在快速成長的全球國際醫療產業中，我國醫療服務水準執全球牛耳，多項醫療技術的先進，聞名國際，在舉世前200大醫院中，我國就佔了14家，僅次於美國及德國，排名全球第三，凸顯我國醫療實力。然而醫療技術與世界醫療菁英國齊頭並進的同時，我國醫療醫病環境卻逐漸在衰敗。學者過去對全台醫師做的實證研究，遇到醫療糾紛以司法程序解決的比例在民國84年時為15.7%，至94年時則升高至23.1%，反映採司法途徑解決醫療糾紛的比例日漸增加的狀況。礙於我國法律制度的制度規定下，病家對於醫療行為與損害間的因果關係及醫師的過失負有舉證責任，由於病患並非醫療專業，即便現今病歷之取得相當方便，仍會面臨無法舉證而敗訴。醫療處置過程之還原及釐清疏失與否亟需專業之鑑定意見，依據衛生福利部醫事審議委員會醫事鑑定作業要點，該鑑定小組僅接受司法與檢察單位之委託，一般病家無法自行委託，現行刑事訴訟程序，可由檢察官蒐集證據以免除自己蒐集證據之負擔，並以刑事訴訟程序追加民事損害賠償的機制藉此節省訴訟費用，上述等等理由，造成我國現在以刑逼民之現象氾濫。 我國醫療糾紛處理相關法案經冗長提案及醫法雙方討論過程，歷經政黨輪替與版本修正，至民國101年行政院提出政院版「醫療糾紛處理與醫療事故補償法草案」，該法具備兩大核心制度，一為以關懷、強化協商機制為主的調解先行制度，二則為不責難精神為宗旨的無過失補償制度，以期能免於動輒進入訴訟進程並達簡化醫療糾紛處理之目標。然該法在103年進入立法院二讀，卻遭到國內醫療從業人員的集體反對，最終未能達陣。 103年送進立法院會討論之行政院版醫糾法草案立法精神可嘉，但深究其處理機制仍有研議之空間，考量醫療行為的特殊性，一部專屬於處理醫療糾紛機制的法案有其必要性。本研究採文獻探討與比較研究法，蒐集並彙整本研究主題相關之文獻如國內外期刊、學術著作、論文、官方統計資料、新聞報導、相關判決、立法或修法草案。歸納、整理、分析並比較其在實務面運作之結果與我國現行法制作比較，再以臨床角度分析該草案，最後以醫療人員角度提出幾點建議:一、非告訴乃論之刑事醫療爭議案件亦應強制調解；二、創建分層調解機制，分流調解案件以加速調解作業的實質效率；三、重劃醫療事故補償金財源，回歸疾病無差別之本質，採全民徵收；四、推行就醫人醫療意外險與醫療平安險，強化損害填補機制；五、透過修正刑事政策，在非告訴乃論醫療糾紛案件中，有條件限制公訴機關及法院之司法裁量權。在符合法理精神下亦達醫界之期待，以期透過該醫療糾紛專法處理機制弭平醫病對立達到一次性解決紛爭之目的!

本文將負面醫療結果(醫療傷害)統稱為醫療事故(medical incident)，而醫療事故中又分為醫療過失(medical negligence)、醫療不幸（medical mishap，又名醫療災禍）及醫療意外(medical accident)三種情況。造成醫療傷害可能是因為醫療的過失責任，也可能是無醫療過失責任，本文特意將無醫療過失責任再細分為無過失責任、非過失責任與無法律責任（自然死亡或自然病程）三種，並將「無過失責任」no fault liability一詞泛以「無關過失責任」稱之；醫療行為中可預知的合併症與副作用的「醫療不幸」及不可預知、不可抗力的「醫療意外」屬非過失責任範疇，而不可避免性的自然死亡及自然病程，則屬無法律責任的範疇。 責任負擔可分為賠償、補償、救濟三種。賠償者，以不法之侵權行為，致使他人受損害時，因而填補其所受之損害，謂之賠償，英文為indemnity。補償者，指根據該法所指定的人員敲定的額度提供的金錢補助，而不是指針對不法行為或違反契約依法起訴所獲得的補償性賠償金，英文為compensation。救濟者，特別指由國家向貧困者提供的財政幫助，英文為relief。 過失責任的歸責原因是醫療疏失，所以是以損害填補原則及不當得利禁止原則，以填補受害者所受損害及所失利益；因此，過失責任要負的是損害「賠償責任」。非過失責任的歸責原因包括醫療不幸（即副作用、合併症）與醫療意外兩種，因為醫師客觀上已盡注意義務，不論有無結果預知義務或結果迴避義務，醫師已盡力防阻，仍不免發生醫療傷害，故並無醫療疏失可言，應由國家社會對受害者予以救濟；因此，非過失責任理應由福利國家的救濟制度來負責。無關過失責任no fault liability的歸責原因是危險責任，針對所有醫療事故，不論對錯無關過失下，只要有了醫療傷害，加害人就予以被害人限額補償的基本保障。因為醫師身為危險責任主體，依報償責任理論（利之所存，險之所擔）、危險控制理論及危險分擔理論下必須承擔危險責任，因以，無關過失責任應負醫療事故補償責任。 賠償、補償、救濟三種責任負擔都可以分別採用基金模式或保險模式來解決；本文則認為，醫療過失責任宜採取醫師專業責任保險，予受害人損害賠償。醫療無關過失責任宜採取醫事人員強制責任保險，輔以醫療事故特別補償基金，予受害人基本保障補償。醫療非過失責任宜採取醫療風險救濟基金，予受害人風險救濟，急難救助。 故本文結論提出事故補償、風險救濟、損害賠償三階層的保險與基金制度架構，以解決醫療糾紛民事責任問題即；第一層事故補償—針對醫療事故，以醫事人員強制責任保險無關過失，限額補償；第二層風險救濟—針對醫療意外，整合醫療風險救濟基金定額救濟；第三層損害賠償—針對過失責任，以醫師責任保險損害填補。 / In this paper, we study negative outcomes associated with the delivery health care, which are collectively referred to as “medical incident”. This is further divided into “medical negligence”, “medical mishap” (also known as “medical disaster”), and “medical accidents”. Medical injuries may be in consequence of medical negligence or otherwise, that is they may be with fault or without fault. In this paper we further medical injuries without fault into three categories: (1) liability regardless of fault, (2) liability without fault, and (3) no legal liability. Notably, we refer to “no-fault liability” as “liability regardless of fault” to better distinguish its legal implications with respect to other kinds of medical injuries without fault. Predictable complications and side effects of medical treatments are considered “medical mishap”; unavoidable natural death or nature course of disease have “no legal liability”. The burden of duty can be divided into three categories: indemnity, compensation, and relief. Indemnity is secondary to the violation of rights leading to injury and damages. Compensation is set by appointed experts