CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 22 novembre 2022

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margin-left:34pt; margin-bottom:0pt; text-indent:-17pt; text-align:justify } .sE5BF05B1 { width:2.33pt; font:7pt 'Times New Roman'; display:inline-block } .s7F175FE6 { margin-top:0pt; margin-left:51.05pt; margin-bottom:0pt; text-indent:-17.05pt; text-align:justify } .sE5C1F6E3 { width:3.33pt; font:7pt 'Times New Roman'; display:inline-block } .s2D9C6089 { margin-top:12pt; margin-bottom:12pt; text-indent:14.2pt; text-align:justify; page-break-inside:avoid; page-break-after:avoid } .s69DCC830 { margin-top:36pt; margin-bottom:0pt } .sC986E16F { font-family:Arial; color:#ffffff } .s5749FA4E { width:31.55pt; display:inline-block } .s4D5F7D2B { width:138.77pt; display:inline-block } .s5A65B3DC { width:46.56pt; display:inline-block } .s44B8752F { width:177.11pt; display:inline-block }   SECOND SECTION CASE OF G.M. AND OTHERS v. THE REPUBLIC OF MOLDOVA (Application no. 44394/15)   JUDGMENT   Art 3 (procedural) • Ineffective investigation into allegations of forced abortions and forced contraception after rape by doctor in neuropsychiatric residential asylum of three intellectually disabled applicants with legal capacity Art 3 (substantive) • Positive obligations • Inhuman or degrading treatment • Respondent State’s failure to establish and apply effectively a system providing protection to intellectually disabled women in psychiatric institutions against serious breaches of their integrity • Domestic legal framework lacking adequate safeguards of obtaining valid, free and proper consent from intellectually disabled persons for medical interventions • Inadequate criminal legislation and lack of mechanisms to prevent such abuse • Failure to protect applicants’ physical integrity from non-consensual abortion and regarding first applicant also forced contraception • Absence of prima facie evidence showing remaining applicants subjected to forced contraception   STRASBOURG 22 November 2022 FINAL   22/02/2023   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision.   In the case of G.M. and Others v. the Republic of Moldova, The European Court of Human Rights (Second Section), sitting as a Chamber composed of:   Jon Fridrik Kjølbro , President ,   Carlo Ranzoni,   Branko Lubarda,   Pauliine Koskelo,   Jovan Ilievski,   Gilberto Felici,   Diana Sârcu , judges , and Hasan Bakırcı, Section Registrar, Having regard to: the application (no.   44394/15) against the Republic of Moldova lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by three Moldovan nationals, Ms G.M., Ms T.M. and Ms M.P. (“the applicants”), on 5 September 2015; the decision to give notice of the application to the Moldovan Government (“the Government”); the decision not to disclose the applicants’ names; the observations submitted by the Government and the observations in reply submitted by the applicants; the comments submitted by Validity, ORDO IURIS and the European Centre for Law and Justice, who were granted leave to intervene by the President of the Section; Having deliberated in private on 18 October 2022, Delivers the following judgment, which was adopted on that date: INTRODUCTION 1.     The case concerns the allegedly involuntary termination of pregnancies and birth-control measures imposed on persons with intellectual disabilities, and the alleged ineffective investigation into their complaints concerning the non-consensual medical interventions in question. The applicants complained of a violation of their rights under Article 8 of the Convention. THE FACTS 2.     The first applicant, G.M., and the second applicant, T.M. were born in 1984. The third applicant, M.P., was born in 1973. The applicants were represented by Ms V. Gaşiţoi , a lawyer practising in Chișinău. 3.     The Government were represented by their Agent, Mr O. Rotari. 4.     The facts of the case may be summarised as follows. 5.     The applicants are affected by intellectual disabilities of varying levels of severity and have been institutionalised in the Bălți neuropsychiatric residential asylum (“the asylum”) for different periods of time. During their stays in the asylum they were raped on various occasions by F.S., the head doctor of one of the units (see paragraph 35 below). The first and third applicants claim to have become pregnant after being raped by F.S. and all three applicants claim to have been subjected to forced abortions. All three applicants also claim that after the forced abortions, intrauterine contraceptive devices were implanted without their consent inside their uteruses to prevent further pregnancies. The first applicant 6.     The first applicant was resident in the Bălți asylum from 2002 to 2013. According to her, she became pregnant after being raped by F.S. In November 2003 the doctors at the asylum learned that she was between seventeen and eighteen weeks pregnant and sent her to the Bălți maternity hospital for the pregnancy to be terminated. 7.     On 3 December 2003 the applicant was escorted by a nurse from the asylum to the maternity hospital. The same day a medical committee issued decision no.   253 on the termination of the pregnancy. 8.     