JUDGMENT NO. 89

YEAR 2024

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Augusto Antonio BARBERA; Judges: Franco MODUGNO, Giulio PROSPERETTI, Giovanni AMOROSO, Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Filippo PATRONI GRIFFI, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI,

has issued the following

JUDGMENT

in the proceedings concerning the constitutional legitimacy of Articles 1, 2, and 3 of the Law of the Puglia Region No. 12 of 15 June 2023 (Dental services for fragile patients provided in territorial public facilities), initiated by the President of the Council of Ministers with a claim notified on 9-16 August 2023, filed with the Court Registry on 9 August 2023, registered under No. 24 of the 2023 claim register, and published in the Official Gazette of the Republic No. 36, first special series, of the year 2023.

Seen the instrument of appearance of the Puglia Region;

Heard at the public hearing of 20 March 2024, the Reporting Judge Maria Rosaria San Giorgio;

Heard the State Attorney Sergio Fiorentino for the President of the Council of Ministers and the lawyer Mariangela Rosato for the Puglia Region;

Deliberated in the council chamber of 20 March 2024.

Statement of Facts

1. – With a claim filed on 9 August 2023 (claim reg. no. 24 of 2023), the President of the Council of Ministers, represented and defended by the State Attorney General, initiated, with reference to Article 117, third paragraph, of the Constitution, questions of constitutional legitimacy of Articles 1, 2, and 3 of the Law of the Puglia Region No. 12 of 15 June 2023 (Dental services for fragile patients provided in territorial public facilities).

The challenged provisions bind the health authorities of the Region to provide "dental services with minor, medium, and major invasiveness" to "fragile patients with psychomotor disabilities or behavioral disorders," provided that "the [...] observation period for post-intervention complications does not exceed twenty-four hours from the end of the procedure" (Article 1). It is provided that, for each health authority, at least two facilities must be designated for the described services, to be located "within a protected environment corresponding to the Territorial Assistance Points equipped with surgical services and related anesthesiology service" (Article 2). For the aforementioned purposes, it is established that the health authorities increase the hours of territorial services "up to a maximum of thirty-eight hours per week for each identified facility" (Article 3, paragraph 1). This increase is carried out through a reconversion of the company's allocation for specialist outpatient services or with the assignment, through resolution of the Regional Council, of hours dedicated and restricted to the dental branch (Article 3, paragraph 2).

According to the claimant, the aforementioned provisions would not comply with the constitutional principle of "necessary coordination with public finances as per Article 117, third paragraph of the Constitution."

In particular, Article 1 would introduce "a further level of healthcare assistance compared to the essential levels of services borne by the regional healthcare service," with a consequent violation of "the regulations concerning financial recovery plans," to which the Puglia Region has been subject since 2010. These plans, the claimant recalls, "constitute elements of harmonization of public budgets and coordination of public finances" and impose the "prohibition of non-compulsory expenses."

In the claim, it is noted that the scope of beneficiaries of dental services, as identified by Article 1 of the Puglia Region Law No. 12 of 2023, "is broader than that provided for by national legislation," resulting in "greater non-compulsory healthcare spending."

The claimant believes that, in matters of dental assistance, the national legislation – identified by the claimant in the provisions dictated by Legislative Decree No. 502 of 30 December 1992 (Reorganization of regulations in healthcare matters, pursuant to Article 1 of Law No. 241 of 23 October 1992), and by the Decree of the President of the Council of Ministers of 29 November 2001 (Definition of essential levels of assistance) – limits the dental assistance interventions covered by the National Health Service (NHS) to only the dental health protection programs in developmental age and only dental and prosthetic assistance for certain categories of subjects in conditions of particular vulnerability.

These conditions are indicated by the subsequent Decree of the President of the Council of Ministers of 12 January 2017 (Definition and updating of the essential levels of assistance, referred to in Article 1, paragraph 7, of Legislative Decree No. 502 of 30 December 1992), "in Annex C" (recte: 4C). The latter identifies, for this purpose, two specific types of "vulnerability": the "health" and the "social" vulnerability.

The first is recognized for people suffering from serious pathologies, whose already precarious health conditions could be further compromised by a concomitant dental pathology, to the point that failure to access the related care could jeopardize their survival. To this category of people – the claimant specifies – all dental services included in the "nomenclature of specialist outpatient assistance" must be guaranteed, with the sole exclusion of prostheses and aesthetic procedures.

