Blood Transfusions and Jehovah’s Witnesses: Why the European Court of Human Rights Ruled Against Spain

 SPAIN

Blood Transfusions and Jehovah’s Witnesses: Why the European Court of Human Rights Ruled Against Spain

10/02/2024

The Grand Chamber unanimously ruled that a competent adult patient has the right to refuse any medical treatment, including blood transfusion.

by Massimo Introvigne

On September 17, 2024, with the decision “Pindo Mulla v. Spain,” the Grand Chamber of the European Court of Human Rights (ECHR) awarded to the Jehovah’s Witnesses another resounding legal victory, this time about the often-discussed issue of blood transfusions. It was a rare substantially unanimous judgement of all the Grand Chamber’s 17 judges (8 expressed a partially dissenting opinion not on the substance of the matter but only on the issue of non-pecuniary damage).

The case concerned Rosa Edelmira Pindo Mulla, an Ecuadorian woman who lives in Spain. In May 2017, she was diagnosed with a uterine fibroid, and a hysterectomy was recommended. Anticipating surgery, she completed a new Durable Power of Attorney (DPA) refusing blood transfusions on August 4, 2017, along with a similarly worded Advance Medical Directive (AMD) that she registered in Spain’s national registry of AMDs. The hysterectomy was eventually delayed.

On June 6, 2018, Pindo was admitted to Soria Hospital due to significant bleeding from her uterine fibroid, and her hemoglobin level dropped to 4.7 g/dl. The gynecologist treating her recommended a blood transfusion, which she refused. Both Pindo and the doctor signed a “consent” form confirming her refusal. She was administered tranexamic acid, which stopped the bleeding, and arrangements were made to transfer her to La Paz Hospital in Madrid for uterine artery embolization—a minimally invasive procedure aimed at preventing future bleeding.

During the ambulance transfer to La Paz Hospital, doctors obtained an ex parte court order authorizing them to administer “any treatment” they deemed necessary. They failed to inform the duty judge that Pindo was conscious and had repeatedly refused blood transfusions through her DPA, AMD, discussions with the Soria doctors, and the signed “consent” form. Pindo was not informed about the court order either.

Upon arriving at La Paz Hospital Pindo, expecting a uterine artery embolization, was taken to the operating room, sedated, and subjected to a hysterectomy and three blood transfusions. 

Following her release, Pindo appealed the duty judge’s order. Her appeals were dismissed in Spain by the trial court, the appeal court, and the Constitutional Court, and she took her case to the ECHR.

The Grand Chamber first clarified that the Pindo case should not be confused (as France, which intervened in the proceedings, had tried to do) with those about assisted suicide. Pindo did not want to die. She wanted to live, avoiding however blood transfusions. As a Jehovah’s Witness, she shared the belief that blood transfusions violate the Biblical prohibition of “eating blood” and that adherents should “obey Jehovah’s law regarding blood by refusing to accept a blood transfusion, even during a medical emergency” (“Cherish God’s Gift of Life,” “The Watchtower” [Study Edition], February 2023, 20–25 [23]).

The Grand Chamber also noted that the case concerned an adult, and the issue on whether parents who are Jehovah’s Witnesses can refuse a blood transfusion for their minor children did not thus need to be addressed in the verdict.

In the case of adults, the judges reiterated that, “In the sphere of health care, respect for personal autonomy is a general and fundamental principle. It is safeguarded notably by the universally recognized rule of free and informed consent. The legally competent patient who has been duly informed about his or her health condition and the available treatments, as well as the implications if no treatment is accepted, has the right to freely decide whether to give consent to treatment or to withhold it” (par. 138). Even when refusal of treatment “might lead to a fatal outcome, the imposition of medical treatment without the consent of a mentally competent adult patient would interfere with a person’s physical integrity” and violate the European Convention of Human Rights (par. 139).

Pindo had mentioned the two ECHR cases “Jehovah’s Witnesses of Moscow and Others v. Russia” (10 June 2010) and “Taganrog LRO and Others v. Russia” ( 7 June 2022)., which acknowledged the right of adult Jehovah’s Witnesses to refuse blood transfusions.It is true, the ECHR said, that as Spain (and France) objected, “the context of those cases was very different to that of the present one. They involved the dissolution and banning of Jehovah’s Witness organisations in Russia. Consequently, the Convention rights at issue were different, notably those of freedom of association and freedom of religion. The right of the patient to refuse medical treatment was not directly addressed as such. Even so, these judgments may be recalled here inasmuch as they affirm, in relation to Jehovah’s Witness beliefs,… that the freedom to accept or refuse specific medical treatment was vital to self-determination and personal autonomy” (par. 140). 

