Clinical Practice Guideline for Eating Disorders.

  1. Introduction
  2. Scope and Objectives
  3. Methodology
  4. Definition and Classification of Eating Disorders
  5. Prevention of Eating Disorders
  6. Detection of Eating Disorders
  7. Diagnosis of Eating Disorders
  8. Interventions at the Different Levels of Care in the Management of Eating Disorders
  9. Treatment of Eating Disorders
  10. Assessment of Eating Disorders
  11. Prognosis of Eating Disorders
  12. Legal Aspects Concerning Individuals with Eating Disorders in Spain
  13. Detection, Diagnosis and Treatment Strategies for Eating Disorders
  14. Dissemination and Implementation
  15. Recommendations for Future Research
  16. Annexes
  17. Bibliography
  18. Full list of tables and figures


Abre nueva ventana: Section 12 en versión pdf
Download CPG for Eating Disorders Abre nueva ventana(3,6 Mb)

12. Legal Aspects Concerning Patients with Eating Disorders in Spain

Key Questions

12.1. What legal procedure must be followed when a patient with an eating disorder refuses to receive treatment?

12.2. Is the informed consent of a minor with an eating disorder legally valid?

12.3. In the case of a minor with an eating disorder, what is the legal solution to the dilemma stemming from the responsibility of confidentiality, respect of autonomy and obligations towards the minor’s parents or legal guardians?

12.1. What legal procedure must be followed when a patient with an eating disorder refuses to receive treatment?

To receive a medical treatment an informed consent is needed after the patient is informed of all the pertaining information in relation to the treatment, in virtue of Article 10 of the Ethics Code 405 and Articles 4, 8 and 9 of Law 41/2002406.

Legally, the informed consent form is a non-transferable, non-delegable personal act. It is not a formal legal act and because of this it is not regulated by the civil code. Hence, the personal informed consent of the patients is a right that must be respected at all times, save for those exceptions explicitly established by the law.

One exception to the above is the lack of capacity of the patient. Spanish law allows the physician to carry out any clinical interventions that are essential even without the consent of the affected individual (article 9.2 Law 41/2002)406 in cases where there is severe immediate risk to the individual’s physical or mental integrity, prior consultation with family members or people related to the affected individual.

The application of Law 41/2002406 sets forth some exceptional scenarios to the valid consent of a patient aged 16-17 years, since the legal age to make health-related decisions is 16 years in the application scope of this guide.

Any treatment that might require admission to hospital (article 9.4 Ethics Code)405 must be regulated by the organic law and provide sufficient warranties, as it represents an exception to the freedom of articles 17 of the Spanish Constitution407 and 5 of the Rome Convention of the 4th of November, for the protection of human rights and fundamental freedoms 408.

In cases where total hospitalisation is deemed essential without having obtained the informed consent, article 763 of Law 1/2000 of 7th of January of the Civil Procedures Rules409 establishes the occurrence of two situations: for the condition to be a psychological/psychiatric disorder and for the affected individual to be unable to make his or her own decisions.

Two situations are foreseen:

  1. To apply for a Court authorisation for voluntary admission to hospital.
  2. To admit the patient first and to report the admission to the Court with jurisdiction over the case within 24 hours.

In either of these two scenarios, it is a non-contradictory procedure before a Court, being the affected individual able to express his or her agreement or disagreement by themselves and if the individual so requires by means of representation and defence. The Court will issue either an order of authorisation or denial that will be open to appeal. The Court will state in the order the obligation on the part of the physicians to inform such Court of the need to maintain the measure every six months, being possible to establish a shorter period depending upon the type of disorder.

It is the physician’s ultimate responsibility to decide when to discharge the hospitalised individual and the physician shall inform the Court immediately of such decision.


Recommendation

According to current legislation 12.1. The use of legal (judicial) channels is recommended in cases where the health professional deems it appropriate to safeguard the health of the patient, observing in all circumstances the patient’s right to be heard and to be conveniently informed of the process and the medical and legal measures that will be applied. The well-informed procedure not only respects the right to information but also encourages the patient’s cooperation and motivation and that of his or her closer relatives in the total hospitalisation procedure.
Current legislation

— Article 10 of the Ethics Code and Medical Deontology, 1999. OMC, Revista del Consejo General de Colegios Médicos de España, 1999 (66): 2.124 y 2.931405.

— Articles 4, 8 and 9 of Law 41/2002, of 14th November, a basic regulatory law that governs the patient’s autonomy and embraces rights and obligations concerning clinical information and documentation (State’s Official Gazette no. 274, dated 15-11-2002, pp. 40.126-40.132)406.

