衛(wèi)生法學(xué)課件：第六講 醫(yī)療糾紛中的刑事責(zé)任及我國醫(yī)療法律制度改革與域外視野

醫(yī)療糾紛中的刑事責(zé)任一、刑事責(zé)任概述刑事責(zé)任，是依據(jù)國家刑事法律規(guī)定，對犯罪分子依照刑事法律的規(guī)定追究的法律責(zé)任。刑事責(zé)任是最嚴(yán)厲的制裁。刑事責(zé)任包括兩類問題：一是犯罪；二是刑罰。刑法的基本原則1、罪刑法定原則。依據(jù)為《刑法》第3條：法律明文規(guī)定為犯罪行為的，依照法律定罪處刑；法律沒有明文規(guī)定為犯罪行為的，不得定罪處刑（法無明文規(guī)定不為罪，法無明文規(guī)定不處罰）；2、罪刑相適應(yīng)原則。依據(jù)為《刑法》第5條：刑罰的輕重，應(yīng)當(dāng)與犯罪分子所犯罪行和承擔(dān)的刑事責(zé)任相適應(yīng)；3、法律面前人人平等。依據(jù)為我國《刑法》第4條：對任何人犯罪，在適用法律上一律平等。不允許任何人有超越法律的特權(quán)。一、醫(yī)療事故罪第三百三十五條【醫(yī)療事故罪】醫(yī)務(wù)人員由于嚴(yán)重不負(fù)責(zé)任，造成就診人死亡或者嚴(yán)重?fù)p害就診人身體健康的，處三年以下有期徒刑或者拘役。最高檢、公安部關(guān)于印發(fā)《最高檢、公安部關(guān)于公安機(jī)關(guān)管轄的刑事案件立案追訴標(biāo)準(zhǔn)的規(guī)定（一）》的通知公通字[2008]36號）第五十六條[醫(yī)療事故案（刑法第三百三十五條）]醫(yī)務(wù)人員由于嚴(yán)重不負(fù)責(zé)任，造成就診人死亡或者嚴(yán)重?fù)p害就診人身體健康的，應(yīng)予立案追訴。具有下列情形之一的，屬于本條規(guī)定的"嚴(yán)重不負(fù)責(zé)任"：（一）擅離職守的；（二）無正當(dāng)理由拒絕對危急就診人實(shí)行必要的醫(yī)療救治的；（三）未經(jīng)批準(zhǔn)擅自開展試驗(yàn)性醫(yī)療的；（四）嚴(yán)重違反查對、復(fù)核制度的；（五）使用未經(jīng)批準(zhǔn)使用的藥品、消毒藥劑、醫(yī)療器械的；（六）嚴(yán)重違反國家法律法規(guī)及有明確規(guī)定的診療技術(shù)規(guī)范、常規(guī)的；（七）其他嚴(yán)重不負(fù)責(zé)任的情形。本條規(guī)定的"嚴(yán)重?fù)p害就診人身體健康"，是指造成就診人嚴(yán)重殘疾、重傷、感染艾滋病、病毒性肝炎等難以治愈的疾病或者其他嚴(yán)重?fù)p害就診人身體健康的后果。案例討論福建婦產(chǎn)科醫(yī)生李建雪的遭遇。2015年2月被公訴起關(guān)以醫(yī)療事故罪提起訴訟。討論：李建雪是否構(gòu)成醫(yī)療事故罪，理由是什么？證據(jù)是什么？案例介紹2011年12月28日，產(chǎn)婦陳某某來到長樂市醫(yī)院婦科病房住院待產(chǎn)，該院產(chǎn)科醫(yī)生為其進(jìn)行產(chǎn)前檢查。第二天，陳某某做了血液、尿液、B超、心電圖等相關(guān)檢查。陳某某的經(jīng)管醫(yī)生吳某，在29日下班輪休前，并未交代接班醫(yī)生代為查看陳某某的化驗(yàn)報(bào)告，也未繼續(xù)跟蹤過問，導(dǎo)致陳某某的檢驗(yàn)結(jié)果異常無人查看。