pravno shvatanje namerne lekarske...

33UTICAJ PRISUSTVA METABOLIČKOG SINDROMA NA NALAZ TESTA FIZIČKIM OPTEREĆENJEM

Mirza Totić1 PRAVNO SHVATANJE NAMERNE LEKARSKE GREŠKE

Sažetak: Rad je posvećen lekaru, profesionalcu i humanisti koji se posve-tio medicini i obavezao na doživotno učenje, na etiku i pružanje pomoći ugroženim, čak i protiv njihovog izričitog pristanka. Tema je fokusirana na problem namerne lekarske greške, sa ciljem da istu negira u tom kon-tekstu, da savesnog lekara zaštiti od delikta i oslobodi moralnog tereta. U radu se teži odgovoru na pitanje, ako je greška nastala kao promašaj lekara na štetu korisnika (pacijent), kako u tom slučaju tretirati njegov pokušaj, učinjen profesionalno i sa najboljom namerom, bez obzira na fatalan ishod? Osim toga, medicinsko-pravna teorija i praksa, pored namerne, poznaju i nenamernu lekarsku grešku za čije nastajanje nije predviđena nikakva odgovornost, jer se ponašanje lekara ne kosi sa medicinskom etikom, standardima i pravilima. S tim u vezi, autor svoje istraživanje bazira na sledećim pitanjima: da li uopšte postoji namerna lekarska greška, ko je spreman da svesno ugrozi pacijenta postupcima protivnim medicinskim pravilima (nemar, izbegavanje pružanja pomoći, pogrešna dijagnoza, nepropisna terapija, neodgovoran odnos, diskriminacija), ko je kompetentan da preduzetu radnju proglasi greškom (namerna, nena-merna) i koji su dokazi potrebni da bi se surovo atakovalo na integritet vrhunskog stručnjaka, koji će biti okrivljen i procesuiran?

Literatura obiluje tvrdnjama da je lekarska greška stara koliko i sama medicina, što nije tačno. Takođe, netačno je da se njeno prvo pojavlji-vanje vezuje za sredinu XIX veka. U pitanju je grubo potiranje davnih medicinskih tragova, imajući u vidu da je i pre navedenog perioda postojala vrlo uspešna medicina sa kvalitetnim narodnim lekarima i njihovim briljantnim uspesima, ali i sa bolestima i umrlim licima. Što se tiče podatka o tačnom nastanku lekarske greške, stav autora je da isti nikada ne mora biti saopšten jer je u domenu istorije koja, za razliku od mnogih nauka, nije egzaktna i ne mora joj se uvek verovati. Svaka lekarska greška je višestruko zanimljiva, najpre istraživačima u pravom smislu te reči, a onda i kolumnistima senzacionalistima. Potonji vide krivca jedino u lekaru, jer mnogi od njih nisu prisustvovali sceni kada isti poražen napušta Službu hitne pomoći, ordinaciju, operacionu salu ili drugi zdravstveni prostor, jer mu se dogodilo nešto najstrašnije u struci

1 Internacionalni univerzitet Novi Pazar, e-mail: [email protected]

34 MEDICINSKI GLASNIK / str. 33-46

– izgubio je pacijenta. Senzacionalisti se retko bave scenama kada očaj i suze ustupaju mesto radostima, osmehu i egzaltaciji. Ne shvataju da je nemoguće sresti lekara koji će potpuno svesno, dakle, namerno po-gaziti struku, etičke vrednosti, Hipokratovu zakletvu, direktno ugroziti zdravlje ili život pacijenta, odnosno napraviti namernu grešku i izvršiti krivično delo.

Ključne reči: lekarska greška, pacijent, medicinski standardi, medicinsko pravo, veštačenje

UVOD

Rasprave o lekarskoj greški tradicionalno izazivaju žučne polemike. U slučaju njenog nastanka, po inerciji se javljaju pozvani i nepozvani, mahom laici, da izne-su svoja mišljenja, da polemišu, da li je namerno ili nenamerno učinjena i da bez relevantnih dokaza unapred presude lekaru. Zanimljivo je da u raspravama, pored velikog dela javnosti, učestvuju mnogi teoretičari koji bez dvoumljenja u epicentar stavljaju lekara, tako što mu pripisuju namerno kršenje standardnih medicinskih pravila, svesno postupanje suprotno dobroj medicinskoj praksi, nepoštovanje ele-mentarne medicinske etike, neprofesionalan odnos prema pacijentu I, što je najgore, ponašanje protivno vlastitoj profesiji. Kada je u pitanju lekarska greška prima facie se radi o prenebregavanju pravila koja čine suštinu odnosa između lekara i pacijenta, pri čemu je posebno akcentirano ponašanje medicinskih radnika (5), u prvom redu lekara. Stav je prihvatljiv, s tim što ne znači da nepoštovanje pomenutih pravila od strane lekara mora uvek izazvati namernu grešku koju je teško pravilno proceniti i dosledno objasniti. Pravničko tumačenje (12) je da je lekarska greška izraz svesnog postupanja lekara protivno pravilima medicinske struke (lat. contra legem artis) ili nepoštovanje medicinskih standarda, propisa, pravila, procedura i mera kojih se morao pridržavati, a nije, čime je generisao njeno nastajanje i naneo štetu pacijentu. Ako je namerna lekarska greška dokazana, a šteta kod pacijenta utvrđena (17), onda je potpuno prirodno da se protiv lekara učinioca preduzmu sankcije predviđene me-dicinskim pravilnikom i/ili zakonom, s tim što se u takvim slučajevima preporučuje oprezno postupanje.

Prvo, ne sme se po svaku cenu uzimati u obzir sud javnosti koja za sve probleme pod krovom zdravstvene ustanove isključivo okrivljuje lekara, smatrajući da protiv istog obavezno treba pokrenuti i voditi krivični postupak. Drugo, lekarska greška podrazumeva postojanje neoborivih dokaza o nestručnom vršenju zdravstvene radnje sa posledicama i samo na osnovu njih lekar može biti krivično odgovoran. Treće, od-govornost lekara postoji i kada su u pitanju greške nastale neodgovornim ponašanjem drugih zdravstvenih radnika, iako to nekada ne izgleda etički. Međutim, lekar koji je profesionalno obavio svoj deo posla, koji ničim nije ukazivao na nepovoljan ishod,


može snositi krivicu zbog greške drugog zdravstvenog radnika, ako nije profesionalno i do kraja ispratio njegovo ponašanje. Utvrđene namerne lekarske greške se u svim državama sankcionišu na osnovu Krivičnog zakona. Međutim, ne mora svaki promašaj lekara imati sudski epilog iz prostog razloga što Zakoni o zdravstvenoj zaštiti decidno regulišu rad i ponašanje lekara i zdravstvenih ustanova i što se veliki broj delikatnih slučajeva rešava u okviru institucija, dakle, na nivou i u okviru struke.

U opštem je interesu da se zna, i zato ne treba tajiti, da je Krivični zakon u senci Zakona o zdravstvenoj zaštiti, da njegovi promoteri (sudije, tužioci, advokati) nemaju medicinsko obrazovanje, da su nedovoljno stručni da adekvatno ocenjuju rad lekara i drugih zdravstvenih radnika, za šta je jedino struka kompetentna. Ovde nije reč o nadmetanju medicinskih i pravnih instituta ili njihovih predstavnika, na-protiv, radi se o isticanju značaja i poštovanju profesija kojih je, prema stručnom mišljenju, samo tri u svetu (28) i to su medicina, pravo i sveštenstvo. Ostalo su struke, zanimanja, zanati, veštine i sl. Iluzija je, da je ponašanje lekara (i drugih zdravstvenih radnika) propisano samo zakonom, ono je pre odraz sveopšteg ljudskog vaspitanja, demonstracija sopstvene kulture, životni stil, manir, ali i pravo na lični izbor, što je vrhunac čovekove slobode (23). Ipak, navedeno ne sme biti shvaćeno kao garancija, da je svaki lekar savestan, da samo zbog ličnih manira neće postupati suprotno zakonu (5) i da će pre ulaska u ordinaciju, hiruršku salu ili savetovalište, odnosno pre direktnog kontakta sa pacijentom, čitati zakonske propise kako bi opredelio svoje ponašanje.

O ponašanju lekara kada nastane profesionalna greška nije dovoljna samo kon-statacija da je ista nastala, jer to nije dovoljan dokaz i ne nudi pravi razlog. Zato se dokazi najčešće utvrđuju, putem veštačenja, koje sprovode stručna lica (veštak) radi utvrđivanja ili razjašnjenja činjenica. Za veštačenje je potrebno stručno znanje (ek-spert) kojim sud ne mora u datom slučaju raspolagati, iako može biti karakteristično i povezano sa složenim krivičnim ili parničnim sudskim postupcima. Veštak mora, pored neophodnog znanja, posedovati i moć stručnog zaključivanja, jer može biti pozvan na raspravu povodom pitanja iz raznih stručnih i naučnih oblasti (medicina, saobraćaj, građevina, finansije i sl.). Uloga veštaka je da pravnicima pruži stručne instrukcije, podršku i sud o području iz koga je predmet rasprave i da ih upozna sa područjima ljudske delatnosti koja im, na osnovu njihovog opšteg i specijalnog prav-nog obrazovanja, nisu dovoljno poznata.

