JUDGMENT NO. 161

YEAR 2025

ITALIAN REPUBLIC

IN THE NAME OF THE ITALIAN PEOPLE

THE CONSTITUTIONAL COURT

composed of:

President: Giovanni AMOROSO;

Judges: Francesco VIGANÒ, Luca ANTONINI, Stefano PETITTI, Angelo BUSCEMA, Emanuela NAVARRETTA, Maria Rosaria SAN GIORGIO, Marco D’ALBERTI, Giovanni PITRUZZELLA, Antonella SCIARRONE ALIBRANDI, Massimo LUCIANI, Maria Alessandra SANDULLI, Roberto Nicola CASSINELLI, Francesco Saverio MARINI,

has rendered the following

JUDGMENT

in the constitutional legitimacy review proceeding concerning the Law of the Puglia Region of December 10, 2024, no. 41, concerning "Provisions regarding psychological support in the oncological field (psycho-oncologist)”, initiated by the President of the Council of Ministers with an appeal notified on February 7, 2025, filed with the Registry on the same date, registered under no. 9 of the appeals registry for 2025, and published in the Official Gazette of the Republic no. 10, first special series, of 2025.

Heard in the public hearing of September 24, 2025, the Rapporteur Judge Francesco Saverio Marini;

heard the State Attorney Giammarco Rocchitta for the President of the Council of Ministers;

deliberated in the council chamber of September 24, 2025.
Facts Considered

1.– With an appeal notified and filed on February 7, 2025, registered under no. 9 of the appeals registry for 2025, the President of the Council of Ministers, represented and defended by the State Attorney General's Office, challenged the entirety of the Law of the Puglia Region of December 10, 2024, no. 41, concerning "Provisions regarding psychological support in the oncological field (psycho-oncologist)”, with reference to Article 117, third paragraph, of the Constitution, insofar as it reserves to the State the determination of fundamental principles in the concurrent legislative matter of "professions”, as well as those concerning the matter of "coordination of public finance”, "taking into account the budget constraints to which public entities are subject, pursuant to Articles 81 and 97, paragraph 1, of the Constitution”.

2.– The challenged regional law introduces, on an experimental basis for a duration of two years, the "psycho-oncology” service, intended for the psychological assistance of oncological patients, their families, and the multidisciplinary medical teams working in the oncology wards of the hospital agencies of the Puglia Region (Article 1).

Regional Law no. 41 of 2024 further establishes that this form of psychological assistance may be entrusted not only to personnel already in service, but also to external professional figures, to be hired on a fixed-term contract (not exceeding two years), drawing from the current lists for permanent public competitions or through specific competitions based on qualifications and examinations (Article 2, paragraph 1).

The challenged regional law also provides that said assistance activity may be performed exclusively by psychologists or by medical practitioners who have followed a specialization course in psychotherapy of at least four years at a university specialization school or at institutes recognized for this purpose by Law of February 18, 1989, no. 56 (Regulation of the profession of psychologist) (Article 2, paragraph 2).

Finally, regarding finance, Regional Law no. 41 of 2024 stipulates that the coverage of the expenses, quantified at Euro 1,500,000.00 for the year 2024, shall be met within the global fund for the financing of regional laws currently being adopted; while for subsequent financial years, coverage shall be provided within the limits of the appropriations established by annual and multi-year budget laws (Article 3).

3.– In the opinion of the appellant, the establishment of the "psycho-oncologist” by the Puglia Region has introduced a new professional figure not provided for by national legislation, in violation of Article 117, third paragraph, of the Constitution, where it reserves to the State the determination of fundamental principles in the concurrent matter of "professions”.

Indeed, according to the State defense, the professional figure of the "psycho-oncologist” lacks any legal basis within the scope of national legislation. As proof of this, the appellant states that the bill A.C. no. 481 of October 26, 2022 - XIX Legislature, specifically concerning "Provisions for the establishment, strengthening, and integration of psycho-oncology services within the assistance and care pathway for oncological and onco-hematological patients”, is still pending in Parliament. Similarly, it is noted that a specific specialization school in "psycho-oncology” has not even been established at the national level.

