【作者】 秦雅静；

【导师】 吴元元；

【作者基本信息】 西南财经大学 ， 人口学， 2014， 博士

【摘要】 近年来医疗纠纷案件在诉讼中呈增长趋势。医患关系日益成为社会关注的热点也是难点。辱骂、殴打甚至杀害医生的事件屡见不鲜,医患关系日趋紧张。造成医患纠纷的原因是多方面的,包括经济因素、政治因素和社会因素等等。法律是定纷止争的重要工具。在法律制度方面,在解决医患矛盾、缓解医患紧张关系、协调医患双方利益方面最重要的制度之一是医疗侵权举证责任分配制度。法律通过举证责任分配制度调整医患双方的利益。在诉讼中,举证责任分配直接关系到诉讼的输赢,尤其是在医疗诉讼中直接关系到法律对医患关系的调整和规制。举证责任分配的一般规则既可以避免一方滥用诉权,也能避免一方滥用抗辩权。由于医疗领域的专业性和特殊性,医疗侵权案件与环境污染、专利纠纷和高空抛物致人损害案件一样,适用举证责任分配的一般规则,不能达到保护医患双方实体权益的目的。医疗侵权举证责任适用特殊规则期间引发了患者的恶意诉讼和医院的防御性治疗,矫枉过正。在这种情况下,法律需要重新设计医疗侵权举证责任分配制度,指引医患双方的行为选择,医患双方从自己的根本利益出发,理性选择诉讼或非诉讼的方式解决纠纷。医疗侵权举证责任分配作为一项具体的微观制度设计,与“三个至上”、“能动司法”和“大调解”相呼应,共同减轻法院的负担。举证责任分配制度影响到法院对医疗侵权案件的判决,法院判决结果又直接影响患者和医院在解决医患纠纷时的策略选择。医疗侵权举证责任分配制度——法院的判决结果——医患双方利益——医患的行为选择——法院的案件数量——医疗侵权举证责任分配制度为文章的逻辑结构。研究医疗侵权举证责任分配制度,分析医疗侵权举证责任分配制度变化的原因,在法律制度上完善举证责任分配规则,妥善处理医患纠纷,保护医患双方的利益,具有重要的理论意义和现实意义。文章分别从实体规则的视角、程序规则的视角、司法实践的视角具体阐述了医疗侵权举证责任分配制度,提出完善医疗侵权举证责任分配制度的建议。文章主要内容如下：第一章,我国医疗侵权举证责任分配制度的演变及其原因。医疗侵权举证责任分配的变化是本文的逻辑起点,并重点分析了医疗侵权举证责任分配制度变化的原因。医疗侵权举证责任变化的原因是多方面的,法院的判决结果关系医患双方的利益,医患双方的博弈导致举证责任分配的变化。医疗侵权举证责任分配影响法院的判决结果,法院的判决结果影响法院的案件数量,案件的数量增多,法官的审判压力增加,司法审判的压力要求改变举证责任分配。在司法体制改革的背景下,法院减负推动了医疗侵权举证责任的变化。因此,医疗侵权举证责任分配的变化及时调整了医患双方和法院的利益,满足各方的利益诉求。第二章,实体规则视角下医疗侵权举证责任分配：过错和因果关系。“过错”和“因果关系”作为侵权责任的构成要件,在医疗侵权司法实践中存在证明上的难度。“过错”证明中,法律通过过错责任原则把举证责任分配给医方,通过无过错责任原则把举证责任分配给患方,医疗侵权过错的举证分配与归责原则紧密相关。医疗侵权“因果关系”证明是困扰理论界和实务界的难题,但是因果关系的举证分配在《侵权责任法》中并未涉及。因果关系的理论颇多,适用责任成立的因果关系和责任范围内的因果关系,影响举证责任分配。第三章,医疗侵权举证责任分配：医疗鉴定视角。医疗侵权举证责任分配在医疗鉴定前双轨制阶段、医疗鉴定双轨制阶段和医疗鉴定后双轨制阶段中适用的规则不同。在实践中,医疗鉴定机构具有中立性,医疗鉴定结论弥补了法官专业知识的不足,减轻医患双方的举证责任。但是医疗鉴定仍然需要从构建专家责任库、增加医疗鉴定的透明度、保障医疗鉴定机构的中立性、公正性和权威性方面,完善医疗鉴定制度,明确举证责任分配。第四章,司法实证视角下举证责任分配：医疗纠纷解决机制。医患纠纷解决方式分为私力救济和公力救济两种。纠纷解决的方式和成本影响医疗纠纷机制的选择,主要从法院解决纠纷的成本,当事人的诉讼成本,包括当事人的诉讼费用,时间成本和其他成本支出,医院的成本,包括医院的赔偿数额,医院的声誉和医生的心理负担方面分析举证责任分配与医院、患者和法院的利益直接相关。法律要对各方利益进行整合和分配,基于成本和现实的考虑,医疗侵权举证责任分配制度变迁是客观需求,是调整医患关系的必然选择。举证责任分配实践运作效应上影响法院的效率与患者纠纷机制的选择。第五章,医疗侵权举证责任分配制度的完善。实体规则上适用过错责任原则,完善证据制度,详细分析了医疗侵权中的书证、物证、鉴定结论、视听资料。司法实践上保障医疗知情同意权,完善举证责任分配制度。介绍医疗知情同意权及医疗知情同意权的行使弥补举证责任分配制度的不足,完善医疗知情同意权,保障举证责任顺利完成。程序上完善医疗举证责任分配制度,具体包括细化“附条件的单项倒置”的“条件”,在医疗举证责任上构建专家辅助制度和证据保全制度。更多还原

