Avis juridique important

Order of the President of the Court of 11 April 2001. - Commission of the European Communities v Cambridge Healthcare Supplies Ltd. - Appeal - Order of the President of the Court of First Instance in proceedings for interim relief - Withdrawal of marketing authorisations for medicinal products for human use containing "phentermine" - Second Directive 75/319/EEC - Urgency - Balancing of interests. - Case C-471/00 P (R). European Court reports 2001 Page I-02865

Summary Parties Grounds Operative part

1. Appeals - Pleas in law - Plea alleging incorrect appraisal of the facts - Inadmissibility - Review by the Court of Justice of the appraisal of the evidence submitted to the Court of First Instance - Possible only where the clear sense of the evidence has been distorted

(Art. 225 EC; EC Statute of the Court of Justice, Art. 51)

2. Appeals - Admissibility - Assessment in relation to the case at issue

(EC Statute of the Court of Justice, Art. 49)

3. Approximation of laws - Proprietary medicinal products - Marketing authorisation - Evaluation of the products - Assessment of their harmfulness and efficacy - Examination in relation to each other - Ongoing nature of the assessment

(Council Directives 65/65, Art. 5, and 75/318, annex)

4. Approximation of laws - Proprietary medicinal products - Marketing authorisation - Withdrawal of authorisation - Discretion of the Community authorities - Judicial review - Limits

(Council Directives 65/65, Art. 11, and 75/319, Arts 13 and 14)

1. The Court of First Instance has exclusive jurisdiction to find the facts, save where a substantive inaccuracy in its findings is attributable to the documents submitted to it, and to appraise those facts. That appraisal thus does not, save where the clear sense of the evidence has been distorted, constitute a point of law which is subject, as such, to review by the Court of Justice on appeal.

( see para. 48 )

2. The conditions governing the admissibility of appeals laid down by Article 49 of the Statute of the Court of Justice are assessed in relation to the case at issue and that alone. The fact that the grounds of an order of the Court of First Instance which has become definitive are identical to those of an order subject to appeal does not prevent the appellant from contesting such grounds.

( see para. 51 )

3. Under Article 5 of Directive 65/65 relating to proprietary medicinal products, the evaluation of every medicinal product relates to its efficacy, its harmlessness and its quality. Compliance with those three conditions is intended to protect public health. The very concept of the protection of public health means that the medicinal product in question not only must not be harmful but also must be effective. The degree of harmfulness which the competent authority may regard as acceptable thus depends on the benefits which the medicinal product is considered to provide. As stated in the seventh and eighth recitals in the preamble to Directive 75/318 relating to analytical, pharmaco-toxicological and clinical standards and protocols in respect of the testing of medicinal products, the concepts of harmfulness and therapeutic efficacy can only be examined in relation to each other. Accordingly, the reasons which have led a competent authority to preserve a marketing authorisation for a medicinal product notwithstanding certain harmful effects may cease to apply if that authority considers that the benefits justifying such an authorisation, that is to say the existence of a therapeutic effect, are no longer present. As stated in the introduction to the annex to Directive 75/318, as amended by Directive 91/507, after issue of the marketing authorisation any new data or information are to be submitted to the competent authorities in order to monitor the benefit/risk assessment.

( see paras 60, 63 )

4. Any decision withdrawing a marketing authorisation which is adopted in accordance with the procedure laid down in Articles 13 and 14 of Directive 75/319 relating to proprietary medicinal products must comply with the substantive conditions under Article 11 of Directive 65/65, which relate to the efficacy, safety and quality of the medicinal product. This type of decision is thus the outcome of complex assessments in the medico-pharmacological field. In principle, such assessments are subject to limited judicial review. Where a Community authority is called upon, in the performance of its duties, to make complex assessments, it enjoys a wide measure of discretion, the exercise of which is subject to a limited judicial review in the course of which the Community judicature may not substitute its assessment of the facts for the assessment made by the authority concerned. Thus, in such cases, the Community judicature must restrict itself to examining the accuracy of the findings of fact and law made by the authority concerned and to verifying, in particular, that the action taken by that authority is not vitiated by a manifest error or a misuse of powers and that it did not clearly exceed the bounds of its discretion.

( see paras 95-96 )

In Case C-471/00 P(R),

Commission of the European Communities, represented by H. Støvlbæk, M. Shotter and K. Fitch, acting as Agents, with an address for service in Luxembourg,

appellant,

supported by

French Republic, represented by G. de Bergues and R. Loosli-Surrans, acting as Agents,

intervener on appeal,

APPEAL against the order of the President of the Court of First Instance of the European Communities of 31 October 2000 in Case T-137/00 R Cambridge Healthcare Supplies v Commission [2000] ECR II-3653, seeking to have that order set aside,

the other party to the proceedings being:

Cambridge Healthcare Supplies Ltd, whose registered office is in Norfolk (United Kingdom), represented by D. Vaughan QC and K. Bacon, Barrister, instructed by S. Davis, Solicitor, with an address for service in Luxembourg,

applicant at first instance,

THE PRESIDENT OF THE COURT

after hearing Advocate General Stix-Hackl,

makes the following

Order

1 By application lodged at the Registry of the Court of Justice on 27 December 2000, the Commission of the European Communities brought an appeal pursuant to Article 225 EC and the second paragraph of Article 50 of the EC Statute of the Court of Justice against the order made by the President of the Court of First Instance on 31 October 2000 in Case T-137/00 R Cambridge Healthcare Supplies v Commission [2000] ECR II-3653 (the order under appeal), by which the President of the Court of First Instance suspended operation of Commission Decision C(2000) 452 of 9 March 2000 concerning the withdrawal of marketing authorisations of medicinal products for human use which contain the following substance: Phentermine (the contested decision).

2 By document lodged at the Registry of the Court of Justice on 16 February 2001, Cambridge Healthcare Supplies Ltd (CHS), the company which was the applicant at first instance, submitted its written observations to the Court of Justice.

3 By application lodged at the Registry of the Court of Justice on 29 January 2001, the French Republic sought leave to intervene in the present proceedings in support of the Commission.

4 Pursuant to the first and fourth paragraphs of Article 37 of the EC Statute of the Court of Justice and Article 93(1) and (2) of the Rules of Procedure, the application by the French Republic for leave to intervene in the present proceedings should be granted.

5 The French Republic lodged its statement in intervention on 19 February 2001.

6 The parties presented oral argument at the hearing on 7 March 2001.

Legal background

7 On 26 January 1965, the Council adopted Directive 65/65/EEC on the approximation of provisions laid down by law, regulation or administrative action relating to proprietary medicinal products (OJ, English Special Edition 1965-1966, p. 20). That directive has been amended on several occasions, in particular by Council Directive 89/341/EEC of 3 May 1989 (OJ 1989 L 142, p. 11) and Council Directive 93/39/EEC of 14 June 1993 (OJ 1993 L 214, p. 22) (Directive 65/65). Article 3 of Directive 65/65 lays down the principle that no medicinal product may be placed on the market of a Member State unless an authorisation has first been issued by the competent authorities of that Member State in accordance with the directive or an authorisation has been granted in accordance with Council Regulation (EEC) No 2309/93 of 22 July 1993 laying down Community procedures for the authorisation and supervision of medicinal products for human and veterinary use and establishing a European Agency for the Evaluation of Medicinal Products (OJ 1993 L 214, p. 1).

