Lieči lekár (len) liekmi? Právne aspekty vzťahu liekov a výživových doplnkov pri poskytovaní zdravotnej starostlivosti | Medicínske právo
              

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Lieči lekár (len) liekmi? Právne aspekty vzťahu liekov a výživových doplnkov pri poskytovaní zdravotnej starostlivosti


 | 24.6.2015 | komentárov: 1553

Poskytovanie zdravotnej starostlivosti je laickou verejnosťou častokrát vnímané ako návšteva lekára, od ktorého sa štandardne odchádza s predpísanými liekmi. Keďže úlohou lekára je liečiť, bude práve táto myšlienková skratka dôvodom na taktúto formuláciu: "Lekár lieči liekmi". Táto veta však v určitých situáciách zdravotníckej reality nemusí dostatočne odrážať komplex vzťahov, povinností a postupov, ktoré pri poskytovaní zdravotnej starostlivosti existujú.

Obrazok

I. Poskytovanie zdravotnej starostlivosti - úvodné východiská

Poskytovanie zdravotnej starostlivosti je laickou verejnosťou častokrát vnímané ako návšteva lekára, od ktorého sa štandardne odchádza s predpísanými liekmi. Keďže úlohou lekára je liečiť, bude práve táto myšlienková skratka dôvodom na taktúto formuláciu: "Lekár lieči liekmi". Táto veta však v určitých situáciách zdravotníckej reality nemusí dostatočne odrážať komplex vzťahov, povinností a postupov, ktoré pri poskytovaní zdravotnej starostlivosti existujú.

Keď sa pozrieme do primárneho kódexu medicínskeho práva - zákona 576/2004 Z.z. o zdravotnej starostlivosti, službách súvisiacich s poskytovaním zdravotnej starostlivosti a o zmene a doplnení niektorých zákonov (ďalej v texte aj len "zákon o zdravotnej starostlivosti"), nájdeme v jeho druhom paragrafe definíciu pojmu zdravotná starostlivosť, ktorou je (cit.): "súbor pracovných činností, ktoré vykonávajú zdravotnícki pracovníci, vrátane poskytovania liekov, zdravotníckych pomôcok a dietetických potravín s cieľom predĺženia života fyzickej osoby, zvýšenia kvality jej života a zdravého vývoja budúcich generácií; zdravotná starostlivosť zahŕňa prevenciu, dispenzarizáciu, diagnostiku, liečbu, biomedicínsky výskum, ošetrovateľskú starostlivosť a pôrodnú asistenciu."[1] Pri ambícii analyzovať a následne vyvodiť kľúčové východiská tohto článku z tejto legálnej definície dospejeme k tomu, že slovenská právna úprava výslovne počíta s poskytovaním liekov, zdravotníckych pomôcok a dietetických potravín, no zároveň hovorí o pojmoch ako prevencia, dispenzarizácia, diagnostika, liečba. Rovnaký paragraf ďalej tieto pojmy definuje[2]  a demaskuje v hrubých rysoch zákonný koncept poskytovania zdravotnej starostlivosti v podmienkach Slovenskej republiky. Zákonodarca  definoval „liečbu“ ako (cit.): "vedomé ovplyvnenie zdravotného stavu osoby s cieľom navrátiť jej zdravie, zabrániť ďalšiemu zhoršovaniu jej zdravotného stavu alebo zmierniť prejavy a dôsledky jej choroby.". Z uvedeného teda vyplýva, že liečba je zákonne vymedzená cez prizmu cieľa a nie prostredníctvom prostriedku, ktorým má byť uskutočnená.

Ako sme už uviedli vyššie výkon poskytovania zdravotnej starostlivosti bol zákonom vyhradený skupine osôb tzv. zdravotníckym pracovníkom. V zmysle §27 zákona 578/2004 Z.z. o poskytovateľoch zdravotnej starostlivosti, zdravotníckych pracovníkoch, stavovských organizáciách v zdravotníctve a o zmene a doplnení niektorých zákonov (ďalej v texte aj len "zákon o poskytovateľoch zdravotnej starostlivosti") je okrem iných zdravotníckym pracovníkom lekár a farmaceut. Paragraf č. 80 identického právneho predpisu ustanovuje povinnosti zdravotníckeho pracovníka medzi, ktoré je zaradená aj povinnosť vykonávať svoje zdravotnícke povolanie odborne, v súlade so všeobecne záväznými právnymi predpismi a s etickým kódexom (§80 ods. 1 písm e) zákona 578/2004 Z.z.).

Jednou z najdôležitejších povinností poskytovateľa je prostredníctvom svojich zdravotnických pracovníkov poskytovať zdravotnú starostlivosť lege artis. V zmysle § 4 ods. 3 zákona č. 576/2004 Z.z. o zdravotnej starostlivosti (cit.): Poskytovateľ je povinný poskytovať zdravotnú starostlivosť správne. Zdravotná starostlivosť je poskytnutá správne, ak sa vykonajú všetky zdravotné výkony na správne určenie choroby so zabezpečením včasnej a účinnej liečby s cieľom uzdravenia osoby alebo zlepšenia stavu osoby pri zohľadnení súčasných poznatkov lekárskej vedy.

Postup lege artis v doslovnom preklade znamená „postup v súlade so zákonom“. Podstatným znakom postupu lege artis je súlad s poznatkami medicíny a biomedicínskych vied. Vo všeobecnosti možno za stav lekárskej vedy považovať poznatky, ktoré sa vyučujú na lekárskych fakultách, resp. sú súhlasne prijímané na odborných medicínskych fórach a súčasne predstavujú najvyššie dosiahnuté poznanie v danej medicínskej oblasti.  Gecík[3] správne upozorňuje, že pod súčasnými poznatkami je potrebné rozumieť všetky poznatky, ktoré boli v oblasti medicínskych vied získané od ich počiatkov až po súčasnosť, a že sa jedná o špecifický - trvalý poznávací proces.

