거버넌스관점에서 무의미한 연명치료중단의 문제점과 합리화방안에 관한 고찰

전수영(JEON, Su-Young) 강원대학교 비교법학연구소 2015 江原法學 Vol.45 No.-

인간의 생명이 회생가능성이 없는 상태에서 별다른 인간성의 지표 없이 단지 기계장치에 의하여 무의미한 치료를 계속하고 있는 상황이라면 헌법이 보장하는 자기결정권에 근거하여 구체적인 사정에 따라 연명치료의 중단을 요구할 수 있고, 그 경우 연명치료를 행하는 의사는 환자의 자기결정권에 근거한 무의미한 연명치료의 중단 요구를 존중하여야 할 것이다. 하지만, 환자의 요청에 의한 의료인의 연명치료중단 행위가 현행 형법에 의하여 촉탁승낙의 살인에 해당하는 행위로 금지되어 있는 상황에서는 보라매 병원 사건 이후 일어난 현상처럼 중환자실에서 임종할 때까지 연명치료 장치를 부착하고 이를 떼어내지도 못하는 상태로 유지할 수밖에 없는 실정이다. 세브란스 김 할머니 사건과 같이 법원에 인공호흡기 제거 청구소송을 제기하여 법원에 의한 판결로서 매번 치료중단이 허용되는 상황을 지켜보는 수밖에 없다. 하지만, 개개의 사례들을 모두 소송사건화하여 일일이 법원의 판단을 받게 하는 것도 비현실적이라고 할 수 있다. 우리나라의 경우 2014년 만성질환으로 사망한 사람들 중 인공호흡기를 적용한 비율이 16.5%나 많으면서, 다른 한편에서는 인공호흡기 적용의 유보 혹은 중단이 법적 뒷받침 없이 83.5%의 말기환자에서 이루어지고 있다는 현실에 비추어 볼 때 연명치료중단은 철저하게 환자의 자기결정권이라는 기본권실현관점에서 법제화의 논의가 이루어져야 한다. 어떠한 경우에도 자살권이라는 죽을 권리가 인정될 수는 없지만, 한정된 범위 내에서 자연사할 권리, 존엄하게 죽음을 선택하고 결정할 권리라는 범주 내에서 연명치료의 중단을 요청할 권리는 헌법적 근거를 가진다고 볼수 있다. 인공호흡기 청구사건의 대법원 판결이 이를 인정하면서 기본권 차원에서의 헌법적 근거를 가지게 되었다. 헌법적 근거를 가졌다고 하여 문제해결이 전적으로 이루어진 것은 아니므로 그 다음의 단계로 절차와 방법론의 문제로서 법제화의 구체화 작업이 필요하다고 본다. 이에 본 논문은 2013.5.국가생명윤리위원회의 ‘연명의료 결정에 관한 권고안’과 신상진 의원이 발의한 2015.6.9. ‘존엄사법안’을 검토하여 거버넌스관점에서 문제되고 있는 무의미한 연명치료중단의 문제점과 합리화방안에 대해서 모색해보고자 한다. Medical Practice can be justified when there are medical indication and the consent of patient. According to the Medical Act Article 15 ①,the doctor can’t reject the practice when patient request, if there is no justifiable reason. Most scholars agree that some types of euthanasia can be justifiable. Some argue that the patient voluntarily request euthanasia, their is no treatment method, and the pain is unbearable, the nearness of death, etc. Others argue that the consent to euthanasia, is the major requirement. The concept of medical futility is similar to euthanasia, but it is different notion. When the medical treatment is futile is decided based on the medical indication. So the range of medical futility is broader than euthanasia. While doctors have an ethical and regal responsibility to respect an autonomous patient’s wish for life-prolonging treatment there is a consensus among the professionals that this imperative should be bounded by the medical indication. The concept of medical futility is premised on an idea that if there is no medical indication, the doctor has no duty to treatment. In other words, when further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure. In that case, the doctor is not punished because of the non- treatment or stopping the life-prolonging treatment. Even Though we can agree the concept of the medical futility, it is necessary to consider the wish of the patient. So the doctor can stop the treatment when there is no medical indication(medically futile) and the consent of the patient to stop the life- prolonging treatment. If we agree the two element of medical futility, which is not punished, this concept of medical futility can satisfy the principle of respect to autonomy and principle of justice. If we cannot obtain the consent of patient because of the lack of the ability to consent, the third party should decide for the patient whether the treatment may stop or not. The court, the IRB(Institution Review Board)of the hospital or ethical committee of the hospital can be the third party which decide the stop of treatment. When they decide that, they should seriously consider the patient’s value system or wishes which were expressed when he has the ability to express.

