CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 20 septembre 2022

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page-break-after:avoid } .s9D7227A3 { margin-top:14pt; margin-left:25.5pt; margin-bottom:12pt; text-align:center; page-break-inside:avoid; page-break-after:avoid } .s33165EBA { font-family:Arial; font-size:8pt; vertical-align:super; color:#0069d6 } .s4DDA3AA3 { font-family:Arial; font-weight:bold; font-style:italic } .sF6A12959 { width:33%; height:1px; text-align:left } .s85226119 { margin-top:0pt; margin-bottom:0pt; text-align:justify; font-size:10pt } .s653E6C45 { font-family:Arial; font-size:6.67pt; vertical-align:super; color:#0069d6 } .s3DC36BA9 { font-family:Arial; text-decoration:underline; color:#0069d6 } .s164635C0 { margin-top:0pt; margin-bottom:0pt; text-align:justify; font-size:10pt; background-color:#ffffff }   THIRD SECTION CASE OF Y.P. v. RUSSIA (Application no. 43399/13)     JUDGMENT Art 3 • Inhuman and degrading treatment • Sterilisation without consent not reaching requisite threshold of severity in case circumstances • Decision made in context of unexpected and urgent situation, after thorough consideration by a medical panel, and driven by genuine concerns for health and safety • Absence of bad faith on doctors’ part Art 8 • Private life • Failure of doctors to seek and obtain express, free and informed consent for sterilisation, as required by domestic law • Failure of national courts to establish responsibility • Art 8 procedural safeguards not respected • No redress for infringement   STRASBOURG 20 September 2022   FINAL   20/12/2022   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision.   In the case of Y.P. v. Russia, The European Court of Human Rights (Third Section), sitting as a Chamber composed of:   Georges Ravarani, President,   Georgios A. Serghides,   María Elósegui,   Darian Pavli,   Peeter Roosma,   Andreas Zünd,   Mikhail Lobov, judges, and Olga Chernishova, Deputy Section Registrar, Having regard to: the application (no.   43399/13) against the Russian Federation lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Russian national, Ms Y.P. (“the applicant”), on 11 June 2013; the decision to give notice to the Russian Government (“the Government”) of the complaints under Articles 3 and 8 of the Convention concerning the applicant’s sterilisation and the lack of a judicial response in that connection and to declare the remainder of the application inadmissible; the decision not to have the applicant’s name disclosed; the parties’ observations; Having deliberated in private on 24 May and 5 July 2022, Delivers the following judgment, which was adopted on the last-mentioned date: INTRODUCTION 1.     The case concerns the applicant’s sterilisation in a public hospital without her informed consent. THE FACTS 2.     The applicant was born in 1980 and lives in Krasnoyarsk. She was represented by Mr P.   Tomarovskiy, a lawyer practising in Krasnoyarsk. 3.     The Government were initially represented by Mr   M.   Galperin, Representative of the Russian Federation to the European Court of Human Rights, and later by his successor in that office, Mr   M.   Vinogradov. 4.     The facts of the case, as submitted by the parties, may be summarised as follows. Background events 5.     On 18 September 2007 the applicant had an urgent operation in municipal hospital no.   4 in connection with an ectopic pregnancy. Her right fallopian tube was removed. 6.     On 24 September 2007 the applicant was discharged from hospital with a recommendation that for the next six months she avoid getting pregnant. It appears that she became pregnant three months after the surgery. the applicant’s sterilisation 7.     On 1 August 2008 the applicant, who was then in the thirtieth or thirty-first week of pregnancy, was admitted to municipal maternity hospital no.   2 showing symptoms of rhesus incompatibility and excess amniotic fluid (polyhydramnios). 8.     On 10 August 2008, after examining the applicant, doctors at the hospital decided to perform an emergency Caesarean section as the foetus’s condition had deteriorated and there were signs of hypoxia. 9 .     The applicant signed a consent form for a Caesarean section without sterilisation. The consent form read as follows: “[I]n view of her diagnosis, pregnancy at 32-33 weeks, rhesus negative, suspected rhesus incompatibility, polyhydramnios, ..., hypoxia of the foetus, [the applicant] needs to undergo a Caesarean section without sterilisation. [The applicant] has been informed that examinations and the operation will be conducted in accordance with the standards set at maternity hospital no.   2, aiming to protect her from all possible complications. Nevertheless, complications such as bleeding during or after the operation, obstruction of the bowel, healing of the suture by secondary adhesion, or injury to the bladder, ureters or bowel, as well as the expansion of the scope of the operation, cannot be completely ruled out. On the basis of the foregoing, [the applicant] gives her consent to the Caesarean section and undertakes to follow all the doctor’s recommendations.” 10.     