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Zmluvný model vzťahu pacient-lekár a zánik lekárskej profesionality


 | 26.4.2013 | komentárov: 369

Existuje niekoľko koncepcií (modelov), ktoré možno aplikovať na vzťah lekára a pacienta. Jedným z navrhovaných reformných modelov, je zmluvný model vo vzťahu lekára a pacienta a chápanie zdravotnej starostlivosti ako poskytovanie služby. Nižšie publikovaný článok Edwina Huia prináša niekoľko významných protiargumentov proti tomuto poňatiu.

Obrazok V predchádzajúcej diskusii o vzťahu pacienta a lekára bolo uvedené, že informačný/inžiniersky model vzťahu lekára a pacienta vychádza z predpokladu, že lekári majú výhradný prístup k medicínskym ‚faktom‘ a pacienti zase k osobným hodnotám a preferenciám, čo odôvodňuje neobmedzenú autonómiu pacienta v rozhodovaní o liečebnom postupe. Táto úplná separácia pojmov ‘fakt- hodnota‘ má negatívne následky prispievajúce ku komercializácii modernej medicíny, kde sú lekári vnímaní ako poskytovatelia služieb/dodávatelia (alebo predajcovia lekárskej praxe), pacienti ako spotrebitelia, ktorí nakupujú medicínske produkty;  a teda vzťah pacient -lekár je ponímaný ako obchodný alebo zmluvný vzťah.

Moderná liberálna spoločnosť zahŕňa pod zmluvný vzťah široké spektrum ľudských transakcií a interakcií, v ktorých sa rovnocenné subjekty slobodne a dobrovoľne autonómne zaväzujú k určitým záväzkom sledujúc špecifické záujmy, zámery a ciele. V súkromnej lekárskej praxi si lekári udržiavajú väčšiu kontrolu nad typom, rozsahom, miestom a podmienkami poskytovania služieb, zmluvná povaha vzťahu lekár- pacient je  v danom prípade výraznejšia. Avšak dokonca aj v nesúkromných zariadeniach, kde chýba špecifický súhlas, resp. dohovor, kedykoľvek lekár nariadi liečbu alebo starostlivosť o pacienta, je právne viazaný implicitnou zmluvou s pacientom; a následné správanie lekára je taktiež riadené ‘implicitnou zmluvou‘ pre poskytnutie starostlivosti podľa  zavedených štandardov.

Preto common law často považuje zmluvný model za východiskový pre analýzu odškodnenia vo vzťahu lekár- pacient, a takýto prístup nie je bez výhod. Po prvé, dodaním silného zmyslu pre rovnosť, symetriu  a vzájomnosť do vzťahu pacient- lekár zmluvný model podkopáva tradičné viac autoritatívne (ako napr. kňazské alebo rodičovské) modely. Po druhé, pretože zmluvasa riadi  záujmami a cieľmi zmluvných strán a každá strana ‘používa‘ zmluvu v súlade s jeho/jej  vlastným účelom a výhodami, odstraňuje sa tak dominantný prvok filantropie alebo ‘blahosklonnosti ku dobročinnosti‘ často prejavený doktormi vo vzťahu pacient- lekár. Napokon, uvedením alebo odkazom na explicitne stanovené zmluvné podmienky, ktoré sú právne vymáhateľné, model poskytuje formálnu ochranu strán vo vzťahu lekár- pacient. Riešený zmluvný vzťah má ale oveľa viac nevýhod než výhod, a tu sú  niektoré z kľúčových obmedzení, ktoré predkladáme.

