Clara pacta, boni amici - „zmluvnosť“ vo vzťahu medzi pacientom a poskytovateľom zdravotnej starostlivosti II. | Medicínske právo
              

Články


Clara pacta, boni amici - „zmluvnosť“ vo vzťahu medzi pacientom a poskytovateľom zdravotnej starostlivosti II.


 | 30.12.2013 | komentárov: 700

Článok sa venuje aktuálnej téme – analýze zmluvného právneho vzťahu medzi pacientom a poskytovateľom zdravotnej starostlivosti. Článok si dáva za cieľ ponúknuť komplexný pohľad na uvádzaný vzťah nielen z hľadiska právneho, či ekonomického, ale v rámci možností aj etického. V prípade vzťahu poskytovateľ – pacient sa jedná sa o špecifickú reláciu, ktorá obsahuje prvky administratívneho, zmluvného, a vykazuje prítomnosť znakov aj spotrebiteľského vzťahu. Slovenská právna úprava s týmto prierezovým chápaním doteraz nerátala. Z tohto dôvodu je nutné opätovné prehodnotenie právneho postavenia medzi pacientom a poskytovateľom zdravotnej starostlivosti. Na základe takéhoto postoja bude možné hlbšie pochopiť špecifickosť tohto vzťahu a prispôsobiť tomu právne využitie zmluvnej slobody v duchu „Clara pacta, boni amici“. Pre jasnejšiu ilustráciu je ponúknutá komparácia právneho vzťahu lekár – pacient a jeho tradícia v podmienkach Slovenskej republiky s vývinom tohto inštitútu v podmienkach vybraných zahraničných štátov, ako aj názory zahraničných autorít.

Obrazok
III. Je pacient spotrebiteľom?


Ktoré znaky sú charakteristické pre vzťahy vznikajúce medzi spotrebiteľom a poskytovateľom služby na trhu? Downie (1988) (22) je názoru, že klasické spotrebiteľské vzťahy sa vyznačujú týmito znakmi:
a)    každá zo strán sa v rámci nadviazaného vzťahu pre seba snaží dosiahnuť maximálny profit (nemusí byť vždy finančnej povahy)
b)    každá zo strán sa riadi informáciami, ktoré jej pomáhajú zhodnotiť benefity potenciálneho zmluvného vzťahu
c)    každá zo strán je slobodná v rozhodovaní, či do právneho vzťahu vstúpi alebo nie
d)    ako poskytovateľ, tak aj spotrebiteľ znáša svoje náklady spojené so zmluvou
e)    tento vzťah sa vyznačuje konkurenciou na strane poskytovateľa služby a to v dvojitom zmysle – poskytovateľ sa snaží vo vzťahu k spotrebiteľovi dosiahnuť čo najväčší zisk a súčasne sa snaží vo vzťahu k iným poskytovateľom pritiahnuť pozornosť čo najväčšieho počtu spotrebiteľov
f)    táto súťaž by mala byť regulovaná právom tak, aby bola férová.

V poslednom období sa globálna ekonomika nachádza v kríze. Tá sa dotkla každej jej súčasti a neobišla ani zdravotnícky sektor. Hartzband (2011) (23) hovorí, že práve nedostatok zdrojov v zdravotníctve generuje úsilie začať efektívne kontrolovať neustále stúpajúce náklady na zdravotnú starostlivosť. To je podľa neho dôvod prečo mnohí ekonómovia a autori zdravotníckych politík navrhujú, aby bol pacient štandardizovaný, a aby bolo možné vyčísliť náklady na starostlivosť o jeho zdravie. Nemocnice by z hľadiska týchto názorov mali fungovať ako moderné továrne na zdravie a archaické označenia doteraz vžitých kategórií ako „lekár“, či „pacient“ by mali byť nahradené novými, ktoré budú korešpondovať s ekonomickou povahou zdravotnej starostlivosti. Zmena jazyka, ktorým sa verbalizujú vzťahy, práva a povinnosti má veľký vplyv aj na ich konečný obsah. Ako ďalej uvádza Hartzband (2011) slová ktorými vysvetľujeme naše roly majú veľkú moc, keďže predstavujú naše očakávania (od nich) a formujú naše správanie. Nielen v našom právnom poriadku, ale aj v zahraničí sa na označenie subjektu, ktorý poskytuje zdravotnú starostlivosť používa pojem poskytovateľ. Jedným z vplyvov na zmenu vzťahu medzi poskytovateľom zdravotnej starostlivosti a pacientom je aj orientácia medicíny viac na služby prevencie ako na služby liečby choroby. Tento jav je viditeľný napríklad v epidemologických opatreniach štátov a v spoločenskom tlaku na zodpovednosť pacienta za svoje zdravie. Uvedené sa v právno-filozofickom vnímaní prejavuje tým, že pokiaľ v medicíne doteraz existovala prevalencia liečebných úloh zdravotná starostlivosť bola vnímaná cez optiku “trhu” predajcu (poskytovateľa). Naopak, ak je dnes medicína orientovaná na prevenciu – čo si vyžaduje proaktívnu úlohu pacienta, je zdravotná starostlivosť vnímaná optikou “nákupcu služby” (pacienta). Práve uvedený moment má podľa Reedera (1972) (24) potenciál robiť z pacienta spotrebiteľa.
Hartzband (2011) ale aj ďalší autori (prevažne z medicínskeho prostredia) k týmto „novým“ pojmom formulujú výhrady, keďže označenia ako poskytovateľ, či spotrebiteľ podľa nich redukujú esenciu vzťahu medzi lekárom a pacientom , ktorý má silnú psychologickú, spirituálnu a ľudskú dimenziu – teda ignorujú aspekty ktoré z medicíny vytvorili nie zamestnanie ale povolanie, v ktorom altruizmus prevyšoval osobné ciele lekára (25).  Uvedené vplýva aj na posudzovanie ďalších aspektov vzťahu pacient – poskytovateľ/lekár, a to či už na obsah zmluvných dojednaní medzi nimi, alebo na zodpovednosť za vady a spôsobenú škodu (26).

