G.R. No.

122445 November 18, 1997 It is via the latter type of action that the
heirs of the deceased sought redress for
DR. NINEVETCH CRUZ, petitioner,
the petitioner's alleged imprudence and
vs.
negligence in treating the deceased
COURT OF APPEALS and LYDIA
thereby causing her death. The petitioner
UMALI, respondents.
and one Dr. Lina Ercillo who was the
FRANCISCO, J.: attending anaesthesiologist during the
operation of the deceased were charged
Doctors are protected by a special rule of
with "reckless imprudence and negligence
law. They are not guarantors of care. They
resulting to (sic) homicide" in an
do not even warrant a good result. They
information which reads:
are not insurers against mishaps or
unusual consequences. Furthermore they That on or about March 23, 1991, in the
are not liable for honest mistakes of City of San Pablo, Republic of the
judgment . . . 1 Philippines and within the jurisdiction of
this Honorable Court, the accused above
The present case against petitioner is in
named, being then the attending
the nature of a medical malpractice suit,
anaesthesiologist and surgeon,
which in simplest terms is the type of claim
respectively, did then and there, in a
which a victim has available to him or her
negligence (sic), careless, imprudent, and
to redress a wrong committed by a
incompetent manner, and failing to supply
medical professional which has caused
or store sufficient provisions and facilities
bodily harm. 2 In this jurisdiction, however,
necessary to meet any and all exigencies
such claims are most often brought as a
apt to arise before, during and/or after a
civil action for damages under Article 2176
surgical operation causing by such
of the Civil Code, 3 and in some instances,
negligence, carelessness, imprudence, and
as a criminal case under Article 365 of the
incompetence, and causing by such failure,
Revised Penal Code 4 with which the civil
including the lack of preparation and
action for damages is impliedly instituted.
foresight needed to avert a tragedy, the
untimely death of said Lydia Umali on the decision promulgated by the Court of
day following said surgical operation. 5 Appeals on October 24, 1995 affirming
petitioner's conviction with modification
Trial ensued after both the petitioner and
that she is further directed to pay the heirs
Dr. Lina Ercillo pleaded not guilty to the
of Lydia Umali P50,000.00 as indemnity for
above-mentioned charge. On March 4,
her death.8
1994, the Municipal Trial Court in Cities
(MTCC) of San Pablo City rendered a In substance, the petition brought before
decision, the dispositive portion of which is this Court raises the issue of whether or
hereunder quoted as follows: not petitioner's conviction of the crime of
reckless imprudence resulting in homicide,
WHEREFORE, the court finds the accused
arising from an alleged medical
Dra. Lina Ercillo not guilty of the offense
malpractice, is supported by the evidence
charged for insufficiency of evidence while
on record.
her co-accused Dra. Ninevetch Cruz is
hereby held responsible for the death of First the antecedent facts.
Lydia Umali on March 24, 1991, and
On March 22, 1991, prosecution witness,
therefore guilty under Art. 365 of the
Rowena Umali De Ocampo, accompanied
Revised Penal Code, and she is hereby
her mother to the Perpetual Help Clinic and
sentenced to suffer the penalty of 2
General Hospital situated in Balagtas
months and 1 day imprisonment of arresto
Street, San Pablo City, Laguna. They
mayor with costs. 6
arrived at the said hospital at around 4:30
The petitioner appealed her conviction to in the afternoon of the same day. 9 Prior to
the Regional Trial Court (RTC) which March 22, 1991, Lydia was examined by
affirmed in toto the decision of the the petitioner who found a "myoma" 10 in
MTCC 7 prompting the petitioner to file a her uterus, and scheduled her for a
petition for review with the Court of hysterectomy operation on March 23,
Appeals but to no avail. Hence this petition 1991. 11 Rowena and her mother slept in
for review on certiorari assailing the the clinic on the evening of March 22, 1991
as the latter was to be operated on the this time to ask them to buy blood for
next day at 1:00 o'clock in the Lydia. They bought type "A" blood from the
afternoon. 12 According to Rowena, she St. Gerald Blood Bank and the same was
noticed that the clinic was untidy and the brought by the attendant into the
window and the floor were very dusty operating room. After the lapse of a few
prompting her to ask the attendant for a hours, the petitioner informed them that
rag to wipe the window and the floor the operation was finished. The operating
with. 13 Because of the untidy state of the staff then went inside the petitioner's clinic
clinic, Rowena tried to persuade her to take their snacks. Some thirty minutes
mother not to proceed with the after, Lydia was brought out of the
14
operation.   The following day, before her operating room in a stretcher and the
mother was wheeled into the operating petitioner asked Rowena and the other
room, Rowena asked the petitioner if the relatives to buy additional blood for Lydia.
operation could be postponed. The Unfortunately, they were not able to
petitioner called Lydia into her office and comply with petitioner's order as there was
the two had a conversation. Lydia then no more type "A" blood available in the
informed Rowena that the petitioner told blood bank. Thereafter, a person arrived to
her that she must be operated on as donate blood which was later transfused to
scheduled. 15 Lydia. Rowena then noticed her mother,
who was attached to an oxygen tank,
Rowena and her other relatives, namely
gasping for breath. Apparently the oxygen
her husband, her sister and two aunts
supply had run out and Rowena's husband
waited outside the operating room while
together with the driver of the accused had
Lydia underwent operation. While they
to go to the San Pablo District Hospital to
were waiting, Dr. Ercillo went out of the
get oxygen. Lydia was given the fresh
operating room and instructed them to buy
supply of oxygen as soon as it
tagamet ampules which Rowena's sister
arrived. 16 But at around 10:00 o'clock P.M.
immediately bought. About one hour had
she went into shock and her blood
passed when Dr. Ercillo came out again
pressure dropped to 60/50. Lydia's petitioner was closing the abdominal wall,
unstable condition necessitated her the patient died. 21 Thus, on March 24,
transfer to the San Pablo District Hospital 1991, at 3:00 o'clock in the morning, Lydia
so she could be connected to a respirator Umali was pronounced dead. Her death
and further examined. 17 The transfer to certificate states "shock" as the immediate
the San Pablo District Hospital was without cause of death and "Disseminated
the prior consent of Rowena nor of the Intravascular Coagulation (DIC)" as the
other relatives present who found out antecedent cause. 22
about the intended transfer only when an
In convicting the petitioner, the MTCC
ambulance arrived to take Lydia to the San
found the following circumstances as
Pablo District Hospital. Rowena and her
sufficient basis to conclude that she was
other relatives then boarded a tricycle and
indeed negligent in the performance of the
followed the ambulance. 18
operation:
Upon Lydia's arrival at the San Pablo
. . . , the clinic was untidy, there was lack
District Hospital, she was wheeled into the
of provision like blood and oxygen to
operating room and the petitioner and Dr.
prepare for any contingency that might
Ercillo re-operated on her because there
happen during the operation. The manner
was blood oozing from the abdominal
and the fact that the patient was brought
incision. 19 The attending physicians
to the San Pablo District Hospital for
summoned Dr. Bartolome Angeles, head of
reoperation indicates that there was
the Obstetrics and Gynecology Department
something wrong in the manner in which
of the San Pablo District Hospital. However,
Dra. Cruz conducted the operation. There
when Dr. Angeles arrived, Lydia was
was no showing that before the operation,
already in shock and possibly dead as her
accused Dra. Cruz had conducted a cardio
blood pressure was already 0/0. Dr.
pulmonary clearance or any typing of the
Angeles then informed petitioner and Dr.
blood of the patient. It was (sic) said in
Ercillo that there was nothing he could do
medical parlance that the "the abdomen of
to help save the patient. 20 While the
the person is a temple of surprises" The RTC reiterated the abovementioned
because you do not know the whole thing findings of the MTCC and upheld the
the moment it was open (sic) and surgeon latter's declaration of "incompetency,
must be prepared for any eventuality negligence and lack of foresight and skill of
thereof. The patient (sic) chart which is a appellant (herein petitioner) in handling
public document was not presented the subject patient before and after the
because it is only there that we could operation." 24 And likewise affirming the
determine the condition of the patient petitioner's conviction, the Court of
before the surgery. The court also noticed Appeals echoed similar observations, thus:
in Exh. "F-1" that the sister of the
. . . While we may grant that the untidiness
deceased wished to postpone the
and filthiness of the clinic may not by itself
operation but the patient was prevailed
indicate negligence, it nevertheless shows
upon by Dra. Cruz to proceed with the
the absence of due care and supervision
surgery. The court finds that Lydia Umali
over her subordinate employees. Did this
died because of the negligence and
unsanitary condition permeate the
carelessness of the surgeon Dra. Ninevetch
operating room? Were the surgical
Cruz because of loss of blood during the
instruments properly sterilized? Could the
operation of the deceased for evident
conditions in the OR have contributed to
unpreparedness and for lack of skill, the
the infection of the patient? Only the
reason why the patient was brought for
petitioner could answer these, but she
operation at the San Pablo City District
opted not to testify. This could only give
Hospital. As such, the surgeon should
rise to the presumption that she has
answer for such negligence. With respect
nothing good to testify on her defense.
to Dra. Lina Ercillo, the anaesthesiologist,
Anyway, the alleged "unverified statement
there is no evidence to indicate that she
of the prosecution witness" remains
should be held jointly liable with Dra. Cruz
unchallenged and unrebutted.
who actually did the operation. 23
Likewise undisputed is the prosecution's standard requirements before a patient is
version indicating the following facts: that subjected to surgery. Did the petitioner
the accused asked the patient's relatives determine as part of the pre-operative
to buy Tagamet capsules while the evaluation, the bleeding parameters of the
operation was already in progress; that patient, such as bleeding time and clotting
after an hour, they were also asked to buy time? There is no showing that these were
type "A" blood for the patient; that after done. The petitioner just appears to have
the surgery, they were again asked to been in a hurry to perform the operation,
procure more type "A" blood, but such was even as the family wanted a postponement
not anymore available from the source; to April 6, 1991. Obviously, she did not
that the oxygen given to the patient was prepare the patient; neither did she get
empty; and that the son-in-law of the the family's consent to the operation.
patient, together with a driver of the Moreover, she did not prepare a medical
petitioner, had to rush to the San Pablo chart with instructions for the patient's
City District Hospital to get the much- care. If she did all these, proof thereof
needed oxygen. All these conclusively should have been offered. But there is
show that the petitioner had not prepared none. Indeed, these are overwhelming
for any unforeseen circumstances before evidence of recklessness and
25
going into the first surgery, which was not imprudence. 
emergency in nature, but was elective or
This Court, however, holds differently and
pre-scheduled; she had no ready
finds the foregoing circumstances
antibiotics, no prepared blood, properly
insufficient to sustain a judgment of
typed and cross-matched, and no sufficient
conviction against the petitioner for the
oxygen supply.
crime of reckless imprudence resulting in
Moreover, there are a lot of questions that homicide. The elements of reckless
keep nagging Us. Was the patient given imprudence are: (1) that the offender does
any cardio-pulmonary clearance, or at or fails to do an act; (2) that the doing or
least a clearance by an internist, which are the failure to do that act is voluntary; (3)
that it be without malice; (4) that material same level of care that any other
damage results from the reckless reasonably competent doctor would use to
imprudence; and (5) that there is treat a condition under the same
inexcusable lack of precaution on the part circumstances. It is in this aspect of
of the offender, taking into consideration medical malpractice that expert testimony
his employment or occupation, degree of is essential to establish not only the
intelligence, physical condition, and other standard of care of the profession but also
circumstances regarding persons, time and that the physician's conduct in the
place. treatment and care falls below such
standard. 28 Further, inasmuch as the
Whether or not a physician has committed
causes of the injuries involved in
an "inexcusable lack of precaution" in the
malpractice actions are determinable only
treatment of his patient is to be
in the light of scientific knowledge, it has
determined according to the standard of
been recognized that expert testimony is
care observed by other members of the
usually necessary to support the
profession in good standing under similar 29
conclusion as to causation. 
circumstances bearing in mind the
advanced state of the profession at the Immediately apparent from a review of the
time of treatment or the present state of records of this case is the absence of any
medical science. 26 In the recent case expert testimony on the matter of the
of Leonila Garcia-Rueda v. Wilfred standard of care employed by other
27
L. Pascasio, et al.,   this Court stated that physicians of good standing in the conduct
in accepting a case, a doctor in effect of similar operations. The prosecution's
represents that, having the needed expert witnesses in the persons of Dr.
training and skill possessed by physicians Floresto Arizala and Dr. Nieto Salvador, Jr.
and surgeons practicing in the same field, of the National Bureau of Investigation
he will employ such training, care and skill (NBI) only testified as to the possible cause
in the treatment of his patients. He of death but did not venture to illuminate
therefore has a duty to use at least the
the court on the matter of the standard of the latter possess unusual technical skills
care that petitioner should have exercised. which laymen in most instances are
incapable of intelligently
All three courts below bewail the 31
evaluating.   Expert testimony should
inadequacy of the facilities of the clinic and
have been offered to prove that the
its untidiness; the lack of provisions such
circumstances cited by the courts below
as blood, oxygen, and certain medicines;
are constitutive of conduct falling below
the failure to subject the patient to a
the standard of care employed by other
cardio-pulmonary test prior to the
physicians in good standing when
operation; the omission of any form of
performing the same operation. It must be
blood typing before transfusion; and even
remembered that when the qualifications
the subsequent transfer of Lydia to the San
of a physician are admitted, as in the
Pablo Hospital and the reoperation
instant case, there is an inevitable
performed on her by the petitioner. But
presumption that in proper cases he takes
while it may be true that the
the necessary precaution and employs the
circumstances pointed out by the courts
best of his knowledge and skill in attending
below seemed beyond cavil to constitute
to his clients, unless the contrary is
reckless imprudence on the part of the
sufficiently established. 32 This
surgeon, this conclusion is still best arrived
presumption is rebuttable by expert
at not through the educated surmises nor
opinion which is so sadly lacking in the
conjectures of laymen, including judges,
case at bench.
but by the unquestionable knowledge of
expert witnesses. For whether a physician Even granting arguendo that the
or surgeon has exercised the requisite inadequacy of the facilities and untidiness
degree of skill and care in the treatment of of the clinic; the lack of provisions; the
his patient is, in the generality of cases, a failure to conduct pre-operation tests on
matter of expert opinion. 30 The deference the patient; and the subsequent transfer of
of courts to the expert opinion of qualified Lydia to the San Pablo Hospital and the
physicians stems from its realization that reoperation performed on her by the
petitioner do indicate, even without expert negligence and the injury must be a direct
testimony, that petitioner was recklessly and natural sequence of events, unbroken
imprudent in the exercise of her duties as by intervening efficient causes." In other
a surgeon, no cogent proof exists that any words, the negligence must be the
of these circumstances caused petitioner's proximate cause of the injury. For,
death. Thus, the absence of the fourth "negligence, no matter in what it consists,
element of reckless imprudence: that the cannot create a right of action unless it is
injury to the person or property was a the proximate cause of the injury
consequence of the reckless imprudence. complained of ." And "the proximate cause
of an injury is that cause, which, in natural
In litigations involving medical negligence,
and continuous sequence, unbroken by
the plaintiff has the burden of establishing
any efficient intervening cause, produces
appellant's negligence and for a
the injury, and without which the result
reasonable conclusion of negligence, there
would not have occurred." 35 (Emphasis
must be proof of breach of duty on the part
supplied.)
of the surgeon as well as a causal
connection of such breach and the Dr. Arizala who conducted an autopsy on
resulting death of his patient.  33 In Chan the body of the deceased summarized his
Lugay v. St. Luke's Hospital, Inc., 34 where findings as follows:
the attending physician was absolved of
Atty. Cachero:
liability for the death of the complainant's
wife and newborn baby, this Court held Q. You mentioned about your Autopsy
that: Report which has been marked as Exh. "A-
1-b". There appears here a signature
In order that there may be a recovery for
above the typewritten name Floresto
an injury, however, it must be shown that
Arizala, Jr., whose signature is that?
the "injury for which recovery is sought
must be the legitimate consequence of the A. That is my signature, sir.
wrong done; the connection between the
Q. Do you affirm the truth of all the Hemoperitoneum: 300 s.s.,
contents of Exh. "A-1-b"? right paracolic gutter,
50 c.c., left paracolic gutter
A. Only as to the autopsy report no. 91-09,
200 c.c., mesentric area,
the time and place and everything after
100 c.c., right pelvic gutter
the post mortem findings, sir.
stomach empty.
Q. You mentioned on your "Post Mortem
Other visceral organs, pale.,
Findings" about surgical incision, 14:0 cm.,
infraumbilical area, anterior abdominal will you please explain that on (sic) your
area, midline, will you please explain that own language or in ordinary. . . . . . . . . . . .
in your own language?
A. There was a uterus which was not
A. There was incision wound (sic) the area attached to the adnexal structures namely
just below the navel, sir. ovaries which were not present and also
sign of previous surgical operation and
Q. And the last paragraph of the
there were (sic) clotted blood, sir.
postmortem findings which I read: Uterus,
pear-shaped and pale measuring 7.5 x 5.5 Q. How about the ovaries and adnexal
x 5.0 cm. with some surface nodulation of structures?
the fundic area posteriorly. Cut-section
A. They are missing, sir.
shows diffusely pale myometrium with
areas of streak induration. The ovaries and Q. You mean to say there are no ovaries?
adnexal structures are missing with the
A. During that time there are no ovaries,
raw surfaces patched with clotted blood.
sir.
Surgical sutures were noted on the
operative site. Q. And there were likewise sign of surgical
sutures?
Intestines and mesenteries are pale with
blood clots noted between the mesentric A. Yes, sir.
folds.
Q. How about the intestines and A. Unattended hemorrhage,
mesenteries are place (sic) with blood clots sir. 36 (Emphasis supplied.)
noted between the mesenteric folds, will
The foregoing was corroborated by Dr.
you please explain on (sic) this?
Nieto Salvador:
A. In the peritoneal cavity, they are mostly
Q. And were you able to determine the
perritonial blood . . . . . . . .
cause of death by virtue of the
Q. And what could have caused this blood? examination of the specimen submitted by
Dr. Arizala?
A. Well, ordinarily blood is found inside the
blood vessel. Blood were (sic) outside as a A. Without knowledge of the autopsy
result of the injuries which destroyed the findings it would be difficult for me to
integrity of the vessel allowing blood to sip determine the cause of death, sir.
(sic) out, sir.
Q. Have you also examined the post
Q. By the nature of the postmortem mortem of Dr. Arizala?
findings indicated in Exh. A-1-B, can you
A. Yes, sir, and by virtue of the autopsy
tell the court the cause of death?
report in connection with your pathology
A. Yes, sir. The cause of death is: Gross report.
findings are compatible with hemorrhagic
Q. What could have caused the death of
shock.
the victim?
Q. Can you tell the us what could have
A. This pathologic examination are (sic)
caused this hemorrhagic shock?
compatible with the person who died, sir.
A. Well hemorrhagic shock is the result of
Q. Will you explain to us the meaning of
blood loss.
hemorrhagic compatible?
Q. What could have the effect of that loss
A. It means that a person died of blood
of blood?
loss. Meaning a person died of non-
replacement of blood and so the victim cause of death. However, as likewise
before she died there was shock of testified to by the expert witnesses in open
diminish of blood of the circulation. She court, hemorrhage or hemorrhagic shock
died most probably before the actual during surgery may be caused by several
complete blood loss, sir. different factors. Thus, Dr. Salvador's
elaboration on the matter:
Court: Is it possible doctor that the loss of
the blood was due on (sic) operation? Atty. Pascual:
A. Based on my pathologist finding, sir. Q. Doctor, among the causes of
hemorrhage that you mentioned you said
Q. What could have caused this loss of
that it could be at the moment of operation
blood?
when one losses (sic) control of the
A. Many, sir. A patient who have presence, is that correct? During the
undergone surgery. Another may be a operation there is lost (sic) of control of the
blood vessel may be cut while on cut vessel?
operation and this cause (sic) bleeding, or
A. Yes, sir.
may be set in the course of operation, or
may be (sic) he died after the Q. Or there is a failure to ligate a vessel of
operation. Of course there are other cause considerable size?
(sic).
A. Yes, sir.
Atty. Cachero:
Q. Or even if the vessel were ligated the
Q. Especially so doctor when there was no knot may have slipped later on?
blood replacement?
A. Yes, sir.
37
A. Yes, sir.   (Emphasis supplied.)
Q. And you also mentioned that it may be
The testimonies of both doctors establish possible also to some clotting defect, is
hemorrhage or hemorrhagic shock as the that correct?
A. May be (sic). 38 (Emphasis supplied). A. In general sir, if there was an operations
(sic) and it is possible that the ligature in
Defense witness, Dr. Bu C. Castro also
the suture was (sic) become (sic) loose, it
gave the following expert opinion:
is (sic) becomes loose if proven..
Q. Doctor even a patient after an
x x x           x x x          x x x
operations (sic) would suffer hemorrage
what would be the possible causes of such Q. If the person who performed an autopsy
hemorrage (sic)? does not find any untight (sic) clot (sic)
blood vessel or any suture that become
A. Among those would be what we call
(sic) loose the cause of the bleeding could
Intravascular Coagulation and this is the
not be attributed to the fault of the
reason for the bleeding, sir, which cannot
subject?
be prevented by anyone, it will happen to
anyone, anytime and to any persons (sic), A. Definitely, sir. 39 (Emphasis supplied.)
sir.
According to both doctors, the possible
COURT: causes of hemorrhage during an operation
are: (1) the failure of the surgeon to tie or
What do you think of the cause of the
suture a cut blood vessel; (2) allowing a
bleeding, the cutting or the operations
cut blood vessel to get out of control; (3)
done in the body?
the subsequent loosening of the tie or
A. Not related to this one, the bleeding suture applied to a cut blood vessel; and
here is not related to any cutting or (4) and a clotting defect known as DIC. It is
operation that I (sic) have done. significant to state at this juncture that the
autopsy conducted by Dr. Arizala on the
Q. Aside from the DIC what could another
body of Lydia did not reveal any untied or
causes (sic) that could be the cause for the
unsutured cut blood vessel nor was there
hemorrhage or bleeding in a patient by an
any indication that the tie or suture of a
operations (sic)?
cut blood vessel had become loose thereby
causing the hemorrhage. 40 Hence the A: I could not recall any loose sutured (sic),
following pertinent portion of Dr. Arizala's sir. 41
testimony:
On the other hand, the findings of all three
Q: Doctor, in examining these structures doctors do not preclude the probability
did you know whether these were sutured that DIC caused the hemorrhage and
ligature or plain ligature consequently, Lydia's death. DIC which is a
clotting defect creates a serious bleeding
A: Ligature, sir.
tendency and when massive DIC occurs as
Q: We will explain that later on. Did you a complication of surgery leaving raw
recall if the cut structures were tied by first surface, major hemorrhage occurs. 42 And
suturing it and then tying a knot or the tie as testified to by defense witness, Dr. Bu
was merely placed around the cut C. Castro, hemorrhage due to DIC "cannot
structure and tied? be prevented, it will happen to anyone,
anytime." 43 He testified further:
A: I cannot recall, sir.
Q. Now, under that circumstance one of
Q: As a matter of fact, you cannot recall
the possibility as you mentioned in (sic)
because you did not even bothered (sic) to
DIC?
examine, is that correct?
A. Yes, sir.
A: Well, I bothered enough to know that
they were sutured, sir. Q. And you mentioned that this cannot be
prevented?
Q: So, therefore, Doctor, you would not
know whether any of the cut structures A. Yes, sir.
were not sutured or tied neither were you
Q. Can you even predict if it really happen
able to determine whether any loose
(sic)?
suture was found in the peritoneal cavity?
A. Possible, sir.
Q. Are there any specific findings of We will moved (sic) to strike out the (sic)
autopsy that will tell you whether this based on finding they just read the chart
patient suffered among such things as as well as the other record.
DIC?
ATTY. PASCUAL:
A. Well, I did reserve because of the
Precisely based on this examination.
condition of the patient.
ATTY. MALVEDA:
Q. Now, Doctor you said that you went
through the record of the deceased Lydia Not finding, there was no finding made.
Umali looking for the chart, the operated
COURT:
(sic) records, the post mortem findings on
the histophanic (sic) examination based on He is only reading the record.
your examination of record, doctor, can
ATTY. PASCUAL:
you more or less says (sic) what part are
(sic) concerned could have been the Yes, sir.
caused (sic) of death of this Lydia Umali?
A. No, sir, there is no fault on the part of
A. As far as the medical record is concern the surgeon, sir. 44
(sic) the caused (sic) of death is
This Court has no recourse but to rely on
dessimulated (sic) Intra Vascular
the expert testimonies rendered by both
Coagulation or the DIC which resulted to
prosecution and defense witnesses that
hemorrhage or bleedings, sir.
substantiate rather than contradict
Q. Doctor based on your findings then petitioner's allegation that the cause of
there is knowing (sic) the doctor would say Lydia's death was DIC which, as attested to
whether the doctor her (sic) has been (sic) by an expert witness, cannot be attributed
fault? to the petitioner's fault or negligence. The
probability that Lydia's death was caused
ATTY. MALVEDA:
by DIC was unrebutted during trial and has
engendered in the mind of this Court a no amount of compassion and
reasonable doubt as to the petitioner's commiseration nor words of bereavement
guilt. Thus, her acquittal of the crime of can suffice to assuage the sorrow felt for
reckless imprudence resulting in homicide. the loss of a loved one. Certainly, the
While we condole with the family of Lydia award of moral and exemplary damages in
Umali, our hands are bound by the dictates favor of the heirs of Lydia Umali are proper
of justice and fair dealing which hold in the instant case.
inviolable the right of an accused to be
WHEREFORE, premises considered,
presumed innocent until proven guilty
petitioner DR. NINEVETCH CRUZ is hereby
beyond reasonable doubt. Nevertheless,
ACQUITTED of the crime of reckless
this Court finds the petitioner civilly liable
imprudence resulting in homicide but is
for the death of Lydia Umali, for while a
ordered to pay the heirs of the deceased
conviction of a crime requires proof
Lydia Umali the amount of FIFTY
beyond reasonable doubt, only a
THOUSAND PESOS (P50,000.00) as civil
preponderance of evidence is required to
liability, ONE HUNDRED THOUSAND PESOS
establish civil liability. 45
(P100,000.00) as moral damages, and
The petitioner is a doctor in whose hands a FIFTY THOUSAND PESOS (P50,000.00) as
patient puts his life and limb. For exemplary damages.
insufficiency of evidence this Court was not
Let a copy of this decision be furnished to
able to render a sentence of conviction but
the Professional Regulation Commission
it is not blind to the reckless and
(PRC) for appropriate action.
imprudent manner in which the petitioner
carried out her duties. A precious life has SO ORDERED.
been lost and the circumstances leading
Romero, Melo and Panganiban, JJ., concur.
thereto exacerbated the grief of those left
behind. The heirs of the deceased continue Narvasa, C.J., is on leave.
to feel the loss of their mother up to the
present time 46 and this Court is aware that
G.R. No. 159132             December 18,
2008
FE CAYAO-LASAM, petitioner,
vs.
SPOUSES CLARO and EDITHA
RAMOLETE, respondents.*
DECISION
AUSTRIA-MARTINEZ, J.:
Before the Court is a Petition for Review
on Certiorari under Rule 45 of the Rules of
Court filed by Dr. Fe Cayao-Lasam
(petitioner) seeking to annul the
1
Decision  dated July 4, 2003 of the Court of
Appeals (CA) in CA-G.R. SP No. 62206.
The antecedent facts:
On July 28, 1994, respondent, three
months pregnant Editha Ramolete (Editha)
was brought to the Lorma Medical Center
(LMC) in San Fernando, La Union due to
vaginal bleeding. Upon advice of petitioner
relayed via telephone, Editha was admitted
to the LMC on the same day. A pelvic
sonogram2 was then conducted on Editha
revealing the fetus’ weak cardiac
3
pulsation.  The following day, Editha’s
repeat pelvic sonogram4 showed that aside Malpractice against petitioner before the
from the fetus’ weak cardiac pulsation, no Professional Regulations Commission
fetal movement was also appreciated. Due (PRC).
to persistent and profuse vaginal bleeding,
Respondents alleged that Editha’s
petitioner advised Editha to undergo a
hysterectomy was caused by petitioner’s
Dilatation and Curettage Procedure (D&C)
unmitigated negligence and professional
or "raspa."
incompetence in conducting the D&C
On July 30, 1994, petitioner performed the procedure and the petitioner’s failure to
D&C procedure. Editha was discharged remove the fetus inside Editha’s
8
from the hospital the following day. womb.  Among the alleged acts of
negligence were: first, petitioner’s failure
On September 16, 1994, Editha was once
to check up, visit or administer medication
again brought at the LMC, as she was
on Editha during her first day of
suffering from vomiting and severe
confinement at the LMC;9 second,
abdominal pains. Editha was attended by
petitioner recommended that a D&C
Dr. Beatriz de la Cruz, Dr. Victor B. Mayo
procedure be performed on Editha without
and Dr. Juan V. Komiya. Dr. Mayo allegedly
conducting any internal examination prior
informed Editha that there was a dead
to the procedure;10 third, petitioner
fetus in the latter’s womb. After, Editha
immediately suggested a D&C procedure
underwent laparotomy,5 she was found to
instead of closely monitoring the state of
have a massive intra-abdominal
pregnancy of Editha.11
hemorrhage and a ruptured uterus. Thus,
Editha had to undergo a procedure for In her Answer,12 petitioner denied the
hysterectomy6 and as a result, she has no allegations of negligence and
more chance to bear a child. incompetence with the following
explanations: upon Editha’s confirmation
On November 7, 1994, Editha and her
that she would seek admission at the LMC,
husband Claro Ramolete (respondents)
petitioner immediately called the hospital
filed a Complaint7 for Gross Negligence and
to anticipate the arrival of Editha and discharged; petitioner agreed, but she
ordered through the telephone the advised Editha to return for check-up on
medicines Editha needed to take, which August 5, 1994, which the latter failed to
the nurses carried out; petitioner visited do.
Editha on the morning of July 28, 1994
Petitioner contended that it was Editha’s
during her rounds; on July 29, 1994, she
gross negligence and/or omission in
performed an internal examination on
insisting to be discharged on July 31, 1994
Editha and she discovered that the latter’s
against doctor’s advice and her unjustified
cervix was already open, thus, petitioner
failure to return for check-up as directed
discussed the possible D&C procedure,
by petitioner that contributed to her life-
should the bleeding become more profuse;
threatening condition on September 16,
on July 30 1994, she conducted another
1994; that Editha’s hysterectomy was
internal examination on Editha, which
brought about by her very abnormal
revealed that the latter’s cervix was still
pregnancy known as placenta
open; Editha persistently complained of
increta, which was an extremely rare and
her vaginal bleeding and her passing out of
very unusual case of abdominal placental
some meaty mass in the process of
implantation. Petitioner argued that
urination and bowel movement; thus,
whether or not a D&C procedure was done
petitioner advised Editha to undergo D&C
by her or any other doctor, there would be
procedure which the respondents
no difference at all because at any stage of
consented to; petitioner was very vocal in
gestation before term, the uterus would
the operating room about not being able to
rupture just the same.
see an abortus;13 taking the words of
Editha to mean that she was passing out On March 4, 1999, the Board of Medicine
some meaty mass and clotted blood, she (the Board) of the PRC rendered a
assumed that the abortus must have been Decision,14 exonerating petitioner from the
expelled in the process of bleeding; it was charges filed against her. The Board held:
Editha who insisted that she wanted to be
Based on the findings of the doctors who curettage is done only within the uterus.
conducted the laparotomy on Editha, hers Therefore, a more extensive operation
is a case of Ectopic Pregnancy Interstitial. needed in this case of pregnancy in order
This type of ectopic pregnancy is one that to remove the fetus.15
is being protected by the uterine muscles
Feeling aggrieved, respondents went to
and manifestations may take later than
the PRC on appeal. On November 22,
four (4) months and only attributes to two
2000, the PRC rendered a
percent (2%) of ectopic pregnancy cases. 16
Decision  reversing the findings of the
When complainant Editha was admitted at Board and revoking petitioner’s authority
Lorma Medical Center on July 28, 1994 due or license to practice her profession as a
to vaginal bleeding, an ultra-sound was physician.17
performed upon her and the result of the
Petitioner brought the matter to the CA in
Sonogram Test reveals a morbid fetus but
a Petition for Review under Rule 43 of the
did not specify where the fetus was
Rules of Court. Petitioner also dubbed her
located. Obstetricians will assume that the
petition as one for certiorari18 under Rule
pregnancy is within the uterus unless so
65 of the Rules of Court.
specified by the Sonologist who conducted
the ultra-sound. Respondent (Dr. Lasam) In the Decision dated July 4, 2003, the CA
cannot be faulted if she was not able to held that the Petition for Review under
determine that complainant Editha is Rule 43 of the Rules of Court was an
having an ectopic pregnancy interstitial. improper remedy, as the enumeration of
The D&C conducted on Editha is necessary the quasi-judicial agencies in Rule 43 is
considering that her cervix is already open exclusive.19 PRC is not among the quasi-
and so as to stop the profuse bleeding. judicial bodies whose judgment or final
Simple curettage cannot remove a fetus if orders are subject of a petition for review
the patient is having an ectopic pregnancy, to the CA, thus, the petition for review of
since ectopic pregnancy is pregnancy the PRC Decision, filed at the CA, was
conceived outside the uterus and improper. The CA further held that should
the petition be treated as a petition JURISDICTION, OR WHERE THE DECISION
for certiorari under Rule 65, the same WAS A PATENT NULLITY;
would still be dismissed for being improper
3. HEREIN RESPONDENTS-SPOUSES ARE
and premature. Citing Section 2620 of
NOT ALLOWED BY LAW TO APPEAL FROM
Republic Act (R.A.) No. 2382 or the Medical
THE DECISION OF THE BOARD OF
Act of 1959, the CA held that the plain,
MEDICINE TO THE PROFESSIONAL
speedy and adequate remedy under the
REGULATION[S] COMMISSION;
ordinary course of law which petitioner
should have availed herself of was to 4. THE COURT OF APPEALS COMMITTED
appeal to the Office of the President.21 GRAVE ABUSE OF DISCRETION IN DENYING
FOR IMPROPER FORUM THE PETITION FOR
Hence, herein petition, assailing the
REVIEW/PETITION FOR CERTIORARI
decision of the CA on the following
WITHOUT GOING OVER THE MERITS OF
grounds:
THE GROUNDS RELIED UPON BY THE
1. THE COURT OF APPEALS ERRED ON A PETITIONER;
QUESTION OF LAW IN HOLDING THAT THE
5. PRC’S GRAVE OMISSION TO AFFORD
PROFESSIONAL REGULATION[S]
HEREIN PETITONER A CHANCE TO BE
COMMISSION (PRC) WAS EXCLUDED
HEARD ON APPEAL IS A CLEAR VIOLATION
AMONG THE QUASI-JUDICIAL AGENCIES
OF HER CONSTITUTIONAL RIGHT TO DUE
CONTEMPLATED UNDER RULE 43 OF THE
PROCESS AND HAS THE EFFECT OF
RULES OF CIVIL PROCEDURE;
RENDERING THE JUDGMENT NULL AND
2. EVEN ASSUMING, ARGUENDO, THAT PRC VOID;
WAS EXCLUDED FROM THE PURVIEW OF
6. COROLLARY TO THE FOURTH ASSIGNED
RULE 43 OF THE RULES OF CIVIL
ERROR, PRC COMMITTED GRAVE ABUSE OF
PROCEDURE, THE PETITIONER WAS NOT
DISCRETION, AMOUNTING TO LACK OF
PRECLUDED FROM FILING A PETITION FOR
JURISDICTION, IN ACCEPTING AND
CERTIORARI WHERE THE DECISION WAS
CONSIDERING THE MEMORANDUM ON
ALSO ISSUED IN EXCESS OF OR WITHOUT
APPEAL WITHOUT PROOF OF SERVICE TO ACTUALLY CONTRARY TO EVIDENCE ON
HEREIN PETITIONER, AND IN VIOLATION OF RECORD.22
ART. IV, SEC. 35 OF THE RULES AND
The Court will first deal with the procedural
REGULATIONS GOVERNING THE
issues.
REGULATION AND PRACTICE OF
PROFESSIONALS; Petitioner claims that the law does not
allow complainants to appeal to the PRC
7. PRC COMMITTED GRAVE ABUSE OF
from the decision of the Board. She
DISCRETION IN REVOKING PETITIONER’S
invokes Article IV, Section 35 of the Rules
LICENSE TO PRACTICE MEDICINE WITHOUT
and Regulations Governing the Regulation
AN EXPERT TESTIMONY TO SUPPORT ITS
and Practice of Professionals, which
CONCLUSION AS TO THE CAUSE OF
provides:
RESPONDENT EDITHAT [SIC] RAMOLETE’S
INJURY; Sec. 35. The respondent may appeal the
decision of the Board within thirty days
8. PRC COMMITTED AN EVEN GRAVER
from receipt thereof to the Commission
ABUSE OF DISCRETION IN TOTALLY
whose decision shall be
DISREGARDING THE FINDING OF THE
final. Complainant, when allowed by
BOARD OF MEDICINE, WHICH HAD THE
law, may interpose an appeal from the
NECESSARY COMPETENCE AND EXPERTISE
Decision of the Board within the same
TO ESTABLISH THE CAUSE OF
period. (Emphasis supplied)
RESPONDENT EDITHA’S INJURY, AS WELL
AS THE TESTIMONY OF THE EXPERT Petitioner asserts that a careful reading of
WITNESS AUGUSTO MANALO, M.D. ;[and] the above law indicates that while the
respondent, as a matter of right, may
9. PRC COMMITTED GRAVE ABUSE OF
appeal the Decision of the Board to the
DISCRETION IN MAKING CONCLUSIONS OF
Commission, the complainant may
FACTS THAT WERE NOT ONLY
interpose an appeal from the decision of
UNSUPPORTED BY EVIDENCE BUT WERE
the Board only when so allowed by
law.23 Petitioner cited Section 26 of For one, the principle of double jeopardy
Republic Act No. 2382 or "The Medical Act finds no application in administrative
of 1959," to wit: cases. Double jeopardy attaches only: (1)
upon a valid indictment; (2) before a
Section 26. Appeal from judgment. The
competent court; (3) after arraignment; (4)
decision of the Board of Medical Examiners
when a valid plea has been entered; and
(now Medical Board) shall automatically
(5) when the defendant was acquitted or
become final thirty days after the date of
convicted, or the case was dismissed or
its promulgation unless the respondent,
otherwise terminated without the express
during the same period, has appealed to
consent of the accused.25 These elements
the Commissioner of Civil Service (now
were not present in the proceedings before
Professional Regulations Commission) and
the Board of Medicine, as the proceedings
later to the Office of the President of the
involved in the instant case were
Philippines. If the final decision is not
administrative and not criminal in nature.
satisfactory, the respondent may ask for a
The Court has already held that double
review of the case, or may file in court a
jeopardy does not lie in administrative
petition for certiorari.
cases.26
Petitioner posits that the reason why the
Moreover, Section 35 of the Rules and
Medical Act of 1959 allows only the
Regulations Governing the Regulation and
respondent in an administrative case to file
Practice of Professionals cited by petitioner
an appeal with the Commission while the
was subsequently amended to read:
complainant is not allowed to do so is
double jeopardy. Petitioner is of the belief Sec. 35.
that the revocation of license to practice a The complainant/respondent may
profession is penal in nature.24 appeal the order, the resolution or the
decision of the Board within thirty (30)
The Court does not agree.
days from receipt thereof to the
Commission whose decision shall be final
and executory. Interlocutory order shall not resolution without an appeal being
be appealable to the Commission. perfected or taken by either the
(Amended by Res. 174, Series of respondent or the complainant. A party
1990).27 (Emphasis supplied) aggrieved by the decision, order or
resolution may file a notice of appeal
Whatever doubt was created by the
from the decision, order or resolution
previous provision was settled with said
of the Board to the Commission within
amendment. It is axiomatic that the right
fifteen (15) days from receipt
to appeal is not a natural right or a part of
thereof, and serving upon the adverse
due process, but a mere statutory privilege
party a notice of appeal together with the
that may be exercised only in the manner
appellant’s brief or memorandum on
prescribed by law.28 In this case, the clear
appeal, and paying the appeal and legal
intent of the amendment is to render the
research fees. x x x29
right to appeal from a decision of the
Board available to both complainants and The above-stated provision does not
respondents. qualify whether only the complainant or
respondent may file an appeal; rather, the
Such conclusion is bolstered by the fact
new rules provide that "a party aggrieved"
that in 2006, the PRC issued Resolution No.
may file a notice of appeal. Thus, either
06-342(A), or the New Rules of Procedure
the complainant or the respondent who
in Administrative Investigations in the
has been aggrieved by the decision, order
Professional Regulations Commission and
or resolution of the Board may appeal to
the Professional Regulatory Boards, which
the Commission. It is an elementary rule
provides for the method of appeal, to wit:
that when the law speaks in clear and
Sec. 1. Appeal; Period Non- categorical language, there is no need, in
Extendible.- The decision, order or the absence of legislative intent to the
resolution of the Board shall be final and contrary, for any interpretation.30 Words
executory after the lapse of fifteen (15) and phrases used in the statute should be
days from receipt of the decision, order or
given their plain, ordinary, and common Commission, Office of the President, Land
usage or meaning.31 Registration Authority, Social Security
Commission, Civil Aeronautics Board,
Petitioner also submits that appeals from
Bureau of Patents, Trademarks and
the decisions of the PRC should be with the
Technology Transfer, National
CA, as Rule 4332 of the Rules of Court was
Electrification Administration, Energy
precisely formulated and adopted to
Regulatory Board, National
provide for a uniform rule of appellate
Telecommunications Commission,
procedure for quasi-judicial
33 Department of Agrarian Reform under
agencies.  Petitioner further contends that
Republic Act No. 6657, Government
a quasi-judicial body is not excluded from
Service Insurance System, Employees
the purview of Rule 43 just because it is
Compensation Commission, Agricultural
not mentioned therein.34
Inventions Board, Insurance Commission,
On this point, the Court agrees with the Philippine Atomic Energy Commission,
petitioner. Board of Investments, Construction
Industry Arbitration Commission, and
Sec. 1, Rule 43 of the Rules of Court
voluntary arbitrators authorized by law.
provides:
(Emphasis supplied)
Section 1. Scope. - This Rule shall apply
Indeed, the PRC is not expressly
to appeals from judgments or final orders
mentioned as one of the agencies which
of the Court of Tax Appeals, and from
are expressly enumerated under Section 1,
awards, judgments, final orders or
Rule 43 of the Rules of Court. However, its
resolutions of or authorized by any
absence from the enumeration does not,
quasi-judicial agency in the exercise
by this fact alone, imply its exclusion from
of its quasi-judicial functions. Among
the coverage of said Rule.35 The Rule
these agencies are the Civil Service
expressly provides that it should be
Commission, Central Board of Assessment
applied to appeals from awards, judgments
Appeals, Securities and Exchange
final orders or resolutions of any quasi-
judicial agency in the exercise of its quasi- are now exclusively cognizable by the
judicial functions. The phrase "among Court of Appeals.39 (Emphasis supplied)
these agencies" confirms that the
Clearly, the enactment of B.P. Blg. 129, the
enumeration made in the Rule is not
precursor of the present Rules of Civil
exclusive to the agencies therein listed. 36
Procedure,40 lodged with the CA such
Specifically, the Court, in Yang v. Court of jurisdiction over the appeals of decisions
Appeals,37 ruled made by the PRC.
that Batas Pambansa (B.P.) Blg. 12938 conf
Anent the substantive merits of the case,
erred upon the CA exclusive appellate
petitioner questions the PRC decision for
jurisdiction over appeals from decisions of
being without an expert testimony to
the PRC. The Court held:
support its conclusion and to establish the
The law has since been changed, however, cause of Editha’s injury. Petitioner avers
at least in the matter of the particular that in cases of medical malpractice,
court to which appeals from the expert testimony is necessary to support
Commission should be taken. On August the conclusion as to the cause of the
14, 1981, Batas Pambansa Bilang 129 injury.41
became effective and in its Section 29,
Medical malpractice is a particular form of
conferred on the Court of Appeals
negligence which consists in the failure of
"exclusive appellate jurisdiction over all
a physician or surgeon to apply to his
final judgments, decisions, resolutions,
practice of medicine that degree of care
orders or awards of Regional Trial Courts
and skill which is ordinarily employed by
and quasi-judicial agencies,
the profession generally, under similar
instrumentalities, boards or commissions
conditions, and in like surrounding
except those falling under the appellate
circumstances.42 In order to successfully
jurisdiction of the Supreme Court. x x x." In
pursue such a claim, a patient must prove
virtue of BP 129, appeals from the
that the physician or surgeon either failed
Professional Regulations Commission
to do something which a reasonably
prudent physician or surgeon would not usually necessary to support the
48
have done, and that the failure or action conclusion as to causation.
caused injury to the patient.43
In the present case, respondents did not
There are four elements involved in present any expert testimony to support
medical negligence cases: duty, breach, their claim that petitioner failed to do
injury and proximate causation.44 something which a reasonably prudent
physician or surgeon would have done.
A physician-patient relationship was
created when Editha employed the Petitioner, on the other hand, presented
services of the petitioner. As Editha’s the testimony of Dr. Augusto M. Manalo,
physician, petitioner was duty-bound to who was clearly an expert on the subject.
use at least the same level of care that any
Generally, to qualify as an expert witness,
reasonably competent doctor would use to
one must have acquired special knowledge
treat a condition under the same
of the subject matter about which he or
circumstances.45 The breach of these
she is to testify, either by the study of
professional duties of skill and care, or
recognized authorities on the subject or by
their improper performance by a physician
practical experience.49
surgeon, whereby the patient is injured in
body or in health, constitutes actionable Dr. Manalo specializes in gynecology and
malpractice.46 As to this aspect of medical obstetrics, authored and co-authored
malpractice, the determination of the various publications on the subject, and is
reasonable level of care and the breach a professor at the University of the
thereof, expert testimony is Philippines.50 According to him, his
47
essential.  Further, inasmuch as the diagnosis of Editha’s case was "Ectopic
causes of the injuries involved in Pregnancy Interstitial (also referred to as
malpractice actions are determinable only Cornual), Ruptured."51 In stating that the
in the light of scientific knowledge, it has D&C procedure was not the proximate
been recognized that expert testimony is cause of the rupture of Editha’s uterus
resulting in her hysterectomy, Dr. Manalo patient was discharged, after the D&C was
testified as follows: conducted. Would you tell us whether
there is any relation at all of the D&C and
Atty. Hidalgo:
the rupture in this particular instance?
Q:     Doctor, we want to be clarified on this
A:     I don’t think so for the two
matter. The complainant had testified here
reasons that I have just mentioned-
that the D&C was the proximate cause of
that it would not be possible for the
the rupture of the uterus. The condition
instrument to reach the site of
which she found herself in on the second
pregnancy. And, No. 2, if it is because of
admission. Will you please tell us whether
the D&C that rupture could have occurred
that is true or not?
earlier.52 (Emphases supplied)
A:     Yah, I do not think so for two
Clearly, from the testimony of the expert
reasons. One, as I have said earlier, the
witness and the reasons given by him, it is
instrument cannot reach the site of the
evident that the D&C procedure was not
pregnancy, for it to further push the
the proximate cause of the rupture of
pregnancy outside the uterus. And, No. 2, I
Editha’s uterus.
was thinking a while ago about another
reason- well, why I don’t think so, because During his cross-examination, Dr. Manalo
it is the triggering factor for the rupture, it testified on how he would have addressed
could have–the rupture could have Editha’s condition should he be placed in a
occurred much earlier, right after the D&C similar circumstance as the petitioner. He
or a few days after the D&C. stated:
Q:     In this particular case, doctor, the Atty. Ragonton:
rupture occurred to have happened
Q:     Doctor, as a practicing OB-Gyne,
minutes prior to the hysterectomy or right
when do you consider that you have done
upon admission on September 15, 1994
a good, correct and ideal dilatation and
which is about 1 ½ months after the
curettage procedure?
A:     Well, if the patient recovers. If the A:     Well, the fact that it was
patient gets well. Because even after the described means, I assume that it was
procedure, even after the procedure you checked, ‘no. It was described as scanty
may feel that you have scraped and the color also, I think was
everything, the patient stops bleeding, she described. Because it would be very
feels well, I think you should still have unusual, even improbable that it
some reservations, and wait a little more would not be examined, because
time. when you scrape, the specimens are
right there before your eyes. It’s in
Q:     If you were the OB-Gyne who
front of you. You can touch it. In fact,
performed the procedure on patient Editha
some of them will stick to the
Ramolete, would it be your standard
instrument and therefore to peel it off
practice to check the fetal parts or fetal
from the instrument, you have to
tissues that were allegedly removed?
touch them. So, automatically they
A:     From what I have removed, yes. But are examined closely.
in this particular case, I think it was
Q:     As a matter of fact, doctor, you also
assumed that it was part of the meaty
give telephone orders to your patients
mass which was expelled at the time she
through telephone?
was urinating and flushed in the toilet. So
there’s no way. A:     Yes, yes, we do that, especially here
in Manila because you know, sometimes a
Q:     There was [sic] some portions of the
doctor can also be tied-up somewhere and
fetal parts that were removed?
if you have to wait until he arrive at a
A:     No, it was described as scanty certain place before you give the order,
scraping if I remember it right–scanty. then it would be a lot of time wasted.
Because if you know your patient, if you
Q:     And you would not mind checking
have handled your patient, some of the
those scant or those little parts that were
symptoms you can interpret that comes
removed?
with practice. And, I see no reason for From the foregoing testimony, it is clear
not allowing telephone orders unless that the D&C procedure was conducted in
it is the first time that you will be accordance with the standard practice,
encountering the patient. That you with the same level of care that any
have no idea what the problem is. reasonably competent doctor would use to
treat a condition under the same
Q:     But, doctor, do you discharge
circumstances, and that there was nothing
patients without seeing them?
irregular in the way the petitioner dealt
A:     Sometimes yes, depending on how with Editha.
familiar I am with the patient. We are on
Medical malpractice, in our jurisdiction, is
the question of telephone orders. I am not
often brought as a civil action for damages
saying that that is the idle [sic] thing to do,
under Article 217654 of the Civil Code. The
but I think the reality of present day
defenses in an action for damages,
practice somehow justifies telephone
provided for under Article 2179 of the Civil
orders. I have patients whom I have
Code are:
justified and then all of a sudden, late in
the afternoon or late in the evening, would Art. 2179. When the plaintiff’s own
suddenly call they have decided that they negligence was the immediate and
will go home inasmuch as they anticipated proximate cause of his injury, he
that I will discharge them the following cannot recover damages. But if his
day. So, I just call and ask our resident on negligence was only contributory, the
duty or the nurse to allow them to go immediate and proximate cause of the
because I have seen that patient and I injury being the defendant’s lack of due
think I have full grasp of her problems. So, care, the plaintiff may recover damages,
that’s when I make this telephone orders. but the courts shall mitigate the damages
And, of course before giving that order I to be awarded.
ask about how she feels.53 (Emphases
Proximate cause has been defined as that
supplied)
which, in natural and continuous sequence,
unbroken by any efficient intervening examined her thoroughly.57 x x x
cause, produces injury, and without which (Emphases supplied)
the result would not have occurred.55 An
Also, in the testimony of Dr. Manalo, he
injury or damage is proximately caused by
stated further that assuming that there
an act or a failure to act, whenever it
was in fact a misdiagnosis, the same would
appears from the evidence in the case that
have been rectified if Editha followed the
the act or omission played a substantial
petitioner’s order to return for a check-up
part in bringing about or actually causing
on August 4, 1994. Dr. Manalo stated:
the injury or damage; and that the injury or
damage was either a direct result or a Granting that the obstetrician-
reasonably probable consequence of the gynecologist has been misled
act or omission.56 (justifiably) up to thus point that
there would have been ample
In the present case, the Court notes the
opportunity to rectify the
findings of the Board of Medicine:
misdiagnosis, had the patient
When complainant was discharged on July returned, as instructed for her follow-
31, 1994, herein respondent advised up evaluation. It was one and a half
her to return on August 4, 1994 or months later that the patient sought
four (4) days after the D&C. This consultation with another doctor. The
advise was clear in complainant’s continued growth of an ectopic pregnancy,
Discharge until its eventual rupture, is a dynamic
Sheet. However, complainant failed to process. Much change in physical findings
do so. This being the case, the chain of could be expected in 1 ½ months,
continuity as required in order that the including the emergence of suggestive
doctrine of proximate cause can be validly ones.58
invoked was interrupted. Had she
It is undisputed that Editha did not return
returned, the respondent could have
for a follow-up evaluation, in defiance of
the petitioner’s advise. Editha omitted the
diligence required by the circumstances act, which contributed to the principal
which could have avoided the injury. The occurrence as one of its determining
omission in not returning for a follow-up factors, he cannot recover damages for the
evaluation played a substantial part in injury.61 Again, based on the evidence
bringing about Editha’s own injury. Had presented in the present case under
Editha returned, petitioner could have review, in which no negligence can be
conducted the proper medical tests and attributed to the petitioner, the
procedure necessary to determine Editha’s immediate cause of the accident
health condition and applied the resulting in Editha’s injury was her
corresponding treatment which could have own omission when she did not return
prevented the rupture of Editha’s uterus. for a follow-up check up, in defiance
The D&C procedure having been of petitioner’s orders. The immediate
conducted in accordance with the standard cause of Editha’s injury was her own
medical practice, it is clear that Editha’s act; thus, she cannot recover
omission was the proximate cause of her damages from the injury.
own injury and not merely a contributory
Lastly, petitioner asserts that her right to
negligence on her part.
due process was violated because she was
Contributory negligence is the act or never informed by either respondents or
omission amounting to want of ordinary by the PRC that an appeal was pending
care on the part of the person injured, before the PRC.62 Petitioner claims that a
which, concurring with the defendant’s verification with the records section of the
negligence, is the proximate cause of the PRC revealed that on April 15, 1999,
injury.59 Difficulty seems to be respondents filed a Memorandum on
apprehended in deciding which acts of the Appeal before the PRC, which did not
injured party shall be considered attach the actual registry receipt but was
immediate causes of the accident. 60 Where merely indicated therein.63
the immediate cause of an accident
resulting in an injury is the plaintiff’s own
Respondents, on the other hand avers that which the National Labor Relations
if the original registry receipt was not Commission failed to order the private
attached to the Memorandum on Appeal, respondent to furnish the petitioner a copy
PRC would not have entertained the appeal of the Appeal Memorandum, the Court held
or accepted such pleading for lack of that said failure deprived the petitioner of
notice or proof of service on the other procedural due process guaranteed by the
party.64 Also, the registry receipt could not Constitution, which could have served as
be appended to the copy furnished to basis for the nullification of the
petitioner’s former counsel, because the proceedings in the appeal. The same holds
registry receipt was already appended to true in the case at bar. The Court finds that
the original copy of the Memorandum of the failure of the respondents to furnish
Appeal filed with PRC.65 the petitioner a copy of the Memorandum
of Appeal submitted to the PRC constitutes
It is a well-settled rule that when service of
a violation of due process. Thus, the
notice is an issue, the rule is that the
proceedings before the PRC were null and
person alleging that the notice was served
void.
must prove the fact of service. The burden
of proving notice rests upon the party All told, doctors are protected by a special
asserting its existence.66 In the present rule of law. They are not guarantors of
case, respondents did not present any care. They are not insurers against
proof that petitioner was served a copy of mishaps or unusual
68
the Memorandum on Appeal. Thus, consequences  specially so if the patient
respondents were not able to satisfy the herself did not exercise the proper
burden of proving that they had in fact diligence required to avoid the injury.
informed the petitioner of the appeal
WHEREFORE, the petition
proceedings before the PRC.
is GRANTED. The assailed Decision of the
In EDI-Staffbuilders International, Inc. v. Court of Appeals dated July 4, 2003 in CA-
National Labor Relations Commission,67 in GR SP No. 62206 is
hereby REVERSED and SET ASIDE. The
Decision of the Board of Medicine dated
March 4, 1999 exonerating petitioner
is AFFIRMED. No pronouncement as to
costs.
SO ORDERED.
G.R. No. 178763               April 21, case entitled, "Peter Paul Patrick Lucas,
2009 Fatima Gladys Lucas, Abbeygail Lucas and
Gillian Lucas v. Prospero Ma. C. Tuaño,"
PETER PAUL PATRICK LUCAS, FATIMA
docketed as Civil Case No. 92-2482.
GLADYS LUCAS, ABBEYGAIL LUCAS
AND GILLIAN LUCAS, Petitioners, From the record of the case, the
vs. established factual antecedents of the
DR. PROSPERO MA. C. present petition are:
TUAÑO, Respondent.
Sometime in August 1988, petitioner Peter
DECISION Paul Patrick Lucas (Peter) contracted "sore
eyes" in his right eye.
CHICO-NAZARIO, J.:
On 2 September 1988, complaining of a
In this petition for review on
1 red right eye and swollen eyelid, Peter
certiorari  under Rule 45 of the Revised
made use of his health care insurance
Rules of Court, petitioners Peter Paul
issued by Philamcare Health Systems, Inc.
Patrick Lucas, Fatima Gladys Lucas,
(Philamcare), for a possible consult. The
Abbeygail Lucas and Gillian Lucas seek the
Philamcare Coordinator, Dr. Edwin Oca,
reversal of the 27 September 2006
M.D., referred Peter to respondent, Dr.
Decision2 and 3 July 2007 Resolution,3 both
Prospero Ma. C. Tuaño, M.D. (Dr. Tuaño),
of the Court of Appeals in CA-G.R. CV No.
an ophthalmologist at St. Luke’s Medical
68666, entitled "Peter Paul Patrick Lucas,
Center, for an eye consult.
Fatima Gladys Lucas, Abbeygail Lucas and
Gillian Lucas v. Prospero Ma. C. Tuaño." Upon consultation with Dr. Tuaño, Peter
narrated that it had been nine (9) days
In the questioned decision and resolution,
since the problem with his right eye began;
the Court of Appeals affirmed the 14 July
and that he was already taking Maxitrol to
2000 Decision of the Regional Trial Court
address the problem in his eye. According
(RTC), Branch 150, Makati City, dismissing
to Dr. Tuaño, he performed "ocular routine
the complaint filed by petitioners in a civil
examination" on Peter’s eyes, wherein: (1) Peter had already been using Maxitrol prior
a gross examination of Peter’s eyes and to his consult with Dr. Tuaño.
their surrounding area was made; (2)
On 21 September 1988, Peter saw Dr.
Peter’s visual acuity were taken; (3)
Tuaño for a follow-up consultation. After
Peter’s eyes were palpated to check the
examining both of Peter’s eyes, Dr. Tuaño
intraocular pressure of each; (4) the
instructed the former to taper down10 the
motility of Peter’s eyes was observed; and
dosage of Maxitrol, because the EKC in his
(5) the ophthalmoscopy4 on Peter’s eyes
right eye had already resolved. Dr. Tuaño
was used. On that particular consultation,
specifically cautioned Peter that, being a
Dr. Tuaño diagnosed that Peter was
steroid, Maxitrol had to be withdrawn
suffering from conjunctivitis5 or "sore
gradually; otherwise, the EKC might
eyes." Dr. Tuaño then prescribed
6 recur.11
Spersacet-C  eye drops for Peter and told
the latter to return for follow-up after one Complaining of feeling as if there was
week. something in his eyes, Peter returned to
Dr. Tuaño for another check-up on 6
As instructed, Peter went back to Dr.
October 1988. Dr. Tuaño examined Peter’s
Tuaño on 9 September 1988. Upon
eyes and found that the right eye had once
examination, Dr. Tuaño told Peter that the
more developed EKC. So, Dr. Tuaño
"sore eyes" in the latter’s right eye had
instructed Peter to resume the use of
already cleared up and he could
Maxitrol at six (6) drops per day.
discontinue the Spersacet-C. However, the
same eye developed Epidemic Kerato On his way home, Peter was unable to get
Conjunctivitis (EKC),7 a viral infection. To a hold of Maxitrol, as it was out of stock.
address the new problem with Peter’s right Consequently, Peter was told by Dr. Tuano
eye, Dr. Tuaño prescribed to the former a to take, instead, Blephamide12 another
steroid-based eye drop called Maxitrol, 8 a steroid-based medication, but with a lower
dosage of six (6) drops per day. 9 To recall, concentration, as substitute for the
unavailable Maxitrol, to be used three (3)
times a day for five (5) days; two (2) times Prolonged use may result in glaucoma,
a day for five (5) days; and then just once with damage to the optic nerve, defects in
a day.13 visual acuity and fields of vision, and
posterior, subcapsular cataract formation.
Several days later, on 18 October 1988,
Prolonged use may suppress the host
Peter went to see Dr. Tuaño at his clinic,
response and thus increase the hazard of
alleging severe eye pain, feeling as if his
secondary ocular infractions, in those
eyes were about to "pop-out," a headache
diseases causing thinning of the cornea or
and blurred vision. Dr. Tuaño examined
sclera, perforations have been known to
Peter’s eyes and discovered that the EKC
occur with the use of topical steroids. In
was again present in his right eye. As a
acute purulent conditions of the eye,
result, Dr. Tuaño told Peter to resume the
steroids may mask infection or enhance
maximum dosage of Blephamide.
existing infection. If these products are
Dr. Tuaño saw Peter once more at the used for 10 days or longer, intraocular
former’s clinic on 4 November 1988. Dr. pressure should be routinely monitored
Tuaño’s examination showed that only the even though it may be difficult in children
periphery of Peter’s right eye was positive and uncooperative patients.
for EKC; hence, Dr. Tuaño prescribed a
Employment of steroid medication in the
lower dosage of Blephamide.
treatment of herpes simplex requires great
It was also about this time that Fatima caution.
Gladys Lucas (Fatima), Peter’s spouse,
xxxx
read the accompanying literature of
Maxitrol and found therein the following ADVERSE REACTIONS:
warning against the prolonged use of such
Adverse reactions have occurred with
steroids:
steroid/anti-infective combination drugs
WARNING: which can be attributed to the steroid
component, the anti-infective component,
or the combination. Exact incidence figures On 26 November 1988, Peter returned to
are not available since no denominator of Dr. Tuaño’s clinic, complaining of "feeling
treated patients is available. worse."14 It appeared that the EKC had
spread to the whole of Peter’s right eye yet
Reactions occurring most often from the
again. Thus, Dr. Tuaño instructed Peter to
presence of the anti-infective ingredients
resume the use of Maxitrol. Petitioners
are allergic sensitizations. The reactions
averred that Peter already made mention
due to the steroid component in
to Dr. Tuaño during said visit of the above-
decreasing order to frequency are
quoted warning against the prolonged use
elevation of intra-ocular pressure (IOP)
of steroids, but Dr. Tuaño supposedly
with possible development of glaucoma,
brushed aside Peter’s concern as mere
infrequent optic nerve damage; posterior
paranoia, even assuring him that the
subcapsular cataract formation; and
former was taking care of him (Peter).
delayed wound healing.