The Government submitted a copy of an excerpt from that decision, which read as follows: “Name: [G.M.] [Year of birth]: 1984 Residence: Neuropsychiatric asylum Diagnosis: 17-18 weeks pregnant. Moderate mental impairment [ Retard mental mediu ]. Psychopathological syndrome. Single. Certificate no. 01/06-354 from the neuropsychiatric asylum. [Ultrasound] of 21/11/2003.” 9.     According to the first applicant, she refused to take the prescribed medication for several days. On 5 December 2003 she was forcefully subjected to abortion by amniotomy. The following day, the applicant gave birth to a baby boy and underwent curettage under anaesthetic. She was discharged on 8 December 2003. 10 .     On 1 April 2014 the first applicant underwent a gynaecological medical examination. The ultrasound investigation revealed a “hyperechoic formation in the cervical cavity”, which the doctor believed to be an intrauterine contraceptive device. On an unspecified date, the doctor attempted to extract the device but was unable to locate it in the cervical cavity. The doctor concluded that the device must either have become embedded in the uterine wall or that it was not there at all. The doctor recommended additional ultrasound examinations. 11.     The first applicant has not had any other children. The second applicant 12.     The second applicant has been resident in the Bălți asylum since 2001. On 22 November 2007 the doctors at the asylum learned that she was seven weeks pregnant. Five days later she was hospitalised in the Bălți maternity hospital and subjected to a medical abortion and curettage. She was discharged the following day. 13.     The copies of the applicant’s medical file, submitted by the Government, indicated that she had been hospitalised with vaginal bleeding and abdominal pain, and a “spontaneous miscarriage in progress [ în evoluție ]”. The diagnosis read “7-8 weeks pregnant. Mental impairment [ Retard mental ]”. The doctor prescribed laboratory tests and curettage of the uterus for medical reasons. 14 .     The Government submitted a copy of an informed consent form with a handwritten letter “M.” in the fields for the patient’s name and signature. The document does not contain any information concerning the identification data of the patient, the date or a description of the medical intervention concerned. 15.     The Government also submitted a copy of an excerpt from decision no. 30 of 27 November 2007 issued by the committee on the termination of pregnancy, which read as follows: “Name: [T.M.] [Year of birth]: 1984 Residence: [address of the neuropsychiatric asylum] Diagnosis: 6-7 weeks pregnant. Mental impairment [ Retard mental ]. Certificate no.   01/06-627 of 23/11/2007. [Ultrasound] of 27/11/2007.” 16 .     According to the applicant, in 2014 during a medical check-up the doctor extracted an intrauterine contraceptive device, which the applicant believed must have been inserted after the abortion. 17.     At the time she lodged her application in 2015, she had not had any other children. The Government submitted documents confirming that in July 2015 and November 2016 the applicant had had two spontaneous miscarriages and in 2019 and 2020 she had given birth to two children. The third applicant 18.     The third applicant was resident in the Bălți asylum from 1988 to 1998 and then from 2009 onwards. 19.     According to the third applicant, in 1998 she became pregnant after being raped by F.S. and was subjected to a forced abortion. Because she complained about these events, she was transferred on 10 August 1998 to another psychiatric asylum. She has not had any other children and submitted that an intrauterine contraceptive device had been implanted in her uterus. 20.     The Government submitted that there were no medical records of the applicant’s alleged pregnancy nor of any medical intervention in the Bălți maternity hospital. Investigation into the applicants’ complaints 21.     On 19 April 2014 the applicants lodged criminal complaints concerning the termination of their pregnancies and birth-control measures imposed on them without their consent. They relied directly on Article 8 of the Convention. 22 .     On 12 May 2014 the police replied in a letter that the termination of their pregnancies had been lawful and provided for by domestic law. The relevant parts of the letter read as follows: “It has been established that ... in December 2003 the feldsher , G., was instructed by F.S. to take [the first applicant] to the Bălți maternity hospital to have her examined by a gynaecologist and to terminate her pregnancy. At [the maternity hospital] ... it was confirmed that [the first applicant] was eighteen weeks pregnant and a decision to terminate the pregnancy was taken. [The first applicant] requested and agreed to the termination of the pregnancy for health reasons and she was hospitalised. She was at the hospital from 3 to 8 December 2003, after which she expelled the contents of the uterine cavity, which is confirmed by the medical records. Throughout her entire stay in the maternity hospital, she was under the surveillance of Doctor S.C. When discharged, [the first applicant] asked for her dead ‘child’ in order to bury him, which she did. [The first applicant] never became pregnant again after that. ... [The second applicant] was pregnant only