Tým, že sa Slovensko nachádza v európskom priestore je potrebné otázku postavenia pacienta ako spotrebiteľa vnímať nielen z „národného“, ale aj z „európskeho“ uhlu pohľadu. Zámerom tohto príspevku nie je podrobiť vývoj európskeho spotrebiteľského práva podrobnej analýze, a preto je ďalší text smerovaný iba k stručnej ilustrácii základných aspektov ochrany spotrebiteľa.

Ochrana spotrebiteľa je jednou zo stabilných politík Európskej Únie (ďalej ako „EÚ“) a tejto oblasti je vyčlenený  široký priestor. Dá sa predpokladať, že uvedený trend bude pokračovať a súčasne s tvorbou novej legislatívy sa bude prehodnocovať aj rozsah ochrany spotrebiteľa (v prospech spotrebiteľa), ako aj samotný obsah pojmu „spotrebiteľ“. Rozvoj a implementácia právnej úpravy ochrany spotrebiteľa v EÚ je postupným procesom, ktorý napreduje v paralele s vývojom úpravy vnútorného trhu. Podstatnými míľnikmi v tejto oblasti je uzatvorenie dôležitých zmlúv týkajúcich sa EÚ (Rím 1957, Maastricht 1992, Amsterdam 1997, Lisabon 2007) (27). Za zmienku stojí Prvý program ochrany spotrebiteľa (pod taktovkou EÚ) z roku 1975, ktorý upravoval päť základných spotrebiteľských práv:
a)    právo na ochranu zdravia
b)    právo na bezpečnosť
c)    právo na ochranu ekonomických záujmov spotrebiteľa
d)    právo na informácie a na vzdelanie
e)    právo byť vypočutým (28)

Program ochrany spotrebiteľa bol aktualizovaný do jeho poslednej verzie pokrývajúcej roky 2014 – 2020 (COM(2011) 707 final). V roku 2011 bola prijatá dlho pripravovaná  smernica Európskeho parlamentu a Rady č 2011/83/EÚ o právach spotrebiteľov, ktorou sa mení a dopĺňa smernica Rady 93/13/EHS a smernica Európskeho parlamentu a Rady 1999/44/ES, a ktorou sa zrušuje smernica Rady 85/577/EHS a smernica Európskeho parlamentu a Rady 97/7/ES. Napriek odvážne formulovaným cieľom táto smernica, ktorú sme povinní transponovať do národnej úpravy do 13.12.2013, nesplnila očakávania a nepriniesla vo vzťahu ku požadovanej komplexnosti ochrany spotrebiteľa výraznejší benefit (29). Ako sa smernica č. 2011/83/EÚ stavia k službám zdravotnej starostlivosti (aby sme nepredbiehali) povieme na záver tejto kapitoly.
Ochranu spotrebiteľa na Slovensku zabezpečuje viacero právnych predpisov zákonnej, ako aj podzákonnej sily. Medzi základné predpisy patrí zákon č. 250/2007 Z.z. o ochrane spotrebiteľa a o zmene zákona Slovenskej národnej rady č. 372/1990 Zb. o priestupkoch v znení neskorších predpisov (ďalej ako „Zákon o ochrane spotrebiteľa“) (30), ale aj časť Občianskeho zákonníka týkajúca sa spotrebiteľských zmlúv (§§ 52 - 54). Podľa definície spotrebiteľa v § 52 ods. 4 Občianskeho zákonníka (31), ako aj podľa § 2 písm. a/ Zákona o ochrane spotrebiteľa (32) pacient spĺňa formálne kritéria na to, aby sme ho označili za spotrebiteľa:
a)    je fyzickou osobou, ktorá
b)    používa služby (zdravotnú starostlivosť) pre svoju potrebu (nie v rámci svojej podnikateľskej činnosti).
Stačí splnenie formálnych požiadaviek na to, aby sme pacienta pasovali do pozície spotrebiteľa? Odpoveď na túto otázku závisí od niekoľkých premenných – kvalitatívnych (ani nie tak formálnych) charakteristík spotrebiteľa.
 
