【摘要】：現(xiàn)階段,我國的醫(yī)療糾紛急劇增長,且愈演愈烈,這已成為當前的社會焦點問題,醫(yī)患關(guān)系緊張成了人們普遍的認識,醫(yī)患之間的信任降到了谷底。因此,如何在追求社會和諧的大目標下,合理、有效地解決醫(yī)療糾紛,已然成為緩解社會矛盾,維護社會穩(wěn)定的重大問題�，F(xiàn)階段醫(yī)療糾紛激增的原因有多種,其中醫(yī)療事故頻發(fā)是主要原因之一,而醫(yī)療事故中有相當大一部分是由于醫(yī)療機構(gòu)以及醫(yī)療人員違反醫(yī)療規(guī)章制度而引起的。當前,我國解決醫(yī)療事故糾紛的主要途徑是醫(yī)療機構(gòu)承擔醫(yī)療損害賠償?shù)拿袷仑熑?追究行政責任(如責令暫停執(zhí)業(yè)活動或吊銷執(zhí)業(yè)證書等)的情況相對較少,而追究刑事責任的更是少之又少,其直接表現(xiàn)就是,1997年《刑法》為了懲治醫(yī)療過失犯罪而新設(shè)的醫(yī)療事故罪在實踐中幾乎形同虛設(shè)。也就是說,過于依賴民事賠償,而忽視民事、行政、刑事責任的銜接與配合,尤其是刑法在規(guī)制醫(yī)療過失,預(yù)防醫(yī)療責任事故方面無法發(fā)揮應(yīng)有的作用,是我國醫(yī)療事故法律規(guī)制的現(xiàn)狀和問題點,同時也是無法對醫(yī)療事故進行有效的預(yù)防,從而減少醫(yī)療糾紛的重要原因。 目前,刑法在規(guī)制和預(yù)防醫(yī)療責任事故方面無法發(fā)揮應(yīng)有的作用,其原因是多方面的,因此,如何改變這一局面,不是單靠刑法就能徹底解決的問題。但是這并不意味著在刑法力所能及的范圍內(nèi)無法找出一定的解決方案。從刑法學的角度講,醫(yī)療責任事故屬于業(yè)務(wù)過失犯罪的范疇,因此,對醫(yī)療過失這一核心要件進行系統(tǒng)而深入的研究對于醫(yī)療責任事故的刑法規(guī)制而言具有根本性意義。我國刑法在分則中單設(shè)了處罰醫(yī)療過失犯罪的醫(yī)療事故罪,因此在該罪中探討醫(yī)療過失這一要件不可謂不當,這也是我國理論界的通行做法。但是,從刑法學的角度研究醫(yī)療過失的意義并不局限于醫(yī)療事故罪的認定,而且這種研究路徑導致我國對這一問題的研究缺乏體系性和深度。鑒于此,本文擬從醫(yī)事刑法的基礎(chǔ)理論角度出發(fā),緊緊圍繞醫(yī)療過失這一個要件展開較為全面、系統(tǒng)、深入的研究,而對于醫(yī)療行為及其主體的合法性、因果關(guān)系、危害結(jié)果、醫(yī)療事故鑒定等醫(yī)療事故罪中的其他問題則不予涉及,或者只在必要的限度內(nèi)予以涉及。 不同于我國大陸絕大多數(shù)學者采用的研究模式,本文試圖在構(gòu)建刑事醫(yī)療過失的理論體系的基礎(chǔ)上,對這一問題展開較為詳盡的研究。這一理論體系包括醫(yī)療過失概述、醫(yī)療過失本體論、醫(yī)療過失認定論以及醫(yī)療過失限制論等四部分。全文共分五章,除了第一章緒論和結(jié)語之外,第二至第五章分別對應(yīng)這四部分。 第一部分為醫(yī)療過失概述(全文第二章),共分兩節(jié)。醫(yī)療過失是“醫(yī)療行為”過程中發(fā)生的過失,同時,醫(yī)療行為的特征對于醫(yī)療過失的認定具有重要影響,因此,本章第一節(jié)首先探討了醫(yī)療行為的概念與特征。本文認為,應(yīng)當先將醫(yī)療行為與醫(yī)療類似行為區(qū)別開來,在此基礎(chǔ)上,醫(yī)療行為可以根據(jù)醫(yī)療目的的有無劃分為廣狹兩義。本文中的醫(yī)療行為采廣義,但由于狹義的醫(yī)療行為更具有普遍性和代表性,因此,下文中的理論探討和案例分析將以狹義的醫(yī)療行為為主。在界定了醫(yī)療行為的概念之后,本節(jié)探討了對醫(yī)療過失的認定具有重要影響的醫(yī)療行為的一系列特征,它們分別是：危險性、有用性、專業(yè)性和不確定性。 本章第二節(jié)主要探討了醫(yī)療過失的概念與分類。首先,本文認為醫(yī)療過失應(yīng)當界定為：醫(yī)療行為人在具體醫(yī)療行為過程中違反了必要的注意義務(wù)的情形。