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Zanedbanie lekárskej starostlivosti: Ako sa vo svete vyhrávajú lekárske spory


 | 10.7.2011 | komentárov: 408

Stretnutie praxe práva a medicíny môže byť často frustrujúce, zložité a plné zdanlivo neprekonateľného napätia. Najtypickejšími situáciami, v ktorých sa právo a medicína stretávajú je zanedbanie lekárskej starostlivosti. Teória týkajúca sa zanedbania lekárskej starostlivosti hovorí, že finančné sankcie za spôsobenie ujmy pacientom prostredníctvom klinických pochybení budú faktorom ovplyvňujúcim zodpovednosť lekára. Inými slovami, ak lekár musí za svoje chyby a nedbanlivosť zaplatiť, bude pracovať poriadnejšie, aby predišiel pochybeniam a pacientovi tak bude poskytnutá kvalitnejšia liečba. Tak ako vo väčšine aspektov života sa však aj tu vyskytujú mnohé komplikácie v prípade, keď sa teória uvádza do praxe. Aj keď sa tieto problémy vyskytujú v krajinách po celom svete – v rôznych kultúrnych a sociálnych podmienkach – ich prejavy a následky sú v mnohom odlišné a v mnohom podobné.

Obrazok
Kanada je krajinou, v ktorej je táto problematika jasne viditeľná. Často porovnávaná s USA, Kanada je rovnako kritizovaná za zanedbávanie lekárskej starostlivosti ako USA. Avšak dôvody takejto kritiky sú predsa len trochu odlišné. Aj keď obvyklý je názor, že spory týkajúce sa zanedbanie zdravotnej starostlivosti v USA sú nákladné, naproti tomu veľa ľudí tvrdí, že právna systém Kanady umožňuje poskytnúť pacientovi len neprimerane nízku náhradu utrpenej ujmy.

V Kanade je povinné, aby lekári boli poistený pre prípad spôsobenia škody pri výkone svojho povolania prostredníctvom Kanadskej lekárskej ochrannej asociácie (Canadian Medical Protective Association – CMPA), ktorá nielenže zaplatí náhradu za škodu spôsobenú zanedbaním lekárskej starostlivosti, ale rovnako počas súdneho procesu obhajuje lekára. Asociácia je často kritizovaná za svoj agresívny prístup pri obhajobe lekárov, avšak často odmietajúc primerané a spravodlivé urovnanie sporu sa pokúša odradiť ostatných od začatia nových procesov s podobnými predmetmi konania.

Aj v Kanade však existujú právne prekážky pre žalovanie z dôvodu pochybenia pri poskytovaní zdravotnej starostlivosti. Právny systém Kanady, ktorý stanovuje, že porazená strana súdneho sporu je povinná nahradiť protistrane dve tretiny trov, ktoré platila v súvislosti s konaním. Práve to predstavuje zjavný risk, obzvlášť pre obyvateľov z nižších sociálnych vrstiev. Najvyšší súd Kanady (The Supreme Court of Canada) v prípade Koukounakis proti Stainrod z roku 1995 tiež stanovil, že maximálnou náhradou škody v prípadoch zanedbania lekárskej starostlivosti bude 100.000 kanadských dolárov, a aj to iba výnimočne - za obzvlášť nezvyčajných okolností prípadu. Rozhodnutím súdu v prípade Whiten proti Pilot z roku 2002 boli rovnako obmedzené druhy prípadov, v ktorých je možné vymáhať náhradu škody.

V konečnom dôsledku uvedené postupy poskytujú pre lekára akúsi záchrannú sieť. Často sú okolnosťou odradzujúcou pacienta od podania návrhu na začatie súdneho sporu. Podľa výskumu z roku 2005 bolo zistené, že v USA sa oproti Kanade uskutočňuje 350% takýchto súdnych sporov. Na jednej strane, zneužitie systému je predchádzané s dôsledkom ekonomickej výhodnosti, na strane druhej však ochrana, ktorú poskytuje právo pacientom v prípade zanedbania lekárskej starostlivosti je znížená.