Petitioners further alleged that after
Secondary infection: The development of
Peter’s 26 November 1988 visit to Dr.
secondary has occurred after use of
Tuaño, Peter continued to suffer pain in his
combination containing steroids and
right eye, which seemed to "progress,"
antimicrobials. Fungal infections of the
with the ache intensifying and becoming
correa are particularly prone to develop
more frequent.
coincidentally with long-term applications
of steroid. The possibility of fungal invasion Upon waking in the morning of 13
must be considered in any persistent December 1988, Peter had no vision in his
corneal ulceration where steroid treatment right eye. Fatima observed that Peter’s
has been used. right eye appeared to be bloody and
swollen.15 Thus, spouses Peter and Fatima
Secondary bacterial ocular infection
rushed to the clinic of Dr. Tuaño. Peter
following suppression of host responses
reported to Dr. Tuaño that he had been
also occurs.
suffering from constant headache in the Peter went to see another ophthalmologist,
afternoon and blurring of vision. Dr. Ramon T. Batungbacal (Dr.
Batungbacal), on 21 December 1988, who
Upon examination, Dr. Tuaño noted the
allegedly conducted a complete
hardness of Peter’s right eye. With the use
ophthalmological examination of Peter’s
of a tonometer16 to verify the exact
eyes. Dr. Batungbacal’s diagnosis was
intraocular pressure17 (IOP) of Peter’s eyes,
Glaucoma25 O.D.26 He recommended Laser
Dr. Tuaño discovered that the tension in
Trabeculoplasty27 for Peter’s right eye.
Peter’s right eye was 39.0 Hg, while that
of his left was 17.0 Hg. 18 Since the tension When Peter returned to Dr. Tuaño on 23
in Peter’s right eye was way over December 1988,28 the tonometer
the normal IOP, which merely ranged measured the IOP of Peter’s right eye to
from 10.0 Hg to 21.0 Hg,19 Dr. Tuaño be 41.0 Hg,29 again, way above normal.
ordered20 him to immediately discontinue Dr. Tuaño addressed the problem by
the use of Maxitrol and prescribed to the advising Peter to resume taking Diamox
latter Diamox21 and Normoglaucon, along with Normoglaucon.
22
instead.  Dr. Tuaño also required Peter to
During the Christmas holidays, Peter
go for daily check-up in order for the
supposedly stayed in bed most of the time
former to closely monitor the pressure of
and was not able to celebrate the season
the latter’s eyes.
with his family because of the debilitating
On 15 December 1988, the tonometer effects of Diamox.30
reading of Peter’s right eye yielded a high
On 28 December 1988, during one of
normal level, i.e., 21.0 Hg. Hence, Dr.
Peter’s regular follow-ups with Dr. Tuaño,
Tuaño told Peter to continue using Diamox
the doctor conducted another ocular
and Normoglaucon. But upon Peter’s
routine examination of Peter’s eyes. Dr.
complaint of "stomach pains and tingling
Tuaño noted the recurrence of EKC in
sensation in his fingers,"23 Dr. Tuaño
Peter’s right eye. Considering, however,
discontinued Peter’s use of Diamox.24
that the IOP of Peter’s right eye was still
quite high at 41.0 Hg, Dr. Tuaño was at a considering that the IOP is still
32
loss as to how to balance the treatment of uncontrolled.
Peter’s EKC vis-à-vis the presence of
On 29 December 1988, Peter went to see
glaucoma in the same eye. Dr. Tuaño,
Dr. Agulto at the latter’s clinic. Several
thus, referred Peter to Dr. Manuel B.
tests were conducted thereat to evaluate
Agulto, M.D. (Dr. Agulto), another
the extent of Peter’s condition. Dr. Agulto
ophthalmologist specializing in the
31 wrote Dr. Tuaño a letter containing the
treatment of glaucoma.  Dr. Tuaño’s letter
following findings and recommendations:
of referral to Dr. Agulto stated that:
Thanks for sending Peter Lucas. On
Referring to you Mr. Peter Lucas for
examination conducted vision was 20/25 R
evaluation & possible management. I
and 20/20L. Tension curve 19 R and 15 L
initially saw him Sept. 2, 1988 because of
at 1210 H while on Normoglaucon BID OD
conjunctivitis. The latter resolved and he
& Diamox ½ tab every 6h po.
developed EKC for which I gave Maxitrol.
The EKC was recurrent after stopping Slit lamp evaluation33 disclosed
steroid drops. Around 1 month of steroid subepithelial corneal defect outer OD.
treatment, he noted blurring of vision & There was circumferential peripheral iris
pain on the R. however, I continued the atrophy, OD. The lenses were clear.
steroids for the sake of the EKC. A month
Funduscopy34 showed vertical cup disc of
ago, I noted iris atrophy, so I took the IOP
0.85 R and 0.6 L with temporal slope R>L.
and it was definitely elevated. I stopped
the steroids immediately and has (sic) Zeiss gonioscopy35 revealed basically open
been treating him medically. angles both eyes with occasional
36
PAS,  OD.
It seems that the IOP can be controlled
only with oral Diamox, and at the moment, Rolly, I feel that Peter Lucas has really
the EKC has recurred and I’m in a fix sustained significant glaucoma damage. I
whether to resume the steroid or not suggest that we do a baseline visual fields
and push medication to lowest possible at 21.0 Hg,42 as he had been without
levels. If I may suggest further, I think we Diamox for the past three (3) days.
should prescribe Timolol37 BID38 OD in lieu
On 4 January 1989, Dr. Tuaño conducted a
of Normoglaucon. If the IOP is still
visual field study43 of Peter’s eyes, which
inadequate, we may try D’epifrin 39 BID OD
revealed that the latter had tubular
(despite low PAS). I’m in favor of retaining
vision44 in his right eye, while that of his
Diamox or similar CAI.40
left eye remained normal. Dr. Tuaño
If fields show further loss in say – 3 mos. directed Peter to religiously use the
then we should consider trabeculoplasty. Diamox and Normoglaucon, as the tension
of the latter’s right eye went up even
I trust that this approach will prove
further to 41.0 Hg in just a matter of two
reasonable for you and Peter.41
(2) days, in the meantime that Timolol
Peter went to see Dr. Tuaño on 31 B.I.D. and D’epifrin were still not available
December 1988, bearing Dr. Agulto’s in the market. Again, Dr. Tuaño advised
aforementioned letter. Though Peter’s right Peter to come for regular check-up so his
and left eyes then had normal IOP of 21.0 IOP could be monitored.
Hg and 17.0 Hg, respectively, Dr. Tuaño
Obediently, Peter went to see Dr. Tuaño on
still gave him a prescription for Timolol
the 7th, 13th, 16th and 20th of January
B.I.D. so Peter could immediately start
1989 for check-up and IOP monitoring.
using said medication. Regrettably, Timolol
B.I.D. was out of stock, so Dr. Tuaño In the interregnum, however, Peter was
instructed Peter to just continue using prodded by his friends to seek a second
Diamox and Normoglaucon in the medical opinion. On 13 January 1989, Peter
meantime. consulted Dr. Jaime Lapuz, M.D. (Dr.
Lapuz), an ophthalmologist, who, in turn,
Just two days later, on 2 January 1989, the
referred Peter to Dr. Mario V. Aquino, M.D.
IOP of Peter’s right eye remained elevated
(Dr. Aquino), another ophthalmologist who
specializes in the treatment of glaucoma
and who could undertake the long term Quezon City. The case was docketed as
care of Peter’s eyes. Civil Case No. 92-2482.
According to petitioners, after Dr. Aquino In their Complaint, petitioners specifically
conducted an extensive evaluation of averred that as the "direct consequence of
Peter’s eyes, the said doctor informed [Peter’s] prolonged use of Maxitrol, [he]
Peter that his eyes were relatively normal, suffered from steroid induced glaucoma
though the right one sometimes which caused the elevation of his intra-
manifested maximum borderline tension. ocular pressure. The elevation of the intra-
Dr. Aquino also confirmed Dr. Tuaño’s ocular pressure of [Peter’s right eye]
diagnosis of tubular vision in Peter’s right caused the impairment of his vision which
eye. Petitioners claimed that Dr. Aquino impairment is not curable and may even
essentially told Peter that the latter’s lead to total blindness."49
condition would require lifetime medication
Petitioners additionally alleged that the
and follow-ups.
visual impairment of Peter’s right eye
In May 1990 and June 1991, Peter caused him and his family so much grief.
underwent two (2) procedures of laser Because of his present condition, Peter
trabeculoplasty to attempt to control the now needed close medical supervision
high IOP of his right eye. forever; he had already undergone two (2)
laser surgeries, with the possibility that
Claiming to have steroid-induced
45 more surgeries were still needed in the
glaucoma  and blaming Dr. Tuaño for the
future; his career in sports casting had
same, Peter, joined by: (1) Fatima, his
suffered and was continuing to suffer; 50 his
spouse46; (2) Abbeygail, his natural child 47;
anticipated income had been greatly
and (3) Gillian, his legitimate child 48 with
reduced as a result of his "limited"
Fatima, instituted on 1 September 1992, a
capacity; he continually suffered from
civil complaint for damages against Dr.
"headaches, nausea, dizziness, heart
Tuaño, before the RTC, Branch 150,
palpitations, rashes, chronic rhinitis,
sinusitis,"51 etc.; Peter’s relationships with 2. The amount of ₱300,000.00 to spouses
his spouse and children continued to be Lucas as and by way of actual damages
strained, as his condition made him highly plus such additional amounts that may be
irritable and sensitive; his mobility and proven during trial.
social life had suffered; his spouse, Fatima,
3. The amount of ₱1,000,000.00 as and by
became the breadwinner in the
52 way of moral damages.
family;  and his two children had been
deprived of the opportunity for a better life 4. The amount of ₱500,000.00 as and by
and educational prospects. Collectively, way of exemplary damages.
petitioners lived in constant fear of Peter
5. The amount of ₱200,000.00 as and by
becoming completely blind.53
way of attorney’s fees plus costs of suit. 54
In the end, petitioners sought pecuniary
In rebutting petitioners’ complaint, Dr.
award for their supposed pain and
Tuaño asserted that the "treatment made
suffering, which were ultimately brought
by [him] more than three years ago has no
about by Dr. Tuaño’s grossly negligent
causal connection to [Peter’s] present
conduct in prescribing to Peter the
glaucoma or condition."55 Dr. Tuaño
medicine Maxitrol for a period of three (3)
explained that "[d]rug-induced glaucoma is
months, without monitoring Peter’s IOP, as
temporary and curable, steroids have the
required in cases of prolonged use of said
side effect of increasing intraocular
medicine, and notwithstanding Peter’s
pressure. Steroids are prescribed to treat
constant complaint of intense eye pain
Epidemic Kerato Conjunctivitis or EKC
while using the same. Petitioners
which is an infiltration of the cornea as a
particularly prayed that Dr. Tuaño be
result of conjunctivitis or sore eyes." 56 Dr.
adjudged liable for the following amounts:
Tuaño also clarified that (1) "[c]ontrary to
1. The amount of ₱2,000,000.00 to plaintiff [petitioners’] fallacious claim, [he] did NOT
Peter Lucas as and by way of continually prescribe the drug Maxitrol
compensation for his impaired vision. which contained steroids for any prolonged
period"57 and "[t]he truth was the Maxitrol be due to other causes not attributable to
was discontinued x x x as soon as EKC steroids, certainly not attributable to [his]
disappeared and was resumed only when treatment of more than three years ago x
EKC reappeared"58; (2) the entire time he x x.
was treating Peter, he "continually
From a medical point of view, as revealed
monitored the intraocular pressure of
by more current examination of [Peter],
[Peter’s eyes] by palpating the eyes and by
the latter’s glaucoma can only be long
putting pressure on the eyeballs," and no
standing glaucoma, open angle glaucoma,
hardening of the same could be detected,
because of the large C:D ratio. The steroids
which meant that there was no increase in
provoked the latest glaucoma to be
the tension or IOP, a possible side reaction
revealed earlier as [Peter] remained
to the use of steroid medications; and (3) it
asymptomatic prior to steroid application.
was only on 13 December 1988 that Peter
Hence, the steroid treatment was in fact
complained of a headache and blurred
beneficial to [Peter] as it revealed the
vision in his right eye, and upon measuring
incipient open angle glaucoma of [Peter] to
the IOP of said eye, it was determined for
allow earlier treatment of the same. 60
the first time that the IOP of the right eye
had an elevated value. In a Decision dated 14 July 2000, the RTC
dismissed Civil Case No. 92-2482 "for
But granting for the sake of argument that
insufficiency of evidence."61 The decretal
the "steroid treatment of [Peter’s] EKC
part of said Decision reads:
caused the steroid induced
59
glaucoma,"  Dr. Tuaño argued that: Wherefore, premises considered, the
instant complaint is dismissed for
[S]uch condition, i.e., elevated intraocular
insufficiency of evidence. The counter
pressure, is temporary. As soon as the
claim (sic) is likewise dismissed in the
intake of steroids is discontinued, the
absence of bad faith or malice on the part
intraocular pressure automatically is
of plaintiff in filing the suit.62
reduced. Thus, [Peter’s] glaucoma can only
The RTC opined that petitioners failed to established, a medical practitioner who
prove by preponderance of evidence that departed thereof breaches his duty and
Dr. Tuaño was negligent in his treatment of commits negligence rendering him liable.
Peter’s condition. In particular, the record Without such testimony or enlightenment
of the case was bereft of any evidence to from an expert, the court is at a loss as to
establish that the steroid medication and what is then the established norm of duty
its dosage, as prescribed by Dr. Tuaño, of a physician against which defendant’s
caused Peter’s glaucoma. The trial court conduct can be compared with to
reasoned that the "recognized standards of determine negligence.64
the medical community has not been
The RTC added that in the absence of "any
established in this case, much less has
medical evidence to the contrary, this
causation been established to render
court cannot accept [petitioners’] claim
[Tuaño] liable."63 According to the RTC:
that the use of steroid is the proximate
[Petitioners] failed to establish the duty cause of the damage sustained by [Peter’s]
required of a medical practitioner against eye."65
which Peter Paul’s treatment by defendant
Correspondingly, the RTC accepted Dr.
can be compared with. They did not
Tuaño’s medical opinion that "Peter Paul
present any medical expert or even a
must have been suffering from normal
medical doctor to convince and expertly
tension glaucoma, meaning, optic nerve
explain to the court the established norm
damage was happening but no elevation of
or duty required of a physician treating a
the eye pressure is manifested, that the
patient, or whether the non taking (sic) by
steroid treatment actually unmasked the
Dr. Tuaño of Peter Paul’s pressure a
condition that resulted in the earlier
deviation from the norm or his non-
treatment of the glaucoma. There is
discovery of the glaucoma in the course of
nothing in the record to contradict such
treatment constitutes negligence. It is
testimony. In fact, plaintiff’s Exhibit ‘S’
important and indispensable to establish
even tends to support them."
such a standard because once it is
Undaunted, petitioners appealed the Agulto was not presented by [petitioners]
foregoing RTC decision to the Court of as a witness to confirm what he allegedly
Appeals. Their appeal was docketed as CA- told Peter and, therefore, the latter’s
G.R. CV No. 68666. testimony is hearsay. Under Rule 130,
Section 36 of the Rules of Court, a witness
On 27 September 2006, the Court of
can testify only to those facts which he
Appeals rendered a decision in CA-G.R. CV
knows of his own personal knowledge, x x
No. 68666 denying petitioners’ recourse
x. Familiar and fundamental is the rule that
and affirming the appealed RTC Decision.
hearsay testimony is inadmissible as
The fallo of the judgment of the appellate
evidence.67
court states:
Like the RTC, the Court of Appeals gave
WHEREFORE, the Decision appealed from
great weight to Dr. Tuaño’s medical
is AFFIRMED.66
judgment, specifically the latter’s
The Court of Appeals faulted petitioners explanation that:
because they –
[W]hen a doctor sees a patient, he cannot
[D]id not present any medical expert to determine whether or not the latter would
testify that Dr. Tuano’s prescription of react adversely to the use of steroids, that
Maxitrol and Blephamide for the treatment it was only on December 13, 1989, when
of EKC on Peter’s right eye was not proper Peter complained for the first time of
and that his palpation of Peter’s right eye headache and blurred vision that he
was not enough to detect adverse reaction observed that the pressure of the eye of
to steroid. Peter testified that Dr. Manuel Peter was elevated, and it was only then
Agulto told him that he should not have that he suspected that Peter belongs to the
used steroid for the treatment of EKC or 5% of the population who reacts adversely
that he should have used it only for two (2) to steroids.68
weeks, as EKC is only a viral infection
which will cure by itself. However, Dr.
Petitioners’ Motion for Reconsideration was III.
denied by the Court of Appeals in a
THE COURT OF APPEALS COMMITTED
Resolution dated 3 July 2007.
GRAVE REVERSIBLE ERROR IN NOT
Hence, this Petition for Review on FINDING THE RESPONDENT LIABLE TO THE
Certiorari under Rule 45 of the Revised PETITIONERS’ FOR ACTUAL, MORAL AND
Rules of Court premised on the following EXEMPLARY DAMAGES, ASIDE FROM
assignment of errors: ATTORNEY’S FEES, COSTS OF SUIT, AS A
RESULT OF HIS GROSS NEGLIGENCE.69
I.
A reading of the afore-quoted reversible
THE COURT OF APPEALS COMMITTED
errors supposedly committed by the Court
GRAVE REVERSIBLE ERROR IN AFFIRMING
of Appeals in its Decision and Resolution
THE DECISION OF THE TRIAL COURT
would reveal that petitioners are
DISMISSING THE PETITIONERS’ COMPLAINT
fundamentally assailing the finding of the
FOR DAMAGES AGAINST THE RESPONDENT
Court of Appeals that the evidence on
ON THE GROUND OF INSUFFICIENCY OF
record is insufficient to establish
EVIDENCE;
petitioners’ entitlement to any kind of
II. damage. Therefore, it could be said that
the sole issue for our resolution in the
THE COURT OF APPEALS COMMITTED
Petition at bar is whether the Court of
GRAVE REVERSIBLE ERROR IN DISMISSING
Appeals committed reversible error in
THE PETITIONERS’ COMPLAINT FOR
affirming the judgment of the RTC that
DAMAGES AGAINST THE RESPONDENT ON
petitioners failed to prove, by
THE GROUND THAT NO MEDICAL EXPERT
preponderance of evidence, their claim for
WAS PRESENTED BY THE PETITIONERS TO
damages against Dr. Tuaño.
PROVE THEIR CLAIM FOR MEDICAL
NEGLIGENCE AGAINST THE RESPONDENT; Evidently, said issue constitutes a question
AND of fact, as we are asked to revisit anew the
factual findings of the Court of Appeals, as
well as of the RTC. In effect, petitioners allegations and arguments in the instant
would have us sift through the evidence on Petition.1avvphi1.zw+
record and pass upon whether there is
Petitioners contend, that "[c]ontrary to the
sufficient basis to establish Dr. Tuaño’s
findings of the Honorable Court of Appeals,
negligence in his treatment of Peter’s eye
[they] were more than able to establish
condition. This question clearly involves a
that: Dr. Tuaño ignored the standard
factual inquiry, the determination of which
medical procedure for ophthalmologists,
is not within the ambit of this Court’s
administered medication with
power of review under Rule 45 of the 1997
recklessness, and exhibited an absence of
Rules Civil Procedure, as amended.70
competence and skills expected from
Elementary is the principle that this Court him."72 Petitioners reject the necessity of
is not a trier of facts; only errors of law are presenting expert and/or medical
generally reviewed in petitions for review testimony to establish (1) the standard of
on certiorari criticizing decisions of the care respecting the treatment of the
Court of Appeals. Questions of fact are not disorder affecting Peter’s eye; and (2)
entertained.71 whether or not negligence attended Dr.
Tuaño’s treatment of Peter, because, in
Nonetheless, the general rule that only
their words –
questions of law may be raised on appeal
in a petition for review under Rule 45 of That Dr. Tuaño was grossly negligent in the
the Rules of Court admits of certain treatment of Peter’s simple eye ailment is
exceptions, including the circumstance a simple case of cause and effect. With
when the finding of fact of the Court of mere documentary evidence and based on
Appeals is premised on the supposed the facts presented by the petitioners,
absence of evidence, but is contradicted respondent can readily be held liable for
by the evidence on record. Although damages even without any expert
petitioners may not explicitly invoke said testimony. In any case, however, and
exception, it may be gleaned from their contrary to the finding of the trial court
and the Court of Appeals, there was a [petitioners]."75 Clearly, the present
medical expert presented by the petitioner controversy is a classic illustration of a
showing the recklessness committed by medical negligence case against a
[Dr. Tuaño] – Dr. Tuaño himself. [Emphasis physician based on the latter’s professional
supplied.] negligence. In this type of suit, the patient
or his heirs, in order to prevail, is required
They insist that Dr. Tuaño himself gave
to prove by preponderance of evidence
sufficient evidence to establish his gross
that the physician failed to exercise that
negligence that ultimately caused the
degree of skill, care, and learning
impairment of the vision of Peter’s right
possessed by other persons in the same
eye,73 i.e., that "[d]espite [Dr. Tuaño’s]
profession; and that as a proximate result
knowledge that 5% of the population
of such failure, the patient or his heirs
reacts adversely to Maxitrol, [he] had no
suffered damages.
qualms whatsoever in prescribing said
steroid to Peter without first determining For lack of a specific law geared towards
whether or not the (sic) Peter belongs to the type of negligence committed by
the 5%."74 members of the medical profession, such
claim for damages is almost always
We are not convinced. The judgments of
anchored on the alleged violation of Article
both the Court of Appeals and the RTC are
2176 of the Civil Code, which states that:
in accord with the evidence on record, and
we are accordingly bound by the findings ART. 2176. Whoever by act or omission
of fact made therein. causes damage to another, there being
fault or negligence, is obliged to pay for
Petitioners’ position, in sum, is that Peter’s
the damage done. Such fault or
glaucoma is the direct result of Dr. Tuaño’s
negligence, if there is no pre-existing
negligence in his improper administration
contractual relation between the parties, is
of the drug Maxitrol; "thus, [the latter]
called a quasi-delict and is governed by
should be liable for all the damages
the provisions of this Chapter.
suffered and to be suffered by
In medical negligence cases, also called same level of care that any other
medical malpractice suits, there exist a reasonably competent physician would use
physician-patient relationship between the to treat the condition under similar
doctor and the victim. But just like any circumstances.
other proceeding for damages, four
This standard level of care, skill and
essential (4) elements i.e., (1) duty; (2)
diligence is a matter best addressed by
breach; (3) injury; and (4) proximate
expert medical testimony, because the
causation,76 must be established by the
standard of care in a medical malpractice
plaintiff/s. All the four (4) elements must
case is a matter peculiarly within the
co-exist in order to find the physician
knowledge of experts in the field.79
negligent and, thus, liable for damages.
There is breach of duty of care, skill and
When a patient engages the services of a
diligence, or the improper performance of
physician, a physician-patient relationship
such duty, by the attending physician
is generated. And in accepting a case, the
when the patient is injured in body or in
physician, for all intents and purposes,
health [and this] constitutes the actionable
represents that he has the needed training
malpractice.80 Proof of such breach must
and skill possessed by physicians and
likewise rest upon the testimony of an
surgeons practicing in the same field; and
expert witness that the treatment
that he will employ such training, care, and
accorded to the patient failed to meet the
skill in the treatment of the patient.77 Thus,
standard level of care, skill and diligence
in treating his patient, a physician is under
which physicians in the same general
a duty to [the former] to exercise that
neighborhood and in the same general line
degree of care, skill and diligence which
of practice ordinarily possess and exercise
physicians in the same general
in like cases.
neighborhood and in the same general line
of practice ordinarily possess and exercise Even so, proof of breach of duty on the
in like cases.78 Stated otherwise, the part of the attending physician is
physician has the duty to use at least the insufficient, for there must be a causal
connection between said breach and the ken of the average layperson; using the
resulting injury sustained by the patient. specialized knowledge and training of his
Put in another way, in order that there may field, the expert’s role is to present to the
be a recovery for an injury, it must be [court] a realistic assessment of the
shown that the "injury for which recovery likelihood that [the physician’s] alleged
is sought must be the legitimate negligence caused [the patient’s] injury. 83
consequence of the wrong done; the
From the foregoing, it is apparent that
connection between the negligence and
medical negligence cases are best proved
the injury must be a direct and natural
by opinions of expert witnesses belonging
sequence of events, unbroken by
81 in the same general neighborhood and in
intervening efficient causes";  that is, the
the same general line of practice as
negligence must be the proximate cause of
defendant physician or surgeon. The
the injury. And the proximate cause of an
deference of courts to the expert opinion
injury is that cause, which, in the natural
of qualified physicians [or surgeons] stems
and continuous sequence, unbroken by
from the former’s realization that the latter
any efficient intervening cause, produces
possess unusual technical skills which
the injury, and without which the result
laymen in most instances are incapable of
would not have occurred.82
intelligently evaluating;84 hence, the
Just as with the elements of duty and indispensability of expert testimonies.
breach of the same, in order to establish
In the case at bar, there is no question that
the proximate cause [of the injury] by a
a physician-patient relationship developed
preponderance of the evidence in a
between Dr. Tuaño and Peter when Peter
medical malpractice action, [the patient]
went to see the doctor on 2 September
must similarly use expert testimony,
1988, seeking a consult for the treatment
because the question of whether the
of his sore eyes. Admittedly, Dr. Tuaño, an
alleged professional negligence caused
ophthalmologist, prescribed Maxitrol when
[the patient’s] injury is generally one for
Peter developed and had recurrent EKC.
specialized expert knowledge beyond the
Maxitrol or neomycin/polymyxin B and (3) that the injury or damage to
sulfates/dexamethasone ophthalmic Peter’s right eye, i.e., his glaucoma, was
ointment is a multiple-dose anti-infective the result of his use of Maxitrol, as
steroid combination in sterile form for prescribed by Dr. Tuaño. Petitioners’
topical application.85 It is the drug which failure to prove the first element alone is
petitioners claim to have caused Peter’s already fatal to their cause.
glaucoma.
Petitioners maintain that Dr. Tuaño failed
However, as correctly pointed out by the to follow in Peter’s case the required
Court of Appeals, "[t]he onus probandi was procedure for the prolonged use of
on the patient to establish before the trial Maxitrol. But what is actually the required
court that the physicians ignored standard procedure in situations such as in the case
medical procedure, prescribed and at bar? To be precise, what is the standard
administered medication with recklessness operating procedure when
and exhibited an absence of the ophthalmologists prescribe steroid
competence and skills expected of general medications which, admittedly, carry some
practitioners similarly modicum of risk?
86
situated."  Unfortunately, in this case,
Absent a definitive standard of care or
there was absolute failure on the part of
diligence required of Dr. Tuaño under the
petitioners to present any expert
circumstances, we have no means to
testimony to establish: (1) the standard of
determine whether he was able to comply
care to be implemented by competent
with the same in his diagnosis and
physicians in treating the same condition
treatment of Peter. This Court has no
as Peter’s under similar circumstances; (2)
yardstick upon which to evaluate or weigh
that, in his treatment of Peter, Dr. Tuaño
the attendant facts of this case to be able
failed in his duty to exercise said standard
to state with confidence that the acts
of care that any other competent physician
complained of, indeed, constituted
would use in treating the same condition
as Peter’s under similar circumstances;
negligence and, thus, should be the every time Peter went to see him for
subject of pecuniary reparation. follow-up consultation and/or check-up.
Petitioners assert that prior to prescribing We cannot but agree with Dr. Tuaño’s
Maxitrol, Dr. Tuaño should have assertion that when a doctor sees a
determined first whether Peter was a patient, he cannot determine immediately
"steroid responder."87 Yet again, whether the latter would react adversely to
petitioners did not present any convincing the use of steroids; all the doctor can do is
proof that such determination is actually map out a course of treatment recognized
part of the standard operating procedure as correct by the standards of the medical
which ophthalmologists should unerringly profession. It must be remembered that a
follow prior to prescribing steroid physician is not an insurer of the good
medications. result of treatment. The mere fact that the
patient does not get well or that a bad
In contrast, Dr. Tuaño was able to clearly
result occurs does not in itself indicate
explain that what is only required of
failure to exercise due care. 89 The result is
ophthalmologists, in cases such as Peter’s,
not determinative of the performance [of
is the conduct of standard tests/procedures
the physician] and he is not required to be
known as "ocular routine
88 infallible.90
examination,"  composed of five (5)
tests/procedures – specifically, gross Moreover, that Dr. Tuaño saw it fit to
examination of the eyes and the prescribe Maxitrol to Peter was justified by
surrounding area; taking of the visual the fact that the latter was already using
acuity of the patient; checking the the same medication when he first came to
intraocular pressure of the patient; see Dr. Tuaño on 2 September 1988 and
checking the motility of the eyes; and had exhibited no previous untoward
using ophthalmoscopy on the patient’s eye reaction to that particular drug. 91
– and he did all those tests/procedures
Also, Dr. Tuaño categorically denied
petitioners’ claim that he never monitored
the tension of Peter’s eyes while the latter caused the injury. A verdict in a
was on Maxitrol. Dr. Tuaño testified that he malpractice action cannot be based on
palpated Peter’s eyes every time the latter speculation or conjecture. Causation must
came for a check-up as part of the doctor’s be proven within a reasonable medical
ocular routine examination, a fact which probability based upon competent expert
petitioners failed to rebut. Dr. Tuaño’s testimony.93
regular conduct of examinations and tests
The causation between the physician’s
to ascertain the state of Peter’s eyes
negligence and the patient’s injury may
negate the very basis of petitioners’
only be established by the presentation of
complaint for damages. As to whether Dr.
proof that Peter’s glaucoma would not
Tuaño’s actuations conformed to the
have occurred but for Dr. Tuaño’s
standard of care and diligence required in
supposed negligent conduct. Once more,
like circumstances, it is presumed to have
petitioners failed in this regard.
so conformed in the absence of evidence
to the contrary. Dr. Tuaño does not deny that the use of
Maxitrol involves the risk of increasing a
Even if we are to assume that Dr. Tuaño
patient’s IOP. In fact, this was the reason
committed negligent acts in his treatment
why he made it a point to palpate Peter’s
of Peter’s condition, the causal connection
eyes every time the latter went to see him
between Dr. Tuaño’s supposed negligence
-- so he could monitor the tension of
and Peter’s injury still needed to be
Peter’s eyes. But to say that said
established. The critical and clinching
medication conclusively caused Peter’s
factor in a medical negligence case is proof
glaucoma is purely speculative. Peter was
of the causal connection between the
diagnosed with open-angle glaucoma. This
negligence which the evidence established
kind of glaucoma is characterized by an
and the plaintiff’s injuries.92 The plaintiff
almost complete absence of symptoms
must plead and prove not only that he has
and a chronic, insidious course. 94 In open-
been injured and defendant has been at
angle glaucoma, halos around lights and
fault, but also that the defendant’s fault
blurring of vision do not occur unless there Philippine Board of Ophthalmology; that he
has been a sudden increase in the occupies various teaching posts (at the
intraocular vision.95 Visual acuity remains time of the filing of the present complaint,
good until late in the course of the he was the Chair of the Department of
disease.96 Hence, Dr. Tuaño claims that Ophthalmology and an Associate Professor
Peter’s glaucoma "can only be long at the University of the Philippines-
standing x x x because of the large Philippine General Hospital and St. Luke’s
C:D97 ratio," and that "[t]he steroids Medical Center, respectively); and that he
provoked the latest glaucoma to be held an assortment of positions in
revealed earlier" was a blessing in disguise numerous medical organizations like the
"as [Peter] remained asymptomatic prior to Philippine Medical Association, Philippine
steroid application." Academy of Ophthalmology, Philippine
Board of Ophthalmology, Philippine Society
Who between petitioners and Dr. Tuaño is
of Ophthalmic Plastic and Reconstructive
in a better position to determine and
Surgery, Philippine Journal of
evaluate the necessity of using Maxitrol to
Ophthalmology, Association of Philippine
cure Peter’s EKC vis-à-vis the attendant
Ophthalmology Professors, et al.
risks of using the same?
It must be remembered that when the
That Dr. Tuaño has the necessary training
qualifications of a physician are admitted,
and skill to practice his chosen field is
as in the instant case, there is an
beyond cavil. Petitioners do not dispute Dr.
inevitable presumption that in proper
Tuaño’s qualifications – that he has been a
cases, he takes the necessary precaution
physician for close to a decade and a half
and employs the best of his knowledge and
at the time Peter first came to see him;
skill in attending to his clients, unless the
that he has had various medical training;
contrary is sufficiently established. 98 In
that he has authored numerous papers in
making the judgment call of treating
the field of ophthalmology, here and
Peter’s EKC with Maxitrol, Dr. Tuaño took
abroad; that he is a Diplomate of the
the necessary precaution by palpating
Peter’s eyes to monitor their IOP every burden of evidence shifts to defendant to
time the latter went for a check-up, and he controvert plaintiff’s prima facie case;
employed the best of his knowledge and otherwise, a verdict must be returned in
skill earned from years of training and favor of plaintiff.99 The party having the
practice. burden of proof must establish his case by
a preponderance of evidence.100 The
In contrast, without supporting expert
concept of "preponderance of evidence"
medical opinions, petitioners’ bare
refers to evidence which is of greater
assertions of negligence on Dr. Tuaño’s
weight or more convincing than that which
part, which resulted in Peter’s glaucoma,
is offered in opposition to it; 101 in the last
deserve scant credit.
analysis, it means probability of truth. It is
Our disposition of the present controversy evidence which is more convincing to the
might have been vastly different had court as worthy of belief than that which is
petitioners presented a medical expert to offered in opposition thereto.102 Rule 133,
establish their theory respecting Dr. Section 1 of the Revised Rules of Court
Tuaño’s so-called negligence. In fact, the provides the guidelines for determining
record of the case reveals that petitioners’ preponderance of evidence, thus:
counsel recognized the necessity of
In civil cases, the party having the burden
presenting such evidence. Petitioners even
of proof must establish his case by a
gave an undertaking to the RTC judge that
preponderance of evidence. In determining
Dr. Agulto or Dr. Aquino would be
where the preponderance or superior
presented. Alas, no follow-through on said
weight of evidence on the issues involved
undertaking was made.1avvphi1
lies the court may consider all the facts
The plaintiff in a civil case has the burden and circumstances of the case, the
of proof as he alleges the affirmative of the witnesses’ manner of testifying, their
issue. However, in the course of trial in a intelligence, their means and opportunity
civil case, once plaintiff makes out a prima of knowing the facts to which they are
facie case in his favor, the duty or the testifying, the nature of the facts to which
they testify, the probability or through expert medical witnesses, then
improbability of their testimony, their courts have no standard by which to gauge
interest or want of interest, and also their the basic issue of breach thereof by the
personal credibility so far as the same physician or surgeon. The RTC and Court of
legitimately appear upon the trial. The Appeals, and even this Court, could not be
court may also consider the number of expected to determine on its own what
witnesses, though the preponderance is medical technique should have been
not necessarily with the greater number. utilized for a certain disease or injury.
Absent expert medical opinion, the courts
Herein, the burden of proof was clearly
would be dangerously engaging in
upon petitioners, as plaintiffs in the lower
speculations.
court, to establish their case by a
preponderance of evidence showing a All told, we are hard pressed to find Dr.
reasonable connection between Dr. Tuaño liable for any medical negligence or
Tuaño’s alleged breach of duty and the malpractice where there is no evidence, in
damage sustained by Peter’s right eye. the nature of expert testimony, to
This, they did not do. In reality, petitioners’ establish that in treating Peter, Dr. Tuaño
complaint for damages is merely anchored failed to exercise reasonable care,
on a statement in the literature of Maxitrol diligence and skill generally required in
identifying the risks of its use, and the medical practice. Dr. Tuaño’s testimony,
purported comment of Dr. Agulto – another that his treatment of Peter conformed in all
doctor not presented as witness before the respects to standard medical practice in
RTC – concerning the prolonged use of this locality, stands unrefuted.
Maxitrol for the treatment of EKC. Consequently, the RTC and the Court of
Appeals correctly held that they had no
It seems basic that what constitutes proper
basis at all to rule that petitioners were
medical treatment is a medical question
deserving of the various damages prayed
that should have been presented to
for in their Complaint.
experts. If no standard is established
WHEREFORE, premises considered, the
instant petition is DENIED for lack of merit.
The assailed Decision dated 27 September
2006 and Resolution dated 3 July 2007,
both of the Court of Appeals in CA-G.R. CV
No. 68666, are hereby AFFIRMED. No cost.
SO ORDERED.
G.R. No. 171127               March 11, medical negligence, commonly assailing
2015 the October 29, 2004 decision2 and the
January 12, 2006 resolution3 of the Court of
NOEL CASUMPANG, RUBY SANGA-
Appeals (CA) in CA-G.R. CV No. 56400. This
MIRANDA and SAN JUAN DEDIOS
CA decision affirmed en totothe ruling of
HOSPITAL, Petitioners,
the Regional Trial Court (RTC), Branch 134,
vs.
Makati City.
NELSON CORTEJO, Respondent.
The RTC awarded Nelson Cortejo
x-----------------------x
(respondent) damages in the total amount
G.R. No. 171217 of ₱595,000.00, for the wrongful death of
his son allegedly due to the medical
DRA. RUBY SANGA-
negligence of the petitioning doctors and
MIRANDA, Petitioner,
the hospital.
vs.
NELSON CORTEJO, Respondent. Factual Antecedents
x-----------------------x The common factual antecedents are
briefly summarized below.
G.R. No. 171228
On April 22, 1988, at about 11:30 in the
SAN JUAN DEDIOS
morning, Mrs. Jesusa Cortejo brought her
HOSPITAL, Petitioner,
11-year old son, Edmer Cortejo (Edmer), to
vs.
the Emergency Room of the San Juan de
NELSON CORTEJO, Respondent.
Dios Hospital (SJDH) because of difficulty in
DECISION breathing, chest pain, stomach pain, and
fever.4
BRION, J.:
Dr. Ramoncito Livelo (Dr. Livelo) initially
We resolve the three (3) consolidated
attended to and examined Edmer. In her
petitions for review on Certiorari 1 involving
testimony, Mrs. Cortejo narrated that in the
morning of April 20, 1988, Edmer had At 5:30 in the afternoon of the same day,
developed a slight fever that lasted for one Dr. Casumpang for the first time examined
day; a few hours upon discovery, she Edmer in his room. Using only a
brought Edmer to their family doctor; and stethoscope, he confirmed the initial
two hours after administering medications, diagnosis of "Bronchopneumonia."9
Edmer’s fever had subsided.5
At that moment, Mrs. Cortejo recalled
After taking Edmer’s medical history, Dr. entertaining doubts on the doctor’s
Livelo took his vital signs, body diagnosis. She immediately advised Dr.
6
temperature, and blood pressure.  Based Casumpang that Edmer had a high fever,
on these initial examinations and the chest and had no colds or cough10 but Dr.
x-ray test that followed, Dr. Livelo Casumpang merely told her that her son’s
diagnosed Edmer with "blood pressure is just being active," 11 and
7
"bronchopneumonia.  " Edmer’s blood was remarked that "that’s the usual
also taken for testing, typing, and for bronchopneumonia, no colds, no
12
purposes of administering antibiotics. phlegm."  Dr. Casumpang next visited and
Afterwards, Dr. Livelo gave Edmer an examined Edmer at 9:00 in the morning
antibiotic medication to lessen his fever the following day.13 Still suspicious about
and to loosen his phlegm. his son’s illness, Mrs. Cortejo again called
Dr. Casumpang’s attention and stated that
Mrs. Cortejo did not know any doctor at
Edmer had a fever, throat irritation, as well
SJDH. She used her Fortune Care card and
as chest and stomach pain. Mrs. Cortejo
was referred to an accredited Fortune Care
also alerted Dr. Casumpang about the
coordinator, who was then out of town. She
traces of blood in Edmer’s sputum. Despite
was thereafter assigned to Dr. Noel
these pieces of information, however, Dr.
Casumpang (Dr. Casumpang), a
Casumpang simply nodded, inquired if
pediatrician also accredited with Fortune
Edmer has an asthma, and reassured Mrs.
Care.8
Cortejo that Edmer’s illness is
14
bronchopneumonia.
At around 11:30 in the morning of April 23, fever and not continuing; and the rashes in
1988, Edmer vomited "phlegm with blood the patient’s skin were not
streak"15 prompting the respondent
"Herman’s Rash" and not typical of dengue
(Edmer’s father) to request for a doctor at
fever.18
the nurses’ station.16 Forty-five minutes
later, Dr. Ruby Miranda-Sanga (Dr. Sanga), At 3:00 in the afternoon, Edmer once again
one of the resident physicians of SJDH, vomited blood. Upon seeing Dr. Sanga, the
arrived. She claimed that although aware respondent showed her Edmer’s blood
that Edmer had vomited "phlegm with specimen, and reported that Edmer had
blood streak," she failed to examine the complained of severe stomach pain and
blood specimen because the respondent difficulty in moving his right leg.19
washed it away. She then advised the
Dr. Sanga then examined Edmer’s "sputum
respondent to preserve the specimen for
with blood" and noted that he was
examination.
bleeding. Suspecting that he could be
Thereafter, Dr. Sanga conducted a physical afflicted with dengue, she inserted a
check-up covering Edmer’s head, eyes, plastic tube in his nose, drained the liquid
nose, throat, lungs, skin and abdomen; and from his stomach with ice cold normal
found that Edmer had a low-grade non- saline solution, and gave an instruction not
continuing fever, and rashes that were not to pull out the tube, or give the patient any
typical of dengue fever.17 Her medical oral medication.
findings state:
Dr. Sanga thereafter conducted a
the patient’s rapid breathing and then the tourniquet test, which turned out to be
lung showed sibilant and the patient’s nose negative.20 She likewise ordered the
is flaring which is a sign that the patient is monitoring of the patient’s blood pressure
in respiratory distress; the abdomen has and some blood tests. Edmer’s blood
negative finding; the patient has low grade pressure was later found to be normal. 21
At 4:40 in the afternoon, Dr. Sanga called requested for an ambulance but he was
up Dr. Casumpang at his clinic and told informed that the driver was nowhere to
him about Edmer’s condition. 22 Upon being be found. This prompted him to hire a
informed, Dr. Casumpang ordered several private ambulance that cost him ₱600.00.23
procedures done including: hematocrit,
At 12:00 midnight, Edmer, accompanied by
hemoglobin, blood typing, blood
his parents and by Dr. Casumpang, was
transfusion and tourniquet tests.
transferred to Makati Medical Center.
The blood test results came at about 6:00
Dr. Casumpang immediately gave the
in the evening.
attending physician the patient’s clinical
Dr. Sanga advised Edmer’s parents that history and laboratory exam results. Upon
the blood test results showed that Edmer examination, the attending physician
was suffering from "Dengue Hemorrhagic diagnosed "Dengue Fever Stage IV" that
Fever." One hour later, Dr. Casumpang was already in its irreversible stage.
arrived at Edmer’s room and he
Edmer died at 4:00 in the morning of April
recommended his transfer to the Intensive
24, 1988.24 His Death Certificate indicated
Care Unit (ICU), to which the respondent
the cause of death as "Hypovolemic
consented. Since the ICU was then full, Dr.
Shock/hemorrhagic shock;" "Dengue
Casumpang suggested to the respondent
Hemorrhagic Fever Stage IV."
that they hire a private nurse. The
respondent, however, insisted on Believing that Edmer’s death was caused
transferring his son to Makati Medical by the negligent and erroneous diagnosis
Center. of his doctors, the respondent instituted an
action for damages against SJDH, and its
After the respondent had signed the
attending physicians: Dr. Casumpang and
waiver, Dr. Casumpang, for the last time,
Dr. Sanga (collectively referred to as the
checked Edmer’s condition, found that his
"petitioners") before the RTC of Makati
blood pressure was stable, and noted that
City.
he was "comfortable." The respondent
The Ruling of the Regional Trial Court The trial court also found that aside from
their self-serving testimonies, the
In a decision25 dated May 30, 1997, the
petitioning doctors did not present other
RTC ruled in favor of the respondent, and
evidence to prove that they exercised the
awarded actual and moral damages, plus
proper medical attention in diagnosing and
attorney's fees and costs.
treating the patient, leading it to conclude
In ruling that the petitioning doctors were that they were guilty of negligence. The
negligent, the RTC found untenable the RTC also held SJDH solidarily liable with the
petitioning doctors’ contention that petitioning doctors for damages based on
Edmer’s initial symptoms did not indicate the following findings of facts: first, Dr.
dengue fever. It faulted them for heavily Casumpang, as consultant, is an ostensible
relying on the chest x-ray result and for agent of SJDH because before the hospital
not considering the other manifestations engaged his medical services, it
that Edmer’s parents had relayed. It held scrutinized and determined his fitness,
that in diagnosing and treating an illness, qualifications, and competence as a
the physician’s conduct should be judged medical practitioner; and second, Dr.
not only by what he/she saw and knew, but Sanga, as resident physician, is an
also by what he/she could have reasonably employee of SJDH because like Dr.
seen and known. It also observed that Casumpang, the hospital, through its
based on Edmer’s signs and symptoms, his screening committee, scrutinized and
medical history and physical examination, determined her qualifications, fitness,and
and also the information that the competence before engaging her services;
petitioning doctors gathered from his the hospital also exercised control over her
family members, dengue fever was a work.
reasonably foreseeable illness; yet, the
The dispositive portion of the decision
petitioning doctors failed to take a second
reads:
look, much less, consider these indicators
of dengue.
WHEREFORE, judgment is hereby rendered "dengue fever" expected of an ordinary
in favor of the plaintiff and against the doctor as medical negligence. The CA also
defendants, ordering the latter to pay considered the petitioning doctors’
solidarily and severally plaintiff the testimonies as self-serving, noting that
following: they presented no other evidence to prove
that they exercised due diligence in
(1) Moral damages in the amount of
diagnosing Edmer’s illness.
₱500,000.00;
The CA likewise found Dr. Rodolfo Jaudian’s
(2) Costs of burial and funeral in the
(Dr. Jaudian) testimony admissible. It gave
amount of ₱45,000.00;
credence to his opinion26 that: (1) given
(3) Attorney’s fees of ₱50,000.00; and the exhibited symptoms of the patient,
dengue fever should definitely be
(4) Cost of this suit.
considered, and bronchopneumonia could
SO ORDERED. be reasonably ruled out; and (2) dengue
fever could have been detected earlier
The petitioners appealed the decision to
than 7:30 in the evening of April 23, 1988
the CA.
because the symptoms were already
The Ruling of the Court of Appeals evident; and agreed with the RTC that the
petitioning doctors should not have solely
In its decision dated October 29, 2004, the
relied on the chest-x-ray result, as it was
CA affirmed en toto the RTC’s ruling,
not conclusive.
finding that SJDH and its attending
physicians failed to exercise the minimum On SJDH’s solidary liability, the CA ruled
medical care, attention, and treatment that the hospital’s liability is based on
expected of an ordinary doctor under like Article 2180 of the Civil Code. The CA
circumstances. opined that the control which the hospital
exercises over its consultants, the
The CA found the petitioning doctors’
hospital’s power to hire and terminate
failure to read even the most basic signs of
their services, all fulfill the employer- Dr. Casumpang also contends that dengue
employee relationship requirement under fever occurs only after several days of
Article 2180. confinement. He alleged that when he had
suspected that Edmer might be suffering
Lastly, the CA held that SJDH failed to
from dengue fever, he immediately
adduce evidence showing that it exercised
attended and treated him.
the diligence of a good father of a family in
the hiring and the supervision of its Dr. Casumpang likewise raised serious
physicians. doubts on Dr. Jaudian’s credibility, arguing
that the CA erred in appreciating his
The petitioners separately moved to
testimony as an expert witness since he
reconsider the CA decision, but the CA
lacked the necessary training, skills, and
denied their motion in its resolution of
experience as a specialist in dengue fever
January 12, 2006; hence, the present
cases.
consolidated petitions pursuant to Rule 45
of the Rules of Court. II. Dr. Sanga’s Position (G.R. No. 171217)
The Petitions In her petition, Dr. Sanga faults the CA for
holding her responsible for Edmer’s wrong
I. Dr. Casumpang’s Position (G.R. No.
diagnosis, stressing that the function of
171127)
making the diagnosis and undertaking the
Dr. Casumpang contends that he gave his medical treatment devolved upon Dr.
patient medical treatment and care to the Casumpang, the doctor assigned to Edmer,
best of his abilities, and within the proper and who confirmed "bronchopneumonia."
standard of care required from physicians
Dr. Sanga also alleged that she exercised
under similar circumstances. He claims
prudence in performing her duties as a
that his initial diagnosis of
physician, underscoring that it was her
bronchopneumonia was supported by the
professional intervention that led to the
chest x-ray result.
correct diagnosis of "Dengue Hemorrhagic
Fever." Furthermore, Edmer’s Complete consequently, Article 2180 of the Civil
Blood Count (CBC) showed leukopenia and Code does not apply.
an increase in balance as shown by the
SJDH likewise anchored the absence of
differential count, demonstrating that
employer-employee relationship on the
Edmer’s infection, more or less, is of
following circumstances: (1) SJDH does not
bacterial and not viral in nature.
hire consultants; it only grants them
Dr. Sanga as well argued that there is no privileges to admit patients in the hospital
causal relation between the alleged through accreditation; (2) SJDH does not
erroneous diagnosis and medication for pay the consultants wages similar to an
"Bronchopneumonia," and Edmer’s death ordinary employee; (3) the consultants
due to "Dengue Hemorrhagic Fever." earn their own professional fees directly
from their patients; SJDH does not fire or
Lastly, she claimed that Dr. Jaudianis not a
terminate their services; and (4) SJDH does
qualified expert witness since he never
not control or interfere with the manner
presented any evidence of formal
and the means the consultants use in the
residency training and fellowship status in
treatment of their patients. It merely
Pediatrics.
provides them with adequate space in
III. SJDH’s Position (G.R. No. 171228) exchange for rental payment.
SJDH, on the other hand, disclaims liability Furthermore, SJDH claims that the CA
by asserting that Dr. Casumpang and Dr. erroneously applied the control test when
Sanga are mere independent contractors it treated the hospital’s practice of
and "consultants" (not employees) of the accrediting consultants as an exercise of
hospital. SJDH alleges that since it did not control. It explained that the control
exercise control or supervision over the contemplated by law is that which the
consultants’ exercise of medical employer exercises over the: (i) end result;
profession, there is no employer-employee and the (ii) manner and means to be used
relationship between them, and to reach this end, and not any kind of
control, however significant, in accrediting more, extend its personality to physicians
the consultants. to practice medicine on its behalf.
SJDH moreover contends that even if the Lastly, SJDH maintains that the petitioning
petitioning doctors are considered doctors arrived at an intelligently deduced
employees and not merely consultants of and correct diagnosis. It claimed that
the hospital, SJDH cannot still be held based on Edmer's signs and symptoms at
solidarily liable under Article 2180 of the the time of admission (i.e., one day
Civil Code because it observed the fever,28 bacterial infection,29 and lack of
diligence of a good father of a family in hemorrhagic manifestations30), there was
their selection and supervision as shown no reasonable indication yet that he was
by the following: (1) the adequate suffering from dengue fever, and
measures that the hospital undertakes to accordingly, their failure to diagnose
ascertain the petitioning doctors’ dengue fever, does not constitute
qualifications and medical competence; negligence on their part.
and (2) the documentary evidence that the
The Case for the Respondent
petitioning doctors presented to prove
their competence in the field of In his comment, the respondent submits
pediatrics. 27
that the issues the petitioners raised are
mainly factual in nature, which a petition
SJDH likewise faults the CA for ruling that
for review on certiorari under Rule 45 of
the petitioning doctors are its agents,
the Rules of Courts does not allow.
claiming that this theory, aside from being
inconsistent with the CA’s finding of In any case, he contends that the
employment relationship, is unfounded petitioning doctors were negligent in
because: first, the petitioning doctors are conducting their medical examination and
independent contractors, not agents of diagnosis based on the following: (1) the
SJDH; and second, as a medical institution, petitioning doctors failed to timely
SJDH cannot practice medicine, much diagnose Edmer’s correct illness due to
their non-observance of the proper and precaution" in diagnosing and in treating
acceptable standard of medical the patient;
examination; (2) the petitioning doctors’
2. Whether or not the petitioner hospital is
medical examination was not
solidarily liable with the petitioning
comprehensive, as they were always in a
doctors;
rush; and (3) the petitioning doctors
employed a guessing game in diagnosing 3. Whether or not there is a causal
bronchopneumonia. connection between the petitioners’
negligent act/omission and the patient’s
The respondent also alleges that there is a
resulting death; and
causal connection between the petitioning
doctors’ negligence and Edmer’s untimely 4. Whether or not the lower courts erred in
death, warranting the claim for damages. considering Dr. Rodolfo Tabangcora
Jaudian as an expert witness.
The respondent, too, asserted that SJDH is
also negligent because it was not equipped Our Ruling
with proper paging system, has no
We find the petition partly meritorious.
bronchoscope, and its doctors are not
proportionate to the number of its patients. A Petition for Review on Certiorari
He also pointed out that out of the seven under Rule 45 of the Rules of Court
resident physicians in the hospital, only is Limited to Questions of Law.
two resident physicians were doing rounds
The settled rule is that the Court’s
at the time of his son’s confinement.
jurisdiction in a petition for review on
The Issues certiorari under Rule 45 of the Rules of
Court is limited only to the review of pure
The case presents to us the following
questions of law. It is not the Court’s
issues:
function to inquire on the veracity of the
1. Whether or not the petitioning doctors appellate court’s factual findings and
had committed "inexcusable lack of
conclusions; this Court is not a trier of The claim for damages is based on the
facts.31 petitioning doctors’ negligence in
diagnosing and treating the deceased
A question of law arises when there is
Edmer, the child of the respondent. It is a
doubt as to what the law is on a certain
medical malpractice suit, an action
state of facts, while there is a question of
available to victims to redress a wrong
fact when the doubt arises as to the truth
committed by medical professionals who
or falsity of the alleged facts.32
caused bodily harm to, or the death of, a
These consolidated petitions before us patient.33 As the term is used, the suit is
involve mixed questions of fact and law. As brought whenever a medical practitioner or
a rule, we do not resolve questions of fact. health care provider fails to meet the
However, in determining the legal question standards demanded by his profession, or
of whether the respondent is entitled to deviates from this standard, and causes
claim damages under Article 2176 of the injury to the patient.
Civil Code for the petitioners’ alleged
To successfully pursue a medical
medical malpractice, the determination of
malpractice suit, the plaintiff (in this case,
the factual issues – i.e., whether the
the deceased patient’s heir) must prove
petitioning doctors were grossly negligent
that the doctor either failed to do what a
in diagnosing the patient’s illness, whether
reasonably prudent doctor would have
there is causal relation between the
done, or did what a reasonably prudent
petitioners’ act/omission and the patient’s
doctor would not have done; and the act or
resulting death, and whether Dr. Jaudian is
omission had caused injury to the
qualified as an expert witness– must
patient.34 The patient’s heir/s bears the
necessarily be resolved. We resolve these
burden of proving his/her cause of action.
factual questions solely for the purpose of
determining the legal issues raised. The Elements of a Medical Malpractice Suit
Medical Malpractice Suit as a
Specialized Area of Tort Law
The elements of medical negligence are: physician’s affirmative action to diagnose
(1) duty; (2) breach; (3) injury; and (4) and/or treat a patient, or in his
proximate causation. participation in such diagnosis and/or
treatment.41 The usual illustration would be
Duty refers to the standard of behavior
the case of a patient who goes to a
that imposes restrictions on one's
35 hospital or a clinic, and is examined and
conduct.  It requires proof of professional
treated by the doctor. In this case, we can
relationship between the physician and the
infer, based on the established and
patient. Without the professional
customary practice in the medical
relationship, a physician owes no duty to
community that a patient-physician
the patient, and cannot therefore incur any
relationship exists.
liability.
Once a physician-patient relationship is
A physician-patient relationship is created
established, the legal duty of care follows.
when a patient engages the services of a
The doctor accordingly becomes duty-
physician,36 and the latter accepts or
bound to use at least the same standard of
agrees to provide care to the patient.37 The
care that a reasonably competent doctor
establishment of this relationship is
would use to treat a medical condition
consensual,38 and the acceptance by the
under similar circumstances.
physician essential. The mere fact that an
individual approaches a physician and Breach of duty occurs when the doctor fails
seeks diagnosis, advice or treatment does to comply with, or improperly performs his
not create the duty of care unless the duties under professional standards. This
physician agrees.39 determination is both factual and legal,
and is specific to each individual case. 42
The consent needed to create the
relationship does not always need to be If the patient, as a result of the breach of
express.40 In the absence of an express duty, is injured in body or in health,
agreement, a physician-patient actionable malpractice is committed,
relationship may be implied from the entitling the patient to damages.43
To successfully claim damages, the patient treatment of Edmer. On the other hand,
must lastly prove the causal relation Edmer’s parents, on their son’s behalf,
between the negligence and the injury. manifested their consent by availing of the
This connection must be direct, natural, benefits of their health care plan, and by
and should be unbroken by any accepting the hospital’s assigned doctor
intervening efficient causes. In other without objections.
words, the negligence must be the
b. The Relationship Between Dr. Sanga and
proximate cause of the injury.44 The injury
Edmer
or damage is proximately caused by the
physician’s negligence when it appears, With respect to Dr. Sanga, her professional
based on the evidence and the expert relationship with Edmer arose when she
testimony, that the negligence played an assumed the obligation to provide resident
integral part in causing the injury or supervision over the latter. As second year
damage, and that the injury or damage resident doctor tasked to do rounds and
was either a direct result, or a reasonably assist other physicians, Dr. Sanga is
probable consequence of the physician’s deemed to have agreed to the creation of
negligence.45 physician-patient relationship with the
hospital’s patients when she participated
a. The Relationship Between Dr.
in the diagnosis and prescribed a course of
Casumpang and Edmer
treatment for Edmer.
In the present case, the physician-patient
The undisputed evidence shows that Dr.
relationship between Dr. Casumpang and
Sanga examined Edmer twice (at around
Edmer was created when the latter’s
12:00 and 3:30 in the afternoon of April 23,
parents sought the medical services of Dr.
1988),and in both instances, she
Casumpang, and the latter knowingly
prescribed treatment and participated in
accepted Edmer as a patient. Dr.
the diagnosis of Edmer’s medical
Casumpang’s acceptance is implied from
condition. Her affirmative acts amounted
his affirmative examination, diagnosis and
to her acceptance of the physician-patient
relationship, and incidentally, the legal A determination of whether or not the
duty of care that went with it. petitioning doctors met the required
standard of care involves a question of
In Jarcia, Jr. v. People of the
46 mixed fact and law; it is factual as medical
Philippines,  the Court found the doctors
negligence cases are highly technical in
who merely passed by and were requested
nature, requiring the presentation of
to attend to the patient, liable for medical
expert witnesses to provide guidance to
malpractice. It held that a physician-
the court on matters clearly falling within
patient relationship was established when
the domain of medical science, and legal,
they examined the patient, and later
insofar as the Court, after evaluating the
assured the mother that everything was
expert testimonies, and guided by medical
fine.
literature, learned treatises, and its fund of
In the US case of Mead v. Legacy Health common knowledge, ultimately determines
System,47 the Court also considered the whether breach of duty took place.
rendering of an opinion in the course of the Whether or not Dr. Casumpang and Dr.
patient’s care as the doctor’s assent to the Sanga committed a breach of duty is to be
physician-patient relationship. It ruled that measured by the yardstick of professional
the relationship was formed because of the standards observed by the other members
doctor’s affirmative action. Likewise, in of the medical profession in good standing
Wax v. Johnson,48 the court found that a under similar circumstances. 49 It is in this
physician patient relationship was formed aspect of medical malpractice that expert
between a physician who "contracts, testimony is essential to establish not only
agrees, undertakes, or otherwise assumes" the professional standards observed in the
the obligation to provide resident medical community, but also that the
supervision at a teaching hospital, and the physician’s conduct in the treatment of
patient with whom the doctor had no direct care falls below such standard.50
or indirect contract.
In the present case, expert testimony is
Standard of Care and Breach of Duty crucial in determining first, the standard
medical examinations, tests, and Furthermore, the standard of care
procedures that the attending physicians according to Dr. Jaudian is to administer
should have undertaken in the diagnosis oxygen inhalation, analgesic, and fluid
and treatment of dengue fever; and infusion or dextrose.53 If the patient had
second, the dengue fever signs and twice vomited fresh blood and
symptoms that the attending physicians thrombocytopenia has already occurred,
should have noticed and considered. the doctor should order blood transfusion,
monitoring of the patient every 30
Both the RTC and the CA relied largely on
minutes, hemostatic to stop bleeding, and
Dr. Jaudian’s expert testimony on dengue
oxygen if there is difficulty in breathing. 54
diagnosis and management to support
their finding that the petitioning doctors We find that Dr. Casumpang, as Edmer’s
were guilty of breach of duty of care. attending physician, did not act according
to these standards and, hence, was guilty
Dr. Jaudian testified that Edmer’s rapid
of breach of duty. We do not find Dr. Sanga
breathing, chest and stomach pain, fever,
liable for the reasons discussed below.
and the presence of blood in his saliva are
classic symptoms of dengue fever. Dr. Casumpang’s Negligence
According to him, if the patient was
a. Negligence in the Diagnosis
admitted for chest pain, abdominal pain,
and difficulty in breathing coupled with At the trial, Dr. Casumpang declared that a
fever, dengue fever should definitely be doctor’s impression regarding a patient’s
considered;51 if the patient spits coffee illness is 90% based on the physical
ground with the presence of blood, and the examination, the information given by the
patient’s platelet count drops to 47,000, it patient or the latter’s parents, and the
becomes a clear case of dengue fever, and patient’s medical history.55 He testified
bronchopneumonia can be reasonably that he did not consider either dengue
ruled out.52 fever or dengue hemorrhagic fever
because the patient’s history showed that
Edmer had low breath and voluntary symptoms of dengue (as Dr. Jaudian
submission, and that he was up and about testified) are: patient’s rapid breathing;
playing basketball.56 He based his chest and stomach pain; fever; and the
diagnosis of bronchopneumonia on the presence of blood in his saliva. All these
following observations: "difficulty in manifestations were present and known to
breathing, clearing run nostril, harsh Dr. Casumpang at the time of his first and
breath sound, tight air, and sivilant second visits to Edmer. While he noted
sound."57 some of these symptoms in confirming
bronchopneumonia, he did not seem to
It will be recalled that during Dr.
have considered the patient’s other
Casumpang’s first and second visits to
manifestations in ruling out dengue fever
Edmer, he already had knowledge of
or dengue hemorrhagic fever.58 To our
Edmer’s laboratory test result (CBC),
mind, Dr. Casumpang selectively
medical history, and symptoms (i.e., fever,
appreciated some, and not all of the
rashes, rapid breathing, chest and stomach
symptoms; worse, he casually ignored the
pain, throat irritation, difficulty in
pieces of information that could have been
breathing, and traces of blood in the
material in detecting dengue fever. This is
sputum). However, these information did
evident from the testimony of Mrs. Cortejo:
not lead Dr. Casumpang to the possibility
that Edmer could be suffering from either TSN, Mrs. Cortejo, November 27, 1990
dengue fever, or dengue hemorrhagic
Q: Now, when Dr. Casumpang visited your
fever, as he clung to his diagnosis of
son for the first time at 5:30 p.m., what did
broncho pneumonia. This means that given
he do, if any?
the symptoms exhibited, Dr. Casumpang
already ruled out the possibility of other A: He examined my son by using
diseases like dengue. stethoscope and after that, he confirmed
to me that my son was suffering from
In other words, it was lost on Dr.
broncho pneumonia.