8 Article 4 of Directive 65/65 provides in particular that, in order to obtain a marketing authorisation as provided for in Article 3, the person responsible for placing the product on the market is to apply to the competent authority of the Member State concerned.

9 Article 5 of Directive 65/65 states:

The authorisation provided for in Article 3 shall be refused if, after verification of the particulars and documents listed in Article 4, it proves that the medicinal product is harmful in the normal conditions of use, or that its therapeutic efficacy is lacking or is insufficiently substantiated by the applicant, or that its qualitative and quantitative composition is not as declared.

Authorisation shall likewise be refused if the particulars and documents submitted in support of the application do not comply with Article 4.

10 Article 10 of Directive 65/65 provides that the authorisation is valid for five years and is renewable for five-year periods after consideration by the competent authority of a dossier containing in particular details of the data on pharmacovigilance and other information relevant to the monitoring of the medicinal product.

11 The first paragraph of Article 11 of Directive 65/65 provides:

The competent authorities of the Member States shall suspend or revoke an authorisation to place a medicinal product on the market where that product proves to be harmful in the normal conditions of use, or where its therapeutic efficacy is lacking, or where its qualitative and quantitative composition is not as declared. Therapeutic efficacy is lacking when it is established that therapeutic results cannot be obtained with the [medicinal] product.

12 Under Article 21 of Directive 65/65, an authorisation to market a medicinal product may not be refused, suspended or revoked except on the grounds set out in that directive.

13 Council Directive 75/318/EEC of 20 May 1975 on the approximation of the laws of Member States relating to analytical, pharmaco-toxicological and clinical standards and protocols in respect of the testing of medicinal products (OJ 1975 L 147, p. 1), as amended by Directive 89/341 (Directive 75/318), provides, in the first paragraph of Article 1, that the Member States are to take all appropriate measures to ensure that the particulars and documents which must accompany applications for authorisation to place a medicinal product on the market pursuant to points 3, 4, 6, 7 and 8 of the second paragraph of Article 4 of Directive 65/65 are submitted by the persons concerned in accordance with the annex to Directive 75/318.

14 The seventh and eighth recitals in the preamble to Directive 75/318 are worded as follows:

... the concepts of "harmfulness" and "therapeutic efficacy" referred to in Article 5 of Directive 65/65/EEC can only be examined in relation to each other and have only a relative significance depending on the progress of scientific knowledge and the use for which the medicinal product is intended; ... the particulars and documents which must accompany an application for authorisation to place a medicinal product on the market [must] demonstrate that potential risks are outweighed by the therapeutic efficacy of the product; ... failing such demonstration, the application must be rejected;

... the evaluation of "harmfulness" and "therapeutic efficacy" may be modified in the light of new discoveries and standards and protocols must be amended periodically to take account of scientific progress.

15 The Second Council Directive (75/319/EEC) of 20 May 1975 on the approximation of provisions laid down by law, regulation or administrative action relating to proprietary medicinal products (OJ 1975 L 147, p. 13), as amended by Directive 93/39 (Directive 75/319), provides for a number of arbitration procedures before the Committee for Proprietary Medicinal Products (the CPMP) of the European Agency for the Evaluation of Medicinal Products. Such a procedure is applied where a Member State considers, in the context of the procedure for the mutual recognition of national marketing authorisations which is provided for by Article 9 of Directive 75/319, that there are grounds for supposing that the authorisation of the medicinal product concerned may present a risk to public health (Article 10 of that directive), where divergent decisions have been adopted concerning the grant, suspension or withdrawal of national authorisations (Article 11), in specific cases where the interests of the Community are involved (Article 12), and in the case of variations of harmonised authorisations (Articles 15, 15a and 15b).

16 Article 12 of Directive 75/319 provides that the Member States among others may, in specific cases where the interests of the Community are involved, refer the matter to the CPMP for the application of the procedure laid down in Article 13 before reaching a decision on a request for a marketing authorisation or on the suspension or withdrawal of an authorisation, or on any other variation to its terms which appears necessary, in particular to take account of the information collected in the context of the pharmacovigilance system provided for in Chapter Va of Directive 75/319.

17 Article 15a of Directive 75/319 states:

1. Where a Member State considers that the variation of the terms of a marketing authorisation which has been granted in accordance with the provisions of this Chapter or its suspension or withdrawal is necessary for the protection of public health, the Member State concerned shall forthwith refer the matter to the Committee for the application of the [procedures] laid down in Articles 13 and 14.

2. Without prejudice to the provisions of Article 12, in exceptional cases, where urgent action is essential to protect public health, until a definitive decision is adopted a Member State may suspend the marketing and the use of the medicinal product concerned on its territory. It shall inform the Commission and the other Member States no later than the following working day of the reasons for its action.

18 Article 13 of Directive 75/319 sets out the procedure before the CPMP. Article 14 lays down the procedure to be followed after the Commission receives the opinion of the CPMP. The third subparagraph of Article 14(1) states that where, exceptionally, the [Commission's] draft decision is not in accordance with the opinion of the Agency, the Commission shall also annex a detailed explanation of the reasons for the differences.

Facts and procedure

19 CHS is the holder of a marketing authorisation for a medicinal product containing phentermine. The facts of the case are set out in the order under appeal as follows:

9 On 17 May 1995 the Federal Republic of Germany made a referral to the CPMP in accordance with Article 12 of Directive [75/319] as amended by Directive 93/39, expressing its fears as regards anorectics, which include medicinal products containing phentermine, liable to cause serious pulmonary artery hypertension.

10 The procedure initiated by this referral led to the adoption of Commission Decision C(96) 3608 of 9 December 1996 ["the decision of 9 December 1996"], based on Article 14(1) and (2) of Directive 75/319, recommending the Member States to vary certain clinical information which had to appear in the national authorisations to place the medicinal products in question on the market.

11 By letter of 7 November 1997 addressed to the chairman of the CPMP, the Belgian Minister for Social Affairs, Public Health and Environment expressed inter alia his fears that there was a causal link between cardiac valve disorders and the use of medicinal products containing phentermine. He therefore requested the CPMP, pursuant to Articles 13 and 15a of Directive 75/319, to issue a reasoned opinion on the medicinal products in question.