Furthermore, according to the appellant, the Puglian legislator – precisely due to the absence of such a specific specialization pathway – has provided for the recruitment, as "psycho-oncologists”, of psychologists or, alternatively, medical practitioners who have followed a specialization course in psychotherapy of at least four years.

This provision is in conflict with Article 117, third paragraph, of the Constitution, due to the violation of Article 52 of Presidential Decree of December 10, 1997, no. 483 (Regulation concerning competitive examination procedures for managerial personnel of the National Health Service), assumed as an interposed norm, which governs professional profiles within the National Health Service. In the appellant's view, the aforementioned Article 52, for the first-level managerial functional position of the psychologist professional profile, limits recruitment to those possessing a specialization title, contemplated by the Decree of the Minister of Education, University and Research of January 21, 2019, no. 50 (Reorganization of the educational regulations of the psychological area specialization schools), which does not include the title instead mentioned in the challenged Article 2, paragraph 2, of Regional Law no. 41 of 2024.

The Puglian regional provision, therefore, by introducing a new professional figure and providing for recruitment within the entities of the National Health Service also of psychologists or medical practitioners lacking the specialization requirements set by the State for recruitment in such entities, would be in evident contrast with Article 117, third paragraph, of the Constitution, through the aforementioned interposed norm, read in conjunction with the cited Ministerial Decree no. 50 of 2019. The principle enunciated by this Court, according to which "the identification of professional figures, with the relative profiles and qualifying titles, is reserved, by its necessarily unitary nature, to the State” (citing, among others, Judgments no. 172 of 2018 and no. 98 of 2013), would also be violated.

Moreover – still according to the State defense – the reference in the challenged regional law (Article 1, paragraph 3) to the document approved at the State-Regions Conference, concerning the "Agreement between the Government, the Regions and the Autonomous Provinces of Trento and Bolzano on the document regarding ‘Revision of the Organizational Guidelines and Recommendations for the Oncology Network integrating acute and post-acute hospital activities with territorial activities’” of April 17, 2019, would be irrelevant, since the latter did not establish the professional figure of the "psycho-oncologist” at the state level, but merely provided organizational "guidelines” for the functioning of oncology networks, adding the commitment of the Puglia Region to implement specific actions to ensure the reduction of overall healthcare expenditure, including that related to personnel costs.

4.– Under a further aspect, Regional Law no. 41 of 2024, by "withdrawing substantial financial resources from the Recovery Plan for the deficit in the healthcare sector,” violates Article 117, third paragraph, of the Constitution, also in the part where it reserves to the State the determination of fundamental principles in the matter of coordination of public finance, taking into account the budget constraints to which public entities are subject pursuant to Articles 81 and 97, first paragraph, of the Constitution.

The violation of these constitutional parameters stems from the fact that the Puglia Region is engaged in the Healthcare Deficit Recovery Plan, stipulated on November 29, 2010 (Agreement between the Minister of Health, the Minister of Economy and Finance, and the Puglia Region for the approval of the Restructuring and Reorganization Recovery Plan and the identification of interventions for achieving economic balance pursuant to Article 1, paragraph 180 of Law of December 30, 2004, no. 311).

In this context, the psychological support service in the oncological field, introduced by the challenged regional law, would constitute an additional level of assistance that is not included among the so-called "mandatory expenditures” permitted to regions engaged in deficit recovery. These regions – the appeal recalls – are subject to the prohibition of incurring non-mandatory expenditures, pursuant to Article 1, paragraph 174, of Law of December 30, 2004, no. 311, concerning "Provisions for the formation of the annual and multi-year State budget (Financial Law 2005),” and must limit themselves to guaranteeing the essential levels of performance (Livelli Essenziali di Assistenza - LEA).

In the State’s view, the healthcare services introduced by the Puglia Region with the challenged law must be considered "extra LEA” also due to the experimental nature that Regional Law no. 41 of 2024 attributes to them (in particular, Article 1). This is because services included in the Essential Levels of Assistance (LEA) cannot constitute an experiment, as they are already identified by the Prime Ministerial Decree of January 12, 2017, concerning "Definition and updating of the Essential Levels of Assistance, pursuant to Article 1, paragraph 7, of Legislative Decree of December 30, 1992, no. 502” (so-called D.P.C.M. LEA), pursuant to Article 1, paragraph 174, of the aforementioned Law no. 311 of 2004, and are, therefore, provided in a structured manner within the National Health Service.