무의미한 연명치료의 중단: 정당화가능성과 방향

이주희 경상대학교 법학연구소 2012 法學硏究 Vol.20 No.1

본 논문은 무의미한 연명치료 중단에 대한 형법 해석적 그리고 형법 정책적 논의를 수행하였다. 무의미한 연명치료 중단은 소극적 안락사나 조력자살과는 구별되는 고유한 의미를 담고 있다. 그리고 무의미한 연명치료 중단이 기존의 형법에서는 원칙적으로 살인 관련 범죄로 처벌될 가능성이 높다고 할 수 있다. 그러나 이러한 형법의 태도에 대하여 다양한 이의가 제기되고 있다. 특히 연명치료를 중단하겠다는 환자의 스스로의 결정이 존중되어야 한다는, 즉 환자의 자기결정권이 보장되어야 한다는 논거가 강력하게 제기되고 있다. 그러나 이러한 주장은 무시할 수 없는 문제점을 내재하고 있으며, 이러한 문제점을 해소하기 위해서는 일정한 전제조건이 충족되어야 한다. 다양한 문제점에도 불구하고 무의미한 연명치료 중단을 허용해야 한다는 학계와 실무에서의 주장은 강력하며, 앞으로 상당한 영향력을 미칠 것으로 예상된다. 형법 해석론의 변화를 통해 무의미한 연명치료 중단을 정당화하는 방안을 생각해 볼 수 있지만, 대체로 한계가 있다. 결국 형법 및 관련 법률을 개정 또는 제정함으로써 무의미한 연명치료 중단의 논의를 해결할 수밖에 없다. 새로 만들어질 법은 무의미한 연명치료 중단의 객관성과 엄정성을 확보할 수 있는 장치가 마련되어 있어야 한다. 무엇보다 무의미한 연명치료 중단의 남용을 방지하는 것이 중요한 과제이기 때문이다. 비록 무의미한 연명치료 중단에 대한 강력한 규제가 현실의 사정과는 다소 거리가 있다고 하여도, 형법은 생명보호의 비상브레이크로서의 역할을 소홀히 해서는 안 될 것이다. This paper deals with discussion about the interpretation and policy of criminal law in connection with the withdrawal of meaningless life-sustaining treatment. The withdrawal of meaningless life-sustaining has a intrinsic meaning as distinct from passive euthanasia and death with dignity. Furthermore, it is quite possible that this behavior will be punished on murder charges according to the current criminal law. But this result encounters lots of challenges. The strong grounds for an argument is the respect of self-determination of the patient about the withdrawal of treatment. Though this argument has a considerable problem, so that some conditions should be satisfied in order to solve this problem. Despite of many problems, it is very strong to argue that the withdrawal of meaningless life-sustaining treatment should be allowed. This assertion must have a effect in the future. First of all, it is possible to allow the withdrawal of meaningless life-sustaining treatment through the interpretation of criminal law. But this has some limits. Therefore this issue of the withdrawal of meaningless life-sustaining treatment can be resolved through the revision or the enactment of relevant regulation. The new regulation should have some guarantees to secure the objectivity of fairness of the withdrawal of meaningless life-sustaining treatment. It is an urgent problem to prevent possible abuses of the withdrawal of meaningless life-sustaining treatment. Even if tightening the regulation is often far from reality, but criminal law must fulfill its duties as an emergency break to protect lives.

