24 is it acceptable to get the opinion of the patient during the surgical or peri-operative procedure because the patient is under surgical stress and anesthesia, even though the latter is local. 6. Dr. Vargas has referred to "communicating" the tubal ligation to the patient during the peri-operative period; but, in his progress note dated July 3, he stated: yesterday, he had "communicated" to the patient that the bilateral tube ligation had been performed out of medical necessity. 7. It was verified that, in the Record of Caesarean or Emergency Operations in the Hospital’s operating theater, there is no record on July 1, 2000, of the operation corresponding to [I.V.]. [...]68 79. Based on this report, the Committee identified five aspects – medical decision and implementation of norms and protocols; inexistence of written consent to the tubal ligation; problems in following up on the explanatory process; administrative problems concerning the inexistence of records of surgical procedures, and inexistence of the anesthesia record – that led them to make several recommendations, including: the dismissal of the physician, an audit of the Women’s Hospital; training regarding malpractice for the Women’s Hospital; a reprimand to the Management of the Women’s Hospital owing to “loss of documentation and negligence in the control of completion of medical and administrative records,” and the “forward[ing of] a report of the Medical Audit to the [Departmental Health Service] SEDES, so that it could implement the corresponding sanctions and advise [I.V.] of the conclusions reached by the Medical Audit Decisions Committee.”69 C.4 Report of the Ethics Tribunal of the La Paz Departmental Medical Association 80. The Ethics Tribunal of the La Paz Departmental Medical Association issued a report on the case of I.V. dated October 5, 2001, in response to the notes received from the Minister of Health and Social Services and the Director of the Complaints Department of the Ombudsman’s Office in August and September 2001, respectively.70 The Ethics Tribunal disagreed with the decision reached by the Medical Audit Decisions Committee of the General Directorate of Health Services of the Ministry of Health and Social Services, which had conducted the preceding audit. 81. Among its considerations, it affirmed that, the documentation analyzed included an institutional form of the Women’s Hospital signed by the patient’s husband and authorizing the caesarean section and, if necessary, any “special treatment” that had to be carried out “in anticipation of the different surgical findings, contingencies and/or complications that could occur during the caesarean section procedure, which could require the execution of additional corrective or preventive procedures.”71 The Ethics Tribunal considered that the Pomeroy-type bilateral tubal ligation would fall within this concept.72 82. Additionally, the Ethics Tribunal indicated that “it was not possible to have the specific, written informed consent for the tubal ligation, because this procedure was not anticipated, and it was performed by the surgeon owing to the necessity revealed by the findings during the operation”;73 Report issued by the Medical Audit Decisions Committee of March 13, 2001 (evidence file, volume VII, annex 3 to the submission of the case, folios 2120 to 2133). 68 Report issued by the Medical Audit Decisions Committee of March 13, 2001 (evidence file, volume VII, annex 3 to the submission of the case, folio 2121). 69 Cf. Report of the Ethics Tribunal of the La Paz Departmental Medical College / Case of claim by the patient I.V. of October 5, 2001 (evidence file, volume VII, annex 19 to the submission of the case, folio 2166). 70 Report of the Ethics Tribunal of the La Paz Departmental Medical College / Case of claim by the patient I.V. of October 5, 2001 (evidence file, volume VII, annex 19 to the submission of the case, folio 2168). 71 Cf. Report of the Ethics Tribunal of the La Paz Departmental Medical College / Case of claim by the patient I.V. of October 5, 2001 (evidence file, volume VII, annex 19 to the submission of the case, folio 2168). 72 73 Report of the Ethics Tribunal of the La Paz Departmental Medical College / Case of claim by the patient I.V. of October