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Introduction:

Mandatory Subject in Lawschool (Rules of Court 138, Sec 5)


Section 5. Additional requirements for other applicants. All applicants for admission other than those referred to in
the two preceding section shall, before being admitted to the examination, satisfactorily show that they have regularly
studied law for four years, and successfully completed all prescribed courses, in a law school or university, officially
approved and recognized by the Secretary of Education. The affidavit of the candidate, accompanied by a certificate from
the university or school of law, shall be filed as evidence of such facts, and further evidence may be required by the court.
No applicant shall be admitted to the bar examinations unless he has satisfactorily completed the following courses in a
law school or university duly recognized by the government: civil law, commercial law, remedial law, criminal law, public
and private international law, political law, labor and social legislation, medical jurisprudence, taxation and legal ethics
Medical jurisprudence: The branch of the law that deals with the application of law to medicine or, conversely, the
application of medical science to legal problems. Medical jurisprudence may be involved in cases concerning genetic
relationships (eg, paternity testing) or injury or death resulting from violence. An autopsy may be done to help determine
the agent of death (eg, a gun shot, poison) and how long the person has been dead.. Forensic medicine is also important
in cases involving rape. Modern techniques use such specimens as semen, blood, and hair to identify the body of a victim
and to compare the DNA of the criminal to that of the defendant through DNA fingerprinting.
(http://www.medicinenet.com/script/main/art.asp?articlekey=23312)
Forensic Medicine: The branch of medicine dealing with the application of medical knowledge to establish facts in civil or
criminal legal cases, such as an investigation into the cause and time of a suspicious death. Also known as forensic
pathology. (http://www.medicinenet.com/script/main/art.asp?articlekey=10606)
G.R. No. 86890 January 21, 1994
LEANDRO CARILLO, petitioner, vs. PEOPLE OF THE PHILIPPINES, respondent.
Facts:
The deceased, Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and Yolanda Acosta, complained to her
father at about 10:30 o'clock in the morning of May 31, 1981 of pains in the lower part of her abdomen. The child was
brought to Baclaran General Hospital and was scheduled for operation at 5:00 pm. The child was feeling very well when
brought to the operating room at 5:45 pm. The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was
assisted by appellant, Dr. Leandro Carillo, an anesthesiologists. At around 6:30 p.m., Dr. Emilio Madrid went outside the
operating room and Yolanda Acosta was allowed to enter the first door. When asked, the doctor told them the child was
already out of danger but the operation was not yet finished. It has also been established that the deceased was not
weighed before the administration of anesthesia on her. The operation was finished at 7:00 o'clock in the evening and
when the child was brought out from the operating room, she was observed to be shivering (nanginginig); her heart beat
was not normal; she was asleep and did not wake up; she was pale; and as if she had difficulty in breathing and Dr.
Emilio Madrid suggested that she placed under oxygen tank; that oxygen was administered to the child when she was
already in the room. When Catherine remained unconscious until noontime the next day, a neurologist examined her and
she was diagnosed as comatose. Three (3) days later, Catherine died without regaining consciousness. RTC and CA
convicted the accused.
Issue:
Whether or not the findings of fact of the Court of Appeals adequately support the conclusion that petitioner Dr. Carillo
was, along with Dr. Madrid, guilty of simple negligence which resulted in homicide.
Held:
YES. They are guilty of criminal negligence.
What is of critical importance for present purposes is not so much the identification of the "true cause" or "real cause" of
Catherine's death but rather the set of circumstances which both the trial court and the Court of Appeals found
constituted simple (as distinguished from reckless) negligence on the part of the two accused Dr. Madrid and Dr. Carillo
leading to the death of Catherine.
The circumstances are the following: (1) the failure of petitioner and Dr. Madrid to appreciate the serious post-surgery
condition of their patient and to monitor her condition and provide close patient care to her; (2) the summons of
petitioner by Dr. Madrid and the cardiologist after the patient's heart attack on the very evening that the surgery was
completed; (3) the low level of care and diligence exhibited by petitioner in failing to correct Dr. Madrid's prescription of

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Nubain for post-operative pain; (4) the extraordinary failure or refusal of petitioner and Dr. Madrid to inform the parents
of Catherine Acosta of her true condition after surgery, in disregard of the requirements of the Code of Medical Ethics;
and (5) the failure of petitioner and Dr. Madrid to prove that they had in fact exercised the necessary and appropriate
degree of care and diligence to prevent the sudden decline in the condition of Catherine Acosta and her death three (3)
days later, leads the Court to the conclusion, with moral certainty, that petitioner and Dr. Madrid were guilty of simple
negligence resulting in homicide. CA decision is AFFIRMED.
G.R. No. 118231 July 5, 1996
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs. COURT OF APPEALS, SPOUSES
QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS, respondents.
Facts:
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City from January 9, 1978
to September 1989. Mrs. Villegas is a married woman who submitted to Dr. Batiquin for prenatal care as the latter's
private patient sometime before September 21, 1988. In the morning of September 21, 1988 Dr. Batiquin, with the
assistance of Dr. Doris Teresita Sy, C.I. and O.R. Nurse Arlene Diones and some student nurses performed a simple
caesarean section on Mrs. Villegas at the Negros Oriental Provincial Hospital and after 45 minutes Mrs. Villegas
delivered her first child, Rachel Acogido, at about 11:45 that morning. On September 28, 1988 Mrs. Villegas checked out
of the Hospital. . . and on that same day she paid Dr. Batiquin, thru the latter's secretary, the amount of P1,500.00 as
"professional fee". Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and complained of being
feverish. She also gradually lost her appetite, so she consulted Dr. Batiquin at the latter's polyclinic who prescribed for
her certain medicines which she had been taking up to December, 1988. The abdominal pains and fever kept on recurring
and bothered Mrs. Villegas. When the pains became unbearable and she was rapidly losing weight she consulted Dr. Ma.
Salud Kho at the Holy Child's Hospital in Dumaguete City on January 20, 1989. Upon examination she felt an abdominal
mass one finger below the umbilicus which she suspected to be either a tumor of the uterus or an ovarian cyst, either of
which could be cancerous. The results of all examinations impelled Dr. Kho to suggest that Mrs. Villegas submit to
another surgery to which the latter agreed.
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow discharge inside, an ovarian cyst on each of
the left and right ovaries which gave out pus, dirt and pus behind the uterus, and a piece of rubber material on the right
side of the uterus embedded on [sic] the ovarian cyst, 2 inches by 3/4 inch in size. This piece of rubber material which Dr.
Kho described as a "foreign body" looked like a piece of a "rubber glove". . . and which is [sic] also "rubber-drain like". . . .
It could have been a torn section of a surgeon's gloves or could have come from other sources. And this foreign body was
the cause of the infection of the ovaries and consequently of all the discomfort suffered by Mrs. Villegas after her delivery
on September 21, 1988. RTC favored the doctors. CA reversed the decision.
Issue:
Whether or not the CA committed grave abuse of discretion.
Held:
NO. Dr. Kho saw a piece of rubber in private respondent Villegas's abdomen, and that she sent it to a laboratory and then
to Cebu City for examination by a pathologist. Not even the Pathologist's Report, although devoid of any mention of a
piece of rubber, could alter what Dr. Kho saw. Furthermore, Dr. Kho's knowledge of the piece of rubber could not be
based on other than first-hand knowledge. Petitioners cannot belie the fact that Dr. Kho found a piece of rubber near
private respondent Villegas's uterus. And even if we were to doubt Dr. Kho as to what she did to the piece of rubber, i.e.,
whether she threw it away or sent it to Cebu City, we are not justified in distrusting her as to her recovery of a piece of
rubber from private respondent Villegas's abdomen.
Considering that we have assessed Dr. Kho to be a credible witness, her positive testimony [that a piece of rubber was
indeed found in private respondent Villega's abdomen] prevails over the negative testimony in favor of the petitioners. As
such, the rule of res ipsa loquitur comes to fore. As Black's Law Dictionary puts it:
Res ipsa loquitur. The thing speaks for itself. It is [a] rule of evidence whereby negligence of [the] alleged wrongdoer may
be inferred from [the] mere fact that [the] accident happened provided [the] character of [the] accident and
circumstances attending it lead reasonably to belief that in [the] absence of negligence it would not have occurred and
that thing which caused injury is shown to have been under [the] management and control of [the] alleged wrongdoer.
***The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence which recognizes

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that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of
negligence. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is
absent and not readily available.
In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the
caesarean section were under the exclusive control of Dr. Batiquin. In this light, the private respondents were bereft of
direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent
Villegas's body, which, needless to say, does not occur unless through the intersection of negligence. Second, since aside
from the caesarean section, private respondent Villegas underwent no other operation which could have caused the
offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the
caesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the presumption of
negligence arising from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is therefore liable for negligently leaving
behind a piece of rubber in private respondent Villegas's abdomen and for all the adverse effects thereof.
As a final word, this Court reiterates its recognition of the vital role the medical profession plays in the lives of the people,
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 trauma."
[G.R. No. 118141. September 5, 1997]
LEONILA GARCIA-RUEDA, petitioner, vs. WILFREDO L. PASCASIO, RAUL R. ARNAU, ABELARDO L.
APORTADERA JR., Honorable CONDRADO M. VASQUEZ, all of the Office of the Ombudsman; JESUS F.
GUERRERO, PORFIRIO MACARAEG, and GREGORIO A. ARIZALA, all of the Office of the City
Prosecutor, Manila, respondents.
Facts:
Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent surgical operation at the UST hospital
for the removal of a stone blocking his ureter. He was attended by Dr. Domingo Antonio, Jr. who was the surgeon, while
Dr. Erlinda Balatbat-Reyes was the anaesthesiologist. Six hours after the surgery, however, Florencio died of
complications of unknown cause, according to officials of the UST Hospital. Not satisfied with the findings of the
hospital, petitioner requested the National Bureau of Investigation (NBI) to conduct an autopsy on her husbands
body. Consequently, the NBI ruled that Florencios death was due to lack of care by the attending physician in
administering anaesthesia. Pursuant to its findings, the NBI recommended that Dr. Domingo Antonio and Dr. Erlinda
Balatbat-Reyes be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor.
The case was initially assigned to Prosecutor Antonio M. Israel, who had to inhibit himself because he was related to
the counsel of one of the doctors. As a result, the case was re-raffled to Prosecutor Norberto G. Leono who was, however,
disqualified on motion of the petitioner since he disregarded prevailing laws and jurisprudence regarding preliminary
investigation. The case was then referred to Prosecutor Ramon O. Carisma, who issued a resolution recommending that
only Dr. Reyes be held criminally liable and that the complaint against Dr. Antonio be dismissed.
Assistant City Prosecutor Josefina Santos Sioson recommended that the case be re-raffled on the ground that
Prosecutor Carisma was partial to the petitioner. The case was transferred to Prosecutor Leoncia R. Dimagiba, where
a volte face occurred again with the endorsement that the complaint against Dr. Reyes be dismissed and instead, a
corresponding information be filed against Dr. Antonio. Petitioner filed a motion for reconsideration, questioning the
findings of Prosecutor Dimagiba.
Pending the resolution of petitioners motion for reconsideration regarding Prosecutor Dimagibas resolution, the
case was again assigned to another prosecutor, Eudoxia T. Gualberto, who recommended that Dr. Reyes be included in
the criminal information of Homicide through Reckless Imprudence. While the recommendation of Prosecutor
Gualberto was pending, the case was transferred to Senior State Prosecutor Gregorio A. Arizala, who resolved to
exonerate Dr. Reyes from any wrongdoing, a resolution which was approved by both City Prosecutor Porfirio G.
Macaraeg and City Prosecutor Jesus F. Guerrero.
Aggrieved, petitioner filed graft charges specifically for violation of Section 3(e) of Republic Act No. 3019 [3] against
Prosecutors Guerrero, Macaraeg, and Arizala for manifest partiality in favor of Dr. Reyes before the Office of the
Ombudsman. However, on July 11, 1994, the Ombudsman issued the assailed resolution dismissing the complaint for
lack of evidence.
In fine, petitioner assails the exercise of the discretionary power of the Ombudsman to review the recommendations
of the government prosecutors and to approve and disapprove the same. Petitioner faults the Ombudsman for, allegedly
in grave abuse of discretion, refusing to find that there exists probable cause to hold public respondent City Prosecutors
liable for violation of Section 3(e) of R.A. No. 3019.

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Issue:
Whether or not the Ombudsman acted in grave abuse of discretion in dismissing the case against the City Prosecutors.

Held:
From a procedural standpoint, it is certainly odd why the successive transfers from one prosecutor to another were not
sufficiently explained in the Resolution of the Ombudsman. Being the proper investigating authority with respect to
misfeasance, non-feasance and malfeasance of public officials, the Ombudsman should have been more vigilant and
assiduous in determining the reasons behind the buckpassing to ensure that no irregularity took place.
While it is true that a preliminary investigation is essentially inquisitorial, and is often the only means to discover
who may be charged with a crime, its function is merely to determine the existence of probable cause.
No less than the NBI pronounced after conducting an autopsy that there was indeed negligence on the part of the
attending physicians in administering the anaesthesia. [11] The fact of want of competence or diligence is evidentiary in
nature, the veracity of which can best be passed upon after a full-blown trial for it is virtually impossible to ascertain the
merits of a medical negligence case without extensive investigation, research, evaluation and consultations with medical
experts. Clearly, the City Prosecutors are not in a competent position to pass judgment on such a technical matter,
especially when there are conflicting evidence and findings. The bases of a partys accusation and defenses are better
ventilated at the trial proper than at the preliminary investigation.
A word on medical malpractice or negligence cases.
In its simplest terms, the type of lawsuit which has been called medical malpractice or, more appropriately, medical
negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical
professional which has caused bodily harm.
There are four elements involved in medical negligence cases: duty, breach, injury and proximate causation.
Dr. Antonio and Dr. Reyes in effect represented that, having the needed training and skill possessed by physicians
and surgeons practicing in the same field, they will employ such training, care and skill in the treatment of their patients.
[13]
They have a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a
condition under the same circumstances. The breach of these professional duties of skill and care, or their improper
performance, by a physician surgeon whereby the patient is injured in body or in health, constitutes actionable
malpractice.[14] Consequently, in the event that any injury results to the patient from want of due care or skill during the
operation, the surgeons may be held answerable in damages for negligence.
Another element in medical negligence cases is causation which is divided into two inquiries: whether the doctors
actions in fact caused the harm to the patient and whether these were the proximate cause of the patients injury. Indeed
here, a causal connection is discernible from the occurrence of the victims death after the negligent act of the
anaesthesiologist in administering the anesthesia, a fact which, if confirmed, should warrant the filing of the appropriate
criminal case. To be sure, the allegation of negligence is not entirely baseless.
The City Prosecutors were charged with violating Section 3(e) of the Anti-Graft and Corrupt Practices Act which
requires the following facts:
1. The accused is a public officer discharging administrative or official functions or private persons charged in
conspiracy with them;
2.
The public officer committed the prohibited act during the performance of his official duty or in relation to his
public position;
3.

The public officer acted with manifest partiality, evident bad faith or gross, inexcusable negligence; and

4.
His action caused undue injury to the Government or any private party, or gave any party any unwarranted benefit,
advantage or preference to such parties.
The better and more logical remedy under the circumstances would have been to appeal the resolution of the City
Prosecutors dismissing the criminal complaint to the Secretary of Justice under the Department of Justices Order No.
223, otherwise known as the 1993 Revised Rules on Appeals From Resolutions In Preliminary
Investigations/Reinvestigations, as amended by Department Order No. 359, Section 1 of which provides:

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Section 1. What May Be Appealed. - Only resolutions of the Chief State Prosecutor/Regional State Prosecutor/Provincial
or City Prosecutor dismissing a criminal complaint may be the subject of an appeal to the Secretary of Justice except as
otherwise provided in Section 4 hereof.
The Ombudsman acted within his power and authority in dismissing the complaint against the Prosecutors and this
Court will not interfere with the same. The instant petition is DISMISSED, without prejudice to the filing of an appeal by
the petitioner with the Secretary of Justice assailing the dismissal of her criminal complaint by the respondent City
Prosecutors.

G.R. No. 122445 November 18, 1997


DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, respondents.
Facts:
On March 22, 1991, Rowena Umali De Ocampo, accompanied her mother to the Perpetual Help Clinic and General
Hospital because Lydia was previously examined by the petitioner who found a "myoma" in her uterus, and scheduled
her for a hysterectomy operation on March 23,1991. Rowena noticed that the clinic was untidy and the window and the
floor were very dusty. Rowena tried to persuade her mother not to proceed with the operation. Lydia then informed
Rowena that the petitioner told her that she must be operated on as scheduled.
Rowena and a few relatives waited outside the operating room while Lydia underwent operation. Dr. Ercillo went out of
the operating room and instructed them to buy tagamet ampules. About one hour had passed when Dr. Ercillo came out
again this time to ask them to buy Type A blood for Lydia from the St. Gerald Blood Bank. Some thirty minutes after,
Lydia was brought out of the operating room in a stretcher and the petitioner asked Rowena and the other relatives to
buy additional blood for Lydia. A person arrived to donate blood which was later transfused to Lydia. Rowena then
noticed her mother, who was attached to an oxygen tank, gasping for breath. Apparently the oxygen supply had run out
and Rowena's husband together with the driver of the accused had to go to the San Pablo District Hospital to get oxygen.
Lydia was given the fresh supply of oxygen as soon as it arrived. But at around 10:00 o'clock P.M. she went into shock
and her blood pressure dropped to 60/50. Lydia's unstable condition necessitated her transfer to the San Pablo District
Hospital so she could be connected to a respirator and further examined. The transfer to the San Pablo District Hospital
was without the prior consent of Rowena nor of the other relatives present who found out about the intended transfer
only when an ambulance arrived to take Lydia to the San Pablo District Hospital.
Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating room and the petitioner and
Dr. Ercillo re-operated on her because there was blood oozing from the abdominal incision. The attending physicians
summoned Dr. Bartolome Angeles, head of the Obstetrics and Gynecology Department of the San Pablo District Hospital.
However, when Dr. Angeles arrived, Lydia was already in shock and possibly dead as her blood pressure was already 0/0.
Dr. Angeles then informed petitioner and Dr. Ercillo that there was nothing he could do to help save the patient. While
the petitioner was closing the abdominal wall, the patient died. Thus, on March 24, 1991, at 3:00 o'clock in the morning,
Lydia Umali was pronounced dead. Her death certificate states "shock" as the immediate cause of death and
"Disseminated Intravascular Coagulation (DIC)" as the antecedent cause.
MTCC found the petitioner doctors guilty. RTC and CA affirmed the decision.
Issue:
Whether or not CA acted in grave abuse of discretion in convicting petitioner.
Held:
YES. This Court finds the circumstances insufficient to sustain a judgment of conviction against the petitioner for the
crime of reckless imprudence resulting in homicide. The elements of reckless imprudence are: (1) that the offender does
or fails to do an act; (2) that the doing or the failure to do that act is voluntary; (3) that it be without malice; (4) that
material damage results from the reckless imprudence; and (5) that there is inexcusable lack of precaution on the part of
the offender, taking into consideration his employment or occupation, degree of intelligence, physical condition, and
other circumstances regarding persons, time and place.

