The purpose of the study is to analyze in detail and identify the issues related to the legal and ethical aspects of medical rehabilitation. Differentiation between such concepts as ‘medical rehabilitation’ and ‘treatment’ promotes a more accurate and effective understanding of medical rehabilitation issues and allows to avoid legal ambiguities.

Explaining the concept of medical rehabilitation will help doctors avoid legal risks associated with their professional activity, and provide them with landmarks for making ethically sound decisions in complex clinical situations. Understanding modern legal and ethical standards will improve the quality of medical care, which in turn will increase patients’ trust in medical institutions and specialists.

Patients will receive more complete and accurate information about their rights and opportunities within the framework of medical rehabilitation. This will allow them to make informed decisions about their health and treatment.

LEGAL ASPECTS OF MEDICAL REHABILITATION

In 1946, at the Congress on the rehabilitation of patients with tuberculosis in Washington (USA), one of the first official definitions of ‘medical rehabilitation’ was proposed. It was defined as a multidimensional process in the form of ‘restoration of the physical and spiritual strength of the victim, as well as of the victim’s professional skills’. This definition laid the foundation for further development of the concept, strengthening an integrated approach to the issue [1].

Over the past time, the concept of ‘medical rehabilitation’ has undergone numerous changes and clarifications. In 1980, the World Health Organization (WHO) formulated a widely used definition, where medical rehabilitation is understood as an active process with the goal of achieving complete restoration of functions impaired due to a disease or an injury, and if this is not possible, of developing compensatory and replacement devices (functions) [2, 3]. Most publications on this topic, both at the Russian and international levels, are based on this conceptual definition. The formulation developed by the WHO also highlights the need for an integrated approach that promotes a more complete and comprehensive recovery of patients. The active role of the patient in rehabilitation, development and implementation of new rehabilitation programs, increasing patient motivation and improving rehabilitation results is emphasized. The developed compensatory and substitution mechanisms allow patients to adapt to new living conditions and be as much independent as possible.

The above definition of medical rehabilitation can be applied mainly in specialized medical literature, where it significantly differs from the interpretations presented in commonly used explanatory dictionaries. This is due to the fact that the WHO definition is highly specialized and can be used within the professional medical community only. At the same time, definitions in explanatory dictionaries are often more generalized and even more simplified, which makes them accessible to a wide audience.

For example, the Explanatory Dictionary of the Russian language, edited by Ozhegov SI and Shvedova NYu (1992), considers medical rehabilitation in a rather narrow sense, focusing mainly on eliminating the consequences of severe diseases or injuries [4]. In contrast, the definition presented in the Explanatory Dictionary of the Modern Russian Language (2013) reflects a broader and multifaceted approach to understanding medical rehabilitation and designates medical rehabilitation as a complex of medical, pedagogical, professional measures aimed at restoring (or compensating) impaired bodily functions and labor ability of patients and the disabled [5].

Another example is the Dictionary of Terms of the Ministry of Emergency Situations, in which medical rehabilitation is understood as a system of medical measures aimed at preventing decreased and lost labor ability, early restoration of impaired functions, prevention of complications and relapses of diseases, and early return to a professional activity [6]. In this case, the emphasis is made on the preventive manner of rehabilitation measures. This approach emphasizes that rehabilitation is required not only to restore lost functions, but also to prevent further deterioration of health and preserve the labor potential of patients.

As the term ‘medical rehabilitation’ is interpreted in specialized medical literature and commonly used explanatory dictionaries in a different way, representatives of the professional medical community have repeatedly raised the issue of the need to develop a unified definition of this concept and its consolidation in regulatory legal acts [7]. Such unification of terminology at the legislative level is considered as an important condition to eliminate legal uncertainty, ensure uniformity in law enforcement practice and create a reliable legal basis for the implementation of rehabilitation activities in the field of healthcare.

Though the concept of medical rehabilitation has been actively developed in the global medical practice and scientific literature, there has been no clear definition of this concept in the Russian legislation for a long time. The regulations adopted before 2003 used terms such as ‘restorative treatment’ and ‘follow-up treatment’, which only partially reflected the essence and content of the rehabilitation process.

Since 2003, the term ‘restorative medicine’ has appeared in regulatory legal acts, namely in Order of the Ministry of Health of the Russian Federation dated 07/01/2003 No. 297 ‘On rehabilitation doctor’ and order of the Ministry of Health of the Russian Federation dated 03/9/2007 No. 156 ‘On the Procedure for organizing medical care in restorative medicine’ [8, 9]. According to experts, the introduction of the term ‘restorative medicine’ has become an important step towards recognizing rehabilitation as an independent area of medical activity. However, this concept neither fully reflected all aspects of the rehabilitation process nor allowed for a clear distinction between rehabilitation and other types of medical care [10].

