以臨床醫師的角度探討醫療紛爭解決機制

Clinical Perspective on the Settlement of Medical Disputes

系所名稱：科技法律研究所 學位別：碩士 畢業學年：97年 指導教授：郭麗珍、侯英泠 1月20日中國時報頭版標題「世界第一 每3個月 1醫師定罪」，相信很多醫界同仁，法界人士與社會大眾又再度陷入醫療與法律的迷失。目前醫病關係已由昔日信賴關係（醫者視病猶親，病家衷心感謝），逐漸轉變成為非人格的商業事務關係，醫病關係有日漸淡薄的趨勢，隨之而來的醫療糾紛亦相形增加。理論上，醫療與法律都是在追求人類健康、快樂、自由，維持人性尊嚴與社會公平正義。然而醫療行為與法律保障病人健康權的糾葛在醫療訴訟中又呈現不同思考邏輯，因此希望醫界同仁能瞭解法界的思維，也期望法界人士能理解醫學與人的極限。 醫療意外除人為明顯的疏失所造成，應該有可能其他原因存在，一般人往往很難加以確定事故的真相。從另一角度看，疾病治療具有一定風險，但發生風險與否並不一定能事先確定。目前對於醫療事故的鑑定，係就醫學累積的經驗加以判斷，亦非具有絕對性，其間的因果關係，有時也許僅是或然發生，或是未注意而事先做好預防性治療，這是目前司法系統要認定醫師責任的困難之處。何況醫師治療縱有疏失，也不一定與結果之發生有確切的因果關係。 由法務部起訴書查詢系統，自民國86年至96年醫療糾判決有罪、無罪確定所需的時間最長十年三個月、最短一年、平均四年六個月。這顯示醫療爭議事件有許多認定的困難，在法律漫長處理過程中，要維持符合真正社會公平正義，對於醫療人員與病人及家屬是相當煎熬的心路歷程。 有醫療損害的結果，理論上有原因要件的成立，我們的研究顯示有醫療紛爭的個案，很明顯地百分之七十應該有醫療行為與醫療損害的相關性。大家都明白醫療有其風險，不可能百分之百成功，然而紛爭事件中，有將近70% 病人或家屬感覺沒有被給予充份告知說明病情，無法充份瞭解醫療行為的發展，以致於當有損害發生時，無可避免地無法接受醫療結果而有爭議。相信這些數據顯示在醫療有能力極限之下，醫界同仁必須體認告知說明義務有其相當重要的角色。 對於國內的醫療紛爭，本研究下列幾點建議提供醫界、法界及社會大眾參考： 1. 一般而言，只要飛機駕駛人員本身沒有犯罪意圖，司法單位並不會因為發生空難就起訴機師，我們希望失事的飛行員要誠實的面對失事的問題，避免相似災難再發生。同樣地，我們希望醫師更「誠實」面對疏失，減少醫療錯誤的有效方法是建立「通報制度」，讓醫事人員自發性的報告過錯，進而公開討論，使其他人員從中學習，而不再犯同樣的錯誤。因此，規定通報的資料不得作為檢察官起訴或法官論罪之證據，對於主動向衛生機關通報醫療錯誤者，得視其情節輕重，減輕或免除其刑罰。 2. 惟為考量醫療糾紛之判決涉及專業性醫療知識與技術，將來司法「參審制」實施之後，由醫療專家實際參與醫療案件之審判，期能迅速審結醫療案件，並有效提升醫療案件之裁判品質。 3. 醫療糾紛鑑定由行政院衛生署審定之各醫學中心接受委託鑑定，惟鑑定結果應具體說明所憑之依據係醫學文獻或醫學理論，以證明其意見的公平性及可靠性，並且應採取兩造聽審制度，由當事人陳述對鑑定內容之意見，惟有如此，鑑定結果始能獲得民眾信賴。 4. 照顧國民的健康是政府應負之義務，應考慮由政府開辦社會保險，例如：醫師責任險、醫療機構責任險等的方式來替代無過失補償制度，對當事人而言，可以鼓勵醫師發揮其醫療專業，不至有後顧之憂，病人亦可獲較佳之醫療事後之保障。 5. 人的器官之間有其協調性，有如中醫的陰陽理論。某一個器官失序，則會造成很多疾病複雜症狀的表現。人的能力有限，不能改變命運；醫師必須隨時檢視自己的極限，更努力學習面對所謂因難的疾病。醫學倫理教導我們要尊重病人的自主權、遵守公平正義原則、實行不傷害原則及行善原則，不管醫學倫理觀有多少原則其實只有一個原則，那就是「愛」。就像地球上有三大洋五大洲，其實只有一個海洋環繞著由海底拱起的陸地，不論是家屬─病人─醫療人員都是「生命共同體」，願醫界、法界共勉之。 本文刋載於1月21日中國時報A15版時論廣場

The doctor-patient relationship has changed from one of mutual-trust into an impersonal transactional affair. As a result, there have been an increase in the number of medical disputes. Theoretically speaking, both medicine and law aim to maintain individuals’ human rights to health, happiness and dignity; nevertheless, they are framed by different logics which act differently in the face of medical litigation. This paper, attempts to bridge the gap in the understanding between medical practitioners and legal professionals.Most medical treatments will follow clinical guidelines or evidenced-based medicine, however, in some cases of medical malpractice, which may require well experienced physicians to identify the medical faults resulting in harm. In cases of medical dispute in Taiwan, there is typically a time lag of 14 months in seeking such medical expertise, and patients and doctors are generally dissatisfied with the processes of the law court. This study is based on: (1) Analysis of the characteristics of medical practice issues using legal theories; (2) Reference to the opinions expressed in legal cases and by scholars; (3) Disclosure of the causes of medical disputes from clinical patients and the extent to which the principles of tort and default are applicable to medical practice. The paper arrives at the following conclusions, which are ultimately derived from the study of medical litigation: (1) It is imperative that regulations be established to allow medical experts to participate in trials involving medical disputes; (2) We propose that a diverse number of medical centers be made responsible for providing medical expertise in cases in dispute. The comments should be based on medical science or medical guidelines instead of personal experience, and the documents should be disclosed to the public for discussion; (3) Medical negligence in cases of medical malpractice lawsuits should take medical environments and risk liability into account; (4) We call for a patient compensation insurance system to replace the strict-liability compensation system to avoid the introduction of defensive medical practices; (5) Medical law needs to be formulated that will apply to the diversity of medical disputes and justified to all members of society; (6) Informed consent is the most important factor in communications between patients and doctors during medical treatment. We suggest that every doctor carefully and clearly communicate with patients o ensure that patients and their families are well informed. This is the keystone issue in medical-legal issues. Finally, I believe love is the only principle in the medical ethics to take care of patients in the daily medical practice.