Lege artis poskytnutá zdravotná starostlivosť musí ďalej spĺňať podmienku odbornosti, ale aj podmienku rešpektovania osobnostných práv pacienta - napr. právo na súkromie, právo na telesnú a psychickú integritu[4]. Ako uzatvára Žďárek (cit.): "...lege artis neznamená nic jiného než odborně správný postup." .[5]

Záväzok poskytovateľa postupovať správne sa podľa nášho názoru netýka len samotného zdravotného výkonu (operácie, vyšetrenia, zavedenia transfúzie a pod.) ale vzťahuje sa na celkový manažment pacienta (celkovú starostlivosť). Poskytovateľ je v zmysle uvedeného názoru povinný pacienta nielen správne ošetriť, ale ho aj správne poučiť o liečebnom režime, upozorniť ho na možné komplikácie, či odporučiť ho na iných špecialistov (rozsah povinnosti „lege artis largo sensu“).

Je potrebné pripomenúť, že povinnosť postupu lege artis nie je ukotvená iba na vnútroštátnej báze ale aj na medzinárodnej úrovni. Dohovor o ľudských právach a biomedicíne v čl. 4 hovorí, že (cit.): "Každý zásah do oblasti zdravia vrátane výskumu sa musí robiť v súlade s príslušnými zmluvnými  záväzkami a štandardmi.".[6]

Po úvodnom exkurze do zákonnej bázy poskytovania zdravotnej starostlivosti máme za to, že zákonodarca vidí poskytovanie zdravotnej starostlivosti cez III. piliere: I. účelnosť, II. čo najväčšie dobro pre pacienta a III. správnosť (postup "lege artis"). V ďalšom texte sa zmienime o tom, ako sa tieto piliere uplatňujú v praxi ako aj o tom, že či a ako je potrebné reagovať na inovácie, ktoré priniesla doba v podobe výživových doplnkov.

 

II. Od lekára do lekárne

Ako vyplýva z textu vyššie, z pohľadu pacienta je pre riešenie zdravotného problému potrebné navštíviť zdravotnícke zariadenie (zákon používa termín "poskytovateľ zdravotnej starostlivosti"). Podľa miery akútnosti a závažnosti problému si ale pacient častokrát vyberá, či mu postačí rada lekárnika alebo sa nechá vyšetriť lekárom a nechá si ním naordinovať liečbu. Keďže zdravotníckym pracovníkom je aj lekárnik - je to práve on, kto má kompetenciu zorientovať pacienta vo "voľnopredajnom" sortimente lekárne a poskytnúť mu odporúčanie ako ďalej postupovať. V zmysle základnej definície poskytovania zdravotnej starostlivosti, a teda v súlade s účelom právnej úpravy, je nevyhnutné aby v prípade, ak lekárnik nie je schopný pacientovi pomôcť poskytnutím voľnopredajného sortimentu mal by ho „navigovať“ do ordinácie lekára. V prípade, ak voľnopredajný sortiment lekárne umožňuje lekárnikovi, aby pacientovi poskytol odbornú pomoc, máme za to, že lekárnik ak ide o lieky, zdravotnícke pomôcky a dietetické potraviny tak urobiť musí. V prípade doplnkového sortimentu lekárne, medzi ktoré môžme zaradiť výživové doplnky takúto poučovaciu povinnost nemá (pokiaľ sa na jeho povinnosti pozeráme úzko). V rámci starostlivosti o pacienta/klienta je však podľa nášho názoru prirodzené, že by mu mal poskytnúť komplexné informácie, ktoré okrem liekov zahrnú aj iné prostriedky riešenia pacientovho zdravotného stavu. Pokúsme sa opísať celý postup od začiatku.

Pacient príde k lekárovi na vyšetrenie. V súlade s §12 zákona o zdravotnej starostlivosti dôjde k uzavretiu dohody o poskytovaní zdravotnej starostlivosti okrem prípadov ak zákon neustanovuje inak[7]. Lekár následne aplikovaním príslušných medicínskych vyšetrovacích metód za podmienky dodržania lege artis postupu dospeje k záverom, podľa ktorých navrhne pacientovi ďalšie kroky t.j. nastaví liečbu. Navrhovaná terapia môže variovať od jednoduchých odporúčaní pacientovi týkajúcich sa životného štýlu a stravovania, až po predpísanie farmakoterapie, či návrhu na hospitalizáciu a operačné riešenie zdravotného problému.

Čo sa týka farmakoterapie, v zákone 362/2011 Z.z. o liekoch a zdravotníckych pomôckach a o zmene a doplnení niektorých zákonov (ďalej len "zákon o liekoch") je upravené predpisovanie humánnych liekov, zdravotníckych pomôcok a dietetických potravín (§119). Oprávnenie predpisovať je odvádzané od právneho titulu, na základe ktorého lekár (resp. zubný lekár) poskytuje zdravotní starostlivosť. Napríklad lekár v ambulantnom zdravotníckom zariadení je oprávnený predpísať humánny liek a dietetickú potravinu na lekársky predpis alebo na objednávku a zdravotnícku pomôcku na lekársky poukaz alebo na objednávku, prípadne humánny liek s obsahom omamnej látky II. skupiny alebo psychotropnej látky II. skupiny na osobitnom tlačive lekárskeho predpisu označenom šikmým modrým pruhom alebo na osobitnom tlačive objednávky označenom šikmým modrým pruhom. Tieto tlačivá je povinný evidovať.[8]

Keď objekt nášho záujmu, pre účely tohto článku, zúžime len na humánne lieky na predpis, ktoré neobsahujú omamné látky II. skupiny alebo psychotropné látky II. skupiny nájdeme v zákone o liekoch presný "guide line" ako má lekár postupovať :

A/ Ak chce lekár liečiť pomocou liekov s obsahom liečiva uvedeného v prílohe č. 1 zákona a zozname kategorizovaných liekov uvedie názov liečiva, cestu podania, liekovú formy, množstvo liečiva v liekovej forme, veľkosť balenia a počet balení podľa údajov uvedených v zozname kategorizovaných liekov. Zákon lekárovi umožňuje uviesť po uvedení liečiva aj názov humánneho lieku.

B/ Ak chce lekár liečiť pomcou liekov s obsahom liečiva uvedeného v prílohe č. 1 zákona alebo dve alebo viac liečiv je povinný namiesto názvu liečiva uviesť názov humánneho lieku, cestu podania, liekovú formu, množstvo liečiva v liekovej forme, veľkosť balenia a počet balení. Zákon v §119 ods. 5 výslovne hovorí (cit.): "Za správny výber liečiva alebo humánneho lieku, cesty podania, liekovej formy, množstva liečiva v liekovej forme, veľkosti balenia, počtu balení a dávkovania lieku pri predpisovaní humánneho lieku v rámci poskytovania zdravotnej starostlivosti je zodpovedný predpisujúci lekár."[9]. 

