医疗损害纠纷中的免责制度研究

　　中文摘要

　　患者就医时，都希望就诊医院设施完备、医务人员医术精湛，从而能早日康复。但由于医疗的复杂性和高风险性，条件和水平的参差不齐，有时会发生医疗损害，引发医患纠纷。损害发生时，医院、医生是否承担责任、承担何种责任等，常成为争议焦点。医疗行为系特殊民事行为，其特殊性决定了医疗损害免责之规则应符合行业的独特性，有利于医疗事业的可持续发展。尽管医疗纠纷解决方式多样，但现阶段，诉讼仍是解决医疗损害纠纷的主要形式。

　　在诉讼中，法律规则和技术鉴定发挥着重要作用。制度的不完善使得相似案件出现了地区和法官个体的差异性。相较之前的法律，我国《侵权责任法》对损害责任之规定有很大进步，但该法和《医疗事故处理条例》的一些规定已经明显无法满足当前的现实需求。

　　考虑医疗行为的专业特性，有必要实行医疗损害的有限免责。有限免责有利于医疗事业的发展，能适度降低医疗行为的风险，使医疗行为理性化。《侵权责任法》、《医疗事故处理条例》的免责规定具有缺陷，没有举证缓和制度，没有考虑医疗水平的地区差异，对免责事由规定过于简单、宽泛，未规定责任鉴定制。医疗免责举证责任的重建应考虑引入表见证明理论及限制性举证责任倒置理论，需要正确界定医疗风险范围，适度扩大法官自由裁量权。在法定的免责事由中，应增加患者自甘风险和医疗意外的事由。我国应通过司法解释使医疗损害责任的法律规定更为明确、精细，强化医疗损害责任保险制度，将其作为免责制度的有益补充，并对医疗损害赔偿额度作出适当限制。

　　关键词：医疗损害纠纷  医疗免责  举证责任  损害赔偿

　　Abstract

　　When seeing a doctor, all patients hope the treating hospital has perfect medicalequipment, the professional medical staff possesses perfect skills, so they can recoverquickly. But due tothe complexity and the high risk of medical service, the different levelof medical care and condition limitations, sometimes medical damage happens and resultsin medical disputes.Under the circumstance of fact of damage, the scope of the liability forthe medical service becomes the main focus in dispute.As the medical practice is a specialcivil action, the exemption shall be accord with the with the features of healthcareservice ,which is beneficial for the development of medical service.

　　There is a variety of ways to handle medical disputes. At present stage, litigation isstill regarded as the main way. The application of law and the technical appraisal ofmedical malpractice play a significant role in medical litigation.But imperfect of thelitigation reach the different verdicts by judges and areas in similar cases. Compared withthe previous regulations, “the Tort Liability Law of the People's Republic ofChina” achieves greater progress, however, the regulations stipulated in the Tort LiabilityLaw of the People's Republic of China and “Regulations on Handling MedicalAccidents” obviously cannot meet the real requirements.

　　In consideration of the features of medical practice, the limited liability in medicalinjury is necessary. Limited liability is in favor of the development of healthcare service,the reduction of medical risk and rationalization of medical practice. There areInsufficiency and flaws in the Tort Liability Law of the People's Republic of China and“Regulations on Handling Medical Accidents”, for instance, absence of the alleviation ofburden of proof, regional disparity of medical level, the generic and simple exemptionclause, no legal liability appraisal.The Prima Facie Bewies theory, inversion of burden ofproof, the scope of medical risk, and wide discretion should be taken into account in thereestablishment of the evidential burden in the exemption clause. Assumption of risk andmedical accident should be listed into the legal exemption reasons. The necessary judicialinterpretation can make the stipulations of the liability of medical damage moreprecise. Enhancement of the Liability insurance system is a useful supplement to theexemption clause. The amount of compensation should be to a reasonable restriction.

　　Key Words: Medical damage disputes; medical immunity; burden of proof; compensation fordamage

    目 录

　　引 言……1

　　一、医疗损害有限免责之立法基础……3

　　（一）医疗损害的概念……3

　　（二）免责事由、抗辩事由与违法阻却……4

　　（三）与免责相关的医疗行为特性……5

　　1.专业性……5

　　2.道德性……6

　　3.公益性……6

　　4.高风险性……7

　　（四）医疗损害有限免责的必要性……7

　　1.过度责任妨碍吸引人才，有碍医疗事业发展……7

　　2.认知局限性导致存在无法预知的风险……8

　　3.适度的豁免有利医疗行为的理性化……8

　　二、医疗损害免责法律现状及具体免责事由……9

　　（一）目前我国法律对医疗免责的规定……9

　　1.《医疗事故处理条例》规定的免责事由……9

　　2.《侵权责任法》规定的免责事由……12

　　（二）《侵权责任法》、《医疗事故处理条例》对医疗责任规定之不足……13

　　1.对医疗责任没有设定举证缓和规则……13

　　2.将“当时医疗水平”作为衡量标准，罔顾地域差异 ……14

　　3.免责事由规定过于简单宽泛……14

　　4.对医疗责任鉴定没有作出规定……15

　　5.未突出医疗赔偿责任的特殊性……16

　　（三）医疗损害一般免责事由之分析……17

　　1.患者故意……17

　　2.第三人的过错……17

　　3.不可抗力……18

　　4.医疗意外……18

　　（四）事先所订免责条款之效力……18

　　三、医疗损害免责的认定……20

　　（一）医疗责任之认定条件……20

　　（二）医疗免责认定方式及建议……21

　　（三）医疗免责之举证制度及重构建议……22

　　1.在医疗赔偿制中引入德国式举证理论……23

　　2.正确界定医疗风险范围……24

　　3.适度扩大法官的自由裁量权……25

　　四、完善我国医疗赔偿制度的建议……26

　　（一）增设自甘风险和医疗意外之免责事由……26

　　（二）通过司法解释明确医疗责任之规定……28

　　（三）强化医疗损害责任保险制，作为免责制的有益补充……30

　　（四）对医疗损害赔偿额作出适当限制……31

　　结 语……34

　　参考文献……35

　　致 谢……38