即刑事醫(yī)療過失的主體不包括醫(yī)療機構(gòu),且醫(yī)療人員在具體醫(yī)療行為過程之外違反相關(guān)注意義務(wù)的情形也不能稱之為醫(yī)療過失。其次,關(guān)于醫(yī)療過失的分類,醫(yī)療過失可以從不同的角度進行多種分類,本節(jié)選取了對醫(yī)療過失的刑法規(guī)制具有總論性指導意義的兩種分類展開了較為深入的探討,它們是：單純技術(shù)性過失與醫(yī)學判斷過失,醫(yī)療責任過失與醫(yī)療技術(shù)過失。其中,第一種分類是刑事醫(yī)療過失理論體系的基石與出發(fā)點,本文亦將該種分類貫徹于相關(guān)問題的分析和論證,即刑法應(yīng)當將單純技術(shù)性過失作為規(guī)制的重點,而就醫(yī)學判斷過失而言,刑法的規(guī)制對象應(yīng)當僅限于明顯脫離醫(yī)療水準者。 第二部分為醫(yī)療過失本體論(全文第三章),共分四節(jié)。這一部分屬于醫(yī)療過失的基礎(chǔ)理論與一般理論,它是對具體的醫(yī)療過失進行抽象與總結(jié)而形成的,因此,對于醫(yī)療過失的具體認定具有總論性的指導意義。 從根本上講,醫(yī)療過失屬于過失的一種,因此,過失犯理論的基本立場將直接決定如何分析和論證醫(yī)療過失的相關(guān)問題,以及對這些問題持何種觀點�；诖�,本章第一節(jié)首先探討了大陸法系國家和地區(qū)有關(guān)過失犯理論的基本立場,并得出結(jié)論：新過失論總體而言更具有合理性,而且也更適合分析醫(yī)療過失的相關(guān)問題。其次,我國大陸在過失犯的基本立場上不存在觀點的對立,本文經(jīng)分析認為,我國大陸的基本立場與新過失論之間更具有親和力。據(jù)此,本文從行為無價值二元論出發(fā),在全文中貫徹了新過失論的立場和觀點。 第二節(jié)緊密結(jié)合醫(yī)療領(lǐng)域(醫(yī)療行為)的特點,重點探討了醫(yī)療人員注意義務(wù)的內(nèi)容和根據(jù)。就注意義務(wù)的內(nèi)容而言,本節(jié)探討了醫(yī)療人員在各種具體醫(yī)療行為中負有的共通的結(jié)果預(yù)見義務(wù)與結(jié)果回避義務(wù),這些義務(wù)體現(xiàn)了醫(yī)療過失區(qū)別于其他過失的特殊性。就注意義務(wù)的根據(jù)而言,本節(jié)探討了與保障具體醫(yī)療行為安全密切相關(guān)的注意義務(wù)的來源與根據(jù)。 第三節(jié)主要探討了醫(yī)療人員的注意能力。本文認為,在普通過失中,注意能力的判斷標準應(yīng)采折中說,而在業(yè)務(wù)過失,尤其是醫(yī)療過失中,應(yīng)采客觀說,即能否預(yù)見和避免危害結(jié)果,應(yīng)當以行為當時一般醫(yī)療人員能夠認識的情況以及行為人特別認識到的情況為判斷資料,在此基礎(chǔ)上,以一般醫(yī)療人員能否預(yù)見和避免該危害結(jié)果為標準進行判斷。而“一般醫(yī)療人員”應(yīng)當界定為：具有相同或相似醫(yī)療條件的地區(qū)或醫(yī)療機構(gòu)中,具有相同或類似的職稱或地位的,行為人實施的醫(yī)療行為所屬的專業(yè)領(lǐng)域中的醫(yī)療人員。 第四節(jié)探討了醫(yī)療過失的判斷標準,它們分別是：醫(yī)療水準、裁量性以及緊急性。醫(yī)療水準是醫(yī)療過失的一般性判斷標準,但是應(yīng)當充分考慮醫(yī)療水準的地域性差異。裁量性作為醫(yī)療過失的判斷標準,主要適用于醫(yī)學判斷過失,從效果上看,裁量性具有限制醫(yī)療過失成立的作用。緊急性作為醫(yī)療過失的判斷標準,其作用在于緊急情況下緩和醫(yī)療人員的注意義務(wù)而適用較低的認定標準,但不是免除注意義務(wù)。 第三部分為醫(yī)療過失認定論(全文第四章),共分五節(jié)。研究醫(yī)療過失的直接目的就是為了認定某種醫(yī)療行為有沒有違反相關(guān)的注意義務(wù),因此,這一部分對于司法實踐而言,具有更直接的指導意義。