— Article 9.2 of Law 41/2002, of 14th November, a basic regulatory law that governs the patient’s autonomy and embraces rights and obligations concerning clinical information and documentation (State’s Official Gazette no. 274, dated 15-11-2002, pp. 40.126-40.132)406.

— Article 9.4 of the Ethics Code and Medical Deontology, 1999. OMC, Revista del Consejo General de Colegios Médicos de España, 1999 (66): 2.124 y 2.931, concerning observance of the patient’s freedom and the possibility to request judicial intervention, if and when necessary405.

— Article 17.1 of the Spanish Constitution of 6th of December 1978, concerning the right to freedom and the prohibition against deprivation of freedom, save for those cases expressly stipulated by the Law, as approved by the General Courts in plenary sessions of the Congress of Deputies and the Senate held on the 31st of October 1978 and ratified by the Spanish people via referendum on the 6th of December 1978 and sanctioned by his Royal Majesty the King before the General Courts on the 27th of December 1978407.

— Article 5 of the European Convention for the Protection of Human Rights and Fundamental Freedoms of 4th November, ratified by Spain with date 26th of September 1979 and published in the Spanish Official Gazette on the 10th of October 1979. Revised in conformity with Protocol number 11 (coming into effect date 1 November 1998), based upon which the causes for non-voluntary admission to hospital may only be regulated by law408.

— Article 763 of Law 1/2000, of 7th of January of the Civil Procedures Rules. Non-voluntary admission to hospital due to a psychological/psychiatric disorder, which regulates two types: non-voluntary admission to hospital and emergency admission to hospital 409. arriba


12.2. Is the informed consent of an under-age individual suffering from ED legally valid?

Legislation accepts the legal validity of the minor’s autonomy contingent upon the minor’s level of maturity in accordance with Organic Law for the Protection of Minors 1/1996, of 15th of January, which regards the minor as a titleholder of rights and not just as a mere object of such rights 410.

The legal treatment (article 9.3.c. of Law 41/2002) of an informed consent issued by a minor takes into account objective considerations (age) as well as subjective considerations (the patient’s capacity to discern correctly)406.

In general, in lieu of the Spanish legislation, the physician is obliged to listen to the minor (article 10.6 of the Ethics Code405 and article 9.3.c. of Law 41/2002406) and make the will of the family prevail in those cases in which the minor is unable to decide neither emotionally nor intellectually, by means of the informed consent form, under the following legal limitations:

  1. It is the obligation of the physician to always listen to minors aged 12 and over and to take into account their opinion contingent upon their level of mental growth and personal attitude, making them participate in as much as possible in the making of decisions throughout the health process.
  2. Over the age of 16, the Law understand that the consent must be rendered directly by the patients in all cases, save for situations that pose severe immediate risk to health, in which the physician shall only inform and listen to the parent’s views and opinions.

Recommendation

According to current legislation 12.2. One characteristic symptom of EDs and specifically of AN is the absence of awareness of the disease among sufferers. The disease itself often causes a lack of sufficient judgement to issue a valid and unbiased consent concerning the acceptance and choice of treatment. Hence, in the assumptions of severe risk to the health of a minor afflicted with AN who refuses treatment, established legal and judicial channels must specially be followed.
Current legislation

— Organic Law 1/1996, of 15th of January, for Legal Protection of Minors, partial amendment of the Civil Code and the Civil Procedures Rules Law. Spanish Official Gazette, 17th January 1996 (number 0015)410.

— Article 9.3.c. of Law 41/2002, of 14th November, a basic regulatory law governing the patient’s autonomy and the rights and obligations with regard to clinical information and documentation (Official Gazette no. 274, de 15-11-2002, pp. 40.126-40.132)406.

— Article 10.6 of the Ethics Code and Medical Deontology, 1999. OMC, Revista del Consejo General de Colegios Médicos de España, 1999 (66): 2.124 y 2.931, concerning observance of the patient’s freedom and possibility to apply for the intervention of the Court, in cases where deemed necessary405.


arriba

12.3. In the case of a minor diagnosed with ED, how is the dilemma: duty of confidentiality, respect to autonomy, and obligations with regard to the parents or legal guardians of the minor solved?

The controversy between the knowledge and authorisation from the parents or legal guardians and the right to privacy and confidentiality of the minor (article 7 of Law 41/2002)406, is present in all norms and regulations and there is not one single norm that serves as a guide to the physician to generalise cases. In general, regulation tends to be inspired on some general principles concerning respect to privacy and professional secret, and to establish certain limitations and exceptions to the main general principle.

The physician may –according to article 16.1.d) of the Ethics Code405– disclose the secret prior authorisation from the patient or without such authorisation in cases in which the physician’s silence may cause damage to the actual patient or to third parties.

Likewise, in an extended reading of the Civil Code on how the minor must be regarded, it is important for the physician to take into account the minor’s age and maturity level.