29日12時~31日11時50分，陳某某離開病房回家休息，31日晚21時24分，陳某某于長樂市醫(yī)院產(chǎn)房通過會陰側(cè)切順產(chǎn)一名健康女嬰，產(chǎn)后陳某某陰道出現(xiàn)出血情況。21時37分，一線值班醫(yī)生李建雪接到產(chǎn)房電話后前往處理，發(fā)現(xiàn)陳某某宮縮欠佳，注射藥物后好轉(zhuǎn)，但陰道仍有活動性出血，便上報(bào)二線值班醫(yī)生。隨后李建雪又配合上級醫(yī)師修補(bǔ)裂傷口；估計(jì)出血量為1500毫升，并給予陳某某輸血800毫升和輸液治療。23時，陳某某開始輸血。上級醫(yī)生認(rèn)為陳某某病情穩(wěn)定，沒有生命危險(xiǎn)，便離開產(chǎn)房，臨走時叮囑李建雪有情況隨時匯報(bào)。2012年1月1日凌晨1時，李建雪見陳某某尿少，給陳某某靜脈推了一支20毫克速尿針劑，后李建雪見其尿量未明顯增多，便電話請示上級醫(yī)生，上級醫(yī)生指示李建雪繼續(xù)輸液。2時，陳某某排尿300毫升，陰道出血10毫升。2時35分許，陳某某被送出產(chǎn)房。2時45分，陳某某出現(xiàn)面色蒼白，煩躁。3時20分，陳某某出現(xiàn)譫妄表現(xiàn)，李建雪趕到病房后發(fā)現(xiàn)陳某某有生命危險(xiǎn)，立即電話通知上級醫(yī)生，上級醫(yī)生趕往病房后又通知三線醫(yī)生及值班醫(yī)生等趕往病房組織搶救。3時40分許，陳某某脈搏消失。4時30分，陳某某被宣告死亡2015年4月9日，福建省長樂市醫(yī)院婦產(chǎn)科醫(yī)生李建雪以醫(yī)療事故罪被起訴一事見諸報(bào)端。醫(yī)學(xué)會鑒定結(jié)果2012年5月9日，福州市醫(yī)學(xué)會鑒定認(rèn)為：因本例未行尸檢，死亡原因不確定，根據(jù)現(xiàn)有資料，患者死于產(chǎn)后出血性休克或伴急性肺動脈血栓栓塞可能性大。患者存在腎臟損害(腎病綜合征)、血液高凝狀態(tài)等基礎(chǔ)疾病。醫(yī)方對病情觀察不仔細(xì)，產(chǎn)后出血量估計(jì)不足，處理不到位。2012年9月20日，福建省醫(yī)學(xué)會進(jìn)行二次鑒定，認(rèn)為產(chǎn)婦入院分娩前，紅細(xì)胞壓積43.8%，纖維蛋白原5.76、白蛋白3++，存在子癇前期重度、低蛋白血癥，與宮縮乏力導(dǎo)致產(chǎn)后出血有一定的關(guān)系;醫(yī)方對病情認(rèn)識不足，搶救措施不力，與患者的死亡存在因果關(guān)系。案件性質(zhì)被定位為一級甲等醫(yī)療事故，醫(yī)方承擔(dān)主要責(zé)任。非法行醫(yī)罪第三百三十六條【非法行醫(yī)罪】未取得醫(yī)生執(zhí)業(yè)資格的人非法行醫(yī)，情節(jié)嚴(yán)重的，處三年以下有期徒刑、拘役或者管制，并處或者單處罰金；嚴(yán)重?fù)p害就診人身體健康的，處三年以上十年以下有期徒刑，并處罰金；造成就診人死亡的，處十年以上有期徒刑，并處罰金。最高檢、公安部關(guān)于印發(fā)《最高檢、公安部關(guān)于公安機(jī)關(guān)管轄的刑事案件立案追訴標(biāo)準(zhǔn)的規(guī)定（一）》的通知公通字[2008]36號）第五十七條[非法行醫(yī)案（刑法第三百三十六條第一款）]未取得醫(yī)生執(zhí)業(yè)資格的人非法行醫(yī)，涉嫌下列情形之一的，應(yīng)予立案追訴：（一）造成就診人輕度殘疾、器官組織損傷導(dǎo)致一般功能障礙，或者中度以上殘疾、器官組織損傷導(dǎo)致嚴(yán)重功能障礙，或者死亡的；（二）造成甲類傳染病傳播、流行或者有傳播、流行危險(xiǎn)的；（三）使用假藥、劣藥或不符合國家規(guī)定標(biāo)準(zhǔn)的衛(wèi)生材料、醫(yī)療器械，足以嚴(yán)重危害人體健康的；（四）非法行醫(yī)被衛(wèi)生行政部門行政處罰兩次以后，再次非法行醫(yī)的；（五）其他情節(jié)嚴(yán)重的情形。