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Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his patient is to be
determined according to the standard of care observed by other members of the profession in good standing under
similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state
of medical science. Immediately apparent from a review of the records of this case is the absence of any expert testimony
on the matter of the standard of care employed by other physicians of good standing in the conduct of similar operations.
The prosecution's expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National
Bureau of Investigation (NBI) only testified as to the possible cause of death but did not venture to illuminate the court
on the matter of the standard of care that petitioner should have exercised.
Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of
conduct falling below the standard of care employed by other physicians in good standing when performing the same
operation. It must be remembered that when the qualifications of a physician are admitted, as in the instant case, there is
an inevitable presumption that in proper cases he takes the necessary precaution and employs the best of his knowledge
and skill in attending to his clients, unless the contrary is sufficiently established. 32 This presumption is rebuttable by
expert opinion which is so sadly lacking in the case at bench.
Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of provisions; the
failure to conduct pre-operation tests on the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and
the reoperation performed on her by the petitioner do indicate, even without expert testimony, that petitioner was
recklessly imprudent in the exercise of her duties as a surgeon, no cogent proof exists that any of these circumstances
caused petitioner's death. Thus, the absence of the fourth element of reckless imprudence: that the injury to the person or
property was a consequence of the reckless imprudence.
In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's negligence and for a
reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a causal
connection of such breach and the resulting death of his patient.
The testimonies of both doctors establish hemorrhage or hemorrhagic shock as the cause of death. However, as likewise
testified to by the expert witnesses in open court, hemorrhage or hemorrhagic shock during surgery may be caused by
several different factors.
According to both doctors, the possible causes of hemorrhage during an operation are: (1) the failure of the surgeon to tie
or suture a cut blood vessel; (2) allowing a cut blood vessel to get out of control; (3) the subsequent loosening of the tie or
suture applied to a cut blood vessel; and (4) and a clotting defect known as DIC. It is significant to state at this juncture
that the autopsy conducted by Dr. Arizala on the body of Lydia did not reveal any untied or unsutured cut blood vessel
nor was there any indication that the tie or suture of a cut blood vessel had become loose thereby causing the
hemorrhage.
On the other hand, the findings of all three doctors do not preclude the probability that DIC caused the hemorrhage and
consequently, Lydia's death. DIC which is a clotting defect creates a serious bleeding tendency and when massive DIC
occurs as a complication of surgery leaving raw surface, major hemorrhage occurs. 42And as testified to by defense
witness, Dr. Bu C. Castro, hemorrhage due to DIC "cannot be prevented, it will happen to anyone,
anytime."
This Court has no recourse but to rely on the expert testimonies rendered by both prosecution and defense witnesses that
substantiate rather than contradict petitioner's allegation that the cause of Lydia's death was DIC which, as attested to by
an expert witness, cannot be attributed to the petitioner's fault or negligence. The probability that Lydia's death was
caused by DIC was unrebutted during trial and has engendered in the mind of this Court a reasonable doubt as to the
petitioner's guilt. Thus, her acquittal of the crime of reckless imprudence resulting in homicide.
For insufficiency of evidence this Court was not able to render a sentence of conviction but it is not blind to the reckless
and imprudent manner in which the petitioner carried out her duties.

G.R. No. 124354 December 29, 1999


ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of the minors,
ROMMEL RAMOS, ROY RODERICK RAMOS and RON RAYMOND RAMOS, petitioners, vs. COURT OF

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APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA
GUTIERREZ, respondents.
The Hippocratic Oath mandates physicians to give primordial consideration to the health and welfare of their patients. If
a doctor fails to live up to this precept, he is made accountable for his acts. A mistake, through gross negligence or
incompetence or plain human error, may spell the difference between life and death. In this sense, the doctor plays God
on his patient's fate. 1
In the case at bar, the Court is called upon to rule whether a surgeon, an anesthesiologist and a hospital should be made
liable for the unfortunate comatose condition of a patient scheduled for cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of Appeals, dated 29 May 1995, which overturned the
decision 4 of the Regional Trial Court, dated 30 January 1992, finding private respondents liable for damages arising
from negligence in the performance of their professional duties towards petitioner Erlinda Ramos resulting in her
comatose condition.
The antecedent facts as summarized by the trial court are reproduced hereunder:
Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old (Exh. "A") robust woman
(TSN, October 19, 1989, p. 10). Except for occasional complaints of discomfort due to pains allegedly
caused by the presence of a stone in her gall bladder (TSN, January 13, 1988, pp. 4-5), she was as normal
as any other woman. Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone
Company, she has three children whose names are Rommel Ramos, Roy Roderick Ramos and Ron
Raymond Ramos (TSN, October 19, 1989, pp. 5-6).
Because the discomforts somehow interfered with her normal ways, she sought professional advice. She
was advised to undergo an operation for the removal of a stone in her gall bladder (TSN, January 13,
1988, p. 5). She underwent a series of examinations which included blood and urine tests (Exhs. "A" and
"C") which indicated she was fit for surgery.
Through the intercession of a mutual friend, Dr. Buenviaje (TSN, January 13, 1988, p. 7), she and her
husband Rogelio met for the first time Dr. Orlino Hozaka (should be Hosaka; see TSN, February 20,
1990, p. 3), one of the defendants in this case, on June 10, 1985. They agreed that their date at the
operating table at the DLSMC (another defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka
decided that she should undergo a "cholecystectomy" operation after examining the documents (findings
from the Capitol Medical Center, FEU Hospital and DLSMC) presented to him. Rogelio E. Ramos,
however, asked Dr. Hosaka to look for a good anesthesiologist. Dr. Hosaka, in turn, assured Rogelio that
he will get a good anesthesiologist. Dr. Hosaka charged a fee of P16,000.00, which was to include the
anesthesiologist's fee and which was to be paid after the operation (TSN, October 19, 1989, pp. 14-15, 2223, 31-33; TSN, February 27, 1990, p. 13; and TSN, November 9, 1989, pp. 3-4, 10, 17).
A day before the scheduled date of operation, she was admitted at one of the rooms of the DLSMC,
located along E. Rodriguez Avenue, Quezon City (TSN, October 19,1989, p. 11).
At around 7:30 A.M. of June 17, 1985 and while still in her room, she was prepared for the operation by
the hospital staff. Her sister-in-law, Herminda Cruz, who was the Dean of the College of Nursing at the
Capitol Medical Center, was also there for moral support. She reiterated her previous request for
Herminda to be with her even during the operation. After praying, she was given injections. Her hands
were held by Herminda as they went down from her room to the operating room (TSN, January 13, 1988,
pp. 9-11). Her husband, Rogelio, was also with her (TSN, October 19, 1989, p. 18). At the operating room,
Herminda saw about two or three nurses and Dr. Perfecta Gutierrez, the other defendant, who was to
administer anesthesia. Although not a member of the hospital staff, Herminda introduced herself as
Dean of the College of Nursing at the Capitol Medical Center who was to provide moral support to the
patient, to them. Herminda was allowed to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a nearby phone to look for Dr. Hosaka who was not yet in
(TSN, January 13, 1988, pp. 11-12). Dr. Gutierrez thereafter informed Herminda Cruz about the prospect
of a delay in the arrival of Dr. Hosaka. Herminda then went back to the patient who asked, "Mindy, wala
pa ba ang Doctor"? The former replied, "Huwag kang mag-alaala, darating na iyon" (Ibid.).

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Page 7

Thereafter, Herminda went out of the operating room and informed the patient's husband, Rogelio, that
the doctor was not yet around (id., p. 13). When she returned to the operating room, the patient told her,
"Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor." So, she went out again and told Rogelio
about what the patient said (id., p. 15). Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was "already dying [and] waiting for the arrival of the doctor"
even as he did his best to find somebody who will allow him to pull out his wife from the operating room
(TSN, October 19, 1989, pp. 19-20). He also thought of the feeling of his wife, who was inside the
operating room waiting for the doctor to arrive (ibid.). At almost 12:00 noon, he met Dr. Garcia who
remarked that he (Dr. Garcia) was also tired of waiting for Dr. Hosaka to arrive (id., p. 21). While talking
to Dr. Garcia at around 12:10 P.M., he came to know that Dr. Hosaka arrived as a nurse remarked,
"Nandiyan na si Dr. Hosaka, dumating na raw." Upon hearing those words, he went down to the lobby
and waited for the operation to be completed (id., pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was inside the operating room with the patient, heard
somebody say that "Dr. Hosaka is already here." She then saw people inside the operating room "moving,
doing this and that, [and] preparing the patient for the operation" (TSN, January 13, 1988, p. 16). As she
held the hand of Erlinda Ramos, she then saw Dr. Gutierrez intubating the hapless patient. She
thereafter heard Dr. Gutierrez say, "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki
ang tiyan" (id., p. 17). Because of the remarks of Dra. Gutierrez, she focused her attention on what Dr.
Gutierrez was doing. She thereafter noticed bluish discoloration of the nailbeds of the left hand of the
hapless Erlinda even as Dr. Hosaka approached her. She then heard Dr. Hosaka issue an order for
someone to call Dr. Calderon, another anesthesiologist (id., p. 19). After Dr. Calderon arrived at the
operating room, she saw this anesthesiologist trying to intubate the patient. The patient's nailbed became
bluish and the patient was placed in a trendelenburg position a position where the head of the patient
is placed in a position lower than her feet which is an indication that there is a decrease of blood supply
to the patient's brain (Id., pp. 19-20). Immediately thereafter, she went out of the operating room, and
she told Rogelio E. Ramos "that something wrong was . . . happening" (Ibid.). Dr. Calderon was then able
to intubate the patient (TSN, July 25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the operating room, saw a respiratory machine being rushed
towards the door of the operating room. He also saw several doctors rushing towards the operating
room. When informed by Herminda Cruz that something wrong was happening, he told her (Herminda)
to be back with the patient inside the operating room (TSN, October 19, 1989, pp. 25-28).
Herminda Cruz immediately rushed back, and saw that the patient was still in trendelenburg position
(TSN, January 13, 1988, p. 20). At almost 3:00 P.M. of that fateful day, she saw the patient taken to the
Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos was able to talk to Dr. Hosaka. The latter informed the
former that something went wrong during the intubation. Reacting to what was told to him, Rogelio
reminded the doctor that the condition of his wife would not have happened, had he (Dr. Hosaka) looked
for a good anesthesiologist (TSN, October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked by the hospital to explain what happened to the patient.
The doctors explained that the patient had bronchospasm (TSN, November 15, 1990, pp. 26-27).
Erlinda Ramos stayed at the ICU for a month. About four months thereafter or on November 15, 1985,
the patient was released from the hospital.
During the whole period of her confinement, she incurred hospital bills amounting to P93,542.25 which
is the subject of a promissory note and affidavit of undertaking executed by Rogelio E. Ramos in favor of
DLSMC. Since that fateful afternoon of June 17, 1985, she has been in a comatose condition. She cannot
do anything. She cannot move any part of her body. She cannot see or hear. She is living on mechanical
means. She suffered brain damage as a result of the absence of oxygen in her brain for four to five
minutes (TSN, November 9, 1989, pp. 21-22). After being discharged from the hospital, she has been
staying in their residence, still needing constant medical attention, with her husband Rogelio incurring a
monthly expense ranging from P8,000.00 to P10,000.00 (TSN, October 19, 1989, pp. 32-34). She was
also diagnosed to be suffering from "diffuse cerebral parenchymal damage" (Exh. "G"; see also TSN,
December 21, 1989,
p. 6). 5

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Page 8

Thus, on 8 January 1986, petitioners filed a civil case 6 for damages with the Regional Trial Court of Quezon City against
herein private respondents alleging negligence in the management and care of Erlinda Ramos.
During the trial, both parties presented evidence as to the possible cause of Erlinda's injury. Plaintiff presented the
testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to prove that the sustained by Erlinda was due to lack of
oxygen in her brain caused by the faulty management of her airway by private respondents during the anesthesia phase.
On the other hand, private respondents primarily relied on the expert testimony of Dr. Eduardo Jamora, a
pulmonologist, to the effect that the cause of brain damage was Erlinda's allergic reaction to the anesthetic agent,
Thiopental Sodium (Pentothal).
After considering the evidence from both sides, the Regional Trial Court rendered judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in the finding of facts set forth earlier, and applying the aforecited
provisions of law and jurisprudence to the case at bar, this Court finds and so holds that defendants are
liable to plaintiffs for damages. The defendants were guilty of, at the very least, negligence in the
performance of their duty to plaintiff-patient Erlinda Ramos.
On the part of Dr. Perfecta Gutierrez, this Court finds that she omitted to exercise reasonable care in not
only intubating the patient, but also in not repeating the administration of atropine (TSN, August 20,
1991, pp. 5-10), without due regard to the fact that the patient was inside the operating room for almost
three (3) hours. For after she committed a mistake in intubating [the] patient, the patient's nailbed
became bluish and the patient, thereafter, was placed in trendelenburg position, because of the decrease
of blood supply to the patient's brain. The evidence further shows that the hapless patient suffered brain
damage because of the absence of oxygen in her (patient's) brain for approximately four to five minutes
which, in turn, caused the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds that he is liable for the acts of Dr. Perfecta Gutierrez
whom he had chosen to administer anesthesia on the patient as part of his obligation to provide the
patient a good anesthesiologist', and for arriving for the scheduled operation almost three (3) hours late.
On the part of DLSMC (the hospital), this Court finds that it is liable for the acts of negligence of the
doctors in their "practice of medicine" in the operating room. Moreover, the hospital is liable for failing
through its responsible officials, to cancel the scheduled operation after Dr. Hosaka inexcusably failed to
arrive on time.
In having held thus, this Court rejects the defense raised by defendants that they have acted with due
care and prudence in rendering medical services to plaintiff-patient. For if the patient was properly
intubated as claimed by them, the patient would not have become comatose. And, the fact that another
anesthesiologist was called to try to intubate the patient after her (the patient's) nailbed turned bluish,
belie their claim. Furthermore, the defendants should have rescheduled the operation to a later date.
This, they should have done, if defendants acted with due care and prudence as the patient's case was an
elective, not an emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing, judgment is rendered in favor of the plaintiffs and against
the defendants. Accordingly, the latter are ordered to pay, jointly and severally, the former the following
sums of money, to wit:
1) the sum of P8,000.00 as actual monthly expenses for the plaintiff Erlinda Ramos
reckoned from November 15, 1985 or in the total sum of P632,000.00 as of April 15,
1992, subject to its being updated;
2) the sum of P100,000.00 as reasonable attorney's fees;
3) the sum of P800,000.00 by way of moral damages and the further sum of
P200,000,00 by way of exemplary damages; and,
4) the costs of the suit.

Reyes, Hazel

Page 9

SO ORDERED. 7
Private respondents seasonably interposed an appeal to the Court of Appeals. The appellate court rendered a Decision,
dated 29 May 1995, reversing the findings of the trial court. The decretal portion of the decision of the appellate court
reads:
WHEREFORE, for the foregoing premises the appealed decision is hereby REVERSED, and the
complaint below against the appellants is hereby ordered DISMISSED. The counterclaim of appellant De
Los Santos Medical Center is GRANTED but only insofar as appellees are hereby ordered to pay the
unpaid hospital bills amounting to P93,542.25, plus legal interest for justice must be tempered with
mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June 1995 by petitioner Rogelio Ramos who was mistakenly
addressed as "Atty. Rogelio Ramos." No copy of the decision, however, was sent nor received by the Coronel Law Office,
then counsel on record of petitioners. Rogelio referred the decision of the appellate court to a new lawyer, Atty. Ligsay,
only on 20 June 1995, or four (4) days before the expiration of the reglementary period for filing a motion for
reconsideration. On the same day, Atty. Ligsay, filed with the appellate court a motion for extension of time to file a
motion for reconsideration. The motion for reconsideration was submitted on 4 July 1995. However, the appellate court
denied the motion for extension of time in its Resolution dated 25 July 1995. 9Meanwhile, petitioners engaged the
services of another counsel, Atty. Sillano, to replace Atty. Ligsay. Atty. Sillano filed on 7 August 1995 a motion to admit
the motion for reconsideration contending that the period to file the appropriate pleading on the assailed decision had
not yet commenced to run as the Division Clerk of Court of the Court of Appeals had not yet served a copy thereof to the
counsel on record. Despite this explanation, the appellate court still denied the motion to admit the motion for
reconsideration of petitioners in its Resolution, dated 29 March 1996, primarily on the ground that the fifteen-day (15)
period for filing a motion for reconsideration had already expired, to wit:
We said in our Resolution on July 25, 1995, that the filing of a Motion for Reconsideration cannot be
extended; precisely, the Motion for Extension (Rollo, p. 12) was denied. It is, on the other hand, admitted
in the latter Motion that plaintiffs/appellees received a copy of the decision as early as June 9, 1995.
Computation wise, the period to file a Motion for Reconsideration expired on June 24. The Motion for
Reconsideration, in turn, was received by the Court of Appeals already on July 4, necessarily, the 15-day
period already passed. For that alone, the latter should be denied.
Even assuming admissibility of the Motion for the Reconsideration, but after considering the
Comment/Opposition, the former, for lack of merit, is hereby DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on 11 April 1996. The next day, or on 12 April 1996, Atty.
Sillano filed before this Court a motion for extension of time to file the present petition for certiorari under Rule 45. The
Court granted the motion for extension of time and gave petitioners additional thirty (30) days after the expiration of the
fifteen-day (15) period counted from the receipt of the resolution of the Court of Appeals within which to submit the
petition. The due date fell on 27 May 1996. The petition was filed on 9 May 1996, well within the extended period given
by the Court.
Petitioners assail the decision of the Court of Appeals on the following grounds:
I
IN PUTTING MUCH RELIANCE ON THE TESTIMONIES OF RESPONDENTS DRA. GUTIERREZ,
DRA. CALDERON AND DR. JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF PETITIONER ERLINDA RAMOS;