Cilj rada

Cilj istraživanja je da ne bude shvaćeno samo kao pretenciozna glorifikacija savesnih lekara koji su svojim profesionalnim postupcima i postignutim rezultatima uspeli da overe svoje vrednosti i zauzmu zasluženo visoko mesto u prvim društve-nim redovima (15), već i odijum prema svima koji su spremni na prljave postupke,


a zovu se „lekarima”. S obzirom na to da se o lekarskoj greški neprestano i sa dosta argumenata jednako polemiše u akademskim (16) i stručnim krugovima (22), ali i u medijima (1), bilo bi neodgovorno negirati njeno postojanje. Međutim, najpre treba uzeti medalju u ruku, uveriti se da zaista ima dve potpuno različite strane i onda napraviti jasnu distinkciju između namernih i nenamernih grešaka, odnosno između postupaka savesnih i nesavesnih lekara. Dosadašnja medicinska praksa nije daleko otišla u sankcionisanju lekara koji su iskazali nepoštene namere, ali i druge instance, koje evaluiraju posledice nepoštenog postupanja, takođe nemaju čime da se pohvale. Cilj rada je u prvom redu negacija namerne lekarske greške. Ukoliko je do iste zaista došlo, što mora biti dokazano, onda sledi utvrđivanje njene suštine i sagledavanje spremnosti pravnih institucija da, na osnovu valjanih dokaza i shodno utvrđenim činjenicama, sankcionišu lekara učinioca.

Suština lekarske greške

Na samom početku treba istaći da lekarska greška postoji u širem i užem smislu. U širem smislu ne mora biti izraz povrede pravila medicinske struke, već povreda garantovanih prava pacijenta iz domena zdravstvene zaštite i kršenje širih pravila le-karskog dužnog postupanja. Ona više od pola veka intenzivno zaokuplja interesovanje pravnika i lekara i jedan je od najznačajnijih problema sa kojim se medicinsko pravo neprestano suočava. Svesni toga, poznati teoretičari (McKee, Mossialos, Belcher) nemaju dilemu da ispred svih funkcionalnosti u okviru zdravstvene delatnosti postave odgovornost zdravstvenih radnika, u prvom redu lekara i postojanje izvesnih rizika koji su smetnja obezbeđivanju adekvatne zdravstvene zaštite građana kao univerzal-nog i najsigurnijeg resursa (6). Stav je formiran na osnovu saznanja o dugogodišnjem ponašanju lekara, o njihovim čestim greškama i propustima drugih zdravstvenih rad-nika, kvaliteta pruženih medicinskih usluga i zadovoljstva pacijenata. Česte greške su pobudile interesovanje predstavnika pravne teorije i sudske prakse i intenzivirale njihovu nameru da pronađu efektne krivičnopravne propise čija bi upotreba omogućila precizno utvrđivanje krivičnih dela i okončanje velikog broja sudskih sporova koji se decenijama bezuspešno vode.

Nastala lekarska greška, osim što je čin postupanja nesavesnog lekara protivno pravilima vlastite struke (contra legem artis) u smislu grube povrede medicinskih standarda, istovremeno je i osnov za krivičnu ili neku drugu odgovornost. Savremenija shvatanja medicinske i pravne nauke idu u smeru da lekar čini namernu grešku (dis-kutabilno pitanje) prvo, zbog nedovoljne informisanosti o postojanju novih naučnih saznanja i o mogućnostima primene modernih tehnološko-medicinskih dostignuća, i/ili drugo, ukoliko je znao da navedena postoje, ali ih i pored postojećih uslova u datom momentu nije svesno primenio. Lekar takođe pravi grešku ukoliko ne shvati na vreme da je medicina kao retko koja druga nauka podložna drastičnim promenama i da su

moderna naučna saznanja njena svakodnevica. Na nepropisan način demonstrira neozbiljno shvatanje sopstvene profesije, izbegava radne obaveze i prouzrokuje nastajanje patnji kod pacijenta. Međutim, pomenuta gledišta u medicinskoj nauci izazivaju oprečne stavove. Naime, mnoge savremene metode, modeli, procedure ili radnje mogu biti priznate od strane velikog broja eminentnih medicinskih stručnjaka, što ne znači da moraju biti opšteprihvaćene, priznate i u svakoj situaciji primenjive. Time nije istaknuta namera da se izbriše krivica lekara, već je otvoreno novo pitanje, da li on zaista čini grešku kada postupa isključivo prema sopstvenom uverenju? Da li je moguće da neko ko insistira na zdravstveno-vaspitnom radu, na edukaciji pacijenta, vođenju kvalitetnog života, očuvanju i unapređenju kolektivnog zdravlja i/ili pruža stručnu pomoć, propisuje kvalitetnu terapiju ili uspešno obavlja složene operativne zahvate, svesno (namerno) napravi grešku i učini da stvari krenu po zlu? Nažalost, moguće je i tada slučaj postaje zanimljiv javnim tužiocima, sudijama i advokatima.

I pored dileme o namernoj lekarskoj greški, izvesno je da lekar istu čini u ve-likom broju slučajeva. Mora imati u vidu da je medicinska nauka veoma dinamična i da se njeni standardi vrlo brzo menjaju i da se stalno, u skladu sa novonastalim stanjem u nauci i praksi, modifikuju, dograđuju i dograđeni primenjuju (8). Lekar kao stručnjak koji se zakleo na doživotno učenje ima obavezu da bude u toku sa savremenim medicinskim trendovima (9) i mora dodatno računati na stalno rastući nivo zdravstvene prosvećenosti građana (osiguranici-pacijenti). Uprkos svemu, lekarska greška retko nastaje zbog kršenja medicinskog standarda, jer se od svakog lekara očekuje da u zbrinjavanju pacijenta načini briljantan pokušaj bez obzira što se mnoga očekivanja ne ostvaruju. Ukoliko takav pokušaj ne učini onda nije kriv standard, kriv je on, nesavestan lekar, kome ni dobar standard nije od pomoći. Dobar standard, smatra Kacenmajer, nije lako utvrditi, posebno u medicini u kojoj ne postoji iscrpan kodeks čvrstih pravila koja garantuju sigurnost i kvalitet iz kojih bi se, s vremena na vreme, stanje nauke moglo pouzdano videti (3). Budući da su medicinska nauka i lekarska iskustvena saznanja podložna stalnim promenama, vrlo čest problem predstavlja utvrđivanje standarda koji će važiti u trenutku pružanja medicinske usluge, što upućuje na zaključak da lekar nije, ali i ne mora uvek biti, u mogućnosti da izabere najsigurniji. Ukoliko ne uspe u izboru i primeni pravog standarda, lekar mora biti svestan da time preuzima veći rizik prema pacijentu u pogledu izlečenja i da mora imati opravdanje za sve postupke koje je samoinicija-tivno preduzeo (29), a koje izabrani standard ne sadrži.

Mnogi teoretičari, suočeni sa svakodnevnim događajima u medicinskoj, ali i pravničkoj praksi, tragaju za razlozima, zbog kojih je ravnotežna tačka u ponašanju zdravstvenih radnika (lekari) pomerena sa krivične na građansku odgovornost. Do sada su došli do saznanja da je glavni razlog tome što se pravna teorija, koliko do juče, značajnije bavila njihovom krivičnom nego građanskom odgovornošću. Osnovni


razlog za odgovornost lekara je, prvo, u skrivanju povrede radnih obaveza koje se reflektuju kao povreda dužne pažnje (10) prilikom medicinskog tretmana pacijenta, i drugo, kod svesnog preduzimanja medicinskih radnji prema pacijentu bez njegove izričite saglasnosti. Međutim, ta lepeza razloga se širi na prekršaje koje lekari čine izvan struke (učešće u kriminalu), što nema direktnog dodira sa medicinskim radnjama (dijagnostika, medicinski tretman, operativni zahvati, neodgovarajuća farmaceutska zaštita i sl.). Koliko je bitno realno shvatiti lekara kao ličnost, stručnjaka, profesio-nalca i etika, toliko je bitno odvojiti njegov zdravstveni rad od drugih vrsta poslova kojima se u životu može baviti. Zato se moraju razlikovati postupci lekara kada pravi namernu stručnu grešku od one koju pravi kao građanin, iako se najčešće obe čine u zdravstvenoj ustanovi ili na drugom mestu na kome je ostvaren kontakt između lekara i pacijenta (ili njegovog posrednika). U ovom slučaju „lekar” nije lekar, već kriminalac koji zloupotrebljava svoj položaj, blati svoju struku i vređa branšu koja je pozvana da stručno štiti zdravlje pacijenata.

Zbog kompleksnosti pojma lekarske greške, najbitnije je odvojiti neuspeh u lečenju obolelog od greške u toku lečenja. Neuspeh u lečenju ne mora uvek biti le-karska greška, jer su u pitanju slučajevi kada lekar (ili ceo tim) ima najbolju nameru i zbog želje da postigne željeni ishod preduzima sve što jeste i što nije dozvoljeno u medicini. Pravilo je da savestan lekar nikada ne preuzima ex ante rizik na sebe, odnosno nikada ne daje nerealne procene i ne garantuje uspešno izlečenje (18), jer bi takvo ponašanje bilo vrhunac neozbiljnosti, licemerstva i mačevanje sa vetrom. Međutim, svaki lekar, shodno ukupnim uslovima, može garantovati savesno, profesi-onalno i uspešno preduzimanje akcija u lečenju, što se drastično razlikuje. Na drugoj strani, od lekara se ne sme zahtevati nemoguće, ali se može očekivati uspeh, iako on ne zavisi isključivo od stručnosti, veština u vršenju različitih medicinskih radnji ili instrumentarijuma sa kojim se služi. Za uspeh se nikada ne pita kako je postignut, jer njegova vrednost svaku grešku, ako takva postoji, čini minimalnom. U mnogim situacijama ishod lečenja je u najvećoj meri vezan za vrstu bolesti, fazu u kojoj se bolest nalazi, hitnost u prijemu obolelog, vreme javljanja lekaru, za psiho-fizičke karakteristike pacijenta, kapacitet mogućnosti za uspešno izlečenje, s tim što se ni faktor sreće ne sme zanemariti. U drugim situacijama se dešava da je lekar (ili ceo tim) sve medicinske radnje obavio krajnje profesionalno, ali oboleli zbog nedostatka potrebnog kapaciteta nije uspešno izlečen i takav ishod se smatra neuspehom u lečenju. U vezi sa tim, veoma je važno napraviti razliku između lekarske greške i nesrećnog slučaja. Pomenute situacije se sa pravnog aspekta mogu posmatrati kao sporne, jer u sebi sadrže pravnu ocenu lečenja, što nije uvek dovoljno, zbog čega između njih još uvek nema jasno povučenih granica.