Consequently, they cannot be introduced by Puglia, given that, as recalled, the only authorized expenditures for a region engaged in recovery from deficit are those mandatory deriving from the satisfaction of the LEA, within the economic-financial framework outlined by the plan (citing this Court's Judgment no. 172 of 2018).

In this context – still according to the State defense – through the Regional Healthcare System Recovery and Requalification Plan, approved by the aforementioned agreement of 2010, as well as subsequent operational programs, the Puglia Region has undertaken to implement specific actions to ensure the reduction of overall healthcare expenditure, including that related to personnel costs. Therefore, the challenged regional law – to the extent that it compromises the achievement of this objective – is also in contrast with what is provided for by Article 2, paragraphs 80 and 95, of Law of December 23, 2009, no. 191, concerning "Provisions for the formation of the annual and multi-year State budget (Financial Law 2010),” according to which "[t]he interventions identified by the plan [of recovery] are binding for the region, which is obliged to remove measures, including legislative ones, and not to adopt new ones that hinder the full implementation of the plan” (Article 2, paragraph 95, cited).

In support of the challenge, the appellant invokes the consolidated orientation of this Court according to which there is a "fundamental principle aimed at containing public healthcare expenditure [and] an expression of a related principle of coordination of public finance,” with the consequent preclusion for regions that have signed recovery plans to provide in their budgets for healthcare expenditures additional to those related to the LEA (citing Judgments no. 91 of 2012, no. 163 and no. 123 of 2011).

5.– The Puglia Region did not appear in the proceedings.

In Law Considered

1.– With the appeal indicated in the heading (reg. ric. 9 of 2025), the President of the Council of Ministers, represented and defended by the State Attorney General's Office, challenged the entirety of Regional Law no. 41 of 2024, with reference to Article 117, third paragraph, of the Constitution, insofar as it reserves to the State the determination of fundamental principles both in the concurrent legislative matter of "professions” and in that of the "coordination of public finance”, "taking into account the budget constraints to which public entities are subject, pursuant to Articles 81 and 97, paragraph 1, of the Constitution”.

The challenged regional law institutes a experimental regional service of psychological assistance for oncological patients and their families, assigning them to psychologists or medical practitioners specialized in psychotherapy, and granting them the title of psycho-oncologists.

2.– The appellant believes, firstly, that, by so providing, the regional legislator has identified a professional figure extraneous to state legislation, encroaching upon the sphere of concurrent legislative competence in the matter of "professions” (Article 117, third paragraph, Constitution).

In particular, Article 52 of Presidential Decree no. 483 of 1997, which establishes the admission requirements for the competition for psychologists competing for the first-level managerial functional position within the National Health Service, is deemed to be violated.

2.1.– The issue raised with reference to Article 117, third paragraph, of the Constitution, in relation to the matter of "professions”, is unfounded.

It is true that this Court has consistently affirmed that the identification of professional figures with their respective profiles and qualifying titles is reserved to the State, while the adoption of detailed regulations concerning any organizational profiles of professions that have a connection with the regional reality is attributed to the Regions (Judgments no. 127 of 2023, no. 98 of 2013, no. 138 of 2009, no. 93 of 2008, no. 40 of 2006, and no. 424 of 2005).

However, the challenged regional law in no way has the effect of giving rise to a novel professional figure, distinct from those operating under state legislation.

This Court has already held that it is for the Regions, in the exercise of their sphere of competence in the concurrent legislative matter of "protection of health”, to establish psychological assistance services, the exercise of which is reserved to professionals qualified therefor by state legislation (Judgment no. 241 of 2021); such is precisely the purpose and subject matter of the challenged regulation, to be attributed to the same competence.

Article 1 challenged provides, in particular, that the purpose of Regional Law no. 41 of 2024 is to support, for a duration of two years, subjects undergoing experimental treatments for oncological diseases through the introduction of a psychological assistance service for patients, families, the oncology team, and operators of oncology departments, in consistency with the objectives contained in the document approved at the State-Regions Conference on April 17, 2019.

