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Souhlas s použitím krve pro potřeby lékařské vědy a výzkumu


 | 2.5.2011 | komentárov: 605

Již delší čas vedu v českých medicínsko-právních luzích a hájích se svými kolegy debatu o tom, jakou podobu vyjádření souhlasu vyžaduje právní řád pro to, aby mohla být odebraná lidská krev využita pro potřeby lékařské vědy a výzkumu.Klíčová otázka zní: Použije se ustanovení § 26 odst. 4 písm. a) ve spojení s odst. 7 zákona č. 20/1966 Sb., o péči o zdraví lidu, ve znění pozdějších předpisů, (dále jen ZPZL) i v případě úmyslu uchovat a použít pro potřeby lékařské vědy a výzkumu lidskou krev?

Obrazok Dovolte mi nejprve lehké seznámení s citovanými ustanoveními ZPZL.
V § 26 odst. 4 písm. a) ZPZL se uvádí, že „pokud byla v souvislosti s léčebně preventivní péčí pacientovi odebrána jakákoliv část jeho těla, lze ji uchovat a použít (...) pro potřeby lékařské vědy, výzkumu nebo k výukovým účelům, (...)a to pouze pokud byla pacientovi o možnosti jejího uchování a použití pro lékařské potřeby (pozn. tím se myslí právě např. potřeby lékařské vědy a výzkumu) podána ošetřujícím lékařem informace a pacient s tím vyslovil prokazatelný písemný souhlas; součástí souhlasu je vymezení účelu použití částí těla pacienta.“

Sedmý odstavec § 26 ZPZL pak následně stanoví, co se považuje za „prokazatelný písemný souhlas“. Ten může mít celkem tři modality:

  1. písemný souhlas pacienta s jeho úředně ověřeným podpisem,
  2. písemný souhlas pacienta vyslovený ve zdravotnickém zařízení podepsaný pacientem, svědkem určeným pacientem a ošetřujícím lékařem, nebo
  3. vyslovení souhlasu pacienta ve zdravotnickém zařízení do záznamu o zjištění prokazatelného písemného souhlasu; takto vyslovený souhlas podepíše pacient, svědek určený pacientem a ošetřující lékař; pokud pacient s ohledem na svůj zdravotní stav nemůže záznam podepsat, popřípadě určit svědka, stvrdí jeho nepochybný projev vůle svým podpisem ošetřující lékař a další svědek, který není zdravotnickým pracovníkem; v záznamu se uvede způsob, jakým pacient svou vůli projevil, a zdravotní důvody bránící podpisu pacienta nebo určení svědka.
Pro posouzení shora položené otázky vidím hned několik okruhů argumentů proti i proti.


1. okruh argumentů

Proti:
Právní úprava v § 26 odst. 4 ZPZL se výlučně vztahuje na uchování a použití odebraných částí lidského těla. Je tedy sporné, zda se vztahuje i na krev, která sice proudí v lidském těle, ale není jeho pevnou součástí.
Lidská krev ve vztahu k lidskému tělu neodpovídá obecné představě části a celku. Bylo by to stejné jako tvrdit, že káva je částí šálku nebo že benzín či nafta jsou částí automobilu.

Pro:
Úvodní věta § 26 odst. 1 ZPZL uvádí, že jak odběr krve, tak odnímání částí lidských těl provádějí a organizují zdravotnická zařízení pro potřeby léčebně preventivní péče a lékařské vědy, výzkumu a k výukovým účelům.
§ 26 odst. 4 ZPZL následně stanoví podmínky pro uchovávání a používání odebraných částí lidského těla pro lékařské potřeby, přičemž tyto podmínky vztahuje k jakýmkoliv částem lidského těla.
Také krev je součástí lidského těla. Za část lidského těla nelze považovat pouze ty části, které jsou v pevném skupenství – orgány a tkáně či jejich části, ale také ty části, které jsou v kapalném skupenstvím.
Krev taktéž nelze přirovnávat k produktům lidského metabolismu jako např. moč čili kapalina, která v určité podobě do těla vejde a v pozměněné zase z těla vyjde. Krev je produkt lidského těla.
Krev je součástí lidského těla, neboť je nezbytnou podmínkou fungování celého organismu.
Konec konců, co vše lze považovat za součásti lidského těla, autoritativně uvádí § 2 písm. b) transplantačního zákona: orgány, tkáně, buňky, krev a její složky, pohlavní buňky, embryonální a fetální tkáně a orgány, vlasy, nehty, placenta a odpadové produkty tělního metabolismu.


