Asociación de Esclerosis Múltiple de Salta v. Ministerio de Salud – Estado Nacional

The 939/00 Obligatory Medical Program provided medication to persons suffering from multiple sclerosis and isolated demyelinating syndrome, a precondition of multiple sclerosis. The National Ministry of Health passed a resolution to amend this program. The resolution had the effect of excluding from the program all isolated demyelinating syndrome sufferers and any multiple sclerosis sufferers who had not suffered two outbreaks in the last two years.

The Multiple Sclerosis Association of Salta filed for a guarantee of protection of individual constitutional rights (amparo protection), seeking to annul this resolution. Their application was supported by a special petition from the Federal Public Defender, which was joined by statements of approval from the Multiple Sclerosis Associations of Argentina, La Pampa, Mendoza and Corrientes. The lower court granted the amparo protection, on the basis that it violated the right to health. The Ministry appealed, arguing that the measure protected the ability to decline unnecessary treatments, and that the amparo protection was inadmissible because it was an abstract question that was a matter of state policy. The Ministry also challenged the standing of the Federal Public Defender and the standing of the Multiple Sclerosis Associations that were not from the Province of Salta.

The Supreme Court, adopting the reasoning contained in a report of the Attorney General, ruled that the Public Defender had no procedural standing, and that the approvals of the Multiple Sclerosis Associations of Argentina, La Pampa, Mendoza and Corrientes were not admissible based on prior jurisprudence. However, the Multiple Sclerosis Association of Salta had validly exercised its standing as a holder of a collective right, and the appeal in this respect could proceed.

The Attorney General then stated that amparo protection was available in this case. He considered that the constitutional right to life was the most fundamental right and its protection was an essential function of the Court. As the right to health was derivative of the right to life, and was also incorporated in multiple international treaties that had constitutional status, it was valid to use amparo protection to protect the right to health.

The Attorney General reasoned that in this case, the resolution violated the right to health. He rejected the Ministry’s argument that the resolution was needed to prevent unnecessary treatments, as the resolution allowed patients who had already started the ‘unnecessary’ treatments to continue receiving them. This not only discriminated between patients in the same situation who had started treatments at different times, but showed that the measure did not have a logical basis.

The Attorney General also found that the medical evidence did not support a blanket cut-off for isolated demyelinating syndrome or for multiple sclerosis sufferers with no outbreaks in the last two years. The development from isolated demyelinating syndrome to clinically defined multiple sclerosis was complex and needed to be determined by monitoring of various risk factors. Where those risk factors were present, early treatment could have beneficial effects, but where they were not present, careful consideration needed to be given to the side effects.

The Attorney General therefore considered that the diagnosis of ailments should be separated from the question of their coverage. Diagnosis was a question for medical professionals, and it was not up to the regulatory authorities to decide which treatments were ‘unnecessary’ and to deny coverage of them. Such withdrawal of coverage was arbitrary and therefore violated the right to health.

Adopting this reasoning, the Court upheld the lower court's finding that amparo was available and should be granted in favour of the Multiple Sclerosis Association of Salta. However, in light of its findings on standing, the Court repealed remedies granted in respect of the claims of the Federal Public Defender and the remaining Multiple Sclerosis Associations.

Two judges wrote separate opinions, one dissenting in part and ruling that the consideration of the Public Defender’s standing was irrelevant, and another dissenting wholly and ruling that the case was inadmissible.

Part VII, Attorney General: "[R]esulta oportuno mencionar que el amparo es el procedimiento judicial más simple y breve para tutelar real y verdaderamente los derechos consagrados por la Ley Fundamental. En este sentido, la Corte ha dicho reiteradamente que tiene por objeto una efectiva protección de derechos […] y ha explicitado la imprescindible necesidad de ejercer esa vía excepcional para la salvaguarda del derecho fundamental de la vida y de la salud."

Part VII, Attorney General: "En efecto, en el último de esos precedentes la Corte ha declarado que '...el derecho a la vida es el primer derecho natural de la persona humana preexistente a toda legislación positiva que resulta garantizado por la Constitución Nacional […]'. Asimismo, ha entendido que la vida de los individuos y su protección—en especial el derecho a la salud—constituyen un bien fundamental en sí mismo, que, a su vez, resulta imprescindible para el ejercicio de la autonomía personal. El derecho a la vida, más que un derecho no enumerado en los términos del art. 33 de la Ley Fundamental, es un derecho implícito, ya que el ejercicio de los derechos reconocidos expresamente requiere necesariamente de él y, a su vez, el derecho a la salud—especialmente cuando se trata de enfermedades graves—está íntimamente relacionado con el primero y con el principio de autonomía personal, toda vez que un individuo gravemente enfermo no está en condiciones de optar libremente por su propio plan de vida. A mayor abundamiento, sostuvo también que el derecho a la salud, desde el punto de vista normativo, está reconocido en los tratados internacionales con rango constitucional (art. 75, inc. 22) entre ellos, el art. 12, inc. c del Pacto Internacional de Derechos Económicos, Sociales y Culturales; inc. 1, arts. 4 y 5 de la Convención sobre Derechos Humanos—Pacto de San José de Costa Rica—e inc. 1, del art. 6 del Pacto Internacional de Derechos Civiles y Políticos, extensivo no sólo a la salud individual sino también a la salud colectiva […]."