最高檢、公安部關(guān)于印發(fā)《最高檢、公安部關(guān)于公安機(jī)關(guān)管轄的刑事案件立案追訴標(biāo)準(zhǔn)的規(guī)定（一）》的通知公通字[2008]36號）具有下列情形之一的，屬于本條規(guī)定的"未取得醫(yī)生執(zhí)業(yè)資格的人非法行醫(yī)"：（一）未取得或者以非法手段取得醫(yī)師資格從事醫(yī)療活動的；（二）個人未取得《醫(yī)療機(jī)構(gòu)執(zhí)業(yè)許可證》開辦醫(yī)療機(jī)構(gòu)的；（三）被依法吊銷醫(yī)師執(zhí)業(yè)證書期間從事醫(yī)療活動的；（四）未取得鄉(xiāng)村醫(yī)生執(zhí)業(yè)證書，從事鄉(xiāng)村醫(yī)療活動的；（五）家庭接生員實(shí)施家庭接生以外的醫(yī)療活動的。本條規(guī)定的"輕度殘疾、器官組織損傷導(dǎo)致一般功能障礙"、"中度以上殘疾、器官組織損傷導(dǎo)致嚴(yán)重功能障礙"，參照衛(wèi)生部《醫(yī)療事故分級標(biāo)準(zhǔn)（試行）》認(rèn)定。針對患者的刑事責(zé)任《醫(yī)療事故處理?xiàng)l例》第五十九條以醫(yī)療事故為由，尋釁滋事、搶奪病歷資料，擾亂醫(yī)療機(jī)構(gòu)正常醫(yī)療秩序和醫(yī)療事故技術(shù)鑒定工作，依照刑法關(guān)于擾亂社會秩序罪的規(guī)定，依法追究刑事責(zé)任；尚不夠刑事處罰的，依法給予治安管理處罰。刑法修正案（九）2015年11月1日實(shí)施）三十一、將刑法第二百九十條第一款修改為：“聚眾擾亂社會秩序，情節(jié)嚴(yán)重，致使工作、生產(chǎn)、營業(yè)和教學(xué)、科研、醫(yī)療無法進(jìn)行，造成嚴(yán)重?fù)p失的，對首要分子，處三年以上七年以下有期徒刑；對其他積極參加的，處三年以下有期徒刑、拘役、管制或者剝奪政治權(quán)利刑法修正案（九）2015年11月1日實(shí)施）三十一、將刑法第二百九十條第一款修改為：“聚眾擾亂社會秩序，情節(jié)嚴(yán)重，致使工作、生產(chǎn)、營業(yè)和教學(xué)、科研、醫(yī)療無法進(jìn)行，造成嚴(yán)重?fù)p失的，對首要分子，處三年以上七年以下有期徒刑；對其他積極參加的，處三年以下有期徒刑、拘役、管制或者剝奪政治權(quán)利?！睂γ绹t(yī)療過失訴訟制度及其改革的考察一美國醫(yī)療過失訴訟制度概述(一)起源宗教與文化:宗教宿命令的急劇下滑及宗教完美主義的上升市場因素任何職業(yè)者都是自由職業(yè)，包括醫(yī)生法律因素降低起訴標(biāo)準(zhǔn)一美國醫(yī)療過失訴訟制度概述(二)發(fā)展醫(yī)學(xué)方面的原因技術(shù)進(jìn)步與風(fēng)險(xiǎn)醫(yī)學(xué)標(biāo)準(zhǔn)與不確定醫(yī)生責(zé)任保險(xiǎn)法律方面的原因風(fēng)險(xiǎn)收費(fèi)；陪審團(tuán)；民事侵權(quán)的定性二美國醫(yī)療過失訴訟制度的現(xiàn)狀