12 On 22 April 1999 the CPMP gave an opinion on the scientific evaluation of medicinal products containing phentermine and recommended that the authorisations to place them on the market should be withdrawn. The applicant appealed against that opinion. A hearing was held on 28 July 1999. In its final opinion, adopted on 31 August 1999, the CPMP concluded that, although the concerns expressed by the Belgian minister could not altogether be excluded, there was no evidence to substantiate them. However, it concluded that medicinal products containing phentermine had an unfavourable benefit/risk balance, and recommended that the authorisations to place those products on the market should be withdrawn.

13 On the basis of that opinion, the Commission on 9 March 2000 adopted the decision concerning the withdrawal of marketing authorisations of medicinal products for human use which contain the following substance: "Phentermine" ... Article 2 of the contested decision refers to the views expressed by the CPMP in that opinion. Article 3 prescribes that the Member States are to withdraw the marketing authorisations for all the medicinal products mentioned in Annex I to the contested decision within 30 days of its notification.

20 By application lodged at the Registry of the Court of First Instance on 22 May 2000, CHS brought an action before the Court of First Instance under the fourth paragraph of Article 230 EC for annulment of the contested decision.

21 By separate document lodged at the Court Registry on the same day, CHS made an application for suspension of operation of the contested decision, together with an application on the basis of Article 105(2) of the Rules of Procedure of the Court of First Instance for an urgent decision on the claim for interim relief.

22 On 20 July 2000, the President of the Court of First Instance granted the application based on Article 105(2) of the Rules of Procedure and ordered that operation of the contested decision should be suspended until the making of the order terminating the proceedings for interim relief.

23 Apart from the contested decision, the Commission adopted two other decisions on 9 March 2000, concerning the withdrawal of marketing authorisations of medicinal products for human use which contain the substance amfepramone (C(2000) 453) and the substances clobenzorex, fenbutrazate, fenproporex, mazindol, mefenorex, norpseudoephedrine, phenmetrazine, phendimetrazine and propylhexedrine (C(2000) 608). All those decisions concern medicinal products for the treatment of obesity, which had already been referred to in the decision of 9 December 1996, and they were prompted by a re-evaluation of those medicinal products under Article 15a of Directive 75/319 which had been requested by two Member States. The evaluation procedure resulted in a number of opinions of the CPMP, adopted by its members almost unanimously, recommending withdrawal of the marketing authorisations for all the medicinal products for very similar reasons. The Commission decisions of 9 March 2000 are founded on those opinions.

24 Nine applications for interim relief were made in respect of the three decisions referred to in the preceding paragraph. By order of 28 June 2000 in Case T-74/00 R Artegodan v Commission [2000] ECR II-2583, the President of the Court of First Instance decided one of those applications and ordered suspension of the operation of Decision C(2000) 453 in relation to Artegodan GmbH. No appeal was brought against that order. The President of the Court of First Instance decided the other eight applications for interim relief by order of 19 October 2000 in Case T-141/00 R Trenker v Commission [2000] ECR II-3313, and by seven orders of 31 October 2000: in Case T-76/00 R Bruno Farmaceutici and Others v Commission [2000] ECR II-3557, Case T-83/00 R II Schuck v Commission [2000] ECR II-3585, Case T-83/00 R I Hänseler v Commission [2000] ECR II-3565, Case T-84/00 R Roussel and Roussel Diamant v Commission [2000] ECR II-3591, Case T-85/00 R Roussel and Roussel Iberica v Commission [2000] ECR II-3613, Case T-132/00 R Gerot Pharmazeutika v Commission [2000] ECR II-3625, and the order under appeal. Those eight orders, against which the Commission has brought appeals, and the order in Artegodan v Commission, are founded on almost identical grounds.

The order under appeal

25 By the order under appeal, the President of the Court of First Instance granted CHS's application for interim relief and ordered suspension of the operation of the contested decision in respect of that company.

26 The President of the Court of First Instance held that the condition relating to the establishment of a prima facie case was satisfied in the case in point. In this connection, he set out the following factors at paragraph 34 of the order under appeal:

34 As regards the question of a prima facie case, the pleas raised by the applicant do not prima facie appear to be entirely unfounded. First, it appears that the competence of the Commission to adopt the contested decision depends on the nature of the decision of 9 December 1996, which is open to debate. Second, the Commission has not adduced convincing evidence to explain why that decision and the contested decision reached diametrically opposed results. The pleas raised by the applicant therefore deserve detailed consideration, a consideration which, however, in fact and in law, goes beyond the scope of the present interim proceedings.

27 As regards the question of urgency, the President of the Court of First Instance concluded that any damage occasioned by the immediate operation of the contested decision would be serious and irreparable. In reaching that conclusion, he relied on the following considerations:

43 In the present case, immediate operation of the contested decision means the complete withdrawal from the market of the medicinal products referred to in Article 1 of the decision. It therefore means that, if operation of the contested decision is not suspended, substitute medicinal products, the existence of which is acknowledged by both parties, will very probably take the place of the products withdrawn. Even if the statements that the product withdrawn presents a danger to patients' health are subsequently disproved, it is often impossible to restore confidence in the product, other than in special cases where the qualities of the medicinal product are especially valued by users and there is no perfect substitute product, or where the manufacturer enjoys an exceptionally good reputation, so that it cannot be said that he will be unable to repossess the market shares he held before withdrawal. However, there are no such special cases here.

44 Moreover, if the contested decision were to be annulled by the Court of First Instance and the applicant thus authorised to resume marketing its medicinal product, the financial damage it suffered because of a fall in sales as a result of loss of confidence in its product could not in practice be quantified sufficiently completely for the purposes of making reparation.

28 The President of the Court of First Instance found that in the case in point the balance of interests favoured suspension of the operation of the contested decision, on the basis of the following considerations:

49 Thus it appears highly probable that the operation of the contested decision would entail the definitive loss of the applicant's position in the market, even if the court hearing the main application were to annul the decision.

50 In opposition to the commercial interests of the applicant, the Commission submits that suspension of operation of the contested decision could harm public health. On this point, it must be emphasised that in principle the requirements of the protection of public health must unquestionably be given precedence over economic considerations (order [of the Court of Justice] in [Case C-180/96 R] United Kingdom v Commission [[1996] ECR I-3903], paragraph 93; judgment in Case C-183/95 Affish v Rijksdienst Keuring Vee en Vlees [1997] ECR I-4315, paragraph 43; order of the Court of First Instance in Case T-136/95 Industria del Frio Auxiliar Conservera v Commission [1998] ECR II-3301, paragraph 58; and order of the President of the Court of First Instance in Case T-70/99 R Alpharma v Commission [1999] ECR II-2027, paragraph 152).

51 However, it must be noted that in this context the mere reference to the protection of public health cannot exclude an examination of the circumstances of the case, in particular of the relevant facts.

