Res. 13548-2007 Sala Constitucional — Delay of pediatric surgery violates right to health and best interests of the child

OutcomeResultado

GrantedCon lugar

The Chamber granted the amparo and ordered the hospital to immediately perform surgery on the minor, finding the waiting period disproportionate to the child's best interests and right to health.La Sala declaró con lugar el recurso y ordenó al hospital realizar de inmediato la cirugía a la menor, al considerar desproporcionada la espera frente al interés superior del niño y su derecho a la salud.

SummaryResumen

The Constitutional Chamber heard an amparo filed by the mother of a two-year-and-ten-month-old girl who needed surgery for grade III bilateral vesicoureteral reflux. The mother argued that, although the treating physician indicated that only surgery could halt the condition, the National Children's Hospital scheduled the operation for June 2008—ten months after the hospitalization order. During proceedings, the hospital moved the date to March 2008, but the Chamber found that any months-long wait for such a young child was disproportionate and violated her right to health and the principle of the best interests of the child. The majority granted the amparo and ordered immediate surgery, awarding costs and damages against the CCSS. One judge dissented, arguing that the treating physician should determine urgency and that the court order allowed queue-jumping.La Sala Constitucional conoció un recurso de amparo presentado por la madre de una niña de dos años y diez meses que requería una intervención quirúrgica por reflujo vesicoureteral bilateral grado III. La madre alegó que, aunque el médico tratante indicó que solo la cirugía podría frenar el padecimiento, el Hospital Nacional de Niños programó la operación para junio de 2008, es decir, diez meses después de la orden de internamiento. Durante el trámite, el hospital adelantó la fecha a marzo de 2008, pero la Sala consideró que cualquier espera de meses para una niña tan pequeña resultaba desproporcionada y violatoria de su derecho a la salud y del principio de interés superior del niño. La mayoría declaró con lugar el recurso y ordenó la realización inmediata de la cirugía, condenando a la CCSS al pago de costas, daños y perjuicios. Un magistrado salvó el voto, argumentando que correspondía al médico tratante determinar la urgencia y que la orden judicial permitía saltar la lista de espera.

Key excerptExtracto clave

“IV.- On the specific case.- With regard to exams, treatments, or surgical interventions, this Chamber has held that the State must ensure that they are provided within a reasonable time, without denial, since the right to health is involved. This, coupled with what was established in the preceding recital on the best interests of the child, leads this Chamber to conclude that in this case a violation of the protected minor's right to health has occurred. Indeed, from the report submitted by the representative of the respondent authority—given under oath with the even criminal consequences provided in Article 44 of the Law governing this Jurisdiction—it is confirmed that the protected minor has a kidney disease requiring surgery, and that despite this, such intervention was scheduled for June 2008, that is, TEN MONTHS later. In this regard, the respondent authorities indicate that such intervention is not urgent and that there are similar waiting cases. For this Constitutional Court, those arguments are not admissible, since the minor, only two and a half years old, must wait a number of months that represents almost half of her years of life. And even though, after the filing of this amparo, the date was moved to March 25, 2008—and not to June 2008 as originally set—such period is equally unreasonable, not only because of the minor's very young age, but because the best interests of the child make it disproportionate for her to wait so long for surgery, especially when a state institution whose vocation is the protection of children's health is involved. Furthermore, while the months of waiting pass, the minor's quality of life, having to take an alternative treatment that does not resolve her condition, is diminished. Thus, given that the period to perform the surgery on the protected minor is disproportionate—even with the date being moved up—the amparo must be granted, and the immediate scheduling of the surgical intervention ordered.”“IV.- Sobre el caso concreto.- En cuanto a la práctica de exámenes, tratamientos o intervenciones quirúrgicas a personas, ésta Sala ha sostenido que el Estado debe velar por que ellos sean dados en un plazo razonable, sin denegación, por estar involucrado el derecho a la salud. Lo cual, aunado a lo establecido en el considerando anterior sobre el interés superior del niño (a) lleva a concluir a esta Sala que en este caso se ha producido una violación al derecho a la salud de la menor amparada. En efecto, del informe rendido por el representante de la autoridad recurrida -que se tienen por dados bajo fe de juramento con las consecuencias, incluso penales, previstas en el artículo 44 de la Ley que rige esta Jurisdicción, se comprueba que efectivamente la menor amparada tiene una enfermedad renal que requiere de intervención quirúrgica, y que a pesar de ello, tal intervención le fue programada hasta para el mes de junio del 2008, es decir, DIEZ MESES después. Al respecto, las autoridades recurridas indican que tal intervención no es urgente y que existen casos similares que esperan. Para este Tribunal Constitucional dichos argumentos no son admisibles, puesto que la menor, de tan sólo dos años y medio, tiene que esperar para ser tratada una cantidad de meses que representan casi la mitad de sus años de vida. Y aunque, luego de la presentación de este recurso se le adelantó la fecha para el 25 de marzo del 2008 –y no para el junio del 2008 como originalmente se le consignó-, igualmente tal plazo resulta irrazonable, no sólo por la edad tan corta de la menor, sino porque el interés superior del niño (a) hace desproporcionado que ésta deba esperar tanto tiempo para ser intervenida quirúrgicamente, máxime si se trata de una institución estatal cuya vocación es el resguardo del derecho a la salud de las niños. Además, entretanto pasan los meses de espera, la calidad de vida de la menor, al tener que estar tomando un tratamiento alternativo que no resuelve su padecimiento, se ve mermada. Así entonces, dado que el plazo para practicarle la intervención quirúrgica a la menor amparada resulta desproporcionado -aún con el adelantamiento de la fecha- el recurso debe declararse con lugar, y ordenarse la programación inmediata de la intervención quirúrgica.”

Pull quotesCitas destacadas

"La familia, como elemento natural y fundamento de la sociedad, tiene derecho a la protección especial del Estado. Igualmente tendrán derecho a esa protección la madre, el niño, el anciano y el enfermo desvalido."

"The family, as the natural element and foundation of society, has the right to special protection of the State. Similarly, the mother, the child, the elderly, and the helpless sick shall have the right to that protection."

Considerando III

"La familia, como elemento natural y fundamento de la sociedad, tiene derecho a la protección especial del Estado. Igualmente tendrán derecho a esa protección la madre, el niño, el anciano y el enfermo desvalido."

Considerando III

"Todo niño tiene derecho, sin discriminación alguna... a las medidas de protección que su condición de menor requiere, tanto por parte de su familia como de la sociedad y del Estado."

"Every child has the right, without any discrimination... to the protection measures that his or her condition as a minor requires, from his or her family as well as from society and the State."

Considerando III

"Todo niño tiene derecho, sin discriminación alguna... a las medidas de protección que su condición de menor requiere, tanto por parte de su familia como de la sociedad y del Estado."

Considerando III

"Para este Tribunal Constitucional dichos argumentos no son admisibles, puesto que la menor, de tan sólo dos años y medio, tiene que esperar para ser tratada una cantidad de meses que representan casi la mitad de sus años de vida."

"For this Constitutional Court, those arguments are not admissible, since the minor, only two and a half years old, must wait a number of months that represents almost half of her years of life."

Considerando IV

"Para este Tribunal Constitucional dichos argumentos no son admisibles, puesto que la menor, de tan sólo dos años y medio, tiene que esperar para ser tratada una cantidad de meses que representan casi la mitad de sus años de vida."

Considerando IV

Full documentDocumento completo

Res. No. 2007013548 CONSTITUTIONAL CHAMBER OF THE SUPREME COURT OF JUSTICE. San José, at fifteen hours and fourteen minutes of the eighteenth of September of two thousand seven.

Amparo action filed by ADRIANA CAROLINA ANGELE MARTINEZ, identity card number 0110160477, on behalf of ANA CRISTINA RAMOS ANGELE, against the DIRECTOR OF THE HOSPITAL NACIONAL DE NIÑOS.