Ova ocena je prihvaćena u skoro svim pravnim sistemima zbog zahteva da se studiozno i pažljivo, medicinski i pravno, sagledaju svi slučajevi, kako se ne bi potkrala greška u proceni zbog koje bi lekar bio proglašen krivcem. U državama sa anglosak-


sonskim pravnim sistemom (Sjedinjene Američke Države, Irska, Velika Britanija, Kanada) lekarska greška je bolje pojašnjena usvajanjem termina: medicinske pogrešne prakse (malpractice), na kome se zasniva pravni koncept lekarske odgovornosti za učinjenu štetu pacijentu (21). Nadovezujući se na prethodni citat Mujović-Zornić nudi bliža objašnjenja koja se odnose na druge pojmove. Razlikuje aktivnu grešku koja se događa na operativnom nivou, čije su štetne posledice u najvećoj meri neposred-no vidljive (11). Prema njenom mišljenju, obična greška je sinonim za propuštanje prilike da planirana medicinska radnja bude ostvarena kako je nameravano, ili je akt primene pogrešnog plana za dostizanje postavljenog cilja. Latentnu grešku za koju važi pravilo da vodi do operativne greške i da njeni efekti tipično ostaju u sistemu i određeno vreme nisu vidljivi (12), posmatra kroz različite manifestacije, najčešće u obliku, organizaciji, obuci ili održavanju. U dosadašnjim komentarima o namernoj lekarskoj greški nema slučajeva za koje se može tvrditi da je ponašanje lekara prema pacijentu bilo neprofesionalno, da je plod nemarnosti, neznanja ili namernog vršenja nedozvoljene medicinske radnje.

Veliki je broj lekarskih grešaka koje nisu u direktnoj vezi sa lečenjem ali njima se uglavnom bave mediji. Obaveštavaju javnost o učešću lekara u prljavim poslovima (prodaja beba, misteriozni nestanci dece iz porodilišta, proglašavanje novorođenčadi mrtvim, prodaja organa i sl.), koji nisu u direktnoj vezi sa lečenjem, ali na kraju čine bitnu kariku u lancu organizovanog kriminala. Žestoko je odjeknula vest (24) da je u Republici Kini, koja ima problem sa poštovanjem ljudskih prava, na smrt osuđena „lekarka” koja je otela i prodala nekoliko novorođenčadi iz bolnice u kojoj je radila. Priznanje da je prisvajala bebe, ali tek nakon što bi roditeljima saopštila da imaju urođene telesne mane zbog kojih treba da ih se odreknu, krajnje je morbidno. Reč je o pripadnici organizovanog kriminala koja je sarađivala sa otmičarima koji su pro-davali bebe po drugim kineskim provincijama i gradovima. Prema citiranom izvoru, lekarki bi nakon otmice jednog dečaka pripadalo 3.500 $ USA, a prodavci bi kasnije inkasirali oko 10.000 $ USA.

Autoriteti koji se bave pitanjima zdravstvene zaštite smatraju da se medicina susreće sa problemima kada je potcenjena uloga i značaj preventivne zdravstvene zaštite. To znači od njene promocije 1978. u Alma-Ati (Kazahstan), preko konferencije u Rigi (Letonija) 1988. godine, u Ljubljani (Slovenija) 1996. godine, pa dalje, kada je bila zamišljena da bude stub nosač u zaštiti čovekovog zdravlja (27). Zauzeti stav nije opstao, a danas u svakoj državi sveta na sceni je „preskakanje” lekarskih nivoa i traženje pomoći na višim instancama (sekundarna, tercijarna zaštita), pri čemu upra-vo pacijenti koji neguju takvu praksu najviše gube. Tada obično bude isuviše kasno za uspešnu lekarsku intervenciju, što figurira kao propust u lečenju, kao zakasnela intervencija, nepripadanje izabranom lekaru i sl. Da li i u ovakvim slučajevima treba tražiti lekarsku grešku na bilo kom nivou? Ne treba, zato što nema govora o namernom i lošem postupanju lekara prema pacijentu, a drugo, pacijent ima pravo na izbor lekara


i u takvim slučajevima postupa prema sopstvenom nahođenju, bez obzira na upozore-nje njegovog izabranog lekara da se pridržava stručnih saveta i da se disciplinovano vlada u odnosu na svoj zdravstveni status. Polazeći od činjenice da je prevencija u medicini izgubila svoju poziciju (25), a mogla je mnoge nesrećne slučajeve povolj-no da reši, postavlja se pitanje kako reaguje pravosuđe i ima li osnova da u takvim slučajevima traži namernu grešku bilo kog lekara. Fakat, ona može nastupiti i svako svestan principa errare humanum est mora na nju računati, ali je veliko pitanje da li je ljudski namerno grešiti da bi krajnji ishod bio poguban? Naravno da nije i zato je teško tvrditi da prilikom lečenja lekar namerno greši i nanosi štetu pacijentu. Još je u staroj Kini u knjizi Kanoni medicine („Nuci King), koja se smatra autorskim delom imperatora Xuang Tia iz 2800. godine p/H, bilo posebno izdvojeno pravilo da: „… medicina nikog ne može spasiti od smrti, da je u stanju samo da produži život, da učvr-sti moral, pojačavajući vrlinu i iskorenjujući porok kao smrtnog neprijatelja zdravlja. Medicina ne može da izleči mnoge bolesti koje napadaju jadno čovečanstvo… ali se trudi da ojača narode i državu, pružanjem higijenskih saveta” (14).

Medicinsko pravo i lekarska greška

Naučna medicina je znatno ranije, ali posebno krajem XX i početkom XXI veka, počela svoj ekspanzivan razvoj. Praktična primena savremenih dostignuća je najviše doprinela unapređenju globalnog zdravstvenog kvaliteta i razvoju savremenih zdravstvenih sistema. Time je globalnom zdravstvu obezbedila visok status i učinila ga izuzetno bitnom društvenom funkcijom (26). Nova saznanja koja karakterišu sa-vremenu naučnu medicinu skoro su nesaglediva i ogledaju se u preciznoj dijagnostici, savremenim operativnim metodama i zahvatima, efektnim terapijskim procedurama i/ili u ponudi velikog broja mogućnosti za rešavanje složenih problema. Nemoguć-nost pojedinih država da apliciraju savremena dostignuća ne umanjuje njihov značaj, jer su države koje ne kaskaju u razvoju i koje ih lako i blagovremeno primenjuju već odavno ostvarile izvanredne rezultate. Sadržajna i kvalitetna naučna medicina najbolja je garancija osiguranicima/pacijentima da mogu računati na moderne medi-cinske tretmane, savremenu zdravstvenu zaštitu i da mogu gajiti nadu u bolje lečenje i konačno izlečenje. Na drugoj strani lekar, a sa njim i drugi zdravstveni radnici, odjednom su postali dodatno odgovorni profesionalci ne samo prema bolesnicima, već i prema struci i društvenoj zajednici u celini, čijem ukupnom razvoju značajno doprinose. Zbog toga su relevantni državni organi bili primorani da ozbiljno shvate njihovu poziciju i da preuzmu obavezu da ih zaštite, u prvom redu od nekorektnih postupaka nezadovoljnih pacijenata čije su potrebe za stručnom brigom i zaštitom najčešće. Iz tog razloga je, poslednjih decenija XX veka, proistekla ideja da se kao nova naučna disciplina razvije medicinsko pravo koje bi uređivalo specifične pravne oblasti i rešavalo komplikovane medicinsko-pravne probleme.


Medicinsko pravo je grana prava koja sadrži pravne norme koje uređuju sve vrste odnosa između osiguranika/pacijenata i medicinskih radnika u okviru medicinske delatnosti, ali i u okviru zdravstvenog sistema u celini. One su alati pomoću kojih društvena zajednica uspostavlja i održava spoljašnu kontrolu nad radom i ponaša-njem zdravstvenih radnika, u prvom redu lekara. Cilj kontrole je zaštita zajamčenih prava i interesa ne samo zdravstvenih radnika, već i bolesnika, odnosno osiguranika. Međutim, treba imati na umu da, bez obzira kolika je snaga medicinskog prava ili njegovih normi, ne treba gajiti veliki optimizam i još manje nerealna očekivanja, da će njihova primena dovesti do brzih i lakih rešenja i da će uspešno odmrsiti vrlo zamršene odnose. Praksa je to vrlo brzo pokazala. Medicinsko pravo je od strane lekara i drugih zdravstvenih radnika shvaćeno kao pretnja. Postalo je meta prozivki, da je nasrtljivo i da direktno koči razvoj medicine uopšte, jer se preterano upliće u njihov rad i kompetencije. U vezi sa iznetim stavom mišljenja su podeljena. Mnogi smatraju da su zdravstveni radnici na čelu sa lekarima u pravu i da je pravnoj nauci i pravnicima mesto u sudnici, dok drugi smatraju da su negodovanja lekara i drugih zdravstvenih radnika neosnovana, samim tim što medicinsko pravo nije pozvano da stvara nepoverenje između njih i pacijenata. Međusobno nepoverenje je stvorilo prostor na kome je pravo pozvano da interveniše.