Casumpang that the characteristic
Q: After he confirmed that your son was traces of blood in my son’s sputum and I
suffering broncho pneumonia, what did told him what is all about and he has
you say if any? throat irritation.
A: Again, I told Dr. Casumpang, how come Q: What did he tell you?
it was broncho pneumonia when my son
A: He just nodded his head but he did not
has no cough or colds.
take the initiative of looking at the throat
Q: What was the answer of Dr. Casumpang of my son.
to your statement?
Q: So what happened after that?
xxxx
A: I also told Dr. Casumpang about his
A: And then, Dr. Casumpang answered chest pain and also stomach pain.
"THAT’S THE USUAL BRONCHO
Q: So what did Dr. Casumpang do after you
PNEUMONIA, NO COLDS, NO PHLEGM."
have narrated all these complaints of your
Q: How long did Dr. Casumpang stay in son?
your son’s room?
A: Nothing. He also noticed the rapid
A: He stayed for a minute or 2. breathing of my son and my son was
almost moving because of rapid breathing
xxxx
and he is swaying in the bed.
Q: When Dr. Casumpang arrived at 9:00
Q: Do you know what action was taken by
o’clock a.m. on April 23, what did you tell
Dr. Casumpang when you told him that
him, if any?
your son is experiencing a rapid breathing?
xxxx
A: No action. He just asked me if my son
A: I told Dr. Casumpang… After examining has an asthma but I said none.
my son using stethoscope and nothing
Q: So how long did Dr. Casumpang stay
more, I told Dr. Casumpang about the
and attended your son on April 23?
A: More or less two (2) minutes then I only used a stethoscope in coming up with
followed him up to the door and I repeated the diagnosis that Edmer was suffering
about the fever of my son. from bronchopneumonia; he never
confirmed this finding with the use of a
Q: What did he tell you, if any, regarding
bronchoscope. Furthermore, Dr.
that information you gave him that your
Casumpang based his diagnosis largely on
son had a fever?
the chest x-ray result that is generally
A: He said, that is broncho pneumonia, It’s inconclusive.61
only being active now. [Emphasis supplied]
Significantly, it was only at around 5:00 in
We also find it strange why Dr. Casumpang the afternoon of April 23, 1988 (after
did not even bother to check Edmer’s Edmer’s third episode of bleeding) that Dr.
throat despite knowing that as early as Casumpang ordered the conduct of
9:00 in the morning of April 23, 1988, hematocrit, hemoglobin, blood typing,
Edmer had blood streaks in his sputum. blood transfusion and tourniquet tests.
Neither did Dr. Casumpang order These tests came too late, as proven by:
confirmatory tests to confirm the source of (1) the blood test results that came at
bleeding. The Physician’s Progress about 6:00 in the evening, confirming that
59
Notes  stated: "Blood streaks on phlegm Edmer’s illness had developed to "Dengue
can be due to bronchial irritation or Hemorrhagic Fever;" and (2) Dr. Jaudian’s
congestion," which clearly showed that Dr. testimony that "dengue fever could have
Casumpang merely assumed, without been detected earlier than 7:30 in the
confirmatory physical examination, that evening of April 23, 1988 because the
bronchopneumonia caused the bleeding. symptoms were already evident."62
Dr. Jaudian likewise opined that Dr. In Spouses Flores v. Spouses Pineda,63 a
Casumpang’s medical examination was not case involving a medical malpractice suit,
comprehensive enough to reasonably lead the Court ruled that the petitioner doctors
to a correct diagnosis.60 Dr. Casumpang were negligent because they failed to
immediately order tests to confirm the exercise reasonable prudence in
patient’s illness. Despite the doctors’ ascertaining the extent of the patient’s
suspicion that the patient could be injuries, this Court declared that:
suffering from diabetes, the former still
In failing to perform an extensive medical
proceeded to the D&C operation. In that
examination to determine the extent of
case, expert testimony showed that tests
Roy Jr.’s injuries, Dr. Jarcia and Dr. Bastan
should have been ordered immediately on
were remiss of their duties as members of
admission to the hospital in view of the
the medical profession. Assuming for the
symptoms presented. The Court held:
sake of argument that they did not have
When a patient exhibits symptoms typical the capacity to make such thorough
of a particular disease, these symptoms evaluation at that stage, they should have
should, at the very least, alert the referred the patient to another doctor with
physician of the possibility that the patient sufficient training and experience instead
may be afflicted with the suspected of assuring him and his mother that
disease. everything was all right. [Emphasis
supplied]
The Court also ruled that reasonable
prudence would have shown that diabetes Even assuming that Edmer’s symptoms
and its complications were foreseeable completely coincided with the diagnosis of
harm. However, the petitioner doctors bronchopneumonia (so that this diagnosis
failed to take this into consideration and could not be considered "wrong"), we still
proceeded with the D&C operation. Thus, find Dr. Casumpang guilty of negligence.
the Court ruled that they failed to comply
First, we emphasize that we do not decide
with their duty to observe the standard of
the correctness of a doctor’s diagnosis, or
care to be given to hyperglycemic/diabetic
the accuracy of the medical findings and
patients.
treatment. Our duty in medical malpractice
Similarly, in Jarcia,64 involving the cases is to decide – based on the evidence
negligence of the doctors in failing to
adduced and expert opinion presented– In the present case, evidence on record
whether a breach of duty took place. established that in confirming the
diagnosis of bronchopneumonia, Dr.
Second, we clarify that a wrong diagnosis
Casumpang selectively appreciated some
is not by itself medical
65 and not all of the symptoms presented,
malpractice.  Physicians are generally not
and failed to promptly conduct the
liable for damages resulting from a bona
appropriate tests to confirm his findings. In
fide error of judgment. Nonetheless, when
sum, Dr. Casumpang failed to timely
the physician’s erroneous diagnosis was
detect dengue fever, which failure,
the result of negligent conduct (e.g.,
especially when reasonable prudence
neglect of medical history, failure to order
would have shown that indications of
the appropriate tests, failure to recognize
dengue were evident and/or foreseeable,
symptoms), it becomes an evidence of
constitutes negligence.
medical malpractice.
a. Negligence in the Treatment and
Third, we also note that medicine is not an
Management of Dengue
exact science;66 and doctors, or even
specialists, are not expected to give a Apart from failing to promptly detect
100% accurate diagnosis in treating dengue fever, Dr. Casumpang also failed to
patients who come to their clinic for promptly undertake the proper medical
consultations. Error is possible as the management needed for this disease.
exercise of judgment is called for in
As Dr. Jaudian opined, the standard
considering and reading the exhibited
medical procedure once the patient had
symptoms, the results of tests, and in
exhibited the classic symptoms of dengue
arriving at definitive conclusions. But in
fever should have been: oxygen inhalation,
doing all these, the doctor must have
use of analgesic, and infusion of fluids or
acted according to acceptable medical
dextrose;67 and once the patient had twice
practice standards.
vomited fresh blood, the doctor should
have ordered: blood transfusion,
monitoring of the patient every 30 Q: What was the blood pressure of the
minutes, hemostatic to stop bleeding, and patient?
oxygen if there is difficulty in breathing. 68
A: During those times, the blood pressure
Dr. Casumpang failed to measure up to of the patient was even normal during
these standards. The evidence strongly those times.
suggests that he ordered a transfusion of
Q: How about the respiratory rate?
platelet concentrate instead of blood
transfusion. The tourniquet test was only A: The respiratory rate was fast because
conducted after Edmer’s second episode of the patient in the beginning since
bleeding, and the medical management admission had difficulty in breathing.
(as reflected in the records) did not include
Q: Then, after that, what did you do with
antibiotic therapy and complete physical
the patient? Doctor?
examination. Dr. Casumpang’s testimony
states: A: We transfused platelet concentrate and
at the same time, we monitor [sic] the
Q: Now, after entertaining – After
patient.
considering that the patient Edmer Cortero
was already suffering from dengue Q: Then, who monitor [sic] the patient?
hemorrhagic fever, what did you do, if
A: The pediatric resident on duty at that
any?
time.
A: We ordered close monitoring of the
Q: Now, what happened after that?
blood pressure, the cardiac rate and
respiratory rate of the patient. Q: While monitoring the patient, all his vital
signs were _____; his blood pressure was
Q: Now, was your instructions carried on?
normal so we continued with the
A: Yes, sir. supportive management at that time.
Q: Now, after that?
A: In the evening of April 23, 1988, I stayed these witnesses failed to dispute the
in the hospital and I was informed by the standard of action that Dr. Jaudian
pediatric resident on duty at around 11:15 established in his expert opinion. We
in the evening that the blood pressure of cannot consider them expert witnesses
the patient went down to .60 palpatory. either for the sole reason that they did not
testify on the standard of care in dengue
Q: What did you do upon receipt of that
cases.69
information?
On the whole, after examining the totality
A: I immediately went up to the room of
of the adduced evidence, we find that the
the patient and we changed the IV fluid
lower courts correctly did not rely on Dr.
from the present fluid which was D5 0.3
Casumpang’s claim that he exercised
sodium chloride to lactated ringers
prudence and due diligence in handling
solution.
Edmer’s case. Aside from being self-
Q: You mean to say you increased the serving, his claim is not supported by
dengue [sic] of the intervenus [sic] fluid? competent evidence. As the lower courts
did, we rely on the uncontroverted fact
A: We changed the IV fluid because
that he failed, as a medical professional, to
lactated ringers was necessary to resume
observe the most prudent medical
the volume and to bring back the blood
procedure under the circumstances in
pressure, to increase the blood pressure.
diagnosing and treating Edmer.
[Emphasis supplied]
Dr. Sanga is Not Liable for Negligence
Although Dr. Casumpang presented the
testimonies of Dr. Rodolfo Jagonap and Dr. In considering the case of Dr. Sanga, the
Ellewelyn Pasion (Dr. Pasion), Personnel junior resident physician who was on-duty
Officer and Medical Director of SJDH, at the time of Edmer’s confinement, we
respectively as well as the testimonies of see the need to draw distinctions between
Dr. Livelo and Dr. Reyes (the radiologist the responsibilities and corresponding
who read Edmer’s chest x-ray result),
liability of Dr. Casumpang, as the attending ultimately responsible for the diagnosis
physician, and that of Dr. Sanga. and treatment of the patient, the
standards applicable to and the liability of
In his testimony, Dr. Pasion declared that
the resident for medical malpractice is
resident applicants are generally doctors of
theoretically less than that of the attending
medicine licensed to practice in the
physician. These relative burdens and
Philippines and who would like to pursue a
distinctions, however, do not translate to
particular specialty.70 They are usually the
immunity from the legal duty of care for
front line doctors responsible for the first
residents,76 or from the responsibility
contact with the patient. During the scope
arising from their own negligent act.
of the residency program,71 resident
physicians (or "residents")72 function under In Jenkins v. Clark,77 the Ohio Court of
the supervision of attending physicians73 or Appeals held that the applicable standard
of the hospital’s teaching staff. Under this of care in medical malpractice cases
arrangement, residents operate merely as involving first-year residents was that of a
subordinates who usually defer to the reasonably prudent physician and not that
attending physician on the decision to be of interns. According to Jenkins:
made and on the action to be taken.
It is clear that the standard of care
The attending physician, on the other required of physicians is not an
hand, is primarily responsible for managing individualized one but of physicians in
the resident’s exercise of duties. While general in the community. In order to
attending and resident physicians share establish medical malpractice, it must be
the collective responsibility to deliver safe shown by a preponderance of the evidence
and appropriate care to the patients, 74 it is that a physician did some particular thing
the attending physician who assumes the or things that a physician or surgeon of
principal responsibility of patient ordinary skill, care and diligence would not
75
care.  Because he/she exercises a have done under like or similar conditions
supervisory role over the resident, and is or circumstances, or that he failed or
omitted to do some particular thing or he/she will exercise reasonable skill,
things that a physician or surgeon of diligence, and care in treating the patient.
ordinary skill, care and diligence would
We find that Dr. Sanga was not
have done under like or similar conditions
independently negligent. Although she had
or circumstances, and that the inquiry
greater patient exposure, and was subject
complained of was the direct result of such
to the same standard of care applicable to
doing or failing to do such thing or things.
attending physicians, we believe that a
We note that the standard of instruction finding of negligence should also depend
given by the court was indeed a proper on several competing factors, among
one. It clearly informed the jury that the them, her authority to make her own
medical care required is that of reasonably diagnosis, the degree of supervision of the
careful physicians or hospital emergency attending physician over her, and the
room operators, not of interns or residents. shared responsibility between her and the
[Emphasis supplied] attending physicians.
A decade later, Centman v. In this case, before Dr. Sanga attended to
78
Cobb,  affirmed the Jenkins ruling and held Edmer, both Dr. Livelo and Dr. Casumpang
that interns and first-year residents are had diagnosed Edmer with
"practitioners of medicine required to bronchopneumonia. In her testimony, Dr.
exercise the same standard of care Sanga admitted that she had been briefed
applicable to physicians with unlimited about Edmer’s condition, his medical
licenses to practice." The Indiana Court history, and initial diagnosis;79 and based
held that although a first-year resident on these pieces of information, she
practices under a temporary medical confirmed the finding of
permit, he/she impliedly contracts that bronchopneumonia.
he/she has the reasonable and ordinary
Dr. Sanga likewise duly reported to Dr.
qualifications of her profession and that
Casumpang, who admitted receiving
updates regarding Edmer’s
condition.80 There is also evidence A: No, sir, I did not because according to
supporting Dr. Sanga’s claim that she the father he wash [sic] his hands.
extended diligent care to Edmer. In fact,
xxxx
when she suspected – during Edmer’s
second episode of bleeding– that Edmer Q: Now, from you knowledge, what does
could be suffering from dengue fever, she that indicate if the patient expels a phlegm
wasted no time in conducting the and blood streak?
necessary tests, and promptly notified Dr.
A: If a patient cocked [sic] out phlegm then
Casumpang about the incident.
the specimen could have come from the
Indubitably, her medical assistance led to
lung alone.82 [Emphasis supplied]
the finding of dengue fever.
xxxx
We note however, that during Edmer’s
second episode of bleeding,81 Dr. Sanga TSN, June 17, 1993:
failed to immediately examine and note
Q: Now, in the first meeting you had, when
the cause of the blood specimen. Like Dr.
that was relayed to you by the father that
Casumpang, she merely assumed that the
Edmer Cortejo had coughed out blood,
blood in Edmer’s phlegm was caused by
what medical action did you take?
bronchopneumonia. Her testimony states:
A: I examined the patient and I thought
TSN, June 8, 1993:
that, that coughed out phlegm was a
Q: Let us get this clear, you said that the product of broncho pneumonia.
father told you the patient cocked [sic] out
xxxx
phlegm.
Q: So what examination did you
A: With blood streak.
specifically conduct to see that there was
Q: Now, you stated specimen, were you no internal bleeding? A: At that time I did
not able to examine the specimen? not do anything to determine the cause of
coughing of the blood because I presumed
that it was a mucous (sic) produced by court and before this Court was Dr.
broncho pneumonia, And besides the Jaudian’s competence and credibility as an
patient did not even show any signs of any expert witness. The petitioners tried to
other illness at that time.83 discredit his expert testimony on the
ground that he lacked the proper training
Based on her statements we find that Dr.
and fellowship status in pediatrics.
Sanga was not entirely faultless.
Nevertheless, her failure to discern the ● Criteria in Qualifying as an Expert
import of Edmer’s second bleeding does Witness
not necessarily amount to negligence as
The competence of an expert witness is a
the respondent himself admitted that Dr.
matter for the trial court to decide upon in
Sanga failed to examine the blood
the exercise of its discretion. The test of
specimen because he wash edit away. In
qualification is necessarily a relative one,
addition, considering the diagnosis
depending upon the subject matter of the
previously made by two doctors, and the
investigation, and the fitness of the expert
uncontroverted fact that the burden of
witness.84 In our jurisdiction, the criterion
final diagnosis pertains to the attending
remains to be the expert witness’ special
physician (in this case, Dr. Casumpang),
knowledge experience and practical
we believe that Dr. Sanga’s error was
training that qualify him/her to explain
merely an honest mistake of judgment
highly technical medical matters to the
influenced in no small measure by her
Court.
status in the hospital hierarchy; hence, she
should not be held liable for medical In Ramos v. Court of Appeals,85 the Court
negligence. found the expert witness, who is a
pulmonologist, not qualified to testify on
Dr. Jaudian’s Professional Competence and
the field of anesthesiology. Similarly, in
Credibility
Cereno v. Court of Appeals, 86 a 2012 case
One of the critical issues the petitioners involving medical negligence, the Court
raised in the proceedings before the lower excluded the testimony of an expert
witness whose specialty was of a medical expert witness, regardless of
anesthesiology, and concluded that an his/her specialty, is to afford assistance to
anesthesiologist cannot be considered an the courts on medical matters, and to
expert in the field of surgery or even in explain the medical facts in issue.
surgical practices and diagnosis.
Furthermore, there was no reasonable
Interestingly in this case, Dr. Jaudian, the indication in Ramos and Cereno that the
expert witness was admittedly not a expert witnesses possess a sufficient
pediatrician but a practicing physician who familiarity with the standard of care
specializes in pathology.87 He likewise does applicable to the physicians’ specialties.
not possess any formal residency training US jurisprudence on medical malpractice
in pediatrics. Nonetheless, both the lower demonstrated the trial courts’ wide latitude
courts found his knowledge acquired of discretion in allowing a specialist from
through study and practical experience another field to testify against a defendant
sufficient to advance an expert opinion on specialist.
dengue-related cases.
In Brown v. Sims,88 a neurosurgeon was
We agree with the lower courts. found competent to give expert testimony
regarding a gynecologist's standard of pre-
A close scrutiny of Ramos and Cereno
surgical care. In that case, the court held
reveals that the Court primarily based the
that since negligence was not predicated
witnesses’ disqualification to testify as an
on the gynecologist’s negligent
expert on their incapacity to shed light on
performance of the operation, but primarily
the standard of care that must be
on the claim that the pre-operative
observed by the defendant-physicians.
histories and physicals were inadequate,
That the expert witnesses’ specialties do
the neurosurgeon was competent to testify
not match the physicians’ practice area
as an expert.
only constituted, at most, one of the
considerations that should not be taken Frost v. Mayo Clinic89 also allowed an
out of context. After all, the sole function orthopedic surgeon to testify against a
neurologist in a medical malpractice In another case,90 the court declared that it
action. The court considered that the is the specialist’s knowledge of the
orthopedic surgeon’s opinion on the requisite subject matter, rather than
"immediate need for decompression" need his/her specialty that determines his/her
not come from a specialist in qualification to testify.
neurosurgery. The court held that:
Also in Evans v. Ohanesian, 91 the court set
It is well established that "the testimony of a guideline in qualifying an expert witness:
a qualified medical doctor cannot be
To qualify a witness as a medical expert, it
excluded simply because he is not a
must be shown that the witness (1) has the
specialist x x x." The matter of "x x x
required professional knowledge, learning
training and specialization of the witness
and skill of the subject under inquiry
goes to the weight rather than
sufficient to qualify him to speak with
admissibility x x x."
authority on the subject; and (2) is familiar
xxxx with the standard required of a physician
under similar circumstances; where a
It did not appear to the court that a
witness has disclosed sufficient knowledge
medical doctor had to be a specialist in
of the subject to entitle his opinion to go to
neurosurgery to express the opinions
the jury, the question of the degree of his
permitted to be expressed by plaintiffs’
knowledge goes more to the weight of the
doctors, e.g., the immediate need for a
evidence than to its admissibility.
decompression in the light of certain
neurological deficits in a post-laminectomy xxxx
patient. As stated above, there was no
Nor is it critical whether a medical expert is
issue as to the proper execution of the
a general practitioner or a specialist so
neurosurgery. The medical testimony
long as he exhibits knowledge of the
supported plaintiffs’ theory of negligence
subject. Where a duly licensed and
and causation. (Citations omitted)
practicing physician has gained knowledge
of the standard of care applicable to a In the case and the facts before us, we find
specialty in which he is not directly that Dr. Jaudian is competent to testify on
engaged but as to which he has an opinion the standard of care in dengue fever
based on education, experience, cases.1avvphi1
observation, or association wit that
Although he specializes in pathology, it
specialty, his opinion is competent.
was established during trial that he had
(Emphasis supplied)
attended not less than 30 seminars held by
Finally, Brown v. Mladineo92 adhered to the the Pediatric Society, had exposure in
principle that the witness’ familiarity, and pediatrics, had been practicing medicine
not the classification by title or specialty, for 16 years, and had handled not less
which should control issues regarding the than 50 dengue related cases.
expert witness’ qualifications:
As a licensed medical practitioner
The general rule as to expert testimony in specializing in pathology, who had
medical malpractice actions is that "a practical and relevant exposure in
specialist in a particular branch within a pediatrics and dengue related cases, we
profession will not be required." Most are convinced that Dr. Jaudian
courts allow a doctor to testify if they are demonstrated sufficient familiarity with the
satisfied of his familiarity with the standard of care to be applied in dengue
standards of a specialty, though he may fever cases. Furthermore, we agree that he
not practice the specialty himself. One possesses knowledge and experience
court explained that "it is the scope of the sufficient to qualify him to speak with
witness’ knowledge and not the artificial authority on the subject.
classification by title that should govern
The Causation Between Dr. Casumpang’s
the threshold question of admissibility.
Negligent Act/Omission, and the Patient’s
(Citations omitted)
Resulting Death was Adequately Proven
● Application to the Present Case
Dr. Jaudian’s testimony strongly suggests symptoms; and as a consequence of the
that due to Dr. Casumpang’s failure to delayed diagnosis, he also failed to
timely diagnose Edmer with dengue, the promptly manage Edmer’s illness. Had he
latter was not immediately given the immediately conducted confirmatory tests,
proper treatment. In fact, even after Dr. (i.e., tourniquet tests and series of blood
Casumpang had discovered Edmer’s real tests)and promptly administered the
illness, he still failed to promptly perform proper care and management needed for
the standard medical procedure. We agree dengue fever, the risk of complications or
with these findings. even death, could have been substantially
reduced.
As the respondent had pointed out, dengue
fever, if left untreated, could be a life Furthermore, medical literature on dengue
threatening disease. As in any fatal shows that early diagnosis and
diseases, it requires immediate medical management of dengue is critical in
attention.93 With the correct and timely reducing the risk of complications and
diagnosis, coupled with the proper medical avoiding further spread of the virus. 96 That
management, dengue fever is not a life Edmer later died of "Hypovolemic
threatening disease and could easily be Shock/hemorrhagic shock," "Dengue
cured.94 Hemorrhagic Fever Stage IV," a severe and
fatal form of dengue fever, established the
Furthermore, as Dr. Jaudian testified, with
causal link between Dr. Casumpang’s
adequate intensive care, the mortality rate
negligence and the injury.
of dengue fever should fall to less than 2%.
Hence, the survival of the patient is Based on these considerations, we rule
directly related to early and proper that the respondent successfully proved
management of the illness.95 the element of causation.
To reiterate, Dr. Casumpang failed to Liability of SJDH
timely diagnose Edmer with dengue fever
We now discuss the liability of the hospital.
despite the presence of its characteristic
The respondent submits that SJDH should not its employees but are mere
not only be held vicariously liable for the consultants and independent contractors.
petitioning doctors’ negligence but also for
We affirm the hospital’s liability not on the
its own negligence. He claims that SJDH fell
basis of Article 2180 of the Civil Code, but
short of its duty of providing its patients
on the basis of the doctrine of apparent
with the necessary facilities and equipment
authority or agency by estoppel.
as shown by the following circumstances:
There is No Employer-Employee
(a) SJDH was not equipped with proper
Relationship
paging system;
Between SJDH and the Petitioning Doctors
(b) the number of its doctors is not
proportionate to the number of patients; In determining whether an employer-
employee relationship exists between the
(c) SJDH was not equipped with a
parties, the following elements must be
bronchoscope;
present: (1) selection and engagement of
(d) when Edmer’s oxygen was removed, services; (2) payment of wages; (3) the
the medical staff did not immediately power to hire and fire; and (4) the power to
provide him with portable oxygen; control not only the end to be achieved,
but the means to be used in reaching such
(e) when Edmer was about to be
an end.97
transferred to another hospital, SJDH’s was
not ready and had no driver; and Control, which is the most crucial among
the elements, is not present in this case.
(f) despite Edmer’s critical condition, there
was no doctor attending to him from 5:30 Based on the records, no evidence exists
p.m. of April 22, to 9:00 a.m. of April 23, showing that SJDH exercised any degree of
1988. control over the means, methods of
procedure and manner by which the
SJDH on the other hand disclaims liability
petitioning doctors conducted and
by claiming that the petitioning doctors are
performed their medical profession. SJDH hospitals’ immunity to vicarious liability of
did not control their diagnosis and independent contractor physicians. In that
treatment. Likewise, no evidence was case, the Illinois Supreme Court held that
presented to show that SJDH monitored, under the doctrine of apparent authority,
supervised, or directed the petitioning hospitals could be found vicariously liable
doctors in the treatment and management for the negligence of an independent
of Edmer’s case. In these lights, the contractor:
petitioning doctors were not employees of
Therefore, we hold that, under the doctrine
SJDH, but were mere independent
of apparent authority, a hospital can be
contractors.
held vicariously liable for the negligent
SJDH is Solidarily Liable Based acts of a physician providing care at the
on The Principle of Agency or Doctrine hospital, regardless of whether the
of Apparent Authority physician is an independent contractor,
unless the patient knows, or should have
Despite the absence of employer-
known, that the physician is an
employee relationship between SJDH and
independent contractor. The elements of
the petitioning doctors, SJDH is not free
the action have been set out as follows:
from liability.98
For a hospital to be liable under the
As a rule, hospitals are not liable for the
doctrine of apparent authority, a plaintiff
negligence of its independent contractors.
must show that: (1) the hospital, or its
However, it may be found liable if the
agent, acted in a manner that would lead a
physician or independent contractor acts
reasonable person to conclude that the
as an ostensible agent of the hospital. This
individual who was alleged to be negligent
exception is also known as the "doctrine of
was an employee or agent of the hospital;
apparent authority."99
(2) where the acts of the agent create the
The US case of Gilbert v. Sycamore appearance of authority, the plaintiff must
Municipal Hospital100 abrogated the also prove that the hospital had knowledge
of and acquiesced in them; and (3) the an inquiry on whether the plaintiff acted in
plaintiff acted in reliance upon the conduct reliance upon the conduct of the hospital
of the hospital or its agent, consistent with or its agent, consistent with ordinary care
ordinary care and prudence. (Emphasis and prudence. (Citation omitted)
supplied)
In sum, a hospital can be held vicariously
The doctrine was applied in Nogales v. liable for the negligent acts of a physician
Capitol Medical Center101 where this Court, (or an independent contractor) providing
through the ponencia of Associate Justice care at the hospital if the plaintiff can
Antonio T. Carpio, discussed the two prove these two factors: first, the hospital’s
factors in determining hospital liability as manifestations; and second, the patient’s
follows: reliance.
The first factor focuses on the hospital’s a. Hospital’s manifestations
manifestations and is sometimes described
It involves an inquiry on whether the
as an inquiry whether the hospital acted in
hospital acted in a manner that would lead
a manner which would lead a reasonable
a reasonable person to conclude that the
person to conclude that the individual who
individual alleged to be negligent was an
was alleged to be negligent was an
employee or agent of the hospital. As
employee or agent of the hospital. In this
pointed out in Nogales, the hospital need
regard, the hospital need not make
not make express representations to the
express representations to the patient that
patient that the physician or independent
the treating physician is an employee of
contractor is an employee of the hospital;
the hospital; rather a representation may
representation may be general and
be general and implied.
implied.102
xxxx
In Pamperin v. Trinity Memorial
103
The second factor focuses on the patient's Hospital,  questions were raised on "what
reliance. It is sometimes characterized as acts by the hospital or its agent are
sufficient to lead a reasonable person to the hospital or its agent, consistent with
conclude that the individual was an agent ordinary care and prudence.104
of the hospital." In ruling that the hospital’s
In Pamperin, the court held that the
manifestations can be proven without the
important consideration in determining the
express representation by the hospital, the
patient’s reliance is: whether the plaintiff is
court relied on several cases from other
seeking care from the hospital itself or
jurisdictions, and held that:
whether the plaintiff is looking to the
(1) the hospital, by providing emergency hospital merely as a place for his/her
room care and by failing to advise patients personal physician to provide medical
that they were being treated by the care.105 Thus, this requirement is deemed
hospital’s agent and not its employee, has satisfied if the plaintiff can prove that
created the appearance of agency; and he/she relied upon the hospital to provide
care and treatment, rather than upon a
(2) patients entering the hospital through
specific physician. In this case, we shall
the emergency room, could properly
limit the determination of the hospital’s
assume that the treating doctors and staff
apparent authority to Dr. Casumpang, in
of the hospital were acting on its
view of our finding that Dr. Sanga is not
behalf.1âwphi1
liable for negligence.
In this case, the court considered the act of
SJDH Clothed Dr. Casumpang With
the hospital of holding itself out as
Apparent Authority
provider of complete medical care, and
considered the hospital to have impliedly SJDH impliedly held out and clothed Dr.
created the appearance of authority. Casumpang with apparent authority
leading the respondent to believe that he
b. Patient’s reliance
is an employee or agent of the hospital.
It involves an inquiry on whether the
Based on the records, the respondent
plaintiff acted in reliance on the conduct of
relied on SJDH rather than upon Dr.
Casumpang, to care and treat his son member of Fortune Care, but also as a
Edmer. His testimony during trial showed member of its medical staff. SJDH cannot
that he and his wife did not know any now disclaim liability since there is no
doctors at SJDH; they also did not know showing that Mrs. Cortejo or the
that Dr. Casumpang was an independent respondent knew, or should have known,
contractor. They brought their son to SJDH that Dr. Casumpang is only an independent
for diagnosis because of their family contractor of the hospital. In this case,
doctor’s referral. The referral did not estoppel has already set in.
specifically point to Dr. Casumpang or
We also stress that Mrs. Cortejo’s use of
even to Dr. Sanga, but to SJDH.
health care plan (Fortune Care) did not
Significantly, the respondent had relied on
affect SJDH’s liability. The only effect of the
SJDH’s representation of Dr. Casumpang’s
availment of her Fortune Care card
authority. To recall, when Mrs. Cortejo
benefits is that her choice of physician is
presented her Fortune Care card, she was
limited only to physicians who are
initially referred to the Fortune Care
accredited with Fortune Care. Thus, her
coordinator, who was then out of town. She
use of health care plan in this case only
was thereafter referred to Dr. Casumpang,
limited the choice of doctors (or coverage
who is also accredited with Fortune Care.
of services, amount etc.) and not the
In both instances, SJDH through its agent
liability of doctors or the hospital.
failed to advise Mrs. Cortejo that Dr.
Casumpang is an independent contractor. WHEREFORE, premises considered, this
Court PARTLY GRANTS the consolidated
Mrs. Cortejo accepted Dr. Casumpang’s
petitions. The Court finds Dr. Noel
services on the reasonable belief that such
Casumpang and San Juan de Dios Hospital
were being provided by SJDH or its
solidarily liable for negligent medical
employees, agents, or servants. By
practice. We SET ASIDE the finding of
referring Dr. Casumpang to care and treat
liability as to Dr. Ruby Miranda-Sanga. The
for Edmer, SJDH impliedly held out Dr.
amounts of ₱45,000.00 as actual damages
Casumpang, not only as an accredited
and ₱500,000.00 as moral damages should
each earn legal interest at the rate of six
percent (6%) per annum computed from
the date of the judgment of the trial court.
The Court AFFIRMS the rest of the Decision
dated October 29, 2004 and the Resolution
dated January 12, 2006 in CA-G.R. CV No.
56400.
SO ORDERED.
[G.R. No. 118141. September 5, 1997] the inquiry; or he may proceed with the
investigation of the complaint if, in his
LEONILA GARCIA-
view, it is in due and proper form.
RUEDA, Petitioner, v. WILFREDO L.
PASCASIO, RAUL R. ARNAU, Does the instant case warrant a departure
ABELARDO L. APORTADERA JR., from the foregoing general rule? When a
Honorable CONDRADO M. VASQUEZ, patient dies soon after surgery under
all of the Office of the Ombudsman; circumstances which indicate that the
JESUS F. GUERRERO, PORFIRIO attending surgeon and anaesthesiologist
MACARAEG, and GREGORIO A. may have been guilty of negligence but
ARIZALA, all of the Office of the City upon their being charged, a series
Prosecutor, Manila, Respondents. of nine prosecutors toss the responsibility
of conducting a preliminary investigation
DECISION
to each other with contradictory
ROMERO, J.: recommendations, ping-pong style,
perhaps the distraught widow is not to be
May this Court review the findings of the
blamed if she finally decides to accuse the
Office of the Ombudsman? The general
City Prosecutors at the end of the line for
rule has been enunciated in Ocampo v.
partiality under the Anti-Graft and Corrupt
Ombudsman 1 which states:
Practices Act. Nor may she be entirely
In the exercise of its investigative power, faulted for finally filing a petition before
this Court has consistently held that courts this Court against the Ombudsman for
will not interfere with the discretion of the grave abuse of discretion in dismissing her
fiscal or the Ombudsman to determine the complaint against said City Prosecutors on
specificity and adequacy of the averments the ground of lack of evidence. Much as we
of the offense charged. He may dismiss the sympathize with the bereaved widow,
complaint forthwith if he finds it to be however, this Court is of the opinion that
insufficient in form and substance or if he the general rule still finds application in
otherwise finds no ground to continue with instant case. In other words, the
respondent Ombudsman did not commit Antonio and Dr. Erlinda Balatbat-Reyes be
grave abuse of discretion in deciding charged for Homicide through Reckless
against filing the necessary information Imprudence before the Office of the City
against public respondents of the Office of Prosecutor.
the City Prosecutor.
During the preliminary investigation, what
The following facts are borne out by the transpired was a confounding series of
records. events which we shall try to disentangle.
The case was initially assigned to
Florencio V. Rueda, husband of petitioner
Prosecutor Antonio M. Israel, who had to
Leonila Garcia-Rueda, underwent surgical
inhibit himself because he was related to
operation at the UST hospital for the
the counsel of one of the doctors. As a
removal of a stone blocking his ureter. He
result, the case was re-raffled to
was attended by Dr. Domingo Antonio, Jr.
Prosecutor Norberto G. Leono who was,
who was the surgeon, while Dr. Erlinda
however, disqualified on motion of the
Balatbat-Reyes was the anaesthesiologist.
petitioner since he disregarded prevailing
Six hours after the surgery, however,
laws and jurisprudence regarding
Florencio died of complications of unknown
preliminary investigation. The case was
cause, according to officials of the UST
then referred to Prosecutor Ramon O.
Hospital.2chanroblesvirtuallawlibrary
Carisma, who issued a resolution
Not satisfied with the findings of the recommending that only Dr. Reyes be held
hospital, petitioner requested the National criminally liable and that the complaint
Bureau of Investigation (NBI) to conduct an against Dr. Antonio be dismissed.
autopsy on her husbands body.
The case took another perplexing turn
Consequently, the NBI ruled that Florencios
when Assistant City Prosecutor Josefina
death was due to lack of care by the
Santos Sioson, in the interest of justice and
attending physician in administering
peace of mind of the parties,
anaesthesia. Pursuant to its findings, the
recommended that the case be re-raffled
NBI recommended that Dr. Domingo
on the ground that Prosecutor Carisma was Aggrieved, petitioner filed graft charges
partial to the petitioner. Thus, the case specifically for violation of Section 3(e) of
was transferred to Prosecutor Leoncia R. Republic Act No. 3019 3 against
Dimagiba, where a volte face occurred Prosecutors Guerrero, Macaraeg, and
again with the endorsement that the Arizala for manifest partiality in favor of Dr.
complaint against Dr. Reyes be dismissed Reyes before the Office of the
and instead, a corresponding information Ombudsman. However, on July 11, 1994,
be filed against Dr. Antonio. Petitioner filed the Ombudsman issued the assailed
a motion for reconsideration, questioning resolution dismissing the complaint for lack
the findings of Prosecutor Dimagiba. of evidence.
Pending the resolution of petitioners In fine, petitioner assails the exercise of
motion for reconsideration regarding the discretionary power of the Ombudsman
Prosecutor Dimagibas resolution, the to review the recommendations of the
investigative pingpong continued when the government prosecutors and to approve
case was again assigned to another and disapprove the same. Petitioner faults
prosecutor, Eudoxia T. Gualberto, who the Ombudsman for, allegedly in grave
recommended that Dr. Reyes be included abuse of discretion, refusing to find that
in the criminal information of Homicide there exists probable cause to hold public
through Reckless Imprudence. While the respondent City Prosecutors liable for
recommendation of Prosecutor Gualberto violation of Section 3(e) of R.A. No. 3019.
was pending, the case was transferred to
Preliminarily, the powers and functions of
Senior State Prosecutor Gregorio A. Arizala,
the Ombudsman have generally been
who resolved to exonerate Dr. Reyes from
categorized into the following:
any wrongdoing, a resolution which was
investigatory powers, prosecutory power,
approved by both City Prosecutor Porfirio
public assistance function, authority to
G. Macaraeg and City Prosecutor Jesus F.
inquire and obtain information, and
Guerrero.
function to adopt, institute and implement
preventive to perform a duty enjoined by, or in
measures. 4chanroblesvirtuallawlibrary contemplation of
7
law.  chanroblesvirtuallawlibrary
As protector of the people, the Office of the
Ombudsman has the power, function and From a procedural standpoint, it is
duty to act promptly on complaints filed in certainly odd why the successive transfers
any form or manner against public officials from one prosecutor to another were not
and to investigate any act or omission of sufficiently explained in the Resolution of
any public official when such act or the Ombudsman. Being the proper
omission appears to be illegal, unjust, investigating authority with respect to
improper or misfeasance, non-feasance and
5
inefficient.  chanroblesvirtuallawlibrary malfeasance of public officials, the
Ombudsman should have been more
While the Ombudsman has the full
vigilant and assiduous in determining the
discretion to determine whether or not a
reasons behind the buckpassing to ensure
criminal case should be filed, this Court is
that no irregularity took place.
not precluded from reviewing the
Ombudsmans action when there is an Whether such transfers were due to any
abuse of discretion, in which case Rule 65 outside pressure or ulterior motive is a
of the Rules of Court may exceptionally be matter of evidence. One would have
invoked pursuant to Section I, Article VIII of expected the Ombudsman, however, to
the 1987 inquire into what could hardly qualify as
6
Constitution.  chanroblesvirtuallawlibrary standard operating procedure, given the
surrounding circumstances of the case.
In this regard, grave abuse of discretion
has been defined as where a power is While it is true that a preliminary
exercised in an arbitrary or despotic investigation is essentially inquisitorial,
manner by reason of passion or personal and is often the only means to discover
hostility so patent and gross as to amount who may be charged with a crime, its
to evasion of positive duty or virtual refusal function is merely to determine the
existence of probable cause. 8 Probable In the instant case, no less than the NBI
cause has been defined as the existence of pronounced after conducting an autopsy
such fact and circumstances as would that there was indeed negligence on the
excite the belief, in a reasonable mind, part of the attending physicians in
acting on the facts within the knowledge of administering the anaesthesia. 11 The fact
the prosecution, that the person charged of want of competence or diligence is
was guilty of the crime for which he was evidentiary in nature, the veracity of which
prosecuted.9chanroblesvirtuallawlibrary can best be passed upon after a full-blown
trial for it is virtually impossible to
Probable cause is a reasonable ground of
ascertain the merits of a medical
presumption that a matter is, or may be,
negligence case without extensive
well founded, such a state of facts in the
investigation, research, evaluation and
mind of the prosecutor as would lead a
consultations with medical experts.
person of ordinary caution and prudence to
Clearly, the City Prosecutors are not in a
believe, or entertain an honest or strong
competent position to pass judgment on
suspicion, that a thing is so. The term does
such a technical matter, especially when
not mean actual and positive cause nor
there are conflicting evidence and findings.
does it import absolute certainty. It is
The bases of a partys accusation and
merely based on opinion and reasonable
defenses are better ventilated at the trial
belief. Thus, a finding of probable cause
proper than at the preliminary
does not require an inquiry into whether
investigation.
there is sufficient evidence to procure a
conviction. It is enough that it is believed A word on medical malpractice or
that the act or omission complained of negligence cases.
constitutes the offense charged. Precisely,
In its simplest terms, the type of lawsuit
there is a trial for the reception of evidence
which has been called medical malpractice
of the prosecution in support of the
or, more appropriately, medical
charge.10chanroblesvirtuallawlibrary
negligence, is that type of claim which a
victim has available to him or her to the same level of care that any other
redress a wrong committed by a medical reasonably competent doctor would use to
professional which has caused bodily treat a condition under the same
harm. circumstances. The breach of these
professional duties of skill and care, or
In order to successfully pursue such a
their improper performance, by a physician
claim, a patient must prove that a health
surgeon whereby the patient is injured in
care provider, in most cases a physician,
body or in health, constitutes actionable
either failed to do something which a
malpractice.14 Consequently, in the event
reasonably prudent health care provider
that any injury results to the patient from
would have done, or that he or she did
want of due care or skill during the
something that a reasonably prudent
operation, the surgeons may be held
provider would not have done; and that
answerable in damages for
that failure or action caused injury to the 15
negligence. chanroblesvirtuallawlibrary
patient.12chanroblesvirtuallawlibrary
Moreover, in malpractice or negligence
Hence, there are four elements involved in
cases involving the administration of
medical negligence cases: duty, breach,
anaesthesia, the necessity of expert
injury and proximate causation.
testimony and the availability of the
Evidently, when the victim employed the charge of res ipsa loquitur to the plaintiff,
services of Dr. Antonio and Dr. Reyes, a have been applied in actions against
physician-patient relationship was created. anaesthesiologists to hold the defendant
In accepting the case, Dr. Antonio and Dr. liable for the death or injury of a patient
Reyes in effect represented that, having under excessive or improper
the needed training and skill possessed by 16
anaesthesia.  Essentially, it requires two-
physicians and surgeons practicing in the pronged evidence: evidence as to the
same field, they will employ such training, recognized standards of the medical
care and skill in the treatment of their community in the particular kind of case,
patients.13 They have a duty to use at least and a showing that the physician in
question negligently departed from this these precautionary measures were
standard in his disregarded must be sufficiently explained.
17
treatment. chanroblesvirtuallawlibrary
The City Prosecutors were charged with
Another element in medical negligence violating Section 3(e) of the Anti-Graft and
cases is causation which is divided into two Corrupt Practices Act which requires the
inquiries: whether the doctors actions in following facts:
fact caused the harm to the patient and
1. The accused is a public officer
whether these were the proximate cause
discharging administrative or official
of the patients injury.18 Indeed here, a
functions or private persons charged in
causal connection is discernible from the
conspiracy with them;
occurrence of the victims death after the
negligent act of the anaesthesiologist in 2. The public officer committed the
administering the anesthesia, a fact which, prohibited act during the performance of
if confirmed, should warrant the filing of his official duty or in relation to his public
the appropriate criminal case. To be sure, position;
the allegation of negligence is not entirely
3. The public officer acted with manifest
baseless. Moreover, the NBI deduced that
partiality, evident bad faith or gross,
the attending surgeons did not conduct the
inexcusable negligence; and
necessary interview of the patient prior to
the operation. It appears that the cause of 4. His action caused undue injury to the
the death of the victim could have been Government or any private party, or gave
averted had the proper drug been applied any party any unwarranted benefit,
to cope with the symptoms of malignant advantage or preference to such
20
hyperthermia. Also, we cannot ignore the parties.  chanroblesvirtuallawlibrary
fact that an antidote was readily available
Why did the complainant, petitioner in
to counteract whatever deleterious effect
instant case, elect to charge respondents
the anaesthesia might produce. 19 Why
under the above law?
While a party who feels himself aggrieved 223 states: The Secretary of Justice may
is at liberty to choose the appropriate reverse, affirm or modify the appealed
weapon from the armory, it is with no little resolution. On the other hand, He
surprise that this Court views the choice may motu proprio or on motion of the
made by the complainant widow. appellee, dismiss outright the appeal on
specified
To our mind, the better and more logical
grounds. 22chanroblesvirtuallawlibrary
remedy under the circumstances would
have been to appeal the resolution of the In exercising his discretion under the
City Prosecutors dismissing the criminal circumstances, the Ombudsman acted
complaint to the Secretary of Justice under within his power and authority in
the Department of Justices Order No. dismissing the complaint against the
223, 21 otherwise known as the 1993 Prosecutors and this Court will not interfere
Revised Rules on Appeals From Resolutions with the same.
In Preliminary
WHEREFORE, in view of the foregoing, the
Investigations/Reinvestigations, as
instant petition is DISMISSED, without
amended by Department Order No. 359,
prejudice to the filing of an appeal by the
Section 1 of which provides:
petitioner with the Secretary of Justice
Section 1. What May Be Appealed. - Only assailing the dismissal of her criminal
resolutions of the Chief State complaint by the respondent City
Prosecutor/Regional State Prosecutors. No costs.
Prosecutor/Provincial or City Prosecutor
SO ORDERED.
dismissing a criminal complaint may be the
subject of an appeal to the Secretary of
Justice except as otherwise provided in
Section 4 hereof.
What action may the Secretary of Justice
take on the appeal? Section 9 of Order No.
G.R. No. 130547               October 3, January 8, 1987, Jorge had been suffering
2000 from a recurring fever with chills. After he
failed to get relief from some home
LEAH ALESNA REYES, ROSE NAHDJA,
medication he was taking, which consisted
JOHNNY, and minors LLOYD and
of analgesic, antipyretic, and antibiotics,
KRISTINE, all surnamed REYES,
he decided to see the doctor.
represented by their mother, LEAH
ALESNA REYES, petitioners, On January 8, 1987, he was taken to the
vs. Mercy Community Clinic by his wife. He
SISTERS OF MERCY HOSPITAL, SISTER was attended to by respondent Dr. Marlyn
ROSE PALACIO, DR. MARVIE BLANES, Rico, resident physician and admitting
and DR. MARLYN RICO, respondents. physician on duty, who gave Jorge a
physical examination and took his medical
DECISION
history. She noted that at the time of his
MENDOZA, J.: admission, Jorge was conscious,
ambulatory, oriented, coherent, and with
This is a petition for review of the
respiratory distress.2 Typhoid fever was
decision1 of the Court of Appeals in CA-G.R.
then prevalent in the locality, as the clinic
CV No. 36551 affirming the decision of the
had been getting from 15 to 20 cases of
Regional Trial Court, Branch IX, Cebu City
typhoid per month.3 Suspecting that Jorge
which dismissed a complaint for damages
could be suffering from this disease, Dr.
filed by petitioners against respondents.
Rico ordered a Widal Test, a standard test
The facts are as follows: for typhoid fever, to be performed on
Jorge. Blood count, routine urinalysis, stool
Petitioner Leah Alesna Reyes is the wife of
examination, and malarial smear were also
the late Jorge Reyes. The other petitioners,
made.4 After about an hour, the medical
namely, Rose Nahdja, Johnny, Lloyd, and
technician submitted the results of the test
Kristine, all surnamed Reyes, were their
from which Dr. Rico concluded that Jorge
children. Five days before his death on
was positive for typhoid fever. As her shift
was only up to 5:00 p.m., Dr. Rico indorsed suction machine, and administered
Jorge to respondent Dr. Marvie Blanes. hydrocortisone, temporarily easing the
patient’s convulsions. When he regained
Dr. Marvie Blanes attended to Jorge at
consciousness, the patient was asked by
around six in the evening. She also took
Dr. Blanes whether he had a previous
Jorge’s history and gave him a physical
heart ailment or had suffered from chest
examination. Like Dr. Rico, her impression
pains in the past. Jorge replied he did
was that Jorge had typhoid fever.
not.5 After about 15 minutes, however,
Antibiotics being the accepted treatment
Jorge again started to vomit, showed
for typhoid fever, she ordered that a
restlessness, and his convulsions returned.
compatibility test with the antibiotic
Dr. Blanes re-applied the emergency
chloromycetin be done on Jorge. Said test
measures taken before and, in addition,
was administered by nurse Josephine
valium was administered. Jorge, however,
Pagente who also gave the patient a dose
did not respond to the treatment and
of triglobe. As she did not observe any
slipped into cyanosis, a bluish or purplish
adverse reaction by the patient to
discoloration of the skin or mucous
chloromycetin, Dr. Blanes ordered the first
membrane due to deficient oxygenation of
five hundred milligrams of said antibiotic to
the blood. At around 2:00 a.m., Jorge died.
be administered on Jorge at around 9:00
He was forty years old. The cause of his
p.m. A second dose was administered on
death was "Ventricular Arrythemia
Jorge about three hours later just before
Secondary to Hyperpyrexia and typhoid
midnight.
fever."
At around 1:00 a.m. of January 9, 1987, Dr.
On June 3, 1987, petitioners filed before
Blanes was called as Jorge’s temperature
the Regional Trial Court of Cebu City a
rose to 41°C. The patient also experienced
complaint6 for damages against
chills and exhibited respiratory distress,
respondents Sisters of Mercy, Sister Rose
nausea, vomiting, and convulsions. Dr.
Palacio, Dr. Marvie Blanes, Dr. Marlyn Rico,
Blanes put him under oxygen, used a
and nurse Josephine Pagente. On
September 24, 1987, petitioners amended carelessness, imprudence, and lack of skill
their complaint to implead respondent or foresight on the part of defendants; (2)
Mercy Community Clinic as additional whether respondent Mercy Community
defendant and to drop the name of Clinic was negligent in the hiring of its
Josephine Pagente as defendant since she employees; and (3) whether either party
was no longer connected with respondent was entitled to damages. The case was
hospital. Their principal contention was then heard by the trial court during which,
that Jorge did not die of typhoid in addition to the testimonies of the
fever.7 Instead, his death was due to the parties, the testimonies of doctors as
wrongful administration of chloromycetin. expert witnesses were presented.
They contended that had respondent
Petitioners offered the testimony of Dr.
doctors exercised due care and diligence,
Apolinar Vacalares, Chief Pathologist at the
they would not have recommended and
Northern Mindanao Training Hospital,
rushed the performance of the Widal Test,
Cagayan de Oro City. On January 9, 1987,
hastily concluded that Jorge was suffering
Dr. Vacalares performed an autopsy on
from typhoid fever, and administered
Jorge Reyes to determine the cause of his
chloromycetin without first conducting
death. However, he did not open the skull
sufficient tests on the patient’s
to examine the brain. His findings 9 showed
compatibility with said drug. They charged
that the gastro-intestinal tract was normal
respondent clinic and its directress, Sister
and without any ulceration or enlargement
Rose Palacio, with negligence in failing to
of the nodules. Dr. Vacalares testified that
provide adequate facilities and in hiring
Jorge did not die of typhoid fever. He also
negligent doctors and nurses.8
stated that he had not seen a patient die of
Respondents denied the charges. During typhoid fever within five days from the
the pre-trial conference, the parties agreed onset of the disease.
to limit the issues on the following: (1)
For their part, respondents offered the
whether the death of Jorge Reyes was due
testimonies of Dr. Peter Gotiong and Dr.
to or caused by the negligence,
Ibarra Panopio. Dr. Gotiong is a diplomate pathologist of the Andres Soriano Jr.
in internal medicine whose expertise is Memorial Hospital in Toledo City. Dr.
microbiology and infectious diseases. He is Panopio stated that although he was
also a consultant at the Cebu City Medical partial to the use of the culture test for its
Center and an associate professor of greater reliability in the diagnosis of
medicine at the South Western University typhoid fever, the Widal Test may also be
College of Medicine in Cebu City. He had used. Like Dr. Gotiong, he agreed that the
treated over a thousand cases of typhoid 1:320 ratio in Jorge’s case was already the
patients. According to Dr. Gotiong, the maximum by which a conclusion of typhoid
patient’s history and positive Widal Test fever may be made. No additional
results ratio of 1:320 would make him information may be deduced from a higher
suspect that the patient had typhoid fever. dilution.11 He said that Dr. Vacalares’
As to Dr. Vacalares’ observation regarding autopsy on Jorge was incomplete and thus
the absence of ulceration in Jorge’s gastro- inconclusive.
intestinal tract, Dr. Gotiong said that such
On September 12, 1991, the trial court
hyperplasia in the intestines of a typhoid
rendered its decision absolving
victim may be microscopic. He noted that
respondents from the charges of
since the toxic effect of typhoid fever may
negligence and dismissing petitioners’
lead to meningitis, Dr. Vacalares’ autopsy
action for damages. The trial court likewise
should have included an examination of
dismissed respondents’ counterclaim,
the brain.10
holding that, in seeking damages from
The other doctor presented was Dr. Ibarra respondents, petitioners were impelled by
Panopio, a member of the American Board the honest belief that Jorge’s death was
of Pathology, examiner of the Philippine due to the latter’s negligence.
Board of Pathology from 1978 to 1991,
Petitioners brought the matter to the Court
fellow of the Philippine Society of
of Appeals. On July 31, 1997, the Court of
Pathologist, associate professor of the
Cebu Institute of Medicine, and chief
Appeals affirmed the decision of the trial a physician or surgeon to apply to his
court. practice of medicine that degree of care
and skill which is ordinarily employed by
Hence this petition.
the profession generally, under similar
Petitioners raise the following assignment conditions, and in like surrounding
of errors: circumstances.12 In order to successfully
pursue such a claim, a patient must prove
I. THE HONORABLE COURT OF APPEALS
that the physician or surgeon either failed
COMMITTED A REVERSIBLE ERROR WHEN
to do something which a reasonably
IT RULED THAT THE DOCTRINE OF RES
prudent physician or surgeon would have
IPSA LOQUITUR IS NOT APPLICABLE IN THE
done, or that he or she did something that
INSTANT CASE.
a reasonably prudent physician or surgeon
II. THE HONORABLE COURT OF APPEALS would not have done, and that the failure
COMMITTED REVERSIBLE ERROR WHEN IT or action caused injury to the
MADE AN UNFOUNDED ASSUMPTION THAT 13 
patient. There are thus four elements
THE LEVEL OF MEDICAL PRACTICE IS involved in medical negligence cases,
LOWER IN ILIGAN CITY. namely: duty, breach, injury, and
proximate causation.
III. THE HONORABLE COURT OF APPEALS
GRAVELY ERRED WHEN IT RULED FOR A In the present case, there is no doubt that
LESSER STANDARD OF CARE AND DEGREE a physician-patient relationship existed
OF DILIGENCE FOR MEDICAL PRACTICE IN between respondent doctors and Jorge
ILIGAN CITY WHEN IT APPRECIATE[D] NO Reyes. Respondents were thus duty-bound
DOCTOR’S NEGLIGENCE IN THE to use at least the same level of care that
TREATMENT OF JORGE REYES. any reasonably competent doctor would
use to treat a condition under the same
Petitioner’s action is for medical
circumstances. It is breach of this duty
malpractice. This is a particular form of
which constitutes actionable
negligence which consists in the failure of 14 
malpractice. As to this aspect of medical
malpractice, the determination of the matters that are within the common
reasonable level of care and the breach knowledge of mankind which may be
thereof, expert testimony is essential. testified to by anyone familiar with the
Inasmuch as the causes of the injuries facts. Ordinarily, only physicians and
involved in malpractice actions are surgeons of skill and experience are
determinable only in the light of scientific competent to testify as to whether a
knowledge, it has been recognized that patient has been treated or operated upon
expert testimony is usually necessary to with a reasonable degree of skill and care.
support the conclusion as to causation. 15 However, testimony as to the statements
and acts of physicians and surgeons,
Res Ipsa Loquitur
external appearances, and manifest
There is a case when expert testimony conditions which are observable by any
may be dispensed with, and that is under one may be given by non-expert
the doctrine of res ipsa loquitur. As held witnesses. Hence, in cases where the res
in Ramos v. Court of Appeals:16 ipsa loquitur is applicable, the court is
permitted to find a physician negligent
Although generally, expert medical
upon proper proof of injury to the patient,
testimony is relied upon in malpractice
without the aid of expert testimony, where
suits to prove that a physician has done a
the court from its fund of common
negligent act or that he has deviated from
knowledge can determine the proper
the standard medical procedure, when the
standard of care. Where common
doctrine of res ipsa loquitor is availed by
knowledge and experience teach that a
the plaintiff, the need for expert medical
resulting injury would not have occurred to
testimony is dispensed with because the
the patient if due care had been exercised,
injury itself provides the proof of
an inference of negligence may be drawn
negligence. The reason is that the general
giving rise to an application of the doctrine
rule on the necessity of expert testimony
of res ipsa loquitur without medical
applies only to such matters clearly within
evidence, which is ordinarily required to
the domain of medical science, and not to
show not only what occurred but how and Petitioners asserted in the Court of Appeals
why it occurred. When the doctrine is that the doctrine of res ipsa
appropriate, all that the patient must do is loquitur applies to the present case
prove a nexus between the particular act because Jorge Reyes was merely
or omission complained of and the injury experiencing fever and chills for five days
sustained while under the custody and and was fully conscious, coherent, and
management of the defendant without ambulant when he went to the hospital.
need to produce expert medical testimony Yet, he died after only ten hours from the
to establish the standard of care. Resort time of his admission.
to res ipsa loquitor is allowed because
This contention was rejected by the
there is no other way, under usual and
appellate court.
ordinary conditions, by which the patient
can obtain redress for injury suffered by Petitioners now contend that all requisites
him. for the application of res ipsa loquitur were
present, namely: (1) the accident was of a
Thus, courts of other jurisdictions have
kind which does not ordinarily occur unless
applied the doctrine in the following
someone is negligent; (2) the
situations: leaving of a foreign object in the
instrumentality or agency which caused
body of the patient after an operation,
the injury was under the exclusive control
injuries sustained on a healthy part of the
of the person in charge; and (3) the injury
body which was not under, or in the area,
suffered must not have been due to any
of treatment, removal of the wrong part of
voluntary action or contribution of the
the body when another part was intended,
person injured.18
knocking out a tooth while a patient’s jaw
was under anesthetic for the removal of his The contention is without merit. We agree
tonsils, and loss of an eye while the patient with the ruling of the Court of Appeals. In
was under the influence of anesthetic, the Ramos case, the question was whether
during or following an operation for a surgeon, an anesthesiologist, and a
appendicitis, among others.17 hospital should be made liable for the
comatose condition of a patient scheduled Respondents alleged failure to observe due
for cholecystectomy.19 In that case, the care was not immediately apparent to a
patient was given anesthesia prior to her layman so as to justify application of res
operation. Noting that the patient was ipsa loquitur. The question required expert
neurologically sound at the time of her opinion on the alleged breach by
operation, the Court applied the doctrine respondents of the standard of care
of res ipsa loquitur as mental brain required by the circumstances.
damage does not normally occur in a Furthermore, on the issue of the
gallblader operation in the absence of correctness of her diagnosis, no
negligence of the anesthesiologist. Taking presumption of negligence can be applied
judicial notice that anesthesia procedures to Dr. Marlyn Rico.As held in Ramos:
had become so common that even an
. . . . Res ipsa loquitur is not a rigid or
ordinary person could tell if it was
ordinary doctrine to be perfunctorily used
administered properly, we allowed the
but a rule to be cautiously applied,
testimony of a witness who was not an
depending upon the circumstances of each
expert. In this case, while it is true that the
case. It is generally restricted to situations
patient died just a few hours after
in malpractice cases where a layman is
professional medical assistance was
able to say, as a matter of common
rendered, there is really nothing unusual or
knowledge and observation, that the
extraordinary about his death. Prior to his
consequences of professional care were
admission, the patient already had
not as such as would ordinarily have
recurring fevers and chills for five days
followed if due care had been exercised. A
unrelieved by the analgesic, antipyretic,
distinction must be made between the
and antibiotics given him by his wife. This
failure to secure results, and the
shows that he had been suffering from a
occurrence of something more unusual and
serious illness and professional medical
not ordinarily found if the service or
help came too late for him.
treatment rendered followed the usual
procedure of those skilled in that particular
practice. It must be conceded that the Training Hospital, Cagayan de Oro City,
doctrine of res ipsa loquitur  can have no who performed an autopsy on the body of
application in a suit against a physician or Jorge Reyes. Dr. Vacalares testified that,
a surgeon which involves the merits of a based on his findings during the autopsy,
diagnosis or of a scientific treatment. The Jorge Reyes did not die of typhoid fever but
physician or surgeon is not required at his of shock undetermined, which could be
peril to explain why any particular due to allergic reaction or chloromycetin
diagnosis was not correct, or why any overdose. We are not persuaded.
particular scientific treatment did not
First. While petitioners presented Dr.
produce the desired result.20
Apolinar Vacalares as an expert witness,
Specific Acts of Negligence we do not find him to be so as he is not a
specialist on infectious diseases like
We turn to the question whether
typhoid fever. Furthermore, although he
petitioners have established specific acts
may have had extensive experience in
of negligence allegedly committed by
performing autopsies, he admitted that he
respondent doctors.
had yet to do one on the body of a typhoid
Petitioners contend that: (1) Dr. Marlyn victim at the time he conducted the
Rico hastily and erroneously relied upon postmortem on Jorge Reyes. It is also plain
the Widal test, diagnosed Jorge’s illness as from his testimony that he has treated only
typhoid fever, and immediately prescribed about three cases of typhoid fever. Thus,
the administration of the antibiotic he testified that:23
chloromycetin;21 and (2) Dr. Marvie Blanes
ATTY. PASCUAL:
erred in ordering the administration of the
second dose of 500 milligrams of Q Why? Have you not testified earlier that
chloromycetin barely three hours after the you have never seen a patient who died of
first was given.22 Petitioners presented the typhoid fever?
testimony of Dr. Apolinar Vacalares, Chief
Pathologist of the Northern Mindanao
A In autopsy. But, that was when I was a A Way back after my training in UP.
resident physician yet.
Q Clinically?
Q But you have not performed an autopsy
A Way back before my training.
of a patient who died of typhoid fever?
He is thus not qualified to prove that Dr.
A I have not seen one.
Marlyn Rico erred in her diagnosis. Both
Q And you testified that you have never lower courts were therefore correct in
seen a patient who died of typhoid fever discarding his testimony, which is really
within five days? inadmissible.
A I have not seen one. In Ramos, the defendants presented the
testimony of a pulmonologist to prove that
Q How many typhoid fever cases had you
brain injury was due to oxygen deprivation
seen while you were in the general
after the patient had
practice of medicine? 24 
bronchospasms triggered by her allergic
A In our case we had no widal test that response to a drug,25 and not due to faulty
time so we cannot consider that the intubation by the anesthesiologist. As the
typhoid fever is like this and like that. And issue was whether the intubation was
the widal test does not specify the time of properly performed by an anesthesiologist,
the typhoid fever. we rejected the opinion of the
pulmonologist on the ground that he was
Q The question is: how many typhoid fever
not: (1) an anesthesiologist who could
cases had you seen in your general
enlighten the court about anesthesia
practice regardless of the cases now you
practice, procedure, and their
practice?
complications; nor (2) an allergologist who
A I had only seen three cases. could properly advance expert opinion on
allergic mediated processes; nor (3) a
Q And that was way back in 1964?
pharmacologist who could explain the
pharmacologic and toxic effects of the the disease could not be discounted. His
drug allegedly responsible for the testimony is as follows:30
bronchospasms.