The situation changed in 2011 only, when the official definition of medical rehabilitation was fixed in Federal Law No. 323-FZ dated 11/21/2011 ‘On the Basics of Public Health Protection in the Russian Federation’ [11].

In accordance with Part 1 of Article 40 of the said Federal Law, it was determined that medical rehabilitation is a set of medical and psychological measures aimed at the complete or partial restoration of the impaired and (or) compensation for the lost functions of the affected organ or body system, maintaining body functions during the completion of an acutely developed pathological process or exacerbation of a chronic pathological process in the body, as well as for the prevention, early diagnosis and correction of possible violations of the functions of damaged organs or body systems, prevention and reduction of possible disability, improvement of quality of life, preservation of the patients’ working capacity and their social integration into society.

An official definition of medical rehabilitation has become an important milestone in the development of this medical specialty [12]. The consolidation of the legal definition at the federal law level indicates that the state has recognized the importance of rehabilitation in the healthcare system and the need to create an appropriate regulatory framework to allow its functioning.

However, this formulation does not allow for a sufficiently clear differentiation between rehabilitation measures and other types of medical care, such as treatment and prevention. In addition, the wording used in the law does not fully take into account the multidimensional nature of the rehabilitation process, which includes not only medical and psychological, but also professional and social components.

As such legal concepts as ‘treatment’ and ‘medical rehabilitation’ are interpreted in an ambiguous way, it complicates not only the regulation of medical activity as such, but also becomes the subject of discussion when solving the problem of insurance and financing. The answer to the question about which types of rehabilitation services should be covered by insurance or government programs may depend on whether rehabilitation is qualified as part of the treatment process or as a separate category of medical services.

Treatment is aimed at combating the disease and its causes. It includes diagnostics, appointment and implementation of therapeutic activities to eliminate or compensate for the disease. The treatment can be both active and passive. It does not always require active participation of the patient. It is focused on the present state of the body and manifestations of the disease. Medical rehabilitation (MR), in turn, is aimed at restoring body functions after a disease or injury. It includes a set of measures aimed at mobilizing the body’s defense mechanisms, restoring lost functions and adapting to life with limitations, if any. Rehabilitation requires active participation of the patient and is focused on the future, returning to normal life and restoring the working capacity. While comparing overlapping medical definitions, it is necessary to consider the term ‘medical prevention’, which means a set of measures aimed at preventing development of diseases, reducing their spread among the population, as well as reducing or eliminating risk factors contributing to occurrence and development of pathological conditions.

In table, the main criteria for differences in formulation of these established medical concepts are considered.

According to Resolution No. 291 dated 04/16/2012 [13] of Government of the Russian Federation and adopted substituting Resolution No. 852 dated 06/01/2021 [14], medical rehabilitation is a separate service, the implementation of which is subject to licensing. The procedure for organizing this activity is regulated by Orders of the Ministry of Health of the Russian Federation dated 10/23/2019 No. 878н and 07/31/2020 No. 788н in relation to children and adults respectively [15, 16]. These regulatory legal acts indicate that medical rehabilitation is carried out in medical organizations licensed for medical activities, including work (services) on medical rehabilitation, and they also differentiate between early, late and supportive rehabilitation.

An important change was that MR is now carried out at all stages by a multidisciplinary rehabilitation team (MDRT), which carries out its activities in accordance with the approved procedure, and MDRT functions under the guidance of an expert, physical and rehabilitation medicine/medical rehabilitation doctor.

It should be noted that these regulatory and legal provisions have made the tasks and scope of activities of specialized institutions related to medical rehabilitation clearer and more specific, and have become an impetus for further rehabilitation development.

ETHICAL ASPECTS

The foundation for the consideration of ethical issues in medicine includes four basic principles of medical ethics such as respect for patient autonomy, integrity, charity and justice.

Dilemmas arise due to differences in the interpretation and application of terms in different contexts, which can lead to conflicts between the interests of patients, medical professionals and the healthcare system as a whole.

Disease prevention addresses issues of mandatory vaccination, screening and lifestyle. Here, ethical dilemmas are often related to the balance between individual freedom and public good, so, for example, vaccination can be taken as a violation of autonomy, though it also protects public health. Vaccination against COVID-19 can serve as an example. On the one hand, it saves lives and prevents the spread of the virus, and, on the other hand, people expressed concerns about the rapid development of vaccines and potential side effects.

In the context of treatment, an ethical choice may arise in a situation when interests of the patient conflict with medical standards and recommendations, or when the doctor mainly focuses on the research process in which the patient participates. It is important to concentrate on the patient’s well-being trying not to ignore his interests.

