Natisni vsebino

2.9. Health care

Annual Report 2001

2.9. Health care

We received 40 complaints in the area of health care, as opposed to 18 in the previous year. This year, too, the virtually common denominator is the allegation of irregularity and errors in treatment procedures. Several complaints were made because of the waiting required in order to be next in line for the desired health service. There are also problems once again being faced by patients and those close to them in exercising the right to access their health documentation. In several cases dealt with we gained the impression that the attitude towards the patient was not always proper, and also in the confidential doctor-patient relationship much could be improved by a little good will on both sides. The complaint that the attitude of health personnel was not appropriate or proper cannot always be ascribed simply to the unjustified indignation of numerous patients.

The increased number of complaints confirms that the interest in issues of patients’ rights is constantly growing. There is an increasingly comprehensive awareness among individuals of their rights as patients. Generally recognised human rights and fundamental freedoms are also being reflected in the area of health care, and especially in protection of dignity, physical and mental integrity and respect of the patient as a person.

The basic right in the area of health is the right to quality health care. The primary responsibility in the treatment process lies of course with the physician. In their work, physicians must act according to the established knowledge of their science and professionally verified methods. In making professional decisions, physicians are independent, and freely choose the method of treatment that is most appropriate in the given circumstances. Yet the emphasis on human personality and rights, including the right to decide freely about oneself, gives rise to a situation where the patient is no longer merely an object, but increasingly an equal subject in the process of treatment. Of course this does not mean that the physician and patient are becoming equal in this situation, for the patient is clearly in a subordinate and dependent position through their illness and with the associated mental pressure. Treatment in fact signifies an intervention in a person’s physical and mental integrity. And precisely because of the patient’s subordinate position, there is an urgent need for a clear legal framework for the area of health care services, including professional controls.

Deciding on one’s own health and life is a basic personal right of the individual. Free and acknowledged consent from the patient excludes the element of the impermissible. Consent is not just the patient’s right, but above all the duty of the physician only to carry out treatment when the patient has been informed of it and has freely consented to it. Willing informed consent includes the duty of the physician to explain to the patient the envisaged diagnostic procedures and the proposed treatment. The patient must be informed of the state and possibilities of treatment such that they may decide as freely as possible to take the treatment. For this reason the explanation must be such that any patient can understand it, taking into account their state of health and psychological condition. The right to self-determination is a basic right of the patient, whereby on the basis of an appropriate and adapted explanation of all the relevant facts they may consent freely to the proposed treatment.

Within the doctor – patient relationship, the right to have access to health documentation is especially important. Unfortunately we are still frequently encountering cases where the patient and those close to them have been refused permission by the health institution or by the actual physician to see their health documentation.

Citing the claim that the physician is bound to protect medical secrets, even after the patient’s death, has a basis in law only in relation to the public or to third persons, and not in relation to the patient and those closest to them. The physician’s duty to protect as professional secrets data on the patient’s state of health is not provided in favour of the physician. It is provided in order to protect the rights and legally protected interests of the affected person, in other words the actual patient above all, as well as those close to them (such as children, spouse and parents). In previous annual reports we already pointed out that the principle of confidentiality and privacy in connection with patients’ rights cannot be understood to mean that after a patient’s death those most closely related should be refused the right to see the health documentation. The rights and legal interests of the patient following death may in fact be best and most justifiably represented by those who were close to the patient.

This view was also upheld by the Supreme Court in its judgement in an administrative dispute of 12 July 2001, ref. I Up 517/2000. In its explanation of the judgement the Supreme Court stated that when a person is still alive, they have as a person the interest in enjoying a certain protection after they are dead, too. For this reason the law recognises the right to reverence, respect and good memory of a deceased person. Following the death of the holder of personal rights, certain of their personal benefits are therefore protected as personal benefits of those close to the deceased, that is, on the basis of personal rights pertaining to them. This also applies to personal data. The duty to protect medical secrets does not apply in relation to the patient’s closest relatives. If a deceased woman has not forbidden a physician from giving her son data on her state of health, then the son may not be refused the right of access to the health documentation of his late mother.

All natural and legal persons are bound to observe a court judgement, and this therefore includes physicians and health institutions. We therefore expect that in future there will be fewer problems in ensuring the right of access to and obtaining of health documentation on the part of patients and their closest relatives. This right is also important because familiarity with the full medical documentation is a fundamental condition for formulating any kind of complaint. Denying the right of access to health documentation also denies people the right to complain.

