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Problematika poskytnutia súhlasu pri transplantáciách ex mortuo a ex vivo


 | 23.1.2015 | komentárov: 791

Inštitút informovaného súhlasu predstavuje jeden z najdôležitejších právnych inštitútov pri poskytovaní zdravotnej starostlivosti. Je neoddeliteľnou súčasťou v praxi uskutočňovaných zdravotníckych výkonov a zohráva mimoriadnu úlohu pri tak závažných zásahoch do ľudského organizmu akými nepochybne transplantácie orgánov sú (1).

Obrazok

Naša právna úprava sa zaoberá inštitútom poučenia a informovaného súhlasu v § 6 zák. č.576/2004 Z. z. v znení neskorších predpisov, ktorý ustanovuje,  povinnosť ošetrujúceho zdravotníckeho pracovníka informovať o účele, povahe, následkoch a rizikách poskytnutia zdravotnej starostlivosti, o možnosti voľby navrhovaných postupov a rizikách odmietnutia poskytnutia zdravotnej starostlivosti (2). Z tohto ustanovenia teda možno vyvodiť, že dotknuté osoby (v našom prípade darca, príjemca- ex vivo, príjemca- ex mortuo) musia byť  informované o relevantných skutočnostiach, týkajúcich sa uskutočňovaného zásahu a to nielen v rámci objektívnych medicínskych kritérií ale aj z hľadiska individuálnych charakteristík, ktoré sú typické pre každého pacienta ako sú napr. vek pacienta, existencia iného ochorenia a pod. V prípade pochybnosti resp. nepochopenia účelu, rizík resp. postupov pri zdravotnom výkone je ošetrujúci pracovník povinný zodpovedať na doplňujúce otázky pacienta, ktoré by mu vzniknuté pochybnosti odstránili (3). Pacient musí byť informovaný pomocou pojmov, ktoré môže pochopiť tak, aby vedel zvážiť nutnosť či užitočnosť cieľa a metód  zákroku v porovnaní s jeho rizikami a nepohodlím. Poskytnuté poučenie nesmie byť v žiadnom prípade zavádzajúce alebo dokonca nepravdivé (4). Problematika informovaného súhlasu ako takého je nepochybne veľmi rozsiahlym inštitútom. V mojej práci sa preto venujem  výlučne problematike súhlasu v prípadoch transplantácii ex mortuo a ex vivo.

Súhlas darcu na odňatie transplantátu ex mortuo

Vo všeobecnosti možno povedať, že existujú dve formy ako vyjadriť to či súhlasíme resp. nesúhlasíme s darcovstvom. Rozoznávame tzv. priamy súhlas (opting- in). tzn., že darca počas svojho života jednoznačne vyjadrí, že s darovaním súhlasí. Druhá forma je tzv. predpokladaný súhlas (opting-out), čo znamená, že každý človek má počas svojho života právo na to, aby vyjadril nesúhlas s darcovstvom, a ak to neurobí, tak sa automaticky predpokladá, že s darovaním orgánov súhlasí (5).

Takáto právna úprava s inštitútom predpokladaného súhlasu je príznačná aj pre Slovenskú republiku. Náš zákon 576/2004 Z. z. vo svojom § 37 ods. 1  ustanovuje , že  odobrať orgány, tkanivá alebo bunky z tiel mŕtvych darcov možno len vtedy, ak osoba počas svojho života neurobila písomné vyhlásenie, že s týmto zásahom do svojej telesnej integrity nesúhlasí, alebo vyhlásenie, že nesúhlasí s vykonaním pitvy podľa osobitného predpisu, ktorým je § 48 ods. 4 zák. č. 581/2004 Z. z. v znení neskorších predpisov (6). 

Jednou z otázok, na ktorú treba pri transplantáciách ex mortuo poskytnúť odpoveď, je otázka, či pozostalí majú alebo nemajú právo vysloviť nesúhlas s odberom orgánov v prípadoch, keď mŕtvy nezanechal žiadne písomné vyhlásenie, ktorým by nesúhlasil s odberom.  Naša právna úprava takéto právo na odmietnutie odberu orgánov pozostalými nepripúšťa, čo je evidentné zo znenia § 37 zák. č. 576/2004 Z. z. v znení neskorších predpisov, kde sa vyžaduje podmienka, aby osoba počas svojho života urobila vyhlásenie, že s odberom na transplantačné účely nesúhlasí. Na podporu takéhoto tvrdenia niektorí autori uvádzajú, že v čase života takéhoto potenciálneho darcu jeho telo patri výlučne do jeho osobnej dispozície a tak by to malo ostať aj po jeho smrti (7). 