On 11 August 2008 doctors at the hospital performed a Caesarean section on the applicant. They removed the baby, who was suffering from acute respiratory failure and a number of other serious complications. The baby later developed cerebral palsy. 11 .     During surgery the doctors also identified a rupture of the uterus, without bleeding. A medical panel was urgently convened, including the hospital’s chief medical officer. They discussed whether to perform a hysterectomy or to suture the rupture and keep the uterus. Given the applicant’s age, 28 years, the doctors decided to suture the rupture and keep the uterus. However, given the two surgical interventions on the uterus, the Caesarean section and the hysterography (repair of the uterus), the doctors decided that there was a real risk that the uterus would rupture in a future pregnancy, which could endanger the applicant’s life, and that therefore she should be sterilised. They then sealed the applicant’s left fallopian tube. 12.     According to the applicant, she was told the day after the surgery that her only remaining fallopian tube had been sterilised, but she was not given any further details about what the procedure meant. The doctor in charge advised the applicant that her “husband does not need to know about the sterilisation” because “men have a negative view of such things”. According to the applicant, she did not clearly understand the consequences of the procedure. 13.     Two years later the applicant and her husband decided to have a child and as she could not get pregnant, she saw a gynaecologist, who explained that she could only get pregnant via in vitro fertilisation because she had been sterilised during the Caesarean section in 2008. Civil proceedings The applicant’s claim 14.     On 22 August 2011 the applicant brought a civil claim against maternity hospital no. 2 in the Sovetskiy District Court of Krasnoyarsk (“the District Court”), seeking compensation in respect of non-pecuniary damage in connection with her sterilisation. She alleged that the doctors at the defendant hospital had acted in breach of existing legislation and regulations in sterilising her without her consent. She argued, in particular, that sterilisation had not been justified by the need to save her life as there had been no immediate risk to it at the time of the surgery. She complained that her right to choose to become a mother had been violated. She further submitted that after the sterilisation she had consulted various gynaecologists, who had confirmed that the state of her health, and in particular the condition of her uterus, did not show that she should avoid pregnancy, and that if she had not been sterilised she could have conceived naturally, without recourse to in vitro fertilisation. The defendant hospital’s submissions 15 .     The defendant hospital’s representatives argued that she had been sterilised as part of preventive surgery aimed at saving her uterus. They submitted that the panel of doctors had considered two options during surgery: a hysterectomy, as recommended in cases of a ruptured uterus, or preserving the uterus and sterilising the applicant to prevent her from getting pregnant, which could possibly cause a new rupture of the uterus and put her life at risk. In either case, the applicant would have become infertile, but the second scenario had avoided a number of complications for the applicant’s well-being. The doctors had thoroughly considered the consequences of each measure for the applicant’s health and had decided against a hysterectomy. They had therefore done what, in their view, had been in the applicant’s best interests. The representatives argued that the decision about which path to take had had to be taken quickly during surgery, when it had been impossible to ask for the applicant’s consent for sterilisation as she had been under the effects of strong medication. 16.     The defendant hospital also argued that, in the applicant’s case, sterilisation had not been the same as the intervention described in section 37 of the Healthcare Act (see paragraph 25 below), to which the provisions of that Act would have applied. According to the defendant hospital, the aim of the intervention in the applicant’s case had been different as it had been aimed at preserving her uterus and eliminating any future danger to her life. They insisted that the applicant’s consent to the expansion of the scope of the operation could be understood as her consenting to sterilisation. Expert report of 21 May 2012 17.     The District Court ordered a forensic medical expert examination. A panel of eight experts was appointed to establish how and when the rupture of the uterus had occurred; whether there had been any medical grounds for sterilisation of the applicant at the maternity hospital; whether it had been possible to keep the uterus without sterilisation; whether the applicant had been able to give her consent to or refuse sterilisation during the Caesarean section; whether any damage to the applicant’s health had been caused by sterilisation, and, if so, how severe that damage had been; whether the medical services provided to the applicant had been of a high quality, and, if there had been any defects in those services, by whom and when they had been caused; and whether the doctors had complied with the existing methods and standards for such surgery. 