卫生与法医疗过失的司法认定探析——基于243例医疗损害赔偿诉讼民事判决的数据

医疗过失是构成医疗损害赔偿责任的要件和前提,通过对243份医疗损害赔偿纠纷案件民事判决书中医疗过失的统计分析表明,我国医疗过失的判定没有统一标准,未能体现医学判断和法律判断的双重属性;医疗过失的鉴定机制二元化,医疗过失责任程度阐释不明,导致医患难以信服,破坏了我国司法统一的法治原则。《侵权责任法》实施后,应确立当时医疗水平为判定医疗过失的法律标准,建立一套可操作性的医疗过失认定规则和统一的医疗损害鉴定机制,以发挥司法处理医疗纠纷的法律功能和社会作用。     

医疗保险制度改革的新视角——基于美国医疗过失诉讼与医疗保险关联性的分析路径

医疗过失诉讼制度与医疗保险制度在制度目的与参与主体层面具有很强的同一性.医疗服务提供者在这两种制度中的不同力量以及医患双方利益的联动性是医疗过失诉讼制度与医疗保险制度相关联的纽带.医疗过失诉讼制度对美国传统医疗保险与管理式医疗保险都有明显的阻碍作用.我国医疗保险制度改革宜重视这两种制度的关联性并建议协同改革这两种制度.     

论疾病风险与医疗风险

目的：根据疾病风险与医疗风险的特征、区别与联系,探讨风险责任的公平承担原则与方式。方法：根据医学科学的一般原理,结合马克思主义哲学以及当今中国的法律制度,分析疾病风险与医疗风险各自特征、相互作用以及对患者的影响。明确不同风险的承担主体。结果：疾病风险与医疗风险既有本质区别又有必然联系,不同的风险应有不同的承担主体。医疗过错风险具有主观过失性、可能动控制性和不可避免性。医疗机构和医务人员应当只对医疗过错风险承担有限责任。结论：正确处理医患纠纷,必须分清疾病风险、医疗非过错风险和医疗过错风险,严格执行医疗过错风险责任承担制度、风险后果责任制度和有限责任制度。在保护患者合法权益的同时,注重对医疗机构和医务人员合法权益的保护,这样才有利于构建和谐的医患关系。     

论疾病风险与医疗风险

目的：根据疾病风险与医疗风险的特征、区别与联系,探讨风险责任的公平承担原则与方式。方法：根据医学科学的一般原理,结合马克思主义哲学以及当今中国的法律制度,分析疾病风险与医疗风险各自特征、相互作用以及对患者的影响。明确不同风险的承担主体。结果：疾病风险与医疗风险既有本质区别又有必然联系,不同的风险应有不同的承担主体。医疗过错风险具有主观过失性、可能动控制性和不可避免性。医疗机构和医务人员应当只对医疗过错风险承担有限责任。结论：正确处理医患纠纷,必须分清疾病风险、医疗非过错风险和医疗过错风险,严格执行医疗过错风险责任承担制度、风险后果责任制度和有限责任制度。在保护患者合法权益的同时,注重对医疗机构和医务人员合法权益的保护,这样才有利于构建和谐的医患关系。     

关于无过失医疗缺陷的思考

目前,在处理医疗纠纷中一个比较棘手的问题,就是无过失医疗缺陷的认定和定性.对病家而言,无过失医疗缺陷所造成的不良后果,无疑是一种人身损害,讨个说法,要求赔偿无可厚非.但实质上,无过失医疗缺陷又是目前尚无法解决的医学本身缺陷所造成的,要医家承担全部责任亦非公平.而在现行的<医疗事故处理条例>中,并无"无过失医疗缺陷"的有关条款,导致医疗鉴定的准确性和公正性受到影响.因此,有必要对这一类历来就有,但尚未获共识的医疗缺陷问题,做深入的思考和探讨,找出一个合理的处理方法,使医患双方权益均能得到依法保护.     

