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Oznámenia o sex. zneužívaní vs. povinná mlčanlivosť


 | 3.3.2010 | komentárov: 298

Ministerstvo zdravotníctva SR zverejnilo odborné usmernenie o postupe poskytovateľov zdravotnej starostlivosti pri oznamovaní prípadov podozrenia zo sexuálneho zneužívania osôb do osemnásť rokov. Usmernenie má slúžiť ako pomôcka pre určenie toho, či u dieťaťa na základe somatických, resp. psychosomatických príznakov došlo k sexuálnemu zneužívaniu. Taktiež upravuje postup poskytovateľa a jeho súčinnosť s príslušným orgánom činným v trestnom konaní. V týchto súvislostiach do popredia vystupujú otázky povinnej mlčanlivosti zdravotníckych pracovníkov a výnimky z jej dodržiavania.

Obrazok Usmernenie rozlišuje špecifické príznaky sexuálneho zneužívania a nešpecifické príznaky sexuálneho zneužívania. Do prvej skupiny sú zaradené poranenia genitálnej oblasti, deflorácia vaginálnej membrány u neplnoletých dievčat, nemenštruačné, nehormonálne krvácanie z genitálií u dievčat, hematómy, opuchy, trhliny, odierky, ragády na genitáliách a ich okolí, tehotnosť maloletého dievčaťa,, rovnako ako aj poranenia u dieťaťa v análnej oblasti prejavujúce sa začervenaním, opuchmi, trhlinami, hematómami, rozšírením žilnej pletene, otvorený anus, ktorý je fyziologicky pri vyšetrení zatvorený a taktiež  prítomnosť výtoku, spermií a slín, bolestivosť pri vyšetrení okolia konečníka a bolestivosť pri chôdzi, sedení a vyprázdňovaní, príznaky pohlavnej prenosnej choroby, poranenia hrdla po orálnom sexe. Nešpecifickými znakmi sú podľa usmernenia rôzne zmeny prejavujúce sa v oblasti psychiky a tiež zmenami sociálneho správania dieťaťa.

Poskytovatelia zdravotnej starostlivosti majú podozrenia na sexuálne zneužívanie nahlásiť telefonicky (!) operačnému stredisku PZ, ak diagnostika dieťaťa potvrdzuje prítomnosť špecifických príznakov sexuálneho zneužívania alebo prítomnosť nešpecifických príznakov, ktoré sú podporené ďalšími zisteniami poskytovateľa týkajúcimi sa celkovej anamnézy dieťaťa.

Ministerstvo napriek nepochybnej snahe o riešenie negatívneho fenoménu sexuálneho zneužívania v usmernení predpokladá súčinnosť rodiča dieťaťa pri vyšetrení, tá však v prípadoch sexuálneho zneužívania s najväčšou pravdepodobnosťou bude odmietnutá. Zdravotná starostlivosť, ktorá zahŕňa aj diagnostiku môže byť poskytnutá len na základe informovaného súhlasu pacienta a pokiaľ sa jedná o neplnoletú osobu (teda nespôsobilú dať súhlas), tak na základe súhlasu jej zákonného zástupcu. Ak teda rodič dieťaťa, ktorý nebol zbavený rodičovských práv odmietne dať súhlas na vyšetrenie dieťaťa, poskytovateľ nie je oprávnený proti jeho vôli vyšetrenie realizovať.  Jeho súhlas nie je oprávnený nahradiť žiaden iný subjekt, iba súd. Zákon o zdravotnej starostlivosti oprávňuje poskytovateľa žiadať súd, aby informovaný súhlas zákonného zástupcu nahradil svojím rozhodnutím (§ 6 ods. 7), no do času rozhodnutia súdu môže vykonať len také zdravotné výkony, ktoré smerujú k zachovaniu života dieťaťa. Diagnostika, ktorá má potvrdiť prítomnosť príznakov sexuálneho zneužívania takú povahu nemá a preto poskytovateľovi neostáva nič iné, len počkať na rozhodnutie súdu.

Usmernenie obsahuje nepresnosť týkajúcu sa možnosti vypovedať o zdravotnom stave dieťaťa, keď uvádza, že v prípade potreby poskytnúť viac informácií o zdravotnom stave dieťaťa môže zdr. pracovníka zbaviť mlčanlivosti Ministerstvo zdravotníctva na základe žiadosti orgánu činného v trestnom konaní.  Kde je hranica, ktorá určuje ktoré informácie môže zdravotnícky pracovník poskytnúť a ktoré už nie, pretože by porušil svoju povinnosť mlčanlivosti? Zároveň sa dostávame do konfrontácie so skutočnosťou, že zákon o poskytovateľoch zdr. starostlivosti neupravuje povinnosť mlčanlivosti pre poskytovateľa, ale len pre zdravotníckeho pracovníka. Zdravotníckeho pracovníka môže okrem samotného pacienta zbaviť mlčanlivosti orgán vydávajúci povolenie na poskytovanie zdravotnej starostlivosti. Tým však nie je len ministerstvo zdravotníctva (ktoré v zmysle usmernenia má zbaviť zdravotníckeho prac. mlčanlivosti), ale pri určitých druhoch zdravotníckych zariadení aj samosprávny kraj. Vyšetrovateľ musí teda v každom prípade osobitne posudzovať, ktorý orgán vydal poskytovateľovi u ktorého zdravotnícky pracovník pracuje povolenie na poskytovanie zdravotnej starostlivosti a na neho adresovať svoju žiadosť.
Ako je zrejmé, otázka oznamovania informácií o podozrení na sexuálne zneužívanie má širší kontext a ťažiskovo sa dotýka všeobecne stanovenej povinnosti mlčanlivosti o informáciách získaných pri poskytovaní zdravotnej starostlivosti s presahom na základné ľudské práva fyzických osôb na ochranu súkromia a fyzickej integrity. Z nášho pohľadu je platná legislatíva upravujúca mlčanlivosť nedostatočná, pretože mlčanlivosťou zaväzuje de facto len zdravotníckych pracovníkov ako fyzické osoby, hoci vo vzťahoch k orgánom štátnej moci mnohokrát vystupujú nielen tieto osoby, ale aj samotní poskytovatelia zdravotnej starostlivosti ktorí sú často právnickou osobou. Zákon o poskytovateľoch by preto mal precíznejšie definovať povinnú mlčanlivosť a podrobne upraviť výnimky z jej dodržiavania. Tá by sa mala okrem zdravotníckych pracovníkov vzťahovať aj na poskytovateľov zdravotnej starostlivosti. 

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