doc. JUDr. Ján D r g o n e c, DrSc.: DOSTUPNOSŤ ZÁKLADNÝCH PRÁV V ZDRAVOTNÍCTVE časť III. | Medicínske právo
              

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doc. JUDr. Ján D r g o n e c, DrSc.: DOSTUPNOSŤ ZÁKLADNÝCH PRÁV V ZDRAVOTNÍCTVE časť III.


 | 25.1.2012 | komentárov: 441

Významným znakom demokraticky organizovaného štátu a demokraticky fungujúcej spoločnosti je participácia jednotlivcov na rozhodovaní o verejných veciach. Tým viac k demokratickému fungovaniu spoločnosti patrí rozhodovanie jednotlivca o sebe samom. V slovenskom zdravotníctve táto samozrejmosť nie je samozrejmá. Jej odmietanie sa zakladá na predstave o odbornej náročnosti a zložitosti zdravotnej starostlivosti, kde pacient zväčša nie je pripravený na to, aby sa podieľal na rozhodovaní o vlastnej liečbe. Bez pochyby tomu tak je. Bežný pacient skutočne nie je pri vstupe do zdravotníckeho zariadenia spôsobilý kvalifikovane posúdiť svoj zdravotný stav a prijať rozhodnutie o zdravotníckom výkone, ktorému sa má podrobiť. V demokratickom a právnom štáte však na základe tejto skutočnosti pred pacientovým rozhodovaním o sebe samom nezatvárajú dvere. Nedostatky vo vzdelaní a informáciách o jeho zdravotnom stave sa prekonávajú pomocou poučenia, ktoré je lekár povinný pacientovi poskytnúť, aby sa pacient mohol plnohodnotne rozhodnúť, akému zdravotnému výkonu sa podrobí.

Obrazok

ZÁKLADNÉ PRÁVO PACIENTA NA SÚKROMIE

     Dohovor o ochrane ľudských práv a dôstojnosti človeka v súvislosti s aplikáciou biológie a medicíny (Dohovor o ľudských právach a biomedicíne) je uverejnený oznámením Ministerstva zahraničných vecí Slovenskej republiky č. 40/2000 Z. z. Národná rada SR s dohovorom vyslovila súhlas 2. októbra 1997, prezident SR ho ratifikoval 22. decembra 1997. Dohovor o ľudských právach a biomedicíne je medzinárodným dohovorom s prednosťou pred zákonmi Slovenskej republiky podľa čl. 154c ods. 1 Ústavy Slovenskej republiky.
     Podľa čl. 5 Dohovoru:
     „Zásah v oblasti zdravia sa môže vykonať iba vtedy, ak osoba, ktorej sa týka, bola informovaná a so zásahom vyjadrila súhlas.
      Pred zákrokom musí byť osoba primerane informovaná o jeho účele a povahe, ako aj o následkoch a rizikách zákroku.
      Príslušná osoba môže svoj súhlas kedykoľvek slobodne zrušiť.“
      Súhlas maloletých a dospelých osôb postihnutých duševnou poruchou alebo chorobou sa za určitých podmienok nahrádza súhlasom zástupcu, inštitúcie alebo osoby, či orgánu ustanoveného zákonom. V takom prípade podľa čl. 6 ods. 4 Dohovoru zástupca, inštitúcia alebo osoba, či orgán dostanú informácie uvedené v čl. 5 za rovnakých podmienok ako chorý.
     Podľa čl. 9 Dohovoru: „U pacienta, ktorý v čase zákroku nie je v takom stave, že môže vyjadriť svoje prianie, treba prihliadať na prianie, ktoré vyslovil s vykonaním zákroku skôr.“
     
     Orgány Európskej únie vyhlásili Chartu základných práv Európskej únie (2007/C 303/01 Úradný vestník Európskej únie). V čl. 3 ods. 2 písm. a) sa uvádza: „V oblastiach medicíny a biológie sa musí rešpektovať najmä slobodný a informovaný súhlas dotknutej osoby za podmienok vymedzených zákonom.“