18 .     In their report of 21 May 2012, the experts stated that the doctors’ decision to keep the uterus but take away her ability to reproduce had been reasonable because any future pregnancy would threaten the applicant’s life. The experts also pointed out that in accordance with Ministerial Decree no.   303 (see paragraph 26 below), sterilisation could be performed only with the woman’s consent, and such consent had not been obtained in the present case. 19 .     The experts stated that the sterilisation procedure had been performed in accordance with existing standards, except for the lack of informed consent by the patient. At the same time, the experts emphasised that there had been “medical grounds” for sterilisation and that even if informed consent had not been given, the intervention had been justified. 20.     The experts concluded that sterilisation had not caused any damage to the applicant’s health as she had kept her sexual function and could still conceive by in vitro fertilisation. The experts noted that in cases like the applicant’s, when a woman had tubal infertility, she and her partner were entitled to in vitro fertilisation free of charge. Court decisions 21 .     By a judgment of 21 September 2012, the District Court dismissed the applicant’s claim. It relied on the conclusions of the expert report of 21 May 2012 and held that the lack of informed free consent in the applicant’s case had not breached domestic law, in particular Ministerial Decree no. 303 (see paragraph 26 below), as there had been “medical grounds” for sterilisation. Those grounds had been established during the operation by a panel of doctors who, having discovered a ruptured uterus, had had to decide as a matter of urgency on the scope of the surgery, given that the rupture could have provoked heavy bleeding and endangered the applicant’s life. The court noted that in those circumstances even a hysterectomy (removal of the uterus) would have been justified; however, the doctors had decided to keep the uterus, suture the rupture and sterilise her as part of an operation to save her organs. 22.     The District Court also noted, with reference to the conclusions of the expert report of 21 May 2012, that the applicant’s condition during surgery had prevented any conscious action on her part. It also considered that the suturing of the ruptured uterus and sterilisation had been the best solution in the applicant’s case and had been performed as an expansion of the scope of the Caesarean section, to which the applicant had consented. The court agreed with the experts that sterilisation had been performed in order to protect the applicant’s life. 23.     The District Court dismissed the applicant’s arguments about conflicting conclusions in the expert report, which, on the one hand, had stated that sterilisation had been necessary as a future pregnancy would put the applicant’s life at risk, and, on the other hand, had stated that she could conceive by in vitro fertilisation. The court saw no conflict in those conclusions and quoted the experts’ statements on the danger to the applicant of any future pregnancy. It noted that as she had been made fully aware of that danger, she was free to decide whether or not to try in vitro fertilisation. 24 .     On 12 December 2012 the Krasnoyarsk Regional Court (“the Regional Court”) upheld the decision of the District Court on appeal. The Regional Court agreed with the District Court’s conclusion that sterilisation had been performed as an extension of the Caesarean section, and that there had been medical grounds for sterilisation in the applicant’s case. RELEVANT LEGAL FRAMEWORK Relevant domestic law Healthcare Act 25 .     The Law on basic principles of public health (Federal Law no. 5487 ‑ 1 of 22 July 1993 – “the Healthcare Act”), as in force at the relevant time, provided as follows, in so far as relevant: Section 30: Rights of the patient “When seeking medical advice and receiving medical treatment, a patient has the right to ... informed free consent to medical intervention ... [as well as the right to] refuse medical intervention.” Section 32: Consent to medical intervention “Informed free consent by [the person concerned] is a prerequisite for medical intervention. Where the condition of the person concerned does not allow him or her to express his or her will and medical intervention is urgent, the decision to perform [a medical intervention] shall be made by a panel of doctors ...” Section 36: Artificial termination of pregnancy “Every woman has the right to independently decide whether to become a mother.” Section 37: Medical sterilisation “Medical sterilisation as a special procedure to deprive [the person concerned] of the ability to reproduce or as a birth control method may be carried out only upon a written application by a person who is at least 35 years old and has at least two children. If there are medical grounds for sterilisation and the patient has consented, it can be conducted irrespective of age and the number of children.” Ministerial Decree no. 303 26 .     