The legal definition of ‘treatment’ implies active actions aimed to eliminate or alleviate the symptoms of the disease. However, doctors may face a situation where the patient refuses the proposed treatment, even if it can save his life. There is a dilemma between respecting the patient’s autonomy and desire to act in the patient’s best interests.

In the field of rehabilitation, ethical issues are often related to availability and necessity of services provided to the patient by a medical institution. Rehabilitation is aimed at bringing the patient to life, which requires an MR specialist to pay attention not only to the physical, but also to the psychological state of the patient. It is important to maintain a balance between using technologies to improve the quality of rehabilitation and maintaining a personal contact with the patient to ensure his motivation and participation in the recovery process, which is especially important when rehabilitation efforts meet limited resources and the need for rational allocation hereof.

One of the main ethical dilemmas associated herewith is the prioritization and allocation of resources between treatment and rehabilitation. When healthcare system resources are limited, we can invest either in expensive medical procedures that can prolong the patient’s life, or in rehabilitation services that improve the patient’s quality of life.

The question of using the ‘medical necessity’ term in the context of justifying the provision of rehabilitation equipment is raised. Ethical considerations influence the definition of the concept of medical necessity, since insurance companies can cover the cost of medical equipment only if it is necessary to use it for carrying out medical and diagnostic measures. This underlines the importance of provision of a clear and objective definition of medical necessity at the legislative level, so that specialized rehabilitation equipment could be as accessible as possible to those in need of it.

Sometimes, after successful high-quality treatment, patients are discharged from medical institutions in an environment that goes against the needs of rehabilitation. Often, the financial and household constraints of the patient or his family, as well as the lack of places in specialized institutions, do not allow for proper care. Discharge to unsuitable conditions may negatively affect health and subsequent rehabilitation of the patient. It is necessary to increase the availability of rehabilitation and social services, improve coordination between medical and social services, and involve patients and their families in planning and conducting rehabilitation activities.

Coding and billing conflicts pose a serious ethical dilemma. On the one hand, medical professionals strive to provide patients with the best possible care and the necessary amount of rehabilitation services. On the other hand, they have to work within the limits imposed by the health insurance system, the institution’s budget and administrative rules. The need to comply with limited number and duration of rehabilitation procedures covered by insurance, pressure from the administration to reduce costs and increase profits, the complexity of the rules for coding services, which do not always show the real cost of time and effort, significantly complicate the work of a doctor who has to balance between these conflicting requirements. As a result, medical professionals may face difficult choices. For example, they have to divide one long procedure into several short sessions in order to fit into the limits, or to choose a treatment method that is not the most effective for the patient, but can be considered more ‘profitable’ from the point of view of coding. Such decisions can be in conflict with professional ethics and personal values. It is necessary to improve the coding and payment system for rehabilitation services, taking into account real labor costs, develop ethical guidelines for resolving conflicts between financial and clinical priorities, and train how to communicate with the administration effectively to defend the interests of patients.

Interdisciplinary cooperation plays an important role in treatment and care for patients in the context of medical rehabilitation and ethics. It includes the work of doctors, nursing staff, psychologists and other specialists as a single team with a common goal, which consists in returning the patient to a full life. This requires each team member to be willing to work together, open to share knowledge, and respect the professional contributions of colleagues. Effective interaction between doctors of different specialties is the main criterion of a patient-oriented approach, contributing to the creation of an integrated treatment and rehabilitation plan that takes into account all aspects of the patient’s health and well-being.

Respectful attitude helps to create an atmosphere of trust and open communication, which allows team members to freely share their ideas, experiences and suggestions for improving treatment and rehabilitation processes. All actions and decisions of the interdisciplinary team should be aimed at increasing the benefits for the patient and minimizing possible risks, which implies a willingness to find a joint solution in case of disagreement. It is necessary to develop internal protocols and procedures governing interaction between specialists, conduct joint consultations, use common standards and treatment protocols, and introduce information technologies to facilitate communication and dynamic exchange of patient-related data between specialists.

CONCLUSION

Legal norms in medicine are often based on ethical principles. However, there are differences between these two areas. Law is a system of mandatory rules, the violation of which entails legal responsibility, while ethics is focused on the moral aspects of activity and is often advisory in nature.

The legal definitions of ‘treatment’ and ‘rehabilitation’ carry important ethical aspects related to the rights of patients, duties of medical professionals and social values. It is important that the legal framework maintains high ethical standards in medical practice, while ensuring adaptation to changes in medical technology and in public expectations of medical care. This requires an ongoing dialogue between medical professionals, lawyers, ethicists, and society as a whole to ensure that legal definitions and practices reflect and protect core ethical principles and values.

An open discussion of these problems by the professional community will help to find ethically acceptable solutions and better cope with moral distress, while being committed to the duty to patients.