Resultando:

1.- By writing received in the Secretariat of the Chamber at 16 hours 22 minutes on September 5, 2007, the petitioner files an amparo action against the DIRECTOR OF THE HOSPITAL NACIONAL DE NIÑOS and states that: a) Her daughter Ana Cristina Ramos Angelé, two years and ten months old, suffers from a kidney condition, according to a medical diagnosis dated August 22, 2007, signed by Dr. Konrad Jiménez Vega, an official of said hospital. One of her daughter's kidneys functions at 75% of its capacity and the other at 25% of its normal capacity. The treating physician states that no improvement or cure is guaranteed under treatment, except for the possibility of a surgical intervention that could halt the ailment afflicting the minor. The reflux referred to in the report consists of the fact that not all urine exits the body; instead, upon reaching the bladder, rather than being expelled, part of it returns to the kidneys, further feeding any deposited bacteria; b) It is urgent to perform a surgical intervention on the girl; otherwise, it could have fatal consequences; c) The respondent Hospital initially gave her an appointment for the month of June 2008, later determining that the patient remains waiting to be called for surgery, which is the same as saying to wait eight months or more. She requests that the action be granted, and that the respondent Hospital be ordered to schedule the surgical intervention of the protected minor as soon as possible, setting a time and date, to occur no later than within the next forty-eight hours counted from the finality of the ruling.

2.- RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, reports under oath (folio 020), that: a) He attaches the report of doctor Konrad Roberto Jiménez Vega, treating physician of the protected minor. According to the analysis of the file, the minor was seen for the first time on August 22, 2007, referred by general pediatrics for presenting bilateral vesicoureteral reflux grade III. That same day, a hospitalization order was granted for surgical correction of the condition; b) Patients with reflux are initially managed with prophylactic antibiotics at night, awaiting spontaneous resolution over time. In this case, surgical management was decided upon, associated with medical management using antibiotics. While she is on antibiotics, the possibility of urinary tract deterioration is low; c) There is a waiting list of patients with the same diagnosis whose hospitalization orders were granted earlier; but as it is a standard of this Hospital to safeguard the health of children, a hospitalization date will be granted for the patient's surgical resolution for March 25, 2008. He also adds the report rendered in this regard by KONRAD JIMENEZ VEGA, in his capacity as Treating Physician of the protected party, where he indicates that in this case surgical management associated with prophylactic antibiotics was decided upon, and that while she is on antibiotics the possibility of urinary deterioration is low. He requests that the action filed be dismissed.

3.- EDUARDO DORYAN GARRON, in his capacity as Executive President of the Caja Costarricense de Seguro Social, reports under oath (folio 053), exactly in the same sense as the previous respondent, adding that at no time is the performance of the required intervention being denied, but rather that she is on a waiting list; therefore, the medical protocol that establishes priorities for carrying out surgical interventions must be followed, respecting the criteria of priority and equality of patients. He requests that the action filed be dismissed.

4.- In the proceedings followed, the legal prescriptions have been observed.

Drafted by Magistrate González Quiroga; and,

Considerando:

I.- Object of the action.- The petitioner, mother of the protected minor, considers that the latter's right to health is being violated because, despite the medical opinion having already determined that her daughter's condition would only improve with a surgical intervention, such intervention has not been scheduled for her, but rather an appointment has only been granted until June 2008.

II.- Proven facts.- Of importance for the decision in this matter, the following facts are deemed duly demonstrated, either because they have been accredited or because the respondent has omitted to refer to them as prescribed in the initial order:

a. That the minor was seen for the first time on August 22, 2007, at the respondent Hospital, referred by general pediatrics for presenting bilateral vesicoureteral reflux grade III. That same day, a hospitalization order was granted for the surgical correction of the condition (report on folio 020).

b. That the respondents decided, in this case, on surgical management associated with medical management using antibiotics (report on folio 021).

c. That according to the treating physician's opinion, while the minor is on antibiotics, the possibility of urinary tract deterioration is low (report on folio 022).

d. That there is a waiting list with patients with the same diagnosis whose hospitalization orders were granted earlier (report on folio 021).

e. That after the filing of this action, a hospitalization date for surgical resolution was granted to the protected party for March 25, 2008 (report on folio 021).

III.- On the best interests of the child and their right to health.- In matters of the special rights held by children, there are various norms of constitutional, international, and infra-constitutional rank; all of them recognizing the best interests of the child as a criterion for all public or private action concerning a person under eighteen years of age. "The family, as a natural element and foundation of society, has the right to the special protection of the State. Likewise, the mother, the child, the elderly, and the destitute sick shall have the right to that protection" thus states article 51 of our Magna Carta. In the same sense, the United Nations Convention on the Rights of the Child (approved and ratified by our country, through Law No. 7184 of July 18, 1990, which entered into force, pursuant to numeral 2 of that legal instrument, on the day of its publication in La Gaceta No. 149 of August 9, 1990), establishes a series of rights for any child, regardless of their race or nationality (article 2), such as: the right to be cared for by their parents (article 7), the right to a "standard of living adequate for the child's physical, mental, spiritual, moral and social development" recognizing parents as primarily responsible for providing the necessary living conditions for their development and the State's duty to adopt "appropriate measures to assist parents and others responsible for the child to implement this right" (article 27) and, in the case of a mentally or physically disabled child, the right to "enjoy a full and decent life, in conditions which ensure dignity, promote self‑reliance and facilitate the child's active participation in the community" as well as to "receive special care" (article 23). On the other hand, the Universal Declaration of Human Rights of December 10, 1948, specifies in its article 16, paragraph 3, that "The family is the natural and fundamental group unit of society and is entitled to protection by society and the State" (in identical sense article 23, paragraph 1, of the International Covenant on Civil and Political Rights of December 19, 1966). For its part, article 25, paragraph 2, of the abovementioned Declaration indicates that "Motherhood and childhood are entitled to special care and assistance..." and, finally, in article 24, paragraph 1, it is established that "Every child, without any discrimination whatsoever, is entitled to such measures of protection as are required by his status as a minor, on the part of his family, society and the State." From the provisions of the international instruments on Human Rights transcribed above, it is abundantly clear that States have as fundamental duties the protection of the best interests of the child. Human or fundamental rights and the correlative obligations of public powers have also been developed at the infra-constitutional level; thus we have the Código de la Niñez y de la Adolescencia in general and the Law on Equal Opportunities for Persons with Disabilities, when also dealing with a child with special needs. Thus, the Código de la Niñez y de la Adolescencia (Law No. 7739) specifies that the interpretive guide for all public or private action must be the best interests of the child (article 5). Ordinal 12 of that normative body stipulates that the State must guarantee the right to life "with economic and social policies that ensure dignified conditions for gestation, birth, and integral development." Numeral 29 establishes the obligation of the father, mother, or person in charge to "ensure the physical, intellectual, moral, spiritual, and social development of their children under eighteen years of age" and "to comply with the instructions and controls prescribed to ensure the health of minors under their care" (article 45). Furthermore, in addition to all the above, when the child requires special needs due to their disability, understood as "a physical, mental, or sensory impairment, whether permanent or temporary, that limits the capacity to perform one or more essential activities of daily life, which may be caused or aggravated by the economic and social environment" (article I of the Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with Disabilities), the rights of disabled persons, also recognized in international norms (Inter-American Convention on the Elimination of All Forms of Discrimination against Persons with Disabilities ratified by the Legislative Assembly through Law No. 7948) and at the legal rank, the Equal Opportunities Law for Persons with Disabilities No. 7600, published in La Gaceta of May 29, 1996, are also applicable. Thus, persons with disabilities must be guaranteed equal opportunities, through the suppression of all socially determined obstacles, whether physical, economic, social, or psychological, that exclude or restrict their full participation in society; in this sense, article 2 defines early stimulation as all that "care provided to children between zero and seven years of age to enhance and maximize their physical, intellectual, sensory, and affective possibilities, through systematic and sequential programs covering all areas of human development..." and article 13 of the General Health Law No. 5395, of October 30, 1973, when it recognizes the duty of parents and the State to ensure the health and development of children: "Children have the right that their parents and the State ensure their health and their social, physical, and psychological development. Therefore, they shall have the right to state health benefits from birth until the age of majority. Children with physical, sensory, intellectual, and emotional disabilities shall enjoy specialized services." In conclusion, after all that has been said, it is clear that children are assisted by a series of special rights and, correlatively, the State and parents or guardians of children are assisted by a series of obligations and duties towards them, even more so when it relates to the protection of their right to life and health.