52 In the present case, the Commission has indeed established that there is uncertainty as regards the risks associated with medicinal products containing phentermine, even if those risks are slight. Nevertheless, although the decision of 9 December 1996 and the contested decision are based on identical data, the measures taken by the Commission in 1996 and 2000 for the protection of public health with respect to those risks differ fundamentally. In those circumstances, the Commission was obliged to show that the precautionary measures in the decision of 9 December 1996 proved to be insufficient to protect public health, so that the protective measures it adopted in the contested decision were not manifestly excessive. The Commission has not been able to show this, however.

53 Moreover, the fact that the health risks which determined the adoption of the contested decision had already been taken into account in the Commission's decision of 9 December 1996 and had resulted in a change to the compulsory information concerning medicinal products supplied on prescription indicates that implementation of the contested decision is not urgent.

The appeal

Arguments of the parties

29 The Commission founds its appeal on seven pleas in law.

30 By its first plea, the Commission, supported by the French Government, complains that the President of the Court of First Instance failed to apply properly, or at all, the precautionary principle in his balancing of the interests. This principle means that the Commission may take protective measures without having to wait until the reality and seriousness of those risks become fully apparent (Case C-157/96 National Farmers' Union and Others [1998] ECR I-2211, paragraph 63).

31 The basis of the second plea is that the President of the Court of First Instance misunderstood the nature of the contested decision and the process leading to its adoption.

32 The Commission submits that, when it adopts measures to protect public health with regard to medicinal products, the scientific process of assessing risk is not undertaken by it but by scientific experts, namely the members of the CPMP. It is on the basis of that assessment that the Commission then takes its policy decision (risk management decision), weighing the result of the risk assessment with other factors to be taken into account. The lack of reference to the scientific opinion of the CPMP in the order under appeal reveals a fundamental misunderstanding of the procedure leading to the adoption of the contested decision.

33 According to the Commission, the reason why, on 9 March 2000, it adopted a decision which differed from that of 9 December 1996 is directly connected with the final opinion of the CPMP dated 31 August 1999. The Commission points out that the statement of reasons for the contested decision referred to the fact that, in the CPMP's view, medicinal products containing phentermine lacked therapeutic efficacy in the treatment of obesity when assessed on the basis of accumulated scientific knowledge acquired over the years and current medical recommendations.

34 Between the adoption of the decision of 9 December 1996 and that of the contested decision, the guidelines concerning the therapeutic efficacy of medicinal products for the treatment of obesity and the medical guidelines on the treatment of obesity had changed, causing the CPMP to alter its scientific assessment. Those guidelines represent a fundamental change in the scientific community's assessment of how to treat obesity. By failing to take account of that fundamental factor and focusing exclusively on the identicalness of the data upon which both the abovementioned decisions are based, the President of the Court of First Instance made a material error in assessing the balance of interests. Nor is it clear from the order under appeal that the President of the Court of First Instance took account of the fact that the contested decision introduced a higher level of health protection than that resulting from the decision of 9 December 1996.

35 The French Government essentially agrees with that line of argument, submitting that the President of the Court of First Instance distorted the content of the contested decision within the meaning of the judgment in Case C-164/98 P DIR International Film and Others v Commission [2000] ECR I-447, at paragraphs 48 and 49. Such a distortion is the result of a partial reading of the decision. The President of the Court of First Instance did not take Annex II to the decision into consideration in that he failed to note that the CPMP examined additional scientific data subsequent to 1996 and omitted the fact that, according to the CPMP, the medicinal products containing phentermine did not have the required efficacy.

36 In its third plea, the Commission complains that the order under appeal exceeds the proper boundaries of judicial review. It submits that the President of the Court of First Instance erred in law by substituting his assessment as to the appropriate level of public health protection for that of the body competent to exercise its discretion in that field, namely the Commission. The French Government essentially endorses this plea, pointing out that the Court has previously held, in Case C-120/97 Upjohn [1999] ECR I-223, at paragraphs 33 and 34, that complex assessments in the medico-pharmacological field can be subject only to limited judicial review.

37 The fourth plea alleges breach of the requirement to balance the interests involved. The President of the Court of First Instance erred in law by failing to balance properly the interests concerned, in that he examined and took into account only the economic damage to the undertaking seeking suspension of the operation of the contested decision, without taking proper account of the seriousness and the irreparable nature of harm to patients treated with the medicinal product in question. The President of the Court of First Instance did not accord to the protection of public health the precedence that is required by the Court of Justice's case-law, when the risks to human health had been established by the scientific experts on the CPMP.

38 The fifth plea concerns an error of law with regard to the standard of proof required of the Commission. The President of the Court of First Instance proceeded on the assumption that the Commission, assisted by the CPMP, is, on its own, in a position to demonstrate that a medicinal product lacks therapeutic efficacy or is harmful in the normal conditions of use. The Commission points out that the provision of data on the safety and therapeutic efficacy of a medicinal product is largely dependent on the holder of the marketing authorisation and that it is neither the Commission's nor the CPMP's role to conduct clinical trials. The approach of the President of the Court of First Instance with regard to the standard of proof would prevent the Commission from revising its marketing authorisation decisions unless relevant new data had arisen.

39 The sixth plea alleges material errors in relation to the finding, made in point 52 of the order under appeal, that, while there is uncertainty as regards the risks associated with medicinal products containing phentermine, such health risks are slight. The documents submitted to the Court of First Instance clearly show that the risks associated with those medicinal products, in particular the increased risk of primary pulmonary hypertension and cardiac valve disorders, are not slight. The President of the Court of First Instance replaced the CPMP's assessment with his own.

40 The seventh plea alleges a lack of reasoning in the order under appeal with regard to the assessment by the President of the Court of First Instance that the risks associated with medicinal products containing phentermine are slight. In the Commission's submission, no explanation is given, either in paragraph 52 or elsewhere in the order under appeal, making it possible to understand the reasons for such an assessment.

41 CHS points out with regard to the precautionary principle that it forms only part of the analysis which the Court must carry out under the test of proportionality. The principle of proportionality cannot be regarded as complied with in every case merely because it is asserted that there is uncertainty with regard to the risks to human health. Nor can the mere reference to the protection of public health exclude examination of the circumstances of the case.

42 With regard to the second plea put forward by the Commission, CHS contends that, if the order under appeal is read as a whole, taking account of every part of it and, in particular, paragraphs 9 to 13 and 33 and 34, it is clear that all the aspects of the contested decision were understood and taken into consideration by the President of the Court of First Instance. CHS also submits that the alleged fundamental change in the medical community's scientific assessment of how to treat obesity - a change which CHS in any event disputes - is not as important as the Commission claims, given that the Commission did not mention it in its written observations on the application to the Court of First Instance for interim relief. The President of the Court of First Instance recognised, in paragraph 52 of the order under appeal, that there was a higher level of protection of public health, but found it excessive.