Kada je u pitanju namerna lekarska greška uloga medicinskog prava je zane-marljiva u odnosu na krivično pravo. Imajući u vidu da predstavlja načelno kršenje propisanih profesionalnih i etičkih dužnosti, vrlo je bitno utvrditi činjenice o njenoj relevantnosti i izreći kvalifikaciju da je učinjena namerno. Procena kreće sa stanovišta da je učinilac razumno, stručno i odgovorno lice, tako da se stvara dilema da li je kao takvo spremno na oblik ponašanja koje za rezultat ima kršenje propisane obaveze. Osim toga, svako ponašanje se ogleda u određenom činjenju ili nečinjenju lekara pre-ma pacijentu (prilikom dijagnostiranja, propisivanja terapije, a naročito kod složenih operativnih zahvata i medicinske nege pre i posle ozbiljnih medicinskih tretmana), tako da je vrlo teško ispravno proceniti da li je reč o svesnoj nameri ili o propustu. Kada procenu vrše nemački pravni stručnjaci, reč je o dužnosti saobraćanja (20), a kada to isto čine francuski ili američki pravnici tada je reč o dužnosti staranja (4). Zaključak je da ne postoji suštinska razlika između dužnosti pažljivog postupanja koje lekar demonstrira prema svom pacijentu u skladu sa zaključenim ugovorom i onog koje nastaje po osnovu ponašanja iz koga je proistekao delikt. U tom smislu su ugovorne i deliktne dužnosti pažljivog ponašanja lekara načelno identične.

Prema medicinskom, ali i krivičnom, pravu lekar postupa suprotno svojoj dužnosti u dva slučaja. Prvo, kada istovremeno ili nevezano krši postojeća pravila struke (lekarske veštine), i drugo, kada krši ustanovljena pravila pažnje. Lekar koji je zanemario pažnju i na taj način prouzrokovao grešku ne može se radi izbegavanja odgovornosti pozivati na druga ista ili slična lekarska mišljenja ili na medicinsku praksu. Dakle, lekar se ne može osloboditi sopstvene greške (negativna ocena) tako


što će izneti primedbu da iste čine i drugi lekari. Što se tiče kriterijuma kojim se meri potrebna pažnja, on je objektivan samim tim što predstavlja profesionalno merilo koje ne važi samo za lekare i zdravstvene radnike, već i za zaposlene u drugim delatnostima. Pažljivo postupanje prema pacijentu odražava kvalitet u pružanju lekarske usluge. Kada se polazi od objektivnog standarda pažnje koji se smatra konstantom, misli se na onu koja se, prema nemačkom pravu, realno može očekivati od savesnog lekara istog ranga. Prema francuskom pravu, pažnja se može očekivati od dobrog stručnjaka koji je u istoj kategoriji i u istom rangu sa lekarom koji vrši procenu njegovog ponašanja. U anglosaksonskom pravu se ta procena vrši na osnovu ponašanja razumno kompe-tentnog lekara čije se ponašanje i poštovanje dužne pažnje procenjuje (2). Ovde se metodološki pravi razlika u ponašanju, premda se smatra da i stručna greška eo ipso sadrži u sebi nepažnju i to čini merilo za procenu ispravnosti postupanja u svakom pojedinačnom slučaju. Zato predstavnici nemačkog zakonodavstva uvek govore o potrebnoj pažnji (19), iako je očigledno, ukoliko se samo tumači zakon, da se ne može u pojedinostima propisati šta se smatra pažljivim, a šta nepažljivim ponašanjem, imajući u vidu da procena uvek zavisi od konkretnog slučaja.

Lekarske greške kao uzrok smrti

Neretko se greške zdravstvenih radnika, u prvom redu lekara, smatraju namernim i u slučaju fatalnog ishoda uznemiravaju porodicu pacijenta, javnost, ali i zaposlene u zdravstvenoj ustanovi. Ukoliko se za smrt pacijenta utvrdi krivica lekara i ako zbog toga bude osuđen, stvara se dilema šta se dobija tim činom? Ukoliko je lekar lišen slobode i ako na određeno vreme bude van struke zbog jednog fatalnog ishoda, šta mogu da očekuju drugi pacijenti i da li je u tom slučaju veća korist ili šteta? Ponu-đeni odgovor se nekome svakako ne bi dopao. Kada su u pitanju sudske presude na štetu lekara zanimljivo je da li su kao takve efektan oblik borbe protiv nepropisnog ponašanja lekara i njihovog „doprinosa” u nastajanju grešaka ili su podstrek za vrše-nje drugih nepodobnih medicinskih radnji. Taj problem je prisutan kod korupcije, s tim što ona ne mora imati značajnijeg uticaja na ishod lečenja, ali govori o prisnom odnosu lekara mitomana i pacijenta, davaoca mita. Međutim, ni tada nema garancije da podmićeni lekar neće napraviti grešku, jer nekada i najbanalniji tretman može dovesti do fatalnog ishoda.

Mnogo je dokaza da nijedna grana prava ne može da postavlja brane medicini iako, pravnički tumačeno, svaka hirurška intervencija predstavlja telesnu povredu, odnosno direktan atak na ljudsko telo, nezavisno što se vrši u cilju poboljšanja pacijen-tovog zdravstvenog statusa. Apsurd je da se zbog rizika i najjednostavnije medicinske radnje mogu izazvati katastrofalne telesne povrede. To znači da je visoki rizik redovni saputnik postupaka i ponašanja kako savesnih tako i nesavesnih lekara, da je uzročnik nemilih događaja, ali i faktor koji ih štiti od odgovornosti ili je značajnije pojačava.


Lekar mora činiti i ono što ne može, pa se često odlučuje na neizvesne i riskantne poduhvate prvo, zbog moralne i pravne dužnosti i drugo, zbog dostojanstva svoje profesije. Ukoliko pri tome pokaže potrebnu pažnju, ne može odgovarati za neuspeh učinjenog dela niti za nastala štetna dejstva (7). Sa druge strane, pogoršanje zdravlja ili smrt pacijenta uoči ili za vreme operativnog zahvata nisu sami po sebi pravi razlozi da se isti oceni kao protivpravan i da se lekar proglasi krivcem. Lekar može biti okrivljen ako pacijent nepredviđeno reaguje na korišćenu terapiju, ako propiše pogrešan lek u uverenju da je utvrđena dijagnoza ispravna ili ako svesno nastavi operativni zahvat, a bilo je poželjno da ga obustavi.

Krivična odgovornost je predviđena za učinioce teške ili grube lekarske greške koja za sobom povlači sudski proces i zahteva određenu krivičnu sankciju. Pre toga je neophodna njena klasifikacija, procena nastale štete i izvođenje zaključka, da li se i u kojim slučajevima može dogoditi savesnom i priznatom lekaru-stručnjaku. Praksa je da se za krivca proglašava samo lekar koji je prema svojim sposobnosti-ma i individualnom medicinskom znanju stekao mogućnost da se ponaša shodno očekivanjima, odnosno kao prosečno sposoban i savestan pripadnik određene specijalnosti. Uprkos svemu, nesavesno pružanje medicinske pomoći je potpuno opravdan razlog da se protiv neodgovornog lekara pokrene krivični postupak. Što se tiče krivičnog dela, ono postoji samo u slučaju da je lekar prima facie primenio nepodobno sredstvo ili nepodoban način lečenja (prihvaćena kažnjivost težih, grubih grešaka) prema obolelom.

Pravničko tumačenje je sadržano u činjenici da nastajanje lekarske greške ge-neriše materijalnu ili nematerijalnu štetu kod pacijenta i da se mora utvrditi uzrok njenog nastajanja kako bi se iskoristila kao dokaz na osnovu koga lekar (ne)može biti proglašen krivim. Pod štetom se podrazumeva narušeno zdravstveno stanje pacijenta iz koga je potrebno apstrahovati sve faktore osim direktne lekarske greške. Procenu i konačan sud o postojanju uzročne veze između lekarske greške i nastale štete po pacijentovo zdravlje donosi sudija na osnovu mišljenja medicinskih veštaka, odnosno na osnovu shvatanja pravne nauke i prakse (13). Kada je reč o uzročnoj vezi između lekarske greške i nastale materijalne/nematerijalne štete, tužilac mora dokazati da je lekar pogrešio i da je, u skladu sa saznanjima medicinske nauke i lekarske prakse, time doprineo nastajanju štete. Da bi lekar bio procesuiran i da bi snosio krivičnu odgovor-nost za sopstvenu grešku, izvesnost uzročne veze između štete i posledice mora biti utvrđena sa većom sigurnošću. Shodno navedenom, Nenadović, polazeći od najgore solucije, smrti pacijenta koja je nastupila kao posledica lekarske greške, i apostrofira da se uzročna veza između: „ … lekarske greške i smrti pacijenta smatra utvrđenom samo ako je sud, na osnovu mišljenja medicinskih veštaka, došao do zaključka da bi propisno ponašanje lekara spasilo ili produžilo život pacijenta sa verovatnoćom koja se graniči sa sigurnošću” (14). Verovatnoća koja se graniči sa sigurnošću znači stepen izvesnosti koji isključuje svaku razumnu sumnju (in dubio pro reo).


Greške zdravstvenih radnika su uobičajena praksa. Nastaju kao posledica nemara i postale su vrlo opasne po život lečenih pacijenata, što za neupućene može biti novi-na. Nezavisno da li su namerne ili nenamerne, lekarske greške su našle svoje mesto na spisku opakih ubica. Odnose više ljudskih života nego pripadnici organizovanog, surovog i narastajućeg kriminala. Nedavna studija koja je vršena za teritoriju Sjedi-njenih Američkih Država pokazala je da su treći uzročnik smrti, odmah iza kardio-bolesti i karcinoma.