Decree no. 303 of 28 December 1993 of the Russian Ministry of Health, in force at the material time, reiterated the principles set out in section   37 of the Healthcare Act. It also provided a list of medical grounds for sterilisation. International materials A.     Council of Europe documents The Convention on Human Rights and Biomedicine 27 .     The Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine of 1997, also known as the Convention on Human Rights and Biomedicine or the Oviedo Convention (Council of Europe Treaty Series No. 164), is the only binding international treaty in the field, which is ratified by 29 States and signed by 7 others. The Russian Federation has not signed or ratified the Oviedo Convention. Its relevant provisions read as follows: Article 1 – Purpose and object “Parties to this Convention shall protect the dignity and identity of all human beings and guarantee everyone, without discrimination, respect for their integrity and other rights and fundamental freedoms with regard to the application of biology and medicine. Each Party shall take in its internal law the necessary measures to give effect to the provisions of this Convention. ...” Article 4 – Professional standards “Any intervention in the health field, including research, must be carried out in accordance with relevant professional obligations and standards.” Chapter II – Consent Article 5 – General rule “An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time. ...” Article 8 – Emergency situation “When because of an emergency situation the appropriate consent cannot be obtained, any medically necessary intervention may be carried out immediately for the benefit of the health of the individual concerned.” 28.     The relevant parts of the Explanatory Report to the Oviedo Convention provide: “Article 4 – Professional standards ... 33. Further, a particular course of action must be judged in the light of the specific health problem raised by a given patient. In particular, an intervention must meet criteria of relevance and proportionality between the aim pursued and the means employed. Another important factor in the success of medical treatment is the patient’s confidence in his or her doctor. This confidence also determines the duties of the doctor towards the patient. An important element of these duties is the respect of the rights of the patient. The latter creates and increases mutual trust. The therapeutic alliance will be strengthened if the rights of the patient are fully respected. ... Article 5 – General rule 34. This article deals with consent and affirms at the international level an already well-established rule, that is that no one may in principle be forced to undergo an intervention without his or her consent. Human beings must therefore be able freely to give or refuse their consent to any intervention involving their person. This rule makes clear patients’ autonomy in their relationship with health care professionals and restrains the paternalist approaches which might ignore the wish of the patient. ... 35. The patient’s consent is considered to be free and informed if it is given on the basis of objective information from the responsible health care professional as to the nature and the potential consequences of the planned intervention or of its alternatives, in the absence of any pressure from anyone. Article 5, paragraph 2, mentions the most important aspects of the information which should precede the intervention but it is not an exhaustive list: informed consent may imply, according to the circumstances, additional elements. In order for their consent to be valid the persons in question must have been informed about the relevant facts regarding the intervention being contemplated. This information must include the purpose, nature and consequences of the intervention and the risks involved. Information on the risks involved in the intervention or in alternative courses of action must cover not only the risks inherent in the type of intervention contemplated, but also any risks related to the individual characteristics of each patient, such as age or the existence of other pathologies. Requests for additional information made by patients must be adequately answered. 36. Moreover, this information must be sufficiently clear and suitably worded for the person who is to undergo the intervention. The patient must be put in a position, through the use of terms he or she can understand, to weigh up the necessity or usefulness of the aim and methods of the intervention against its risks and the discomfort or pain it will cause. ... Article 8 – Emergency situations 56. In emergencies, doctors may be faced with a conflict of duties between their obligations to provide care and seek the patient’s consent. This article allows the practitioner to act immediately in such situations without waiting until the consent of the patient or the authorisation of the legal representative where appropriate can be given. As it departs from the general rule laid down in Articles 5 and 6, it is accompanied by conditions. 