Lekár teda vo všeobecnosti buď píše na recept liečivo a odporúča konkrétny liek alebo v druhom prípade píše priamo liek. Môže však aj zakázať výdaj náhradného humánneho lieku, ktorý je pre pacienta z medicínskych dôvodov nevhodný. Medicínske dôvody prečo zakazuje vydať náhradný humánny liek lekár povinne zaznamená do zdravotnej dokumentácie a uvedie na rubovej strane lekárskeho predpisu. Taktiež má predpisujúci lekár napríklad povinnosť pri predpisovaní humánneho lieku postupovať účelne a hospodárne podľa súčasných poznatkov farmakoterapie v súlade so súhrnom charakteristických vlastností humánneho lieku schválenom pri jeho registrácii, zaznamenať v zdravotnej dokumentácii pacienta a v liekovej knižke poistenca, ak ju poistencovi vydala zdravotná poisťovňa, predpísanie humánneho lieku, informovať pacienta o maximálnej výške doplatku pacienta za navrhovaný humánny liek, o možnosti náhradného humánneho lieku a o maximálnej výške doplatku pacienta za náhradný humánny liek, používať tlačivo lekárskeho predpisu, viesť evidenciu o predpísaných humánnych liekoch, zdravotníckych pomôckach alebo dietetických potravinách v rozsahu a spôsobom podľa dohody uzatvorenej so zdravotnou poisťovňou ako aj zákaz určovať pacientovi, v ktorej verejnej lekárni si má humánny liek vybrať.[10]

Ako sme už uviedli vyššie, lekárom navrhovaná terapia nemusí nevyhnutne mať charakter farmakoliečby. Pokiaľ na základe zhodnotenia zdravotného stavu pacienta lekár usúdi, že na jeho zlepšenie, prinávrátenie, či zníženie nepohodlia/bolesti postačuje zmena návykov pacienta, môže mať navrhovaná terapia povahu takéhoto oporúčania.  Je typické, že lekár zápisom do zdravotnej dokumentácie odporúča pacientovi napríklad viac športu alebo skoncovanie s fajčením. Taktiež je časté, že s cieľom vyriešiť problémy pacienta mu lekár odporučí konzumáciu konkrétnej potraviny prípadne iného doplnku stravy[11]. Úlohou lekára je teda výber najvhodnejších prostriedkov k naplneniu tohto cieľa zdravotnej starostlivosti .

Po vymedzení povinností lekára sa zdá byť evidenté, že je to práve tento zdravotnícky pracovník, na ktorého bedrách leží výber a koncepcia liečby pacienta. Zodpovednosť v zmysle lex generalis súkromného práva v Slovenskej republike Občianskeho zákonníka zákon č. 40/1964 Zb. bude niesť poskytovateľ zdravotnej starostlivosti, u ktorého predpisujúci lekár pôsobí, keďže (cit.): "škoda je spôsobená právnickou osobou alebo fyzickou osobou, keď bola spôsobená pri ich činnosti tými, ktorých na túto činnosť použili. Tieto osoby samy za škodu takto spôsobenú podľa tohto zákona nezodpovedajú; ich zodpovednosť podľa pracovnoprávnych predpisov nie je tým dotknutá."[12].

S vypísaný receptom od lekára je často prvou cestou pacienta cesta do lekárne, kde si vyberie liek, ktorý mu bol predpísaný prípadne tzv. náhradný humánny liek. Čo sa týka termínu náhradný humánny liek, ten je zákonne definovaný ako humánny liek s rovnakým liečivom, rovnakou cestou podania, rovnakou liekovou formou a rovnakým množstvom liečiva v liekovej forme, rovnakou alebo nižšou úhradou zdravotnej poisťovne a s rovnakou alebo nižšou úhradou pacienta ako liek predpísaný na lekárskom predpise.[13] Postup pri výdaji humánnych liekov je upravený v §121 zákona o liekoch. V zmysle uvedeného paragrafu je osoba, ktorá vydáva humánny liek (t.j. lekárnik) povinná kontrolovať správnosť dávkovania humánneho lieku z hľadiska prekročenia najvyššej jednotlivej a dennej dávky liečiva a upozorniť na osobitné varovania pri užívaní a používaní humánneho lieku. V prípade, že má pochybnosti o správnosti lekárskeho predpisu alebo lekárskeho poukazu alebo o správnosti dávkovania humánneho lieku má dokonca v prípade naplnenia zákonných dôvodov povinnosť liek nevydať.

 

Dôležité povinnosti zakotvuje §121 ods. 3 zákona o liekoch, na základe ktorého je lekárnik povinný:

  1. pri výdaji informovať pacienta o možnosti výberu náhradného humánneho lieku a o výške doplatku pacienta za všetky náhradné humánne lieky podľa platného zoznamu kategorizovaných liekov, ktoré je možné vydať na základe predloženého lekárskeho predpisu,
  2. vydať pacientovi humánny liek, ktorého liečivo je uvedené v prílohe č. 1, ktorý je bez doplatku alebo s najnižším doplatkom pacienta, a ktorý je dostupný, ak si pacient nevyberie inak,
  3. vyznačiť na lekárskom predpise alebo lekárskom poukaze názov a kód vydaného humánneho lieku.