IV.- On the specific case.- Regarding the performance of examinations, treatments, or surgical interventions on persons, this Chamber has held that the State must ensure that these are provided within a reasonable timeframe, without denial, as the right to health is involved. This, coupled with what was established in the previous recital regarding the best interests of the child, leads this Chamber to conclude that in this case a violation of the protected minor's right to health has occurred. Indeed, from the report rendered by the representative of the respondent authority - which is accepted as given under oath with the consequences, including criminal ones, provided for in article 44 of the Law that governs this Jurisdiction - it is verified that the protected minor indeed has a kidney disease that requires surgical intervention, and that despite this, such intervention was scheduled until the month of June 2008, that is, TEN MONTHS later. In this regard, the respondent authorities indicate that such intervention is not urgent and that there are similar cases waiting. For this Constitutional Court, these arguments are inadmissible, given that the minor, only two and a half years old, must wait to be treated for a number of months that represents nearly half the years of her life. And although, after the filing of this action, the date was moved up to March 25, 2008 – and not to June 2008 as originally assigned –, such a timeframe is still unreasonable, not only because of the minor's very young age, but because the best interests of the child make it disproportionate for her to have to wait so long to undergo surgery, especially considering that this is a state institution whose vocation is the safeguarding of children's right to health. Moreover, while the months of waiting pass, the quality of life of the minor, having to take an alternative treatment that does not resolve her condition, is diminished. Therefore, given that the timeframe to perform the surgical intervention on the protected minor is disproportionate – even with the advancement of the date – the action must be granted, and the immediate scheduling of the surgical intervention must be ordered. Magistrate Vargas dissents and declares the action without merit.

Por tanto:

The action is GRANTED; consequently, RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever occupies this position in his stead, is ordered to immediately issue the order to proceed with the surgical intervention that the protected minor requires, as determined by her treating physician, under their entire professional responsibility and with proper medical supervision. The foregoing is under warning that they could incur the crime defined in article 71 of the Law of Constitutional Jurisdiction, which provides that a sentence of imprisonment of three months to two years, or a fine of twenty to sixty days, shall be imposed on anyone who, having received an order that must be complied with or enforced, issued in an amparo action, does not comply with it or does not enforce it, provided the crime is not more severely punished. The Caja Costarricense de Seguro Social is ordered to pay the costs, damages, and losses caused by the facts serving as the basis for this declaration, which shall be liquidated in the enforcement of the sentence of the contentious-administrative proceeding. Notify personally RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever occupies this position in his stead. Notify all parties.

Luis Fernando Solano C. President Ana Virginia Calzada M. Adrián Vargas B.

Gilbert Armijo S. Ernesto Jinesta L.

Teresita Rodríguez A. Horacio González Q.

Dissenting vote of Magistrate Vargas Benavides.

I depart from the majority opinion and declare the filed action without merit. In matters referring to health services, such as the performance of examinations, consultations, treatments, or surgical interventions, the Chamber has held that the State must ensure that these are provided without denial to insured persons, as the right to health is involved. However, this Court has also been clear in asserting that it is not its role to determine what timeframe is just from a medical point of view for attending to sick persons, since this is the exclusive competence of the treating physician, who issues the respective criteria regarding these aspects, which must be respected by the Caja Costarricense de Seguro Social, as constitutional jurisprudence has sustained. In the specific case, I consider that there is no violation whatsoever of the protected party's rights, since the fact that she was placed on the surgical waiting list is because the treatment she currently receives greatly reduces the effects that the condition she suffers has on her health, as indicated by her treating physician in his report. For the foregoing reasons, I consider it inappropriate for the Chamber to order the respondents to perform the surgery on the minor, because by doing so it allows the interested party to skip the waiting list through the mere filing of an amparo action, thus violating the right to health of the persons who are ahead of the protected party on the waiting list, and who suffer exactly the same condition as the ward, as the respondents state. On the other hand, from the evidence provided in the records and from the reports rendered under oath by the respondents, it is deduced that the protected party has received at the Hospital Nacional de Niños the medical treatment she requires, which is why I consider that the interested party has not been denied access to the health services provided by the Caja Costarricense de Seguro Social. Thus, for the reasons stated above, I consider that the action should be dismissed.

Adrián Vargas B.

