The human rights in patient care framework (HRPC) refers to the application of human rights principles to the context of patient care. It brings together the rights of both patients and providers and focuses on systemic issues and the role of the state . HRPC is a useful framework for understanding the nature of forced and coerced sterilization and thus how best to address it to ensure that the practice ends and victims are properly provided with redress.
There are four particular concepts under HRPC which help in illuminating the best ways to end the practice of forced and coerced sterilization. First, HRPC highlights the particular vulnerability of marginalized population to discrimination in health care settings, and the framework “reveals issues of discrimination and social exclusion that often underlie abuse against patients” . Forced and coerced sterilization primarily targets women who are perceived as inferior or unworthy of procreation. Forced and coerced sterilization of marginalized women is part of existing stigma and discrimination facing the marginalized population. For instance, in Eastern Europe, Roma women are subjected to severe stigma and discrimination not only in healthcare settings, but also in education and in housing, among others.
Second, HRPC acknowledges the importance of the rights of medical providers. Medical providers have rights to decent working conditions, freedom of association, and due process, among others. Within the context of forced and coerced sterilization, this means that individual medical providers should not be targeted by government when the cause of the forced and coerced sterilization is structural and not merely the act of one individual medical provider. Often countries may argue that cases of coerced and forced sterilization are due to medical negligence or malfeasance on the part of individual providers. However, when numerous cases of coerced and forced sterilizations are documented, the problem is unlikely to resolve itself without addressing the structural issues, such as policies around how informed consent is obtained and the reduction of stigma and discrimination against targeted populations.
Third, HRPC focuses on the role of the state in appropriate patient care and in addressing any violations of human rights in such settings. In the recent cases of forced and coerced sterilization of marginalized women, the state’s role in creating the conditions where such practices can and have occurred and in failing to take appropriate action when such cases have been reported are central to understanding and addressing forced and coerced sterilization.
Finally, the HRPC framework applies human rights guaranteed under international treaties to patient care. The content of those rights relevant to forced and coerced sterilization are discussed in more detail below in order to aid in the understanding of how coerced and forced sterilization can violate international human rights. The particular rights relevant to forced and coerced sterilization are the right to health; the right to information; the right to liberty and security of the person; the right to be free from torture and cruel, inhuman and degrading treatment; and the right to be free from discrimination and equality.
The right to health
The right to health is guaranteed under the International Covenant on Economic, Social and Cultural Rights (ICESCR), Convention on the Rights of Persons with Disabilities (CRPD), and the Convention on the Rights of the Child [8,9,10]. Bodily autonomy is an integral part of the right to health. The Committee on Economic, Social and Cultural Rights (CESCR), tasked with determining the content and scope of the rights guaranteed under the ICESCR, has noted that the right to health includes the “right to control one’s health and body, including sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, non-consensual medical treatment and experimentation.” .
The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) also guarantees women the right to adequate services for maternal health  and protects a woman’s right to reproductive choice under article 16. The Committee on the Elimination of Discrimination Against Women (CEDAW Committee), tasked with determining the content and scope of the rights guaranteed under CEDAW, has noted that the right to quality health care services includes an obligation on states to ensure that health services are accessible and acceptable . Acceptable services are services which allow for reproductive choice and are delivered in a way that ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality, and is sensitive to her needs and perspectives .
The CEDAW Committee has explicitly noted that countries should not permit forced or coerced sterilization . The CEDAW Committee addressed the coerced sterilization of a Roma woman in AS v Hungary . AS was rushed to the hospital while pregnant with heavy bleeding. At the hospital, the doctor found that AS would need a caesarian section to remove her baby as the baby was dead. She signed a consent form while on the operating table for her caesarian section and for sterilization. The consent for the sterilization was handwritten by the doctor. The CEDAW Committee found that the coerced sterilization violated AS’s right to health, among other rights. In particular, the CEDAW Committee found that AS had a right to “specific information on sterilization and alternative procedures for family planning in order to guard against such an intervention being carried out without her having made a fully informed choice.”  The CEDAW Committee pointed to the following facts in finding that AS did not receive all the appropriate information in a way in which she could understand and thus her informed consent was not obtained: AS was in a poor state of health when she arrived at the hospital; had to be prepared for surgery, sign consent documents, and underwent two medical procedures in 17 min; and did not understand the Latin term for sterilization which is what was used in the consent form; and the consent form was barely legible and handwritten .
