论医疗过失诉讼机制

医疗过失诉讼不同于一般的过失诉讼。它的基本特征有医疗过失认定的专业性、医疗损害事实认定的复杂性以及医疗损害因果关系判断的多元性。在司法实践中,存在证明责任的医患两难性、过失认定的不确定性以及审判中的医疗技术制约性。医疗过失诉讼导致的防御性医疗非常普遍、并给患者与社会带来了诸多负面影响。医疗过失诉讼机制的运用需要慎重。     

美国医疗过失诉讼制度改革及其借鉴

高发的诉讼频率、高额的赔偿金额、高昂的制度成本、有限的制度效果以及对医疗责任保险、健康保险和医疗服务提供者产生的负面影响是美国政府改革医疗过失诉讼制度的主要成因。为此,美国各州如加利福尼亚州积极采取各种措施,推动医疗过失诉讼制度改革,取得了一定效果。为应对各种新旧问题,美国针对医疗过失诉讼制度的下一步改革将会集中在提高医疗诉讼进入法院的门槛、增加患方胜诉的难度、限制医疗损害赔偿金的无序增长以及变革传统的医疗侵权责任等方面。我国应重视医疗过失诉讼制度对健康保险的负面影响,改革开放式的医疗过失诉讼制度,推进医疗损害赔偿特别立法并适度限制赔偿金的额度。     

“事实自己说明”在英美医疗过失诉讼中的应用——兼与我国医疗侵权的举证责任分配相比较

在英美过失侵权中,通过“事实自己说明”原则的适用,推断出被告具有过失,举证责任转移至被告。在医疗过失案件中,“事实自己说明”适用于不需要专家证据,“一般人通过常识即可推断出被告具有过失”的情形。在我国医疗侵权诉讼中,实行的是双重推定。比较“事实自己说明”与双重推定,我国的双重推定违背了侵权法的预防与补偿功能。导致防御性医疗的出现,不利于医患关系的和谐。建议修改我国的双重推定制度,仅对于不需要鉴定即可推断被告有过失的简单情形,才可实行过失推定。     

侵权法视域下医疗过失认定标准的完善-兼论循证医学在医疗过失认定中的地位

医疗侵权诉讼中医疗过失的认定始终是一个热门而且沉重的话题。我国《侵权责任法》在医疗过失认定中坚守了“过错责任原则”,但由于规定较模糊和缺乏阐释,法官对依照何种标准认定医疗过失陷入了困境。有鉴于此,本文在科学界定医疗过失概念的基础上,考察了域外法医疗过失认定的抽象标准和具体标准,阐述了域外法理论和实务中循证医学在医疗过失中的优势和地位,最后结合我国现行的医疗过失认定标准的规定,从医疗过失认定抽象标准的完善、注意义务类型化和文本化、确立循证医学的证据地位、注意医疗过失认定标准和现有法律制度的衔接四个方面提出了建议和对策,以期为实务中医疗侵权诉讼的合理解决提供理论上的依据。     

眼科学实践中医疗过失

传统观念认为眼科是低风险的科室 ,但随着公民法制观念加强 ,许多以前未曾注意到的眼科医疗过失出现 ,涉及眼科诊疗的各个环节如眼科疾病的误诊、漏诊 ,未彻底实施告知义务 ,手术麻醉问题 ,手术中的过失等 ,都可以引起医疗诉讼。眼科医生应重视诊疗过程中的每一环节 ,以防范医疗过失的发生。     

眼科学实践中医疗过失

传统观念认为眼科是低风险的科室,但随着公民法制观念加强,许多以前未曾注意到的眼科医疗过失出现,涉及眼科诊疗的各个环节如眼科疾病的误诊、漏诊,未彻底实施告知义务,手术麻醉问题,手术中的过失等,都可以引起医疗诉讼.眼科医生应重视诊疗过程中的每一环节,以防范医疗过失的发生.     

论医疗美容案件中原告适格的扩张

目前由于缺乏法律上的完善的规定,我国的美容市场相当的混乱,严重损害了消费者的合法 权益.我国在立法上,对于与医疗美容相关的诸多方面的规定都是空白,并且,无论是<医 疗事故处理办法>还是<消费者权益保护法>都有不合理的地方,同时,执法水平也受执法 人员的数量和素质所限,不令人满意.而医疗美容是风险较高的行业,并且一种美容手段的 采用,不仅消费者个体利益受到侵害,还可能会涉及多数消费者共同利益受到损害.这样,医疗美容诉讼就具有了现代型诉讼的特点.所谓现代型诉讼是与传统型诉讼的对称,是超越 个人利害关系、涉及一般公共利益的纠纷而发生的诉讼.如:大规模使用注射硅胶隆胸而造 成女性身体受到损害的案件就可以被归入现代型的诉讼.本文限于篇幅,结合现代型诉讼的 要求和我国美容业的现状,仅就医疗美容案件中诉讼制度亟待完善的一个方面--"原告适格的扩张"进行以下理论探讨.     

