Aktuálne otázky občianskoprávnej zodpovednosti za škodu pri poskytovaní zdravotnej starostlivosti (II.) | Medicínske právo
              

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Aktuálne otázky občianskoprávnej zodpovednosti za škodu pri poskytovaní zdravotnej starostlivosti (II.)


 | 24.5.2016 | komentárov: 361

Otázka náhrady škody na zdraví trápi mnohých pacientov. Prinášame vám pohľad odborníkov, ktorí vám pomôžu sa v otázke náhrady škody zorientovať. V prvej časti príspevku sme načrtli základné teoretické východiská otázky zodpovednosti za škodu. V tejto časti príspevku sa budeme venovať konkrétnym druhom zodpovednosti a rizikám úspešného preukázania škody na zdraví.

Obrazok

Osobitná „objektívna“ zodpovednosť za škodu spôsobenú okolnosťami, ktoré majú pôvod v povahe prístroja alebo veci, ktoré sa použili pri plnení záväzku (§ 421a Občianskeho zákonníka)

V oblasti poskytovania zdravotníckej starostlivosti sa s aplikáciou objektívnej zodpovednosti najvypuklejšie stretávame pri zodpovednosti za škodu spôsobenú okolnosťami, ktoré majú pôvod v povahe prístroja alebo veci, ktoré sa pri plnení záväzku použili (§ 421a Občianskeho zákonníka)1 . Ustanovenie § 421a rieši otázku, kto má niesť riziko prípadných komplikácií alebo škodlivých následkov v situáciách, keď síce šlo o výkon indikovaný a lege artis prevedený, po ktorom však došlo k vážnym, nečakaným následkom.2

Okolnosťami, ktoré majú pôvod v povahe prístroja alebo veci sú napr. okolnosti, ktoré vyplynú z ich vadnosti. Môže ísť o vadu elektrického prístroja, RTG prístroja, lieku, injekčnej striekačky.3 Obdobné závery možno nájsť aj v rozhodnutí Nejvyššího soudu ČR pod sp. zn.: 25 Cdo 2542/2003 (cit.): „Okolnosti, které mají původ v povaze přístroje nebo jiné věci, jsou např. okolnosti, které vyplynou z vadnosti přístroje (např. rentgenového přístroje, injekční stříkačky, léku apod.), přičemž není rozhodné, zda jde o vadnost vyskytující se ojediněle, opakovaně nebo pravidelně. Jde o odpovědnost za bezvadnost látky v době poskytnutí činnosti ke splnění závazku a za selhání použitého přístroje. Odpovědnost je dána tehdy, jestliže látka nebo přístroj vyvolaly účinky, ke kterým obecně nedochází, ale kde byly dány k vyvolání účinků jiné konkrétní podmínky (např. alergie nebo idiosynkrazie osoby, u které byly přístroj nebo látky použity). Jestliže např. k onemocnění pacienta došlo v důsledku použití nesterilní injekční jehly při léčebném zákroku, jde o objektivní odpovědnost zdravotnického zařízení za škodu tím způsobenou pacientovi na zdraví.“

Z praxe sú známe aj prípady prasknutej žiarovky v priebehu fyzioterapeutických zákrokov a následného popálenia pacienta jej rozpálenými črepmi.4 Podstatnou podmienkou však stále ostáva, že k založeniu tohoto druhu extra prísnej zodpovednosti môže dôjsť len v prípade ak škoda vznikla v dôsledku vlastnosti veci, nie v dôsledku vlastností/choroby človeka. Uvedené sa zdôrazňuje aj Nejvyšší soud ČR v rozhodnutí sp. zn.: 2 Cdon 961/96 (cit.): „Došlo-li k onemocnění pacienta v důsledku použití nesterilní injekční jehly při léčebném zákroku, jde o objektivní odpovědnost zdravotnického zařízení za škodu způsobenou pacientovi na zdraví. Jestliže k nákaze pacienta došlo proto, že při lékařském zákroku se dostal do kontaktu s pracovníkem zdravotnického zařízení, jenž byl nosičem viru, nebyla škoda způsobena okolnostmi, které mají původ v povaze přístroje nebo jiné věci."