Mohlo by sa zdať, že toto ustanovenie spochybňuje § 15 OZ, ktorý ustanovuje, že po smrti fyzickej osoby patrí uplatňovať právo na ochranu jej osobnosti manželom a deťom, a ak ich niet, jej rodičom (8). V tomto zmysle je potrebné povedať, že telo mŕtvej fyzickej osoby a jej časť nemožno považovať za veci v zmysle § 118 OZ, ale stále ako súčasť osobnosti fyzickej osoby, pretože telo je aj po smrti fyzickej osoby stále individualizované (9). V §  15 OZ sa pojednáva o ochrane subjektívnych osobnostných práv osoby, ktorá už nie je na žive. Z toho vyplýva, že v prípade ak ide o mŕtvu osobu, ochrana práva na telesnú integritu taxatívne vymedzenými osobami uvedená v tomto paragrafe už nemôže smerovať k ochrane života a zdravia (10). 

Domnievam sa, že naša právna úprava v tomto smere ide správnym smerom, nakoľko  mám za to, že je potrebné  vnímať to, že na konci celého tohto transplantačného reťazca, je človek, ktorý čaká na orgán, ktorý mu nepochybne môže zachrániť život, čo zodpovedá aj ústavným či zákonným princípom zabezpečenia práva na život a tiež zdravotnej starostlivosti podľa najnovších poznatkov vedy (11).

Je potrebné podotknúť, že aj keď v našej krajine platí legislatíva predpokladaného súhlasu, to neznamená, že príslušný zodpovedný lekár z oddelenia, kde bol pacient- potenciálny darca orgánu hospitalizovaný resp. transplantačný koordinátor  nekonzultujú s príbuznými zosnulého želania takéhoto mŕtveho. Každý takýto rozhovor s príbuznými musí mať jasnú štruktúru, relevantný obsah odrážajúci všetky momenty darcovského procesu a teda vysvetlenie konceptu mozgovej smrti, konceptu darcovstva orgánov a transplantácie a musí byť realizované profesionálne, čo sa týka prejavu (verbálny, non-verbálny prejav) a smerovania. Pri rozhovore s príbuznými v čase, keď títo dostanú informáciu o tom, že práve prišli o svojho blízkeho sa zdôrazňuje najmä to, že s ich pomocou a šľachetnosťou možno pomôcť iným ľudom. Aj keď je takýto rozhovor s príbuznými mŕtveho darcu vedený korektne a prístup k príbuzným je vysoko humánny, častokrát  po prvom rozhovore majú príbuzní negatívny názor na odber orgánov na transplantačné účely. MUDr. Beňa vo svojej publikácii zdôrazňuje, že takýto negatívny záver je potrebné rešpektovať, ale zároveň zdôrazňuje povinnosť identifikovať dôvod nesúhlasu príbuzných a snažiť sa nájsť stratégiu ako nesúhlas prekonať o to viac, že aktuálna platná legislatíva v našich krajinách nedáva príbuzným možnosť odmietnuť darovanie orgánov ich príbuzného, pokiaľ tento tak neučinil za svojho života. Medzi najčastejšie príčiny odmietnutia darcovstva možno uviesť: nesúhlas potenciálneho darcu, sťažnosť na zdravotnícky systém, nepochopenie koncepcie mozgovej smrti, strach zo straty integrity tela , náboženské problémy, sociálne problémy atď (12).

Zo získaných informácií teda možno vyvodiť záver, že aj keď naša aktuálna právna úprava nedáva príbuzným možnosť odmietnuť darovanie orgánov ich zosnulého príbuzného, v praxi sa v prípade takéhoto pretrvávajúceho  negatívneho postoja  odber orgánu už zo spomínaných dôvodoch neuskutoční (13).

Súhlas darcu na odňatie transplantátu ex vivo

V prípade transplantácií z tiel živých darcov je potrebné  zdôrazniť, že takýmto darcom môže byť len osoba , ktorá je plne spôsobilá na právne úkony, ktorá dala na odber písomný informovaný súhlas po predchádzajúcom poučení. A teda v prípade odberov orgánov na transplantačné účely nie je možné, aby za osobu čiastočne alebo úplne nespôsobilú dal takýto súhlas jej zákonný zástupca (rodič, osvojiteľ, opatrovník) ani nijaká iná osoba, orgán či organizácia. Na takýto súhlas totiž tieto osoby nie sú oprávnené, nakoľko odňatie orgánu z tela živého darcu a s tým spojené výkony nie sú v záujme jednotlivca, ale na jeho ujmu (14).  