Those who, on the other hand, suffer from other pathologies or conditions with which dental complications are frequently associated could access dental care only if they are also in a situation of "social" vulnerability, that is, in a "condition of social disadvantage (low income and/or marginalization and/or social exclusion)."

The challenged regional provisions would deviate from the described national framework, first of all from a subjective point of view: the services de quo would in fact be extended "to a wider pool of beneficiaries." In this regard, the claimant observes that Article 1, in establishing the criterion for accessing dental care, does not associate the pathological condition (different, in theory, from that provided for by national legislation) with the condition of social vulnerability. And this is despite the fact that the Region possesses "the instruments to define the indices revealing the conditions of economic and social disadvantage," which constitute the extremes of such vulnerability.

The non-compliance with national legislation, moreover, would also be appreciable from an objective point of view. The dental services guaranteed by Article 1 of the Puglia law would be "different" from those guaranteed by the national reference standard, referred to in "Annex 4" (recte: 4C) of the Decree of the President of the Council of Ministers of 12 January 2017 (which indicates the following: dental examination; dental extractions; fillings and root canal therapies; tartar removal; application of removable prostheses, excluding the prosthetic device; application of orthodontic appliances to subjects from zero to fourteen years with "IOTN index [index of need for orthodontic treatment] = 4th or 5th°," excluding the cost of the device; apicification to subjects from zero to fourteen years).

The claimant, therefore, "as per constant constitutional jurisprudence," reproaches the Puglia Region, subject to the regulations of the plan for the recovery of healthcare expenditure deficits, for introducing new and further levels of assistance through the use of its own resources or resources "pertaining to the undifferentiated share of the National Health Fund"; all of this, with the further critical issue relating to the "adequate coverage of public spending," as the use of resources for non-essential services would, correspondingly, reduce the resources for essential services.

The constitutional illegitimacy of Article 1 of the Puglia Region Law No. 12 of 2023 would also vitiate, derivatively, the subsequent Articles 2 and 3, as they are implementing provisions.

2. – With a document filed on 22 September 2023, the Puglia Region, in the person of the President pro tempore of the Regional Council, appeared in court, filing documents and concluding for the inadmissibility and/or the unfoundedness of the questions of constitutional legitimacy.

Under the first profile, the Region highlights the "incorrectness" of the reference made by the claimant to the interposed legislative parameters that are assumed to be violated.

It is noted in the instrument of appearance that Annex 4C to the Decree of the President of the Council of Ministers of 12 January 2017, evoked by the claim (albeit with the incorrect numbering of "Annex 4"), "is not currently in force": in fact, its entry into force was subordinated to the conclusion of the procedure aimed at the issuance of the ministerial decree defining the maximum rates for healthcare services (a decree that, at the moment, would still be "in the preparatory phase"). Therefore, under current legislation, the Region specifies, the regulation regarding dental assistance should be traced back to the Decree of the President of the Council of Ministers of 29 November 2001, which, in turn, refers to the decree of the Minister of Health of 22 July 1996 (Specialist outpatient assistance services that can be provided within the National Health Service and related rates). The latter establishes that essential dental assistance must be provided to subjects in conditions of social or health vulnerability, "without providing for further restrictive criteria."

The respondent adds that the matter is regulated by the subsequent decree of the Minister of Health of 9 December 2015 (Conditions of service delivery and indications of prescriptive appropriateness of outpatient assistance services that can be provided within the National Health Service), of which the challenged regional law would represent "direct emanation and implementation." This source – the Region specifies – establishes the control measures of the conditions of service delivery and contains indications of the prescriptive appropriateness of specialist outpatient assistance services, with charges borne by the NHS.

In this context, the challenged Puglia law would find its scope of application in the criterion of "health vulnerability" as declined by the Ministerial Decree of 9 December 2015, according to the so-called "descending" meaning, based on which the services de quibus must be guaranteed "at least to citizens suffering from serious pathologies, whose health conditions may be seriously prejudiced by a concomitant dental pathology" (Annex 3). In this last category, the Region notes, the "fragile patients with psychomotor disabilities or behavioral disorders," identified by Article 1 of the Puglia Region Law No. 12 of 2023 as recipients of the guaranteed services, would precisely fall. Consequently, the Puglia legislator would not have expanded the pool of beneficiaries at all.

