医疗损害侵权因果关系问题研究

发布时间：2018-06-29 00:59

本文选题：医疗损害侵权 + 因果关系　；参考：《华东政法大学》2015年硕士论文

【摘要】：2014年我国的医疗纠纷总数为11.5万起,作为占据侵权纠纷很大比例的医疗侵权纠纷,研究其因果关系具有现实意义。我国2010年开始生效的《中华人民共和国侵权责任法》,改变了原有将医疗侵权分为医疗事故侵权和一般侵权的格局,并对医疗机构及其内部医护人员的义务及违反义务应当承担的责任做出了更加具体的规定。本文以已有的国内外立法、理论为基础,通过对医疗损害侵权因果关系的梳理及其疑难点的探讨,来解决在医疗侵权案件的学习过程中产生的问题。为实践中处理医疗损害侵权因果关系疑难问题提供借鉴。我国法律规制医疗损害侵权相关问题的条款主要分布于《中华人民共和国侵权责任法》第七章第54至64条及《医疗事故处理条例》共74个条款。《侵权责任法》和《医疗事故处理条例》虽然针对医疗损害侵权有相当的规制,但是其针对医疗损害侵权因果关系的条文寥寥可数。鉴于因果关系是构成侵权责任的必要条件,其认定标准的确定,尤为重要。医疗损害侵权因果关系应当在事实因果关系与法律因果关系“二分法”基础上进行判断。本文所指“二分法”概括为:在判断侵权因果关系时,事实上因果关系与法律上因果关系应严于区别,前者着重于调查被告的医疗违法行为是否确实导致了原告的损害结果,是否是导致原告损害结果的实质性因素。后者需要判断即使被告的医疗违法行为是导致原告损害结果的实质性因素,但是否在法律上仍有合理的理由可以认定被告不需要承担责任或者一定要承担责任。因此,若被告的医疗违法行为与损害结果之间成立事实因果关系,但是从因果关系相当性、可预见性或者法规政策目的出发考量,需要限制被告的医疗违法行为对损害发生的责任范围时,可以减轻或者免除被告的责任。在分别判断事实因果关系和法律因果关系时,需要有以下认定标准:前者以条件说作为认定基础,以实质因素说作为辅助标准;后者以理论界较为认可的相当因果关系理论、合理可预见说及法规目的说为判断依据。在“二分法”适用于医疗损害侵权因果关系判定过程中,笔者针对以下三个较为复杂及疑难的问题展开论述并得出结论:一是医疗损害侵权因果关系不确定问题。医疗损害侵权因果关系不确定是指难以确定医疗违法行为与损害结果之间是否存在事实因果关系。笔者结合实践案例总结出因果关系不确定的两种主要表现形式:1.因共同危险行为引发的事实因果关系不确定。根据我国《侵权责任法》的规定,医疗侵权共同危险行为中,多个医疗机构的医疗违法行为造成患者损害的,若能够确定具体侵权责任方的,由具体侵权责任方承担责任,不能确定具体侵权责任方的,数个医疗机构要承担连带责任;2.因患者病情严重而引发的事实因果关系不确定。第二种情况在实践中较为常见,其关键在于“全有或全无规则”和“存活机会丧失理论”的选择问题。结合我国立法、理论、实践,笔者提出引入“存活机会丧失理论”解决因患者病情严重而引发的事实因果关系不确定问题的论点。在事实因果关系不确定的情况下,适用“生存机会丧失”理论,从另外一个视角来分析该问题,将“治愈或生存机会丧失”这一健康利益作为保护的法益进行考虑,适用“存活机会丧失理论”,其实质上意味着医护人员的违法行为与“治愈或生存机会丧失”的损害结果之间建立起事实因果关系,使原本不确定的事实因果关系确定下来,再依据比例原则判断违法行为与损害结果之间的法律因果关系赔偿责任范围。诚然,在符合“全有或全无原则”优势证据规则的案件中,一般不适用存活机会丧失理论,减轻医护人员的责任。二是医疗损害侵权因果关系中断问题。因果关系中断是指违法行为之后发生的介入原因,阻断了先前原因与损害结果之间的因果关系。因果关系中断的意义主要在于有利于寻找造成损害结果的真正原因,且可以限制因事实因果关系认定宽泛而导致的因果关系过分扩张。因果关系中断有两种情况:一是违法行为人从事违法行为,在损害没有发生之前,因为有其他因素的介入,从而使得损害没有发生或者没有按照原来的因果关系历程发生。二是违法行为人从事违法行为,由于第三人的行为或者事件的介入,导致了一种新的损害的发生。因果关系中断主要有三种事由:1.第三人行为。即第三人故意、重大过失的行为介入到因果关系的链条中,而阻断因果关系。需注意的是,可预见之第三人故意行为及第三人犯罪行为并非中断因果关系之原因。但若医护人员的违法行为提供第三人从事侵权行为机会时,第三人的违法行为仍构成中断原因,除非医护人员在违法行为时,知悉或应知悉其行为将引起某种机会,且第三人会利用此机会从事侵权行为或犯罪行为;2.自然事件。自然事件是不寻常的事件,即不可抗力、意外事件等因素的介入,阻断了因果关系的链条。但是若医护人员知悉或应知悉自然事件的发生或者医护人员利用自然事件以促使结果的发生的情况,无论该自然事件如何异常,因果关系仍不中断;3.自愿行为。患者故意使事件发生的行为可以中断因果关系。但医务人员利用自愿行为或者明知其行为足以促使结果发生的情况,因果关系不中断。三是医疗损害侵权中患者特殊体质问题。即在医疗损害侵权案件中,医护人员的医疗违法行为给患者造成的损害程度和范围,因为患者固有的某种体质特征和倾向而超过了医护人员的预期,造成了医护人员难以预料到的损害结果,此时,医疗机构应当对其违法行为造成的损害结果承担什么样的责任?学者针对此问题有三种理论:1.医护人员针对因患者特殊体质而导致的损害的扩大不进行赔偿;2.医护人员对因其违法行为引发的损害结果进行全部赔偿;3.三是医护人员与患者分担赔偿。在实践中,愈来愈多的国家对特殊体质受害人的赔偿范围应以全部赔偿为原则,会综合考量医疗机构承受能力、医疗过错行为导致损害结果的参与度、患者自身特殊体质导致损害结果的参与度及患者经济状况等因素适当分配损害责任的承担。笔者通过对三种观点的归纳总结,得出相应的结论:首先,若患者知悉其特殊体质并告知医护人员或者患者并未告知医护人员,但是医护人员尽一般的医疗注意义务应当知悉患者特殊体质。这种情况下,应当建立医护人员的医疗违法行为与损害结果之间的因果关系,医疗机构对损害结果承担责任;其次,若仅患者知悉其特殊体质,且医护人员尽了一般的医疗注意义务仍然难以知悉其特殊体质。双方都应当对最终的损害承担责任,按照患者特殊体质与损害之间的因果关系责任范围大小,进行责任分配;最后,若患者不知其特殊体质,且医务人员尽了一般的医疗注意义务也难以知悉其特殊体质,此时,法律目的偏重保护患者的利益,医疗机构对损害结果承担责任。本文运用文献分析法、文本分析法、比较法以及理论与实务相结合的应用分析方法对医疗损害侵权中的因果关系问题进行探讨研究。从事实因果关系与法律因果关系两个层次出发,透过他国的做法总结出可为我国借鉴的启示,理论与实践相结合,集中解决医疗损害侵权中因果关系不确定问题、因果关系中断问题及患者特殊体质问题。解决医疗损害侵权因果关系有极强的理论性及实践运用性,理论用于指导实践,同时为实践服务,更具有现实意义。
[Abstract]:The total number of medical disputes in China in 2014 is 115 thousand. As a medical tort dispute which occupies a large proportion of the tort disputes, it is of practical significance to study its causality. The "tort liability law of People's Republic of China", which began to come into force in China in 2010, has changed the original pattern that medical tort is divided into medical accident tort and general tort. The obligations of medical institutions and their internal medical staff and their duties should be more specific. Based on the existing domestic and foreign legislation and theory, this paper solves the problems arising in the learning process of medical tort cases by combing the causation of medical damage torts and discussing their difficult points. In order to provide reference for dealing with the problem of causation in medical damage tort in practice, the provisions of China's legal regulation on medical damage infringement are mainly distributed in the People's Republic of China tort liability law, seventh chapters fifty-fourth to 64 and 74 provisions in the regulations for treatment of medical accidents. However, there are quite a few regulations on the tort of medical damage, but there are few articles on the causality of medical damage infringement. In view of the causality is the necessary condition to constitute the tort liability, the determination of its identification standard is particularly important. The causality of medical damage tort should be "dichotomy" in the actual causality and the legal cause and effect relationship. On the basis of the judgment, the dichotomy in this