醫療契約之比較研究－以我國及美國不同醫療給付制度為中心

A Comparative Contractual Theory Perspectives of the Relationship between Physicians and Patients in Different Health Provider Systems － Focusing on the Difference between Doctors’ Contractual Liability in Taiwan and United State of America

許修誠(Hsiu-Cheng Hsu)

指導教授 ： 郭振恭

中原大學/商學院/財經法律研究所/碩士(2011年)

https://doi.org/10.6840/cycu201101049

摘要

醫療契約，為契約之一種，我國通說認為屬近似委任之無名契約，契約一方當事人為病患，另一方則多認定為醫院或獨立自行開設診所營業之醫師。我國多數說認為於掛號時，病患向醫療機構要約，醫療機構於掛號處給予相當於承諾的掛號行為，成立醫療契約。美國傳統見解認為醫療契約係發生於醫師與病患間，由病患要約，醫師承諾。如醫師為醫院之僱用人，醫院依據respondent superior原則，尚需負監督責任；如醫師為independent contractor，則自負完全醫療責任，與醫院無涉，醫院僅負家管責任。
美國早期將醫院視為慈善組織，因而儘可能減免醫院責任。後為擴大對病患之保護，逐漸發展出醫療機構責任理論，包括家管責任、替代責任、法人自身責任與不可替代責任。醫療契約關係於醫療保險人—健康管理組織（HMOs）出現後，益加複雜。美國法將醫療人員與組織，自下游基層醫療人員，往上至醫院甚至HMOs，將之整個視為醫療企業。企業內自下至上均需負擔醫療過失責任。
醫療契約成立前，醫病間已先因信賴而成立特別結合關係。醫療契約之前契約保護義務以忠實告知義務為中心，須揭露醫師個人情狀以及與病患相關之實際營運情況。我國學說認為，院內感染管控能力有主動告知之義務；醫師個人情狀、新手醫師能力，我國實務與學說、與美國法院判決則各有不同之觀點。美國基於習慣法特性，告知範圍較大陸法系國家為詳細且嚴格。告知程度之認定標準有四種基準。我國與美國基準亦大有不同，我國最高法院採行的具體病患說標準甚至比美國通說還嚴苛。
契約義務群為評價醫療契約履行之標尺，然而實務上卻較不傾向細分此類義務群，而認均得為不完全給付之請求基礎。給付義務與附隨義務範圍之認定，我國仍未明確化，也衍生出一些具有爭議之判決。我國法院判斷醫療過失責任，多考慮醫療過程是否有疏失、醫療行為是否符合醫療常規，以及因果關係是否存在。此標準其實缺乏客觀、易操作之標準。美國法院基於判決的累積，發展出醫療照顧水準學說(standard of care)。美國法院並發展出「低於醫療照顧水準的抗辯」，以玆衡平。急診醫療行為，其法律關係，本文認為存有法律漏洞，尤其於病患意識不清且無法定代理人之情狀下。為求民事法律體系之完備與公益之維護，本文建議修改民法無因管理之相關規定。醫療行為是否能成立與有過失，我國少有學說表示意見。我國學說對與有過失人之注意義務原則上採善良管理人之注意義務，與美國見解有差異。美國對於醫療上與有過失人之注意義務採重大過失或低於重大過失之標準。
多數醫療契約為繼續性契約，醫療契約之單複數認定可能因須一再行告知後同意而有爭論。債之更改或契約改定可援引解釋此種契約狀態。承諾達成一定醫療結果不一定該當承攬或包醫契約行為。如承諾為一定醫療結果之行為(promise a specific manner)，則與現行醫療契約之通說接近；如果為承諾為一定醫療效果之行為(promise a specific outcome)，則接近於承攬包醫。對於醫療結果不如人意，宜將醫療過失區分為「醫療結果過失」與「醫療程序過失」來輔助確立基於契約或侵權行為之舉證內容。身體檢查契約與不與病患直接接觸之契約關係屬特別型態之醫療契約。身體檢查契約義務範圍，依據檢查目的區分說與善良管理人注意義務說，有不同之界定標準，實務宜表示明確立場，以杜爭議。美國不認為不與病患直接接觸情形下之醫療契約關係，與通常之醫療契約關係有異；然而，我國實務判決卻有將此類契約給付內容認定為供臨床科醫師「參考」之用，而異於為責任之對待。新醫療儀器或新醫療技術之引入，應於何時間點引入以避免淪於低於通常之照顧水準，迄今仍未有定論。美國法上的韓德法則可輔助認定，日本也發展出了醫療水準論，我國仍待實務案例與學說之補充。
醫師僅為醫療企業之最下游，現實上醫療行為受健康保險制度之牽制與左右程度甚大，我國不對整個企業課與義務；反而身處醫療企業上游者，尚可因民法188III之規定，再將責任轉由最下游、最受牽制且最無資力者承擔。文末倡議區分醫師之「直接裁量過失」與「間接裁量過失」，重新衡量醫療過失之原因責任，或許可喚醒實際主導與分配醫療者，對現制責任歸屬不合理之警覺。

