Pindo Mulla v. Spain (2024)

Case Name: Pindo Mulla v. Spain (2024) 

Case Name: Pindo Mulla v. Spain (2024) 

Application No: 15541/20 

Court Name and Bench: 

European Court of Human Rights (ECHR) 

Grand Chamber  

Judges: Síofra O’Leary (President), Marko Bošnjak, Gabriele Kucsko-Stadlmayer, Pere Pastor  Vilanova, Arnfinn Bårdsen, Georges Ravarani, Egidijus Kūris, Branko Lubarda, Mārtiņš Mits,  Stéphanie Mourou-Vikström, Pauliine Koskelo, María Elósegui, Anja Seibert-Fohr, Ioannis  Ktistakis, Frédéric Krenc, Mykola Gnatovskyy, Anne Louise Bormann. 

Judgement: 17 September 2024 

Parties Involved: 

Petitioner- Rosa Edelmira Pindo Mulla, a Jehova’s witness, lives in Soria, Leon, Spain  Respondent- Kingdom of Spain  

Facts of The Case: 

In 2017 the applicant, who is Jehova’s witness, was advised to have surgery because of her health  issue. However, she agreed on treatment other than blood transfusion because of her religious  beliefs. Moreover, she registered an advance directive order recording refusal of blood transfusion  no matter what her health condition is. In 2018, she suffered internal bleeding and got admitted to  a local hospital and there she signed an informal consent refusing blood transfusion. Later, she was  transferred to another hospital in Madrid which was known for treating such patients using other  methods. But in seriousness of the situation the doctors filed an application to a judge via facsimile  for instructions on what to do in this situation. In the application they included that she is Jehova’s witness and she verbally rejected any form of treatment that involves blood transfusion. As the  judge did not know the patients then condition and her precise wishes regarding not wanting blood  transfusion, he ordered the doctors to perform all the surgical procedures to save the patient’s life. As a result, to protect life in emergency the consent and the advance directive of the patient was  not followed. The patient was not informed of the blood transfusion procedure. The constitution  court of the Spain later said the Judge’s decision was valid and considered the applicants appeal  for legal remedy was ruled out. However, the Grand Chamber of ECHR took the case. 

Issues Raised: 

1. Whether state has violated Article 8 (private life/autonomy) by transfusing blood despite  the refusal of the applicant?
2. Whether state has violated Article 9 (freedom of religion) by ignoring the request of blood  transfusion which was made in religion mind? 
3. Whether the emergency procedure was justified? 

Arguments of the Parties: 

The applicant argued that she had clearly rejected the blood transfusion as she had advance  directive order authorizing not to do blood transfusion. The advance directive order showed  that she had the right to exercise her autonomy in case of medical treatment. Moreover, she  was an adult and with full mental capacity when she signed the advance directive order. She  signed the document knowing it might lead her to death. Besides, she accepted all other kinds  of medical treatment except the blood transfusion. In this case the state had violated Article 8  by not respecting her personal autonomy and freedom.  

As the applicant was also Jehova’s witness and blood transfusion was contradictory to the core  belief of the religion’s core beliefs. As the state failed to respect the religion of the applicant,  Article 9 was violated. On the other hand, the information provided to the judge was  incomplete during the decision-making process during the emergency. The information  provided by the doctors, she refused all kinds of treatment and gave only verbal consent, was  not true. Furthermore, the hospital failed to check the applicants advance directive order  document and failed to provide this information to judge. 

The doctors believed that to save her life they could overlook her autonomy. In emergency two  rights came into conflict. Article 2 (Right to life) and Article 8(Autonomy). Normally, patients’ autonomy gets the initial priority, however, as the state must protect life under Article the doctors choose to save the patient’s life. Besides, the emergency made it complex to involve  the patient in the judicial process. The duty judge also had very little time to investigate further.  In that critical situation the judge had very little time to consider all the factors as saving a life  was on the line. In this case, saving life was the main concern. As a result, the patient’s  autonomy was neglected. If the necessary treatment had not given, the patient could have died.  For this reason, the authority shifted to the doctors not the patient. The council of Europe  recognized advance directive order; however, it is not binding. States decide how to use it. 

On top of that, the interference was not based on her religious beliefs. Doctors acted because  her life was in danger and it had nothing to do with her religious beliefs. 

Judgement:

The court held that Article 8 was violated as the state failed to respect the patient’s autonomy.  Despite the patient’s clear refusal through advance directive the hospital did the blood  transfusion. Although there were no failures or faults in medical procedures, there were sufficient procedural mistakes. The court also held that there was no violation of Article 9 as  the act was based on her emergency medical situation, not her religious beliefs. Under Article  41(Just Satisfaction) Spain was ordered to pay twelve thousand Euro. 

Ratio Decidendi: 

The court recognized that this case is different from other medical law cases and therefore it  must be analyzed differently. The court acknowledged that the applicant was an adult and with  full mental capacity when she gave her written consent rejecting blood transfusion. The court  kept the fact in mind that the applicant did not want to die either, she agreed to all other medical  procedures except the blood transfusion. She just refused blood transfusions on herself even if  she dies and this did not harm any other third parties. The court looked at Reyes Jimenez v.  Spain no. 57020/18 and found that Spain’s laws were consistent with Oviedo convention. So,  it means Spain acknowledged the patient’s autonomy and rights under international standards. In other words, Spain chose to give binding effect to advance directive order. Besides, the  information provided to the Judge was incomplete and based on that the duty judge gave orders. 

Although the court recognized that the doctors performed the blood transfusion in good faith,  it violated Article 8. The court also accepted that there were no medical failures, however, the  medical procedure was faulty as the doctors did not consult the family members and failed to  respect the advance directive order. Besides, if she lacked decision making capacity at that time  then the advance directive should get priority. 

Judge Mourou Vikstrom supported personal autonomy in this case.  

‘It would thus be reasonable to posit that the judgment should be founded upon the principles  of self-determination and personal autonomy, and that the duty judge should have been held  accountable for any failure to respect these principles.’ 

By referring Jehovah’s Witnesses of Moscow and Others v. Russia (Application no. 302/02) the court said the public interest of saving life must not contradict a patients own choice and  the wishes of patients must held more important than the public interest.