P54（一）高發(fā)的醫(yī)療過失訴訟頻率（二）高額的醫(yī)療損害賠償二美國醫(yī)療過失訴訟制度的現(xiàn)狀

（三）昂貴的制度成本（P60）（四）有限的制度效果（P62）三、美國醫(yī)療過失訴訟制度的改革措施（一）各州政府的改革措施（P157）第一代改革措施第一代改革措施。第一代改革措施主要是由醫(yī)療服務(wù)工作者和醫(yī)療責(zé)任保險(xiǎn)機(jī)構(gòu)提出，包括許多州在20世紀(jì)70年代和80年代采取的用以限制醫(yī)療過失索賠頻率和索賠強(qiáng)度的改革措施，根據(jù)立法目的即削減索賠強(qiáng)度、削減索賠頻率、限制原告勝訴的能力、改善裁決程序，把第一代改革措施分為四大類。減少索賠強(qiáng)度損害賠償金的封頂分期支付旁補(bǔ)償規(guī)則抵消針對索賠頻率審判前審查機(jī)制仲裁訴訟時效的限制律師費(fèi)用的控制索賠價(jià)值證明書針對原告勝訴困難（或成本要求專家證詞知情同意的限制職業(yè)注意標(biāo)準(zhǔn)的修訂事實(shí)自證原則的限制醫(yī)療承諾欺詐的立法針對審判過程的成本/作用調(diào)解起訴的告知要求會議前進(jìn)行討論優(yōu)先程序的設(shè)計(jì)第二代改革措施主要出現(xiàn)于20世紀(jì)80年代晚期和90年代早期，這些措施由學(xué)者和一些感興趣的利益相關(guān)者提出，其目的是使醫(yī)療過失裁決和補(bǔ)償制度更有理性和更有效率而認(rèn)為沒有必要控制索賠頻率和強(qiáng)度，包括運(yùn)用醫(yī)療執(zhí)業(yè)指南來設(shè)定醫(yī)療注意標(biāo)準(zhǔn)，損害賠償金的預(yù)先設(shè)定（Schedulingofdamages）、強(qiáng)制運(yùn)用替代性糾紛解決機(jī)制用以代替審判、行政管理模式的過錯責(zé)任制度、無過錯責(zé)任、企業(yè)責(zé)任、以及私人契約的運(yùn)用。四、中美兩國醫(yī)療損害責(zé)任制度改革的比較對待起訴的態(tài)度損害賠償?shù)南拗苹颊邉僭V的難度以上方面中美兩國完全朝著相反的方向發(fā)展MalpracticeMobs:MedicalDisputeResolutioninChinaAuthor:BenjaminL.LiebmanSchoolofLawColumbiaUniversityLecture:LiuzhenXiaoMainContent(1)PartIbeginswithadiscussionofchangesinChina'shealthcaresystem,thensurveystheconfusedlegallandscapeconcerningmedicaldisputesandintroducessomeoftheintermediariesinfluencingmedicaldisputes.MainContent(2)PartIIanalyzes152casescollectedfromMunicipalityA.Thisprojectaimedtostudyeverycourtjudgmentinwhichahospitalormedicalproviderwasadefendantinacivilsuitinonemunicipality,orshi,inacentralprovincefrom2000to2009.