“生前预嘱”概念体系梳理及立法选择

我国目前正处于生前预嘱概念推广阶段,尚未建立生前预嘱制度及预先医疗指示制度,因此需要我们在立法前做好充分的理论准备。首先要重视生前预嘱概念的准确性,"生前"的表述并不准确,应予重视概念所属制度体系的逻辑性、合理性。有些学者的理论表述并不严谨,将预先医疗指示与生前预嘱等同,其实这对概念是包含与被包含的关系,在对制度进行立法选择时要坚持正确的理论基础。我们还要重视制度内容上的一些特别问题,如孕产妇的生前预嘱效力问题,以及生前预嘱的灵活适用问题,为我国相关制度的立法选择提供帮助。     

医疗诉讼证据问题研究

诉讼的关键在于证据本身及其规则。一般来说,解决医疗诉讼的方式是：通过对各种医疗诉讼证据的运用来认知医疗争议事实。从而认定争议事实的客观真相,以此分辨出这争议事实中的是与非。从而顺利解决该纠纷;当出现证据不足或者证据灭失而导致无法认识医疗争议的客观真相时,就只能依靠医疗诉讼中证明规则来解决纠纷。病历真实、客观的疑问以及鉴定结论对因果关系认定的困难,使案件事实真相的认定出现障碍。应该改革病历的制作与管理,实行专家证人制度。我国现行的医疗诉讼实行举证责任倒置的证据规则,使医疗诉讼迅速增加,致使医院因赔偿导致的费用支出也大幅上涨。从而导致医疗费用的上涨以及医方为了减少医疗诉讼而采取防御性医疗措施,进一步加深了医患双方之间的矛盾。应该对举证责任倒置规则有所限制。     

论医疗告知义务——以经济学和法学为视角

医疗告知是医疗单位在医疗过程中的一项法定义务,是以患者知情同意权为其理论基础,是判定医疗行为是否存在过失的一项重要标准。我国目前医疗实践中医疗纠纷频发的主要原因在于我国医疗告知义务立法不完善以及学界对医疗告知义务研究甚少。文章以经济学和法学为视角,从医疗告知义务之经济学基础、医疗告知义务之法学基础、医疗告知义务之履行及其评判标准等方面,结合我国立法现状,就医疗告知义务进行了深入研究,以期为我国医疗实践和司法实践提供理论根据。     

Medical malpractice litigation: do the British have a better remedy?

Medical malpractice claims are filed nearly ten times more frequently in America than they are in Great Britain. British patients generally adopt a less adversarial stance toward medical malpractice than do American patients. This Article examines the British malpractice system, as compared with the American system, and explores the differences between the two, in terms of costs and fees, liability rules, statutory provisions, and judicial attitudes toward malpractice litigation. The Article also discusses British social and institutional factors, such as the "taint" of litigation and the National Health Service, and evaluates how these factors affect British malpractice litigation. The Article presents the alternative forums available to British patients in seeking satisfaction for their medical service complaints. The Article concludes with an evaluation of how these factors achieve the three societal objectives of malpractice litigation: reparation, emotional vindication and deterrence.     

The structure of medical malpractice decision-making in Japan

The article summarises the problems in the medical malpractice litigation systems in the United Kingdom and Japan, demonstrating the similarities and identifying the length of time between initiating an action and its decision and other factors responsible for lengthy litigation. Based on analysis of decisions of medical malpractice cases between 1986 and 1998 in Japan, the functioning of the Japanese medical malpractice litigation system is discussed. Lengthy litigation is shown to be correlated with outcome and implies that the Japanese medical dispute resolution mechanism favours those who can endure lengthy litigation, namely the defendants, who are physicians or hospitals. In view of the similarities between the two systems, it is likely that the same bias--that the wealthier party in the litigation is more likely to win the case--also occurs in medical malpractice litigation in the United Kingdom and Australia.     

Loss of a chance in medical malpractice litigation: expanding liability of health professionals versus providing justice to those who have lost

The loss of a chance doctrine in medical malpractice litigation is essentially based on the perceived unfairness of denying recovery to a patient when a health provider's malpractice has reduced the patient's chance of a better outcome. It is the thesis of the article that loss of a chance must the recognised at law, notwithstanding that the chance is less than even or not subject to the benefit of statistical and/or scientific proof and that each lost chance should be assessed according to the value of that chance. Varying approaches to allocating value to the chance lost are examined both historically and internationally. The author contends that the policy arguments--which include potential for increased medical malpractice litigation, tainted reputations and an increase in professional indemnity policies--are insignificant when compared to the value and quality of human life and therefore cannot be supported.     