2. okruh argumentů

Proti:
Úvodní věta § 26 odst. 1 ZPZL („Odběr krve a odnímání částí lidských těl provádějí a organizují zdravotnická zařízení, a to pouze pro potřeby léčebně preventivní péče a lékařské vědy, výzkumu a k výukovým účelům.“) odlišuje dvě témata, která mají být předmět regulace v tomto ustanovení – jednak odběr krve, jednak odnímání částí lidských těl.
I kdybychom připustili, že krev je částí lidského těla, zákonodárce zde pro účely právní regulace používá dva termíny krev a části lidského těla, z čehož vyplývá, že z rozsahu pojmu „části lidského těla“ krev vylučuje.
Jestliže pak § 26 odst. 4 ZPZL stanoví podmínky uchovávání a používání odebraných částí lidského těla, tak vzhledem k uvedenému terminologickému odlišení tím myslí části lidského těla mimo krev.

Pro:
Úvod první věty § 26 odst. 1 ZPZL, kde se jakoby činí rozdíl mezi termíny „krev“ a „část lidského těla“, může vyvolat pro souhlasný závěr vůči úvodní otázce určité pochybnosti. Mám však za to, že ono oddělování pojmů „krev“ a „části lidského těla“ bylo spíše provedeno vzhledem k použití slov „odběr“ a „odnímání“ a že je tato věta mnohem pravděpodobněji myšlena v podobě „odběr krve a odnímání ostatních částí lidských těl“. Tomu napovídají i formulace v dalších odstavcích.
§ 26 odst. 3 ZPZL („Odběr tkáně nebo krve pro diagnostické účely lze z těla zemřelého provést pouze v nezbytně nutné míře a při zachování piety.“) používá spojení „odběr tkáně nebo krve“ tedy již nepoužívá zdánlivou bipartici „krev“ a „část lidského těla“.
Stejně tak § 26 odst. 4 ZPZL hovoří o jakýchkoliv částech lidského těla tedy nerozlišuje mezi různými částmi lidského těla, ale zahrnuje vše, co je částí lidského těla.
Určité terminologické nepřesnosti lze v případě § 26 ZPZL připsat i tomu, že jeho původ není ve vládním návrhu zákona, ale v pozměňovacím návrhu, který ve druhém čtení projednávání v Poslanecké sněmovně Parlamentu předložil Výbor pro sociální politiku a zdravotnictví (viz průběh projednávání sněmovního tisku č. 1053, Poslanecká sněmovna Parlamentu České republiky, III. volební období). Návrh tedy není dílem profesionálních legislativců, ale dílem poslanecké iniciativy.


3. okruh argumentů

Proti:
§ 26 odst. 2 ZPZL uvádí, že odběr krve může být proveden se souhlasem dárce a nesmí ohrožovat jeho zdravotní stav a musí být proveden takovým způsobem, který neohrozí zdraví jiného člověka.
Zákonodárce zde stanoví podmínky pro odběr krve pro všechny důvody odběru a to jak
pro účely léčebně preventivní péče, tak pro účely lékařské vědy a výzkumu.

Pro:
§ 26 odst. 2 ZPZL sice stanoví určité podmínky – souhlas dárce, nesmí ohrožovat jeho zdravotní stav, musí být proveden takovým způsobem, který neohrozí zdraví jiného člověka –, avšak jedná se o podmínky, za kterých může být proveden odběr krve.
Oproti tomu § 26 odst. 4 ZPZL stanoví podmínky pro uchování a použití odebrané části lidského těla, tedy i krve, pro potřeby lékařské vědy a výzkumu.
Každé ustanovení tak stanoví podmínky pro něco jiného – § 26 odst. 2 ZPZL pro odběr krve, § 26 odst. 4 ZPZL pro uchování a použití již odebrané krve po potřeby lékařské vědy
a výzkumu.
Nejedná se tak o ustanovení konkurenční, kdy by použití jednoho vylučovalo použití druhého.
Pokud by se § 26 odst. 4 ZPZL nevztahoval na lidskou krev, neexistovala by žádná právní norma, která by zdravotnickému zařízení umožňovala uchovat a pro potřeby lékařské vědy
a výzkumu použít odebranou krev.


