Conflict is an important aspect in the practice of emergency medicine. Successful conflict resolution in emergency medicine requires immediate intervention. As ethical issues are commonly integral to these conflicts, it is advisable to describe them in terms of rationality and to use a conventional, bioethical approach to resolution. This involves the case - study method, a well - known sociological research approach. The article provides examples of the application of this approach to emergency medicine.

Full Text

The majority of Russian citizens think justice in medicine to be a general right to receive free medical care. Article 41 of the Constitution of the Russian Federation guarantees possibility to obtain free medical care: «Medical 46 aid in state and municipal health establishments shall be rendered to individuals gratis, at the expense of the corresponding budget, insurance contributions and other proceeds». The inability to receive qualified medical aid due to lack of material security in the modern civilized world is considered to be a violation of human rights and a fundamental problem of public policy and medical ethics [19]. In accordance with Article 10 of the Federal Law dated November 21st, 2011 № 323 - FZ «On the basis of public health protection in the Russian Federation» availability and quality of medical care should be provided with the application of the procedure and standards of medical care and the provision by medical organization the guaranteed medical care in accordance with the program of state guarantees. At the same time standards of provision of medical care to patients with arterial hypertension in medical organizations are not fully done. Main reasons for this situation are the lack of personnel, medical equipment and drugs [5, 6, 11, 16, 17]. The bioethics principle of justice implies equality of all citizens to health care and a high level of social protection. Health should not be a luxury or a privilege of the elite. Medicine, which sets the intensity of medical care to the patient in accordance with his age, gender, or religious affiliation, social status or material welfare, turns justice into an idea that «one can only rely on what he deserved» [22]. However, the principle of justice is not so much in free medical care, but in the availability to qualitative health services. «Only services that provide additional comfort could be expensive, but not health», - notes V.N. Zasukhina. Equal access of the population to qualitative medical services and pharmacological resources is a basic component of a just social order [22]. E.V. Karchagin considers the principle of justice on the health system level, as the equal availability of all groups of the population to obtain biomedical services and benefits, the availability of pharmacological resources, protection the most vulnerable segments of the population [8]. Article 14 of the Overall Declaration on Bioethics and Human Rights states that «the achievement of the highest possible standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition», so the progress in science and technology should facilitate availability to qualitative health care and essential medicaments, especially in regard to the health of women and children, because health is the most important essence to life itself and must be considered as a social and human good. M. Kottow [9] offers to solve the problem of real inequality and injustice in the health sector by means of wide introduction of bioethical concept of ethics of protection. In the situation of insufficiency of effectiveness of the liberal paradigm to ensure the effectiveness of public health, which leads to the exclusion of socially disadvantaged groups and subjects, bioethics will continue to insist that it is necessary to cover the insufficiency of resources in medical queries for those who are not financially able to cover them [1]. John Rawls in his work «Justice as Fairness» called one of the principles of justice according to which social and economic institutions should act in such a way so to maximize the availability of benefits for citizens who find themselves in the worst conditions the principle of differentiation [14]. Arterial hypertension is considered as to be a medical and social problem in the modern world today because of its wide spreading and its leading role in the development of cardiovascular sequela, mortality, temporary or permanent disability, and deterioration of the quality of life of patients [7]. Thus the availability to medical aid for this group of the population is extremely important. The possibility of well - timed medical examination, qualitative treatment make it possible to reduce the risk of cardiovascular complications and disability, to prolong life and to optimize the quality of life of patients [10]. To analyze the accessibility of medical care to patients with arterial hypertension, we drew up a medico - social portrait of this group of patients. On a random sample basis 409 respondents of working age (55.5% women), with essential arterial hypertension and being observed in outpatient clinics of Saratov were included into the research.Distribution of respondents by gender is characteristically to the general prevalence in the population. A strong tendency of increasing the number of respondents with increasing age is noted in the study. The most of employable patients with arterial hypertension who visit clinic in the place of residence, were