非法行医致人损害，患者起诉是否适用举证倒置？

论医疗纠纷中的举证责任关于医疗纠纷中的

作者单位: 中国人民大学 中文题名: 医疗事故民事举证责任问题探讨 外文题名: The Research on the Burden of proof of the Medical Malpractice 著者: 郝晓明 语种: 保密级别: 公开 学位级别: 硕士论文 答辩日期: 2004-06-01 所属院系: 中国人民大学 著者专业: 法律硕士 导师姓名: 姚欢庆 导师单位: 中国人民大学 中文文摘: 自建国以来，医疗纠纷就在社会生活中经常地、大量地存在，1978年以前主要由人民法院以及卫生行政部门处理，缺乏法律的规范。 1987年6月29日国务院发布的《医疗...全部

  作者单位: 中国人民大学 中文题名: 医疗事故民事举证责任问题探讨 外文题名: The Research on the Burden of proof of the Medical Malpractice 著者: 郝晓明 语种: 保密级别: 公开 学位级别: 硕士论文 答辩日期: 2004-06-01 所属院系: 中国人民大学 著者专业: 法律硕士 导师姓名: 姚欢庆 导师单位: 中国人民大学 中文文摘: 自建国以来，医疗纠纷就在社会生活中经常地、大量地存在，1978年以前主要由人民法院以及卫生行政部门处理，缺乏法律的规范。
  1987年6月29日国务院发布的《医疗事故处理办法》是第一部处理医疗事故的行政性法规，在当时的社会经济等历史条件下，对医疗纠纷的处理，维护医患双方的合法权益，保障医疗秩序和医疗安全，起到了积极的作用。
  随着市场经济体制的建立，行政处理模式失去了存在的基础，2002年9月1日国务院制定的《医疗事故处理条例》（以下简称《条例》）正式施行。新《条例》对医疗事故的概念做了明确的界定，把医疗事故民事责任的性质归属于民法上的侵权责任。
  2002年4月1日《最高人民法院关于民事诉讼证据的若干规定》正式实施。该《规定》第4条规定：“下列侵权诉讼，按照以下规定承担举证责任：“……由医疗行为引起的侵权诉讼，由医疗机构就医疗行为与损害结果之间不存在因果关系及不存在医疗过错承担举证责任。
  ”最高人民法院这一司法解释将过错推定原则作为医疗事故民事责任的归责原则，明确了在医疗事故纠纷案件中实行举证责任倒置，为近年来在医疗事故纠纷案件中的举证责任之争论划上了一个句号。 在我国目前的医疗事故纠纷解决机制中，诉讼占据着主要地位，举证责任的分配在一定程度上决定着实体法的应用，从而决定着诉讼的结果。
  依民事诉讼法的规定，举证责任遵循“谁主张，谁举证”的原则，这一原则也一直被运用于医疗事故纠纷的审理中。而在医疗事故纠纷中处于弱势地位的患者一方往往由于举证困难而最终败诉，其合法权益未得到应有的保障，而患者在因无法举证败诉后可能就会导致“私力救济”，与医生和医疗机构发生冲突，从而激化了矛盾。
  实行医疗事故举证责任倒置后，由医疗机构就医疗行为与损害结果之间不存在因果关系及不存在医疗过错承担举证责任，作为被告的医方，在医疗过程中保有全部的医疗行为的证据（诸如病情诊断、手术记录之类的材料），因此由持有证据的医方对过错事实承担举证的责任，更有利于查清事实，体现了民法的公正和效率的原则，同时在一定程度上缓解了医患矛盾。
   医疗事故纠纷实行举证责任倒置，扩大了对患者的保护范围，增加了医疗机构的举证责任，但并不意味着所有的举证责任均由医疗机构承担，患者也要承担一定的举证责任，即患者应当就自己受损害的事实和接受过医疗的事实提出证据。
  医疗机构只是对医疗行为与损害结果之间不存在因果关系及不存在医疗过错承担举证责任，即医疗机构只要证明医疗行为与损害结果不存在因果关系或只要证明主观上无过错就不承担责任。在实行举证责任倒置后，作为民事诉讼的证据之一的医疗事故鉴定结论属于医疗机构的举证范围，应由医疗机构提供。
  《条例》中规定了6种不属于医疗事故的情形，医疗机构可以不承担赔偿责任。另外考虑到医学科学的特殊性，对于一些特殊的情形医疗机构可以免责，包括：患者知情同意采取的医疗措施、必须通过尸体解剖才能确定死因而患者家属拒绝的、涉及医疗事故技术鉴定而患者拒绝配合的情况。
  免责并不意味着医疗机构的举证责任可以免除，医疗机构要有充分的证据证明上述情形的客观存在，从而证明自己无过错或医疗行为与损害结果之间无因果关系。 《条例》和《规定》的相继出台，进一步加强了向在医疗纠纷中处于弱势地位的患者倾斜，对患者和医疗界的影响是不言而喻的，存在的问题也是不可忽视的。
  来自患者方的问题主要有：1。 患者的举证意识减轻，出现了只要是不满意或怀疑治疗就去告医院的情况，在一定程度上干扰了医院的正常工作；2。 虽然≤规定≥第61条规定了“专家辅助人制度”，但是由于医疗事故纠纷具有极强的专业性，在我国目前的情况下，患者实际是很难聘请到具有专门知识的医学专家出庭就专门性问题进行说明。
  同时，医疗界对实行举证责任倒置也普遍存在着担心，主要有：1。 减轻了患者的举证责任，医院的官司会越来越多；2。 医学上尚有许多未知的难题造成医疗方举证困难；3。由于患者的原因造成误诊等情况医院也难以举证等；4。
   由于医生担心自己被起诉而采取“防御性医疗”态度，将在一定程度上影响医学的发展。对于患方存在的问题，有待于立法的进一步细化以增强其操作性，另外培养专门的卫生法律人才也是解决问题的途径之一。而医疗机构以及医务人员应当认识到实行举证责任倒置的必要性和强制性，在医疗、护理过程中严格遵守法律、法规和卫生部颁布的卫生规章、操作常规和规范，在诉讼中提出相应的证据并不是很困难。
  至于因人类认知而引起的误诊事故，只要能提出相应的证据也是可以免责的。在规范和制度层面上，《条例》和《规定》对于举证责任的规定还需细化，可以借鉴大陆法系一些国家在证据问题上的救济制度，由法官根据医疗方在医疗事故中的过失程度，合理公正地分配举证责任，即赋予法官一定的自由裁量权；另外，应在新的《民法典》中明确规定医疗事故侵权责任，同时加快民事证据立法工作；最后，应建立完善包括医生执业保险制度在内的医疗保险制度，以解除医生的后顾之忧，降低医疗机构的经济风险。
   诚然，医疗行为必定伴随着风险，但是医患之间的沟通可能会使这种风险大大降低，医疗方应当在严格遵守医疗规章制度的基础上，提高医疗技术水平，尊重并确保患者的知情权和选择权。而作为患者，也应当对医护人员多一份理解和协助。
  愿立法及司法能遵循民事立法的价值取向合理地分配举证责任，一方面保护医疗事故中处于弱势地位的患者之权益，更加切实保护公民之基本人权；一方面保护医务人员开展科研和教学的积极性，保证医学科学的稳步发展。
  相信在法律工作和医务工作者共同的不懈的努力下，随着民事法律和医事法律的完善和健全，将使医患关系走上更加健康发展的法制的轨道。 外文文摘: From the foundation of the Republic of China, the medical disputes exists regularly, heavily in the society, and they are mainly settled by the people’s courts and the health administrative departments, and lack the legal stipulation。
   The 《procedures for the handling of medical malpractices》,enacted by the state department on June 29th, 1987 is the first administrative statute to settle the medical malpractice, and it did played an important role in solving the medical disputes , protecting the respective legal rights and interests of the hospital and the patients, maintaining the medical order and medical safeness under the background of that time。
