【作者】 宋平；

【导师】 李祖军；

【作者基本信息】 西南政法大学 ， 诉讼法学， 2009， 博士

【摘要】 医患关系与民众的切身利益息息相关,医生离不开患者,患者也离不开医生。近年来,我国医患纠纷逐年激增、医患矛盾日益加大,已经成为影响整个社会和谐的突出社会问题。然而,由于医患纠纷的医学专业性,导致医患纠纷解决难度大、纠纷解决成本高。与一般民事法律关系不同,医患双方并不是单纯的利益对等的合同法律关系,在医疗服务过程中,医患之间的利益一致,都是为了患者疾病的治愈。患者疾病被治愈后,医疗机构向患者收取的医疗费用并不具备民事法律关系中的等价有偿性,患者所支付的医疗费用远低于医疗机构付出的实际治疗成本。因此,医疗机构大多都是事业单位,国家在一定程度上给予财政补贴。另一方面,随着我国卫生体制改革的深入,医疗行业市场化、医疗服务竞争性改革措施的实施,导致患者的医疗费用大幅增加。医患之间缺乏有效的沟通和理解、患者对疾病治疗效果的高要求、以及部分医务人员责任心不强等因素,造成医患纠纷逐年递增,医患矛盾日益尖锐。为了构建和谐的医患关系,医患纠纷的解决就成了我国行政部门、司法机关等相关部门的重要任务。作为强制性、终局性、权威性的民事纠纷解决机制——医患纠纷诉讼程序,在现今并没有体现出医疗纠纷的专业性、诉讼主体特殊性等特征,并没有起到公正解决医患纠纷的目的。为了规范医疗事故行政处理程序,国务院于2002年颁布了《医疗事故处理条例》,对医疗事故的构成、医疗事故鉴定程序、医疗事故赔偿标准等进行了规范,但是这些规范仅仅适用于医患纠纷的行政处理。最高人民法院于2001年颁布了《最高人民法院关于民事诉讼证据的若干规定》,对医疗侵权诉讼做出了举证责任倒置的规定,使患者的举证负担大大减轻。紧接着最高人民法院于2003年颁布了《最高人民法院关于参照<医疗事故处理条例>审理医疗纠纷民事案件的通知》,将医疗侵权诉讼划分为医疗事故赔偿纠纷和其它医疗赔偿纠纷,并规定这两种诉适用不同的实体法和诉讼法。这就造成医患纠纷解决依据的二元化,特别是在认定医务人员主观过错上,出现不同鉴定程序、不同的鉴定结论。以上行政法规、司法解释已经造成了我国现阶段医患纠纷诉讼程序在某种程度上的混乱状况。本文是一篇系统构建诉讼程序为中心的医患纠纷诉讼程序博士学位论文。全文由导论和正文六章组成,共18万余字。本文以医患纠纷诉讼程序的重构为研究重点,对在我国医患纠纷司法实践中出现诉权保障、法律适用二元化、司法鉴定权与审判权界限之理性回归、医疗侵权诉讼举证责任分配与实体法归责原则之冲突等突出的诉讼法理论、证据法理论问题进行深入且细致的研究。主要探讨我国医患纠纷诉讼程序中出现的具体问题,并借鉴大陆法系先进国家关于医患纠纷诉讼的司法经验,最终拟建构我国公正、高效的医患纠纷诉讼程序制度。导论导论概述本文的选题背景、选题意义、论文研究的内容创新和研究方法。针对我国医患纠纷逐年激增、医患矛盾日益激化等现状,为了树立司法权威,彻底解决医患纠纷,并对其它医患纠纷非讼解决方式树立纠纷解决标准,公平、公正、高效之医患纠纷诉讼程序的建构尤为迫切。公正、公平、高效的医患纠纷诉讼程序之建构,前提条件是该诉讼程序必须满足程序正义的基本要素。本文的主要特征在于将公正、公平的医患纠纷诉讼程序的建构作为主线,以诉权保障、司法鉴定程序理性回归、举证责任公平分配、医患纠纷诉讼判决的既判力为着力点,主要采取比较法和实证研究方法,对医患纠纷诉讼程序的重构进行深入探讨。第一章医患纠纷本论。本章厘清了医患纠纷的基本概念、定义、种类等。本章界定了医忠纠纷属于医源性医疗纠纷,对医患纠纷的特点、要件、成因进行了详细的阐述。本章在医患纠纷诉讼调解部分提出,医患纠纷诉前和诉后均可以由附设于法院的专职医疗非讼调解委员会进行调解,以期通过医学专业调解人的斡旋,从多种渠道化解矛盾激化的医患纠纷。本章对民事诉讼中独特的医患纠纷诉讼进行了简要论述。对于医患纠纷诉讼标的的界定,依据诉讼法说中一分肢说,将医患纠纷诉讼当事人的攻击防御方法与诉讼标的明确区分,当事人事实之主张与举证与法官法律适用权准确界定。法官对医患纠纷事实适用侵权法或合同法有自由裁量权,当事人对于诉讼标的、诉讼请求具有主导权。第二章医患纠纷诉讼诉权论。主要研究诉权基本理论为基础,将起诉要件、诉讼要件、权利保护要件进行清晰和明确的界定。并针对我国民事诉讼立法和司法实践对于当事人诉权之限制、诉讼要件和权利保护要件相混淆的现状,提出重构我国民事诉权立法与理论。以医患纠纷诉权保障为目标,本章通过医患纠纷鉴定前置导致起诉难等现状,提出建构医患纠纷起诉要件、诉讼要件、实体权利保护要件之独立、分隔,最大限度保护医患纠纷当事人的程序利益和实体利益。第三章医患纠纷诉讼证据法方论。本章以医疗机构诊疗护理过程为主线,突出分析患者病历资料、患者受伤身体、死亡尸体为载体的书证、物证,以及医疗侵权司法鉴定结论,注重探讨医患纠纷民事诉讼程序中证据方法之特殊性。第四章医患纠纷鉴定论。由于现今我国医疗侵权纠纷受医疗行政管理与医疗侵权诉讼体制双重规制,决定了二元化的医疗侵权鉴定体制,即医疗事故鉴定和医疗侵权司法鉴定。医疗事故鉴定适用于医患纠纷行政处理程序,也适用于医患纠纷诉讼程序,而医疗侵权司法鉴定仅适用于诉讼程序。这种矛盾的医疗侵权鉴定体制已经使医疗侵权纠纷的处理陷于混乱,进而会使法院在医患纠纷的审理中由于采纳不同的鉴定结论,造成同一自然历史事实做出不同的纠纷司法事实认定。最后,同一医患纠纷法院如果采纳不同鉴定结论造成其要件事实认定上的不统一、法律适用上的混乱,终究将影响司法权威性。因此,本章认为应当对这两种医学鉴定体制进行一元化的改革。医疗事故鉴定与司法鉴定之理论与原理发生重大冲突,医学会组织的医疗事故鉴定程序更像是鉴定委员会进行的一种准司法裁决程序。因此,医疗事故鉴定不符合司法鉴定之要件,不能在医患纠纷民事诉讼中作为鉴定结论被适用,进而也不属于民事诉讼中的法定证据方法。本章认为,我国医患侵权司法鉴定程序中,司法鉴定人进行的侵权行为鉴定程序及鉴定结论违反司法鉴定法理,在其鉴定结论中对属于法评价要件的主观过错进行认定。因此,侵权司法鉴定的鉴定人超越了的事实鉴定权,行使了专属于法官的法律适用权。而大多数法官对于鉴定人越权侵蚀法官对于过错法律要件的认定权,并不持异议,而且许多法官做出的鉴定委托书中的委托事项就是行为人的主观过错。在医疗侵权诉讼中,法官也乐于“拱手让出”自己对于行为人主观过错的法律适用权,委托鉴定人对医务人员主观过错进行鉴定。最终结果导致医患纠纷诉讼中法官与司法鉴定人角色混淆。本章认为,司法鉴定人与法官在医患纠纷民事诉讼中应当各司其职,鉴定人进行事实之鉴定,法官进行法律之适用,鉴定人协助法官对当事人主观过错进行认定。司法鉴定人的职责是提供给法官涉案医疗行为的标准医学规范、医学经验法则和因果关系,法官在综合医疗机构等级、医务人员学历和职称、患者就诊时的紧急情况等进行过错认定。第五章医患纠纷诉讼举证责任论。本章结合民事实体法关于侵权行为归责原则之理论与实践,认为我国最高法院司法解释和民事诉讼理论界通说将医患纠纷举证责任分配界定为举证责任倒置之情形值得商榷。民事诉讼中举证责任倒置与侵权行为法中行为人主观过错的归责原则应当统一。大多数国家都将特殊侵权行为单独立法,适用无过错归责原则与过错推定归责原则,与此相适应,在民事诉讼举证责任分配规则上,这些特殊侵权行为适用举证责任分配倒置之规定。医疗侵权行为在大陆法系国家中几乎都被界定为过错责任归责原则,我国《民法通则》也不例外。因此,为了维护当事人合法权益、维护程序公正,本章认为医疗侵权诉讼应当以实体法上过错责任原则相适应,适用法律要件分类说之举证责任分配规则。为了平衡医患双方当事人的诉讼力量,使他们的诉讼地位基本达到平等,法律只有规定若干影响法官证明评价的诉讼证明方法来辅助在举证能力上处于弱势地位的患者。本章认为,为了充分保障患者利益,加强患者的诉讼能力及举证能力,民事诉讼立法和司法实践应当通过表见证明、文书提出义务、证明妨碍、摸索证明理论与规则辅助处于弱势的患者,促使法官对侵权事实之成立易于达到盖然性的优势。第六章医患纠纷判决论主要对医患纠纷后发性后遗症诉讼和判决后的情势变更进行探讨。对于医患纠纷民事判决发生既判力后,发生当事人不能在前诉中遇见的后发性后遗症,应当允许再诉。医患民事法律关系动态性的特点,决定既判力生效后,即基准时后发生情势变更的,也可以再诉。更多还原

