关于我国医方权利的法学研究

【作者】 张慧姝；

【导师】 图娅；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2010， 博士

【摘要】 在全社会稳步向民主、法制的和谐社会迈进之时,医师的执业生存环境却日益恶化。医疗行业是一种高科技、高风险、高责任、高奉献的职业。职业的公益性决定了医师权利义务分配的不平衡性,医师被要求履行更多的职业义务与伦理义务。发达国家普遍从法律和制度层面保障医师执业权利的实现和享有较高的社会地位及收入,并建立了完善的商业保险制度和社会保障制度来救济这种权利义务失衡的状态,分担医师的执业风险。反观我国,医师的权利保护现状令人担忧：医师工作时间长、负荷重,工资水平、福利待遇低,付出与所得不成比例；媒体的舆论误导致使医务人员无法享受应得尊重与理解；医疗责任保险制度不健全,无法分担医师的执业风险。医师在医疗执业中承担了过多的法定义务、道德义务和法律责任,这种生存执业环境使医师的身心受到伤害。如何改善医师恶劣的执业环境,全面保障医方的合法权益,本文拟从三个方面进行研究与探讨。第一部分医方权利概述本节讨论的主要内容是医方权利概况。首先,通过对医方权利的法律渊源的详细列举,归纳出医方权利的具体内容。医方包括医疗机构和医务人员,相应的,医方权利是医疗机构的权利和医务人员的权利两部分的合称。根据我国相关法律法规规定,医疗机构享有医疗费用请求权、管理权、中止履行权及法人享有的其他合法权利,如财产权、名誉权、知识产权等相关权利。医务人员权利中,医师权利是本文探讨的重点,故未涉及护士及其他医技人员的执业权利。医师享有以下权利：执业特权和相关权利。执业特权又包含询问权、检查权、诊疗权、证明权、特殊干预权、医疗行为豁免权、医疗裁量权。相关权利包括执业保障权、获得报酬权、获得尊重权、专业研习权、参与民主管理权等方面。其次,归纳医方义务及患者权利义务,探讨医患间权利义务的关系。根据权利义务的一般法理学研究,结合医患关系的特殊性,得出结论：医患之间的权利义务关系是医患法律关系的核心内容。医方权利的实现与医方义务、患者的权利义务密不可分。医患关系中,医患双方权利义务具有统一性、一致性、平等性等特点。再次,对不同医学模式下的医患关系进行总结,分析医患双方权利义务的变迁。从医学诞生至今,人类社会经历了四种医学模式。远古时代,神灵主义医学模式时期巫医同源,巫医作为神的旨意的执行者,具有至高无上的权威。反之,病人被认为是被神抛弃的人,氏族部落成员对其往往不闻不问,听任自然。病人的权利同医师的义务一样无从谈起。自然哲学医学模式时期,东西方医德伦理均获得长足发展,医师竭尽所能解除病人病痛,患者真诚信赖医师,将健康与生命完全交于医师之手,无权利可言。生物医学模式时期,机械论在医学中的运用,将医患关系机械化、物化和非人性化。高度发达的医学技术和物化的医患关系使医师权利到达了顶峰,医师在治疗中拥有绝对的权威,家长式医疗盛行,病人只有服从的义务。现代生物-心理-社会医学模式时期,病人权利运动风起云涌,病人的自主权受到尊重,医师的权利范围缩小,须履行更多法定义务和道德义务,医患间地位更加趋于平等。结论：纵观各个医学模式,医患间权利义务变迁呈现出医方权利范围日益缩小,同时被课以更多义务的趋势。第二部分医方权利各论理论研究及法律保护上篇医方权利各论理论研究在医疗实践中,医方的某些权利缺乏立法保护或制度支持,医方在行使权利时因权限界定的模糊而无法真正享有这些权利。医方权利保护不力所产生的不良影响损害了医患双方的合法权益,导致医患关系恶化,成为引发医疗纠纷的导火索。具体而言,医师的特殊干预权、医疗裁量权、医疗行为豁免权和医师执业保障权存在保护不力的问题,本节对上述各权利的内涵、渊源、表现形式逐一探讨,并结合国外相关理论研究现状和司法实践,分析各权利保护不力的成因及不良影响,以期找到完善立法建设和制度保障的方法。内容分述如下：特殊干预权是医师的基本权利之一,但我国尚未对该权利以明确的权利形式予以立法肯定,只在《侵权责任法》中以抢救危重病人的适格行为中规定了该权利,及在《执业医师法》中以强制义务形式出现。特殊干预权立法地位模糊,由于于法无据,医师无法采取某些必要医疗行为,直接损伤了患者的生命健康权益。最典型的例子是“肖志军拒签案”。梳理国内外理论研究和实践经验发现,日本、美国成文法中均规定了特殊干预权的权限范围、适用条件、法律效力并辅以可行程序,具有很强的实践性。我国理论界也多对该权利的立法意义持肯定意见。通过分析患者医疗自主权、家属的代理权限与医方特殊干预权之间的权利冲突,可以得出以下结论：明确特殊干预权的法律地位,完善权利的行使要件和程序,可以制约患者及家属滥用自主权和代理权限,有利于实现患者的最佳利益。医疗裁量权有广义、狭义之分,广义权利是指在治疗疾病的过程中,医师有根据病情的变化决定治疗方案并随时调整治疗方案的权利,狭义权利是指医师履行告知义务时对病情告知尺度的裁量。我国《执业医师法》第二十六条规定医师履行告知义务时应避免对病人产生不利后果,这是医疗裁量权法的渊源。日本、美国等国对医疗裁量权的规定多见于司法实践的判例中,承认医师的医疗裁量权是各国司法的通例。反观我国,对医疗裁量权界定不明导致医师行使该权利时与患者的知情同意权发生冲突。明确医师的医疗裁量权,完善告知义务履行程序是解决权利冲突的途径。医疗行为豁免权是一个较为特殊的权利,它在上升为法律权利之前就一直作为一条重要的伦理学原则长期存在着。分析医疗行为的特点,可以发现医疗行为的侵袭性、高风险性和医学技术的局限性决定了医疗损害必然发生,这就构成了医疗行为豁免权的免责事由。医疗行为豁免权在医疗实践中的运用主要体现在两个方面：手术知情同意书免责条款的效力探究和无过失医疗损害赔偿责任的认定。尽管大多数学者认为目前我国医疗机构拟定的手术知情同意书的免责条款不能成为免责的依据,但笔者从法理学、伦理学的双重角度论证免责条款具有合理性,应被法律所承认和保护。目前,我国公立医院的无过失医疗损害赔偿责任主要由医院承担,这明显显失公平。明确医疗机构享有医疗行为豁免权方能从根本上减轻医方因无过失医疗损害而产生的赔偿责任。执业保障权本节讨论的执业保障权是基于医师的执业特权而产生的广义的执业保障权。包括获得报酬权、执业保障权(狭义权利：医师在各类医疗卫生机构执业,有权获得与其执业活动相当的医疗设备基本条件,医疗卫生机构应当提供相应的基本条件并逐步改善提高,保证医师执业技能和水平的充分发挥。)、专业研习权、获得尊重权等内容。笔者选取北京一至三级六家医院投放180份医师工作满意度调查问卷,考察北京地区医师工作满意度情况,统计结果后发现医师工作满意度普遍较低,结合文献资料得出结论：尽管《执业医师法》对上述权利做了明确规定,但现实中医师权利保护不力的现象广泛存在,已成为医师执业环境恶化的首要因素。尽快建立完善的医师执业保障权利制度体系,加大司法保障力度,方能从根本上改善医师执业环境,保护医师合法权利。下篇医方权利各论法律保护我国目前虽有《执业医师法》、《医疗机构管理条例》、《医疗事故处理条例》等一系列调整医疗活动中社会关系的法律法规和行政规章,但尚未形成一个完整的、调整医患关系的法律规范体系。且这些法律条例在实践中有不完善之处。借鉴世界发达国家经验,我国有必要制定一部独立的《医事法》,全面调整医事法律关系。针对本文内容,《医事法》涉及的内容应该包括医方特殊干预权、医疗裁量权、医疗行为豁免权、执业保障权；患者知情同意权、医疗自主权；医疗损害赔偿责任的等内容。具体内容包括以下几点：第一,从立法角度完善患者知情同意权制度：明确患者知情同意权内容和范围；明确知情同意权的主体,建立诊前知情同意转让制度,完善对权利主体行为能力的规定；明确行使知情同意权的界限,限制权利主体滥用同意权。第二,医师的特殊干预权的立法设想：通过立法保障特殊干预权行使；完善特殊干预权的实施程序；建立司法监督评判机构；界定代理制度中的特殊干预权。第三,完善告知制度,保障医方医疗裁量权的实现：立法应进一步明确医方履行告知义务的形式及各种告知方式适用的范围；完善告知程序；明确告知的具体内容；免除医师对告知患者病情所可能产生的不利后果的注意义务。