연명의료결정법의 개정방안

손경찬(Son, Kyoung chan) 한국법학회 2020 법학연구 Vol.79 No.-

이 연구는 현행 연명의료결정법의 바람직한 개정방안을 찾아보기 위한 연구이다. ‘존엄사(자연사)’ 문제는 2004년 의료진에게 살인죄를 적용한 보라매 병원 사건으로 촉발되었고, 2009년 대법원 판결에서 지속적 식물상태(VS/UWS)인 김 할머니의 연명치료 장치를 제거할 것을 허용하면서, 그 찬반여부를 둘러싸고 폭발적인 논쟁과 사회적 격변을 거쳤다. 그리고 2018년부터 소위 연명의료결정법이 시행되고 있다. 연명의료결정법은 2000~2018년까지 각계각층의 고민과 염려를 담은 훌륭한 노작이다. 그런데 연명의료결정법은 지속적 식물상태 환자에게 적용할 수 없다는 한계를 가지고 있다. 동법의 제정으로 환자는 인간의 존엄권에 기한 자기결정권을 보장받게 되었고, 의료진은 연명의료결정에 관한 법적인 책임에서 벗어날 수 있게 되었다. 무엇보다 동법은 인간이 자신의 삶을 돌아보고 죽음을 어떻게 준비할 것인가를 결정할 수 있게 하였다는 의미가 있다. 다만, 동법은 지속적 식물상태 환자의 연명의료를 어떻게 결정할 것인지에 대한 규정이 누락되어 있다. 비교법적으로 미국・독일・일본의 판결과 법제에서도 지속적 식물상태 환자의 연명의료를 지속할 것인지 말 것인지가 문제된 사례가 많았으며, 한국에서 이 논의를 촉발하게 한 김 할머니 사건의 당사자도 지속적 식물상태였다. 따라서 앞으로 동법에서는 지속적 식물상태의 환자인 경우 연명의료결정을 어떻게 할 것인가를 신중히 논의한 뒤 규정하여야 한다. 특히 지속적 식물상태 환자의 추정적 의사를 판단할 수 없는 경우에는, 병원윤리위원회의 판단 만으로 연명의료중단을 할 수 없고, 행정기관 혹은 법원의 판결을 통해 해결하는 것이 필요하다. 다만 급식관 중단의 문제는 의사조력자살에 비견될 수 있어, 이를 합법으로 판단하기는 곤란하다. 따라서 환자가 자발호흡이 없는 뇌사상태에 준하는 지속적 식물상태인 경우 국가기관의 엄격한 심리와 판정을 거쳐 삶을 끝낼 수 있는 길을 열어주어야 한다. 이러한 주장은 종국에는 안락사를 허용하자는 미끄러운 경사길 논증은 결코 아니다. This study aims to find a desirable amendment for the current 「Act on Life-Sustaining Medical Care Determination」. The issue of ’Death with dignity (Natural death)’ was triggered by the incident at Boramae Medical Center, in which some medical staffs were convicted of murder by the Supreme Court in 2004. Further, it went through explosive debate over the pros and cons after the incident in 2009, that the Supreme Court released its final decision to approve the removal of life-sustaining medical device from elderly women Kim who had been in persistent vegetative state (vegetative state/unresponsive wakefulness syndrome [VS/UWS]). From 2018, the so-called 「Act on Life-Sustaining Treatment Determination」 has been in effect. The 「Act on Life-Sustaining Treatment Determination」 is an excellent work that contains the concerns of all walks of life from 2000 to 2018. With the enactment of this law, patients are guaranteed the right of Self-Determination based on human dignity, and medical staff can be free from legal responsibility for life-sustaining medical treatment. Furthermore, this law is meaningful as it allows each individual to take a moment to look back on his or her life and prepare for death. However, the 「Act on Life-Sustaining Medical Care Determination」 has limitations that it cannot be applied to patients in VS/UWS. It fails to contain regulations on how to determine life-sustaining medical treatment in patients with persistent vegetative state. Comparatively, there are numerous cases in which the permanent vegetative state of patients has been a problem even in the cases and legal systems of the United States, Germany, and Japan. The elderly women Kim, the party to the case which initiated the discussion on life-sustaining treatment in Korea was also in VS/UWS patients. Therefore, this act must discuss how to deal with life-sustaining treatment in patients in VS/UWS and define the results. Particularly in cases where presumptive intention of patient in VS/UWS is cannot be determined, it is not possible to stop life-sustaining treatment only by the judgment of the hospital ethics committee, so thus it is necessary to resolve the cases through the verdict of an administrative agency or court. However, it is difficult to legalize the removal of feeding tube from patients in VS/UWS, as it can be considered as a doctor-assisted suicide. Thus, if the patient is in a VS/UWS comparable to a brain-death state without spontaneous breathing, it is necessary to open a way to end life through strict screening and confirmation by administrative agency. This argument is definitely not a slippery slope argument to allow euthanasia in the end.

