氣切手術相關醫療行為與刑事過失責任之探討

Investigation of Tracheostomy-related Medical Practices and Criminal Negligence

王文弘(Wen-Hung Wang)

指導教授 ： 盧映潔

國立中正大學/法學院/法律學系/碩士(2014年)

摘要

在各種醫療的急症中，以呼吸道的問題最為緊急，當呼吸因為阻塞而發生中止後，病人通常在一分鐘內會失去腦幹功能，五分鐘後即會產生嚴重的腦細胞損傷。因此病人即使經由心肺復甦術救回一命，卻常常因缺氧性腦病變而成了植物人或死亡的結果，因此緊急的呼吸道處置必須在更短的二到三分鐘之內完成。若第一線醫師無法立即建立通暢的呼吸道，待支援醫師到達時，往往已造成不可逆的後果，家屬心裡往往因突發其來的結果而不易接受，容易產生醫療糾紛。
然而醫師在如此緊急救治狀況下與時間搶生命，僅｢當時｣｢現場｣醫師最知道當時危急場面，當醫療行為結束後，未盡家屬期待或滿意時，即向法院提出民、刑事告訴，法院受理後，送醫事鑑定，醫事鑑定委員會以事後平靜從容的心態，作出如同當時親臨現場的鑑定報告，鑑定意見又充斥著所謂「醫療常規」一詞如影隨形，一旦不依「醫療常規」的醫療行為，在現行實務上極可能被視為違反注意義務，法官及檢察官亦多僅依醫事鑑定報告，模擬現場狀況下判決，就可能換來刑法處罰。然而人體體質各異，即使同一種疾病變化又可能差異甚大，「醫療常規」不可能窮盡一切「可能性」時，如果僅依「醫療常規」來從事醫療行為，醫師就只能「依法（律）看病」，法律成為了醫療準則，凌駕於醫學之上。醫師在這種氛圍環境壓力下，醫療行為只好趨於保守，少看高風險的病患，從事低風險的科別，治小病不醫大病，病情解釋模擬兩可，形成所謂的防禦性醫療。而目前文獻上仍未有針對呼吸道緊急處置的相關刑事過失責任作探討。
在本研究中，我們分析刑事訴訟關於呼吸道緊急處置判決的結果發現，醫師敗訴率達30%，尤其在地方法院醫師敗訴率更高達50%。遠比過去文獻報告全體醫師或高風險的急診科、心臟外科專科醫師的刑事訴訟案件裁判結果醫師敗訴率約介於3.4%到28% 之間還要來的更高。另外我們分析更發現醫審會的鑑定結果強烈主導了最終判決結果，客觀歸責（行為非價）及因果關係（結果非價）都通過或都不通過醫審會的檢驗時，被告醫師的命運不是無罪就是一定有罪；客觀歸責及因果關係之鑑定結果若是模糊不清時，地方法院法官的心證幾乎都傾向被告醫師是有罪的（80%）。醫師們在面對高風險呼吸道醫療處置之病人身上，病情的變化往往瞬息萬變，搶救病患生命及當下的決定僅在分秒瞬間的情況下如何自保?
而且這類型醫療糾紛可能成為被告的醫師，將不限於高風險科別（如急診科、心臟外科醫師、腦神經外科醫師），其它科別專科醫師（如麻醉科、胸腔外科、胸腔內科、耳鼻喉科、復健科）都有可能會面臨到緊急呼吸道窘迫症的處置不理想而成為被告。因此我們想知道在實務上認定在緊急呼吸道處置(包括困難插管、插管失敗、困難更換氣切套管)的醫療常規以及標準作業流程是如何?醫師如不依照醫療常規，是否就註定了被宣判注意義務違反的宿命?因果關係在緊急救治狀況下是否成為醫師擺脫不掉的魔箍?此乃為本論文研究之目的所在。
最後，本文提出三點建議：(1) 在緊急呼吸道處置之醫療行為，醫師應放棄單打獨鬥的心態，打破本位主義，並繪製整個緊急呼吸道處置之標準作業流程圖，以作為醫界日後在相關教育訓練的參考。(2) 法院不應再以醫療行為有無符合醫療常規來作為審查注意義務違反的唯一標準。並將緊急呼吸道案件醫療行為客觀歸責審查的步驟繪製成流程圖，以作為法院日後在判斷注意義務違反的參考，審查的重點在於該行為是否屬於｢迴避病患傷害或死亡結果之必要?｣。(3) 本文將判斷呼吸道案件因果關係繪製成流程圖，以作為法院日後在判斷因果關係的參考。驗證的方法為｢腦缺氧病變之自然進程是否可由呼吸道醫療行為有效地加以避免或攔截?｣，希望能藉由此審查方式來減少法院在認定因果關係時，以條件因果關係來思考，而造成醫師動則得咎的醫療困境。

