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O tratamento médico e a sua recusa : uma análise à luz do direito penal
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O avanço da medicina, por muito vantajoso que possa ser, acarreta também dificuldades para os profissionais de saúde e para os pacientes.
Atualmente verificamos, pelo menos na maior parte dos campos que à medicina diz respeito, uma mudança de paradigma. Abandonou-se a época de paternalismo que se encontrava presente na época de Hipócrates dando-se lugar ao surgimento do princípio da autonomia do paciente.
Com esta evolução surge o conceito de consentimento, algo que foi tomando contornos mais vincados à medida que o paciente, enquanto parte nas intervenções médicas, foi assumindo um papel mais relevante.
Ao longo da dissertação iremos centrar a nossa atenção nos casos de recusa de tratamento médico, com especial incidência nas transfusões de sangue. Esta recusa, ainda que possa ter como fundamento diversos motivos recairá, essencialmente, na que tenha por base motivos religiosos. Falamos aqui das Testemunhas de Jeová.
Hoje em dia é impensável, salvo raras exceções, proceder-se à realização de um tratamento ou intervenção médica sem, a título prévio, se obter o consentimento do doente para a mesma. As atuações dos profissionais de saúde já não se realizam à margem do paciente, antes pelo contrário. O doente é, nos nossos dias, o detentor do poder quanto ao destino da sua saúde.
As exceções que se verificam à ideia que supra se mencionou prendem-se, essencialmente, com a incapacidade, isto é, caso um paciente não reúna os pressupostos necessários para prestar o seu consentimento, não poderá este decidir sobre a atuação dos médicos.
As situações tendencialmente mais problemáticas ou que, pelo menos, mais discussão têm criado, situam-se nos menores. Estes, em virtude da idade que possuem são tidos como incapazes para decidir relativamente a questões médicas, nomeadamente à recusa de um tratamento. Como se verá, neste tópico a solução que tem sido apresentada não é alvo de concordância por nós, suscitando-se muitas questões que, salvo melhor opinião, deveriam ser melhor apreciadas.
Nesta dissertação serão também abordados os contornos das DAV, nomeadamente, qual o fundamento da sua existência, que pressupostos têm de se encontrar como preenchidos para que sejam válidas e qual a relevância que lhes deve ser atribuída, isto é, procurar-se-á determinar se têm carácter vinculativo ou indicativo.
Ainda referente à recusa de tratamento médico será abordada a existência de tratamentos alternativos às transfusões de sangue, os riscos que se encontram associados às mesmas e, ainda, se o paciente que recusa uma transfusão de sangue com base em motivos religiosos pode ser considerado um suicida.
Entendemos que a doutrina, não tem acompanhado totalmente a evolução que se tem feito sentir no seio da medicina, olvidando ou, até mesmo, não conhecendo que existem tratamentos alternativos às transfusões de sangue que não comportam riscos e que deveriam ser garantidos ao paciente. Só desta forma poderá este ter um verdadeiro direito de escolha e não se encontrar confrontado com o cenário de “se não escolheres a transfusão de sangue, não és tratado”. Se existem tratamentos alternativos, afigurando-se como mais benéficos e comportando menos custos, não poderá o paciente ver a sua vontade negada e ser equiparado a um suicida. Também no caso dos menores consideramos que alguns pontos não são corretamente avaliados, nomeadamente na ausência de atribuição de poder decisório aos pais quando decidam de forma contrário ao que o profissional de saúde entende ser o melhor para o menor.
Assim, em alguns aspetos, partimos do entendimento de que a recusa de tratamento médico poderá, ainda, ver-se presa numa lógica de paternalismo médico, não retratando, como devia, o princípio da autonomia do paciente. Ao longo da exposição que se segue deixaremos mais clara esta ideia com base em diversos argumentos.