【Abstract】 The medical trouble relations are closely linked with populace’s vital interest,doctor cannot leave the patient,the patient also cannot leave doctor.In recent years,my Chinese medicine trouble dispute increased sharply,the medical trouble contradictory to enlarge day by day year by year,already became the influence entire society harmonious prominent society question.However,as a result of the medical trouble dispute’s medicine specialization,causes the medical trouble dispute to solve the difficulty to be big,the dispute solves the cost to be high.Is different with the general civil legal relationship,medical trouble both sides are not the pure benefit coordinated contract legal relationships,in the medical service process,between the medical trouble’s benefit is consistent,is for the patient disease’s cure.After patient disease cures,the Medical establishment the medical expense which gathers to the patient does not have in civil legal relationship equal paid,the medical expense which the patient pays far is lower than the actual treatment cost which the Medical establishment pays.Therefore,the Medical establishment mostly is the Institution,the country gives the fiscal subsidy to a certain extent.On the other hand,along with our country health organizational reform’s thorough,the medical profession marketability,the medical service competitiveness reform measure’s implementation,causes patient’s medical expense to increase largely.Between the medical trouble lacks the effective communication and the understanding,the patient to the disease treatment result high request,as well as the partial medical personnel sense of responsibility not strong and so on factors,causes the medical trouble dispute to increase progressively year by year,medical trouble contradictory day by day incisive.In order to construct the harmonious medical trouble relations,the medical trouble dispute’s solution has become our country Administrative department,the judicial organ and so on related department’s important task.As compulsory,the result,the authority civil dispute solve the mechanism--medicine trouble dispute legal procedure,has not manifested medical characteristics and so on dispute’s specialization,lawsuit main body particularity in the nowadays,has not had the fair solution medicine trouble dispute’s goal.For the standard incident of malpractice administration disposal procedure,the State Council promulgated "Incident of malpractice in 2002 To process Rule",to incident of malpractice’s constitution,the incident of malpractice evaluation program,the incident of malpractice measure of indemnity and so on has carried on the standard,but these standards were suitable merely for medical trouble dispute’s administrative processing.The Supreme People’s Court has promulgated "Supreme People’s Court in 2001 about Civil action Evidence Certain Stipulations",has made the onus probandi inversion stipulation to the medical service infringement suit,causes the patient to present evidence the burden to reduce greatly. Followed closely the Supreme People’s Court to promulgate "Supreme People’s Court in 2003 about Reference Trying Medical service Dispute Civil case’s Notice",divided the medical service infringement suit into the incident of malpractice compensation dispute and other medical compensation dispute,and stipulated that these two kinds sued are suitable the different substantive law and the procedural law.This causes the medical trouble dispute to solve the basis dualization,specially in recognized that in the medical personnel subjective mistake,presents the different evaluation program,the different appraisal conclusion.The above administrative rules and regulations,the judicial interpretation had already made our country present stage medicine trouble dispute legal procedure chaotic condition to a certain extent.This article is a system construction legal procedure for the central medical trouble dispute legal procedure doctorate paper.The full text is composed of the introductory remarks and the main text six chapters,altogether 170,000 characters.This article take medical trouble of dispute legal procedure restructuring as research key,to presents the right of suit safeguard,the law in my Chinese medicine trouble dispute judicature practice to be suitable the dualization,rationality of retum,the medical service infringement suit