The liability of medical directors for utilization review decisions

Managed Care Organizations (MCOs) have turned to numerous cost-containment measures to combat rising healthcare costs. One of the most common is the use of utilization review to ascertain whether a recommended mode of treatment is "medically necessary." When the medical director of an MCO determines that care recommended by a patient's treating physician is not medically necessary and not eligible for coverage (and, as a result, potentially unattainable due to cost), the stage is set for litigation. In such situations, medical directors may become potentially liable for disciplinary action by their state medical licensing board as well as lawsuits for malpractice or negligence. However, plaintiffs wishing to recover damages for improper determinations of this nature or state boards trying to discipline these physicians, face the hurdles of the preemptive force of ERISA, and state doctrines to the effect that corporations (and, derivatively, their medical directors) cannot practice medicine and therefore cannot be liable for malpractice. Conflicting decisions and opinions make it impossible at the present time to have a settled expectation regarding the potential liability of medical directors in this context, although the law appears to be moving toward the treatment of utilization review as medical decisionmaking; therefore, it appears likely that the activities of medical directors increasingly will face state oversight--including the imposition of common law liability in appropriate situations.     

Practice guidelines and malpractice litigation: collision or cohesion?

Practice guidelines are standardized specifications for managing particular clinical problems and are intended to improve the outcomes of medical care by increasing adherence to standards of care. They are also meant to make medicine more cost-effective by eliminating unnecessary procedures. A relatively recent phenomenon, the practice guidelines now emerging will have implications for malpractice, which also intends to bring about better care. They will probably not revolutionize the procedures that courts use to determine negligence, but judges will integrate guidelines into their decision-making process. This development should be welcomed. Guidelines should prove to be useful as either inculpatory or exculpatory evidence of negligence. They are unlikely to generate much new litigation, although there is some potential for suits against those who issue guidelines, especially if guidelines are not revised as the technology of medical care changes.     

Reforming the relationship between medicine and the law of tort

The Australian Government's medical indemnity package is predicated on the belief that the current crisis is primarily one of insurance. However, an examination of the fault-based tort system illustrates that, irrespective of their insurance status, doctors are profoundly affected by the adversarial process and their response to it is leading to sub-optimal patient care. This article argues that the adversarial system of medical negligence fails to satisfy the main aims of tort law, those being equitable compensation of plaintiffs, correction of mistakes and deterrence of negligence. Instead, doctors experience litigation as a punishment and, in order to avoid exposure to the system, have resorted not to corrective or educational measures but to defensive medicine, a practice which the evidence indicates both decreases patient autonomy and increases iatrogenic injury. This is unacceptable and suggests that the package has missed the point. This article proposes an alternative medico-legal tort scheme which attempts to overcome some of these problems.     

浅谈《侵权责任法》对医疗纠纷诉讼规则之影响

文章通过对两个医疗纠纷诉讼案件生效判例的分析,例举医疗纠纷诉讼中三个常见问题,即案由二元化、法律适用二元化以及举证倒置对纠纷处理的负面影响,并通过比较而探讨《侵权责任法》对医疗纠纷诉讼规则的影响。     

The unrealized potential of malpractice arbitration

Although the use of arbitration in the commercial arena has increased tremendously in recent years, there has been a reluctance to adopt arbitration of medical malpractice claims in place of litigation. After discussing the benefits of arbitration in medical malpractice cases, Professor Metzloff examines why the use of arbitration has not become predominant, discussing such factors as judicial hostility, failure of state statutes designed to encourage arbitration, and lack of hard evidence that arbitration works. Professor Metzloff then explores the future of arbitration in medical malpractice cases, citing examples from his own work experience with Duke Law School's Private Adjudication Center, and discusses attributes which would make malpractice arbitration successful in the future.     

The Effects of Medical Accidents and Litigation on Doctors and Patients*

Medical accidents and litigation can have a profound and long lasting effect on both doctors and patients. Research has shown that for doctors, working in a profession which is intrinsically stressful, the added stress of litigation and accidents is leading to considerable strain and sometimes to maladaptive and inappropriate behaviors on the part of some doctors. For many it is leading to the practice of defensive medicine. For patients the picture is not better. Some are left with no clear idea of what has happened or why they have been injured by their medical treatment. Many are left needing further remedial treatment and for some the psychological effects are akin to those suffered by victims of major disasters. In this paper we have looked at these issues and have put forward proposals to suggest how things can be improved for both doctors and patients.     

医疗纠纷处理机制的现状研究

医疗纠纷已成为困扰和影响医院正常工作,甚至威胁医护人员安全,扰乱社会和谐的问题。如何公平、公正、合法、高效地处理医疗纠纷已成为目前不容忽视的问题。本文通过协商、行政调解,诉讼和第三方调解等几种目前医疗纠纷处理机制进行分析研究,以求为更好地处理医疗纠纷提供有益的参考。