Why Are Assisted Suicide and Euthanasia Not Accepted in Eastern Cultures?

COMMENTARY

"Oh, East is East and West is West, and never the twain shall meet…”—Rudyard Kipling

The famous lines from Kipling’s poem, “The Ballad of East and West,” are often taken out of context and interpreted to mean that there are irreconcilable differences between Eastern and Western cultures. Actually, the subsequent lines of the poem suggest the opposite, that these cultural divisions vanish when individuals of equal strength meet, “tho’ they come from the ends of the earth!"

Perhaps so—but in the matter of assisted suicide and euthanasia (AS/E), there are indeed serious and perhaps irreconcilable differences between many countries of the “West” and those of the Asian “East.” To be sure, the terms East and West are rough and imprecise designations. In broad terms, for the purposes of this discussion, we include in the West primarily the European countries, such as Belgium, Luxembourg and the Netherlands, along with the US, the UK, and Canada. Some would include Australia and New Zealand. Included in the East are, among others, China, Japan, India, and Korea. But as we will explain, the terms East and West in this article refer primarily to historically different cultural, philosophical, and spiritual traditions—all of which have great bearing on the matter of AS/E. These matters are of more than academic interest to psychiatrists, since patients of Eastern and Western cultural heritage may view end-of-life care—often involving psychiatric interventions—quite differently.¹

Implicit in our discussion is the premise that “assisted suicide” is, in fact, suicide, contrary to some proponents of so-called medical aid in dying (MAID). Indeed, we believe there is no clinically valid or reliable way to distinguish AS/E from suicide, as psychiatrists typically understand it. And while we are opposed to AS/E on medical-ethical grounds,² this article will focus primarily on the cultural, religious, philosophical, and psychological factors that differentiate Eastern and Western values regarding AS/E.

The Spread of Assisted Suicide and Euthanasia: East vs West

AS/E has emerged as a legally sanctioned option for end-of-life care in an increasing number of countries. As of 2025, over 200 million individuals were living in jurisdictions permitting some form of assisted dying.³ Indeed, “As of May 2025, 12 countries have regulated assisted dying nationally or in selected jurisdictions, including Australia, Austria, Belgium, Canada, Colombia, Cuba, Luxembourg, the Netherlands, New Zealand, Spain, Switzerland, and some US states, and legislation is actively being discussed in other countries, including Ecuador, France, Germany, Ireland, Italy, Portugal, Slovenia, and the UK.”³

On the other hand, on March 17th, 2026, the Scottish Parliament voted 69 to 57 to reject an assisted suicide bill.⁴ Additionally, on November 23,2025, the Slovenian people voted by referendum to rescind a previously passed assisted suicide law.⁵

AS/E deaths have risen steadily and substantially over the past decade, particularly in the use of euthanasia. Note that this trend has taken place exclusively in Western countries. Furthermore, “…there is currently no internationally comparable standard [in the West] regarding the quality of care, safeguards, and support that people receive when accessing assisted dying.”⁶

In contrast, to the best of our knowledge, no Asian country (as of March 2026) has legalized active euthanasia or physician-assisted suicide (PAS). That said, several Asian nations permit the withdrawal of life-sustaining treatment (sometimes confusingly called “passive euthanasia") under strict conditions. However, the direct administration of lethal substances by a physician remains illegal across the Asian continent, and the process of legalizing AS/E has met considerable resistance throughout Asia.⁶

The remainder of our article focuses on possible explanations for this resistance.

The Western Triad: Hyper-Autonomy, the Consumer Movement, and Weakening of Suicide Taboo

In our view, 3 interrelated, cultural forces—particularly characteristic of secular perspectives ascendant in Western societies—have shaped Western attitudes toward AS/E over the past half century: hyper-autonomy, the consumer movement, and the weakening of the suicide taboo. The term autonomy is derived from the Greek words autos (self) and nomos (law).⁷ It is commonly defined as “…an individual’s capacity for self-determination or self-governance.” Physicians will recognize autonomy as 1 of the 4 central principles of medical ethics, along with nonmaleficence, beneficence, and justice.⁸ In theory, these principles are of equal prima facie importance. However, as Daniel Fu-Chang Tsai, MD, PhD, has observed, “Western liberal viewpoints… argue for the centrality and priority of respect for autonomy over the others.”⁹ Indeed, we would argue that, in recent decades, Western values have reflected a kind of hyper-autonomy, such that the other 3 principles—grounded more in communitarian and relational values—have been relegated to a second-tier status. Hyper-autonomy entails the belief that individual self-determination must always take precedence over competing communitarian and relational values.