Zmluvný model je neadekvátny pre zachytenie  zložitosti vzťahu lekára a pacienta

V bežných komerčných záležitostiach, sú zmluvné vzťahy relatívne jednoduché, napr. prenájom nehnuteľností. Na rozdiel od  vzťahu lekár –pacient, ktorý je zložitý navonok ale aj vo vnútri. Na porovnanie s jednoduchými obchodnými zmluvami, je vzťah lekár- pacient predmetom pôsobenia mnohých sociálnych a inštitucionálnych tlakov zvonka a nekontrolovaný stranami, ktoré predstavujú subjekty vzťahu. Tlak môže vyplývať zo zdravotnej politiky vlády, profesionálnych etických kódexov, právnych predpisov, inštitucionálneho nátlaku, poistenia/ platobných systémov, rodinných /kultúrnych tradícii, osobných hodnôt, náboženskej príslušnosti, atď., a  všetky tieto prvky ovplyvňujú vzťah lekár- pacient svojou zložitosťou  a obmedzeniami. Vzťah lekár- pacient je tiež zložitý, pretože nie sú "zazmluvnení" ako obvyklí kupujúci a predajcovia. Po prvé, pacienti sotva ‘dobrovoľne pristupujú‘ k ‘ nákupu‘ zdravotnej starostlivosti  rovnako ako zákazníci, ktorí dohodou pristupujú ku kúpe auta.
Potreba ‘nákupu’ zdravotnej starostlivosti je nežiaduca a často je dôsledkom akútnej alebo núdzovej situácie,  ktorá neposkytuje dostatočné množstvo času na  vykonanie dôkladnej analýzy dostupných lekárskych služieb, i keď by to bolo možné.  Po druhé, lekári majú takmer úplný monopol na ‘tovar‘ , ktorý pacienti potrebujú a vyjednávacia sila pacientov je viac podobná vzťahu, ktorý má jednotlivec voči verejnému statku než akú má potencionálny kupec auta v obchodnom jednaní. Po tretie, ide o osobný a dôverný vzťah, v ktorom je jedna strana- pacient, chorá, zraniteľná, závislá a bezmocná osoba, ktorej ‘choroba je neodmysliteľne ponižujúca a neľudská a ... ohrozuje telo chorej osoby, dušu a intímne vzťahy.‘
Na rozdiel od toho, druhá strana- lekár, je sebavedomý, nezávislý, vybavený vyšším vzdelaním a skúsenosťami a spoločensky nadradený. Stručne povedané, je vo vzťahu lekár -pacient významná asymetria v moci, znalosti, a postavení. Napokon, aby lekár mohol vykonať vyšetrenie,  pacienti často odhaľujú svoje telo a neochotne prezrádzajú osobné / rodinné informácie ich lekárovi, ktoré sú potom udržiavané v najprísnejšej tajnosti. Inými slovami, vzťah lekára a pacienta je viac komplikovaný než  nákup tovaru alebo služieb na liečbu ochorení. So všetkými nerovnováhami a asymetriami, vzťah lekár -pacient existuje preto, aby opätovne ‘poľudštil’ choré osoby, ktoré nielenže sú telesne postihnuté, ale aj  pre prípad, že sú ohrozené hodnoty, ktoré človek vyznáva. Táto komplexná a hlboko osobná ‘zdravotná transakcia‘ ďaleko presahuje to, čo zmluvná forma môže popísať alebo uvádzať.

Zmluvný model neadekvátne reguluje vzťah lekár-pacient

Zmluvy môžu byť veľmi efektívne pri regulácii obchodných transakcií, kde jednotlivé strany nemajú medzi sebou blízky vzťah  a ktoré sa vyskytujú v bežnom vzťahu kupujúci- predávajúci, ale sú čiastočne nedostatočné, pokiaľ ide o zložitosť vo vzťahu lekár- pacient. Strany v obchodnej zmluve sú napokon motivované svojimi vlastnými záujmami, za predpokladu, že každá z nich by mala chrániť vlastný záujem pred cudzím. To znamená, že záujmy kontrahujúcich zmluvných strán sú potenciálne v konflikte a ich vzťah je protichodnej povahy
Toto je alarmujúco nespravodlivé vo vzťahu lekár- pacient, kde je jedna strana zraniteľnejšia (pacient) a druhá silnejšia, ak nie zdanlivo nadriadenejšia (lekár). V poslednej dobe sú pod  vplyvom zmluvného modelu pacienti taktiež nazývaní "klienti" a lekári zase "poskytovatelia" – tieto termíny však nielenže nezachytávajú význam pojmov "pacient" a "lekár", ale taktiež naznačujú, že poskytovatelia / lekári a klienti / pacienti sa navzájom zaväzujú minimálnou trhovou morálkou, napr. zákaz podvodov a donútenia, tak ako sa zaväzujú automobiloví mechanici voči svojim zákazníkom. Takéto zmluvné / obchodné poňatie vzťahu lekár- pacient je zle vybavené a slabé nato, aby zabezpečilo pacientovi spravodlivé zaobchádzanie.

