Open Decision Ledger · Criminal law
Causation proof required for a doctor's professional negligence homicide
Supreme Court, Aug. 31, 2023, 2021Do1833 (judgment)
Case name: 업무상과실치사·의료법위반[의사인 피고인이 간호사에게 환자 감시 업무를 맡기고 수술실을 이탈한 후 피해자인 환자에게 심정지가 발생하여 사망한 사건]
Official text on the National Law Information Center
Question
Where an anaesthesiologist breached the duty of patient monitoring during an operation but the 73-year-old patient died of an unclear cause, must the prosecution prove beyond reasonable doubt that the breach caused the death, and may that finding differ from a civil judgment on the same facts?
Holding
It must. The Court held that proof of the doctor's negligence alone neither presumes causation nor lowers the degree of proof, and because the criminal trial requires proof leaving no reasonable doubt, the causation finding may differ from a civil judgment on the same facts. On these facts the negligence finding was sound, but the prosecution's evidence alone did not show what further measures the defendant could have taken if he had returned promptly, or that the patient would have avoided cardiac arrest, so causation was not proved to that standard.
Summary of the holding, verbatim
의사의 업무상과실이 증명되었다는 사정만으로 인과관계가 추정되거나 증명 정도가 경감되는 것은 아니다.
Unofficial English translation
The mere fact that a physician's occupational negligence has been proved does not give rise to a presumption of causation or reduce the degree of proof.
Disposition
Partly reversed and remanded Stated in the decision
원심판결 중 피고인의 업무상과실치사에 관한 부분을 파기하고, 이 부분 사건을 서울중앙지방법원에 환송한다. 나머지 상고를 기각한다.
Unofficial English translation
The judgment of the court below is reversed insofar as it relates to the defendant's occupational negligent homicide, and this part of the case is remanded to the Seoul Central District Court. The remainder of the final appeal is dismissed.
Form of the test
Elements stated Stated in the decision
의료행위 과정에서 공소사실에 기재된 업무상과실의 존재는 물론 그러한 업무상과실로 인하여 환자에게 상해·사망 등 결과가 발생한 점에 대하여도 엄격한 증거에 따라 합리적 의심의 여지가 없을 정도로 증명이 이루어져야 한다
Unofficial English translation
In the course of medical practice, not only the existence of occupational negligence as stated in the facts charged but also the fact that results such as injury or death were caused to the patient as a result of such occupational negligence must be proved by strict evidence to such a degree that no reasonable doubt remains
Factors
- 공소사실에 기재된 업무상과실의 존재는 물론 그러한 업무상과실로 인하여 환자에게 상해·사망 등 결과가 발생한 점에 대하여도 엄격한 증거에 따라 합리적 의심의 여지가 없을 정도로 증명이 이루어져야 한다
- 의사의 업무상과실이 증명되었다는 사정만으로 인과관계가 추정되거나 증명 정도가 경감되는 것은 아니다
- 검사가 제출한 증거만으로는 피고인이 직접 갑을 관찰하거나 을의 호출을 받고 신속히 수술실에 가서 대응하였다면 구체적으로 어떤 조치를 더 할 수 있는지, 그러한 조치를 취하였다면 갑이 심정지에 이르지 않았을 것인지 알기 어렵고
- 반복적인 혈압상승제 투여에도 불구하고 알 수 없는 원인으로 계속적으로 혈압 저하 증상을 보이다가 사망하였는데
Unofficial English translation
• Not only the existence of occupational negligence as stated in the facts charged but also the fact that results such as injury or death were caused to the patient as a result of such occupational negligence must be proved by strict evidence to such a degree that no reasonable doubt remains
• The mere fact that a physician's occupational negligence has been proved does not give rise to a presumption of causation or reduce the degree of proof
• On the evidence submitted by the prosecutor alone, it is difficult to ascertain what specific additional measures could have been taken had the defendant directly observed A or promptly gone to the operating room upon being called by B and responded thereto, and whether A would not have suffered cardiac arrest had such measures been taken, and
• A, despite repeated administration of vasopressors, continued to exhibit symptoms of declining blood pressure for unknown causes and died
Relation to precedent
Follows earlier decisions Stated in the decision
대법원 2023. 1. 12. 선고 2022도11163 판결(공2023상, 463)
Unofficial English translation
Supreme Court Decision 2022Do11163 decided January 12, 2023 (Gong 2023 Sang, 463)
Decisions referred to
[1] 대법원 2011. 4. 28. 선고 2010도14102 판결, 대법원 2023. 1. 12. 선고 2022도11163 판결(공2023상, 463)
Burden of proof
The prosecution Stated in the decision
검사는 공소사실에 기재한 업무상과실과 상해·사망 등 결과 발생 사이에 인과관계가 있음을 합리적인 의심의 여지가 없을 정도로 증명하여야 하고, 의사의 업무상과실이 증명되었다는 사정만으로 인과관계가 추정되거나 증명 정도가 경감되는 것은 아니다.