防御性医疗的法律规制探讨

医疗行为的结果存在许多不确定性,随着患者维权意识的增强以及日益紧张的医患关系,医师在临床决策中不得不采取更多的防御性医疗行为。防御性医疗行为的危害主要包括患者医疗成本增加、医疗资源浪费、妨碍医学科技发展、医患互信进一步降低等。目前我国尚无立法明确对其进行规制。本文从现行医疗法律制度与防御性医疗行为的关系、医疗行为的“可容性危险”原则适用等角度出发,重点分析了防御性医疗行为的法律属性及构成,分析比较了防御性医疗和过度性医疗、保护性医疗的异同;为防御性医疗的法律判定与认定、侵权责任的法律构成与归责原则提供建议,同时为法律制度层面规制防御性医疗提供思路。     

医疗损害责任纠纷判例分析及防范策略

目的 分析广西医疗损害纠纷案例的发生规律与基本特征,为缓和医患关系及降低医疗纠纷发生概率提供参考性建议。方法 以中国裁判文书网检索的广西2017—2021年共549份医疗损害纠纷民事判决书为研究对象,对549份判例从分布、鉴定情况、责任划分、赔偿金额四个维度进行回顾性描述性统计分析。结果 从分布特点分析,发生纠纷的医疗机构类型主要以二级以上综合医院为主,以妇产科、急诊科、骨科为纠纷高发科室;从鉴定情况分析,鉴定方式多采用医疗过错司法鉴定,法院对鉴定结果的采信度达到93.3%,判例审理平均时长约11.8个月;从责任划分分析,医疗机构承担次要责任居多,占37.5%;从赔偿金额分析,案均赔偿金额逐年增高。结论 医患关系依旧紧张,医疗机构需减少诉讼案件发生,降低诉讼赔偿。应加强医疗风险识别,强化医疗安全管理,引导人民调解,探索医疗风险分担机制,完善司法鉴定独立性与专业性,规范尸检告知,落实专家辅助人,最大限度地减少医疗纠纷与诉讼。     

论医疗过失的判断标准

本文首先分析了侵权法的过失的主观标准和客观标准及民法上过失判断标准客观化的立法趋势；接着分析了医疗行为的法律性质和法律特征，并探讨了医疗责任的法律基础和法律本质，医疗责任的法律基础是过失，法律本质是侵权责任；然后进一步探讨了医疗过失的判断标准问题。医疗过失的判断标准是客观标准，同一专业通常合理医护人员的注意义务是医疗过失的判断标准；最后具体探讨了医疗法规、医疗指导准则、医疗实践惯例、医疗水准等因素与医疗过失判断的关系。     

某大型综合医院非医疗过失性医疗纠纷的原因分析和对策

近年来,医患关系日趋紧张,医疗纠纷大幅上升,其中非医疗过失性医疗纠纷所占比重明显大于医疗过失性医疗纠纷。本文就某大型综合性医院2006-2008年发生的医疗纠纷进行分析,了解非医疗过失性医疗纠纷形成的原因,探讨防范非医疗过失性医疗纠纷的有效措施,促进和谐医患关系的构建。     

医疗缺陷的成因及防范措施

随着医院改革的深入和利益格局的调整,涉及到患者利益的各种问题层出不穷,在各类医疗投诉和纠纷中,由医疗缺陷引发的纠纷占各家医院相当高的比例。医疗缺陷（Medical Defect）是指在医疗行为过程中造成患者人身损害的医疗不当、过失、差错。广义的医疗缺陷,可包括诊断缺陷、手术与操作缺陷、用药缺陷、查房缺陷、护理缺陷、营养缺陷、院内感染控制缺陷等。此类缺陷未明显违反医疗规范和技术常规,且与患者本次发生的不良后果不存在直接因果关系,故不构成医疗事故。这类医疗缺陷由于被鉴定为非医疗事故或医患双方通过协商解决而被忽视,但其潜在的危害性是显而易见的,     