V prípade Nemecka sa počet súdnych sporov týkajúcich sa zanedbania lekárskej starostlivosti neodráža pravdivo v počte prípadov, ktoré sa v tejto oblasti stali. Hlavným dôvodom je rozsiahly systém sociálneho zabezpečenia ponúkaný nemeckou vládou. Z dôvodu takéhoto mechanizmu sú pacienti zaťažovaní poplatkami v prípadoch zanedbania lekárskej starostlivosti len minimálne a majú pomerne malý záujem začať súdne konanie. Tí, ktorí majú snahu o urovnanie sporu sa podľa prieskumu až v 92 percentách neobrátia na súdny systém, ale spor vyriešia za pomoci lekárskej spoločnosti a konzultanta v oblasti poisťovníctva, ktorí tu pôsobia ako arbitri. Náhrady pacientom v takýchto sporoch sú spravidla relatívne nízke.

Dôsledky zanedbania lekárskej starostlivosti v Nemecku sú podobné ako tie v Kanade. Okrem faktoru straty zodpovednosti na lekárov pôsobí aj neochota pacientov hrnúť sa do súdneho sporu, čo v podstate predstavuje, že podstatnú mieru bremena v prípadoch pochybenia lekárov spočívajúceho v zanedbaní lekárskej starostlivosti znáša sociálny systém. To vytvára nepriaznivé podmienky, ktoré môžu poškodzovať ekonomiku štátu v takom rozsahu, ako ju môžu poškodzovať príliš časté súdne spory v prípadoch zanedbania lekárskej starostlivosti.

V Indii je situácia odlišná. V roku 1986 bol prijatý Zákon na ochranu spotrebiteľa (Consumer Protection Act) a v roku 1995 a súd rozhodol v spore Indickej lekárskej spoločnosti (Indian Medical Association) proti V.P. Shantha, A.I.R. že pacienti podľa tohto zákona sú považovaní za spotrebiteľov. To v praxi znamená, že pacient môže dosiahnuť náhradu škody oveľa skôr ako keby postupoval klasickým spôsobom pomocou trestného práva. Trestné právo a civilno-právne postupy sú tu stále k dispozícii, avšak novou možnosťou na dosiahnutie nápravy na súde je využitie prostriedkov ochrany spotrebiteľa. Hoci táto štruktúra by mohla byť navrhnutá inak, v Indii nie je podľa výskumov príliš vysoký počet sporov týkajúcich sa zanedbania lekárskej starostlivosti.

Aj keď je dôležité pozerať sa na zákony zaoberajúce sa zanedbaním lekárskej starostlivosti aj s ohľadom na široké následky v oblasti verejného zdravia a ekonomiky, je extrémne nebezpečné ignorovať jej vplyv na úrovni jednotlivca. Hrozba právnych postihov má potenciál nútiť lekárov zmeniť ťažisko rozhodovania z potrieb pacientov na ich samých. Toto ústí do často používaných postupov defenzívnej medicíny – úkony, ktoré pravdepodobne nemôžu zlepšiť pacientov zdravotný stav sú vykonávané len preto, aby z právneho hľadiska zlepšili pohľad na vykonanú prácu lekára. Práve toto podkopáva teóriu zanedbania lekárskej starostlivosti. Nejde tu nevyhnutne o poskytovanie lepších služieb pre pacientov, ale o poskytovanie služieb vo väčšom počte. Podľa výskumu z roku 2004, má hrozba súdnych sporov veľký dopad na niektoré klinické rozhodnutia: jedným z hlavných následkov je jasný nárast rozhodnutí o použití testov ako napríklad MRI/CT, rádioizotopov a skiaskopie. Diskutabilné je do akej miery boli tieto zvýšené použitia testov užitočné a do akej miery zbytočné, či až škodlivé.



Aké sú teda najvhodnejšie postupy pri príprave právnej úpravy v oblasti zanedbania lekárskej starostlivosti? Je možné chrániť pacienta a súčasne aj lekára? Ako môžeme docieliť, že tí, ktorí majú menej finančných prostriedkov neboli vyčleňovaní na okraj takéhoto systému? Spojenie medzi právom a medicínou je miestom byrokracie a konfliktu záujmov tak ako je tomu v každom prípade, v pozadí ktorého stojí stávka o život. Systém každej krajiny má svoje chyby ale i kvality, a vzťah medzi nimi sa javí ako frustrujúca hra ktorej cieľom je dosiahnuť kompromis. Aký je teda tento kompromis, ktorý sa snažíme dosiahnuť? Odpoveď je zložité, ako je aj dôležité.  



Autor: Catherine Chan
Pôvodný text: CHEN, C: Medical Malpractice: How Medical Lawsuits are Won Around the World, Yale Journal of Medicine & Law, April 7, 2011 (pôvodne tu)
Preklad: Tomáš Szalontay
Obrázok: ucps.sk


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