Unofficial English translation
The prosecutor must prove to such a degree that no reasonable doubt remains that there is causation between the occupational negligence stated in the facts charged and the occurrence of results such as injury or death, and the mere fact that a physician's occupational negligence has been proved does not give rise to a presumption of causation or reduce the degree of proof.
Open question and revisit condition
When an autopsy leaves the cause of death unknown, what evidence can show beyond reasonable doubt that direct observation and prompt intervention would have prevented the cardiac arrest?
The remand judgment of the Seoul Central District Court in case 2019No369, once it re-hears the professional negligence causing death charge, will show how the proof of causation works in practice. A later Supreme Court decision that tightens or relaxes that proof, or an amendment to Article 268 of the Criminal Act or Article 307 of the Criminal Procedure Act, would require this entry to be read again.
Cross-family AI independent reading & axis check
7 of 8 axes matched GPT-6 Astra (OpenAI, codex CLI) · 2026-10-25
A reader from another model family (GPT-6 Astra), given the official text but not the primary reading, agreed on 7 of the 8 axes; the readings differed on axis 4 (form of the test).
Axis 4 (Form of the test): Primary “Elements stated” vs Independent “Existing test applied”
Both record the prosecution as bearing the burden, so the values match; the independent reading states the rule as a standalone requirement with no presumption, while the primary reading ties it to the stated standard of proof.
피고인의 업무상과실로 갑이 사망하게 되었다는 점이 합리적인 의심의 여지가 없을 정도로 증명되었다고 보기 어렵다는 이유로Raw responses and comparison record: Protocol · Blind readings (JSONL) · Axis comparison (JSONL) · SHA-256 (JSON)
Lower-court contrast & scope of application
Lower-court reading vs. Supreme Court holding
Lower-court context: The Seoul Central District Court, in its judgment of 21 January 2021 (2019No369), convicted the defendant, an anaesthesiologist, of professional negligence causing death and of violations of the Medical Act. It held that handing the patient's monitoring to a nurse who was not an anaesthesia nurse and had done the work only for two to three months, moving between other operating rooms to anaesthetise other patients, and resting rather than returning promptly when called after the vital-signs monitor sounded, was a breach of the duty of care during anaesthesia, and that adequate causation existed between that breach and the patient's death.
Supreme Court standard: The Supreme Court found no error in the finding of professional negligence. On causation, however, it held that the evidence the prosecution submitted did not show what concrete further measures the defendant could have taken had he observed the patient directly or responded promptly to the nurse's calls, or that those measures would have averted cardiac arrest, and that the cause of death remained unclear even after autopsy, so the death caused by the negligence was not proved beyond reasonable doubt. It reversed the professional negligence causing death part and remanded it to the Seoul Central District Court, dismissed the rest of the appeal, and kept the Medical Act parts, which drew fine sentences, outside the scope of reversal because they must be treated separately in procedure from the part drawing imprisonment.
Distinguishing conditions
- A case in which the prosecution's evidence shows what concrete measure the doctor could have taken and, beyond reasonable doubt, that the patient would not have gone into cardiac arrest without it.
- A civil claim for damages on the same medical facts, since the Court held that the criminal causation finding may differ from the civil judgment.
- A charge under the Medical Act that drew a fine sentence, which the Court held is treated separately in procedure from the charge drawing imprisonment and lies outside the scope of reversal.
Record verification notes
Set the file against the operative timeline: the blood-pressure falls to about 70/42, 75/55 and 80/55 mmHg at about 10:25, 10:45 and 11:00 on 30 December 2015, the ephedrine doses of 10 mg, 10 mg and 5 mg, and the autopsy that left the cause of death unclear. Ask what specific measure the prosecution says was available when the nurse called, and whether expert evidence links that measure to avoiding the cardiac arrest. Check separately whether the Medical Act parts have become final, since the Supreme Court did not reverse them.