onus probandi assignment and the substantive law the expert evidence power and the judicial authority boundary turns over to conflict of the responsibility principle and so on prominent procedural law theory,the evidence act theory question to conduct thorough and the careful research.Mainly discusses the concrete question which in my Chinese medicine trouble dispute legal procedure appears,and profits from the mainland legal system advanced countries about the medical trouble dispute lawsuit judicial experience, plans to construct our country fairly finally,the highly effective medical trouble dispute legal procedure system.Introductory remarks introductory remarks outline this article selected topic background,selected topic significance,paper research content innovation and research technique.Increases sharply in view of my Chinese medicine trouble dispute,the medical trouble contradictory to intensify and so on present situations day by day year by year,to set up the judicial authority,the thorough settlement medicine trouble dispute,and to other medical trouble dispute must disputed that the solution way sets up the dispute to solve the standard,fair,fair,the highly effective medical trouble dispute legal procedure’s construction is especially urgent.Fair,fair,construction of the highly effective medical trouble dispute legal procedure,the prerequisite is this legal procedure must satisfy the procedure just base element.This article chief feature will lie will be fair,the fair medical trouble dispute legal procedure construction to take the master line,take the right of suit safeguard,the expert evidence procedure rationality return,the onus probandi fair assignment,the medical trouble dispute lawsuit decision already will sentence the strength as the point of application,mainly will adopt the comparison test and the empirical study method,will carry on the thorough discussion to medical trouble dispute legal procedure’s restructuring.The first chapter medical trouble dispute this theory.This chapter has defined clearly the medical trouble dispute’s basic concept,the definition,the type and so on.This chapter limited the medical trouble dispute to belong to the medical source medical service dispute,to the medical trouble dispute’s characteristic,the important document,the origin has carried on the detailed elaboration.This chapter proposed in the medical trouble dispute lawsuit mediation part that after before the medical trouble dispute sues,and sues,may by set up as an attachment in the court professional medical service must disputed the Redressing committee carries on the mediation,by the time through the medicine specialized peacemaker’s mediation,melts contradictory intensified from many kinds of channels the medical trouble dispute.This chapter the unique medical trouble dispute lawsuit has carried on the brief elaboration to the civil action.Regarding medical trouble dispute lawsuit sign the limits,based on the procedural law said that one point extremity said that is clear about the discrimination the medical trouble dispute lawsuit litigant’s attack defensive measure and the lawsuit sign,position of the litigant fact with presents evidence the law is suitable the power with judge to limit accurately.Judge is suitable the right infringement law or the law of contract to the medical trouble dispute fact has the freedom to decide after deliberation the power,the litigant regarding the lawsuit sign,the lawsuit requested that has the leading power.The second chapter medical trouble dispute right of suit theory.The main research right of suit elementary theory is a foundation,will sue the important document,the lawsuit important document,the right protection important document to carry on clear and the explicit limits.And aims at our country civil action legislation and the judicial practice the present situation which limit,the lawsuit important document and the right protection