57. First, this possibility is restricted to emergencies which prevent the practitioner from obtaining the appropriate consent... An example that might be put forward is that of a patient in a coma who is thus unable to give his consent (see also paragraph 43 above), or that of a doctor who is unable to contact an incapacitated person’s legal representative who would normally have to authorise an urgent intervention. Even in emergency situations, however, health care professionals must make every reasonable effort to determine what the patient would want. 58. Next, the possibility is limited solely to medically necessary interventions which cannot be delayed. Interventions for which a delay is acceptable are excluded. However, this possibility is not reserved for life-saving interventions. 59. Lastly, the article specifies that the intervention must be carried out for the immediate benefit of the individual concerned.” B.     United Nations 29.     The Universal Declaration on Bioethics and Human Rights was adopted by UNESCO’s General Conference on 19 October 2005. Its relevant provisions read as follows: Article 5 – Autonomy and individual responsibility “The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests.” Article 6 – Consent “1. Any preventive, diagnostic and therapeutic medical intervention is only to be carried out with the prior, free and informed consent of the person concerned, based on adequate information. The consent should, where appropriate, be express and may be withdrawn by the person concerned at any time and for any reason without disadvantage or prejudice.” 30 .     The World Health Organisation (WHO) European consultation meeting on the rights of patients, held in Amsterdam in March 1994, endorsed a document entitled “Principles of the rights of patients in Europe” as a set of principles for the promotion and implementation of patients’ rights in the European Member States of the WHO. Its relevant parts read as follows: “2. INFORMATION 2.2 Patients have the right to be fully informed about their health status, including the medical facts about their condition; about the proposed medical procedures, together with the potential risks and benefits of each procedure; about alternatives to the proposed procedures, including the effect of non-treatment; and about the diagnosis, prognosis and progress of treatment. ... 2.4 Information must be communicated to the patient in a way appropriate to the latter’s capacity for understanding, minimizing the use of unfamiliar technical terminology. ... ...   3. CONSENT 3.1 The informed consent of the patient is a prerequisite for any medical intervention. 3.2 A patient has the right to refuse or to halt a medical intervention. The implications of refusing or halting such an intervention must be carefully explained to the patient.” THE LAW ALLEGED VIOLATION OF ARTICLE 3 OF THE CONVENTION 31.     The applicant complained that she had been subjected to inhuman and degrading treatment as a result of being sterilised without her consent. She referred to Article 3 of the Convention, which reads as follows: “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.” 32.     The Government argued that the applicant could not be said to have been subjected to inhuman and degrading treatment in breach of Article 3 on account of her sterilisation. They pointed out to the absence of any medical or physiological consequences of that medical intervention. They also argued that although the applicant could no longer conceive naturally, she could benefit from in vitro fertilisation. 33 .     The applicant maintained her complaint, arguing that the sterilisation had had serious psychological and emotional effects on her and her relationship with her husband. 34.     The Court observes that cases concerning medical interventions, including those carried out without the consent of the patient, will generally lend themselves to be examined under Article 8 of the Convention (see, for instance, Y.F. v. Turkey , no. 24209/94, §   33, ECHR 2003 ‑ IX; Glass v.   the   United Kingdom , no. 61827/00, §   70, ECHR 2004 ‑ II; M.A.K. and R.K. v. the United Kingdom , nos. 45901/05 and 40146/06, §   75, 23 March 2010; Solomakhin v. Ukraine , no. 24429/03, § 33, 15 March 2012; and Csoma v.   Romania , no. 8759/05, § 45, 15 January 2013). In a number of cases the Court has nonetheless accepted that under certain conditions, medical interventions can reach the threshold of severity to be regarded as treatment prohibited by Article 3 of the Convention. In particular, it has found that the sterilisation of a mentally competent adult without her full and informed consent, when there was no immediate threat to her life, amounted to treatment contrary to Article   3 of the Convention. The Court reached that conclusion taking into account the particular circumstances of the cases concerned, including the fact that the applicants belonged to a vulnerable population group (Roma); their young age and the fact that they were at an early stage of their reproductive life; the absence of imminent medical necessity; and the serious medical and psychological after-effects of the sterilisation procedure (see V.C. v. Slovakia , no. 18968/07, §§   116-19, 8   November 2011; N.B. v.   