二十一医疗纠纷.docx

二十一医疗纠纷.docx

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二十一医疗纠纷

二十一医疗纠纷

第二十一章

医疗纠纷与医疗事故

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教学纲要

教学要求：

1.掌握：

医疗纠纷的概念与特点；医疗事故的概念与构成的条件；医疗纠纷的类型和发生原因；医疗事故的类型和发生的原因；法医在医疗纠纷和医疗事故鉴定中的作用；法医尸体解剖在医疗纠纷处理中的作用；非法行医的概念与常见类型。

2.熟悉：

医疗事故的分级；医疗纠纷或医疗事故的处理程序；鉴定及鉴定程序；医疗纠纷法医病理学鉴定注意事项。

3．了解：

医疗纠纷和医疗事故民事责任的确定；医疗纠纷和医疗事故行政责任的确定；医疗纠纷中的刑事责任。

【教学内容】

第一节概述

一、医疗纠纷的概念与特点

二、医疗事故的概念与构成条件

第二节医疗纠纷与医疗事故的类型和发生原因

一、医疗纠纷的类型和发生原因

二、医疗事故的类型和发生原因

三、医疗事故的分级

第三节医疗纠纷与医疗事故的责任类型

一、医疗纠纷或医疗事故民事责任的确定

二、医疗纠纷或医疗事故行政责任的确定

三、医疗纠纷中的刑事责任

第四节医疗纠纷或医疗事故的处理与鉴定

一、医疗纠纷或医疗事故的处理程序

二、法医在医疗纠纷和医疗事故鉴定中的作用

三、法医尸体解剖在医疗纠纷处理中的作用

第五节非法行医与非法行医罪

一、非法行医的概念与常见类型

二、非法行医罪

一、单选题

1、《医疗事故处理条例》规定患者死亡，医患双方当事人不能确定死因或者对死因有异议的，应当在患者死亡后（）小时内进行尸检。

拒绝或者拖延尸检，超过规定时间，影响对死因判定的，由拒绝或者拖延的一方承担责任。

A、96B、72C、48D、24

二、名词解释

1、医疗纠纷（medicaltangle）

2、医疗事故（medicalnegligence或medicalmalpractice）

3、医源性医疗纠纷（iatrogenicmedicaltangle）

4、医疗过失纠纷（tanglefrommedicalfault）

5、非医源性医疗纠纷（noniatrogenicmedicaltangle）

6、医疗意外（medicalaccident）

7、一级甲等医疗事故

8、一级乙等医疗事故

9、假药

10、劣药

11、非法行医（illegalmedicalpractice）

三、问答题

1、医疗事故的构成条件有哪几点？

Italy:

medicalnegligenceasacrime

MedicalnegligenceclaimsinItalyareontheincrease.Intheabsenceoflegalaid,mostclaimantspursuedoctorsviathecriminaljusticesystembutwithastandardnotof“beyondallreasonabledoubt”butmerely“onthebalanceofprobability”.Asaresult,mostcasesaresettledoutofcourt,oftenregardlessofmerit.Mostdoctorsnowliveinfearthatthenext“informingwarrant”maybeforthem.

TheItalianhealth-caresystemhasundergonesignificantchangeinrecentyears.Forexample,theformerUSLs（localhealthauthorities）arenowcalled“firms”andthebalanceofincome/expenditureisameasureofperformance.Ashareofthe“profits”isallocatedtomanagementandhealthworkersinsomeunits.Thehandlingofmedicalnegligencehasalteredtoo.OnJune2,1999,Italy'sciviljusticesystemrevertedtoatwo-trackprocedure.Italyprovidesnolegalaidandmostcasesofallegedmedicalnegligencearepursuedviathecriminalcourtsatnocosttotheclaimant.Alternativedisputeresolutionisseeingsomegrowth.

Civilprocedure

Forclaimantswhocanaffordcivillitigation,therearenoparticularregulationsorprotocolsthatmightdeliverafast,efficient,effective,andeconomicalservice.Theprocesscanbeslowandbureaucratic,somecasestakingmanyyearstocometotrial.TheCodiceCivileregulatestherelationsbetweendoctorandpatientbutwithrulesapplicabletoanyintellectualprofession.

