생명권과 자기결정권, 그리고 의사의 진료의무

유승룡 대한의료법학회 2008 의료법학 Vol.9 No.2

Based on foreign examples and past debates, the minimal conditions for passive euthanasia can be suggested as following; ① The patient is incurable by modern medical practice and his death is impending (less than 6 months), ② Euthanasia is practiced solely to relieve physical pain of the patient, ③ If the patient can express his will, there should be a clear and sincere request or consent, ④ More than 2 doctors including doctor in charge should consent, ⑤ Euthanasia should be practiced in ethical way, ⑥ Patient family should agree(when the patient will is assumed.) It is hard to resolve issues regarding euthanasia based on past rulings and cases without concrete law. As in United States and Germany, clear and objective provisions of euthanasia and definitive method for patient's advanced directive should be legislated to resolve medical conflict and to relieve patient and family from agony. And death with dignity debate will not be able to proceed if it is only substantively approached because of unclear definition of euthanasia and benefit comparison way of thinking. Thus it is important to establish definitive process to decided legislation of euthanasia act and resolving conflicts arising from each step of the process among interested parties exchanging medical/ethical opinions.

간호법 제정의 법적 쟁점과 향후 과제

김민우 한국비교공법학회 2023 공법학연구 Vol.24 No.2

Conflicts in the medical field are intensifying over whether or not to enact the Nursing Act, which has emerged as a “hot potato” in the medical field. The Nursing Act is a bill that made provisions related to nursing personnel independent of the current Medical Act. In particular, it guarantees the role of nurses who are active in the community outside the hospital and improves the treatment of nurses, thereby expanding the scope of work for nurses and strengthening the treatment and role of nurses by securing nurse-related resources separately. The problem is that most occupational groups except nurses oppose the enactment of the Nursing Act as conflicts grow across the medical field over the Nursing Act. There was sharp confrontation in the political world over the enactment of the Nursing Act, but the Nursing Act was passed led by the opposition party. Since then, the ruling party and other medical organizations that have opposed the enactment of the Nursing Act expressed regret at once and urged the President to veto the bill (right to request reconsideration). In response, the President exercised the right to veto the enactment of the Nursing Act (right to request reconsideration), and the Nursing Act was re-voted in the National Assembly, but in the end the Nursing Act was abolished. However, it is quite meaningful that the Nursing Act, which separated the nursing area from the medical law system maintained for 70 years, passed the plenary session of the National Assembly, leaving behind conflicts in the medical field. We must not forget that securing nursing personnel is a task of the future as we enter an aging society. Since the Nursing Act is related to the reform of the health care system that has been maintained for more than 70 years, it is desirable to pass the bill again after sufficient discussions with other medical professions. 의료계의 ‘뜨거운 감자’로 떠오른 간호법 제정 여부를 놓고 의료계의 갈등이 격화되고 있다. 간호법은 현행 의료법에서 간호 인력과 관련한 조항을 독립적으로 만든 법안이다. 특히 병원 밖 지역사회에서 활동하는 간호사의 역할을 보장하고, 간호사의 처우개선 등을 담고 있어 간호사의 업무 범위가 확대되고, 간호사 관련 재원을 따로 확보할 수 있어서 간호사의 처우와 역할이 강화된다. 문제는 이런 간호법을 두고 의료계 전반에 갈등이 커지면서 간호사를 제외한 대부분의 직군이 간호법 제정을 반대하고 있다. 간호법 제정을 놓고 정치권에서도 첨예하게 대립하였지만, 야당 주도로 간호법이 통과되었다. 이후 간호법 제정안을 반대해 온 여당과 다른 의료 단체들이 일제히 유감을 표시하며 대통령의 법률안 거부권(재의요구권)을 촉구하였다. 이에, 대통령은 간호법 제정안에 대해 법률안 거부권(재의요구권)을 행사하여 국회에서 재의결을 하였으나 결국 폐기되었다. 그러나 70여년 동안 유지된 의료법 체계에서 간호 영역을 분리한 간호법이 의료계의 갈등을 뒤로 한 채 국회 본회의를 통과한 것은 상당히 의미있는 일이다. 간호인력의 확보는 고령사회로의 진입에서 앞으로의 시대적 과제임을 잊어서는 안 된다. 간호법은 70년 이상 유지해온 보건의료체계 개편과 관련되기 때문에 좀 더 시간을 갖고 다른 의료직군과 충분한 논의를 거친 후에 다시 법안을 추진하는 것이 바람직하다.