Polemika vzniká, či je zodpovednosť daná aj v prípade, ak liek, látka či prístroj boli v požadovanej kvalite (teda „bez vady“), ale napriek tomu došlo ku škodlivému následku. Môže ísť napr. o neobvyklú a nečakanú alergickú reakciu pacienta na určitú látku alebo liek. Podľa judikatúry je aj v takýchto prípadoch zodpovednosť daná. Zákon totiž nevyžaduje, aby výrobca, dodávateľ alebo poskytovateľ služby akokoľvek škodu zavinil. Vyžaduje iba, aby bola škoda spôsobená okolnosťami, ktoré majú pôvod v povahe prístroja alebo veci. Pritom môže ísť o vec bezvadnú a použitú lege artis pri poskytovaní zdravotnej starostlivosti. Rovnako podľa judikatúry vzniká zodpovednosť aj za úplne nezávadný liek, aplikovaný správne a dôvodne. V prípade vady nie je tiež rozhodné, či ide o vadu vyskytujúcu sa ojedinele, opakovane alebo pravidelne. Často citovaným (a v súčasnej dobe zároveň kritizovaným) judikátom je rozsudok Najvyššieho súdu SSR Rc 9/77, v ktorom Najvyšší súd rozhodol, že zdravotnícka organizácia zodpovedá za škodu spôsobenú okolnosťami, ktoré majú pôvod v povahe použitého prístroja, nástroja, lieku alebo inej veci použitej pri poskytnutí zdravotníckych služieb, a to aj keď ide o vedľajšie účinky, ktoré mali za následok vznik škody, o ktorých nebolo zdravotníckej organizácii známe, že k nim dochádza.5 Najvyšší súd v tomto prípade podal extenzívny výklad § 421a OZ (v tom čase § 238 OZ), keď zodpovednosť zdravotníckej organizácie rozšíril na vedľajšie účinky liekov, ktoré boli zdravotníckej organizácii známe, ale aj na tie, ktoré v čase aplikácie lieku známe neboli a nevyskytovali sa.6 Obdobný názor bol vyslovený aj v judikáte týkajúcom sa použitia implantovateľnej zdravotníckej pomôcky, ktorá tlakom na miechu vyvolala u pacienta poškodenie zdravia – rozhodnutie Nejvyššího soudu ČR sp. zn. 25 Cdo 1129/2005 (cit.): „Tlak drátěné fixační kličky na míchu uvnitř páteřního kanálu je okolností, jež má původ v povaze věci užité při lékařském zákroku.“

Ustanovenie § 421a OZ možno aplikovať len na zodpovednosť za škodu, ktorej príčinou sú vlastnosti a povaha predmetu použitého pri plnení záväzku, toto ustanovenie neupravuje zodpovednosť za škodu vzniknutú nesprávnym lekárskym zákrokom. Podľa rozsudku R 2/1987 je vylúčené, aby sa podľa ustanovenia § 238 OZ (terajší § 421a OZ) posúdila zodpovednosť zdravotníckej organizácie za škodu, ktorá nemala príčinu v povahe konkrétneho použitého prístroja alebo veci, ale v samostatnom zdravotníckom zákroku, prípadne v spôsobe jeho výkonu. V takom prípade zodpovedá zdravotnícka organizácia za škodu podľa ustanovenia § 421 OZ (terajší § 420 OZ).7

Čo je najpodstatnejšie z vyššie uvedeného? Rozdiel medzi (1) všeobecnou zodpovednosťou za škodu podľa §420 OZ a (2) osobitnou zodpovednosťou za škodu spôsobenú povahou veci podľa §421a OZ je v tom, že: pri prvej z nich je podmienkou aby škoda vznikla ako následok non lege artis postupu pri druhej z nich musí byť škoda spôsobená vlastnosťou (povahou) veci – lieku, zdravotníckej pomôcky použitej pri poskytnutí zdravotnej starostlivosti pri prvej z nich musí byť prítomné aspoň nedbanlivostné zavinenie pri druhej z nich je irelevatné, že poskytovateľ urobil všetko tak ako mal – teda že vec použil správne a lege artis. Oba druhy zodpovednosti majú rovnakých niekoľko znakov – predovšetkým, žalobca (pacient) musí pri každej z nich preukázať príčinnú súvislosť. Súčasne musí nárok uplatniť na súde v zákonnej premlčacej lehote.