important document regarding the litigant right of suit confuses,proposed that restructures our country civil right of suit legislation and the theory.Take the medical trouble dispute right of suit safeguard as the goal,this chapter appraises through the medical trouble dispute pretage causes to sue and so on present situations difficultly,proposed that the construction medicine trouble dispute prosecution important document,the lawsuit important document, independence,the separation the entity right protection important document,maximum limit protect the medical trouble dispute litigant’s procedure benefit and the entity benefit.The third chapter medical trouble dispute evidence France side theory.This chapter diagnoses and treats the nursing process take the Medical establishment as a master line, analyzes the patient case book,the patient to be injured prominently the body,the death corpse for the carrier book card,matter witness,as well as the medical right infringement expert evidence conclusion,pays great attention to discuss in the medical trouble dispute civil proceedings particularity of the evidence method.The fourth chapter medical trouble dispute appraisal theory.Because the nowadays our country medical service right infringement dispute the medical service administration and the medical service infringement suit system dual rules and regulations,has decided the dualization medical right infringement appraisal system,namely incident of malpractice appraisal and medical right infringement expert evidence.The incident of malpractice appraises is suitable for the medical trouble dispute administration disposal procedure,is also suitable for the medical trouble dispute legal procedure,but the medical right infringement expert evidence is only suitable for the legal procedure.This kind of contradictory medical right infringement appraisal system already enabled medical right infringement dispute’s processing to sink into the confusion,will then cause the court in medical trouble dispute’s trying,because will accept the different appraisal conclusion,will cause the identical natural historical fact to make the different dispute judicature fact to recognize.Finally, identical medical trouble dispute court,if accepts the different appraisal conclusion to cause its important document fact to recognize not unified,the law is suitable the confusion,will affect the judicial authority eventually.Therefore,this chapter thought that must carry on unified to these two medicine appraisal system the reform.Theory and the principle the incident of malpractice appraisal and the expert evidence has the significant conflict,the incident of malpractice evaluation program which of the medical society organizes is one kind of accurate judicial ruling procedure which likely the Certifying commission carries on.Therefore,the incident of malpractice appraises does not conform to important document of the expert evidence,cannot be suitable in the medical trouble dispute civil action as the appraisal conclusion,then does not belong to civil action’s legal evidence method.This chapter believed that in my Chinese medicine trouble right infringement expert evidence procedure,the judicial expert carries on the abuse of authority evaluation program and the appraisal conclusion violate the expert evidence legal principle theory of law,to belongs to the law appraisal important document subjective mistake in its appraisal conclusion to carry on recognized.Therefore,the right infringement expert evidence’s expert has surmounted the fact appraisal power,exercised belonged to judge’s law to be suitable the power specially.But majority judges exceed authority regarding the expert to corrode judge to recognize the power regarding the mistake law important document,does not dissent, moreover many judges make in the appraisal warrant’s request item is author’s subjective mistake.In the medical service infringement suit,judge