paper is summarized as: in judging the causation of the tort, the fact that the causality and the legal causality should be strictly different, the former focuses on whether the medical illegal behavior of the defendant does lead to the result of the plaintiff's damage, and whether it is the substantial factor that leads to the result of the plaintiff's damage. It is necessary to judge that even if the defendant's medical illegal act is the substantial factor that leads to the result of the plaintiff's damage, whether there is still a reasonable reason for the legal reason can be found that the defendant does not have to bear the responsibility or bear the responsibility. If the relationship is comparable, the predictability or the purpose of the law and policy is to be considered, the defendant's responsibility can be reduced or exempted from the responsibility of the defendant's medical illegal behavior to the liability of the damage. The following criteria are required when judging the factual causality and the legal cause and effect relationship respectively: the former is determined by the conditional theory. Based on the theory of substantial factors as the auxiliary standard, the latter is based on the theory of considerable causality, reasonable predictability and the purpose of regulation. In the course of the "dichotomy" applicable to the determination of the causality of medical damage infringement, the author discusses the following three more complicated and difficult problems. Conclusion: one is the uncertainty of causality of medical damage tort. The uncertainty of causality of medical damage tort refers to the fact that there is no causal relationship between medical illegal behavior and the result of damage. Two main forms of manifestation of uncertainty of causality are summed up in the case of practice: 1. because of common dangerous behavior In accordance with the provisions of the tort liability law of China, in the common dangerous acts of medical tort, the medical violations of multiple medical institutions cause damage to the patient, if the specific tort liability party can be determined, the specific tort liability party is responsible and can not determine the specific tort liability party, several medical machines. 2. the fact causality caused by the patient's serious illness is uncertain. The second cases are more common in practice. The key lies in the choice of "all or all rules" and "the theory of survival chance loss". The author introduces the theory of survival opportunity loss in combination with the legislation, theory and Practice of our country. "To solve the problem of indeterminate factual causality caused by the patient's serious illness. In the case of uncertainty of the fact causality, the theory of" loss of survival opportunity "is applied to the analysis of the problem from another perspective, and the health interests of" cure or the loss of survival "are considered as the legal benefits of protection. The theory of "loss of survival opportunity" actually means that the illegal behavior of the medical staff and the result of the loss of "cure or the loss of survival" will establish a causal relationship between the cause and causality of the original uncertain facts, and then judge the legal causality between the illegal behavior and the result of damage according to the principle of proportion. It is true that in cases that conform to the "all or no principle" rule of evidence, the theory of loss of survival opportunity is generally not applicable and the responsibility of medical staff is lessen. Two is the interruption of causality in medical damage infringement. The interruption of causality refers to the cause of intervention after the violation of the law, which has blocked the previous cause and The significance of the interruption of causality mainly lies in the fact that it is beneficial to find the true cause of the result of the damage, and can limit the excessive expansion of causality caused by the broad identification of the fact causality. There are two cases of causality interruption: one is that the violator is engaged in illegal behavior, and the damage is not issued. Before birth, because of the intervention of other factors, the damage did not occur or did not occur according to the original cause and effect relationship. Two is the illegal behavior of the illegal behavior, Third People's behavior or the involvement of events, resulting in a new kind of damage. There are three main causes of cause and effect interruption: 