ATTY. PASCUAL:
Second. On the other hand, the two
Q If with that count with the test of positive
doctors presented by respondents clearly
for 1 is to 320, what treatment if any would
were experts on the subject. They vouched
be given?
for the correctness of Dr. Marlyn Rico’s
diagnosis. Dr. Peter Gotiong, a diplomate A If those are the findings that would be
whose specialization is infectious diseases presented to me, the first thing I would
and microbiology and an associate consider would be typhoid fever.
professor at the Southwestern University
Q And presently what are the treatments
College of Medicine and the Gullas College
commonly used?
of Medicine, testified that he has already
treated over a thousand cases of typhoid A Drug of choice of chloramphenical.
fever.26 According to him, when a case of
Q Doctor, if given the same patient and
typhoid fever is suspected, the Widal test
after you have administered
is normally used,27 and if the 1:320 results
chloramphenical about 3 1/2 hours later,
of the Widal test on Jorge Reyes had been
the patient associated with chills,
presented to him along with the patient’s o
temperature - 41 C, what could possibly
history, his impression would also be that
come to your mind?
the patient was suffering from typhoid
fever.28 As to the treatment of the disease, A Well, when it is change in the clinical
he stated that chloromycetin was the drug finding, you have to think of complication.
of choice.29 He also explained that despite
Q And what will you consider on the
the measures taken by respondent doctors
complication of typhoid?
and the intravenous administration of two
doses of chloromycetin, complications of A One must first understand that typhoid
fever is toximia. The problem is
complications are caused by toxins minutes later, have seizure and cyanosis
produced by the bacteria . . . whether you and rolling of eyeballs and vomitting . . .
have suffered complications to think of -- and death: what significance would you
heart toxic myocardities; then you can attach to this development?
consider a toxic meningitis and other
A We are probably dealing with typhoid to
complications and perforations and
meningitis.
bleeding in the ilium.
Q In such case, Doctor, what finding if any
Q Even that 40-year old married patient
could you expect on the post-mortem
who received medication of chloromycetin
examination?
of 500 milligrams intravenous, after the
skin test, and received a second dose of A No, the finding would be more on the
chloromycetin of 500 miligrams, 3 hours meninges or covering of the brain.
later, the patient developed chills . . . rise
Q And in order to see those changes would
in temperature to 41oC, and then about 40
it require opening the skull?
minutes later the temperature rose to
100oF, cardiac rate of 150 per minute who A Yes.
appeared to be coherent, restless,
As regards Dr. Vacalares’ finding during
nauseating, with seizures: what
the autopsy that the deceased’s gastro-
significance could you attach to these
intestinal tract was normal, Dr. Rico
clinical changes?
explained that, while hyperplasia31 in the
A I would then think of toxemia, which was payer’s patches or layers of the small
toxic meningitis and probably a toxic intestines is present in typhoid fever, the
meningitis because of the high cardiac same may not always be grossly visible
rate. and a microscope was needed to see the
texture of the cells.32
Q Even if the same patient who, after
having given intramuscular valium, Respondents also presented the testimony
became conscious and coherent about 20 of Dr. Ibarra T. Panopio who is a member
of the Philippine and American Board of all known practitioners from the best to the
Pathology, an examiner of the Philippine worst and from the most to the least
Board of Pathology, and chief pathologist experienced, but the reasonable average
at the MetroCebu Community Hospital, merit among the ordinarily good
37 
Perpetual Succor Hospital, and the Andres physicians. Here, Dr. Marlyn Rico did not
Soriano Jr. Memorial Medical Center. He depart from the reasonable standard
stated that, as a clinical pathologist, he recommended by the experts as she in fact
recognized that the Widal test is used for observed the due care required under the
typhoid patients, although he did not circumstances. Though the Widal test is
encourage its use because a single test not conclusive, it remains a standard
would only give a presumption diagnostic test for typhoid fever and, in the
necessitating that the test be repeated, present case, greater accuracy through
becoming more conclusive at the second repeated testing was rendered
and third weeks of the disease. 33 He unobtainable by the early death of the
corroborated Dr. Gotiong’s testimony that patient. The results of the Widal test and
the danger with typhoid fever is really the the patient’s history of fever with chills for
possible complications which could five days, taken with the fact that typhoid
develop like perforation, hemorrhage, as fever was then prevalent as indicated by
well as liver and cerebral the fact that the clinic had been getting
34 
complications. As regards the 1:320 about 15 to 20 typhoid cases a month,
results of the Widal test on Jorge Reyes, were sufficient to give upon any doctor of
Dr. Panopio stated that no additional reasonable skill the impression that Jorge
information could be obtained from a Reyes had typhoid fever.
higher ratio.35 He also agreed with Dr.
Dr. Rico was also justified in
Gotiong that hyperplasia in the payer’s
recommending the administration of the
patches may be microscopic.36
drug chloromycetin, the drug of choice for
Indeed, the standard contemplated is not typhoid fever. The burden of proving that
what is actually the average merit among Jorge Reyes was suffering from any other
illness rested with the petitioners. As they meningitis, typhoid fever, rickettsial
failed to present expert opinion on this, infections, bacteriodes infections, etc."
preponderant evidence to support their (PIMS Annual, 1994, p. 211) The dosage
contention is clearly absent. likewise including the first administration
of five hundred milligrams (500 mg.) at
Third. Petitioners contend that respondent
around nine o’clock in the evening and the
Dr. Marvie Blanes, who took over from Dr.
second dose at around 11:30 the same
Rico, was negligent in ordering the
night was still within medically acceptable
intravenous administration of two doses of
limits, since the recommended dose of
500 milligrams of chloromycetin at an
chloromycetin is one (1) gram every six (6)
interval of less than three hours.
hours. (cf. Pediatric Drug Handbook, 1st
Petitioners claim that Jorge Reyes died of
Ed., Philippine Pediatric Society,
anaphylactic shock38 or possibly from
Committee on Therapeutics and
overdose as the second dose should have
Toxicology, 1996). The intravenous route is
been administered five to six hours after
likewise correct. (Mansser, O’Nick,
the first, per instruction of Dr. Marlyn Rico.
Pharmacology and Therapeutics) Even if
As held by the Court of Appeals, however:
the test was not administered by the
That chloromycetin was likewise a proper physician-on-duty, the evidence introduced
prescription is best established by medical that it was Dra. Blanes who interpreted the
authority. Wilson, et. al., in Harrison’s results remain uncontroverted.
Principle of Internal Medicine, 12th ed. (Decision, pp. 16-17) Once more, this Court
write that chlorampenicol (which is the rejects any claim of professional
generic of chloromycetin) is the drug of negligence in this regard.
choice for typhoid fever and that no drug
....
has yet proven better in promoting a
favorable clinical response. As regards anaphylactic shock, the usual
"Chlorampenicol (Chloromycetin) is way of guarding against it prior to the
specifically indicated for bacterial administration of a drug, is the skin test of
which, however, it has been observed: competence and skills expected of general
"Skin testing with haptenic drugs is practitioners similarly situated.39
generally not reliable. Certain drugs cause
Fourth. Petitioners correctly observe that
nonspecific histamine release, producing a
the medical profession is one which, like
weal-and-flare reaction in normal
the business of a common carrier, is
individuals. Immunologic activation of mast
affected with public interest. Moreover,
cells requires a polyvalent allergen, so a
they assert that since the law imposes
negative skin test to a univalent haptenic
upon common carriers the duty of
drug does not rule out anaphylactic
observing extraordinary diligence in the
sensitivity to that drug." (Terr,
vigilance over the goods and for the safety
"Anaphylaxis and Urticaria" in Basic and
of the passengers,40 physicians and
Clinical Immunology, p. 349) What all this
surgeons should have the same duty
means legally is that even if the deceased
toward their patients.41 They also contend
suffered from an anaphylactic shock, this,
that the Court of Appeals erred when it
of itself, would not yet establish the
allegedly assumed that the level of
negligence of the appellee-physicians for
medical practice is lower in Iligan City,
all that the law requires of them is that
thereby reducing the standard of care and
they perform the standard tests and
degree of diligence required from
perform standard procedures. The law
physicians and surgeons in Iligan City.
cannot require them to predict every
possible reaction to all drugs administered. The standard of extraordinary diligence is
The onus probandi was on the appellants peculiar to common carriers. The Civil
to establish, before the trial court, that the Code provides:
appellee-physicians ignored standard
Art. 1733. Common carriers, from the
medical procedure, prescribed and
nature of their business and for reasons of
administered medication with recklessness
public policy, are bound to observe
and exhibited an absence of the
extraordinary diligence in the vigilance
over the goods and for the safety of the
passengers transported by them, Appeals called it, the reasonable "skill and
according to the circumstances of each competence . . . that a physician in the
case. . . . same or similar locality . . . should apply."
The practice of medicine is a profession WHEREFORE, the instant petition is
engaged in only by qualified DENIED and the decision of the Court of
individuals.1âwphi1 It is a right earned Appeals is AFFIRMED.
through years of education, training, and
SO ORDERED.
by first obtaining a license from the state
through professional board examinations.
Such license may, at any time and for
cause, be revoked by the government. In
addition to state regulation, the conduct of
doctors is also strictly governed by the
Hippocratic Oath, an ancient code of
discipline and ethical rules which doctors
have imposed upon themselves in
recognition and acceptance of their great
responsibility to society. Given these
safeguards, there is no need to expressly
require of doctors the observance of
"extraordinary" diligence. As it is now, the
practice of medicine is already conditioned
upon the highest degree of diligence. And,
as we have already noted, the standard
contemplated for doctors is simply the
reasonable average merit among ordinarily
good physicians. That is reasonable
diligence for doctors or, as the Court of
G.R. No. 192123               March 10, excrete through a colostomy bag attached
2014 to the side of his body.4
DR. FERNANDO P. SOLIDUM, Petitioner, On May 17, 1995, Gerald, then three years
vs. old, was admitted at the Ospital ng Maynila
PEOPLE OF THE for a pull-through operation. 5 Dr. Leandro
PHILIPPINES, Respondent. Resurreccion headed the surgical team,
and was assisted by Dr. Joselito Luceño,
DECISION
Dr. Donatella Valeña and Dr. Joseph Tibio.
BERSAMIN, J.: The anesthesiologists included Dr. Marichu
Abella, Dr. Arnel Razon and petitioner Dr.
This appeal is taken by a physician-
Fernando Solidum (Dr. Solidum). 6 During
anesthesiologist who has been pronounced
the operation, Gerald experienced
guilty of reckless imprudence resulting in
bradycardia,  and went into a coma. 8 His
7
serious physical injuries by the Regional
coma lasted for two weeks,9 but he
Trial Court (RTC) and the Court of Appeals
regained consciousness only after a
(CA). He had been part of the team of
month.10 He could no longer see, hear or
anesthesiologists during the surgical pull-
move.11
through operation conducted on a three-
year old patient born with an imperforate Agitated by her son’s helpless and
anus.1 unexpected condition, Ma. Luz Gercayo
(Luz) lodged a complaint for reckless
The antecedents are as follows:
imprudence resulting in serious physical
Gerald Albert Gercayo (Gerald) was born injuries with the City Prosecutor’s Office of
on June 2, 19922 with an imperforate anus. Manila against the attending physicians. 12
Two days after his birth, Gerald underwent
Upon a finding of probable cause, the City
colostomy, a surgical procedure to bring
Prosecutor’s Office filed an information
one end of the large intestine out through
solely against Dr. Solidum,13 alleging: –
the abdominal wall,3 enabling him to
That on or about May 17, 1995, in the City speaking or hearing, to his damage and
of Manila, Philippines, the said accused, prejudice.
being then an anesthesiologist at the
Contrary to law.14
Ospital ng Maynila, Malate, this City, and
as such was tasked to administer the The case was initially filed in the
anesthesia on three-year old baby boy Metropolitan Trial Court of Manila, but was
GERALD ALBERT GERCAYO, represented by transferred to the RTC pursuant to Section
his mother, MA. LUZ GERCAYO, the former 5 of Republic Act No. 8369 (The Family
having been born with an imperforate anus Courts Act of 1997),15 where it was
[no anal opening] and was to undergo an docketed as Criminal Case No. 01-190889.
operation for anal opening [pull through
Judgment of the RTC
operation], did then and there willfully,
unlawfully and feloniously fail and neglect On July 19, 2004, the RTC rendered its
to use the care and diligence as the best of judgment finding Dr. Solidum guilty
his judgment would dictate under said beyond reasonable doubt of reckless
circumstance, by failing to monitor and imprudence resulting to serious physical
regulate properly the levels of anesthesia injuries,16 decreeing:
administered to said GERALD ALBERT
WHEREFORE, premises considered, the
GERCAYO and using 100% halothane and
Court finds accused DR. FERNANDO P.
other anesthetic medications, causing as a
SOLIDUM GUILTY beyond reasonable doubt
consequence of his said carelessness and
as principal of the crime charged and is
negligence, said GERALD ALBERT
hereby sentenced to suffer the
GERCAYO suffered a cardiac arrest and
indeterminate penalty of TWO (2) MONTHS
consequently a defect called hypoxic
and ONE (1) DAY of arresto mayor as
encephalopathy meaning insufficient
minimum to ONE (1) YEAR, ONE (1) MONTH
oxygen supply in the brain, thereby
and TEN (10) DAYS of prision correccional
rendering said GERALD ALBERT GERCAYO
as maximum and to indemnify, jointly and
incapable of moving his body, seeing,
severally with the Ospital ng Maynila, Dr.
Anita So and Dr. Marichu Abella, private ₱500,000.00 as moral damages and
complainant Luz Gercayo, the amount of ₱100,000 as exemplary damages and to
₱500,000.00 as moral damages and pay the costs.
₱100,000.00 as exemplary damages and
Accordingly, the bond posted by the
to pay the costs.
accused for his provisional liberty is hereby
Accordingly, the bond posted by the cancelled.19
accused for his provisional liberty is hereby
Decision of the CA
CANCELLED.
On January 20, 2010, the CA affirmed the
SO ORDERED.17
conviction of Dr. Solidum,20 pertinently
Upon motion of Dr. Anita So and Dr. stating and ruling:
Marichu Abella to reconsider their solidary
The case appears to be a textbook
liability,18 the RTC excluded them from
example of res ipsa loquitur.
solidary liability as to the damages,
modifying its decision as follows: xxxx
WHEREFORE, premises considered, the x x x [P]rior to the operation, the child was
Court finds accused Dr. Fernando Solidum, evaluated and found fit to undergo a major
guilty beyond reasonable doubt as operation. As noted by the OSG, the
principal of the crime charged and is accused himself testified that pre-
hereby sentenced to suffer the operation tests were conducted to ensure
indeterminate penalty of two (2) months that the child could withstand the surgery.
and one (1) day of arresto mayor as Except for his imperforate anus, the child
minimum to one (1) year, one (1) month was healthy. The tests and other
and ten (10) days of prision correccional as procedures failed to reveal that he was
maximum and to indemnify jointly and suffering from any known ailment or
severally with Ospital ng Maynila, private disability that could turn into a significant
complainant Luz Gercayo the amount of risk. There was not a hint that the nature
of the operation itself was a causative the patient must do is prove a nexus
factor in the events that finally led to between the particular act or omission
hypoxia. complained of and the injury sustained
while under the custody and management
In short, the lower court has been left with
of the defendant without need to produce
no reasonable hypothesis except to
expert medical testimony to establish the
attribute the accident to a failure in the
standard of care. Resort to res ipsa loquitur
proper administration of anesthesia, the
is allowed because there is no other way,
gravamen of the charge in this case. The
under usual and ordinary conditions, by
High Court elucidates in Ramos vs. Court of
which the patient can obtain redress for
Appeals 321 SCRA 584 –
injury suffered by him.
In cases where the res ipsa loquitur is
The lower court has found that such a
applicable, the court is permitted to find a
nexus exists between the act complained
physician negligent upon proper proof of
of and the injury sustained, and in line with
injury to the patient, without the aid of
the hornbook rules on evidence, we will
expert testimony, where the court from its
afford the factual findings of a trial court
fund of common knowledge can determine
the respect they deserve in the absence of
the proper standard of care.
a showing of arbitrariness or disregard of
Where common knowledge and experience material facts that might affect the
teach that a resulting injury would not disposition of the case. People v. Paraiso
have occurred to the patient if due care 349 SCRA 335.
had been exercised, an inference of
The res ipsa loquitur test has been known
negligence may be drawn giving rise to an
to be applied in criminal cases. Although it
application of the doctrine of res ipsa
creates a presumption of negligence, it
loquitur without medical evidence, which is
need not offend due process, as long as
ordinarily required to show not only what
the accused is afforded the opportunity to
occurred but how and why it occurred.
go forward with his own evidence and
When the doctrine is appropriate, all that
prove that he has no criminal intent. It is in ACQUITTAL OF THE PETITIONER. FURTHER,
this light not inconsistent with the THE HONORABLE COURT ERRED IN
constitutional presumption of innocence of AFFIRMING THE SAID DECISION OF THE
an accused. LOWER COURT, AS THIS BREACHES THE
CRIMINAL LAW PRINCIPLE THAT THE
IN VIEW OF THE FOREGOING, the modified
PROSECUTION MUST PROVE THE
decision of the lower court is affirmed.
ALLEGATIONS OF THE INFORMATION
SO ORDERED.21 BEYOND REASONABLE DOUBT, AND NOT
ON THE BASIS OF ITS PRESUMPTIVE
Dr. Solidum filed a motion for
CONCLUSION.
reconsideration, but the CA denied his
motion on May 7, 2010.22 II.
Hence, this appeal. THE HONORABLE COURT OF APPEALS
ERRED IN APPLYING THE PRINCIPLE OF RES
Issues
IPSA LOQUITOR (sic) WHEN THE DEFENSE
Dr. Solidum avers that: WAS ABLE TO PROVE THAT THERE IS NO
NEGLIGENCE ON THE PART OF THE
I.
PETITIONER, AND NO OVERDOSING IN THE
THE HONORABLE COURT OF APPEALS APPLICATION OF THE ANESTHETIC AGENT
ERRED IN AFFIRMING THE DECISION OF BECAUSE THERE WAS NO 100%
THE LOWER COURT IN UPHOLDING THE HALOTHANE ADMINISTERED TO THE
PETITIONER’S CONVICTION FOR THE CRIME CHILD, BUT ONLY ONE (1%) PERCENT AND
CHARGED BASED ON THE TRIAL COURT’S THE APPLICATION THEREOF, WAS
OPINION, AND NOT ON THE BASIS OF THE REGULATED BY AN ANESTHESIA MACHINE.
FACTS ESTABLISHED DURING THE TRIAL. THUS, THE APPLICATION OF THE PRINCIPLE
ALSO, THERE IS A CLEAR OF RES IPSA LOQUITOR (sic)
MISAPPREHENSION OF FACTS WHICH IF CONTRADICTED THE ESTABLISHED FACTS
CORRECTED, WILL RESULT TO THE AND THE LAW APPLICABLE IN THE CASE.
III. injury is shown to be under the
management of the defendant, and the
THE AWARD OF MORAL DAMAGES AND
accident is such as in the ordinary course
EXEMPLARY DAMAGES IS NOT JUSTIFIED
of things does not happen if those who
THERE BEING NO NEGLIGENCE ON THE
have the management use proper care, it
PART OF THE PETITIONER. ASSUMING THAT
affords reasonable evidence, in the
THE CHILD IS ENTITLED TO FINANCIAL
absence of an explanation by the
CONSIDERATION, IT SHOULD BE ONLY AS A
defendant, that the accident arose from
FINANCIAL ASSISTANCE, BECAUSE THERE
want of care."24 It is simply "a recognition
WAS NO NEGLIGENCE, AND NO
of the postulate that, as a matter of
OVERDOSING OF ANESTHETIC AGENT AND
common knowledge and experience, the
AS SUCH, THE AWARD IS SO EXCESSIVE,
very nature of certain types of occurrences
AND NO FACTUAL AND LEGAL BASIS.23
may justify an inference of negligence on
To simplify, the following are the issues for the part of the person who controls the
resolution, namely: (a) whether or not the instrumentality causing the injury in the
doctrine of res ipsa loquitur was applicable absence of some explanation by the
herein; and (b) whether or not Dr. Solidum defendant who is charged with negligence.
was liable for criminal negligence. It is grounded in the superior logic of
ordinary human experience and on the
Ruling
basis of such experience or common
The appeal is meritorious. knowledge, negligence may be deduced
from the mere occurrence of the accident
Applicability of the Doctrine of Res Ipsa
itself.
Loquitur
Hence, res ipsa loquitur is applied in
Res ipsa loquitur is literally translated as
conjunction with the doctrine of common
"the thing or the transaction speaks for
knowledge."25
itself." The doctrine res ipsa loquitur
means that "where the thing which causes
Jarcia, Jr. v. People26 has underscored that cause of that harm. The application of res
the doctrine is not a rule of substantive ipsa loquitur in medical negligence cases
law, but merely a mode of proof or a mere presents a question of law since it is a
procedural convenience. The doctrine, judicial function to determine whether a
when applicable to the facts and certain set of circumstances does, as a
circumstances of a given case, is not matter of law, permit a given inference.
meant to and does not dispense with the
Although generally, expert medical
requirement of proof of culpable
testimony is relied upon in malpractice
negligence against the party charged. It
suits to prove that a physician has done a
merely determines and regulates what
negligent act or that he has deviated from
shall be prima facie evidence thereof, and
the standard medical procedure, when the
helps the plaintiff in proving a breach of
doctrine of res ipsa loquitur is availed by
the duty. The doctrine can be invoked
the plaintiff, the need for expert medical
when and only when, under the
testimony is dispensed with because the
circumstances involved, direct evidence is
injury itself provides the proof of
absent and not readily available.27
negligence. The reason is that the general
The applicability of the doctrine of res ipsa rule on the necessity of expert testimony
loquitur in medical negligence cases was applies only to such matters clearly within
significantly and exhaustively explained in the domain of medical science, and not to
Ramos v. Court of Appeals,28 where the matters that are within the common
Court said – knowledge of mankind which may be
testified to by anyone familiar with the
Medical malpractice cases do not escape
facts. Ordinarily, only physicians and
the application of this doctrine. Thus, res
surgeons of skill and experience are
ipsa loquitur has been applied when the
competent to testify as to whether a
circumstances attendant upon the harm
patient has been treated or operated upon
are themselves of such a character as to
with a reasonable degree of skill and care.
justify an inference of negligence as the
However, testimony as to the statements
and acts of physicians and surgeons, res ipsa loquitur is allowed because there
external appearances, and manifest is no other way, under usual and ordinary
conditions which are observable by any conditions, by which the patient can obtain
one may be given by non-expert redress for injury suffered by him.
witnesses. Hence, in cases where the res
Thus, courts of other jurisdictions have
ipsa loquitur is applicable, the court is
applied the doctrine in the following
permitted to find a physician negligent
situations: leaving of a foreign object in the
upon proper proof of injury to the patient,
body of the patient after an operation,
without the aid of expert testimony, where
injuries sustained on a healthy part of the
the court from its fund of common
body which was not under, or in the area,
knowledge can determine the proper
of treatment, removal of the wrong part of
standard of care. Where common
the body when another part was intended,
knowledge and experience teach that a
knocking out a tooth while a patient’s jaw
resulting injury would not have occurred to
was under anesthetic for the removal of his
the patient if due care had been exercised,
tonsils, and loss of an eye while the patient
an inference of negligence may be drawn
plaintiff was under the influence of
giving rise to an application of the doctrine
anesthetic, during or following an
of res ipsa loquitur without medical
operation for appendicitis, among others.
evidence, which is ordinarily required to
show not only what occurred but how and Nevertheless, despite the fact that the
why it occurred. When the doctrine is scope of res ipsa loquitur has been
appropriate, all that the patient must do is measurably enlarged, it does not
prove a nexus between the particular act automatically apply to all cases of medical
or omission complained of and the injury negligence as to mechanically shift the
sustained while under the custody and burden of proof to the defendant to show
management of the defendant without that he is not guilty of the ascribed
need to produce expert medical testimony negligence. Res ipsa loquitur is not a rigid
to establish the standard of care. Resort to or ordinary doctrine to be perfunctorily
used but a rule to be cautiously applied, accomplished. The real question, therefore,
depending upon the circumstances of each is whether or not in the process of the
case. It is generally restricted to situations operation any extraordinary incident or
in malpractice cases where a layman is unusual event outside of the routine
able to say, as a matter of common performance occurred which is beyond the
knowledge and observation, that the regular scope of customary professional
consequences of professional care were activity in such operations, which, if
not as such as would ordinarily have unexplained would themselves reasonably
followed if due care had been exercised. A speak to the average man as the negligent
distinction must be made between the cause or causes of the untoward
failure to secure results, and the consequence. If there was such extraneous
occurrence of something more unusual and intervention, the doctrine of res ipsa
not ordinarily found if the service or loquitur may be utilized and the defendant
treatment rendered followed the usual is called upon to explain the matter, by
procedure of those skilled in that particular evidence of exculpation, if he could.
practice. It must be conceded that the
In order to allow resort to the doctrine,
doctrine of res ipsa loquitur can have no
therefore, the following essential requisites
application in a suit against a physician or
must first be satisfied, to wit: (1) the
surgeon which involves the merits of a
accident was of a kind that does not
diagnosis or of a scientific treatment. The
ordinarily occur unless someone is
physician or surgeon is not required at his
negligent; (2) the instrumentality or
peril to explain why any particular
agency that caused the injury was under
diagnosis was not correct, or why any
the exclusive control of the person
particular scientific treatment did not
charged; and (3) the injury suffered must
produce the desired result. Thus, res ipsa
not have been due to any voluntary action
loquitur is not available in a malpractice
or contribution of the person injured.29
suit if the only showing is that the desired
result of an operation or treatment was not
The Court considers the application here of physicians, including the anesthesiologists,
the doctrine of res ipsa loquitur had caused the injury. In fact, the
inappropriate. Although it should be anesthesiologists attending to him had
conceded without difficulty that the second sensed in the course of the operation that
and third elements were present, the lack of oxygen could have been
considering that the anesthetic agent and triggered by the vago-vagal reflex,
the instruments were exclusively within prompting them to administer atropine to
the control of Dr. Solidum, and that the the patient.30
patient, being then unconscious during the
This conclusion is not unprecedented. It
operation, could not have been guilty of
was similarly reached in Swanson v.
contributory negligence, the first element
Brigham,31 relevant portions of the decision
was undeniably wanting. Luz delivered
therein being as follows:
Gerald to the care, custody and control of
his physicians for a pull-through operation. On January 7, 1973, Dr. Brigham admitted
Except for the imperforate anus, Gerald 15-year-old Randall Swanson to a hospital
was then of sound body and mind at the for the treatment of infectious
time of his submission to the physicians. mononucleosis. The patient's symptoms
Yet, he experienced bradycardia during the had included a swollen throat and some
operation, causing loss of his senses and breathing difficulty. Early in the morning of
rendering him immobile. Hypoxia, or the January 9 the patient was restless, and at
insufficiency of oxygen supply to the brain 1:30 a.m. Dr. Brigham examined the
that caused the slowing of the heart rate, patient. His inspection of the patient's air
scientifically termed as bradycardia, would passage revealed that it was in satisfactory
not ordinarily occur in the process of a pull- condition. At 4:15 a.m. Dr. Brigham
through operation, or during the received a telephone call from the hospital,
administration of anesthesia to the patient, advising him that the patient was having
but such fact alone did not prove that the respiratory difficulty. The doctor ordered
negligence of any of his attending that oxygen be administered and he
prepared to leave for the hospital. Ten that the injury was probably caused by
minutes later, 4:25 a.m., the hospital someone's negligence. Mason v. Ellsworth,
called a second time to advise the doctor 3 Wn. App. 298, 474 P.2d 909 (1970). Nor
that the patient was not responding. The is a bad result by itself enough to warrant
doctor ordered that a medicine be the application of the doctrine. Nelson v.
administered, and he departed for the Murphy, 42 Wn.2d 737, 258 P.2d 472
hospital. When he arrived, the physician (1953). See 2 S. Speiser, The Negligence
who had been on call at the hospital had Case – Res Ipsa Loquitur § 24:10 (1972).
begun attempts to revive the patient. Dr. The evidence presented is insufficient to
Brigham joined him in the effort, but the establish the first element necessary for
patient died. application of res ipsa loquitur doctrine.
The acute closing of the patient’s air
The doctor who performed the autopsy
passage and his resultant asphyxiation
concluded that the patient died between
took place over a very short period of time.
4:25 a.m. and 4:30 a.m. of asphyxia, as a
Under these circumstances it would not be
result of a sudden, acute closing of the air
reasonable to infer that the physician was
passage. He also found that the air
negligent. There was no palpably negligent
passage had been adequate to maintain
act. The common experience of mankind
life up to 2 or 3 minutes prior to death. He
does not suggest that death would not be
did not know what caused the air passage
expected without negligence. And there is
to suddenly close.
no expert medical testimony to create an
xxxx inference that negligence caused the
injury.
It is a rare occurrence when someone
admitted to a hospital for the treatment of Negligence of Dr. Solidum
infectious mononucleosis dies of
In view of the inapplicability of the doctrine
asphyxiation. But that is not sufficient to
of res ipsa loquitur, the Court next
invoke res ipsa loquitur. The fact that the
determines whether the CA correctly
injury rarely occurs does not in itself prove
affirmed the conviction of Dr. Solidum for the dosage of the anesthetic agent
criminal negligence. administered to the child. He declared that
he made a mistake in reporting a 100%
Negligence is defined as the failure to
halothane and said that based on the
observe for the protection of the interests
records it should have been 100% oxygen.
of another person that degree of care,
precaution, and vigilance that the The records he was relying on, as he
circumstances justly demand, whereby explains, are the following:
such other person suffers injury.32 Reckless
(a) the anesthesia record – A portion of the
imprudence, on the other hand, consists of
chart in the record was marked as Exhibit
voluntarily doing or failing to do, without
1-A and 1-B to indicate the administration
malice, an act from which material damage
at intervals of the anesthetic agent.
results by reason of an inexcusable lack of
precaution on the part of the person (b) the clinical abstract – A portion of this
performing or failing to perform such act. 33 record that reads as follows was marked
Exhibit 3A. 3B – Approximately 1 hour and
Dr. Solidum’s conviction by the RTC was
45 minutes through the operation, patient
primarily based on his failure to monitor
was noted to have bradycardia (CR = 70)
and properly regulate the level of
and ATSO4 0.2 mg was immediately
anesthetic agent administered on Gerald
administered. However, the bradycardia
by overdosing at 100% halothane. In
persisted, the inhalational agent was shut
affirming the conviction, the CA observed:
off, and the patient was ventilated with
On the witness stand, Dr. Vertido made a 100% oxygen and another dose of ATSO4
significant turnaround. He affirmed the 0.2 mg was given. However, the patient
findings and conclusions in his report did not respond until no cardiac rate can
except for an observation which, to all be auscultated and the surgeons were
intents and purposes, has become the immediately told to stop the operation. The
storm center of this dispute. He wanted to patient was put on a supine position and
correct one piece of information regarding CPR was initiated. Patient was given 1 amp
of epinephrine initially while continuously agent and that 1 hour and 45 minutes after
doing cardiac massage – still with no the operation began, bradycardia occurred
cardiac rate appreciated; another ampule after which the inhalational agent was shut
of epinephrine was given and after 45 off and the patient administered with 100%
secs, patient’s vital signs returned to oxygen. It would be apparent that the
normal. The entire resuscitation lasted 100% oxygen that Dr. Vertido said should
approximately 3-5 mins. The surgeons be read in lieu of 100% halothane was the
were then told to proceed to the closure pure oxygen introduced after something
and the child’s vital signs throughout and went amiss in the operation and the
until the end of surgery were: BP = 110/70; halothane itself was reduced or shut off.
CR = 116/min and RR = 20-22 cycles/min
The key question remains – what was the
(on assisted ventilation).
quantity of halothane used before
Dr. Vertido points to the crucial passage in bradycardia set in?
the clinical abstract that the patient was
The implication of Dr. Vertido’s admission
ventilated with 100% oxygen and another
is that there was no overdose of the
dose of ATSO4 when the bradycardia
anesthetic agent, and the accused Dr.
persisted, but for one reason or another,
Solidum stakes his liberty and reputation
he read it as 100% halothane. He was
on this conclusion. He made the assurance
asked to read the anesthesia record on the
that he gave his patient the utmost
percentage of the dosage indicated, but he
medical care, never leaving the operating
could only sheepishly note I can’t
room except for a few minutes to answer
understand the number. There are no clues
the call of nature but leaving behind the
in the clinical abstract on the quantity of
other members of his team Drs. Abella and
the anesthetic agent used. It only contains
Razon to monitor the operation. He
the information that the anesthetic plan
insisted that he administered only a point
was to put the patient under general
1% not 100% halothane, receiving
anesthesia using a nonrebreathing system
corroboration from Dr. Abella whose initial
with halothane as the sole anesthetic
MA in the record should be enough to show xxxx
that she assisted in the operation and was
In finding the accused guilty, despite these
therefore conversant of the things that
explanations, the RTC argued that the
happened. She revealed that they were
volte-face of Dr. Vertido on the question of
using a machine that closely monitored the
the dosage of the anesthetic used on the
concentration of the agent during the
child would not really validate the non-guilt
operation.
of the anesthesiologist. Led to agree that
But most compelling is Dr. Solidum’s the halothane used was not 100% as
interpretation of the anesthesia record initially believed, he was nonetheless
itself, as he takes the bull by the horns, so unaware of the implications of the change
to speak. In his affidavit, he says, reading in his testimony. The court observed that
from the record, that the quantity of Dr. Vertido had described the condition of
halothane used in the operation is one the child as hypoxia which is deprivation of
percent (1%) delivered at time intervals of oxygen, a diagnosis supported by the
15 minutes. He studiedly mentions – the results of the CT Scan. All the symptoms
concentration of halothane as reflected in attributed to a failing central nervous
the anesthesia record (Annex D of the system such as stupor, loss of
complaint-affidavit) is only one percent consciousness, decrease in heart rate, loss
(1%) – The numbers indicated in 15 minute of usual acuity and abnormal motor
increments for halothane is an indication function, are manifestations of this
that only 1% halothane is being delivered condition or syndrome. But why would
to the patient Gerard Gercayo for his entire there be deprivation of oxygen if 100%
operation; The amount of halothane oxygen to 1% halothane was used?
delivered in this case which is only one Ultimately, to the court, whether oxygen or
percent cannot be summated because halothane was the object of mistake, the
halothane is constantly being rapidly detrimental effects of the operation are
eliminated by the body during the entire incontestable, and they can only be led to
operation. one conclusion – if the application of
anesthesia was really closely monitored, practicing in the same field, he will employ
the event could not have happened.34 such training, care and skill in the
treatment of his patients. He therefore has
The Prosecution did not prove the
a duty to use at least the same level of
elements of reckless imprudence beyond
care that any other reasonably competent
reasonable doubt because the
doctor would use to treat a condition under
circumstances cited by the CA were
the same circumstances. It is in this aspect
insufficient to establish that Dr. Solidum
of medical malpractice that expert
had been guilty of inexcusable lack of
testimony is essential to establish not only
precaution in monitoring the
the standard of care of the profession but
administration of the anesthetic agent to
also that the physician's conduct in the
Gerald. The Court aptly explained in Cruz
treatment and care falls below such
v. Court of Appeals35 that:
standard. Further, inasmuch as the causes
Whether or not a physician has committed of the injuries involved in malpractice
an "inexcusable lack of precaution" in the actions are determinable only in the light
treatment of his patient is to be of scientific knowledge, it has been
determined according to the standard of recognized that expert testimony is usually
care observed by other members of the necessary to support the conclusion as to
profession in good standing under similar causation.
circumstances bearing in mind the
xxxx
advanced state of the profession at the
time of treatment or the present state of In litigations involving medical negligence,
medical science. In the recent case of the plaintiff has the burden of establishing
Leonila Garcia-Rueda v. Wilfred L. Pacasio, appellant's negligence and for a
et. al., this Court stated that in accepting a reasonable conclusion of negligence, there
case, a doctor in effect represents that, must be proof of breach of duty on the part
having the needed training and skill of the surgeon as well as a causal
possessed by physicians and surgeons connection of such breach and the
resulting death of his patient. In Chan calls for the plaintiff to prove by competent
Lugay v. St Luke's Hospital, Inc., where the evidence each of the following four
attending physician was absolved of elements, namely: (a) the duty owed by
liability for the death of the complainant’s the physician to the patient, as created by
wife and newborn baby, this Court held the physician-patient relationship, to act in
that: accordance with the specific norms or
standards established by his profession;
"In order that there may be a recovery for
(b) the breach of the duty by the
an injury, however, it must be shown that
physician’s failing to act in accordance
the ‘injury for which recovery is sought
with the applicable standard of care; (3)
must be the legitimate consequence of the
the causation, i.e., there must be a
wrong done; the connection between the
reasonably close and causal connection
negligence and the injury must be a direct
between the negligent act or omission and
and natural sequence of events, unbroken
the resulting injury; and (4) the damages
by intervening efficient causes.’ In other
suffered by the patient.36
words, the negligence must be the
proximate cause of the injury. For, In the medical profession, specific norms
‘negligence, no matter in what it consists, or standards to protect the patient against
cannot create a right of action unless it is unreasonable risk, commonly referred to
the proximate cause of the injury as standards of care, set the duty of the
complained of.’ And ‘the proximate cause physician to act in respect of the patient.
of an injury is that cause, which, in natural Unfortunately, no clear definition of the
and continuous sequence, unbroken by duty of a particular physician in a
any efficient intervening cause, produces particular case exists. Because most
the injury, and without which the result medical malpractice cases are highly
would not have occurred.’" technical, witnesses with special medical
qualifications must provide guidance by
An action upon medical negligence –
giving the knowledge necessary to render
whether criminal, civil or administrative –
a fair and just verdict. As a result, the
standard of medical care of a prudent Here, the Prosecution presented no
physician must be determined from expert witnesses with special medical
testimony in most cases; and in the case of qualifications in anesthesia to provide
a specialist (like an anesthesiologist), the guidance to the trial court on what
standard of care by which the specialist is standard of care was applicable. It would
judged is the care and skill commonly consequently be truly difficult, if not
possessed and exercised by similar impossible, to determine whether the first
specialists under similar circumstances. three elements of a negligence and
The specialty standard of care may be malpractice action were attendant.
higher than that required of the general
Although the Prosecution presented Dr.
practitioner.37
Benigno Sulit, Jr., an anesthesiologist
The standard of care is an objective himself who served as the Chairman of the
standard by which the conduct of a Committee on Ethics and Malpractice of
physician sued for negligence or the Philippine Society of Anesthesiologists
malpractice may be measured, and it does that investigated the complaint against Dr.
not depend, therefore, on any individual Solidum, his testimony mainly focused on
physician’s own knowledge either. In how his Committee had conducted the
attempting to fix a standard by which a investigation.39 Even then, the report of his
court may determine whether the Committee was favorable to Dr.
40
physician has properly performed the Solidum,  to wit:
requisite duty toward the patient, expert
Presented for review by this committee is
medical testimony from both plaintiff and
the case of a 3 year old male who
defense experts is required. The judge, as
underwent a pull-thru operation and was
the trier of fact, ultimately determines the
administered general anesthesia by a team
standard of care, after listening to the
of anesthesia residents. The patient, at the
testimony of all medical experts.38
time when the surgeons was manipulating
the recto-sigmoid and pulling it down in
preparation for the anastomosis, had concentrated on the results of the physical
bradycardia. The anesthesiologists, examination he had conducted on Gerald,
sensing that the cause thereof was the as borne out by the following portions of
triggering of the vago-vagal reflex, his direct examination, to wit:
administered atropine to block it but
FISCAL CABARON Doctor, what do you
despite the administration of the drug in
mean by General Anesthetic Agent?
two doses, cardiac arrest ensued. As the
records show, prompt resuscitative WITNESS General Anesthetic Agent is a
measures were administered and substance used in the conduction of
spontaneous cardiac function re- Anesthesia and in this case, halothane was
established in less than five (5) minutes used as a sole anesthetic agent.
and that oxygen was continuously being
xxxx
administered throughout, unfortunately, as
later become manifest, patient suffered Q Now under paragraph two of page 1 of
permanent irreversible brain damage. your report you mentioned that after one
hour and 45 minutes after the operation,
In view of the actuations of the
the patient experienced a bradycardia or
anaesthesiologists and the administration
slowing of heart rate, now as a doctor,
of anaesthesia, the committee find that the
would you be able to tell this Honorable
same were all in accordance with the
Court as to what cause of the slowing of
universally accepted standards of medical
heart rate as to Gerald Gercayo?
care and there is no evidence of any fault
or negligence on the part of the WITNESS Well honestly sir, I cannot give
anaesthesiologists. you the reason why there was a
bradycardia of time because is some
Dr. Antonio Vertido, a Senior Medico-Legal
reason one way or another that might
Officer of the National Bureau of
caused bradycardia.
Investigation, was also presented as a
Prosecution witness, but his testimony
FISCAL CABARON What could be the in the supply of oxygen by the patient,
possible reason? would that also cause the slowing of the
heart rate?
A Well bradycardia can be caused by
anesthetic agent itself and that is a A Well that is a possibility sir, I mean not
possibility, we’re talking about possibility as slowing of the heart rate, if there is a
here. hypoxia or there is a low oxygen level in
the blood, the normal thing for the heart is
Q What other possibility do you have in
to pump or to do not a bradycardia but a …
mind, doctor?
to counter act the Hypoxia that is being
A Well, because it was an operation, experienced by the patient
anything can happen within that situation.
(sic).
FISCAL CABARON Now, this representation
xxxx
would like to ask you about the slowing of
heart rate, now what is the immediate Q Now, you made mention also doctor that
cause of the slowing of the heart rate of a the use of general anesthesia using 100%
person? halothane and other anesthetic
medications probably were contributory to
WITNESS Well, one of the more practical
the production of hypoxia.
reason why there is slowing of the heart
rate is when you do a vagal reflex in the A Yes, sir in general sir.41
neck wherein the vagal receptors are
On cross-examination, Dr. Vertido
located at the lateral part of the neck,
expounded more specifically on his
when you press that, you produce the
interpretation of the anesthesia record and
slowing of the heart rate that produce
the factors that could have caused Gerald
bradycardia.
to experience bradycardia, viz:
Q I am pro[p]ounding to you another
ATTY. COMIA I noticed in, may I see your
question doctor, what about the deficiency
report Doctor, page 3, will you kindly read
to this Honorable court your last paragraph is, you just call me and even the attention
and if you will affirm that as if it is correct? of the Presiding Judge of this Court. Okay,
you read one by one.
A "The use of General Anesthesia, that is
using 100% Halothane probably will be WITNESS Well, are you only asking 100%,
contributory to the production of Hypoxia sir?
and - - - -"
ATTY. COMIA I’m asking you, just answer
ATTY COMIA And do you affirm the figure my question, did you see there 100% and
you mentioned in this Court Doctor? 100 figures, tell me, yes or no?
WITNESS Based on the records, I know the WITNESS I’m trying to look at the 100%,
--- there is no 100% there sir.
Q 100%? ATTY. COMIA Okay, that was good, so you
Honor please, may we request also
A 100% based on the records.
temporarily, because this is just a xerox
Q I will show you doctor a clinical record. I copy presented by the fiscal, that the
am a lawyer I am not a doctor but will you percentage here that the Halothane
kindly look at this and tell me where is administered by Dr. Solidum to the patient
100%, the word "one hundred" or 1-0-0, is 1% only so may we request that this
will you kindly look at this Doctor, this portion, temporarily your Honor, we are
Xerox copy if you can show to this marking this anesthesia record as our
Honorable Court and even to this Exhibit 1 and then this 1% Halothane also
representation the word "one hundred" or be bracketed and the same be marked as
1-0-0 and then call me. our Exhibit "1-A".
xxxx xxxx
ATTY. COMIA Doctor tell this Honorable ATTY. COMIA Doctor, my attention was
Court where is that 100, 1-0-0 and if there called also when you said that there are so
many factors that contributed to Hypoxia is Q In other words, when you say major
that correct? operation conducted to this Gerald, there
is a possibility that this Gerald might [be]
WITNESS Yes, sir.
exposed to some risk is that correct?
Q I remember doctor, according to you
A That is a possibility sir.
there are so many factors that contributed
to what you call hypoxia and according to Q And which according to you that Gerald
you, when this Gerald suffered hypoxia, suffered hypoxia is that correct?
there are other factors that might lead to
A Yes, sir.
this Hypoxia at the time of this operation is
that correct? Q And that is one of the risk of that major
operation is that correct?
WITNESS The possibility is there, sir.
A That is the risk sir.42
Q And according to you, it might also be
the result of such other, some or it might At the continuation of his cross-
be due to operations being conducted by examination, Dr. Vertido maintained that
the doctor at the time when the operation Gerald’s operation for his imperforate
is being done might also contribute to that anus, considered a major operation, had
hypoxia is that correct? exposed him to the risk of suffering the
same condition.43 He then corrected his
A That is a possibility also.
earlier finding that 100% halothane had
xxxx been administered on Gerald by saying
that it should be 100% oxygen.44
ATTY. COMIA How will you classify now the
operation conducted to this Gerald, Dr. Solidum was criminally charged for
Doctor? "failing to monitor and regulate properly
the levels of anesthesia administered to
WITNESS Well, that is a major operation
said Gerald Albert Gercayo and using
sir.
100% halothane and other anesthetic
medications."45 However, the foregoing x x x is a doubt growing reasonably out of
circumstances, taken together, did not evidence or the lack of it. It is not a
prove beyond reasonable doubt that Dr. captious doubt; not a doubt engendered
Solidum had been recklessly imprudent in merely by sympathy for the unfortunate
administering the anesthetic agent to position of the defendant, or a dislike to
Gerald. Indeed, Dr. Vertido’s findings did accept the responsibility of convicting a
not preclude the probability that other fellow man. If, having weighed the
factors related to Gerald’s major operation, evidence on both sides, you reach the
which could or could not necessarily be conclusion that the defendant is guilty, to
attributed to the administration of the that degree of certainty as would lead you
anesthesia, had caused the hypoxia and to act on the faith of it in the most
had then led Gerald to experience important and crucial affairs of your life,
bradycardia. Dr. Vertido revealingly you may properly convict him. Proof
concluded in his report, instead, that beyond reasonable doubt is not proof to a
"although the anesthesiologist followed the mathematical demonstration. It is not
normal routine and precautionary proof beyond the possibility of mistake.
procedures, still hypoxia and its
46 We have to clarify that the acquittal of Dr.
corresponding side effects did occur."
Solidum would not immediately exempt
The existence of the probability about him from civil liability.1âwphi1 But we
other factors causing the hypoxia has cannot now find and declare him civilly
engendered in the mind of the Court a liable because the circumstances that have
reasonable doubt as to Dr. Solidum’s guilt, been established here do not present the
and moves us to acquit him of the crime of factual and legal bases for validly doing so.
reckless imprudence resulting to serious His acquittal did not derive only from
physical injuries. "A reasonable doubt of reasonable doubt. There was really no firm
guilt," according to United States v. and competent showing how the injury to
Youthsey:47 Gerard had been caused. That meant that
the manner of administration of the
anesthesia by Dr. Solidum was not been charged along with Dr. Solidum. The
necessarily the cause of the hypoxia that lower courts thereby acted capriciously
caused the bradycardia experienced by and whimsically, which rendered their
Gerard. Consequently, to adjudge Dr. judgment against Ospital ng Maynila void
Solidum civilly liable would be to speculate as the product of grave abuse of discretion
on the cause of the hypoxia. We are not amounting to lack of jurisdiction.
allowed to do so, for civil liability must not
Not surprisingly, the flawed decree raises
rest on speculation but on competent
other material concerns that the RTC and
evidence.
the CA overlooked. We deem it important,
Liability of Ospital ng Maynila then, to express the following observations
for the instruction of the Bench and Bar.
Although the result now reached has
resolved the issue of civil liability, we have For one, Ospital ng Maynila was not at all a
to address the unusual decree of the RTC, party in the proceedings. Hence, its
as affirmed by the CA, of expressly holding fundamental right to be heard was not
Ospital ng Maynila civilly liable jointly and respected from the outset. The R TC and
severally with Dr. Solidum. The decree was the CA should have been alert to this
flawed in logic and in law. fundamental defect. Verily, no person can
be prejudiced by a ruling rendered in an
In criminal prosecutions, the civil action for
action or proceeding in which he was not
the recovery of civil liability that is deemed
made a party. Such a rule would enforce
instituted with the criminal action refers
the constitutional guarantee of due
only to that arising from the offense
process of law.
charged.48 It is puzzling, therefore, how the
RTC and the CA could have adjudged Moreover, Ospital ng Maynila could be held
Ospital ng Maynila jointly and severally civilly liable only when subsidiary liability
liable with Dr. Solidum for the damages would be properly enforceable pursuant to
despite the obvious fact that Ospital ng Article 103 of the Revised Penal Code. But
Maynila, being an artificial entity, had not the subsidiary liability seems far-fetched
here. The conditions for subsidiary liability AND SETS ASIDE the decision promulgated
to attach to Ospital ng Maynila should first on January 20, 2010; ACQUITS Dr.
be complied with. Firstly, pursuant to Fernando P. Solidum of the crime of
Article 103 of the Revised Penal Code, reckless imprudence resulting to serious
Ospital ng Maynila must be shown to be a physical injuries; and MAKES no
corporation "engaged in any kind of pronouncement on costs of suit.
industry." The term industry means any
SO ORDERED.
department or branch of art, occupation or
business, especially one that employs
labor and capital, and is engaged in
industry.49 However, Ospital ng Maynila,
being a public hospital, was not engaged in
industry conducted for profit but purely in
charitable and humanitarian
50
work.  Secondly, assuming that Ospital ng
Maynila was engaged in industry for profit,
Dr. Solidum must be shown to be an
employee of Ospital ng Maynila acting in
the discharge of his duties during the
operation on Gerald. Yet, he definitely was
not such employee but a consultant of the
hospital. And, thirdly, assuming that civil
liability was adjudged against Dr. Solidum
as an employee (which did not happen
here), the execution against him was
unsatisfied due to his being insolvent.
WHEREFORE, the Court GRANTS the
petition for review on certiorari; REVERSES
G.R. No. 175540               April 7, 2014 years old, was brought to the East Avenue
Medical Center (EAMC) in Quezon City by
DR. FILOTEO A. ALANO, Petitioner,
two sidewalk vendors, who allegedly saw
vs.
the former fall from the overpass near the
ZENAIDA MAGUD-
Farmers’ Market in Cubao, Quezon City.
LOGMAO, Respondent.
The patient’s data sheet identified the
DECISION patient as Angelito Lugmoso of Boni
Avenue, Mandaluyong. However, the
PERALTA, J.:
clinical abstract prepared by Dr. Paterno F.
This deals with the Petition for Review on Cabrera, the surgical resident on-duty at
Certiorari under Rule 45 of the Rules of the Emergency Room of EAMC, stated that
Court praying that the Decision1 of the the patient is Angelito [Logmao].
Court of Appeals (CA), dated March 31,
Dr. Cabrera reported that [Logmao] was
2006, adjudging petitioner liable for
drowsy with alcoholic breath, was
damages, and the Resolution2 dated
conscious and coherent; that the skull x-
November 22, 2006, denying petitioner's
ray showed no fracture; that at around
motion for reconsideration thereof, be
4:00 o’clock in the morning of March 2,
reversed and set aside.
1988, [Logmao] developed generalized
The CA's narration of facts is accurate, to seizures and was managed by the neuro-
wit: surgery resident on-duty; that the
condition of [Logmao] progressively
Plaintiff-appellee Zenaida Magud-Logmao
deteriorated and he was intubated and
is the mother of deceased Arnelito
ambu-bagging support was provided; that
Logmao. Defendant-appellant Dr. Filoteo
admission to the Intensive Care Unit (ICU)
Alano is the Executive Director of the
and mechanical ventilator support became
National Kidney Institute (NKI).
necessary, but there was no vacancy at
At around 9:50 in the evening of March 1, the ICU and all the ventilator units were
1988, Arnelito Logmao, then eighteen (18) being used by other patients; that a
resident physician of NKI, who was rotating Jennifer Misa verified on the same day,
at EAMC, suggested that [Logmao] be March 2, 1988, from EAMC the identity of
transferred to NKI; and that after Lugmoso and, upon her request, she was
arrangements were made, [Logmao] was furnished by EAMC a copy of the patient’s
transferred to NKI at 10:10 in the morning. date sheet which bears the name Angelito
Lugmoso, with address at Boni Avenue,
At the NKI, the name Angelito [Logmao]
Mandaluyong. She then contacted several
was recorded as Angelito Lugmoso.
radio and television stations to request for
Lugmoso was immediately attended to and
air time for the purpose of locating the
given the necessary medical treatment. As
family of Angelito Lugmoso of Boni
Lugmoso had no relatives around, Jennifer
Avenue, Mandaluyong, who was confined
B. Misa, Transplant Coordinator, was asked
at NKI for severe head injury after
to locate his family by enlisting police and
allegedly falling from the Cubao overpass,
media assistance. Dr. Enrique T. Ona,
as well as Police Station No. 5, Eastern
Chairman of the Department of Surgery,
Police District, whose area of jurisdiction
observed that the severity of the brain
includes Boni Avenue, Mandaluyong, for
injury of Lugmoso manifested symptoms of
assistance in locating the relatives of
brain death. He requested the Laboratory
Angelito Lugmoso. Certifications were
Section to conduct a tissue typing and
issued by Channel 4, ABS-CBN and GMA
tissue cross-matching examination, so that
attesting that the request made by the NKI
should Lugmoso expire despite the
on March 2, 1988 to air its appeal to locate
necessary medical care and management
the family and relatives of Angelito
and he would be found to be a suitable
Lugmoso of Boni Avenue, Mandaluyong
organ donor and his family would consent
was accommodated. A Certification was
to organ donation, the organs thus
likewise issued by Police Station No. 5,
donated could be detached and
Eastern Police District, Mandaluyong
transplanted promptly to any compatible
attesting to the fact that on March 2, 1988,
beneficiary.
at about 6:00 p.m., Jennifer Misa requested
for assistance to immediately locate the Filoteo A. Alano, Executive Director of NKI,
family and relatives of Angelito Lugmoso to authorize the removal of specific organs
and that she followed up her request until from the body of Lugmoso for
March 9, 1988. transplantation purposes. Dr. Ona likewise
instructed Dr. Rose Marie Rosete-Liquete
On March 3, 1988, at about 7:00 o’clock in
to secure permission for the planned organ
the morning, Dr. Ona was informed that
retrieval and transplantation from the
Lugmoso had been pronounced brain dead
Medico-Legal Office of the National Bureau
by Dr. Abdias V. Aquino, a neurologist, and
of Investigation (NBI), on the assumption
by Dr. Antonio Rafael, a neurosurgeon and
that the incident which lead to the brain
attending physician of Lugmoso, and that a
injury and death of Lugmoso was a medico
repeat electroencephalogram (EEG) was in
legal case.
progress to confirm the diagnosis of brain
death. Two hours later, Dr. Ona was On March 3, 1988, Dr. Alano issued to Dr.
informed that the EEG recording exhibited Ona a Memorandum, which reads as
a flat tracing, thereby confirming that follows:
Lugmoso was brain dead. Upon learning
This is in connection with the use of the
that Lugmoso was a suitable organ donor
human organs or any portion or portions of
and that some NKI patients awaiting organ
the human body of the deceased patient,
donation had blood and tissue types
identified as a certain Mr. Angelito
compatible with Lugmoso, Dr. Ona inquired
Lugmoso who was brought to the National
from Jennifer Misa whether the relatives of
Kidney Institute on March 2, 1988 from the
Lugmoso had been located so that the
East Avenue Medical Center.
necessary consent for organ donation
could be obtained. As the extensive search As shown by the medical records, the said
for the relatives of Lugmoso yielded no patient died on March 3, 1988 at 9:10 in
positive result and time being of the the morning due to craniocerebral injury.
essence in the success of organ Please make certain that your Department
transplantation, Dr. Ona requested Dr. has exerted all reasonable efforts to locate
the relatives or next of kin of the said even in the absence of consent from the
deceased patient such as appeal through family of the deceased; and that he
the radios and television as well as through verbally agreed to organ retrieval.
police and other government agencies and
At 3:45 in the afternoon of March 3, 1988,
that the NBI [Medico-Legal] Section has
a medical team, composed of Dr. Enrique
been notified and is aware of the case.
Ona, as principal surgeon, Drs. Manuel
If all the above has been complied with, in Chua-Chiaco, Jr., Rose Marie Rosete-
accordance with the provisions of Republic Liquete, Aurea Ambrosio, Ludivino de
Act No. 349 as amended and P.D. 856, Guzman, Mary Litonjua, Jaime Velasquez,
permission and/or authority is hereby Ricardo Fernando, and Myrna Mendoza,
given to the Department of Surgery to removed the heart, kidneys, pancreas,
retrieve and remove the kidneys, liver and spleen of Lugmoso. The medical
pancreas, liver and heart of the said team then transplanted a kidney and the
deceased patient and to transplant the pancreas of Lugmoso to Lee Tan Hoc and
said organs to any compatible patient who the other kidney of Lugmoso to Alexis
maybe in need of said organs to live and Ambustan. The transplant operation was
survive. completed at around 11:00 o’clock in the
evening of March 3, 1988.
A Certification dated March 10, 1988 was
issued by Dr. Maximo Reyes, Medico-Legal On March 4, 1988, Dr. Antonio R. Paraiso,
Officer of the NBI, stating that he received Head of the Cadaver Organ Retrieval Effort
a telephone call from Dr. Liquete on March (CORE) program of NKI, made
3, 1988 at 9:15 a.m. regarding the case of arrangements with La Funeraria Oro for the
Lugmoso, who was declared brain dead; embalmment of the cadaver of Lugmoso
that despite efforts to locate the latter’s good for a period of fifteen (15) days to
relatives, no one responded; that Dr. afford NKI more time to continue searching
Liquete sought from him a second opinion for the relatives of the latter. On the same
for organ retrieval for donation purposes day, Roberto Ortega, Funeral Consultant of
La Funeraria Oro, sent a request for missing. Upon receiving the news from
autopsy to the NBI. The Autopsy Report Aida, plaintiff and her other children went
and Certification of Post-Mortem to La Funeraria Oro, where they saw
Examination issued by the NBI stated that Arnelito inside a cheap casket.
the cause of death of Lugmoso was
On April 29, 1988, plaintiff filed with the
intracranial hemorrhage secondary to skull
court a quo a complaint for damages
fracture.
against Dr. Emmanuel Lenon, Taurean
On March 11, 1988, the NKI issued a press Protectors Agency, represented by its
release announcing its successful double Proprietor, Celso Santiago, National Kidney
organ transplantation. Aida Doromal, a Institute, represented by its Director, Dr.
cousin of plaintiff, heard the news aired on Filoteo A. Alano, Jennifer Misa, Dr. Maximo
television that the donor was an eighteen Reyes, Dr. Enrique T. Ona, Dr. Manuel
(18) year old boy whose remains were at Chua-Chiaco, Jr., Dr. Rose Marie O. Rosete-
La Funeraria Oro in Quezon City. As the Liquete, Dr. Aurea Z. Ambrosio, Dr.
name of the donor sounded like Arnelito Ludivino de Guzman, Dr. Mary Litonjua, Dr.
Logmao, Aida informed plaintiff of the Jaime Velasquez, Dr. Ricardo Fernando, Dr.
news report. Myrna Mendoza, Lee Tan Koc, Alexis
Ambustan, Dr. Antonio R. Paraiso, La
It appears that on March 3, 1988, Arlen
Funeraria Oro, Inc., represented by its
Logmao, a brother of Arnelito, who was
President, German E. Ortega, Roberto
then a resident of 17-C San Pedro Street,
Ortega alias Bobby Ortega, Dr. Mariano B.
Mandaluyong, reported to Police Station
Cueva, Jr., John Doe, Peter Doe, and Alex
No. 5, Eastern Police District, Mandaluyong
Doe in connection with the death of her
that the latter did not return home after
son Arnelito. Plaintiff alleged that
seeing a movie in Cubao, Quezon City, as
defendants conspired to remove the
evidenced by a Certification issued by said
organs of Arnelito while the latter was still
Station; and that the relatives of Arnelito
alive and that they concealed his true
were likewise informed that the latter was
identity.
On January 17, 2000, the court a quo Petitioner then elevated the matter to this
rendered judgment finding only Dr. Filoteo Court via a petition for review on certiorari,
Alano liable for damages to plaintiff and where the following issues are presented
dismissing the complaint against the other for resolution:
defendants for lack of legal basis.3
A. WHETHER THE COURT OF APPEALS
After finding petitioner liable for a quasi- DISREGARDED EXISTING JURISPRUDENCE
delict, the Regional Trial Court of Quezon PRONOUNCED BY THIS HONORABLE
City (RTC) ordered petitioner to pay SUPREME COURT IN HOLDING PETITIONER
respondent ₱188,740.90 as actual DR. FILOTEO ALANO LIABLE FOR MORAL
damages; ₱500,000.00 as moral damages; AND EXEMPLARY DAMAGES AND
₱500,000.00 as exemplary damages; ATTORNEY'S FEES DESPITE THE FACT THAT
₱300,000.00 as attorney's fees; and costs THE ACT OF THE PETITIONER IS NOT THE
of suit. Petitioner appealed to the CA. PROXIMATE CAUSE NOR IS THERE ANY
FINDING THAT THE ACT OF THE
On March 31, 2006, the CA issued its
PETITIONER WAS THE PROXIMATE CAUSE
Decision, the dispositive portion of which
OF THE INJURY OR DAMAGE ALLEGEDLY
reads as follows:
SUSTAINED BY RESPONDENT ZENAIDA
WHEREFORE, the Decision appealed from MAGUD-LOGMAO.
is AFFIRMED, with MODIFICATION by
B. WHETHER THE COURT OF APPEALS
DELETING the award of ₱188,740.90 as
GRAVELY ERRED IN REFUSING AND/OR
actual damages and REDUCING the award
FAILING TO DECLARE THAT PETITIONER
of moral damages to ₱250,000.00, the
DR. ALANO ACTED IN GOOD FAITH AND
award of exemplary damages to
PURSUANT TO LAW WHEN HE ISSUED THE
₱200,000.00 and the award of attorney's
AUTHORIZATION TO REMOVE AND
fees to ₱100,000.00.
RETRIEVE THE ORGANS OF ANGELITO
SO ORDERED.4 LUGMOSO (LATER IDENTIFIED TO BE IN
FACT ARNELITO LOGMAO) CONSIDERING
THAT NO NEGLIGENCE CAN BE next of kin of respondent's son. In fact,
ATTRIBUTED OR IMPUTED ON HIM IN HIS announcements were made through radio
PERFORMANCE OF AN ACT MANDATED BY and television, the assistance of police
LAW. authorities was sought, and the NBI
Medico-Legal Section was notified. Thus,
C. WHETHER THE COURT OF APPEALS
petitioner insists that he should not be held
GRAVELY ERRED IN AWARDING
responsible for any damage allegedly
RESPONDENT ZENAIDA MAGUD-LOGMAO
suffered by respondent due to the death of
MORAL AND EXEMPLARY DAMAGES AND
her son and the removal of her son’s
ATTORNEY'S FEES THAT ARE NOT IN
internal organs for transplant purposes.