第四,明确医疗行为豁免权的法律效力,完善手术知情同意书的立法体例和立法内容,并在司法规制中适用可容性危险原则减轻医方的赔偿责任。第五,明确医疗损害赔偿责任的分配原则：将医疗事故概念扩大为医疗损害,加大赔偿力度；公立医院的无过失医疗损害赔偿责任应适用国家赔偿法。第三部分医方权利制度保护机制探讨要解决我国医方权利保护不力的现状,除了完善法律法规建设,建立健全法制体系。还应在以下方面做出努力：建立有效地医疗责任保险制度,抵御风险,减少损失；改革医疗机构目前的薪酬制度,提高医师的收入水平；完善医师的培训制度,特别是明确医师培训制度的法律地位,为保障医师的专业研习权提供法律依据。1、建立有效的医疗责任保险制度医疗责任保险是医疗机构向社会分摊医疗风险带来的损失,从而减轻医疗机构和医师的经济压力的一种经济转嫁机制。医疗责任保险在发达国家已经发展了一百多年,形成了成熟有效的运行模式。我国的医疗责任保险发展起步晚,没有全国性的法律规范,相关立法层次低；保险费偏高,且厘定标准不够科学；赔偿限额低,责任期限短；法律适用混乱导致赔偿标准不统一。这些存在的问题导致医疗机构对医疗责任保险有效需求不足,医疗责任保险制度在我国不能真正起到分担风险的作用。通过借鉴美国、英国、日本等国成熟经验,探索我国医疗责任保险制度发展对策：用立法手段强制实施医疗责任保险；建立多种模式结合的医疗责任保险制度；完善医疗责任保险合同条款,丰富保险险种；建立专属机构处理医疗责任保险理赔。2、增加医师收入的制度探讨国家对卫生事业和公立医疗机构的有效投入不足,医师的劳务价值被低估,薪酬制度僵化等原因导致医师收入一直处于较低水平,不能体现薪酬制度的公平性和合理性。低收入产生以下的不良影响：引发医师道德风险,加剧患者“看病贵”的现象；医师工作积极性被挫伤,工作满意度低。提高医师收入,完善现行的薪酬体制,是激励医师更好发挥工作积极性的有益手段。从长远的角度看,更有利于国家医疗卫生事业的健康发展。改革薪酬制度内容,提高薪酬水平,加大国家投入,使公立医院回归公益本质是增加医师收入的有效途径。3、健全医师培训制度,保障医师专业研习权利医学是需要终身学习的职业,健全医师培训制度,完善医师培养模式是医师享有专业研习权的根本保证。现行的医学教育模式中存在的某些问题逐渐凸显出来：如学校教育学制设置繁多,缺失人文精神培养；毕业后教育内容规定不完善；全科医师培训制度建设不能满足现实需求,这些问题成为制约医学教育健康发展的瓶颈。健全医学教育培养模式,完善医师培训制度,要做到加强各阶段医学教育中的医学法律法规教育和人文精神培养；明确住院医师培训制度的法律地位,构建医师执业资格准入制度和淘汰制度；建立健全全科医师培训制度。更多还原

【Abstract】 While our society is becoming more and more democratic, harmonious, and reasonably ruled by law, the occupational environment for doctors is deteriorating day by day. The medical profession is characterized by high technicality and high riskiness, requiring doctors to take more responsibilities and to dedicate a lot. In developed countries doctors’ rights and high social position with matched salary are ensured by laws and regulations; regular commercial insurance system and social security system are established to balance the doctors’ rights and duties and to lessen their occupational risks, yet in our country, doctors’ rights are poorly ensured due to the absence of perfect medical responsibility insurance system, dedication out of proportion with reward, manifested in prolonged work, intensive labor, low salary, poor welfare, and little respect or understanding resulted from media’s misleading. Such occupational environment burdens doctors with more responsibilities, hurting them physically and mentally. How to improve the situation? This paper discussed it in three sections.Section One:Briefly on the Rights of Medical Personnel and ServicesThis section was discussed in three parts. Firstly, the rights of medical services and personnel were summed up by detailing the origin of related laws, according to which, medical services enjoy the right to claim medical expenses, the right of management, the right to suspend performance, and any rights a legal person enjoys such as property right, reputation right, and IPRs. Among the rights of medical personnel, doctors’ rights were made the focal point, which include practice privileges such as the right to enquire, the right to examine, the right to diagnose and treat, the right to give certificate, the special right to intervene, medical immunity, and medical discretion; other related rights include the right to be rewarded and respected, the right to be trained, and the right to participate in democratic management. Secondly, relations between medical personnel and patients were discussed by summarizing the duties of medical personnel and patients. According to general jurisprudence research, the paper concluded that the right-and-duty relations between medical personnel and patients are