once, and on 27 November 2007 the pregnancy was terminated around the sixth to seventh week ... which is confirmed by the medical records ... The decision to terminate the pregnancy was taken because her relatives are not in contact with her and taking into account her health condition ... [The third applicant] was never pregnant. ... In all cases the termination of the pregnancies of residents at the neuropsychiatric asylum took into consideration order no. 313 of 25 July 2006; the Regulation on medical services for the termination of pregnancy; order no. of 26 February 2007 modifying [the above-mentioned] Regulation; order no. 21 of 3 February 2012; order no. 18 of 27   January 2011; order no. 647 of 21 September 2010; the Regulation on voluntary termination of pregnancy; Regulation no. 313 of 25 July 2006 on the voluntary termination of pregnancy in the first months of pregnancy; and the residents’ health condition, social status and consent. ... In respect of spontaneous termination of births [ sic ], no breaches of the law have been found, the curettage was lawful and provided for by existing legal provisions. ... The case file was referred to the prosecutor’s office with the proposal to refuse the initiation of criminal proceedings.” The letter referred to two other residents at the asylum, S.T. and O.C., who had had their pregnancies terminated in similar circumstances, between the twenty-first and twenty-second weeks in 1998 and between the seventh and eighth weeks in 2008, respectively. 23.     The applicants’ representative appealed against the reply from the police, noting, inter alia , that it was incomplete, as no investigation into the facts in respect of the third applicant had been carried out and it only made reference to ministerial regulations without properly investigating the lack of consent. 24 .     On 16 June 2014 the prosecutor refused to initiate criminal proceedings, finding that the facts did not reveal any elements of the crime of illegal termination of a pregnancy or of illegal surgical sterilisation (see paragraph 37 below). In particular, the prosecutor concluded that the pregnancies of the first and second applicants had been terminated in accordance with the law and with their consent; that, in the absence of medical records to the contrary, the third applicant had never been pregnant; and that the applicants had not been sterilised. The prosecutor relied on the witness statements of employees at the neuropsychiatric asylum but did not cite their content. 25 .     The Government provided the Court with several witness statements made from May to July 2014 in the course of the inquiry. According to them, the manager of the Bălți maternity hospital submitted that the first applicant had provided written consent before the decision to terminate her pregnancy had been taken by the medical committee. Doctor N.F., who had witnessed the first applicant’s abortion, submitted that the law at the time had not required the patient’s consent as a precondition and that the procedure had been carried out after a discussion with the patient. O.G., the feldsher , submitted that the decision to terminate the second applicant’s pregnancy had been taken by the gynaecologist at the Bălți asylum. 26.     The applicants appealed against the prosecutor’s decision, arguing that the first applicant had not consented to the termination of her pregnancy or to the birth-control measure, that the consent allegedly signed by the second applicant was flawed (it was not clear who had signed it, and there was no patient identification data or description of the medical procedure for which it had been given), and that no investigation had been carried out into the complaints concerning forced birth-control measures or in respect of the third applicant who had stayed at different facilities throughout the years. 27.     On 14 July 2014 the hierarchically superior prosecutor upheld the applicants’ appeal and remitted the case for additional investigation. 28 .     On 1 October 2014 the prosecutor once again refused to initiate criminal proceedings on the same grounds as before, reiterating the statements contained in the police letter of 12 May 2014 (see paragraph 22 above). The prosecutor noted that until 2006 the national law had not required the patient’s consent for the termination of a pregnancy and, despite the reference to the first and second applicants’ statements as to the absence of their consent both for the abortion and the birth control-measure, he concluded that all three applicants had agreed to the medical interventions. 29 .     The applicants appealed against the prosecutor’s decision, referring extensively to the statements made by medical staff which allegedly confirmed that the applicants, who were intellectually disabled, were not allowed to give birth and that the placement of an intrauterine contraceptive device had not required the applicants’ consent because “they were unable to take responsibility for their actions”. The appeal provided details as to how the first applicant had learned about the intrauterine device during a medical check-up (see paragraph 10 above), and relied on Articles 3 and 8 of the Convention. 30.     