Right to information
The right to information, guaranteed under the International Covenant on Civil and Political Rights (ICCPR) and the CRPD, is closely linked with the exercise of other fundamental rights, including the right to health [9, 15]. In interpreting the right to health, the CESCR has stated that health facilities, goods, and services must be accessible and that this includes, among other things, the “right to seek, receive and impart information and ideas concerning health issues.”  The CESCR has also confirmed that countries have an obligation to ensure that health information provided by service providers is accurate. This includes requirements that information not be withheld or intentionally misrepresented, particularly to propagate the specific religious or cultural beliefs of individual health workers . The CEDAW Committee affirmed the close link between the right to information and the right to health in AS v Hungary where it held that the failure to provide AS with necessary information for informed consent violated her rights .
Right to liberty and security of person
The right to security of person, guaranteed under the ICCPR, includes the right to determine what happens to one’s body . The United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (Special Rapporteur on the Right to Health) has expressed that “guaranteeing informed consent is a fundamental feature of respecting an individual’s autonomy, self-determination and human dignity in an appropriate continuum of voluntary health care services” .
Right to be free from cruel, inhuman, and degrading treatment
The right to be free from cruel, inhuman, and degrading treatment is guaranteed under the ICCPR, CRPD, and the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT). Coerced and forced sterilization is a clear violation of this right. The Human Rights Committee, tasked with determining the content and scope of the rights guaranteed under the ICCPR, has noted that the purpose of the right is to protect both dignity and the physical and mental integrity of the individual from acts that cause not only physical but also mental suffering. It has further noted that the right protects individuals from cruel, inhuman, or degrading treatment in “medical institutions” .
The Committee Against Torture has recommended that countries take urgent measures to investigate promptly, impartially, thoroughly, and effectively all allegations of involuntary sterilization of women, prosecute and punish the perpetrators, and provide the victims with fair and adequate compensation . The United Nations Special Rapporteur on torture and other cruel, inhuman, or degrading treatment or punishment has emphasized that forced sterilization of women may constitute torture or cruel or inhuman treatment .
Right to non-discrimination and equality
The right to equality and to be free from discrimination is guaranteed in numerous international treaties. CEDAW prohibits discrimination against women in accessing healthcare services. CRPD prohibits discrimination on the basis of disability and, in particular, recognizes that women and girls with disability face multiple discrimination. The ICCPR and the ICESCR also prohibit discrimination on the basis of gender, sexual orientation, health status, and race, among others. The ICCPR also provides for the right to equality. Failure to provide health care services that only women need is a form of discrimination against women . General Recommendation 19 of the CEDAW Committee states that “[d]iscrimination against women includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty” .
Discrimination under international law is defined as
imply[ing] any distinction, exclusion, restriction or preference which is based on any ground such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status, and which has the purpose or effect of nullifying or impairing the recognition, enjoyment or exercise by all persons, on an equal footing, of all rights and freedoms .Footnote 4
The prohibition applies to both direct and indirect discrimination. Direct discrimination is generally defined as “when an individual is treated less favourably than another person in a similar situation for a reason related to a prohibited ground” . Indirect discrimination “refers to laws, policies or practices which appear neutral at face value, but have a disproportionate impact on the  rights… as distinguished by prohibited grounds of discrimination.”  Finally, the ICCPR and ICESCR prohibit discrimination on the basis of race, sex, and health status, among others.