The challenged regional law, therefore, in the part where it identifies the tasks assigned to the psycho-oncologist and the purposes for which the psychological assistance service for oncological patients is activated in the Puglia Region, does not define a new profession in any way, but merely introduces an experimental service of psychological assistance to oncological patients. This is supported not only by the fact (not decisive, but of evidentiary value) that the regional legislator has not established any new professional register, but above all by the consideration that the psychotherapeutic assistance service may be carried out precisely and only by those whom state law authorizes to practice psychotherapy. Indeed, the regional law (Article 2, paragraph 2), providing that the activity is carried out by psychologists or medical practitioners who have obtained a specialization title in psychotherapy following a course of at least four years at a university specialization school or recognized institutes, expressly refers to Law no. 56 of 1989 and fully respects the conditions set by it for the exercise of psychotherapeutic activity under Article 3 of the same law. Nor does the regional provision refer, contrary to what the appellant claims, to a novel specialization school in "psycho-oncology”.

Article 3 of Law no. 56 of 1989, in fact, contains the fundamental principle to which the challenged regional law has adhered in identifying the professionals to be placed in charge of the psycho-oncology service. Article 52 of Presidential Decree no. 483 of 1997, erroneously cited as an interposed norm by the appellant, which merely establishes the requirements for admission to competitions within the National Health Service, is entirely irrelevant.

Moreover, the psycho-oncology service is already provided for by the aforementioned State-Regions Agreement of April 17, 2019, without this requiring legislative intervention to entrust it to a new professional figure.

With this agreement, the State, the Regions, and the Autonomous Provinces of Trento and Bolzano, implementing the principle of loyal cooperation provided for by Legislative Decree of August 28, 1997, no. 281 (Definition and expansion of the powers of the Permanent Conference for relations between the State, the Regions, and the Autonomous Provinces of Trento and Bolzano and unification, for matters and tasks of common interest for the Regions, Provinces, and Municipalities, with the State-City and Local Autonomies Conference), agreed to approve a document revising the organizational guidelines for the oncology network that integrates the LEA.

This document expressly provides, in its Annex, point 7.4., for psycho-oncological support, holding that psychosocial care in oncology is an integral part of a broader care strategy, starting from diagnosis and throughout the entire course of the illness, including active treatments, remission, survival, recurrence or relapse, and the advanced and end-of-life stage.

The new 2023-2027 Oncology Plan (National Oncology Plan: Planning and Guidance Document for the Prevention and Control of Cancer 2023-2027), adopted on January 26, 2023, with agreement in the same Conference, also expressly refers to the figure of the psycho-oncologist, as a psychotherapist to be included in the multidisciplinary teams for the care of oncological patients. These acts are an expression of a renewed personalistic approach of medical science and, more generally, of the protection of health, and aim to bring the purposes of Article 32 of the Constitution not only to the cure of the disease, but to the patient, pursuing the realization of their general well-being, which requires taking into account psychological aspects and the social and relational context in which the person is situated.

3.– The questions of constitutional legitimacy of the challenged regional law raised with regard to Article 117, third paragraph, of the Constitution, for violation of the fundamental principles of coordination of public finance, to which the appellant aligns the budget constraints to which public entities are subject pursuant to Articles 81 and 97, first paragraph, of the Constitution, are, however, inadmissible with regard to all the parameters invoked.

3.1.– The challenge concerning the violation of Article 97, first paragraph, of the Constitution, is inadmissible because the Council of Ministers' resolution contains no trace of the aforementioned constitutional parameter and, as is known, in principal review proceedings there must be a "full and necessary correspondence between the resolution by which the authorized body determines to appeal and the content of the appeal, given the political nature of the act of appeal” (among others, Judgment no. 126 of 2024).

3.2.– The other complaints are, however, inadmissible due to insufficient clarity in the reasoning.

