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國立高雄第一科技大學科技法律研究所

課程：醫療與法律案例討論： Hall v. Hilbun

科法所 95 碩專班學 號： 9520707

姓 名：陳 文 洲 97.04.09

指導教授：周 天 所長

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Glenn Hall （ P ）

（專家證人）excluded

vs Dr. Hilbun （ D ）

（專家證人）

Circuit Court Directed verdict for surgeon

Supreme Court Reversed and remandedFor new trial

Locality rule

民事訴訟 - 侵權行為

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事實（ 1）

Terry O. Hall was admitted to the Singing River Hospital in Jackson County, Mississippi, in the early morning hours of May 18, 1978, complaining of abdominal discomfort. Because he was of the opinion his patient had a surgical problem, Dr. R.D. Ward, her physician, requested Dr. Glyn R. Hilbun, a general surgeon, to enter the case for consultation. Examination suggested that the discomfort and illness were probably caused by an obstruction of the small bowel. Dr. Hilbun recommended an exploratory laparotomy. Consent being given, Dr. Hilbun performed the surgery about noon on May 20, 1978, with apparent success.

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事實（ 2）

Following surgery Mrs. Hall was moved to a recovery room at 1:35 p.m., where Dr. Hilbun remained in attendance with her until about 2:50 p.m. At that time Mrs. Hall was alert and communicating with him. All vital signs were stable. Mrs. Hall was then moved to a private room where she expired some 14 hours later.

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程序

目前是第三審，審理法院是 Supreme Court of

Mississippi.

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爭點

對於事實的認定，雙方都沒有爭議。 Mr. Hall 認為 Dr. Hilbun 所提供的照護標準

（ standard of care ）明顯不足。 Dr. Hilbun 及他請來的一位專家證人，認為照

護標準存在地方性的差異。 Circuit Court 認為根據 locality rule, Mr. Hall

請來的兩位專家證人的證詞不能被採用。

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抗辯— Appellant （ 1 ）

The plaintiff sought to establish that there is a national standard of surgical practice and surgical care of patients in the United States to which all surgeons, including Dr. Hilbun, are obligated to adhere.

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抗辯— Appellant （ 2 ）

Dr. David Peter Lango Sachs ： There are different ways that a surgeon can keep track of his

patient-“follow her” as the expression goes-besides a bedside visit, which is the best way and which need not be very long at all, in which the vital signs are checked over. The surgeon gets a general impression of what's going on. He can delegate this responsibility to a competent physician, who need not be a surgeon but could be a knowledgeable family practitioner. He could call in and ask to speak to the registered nurse in charge of the patient and determine through her what the vital signs are, and if she is an experienced Registered Nurse what her evaluation of the patient is. From my review of the record, none of these things took place, and there is no effort as far as I can see that Dr. Hilbun made any effort to find out what was going on with this patient during that period of time.

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抗辯— Appellee

Dr. Donald Dohn ： 1. There was a great difference in the standard of care in

medical procedures in Cleveland, Ohio, and those in

Pascagoula, Mississippi.

2. Well, there are personnel differences. There are equipment

differences. There are diagnostic differences. There are

differences in staff responsibility and so on.

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判決

Reversed and remanded for new trial.

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判決理由（ 1 ）

案例解釋：

1. Dazet v. Bass, 254 So.2d 183 (Miss.1971)

Circuit Court 援用此案例，固守 locality rule 。

2. King v. Murphy, 424 So.2d 547 (Miss.1982) 擴大解釋 locality rule 。 3. Pederson v. Dumouchel, 72 Wash.2d 73, 431 P.2d 973 (1967)

judicial abolition of the old locality rule. 4. Brune v. Belinkoff, 354 Mass. 102, 235 N.E.2d 793 (1968)

permits consideration of “the medical resources available to

the physician”.

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判決理由（ 2 ）

Locality rule

Rule of substantive law

Rule of evidence

A physician is bound to bestow to each patient such reasonable and ordinary care, skill, and diligence and to exercise such good medical judgment as physicians and surgeons in good standing in the same neighborhood or locality, in the same general line of practice, ordinarily have and exercise in like cases.

A medical expert would not be allowed to testify in a medical malpractice case unless he practiced in the neighborhood or locality and was familiar with the local standard of care.