V prvom rade spotrebiteľa spotrebiteľom robí to, že kupuje tovar alebo službu od predajcu/poskytovateľa. Snaží sa využiť informácie a svoje schopnosti, aby kúpa bola dobrou voľbou, snaží sa za čo najvyššiu kvalitu zaplatiť čo najnižšiu cenu, ktorú je nakoniec povinný aj uhradiť. Spĺňa dnešný pacient tieto charakteristiky, umožňuje mu systém byť takýmto spotrebiteľom a vôbec, mal by pacient takýmto spotrebiteľom byť?
Medzi konceptom osoby v tradičnom postavení pacienta a jej postavením ako spotrebiteľa je výrazný obsahový rozdiel. Osoba (pacient - spotrebiteľ) ktorá má v záujme získať zdravotnú starostlivosť v rámci svojho spotrebiteľského správania zvažuje náklady tejto služby voči očakávaným benefitom a hľadá poskytovateľa, ktorý jej túto službu poskytne v najlepšej kvalite. Postavenie tradičného pacienta má opačný náboj – je to postavenie trpiacej osoby, závislej na rozhodovaní iných osôb a spoliehajúcej sa na nimi odporučanú starostlivosť (33). Pnutie medzi statusom tradičného pacienta a statusom pacienta - spotrebiteľa má pomerne dlhú históriu (34) a uvažovanie o pacientovi, ktorý by mal byť schopný rozhodovať o zdravotnej starostlivosti, ktorá sa mu má poskytnúť bolo zväčša ovplyvnené rapídnym nárastom nákladov na zdravotnú starostlivosť. V USA sa koncepcia pacienta ako spotrebiteľa začala na poli medicínskeho práva a etiky významnejšie formovať na začiatku 60-tych rokov 20. storočia (35) a to v súvislosti s hnutím organizácií pacientskych práv voči paternalizmu vo vzťahu medzi lekárom a pacientom (36). Spotrebiteľské vnímanie role pacienta opätovne nabralo na sile v 80-tych rokoch 20. storočia a to opätovne v súvislosti so snahou eliminovať a kontrolovať stále sa zvyšujúce výdavky na zdravotnú starostlivosť (37). V Anglicku pacientske spotrebiteľské hnutia svoju angažovanosť výrazne manifestovali v priebehu 80-tych a 90-tych rokov. V časopise Which? sa pravidelne uverejňovali prieskumy ktoré sa týkali čakacích lehôt u jednotlivých poskytovateľoch, kvality zdravotníckych zariadení, či výdajní zdravotníckych pomôcok. Cieľom týchto spotrebiteľských organizácii bolo vytvoriť priestor pre pacienta, ktorý bude schopný sám rozhodnúť čo je pre neho vhodné, a ktorý bude mať na základe potrebných informácií od poskytovateľa efektívnu možnosť voľby (38).

Podľa niektorých autorov (musíme podotknúť že prevažne z USA) bol pacient od počiatku spotrebiteľom. Pred tým ako sa súčasťou systému zdravotnej starostlivosti stalo zdravotné poistenie pacient „nakupoval“ zdravotnú starostlivosť obdobne ako iné druhy služieb či tovarov. Tento moment je v štátoch, ktoré nemajú nastavený systém verejného zdravotného poistenia tak ako Slovensko v istej podobe prítomný dodnes. Hall (2008) uvádza, že v roku 2008 v USA až 15% pacientov vzhľadom na to že neboli zdravotne poistení „nakupovalo“ zdravotnú starostlivosť priamo. Moment platby a rozhodovanie o tom, kde a ako ju vynaložiť je prítomný aj prostredníctvom rozličných druhov nepovinného pripoistenia a v šedom priestore aj v podobe extra platieb, či dokonca úplatkov pre zdravotnícky personál (39). Môžeme povedať, že úhrada za poskytovanie zdravotnej starostlivosti (či už cez zdravotné poistenie alebo priamo) je najvýraznejším spotrebiteľským aspektom zdravotnej starostlivosti (40).  Pokiaľ sa zamyslíme nad povahou právnych predpisov upravujúcich postavenie spotrebiteľa a nad právnymi predpismi upravujúcimi postavenie pacienta zistíme, že vychádzajú akoby z rôznych právno-filozofických prepozícií. Mariner (2004) je názoru, že je to spôsobené tým, že úprava postavenia pacienta a jeho práv je koncipovaná na princípe zhodnotenia jeho jedinečného statusu vo vzťahu k poskytovateľovi zdravotnej starostlivosti (koncept statusu), pričom úprava spotrebiteľského postavenia je budovaná na princípe “zmluvnej voľnosti”(41) cez ktorú sa realizuje nadobúdanie tovaru, či služieb.