ACCORDANCE WITH AND ARE CONTRARY
TO ESTABLISHED JURISPRUDENCE.5 The appellate court affirmed the trial
court's finding that there was negligence
The first two issues boil down to the
on petitioner's part when he failed to
question of whether respondent's
ensure that reasonable time had elapsed
sufferings were brought about by
to locate the relatives of the deceased
petitioner's alleged negligence in granting
before giving the authorization to remove
authorization for the removal or retrieval of
said deceased's internal organs for
the internal organs of respondent's son
transplant purposes. However, a close
who had been declared brain dead.
examination of the records of this case
Petitioner maintains that when he gave would reveal that this case falls under one
authorization for the removal of some of of the exceptions to the general rule that
the internal organs to be transplanted to factual findings of the trial court, when
other patients, he did so in accordance affirmed by the appellate court, are
with the letter of the law, Republic Act binding on this Court. There are some
(R.A.) No. 349, as amended by Presidential important circumstances that the lower
Decree (P.D.) 856, i.e., giving his courts failed to consider in ascertaining
subordinates instructions to exert all whether it was the actions of petitioner
reasonable efforts to locate the relatives or
that brought about the sufferings of A careful reading of the above shows that
respondent.6 petitioner instructed his subordinates to
"make certain" that "all reasonable efforts"
The Memorandum dated March 3, 1988
are exerted to locate the patient's next of
issued by petitioner, stated thus:
kin, even enumerating ways in which to
As shown by the medical records, the said ensure that notices of the death of the
patient died on March 3, 1988 at 9:10 in patient would reach said relatives. It also
the morning due to craniocerebral injury. clearly stated that permission or
Please make certain that your Department authorization to retrieve and remove the
has exerted all reasonable efforts to locate internal organs of the deceased was being
the relatives or next-of-kin of the said given ONLY IF the provisions of the
deceased patient, such as appeal through applicable law had been complied with.
the radios and television, as well as Such instructions reveal that petitioner
through police and other government acted prudently by directing his
agencies and that the NBI [Medico-Legal] subordinates to exhaust all reasonable
Section has been notified and is aware of means of locating the relatives of the
the case. deceased. He could not have made his
directives any clearer. He even specifically
If all the above has been complied with, in
mentioned that permission is only being
accordance with the provisions of Republic
granted IF the Department of Surgery has
Act No. 349 as amended and P.D. 856,
complied with all the requirements of the
permission and/or authority is hereby
law. Verily, petitioner could not have been
given to the Department of Surgery to
faulted for having full confidence in the
retrieve and remove the kidneys,
ability of the doctors in the Department of
pancreas, liver and heart of the said
Surgery to comprehend the instructions,
deceased patient and to transplant the
obeying all his directives, and acting only
said organs to any compatible patient who
in accordance with the requirements of the
maybe in need of said organs to live and
law.
survive.7
Furthermore, as found by the lower courts ascertain the name of the deceased, who
from the records of the case, the doctors recorded the wrong information regarding
and personnel of NKI disseminated notices the deceased's identity to NKI. The NKI
of the death of respondent's son to the could not have obtained the information
media and sought the assistance of the about his name from the patient, because
appropriate police authorities as early as as found by the lower courts, the deceased
March 2, 1988, even before petitioner was already unconscious by the time he
issued the Memorandum. Prior to was brought to the NKI.
performing the procedure for retrieval of
Ultimately, it is respondent's failure to
the deceased's internal organs, the doctors
adduce adequate evidence that doomed
concerned also the sought the opinion and
this case.1âwphi1 As stated in Otero v.
approval of the Medico-Legal Officer of the
Tan,8 "[i]n civil cases, it is a basic rule that
NBI.
the party making allegations has the
Thus, there can be no cavil that petitioner burden of proving them by a
employed reasonable means to preponderance of evidence. The parties
disseminate notifications intended to reach must rely on the strength of their own
the relatives of the deceased. The only evidence and not upon the weakness of
question that remains pertains to the the defense offered by their
9
sufficiency of time allowed for notices to opponent."  Here, there is to proof that,
reach the relatives of the deceased. indeed, the period of around 24 hours from
the time notices were disseminated,
If respondent failed to immediately receive
cannot be considered as reasonable under
notice of her son's death because the
the circumstances. They failed to present
notices did not properly state the name or
any expert witness to prove that given the
identity of the deceased, fault cannot be
medical technology and knowledge at that
laid at petitioner's door. The trial and
time in the 1980's, the doctors could or
appellate courts found that it was the
should have waited longer before
EAMC, who had the opportunity to
harvesting the internal organs for
transplantation.
Verily, the Court cannot, in conscience,
agree with the lower court. Finding
petitioner liable for damages is improper. It
should be emphasized that the internal
organs of the deceased were removed only
after he had been declared brain dead;
thus, the emotional pain suffered by
respondent due to the death of her son
cannot in any way be attributed to
petitioner. Neither can the Court find
evidence on record to show that
respondent's emotional suffering at the
sight of the pitiful state in which she found
her son's lifeless body be categorically
attributed to petitioner's conduct.
WHEREFORE, the petition is GRANTED. The
Decision of the Court of Appeals, dated
March 31, 2006, is REVERSED and SET
ASIDE. The complaint against petitioner is
hereby DISMISSED.
SO ORDERED.
G.R. No. 158996             November 14, SD-1233. The dispositive portion of the
2008 assailed CA decision states:
SPOUSES FREDELICTO FLORES WHEREFORE, premises considered, the
(deceased) and FELICISIMA assailed Decision of the Regional Trial
FLORES, petitioners, Court of Baloc, Sto. Domingo, Nueva Ecija,
vs. Branch 37 is hereby AFFIRMED but with
SPOUSES DOMINADOR PINEDA and modifications as follows:
VIRGINIA SACLOLO, and FLORENCIO,
1) Ordering defendant-appellants Dr. and
CANDIDA, MARTA, GODOFREDO,
Dra. Fredelicto A. Flores and the United
BALTAZAR and LUCENA, all surnamed
Doctors Medical Center, Inc. to jointly and
PINEDA, as heirs of the deceased
severally pay the plaintiff-appellees - heirs
TERESITA S. PINEDA, and UNITED
of Teresita Pineda, namely, Spouses
DOCTORS MEDICAL CENTER,
Dominador Pineda and Virginia Saclolo and
INC., respondents.
Florencio, Candida, Marta, Godofredo,
DECISION Baltazar and Lucena, all surnamed Pineda,
the sum of P400,000.00 by way of moral
BRION, J.:
damages;
This petition involves a medical negligence
2) Ordering the above-named defendant-
case that was elevated to this Court
appellants to jointly and severally pay the
through an appeal by certiorari under Rule
above-named plaintiff-appellees the sum
45 of the Rules of Court. The petition
of P100,000.00 by way of exemplary
assails the Decision1 of the Court of
damages;
Appeals (CA) in CA G.R. CV No. 63234,
which affirmed with modification the 3) Ordering the above-named defendant-
Decision2 of the Regional Trial Court (RTC) appellants to jointly and severally pay the
of Nueva Ecija, Branch 37 in Civil Case No. above-named plaintiff-appellees the sum
of P36,000.00 by way of actual and United Doctors Medical Center (UDMC) in
compensatory damages; and Quezon City for a general check-up. As for
her other symptoms, he suspected that
4) Deleting the award of attorney's fees
Teresita might be suffering from diabetes
and costs of suit.
and told her to continue her medications. 4
SO ORDERED.
Teresita did not return the next week as
While this case essentially involves advised. However, when her condition
questions of facts, we opted for the persisted, she went to further consult Dr.
requested review in light of questions we Flores at his UDMC clinic on April 28, 1987,
have on the findings of negligence below, travelling for at least two hours from
on the awarded damages and costs, and Nueva Ecija to Quezon City with her sister,
on the importance of this type of ruling on Lucena Pineda. They arrived at UDMC at
medical practice.3 around 11:15 a.m.. Lucena later testified
that her sister was then so weak that she
BACKGROUND FACTS
had to lie down on the couch of the clinic
Teresita Pineda (Teresita) was a 51-year while they waited for the doctor. When Dr.
old unmarried woman living in Sto. Fredelicto arrived, he did a routine check-
Domingo, Nueva Ecija. She consulted on up and ordered Teresita's admission to the
April 17, 1987 her townmate, Dr. Fredelicto hospital. In the admission slip, he directed
Flores, regarding her medical condition. the hospital staff to prepare the patient for
She complained of general body weakness, an "on call" D&C5 operation to be
loss of appetite, frequent urination and performed by his wife, Dr. Felicisima Flores
thirst, and on-and-off vaginal bleeding. Dr. (Dr. Felicisima). Teresita was brought to
Fredelicto initially interviewed the patient her hospital room at around 12 noon; the
and asked for the history of her monthly hospital staff forthwith took her blood and
period to analyze the probable cause of urine samples for the laboratory
the vaginal bleeding. He advised her to 6
tests  which Dr. Fredelicto ordered.
return the following week or to go to the
At 2:40 p.m. of that same day, Teresita ultrasound examination as a confirmatory
was taken to the operating room. It was procedure. The results showed that she
only then that she met Dr. Felicisima, an had an enlarged uterus and myoma
obstetrician and gynecologist. The two uteri.9 Dr. Felicisima, however, advised
doctors - Dr. Felicisima and Dr. Fredelicto, Teresita that she could spend her recovery
conferred on the patient's medical period at home. Still feeling weak, Teresita
condition, while the resident physician and opted for hospital confinement.
the medical intern gave Dr. Felicisima their
Teresita's complete laboratory
own briefings. She also interviewed and
examination results came only on that day
conducted an internal vaginal examination
(April 29, 1987). Teresita's urinalysis
of the patient which lasted for about 15
showed a three plus sign (+++) indicating
minutes. Dr. Felicisima thereafter called up
that the sugar in her urine was very high.
the laboratory for the results of the tests.
She was then placed under the care of Dr.
At that time, only the results for the blood
Amado Jorge, an internist.
sugar (BS), uric acid determination,
cholesterol determination, and complete By April 30, 1987, Teresita's condition had
blood count (CBC) were available. worsened. She experienced difficulty in
Teresita's BS count was 10.67mmol/l 7 and breathing and was rushed to the intensive
her CBC was 109g/l.8 care unit. Further tests confirmed that she
was suffering from Diabetes Mellitus
Based on these preparations, Dr. Felicisima
Type II.10 Insulin was administered on the
proceeded with the D&C operation with Dr.
patient, but the medication might have
Fredelicto administering the general
arrived too late. Due to complications
anesthesia. The D&C operation lasted for
induced by diabetes, Teresita died in the
about 10 to 15 minutes. By 3:40 p.m.,
morning of May 6, 1987.11
Teresita was wheeled back to her room.
Believing that Teresita's death resulted
A day after the operation (or on April 29,
from the negligent handling of her medical
1987), Teresita was subjected to an
needs, her family (respondents) instituted
an action for damages against Dr. vaginal bleeding. In addition, they claim
Fredelicto Flores and Dr. Felicisima Flores that nothing on record shows that the
(collectively referred to as the petitioner death of Teresita could have been averted
spouses) before the RTC of Nueva Ecija. had they employed means other than what
they had adopted in the ministration of the
The RTC ruled in favor of Teresita's family
patient.
and awarded actual, moral, and exemplary
damages, plus attorney's fees and THE COURT'S RULING
costs.12 The CA affirmed the judgment, but
We do not find the petition
modified the amount of damages awarded
meritorious.
and deleted the award for attorney's fees
and costs of suit.13 The respondents' claim for damages is
predicated on their allegation that the
Through this petition for review
decision of the petitioner spouses to
on certiorari, the petitioner spouses -Dr.
proceed with the D&C operation,
Fredelicto (now deceased) and Dr.
notwithstanding Teresita's condition and
Felicisima Flores - allege that the RTC and
the laboratory test results, amounted to
CA committed a reversible error in finding
negligence. On the other hand, the
them liable through negligence for the
petitioner spouses contend that a D&C
death of Teresita Pineda.
operation is the proper and accepted
ASSIGNMENT OF ERRORS procedure to address vaginal bleeding -
the medical problem presented to them.
The petitioner spouses contend that they
Given that the patient died after the D&C,
exercised due care and prudence in the
the core issue is whether the decision to
performance of their duties as medical
proceed with the D&C operation was an
professionals. They had attended to the
honest mistake of judgment or one
patient to the best of their abilities and
amounting to negligence.
undertook the management of her case
based on her complaint of an on-and-off
Elements of a Medical Negligence preponderance of evidence that, one,
Case the physician either failed to do something
which a reasonably prudent health care
A medical negligence case is a type of
provider would have done, or that he did
claim to redress a wrong committed by a
something that a reasonably prudent
medical professional, that has caused
provider would not have done;
bodily harm to or the death of a patient.
and two, the failure or action caused
There are four elements involved in a
injury to the patient.18 Expert testimony is
medical negligence case, namely: duty,
therefore essential since the factual issue
breach, injury, and proximate causation. 14
of whether a physician or surgeon has
Duty refers to the standard of behavior exercised the requisite degree of skill and
which imposes restrictions on one's care in the treatment of his patient is
conduct.15 The standard in turn refers to generally a matter of expert opinion.19
the amount of competence associated with
Standard of Care and Breach of Duty
the proper discharge of the profession. A
physician is expected to use at least the D&C is the classic gynecologic procedure
same level of care that any other for the evaluation and possible therapeutic
reasonably competent doctor would use treatment for abnormal vaginal
20
under the same circumstances. Breach of bleeding.  That this is the recognized
duty occurs when the physician fails to procedure is confirmed by Drs. Salvador
comply with these professional standards. Nieto (Dr. Nieto) and Joselito Mercado (Dr.
If injury results to the patient as a result of Mercado), the expert witnesses presented
this breach, the physician is answerable for by the respondents:
negligence.16
DR. NIETO: [W]hat I know among
As in any civil action, the burden to prove obstetricians, if there is bleeding, they
the existence of the necessary elements perform what we call D&C for diagnostic
rests with the plaintiff. 17 To successfully purposes.
pursue a claim, the plaintiff must prove by
xxx xxx xxx COURT: In other words, the operation
conducted on the patient, your opinion,
Q: So are you trying to tell the Court that
that it is inappropriate?
D&C can be a diagnostic treatment?
A: The timing of [when] the D&C [was]
A: Yes, sir. Any doctor knows this.21
done, based on the record, in my personal
Dr. Mercado, however, objected with opinion, that D&C should be postponed a
respect to the time the D&C operation day or two.22
should have been conducted in Teresita's
The petitioner spouses countered that, at
case. He opined that given the blood sugar
the time of the operation, there was
level of Teresita, her diabetic condition
nothing to indicate that Teresita was
should have been addressed first:
afflicted with diabetes: a blood sugar level
Q: Why do you consider the time of of 10.67mmol/l did not necessarily mean
performance of the D&C not appropriate? that she was a diabetic considering that
this was random blood sugar;23 there
A: Because I have read the record and I
were other factors that might have caused
have seen the urinalysis, [there is] spillage
Teresita's blood sugar to rise such as the
in the urine, and blood sugar was 10.67
taking of blood samples during lunchtime
Q: What is the significance of the spillage and while patient was being given intra-
in the urine? venous dextrose.24 Furthermore, they claim
that their principal concern was to
A: It is a sign that the blood sugar is very
determine the cause of and to stop the
high.
vaginal bleeding.
Q: Does it indicate sickness?
The petitioner spouses' contentions, in our
A: 80 to 95% it means diabetes mellitus. view, miss several points. First, as early as
The blood sugar was 10.67. April 17, 1987, Teresita was already
suspected to be suffering from
xxx xxx xxx 25
diabetes.  This suspicion again
arose right before the D&C operation on self-serving view that even reflects on their
April 28, 1987 when the laboratory result competence.
revealed Teresita's increased blood sugar
Taken together, we find that reasonable
level.26 Unfortunately, the petitioner
prudence would have shown that diabetes
spouses did not wait for the full medical
and its complications were foreseeable
laboratory results before proceeding with
harm that should have been taken into
the D&C, a fact that was never considered
consideration by the petitioner spouses. If
in the courts below. Second, the petitioner
a patient suffers from some disability
spouses were duly advised that the patient
that increases the magnitude of risk
was experiencing general body weakness,
to him, that disability must be taken
loss of appetite, frequent urination, and
into account so long as it is or should
thirst - all of which are classic symptoms of
have been known to the
diabetes.27 When a patient exhibits 29
physician.  And when the patient is
symptoms typical of a particular disease,
exposed to an increased risk, it is
these symptoms should, at the very least,
incumbent upon the physician to take
alert the physician of the possibility that
commensurate and adequate precautions.
the patient may be afflicted with the
suspected disease: Taking into account Teresita's high blood
Expert testimony for the plaintiff showed that] tests should have been sugar,30 Dr. Mendoza opined that the
ordered immediately on admission to the hospital in view of the symptoms attending physician should have
presented, and that failure to recognize the existence of diabetes postponed the D&C operation in order to
constitutes negligence.28 conduct a confirmatory test to make a
conclusive diagnosis of diabetes and to
Third, the petitioner spouses cannot claim refer the case to an internist or
that their principal concern was the vaginal diabetologist. This was corroborated by Dr.
bleeding and should not therefore be held Delfin Tan (Dr. Tan), an obstetrician and
accountable for complications coming from gynecologist, who stated that the patient's
other sources. This is a very narrow and diabetes should have been managed by an
internist prior to, during, and after the an immediate emergency D&C operation.
operation.31 Dr. Tan35 and Dr. Mendoza36 both testified
that the medical records of Teresita failed
Apart from bleeding as a complication of
to indicate that there was profuse vaginal
pregnancy, vaginal bleeding is only rarely
bleeding. The claim that there was profuse
so heavy and life-threatening that urgent
vaginal bleeding although this was not
first-aid measures are required.32 Indeed,
reflected in the medical records strikes us
the expert witnesses declared that a D&C
as odd since the main complaint is vaginal
operation on a hyperglycemic patient may
bleeding. A medical record is the only
be justified only when it is an emergency
document that maintains a long-term
case - when there is profuse vaginal
transcription of patient care and as such,
bleeding. In this case, we choose not to
its maintenance is considered a priority in
rely on the assertions of the petitioner
hospital practice. Optimal record-keeping
spouses that there was profuse bleeding,
includes all patient inter-actions. The
not only because the statements were self-
records should always be clear, objective,
serving, but also because the petitioner
and up-to-date.37 Thus, a medical record
spouses were inconsistent in their
that does not indicate profuse medical
testimonies. Dr. Fredelicto testified earlier
bleeding speaks loudly and clearly of what
that on April 28, he personally saw the
it does not contain.
bleeding,33 but later on said that he did not
see it and relied only on Teresita's That the D&C operation was conducted
statement that she was bleeding. 34 He principally to diagnose the cause of the
went on to state that he scheduled the vaginal bleeding further leads us to
D&C operation without conducting any conclude that it was merely an elective
physical examination on the patient. procedure, not an emergency case. In an
elective procedure, the physician must
The likely story is that although Teresita
conduct a thorough pre-operative
experienced vaginal bleeding on April 28, it
evaluation of the patient in order to
was not sufficiently profuse to necessitate
adequately prepare her for the operation
and minimize possible risks and surgical management.39 [Emphasis
complications. The internist is responsible supplied.]
for generating a comprehensive evaluation
Significantly, the evidence strongly
of all medical problems during the pre-
suggests that the pre-operative evaluation
operative evaluation.38
was less than complete as the laboratory
The aim of pre-operative evaluation is not results were fully reported only on the day
to screen broadly for undiagnosed disease, following the D&C operation. Dr. Felicisima
but rather to identify and quantify only secured a telephone report of the
comorbidity that may impact on the preliminary laboratory result prior to the
operative outcome. This evaluation is D&C. This preliminary report did not
driven by findings on history and physical include the 3+ status of sugar in the
examination suggestive of organ system patient's urine40 - a result highly
dysfunction…The goal is to uncover confirmatory of diabetes.
problem areas that may require
Because the D&C was merely an elective
further investigation or be amenable
procedure, the patient's uncontrolled
to preoperative optimization.
hyperglycemia presented a far greater risk
If the preoperative evaluation uncovers than her on-and-off vaginal bleeding. The
significant comorbidity or evidence of poor presence of hyperglycemia in a surgical
control of an underlying disease process, patient is associated with poor clinical
consultation with an internist or medical outcomes, and aggressive glycemic control
specialist may be required to facilitate the positively impacts on morbidity and
work-up and direct management. In this mortality.41 Elective surgery in people with
process, communication between the uncontrolled diabetes should preferably be
surgeons and the consultants is essential scheduled after acceptable glycemic
  42
to define realistic goals for this control has been achieved.  According to
optimization process and to expedite Dr. Mercado, this is done by administering
insulin on the patient.43
The management approach in this kind of ultrasound test confirmed that Teresita
patients always includes insulin therapy  in had a myoma in her uterus, she was
combination with dextrose and potassium advised that she could be discharged a day
infusion. Insulin xxx promotes glucose after the operation and that her recovery
uptake by the muscle and fat cells  while could take place at home. This advice
decreasing glucose production by the liver implied that a day after the operation and
xxx. The net effect is to lower blood even after the complete laboratory results
glucose levels.44 were submitted, the petitioner spouses still
did not recognize any post-operative
The prudent move is to address the
concern that would require the monitoring
patient's hyperglycemic state immediately
of Teresita's condition in the hospital.
and promptly before any other procedure
is undertaken. In this case, there was no The above facts, point only to one
evidence that insulin was administered on conclusion - that the petitioner spouses
Teresita prior to or during the D&C failed, as medical professionals, to comply
operation. Insulin was only administered with their duty to observe the standard of
two days after the operation. care to be given to hyperglycemic/diabetic
patients undergoing surgery. Whether this
As Dr. Tan testified, the patient's
breach of duty was the proximate cause of
hyperglycemic condition should have been
Teresita's death is a matter we shall next
managed not only before and during the
determine.
operation, but also immediately after.
Despite the possibility that Teresita was Injury and Causation
afflicted with diabetes, the possibility was
As previously mentioned, the critical and
casually ignored even in the post-operative
clinching factor in a medical negligence
evaluation of the patient; the concern, as
case is proof of the causal
the petitioner spouses expressly admitted,
connection between the negligence which
was limited to the complaint of vaginal
the evidence established and the plaintiff's
bleeding. Interestingly, while the
injuries;45 the plaintiff must plead and
prove not only that he had been injured death:
and defendant has been at fault, but also
that the defendant's fault caused the Stress, whether physical or emotional, is a
injury. A verdict in a malpractice action factor that can aggravate diabetes; a D&C
cannot be based on speculation or operation is a form of physical stress. Dr.
conjecture. Causation must be proven Mendoza explained how surgical stress can
within a reasonable medical probability aggravate the patient's hyperglycemia:
based upon competent expert testimony.46 when stress occurs, the diabetic's body,
The respondents contend that especially the autonomic system, reacts by
unnecessarily subjecting Teresita to a D&C secreting hormones which are counter-
operation without adequately preparing regulatory; she can have prolonged
her, aggravated her hyperglycemic state hyperglycemia which, if unchecked, could
and caused her untimely demise. The lead to death.48 Medical literature further
death certificate of Teresita lists down the explains that if the blood sugar has
following causes of death: become very high, the patient becomes
comatose (diabetic coma). When this
Immediate cause: Cardiorespiratory happens over several days, the body uses
arrest its own fat to produce energy, and the
result is high levels of waste products
Antecedent Septicemic (called ketones) in the blood and urine
cause: shock, ketoacidocis (called diabetic ketoacidiosis, a medical
emergency with a significant
49
mortality).  This was apparently what
Underlying cause: Diabetes Mellitus II
happened in Teresita's case; in fact, after
she had been referred to the internist Dr.
Other significant conditions Jorge, laboratory test showed that her
blood sugar level shot up to 14.0mmol/l,
contributing to Renal Failure - Acute way above the normal blood sugar range.
Thus, between the D&C and death was the Q: On what aspect did you and your wife
diabetic complication that could have been consult [with] each other?
prevented with the observance of standard
A: We discussed on the finding of the
medical precautions. The D&C operation
laboratory [results] because the
and Teresita's death due to aggravated
hemoglobin was below normal, the blood
diabetic condition is therefore sufficiently
sugar was elevated, so that we have to
established.
evaluate these laboratory results - what it
The trial court and the appellate court means.
pinned the liability for Teresita's death on
Q: So it was you and your wife who made
both the petitioner spouses and this Court
the evaluation when it was phoned in?
finds no reason to rule otherwise. However,
we clarify that Dr. Fredelicto's negligence A: Yes, sir.
is not solely the act of ordering an "on call"
Q: Did your wife, before performing D&C
D&C operation when he was mainly
ask your opinion whether or not she can
an anaesthesiologist who had made a
proceed?
very cursory examination of the patient's
vaginal bleeding complaint. Rather, it was A: Yes, anyway, she asked me whether we
his failure from the very start to identify can do D&C based on my experience.
and confirm, despite the patient's
Q: And your answer was in the
complaints and his own suspicions, that
positive notwithstanding the
diabetes was a risk factor that should be
elevation of blood sugar?
guarded against, and his participation in
the imprudent decision to proceed with the A: Yes, sir, it was both our disposition
D&C operation despite his early suspicion to do the D&C. [Emphasis supplied.]50
and the confirmatory early laboratory
If Dr. Fredelicto believed himself to be
results. The latter point comes out clearly
incompetent to treat the diabetes, not
from the following exchange during the
being an internist or a diabetologist (for
trial:
which reason he referred Teresita to Dr. on the matter. Consequently, the RTC's
Jorge),51 he should have likewise refrained decision, as affirmed by the CA, stands.
from making a decision to proceed with the
Award of Damages
D&C operation since he was niether an
obstetrician nor a gynecologist. Both the trial and the appellate court
awarded actual damages as compensation
These findings lead us to the conclusion
for the pecuniary loss the respondents
that the decision to proceed with the D&C
suffered. The loss was presented in terms
operation, notwithstanding Teresita's
of the hospital bills and expenses the
hyperglycemia and without adequately
respondents incurred on account of
preparing her for the procedure, was
Teresita's confinement and death. The
contrary to the standards observed by the
settled rule is that a plaintiff is entitled to
medical profession. Deviation from this
be compensated for proven pecuniary
standard amounted to a breach of duty
loss.52 This proof the respondents
which resulted in the patient's death. Due
successfully presented. Thus, we affirm the
to this negligent conduct, liability must
award of actual damages of P36,000.00
attach to the petitioner spouses.
representing the hospital expenses the
Liability of the Hospital patient incurred.
In the proceedings below, UDMC was the In addition to the award for actual
spouses Flores' co-defendant. The RTC damages, the respondent heirs of Teresita
found the hospital jointly and severally are likewise entitled to P50,000.00
liable with the petitioner spouses, which as death indemnity pursuant to Article
decision the CA affirmed. In a Resolution 2206 of the Civil Code, which states that
dated August 28, 2006, this Court however "the amount of damages for death caused
denied UDMC's petition for review by a xxx quasi-delict shall be at least three
on certiorari. Since UDMC's appeal has thousand pesos,53 even though there may
been denied and they are not parties to have been mitigating circumstances
this case, we find it unnecessary to delve xxx." This is a question of law that the CA
missed in its decision and which we now suppress the wanton acts of an
55
decide in the respondents' favor. offender.  We therefore affirm the CA's
award as an example to the medical
The same article allows the recovery of
profession and to stress that the public
moral damages in case of death caused by
good requires stricter measures to avoid
a quasi-delict and enumerates the spouse,
the repetition of the type of medical
legitimate or illegitimate ascendants or
malpractice that happened in this case.
descendants as the persons entitled
thereto. Moral damages are designed to With the award of exemplary damages, the
compensate the claimant for the injury grant of attorney's fees is legally in
suffered, that is, for the mental anguish, order.56 We therefore reverse the CA
serious anxiety, wounded feelings which decision deleting these awards, and grant
the respondents herein must have surely the respondents the amount
felt with the unexpected loss of their of P100,000.00 as attorney's fees taking
daughter. We affirm the appellate court's into consideration the legal route this case
award of P400,000.00 by way of moral has taken.
damages to the respondents.
WHEREFORE, we AFFIRM the Decision of
We similarly affirm the grant of exemplary the CA dated June 20, 2003 in CA G.R. CV
damages. Exemplary damages are No. 63234 finding petitioner spouses liable
imposed by way of example or correction for negligent medical practice. We
for the public good.54 Because of the likewise AFFIRM the awards of actual and
petitioner spouses' negligence in compensatory damages of P36,000.00;
subjecting Teresita to an operation without moral damages of P400,000.00; and
first recognizing and addressing her exemplary damages of P100,000.00.
diabetic condition, the appellate court
We MODIFY the CA Decision by
awarded exemplary damages to the
additionally granting an award
respondents in the amount of P100,000.00.
of P50,000.00 as death indemnity and by
Public policy requires such imposition to
reversing the deletion of the award of
attorney's fees and costs and restoring the COURT OF APPEALS, SPOUSES QUEDO
award of P100,000.00 as attorney's fees. D. ACOGIDO and FLOTILDE G.
Costs of litigation are adjudged against VILLEGAS, respondents.
petitioner spouses.
DAVIDE, JR., J.:p
To summarize, the following awards shall
Throughout history, patients have
be paid to the family of the late Teresita
consigned their fates and lives to the skill
Pineda:
of their doctors. For a breach of this trust,
1. The sum of P36,000.00 by way of actual men have been quick to demand
and compensatory damages; retribution. Some 4,000 years ago, the
Code of Hammurabi1 then already
2. The sum of P50,000.00 by way of death
provided: "If a physician make a deep
indemnity;
incision upon a man with his bronze lancet
3. The sum of P400,000.00 by way of and cause the man's death, or operate on
moral damages; the eye socket of a man with his bronze
lancet and destroy the man's eyes, they
4. The sum of P100,000.00 by way of
shall cut off his hand." 2 Subsequently,
exemplary damages;
Hippocrates3 wrote what was to become
5. The sum of P100,000.00 by way of part of the healer's oath: "I will follow that
attorney's fees; and method of treatment which according to
my ability and judgment, I consider for the
6. Costs.
benefit of my patients, and abstain from
SO ORDERED. whatever is deleterious and
mischievous. . . . While I continue to keep
G.R. No. 118231 July 5, 1996
this oath unviolated may it be granted me
DR. VICTORIA L. BATIQUIN and ALLAN to enjoy life and practice the art, respected
BATIQUIN, petitioners, by all men at all times but should I
vs. trespass and violate this oath, may the
reverse be my lot." At present, the primary Head of the Department of Obstetrics and
objective of the medical profession if the Gynecology at the said Hospital.
preservation of life and maintenance of the
Mrs. Villegas is a married woman who
health of the people.4
submitted to Dr. Batiquin for prenatal care
Needless to say then, when a physician as the latter's private patient sometime
strays from his sacred duty and endangers before September 21, 1988.
instead the life of his patient, he must be
In the morning of September 21, 1988 Dr.
made to answer therefor. Although society
Batiquin, with the assistance of Dr. Doris
today cannot and will not tolerate the
Teresita Sy who was also a Resident
punishment meted out by the ancients,
Physician at the same Hospital, C.I. and
neither will it and this Court, as this case
O.R. Nurse Arlene Diones and some
would show, let the act go uncondemned.
student nurses performed a simple
The petitioners appeal from the caesarean section on Mrs. Villegas at the
5
decision  of the Court of Appeals of 11 May Negros Oriental Provincial Hospital and
1994 in CA-G.R. CV No. 30851, which after 45 minutes Mrs. Villegas delivered
reversed the decision6 of 21 December her first child, Rachel Acogido, at about
1990 of Branch 30 of the Regional Trial 11:45 that morning. Thereafter, Plaintiff
Court (RTC) of Negros Oriental in Civil Case remained confined at the Hospital until
No. 9492. September 27, 1988 during which period of
confinement she was regularly visited by
The facts, as found by the trial court, are
Dr. Batiquin. On September 28, 1988 Mrs.
as follows:
Villegas checked out of the Hospital. . . and
Dr. Batiquin was a Resident Physician at on that same day she paid Dr. Batiquin,
the Negros Oriental Provincial Hospital, thru the latter's secretary, the amount of
Dumaguete City from January 9, 1978 to P1,500.00 as "professional fee". . . .
September 1989. Between 1987 and
Soon after leaving the Hospital Mrs.
September, 1989 she was also the Actg.
Villegas began to suffer abdominal pains
and complained of being feverish. She also examination she felt an abdominal mass
gradually lost her appetite, so she one finger below the umbilicus which she
consulted Dr. Batiquin at the latter's suspected to be either a tumor of the
polyclinic who prescribed for her certain uterus or an ovarian cyst, either of which
medicines. . . which she had been taking could be cancerous. She had an x-ray
up to December, 1988. taken of Mrs. Villegas' chest, abdomen and
kidney. She also took blood tests of
In the meantime, Mrs. Villegas was given a
Plaintiff. A blood count showed that Mrs.
Medical Certificate by Dr. Batiquin on
Villegas had [an] infection inside her
October 31, 1988. . . certifying to her
abdominal cavity. The results of all those
physical fitness to return to her work on
examinations impelled Dr. Kho to suggest
November 7, 1988. So, on the second
that Mrs. Villegas submit to another
week of November, 1988 Mrs. Villegas
surgery to which the latter agreed.
returned to her work at the Rural Bank of
Ayungon, Negros Oriental. When Dr. Kho opened the abdomen of Mrs.
Villegas she found whitish-yellow discharge
The abdominal pains and fever kept on
inside, an ovarian cyst on each of the left
recurring and bothered Mrs. Villegas no
and right ovaries which gave out pus, dirt
end despite the medications administered
and pus behind the uterus, and a piece of
by Dr. Batiquin. When the pains became
rubber material on the right side of the
unbearable and she was rapidly losing
uterus embedded on [sic] the ovarian cyst,
weight she consulted Dr. Ma. Salud Kho at
2 inches by 3/4 inch in size. This piece of
the Holy Child's Hospital in Dumaguete
rubber material which Dr. Kho described as
City on January 20, 1989.
a "foreign body" looked like a piece of a
The evidence of Plaintiffs show that when "rubber glove". . . and which is [sic] also
Dr. Ma. Salud Kho examined Mrs. Villegas "rubber-drain like". . . . It could have been
at the Holy Child's Hospital on January 20, a torn section of a surgeon's gloves or
1989 she found Mrs. Villegas to be could have come from other sources. And
feverish, pale and was breathing fast. Upon this foreign body was the cause of the
infection of the ovaries and consequently them to express her agreement
15
of all the discomfort suffered by Mrs. thereto. . . ."  The trial court also refused
Villegas after her delivery on September to give weight to Dr. Kho's testimony
21, 1988.7 regarding the subject piece of rubber as
Dr. Kho "may not have had first-hand
The piece of rubber allegedly found near
knowledge" thereof,16 as could be gleaned
private respondent Flotilde Villegas's
from her statement, thus:
uterus was not presented in court, and
although Dr. Ma. Salud Kho Testified that A . . . I have heard somebody that [sic]
she sent it to a pathologist in Cebu City for says [sic] there is [sic] a foreign body that
examination,8 it was not mentioned in the goes with the tissues but unluckily I don't
pathologist's Surgical Pathology Report. 9 know where the rubber was. 17
Aside from Dr. Kho's testimony, the The trial court deemed vital Dr. Victoria
evidence which mentioned the piece of Batiquin's testimony that when she
rubber are a Medical Certificate, 10 a confronted Dr. Kho regarding the piece of
Progress Record,11 an Anesthesia rubber, "Dr. Kho answered that there was
12
Record,  a Nurse's Record,13 and a rubber indeed but that she threw it
14
Physician's Discharge Summary.  The trial away."18 This statement, the trial court
court, however, regarded these noted, was never denied nor disputed by
documentary evidence as mere hearsay, Dr. Kho, leading it to conclude:
"there being no showing that the person or
There are now two different versions on
persons who prepared them are deceased
the whereabouts of that offending "rubber"
or unable to testify on the facts therein
— (1) that it was sent to the Pathologist in
stated. . . . Except for the Medical
Cebu as testified to in Court by Dr. Kho and
Certificate (Exhibit "F"), all the above
(2) that Dr. Kho threw it away as told by
documents were allegedly prepared by
her to Defendant. The failure of the
persons other than Dr. Kho, and she
Plaintiffs to reconcile these two different
merely affixed her signature on some of
versions serve only to weaken their claim see another doctor in January, 1989 when
against Defendant Batiquin.19 she was not getting any better under the
care of appellee Dr. Batiquin. . . . Appellee
All told, the trial court held in favor of the
Dr. Batiquin admitted on the witness stand
petitioners herein.
that she alone decided when to close the
The Court of Appeals reviewed the entirety operating area; that she examined the
of Dr. Kho's testimony and, even without portion she operated on before closing the
admitting the private respondents' same. . . Had she exercised due diligence,
documentary evidence, deemed Dr. Kho's appellee Dr. Batiquin would have found the
positive testimony to definitely establish rubber and removed it before closing the
that a piece of rubber was found near operating area.20
private respondent Villegas's uterus. Thus,
The appellate court then ruled:
the Court of Appeals reversed the decision
of the trial court, holding: Appellants' evidence show[s] that they
paid a total of P17,000.00 [deposit of
4. The fault or negligence of appellee Dr.
P7,100.00 (Exh. G-1-A) plus hospital and
Batiquin is established by preponderance
medical expenses together with doctor's
of evidence. The trial court itself had
fees in the total amount P9,900.00 (Exhs.
narrated what happened to appellant
G and G-2)] for the second operation that
Flotilde after the caesarean operation
saved her life.
made by appellee doctor. . . . After the
second operation, appellant Flotilde For the miseries appellants endured for
became well and healthy. Appellant more than three (3) months, due to the
Flotilde's troubles were caused by the negligence of appellee Dr. Batiquin they
infection due to the "rubber" that was left are entitled to moral damages in the
inside her abdomen. Both appellant; amount of P100,000.00; exemplary
testified that after the operation made by damages in the amount of P20,000.00 and
appellee doctor, they did not go to any attorney's fees in the amount of
other doctor until they finally decided to P25,000.00.
The fact that appellant Flotilde can no abuse of discretion by resorting to findings
longer bear children because her uterus of fact not supported by the evidence on
and ovaries were removed by Dr. Kho is record, and (2) exceeded its discretion,
not taken into consideration as it is not amounting to lack or excess of jurisdiction,
shown that the removal of said organs when it gave credence to testimonies
were the direct result of the rubber left by punctured with contradictions and falsities.
appellee Dr. Batiquin near the uterus.
The private respondents commented that
What is established is that the rubber left
the petition raised only questions of fact,
by appellee caused infection, placed the
which were not proper for review by this
life of appellant Flotilde in jeopardy and
Court.
caused appellant fear, worry and
anxiety. . . . While the rule is that only questions of law
may be raised in a petition for review
WHEREFORE, the appealed judgment,
on certiorari, there are exceptions, among
dismissing the complaint for damages is
which are when the factual findings of the
REVERSED and SET ASIDE. Another
trial court and the appellate court conflict,
judgment is hereby entered ordering
when the appealed decision is clearly
defendants-appellees to pay plaintiffs-
contradicted by the evidence on record, or
appellants the amounts of P17,000.00 as
when the appellate court misapprehended
and for actual damages; P100,000.00 as
the facts.22
and for moral damages; P20,000.00 as and
for exemplary damages; and P25,000.00 After deciphering the cryptic petition, we
as and for attorney's fees plus the costs of find that the focal point of the instant
litigation. appeal is the appreciation of Dr. Kho's
testimony. The petitioners contend that
SO ORDERED.21
the Court of Appeals misappreciated the
From the above judgment, the petitioners following portion of Dr. Kho's testimony:
appealed to this Court claiming that the
Q What is the purpose of the examination?
appellate court: (1) committed grave
A Just in case, I was just thinking at the abdomen, there was an ovarian cyst on the
back of my mind, just in case this would left and side and there was also an ovarian
turn out to be a medico-legal cyst on the right which, on opening up or
case, I have heard somebody that [sic] say freeing it up from the uterus, turned out to
s [sic] there is [sic] a be pus. Both ovaries turned out. . . to have
foreign body that goes with the tissues but  pus. And then, cleaning up the uterus, at
unluckily I don't know where the rubber wa the back of the uterus it was very dirty, it
s. It was not in the Lab, it was not in was full of pus. And there was a [piece of]
Cebu. 23 (emphasis supplied) rubber, we found a [piece of] rubber on the
right
The petitioners prefer the trial court's
side. 24
interpretation of the above testimony, i.e.,
that Dr. Kho's knowledge of the piece of We agree with the Court of Appeals. The
rubber was based on hearsay. The Court of phrase relied upon by the trial court does
Appeals, on the other hand, concluded that not negate the fact that Dr. Kho saw a
the underscored phrase was taken out of piece of rubber in private respondent
context by the trial court. According to the Villegas's abdomen, and that she sent it to
Court of Appeals, the trial court should a laboratory and then to Cebu City for
have likewise considered the other examination by a pathologist. 25 Not even
portions of Dr. Kho's testimony, especially the Pathologist's Report, although devoid
the following: of any mention of a piece of rubber, could
alter what Dr. Kho saw. Furthermore, Dr.
Q So you did actually conduct the
Kho's knowledge of the piece of rubber
operation on her?
could not be based on other than first-hand
A Yes, I did. knowledge for, as she asserted before the
trial court:
Q And what was the result?
Q But you are sure you have seen [the
A Opening up her abdomen, there was
piece of rubber]?
whitish-yellow discharge inside the
A Oh yes. I was not the only one who saw found to have deliberately falsified in some
it. 26 material particulars, it is not required that
the whole of his uncorroborated testimony
The petitioners emphasize that the private
be rejected, but such portions thereof
respondents never reconciled Dr. Kho's
deemed worthy of belief may be credited.29
testimony with Dr. Batiquin's claim on the
witness stand that when Dr. Batiquin It is here worth noting that the trial court
confronted Dr. Kho about the foreign body, paid heed to the following portions of Dr.
the latter said that there was a piece of Batiquin's testimony: that no rubber drain
rubber but that she threw it away. was used in the operation, 30 and that there
Although hearsay, Dr. Batiquin's claim was was neither any tear on Dr. Batiquin's
not objected to, and hence, the same is gloves after the operation nor blood
admissible27 but it carries no probative smears on her hands upon removing her
value.28 Nevertheless, assuming otherwise, gloves.31 Moreover, the trial court pointed
Dr. Batiquin's statement cannot belie the out that the absence of a rubber drain was
fact that Dr. Kho found a piece of rubber corroborated by Dr. Doris Sy, Dr. Batiquin's
near private respondent Villegas's uterus. assistant during the operation on private
And even if we were to doubt Dr. Kho as to respondent Villegas.32 But the trial court
what she did to the piece of rubber, i.e., failed to recognize that the assertions of
whether she threw it away or sent it to Drs. Batiquin and Sy were denials or
Cebu City, we are not justified in negative testimonies. Well-settled is the
distrusting her as to her recovery of a rule that positive testimony is stronger
piece of rubber from private respondent than negative testimony.33 Of course, as
Villegas's abdomen. On this score, it is the petitioners advocate, such positive
perfectly reasonable to believe the testimony must come from a credible
testimony of a witness with respect to source, which leads us to the second
some facts and disbelieve his testimony assigned error.
with respect to other facts. And it has been
aptly said that even when a witness is
While the petitioners claim that testimony [that a piece of rubber was
contradictions and falsities punctured Dr. indeed found in private respondent
Kho's testimony, a regarding of the said Villega's abdomen] prevails over the
testimony reveals no such infirmity and negative testimony in favor of the
establishes Dr. Kho as a credible witness. petitioners.
Dr. Kho was frank throughout her turn on
As such, the rule of res ipsa loquitur comes
the witness stand. Furthermore, no motive
to fore. This Court has had occasion to
to state any untruth was ever imputed
delve into the nature and operation of this
against Dr. Kho, leaving her
34 doctrine:
trustworthiness unimpaired.  The trial
court's following declaration shows that This doctrine [res ipsa loquitur] is stated
while it was critical of the lack of care with thus: "Where the thing which causes injury
which Dr. Kho handled the piece of rubber, is shown to be under the management of
it was not prepared to doubt Dr. Kho's the defendant, and the accident is such as
credibility, thus only supporting our in the ordinary course of things does not
appraisal of Dr. Kho's trustworthiness: happen in those who have the
management use proper care, it affords
This is not to say that she was less than
reasonable evidence, in the absence of an
honest when she testified about her
explanation by the defendant, that the
findings, but it can also be said that she
accident arose from want of care." Or
did not take the most appropriate
as Black's Law Dictionary puts it:
precaution to preserve that "piece of
rubber" as an eloquent evidence of what Res ipsa loquitur. The thing speaks for
she would reveal should there be a "legal itself. Rebuctable presumption or inference
problem" which she claim[s] to have that defendant was negligent, which arises
anticipated.35 upon proof that [the] instrumentality
causing injury was in defendant's exclusive
Considering that we have assessed Dr. Kho
control, and that the accident was one
to be a credible witness, her positive
which ordinary does not happen in
absence of negligence. Res ipsa loquitur is substitute for specific proof of negligence.
[a] rule of evidence whereby negligence of The doctrine is not a rule of substantive
[the] alleged wrongdoer may be inferred law, but merely a mode of proof or a mere
from [the] mere fact that [the] accident procedural convenience. The rule, when
happened provided [the] character of [the] applicable to the facts and circumstances
accident and circumstances attending it of a particular case, is not intended to and
lead reasonably to belief that in [the] does not dispense with the requirement of
absence of negligence it would not have proof of culpable negligence on the party
occurred and that thing which caused charged. It merely determines and
injury is shown to have been under [the] regulates what shall be prima
management and control of [the] alleged facie evidence thereof and facilitates the
wrongdoer. . . . Under [this] doctrine burden of plaintiff of proving a breach of
. . . the happening of an injury permits an the duty of due care. The doctrine can be
inference of negligence where plaintiff invoked when and only when, under the
produces substantial evidence that [the] circumstances involved, direct evidence is
injury was caused by an agency or absent and not readily available.36
instrumentality under [the] exclusive
In the instant case, all the requisites for
control and management of defendant,
recourse to the doctrine are present. First,
and that the occurrence [sic] was such that
the entire proceedings of the caesarean
in the ordinary course of things would not
section were under the exclusive control of
happen if reasonable care had been used.
Dr. Batiquin. In this light, the private
x x x           x x x          x x x respondents were bereft of direct evidence
as to the actual culprit or the exact cause
The doctrine of [r]es ipsa loquitur as a rule
of the foreign object finding its way into
of evidence is peculiar to the law of
private respondent Villegas's body, which,
negligence which recognizes that prima
needless to say, does not occur unless
facie negligence may be established
through the intersection of negligence.
without direct proof and furnishes a
Second, since aside from the caesarean
section, private respondent Villegas tortious conduct, the petitioner
underwent no other operation which could endangered the life of Flotilde Villegas, in
have caused the offending piece of rubber violation of her profession's rigid ethical
to appear in her uterus, it stands to reason code and in contravention of the legal
that such could only have been a by- standards set forth for professionals, in
product of the caesarean section general,40 and members of the medical
performed by Dr. Batiquin. The petitioners, profession,41 in particular.
in this regard, failed to overcome the
WHEREFORE, the challenged decision of 11
presumption of negligence arising from
May 1994 of the Court of Appeals in CA-
resort to the doctrine of res ipsa loquitur.
G.R. CV No. 30851 is hereby AFFIRMED in
Dr. Batiquin is therefore liable for
toto.
negligently leaving behind a piece of
rubber in private respondent Villegas's Costs against the petitioners.
abdomen and for all the adverse effects
SO ORDERED.
thereof.
As a final word, this Court reiterates its
recognition of the vital role the medical
profession plays in the lives of the
people,3 7 and the State's compelling
interest to enact measures to protect the
public from "the potentially deadly effects
of incompetence and ignorance in those
who would undertake to treat our bodies
and minds for disease or
38
trauma."  Indeed, a physician is bound to
serve the interest of his patients "with the
greatest of solicitude, giving them always
his best talent and skill."39 Through her
G.R. No. 160889             April 27, 2007 However, at around 3:30 a.m., Nora
suffered profuse bleeding inside her womb
DR. MILAGROS L. CANTRE, Petitioner,
due to some parts of the placenta which
vs.
were not completely expelled from her
SPS. JOHN DAVID Z. GO and NORA S.
womb after delivery. Consequently, Nora
GO, Respondents.
suffered hypovolemic shock, resulting in a
DECISION drop in her blood pressure to "40" over "0."
Petitioner and the assisting resident
QUISUMBING, J.:
physician performed various medical
For review on certiorari are the procedures to stop the bleeding and to
1
Decision  dated October 3, 2002 and restore Nora’s blood pressure. Her blood
Resolution2 dated November 19, 2003 of pressure was frequently monitored with
the Court of Appeals in CA-G.R. CV No. the use of a sphygmomanometer. While
58184, which affirmed with modification petitioner was massaging Nora’s uterus for
the Decision3 dated March 3, 1997 of the it to contract and stop bleeding, she
Regional Trial Court of Quezon City, Branch ordered a droplight to warm Nora and her
98, in Civil Case No. Q-93-16562. baby.4 Nora remained unconscious until
she recovered.
The facts, culled from the records, are as
follows: While in the recovery room, her husband,
respondent John David Z. Go noticed a
Petitioner Dr. Milagros L. Cantre is a
fresh gaping wound two and a half (2 ½)
specialist in Obstetrics and Gynecology at
by three and a half (3 ½) inches in the
the Dr. Jesus Delgado Memorial Hospital.
inner portion of her left arm, close to the
She was the attending physician of
armpit.5 He asked the nurses what caused
respondent Nora S. Go, who was admitted
the injury. He was informed it was a burn.
at the said hospital on April 19, 1992.
Forthwith, on April 22, 1992, John David
At 1:30 a.m. of April 20, 1992, Nora gave filed a request for investigation. 6 In
birth to her fourth child, a baby boy. response, Dr. Rainerio S. Abad, the medical
director of the hospital, called petitioner three inches in length, the thickest portion
and the assisting resident physician to rising about one-fourth (1/4) of an inch
explain what happened. Petitioner said the from the surface of the skin. The costs of
blood pressure cuff caused the injury. the skin grafting and the scar revision were
shouldered by the hospital.12
On May 7, 1992, John David brought Nora
to the National Bureau of Investigation for Unfortunately, Nora’s arm would never be
a physical examination, which was the same.1a\^/phi1.net Aside from the
conducted by medico-legal officer Dr. unsightly mark, the pain in her left arm
Floresto Arizala, Jr.7 The medico-legal remains. When sleeping, she has to cradle
officer later testified that Nora’s injury her wounded arm. Her movements now are
appeared to be a burn and that a droplight also restricted. Her children cannot play
when placed near the skin for about 10 with the left side of her body as they might
minutes could cause such burn. 8 He accidentally bump the injured arm, which
dismissed the likelihood that the wound aches at the slightest touch.
was caused by a blood pressure cuff as the
Thus, on June 21, 1993, respondent
scar was not around the arm, but just on
spouses filed a complaint13 for damages
one side of the arm.9
against petitioner, Dr. Abad, and the
On May 22, 1992, Nora’s injury was hospital. Finding in favor of respondent
referred to a plastic surgeon at the Dr. spouses, the trial court decreed:
Jesus Delgado Memorial Hospital for skin
In view of the foregoing consideration,
grafting.10 Her wound was covered with
judgment is hereby rendered in favor of
skin sourced from her abdomen, which
the plaintiffs and against the defendants,
consequently bore a scar as well. About a
directing the latters, (sic) jointly and
year after, on April 30, 1993, scar revision
severally –
had to be performed at the same
hospital.11 The surgical operation left a
healed linear scar in Nora’s left arm about
(a) to pay the sum of Five Hundred 1. Ordering defendant-appellant Dra.
Thousand Pesos (P500,000.00) in moral Milagros [L.] Cantre only to pay plaintiffs-
damages; appellees John David Go and Nora S. Go
the sum of P200,000.00 as moral
(b) to pay the sum of One Hundred Fifty
damages;
Thousand Pesos (P150,000.00) exemplary
damages; 2. Deleting the award [of] exemplary
damages, attorney’s fees and expenses of
(c) to pay the sum of Eighty Thousand
litigation;1awphi1.nét
Pesos (P80,000.00) nominal damages;
3. Dismissing the complaint with respect to
(d) to pay Fifty Thousand Pesos
defendants-appellants Dr. Rainerio S. Abad
(P50,000.00) for and as attorney’s fees;
and Delgado Clinic, Inc.;
and
4. Dismissing the counterclaims of
(e) to pay Six Thousand Pesos (P6,000.00)
defendants-appellants for lack of merit;
litigation expenses.
and
SO ORDERED.14
5. Ordering defendant-appellant Dra.
Petitioner, Dr. Abad, and the hospital all Milagros [L.] Cantre only to pay the costs.
appealed to the Court of Appeals, which
SO ORDERED.15
affirmed with modification the trial court
decision, thus: Petitioner’s motion for reconsideration was
denied by the Court of Appeals. Hence, the
WHEREFORE, in view of all the foregoing,
instant petition assigning the following as
and finding no reversible error in the
errors and issues:
appealed Decision dated March 3, 1997 of
Branch 98 of the Regional Trial Court of I.
Quezon City in Civil Case No. Q-93-16562,
WHETHER OR NOT, THE LOWER COURT,
the same is hereby AFFIRMED, with the
AND THE COURT OF APPEALS COMMITTED
following MODIFICATIONS:
GRAVE ABUSE OF THEIR DISCRETION DISCRETION WHEN, CONTRARY TO
WHEN, NOTWITHSTANDING THAT BOTH PREPONDERANCE OF EVIDENCE
PARTIES HAVE RESTED THEIR RESPECTIVE PRESENTED BY THE PETITIONER, IT RULED
CASES, THE LOWER COURT ADMITTED THE THAT PETITIONER DRA. CANTRE WAS NOT
ADDITIONAL EXHIBITS FURTHER OFFERED ABLE TO AMPLY EXPLAIN HOW THE INJURY
BY RESPONDENTS NOT TESTIFIED TO BY (BLISTERS) IN THE LEFT INNER ARM OF
ANY WITNESS AND THIS DECISION OF THE RESPONDENT MRS. GO CAME ABOUT;
LOWER COURT WAS UPHELD BY THE
IV.
COURT OF APPEALS LIKEWISE COMMITTING
GRAVE ABUSE OF DISCRETION; WHETHER OR NOT THE COURT OF APPEALS
COMMITTED GRAVE ABUSE OF ITS
II.
DISCRETION WHEN IT MADE A RULING ON
WHETHER OR NOT THE LOWER COURT THE RESPONDENT’S INJURY QUOTING THE
COMMITTED GRAVE ABUSE OF ITS TESTIMONY OF SOMEONE WHO WAS NOT
DISCRETION WHEN, CONTRARY TO PRESENT AND HAS NOT SEEN THE
PREPONDERANCE OF EVIDENCE ORIGINAL, FRESH INJURY OF RESPONDENT
PRESENTED BY THE PETITIONER, IT RULED MRS. NORA GO;
THAT THE PETITIONER HAS NOT AMPLY
V.
SHOWED THAT THE DROPLIGHT DID NOT
TOUCH THE BODY OF MRS. NORA GO, AND WHETHER OR NOT THE COURT OF APPEALS
THIS DECISION OF THE LOWER COURT GRAVELY ABUSING ITS DISCRETION RULED
WAS UPHELD BY THE COURT OF APPEALS THAT PETITIONER DRA. CANTRE SHOULD
LIKEWISE COMMITTING GRAVE ABUSE OF HAVE INTENDED TO INFLICT THE INJURY TO
DISCRETION; SAVE THE LIFE OF RESPONDENT MRS. GO;
III. VI.
WHETHER OR NOT THE LOWER COURT WHETHER OR NOT THE LOWER COURT
COMMITTED GRAVE ABUSE OF ITS AND THE COURT [OF] APPEALS
COMMITTED GRAVE ABUSE OF DISCRETION any witness are inadmissible in evidence
WHEN, CONTRARY TO THE DETAILED because they deprived her of her
PROCEDURES DONE BY PETITIONER, BOTH constitutional right to confront the
RULED THAT THE RESPONDENT WAS LEFT witnesses against her. Petitioner insists the
TO THE CARE OF THE NURSING STAFF; droplight could not have touched Nora’s
body. She maintains the injury was due to
VII.
the constant taking of Nora’s blood
WHETHER OR NOT THE LOWER COURT pressure. Petitioner also insinuates the
COMMITTED GRAVE ABUSE OF DISCRETION Court of Appeals was misled by the
WHEN, CONTRARY TO THE MEDICAL testimony of the medico-legal officer who
PURPOSES OF COSMETIC SURGERY, IT never saw the original injury before plastic
RULED THAT THE COSMETIC SURGERY surgery was performed. Finally, petitioner
MADE THE SCARS EVEN MORE UGLY AND stresses that plastic surgery was not
DECLARED THE COSMETIC SURGERY A intended to restore respondent’s injury to
FAILURE; its original state but rather to prevent
further complication.
VIII.
Respondents, however, counter that the
WHETHER OR NOT THE LOWER COURT
genuineness and due execution of the
GRAVELY ABUSE OF (SIC) DISCRETION
additional documentary exhibits were duly
WHEN, CONTRARY TO RESPONDENTS’
admitted by petitioner’s counsel.
CONTRARY TESTIMONIES AND THE
Respondents point out that petitioner’s
ABSENCE OF ANY TESTIMONY, IT RULED
blood pressure cuff theory is highly
THAT THEY ARE ENTITLED TO DAMAGES
improbable, being unprecedented in
AND WHICH WAS UPHELD, ALTHOUGH
medical history and that the injury was
MODIFIED, BY THE COURT OF APPEALS
definitely caused by the droplight. At any
LIKEWISE ABUSING ITS DISCRETION.16
rate, they argue, even if the injury was
Petitioner contends that additional brought about by the blood pressure cuff,
documentary exhibits not testified to by
petitioner was still negligent in her duties Petitioner’s contention that the medico-
as Nora’s attending physician. legal officer who conducted Nora’s physical
examination never saw her original injury
Simply put, the threshold issues for
before plastic surgery was performed is
resolution are: (1) Are the questioned
without basis and contradicted by the
additional exhibits admissible in evidence?
records. Records show that the medico-
(2) Is petitioner liable for the injury
legal officer conducted the physical
suffered by respondent Nora Go?
examination on May 7, 1992, while the skin
Thereafter, the inquiry is whether the
grafting and the scar revision were
appellate court committed grave abuse of
performed on Nora on May 22, 1992 and
discretion in its assailed issuances.
April 30, 1993, respectively.
As to the first issue, we agree with the
Coming now to the substantive matter, is
Court of Appeals that said exhibits are
petitioner liable for the injury suffered by
admissible in evidence. We note that the
respondent Nora Go?
questioned exhibits consist mostly of
Nora’s medical records, which were The Hippocratic Oath mandates physicians
produced by the hospital during trial to give primordial consideration to the
pursuant to a subpoena duces tecum. well-being of their patients. If a doctor fails
Petitioner’s counsel admitted the existence to live up to this precept, he is accountable
of the same when they were formally for his acts. This notwithstanding, courts
offered for admission by the trial court. In face a unique restraint in adjudicating
any case, given the particular medical negligence cases because
circumstances of this case, a ruling on the physicians are not guarantors of care and,
negligence of petitioner may be made they never set out to intentionally cause
based on the res ipsa loquitur doctrine injury to their patients. However, intent is
even in the absence of such additional immaterial in negligence cases because
exhibits. where negligence exists and is proven, it
automatically gives the injured a right to Second, whether the injury was caused by
reparation for the damage caused.17 the droplight or by the blood pressure cuff
is of no moment. Both instruments are
In cases involving medical negligence, the
deemed within the exclusive control of the
doctrine of res ipsa loquitur allows the
physician in charge under the "captain of
mere existence of an injury to justify a
the ship" doctrine. This doctrine holds the
presumption of negligence on the part of
surgeon in charge of an operation liable for
the person who controls the instrument
the negligence of his assistants during the
causing the injury, provided that the
time when those assistants are under the
following requisites concur:
surgeon’s control.19 In this particular case,
1. The accident is of a kind which ordinarily it can be logically inferred that petitioner,
does not occur in the absence of the senior consultant in charge during the
someone’s negligence; delivery of Nora’s baby, exercised control
over the assistants assigned to both the
2. It is caused by an instrumentality within
use of the droplight and the taking of
the exclusive control of the defendant or
Nora’s blood pressure. Hence, the use of
defendants; and
the droplight and the blood pressure cuff is
3. The possibility of contributing conduct also within petitioner’s exclusive control.
which would make the plaintiff responsible
Third, the gaping wound on Nora’s left
is eliminated.18
arm, by its very nature and considering her
As to the first requirement, the gaping condition, could only be caused by
wound on Nora’s arm is certainly not an something external to her and outside her
ordinary occurrence in the act of delivering control as she was unconscious while in
a baby, far removed as the arm is from the hypovolemic shock. Hence, Nora could not,
organs involved in the process of giving by any stretch of the imagination, have
birth. Such injury could not have happened contributed to her own injury.
unless negligence had set in somewhere.
Petitioner’s defense that Nora’s wound was exercise of her profession stands
caused not by the droplight but by the unrebutted. In this connection, the Civil
constant taking of her blood pressure, Code provides:
even if the latter was necessary given her
ART. 2176. Whoever by act or omission
condition, does not absolve her from
causes damage to another, there being
liability. As testified to by the medico-legal
fault or negligence, is obliged to pay for
officer, Dr. Arizala, Jr., the medical practice
the damage done.…
is to deflate the blood pressure cuff
immediately after each use. Otherwise, the ART. 2217. Moral damages include physical
inflated band can cause injury to the suffering, mental anguish, fright, serious
patient similar to what could have anxiety, besmirched reputation, wounded
happened in this case. Thus, if Nora’s feelings, moral shock, social humiliation,
wound was caused by the blood pressure and similar injury. Though incapable of
cuff, then the taking of Nora’s blood pecuniary computation, moral damages
pressure must have been done so may be recovered if they are the
negligently as to have inflicted a gaping proximate result of the defendant’s
wound on her arm,20 for which petitioner wrongful act or omission.
cannot escape liability under the "captain
Clearly, under the law, petitioner is obliged
of the ship" doctrine.
to pay Nora for moral damages suffered by
Further, petitioner’s argument that the the latter as a proximate result of
failed plastic surgery was not intended as a petitioner’s negligence.
cosmetic procedure, but rather as a
We note, however, that petitioner has
measure to prevent complication does not
served well as Nora’s obstetrician for her
help her case. It does not negate
past three successful deliveries. This is the
negligence on her part.
first time petitioner is being held liable for
Based on the foregoing, the presumption damages due to negligence in the practice
that petitioner was negligent in the of her profession. The fact that petitioner
promptly took care of Nora’s wound before
infection and other complications set in is
also indicative of petitioner’s good
intentions. We also take note of the fact
that Nora was suffering from a critical
condition when the injury happened, such
that saving her life became petitioner’s
elemental concern. Nonetheless, it should
be stressed that all these could not justify
negligence on the part of petitioner.
Hence, considering the specific
circumstances in the instant case, we find
no grave abuse of discretion in the assailed
decision and resolution of the Court of
Appeals. Further, we rule that the Court of
Appeals’ award of Two Hundred Thousand
Pesos (₱200,000) as moral damages in G.R. No. 124354 December 29, 1999
favor of respondents and against petitioner ROGELIO E. RAMOS and ERLINDA
is just and equitable.21 RAMOS, in their own behalf and as
WHEREFORE, the petition is DENIED. The natural guardians of the minors,
Decision dated October 3, 2002 and ROMMEL RAMOS, ROY RODERICK
Resolution dated November 19, 2003 of RAMOS and RON RAYMOND
the Court of Appeals in CA-G.R. CV No. RAMOS, petitioners,
58184 are AFFIRMED. vs.