Before1995therewereonlytworoutes,thePreturaandtheTribunale（sittingwiththreemagistrates）.Thenathree-tracksystemwasestablishedtospeedupciviljusticeandinamannersimilartotherecentWoolfreformsintheUK.1Thesystemaimedtoallocatecasesappropriatelytooneofthreetracksandattemptedtointroducesomerulesandguidelinesfortheactivemanagementofeachparticularcase.Thethreetrackswere:

thegiudicedipace（ajusticeofthepeace,oftenalawyer）;thepretore,ajudgesittingalone;andthetribunalecivile,withthreejudges,formorecomplexcases.Thegiudicedipacelargelyachievedtheobjectivesofspeedingupproceedingssothatclaimsupto5millionlire（£1700）couldbeheardwithinayear.Doctorsspecialisinginmedicallawwereoftencalledtoestimatedamages.

Thepretoreheardcasesupto30millionlire（£10000）.Againtheproportionofcasesdealtwithinlessthanayearincreasedsignificantlybetween1995and1999.Claimantanddefendantcalledexpertsandthejudgecalledhisownmedicolegalcourt-appointeddoctorandspecificexperts.Themedicolegaldoctorwasaskedtogivehisopinionofcurrentbestpractice.However,thiswasnottheBolamstandard,wherethedoctorisjudgedagainstthereasonableandacceptablepracticeofthetime（notbestpractice）.Decidingwhatcontemporarybestpracticeiscanbedifficultenough,anditisevenmoredifficulttosaywhatbestpracticewasatthetimeoftheeventcomplainedof.ThispretorelevelwasabolishedfromJune,1999.

Thetwo-tracksystemintroducedinJunelastyearretainsthegiudicedipacebutthetribunalsnowsitwithasinglejudge.Havingonejudgeinsteadofthreereducesthetimetakenforcasestocometocourtandthecostofindividualcases.Toaccessthenewsystemapatientseekingcompensationviatheciviljusticesystemusuallyhastogetasecondopinionfromanotherconsultantorfromthespecialistmedicolegaldoctor（seebelow）toestablishwhetherornotthereisaprimafaciecaseofnegligence.

Withinthecivilsystemproblemsremain,despitetherecentchanges.Thereisnostrictcasemanagement;vastnumbersofexpertsmaybecalled;theabsenceoflegalaidpromptsclaimantstopursuedoctorsviathecriminalroute,leadingtocriminalcharges,guiltyverdicts,andonoccasionprisonsentences;thestandardofproof（"bestpractice”）hasyettobedefinedinItalianlaw;andtheroleofthemedicolegaldoctorisparamount.

Themedicolegaldoctorisaspecialisttrainedinmedicineandlaw.Heorshewilloftenbeappointedbythecourtandwillhaveadutytothecourt,advisingthecourton“bestpractice”.Thisadvicecanbedifficultsincetherewillbeexpertsfortheclaimantandforthedefencefromdifferentschoolsofthought.Medicolegaldoctorsmayalsocalltheirownexpertstosupportaparticularviewofbestpractice.

Themedicalexperthasadutytotheclient（claimantordefendant）,notthecourt.Allinformationgleanedduringproceedingsandinstructionsisprivileged.MedicalexpertshavebecomeagrowthindustryinItaly（alongwiththeriseinlitigation）.Significantnumbersofexpertsmaybecalledatanyonetrial;numbersarecontrolledtosomeextentsincethenumberofexpertscalledforeachsidemustbeequaltoorlessthanthenumbercalledbythejudge.Expertsareoftenseenasworkingonthedefenceorclaimant'steamsratherthanbeingindependentprofessionals.

Criminalprocedure

TheItalianhealth-caresystem,publicandprivate,hasfacedanexponentialriseinnegligenceclaimsoverthepast10years.Mostoftheseclaimshavebeenpursuedthroughthecriminalcourts.Thisavenueisfreetotheclaimant,andthestatebearsalltheexpenseofevidencegatheringandprosecution.Thismeansofredressisvitallyimportantforthepoorbuttherearehugenumbersofillfoundedclaimstoo.