Grafikon 1. Smrtni slučajevi u Sjedinjenim Američkim Državama kao posledica lekar-ske greške

Uprkos mišljenju da je nemoguće da zdravstveni radnik postupi protivno medi-cinskim pravilima, da ne postoji namerna lekarska greška i da načelo humanosti pred-stavlja par excellence paradigmu ponašanja, podaci iz pomenute studije i komentari ispitanika navode na suprotan zaključak. Izjave medicinskih sestara o slučajevima u kojima se pacijentima daju snažniji lekovi od predviđenih propisanom terapijom izazivaju pravu noćnu moru, bilo kod obolelih ili kod njihovih najbližih koji su svesni da im takva pomoć ne ide naruku. Frapantno zvuči podatak da hirurzi prilikom čak rutinskih operativnih zahvata nad pacijentima iz nekih razloga uklanjaju pogrešne organe ili delove tela. Pomenuto istraživanje je pokazalo da medicinske greške (ne precizira se da li su namerne ili nenamerne) nastaju u bolnicama i u drugim zdravstve-nim objektima u Sjedinjenim Američkim Državama i da imaju zajedničku dimenziju, da svake godine usmrte oko 250.000 ljudi, što je mnogo više od posledica respirator-


nih bolesti, različitih nesreća, moždanog udara ili Alchajmerove bolesti. Istraživači sa univerziteta Džons Hopkins (Johns Hopkins University School of Medicine) su u intervjuu za Vašington post (Washington Post) izjavili da su obuhvaćene sve kate-gorije lekara i da su operativni zahvati izvršeni nad pacijentima činili 80% smrtnih slučajeva. Dakle, ljudi više umiru od posledica korišćene medicinske usluge nego od bolesti za koju je ista pružena. Primer sigurno nije jedinstven, ali je poražavajući jer se odnosi na najrazvijeniji zdravstveni sistem na svetu, u kome se iz bruto domaćeg proizvoda (BDP) na godišnjem nivou za zdravstvenu zaštitu izdvaja oko 18.000 $ US per capita (27).

Zaključak

Pojam medicinske (lekarske) greške označava medicinski propust ili promašaj koji je sa

pravnog aspekta relevantan, jer jedino tako kvalifikovan može da pokrene odre-đeni oblik odgovornosti (disciplinska, krivična). Pitanje da li je lekar napravio grešku prilikom medicinskog tretmana pacijenta, ili je propustio da ukaže dužnu pažnju, više je pravničko nego medicinsko. Njeno nastajanje, procena štete, procesuiranje i sankcionisanje krivaca pitanje je prvenstveno za pravnike, o čemu merodavnu odluku može doneti samo nadležni sud. Što se tiče medicinskog kategorisanja ponašanja le-kara i konačnih ishoda njegovog poduhvata, to su u takvim slučajevima samo polazne tačke. U sudskim ili parničnim procesima sudija često sam ili uz pomoć medicinskih veštaka može pravilno da procenjuje težinu slučaja, s tim što nije dužan da se saglasi sa izjavom lekara učinioca greške i da preuzme njegov (medicinski) opus pojmova. To je ispravan stav, jer njegov opus u nekim stvarima može biti širi, ali i uži od prav-nog opusa koji se prilikom primene zakona uzima kao osnov za vođenje postupka. Iako je lekarska greška predmet pravne struke, zvaničan stav je da nije za svaku vrstu spornih postupaka, zbog kojih se učinioci sumnjiče, neophodno sudsko medicinsko veštačenje. Dakle, nije svaka lekarska greška povreda pravnih pravila i medicinske profesije, odnosno zdravstvene struke u užem smislu.

Pravničko razmišljanje ide u pravcu da lekarska greška može biti povreda usta-vom i zakonom garantovanih prava pacijenta i da nastaje samo ukoliko dođe do kršenja lekarskog dužnog postupanja. S obzirom na to da u zaključku ne može stajati pouzdana konstatacija, da zaista postoji namerna lekarska greška (iako su deo svakodnevice), neophodno je afirmisati zasluge veštaka koji mogu presudno uticati na određivanje sudbine lekara i visine nastale štete kod pacijenta. Pod veštačenjem se podrazumeva pomoć veštaka (stručnjak za određenu oblast) u postupku pred sudom prilikom utvr-đivanja činjenica u vezi sa lekarskom greškom. Pojam lekarske (medicinska) greške prisutan je u medicinskoj i pravnoj teoriji i praksi, iako za sada nijedna od njih nema preciznu definiciju datog pojma. To je sasvim razumljivo, jer lekarska greška ne može


biti decidno definisana, ali nema prepreka da neki autor saopšti njenu opštu, odnosno neodređenu formulaciju koja bi u krajnjem slučaju predstavljala samo deklarativno određenje. Osim posledica koje ostavlja lekarska greška, postoje i druge koje su u tesnoj korelaciji sa direktnim/indirektnim pružanjem zdravstvenih usluga i koje takođe mogu naneti fatalnu štetu. Pravna teorija se bavi klasifikovanjem i sistematizovanjem lekarskih grešaka i njihovih posledica u svakoj državi u kojoj je zdravstvena zaštita građana uređena propisima. S obzirom na to da u pravnoj teoriji pozicija namerne lekarske greške nije precizno određena, teško je očekivati da će u tom pravcu značajniji korak napraviti medicinsko pravo. Čak postoji bojazan da isto može uneti dodatne nejasnoće i doprineti rasplamsavanju sukoba između medicinske i pravne profesije. Njegova misija je u ocenjivanju i sankcionisanju postupaka zdravstvenih radnika, što kod istih, ali i kod pacijenata, izaziva novi talas nezadovoljstva.

Nastojanje da se u raspoloživoj literaturi pronađe izvor koji bi ciljano upućivao na namernu lekarsku grešku (osim primera o prodaji beba u Republici Kini) završilo je bez uspeha. To znači da se kao takva pre može negirati nego afirmisati, što je veoma dobro. Na kraju, lekar neće (a i ne mora pod bilo kojim uslovima) slepo slediti zakon, ako može efektno pomoći čoveku u ispunjenju njegove jedine prave želje, a to je posedovanje i očuvanje kvalitetnog zdravlja. Nijedan zakon ne sme uticati na lekara da zauzme suprotan stav od onoga koji je paradigma njegove humane misije. Uosta-lom, u praksi nisu poznati zakoni koji ljudima garantuju sreću, dok je sa medicinskim dostignućima drugačiji slučaj. Obostrana sreća pacijenta i lekara, kada se zdravstveni problem reši na zadovoljavajući način, teško da se može sa nečim uporediti. Tada se pacijent ne zahvaljuje nijednom zakonu, već lekaru za kvalitetno pruženu zdravstvenu uslugu, što znači (nije prejaka reč) da je on autoritet koji svesno odlučuje o svojim postupcima pomoću jednog zakona koji je najstariji i uvek pobeđuje, a to je ljubav prema poslu, profesiji, pacijentu… on isključuje pravo, sudiju, tužioca i predstavlja nagradu njegovoj savesti, jer u svom radu ne pravi razliku između onih koji sude i onih kojima se sudi i presuđuje.

47THE LEGAL UNDERSTANDING OF INTENTIONAL MEDICAL ERROR

Mirza Totic1 THE LEGAL UNDERSTANDING OF INTENTIONAL MEDICAL ERROR

Abstract: The paper is devoted to doctor, a professional and humanist who dedicated himself to medicine and is committed to lifelong learning, ethics and assistance to victims, even against their express consent. The theme is focused on the problem of intentional medical error in order to negate it in the context that the conscientious doctors should be pro-tected from tort and free of moral burden. This paper seeks to answer the question, if the error represents a doctor’s failure to the detriment of the user (patient), how should we treat his attempt, made professionally and with the best intentions, regardless of the fatal outcome? In addition, medical-legal theory and practice beside intentional medical mistake mention also the unintentional, whose formation does not require any kind of responsibility because the doctor’s behavior in that case was not inconsistent with medical ethics, standards and rules. In this regard, the author’s research was based on the following questions: is there a deliberate medical error, who is ready to knowingly endanger the patient by doing medical procedures contrary to the rules (neglect, avoidance of assistance, misdiagnosis, improper treatment, indifference, discriminati-on), who is competent to qualify the taken action as an error (intentional, unintentional) and what evidences are required for the brutal attack on the integrity of top experts, that will be charged and prosecuted?

Literature abounds with assertions that medical errors are as old as me-dicine, which is not true. Also, it is incorrect to say that it had appeared for the first time in the middle of the nineteenth century. That would be a roughly canceling of ancient medical marking, bearing in mind that even before the mentioned period, there had been a very successful medicine with high quality doctors and their brilliant achievements, but also with illnesses and dead persons. As far the data on the exact occurrence of medical errors are considered, the numerous authors claim that it does not have to be communicated, since it is placed in the field of history, that unlike many science is not exact, and should not always be considered as reliable. Any medical error makes a multiple interests, firstly of the researchers in the true sense of the word, and secondly, of the sensatio-

1 Internacional University of Novi Pazar, e-mail: [email protected]


nalist columnists. The latter see the culprit only in the doctor, because many of them never presented the scene when defeated doctor leaves the Service ambulance, clinic, emergency room or any other health care area, because the most terrible thing in the profession has happened -the lost of a patient. Sensationalists are rarely present when despair and tears are being replaced by joy, smile and exaltation. They do not understand that it is impossible to meet the doctor who will be prepared to deliberately violate the profession, ethical values, Hippocratic oath, to directly endanger the health or life of the patient, or make a deliberate mistake and commit an offense.