某市167例法院受理医疗损害责任案例成因分析与防范

目的探讨医疗行为不当所致医疗损害的成因及防范对策。方法回顾性分析某市2006-2016年167例法院公示的医疗损害责任案例,从司法视角探讨医疗行为不当所致医疗损害的成因、责任界定及赔付原因。结果三级医院出现的医疗损害责任纠纷案件多于一、二级医院,外科出现的概率偏高;由医学会开展的医疗损害鉴定其确认医院有因果关系的比例(68.97%)低于司法鉴定者(95.65%),两组之间存在显著性差异(P0.01);外科操作不当、侵犯患方知情权、漏诊、病历质量缺陷、误诊误治是导致医疗纠纷的主要原因。结论加强围术期并发症的防控,保护患方知情同意权和隐私权,防范误诊漏诊,持续加大院、科两级质控管理力度,健全医疗安全与风险管理体系,基于信息化平台织密医疗质量督查与医疗安全风险防控网,是降低医疗损害责任纠纷的关键。     

医改后社区卫生服务面临的机遇和挑战

为了解医改对病人求医意向的影响,医改是否会提高社区卫生服务的利用率并成为社区卫生服务新的发展机遇,我们调查了四川大学华西医学中心附属第一医院的门诊病人203名,结果表明,医改后病人选择医院看病的意向发生了变化,医改前,无论是看大病,小病,患者主要选择定点医院看病,医改后对小病主要选择不看病,自己买药,自我医疗或到大医院看病药店取药（61%）;其次为在单位的职工医院看病（17%）,看大病主要选择省级医院就医,表明医改后病人并未因费用负担形式的变化主动选择社区卫生服务中心就医,调查显示,社区卫生服务目前存在的主要问题是病人对其不了解,认为其技术水平低,不信任及费用问题等,针对存在的问题,文章分析了医改给社区卫生服务带来的机遇及挑战,并提出应该采取措施,抓抓住机遇,推进社区卫生服务的向前发展。     

Product liability

In these days of increasing legal actions against the medical profession, it is important for doctors to take heed of new regulations which affect the practice of medicine. The new Consumer Protection Act of 1987 covers product liability. This chapter stresses the importance for doctors of following the guidelines already laid down by the profession.     

The malpractice crisis in obstetrics and gynecology: is there a solution?

The malpractice ripoff began when the no-fault automobile accident law was passed. Many lawyers were in a panic at this time and turned to medical malpractice litigation to make a living. It became the conduit to quick wealth. The patient was the loser, the lawyer the winner, and the physician often devastated by the patient''s ingratitude. For a patient-plaintiff to maintain a successful lawsuit for medical negligence against a physician, four elements must be alleged and proved in a court of law: duty, breach of duty, causation, and damages. Each must be proved by a patient to prevail against a physician. Since this is very difficult to do, the lawyers have subtly brought in a new approach called maloccurrence. This is defined as a bad outcome unrelated to the quality of care provided. The lawyers need not prove the four elements to win a malpractice case; many are won on deceit and in violation of the law by introducing the concept of maloccurrence. Not only are tort reforms needed but out of court alternatives must be mandated by law or our health care delivery system will be destroyed. Government interference and the malpractice ripoff has had a devastating effect on the talent attracted to medical school, and the number of applicants is falling rapidly. The medical malpractice crisis could soon be translated into a health delivery service crisis. Concerned citizens must join together with the medical profession and leaders of the legal profession to halt this monstrous injustice. The litigation milieu has not only paralyzed the health care industry but it has had a devastating effect across the board on the way Americans live and do business. It must be solved now for justice delayed is justice denied.     

Complaints, shame and defensive medicine

While the complaints process is intended to improve healthcare, some doctors appear to practise defensive medicine after receiving a complaint. This response occurs in countries that use a tort-based medicolegal system as well as in countries with less professional liability. Defensive medicine is based on avoiding malpractice liability rather than considering a risk-benefit analysis for both investigations and treatment. There is also evidence that this style of practice is low quality in terms of decision-making, cost and patient outcomes. Western medical practice is based on biomedicine: determining medical failure using the underlying, taken-for-granted assumptions of biomedicine can potentially contribute to a response of shame after an adverse outcome or a complaint. Shame is implicated in the observable changes in practising behaviour after receipt of a complaint. Identifying and responding to shame is required if doctors are to respond to a complaint with an overall improvement in clinical practice. This will eventually improve the outcomes of the complaints process.     