醫(yī)療過失是醫(yī)療行為過程中發(fā)生的過失,因此醫(yī)療過失的認定必須結(jié)合具體醫(yī)療行為進行。但是,醫(yī)療行為種類繁多,而且隨著醫(yī)學的發(fā)展,其內(nèi)容又在不斷地被細分化,因此探討所有醫(yī)療行為過程中發(fā)生的過失顯然不現(xiàn)實。基于此,本章選取了實踐中容易引發(fā)醫(yī)療事故的診斷行為、注射行為、輸血行為、麻醉行為以及手術(shù)行為作為考察對象,對實施這些醫(yī)療行為時發(fā)生的過失進行概述之后,結(jié)合具體案例,探討了這些醫(yī)療過失的具體認定問題。具體而言,第一節(jié)的診斷過失一般包括診斷過程中的過失與診斷內(nèi)容的過失。第二節(jié)的注射過失一般包括：注射的必要性以及時機的判斷過失、有關(guān)注射液的種類以及劑量的過失、有關(guān)注射的部位以及方法的過失、注射器具的消毒過失,以及注射后的觀察過失等。第三節(jié)的輸血過失一般包括：采集血液過程中的過失與輸入血液過程中的過失。第四節(jié)的麻醉過失一般包括：麻醉適應(yīng)性的判斷過失、麻醉劑以及麻醉方法的選擇過失、麻醉過程中的技術(shù)操作過失,以及麻醉后的患者管理過失等。第五節(jié)的手術(shù)過失一般包括：手術(shù)必要性和可行性的判斷過失、手術(shù)時機的判斷過失、手術(shù)方法的選擇過失、手術(shù)過程中的技術(shù)操作過失,以及手術(shù)后的患者管理過失等。 第四部分為醫(yī)療過失限制論(全文第五章),共分兩節(jié)。以上從正面探討了何種情況下成立醫(yī)療過失,而這一部分將從反面研究醫(yī)療過失的阻卻事由。關(guān)于阻卻過失犯成立的事由,理論上一般認為有被允許的危險理論,危險分配理論以及信賴原則。就被允許的危險理論而言,醫(yī)療人員遵守醫(yī)療規(guī)章制度和診療護理常規(guī)是適用該理論的前提和核心要件,但是,遵守了這些規(guī)定時,本身就不存在客觀注意義務(wù)的違反,或者說不滿足犯罪構(gòu)成的客觀方面,因而自始不成立過失犯。也就是說,作為過失犯的阻卻事由,被允許的危險理論不具有獨立意義,因此本章將不對此展開單獨的討論。關(guān)于危險分配理論,一般認為其與信賴原則是互為表里的關(guān)系,因此,危險分配理論將寓于信賴原則之中加以展開。除了信賴原則之外,被害人的危險承受也是阻卻醫(yī)療過失的重要事由,但是學界幾乎沒有學者對此進行探討�；诖�,本章圍繞信賴原則與被害人的危險承受如何限制醫(yī)療過失的問題展開了較為深入的研究。 第一節(jié)在闡述了信賴原則在醫(yī)療過失中的適用條件的基礎(chǔ)上,重點探討了該原則在醫(yī)療過失中的適用問題�？紤]到醫(yī)師在醫(yī)療行為中的主導性地位,本文將信賴原則在醫(yī)療過失中的適用分成了三種情形進行探討,即醫(yī)師與患者之間,醫(yī)師之間,以及醫(yī)師與其他醫(yī)療人員之間。其中,第一種情形可以適用信賴原則,但其適用余地相對較小。第二種情形可以劃分為水平的醫(yī)療分業(yè)關(guān)系和垂直的醫(yī)療分業(yè)關(guān)系,前一種關(guān)系可以適用信賴原則,而在后一種關(guān)系中,由于牽涉到監(jiān)督過失的問題,因此信賴原則的適用會受到一定限制。關(guān)于第三種情形：(1)醫(yī)師與護理人員之間能否適用信賴原則應(yīng)視醫(yī)療行為的具體內(nèi)容而定；(2)醫(yī)師與藥劑師之間,在存在醫(yī)藥分業(yè)的情況下可以適用信賴原則；(3)醫(yī)師與檢驗人員之間原則上可以適用信賴原則。 第二節(jié)首先評析了被害人的危險承受阻卻過失犯成立的各種理論根據(jù),并表明了本文贊同的觀點——被害人自我答責理論。在此基礎(chǔ)上,本節(jié)探討了危險的承受在醫(yī)療過失中的適用問題。具體而言,首先,闡明了危險的承受與患者同意之間的關(guān)系,并指出危險的承受能夠阻卻醫(yī)療過失的,僅限于醫(yī)療行為的對象承受不被允許的危險的場合。其次,探討了醫(yī)療過失中適用危險的承受理論的一般性要件。最后,探討了危險的承受在醫(yī)療過失中的具體適用情形,包括醫(yī)療過失中的基于合意的他人危殆化與自我危殆化的參與。
[Abstract]:At present, the medical disputes in China are growing rapidly and increasing, which has become the focus of the society at present. The tension between doctors and patients has become a common understanding, and the trust between doctors and patients has fallen to the bottom of the valley. Therefore, how to solve medical disputes reasonably and effectively in the pursuit of social harmony has become a social contradiction. There are many reasons for the surge of medical disputes at the present stage, among which the frequent occurrence of medical accidents is one of the main reasons, and a considerable proportion of medical accidents are caused by medical institutions and medical personnel violating medical rules and regulations. At present, the main way to solve medical malpractice disputes is medical treatment. The medical institution bears the civil liability for the compensation for medical damage, and investigates the administrative responsibility (such as the duty to suspend practice or revocation of the practice certificate, etc.), and the criminal responsibility is few. The direct manifestation is that in 1997, the crime of medical malpractice for the punishment of medical negligence is almost in practice. That is to say, it is too dependent on civil compensation, but neglecting the connection and coordination of civil, administrative and criminal liability, especially the criminal law can not play its due role in regulating medical negligence and preventing medical liability accidents. It is the present and problem point of the legal regulation of medical accidents in China, and it is also unable to carry out medical accidents. Effective prevention, thereby reducing the important causes of medical disputes.