Slovakia , no. 29518/10, §§   79-80, 12 June 2012; and I.G. and Others v.   Slovakia , no. 15966/04, §   123-25, 13   November 2012). 35.     In this connection, the Court reaffirms that the assessment of whether a particular form of ill-treatment reaches the threshold of severity capable of bringing it within the scope of Article 3 is relative and depends on all the circumstances of the case, such as the duration of the treatment, its physical and mental effects and, in some cases, the sex, age and state of health of the victim. In assessing evidence, the Court has generally applied the standard of proof “beyond reasonable doubt”. Such proof may follow from the coexistence of sufficiently strong, clear and concordant inferences or of similar unrebutted presumptions of fact (see, among other authorities, Akopyan v. Ukraine , no. 12317/06, § 103, 5 June 2014). The Court has considered treatment to be “inhuman” because,   inter alia , it was premeditated, was applied for hours at a stretch and caused either actual bodily injury or intense physical and mental suffering. Treatment has been held to be “degrading” when it was such as to arouse in its victims feelings of fear, anguish and inferiority capable of humiliating and debasing them and possibly breaking their physical or moral resistance, or when it was such as to drive the victim to act against his will or conscience (see Gäfgen v.   Germany [GC], no. 22978/05, § 89, ECHR 2010). Although the purpose of such treatment is a factor to be taken into account, in particular the question of whether it was intended to humiliate or debase the victim, the absence of any such purpose does not inevitably lead to a finding that there has been no violation of Article 3 (see, among other authorities, V.C. v. Slovakia , cited above, § 101). In order for treatment to be “inhuman” or “degrading”, the suffering or humiliation involved must in any event go beyond the inevitable element of suffering or humiliation connected with a given form of legitimate treatment (ibid., § 104). 36.     In the present case, the applicant was sterilised, as the doctors considered that her future pregnancy could lead to a rupture of her uterus and thus put her life at risk. The Court is mindful that sterilisation constitutes a major interference with a person’s reproductive health status and concerns one of the essential bodily functions of human beings (see V.C. v. Slovakia , cited above, § 106). It notes the applicant’s general argument that her sterilisation had had psychological and emotional effects on her and her relationship with her husband (see paragraph 33 above) and is prepared to accept that she felt humiliated and degraded. At the same time, the Court observes that during a routine medical intervention (Caesarean section), the health professionals were suddenly faced with a situation (ruptured uterus), where they had to decide as a matter of urgency on the scope of the surgery, and where even a hysterectomy (removal of uterus) could have been justified (see the first-instance court’s relevant findings, with reference to an expert report, in paragraphs 21 and 22 of the draft). The decision to keep the uterus, suture the rupture and sterilise the applicant had been taken by a panel of doctors including the chief medical officer, after a thorough consideration, on the medical grounds that were confirmed by the subsequent expert report (see paragraph 19 above), and was considered by those health professionals to be necessary to prevent a risk to the applicant’s life in the future (see paragraphs   11 and 15 above). 37.     Against that background, the Court considers that when taking the decision to sterilise the applicant the doctors had not acted in bad faith, let alone with an intent of ill-treating or degrading her. The said decision, albeit clearly disrespectful of the applicant’s autonomy was driven by the doctors’ genuine concerns for her health and safety. The Court furthermore does not discern any additional elements such as, for instance, the applicant’s particular vulnerability, to enable it to conclude that the requisite threshold of severity was reached in the particular circumstances of the present case to bring Article 3 into play. 38.     The Court has therefore no sufficient basis to conclude that the applicant was treated in such a way as to reach the threshold of Article 3 of the Convention. It follows that this complaint is incompatible ratione materiae with the provisions of the Convention within the meaning of Article   35 §   3   (a) and must be rejected in accordance with Article 35 §   4. ALLEGED VIOLATION OF ARTICLE 8 OF THE CONVENTION 39.     The applicant complained that her right to respect for her private life had been breached as a result of her sterilisation without her informed consent and that she had received no adequate response at the domestic level in that connection. She relied on Article 8 of the Convention, the relevant part of which reads as follows: “1.     