GRAND CHAMBER
CASE OF PINDO MULLA v. SPAIN
(Application no. 15541/20)
 
JUDGMENT
 
Art 8 read in light of Art 9 • Private life • Medical treatment in the form of blood transfusions administered to a Jehovah’s Witness, during emergency surgery, despite her expressed refusal to undergo a blood transfusion of any kind • Competent adult patients free to decide on surgery or medical treatment, including blood transfusion • Need for robust legal and institutional safeguards in decision-making process • Elucidation of procedural requirements applicable to decision-making process • Decision to refuse life-saving treatment must be clear, specific and unambiguous and represent the patient’s current position on the matter • In the event of doubt, health care professionals under a duty to make every reasonable effort to determine patient’s wishes • When in an emergency, despite efforts to dispel doubts, reasonable grounds exist to doubt an individual’s decision to refuse life-saving treatment, proceeding with such treatment cannot be considered a failure to respect his or her personal autonomy •  In life-threatening situations, the right to life arises in tandem with an individual’s right to decide autonomously on medical treatment • No European consensus in relation to the modalities for reconciling those two rights by taking into account a patient’s previously expressed wishes • Principle of giving binding legal effect to advance directive and related formal and practical modalities within a State’s margin of appreciation • Need for a system of advance medical directives relied on by patients to function effectively  •  Well-developed domestic framework, in conformity with the Oviedo Convention, for ensuring respect for patient autonomy in the domestic health system • Shortcomings in decision-making process in the present case did not afford sufficient respect for the applicant’s autonomy • Failure to provide duty judge with an adequate factual basis of the decision regarding applicant’s refusal of treatment recorded in writing in various forms and at various times  • Lack of essential and accurate information had a determinative effect on the duty-judge’s decision-making • Failure to take into account applicant’s decision-making capacity • Shortcomings not remedied by the Higher Courts
 
Prepared by the Registry. Does not bind the Court. STRASBOURG
17 September 2024
 
This judgment is final but it may be subject to editorial revision. Table of Contents
INTRODUCTION
PROCEDURE
THE FACTS
THE CIRCUMSTANCES OF THE CASE
A. Treatment of the applicant at Soria hospital
B. Transfer of the applicant to La Paz hospital
C. Application by La Paz doctors to the duty judge
D. Treatment of the applicant at La Paz hospital
E. The ensuing proceedings
1. Initial examination of the applicant’s appeal
2. Proceedings before the Audiencia Provincial
3. The applicant’s appeal to the Constitutional Court
4. Provision to the applicant of the signed informed consent document
RELEVANT LEGAL FRAMEWORK AND PRACTICE
I. DOMESTIC LAW AND PRACTICE
A. Spanish Constitution
B. State legislation
C. Regional legislation
D. Relevant domestic case-law
1. Constitutional Court
(a) Judgment 120/1990 of 27 June 1990
(b) Judgment 37/2011 of 28 March 2011
(c) Judgment 19/2023 of 25 April 2023
(d) Judgment 44/2023 of 9 May 2023
2. From the ordinary courts
(a) Audiencia Provincial of Guipúzcoa (Section 2), appeal no. 2086/2004, Decision of 22 September 2004
(b) Audiencia Provincial of Lleida (Section 1), appeal no. 440/2010, Decision no. 28/2011 of 25 January 2011
II. RELEVANT INTERNATIONAL MATERIALS
A. Council of Europe
1. The Convention on Human Rights and Biomedicine – the Oviedo Convention
2. Text adopted by the Committee of Ministers
3. Text adopted by the Parliamentary Assembly
4. Guide on the decision-making process regarding medical treatment in end‑of-life situations
B. European Union
C. United Nations
D. Other relevant materials
III. COMPARATIVE LAW
THE LAW
I. ALLEGED VIOLATIONS OF ARTICLES 8 AND 9 OF THE CONVENTION
A. Admissibility
1. The parties’ submissions
(a) The Government
(b) The applicant
2. The Court’s assessment
B. Merits
1. Legal characterisation of the case
2. The parties’ submissions
(a) The applicant
(b) The Government
(c) The third parties
(i) The European Association of Jehovah’s Witnesses
(ii) The French Government
3. The Court’s assessment
(a) Preliminary observations
(b) The interference with the applicant’s right to respect for private life
(c) Justification for the interference
(i) Lawfulness of the interference
(ii) Aim of the interference
(iii) Necessity of the interference
(α) Relevant case-law principles
‒ On personal autonomy in the sphere of health care
‒ On the duty of the State to protect the life and health of patients
‒ On procedural safeguards
(β) Reconciling the Convention rights and duties at stake
‒ Previously expressed wishes of the patient
(γ) Application of the above principles and considerations to the present case
‒ Safeguards under the domestic legal framework
‒ The application to the duty judge
‒ The consideration of the application by the duty judge              
‒ The terms of the decision
‒ The implementation of the decision
‒ The review of the decision
‒ Overall assessment of the decision-making process
‒ Conclusion
II. APPLICATION OF ARTICLE 41 OF THE CONVENTION
A. Damage
B. Costs and expenses

Article of the Convention at issue: Article 8
Outcome: violation