The hierarchically superior prosecutor rejected the applicants’ appeal. The applicants appealed against his decision before the investigating judge, reiterating the same grounds for appeal as before. 31 .     On 5 December 2014 the Bălți investigating judge upheld the applicants’ appeal and remitted the case for additional verification of the facts, in particular, to find out whether domestic law allowed for the termination of pregnancies as advanced as sixteen to eighteen weeks, and to hear the doctors who had carried out the abortions and to assess whether the applicants had legal capacity or not. On 28 January 2015 the Bălți Court of Appeal upheld this decision, rejecting the prosecutor’s appeal on points of law. 32 .     On 10 July 2015 the prosecutor once again refused to initiate criminal proceedings. The decision reiterated the exact content of the previous decisions (see paragraphs 24 and 28 above) with the addition of statements made by an obstetrician, A.M., who had terminated the first applicant’s pregnancy and a graphology expert report in respect of the signature on the consent form. A.M. submitted that she did not remember if the first applicant had agreed to or opposed the procedure and that in any event her consent had not been required at the time. The graphology expert was unable to ascertain if the signature belonged to the second applicant. This decision was upheld by the hierarchically superior prosecutor on 5 August 2015. 33 .     On 21 September 2015 the Bălți investigating judge upheld the applicants’ appeal against the decisions of the prosecutors and remitted the case for additional investigation, noting as follows: “On the basis of the [applicants’] complaints and the materials in the case file, the court notes the absence of consent given by [all three applicants] in respect of the termination of their pregnancies ... and sterilisations, including the doubt as to the veracity of [the second applicant’s] signature on the consent form ... The graphology expert was unable to conclude who the signature belonged to owing to the limited amount of handwriting, a single letter, ... and [the court] considers that it was necessary to appoint an expert committee [to investigate that issue]. ... The court also notes that the complaint refers to the termination of a pregnancy at sixteen to eighteen weeks, whereas Article 159 § 1 (c) of the Criminal Code prohibits the termination of a pregnancy after twelve weeks in the absence of medical indications established by the Ministry of Health. ... In the absence of such indications, according to Article 159 of the Criminal Code the [termination of a pregnancy] should be classified [as an illegal termination of a pregnancy]. ... The criminal investigating authority also did not appoint a psychiatric expert to assess if at the time of the abortions the [applicants] had been aware of their actions or inactions and able to take a conscious decision, or whether they had been deprived of legal capacity by a court judgment or not; these are circumstances which should be clarified during an additional consideration of the case.” 34 .     The prosecutor reopened the case and ordered an expert opinion concerning the lawfulness of the medical decisions to terminate the pregnancies of the first and second applicants. Examining the first applicant’s medical file, on 4 November 2016 the experts concluded the following: “According to medical record no. 3936 in respect of [the first applicant.], aged 19, on 5 December 2003 her pregnancy was terminated at between eighteen and nineteen weeks by amniotomy on the basis of excerpt no. 253 of the committee decision of 3   December 2003 to terminate the pregnancy, after which [the first applicant] expelled a dead foetus ... According to annex no. 2 of order no. 152 of 3 August 1994 of the Ministry of Health, the termination of a pregnancy for medical reasons is possible in respect of a pregnancy not exceeding between twenty-four and twenty-five weeks. Under the heading ‘Illnesses in respect of which pregnancy is contraindicated’, Chapter V of the same annex listed a diagnosis of mental impairment of moderate, severe and profound severity, from which [the first applicant] suffered. Based on this, it follows that the committee’s decision no. 253 of 3 December 2003 to terminate the pregnancy was reasoned and based on the law in force at the time.” Examining the second applicant’s medical file, on 30 November 2016 the experts concluded the following: “According to medical record no. 1858 ... on 28 February 2007 [the second applicant’s] pregnancy was terminated at between six and seven weeks on the basis of committee decision no.   30 of 27 November 2007 to terminate the pregnancy ... [This decision] was reasoned and complied with order no.   2 of 4 January 1999 amending annex no. 2 of order no. 152 of 3 August 1994 of the Ministry of Health.” Both expert reports concluded that no violation of medical assistance rules or methods for the termination of pregnancies had been committed, that the two applicants had not been injured in the process and that no negative consequences had been recorded in their medical files. 35 .     