COURT OF APPEALS, DELOS SANTOS
No pronouncement as to costs. MEDICAL CENTER, DR. ORLINO
SO ORDERED.
HOSAKA and DRA. PERFECTA their professional duties towards petitioner
GUTIERREZ, respondents. Erlinda Ramos resulting in her comatose
condition.
KAPUNAN, J.:
The antecedent facts as summarized by
The Hippocratic Oath mandates physicians
the trial court are reproduced hereunder:
to give primordial consideration to the
health and welfare of their patients. If a Plaintiff Erlinda Ramos was, until the
doctor fails to live up to this precept, he is afternoon of June 17, 1985, a 47-year old
made accountable for his acts. A mistake, (Exh. "A") robust woman (TSN, October 19,
through gross negligence or incompetence 1989, p. 10). Except for occasional
or plain human error, may spell the complaints of discomfort due to pains
difference between life and death. In this allegedly caused by the presence of a
sense, the doctor plays God on his stone in her gall bladder (TSN, January 13,
patient's fate. 1 1988, pp. 4-5), she was as normal as any
other woman. Married to Rogelio E. Ramos,
In the case at bar, the Court is called upon
an executive of Philippine Long Distance
to rule whether a surgeon, an
Telephone Company, she has three
anesthesiologist and a hospital should be
children whose names are Rommel Ramos,
made liable for the unfortunate comatose
Roy Roderick Ramos and Ron Raymond
condition of a patient scheduled for
Ramos (TSN, October 19, 1989, pp. 5-6).
cholecystectomy. 2
Because the discomforts somehow
Petitioners seek the reversal of the
interfered with her normal ways, she
decision 3 of the Court of Appeals, dated 29
sought professional advice. She was
May 1995, which overturned the
4 advised to undergo an operation for the
decision   of the Regional Trial Court, dated
removal of a stone in her gall bladder
30 January 1992, finding private
(TSN, January 13, 1988, p. 5). She
respondents liable for damages arising
underwent a series of examinations which
from negligence in the performance of
included blood and urine tests (Exhs. "A"
and "C") which indicated she was fit for A day before the scheduled date of
surgery. operation, she was admitted at one of the
rooms of the DLSMC, located along E.
Through the intercession of a mutual
Rodriguez Avenue, Quezon City (TSN,
friend, Dr. Buenviaje (TSN, January 13,
October 19,1989, p. 11).
1988, p. 7), she and her husband Rogelio
met for the first time Dr. Orlino Hozaka At around 7:30 A.M. of June 17, 1985 and
(should be Hosaka; see TSN, February 20, while still in her room, she was prepared
1990, p. 3), one of the defendants in this for the operation by the hospital staff. Her
case, on June 10, 1985. They agreed that sister-in-law, Herminda Cruz, who was the
their date at the operating table at the Dean of the College of Nursing at the
DLSMC (another defendant), would be on Capitol Medical Center, was also there for
June 17, 1985 at 9:00 A.M.. Dr. Hosaka moral support. She reiterated her previous
decided that she should undergo a request for Herminda to be with her even
"cholecystectomy" operation after during the operation. After praying, she
examining the documents (findings from was given injections. Her hands were held
the Capitol Medical Center, FEU Hospital by Herminda as they went down from her
and DLSMC) presented to him. Rogelio E. room to the operating room (TSN, January
Ramos, however, asked Dr. Hosaka to look 13, 1988, pp. 9-11). Her husband, Rogelio,
for a good anesthesiologist. Dr. Hosaka, in was also with her (TSN, October 19, 1989,
turn, assured Rogelio that he will get a p. 18). At the operating room, Herminda
good anesthesiologist. Dr. Hosaka charged saw about two or three nurses and Dr.
a fee of P16,000.00, which was to include Perfecta Gutierrez, the other defendant,
the anesthesiologist's fee and which was to who was to administer anesthesia.
be paid after the operation (TSN, October Although not a member of the hospital
19, 1989, pp. 14-15, 22-23, 31-33; TSN, staff, Herminda introduced herself as Dean
February 27, 1990, p. 13; and TSN, of the College of Nursing at the Capitol
November 9, 1989, pp. 3-4, 10, 17). Medical Center who was to provide moral
support to the patient, to them. Herminda
was allowed to stay inside the operating room (TSN, October 19, 1989, pp. 19-20).
room. He also thought of the feeling of his wife,
who was inside the operating room waiting
At around 9:30 A.M., Dr. Gutierrez reached
for the doctor to arrive (ibid.). At almost
a nearby phone to look for Dr. Hosaka who
12:00 noon, he met Dr. Garcia who
was not yet in (TSN, January 13, 1988, pp.
remarked that he (Dr. Garcia) was also
11-12). Dr. Gutierrez thereafter informed
tired of waiting for Dr. Hosaka to arrive
Herminda Cruz about the prospect of a
(id., p. 21). While talking to Dr. Garcia at
delay in the arrival of Dr. Hosaka.
around 12:10 P.M., he came to know that
Herminda then went back to the patient
Dr. Hosaka arrived as a nurse remarked,
who asked, "Mindy, wala pa ba ang
"Nandiyan na si Dr. Hosaka, dumating na
Doctor"? The former replied, "Huwag kang
raw." Upon hearing those words, he went
mag-alaala, darating na iyon" (Ibid.).
down to the lobby and waited for the
Thereafter, Herminda went out of the operation to be completed (id., pp. 16, 29-
operating room and informed the patient's 30).
husband, Rogelio, that the doctor was not
At about 12:15 P.M., Herminda Cruz, who
yet around (id., p. 13). When she returned
was inside the operating room with the
to the operating room, the patient told her,
patient, heard somebody say that "Dr.
"Mindy, inip na inip na ako, ikuha mo ako
Hosaka is already here." She then saw
ng ibang Doctor." So, she went out again
people inside the operating room "moving,
and told Rogelio about what the patient
doing this and that, [and] preparing the
said (id., p. 15). Thereafter, she returned to
patient for the operation" (TSN, January 13,
the operating room.
1988, p. 16). As she held the hand of
At around 10:00 A.M., Rogelio E. Ramos Erlinda Ramos, she then saw Dr. Gutierrez
was "already dying [and] waiting for the intubating the hapless patient. She
arrival of the doctor" even as he did his thereafter heard Dr. Gutierrez say, "ang
best to find somebody who will allow him hirap ma-intubate nito, mali yata ang
to pull out his wife from the operating pagkakapasok. O lumalaki ang tiyan" (id.,
p. 17). Because of the remarks of Dra. doctors rushing towards the operating
Gutierrez, she focused her attention on room. When informed by Herminda Cruz
what Dr. Gutierrez was doing. She that something wrong was happening, he
thereafter noticed bluish discoloration of told her (Herminda) to be back with the
the nailbeds of the left hand of the hapless patient inside the operating room (TSN,
Erlinda even as Dr. Hosaka approached October 19, 1989, pp. 25-28).
her. She then heard Dr. Hosaka issue an
Herminda Cruz immediately rushed back,
order for someone to call Dr. Calderon,
and saw that the patient was still in
another anesthesiologist (id., p. 19). After
trendelenburg position (TSN, January 13,
Dr. Calderon arrived at the operating room,
1988, p. 20). At almost 3:00 P.M. of that
she saw this anesthesiologist trying to
fateful day, she saw the patient taken to
intubate the patient. The patient's nailbed
the Intensive Care Unit (ICU).
became bluish and the patient was placed
in a trendelenburg position — a position About two days thereafter, Rogelio E.
where the head of the patient is placed in Ramos was able to talk to Dr. Hosaka. The
a position lower than her feet which is an latter informed the former that something
indication that there is a decrease of blood went wrong during the intubation. Reacting
supply to the patient's brain (Id., pp. 19- to what was told to him, Rogelio reminded
20). Immediately thereafter, she went out the doctor that the condition of his wife
of the operating room, and she told Rogelio would not have happened, had he (Dr.
E. Ramos "that something wrong was . . . Hosaka) looked for a good anesthesiologist
happening" (Ibid.). Dr. Calderon was then (TSN, October 19, 1989, p. 31).
able to intubate the patient (TSN, July 25,
Doctors Gutierrez and Hosaka were also
1991, p. 9).
asked by the hospital to explain what
Meanwhile, Rogelio, who was outside the happened to the patient. The doctors
operating room, saw a respiratory machine explained that the patient had
being rushed towards the door of the bronchospasm (TSN, November 15, 1990,
operating room. He also saw several pp. 26-27).
Erlinda Ramos stayed at the ICU for a also TSN, December 21, 1989,
month. About four months thereafter or on p. 6). 5
November 15, 1985, the patient was
Thus, on 8 January 1986, petitioners filed a
released from the hospital.
civil case 6 for damages with the Regional
During the whole period of her Trial Court of Quezon City against herein
confinement, she incurred hospital bills private respondents alleging negligence in
amounting to P93,542.25 which is the the management and care of Erlinda
subject of a promissory note and affidavit Ramos.
of undertaking executed by Rogelio E.
During the trial, both parties presented
Ramos in favor of DLSMC. Since that
evidence as to the possible cause of
fateful afternoon of June 17, 1985, she has
Erlinda's injury. Plaintiff presented the
been in a comatose condition. She cannot
testimonies of Dean Herminda Cruz and
do anything. She cannot move any part of
Dr. Mariano Gavino to prove that the
her body. She cannot see or hear. She is
sustained by Erlinda was due to lack of
living on mechanical means. She suffered
oxygen in her brain caused by the faulty
brain damage as a result of the absence of
management of her airway by private
oxygen in her brain for four to five minutes
respondents during the anesthesia phase.
(TSN, November 9, 1989, pp. 21-22). After
On the other hand, private respondents
being discharged from the hospital, she
primarily relied on the expert testimony of
has been staying in their residence, still
Dr. Eduardo Jamora, a pulmonologist, to
needing constant medical attention, with
the effect that the cause of brain damage
her husband Rogelio incurring a monthly
was Erlinda's allergic reaction to the
expense ranging from P8,000.00 to
anesthetic agent, Thiopental Sodium
P10,000.00 (TSN, October 19, 1989, pp.
(Pentothal).
32-34). She was also diagnosed to be
suffering from "diffuse cerebral After considering the evidence from both
parenchymal damage" (Exh. "G"; see sides, the Regional Trial Court rendered
judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in which, in turn, caused the patient to
the finding of facts set forth earlier, and become comatose.
applying the aforecited provisions of law
On the part of Dr. Orlino Hosaka, this Court
and jurisprudence to the case at bar, this
finds that he is liable for the acts of Dr.
Court finds and so holds that defendants
Perfecta Gutierrez whom he had chosen to
are liable to plaintiffs for damages. The
administer anesthesia on the patient as
defendants were guilty of, at the very
part of his obligation to provide the patient
least, negligence in the performance of
a good anesthesiologist', and for arriving
their duty to plaintiff-patient Erlinda
for the scheduled operation almost three
Ramos.
(3) hours late.
On the part of Dr. Perfecta Gutierrez, this
On the part of DLSMC (the hospital), this
Court finds that she omitted to exercise
Court finds that it is liable for the acts of
reasonable care in not only intubating the
negligence of the doctors in their "practice
patient, but also in not repeating the
of medicine" in the operating room.
administration of atropine (TSN, August 20,
Moreover, the hospital is liable for failing
1991, pp. 5-10), without due regard to the
through its responsible officials, to cancel
fact that the patient was inside the
the scheduled operation after Dr. Hosaka
operating room for almost three (3) hours.
inexcusably failed to arrive on time.
For after she committed a mistake in
intubating [the] patient, the patient's In having held thus, this Court rejects the
nailbed became bluish and the patient, defense raised by defendants that they
thereafter, was placed in trendelenburg have acted with due care and prudence in
position, because of the decrease of blood rendering medical services to plaintiff-
supply to the patient's brain. The evidence patient. For if the patient was properly
further shows that the hapless patient intubated as claimed by them, the patient
suffered brain damage because of the would not have become comatose. And,
absence of oxygen in her (patient's) brain the fact that another anesthesiologist was
for approximately four to five minutes called to try to intubate the patient after
her (the patient's) nailbed turned bluish, 4) the costs of the suit.
belie their claim. Furthermore, the
SO ORDERED. 7
defendants should have rescheduled the
operation to a later date. This, they should Private respondents seasonably interposed
have done, if defendants acted with due an appeal to the Court of Appeals. The
care and prudence as the patient's case appellate court rendered a Decision, dated
was an elective, not an emergency case. 29 May 1995, reversing the findings of the
trial court. The decretal portion of the
x x x           x x x          x x x
decision of the appellate court reads:
WHEREFORE, and in view of the foregoing,
WHEREFORE, for the foregoing premises
judgment is rendered in favor of the
the appealed decision is hereby
plaintiffs and against the defendants.
REVERSED, and the complaint below
Accordingly, the latter are ordered to pay,
against the appellants is hereby ordered
jointly and severally, the former the
DISMISSED. The counterclaim of appellant
following sums of money, to wit:
De Los Santos Medical Center is GRANTED
1) the sum of P8,000.00 as actual monthly but only insofar as appellees are hereby
expenses for the plaintiff Erlinda Ramos ordered to pay the unpaid hospital bills
reckoned from November 15, 1985 or in amounting to P93,542.25, plus legal
the total sum of P632,000.00 as of April 15, interest for justice must be tempered with
1992, subject to its being updated; mercy.
2) the sum of P100,000.00 as reasonable SO ORDERED. 8
attorney's fees;
The decision of the Court of Appeals was
3) the sum of P800,000.00 by way of moral received on 9 June 1995 by petitioner
damages and the further sum of Rogelio Ramos who was mistakenly
P200,000,00 by way of exemplary addressed as "Atty. Rogelio Ramos." No
damages; and, copy of the decision, however, was sent
nor received by the Coronel Law Office,
then counsel on record of petitioners. Resolution, dated 29 March 1996, primarily
Rogelio referred the decision of the on the ground that the fifteen-day (15)
appellate court to a new lawyer, Atty. period for filing a motion for
Ligsay, only on 20 June 1995, or four (4) reconsideration had already expired, to
days before the expiration of the wit:
reglementary period for filing a motion for
We said in our Resolution on July 25, 1995,
reconsideration. On the same day, Atty.
that the filing of a Motion for
Ligsay, filed with the appellate court a
Reconsideration cannot be extended;
motion for extension of time to file a
precisely, the Motion for Extension (Rollo,
motion for reconsideration. The motion for
p. 12) was denied. It is, on the other hand,
reconsideration was submitted on 4 July
admitted in the latter Motion that
1995. However, the appellate court denied
plaintiffs/appellees received a copy of the
the motion for extension of time in its
decision as early as June 9, 1995.
Resolution dated 25 July
9 Computation wise, the period to file a
1995.   Meanwhile, petitioners engaged
Motion for Reconsideration expired on June
the services of another counsel, Atty.
24. The Motion for Reconsideration, in turn,
Sillano, to replace Atty. Ligsay. Atty. Sillano
was received by the Court of Appeals
filed on 7 August 1995 a motion to admit
already on July 4, necessarily, the 15-day
the motion for reconsideration contending
period already passed. For that alone, the
that the period to file the appropriate
latter should be denied.
pleading on the assailed decision had not
yet commenced to run as the Division Even assuming admissibility of the Motion
Clerk of Court of the Court of Appeals had for the Reconsideration, but after
not yet served a copy thereof to the considering the Comment/Opposition, the
counsel on record. Despite this former, for lack of merit, is hereby DENIED.
explanation, the appellate court still denied
SO ORDERED. 10
the motion to admit the motion for
reconsideration of petitioners in its
A copy of the above resolution was UNFORTUNATE COMATOSE CONDITION OF
received by Atty. Sillano on 11 April 1996. PETITIONER ERLINDA RAMOS;
The next day, or on 12 April 1996, Atty.
III
Sillano filed before this Court a motion for
extension of time to file the present IN NOT APPLYING THE DOCTRINE OF RES
petition for certiorari under Rule 45. The IPSA LOQUITUR. 11
Court granted the motion for extension of
Before we discuss the merits of the case,
time and gave petitioners additional thirty
we shall first dispose of the procedural
(30) days after the expiration of the
issue on the timeliness of the petition in
fifteen-day (15) period counted from the
relation to the motion for reconsideration
receipt of the resolution of the Court of
filed by petitioners with the Court of
Appeals within which to submit the
Appeals. In their
petition. The due date fell on 27 May 1996. 12
Comment,   private respondents contend
The petition was filed on 9 May 1996, well
that the petition should not be given due
within the extended period given by the
course since the motion for reconsideration
Court.
of the petitioners on the decision of the
Petitioners assail the decision of the Court Court of Appeals was validly dismissed by
of Appeals on the following grounds: the appellate court for having been filed
beyond the reglementary period. We do
I
not agree.
IN PUTTING MUCH RELIANCE ON THE
A careful review of the records reveals that
TESTIMONIES OF RESPONDENTS DRA.
the reason behind the delay in filing the
GUTIERREZ, DRA. CALDERON AND DR.
motion for reconsideration is attributable
JAMORA;
to the fact that the decision of the Court of
II Appeals was not sent to then counsel on
record of petitioners, the Coronel Law
IN FINDING THAT THE NEGLIGENCE OF THE
Office. In fact, a copy of the decision of the
RESPONDENTS DID NOT CAUSE THE
appellate court was instead sent to and Resolution, dated 29 March 1996, which
received by petitioner Rogelio Ramos on 9 superseded the earlier resolution issued on
June 1995 wherein he was mistakenly 25 July 1995, and denied the motion for
addressed as Atty. Rogelio Ramos. Based reconsideration of petitioner, we believed
on the other communications received by that the receipt of the former should be
petitioner Rogelio Ramos, the appellate considered in determining the timeliness of
court apparently mistook him for the the filing of the present petition. Based on
counsel on record. Thus, no copy of the this, the petition before us was submitted
decision of the counsel on record. on time.
Petitioner, not being a lawyer and unaware
After resolving the foregoing procedural
of the prescriptive period for filing a
issue, we shall now look into the merits of
motion for reconsideration, referred the
the case. For a more logical presentation of
same to a legal counsel only on 20 June
the discussion we shall first consider the
1995.
issue on the applicability of the doctrine
It is elementary that when a party is of res ipsa loquitur to the instant case.
represented by counsel, all notices should Thereafter, the first two assigned errors
be sent to the party's lawyer at his given shall be tackled in relation to the res ipsa
address. With a few exceptions, notice to a loquitur doctrine.
litigant without notice to his counsel on
Res ipsa loquitur is a Latin phrase which
record is no notice at all. In the present
literally means "the thing or the
case, since a copy of the decision of the
transaction speaks for itself." The phrase
appellate court was not sent to the counsel
"res ipsa loquitur'' is a maxim for the rule
on record of petitioner, there can be no
that the fact of the occurrence of an injury,
sufficient notice to speak of. Hence, the
taken with the surrounding circumstances,
delay in the filing of the motion for
may permit an inference or raise a
reconsideration cannot be taken against
presumption of negligence, or make out a
petitioner. Moreover, since the Court of
plaintiff's prima facie case, and present a
Appeals already issued a second
question of fact for defendant to meet with in conjunction with the doctrine of common
an explanation. 13 Where the thing which knowledge.
caused the injury complained of is shown
However, much has been said that res ipsa
to be under the management of the
loquitur is not a rule of substantive law
defendant or his servants and the accident
and, as such, does not create or constitute
is such as in ordinary course of things does
an independent or separate ground of
not happen if those who have its
liability. 17 Instead, it is considered as
management or control use proper care, it
merely evidentiary or in the nature of a
affords reasonable evidence, in the
procedural rule. 18 It is regarded as a mode
absence of explanation by the defendant,
of proof, or a mere procedural of
that the accident arose from or was caused
convenience since it furnishes a substitute
by the defendant's want of care. 14
for, and relieves a plaintiff of, the burden
The doctrine of res ipsa loquitur is simply a of producing specific proof of
19
recognition of the postulate that, as a negligence.   In other words, mere
matter of common knowledge and invocation and application of the doctrine
experience, the very nature of certain does not dispense with the requirement of
types of occurrences may justify an proof of negligence. It is simply a step in
inference of negligence on the part of the the process of such proof, permitting the
person who controls the instrumentality plaintiff to present along with the proof of
causing the injury in the absence of some the accident, enough of the attending
explanation by the defendant who is circumstances to invoke the doctrine,
charged with negligence. 15 It is grounded creating an inference or presumption of
in the superior logic of ordinary human negligence, and to thereby place on the
experience and on the basis of such defendant the burden of going forward
experience or common knowledge, with the proof. 20 Still, before resort to the
negligence may be deduced from the mere doctrine may be allowed, the following
occurrence of the accident requisites must be satisfactorily shown:
16
itself.   Hence, res ipsa loquitur is applied
1. The accident is of a kind which ordinarily cause of that harm. 25 The application
does not occur in the absence of of res ipsa loquitur in medical negligence
someone's negligence; cases presents a question of law since it is
a judicial function to determine whether a
2. It is caused by an instrumentality within
certain set of circumstances does, as a
the exclusive control of the defendant or
matter of law, permit a given inference. 26
defendants; and
Although generally, expert medical
3. The possibility of contributing conduct
testimony is relied upon in malpractice
which would make the plaintiff responsible
suits to prove that a physician has done a
is eliminated. 21
negligent act or that he has deviated from
In the above requisites, the fundamental the standard medical procedure, when the
element is the "control of instrumentality" doctrine of res ipsa loquitur is availed by
which caused the damage. 22 Such element the plaintiff, the need for expert medical
of control must be shown to be within the testimony is dispensed with because the
dominion of the defendant. In order to injury itself provides the proof of
have the benefit of the rule, a plaintiff, in negligence. 27 The reason is that the
addition to proving injury or damage, must general rule on the necessity of expert
show a situation where it is applicable, and testimony applies only to such matters
must establish that the essential elements clearly within the domain of medical
of the doctrine were present in a particular science, and not to matters that are within
incident. 23 the common knowledge of mankind which
may be testified to by anyone familiar with
Medical malpractice 24 cases do not escape
the facts. 28 Ordinarily, only physicians and
the application of this doctrine. Thus, res
surgeons of skill and experience are
ipsa loquitur has been applied when the
competent to testify as to whether a
circumstances attendant upon the harm
patient has been treated or operated upon
are themselves of such a character as to
with a reasonable degree of skill and care.
justify an inference of negligence as the
However, testimony as to the statements
and acts of physicians and surgeons, to res ipsa loquitur is allowed because
external appearances, and manifest there is no other way, under usual and
conditions which are observable by any ordinary conditions, by which the patient
one may be given by non-expert can obtain redress for injury suffered by
witnesses. 29 Hence, in cases where the res him.
ipsa loquitur is applicable, the court is
Thus, courts of other jurisdictions have
permitted to find a physician negligent
applied the doctrine in the following
upon proper proof of injury to the patient,
situations: leaving of a foreign object in the
without the aid of expert testimony, where
body of the patient after an
the court from its fund of common 32
operation,   injuries sustained on a healthy
knowledge can determine the proper
part of the body which was not under, or in
standard of care. 30 Where common
the area, of treatment, 33 removal of the
knowledge and experience teach that a
wrong part of the body when another part
resulting injury would not have occurred to
was intended, 34 knocking out a tooth while
the patient if due care had been exercised,
a patient's jaw was under anesthetic for
an inference of negligence may be drawn
the removal of his tonsils, 35 and loss of an
giving rise to an application of the doctrine
eye while the patient plaintiff was under
of res ipsa loquitur without medical
the influence of anesthetic, during or
evidence, which is ordinarily required to
following an operation for
show not only what occurred but how and 36
appendicitis,   among others.
why it occurred. 31 When the doctrine is
appropriate, all that the patient must do is Nevertheless, despite the fact that the
prove a nexus between the particular act scope of res ipsa loquitur has been
or omission complained of and the injury measurably enlarged, it does not
sustained while under the custody and automatically apply to all cases of medical
management of the defendant without negligence as to mechanically shift the
need to produce expert medical testimony burden of proof to the defendant to show
to establish the standard of care. Resort that he is not guilty of the ascribed
negligence. Res ipsa loquitur is not a rigid malpractice suit if the only showing is that
or ordinary doctrine to be perfunctorily the desired result of an operation or
used but a rule to be cautiously applied, treatment was not accomplished. 40 The
depending upon the circumstances of each real question, therefore, is whether or not
case. It is generally restricted to situations in the process of the operation any
in malpractice cases where a layman is extraordinary incident or unusual event
able to say, as a matter of common outside of the routine performance
knowledge and observation, that the occurred which is beyond the regular
consequences of professional care were scope of customary professional activity in
not as such as would ordinarily have such operations, which, if unexplained
followed if due care had been would themselves reasonably speak to the
37
exercised.   A distinction must be made average man as the negligent cause or
between the failure to secure results, and causes of the untoward consequence. 41 If
the occurrence of something more unusual there was such extraneous interventions,
and not ordinarily found if the service or the doctrine of res ipsa loquitur may be
treatment rendered followed the usual utilized and the defendant is called upon to
procedure of those skilled in that particular explain the matter, by evidence of
practice. It must be conceded that the exculpation, if he could. 42
doctrine of res ipsa loquitur can have no
We find the doctrine of res ipsa
application in a suit against a physician or
loquitur appropriate in the case at bar. As
surgeon which involves the merits of a
will hereinafter be explained, the damage
diagnosis or of a scientific
38 sustained by Erlinda in her brain prior to a
treatment.   The physician or surgeon is
scheduled gall bladder operation presents
not required at his peril to explain why any
a case for the application of res ipsa
particular diagnosis was not correct, or
loquitur.
why any particular scientific treatment did
not produce the desired result. 39 Thus, res A case strikingly similar to the one before
ipsa loquitur is not available in a us is Voss vs. Bridwell, 43 where the Kansas
Supreme Court in applying the res ipsa ordinarily have followed if due care had
loquitur stated: been exercised.
The plaintiff herein submitted himself for a Here the plaintiff could not have been
mastoid operation and delivered his person guilty of contributory negligence because
over to the care, custody and control of his he was under the influence of anesthetics
physician who had complete and exclusive and unconscious, and the circumstances
control over him, but the operation was are such that the true explanation of event
never performed. At the time of is more accessible to the defendants than
submission he was neurologically sound to the plaintiff for they had the exclusive
and physically fit in mind and body, but he control of the instrumentalities of
suffered irreparable damage and injury anesthesia.
rendering him decerebrate and totally
Upon all the facts, conditions and
incapacitated. The injury was one which
circumstances alleged in Count II it is held
does not ordinarily occur in the process of
that a cause of action is stated under the
a mastoid operation or in the absence of
doctrine of res ipsa loquitur. 44
negligence in the administration of an
anesthetic, and in the use and employment Indeed, the principles enunciated in the
of an endoctracheal tube. Ordinarily a aforequoted case apply with equal force
person being put under anesthesia is not here. In the present case, Erlinda
rendered decerebrate as a consequence of submitted herself for cholecystectomy and
administering such anesthesia in the expected a routine general surgery to be
absence of negligence. Upon these facts performed on her gall bladder. On that
and under these circumstances a layman fateful day she delivered her person over
would be able to say, as a matter of to the care, custody and control of private
common knowledge and observation, that respondents who exercised complete and
the consequences of professional exclusive control over her. At the time of
treatment were not as such as would submission, Erlinda was neurologically
sound and, except for a few minor
discomforts, was likewise physically fit in under the influence of anesthetics which
mind and body. However, during the rendered her unconscious.
administration of anesthesia and prior to
Considering that a sound and unaffected
the performance of cholecystectomy she
member of the body (the brain) is injured
suffered irreparable damage to her brain.
or destroyed while the patient is
Thus, without undergoing surgery, she
unconscious and under the immediate and
went out of the operating room already
exclusive control of the physicians, we hold
decerebrate and totally incapacitated.
that a practical administration of justice
Obviously, brain damage, which Erlinda
dictates the application of res ipsa loquitur.
sustained, is an injury which does not
Upon these facts and under these
normally occur in the process of a gall
circumstances the Court would be able to
bladder operation. In fact, this kind of
say, as a matter of common knowledge
situation does not in the absence of
and observation, if negligence attended
negligence of someone in the
the management and care of the patient.
administration of anesthesia and in the use
Moreover, the liability of the physicians
of endotracheal tube. Normally, a person
and the hospital in this case is not
being put under anesthesia is not rendered
predicated upon an alleged failure to
decerebrate as a consequence of
secure the desired results of an operation
administering such anesthesia if the proper
nor on an alleged lack of skill in the
procedure was followed. Furthermore, the
diagnosis or treatment as in fact no
instruments used in the administration of
operation or treatment was ever
anesthesia, including the endotracheal
performed on Erlinda. Thus, upon all these
tube, were all under the exclusive control
initial determination a case is made out for
of private respondents, who are the
the application of the doctrine of res ipsa
physicians-in-charge. Likewise, petitioner
loquitur.
Erlinda could not have been guilty of
contributory negligence because she was Nonetheless, in holding that res ipsa
loquitur is available to the present case we
are not saying that the doctrine is Court of Appeals rationalized that she was
applicable in any and all cases where candid enough to admit that she
injury occurs to a patient while under experienced some difficulty in the
45
anesthesia, or to any and all anesthesia endotracheal intubation   of the patient
cases. Each case must be viewed in its and thus, cannot be said to be covering
own light and scrutinized in order to be her negligence with falsehood. The
within the res ipsa loquitur coverage. appellate court likewise opined that private
respondents were able to show that the
Having in mind the applicability of the res
brain damage sustained by Erlinda was not
ipsa loquitur doctrine and the presumption
caused by the alleged faulty intubation but
of negligence allowed therein, the Court
was due to the allergic reaction of the
now comes to the issue of whether the
patient to the drug Thiopental Sodium
Court of Appeals erred in finding that
(Pentothal), a short-acting barbiturate, as
private respondents were not negligent in
testified on by their expert witness, Dr.
the care of Erlinda during the anesthesia
Jamora. On the other hand, the appellate
phase of the operation and, if in the
court rejected the testimony of Dean
affirmative, whether the alleged
Herminda Cruz offered in favor of
negligence was the proximate cause of
petitioners that the cause of the brain
Erlinda's comatose condition. Corollary
injury was traceable to the wrongful
thereto, we shall also determine if the
insertion of the tube since the latter, being
Court of Appeals erred in relying on the
a nurse, was allegedly not knowledgeable
testimonies of the witnesses for the private
in the process of intubation. In so holding,
respondents.
the appellate court returned a verdict in
In sustaining the position of private favor of respondents physicians and
respondents, the Court of Appeals relied on hospital and absolved them of any liability
the testimonies of Dra. Gutierrez, Dra. towards Erlinda and her family.
Calderon and Dr. Jamora. In giving weight
We disagree with the findings of the Court
to the testimony of Dra. Gutierrez, the
of Appeals. We hold that private
respondents were unable to disprove the ATTY. PAJARES:
presumption of negligence on their part in
Q: In particular, what did Dra. Perfecta
the care of Erlinda and their negligence
Gutierrez do, if any on the patient?
was the proximate cause of her piteous
condition. A: In particular, I could see that she was
intubating the patient.
In the instant case, the records are helpful
in furnishing not only the logical scientific Q: Do you know what happened to that
evidence of the pathogenesis of the injury intubation process administered by Dra.
but also in providing the Court the legal Gutierrez?
nexus upon which liability is based. As will
ATTY. ALCERA:
be shown hereinafter, private respondents'
own testimonies which are reflected in the She will be incompetent Your Honor.
transcript of stenographic notes are
COURT:
replete of signposts indicative of their
negligence in the care and management of Witness may answer if she knows.
Erlinda.
A: As have said, I was with the patient, I
With regard to Dra. Gutierrez, we find her was beside the stretcher holding the left
negligent in the care of Erlinda during the hand of the patient and all of a sudden
anesthesia phase. As borne by the records, heard some remarks coming from Dra.
respondent Dra. Gutierrez failed to Perfecta Gutierrez herself. She was saying
properly intubate the patient. This fact was "Ang hirap ma-intubate nito, mali yata ang
attested to by Prof. Herminda Cruz, Dean pagkakapasok. O lumalaki ang tiyan.
of the Capitol Medical Center School of
x x x           x x x          x x x
Nursing and petitioner's sister-in-law, who
was in the operating room right beside the ATTY. PAJARES:
patient when the tragic event occurred. Q: From whom did you hear those words
Witness Cruz testified to this effect: "lumalaki ang tiyan"?
A: From Dra. Perfecta Gutierrez. Q: What happened to the patient?
x x x           x x x          x x x A: When Dr. Calderon try (sic) to intubate
the patient, after a while the patient's
Q: After hearing the phrase "lumalaki ang
nailbed became bluish and I saw the
tiyan," what did you notice on the person
patient was placed in trendelenburg
of the patient?
position.
A: I notice (sic) some bluish discoloration
x x x           x x x          x x x
on the nailbeds of the left hand where I
was at. Q: Do you know the reason why the patient
was placed in that trendelenburg position?
Q: Where was Dr. Orlino Ho[s]aka then at
that particular time? A: As far as I know, when a patient is in
that position, there is a decrease of blood
A: I saw him approaching the patient
supply to the brain. 46
during that time.
x x x           x x x          x x x
Q: When he approached the patient, what
did he do, if any? The appellate court, however, disbelieved
Dean Cruz's testimony in the trial court by
A: He made an order to call on the
declaring that:
anesthesiologist in the person of Dr.
Calderon. A perusal of the standard nursing
curriculum in our country will show that
Q: Did Dr. Calderon, upon being called,
intubation is not taught as part of nursing
arrive inside the operating room?
procedures and techniques. Indeed, we
A: Yes sir. take judicial notice of the fact that nurses
do not, and cannot, intubate. Even on the
Q: What did [s]he do, if any?
assumption that she is fully capable of
A: [S]he tried to intubate the patient. determining whether or not a patient is
properly intubated, witness Herminda
Cruz, admittedly, did not peep into the surgeon, external appearances, and
throat of the patient. (TSN, July 25, 1991, manifest conditions which are observable
p. 13). More importantly, there is no by any one. 48 This is precisely allowed
evidence that she ever auscultated the under the doctrine of res ipsa
patient or that she conducted any type of loquitur where the testimony of expert
examination to check if the endotracheal witnesses is not required. It is the accepted
tube was in its proper place, and to rule that expert testimony is not necessary
determine the condition of the heart, for the proof of negligence in non-technical
lungs, and other organs. Thus, witness matters or those of which an ordinary
Cruz's categorical statements that person may be expected to have
appellant Dra. Gutierrez failed to intubate knowledge, or where the lack of skill or
the appellee Erlinda Ramos and that it was want of care is so obvious as to render
Dra. Calderon who succeeded in doing so expert testimony unnecessary. 49 We take
clearly suffer from lack of sufficient factual judicial notice of the fact that anesthesia
bases. 47 procedures have become so common, that
even an ordinary person can tell if it was
In other words, what the Court of Appeals
administered properly. As such, it would
is trying to impress is that being a nurse,
not be too difficult to tell if the tube was
and considered a layman in the process of
properly inserted. This kind of observation,
intubation, witness Cruz is not competent
we believe, does not require a medical
to testify on whether or not the intubation
degree to be acceptable.
was a success.
At any rate, without doubt, petitioner's
We do not agree with the above reasoning
witness, an experienced clinical nurse
of the appellate court. Although witness
whose long experience and scholarship led
Cruz is not an anesthesiologist, she can
to her appointment as Dean of the Capitol
very well testify upon matters on which
Medical Center School at Nursing, was fully
she is capable of observing such as, the
capable of determining whether or not the
statements and acts of the physician and
intubation was a success. She had
extensive clinical experience starting as a DRA. GUTIERREZ:
staff nurse in Chicago, Illinois; staff nurse
A: Yes sir.
and clinical instructor in a teaching
hospital, the FEU-NRMF; Dean of the Q: Did you pull away the tube
Laguna College of Nursing in San Pablo immediately?
City; and then Dean of the Capitol Medical
A: You do not pull the . . .
Center School of Nursing. 50 Reviewing
witness Cruz' statements, we find that the Q: Did you or did you not?
same were delivered in a straightforward
A: I did not pull the tube.
manner, with the kind of detail, clarity,
consistency and spontaneity which would Q: When you said "mahirap yata ito," what
have been difficult to fabricate. With her were you referring to?
clinical background as a nurse, the Court is
A: "Mahirap yata itong i-intubate," that was
satisfied that she was able to demonstrate
the patient.
through her testimony what truly
transpired on that fateful day. Q: So, you found some difficulty in
inserting the tube?
Most of all, her testimony was affirmed by
no less than respondent Dra. Gutierrez A: Yes, because of (sic) my first attempt, I
who admitted that she experienced did not see right away. 51
difficulty in inserting the tube into Erlinda's Curiously in the case at bar, respondent
trachea, to wit: Dra. Gutierrez made the haphazard
ATTY. LIGSAY: defense that she encountered hardship in
the insertion of the tube in the trachea of
Q: In this particular case, Doctora, while
Erlinda because it was positioned more
you were intubating at your first attempt
anteriorly (slightly deviated from the
(sic), you did not immediately see the
normal anatomy of a person) 52 making it
trachea?
harder to locate and, since Erlinda is obese
and has a short neck and protruding teeth, toward the central nervous system,
it made intubation even more difficult. cardiovascular system, lungs and upper
airway. 55 A thorough analysis of the
The argument does not convince us. If this
patient's airway normally involves
was indeed observed, private respondents
investigating the following: cervical spine
adduced no evidence demonstrating that
mobility, temporomandibular mobility,
they proceeded to make a thorough
prominent central incisors, diseased or
assessment of Erlinda's airway, prior to the
artificial teeth, ability to visualize uvula
induction of anesthesia, even if this would
and the thyromental distance. 56 Thus,
mean postponing the procedure. From
physical characteristics of the patient's
their testimonies, it appears that the
upper airway that could make tracheal
observation was made only as an
intubation difficult should be
afterthought, as a means of defense. 57
studied.   Where the need arises, as when
The pre-operative evaluation of a patient initial assessment indicates possible
prior to the administration of anesthesia is problems (such as the alleged short neck
universally observed to lessen the and protruding teeth of Erlinda) a thorough
possibility of anesthetic accidents. Pre- examination of the patient's airway would
operative evaluation and preparation for go a long way towards decreasing patient
anesthesia begins when the morbidity and mortality.
anesthesiologist reviews the patient's
In the case at bar, respondent Dra.
medical records and visits with the patient,
Gutierrez admitted that she saw Erlinda for
traditionally, the day before elective
the first time on the day of the operation
surgery. 53 It includes taking the patient's
itself, on 17 June 1985. Before this date, no
medical history, review of current drug
prior consultations with, or pre-operative
therapy, physical examination and
54 evaluation of Erlinda was done by her.
interpretation of laboratory data.   The
Until the day of the operation, respondent
physical examination performed by the
Dra. Gutierrez was unaware of the
anesthesiologist is directed primarily
physiological make-up and needs of
Erlinda. She was likewise not properly Q: Would you agree, Doctor, that it is good
informed of the possible difficulties she medical practice to see the patient a day
would face during the administration of before so you can introduce yourself to
anesthesia to Erlinda. Respondent Dra. establish good doctor-patient relationship
Gutierrez' act of seeing her patient for the and gain the trust and confidence of the
first time only an hour before the patient?
scheduled operative procedure was,
DRA. GUTIERREZ:
therefore, an act of exceptional negligence
and professional irresponsibility. The A: As I said in my previous statement, it
measures cautioning prudence and depends on the operative procedure of the
vigilance in dealing with human lives lie at anesthesiologist and in my case, with
the core of the physician's centuries-old elective cases and normal cardio-
Hippocratic Oath. Her failure to follow this pulmonary clearance like that, I usually
medical procedure is, therefore, a don't do it except on emergency and on
clear indicia of her negligence. cases that have an abnormalities (sic). 58
Respondent Dra. Gutierrez, however, However, the exact opposite is true. In an
attempts to gloss over this omission by emergency procedure, there is hardly
playing around with the trial court's enough time available for the fastidious
ignorance of clinical procedure, hoping demands of pre-operative procedure so
that she could get away with it. that an anesthesiologist is able to see the
Respondent Dra. Gutierrez tried to muddle patient only a few minutes before surgery,
the difference between an elective surgery if at all. Elective procedures, on the other
and an emergency surgery just so her hand, are operative procedures that can
failure to perform the required pre- wait for days, weeks or even months.
operative evaluation would escape Hence, in these cases, the anesthesiologist
unnoticed. In her testimony she asserted: possesses the luxury of time to be at the
patient's beside to do a proper interview
ATTY. LIGSAY:
and clinical evaluation. There is ample
time to explain the method of anesthesia, Private respondents repeatedly hammered
the drugs to be used, and their possible the view that the cerebral anoxia which led
hazards for purposes of informed consent. to Erlinda's coma was due to
59
Usually, the pre-operative assessment is bronchospasm   mediated by her allergic
conducted at least one day before the response to the drug, Thiopental Sodium,
intended surgery, when the patient is introduced into her system. Towards this
relaxed and cooperative. end, they presented Dr. Jamora, a Fellow of
the Philippine College of Physicians and
Erlinda's case was elective and this was
Diplomate of the Philippine Specialty Board
known to respondent Dra. Gutierrez. Thus,
of Internal Medicine, who advanced private
she had all the time to make a thorough
respondents' theory that the oxygen
evaluation of Erlinda's case prior to the
deprivation which led to anoxic
operation and prepare her for anesthesia. 60
encephalopathy,   was due to an
However, she never saw the patient at the
unpredictable drug reaction to the short-
bedside. She herself admitted that she had
acting barbiturate. We find the theory of
seen petitioner only in the operating room,
private respondents unacceptable.
and only on the actual date of the
cholecystectomy. She negligently failed to First of all, Dr. Jamora cannot be
take advantage of this important considered an authority in the field of
opportunity. As such, her attempt to anesthesiology simply because he is not an
exculpate herself must fail. anesthesiologist. Since Dr. Jamora is a
pulmonologist, he could not have been
Having established that respondent Dra.
capable of properly enlightening the court
Gutierrez failed to perform pre-operative
about anesthesia practice and procedure
evaluation of the patient which, in turn,
and their complications. Dr. Jamora is
resulted to a wrongful intubation, we now
likewise not an allergologist and could not
determine if the faulty intubation is truly
therefore properly advance expert opinion
the proximate cause of Erlinda's comatose
on allergic-mediated processes. Moreover,
condition.
he is not a pharmacologist and, as such,
could not have been capable, as an expert Q: But not in particular when you practice
would, of explaining to the court the pulmonology?
pharmacologic and toxic effects of the
A: No.
supposed culprit, Thiopental Sodium
(Pentothal). Q: In other words, your knowledge about
pentothal is based only on what you have
The inappropriateness and absurdity of
read from books and not by your own
accepting Dr. Jamora's testimony as an
personal application of the medicine
expert witness in the anesthetic practice of
pentothal?
Pentothal administration is further
supported by his own admission that he A: Based on my personal experience also
formulated his opinions on the drug not on pentothal.
from the practical experience gained by a
Q: How many times have you used
specialist or expert in the administration
pentothal?
and use of Sodium Pentothal on patients,
but only from reading certain references, A: They used it on me. I went into
to wit: bronchospasm during my appendectomy.
ATTY. LIGSAY: Q: And because they have used it on you
and on account of your own personal
Q: In your line of expertise on
experience you feel that you can testify on
pulmonology, did you have any occasion to
pentothal here with medical authority?
use pentothal as a method of
management? A: No. That is why I used references to
support my claims. 61
DR. JAMORA:
An anesthetic accident caused by a rare
A: We do it in conjunction with the
drug-induced bronchospasm properly falls
anesthesiologist when they have to
within the fields of anesthesia, internal
intubate our patient.
medicine-allergy, and clinical
pharmacology. The resulting anoxic of the subject matter about which he or
encephalopathy belongs to the field of she is to testify, either by the study of
neurology. While admittedly, many recognized authorities on the subject or by
bronchospastic-mediated pulmonary practical experience. 63 Clearly, Dr. Jamora
diseases are within the expertise of does not qualify as an expert witness
pulmonary medicine, Dr. Jamora's field, the based on the above standard since he
anesthetic drug-induced, allergic mediated lacks the necessary knowledge, skill, and
bronchospasm alleged in this case is within training in the field of anesthesiology.
the disciplines of anesthesiology, Oddly, apart from submitting testimony
allergology and pharmacology. On the from a specialist in the wrong field, private
basis of the foregoing transcript, in which respondents' intentionally avoided
the pulmonologist himself admitted that he providing testimony by competent and
could not testify about the drug with independent experts in the proper areas.
medical authority, it is clear that the
Moreover, private respondents' theory,
appellate court erred in giving weight to
that Thiopental Sodium may have
Dr. Jamora's testimony as an expert in the
produced Erlinda's coma by triggering an
administration of Thiopental Sodium.
allergic mediated response, has no support
The provision in the rules of in evidence. No evidence of stridor, skin
62
evidence   regarding expert witnesses reactions, or wheezing — some of the
states: more common accompanying signs of an
allergic reaction — appears on record. No
Sec. 49. Opinion of expert witness. — The
laboratory data were ever presented to the
opinion of a witness on a matter requiring
court.
special knowledge, skill, experience or
training which he is shown to possess, may In any case, private respondents
be received in evidence. themselves admit that Thiopental induced,
allergic-mediated bronchospasm happens
Generally, to qualify as an expert witness,
only very rarely. If courts were to accept
one must have acquired special knowledge
private respondents' hypothesis without that the injury or damage was either a
supporting medical proof, and against the direct result or a reasonably probable
weight of available evidence, then every consequence of the act or omission. 65 It is
anesthetic accident would be an act of the dominant, moving or producing cause.
God. Evidently, the Thiopental-allergy
Applying the above definition in relation to
theory vigorously asserted by private
the evidence at hand, faulty intubation is
respondents was a mere afterthought.
undeniably the proximate cause which
Such an explanation was advanced in
triggered the chain of events leading to
order to advanced in order to absolve
Erlinda's brain damage and, ultimately, her
them of any and all responsibility for the
comatosed condition.
patient's condition.
Private respondents themselves admitted
In view of the evidence at hand, we are
in their testimony that the first intubation
inclined to believe petitioners' stand that it
was a failure. This fact was likewise
was the faulty intubation which was the
observed by witness Cruz when she heard
proximate cause of Erlinda's comatose
respondent Dra. Gutierrez remarked, "Ang
condition.
hirap ma-intubate nito, mali yata ang
Proximate cause has been defined as that pagkakapasok. O lumalaki ang tiyan."
which, in natural and continuous sequence, Thereafter, witness Cruz noticed
unbroken by any efficient intervening abdominal distention on the body of
cause, produces injury, and without which Erlinda. The development of abdominal
the result would not have occurred. 64 An distention, together with respiratory
injury or damage is proximately caused by embarrassment indicates that the
an act or a failure to act, whenever it endotracheal tube entered the esophagus
appears from the evidence in the case, instead of the respiratory tree. In other
that the act or omission played a words, instead of the intended
substantial part in bringing about or endotracheal intubation what actually took
actually causing the injury or damage; and place was an esophageal intubation.
During intubation, such distention endotracheal tube finally found its way into
indicates that air has entered the the proper orifice of the trachea, the same
gastrointestinal tract through the gave no guarantee of oxygen delivery, the
esophagus instead of the lungs through hallmark of a successful intubation. In fact,
the trachea. Entry into the esophagus cyanosis was again observed immediately
would certainly cause some delay in after the second intubation. Proceeding
oxygen delivery into the lungs as the tube from this event (cyanosis), it could not be
which carries oxygen is in the wrong place. claimed, as private respondents insist, that
That abdominal distention had been the second intubation was accomplished.
observed during the first intubation Even granting that the tube was
suggests that the length of time utilized in successfully inserted during the second
inserting the endotracheal tube (up to the attempt, it was obviously too late. As aptly
time the tube was withdrawn for the explained by the trial court, Erlinda already
second attempt) was fairly significant. Due suffered brain damage as a result of the
to the delay in the delivery of oxygen in inadequate oxygenation of her brain for
her lungs Erlinda showed signs of about four to five minutes. 68
cyanosis. 66 As stated in the testimony of
The above conclusion is not without basis.
Dr. Hosaka, the lack of oxygen became
Scientific studies point out that intubation
apparent only after he noticed that the
problems are responsible for one-third
nailbeds of Erlinda were already
67 (1/3) of deaths and serious injuries
blue.   However, private respondents
associated with
contend that a second intubation was 69
anesthesia.   Nevertheless, ninety-eight
executed on Erlinda and this one was
percent (98%) or the vast majority of
successfully done. We do not think so. No
difficult intubations may be anticipated by
evidence exists on record, beyond private
performing a thorough evaluation of the
respondents' bare claims, which supports
patient's airway prior to the
the contention that the second intubation 70
operation.   As stated beforehand,
was successful. Assuming that the
respondent Dra. Gutierrez failed to observe
the proper pre-operative protocol which manner. Respondent Dr. Hosaka's
could have prevented this unfortunate negligence can be found in his failure to
incident. Had appropriate diligence and exercise the proper authority (as the
reasonable care been used in the pre- "captain" of the operative team) in not
operative evaluation, respondent physician determining if his anesthesiologist
could have been much more prepared to observed proper anesthesia protocols. In
meet the contingency brought about by fact, no evidence on record exists to show
the perceived anatomic variations in the that respondent Dr. Hosaka verified if
patient's neck and oral area, defects which respondent Dra. Gutierrez properly
would have been easily overcome by a intubated the patient. Furthermore, it does
prior knowledge of those variations not escape us that respondent Dr. Hosaka
together with a change in technique. 71 In had scheduled another procedure in a
other words, an experienced different hospital at the same time as
anesthesiologist, adequately alerted by a Erlinda's cholecystectomy, and was in fact
thorough pre-operative evaluation, would over three hours late for the latter's
have had little difficulty going around the operation. Because of this, he had little or
short neck and protruding teeth. 72 Having no time to confer with his anesthesiologist
failed to observe common medical regarding the anesthesia delivery. This
standards in pre-operative management indicates that he was remiss in his
and intubation, respondent Dra. Gutierrez' professional duties towards his patient.
negligence resulted in cerebral anoxia and Thus, he shares equal responsibility for the
eventual coma of Erlinda. events which resulted in Erlinda's
condition.
We now determine the responsibility of
respondent Dr. Orlino Hosaka as the head We now discuss the responsibility of the
of the surgical team. As the so-called hospital in this particular incident. The
"captain of the ship," 73 it is the surgeon's unique practice (among private hospitals)
responsibility to see to it that those under of filling up specialist staff with attending
him perform their task in the proper and visiting "consultants," 74 who are
allegedly not hospital employees, presents moderate grand rounds and patient audits
problems in apportioning responsibility for and perform other tasks and
negligence in medical malpractice cases. responsibilities, for the privilege of being
However, the difficulty is only more able to maintain a clinic in the hospital,
apparent than real. and/or for the privilege of admitting
patients into the hospital. In addition to
In the first place, hospitals exercise
these, the physician's performance as a
significant control in the hiring and firing of
specialist is generally evaluated by a peer
consultants and in the conduct of their
review committee on the basis of mortality
work within the hospital premises. Doctors
and morbidity statistics, and feedback from
who apply for "consultant" slots, visiting or
patients, nurses, interns and residents. A
attending, are required to submit proof of
consultant remiss in his duties, or a
completion of residency, their educational
consultant who regularly falls short of the
qualifications; generally, evidence of
minimum standards acceptable to the
accreditation by the appropriate board
hospital or its peer review committee, is
(diplomate), evidence of fellowship in most
normally politely terminated.
cases, and references. These requirements
are carefully scrutinized by members of In other words, private hospitals, hire, fire
the hospital administration or by a review and exercise real control over their
committee set up by the hospital who attending and visiting "consultant" staff.
either accept or reject the While "consultants" are not, technically
75
application.   This is particularly true with employees, a point which respondent
respondent hospital. hospital asserts in denying all
responsibility for the patient's condition,
After a physician is accepted, either as a
the control exercised, the hiring, and the
visiting or attending consultant, he is
right to terminate consultants all fulfill the
normally required to attend clinico-
important hallmarks of an employer-
pathological conferences, conduct bedside
employee relationship, with the exception
rounds for clerks, interns and residents,
of the payment of wages. In assessing
whether such a relationship in fact exists, who should prove that they observed the
the control test is determining. diligence of a good father of a family to
Accordingly, on the basis of the foregoing, prevent damage.
we rule that for the purpose of allocating
In the instant case, respondent hospital,
responsibility in medical negligence cases,
apart from a general denial of its
an employer-employee relationship in
responsibility over respondent physicians,
effect exists between hospitals and their
failed to adduce evidence showing that it
attending and visiting physicians. This
exercised the diligence of a good father of
being the case, the question now arises as
a family in the hiring and supervision of
to whether or not respondent hospital is
the latter. It failed to adduce evidence with
solidarily liable with respondent doctors for
regard to the degree of supervision which
petitioner's condition. 76
it exercised over its physicians. In
The basis for holding an employer neglecting to offer such proof, or proof of a
solidarily responsible for the negligence of similar nature, respondent hospital thereby
its employee is found in Article 2180 of the failed to discharge its burden under the
Civil Code which considers a person last paragraph of Article 2180. Having
accountable not only for his own acts but failed to do this, respondent hospital is
also for those of others based on the consequently solidarily responsible with its
former's responsibility under a relationship physicians for Erlinda's condition.
of patria potestas. 77 Such responsibility
Based on the foregoing, we hold that the
ceases when the persons or entity
Court of Appeals erred in accepting and
concerned prove that they have observed
relying on the testimonies of the witnesses
the diligence of a good father of the family
for the private respondents. Indeed, as
to prevent damage. 78 In other words, while
shown by the above discussions, private
the burden of proving negligence rests on
respondents were unable to rebut the
the plaintiffs, once negligence is shown,
presumption of negligence. Upon these
the burden shifts to the respondents
disquisitions we hold that private
(parent, guardian, teacher or employer)
respondents are solidarily liable for chronically ill for the purpose of providing a
damages under Article 2176 79 of the Civil proper milieu adequate to meet minimum
Code. standards of care. In the instant case for
instance, Erlinda has to be constantly
We now come to the amount of damages
turned from side to side to prevent
due petitioners. The trial court awarded a
bedsores and hypostatic pneumonia.
total of P632,000.00 pesos (should be
Feeding is done by nasogastric tube. Food
P616,000.00) in compensatory damages to
preparation should be normally made by a
the plaintiff, "subject to its being updated"
dietitian to provide her with the correct
covering the period from 15 November
daily caloric requirements and vitamin
1985 up to 15 April 1992, based on
supplements. Furthermore, she has to be
monthly expenses for the care of the
seen on a regular basis by a physical
patient estimated at P8,000.00.
therapist to avoid muscle atrophy, and by
At current levels, the P8000/monthly a pulmonary therapist to prevent the
amount established by the trial court at accumulation of secretions which can lead
the time of its decision would be grossly to respiratory complications.
inadequate to cover the actual costs of
Given these considerations, the amount of
home-based care for a comatose
actual damages recoverable in suits arising
individual. The calculated amount was not
from negligence should at least reflect the
even arrived at by looking at the actual
correct minimum cost of proper care, not
cost of proper hospice care for the patient.
the cost of the care the family is usually
What it reflected were the actual expenses
compelled to undertake at home to avoid
incurred and proved by the petitioners
bankruptcy. However, the provisions of the
after they were forced to bring home the
Civil Code on actual or compensatory
patient to avoid mounting hospital bills.
damages present us with some difficulties.
And yet ideally, a comatose patient should
Well-settled is the rule that actual
remain in a hospital or be transferred to a
damages which may be claimed by the
hospice specializing in the care of the
plaintiff are those suffered by him as he which would meet pecuniary loss certain to
has duly proved. The Civil Code provides: be suffered but which could not, from the
nature of the case, be made with
Art. 2199. — Except as provided by law or
certainty. 80 In other words, temperate
by stipulation, one is entitled to an
damages can and should be awarded on
adequate compensation only for such
top of actual or compensatory damages in
pecuniary loss suffered by him as he has
instances where the injury is chronic and
duly proved. Such compensation is
continuing. And because of the unique
referred to as actual or compensatory
nature of such cases, no incompatibility
damages.
arises when both actual and temperate
Our rules on actual or compensatory damages are provided for. The reason is
damages generally assume that at the that these damages cover two distinct
time of litigation, the injury suffered as a phases.
consequence of an act of negligence has
As it would not be equitable — and
been completed and that the cost can be
certainly not in the best interests of the
liquidated. However, these provisions
administration of justice — for the victim in
neglect to take into account those
such cases to constantly come before the
situations, as in this case, where the
courts and invoke their aid in seeking
resulting injury might be continuing and
adjustments to the compensatory
possible future complications directly
damages previously awarded — temperate
arising from the injury, while certain to
damages are appropriate. The amount
occur, are difficult to predict.
given as temperate damages, though to a
In these cases, the amount of damages certain extent speculative, should take into
which should be awarded, if they are to account the cost of proper care.
adequately and correctly respond to the
In the instant case, petitioners were able to
injury caused, should be one which
provide only home-based nursing care for
compensates for pecuniary loss incurred
a comatose patient who has remained in
and proved, up to the time of trial; and one
that condition for over a decade. Having Describing the nature of the injury, the
premised our award for compensatory Court therein stated:
damages on the amount provided by
As a result of the accident, Ma. Lourdes
petitioners at the onset of litigation, it
Valenzuela underwent a traumatic
would be now much more in step with the
amputation of her left lower extremity at
interests of justice if the value awarded for
the distal left thigh just above the knee.
temperate damages would allow
Because of this, Valenzuela will forever be
petitioners to provide optimal care for their
deprived of the full ambulatory functions of
loved one in a facility which generally
her left extremity, even with the use of
specializes in such care. They should not
state of the art prosthetic technology. Well
be compelled by dire circumstances to
beyond the period of hospitalization (which
provide substandard care at home without
was paid for by Li), she will be required to
the aid of professionals, for anything less
undergo adjustments in her prosthetic
would be grossly inadequate. Under the
devise due to the shrinkage of the stump
circumstances, an award of P1,500,000.00
from the process of healing.
in temperate damages would therefore be
reasonable. 81 These adjustments entail costs, prosthetic
replacements and months of physical and
In Valenzuela vs. Court of Appeals, 82 this
occupational rehabilitation and therapy.
Court was confronted with a situation
During the lifetime, the prosthetic devise
where the injury suffered by the plaintiff
will have to be replaced and readjusted to
would have led to expenses which were
changes in the size of her lower limb
difficult to estimate because while they
effected by the biological changes of
would have been a direct result of the
middle-age, menopause and aging.
injury (amputation), and were certain to be
Assuming she reaches menopause, for
incurred by the plaintiff, they were likely to
example, the prosthetic will have to be
arise only in the future. We awarded
adjusted to respond to the changes in bone
P1,000,000.00 in moral damages in that
resulting from a precipitate decrease in
case.
calcium levels observed in the bones of all Petitioner Erlinda Ramos was in her mid-
post-menopausal women. In other words, forties when the incident occurred. She has
the damage done to her would not only be been in a comatose state for over fourteen
permanent and lasting, it would also be years now. The burden of care has so far
permanently changing and adjusting to the been heroically shouldered by her husband
physiologic changes which her body would and children, who, in the intervening years
normally undergo through the years. The have been deprived of the love of a wife
replacements, changes, and adjustments and a mother.
will require corresponding adjustive
Meanwhile, the actual physical, emotional
physical and occupational therapy. All of
and financial cost of the care of petitioner
these adjustments, it has been
would be virtually impossible to quantify.
documented, are painful.
Even the temperate damages herein
x x x           x x x          x x x awarded would be inadequate if
petitioner's condition remains unchanged
A prosthetic devise, however
for the next ten years.
technologically advanced, will only allow a
reasonable amount of functional We recognized, in Valenzuela that a
restoration of the motor functions of the discussion of the victim's actual injury
lower limb. The sensory functions are would not even scratch the surface of the
forever lost. The resultant anxiety, resulting moral damage because it would
sleeplessness, psychological injury, mental be highly speculative to estimate the
and physical pain are inestimable. 83 amount of emotional and moral pain,
psychological damage and injury suffered
The injury suffered by Erlinda as a
by the victim or those actually affected by
consequence of private respondents'
the victim's condition. 84 The husband and
negligence is certainly much more serious
the children, all petitioners in this case, will
than the amputation in the Valenzuela
have to live with the day to day
case.
uncertainty of the patient's illness,
knowing any hope of recovery is close to automatically gives the injured a right to
nil. They have fashioned their daily lives reparation for the damage caused.
around the nursing care of petitioner,
Established medical procedures and
altering their long term goals to take into
practices, though in constant flux are
account their life with a comatose patient.
devised for the purpose of preventing
They, not the respondents, are charged
complications. A physician's experience
with the moral responsibility of the care of
with his patients would sometimes tempt
the victim. The family's moral injury and
him to deviate from established
suffering in this case is clearly a real one.
community practices, and he may end a
For the foregoing reasons, an award of
distinguished career using unorthodox
P2,000,000.00 in moral damages would be
methods without incident. However, when
appropriate.
failure to follow established procedure
Finally, by way of example, exemplary results in the evil precisely sought to be
damages in the amount of P100,000.00 are averted by observance of the procedure
hereby awarded. Considering the length and a nexus is made between the
and nature of the instant suit we are of the deviation and the injury or damage, the
opinion that attorney's fees valued at physician would necessarily be called to
P100,000.00 are likewise proper. account for it. In the case at bar, the
failure to observe pre-operative
Our courts face unique difficulty in
assessment protocol which would have
adjudicating medical negligence cases
influenced the intubation in a salutary way
because physicians are not insurers of life
was fatal to private respondents' case.
and, they rarely set out to intentionally
cause injury or death to their patients. WHEREFORE, the decision and resolution
However, intent is immaterial in of the appellate court appealed from are
negligence cases because where hereby modified so as to award in favor of
negligence exists and is proven, the same petitioners, and solidarily against private
respondents the following: 1)
P1,352,000.00 as actual damages
computed as of the date of promulgation
of this decision plus a monthly payment of
P8,000.00 up to the time that petitioner
Erlinda Ramos expires or miraculously
survives; 2) P2,000,000.00 as moral
damages, 3) P1,500,000.00 as temperate
damages; 4) P100,000.00 each as
exemplary damages and attorney's fees;
and, 5) the costs of the suit.
SO ORDERED.
G.R. No. 165279               June 7, 2011 cancer of the bone which usually afflicts
teenage children. Following this diagnosis
DR. RUBI LI, Petitioner,
and as primary intervention, Angelica’s
vs.
right leg was amputated by Dr. Jaime
SPOUSES REYNALDO and LINA
Tamayo in order to remove the tumor. As
SOLIMAN, as parents/heirs of
adjuvant treatment to eliminate any
deceased Angelica
remaining cancer cells, and hence
Soliman, Respondents.
minimize the chances of recurrence and
DECISION prevent the disease from spreading to
other parts of the patient’s body
VILLARAMA, JR., J.:
(metastasis), chemotherapy was
Challenged in this petition for review on suggested by Dr. Tamayo. Dr. Tamayo
certiorari is the Decision1 dated June 15, referred Angelica to another doctor at
2004 as well as the Resolution2 dated SLMC, herein petitioner Dr. Rubi Li, a
September 1, 2004 of the Court of Appeals medical oncologist.