Key words: medical errors, patient, medical standards, medical law, expertise

Introduction

Discussions about medical errors traditionally cause the heated controversies. In the case of its existence, the invited and uninvited persons, mostly lay people, appear by inertia to express their opinions, to argue whether the mistake was done intentionally or unintentionally, and to make an early pre-judgment with no relevant evidences. It is interesting that a large number of theorists participate in these public discussions while without any doubt put the doctor in the epicenter by ascribing him the intentional violation of standard medical rules, knowingly acting contrary to good medical practice and disregard of elementary medical ethics, unprofessional attitude towards the patient and, the worst, behavior contrary to his own profession. When it comes to medical error prima facie it is a disregard of rules that constitute the essence of the relationship between doctor and patient, where the behavior of medical professionals is particularly emphasized (5), primarily the behavior of doctors. This attitude is acceptable, but it does not mean that the doctor’s disrespect of the mentio-ned rules must always cause a deliberate error difficult to be properly evaluated and consistently explained. The lawyer’s interpretation would be (12) that the medical error is a doctor’s conscious act made contrary to the rules of medical profession (lat. Contra legem artis) or non-compliance of medical standards, regulations, rules, procedures and measures that suppose to lead him, but in this case it was contrary, which generated and caused the damage to the patient. If the intentional medical error was proved and the patient’s damage was identified (17), in that case it is quite natural to take actions provided by medical ordinance and / or law against the doctor (offender), but acting in good faith is highly recommended.

Firstly, the public opinion should not be taken into account at any cost for all the problems under the roof of a health institution, since it always exclusively blames doc-tors, claiming that they should be objects of criminal proceedings. Secondly, medical


error implies the existence of irrefutable evidence of unprofessional performance of the health actions with consequences, as the only basis on which the doctor may be criminally responsible. Thirdly, the doctor’s responsibility also exists when it comes to mistakes caused by irresponsible behavior of other health care workers, even tho-ugh it sometimes might not seem ethical. However, a doctor who has professionally done his job without hinting by any chance at an unfavorable outcome, might be held responsible for mistakes of other health care workers, if did not professionally controlled their behavior. In all countries an identified intentional medical error is sanctioned under the criminal law. However, not every doctor’s failure has to be an object of a criminal conduct, for the simple reason that health care laws precisely regulate the work and behavior of doctors and health care institutions and a large number of sophisticated cases is resolved within the institutions, therefore, on the level and within the profession.

General interest is to be known and therefore shall not be denied that the Cri-minal Code stands in the shadow of the Health Care Act, that its promoters (judges, prosecutors, lawyers) do not have medical training or required expertise to adequately assess the work of doctors and other health workers, for which the profession has the only competence. It is not about the competing of medical and legal institutes or their representatives, on the contrary, it’s about emphasizing the importance and respect of the professions, of which there are, according to professional opinion, only three in the world (28), the medicine, law and priesthood. Others activities are considered to be occupations, trades, skills, etc. It is illusion that the behavior of doctors (and other health workers) is regulated by law, it represents more a reflection of pre universal human education, demonstration of their culture, lifestyle, manners, or the right to personal choice, which is the pinnacle of human freedom (23). However, that must not be understood as a guarantee that every conscientious doctor would not act contrary to the law just because of personal manners (5) and that before entering the clinic, surgical theater or counseling, or pre direct contact with the patient, he would read the legislation to choose his behavior.

It is not enough just to make a statement about doctor’s behavior when the professional error has occurred, because that is not the right proof and offers no real reason. Therefore, the evidence is mostly determined through expertise, conducted by professionals (expert) in order to clarify the facts. Expertise requires necessary professional skills (expert) that the court does not need at disposal in particular case, although it could be characteristic and associated with complex criminal or civil co-urt proceedings. The expert must possess the necessary knowledge in addition to the power of professional reasoning, because he might be called to a hearing regarding the issues from a variety of professional and scientific fields (medicine, transport, building, finance, etc.). The role of expert is to provide the lawyers with professional advices, support and judgment on the field that is the subject of discussion and to


inform them about different areas of human activity, to which the lawyers regarding their own general and special legal education are not very familiar with.

The goal of the paper

The aim of the paper is not to be understood only as pretentious glorification of conscientious doctors who, through their professional actions and achieved results, have managed to certify own values and take the rightful high place in the first social ranks (15), it is also the odium for all those willing to dirty procedures, also called “doctors”. Since the medical errors are constantly and with a lot of arguments equally debated in academic (16) and professional circles (22), but also in the media (1), it would be irresponsible to deny their existence. However, at first place we should take a medal in hand to make sure that it really has two completely different sides and then make a clear distinction between intentional and unintentional errors, or between procedures of conscientious and unscrupulous doctors. The current medical practice has not achieved much in sanctioning the doctors who expressed unfair intentions, but also the other instances which are called to evaluate the consequences of similar behaviors have nothing to be proud of. The main goal of this paper is the negation of intentional medical error. If it really comes to it, which must be proven, it has to be followed by the determination of the essence and the assessment of the readiness of legal institutions to sanction the doctor (offender) on the basis of valid evidences and established facts.

The essence of medical error

At first, it should be noted that the medical error exists in a wider and narrower sense. In a wider sense, it does not have to be an expression of violation of the medical profession rules, but also a violation of rights guaranteed to the patient in the field of health care and broader violations of the rules of conscientious medical treatment. It has been in the middle of the interest of lawyers and doctors for more than a half of century, and represents one of the most important problems that medical law is con-stantly facing. Being aware of it, well-known theorists (McKee, Mossialos, Belcher) have no doubt to place the responsibility of health professionals in front of all the functionalities in the context of health services, primarily doctor’s, and the existence of certain risks that are an obstacle to providing the adequate health care to the ci-tizens, as a universal and safest resource (6). This attitude is formed on the basis of knowledge on the long-term behavior of doctors, their numerous errors and omissions of other health professionals, the quality of provided medical services and patient’s satisfaction. Common mistakes have aroused interest of participants of legal theory


and jurisprudence and intensified their intention to find effective criminal legislation that would allow the use of precise determination of crimes and an end to the large number of criminal procedures unsuccessfully conducted for many decades.

The resulting medical errors, in addition to being an act of negligence or doctor’s conduct contrary to the rules of profession (contra legem artis) in terms of gross violation of medical standards, in the same time represent the basis for a cri-minal or other responsibility. Modern understanding of medical and legal doctrines goes in the direction that doctor makes a deliberate error (debatable question) first, because of the lack of information about the existence of new scientific knowledge about the possibilities of application of modern technological and medical advances and / or, if he was aware of their existence, but did not use them at a given moment despite all possible options on his disposal. The doctor also makes a mistake if he does not realize in time that the medicine is like no other science subjected to drastic changes and that modern scientific knowledge is part of everyday life. He improperly demonstrates unserious understanding of his profession, avoids the labor liabilities and causes the suffering of patient. However, the mentioned views in medical sci-ence are causing different opinions. In fact, many contemporary methods, models, procedures or actions can be recognized by a large number of eminent medical experts, which does not mean that they must be generally accepted, recognized and applicable in every situation. Doing so will not highlight the intention to erase the doctor’s fault, but will open a new question, does he really make a mistake while acting solely according to his conscience? Is it possible that someone who insists on health educational work, education of the patient, management of quality of life, preservation and improvement of the collective health and / or providing technical assistance, who prescribes quality therapy or successfully perform complex sur-geries, might consciously (deliberately) make mistake, and make the things to go wrong? Unfortunately, it is possible and then the whole case becomes interesting for the public prosecutors, judges and lawyers.

Despite the doubt about the intentional medical error, doctors definitely make mistakes in many cases. It must be borne in mind that medical science is very dynamic and its standards are changing rapidly and continuously in accordance with present situation in the science and practice while being modified, extended and applied after the upgrade (8). The doctor, as a professional who has sworn to lifelong learning, has an obligation to keep abreast of modern medical trends (9) and must additionally count on a steadily growing level of health education of citizens (insured-patients). Nevertheless, medical error rarely occurs because of a violation of medical standards, because every doctor is expected to make a brilliant attempt in the care of the patient, regardless of the fact that many expectations will not be realized. If such an attempt was not made, it is not the standard’s fault, but the doctor, a negligent to whom even a good standard cannot help. Good standard, claims Kacenmajer, is not easy to determi-


ne, particularly in medicine where there is no comprehensive code of solid rules that guarantee the safety and quality from which, now and then, the state of science could be reliably seen (3). Since the medical science and medical experiential knowledge are subjected to constant changes, as a very common problem arises the setting of the standards that will be in force at the time of providing the medical services, which suggests that doctor is not, and may not always be able to choose the safest one. If fails in the selection and application of the correct standard, the doctor should be aware that by doing so he takes a greater risk to the patient in terms of healing and must be justified for any actions taken on his own initiative (29), without being contained in a chosen standard.

Many theorists faced with everyday events in the medical or legal profession and practice are searching the reasons for which the equilibrium point in the behavior of health workers (doctors) was moved from criminal to civil liability. So far they have come to knowledge that the main reason is the fact that the legal theory until recently was significantly dealing with their criminal, rather than civil liability. The main rea-son for the doctor’s responsibility was, at first, in hiding the violations of obligations which are reflected as a violation of due diligence (10) during the medical treatment of the patient and, second, the deliberate taking of medical acts towards the patient without his or her expressed consent. However, this variety of reasons is extending to offenses that doctors made doing other life activities (participation in the crime), although they have no direct contact with medical actions (diagnostics, medical trea-tment, surgical procedures, inadequate protection of pharmaceutical, etc.). It is very important to understand the doctor as a person, expert, professional ethics, but it is also important to separate his health work from other types of activities that might be doing in life. Therefore, we must distinguish the actions of doctor when he makes deliberate error from the one made as a citizen, although both are usually made in a health institution or in some other place where contact has been made between doctors and patients (or their intermediaries). In this case, “the doctor” is not a doctor, but a criminal who abuses his position, smears his profession and insults branch invited to professionally protect the health of patients.