Nor would it have affected the type of dental services that can be provided, with reference to those with "minor, medium, and major invasiveness," as defined by Regional Regulation No. 5 of 31 March 2020 (Implementation of the Regional Law No. 9/2017 and subsequent amendments. Identification of the services that can be provided in dental practices and clinics and definition of structural, organizational, and technological requirements). The Puglia law would have intended to indicate only the facilities called upon to provide the services in question (Article 2) and the related methods of delivery (Article 3). Thus, only "territorial public facilities" would be involved, without any additional cost. The purpose pursued by the regional legislator, ultimately, would only be to plan and guarantee the provision of dental services already included in the essential levels of assistance (LEA) for certain fragile patients who, otherwise, "would have to resort to inappropriate hospitalizations with sedation treatment, as they suffer from psychomotor disabilities or behavioral disorders."

The Region then raises an objection of inadmissibility regarding the challenge of Articles 2 and 3 of the Puglia Region Law No. 12 of 2023 for "generality, lack of specification, and indeterminacy." The claimant, in fact, would not have demonstrated "how the challenged Regional Law No. 12/2023 is likely to prejudice the achievement of the savings objectives provided for by the Recovery Plan," failing to provide demonstration, "in practical and concrete terms," of the suspected defect of constitutional illegitimacy.

Furthermore, the respondent observes that the challenged regional law "does not entail additional burdens and does not provide for the use of its own resources," so much so that it "is neutral from a financial point of view and does not contain any provision for budget variations," as also "specified in the report that led to the approval of the law."

Finally, the respondent invokes the principle of loyal cooperation between State and regions, "as delineated" by this Court in judgment No. 242 of 2022, "with reference to the specific circumstance of the delayed definition of the procedure relating to the ministerial decree necessary for the validity of Annex 4C to the Decree of the President of the Council of Ministers of 17/01/2017 [recte: 12 January 2017]." In this perspective, recalling the affirmations of this Court, the respondent specifies that the time elapsed for the non-updating and/or delayed updating of the LEA "determines the compromise of the right to health in equal conditions throughout the national territory," without this being justified by the need to complete the related procedure, "since the mere passage of time translates into the obsolescence of healthcare."

With a subsequent brief, filed on 30 January 2024, the Puglia Region reiterated its defensive arguments, insisting on the rejection, or on the declaration of inadmissibility, of the questions of constitutional legitimacy.

Legal Reasoning

1. – The President of the Council of Ministers, represented and defended by the State Attorney General, initiated questions of constitutional legitimacy of Articles 1, 2, and 3 of the Puglia Region Law No. 12 of 2023, alleging the violation of Article 117, third paragraph, of the Constitution.

The challenged provisions prescribe that regional health authorities provide "dental services with minor, medium, and major invasiveness for fragile patients with psychomotor disabilities or behavioral disorders, whose observation period for post-intervention complications does not exceed twenty-four hours from the end of the procedure" (Article 1). The facilities authorized for the aforementioned services "cannot be less than two for each health authority, located within a protected environment corresponding to the Territorial Assistance Points equipped with surgical services and related anesthesiology service" (Article 2). For the achievement of the purposes referred to in Article 1, it is established that "the health authorities increase the hours of territorial services up to a maximum of thirty-eight hours per week for each identified facility" (Article 3, paragraph 1), based on "a reconversion of the company's allocation for specialist outpatient services or with the assignment, through resolution of the Regional Council, of hours dedicated and restricted to the dental branch" (Article 3, paragraph 2).

In the opinion of the claimant, in this way, healthcare services additional to the essential levels of assistance established by national standards would be introduced at the expense of the Regional Health Service: this, both from a subjective point of view, as the pool of beneficiaries would be expanded, and from an objective point of view, with regard to the type of services guaranteed (which would not have an exact correspondence with those that, according to national law, fall within the LEA).

In this regard, the claim refers to the "national legislation on dental assistance," which would be found in the provisions of Legislative Decree No. 502 of 1992, as well as in the Decrees of the President of the Council of Ministers that defined the essential levels of assistance (the Decrees of the President of the Council of Ministers of 29 November 2001 and 12 January 2017, and related Annexes, are cited).