Ak by sme teda mali pre účely tohto článku zosumarizovať náležitosti, kedy je vydanie náhradného humánneho lieku povinnosťou lekárnika boli by to:

  1.          predpísaný liek má alternatívu
  2.          alternatívou je liek
  3.          ide o liek s rovnakým liečivom, rovnakou cestou podania, rovnakou liekovou formou a rovnakým množstvom liečiva v liekovej forme
  4.          ide o liek s rovnakou alebo nižšou úhradou zdravotnej poisťovne a s rovnakou alebo nižšou úhradou pacienta

Na chvíľu sa ešte pristavme pri osobe lekárnika. Lekárnik, ako zdravotnícky pracovník, poskytuje tzv. lekárenskú starostlivosť. Tá je definovaná v zákone o liekoch v §20. Lekárenská starostlivosť zahŕňa aj a) zabezpečovanie, uchovávanie, prípravu, kontrolu a výdaj liekov vrátane internetového výdaja, b) zabezpečovanie, uchovávanie a výdaj zdravotníckych pomôcok vrátane internetového výdaja,  c) zhotovovanie zdravotníckych pomôcok na mieru a ich výdaj,  d) zabezpečovanie a výdaj dietetických potravín, e) poskytovanie odborných informácií a rád o liekoch, zdravotníckych pomôckach a dietetických potravinách potrebných na kvalitné poskytovanie zdravotnej starostlivosti podľa bezpečnej a racionálnej liekovej terapie,  f) dohľad nad liekmi a dohľad nad zdravotníckymi pomôckami,  g) zabezpečovanie, uchovávanie a výdaj doplnkového sortimentu,  h) vykonávanie fyzikálnych a biochemických vyšetrení zameraných na primárnu prevenciu a sledovanie účinnosti a bezpečnosti farmakoterapie, ktoré si nevyžadujú ďalšie laboratórne spracovanie,  i) výmenu, predaj a spätný predaj liekov držiteľovi povolenia na veľkodistribúciu liekov alebo inému držiteľovi povolenia na poskytovanie lekárenskej starostlivosti.

 Z uvedeného vyplýva, že lekárnik má povinnosť odborne informovať o liekoch, zdravotníckych pomôckach a dietetických potravinách potrebných na kvalitné poskytovanie zdravotnej starostlivosti podľa bezpečnej a racionálnej liekovej terapie, zatiaľ čo pri doplnkovom sortimente je jeho povinnosťou len zabezpečovanie, uchovávanie a jeho výdaj. Zo zákona o liekoch explicitne nevyplýva povinnosť lekárnika informovať pacienta o doplnkovom sortimente lekárne ani o prípadných pozitívnych vplyvoch tohoto sortimentu na zdravie pacienta. Nie je však možné existenciu takejto povinnosti úplne vylúčiť. Ako sme uviedli vyššie, poskytovateľ má povinnosť poskytovať zdravotnú starostlivosť správne (táto povinnosť sa týka aj lekárenskej starostlivosti), pričom „správny postup“ má extrémne široký obsah. I keď sa v texte definície zdravotnej starostlivosti (stricto sensu) poskytovanie informácií, či predaj doplnkov k strave nenachádza (pozri § 2 ods. 1 zákona o zdravotnej starostlivosti)[14], lekárnik ako odborník v prípade ak má vedomosť, že k zlepšeniu pacientovho zdravotného stavu môže okrem liekov napomôcť aj iný sortiment jeho lekárne má takúto informáciu (hoc na báze etického záväzku) pacientovi poskytnúť. On je tým odborníkom, ktorý má schopnosť na základe pacientovho opisu problémov a v súlade s predpisom lekára ponúknuť okrem liekov aj ďalšie prostriedky, ktoré by mali pomôcť pri liečbe pacienta.[15]

 

Sortiment lekárne je s poukázaním na text príslušných ustnaovení zákona o liekoch možné rozdeliť na dve skupiny

  • základný sortiment a
  • doplnkový sortiment

Toto delenie používa zákon o liekoch v § 24, ktorý medzi základný sortimenty zaraďuje liečivá a humánne lieky, zdravotnícke pomôcky a dietetické potraviny, za podmienky, že sú zaradené v kategorizovanom zozname. Doplnkový sortiment a iný sortiment verejnej lekárne (a výdajne zdravotníckych pomôcok) tvoria dietetické potraviny okrem kategorizovaných dietetických potravín, detská výživa, prírodné liečivé vody, prírodné minerálne vody, potraviny na osobitné výživové účely, kozmetické výrobky, registrované veterinárne lieky a iné výrobky určené na ochranu a podporu zdravia ľudí a zvierat, ktoré spĺňajú požiadavky na uvedenie na trh.[16]. Čo sa týka právnej úpravy výdaja liekov, tá je obmedzená tak, že humánne lieky na predpis je oprávnená vydávať fyzická osoba, ktorá získala vysokoškolské vzdelanie druhého stupňa v študijnom odbore farmácia a humánne lieky, ktorých výdaj nie je viazaný na lekársky predpis môže vydať aj fyzická osoba, ktorá získala stredoškolské vzdelanie na strednej zdravotníckej škole v študijnom odbore farmaceutický laborant a má špecializáciu v špecializačnom odbore lekárenstvo.

 

III. Výživové doplnky ako náhrada liekov?

 

Fenoménom, ktorý sa v poslednom období dostáva čím ďalej tým viac do povedomia ako odbornej tak aj širokej verejnosti sú výživové doplnky.  Ide o častokrát temer identicky vyzerajúce „krabičky“ pripomínajúce lieky, ktoré však liekmi nie sú. Pojmovo totiž nezapadajú do liekovej definície a ich cesta na poličku lekárne je jednoduchšia ako u liekov. Mnohí lekári sú dnes konfrontovaní s požiadavkami pacienta o „predpis“ výživového doplnku, alebo sami uvažujú o tom, či v rámci terapie môžu pacientovi namiesto štandardného lieku odporučiť výživový doplnok. Otázka na prvý pohľad jednoduchá v skutočnosti až takou jasnou však nie je.

Keby sme chceli v slovenskej vnútroštátnej legislatíve nájsť definíciu výživových doplnkov, naša pozornosť by sa mala upriamiť na Výnos Ministerstva pôdohospodárstva SR a Ministerstva zdravotníctva SR z 25. júla 2007 č. 16826/2007-OL, ktorým sa vydáva hlava Potravinového kódexu Slovenskej republiky upravujúca požiadavky na potraviny na osobitné výživové účely a na výživové doplnky (v texte aj len "výnos"), ktorý vydalo Ministerstvo pôdohospodárstva SR a Ministerstvo zdravotníctva SR podľa §3 ods. 1, §30 ods. 1 a 2 a §30a zákona Národnej rady Slovenskej republiky č. 152/1995 Z. z. o potravinách v znení neskorších predpisov.

