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1、医疗损害赔偿若干问题研究 摘 要随着医疗纠纷的激增以及人们维权意识的不断高涨,医患纠纷逐步成为社会的热点问题之一。如何平衡医方与患方之间的利益,既保护医疗机构和医务人员正当的医疗权,同时又保障患者及家属的合法权益是公平、合理解决医疗纠纷的关键,也是医疗损害赔偿问题研究的核心所在。医疗损害赔偿本质上仍属于民事责任范畴,用民事赔偿法原理解决该问题能够有效避免行政立法的尴尬,充分维护患方合法权益。本文主要采取综合比较和文献研究方法,通过借鉴国内外民法理论成果,拟从责任的性质、归责原则、构成要件、举证责任和赔偿范围等方面分析医疗损害赔偿的特点,并结合现行法律、法规对完善我国医疗损害赔偿制度阐释了自己的
2、观点。 全文约三万一千余字,共分五个部分。 第一部分医疗损害的概念。该部分从介绍医疗事故概念的演变、分析其缺陷入手,提出用医疗损害替代医疗事故有助于囊括医疗活动中患方所有合法权益受损害的状态。依据损害的定义和特征,对医疗损害定义的内涵、外延及特征进行归纳。本文认为,医疗损害是指在医疗活动中,因医疗机构及医务人员的过错给患者或家属的人身和财产等合法权益造成的不利益的后果和事实。 第二部分医疗损害赔偿责任。主要分析医疗损害赔偿责任的性质、归责原则和构成要件等。该部分首先提出理论界关于医疗损害赔偿责任的性质的三种不同的观点,对这三种观点进行分析,从而提出本文主张?侵权责任,并指出医疗侵权实际上已成为
3、我国民法上特殊侵权责任的一种。无过错责任已被一些国家运用到医疗损害赔偿的立法和司法活动中,但我国尚未建立完善的责任保险制度,缺乏适用无过错责任的现实可能性,因此仍应坚持过错归责原则,并提出医疗损害中的过错推定原则。本文将医疗损害赔偿责任构成要件分为三项:损害事实、过错和因果关系。其中认定医疗过错的标准是有无违反同等条件下通常医疗机构及医务人员应当承担的注意义务(医疗水准),在应用医疗水准这个抽象判断标准时要注意考虑医疗的专门性、地域性、紧急性等因素;认定因果关系则可从事实上和法律上两个层面进行。此外,本文在讨论医疗事故处理条例免责条款内容的基础上,提出重新构建医疗损害抗辩事由。 第三部分医疗损
4、害赔偿诉讼的举证责任分配和医疗损害鉴定。通过分析西方国家的举证责任分配理论,结合我国理论界的观点和实践,指出我国的医疗损害赔偿的侵权之诉中,采用举证责任倒置分配原则的合理性。 实践中,医疗损害鉴定是争议最多的问题,人为区分为不同的医疗损害鉴定1 是不可取的,而且医疗事故鉴定内容也无法完全满足案件审理的需要,从我国目前情况看建议统一由司法鉴定机构组织医疗损害鉴定。 第四部分医疗损害的赔偿范围。本文主张医疗损害赔偿的原则应区分情况具体采用下列原则为宜:一是对患者所造成的直接损失实行全额赔偿原则,损失多少赔偿多少;二是对患者所造成的间接损失,实行限额赔偿原则;三是对患者所造成的精神损失则采取适当限制
5、原则和法官自由裁量原则,以兼顾医患双方利益。赔偿的具体范围包括直接损失、间接损失和精神损失。在医疗损害赔偿范围和数额确定之后,对如何分担赔偿责任提出自己的看法。 第五部分完善医疗损害赔偿制度的设想。本文从当前医疗损害赔偿纠纷处理现状和分析医疗损害赔偿依据的现行法律法规出发,提出在一定的法律、社会基础上,出台一部“医疗损害赔偿法”和建立医疗责任保险制度的可能。关键词:医疗损害 构成要件 举证责任 损害赔偿 2 AbstractWith the surge of the medical disputes and the people are conscious to safeguard their
6、 rights, the medical disputes become one of the hotspot problems of the societyHow to balance the interests between doctors and patients is key to solve the medical dispute fairly and rationally, It is also the key to study the medical compensation for damage .In essence, compensation for medical da
7、mage belongs to the range of civil liability. Using the principle of the civil law to Solve this problem can avoid the embarrassment of the administrative legislation effectively, and fully safeguard the patients legitimate rights and interests. This text mainly adopts the methods of comparing synth
8、etically and studying on the literature .The author attempt to analyze the characteristics of compensation for medical damage, the principle of bearing responsibility, constituent elements of medical damages liability, the burden of proof and range of compensation, etc., through drawing lessons from
9、 the achievement of the domestic and international civil law theory. At last, the author explained his own view on improving the system of medical compensation for damage of our countryThis text is about 31,000 words, and it is divided into five partsIn part one, the author explain the concept of me
10、dical damages. this Part start with introducing the variance of the conception “medical accident” and analyzing its shortcoming , and the author raise that using “medical damage” but “medical accident” is useful for summarizing all of states that patients legitimate rights and interests are damaged
11、in medical activitiesPart two, nature, imputation principles and constituent elements of medical damages liability. At first in the part expressed three different perspectives in academia about the nature of the imputation of medical damages liability, then through the analysis of those perspectives
12、 stated the point of the article, tort liability namely, and especially noted that in fact medical infringements have become one of special tort liabilities in our Civil Code. In many country no-fault liability has been applied in legislative and judicial activities for medical damages liability , b