   However, along with the foundation of the market-oriented economy system, the module of administrative handling has lost its existing basis。
   On September 1st, 2002, the 《the handling ordinance of medical malpractice》 (referred as 《ordinance》 below) was formally putted into practice, the new 《ordinance》 explicitly defined the definition of “medical malpractice”, and attributed the nature of the civil liabilities of medical malpractice to the tort liabilities in civil law。
   On April 1st, 2002, the 《the supreme court’s some stipulations concerning the civil litigation evidence》 was formally put into practice, the article 4 of the 《stipulation》 provides:“ the tort litigations below should assume the burden of proof according the stipulations below：“……for the tort litigation caused by the acts of medical treatments, the medical establishments should bear the burden of proof to prove there is no causality between the acts of medical treatment and the harmful consequence, and to prove that there are no medical faults。
  ” The judicial interpretation herein of the people’s supreme court explicitly provided the doctrine of the liability fixation of the medical liability as “liability of fault”, that is to say the swift of burden of proof apply in the cases concerning with the medical malpractice, and this ended the arguments of the burden of proof in the medical malpractice cases。
   In the current mechanism of the settlement of the medical malpractice disputes, litigations play a major part, and the allocation of the burden of proof decides the application of the substantive law to some extent。
   According to the provisions of the civil litigation, the burden of proof apply the principle of “ who claim, who adduce evidences”, and the principle has always been used in the settlement of the medical malpractice, thereto the patients party who are in the disadvantage status in the disputes of medical malpractice always lose in the litigation because of the difficulty to put forwards evidences, and their lawful rights and interests cannot be protected reasonably。
   And when the patients loose the lawsuit because of the difficulty of producing evidence, they may appeal to “private remedy”, and the conflict between them and the doctors, the hospital may happen, and the contradiction may become more and serious。
   And after the application the swift of burden of proof, the medical establishments are responsible for the burden of proof to prove that there is no causality between the acts of medical treatment and the harmful consequence, and to prove that there are no medical faults The medical establishments, as the defendants in the litigation, kept all the evidence (such as materials relating with diagnosis of the states of illness, operation reports) of the acts of medical treatments during the medical treatments, so it is convenient to discover the facts and incarnate the fair and efficient principle of the civil law and to some intent relax the contradiction between the medical establishments and the patients by attributing the burden of proof to the medical establishment who maintain the evidences。
   The application of the swift of burden of proof in the settlement of the medical disputes extends the protective range for the patients, and adds the burden of proof of the medical establishments, but that does not mean all the burdens of proof herein should be born by the medical establishments。
   The patients should also bear some burden of proof, and that is to say the patients should put forwards evidences to proove the facts that they have been harmed, and to prove they have accepted the treatments of the medical establishments。
