연명치료 중단에 관한 연구

Abstract

의료기술의 발달로 인해 인간의 생명탄생과 죽음의 시점에 대해 과거에는 분명하던 것이 점차 설명하기 어려운 법적, 윤리적 문제를 야기하고 있다. 기존의 의료로는 인식할 수 없을 정도로 짧았거나 또는 극히 소수의 환자에게 볼 수 있던 죽음의 과정이 중환자 진료기술의 발달로 삶이 아니면 죽음?이라는 단순한 논리로는 죽음의 과정을 단축하는 일조차 살인이 될 수 있다. 실제 의료현실에서는 여러 가지 이유로 본인의 의사와는 관계없이 생명을 단축하는 사례가 빈번히 발생하고 있다. 우리 사회에서 죽음f에 대해 말하는 것은 여전히 어렵고 결론이 쉽게 나지 않는 문제이다. 그동안 식물인간상태의 환자나 말기환자의 연명치료 중단에 관한 사건이 터질 때 마다 소위 ?g죽을 권리에 대해 환자에게 인간답게 죽을 권리를 줘야 한다" 찬성 측 논리와 "사람의 생명이 타인의 판단에 따라 결정될 수 없으며 이는 생명 경시 풍조로 이어진다"라는 반대 측의 논쟁이 이루어졌지만, 단지 일회적인 논쟁으로 되풀이 됐다. 논의 과정에서 혼란을 초래하고 있는 원인의 상당 부분이 용어 문제이다. 이와 같은 혼란을 최소화하기 위하여 개념 및 용어에 대한 사회적 합의가 절실히 요구되고 있다. 초기에는 안락사라는 용어만을 사용하면서 이를 소극적 안락사, 적극적 안락사, 간접적 안락사 등으로 구분하였으나, 이후 존엄사, 자연사, 연명치료 중단, 의사조력자살 등의 개념이 소개되면서 위 각 개념을 학자마다 다르게 정의하고 있어 혼선이 있다. 연명치료 중단이라는 용어는 일반적으로 소극적 안락사 또는 존엄사라는 용어와 특별한 구별 없이 혼용하여 사용되고 있으나 개념상 서로 구분하여 통일적인 관점에서 정의해야 한다. 연명치료 중단의 법적성질은 의료계약의 해지로 볼 수 있지만 생명을 박탈한다는 점에서 일방적인 의사표시로 의료계약의 해지의 자유를 주장할 수 없으며 진료행위를 중단할 것인지 여부는 극히 제한적으로 판단하여야 한다. 연명치료의 거부가 생명의 마감을 초래하더라도 원칙적으로는 환자의 자기결정권이 존중되어야 하는 것이지만, 인간의 생명은 고귀하고 생명권은 헌법에 규정된 모든 기본권의 전제로서 기능하는 기본권 중의 기본권이므로, 환자의 생명과 직결되는 진료행위를 중단할 것인지 여부는 극히 제한적으로 신중하게 판단하여야 한다. 결과적으로 생명의 종결과 직결된 진료거부나 중단은 개인의 자기결정권에 전적으로 위임할 수 없는 것이지만, 회복가능성이 없는 환자의 경우에는 이러한 자기결정권의 제한을 다시 완화하는 것으로 해석된다. 말기 환자나 환자 보호자의 입장에서는 연명치료 중단의 결정이 환자의 자기결정권이 확장되는 것으로 이해할 수 있을 것이다. 즉 환자의 신체 침해를 수반하는 구체적인 진료행위가 환자의 동의를 받아 제공될 수 있는 것과 마찬가지로, 그 진료행위를 계속할 것인지 여부에 관한 환자의 결정권 역시 존중되어야 한다는 점에서 이러한 이해방식은 긍정적인 측면이 있다. 그런데 환자가 연명치료 중단을 선택할 때 그가 죽을 권리마저 갖는 것으로 이해해서는 곤란하다. 연명치료 중단 객관적 허용요건으로 회복 불가능한 사망의 단계에 이른 후에 대해 현실적으로 환자가 회복불가능한 사망의 단계에 진입하였다고 단정하기 어렵다는 이유로 판단에 있어 신중해야 한다. 또한 명시적으로 의학적 무의미함을 요건으로 밝히지는 않았지만 의학적 판단으로서 회생불가능 외에 치료중단 허용 여부의 법적 판단을 위해 의학적 무의미성도 추가하는 것이 타당하다고 본다. 치료의 의학적 무의미성 판단은 의사에 의한 의학적 판단으로 무엇보다 해당 환자의 상태를 가장 잘 아는 담당 주치의의 판단이 반영되어야 한다. 주관적 허용요건으로는 주관적 요건으로 환자의 의사표시를 확인할 것을 요구한다. 본 연구의 주요 관심 또한 연명치료 거부에 있어서 환자의 의사표시는 여러 가지 이유로 반영되지 못하는 현실에서 환자의 의사를 어떻게 확인하고 반영할지에 대해서 맞춰져 있다. 연명치료를 중단하기 위한 전제조건으로 가장 중요한 것은 환자 본인의 자율적 요구에 따라야 한다. 대상자가 스스로 판단하고 결정하며, 이를 표현할 수 있는 능력을 상실한 경우 제3자의 결정에 의해 파생되는 결과는 비가역적이므로 신중해야 하기 때문이다. 현재 환자의 의사를 명확히 확인할 수 있는 방법으로 '사전의료지시서'가 최선의 해결책이라는 인식이 확산되고 있다. 사전의료지시가 있는 경우에는 첫째 환자에게 의사결정능력이 있을 것, 둘째 환자가 의사로부터 직접 충분한 의학적 정보를 제공 받은 후 구체적인 진료행위에 관한 의사를 결정할 것, 셋째 위의 의사결정 과정에서 환자 자신이 의사를 상대로 직접 작성한 서면이나 의사가 진료과정에서 작성한 진료기록 등에 의해 진료중단 시점에서 명확하게 입증될 수 있어야 한다. 한편 사전의료지시서의 남용으로 오히려 환자의 생명에 위험이 가해질 수 있다는 이유로 사전의료지시서 제도의 도입을 반대하는 견해도 있지만 다른 제도적 장치가 없는 한 우리나라 실정에 맞게 도입하는 것이 타당하다고 본다. 그리고 우리나라의 경우 명시적인 의사를 표시하지 않은 채 의사능력을 상실하는 경우가 대부분이라는 점에서 추정적 의사가 강조된다. 환자의 추정적 의사를 확인하는 방법으로 간접증거에 기초하여 환자의 실제적인 의사를 객관적으로 확인할 수 있다면 확인된 의사에 따라야 한다. 환자가 사전에 한 의사표시, 성격, 가치관, 종교관, 가족과의 친밀도, 생활태도, 나이, 기대생존기간, 환자의 상태 등을 고려하여 환자의 치료중단 의사를 추정할 수 있다. 반면에 환자의 의사 확인할 수 없는 의사제한능력자에 대하여 연명치료 중단을 요구하는 상황이 발생할 경우 이를 받아들일 수 있을 것인지 논란의 여지가 있다. 미성년자나 신생아에 대한 연명치료 중단의 경우 치료중단의 결정에 있어서도 친권자 또는 법정대리인의 동의를 얻도록 하는 것이 바람직할 것이다. 이는 친권의 행사라고 보아야 할 것이며, 친권자가 2인 이상인 경우에는 친권자의 합의에 의한 동의가 필요할 것이다. 뇌사상태는 뇌가 불가역적으로 손상되어 회복이 불가능한 상태이지만 식물인간상태는 뇌사상태와 다르고 회복의 가능성이 미미하나마 있다고 보아야 한다. 1년 이상의 혼수상태에서 회복한 사례들이 종종 있다. 의학은 절대적 확신을 가지고 판단하지 못한다. 지속적 식물상태의 환자로서 인공호흡기나 투석과 같은 특수 연명치료를 장기간 받고 있는 경우도 치료의 지속여부에 대한 지속적인 논의가 필요하다. 그러나 지속적 식물상태로서 일반 연명치료로써 생명이 유지되는 환자는 연명치료 중지의 대상이 될 수 없다. 다만 특별한 이유로 가족들이 영양공급 중단 등과 같은 연명치료 중단을 요청한다면 이는 법원의 판단에 따라야 할 것이다. 이와 같이 환자가 승낙능력이 없거나 추정적 의사조차 확인할 수 없는 경우에는 객관적으로 환자의 최선의 이익을 고려하여 연명치료 중단 또는 계속 여부를 결정해야 한다.;Concerning the time of birth and death of a human life, what was clear in the past is gradually causing hardly explainable legal and ethical problems due to the advance of medical technology. In the past, the death process was too short for traditional medicine to recognize or was observed only in an extremely small number of patients, but now with the development of medical technologies for patients under intensive care, even reducing the death process can be ‘a murder’ if we think in the simple logic of ‘life or death.’ In actual medical practices, there are many cases that a patient’s life is ceased apart from the patient’s intention for various reasons. In our society, it is still difficult to talk about ‘death’ and this issue is extremely controversial. Whenever our society has an incident related to the withdrawal of life-sustaining treatment for a patient in a vegetative state or a terminal patient, there have been debates between those who advocate so-called “right to die,” saying that patients should be given the right to die with dignity, and those who oppose the position, saying that a human life cannot be determined by others’ judgment and such a right may lead to the trend of making light of human life, but such debates have usually ended without any conclusion. A large part of confusion in such debates comes from terminology. In order to minimize such confusion, it is urgently required to reach a social agreement on concepts and terms. At the beginning, only the term euthanasia was used and it was divided into passive euthanasia, active euthanasia, indirect euthanasia, etc., but later new concepts such as death with dignity, natural death, withdrawal of life-sustaining treatment and physician-assisted suicide have been introduced and their definitions various among scholars are causing confusion. The term ‘withdrawal of life-sustaining treatment’ is generally used interchangeably with passive euthanasia or death with dignity, but these concepts need to be distinguished and defined from a unified viewpoint. The legal nature of withdrawal of life-sustaining treatment can be regard as the termination of a medical contract, but one cannot assert the freedom to terminate a medical contract through a one-sided expression of intention in that it deprives the person of his/her life. Whether to withdraw medical treatment must be considered only in extremely exceptional cases. Even if a patient’s refusal of life-sustaining treatment results in the end of his/her life, the patient’s self-determination should be respected in principle, but human life is of high value and the right of life is the most basic of basic rights functioning as the premise of all other basic rights provided in the Constitution. For this reason, whether to withdraw medical treatment, which is directly linked to the patient’s life, should be decided with the utmost prudence. Consequently, refusal or withdrawal of medical treatment directly linked to the termination of life cannot be fully left to the patient’s self-determination, but in case of patients without possibility to recover such a restriction on self-determination may need to be eased. From the position of terminal patients or their guardians, a decision to withdraw life-sustaining treatment can be understood as the expansion of the patients’ self-determination. That is, like a specific medical treatment accompanied with the patient’s physical infringement is provided with the patient’s consent, a patient’s right to decide on whether to continue medical treatment should be respected. In this sense, this way of understanding has a positive aspect. When the patient chooses to withdraw life-sustaining treatment, however, it is unreasonable to understand that he/she has also the ‘right to die.’ As for the condition to allow withdrawal of life-sustaining treatment objective “After reaching the stage of irrecoverable death,” a decision should be made carefully because it is practically difficult to assert that a patient has entered into the stage of irrecoverable death. Although medical futility is not an explicitly mentioned condition, moreover, it is considered reasonable to add medical futility besides revival impossibility for a legal decision on whether to allow the withdrawal of treatment. The revival futility of medical treatment is the physician’s medical judgment, so it must reflect the judgment of the attending physician who is most familiar with the patient’s condition. As a subjective condition to allow the withdrawal of treatment, it is demanded to confirm the patient’s expression of intention. The main focus of this study is also placed on how to confirm and reflect the patient’s intention in the current situation that patients’ patient’s expression of intention is not reflected in the refusal of life-sustaining treatment