Siedma hlava nazvaná Požiadavky na potraviny na osobitné výživové účely a na výživové doplnky obsahuje Šiesty oddiel titulovaný "Výživové doplnky". § 16 vo svojom úvodnom odseku obsahuje legálnu definíciu toho, čo sa za výživový doplnok považuje (cit.): "Výživové doplnky sú potraviny na doplnenie prirodzenej stravy, ktoré sú koncentrovanými zdrojmi živín, ako sú vitamíny a minerálne látky alebo iných látok s výživovým alebo fyziologickým účinkom, jednotlivo alebo v kombinácii. Výživové doplnky sa umiestňujú na trh v dávkovanej forme, ako sú kapsuly, pastilky, tablety, piluly a ostatné podobné formy, vrecúška s práškom, ampulky s tekutinami, fľašky s dávkovačom kvapiek a ostatné podobné formy tekutín a práškov navrhnuté tak, aby ich bolo možné brať v odmeraných malých jednotkových množstvách."[17]. Je dôležité pripomenúť, že ustanovenia rozoberaného oddielu sa netýkajú liekov[18], alebo aj to, že prevádzkovateľ, ktorý vyrába alebo umiestňuje na trh výživové doplnky, má povinnosť oznámiť ich prvé umiestnenie na trh ako aj povinnosť zaslať vzorky etikiet použitých na týchto potravinách.[19]. Náležitosti označenia (okrem požiadaviek na označovanie potravín podľa druhej hlavy druhej časti potravinového kódexu) ustanovuje výnos v § 17, z ktorého je pre účely rozboru vzťahu liek vs. výživový doplnok dôležité ustanovenie ods. 2, ktoré hovorí (cit.): "Označovanie, prezentácia a reklama nesmie prisudzovať výživovým doplnkom schopnosť prevencie, liečby alebo vyliečenia ľudských chorôb alebo odvolávať sa na také schopnosti."[20].

Otázky výživových doplnkov nie sú doménou len vnútroštátnej legislatívy (t.j. právnych predpisov výdaných orgánmi Slovenskej republiky), ale časť právnych aktov je upravených aj na úrovni Európskej únie. Ide napríklad o Nariadenie Európskeho parlamentu a Rady (ES) Č. 1924/2006 z 20. decembra 2006 o výživových a zdravotných tvrdeniach o potravinách, Nariadenie komisie (EÚ) č. 432/2012 zo 16. mája 2012 o povolení určitých zdravotných tvrdení o iných potravinách, ako sú tie, ktoré odkazujú na zníženie rizika ochorenia a na vývoj a zdravie detí alebo Nariadenie komisie (EÚ) č. 1047/2012 z 8. novembra 2012, ktorým sa mení a dopĺňa nariadenie (ES) č. 1924/2006, pokiaľ ide o zoznam výživových tvrdení[21].

K prvému uvedenému Nariadeniu Európskeho parlamentu a Rady (ES) Č. 1924/2006 uvádzame, že ide o únijnú bázu a zaktovenie základov výživových doplnkov. Nariadenie diferencuje medzi pojmami  „výživové tvrdenie“ (každé tvrdenie, ktoré udáva, naznačuje alebo vyvoláva dojem, že potravina má osobitné pozitívne výživové vlastnosti v dôsledku energetickej (kalorickej) hodnoty, resp. živín alebo iných látok.)[22], „zdravotné tvrdenie“ (každé tvrdenie, ktoré udáva, naznačuje alebo vyvoláva dojem, že existuje súvislosť medzi kategóriou potravín, potravinou alebo jednou z jej zložiek a zdravím)[23] a „tvrdenie o znížení rizika ochorenia“ (každé zdravotné tvrdenie, ktoré udáva, naznačuje alebo vyvoláva dojem, že konzumácia nejakej kategórie potravín, potraviny alebo jednej z jej zložiek vo významnej miere znižuje rizikový faktor výskytu ochorenia u ľudí)[24] V ďalšom texte právneho predpisu, konkrétne v čl. 3 a 5 a kapitolách III. a IV. sú zaktovené náležitosti používania výživových a zdravotných tvrdení.

Môže lekár liečiť výživovými doplnkami? Podľa nášho názoru môže, pokiaľ na základe zhodnotenia zdravotného stravu pacienta, teda správneho a úplného odobratia anamnézy, výsledkov primárnych a sekundárnych vyšetrení je názoru, že zdravotný problém pacienta môžno riešiť prostredníctvom úpravy stravy. Lekár musí zvážiť, či zdravotný stav pacienta vyžaduje nasadenie farmakoliečby, ale rovnako je v jeho kompetencii pacientovi odporučiť kombináciu famarkoliečby s výživovými doplnkami, ktoré svojím zložením môžu jeho organizmus posilniť, alebo potlačiť vedľajšie účinky farmakoliečby. Obdobne podľa nášho názoru má lekár v súlade s povinnosťou postupovať lege artis možnosť po zhodnotení zdravotného stavu pacienta odporučiť pacientovi len úpravu stravy, či jej doplnenie prostredníctvom výživového doplnku. Uvedené kladie na lekára samozrejme vysokú mieru zodpovednosti a ten musí mať na pamäti, že výživové doplnky nie sú liekmi. Recentné zmeny európskej legislatívy, ktorú sme spomenuli vyššie v každom prípade uľahčujú orientáciu v množstve výživových doplnkov, kedže tvrdenia uvádzané na obaloch musia byť schválené Komisiou a tým nadobúdaju inú kvalitu a relevanciu[25].

Výživový doplnok nie je možné predpísať receptom, keďže recept slúži jedine na predpis farmakoliečby, či už uvedením účinnej látky, alebo uvedením názvu lieku (rozdiely viď vyššie). Ak sa teda lekár rozhodne pacientovi odporučiť výživový doplnok nerobí tak prostredníctvom receptu, ale mal by navrhovanú terapiu zaznačiť do zdravotnej dokumentácie pacienta. Na výživové doplnky sa nevzťahujú poučovacie povinnosti, ktoré má v zmysle zákona o liekoch lekár pri predpise účinnej látky, resp. konkrétneho lieku. Ak sa teda lekár vzhľadom na zdravotný stav pacienta rozhodne, že pacientovi odporučí úpravu a doplnenie stravy je v jeho záujme, aby svoj odborný názor a poučenie o užívaní (ako svoju prípadnú ochranu pro futuro) zaznamenal do zdravotnej dokumentácie pacienta a prijatie tejto informácie si nechal pacientom aj potvrdiť.

