医患关系的形成与扩展:对美国法上几则新近案例的释读

在美国法中 ，存在医患关系是主张医疗损害赔偿的一个先决条件。医患关系是一种基于双方自愿的契约关系。医生没有直接接触患者并不妨碍医患关系的建立，医疗建议可以启动医患关系。与一个想分娩健康婴儿的孕妇形成医患关系的医生也与胎儿形成了医患关系。与医生这一职业人员存在相互关系的人可包括没有与职业人员建立严格/直接的契约关系的人群。医生的注意义务可扩展到与其不存在直接的医患关系但存在特殊关系的非患者。如果通行的注意标准所创设的义务明显有益于某些可以确定的第三方，该第三方处于可预见的危险区域，而医生知道此类第三方的存在，那么医生的义务将指向该第三方。当医生仅仅提供检查而没有对受雇者提供医疗和照护时，医生与被检查人员之间不存在医患关系。     

浅论医疗损害鉴定之医疗注意义务评价

医疗注意义务要求医务人员在诊疗活动中做到高度谨慎和注意，避免给患者造成不必要的危险或伤害。医疗损害鉴定中，诊疗规范是评价医务人员是否尽到注意义务的客观标准；个体化医疗考虑患者的不同因素，体现相同疾病的不同患者的不同注意义务，是主观标准，且要求更高。个体化医疗中未能考虑不同患者的个体化因素，是医务人员未尽注意义务的主要原因，但过度严苛要求医务人员的注意义务反而会使过度医疗问题更加严重。过度医疗超出患者病情的需要，增加患方负担，造成医疗资源浪费，损害社会医疗公平，恶化医患关系。用适度医疗的标准评价个体化医疗之注意义务，考虑地域、医院、医生、患者等因素，有利于医疗的发展和患者的利益，也应当成为医疗损害鉴定中对医疗过错的评价标准。     

基于主题效价分析的医患关系影响因素探究

为考察医患关系的影响因素,研究调查河南省三个地区298名医生和220名患者,通过对所列举因素进行主题提取,形成效价矩阵,对效价进行差异检验。结果发现,医生更倾向归因于医患共情,患者强调医生的职业修养,双方都重视患者认知与情绪的作用。男性医生和女性患者更注重社会环境的影响,公立制医院医生较之非公立制医院医生更强调医学现实更不强调医患共情,本科及以下学历较之硕士及以上学历的医生更注重医患共情与政策法律保障。医患关系满意度高分组医生更注重医生的职业修养,低分组医生和高分组患者更注重医学现实的作用。探究影响医患关系的因素,对促进医患信任具有理论指导意义。     

知情同意理论中医生说明义务的构成

医疗损害赔偿范畴内的知情同意理论是从医患关系之利益依赖模式为基础而建立的 ,具有医学伦理和医疗法律、消级性和积极性等不同层面的功能。知情同意作为医患之间的权利义务关系具有整体性 ,可构成责任基础和权利请求的独立根据。而知情同意范畴内医生说明义务 ,应以其作为有效同意之逻辑前提为宜 ,将“知情同意。作为一整体性独立义务施加于医疗机构。医生的说明义务履行充分性的判断应以理性医生标准为基础 ,并充分平衡病人标准对病人利益为保护     

论医患法律关系

对医患法律关系的认识上的欠缺直接影响了人们对医患关系的认识和对医疗纠纷的处理。要正确认识医患法律关系,必须先对作为普通社会关系的医患关系有所认识。从医患关系的实际情况出发,可以将医患关系中的“医”和“患”界定为与医疗活动有直接关系的双方当事人,即医院和患者。为法律所规制的医患关系,不仅只是社会关系、道德关系,更是一种特殊的医疗服务合同关系。     

医患信任关系的特征、现状与研究展望

我国医患间的"关系信任取向"明显,医生被赋予高角色期待,不同科室、不同等级医院及城乡医疗机构的医患信任水平差异显著。近年来我国医患信任水平持续下滑,具体表现为医患纠纷与暴力事件的发生频次上升、对医疗服务满意的患者比例减少、医患彼此的评价及信任度降低等方面。已有研究集中于患者人口统计特征、心理契约、医务工作者的人格特质等个体因素对医患信任的影响,注意到医患信任具有影响医患双方态度与行为以及临床疗效的功能,然而医患信任危机产生的社会心理机制、医患信任建立和维持的过程机制仍不明晰。同时,医患信任现状评估和测量指标构建还不够健全,医患信任关系的行为决策实验设计等方面还有待加强。     