(CA) in CA-G.R. CV No. 58013 which
On August 18, 1993, Angelica was
modified the Decision3 dated September 5,
admitted to SLMC. However, she died on
1997 of the Regional Trial Court of Legazpi
September 1, 1993, just eleven (11) days
City, Branch 8 in Civil Case No. 8904.
after the (intravenous) administration of
The factual antecedents: the first cycle of the chemotherapy
regimen. Because SLMC refused to release
On July 7, 1993, respondents’ 11-year old
a death certificate without full payment of
daughter, Angelica Soliman, underwent a
their hospital bill, respondents brought the
biopsy of the mass located in her lower
cadaver of Angelica to the Philippine
extremity at the St. Luke’s Medical Center
National Police (PNP) Crime Laboratory at
(SLMC). Results showed that Angelica was
Camp Crame for post-mortem
suffering from osteosarcoma, osteoblastic
examination. The Medico-Legal Report
type,4 a high-grade (highly malignant)
issued by said institution indicated the
cause of death as "Hypovolemic shock Angelica’s untimely demise. Further, it was
secondary to multiple organ hemorrhages specifically averred that petitioner assured
and Disseminated Intravascular the respondents that Angelica would
5
Coagulation." recover in view of 95% chance of healing
with chemotherapy ("Magiging normal na
On the other hand, the Certificate of
ang anak nyo basta ma-chemo. 95% ang
Death6 issued by SLMC stated the cause of
healing") and when asked regarding the
death as follows:
side effects, petitioner mentioned only
Immediate cause : a. Osteosarcoma, slight vomiting, hair loss and weakness
Status Post AKA ("Magsusuka ng kaunti. Malulugas ang
buhok. Manghihina"). Respondents thus
Antecedent cause : b. (above knee
claimed that they would not have given
amputation)
their consent to chemotherapy had
Underlying cause : c. Status Post petitioner not falsely assured them of its
Chemotherapy side effects.
On February 21, 1994, respondents filed a In her answer,8 petitioner denied having
damage suit7 against petitioner, Dr. Leo been negligent in administering the
Marbella, Mr. Jose Ledesma, a certain Dr. chemotherapy drugs to Angelica and
Arriete and SLMC. Respondents charged asserted that she had fully explained to
them with negligence and disregard of respondents how the chemotherapy will
Angelica’s safety, health and welfare by affect not only the cancer cells but also the
their careless administration of the patient’s normal body parts, including the
chemotherapy drugs, their failure to lowering of white and red blood cells and
observe the essential precautions in platelets. She claimed that what happened
detecting early the symptoms of fatal to Angelica can be attributed to malignant
blood platelet decrease and stopping early tumor cells possibly left behind after
on the chemotherapy, which bleeding led surgery. Few as they may be, these have
to hypovolemic shock that caused the capacity to compete for nutrients such
that the body becomes so weak year from his jewelry and watch repairing
structurally (cachexia) and functionally in business.9 Petitioner, however, assured
the form of lower resistance of the body to them not to worry about her professional
combat infection. Such infection becomes fee and told them to just save up for the
uncontrollable and triggers a chain of medicines to be used.
events (sepsis or septicemia) that may
Petitioner claimed that she explained to
lead to bleeding in the form of
respondents that even when a tumor is
Disseminated Intravascular Coagulation
removed, there are still small lesions
(DIC), as what the autopsy report showed
undetectable to the naked eye, and that
in the case of Angelica.
adjuvant chemotherapy is needed to clean
Since the medical records of Angelica were out the small lesions in order to lessen the
not produced in court, the trial and chance of the cancer to recur. She did not
appellate courts had to rely on testimonial give the respondents any assurance that
evidence, principally the declarations of chemotherapy will cure Angelica’s cancer.
petitioner and respondents themselves. During these consultations with
The following chronology of events was respondents, she explained the following
gathered: side effects of chemotherapy treatment to
respondents: (1) falling hair; (2) nausea
On July 23, 1993, petitioner saw the
and vomiting; (3) loss of appetite; (4) low
respondents at the hospital after
count of white blood cells [WBC], red blood
Angelica’s surgery and discussed with
cells [RBC] and platelets; (5) possible
them Angelica’s condition. Petitioner told
sterility due to the effects on Angelica’s
respondents that Angelica should be given
ovary; (6) damage to the heart and
two to three weeks to recover from the
kidneys; and (7) darkening of the skin
operation before starting chemotherapy.
especially when exposed to sunlight. She
Respondents were apprehensive due to
actually talked with respondents four
financial constraints as Reynaldo earns
times, once at the hospital after the
only from ₱70,000.00 to ₱150,000.00 a
surgery, twice at her clinic and the fourth
time when Angelica’s mother called her supposedly assisted by her trainees Dr.
through long distance.10 This was disputed Leo Marbella18 and Dr. Grace Arriete.19 In
by respondents who countered that his testimony, Dr. Marbella denied having
petitioner gave them assurance that there any participation in administering the said
is 95% chance of healing for Angelica if she chemotherapy drugs.20
undergoes chemotherapy and that the only
On the second day of chemotherapy,
side effects were nausea, vomiting and
August 20, respondents noticed reddish
hair loss.11 Those were the only side-effects
discoloration on Angelica’s face.21 They
of chemotherapy treatment mentioned by
asked petitioner about it, but she merely
petitioner.12
quipped, "Wala yan. Epekto ng
22
On July 27, 1993, SLMC discharged gamot."  Petitioner recalled noticing the
Angelica, with instruction from petitioner skin rashes on the nose and cheek area of
that she be readmitted after two or three Angelica. At that moment, she entertained
weeks for the chemotherapy. the possibility that Angelica also had
systemic lupus and consulted Dr. Victoria
On August 18, 1993, respondents brought
Abesamis on the matter.23
Angelica to SLMC for chemotherapy,
bringing with them the results of the On the third day of chemotherapy, August
laboratory tests requested by petitioner: 21, Angelica had difficulty breathing and
Angelica’s chest x-ray, ultrasound of the was thus provided with oxygen inhalation
liver, creatinine and complete liver apparatus. This time, the reddish
function tests.13 Petitioner proceeded with discoloration on Angelica’s face had
the chemotherapy by first administering extended to her neck, but petitioner
hydration fluids to Angelica.14 dismissed it again as merely the effect of
medicines.24 Petitioner testified that she
The following day, August 19, petitioner
did not see any discoloration on Angelica’s
began administering three chemotherapy
face, nor did she notice any difficulty in the
drugs – Cisplatin,15 Doxorubicin16 and
child’s breathing. She claimed that
Cosmegen17 – intravenously. Petitioner was
Angelica merely complained of nausea and The following day, August 23, petitioner
was given ice chips.251avvphi1 yielded to respondents’ request to take
Angelica home. But prior to discharging
On August 22, 1993, at around ten o’clock
Angelica, petitioner requested for a repeat
in the morning, upon seeing that their child
serum calcium determination and
could not anymore bear the pain,
explained to respondents that the
respondents pleaded with petitioner to
chemotherapy will be temporarily stopped
stop the chemotherapy. Petitioner
while she observes Angelica’s muscle
supposedly replied: "Dapat 15 Cosmegen
twitching and serum calcium level. Take-
pa iyan. Okay, let’s observe. If pwede na,
home medicines were also prescribed for
bigyan uli ng chemo." At this point,
Angelica, with instructions to respondents
respondents asked petitioner’s permission
that the serum calcium test will have to be
to bring their child home. Later in the
repeated after seven days. Petitioner told
evening, Angelica passed black stool and
respondents that she will see Angelica
reddish urine.26 Petitioner countered that
again after two weeks, but respondents
there was no record of blackening of stools
can see her anytime if any immediate
but only an episode of loose bowel
problem arises.28
movement (LBM). Petitioner also testified
that what Angelica complained of was However, Angelica remained in
carpo-pedal spasm, not convulsion or confinement because while still in the
epileptic attack, as respondents call it premises of SLMC, her "convulsions"
(petitioner described it in the vernacular as returned and she also had LBM. Angelica
"naninigas ang kamay at paa"). She then was given oxygen and administration of
requested for a serum calcium calcium continued.29
determination and stopped the
The next day, August 24, respondents
chemotherapy. When Angelica was given
claimed that Angelica still suffered from
calcium gluconate, the spasm and
convulsions. They also noticed that she
numbness subsided.27
had a fever and had difficulty
breathing.30 Petitioner insisted it was lesser in amount and in frequency.
carpo-pedal spasm, not convulsions. She Petitioner also denied that there were
verified that at around 4:50 that afternoon, gadgets attached to Angelica at that
Angelica developed difficulty in breathing time.34
and had fever. She then requested for an
On August 29, Angelica developed ulcers in
electrocardiogram analysis, and infused
her mouth, which petitioner said were
calcium gluconate on the patient at a "stat
blood clots that should not be removed.
dose." She further ordered that Angelica
Respondents claimed that Angelica passed
be given Bactrim,31 a synthetic
about half a liter of blood through her anus
antibacterial combination drug,32 to
at around seven o’clock that evening,
combat any infection on the child’s body. 33
which petitioner likewise denied.
By August 26, Angelica was bleeding
On August 30, Angelica continued
through the mouth. Respondents also saw
bleeding. She was restless as endotracheal
blood on her anus and urine. When Lina
and nasogastric tubes were inserted into
asked petitioner what was happening to
her weakened body. An aspiration of the
her daughter, petitioner replied, "Bagsak
nasogastric tube inserted to Angelica also
ang platelets ng anak mo." Four units of
revealed a bloody content. Angelica was
platelet concentrates were then transfused
given more platelet concentrate and fresh
to Angelica. Petitioner prescribed
whole blood, which petitioner claimed
Solucortef. Considering that Angelica’s
improved her condition. Petitioner told
fever was high and her white blood cell
Angelica not to remove the endotracheal
count was low, petitioner prescribed
tube because this may induce further
Leucomax. About four to eight bags of
bleeding.35 She was also transferred to the
blood, consisting of packed red blood cells,
intensive care unit to avoid infection.
fresh whole blood, or platelet concentrate,
were transfused to Angelica. For two days The next day, respondents claimed that
(August 27 to 28), Angelica continued Angelica became hysterical, vomited blood
bleeding, but petitioner claimed it was and her body turned black. Part of
Angelica’s skin was also noted to be to take blood samples from Angelica but
shredding by just rubbing cotton on it. were unsuccessful because they could not
Angelica was so restless she removed even locate her vein. Angelica asked for a
those gadgets attached to her, saying fruit but when it was given to her, she only
"Ayaw ko na"; there were tears in her eyes smelled it. At this time, Reynaldo claimed
and she kept turning her head. Observing he could not find either petitioner or Dr.
her daughter to be at the point of death, Marbella. That night, Angelica became
Lina asked for a doctor but the latter could hysterical and started removing those
not answer her anymore.36 At this time, the gadgets attached to her. At three o’clock in
attending physician was Dr. Marbella who the morning of September 1, a priest came
was shaking his head saying that and they prayed before Angelica expired.
Angelica’s platelets were down and Petitioner finally came back and
respondents should pray for their supposedly told respondents that there
daughter. Reynaldo claimed that he was was "malfunction" or bogged-down
37
introduced to a pediatrician who took over machine.
his daughter’s case, Dr. Abesamis who also
By petitioner’s own account, Angelica was
told him to pray for his daughter. Angelica
merely irritable that day (August 31).
continued to have difficulty in her
Petitioner noted though that Angelica’s
breathing and blood was being suctioned
skin was indeed sloughing off.38 She
from her stomach. A nurse was posted
stressed that at 9:30 in the evening,
inside Angelica’s room to assist her
Angelica pulled out her endotracheal
breathing and at one point they had to
tube.39 On September 1, exactly two weeks
revive Angelica by pumping her chest.
after being admitted at SLMC for
Thereafter, Reynaldo claimed that Angelica
chemotherapy, Angelica died.40 The cause
already experienced difficulty in urinating
of death, according to petitioner, was
and her bowel consisted of blood-like fluid.
septicemia, or overwhelming infection,
Angelica requested for an electric fan as
which caused Angelica’s other organs to
she was in pain. Hospital staff attempted
fail.41 Petitioner attributed this to the
patient’s poor defense mechanism brought lower portion, due to accumulation of
about by the cancer itself.42 fluids; (4) yellowish discoloration of the
liver; (5) kidneys showed appearance of
While he was seeking the release of
facial shock on account of hemorrhages;
Angelica’s cadaver from SLMC, Reynaldo
and (6) reddishness on external surface of
claimed that petitioner acted arrogantly
the spleen. All these were the end result of
and called him names. He was asked to
"hypovolemic shock secondary to multiple
sign a promissory note as he did not have
organ hemorrhages and disseminated
cash to pay the hospital bill.43
intravascular coagulation." Dr. Vergara
Respondents also presented as witnesses opined that this can be attributed to the
Dr. Jesusa Nieves-Vergara, Medico-Legal chemical agents in the drugs given to the
Officer of the PNP-Crime Laboratory who victim, which caused platelet reduction
conducted the autopsy on Angelica’s resulting to bleeding sufficient to cause the
cadaver, and Dr. Melinda Vergara victim’s death. The time lapse for the
Balmaceda who is a Medical Specialist production of DIC in the case of Angelica
employed at the Department of Health (from the time of diagnosis of sarcoma)
(DOH) Operations and Management was too short, considering the survival rate
Services. of about 3 years. The witness conceded
that the victim will also die of
Testifying on the findings stated in her
osteosarcoma even with amputation or
medico-legal report, Dr. Vergara noted the
chemotherapy, but in this case Angelica’s
following: (1) there were fluids recovered
death was not caused by osteosarcoma.
from the abdominal cavity, which is not
Dr. Vergara admitted that she is not a
normal, and was due to hemorrhagic shock
pathologist but her statements were based
secondary to bleeding; (2) there was
on the opinion of an oncologist whom she
hemorrhage at the left side of the heart;
had interviewed. This oncologist
(3) bleeding at the upper portion of and
supposedly said that if the victim already
areas adjacent to, the esophagus; (4) lungs
were heavy with bleeding at the back and
had DIC prior to the chemotherapy, the of osteosarcoma at the time of modern
hospital staff could have detected it.44 chemotherapy and early diagnosis still
remains at 80% to 90%. Usually, deaths
On her part, Dr. Balmaceda declared that it
occur from metastasis, or spread of the
is the physician’s duty to inform and
cancer to other vital organs like the liver,
explain to the patient or his relatives every
causing systemic complications. The
known side effect of the procedure or
modes of therapy available are the
therapeutic agents to be administered,
removal of the primary source of the
before securing the consent of the patient
cancerous growth and then the residual
or his relatives to such procedure or
cancer cells or metastasis should be
therapy. The physician thus bases his
treated with chemotherapy. Dr. Tamayo
assurance to the patient on his personal
further explained that patients with
assessment of the patient’s condition and
osteosarcoma have poor defense
his knowledge of the general effects of the
mechanism due to the cancer cells in the
agents or procedure that will be allowed on
blood stream. In the case of Angelica, he
the patient. Dr. Balmaceda stressed that
had previously explained to her parents
the patient or relatives must be informed
that after the surgical procedure,
of all known side effects based on studies
chemotherapy is imperative so that
and observations, even if such will
metastasis of these cancer cells will
aggravate the patient’s condition.45
hopefully be addressed. He referred the
Dr. Jaime Tamayo, the orthopaedic patient to petitioner because he felt that
surgeon who operated on Angelica’s lower petitioner is a competent oncologist.
extremity, testified for the defendants. He Considering that this type of cancer is very
explained that in case of malignant aggressive and will metastasize early, it
tumors, there is no guarantee that the will cause the demise of the patient should
ablation or removal of the amputated part there be no early intervention (in this case,
will completely cure the cancer. Thus, the patient developed sepsis which caused
surgery is not enough. The mortality rate her death). Cancer cells in the blood
cannot be seen by the naked eye nor chemotherapy on the patient, adding that
detected through bone scan. On cross- a wrong decision is not by itself
examination, Dr. Tamayo stated that of the negligence. Respondents were ordered to
more than 50 child patients who had pay their unpaid hospital bill in the amount
osteogenic sarcoma he had handled, he of ₱139,064.43.48
thought that probably all of them died
Respondents appealed to the CA which,
within six months from amputation
while concurring with the trial court’s
because he did not see them anymore
finding that there was no negligence
after follow-up; it is either they died or had
committed by the petitioner in the
seen another doctor.46
administration of chemotherapy treatment
In dismissing the complaint, the trial court to Angelica, found that petitioner as her
held that petitioner was not liable for attending physician failed to fully explain
damages as she observed the best known to the respondents all the known side
procedures and employed her highest skill effects of chemotherapy. The appellate
and knowledge in the administration of court stressed that since the respondents
chemotherapy drugs on Angelica but have been told of only three side effects of
despite all efforts said patient died. It cited chemotherapy, they readily consented
the testimony of Dr. Tamayo who testified thereto. Had petitioner made known to
that he considered petitioner one of the respondents those other side effects which
most proficient in the treatment of cancer gravely affected their child -- such as
and that the patient in this case was carpo-pedal spasm, sepsis, decrease in the
afflicted with a very aggressive type of blood platelet count, bleeding, infections
cancer necessitating chemotherapy as and eventual death -- respondents could
adjuvant treatment. Using the standard of have decided differently or adopted a
negligence laid down in Picart v. different course of action which could have
Smith,47 the trial court declared that delayed or prevented the early death of
petitioner has taken the necessary their child.
precaution against the adverse effect of
The CA thus declared: appellants so much trouble, pain and
suffering.
Plaintiffs-appellants’ child was suffering
from a malignant disease. The attending On this point therefore, [w]e find
physician recommended that she undergo defendant-appellee Dr. Rubi Li negligent
chemotherapy treatment after surgery in which would entitle plaintiffs-appellants to
order to increase her chances of survival. their claim for damages.
Appellants consented to the chemotherapy
xxxx
treatment because they believed in Dr.
Rubi Li’s representation that the deceased WHEREFORE, the instant appeal is hereby
would have a strong chance of survival GRANTED. Accordingly, the assailed
after chemotherapy and also because of decision is hereby modified to the extent
the representation of appellee Dr. Rubi Li that defendant-appellee Dr. Rubi Li is
that there were only three possible side- ordered to pay the plaintiffs-appellants the
effects of the treatment. However, all sorts following amounts:
of painful side-effects resulted from the
1. Actual damages of P139,064.43, plus
treatment including the premature death
P9,828.00 for funeral expenses;
of Angelica. The appellants were clearly
and totally unaware of these other side- 2. Moral damages of P200,000.00;
effects which manifested only during the
3. Exemplary damages of P50,000.00;
chemotherapy treatment. This was shown
by the fact that every time a problem 4. Attorney’s fee of P30,000.00.
would take place regarding Angelica’s
SO ORDERED.49 (Emphasis supplied.)
condition (like an unexpected side-effect
manifesting itself), they would immediately Petitioner filed a motion for partial
seek explanation from Dr. Rubi Li. Surely, reconsideration which the appellate court
those unexpected side-effects culminating denied.
in the loss of a love[d] one caused the Hence, this petition.
Petitioner assails the CA in finding her everything within her professional
guilty of negligence in not explaining to the competence to attend to the medical
respondents all the possible side effects of needs of Angelica.
the chemotherapy on their child, and in
Citing numerous trainings, distinctions and
holding her liable for actual, moral and
achievements in her field and her current
exemplary damages and attorney’s fees.
position as co-director for clinical affairs of
Petitioner emphasized that she was not
the Medical Oncology, Department of
negligent in the pre-chemotherapy
Medicine of SLMC, petitioner contends that
procedures and in the administration of
in the absence of any clear showing or
chemotherapy treatment to Angelica.
proof, she cannot be charged with
On her supposed non-disclosure of all negligence in not informing the
possible side effects of chemotherapy, respondents all the side effects of
including death, petitioner argues that it chemotherapy or in the pre-treatment
was foolhardy to imagine her to be all- procedures done on Angelica.
knowing/omnipotent. While the theoretical
As to the cause of death, petitioner insists
side effects of chemotherapy were
that Angelica did not die of platelet
explained by her to the respondents, as
depletion but of sepsis which is a
these should be known to a competent
complication of the cancer itself. Sepsis
doctor, petitioner cannot possibly predict
itself leads to bleeding and death. She
how a particular patient’s genetic make-
explains that the response rate to
up, state of mind, general health and body
chemotherapy of patients with
constitution would respond to the
osteosarcoma is high, so much so that
treatment. These are obviously dependent
survival rate is favorable to the patient.
on too many known, unknown and
Petitioner then points to some probable
immeasurable variables, thus requiring
consequences if Angelica had not
that Angelica be, as she was, constantly
undergone chemotherapy. Thus, without
and closely monitored during the
chemotherapy, other medicines and
treatment. Petitioner asserts that she did
supportive treatment, the patient might The type of lawsuit which has been called
have died the next day because of massive medical malpractice or, more
infection, or the cancer cells might have appropriately, medical negligence, is that
spread to the brain and brought the type of claim which a victim has available
patient into a coma, or into the lungs that to him or her to redress a wrong
the patient could have been hooked to a committed by a medical professional which
respirator, or into her kidneys that she has caused bodily harm. In order to
would have to undergo dialysis. Indeed, successfully pursue such a claim, a patient
respondents could have spent as much must prove that a health care provider, in
because of these complications. The most cases a physician, either failed to do
patient would have been deprived of the something which a reasonably prudent
chance to survive the ailment, of any hope health care provider would have done, or
for life and her "quality of life" surely that he or she did something that a
compromised. Since she had not been reasonably prudent provider would not
shown to be at fault, petitioner maintains have done; and that that failure or action
that the CA erred in holding her liable for caused injury to the patient.51
the damages suffered by the
50 This Court has recognized that medical
respondents.
negligence cases are best proved by
The issue to be resolved is whether the opinions of expert witnesses belonging in
petitioner can be held liable for failure to the same general neighborhood and in the
fully disclose serious side effects to the same general line of practice as defendant
parents of the child patient who died while physician or surgeon. The deference of
undergoing chemotherapy, despite the courts to the expert opinion of qualified
absence of finding that petitioner was physicians stems from the former’s
negligent in administering the said realization that the latter possess unusual
treatment. technical skills which laymen in most
instances are incapable of intelligently
The petition is meritorious.
evaluating, hence the indispensability of relationships goes far back into English
expert testimonies.52 common law. As early as 1767, doctors
were charged with the tort of "battery"
In this case, both the trial and appellate
(i.e., an unauthorized physical contact with
courts concurred in finding that the alleged
a patient) if they had not gained the
negligence of petitioner in the
consent of their patients prior to
administration of chemotherapy drugs to
performing a surgery or procedure. In the
respondents’ child was not proven
United States, the seminal case was
considering that Drs. Vergara and
Schoendorff v. Society of New York
Balmaceda, not being oncologists or
Hospital53 which involved unwanted
cancer specialists, were not qualified to
treatment performed by a doctor. Justice
give expert opinion as to whether
Benjamin Cardozo’s oft-quoted opinion
petitioner’s lack of skill, knowledge and
upheld the basic right of a patient to give
professional competence in failing to
consent to any medical procedure or
observe the standard of care in her line of
treatment: "Every human being of adult
practice was the proximate cause of the
years and sound mind has a right to
patient’s death. Furthermore, respondents’
determine what shall be done with his own
case was not at all helped by the non-
body; and a surgeon who performs an
production of medical records by the
operation without his patient’s consent,
hospital (only the biopsy result and
commits an assault, for which he is liable
medical bills were submitted to the court).
in damages."54 From a purely ethical norm,
Nevertheless, the CA found petitioner
informed consent evolved into a general
liable for her failure to inform the
principle of law that a physician has a duty
respondents on all possible side effects of
to disclose what a reasonably prudent
chemotherapy before securing their
physician in the medical community in the
consent to the said treatment.
exercise of reasonable care would disclose
The doctrine of informed consent within to his patient as to whatever grave risks of
the context of physician-patient injury might be incurred from a proposed
course of treatment, so that a patient, reliance upon the physician is a trust of the
exercising ordinary care for his own kind which traditionally has exacted
welfare, and faced with a choice of obligations beyond those associated with
undergoing the proposed treatment, or armslength transactions.58 The physician is
alternative treatment, or none at all, may not expected to give the patient a short
intelligently exercise his judgment by medical education, the disclosure rule only
reasonably balancing the probable risks requires of him a reasonable explanation,
against the probable benefits.55 which means generally informing the
patient in nontechnical terms as to what is
Subsequently, in Canterbury v.
56 at stake; the therapy alternatives open to
Spence  the court observed that the duty
him, the goals expectably to be achieved,
to disclose should not be limited to medical
and the risks that may ensue from
usage as to arrogate the decision on
particular treatment or no treatment. 59 As
revelation to the physician alone. Thus,
to the issue of demonstrating what risks
respect for the patient’s right of self-
are considered material necessitating
determination on particular therapy
disclosure, it was held that experts are
demands a standard set by law for
unnecessary to a showing of the
physicians rather than one which
materiality of a risk to a patient’s decision
physicians may or may not impose upon
on treatment, or to the reasonably,
themselves.57 The scope of disclosure is
expectable effect of risk disclosure on the
premised on the fact that patients
decision. Such unrevealed risk that should
ordinarily are persons unlearned in the
have been made known must further
medical sciences. Proficiency in diagnosis
materialize, for otherwise the omission,
and therapy is not the full measure of a
however unpardonable, is without legal
physician’s responsibility. It is also his duty
consequence. And, as in malpractice
to warn of the dangers lurking in the
actions generally, there must be a causal
proposed treatment and to impart
relationship between the physician’s
information which the patient has every
right to expect. Indeed, the patient’s
failure to divulge and damage to the information is material to the decision. The
patient.60 test therefore for determining whether a
potential peril must be divulged is its
Reiterating the foregoing considerations,
materiality to the patient’s decision. 63
Cobbs v. Grant61 deemed it as integral part
of physician’s overall obligation to patient, Cobbs v. Grant further reiterated the
the duty of reasonable disclosure of pronouncement in Canterbury v. Spence
available choices with respect to proposed that for liability of the physician for failure
therapy and of dangers inherently and to inform patient, there must be causal
potentially involved in each. However, the relationship between physician’s failure to
physician is not obliged to discuss inform and the injury to patient and such
relatively minor risks inherent in common connection arises only if it is established
procedures when it is common knowledge that, had revelation been made, consent to
that such risks inherent in procedure of treatment would not have been given.
very low incidence. Cited as exceptions to
There are four essential elements a
the rule that the patient should not be
plaintiff must prove in a malpractice action
denied the opportunity to weigh the risks
based upon the doctrine of informed
of surgery or treatment are emergency
consent: "(1) the physician had a duty to
cases where it is evident he cannot
disclose material risks; (2) he failed to
evaluate data, and where the patient is a
disclose or inadequately disclosed those
child or incompetent.62 The court thus
risks; (3) as a direct and proximate result
concluded that the patient’s right of self-
of the failure to disclose, the patient
decision can only be effectively exercised if
consented to treatment she otherwise
the patient possesses adequate
would not have consented to; and (4)
information to enable him in making an
plaintiff was injured by the proposed
intelligent choice. The scope of the
treatment." The gravamen in an informed
physician’s communications to the patient,
consent case requires the plaintiff to "point
then must be measured by the patient’s
to significant undisclosed information
need, and that need is whatever
relating to the treatment which would have That death can possibly result from
altered her decision to undergo it.64 complications of the treatment or the
underlying cancer itself, immediately or
Examining the evidence on record, we hold
sometime after the administration of
that there was adequate disclosure of
chemotherapy drugs, is a risk that cannot
material risks inherent in the
be ruled out, as with most other major
chemotherapy procedure performed with
medical procedures, but such conclusion
the consent of Angelica’s parents.
can be reasonably drawn from the general
Respondents could not have been unaware
side effects of chemotherapy already
in the course of initial treatment and
disclosed.
amputation of Angelica’s lower extremity,
that her immune system was already weak As a physician, petitioner can reasonably
on account of the malignant tumor in her expect the respondents to have considered
knee. When petitioner informed the the variables in the recommended
respondents beforehand of the side effects treatment for their daughter afflicted with
of chemotherapy which includes lowered a life-threatening illness. On the other
counts of white and red blood cells, hand, it is difficult to give credence to
decrease in blood platelets, possible respondents’ claim that petitioner told
kidney or heart damage and skin them of 95% chance of recovery for their
darkening, there is reasonable expectation daughter, as it was unlikely for doctors like
on the part of the doctor that the petitioner who were dealing with grave
respondents understood very well that the conditions such as cancer to have falsely
severity of these side effects will not be assured patients of chemotherapy’s
the same for all patients undergoing the success rate. Besides, informed consent
procedure. In other words, by the nature of laws in other countries generally require
the disease itself, each patient’s reaction only a reasonable explanation of potential
to the chemical agents even with pre- harms, so specific disclosures such as
treatment laboratory tests cannot be statistical data, may not be legally
precisely determined by the physician. necessary.65
The element of ethical duty to disclose As society has grappled with the
material risks in the proposed medical juxtaposition between personal autonomy
treatment cannot thus be reduced to one and the medical profession's intrinsic
simplistic formula applicable in all impetus to cure, the law defining
instances. Further, in a medical "adequate" disclosure has undergone a
malpractice action based on lack of dynamic evolution. A standard once guided
informed consent, "the plaintiff must prove solely by the ruminations of physicians is
both the duty and the breach of that duty now dependent on what a reasonable
through expert testimony.66 Such expert person in the patient’s position regards as
testimony must show the customary significant. This change in perspective is
standard of care of physicians in the same especially important as medical
practice as that of the defendant doctor. 67 breakthroughs move practitioners to the
cutting edge of technology, ever
In this case, the testimony of Dr.
encountering new and heretofore
Balmaceda who is not an oncologist but a
unimagined treatments for currently
Medical Specialist of the DOH’s Operational
incurable diseases or ailments. An
and Management Services charged with
adaptable standard is needed to account
receiving complaints against hospitals,
for this constant progression.
does not qualify as expert testimony to
Reasonableness analyses permeate our
establish the standard of care in obtaining
legal system for the very reason that they
consent for chemotherapy treatment. In
are determined by social norms, expanding
the absence of expert testimony in this
and contracting with the ebb and flow of
regard, the Court feels hesitant in defining
societal evolution.
the scope of mandatory disclosure in cases
of malpractice based on lack of informed As we progress toward the twenty-first
consent, much less set a standard of century, we now realize that the legal
disclosure that, even in foreign standard of disclosure is not subject to
jurisdictions, has been noted to be an construction as a categorical imperative.
evolving one. Whatever formulae or processes we adopt
are only useful as a foundational starting
point; the particular quality or quantity of
disclosure will remain inextricably bound
by the facts of each case. Nevertheless,
juries that ultimately determine whether a
physician properly informed a patient are
inevitably guided by what they perceive as
the common expectation of the medical
consumer—"a reasonable person in the
patient’s position when deciding to accept
or reject a recommended medical
68
procedure."  (Emphasis supplied.)
WHEREFORE, the petition for review on
certiorari is GRANTED. The Decision dated
June 15, 2004 and the Resolution dated
September 1, 2004 of the Court of Appeals
in CA-G.R. CV No. 58013 are SET ASIDE.
The Decision dated September 5, 1997 of
the Regional Trial Court of Legazpi City,
Branch 8, in Civil Case No. 8904 is
REINSTATED and UPHELD.
No costs.
SO ORDERED.
G.R. No. 210445, December 07, 2015 (DDH) showed that he fractured his jaw.
Rosit was then referred to Dr. Gestuvo, a
NILO B. ROSIT, Petitioner, v. DAVAO
specialist in mandibular injuries,4 who, on
DOCTORS HOSPITAL AND DR.
January 19, 1999, operated on Rosit.
ROLANDO G. GESTUVO, Respondent.
DECISION During the operation, Dr. Gestuvo used a
metal plate fastened to the jaw with metal
VELASCO JR., J.:
screws to immobilize the mandible. As the
The Case operation required the smallest screws
available, Dr. Gestuvo cut the screws on
This is a petition filed under Rule 45 of the
hand to make them smaller. Dr. Gestuvo
Rules of Court assailing the Decision and
knew that there were smaller titanium
Resolution dated January 22, 20131 and
screws available in Manila, but did not so
November 7, 2013,2 respectively, of the
inform Rosit supposing that the latter
Court of Appeals, Cagayan De Oro City
would not be able to afford the same. 5
(CA), in CA-G.R. CV No. 00911-MIN. The CA
Decision reversed the Decision dated
Following the procedure, Rosit could not
September 14, 20043 of the Regional Trial
properly open and close his mouth and was
Court, Branch 33 in Davao City-(RTC) in
in pain. X-rays done on Rosit two (2) days
Civil Case No. 27,354-99, a suit for
after the operation showed that the
damages thereat which Nilo B. Rosit (Rosit)
fracture in his jaw was aligned but the
commenced against Dr. Rolando Gestuvo
screws used on him touched his molar.
(Dr. Gestuvo).
Given the X-ray results, Dr. Gestuvo
Factual Antecedents referred Rosit to a dentist. The dentist who
checked Rosit, Dr. Pangan, opined that
another operation is necessary and that it
On January 15, 1999, Rosit figured in a
is to be performed in Cebu. 6
motorcycle accident. The X-ray soon taken
the next day at the Davao Doctors Hospital
Alleging that the dentist told him that the and screws that Dr. Pangan installed. Dr.
operation conducted on his mandible was Gestuvo refused to pay.8
improperly done, Rosit went back to Dr.
Gestuvo to demand a loan to defray the Thus, Rosit filed a civil case for damages
cost of the additional operation as well as and attorney's fees with the RTC against
the expenses of the trip to Cebu. Dr. Dr. Gestuvo and DDH, the suit docketed as
Gestuvo gave Rosit P4,500. Civil Case No. 27,354-99.
The Ruling of the Regional Trial Court
Rosit went to Cebu on February 19, 1999,
still suffering from pain and could hardly
open his mouth. The RTC freed DDH from liability on the
ground that it exercised the proper
In Cebu, Dr. Pangan removed the plate and diligence in the selection and supervision
screws thus installed by Dr. Gestuvo and of Dr. Gestuvo, but adjudged Dr. Gestuvo
replaced them with smaller titanium plate negligent and ruled, thus:
and screws. Dr. Pangan also extracted
FOR ALL THE FOREGOING, finding the
Rosit's molar that was hit with a screw and
plaintiff Nilo B. Rosit to have
some bone fragments. Three days after the
preponderantly established his cause of
operation, Rosit was able to eat and speak
action in the complaint against defendant
well and could open and close his mouth
Dr. Rolando G. Gestuvo only, judgment is
normally.7
hereby rendered for the plaintiff and
against said defendant, ordering the
On his return to Davao, Rosit demanded
defendant DR. ROLANDO G. GESTUVO to
that Dr. Gestuvo reimburse him for the
pay unto plaintiff NILO B. ROSIT the
cost of the operation and the expenses he
following:chanRoblesvirtualLawlibrary
incurred in Cebu amounting to P140,000,
as well as for the P50,000 that Rosit would a) the sum of ONE HUNDRED FORTY
have to spend for the removal of the plate THOUSAND ONE HUNDRED NINETY
 NINE PESOS and 13/100 (P140,199.13) ordered DISMISSED.
representing reimbursement of actual
expenses incurred by plaintiff in the Cost against Dr. Rolando G. Gestuvo.
operation and re-operation of his
mandible; SO ORDERED.
In so ruling, the trial court applied the res
b) the sum of TWENTY NINE THOUSAND ipsa loquitur principle holding that "the
AND SIXTY EIGHT PESOS (P29,068.00) need for expert, medical testimony may be
representing reimbursement of the dispensed with because the injury itself
filing fees and appearance fees; provides the proof of negligence."
c) the sum of ONE HUNDRED FIFTY Therefrom, both parties appealed to the
THOUSAND PESOS (P150,000.00) as CA.
and for attorney's fees;
The Ruling of the Court of Appeals
d) the amount of FIFTY THOUSAND
PESOS (P50,000.00) as moral In its January 22, 2013 Decision, the CA
damages; modified the appealed judgment by
deleting the awards made by the trial
e) the amount of TEN THOUSAND PESOS
court, disposing as follows:
(P10,000.00) as exemplary damages;
and WHEREFORE, the appeal filed by Gestuvo
is GRANTED. The Decision dated
f) the costs of the suit. September 14, 2004 of the Regional Trial
Court, Branch 33, Davao City, rendered in
Civil Case No. 27,354-99 is hereby
For lack of merit, the complaint against MODIFIED. The monetary awards adjudged
defendant DAVAO DOCTORS HOSPITAL and in favor of Nilo B. Rosit are hereby
the defendants' counterclaims are hereby
DELETED for lack of basis.
The petition is impressed with merit.
SO ORDERED.
In Flores v. Pineda,9 the Court explained
Unlike the RTC, the CA ruled that the res
the concept of a medical negligence case
ipsa loquitur principle is not applicable and
and the elements required for its
that the testimony of an expert witness is
prosecution, viz:chanRoblesvirtualLawlibrar
necessary for a finding of negligence. The
y
appellate court also gave credence to Dr.
Pangan's letter stating the opinion that Dr.
A medical negligence case is a type of
Gestuvo did not commit gross negligence
claim to redress a wrong committed by a
in his emergency management of Rosit's
medical professional, that has caused
fractured mandible.
bodily harm to or the death of a
patient. There are four elements
Rosit's motion for reconsideration was
involved in a medical negligence case,
denied in the CA's November 7, 2013
namely: duty, breach, injury, and
Resolution.
proximate causation.

Hence, the instant appeal. Duty refers to the standard of behavior

which imposes restrictions on one's
The Issue
conduct. The standard in turn refers to the
amount of competence associated with the
The ultimate issue for our resolution is proper discharge of the profession. A
whether the appellate court correctly physician is expected to use at least the
absolved Dr. Gestuvo from liability. same level of care that any other
reasonably competent doctor would use
The Court's Ruling
under the same circumstances. Breach of
duty occurs when the physician fails to
comply with these professional standards. Although generally, expert medical
If injury results to the patient as a result of testimony is relied upon in
this breach, the physician is answerable for malpractice suits to prove that a
negligence. (Emphasis supplied) physician has done a negligent act or
that he has deviated from the
standard medical procedure, when
An expert witness is not necessary as the doctrine of res ipsa loquitur is
the res ipsa loquitur doctrine is availed by the plaintiff, the need for
applicable expert medical testimony is dispensed
with because the injury itself provides
To establish medical negligence, this Court the proof of negligence. The reason is
has held that an expert testimony is that the general rule on the necessity of
generally required to define the standard expert testimony applies only to such
of behavior by which the court may matters clearly within the domain of
determine whether the physician has medical science, and not to matters that
properly performed the requisite duty are within the common knowledge of
toward the patient. This is so considering mankind which may be testified to by
that the requisite degree of skill and care anyone familiar with the facts. x x x
in the treatment of a patient is usually a
matter of expert opinion.10 Thus, courts of other jurisdictions have
applied the doctrine in the following
Solidum v. People of the situations: leaving of a foreign object in the
11
Philippines  provides an exception. There, body of the patient after an operation,
the Court explained that where the injuries sustained on a healthy part of the
application of the principle of res ipsa body which was not under, or in the area,
loquitur is warranted, an expert testimony of treatment, removal of the wrong part of
may be dispensed with in medical the body when another part was intended,
negligence cases: knocking out a tooth while a patient's jaw
was under anesthetic for the removal of his is the same molar that was hit by the
tonsils, and loss of an eye while the patient screw installed by Dr. Gestuvo in Rosit's
plaintiff was under the influence of mandible. Further, a second operation was
anesthetic, during or following an conducted within the 5-week usual healing
operation for appendicitis, among others. period of the mandibular fracture so that
the second element cannot be considered
We have further held that resort to the
present. Lastly, the CA pointed out that the
doctrine of res ipsa loquitur as an
X-ray examination conducted on Rosit prior
exception to the requirement of an expert
to his first surgery suggests that he had
testimony in medical negligence cases
"chronic inflammatory lung disease
may be availed of if the following essential
compatible," implying that the injury may
requisites are satisfied: (1) the accident
have been due to Rosit's peculiar
was of a kind that does not ordinarily occur
condition, thus effectively negating the
unless someone is negligent; (2) the
presence of the third element. 13
instrumentality or agency that caused the
injury was under the exclusive control of
After careful consideration, this Court
the person charged; and (3) the injury
cannot accede to the CA's findings as it is
suffered must not have been due to any
at once apparent from the records that the
voluntary action or contribution of the
essential requisites for the application of
person injured.12
the doctrine of res ipsa loquitur are
present.
In its assailed Decision, the CA refused to
acknowledge the application of the res
The first element was sufficiently
ipsa loquitur doctrine on the ground that
established when Rosit proved that one of
the foregoing elements are absent. In
the screws installed by Dr. Gestuvo struck
particular, the appellate court is of the
his molar. It was for this issue that Dr.
position that post-operative pain is not
Gestuvo himself referred Rosit to Dr.
unusual after surgery and that there is no
Pangan. In fact, the affidavit of Dr. Pangan
proof that the molar Dr. Pangan removed
presented by Dr. Gestuvo himself before Gestuvo cut the same, it is apparent that
the trial court narrated that the same he negligently placed one of the screws in
molar struck with the screw installed by Dr. the wrong area thereby striking one of
Gestuvo was examined and eventually Rosit's teeth.
operated on by Dr. Pangan. Dr. Gestuvo
cannot now go back and say that Dr. In any event, whether the screw hit Rosit's
Pangan treated a molar different from that molar because it was too long or
which was affected by the first operation. improperly placed, both facts are the
product of Dr. Gestuvo's negligence. An
Clearly, had Dr. Gestuvo used the proper average man of common intelligence
size and length of screws and placed the would know that striking a tooth with any
same in the proper locations, these would foreign object much less a screw would
not have struck Rosit's teeth causing him cause severe pain. Thus, the first essential
pain and requiring him to undergo a requisite is present in this case.
corrective surgery.
Anent the second element for the res ipsa
Dr. Gestuvo knew that the screws he used loquitur doctrine application, it is sufficient
on Rosit were too large as, in fact, he cut that the operation which resulted in the
the same with a saw. 14 He also stated screw hitting Rosit's molar was, indeed,
during trial that common sense dictated performed by Dr. Gestuvo. No other doctor
that the smallest screws available should caused such fact.
be used. More importantly, he also knew
that these screws were available locally at The CA finds that Rosit is guilty of
the time of the operation.15 Yet, he did not contributory negligence in having Dr.
avail of such items and went ahead with Pangan operate on him during the healing
the larger screws and merely sawed them period of his fractured mandible. What the
off. Even assuming that the screws were CA overlooked is that it was Dr. Gestuvo
already at the proper length after Dr. himself who referred Rosit to Dr. Pangan.
Nevertheless, Dr. Pangan's participation higher price.16 As testified to by Dr.
could not have contributed to the reality Gestuvo himself:
that the screw that Dr. Gestuvo installed
hit Rosit's molar. Court This titanium materials according
Alright to you were already available in
Lastly, the third element that the injury . the Philippines since the time of
suffered must not have been due to any Rosit's accident?
voluntary action or contribution of the
person injured was satisfied in this case. It Witnes Yes, your Honor.
was not shown that Rosit's lung disease s
could have contributed to the pain. What is
clear is that he suffered because one of the xxxx
screws that Dr. Gestuvo installed hit Rosit's
molar. Court Did you inform Rosit about the
existence of titanium screws and
Clearly then, the res ipsa plates which according to you is
loquitur doctrine finds application in the screws and plates of choice?
the instant case and no expert
Witnes No, your Honor.
testimony is required to establish the
s
negligence of defendant Dr. Gestuvo.
xxxx
Petitioner was deprived of the
opportunity to make an "informed Witnes The reason I did not inform him
consent" s anymore Judge because what I
thought he was already hard up
What is more damning for Dr. Gestuvo is with the down payment. And if I
his failure to inform Rosit that such smaller will further introduce him this
screws were available in Manila, albeit at a screws, the more he will not be
 able to afford the operation. disclose to his patient as to whatever
grave risks of injury might be incurred
xxxx from a proposed course of treatment,
so that a patient, exercising ordinary
Court This titanium screws and plates care for his own welfare, and faced
were available then it is up to with a choice of undergoing the
Rosit to decide whether to use it proposed treatment, or alternative
or not because after all the treatment, or none at all, may
material you are using is paid by intelligently exercise his judgment by
the patient himscll, is it not? reasonably balancing the probable
risks against the probable benefits.
Witnes Yes, that is true.
s x x x x

Li v. Soliman17 made the following There are four essential elements a

disquisition on the relevant Doctrine of plaintiff must prove in a malpractice
Informed Consent in relation to medical action based upon the doctrine of
negligence cases, to wit: informed consent: "(1) the physician
The doctrine of informed had a duty to disclose material risks;
consent within the context of physician- (2) he failed to disclose or
patient relationships goes far back into inadequately disclosed those risks;
English common law. x x x From a purely (3) as a direct and proximate result of
ethical norm, informed consent the failure to disclose, the patient
evolved into a general principle of law consented to treatment she otherwise
that a physician has a duty to disclose would not have consented to; and (4)
what a reasonably prudent physician plaintiff was injured by the proposed
in the medical community in the treatment." The gravamen in an informed
exercise of reasonable care would consent case requires the plaintiff to "point
to significant undisclosed information to replace the screws that were used by
relating to the treatment which would have Dr. Gestuvo.
altered her decision to undergo it."
(Emphasis supplied) Fourth, as a result of using the larger
screws, Rosit experienced pain and could
The four adverted essential elements
not heal properly because one of the
above are present here.
screws hit his molar. This was evident from
the fact that just three (3) days after Dr.
First, Dr. Gestuvo clearly had the duty of
Pangan repeated the operation conducted
disclosing to Rosit the risks of using the
by Dr. Gestuvo, Rosit was pain-free and
larger screws for the operation. This was
could already speak. This is compared to
his obligation as the physician undertaking
the one (1) month that Rosit suffered pain
the operation.
and could not use his mouth after the
operation conducted by Dr. Gestuvo until
Second, Dr. Gestuvo failed to disclose
the operation of Dr. Pangan.
these risks to Rosit, deciding by himself
that Rosit could not afford to get the more
Without a doubt, Dr. Gestuvo is guilty of
expensive titanium screws.
withholding material information which
would have been vital in the decision of
Third, had Rosit been informed that there
Rosit in going through with the operation
was a risk that the larger screws are not
with the materials at hand. Thus, Dr.
appropriate for the operation and that an
Gestuvo is also guilty of negligence on this
additional operation replacing the screws
ground.
might be required to replace the same, as
what happened in this case, Rosit would
Dr. Pangan's Affidavit is not
not have agreed to the operation. It bears
admissible
pointing out that Rosit was, in fact, able to
afford the use of the smaller titanium
The appellate court's Decision absolving
screws that were later used by Dr. Pangan
Dr. Gestuvo of negligence was also weight they choose upon such testimonies
anchored on a letter signed by Dr. Pangan in accordance with the facts of the case.
who stated the opinion that Dr. Gestuvo The relative weight and sufficiency of
did not commit gross negligence in his expert testimony is peculiarly within the
emergency management of Mr. Rosit's province of the trial court to decide,
fractured mandible.18 Clearly, the appellate considering the ability and character of the
court overlooked the elementary principle witness, his actions upon the witness
against hearsay evidence. stand, the weight and process of the
reasoning by which he has supported his
In Dantis v. Maghinang, Jr.,19 the Court opinion, his possible bias in favor of the
reiterated the oft-repeated rule that "an side for whom he testifies, and any other
affidavit is merely hearsay evidence where matters which serve to illuminate his
its affiant/maker did not take the witness statements. The opinion of an expert
stand." Here, Dr. Pangan never took the should be considered by the court in view
witness stand to affirm the contents of his of all the facts and circumstances of the
affidavit. Thus, the affidavit is inadmissible case. The problem of the evaluation of
and cannot be given any weight. The CA, expert testimony is left to the discretion of
therefore, erred when it considered the the trial court whose ruling thereupon is
affidavit of Dr. Pangan, mpreso for not revicwable in the absence of an abuse
considering the same as expert testimony. of that discretion.
Thus, the belief of Dr. Pangan whether Dr.
Moreover, even if such affidavit is
Gestuvo is guilty of negligence or not will
considered as admissible and the
not bind the Court. The Court must weigh
testimony of an expert witness, the Court
and examine such testimony and decide
is not bound by such testimony. As ruled
for itself the merits thereof.
in Ilao-Quianay v. Mapile:20
Indeed, courts are not bound by expert As discussed above, Dr. Gestuvo's
testimonies. They may place whatever negligence is clearly demonstrable by the
doctrines of res ipsa loquitur and informed could not properly use his jaw to speak or
consent. eat.

Damages The trial court also properly awarded

attorney's fees and costs of suit under
For the foregoing, the trial court properly Article 2208 of the Civil Code, 23 since Rosit
awarded Rosit actual damages after he was compelled to litigate due to Dr.
was able to prove the actual expenses that Gestuvo's refusal to pay for Rosit's
he incurred due to the negligence of Dr. damages.
Gestuvo. In Mendoza v. Spouses
21
Gomez,  the Court explained that a As to the award of exemplary damages,
claimant is entitled to actual damages the same too has to be affirmed.
when the damage he sustained is the In Mendoza,24 the Court enumerated the
natural and probable consequences of the requisites for the award of exemplary
negligent act and he adequately proved damages:
the amount of such damage.
Our jurisprudence sets certain conditions
when exemplary damages may be
Rosit is also entitled to moral damages as
awarded: First, they may be imposed by
provided under Article 2217 of the Civil
way of example or correction only in
Code,22 given the unnecessary physical
addition, among others, to compensatory
suffering he endured as a consequence of
damages, and cannot be recovered as a
defendant's negligence.
matter of right, their determination
depending upon the amount of
To recall, from the time he was negligently
compensatory damages that may be
operated upon by Dr. Gestuvo until three
awarded to the claimant. Second, the
(3) days from the corrective surgery
claimant must first establish his right to
performed by Dr. Pangan, or for a period of
moral, temperate, liquidated or
one (1) month, Rosit suffered pain and
compensatory damages. Third, the
wrongful act must be accompanied by bad 2004 of the Regional Trial Court, Branch 33
faith, and the award would be allowed only in Davao City in Civil Case No. 27,345-99 is
if the guilty party acted in a wanton, hereby REINSTATED and AFFIRMED.
fraudulent, reckless, oppressive or
malevolent manner. SO ORDERED.
The three (3) requisites are met. Dr.
Gestuvo's actions are clearly negligent.
Likewise, Dr. Gestuvo acted in bad faith or
in a wanton, fraudulent, reckless,
oppressive manner when he was in breach
of the doctrine of informed consent. Dr.
Gestuvo had the duty to fully explain to
Rosit the risks of using large screws for the
operation. More importantly, he concealed
the correct medical procedure of using the
smaller titanium screws mainly because of
his erroneous belief that Rosit cannot
afford to buy the expensive titanium
screws. Such concealment is clearly a valid
basis for an award of exemplary damages.

WHEREFORE, the instant petition

is GRANTED. The CA Decision dated
January 22, 2013 and Resolution dated
November 7, 2013 in CA-G.R. CV No.
00911-MIN are
hereby REVERSED and SET ASIDE.
Further, the Decision dated September 14,
G.R. No. 126297             January 31, DECISION
2007
SANDOVAL-GUTIERREZ, J.:
PROFESSIONAL SERVICES,
Hospitals, having undertaken one of
INC., Petitioner,
mankind’s most important and delicate
vs.
endeavors, must assume the grave
NATIVIDAD and ENRIQUE
responsibility of pursuing it with
AGANA, Respondents.
appropriate care. The care and service
x-----------------------x dispensed through this high trust, however
technical, complex and esoteric its
G.R. No. 126467            January 31,
character may be, must meet standards of
2007
responsibility commensurate with the
NATIVIDAD (Substituted by her undertaking to preserve and protect the
children MARCELINO AGANA III, health, and indeed, the very lives of those
ENRIQUE AGANA, JR., EMMA AGANA placed in the hospital’s keeping.1
ANDAYA, JESUS AGANA, and
Assailed in these three consolidated
RAYMUND AGANA) and ENRIQUE
petitions for review on certiorari is the
AGANA, Petitioners,
Court of Appeals’ Decision 2 dated
vs.
September 6, 1996 in CA-G.R. CV No.
JUAN FUENTES, Respondent.
42062 and CA-G.R. SP No. 32198 affirming
x- - - - - - - - - - - - - - - - - - - -- - - - x with modification the Decision 3 dated
March 17, 1993 of the Regional Trial Court
G.R. No. 127590            January 31,
(RTC), Branch 96, Quezon City in Civil Case
2007
No. Q-43322 and nullifying its Order dated
MIGUEL AMPIL, Petitioner, September 21, 1993.
vs.
The facts, as culled from the records, are:
NATIVIDAD AGANA and ENRIQUE
AGANA, Respondents.
On April 4, 1984, Natividad Agana was "sponge count lacking 2
rushed to the Medical City General Hospital
"announced to surgeon searched (sic)
(Medical City Hospital) because of difficulty
done but to no avail continue for closure."
of bowel movement and bloody anal
discharge. After a series of medical On April 24, 1984, Natividad was released
examinations, Dr. Miguel Ampil, petitioner from the hospital. Her hospital and medical
in G.R. No. 127590, diagnosed her to be bills, including the doctors’ fees, amounted
suffering from "cancer of the sigmoid." to P60,000.00.
On April 11, 1984, Dr. Ampil, assisted by After a couple of days, Natividad
the medical staff4 of the Medical City complained of excruciating pain in her anal
Hospital, performed an anterior resection region. She consulted both Dr. Ampil and
surgery on Natividad. He found that the Dr. Fuentes about it. They told her that the
malignancy in her sigmoid area had spread pain was the natural consequence of the
on her left ovary, necessitating the surgery. Dr. Ampil then recommended that
removal of certain portions of it. Thus, Dr. she consult an oncologist to examine the
Ampil obtained the consent of Natividad’s cancerous nodes which were not removed
husband, Enrique Agana, to permit Dr. Juan during the operation.
Fuentes, respondent in G.R. No. 126467, to
On May 9, 1984, Natividad, accompanied
perform hysterectomy on her.
by her husband, went to the United States
After Dr. Fuentes had completed the to seek further treatment. After four
hysterectomy, Dr. Ampil took over, months of consultations and laboratory
completed the operation and closed the examinations, Natividad was told she was
incision. free of cancer. Hence, she was advised to
return to the Philippines.
However, the operation appeared to be
flawed. In the corresponding Record of On August 31, 1984, Natividad flew back to
Operation dated April 11, 1984, the the Philippines, still suffering from pains.
attending nurses entered these remarks: Two weeks thereafter, her daughter found
a piece of gauze protruding from her Dr. Ampil, and Dr. Fuentes, docketed as
vagina. Upon being informed about it, Dr. Civil Case No. Q-43322. They alleged that
Ampil proceeded to her house where he the latter are liable for negligence for
managed to extract by hand a piece of leaving two pieces of gauze inside
gauze measuring 1.5 inches in width. He Natividad’s body and malpractice for
then assured her that the pains would soon concealing their acts of negligence.
vanish.
Meanwhile, Enrique Agana also filed with
Dr. Ampil’s assurance did not come true. the Professional Regulation Commission
Instead, the pains intensified, prompting (PRC) an administrative complaint for gross
Natividad to seek treatment at the negligence and malpractice against Dr.
Polymedic General Hospital. While confined Ampil and Dr. Fuentes, docketed as
there, Dr. Ramon Gutierrez detected the Administrative Case No. 1690. The PRC
presence of another foreign object in her Board of Medicine heard the case only with
vagina -- a foul-smelling gauze measuring respect to Dr. Fuentes because it failed to
1.5 inches in width which badly infected acquire jurisdiction over Dr. Ampil who was
her vaginal vault. A recto-vaginal fistula then in the United States.
had formed in her reproductive organs
On February 16, 1986, pending the
which forced stool to excrete through the
outcome of the above cases, Natividad
vagina. Another surgical operation was
died and was duly substituted by her
needed to remedy the damage. Thus, in
above-named children (the Aganas).
October 1984, Natividad underwent
another surgery. On March 17, 1993, the RTC rendered its
Decision in favor of the Aganas, finding
On November 12, 1984, Natividad and her
PSI, Dr. Ampil and Dr. Fuentes liable for
husband filed with the RTC, Branch 96,
negligence and malpractice, the decretal
Quezon City a complaint for damages
part of which reads:
against the Professional Services, Inc.
(PSI), owner of the Medical City Hospital,
WHEREFORE, judgment is hereby rendered 3. As exemplary damages, the sum of
for the plaintiffs ordering the defendants P300,000.00;
PROFESSIONAL SERVICES, INC., DR.
4. As attorney’s fees, the sum of
MIGUEL AMPIL and DR. JUAN FUENTES to
P250,000.00;
pay to the plaintiffs, jointly and severally,
except in respect of the award for 5. Legal interest on items 1 (a), (b), and
exemplary damages and the interest (c); 2; and 3 hereinabove, from date of
thereon which are the liabilities of filing of the complaint until full payment;
defendants Dr. Ampil and Dr. Fuentes only, and
as follows:
6. Costs of suit.
1. As actual damages, the following
SO ORDERED.
amounts:
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil
a. The equivalent in Philippine Currency of
interposed an appeal to the Court of
the total of US$19,900.00 at the rate of
Appeals, docketed as CA-G.R. CV No.
P21.60-US$1.00, as reimbursement of
42062.
actual expenses incurred in the United
States of America; Incidentally, on April 3, 1993, the Aganas
filed with the RTC a motion for a partial
b. The sum of P4,800.00 as travel taxes of
execution of its Decision, which was
plaintiffs and their physician daughter;
granted in an Order dated May 11, 1993.
c. The total sum of P45,802.50, Thereafter, the sheriff levied upon certain
representing the cost of hospitalization at properties of Dr. Ampil and sold them for
Polymedic Hospital, medical fees, and cost P451,275.00 and delivered the amount to
of the saline solution; the Aganas.
2. As moral damages, the sum of Following their receipt of the money, the
P2,000,000.00; Aganas entered into an agreement with PSI
and Dr. Fuentes to indefinitely suspend
any further execution of the RTC Decision. On September 6, 1996, the Court of
However, not long thereafter, the Aganas Appeals rendered its Decision jointly
again filed a motion for an alias writ of disposing of CA-G.R. CV No. 42062 and CA-
execution against the properties of PSI and G.R. SP No. 32198, thus:
Dr. Fuentes. On September 21, 1993, the
WHEREFORE, except for the modification
RTC granted the motion and issued the
that the case against defendant-appellant
corresponding writ, prompting Dr. Fuentes
Dr. Juan Fuentes is hereby DISMISSED, and
to file with the Court of Appeals a petition
with the pronouncement that defendant-
for certiorari and prohibition, with prayer
appellant Dr. Miguel Ampil is liable to
for preliminary injunction, docketed as CA-
reimburse defendant-appellant
G.R. SP No. 32198. During its pendency,
Professional Services, Inc., whatever
the Court of Appeals issued a
5 amount the latter will pay or had paid to
Resolution  dated October 29, 1993
the plaintiffs-appellees, the decision
granting Dr. Fuentes’ prayer for injunctive
appealed from is hereby AFFIRMED and the
relief.
instant appeal DISMISSED.
On January 24, 1994, CA-G.R. SP No. 32198
Concomitant with the above, the petition
was consolidated with CA-G.R. CV No.
for certiorari and prohibition filed by herein
42062.
defendant-appellant Dr. Juan Fuentes in
Meanwhile, on January 23, 1995, the PRC CA-G.R. SP No. 32198 is hereby GRANTED
Board of Medicine rendered its Decision 6 in and the challenged order of the
Administrative Case No. 1690 dismissing respondent judge dated September 21,
the case against Dr. Fuentes. The Board 1993, as well as the alias writ of execution
held that the prosecution failed to show issued pursuant thereto are hereby
that Dr. Fuentes was the one who left the NULLIFIED and SET ASIDE. The bond
two pieces of gauze inside Natividad’s posted by the petitioner in connection with
body; and that he concealed such fact the writ of preliminary injunction issued by
from Natividad.
this Court on November 29, 1993 is hereby doctrine of res ipsa loquitur. They contend
cancelled. that the pieces of gauze are prima facie
proofs that the operating surgeons have
Costs against defendants-appellants Dr.
been negligent.
Miguel Ampil and Professional Services,
Inc. Finally, in G.R. No. 127590, Dr. Ampil
asserts that the Court of Appeals erred in
SO ORDERED.
finding him liable for negligence and
Only Dr. Ampil filed a motion for malpractice sans evidence that he left the
reconsideration, but it was denied in a two pieces of gauze in Natividad’s vagina.
Resolution7 dated December 19, 1996. He pointed to other probable causes, such
as: (1) it was Dr. Fuentes who used gauzes
Hence, the instant consolidated petitions.
in performing the hysterectomy; (2) the
In G.R. No. 126297, PSI alleged in its attending nurses’ failure to properly count
petition that the Court of Appeals erred in the gauzes used during surgery; and (3)
holding that: (1) it is estopped from raising the medical intervention of the American
the defense that Dr. Ampil is not its doctors who examined Natividad in the
employee; (2) it is solidarily liable with Dr. United States of America.
