Abstract: Because of its specialty and complexity, the causation in medical accident crime is difficult to identify in judicial practice. Based on the statistical analysis of the judicial adjudications of medical accident crime from 2012 to 2021, it is found that the practical difficulties in the determination of causation in medical accident crime mainly lie in the neglect of causal relationship argumentation by judges, the lack of evidence in proving complex causal relationships, the alienation of judicial functions caused by "using appraisal as a substitute for trial", conflicting appraisal opinions, and difficulties in cross examination, et al. In view of these problems, we can provide guidance for judicial practice by establishing specific identification rules, such as applying the theory of accident participation to divide the causal force, applying the "practice behavior theory + equivalent causal relationship theory" to identify the interventional causal relationship, applying the "condition theory + exclusion method" to identify the direct causal relationship, and using the method of free evaluation of evidence to identify the fuzzy causal relationship.