     K príčinám, pre ktoré sa v slovenskom zdravotníctve veľmi neuznáva požiadavka účasti pacienta na rozhodovaní o zdravotnom výkone, ktorému sa podrobí, patrí aj dlhodobo pretrvávajúca prax, ktorá zvádza k označeniu za tradíciu. Právna prax v období socializmu sa vydala cestou výkladov o tom, že vzťah medzi lekárom a pacientom nie je občianskoprávnym vzťahom, ale špeciálnym administratívnoprávnym vzťahom „kuratívneho charakteru“. Tým sa vytvorilo zdanie, že lekár zdravotnými výkonmi nevstupuje do sféry chránenej právami na ochranu osobnosti podľa Občianskeho zákonníka, kde sa podľa zákona vyžaduje o.i. súhlas oprávnenej osoby so zásahom do telesnej integrity. Pacient sa dostal do postavenia, keď sa od neho očakávalo a vyžadovalo, že sa bez odporu podrobí „kuratívnym aktom“ lekára, prípadne iných zdravotníckych pracovníkov. Súhlas pacienta sa síce vyžadoval, ale iba formálne a podľa osobitného zákona (1) po poučení, ktoré podľa zákona malo byť „vhodné“. Vhodné poučenie sa v zásade dalo naplniť v podobe úplného poučenia o všetkých podstatných okolnostiach zdravotného stavu konkrétneho pacienta, ale táto možnosť nepatrila k obvyklému postupu voči pacientom, najmä keď zákon v značnom rozsahu umožňoval nahradiť „vhodné“ poučenie domnienkou súhlasu pacienta s medicínskym výkonom. (2)
     Po páde socializmu sa do právneho poriadku vniesla zmena zákonom č. 277/1994 Z. z.
     Podľa § 13 ods. 1 zák. č. 277/1994 Z. z.: „Vyšetrovacie a liečebné výkony sa vykonávajú so súhlasom pacienta.“
     Podľa § 13 ods. 2 zák. č. 277/1994 Z. z.: „Na osobitne závažné vyšetrovacie alebo liečebné výkony alebo na výkony závažne meniace spôsob ďalšieho života si lekár vyžiada súhlas pacienta udelený v písomnej alebo inak preukázateľnej forme (pozitívny reverz).“
     Dohovor o ľudských právach a biomedicíne mal povahu prameňa práva s prednosťou pred zákonom č. 277/1994 Z. z. najskôr podľa čl. 11 Ústavy SR a od 1. júla 2011 podľa čl. 154c ods. 1 Ústavy SR v znení ústavného zákona č. 90/2001 Z. z., lebo v čl. 5 výslovne určoval obsahové náležitosti povinného poučenia predchádzajúceho udelenie informovaného súhlasu.
     V súčasnosti táto právna úprava patrí minulosti. Prameňom platného vnútroštátneho práva je zák. č. 576/2004 Z. z. o zdravotnej starostlivosti, službách súvisiacich s poskytovaním zdravotnej starostlivosti a o zmene a doplnení niektorých zákonov v znení neskorších predpisov.
     Podľa § 4 ods. 4: „Na poskytovanie zdravotnej starostlivosti sa vyžaduje informovaný súhlas (§ 6 ods. 4), ak v tomto zákone nie je ustanovené inak (§ 6 ods. 9).“
     Podľa § 6 ods. 4: „Informovaný súhlas je preukázateľný súhlas s poskytnutím zdravotnej starostlivosti, ktorému predchádzalo poučenie podľa tohto zákona. Informovaný súhlas je aj taký preukázateľný súhlas s poskytnutím zdravotnej starostlivosti, ktorému predchádzalo odmietnutie poučenia, ak v tomto zákone nie je ustanovené inak (§ 6b, § 27 ods. 1, § 36 ods. 2, § 38 ods. 1, § 40 ods. 2).“
     Predpokladom súhlasu je predchádzajúce poučenie o zdravotnom stave a rizikách zamýšľaného zásahu do organizmu chorého, na základe ktorého sa vytvára informovanosť (vedomosť) o čiastkových otázkach, ktoré pacient potrebuje vziať do úvahy pri rozhodovaní, či súhlasí s výkonom zdravotnej starostlivosti, ktorému sa má podrobiť.. Povinnosť poskytnúť poučenie zaťažuje ošetrujúceho zdravotníckeho pracovníka. Ošetrujúci zdravotnícky pracovník podľa § 6 ods. 1 je povinný informovať o
- účele,
- povahe,
- následkoch a rizikách
- možnostiach voľby a
- rizikách odmietnutia poskytnutia zdravotnej starostlivosti.
     Popri obsahu poučenia zákon ustanovuje aj spôsob, akým musí ošetrujúci zdravotnícky pracovník splniť svoju povinnosť poučiť pacienta (§ 6 ods. 2). Poučenie je povinný poskytnúť
- zrozumiteľne,
- ohľaduplne,
- bez nátlaku,
- s možnosťou slobodne sa rozhodnúť pre informovaný súhlas
- s dostatočným časom slobodne sa rozhodnúť pre informovaný súhlas.
     Ošetrujúci zdravotnícky pracovník je týmto spôsobom povinný poučiť pacienta primerane rozumovej a vôľovej vyspelosti a zdravotnému stavu osoby, ktorú má poučiť.   
     Zákon neustanovuje formu, v akej má ošetrujúci zdravotnícky pracovník povinnosť poučiť pacienta. Z ustanovenia § 6 ods. 4: „Informovaný súhlas je preukázateľný súhlas s poskytnutím zdravotnej starostlivosti“ možno vyvodiť, že ošetrujúci zdravotnícky pracovník musí poučenie poskytnúť vo forme, ktorá umožní v prípade sporu preukázať, že poučenie poskytol, aj obsah poučenia, ktoré poskytol. Takou formou môže byť ústne poučenie v prítomnosti svedka, písomné poučenie alebo poučenie zaznamenané na nosič zvukového alebo zvukovo-obrazového záznamu.  
     