 

Súčasná situácia a momentálne trendy vo farmaceutickom sektore v súvislosti s liekmi a výživovými doplnkami kladú pred lekára a lekárnika pomerne veľké výzvy. Nájdenie pomyselnej hranice, ktorý výrobok je liekom, a ktorý výživovým doplnkom (vzhľadom na indikáciu a zloženie, nie na formálne zatriedenie) môže dnes predstavovať problém aj pre samotných regulátorov liekového trhu (ŠÚKL, MZ SR). Z pohľadu výrobcu a držiteľa registrácie lieku, resp. dovozcu potraviny je však zatriedenie výrobku do kategórie lieku, alebo do kategórie výživového doplnku extrémne rozhodujúce s dopadmi na nákladové položky, schopnosť reagovať na dopyt (napr. vývoj originálneho lieku trvá aj desať rokov a pohybuje sa nákladovo v hodnote niekoľkých miliárd dolárov), možnosťami marketovania výrobku a podobne. Rozhodujúcim faktorom na zatriedenie výrobku (liek/potravina) nie je len skutočnosť, či pomáha ľudskému organizmu. Ako vypýva z judikatúry Súdneho dvora EÚ, to že výživový doplnok pozitívne vplýva na zdravie neznamená, že ho je potrebné registrovať ako liek.  


IV. Európska judikatúra lieky vs. výživové doplnky

 

Pri hľadaní odpovede na otázku, ako je možné rozlíšiť lieky a potravinové doplnky je užitočné využiť aj  judikatúru Súdneho dvora Európskej únie, ktorý sa k týmto otázkam viackrát vyjadril.

Bod 39 rozsudku Hecht-Pharma hovorí (cit.): "... príslušné vnútroštátne orgány, ktoré pracujú pod kontrolou súdov, musia prijať rozhodnutie, či spadá výrobok pod definíciu lieku na základe funkcie v zmysle smernice 2001/83 osobitne v každom jednotlivom prípade, pričom musia zohľadniť všetky vlastnosti výrobku, najmä jeho zloženie, jeho farmakologické, imunologické alebo metabolické vlastnosti, ktoré sa dajú určiť na základe súčasného stavu vedy, spôsob jeho používania, rozsah jeho rozšírenia, rozsah, v akom je známy spotrebiteľom, a riziká, ktoré môže spôsobiť jeho používanie."[26]

Na farmakologické vlastnosti výrobku bolo poukázané aj v skorškom rozhodnutí vo veci HLH Warenvertrieb a Orthica (cit.): "Farmakologické vlastnosti výrobku sú faktorom, na základe ktorého orgány členských štátov majú posúdiť, vychádzajúc z možných účinkov tohto výrobku, či výrobok v zmysle článku 1 bodu 2 druhého pododseku smernice 2001/83 je určený na to, aby bol použitý v ľudskom tele alebo na ňom, na stanovenie liečebnej diagnózy alebo na obnovu, zlepšenie alebo upravenie fyziologických funkcií."[27] "V tejto súvislosti je potrebné poukázať na skutočnosť, že kritérium spôsobilosti obnoviť, upraviť alebo zmeniť fyziologické funkcie nesmie viesť k tomu, že sa výrobky zaradia medzi lieky na základe funkcie, ktoré síce pôsobia na ľudský organizmus, ale nemajú významný fyziologický účinok, a teda v pravom zmysle slova nemenia podmienky jeho fungovania"[28]

Súdny dvor EÚ apeluje aj na potrebu zohľadniť obvyklé podmienky užívania predmetného výrobku (cit.) "keďže okolnosť, že výrobok môže mať významný fyziologický účinok, ak sa užíva v dávke vyššej, než je uvádzané v pribalenej informácii alebo na obale, je irelevantná."[29]

Za čiastočný záver možno považovať tvrdenie v bode 42 už citovaného rozsudku Hecht‑Pharma, ktorý jasne konštatuje, že (cit.): "výrobok, odhliadnuc od prípadu látok alebo kombinácie látok, ktoré sú určené na stanovenie lekárskej diagnózy, nie je možné považovať za liek na základe funkcie so zreteľom na jeho zloženie vrátane dávkovania účinných látok a za podmienok bežného užívania, keď nie je spôsobilý významným spôsobom obnoviť, upraviť alebo zmeniť fyziologické funkcie človeka."[30]

Ako uviedol Súdny dvor v rozsudku Komisia/Nemecko (cit.): "skutočnosť, že konzumácia dotknutého výrobku predstavuje zdravotné riziko, nie je skutočnosťou, ktorá umožňuje uviesť, že má farmakologickú účinnosť. Z judikatúry totiž vyplýva, že zdravotné riziko síce treba zohľadňovať v rámci kvalifikácie výrobku ako lieku na základe funkcie, je však samostatným faktorom"[31]

"Nestačí, aby výrobok mal vlastnosti priaznivé pre zdravie vo všeobecnosti, ale jeho funkciou v pravom zmysle slova musí byť prevencia alebo liečenie chorôb. Toto tvrdenie je o to relevantnejšie v prípade výrobkov, ktoré okrem toho, že sú potravinami, sú uznávané aj pre svoj priaznivý účinok na zdravie. Ako uviedla generálna advokátka v bode 60 svojich návrhov, existuje totiž veľa výrobkov, ktoré sú všeobecne považované za potraviny, ale môžu objektívne slúžiť na liečebné účely. Táto okolnosť však nemôže stačiť na to, aby im bola priznaná povaha lieku v zmysle smernice 2001/83."[32] Teda: "Na druhej strane existencia alebo neexistencia zdravotného rizika nie je vlastnosťou výrobku, ktorá by mala byť príslušnými vnútroštátnymi orgánmi zohľadnená pri posudzovaní, či výrobok je liekom v zmysle článku 1 bodu 2 písm. b) smernice 2001/83, a nemôže byť sama osebe rozhodujúca."[33]

Výklad čl. 1 bod 2 smernice 2001/83 sa má v zmysle judikatúry Súdneho dvora EÚ vykladať tak, že (cit.): "výrobok, ktorého zloženie obsahuje látku, ktorá má fyziologický účinok, ak sa užíva v určitej dávke, nie je liekom na základe funkcie, keď vzhľadom na jeho dávku aktívnych látok za obvyklých podmienok užívania predstavuje zdravotné riziko, bez toho, že by mohol obnoviť, upraviť alebo zmeniť fyziologické funkcie človeka."[34]