V prípade odberu regeneratívneho tkaniva je situácia značne odlišná. Dohovor o ľudských právach a biomedicíne zakotvuje v článku 20 možnosť vykonať odber regeneratívneho tkaniva vo výnimočných prípadoch aj od osôb, ktoré nemajú plnú spôsobilosť na právne úkony, a teda maloletých a osôb pozbavených alebo obmedzených v spôsobilosti na právne úkony. Aj keď Dohovor obsahuje zákaz odberu akéhokoľvek orgánu od osôb, ktoré nie sú spôsobilé dať s odberom súhlas, no súčasne tiež ustanovuje, že výnimočne, v súlade s ochrannými ustanoveniami upravenými zákonom, a po splnení taxatívne uvedených podmienok, možno schváliť odobratie regeneratívneho tkaniva  od osôb, ktoré nie sú spôsobilé vyjadriť svoj súhlas (15).

Dohovor v zmysle vyššie uvedeného obsahuje nasledujúce podmienky:

  • nie je k dispozícii kompatibilný darca, ktorý je spôsobilý vyjadriť súhlas,
  • príjemca je brat alebo sestra darcu,
  • darcovstvo musí mať pre príjemcu život zachraňujúci potenciál,
  • súhlas je vyjadrený špecificky a písomne v súlade so zákonom a so schválením kompetentného orgánu,
  • potenciálny darca nemá námietky (16)

Na tento Dohovor reagovala novela zák. č. 576/2004 v znení neskorších predpisov, čo sa premietlo v ustanovení § 36 ods.2 zák. č. 581/2004 v znení neskorších predpisov.

Pre príklad postupu pri transplantáciách ex vivo možno uviesť  transplantáciu obličky od žijúceho darcu.  V tomto prípade podobne ako v početných prípadoch transplantácii aj iných orgánov , tkanív či buniek, platí, že každý darca má právo na informácie, ktoré mu umožnia vyvážený pohľad na výhody a nevýhody transplantácie od žijúceho darcu. Rovnako  mu musia byť poskytnuté potrebné informácie týkajúce sa rizík, ktoré takáto transplantácia prináša a tiež informácie o miere pravdepodobnosti úspechu transplantácie u príjemcu. Už poskytnutý súhlas je darca oprávnený v ktoromkoľvek štádiu vyšetrovacieho procesu odvolať, pričom lekársky tím umožní odôvodniť rozhodnutie medicínskymi kontraindikáciami a nie pravými osobnými dôvodmi na strane darcu. Záverečný informovaný súhlas je darca povinný pred transplantáciou obličky (nefrektómiou) vyjadriť písomnou formou (17).

V súvislosti s udelením súhlasu na výkon transplantácie nemožno opomenúť novelu zák. č. 576/2004 Z. z. v znení neskorších predpisov pod č. 313/2012, ktorá ustanovuje, že v prípadoch ak ide o odber orgánov na účely transplantácie do tela osoby priamo geneticky príbuznej s darcom, tak sa takáto transplantácia môže vykonať len po schválení konzíliom transplantačného centra. V prípade osoby vzdialene geneticky príbuznej s darcom alebo osoby nepríbuznej s darcom sa odber orgánov, tkanív a buniek za účelom transplantácie môže vykonať len po schválení konzíliom, ktoré na tieto účely určí ministerstvo zdravotníctva (18). Na základe tejto novely došlo k precizovaniu textu toho zákonného ustanovenia, pričom priodberoch  tkanív a buniek, ktoré sa neuskutočňujú u živých darcov sa nevyžaduje posúdenie odborným konzíliom transplantačného centra alebo konzíliom zriadeným ministerstvom (19).