43 So far as concerns the third and sixth pleas, CHS contends that, in considering that the risks associated with medicinal products containing phentermine were slight, the President of the Court of First Instance merely described the findings of the Commission in the contested decision.

44 In rebutting the fourth plea, relating to an error of law in the balancing of interests, CHS contends that the Commission does not identify an error of law, but merely indicates its disagreement with the result reached by the President of the Court of First Instance. It is evident from paragraphs 50 to 53 of the order under appeal that he took account of the risks said by the CPMP to be associated with medicinal products containing phentermine. Nor does the opinion of the CPMP refer to the existence of serious and irreparable harm of the kind alleged by the Commission in its appeal.

45 As to the fifth plea, concerning the standard of proof, CHS considers that the Commission confuses the question of proof with that of provision of data. It is true that it is not the role of either the Commission or the CPMP to conduct clinical trials. It is for that reason that the CPMP may request information from the marketing authorisation holder, third parties and experts. This does not affect the question of the standard of proof required of the Commission when it adopts a particular decision. Moreover, paragraph 52 of the order under appeal does not require any particular standard of proof regarding the safety and efficacy of phentermine, but merely addresses the question whether the contested decision was manifestly excessive.

46 As to the Commission's seventh plea, alleging a lack of reasoning in the order under appeal, CHS contends that the characterisation of the risks associated with medicinal products containing phentermine as slight is an accurate portrayal of the facts upon which the Commission relied when adopting the contested decision. The President of the Court of First Instance also explained, in paragraph 53 of the order under appeal, the reasons which led him to conclude that implementation of the contested decision was not urgent.

Findings

47 In accordance with Article 225 EC and Article 51 of the EC Statute of the Court of Justice, appeals are limited to points of law and lie solely on the grounds of lack of competence of the Court of First Instance, a breach of procedure before it which adversely affects the interests of the appellant or the infringement of Community law by the Court of First Instance.

48 The Court of First Instance has exclusive jurisdiction to find the facts, save where a substantive inaccuracy in its findings is attributable to the documents submitted to it, and to appraise those facts. That appraisal thus does not, save where the clear sense of the evidence has been distorted, constitute a point of law which is subject, as such, to review by the Court of Justice on appeal (see, in particular, Case C-390/95 P Antillean Rice Mills and Others v Commission [1999] ECR I-769, paragraph 29).

49 It is in the light of those considerations that the appellant's pleas should be considered.

50 First of all, since there is a question of an absolute bar, the Court must consider of its own motion whether the appeal is inadmissible in so far as it disregards the binding authority of the order in Artegodan v Commission, cited above, such a plea having been raised in Case C-459/00 P(R) Commission v Trenker, decided by an order made today.

51 It need only be observed that the conditions governing the admissibility of appeals laid down by Article 49 of the EC Statute of the Court of Justice are assessed in relation to the case at issue and that alone. The fact that the grounds of an order of the Court of First Instance which has become definitive are identical to those of an order subject to appeal does not prevent the appellant from contesting such grounds (see, with regard to a judgment of the Court of First Instance upholding an objection of illegality raised against a legislative measure, the judgment of 5 October 2000 in Joined Cases C-432/98 P and C-433/98 P Council v Chvatal and Others [2000] ECR I-8535, paragraph 22).

52 Accordingly, the appeal is admissible.

53 The plea concerning distortion of the content of the contested decision should be considered first.

54 In this connection, it is clear from the grounds of the order under appeal relating to both the establishment of a prima facie case and the balancing of interests that the following considerations were decisive in the reasoning of the President of the Court of First Instance:

- ... the Commission has not adduced convincing evidence to explain why [the decision of 9 December 1996] and the contested decision reached diametrically opposed results (paragraph 34);

- ... although the decision of 9 December 1996 and the contested decision are based on identical data, the measures taken by the Commission in 1996 and 2000 for the protection of public health with respect to those risks differ fundamentally. In those circumstances, the Commission was obliged to show that the precautionary measures in the decision of 9 December 1996 proved to be insufficient to protect public health, so that the protective measures it adopted in the contested decision were not manifestly excessive (paragraph 52);

- ... the health risks which determined the adoption of the contested decision had already been taken into account in the Commission's decision of 9 December 1996 and had resulted in a change to the compulsory information concerning medicinal products supplied on prescription (paragraph 53).

55 Those findings are not based on even a cursory analysis of the statement of reasons for the contested decision as set out in Annex II to the decision, to which Article 2 refers.

56 Annex II to the contested decision, which sets out the scientific conclusions of the CPMP in order to indicate the reasons which led to the withdrawal of the marketing authorisations for the medicinal products listed in Annex I to that decision, contains first of all an analysis of the efficacy of those products. It is concluded in Annex II that phentermine-containing medicinal products lack therapeutic efficacy in the treatment of obesity when assessed on the basis of accumulated scientific knowledge acquired over the years and current medical recommendations.

57 In reaching such a conclusion, Annex II states that rapid weight regain occurs once treatment is discontinued and there are no controlled studies which demonstrate that a limited short term effect has any long term clinically relevant influence on body weight or provides a clinical benefit within an anti-obesity program. It is also observed that the risk of drug abuse and drug dependence precludes that phentermine should be used for long-term treatment and that the claims that it may facilitate or improve longer-term strategies when used as an adjunct have not been substantiated with adequate evidence.

58 According to Annex II, therapeutic efficacy in treating obesity requires a significant and long-term lowering of body weight, over at least one year. It states: This is based on accumulated scientific knowledge acquired over the years and is laid down in current medical recommendations; this is reflected in the Note for Guidance on Clinical Investigation of Drugs Used in Weight Control (CPMP/EWP/281/96). This is also expressed in current guidelines, e.g. the Scottish guideline (1996), a guideline from the Royal College of Physicians (1998) and in a guideline from the American Society for Clinical Nutrition (1998).

59 The importance of those reasons given the subject-matter of the contested decision and in the light of the applicable law concerning the evaluation of medicinal products should be noted.

60 Under Article 5 of Directive 65/65, the evaluation of every medicinal product relates to its efficacy, its harmlessness and its quality. Compliance with those three conditions is intended to protect public health. The very concept of the protection of public health means that the medicinal product in question not only must not be harmful but also must be effective. As the footnotes to Article 10(1) of Directive 75/319 and Article 7a of Directive 65/65 state, the expression "risk to public health" refers to the quality, safety and efficacy of the medicinal product.

61 The importance attached to the efficacy of the medicinal product, which is fundamental to the contested decision, is due to the fact that the first subparagraph of Article 1(2) of Directive 65/65 adopts the presentation criterion when defining a medicinal product. The Court has consistently held that this criterion is designed to catch not only medicinal products having a genuine therapeutic or medical effect but also those which are not sufficiently effective or do not have the effect which their presentation might lead to expect, in order to protect consumers not only from harmful or toxic medicinal products as such but also from a variety of products used instead of the proper remedies (see, most recently, Case C-219/91 Ter Voort [1992] ECR I-5485, paragraph 16).