从“消费者”的角度谈患者的法律保护

患者在医患关系中居于弱者地位,其合法权益容易受到侵犯。《消费者权益保护法》修订在即,本文从分析医患关系属于民事合同关系的角度出发,认为患者应当纳入消费者范畴,具备了依据《消费者权益保护法》的规定享受医疗机构方提供医疗服务的法律地位,并在发生医患纠纷时可以获得多种途径予以救济。     

论人与自然关系的法律化

当代人与自然关系存在阻碍生产力发展的趋势,不符合社会正义原则,违背了国家在人与自然关系上必须承担的国家契约义务;第三次法律革命的直接结果就是人与自然关系成为法律调整的对象。在此基础上,本文论证了法律调整人与自然关系的正当性和必要性。     

医疗行为中的注意义务

注意义务是医疗行为之核心,亦为判断医疗侵权责任之核心,各国关于过失的判断标准大抵都是是否违反注意义务,医疗行为之注意义务的依据不在少数,例如有关医疗侵权之法律法规、临床医疗准则、医疗惯例、因医疗契约所生之注意义务等等。注意义务的具体内容又分为诊疗义务和说明义务,而诊疗义务中的医生裁量权是为医疗侵权责任讨论之要点,说明义务中的各项内容均为现代医学与法学重视之焦点。     

论医患关系是民事法律关系中的合同关系

本文从民法的角度全面论述了医患关系的法律性质为民事法律关系中的 合同关系,阐述并分析了医疗合同的订立与生效以及医患双方的主要权利与义务,并对医疗合同的特点作了系统性地论述。     

医患关系与消费者-经营者关系:揭开争论的面纱

本文针对争论多年的医患关系是否是消费者-经营者关系的问题,以现行法为依据展开讨论。文章首先讨论了"医患关系"和"消费者-经营者关系"的法律含义,以确定这两个范畴间是否存在交集;接着列举并系统地辨析了持肯定观点者和持否定观点者各自的论据。之后,文章探讨了若患者是消费者,将会对患者的权利和医疗机构的义务和法律责任造成的影响;最后从法律政策的角度分析法律是否应当认可患者的消费者地位。     

论注册会计师不实财务报告的民事责任

注册会计师因过失出具虚假财务报告而致第三人受损的,应作为独立的责任主体对第三人承担责任,此种责任的归责原则为过错推定。独立审计准则是行业协会的内部自律性规则,不能作为认定会计师过错的法定标准,应以“职业注意义务”作为衡量会计师过错的标准,会计师一旦因故意或过失出具不实财务报告,应认定与委托人构成共同侵权,对第三人承担连带赔偿责任。     

The need to know versus the right to know: privacy of patient medical data in an information-based society

"Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."(1) "Safeguards to privacy in individual health care information are imperative to preserve the health care delivery relationship and the integrity of the patient record."(2) As early as the fourth and fifth centuries B.C., Hippocrates contemplated the importance of medical information to the care and treatment of patients. His oath suggests that privacy of a patient's medical information creates the foundation upon which a patient reposes trust in his or her physician. While defining the earliest version of the physician-patient privilege, the oath does not envision the extent of modern day access to healthcare information. A patient's relationship with the modern healthcare delivery system often includes a team of physicians, nurses, and other clinical support personnel. This relationship extends beyond direct caregivers and may include healthcare administrators, payor organizations, and persons unfamiliar with a patient's identity, such as researchers and public health officials. Accessing a patient's medical information links these participants to the patient's healthcare delivery relationship. The Hippocratic Oath does not contemplate such broad access, nor does it contemplate the emerging privacy crisis resulting from the application of computer technology to medical record storage and retrieval. The combination of broad access, individual privacy rights, and computer technology requires a rethinking of measures designed to protect the realities of the modern medical information society.     

韩国的医师说明义务与患者知情同意权

医师的说明义务与患者的知情同意权是医疗关系的核心内容,并成为医疗责任认定的主要依据。韩国对于这一对权利义务关系的认识经历了从传统医疗模式向人道模式的转变,使得患者从医疗关系的客体转变为主体。这一转变不仅改变了患者的地位,更体现出法律的进步。然而,单纯强调患者的知情同意权将会导致医师实施保守治疗,因此,平衡医师的说明义务与患者知情同意权之间的关系显得尤为重要。     

Competition among physicians, revisited

Ten years ago we developed a model of demand inducement in the physician services market and explored the properties of that model. We found that predictions concerning physicians' prices, workloads, and income were ambiguous and in many cases were consistent with those derived from a standard monopoly pricing model. Spurred in part by our work, numerous empirical studies of the demand inducement model have been conducted. These studies found little evidence of demand inducement for primary care physician services. Demand inducement may exist in the market for surgical services, but its extent is less than previously estimated. We disagree with those who say that physicians generate demand to avoid price controls and that national health care spending is proportional to the number of physicians; the evidence does not support these arguments. Substantial uncertainty may surround the physician's choice of diagnosis and treatment mode. However, this does not imply a breakdown of the agency relationship. In this paper we extend our earlier model of demand inducement to include variations in the quantity of services (which was previously assumed to be less than socially ideal). Using the model, we conclude that the major objection to government price setting is not that physicians will get around the controls by inducing demand; rather, price controls result in a quantity and quality of physicians' services that is not ideal and may be inferior to those provided in an unregulated monopoly.     