While on antibiotics, the possibility of deterioration of the urinary tract is low; c) There is a waiting list with patients with the same diagnosis and whose admission orders were issued earlier; but as it is the norm of this Hospital to ensure the health of children, an admission date for the surgical resolution of the patient will be granted for March 25, 2008. The report rendered in this regard by KONRAD JIMENEZ VEGA, in his capacity as treating physician of the protected party, also adds that in this case, surgical management associated with prophylactic antibiotics was decided, and that while she is on antibiotics, the possibility of urinary deterioration is low. He requests that the filed appeal be dismissed. </div> <div> 3.- EDUARDO DORYAN GARRON, in his capacity as Executive President of <st1:PersonName ProductID="la Caja Costarricense" w:st="on">la Caja Costarricense</st1:PersonName> de Seguro Social, reports under oath (folio 053), exactly in the same sense as the previous respondent, adding that at no time is the performance of the required intervention being denied, but rather that she is on a waiting list, and therefore the medical protocol establishing priorities for carrying out surgical interventions must be followed, respecting the criteria of priority and equality of patients. He requests that the filed appeal be dismissed. </div> <div> 4.- In the followed proceedings, the legal prescriptions have been observed. </div> <div> Drafted by Judge González Quiroga; and, <o:p> </o:p> <o:p> </o:p> </div> Considerando: <div> I.-Object of the appeal.- The petitioner, mother of the protected minor, considers that the latter's right to health is being violated because, despite the fact that the medical opinion has already determined that her daughter's condition would only improve with a surgical intervention, such intervention has not been scheduled for her, but rather she has only been given an appointment until June 2008. </div> <div> II.- Proven facts.- Of importance for the decision in this matter, the following facts are deemed duly proven, either because they have been accredited or because the respondent has omitted to refer to them according to what was provided in the initial order: </div> <div> <![if !supportLists]>a.      <![endif]>That the minor was seen for the first time on August 22, 2007 at the respondent Hospital, referred by general pediatrics for presenting bilateral vesicoureteral reflux grade III. That same day, an admission order for the surgical correction of the condition was issued (report on folio 020). <o:p></o:p> </div> <div> <![if !supportLists]>b.      <![endif]>That the respondents decided, in this case, surgical management associated with medical management with antibiotics (report on folio 021). <o:p></o:p> </div> <div> <![if !supportLists]>c.       <![endif]>That according to the treating physician's opinion, while the minor is on antibiotics, the possibility of deterioration of the urinary tract is low (report on folio 022). <o:p></o:p> </div> <div> <![if !supportLists]>d.      <![endif]>That there is a waiting list with patients with the same diagnosis and whose admission orders were issued earlier (report on folio 021). <o:p></o:p> </div> <div> <![if !supportLists]>e.       <![endif]>That after the filing of this appeal, the protected party is granted an admission date for surgical resolution for March 25, 2008 (report on folio 021). <o:p></o:p> </div> <div> III.- On the best interests of the child and their right to health.- In the matter of the special rights that children have, there are various norms of constitutional, international, and infra-constitutional rank; all of them recognize the best interests of the child as the criterion for any public or private action concerning a person under eighteen years of age. "The family, as the natural element and foundation of society, has the right to the special protection of the State. Likewise, the mother, the child, the elderly, and the helpless sick shall have the right to that protection," thus states Article 51 of our Magna Carta. In the same sense, <st1:PersonName ProductID="la Convención" w:st="on">la Convención</st1:PersonName> on the Rights of the Child of the United Nations (approved and ratified by our country, through, <st1:PersonName ProductID="la Ley No." w:st="on">la Ley No.</st1:PersonName> 7184 of July 18, 1990, which entered into force, according to numeral 2 of that legal instrument, on the day of its publication in <st1:PersonName ProductID="La Gaceta No." w:st="on">La Gaceta No.</st1:PersonName> 149 of August 9, 1990), establishes a series of rights for any child, regardless of race or nationality (Article 2), such as: the right to be cared for by their parents (Article 7), the right to a "standard of living adequate for the child's physical, mental, spiritual, moral and social development" recognizing parents as the primary responsible for providing the living conditions necessary for their development and the State's duty to adopt "appropriate measures to assist parents and others responsible for the child to implement this right" (Article 27), and in the case of a mentally or physically disabled child, the right to "enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child's active participation in the community" in addition to "special care" (Article 23). On the other hand, <st1:PersonName ProductID="la Declaración Universal" w:st="on">la Declaración Universal</st1:PersonName> de Derechos Humanos of December 10, 1948, specifies in its Article 16, paragraph 3, that "The family is the natural and fundamental group unit of society and is entitled to protection by society and the State" (in identical sense Article 23, paragraph 1, of the International Covenant on Civil and Political Rights of December 19, 1966). For its part, Article 25, paragraph 2, of the aforementioned Declaration indicates that "Motherhood and childhood are entitled to special care and assistance..." and, finally, in Article 24, paragraph 1, it is established that "Every child shall have, without any discrimination... the right to such measures of protection as are required by his status as a minor, on the part of his family, society and the State". From the norms of the international instruments on Human Rights transcribed, it results, clearly, that States have as fundamental duties the protection of the best interests of the child. Human or fundamental rights and the correlative obligations of public powers have also been developed at the infra-constitutional level; we thus have the Code of <st1:PersonName ProductID="la Niñez" w:st="on">la Niñez</st1:PersonName> y de <st1:PersonName ProductID="la Adolescencia" w:st="on">la Adolescencia</st1:PersonName> in general and <st1:PersonName ProductID="la Ley" w:st="on">la Ley</st1:PersonName> de Igualdad de Oportunidades para las Personas con Discapacidad, when it also concerns a child with special needs. Thus, the Code of <st1:PersonName ProductID="la Niñez" w:st="on">la Niñez</st1:PersonName> y de <st1:PersonName ProductID="la Adolescencia" w:st="on">la Adolescencia</st1:PersonName> (Ley No. 7739) points out that the interpretive guide for any public or private action must be the best interests of the child (Article 5). Ordinal 12 of that normative body stipulates that the State must guarantee the right to life "with economic and social policies that ensure dignified conditions for gestation, birth, and integral development." Numeral 29 establishes the obligation of the father, the mother, or the responsible person to "ensure the physical, intellectual, moral, spiritual, and social development of their children under eighteen years of age" and to "comply with the instructions and controls prescribed to ensure the health of minors under their care" (Article 45). For its part, in addition to all that has been said, when the child requires special needs due to their disability, understood as "a physical, mental, or sensory impairment, whether permanent or temporary, that limits the capacity to perform one or more essential activities of daily life, which may be caused or aggravated by the economic and social environment" (Article I of <st1:PersonName ProductID="la Convención Americana" w:st="on">la Convención Americana</st1:PersonName> para <st1:PersonName ProductID="la Eliminación" w:st="on">la Eliminación</st1:PersonName> de todas las Formas de Discriminación contra las Personas con Discapacidad), the rights of disabled persons, also recognized in international norms (Convención Americana para <st1:PersonName ProductID="la Eliminación" w:st="on">la Eliminación</st1:PersonName> de todas las Formas de Discriminación contra las Personas con Discapacidad ratified by <st1:PersonName ProductID="la Asamblea Legislativa" w:st="on">la Asamblea Legislativa</st1:PersonName> through Ley N° 7948) and with legal rank <st1:PersonName ProductID="la Ley" w:st="on">la Ley</st1:PersonName> de Igualdad de Oportunidades para las Personas con Discapacidad N° 7600, published in <st1:PersonName ProductID="La Gaceta" w:st="on">La Gaceta</st1:PersonName> of May 29, 1996, are also applicable. Thus, disabled persons must be guaranteed equal opportunities, through the elimination of all socially determined obstacles, whether physical, economic, social, or psychological that exclude or restrict their full participation in society; in this sense, Article 2 defines early stimulation when it says it is all that "care provided to the child between zero and seven years of age to enhance and develop to the maximum their physical, intellectual, sensory, and affective possibilities, through systematic and sequenced programs that encompass all areas of human development…" and Article 13 of <st1:PersonName ProductID="la Ley General" w:st="on">la Ley General</st1:PersonName> de Salud No. 5395, of October 30, 1973, when it recognizes the duty of parents and the State to ensure the health and development of children: "Children have the right to have their parents and the State ensure their health and their social, physical, and psychological development. Therefore, they shall have the right to state health benefits from birth until the age of majority. Children with physical, sensory, intellectual, and emotional disabilities shall enjoy specialized services.". In conclusion, after all that has been said, it is clear that children are entitled to a series of special rights and correlatively, the State and the parents or those in charge of the children are subject to a series of obligations and duties towards them, even more so when it concerns the protection of their right to life and health. </div> <div> IV.- On the specific case.- Regarding the performance of examinations, treatments, or surgical interventions on persons, this Chamber has held that the State must ensure that they are provided within a reasonable time, without denial, since the right to health is involved. Which, coupled with what was established in the preceding Considerando on the best interests of the child, leads this Chamber to conclude that in this case, a violation of the right to health of the protected minor has occurred. Indeed, from the report rendered by the representative of the respondent authority—which is taken as given under oath with the consequences, including criminal ones, provided for in Article 44 of <st1:PersonName ProductID="la Ley" w:st="on">la Ley</st1:PersonName> that governs this Jurisdiction—it is verified that the protected minor effectively has a kidney disease that requires surgical intervention, and that despite this, such intervention was scheduled only for the month of June 2008, that is, TEN MONTHS later. In this regard, the respondent authorities indicate that such intervention is not urgent and that there are similar cases waiting. For this Constitutional Court, said arguments are not admissible, since the minor, only two and a half years old, must wait to be treated for a number of months that represents almost half of her years of life. And although, after the filing of this appeal, the date was brought forward to March 25, 2008—and not to June 2008 as originally assigned—, such a timeframe is equally unreasonable, not only because of the minor's very young age, but also because the best interests of the child make it disproportionate for her to have to wait so long to undergo surgery, especially if it involves a state institution whose vocation is the safeguarding of children's right to health. Furthermore, while the months of waiting pass, the minor's quality of life, having to take an alternative treatment that does not resolve her condition, is diminished. Thus then, given that the timeframe for performing the surgical intervention on the protected minor is disproportionate—even with the advancing of the date—the appeal must be declared with merit, and the immediate scheduling of the surgical intervention must be ordered. Judge Vargas dissents and declares the appeal without merit. </div> <div> <o:p> </o:p> </div> Por tanto: <div> The appeal is declared WITH MERIT, consequently, RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever holds this position in his stead, is ordered to immediately issue the order to proceed with the surgical intervention that the protected minor requires, as determined by her treating physician, under his entire professional responsibility and with the due medical supervision. The foregoing under warning that he could incur the crime typified in Article 71 of <st1:PersonName ProductID="la Ley" w:st="on">la Ley</st1:PersonName> de <st1:PersonName ProductID="la Jurisdicción Constitucional" w:st="on">la Jurisdicción Constitucional</st1:PersonName>, which provides that imprisonment of three months to two years, or a fine of twenty to sixty days, shall be imposed on anyone who receives an order that must be complied with or enforced, issued in an amparo appeal, and does not comply with it or does not enforce it, provided the crime is not more severely punished. <st1:PersonName ProductID="la Caja Costarricense" w:st="on">la Caja Costarricense</st1:PersonName> de Seguro Social is condemned to pay the costs, damages, and losses caused by the facts that serve as the basis for this declaration, which shall be liquidated in the execution of judgment of the contentious-administrative proceeding. Notify personally RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever holds this position in his stead. Notify all parties. </div> <o:p> </o:p> Luis Fernando Solano C.<o:p></o:p> Presidente<o:p></o:p> <o:p> </o:p> <o:p> </o:p>             Ana Virginia Calzada M.                                                          Adrián Vargas B. <o:p> </o:p>             Gilbert Armijo S.                                                                      Ernesto Jinesta L. <o:p> </o:p>             Teresita Rodríguez A.                                                             Horacio González Q. <o:p> </o:p> <o:p> </o:p> Dissenting vote of Judge Vargas Benavides. <div> <o:p> </o:p> </div> <div> <o:p> </o:p> </div> <div> I dissent from the majority opinion and declare the filed appeal without merit. In matters concerning health services, such as the performance of examinations, consultations, treatments, or surgical interventions, <st1:PersonName ProductID="la Sala" w:st="on">la Sala</st1:PersonName> has held that the State must ensure that they are granted without denial to the insured, as the right to health is involved. However, this Court has also been clear in stating that it is not its task to determine how much time is fair from a medical point of view to attend to sick persons, as this is the exclusive competence of the treating physician, who issues the respective criteria regarding these aspects, which must be respected by <st1:PersonName ProductID="la Caja Costarricense" w:st="on">la Caja Costarricense</st1:PersonName> de Seguro Social, as constitutional jurisprudence has held. In the specific case, I consider that there is no violation whatsoever of the protected party's rights, because the fact that she was placed on the waiting list for surgery is due to the fact that the treatment she currently receives greatly reduces the effects that the condition she suffers has on her health, as her treating physician states in his report. For the foregoing, I consider it improper for <st1:PersonName ProductID="la Sala" w:st="on">la Sala</st1:PersonName> to order the respondents to perform the surgery on the minor, because by doing so, it allows the interested party to skip the waiting list merely through the filing of an amparo appeal, thus violating the right to health of the persons who are ahead of the protected party on the appointment list, and who suffer exactly the same condition as the petitioner, as stated by the respondents. On the other hand, from the evidence provided in the case file, and from the reports rendered under oath by the respondents, it is deduced that the protected party has received the medical treatment she requires at the Hospital Nacional de Niños, which is why I consider that the interested party has not been denied access to the health services provided by <st1:PersonName ProductID="la Caja Costarricense" w:st="on">la Caja Costarricense</st1:PersonName> de Seguro Social.

