pressing practical needs, enacting unified national legislation on living wills is an inevitable choice for China in responding to population aging, optimizing the allocation of medical resources and safeguarding citizens' autonomy.

First, as the core legal instrument through which people exercise autonomy over end-of-life medical interventions, a living will depends for its effectiveness on the standard applied to the legal capacity of the person executing it. This standard directly determines whether the end-of-life medical decisions contained in the living will can be validly implemented. Where a patient lacks the requisite capacity at the time of making a living will, the will is rendered invalid. It is therefore necessary to clarify who is qualified to make a living will, that is, to specify what level of legal capacity a person must have for the will to be valid. However, the Shenzhen Regulations merely provide that a living will may be submitted to a medical institution by “the patient or their close relatives,” without explicitly stipulating the capacity requirements for the person executing the will. On the question of how to assess a patient's capacity, many jurisdictions have introduced the specific concept of “medical decision-making capacity” in their medical legislation to determine whether an individual is competent to make autonomous end-of-life treatment decisions. By contrast, the current Chinese legal system has not yet established such a specialized concept. Assessment of capacity must therefore still rely on the general rules in China's Civil Code. Under the Civil Code, possession of the corresponding civil capacity is one of the necessary conditions for a civil subject's juridical acts to take legal effect. Scholars generally consider a living will to be a new type of civil juridical act unilaterally performed by a civil subject through a declaration of intention (20). Accordingly, the person executing a living will should have the corresponding civil capacity (21). Yet the classification of civil capacity is fundamentally based on a natural person's age, intellectual development and mental health status. Only living wills executed by persons with full civil capacity have legal effect under civil law (22). Minors and persons with mental disorders who have no or only limited civil capacity, even if they are to some extent able to understand and express their wishes regarding their own medical affairs, are still unable to execute a living will.

Second, the Shenzhen Regulations limit the circumstances in which a living will may take effect to two core situations: where the patient is in the “terminal stage of an incurable illness” or in a “dying state.” A living will may be implemented only when the patient is in one of these two conditions. The Shenzhen Regulations, however, do not clearly define the specific meaning of “terminal stage of an incurable illness” or “dying state,” nor do they specify who is authorized to make such determinations.

In fact, the criteria for determining the “terminal stage of illness” differ across national and regional legal systems. Singapore's Advance Medical Directive Act defines it as a situation in which “terminal illness means an incurable condition caused by injury or disease from which there is no reasonable prospect of a temporary or permanent recovery” (23); the United States Uniform Rights of the Terminally Ill Act defines a “terminal condition” as “an incurable or irreversible condition that, without the administration of life-sustaining treatment, will result in death within a relatively short time” (24). These definitions illustrate that there is already a divergence between broader and narrower understandings of “terminal” in foreign legislative practice, while Chinese legislation has not provided a precise textual definition of this concept. Moreover, Article 78 does not specify which institutions or actors are competent to assess whether a patient is indeed in the terminal stage of an incurable illness.

Such conceptual vagueness not only exacerbates confusion between patients and medical staff and among medical institutions, but may also lead to inconsistent thresholds for when a living will takes effect, thereby directly undermining the uniformity and fairness of the system's implementation.

In addition, neither Article 78 of the Shenzhen Regulations nor the chapter on legal liability establishes specific provisions on liability tailored to the living will system. More specifically, the current legislation is deficient in two respects. First, where a medical institution fails to implement a patient's living will, the existing provisions neither clarify the type of liability to be borne (for example, administrative or civil liability) nor delineate the concrete content and scope of such liability. Consequently, the requirement in Article 78 that “the expression of intent in a patient's living will shall be respected” operates only as a general, principle-based guideline for medical institutions: it merely calls upon them to attach importance to patients' expressed wishes, without conferring coercive force on the provision or imposing a binding obligation on medical institutions to provide diagnosis and treatment strictly in accordance with the living will. This absence of clearly articulated legal liability means that, within the framework of the Shenzhen Regulations, living wills lack robust, mandatory safeguards and their legal effect remains inherently limited. Second, the Shenzhen Regulations do not establish any safe-harbor or immunity provision shielding medical personnel from liability when they act in good faith in implementing a living will. Even where a living will be valid, medical personnel who are confronted with opposition from the patient's family often find it difficult to follow the patient's own wishes because they fear incurring civil, or even criminal, liability. In practice, such legal gaps can impede implementation: a survey on the implementation of living wills in Shenzhen indicates that even with a valid living will, if the patient did not communicate it to family members in advance or the family disagrees, hospitals often avoid relying on the directive alone and proceed only after relatives sign the necessary consent forms to avert disputes and litigation (25).