62 Consequently, as follows from the very wording of Article 11 of Directive 65/65, the competent authority is required to suspend or revoke a marketing authorisation not only where the medicinal product proves to be harmful or its quality not to be as declared, but also where it proves not to be effective.

63 The degree of harmfulness which the competent authority may regard as acceptable thus depends on the benefits which the medicinal product is considered to provide. As the seventh and eighth recitals in the preamble to Directive 75/318 state, the concepts of harmfulness and therapeutic efficacy can only be examined in relation to each other. Accordingly, the reasons which have led a competent authority to preserve a marketing authorisation for a medicinal product notwithstanding certain harmful effects may cease to apply if that authority considers that the benefits justifying such an authorisation, that is to say the existence of a therapeutic effect, are no longer present. It is stated in the introduction to the annex to Directive 75/318, as amended by Commission Directive 91/507/EEC of 19 July 1991 (OJ 1991 L 270, p. 32), that after issue of the marketing authorisation any new data or information are to be submitted to the competent authorities in order to monitor the benefit/risk assessment.

64 It is clear that, in its assessments regarding the establishment of a prima facie case and the balance of interests, the order under appeal makes no mention of the considerations in the statement of reasons for the contested decision relating to the change in the scientific criteria for evaluating medicinal products for the treatment of obesity and to the lack of therapeutic efficacy of medicinal products containing phentermine.

65 In accordance with the very wording of the contested decision, such a change appears to be a decisive factor in the evaluation of those medicinal products by the CPMP and the Commission.

66 Furthermore, because of that omission, the risks to which paragraphs 52 and 53 of the order under appeal refer concern only the harmfulness of the medicinal product considered in isolation, without the harmfulness being related to the medicinal product's lack of therapeutic efficacy.

67 It follows from the foregoing that, inasmuch as the order under appeal fails to take account of essential aspects of the statement of reasons for the contested decision and, therefore, distorts the latter's content, it is vitiated by an error of law.

68 Accordingly, without it being necessary to rule on the remaining pleas, the appeal must be allowed and the order under appeal set aside.

69 In accordance with the first paragraph of Article 54 of the EC Statute of the Court of Justice, if the appeal is well founded the Court of Justice is to quash the decision of the Court of First Instance. It may then itself decide the matter directly, where the state of the proceedings so permits, or refer the case back to the Court of First Instance for judgment. Since the state of the proceedings so permits, it is appropriate to give a final decision on the application for interim relief.

The application for interim relief

Prima facie case

70 CHS puts forward several pleas in law to establish a prima facie case for the interim relief sought.

71 First, it submits that the Commission was not competent to adopt the contested decision. Article 15a of Directive 75/319 does not constitute a valid legal basis for the procedure used in the present case. Article 15a allows a Member State to initiate the procedure provided for in that directive only in the case of marketing authorisations which have been granted in accordance with Chapter III of the directive. However, the authorisations in question are national authorisations, not authorisations granted in accordance with Directive 75/319. The fact that they were varied by the decision of 9 December 1996, following a procedure initiated under Article 12 of Directive 75/319, does not affect that conclusion.

72 CHS adds that the CPMP was entitled to consider only the question referred to it, namely the link between phentermine and cardiac valve disorders. The Belgian authorities had requested an examination of the risks of cardiac valve disorders caused by taking medicinal products containing phentermine and no Member State had made a request for an assessment of the benefit/risk balance of those products. The CPMP's opinion thus exceeded the limits of the referral to it and was therefore invalid. Accordingly, it could not constitute a valid legal basis for the contested decision.

73 According to the Commission, the decision of 9 December 1996 constitutes a marketing authorisation granted in accordance with Chapter III of Directive 75/319. It adds that that decision was adopted on the basis of Article 12 of Directive 75/319 and resulted in harmonisation of the marketing authorisations for the medicinal products listed in it, one of which is that produced by CHS. The Commission observes that that decision substantially alters, on the basis of Community law, the national marketing authorisations in such a way that, following expiry of the period set in Article 3 thereof, the medicinal products concerned may be marketed only if their presentation includes the clinical information set out in the decision.

74 The Commission also submits that, under the Community legislation on medicinal products, safety and efficacy are interdependent requirements. It follows that it was incumbent upon the CPMP to take those requirements into account and to examine the issues raised by the referral in a wider context.

75 When the judge hearing an application for suspension of the operation of a measure assesses whether there is a prima facie case, his task is not to give a final decision on the interpretation of the provisions applicable to the dispute.

76 Subject to that proviso, it must be acknowledged that, even though the decision of 9 December 1996 did not precede the issue of the national marketing authorisations, it cannot be inferred from that circumstance that following its adoption the Member States had absolute freedom so far as concerns preservation of those national authorisations, with the risk that the harmonisation achieved by that decision would be undone. At first sight, CHS's argument would render redundant Commission decisions concerning marketing authorisations already issued, adopted in accordance with the procedure laid down in Articles 13 and 14 of Directive 75/319.

77 In addition, it is clear from paragraph 63 of this order that, even if the referral to the CPMP was due to considerations relating to the harmfulness of medicinal products containing phentermine, the decision which brings to an end the procedure provided for in Articles 13 and 14 of Directive 75/319 may prima facie take account of whether the benefits of the product continue to outweigh its harmful effects.

78 Accordingly, the arguments put forward by CHS do not appear, on an initial analysis, to establish that the Commission was not competent to adopt the contested decision.

79 Second, CHS submits that the procedure before the CPMP and the Commission in this instance was marked by a serious breach of procedural rules, in that the procedure for adoption of the contested decision was excessively delayed at all stages and the time-limits laid down in Directive 75/319 were not complied with. CHS adds that, since the outcome of the procedure was predetermined and relevant information was concealed from it, it was denied the right to defend its interests effectively when the CPMP was examining the case before giving its first opinion. In particular, CHS states that, before the CPMP's first opinion, it was never informed of the fact that the CPMP was considering recommending withdrawal of phentermine on grounds of efficacy, although this was ultimately the only basis on which withdrawal was recommended. These defects infringed fundamental procedural guarantees and were not cured by the remedies available at later stages of the procedure.

80 With regard to CHS's argument that the time-limits laid down in Articles 13 and 14 of Directive 75/319 were not complied with, the Commission states that the delays held against it were due, in particular, to the fact that the CPMP had to examine in detail the appropriateness of the various recommendations which could be made, the large number of medicinal products subject to the examination procedure in the present case, and the fact that, in order to carry out a fair and detailed assessment of each product on its own merits, the CPMP had to have the time necessary to evaluate all the available data. The Commission adds that the failure to comply with the time-limits does not automatically entail the invalidity of the CPMP's opinion and that the delays alleged did not prejudice CHS.