4. okruh argumentů

Proti:
Vzhledem k tomu, že § 26 ZPZL neobsahuje žádné další podmínky pro použití odebrané krve pro potřeby lékařské vědy a výzkumu, použije se obecné ustanovení § 27c ZPZL („Každý lékařský výkon, který není v bezprostředním zájmu osoby, na které má být proveden, lze provést pouze s předchozím písemným souhlasem takové osoby. Před udělením souhlasu musí být osoba úplně informována o povaze výkonu a jeho rizicích.“), které pouze vyžaduje předchozí písemný souhlas pacienta poté, co byl úplně informován o povaze výkonu a jeho rizicích.
Není tedy třeba prokazatelný písemný souhlas ve smyslu § 26 odst. 7 ZPZL.

Pro:
Úvahy o použití § 27c ZPZL pro řešení této otázky jsou zcela na místě, ale nikoli z toho hlediska, že by dostačoval písemný souhlas ve smyslu § 27c ZPZL.
Souhlas podle § 27c ZPZL je totiž souhlasem „s lékařským výkonem, který není
v bezprostředním zájmu osoby, na které má být proveden“. Jediný výkon, který by mohl být na osobě proveden v souvislosti s řešenou otázkou, je odběr krve.
Ustanovení § 27c ZPZL se tak v kontextu analyzovaného problému uplatní pouze tehdy, pokud se odběr krve neprovádí pro účely léčebně preventivní péče a teprve následně má být část odebrané krve použita pro potřeby lékařské vědy a výzkumu, ale provádí se pouze
za účelem získání vzorku pro potřeby lékařské vědy a výzkumu.
Ani ustanovení § 27c ZPZL není konkurenční k ustanovení § 26 odst. 4 ZPZL, neboť první zmíněné řeší souhlas s výkonem tedy s odběrem krve, avšak předmětem posléze uvedeného je souhlas s uchováním a použitím odebrané krve. První ustanovení tak stanoví povinnou formu informovaného souhlasu se zdravotním výkonem, druhé reguluje podmínky, za kterých lze nakládat s odebraným vzorkem krve.


5. okruh argumentů

Proti:
Ministerstvo zdravotnictví vydalo vyhlášku o lidské krvi (č. 143/2008 Sb.), která v relativně podrobném vymezení toho, jaké informace jsou dárci krve poskytovány zařízením transfuzní služby a co vše dárce krve písemně potvrzuje, předpokládá pouze písemný souhlas dárce s provedením odběru krve a s laboratorním vyšetřením, který kromě dárce podepíše jen zdravotnický pracovník provádějící rozhovor s dárcem a posouzení způsobilosti dárce k odběru (část B přílohy 2 k vyhlášce). Nic se zde nehovoří o potřebě podpisu svědka, ani
o informování o možnosti uchování a použití odebrané krve pro lékařské potřeby
a konkrétním účelu použití krve.
Zařízení transfuzní služby odebírají od dárců krev proto, aby se z ní vyrobily léčivé přípravky (transfuzní přípravky, krevní deriváty – viz § 2 odst. 2 písm. l) a n) zákona o léčivech). Jedná se tak o situaci předvídanou v § 26 odst. 4 písm. b) ZPZL, neboť dochází k uchování a použití odebrané krve „pro výrobu nebo přípravu léčiv podle zvláštního právního předpisu“.
Ministerstvo zdravotnictví tak očividně nesdílí stanovisko, že se § 26 odst. 4 použije
i na uchování a použití lidské krve, jinak by stěží mohlo vydat vyhlášku o lidské krvi, která s režimem, jež z uvedeného stanoviska vyplývá, nijak nepočítá.

Pro:
Argument, že vyhláška o lidské krvi nevyžaduje písemný souhlas s uchováním a použitím krve pro jiný z účelů řazených podle § 26 odst. 4 ZPZL mezi tzv. lékařské potřeby, z čehož lze dovodit, že se § 26 odst. 4 ZPZL nevztahuje na krev, není přesvědčivý.
Předně jedná se o vyhlášku tedy předpis nižší právní síly, než je ZPZL. Vedle toho, byť tato vyhláška celkem podrobně upravuje, o čem má být dárce před odběrem krve informován
a s čím má vyslovit souhlas, přísně vzato žádné ustanovení vyhlášky o lidské krvi nevylučuje taktéž postup podle § 26 odst. 4 ZPZL.
Na podobě vyhlášky o lidské krvi se nepochybně projevilo to, že tato vyhláška implementuje do českého právního řádu vedle dalších tří evropských směrnic také směrnici Komise 2004/33/ES ze dne 22. března 2004, kterou se provádí směrnice Evropského parlamentu a Rady 2002/98/ES, pokud jde o některé technické požadavky na krev a krevní složky.
Text vyhlášky (část B přílohy 2 k vyhlášce), který uvádí, co všechno má být dárci sděleno
a s čím má vyslovit souhlas, je v podstatě shodný s textem části B přílohy II k uvedené směrnici. Autor návrhu vyhlášky tak pouze okopíroval text směrnice, neboť jeho hlavním úkolem bylo zapracovat čtyři evropské směrnice, a nezamýšlel se blíže nad dalšími souvislostmi v rámci českého právního řádu. Tento snadný postup implementace evropské předpisu do českého právní řádu je bohužel častým jevem a stejně tak je častým předmětem odborné kritiky.