Motívom pacienta – spotrebiteľa pre jeho vstup do zmluvného vzťahu s poskytovateľom zdravotnej starostlivosti je jednoducho povedané záujem na zachovaní hodnoty – zdravia. Bezprostredným dôvodom môže byť choroba (záujem na vyliečení), ale aj prevencia (záujem vyhnúť sa zhoršeniu zdravia), či záujem na vylepšení určitých telesných znakov pacienta (plastická chirurgia – výkony neliečebnej povahy, skrášľovacie zákroky a podobne) (42). Jednou z podstatných znakov spotrebiteľskej zmluvy je dohoda o cene služby. Aj v tomto smere má zmluva, na základe ktorej sa poskytuje zdravotná starostlivosť svoje špecifiká.  Vo všeobecnosti sa pacienti neradi pýtajú na ceny, aj keď s nimi mnohokrát nesúhlasia (napríklad v prípade priamych platieb, či rôznych poplatkov vyberaných pri návšteve ambulancie). Aj keby pacient poznal odhad nákladov zdravotnej starostlivosti, iba pacient ktorý presne vie čo potrebuje, vie zvážiť plusy a mínusy u jednotlivých poskytovateľoch. Je však možné vopred kalkulovať koľko zdravotná starostlivosť bude stáť? Možno v jednoduchých prípadoch áno, ale v zložitejších situáciách to viac-menej neprichádza do úvahy. Pri zvažovaní ceny hrá dôležitú úlohu aj stav, v ktorom sa pacient nachádza. Ak sa chceme zbaviť bolesti sme v danej situácii ochotní urobiť čokoľvek, a to aj z finančného hľadiska. Povaha služby, ktorá sa pacientovi poskytuje, ako aj povaha vzťahu medzi ním a lekárom alebo len čiastočná schopnosť rozumieť svojmu zdravotnému problému a jeho riešeniu a v neposlednom rade fenomén bolesti, strachu a zraniteľnosti, ktoré sú s chorobou často úzko spojené sťažujú pacientovi, aby „nakupoval“ zdravotné služby porovnateľným spôsobom, ako nakupuje iné druhy tovaru (43). Teda cena v prípade zdravotnej starostlivosti nie je výsledkom slobodného negociovania, ale na to, či ju pacient akceptuje vplýva mnoho ďalších faktorov (44). Uvedené sa vymyká štandardnému zvažovaniu výhodnosti ceny, tak ako tomu je u spotrebiteľských zmlúv.

Ako sme už spomenuli, pacient je vzhľadom na svoju chorobu a zdravotné ťažkosti zraniteľným a nie je tradičným “obchodným” partnerom, ktorý by bol schopný samostatne získať potrebné informácie o svojom probléme (a s nimi efektívne pracovať) a v rámci rozhodovania o prijatí/neprijatí zdravotnej starostlivosti nie je zďaleka nezávislým (45) (napr. položme si otázku, ako ovplyvňuje strach, neistota, bolesť vôľu pacienta?). Uvedený moment ho voči poskytovateľovi stavia do slabšieho postavenia. Podľa Hondiusa (2012) práve spotrebiteľské právo ukázalo, že „pacta sund servanda“ nie je jedinou paradigmou zmluvného práva, a že rovnako dôležitými charakteristikami je ochrana slabšej strany, ktorá v zmluvnou vzťahu medzi spotrebiteľom a podnikateľom ťahá za kratší koniec (46). To podľa neho značí, že princíp zmluvnej voľnosti nebol zásadami spotrebiteľského práva nahradený, ale doplnený o nové rovnako platné zásady (47).