In jurisdictions that recognize living wills, most require a unified system for the registration and filing of such instruments, which is a critical precondition for their effective implementation. Although Article 78(2) of the Shenzhen Regulations specifies three lawful forms for creating a living will—namely notarization, attestation by witnesses, and audio-visual recording—China has not yet established a nationwide, unified registration and filing mechanism for living wills. In practice, when a patient executes a living will in one of these forms before losing decision-making capacity but does not inform close relatives or medical institutions in a timely manner, the relevant parties are likely to remain unaware of the document, thereby undermining its practical effect. Even when a living will is notarized and the notary office maintains an internal record, privacy-protection requirements impose strict limits on who may access that record and under what conditions. As a result, medical institutions often cannot obtain information about a declarant's living will at the time critical treatment decisions are made, which may again result in the frustration of the declarant's genuine wishes in individual cases.

Moreover, the core value of living wills lies in fully respecting patients' decisional autonomy in medical care, and such autonomy should be reflected not only at the stage of execution but also throughout the entire process of amendment and revocation. When changes in a patient's clinical condition, understanding, or preferences lead the patient to wish to withdraw or revise an existing living will, the principle of self-determination requires that the law permit the patient to exercise the right to amend or revoke that instrument. While the Shenzhen Regulations explicitly require that living wills be created through specified formal mechanisms, such as notarization or witnessing, to safeguard the authenticity and accuracy of their contents and to prevent forgery or tampering, they do not specify the procedures by which a living will may subsequently be amended or revoked. This gap has given rise to a central practical controversy: must amendments to or revocations of a living will satisfy exactly the same formal requirements as its initial execution? For example, if a living will was executed by notarization, must any subsequent amendment also be notarized? If it was executed through witnessing, must the original witnesses appear again, or may new witnesses be engaged for any modification? If amendments and revocations are required to comply with procedures that are as stringent as those governing execution, this may create substantial practical barriers for patients with limited mobility or severe illness, thereby paradoxically constraining their autonomy. Conversely, if the formal requirements are relaxed, the validity of living wills may become more vulnerable to challenge and to malicious interference by others, making it difficult to strike an appropriate balance between procedural rigor and practical feasibility.

In the context of traditional Chinese culture, death has long been a highly sensitive topic. People are generally reluctant to refer to it directly and instead rely on euphemistic expressions in everyday life. The well-known Confucian dictum, “You do not yet understand life—how could you possibly understand death?” (26), has exerted a profound influence on popular thinking. This emphasis on life coupled with the avoidance of death directly constrains public acceptance of living wills. Because of limited awareness, many patients conflate living wills with euthanasia or testamentary wills and therefore misinterpret the act of signing a living will as “abandoning life” or “passively awaiting death” (27). As a result, they resist engaging with this mechanism at a psychological level and, even when confronted with terminal illness, are reluctant to consider relevant arrangements. According to a 2020 study by Luo Yuping and colleagues, the “Choice and Dignity” website—the first platform in mainland China dedicated to promoting living wills—had registered only around 50,000 users, of whom 21,618 had actually completed a living will form (28), a vanishingly small number in a country of 1.4 billion people. By contrast, survey data from the United States indicate that, among 7,946 respondents, 26.3% reported having signed an advance directive (29). This stark cross-national contrast in prevalence further highlights the cognitive barriers faced by the Chinese public.