On 3 January 2017 the prosecutor once again refused to institute criminal proceeding on the same grounds as before. The decision reiterated the exact content of the previous decisions (see paragraphs 24, 28 and 32 above), adding a reference to the medical expert reports (see paragraph 34 above). The prosecutor concluded that the actions taken in respect of the applicants did not contain the elements of the criminal offences of illegal termination of a pregnancy or of medical negligence (see paragraph 37 below). The applicants did not appeal against this decision. 36.     On 19 November 2019 F.S. was finally convicted of raping a total of sixteen female residents of the Bălți asylum, including all three applicants. He was sentenced to fifteen years’ imprisonment and ordered to pay 70,000   Moldovan lei ((MDL) – equivalent to 3,570 euros (EUR)) to the first applicant, and MDL 50,000 (equivalent to EUR 2,550) each to the second and third applicants. The final judgment cited two witness statements mentioning the pregnancy of the third applicant and her referral to the Bălți maternity hospital for her pregnancy to be terminated. In addition, V.N., a staff member, cited the case of another resident at the asylum who had become pregnant after being raped by F.S. and who had been forced to terminate her pregnancy. He submitted that female residents “were allowed to live with men on the condition that they did not become pregnant”. RELEVANT DOMESTIC AND INTERNATIONAL LEGAL FRAMEWORK RELEVANT DOMESTIC LAW 37 .     At the time of the events the relevant parts of the Criminal Code of the Republic of Moldova, enacted by Law no. 895 of 18 April 2002, read as follows: Article 151 Intentional serious bodily injury “1.     Intentional serious bodily injury, which ... has resulted in the termination of a pregnancy ..., shall be punished by imprisonment of five to ten years. 2.     The same action committed: ... (b)     deliberately in respect of a pregnant woman or by taking advantage of the victim’s known or obvious vulnerability, owing to age, health condition, disability or other factor; ... (i)     owing to prejudice; ... shall be punished by imprisonment of ten to twelve years.” Article 159 Illegal termination of a pregnancy “1.     Termination of a pregnancy, by any means, committed: (a)     outside authorised medical institutions or centres; (b)     by a person without special medical education; (c)     in respect of a pregnancy exceeding twelve weeks, in the absence of medical indications established by the Ministry of Health; (d)     if such a procedure is medically contraindicated; or (e)     in unsanitary conditions shall be punished by a fine ... or by imprisonment of up to two years. ...” Article 160 Illegal surgical sterilisation “1.     Illegal surgical sterilisation committed by a doctor shall be punished by a fine ... with (or without) the deprivation of the right to hold a certain position or exercise a certain activity for up to three years. ...” Article 213 Negligent violation of rules and methods for providing medical assistance [medical negligence] “The violation by a doctor or another member of medical staff of the rules or methods for the provision of medical assistance, if this has resulted in: (a)     a serious bodily injury; or (b)     the patient’s death, shall be punished by imprisonment of up to three years with (or without) the deprivation of the right to hold a certain position or exercise a certain activity for between two and five years.” 38 .     Law no. 411 of 28 March 1995 on health protection, in force since 22   June 1995, reads as follows: Article 23 Consent for medical services “1.     The patient’s consent is necessary for any proposed medical service (for prophylactic, diagnostic, therapeutic or recovery purposes). 2.     In the absence of manifest opposition, consent shall be presumed for any service which does not pose significant risks for the patient or which is not likely to violate his or her intimacy. 3.     In the absence of a patient’s legal capacity ... the patient’s legal representative or, in his or her absence, the next of kin may give his or her consent. 4.     The consent of a patient lacking legal capacity, either temporarily or permanently, shall be presumed in the event of imminent death or a serious threat to his or her health. ... 7.     The consent or refusal of a patient or of his or her legal representative is to be confirmed in writing by the signature of the treating doctor or of the medical team on duty, or in exceptional cases by the signature of the head of the medico-sanitary institution.” Article 32 Voluntary termination of pregnancy “1.     Women shall be entitled to personally decide on their own maternity. 2.     Termination of a pregnancy may be carried out before the end of the first twelve weeks of pregnancy only in public medical institutions. 3.     Terminations of pregnancy after the first twelve weeks shall be regulated by the Ministry of Health.” 39 .     Law no.   1402 of 16 December 1997 on psychiatric assistance (renamed in 2008 to “on mental health”), in force since 21 May 1998, reads as follows: Article 5 The rights of persons suffering from mental disorders “1.     Persons suffering from mental disorders shall enjoy all citizen’s rights and freedoms provided for in the Constitution and in other laws. Limitations on their rights and freedoms owing to their mental disorders shall be permitted only in the cases provided for in the present law and other normative acts. ... 