Sme názoru, že pacient, ktorý priamo či nepriamo platí za zdravotnú starostlivosť získava v určitom kontexte postavenie spotrebiteľa a je voči poskytovateľovi zdravotnej starostlivosti v slabšom postavení. Je to dané na základe viacerých dôvodov, v prvom rade na základe toho, že lekár má voči nemu akýsi monopol informácií (48) (a monopol na poskytnutie toho čo pacient potrebuje) a špeciálnej kompetencie „liečiť“, ako aj tým, že pacient sa vzhľadom na svoj zdravotný problém prirodzene ocitá v polohe charakteristickej zraniteľnosťou a závislosťou (49). Jeho slabšiu pozíciu zvýrazňuje dokonca aj samotná rola lekára, ktorý je opakom pacienta – v konkrétnej situácii je lekár tou osobu, ktorá je kompetentná, nezávislá, vybavené skúsenosťou a potrebnou zručnosťou a v neposlednom rade aj určitým sociálnym postavením (50). Je zjavné, že aj dnes ostáva inherentnou súčasťou vzťahu medzi lekárom a pacientom informačná a vedomostná asymetria – a to bez ohľadu na snahu postaviť pacienta do centra rozhodovania o zdravotnej starostlivosti, či na zmluvný základ ich vzťahu (51). Zmluvnú voľnosť, ktorá je typická pre súkromnoprávne vzťahy /medzi ktoré podľa nášho názoru zmluva o poskytovaní zdravotnej starostlivosti patrí (52)/, vo vzťah pacient – poskytovateľ modifikujú mnohé osobitné premenné.

Osobitnú povahu zdravotníckych služieb (v kontexte ochrany spotrebiteľa) si zjavne uvedomuje aj európsky normotvorca, ktorý v rámci zásad (č. 30) smernice č. 2011/83/EÚ uviedol že (cit.): „Zdravotná starostlivosť si z dôvodu svojej technickej komplexnosti, významu pre služby všeobecného záujmu a rozsiahleho financovania z verejných zdrojov vyžaduje osobitné právne predpisy... Ustanovenia tejto smernice nie sú vhodné pre zdravotnú starostlivosť, ktorá by preto mala byť z rozsahu jej pôsobnosti vyňatá.“  Z vecnej pôsobnosti smernice sú v zmysle Čl. 3 ods. 3 psím. b/ vylúčené zmluvy (cit.): „...o zdravotnej starostlivosti, ako je definovaná v článku 3 písm. a) smernice 2011/24/EÚ, bez ohľadu na to, či je, alebo nie je poskytovaná v zdravotníckych zariadeniach“.

Otázku, či je pacient spotrebiteľom môžeme v nadväznosti na vyššie uvedené zodpovedať tak, že aj keď pacient za zdravotnú starostlivosť platí (nepriamo/priamo) a tá je pre neho službou, nie je podľa nášho názoru spotrebiteľom v pravom zmysle slova. Skôr by ho vystihovalo pomenovanie „kvázi spotrebiteľ“, teda zmluvná strana, ktorá by síce mala byť k svojmu zmluvnému partnerovi v rovnocennom postavení, ale ktorá si z osobitných dôvodov zasluhuje špeciálnu ochranu práva. Na druhej strane je tiež možné konštatovať, že ani poskytovateľ zdravotnej starostlivosti nie je „štandardným“ dodávateľom služby. Ako hovorí Hall (2008) pacient je cudzincom v cudzej krajine, zraniteľným vďaka svojej chorobe. V dôsledku situácie, v ktorej sa nachádza si chtiac či nechtiac s lekárom vytvára vzťah závislosti (53) a dôvery v neho a ďalších zdravotníckych pracovníkov, ktorí mu poskytujú starostlivosť. Tento osobitný obsah vzťahu v ktorom sa poskytuje zdravotná starostlivosť odôvodňuje, aby právo formulovalo zásady ochrany nielen osobnostných práv pacienta, ale aj ochrany jeho ekonomických záujmov (54).  Súčasne nám však špecifický vzťah medzi poskytovateľom a pacientom znemožňuje automaticky na jeho úpravu a reguláciu použiť všeobecné predpisy spotrebiteľského práva.



IV. Zmluva medzi poskytovateľom a pacientom a jej význam


Má vôbec význam, aby poskytovateľ svoj vzťah voči pacientovi formalizoval v podobe písomnej zmluvy? Nie je to len ďalšia z byrokratických požiadaviek nemocničných právnikov, ktorí nevedia o čom zdravotná starostlivosť vlastne v praxi je? Naša odpoveď je jednoduchá: Zmluva zmysel má. Zmluva v našom ponímaní  nie je len text, ale je vyjadrením postavenia, rovnocennosti, záujmu veci riešiť transparentne. Dobrá zmluva o zdravotnej službe vyjadruje odhodlanie poskytovateľa napĺňať úlohu medicíny. Dobrá zmluva robí z pacienta partnera, bez aktívnej spolupráce ktorého sa liečba len veľmi ťažko stretne s úspechom. Dobrá zmluva je o etike. Rovnako dôležitý ako obsah zmluvy je aj spôsob rokovania o jej uzavretí. Je zaujímavé, že obsah zmluvy vypovedá aj o spôsobe využitia „kompetencie“ / „moci“, s ktorou disponuje každá z jej zmluvných strán (a s ktorou do zmluvného vzťahu vstupuje). Moc môžeme definovať ako schopnosť niečo urobiť, alebo vykonať. V medziľudských vzťahoch v spoločnosti moc vyviera z troch základných zdrojov: sily, materiálnych možností/zdrojov a poznania. Väčšina ďalších foriem moci pochádza z týchto troch. Napríklad štátna autorita sa opiera aj o potenciálne vynútenie prostredníctvom silových zložiek štátu. Materiálna sila zahŕňa kontrolu nad materiálnymi zdrojmi a možnosťou rozhodovať o ich využití. Moc poznania, ktorá sa stále viac stáva základnou „menou“ súčasnosti  závisí od získavania a výmeny vedomostí a informácií (55).