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Page 10

III
IN NOT APPLYING THE DOCTRINE OF RES IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of the procedural issue on the timeliness of the petition in
relation to the motion for reconsideration filed by petitioners with the Court of Appeals. In their
Comment, 12 private respondents contend that the petition should not be given due course since the motion for
reconsideration of the petitioners on the decision of the Court of Appeals was validly dismissed by the appellate court for
having been filed beyond the reglementary period. We do not agree.
A careful review of the records reveals that the reason behind the delay in filing the motion for reconsideration is
attributable to the fact that the decision of the Court of Appeals was not sent to then counsel on record of petitioners, the
Coronel Law Office. In fact, a copy of the decision of the appellate court was instead sent to and received by petitioner
Rogelio Ramos on 9 June 1995 wherein he was mistakenly addressed as Atty. Rogelio Ramos. Based on the other
communications received by petitioner Rogelio Ramos, the appellate court apparently mistook him for the counsel on
record. Thus, no copy of the decision of the counsel on record. Petitioner, not being a lawyer and unaware of the
prescriptive period for filing a motion for reconsideration, referred the same to a legal counsel only on 20 June 1995.
It is elementary that when a party is represented by counsel, all notices should be sent to the party's lawyer at his given
address. With a few exceptions, notice to a litigant without notice to his counsel on record is no notice at all. In the
present case, since a copy of the decision of the appellate court was not sent to the counsel on record of petitioner, there
can be no sufficient notice to speak of. Hence, the delay in the filing of the motion for reconsideration cannot be taken
against petitioner. Moreover, since the Court of Appeals already issued a second Resolution, dated 29 March 1996, which
superseded the earlier resolution issued on 25 July 1995, and denied the motion for reconsideration of petitioner, we
believed that the receipt of the former should be considered in determining the timeliness of the filing of the present
petition. Based on this, the petition before us was submitted on time.
After resolving the foregoing procedural issue, we shall now look into the merits of the case. For a more logical
presentation of the discussion we shall first consider the issue on the applicability of the doctrine of res ipsa loquitur to
the instant case. Thereafter, the first two assigned errors shall be tackled in relation to the res ipsa loquitur doctrine.
Res ipsa loquitur is a Latin phrase which literally means "the thing or the transaction speaks for itself." The phrase "res
ipsa loquitur'' is a maxim for the rule that the fact of the occurrence of an injury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of negligence, or make out a plaintiff's prima faciecase,
and present a question of fact for defendant to meet with an explanation. 13 Where the thing which caused the injury
complained of is shown to be under the management of the defendant or his servants and the accident is such as in
ordinary course of things does not happen if those who have its management or control use proper care, it affords
reasonable evidence, in the absence of explanation by the defendant, that the accident arose from or was caused by the
defendant's want of care. 14
The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common knowledge and
experience, the very nature of certain types of occurrences may justify an inference of negligence on the part of the person
who controls the instrumentality causing the injury in the absence of some explanation by the defendant who is charged
with negligence. 15 It is grounded in the superior logic of ordinary human experience and on the basis of such experience
or common knowledge, negligence may be deduced from the mere occurrence of the accident itself. 16 Hence, res ipsa
loquitur is applied in conjunction with the doctrine of common knowledge.
However, much has been said that res ipsa loquitur is not a rule of substantive law and, as such, does not create or
constitute an independent or separate ground of liability. 17 Instead, it is considered as merely evidentiary or in the nature
of a procedural rule. 18 It is regarded as a mode of proof, or a mere procedural of convenience since it furnishes a
substitute for, and relieves a plaintiff of, the burden of producing specific proof of negligence. 19 In other words, mere
invocation and application of the doctrine does not dispense with the requirement of proof of negligence. It is simply a
step in the process of such proof, permitting the plaintiff to present along with the proof of the accident, enough of the
attending circumstances to invoke the doctrine, creating an inference or presumption of negligence, and to thereby place
on the defendant the burden of going forward with the proof. 20 Still, before resort to the doctrine may be allowed, the
following requisites must be satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur in the absence of someone's
negligence;

Reyes, Hazel

Page 11

2. It is caused by an instrumentality within the exclusive control of the defendant or


defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated. 21
In the above requisites, the fundamental element is the "control of instrumentality" which caused the damage. 22Such
element of control must be shown to be within the dominion of the defendant. In order to have the benefit of the rule, a
plaintiff, in addition to proving injury or damage, must show a situation where it is applicable, and must establish that
the essential elements of the doctrine were present in a particular incident. 23
Medical malpractice 24 cases do not escape the application of this doctrine. Thus, res ipsa loquitur has been applied when
the circumstances attendant upon the harm are themselves of such a character as to justify an inference of negligence as
the cause of that harm. 25 The application of res ipsa loquitur in medical negligence cases presents a question of law since
it is a judicial function to determine whether a certain set of circumstances does, as a matter of law, permit a given
inference. 26
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitur is
availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. 27 The reason is that the general rule on the necessity of expert testimony applies only to such matters
clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind
which may be testified to by anyone familiar with the facts. 28 Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of
skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and
manifest conditions which are observable by any one may be given by non-expert witnesses. 29 Hence, in cases where
theres ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the
patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the
proper standard of care. 30 Where common knowledge and experience teach that a resulting injury would not have
occurred to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an
application of the doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only
what occurred but how and why it occurred. 31 When the doctrine is appropriate, all that the patient must do is prove a
nexus between the particular act or omission complained of and the injury sustained while under the custody and
management of the defendant without need to produce expert medical testimony to establish the standard of care. Resort
to res ipsa loquitur is allowed because there is no other way, under usual and ordinary conditions, by which the patient
can obtain redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in the
body of the patient after an operation, 32 injuries sustained on a healthy part of the body which was not under, or in the
area, of treatment, 33 removal of the wrong part of the body when another part was intended, 34 knocking out a tooth
while a patient's jaw was under anesthetic for the removal of his tonsils, 35 and loss of an eye while the patient plaintiff
was under the influence of anesthetic, during or following an operation for appendicitis, 36 among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does not automatically
apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant to show that he is
not guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a
rule to be cautiously applied, depending upon the circumstances of each case. It is generally restricted to situations in
malpractice cases where a layman is able to say, as a matter of common knowledge and observation, that the
consequences of professional care were not as such as would ordinarily have followed if due care had been
exercised. 37 A distinction must be made between the failure to secure results, and the occurrence of something more
unusual and not ordinarily found if the service or treatment rendered followed the usual procedure of those skilled in that
particular practice. It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a
physician or surgeon which involves the merits of a diagnosis or of a scientific treatment. 38 The physician or surgeon is
not required at his peril to explain why any particular diagnosis was not correct, or why any particular scientific
treatment did not produce the desired result. 39 Thus, res ipsa loquitur is not available in a malpractice suit if the only
showing is that the desired result of an operation or treatment was not accomplished. 40 The real question, therefore, is
whether or not in the process of the operation any extraordinary incident or unusual event outside of the routine
performance occurred which is beyond the regular scope of customary professional activity in such operations, which, if
unexplained would themselves reasonably speak to the average man as the negligent cause or causes of the untoward
consequence. 41 If there was such extraneous interventions, the doctrine of res ipsa loquitur may be utilized and the
defendant is called upon to explain the matter, by evidence of exculpation, if he could. 42

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Page 12

We find the doctrine of res ipsa loquitur appropriate in the case at bar. As will hereinafter be explained, the damage
sustained by Erlinda in her brain prior to a scheduled gall bladder operation presents a case for the application of res
ipsa loquitur.
A case strikingly similar to the one before us is Voss vs. Bridwell, 43 where the Kansas Supreme Court in applying theres
ipsa loquitur stated:
The plaintiff herein submitted himself for a mastoid operation and delivered his person over to the care,
custody and control of his physician who had complete and exclusive control over him, but the operation
was never performed. At the time of submission he was neurologically sound and physically fit in mind
and body, but he suffered irreparable damage and injury rendering him decerebrate and totally
incapacitated. The injury was one which does not ordinarily occur in the process of a mastoid operation
or in the absence of negligence in the administration of an anesthetic, and in the use and employment of
an endoctracheal tube. Ordinarily a person being put under anesthesia is not rendered decerebrate as a
consequence of administering such anesthesia in the absence of negligence. Upon these facts and under
these circumstances a layman would be able to say, as a matter of common knowledge and observation,
that the consequences of professional treatment were not as such as would ordinarily have followed if
due care had been exercised.
Here the plaintiff could not have been guilty of contributory negligence because he was under the
influence of anesthetics and unconscious, and the circumstances are such that the true explanation of
event is more accessible to the defendants than to the plaintiff for they had the exclusive control of the
instrumentalities of anesthesia.
Upon all the facts, conditions and circumstances alleged in Count II it is held that a cause of action is
stated under the doctrine of res ipsa loquitur. 44
Indeed, the principles enunciated in the aforequoted case apply with equal force here. In the present case, Erlinda
submitted herself for cholecystectomy and expected a routine general surgery to be performed on her gall bladder. On
that fateful day she delivered her person over to the care, custody and control of private respondents who exercised
complete and exclusive control over her. At the time of submission, Erlinda was neurologically sound and, except for a
few minor discomforts, was likewise physically fit in mind and body. However, during the administration of anesthesia
and prior to the performance of cholecystectomy she suffered irreparable damage to her brain. Thus, without undergoing
surgery, she went out of the operating room already decerebrate and totally incapacitated. Obviously, brain damage,
which Erlinda sustained, is an injury which does not normally occur in the process of a gall bladder operation. In fact,
this kind of situation does not in the absence of negligence of someone in the administration of anesthesia and in the use
of endotracheal tube. Normally, a person being put under anesthesia is not rendered decerebrate as a consequence of
administering such anesthesia if the proper procedure was followed. Furthermore, the instruments used in the
administration of anesthesia, including the endotracheal tube, were all under the exclusive control of private
respondents, who are the physicians-in-charge. Likewise, petitioner Erlinda could not have been guilty of contributory
negligence because she was under the influence of anesthetics which rendered her unconscious.
Considering that a sound and unaffected member of the body (the brain) is injured or destroyed while the patient is
unconscious and under the immediate and exclusive control of the physicians, we hold that a practical administration of
justice dictates the application of res ipsa loquitur. Upon these facts and under these circumstances the Court would be
able to say, as a matter of common knowledge and observation, if negligence attended the management and care of the
patient. Moreover, the liability of the physicians and the hospital in this case is not predicated upon an alleged failure to
secure the desired results of an operation nor on an alleged lack of skill in the diagnosis or treatment as in fact no
operation or treatment was ever performed on Erlinda. Thus, upon all these initial determination a case is made out for
the application of the doctrine of res ipsa loquitur.
Nonetheless, in holding that res ipsa loquitur is available to the present case we are not saying that the doctrine is
applicable in any and all cases where injury occurs to a patient while under anesthesia, or to any and all anesthesia cases.
Each case must be viewed in its own light and scrutinized in order to be within the res ipsa loquitur coverage.
Having in mind the applicability of the res ipsa loquitur doctrine and the presumption of negligence allowed therein, the
Court now comes to the issue of whether the Court of Appeals erred in finding that private respondents were not
negligent in the care of Erlinda during the anesthesia phase of the operation and, if in the affirmative, whether the alleged
negligence was the proximate cause of Erlinda's comatose condition. Corollary thereto, we shall also determine if the
Court of Appeals erred in relying on the testimonies of the witnesses for the private respondents.

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Page 13

In sustaining the position of private respondents, the Court of Appeals relied on the testimonies of Dra. Gutierrez, Dra.
Calderon and Dr. Jamora. In giving weight to the testimony of Dra. Gutierrez, the Court of Appeals rationalized that she
was candid enough to admit that she experienced some difficulty in the endotracheal intubation 45 of the patient and
thus, cannot be said to be covering her negligence with falsehood. The appellate court likewise opined that private
respondents were able to show that the brain damage sustained by Erlinda was not caused by the alleged faulty
intubation but was due to the allergic reaction of the patient to the drug Thiopental Sodium (Pentothal), a short-acting
barbiturate, as testified on by their expert witness, Dr. Jamora. On the other hand, the appellate court rejected the
testimony of Dean Herminda Cruz offered in favor of petitioners that the cause of the brain injury was traceable to the
wrongful insertion of the tube since the latter, being a nurse, was allegedly not knowledgeable in the process of
intubation. In so holding, the appellate court returned a verdict in favor of respondents physicians and hospital and
absolved them of any liability towards Erlinda and her family.
We disagree with the findings of the Court of Appeals. We hold that private respondents were unable to disprove the
presumption of negligence on their part in the care of Erlinda and their negligence was the proximate cause of her
piteous condition.
In the instant case, the records are helpful in furnishing not only the logical scientific evidence of the pathogenesis of the
injury but also in providing the Court the legal nexus upon which liability is based. As will be shown hereinafter, private
respondents' own testimonies which are reflected in the transcript of stenographic notes are replete of signposts
indicative of their negligence in the care and management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of Erlinda during the anesthesia phase. As borne by the
records, respondent Dra. Gutierrez failed to properly intubate the patient. This fact was attested to by Prof. Herminda
Cruz, Dean of the Capitol Medical Center School of Nursing and petitioner's sister-in-law, who was in the operating room
right beside the patient when the tragic event occurred. Witness Cruz testified to this effect:
ATTY. PAJARES:
Q: In particular, what did Dra. Perfecta Gutierrez do, if any on the patient?
A: In particular, I could see that she was intubating the patient.
Q: Do you know what happened to that intubation process administered by Dra.
Gutierrez?
ATTY. ALCERA:
She will be incompetent Your Honor.
COURT:
Witness may answer if she knows.
A: As have said, I was with the patient, I was beside the stretcher holding the left hand of
the patient and all of a sudden heard some remarks coming from Dra. Perfecta Gutierrez
herself. She was saying "Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O
lumalaki ang tiyan.
xxx xxx xxx
ATTY. PAJARES:
Q: From whom did you hear those words "lumalaki ang tiyan"?
A: From Dra. Perfecta Gutierrez.
xxx xxx xxx
Q: After hearing the phrase "lumalaki ang tiyan," what did you notice on the person of
the patient?
A: I notice (sic) some bluish discoloration on the nailbeds of the left hand where I was at.
Q: Where was Dr. Orlino Ho[s]aka then at that particular time?
A: I saw him approaching the patient during that time.
Q: When he approached the patient, what did he do, if any?
A: He made an order to call on the anesthesiologist in the person of Dr. Calderon.
Q: Did Dr. Calderon, upon being called, arrive inside the operating room?
A: Yes sir.
Q: What did [s]he do, if any?
A: [S]he tried to intubate the patient.
Q: What happened to the patient?
A: When Dr. Calderon try (sic) to intubate the patient, after a while the patient's nailbed
became bluish and I saw the patient was placed in trendelenburg position.
xxx xxx xxx
Q: Do you know the reason why the patient was placed in that trendelenburg position?
A: As far as I know, when a patient is in that position, there is a decrease of blood supply
to the brain. 46

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xxx xxx xxx


The appellate court, however, disbelieved Dean Cruz's testimony in the trial court by declaring that:
A perusal of the standard nursing curriculum in our country will show that intubation is not taught as
part of nursing procedures and techniques. Indeed, we take judicial notice of the fact that nurses do not,
and cannot, intubate. Even on the assumption that she is fully capable of determining whether or not a
patient is properly intubated, witness Herminda Cruz, admittedly, did not peep into the throat of the
patient. (TSN, July 25, 1991, p. 13). More importantly, there is no evidence that she ever auscultated the
patient or that she conducted any type of examination to check if the endotracheal tube was in its proper
place, and to determine the condition of the heart, lungs, and other organs. Thus, witness Cruz's
categorical statements that appellant Dra. Gutierrez failed to intubate the appellee Erlinda Ramos and
that it was Dra. Calderon who succeeded in doing so clearly suffer from lack of sufficient factual bases. 47
In other words, what the Court of Appeals is trying to impress is that being a nurse, and considered a layman in the
process of intubation, witness Cruz is not competent to testify on whether or not the intubation was a success.
We do not agree with the above reasoning of the appellate court. Although witness Cruz is not an anesthesiologist, she
can very well testify upon matters on which she is capable of observing such as, the statements and acts of the physician
and surgeon, external appearances, and manifest conditions which are observable by any one. 48 This is precisely allowed
under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. It is the accepted rule that
expert testimony is not necessary for the proof of negligence in non-technical matters or those of which an ordinary
person may be expected to have knowledge, or where the lack of skill or want of care is so obvious as to render expert
testimony unnecessary. 49 We take judicial notice of the fact that anesthesia procedures have become so common, that
even an ordinary person can tell if it was administered properly. As such, it would not be too difficult to tell if the tube
was properly inserted. This kind of observation, we believe, does not require a medical degree to be acceptable.
At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long experience and scholarship led
to her appointment as Dean of the Capitol Medical Center School at Nursing, was fully capable of determining whether or
not the intubation was a success. She had extensive clinical experience starting as a staff nurse in Chicago, Illinois; staff
nurse and clinical instructor in a teaching hospital, the FEU-NRMF; Dean of the Laguna College of Nursing in San Pablo
City; and then Dean of the Capitol Medical Center School of Nursing. 50Reviewing witness Cruz' statements, we find that
the same were delivered in a straightforward manner, with the kind of detail, clarity, consistency and spontaneity which
would have been difficult to fabricate. With her clinical background as a nurse, the Court is satisfied that she was able to
demonstrate through her testimony what truly transpired on that fateful day.
Most of all, her testimony was affirmed by no less than respondent Dra. Gutierrez who admitted that she experienced
difficulty in inserting the tube into Erlinda's trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case, Doctora, while you were intubating at your first attempt (sic),
you did not immediately see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube immediately?
A: You do not pull the . . .
Q: Did you or did you not?
A: I did not pull the tube.
Q: When you said "mahirap yata ito," what were you referring to?
A: "Mahirap yata itong i-intubate," that was the patient.
Q: So, you found some difficulty in inserting the tube?
A: Yes, because of (sic) my first attempt, I did not see right away. 51
Curiously in the case at bar, respondent Dra. Gutierrez made the haphazard defense that she encountered hardship in the
insertion of the tube in the trachea of Erlinda because it was positioned more anteriorly (slightly deviated from the
normal anatomy of a person) 52 making it harder to locate and, since Erlinda is obese and has a short neck and protruding
teeth, it made intubation even more difficult.
The argument does not convince us. If this was indeed observed, private respondents adduced no evidence
demonstrating that they proceeded to make a thorough assessment of Erlinda's airway, prior to the induction of

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anesthesia, even if this would mean postponing the procedure. From their testimonies, it appears that the observation
was made only as an afterthought, as a means of defense.
The pre-operative evaluation of a patient prior to the administration of anesthesia is universally observed to lessen the
possibility of anesthetic accidents. Pre-operative evaluation and preparation for anesthesia begins when the
anesthesiologist reviews the patient's medical records and visits with the patient, traditionally, the day before elective
surgery. 53 It includes taking the patient's medical history, review of current drug therapy, physical examination and
interpretation of laboratory data. 54 The physical examination performed by the anesthesiologist is directed primarily
toward the central nervous system, cardiovascular system, lungs and upper airway. 55 A thorough analysis of the
patient's airway normally involves investigating the following: cervical spine mobility, temporomandibular mobility,
prominent central incisors, diseased or artificial teeth, ability to visualize uvula and the thyromental distance. 56 Thus,
physical characteristics of the patient's upper airway that could make tracheal intubation difficult should be
studied. 57 Where the need arises, as when initial assessment indicates possible problems (such as the alleged short neck
and protruding teeth of Erlinda) a thorough examination of the patient's airway would go a long way towards decreasing
patient morbidity and mortality.
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first time on the day of the operation
itself, on 17 June 1985. Before this date, no prior consultations with, or pre-operative evaluation of Erlinda was done by
her. Until the day of the operation, respondent Dra. Gutierrez was unaware of the physiological make-up and needs of
Erlinda. She was likewise not properly informed of the possible difficulties she would face during the administration of
anesthesia to Erlinda. Respondent Dra. Gutierrez' act of seeing her patient for the first time only an hour before the
scheduled operative procedure was, therefore, an act of exceptional negligence and professional irresponsibility. The
measures cautioning prudence and vigilance in dealing with human lives lie at the core of the physician's centuries-old
Hippocratic Oath. Her failure to follow this medical procedure is, therefore, a clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this omission by playing around with the trial court's
ignorance of clinical procedure, hoping that she could get away with it. Respondent Dra. Gutierrez tried to muddle the
difference between an elective surgery and an emergency surgery just so her failure to perform the required pre-operative
evaluation would escape unnoticed. In her testimony she asserted:
ATTY. LIGSAY:
Q: Would you agree, Doctor, that it is good medical practice to see the patient a day
before so you can introduce yourself to establish good doctor-patient relationship and
gain the trust and confidence of the patient?
DRA. GUTIERREZ:
A: As I said in my previous statement, it depends on the operative procedure of the
anesthesiologist and in my case, with elective cases and normal cardio-pulmonary
clearance like that, I usually don't do it except on emergency and on cases that have an
abnormalities (sic). 58
However, the exact opposite is true. In an emergency procedure, there is hardly enough time available for the fastidious
demands of pre-operative procedure so that an anesthesiologist is able to see the patient only a few minutes before
surgery, if at all. Elective procedures, on the other hand, are operative procedures that can wait for days, weeks or even
months. Hence, in these cases, the anesthesiologist possesses the luxury of time to be at the patient's beside to do a
proper interview and clinical evaluation. There is ample time to explain the method of anesthesia, the drugs to be used,
and their possible hazards for purposes of informed consent. Usually, the pre-operative assessment is conducted at least
one day before the intended surgery, when the patient is relaxed and cooperative.
Erlinda's case was elective and this was known to respondent Dra. Gutierrez. Thus, she had all the time to make a
thorough evaluation of Erlinda's case prior to the operation and prepare her for anesthesia. However, she never saw the
patient at the bedside. She herself admitted that she had seen petitioner only in the operating room, and only on the
actual date of the cholecystectomy. She negligently failed to take advantage of this important opportunity. As such, her
attempt to exculpate herself must fail.
Having established that respondent Dra. Gutierrez failed to perform pre-operative evaluation of the patient which, in
turn, resulted to a wrongful intubation, we now determine if the faulty intubation is truly the proximate cause of Erlinda's
comatose condition.
Private respondents repeatedly hammered the view that the cerebral anoxia which led to Erlinda's coma was due to
bronchospasm 59 mediated by her allergic response to the drug, Thiopental Sodium, introduced into her system. Towards
this end, they presented Dr. Jamora, a Fellow of the Philippine College of Physicians and Diplomate of the Philippine