     Ústava SR vymedzuje vzťah medzinárodného práva a právneho poriadku Slovenskej republiky pomocou doložiek prednosti v relatívne zložitom systéme, lebo doložky prednosti prameňov medzinárodného práva pred zákonmi SR určuje v čl. 7 ods. 4 a čl. 154c ods. 1, pričom prednosť právne záväzných aktov Európskych spoločenstiev a Európskej únie pred zákonmi SR priznáva ďalšie ustanovenie čl. 7 ods. 3 Ústavy SR. V prípade oboch citovaných úprav to znamená, že prednosť Dohovoru o ľudských právach a biomedicíne pred zákonmi SR zakladá čl. 154c ods. 1 ústavy SR za podmienok určených v tomto ustanovení. Charta základných práv Európskej únie podlieha úprave čl. 7 ods. 3 Ústavy SR. Zložitosť úpravy o doložkách prednosti sama o sebe vytvára základ pre spor, ktorý dosiaľ nevstúpil do poskytovania zdravotníckej starostlivosti predovšetkým z dôvodu, že súčasná medicínska prax na Slovensku nie je veľmi poznamenaná úsilím o plnohodnotné dodržovanie práv pacienta. Nejde o druhovú raritnosť právnych vzťahov v zdravotníctve, ale o úkaz kolorujúci záujem spoločnosti o existenciu právneho štátu.
     Prednosť čl. 5 Dohovoru o ľudských právach a biomedicíne pred zákonom č. 576/2004 Z. z. v znení neskorších predpisov možno vylúčiť vo vzťahu k úprave § 6 ods. 1. Obsahové náležitosti poučenia podľa § 6 ods. 1 zákona sú zhodné s obsahovými náležitosťami poučenia podľa čl. 5. Nad rámec medzinárodného štandardu sa podľa § 6 ods. 1 k obsahovým náležitostiam poučenia zaraďuje aj poučenie o možnostiach voľby navrhovaných postupov a poučenie o rizikách odmietnutia poskytnutia zdravotnej starostlivosti. Zákonom sa priznáva aj právo kedykoľvek slobodne odvolať informovaný súhlas (§ 6 ods. 9), čím sa vylučuje prednosť čl. 5 pred zákonom aj v druhej časti úpravy podľa čl. 5.
 