무의미한 연명치료의 중단

점승헌 원광대학교 법학연구소 2013 의생명과학과 법 Vol.9 No.-

Lately, heated discussions have developed in the medical and academic circles as to whether patients' self-decision to cease their own life-sustaining care could be justified in light of respect toward death with dignity. What served as a decisive momentum for such discussions was the ethical and medical view of care for the terminally ill, followed by vehement debates in full scale from the medico-legal standpoint. The criminal law has maintained its firm stand against withdrawal of meaningless life-sustaining care from the view of so-called "the principle of absolute protection of human life". There have on the one hand been angles arguing that such perspective of the criminal law does not coincide with the reality but does only add extra burden on the part of patients' families and even medical staff as well, worsening their legal stability and possible anticipation in their living. On the other hand, there have been positions claiming that it would be too early to introduce withdrawal of meaningless life-sustaining care like shock therapy in theoretic as well as real terms. Lots of debates have already been well under way about the death with dignity along with the issue of euthanasia in Korea but have not met any positive approaches toward its solution. In this midst, the Supreme Court of Korea provided recently a criterion for death with dignity on the occasion of its first decree allowing such death. This measure is widely accepted as a representative example of 'judicial activism' with which the court ventured to stop gap between incomplete legislation and real situation by means of positive interpretation of laws in consideration of social pressure to see the death with dignity allowed whereas the National Assembly and the Administration have been overtly conscious of the public opinion. However, under the circumstances in which there is no legal support to determine the death with dignity in legal terms, there may still exist limitation in solving legal disputes to follow in the future by making use of this decree as the only legal basis. Since the court is essentially expected to interpret and apply the laws, it must be beyond its capacity to decide the issue of death with dignity since it requires of the court the sense of judgement equivalent almost to legislation.

생명 말기의 법적 안정성 : 환자의 생명 징후와 관련한 연명치료 중단의 허용 요건을 중심으로

류화신(Ryoo Hwa-Shin) 忠北大學校 法科大學 法學硏究所 2010 法學硏究 Vol.21 No.2

This study discusses legal issues surrounding the withdrawal of treatment for terminal patients. on May 21, 2009, the Supreme Court of Korea ruled that patients have the right to terminate medically meaningless treatment upon confirmation that their illness is indeed irreversible. The Supreme Court´s decision thus makes proof of the irreversibility of a patient´s condition an important process in legitimatizing a patient´s decision to terminate life-sustaining treatment. However, since medical practice rejects explanations in terms of "essences" and is affected by issues of subjectivity, I argue that physicians cannot give indisputable confirmation of the irreversibility of a patient´s terminal illness, as required by the Supreme Court´ ruling. So, this study points to a need for greater social consensus in Korea on the permissible level for the rejection of life-sustaining treatment not to damage the legal stability.