III. Aké sú hlavné riziká úspešného preukázania nároku na náhradu škody

Medzi najvýraznejšie „neisté premenné“ v konaniach o náhradu škody na zdraví patrí už spomenutý problém spoľahlivo preukázať príčinnú súvislosť medzi nesprávnym postupom a vznikom škody (resp. medzi vlastnosťou veci a vznikom škody) a tak isto aj problematika premlčania samotného nároku. Oba tieto okruhy by si zaslúžili samostatné zamyslenie a preto sa v závere nášho príspevku ani nie je radno do nich púšťať. Vo vzťahu k premlčaniu snáď v skratke stojí za zmienku, že súčasná nálada v súdnych sieňach nasvedčuje postupnému zmäkčovaniu doteraz striktne požadovanej 100% dokázanosti príčinnej súvislosti8 . Sme názoru, že tento trend je opodstateľný – veď každý organizmus je jedinečný a v samotnej podstate vylučuje, aby sme mohli príčinnú súvislosť vystavať nespochybniteľne a úplne naisto. Právo aj prax súdov, ktoré ho svojou činnosťou aplikujú musí rešpektovať okrem partikulárnych normatívov obsiahnutých v konkrétnych zákonoch aj samotné právne princípy spravodlivosti a rovnosti. Takýmto smerom uvažoval aj Ústavný soud ČR v rozhodnutí sp.zn.: I. ÚS 1919/2008, keď uviedol (cit.): „Závěry nalézacího soudu stran "stoprocentního" prokázání objektivní příčinné souvislosti se jeví Ústavnímu soudu jako nereálné, neboť nedosažitelné a neudržitelné. Určovat v lékařských postupech jednoduchý vztah příčiny a následku je samo o sobě velmi obtížné. Podstatou lékařství je vlastně vstupovat do celého řetězce příčin a následků, do procesů, které probíhají v lidském těle, a vnějším zásahem tyto procesy ovlivňovat, měnit jejich směr, působení atd. Zásah lékaře tak vlastně sám o sobě mění "přirozený běh věcí" v lidském těle, zasahuje do komplexních vztahů příčin a následků. I v případě aktivního jednání lékaře, který zvolí určitý léčebný postup, je velmi obtížné, ba vyloučené stanovit, zda tento postup byl nade vši rozumnou pochybnost jedinou možnou příčinou škodlivého stavu, který nastal. O to obtížnější je to v případě opomenutí, kdy lékař nezvolí postup, který na základě soudobých a dostupných znalostí lékařství zvolit mohl a měl. Prokázat, že právě a pouze toto opomenutí tvoří se škodlivým důsledkem ničím nenarušený vztah, je v podstatě nemožné. V důsledku toho je výrazně oslabeno postavení poškozeného. Vzhledem k tomu, že pojem příčinná souvislost není právními předpisy v České republice nijak definován, což ostatně zdůraznil ve svém rozsudku i nalézací soud, nic nebrání judikatuře českých soudů, aby požadavek "stoprocentně" prokazované příčinné souvislosti přehodnotila a přijala adekvátnější a realističtější výklad "způsobení škody", který by vyrovnával slabší postavení poškozených. Naznačené řešení užívané v zemích common law se dle přesvědčení Ústavního soudu více přibližuje ideji spravedlivého řešení následků majících původ ve vztahu lékař - pacient, který je třeba nahlížet jako vztah panství, v němž má z mnoha důvodů, avšak především z důvodů znalostních, převahu moci právě lékař. Proto je třeba důsledněji chránit pacientovo základní právo na tělesnou integritu a v posledku, jak dokazuje řešený případ, i právo na život, a to i skrze výklad příslušných ustanovení občanského zákoníku týkajících se náhrady škody.“