In the claimant's opinion, the Puglia Region would therefore incur "greater non-compulsory healthcare spending," with a consequent exceeding of the limits – to which the same Region has been subject since 2010 – arising from the national provisions on the recovery from the healthcare deficit, which require the regions involved to implement only interventions aimed at recovering the deficit.

2. – It is appropriate to preface a summary reconstruction of the reference regulatory framework.

The scope of dental services that fall within the LEA is circumscribed, by national legislation, to the "dental health protection programs in developmental age" and to "dental and prosthetic assistance to certain categories of subjects in conditions of particular vulnerability" (Article 9, paragraph 5, letter c, of Legislative Decree No. 502 of 1992). Outside of these boundaries, by express provision of Article 9, paragraph 4, letter a), of the same decree, "additional services, not included in the essential and uniform levels of assistance" come into play, which can be satisfied with the supplementary funds of the NHS.

The described delimitation has not, initially, found adequate clarification in the secondary rules that have defined the services included in the LEA. In fact, the Decree of the President of the Council of Ministers of 29 November 2001, in indicating the specialist outpatient services included in the same LEA (Annex 2B, letter a, "dental assistance"), made a mere reference "to the user groups and conditions indicated in paragraph 5, Article 9 of Legislative Decree No. 502 of 30 December 1992, and subsequent amendments and additions."

The more precise definition of the concept of "particular vulnerability," and a detailed indication of the type of dental services included in the LEA, are due to the subsequent Ministerial Decree of 9 December 2015, adopted pursuant to Article 9-quater of Decree-Law No. 78 of 19 June 2015 (Urgent provisions on territorial entities. Provisions to ensure the continuity of security and territorial control devices. Rationalization of the expenses of the National Health Service as well as regulations on waste and industrial emissions), converted, with amendments, into Law No. 125 of 6 August 2015. Annex 3 of this decree dictated the "[c]riteria for the definition of the conditions of eligibility for dental services," and its provisions were then transposed into Annex 4C to the Decree of the President of the Council of Ministers of 12 January 2017 (which the claim, with a mere material error, indicates as "Annex 4" or as "Annex C"), with which the LEA were updated.

This last Annex, like the previous one, is dedicated precisely to the specialist outpatient dental services and is in fact, like the other, entitled "Criteria for the definition of the conditions of eligibility for dental services." It came into force, replacing the previous one, on 4 August 2023, based on the provisions of the transitional rule of Article 64, paragraph 2, of the same Decree of the President of the Council of Ministers of 12 January 2017, which subordinated its validity to the publication of the ministerial decree called upon to redefine the maximum rates for services. The Decree of the Minister of Health of 23 June 2023 (Definition of the rates for specialist outpatient and prosthetic assistance), precisely, was published in the Official Gazette of 4 August 2023.

Currently, therefore, Annex 4C to the Decree of the President of the Council of Ministers of 12 January 2017 represents the national reference parameter for establishing which dental assistance services, and for which subjects, are included in the LEA. It, as far as is relevant here, declines the subjective condition of "particular vulnerability" according to the profiles of the so-called "health vulnerability," referring to "health conditions that make dental care indispensable or necessary," and "social vulnerability," which allows access to services to those who are in "conditions of social and economic disadvantage (normally correlated to low income and/or conditions of marginalization and/or social exclusion) that prevent access to paid dental care due to the high costs present in private facilities."

More precisely, the requirement of health vulnerability is defined, in Annex 4C, on the basis of two different criteria, called, one, "’ascending’ criterion" (which "takes into consideration the diseases and conditions with which complications of a dental nature are frequently or always associated") and the other, "’descending’ criterion" (which "takes into consideration the diseases and conditions in which health conditions could be aggravated or prejudiced by concomitant dental pathologies").