aged between 50 and 59 years old. The average age of respondents was 47.5 years old. 47 Most of the respondents have specialized secondary education and lower levels of education. According to their social status all the patients wre divided as follows: students - 4 persons (1.2%), representatives of working professions - 108 persons (34.5%), engineering and technical employees - 82 persons (26.2%), public officials - 35 persons (11.3%), unemployed - 34 persons (11.3%), housewives - 43 persons (13.7%), individual entrepreneurs - 6 persons (1.8%). The respondents were diagnosed arterial hypertension in accordance with recommendations of the Russian Medical Society of Arterial Hypertension and the All - Russian Scientific Society of Cardiologists [3]. Arterial hypertension duration ranged from some months to several decades, on the average the duration was about 6 years.Availability of medical care to patients includes a variety of settings. Among them, A.V. Reshetnikov points out the economic availability of medical care, which depends on the cost share of the medical care in the family budget; among the drug availability he points out an important role to the availability of drugs from the point of view of the financial capability of individuals. Those who feel it economically inaccessible medical care in healing preventive institution, family budget does not include costs for the purchase of expensive drugs and receiving medical care [15]. In the study of N.N. Sedova and L.A. Ertel [18] nearly 40% of women and a third of men noted that only a small part, or almost nothing from the list of the essential drugs is available for them. That is, social stratification forms different cultural patterns of consumption of medical services, and patient compliance as an integral part of the culture of consumption of medical services is directly proportional to the level of well - being. To the question «Why do you think, patients do not take prescribed by the doctor antihypertensive drugs?» the majority of respondents (51%) chose the answer «we do not have enough money for drugs». All respondents were divided into 4 degrees of deprivation [4]. 28 respondents belong to the 4th degree of deprivation (6.8%), 106 respondents belong to the 3rd degree of deprivation, 65 respondents belong to the 2nd degree of deprivation, 198 respondents belong to the 1st degree of deprivation. Only 12 (2.9%) of the respondents do not have restrictions in social life. 48.7% of the respondents in our study have a high risk of developing arterial hypertension and complications occurring because of the inaccessibility of an adequate qualitative antihypertensive therapy.We get the health care system in which medical aid is simply not available to a large number of people. Inequality in access to health care occupies the second place in the ranking of the most acute and painful types of inequalities both for the society as a whole and for the poor people [13]. According to the WHO modern concept, one of the main purposes of the health care system is to ensure the correspondence of medical activities to patients’ legitimate expectations [2]. The right to health in all of its forms and at all levels contains a right of availability of medical care, i.e. institutions, goods and services must be available to every patient without any discrimination. All persons with incomes below the poverty line and even slightly exceeds it cannot cope with the payments required for availability to medical care [21]. Public health could achieve a state close to ideal, if all citizens, regardless of their level of wealth and position in the society, use one and the same public health. When the President and members of the government, both rich and poor people will be treated in the same medical institutions and receive exactly the same care [1]. The overcoming of disparity in the availability to medical care is a long and complex process. Currently, there is no such a country which would have been completely satisfied with the state of its public health system. Practically every country is in the process of its correction and is carrying out the transformations and reforms And one of the tasks of all these transformations is justice, that is, the equality of all citizens to the availability to high - quality medical assistance [20]. It is necessary to increase the investments into the health of the population in order to reduce poverty and differences in health status [12]. Medical assistance should not be a weal, which is available only to solvent patients. The actual status of «medicine for the rich» should be transformed [8].

About the authors

N. Yu Zhuzhlova

Saratov state medical University n.a. V.I. Razumovsky

Saratov, Russia
post - graduate student of the Department of public health and health care (with the courses of law and of the history of medicine)

I. L Krom

Saratov state medical University n.a. V.I. Razumovsky

Saratov, Russia
Professor of the Department of public health and health care (with the courses of law and of the history of medicine), doctor of medical Sciences, Center for medical and sociological research

G. Yu Sazanova

Saratov state medical University n.a. V.I. Razumovsky

Saratov, Russia
associate Professor of the Department of public health and health care (with the courses of law and of the history of medicine), associate Professor, candidate of medical Sciences


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