for various reasons. What is most important as a precondition for the withdrawal of life-sustaining treatment is following the patient’s autonomous demand. In case a patient has lost abilities to judge, decide and express the decision, the outcome of any decision made by a third person is irreversible, and in this sense, such a decision should be made prudently. At present, ‘advance medical directive’ is regarded as the best solution to clarify patients’ intention. In case there is an advance medical directive, first, the patient should have abilities to make decisions; second, the patient should be given sufficient medical information directly by the physician and decide his/her intention on specific medical treatment; and third, any written document signed by the patient toward the physician in the process of decision making as above or medical records made by the physician through the process of medical treatment should be reviewed clearly at the time of the withdrawal of treatment. On the other hand, some oppose the introduction of the advance medical directive system for the reason that the abuse of advance medical directive may rather pose a risk to patients’ life, but as long as there is no other institutional device, it is considered valid to introduce the system fittingly to the current situation of Korea. In Korea, moreover, presumptive intention is emphasized because most of patients lose their mental capacity without expressing an explicit intention. If a patient’s actual intention can be confirmed objectively based on indirect evidence by a method of confirming the patient’s presumptive intention, the confirmed intention should be followed. A patient’s intention to withdraw treatment may be presumed in consideration of the patient’s advance expression of intention, personality, value, religious view, intimacy to the family, life attitude, age, expected survival period, clinical condition, etc. For a patient under disability to express intention whose intention cannot be confirmed, on the contrary, it is controversial whether it may be admitted if the withdrawal of life-sustaining treatment is demanded for such a patient. In case of the withdrawal of life-sustaining treatment for a minor or a neonate, it will be desirable to obtain consent from the person in parental authority or the legal representative in deciding the withdrawal of treatment. This may be regarded as the exercise of parental authority, and if there are two or more persons in parental authority, an agreement among them will be required. Brain death is a state that the brain has been damaged irreversible and thus is irrecoverable, but a vegetative state is different from brain death and has a possibility of recovery, though very low. Those who have been in a coma for over a year occasionally recover consciousness. Medicine cannot make a decision with absolute confidence. For patients in a persistent vegetative state and receiving long-term special life-sustaining treatment such as artificial respiration or dialysis as well, continuous discussions are necessary on whether to continue treatment. However, patients in a persistent vegetative state sustaining their life by ordinary life-sustaining treatment should not be subject to the withdrawal of life-sustaining treatment. If the family requests the withdrawal of life-sustaining treatment such as the withdrawal of nutrition supply for any special reason, this should follow the court’s decision. In this way, if a patient does not have abilities to approve or even his/her presumptive intention cannot be confirmed, the withdrawal or continuance of life-sustaining treatment should be decided by considering the patient’s best interests objectively. Concerning the time of birth and death of a human life, what was clear in the past is gradually causing hardly explainable legal and ethical problems due to the advance of medical technology. In the past, the death process was too short for traditional medicine to recognize or was observed only in an extremely small number of patients, but now with the development of medical technologies for patients under intensive care, even reducing the death process can be ‘a murder’ if we think in the simple logic of ‘life or death.’ In actual medical practices, there are many cases that a patient’s life is ceased apart from the patient’s intention for various reasons. In our society, it is still difficult to talk about ‘death’ and this issue is extremely controversial. Whenever our society has an incident related to the withdrawal of life-sustaining treatment for a patient in a vegetative state or a terminal patient, there have been debates between those who advocate so-called “right to die,” saying that patients should be given the right to die with dignity, and those who oppose the position, saying that a human life cannot be determined by others’ judgment and such a right may lead to the trend of making light of human life, but such debates have usually ended without any conclusion. A large part of confusion in such debates comes from terminology. In order to minimize such confusion, it is urgently required to reach a social agreement on concepts and terms. At the beginning, only the term euthanasia was used and it was divided into passive euthanasia, active euthanasia, indirect euthanasia, etc., but later new concepts such as death with dignity, natural death, withdrawal of life-sustaining treatment and physician-assisted suicide have been introduced and their definitions various among scholars are causing confusion. The term ‘withdrawal of life-sustaining treatment’ is generally used interchangeably with passive euthanasia or death with dignity, but these concepts need to be distinguished and defined from a unified viewpoint. The legal nature of withdrawal of life-sustaining treatment can be regard as the termination of a medical contract, but one cannot assert the freedom to terminate a medical contract through a one-sided expression of intention in that it deprives the person of his/her life. Whether to withdraw medical treatment must be considered only in extremely exceptional cases. Even if a patient’s refusal of life-sustaining treatment results in the end of his/her life, the patient’s self-determination should be respected in principle, but human life is of high value and the right of life is the most basic of basic rights functioning as the premise of all other basic rights provided in the Constitution. For this reason, whether to withdraw medical treatment, which is directly linked to the patient’s life, should be decided with the utmost prudence. Consequently, refusal or withdrawal of medical treatment directly linked to the termination of life cannot be fully left to the patient’s self-determination, but in case of patients without possibility to recover such a restriction on self-determination may need to be eased. From the position of terminal patients or their guardians, a decision to withdraw life-sustaining treatment can be understood as the expansion of the patients’ self-determination. That is, like a specific medical treatment accompanied with the patient’s physical infringement is provided with the patient’s consent, a patient’s right to decide on whether to continue medical treatment should be respected. In this sense, this way of understanding has a positive aspect. When the patient chooses to withdraw life-sustaining treatment, however, it is unreasonable to understand that he/she has also the ‘right to die.’ As for the condition to allow withdrawal of life-sustaining treatment objective “After reaching the stage of irrecoverable death,” a decision should be made carefully because it is practically difficult to assert that a patient has entered into the stage of irrecoverable death. Although medical futility is not an explicitly mentioned condition, moreover, it is considered reasonable to add medical futility besides revival impossibility for a legal decision on whether to allow the withdrawal of treatment. The revival futility of medical treatment is the physician’s medical judgment, so it must reflect the judgment of the attending physician who is most familiar with the patient’s