and given in direct consequence of the occurrence of the injury, and is independently of the determination of legality and contract fulfillment. Relief specifically refers to financial assistance given by government entities to those in need. At-fault liability follows medical negligence, and as such indemnity is given for reparation of damages and the prohibition of gains from the provision of negligent medical care. Causes of liability with no fault include medical mishaps and medical accidents. In these cases, the physician has fulfilled duties as medical professionals and in so doing have done their best to prevent medical incidents. Nevertheless due to circumstances beyond control, medical injuries occur. Because there is no negligence on the part of the physician, these losses are ideally dealt with by the governmental agencies. Liability regardless of fault attributes liability based on risk alone. Under this system, for all medical incidents, whether or not they are the consequence of negligence, the victim receives relief at a pre-determined amount. This relief serves as the basic protection of patients. Since the physician as the chief medical care provider is also at the center of medical risk, by principles of risk management, liability regardless of fault should in addition be organized as medical incidents compensation. The three forms of duty burden–indemnity, compensation, and relief–can be organized either as foundations or as insurances. We argue that duty burden for medical negligence is best managed by professional liability insurance to provide compensation to the victims. Medical liability regardless of fault is best managed by compulsory medical provider liability insurance with additional medical incidence compensation fund to provide at least a basic level of compensation to the victims. Medical liability without fault is best managed by medical risk relief fund for assistance for the victims. In conclusion, in this paper we analyze various forms of liability and management of medical risks, and propose the use of professional liability insurance for medical injuries with fault, compulsory liability insurance for liability without fault, and relief fund for liability regardless of fault, in the setting of medical incidence. This provides a comprehensive, three-layered solution to the emerging problem of proliferation of medical incident cases in the courts. The first layer is incidence compensation, directed at all medical incidents, via compulsory medical personnel liability insurance regardless of fault. The second layer is risk relief, directed at medical mishaps and medical accidents, via risk relief funds. The third layer is damage indemnity, directed at at-fault liability, via physician professional liability insurance, to fulfill the victims’ damages.

醫療糾紛的解決途徑，有訴訟上與訴訟外之解決機制。惟醫療行為具有高度專業性與特殊性，且當事人泰半有追求真相之需求，訴訟中加上鑑定程序因而導致時間冗長，當事人無法獲得即時保障，不能滿足雙方之需求。從而，透過訴訟外紛爭解決機制以補缺，利用訴訟外機制之多元彈性，得以針對醫療糾紛之特質，依照衝突內容提供特殊之程序形式，尋求更適切之解決方式。 然而我國並未針對醫療糾紛訴訟外紛爭解決機制訂立專法，多半係由地方自行整合當地司法資源與醫療院所，發展出具有個人特色之糾紛解決模式。我國在2014年曾提出專法「醫療糾紛處理及醫療事故補償法」草案，卻因當中之補償問題而未通過。本文將以草案為基底，輔以外國醫療糾紛訴訟外紛爭解決機制，汲取各國法制優點，以訴訟外調解為核心，提出草案未來改革之方向與調解機制於我國之可能發展。希冀在未來之調解程序中，加入鑑定程序，讓醫療糾紛之訴訟外紛爭解決機制能夠有效發揮消弭紛爭、減少訟源之作用。 最後，由各地方所發展而出之訴訟外解決模式中，調解成功率最高者為臺中地方法院醫療試辦制度，故文中將以此為例。藉由檢視此制度，結合醫療糾紛處理及醫療事故補償法草案中之調解與司法調解，試提出若干問題，期能改善現況，建構適合我國的起訴前之紛爭處理模式。 / 無