Everyone has the right to respect for his private ... life ...” Admissibility 40.     The Government were of the view that the sterilisation had had no adverse physical or psychological consequences for the applicant and that therefore her right to respect for her private life as secured by Article 8 of the Convention was not engaged. 41.     The applicant maintained her complaint. 42.     The Court reiterates that the notion of “private life” includes a person’s physical and psychological integrity (see, for instance, Tysiąc v.   Poland , no. 5410/03, §   107, ECHR 2007 ‑ I, and the cases cited therein) and also applies to decisions both to have and not to have a child or become parents (see Evans v. the United Kingdom [GC], no. 6339/05, § 71, ECHR   2007 ‑ I; A,   B and C v. Ireland [GC], no. 25579/05, § 212, ECHR 2010; and R.R.   v.   Poland , no. 27617/04, § 180, ECHR 2011). Moreover, individuals’ involvement in the choice of medical care provided to them and consent to such treatment fall within the scope of Article 8 of the Convention (see A.K.   v. Latvia , no. 33011/08, §   63, 24 June 2014, with further references). Having regard to the circumstances of the present case, the Court considers that the applicant’s complaint falls within the scope of Article 8 of the Convention. 43.     It notes that this complaint is neither manifestly ill-founded nor inadmissible on any other grounds listed in Article   35 of the Convention. It must therefore be declared admissible. Merits The parties’ submissions 44.     The applicant argued that her sterilisation in the absence of her informed consent had constituted a serious interference with her rights secured by Article 8 of the Convention. She contended, in particular, that she had not consented to the sterilisation as required by international standards. Nor had her sterilisation been in compliance with the relevant domestic law (see paragraphs 25-26 above), which provided that informed and free consent was a prerequisite for medical intervention, and that sterilisation required informed consent by the patient. She also stressed in that connection that the consent form which she had signed prior to her Caesarean section had specifically excluded sterilisation. 45.     Furthermore, the applicant argued that there had been no medical necessity for her sterilisation. In particular, it had not been a life-saving intervention since there had been no established risk to her life that required her urgent sterilisation without her consent at the time when a Caesarean section had been performed. The applicant argued that any potential risk to her life during future pregnancies could not be regarded as sufficient grounds for sterilising her in the absence of her full and informed consent. She pointed out that in an attempt to prevent some hypothetical risks, the doctors had in fact inflicted very serious harm on her health, having rendered her infertile. The applicant also maintained that she had had no adequate judicial response at the domestic level in connection with her sterilisation without her consent. 46.     The Government argued that even assuming that the sterilisation procedure had constituted an interference with the applicant’s right to respect for her private life under Article 8 of the Convention, that interference had been justified under the second paragraph of that provision. 47 .     They contended that the consent form signed by the applicant provided for the possibility of expanding the scope of the surgery and that, therefore, the applicant had consented to the sterilisation. Moreover, during the Caesarean section the doctors had detected a rupture of the applicant’s uterus, the condition that had put her life at immediate risk. In such circumstances, the doctors would have been justified in removing the uterus, but instead they had chosen to preserve that organ and to sterilise the applicant to exclude any risk to her life in the future. In that connection, the Government argued that there had clearly been a medical necessity for the intervention in question, and more specifically the risk of grave health problems during future pregnancies had justified performing the sterilisation without the applicant’s clearly expressed consent. In particular, they noted the high risk of rupture of the uterus along the post-operative scar. 48 .     The Government also argued that it was still possible for the applicant to become pregnant through in vitro fertilisation. They also insisted that the applicant had been provided with adequate judicial protection of her rights at the domestic level, given that her claim against the hospital had been examined at two levels of jurisdiction. The Court’s assessment (a)    General principles 49 .     