Thus, based on the foregoing, I consider that the appeal must be dismissed.

**Adrián Vargas B.** Therefore, they shall be entitled to state health benefits from birth until the age of majority. Children with physical, sensory, intellectual, and emotional disabilities shall enjoy specialized services.". In conclusion, after all that has been said, it is clear that children are entitled to a series of special rights, and correlatively, the State and the parents or guardians of children are subject to a series of obligations and duties towards them, even more so when it concerns the protection of their right to life and to health.

**IV.- Regarding the specific case.-** Regarding the performance of examinations, treatments, or surgical interventions on persons, this Chamber has held that the State must ensure that they are provided within a reasonable time, without denial, because the right to health is involved. This, coupled with what was established in the preceding recital (considerando) regarding the best interests of the child, leads this Chamber to conclude that in this case, a violation of the protected minor's right to health has occurred. Indeed, from the report provided by the representative of the respondent authority —which is accepted as given under oath with the consequences, even criminal, provided for in Article 44 of the Law governing this Jurisdiction— it is verified that the protected minor indeed has a kidney disease requiring surgical intervention, and that despite this, such intervention was scheduled only for the month of June 2008, that is, TEN MONTHS later. In this regard, the respondent authorities indicate that such intervention is not urgent and that there are similar cases waiting. For this Constitutional Tribunal, these arguments are not admissible, since the minor, barely two and a half years old, must wait for treatment for a number of months that represents almost half of her lifetime. And although, after the filing of this appeal (recurso), the date was moved up to March 25, 2008 —and not June 2008 as originally scheduled—, such a time frame remains unreasonable, not only because of the minor's very young age, but also because the best interests of the child make it disproportionate for her to wait so long for surgical intervention, especially since it concerns a state institution whose vocation is the safeguarding of children's right to health. Furthermore, while the months of waiting pass, the quality of life of the minor, having to take an alternative treatment that does not resolve her condition, is diminished. Thus then, given that the time frame to perform the surgical intervention on the protected minor is disproportionate —even with the date moved up— the appeal (recurso) must be granted, and the immediate scheduling of the surgical intervention must be ordered. **Judge Vargas dissents (salva el voto) and declares the appeal (recurso) without merit."** "I depart from the majority opinion (criterio) and declare the filed appeal (recurso) without merit. In matters concerning health services, such as the performance of examinations, consultations, treatments, or surgical interventions, the Chamber has held that the State must ensure that they are granted without denial to insured persons, because the right to health is involved. However, this Tribunal has also been clear in asserting that it is not its place to determine what time frame is just from a medical standpoint for treating sick persons, since this is the exclusive competence of the treating physician, who issues the respective opinions regarding these aspects, which must be respected by the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social), as constitutional jurisprudence has held. In the specific case, I consider that there is no violation whatsoever of the protected person's (amparada) rights, since the fact that she was placed on the waiting list for surgery is due to the fact that the treatment she currently receives greatly reduces the effects that her condition has on her health, as her treating physician indicates in his report. For the foregoing, I consider it improper for the Chamber to order the respondents to perform the surgery on the minor, because in doing so, it allows the interested party to skip the waiting list merely by filing an amparo appeal (recurso de amparo), thus violating the right to health of the persons who are ahead of the protected person (amparada) on the appointment list, and who suffer exactly the same condition as the person under protection (tutelada), as stated by the respondents. On the other hand, from the evidence provided in the case file (autos), and from the reports made under oath by the respondents, it is deduced that the protected person (amparada) has received the medical treatment she requires at the National Children's Hospital (Hospital Nacional de Niños), for which reason I consider that the interested party has not been denied access to the health services provided by the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social). Thus, based on the foregoing, I consider that the appeal (recurso) should be dismissed." Requests that the recourse filed be dismissed.

**3.-** EDUARDO DORYAN GARRON, in his capacity as Executive President of la Caja Costarricense de Seguro Social, reports under oath (folio 053), exactly in the same sense as the previous respondent, adding that at no time is the performance of the intervention she requires being denied but rather that she is on a waiting list, and therefore the medical protocol establishing priorities for performing surgical interventions must be followed, respecting the criteria of priority and equality of patients. Requests that the recourse filed be dismissed.

**4.-** In the proceedings followed, the legal prescriptions have been observed.

Drafted by Magistrate **González Quiroga**; and, **Considering:** **I.- Purpose of the recourse.-** The petitioner, mother of the protected minor, considers that the minor's right to health is being violated because, despite the medical opinion having already determined that her daughter's condition would only improve with a surgical intervention, such intervention has not been scheduled, but rather she has only been given an appointment for June 2008.

**II.- Proven facts.-** Of importance for the decision in this matter, the following facts are deemed duly demonstrated, either because they have been accredited or because the respondent has omitted to refer to them as prescribed in the initial order:

a. That the minor was seen for the first time on August 22, 2007 at the respondent Hospital, referred by general pediatrics for presenting grade III bilateral vesicoureteral reflux. On that same day, a hospitalization (internamiento) order was issued for the surgical correction of the condition (report at folio 020).

b. That the respondents decided, in this case, on surgical management associated with medical management with antibiotics (report at folio 021).

c. That according to the attending physician's opinion, as long as the minor is on antibiotics, the possibility of deterioration of the urinary tract is low (report at folio 022).

d. That there is a waiting list with patients with the same diagnosis and whose hospitalization (internamiento) orders were issued earlier (report at folio 021).

e. That after the filing of this recourse, the protected party was given a hospitalization (internamiento) date for surgical resolution for March 25, 2008 (report at folio 021).