Part VIII, Attorney General: "[L]a modificación introducida al originario Plan Médico Obligatorio en lo referente a la cobertura de medicamentos en los casos de esclerosis múltiple, sus clases y variantes, lesiona el derecho a la salud de quienes sufren esta enfermedad discapacitante—garantía resguardada no sólo por normas nacionales sino también de protección internacional que tienden a una actitud de apoyo progresivo en el tratamiento de estas manifestaciones del aparato neurológico—. [… N]o sólo marca una desigualdad de trato entre enfermos de una misma clase (por ejemplo, un enfermo con síndrome desmielizante aislado que esté en tratamiento mediante la cobertura del 100% en el medicamento, en cambio el que no lo haya comenzado no tendrá ese porcentaje) sino que echa por tierra el único argumento del Ministerio de Salud para sostener la validez de la resolución,cual es que la exclusión de determinados casos de la cobertura estriba en una protección a la salud de los enfermos al evitar autorizar, de ese modo, tratamientos innecesarios frente a la inexistencia de diagnósticos certeros. En ese entendimiento, si el fin de eliminar la cobertura del 100% es evitar el medicamento para aquellos con síndrome desmielizante aislado o que tengan esclerosis múltiple pero no hayan tenido dos brotes o exacerbaciones en los últimos dos años, en aras de protegerles la salud, no se entiende lógicamente que sí se pueda mantener para los mismos casos si ya han iniciado el tratamiento. O se 'protege la salud' en todos los supuestos en iguales condiciones, en cuyo caso el ministerio debería limitar todos esos tratamientos en lugar de asegurarles cobertura, aún los que están en curso de ejecución, o el argumento es netamente falaz. Me inclino por esto último."

Part VIII, Attorney General: "El debate aquí planteado no es […] salvaguardar a los enfermos de posibles reacciones adversas y contraindicaciones del fácmaco—lo que insisto será evaluando por el médico y no por una autoridad administrativa—sino el grado de cobertura del remedio por las obras sociales y prepagas para un tipo de enfermedad considerada de alto riesgo y baja incidencia […] sin que el ministerio haya logrado probar cuál es el motivo para determinar que una enfermedad discapacitante que tenía el 100% de cobertura en los medicamentos, ahora en algunos supuestos no la tenga, circunstancia que, al afectar directamente el derecho de los enfermos de esclerosis múltiple a la protección de la salud, torna, a mi criterio, al acto en arbitrario."

Part IX, Attorney General: Por todo lo expuesto, opino que corresponde admitir formalmente el recurso extraordinario interpuesto por el Estado Nacional (Ministerio de Salud), tener por mal concedidos aquellos intentados por las asociaciones de esclerosis múltiple de La Pampa, Mendoza, Corrientes y de Argentina, revocar la sentencia en cuanto a la legitimación del Defensor del Pueblo de la Nación.

English:

“On this basis, if the goal of eliminating the 100% coverage is to avoid medicine for those with the isolated demyelinating syndrome or those that have multiple sclerosis but have not had two outbreaks or exacerbations in the last two years, in order to protect their health, it does not make sense that it can be applied to the same cases if they have already commenced treatment. Either it “protects health” in all events in equal conditions, in which case the Ministry should limit all those treatments instead of ensuring coverage, even those that are ongoing, or the argument is clearly false. I am inclined to agree with the latter.” Translation part VIII of the Attorney General Opinion.

“In any event, this debate is not, as the Ministry of Health says, safeguarding the ill from possible adverse reactions and pharmacological contraindications which I insist must be evaluated by the doctor and not by an administrative authority – but rather the degree of coverage of the remedy by the social welfare agencies and prepaid medicine companies for a type of disease considered high risk and low incidence – according to the proceedings, some 6,500 patients in the entire country – without the ministry having proven what the motive is for determining that a disabling disease that had 100% medication coverage now in some cases has none, a circumstance that, by directly affecting the right of the multiple sclerosis patients to the protection of health, renders the act, under my criteria, arbitrary.” Translation part VIII of the Attorney General Opinion.