Posúdenie odborným konzíliom v prípade transplantácii orgánov, tkanív a buniek v prípadoch osôb geneticky príbuzných je dôležité okrem iného aj z dôvodu zistenia motivácie darcu v prípadoch, ak príjemcom je geneticky príbuzná osoba, aby sa vylúčila možnosť určitého psychologického nátlaku zo strany blízkych (20). Stotožňujem sa s názorom, že v prípade rozhodovania o možnosti darovať svoj orgán za života a v prípadoch, ak ide o emočne blízkeho príjemcu, sa nemožno vyhnúť tlaku, ktorý z takéhoto rozhodnutia vyplýva. Je to však v určitej miere nátlak vlastnej zodpovednosti a vlastného svedomia a nie okolia, čo treba rozlišovať (21). V tejto súvislosti možno zdôrazniť, že súhlas s transplantáciou sa nemôže vymáhať nijakým spôsobom, v žiadnom prípade neprichádza do úvahy ani psychicky nátlak rodiny, nakoľko darovanie orgánov nesmie byť chápané ako povinnosť, stále musí ísť len o slobodné a dobrovoľné rozhodnutie darcu (22). Vylúčená je tiež aplikácia krajnej núdze  alebo odvolávanie sa na pomoc inému. Odoberanie orgánov alebo tkanív bez súhlasu darcu môže naplniť skutkovú podstatu trestného činu neoprávneného odoberania orgánov, tkanív, buniek a nezákonnej sterilizácie podľa ustanovenia §159 TZ (23).

Súhlas príjemcu

Príjemca je tou osobu do ktorej tela sa transplantuje orgán, tkanivo alebo bunka. Aj táto osoba musí splniť podmienky na to, aby bolo možné takúto osobu označiť za "vhodného“ príjemcu. Jedným z predpokladov je práve písomný informovaný súhlas po predchádzajúcom poučení.

V prípade ak ide o príjemcu mladšieho ako 18 rokov alebo príjemcu, ktorý je pozbavený resp. obmedzený v spôsobilosti na právne úkony, vyžaduje sa okrem súhlasu takéhoto príjemcu aj písomný informovaný súhlas jeho zákonného zástupcu. V prípade, že zákonný zástupca súhlas nedá, rozhodne na návrh zdravotníckeho zariadenia súd. V takomto prípade súhlas súdu s poskytnutím zdravotnej starostlivosti nahrádza (24).

Informovanosť  pacienta o jeho zdravotnom stave v medicínskej praxi naráža na rôzne otázky, o ktorých sa vedú bohaté diskusie. Jednou z nich je aj otázka rozsahu informácií pacienta, ktoré mu ma poskytnúť lekár. V prípadoch bežnej liečby možno súhlasiť s požiadavkou zachovať určitý kompromis medzi právom pacienta vedieť  aký je jeho zdravotný stav a ako sa s ním bude v priebehu liečby nakladať a povinnosťou lekára dbať o pacientov duševný pokoj, ktorý je často účinný liečebný prostriedok (25). Pri výkone transplantácii je situácia v zásade odlišná. Riziko neúspechu výkonov transplantácie je omnoho väčšie ako pri bežnej liečbe, preto je dôležité , aby príjemca udelil svoj súhlas až po dôkladnom poučení o všetkých okolnostiach, ktoré majú význam pre zhodnotenie jeho zdravotného stavu. A teda pacient musí vedieť, čo sa operáciou sleduje, musí byť oboznámený s prínosom ale aj rizikami takéto výkonu ako sú napr. časté infekcie, musí byť oboznámený aj o tom, že sa vyčerpali všetky tradičné liečebné metódy, o potrebe doživotnej farmakológie, o vplyve transplantácie na jeho ďalší život (aspekty rodičovstva, výkon športovej činnosti, zamestnanie) a tiež musí byť informovaný o tom, že v prípade ak nebude súhlasiť s výkonom transplantácie môže to mať za následok smrť (26). Tieto informácie sa poskytujú z dôvodu autonómnej vôle pacienta rozhodnúť sa  v súlade s objektívne predloženými informáciami. Mám za to, že pacient, ktorý je v stave ohrozenia života, vykoná všetko pre záchranu svojho života aj za cenu rizík, ktoré transplantácia obnáša. Nech sú informácie lekára akokoľvek objektívne, vždy preváži subjektívny postoj pacienta, ktorý v takomto stave nie je plne schopný vidieť ,,aj rizika“.  Preto informácie poskytnuté lekárom príjemcovi by mali byť šetrné, čo do formy, ale úplne, čo do obsahu a mali by súčasne objektivizovať prínosy a riziká transplantácii a eliminovať subjektívne nazeranie pacienta (27).