81 As to CHS's argument that it had no opportunity to defend its interests properly before the CPMP's first opinion, the Commission argues that CHS was requested to provide data on the efficacy of the medicinal product at issue and to present oral observations to the CPMP before the latter gave its opinion.

82 On an initial analysis, it does not appear to follow from the terms in which Articles 13 and 14 of Directive 75/319 are couched that the time-limits the exceeding of which CHS criticises are mandatory in nature. Nor does CHS specify at all what particular prejudice was caused by the delays recorded or to what extent they had any effect on rights of the defence or the content of the contested decision.

83 Furthermore, the file shows, first, that CHS, which was requested to provide data on the efficacy of its medicinal product at the very beginning of the procedure, presented oral observations to the CPMP before it issued its first opinion and, second, that it was able to adopt a position on that opinion, and thus to put forward its point of view before the CPMP adopted its final opinion.

84 In those circumstances, CHS's arguments do not succeed in establishing, on an initial analysis, that the procedural irregularities pleaded prejudiced its rights of defence or had the slightest effect on the outcome of the procedure.

85 Third, CHS pleads that the contested decision fails to comply with Articles 11 and 21 of Directive 65/65 which lay down the conditions for the withdrawal of a marketing authorisation. In the present case, for the withdrawal of the marketing authorisation held by CHS to be ordered, it must be established that medicinal products containing phentermine are harmful, that they have no therapeutic efficacy or that they do not have the qualitative and quantitative composition declared. Contrary to Article 11 of Directive 65/65, the Commission had recourse to a totally different criterion, namely the benefit/risk balance.

86 The Commission denies that the contested decision is unlawful on the ground that the benefit/risk analysis on which it is based is not provided for by Article 11 of Directive 65/65. It submits that such an analysis is provided for in the context of grant of a marketing authorisation for a medicinal product and it follows that that analysis is likewise possible with respect to withdrawal of the authorisation, governed by Article 11 of Directive 65/65.

87 As to that, the statement of reasons for the contested decision, of which the CPMP's opinion is an integral part, indicates that the decision is founded on the lack of therapeutic efficacy of the medicinal products containing phentermine.

88 Furthermore, as is apparent from paragraph 63 of this order, the requirement that the benefits of the medicinal product must outweigh its harmful effects is not applicable solely on the grant of a marketing authorisation, but may also justify its withdrawal, since the benefit/risk assessment must also be monitored after the marketing authorisation has been issued, as is expressly stated in the introduction to the annex to Directive 75/318.

89 Fourth, CHS submits that the decision infringes Article 253 EC, in that it merely adopts the opinion of the CPMP without further reasoning or explanation, despite the legal and scientific flaws in the opinion which CHS and other holders of marketing authorisations for medicinal products containing phentermine pointed out to the Commission.

90 Without prejudice to the analysis of the statement of reasons for the contested decision which will have to be carried out by the Court which adjudicates on the substance, suffice it to state that, under Article 14 of Directive 75/319, it is only where, exceptionally, the Commission's draft decision is not in accordance with the opinion of the CPMP that the Commission must provide a detailed explanation of the reasons for the differences between its decision and the opinion. The fact that the Commission adopted the CPMP's opinion does not, on an initial analysis, appear to show that the statement of grounds for the contested decision is defective.

91 Finally, CHS contends that the Commission misallocated the burden of proof, failing to observe the rule that the burden of proving the grounds for withdrawal set out in the contested decision must lie with the competent authorities. The Commission expected the holders of marketing authorisations concerned to adduce appropriate evidence of the efficacy of phentermine whereas it should itself have proved the inefficacy of that substance. CHS also alleges that the Commission manifestly erred in its assessment. It submits that the Commission's conclusions on the safety and efficacy of the medicinal product at issue, based on the opinion of the CPMP, are not supported by the evidence before the CPMP and the Commission, in particular the guidelines cited in the contested decision. Neither the Commission nor the CPMP indicated that new evidence had emerged since 1996, when the CPMP considered that phentermine was efficacious and not unsafe and therefore recommended that its marketing should be authorised, a recommendation which the Commission followed.

92 The Commission counters that the CPMP established clearly, in the opinion which is the basis of the contested decision, that, in light of the state of scientific knowledge as reflected in particular by the guidelines, medicinal products containing phentermine do not have the therapeutic efficacy necessary to treat obesity. Furthermore, the CPMP established that those medicinal products entail a potential risk of cardiac valve disorders, a risk of primary pulmonary hypertension and other serious consequences for the cardio-vascular system and the central nervous system.

93 It must be stated first of all that, contrary to CHS's allegation, the decision of 9 November 1996 did not describe phentermine as a not unsafe substance. On the contrary, in that decision the Commission set out a number of harmful effects.

94 Next, without prejudice to the analysis which the Court adjudicating on the substance will have to carry out with regard to the effect of the guidelines cited in the contested decision, it should be noted that most of them date from after 1996 and therefore were not taken into consideration by the Commission in its decision of 9 December 1996.

95 Finally, CHS's arguments, referred to in paragraph 91 of this order, mainly concern the way in which the Commission exercised the discretion available to it when assessing the need for a measure withdrawing a market authorisation. It is not in dispute that any decision withdrawing a marketing authorisation which is adopted in accordance with the procedure laid down in Articles 13 and 14 of Directive 75/319 must comply with the substantive conditions under Article 11 of Directive 65/65, which relate to the efficacy, safety and quality of the medicinal product. This type of decision is thus the outcome of complex assessments in the medico-pharmacological field.

97 In the present case, it does not appear, prima facie, that the contested decision, which is founded on the CPMP's opinion, is vitiated by a manifest error or a misuse of powers or that the Commission clearly exceeded the bounds of its discretion.

98 It follows from the foregoing considerations that, without prejudice to the assessments to be made when the substance of the case is examined, the pleas put forward by CHS in the proceedings for interim relief do not, on an initial examination, prevail over those which the Commission relies on to contend that the contested decision is lawful.

99 Nevertheless, inasmuch as the pleas relied on by CHS do not appear to be entirely without foundation, the interim relief sought cannot be refused after examination of whether a prima facie case is established without also examining the urgency that is pleaded and the balance of the competing interests.

Urgency and balancing of interests

100 CHS submits that if operation of the contested decision is not suspended it will suffer serious and irreparable damage.

101 In particular, it maintains that withdrawal of the marketing authorisation for the medicinal product containing phentermine would have the consequence that, even if the withdrawal of the authorisation were annulled, it would not be possible to reintroduce the medicinal product concerned under the same conditions, since it will prove very difficult and often impossible to re-establish in the market a medicinal product which has been absent for a long time. CHS also contends that, if the suspension were not granted, it would have to submit a new application for a marketing authorisation, even if the contested decision were annulled. It would therefore find it necessary to conduct long clinical trials of that product, whose duration, taking account of the preparatory work, would amount to at least two years.