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Specialty Board of Internal Medicine, who advanced private respondents' theory that the oxygen deprivation which led to
anoxic encephalopathy, 60 was due to an unpredictable drug reaction to the short-acting barbiturate. We find the theory
of private respondents unacceptable.
First of all, Dr. Jamora cannot be considered an authority in the field of anesthesiology simply because he is not an
anesthesiologist. Since Dr. Jamora is a pulmonologist, he could not have been capable of properly enlightening the court
about anesthesia practice and procedure and their complications. Dr. Jamora is likewise not an allergologist and could
not therefore properly advance expert opinion on allergic-mediated processes. Moreover, he is not a pharmacologist and,
as such, could not have been capable, as an expert would, of explaining to the court the pharmacologic and toxic effects of
the supposed culprit, Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora's testimony as an expert witness in the anesthetic practice
of Pentothal administration is further supported by his own admission that he formulated his opinions on the drug not
from the practical experience gained by a specialist or expert in the administration and use of Sodium Pentothal on
patients, but only from reading certain references, to wit:
ATTY. LIGSAY:
Q: In your line of expertise on pulmonology, did you have any occasion to use pentothal
as a method of management?
DR. JAMORA:
A: We do it in conjunction with the anesthesiologist when they have to intubate our
patient.
Q: But not in particular when you practice pulmonology?
A: No.
Q: In other words, your knowledge about pentothal is based only on what you have read
from books and not by your own personal application of the medicine pentothal?
A: Based on my personal experience also on pentothal.
Q: How many times have you used pentothal?
A: They used it on me. I went into bronchospasm during my appendectomy.
Q: And because they have used it on you and on account of your own personal
experience you feel that you can testify on pentothal here with medical authority?
A: No. That is why I used references to support my claims. 61
An anesthetic accident caused by a rare drug-induced bronchospasm properly falls within the fields of anesthesia,
internal medicine-allergy, and clinical pharmacology. The resulting anoxic encephalopathy belongs to the field of
neurology. While admittedly, many bronchospastic-mediated pulmonary diseases are within the expertise of pulmonary
medicine, Dr. Jamora's field, the anesthetic drug-induced, allergic mediated bronchospasm alleged in this case is within
the disciplines of anesthesiology, allergology and pharmacology. On the basis of the foregoing transcript, in which the
pulmonologist himself admitted that he could not testify about the drug with medical authority, it is clear that the
appellate court erred in giving weight to Dr. Jamora's testimony as an expert in the administration of Thiopental Sodium.
The provision in the rules of evidence 62 regarding expert witnesses states:
Sec. 49. Opinion of expert witness. The opinion of a witness on a matter requiring special knowledge,
skill, experience or training which he is shown to possess, may be received in evidence.
Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject matter about which
he or she is to testify, either by the study of recognized authorities on the subject or by practical experience. 63 Clearly, Dr.
Jamora does not qualify as an expert witness based on the above standard since he lacks the necessary knowledge, skill,
and training in the field of anesthesiology. Oddly, apart from submitting testimony from a specialist in the wrong field,
private respondents' intentionally avoided providing testimony by competent and independent experts in the proper
areas.
Moreover, private respondents' theory, that Thiopental Sodium may have produced Erlinda's coma by triggering an
allergic mediated response, has no support in evidence. No evidence of stridor, skin reactions, or wheezing some of the
more common accompanying signs of an allergic reaction appears on record. No laboratory data were ever presented
to the court.
In any case, private respondents themselves admit that Thiopental induced, allergic-mediated bronchospasm happens
only very rarely. If courts were to accept private respondents' hypothesis without supporting medical proof, and against

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the weight of available evidence, then every anesthetic accident would be an act of God. Evidently, the Thiopental-allergy
theory vigorously asserted by private respondents was a mere afterthought. Such an explanation was advanced in order
to advanced in order to absolve them of any and all responsibility for the patient's condition.
In view of the evidence at hand, we are inclined to believe petitioners' stand that it was the faulty intubation which was
the proximate cause of Erlinda's comatose condition.
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient
intervening cause, produces injury, and without which the result would not have occurred. 64 An injury or damage is
proximately caused by an act or a failure to act, whenever it appears from the evidence in the case, that the act or
omission played a substantial part in bringing about or actually causing the injury or damage; and that the injury or
damage was either a direct result or a reasonably probable consequence of the act or omission. 65 It is the dominant,
moving or producing cause.
Applying the above definition in relation to the evidence at hand, faulty intubation is undeniably the proximate cause
which triggered the chain of events leading to Erlinda's brain damage and, ultimately, her comatosed condition.
Private respondents themselves admitted in their testimony that the first intubation was a failure. This fact was likewise
observed by witness Cruz when she heard respondent Dra. Gutierrez remarked, "Ang hirap ma-intubate nito, mali yata
ang pagkakapasok. O lumalaki ang tiyan." Thereafter, witness Cruz noticed abdominal distention on the body of Erlinda.
The development of abdominal distention, together with respiratory embarrassment indicates that the endotracheal tube
entered the esophagus instead of the respiratory tree. In other words, instead of the intended endotracheal intubation
what actually took place was an esophageal intubation. During intubation, such distention indicates that air has entered
the gastrointestinal tract through the esophagus instead of the lungs through the trachea. Entry into the esophagus would
certainly cause some delay in oxygen delivery into the lungs as the tube which carries oxygen is in the wrong place. That
abdominal distention had been observed during the first intubation suggests that the length of time utilized in inserting
the endotracheal tube (up to the time the tube was withdrawn for the second attempt) was fairly significant. Due to the
delay in the delivery of oxygen in her lungs Erlinda showed signs of cyanosis. 66 As stated in the testimony of Dr. Hosaka,
the lack of oxygen became apparent only after he noticed that the nailbeds of Erlinda were already blue. 67 However,
private respondents contend that a second intubation was executed on Erlinda and this one was successfully done. We do
not think so. No evidence exists on record, beyond private respondents' bare claims, which supports the contention that
the second intubation was successful. Assuming that the endotracheal tube finally found its way into the proper orifice of
the trachea, the same gave no guarantee of oxygen delivery, the hallmark of a successful intubation. In fact, cyanosis was
again observed immediately after the second intubation. Proceeding from this event (cyanosis), it could not be claimed,
as private respondents insist, that the second intubation was accomplished. Even granting that the tube was successfully
inserted during the second attempt, it was obviously too late. As aptly explained by the trial court, Erlinda already
suffered brain damage as a result of the inadequate oxygenation of her brain for about four to five minutes. 68
The above conclusion is not without basis. Scientific studies point out that intubation problems are responsible for onethird (1/3) of deaths and serious injuries associated with anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the
vast majority of difficult intubations may be anticipated by performing a thorough evaluation of the patient's airway prior
to the operation. 70 As stated beforehand, respondent Dra. Gutierrez failed to observe the proper pre-operative protocol
which could have prevented this unfortunate incident. Had appropriate diligence and reasonable care been used in the
pre-operative evaluation, respondent physician could have been much more prepared to meet the contingency brought
about by the perceived anatomic variations in the patient's neck and oral area, defects which would have been easily
overcome by a prior knowledge of those variations together with a change in technique. 71 In other words, an experienced
anesthesiologist, adequately alerted by a thorough pre-operative evaluation, would have had little difficulty going around
the short neck and protruding teeth. 72 Having failed to observe common medical standards in pre-operative
management and intubation, respondent Dra. Gutierrez' negligence resulted in cerebral anoxia and eventual coma of
Erlinda.
We now determine the responsibility of respondent Dr. Orlino Hosaka as the head of the surgical team. As the so-called
"captain of the ship," 73 it is the surgeon's responsibility to see to it that those under him perform their task in the proper
manner. Respondent Dr. Hosaka's negligence can be found in his failure to exercise the proper authority (as the "captain"
of the operative team) in not determining if his anesthesiologist observed proper anesthesia protocols. In fact, no
evidence on record exists to show that respondent Dr. Hosaka verified if respondent Dra. Gutierrez properly intubated
the patient. Furthermore, it does not escape us that respondent Dr. Hosaka had scheduled another procedure in a
different hospital at the same time as Erlinda's cholecystectomy, and was in fact over three hours late for the latter's
operation. Because of this, he had little or no time to confer with his anesthesiologist regarding the anesthesia delivery.
This indicates that he was remiss in his professional duties towards his patient. Thus, he shares equal responsibility for
the events which resulted in Erlinda's condition.

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We now discuss the responsibility of the hospital in this particular incident. The unique practice (among private
hospitals) of filling up specialist staff with attending and visiting "consultants," 74 who are allegedly not hospital
employees, presents problems in apportioning responsibility for negligence in medical malpractice cases. However, the
difficulty is only more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their
work within the hospital premises. Doctors who apply for "consultant" slots, visiting or attending, are required to submit
proof of completion of residency, their educational qualifications; generally, evidence of accreditation by the appropriate
board (diplomate), evidence of fellowship in most cases, and references. These requirements are carefully scrutinized by
members of the hospital administration or by a review committee set up by the hospital who either accept or reject the
application. 75 This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to attend clinicopathological conferences, conduct bedside rounds for clerks, interns and residents, moderate grand rounds and patient
audits and perform other tasks and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the physician's performance as a
specialist is generally evaluated by a peer review committee on the basis of mortality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in his duties, or a consultant who regularly
falls short of the minimum standards acceptable to the hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting "consultant" staff.
While "consultants" are not, technically employees, a point which respondent hospital asserts in denying all
responsibility for the patient's condition, the control exercised, the hiring, and the right to terminate consultants all fulfill
the important hallmarks of an employer-employee relationship, with the exception of the payment of wages. In assessing
whether such a relationship in fact exists, the control test is determining. Accordingly, on the basis of the foregoing, we
rule that for the purpose of allocating responsibility in medical negligence cases, an employer-employee relationship in
effect exists between hospitals and their attending and visiting physicians. This being the case, the question now arises as
to whether or not respondent hospital is solidarily liable with respondent doctors for petitioner's condition. 76
The basis for holding an employer solidarily responsible for the negligence of its employee is found in Article 2180 of the
Civil Code which considers a person accountable not only for his own acts but also for those of others based on the
former's responsibility under a relationship of patria potestas. 77 Such responsibility ceases when the persons or entity
concerned prove that they have observed the diligence of a good father of the family to prevent damage. 78 In other words,
while the burden of proving negligence rests on the plaintiffs, once negligence is shown, the burden shifts to the
respondents (parent, guardian, teacher or employer) who should prove that they observed the diligence of a good father
of a family to prevent damage.
In the instant case, respondent hospital, apart from a general denial of its responsibility over respondent physicians,
failed to adduce evidence showing that it exercised the diligence of a good father of a family in the hiring and supervision
of the latter. It failed to adduce evidence with regard to the degree of supervision which it exercised over its physicians. In
neglecting to offer such proof, or proof of a similar nature, respondent hospital thereby failed to discharge its burden
under the last paragraph of Article 2180. Having failed to do this, respondent hospital is consequently solidarily
responsible with its physicians for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred in accepting and relying on the testimonies of the
witnesses for the private respondents. Indeed, as shown by the above discussions, private respondents were unable to
rebut the presumption of negligence. Upon these disquisitions we hold that private respondents are solidarily liable for
damages under Article 2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The trial court awarded a total of P632,000.00 pesos (should be
P616,000.00) in compensatory damages to the plaintiff, "subject to its being updated" covering the period from 15
November 1985 up to 15 April 1992, based on monthly expenses for the care of the patient estimated at P8,000.00.
At current levels, the P8000/monthly amount established by the trial court at the time of its decision would be grossly
inadequate to cover the actual costs of home-based care for a comatose individual. The calculated amount was not even
arrived at by looking at the actual cost of proper hospice care for the patient. What it reflected were the actual expenses
incurred and proved by the petitioners after they were forced to bring home the patient to avoid mounting hospital bills.

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And yet ideally, a comatose patient should remain in a hospital or be transferred to a hospice specializing in the care of
the chronically ill for the purpose of providing a proper milieu adequate to meet minimum standards of care. In the
instant case for instance, Erlinda has to be constantly turned from side to side to prevent bedsores and hypostatic
pneumonia. Feeding is done by nasogastric tube. Food preparation should be normally made by a dietitian to provide her
with the correct daily caloric requirements and vitamin supplements. Furthermore, she has to be seen on a regular basis
by a physical therapist to avoid muscle atrophy, and by a pulmonary therapist to prevent the accumulation of secretions
which can lead to respiratory complications.
Given these considerations, the amount of actual damages recoverable in suits arising from negligence should at least
reflect the correct minimum cost of proper care, not the cost of the care the family is usually compelled to undertake at
home to avoid bankruptcy. However, the provisions of the Civil Code on actual or compensatory damages present us with
some difficulties.
Well-settled is the rule that actual damages which may be claimed by the plaintiff are those suffered by him as he has
duly proved. The Civil Code provides:
Art. 2199. Except as provided by law or by stipulation, one is entitled to an adequate compensation
only for such pecuniary loss suffered by him as he has duly proved. Such compensation is referred to as
actual or compensatory damages.
Our rules on actual or compensatory damages generally assume that at the time of litigation, the injury suffered as a
consequence of an act of negligence has been completed and that the cost can be liquidated. However, these provisions
neglect to take into account those situations, as in this case, where the resulting injury might be continuing and possible
future complications directly arising from the injury, while certain to occur, are difficult to predict.
In these cases, the amount of damages which should be awarded, if they are to adequately and correctly respond to the
injury caused, should be one which compensates for pecuniary loss incurred and proved, up to the time of trial; and one
which would meet pecuniary loss certain to be suffered but which could not, from the nature of the case, be made with
certainty. 80 In other words, temperate damages can and should be awarded on top of actual or compensatory damages in
instances where the injury is chronic and continuing. And because of the unique nature of such cases, no incompatibility
arises when both actual and temperate damages are provided for. The reason is that these damages cover two distinct
phases.
As it would not be equitable and certainly not in the best interests of the administration of justice for the victim in
such cases to constantly come before the courts and invoke their aid in seeking adjustments to the compensatory
damages previously awarded temperate damages are appropriate. The amount given as temperate damages, though to
a certain extent speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a comatose patient who has
remained in that condition for over a decade. Having premised our award for compensatory damages on the amount
provided by petitioners at the onset of litigation, it would be now much more in step with the interests of justice if the
value awarded for temperate damages would allow petitioners to provide optimal care for their loved one in a facility
which generally specializes in such care. They should not be compelled by dire circumstances to provide substandard care
at home without the aid of professionals, for anything less would be grossly inadequate. Under the circumstances, an
award of P1,500,000.00 in temperate damages would therefore be reasonable. 81
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with a situation where the injury suffered by the plaintiff
would have led to expenses which were difficult to estimate because while they would have been a direct result of the
injury (amputation), and were certain to be incurred by the plaintiff, they were likely to arise only in the future. We
awarded P1,000,000.00 in moral damages in that case.
Describing the nature of the injury, the Court therein stated:
As a result of the accident, Ma. Lourdes Valenzuela underwent a traumatic amputation of her left lower
extremity at the distal left thigh just above the knee. Because of this, Valenzuela will forever be deprived
of the full ambulatory functions of her left extremity, even with the use of state of the art prosthetic
technology. Well beyond the period of hospitalization (which was paid for by Li), she will be required to
undergo adjustments in her prosthetic devise due to the shrinkage of the stump from the process of
healing.

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These adjustments entail costs, prosthetic replacements and months of physical and occupational
rehabilitation and therapy. During the lifetime, the prosthetic devise will have to be replaced and
readjusted to changes in the size of her lower limb effected by the biological changes of middle-age,
menopause and aging. Assuming she reaches menopause, for example, the prosthetic will have to be
adjusted to respond to the changes in bone resulting from a precipitate decrease in calcium levels
observed in the bones of all post-menopausal women. In other words, the damage done to her would not
only be permanent and lasting, it would also be permanently changing and adjusting to the physiologic
changes which her body would normally undergo through the years. The replacements, changes, and
adjustments will require corresponding adjustive physical and occupational therapy. All of these
adjustments, it has been documented, are painful.
xxx xxx xxx
A prosthetic devise, however technologically advanced, will only allow a reasonable amount of functional
restoration of the motor functions of the lower limb. The sensory functions are forever lost. The resultant
anxiety, sleeplessness, psychological injury, mental and physical pain are inestimable. 83
The injury suffered by Erlinda as a consequence of private respondents' negligence is certainly much more serious than
the amputation in the Valenzuela case.
Petitioner Erlinda Ramos was in her mid-forties when the incident occurred. She has been in a comatose state for over
fourteen years now. The burden of care has so far been heroically shouldered by her husband and children, who, in the
intervening years have been deprived of the love of a wife and a mother.
Meanwhile, the actual physical, emotional and financial cost of the care of petitioner would be virtually impossible to
quantify. Even the temperate damages herein awarded would be inadequate if petitioner's condition remains unchanged
for the next ten years.
We recognized, in Valenzuela that a discussion of the victim's actual injury would not even scratch the surface of the
resulting moral damage because it would be highly speculative to estimate the amount of emotional and moral pain,
psychological damage and injury suffered by the victim or those actually affected by the victim's condition. 84The
husband and the children, all petitioners in this case, will have to live with the day to day uncertainty of the patient's
illness, knowing any hope of recovery is close to nil. They have fashioned their daily lives around the nursing care of
petitioner, altering their long term goals to take into account their life with a comatose patient. They, not the
respondents, are charged with the moral responsibility of the care of the victim. The family's moral injury and suffering in
this case is clearly a real one. For the foregoing reasons, an award of P2,000,000.00 in moral damages would be
appropriate.
Finally, by way of example, exemplary damages in the amount of P100,000.00 are hereby awarded. Considering the
length and nature of the instant suit we are of the opinion that attorney's fees valued at P100,000.00 are likewise proper.
Our courts face unique difficulty in adjudicating medical negligence cases because physicians are not insurers of life and,
they rarely set out to intentionally cause injury or death to their patients. However, intent is immaterial in negligence
cases because where negligence exists and is proven, the same automatically gives the injured a right to reparation for the
damage caused.
Established medical procedures and practices, though in constant flux are devised for the purpose of preventing
complications. A physician's experience with his patients would sometimes tempt him to deviate from established
community practices, and he may end a distinguished career using unorthodox methods without incident. However,
when failure to follow established procedure results in the evil precisely sought to be averted by observance of the
procedure and a nexus is made between the deviation and the injury or damage, the physician would necessarily be called
to account for it. In the case at bar, the failure to observe pre-operative assessment protocol which would have influenced
the intubation in a salutary way was fatal to private respondents' case.
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to award in
favor of 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.

