Posílám pro informaci dopis českých pacientů evropskému komisaři pro lidská práva
The Commissioner for Human Rights
Council of Europe
F-67075 Strasbourg Cedex
Mr. Gil-Robles,
with regard to Your letter from 11 June 2001 I send complementary information about a position of Czech patients. On 3 September 2001
I have participated in the meeting of Social, Health and Family Affairs Committee of Council of Europe in Prague. At this meeting I have had the occasion to speak (only shortly) about wishes of Czech patients who need f.e. Physicians law, Hospitals law, Mental Health law, Medicine Research law, Assisted Reproduction law ect.
Minister of Health of the Czech Republic has introduced in government some few bills: Health Facilities Act, Health Care Act, Transplantation Act. No of these bills, however, satisfies neither conditions of Western countries law nor principles of the European Declaration on the Promotion of Patient Rights (from 1994). Partly I know health laws f.e. in Poland ("Physicians act"), Hungary (Health act) or Slovakia (Charter of Patient Rights). I think the Czech Republic in the area of health law is in the worse situation than some other post-communist countries.
The right to self - determination.
Czech Ministry of Health does not resolve the right to self - determination. Only doctors decide wether or not to provide treatment, resuscitation or life - prolonging measures (a conflict between doctor and patient/family is not decided by court). There are no public guidelines of resuscitation or life - prolonging care and physicians decide by own subjective opinion of a quality of patient life (withdraw a patient with "non-quality life" from a mechanical respirator). Neither a patient nor his/her family have not the right on a copy of medical files (the patient has not the right on the second opinion nor alternativ care).
In the Czech Republic the patient can sign "the refusal of hospitalization" (in German "der Revers aus dem Krankenhaus"), but this statement does not resolve patient right on treatment or alternativ care. If the patient signs this "revers", then he/she is in nonlegal situation without the right on any treatment (and he/she risks to be declared as a mental ill person). Our organization has translated f.e. American, Swiss or German legal regulations regarding the right to self - determination but Ministry of Health does not answer to our appeal.
The removal of human organs.
New Transplantation Bill was written for organ removal "at all costs" without legal safety of patients in critical state, especially in critical care units. If the patient signs statement on non-donor, physicians can deny treatment and they can realize postmortem examination (and remove organ or tissue during postmortem examination, under the pretext of "the examination of right treatment" - despite the protest of family; it is not resolved an independent legal medicine). If the patient omits to make statement on non-donor, his/her dead body "is owned by health facility" - family cannot refuse organ removal.
Ministry of Health does not forbid measures for quality of organs that are made before patient death (without his/her consent) even if these measures can reduce patient life. Live donors also are not protected - there is no independent information about risks or about health qualification of donor. General public has not an access to information about transplanting hospitals.
Czech Parliament has resolved the cause of illegal manipulation with human organs in one university hospital - with regard to about 20 organs (from 200 inquiried cases) there is unknown donor and recipient. In about 100 these cases medical records (files about the determining of death) were not right - by the presentation of members of parliament. But "guidelines" (1 page of text) for these medical files regarding examination of donor and for the determining of death is not compatible with regulations of Western countries (I have regulations, guidelines and Richtlinien from USA, Canada, Germany etc.) New Transplantation Bill and new "decree" of Ministry of Health about the determining of death do not improve the situation - these regulations have been written by doctors who want remove organs too quickly and without an independent control. Some important parameters for the examination of the patient (f.e. EEG, angiography) are absent or mistaken.
Psychiatry.
Only physicians decide about transport of the patient to a hospic or home or a psychiatric hospital (without a patient consent). Our organization - without a success - appeals for the second, independent opinion. We have translated f.e. German Unvoluntary Hospitalization Act (Unterbringung Gesetz) but Ministry of Health does not want to change physicians subjective decision-taking.
Recently Czech Constitutional Court has approved a decision by which it is possible to admit a patient into a psychiatric hospital without his/her consent only by satisfying of legal conditions (one woman has been transported - by the decision of doctor - into psychiatric hospital without signs of endangering!). But these legal conditions are very short. The unvoluntary admission the psychiatric hospital has to announce to the court till 24 hours. Court decides till 7 days. But first decision about hospitalization is made by doctor (he/she does not have to be qualified in psychiatry). The person has not the access to advocate. Procedures of court are not resolved sufficiently. Court can decide in absence of the patient or his advocate and without the independent expert opinion.