Literatúra opisuje viacero modelov vzťahu lekár – pacient, ktoré sa istým spôsobom verbalizujú aj v texte zmluvy. Jedným z extrémnych prípadov je, keď lekár robí rozhodnutia o liečbe pacienta bez zainteresovania samotného chorého, teda keď ich robí z moci svojho postavenia /tzv. paternalistický model (56)/. Ďalším modelom je lekár v pozícii pacientovho agenta, teda situácia, keď rozhoduje na základe preferencií, ktorú mu pacient oznámil (57). Posledným z modelov je rozhodovanie o zdravotnej starostlivosti, ktoré robí pacient úplne samostatne a lekár v ňom vystupuje ako subjekt, ktorý len odovzdáva informácie na základe ktorých sa pacient sám rozhoduje (58). Medzi týmito základnými modelmi existuje viacero hybridných modelov kombinujúcich prvky jednotlivých z nich.

Zmluva teda okrem svojho obsahového zamerania slúži zo strany poskytovateľa k pacientovi ako dôležitý komunikačný nástroj, ktorým má poskytovateľ možnosť vyjadriť svoje nastavenie, záväzky, úctu k pacientovi a v neposlednom rade aj hodnoty. Uvedený moment bude v čase, kedy si pacienti starostlivejšie vyberajú poskytovateľov a sú ochotní za služby platiť naberať stále viac a viac na vážnosti.

 V zmluve by si poskytovateľ s pacientom mali upraviť nasledovné okruhy:

a)    špecializáciu – odbor zdravotnej starostlivosti ktorá sa má poskytovať
b)    vymenovanie práv, ktoré pacient a poskytovateľ zdravotnej starostlivosti majú, zameranie na efektívne stanovenie kooperácie medzi zmluvnými stranami
c)    spôsob komunikácie – objednávanie na vyšetrenia (zásady), riešenie otázok, spôsob vybavovania žiadostí o sprístupnenie zdravotnej dokumentácie
d)    v prípade väčších zdravotníckych zariadení otázku a podmienky výberu konkrétneho zdravotníckeho pracovníka
e)    zásady ochrany osobných údajov pacienta – režim sprístupňovania informácií o pacientovi (rozdelenie podľa vzťahu k pacientovi – verejnosť, blízke osoby, rodina)
f)    zodpovednosť za škodu na vnesených veciach – opätovne podľa druhu zdravotníckeho zariadenia a typu zdravotnej starostlivosti
g)    náklady zdravotnej starostlivosti a ďalších služieb, ktoré poskytovateľ (aj ako podnikateľ) pacientovi môže ponúknuť
h)    dohodu o postupe pri mimosúdnom riešení vzniknutých sporov, zásady komunikácie v takýchto prípadoch. Uvedené by vzhľadom na súčasný stav legislatívy malo obsahovať aj úpravu povinnej mlčanlivosti v prípade uplatnenia nárokov voči poskytovateľovi, možnosť zúženia tejto mlčanlivosti (resp. v prípade poskytovateľa povinností súvisiacich s nemožnosťou poskytnúť za účelom obrany informácie o liečbe pacienta právnemu zástupcovi a podobne). Dohoda o riešení sporov môže obsahovať aj určenie mediátora.