3.     It shall be prohibited to limit the rights and freedoms of persons suffering from mental disorders on the sole ground of their psychiatric diagnosis, of their surveillance through hospitalisation, or of their internment in a psychiatric ward or a neuropsychiatric institution. ...” 40 .     Law no. 185 of 24 May 2001 on the protection of reproductive health and family planning, in force since 2 August 2001, reads as follows: Article 5 The right to decide freely on reproduction “1.     Everybody is entitled to decide freely on the number of children [he or she will have] and the timing of birth within or outside wedlock. 2.     The State shall guarantee its non-interference in the exercise of its nationals’ right to decide freely on reproduction.” 41 .     Law no. 263 of 27 October 2005 on the rights and responsibilities of the patient, in force since 30 June 2006, reads as follows: Article 13 Consent and the method to establish informed consent or voluntary refusal for a medical intervention “1.     A mandatory preliminary requirement for a medical intervention is the patient’s consent, except in the cases provided under the present law. 2.     The patient’s consent for a medical intervention can be expressed orally or in writing and is established by recording it in the medical file, with the mandatory signature of the patient or of his or her legal representative (next of kin) and the treating doctor. For high-risk medical interventions (invasive or surgery), consent must be established in writing, by filling in a special form in the medical file, called informed consent. The list of medical interventions which require informed consent in writing and the template for the special form shall be developed by the Ministry of Health, Labour and Social Protection. 3.     The informed-consent form must contain information, expressed in a form accessible to the patient, about the purpose, the expected outcome, and the methods of the medical intervention; the potential risks associated with it; its possible medico-social, psychological, economic and other consequences; and the available alternative treatment or medical care. ... 8.     In the event of an emergency life-saving medical intervention, when the patient is unable to express his or her will and the consent of the patient’s legal representative (next of kin) cannot be obtained in time, the medical personnel, authorised under the law, shall be entitled to take this decision in the patient’s interests.” 42 .     According to the excerpts provided by the Government, unpublished order no. 152 of 3 August 1994 of the Ministry of Health of the Republic of Moldova approved the Instructions for the termination of a pregnancy for medical reasons (annex no. 2). According to these Instructions, intellectual disability of moderate, severe and profound severity ( Retard mental, întârziere mentală medie, severă, profundă ) constituted an illness for which pregnancy was contraindicated. Among the other illnesses listed were, for example, tuberculosis, all forms of cancer and insulin-dependent diabetes mellitus. The Instructions refer to a medical committee set up annually to establish the existence of medical indications for the termination of a pregnancy. In cases of patients with psychiatric disorders and venereal diseases, all documents were to be sent by the heads of the medical institutions directly to this medical committee. The same document ordered the heads of medical institutions to provide contraception (intrauterine devices, surgical sterilization) for free for women at “advanced” social and medical risk. The document does not contain any provisions concerning the patient’s consent. 43 .     The National Standard for the termination of pregnancy in safe conditions, approved by order no. 766 of 18   August 2020 of the Ministry of Health of the Republic of Moldova, lists intellectual disability among the illnesses which constitute medical indications for voluntary abortions (annex no. 1), if such illnesses either endanger the patient’s life or health or there is a risk of severe or incurable foetal malformations. The termination of a pregnancy in the first twelve weeks may be carried out with or without medical or social indications. The termination of a pregnancy after twelve weeks may be carried out only in the event of medical or social indications, as ascertained by a medical committee. The patient’s or her legal representative’s consent is mandatory in all cases and is referred to explicitly in the section concerning mental and behavioural disorders. An informed ‑ consent template provides details concerning various procedures for the medical termination of pregnancy. 44 .     Order no. 300 of 24 July 2007 of the Ministry of Health approved the list of medical interventions which required the patient’s written consent (annex no. 2); these include surgical interventions, parenteral interventions (including vaccinations), paraclinical medical services, physiotherapy and rehabilitation services by physical means. INTERNATIONAL LAW United Nations 45 .     