關鍵字

與有過失 ； 無因管理 ； 健保組織 ； 醫療契約 ； 醫療責任 ； 醫療過失

並列摘要

Medical contracts were recognized as one kind of mandate-like contract between patients and medical institutions in Taiwan. They are formed after the patients make offers to the medical institutions via media or at the registrars where acceptances were then given by the registrar’s persons or their equivalents on behalf of the institutions. In the United States, the offers were tendered by the patients whereas the acceptances were given by the physicians they visited, rather than given by the institutions. If the physicians are employees, the institutions owe the duty to the patients on the theory of respondent superior. If the physicians are independent contractors, the institutions traditionally are not responsible to the physicians’ negligence except the housekeeping responsibility
In the early United States, the medical institutions are immune from medical liability because of their chartable propensities. However, this view had been restricted; instead, concerning the patient protection, the theories of institutional liabilities had been proposed, which included housekeeping, vicarious, organization, and un-delegable liabilities. After the launch of health maintenance organizations (HMOs), the medical liabilities were imposed upon the entire stream of medical industry, from HMOs to the doctors.
The medical institutions should protect the prospective patients on the theory of pre-contractual liabilities. It requests the institutions disclosing the information to the prospective patients about infection control ability and the physicians’ ability. However, the intensity of legal regulations is different between Taiwan and United States. The requirement of informed consent is subjectively patient-oriented in Taiwan.
The judicial issues of medical malpractice litigations in Taiwan are: the doctors’ mistakes during the courses of practice, the obedience of the medical routines and the causations; however, they are too abstract. The doctrine and the defense of standard of care in the United States are clear and easier to be followed. The nature of medical contracts in emergency situation remains unclear, especially when the patients are unconscious. This article suggests modifying the related articles in civil codes focusing on the regulations about the management of affairs without mandate.
The theories of direct and derivate contractual liabilities remain inconclusive in Taiwan, which affect the scopes of contractual liabilities and lead to different results in judgments. Differentiate “promising a specific therapeutic manner” from “promising a specific therapeutic outcome”, which is more close to the hire of work, is helpful to define the scope of contractual liability. The scope outside the purpose of health-check contracts had been considered by some courts as an exemption of contractual liability, but some courts not. The liability of the physicians who tender services to the patients without physical contacts should not be treated differently with those who service in the presence of patients. The numbers of the medical contracts in the courses of medical service are debated, some authors suggest single, some multiple. This article sustains the view of single contract on the basis of contractual modifications.
The doctor’s therapeutic decision-makings in Taiwan are greatly interfered by the regulations and bylaws issued by the monopolized governmental HMO. However, the legal systems, in contrast to the United States, do not charge the HMO who only focuses on the budget management the responsibility to prevent physicians’ negligence. The situations of doctors get worse due to the article 188 of civil code which allows the institutions to ask for the remedies from the employees when malpractices occurred. This article suggests the whole medical enterprise in Taiwan should share the duties to the mal-treated patients. It proposes using the direct and indirect types of medical judgment errors to reinvestigate the share of the responsibility within the medical industry.

並列關鍵字

health maintenance organization (HMO) ； quasi-contract ； medical contracts ； medical liability ； medical negligence ； contributory negligence

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中文部分 (依姓氏筆畫)