heart of the matter. The medical personnel’s rights to enjoy and duties to take are closely correlated with the ones of patients. Thirdly, relations between medical personnel and patients determined by different medical models were summarized to analyze its changes. Since the birth of medicine, man has been experiencing four medical models or periods. In the witch doctor period, doctors, with the power of the deity, had the highest authority over their patients. The natural medicine period, in which doctors, with the development of medical ethnics, tried their best to treat patients, who fully trusted their doctors and enjoyed no rights. The bio-medical model helped to bring about application of machines in medical services; high technology maximized doctors’rights. The present bio-psycho-social medicine model then pays more attention to patients’rights yet makes doctors take on more responsibilities and duties.Section Two:On Theories and Legal Protection of Each RightPart one:Theories of Each Right of Medical Personnel and ServicesIn medical practice, some rights of medical personnel and services are not clearly supported by laws or regulations; as a result, these rights are not really enjoyed, which impairs the legal interest of both doctors and patients and leads to deterioration of the doctor-patient relationship. To put it more specifically, doctors’special right to intervene, medical discretion, medical immunity and the right to secure practicing failed to be protected laws or regulations. In this part, each right’s connotation, origin and form were studied and analyzed with the reference to related theories and legal practice of other countries, anticipant to effectively secure the fulfillment of medical personnel and services’rights.Special right to intervene is one of the doctors’basic rights, but there is no any specific law or regulation at present in our country to definitely secure its fulfillment. It is only defined in "The Tort Law of the People’s Republic of China" as appropriate actions when doctors are saving a heavy patient and in the "Law of the People’s Republic of China on Medical Practitioners" in the form of predatory obligation. Lacking in support of laws or regulations, the special right to intervene cannot be exercised, doctors afraid of taking imperative actions to save a patient in severe condition. By studying the theories and practicing experiences in China and other countries, we found that in the statute laws of America and Japan, special right of intervene is stipulated in its limit of power, situation for application and legal effect, along with feasible procedure to insure its practice. In our country, most experts are positive in the legislation to secure the exercise of the right. And it can be concluded that defining the right’s legal position and establishing a procedure to exercise the right is helpful for preventing patients’abuse of their right.Medical discretion can be explained broadly as the doctors’right to decide and adjust therapeutic regimen according to patient condition; narrowly speaking, it means that doctors have the right to decide what to tell to the patients’family members in performing the duty of disclosure. The "Law of the People’s Republic of China on Medical Practitioners", article 26 stipulated that doctors should avoid any harmful consequence in performing the duty of disclosure. In such countries as America