6. doplňující argument

Pouze pro:
Lidská krev má pro lékařskou vědu a výzkum srovnatelný význam, srovnatelnou „informační hodnotu“ jako tkáně. Z tohoto hlediska, pohlížíme-li na nejednoznačnou právní normu z pohledu racionálního zákonodárce, nedává smysl, aby stanovil jiné podmínky použití krve pro účely lékařské vědy a výzkumu a jiné podmínky použití tkání pro tentýž účel.
Hledisko racionálního zákonodárce je přitom obecně uznávaným přístupem k interpretaci práva v situaci, kdy hledání právní normy jako významu právních předpisů je obtížné.


Závěr

Hledání odpovědi na otázku položenou v úvodu není snadným procesem a zjednodušený přístup k tomuto úkolu může vést k zavádějícím závěrům, které však nejsou s to vyrovnat se s argumenty svědčícími pro opačný závěr.
Teprve podrobný rozbor všech souvisejících ustanovení, poctivé hledání jejich významu
a určitý pohled shora na všechny relevantní normy v jejich kontextu, mnohdy i s přihlédnutím k okolnostem jejich vzniku, může vést ke správnému závěru.
Při práci vedoucí k nalezení odpovědi na otázku vznesenou v úvodu jsem nevycházel
z a priori zaujatého stanoviska, ke kterému jsem hledal argumenty, ale ze stavu, kdy jsem hledal, jaká odpověď je odpovědí reflektující stav, který je podle práva. Shrnul jsem jednotlivé argumenty a spojovali jsem je jako „puzzle“. Výsledný obraz vyplynul z toho, že ke každému z pěti argumentů PROTI bylo možno přiřadit silnější argument PRO a navíc přidat ještě jeden, který potvrzuje kladnou odpověď na základní otázku.
Výsledkem mé práci pak je tato odpověď:
  • V případě úmyslu uchovat a použit lidskou krev pro potřeby lékařské vědy a výzkumu je třeba použít ustanovení § 26 odst. 4 ZPZL ve spojení s ustanovením § 26 odst. 7 ZPZL.
  • I v tomto případě je tak zapotřebí, aby byla pacientovi o možnosti uchování odebrané krve a jejího použití pro lékařské potřeby podána ošetřujícím lékařem informace a toto nelze realizovat bez toho, aby pacient s tím vyslovil prokazatelný písemný souhlas
v podobě, jak tento termín definuje § 26 odst. 7 ZPZL, tedy zpravidla písemný souhlas podepsaný pacientem, svědkem určeným pacientem a ošetřujícím lékařem.


Mgr. Radek Policar

Mgr. Radek Policar rokoch 2000 – 2004 pôsobil vo Fakultnej nemocnici Brno od pozície právnika, až po zástupcu vedúceho odboru právnych vecí. Od roku 2004 pracuje na Masarykovom onkologickom ústave v Brne najskôr ako vedúci právneho úseku, od roku 2008 ako námestník riaditeľa pre právne služby a personalistiku a od roku 2010 tiež ako zástupca riaditeľa. Vyvíja prednáškovú a konzultačnú činnosť v oboru medicínskeho práva a v súvisiacich oblastiach. Ako lektor spolupracuje s Právnickou, Lekárskou a Filozofickou fakultou Masarykovej univerzity, s 1. Lekárskou fakultou Univerzity Karlovej, s Národným centrom ošetrovateľstva a nelekárskych zdravotníckych oborov v Brne, s Academy of Health Care Management v Čelákoviciach, so Spoločnosťou medicínskeho práva a ďalšími. Je spoluautorom učebnice Medicínske právo (C. H. Beck, 2011), autorom publikácie Zdravotnícká dokumentace v praxi (Grada Publishing, 2010) a desiatok odborných textov. Podieľal sa na riešení grantov Grantové agentúry Karlovej Univerzity „Problematika doložky DNR ve zdravotnické praxi; komparatistika, etické aspekty a varianty právního řešení“, 2008-2010. Prispievateľ blogu zdravotnickepravo.info

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