53 – and always according to the State – constituted an exception to the requirement of informed consent in cases in which there was a high probability that another pregnancy would have fatal consequences. First, the Court notes that, even though the 1993 WHO manual established that sterilizations could be performed as a result of medical indication, even in that case, such surgical procedures must be voluntary. Consequently, informed consent must be obtained. Second, even though the text of this manual refers to cases of sterilization due to medical indication in which consent may be waived,219 the Court considers that the wording of this alleged exception is imprecise, and open to two possible interpretations. On the one hand, as the wording was understood by I.V.’s representative, the exception was only applicable to situations of extreme gravity, such as if a woman arrived at the hospital in shock due to a ruptured uterus. On the other hand, in the sense understood by the State, the exception to the requirement of informed consent was applicable in cases where there was a high probability that another pregnancy would have a fatal outcome. 180. In this regard, the Court considers that the former interpretation would make that standard inapplicable to this case, because I.V. was not admitted to the hospital with a ruptured uterus or similar diagnosis. In addition, the Court notes that, if it accepted the interpretation made by the State, this would involve assuming an isolated standard that contradicts consistent and reiterated standards contained in numerous other international documents cited by this Court. In any case and given the uncertainty about the interpretation, the Court concluded that the 1993 WHO manual should be read in connection with the American Convention in light of the autonomy and rights of patients, so that the exception to obtaining consent is only valid in situations where there are medical indications and in circumstances that meet the necessary requirements of urgency and emergency for it to be admissible. ii) The principle of free consent 181. The second element emphasizes the aspect of the freedom of the manifestation of consent. Thus, the Court considers that consent must be given in a free, voluntary and autonomous manner, without pressure of any kind, without using it as a condition for submission to other procedures or benefits, without coercion, threats or disinformation. Furthermore, consent cannot be given as a result of actions by health personnel that persuade individuals to steer their decision in a certain direction, and it cannot be the result of any type of inappropriate incentive. Free consent has been referred to in numerous international documents concerning consent as a mechanism that protects patients’ rights, from the Nuremberg Code of medical ethics to the United Nations Interagency Statement220 (supra paras. 171 and 173). In particular, the Declaration of Helsinki emphasizes that (usually after three or four) or other serious obstetric or medical problems. Some conditions that increase the health risks associated with pregnancy are multiparity, advanced maternal age, previous obstetric complications, medical conditions that can complicate the pregnancy […] and previous abortions.” It also indicates that: “[f]or some clients, pregnancy poses a serious health risk, and contraception is therefore recommended for medical reasons. Sterilization is often considered in these situations. As in other cases, these women should make voluntary, informed, well-considered decisions about contraception; family planning counselling is necessary. However, the nature of counselling is different when contraception has been recommended for medical reasons. When a woman is advised to undergo sterilization for medical reasons, the doctor and other staff members must ensure that she understands the comparative risks associated with pregnancy, sterilization, and other methods of contraceptive. Vasectomy for the partner and long-term methods (intrauterine devices and implantable contraceptives) should also be considered, particularly, if the sterilization surgery poses a significant risk for the woman. If the woman chooses to undergo tubal occlusion, informed consent is necessary.” WHO, Female sterilization: a guide to provision of services, 1993, pp. 72 and 78 (evidence file, volume XIII, annex 3 to the State’s final arguments, folios 5521 and 5527). The guide establishes that “[i]n a few instances sterilization is performed without family planning counselling and consent. For example, if a woman arrives at the hospital in shock due to a ruptured uterus, she must undergo emergency surgery, and a sterilization is often medically necessary because of the high risk of death if the woman becomes pregnant again. In such cases, postoperative counselling is essential to help the patient adjust to her loss of fertility and understand why the surgery was necessary.” WHO, Female sterilization: a guide to provision of services, 1993, pp.72 and 73 (evidence file, volume XIII, annex 3 to the State’s final arguments, folios 5521 and 5522). 219 220 Cf. Declaration of Helsinki, Principles 25 to 32; Declaration of Lisbon on the rights of patients, Principles 3, 7 and 10;