The ombudsman has jurisdiction for overseeing the entire range of health services provided within the framework of the public health service, both on the national and local level. Indirectly, and via the institutions that are bound to oversee private health care, in other words including private medical services, the ombudsman also oversees private health care. The ombudsman is therefore empowered to oversee the Ministry of Health and the Physicians’ Chamber, the latter in the extent to which pursuant to Article 71 of the Health Service Act it performs certain tasks under public authorisation. These tasks of the Chamber include awarding, extending and revoking of licences to physicians (licence to independently perform health services in a certain professional area) and implementation of professional oversight with advisory services.

In the area of providing effective external avenues of complaint, recently there has been much talk of a special ombudsman for patients’ rights. In Maribor a local ombudsman for patients’ rights has already been set up, and the city council has now elected the first such ombudsman. The City of Ljubljana and perhaps others are now also considering the setting up of a local ombudsman for patients’ rights.

The increasing proposals for setting up special ombudsmen reaffirms the standing enjoyed by the ombudsman in his work. Yet in deciding to set up special ombudsmen account will need to be taken of the rationality and economics of setting up special ombudsmen in a small country with limited financial capacity. And it will be even more important to define the relationship between the parliamentary Human Rights Ombudsman and the individual ombudsmen, in order to avoid duplication of work on the one hand or omissions on the other. This is perhaps one reason why more recently the idea of a special ombudsman for patients’ rights on the national level has lost currency somewhat.

There is an important relationship between the existing ombudsman and the special ombudsman in the area of patient’s rights. There might, after all, be an accumulation of related national and local bodies with perhaps insufficiently demarcated jurisdiction to separate them. Since the existing ombudsman represents the final instance of the informal complaints procedure, through his constitutionally defined role he is of course also the body of oversight for all other (special) ombudsmen. Individuals who are dissatisfied with the work, decisions and efficacy of a special ombudsman will therefore be able to make a complaint to the (general) ombudsman. At the same time it would not be possible to demand that the affected person first approach the local ombudsman or the ombudsman for the specific area, before making a complaint to the (general) ombudsman. This is the decision only of the individual, whether to approach first the local ombudsman, or to address their complaint directly to the Human Rights Ombudsman.

The setting up of a special ombudsman for patients’ rights should not also be a connivance and excuse for an ineffectual complaints procedure within the health care system. It would in no way be right for a health institution to decline or process with less diligence and concern a complaint, with the justification that it fell under the jurisdiction of the local ombudsman for patients’ rights. The health institution cannot evade its responsibility to deal with complaints by referring them to the (local) ombudsman of patients’ rights. Any thinking to the contrary would tend to weaken the position of complainants, since it would signify passing the buck in dealing with complaints to a body outside the health care system. This would merely postpone a resolving of the complaint by introducing a new intermediary between the affected person and the alleged violator. A special ombudsman for patients’ rights makes sense only if this will provide for the affected person swifter, more effective and more just decisions regarding the complaint.

Letno poročilo 2001 - Poglavje 2.9

2.9. ZDRAVSTVENO VARSTVO

Prejeli smo 40 pobud s področja zdravstvenega varstva, v prejšnjem letu le 18. Tudi tokrat je skoraj skupni imenovalec zatrjevanje nepravilnosti in napak v postopku zdravljenja. Več pobudnikov se je pritoževalo zaradi čakanja, da pridejo na vrsto za želeno zdravstveno storitev. Ponavljajo se tudi težave, s katerimi se srečujejo bolniki in njihovi svojci pri uveljavljanju pravice do vpogleda v zdravstveno dokumentacijo. V nekaj obravnavanih primerih smo zaslutili, da odnos do bolnika ni bil vedno korekten, pa tudi v zaupnem razmerju zdravnik - bolnik bi bilo z dobro voljo na obeh straneh moč še marsikaj izboljšati. Pritožbe, da odnos zdravstvenega osebja ni primeren ali korekten, ni moč vedno pripisati zgolj neutemeljenemu negodovanju številnih bolnikov.


Večje število pobud potrjuje, da se zanimanje za vprašanja pravic bolnikov nenehno povečuje. Čedalje popolnejše je zavedanje posameznika o njegovih pravicah v vlogi bolnika. Splošno priznane človekove pravice in temeljne svoboščine se odražajo tudi na področju zdravstvenega varstva: zlasti pri varstvu dostojanstva, telesne in duševne celovitosti ter spoštovanja bolnika kot osebe.