종교적 이유로 인한 수혈 거부시 자기결정권과 망인의 생명간의 비교형량 접근방법에 대한 비판적 검토 - 대판 2014.6.26, 2009도14407 판례 평석 -

주지홍 전북대학교 동북아법연구소 2014 동북아법연구 Vol.8 No.2

여호와의 증인의 수혈거부의사표시에 따라 수술도중 위험에 처한 환자에 대해 수혈을 하지 못하게 되었고 결국 상황이 악화되어 환자가 사망하게 되자 의사가 업무상과실치사혐의로 소송을 제기당한 사례이다. 1심과 2심 모두 담당의사가 환자의 치료방법 선택에 따라 수술과정에서 타가수혈을 하지 않은 행위는 위법성이 없다고 판단하였고, 업무상과실치사 공소사실이 범죄의 증명이 없거나 범죄로 되지 않는 경우에 해당한다고 보았다. 이에 대해 대판은 원심의 판단 이유 중에서, 환자의 자기결정권 행사가 의사의 일반적인 의무, 즉 국가의 생명권 보호의무에 기초를 두고 있는 환자의 생명을 구할 의무 등과 직접 충돌하는 상황이 발생할 경우에는 원칙적으로 자기결정권의 행사를 의사의 의무보다 우위에 두어야 한다는 취지로 설시한 부분은 적절하다고 할 수 없다고 비판하였다. 그 이유는 자기결정권의 행사가 유효하다고 하더라도 특별한 사정이 있는 예외적인 경우에 한하여 생명과 대등한 가치를 가지는 것으로 평가된다고 보았다. 다만 원심판단의 논거가 수혈 거부에 대한 환자의 자기결정권 행사에 따른 의사의 진료의무에 관한 법리에 상응하는 것으로 수긍할 수 있고, 여러 가지 사정들을 종합적으로 고려하여 보면, 이 사건에서 환자의 생명과 자기결정권을 비교형량하기 어려운 특별한 사정이 있으므로, 타가수혈하지 아니한 사정만을 가지고 담당의사가 의사로서 진료상의 주의의무를 다하지 아니하였다고 할 수 없다고 보아 업무상과실치사죄를 부정한 1심과 원심판단을 지지하였다. This is the case for Jehovah’s Witness patient’s refusal of blood transfusion. During the surgery, the doctor could not do the blood transfusion timely due to patient’s strong will and therefore the patient died. The doctor was prosecuted by a charge of professional negligence resulting in death. He was sentenced not guilty both in trial and appellate court due to lack of illegality since the doctor treated the patient by the way of patient’s choice. However, the Supreme Court criticized the reasoning of trial and appellate court. The Supreme Court finds that patient’s self-determination right is not necessarily superior to the protecting life duty of the doctor in which the patient self-determination act brings conflict with the protecting life duty of the doctor based on the nation’s duty of protection of life. The Supreme Court finds that the self- determination act is legal only when that act can be evaluated equal to life. If a self-determination act cannot be evaluated as equal to life, or can be evaluated below the life, the act should not have binding effect to the doctor. In this case, the Supreme Court might think that the main issue should be which value is more superior between “the self-determination right by a patient” and “protecting life duty by a doctor” when a Jehovah’s Witness patient reveals his intention of refusal of blood transfusion. When these two conflicting values are compared, the former is not always superior to the latter. The former is equal to the latter only when special conditions are met. Only in this special exceptional case, the doctor can be exempted from the duty of protecting life and he can choose any proper treatment by using his professional discretion. However, I think, the main issue here in this case is not comparing two conflicting values but judging whether a patient’s specific self-determination act steps over the limit of a fundamental right exercise. The Supreme Court should give clear and definite guidelines to avoid confusion but it didn’t. The court demands 3 safety measures to protect life. First, the doctor should warn the patient the risk of specific treatment and treat the patient with due care. The patient’s will of specific treatment is allowed only if the life threatening risk becomes not real. If the life threatening risk becomes real, the things are changed. The patient’s will is no more effective. Second, if the risk becomes real and the life threatening situations happens, then the doctor should reconfirm the patient’s will. If the patient become unconscious, the doctor ask the family’s intention and decide what the best choice is given the patient’s supposed intention, the family’s intention and other circumstances. In this stage, the doctor should evaluate which value is more superior between self- determination right and duty of protecting life. The doctor should respect the patient’s will only if the former is equal to the latter. Third, the court judge the final answer when the dispute appears between the patient and the doctor. Even though the doctor evaluate the self-determination right is equal to the duty of protecting life and treat the patient according to his judge, he can be prosecuted later if the court judged the situation differently. I think the Supreme Court’s 3 stage safety measures are making only chaos in reality. It’s not necessary to demand the doctor again to consider his duty of protection of life in 2nd stage. Since the protection of life is already considered in the first stage, the doctor need not reconsider his duty of protection of life in 2nd stage. If the patient’s specific will is regarded passing the limit of the fundamental right exercise, then the doctor doesn’t have to respect the patient’s illegal will and can do proper treatment what he think. The court should judge whether a patient’s specific refusal of treatment due to religious reasons pass the limit of fundamental right exercise. If the act is within the limit, then the doctor should respect the patient’s will and do exactly what he wants to do in his treatment. If the act is regarded passing the limit, then the doctor doesn’t have to respect the patient’s will.