1. third people. Behavior. That is, third persons intentionally, the act of major negligence intervened in the chain of causality and blocked causality. It is important to note that the foreseeable third person's deliberate act and the three person's criminal act do not interrupt the cause of the causation. But if the illegal acts of the medical and nursing staff provide third persons to engage in tort opportunities, third people Illegal acts still constitute a cause of interruption, unless the medical staff is aware of or should be aware of their behavior when they are in the law, and the third will use this opportunity to engage in torts or criminal acts; 2. natural events. Natural events are unusual events, such as unability, accident and other factors, blocking causality. But if the medical staff knows or should know the occurrence of a natural event or the medical staff use natural events to promote the occurrence of the result, no matter how abnormal the natural event is, the causal relationship remains uninterrupted; 3. voluntary behavior. The patient intentionally causes the event to interrupt the causality. But medical personnel use it. Voluntary behavior or knowing that the behavior is enough to cause the result to happen, the cause and effect is not interrupted. Three is the special physical problem of the patient in the tort of medical damage. That is, the extent and extent of the damage to the patients in the case of medical damage infringement, because of the patient's inherent physical characteristics and tendencies. Beyond the expectations of the medical and nursing staff, it has caused the unforeseen damage to the medical and nursing staff. At this time, what responsibility should the medical institution bear on the damage caused by its illegal behavior? Scholars have three theories on this problem: 1. medical staff do not compensate for the expansion of the damage caused by the patient's special constitution; 2. medicine. In practice, in practice, more and more countries should compensate the victims of special physique with the principle of total compensation, which will take a comprehensive consideration of the capacity of the medical institutions and the participation of medical negligence in the result of the damage. Degree, the patient's own special physique leads to the participation of the damage result and the patient's economic condition to assign the responsibility of the damage properly. Through the summary of the three viewpoints, the author draws the corresponding conclusion: first, if the patient knows his special constitution and informs the medical staff or the patient, the medical and nursing staff are not informed, but the medical and nursing people are not informed. The general medical attention obligation should be aware of the special constitution of the patient. In this case, the causal relationship between the medical staff's medical illegal behavior and the result of the damage should be established, and the medical institution is responsible for the result of the damage; secondly, if only the patient knows his special constitution, and the medical staff do the general medical attention obligation, It is difficult to know the special constitution. Both parties shall be responsible for the ultimate damage, and assign responsibility according to the scope of the causal relationship between the patient's special constitution and the damage. In the end, if the patient does not know its special constitution and the medical staff do the general medical note, it is difficult to know the special constitution, and the legal list is at this time. To protect the interests of the patients, the medical institutions take responsibility for the result of the damage. In this paper, the author uses the literature analysis method, the text analysis method, the comparison method and the application analysis method combining theory and practice to study the cause and effect problem in the medical damage infringement. From the two levels of the factual causation and the legal causality relationship. Through the practice of his country, we summarize the enlightenment that can be used for reference in our country, combine theory with practice, and concentrate on solving the uncertainty of causality in medical damage infringement, the interruption of causality and the special physical problems of the patients. It is of practical significance to serve the practice at the same time.
【学位授予单位】：华东政法大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：D923

【共引文献】