   The medical establishments are only responsible for the burden of proof to prove there is no causality between the acts of medical treatment and the harmful consequence, and to prove that there are no medical faults。
   That is to say the medical establishments only need to prove there is no causality between the acts of medical treatment and the harmful consequence or to prove they have no subject faults, and then they will bear no responsibilities。
   Additionally, the 《ordinance》 stipulates six events that do not belong to medical malpractice in which the medical establishments should not bear any liabilities for compensation。
   In addition, in consideration of the particular characteristics of the medical science, the medical establishments can be exempted in some conditions, these include: the medical treatments applied with the prior content of the patients; the cause of death of the patient can only be certified by anatomy, but his/her folks refused; in the event that concerning with the survey of the medical malpractice, but the folks of the patients refuse to assist; exemption does not mean the burden of proof of the medical establishments can be exempted, the medical establishments should prove the existence of the conditions referred above with adequate evidences, and so to prove there are no faults of themselves or there is no causality between the acts of medical treatments and the harmful consequences。
   To determine the medical malpractice that with high professional difficulty and complex sequence of events, the technical evaluation procedures of medical malpractice are always necessary。
   After the application the swift of the burden of proof, the results of the evaluation of the medical malpractice belong to the area of the burden of proof of the medical establishments, and should be provided by the medical establishments。
   The results of the evaluation of the medical malpractice， as one form of evidences of civil litigation, need the check and analysis of the judgers, and must have the substantive prove materials of the parties, and we should not give up or omit to analyze whether the medical establishments have faults。
   The successive enactments of the 《stipulation》 and the 《ordinance》 strengthened the inclination to the patients who are in the weak status in the medical disputes further, the influences of them on the patients and the medical circles are evident, but the existing problems are also cannot be neglected。
   First, the awareness of the patients become weaker, they may appeal to the lawsuits when they do not satisfy or suspect the medical treatment, and this may disturb the regular works of the hospitals。
   In addition, as the strong professional specialty of the medical disputes, so although the article 61 of the 《stipulation》 provides the “ system of the experts assistants”, in the current situation of our country, the patients have difficulties to find the medical experts to appear in court and explain the professional problems。
   Second, there are prevalent worry about the application of the swift of the burden of proof in the medical circle, they mainly worry about: their lawsuits may become more and more by reliving the liabilities of the patients; there are some medical difficulties which have not been resolved that hamper the medical establishments to adduce proofs; and the hospital is difficult to produce evidence for the misdiagnosis because of the patients; in addition, as the doctor may apply the attitude of “defense treatment” in order to avoid the lawsuit against himself, this may to some extent affect the developments of the medical science。