and Japan, exercise of the medical discretion is most seen in the judicial precedents of judicial practice, yet in our country, medical discretion sometimes conflicts with the right of informed consent due to unclearness in defining the medical discretion.Medical practice immunity is a special right which had long since existed as an ethical principle it became guaranteed by a law. Impairment will some time happen in medical practice due to high riskiness and limited technology, and that explained the reason why there should be such right. The exercise of medical immunity is embodied in two aspects:efficacy of escape clauses in informed consent of operation and the liability to pay compensation when medical damages happen without fault. Although most experts think at present the escape clauses in informed consent of operation drafted by the medical institutes of our country cannot be basis for exemption from liability, the writer of this paper believe that they are sensible and should be affirmed and protected by law after jurisprudence and ethics analyses.The practicing rights of medical practitioner are based on doctors’ practice privileges, including the right to be rewarded, the right to be trained, and the right to be respected. In this paper, the writer selected six hospitals in Beijing, where 180 doctors were investigated with satisfaction questionnaires, and it showed that most doctors were not satisfied. With analysis of other literatures, we concluded that although the "Law of the People’s Republic of China on Medical Practitioners" stipulated those rights, in practice, medical practitioners failed to enjoy them, which had become a leading factor for the deterioration of doctors’occupational environment.Part Two:Legal Protection of Each RightAlthough there are such laws or regulations as "Law of the People’s Republic of China on Medical Practitioners", "Managerial Regulation of the Medical Institutions" and "The Regulation on the Handling of Medical Accidents", there is not an integral and standard system to adjust the doctor-patient relationship. Also, these laws and regulations are imperfect in exercise. With reference to the experiences of developed countries, it is necessary for our country to draw up an independent "Medical Law" which should have involved the medical personnel and services’special right to intervene, medical discretion, medical immunity, the practicing rights of medical practitioner, the right of patients’informed consent, liability to compensate for medical damages, and so on. See the details below.First, perfect the system of the patients’informed consent through legislation:clarify its content and limit.Second, suggestions on legislation of the special right to intervene: legislate to ensure the enjoyment of the right, specify its procedure of implementation, and establish institution of inspection.Third, accomplish notification system, ensuring the enjoyment of medical-discretion:further specify its forms, limit, procedure and content.Forth, clarify the legal effect of medical immunity, and accomplish the legislation form and content of informed consent.Fifth, specify the principle of liability to pay compensation when medical damages happen without fault.Part Three:On Protection of Doctors and Medical Services’ RightTo improve the protection of doctors and medical services’ right, a system of laws and regulations should be established in