각국의 연명의료 관련 결정 절차와 기구에 관한 고찰: 대만, 일본, 미국, 영국을 중심으로

최은경,홍진의,김민선,김범석,김미소,허대석,박혜윤 한국의료윤리학회 2017 한국의료윤리학회지 Vol.20 No.2

The “Act on Life-Sustaining Treatment Determination” was passed in Korea in 2016 and will take effect after the enactment of certain ordinances and rules. In this study, we analyzed the decision-making process regarding the withholding and withdrawal of life-sustaining treatment in four countries: Taiwan, Japan, the US, and the UK. Each country introduced advance directives either through legal forms (Taiwan, the US), limited legal forms (the UK), or arbitrary forms (Japan). Japan takes a guideline-centered approach, whereas Taiwan takes law-centered approach. And while a patient’s will about life-sustaining treatment (LST) is respected as part of a patient’s self-determination in the US, physicians can refuse treatment if its benefits are extremely uncertain. On the other hand, in the UK, if a patient has lost decision-making capacity, physicians can make decision regarding the patient’s best interests. In this article, it is argued that minimal standards should be established in Korea to prevent possible abuse as well as to respect patients’ right to self-determination; however, it is desirable to support good decision-making processes between physicians and patients (and their family members) rather than to over-regulate current practice. 2016년『호스피스ㆍ완화의료 및 임종 과정에 있는 환자의 연명의료 결정에 관한 법률(이하, 연명의료법)』이 제정된 후 시행령 및 시행규칙의 정비를 거쳐 2018년에 시행될 예정이다. 본 연구는 국내의 바람직한 연명의료 관련 결정 가이드를 위해 대만, 일본, 미국, 영국 등 4개 국가에서 연명의료 유보 및 철회 결정에 이르기까지 어떠한 절차와 기구가 마련되어 있는지를 살펴본다. 각국에서는 대만ㆍ미국처럼사전의료지시제도를 법적으로 양식을 결정한 채 도입하거나 영국처럼 사전 거부라는 제한적 형태로 도입하거나 일본처럼 기관별로 도입하여 활용하고 있다. 일본은 가이드라인 중심의 접근을 취하는 반면대만은 법 중심의 접근을 취한다. 한편 미국은 기본적으로 연명의료에 관한 의사 표명을 환자의 자기결정권으로 존중하고 반영하되 치료적 이득이 극히 불분명한 경우 의료진이 거부할 수 있다. 그리고 별도로 의료윤리위원회 기구를 둠으로써 환자와 의사 사이의 의견 불일치를 해소할 수 있다. 반면 영국은 환자의 치료 거부에 관한 의사만을 ‘사전 결정’을 통해 제한적으로 반영하되, 의사결정능력을 상실한 경우최선의 이익 관점에서 의료진이 판단한다. 각국의 사례를 참고하여 한국에서는 남용 방지, 자기결정권보장 등 최소한의 장치를 충실히 구현하고 그 외의 영역에서는 의료진과 환자(그리고 환자 가족)의 합리적 의사결정을 지원하는 것이 바람직하다.