"연명치료 중단"을 둘러싼 한국사회의 법적 논쟁에 관한 연구: 개혁주의적 인간관과 윤리관의 관점에서

이상원 ( Sang Won Lee ) 한국복음주의신학회 2012 성경과신학 Vol.62 No.-

최근 한국의 법원들은 폐질환 치료를 받다가 혼수상태에 빠진 환자로부터 인공호흡기를 제거하라는 판결을 내림으로써 소극적 안락사의 적법성을 둘러싼 논쟁을 다시 한 번 촉발시켰다. 법원들의 판결근거는 환자는 불가역적인 사망의 상태에 있다는 것과 환자 가족들의 대리적 추정판단은 환자자신의 의사로 보아야 한다는 것이었다. 대법원의 판결이 확정된 이후에 법제화를 통하여 대법원 판결을 지원하기 위한 법안들이 준비되었고, 이를 뒷받침하기 위한 보건복지부 주관의 사회적 협의가 진행되었다. 모든 논쟁은 환자의 상태를 어떻게 해석할 것인가 하는 문제와 추정 및 대리판단의 타당성 문제에 집중되었다. 이 두 문제에 대한 개혁주의적 관점에서의 평가는 다음과 같다. Ⅰ. 혼수상태의 환자는 영혼이 살아 있고 신체적 생명도 살아 있는 존재로서 다만 외부로 자기 의사를 표현하는 일에 장애를 가지고 있는 것뿐이다. 그러므로 이 환자로부터 연명치료장치를 제거하는 행위 곧 소극적 안락사는 살아 있는 사람의 생명을 인위적으로 종결시키는 비윤리적인 행동이다. 다만 환자의 명백한 의사표시를 통하여 의학적으로 의미가 없는 치료를 중단할 것을 요구할 때 다수의 의사들의 중층적인 진단과 병원윤리위원회 등의 신중한 검토를 통하여 이 요구를 수용하는 것 곧, 무의미한 진료의 중단은 윤리적으로 타당한 조치로서 소극적 안락사와는 구별되어야 한다. Ⅱ. 생명의 주관권은 오직 하나님에게만 있으므로 생명의 종결에 관한 한 환자의 자기결정권이란 존재하지 않으며, 환자가 자기 의사를 표명할 수 없는 상황에 처하는 경우에 이루어지는 추정 및 대리판단은, 환자의 생전의 언명이 사건 발생 시에도 유지될 수 있는가가 불투명하고 환자의 언질에 대한 여자적 해석이 환자의 마음을 제대로 반영하지 못하는 경우가 있으며(추정판단비판), 가족은 환자 보다는 자신들의 입장에서 판단할 우려가 있다(대리판단비판)는 점 등에 근거하여 환자의 의사표시로 볼 수 없다. Recently the South Korean courts provoked the hitted debates about the ethical and legal legitimacy of passive euthanasia by ordering the hospital to remove a respirator from the patient who fell into coma during the treatment of her lung-disease. The reasons of the decision of the courts were that the patient was in the irreversible dying state and the presumptive and substitutive opinions of the family of the patient about the intent of the patient can be interpreted as reflecting the true intent of the patient herself, After the final decision of the supreme court several bills were proposed and the social conferences hosted by the Ministry of Health and Welfare were prepared in order to support the decision legally. The two central issues of the debates were: how the medical state of the patient must be diagnosed and to what degree the presumptive and substitutive judgments of the family can reflect the true intent of the patient. The appraisals about these two issues in terms of the Christian Reformed viewpoints are as follows. I. The patient in the state of coma (PVS) is one whose spirit and whose physical life are alive, but has only some trouble in expressing his idea to other people. Therefore it is an unethical behavior to remove life-sustaining facilities from him and suspend his life artificially. This means that passive euthanasia must not be permitted legally and ethically. But, when the patient demands the suspension of a medically meaningless treatment voluntarily and apparently, the hospital can accept the demand and suspend the treatment after the repeated diagnoses of several medical doctors and the serious discussions of the hospital ethics committee. This means that the suspension of medically meaningless treatment can be ethically valid and must be distinguished from passive euthanasia. II. The right of self-decision of the patient does not exist in terms of suspension of life, for the right to decide about the suspension of human life belongs to God alone. Presumptive judgment cannot reflect the true intent of the patient, for it is uncertain whether he would have the same mind before and after he fell into coma, and whether the literal interpretation of the sayings of the patient would reflect his mind. Substitutive judgment cannot be identified with the judgment of the patient himself, for family members are prone to think in terms of family interests rather than the patient`s benefits.