addition to the following measures:establish a system of medical responsibility insurance, reform the present payment system, and perfect regulations to ensure doctors’ training, especially for countryside doctors.1 An Effective System of Medical Liability InsuranceMedical liability insurance, the medical institutions to the community to share the health risks caused by the loss, thereby reducing health care institutions and economic pressure on doctors an economic shift mechanism. Medical liability insurance in developed countries has been developed over a hundred years, forming a mature and effective mode of operation. Medical liability insurance in China late development, there is no national legal norms, the low level of relevant legislation; premiums high, and setting standards is not scientific enough; lower liability limits, liability duration; the law applicable to cause confusion in non-uniform standard of compensation. The existing problem caused medical liability insurance, medical institutions for effective demand shortage of medical liability insurance system in our country can not Zhenzheng play Fendan risks. By drawing on the United States, Britain, the experiences of Japan and other countries to explore the development of medical liability insurance system responses:using legislative means to enforce the medical liability insurance; the establishment of integrated multi-mode medical liability insurance system; improve the medical liability insurance contract terms, rich in Insurance insurance coverage; the establishment of exclusive agencies dealing with medical liability insurance claims.2 System of Increasing Physician IncomeState health and public health agencies lack effective input, physician services are undervalued, and other causes rigid pay system at a comparatively low level of physician income, can not reflect a fair and reasonable remuneration system. Low-income following undesirable effects:moral hazard caused physicians, increased patient“doctor you”phenomenon; physicians working enthusiasm was dampened, job satisfaction is low. Increase physician income, improving the existing pay system is working actively encouraging physicians to play a more useful means of. Reform pay system content, raising pay levels and increase state investment to return to public welfare nature of public hospitals is an effective way to increase revenue physicians.3 On Building the System of TrainingMedicine is a life-long learning needs of professional, sound system, physician training, improve physician training mode is the right of physicians to enjoy the fundamental guarantee for professional learning. The current model of medical education exist in some of the problems have gradually surfaced:many settings such as school education curriculum, lack of humanism; training content requirements of education after graduation imperfect; general physician training system construction can not meet the actual needs, as a constraint to medical education healthy development of the bottleneck. Improve medical education training model, improve physician training system should be strengthened in all stages of medical education laws and regulations of medical education and mental fostering; clear legal status of residency training system, building access system for physician qualification and elimination system; establishment sound system of training general practitioners.更多还原