 

Obrázok: freedigitalphotos.net

 

Autor: Andrea JENČÍKOVÁ


 

Zoznam odkazov

  1. Poznámka autora
  2. Porov.: §6 ods. 1 zak. č.576/2004 Z.z. v znení neskorších predpisov
  3. Poznámka autora
  4. Franko, P., Husovský, T. Neplatný súhlas podľa predchádzajúceho právneho stavu ako dôvod protiprávnosti konania.  In: Právo a manažment v zdravotníctve. ISSN 1338-2071, 2014, roč.5, č.4, s.3
  5. Dragúňová, J. 2013.Krátke dejiny transplantácií. In: Impulz revue. [online]. 2013,  č.1. [cit.2014-10-19]. Dostupné na internete: <http://www.impulzrevue.sk/article.php?969>
  6. Porov.: §37 ods. 2 zak. č.576/2004 Z.z. v znení neskorších predpisov
  7.  Drgonec, J, Holländer, P.: Moderná medicína a právo, Bratislava: Obzor, 1998, s. 117-118
  8.  § 15 zák. č. 40/ 1964 Z.z (Občiansky zákonník)
  9.  Repa, P. 2012. Postmortálna ochrana osobnosti. [online] Publikované 24.2.2012. [citované 1.6.2014]. Dostupné na internete   
  10. Cehlárová, Ľ.2010. Darcovstvo ľudských orgánov a transplantácie z pohľadu noriem správneho práva. [online] Publikované 18.10. 2010. [citované 1.6.2014]. Dostupné na internete : <https://www.law.muni.cz/sborniky/cofola2008/files/pdf/sprava/cehlarova_lubica.pdf>
  11. Laca, Ľ.: Právne a etické aspekty transplantácií. In: Zdravotnícke noviny. Bratislava: Sanoma magazines Slovakia s. r. o., č. 34-35, 1996, s. 2
  12.  Baláž, P., Janek, J., Adamec,M a kol. Odběry organu k transplantaci. Odbery orgánov na transplantácie. Prvé vydanie. Praha: Karolinum, 2011. 254s. ISBN 978-80-246-1964-4
  13. Poznámka autora
  14. Gecík, K. Právna zodpovednosť v zdravotníctve a medicíne. Druhé doplnené vydanie. Bratislava: Vydavateľstvo Osveta, 1984. 355s. ISBN 83-70-095-84
  15. Vlček R., Hrubešová Z. Zdravotnícke právo. Šieste vydanie.Bratislava: Ing. Miroslav Mračko, EPOS, 2007. 318s. ISBN 978-80-8057-705-6
  16. Čl.20 ods.2 Oznámenia Ministerstva zahraničných vecí Slovenskej republiky - Dohovor o ľudských právach a biomedicíne ( ďalej len ,,Dohovor“ )
  17. Laca, Ľ, Grandtnerová, B. Transplantácie obličiek od žijúcich darcov. Bratislava: Enterprise, spol.s.r.o.,2003. 156s. ISBN 80-85342-15-4
  18. Porov.: § 36 ods.5 Z.z, v znení neskorších predpisov
  19. Porov.: Čl 1 k bodu 3 . a 4. k Dôvodovej správe k zák. č. 313/2012 Z.z. ktorým sa mení a dopĺňa zákon č. 576/2004 Z. z. o zdravotnej starostlivosti, službách súvisiacich s poskytovaním zdravotnej starostlivosti a o zmene a doplnení niektorých zákonov znení neskorších predpisov a ktorým sa dopĺňajú niektoré zákony
  20. Laca, Ľ, Grandtnerová, B. Transplantácie obličiek od žijúcich darcov. Bratislava: Enterprise, spol.s.r.o., 2003. 156s. ISBN 80-85342-15-4
  21. Breza, ml.,Gulášová ,J. ,Breza, st. Etické problémy transplantácií obličiek od žijúcich darcov. In Orgánové transplantácie: multidisciplinárny časopis pre transplantačnú problematiku. ISSN 1336-7129, 2006, roč.2, č.1-2, s.24
  22. Dragúňová, J. 2013.Krátke dejiny transplantácií. In: Impulz revue. [online]. 2013,  č.1. [cit.2014-10-19].Dostupné na internete: <http://www.impulzrevue.sk/article.php?969>
  23. Vlček R., Hrubešová Z. Zdravotnícke právo. Šieste vydanie. Bratislava: Ing. Miroslav Mračko, EPOS, 2007. 318s. ISBN 978-80-8057-705-6
  24. Tamtiež
  25. Drgonec, J., Holländer, P. Moderná medicína a právo. Druhé vydanie. Bratislava: Vydavateľstvo Obzor, 1988. 304 s. ISBN 65- 017- 88-735-21-85/6
  26. Tamtiež
  27. Poznámka autora





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MichaelStita

(19.1.2021)
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