**III.- On the best interests of the child and their right to health.-** In matters of the special rights held by children, there are various norms of constitutional, international, and infra-constitutional rank; all of them recognizing the best interests of the child as the guiding criterion for any public or private action concerning a person under eighteen years of age. "The family, as the natural element and foundation of society, has the right to the special protection of the State. Likewise, the mother, the child, the elderly, and the destitute sick shall have the right to that protection," so states Article 51 of our Magna Carta. In the same sense, la Convención sobre los Derechos del Niño of the United Nations (approved and ratified by our country through Ley No. 7184 of July 18, 1990, which entered into force, according to numeral 2 of that legal instrument, on the day of its publication in La Gaceta No. 149 of August 9, 1990), establishes a series of rights for any child, regardless of their race or nationality (article 2°), such as: the right to be cared for by their parents (article 7°), the right to a "standard of living adequate for their physical, mental, spiritual, moral, and social development," recognizing parents as those primarily responsible for providing the living conditions necessary for their development and the State's duty to adopt "appropriate measures to assist parents and other persons responsible for the child to give effect to this right" (article 27), and in the case of a mentally or physically disabled child, the right to "enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance, and facilitate the child's active participation in the community," in addition to "receiving special care" (article 23). On the other hand, la Declaración Universal de Derechos Humanos of December 10, 1948, specifies in its article 16, paragraph 3°, that "The family is the natural and fundamental group unit of society and is entitled to protection by society and the State" (in identical sense, article 23, paragraph 1°, of the International Covenant on Civil and Political Rights of December 19, 1966). For its part, article 25, paragraph 2°, of the aforementioned Declaration indicates that "Motherhood and childhood are entitled to special care and assistance..." and, finally, article 24, paragraph 1°, establishes that *"Every child has the right, without any discrimination whatsoever... to such measures of protection as are required by his status as a minor, on the part of his family, society and the State"*. From the norms of the international Human Rights instruments transcribed, it results, in all lights, that States have as fundamental duties the protection of the best interests of the child. Human or fundamental rights and the correlative obligations of public powers have also been developed at the infra-constitutional level; we thus have the Código de la Niñez y de la Adolescencia in general and la Ley de Igualdad de Oportunidades para las Personas con Discapacidad, when it also involves a child with special needs. Thus, the Código de la Niñez y de la Adolescencia (Ley No. 7739) points out that the interpretative north of any public or private action must be the best interests of the child (article 5°). Ordinal 12 of that normative body stipulates that the State must guarantee the right to life "with economic and social policies that ensure dignified conditions for gestation, birth, and integral development." Numeral 29 establishes the obligation of the father, mother, or person in charge to "watch over the physical, intellectual, moral, spiritual, and social development of their children under eighteen years of age" and to "comply with the instructions and controls prescribed to watch over the health of minors under their care" (article 45). For its part, in addition to all that has been said, when the child requires special needs due to their disability, understood as "a physical, mental, or sensory deficiency, whether of a permanent or temporary nature, that limits the capacity to perform one or more essential activities of daily life, which may be caused or aggravated by the economic and social environment" (article I of la Convención Americana para la Eliminación de todas las Formas de Discriminación contra las Personas con Discapacidad), the rights of disabled persons are also applicable, also recognized in international norms (la Convención Americana para la Eliminación de todas las Formas de Discriminación contra las Personas con Discapacidad ratified by la Asamblea Legislativa through Ley N° 7948) and with legal rank la Ley de Igualdad de Oportunidades para las Personas con Discapacidad N° 7600, published in La Gaceta of May 29, 1996. Thus, disabled persons must be guaranteed equality of opportunities, through the suppression of all socially determined obstacles, whether physical, economic, social, or psychological, that exclude or restrict their full participation in society; in this sense, Article 2 defines early stimulation when it says it is all that "attention provided to the child between zero and seven years to maximize and develop their physical, intellectual, sensory, and affective possibilities, through systematic and sequenced programs covering all areas of human development…" and Article 13 of the Ley General de Salud No. 5395, of October 30, 1973, when it recognizes the duty of parents and the State to watch over the health and development of children: "Children have the right for their parents and the State to watch over their health and their social, physical, and psychological development. Therefore, they shall have the right to state health benefits from birth until the age of majority. Children presenting physical, sensory, intellectual, and emotional disabilities shall enjoy specialized services.". In conclusion, after all that has been said, it is clear that children are assisted by a series of special rights and, correlatively, the State and the parents or guardians of the children are assisted by a series of obligations and duties towards them, even more so when it concerns the protection of their right to life and health.

**IV.- On the specific case.-** Regarding the practice of examinations, treatments, or surgical interventions on persons, this Chamber has held that the State must ensure that they are provided within a reasonable time, without denial, as the right to health is involved. Which, coupled with what was established in the previous considering on the best interests of the child, leads this Chamber to conclude that in this case, a violation of the protected minor's right to health has occurred. Indeed, from the report rendered by the representative of the respondent authority – which are taken as given under oath with the consequences, even criminal, provided in Article 44 of the Ley that governs this Jurisdiction – it is proven that the protected minor does indeed have a kidney disease requiring surgical intervention, and that despite this, such intervention was only scheduled for June 2008, that is, TEN MONTHS later. In this regard, the respondent authorities indicate that such intervention is not urgent and that there are similar cases waiting. For this Constitutional Tribunal, those arguments are not admissible, since the minor, barely two and a half years old, has to wait to be treated a number of months that represent almost half of her years of life. And although, after the filing of this recourse, the date was moved up to March 25, 2008 – and not to June 2008 as originally assigned – such a timeframe is equally unreasonable, not only because of the very young age of the minor, but because the best interests of the child make it disproportionate for her to have to wait so long to undergo surgical intervention, especially when it concerns a state institution whose vocation is the safeguarding of children's right to health. Furthermore, while the months of waiting pass, the minor's quality of life, having to be on an alternative treatment that does not resolve her condition, is diminished. Thus, given that the timeframe to perform the surgical intervention on the protected minor is disproportionate – even with the advancement of the date – the recourse must be granted, and the immediate scheduling of the surgical intervention ordered. **Magistrate Vargas dissents and dismisses the recourse.** **Por tanto:** The recourse is declared WITH MERIT, and consequently, RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever holds this position in his place, is ordered to immediately issue the order to proceed with the surgical intervention that the protected minor requires, as determined by her attending physician, under their entire professional responsibility and with the proper medical supervision. The foregoing under the warning that he could incur the crime typified in Article 71 of the Ley de la Jurisdicción Constitucional, which provides that imprisonment of three months to two years, or a fine of twenty to sixty days, shall be imposed on whoever receives an order that must be complied with or enforced, issued in an amparo recourse, and fails to comply with it or fails to enforce it, provided the crime is not more severely punished. La Caja Costarricense de Seguro Social is condemned to pay the costs, damages, and losses caused by the facts serving as the basis for this declaration, which shall be liquidated in the execution of the sentence of the contentious-administrative proceeding. Notify personally RODOLFO HERNANDEZ GOMEZ, in his capacity as General Director of the Hospital Nacional de Niños, or whoever holds this position in his place. Notify all parties.

Luis Fernando Solano C.

President Ana Virginia Calzada M. Adrián Vargas B.

Gilbert Armijo S. Ernesto Jinesta L.

Teresita Rodríguez A. Horacio González Q.

**Dissenting vote of Magistrate Vargas Benavides.** I depart from the majority criterion and dismiss the recourse filed. In matters regarding health services, such as the practice of examinations, consultations, treatments, or surgical interventions, la Sala has held that the State must ensure that they are granted without denial to the insured, as the right to health is involved. However, this Tribunal has also been clear in affirming that it is not for it to determine how much time is just from a medical standpoint to care for sick persons, as this is the exclusive competence of the attending physician, who issues the respective criteria regarding these aspects, which must be respected by la Caja Costarricense de Seguro Social, as constitutional jurisprudence has held. In the specific case, I consider that there is no violation whatsoever of the protected party's rights, since the fact that she was placed on the surgery waiting list is due to the treatment she currently receives greatly reducing the effects that the condition she suffers has on her health, as indicated by her attending physician in their report. For the foregoing, I consider it inappropriate for la Sala to order the respondents to perform surgery on the minor, as by doing so, it allows the interested party to skip the waiting list through the mere filing of an amparo recourse, thus violating the right to health of the persons who are ahead of the protected party on the appointment list and who suffer exactly the same condition as the tutelary, as stated by the respondents. On the other hand, from the evidence provided in the record and from the reports rendered under oath by the respondents, it follows that the protected party has received the medical treatment she requires at the Hospital Nacional de Niños, a reason for which I consider that the interested party has not been denied access to the health services provided by la Caja Costarricense de Seguro Social. Thus, for the reasons stated above, I believe the recourse should be dismissed.

Adrián Vargas B.

Res. Nº 2007013548 SALA CONSTITUCIONAL DE LA CORTE SUPREMA DE JUSTICIA. San José, a las quince horas y catorce minutos del dieciocho de septiembre del dos mil siete.

Recurso de amparo interpuesto por ADRIANA CAROLINA ANGELE MARTINEZ, cédula de identidad número 0110160477, a favor de ANA CRISTINA RAMOS ANGELE, contra el DIRECTOR DEL HOSPITAL NACIONAL DE NIÑOS.