영미법계 성년후견제도에서의 피후견인의 신상보호

정구태 인문사회 21 2017 인문사회 21 Vol.8 No.1

The advance healthcare directive is a future medical treatment with which a person agreed on his or her own volition, which is the first priority later on. To guarantee the right of self-determination, the advance healthcare directive system needs to be introduced into the Korea’s civil act. The directive must be in writing, but a change or retraction does not need documentation. In case a person enters into a temporary guardianship agreement after drawing up an advance healthcare directive, his or her advance healthcare directive is regarded as retracted. In the event that he or she changes his or her intention, there is the need to abide by the change. It is possible that a person loses his or her decision-making ability without issuing an advance healthcare directive, designating his or her guardian, and investing the temporary guardian with the right to consent to the medical treatment. In this regard, institutionally, it is imperative to introduce a system that makes it possible for a substitution for the guardian to consent to the medical treatment in order to realize the best interests of the person concerned. In realizing the best interests of the person concerned, it may be reasonable to give the consent right to one of a spouse, a lineal descendant, a lineal ancestor, a brother or sister, and a person within the five degrees of kinship in the order named. However, the substitution may not exercise the consent right in cases where the medial treatment is likely to directly cause death or considerable disability. In this case, it can be done after the permission of the family court. Meanwhile, it is possible to ask for the permission subsequent to the medical treatment in cases where a life-threatening problem or serious physical or mental disability is likely to occur during the procedure of permission. 이 글에서는 영미법계 성년후견제도로서 영국 정신능력법상의 신상보호제도에 관한 비교법적 연구를 바탕으로 현행 민법의 개정에 관한 입법론을 제시하였는바, 이를 요약하면 다음과 같다. 사전의료지시란 본인이 의사결정능력이 있는 상태에서 미리 장래의 의료행위에 관한동의 여부를 결정해 놓은 경우 그 의사를 우선적으로 존중하는 것인 바, 본인의 자기결정권을 최대한 보장하기 위하여 우리 민법에도 시급히 도입될 필요가 있다. 본인의 의사의존부를 둘러싸고 분쟁이 발생할 여지를 줄이기 위해서 사전의료지시는 서면으로 작성되도록 하는 것이 타당하며, 그 변경이나 철회에는 방식 요건을 구비하도록 할 필요가 없다. 본인이 사전의료지시서를 작성한 후 임의후견계약을 체결한 경우에는 사전의료지시가 철회된 것으로 보되, 본인이 임의후견계약체결시 다른 의사를 표시한 경우에는 그 의사에 좇으면 될 것이다. 의사가 본인의 신체에 침습을 가하는 의료행위를 함에 있어 본인이 의사결정능력을 상실하였음에도, 본인이 사전의료지시를 하지 않았고 본인을 위한 성년후견이 개시된 바 없으며 본인이 사전에 임의후견인에게 동의권을 부여하지도 않은 경우, 본인의 최선의 이익을 실현하기 위해서는 의료행위에 대한 동의권 대행제도가 도입되어야 한다. 본인의 최선의 이익을 최대한 고려할 수 있도록 배우자, 직계비속, 직계존속, 형제자매, 4촌 이내의 친족 순으로 동의권을 대행하도록 하는 것이 타당하다. 다만, 의료행위의 직접적인 결과로 사망하거나 상당한 장애를 입을 위험이 있는 경우에는 동의권을 대행할 수 없고 반드시 가정법원의 허가를 받도록 하되, 허가절차로 의료행위가 지체되어 본인의 생명에 위험을 초래하거나 심신상의 중대한 장애를 초래할 때에는 사후에 허가를 청구하도록 해야 할것이다.

독일 성년후견제도의 개정과정과 한국법에의 시사

백승흠 원광대학 법학연구회 2013 法學硏究 Vol.29 No.4

독일 성년후견제도의 개정과정과 한국법에의 시사

백승흠 원광대학교 법학연구소 2013 圓光法學 Vol.29 No.4

고령자의 판단능력 쇠퇴를 대비한 미래설계와 새로운 성년후견제도

제철웅 ( Cheol Ung Je ) 한양대학교 법학연구소 2015 법학논총 Vol.32 No.1

Traditional adult guardianship, even in western countries such as Germany and England, had targeted at either preventing persons with mental disabilities engaging in legal transactions for their protection or protecting the property of persons with spendthrift habits, regardless of any reasons, for their family members before reformation of guardianship system began from 1990s. The situation in Korea was not different; namely, family members of persons with dementia and brain injury have applied for the opening of guardianship to protect their relatives`` property for applicants`` own interest. However the use of guardianship has been strikingly rare in comparison of other countries, where more or less 100 persons per 100,000 inhabitants are under guardianship, because less than 10 per 100,000 inhabitants have been estimated to be under guardianship in Korea. It seems because most persons with severe mental or intellectual disabilities have been accommodated in closed facilities remote from local communities, which means that there is little needs to prevent them engaging in legal transactions. Such situations can result in few persons having resorted to the application of guardianship, even though adult guardianship was reformed as of 1st July 2013. Traditional guardianship does not fit the needs of elderly and persons with dementia, because they used to have no problems at decision making before the triggering events of dementia and used to express their antipathy to guardianship because of its targeted purposes. As aging societies in western countries progress, future planning schemes for the time of deterioration of capacity have been popular among elderly and persons with dementia and their families, which resulted in the use of enduring power of attorney, lasting power of attorney and advanced directives to medical treatments. This paper suggests that contractual guardianship and alternatives to guardianship have to be provided for elderly and persons with dementia as future planning schemes, and proposes concrete schemes relevant to them.

