醫療誤診刑事責任之探討

梁興禮(Hsin-Li Liang)

指導教授 ： 盧映潔 博士

國立中正大學/法學院/法律學系/碩士(2013年)

摘要

誤診的醫療糾紛並不少見，近年來也可以看到一些誤診案件的判決，但我國還沒有專門研究誤診的論文。本文將先介紹醫師如何進行診斷、診斷的類別、說明誤診的定義並加以類型化。醫療不確定性主要是指無法預期治療的反應與結果，其實診斷也有其獨特的特性，每個特性都可以說明為什麼誤診無法完全避免。雖然診斷屬於整體醫療行為的一部份，但是不同於治療的風險來自於醫療行為本身，誤診的發生不單單只是由醫師所引起，其他的客觀因素也有可能成為誤診發生的原因。

吾人都知道醫師不可能所有的疾病都會診斷，換言之，發生誤診首先應探討診斷的「預見可能性」。醫師診斷時的預見可能性與醫師的注意能力基準有關。本文首先提出，以刑法判斷醫師對於診斷是否具有預見可能性以及是否違反注意義務應該採「相同醫事機構層級及相同專科醫師」作為基準。另外，司法實務在斷定醫療行為是否成立刑事過失時，常常見到以醫療法、醫師法等醫療相關行政法規範之內容，直接移植做為認定刑事過失的基礎，形成未盡符合刑法過失理論之判決理由。本文提出「參考醫療準則進行診察」、「完整蒐集病情資料並加以判斷」、「持續追蹤觀察病情的變化」等等診斷時醫師應注意的義務，並由刑法的角度加以闡述。

對刑法的過失犯與民法的侵權行為而言，因果關係都是責任成立與否的核心問題。為了避免司法實務判斷因果關係上出現混淆，本文整理目前相當因果關係在民、刑法學者及實務上之異同。醫療事故因果關係的判斷比起其他過失類型的案件更加困難，原因就在於疾病本身就已經開始進行一定程度的因果歷程，這時醫療行為條件的加入，就讓情況變得複雜，亦即到底是疾病本身還是醫療行為導致最後的結果？本文將介紹如何藉由疾病的進程與實證醫學兩個角度去探求醫療事件中的因果關係，並提出審查誤診醫療事件時，驗證誤診與病患傷亡之間的因果關係架構為「疾病的自然進程是否可以經由醫療行為有效地加以攔截」。

筆者嘗試從法律學習者以及心臟科醫師的角度研究分析數件心臟疾病誤診醫療事故的刑事判決，發現這些判決的主要盲點在於「無法探求誤診的發生原因」以及「確定因果關係是否存在」。這兩項盲點之所以產生與刑事訴訟法上關於醫療事故鑑定制度的設計息息相關。因此，本文最後一章將針對目前醫療事故鑑定制度提出建議。同時，筆者也嘗試對醫界同儕提出有效減少誤診的建議。盼望本文能夠達到減少醫界發生誤診糾紛以及避免法院誤判誤診案件的目標。

關鍵字

誤診 ； 預見可能性 ； 注意基準 ； 因果關係 ； 疾病進程 ； 實證醫學 ； 醫療鑑定

並列摘要

A medical malpractice dispute due to misdiagnosis is not uncommon. Although some judgments of misdiagnosis cases have taken place in recent years, no dissertation in Taiwan specifically studies the issue of misdiagnosis. The paper firstly introduces a physician’s diagnostic process, the types of diagnosis, and the definition and categories of misdiagnosis. Medical uncertainty refers to the inability to anticipate the reactions and outcomes to treatments. Meanwhile, diagnosis has several unique characteristics and each characteristic shows why a misdiagnosis is not completely preventable. Making a diagnosis is a part of the overall medical practice. However, unlike the treatment-related incident risks, a misdiagnosis is not solely attributable to a physician’s negligence. Other subjective factors also contribute to the occurrence of misdiagnosis.

We all know that physicians cannot possibly diagnose all diseases. Therefore, in a misdiagnosis we need to examine the foreseeable possibility. The foreseeable possibility during physician diagnosis is related to the basis of a physician’s care. This paper firstly proposes that the judgment of a physician’s dereliction of their duty of caring should be determined based on “health care institutions of the same level and physicians of the same specialty”. In the judicial practice of judging whether a medical practice constitutes criminal negligence, the regulatory contents from the Medical Care Act, Physician Act and other relevant administrative laws are often directly applied as the basis for judgment of criminal negligence forming the ratio decidendi for failing to comply with the theory of criminal negligence. This paper also proposes several physician duties when making a diagnosis, including “referencing to medical guideline during examinations”, ”thoroughly collecting information regarding a patient’s condition and making judgments accordingly”, and “continuous doing follow-up and observation for changes in a patient’s condition”. I will elaborate on these duties from a criminal law’s perspective.

Causality of negligence as contained in criminal law and in tort law is the core determinant for liabilities. To prevent confusion in the judgment of causality in judicial practices, this paper presents and sorts the existing variations of relative causality between the academic and practice of the criminal and civil law. The judgment of causality in medical malpractice is more complex than in other negligence cases. Because a certain degree of the causality process develops in the disease itself and the involvement of medical practice further complicates the situation. Specifically, it becomes difficult to determine whether the final outcome is caused by the disease itself or the medical practice. This paper introduces the methods for identifying the causality in medical cases through disease progression and evidence-base medicine. Additionally, this paper proposes a structure for the judging and verifying of causality between misdiagnosis and patient injury or death during medical misdiagnosis case reviews.

The author attempted to analyze the criminal judgments of several medical misdiagnosis cases from the perspectives of a law student and a cardiologist. It was identified that the fundamental flaws of these judgments included the inability to seek the causes of misdiagnosis and to prove the presence of causality. The development of these two flaws is associated with the system design of medical assessment in the Code of criminal procedure. In view of this, the final chapter of this paper contains suggestions for the medical assessment system of the present jurisdiction. Meanwhile, the author proposes recommendations that would effectively reduce misdiagnosis for medical professionals. Hopefully, this paper will assist in decreasing misdiagnosis disputes in medicine and avoiding the misruling of misdiagnosis cases in court.

參考文獻

11.吳俊穎，「由醫療糾紛的觀點看台灣實證醫學未來之發展」，台灣醫學，第8卷第4期，頁573~581，2004年7月。

15.林萍章，「醫療常規與刑事責任—評最高法院九十六年度台上字第3084號刑事判決」，月旦法學雜誌，第175期，頁233~252，2009年12月。

16.林肇峰、顏志軒、侯嘉殷等人，「非ST節段上升心肌梗塞合併致死性Bartunek第Ⅰ型心臟破裂－病例報告」，內科學誌，第17卷第2期，頁78~

20.陳聰富，「侵權行為法上之因果關係」，台大法學論叢，第29卷第2期，頁175~307，2000年1月。

21.張麗卿，「信賴原則在醫療分工之適用—以護士麻醉致死案為例」，東海大學法學研究，第33期，頁45~77，2010年12月。