Due to the complexity of the concept of medical error, it is essential to separate the failure to treat a patient with mistakes during the treatment. The failure of the treatment may not always be caused by medical error, because there are cases when doctor (or entire team) has the best intention and desire to achieve the desired outcome and does everything what is and what is not allowed in medicine. The rule is that a conscientious doctor never takes ex ante risk to himself, and never gives unrealistic estimates and guarantees for successful treatment (18), because such behavior wo-uld be the culmination of frivolity and hypocrisy. However, any doctor according to all conditions can guarantee conscientious, professional and effective actions in the treatment, which is drastically different. On the other hand, doctor should not be


expected to do the impossible, but the success can be expected, even though it does not depend exclusively on his expertise, skills in performing various medical actions or instruments and tools at disposal. It was never asked how the success was achie-ved, because its value makes minimal any error, if such exists. In many situations the treatment outcome is largely tied to the type of disease, stage of the illness, urgency of the patient’s receipt, time of occurrence to doctor, psycho-physical characteristics of the patient, capacity of opportunities for successful treatment, although the factor of luck must not be ignored. In other situations might happen that the doctor (or the whole team) has performed all medical acts very professionally, but the patient due to lack of the necessary capacity has not been successfully cured and such outcome is considered as a failure in treatment. In this regard, it is very important to make a distinction between medical error and accidents. The above-mentioned situation, from a legal point of view could be seen as controversial, because it contains a legal assessment of the treatment, which is not always enough, and that’s why there is still no clearly drawn boundaries between them.

This estimate is accepted in almost all legal systems because of the request to meticulously and carefully, medically and legally review all cases, in order to find the error in the assessment for which the doctor could be marked as the culprit. In countries with Anglo-Saxon legal system (United States of America, Ireland, United Kingdom, Canada) medical error is better clarified by adopting the terms: medical malpractice (malpractice) that applies to the legal concept of medical responsibility for the damage caused to the patient (21). Confirming the previous quote Mujović-Zornić provides more detailed explanations pertaining to other concepts. She distinguishes active error that occurs at the operational level, whose harmful effects are directly visible to the greatest extent (11). According to her opinion, the common error is synonymous for failure to achieve the planned medical action as intended, or the act of applying the wrong plan for achieving the goals. She observes the latent fault for which is known to lead to operational errors and whose effects typically remain in the system invisible for a period of time (12) through different events, usually in the form, organization, training, or maintenance. In previous comments on the deliberate medical error there is no cases which might confirm that doctor’s behavior to the patient was unprofessional, the result of carelessness, ignorance or intentionally false performing of illegal medical activities.

There are a lot of cases with no direct connection to the treatment of medical errors and they are mainly elaborated by the media. The latter inform the public about the participation of doctors in the dirty business (sale of babies, mysterious disappe-arances of children in maternities, newborns declaring as dead, selling organs, etc.), which are not directly related to the treatment, but in the end make an important link in the chain of organized crime. The news (24) that in the Republic of China, a co-untry that has a problem with respect for human rights, the “doctor” who kidnapped


and sold several babies from the hospital where she had worked, is condemned to death, strongly echoed. It was a very morbid recognition that she usurped the babies, but only after saying to parents that they have inherent faults for which should not be accepted. She is the members of organized crime who cooperated with the kidnappers and sold babies in other Chinese provinces and cities. According to the quoted source, after the kidnapping of a boy she earned around 3.5 thousand US $, while the vendors will later cash in almost 10 thousand USA $.

Authorities dealing with health care consider that medicine is facing problems when the role and importance of preventive health care is underestimated. This means since its promotion in 1978 in Alma-Ata (Kazakhstan), through conferences in Riga (Latvia) in 1988, in Ljubljana (Slovenia) in 1996, and so on, when it was meant to be a pillar carrier in the protection of human health (27). Taken attitude did not survive and today in every country in the world we have on the scene a “skip” of medical levels and search for assistance at higher ones (secondary, tertiary care), where the patients who cultivate this practice are mostly at lost. Then, it is usually too late for successful medical intervention, which figures as a failure in the treatment, late reaction, not belonging to the chosen doctor, etc. Is it necessary also in this case to search the me-dical mistake at any level? No, because there is no question of deliberate misconduct of doctor to the patient, and secondly, the patient has the right to choose a doctor and in such cases acts conscientiously, regardless of the warning of his chosen doctor to comply with professional advices and to be disciplined in relation to his own health status. Starting from the fact that the prevention has lost its position in medicine (25), despite being able to favorably solve many accidents, rises the question, how the judi-cial system reacts and is there any basis to require a deliberate mistake of any doctor in such cases. Clearly, it might occur and every person conscious of principles errare humanum est must count on it, but still remains the question is it human to deliberately make a mistake so the final outcome would be fatal? Of course not, and that is why it is so difficult to claim that while treating the doctor deliberately makes a mistake and harms the patient. In the Old China long time ago, in the book ‘’The cannons of medicine’’ (“Nuci King”), which is considered to be the work of emperor Xuang Tia from 2800 bc, was particularly emphasized the rule that: “... medicine cannot save nobody from death, but it has the capacity to prolong life, to strengthen morale, by enhancing the virtue and eradicating the vice as a mortal enemy of health. Medicine cannot cure many diseases that affect the poor humanity ... but tries to strengthen the nations and state, by providing the hygiene advice “(14).

Medical law and medical error

Scientific medicine has much earlier, but especially at the end of XX and be-ginning of XXI century, began its expansive development. Practical application of


modern achievements has contributed mostly to the advancement of global health and quality of the development of modern health care systems. In that way it provided the high status to a global healthcare and made it a very important social function. (26). The new findings, which are characteristic of modern scientific medicine are almost immeasurable, and reflected in precision diagnostics, modern operational methods and procedures, effective therapeutic procedures and / or delivering a large number of possibilities for solving the complex problems. The inability of some countries to apply contemporary achievements does not diminish their importance, because the states which are not lagging behind in development and readily and regularly apply them, had achieved outstanding results long time ago. Meaningful and quality scien-tific medicine is the best guarantee to policyholders / patients that they can count on modern medical treatments, modern health care and that they can have hope for a better treatment and a final cure. On the other hand, doctors and other health care workers, at once have become additionally responsible professionals not only to patients but also to the profession and community as a whole, to which overall development they give a significant contribute. Therefore, the relevant authorities were forced to take seriously their position and to make actions in order to protect them, primarily from incorrect procedures of dissatisfied patients whose needs for professional care and protection are the most numerous. For that reason, in the last decades of the twentieth century, arised the idea that medicine law as a new scientific discipline should be developed, in order to regulate the specific legal field and to solve difficult medical and legal problems.

Medical law is a branch of law which contains legal norms that regulate all types of relations between the insured persons / patients and medical workers in the context of medical activities, but also within the health system as a whole. They are the tools by which the community establishes and maintains external monitoring of the work and behavior of health workers, mainly doctors. The aim of control is to protect the guaranteed rights and interests not only of health professionals but also patients and policyholders. However, we should bear in mind that no matter how great the power of medical law and its norms was, there should not be place for great optimism and even less for unrealistic expectations that their application will lead to a quick and easy solutions, that will successfully unravel highly intri-cate relationships. Practice has shown that very quickly. Doctors and other health workers perceive medical law as a threat. So, It has become the target of criticism for being invasive and seen as something that directly inhibits the development of medicine in general, because excessively interferes in their work and competence. In this regard the opinions are divided. Many believe that the health workers led by doctors are more convincing in their claims, and that the legal theory and legal place has the place in courtroom, while others think that doctors and other health workers disapprovals are unfounded, since the medical authority has no right to


create mistrust between them and patients. Mutual distrust has created a space where the law is called to intervene.

When it comes to intentional medical error, the role of medical law is negligible in relation to the criminal law. Bearing in mind that represents the violation principle of the prescribed professional and ethical duties, it is essential to establish the facts about its relevance and impose a qualification of being done intentionally. The asses-sment starts from the point that the offender is reasonable, competent and responsible person, creating a dilemma, is it ready for the kind of behavior that results in violation of the requirement. In addition, each doctor’s behavior is reflected in a particular act or omission of the doctor to the patient (while giving diagnosis, prescribing therapy, especially for complex surgeries and medical care before and after serious medical treatment), so it is very difficult to properly assess whether it is a conscious intention or omission. When the German experts give the legal assessment, it is the duty of communication (20), and when is done by the French or American lawyers, it becomes the duty of care (4). The conclusion is that there is no essential difference between the duty of careful treatment by a doctor who demonstrates it to his patient in accordance with the agreement, and the one that was formed on the basis of behavior from which a felony derived. In this sense, the contractual and tort duties of careful behavior of doctor, in principle, are identical.

According to medical and criminal law the doctor acts contrary to his duty in the two cases. Firstly, when simultaneously or unrelated to his profession violates the existing rules (medical training) and secondly, when violates the established rules of attention. The doctor who has ignored the attention and caused the error cannot rely on other equal or similar medical opinions or medical practice in order to avoid liability. Thus, the doctor cannot free himself from his own mistakes (negative score) by making the objection that the same thing happens to other doctors too. As for the criteria used to measure the necessary attention, it is clearly objective, since representing the professional criterion that applies not only to doctors and health care workers, but also to employees in other industries. Careful treatment of the patient reflects the quality in the provision of medical services. When starting from the objective standard of attention that is considered to be constant, according to German law, it is the one that can realistically be expected from conscientious doctor of the same rank. According to French law, the attention can be expected from a good expert placed in the same category and the same rank with the doctor who evaluates his behavior. In common law, this assessment is done on the basis of behavior of reasonably competent doctor whose behavior and respect for due diligence are being estimated (2). It is methodological distinction, although it is considered that the expert error eo ipso embraces the negligence which makes the criterion for assessing the safety of treatment in each individual case. Therefore, representatives of the German legislation always talk about the necessary attention


(19) although it is obvious, if only interpret the law, that cannot be prescribed in detail what is considered as careful, and what is negligent behavior, keeping in mind that the assessment always depends on the specific case.