condition. As a subjective condition to allow the withdrawal of treatment, it is demanded to confirm the patient’s expression of intention. The main focus of this study is also placed on how to confirm and reflect the patient’s intention in the current situation that patients’ patient’s expression of intention is not reflected in the refusal of life-sustaining treatment for various reasons. What is most important as a precondition for the withdrawal of life-sustaining treatment is following the patient’s autonomous demand. In case a patient has lost abilities to judge, decide and express the decision, the outcome of any decision made by a third person is irreversible, and in this sense, such a decision should be made prudently. At present, ‘advance medical directive’ is regarded as the best solution to clarify patients’ intention. In case there is an advance medical directive, first, the patient should have abilities to make decisions; second, the patient should be given sufficient medical information directly by the physician and decide his/her intention on specific medical treatment; and third, any written document signed by the patient toward the physician in the process of decision making as above or medical records made by the physician through the process of medical treatment should be reviewed clearly at the time of the withdrawal of treatment. On the other hand, some oppose the introduction of the advance medical directive system for the reason that the abuse of advance medical directive may rather pose a risk to patients’ life, but as long as there is no other institutional device, it is considered valid to introduce the system fittingly to the current situation of Korea. In Korea, moreover, presumptive intention is emphasized because most of patients lose their mental capacity without expressing an explicit intention. If a patient’s actual intention can be confirmed objectively based on indirect evidence by a method of confirming the patient’s presumptive intention, the confirmed intention should be followed. A patient’s intention to withdraw treatment may be presumed in consideration of the patient’s advance expression of intention, personality, value, religious view, intimacy to the family, life attitude, age, expected survival period, clinical condition, etc. For a patient under disability to express intention whose intention cannot be confirmed, on the contrary, it is controversial whether it may be admitted if the withdrawal of life-sustaining treatment is demanded for such a patient. In case of the withdrawal of life-sustaining treatment for a minor or a neonate, it will be desirable to obtain consent from the person in parental authority or the legal representative in deciding the withdrawal of treatment. This may be regarded as the exercise of parental authority, and if there are two or more persons in parental authority, an agreement among them will be required. Brain death is a state that the brain has been damaged irreversible and thus is irrecoverable, but a vegetative state is different from brain death and has a possibility of recovery, though very low. Those who have been in a coma for over a year occasionally recover consciousness. Medicine cannot make a decision with absolute confidence. For patients in a persistent vegetative state and receiving long-term special life-sustaining treatment such as artificial respiration or dialysis as well, continuous discussions are necessary on whether to continue treatment. However, patients in a persistent vegetative state sustaining their life by ordinary life-sustaining treatment should not be subject to the withdrawal of life-sustaining treatment. If the family requests the withdrawal of life-sustaining treatment such as the withdrawal of nutrition supply for any special reason, this should follow the court’s decision. In this way, if a patient does not have abilities to approve or even his/her presumptive intention cannot be confirmed, the withdrawal or continuance of life-sustaining treatment should be decided by considering the patient’s best interests objectively.