At present, the criminal law can not play its due role in the regulation and prevention of medical liability accidents, and its reasons are various. Therefore, how to change this situation is not a problem that can be solved by criminal law alone. But it does not mean that a certain solution can not be found within the scope of the criminal law. From the angle of criminal law. The medical liability accident belongs to the category of business negligence crime. Therefore, the systematic and in-depth study of the core elements of medical negligence is of fundamental significance to the criminal law regulation of medical liability accident. However, the significance of the study of medical negligence from the angle of criminal law is not limited to the identification of the crime of medical accidents, and this research path leads to the lack of system and depth on the study of this problem in China. From a theoretical point of view, a more comprehensive, systematic and in-depth study is carried out around the essential elements of medical negligence, and other problems in the crime of medical malpractice, such as medical behavior and the legitimacy of its main body, causality, harmful results, and medical accident identification, are not involved, or only within the necessary limits.
Different from the research model adopted by most scholars in the mainland of China, this paper tries to make a more detailed study on this issue on the basis of the theoretical system of building criminal medical negligence, which includes four parts, such as the summary of medical negligence, the ontology of medical negligence, the conclusion of medical malpractice and the limitation of medical negligence. The full text is divided into five chapters, in addition to the first chapter introduction and conclusion, second to fifth chapters correspond to the four parts respectively.
The first part is the summary of medical negligence (second chapters). It is divided into two sections. Medical negligence is a fault in the course of "medical behavior". At the same time, the characteristics of medical behavior have an important influence on the identification of medical negligence. Therefore, the first section of this chapter first discusses the concept and characteristics of medical behavior. On this basis, medical behavior can be divided into two meanings according to the medical purpose or not. The medical behavior in this paper is generalized, but the medical behavior in the narrow sense is more universal and representative. Therefore, the theoretical discussion and case analysis below will be based on the narrow sense of medical behavior. After defining the concept of medical behavior, this section explores a series of features of medical behavior that have an important impact on the identification of medical negligence, which are: risk, usefulness, professionalism and uncertainty.
The second section of this chapter mainly discusses the concept and classification of medical negligence. First of all, this article holds that medical negligence should be defined as a violation of the necessary duty of care in the course of a specific medical behavior. The subject of the criminal negligence does not include the medical institution, and the medical personnel are contrary to the specific medical behavior process. The situation of anti related duty of attention can not be referred to as medical negligence. Secondly, on the classification of medical negligence, medical negligence can be classified from different angles. This section selects two kinds of classifications which have general directive significance to the criminal law regulation of medical negligence, which are simple technical The first classification is the cornerstone and starting point of the criminal medical negligence theory system, and the classification is also carried out in the analysis and demonstration of the related problems, that is, the criminal law should focus on the simple technical negligence, and the medical judgment negligence. The object of regulation of criminal law should be limited to those who are clearly separated from the medical standard.
The second part is the ontology of medical negligence (third chapters), which is divided into four sections. This part belongs to the basic theory and general theory of medical negligence. It is formed by abstracting and summarizing the specific medical negligence. Therefore, it has a general guiding significance for the specific identification of medical negligence.
Fundamentally, medical negligence belongs to a kind of negligence. Therefore, the basic position of the negligent crime theory will directly determine how to analyze and demonstrate the related problems of medical negligence and how to hold their views on these problems. Conclusion: the new theory of negligence is more reasonable in general and more suitable for the analysis of the related problems of medical negligence. Secondly, there is no opposition between the basic standpoint of the negligent crime in the mainland of China. After analysis, the basic position of our continent is more affinity with the new theory of negligence. Accordingly, this article from the act is priceless. Based on dualism, the position and viewpoint of the new theory of negligence are implemented in the full text.
The second section closely combines the characteristics of the medical field (medical behavior) and focuses on the content and basis of the duty of care of the medical personnel. In terms of the content of the duty of care, this section discusses the common result foreseeable obligation and the duty avoidance duty of the medical staff in various specific medical behavior, which embodies the medical negligence zone. Apart from the particularity of other faults, this section discusses the origin and basis of the duty of care which is closely related to the safety of specific medical behavior in terms of the basis of the duty of care.