Thecriminalinvestigation1beginswiththedoctorreceivinginformazionedigaranzia（informingwarrant）followingallegationsofprofessionalnegligenceafterthedeathofapatient（culpablehomicide）orduetosomeomissionorcommissioncausingthepatienttobeunwell,ortohavedelayedorinappropriatetreatment,misdiagnosis,orpermanentdisability.Homicideisusuallypursuedattheinstigationofthepolicewhileallegationsofmedicalnegligencewithotherconsequencesareprosecutedonlyifthepatienthaslodgedacomplaint.Criminalproceedingsincasesofnon-fatalinjurycanbestoppedatthebehestoftheclaimant,usuallywhenthecaseissettledbeforetrial,whichitoftenis.

Theprosecution,thedefence,andthecourtitselfwillappointtheirownexperts.Ajudgeforthepreliminaryinquiriesmayalsobeaskedtointervenewhentheneedtoappointadifferentexpertisfelteitherbythedoctororprosecutor.Thisappointeewillbesuperpartes（ie,notactingforeitherside）andswornin,whereastheprosecutor-appointedoneisnot.

Whenanecropsyisorderedbytheprosecutor,thedoctorsbeinginvestigatedhavetobesentwarrants.Theprosecutormayevenissueawarrantagainstunknowndefendantsornameasmanydoctorsashecanfindonthehospital'sstafflist.Doctorscanthusfindthemselvesdefendantsandconfrontedbyanecropsyreportwiththebodyalreadyburiedortheycanfindthemselvesnamedinamultidefendantsuitindiscriminately“justtobeonthesafeside”.

Whenadeathisnotinvolvedtheprosecutordoesnothavetoinformanyone,andsecrecydictatesthatareportcanbebasedondocumentsandsurreptitiousexaminationofthepatient.Thefirststepisoftentosequestertheclinicalnotes,leavingthedoctorwithoutaccesstohisownrecords.Evenifthedoctorknowsoftheexistenceofimportantdocuments,thesemaybewithheldatthediscretionoftheprosecutor,including（andfrequently）,favourableexpertreports.Adeterminedprosecutormaycommissionseveralreportsuntiloneexpertdamnsthedoctor—andthatistheonlyreportpresentedtothecourt.

Tomakemattersworse,thestandardofproofusedbythecourtinacriminalprosecutionofadoctoris“onthebalanceofprobability”.Inmostcasestheinsurerpaysoutandtheclaimantwithdrawsthecaseevenfromthemosteagerofprosecutors.

Warrantsareservedondoctorsattheirplaceofwork,andwithinahospitaltheresultcanbeaclimateofsuspicionandwitch-huntswithsomemanagersanddoctorsinconfrontation.Medicalcolleaguescanbefoundaskingwhothecurrentscapegoatisorhowmuchitwillcosttogetoutofthelineoffire.Thepsychologicaleffectsontheprofessionandthenegativeeffectsonperformancearedifficulttogaugebutdisenchantmentisnowthenorm.Itisalsonotuncommontohearpatients,ontheirfirstapproachtomedicalservices,stateaclearindicationofsuingiftheydonotgetbetter.Isthisthewaytopractisemedicine?

DoctorsinItalytodayareformingalternativeplanstoseethemselvestoretirement,toavoidhavingtoseekpsychiatrichelporthehassleofbeingusedandabusedbythisgrotesquesystem.

一、单选题答案

C

二、名词解释答案

1、医疗纠纷（medicaltangle）

指患方因对诊疗护理过程中发生的不良医疗后果及其产生的原因与医方认识不一致而发生纠纷和争议，要求追究医方责任和赔偿，而向卫生行政管理部门提出处理或向司法机关提请司法诉讼的案件。

2、医疗事故（medicalnegligence或medicalmalpractice）

指医疗机构及其医务人员在医疗活动中，违反了医疗卫生管理法律、法规、部门规章和诊疗护理规范、常规，过失造成患者人身损害的事故。