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SO ORDERED.
G.R. No. 124354

April 11, 2002

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of the minors,
ROMMEL RAMOS, ROY RODERICK RAMOS, and RON RAYMOND RAMOS, petitioners,
vs.
COURT OF APPEALS, DE LOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DR. PERFECTA
GUTIERREZ, respondents.
RESOLUTION
KAPUNAN, J.:
Private respondents De Los Santos Medical Center, Dr. Orlino Hosaka and Dr. Perfecta Gutierrez move for a
reconsideration of the Decision, dated December 29, 1999, of this Court holding them civilly liable for petitioner Erlinda
Ramos comatose condition after she delivered herself to them for their professional care and management.
For better understanding of the issues raised in private respondents respective motions, we will briefly restate the facts
of the case as follows:
Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, was advised to undergo an
operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred to Dr. Hosaka, a surgeon,
who agreed to perform the operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at
private respondent De Los Santos Medical Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner
Rogelio, knew of any anesthesiologist, Dr. Hosaka recommended to them the services of Dr. Gutierrez.
Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. By 7:30 in the morning of the
following day, petitioner Erlinda was already being prepared for operation. Upon the request of petitioner Erlinda, her
sister-in-law, Herminda Cruz, who was then Dean of the College of Nursing at the Capitol Medical Center, was allowed to
accompany her inside the operating room.
At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get in touch with him by phone.
Thereafter, Dr. Gutierrez informed Cruz that the operation might be delayed due to the late arrival of Dr. Hosaka. In the
meantime, the patient, petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor."
By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio already wanted to pull out his wife
from the operating room. He met Dr. Garcia, who remarked that he was also tired of waiting for Dr. Hosaka. Dr. Hosaka
finally arrived at the hospital at around 12:10 in the afternoon, or more than three (3) hours after the scheduled
operation.
Cruz, who was then still inside the operating room, heard about Dr. Hosakas arrival. While she held the hand of Erlinda,
Cruz saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr. Gutierrez utter: "ang hirap ma-intubate nito, mali
yata ang pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlindas nailbeds on her left
hand. She (Cruz) then heard Dr. Hosaka instruct someone to call Dr. Calderon, another anesthesiologist. When he
arrived, Dr. Calderon attempted to intubate the patient. The nailbeds of the patient remained bluish, thus, she was placed
in a trendelenburg position a position where the head of the patient is placed in a position lower than her feet. At this
point, Cruz went out of the operating room to express her concern to petitioner Rogelio that Erlindas operation was not
going well.
Cruz quickly rushed back to the operating room and saw that the patient was still in trendelenburg position. At almost
3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit (ICU). The doctors explained to
petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the
hospital only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained in comatose
condition until she died on August 3, 1999.1
Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private respondents. After
due trial, the court a quo rendered judgment in favor of petitioners. Essentially, the trial court found that private
respondents were negligent in the performance of their duties to Erlinda. On appeal by private respondents, the Court of

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Appeals reversed the trial courts decision and directed petitioners to pay their "unpaid medical bills" to private
respondents.
Petitioners filed with this Court a petition for review on certiorari. The private respondents were then required to submit
their respective comments thereon. On December 29, 1999, this Court promulgated the decision which private
respondents now seek to be reconsidered. The dispositive portion of said Decision states:
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to
award in favor of 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 exemplary damages and attorneys fees; and 5) the
costs of the suit.2
In his Motion for Reconsideration, private respondent Dr. Hosaka submits the following as grounds therefor:
I
THE HONORABLE SUPREME COURT COMMITTED REVERSIBLE ERROR WHEN IT HELD RESPONDENT DR.
HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-THE-SHIP" DOCTRINE.
II
THE HONORABLE SUPREME COURT ERRED IN HOLDING RESPONDENT DR. HOSAKA LIABLE DESPITE THE
FACT THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO HIM.
III
ASSUMING WITHOUT ADMITTING THAT RESPONDENT DR. HOSAKA IS LIABLE, THE HONORABLE SUPREME
COURT ERRED IN AWARDING DAMAGES THAT WERE CLEARLY EXCESSIVE AND WITHOUT LEGAL BASIS. 3
Private respondent Dr. Gutierrez, for her part, avers that:
A. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED THE FACT THAT
THE COURT OF APPEALS DECISION DATED 29 MAY 1995 HAD ALREADY BECOME FINAL AND
EXECUTORY AS OF 25 JUNE 1995, THEREBY DEPRIVING THIS HONORABLE COURT OF JURISDICTION
OVER THE INSTANT PETITION;
B. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED SEVERAL
MATERIAL FACTUAL CIRCUMSTANCES WHICH, IF PROPERLY CONSIDERED, WOULD INDUBITABLY
LEAD TO NO OTHER CONCLUSION BUT THAT PRIVATE RESPONDENT DOCTORS WERE NOT GUILTY OF
ANY NEGLIGENCE IN RESPECT OF THE INSTANT CASE;
B.1 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE
BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER COMPLIANCE WITH THE STANDARDS
OF DUE CARE EXPECTED IN HER RESPECTIVE FIELD OF MEDICAL SPECIALIZATION.
B.2 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE
BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER HAVING SUCCESSFULLY INTUBATED
PATIENT ERLINDA RAMOS
C. THE SUPREME COURT MAY HAVE INADVERTENTLY PLACED TOO MUCH RELIANCE ON THE
TESTIMONY OF PETITIONERS WITNESS HERMINDA CRUZ, DESPITE THE EXISTENCE OF SEVERAL
FACTUAL CIRCUMSTANCES WHICH RENDERS DOUBT ON HER CREDIBILITY
D. THE SUPREME COURT MAY HAVE INADVERTENTLY DISREGARDED THE EXPERT TESTIMONY OF
DR. JAMORA AND DRA. CALDERON

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E. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY AWARDED DAMAGES TO


PETITIONERS DESPITE THE FACT THAT THERE WAS NO NEGLIGENCE ON THE PART OF RESPONDENT
DOCTOR.4
Private respondent De Los Santos Medical Center likewise moves for reconsideration on the following grounds:
I
THE HONORABLE COURT ERRED IN GIVING DUE COURSE TO THE INSTANT PETITION AS THE DECISION OF
THE HONORABLE COURT OF APPEALS HAD ALREADY BECOME FINAL AND EXECUTORY
II
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT AN EMPLOYER-EMPLOYEE [RELATIONSHIP]
EXISTS BETWEEN RESPONDENT DE LOS SANTOS MEDICAL CENTER AND DRS. ORLINO HOSAKA AND
PERFECTA GUTIERREZ
III
THE HONORABLE SUPREME COURT ERRED IN FINDING THAT RESPONDENT DE LOS SANTOS MEDICAL
CENTER IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORS
IV
THE HONORABLE SUPREME COURT ERRED IN INCREASING THE AWARD OF DAMAGES IN FAVOR OF
PETITIONERS.5
In the Resolution of February 21, 2000, this Court denied the motions for reconsideration of private respondents Drs.
Hosaka and Gutierrez. They then filed their respective second motions for reconsideration. The Philippine College of
Surgeons filed its Petition-in-Intervention contending in the main that this Court erred in holding private respondent Dr.
Hosaka liable under the captain of the ship doctrine. According to the intervenor, said doctrine had long been abandoned
in the United States in recognition of the developments in modern medical and hospital practice. 6 The Court noted these
pleadings in the Resolution of July 17, 2000.7
On March 19, 2001, the Court heard the oral arguments of the parties, including the intervenor. Also present during the
hearing were the amicii curiae: Dr. Felipe A. Estrella, Jr., Consultant of the Philippine Charity Sweepstakes, former
Director of the Philippine General Hospital and former Secretary of Health; Dr. Iluminada T. Camagay, President of the
Philippine Society of Anesthesiologists, Inc. and Professor and Vice-Chair for Research, Department of Anesthesiology,
College of Medicine-Philippine General Hospital, University of the Philippines; and Dr. Lydia M. Egay, Professor and
Vice-Chair for Academics, Department of Anesthesiology, College of Medicine-Philippine General Hospital, University of
the Philippines.
The Court enumerated the issues to be resolved in this case as follows:
1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR NEGLIGENCE;
2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE FOR NEGLIGENCE;
AND
3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS LIABLE FOR ANY ACT OF
NEGLIGENCE COMMITTED BY THEIR VISITING CONSULTANT SURGEON AND ANESTHESIOLOGIST. 8
We shall first resolve the issue pertaining to private respondent Dr. Gutierrez. She maintains that the Court erred in
finding her negligent and in holding that it was the faulty intubation which was the proximate cause of Erlindas
comatose condition. The following objective facts allegedly negate a finding of negligence on her part: 1) That the
outcome of the procedure was a comatose patient and not a dead one; 2) That the patient had a cardiac arrest; and 3)
That the patient was revived from that cardiac arrest.9 In effect, Dr. Gutierrez insists that, contrary to the finding of this
Court, the intubation she performed on Erlinda was successful.

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Unfortunately, Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has been
sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient.
Dr. Egay enlightened the Court on what these standards are:
x x x What are the standards of care that an anesthesiologist should do before we administer anesthesia? The
initial step is the preparation of the patient for surgery and this is a pre-operative evaluation because the
anesthesiologist is responsible for determining the medical status of the patient, developing the anesthesia plan
and acquainting the patient or the responsible adult particularly if we are referring with the patient or to adult
patient who may not have, who may have some mental handicaps of the proposed plans. We do pre-operative
evaluation because this provides for an opportunity for us to establish identification and personal acquaintance
with the patient. It also makes us have an opportunity to alleviate anxiety, explain techniques and risks to the
patient, given the patient the choice and establishing consent to proceed with the plan. And lastly, once this has
been agreed upon by all parties concerned the ordering of pre-operative medications. And following this line at
the end of the evaluation we usually come up on writing, documentation is very important as far as when we train
an anesthesiologist we always emphasize this because we need records for our protection, well, records. And it
entails having brief summary of patient history and physical findings pertinent to anesthesia, plan, organize as a
problem list, the plan anesthesia technique, the plan post operative, pain management if appropriate, special
issues for this particular patient. There are needs for special care after surgery and if it so it must be written down
there and a request must be made known to proper authorities that such and such care is necessary. And the
request for medical evaluation if there is an indication. When we ask for a cardio-pulmonary clearance it is not in
fact to tell them if this patient is going to be fit for anesthesia, the decision to give anesthesia rests on the
anesthesiologist. What we ask them is actually to give us the functional capacity of certain systems which maybe
affected by the anesthetic agent or the technique that we are going to use. But the burden of responsibility in
terms of selection of agent and how to administer it rest on the anesthesiologist. 10
The conduct of a preanesthetic/preoperative evaluation prior to an operation, whether elective or emergency, cannot be
dispensed with.11 Such evaluation is necessary for the formulation of a plan of anesthesia care suited to the needs of the
patient concerned.
Pre-evaluation for anesthesia involves taking the patients medical history, reviewing his current drug therapy,
conducting physical examination, interpreting laboratory data, and determining the appropriate prescription of
preoperative medications as necessary to the conduct of anesthesia. 12
Physical examination of the patient entails not only evaluating the patients central nervous system, cardiovascular
system and lungs but also the upper airway. Examination of the upper airway would in turn include an analysis of the
patients cervical spine mobility, temporomandibular mobility, prominent central incisors, deceased or artificial teeth,
ability to visualize uvula and the thyromental distance. 13
Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. As she herself admitted,
she saw Erlinda for the first time on the day of the operation itself, one hour before the scheduled operation. She
auscultated14 the patients heart and lungs and checked the latters blood pressure to determine if Erlinda was indeed fit
for operation.15 However, she did not proceed to examine the patients airway. Had she been able to check petitioner
Erlindas airway prior to the operation, Dr. Gutierrez would most probably not have experienced difficulty in intubating
the former, and thus the resultant injury could have been avoided. As we have stated in our Decision:
In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first time on the day of the
operation itself, on 17 June 1985. Before this date, no prior consultations with, or pre-operative evaluation of
Erlinda was done by her. Until the day of the operation, respondent Dra. Gutierrez was unaware of the
physiological make-up and needs of Erlinda. She was likewise not properly informed of the possible difficulties
she would face during the administration of anesthesia to Erlinda. Respondent Dra. Gutierrez act of seeing her
patient for the first time only an hour before the scheduled operative procedure was, therefore, an act of
exceptional negligence and professional irresponsibility. The measures cautioning prudence and vigilance in
dealing with human lives lie at the core of the physicians centuries-old Hippocratic Oath. Her failure to follow
this medical procedure is, therefore, a clear indicia of her negligence.16
Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that
caused her comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a
medical procedure on her. Even the counsel of Dr. Gutierrez admitted to this fact during the oral arguments:
CHIEF JUSTICE:
Mr. Counsel, you started your argument saying that this involves a comatose patient?

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ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
How do you mean by that, a comatose, a comatose after any other acts were done by Dr. Gutierrez or
comatose before any act was done by her?
ATTY. GANA:
No, we meant comatose as a final outcome of the procedure.
CHIEF JUSTICE:
Meaning to say, the patient became comatose after some intervention, professional acts have been done
by Dr. Gutierrez?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
In other words, the comatose status was a consequence of some acts performed by D. Gutierrez?
ATTY. GANA:
It was a consequence of the well, (interrupted)
CHIEF JUSTICE:
An acts performed by her, is that not correct?
ATTY. GANA:
Yes, Your Honor.
CHIEF JUSTICE:
Thank you.17
What is left to be determined therefore is whether Erlindas hapless condition was due to any fault or negligence on the
part of Dr. Gutierrez while she (Erlinda) was under the latters care. Dr. Gutierrez maintains that the bronchospasm and
cardiac arrest resulting in the patients comatose condition was brought about by the anaphylactic reaction of the patient
to Thiopental Sodium (pentothal).18 In the Decision, we explained why we found Dr. Gutierrez theory unacceptable. In
the first place, Dr. Eduardo Jamora, the witness who was presented to support her (Dr. Gutierrez) theory, was a
pulmonologist. Thus, he could not be considered an authority on anesthesia practice and procedure and their
complications.19
Secondly, there was no evidence on record to support the theory that Erlinda developed an allergic reaction to pentothal.
Dr. Camagay enlightened the Court as to the manifestations of an allergic reaction in this wise:
DR. CAMAGAY:
All right, let us qualify an allergic reaction. In medical terminology an allergic reaction is something
which is not usual response and it is further qualified by the release of a hormone called histamine and
histamine has an effect on all the organs of the body generally release because the substance that entered
the body reacts with the particular cell, the mass cell, and the mass cell secretes this histamine. In a way
it is some form of response to take away that which is not mine, which is not part of the body. So,
histamine has multiple effects on the body. So, one of the effects as you will see you will have redness, if
you have an allergy you will have tearing of the eyes, you will have swelling, very crucial swelling
sometimes of the larynges which is your voice box main airway, that swelling may be enough to obstruct
the entry of air to the trachea and you could also have contraction, constriction of the smaller airways
beyond the trachea, you see you have the trachea this way, we brought some visual aids but unfortunately
we do not have a projector. And then you have the smaller airways, the bronchi and then eventually into
the mass of the lungs you have the bronchus. The difference is that these tubes have also in their walls
muscles and this particular kind of muscles is smooth muscle so, when histamine is released they close
up like this and that phenomenon is known as bronco spasm. However, the effects of histamine also on
blood vessels are different. They dilate blood vessel open up and the patient or whoever has this
histamine release has hypertension or low blood pressure to a point that the patient may have decrease
blood supply to the brain and may collapse so, you may have people who have this.20
These symptoms of an allergic reaction were not shown to have been extant in Erlindas case. As we held in our Decision,
"no evidence of stridor, skin reactions, or wheezing some of the more common accompanying signs of an allergic
reaction appears on record. No laboratory data were ever presented to the court." 21
Dr. Gutierrez, however, insists that she successfully intubated Erlinda as evidenced by the fact that she was revived after
suffering from cardiac arrest. Dr. Gutierrez faults the Court for giving credence to the testimony of Cruz on the matter of

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the administration of anesthesia when she (Cruz), being a nurse, was allegedly not qualified to testify thereon. Rather, Dr.
Gutierrez invites the Courts attention to her synopsis on what transpired during Erlindas intubation:
12:15 p.m. Patient was inducted with sodium pentothal 2.5% (250 mg) given by slow IV. 02 was started by mask.
After pentothal injection this was followed by IV injection of Norcuron 4mg. After 2 minutes 02 was given by
positive pressure for about one minute. Intubation with endotracheal tube 7.5 m in diameter was done with slight
difficulty (short neck & slightly prominent upper teeth) chest was examined for breath sounds & checked if equal
on both sides. The tube was then anchored to the mouth by plaster & cuff inflated. Ethrane 2% with 02 4 liters
was given. Blood pressure was checked 120/80 & heart rate regular and normal 90/min.
12:25 p.m. After 10 minutes patient was cyanotic. Ethrane was discontinued & 02 given alone. Cyanosis
disappeared. Blood pressure and heart beats stable.
12:30 p.m. Cyanosis again reappeared this time with sibilant and sonorous rales all over the chest. D_5%_H20 &
1 ampule of aminophyline by fast drip was started. Still the cyanosis was persistent. Patient was connected to a
cardiac monitor. Another ampule of of [sic] aminophyline was given and solu cortef was given.
12:40 p.m. There was cardiac arrest. Extra cardiac massage and intercardiac injection of adrenalin was given &
heart beat reappeared in less than one minute. Sodium bicarbonate & another dose of solu cortef was given by IV.
Cyanosis slowly disappeared & 02 continuously given & assisted positive pressure. Laboratory exams done (see
results in chart).
Patient was transferred to ICU for further management. 22
From the foregoing, it can be allegedly seen that there was no withdrawal (extubation) of the tube. And the fact that the
cyanosis allegedly disappeared after pure oxygen was supplied through the tube proved that it was properly placed.
The Court has reservations on giving evidentiary weight to the entries purportedly contained in Dr. Gutierrez synopsis. It
is significant to note that the said record prepared by Dr. Gutierrez was made only after Erlinda was taken out of the
operating room. The standard practice in anesthesia is that every single act that the anesthesiologist performs must be
recorded. In Dr. Gutierrez case, she could not account for at least ten (10) minutes of what happened during the
administration of anesthesia on Erlinda. The following exchange between Dr. Estrella, one of the amicii curiae, and Dr.
Gutierrez is instructive:
DR. ESTRELLA
Q
You mentioned that there were two (2) attempts in the intubation period?
DR. GUTIERREZ
Yes.
Q
There were two attempts. In the first attempt was the tube inserted or was the laryngoscope only inserted,
which was inserted?
A
All the laryngoscope.
Q
All the laryngoscope. But if I remember right somewhere in the re-direct, a certain lawyer, you were asked
that you did a first attempt and the question was did you withdraw the tube? And you said you never
withdrew the tube, is that right?
A
Yes.
Q
Yes. And so if you never withdrew the tube then there was no, there was no insertion of the tube during
that first attempt. Now, the other thing that we have to settle here is when cyanosis occurred, is it recorded in
the anesthesia record when the cyanosis, in your recording when did the cyanosis occur?
A
(sic)
Q
Is it a standard practice of anesthesia that whatever you do during that period or from the time of
induction to the time that you probably get the patient out of the operating room that every single action that you
do is so recorded in your anesthesia record?
A
I was not able to record everything I did not have time anymore because I did that after the, when the
patient was about to leave the operating room. When there was second cyanosis already that was the
(interrupted)
Q
When was the first cyanosis?
A
The first cyanosis when I was (interrupted)
Q
What time, more or less?
A
I think it was 12:15 or 12:16.
Q
Well, if the record will show you started induction at 12:15?
A
Yes, Your Honor.