The third section mainly discusses the ability to pay attention to the attention of the medical staff. This article holds that in the common fault, the criterion for judging the ability of attention should be taken in the middle, and in the business fault, especially in the medical negligence, it should be objectively said, that is, whether the result can be foreseen and avoided, which should be understood by the general medical staff at the time and the actor. In particular, the information is judged on the basis of which the general medical staff can foresee and avoid the result of the hazard. "General medical personnel" should be defined as a person who has the same or similar title or status in a region or a medical institution with the same or similar medical conditions. Medical professionals in the field of medical behavior.
The fourth section discusses the criteria for judging medical negligence. They are medical standards, discrepancy and urgency. Medical standards are the general criteria for judging medical negligence. However, the regional differences in medical standards should be fully considered. Discretion is the criterion for medical negligence, which is mainly applicable to medical judgment negligence. Look, discretion has the function of restricting medical negligence. As a standard of judging medical negligence, the role of urgency is to ease the duty of attention of medical personnel in emergency, and apply a lower standard of identification, but it is not exempt from the duty of attention.
The third part is the theory of the cognizance of medical negligence (fourth chapters), which is divided into five sections. The direct purpose of the study of medical negligence is to determine whether some kind of medical behavior violates the relevant duty of attention. Therefore, this part has more direct guiding significance for the judicial practice. Medical negligence is a fault in the process of medical behavior. Therefore, the identification of medical negligence must be combined with specific medical behavior. However, there are a wide variety of medical behavior, and with the development of medicine, its content is constantly being finely differentiated. Therefore, it is obviously unrealistic to explore the fault of all medical behaviors. Based on this, this chapter selects the diagnosis of medical accidents easily in practice. Behavior, injection behavior, transfusion behavior, anesthetic behavior and operation behavior are the object of investigation. After summarizing the negligence of these medical behaviors, the specific identification problems of these medical negligence are discussed in combination with specific cases. In particular, the first section of diagnostic fault generally includes the fault and diagnosis in the diagnosis process. Negligence in the second section. The injection negligence generally includes the necessity of injection and the negligence of timing, the types of injection and the negligence of the dose, the fault of the location and methods of the injection, the negligence of the injecting apparatus, and the observation fault after the injection. The third section of blood transfusion generally includes the collection of blood. The fault in the liquid process and the fault in the process of entering the blood. The fourth section of anesthetic negligence generally includes: the fault of judging the adaptability of the anesthetic, the negligence of the anesthetic and the method of anesthesia, the negligence of the technical operation in the anaesthesia, and the negligence of the patient after the anaesthesia. The surgical negligence in the fifth section generally includes the necessity of the operation. The judgment negligence of the feasibility, the fault of the timing of the operation, the negligence of the operation method, the negligence of the technical operation during the operation, and the negligence of the patient after the operation.
The fourth part is the theory of the limitation of medical negligence (the full text fifth chapters), which is divided into two sections. The above is a positive discussion on the establishment of medical negligence, and this part will study the hindrance of medical negligence from the opposite side. In theory, the theory of the permissible risk theory, the theory of dangerous distribution and the letter are generally considered to be the cause of the negligent offense. According to the permissible theory of danger, the medical staff's compliance with the medical rules and regulations and the treatment and nursing routines are the prerequisites and key elements for the application of the theory. However, when they abide by these regulations, they do not exist in violation of the objective duty of attention, or are not satisfied with the objective aspects of the constitution of the crime. That is to say, as the hindrance of the negligent crime, the permissible danger theory is not independent, so this chapter will not be discussed alone. On the theory of dangerous distribution, it is generally believed that the theory of trust is interrelated with the principle of trust. Therefore, the theory of dangerous distribution will be carried out in the principle of trust, except the principle of trust. In addition, the risk of the victim is also an important cause that hindered medical negligence, but there are almost no scholars in the academic community to discuss this. Based on this, this chapter carried out a more in-depth study on the trust principle and the risk of the victims to accept the problem of how to limit medical negligence.
The first section, on the basis of the application of the principle of trust in medical negligence, focuses on the application of this principle in medical negligence. Taking into account the leading position of the physician in medical behavior, the application of the principle of trust in medical negligence is divided into three cases, that is, doctors and patients.
【學位授予單位】：武漢大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：D924.3
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本文編號：2150826