Resultando:

1.- Por escrito recibido en la Secretaría de la Sala a las 16 horas 22 minutos del 05 de setiembre del 2007, la recurrente interpone recurso de amparo contra el DIRECTOR DEL HOSPITAL NACIONAL DE NIÑOS y manifiesta que: a) Su hija Ana Cristina Ramos Angelé, de dos años y diez meses de edad, sufre un padecimiento en sus riñones, según diagnóstico médico del 22 de agosto del 2007, suscrito por el Dr. Konrad Jiménez Vega, funcionario de dicho hospital. Uno de los riñones de su hija trabaja un 75% de su capacidad y el otro un 25% de su normal capacidad. El médico tratante afirma que no se garantiza mejoría ni cura alguna bajo tratamiento, salvo la posibilidad de una intervención quirúrgica que logre frenar el mal que aqueja la menor. El reflujo que hace referencia el dictamen consiste en que no sale toda la orina del organismo, sino que al llegar a la vejiga, en lugar de bacteria depositada; b) Es urgente practicar una intervención quirúrgica a la niña, caso contrario podría tener consecuencias fatales; c) El Hospital recurrido inicialmente le dio cita para el mes de junio del 2008, determinando luego que la paciente queda en espera de ser llamada para operación, que es lo mismo que decir que esperar ocho meses o más. Solicita se declare con lugar el recurso, se le ordene al Hospital recurrido que a la mayor brevedad posible, debe programar la intervención quirúrgica de la menor amparada, fijando al efecto hora y fecha, sin que ello pase a más tardar dentro de las próximas cuarenta y ocho horas contadas a partir de la firmeza del fallo.

2.- Informa bajo juramento RODOLFO HERNANDEZ GOMEZ, en su calidad de Director general del Hospital Nacional de Niños (folio 020), que: a) Adjunta el informe del doctor Konrad Roberto Jiménez Vega, médico tratante de la menor amparada. Según el análisis del expediente la menor fue vista por primera vez el 22 de agosto del 2007 referida por pediatría general por presentar reflujo vesicouretral bilateral grado III. Ese mismo día se le otorgó orden de internamiento para corrección quirúrgica del padecimiento; b) Los pacientes portadores de reflujo se manejan inicialmente con antibióticos profilácticos en las noches, esperando una curación espontánea con el pasar del tiempo. En este caso se decidió manejo quirúrgico asociado a manejo médico con antibióticos. Mientras esté con antibióticos la posibilidad de deterioro de la vía urinaria es bajo; c) Existe una lista de espera con pacientes con igual diagnóstico y que sus órdenes de internamiento fueron otorgadas antes; pero como es norma de este Hospital velar por la salud de los niños, se le otorgará una fecha de internamiento para la resolución quirúrgica de la paciente para el 25 de marzo del 2008. Agrega además el informe que al respecto rindió KONRAD JIMENEZ VEGA, en su calidad de Médico tratante de la amparada, donde indica que en este caso se decidió manejo quirúrgico asociado con antibióticos profilácticos, siendo que mientras esté con antibióticos la posibilidad de deterioro urinaria es baja. Solicita que se desestime el recurso planteado.

3.- Informa bajo juramento EDUARDO DORYAN GARRON, en su calidad de Presidente Ejecutivo de la Caja Costarricense de Seguro Social (folio 053), exactamente en el mismo sentido que el recurrido anterior, agregando que en ningún momento se le está negando la realización de la intervención que requiere sino que se encuentra en lista de espera, por lo que se debe seguir el protocolo médico que establece las prioridades para llevar a cabo las intervenciones quirúrgicas, respetando los criterios de prioridad e igualdad de los pacientes. Solicita que se desestime el recurso planteado.

4.- En los procedimientos seguidos se ha observado las prescripciones legales.

Redacta el Magistrado González Quiroga; y,

Considerando:

I.-Objeto del recurso.- La recurrente, madre de la menor amparada, considera que a ésta se le están violentando su derecho a la salud por cuanto, pese a que el criterio médico ya determinó que el padecimiento de su hija sólo mejoraría con una intervención quirúrgica, tal intervención no se le ha programado sino que solamente se le ha otorgado cita hasta para junio del 2008.

II.- Hechos probados.- De importancia para la decisión de este asunto, se estiman como debidamente demostrados los siguientes hechos, sea porque así han sido acreditados o bien porque el recurrido haya omitido referirse a ellos según lo prevenido en el auto inicial:

a. Que la menor fue vista por primera vez el 22 de agosto del 2007 en el Hospital recurrido, referida por pediatría general por presentar reflujo vesicouretral bilateral grado III. Ese mismo día se le otorgó orden de internamiento para la corrección quirúrgica del padecimiento (informe al folio 020).

b. Que los recurridos decidieron, en este caso, manejo quirúrgico asociado a manejo médico con antibióticos (informe al folio 021).

c. Que según criterio del médico tratante, mientras la menor esté con antibióticos la posibilidad de deterioro de la vía urinaria es bajo (informe al folio 022).

d. Que existe una lista de espera con pacientes con igual diagnóstico y que sus órdenes de internamiento fueron otorgadas antes (informe al folio 021).

e. Que luego de la presentación de este recurso se le otorga a la amparada una fecha de internamiento para la resolución quirúrgica para el 25 de marzo del 2008 (informe al folio 021).

III.- Sobre el interés superior del niño (a) y su derecho a la salud.- En materia de los derechos especiales que tienen los niños se encuentran varias normas de rango constitucional, internacional e infraconstitucional; reconociéndose en todas ellas el interés superior del niño (a) como criterio de toda acción pública o privada concerniente a una persona menor de dieciocho años. “La familia, como elemento natural y fundamento de la sociedad, tiene derecho a la protección especial del Estado. Igualmente tendrán derecho a esa protección la madre, el niño, el anciano y el enfermo desvalido” así reza el artículo 51 de nuestra Carta Magna. En igual sentido la Convención sobre los Derechos del Niño de las Naciones Unidas (aprobada y ratificada por nuestro país, mediante, la Ley No. 7184 del 18 de julio de 1990, la cual entró en vigencia, a tenor del numeral 2 de ese instrumento legal, el día de su publicación en La Gaceta No. 149 del 9 de agosto de 1990), le establece una serie de derechos a cualquier niño, independientemente, de su raza o nacionalidad (artículo 2°), tales como: el derecho a ser cuidado por sus padres (artículo 7º ), el derecho a un “nivel de vida adecuado para su desarrollo físico, mental, espiritual, moral y social” reconociéndose a los padres como los responsables primordiales de proporcionarles las condiciones de vida necesarias para su desarrollo y el deber del Estado de adoptar “medidas apropiadas para ayudar a los padres y a otras personas responsables por el niño a dar efectividad a este derecho” (artículo 27) y en caso de tratarse además de un niño (a) mental o físicamente impedido el derecho a “disfrutar de una vida plena y decente en condiciones que aseguren dignidad, permitan llegar a bastarse a sí mismo y faciliten la participación activa del niño en la comunidad” además de “recibir cuidados especiales” (artículo 23). Por otro lado, la Declaración Universal de Derechos Humanos del 10 de diciembre de 1948, precisa en su artículo 16, párrafo 3º, que “La familia es el elemento natural y fundamental de la sociedad y tiene el derecho a la protección de la sociedad y del Estado” (en idéntico sentido artículo 23, párrafo 1º, del Protocolo Internacional de Derechos Civiles y Políticos del 19 de diciembre de 1966). Por su parte, el artículo 25, párrafo 2º, de la supraindicada Declaración señala que “La maternidad y la infancia tienen derecho a cuidados y asistencia especiales...” y, finalmente, en el artículo 24, párrafo 1º, se establece que “Todo niño tiene derecho, sin discriminación alguna... a las medidas de protección que su condición de menor requiere, tanto por parte de su familia como de la sociedad y del Estado”. De las normas de los instrumentos internacionales sobre Derechos Humanos transcritas, resulta, a todas luces, que los Estados tienen como deberes fundamentales la protección del interés superior del niño. Los derechos humanos o fundamentales y las obligaciones correlativas de los poderes públicos, han sido también, desarrollados en el plano infraconstitucional, tenemos así el Código de la Niñez y de la Adolescencia en general y la Ley de Igualdad de Oportunidades para las Personas con Discapacidad, cuando se trate además de un niño (a) con necesidades especiales. Así, el Código de la Niñez y de la Adolescencia (Ley No. 7739) puntualiza que el norte interpretativo de toda acción pública o privada debe ser el interés superior del niño (artículo 5º). El ordinal 12 de ese cuerpo normativo estipula que el Estado deberá garantizar el derecho a la vida “con políticas económicas y sociales que aseguren condiciones dignas para la gestación, el nacimiento y el desarrollo integral”. El numeral 29 establece la obligación del padre, la madre o la persona encargada de “velar por el desarrollo físico, intelectual, moral, espiritual y social de sus hijos menores de dieciocho años” y de “cumplir con las instrucciones y los controles que se prescriban para velar por la salud de las personas menores de edad bajo su cuidado” (artículo 45). Por su parte, además de todo lo dicho, cuando el niño (a) requiera de necesidades especiales en razón de su discapacidad entendida como “una deficiencia física, mental o sensorial, ya sea de naturaleza permanente o temporal, que limita la capacidad de ejercer una o más actividades esenciales de la vida diaria, que puede ser causada o agravada por el entorno económico y social” (artículo I de la Convención Americana para la Eliminación de todas las Formas de Discriminación contra las Personas con Discapacidad) es aplicable además los derechos de las personas discapacitadas, reconocidos también en normas internacionales (Convención Americana para la Eliminación de todas las Formas de Discriminación contra las Personas con Discapacidad ratificada por la Asamblea Legislativa mediante Ley N° 7948) y con rango legal la Ley de Igualdad de Oportunidades para las Personas con Discapacidad N° 7600, publicada en La Gaceta del 29 de mayo de 1996. Así pues, a las personas discapacitadas se les debe garantizar igualdad de oportunidades, mediante la supresión de todos los obstáculos determinados socialmente, ya san físicos, económicos, sociales o psicológicos que excluyan o restrinjan su plena participación en la sociedad, en este sentido define el artículo 2 la estimulación temprana cuando dice que es toda aquella “atención brindada al niño entre cero y siete años para potenciar y desarrollar al máximo sus posibilidades físicas, intelectuales, sensoriales y afectivas, mediante programas sistemáticos y secuenciados que abarcan todas las áreas del desarrollo humano…” y el artículo 13 de la Ley General de Salud No. 5395, del 30 de octubre de 1973 cuando reconoce el deber de los padres y el Estado de velar por la salud y el desarrollo de los niños: “Los niños tienen derecho a que sus padres y el Estado velen por su salud y su desarrollo social, físico y psicológico. Por tanto, tendrán derecho a las prestaciones de salud estatales desde su nacimiento hasta la mayoría de edad. Los niños que presenten discapacidades físicas, sensoriales, intelectuales y emocionales gozarán de servicios especializados.". En conclusión, luego de todo lo dicho es claro que a los niños le asisten una serie de derechos especiales y correlativamente al Estado y los padres o encargados de los niños le asisten una serie de obligaciones y deberes para con ellos, más aún cuando se trate de la protección de su derecho a la vida y a la salud.

