Patient Autonomy and Information and Clinical Documentation-Related Rights Within the Context of Spanish Law 41/2002

Abstract

Law 41/2002 Regulating Patient Autonomy and Health Documentation and Information-Related Rights and Obligations regulates matters which the General Health Law of 1986 had fallen short in its attempt to regulate, such as the right to health information, informed consent, health documentation, clinical records and other clinical information. This Law likewise classifies the ways in which capabilities may be limited and attributes physicians with authority over the evaluation thereof. In keeping with the Oviedo Convention on Human Rights and Biomedicine, this study includes the guiding principles of the new bioethics, such as an individuals right to privacy of the health-related information, living wills (or advance medical directives), the patients right to autonomy and to take part in the decision-making process, the refusal of treatment or teenagers being of legal age for health-related decision-making purposes. Said Law, a primary law nation-wide, means a major advancement in physician-patient relations and must be further expanded upon with regard to numerous aspects thereof by the Autonomous Communities. This study is aimed at describing this body of law and at analysing the repercussions thereof on citizen relations, health professionals and the National Health System as regards the matter of clinical documentation and information.