MainContent(3)PartIIIdiscussestheriseofmedicalprotestsandtheimpactofsuchconflictsonhospitals,officials,andthecourts.PartIVdiscussestheimplicationsoftheabovefindingsforunderstandingsofinstitutionaldevelopment,disputeresolution,andgovernanceinChina.PartI:A.China'sHealthcareSystemOverthepastthirtyyears,healthcare,likemuchoftheChineseeconomy,hasundergonedramaticmarketization.ObserversofandparticipantsinChina'shealthcaresystemhavearguedthatmarketizationofthehealthcaresystemhasshiftedpatientexpectationsanddoctor-patientrelationshipsinwaysthatincreaseconflicts.PartI:A.China'sHealthcareSystem(1)Fourtrendsstandout.First,thefactthatpatientsarepayingoutofpocketmeansthatpatientsandtheirfamiliesexpectpositiveoutcomes.Second,thequalityofcareprovidedremainsinconsistent.PartI:A.China'sHealthcareSystem(2)Fourtrendsstandout.Third,distrustinthehealthcaresystemiswidespread,inpartbecauseofcorruptionandquestionablepractices.Fourth,hospitalofficialsanddoctorsblamewidespreadmediacoverageofmedicaldisputesforencouragingpatientprotests.PartI:B.TheLegalLandscape:TheTwoTracksofMedicalMalpracticeLitigationThelegalframeworkgoverningmedicaldisputesischaracterizedbyconfusionandcontroversy.Thissectionprovidesanoverviewoftherelevantlawsandregulationsusedinmedicaldisputes,thedebateovertheappropriatelegalstandardsthatshouldgovernmedicalclaims,andtheofteninconsistentapplicationofsuchrulesinChina'scourts.1.TheMedicalAccidentRegulationsandMedicalReviewBoards.

TheRegulationsweredesignedinparttomakeiteasierforplaintiffstoreceivecompensationandtochanneldisputesintotheformallegalsystem.TheRegulationsplacetheburdenofproofinmedicalcasesondefendants.Inpractice,however,manyobserversofandparticipantsinthelegalsystemcontendthattheregulationsarefavorablefordefendants,fortworeasons.2.AvoidingtheRegulations:TortPrinciplesandJudicialInspections.

NumerousplaintiffshavesoughttoavoidbothdamagelimitationsandmedicalreviewboardsbybringingordinarytortclaimsundertheprovisionsoftheGeneralPrinciplesoftheCivilLawandtheSPG'sInterpretation.3.CourtPracticeProvincialandlocalcourtshavetakenarangeofapproaches,withsomeallbutignoringtheRegulationsandothersrefusingtoacceptcasesnotexaminedbymedicalreviewboards.PartI:C.Lawyers,Intermediaries,andInsurersArangeofintermediarieshelppatientsandtheirfamiliesresolvedisputesandnavigatethehealthcaresystem.Theseincludelawyers,professionalprotesters,appointmenttouts,and"medicalintroducers."Alleitherinfluencetheevolutionofdisputesorreflectproblemsinthehealthcaresystemthatgiverisetodisputes.Inaddition,insurersinfluencedisputeslargelythroughtheirabsencefromtheprocess.1.LawyersLawyersspecializinginmedicalcaseshaveemergedinrecentyears,particularlyinmajorcitiessuchasBeijingandShanghai.Mostlawyerswhospecializeinmedicalcasesareformerdoctors.Contingent-feearrangementsarecommoninmedicalcases,butactualpracticevariesbasedbothonlocationandonindividuallawyersandcases.2.ProfessionalProtestersProfessionalprotesters,operateoutsidemanymajorhospitals,solicitingpatientsandfamilymemberswhoappeartobeindistresswithofferstoobtainafavorablesettlementfromthehospitalinexchangeforapercentageofthesettlementoraflatfee.Professionalprotestersaremostcommoninlargecities.3.AppointmentToutsandMedicalIntroducersAppointmenttouts,haofanzi(literally"numberstraffickers"),sellappointmentslotswithdoctors.Yituo,ormedicalintroducers,likewisecongregateoutsidemajorhospitalsandsolicitpatientsonbehalfofotherhospitals—oftensecondtierhospitals—withpromisesofnodelaysandsometimeslowercost.4.InsurersInsurers,incontrast,aremostnotablefortheirabsencefrommedicaldisputes.Althoughnationalandprovincialauthoritieshaveencouraged(andinsomecasesmandated)medicalliabilityinsurancefordoctorsandhospitals,theinsurancesystemremainslargelyineffective.PartII.INTHECOURTS:FLEXIBILITYANDCOMPROMISEThisprojectaimedtostudyeverycourtjudgmentinwhichahospitalormedicalproviderwasadefendantinacivilsuitinonemunicipality,orshi,inacentralprovincefrom2000to2009.ThisEssayexaminesacollectionof152decisions,gatheredforthisEssay,fifty-ninefromtheintermediate(appellate)courtandninety-threefrombasic-level(firstinstance)courts.Insightsfromthesecases(1)First,thedecisionsrevealahighdegreeofflexibility,bothininterpretingwrittenlawandinbalancingtheinterestsofplaintiffsanddefendants.Second,courtsoverwhelminglyawardsomedamagestoplaintiffs.Insightsfromthesecases(2)Third,thecasessuggestthattherealityofday-to-daycourtdecisionsismorecomplexthanitisoftenperceivedtobe.Fourth,thecasesprovideinsightintoproblemsinthehealthcaresystem,problemsthatleadnotonlytolitigationbutalsotounrest.A.OutcomesThemoststrikingaspectofthecasesisthatplaintiffsreceivedsomecompensationin117,or77%,of152reportedcases.Thisdoesnotmeanthatallthoseplaintiffswon:Mostdamageawardsweremodest,inparticularwhencomparedtoplaintiffdemands.B.UseofRegulationsorSPCInterpretationCourtsinMunicipalityAwereflexibleintheirapplicationoftheRegulationsandrarelyreliedexclusivelyontheRegulationsinresolvingcases.JusttwelvedecisionswerehandledsolelyinaccordancewiththeRegulations.Forty-twoofthecasesreliedonlyontheGeneralPrinciplesandtheSPC'sInterpretation,whiletwenty-onecitedtoboththeGeneralPrinciplesandtotheRegulationsinmakingliabilitydeterminations.C.MedicalReviewBoardsDecisionslikewisesuggestedthatcourtstakeaflexibleapproachtotheuseofmedicalreviewboardsorjudicialinspectionagencies.Fortyeightofthecasesreportedfindingsofmedicalreviewboards.Sixty-eightpercentofthemedicalre-viewboarddecisionsfoundsomeerror.Inasignificantportionofthecases,however,thereviewboardsfoundonlyminorerror.D.EquityandCompromiseCourtdecisionsreflectedstrongconcernsaboutequity,withcourtsawardingcompensationinnumerouscasesabsentfindingsofmedicalerror.Courtsawardeddamagesinthreecasesthatinvolvedpatientswhohadapparentlyattemptedtocommitorhadcommittedsuicide.Courtsalsoimposeddamagesdespitethelackofamedicalreviewboard'sfindingoferror.absentafindingofmedicalerrorincases.E.SettlementsandAppeals

Thirty-fourofthecasescollectedreportedsettlements.Twenty-fourofthesecaseswerefirst-instancedecisions;tensettlementswerereportedonappeal.Mostwereforrelativelymodestamounts,rangingfrom5,000yuanto20,000yuan.F.DamagesMedianandmeanawardsvariedsignificantlyeachyear,reflectingboththesmallnumberofcasesawardingdamagesandtheinfluenceoflargeawards.(Seetable2)G.SourcesforGrievances:China'sHealthcareSystemSuchcasesprovideinsightintoproblemswithChina'shealthcaresystem.Numerouscasesreportedthatpatients'medicalconditionsatleastinpartresultedfromtheirignoringinstructionsforfurthertreatmentortestingorfrompatientsseekingmedicationfromathirdpartyatareducedrate.H.LawyersandOtherRepresentativesMostlitigantsinmedicalcasesinMunicipalityAwererepresentedincourt,althoughnotalwaysbyalawyer.Plaintiffsinforty-nineofninetythreefirst-instancecaseswererepresentedbyalawyer;anadditionaltwenty-sixwererepresentedbyabasic-levellegalworker.Fivemorewererepresentedbyindividualsidentifiedascadres,justicedepartment,orpublicsecuritydepartmentofficials.Defendantswererepresentedbylawyersatahigherrate:PartIII.ONTHESTREETS:PROTESTANDSETTLEMENTA.Protest,Violence,andResponsivenessTheriseinprotestsandinviolenceconcerningmedicaldisputeshasbeenwidelyreportedintheChinesemediaoverthepastdecade,withthetermyinao,or"medicalchaos,"usedtorefertoincidentsofviolenceorprotestarisingfrommedicaldisputes.Mediareportsandinterviewsportrayprotestasacommontoolforpatientsandfamilymembersseekingcompensationfromhospitals