13、ut liability insurance system in our country is poor, its feasibility lacked, so we should take the fault attribution principles, at the same time raised the view on the principles of presumption of fault in medical damageHere constituent elements of medical damage liability summarized as three: dam
14、age facts, faults and causations, in which the judgement standard on medical faults is whether the medical institutions and the medical personnel3 have violated care duty under the same conditions in usual Medical standards , moreover we should take the elements into account as follows : medical pro
15、fessional, regional, urgency etc ; while, the judgement on the causations could be considered from the fact dimension as well as from the legal dimensionIn addition, here pointed out the importance of re-configuring defences subjects about medical damages on basis of discussion about the exemption c
16、lauses in Part three, the burden of proof and identification in medical damages litigationThrough the analysis of western theory of distribution of the burden of proof , which is on basis of the viewpoints and practices in our academia, noticed the rationality of applying principles of inverse distr
17、ibution of the burden of proof in our medical damages tort litigationThe most controversial issues in practices should be the identification in medical damages, identification on medical accident has many shortcoming so in view of our current conditions the identification in medical damages should b
18、e charged by justice identify organPart four, scope of compensation for medical damages. the specific coverage of medical damages including direct damages , indirect damages and moral damages Here adocated that according to specific conditions the principles of medical damages should be takenPart fi
19、ve is about the imagination for improving the system of medical compensation for damage. The author start with the current situation of dealing with the dispute of medical compensation and analysis on current laws and regulations which are formulated for medical compensation for damage and propose t
20、hat they are possible to formulate a law for medical compensation for damage and set up the system of medical liability insurance on the basis of certain law and the social satiationsKeywords: medical damage constituent element burden of proof compensation for damage4 目 录引 言?1 1.医疗损害的相关概念?2 1.1 医疗事故
21、?2 1.2 医疗损害?4 1.2.1 损害的基本特征?4 1.2.2 医疗损害的定义?4 2.医疗损害赔偿责任?7 2.1 医疗损害赔偿责任的性质?7 2.2 医疗损害赔偿责任的归责原则?8 2.2.1 归责原则的历史演变?8 2.2.2 医疗损害赔偿责任的归责原则?9 2.3 医疗损害赔偿责任的构成要件?10 2.3.1 损害事实?10 2.3.2 过错? 11 2.3.2.1 过错认定标准理论? 11 2.3.2.2 医疗过错的认定标准?12 2.3.3 因果关系?14 2.3.3.1 因果关系理论?14 2.3.3.2 医疗损害赔偿责任中的因果关系?15 2.4 抗辩事由?18 2.4
22、.1 现行法规定及评价?18 2.4.2 医疗损害赔偿责任抗辩事由?19 3.医疗损害赔偿诉讼的举证责任分配和医疗损害鉴定?21 3.1 举证责任分配简述?21 3.1.1 德国法的“表见证明”?21 3.1.2 日本法的“大概推定”?22 3.1.3 美国法的“事实本身说明过失”?22 3.2 我国医疗诉讼举证责任分配原则?23 3.3 关于医疗损害的鉴定问题?24 4.医疗损害赔偿范围?26I 5.完善医疗损害赔偿制度的设想?29 5.1 关于设立“医疗损害赔偿法”的建议?29 5.2 建立医疗责任保险制度?30 结 论?31 参考文献?32 后 记?34 II Contentprefac
23、e?1 1. relevant concepts about medical damage?2 1.1 medical accident?2 1.2 medical damage?4 1.2.1 feature of the damage?4 1.2.2 definition of medical damage?4 2. liability of compensation for medical damage?7 2.1 the characters of the liability of compensation for meidical damage?7 2.2 the principle
24、 of imputation?8 2.2.1 variance of the principle?8 2.2.2 the principle of imputation?9 2.3 constituent elements of the liability of compensation for medical damage?10 2.3.1 the fact of damage?10 2.3.2 fault? 11 2.3.2.1 the theory of fault? 11 2.3.2.2 the standard for judging the medical malpractice?