Spain objected that in this case the doctors’ decision was justified by the need to save the life of the patient. The Court disagreed, reminding Spain that the ECHR has repeatedly maintained that “in the ordinary health care context it follows from Article 8 of the [European] Convention [on Human Rights] that the competent, adult patient has the right to refuse, freely and consciously, medical treatment notwithstanding the very serious, even fatal, consequences that such a decision might have. It is a cardinal principle in the sphere of health care that the right of the patient to give or withhold consent to treatment has to be respected” (par. 146). Referring to the case of Jehovah’s Witnesses of Moscow and Others v. Russia, the Grand Chamber noted that “the public interest in preserving the life or health of a patient must yield to the patient’s interest in directing the course of his or her own life” (par. 148). And further, “the wishes of the patient must be treated as being of paramount importance” (par. 149).

In the Pindo case, one question was whether she had unequivocally expressed her refusal of the blood transfusions. In trying to justify the imposed blood transfusions, the Spanish courts and the La Paz doctors relied on contradictory arguments. On the one hand, they claimed that Pindo’s refusal of blood transfusions was not in writing (in fact, as the Grand Chamber noted, her refusal of blood was recorded in writing in her DPA, AMD, and the signed “consent” form). And, on the other hand, they argued that her DPA and AMD were irrelevant because she was fully capable and conscious at the time of the surgery (the Grand Chamber noted that if she was fully conscious, then there was no lawful basis for the order authorizing transfusion). The Grand Chamber was highly critical of these contradictory arguments (par. 159–182).

One of the lawyers for the Spanish government speaking at the ECHR hearing. Screenshot.

With respect to advance directives generally, the Grand Chamber also stated that “both the principle of giving binding legal effect to advance directives [where patients may state in advance that they would refuse a certain medical treatment], as well as the related formal and practical modalities, come within the margin of appreciation of the Contracting States” (par. 153). Spain was not compelled to introduce a system of advance directives but, having done so, it must respect the content of the directives. Even in countries without a system formally recognizing advance directives, the Grand Chamber noted (par. 151–153) that Article 9 of the Oviedo Convention (ratified by most of the 46 countries of the Council of Europe) requires that “previously expressed wishes… shall be taken into account.” The Grand Chamber emphasized (para. 149) the governing principle that the “wishes of the patient must be treated as being of paramount importance.”

In the case of Pindo, the ECHR notes that when the doctors asked a judge to authorize them to administer to the patient “any treatment” they would deem necessary, “what was not communicated to the duty judge was the information that the previous night at Soria hospital a clinician (Dr B.L.) had gone through the relevant consent procedure with the applicant, who had expressed her refusal of blood transfusion in writing on the informed consent document” (par. 159). In other words, the doctors misled the judge about Pindo’s position. 

Additionally, the ECHR notes “that there was no real communication between the medical staff and the applicant about the impending intervention. The usual consent procedure was not followed, and no mention at all was made of the decision issued by the duty judge” (par. 167).

There was no evidence that Pindo was incapacitated at the moment of informing the doctors that she would not accept a blood transfusion or that she changed her mind thereafter. On the contrary, the Grand Chamber noted that on admission to the La Paz hospital, the hospital records confirm that Pindo was “conscious at that time, and indeed fully alert” (par. 167). The ECHR thus concluded that forcibly administering blood transfusions to her “was the result of a decision-making process which, as it operated in this case, did not afford sufficient respect for the applicant’s autonomy as protected by Article 8 [of the European Convention on Human Rights], which autonomy she wished to exercise in order to observe an important teaching of her religion” (par. 183). 

The Grand Chamber concluded that Pindo’s rights under Article 8 (right to respect private life), “read in the light of Article 9” (right to freedom of thought, conscience, and religion) had been violated and ordered Spain to pay to her Euro 12,000 for non-pecuniary damage plus Euro 14,000 for costs and expenses.

Hopefully, this important precedent will persuade the states that still object to the Jehovah’s Witnesses teaching about blood transfusions and even derive from these objections conclusions threatening the legal status of the religious organizations in their countries, that they are violating international law. The latter authorizes competent adult patients to refuse any medical treatment whatever the circumstances and protects freedom of religion of those who do so for religious reasons.

In the photo: 

1. Applicant Rosa Edelmira Pindo Mulla at the ECHR hearing. 

2. President Síofra O’Leary presiding the “Pindo” ECHR hearing.