     Ústavný súd uviedol: „Materiálny právny štát sa nezakladá na zdanlivom dodržiavaní práva či na formálnom rešpektovaní jeho obsahu spôsobom, ktorý predstiera súlad právne významných skutočností s právnym poriadkom. Podstata materiálneho právneho štátu spočíva v uvádzaní platného práva do súladu so základnými hodnotami demokraticky usporiadanej spoločnosti a následne v dôslednom uplatňovaní platného práva bez výnimiek založených na účelových dôvodoch.“ (3)
     „Ide o rozhodnutie historického významu, lebo po prvýkrát počas existencie slovenskej štátnosti sa našiel orgán verejnej moci, ktorý pri uplatnení svojej právomoci vo svojom rozhodnutí spojil právny štát s uplatňovaním platného práva a to označil za materiálny právny štát.“ (4) Stručne zhrnuté, schválením zákona nedôjde k naplneniu podstaty a účelu existencie materiálneho právneho štátu. V materiálnom právnom štáte je schválenie zákona iba zavŕšením prípravnej fázy pre uplatňovanie platných a účinných zákonov. Dodržovanie zákonov plní kriteriálnu funkciu pre hodnotenie štátu ako materiálneho právneho štátu; štát, v ktorom sa zákony neuplatňujú, nie je materiálnym právnym štátom bez ohľadu na to, koľko zákonov ročne schváli jeho parlament. Touto záverečnou skúškou prechádzajú v Slovenskej republike s ťažkosťami pravdepodobne všetky rezorty. Zdravotníctvo nepredstavuje výnimku medzi zlými príkladmi, čo na druhej strane nezakladá dôvod ani pre nadšenie a ovácie.
     Keď sa v súbore základných práv relevantných pre poskytovanie zdravotnej starostlivosti upriami pozornosť na právne postavenie pacienta, na uplatňovanie a dodržovanie práv, ktoré pacientovi priznáva právny poriadok Slovenskej republiky, potom je to predovšetkým súhlas pacienta s medicínskymi zásahmi do jeho tela, pri ktorom sa rozžiari výstražná červená kontrolka.
     Informovaný súhlas pacienta je témou medicínskeho práva, ktorej aktuálnosť na celom svete sa spája s minulosťou spred dvoch – troch desaťročí. (5) S plynutím času sa stratila z epicentra záujmu akademického prostredia zaoberajúceho sa medicínskym právom, lebo právne relevantné otázky sa identifikovali a objasnili, stali sa predmetom úpravy v zákonoch aj ich uplatňovania. Pre množstvo štátov sa tak informovaný súhlas presunul z prednáškových siení právnických a lekárskych fakúlt a z parlamentov do súdnych siení, kde sa v konkrétnych sporoch objasňuje, ktoré čiastkové otázky predvídateľných komplikácií a hrozieb a pri akej štatistickej pravdepodobnosti ich vzniku majú byť predmetom poučenia pacienta, ktorý z lekárov má poskytnúť poučenie, ak sa medicínsky výkon uskutoční prostredníctvom tímu lekárov, aké sú rozdiely v účele poučenia pri výkonoch liečebnej povahy a iných výkonoch poskytovaných zdravotníckymi pracovníkmi (napr. pri kozmetických zásahoch) a podobne. (6)
     Na Slovensku to tak nie je. Národná rada SR schválila ustanovenia o informovanom súhlase v zákone, ale do právneho postavenia pacientov nová právna úprava neprenikla. Prax zdravotníckych zariadení sa ubrala cestou typickou pre formálny právny štát, v ktorom sa predstiera, že sa právo dodržuje. Pacienti buď priamo na centrálnom príjme do zdravotníckeho zariadenia, alebo v ambulancii u ošetrujúceho lekára dostanú na podpis tlačivo, podľa ktorého boli poučení, hoci poučenie pred podpisom, ani po podpise tlačiva nikdy nedostanú. Odmietnuť podpis zdanlivo môžu, ale ak tak urobia kvôli uplatneniu svojho práva byť poučeným pacientom, namiesto poučenia im zvýši iba odchod zo zdravotného zariadenia alebo od lekára. Ak sa poberú do iného zdravotníckeho zariadenia, postup bude zhodný. Tlačivo o poučení na podpis, alebo odchod. Táto prax z právneho hľadiska znamená porušovanie základného práva pacienta. Zo spoločenského hľadiska by sa tiež dala hodnotiť ako prevedenie pacienta z radov ľudských bytostí medzi živočíchy sprevádzané degradáciou lekára na veterinára, avšak k takému odsúdeniu verejnou mienkou nedochádza, lebo vrchnostenský princíp, na ktorom sa zakladá vzťah lekár : pacient, vytvára spoľahlivý základ proti akejkoľvek zmene zaužívaného pohľadu na to, či pacient má nejaké práva a čo môže od lekára, resp. od zdravotníckeho pracovníka očakávať a vyžadovať.
     Úkon zdravotníckej starostlivosti (zdravotný výkon) nie je vydaním individuálneho právneho aktu v „administratívnoprávnom vzťahu kuratívneho charakteru“. Je súkromnoprávnym úkonom zasahujúcim do telesnej integrity. Ustanovenia § 6 zákona č. 576/2004 Z. z. majú povahu  lex specialis  k ustanoveniam § 11 a nasledujúcim Občianskeho zákonníka. Ak ošetrujúci zdravotnícky pracovník zasahuje do telesnej integrity pacienta, nestačí, ak pacient s jeho výkonom vysloví súhlas. Udeleniu súhlasu musí predchádzať poučenie v kvalite podľa § 6 zák. č. 576/2004 Z. z. Ak povinný subjekt také poučenie neposkytne, súhlas so zásahom do telesnej integrity pacienta nespĺňa podmienku ochrany osobnosti určenej podľa § 6 zák. č. 576/2004 Z. z., ale ani podľa Občianskeho zákonníka. Zákon č. 576/2004 Z. z. neustanovuje osobitnú sankciu za porušenie § 6. To má za následok vznik možnosti uplatniť všeobecnú zodpovednosť za porušenie osobnostných práv pacienta podľa § 13 Občianskeho zákonníka vrátane náhrady nemajetkovej ujmy v peniazoch podľa § 13 ods. 2 a 3.