Okrem toho, v rámci vzťahu lekár-pacient, sa lekári dostávajú do styku s pacientom postihnutým chorobou, zločinom, alebo tragédiou, a ich stav je  nepredvídateľný. Neexistuje žiaden spôsob ako vopred presne a vyčerpávajúcim spôsobom určiť liečebné potreby pacientov, lekári musia byť schopní sa vysporiadať s nepredvídateľnými skutočnosťami. Môžu byť povolaní na výkon služieb, ktoré presahujú tie, ktoré by mohli byt uvedené v zmluve alebo pre ktoré nemôžu byť platení. Lekári tiež nesmú jednostranne odstúpiť od svojich zmluvných povinností (explicitne alebo implicitne), jedine, že by boli pripravení vyúčtovať sa s pacientom za odstúpenie. Zmluvný model vzťahu lekár-pacient podporuje minimalizmus, "znižuje všetko na rovnaké protiopatrenie: nerob pre pacientov viac, než zmluva vyžaduje; vykonávaj uvedené služby za určité poplatky a nijaké iné " a spôsobuje doktorom "veľa neprajníkov, veľa výpočtov, nedostatok spontánnosti, príliš rýchle vyčerpanie prejsť druhú míľu s pacientmi po ceste ich tiesne .... " V skratke, povaha vzťahu lekár –pacient a očakávania zo strany spoločnosti od ich lekárskej profesie ďaleko presahujú regulačnú funkciu obchodnej zmluvy, a súdy preto správne, nie vždy, posudzujú lekárske povinnosti nielen na základe analýzy podľa zmluvného práva.


Zmluvný model neživí alebo neudržiava lekársku profesionalitu a etiku

Najzdrvujúcejším dôsledkom obchodnoprávneho pohľadu  na medicínu a zmluvného modelu  vzťahu lekár-pacient je to, že lekári začnú zabúdať na ich "odborný sľub", ktorý kolektívne dali spoločnosti. Tento profesíjný prísľub služby  a záväzku je vyvážený štedrou podporou spoločnosti, (finančnou alebo inou)  pre  prípravu na povolanie lekára, pre vybudovanie nemocníc na vykonávanie ich povolania, ktoré im umožňujú prax a zdokonaľovanie ich zručností na pacientoch a na stanovenie lekárskej profesie ako exkluzívnej skupiny odborníkov s monopolom praxe a vyššieho spoločenského postavenia. Na oplátku sa skladá "profesíjný sľub" o tom, že lekári budú povinní  zachovávať a chrániť zdravie a blahobyt všetkých členov spoločnosti.


Porušenie tohto sľubu naznačuje, že lekári podvedome odstraňujú zo svojej kolektívnej pamäte veľký dlh voči spoločnosti a pacientom, ktorí  im umožnil stať sa a ostať lekármi. Trhovo chápaná medicína a zmluvný vzťah medzi lekárom a pacientom sú morálne neprofesionálne a neakceptovateľné, pretože usudzujú, že doktori nemajú žiadne záväzky voči  spoločnosti a pacientom. Lekári, sú naopak posmeľovaní veriť tomu, že sa stali lekármi výhradne pre to, že majú vynikajúce intelektuálne kvality a ich profesíjny záväzok k pacientom v praxi je výsledkom ich osobných cností, filantropie alebo altruizmu. Mylne sa domnievajú, že liečenie a starostlivosť o pacienta sú prejavom dobročinnosti, kdežto v skutočnosti by mali byť všetky ich činnosti brané ako oddlžovanie sa voči spoločnosti a občanom za poskytnutie profesionálneho vzdelania, praxe a spoločenského postavenia.

Príslušnosť k profesii  je oboje- dar od spoločnosti a sľub daný lekármi. Morálny základ lekárskej odbornosti je založený na veľkorysosti spoločnosti a vďačnosti lekárov, poznačený prvkami darov, zámeny, zadlženosti, a vzájomnosti. To prezentuje etický model vo vzťahu lekára a pacienta, ktorý je značne citlivejší a vnímavejší voči spoločenskej definícii lekárskeho povolania než jeho definícia ako obchodnej zmluvy. Chápanie vzťahu lekára a pacienta ako čisto obchodného vzťahu je blikajúce výstražné svetlo, ktoré upozorňuje na hroziaci morálny bankrot lekárskeho povolania v dnešnej dobe.

AUTOR: EC Hui, MD, PhD. uverejnené v Hong Kong Med J Vol 11 No 5 October 2005
PREKLAD: Ivana Lukáčová
FOTO: medicineforchange.com




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