Sme názoru, že práve týmto smerom by sa mali vydať aj súdy na Slovensku – vnímať špecifickosť zdravotnej starostlivosti a ľudského organizmu a nenástojiť na (bez tak nedosiahnuteľnom) 100% preukázaní príčinnej súvislosti. Súčasne sme názoru, že osobitný druh zodpovednosti za škodu spôsobenú povahou veci použitej pri poskytovaní zdravotnej starostlivosti je nevyhnutné zúžiť, pretože jej aktuálne nastavenie je pre každého poskytovateľa ako „časovaná bomba“ ktorej spustenie de facto sám nevie nijako ovplyvniť. Takýto koncept zodpovednostných vzťahov podľa nášho názoru negatívne vstupuje do komunikácie pacienta a jeho poskytovateľa a stavia poskytovateľa do neistého postavenia.

 


 

Aktuálne otázky občianskoprávnej zodpovednosti za škodu pri poskytovaní zdravotnej starostlivosti (I.)

 


 

Použité zdroje:

1 Pri poskytovaní zdravotnej starostlivosti by samozrejme do úvahy prichádzali aj ďalšie druhy objektívnych zodpovedností ako je zodpovednosť za škodu spôsobenú prevádzkovou činnosťou (420a OZ), a ako aj zodpovednosť za škodu spôsobenú zvlášť nebezpečnou prevádzkou (§ 432 OZ), či škodu spôsobenú na vnesených veciach (§ 433 OZ).

2 LUBY, Š.: Prevencia a zodpovednosť v občianskom práve II. Bratislava, Vydavateľstvo Slovenskej akadémie vied, 1958, str. 156.

3 STOLÍNOVÁ, J., MACH, J.: Právni odpovědnost v medicíne. Praha, Galén, 1998, str. 77.

4 Porovnaj: MILTOHNER, M.: Vymezení rizika a odpovědnosti ve zdravotníctvi. In Zdravotnictví a právo, roč. IV, č. 5, 2000, str. 10.

5 Rc 9/77 rozsudok 1 Cz 110/74 (Zb. sr. 77, 2 – 3: 114), ASPI, Ev. č. 1734 (JUD)

6 K otázke zodpovednosti zdravotníckeho zariadenia za vedľajšie účinky liekov sú rôzne názory. Kramerius napr. takto široko a prísne koncipovanú objektívnu zodpovednosť odmieta a argumentuje, že po lekárovi nie je spravodlivé žiadať, aby sa zodpovedal za nepriaznivý výsledok vzniknutý z rizika, ktoré nemohol ovplyvniť. KRAMERIUS, P.: K odpovědnosti lékaře za vedlejší účinky léku. In Právni rozhledy, roč. 10, č. 6, 2002, str. 281.

7 Pozri: PLANK, K., a kol.: Občianske právo s vysvetlivkami. Bratislava, Iura Edition, 1996, str. 316 - judikatúra.

8 Obdobný príklon je viditeľný predovšetkým v krajinách common law, ale aj v rozhodnutiach zahraničných súdov kontinentálneho práva. Pozro napr.: Cass civ 1st, 23 September 2003: JCP 2003.G.II.10179 (note Jonquet, Maillols, Mainguy and Terrier), pozri KHOURY, L. Uncertain Causation in Medical Liability. OXFORD AND PORTLAND, OREGON, 2006. ISBN-13: 978-1- 84113-517-5, str. 178. Viac k tomuto prípadu pozri HUMENÍK, I., VOLČKO, V.: Povinné očkovanie - téma, ktorá rozdeľuje spoločnosť (II). In Právo a manažment v zdravotníctve, číslo 6/2012, ročník III, ISSN 1338-2071, str. 12 a nasl.




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