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判決理由（ 3 ）

（ 1） surgeon acquired obligation to perform all facets

of surgery with that level of competence and diligence

as might be expected of minimally competent surgeons

under the circumstances throughout the United States

and to direct postoperative care and to insure that,

with respect to all postoperative dangers or

complications reasonably to be anticipated under

circumstances, adequate provision was made for

prompt diagnosis and treatment,

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判決理由（ 4 ）

（ 2 ） each of two proffered medical experts should

have been permitted to testify concerning

physician's standard of care, even though they

were from another region of the country.

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我國相關法律（ 1）

醫療法第 59條：醫院於診療時間外，應依其規模及業務需要 ，指派適當人數之醫師值班，以照顧住院及急診病人。

醫療法第 73條第 1 項：醫院、診所因限於人員、設備及專長能 力，無法確定病人之病因或提供完整治療時，應建議病人轉 診。但危急病人應依第六十條第一項規定，先予適當之急救 ，始可轉診。

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我國相關法律（ 2）

民法第 184條：因故意或過失，不法侵害他人之權利者，負損 害賠償責任。故意以背於善良風俗之方法，加損害於他人者 亦同。

民法第 192條：（ 1 ）不法侵害他人致死者，對於支出醫療及增加生活上需要 之費用或殯葬費之人，亦應負損害賠償責任。（ 2 ）被害人對於第三人負有法定扶養義務者，加害人對於該 第三人亦應負損害賠償責任。（ 3 ）第一百九十三條第二項之規定，於前項損害賠償適用之。

民法第 194條：不法侵害他人致死者，被害人之父、母、子、 女及配偶，雖非財產上之損害，亦得請求賠償相當之金額。

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ARDS急性呼吸窘迫症候群 ARDS一詞，最早由 Dr. Ashbaugh在 1967年提出 (adult

respiratory distress syndrome)，中文譯為成人呼吸窘迫症候群。後來在 1994年，歐美學者針對 ARDS開會討論，做出以下結論：( 一 ) 將 ARDS的‘ A’字由 adult改為 acute，即 ARDS的全名為

「 Acute respiratory distress syndrome」，中文譯為急性呼吸窘迫症候群，使用範圍不限於成人。( 二 ) 將 ARDS統一訂定標準如下﹕ (1)急性發作； (2)氧合指數

(PaO2/FIO2)均小或等於 200毫米汞柱； (3)胸部 X 光呈現兩側肺浸潤； (4)肺動脈楔壓若有測量，須小或等於 18毫米汞柱，若無資料，則以臨床上無左心房高壓現象即可。急性呼吸窘迫症候群病患的肺部變化源於廣泛性的肺泡微血管受損，使得內皮細胞間通透性增加，引發肺泡出血及水腫等現象，最後導致肺內死腔及分流增大，肺順應性與氧合狀況變差，而造成臨床上的呼吸窘迫。大致而言病理變化包含三期：滲出期 (exudates)，增昇期(proliferative)，纖維期 (fibrosis)。最常見之病因以敗血症、肺炎、吸入性肺炎、大量輸血、胰臟炎……等疾病所引發。目前急性呼吸窘迫症候群病患死於呼吸衰竭的機率不高 (<5%)，而大多死於敗血症或多重器官衰竭，死亡率約 50%。對病人而言肺纖維程度也決定患者日後肺功能。

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ARDS急性呼吸窘迫症候群 雖然對此疾病之生理機轉已有較深入之了解，藥物治療上卻無重大進展。

高劑量類固醇曾證實有效，但今年之大型研究已證實此方法無法有效降低死亡率。在呼吸器的使用上則有下列原則：( 一 ) 盡快降低氧氣濃度以避免氧氣毒性。( 二 ) 低潮氣量 (6 ml/kg)之設定以維持高原氣道壓力 (plateau)小於 30-35釐米水柱，可有效減輕呼吸器對肺部造成的二次傷害 ( 肺部過度通氣造成局部或全肺過度膨脹 ) ，及降低死亡率。( 三 ) 容許高血中二氧化碳 (50 00毫米汞柱 ) 。( 四 ) 吐氣末正壓 (PEEP)：增加功能性殘留容積及改善通氣血流灌注比例，進而增進肺部的氧合效果。( 五 ) 其他呼吸治療方式 (1)高頻通氣法 (High frequency ventilation) (2)體外膜性氧合術 (Extra-corporeal membrane

oxygenation) (3)液態或部分液態通氣法 (Liquid or partial liquid ventilation)。 (4)體態 (Posture)：以俯臥 (prone)姿勢，可改善氧合狀況卻無

法降低 死亡率。( 六 ) 給予適當的鎮定劑與肌肉鬆弛劑以增進病人與呼吸器之協調性。

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ARDS急性呼吸窘迫症候群