Ampil; and (3) it is not entitled to its
For our resolution are these three vital
counterclaim against the Aganas. PSI
issues: first, whether the Court of Appeals
contends that Dr. Ampil is not its
erred in holding Dr. Ampil liable for
employee, but a mere consultant or
negligence and malpractice; second,
independent contractor. As such, he alone
whether the Court of Appeals erred in
should answer for his negligence.
absolving Dr. Fuentes of any liability; and
In G.R. No. 126467, the Aganas maintain third, whether PSI may be held solidarily
that the Court of Appeals erred in finding liable for the negligence of Dr. Ampil.
that Dr. Fuentes is not guilty of negligence
I - G.R. No. 127590
or medical malpractice, invoking the
Whether the Court of Appeals Erred in The glaring truth is that all the major
Holding Dr. Ampil circumstances, taken together, as
specified by the Court of Appeals, directly
Liable for Negligence and Malpractice.
point to Dr. Ampil as the negligent party,
Dr. Ampil, in an attempt to absolve thus:
himself, gears the Court’s attention to
First, it is not disputed that the surgeons
other possible causes of Natividad’s
used gauzes as sponges to control the
detriment. He argues that the Court should
bleeding of the patient during the surgical
not discount either of the following
operation.
possibilities: first, Dr. Fuentes left the
gauzes in Natividad’s body after Second, immediately after the operation,
performing hysterectomy; second, the the nurses who assisted in the surgery
attending nurses erred in counting the noted in their report that the ‘sponge
gauzes; and third, the American doctors count (was) lacking 2’; that such anomaly
were the ones who placed the gauzes in was ‘announced to surgeon’ and that a
Natividad’s body. ‘search was done but to no avail’
prompting Dr. Ampil to ‘continue for
Dr. Ampil’s arguments are purely
closure’ x x x.
conjectural and without basis. Records
show that he did not present any evidence Third, after the operation, two (2) gauzes
to prove that the American doctors were were extracted from the same spot of the
the ones who put or left the gauzes in body of Mrs. Agana where the surgery was
Natividad’s body. Neither did he submit performed.
evidence to rebut the correctness of the
An operation requiring the placing of
record of operation, particularly the
sponges in the incision is not complete
number of gauzes used. As to the alleged
until the sponges are properly removed,
negligence of Dr. Fuentes, we are mindful
and it is settled that the leaving of sponges
that Dr. Ampil examined his (Dr. Fuentes’)
or other foreign substances in the wound
work and found it in order.
after the incision has been closed is at or surgeon fails to remove a sponge he has
least prima facie negligence by the placed in his patient’s body that should be
operating surgeon.8 To put it simply, such removed as part of the operation, he
act is considered so inconsistent with due thereby leaves his operation uncompleted
care as to raise an inference of negligence. and creates a new condition which
There are even legions of authorities to the imposes upon him the legal duty of calling
effect that such act is negligence per se. 9 the new condition to his patient’s
attention, and endeavoring with the means
Of course, the Court is not blind to the
he has at hand to minimize and avoid
reality that there are times when danger to
untoward results likely to ensue therefrom.
a patient’s life precludes a surgeon from
further searching missing sponges or Here, Dr. Ampil did not inform Natividad
foreign objects left in the body. But this about the missing two pieces of gauze.
does not leave him free from any Worse, he even misled her that the pain
obligation. Even if it has been shown that a she was experiencing was the ordinary
surgeon was required by the urgent consequence of her operation. Had he
necessities of the case to leave a sponge been more candid, Natividad could have
in his patient’s abdomen, because of the taken the immediate and appropriate
dangers attendant upon delay, still, it is his medical remedy to remove the gauzes
legal duty to so inform his patient within a from her body. To our mind, what was
reasonable time thereafter by advising her initially an act of negligence by Dr. Ampil
of what he had been compelled to do. This has ripened into a deliberate wrongful act
is in order that she might seek relief from of deceiving his patient.
the effects of the foreign object left in her
This is a clear case of medical malpractice
body as her condition might permit. The
or more appropriately, medical negligence.
ruling in Smith v. Zeagler10 is explicit, thus:
To successfully pursue this kind of case, a
The removal of all sponges used is part of patient must only prove that a health care
a surgical operation, and when a physician provider either failed to do something
which a reasonably prudent health care of the missing gauzes from the knowledge
provider would have done, or that he did of Natividad and her family.
something that a reasonably prudent
II - G.R. No. 126467
provider would not have done; and that
failure or action caused injury to the Whether the Court of Appeals Erred in
patient.11 Simply put, the elements are Absolving
duty, breach, injury and proximate
Dr. Fuentes of any Liability
causation. Dr, Ampil, as the lead surgeon,
had the duty to remove all foreign objects, The Aganas assailed the dismissal by the
such as gauzes, from Natividad’s body trial court of the case against Dr. Fuentes
before closure of the incision. When he on the ground that it is contrary to the
failed to do so, it was his duty to inform doctrine of res ipsa loquitur. According to
Natividad about it. Dr. Ampil breached them, the fact that the two pieces of gauze
both duties. Such breach caused injury to were left inside Natividad’s body is a prima
Natividad, necessitating her further facie evidence of Dr. Fuentes’ negligence.
examination by American doctors and
We are not convinced.
another surgery. That Dr. Ampil’s
negligence is the proximate cause12 of Literally, res ipsa loquitur means "the thing
Natividad’s injury could be traced from his speaks for itself." It is the rule that the fact
act of closing the incision despite the of the occurrence of an injury, taken with
information given by the attending nurses the surrounding circumstances, may
that two pieces of gauze were still missing. permit an inference or raise a presumption
That they were later on extracted from of negligence, or make out a plaintiff’s
Natividad’s vagina established the causal prima facie case, and present a question of
link between Dr. Ampil’s negligence and fact for defendant to meet with an
the injury. And what further aggravated explanation.13 Stated differently, where the
such injury was his deliberate concealment thing which caused the injury, without the
fault of the injured, is under the exclusive
control of the defendant and the injury is It was duly established that Dr. Ampil was
such that it should not have occurred if he, the lead surgeon during the operation of
having such control used proper care, it Natividad. He requested the assistance of
affords reasonable evidence, in the Dr. Fuentes only to perform hysterectomy
absence of explanation that the injury when he (Dr. Ampil) found that the
arose from the defendant’s want of care, malignancy in her sigmoid area had spread
and the burden of proof is shifted to him to to her left ovary. Dr. Fuentes performed
establish that he has observed due care the surgery and thereafter reported and
and diligence.14 showed his work to Dr. Ampil. The latter
examined it and finding everything to be in
From the foregoing statements of the rule,
order, allowed Dr. Fuentes to leave the
the requisites for the applicability of the
operating room. Dr. Ampil then resumed
doctrine of res ipsa loquitur are: (1) the
operating on Natividad. He was about to
occurrence of an injury; (2) the thing which
finish the procedure when the attending
caused the injury was under the control
nurses informed him that two pieces of
and management of the defendant; (3) the
gauze were missing. A "diligent search"
occurrence was such that in the ordinary
was conducted, but the misplaced gauzes
course of things, would not have happened
were not found. Dr. Ampil then directed
if those who had control or management
that the incision be closed. During this
used proper care; and (4) the absence of
entire period, Dr. Fuentes was no longer in
explanation by the defendant. Of the
the operating room and had, in fact, left
foregoing requisites, the most instrumental
the hospital.
is the "control and management of the
thing which caused the injury."15 Under the "Captain of the Ship" rule, the
operating surgeon is the person in
We find the element of "control and
complete charge of the surgery room and
management of the thing which caused
all personnel connected with the operation.
the injury" to be wanting. Hence, the
Their duty is to obey his orders. 16 As stated
doctrine of res ipsa loquitur will not lie.
before, Dr. Ampil was the lead surgeon. In
other words, he was the "Captain of the III - G.R. No. 126297
Ship." That he discharged such role is
Whether PSI Is Liable for the Negligence of
evident from his following conduct: (1)
Dr. Ampil
calling Dr. Fuentes to perform a
hysterectomy; (2) examining the work of The third issue necessitates a glimpse at
Dr. Fuentes and finding it in order; (3) the historical development of hospitals and
granting Dr. Fuentes’ permission to leave; the resulting theories concerning their
and (4) ordering the closure of the incision. liability for the negligence of physicians.
To our mind, it was this act of ordering the
Until the mid-nineteenth century, hospitals
closure of the incision notwithstanding that
were generally charitable institutions,
two pieces of gauze remained
providing medical services to the lowest
unaccounted for, that caused injury to
classes of society, without regard for a
Natividad’s body. Clearly, the control and
patient’s ability to pay.18 Those who could
management of the thing which caused
afford medical treatment were usually
the injury was in the hands of Dr. Ampil,
treated at home by their
not Dr. Fuentes. 19
doctors.  However, the days of house calls
In this jurisdiction, res ipsa loquitur is not a and philanthropic health care are over. The
rule of substantive law, hence, does not modern health care industry continues to
per se create or constitute an independent distance itself from its charitable past and
or separate ground of liability, being a has experienced a significant conversion
mere evidentiary rule.17 In other words, from a not-for-profit health care to for-
mere invocation and application of the profit hospital businesses. Consequently,
doctrine does not dispense with the significant changes in health law have
requirement of proof of negligence. Here, accompanied the business-related changes
the negligence was proven to have been in the hospital industry. One important
committed by Dr. Ampil and not by Dr. legal change is an increase in hospital
Fuentes. liability for medical malpractice. Many
courts now allow claims for hospital
vicarious liability under the theories of The owners and managers of an
respondeat superior, apparent authority, establishment or enterprise are likewise
ostensible authority, or agency by responsible for damages caused by their
20
estoppel.  employees in the service of the branches
in which the latter are employed or on the
In this jurisdiction, the statute governing
occasion of their functions.
liability for negligent acts is Article 2176 of
the Civil Code, which reads: Employers shall be liable for the damages
caused by their employees and household
Art. 2176. Whoever by act or omission
helpers acting within the scope of their
causes damage to another, there being
assigned tasks even though the former are
fault or negligence, is obliged to pay for
not engaged in any business or industry.
the damage done. Such fault or
negligence, if there is no pre-existing x x x
contractual relation between the parties, is x x x
called a quasi-delict and is governed by
The responsibility treated of in this article
the provisions of this Chapter.
shall cease when the persons herein
A derivative of this provision is Article mentioned prove that they observed all the
2180, the rule governing vicarious liability diligence of a good father of a family to
under the doctrine of respondeat superior, prevent damage.
thus:
A prominent civilist commented that
ART. 2180. The obligation imposed by professionals engaged by an employer,
Article 2176 is demandable not only for such as physicians, dentists, and
one’s own acts or omissions, but also for pharmacists, are not "employees" under
those of persons for whom one is this article because the manner in which
responsible. they perform their work is not within the
control of the latter (employer). In other
x x x
words, professionals are considered
x x x
personally liable for the fault or negligence The case of Schloendorff v. Society of New
they commit in the discharge of their York Hospital26 was then considered an
duties, and their employer cannot be held authority for this view. The "Schloendorff
liable for such fault or negligence. In the doctrine" regards a physician, even if
context of the present case, "a hospital employed by a hospital, as an independent
cannot be held liable for the fault or contractor because of the skill he exercises
negligence of a physician or surgeon in the and the lack of control exerted over his
treatment or operation of patients."21 work. Under this doctrine, hospitals are
exempt from the application of the
The foregoing view is grounded on the
respondeat superior principle for fault or
traditional notion that the professional
negligence committed by physicians in the
status and the very nature of the
discharge of their profession.
physician’s calling preclude him from being
classed as an agent or employee of a However, the efficacy of the foregoing
hospital, whenever he acts in a doctrine has weakened with the significant
22
professional capacity.  It has been said developments in medical care. Courts
that medical practice strictly involves came to realize that modern hospitals are
highly developed and specialized increasingly taking active role in supplying
23
knowledge,  such that physicians are and regulating medical care to patients. No
generally free to exercise their own skill longer were a hospital’s functions limited
and judgment in rendering medical to furnishing room, food, facilities for
services sans interference. 24 Hence, when treatment and operation, and attendants
a doctor practices medicine in a hospital for its patients. Thus, in Bing v.
setting, the hospital and its employees are Thunig,27 the New York Court of Appeals
deemed to subserve him in his deviated from the Schloendorff doctrine,
ministrations to the patient and his actions noting that modern hospitals actually do
are of his own responsibility.25 far more than provide facilities for
treatment. Rather, they regularly employ,
on a salaried basis, a large staff of
physicians, interns, nurses, administrative However, the difficulty is more apparent
and manual workers. They charge patients than real.
for medical care and treatment, even
In the first place, hospitals exercise
collecting for such services through legal
significant control in the hiring and firing of
action, if necessary. The court then
consultants and in the conduct of their
concluded that there is no reason to
work within the hospital premises. Doctors
exempt hospitals from the universal rule of
who apply for ‘consultant’ slots, visiting or
respondeat superior.
attending, are required to submit proof of
In our shores, the nature of the completion of residency, their educational
relationship between the hospital and the qualifications, generally, evidence of
physicians is rendered inconsequential in accreditation by the appropriate board
view of our categorical pronouncement in (diplomate), evidence of fellowship in most
Ramos v. Court of Appeals 28 that for cases, and references. These requirements
purposes of apportioning responsibility in are carefully scrutinized by members of
medical negligence cases, an employer- the hospital administration or by a review
employee relationship in effect exists committee set up by the hospital who
between hospitals and their attending and either accept or reject the application. x x
visiting physicians. This Court held: x.
"We now discuss the responsibility of the After a physician is accepted, either as a
hospital in this particular incident. The visiting or attending consultant, he is
unique practice (among private hospitals) normally required to attend clinico-
of filling up specialist staff with attending pathological conferences, conduct bedside
and visiting "consultants," who are rounds for clerks, interns and residents,
allegedly not hospital employees, presents moderate grand rounds and patient audits
problems in apportioning responsibility for and perform other tasks and
negligence in medical malpractice cases. responsibilities, for the privilege of being
able to maintain a clinic in the hospital,
and/or for the privilege of admitting between hospitals and their attending and
patients into the hospital. In addition to visiting physicians. "
these, the physician’s performance as a
But the Ramos pronouncement is not our
specialist is generally evaluated by a peer
only basis in sustaining PSI’s liability. Its
review committee on the basis of mortality
liability is also anchored upon the agency
and morbidity statistics, and feedback from
principle of apparent authority or agency
patients, nurses, interns and residents. A
by estoppel and the doctrine of corporate
consultant remiss in his duties, or a
negligence which have gained acceptance
consultant who regularly falls short of the
in the determination of a hospital’s liability
minimum standards acceptable to the
for negligent acts of health professionals.
hospital or its peer review committee, is
The present case serves as a perfect
normally politely terminated.
platform to test the applicability of these
In other words, private hospitals, hire, fire doctrines, thus, enriching our
and exercise real control over their jurisprudence.
attending and visiting ‘consultant’ staff.
Apparent authority, or what is sometimes
While ‘consultants’ are not, technically
referred to as the "holding
employees, x x x, the control exercised,
the hiring, and the right to terminate out" theory, or doctrine of ostensible
consultants all fulfill the important agency or agency by estoppel, 29 has its
hallmarks of an employer-employee origin from the law of agency. It imposes
relationship, with the exception of the liability, not as the result of the reality of a
payment of wages. In assessing whether contractual relationship, but rather
such a relationship in fact exists, the because of the actions of a principal or an
control test is determining. Accordingly, on employer in somehow misleading the
the basis of the foregoing, we rule that for public into believing that the relationship
the purpose of allocating responsibility in or the authority exists.30 The concept is
medical negligence cases, an employer- essentially one of estoppel and has been
employee relationship in effect exists explained in this manner:
"The principal is bound by the acts of his the hospital, then the hospital will be liable
agent with the apparent authority which he for the physician’s negligence.
knowingly permits the agent to assume, or
Our jurisdiction recognizes the concept of
which he holds the agent out to the public
an agency by implication or estoppel.
as possessing. The question in every case
Article 1869 of the Civil Code reads:
is whether the principal has by his
voluntary act placed the agent in such a ART. 1869. Agency may be express, or
situation that a person of ordinary implied from the acts of the principal, from
prudence, conversant with business his silence or lack of action, or his failure to
usages and the nature of the particular repudiate the agency, knowing that
business, is justified in presuming that another person is acting on his behalf
such agent has authority to perform the without authority.
particular act in question.31
In this case, PSI publicly displays in the
The applicability of apparent authority in lobby of the Medical City Hospital the
the field of hospital liability was upheld names and specializations of the
long time ago in Irving v. Doctor Hospital of physicians associated or accredited by it,
Lake Worth, Inc.32 There, it was explicitly including those of Dr. Ampil and Dr.
stated that "there does not appear to be Fuentes. We concur with the Court of
any rational basis for excluding the Appeals’ conclusion that it "is now
concept of apparent authority from the estopped from passing all the blame to the
field of hospital liability." Thus, in cases physicians whose names it proudly
where it can be shown that a hospital, by paraded in the public directory leading the
its actions, has held out a particular public to believe that it vouched for their
physician as its agent and/or employee skill and competence." Indeed, PSI’s act is
and that a patient has accepted treatment tantamount to holding out to the public
from that physician in the reasonable that Medical City Hospital, through its
belief that it is being rendered in behalf of accredited physicians, offers quality health
care services. By accrediting Dr. Ampil and
Dr. Fuentes and publicly advertising their The wisdom of the foregoing ratiocination
qualifications, the hospital created the is easy to discern. Corporate entities, like
impression that they were its agents, PSI, are capable of acting only through
authorized to perform medical or surgical other individuals, such as physicians. If
services for its patients. As expected, these accredited physicians do their job
these patients, Natividad being one of well, the hospital succeeds in its mission of
them, accepted the services on the offering quality medical services and thus
reasonable belief that such were being profits financially. Logically, where
rendered by the hospital or its employees, negligence mars the quality of its services,
agents, or servants. The trial court the hospital should not be allowed to
correctly pointed out: escape liability for the acts of its ostensible
agents.
x x x regardless of the education and
status in life of the patient, he ought not We now proceed to the doctrine of
be burdened with the defense of absence corporate negligence or corporate
of employer-employee relationship responsibility.
between the hospital and the independent
One allegation in the complaint in Civil
physician whose name and competence
Case No. Q-43332 for negligence and
are certainly certified to the general public
malpractice is that PSI as owner, operator
by the hospital’s act of listing him and his
and manager of Medical City Hospital, "did
specialty in its lobby directory, as in the
not perform the necessary supervision nor
case herein. The high costs of today’s
exercise diligent efforts in the supervision
medical and health care should at least
of Drs. Ampil and Fuentes and its nursing
exact on the hospital greater, if not
staff, resident doctors, and medical interns
broader, legal responsibility for the
who assisted Drs. Ampil and Fuentes in the
conduct of treatment and surgery within its
performance of their duties as
facility by its accredited physician or 34
surgeons."  Premised on the doctrine of
surgeon, regardless of whether he is
corporate negligence, the trial court held
independent or employed."33
that PSI is directly liable for such breach of inter alia, in failing to have a sufficient
duty. number of trained nurses attending the
patient; failing to require a consultation
We agree with the trial court.
with or examination by members of the
Recent years have seen the doctrine of hospital staff; and failing to review the
corporate negligence as the judicial answer treatment rendered to the patient." On the
to the problem of allocating hospital’s basis of Darling, other jurisdictions held
liability for the negligent acts of health that a hospital’s corporate negligence
practitioners, absent facts to support the extends to permitting a physician known to
application of respondeat superior or be incompetent to practice at the
apparent authority. Its formulation hospital.37 With the passage of time, more
proceeds from the judiciary’s duties were expected from hospitals,
acknowledgment that in these modern among them: (1) the use of reasonable
times, the duty of providing quality care in the maintenance of safe and
medical service is no longer the sole adequate facilities and equipment; (2) the
prerogative and responsibility of the selection and retention of competent
physician. The modern hospitals have physicians; (3) the overseeing or
changed structure. Hospitals now tend to supervision of all persons who practice
organize a highly professional medical staff medicine within its walls; and (4) the
whose competence and performance need formulation, adoption and enforcement of
to be monitored by the hospitals adequate rules and policies that ensure
commensurate with their inherent quality care for its patients.38 Thus, in
responsibility to provide quality medical Tucson Medical Center, Inc. v. Misevich, 39 it
care.35 was held that a hospital, following the
doctrine of corporate responsibility, has
The doctrine has its genesis in Darling v.
the duty to see that it meets the standards
Charleston Community Hospital.36 There,
of responsibilities for the care of patients.
the Supreme Court of Illinois held that "the
Such duty includes the proper supervision
jury could have found a hospital negligent,
of the members of its medical staff. And in the holding of an immediate inquiry into
Bost v. Riley,40 the court concluded that a the events, if not for the benefit of the
patient who enters a hospital does so with patient to whom the duty is primarily
the reasonable expectation that it will owed, then in the interest of arriving at the
attempt to cure him. The hospital truth. The Court cannot accept that the
accordingly has the duty to make a medical and the healing professions,
reasonable effort to monitor and oversee through their members like defendant
the treatment prescribed and administered surgeons, and their institutions like PSI’s
by the physicians practicing in its hospital facility, can callously turn their
premises. backs on and disregard even a mere
probability of mistake or negligence by
In the present case, it was duly established
refusing or failing to investigate a report of
that PSI operates the Medical City Hospital
such seriousness as the one in Natividad’s
for the purpose and under the concept of
case.
providing comprehensive medical services
to the public. Accordingly, it has the duty It is worthy to note that Dr. Ampil and Dr.
to exercise reasonable care to protect from Fuentes operated on Natividad with the
harm all patients admitted into its facility assistance of the Medical City Hospital’s
for medical treatment. Unfortunately, PSI staff, composed of resident doctors,
failed to perform such duty. The findings of nurses, and interns. As such, it is
the trial court are convincing, thus: reasonable to conclude that PSI, as the
operator of the hospital, has actual or
x x x PSI’s liability is traceable to its failure
constructive knowledge of the procedures
to conduct an investigation of the matter
carried out, particularly the report of the
reported in the nota bene of the count
attending nurses that the two pieces of
nurse. Such failure established PSI’s part in
gauze were missing. In Fridena v.
the dark conspiracy of silence and
Evans,41 it was held that a corporation is
concealment about the gauzes. Ethical
bound by the knowledge acquired by or
considerations, if not also legal, dictated
notice given to its agents or officers within
the scope of their authority and in Among the cases indicative of the
reference to a matter to which their ‘emerging trend’ is Purcell v. Zimbelman,
authority extends. This means that the 18 Ariz. App. 75,500 P. 2d 335 (1972). In
knowledge of any of the staff of Medical Purcell, the hospital argued that it could
City Hospital constitutes knowledge of PSI. not be held liable for the malpractice of a
Now, the failure of PSI, despite the medical practitioner because he was an
attending nurses’ report, to investigate independent contractor within the hospital.
and inform Natividad regarding the missing The Court of Appeals pointed out that the
gauzes amounts to callous negligence. Not hospital had created a professional staff
only did PSI breach its duties to oversee or whose competence and performance was
supervise all persons who practice to be monitored and reviewed by the
medicine within its walls, it also failed to governing body of the hospital, and the
take an active step in fixing the negligence court held that a hospital would be
committed. This renders PSI, not only negligent where it had knowledge or
vicariously liable for the negligence of Dr. reason to believe that a doctor using the
Ampil under Article 2180 of the Civil Code, facilities was employing a method of
but also directly liable for its own treatment or care which fell below the
negligence under Article 2176. In Fridena, recognized standard of care.
the Supreme Court of Arizona held:
Subsequent to the Purcell decision, the
x x x In recent years, however, the duty of Arizona Court of Appeals held that a
care owed to the patient by the hospital hospital has certain inherent
has expanded. The emerging trend is to responsibilities regarding the quality of
hold the hospital responsible where the medical care furnished to patients within
hospital has failed to monitor and review its walls and it must meet the standards of
medical services being provided within its responsibility commensurate with this
walls. See Kahn Hospital Malpractice undertaking. Beeck v. Tucson General
Prevention, 27 De Paul . Rev. 23 (1977). Hospital, 18 Ariz. App. 165, 500 P. 2d 1153
(1972). This court has confirmed the
rulings of the Court of Appeals that a last paragraph of Article 2180 cited earlier,
hospital has the duty of supervising the and, therefore, must be adjudged solidarily
competence of the doctors on its staff. x x liable with Dr. Ampil. Moreover, as we have
x. discussed, PSI is also directly liable to the
Aganas.
x x x x
x x One final word. Once a physician
undertakes the treatment and care of a
In the amended complaint, the plaintiffs
patient, the law imposes on him certain
did plead that the operation was
obligations. In order to escape liability, he
performed at the hospital with its
must possess that reasonable degree of
knowledge, aid, and assistance, and that
learning, skill and experience required by
the negligence of the defendants was the
his profession. At the same time, he must
proximate cause of the patient’s injuries.
apply reasonable care and diligence in the
We find that such general allegations of
exercise of his skill and the application of
negligence, along with the evidence
his knowledge, and exert his best
produced at the trial of this case, are
judgment.
sufficient to support the hospital’s liability
based on the theory of negligent WHEREFORE, we DENY all the petitions and
supervision." AFFIRM the challenged Decision of the
Court of Appeals in CA-G.R. CV No. 42062
Anent the corollary issue of whether PSI is
and CA-G.R. SP No. 32198.
solidarily liable with Dr. Ampil for damages,
let it be emphasized that PSI, apart from a Costs against petitioners PSI and Dr.
general denial of its responsibility, failed to Miguel Ampil.
adduce evidence showing that it exercised
SO ORDERED.
the diligence of a good father of a family in
the accreditation and supervision of the
latter. In neglecting to offer such proof, PSI
failed to discharge its burden under the
 alleged unwarranted actuations of the
petitioner towards its patient, respondent
So Un Chua (Chua), who was confined for
hypertension, diabetes, and related
illnesses.
The antecedents of the case follow:
[G.R. NO. 150355 : July 31, 2006]
On December 13, 1993, respondents filed
MANILA DOCTORS
a Complaint averring that on October 30,
HOSPITAL, Petitioner, v. SO UN CHUA
1990, respondent Chua, the mother of
and VICKY TY, Respondents.
respondent Vicky Ty, was admitted in
DECISION petitioner's hospital for hypertension and
diabetes; that while respondent Chua was
AUSTRIA-MARTINEZ, J.:
confined, Judith Chua, the sister of
Before this Court is a Petition for Review respondent Ty, had been likewise confined
on Certiorari under Rule 45 questioning the for injuries suffered in a vehicular accident;
Decision1 dated October 2, 2001 that partial payments of the hospital bills
promulgated by the Court of Appeals (CA) were made, totaling P435,800.00; that
in CA-G.R. CV No. 61581, which affirmed after the discharge of Judith Chua,
the Decision dated September 30, 1997 of respondent Chua remained in confinement
the Regional Trial Court (RTC), Branch 159, and the hospital bills for both patients
Pasig City, but which reduced the award of accumulated; that respondent Chua was
damages. pressured by the petitioner, through its
Credit and Collection Department, to settle
This case originated from an action for
the unpaid bills; that respondent Ty
damages filed with the RTC by
represented that she will settle the bills as
respondents So Un Chua and Vicky Ty
soon as the funds become available; that
against petitioner Manila Doctors
2 respondent Ty pleaded to the management
Hospital.  The complaint is premised on the
that in view of the physical condition of her Reply, and interposed its counterclaims
mother, respondent Chua, the arguing that as early as one week after
correspondences relating to the settlement respondent Chua had been admitted to its
of the unpaid hospital bills should be hospital, Dr. Rody Sy, her attending
relayed to the former; that these pleas physician, had already given instructions
were unheeded by the petitioner; that for her to be discharged, but respondents
petitioner threatened to implement insisted that Chua remain in confinement;
unpleasant measures unless respondent Ty that, through its staff, petitioner
undertakes her mother's obligation as well accordingly administered medical
as the obligation of her sister, Judith Chua, examinations, all of which yielded negative
to pay the hospitalization expenses; that results; that respondent Ty voluntarily
petitioner made good its threat and undertook, jointly and severally, to pay the
employed unethical, unpleasant and hospital bills for both patients; that
unlawful methods which allegedly although respondent Ty paid up to
worsened the condition of respondent P435,000.00, more or less, she reneged on
Chua, particularly, by (i) cutting off the her commitment to pay the balance in
telephone line in her room and removing violation of the Contract for Admission and
the air-conditioning unit, television set, and Acknowledgment of Responsibility for
refrigerator, (ii) refusing to render medical Payment dated October 30, 1990 which
attendance and to change the hospital she voluntarily executed; that she signed a
gown and bed sheets, and (iii) barring the Promissory Note on June 5, 1992 for the
private nurses or midwives from assisting unpaid balance of P1,075,592.95 and
the patient. Respondents thus prayed for issued postdated checks to cover the
the award of moral damages, exemplary same; that no such undue pressure had
damages, and attorney's fees. been imposed upon respondent Chua to
settle the bills, the truth being that, as a
In its Answer, Amended Answer, and
matter of standard procedure, the
Rejoinder, petitioner specifically denied the
reminders to settle the bills were
material averments of the Complaint and
transmitted not to the patients but to their compensatory damages due to the filing of
relatives who usually undertook to pay the a malicious and unfounded suit, and, in its
same; that respondent Ty deliberately permissive counterclaim, petitioner prayed
evaded the staff of the Credit and for respondents to pay P1,075,592.95, the
Collection Department; that the cutting-off amount representing the due and
of the telephone line and removal of the demandable obligation under the
air-conditioning unit, television set, and Promissory Note dated June 5, 1992,
refrigerator cannot constitute unwarranted including the stipulated interest therein
actuations, for the same were resorted to and the 25 percent of the total amount due
as cost-cutting measures and to minimize as attorney's fees.
respondents' charges that were already
During pre-trial, the parties stipulated on
piling up, especially after respondent Ty
the following issues: First, whether the
refused to settle the balance
respondents are liable to the petitioner to
notwithstanding frequent demands; that
pay the hospital bills arising from the
respondent Ty evaded the staff when the
hospitalization of respondent Chua and
latter attempted to inform her that the
Judith Chua; and second, whether the
room facilities will be cut off to minimize
parties are entitled to their respective
the rising charges; and that respondents
claims for damages.3 Furthermore, the
instituted the present civil case purposely
parties stipulated on the following facts: a)
as leverage against the petitioner after the
Judith Chua was confined from June 14,
latter had filed criminal charges for
1991 to May 2, 1992; b) respondents failed
violation of Batas Pambansa (B.P.) Blg. 22
to pay the balance despite repeated
against respondent Ty for issuing checks,
reminders; c) the said reminders referred
later dishonored, totaling P1,075,592.95,
to the hospital bills of respondent Chua
the amount referring to the unpaid hospital
and Judith Chua; d) one of the attending
bills. In its compulsory counterclaim,
physicians of respondent Chua was Dr.
petitioner prayed, among other items, for
Rody Sy; and e) the petitioner ordered the
the award of no less than P1,000,000.00 as
removal of the facilities in question from
the room of its patient, respondent Chua, hypertension of respondent Chua; that the
with the qualification that they were petitioner acted in bad faith in removing
constrained to discontinue the same after the facilities without prior notice; that her
the representative of respondent Chua condition was aggravated by the pressure
refused to update the hospital bills or employed by the administration upon her
refused to transfer her to semi-deluxe to pay the hospital bills; that the food
room or ward to lessen costs.4 always came late as compared to the other
patients; that the beddings and clothes of
On September 30, 1997, the RTC rendered
respondent Chua were no longer changed
its Decision in favor of the respondents,
and, as a result, bed sores emerged on her
the dispositive portion of which states:
body; that there was an utter lack of
WHEREFORE, premises considered, medical attendance; that, because of
judgment on the complaint is hereby these, respondent Chua suffered from self-
rendered in favor of the [respondents] as pity and depression; that petitioner clearly
against the [petitioner] as follows: discriminated against the respondents;
that respondent Ty had no choice but to
[O]rdering the [petitioner] to pay the
sign the promissory notes in order to
[respondents] the following, to wit:
secure the release of her mother,
a) P200,000.00 as moral damages; respondent Chua; that the foregoing
actuations constitute an abuse of rights;
b) P100,000.00 as exemplary damages;
that petitioner failed to establish the
andcralawlibrary
pecuniary loss it suffered and, hence, it is
c) P50,000.00 as attorney's fees and the not entitled to compensatory damages;
amount of P50,000.00 as litigation costs. and that, since the promissory note is a
contract of adhesion, the petitioner is not
SO ORDERED.5
entitled to the award of attorney's fees as
In brief, the RTC held that the removal of stipulated thereon.
the facilities of the room triggered the
On appeal to the CA, the petitioner IN VIEW OF ALL THE FOREGOING, the
assigned the following errors: appealed Decision is
hereby AFFIRMED with the modification
A.
that the award of moral damages,
THE HONORABLE TRIAL COURT exemplary damages as well as attorney's
COMMITTED REVERSIBLE ERROR BY fees is reduced to Seventy Five Thousand
FINDING THE ACTUATIONS OF THE Pesos (P75,000.00), Thirty Thousand Pesos
ADMINISTRATION OF DEFENDANT- (P30,000.00) and Twenty Thousand Pesos
APPELLANT TO BE IN BAD FAITH, (P20,000.00), respectively. Litigation costs
OPPRESSIVE AND UNNECESSARY AS TO are hereby deleted. Costs against
MAKE IT LIABLE TO PLAINTIFFS-APPELLEES appellant.
FOR DAMAGES AND ATTORNEY'S FEES.
SO ORDERED.7
B.
Apart from the reduction in the award of
THE HONORABLE TRIAL COURT damages, the CA affirmed all salient
COMMITTED REVERSIBLE ERROR BY NOT portions of the RTC Decision and declined
RULING UPON THE PERMISSIVE to disturb the findings of fact.
COUNTERCLAIM OF DEFENDANT-
Petitioner is now before this Court raising
APPELLANT WITH RESPECT TO THE
essentially the same grounds heard by the
P1,075,592.95 REPRESENTING THE
CA.
HOSPITAL BILL OF PLAINTIFFS-APPELLEES,
WHICH OBLIGATION IS NOT DISPUTED AND Incidentally, with respect to the related
WHICH AMOUNT WAS NEVER criminal case against respondent Ty, this
CONTROVERTED BY PLAINTIFFS- Court, on September 27, 2004,
6
APPELLEES. promulgated its Decision entitled Ty v.
People of the Philippines,8 which affirmed
On October 2, 2001, the CA promulgated
the decisions of the lower courts finding
its Decision the dispositive portion of which
respondent Ty guilty of violating B.P. Blg.
reads:
22 and ordering her to pay the private backed up by the measure of preponderant
complainant, herein petitioner, the total evidence.
amount of the dishonored checks.
In brief, the courts a quo concurred in the
The petition is impressed with merit. holding that the petitioner and its staff
failed to take into consideration the
While, as a rule, only questions of law may
physical condition of its patient,
be raised in a Petition for Review
respondent Chua, when it removed the
on Certiorari under Rule 45, under certain
facilities provided in her room;10 that the
exceptions, the Court may re-examine the
removal of these facilities, namely, the air-
evidence presented by the parties during
conditioner, telephone lines, television,
the trial. At least four exceptions exist in
and refrigerator, aggravated the condition
this case, namely: (a) when the conclusion
of the patient, triggered her hypertension,
is a finding grounded entirely on
and caused her blood pressure to
speculation, surmises, or conjectures; (b)
fluctuate,11 considering that there was no
when the judgment is based on a
proper ventilation in the room.12 In view of
misapprehension of facts; (c) when the
the foregoing, the courts a quo concluded
findings of fact are premised on the
that the actuations of the petitioner were
supposed absence of evidence and
oppressive, unnecessary,13 and anti-
contradicted by the evidence on record; 14
social,  done in bad faith without proper
and (d) when the courts a quo manifestly
notice,15 with no intention other than to
overlooked certain relevant facts not
harass or irritate the respondents, 16 all of
disputed by the parties and which, if
which constitute an abuse of rights.17
properly considered, would justify a
different conclusion.9 We do not agree. The conclusions of the
courts a quo are either haphazard
The principal questions are, first, whether
conjectures, or founded on a
the actuations of the petitioner amount to
misapprehension of facts. The record is
actionable wrongs, and second, whether
the counterclaims of the petitioner can be
replete with evidence that justifies a cause the adverse health effects and
different conclusion. emotional trauma the respondents so
claimed. Corollary to this question is
Indeed the operation of private pay
whether the petitioner observed the
hospitals and medical clinics is impressed
diligence of a good father of the family 19 in
with public interest and imbued with a
the course of ascertaining the possible
heavy social responsibility. But the hospital
repercussions of the removal of the
is also a business, and, as a business, it
facilities prior to the removal itself and for
has a right to institute all measures of
a reasonable time thereafter, with a view
efficiency commensurate to the ends for
to prevent damage.20
which it is designed, especially to ensure
its economic viability and survival. And in After an extensive analysis of the record, it
the legitimate pursuit of economic becomes rather worrisome to this Court
considerations, the extent to which the that the courts a quo unreservedly drew
public may be served and cured is their conclusions from the self-serving and
expanded, the pulse and life of the medical uncorroborated testimonies of the
sector quickens, and the regeneration of respondents the probative value of which
the people as a whole becomes more is highly questionable.21 We hold that the
visibly attainable. In the institution of cost- respondents failed to prove the damages
cutting measures, the hospital has a right so claimed.
to reduce the facilities and services that
The evidence in the record firmly
are deemed to be non-essential, such that
establishes that the staff of the petitioner
their reduction or removal would not be
took proactive steps to inform the relatives
detrimental to the medical condition of the
of respondent Chua of the removal of
patient.18 For the moment, the question to
facilities prior thereto, and to carry out the
be considered is whether the subject
necessary precautionary measures to
facilities are indeed non-essential - the air-
ensure that her health and well-being
conditioner, telephone, television, and
would not be adversely affected: as early
refrigerator - the removal of which would
as around two weeks after her admission ultrasound, and CT scan,32 all of which
on October 30, 1990, to the time when the were administered after procuring the
facilities had been removed sometime in consent of respondent Chua's family 33 as
the middle of May 1992,22 and even up to admitted by respondent Ty herself, 34 and
the point when she actually left the even called on other specialists, such as a
premises of the hospital three weeks later, neurologist, endocrinologist, and
or during the first week of June 1992, 23 the gastroenterologist, to look into her
medical condition of respondent Chua, as condition35 and conduct other tests as
consistently and indisputably confirmed by well36 according to their fields of specialty,
her attending physician, Dr. Rody Sy, a all of which yielded no serious
37
cardiologist, who was called as witness for finding;  that her illnesses were "lifelong
both parties,24 whom even respondent illnesses"38 at a stage where they cannot
Chua repeatedly praised to be "my doctor" be totally removed or abolished, 39 making
and "a very good doctor"25 at that, and it clear to her family that "one hundred
whose statements at times had been percent recovery is not possible" despite
corroborated as well by Sister Mary Philip being given daily medication in the
Galeno, SPC, the Administrator of the hospital;40 but that her condition,
41
hospital and who also happens to be a nonetheless, is not serious,  as the blood
registered nurse, had been "relatively pressure is more or less controlled and
well,"26 "ambulatory,"27 "walking around in within acceptable limits,42 "not that critical
the room,"28 and that she was "able to to precipitate any acute attack,"43 nor
leave the hospital on her own without any likely to fall into any emergency, 44 nor yet
assistance;"29 that although she does she require continuous or prolonged
complained of symptoms such as hospitalization45 since she was stable
30
dizziness, weakness,  and abdominal enough to be treated at home and on an
31
discomfort,  Dr. Sy requested several "out-patient" basis, so much so that Dr. Sy
medical examinations, such as the encouraged her to exercise and avoid
laboratory tests, renal tests, MRI, resting all the
time,46 and recommended that "anytime doctor himself.56 When Dr. Sy testified as
she may be discharged"47 rebuttal witness for the respondents
themselves and whose credibility
even in just "two weeks after
48 respondents failed to impeach, he
confinement,"  the propriety of his order
categorically stated that he consented to
of discharge concurred upon by the other
the removal since the removal of the said
specialists as well,49 had it not been for
facilities would not by itself be detrimental
respondents' insistence to stay in the
to the health of his patient, respondent
hospital in view of their hope for absolute
Chua.57 And in this respect, he had been
recovery50 despite the admission of
advising respondent Ty, the daughter of
respondent Chua herself that she cannot
the patient, that the facilities, such as the
anymore be totally cured.51
air-conditioner, television, refrigerator, and
It is also undisputed that the hospital telephone, are not absolutely necessary,
administrator, Sister Galeno, prior to the and, that although they may add to the
removal of the facilities, consulted the comfort of the patient, if absent, they will
attending physician, Dr. Sy.52 To Sister not cause any significant deterioration of
Galeno, also a registered nurse, the matter her condition,58 given that, in his
of removal and its possible repercussions experience as a cardiologist, and after
on the health of the patient, as a matter of personally attending respondent Chua on a
hospital policy, is a critical and sensitive daily basis before, during, and after the
maneuver, and, hence, it is carried out removal and even up to the time of her
only after discussing with the doctors to actual discharge,59 he concluded that many
evaluate all important factors. 53 The fact of hypertensive and diabetic patients, as in
prior consultation54 as well as the medical her case, do not at all need in particular an
determination to the effect that it was safe air-conditioning unit, among the other
to remove the facilities and would cause facilities aforementioned.60 And, contrary
no harmful effect55 had been amply to the findings of the courts a quo and the
corroborated by respondent Chua's own self-serving testimonies of respondents
that the lack of ventilation, after the and direct link to the injury allegedly
removal of the air-conditioner, triggered suffered by the patient:
her hypertension, Dr. Sy categorically
Q - You found it safe to remove these
stated that during his daily rounds with the
facilities from the room of the patient
patient he was certain that, although
suffering from diabetes and hypertension?
admittedly the blood pressure in general
cralawlibrary
would fluctuate daily, there had been no
adverse effect on her, and that her blood A - Yes, Sir. Many hypertensive, diabetic
pressure were within acceptable patients do not need air-conditioning, or
61
limits,  especially considering that he T.V. or refrigerator.
treated the patient on a daily basis up to
Q - Do you agree with me that
the point of actual discharge, 62 and
hypertension is triggered sometimes by
accordingly, as confirmed by the medical
excitement, anger or (sic) a person
records, he made no change in the
suffering from such illness?cralawlibrary
medications thereafter.63 In support of Dr.
Sy's findings, Sister Galeno, testified that A - Hypertension can be triggered by
she knew the condition of the ventilation of anything.
the patient's deluxe room, located at the
Court:
fifth floor, even without the air-
conditioning, notably in times of brownout, Q - And even in other words the discomfort
and that there had been enough can also trigger?cralawlibrary
ventilation since the grilled window of that
A - Sometimes mental stress can trigger.
room was large enough which, if opened,
would permit sufficient ventilation.64 The xxx
Court finds that the premise of the RTC Court:
judgment refers merely to hypothetical
statements which fail to establish any clear
Q - You mentioned earlier that this actually discharged.66 Nor did he find any
hypertension may be triggered mentally? sign of depression, although, admittedly,
cralawlibrary he observed that she had been "very
angry" because of the removal of the
A - Yes, Your Honor.
facilities.67 All the while he did not receive
Court: any complaint from respondent Chua
indicating that she suffered from the
Q - Will the removal of these facilities not
foregoing infirmities,68 considering that it is
affect the patient including the relatives?
the responsibility of the family of the
cralawlibrary
patient to specifically inform the attending
A - It may to a certain extent. And well, physician or the nurses during their rounds
maybe the days after the removal would whatever they feel is important, or if there
prove that fluctuation in blood pressure are were any new developments since the last
within acceptable limits.65 visit.69 As corroborated by Sister Galeno,
throughout respondent Chua's
With respect to the findings of the courts a
confinement, she never received any
quo that bed sores appeared on the body
complaint from the latter or her relatives
of respondent Chua, that she suffered from
that she had not been attended to by the
depression after the disconnection of the
nursing staff.70 Worth noting again is the
said facilities, that her private midwives
fact that the nursing staff and the
were barred, and that the delivery of food
attending physicians, which included Dr.
was delayed, this Court holds, as above,
Sy, in accordance with hospital policy,
that these conclusions are bereft of sound
would routinely make their rounds on a
evidentiary basis, self-serving and
daily basis, or would visit the patient
uncorroborated as they are. Again, Dr. Sy
whenever they are called for any
affirmed that during the daily rounds he
problem,71 and, in the case of the
would make on the patient, he did not
specialists other than the attending
detect any skin lesion or any other
physician, they would visit the patient
abnormality up to the time she was
about once a week.72 The nurses, on the health suffered during the period after the
other hand, would make their rounds more removal of the facilities. The Court finds
frequently, that is, at least once per shift, that the facilities in question are non-
or every eight hours.73 Apart from the self- essential for the care of respondent Chua
serving statements of respondents, which and, hence, they may be lessened or
by now have become rather indicative of removed by the petitioner for the sake of
being mere afterthoughts, there is no clear economic necessity and survival.
showing from the record that the petitioner
Though human experience would show
and its medical staff deviated from the
that the deactivation of the air-conditioner
foregoing policy and practice, nor had they
may cause a temperature differential that
been called upon to look into the alleged
may trigger some physical discomfort, or
physical reactions or emotional trauma
that the removal of entertainment facilities
respondent Chua claims to have suffered
such as the television set, or the
during and after the removal of the
disconnection of communication devices
facilities. It must be emphasized that, as
such as the telephone, may cause some
stated above, respondent Chua herself
exasperation on the part of the one who
explicitly found Dr. Sy to be a "very good
benefits from these, nevertheless, all
doctor" because he personally attended to
things considered, and given the degree of
her "almost every hour."74 And throughout
diligence the petitioner duly exerted, not
her confinement, Dr. Sy positively stated
every suppression of the things that one
that her family employed a private midwife
has grown accustomed to enjoy amounts
who attended to her all the time.75
to an actionable wrong, nor does every
The evidence in the record overwhelmingly physical or emotional discomfort amount
demonstrates that respondent Chua had to the kind of anguish that warrants the
been adequately attended to, and this award of moral damages under the general
Court cannot understand why the courts a principles of tort. The underlying basis for
quo had declared that there was an "utter the award of tort damages is the premise
lack of medical attendance," or that her that an individual was injured in
contemplation of law. Thus, there must Pablo Hospital and the reoperation
first be the breach of some duty and the performed on her by the petitioner. But
imposition of liability for that breach before while it may be true that the
damages may be awarded; it is not circumstances pointed out by the courts
sufficient to state that there should be tort below seemed beyond cavil to constitute
liability merely because the plaintiff reckless imprudence on the part of the
suffered some pain and suffering.76 surgeon, this conclusion is still best arrived
at not through the educated surmises nor
Moreover, this Court must reiterate the
conjectures of laymen, including judges,
standard of tort to arrive at a proper award
but by the unquestionable knowledge of
for damages premised on matters that
expert witnesses. For whether a physician
suggest the application of medical
or surgeon has exercised the requisite
knowledge, especially in the description of
degree of skill and care in the treatment of
the causal link between external or
his patient is, in the generality of cases, a
environmental factors, on one hand, and
matter of expert opinion. The deference of
their effect unto the physical or emotional
courts to the expert opinions of qualified
health of the patient, on the other, expert
physicians stems from its realization that
opinion, as discussed in Cruz v. Court of
the latter possess unusual technical skills
Appeals,77 is generally required:
which laymen in most instances are
All three courts below bewail the incapable of intelligently evaluating. Expert
inadequacy of the facilities of the clinic and testimony should have been offered to
its untidiness; the lack of provisions such prove that the circumstances cited by the
as blood, oxygen, and certain medicines; courts below are constitutive of conduct
the failure to subject the patient to a falling below the standard of care
cardio-pulmonary test prior to the employed by other physicians in good
operation; the omission of any form of standing when performing the same
blood typing before transfusion; and even operation. It must be remembered that
the subsequent transfer of Lydia to the San when the qualifications of a physician are
admitted, as in the instant case, there is an Department.84 After repeated attempts to
inevitable presumption that in proper contact respondent Ty85 and before the
cases he takes the necessary precaution actual removal of the facilities, the staff of
and employs the best of his knowledge and the petitioner tried to personally serve the
skill in attending to his clients, unless the final notice dated April 23, 1992,86 signed
contrary is sufficiently established. This by Sister Gladys Lim, addressed to
presumption is rebuttable by expert respondent Ty, which adopted the tenor of
opinion which is so sadly lacking in the the prior verbal warnings, and which
case at bench.78 expressly and sternly warned the
respondents that the hospital shall be
With respect to the propriety of the notice
constrained to take legal action and that
of removal of facilities, the evidence shows
they shall be compelled to transfer the
that the hospital staff, accompanied by
patient, respondent Chua, to a lower rate
Sister Gladys Lim, SPC, Finance
room unless the balance could be
Administrative Assistant of the
79 satisfied.87 Respondent Ty, for no justifiable
hospital,  through written and verbal
reason, and sticking to her inclination to
notices as per hospital policy, forewarned
avoid the staff, refused to receive or
the respondents, through respondent Ty
acknowledge this letter as well. 88 Worth
and her sister, Judith Chua, of the
noting is that Sister Galeno, testified that,
impending removal of the facilities over a
as a matter of hospital policy the tenor of
week beforehand80 in view of their
which respondents, by virtue of the
obstinate refusal to vacate and transfer to
Contract for Admission dated October 30,
a lower rate room81 or to update the
1990, agreed to comply with,89 the hospital
mounting hospital bills82 which, by then,
can only cut off the non-essential facilities -
had swollen to approximately one million
and only in extreme cases90 - if the patient
pesos.83 Respondent Ty refused to read
occupies a private room all to herself; had
many of the written notices sent by the
the room been semi-private shared by
Credit
other patients, or had it been the ward, the
hospital cannot disconnect the facilities or bodily release its patient, respondent
since this would unduly prejudice the other Chua, until arrangements had been made
patients. But respondent Chua herself to settle the charges.
insisted on staying in a private room
While there are portions of the testimonies
despite her being fully aware of the
of the witnesses for the petitioner which
ballooning charges,91 and even if she could
state that although, as per standard
have freely gone home anytime to her
procedure, the patient "cannot leave" 96 the
condominium unit which, as admitted, was
hospital without the
equipped with an air-conditioner.92 With 97
"discharge,"  "clearance" or "gate pass"
respect to the "pressure" and
issued only after
"harassment" respondents allegedly
suffered daily whenever the hospital staff arrangements on the settlement of bills
would follow up the billing during odd had been made,98 still, it must be
hours, or at 10pm, 11pm, 12 midnight, understood that these are only
1am, or 2am,93 this averment had been demonstrative of the precondition that a
convincingly refuted by the witnesses for patient cannot step out of the premises
the petitioner, namely, Editha L. Vecino, "without the consent" of the hospital, or, in
the Head of Credit and Collection, and other words, that the "clearance" merely
Sister Galeno, in that the Credit and indicates that the hospital expressly
Collection Department would only hold consented to the actual release of the
office hours from 8am to 5pm and, hence, patient,99 but, even without its consent, the
it is impossible to "harass" the respondents patient is still free to leave "anytime" as a
during the times they so claimed.94 matter of policy, in spite of the refusal to
issue a "clearance" or "gate pass," 100 or
The courts a quo found that respondent Ty
even in cases where the accounts have not
had "no choice but to sign the promissory
yet been liquidated or settled, 101 or yet
note in order for her mother to be released
even if no promissory note or post-dated
from the hospital,"95 thus suggesting that
check were executed in favor of the
the hospital refused to actually discharge
petitioner, as testified by no less than upon the person of respondent Chua or
Sister Galeno,102 and corroborated by upon the person of her relatives had been
Editha Vecino;103 and that, petitioner, a imposed by the staff.
private hospital established for
104 Authorities, including those of common law
profit,  being also a business, by warning
origin, explicitly declare that a patient
respondents that it shall withhold
cannot be detained in a hospital for non-
clearance, is simply exercising its right to
payment of the hospital bill. If the patient
protest against an absconding patient as a
cannot pay the hospital or physician's bill,
precursor to avail of other appropriate
the law provides a remedy for them to
legal remedies; that, on the contrary, the
pursue, that is, by filing the necessary suit
respondents opted not to leave because of
in court for the recovery of such fee or
their own promise not to leave unless the
bill.108 If the patient is prevented from
hospital bills were fully settled; 105 that the
leaving the hospital for his inability to pay
accusations found in the Demand Letter
the bill, any person who can act on his
dated May 19, 1992, and signed by the
behalf can apply in court for the issuance
counsel for the respondents,106 particularly,
of the writ of habeas corpus.109
that the petitioner "refused to discharge
the patient, [respondent Chua,] despite The form of restraint must be total;
orders from the attending physician, Dr. movement must be restrained in all
Rody Sy," had all been refuted by Sister directions. If restraint is partial, e.g., in a
Galeno when she read its contents in front particular direction with freedom to
of the counsel for respondents, proceed in another, the restraint on the
emphatically telling him that "we are not person's liberty is not total. 110 However, the
detaining his clients;" that "[respondent hospital may legally detain a patient
Ty] was the one who told us that they are against his will when he is a detained or
not going to leave the hospital unless they convicted prisoner, or when the patient is
have fully paid the hospital;" 107 and that, suffering from a very contagious disease
most importantly, no physical restraint where his release will be prejudicial to
public health, or when the patient is the hospital may nonetheless register its
mentally ill such that his release will protest and may choose to pursue the
endanger public safety,111 or in other legal remedies available under law,
exigent cases as may be provided by law. provided that the hospital may not
Moreover, under the common law physically detain the patient, unless the
doctrines on tort, it does not constitute a case falls under the exceptions
trespass to the person to momentarily abovestated.
prevent him from leaving the premises or
Authorities are of the view that, ordinarily,
any part thereof because he refuses to
a hospital, especially if it is a private pay
comply with some reasonable condition
hospital,113 is entitled to be compensated
subject to which he entered them. In all
for its services, by either an express or an
cases, the condition of this kind of restraint
implied contract, and if no express
must be reasonable in the light of the
contract exists, there is generally an
circumstances.112 At any rate, as stated
implied agreement that the patient will pay
above, the patient is free to leave the
the reasonable value of the services
premises, even in the ostensible violation
rendered;114 when a hospital treats a
of these conditions, after being
patient's injuries, it has an enforceable
momentarily interrupted by the hospital
claim for full payment for its services,
staff for purposes of informing him of those
regardless of the patient's financial
reasonable conditions, such as the
status.115 At this juncture, it must be noted
assessment of whether the patient is fit to
that there is testimony, though to a degree
leave, insane, or suffering from a
disputable, to the effect that the execution
contagious disease, etc., or simply for
of the promissory note and the issuance of
purposes of making a demand to settle the
postdated checks were conditions imposed
bill. If the patient chooses to abscond or
not by the petitioner but voluntarily offered
leave without the consent of the hospital in
by the counsel for respondents. 116 At any
violation of any of the conditions deemed
rate, however, this Court holds, in view of
to be reasonable under the circumstances,
the foregoing authorities, that the
requirement to have the relative of 1992, this Court must refer to the
respondent Chua to execute a promissory discussion of the recent case of Ty v.
note as part of the arrangement to settle People of the Philippines119 where this
the unpaid obligations is a formality that Court affirmed the conviction of
converts any implied contract into written respondent Ty for the issuance of bouncing
form and, moreover, amounts to a checks addressed to the petitioner herein.
reasonable condition, the non-fulfillment of While the instant case is to be
which, in itself, however, as discussed, distinguished from the Ty case in nature,
cannot allow the hospital to detain the applicable law, the standards of evidence,
patient. It must also be stressed, contrary and in the defenses available to the
to the findings of the courts a quo, that parties, hence, the judgment of conviction
such an agreement embodied in a in that case should not at all prejudice the
promissory note, as well as the Contract disposition of this case, even if the facts
for Admission and Acknowledgment of coincide, nonetheless, for purposes of
Responsibility for Payment dated October convenience and instructive utility, the
30, 1990, do not become contracts of Court quotes the relevant portions:
adhesion simply because the person
In this case, far from it, the fear, if any,
signing it was under stress that was not
harbored by Ty was not real and imminent.
the result of the actions of the
Ty claims that she was compelled to issue
hospital,117 especially taking into account
the checks a condition the hospital
that there is testimony to the effect that
allegedly demanded of her before her
respondent Ty signed the Promissory Note
mother could be discharged for fear that
dated June 5, 1992 in the presence of
her mother's health might deteriorate
counsel and acting under his advise.118
further due to the inhumane treatment of
But as to the propriety of the the hospital or worse, her mother might
circumstances surrounding the issuance of commit suicide. This is speculative fear; it
the postdated checks to cover the amount is not the uncontrollable fear contemplated
stated in the Promissory Note dated June 5, by law.
To begin with, there was no showing that opportunity to leave the scene to avoid
the mother's illness was so life-threatening involvement.
such that her continued stay in the hospital
Moreover, petitioner had sufficient
suffering all its alleged unethical treatment
knowledge that the issuance of checks
would induce a well-grounded
without funds may result in a violation of
apprehension of her death. Secondly, it is
B.P. 22. She even testified that her counsel
not the law's intent to say that any fear
advised her not to open a current account
exempts one from criminal liability much
nor issue postdated checks "because the
less petitioner's flimsy fear that her mother
moment I will not have funds it will be a
might commit suicide. In other words, the
big problem." Besides, apart from
fear she invokes was not impending or
petitioner's bare assertion, the record is
insuperable as to deprive her of all volition
bereft of any evidence to corroborate and
and to make her a mere instrument
bolster her claim that she was compelled
without will, moved exclusively by the
or coerced to cooperate with and give in to
hospital's threats or demands.
the hospital's demands.
Ty has also failed to convince the Court
Ty likewise suggests . . . that the justifying
that she was left with no choice but to
circumstance of state of necessity under
commit a crime. She did not take
par. 4, Art. 11 of the Revised Penal Code
advantage of the many opportunities
may find application in this case.
available to her to avoid committing one.
By her very own words, she admitted that We do not agree. The law prescribes the
the collateral or security the hospital presence of three requisites to exempt the
required prior to the discharge of her actor from liability under this paragraph:
mother may be in the form of postdated (1) that the evil sought to be avoided
checks or jewelry. And if indeed she was actually exists; (2) that the injury feared be
coerced to open an account with the bank greater than the one done to avoid it; (3)
and issue the checks, she had all the that there be no other practical and less
harmful means of preventing it.
In the instant case, the evil sought to be Under the circumstances, however, it is
avoided is merely expected or anticipated. quite clear that neither uncontrollable fear
If the evil sought to be avoided is merely nor avoidance of a greater evil or injury
expected or anticipated or may happen in prompted the issuance of the bounced
the future, this defense is not applicable. checks.
Ty could have taken advantage of an
Parenthetically, the findings of fact in the
available option to avoid committing a
Decision of the trial court in the Civil Case
crime. By her own admission, she had the
for damages filed by Ty's mother against
choice to give jewelry or other forms of
the hospital is wholly irrelevant for
security instead of postdated checks to
purposes of disposing the case at bench.
secure her obligation.
While the findings therein may establish a
Moreover, for the defense of state of claim for damages which, we may add,
necessity to be availing, the greater injury need only be supported by a
feared should not have been brought preponderance of evidence, it does not
about by the negligence or imprudence, necessarily engender reasonable doubt as
more so, the willful inaction of the actor. In to free Ty from liability.120
this case, the issuance of the bounced
In view of the foregoing, the Court
checks was brought about by Ty's own
therefore holds that the courts a
failure to pay her mother's hospital bills.
quo committed serious errors in finding
The Court also thinks it rather odd that Ty that the petitioner was
121
has chosen the exempting circumstance of "biased,"  "discriminated" against the
uncontrollable fear and the justifying respondents,122 and "purposely intended to
circumstance of state of necessity to irritate"123 or "harass"124 them; that it
absolve her of liability. It would not have "acted in bad faith in removing the
been half as bizarre had Ty been able to facilities without prior notice;" 125 and that
prove that the issuance of the bounced its acts were "anti-social."126 The
checks was done without her full volition. aforequoted declarations of the witnesses,
significant portions of which this Court We agree with the petitioner that the
considers as expert testimony, are reliable courts a quo seriously erred in mistaking
and remain considerably trustworthy to the case of its compulsory counterclaim for
controvert respondents' assertions as well its permissive counterclaim and for failing
as to reverse the conclusions of fact and to consider the evidence which
law of the CA and the RTC that respondent impressively supports the latter. First, for
Chua suffered the physical and emotional failure without justifiable cause of
anguish so claimed, and so, for these respondents' counsel to comment on the
reasons, the Court holds that the petitioner Partial Formal Offer of Evidence dated
inflicted no actionable wrong. February 14, 1996129 filed by the petitioner,
the RTC issued an order during the course
This Court observes that the courts a
of the trial, which counsel for respondents
quo awarded both respondents moral
neither contested nor raised on appeal,
damages. But it is well-settled that in case
admitting Exhibits "1" to "16", together
of physical injuries, with some
127 with their submarkings and the purposes
exceptions,  moral damages are
for which the same were offered, 130 all of
recoverable only by the party injured and
which had also been previously
not by her spouse, next of kin, or relative
authenticated and their contents verified
who happened to sympathize with the
by the witnesses for the
injured party.128 Hence, even if the courts a 131
petitioner.  These documents include the
quo were correct in their basis for
Contract for Admission of respondent Chua
damages, they should have declined to
dated October 30, 1990, duly executed by
award damages to respondent Ty.
respondent Ty, incorporating therein the
The last issue to be resolved is the rules and regulations of the hospital,
question whether the counterclaims of the including the duty to understand the
petitioner are supported by a same132 as well as the undertaking of
preponderance of evidence. respondent Ty to be jointly and severally
liable for the payment of the hospital bills
of respondent Chua;133 the Promissory Note cannot control the incidents of the instant
dated June 5, 1992 in the amount of case as heretofore stated, it is still worth
P1,075,592.95 duly executed by mentioning, at least for informative
respondent Ty in favor of the petitioner purposes, the findings of this Court in Ty
agreeing to be jointly and severally liable with respect to respondents' obligations to
to pay the unpaid obligations of the petitioner:
respondent Chua and Judith Chua,
Ty's mother and sister availed of the
including interest and attorney's fees in
services and the facilities of the hospital.
case of default;134 the Undertakings signed
For the care given to her kin, Ty had a
by respondent Ty dated March 3, 1992 and
legitimate obligation to pay the hospital by
April 7, 1992 to maintain regular
virtue of her relationship with them and by
deposits;135 and the credit memos and
force of her signature on her mother's
statements of account that support the
Contract of Admission acknowledging
amount referring to the unpaid
136 responsibility for payment, and on the
obligation.  Second, the parties stipulated
promissory note she executed in favor of
during pre-trial that respondents failed to
the hospital.140
pay the balance despite repeated
137
reminders.  And third, respondent Ty in In view of all these findings, the Court
open court identified and admitted that earnestly disagrees with the sweeping
she signed the Contract of Admission conclusion of the CA that "[Petitioner]
dated October 30, 1990 as well as the failed to present any iota of evidence to
Undertakings dated March 3, 1992 and prove his claim,"141 a statement apparently
April 7, 1992 but which, for no justifiable referring to the permissive counterclaim of
reason, she "did not bother to P1,075,592.95. However, with respect to
138
read,"  and, what is more, she repeatedly the compulsory counterclaim predicated
admitted during the course of the trial that on the filing of a baseless suit and injury to
she failed to fully settle the foregoing its reputation, petitioner did not raise this
hospital bills.139 In fact, while the Ty case
matter on appeal and, hence, is deemed to patients for non-payment, in part or in full,
have waived the same. of their hospital bills,144 and, furthermore,
requires patients who have fully recovered
But the Court in Ty made a partial finding
and are financially incapable to settle the
on the civil liability of respondent Ty with
hospitalization expenses to execute a
respect to the amount covered by seven of
promissory note, co-signed by another
the several dishonored checks she issued
individual, to the extent of the unpaid
equivalent to
obligation before leaving the
P210,000.00.142 Since this amount forms a 145
hospital.  While this Court may have
fraction of her total civil liability, then this touched upon these matters in the
amount, in deference to Ty, should be adjudication of the instant case, it must be
deducted therefrom. stated that this decision should in no way
preempt any constitutional challenge to
The claim for attorney's fees, as stipulated
the provisions of Senate Bill No. 337 if
under the Promissory Note dated June 5,
passed into law, bearing in mind the
1992, should be reduced for being
standards for the exercise of the power of
unreasonable under the circumstances,
judicial review146 as well as the recognition
from 25 percent to 12 percent of the total
that the tenor of the bill may adjust with
amount due.143
the times, or that the bill itself may fail to
As a final word, the Court takes judicial pass, according to the dynamism of the
notice of the pending Senate Bill No. 337, legislative process, especially in light of
entitled "An Act Prohibiting the Detention the objections interposed by interest
of Patients in Hospitals and Medical Clinics groups to date.147
on Grounds of Non-Payment of Hospital
WHEREFORE, the petition is GRANTED.
Bills or Medical Expenses," which declares,
The Decision of the Court of Appeals dated
among others, that it shall be unlawful for
October 2, 2001, together with the
any hospital or medical clinic to cause
Decision dated September 30, 1997 of the
directly or indirectly the detention of
Regional Trial Court in Civil Case No.
63958, is REVERSED and SET ASIDE.
Another judgment is entered dismissing
the Complaint and ordering respondents,
jointly and severally, to pay the petitioner
the amount of P865,592.95, with stipulated
interest of 12 percent reckoned from the
date of extrajudicial demand until full
payment, and 12 percent of the total
amount due as attorney's fees.
No pronouncement as to costs.
SO ORDERED.