연명치료중단 법제화의 전제조건에 대한 검토 -세브란스병원사건에 대한 법원 판결의 의미와 시사점-

이상용 ( Sang Yong Lee ) 한국법정책학회 2012 법과 정책연구 Vol.12 No.3

연명치료중단의 문제는 2008년 세브란스병원사건을 계기로 다시 한 번 커다란 사회적 관심의 대상이 되었는데, 이에 대한 법원의 판결에서 연명치료중단의 일정한 기준을 발견할 수 있다는 점에서 관련 논의의 의미 있는 진전을 이루게 되었다고 볼 수 있다. 그러나 일정한 경우 연명치료의 중단이 허용되어야 한다는 데에는 대체로 많은 사회구성원들이 동의하고 있지만, 그 사회적 합의의 구체적 내용에는 불분명한 점들이 여전히 존재한다. 의견이 대립하는 분야는 사전의료지시서의 요건과 효과, 연명치료중단의 대상 환자, 중단될 수 있는 연명치료의 종류 등 여러 가지가 있지만, 그것이 가장 첨예하게 드러나는 사안은 자발적 호흡을 하고 있지만 이미 장기간의 의식불명상태에 빠져있고 또 앞으로도 상당기간 그 의식불명상태가 계속될 것으로 예측되는, 회복의 가능성이 매우 희박한 지속적 식물상태 환자의 영양공급을 중단할 수 있는가라는 문제라고 생각한다. 본 논문은 법원의 판결과 그 이후의 논의의 전개과정에 대한 검토를 통해 연명치료의 중단에 대한 우리 사회의 합의의 범위를 살펴보고, 연명치료중단이 법제화가 되어야 한다면 그것은 어느 범위에서 연명치료의 중단을 허용하는 것이 되어야 할 것이며 어떤 점에 대한 논의와 합의가 필요한지를 살펴보고자 한다. 그리고 합의의 과정에서 자발적 호흡이 가능한 지속적 식물상태의 환자의 경우에도 연명치료 중단의 가능성을 열어놓고 논의를 하는 것이 필요하다고 제안한다. Owing to the remarkable advances in medical science and technology, terminally ill patients can survive longer than ever expected before. But the patients can not regain consciousness in many cases. The Supreme Court of Korea decided that if a patient is in an irreversible condition with imminent death, the discontinuation of treatment can be approved as the patient`s self-determination, in 2009. In this case, a 76-year-old patient was in a persistent vegetative state, with artificial ventilation treatment. The Court approved the request of the patient to remove the artificial ventilation treatment, and allowed the patient to die. Therefore the artificial ventilation treatment was removed, but the patient maintained spontaneous breathing for about seven months, and deceased. This decision presented the general criteria and process of withdrawal of life-sustaining management in Korea for the first time, the majority opinion of the decision ruled that in state of critically irreversible condition the patient can exercise the right to self-determination based on human dignity, value and the right to pursuit of happiness, the withdrawal can be allowed. However, the court defined the concept of ``irreversible condition`` and ``imminent death condition`` vaguely and there is enough ground for controversy. A generally accepted consensus of end-of-life care decision-making appeared in Korean medical society after that decision, and guidelines to withdrawing life-sustaining therapies were published in 2009. Still there is an opposition to the legalization of the withdrawal of life-sustaining management, the majority of people seem to assent to the withdrawal of life-sustaining management in a specific condition, but in particular there are conflicts of opinion, An advance directive is a measure to certify the determination of incompetent patients, but the persistent vegetative state is so rare and unexpected condition, and it may happened suddenly, If the patient have made out an advance directive, there are many difficulties with advance directives. And withdrawal of life-sustaining artificial nutrition and hydration is more serious and critical problem, especially in case of the persistent vegetative state patient. Therefore national consensus should be made before the legislation of the withdrawal of life-sustaining management, especially about the persistent vegetative state.