Medical error as a cause of death

Often the mistakes made by health workers, mainly doctors, are considered to be deliberate and in the case of fatal outcome disturb the patient’s family, public and employees in the health institution. If patient’s death was caused by a doctor whose guilt is proven and he gets convicted, it creates a dilemma, what is the real point of all that? If the doctor is arrested, it means that he will spent a specified time out of the profession because of one fatal case, but what the other patients might expect and does it really bring greater benefit or harm? Not everyone will be pleased with offered answer. As for the issue of a court judgment at the expense of doctors, it is interesting to determine are they an effective form of struggle against the misconduct of doctors and their “contributions” in making mistakes or just an incentive to carry out other unsuitable medical actions. This problem is present in corruption, but it does not have a significant impact on the outcome of the treatment, although showing the intimate relationship of doctor and patient, the one that gives the bribe. However, there is still no guarantee that the bribed doctor will make a mistake, because sometimes even the most banal treatment can lead to a fatal outcome.

There is a lot of proves that none of the branches of law cannot put obstacles to medicine, although legally interpreted, every surgical intervention represents a bodily injury, or a direct attack on the human body, regardless of the fact that was made in order to improve the patient’s health status. The absurdity is that catastrophic injuries might be caused just because of the risk of the simplest medical actions. This means that high-risk is a regular companion of actions and behaviors of conscientious and unscrupulous doctors, that causes the unfortunate events, but also a factor that pro-tects them from liability or may just significantly increases it. Doctor must do even the things that cannot be done, and often decides to take uncertain and risky ventures firstly, because of the moral and legal obligations and, secondly, because of the dignity of his own profession. If he shows necessary attention, he cannot be responsible for the failure of the treatment nor the resulting adverse effects (7). On the other hand, the deterioration of health or death of patients, prior or during the surgery, are not the real reasons the assessment of the intervention to be unlawful and not reliable enough to declare that doctor is guilty. He might be blamed if the patient unexpectedly reacts to the used therapy, if he has prescribed the wrong medicine in the belief that the established diagnosis was correct or if deliberately has continued the surgery, when it was desirable to cancel it.


Criminal liability is provided for perpetrators of serious or gross medical error which entails the judicial process and requires specific criminal sanction. Before that, its classification and assessment of caused damage must be given, but also the conclusion has to be made, whether and in what cases it might occur to conscientious and recognized doctor-specialist. In practice, as the culprit may be declared only the doctor, who according to his own abilities and individual medical knowledge, has gained the capacity to behave according to expectations, respectively as the average capable and conscientious member of a certain specialty. Nevertheless, the negligent provision of medical care is completely legitimate reason to initiate criminal proceedings against the irresponsible doctor. As for crime, it exists only in the case that the doctor has applied (prima facie) obviously inappropriate means or inappropriate method of treatment (accepted the culpability of severe, gross errors) to the patient.

Lawyer’s interpretation is contained in the fact that the formation of medical error generates tangible or intangible damage to the patient and therefore must be determined the cause of its creation in order to be used as evidence by which the doctor will (not) be held guilty. The damage is assumed as deteriorated state of health of the patient from which it is necessary to abstract all factors, except direct medical error. The assessment and final judgment on the existence of a causal link between medical error and resulting damage to the patient’s health, will be given by the judge based on the opinion of medical experts, and understanding of legal science and practice (13). When it comes to causal link between medical error and the resulting tangible / intangible damage, the prosecutor must prove that the doctor has made a mistake, and that according to the findings of medical science and medical practice it led to the caused damages. In order to prosecute the doctor and to incur criminal responsibility for his mistake, the surety of the causal link between the damage and the consequ-ences must be established with greater certainty. Accordingly, Nenadović starting from the patient’s death, as the worst solution, that occurred as a result of medical error, emphasizes that the causal link between “... medical error and patient’s death is considered as established only if the Court, based on the opinion of medical experts came to the conclusion that the properly conduct of doctor would save or prolong the patient’s life with probability bordering on certainty “(14). It means a degree of certainty which excludes any reasonable doubt (in dubio pro reo).

Health worker’s errors are common practice, since they occur as a result of negli-gence and become very dangerous for the life of treated patients, which is something that might be new for the uninitiated persons. Whether intentional or unintentional, medical errors have found their place on the list of vicious killers. They take more lives than members of organized, brutal and growing crime. A recent study carried out on the territory of the United States showed that they are the third cause of death, just behind cardiovascular diseases and cancer.


Figure 1. Deaths in the United States as a result of medical error

Despite the opinion that it is impossible the health worker to act contrary to me-dical rules, that there is no intentional medical error and that the principle of humanity represents a paradigm of behavior par excellence, the data from the aforementioned studies and comments of respondents have imposed the opposite conclusion. Sta-tements taken by the nurses regarding the cases where a patient was given stronger drugs than previously prescribed by therapy, induce a nightmare for patients or their relatives, who are aware that such assistance will not be helpful. Sounds schocking the fact that surgeons even during routine surgical procedures on patients for some reason have removed the wrong bodies or parts of it. This research has shown that medical errors (does not indicate to be intentional or unintentional) occur in hospitals and other health facilities in the United States and have a common dimension, to cause the death of about 250 thousand people every year, which is much more than from respiratory diseases, different accidents, strokes or Alzheimer’s disease. Researchers from Johns Hopkins University School of Medicine stated in an interview with the Washington Post, that they have covered all categories of doctors during the studies and data showed that performed surgeries on patients accounted for 80% of deaths. It comes down to the fact that more people died from the effects of used medical services than from the disease for which the latter was provided. This example is certainly not unique, but it is devastating because applies to the most advanced medical system in the world which for health care annually gives from gross domestic product (GDP) about 18 thousand US $ per capita (27).


Conclusion

The term medical error is used to indicate a medical omission or failure, which is relevant from the legal aspect, because only in that way can be qualified to initiate a certain form of responsibility (disciplinary, criminal). The question, whether the doctor has make a mistake during medical treatment of the patient, or has failed to show due care, is more legal issue than medical. Its formation, assessment of damage, prosecution and punishment of the culprit, is primarily a question for lawyers, since the authoritative decision can be made only by the competent court. As for the medical categorizing of doctor’s behavior and the final outcome of his endeavor, these are only the starting points in such cases. In judicial or litigation processes, judges often alone or only with the help of medical experts can properly assess the severity of the case, but they are not bound to agree with the statement of the doctor who made a mistake and to take his (medical) opus terms. This is the correct position because doctor’s opus in some matters might be wider or narrower than the legal, which is during the application of law taken as the basis for the proceedings. Although the medical error is subject of the legal profession, widespread opinion suggests that it is not necessary to provide forensic medical exper-tise for every type of controversial actions for which the perpetrators are suspected. So, not all medical errors represent the violations of the legal rules and medical profession, respectively the medical profession in the narrow sense.

Lawyers claim that medical error could be a violation of the constitutionally and legally guaranteed rights of patients and occurs only if there is a violation of due medical treatment. Given that the conclusion cannot contain the reliable ascertainment that a deliberate medical error really exists (although is been a part of daily life), it is necessary to promote the merits of experts who decisively influenced the determination of the doctor’s fate and the amount of caused damage to the patient. Expertise is defined as the assistance of an expert (an expert in a particular area) in proceedings before the court while determining the facts in regard to medical error. The term medical error is present in the medical and legal theory and practice, although neither of them currently does not offer the precise definition of it. This is quite understandable, because medical error cannot be precisely defined, but does not do any harm if an author communicates its general or vague formulation in order to provide only some declarative attributes. Except those left by medical error, there are other consequences that are highly corre-lated with direct / indirect provision of health services and which might also cause fatal damage to their users. Legal theory deals with the classification and systematization of medical errors and their consequences in each country where the health protection of citizens is regulated by legal norms. Given that the legal theory does not define precisely the intentional medical error, it is difficult to expect that in this regard a significant step will be made by medical law. There is even a fear that the latter might bring additional confusion and contribute to flare-up the conflicts between the medical and legal profe-


ssions. Its mission is the evaluation and sanction of the acts taken by health workers, which among them, but also among patients, cause a new wave of discontent.

The effort to find a source in the available literature specifically referred to the deliberate medical error (except the sale of babies in Republic of China) ended without success, therefore, as such, it might be rather negated than affirmed, which is very good. In the end, the doctor will not (and should not under any circumstances) blindly follow the law, if he can effectively help a man to fulfill his one true desire, reflected in possession and preservation of quality of health. This means that any law must not affect the doctor to take the opposite view from that paradigm of its humane mission. After all, there are no known laws that guarantee the happiness to people, but the opposite might be said for medical advances. The mutual happiness of patient and doctor cannot be compared to anything, when a health problem is solved in a satisfactory manner. Then, the patient will not be thankful to any law for high-quality provided health services, but to doctor, which means (not a too strong word) that the latter is the authority who consciously decides on his own actions according to only one law which is the oldest and always wins, and that is the love of work, profession, patient ... it excludes the law, judge and prosecutor, it is a reward to his conscience, because while doing his work he does not make a distinction on those who judge and those who are being tried and judged.

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