赤ちゃんの看取りの医療 : 淀川キリスト教病院における倫理的、医学的意志決定のガイドライン <特別論文>

近代医療技術(テクノロジー)の急速な発展により多くの生命が助かるようになってきた一方,回復不能な末期患者に対しても機械的な延命が可能な時代になってきた.このことは新生児医療の分野でも例外ではなく,「How small is too small?」(超低出生体重児の成育限界)というような「やりすぎの医療」と「やらなすぎの医療」の境界を探るNICU(新生児集中治療室)内の倫理問題がにわかにクローズアップしてきた.今回,NICUで大きな問題になっている「やりすぎの医療」に対する治療中止の倫理的根拠を考察すると同時に,当院の倫理委員会で承認を受けた「倫理的,医学的意志決定のガイドライン」を紹介する.さらに新生児の「看取りの医療」のプロセスおよびより人間らしい「緩和的ケア」の導入と今後の研究の必要性について述べる.こうした倫理問題は,ただの医療技術的なTechnical skillだけでなく,より高度なHuman skillを必要とする.その基本は,科学的な予後の見通しと児の最善の利益(Best interests)を倫理的根拠に,医療チームで「自分の愛する子どもであったらどのようにしてあげたいか?」,「自分であったらどのようにしたいか?」を話し合い意志を統一する.そしてその情報を法的代理人である両親に詳しく説明し,もしその選択が倫理的許容範囲内であれば彼らの希望を最大限に尊重し,「緩和的ケア」も含んだ最適な医療の選択を専門的にサポートすることにあると思われる.

Recent rapid advances in medical technology, such as mechanical ventilation and other changing technology, make it possible that many patients at in life-threatening conditions can survive without any sequelae. On the other hand, it also becomes possible that the lives of terminally-ill patients can be artificially prolonged by mechanical measures. This fact is not an exceptional event in the field of neonatal medicine. In recent years ethical problems in NICU have come into the forefront with such searching questions raised as "how small is too small?" in terms of "excessive treatment" or "too little treatment". In this paper, the ethical ground for decision-making is described in regard both to the withholding of treatment or the withdrawing of "excessive treatment" for neonates with life-threatening circumstances. Also introduced are the guidelines for ethical and medical decision-making which have been approved by the ethical committee of our hospital, The procedure for this decision-making in such cases is also explained. These ethical problems require more sophisticated humane skills, rather than technical skills alone. The ethical decision-making is based on a scientific perspective of the prognosis and the "best interests" of the infant. It is vital to consider as a team, "What is the best treatment for this infant, if he or she were my lovely baby or if I were him or her". If the parents' wishes and the informed choice of palliative care are ethically acceptable, they should be professionally supported by the team. For neonates in a clinical situation with life-threatening conditions, further developments and research of the best medical care should be carefully investigated.