‘안락사'의 형사법적 평가 및 과제

김은정 ( Kim Eun-jung ) 한국비교형사법학회 2020 비교형사법연구 Vol.21 No.4

현대의학기술의 비약적 발달은 사망에 임박한 회생가능성이 없는 사람의 죽음에 이르는 과정을 점차 길게 하였다. 그에 따라 오랫동안 사회 각층에서 연명치료가 오히려 인간의 존엄을 오히려 해치는 것은 아닌지, 연명치료를 중단하려면 어떠한 요건을 충족하여야 하는지에 관하여 많은 논의가 있었다. 우리는 2016. 2. 3. 연명의료결정법을 제정하였고 그간 학계 논의와 개별 사건에서 법원의 판단을 통해 해결하였던 연명치료 중단의 문제를 입법적으로 해결하고자 하였지만 현행의 연명의료결정법은 짧은 기간 동안 두 차례개정까지 하였음에도 여전히 의료현실에서 발생하는 문제들을 해결하기에는 추가적인 보완이 필요한 것으로 보인다. 의료현실에 대한 고려와 체계적인 법해석이 부족한 상태에서 사회적 필요에 따라 성급하게 입법화하는 과정에서 그동안 법원의 판단을 통해 해결하였던 문제 이상으로 의료현장에서 발생하는 혼란을 해소하기에는 부족한 법이 만들어진 것으로 보인다. 연명의료결정법이 밝히는 목적과 같이 환자의 최선의 이익을 보장하고, 자기결정을 존중하여 인간으로서의 존엄과 가치를 보호하기 위해서는 ①대상이 되는 환자의 범위를 ‘임종과정에 있는 환자’에 한정할 것이 아니라 말기의 중증환자나 지속적 식물인간 상태에 있는 환자로서 사실상 임종과정에 있는 환자에 준한다고 볼 수 있는 경우에도 그에 부합하는 의학적 판단과 법으로 정하는 절차에 따라 연명의료중단이 가능하게 하되, ②사전에 환자가 연명의료중단을 희망하는 의사를 표시하였음이 환자 본인이 작성한 문서, 녹음물, 녹화물 또는 이에 준하는 기록물 등에서 객관적으로 확인되는 경우 연명의료중단 시점에서 환자의 연명의료중단 의사를 추정하고, ③벌칙 규정과 관련하여 형법상 범죄와 연명의료결정법 제40조의 관계를 보다 명확히 하는 방향으로 입법적인 개선을 지속해 나간다면 현행 연명의료결정법이 가지고 있는 문제를 조금이라도 해소할 수 있을 것이라 생각한다. 앞으로도 심도 있는 논의와 지속적인 연구가 계속되길 기대해 본다. Great strides in modern medical technology have extended the dying process of a person who is unlikely to restore. It triggered many discussions on whether life-sustaining treatment would rather harm human dignity, and what conditions must be met to withdraw life-sustaining treatment. February 3th, 2016, ‘The Act of Hospice Palliative Care and Withdrawing Life Sustaining Treatment’ was legislated. We hoped that the act would legislatively solve the problems about the withdrawal of life-sustaining treatment which had been only solved by academic discussions and judgments in individual cases. But, even though the act has already been amended twice in a short period of time, it seems that additional amendments of the act are still needed to solve the problems in medical practice. It seems that the act is a little bit insufficient to solve various problems in medical practice, because it was hastily legislated only by social demands. There was a lack of systematic legal interpretation in the legislative process. For the protection of human dignity and value by respecting for self-determination of the patients, which is the essential purpose of ‘The Act of Hospice Palliative Care and Withdrawing Life Sustaining Treatment’, the following legislative improvements seem necessary. ①We should enable the withdrawal of life-sustaining treatment not only for the patients in dying process, but also for the patients in Persistent Vegetative State or for terminally ill patients, if it is in accordance with medical decisions and due legal procedures. ②We should estimate the patient’s intention to withdraw life-sustaining treatment if the patient leaves self-written documents or voice/video records of his(or her) intention. ③We should make legislative improvements about clarifying the relations between the Criminal Law and the article 40 of ‘The Act of Hospice Palliative Care and Withdrawing Life Sustaining Treatment’. I look forward to further discussions and research on this issue.