This trend, we believe, has tracked quite closely with the consumer rights movement in Western countries, which emerged in the early 60s.^10,11 The consumer movement, in turn, has influenced Western attitudes toward AS/E. As British journalist Yvonne Roberts has put it,¹²

“. . . as our population ages, choosing when to make an exit will be regarded as a consumer’s right by individuals reared in a society in which market forces dominate and the customer is always correct.”

We further hypothesize that the confluence of hyper-autonomy and the consumer rights movement have tended to weaken the traditional Judeo-Christian taboo against suicide, particularly in the Benelux countries and Canada—and even in the US. Indeed, advocates of PAS now regard it as nothing more than a form of health care. As Attorney Kathryn L. Tucker, executive director of the End of Life Liberty Project, has succinctly put it, “Aid-in-Dying is Health Care.”¹³ (We mordantly wonder how the patient’s “health” would be gauged after this “care” is delivered). Finally—albeit more speculatively—we suspect that the hyper-autonomy movement may be indirectly related to the rise in personal entitlement (as an expression of narcissism and consumerism) among younger cohorts in the US.¹⁴ The role of entitlement in the implementation of AS/E may be hinted at in the demographics of those who chose it, which skews towards the privileged (ie, the 3 W’s: white, wealthy and well educated).¹⁵

The Eastern Triad: Relational Autonomy, Social Harmony, Strong Suicide Taboo

China

Chinese Americans represent the largest proportion of Asian Americans in the United States. If we consider China as an exemplar of Eastern views on AS/E, we can summarize the philosophical background as follows¹⁶:

“China's cultural and philosophical traditions are deeply rooted in Confucianism, Taoism, and Buddhism, all of which emphasize the sanctity of life. In Confucian thought, the principles of filial piety and benevolence dictate that one must respect and care for one's elders, and that taking a life, even one's own, violates the natural order and harmony. Taoism, with its emphasis on following the natural course of things, suggests that life and death are part of the Tao and must remain undisturbed by human action. Buddhism also promotes the sanctity of life, with the first precept prohibiting the taking of life. These philosophical underpinnings have historically influenced the Chinese stance on euthanasia, fostering a societal norm where the practice is largely rejected and frowned upon.”

These philosophical and spiritual traditions are likely account for a very different view of autonomy in Asian culture than that embraced in the West. The term usually applied in the Eastern context is relational autonomy, which is deeply imbued with Confucian ethics. As physician and ethicist Sok K Lee, MD, explains¹⁷:

“…relational autonomy…entails a two-dimensional decision-making process for end-of-life care. Western individualism is rejected, because it insists on, “I am, therefore you are.” Instead, “You are, therefore I am” is the core of Confucian ethics. In the Doctrine of Mean and the dialectics of harmonization, patient and physician invite the family as a three-member group for the purpose of agreeing on important clinical matters. When an Eastern man becomes sick, all family members are afflicted because life’s value is family-centered in spiritual, ethical, and financial matters.”

Lee’s use of the term harmonization leads us to the next element of the Eastern triad: social harmony. As philosopher Julian Baggini has observed, “There is arguably no more important concept than harmony (he) for understanding how China thinks and lives. ‘If we were to choose just one word to characterize the Chinese ideal way of life, that word would be “harmony,”’ says Chinese philosopher Li Chenyang…harmony is the central and most distinctive value in Chinese culture and thought…”¹⁸ It is fair to say, as a general observation, that for most Eastern spiritual traditions, AS/E represents a breakdown in social and societal harmony, in that the individual’s choice of AS/E ruptures the web of mutual obligations that binds family and community.

India

The legal status of AS/E in India is clear: all these practices are illegal. However, “passive euthanasia”—eg, allowing patients to create advance medical directives (living wills) to refuse treatment if in a persistent vegetative state—was legalized by the Indian Supreme Court. To be clear: when the word euthanasia is used in Indian media, it refers to ending futile treatment and getting out of the way of death, akin to the function of hospice—not administering death as in the West. In contrast, the religious, cultural, and philosophical backdrop is complicated in the Indian context, as Khan and Tadros note¹⁹:

“India is a healthy example of a number of varied cultures, customs, and religions which all have preserved their identities and also mingled with the historic Indian philosophies and rituals. Disentangling religion and culture, customs and rituals, and beliefs and attitudes is a Herculean task in the Indian context.”