Ethics and AIDS: a summary of the law and a critical analysis of the individual physician's ethical duty to treat

Persons afflicted with acquired immune deficiency syndrome (AIDS) or its preceding medical conditions face a potential problem with assured access to basic threshold medical care. Subject to certain limitations, there is no guarantee that a physician will fulfill the health care needs of any population of patients. Individuals with AIDS, thus, have a considerable interest in the development of a duty on behalf of physicians to provide treatment. This Note first highlights the limits of the legal duty to treat. It then examines the theoretical impetus propelling an ethical duty to treat. The Note concludes that the grounds for imposing an ethical duty on physicians are too weak to support that result, but the creation of an AIDS-specific legal duty is a viable alternative.     

Ensuring Insurance for Foster Care: Requiring Foster Parents to Obtain Liability Insurance to Cover Harm Done to Foster Children in their Care

This Note proposes that all states should require that foster parents have liability insurance before children are placed in their care. This Note also proposes that the liability insurance needs to cover not just harm to third parties but also harm to the foster children through the negligent acts of the foster parents. This legislation will allow foster children to have standing to bring claims against their foster parents and insurance companies and give them a greater opportunity for recovery. Currently, the policies and statutes governing the policies in place do not cover all types of harm that can occur during the foster parent–child relationship. Certain policies leave children who are harmed by their foster parents’ negligence unable to recover any damages from the people who have harmed them. Because foster parents can be left to defend the actions themselves, they often become judgment proof due to their low income, leaving the children who are harmed with little chance of recovery.

Key Points for the Family Court Community:
• States need to require foster parents to obtain liability insurance, which covers harm done by the foster children to third parties, harm to the home, and any harm done to the child by the foster parents.

     

Futile treatment: the need for legislation and uniform policies

As a matter of social policy, providers should place a top priority on educating colleagues and the public, including lawyers and the courts, so that there is genuine understanding that certain medical conditions, like anencephaly and brain death, cannot be ameliorated, changed, or improved through medical treatment even though the patient may continue to breathe with mechanical assistance for years. If health care professionals do not articulate and adhere to clear, universal standards of practice in this area, the courts will continue to define the duty of the medical profession, and, as Baby K illustrates, that is not acceptable.     

论行政审批与合同效力——以外商投资企业股权转让为线索

行政审批在性质上为行政许可,而非行政确认,由此决定行政审批为合同生效的必要条件,而非充分条件。在须经行政审批的场合,未经审批的合同为未生效合同,而非无效合同。未生效合同不能产生履行的效力,但并非不具有任何法律约束力,合同依法成立后,负有报批义务的一方应依照合同的约定或者法律的规定履行报批的义务,否则,即应承担相应的违约责任。对此,无论从解释论的角度进行分析,还是从立法论的角度进行分析,都可以得出大体相同的结论。考虑到解释论的思路过于曲折,从立法论的角度来探讨这一问题的解决就显得尤为必要。     

TRICARE: certified mental health counselors. Interim final rule

This rule is submitted as an interim final rule (IFR) in order to meet the Congressional requirement set forth in the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2011, Section 724, which required the Department of Defense to prescribe regulations by June 20, 2011, to establish the criteria, as had previously been studied in accordance with Section 717 of the NDAA 2008, that would allow licensed or certified mental health counselors to be able to independently provide care to TRICARE beneficiaries and receive payment for those services. Under current TRICARE requirements, mental health counselors (MHCs) are authorized to practice only with physician referral and supervision. This interim final rule establishes a transition period to phase out the requirement for physician referral and supervision for MHCs and to create a new category of allied health professionals, to be known as certified mental health counselors (CMHCs), who will be authorized to practice independently under TRICARE. During this transition period the MHCs who do not meet the requirements for independent practice as established in this rule, may continue to provide services to TRICARE beneficiaries under the requirements of physician referral and ongoing supervision. This transition period, ending December 31, 2014, will allow time for those MHCs who seek to continue providing services under the TRICARE program to meet the independent practice requirements as outlined in this notice. After December 31, 2014, the Department of Defense will no longer recognize those mental health counselors who do not meet the criteria for a CMHC and will no longer allow them to provide services even upon the referral and supervision of a physician.