According to the appellant, the regional law, by involving new expenses for medical personnel to be assigned to the psycho-oncology service, would conflict with the fundamental principle of coordination of public finance that precludes regions from adopting measures conflicting with the content of the healthcare deficit recovery plan. As a result, Article 1, paragraph 174, of Law no. 311 of 2004, which prohibited regions engaged in reducing healthcare deficit from incurring extra-LEA expenses, considered "non-mandatory expenditures,” and Article 2, paragraphs 80 and 95, of Law no. 191 of 2009, which obliges regions in deficit recovery plans to remove measures, including legislative ones, and not to adopt new ones that hinder the full implementation of the plan, would also be violated.

This Court observes, firstly, that the questions thus raised are relevant in the abstract only with regard to the provisions of the challenged regional law that allow for the hiring of new personnel, whereas they are not referable to the challenged provisions that establish the psycho-oncology service, to which the health administration could well assign personnel already in service, without an increase in expenditure.

As for the recourse to new hiring, as seen, the pivot of all the complaints revolves around the conflict of the challenged norms with the Deficit Recovery Plan stipulated between the State and the Puglia Region in 2010.

This Court has consistently held that regional measures, including legislative ones, in conflict with the obligations to reduce the healthcare deficit to which the region is subject, are constitutionally illegitimate (among others, Judgments no. 57 of 2025, no. 201, no. 197, no. 169 and no. 1 of 2024, no. 134 of 2023, no. 242 and no. 161 of 2022, no. 142 and no. 36 of 2021, no. 177 and no. 166 of 2020, no. 117 of 2018 and no. 91 of 2012).

To conclude that this principle of coordination of public finance has been breached, the appellant must identify the point of conflict between the regional measure and the measure of the plan allegedly violated, in order to provide a clear reasoning for the complaints sufficient to meet the admissibility threshold.

In the present case, the appellant merely asserts apodictically that the regional provisions would violate the recovery plan and subsequent "operational programs,” but illustrates neither the former nor the latter, thus failing to meet its burden of reasoning, which must be assessed with particular rigor in principal review proceedings (among others, Judgments no. 142, no. 141 and no. 123 of 2024 and no. 20 of 2021).

Nor can the fleeting reference to point B.3 of the Plan (sic: of the Annex to the Plan) contained in the appeal, concerning the block of the so-called turnover following departures from service in the regional health administration, which the appellant does not adequately pursue, omitting to account for both the precise content of the provision and its relationship with the hiring procedures for the purpose of the psycho-oncology service, be considered relevant in this case.

Finally, according to the appellant, the provision contained expressly in Article 1, paragraph 174, of Law no. 311 of 2004, which requires regions under a healthcare deficit recovery plan to incur only mandatory expenditures, thus avoiding extra-LEA expenses, would in any case be violated.

For this aspect too, the reasoning is not adequate to permissibly introduce the issue, because the appellant merely infers the assistance nature of the service from its experimental and temporary nature. The argument is not perspicuous because it does not clarify why the psycho-oncology service would not be an organizational measure and would constitute a level of assistance additional to the essential levels.

As for Article 81 of the Constitution, the challenge is devoid of any illustration or reasoning in support, the appellant merely enunciating it as a mere corollary of the violation of Article 117, third paragraph, of the Constitution, in the matter of coordination of public finance.

for these reasons

THE CONSTITUTIONAL COURT

1) declares inadmissible the questions of constitutional legitimacy of the Law of the Puglia Region of December 10, 2024, no. 41, concerning "Provisions regarding psychological support in the oncological field (psycho-oncologist)”, raised, with reference to Articles 81, 97, first paragraph, and 117, third paragraph, of the Constitution, the latter in relation to the matter of "coordination of public finance”, by the President of the Council of Ministers with the appeal indicated in the heading;

2) declares unfounded the question of constitutional legitimacy of Regional Law no. 41 of 2024, raised, with reference to Article 117, third paragraph, of the Constitution, in relation to the matter of "professions”, by the President of the Council of Ministers with the appeal indicated in the heading.

Decided in Rome, at the seat of the Constitutional Court, Palazzo della Consulta on September 24, 2025.

Signed:

Giovanni AMOROSO, President

Francesco Saverio MARINI, Rapporteur

Igor DI BERNARDINI, Chancellor

Filed in the Registry on October 31, 2025