For each of the two subjective aspects of vulnerability, health and social, moreover, Annex 4C, in paragraph 3, identifies the type of dental services that must be considered included in the LEA. In the first case, the Annex refers to the services "reported in Annex 4" (which contains the so-called nomenclature) provided that they are associated therein with the "’health vulnerability’ condition of eligibility"; this, however, with the further clarification that, "[g]iven the premises and the seriousness of the pathologies themselves, subjects thus defined in conditions of health vulnerability must be guaranteed all dental services included in the nomenclature of specialist outpatient assistance, with the exclusion of prosthetic devices and aesthetic procedures." In the second case, and therefore for subjects in a condition of social vulnerability, Annex 4C refers to the services "reported in Annex 1, to which the ‘social vulnerability’ condition of eligibility is associated," with the clarification that certain specific services that are listed, with a specific numbering, at the end of paragraph 3 (fourth page) must at least be guaranteed.

As for the regulatory framework found in the Puglia Region, it is necessary to consider that dental services have received specific regulation, most recently, with Regional Regulation No. 5 of 2020, adopted in implementation of Law No. 9 of the Puglia Region of 2 May 2017 (New regulations on authorization for the construction and operation, institutional accreditation, and contractual agreements of public and private healthcare and social-healthcare facilities). In particular, it identified the services that can be provided in dental practices and in specialist outpatient dental facilities, together with the requirements requested for the issuance of the related operating authorizations, depending on the type of facility. Furthermore, as far as is relevant here, this regional regulation introduced detailed criteria for dividing services according to their "minor, medium, and major invasiveness" (Article 4, paragraph 2) and classified the facilities and dental practices that, after authorization, can provide them (Article 6). Annexes 1A, 2A, and 3A of the regulation contain specific lists of dental services, specifically distinguishing those with low, medium, and high invasiveness.

In this context, the regional law that is the subject of these questions is included, with which the Puglia Region intended to guarantee some specific dental services (those, precisely, with "minor, medium, and major invasiveness, [...] whose observation period for post-intervention complications does not exceed twenty-four hours from the end of the procedure") for a specific category of beneficiaries, identified as "fragile patients with psychomotor disabilities or behavioral disorders."

Both aspects – both the objective one, which refers to the type of services guaranteed, and the subjective one, which identifies the beneficiaries – are subject to criticism by the President of the Council of Ministers, who challenges them in terms of the undue expansion of the LEA: an operation that, as the claimant points out, would not be permitted for the Puglia Region, as it is subject to the constraints of the plan for recovery from healthcare expenditure deficits.

3. – Having stated this, the objection of inadmissibility of the initiated questions, raised by the Puglia Region regarding the challenge of Articles 2 and 3 of the Puglia law, must first be examined. The excessive generality of the criticisms is lamented, which would not have demonstrated "how the challenged Regional Law No. 12/2023 is likely to prejudice the achievement of the savings objectives provided for by the Recovery Plan."

The objection is not worthy of acceptance.

Article 2 of the Puglia Region Law No. 12 of 2023, for the purposes of providing the dental services that are the subject of regulation, introduces, as already mentioned, a corresponding reorganization of health services, establishing the presence of at least two authorized facilities for each health authority that are equipped with specific characteristics. Article 3 affects the consequent personnel costs, as, to cope with the new services, it imposes an increase in working hours, setting the maximum amount and the methods of implementation.

In view of such provisions, the prejudice to the achievement of savings objectives, in the claimant's perspective, must be considered in re ipsa, since "two macro-areas notoriously regulated by the plans for recovery from the healthcare deficit" are involved (thus, most recently, judgment No. 134 of 2023, point 8.2. of the Legal Reasoning, precisely with regard to a similar situation of healthcare reorganization in the Puglia Region).

4. – The questions are inadmissible.

4.1. – First of all, as regards the subjective profile that is involved by the claimant's criticisms in the part in which they lament the expansion, which would have been carried out with Article 1, of the pool of beneficiaries of dental services compared to the corresponding national provisions on the LEA, the claim lacks in the illustration of the interpretative assumption that should support it.

4.1.1. – The claimant's thesis is that the Puglia law, where it indicates as beneficiaries the "fragile patients with psychomotor disabilities or behavioral disorders" (Article 1), would have identified different and additional pathologies compared to those that, based on the national reference source (consisting of Annex 4C to the Decree of the President of the Council of Ministers of 12 January 2017), select the subjects that benefit from dental services; and this would have done so without associating these pathologies with the condition of "social vulnerability."