【Abstract】 There is a growth trend in medical disputes cases in recent years. Doctor-patient relationship is a hot and also a difficult spot of society. It is a common occurrence that doctors are beaten, insulted and even killed. The reasons causing doctor-patient dispute are complicated, including economic factors, political factors, and social factors and so on. In the aspect of legal system which is an important tool to end disputes, the most important institutional arrangement of law is the burden of proof allocation system in resolving doctor-patient conflicts, alleviating doctor-patient strained relation, coordinating doctor-patient interests. The law adjusts the interest between doctor and patient through the burden of proof. In lawsuit, the burden of proof has the direct bearing on winning and losing, especially in medical cases it is directly related to the legal adjustment and regulation of doctor-patient relationship.The general rule of assignation of burden of proof not only can avoid one party’s abuse of litigation but also can avoid the other party’s abuse of the right of defense. Through medical dispute cases apply the general rule of assignation of burden of proof, it still cannot protect the parties’interests of the entity because of its professional and highly technical, as environmental pollution, patent dispute and cases of the objects thrown from the high hurt a person. During the burden of proof for medical tort litigation apply special rules, it causes patients’malicious action and defensive hospital treatment, being hypercorrect. In this case, the law need to redesign the medical tort burden distribution system, guide the behavior choice of doctor and patient in order that both doctor and patient make rational choice of litigation or non-litigation to settle dispute, from their own fundamental interests. As a specific micro system design, the medical tort burden distribution system is parallel to "the three top","active judiciary" and "big mediation" to reduce the burden of the court. The burden of proof allocation system affects the court decision for medical tort cases. The outcome of the judgment influents strategy selection of both hospital and patient in the process of dispute resolution. The logical structure of this paper is the burden of proof allocation system of medical disputes---the court decision----interests of patient and doctor----the behavior choice of doctor and patient---the number of court cases. It is of important theoretical significance and practical significance to research burden of proof allocation system of medical disputes, analyze its cause, perfect the rules of burden of proof distribution on legal system, properly handle the doctor-patient dispute and protect the interests of doctor and patient.This paper elaborates on distribution of evidential burden of medical tort from entitative, procedural and practical perspective, and put forward some suggestions of perfecting evidential burden.The main contents of this paper are as follows:The first chapter, legislative evolution and its reasons of medical tort’s distribution of burden of proof. Medical tort’s distribution of burden of proof is the logical starting point of this article, selectively analyzing the reasons for changes of distribution of evidential burden of medical tort. The reasons for changes of distribution of evidential burden of medical tort are complicated and the court decision is related to interests of doctor and patient and the game between doctor and patient leads to changes of distribution of evidential burden. Distribution of evidential burden of medical tort influent the court’s judgment and the court’s judgment also influent the number of court cases. The more the court cases are, the higher the judge’s pressure. The pressure of judicial judgment asks for the change of distribution of evidential burden. In the background of reform of the judicial system, the change of burden of proof of medical tort takes place to reduce the pressure of the court. Therefore, the changes of burden of proof of medical tort timely adjust interests of doctor-patient and the court, and thus satisfy the interests of all parties.The second chapter, the entity rules perspective of distribution of evidential burden:fault and causality."Fault" and "causality" as the components of tort liability, it’s difficult to proof in judicial practice of medical tort. In proof of "fault", distribution of proof of medical tort fault is closely related to the principle of responsibility that the law distributes the liability to hospital by principle of liability for fault and the liability to patient by principle of liability without fault. The medical tort causality is a difficulty that puzzles the academe and the law and the causality of distribution of proof is not involved in Tort Liability Law. There is a varied causation theory and applying responsibility of causation and responsibility within the scope of causality influent distribution of burden of proof.The third chapter, distribution of evidential burden of medical tort:the perspective of medical appraisal. The applicable rules of burden distribution of medical tort change with the former double-track phase, double-track phase and later double-track phase of medical appraisal. In practice, medical appraisal institutions are neutral, and medical appraisal conclusion makes up for the lack of professional knowledge of the judge and reduces the burden of proof of doctor and patient. However, it still needs to perfect the identification of medical system and definite distribution of evidential burden from the aspects of building expert auxiliary system, increasing transparency of medical appraisal and guaranteeing the neutrality, impartiality and authority of medical appraisal institutions.The forth chapter, practical perspective of distribution of evidential burden: doctor-patient dispute resolution mechanism. Doctor-patient dispute resolution mechanism divides into private relief and public relief. The way and cost of dispute resolution influents the choice of medical dispute resolution mechanism, mainly discussing the direct relation among distribution of proof, hospital and patient and the court from the aspects of court’s cost of solving dispute, the party’s lawsuit cost including lawsuit fees, time cost and other costs and cost of hospital including compensation, reputation and doctor’s heart burden. The law needs consolidation and distribution of interests of all parties. Taking cost and the reality into consideration, the change of distribution of medical tort’s evidential burden is a necessary choice to adjust the doctor-patient relationship. Practical operation effect of distribution of evidential burden he produce an effect on court’s efficiency and the guidance of distribution of evidential burden on patients’choice of dispute resolution mechanism.The fifth chapter, perfection of distribution of medical tort’s evidential burden. On entity rule, there is application of principle of liability for fault and perfection of the evidence system, introducing documentary evidence, physical evidence, expert conclusions and audio-visual materials in medical tort in detail; On judicial practice, it guarantees medical informed consent and perfects distribution of medical tort’s evidential burden and introduces medical informed consent and the exercise of medical informed consent right to make up for the inadequacy of the burden of proof for completing the burden of proof. On procedure, the perfection of burden proof of medical tort includes refinement of the "condition" of "conditional single inversion" and the establishment of expert auxiliary system and evidence preservation system.更多还原