General Recommendation No. 19: Violence against women, adopted in 1992 by the United Nations Committee on the Elimination of Discrimination against Women (CEDAW), stated that compulsory sterilisation and compulsory abortion are forms of gender-based violence, adversely affecting women’s physical and mental health, and infringing on the right of women to decide on the number and spacing of their children. The CEDAW called on States to take measures to prevent coercion in regard to fertility and reproduction. The Republic of Moldova acceded to the UN Convention on the Elimination of All Forms of Discrimination against Women on 1 July 1994. 46 .     In its General Recommendation No. 35, adopted in 2017 (UN Doc.   CEDAW/C/GC/35), which complements and updates General Recommendation No. 19, the CEDAW stated, inter alia , as follows: “18.     Violations of women’s sexual and reproductive health and rights, such as forced sterilizations, forced abortion, ..., are forms of gender-based violence that, depending on the circumstances, may amount to torture or cruel, inhuman or degrading treatment.” 47 .     The relevant parts of the CEDAW’s Concluding Observations on the combined fourth and fifth periodic reports of the Republic of Moldova, UN   Doc. CEDAW/C/MDA/CO/4-5, 29 October 2013, read as follows: “32.     The Committee urges the State party: ... (d)     To amend and develop the regulatory framework, in addition to the guidance provided to medical practitioners, to ensure that sterilization is carried out only in conformity with international law, in particular with the free and informed consent of the women concerned; ... 37.     The Committee notes the limited information and data available on other disadvantaged groups of women, such as older women and women with disabilities. The Committee is concerned about the marginalization of such women and their vulnerability to intersecting forms of discrimination. The Committee is particularly concerned about the situation of women with disabilities in residential institutions, where they are at high risk of abuse, including sexual assault. The Committee is further concerned that such acts often go unreported and that perpetrators are rarely brought to justice. Lastly, the Committee is concerned about the discriminatory guardianship system for women with intellectual and psychosocial disabilities that permits the removal of their legal capacity. 38.     The Committee calls upon the State party: ... (d)     To effectively investigate all cases of sexual assault against women with disabilities in residential institutions, facilitate access by such women to high-quality reproductive health care and ensure that all medical interventions are based on informed consent; ...” 48.     The Convention on the Rights of Persons with Disabilities (CRPD), adopted by the United Nations General Assembly on 13 December 2006 (UN   Doc. A/RES/61/106) was signed and ratified by the Republic of Moldova on 30   March 2007 and 21 September 2010 respectively. The relevant provisions of that Convention read as follows: Article 23 – Respect for home and the family 1.     States Parties shall take effective and appropriate measures to eliminate discrimination against persons with disabilities in all matters relating to marriage, family, parenthood and relationships, on an equal basis with others, so as to ensure that: ... b)     The rights of persons with disabilities to decide freely and responsibly on the number and spacing of their children and to have access to age-appropriate information, reproductive and family planning education are recognized, and the means necessary to enable them to exercise these rights are provided; c)     Persons with disabilities, including children, retain their fertility on an equal basis with others.” Article 25 – Health “States Parties recognise that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. States Parties shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health-related rehabilitation. In particular, States Parties shall: ... d)     Require health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent by, inter alia , raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities through training and the promulgation of ethical standards for public and private health care; ...” 49 .     The relevant part of the Report of the UN Special Rapporteur on extreme poverty and human rights, Magdalena Sepúlveda Carmona, on her mission to the Republic of Moldova (8–14 September 2013), UN Doc.   A/HRC/26/28/Add.2, 20 June 2014, reads as follows: “49.     The Special Rapporteur received reports that severe abuses, such as neglect, mental and physical abuse and sexual violence, continue to be committed against people with psychosocial and intellectual disabilities in residential institutions and psychiatric hospitals. She was concerned about the lack of sexual and reproductive health care in the institutions that she visited, as well as unsanitary and unhygienic conditions. In 2012, the Institutional Ombudsman of Psychiatric Hospitals reported that forced abortions in psychiatric and social care institutions were a common measure to prevent births which were deemed unwanted by institutional staff, in the absence of accessible information about reproductive and sexual health and contraception. The women concerned were victims of multiple forms of discrimination, in breach of both the Convention on the Elimination of All Forms of Discrimination against Women and the Convention on the Rights of Persons with Disabilities. The Special Rapporteur is aware of ongoing criminal proceedings pursuant to the allegations of 19 women concerning serial sexual assault, including rape, over a period of years, at the Bălți neuropsychiatric residential institution. She is concerned at the slow pace of the proceedings, which were initiated in March 2013.” 