연명의료중단의 허용범위 제한에 관한 헌법적 검토

김현귀(Kim Hyun gui) 한국헌법학회 2015 憲法學硏究 Vol.21 No.3

현재 대법원과 헌법재판소가 확인한 연명의료중단에 관한 자기결정권 보장에 관하여 어느 정도 사회적 합의가 모아지고 관련 법률안들이 구체화되고 있다. 관련 법률의 입법과정에서 핵심적인 쟁점이 되고 있는 것은 인공영양공급의 중단금지문제와 연명의료중단이 허용되는 인적범위를 설정하는 문제이다. 우선, 헌법적으로 연명의료중단에 관한 자기결정권의 의의와 보호내용과 한계를 검토하면서 인공영양공급의 중단을 일률적으로 금지하는 것이 환자의 자기결정권을 침해할 가능성이 있음을 지적한다. 더 나아가, 연명의료중단이 허용되는 인적범위를 말기환자 또는 임종과정의 환자로 좁게 형성하는 것이 사회적 합의라면, 이는 이에 포함되지 않는 사람의 자기결정권을 제한하는 것이 되므로 최소한 법률유보원칙에 따라서 이를 판단하는 기준과 절차가 법률로써 마련되어야 한다는 것을 강조한다. 더불어 2009년 김할머니 사건과 최근 유럽인권재판소에서 결정된 프랑스의 벵상 랑베르 사건을 각각 검토하고 비교하여, 짧은 기간 내 사망할 것이 명백한 경우에만 연명의료중단을 허용하는 것이 별로 타당한 기준은 아니라는 점을 논증한다. Now a day, several legislative bills are presented to protect the self-determination right to refusal of life-sustaining treatment identified by Korean Supreme court and Constitutional court. The main issues are whether allow to stop the artificial nutrition and hydration and how determine qualified patients to refusal of life-sustaining treatment. At first, considering meaning and content of the constitutional right on the refusal of life-sustaining treatment and limits of its protection, I will point out that banning all cases of refusal the artificial nutrition and hydration can make some infringement of the constitutional right. Further if it is social consensus to restrict the qualified patient to a terminal or dying case narrowly, the qualifying criteria and process must be arranged by law according to the statute reservation principle at least, because unqualified patients can be deprived their rights. In addition, it is argued that the dying in a short time criteria is not valid for allowing the refusal of life-sustaining treatment, considering and comparing Grandma Kim case of Korean Supreme court in 2009 and Vincent Lambert case of European Court of Human Rights in 2015.

존엄사의 헌법적 보장-죽음에 대한 자기결정권의 구성요건 설정을 중심으로-

주재경 원광대학교 법학연구소 2022 圓光法學 Vol.38 No.4

South Korea recognizes death with dignity only in the form of cessation of life-sustaining treatment for patients in the process of dying. Accordingly, a terminally ill patient or a patient in a persistent vegetative state cannot make a decision to die with dignity, and even if he or she is the target, there are limitations in choosing a method of dying with dignity such as physician-assisted suicide. These limitations cannot preclude discussion from the stage of component requirements. Therefore, in the decision to die with dignity, it is necessary to ensure that death with dignity is sufficiently guaranteed through the establishment of the component requirements for the right to self-determination on death. Regarding the requirements for becoming the subject of the right to self-determination on death in the decision to die with dignity, the requirements of irreversibility and the uselessness of treatment become the focal points. Accordingly, it is against the principle of equality to exclude a patient who has no essential difference from a patient in the process of dying and who meets the requirements from the subject. Therefore, in principle, it is desirable to acknowledge the subjectivity of the right to self-determination on death for these patients. First, in terms of the right to defense of the right to self-determination on death, the subject of the decision to die with dignity can request that the state stop restrictions on physician-assisted suicide. In the same respect, it is possible to ask the state to make a decision to discontinue general life-sustaining treatment. Next, based on the social rights aspect of the right to self-determination on death, the subject of decision to die with dignity can claim the right to receive social insurance and public assistance from the state. In particular, it can be requested that the state prepare overall welfare conditions such as hospice and palliative care systems so that patients' self-determination can be free from economic pressure. And, in terms of the protective right of the right to self-determination on death, the subject of the decision to die with dignity may claim the right to receive assistance from a doctor to the state. For example, if death with dignity is carried out by a private person other than a doctor, the right to self-determination on death may be violated, so the patient can request legislation to the state that obligates the participation of doctors in the decision to die with dignity. Lastly, in terms of the procedural right of the right to self-determination on death, in relation to organizations, supplementary legislative requests can be made to the state to expand the establishment or vitalize the operation of the Medical Institution Ethics Committee or the Public Ethics Committee. Regarding the procedure, it may be possible to request the state to prepare legislation to supplement the procedure for implementing death with dignity.