Temeljna pravica na področju zdravja je pravica do kakovostnega zdravstvenega varstva. Glavna odgovornost v postopku zdravljenja je seveda na zdravniku. Zdravnik se mora pri svojem delu ravnati po spoznanjih znanosti in strokovno preverjenih metodah. Pri sprejemanju strokovnih odločitev je neodvisen ter svobodno izbere način zdravljenja, ki je v danih okoliščinah najprimernejši. Vendar pa poudarjanje človekove osebnosti in njegovih pravic, vključno s pravico svobodnega odločanja o samem sebi, spodbuja razmerje, ko bolnik ni več zgolj objekt, temveč čedalje bolj tudi enakopraven subjekt v postopku zdravljenja. Seveda to ne pomeni, da postajata zdravnik in bolnik v tem razmerju enakopravna, saj je očiten podrejen, odvisen položaj bolnika s svojo boleznijo ter s tem povezano duševno stisko. Zdravljenje pač pomeni poseg v človekovo telesno in duševno celovitost. Prav zaradi bolnikove podrejenosti je nujna jasna pravna ureditev področja zdravstvene dejavnosti, vključno s strokovnim nadzorom.


Odločanje o lastnem zdravju in življenju je temeljna osebnostna pravica posameznika. Svobodna in upoštevana bolnikova privolitev izključuje element nedopustnosti. Privolitev ni le pravica bolnika, pač pa tudi in predvsem zaveza zdravnika, da sme zdravstveni poseg opraviti šele, ko je bolnik o njem poučen in je vanj prostovoljno privolil. Prostovoljna privolitev po pojasnilu vključuje pojasnilno dolžnost zdravnika, da bolnika seznani s predvidenimi diagnostičnimi postopki in s predlaganim zdravljenjem. Bolnik mora biti obveščen o stanju in možnostih zdravljenja tako, da se lahko kolikor toliko svobodno odloči za zdravstveni poseg. Zato mora biti pojasnilo tako, da ga razume vsak bolnik, upoštevaje njegovo zdravstveno in psihično stanje. Pravica do samoodločbe je temeljna bolnikova pravica, da na podlagi ustreznega in prilagojenega pojasnila o vseh relevantnih dejstvih svobodno privoli v predlagani zdravstveni poseg.


V razmerju zdravnik - bolnik ima poseben pomen tudi pravica do vpogleda v zdravstveno dokumentacijo. Žal se še vedno pogosto soočamo s primeri, ko bolniku in njegovim svojcem zdravstveni zavod ali pa kar zdravnik ne dovoli vpogleda v zdravstveno dokumentacijo.

Sklicevanje, da je zdravnik zavezan varovati zdravniško skrivnost, in to tudi po bolnikovi smrti, ima pravno podlago le v razmerju do javnosti oziroma tretjih oseb, ne pa v razmerju do bolnika in ožjih svojcev. Zdravnikova dolžnost varovati kot poklicno skrivnost podatke o zdravstvenem stanju bolnika ni, določena v korist zdravnika. Določena je zaradi varstva pravic in pravno zavarovanih interesov prizadetih oseb, torej zlasti samega bolnika, pa tudi njegovih bližnjih (na primer otrok, zakonca, staršev). Že v prejšnjih letnih poročilih smo opozorili, da načela zaupnosti in zasebnosti v povezavi s pravicami bolnika ni mogoče razumeti tako, da bi po njegovi smrti najbližjim sorodnikom pravico do vpogleda v zdravstveno dokumentacijo odrekli. Pravice in pravne interese bolnika po njegovi smrti pač najbolje in z največjim upravičenjem zastopajo prav njegovi bližnji.


Navedeno stališče je potrdilo tudi vrhovno sodišče s sodbo v upravnem sporu z dne 12.7.2001, opr. št. I Up 517/2000. V obrazložitvi sodbe je vrhovno sodišče med drugim navedlo, da ima umrli v času, ko je živ, interes, da bo kot osebnost tudi še po svoji smrti užival določeno varstvo. Zato pravo priznava pravico do pietete, spoštovanja in lepega spomina na umrlega. Po smrti nosilca osebnostnih pravic se torej določene njegove osebne dobrine varujejo kot osebne dobrine ožjih svojcev, to je na podlagi njim pripadajoče osebnostne pravice. To velja tudi za osebne podatke. Dolžnost varovati zdravniško skrivnost pa ne velja v razmerju do bolnikovih ožjih svojcev. Če pokojnica ni prepovedala, da zdravniki dajejo njenemu sinu podatke o njenem zdravstvenem stanju, potem slednjemu ni mogoče odreči pravice do vpogleda v zdravstveno dokumentacijo svoje pokojne matere.