醫療行爲에 있어 未成年者의 同意能力에 관한 考察 - 독일에서의 논의를 중심으로 -

윤석찬 전남대학교 법학연구소 2008 법학논총 Vol.28 No.1

Wenn der Patient minderjährige ist, sieht sich die Beziehung zwischen Arzt und Patient mit zusätzlichen Problemen konfrontiert. Die deutsche Rechtsprechung ist im ganzen als uneinheitlich zu bewerten. Nach einem Urteil des BGH aus dem Jahre 1958 ist die Einwilligung eines Minderjährigen in eine ärztliche Heilbehandlung keine Willenserklärung, wodurch minderjährige Patienten wirksam in einen ärztlichen Eingriff einwilligen konnten. Dabei ist die Geschäftsfähigkeit des Minderjährigen nicht erforderlich, sondern kam es auf seine Einwilligungsfähigkeit. Der Minderjährige ist einwilligungsfähig, wenn er nach seiner geistigen und sittlichen Reife die Bedeutung und Tragweite des Einfriffs und seiner Gestattung zu ermessen vermag. Die Einwilligung für die Heilbehandlung hat tatsächlich eine andere Qualität. Zudem hat der medizinische Eingriff möglicherweise sehr weitreichende Auswirkungen auf die gegenwärtige und zukünftige Lebensführung des betroffende Patienten. In diesem höchstpersönlichen Bereich muss der Minderjährige immer Subjekt und nicht Objekt der medizinischen Behandlung sein. Stehen sich daher im Konfliktfall die Einwilligung des Einwilligungsfähigen Minderjährigen und die Ablehnung der gesetzlichen Vertreter gegenüber, kann das Eltermrecht nicht dazu führen, die Einwilligung des Minderjährigen zu übergehen und die Behanlung zu verhindern. Also, kein Veto-Recht steht den gesetzlichen Vertretern zu und auch kein Recht, eine Behandlung gegen den Willen des einwilligungsfähigen Minderjährigen durchzuführen. Meiner Meinung nach wird es vorgeschlagen, dass der einwilligungsfähige Minderjährige jedoch nur bei unbedeutenden medizinischen Eingriffen allein einwilligen kann. Bei bedeutenden medizinischen Eingriffen sollte es nicht erlaubt werden, dass er allen in einen ärztlichen Eingriff einwilligen laßt, obwohl der Minderjährige einwilligungsfähig ist. Das den gesetzlichen Vertretern verbleibende Erziehungsrecht tritt in jedem Fall hinter dem Selbstbestimmungsrecht des einwilligungsfähigen Minderjährigen zurück. Außerdem wird vorgeschlgen, den Minderjährigen im Bereich der medizinischen Behandlung die Möglichkeit zu schaffen, selbständig Behandlungsverträge abzuschließen. Der Einwilligungsmöglikeit des einwilligungsfähigen Minderjährigen muss auch die Möglichkeit folgen, einen wirksamen Behandlungsvertrag herbeizuführen. Wenn der Patient minderjährige ist, sieht sich die Beziehung zwischen Arzt und Patient mit zusätzlichen Problemen konfrontiert. Die deutsche Rechtsprechung ist im ganzen als uneinheitlich zu bewerten. Nach einem Urteil des BGH aus dem Jahre 1958 ist die Einwilligung eines Minderjährigen in eine ärztliche Heilbehandlung keine Willenserklärung, wodurch minderjährige Patienten wirksam in einen ärztlichen Eingriff einwilligen konnten. Dabei ist die Geschäftsfähigkeit des Minderjährigen nicht erforderlich, sondern kam es auf seine Einwilligungsfähigkeit. Der