50 .     The relevant parts of the United Nations interagency statement “Eliminating forced, coercive and otherwise involuntary sterilization” (WHO, 2014), read as follows: “Women with intellectual disabilities are particularly vulnerable to coercive and involuntary sterilization. Women with intellectual disabilities are often treated as if they have no control, or should have no control, over their sexual and reproductive choices; they may be forcibly sterilized or forced to terminate wanted pregnancies, based on the paternalistic justification that it is ‘for their own good’. Rather than indicating individual choices, sterilization rates often reflect the policies of residential institutions or community services. Sterilization or long-term contraception are often provided to persons with disabilities on a precautionary basis ... Some states, family members, guardians, courts, review boards or tribunals are permitted under national law to take decisions on behalf of persons with disabilities; this is referred to as substitute decision-making. Article 12 of the CRPD reaffirms that persons with disabilities have the right to recognition everywhere as persons before the law, and that states must ensure that persons with disabilities have access to the support they may require in exercising their legal capacity. This may include supported decision-making where supporters, advocates or other systems assist persons with disabilities to make their own decisions, free of conflict of interest or undue influence, and without transfer of decision- making rights to third parties (as opposed to traditional substitute decision-making or guardianship). The Committee on the Rights of Persons with Disabilities has consistently urged States Parties, including with respect to sterilization, to adopt laws and policies that replace substitute decision-making systems with a supported decision-making model that upholds the autonomy, wishes and preferences of the individuals concerned. ... Persons with disabilities may require support in decision-making about contraception and sterilization, as mandated by the United Nations CRPD. Safeguards may be required to ensure that this support respects the rights and preferences of the person concerned, that there are no conflicts of interest or undue influence, and that the support is proportional and tailored to the circumstances. International human rights law requires these procedural measures in all cases involving sterilization of persons with disabilities who may either appear functionally incapable of, or be legally restricted from, either deciding freely or giving full, free and informed consent. ... Respecting autonomy requires that any counselling, advice or information given by health-care providers or other support staff or family members should be non-directive, enabling individuals to make decisions that are best for themselves ... Clear guidelines that indicate the requirement of full, free and informed consent should be available and should be well understood by practitioners and the public, especially the affected populations. A provider ... has the responsibility to convey accurate, clear information, in a language and format that is readily understandable to the person concerned, together with proper counselling, free from coercion, to achieve full, free and informed decision-making.” 51 .     The relevant parts of General Comment No. 3 (2016) on women and girls with disabilities, adopted by the UN Committee on the Rights of Persons with Disabilities on 25 November 2016 (UN Doc. CRPD/C/GC/3), noted the following: “32.     Certain forms of violence, exploitation and abuse may be considered as cruel, inhuman or degrading treatment or punishment and as breaching a number of international human rights treaties. Among them are: forced, coerced and otherwise involuntary pregnancy or sterilization; any medical procedure or intervention performed without free and informed consent, including procedures and interventions related to contraception and abortion. ... 39.     ...Women with disabilities may also face harmful eugenic stereotypes that assume that they will give birth to children with disabilities and thus lead women with disabilities being discouraged or prevented from realizing their motherhood. ... 44.     In practice, the choices of women with disabilities, especially women with psychosocial or intellectual disabilities, are often ignored and their decisions are often substituted by those of third parties, including legal representatives, service providers, guardians and family members, in violation of their rights under article 12 of the Convention. All women with disabilities must be able to exercise their legal capacity by taking their own decisions, with support when desired, with regard to m