關鍵字

醫療行為 ； 氣管插管 ； 氣管切開手術 ； 刑事過失

並列摘要

In the variety of acute disease, the problem of breathing is most urgent. When breathing stop because of obstruction, the patient will lose the brain stem function within a minute, and will have serious brain cell damage after five minutes. Therefore the patient usually became the vegetative state or the result of death because of hypoxic encephalopathy even CPR can save a life, the consequently urgent airway management must complete within short of 2-3 minutes. If the first line of physicians can not immediately establish airway patency, it usually has already caused irreversible consequences while support physician arrives, family members usually don't easily accept because of unexpected results of its coming, and the medical malpractice will occur.
However, in such emergency situation and time to grab life, only "at the time" and "live" physicians know the critical scenes, when the outcome of the medical act could not entirely satisfied with the families expect, bring civil or criminal told to court. After the court received and send medical identification, medical evaluation committee made the appraisal report as the time to visit the scene, and the opinion was filled with so-called "medical routine", once the medical act failing to "medical routine" in the current practice is likely to be considered a violation of the duty of care, judges and prosecutors often decided according to only medical appraisal report, physicians may bring criminal law penalties. However, the human physique different, they may change greatly even if the same disease, "medical routine" can not fit all the "possibility", if medical act practice only according to "medical routine", physicians will be a "law doctor", the law become a medical criteria, above the medicine. The medical practices of physicians had to be conservative in this atmosphere of ambient pressure, less to see the high-risk patients, to enter the low-risk divisions, to treat minor ailments without medical illness, to explain the disease both analog, which we called as defensive medicine. At present, there is no related criminal negligence of critical airway emergency in the literature review.
In the current study, we analyzed the criminal proceedings concerning emergency treatment of critical airway judgment and found that physicians losing rate of 30%, especially at the local court physician losing as much as 50 percent rate. This rate were far higher than previous reports of all physician, high-risk emergency doctors, and cardiac surgery specialist with the results of losing rate of the criminal proceedings between 3.4% and 28%. In addition, we also found the identification results of medical committee strongly dominated the final verdict, objective imputation (the behavior of non-price) and causality (the results of the non-price) are all adopted or all not by medical review will result in not guilty or certainly guilty for the defendant physician; when objective causal attribution and identification results were vague, the district court judge's evaluation of evidence tend to consider the defendant doctor is guilty (80%). When physicians face the high-risk patients with critical airway, the disease often quick change, life-moment decision to rescue patients must be made in minutes and seconds. How to protect themselves?
A physician could become defendants at this type of medical malpractice will not be limited to high-risk divisions (such as the emergency department, cardiac surgeons, neurosurgeons), other specialist divisions (such as anesthesia, thoracic surgery, chest medicine, otolaryngology, rehabilitation department) are likely to be defendants if magagement of the critical airway is not ideal. So we want to know if practice are not in accordance with the "medical routine" (non-price behavior), it is destined to be sentenced in violation of the duty of care fate? What will be the medical routine of trial court in different stages of airway disposal of current medical practice? Whether does causality (the result of non-price) in an emergency situation become the magic hoop which a physician can not escape? This is the purposes of this thesis lies.
In addition, the judge causality of critical airway cases need to analyze what stage of the natural progression of diseases such as hypoxic encephalopathy has been reached, and whether the diseases can be effectively avoided or blocked by medical practices. Therefore, we propose the authentication method to determine the causal relationship between airway disposal and patients casualties as "whether natural processes of hypoxic encephalopathy can be effectively avoided or intercept by medical practices" and construct a flow chart to determine the causal relationship between critical airway cases, we hope this examine ways to determine the causal relationship of critical airway cases can reduce the judiciary to finds a causal relationship by the conditions at the time of causal thinking, but it was formally known as quite a causal form name.

並列關鍵字

medical practice ； endotracheal intubation ； tracheotomy ； criminal negligence

參考文獻

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