An even more deep-seated source of resistance lies in the entrenched Confucian ideal of filial piety. The Analects (Lunyu) states that “filial piety and brotherly respect are the root of humaneness” (30), treating filial devotion as the core of moral virtue and requiring individuals to take filial piety as a basic norm in managing family and social relationships. With respect to the treatment of one's parents, the Analects further explains that “while they are alive, serve them with ritual; when they die, bury them with ritual and sacrifice to them with ritual” (26), emphasizing that filial obligations must be fulfilled in accordance with ritual both during parents' lifetime and after their death. Under the influence of this ethical framework, family members generally believe that, as long as the patient has not completely lost vital signs, every possible effort should be made to pursue active life-sustaining treatment, which is regarded as the direct embodiment of filial duty. Conversely, raising issues of death while the patient is still alive, or withdrawing or withholding futile treatment in accordance with a living will, is easily stigmatized as “unfilial.” This not only imposes a heavy moral burden of self-reproach on family members but may also expose them to social pressure and criticism from relatives and neighbors, thereby reinforcing instinctive resistance to the implementation of living wills.

Beyond patients and families, the cultural and ethical tensions surrounding living wills also involve physicians. In Chinese traditional medical ethics, physicians are widely regarded as morally esteemed professionals charged with “relieving the suffering of the world and saving lives” (ji shi jiu ren) (31). Accordingly, clinicians asked to implement a living will may experience not only liability concerns but also conscientious and moral distress. As one recent discussion of living wills notes, physicians may claim conscientious objection to implementing a living will, even when the family supports the patient's expressed wishes (32, 33).

As Rousseau observed, “the ultimate law of all laws is engraved neither on marble nor on bronze, but in the hearts of every citizen” The implementation of any legal system must rest on public recognition and acceptance; otherwise, its effectiveness will be substantially diminished (46), and the establishment of a living will system is no exception. When elucidating the value foundations of the living will system, it is essential to consciously situate it within China's indigenous traditional value system and to reinterpret it in that light.

Although Confucian culture in everyday life tends to avoid explicit discussion of death, it nevertheless preserves intellectual traditions that place great importance on the end of life, notably the ideals of shanzhong (“a good death”) and shenzhong zhuiyuan (“paying careful attention to funerary rites and remembering the ancestors even when long gone”). In traditional society, arranging posthumous affairs, making inheritance wills, and choosing burial sites were essentially forms of advance planning for the final stage of life. Accordingly, in the context of modern medicine, the living will can be understood as an institutionalized expression of the ideal of a good death and as a proactive yet prudent arrangement by individuals concerning their later life and the manner of their dying. At the same time, the Confucian classics repeatedly emphasize that one should “follow the intentions of one's parents” (47). Filial piety is expressed not only in providing physical care to one's parents and sustaining their lives, but, more fundamentally, in respecting and fulfilling their genuine wishes. When parents, while still mentally competent, clearly set out their preferences regarding end-of-life treatment in a living will, and their children in practice respect and implement these wishes so as to prevent them from dying amid futile medical interventions and intense suffering, this in substance constitutes a higher form of filial piety. In addition, Chinese traditional medicine emphasizes that clinical decision-making should follow the natural course and the underlying logic of illness, rather than forcing interventions against it (48). From this perspective, a physician's implementation of a living will does not amount to abandoning professional duties. Instead, it can be understood as an ethical commitment to respecting the natural course of life and avoiding unwarranted or futile treatment. Applied to the practice of living wills, this line of thought can serve as a culturally grounded resource for helping clinicians navigate and ease ethical conflicts between beneficence and respect for patient autonomy.

To make this reinterpretation workable in clinical practice, we recommend introducing family conferences and embedding them in routine advance care planning before a crisis occurs. For example, healthcare institutions could arrange a family conference involving the patient (where possible), key family members, the attending clinician, and a trained facilitator (e.g., a social worker or a bioethicist). Such conferences can align the family's understanding of filial piety with the patient's expressed end-of-life directives, clarify prognosis and medical futility, and ease physicians' moral distress through dialogue, thereby making the above cultural reinterpretation workable in practice.