From the official text
Points at issue
[1] 의사에게 의료행위로 인한 업무상과실치사상죄를 인정하기 위한 요건 중 ‘업무상과실과 상해·사망 등 결과 발생 사이에 인과관계가 있음’에 대한 증명책임 소재(=검사) 및 증명 정도(=합리적인 의심의 여지가 없을 정도) / 형사재판에서의 인과관계에 관한 판단이 동일 사안의 민사재판과 달라질 수 있는지 여부(적극) [2] 마취통증의학과 의사인 피고인이 수술실에서 환자인 피해자 갑(73세)에게 마취시술을 시행한 다음 간호사 을에게 환자의 감시를 맡기고 수술실을 이탈하였는데, 이후 갑에게 저혈압이 발생하고 혈압 회복과 저하가 반복됨에 따라 을이 피고인을 수회 호출하자, 피고인은 수술실에 복귀하여 갑이 심정지 상태임을 확인하고 마취해독제 투여, 심폐소생술 등의 조치를 취하였으나, 갑이 심정지 등으로 사망에 이르게 된 사안에서, 피고인에게 업무상과실치사죄를 인정한 원심판단에 의사의 업무상과실과 피해자의 사망 사이의 인과관계 증명 등에 관한 법리오해의 잘못이 있다고 한 사례
Unofficial English translation
[1] The location of the burden of proof (=the prosecutor) and the degree of proof (=to such a degree that no reasonable doubt remains) as to "the existence of causation between occupational negligence and the occurrence of results such as injury or death" among the requirements for finding a physician guilty of the crime of negligent injury or death arising from occupational negligence in the course of medical practice / Whether the determination of causation in a criminal trial may differ from that in a civil trial involving the same matter (affirmative) [2] In a case where the defendant, an anesthesiology and pain medicine physician, performed an anesthetic procedure on the victim A (73 years old), a patient, in the operating room, then entrusted the monitoring of the patient to nurse B and left the operating room, and where, after A developed hypotension and repeated cycles of blood pressure recovery and decline, B called the defendant several times, upon which the defendant returned to the operating room, confirmed that A was in a state of cardiac arrest, and took measures such as administering reversal agents for anesthesia and performing cardiopulmonary resuscitation, but A died as a result of cardiac arrest and the like, a case in which it was held that the determination of the court below, which found the defendant guilty of negligent homicide arising from occupational negligence, was erroneous in that it misapprehended legal principles, among other things, concerning the proof of causation between the physician's occupational negligence and the victim's death
Summary of the holding
[1] 의사에게 의료행위로 인한 업무상과실치사상죄를 인정하기 위해서는, 의료행위 과정에서 공소사실에 기재된 업무상과실의 존재는 물론 그러한 업무상과실로 인하여 환자에게 상해·사망 등 결과가 발생한 점에 대하여도 엄격한 증거에 따라 합리적 의심의 여지가 없을 정도로 증명이 이루어져야 한다. 따라서 검사는 공소사실에 기재한 업무상과실과 상해·사망 등 결과 발생 사이에 인과관계가 있음을 합리적인 의심의 여지가 없을 정도로 증명하여야 하고, 의사의 업무상과실이 증명되었다는 사정만으로 인과관계가 추정되거나 증명 정도가 경감되는 것은 아니다. 이처럼 형사재판에서는 인과관계 증명에 있어서 ‘합리적인 의심이 없을 정도’의 증명을 요하므로 그에 관한 판단이 동일 사안의 민사재판과 달라질 수 있다. [2] 마취통증의학과 의사인 피고인이 수술실에서 환자인 피해자 갑(73세)에게 마취시술을 시행한 다음 간호사 을에게 환자의 감시를 맡기고 수술실을 이탈하였는데, 이후 갑에게 저혈압이 발생하고 혈압 회복과 저하가 반복됨에 따라 을이 피고인을 수회 호출하자, 피고인은 수술실에 복귀하여 갑이 심정지 상태임을 확인하고 마취해독제 투여, 심폐소생술 등의 조치를 취하였으나, 갑이 심정지 등으로 사망에 이르게 된 사안에서, 피고인이 갑에게 마취가 진행되는 동안 마취간호사도 아니고 마취간호 업무를 시작한 지 2~3개월밖에 안 된 을에게 환자의 감시 업무를 맡긴 채 다른 수술실로 옮겨 다니며 다른 환자들에게 마취시술을 하고, 갑의 활력징후 감시장치 경보음을 들은 을로부터 호출을 받고도 신속히 수술실로 가지 않고 휴식을 취하는 등 마취유지 중 환자감시 및 신속한 대응 업무를 소홀히 한 업무상과실이 있다고 본 원심판단은 정당하나, 한편 갑은 반복적인 혈압상승제 투여에도 불구하고 알 수 없는 원인으로 계속적으로 혈압 저하 증상을 보이다가 사망하였는데, 검사가 제출한 증거만으로는 피고인이 직접 갑을 관찰하거나 을의 호출을 받고 신속히 수술실에 가서 대응하였다면 구체적으로 어떤 조치를 더 할 수 있는지, 그러한 조치를 취하였다면 갑이 심정지에 이르지 않았을 것인지 알기 어렵고, 갑에게 심정지가 발생하였을 때 피고인이 갑을 직접 관찰하고 있다가 심폐소생술 등의 조치를 하였더라면 갑이 사망하지 않았을 것이라는 점에 대한 증명도 부족하므로, 피고인의 업무상과실로 갑이 사망하게 되었다는 점이 합리적인 의심의 여지가 없을 정도로 증명되었다고 보기 어렵다는 이유로, 이와 달리 피고인의 업무상과실로 인하여 갑이 사망하였다고 보아 피고인에게 업무상과실치사죄를 인정한 원심판단에 의사의 업무상과실과 피해자의 사망 사이의 인과관계 증명 등에 관한 법리오해의 잘못이 있다고 한 사례.
Order
원심판결 중 피고인의 업무상과실치사에 관한 부분을 파기하고, 이 부분 사건을 서울중앙지방법원에 환송한다. 나머지 상고를 기각한다.
Unofficial English translation
The judgment of the court below is reversed insofar as it relates to the defendant's occupational negligent homicide, and this part of the case is remanded to the Seoul Central District Court. The remainder of the final appeal is dismissed.
Provisions referred to
[1] 형법 제17조, 제268조, 형사소송법 제307조, 제308조 [2] 형법 제17조, 제268조, 형사소송법 제307조, 제308조
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