Khan and Tadros comprehensively review these complex issues. Suffice it to say that among the major, native religious traditions of India—Hinduism, Buddhism, Jainism, and Sikhism—AS/E is not accepted, at least in the sense AS/E is understood in the Western, medical context. The principle of ahimsa—nonviolence toward all living beings—is central to Hinduism, Buddhism, and Jainism, and is highly valued in Sikhism. Hence, AS/E is widely viewed in India as a violation of the ahimsa principle.¹⁹ This has important implications for end-of-life care. For example, one study of Asian Indian patients found that²⁰:

“Traditional cultural values, such as duty to family, greatly influenced end-of-life care preferences and retained importance across generations…. When eliciting Asian Indian patient preferences for end-of-lifecare, clinicians should consider explicitly asking about preferences related to family involvement in care, decision control, and communication; and explore the role of traditional expectations and specific social realities for each patient.”

Finally, though not a native religion of India, Islam is actually the second largest religion in India, representing about 14% of the population. Suicide, assisted suicide, and euthanasia are all strongly prohibited in Islam.¹⁹

Some Differing Trends in Asia

The foregoing review leads to the general conclusion that, in most of East Asian culture, suicide, assisted suicide, and euthanasia are taboo. However, there are some nuances that merit brief discussion.

One study found that Japanese physicians and the general public expressed a more negative stance towards AS/E compared with their counterparts in Western countries. However, roughly a third of the general public supported euthanasia (33%) and assisted suicide (34%).²¹ Moreover, the legal status of AS/E is not always a reflection of popular attitudes or beliefs. For example, AS/E is illegal in South Korea, but recent polls show that roughly 80% of citizens now favor some form of "assisted death with dignity" to avoid being a burden to their families. Indeed, in 2024, South Korea introduced the first version of a bill to legalize physician-assisted death.²² In our view, South Korea’s outlier status may reflect its greater Westernization compared with much of Asia, as well as a decline in the influence of Buddhism there.

Finally, in the Jain religion, suicide per se is clearly prohibited. That said, the controversial Jain practice of sallekhanā involves progressive fasting until death—but only when death is imminent because of incurable disease or old age. Sallekhana is not considered suicide within the Jain community.²³ Indeed, Jainism scholar Professor Claire Maes contends that “…the Jain fast needs to be disentangled from the concept of suicide based on the quality of intent, but also because the process is, in theory and for some time at least, reversible, supported by loved ones and members of the larger Jain community, and dependent on the individual’s continuous and prolonged will of renouncing food and water.”²⁴

Sallekhana has clear parallels with the secular, Western practice of Voluntary Stopping of Eating and Drinking (VSED) which, in one hospice-based study, was associated with better outcomes at end-of-life than seen with PAS. Notably, hospice nurses generally favored VSED over PAS and found that “the quality of the process of dying for most of these [VSED] patients is good.”²⁵

Concluding Thoughts

We have reviewed some of the key cultural differences between Western and Eastern values, as seen in the context of end-of-life care. We have argued that acceptance of AS/E in many Western countries—particularly in Europe—reflects the convergence of 3 historical and cultural streams: hyper-autonomy; the consumer movement, and the weakening of the suicide taboo. In contrast, Eastern culture is anchored in the concepts of relational autonomy; social harmony; and a strong suicide taboo, under the influence of Confucian values (Figure). A failure to appreciate these differences may compromise medical and psychiatric care of patients from East Asian cultures, whose wishes regarding AS/E may reflect cultural and religious values quite different than those of Western patients. This is particularly important for clinicians to understand in euthanasia-permitting countries, like Canada, which consider it an ethical duty to spontaneously inform patients who appear eligible about the euthanasia option—even if the patient does not ask about it. Implementation of that duty may cause considerable harm to some Asian patients.²⁶

At the same time, "Failure to recognize the uniqueness of specific Asian American ethnic groups...may be contributing to a ‘homogenized’ view of Asian Americans, despite the fact that there are over 25 ethnic subgroups of Asian ancestry who reside in the United States."²⁷

Some may argue that the issues we have discussed properly fall under the rubric of cultural anthropology, rather than clinical psychiatry. However, we would argue that the need for cultural sensitivity has immediate relevance to the psychiatrist’s clinical role in end-of-life care, particularly among Asian populations in jurisdictions where AS/E is a legal option.¹

Dr Pies is professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York; a clinical professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts; and editor in chief emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books, including several textbooks on psychopharmacology. A collection of his works can be found on Amazon.

Dr Geppert is professor emeritus of psychiatry and internal medicine and director of ethics education at the University of New Mexico School of Medicine in Albuquerque. She is an adjunct professor of bioethics at the Alden March Bioethics Institute of Albany Medical College. She serves as the ethics editor for Psychiatric Times.

Dr Komrad is a psychiatrist on the teaching staff of Johns Hopkins Hospital in Baltimore, Maryland. He is also a clinical assistant professor of psychiatry at the University of Maryland in Baltimore and on the teaching faculty of psychiatry at Tulane University and Louisiana State University in New Orleans, Louisiana. He is also a founding member of the international physicians’ organization Doctors Say No.