 Premetom zmluvy by podľa nášho názoru nemali byť údaje, ktoré sa pacientovi poskytujú v rámci informovaného súhlasu pred konkrétnym zdravotným výkonom. Účelom nie je aby bola zmluva zložitá, naopak, jej úprava a štruktúra by mala byť pre pacienta (ako aj pre poskytovateľa) zrozumiteľná  a mala by mu byť pomôckou v komunikácii s poskytovateľom. Nastavenie obsahu zmluvy sa líši od druhu poskytovateľa zdravotnej starostlivosti (60) a nie je vylúčené, aby poskytovateľ uzatvoril s pacientom aj viacero druhov kontraktov. Poskytovateľ by si mal pri koncipovaní jej obsahu uvedomiť, že nastavením jasných a zrozumiteľných pravidiel môže eliminovať viaceré druhy rizík, ktoré sa týkajú hlavne diskomunikácie a nesprávneho manažmentu pacienta. Súčasťou zmluvného dojednania s pacientom (v širšom zmysle) môže byť aj dohoda o alternatívnom riešení sporov – cez rozhodcovský súd. Rozhodcovské doložky sú v poslednej dobe súdnou praxou často spochybňované, a preto je potrebné, aby bola rozhodcovská doložka – pokiaľ o ňu má poskytovateľ a pacient záujem – uvedená v osobitnej rozhodcovskej zmluve, teda aby bola dojednaná oddelene od hlavného kontraktu. Koncepcia zmluvy musí rešpektovať kogentné ustanovenia Zákona o zdr. starostlivosti ako aj všeobecné inštitúty občianskeho práva – ako napríklad zodpovednosť za škodu, či úpravu obsiahnutú medzinárodných dohovorov týkajúcich sa ľudských práva a biomedicíny.


V. Záver

Zmena paradigmy o postavení lekára a pacienta prináša množstvo otázok. Tie sú žiaľ z určitej časti výsledkom neefektívnej komunikácie medzi právnymi teoretikmi a tvorcami zdravotných politík. Súčasne sa do úvahy v dostatočnej miere neberie prax, reálne vzťahy, ktoré nie je možné zmeniť šmahom ruky, a ktoré vo svojej podstate nereagujú automaticky na zmenu len ekonomického, či právneho nastavenia zdravotného systému. Ako sme v predošlom texte naznačili, s týmto javom nie sú spojené len právne otázky, ale aj základné otázky vzťahové otázky lekár – pacient. Hartzband (2011) (61), sa obáva, že v rýdzo ekonomickom spôsobe vnímania subjektov zdravotnej starostlivosti nie je ani náznak pôvodnej role lekára ako učiteľa so špeciálnym vzdelaním, ktorý pomáha pacientovi pochopiť dôvody a riziká jeho choroby a možností jej liečby, ako ani potrebné ocenenie úlohy zdravotnej sestry, ktorej blízka prítomnosť je nevyhnutná pre liečbu pacienta. Špecifikami zmluvného vzťahu, ktoré ho odlišujú od bežného spotrebiteľského kontraktu je dôvernosť, možnosť poskytnutia starostlivosti len na základe informovaného súhlasu (62), mlčanlivosť o zdravotnom stave pacienta, či celkový dôraz na úctu voči pacientovi ako jedinečnej osobe. V rozhodnutí Petrillo v. Syntex Labs (63) súd zdôraznil, že medzi lekárom a pacientom nie je uzatvorená obyčajná zmluva „technického“ charakteru, na základe ktorej by lekár mal povinnosť liečiť a pacient platiť. Podstatou ich zmluvného vzťahu je vnútorný záväzok vznikajúci v momente, keď lekár začne pacienta liečiť, ktorý zaväzuje lekára aby v rámci starostlivosti postupoval v záujme o dosiahnutie dobra pre pacienta. Súčasne pacient by mal byť na základe intervencie lekára schopný uveriť, že lekár bude naozaj sledovať jeho dobro a tým potvrdzovať „posvätnú“ povahu ich vzájomného vzťahu.

Hall (2008) si kladie dôležitú otázku (cit.): „Ako by malo právo reagovať v situácii, keď sa z pacienta stáva spotrebiteľ na „bezohľadnom“ trhu? Mal by byť pacient vnímaný ako štandardný (každý iný) spotrebiteľ a poskytovateľ zdravotnej starostlivosti ako každý iný predajca/poskytovateľ služby? Má právo ich zmluvnému vzťahu uvoľniť priestor, alebo ho má regulovať odlišne od iných spotrebiteľských zmlúv?“ (64)

Povaha služby ktorá sa pacientovi poskytuje, ako aj povaha vzťahu medzi ním a lekárom, či (len) čiastočná schopnosť rozumieť svojmu zdravotnému problému a jeho riešeniu a v neposlednom rade fenomén bolesti, strachu a zraniteľnosti ktoré sú s chorobou často úzko spojené sťažujú pacientovi aby „nakupoval“ zdravotné služby porovnateľným spôsobom, ako nakupuje iné druhy tovaru (65). Uvedené aspekty súc neoddeliteľne spojené s chorobou a pacientom znemožňujú nielen dnes, ale aj do budúcna aby bol pacient považovaný za klasického spotrebiteľa.  Na dôvažok, ako  hovorí Campbell (1990) bez ohľadu na to, či súčasné nastavenie poskytovania zdravotnej starostlivosti robí z pacienta spotrebiteľa alebo nie, uvedené samo o sebe nezvýši jej kvalitu ani možnosť výberu (66). To že pacient nie je klasickým spotrebiteľom potrhuje aj fakt, že je oprávnený ovplyvniť zdravotnú starostlivosť (druh) len v určitom rozsahu. Poskytovateľ nie je povinný (dokonca sme názoru že ani nesmie) vyhovieť akejkoľvek požiadavke pacienta o zdravotný výkon, ak tento výkon nie je z jeho odborného pohľadu v prospech pacienta.