Z á v e r

     Uplatňovanie základného práva na bezplatnú zdravotnú starostlivosť na náklady zdravotného poistenia, aj základného práva na súkromie v zdravotníctve na Slovensku sa spája s radom nedostatkov. V prípade základného práva na bezplatnú zdravotnú starostlivosť na náklady zdravotného poistenia na príčine je predovšetkým zlyhávanie štátu, ktorý zdravotné poistenie neorganizuje tak, aby jeho právna úprava slúžila na dosiahnutie účelu základného práva priznaného čl. 40 Ústavy SR. V úprave základného práva na súkromie aktivita štátu vo fáze tvorby práva nestačila na prekonanie zaužívaných pohľadov. K zlyhávaniu dochádza predovšetkým vo fáze aplikácie práva. Napomáhajú mu aj orgány dohľadu nad zdravotnou starostlivosťou, ktoré tolerujú predstierané uplatňovanie práv pacientov, najmä práva na udeľovanie informovaného súhlasu so zdravotnou starostlivosťou. Dlhodobo existujúci stav sa zachováva aj preto, že pacienti nepoznajú svoje práva a v prípade porušenia ich neuplatňujú v rozsahu, ktorý platný právny poriadok dovoľuje.


AUTOR:  doc. JUDr. Ján D r g o n e c, DrSc.- advokát, bývalý sudca Ústavného súdu SR, vedecký pracovník, autor publikácií Ochrana ústavnosti (2010), Základy masmediálneho práva (2008), Základné práva a slobody podľa Ústavy Slovenskej republiky (1999), Ústavné práva a zdravotníctvo (1996), spoluautor monografie Moderná medicína a právo (1982).



ODKAZY:

() zák. č. 20/1966 Zb. o starostlivosti o zdravie ľudu.
(2) Podrobnejšie DRGONEC, J. – HOLLÄNDER, P.: Moderná medicína a právo. Bratislava : Obzor, 1988, s. 91-95.
(3) PL. ÚS 17/08. Zbierka nálezov a uznesení Ústavného súdu Slovenskej republiky 2009, s. 176.
(4) DRGONEC, J.: Ochrana ústavnosti Ústavným súdom Slovenskej republiky. Bratislava : EUROKÓDEX, s.r.o., 2010, s. 287.
(5) Napr.:
BARBER, B.: Informed Consent in Medical Therapy and Research. New Brunswick : Rutgers University Press 1980.
CASSWELL, D. G.: Informed Consent in Canada: Judicial Paternalism Replaces Medical Paternalism. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume I, s. 127-133.
GIESEN, D.: International Medical Malpractice Law. Tűbingen : J.C.B. Mohr (Paul Siebeck) – Dordrecht-Boston-London : Martinus Nijhoff Publishers 1988, s. 252-415.
GRIFFITS, R.: Consent – Scots Law and the Patient´s Right to Know. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume I, s. 355-360.
MARUYAMA, E.: Japanese Law of Informed Consent. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume II, s. 563-566.
NGWENA, Ch. G.: Randomised Therapeutic Trials and the Protection of Patient Autonomy: The Duty of Disclosure. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume II, s. 621-634.
NIEUW, A. D.: Informed Consent. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume II, s. 643-650.
Van OOSTEN, F.F.W.: The Doctor´s Duty of Disclosure and Excessive Information Liability. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume II, s. 901-906.
Van WIJMEN, F.C.B.: Substitute Consent For Incompetent Patients. 9th World Congress On Medical Law. Gent (Belgium) 18-22/VIII/1991. Volume II, s. 913-918.
(6) DRGONEC, J. – CHVISTKOVÁ, J.: Súdne rozhodovanie medicínskoprávnych sporov. Juris index 6/1992. Bratislava : Ministerstvo spravodlivosti Slovenskej republiky 1992, s. 11-40.

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