is also glad "cups one hand in the other across the chest to resign" to be suitable the power regarding the author subjective mistake law,entrusts the expert to carry on the appraisal to the medical personnel subjective mistake.The final outcome causes in the medical trouble dispute lawsuit judge and the judicial expert role confusion.This chapter believed that the judicial expert and judge must perform its own functions in the medical trouble dispute civil action,the expert carries on appraisal of the fact,judge carries on being suitable of the legal,the expert assists judge to carry on to the litigant subjective mistake recognized.The judicial expert’s responsibility is provides to judge is involved in a case the medical behavior standard medicine standard,the medicine empirical rule and the causal relation,judge in the synthesis Medical establishment rank,time the medical personnel school record and the title,the patient seeing a doctor emergency case and so on carries on the mistake to recognize.The fifth chapter medical trouble dispute onus probandi theory.This chapter unifies the civil substantive law to turn over to theory and the practice the responsibility principle about the abuse of authority,thought that our country Supreme court judicial interpretation and the civil action theorists logically coherent argument is worth the medical trouble dispute onus probandi assignment limits situation of for the onus probandi inversion discussing.In the civil action the onus probandi inversion and in the abuse of authority law the author subjective mistake turns over to the responsibility principle to unify.The majority countries alone legislate the special abuse of authority,has not had the mistake file responsibility principle and the mistake suitably estimated that turns over to the responsibility principle,adapts with this,in civil action onus probandi assignment rule,stipulation of these special abuse of authority suitable onus probandi assignment inversion.The medical service abuse of authority is limited nearly in the mainland legal system country turns over to for the mistake responsibility the responsibility principle,our country "the General provisions of the civil law" is not exceptional.Therefore,to defend the litigant legitimate rights and interests,the servicing procedure to be fair,this chapter thought that the medical service infringement suit must the mistake responsibility principle adapt by the substantive law,the applicable legislation important document classification said the onus probandi assignment rule. For the balanced medical trouble both parties’ lawsuit strength,enables their lawsuit status to achieve the equality basically,the law only then stipulated that certain affects judge to prove the appraisal the lawsuit proved the method is auxiliary in presents evidence the patient who in ability is at the weak trend position.This chapter believed that to safeguard the patient benefit fully,strengthens patient’s procedural capacity and presents evidence ability, the civil action legislation and the judicial practice must see the proof,the copy clerk through the table to propose the voluntary,the certificate hindrance,the fumble proof theory and the rule are in the weak trend auxiliary the patient,urges judge easy to achieve the probability to establishment of the right infringement fact superiority.The sixth chapter the medical trouble dispute decides discusses mainly after the medical trouble dispute sends the sequela lawsuit and the decision circumstance change carries on the discussion.Occurs after the medical trouble dispute civil judgment already sentences the strength,has the litigant not to be able which sues after meets sends the sequela,must allow to sue again.The medical trouble civil legal relationship dynamic characteristic,had decided after already sentences the strength becomes effective,after the zero hour,has the circumstance change,may also sue again.更多还原