   For the problems belong to the patients, the detailed provisions of the legislation is needed so to strengthen the operability, and to culture the expert salutary and law qualified personnel is another approach to settle the problems。
   While, the medical establishments and the medical stuff should recognize the necessary and compulsory characteristic of the application of the swift of the burden of proof, and it is not difficult to put forwards the corresponding evidences in the litigation when they have strictly complied with the laws, statutes and the salutary regulations, operative general rules and codes during the medical treatments and the nursing periods。
   And for the misdiagnosis accidents because of the limited recognizing competent of human being, they can also be exempted when they can put forwards corresponding evidences。
   In addition, we can apply different allocation of the burden of proof for the medical malpractices with different faults。
   Last, we should build and perfect the systems of medical insurance that including the system of the insurance for of the certified doctor to relax the worry of the doctors and so to decrease the economic risks of the medical establishments。
   The risks do necessarily accompany with the acts of medical treatments, but the communications between the medical establishments and the patients may decrease the risks heavily, the medical establishments should promote their level of medical technique , adore and ensure the right to learn the truth and the rights of option of the patients premised under the strictly complying the regulations of the medical treatment。
   Meanwhile, the patients should also give more understanding and more assistance to the medical personnel。
   We wish that the legislation and the judicature can comply with the value orientation of the civil law legislation and allocate the burden of proof reasonably, and protect the rights and interests of the patients who in the disadvantage status in the medical malpractice, and protect the basic human rights of the citizens step by step on one side, and on the side, protect the enthusiasm of the medical personnel to do scientific researches and teachings, and ensure the static developments of the medical science。
   We firmly believed that by the cooperative efforts of the law and medical personnel, and along with the completeness of the civil law and the medical law, the relationship between the medical establishments and the patients will step into the orbit of law with more and more ability to develop healthily。
   关键词: 医疗事故、举证责任、举证责任倒置、Medical Malpractice、proof、the Burden of proof 作者单位: 北京大学 中文题名: 医疗责任事故问题研究 外文题名: 著者: 王伟 语种: 中文 保密级别: 学位级别: 法学硕士 答辩日期: 2001-06-08 所属院系: 法学院 著者专业: 法律硕士 导师姓名: 佟强 导师单位: 法学院 中文文摘: 医疗纠纷问题是社会上目前关注的热点问题之一，由于现行的法律、法规 关于医疗事故问题的规定与社会发展的现状不相适应,因医疗事故导致的法律问题不断增多。
  这类问题主要集中在以下几个方面：(一)医疗事故民事责任性质不清楚；(二)医疗事故的鉴定程序缺乏公正性；(三)在处理医疗事故民事赔偿的问题上，法律适用不统一。本文着重医疗责任事故的民事责任性质问题进行论述，论述了医疗责任事故中行为人给病人造成不良损害后果的行为的法律性质，及医疗责任事故的民事责任性质，提出在我国现阶段的社会制度及社会条件下，应适用侵权责任解决医疗责任事故的民事责任问题，其赔偿原则应当遵循侵权损害赔偿原则。
  同时提出，为了切实地保障受害人的合法权益,在适用侵权损害赔偿原则追究医疗责任事故行为人的损害赔偿责任时，应当将举证责任倒置的法律规则引入医疗责任事故法律制度中。本文强调了建立医疗责任事故法律制度的重要性和必要性。
  同时指出医疗技术事故中行为人的不当行为的特征，并将医疗责任事故与医疗技术事故从法律性质上加以区分。提出医疗技术事故民事责任的赔偿应当适用限额赔偿原则。这种区分意义十分重大，既能严厉地处罚违反义务的行为人，对在医疗服务过程中，严重不负责任的行为人给以惩罚；又能维护医疗机构的利益，更大地调动广大医务人员的积极性和创造性，更广泛地保护公民的生命健康权益，以及不断地促进医学科学事业的进步。
   外文文摘: 关键词: 医疗责任事故,侵权行为,侵权责任 。收起