의료행위 동의권자의 결정 -성년후견제 시행에 대비하여-

현소혜 ( So Hye Hyun ) 홍익대학교 법학연구소 2012 홍익법학 Vol.13 No.2

Every person has the right to determine whether he consents to the specific medical treatment or not, even though he cannot make a rational decision. The new adult guardianship system in Korean revised Civil Law guarantees such a right of self-determination of the mentally incapacitated adult. Furthermore, it provides adult-guardians and limited-guardians can make decisions about medical affairs for the mentally incapacitated adult in case of judicial declaration and his being unable to make decision by himself. But who can consent to the medical treatment for the mentally incapacitated adult without adult-guardians or limited-guardians? If the mentally incapacitated adult has appointed a personal guardian for medical affairs, he can be informed of and decide whether to consent to the medical treatment, Besides adult-guardians and limited-guardians, specific guardians has the power of decision-making for the mentally incapacitated person too, when there is no personal guardian, Supervisor of guardianship can consent as a accompanying deputy just in circumstances of emergency. In case of not being any kind of guardians at all, it seems the legislator deems for the court to appoint new guardian for medical affairs, but it demands too much of patient`s family considering its high cost and severe effort, Therefore we should design alternate system of adult guardianship, which enables other person to substitutes guardian`s decision, Otherwise, medics will not give proper medical treatment as a warning for medical malpractice suit. It would be appropriate close relatives of patient, such as spouses, children or parents, to be the legal representatives for the mentally incapacitated person in common sense and medical practice. We should pay attention the power of decision-making for the mentally incapacitated person not to be misused. The interests of patient and those of guardians or relatives are sometimes imcompatible, so Korean revised Civil Law demands the permission of family court when there is a risk of death or considerable disability as a immediate result of medical treatement. Such a provision must be applied to the substitute consent of relatives, and furthermore, when there is a risk of death or considerable disability as a immediate result of denial of medical treatement, too. Finally, advance directives for medical affairs should be introduced in new guardianship system. It will help a right of self-determination of the mentally incapacitated adult be realized in full range. It would be better to make the advance directives for medical affairs a formal act (for example, in writing and with autograph) for securing true intention of patients. But it seems advance directives for medical affairs cannot restrict medics because it is no informed-consent. Advance directives cannot be used for the denial or termination of life-sustaining treatment or organ transplant, either.

연명치료중단에 있어서 의사결정과정의 구체적 쟁점

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

Mittlerweile ist das Selbstbestimmungsrecht eines Patienten als allge meines Grundrecht anerkannt; daher kann ein Patient dieses unter Beruf ung auf die ärztliche Aufklärungsplicht ausüben. Die akute Problematik b ei Indikationsabbrüchen lebenserhaltender Maßnahmen ergibt sich jedoch vor allem daraus, dass dieNutzung des Selbstbestimmungsrechts in jedem Falle einen klaren Bewusstseinszustand voraussetzt, welcher jedoch nich t mehr gegeben ist, wenn der Patient z.B. ohne mächtig ist oder aber b ereits im Komaliegt. In einem solchen Falle liegt auf Seiten des Patiente n grundsätzlich eine sogenannte Einwilligungsunfähigkeit vor. In der Rechtsprechung und herrscht ein Konsens darüber, dass das S elbstbestimmungsrecht des Patienten auch in oben genannten Fällen zu r espektieren ist. Sofern eine ausdrückliche Willensbekundung des Patiente n fehlt und auch nicht mehr rechtzeitig eingeholt werden kann, ist es dah er von besonderer Relevanz, die Äußerungen eines Patienten auch im Fa lle einer gegebenen Einwilligungsunfähigkeit ernst zu nehmen: In diesem Zusammenhang sei etwa die sogenannte Patientenverfügung erwähnt. Den noch bleibt die Frage nicht streitfrei, ob der in der Patientenverfügung fi xierte Wille nun dem aktuellen Wille des Patienten entspricht, oder nicht; daher ist nach wie vor äußerst schwierig, festzustellen, dass der darin g eäußerte Wille zum Zeitpunkt des Abbruches lebenserhaltender Maßnahm en maßgebend ist . Aus der Perspektive der Rechtssicherheit ist die Willensbestimmung aber auch bei einwilligungsunfähigen Patienten noch erforderlich. Für die rechtliche Verbindlichkeit einer Patientenverfügung müssen vor allemhöh ere und restriktivere Anforderungen gegeben sein, und auch deren Reich weite muss noch der gesellschaftlichen Übereinstimmung angeglichen we rden. Sofern der noch kurz zuvor geäußerte Wille bzw. die Patientenverf ügung nicht vorliegen, kann der wirksame mutmaßliche Patientenwille du rch den Betreuer im Sinne des sog. Betreuungsrechts ermittelt werden. I n einem solchen Falle können die Angehörigen eines Patienten jedoch w eder völlig noch grundsätzlich aus dem Willensbestimmungsverlauf unter Berücksichtigung auf koreanischen familienspezifischen Kulturtendenz aus geschlossen werden. Gemäß dem teleologischen Aspekt des Betreuungsr echts können die Familienmitglieder hier nicht als ein selbstständiges Su bjekt, sondern nur für die Aufsichtoder Besichtigung an die Willensauffas sungsgeschehen auftreten. Schließlich ist es bei der von Dritten ermittelten und festgelegten Ein willigung unvermeidlich, das Interesse des Dritten aufzugreifen; daher ist es in theoretischer Hinsicht in der Folge nicht mehr möglich, dem wirkli chen Willen authentisch zu entsprechen. Daraus folgt die Notwendigkeit der Kontrolle über die Willensbestimmung von Dritten, deren Gewährleist ung letztlich eine Aufgabe von (Vormundschafts-) Gerichten darstellt.

