68 other doctor indicated during the domestic administrative procedure that, although it was necessary to perform a tubal ligation from a medical perspective, it was incorrect from a legal perspective, because they should have waited until I.V., following the c-section, took the decision to undergo the said procedure.291 Subsequently, in the statement he submitted to the Court, he asserted that what he had stated previously had been taken out of context and what he had meant to state was that, although the tubal ligation was absolutely advisable, “neither domestic law nor international protocols on the matter established a regulated and legal procedure for complex, difficult or exceptional cases,”292 such as that of I.V. 216. The Court has corroborated that the Code of Medical Ethics, in force at the time of the facts, indicated that it was an obligation of doctors to obtain a patient’s written informed consent in order to perform any medical or surgical procedure, especially in situations that entailed a risk or resulted in damage (mutilación). The Code established that only in cases of emergency and when the consent could not be given, because clinical criteria recommended immediate treatment, was it possible to proceed without authorization. In the specific case of sterilization, this could only be performed at the express, voluntary and documented request of the patient, or in cases of therapeutic indication strictly determined by a medical board.293 217. The State also presented as evidence a letter from the Head of Obstetrics of the Women’s Hospital dated October 26, 2015, in which he indicated that “[o]bstetrics ha[d] no specific protocols for performing tubal ligations due to medical indication, because it [was] a non-protocolized alternative procedure, and constitute[d] a special obstetric situation where, based on his experience and the obstetric evidence and in order to prevent future obstetric complications resulting in maternal and/or fetal death, the specialist decided to perform the corresponding surgical procedure.”294 The Court notes that, according to the corresponding standards, the Code of Medical Ethics in force at the time required informed consent, signed by the patient to be obtained, or else a decision by a medical board. 218. The Court concludes that the standards concerning informed consent and its regulation with regard to surgical procedures for female sterilization in force in Bolivia at the time of the facts were ambiguous, imprecise and even contradictory. On the one hand, written informed consent was required and, on the other, situations were established in which “by medical decision and in grave cases,” sterilization could be performed without the conditions being clearly established in this case. The Court notes that, according to the statements referred to above, not even the health personnel themselves were clear about which standard should be applied in the case of I.V. 219. The Court considers that it could have been understood that the situation based on which I.V. Cf. Final decision No. 020/2002 issued by the Legal Advisory Services Unit of the La Paz Departmental Health Service on July 25, 2002 (evidence file, volume XIV, annex 3 to the representative’s final arguments, folio 5769). 291 Affidavit prepared by Marco Vladimir Vargas Terrazas on April 28, 2016 (evidence file, volume XI, affidavits, folios 3933 and 3939). 292 Cf. Resolution No. 086/2002 issued by the Second Trial Court of La Paz on November 18, 2002 (evidence file, volume VII, annex 24 to the submission of the case, folio 2191). According to this Resolution, articles 19 and 23 of the Code of Medical Ethics at that time, adopted by Law No. 728 of August 4, 1993, indicated the obligation to obtain consent, including in cases of sterilization. The Court notes that the Code of Medical Ethics in the case file contains these obligations in its articles 16, 18, 19 and 22 (file of the procedure before the Commission, volume II, folios 411 and 412). The Court considers it necessary to stress that, for the purposes of the analysis in this section, it will not take into account the Code of Medical Ethics and Deontology, because according to information in the case file and provided by the parties, that Code was adopted by Ministerial Resolution No. 047/04 of July 2004, so that it was not in force at the time of the facts. Nevertheless, the Court underscores that articles 8(6) and (10), 20, 22, 23, 25 and 37 of that Code contain similar provisions to those of the 1993 Code of Medical Ethics (file of the procedure before the Commission, volume II, folios 406 to 408). 293 Letter from the Head of the Obstetric Services of the Women’s Hospital to the Director of this hospital dated October 26. 2015 (evidence file, volume X, annex 10 to the State’s answering brief, folios 3619 and 3620). 294