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Page 27

Q
And the first medication you gave was what?
A
The first medication, no, first the patient was oxygenated for around one to two minutes.
Q
Yes, so, that is about 12:13?
A
Yes, and then, I asked the resident physician to start giving the pentothal very slowly and that was around
one minute.
Q
So, that is about 12:13 no, 12:15, 12:17?
A
Yes, and then, after one minute another oxygenation was given and after (interrupted)
Q
12:18?
A
Yes, and then after giving the oxygen we start the menorcure which is a relaxant. After that relaxant
(interrupted)
Q
After that relaxant, how long do you wait before you do any manipulation?
A
Usually you wait for two minutes or three minutes.
Q
So, if our estimate of the time is accurate we are now more or less 12:19, is that right?
A
Maybe.
Q
12:19. And at that time, what would have been done to this patient?
A
After that time you examine the, if there is relaxation of the jaw which you push it downwards and when I
saw that the patient was relax because that monorcure is a relaxant, you cannot intubate the patient or insert the
laryngoscope if it is not keeping him relax. So, my first attempt when I put the laryngoscope on I saw the trachea
was deeply interiorly. So, what I did ask "mahirap ata ito ah." So, I removed the laryngoscope and oxygenated
again the patient.
Q
So, more or less you attempted to do an intubation after the first attempt as you claimed that it was only
the laryngoscope that was inserted.
A
Yes.
Q
And in the second attempt you inserted the laryngoscope and now possible intubation?
A
Yes.
Q
And at that point, you made a remark, what remark did you make?
A
I said "mahirap ata ito" when the first attempt I did not see the trachea right away. That was when I
(interrupted)
Q
That was the first attempt?
A
Yes.
Q
What about the second attempt?
A
On the second attempt I was able to intubate right away within two to three seconds.
Q
At what point, for purposes of discussion without accepting it, at what point did you make the comment
"na mahirap ata to intubate, mali ata ang pinasukan"
A
I did not say "mali ata ang pinasukan" I never said that.
Q
Well, just for the information of the group here the remarks I am making is based on the documents that
were forwarded to me by the Supreme Court. That is why for purposes of discussion I am trying to clarify this for
the sake of enlightenment. So, at what point did you ever make that comment?
A
Which one, sir?
Q
The "mahirap intubate ito" assuming that you (interrupted)
A
Iyon lang, that is what I only said "mahirap intubate (interrupted)
Q
At what point?
A
When the first attempt when I inserted the laryngoscope for the first time.
Q
So, when you claim that at the first attempt you inserted the laryngoscope, right?
A
Yes.
Q
But in one of the recordings somewhere at the, somewhere in the transcript of records that when the
lawyer of the other party try to inquire from you during the first attempt that was the time when "mayroon ba
kayong hinugot sa tube, I do not remember the page now, but it seems to me it is there. So, that it was on the
second attempt that (interrupted)
A
I was able to intubate.
Q
And this is more or less about what time 12:21?
A
Maybe, I cannot remember the time, Sir.
Q
Okay, assuming that this was done at 12:21 and looking at the anesthesia records from 12:20 to 12:30 there
was no recording of the vital signs. And can we presume that at this stage there was already some problems in
handling the patient?
A
Not yet.
Q
But why are there no recordings in the anesthesia record?
A
I did not have time.
Q
Ah, you did not have time, why did you not have time?
A
Because it was so fast, I really (at this juncture the witness is laughing)
Q
No, I am just asking. Remember I am not here not to pin point on anybody I am here just to more or less
clarify certainty more ore less on the record.
A
Yes, Sir.

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Q
And so it seems that there were no recording during that span of ten (10) minutes. From 12:20 to 12:30,
and going over your narration, it seems to me that the cyanosis appeared ten (10) minutes after induction, is that
right?
A
Yes.
Q
And that is after induction 12:15 that is 12:25 that was the first cyanosis?
A
Yes.
Q
And that the 12:25 is after the 12:20?
A
We cannot (interrupted)
Q
Huwag ho kayong makuwan, we are just trying to enlighten, I am just going over the record ano,kung
mali ito kuwan eh di ano. So, ganoon po ano, that it seems to me that there is no recording from 12:20 to 12:30,
so, I am just wondering why there were no recordings during the period and then of course the second cyanosis,
after the first cyanosis. I think that was the time Dr. Hosaka came in?
A

No, the first cyanosis (interrupted).23

We cannot thus give full credence to Dr. Gutierrez synopsis in light of her admission that it does not fully reflect the
events that transpired during the administration of anesthesia on Erlinda. As pointed out by Dr. Estrella, there was a tenminute gap in Dr. Gutierrez synopsis, i.e., the vital signs of Erlinda were not recorded during that time. The absence of
these data is particularly significant because, as found by the trial court, it was the absence of oxygen supply for four (4)
to five (5) minutes that caused Erlindas comatose condition.
On the other hand, the Court has no reason to disbelieve the testimony of Cruz. As we stated in the Decision, she is
competent to testify on matters which she is capable of observing such as, the statements and acts of the physician and
surgeon, external appearances and manifest conditions which are observable by any one.24 Cruz, Erlindas sister-in-law,
was with her inside the operating room. Moreover, being a nurse and Dean of the Capitol Medical Center School of
Nursing at that, she is not entirely ignorant of anesthetic procedure. Cruz narrated that she heard Dr. Gutierrez remark,
"Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." She observed that the nailbeds of
Erlinda became bluish and thereafter Erlinda was placed in trendelenburg position. 25 Cruz further averred that she
noticed that the abdomen of Erlinda became distended. 26
The cyanosis (bluish discoloration of the skin or mucous membranes caused by lack of oxygen or abnormal hemoglobin
in the blood) and enlargement of the stomach of Erlinda indicate that the endotracheal tube was improperly inserted into
the esophagus instead of the trachea. Consequently, oxygen was delivered not to the lungs but to the gastrointestinal
tract. This conclusion is supported by the fact that Erlinda was placed in trendelenburg position. This indicates that there
was a decrease of blood supply to the patients brain. The brain was thus temporarily deprived of oxygen supply causing
Erlinda to go into coma.
The injury incurred by petitioner Erlinda does not normally happen absent any negligence in the administration of
anesthesia and in the use of an endotracheal tube. As was noted in our Decision, the instruments used in the
administration of anesthesia, including the endotracheal tube, were all under the exclusive control of private respondents
Dr. Gutierrez and Dr. Hosaka.27 In Voss vs. Bridwell,28 which involved a patient who suffered brain damage due to the
wrongful administration of anesthesia, and even before the scheduled mastoid operation could be performed, the Kansas
Supreme Court applied the doctrine of res ipsa loquitur, reasoning that the injury to the patient therein was one which
does not ordinarily take place in the absence of negligence in the administration of an anesthetic, and in the use and
employment of an endotracheal tube. The court went on to say that "[o]rdinarily a person being put under anesthesia is
not rendered decerebrate as a consequence of administering such anesthesia in the absence of negligence. Upon these
facts and under these circumstances, a layman would be able to say, as a matter of common knowledge and observation,
that the consequences of professional treatment were not as such as would ordinarily have followed if due care had been
exercised."29Considering the application of the doctrine of res ipsa loquitur, the testimony of Cruz was properly given
credence in the case at bar.
For his part, Dr. Hosaka mainly contends that the Court erred in finding him negligent as a surgeon by applying the
Captain-of-the-Ship doctrine.30 Dr. Hosaka argues that the trend in United States jurisprudence has been to reject said
doctrine in light of the developments in medical practice. He points out that anesthesiology and surgery are two distinct
and specialized fields in medicine and as a surgeon, he is not deemed to have control over the acts of Dr. Gutierrez. As
anesthesiologist, Dr. Gutierrez is a specialist in her field and has acquired skills and knowledge in the course of her
training which Dr. Hosaka, as a surgeon, does not possess. 31 He states further that current American jurisprudence on the
matter recognizes that the trend towards specialization in medicine has created situations where surgeons do not always
have the right to control all personnel within the operating room,32 especially a fellow specialist.33

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Dr. Hosaka cites the case of Thomas v. Raleigh General Hospital,34 which involved a suit filed by a patient who lost his
voice due to the wrongful insertion of the endotracheal tube preparatory to the administration of anesthesia in
connection with the laparotomy to be conducted on him. The patient sued both the anesthesiologist and the surgeon for
the injury suffered by him. The Supreme Court of Appeals of West Virginia held that the surgeon could not be held liable
for the loss of the patients voice, considering that the surgeon did not have a hand in the intubation of the patient. The
court rejected the application of the "Captain-of-the-Ship Doctrine," citing the fact that the field of medicine has become
specialized such that surgeons can no longer be deemed as having control over the other personnel in the operating room.
It held that "[a]n assignment of liability based on actual control more realistically reflects the actual relationship which
exists in a modern operating room."35 Hence, only the anesthesiologist who inserted the endotracheal tube into the
patients throat was held liable for the injury suffered by the latter.
This contention fails to persuade.
That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does not mean that this
Court will ipso facto follow said trend. Due regard for the peculiar factual circumstances obtaining in this case justify the
application of the Captain-of-the-Ship doctrine. From the facts on record it can be logically inferred that Dr. Hosaka
exercised a certain degree of, at the very least, supervision over the procedure then being performed on Erlinda.
First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In effect, he represented to
petitioners that Dr. Gutierrez possessed the necessary competence and skills. Drs. Hosaka and Gutierrez had worked
together since 1977. Whenever Dr. Hosaka performed a surgery, he would always engage the services of Dr. Gutierrez to
administer the anesthesia on his patient.36
Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus, when Erlinda showed signs of
cyanosis, it was Dr. Hosaka who gave instructions to call for another anesthesiologist and cardiologist to help resuscitate
Erlinda.37
Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka and Gutierrez worked as a team.
Their work cannot be placed in separate watertight compartments because their duties intersect with each other. 38
While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their performance of acts
within their respective fields of expertise for the treatment of petitioner Erlinda, and that one does not exercise control
over the other, they were certainly not completely independent of each other so as to absolve one from the negligent acts
of the other physician.
That they were working as a medical team is evident from the fact that Dr. Hosaka was keeping an eye on the intubation
of the patient by Dr. Gutierrez, and while doing so, he observed that the patients nails had become dusky and had to call
Dr. Gutierrezs attention thereto. The Court also notes that the counsel for Dr. Hosaka admitted that in practice, the
anesthesiologist would also have to observe the surgeons acts during the surgical process and calls the attention of the
surgeon whenever necessary39 in the course of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the
treatment of petitioner Erlinda are therefore not as clear-cut as respondents claim them to be. On the contrary, it is quite
apparent that they have a common responsibility to treat the patient, which responsibility necessitates that they call each
others attention to the condition of the patient while the other physician is performing the necessary medical procedures.
It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to petitioner Erlinda promptly, for
he arrived more than three (3) hours late for the scheduled operation. The cholecystectomy was set for June 17, 1985 at
9:00 a.m., but he arrived at DLSMC only at around 12:10 p.m. In reckless disregard for his patients well being, Dr.
Hosaka scheduled two procedures on the same day, just thirty minutes apart from each other, at different hospitals.
Thus, when the first procedure (protoscopy) at the Sta. Teresita Hospital did not proceed on time, Erlinda was kept in a
state of uncertainty at the DLSMC.
The unreasonable delay in petitioner Erlindas scheduled operation subjected her to continued starvation and
consequently, to the risk of acidosis,40 or the condition of decreased alkalinity of the blood and tissues, marked by sickly
sweet breath, headache, nausea and vomiting, and visual disturbances. 41 The long period that Dr. Hosaka made Erlinda
wait for him certainly aggravated the anxiety that she must have been feeling at the time. It could be safely said that her
anxiety adversely affected the administration of anesthesia on her. As explained by Dr. Camagay, the patients anxiety
usually causes the outpouring of adrenaline which in turn results in high blood pressure or disturbances in the heart
rhythm:
DR. CAMAGAY:

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x x x Pre-operative medication has three main functions: One is to alleviate anxiety. Second is to dry up
the secretions and Third is to relieve pain. Now, it is very important to alleviate anxiety because anxiety
is associated with the outpouring of certain substances formed in the body called adrenalin. When a
patient is anxious there is an outpouring of adrenalin which would have adverse effect on the patient.
One of it is high blood pressure, the other is that he opens himself to disturbances in the heart rhythm,
which would have adverse implications. So, we would like to alleviate patients anxiety mainly because he
will not be in control of his body there could be adverse results to surgery and he will be opened up; a
knife is going to open up his body. x x x42
Dr. Hosaka cannot now claim that he was entirely blameless of what happened to Erlinda. His conduct clearly constituted
a breach of his professional duties to Erlinda:
CHIEF JUSTICE:
Two other points. The first, Doctor, you were talking about anxiety, would you consider a patient's stay
on the operating table for three hours sufficient enough to aggravate or magnify his or her anxiety?
DR. CAMAGAY:
Yes.
CHIEF JUSTICE:
In other words, I understand that in this particular case that was the case, three hours waiting and the
patient was already on the operating table (interrupted)
DR. CAMAGAY:
Yes.
CHIEF JUSTICE:
Would you therefore conclude that the surgeon contributed to the aggravation of the anxiety of the
patient?
DR. CAMAGAY:
That this operation did not take place as scheduled is already a source of anxiety and most operating
tables are very narrow and that patients are usually at risk of falling on the floor so there are restraints
that are placed on them and they are never, never left alone in the operating room by themselves
specially if they are already pre-medicated because they may not be aware of some of their movement
that they make which would contribute to their injury.
CHIEF JUSTICE:
In other words due diligence would require a surgeon to come on time?
DR. CAMAGAY:
I think it is not even due diligence it is courtesy.
CHIEF JUSTICE:
Courtesy.
DR. CAMAGAY:
And care.
CHIEF JUSTICE:
Duty as a matter of fact?
DR. CAMAGAY:
Yes, Your Honor.43
Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner Erlinda is violative, not
only of his duty as a physician "to serve the interest of his patients with the greatest solicitude, giving them always his
best talent and skill,"44 but also of Article 19 of the Civil Code which requires a person, in the performance of his duties, to
act with justice and give everyone his due.
Anent private respondent DLSMCs liability for the resulting injury to petitioner Erlinda, we held that respondent
hospital is solidarily liable with respondent doctors therefor under Article 2180 of the Civil Code 45 since there exists an
employer-employee relationship between private respondent DLSMC and Drs. Gutierrez and Hosaka:
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting "consultant"
staff. While "consultants" are not, technically employees, x x x the control exercised, the hiring and the right to
terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the
exception of the payment of wages. In assessing whether such a relationship in fact exists, the control test is
determining. x x x46

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DLSMC however contends that applying the four-fold test in determining whether such a relationship exists between it
and the respondent doctors, the inescapable conclusion is that DLSMC cannot be considered an employer of the
respondent doctors.
It has been consistently held that in determining whether an employer-employee relationship exists between the parties,
the following elements must be present: (1) selection and engagement of services; (2) payment of wages; (3) the power to
hire and fire; and (4) the power to control not only the end to be achieved, but the means to be used in reaching such an
end.47
DLSMC maintains that first, a hospital does not hire or engage the services of a consultant, but rather, accredits the latter
and grants him or her the privilege of maintaining a clinic and/or admitting patients in the hospital upon a showing by
the consultant that he or she possesses the necessary qualifications, such as accreditation by the appropriate board
(diplomate), evidence of fellowship and references. 48 Second, it is not the hospital but the patient who pays the
consultants fee for services rendered by the latter.49 Third, a hospital does not dismiss a consultant; instead, the latter
may lose his or her accreditation or privileges granted by the hospital.50 Lastly, DLSMC argues that when a doctor refers a
patient for admission in a hospital, it is the doctor who prescribes the treatment to be given to said patient. The hospitals
obligation is limited to providing the patient with the preferred room accommodation, the nutritional diet and
medications prescribed by the doctor, the equipment and facilities necessary for the treatment of the patient, as well as
the services of the hospital staff who perform the ministerial tasks of ensuring that the doctors orders are carried out
strictly.51
After a careful consideration of the arguments raised by DLSMC, the Court finds that respondent hospitals position on
this issue is meritorious. There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka
which would hold DLSMC solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil
Code.
As explained by respondent hospital, that the admission of a physician to membership in DLSMCs medical staff as active
or visiting consultant is first decided upon by the Credentials Committee thereof, which is composed of the heads of the
various specialty departments such as the Department of Obstetrics and Gynecology, Pediatrics, Surgery with the
department head of the particular specialty applied for as chairman. The Credentials Committee then recommends to
DLSMC's Medical Director or Hospital Administrator the acceptance or rejection of the applicant physician, and said
director or administrator validates the committee's recommendation. 52 Similarly, in cases where a disciplinary action is
lodged against a consultant, the same is initiated by the department to whom the consultant concerned belongs and filed
with the Ethics Committee consisting of the department specialty heads. The medical director/hospital administrator
merely acts as ex-officio member of said committee.
Neither is there any showing that it is DLSMC which pays any of its consultants for medical services rendered by the
latter to their respective patients. Moreover, the contract between the consultant in respondent hospital and his patient is
separate and distinct from the contract between respondent hospital and said patient. The first has for its object the
rendition of medical services by the consultant to the patient, while the second concerns the provision by the hospital of
facilities and services by its staff such as nurses and laboratory personnel necessary for the proper treatment of the
patient.
Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda was due to a failure on the part of
respondent DLSMC to provide for hospital facilities and staff necessary for her treatment.
For these reasons, we reverse the finding of liability on the part of DLSMC for the injury suffered by petitioner Erlinda.
Finally, the Court also deems it necessary to modify the award of damages to petitioners in view of the supervening event
of petitioner Erlindas death. In the assailed Decision, the Court awarded actual damages of One Million Three Hundred
Fifty Two Thousand Pesos (P1,352,000.00) to cover the expenses for petitioner Erlindas treatment and care from the
date of promulgation of the Decision up to the time the patient expires or survives. 53 In addition thereto, the Court
awarded temperate damages of One Million Five Hundred Thousand Pesos (P1,500,000.00) in view of the chronic and
continuing nature of petitioner Erlindas injury and the certainty of further pecuniary loss by petitioners as a result of
said injury, the amount of which, however, could not be made with certainty at the time of the promulgation of the
decision. The Court justified such award in this manner:
Our rules on actual or compensatory damages generally assume that at the time of litigation, the injury suffered
as a consequence of an act of negligence has been completed and that the cost can be liquidated. However, these
provisions neglect to take into account those situations, as in this case, where the resulting injury might be

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continuing and possible future complications directly arising from the injury, while certain to occur, are difficult
to predict.
In these cases, the amount of damages which should be awarded, if they are to adequately and correctly respond
to the injury caused, should be one which compensates for pecuniary loss incurred and proved, up to the time of
trial; and one which would meet pecuniary loss certain to be suffered but which could not, from the nature of the
case, be made with certainty. In other words, temperate damages can and should be awarded on top of actual or
compensatory damages in instances where the injury is chronic and continuing. And because of the unique
nature of such cases, no incompatibility arises when both actual and temperate damages are provided for. The
reason is that these damages cover two distinct phases.
As it would not be equitableand certainly not in the best interests of the administration of justicefor the
victim in such cases to constantly come before the courts and invoke their aid in seeking adjustments to the
compensatory damages previously awardedtemperate damages are appropriate. The amount given as
temperate damages, though to a certain extent speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only home-based nursing care for a comatose patient who
has remained in that condition for over a decade. Having premised our award for compensatory damages on the
amount provided by petitioners at the onset of litigation, it would be now much more in step with the interests of
justice if the value awarded for temperate damages would allow petitioners to provide optimal care for their loved
one in a facility which generally specializes in such care. They should not be compelled by dire circumstances to
provide substandard care at home without the aid of professionals, for anything less would be grossly inadequate.
Under the circumstances, an award of P1,500,000.00 in temperate damages would therefore be reasonable. 54
However, subsequent to the promulgation of the Decision, the Court was informed by petitioner Rogelio that petitioner
Erlinda died on August 3, 1999.55 In view of this supervening event, the award of temperate damages in addition to the
actual or compensatory damages would no longer be justified since the actual damages awarded in the Decision are
sufficient to cover the medical expenses incurred by petitioners for the patient. Hence, only the amounts representing
actual, moral and exemplary damages, attorneys fees and costs of suit should be awarded to petitioners.
WHEREFORE, the assailed Decision is hereby modified as follows:
(1) Private respondent De Los Santos Medical Center is hereby absolved from liability arising from the injury suffered by
petitioner Erlinda Ramos on June 17, 1985;
(2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta Gutierrez are hereby declared to be solidarily liable for the
injury suffered by petitioner Erlinda on June 17, 1985 and are ordered to pay petitioners
(a) P1,352,000.00 as actual damages;
(b) P2,000,000.00 as moral damages;
(c) P100,000.00 as exemplary damages;
(d) P100,000.00 as attorneys fees; and
(e) the costs of the suit.
SO ORDERED.