In this regard, it is highlighted in the claim that, based on the aforementioned Annex 4C, access to dental services is guaranteed on the basis of the criterion of "health vulnerability" in cases where it concerns "at least" "citizens suffering from serious pathologies, whose health conditions may be seriously prejudiced by a concomitant dental pathology (a ‘descending’ criterion), to the point that failure to access dental care may jeopardize the patient's "quoad vitam" prognosis."

In this perspective, according to the national regulatory text in question, "at least the following conditions can be identified: 1. patients awaiting transplant and post-transplant (excluding corneal transplant); 2. patients with severe immunodeficiency states; 3. patients with cyanotic congenital heart disease; 4. patients with oncological and hematological pathologies in developmental and adult age being treated with radiotherapy or chemotherapy or in any case at risk of severe infectious complications; 5. patients with severe hemophilia or other serious congenital, acquired, or iatrogenic hemocoagulation pathologies." The claimant also remarks that, for patients suffering from other pathologies, or other conditions to which dental complications may be associated, access to services is in any case allowed, always based on the provisions of Annex 4C, but only if these further pathologies are associated with the condition of "social vulnerability": a condition that, instead, the challenged Puglia law would have disregarded.

4.1.2. – This reconstruction of the relevant national legislation is affected by omissions that result in an inadequate motivation of the alleged defect of constitutional legitimacy.

The claimant, in fact, starts from the implicit assumption that the list of previous pathological states, which enable the patients who carry them to use dental services based only on the condition of "health vulnerability" (third page of Annex 4C to the Decree of the President of the Council of Ministers of 12 January 2017), constitutes a closed catalog, before which, that is, the regions could not attribute relevance to further previous states in the absence of the concurrent requirement of social vulnerability. On the basis of this starting point, the State supports the constitutional illegitimacy of the Puglia law because, with respect to those listed by the cited Annex, it would have selected other and distinct pathologies (psychomotor disabilities and behavioral disorders), setting them as a sufficient requirement for access to dental care.

This interpretative assumption, however, is not argued. In light of the formulation of the interposed national legislation, which is characterized by a high level of technicality, the affirmation of the mandatory nature of the list in question would have required adequate illustration.

This legislation is part of the logic that aims at the identification of the LEA and that, as such, is aimed at rigorously limiting healthcare expenditure for those regions, such as Puglia, that are subject to the recovery plan.

However, the same Annex 4C, where it declines the so-called "descending” criterion of health vulnerability, confers general relevance to "diseases and [...] conditions in which health conditions could be aggravated or prejudiced by concomitant dental pathologies." So that the subsequent list of previous pathologies, also in light of the repeated use of the adverb "at least" that characterizes it, has appeared to the respondent Region to acquire a more open connotation, and this in function of the objective of treating, or not aggravating, the previous state. More specifically, the Puglia Region has emphasized that "fragile patients with psychomotor disabilities or behavioral disorders" would fall within the category of subjects "suffering from serious pathologies, whose health conditions can be seriously prejudiced by a concomitant dental pathology," a category to which the cited Annex 4C guarantees access to dental services.

In this context, the claimant has limited himself to assert, in an assertive way, the mandatory nature of the catalog of pre-existing pathological states referred to in Annex 4C, without adequately illustrating the reasons why the regional legislator, in implementing the LEA with regard to access to dental care, should not have given relevance to the previous pathological states taken into consideration.

4.1.3. – According to the constant orientation of this Court, "it is not enough to indicate the rules to be compared in order to assess the compatibility of one with respect to the prescriptive content of the other, but it is necessary to motivate the negative judgment in this sense and, if necessary, illustrate the interpretative steps taken in order to derive the respective contents of regulation" (ex plurimis, judgments No. 115 of 2020 and No. 212 of 2018). In particular, as regards the proceedings in the main action, in which the need for adequate motivation underlying the request for a declaration of constitutional illegitimacy is even more stringent than in incidental proceedings (among many, judgments No. 68 of 2024, No. 125 of 2023, No. 135, and No. 71 of 2022), this Court constantly affirms that "the claimant has the burden not only of identifying the challenged provisions and the constitutional parameters of which it denounces the violation, but also of supporting the reasons for the alleged conflict by developing an argument that is not merely assertive, sufficiently clear, and complete" (judgment No. 112 of 2023). A burden that, as