연명치료중단에 있어서 의사결정과정의 구체적 쟁점

이재경(Yi Jae Kyeong) 원광대학교 법학연구소 2013 의생명과학과 법 Vol.9 No.-

Mittlerweile ist das Selbstbestimmungsrecht eines Patienten als allge meines Grundrecht anerkannt; daher kann ein Patient dieses unter Beruf ung auf die ärztliche Aufklärungsplicht ausüben. Die akute Problematik bei Indikationsabbrüchen lebenserhaltender Maßnahmen ergibt sich jedoch vor allem daraus, dass dieNutzung des Selbstbestimmungsrechts in jedem Falle einen klaren Bewusstseinszustand voraussetzt, welcher jedoch nicht mehr gegeben ist, wenn der Patient z.B. ohne mächtig ist oder aber bereits im Komaliegt. In einem solchen Falle liegt auf Seiten des Patienten grundsätzlich eine sogenannte Einwilligungsunfähigkeit vor. In der Rechtsprechung und herrscht ein Konsens darüber, dass das Selbstbestimmungsrecht des Patienten auch in oben genannten Fällen zu respektieren ist. Sofern eine ausdrückliche Willensbekundung des Patiente n fehlt und auch nicht mehr rechtzeitig eingeholt werden kann, ist es daher von besonderer Relevanz, die Äußerungen eines Patienten auch im Falle einer gegebenen Einwilligungsunfähigkeit ernst zu nehmen: In diesem Zusammenhang sei etwa die sogenannte Patientenverfügung erwähnt. Den noch bleibt die Frage nicht streitfrei, ob der in der Patientenverfügung fixierte Wille nun dem aktuellen Wille des Patienten entspricht, oder nicht; daher ist nach wie vor äußerst schwierig, festzustellen, dass der darin geäußerte Wille zum Zeitpunkt des Abbruches lebenserhaltender Maßnahmen maßgebend ist. Aus der Perspektive der Rechtssicherheit ist die Willensbestimmung aber auch bei einwilligungsunfähigen Patienten noch erforderlich. Für dierechtliche Verbindlichkeit einer Patientenverfügung müssen vor allemhöhere und restriktivere Anforderungen gegeben sein, und auch deren Reich weite muss noch der gesellschaftlichen Übereinstimmung angeglichen werden. Sofern der noch kurz zuvor geäußerte Wille bzw. die Patientenverfügung nicht vorliegen, kann der wirksame mutmaßliche Patientenwille durch den Betreuer im Sinne des sog. Betreuungsrechts ermittelt werden. In einem solchen Falle können die Angehörigen eines Patienten jedoch weder völlig noch grundsätzlich aus dem Willensbestimmungsverlauf unter Berücksichtigung auf koreanischen familienspezifischen Kulturtendenz aus geschlossen werden. Gemäß dem teleologischen Aspekt des Betreuungsrechts können die Familienmitglieder hier nicht als ein selbstständiges Subjekt, sondern nur für die Aufsichtoder Besichtigung an die Willensauffas sungsgeschehen auftreten. Schließlich ist es bei der von Dritten ermittelten und festgelegten Ein willigung unvermeidlich, das Interesse des Dritten aufzugreifen; daher istes in theoretischer Hinsicht in der Folge nicht mehr möglich, dem wirkli chen Willen authentisch zu entsprechen. Daraus folgt die Notwendigkeit der Kontrolle über die Willensbestimmung von Dritten, deren Gewährleistung letztlich eine Aufgabe von (Vormundschafts-) Gerichten darstellt.

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.

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.