연명의료중지에 관한 법원 판결과 제도화에 관련된 문제들

박종태 대한의사협회 2019 대한의사협회지 Vol.62 No.7

The Supreme Court decision made on May 21, 2009 about the withdrawal of futile life-sustaining medical care from a persistently vegetative patient provided a legal basis for patients to consent to death with dignity, and also spurred a lively debate in Korea. The legal grounding of this decision was based on the principles of human dignity, worth, and the right to pursue happiness articulated in the Article 10 of the Constitution. The Death with Dignity Act was legislated to regulate decisions about life-sustaining medical care on February 3, 2016, after extensive debate and a focus on consensus that led to two revisions. However, the issue has not been completely resolved. First, the definition of the process of dying is unclear, because the points that determine whether a patient is dying are different from a simple assessment of whether an artificial ventilator shall be attached or detached. Second, the purpose of this law is the protection of human dignity, worth, and the right to pursue happiness. However, nutrition, fluids, and oxygen must continue to be supplied, even after cessation of life-sustaining medical care. Is providing a continuous supply of nutrition, fluids, and oxygen a reasonable way to satisfy the goals of Article 10 of the Constitution? Third, if the withdrawal of life-sustaining medical care is possible based on the family’s agreement without the patient’s input, what is the legal value of advance directives? In conclusion, it is necessary to partially revise the law regulating decisions on the withdrawal of life-sustaining medical care through further debate.

Decision making regarding end of life care and its legal aspect in Korea

박준석 전북대학교 동북아법연구소 2013 동북아법연구 Vol.6 No.3

In May of 2009, the Supreme Court of Korea gave a landmark decision granting a dying patient the right to remove the respirator from her body. It was the first case in Korea for the Supreme Court to explicitly approve withdrawal of life-sustaining medical support from the patient with no hope of recovery but still alive. However, hardly any attention has been paid by the Supreme Court, or at least by the majority opinion of its decision, to the on-going debate on the varied themes under the heading of the end-of-life decision making. And it can be said that for physicians as well as commentators the end-of-life decision making is still a blur. This paper aims at reviewing briefly the problem of end-of-life decision making in recent articles published in Korea. Firstly, the legal background and battle over the case of a dying patient whom we may call Ms. Kim, which ended up with three court decisions in her favour, will be reviewed to somewhat detailed extent. Secondly, some critical analyses of the court decisions conducted by commentators in law and medical ethics will be addressed. And lastly, the social and political influence of the landmark decision and the tasks yet to be carried out even after the decision was delivered will also be summarized.

Decision making regarding end of life care and its legal aspect in Korea

Joon Seok PARK 전북대학교 동북아법연구소 2012 동북아법연구 Vol.6 No.3

2009년 5월 한국의 대법원은 죽음을 앞둔 환자에게 연명 치료 장치를 제거할 수 있도록 하는 역사적인 판결을 내린 바 있다. 그것은 한국의 대법원이 회복 가능성이 없지만 여전히 살아있는 환자에게서 연명 치료 장치를 제거할 수 있다는 인정한 최초 의 판결이었다. 그렇지만, 대법원 혹은 대법원 판결의 다수 의견은 생의 마감에 관한 결정이라는 표제 하에 놓일 수 있는 다양한 주제들에 관해 현재 진행되고 있는 논의에 대해서는 거의 아무런 주의를 기울이고 있지 않다. 따라서 논자들에게나 의사들에게나 생의 마감에 관한 결정은 여전히 불투명한 상태로 남아있다고 말할 수 있다. 이 글은 한국에서 최근에 발표된 논저들 속에서 다루어지고 있는 생의 마감에 관한 결정의 문제에 대해 간략하게 검토하고 소개하는 것을 목적으로 하고 있다. 우선 이 글에서는 세 개의 판결로 귀결되었던 이른바 김 할머니라고 불렸던 환자의 사건과 관련하여 그 법적 배경과 법적 공방에 대하여 비교적 상세하게 다루고 있으며, 둘째로 그러한 판결들에 관하여 법학과 의료윤리 분야의 논자들이 제시했던 비판적 분석 들에 관하여 논하고 있다. 마지막으로 이 글에서는 대법원의 역사적인 판결이 지니는 사회적 및 정치적 영향에 관하여 그리고 당해 판결 이후에도 여전히 해결해야 할 과제로 남아있는 문제들에 관하여 정리하고 있다.

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.