The development of medicine, however advantageous it may be, it also poses difficulties for health professionals and patients. We are now seeing, at least in most fields that concern medicine, a paradigm shift. The period of paternalism that was present in the time of Hippocrates was abandoned, giving rise to the emergence of the principle of patient autonomy. With this evolution emerges the concept of consent, something that was taking more defined contours as the patient, as part of the medical interventions, took on a more relevant role. Throughout the dissertation we will focus our attention on cases of refusal of medical treatment, with a special focus on blood transfusions. That refusal, although it may be based on several grounds, will depend essentially on that which is based on religious grounds. We speak here of Jehovah's Witnesses. Nowadays it is unthinkable, with rare exceptions, to carry out a treatment or medical intervention without, prior to obtaining the consent of the patient to the treatment. The actions of health professionals are no longer performed on the patient without his knowledge, rather the opposite. The patient is, in our day, the holder of power as to the fate of his health. The exceptions to the idea mentioned above relate essentially to incapacity, that is to say, if a patient does not meet the necessary conditions to give his consent, he can not decide on the performance of the doctors. The situations that tend to be more problematic or that, at least, more discussion have created, are about minors. These, by virtue of their age, are considered to be incapable of deciding on medical matters, in particular refusal of treatment. As will be seen, in this topic the solution that has been presented is not agreed upon by us, raising many questions that, unless there is a better opinion, should be better appreciated. In this dissertation we will also discuss the contours of the declarations of anticipated will, namely, what is the basis of their existence, what assumptions have to be fulfilled in order to be valid and what relevance should be attributed to them, that is, we will try to determine whether they are binding or indicative. Also regarding the refusal of medical treatment it will be addressed the existence of alternative treatments to blood transfusions, the risks associated with them, and also if the patient who refuses a blood transfusion based on religious grounds can be considered a suicide. We understand that the doctrine has not fully followed the evolution that has been felt in medicine, forgetting or even not knowing that there are alternative treatments to blood transfusions that do not carry risks and that should be guaranteed to the patient. Only in this way can he have a real right to choose and not be confronted with the scenario of "if you do not choose the blood transfusion, you are not treated". If there are alternative treatments, which seem to be more beneficial and cost-saving, the patient will not be able to see his will denied and be treated as suicidal. Also in the case of minors we consider that some points are not correctly evaluated, namely in the absence of decision-making power for parents when they decide contrary to what the health professional believes is best for the child. Thus, in some respects, we start from the understanding that the refusal of medical treatment may still be caught in a logic of medical paternalism, not portraying, as it should, the principle of patient autonomy. Throughout the discussion that follows we will make this idea clearer on the basis of several arguments.
The development of medicine, however advantageous it may be, it also poses difficulties for health professionals and patients. We are now seeing, at least in most fields that concern medicine, a paradigm shift. The period of paternalism that was present in the time of Hippocrates was abandoned, giving rise to the emergence of the principle of patient autonomy. With this evolution emerges the concept of consent, something that was taking more defined contours as the patient, as part of the medical interventions, took on a more relevant role. Throughout the dissertation we will focus our attention on cases of refusal of medical treatment, with a special focus on blood transfusions. That refusal, although it may be based on several grounds, will depend essentially on that which is based on religious grounds. We speak here of Jehovah's Witnesses. Nowadays it is unthinkable, with rare exceptions, to carry out a treatment or medical intervention without, prior to obtaining the consent of the patient to the treatment. The actions of health professionals are no longer performed on the patient without his knowledge, rather the opposite. The patient is, in our day, the holder of power as to the fate of his health. The exceptions to the idea mentioned above relate essentially to incapacity, that is to say, if a patient does not meet the necessary conditions to give his consent, he can not decide on the performance of the doctors. The situations that tend to be more problematic or that, at least, more discussion have created, are about minors. These, by virtue of their age, are considered to be incapable of deciding on medical matters, in particular refusal of treatment. As will be seen, in this topic the solution that has been presented is not agreed upon by us, raising many questions that, unless there is a better opinion, should be better appreciated. In this dissertation we will also discuss the contours of the declarations of anticipated will, namely, what is the basis of their existence, what assumptions have to be fulfilled in order to be valid and what relevance should be attributed to them, that is, we will try to determine whether they are binding or indicative. Also regarding the refusal of medical treatment it will be addressed the existence of alternative treatments to blood transfusions, the risks associated with them, and also if the patient who refuses a blood transfusion based on religious grounds can be considered a suicide. We understand that the doctrine has not fully followed the evolution that has been felt in medicine, forgetting or even not knowing that there are alternative treatments to blood transfusions that do not carry risks and that should be guaranteed to the patient. Only in this way can he have a real right to choose and not be confronted with the scenario of "if you do not choose the blood transfusion, you are not treated". If there are alternative treatments, which seem to be more beneficial and cost-saving, the patient will not be able to see his will denied and be treated as suicidal. Also in the case of minors we consider that some points are not correctly evaluated, namely in the absence of decision-making power for parents when they decide contrary to what the health professional believes is best for the child. Thus, in some respects, we start from the understanding that the refusal of medical treatment may still be caught in a logic of medical paternalism, not portraying, as it should, the principle of patient autonomy. Throughout the discussion that follows we will make this idea clearer on the basis of several arguments.
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Keywords
Direito penal Tratamento médico Recusa Transfusão de sangue Consentimento Menores Teses de mestrado - 2020