Our organization proposes:
- the admission into the psychiatric hospital by the decision of a judge and by an expert opinion of one or two physicians with a defined qualification,
- the right of a person to an immediate contact with an advocate free of charge,
- the access of the advocate to the patient and to a medical record with a consent of the person,
- psychiatric hospitals should have independent board of directors (administrative board) or "review panel" or board of advisers with the participation of general public.
Education of physicians.
A last version of "Education of Health Providers Bill" is not compatible with these laws in Western states (we know f.e. Austrian or American Physicians Law). It is not resolved the education at universities. Postdoctoral and continued training is not resolved for the benefit and safety of patients. Physicians - supervisors (trainers) have not legal responsibility regarding a performance of junior doctors (trainees). In the Czech Republic doctors can discontinue their work without a limitation and without an obligation of refresher courses.
The most of Czech physicians have only short - max. 2,5 years training after graduation. Patients have not the access to information about the qualification and experience of doctor. If the patient needs the second opinion, he/she can be to admit (if any) for example in university hospital by beginning doctor without a licence but this nonquality opinion is taked as the opinion of professor of medicine. Our organization proposes: health insurance fonds (legal entities by public law) should ensure - as in some foreign countries - doctors for the second opinion with more experience and patient right to this second opinion.
The exercise of physicians profession is regulated only by short Medical Chamber Act (only about two pages of text) without state control, non-compatible with Criminal Code (physicians do not announce criminal act) or Administrative Code. For example: Czech Medical Chamber admits decisions (regulations regarding licences etc.) contrary to state regulations. Recently one physician declared sexual abuse of patients but he can continue in his profession.
Complaints.
If patients apply complaints in their health insurance institution, this "public entity" sends patients to Medical Chamber (doctors "resolve" the complaint in absence of the patient to the detriment of the patient). If the patient applies his/her complaint in state office - administrative body (district state administration or Ministry of Health), procedures of these offices and civil servants are not regulated sufficiently. The complaint is not resolved or it is "resolved" by doctor that partially works in health care services and he/she has not a qualification from the area of law (complaints are not resolved by specialized state lawyers).
Our organization proposes to resolve complaints by models in Western states, in Germany, Austria etc., with the participation of health insurance fonds (arbitration proceedings) or with judges in disciplinary proceedings.
Now Ministry of Health transfers various legal regulations (guidelines or "Richtlinien" etc.) into acts (new bills) but the insufficient legal protection of patients "stay put" - the content stays same as in communist régime. By own subjective decision Minister of Health can call "the commission of experts" but members of this commission (doctors) are not known neither the patient nor general public. The commission decides in absence of the patient under unknown proofs.
In the area health care it is not observe Criminal Code by police officers (state bodies for inquiry). People announce our organization that police officers do not want to admit their announcement against doctors. Police officers said our organization that by inner regulation (Ministry of Inner Affairs) they cannot confiscate medical files (medical records) without precede announcement (police officer waits for sending of medical record by hospital). Doctors can manipulate dead body.
Research.
We would need also Medical Research Act. Recently Minister of Health has approved the experimentation regarding oncological patients - the examination new method of treatment, so called "devitalization of tumor". Doctors have not the same opinion, specially surgeons with more experience have remonstrated. There was not realized the official (with state control) experimentation of this kind on animals. Patients get information only from doctors who want this experimentation - there is no independent legal or medical advice (advice bureau). General public and patients in this experimentation do not know members of "review panel" (only doctors).
Data protection.
Government and Parliament have approved the access to patient mecical records for all healthcare providers and for members of Czech Medical Chamber without the consent of the patient. The patient has not the right on the copy of own medical record - doctor can say that the content of medical record could "perturb" the patient... Minister of Health has received the right to collect any information about all patients without their consent and without their knowledge of this personel data collection.
Reform of health system.
I have studied (with the help of Czech expert in law) Czech Health, Social and Pension Insurance Act from 1926 - it was the quality act compatible with present German or Austrian Health/Social Insurance Act. This old Czech act gave insurants the right to elect their representatives into administrative and review board of public health insurance entities and also into body for arbitration (with the participation of the judge - settling of cases out of court). Now Ministry of Health, however, does not want to study this experience. At present "representatives of insurants" (only in one insurance entity - in one central board of directors) are elected by Parliament without a direct relation to insurants. Representatives are not proposed by citizens. Procedures and activities of board of directors of health insurance bodies are not regulated sufficiently. It is not excluded the conflict of interests of members of this board of directors.
