67 decision on contraception.”284 213. However, despite the requirement of informed consent in cases of high reproductive risk, Rule 5 indicated that voluntary surgical contraception “[could be] performed by medical decision by a laparotomy in serious cases, duly documented by the patient’s medical history and consulted with the family,”285 without specifying what this risk involved. This rule was cited in the Administrative Resolution of March 10, 2003, which annulled the decision to dismiss the physician during the administrative procedure without any reasoning or substantiation (supra para. 90). Similarly, Rule 6 of the 1997 Bolivian standard established that, for a woman to be able to undergo surgical sterilization following counseling, the service authorized to perform the procedure should set up a medical committee composed of at least three professionals to analyze the case and, when they had analyzed the case, they had to prepare a decision justifying their approval.286 214. Meanwhile, the 1998 Bolivian standards were adopted to regulate the technique of bilateral tubal occlusion – a technique that results in permanent sterilization – in order to improve the quality of the comprehensive service for women with reproductive risks. 287 These standards expressly recognized reproductive rights including the “right of couples and individuals to decide freely and responsibly on the number and spacing of their children and to receive the necessary information, education and means to do this.”288 They also established that bilateral tubal occlusion would be performed, provided that the user had received adequate guidance and had confirmed her decision by signing or placing her fingerprint on the informed consent document.289 215. Despite the existence of these standards that required informed consent in writing, signed by the patient, the State argued that this was not applicable to the case of I.V., because the 1997 and 1998 Bolivian standards had been adopted for cases in which patients voluntarily, regardless of pregnancy, went to a medical center to request tubal ligation. The State argued that this was not the case of I.V., because her sterilization occurred following a medical incident on the occasion of the caesarean section. This was ratified by statements made by the doctors during the proceedings before this Court. In this regard, one of the doctors who intervened stated that, since the 1998 Bolivian standards were not applicable and the case of I.V. was a special case, verbal consent was permitted, stressing that, even in this situation, sterilization should be voluntary. 290 However, the Bolivian Health standards NB–SNS–04–97, p. 27. They defined general informed consent as the voluntary decision of the patient to undergo a medical or surgical procedure with real awareness and understanding of the pertinent information and without pressure (file of the procedure before the Commission, volume III, folios 894 to 898). 284 285 Bolivian Health standards NB–SNS–04–97, p. 19 (file of the procedure before the Commission, volume III, folio 894). 286 Cf. Bolivian Health standards NB–SNS–04–97, p. 19 (file of the procedure before the Commission, volume III, folio 894). These standards defined reproductive risk as “the probability that a woman will suffer harm if she becomes pregnant in unfavorable health conditions. This is detected in women who are not pregnant.” They also adopted concepts such as obstetric risk, defined as the “probability that a pregnant woman and/or her infant suffer harm due to the presence of risk factors of a biological, environmental or social nature.” Bolivian Health standards MSPS-98, p. 15 (file of the procedure before the Commission, volume I, folio 193). 287 288 Bolivian Health standards MSPS-98, p. 18 (file of the procedure before the Commission, volume I, folio 195). Bolivian Health standards MSPS-98, p. 21 (file of the procedure before the Commission, volume I, folio 196). The 1998 Bolivian standards describe informed choice as the “process by which a person takes a decision regarding health care. It should be based on access to all the necessary information and full comprehension of this. The process should result from a free and informed decision of the person about whether or not they wish to receive the health care service ad, if so, what method or procedure will they choose and do they agree to receive.” Similarly, it defines informed consent as “the act by which a person agrees to receive medical care or treatment, following a process of informed choice.” Bolivian Health standards MSPS-98, p. 17 (file of the procedure before the Commission, volume I, folio 194). 289 Cf. Statement made by Edgar Torrico Ameller before the Inter-American Court during the public hearing held on May 2, 2016. 290