Sme názoru, že bez ohľadu na obmedzenie zmluvnej voľnosti v obsahu zmluvy by mal byť na strane poskytovateľa záujem prostredníctvom zmluvy upraviť rizikové situácie, do ktorých sa jeho vzťah voči pacientovi môže dostať. Zmluva sa môže týmto stať jedným z dôležitých prostriedkov riadenia rizika spojeného s poskytovaním zdravotnej starostlivosti aj keď riziko vzniku zodpovednosti za škodu absolútne vylúčiť (67) nemôže /i keď ho môže eliminovať (68)/.  Zmluvné nastavenie vzťahu medzi poskytovateľom a pacientom  nemôže byť v prospech len niektorého z nich. V zmluve by mala byť okrem povinnosti (záväzku) poskytovateľa “liečiť” zakotvená aj povinnosť pacienta rešpektovať terapeutické odporúčania svojho lekára (69). Celkový obsah zmluvy by mal byť charakteristický vyjadrením rešpektu k pacientovej autonómii, vzájomnou dôverou a zodpovednosťou (70). I keď sa penetrácia zmluvnosti do úpravy poskytovania zdravotnej starostlivosti  môže javiť zvláštna, je výzvou pre ďalšie formovanie vzťahu medzi lekárom/poskytovateľom. Jasné dohody a vysvetlenie princípov spolupráce uľahčuje komunikáciu a môže pomôcť predísť rôznym nepríjemnostiam. Aj v rámci zdravotnej starostlivosti teda platí „clara pacta, boni amici“.






AUTORI: JUDr. Ivan Humeník, PhD., Mgr. Tomáš Lipták
Článok bol uverejnený v publikácii Aké princípy vládnu zdravotníctvu? - Humeník, I., Zoláková, Z. (eds.)



Poznámky pod čiarou


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(31) Ustanovenie § 52 ods. 4 Občianskeho zákonníka (cit.): „Spotrebiteľ je fyzická osoba, ktorá pri uzatváraní a plnení spotrebiteľskej zmluvy nekoná v rámci predmetu svojej obchodnej činnosti alebo inej podnikateľskej činnosti.“
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(62) Až na zákonom definované výnimky, ktoré nie je možné svojvoľne rozširovať. Pozri napr. aj samotnú dikciu § 6 ods. 9 Zákona o zdr. starostlivosti.
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(65) Porovnaj HALL, Mark A., SCHNEIDER, C. E. Patients as consumers: courts, contracts, and the new medical marketplace. In Michigan Law Review, Vol. 106, 2/2008, p. 643 – 689, str. 646.
(66) CAMPBELL, A. V. The patient as consumer. In British Journal of General Practice, 1990, 40, 131-133, str. 132.
(67) Z rozhodovacej praxe USA napr. nedávny prípad  Reid v. Altieri, 950 So.2d 518, 520–524 (Fla. Dist. Ct. App. 2007).
(68) Na Slovensku je zatiaľ vzácnosťou keď je vzťah medzi poskytovateľom a pacientom upavený zmluvou, ktorá by pamätala aj na špeciáne aspekty konkrétnej liečby. Dohoda o zäväzku pacienta riadiť sa liečebným režimom, ktorý je v zmluve zrozumiteľne formulovaný môže v prípade riešenia náhrady škody na zdraví byť na prospech poskytovateľa. Pozri mutatis mutandis  prípad Stepakoff v. Kantar, 473 N.E.2d 1131, 1133–1137 (Mass. 1985) v ktorom súd neuznal poskytovateľa zodpovedným za smrť suicidálneho pacienta aj na základe toho, že mal s pacientom uzatvorený kontrakt opisujúci čo má pacient robiť keď ho prepadnú suicidálne nutkania.
(69) Respektíve skôr by sme mohli povedať že zloženou synalagmou voči záväzku poskytovateľa liečiť je jeho právo na odmenu, ktorú mu uhrádza zdravotná poisťovňa pacienta. K tomu pozri aj HYMAN David A., SILVER, Charles S. The Poor State of Health Care Quality in the U.S.: Is Malpractice Liability Part of the Problem or Part of the Solution?, 90 CORNELL L. REV. 893, 966 (2005)
(70) Porovnaj SIEGLER, Mark. Searching for Moral Certainty in Medicine: A Proposal for a New Model of the Doctor-Patient Encounter. In Bulletin of the New York Academy of Medicine. 1981, 57(1), 56–69.




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