 

V. Záver

Pri liečbe pacienta je možné využiť mnohé prostriedky smerujúce k prinavráteniu alebo zlepšeniu jeho zdravia. V tomto procese hrá svoju významnú rolu viacero premenných, rozhodujúcim však stále ostáva osobný a odborný vklad zdravotníckych pracovníkov. Poskytovateľ zdravotnej starostlivosti prostredníctvom nich plní svoju povinnosť postupovať lege artis, oni sú tými osobami, ktoré v závislosti od svojho odborného zaradenia určujú a ovplyvňujú liečbu pacienta. Lieči lekár naozaj len liekmi? Určite nie, okrem nich je v závislosti od osobitostí toho-ktorého pacienta (jeho zdravotného stavu a podobne) povinný využiť celý rad postupov, ktoré nemusia mať charakter farmakoterapie, ale môžu mať povahu odporúčania na zmenu životosprávy, či úpravu stravovania alebo užívania výživových doplnkov.

Ako sme načrtli v našom príspevku, vzťah lieku a výživového doplnku vo vzťahu k liečbe pacienta sa vyznačuje viacerými otázkami. V nadväznosti na využie výživového doplnku pri riešení zdravotných ťažkostí pacienta sme sa snažili poukázať na vybrané aspekty pri farmakoliečbe a využívaní výživových doplnkov. V prvom rade je potrebné konštatovať, že zákon o liekoch presne stanovuje, čo môže byť obsahom lekárskeho receptu (kogentným spôsobom) a je možné dedukovať, že výživový doplnok nie je možné lekárskym receptom predpísať. Ak by lekár v rámci poskytovania zdravotnej starostivosti usúdil, že by pacientovi pomohol výživový doplnok, máme za to, že mu ho môže odporučiť. Takéto odporúčanie môže urobiť ústnou formou, odkázať pacienta na radu lekárnika prípadne odporúčanie urobí písomne aj priamo lekár - no nie formou receptu. Navrhovanú terapiu je povinný zaznačiť do zdravotnej dokumetácie pacienta.

Ak pacient príde riešiť svoj zdravotný stav priamo do lekárne je lekárnik povinný  poskytnúť mu informácie o voľnopredajných liekoch, zdravotníckych pomôckach a dietetických potravinách. Cez optiku koncepcie postupu lege artis largo sensu sme toho názoru, že i keď mu zákon o liekoch výslovne neukladá povinnosť informovať pacienta o doplnkovom sortimente lekárne, mal by pacientovi poskytnúť informácie aj o vhodných výživových doplnkoch. K uvedenému dodávame, že vo vzťahu lekárnik - pacient je lekárnik tým, kto je odborníkom a tým, kto vidí zdravotný stav pacienta komplexnejšie, zatiaľ čo pacient je vždy laikom. Práve lekárnik pozná sortiment lekárne a vie prečo sa konkrétne produkty v lekárni predávajú. V prípade ak je primárnym cieľom poskytovania zdravotnej starostlivosti pomoc pacientovi, tak si myslíme, že nie je možné vnímať vzťah lekárnik a pacient len v rámci zákonných povinností ale je nutné v ňom vidieť aj potrebu prirodzenej ľudskej snahy pomôcť pacientovi všetkými možnými dostupnými prostriedkami. Nazdávame sa, že aj z tohto dôvodu by mal pacient dostať kompletnú informáciu o sortimente lekárne.

Uvedené platí aj v prípade, ak pacient príde do lekárne s receptom, ktorým ošetrujúci lekár predpísal účinnú látku alebo konkrétny liek. Aj tu by mal lekárnik informovať o doplnkovom sortimente, ktorý sa týka zdravotných ťažkostí pacienta, zdôrazňujeme však, že svojím odporúčaním nemôže meniť povahu liečby nastavenej lekárom.  Ak si teda lekárnik splní svoju zákonnú povinnosť (týkajúcu sa liekov, ich náhrad, zdravotníckych pomôcok a dietetických potravín)  a informuje pacienta aj o výživovom doplnku, je podľa nášho názoru možné  jeho konanie vyhodnotiť ako konanie lege artis.

 

Autori: JUDr. Vladimír Volčko - JUDr. Ivan Humeník, PhD.

h&h PARTNERS, advokátska kancelária s.r.o., www.hhpartners.eu


Poznámky pod čiarou

[1] §2 zákona 576/2004 Z.z.

[2] Pozri § 2 ods. 7-10 zákona 576/2004 Z.z.

[3] Porovnaj GECÍK, K. Právna zodpovednosťodpzdravotníctve a v medicíne. 2. doplnené vydanie. Martin : Osveta, 1984, str. 180.

[4] Pozri HUMENÍK, I. Ochrana osobnosti a medicínske právo. I. vydanie. EUROKODEX, s.r.o., 2011, str. 123.

[5] Pozri TĚŠÍNOVÁ, J. - ŽĎÁREK, R. - POLICAR, R. - Medicínské právo, I. vydanie. C.H.BECK, 2011, str. 25.

[6] Publikovaný v Zbierke zákonov pod č. 40/2000 Z.z. ako OZNÁMENIE Ministerstva zahraničných vecí Slovenskej republiky.

[7] K tomu pozri prípady uvedené v § 6 ods. 9 zákona 576/2004 Z.z. K možnostiam odmietnutia uzavretia dohody pozri §12 zákona.

[8] Pozri §119 zákona o liekoch.

[9] §119 ods. 5 zákona o liekoch.

[10] K náležitostiam lekárskeho predpisu, lekárskeho poukazu a objednávky pozri §120 zákona o liekoch.

[11] Vraciame sa k § 2 ods. 10 zákona o zdravotnej starostlivosti kde je uvedený cieľ zdravotnej starostlivosti, v intenciách ktorého sa lekár sa snaží o navrátenie pacientovho zdravia a zabránenie ďalšiemu zhoršovaniu jeho zdravotného stavu ako aj zmiernenie prejavov a dôsledkov jeho choroby.

[12] Pozri §420 ods. 2 Občianskeho zákonníka.