The Court reaffirms that although the right to health is not as such among the rights guaranteed under the Convention and the Protocols thereto (see Jurica v. Croatia , no. 30376/13, § 84, 2 May 2017, and the cases cited therein), the High Contracting Parties have, parallel to their positive obligations under Article 2 of the Convention, a positive obligation under Article 8, firstly, to have in place regulations compelling both public and private hospitals to adopt appropriate measures for the protection of their patients’ physical integrity and, secondly, to provide victims of medical negligence with access to proceedings in which they may, where appropriate, obtain compensation for damage (ibid.; see also Trocellier v. France (dec.), no. 75725/01, ECHR 2006 ‑ XIV). This latter procedural obligation will be satisfied if the legal system affords victims a remedy in the civil courts, either alone or in conjunction with a remedy in the criminal courts, enabling any responsibility of the doctors concerned to be established and any appropriate civil redress to be obtained. Disciplinary measures may also be envisaged (see Mehmet Ulusoy and Others v. Turkey , no. 54969/09, § 91, 25 June 2019, with further references). 50.     Furthermore, the Court reiterates that in the sphere of medical assistance, even where the refusal to accept a particular treatment might lead to a fatal outcome, the imposition of medical treatment without the consent of a mentally competent adult patient would interfere with his or her right to physical integrity (see V.C. v. Slovakia , cited above, § 105, and the cases cited therein). It has emphasised that it is important for individuals facing risks to their health to have access to information enabling them to assess those risks. It has held in particular that the Contracting States are bound to adopt the necessary regulatory measures to ensure that doctors consider the foreseeable impact of a planned medical procedure on their patients’ physical integrity and inform patients of these consequences beforehand in such a way that the latter are able to give informed consent (see Ioniță v. Romania , no.   81270/12, § 84, 10 January 2017, and the cases cited therein). 51.     As regards, more specifically, sterilisation, the Court has noted that it affects reproductive health status and had repercussions on various aspects of the applicants’ private and family life under Article 8 (see V.C. v.   Slovakia , cited above, §   143). As it concerns one of the essential bodily functions of human beings, it bears on manifold aspects of the individual’s personal integrity including his or her physical and mental well-being and emotional, spiritual and family life. It may be legitimately performed at the request of the person concerned, for example as a method of contraception, or for therapeutic purposes where the medical necessity has been convincingly established. However, the position is different in the case of the imposition of such medical treatment without the consent of a mentally competent adult patient. Such a way of proceeding is to be regarded as incompatible with the requirement of respect for human freedom and dignity, one of the fundamental principles on which the Convention is based (ibid., §§ 106-07, in the context of assessment of the same complaint under Article 3). (b)    Application of the general principles in the present case 52 .     On the facts, the Court observes that the applicant was sterilised in a public hospital in the context of a delivery by Caesarean section. The doctors found a rupture of her uterus and decided to suture it up and to sterilise the applicant to prevent her from getting pregnant in the future, as they considered that a pregnancy could put her life at risk. The domestic courts subsequently considered, in essence, that (a) the applicant had in fact consented to sterilisation as that intervention had been performed as an expansion of the scope of the Caesarean section; (b) that an unexpected complication (a rupture of the uterus) during the Caesarean section had required urgent action to save the applicant’s life, and that even a more radical intervention, such as a hysterectomy, would have been justified; and (c) that in any event it was open to the applicant to have recourse to in vitro fertilisation (see paragraphs 21-24 above). The Government advanced similar arguments (see paragraphs 47-48 above). 53.     In this connection, the Court observes that the relevant consent form, which the applicant signed prior to her Caesarean section, explicitly excluded sterilisation (see paragraph 9 above). Moreover, the expert report clearly pointed to the applicant’s lack of informed consent for her sterilisation (see paragraphs 18-19 above), that finding being accepted by the first-instance court (see paragraph 21 above). The Court cannot accept the argument that the applicant’s sterilisation had been performed as an expansion of the Caesarean section, and that therefore the applicant could be regarded as having consented to it. It emphasises that sterilisation is not a procedure that can be routinely carried out as part, or as an expansion, of a Caesarean section or of any other medical intervention, unless the patient has given her express, free and informed consent to that particular procedure. The only exception concerns emergency situations in which medical treatment cannot be delayed and