Recommendation

According to current legislation 12.3. The balance among the different rights in conflict makes it mandatory for the physician to observe and to interpret the best solution to each case. Nonetheless, it is always of outmost importance to inform and to listen attentively to both sides so that they understand the relationship between safeguarding health and the decision taken by the physician.

Current legislation

— Article 7 of Law 41/2002, of 14th November, a basic regulatory law governing the patient’s autonomy and the rights and obligations with regard to clinical information and documentation (Official Gazette no. 274, de 15-11-2002, pp. 40.126-40.132)406.

— Article 16 of the Ethics Code and Medical Deontology, 1999. OMC, Revista del Consejo General de Colegios Médicos de España, 1999 (66): 2.124 y 2.931, concerning exceptions to the physician’s professional secret405.

— Law 41/2002, of Law 41/2002, of 14th November, a basic regulatory law that governs the patient’s autonomy and embraces rights and obligations concerning clinical information and documentation (State’s Official Gazette no. 274, dated 15-11-2002, pp. 40.126-40.132)406.

— Instrument of ratification for the Convention for the Protection of Human Rights and the Dignity of Human Beings, with regard to the applications of biology and medicine (Convention relating to Human Rights and Biomedicine) signed in Oviedo on the 4th of April 1997. Official Gazette number 251 of 20th October 1999411.

— European Convention for the Protection of Human Rights and Fundamental Freedoms of 4th November, ratified by Spain with date 26th of September 1979 and published in the Spanish Official Gazette on the 10th of October 1979. Revised in conformity with Protocol number 11 (coming into effect date 1 November 1998)408.

— Law 1/2000, of 7th of January, of Civil Procedures Rules (Official Gazette. 7, of 8th January 2000, pp. 575-728. Error corrections that appeared in the Official Gazette no. 90, de 14-04-2000, p. 15.278 and Official Gazette no. 180, dated 28-07-2001, p. 27.746)409.

— Order 129/99 issued by the Constitutional Court concerning circumstances for non-voluntary admission to hospital.412


arriba

Section 12 Bibliography


  1. 405. Organización Médica Colegial. Código de Ética y Deontología Médica. Revista del Consejo General de Colegios Médicos de España. 1999;(66):2124,2931.
  2. 406. Ley 41/2002, de 14 de noviembre, básica reguladora de la autonomía del paciente y de derechos y obligaciones en materia de información y documentación clínica. Madrid: Boletín Oficial del Estado (BOE); núm. 274, de 15-11-2002. p. 40126-40132.
  3. 407. Constitución Española, de 6 de diciembre de 1978. Aprobada por las Cortes en Sesiones Plenarias del Congreso de los Diputados y del Senado celebradas el 31 de octubre de 1978. Ratificada por el Pueblo Español en Referéndum de 6 de diciembre de 1978. Sancionada por S.M. el Rey ante las Cortes el 27 de diciembre de 1978.
  4. 408. Convenio Europeo para la Protección de los Derechos Humanos y Libertades Fundamentales, de 4 de noviembre de 1950, ratificado por España con fecha 26 de septiembre de 1979. Madrid: Boletín Oficial del Estado (BOE); de 10/10/1979. Revisado en conformidad con el Protocolo n° 11 (Fecha de entrada en vigor 1 de noviembre 1998).
  5. 409. Ley 1/2000, de 7 de enero, de Enjuiciamiento Civil. Madrid: Boletín Oficial del Estado (BOE); núm. 7, de 8/01/2000, p. 575-728. Corrección de errores BOE núm. 90, de 14-04-2000, p. 15278 y BOE núm. 180, de 28-07-2001, p. 27746.
  6. 410. Ley Orgánica 1/1996, de 15 de enero, de protección jurídica del menor, de Modificacion parcial del Codigo civil y de la Ley de Enjuiciamiento civil. Madrid: Boletín Oficial del Estado (BOE); núm 15, de 17/01/1996.
  7. 411. Instrumento de ratificación del Convenio para la protección de los derechos humanos y la dignidad del ser humano con respecto a las aplicaciones de la Biología y la Medicina (Convenio relativo a los derechos humanos y la biomedicina) firmado en Oviedo el 4 de abril de 1997. Madrid: Boletín Oficial del Estado (BOE); núm. 251, de 20/10/1999.
  8. 412. Sentencia 129/99 del Tribunal Constitucional sobre las condiciones de un internamiento no voluntario.

Latest update: January 2010

Logo del Ministerio de Sanidad y Consumo Logo del Plan de Calidad del Sistema Nacional de SaludAgència d’Avaluació de Tecnologia i Recerca Mèdiques de Cataluña

 

Copyright | Help | Map