B.Effects:SettlementandFlexibilityFacedwithprotests,mosthospitalsjustpay.Hospitalsarereluctanttosharedataonsettlements.Nevertheless,interviewswithlawyersandhospitalandgovernmentofficialsmakeclearthathospitalssettletheoverwhelmingmajorityofcases,generallymorethan90%.Thisisnotsurprising:Mostcivilcases(inChinaandelsewhere)areresolvedoutsidethecourts.Whatisunusualisthedegreetowhichconcernsaboutprotestsinfluencesettlementpractice.Iv.IMPLICATIONS:ANOVERRESPONSIVESTATE?(1)A.InstitutionalEvolutionMedicalmalpracticelitigationinChinaappearstobeinpartastoryofinstitutionalfailure.Asystemdesignedtoprotecthospitalshasencouragedpatientsandtheirfamiliestoengageindisruptivebehavior.Iv.IMPLICATIONS:ANOVERRESPONSIVESTATE?(2)A.InstitutionalEvolutionInformalmechanismshavedevelopedinsignificantpartbecausetheformalsystemisneitherablenorpermittedtoresolvepatients'claims.Thecreationofnewinstitutionssuchasmedicalreviewboardshashadlittlestabilizingeffect.Facedwithformalinstitutionswidelyperceivedasunfair,patientsandtheirfamiliestakemattersintotheirownhands.

B.LawintheShadowofProtest(1)Despitethreedecadesofemphasisonconstructingacomprehensivelegalframework,medicalcasesshowthatinmanydisputesinChinathe"shadowofthelaw"isweakornonexistent.Inmedicaldisputes,lawoperatesintheshadowofprotest.Thethreatofprotestkeepsmanycasesoutofcourtandalsocastsashadowoverhowcourtshandlecasesthatdowindupintheformallegalsystem.B.LawintheShadowofProtest(2)Asthediscussionabovehasshown,hospitalofficials,judges,andhealthdepartmentofficialsacknowledgethatwhetherornottheyfaceaprotestorthreatthereofisgenerallythemostimportantfactorinfluencingresolutionofmedicaldisputes.Mostdisputesareresolvedwithlittle,ifany,referencetopotentiallegalliability,evidencedbythefactthatnegotiatedoutcomesinmedicaldisputesfrequentlyexceedtheamountsawardableincourt.C.ProtestandResponsiveness:NationalizingPrivateLitigation(1)Medicaldisputesshowhowclaimsthatbeginasprivatelawdisputesbecomeclaimsagainstthestate.Ratherthanfacilitatingthedevelopmentoflegalinstitutionstoresolveprivatedisputes,officialresponsivenesssendsthemessagethatarangeofprivatelawdisputesareinfactclaimsagainstthestate.C.ProtestandResponsiveness:NationalizingPrivateLitigation(2)Thisisnotanobservationuniquetomedicaldisputes:Similardynamicsexistinotherareasthatalsofrequentlygiverisetounrest,includinglandandlabordisputes.Hospitalsarenotpurelyprivateactors:Mostarestate-ownedandremainoverseenbylocalhealthbureaus.Nevertheless,officialresponsivenesstoprotestreinforcespopularviewsthathospitalsarerepresentativesofthestate.CONCLUSION(1)Thelevelofviolenceandunrestinmedicaldisputesisinsomerespectsunsurprising.Thecombinationofhighstakes,ahealthcaresystemwidelyperceivedasfocusedonprofitratherthanpatientcare,lackofasocialsafetynet,andbiaseddisputeresolutioninstitutionsmightwellproduceinstabilityinanysystem.Thetrendtowardresolutionofclaimsthroughprotestand-violenceappearslikelytobecomemorewidespreadabsentsignificantreforms.CONCLUSION(2)Somerecentreformsappeardesignedtoreduceunrest.EffortsbytheSupremePeople'sCourttostreamlinethehandlingofmedicalcase