Standard of care and liability in medical malpractice litigation in Japan

Although the incidence of medical malpractice litigation is increasing in Japan, it remains unclear whether medical malpractice litigation gives doctors and hospitals, an economic incentive to provide high-quality medical care by requiring that they compensate patients for harm caused by negligence. Therefore, to evaluate whether the medical malpractice litigation system contributes to the delivery of high-quality medical care, we first analyzed the decisions made in medical malpractice cases between 1986 and 1998 in ten district courts (n=421). We found the following results: (1) the probability that patients received compensation and the amount of compensation received, increased with the level of negligence, for all injury severity levels; (2) the significant predictors that a case would be decided in favor of the patient were the patient's legal basis (P=0.00) and the severity of injury (P=0.02). Although, it seems that Japanese medical malpractice litigation gives doctors an economic incentive to avoid delivering substandard medical care, since both the severity of injury and negligence were significant predictors, medical litigation in Japan might in fact corrupt the compensation process by creating an adversarial atmosphere.     

医疗纠纷处理模式的若干问题探讨

目前,医疗纠纷的数量急剧上升,现有的法规已难以适应形势的发展,医疗事故鉴定结论的公正性日益受到患者的质疑,其提出的高额赔偿要求已远远超过各省市现行规定的标准。医院管理者作为解决医疗纠纷的一线人员,普遍感到现有法规已难以操作。本文提出以完善立法为基础的几项改革措施：（１）成立卫生法庭（２）建立医疗风险保险（３）加强以行医执照的基础的行业管理（４）加快养老、医疗、残疾等社会保障制度的综合改革步伐。以此     

Defensive medicine during hospital obstetrical care: a byproduct of the technological age

This paper presents an alternative perspective on defensive medicine. Defensive medicine is usually understood as arising from the effect of law on medicine through fear of litigation. Of equal significance, however, is the complementary influence of medicine on law through technological innovation, and, more importantly, the way that medicine and law develop dialectically. Each shapes the other in establishing the standards of care central to both clinical medicine and to actual or potential legal action. Excessive testing owing to fear of litigation indicates that defensive medicine is being practised in a particular setting, but it does not explain why this is so. To understand why defensive medicine occurs and why it is so troubling to clinicians requires an understanding, not only of medical and legal developments, but of a political-economic system and the beliefs and values of a society. Defensive medicine is discussed in relation to hospital obstetrical scenarios commonly associated with fear of litigation: fetal oxygen deprivation ("distress"), which is detected using an electronic fetal monitor, and prolonged labor, known as "dystocia". The material presented is taken from a medical anthropological study of obstetrical care in rural British Columbia, Canada. Litigation fears are shown to result less from rare, albeit often devastating, allegations of malpractice than from doctors adopting a role as "fetal champions", together with the introduction of electronic monitoring technology. The paper concludes by asserting that, rather than being in an adversarial relationship, medical practice and associated litigation primarily work together to reinforce each other, and the social conditions in which defensive medicine occurs.     

医疗纠纷处理适用法律回顾及展望

近几年关于处理医疗纠纷如何适用法律的问题众说纷纭。一种观点认为，医疗纠纷的处理应当适用行政法律，法规，第二种观点认为，应当按民事法律法规来处理；第三种观点认为，医患关系是一种独立的法律关系，医疗纠纷的处理应当有独特的处理原则和方式。此外，我国刑法也对医疗事故罪和非法行医罪做出了明确规定。随着我国医疗卫生体制改革的深入，医疗纠纷的处理必将走向多层次，多元化。     

The medical malpractice crisis: what is the cause? Is there a cure?

Medical malpractice liability insurance premiums have been escalating for years and are at an all-time high. Malpractice reform is highly contentious with doctors, insurance companies, and other business interests lobbying to shield themselves from the high cost of lawsuits and multi-million dollar awards, and trial attorneys and patient advocates claiming that suing is the only recourse for people harmed by the healthcare system. Until the courts, lawmakers, and/or insurance companies agree on a solution, however, there are several things a practice and its administration and physicians can do to minimize the occurrence of a malpractice lawsuit. In addition to practicing sound medicine, physicians and their staffs must follow sound business policies and customer service procedures in their practices.