[G.R. No. 130547. October 3, 2000]

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LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors LLOYD and KRISTINE, all surnamed
REYES, represented by their mother, LEAH ALESNA REYES, petitioners, vs. SISTERS OF
MERCY HOSPITAL, SISTER ROSE PALACIO, DR. MARVIE BLANES, and DR. MARLYN
RICO, respondents.
DECISION
MENDOZA, J.:
This is a petition for review of the decision [1] of the Court of Appeals in CA-G.R. CV No. 36551 affirming the decision
of the Regional Trial Court, Branch IX, Cebu City which dismissed a complaint for damages filed by petitioners against
respondents.
The facts are as follows:
Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners, namely, Rose Nahdja,
Johnny, Lloyd, and Kristine, all surnamed Reyes, were their children. Five days before his death on January 8, 1987,
Jorge had been suffering from a recurring fever with chills. After he failed to get relief from some home medication he
was taking, which consisted of analgesic, antipyretic, and antibiotics, he decided to see the doctor.
On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was attended to by respondent Dr.
Marlyn Rico, resident physician and admitting physician on duty, who gave Jorge a physical examination and took his
medical history. She noted that at the time of his admission, Jorge was conscious, ambulatory, oriented, coherent, and
with respiratory distress. [2] Typhoid fever was then prevalent in the locality, as the clinic had been getting from 15 to 20
cases of typhoid per month.[3] Suspecting that Jorge could be suffering from this disease, Dr. Rico ordered a Widal Test, a
standard test for typhoid fever, to be performed on Jorge. Blood count, routine urinalysis, stool examination, and
malarial smear were also made. [4] After about an hour, the medical technician submitted the results of the test from
which Dr. Rico concluded that Jorge was positive for typhoid fever. As her shift was only up to 5:00 p.m., Dr. Rico
indorsed Jorge to respondent Dr. Marvie Blanes.
Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorges history and gave him a
physical examination. Like Dr. Rico, her impression was that Jorge had typhoid fever. Antibiotics being the accepted
treatment for typhoid fever, she ordered that a compatibility test with the antibiotic chloromycetin be done on Jorge. Said
test was administered by nurse Josephine Pagente who also gave the patient a dose of triglobe. As she did not observe any
adverse reaction by the patient to chloromycetin, Dr. Blanes ordered the first five hundred milligrams of said antibiotic to
be administered on Jorge at around 9:00 p.m. A second dose was administered on Jorge about three hours later just
before midnight.
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature rose to 41C. The patient also
experienced chills and exhibited respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him under
oxygen, used a suction machine, and administered hydrocortisone, temporarily easing the patients convulsions. When he
regained consciousness, the patient was asked by Dr. Blanes whether he had a previous heart ailment or had suffered
from chest pains in the past. Jorge replied he did not.[5] After about 15 minutes, however, Jorge again started to vomit,
showed restlessness, and his convulsions returned. Dr. Blanes re-applied the emergency measures taken before and, in
addition, valium was administered. Jorge, however, did not respond to the treatment and slipped into cyanosis, a bluish
or purplish discoloration of the skin or mucous membrane due to deficient oxygenation of the blood. At around 2:00
a.m., Jorge died. He was forty years old. The cause of his death was Ventricular Arrythemia Secondary to Hyperpyrexia
and typhoid fever.
On June 3, 1987, petitioners filed before the Regional Trial Court of Cebu City a complaint [6]for damages against
respondents Sisters of Mercy, Sister Rose Palacio, Dr. Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine Pagente. On
September 24, 1987, petitioners amended their complaint to implead respondent Mercy Community Clinic as additional
defendant and to drop the name of Josephine Pagente as defendant since she was no longer connected with respondent
hospital. Their principal contention was that Jorge did not die of typhoid fever. [7] Instead, his death was due to the
wrongful administration of chloromycetin. They contended that had respondent doctors exercised due care and diligence,
they would not have recommended and rushed the performance of the Widal Test, hastily concluded that Jorge was
suffering from typhoid fever, and administered chloromycetin without first conducting sufficient tests on the patients
compatibility with said drug. They charged respondent clinic and its directress, Sister Rose Palacio, with negligence in
failing to provide adequate facilities and in hiring negligent doctors and nurses. [8]
Respondents denied the charges. During the pre-trial conference, the parties agreed to limit the issues on the
following: (1) whether the death of Jorge Reyes was due to or caused by the negligence, carelessness, imprudence, and
lack of skill or foresight on the part of defendants; (2) whether respondent Mercy Community Clinic was negligent in the
hiring of its employees; and (3) whether either party was entitled to damages. The case was then heard by the trial court
during which, in addition to the testimonies of the parties, the testimonies of doctors as expert witnesses were presented.

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Petitioners offered the testimony of Dr. Apolinar Vacalares, Chief Pathologist at the Northern Mindanao Training
Hospital, Cagayan de Oro City. On January 9, 1987, Dr. Vacalares performed an autopsy on Jorge Reyes to determine the
cause of his death. However, he did not open the skull to examine the brain. His findings[9] showed that the gastrointestinal tract was normal and without any ulceration or enlargement of the nodules. Dr. Vacalares testified that Jorge
did not die of typhoid fever. He also stated that he had not seen a patient die of typhoid fever within five days from the
onset of the disease.
For their part, respondents offered the testimonies of Dr. Peter Gotiong and Dr. Ibarra Panopio. Dr. Gotiong is a
diplomate in internal medicine whose expertise is microbiology and infectious diseases. He is also a consultant at the
Cebu City Medical Center and an associate professor of medicine at the South Western University College of Medicine in
Cebu City. He had treated over a thousand cases of typhoid patients. According to Dr. Gotiong, the patients history and
positive Widal Test results ratio of 1:320 would make him suspect that the patient had typhoid fever. As to Dr. Vacalares
observation regarding the absence of ulceration in Jorges gastro-intestinal tract, Dr. Gotiong said that such hyperplasia
in the intestines of a typhoid victim may be microscopic. He noted that since the toxic effect of typhoid fever may lead to
meningitis, Dr. Vacalares autopsy should have included an examination of the brain. [10]
The other doctor presented was Dr. Ibarra Panopio, a member of the American Board of Pathology, examiner of the
Philippine Board of Pathology from 1978 to 1991, fellow of the Philippine Society of Pathologist, associate professor of the
Cebu Institute of Medicine, and chief pathologist of the Andres Soriano Jr. Memorial Hospital in Toledo City. Dr.
Panopio stated that although he was partial to the use of the culture test for its greater reliability in the diagnosis of
typhoid fever, the Widal Test may also be used. Like Dr. Gotiong, he agreed that the 1:320 ratio in Jorges case was
already the maximum by which a conclusion of typhoid fever may be made. No additional information may be deduced
from a higher dilution.[11] He said that Dr. Vacalares autopsy on Jorge was incomplete and thus inconclusive.
On September 12, 1991, the trial court rendered its decision absolving respondents from the charges of negligence
and dismissing petitioners action for damages. The trial court likewise dismissed respondents counterclaim, holding
that, in seeking damages from respondents, petitioners were impelled by the honest belief that Jorges death was due to
the latters negligence.
Petitioners brought the matter to the Court of Appeals. On July 31, 1997, the Court of Appeals affirmed the decision
of the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS COMMITTED A REVERSIBLE ERROR WHEN IT RULED THAT
THE DOCTRINE OF RES IPSA LOQUITUR IS NOT APPLICABLE IN THE INSTANT CASE.
II. THE HONORABLE COURT OF APPEALS COMMITTED REVERSIBLE ERROR WHEN IT MADE AN
UNFOUNDED ASSUMPTION THAT THE LEVEL OF MEDICAL PRACTICE IS LOWER IN ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS GRAVELY ERRED WHEN IT RULED FOR A LESSER
STANDARD OF CARE AND DEGREE OF DILIGENCE FOR MEDICAL PRACTICE IN ILIGAN CITY WHEN
IT APPRECIATE[D] NO DOCTORS NEGLIGENCE IN THE TREATMENT OF JORGE REYES.
Petitioners action is for medical malpractice. This is a particular form of negligence which consists in the failure of a
physician or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed by the
profession generally, under similar conditions, and in like surrounding circumstances. [12] In order to successfully pursue
such a claim, a patient must prove that the physician or surgeon either failed to do something which a reasonably prudent
physician or surgeon would have done, or that he or she did something that a reasonably prudent physician or surgeon
would not have done, and that the failure or action caused injury to the patient. [13] There are thus four elements involved
in medical negligence cases, namely: duty, breach, injury, and proximate causation.
In the present case, there is no doubt that a physician-patient relationship existed between respondent doctors and
Jorge Reyes.Respondents were thus duty-bound to use at least the same level of care that any reasonably competent
doctor would use to treat a condition under the same circumstances. It is breach of this duty which constitutes actionable
malpractice.[14] As to this aspect of medical malpractice, the determination of the reasonable level of care and the breach
thereof, expert testimony is essential. Inasmuch as the causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually necessary to
support the conclusion as to causation.[15]

Res Ipsa Loquitur

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There is a case when expert testimony may be dispensed with, and that is under the doctrine of res ipsa loquitur. As
held in Ramos v. Court of Appeals:[16]
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitor is
availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. The reason is that the general rule on the necessity of expert testimony applies only to such matters
clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind
which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of
skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and
manifest conditions which are observable by any one may be given by non-expert witnesses. Hence, in cases where
the res ipsa loquituris applicable, the court is permitted to find a physician negligent upon proper proof of injury to the
patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the
proper standard of care. Where common knowledge and experience teach that a resulting injury would not have occurred
to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but
how and why it occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the
particular act or omission complained of and the injury sustained while under the custody and management of the
defendant without need to produce expert medical testimony to establish the standard of care. Resort tores ipsa
loquitor is allowed because there is no other way, under usual and ordinary conditions, by which the patient can obtain
redress for injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in the
body of the patient after an operation, injuries sustained on a healthy part of the body which was not under, or in the
area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a tooth while a
patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient was under the
influence of anesthetic, during or following an operation for appendicitis, among others. [17]
Petitioners asserted in the Court of Appeals that the doctrine of res ipsa loquitur applies to the present case because
Jorge Reyes was merely experiencing fever and chills for five days and was fully conscious, coherent, and ambulant when
he went to the hospital. Yet, he died after only ten hours from the time of his admission.
This contention was rejected by the appellate court.
Petitioners now contend that all requisites for the application of res ipsa loquitur were present, namely: (1) the
accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency
which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have
been due to any voluntary action or contribution of the person injured. [18]
The contention is without merit. We agree with the ruling of the Court of Appeals. In the Ramos case, the question
was whether a surgeon, an anesthesiologist, and a hospital should be made liable for the comatose condition of a patient
scheduled for cholecystectomy. [19] In that case, the patient was given anesthesia prior to her operation. Noting that the
patient was neurologically sound at the time of her operation, the Court applied the doctrine of res ipsa loquitur as
mental brain damage does not normally occur in a gallblader operation in the absence of negligence of the
anesthesiologist. Taking judicial notice that anesthesia procedures had become so common that even an ordinary person
could tell if it was administered properly, we allowed the testimony of a witness who was not an expert. In this case, while
it is true that the patient died just a few hours after professional medical assistance was rendered, there is really nothing
unusual or extraordinary about his death. Prior to his admission, the patient already had recurring fevers and chills for
five days unrelieved by the analgesic, antipyretic, and antibiotics given him by his wife. This shows that he had been
suffering from a serious illness and professional medical help came too late for him.
Respondents alleged failure to observe due care was not immediately apparent to a layman so as to justify
application of res ipsa loquitur. The question required expert opinion on the alleged breach by respondents of the
standard of care required by the circumstances.Furthermore, on the issue of the correctness of her diagnosis, no
presumption of negligence can be applied to Dr. Marlyn Rico. As held inRamos:
. . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied,
depending upon the circumstances of each case. It is generally restricted to situations in malpractice cases where a
layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were
not as such as would ordinarily have followed if due care had been exercised. A distinction must be made between the
failure to secure results, and the occurrence of something more unusual and not ordinarily found if the service or
treatment rendered followed the usual procedure of those skilled in that particular practice. It must be conceded that the

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doctrine of res ipsa loquitur can have no application in a suit against a physician or a surgeon which involves the merits
of a diagnosis or of a scientific treatment. The physician or surgeon is not required at his peril to explain why any
particular diagnosis was not correct, or why any particular scientific treatment did not produce the desired result.[20]

Specific Acts of Negligence

We turn to the question whether petitioners have established specific acts of negligence allegedly committed by
respondent doctors.
Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously relied upon the Widal test, diagnosed Jorges
illness as typhoid fever, and immediately prescribed the administration of the antibiotic chloromycetin; [21] and (2) Dr.
Marvie Blanes erred in ordering the administration of the second dose of 500 milligrams of chloromycetin barely three
hours after the first was given. [22] Petitioners presented the testimony of Dr. Apolinar Vacalares, Chief Pathologist of the
Northern Mindanao Training Hospital, Cagayan de Oro City, who performed an autopsy on the body of Jorge Reyes. Dr.
Vacalares testified that, based on his findings during the autopsy, Jorge Reyes did not die of typhoid fever but of shock
undetermined, which could be due to allergic reaction or chloromycetin overdose. We are not persuaded.
First. While petitioners presented Dr. Apolinar Vacalares as an expert witness, we do not find him to be so as he is
not a specialist on infectious diseases like typhoid fever. Furthermore, although he may have had extensive experience in
performing autopsies, he admitted that he had yet to do one on the body of a typhoid victim at the time he conducted the
postmortem on Jorge Reyes. It is also plain from his testimony that he has treated only about three cases of typhoid fever.
Thus, he testified that:[23]
ATTY. PASCUAL:
Q Why? Have you not testified earlier that you have never seen a patient who died of typhoid fever?
A In autopsy. But, that was when I was a resident physician yet.
Q But you have not performed an autopsy of a patient who died of typhoid fever?
A I have not seen one.
Q And you testified that you have never seen a patient who died of typhoid fever within five days?
A I have not seen one.
Q How many typhoid fever cases had you seen while you were in the general practice of medicine?
A In our case we had no widal test that time so we cannot consider that the typhoid fever is like this and like that. And
the widal test does not specify the time of the typhoid fever.
Q The question is: how many typhoid fever cases had you seen in your general practice regardless of the cases now you
practice?
A I had only seen three cases.
Q And that was way back in 1964?
A Way back after my training in UP.
Q Clinically?
A Way back before my training.
He is thus not qualified to prove that Dr. Marlyn Rico erred in her diagnosis. Both lower courts were therefore correct in
discarding his testimony, which is really inadmissible.
In Ramos, the defendants presented the testimony of a pulmonologist to prove that brain injury was due to oxygen
deprivation after the patient had bronchospasms [24] triggered by her allergic response to a drug, [25] and not due to faulty
intubation by the anesthesiologist. As the issue was whether the intubation was properly performed by an
anesthesiologist, we rejected the opinion of the pulmonologist on the ground that he was not: (1) an anesthesiologist who
could enlighten the court about anesthesia practice, procedure, and their complications; nor (2) an allergologist who
could properly advance expert opinion on allergic mediated processes; nor (3) a pharmacologist who could explain the
pharmacologic and toxic effects of the drug allegedly responsible for the bronchospasms.