Pravnomočno sodno odločbo so zavezane spoštovati vse fizične in pravne osebe, torej tudi zdravniki in zdravstveni zavodi. Tako pričakujemo, da bo v prihodnje manj težav pri zagotavljanju pravice do vpogleda in pridobivanja zdravniške dokumentacije s strani bolnikov in njihovih svojcev. Ta pravica je pomembna tudi zato, ker je seznanitev s celotno medicinsko dokumentacijo temeljni pogoj za kakršnokoli pritožbo. Zanikanje pravice do vpogleda v zdravstveno dokumentacijo zanika tudi pravico do pritožbe.


Varuh je pristojen za nadzor celotne zdravstvene dejavnosti, ki se opravlja v okviru javne zdravstvene službe, in to na državni in lokalni ravni. Posredno, in sicer prek institucij, ki so zavezane za nadzor zasebne zdravstvene dejavnosti, torej tudi zasebne zdravniške službe, pa izvaja nadzor tudi nad zasebno zdravstveno dejavnostjo. Tako je varuh pristojen za nadzor ministrstva za zdravje in zdravniške zbornice; slednje v obsegu, v katerem opravlja v 71. členu Zakona o zdravniški službi določene naloge kot javna pooblastila. Med temi nalogami zbornice so tudi podeljevanje, podaljševanje in odvzemanje licence zdravnikom (dovoljenja za samostojno opravljanje zdravniške službe na določenem strokovnem področju) ter izvajanje strokovnega nadzora s svetovanjem.


Na področju zagotavljanja učinkovitih zunanjih pritožbenih poti se v zadnjem času veliko govori o posebnem varuhu pravic bolnikov. V Mariboru so že ustanovili lokalnega varuha pravic bolnikov, mestni svet je tudi že izvolil prvo varuhinjo pravic bolnikov. O ustanovitvi lokalnega varuha pravic bolnikov razmišljajo v Mestni občini Ljubljana, pa morda še kje.

Čedalje več predlogov za ustanovitev posebnih varuhov potrjuje ugled, ki ga s svojim delom uživa varuh. Pri odločanju za posebne varuhe pa bo treba upoštevati tudi racionalnost in ekonomičnost ustanavljanja posebnih varuhov v majhni državi z omejenimi finančnimi zmožnostmi. Še pomembnejše pa je, da se določijo razmerja med parlamentarnim varuhom človekovih pravic in posameznimi varuhi, da ne bi po prihajalo do podvajanja dela po eni strani ali opuščanja po drugi. Morda je tudi na tej podlagi zamisel o posebnem varuhu pravic bolnikov na državni ravni v zadnjem času nekoliko utonila v pozabo.


Pomembno je razmerje med obstoječim varuhom in posebnim varuhom na področju pravic bolnikov. Lahko namreč pride do kopičenja sorodnih državnih in lokalnih organov z morda celo ne dovolj razmejenimi pristojnostmi med njimi. Ker je obstoječi varuh vrh stopnjevitosti neformalnih pritožbenih poti, je s svojo ustavno opredeljeno vlogo seveda tudi nadzorni organ za vse druge (posebne) varuhe. Posamezniki, nezadovoljni z delom, odločitvami in učinkom posebnega varuha, bodo torej lahko vložili pobudo (splošnemu) varuhu. Hkrati pa od prizadetega posameznika ni mogoče zahtevati, da bi se moral obrniti najprej na lokalnega varuha oziroma varuha za določeno posebno področje, preden vloži pobudo pri (splošnem) varuhu. Tako je zgolj odločitev posameznika, ali se bo najprej obrnil na lokalnega varuha, ali pa bo svojo pobudo takoj naslovil na varuha človekovih pravic.


Ustanovitev posebnega varuha pravic bolnikov tudi ne sme biti potuha in izgovor za neučinkovite pritožbene poti znotraj sistema zdravstvenega varstva. Nikakor bi ne bilo prav, da bi zdravstveni zavod odklonil ali z manjšo vestnostjo in skrbnostjo obravnaval vloženo pritožbo z utemeljitvijo, da je to v pristojnosti lokalnega varuha pravic bolnikov. Zdravstveni zavod se ne more izogniti svoji odgovornosti za obravnavanje pritožb z napotitvijo na (lokalnega) varuha pravic bolnikov. Nasprotna razmišljanja bi utegnila celo poslabšati položaj pritožnikov, saj bi to pomenilo prelaganje dolžnosti obravnavanja pritožb na organ zunaj sistema zdravstvenega varstva. To bi zgolj odlagalo rešitev pritožbe z vnašanjem novega posrednika med prizadeto osebo in zatrjevanim kršiteljem. Poseben varuh bolnikovih pravic ima svoj smisel le, če prizadeti osebi zagotavlja hitrejšo, učinkovitejšo in pravičnejšo odločitev o vloženi pritožbi.

 

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