102 It adds that it is only a small pharmaceutical company; the medicinal product containing phentermine is the first product acquired by it and represents 35% to 40% of its turnover. If operation of the contested decision is not suspended, it is very doubtful that it will be able to survive as a company.

103 CHS also pleads the harm which would be caused to patients and practitioners, who would be deprived of a medicinal product which has been used to treat obesity for decades. So far as concerns patients, it argues that obesity is a major health problem in Europe and that the alternative medicinal products are more expensive and have more side-effects. As regards the private clinics in which such treatment is provided, the decision withdrawing phentermine would lead to the closure of at least 85% of them, with the loss of jobs that such closure entails for medical and administrative staff.

104 The Commission maintains that the condition relating to urgency is not fulfilled.

105 First, the possibility of a marketing authorisation being withdrawn is one of the normal business risks of any pharmaceutical undertaking. It is for the undertaking concerned to protect itself against the financial consequences of such a withdrawal by an appropriate policy, such as product diversification and adequate turnover.

106 Second, with regard to the need to conduct clinical trials, medicinal products containing phentermine were first authorised more than 20 years ago: updating the dossier by the provision of clinical trial data was possible and would have been useful to the medical community and to patients. In addition, it was only on 13 August 1999 that CHS indicated that it proposed to carry out a long-term clinical trial, but it did not provide details of the clinical studies envisaged. However, the CPMP, which considered that proposal at length, stated that one clinical trial would probably not be enough; a clinical programme would be necessary and would last for several years.

108 It is also apparent from settled case-law that, particularly where harm depends on the occurrence of a number of factors, it is enough for that harm to be foreseeable with a sufficient degree of probability (see, in particular, the orders in Case C-280/93 R Germany v Council [1993] ECR I-3667, paragraph 34, and in Case C-335/99 P(R) HFB and Others v Commission [1999] ECR I-8705, paragraph 67).

109 In the present case, immediate operation of the contested decision means the complete withdrawal from the market of the medicinal products referred to in Article 1 of the decision. Therefore, if operation of the contested decision is not suspended, it is probable that substitute medicinal products, whose existence is acknowledged by the parties, will be prescribed instead of the withdrawn medicinal products while the proceedings on the merits of the case take place.

110 The risk therefore exists that, if the contested decision is annulled, it will then be difficult for CHS to recover the market shares which it held before the contested decision came into operation.

112 It is true that CHS submits that it would be required to apply for a fresh marketing authorisation for the medicinal product containing phentermine even if the contested decision were annulled. However, there are no arguments to support such a contention.

114 Nevertheless, the judge hearing the application for interim relief must examine the circumstances of each case (De Compte v Parliament, cited above, paragraph 4).

115 In that regard, CHS merely pleads generally that it is very doubtful that it will be able to survive as a company, but it has not adduced evidence capable of establishing the truth of its contention that it could not continue trading until the merits of the case were finally decided. As the Commission correctly points out, the draft management accounts for the period from November 1997 to March 1999, which are the only document produced in the proceedings for interim relief, do not in any way support the statements concerning CHS's difficulties in surviving.

116 In addition, account should be taken of the fact that CHS operates in a market, the human medicinal products market, which is highly regulated.

117 In a sector where major investment is often required and the competent authorities may be led to intervene rapidly when public health risks become apparent, for reasons which cannot always be foreseen by the undertakings concerned, it is for those undertakings, if they are not to bear themselves the loss resulting from such intervention, to protect themselves against its consequences by adopting an appropriate policy.

118 It was already pointed out in the decision of 9 December 1996 that medicinal products containing phentermine had harmful effects. In those circumstances, the possibility that a decision could be adopted withdrawing or suspending the marketing authorisation held by CHS had to be taken into account as one of the risks which CHS normally had to bear once a referral had been made to the CPMP by a Member State because it considered that variation of the terms of the marketing authorisation or its suspension or withdrawal was necessary to protect public health.

119 As is apparent from the documents before the Court, CHS commenced trading in January 1998, when the referral to the CPMP had already been made.

120 In any event, even if the risk that damage which is irreparable or reparable only with difficulty would, following application of the contested decision, be suffered while the proceedings on the substance of the case take place were regarded as satisfactorily established, CHS's interest in obtaining suspension of the operation of the contested decision could not prevail in the present case over the interest of the Community in the immediate withdrawal of the marketing authorisation held by CHS, with a view to protecting public health.

121 It must be remembered that, in principle, the requirements of the protection of public health must unquestionably be given precedence over economic considerations (order in United Kingdom v Commission, cited above, paragraph 93).

122 In the present case, it is not in dispute that the CPMP's opinion, to which the contested decision refers, pointed out, as regards effects on the central nervous system, that the medicinal products in question have serious effects such as psychotic reactions or psychosis, depression and convulsions and that the potential for drug abuse and drug dependence is well known. It also found that there were concerns related to the safety profile of phentermine-containing medicinal products regarding the potential risk for cardiac valve disorders with phentermine monotherapy, the risk of primary pulmonary hypertension and other serious cardiovascular ... adverse reactions .... Those considerations bear out the assessments already made on the safety of those medicinal products in 1996.

123 It was following the CPMP's assessments that medicinal products containing phentermine lacked therapeutic efficacy in the treatment of obesity that the Commission, relying on the opinion of that committee, concluded that the benefit/risk assessment was unfavourable.

124 Without prejudice to the assessments to be made in the proceedings on the substance of the case, the judge hearing the application for interim relief cannot, in the absence of evidence of manifest error or misuse of powers, substitute his own assessments for those of the CPMP, which are the result of an in-depth inter partes procedure which led it to recommend the withdrawal of the marketing authorisations for the medicinal products containing phentermine.

125 Having regard to those assessments, it is evident that suspending the operation of the contested decision would be liable to make the users of those medicinal products run serious risks and, in terms of public health, would risk causing harm which could not be remedied if the substantive action were subsequently dismissed.

126 That conclusion cannot be shaken by CHS's argument concerning the harm which would result for patients if operation of the contested decision were not suspended, given that the existence of alternative treatments is not disputed.

127 Furthermore, as regards the alleged damage to the clinics in which obesity treatment is carried out, CHS's assertions that implementation of the contested decision would lead to the closure of at least 85% of the private clinics, with the loss of jobs that such closure entails for medical and administrative staff, are supported only by the letter from the director of one of those clinics, which does not contain the slightest documentary evidence in that regard.

128 It follows from all the foregoing considerations that the application for interim relief must be dismissed.

On those grounds,

THE PRESIDENT OF THE COURT

hereby orders:

1. The order of the President of the Court of First Instance of the European Communities of 31 October 2000 in Case T-137/00 R Cambridge Healthcare Supplies v Commission is set aside.

2. The application for interim relief is dismissed.

3. Costs are reserved.