무의미한 연명치료의 중단

점승헌(Jeom Seung Hun) 원광대학교 법학연구소 2013 의생명과학과 법 Vol.9 No.-

Lately, heated discussions have developed in the medical and academic circles as to whether patients' self-decision to cease their own life-sustaining care could be justified in light of respect toward death with dignity. What served as a decisive momentum for such discussions was the ethical and medical view of care for the terminally ill, followed by vehement debates in full scale from the medico-legal standpoint. The criminal law has maintained its firm stand against withdrawal of meaningless life-sustaining care from the view of so-called "the principle of absolute protection of human life". There have on the one hand been angles arguing that such perspective of the criminal law does not coincide with the reality but does only add extra burden on the part of patients' families and even medical staff as well, worsening their legal stability and possible anticipation in their living. On the other hand, there have been positions claiming that it would be too early to introduce withdrawal of meaningless life-sustaining care like shock therapy in theoretic as well as real terms. Lots of debates have already been well under way about the death with dignity along with the issue of euthanasia in Korea but have not met any positive approaches toward its solution. In this midst, the Supreme Court of Korea provided recently a criterion for death with dignity on the occasion of its first decree allowing such death. This measure is widely accepted as a representative example of 'judicial activism' with which the court ventured to stop gap between incomplete legislation and real situation by means of positive interpretation of laws in consideration of social pressure to see the death with dignity allowed whereas the National Assembly and the Administration have been overtly conscious of the public opinion. However, under the circumstances in which there is no legal support to determine the death with dignity in legal terms, there may still exist limitation in solving legal disputes to follow in the future by making use of this decree as the only legal basis. Since the court is essentially expected to interpret and apply the laws, it must be beyond its capacity to decide the issue of death with dignity since it requires of the court the sense of judgement equivalent almost to legislation.

무의미한 연명치료 중단에 대한 중환자 전담의사의 인식: 포커스그룹 인터뷰를 중심으로

김상현,손명세,고신옥,이일학 한국의료윤리학회 2012 한국의료윤리학회지 Vol.15 No.3

This study was designed to examine intensive care providers’ perceptions of medically futile treatment. Focus group interviews were conducted with 18 intensive care physicians in charge of critical care units at tertiary hospitals in Daegu, Gwangju, and Seoul, South Korea. Results are as follow. 1. More than half of the participants opposed the inclusion of persistent vegetative state (PVS) patients in the category of medically futile treatment. 2. And though the distinctions between ordinary and extraordinary treatment, and between the withholding and withdrawal of treatment, were not clinically meaningful in the intensive care units under study, they are nevertheless relevant because of individual religious beliefs and Korean cultural traditions. 3. Since the beliefs and traditions of family members often makes it difficult for a patient to fill out advance directives, we argue that a gradual approach would be useful in choosing advance directives, making those directives optional rather than mandatory. 4. Economic factors also play a crucial role in the decision-making process regarding futile treatment in Korea. These factors were neglected in earlier surveys. Finally, the participants insisted that the physician’s right to make clinical decisions about medically futile treatment should be legislatively guaranteed based on their convictions. Based on the results of this study, we suggest the follow: a) that detailed criteria for medically futile treatments be established; b) that a decision-making process be developed that is culturally, ethically, medically, and legally acceptable; and c) that ethical education be provided to intensive care physicians.

안락사와 연명치료중단에 관한 우리나라의 최근 동향

최지윤 ( Ji Yoon Choe ),권복규 ( Ivo Kwon ) 한국의료윤리학회 2009 한국의료윤리학회지 Vol.12 No.2

Progress in biomedical technology has resulted in a number of patients experiencing painfully slow deaths by means of artificial ventilators or other inhumane treatments. Such experiences give rise to the question of whether it is right to provide these life-sustaining treatments when no effective or curative therapies are available. The purpose of this study is to examine respective views on this issue given by criminal law experts, the courts, medical professionals, and the public. In Korea, there is still disagreement on the definition of the terms "euthanasia" and "death with dignity." The current criminal law prohibits euthanasia for a dying patient with incurable disease and the withdrawal of life-sustaining treatment for a patient in a persistent vegetative state (PVS). However, a group of judicial and bioethics experts and policy-makers think that euthanasia or the withdrawal of life-sustaining treatment can be permitted under certain conditions. A recent court decision, which permitted the withdrawal of lifesustaining treatment on a PVS patient based on the patient`s right to self-determination and medical futility has stimulated a nationwide discussion for developing a legal framework for dealing with this issue. However, this article argues that care is needed in drafting the appropriate legislation as many unsolved problems related to this issue remain.