25、12 2.3.3 the causility in the liability of compensation for medical damage?14 2.3.3.1 the theory of causality?14 2.3.3.2 the causility in the liability of compensation for medical damage?15 2.4 main content of demur?18 2.4.1 the current regulations and evaluation for them?18 2.4.2 main content of de
26、mur in the liability of compensationfor medical damage?19 3. the burden of proof and identification in the suit for medical damage?21 3.1 burden of proof?21 3.1.1 rule in germany law?21 3.1.2 rule in japanese law?22 3.1.3 rule in America law?22 3.2 burden of proof of medical damage suit in our count
27、ry?23 3.3 identification?24III 4. scope of compensation for medical damage?26 5. suggestion for system of compensation for medical?29 5.1 special law for compensation for medical damage?29 5.2 set up the system of medical liability insurance?30 Repreface?31 Refenerce?32 Postscript?34IV 引 言 引 言2002年
28、4月 4日,国务院颁布医疗事故处理条例。之后,卫生部等又相继颁布了医疗事故技术鉴定暂行办法、医疗事故分级标准试行、医疗事故争议中尸检机构及专业技术人员资格认定办法、病历书写基本规范试行等一批行政规章。这些行政法规和行政规章,在行政层面上,对医疗事故的鉴定、赔偿等都作了具体的规定。但是,这些行政法规和规章的颁布及实施并没有减少医患双方对医疗损害赔偿纠纷处理的正义性、合法性的质疑。医疗纠纷作为一个社会问题越来越在人们的视野里突显。根据中国消费者协会的统计,1996年至 1998年三年间,直接收到有关医疗纠纷的书面投诉总计 328件,1996年收到的医疗投诉每月平均 2.64件,1997年每月平均
29、10.17件,1998年每月平均 11.75件,1999年的前四个月每月平均的投诉就猛增到 22.25件,在仅仅三年多的时间内,这一数字增长了近 10倍。医疗投诉在全国消费者投诉的“愤怒”程度排行榜上位居第五位。中华医院管理学会对全国 326 所医院的问卷调查显示,医疗纠纷发生率高达98.4%。在这 326所医院中,2000年一年发生医疗纠纷索赔金额总计约 6000万元左右,平均每所医院 21万元。 迅猛增长的医疗损害赔偿纠纷不仅是当前社会热门而沉重的话题,也是人身损害赔偿案件中的热点和难点,已经引起法律界的高度关注,并成为民法上的热点问题之一,必然要求法学理论对社会实践中出现的各种新情况予以
30、理论指导,从而使医患双方的合法权利得到切实保护。本文拟从医疗损害的概念分析入手,以医疗损害民事侵权责任理论为基础,全面分析医疗损害赔偿责任的性质、归责原则、构成、举证责任,及医疗损害赔偿范围,提出应进一步完善我国医疗损害赔偿制度,从而使医疗损害赔偿纠纷得到妥善解决,免除患者就医时的各种担忧,同时又令医方敢于放手治疗而不致被患者认为侵犯了人身、财产权益,从而推动医疗卫生事业的进步。因此,对医疗损害赔偿的有关问题作深入的研究,有着重大的理论意义和实践意义。姚世新: 医患纠纷, 投诉多解决少, 中国保险报. 1999-8-17刘虹: 医疗纠纷困扰医院, 健康报. 2002-3-11 1 医疗损害赔偿若干问题研究 1.医疗损害的相关概念1.1 医疗事故 关于医疗事故的概念,国内与国外有着不同的界定。日本法中的医疗事故指在与医疗有关的场合,包括诊断、检查、治疗等医疗有关过程中,以医疗行为的接受者即患者