The present Czech Health Insurance Act does not satisfy fundamental parameters of Insurance Act from 1926; the present act does not contain arrangements for good insurance economics. For example, health insurance bodies have not the sufficient access to information about real expenses of health providers and hospitals. Politicians as members of board of directors of these insurance bodies do not want to use money economicaly. They are absent legal regulations for contracts, for the possibility to influence the quality of health care and economy (I know f.e. the form of contracts in Germany or in the U.S.A).
For successful reform it is needed to ensure the creation of independent institutions for statistics and analyses (activities of present Czech institutions of this kind are not regulated by act and one director - without administrative board - is dependent on Minister of Health).
At the meeting of committee of Council of Europe in Prague it has been typical for Czech Minister - to speak about the profit of health care providers but not about patient rights and the profit of general public.
Vladimíra Bošková
Civic Association for the Protection of Patients
Podskalská 24
120 00 Prague 2
the Czech Republic
10 September 2001
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Evropská charta práv pacientů
WHO i další evropské instituce a orgány podpořily v roce 1994 tzv. prohlášení o ochraně práv pacientů v Evropě s cílem prosadit přijaté principy ve všech členských státech spolupracujících na úrovni Světové zdravotnické organizace.
WHO doporučuje, aby se přijaté principy (na zasedání v Amsterodamu) promítly v členských zemích do národní legislativy, do etických kodexů profesních organizací ve zdravotnictví, do charty práv pacientů vyhlášené na národní úrovni a aby vlády členských zemí tuto snahu evropských institucí plně podpořily.
Tzv. Evropská charta práv pacientů má zhruba deset stran upřesněných práv pacientů. MZ ČR ji přeložilo do češtiny, bohužel ji nepromítlo zatím do žádného zdravotnického zákona ani s obsahem charty neseznamuje veřejnost. Naopak např. slovenská vláda přijala dokument Charta práv pacienta, do něhož již alespoň zčásti zapracovala některé principy doporučené WHO, Evropskou komisí aj.
Některé z hlavních bodů Evropské charty práv pacientů:
* Každý má právo na sebeurčení.
* Každý má právo na svou tělesnou i duševní integritu (nedotknutelnost).
* Každý má právo na respektování svého soukromí.
* Právo na informace o zdravotnických službách včetně kvalifikace profesních pracovníků.
* Právo na plnou informovanost o svém zdravotním stavu, na výslovnou žádost pacienta, včetně práva na kopii zdravotní dokumentace.
* Právo pacienta určit, kdo jiný by měl být informován v jeho zájmu.
* Právo pacientů získat druhý názor na léčbu.
* Při propuštění ze zdravotnického zařízení právo pacienta získat písemnou zprávu o diagnóze, léčbě a další péči.
* Podmínkou jakéhokoli léčebného výkonu je informovaný souhlas pacienta.
* Právo na opravu údajů v dokumentaci nebo na jejich vymazání, pokud jsou nepřesné, neúplné nebo nepřijatelné.
* Právo pacientů být svými zástupci zastoupeni v orgánech
(podle své volby), jež se podílejí na rozhodování ve zdravotnictví.
* Právo na účinné vyřízení stížností prostřednictvím nezávislého orgánu.
Evropská charta obsahuje mnoho dalších bodů týkajících se např. terminální fáze onemocnění, výzkumu apod. Země EU již tyto hlavní principy mají obsaženy ve zdravotnických zákonech, avšak převzaly je i státy, jež zatím stály mimo EU, např. Švýcarsko převzalo uvedené zásady jak do zákonů, tak do stavovských lékařských předpisů (lékařská komora zpracovala nařízení pro úpravu vztahů mezi lékaři a pacienty). Obdobně postupuje SRN, kdy ministerstvo zdravotnictví, lékařská komora a organizace pacientů vydávají pro veřejnost společná prohlášení, v nichž upřesňují práva pacientů do detailů, aby v praxi nedocházelo k nejasnostem. Například se upřesňuje, že pacient má právo jak na léčbu, tak na ustoupení od léčby (rozhoduje o tom pacient, nikoli lékař) a zároveň právo na alternativní, jiný léčebný postup. Dále se v zahraničí tímto veřejným způsobem upřesňují náležitosti vedení zdravotní dokumentace tak, aby obsahovala nejen záznamy o léčbě, ale aby pacient mohl průběžně nahlížet a žádat opravy záznamů, dále zdravotní dokumentace musí obsahovat písemná vysvětlení k léčbě - aby byla kontrola, že pacient byl o léčbě správně informován (pacient potvrzuje vysvětlení od lékaře podpisem a má právo na kopii).
Vladimíra Bošková
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