IV.- Sobre el caso concreto.- En cuanto a la práctica de exámenes, tratamientos o intervenciones quirúrgicas a personas, ésta Sala ha sostenido que el Estado debe velar por que ellos sean dados en un plazo razonable, sin denegación, por estar involucrado el derecho a la salud. Lo cual, aunado a lo establecido en el considerando anterior sobre el interés superior del niño (a) lleva a concluir a esta Sala que en este caso se ha producido una violación al derecho a la salud de la menor amparada. En efecto, del informe rendido por el representante de la autoridad recurrida -que se tienen por dados bajo fe de juramento con las consecuencias, incluso penales, previstas en el artículo 44 de la Ley que rige esta Jurisdicción, se comprueba que efectivamente la menor amparada tiene una enfermedad renal que requiere de intervención quirúrgica, y que a pesar de ello, tal intervención le fue programada hasta para el mes de junio del 2008, es decir, DIEZ MESES después. Al respecto, las autoridades recurridas indican que tal intervención no es urgente y que existen casos similares que esperan. Para este Tribunal Constitucional dichos argumentos no son admisibles, puesto que la menor, de tan sólo dos años y medio, tiene que esperar para ser tratada una cantidad de meses que representan casi la mitad de sus años de vida. Y aunque, luego de la presentación de este recurso se le adelantó la fecha para el 25 de marzo del 2008 –y no para el junio del 2008 como originalmente se le consignó-, igualmente tal plazo resulta irrazonable, no sólo por la edad tan corta de la menor, sino porque el interés superior del niño (a) hace desproporcionado que ésta deba esperar tanto tiempo para ser intervenida quirúrgicamente, máxime si se trata de una institución estatal cuya vocación es el resguardo del derecho a la salud de las niños. Además, entretanto pasan los meses de espera, la calidad de vida de la menor, al tener que estar tomando un tratamiento alternativo que no resuelve su padecimiento, se ve mermada. Así entonces, dado que el plazo para practicarle la intervención quirúrgica a la menor amparada resulta desproporcionado -aún con el adelantamiento de la fecha- el recurso debe declararse con lugar, y ordenarse la programación inmediata de la intervención quirúrgica. El Magistrado Vargas salva el voto y declara sin lugar el recurso.

Por tanto:

Se declara CON LUGAR el recurso, en consecuencia se ordena a RODOLFO HERNANDEZ GOMEZ, en su calidad de Director General del Hospital Nacional de Niños, o a quien en su lugar ocupe este cargo girar de inmediato la orden de proceder a la intervención quirúrgica que la menor amparada requiere, según lo determine su médico tratante, bajo su entera responsabilidad profesional y contando con la debida supervisión médica. Lo anterior bajo apercibimiento de que podría incurrir en el delito tipificado en el artículo 71 de la Ley de la Jurisdicción Constitucional, el cual dispone que se impondrá prisión de tres meses a dos años, o de veinte a sesenta días multa, a quien recibiere una orden que deba cumplir o hacer cumplir, dictada en un recurso de amparo y no la cumpliere o no la hiciere cumplir, siempre que el delito no esté más gravemente penado. Se condena a la Caja Costarricense de Seguro Social al pago de las costas, daños y perjuicios causados con los hechos que sirven de base a esta declaratoria, los que se liquidarán en ejecución de sentencia de lo contencioso administrativo. Notifíquese de forma personal a RODOLFO HERNANDEZ GOMEZ, en su calidad de Director general del Hospital Nacional de Niños, o a quien en su lugar ocupe este cargo. Comuníquese a todas las partes.

Luis Fernando Solano C.

Ana Virginia Calzada M. Adrián Vargas B.

Gilbert Armijo S. Ernesto Jinesta L.

Teresita Rodríguez A. Horacio González Q.

Voto salvado del Magistrado Vargas Benavides.

Me aparto del criterio de mayoría y declaro sin lugar el recurso interpuesto. En asuntos referentes a servicios de salud, tales como práctica de exámenes, consultas, tratamientos o intervenciones quirúrgicas, la Sala ha sostenido que el Estado debe velar porque los mismos sean otorgados sin denegación a los asegurados, por estar involucrado el derecho a la salud. Sin embargo, este Tribunal también ha sido claro en afirmar que no le corresponde determinar cuánto tiempo es el justo desde el punto de vista médico para atender personas enfermas, pues ello es competencia exclusiva del médico tratante, quien emite los criterios respectivos con respecto a estos aspectos, los cuales deben ser respetados por la Caja Costarricense de Seguro Social, tal y como lo ha sostenido la jurisprudencia constitucional. En el caso concreto, estimo que no existe violación alguna a los derechos de la amparada, pues el hecho de que ésta fuera colocada en la lista de espera para cirugía, obedece a que el tratamiento que actualmente recibe reduce en gran medida los efectos que el padecimiento que sufre tiene para su salud, tal y como indica su médico tratante en su informe. Por lo anterior, considero improcedente que la Sala ordene a los recurridos realizar la cirugía a la menor, pues al hacerlo permite a la interesada saltarse la lista de espera por la mera interposición de un recurso de amparo, vulnerando así el derecho a la salud de las personas que se encuentran antes de la amparada en la lista de cita, y que sufren exactamente el mismo padecimiento que la tutelada, según lo manifiestan los recurridos. Por otra parte, de la prueba aportada en autos, y de los informes rendidos bajo juramento por los recurridos se deduce que la amparada ha recibido en tratamiento médico que requiere en el Hospital Nacional de Niños, razón por la cual estimo que no se ha negado a la interesada el acceso a los servicios de salud que otorga la Caja Costarricense de Seguro Social. Así, por lo expuesto anteriormente, considero que el recurso debe ser desestimado.

Adrián Vargas B.

Delay of pediatric surgery violates right to health and best interests of the childRetraso de cirugía pediátrica vulnera derecho a la salud e interés superior del menor

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