Minderjährige ist einwilligungsfähig, wenn er nach seiner geistigen und sittlichen Reife die Bedeutung und Tragweite des Einfriffs und seiner Gestattung zu ermessen vermag. Die Einwilligung für die Heilbehandlung hat tatsächlich eine andere Qualität. Zudem hat der medizinische Eingriff möglicherweise sehr weitreichende Auswirkungen auf die gegenwärtige und zukünftige Lebensführung des betroffende Patienten. In diesem höchstpersönlichen Bereich muss der Minderjährige immer Subjekt und nicht Objekt der medizinischen Behandlung sein. Stehen sich daher im Konfliktfall die Einwilligung des Einwilligungsfähigen Minderjährigen und die Ablehnung der gesetzlichen Vertreter gegenüber, kann das Eltermrecht nicht dazu führen, die Einwilligung des Minderjährigen zu übergehen und die Behanlung zu verhindern. Also, kein Veto-Recht steht den gesetzlichen Vertretern zu und auch kein Recht, eine Behandlung gegen den Willen des einwilligungsfähigen Minderjährigen durchzuführen. Meiner Meinung nach wird es vorgeschlagen, dass der einwilligungsfähige Minderjährige jedoch nur bei unbedeutenden medizinischen Eingriffen allein einwilligen kann. Bei bedeutenden medizinischen Eingriffen sollte es nicht erlaubt werden, dass er allen in einen ärztlichen Eingriff einwilligen laßt, obwohl der Minderjährige einwilligungsfähig ist. Das den gesetzlichen Vertretern verbleibende Erziehungsrecht tritt in jedem Fall hinter dem Selbstbestimmungsrecht des einwilligungsfähigen Minderjährigen zurück. Außerdem wird vorgeschlgen, den Minderjährigen im Bereich der medizinischen Behandlung die Möglichkeit zu schaffen, selbständig Behandlungsverträge abzuschließen. Der Einwilligungsmöglikeit des einwilligungsfähigen Minderjährigen muss auch die Möglichkeit folgen, einen wirksamen Behandlungsvertrag herbeizuführen.

존엄사에 대한 미국의 법제

김장한 대한의료법학회 2008 의료법학 Vol.9 No.2

The end of life problem in the United States has been evolved from the development of concept of brain death over last 50 yr. The invention of ventilator and the development of emergency medicine also played a key role to elongate the end stage of life and which caused the American people to ask a question about the patients self determination and refusing the unwarranted medical treatment in the view of the death with dignity. With regard to the patient unable to self determination, surrogate decision was also considered. To guarantee the self determination, The patient self determination act also enacted on the level of Federal regulation in 1990s. But no law has effectively dealt with the situation when medical treatment became futile. Along with the significant debates on literature and court cases, The American Medical Association's Council on Medical and Judical Affairs presented formal opinion and the Texas was the first states to regulate the medical futile situation in 1999. Even though that definition was in controversy, the concept of medical futility mainly focused on the doctors' right to refuse the treatment.