[13] Pozri §119 ods. 7.  Gramatickým výkladom právneho predpisu je potrebné dôjsť k záveru, že musí ísť o liek.

[14] Sme názoru, že dnešná doba pred nás kladie otázku, či definícia zdravotnej starostlivosti ktorú obsahuje § 2 ods. 2 zákona o zdravotnej starostlivosti postačuje. Text citovaného ustanovenia napríklad neobsahuje jasné zadelenie lekárenskej starosltivosti pod zdravotnú starostlivosť, pričom v iných ustanoveniach zákona, ako aj z obsahového rámca súvisiacich predpisov medicínskeho práva vyplýva, že lekárenská starostlivosť je súčasťou zdravotnej starostlivosti – viď napríklad § 7 ods. 1 písm. c) alebo § 10 zákona o zdravotnej starostlivosti.

[15] Samozrejme nie v rozpore s liečbou ordinovanou lekárom.

[16] Uvedené sa týka verejnej lekárne a výdajne zdravotníckych pomôcok a netýka sa to nemocničnej lekárne. K rozdielom pozri §20 zákona o liekoch.

[17] §16 ods 1. Výnosu.

[18] §15 ods. 2 Výnosu.

[19] §16 ods. 8 Výnosu.

[20]  §17 ods. 2 Výnosu.

[21] Nariadenie je prameňom tzv. sekundárneho práva Európskej únie a medzi jeho pojmové vlastnosti patrí a/ všeobecná pôsobnosť, b/ záväznosť v jeho celistvosti, c/ priama aplikovateľnosť vo všetkých členských štátoch Európskej únie t.j. aj na Slovensku. Viac k tomu pozri MAZÁK, J - JÁNOŠÍKOVÁ, M:. Základy práva Európskej únie 1 - Ústavný systém a súdna ochrana. IURA Edition, spol s r.o., 2009, str. 234 a nasl..

[22] Pozri čl. 2 bod. 2. ods. 4 Nariadeniu Európskeho parlamentu a Rady (ES) Č. 1924/2006).

[23] Pozri čl. 2 bod. 2. ods. 5 Nariadeniu Európskeho parlamentu a Rady (ES) Č. 1924/2006).

[24] Pozri čl. 2 bod. 2. ods. 6 Nariadeniu Európskeho parlamentu a Rady (ES) Č. 1924/2006).

[25] K nariadeniu týkajúcom sa zdravotných tvrdení sa vyjadril aj Úrad verejného zdravotníctva Slovenskej republiky, keď vydal stanovisko k výkladu tejto legislatívy. Z odpovedí Úradu verejného zdravotníctva SR (v texte aj "ÚVZ SR"), ktoré boli vedené pod sp.zn. OHVBPKV 2946/2013/Kr, je dôležitých niekoľko záverov: 1. Prevádzkovatelia sú povinní dodržiavať požiadavky upravené osobitnými predpismi t.j. aj všeobecnej záväznou a priamo aplikatovateľnou legislatívou EÚ a z toho dôvodu je  do obehu zakázané uvádzať  potraviny klamlivo označené alebo ponúkané na spotrebu klamlivým spôsobom.  Podľa Čl. 3 ods. 8 Nariadenia (ES) č. 178/2002 pojem "umiestnenie na trhu“ znamená skladovanie, uchovávanie potravín alebo krmív na účely predaja, vrátane ponúkania na predaj alebo akúkoľvek inú formu prevodu, či už bezplatnú alebo nie a predaj, distribúciu a iné formy prevodu samy o sebe. 2. V prípade, že potraviny na osobitné výživové účely, ktoré obsahujú nekorektné výživové tvrdenia sú súčasťou sortimentu verejnej lekárne úpravu ich označenia (cit.) "vykonáva ten prevádzkovateľ potravinárskeho podniku, ktorý je za označovanie primárne zodpovedný (väčšinou je to výrobca alebo dovozca potraviny)". 3. Akcent na znenie čl. 2 Nariadenia Komisie (EÚ) č. 1047/2012 o tom, že je možné dopredať (nariadenie používa termín "umiestňovať na trh") výrobky umiestnené na trh pred 1. júnom 2014 aj v prípade ak nespĺňajú požiadavky nariadenia (ES) č. 1924/2006 týkajúce výživových tvrdení v označení, prezentácii a reklame.

[26] Rozsudok z 15. januára 2009, Hecht‑Pharma, C‑140/07, Zb. s. I‑41, bod 39.

[27] Rozsudok z 9. júna 2005, HLH Warenvertrieb a Orthica, C‑211/03, C‑299/03 a C‑316/03 až C‑318/03, Zb. s. I‑5141, bod 52.

[28] Rozsudok z 15. januára 2009, Hecht‑Pharma, C‑140/07, Zb. s. I‑41, bod 41. K tomu pozri  aj rozsudok z 15. novembra 2007, Komisia/Nemecko, C‑319/05, Zb. s. I‑9811, bod 60 a rozsudok zo 16. apríla 1991, Upjohn, C‑112/89, Zb. s. I‑1703, bod 22.

[29] Rozsudok z 30. apríla 2009, BIOS Naturprodukte GmbH, C‑27/08, Zb. s. I-03785, bod 22.

[30] Rozsudok z 15. januára 2009, Hecht‑Pharma, C‑140/07, Zb. s. I‑41, bod 42.

[31] Pozri rozsudok z 15. novembra 2007, Komisia/Nemecko, C‑319/05, Zb. s. I‑9811, bod 69 alebo  rozsudok z 9. júna 2005, HLH Warenvertrieb a Orthica, C‑211/03, C‑299/03 a C‑316/03 až C‑318/03, Zb. s. I‑5141, bod 53 alebo rozsudok z 30. apríla 2009, BIOS Naturprodukte GmbH, C‑27/08, Zb. s. I-03785, bod 25.

[32] Pozri rozsudok z 15. novembra 2007, Komisia/Nemecko, C‑319/05, Zb. s. I‑9811, bod 64-65.

[33] Rozsudok z 30. apríla 2009, BIOS Naturprodukte GmbH, C‑27/08, Zb. s. I-03785, bod 26.

[34] Rozsudok z 30. apríla 2009, BIOS Naturprodukte GmbH, C‑27/08, Zb. s. I-03785, bod 27.




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