References

1. Geppert CM, Pies RW. Religious, and ethno-cultural competence in palliative and end-of-life care. OBM Integrative and Complementary Medicine. 2020;5(1):1-13.

2. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. J Clin Psychiatry. 2018;79(6):18lr12566.

3. Sillitti P, Meier C, Blanc S, et al. A public health perspective on assisted dying and its different modalities. Lancet Public Health. 2025;10(11):e1001-e1005.

4. Carrell S. Scottish Parliament votes against assisted dying. The Guardian. March 17, 2026. Accessed March 31, 2026. https://www.theguardian.com/society/2026/mar/17/scottish-parliament-votes-against-legalising-assisted-dying

5. Schadenberg A. Slovenian Supreme Court upholds results of assisted suicide referendum. March 25, 2026. Accessed March 31, 2026. https://alexschadenberg.blogspot.com/2026/03/slovenian-supreme-court-upholds-results.html

6. Wang Y, Zhang H, Zhang Z, et al. Assisted suicide and euthanasia: a comparative analysis of Dutch and east Asian cases. Am J Bioeth. 2022;22(2):74-76.

7. Dryden J. Autonomy. Internet Encyclopedia of Philosophy. https://iep.utm.edu/autonomy/

8. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019.

9. Tsai DF. Personhood and autonomy in multicultural health care settings. Virtual Mentor. 2008;10(3):171-176.

10. Pies RW. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. 2016;33(8).

11. What are consumer rights? Consumers International. Accessed March 31, 2026. https://www.consumersinternational.org/who-we-are/consumer-rights

12. Roberts Y. Foggy guidelines won’t help the dying. The Guardian. September 23, 2009. Accessed March 31, 2026. https://www.theguardian.com/commentisfree/2009/sep/23/assisted-suicide-dpp-guidelines

13. Tucker KL. Aid-in-dying is health care. Juristnews. June 10, 2018. Accessed March 31, 2026. https://www.jurist.org/commentary/2018/06/kathryn-tucker-aid-dying/

14. Twenge JM, Campbell WK. The Narcissism Epidemic: Living in the Age of Entitlement. Atria Books; 2010.

15. Smith A. Rutgers study examines who uses medical aid in dying. Rutgers. July 18, 2022. Accessed March 31, 2026. https://www.rutgers.edu/news/medical-aid-dying-maid-mostly-used-well-educated-white-patients-cancer

16. Zhou W, Hu C, AQ L. Euthanasia controversy in China: do we have the right to die? Hist Philos Med. 2024;6(1):3.

17. Lee SK. East Asian attitudes toward death- a search for the ways to help east Asian elderly dying in contemporary America. Perm J. 2009;13(3):55-60.

18. Baggini J. How the World Thinks. Granta; 2019.

19. Khan F, Tadros G. Physician-assisted suicide and euthanasia in the Indian context: sooner or later the need to ponder. Indian J Psychol Med. 2013;35(1):101-105.

20. Sharma RK, Khosla N, Tulsky JA, Carrese JA. Traditional expectations versus US realities: first- and second-generation Asian Indian perspectives on end-of-life care. J Gen Intern Med. 2012;27(3):311-317.

21. Takimoto Y, Nabeshima T. Disparity in attitudes regarding assisted dying among physicians and the general public in Japan. BMC Med Ethics. 2025;26(1):7.

22. Min-sik Y. 8 in 10 Koreans support legalizing euthanasia: survey. The Korean Herald. February 23, 2025. Accessed March 31, 2026. https://www.koreaherald.com/article/10426453

23. McCarthy J. Fasting to the death: is it a religious rite or suicide? National Public Radio. September 2, 2015. Accessed March 31, 2026. https://www.npr.org/sections/goatsandsoda/2015/09/02/436820789/fasting-to-the-death-is-it-a-religious-rite-or-suicide

24. Maes C. Sallekhana and the end-of-life option of voluntary stopping of eating and drinking: an ethical argument to consider the Jain practice of fasting to death as different from suicide. Religions of South Asia. 2023;17(3):1751-2689.

25. Ganzini L, Goy ER, Miller LL, et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003;349(4):359-365.

26. Canadian Association of MAiD Assessors and Providers. Bringing up Medical Assistance in Dying (MAiD) as a clinical care option. The College of Physicians & Surgeons of Manitoba. Accessed March 31, 2026. https://camapcanada.ca/wp-content/uploads/2022/02/Bringing-up-MAiD.pdf

27. Yang P, Atkinson D, Wolfe M, Hong S. Cultural value similarities and differences among Asian American ethnic groups. Cultur Divers Ethnic Minor Psychol. 2001;7(4):343-361.