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Second. On the other hand, the two doctors presented by respondents clearly were experts on the subject. They
vouched for the correctness of Dr. Marlyn Ricos diagnosis. Dr. Peter Gotiong, a diplomate whose specialization is
infectious diseases and microbiology and an associate professor at the Southwestern University College of Medicine and
the Gullas College of Medicine, testified that he has already treated over a thousand cases of typhoid fever. [26] According
to him, when a case of typhoid fever is suspected, the Widal test is normally used, [27] and if the 1:320 results of the Widal
test on Jorge Reyes had been presented to him along with the patients history, his impression would also be that the
patient was suffering from typhoid fever.[28] As to the treatment of the disease, he stated that chloromycetin was the drug
of choice.[29] He also explained that despite the measures taken by respondent doctors and the intravenous
administration of two doses of chloromycetin, complications of the disease could not be discounted. His testimony is as
follows:[30]
ATTY. PASCUAL:
Q If with that count with the test of positive for 1 is to 320, what treatment if any would be given?
A If those are the findings that would be presented to me, the first thing I would consider would be typhoid fever.
Q And presently what are the treatments commonly used?
A Drug of choice of chloramphenical.
Q Doctor, if given the same patient and after you have administered chloramphenical about 3 1/2 hours later, the
patient associated with chills, temperature - 41oC, what could possibly come to your mind?
A Well, when it is change in the clinical finding, you have to think of complication.
Q And what will you consider on the complication of typhoid?
A One must first understand that typhoid fever is toximia. The problem is complications are caused by toxins
produced by the bacteria . . . whether you have suffered complications to think of -- heart toxic myocardities;
then you can consider a toxic meningitis and other complications and perforations and bleeding in the ilium.
Q Even that 40-year old married patient who received medication of chloromycetin of 500 milligrams intravenous,
after the skin test, and received a second dose of chloromycetin of 500 miligrams, 3 hours later, the patient
developed chills . . . rise in temperature to 41 oC, and then about 40 minutes later the temperature rose to 100 oF,
cardiac rate of 150 per minute who appeared to be coherent, restless, nauseating, with seizures: what significance
could you attach to these clinical changes?
A I would then think of toxemia, which was toxic meningitis and probably a toxic meningitis because of the high
cardiac rate.
Q Even if the same patient who, after having given intramuscular valium, became conscious and coherent about 20
minutes later, have seizure and cyanosis and rolling of eyeballs and vomitting . . . and death: what significance
would you attach to this development?
A We are probably dealing with typhoid to meningitis.
Q In such case, Doctor, what finding if any could you expect on the post-mortem examination?
A No, the finding would be more on the meninges or covering of the brain.
Q And in order to see those changes would it require opening the skull?
A Yes.
As regards Dr. Vacalares finding during the autopsy that the deceaseds gastro-intestinal tract was normal, Dr. Rico
explained that, while hyperplasia [31] in the payers patches or layers of the small intestines is present in typhoid fever, the
same may not always be grossly visible and a microscope was needed to see the texture of the cells. [32]
Respondents also presented the testimony of Dr. Ibarra T. Panopio who is a member of the Philippine and American
Board of Pathology, an examiner of the Philippine Board of Pathology, and chief pathologist at the MetroCebu
Community Hospital, Perpetual Succor Hospital, and the Andres Soriano Jr. Memorial Medical Center. He stated that, as
a clinical pathologist, he recognized that the Widal test is used for typhoid patients, although he did not encourage its use
because a single test would only give a presumption necessitating that the test be repeated, becoming more conclusive at
the second and third weeks of the disease. [33] He corroborated Dr. Gotiongs testimony that the danger with typhoid fever
is really the possible complications which could develop like perforation, hemorrhage, as well as liver and cerebral
complications.[34] As regards the 1:320 results of the Widal test on Jorge Reyes, Dr. Panopio stated that no additional
information could be obtained from a higher ratio.[35] He also agreed with Dr. Gotiong that hyperplasia in the payers
patches may be microscopic.[36]

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Page 38

Indeed, the standard contemplated is not what is actually the average merit among all known practitioners from the
best to the worst and from the most to the least experienced, but the reasonable average merit among the ordinarily good
physicians.[37] Here, Dr. Marlyn Rico did not depart from the reasonable standard recommended by the experts as she in
fact observed the due care required under the circumstances. Though the Widal test is not conclusive, it remains a
standard diagnostic test for typhoid fever and, in the present case, greater accuracy through repeated testing was
rendered unobtainable by the early death of the patient. The results of the Widal test and the patients history of fever
with chills for five days, taken with the fact that typhoid fever was then prevalent as indicated by the fact that the clinic
had been getting about 15 to 20 typhoid cases a month, were sufficient to give upon any doctor of reasonable skill the
impression that Jorge Reyes had typhoid fever.
Dr. Rico was also justified in recommending the administration of the drug chloromycetin, the drug of choice for
typhoid fever. The burden of proving that Jorge Reyes was suffering from any other illness rested with the
petitioners. As they failed to present expert opinion on this, preponderant evidence to support their contention is clearly
absent.
Third. Petitioners contend that respondent Dr. Marvie Blanes, who took over from Dr. Rico, was negligent in
ordering the intravenous administration of two doses of 500 milligrams of chloromycetin at an interval of less than three
hours. Petitioners claim that Jorge Reyes died of anaphylactic shock [38] or possibly from overdose as the second dose
should have been administered five to six hours after the first, per instruction of Dr. Marlyn Rico. As held by the Court of
Appeals, however:
That chloromycetin was likewise a proper prescription is best established by medical authority. Wilson, et. al.,
in Harrisons Principle of Internal Medicine, 12th ed. write that chlorampenicol (which is the generic of chloromycetin) is
the drug of choice for typhoid fever and that no drug has yet proven better in promoting a favorable clinical response.
Chlorampenicol (Chloromycetin) is specifically indicated for bacterial meningitis, typhoid fever, rickettsial infections,
bacteriodes infections, etc. (PIMS Annual, 1994, p. 211) The dosage likewise including the first administration of five
hundred milligrams (500 mg.) at around nine oclock in the evening and the second dose at around 11:30 the same
night was still within medically acceptable limits, since the recommended dose of chloromycetin is one (1) gram every
six (6) hours. (cf. Pediatric Drug Handbook, 1st Ed., Philippine Pediatric Society, Committee on Therapeutics and
Toxicology, 1996). The intravenous route is likewise correct. (Mansser, ONick, Pharmacology and Therapeutics) Even if
the test was not administered by the physician-on-duty, the evidence introduced that it was Dra. Blanes who interpreted
the results remain uncontroverted. (Decision, pp. 16-17) Once more, this Court rejects any claim of professional
negligence in this regard.
....
As regards anaphylactic shock, the usual way of guarding against it prior to the administration of a drug, is the skin test
of which, however, it has been observed: Skin testing with haptenic drugs is generally not reliable. Certain drugs cause
nonspecific histamine release, producing a weal-and-flare reaction in normal individuals. Immunologic activation of
mast cells requires a polyvalent allergen, so a negative skin test to a univalent haptenic drug does not rule out
anaphylactic sensitivity to that drug. (Terr, Anaphylaxis and Urticaria in Basic and Clinical Immunology, p. 349) What
all this means legally is that even if the deceased suffered from an anaphylactic shock, this, of itself, would not yet
establish the negligence of the appellee-physicians for all that the law requires of them is that they perform the standard
tests and perform standard procedures. The law cannot require them to predict every possible reaction to all drugs
administered. The onus probandi was on the appellants to establish, before the trial court, that the appellee-physicians
ignored standard medical procedure, prescribed and administered medication with recklessness and exhibited an
absence of the competence and skills expected of general practitioners similarly situated. [39]
Fourth. Petitioners correctly observe that the medical profession is one which, like the business of a common
carrier, is affected with public interest. Moreover, they assert that since the law imposes upon common carriers the duty
of observing extraordinary diligence in the vigilance over the goods and for the safety of the passengers, [40] physicians and
surgeons should have the same duty toward their patients. [41] They also contend that the Court of Appeals erred when it
allegedly assumed that the level of medical practice is lower in Iligan City, thereby reducing the standard of care and
degree of diligence required from physicians and surgeons in Iligan City.
The standard of extraordinary diligence is peculiar to common carriers. The Civil Code provides:
Art. 1733. Common carriers, from the nature of their business and for reasons of public policy, are bound to observe
extraordinary diligence in the vigilance over the goods and for the safety of the passengers transported by them,
according to the circumstances of each case. . . .

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The practice of medicine is a profession engaged in only by qualified individuals. It is a right earned through years of
education, training, and 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 Appeals called it, the reasonable skill and competence . . . that a physician in the same or similar
locality . . . should apply.
WHEREFORE, the instant petition is DENIED and the decision of the Court of Appeals is AFFIRMED.
SO ORDERED.

SAMUEL R. RUEZ, JR.,


Complainant,

A.M. No. 2005-08-SC


Present:

- versus -

MARYBETH V. JURADO,
Respondent.

DAVIDE, JR., C.J.,


PUNO,
PANGANIBAN,
QUISUMBING,
YNARES-SANTIAGO,
SANDOVAL-GUITERREZ,
CARPIO,
AUSTRIA-MARTINEZ,
CORONA,
CARPIO MORALES,
CALLEJO, SR.,
AZCUNA,
TINGA,
CHICO-NAZARIO, and
GARCIA, JJ.

Promulgated:
December 9, 2005
x-----------------------------------------------------------------------------------------x
DECISION
AZCUNA, J.:

It is unfortunate that this administrative case involves co-workers in this Court. Complainant, Samuel R. Ruez,
Jr. (Ruez, Jr.), is Chief of the Clearance Section, Checks Disbursement Division of the FMO-OCA and is the son of the
aggrieved party, Samuel V. Ruez, Sr. (Ruez, Sr.), Driver I for the Motorpool, Property Division of the OCA. Respondent
is Dr. Marybeth V. Jurado (Dr. Jurado), Medical Officer IV of the Medical and Dental Services. All three were working for
the Court at the time of the incident in issue.
The parties agree that on January 12, 2005, at around 4:20 p.m., Ruez, Sr. arrived by himself at this Courts
clinic complaining of dizziness. His blood pressure and pulse rate were taken by the reception nurse and were registered
at 210/100 mmHg and 112 beats a minute, respectively. What transpired next is disputed. Ruez, Jr. alleged that despite
his fathers medical condition, he was merely advised to go to a hospital and then allowed to walk out of the clinic on his

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own. Dr. Jurado, on the other hand, maintained that after being informed of Ruez, Sr.s blood pressure and heart rate,
she instructed the nurse to administer one tablet of Capoten 25mg, an emergency drug that quickly lowers a patients
blood pressure. She then informed Ruez, Sr. that he will be taken to the hospital, after which she immediately instructed
the ambulance driver, Mr. Jacinto, to stand by for hospital conduction. Minutes later, after having takenCapoten and
being given a chance to rest, Ruez, Sr. stood up and walked out saying, Doktora, hanap lang ho ako ng kasama. Dr.
Jurado said she waited for him to return but he failed to show up. She asked Mr. Almarza, a nurse at the clinic, to look for
Ruez, Sr. but he was unable to locate him.
According to Ruez, Jr., after being informed of his fathers condition, he rushed him to the Manila Doctors
Hospital. There, Ruez, Sr. was treated in the emergency room for approximately four hours before he was discharged at
around 8:30 p.m. and allowed to go home. However, prior to reaching their house in Balintawak, Caloocan City, Ruez,
Sr. began experiencing nausea, abnormal palpitation and uneasiness and had to be brought back to the hospital.
Ruez, Sr. and Ruez, Jr.[1] arrived at the emergency room of the Manila Doctors Hospital at around 10:00 p.m.
after which Ruez, Sr. underwent a C.T. Scan. The C.T. Scan revealed a blood clot necessitating him to be admitted for
treatment and observation. The following morning he suffered a stroke and for a moment was on flat line. The doctors
were able to revive him and thereafter he was transferred to the intensive care unit. Unfortunately, Ruez Sr. never
recovered from his ailment and, on September 12, 2005, he passed away due to medical complications. [2]
On February 15, 2005, Ruez, Jr. filed a letter-complaint with the Office of the Chief Justice regarding the alleged
lack of attention given to his father by Dr. Jurado. Specifically, he claims that Dr. Jurado merely advised his father to go
to the hospital and then allowed him to travel to Manila Doctors Hospital despite the availability of an ambulance at the
disposal of the clinic. Ruez, Jr. submits that his father would not have suffered a stroke if not for the neglect of Dr.
Jurado.
The letter-complaint was referred to Atty. Eden T. Candelaria, Deputy Clerk of Court and Chief of Administrative
Services, for investigation. Atty. Candelaria required Dr. Jurado to submit her comment to the letter-complaint. The
comment was submitted on March 18, 2005, together with supporting affidavits from respondents witnesses. This was
followed by Ruez, Jr.s reply to the comment on April 12, 2005 and Dr. Jurados rejoinder on April 22, 2005. [3]
Atty. Candelaria submitted her report on June 17, 2005. The report gave credence to the account of Dr. Jurado that
Ruez, Sr. was given Capoten, informed that he should be hospitalized and that the ambulance was placed on standby to
take him there. These factual findings of Atty. Candelaria appear to be supported by the affidavits of the clinics
personnel, including the ambulance driver, who witnessed the events that happened between Ruez, Sr. and Dr. Jurado.
The issue now for the Court to resolve is whether, given the accepted facts, there is cause to hold Dr. Jurado
administratively liable. Atty. Candelaria is satisfied that Dr. Jurado provided Ruez, Sr. proper treatment inside the
clinic. However, in her opinion, Dr. Jurados actions after Ruez, Sr. had left were less than the required diligence of a
good father of a family. We quote below the analysis of Atty. Candelaria:

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. . . Records will clearly show that minutes after Mr. Ruez, Sr. left the clinic, Dr. Jurado also left
the clinic to go home. This is shown by her time out registered in the Chronolog Machine on the said date
which was 4:31 p.m. and her inclusion in the list of passengers of Shuttle Bus No. 6. As an efficient and
intelligent doctor, Dr. Jurado should have at least personally exerted all her efforts to determine the
whereabouts of Mr. Ruez, Sr. because of his condition and again at the very least informed his relatives
in the Court in order that they too take the necessary action that very moment. Or in the alternative, if
indeed, Dr. Jurado may have been in a hurry at that time to do some errands, she should have at least[,]
again, turned Mr. Ruez over the a [d]octor who was willing to be left behind after office hours. These
however never happened. All that she relied on was the fact that there was an emergency treatment and
an order for hospital conduction but [the same] didnt materialize and [she] put [the] blame on Mr.
Ruez, Sr. As admitted by complainant, Mr. Ruez, Sr., is a mere driver and perhaps may have no
knowledge at all of the consequences of his 210/100 blood pressure and since he sought refuge from the
[c]linic, the clinic, particularly Dr. Jurado[,] should have made him feel safe and secure in the said
place. . . .

Atty. Candelaria recommends that Dr. Jurado be held liable for simple neglect of duty and suspended for one (1)
month and (1) day. She further recommends that, in light of what happened, Dr. Prudencio Banzon, SC Senior Staff
Officer, Medical and Dental Services, be directed to prepare a flexi-time schedule (until 5:30 p.m.) for all doctors and
nurses in the clinic to enable it to provide immediate and proper attention in case of any emergency medical situation.
The Court does not agree that the acts or omission of Dr. Jurado amount to simple neglect of duty. Simple neglect
of duty is defined as failure to give proper attention to a task expected of an employee resulting from either carelessness
or indifference[4] or signifies a disregard of duty resulting from carelessness or indifference. [5] In Philippine Retirement
Authority,[6] it was stated, The Court has decided the following, inter alia, as constituting the less grave offense of
Simple Neglect of Duty: delay in the transmittal of court records, delay in responding to written queries, and delay of
more than one (1) year and seven (7) months in furnishing a party with a copy of the courts decision. In all the
instances cited by the Court, respondents had the duty or were expected to do certain acts which they failed to do. How
do we determine what acts are expected of Dr. Jurado? Atty. Candelarias report cites the applicable yardstick: a
physician or surgeon is expected to apply in his practice of medicine that degree of care and skill which is ordinarily
employed by the profession, generally, and under similar conditions. [7] Therefore, to find Dr. Jurado liable for simple
neglect of duty the Court has to be convinced that those in the medical profession were also expected to act in the manner
illustrated by Atty. Candelaria, i.e., to exert all efforts to determine the whereabouts of Ruez, Sr., inform his relatives or
turn his case over to a doctor who was available after office hours.
Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:
A physician should attend to his patients faithfully and conscientiously. He should secure for
them all possible benefits that may depend upon his professional skill and care. As the sole tribunal to
adjudge the physicians failure to fulfill his obligation to his patients is, in most cases, his own
conscience, violation of this rule on his part is discreditable and inexcusable.

A doctors duty to his patient is not required to be extraordinary. [8] The standard contemplated for doctors is
simply the reasonable average merit among ordinarily good physicians, i.e. reasonable skill and competence. [9] We are

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persuaded that Dr. Jurado fulfilled such a standard when she treated Ruez, Sr. inside the clinic. But what of Dr. Jurados
conduct after Ruez, Sr. left the clinic and failed to return?
It has been held that a patient cannot attribute to a physician damages resulting from his own failure to follow his
advice, even though he was ignorant of the consequences which would result from his failure. [10] If a patient leaves the
hospital contrary to instructions, the physician is not liable for subsequent events. [11] There is no expectation from doctors
that they track down each patient who apparently missed their appointments or force them to comply with their
directives. After all, a person is still the master of his own body. [12]
Dr. Jurado may have allowed Ruez, Sr. to walk out of the clinic despite her earlier diagnosis of his condition. By
that time Ruez, Sr.s condition had temporarily stabilized and she did not have the authority to stop him just as other
doctors have no power, save in certain instances (such as when the law makes treatment compulsory due to some
communicable disease[13] or when consent is withheld by a minor but non-treatment would be detrimental or when the
court of competent jurisdiction orders the treatment), to force patients into staying under their care. Dr. Jurado relied on
Ruez, Sr.s representation that he would return in order to be brought to the hospital but made no undertaking to wait
for him beyond the clinic hours or to look for him if he did not return. Thus, when Ruez, Sr. failed to show up as of
closing time, and could not be found by the male nurse who looked for him at her instructions, Dr. Jurado had reason to
think that he had decided to disregard her medical advice, which he in fact did when he and Ruez, Jr. decided to go to
the hospital on their own. Ruez, Sr., still of sound mind, had the right to accept or ignore his doctors recommendation.
Dr. Jurado was obligated to care for Ruez, Sr. when the latter asked for medical treatment, which she did, but when he
left on his own accord Dr. Jurado was not expected, much less duty-bound, to seek out her patient and continue being his
doctor.
Some people may interpret Dr. Jurados inaction as indifference, while others may view the same as just proper.
Some would applaud Dr. Jurados dedication had she done all the things mentioned by Atty. Candelaria and yet others
would see them as still insufficient. There will always be a divergence of opinions as to how Dr. Jurado should have
conducted herself but the Court must distinguish between acts that deserve to be emulated or disdained and those that
deserve sanctions. The former is largely a matter of opinion while the latter can only be imposed if there was a failure to
perform a clear duty, expectation or obligation. People may frown upon certain behaviors and chastise others for having
less compassion, but it does not necessarily follow that those acts translate to neglect of duty, misconduct or negligence.
Dr. Jurado could have exerted greater efforts by searching all over the compound for Ruez, Sr. but the fact
remains that these were not part of her duties nor were they expected from her. Simple neglect of duty presupposes a task
expected of an employee. Thus, it cannot be present if there was no expected task on her part. That said, the Court
wishes to exhort Dr. Jurado, and all personnel in its clinic, not to be satisfied with merely fulfilling the minimum, but to
go for the magis, the best service they can render by way of being exemplars for their fellow workers in the Court.
WHEREFORE, the Court finds no reason to hold Dr. Jurado liable for simple neglect of duty, and,
therefore,DISMISSES the complaint for lack of merit. As recommended by Atty. Eden T. Candelaria, Deputy Clerk of

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Court and Chief of Administrative Services, Dr. Prudencio Banzon, Senior Staff Officer, Medical and Dental Services,
isDIRECTED to prepare a flexi-time schedule for all doctors and nurses in the clinic to further develop its capability to
provide immediate and proper attention in emergency medical situations, and to submit the same to Atty. Candelaria in
30 days from receipt of a copy of this decision which should be served upon him forthwith.
SO ORDERED.

G.R. No. 142625

December 19, 2006

ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY, ANGELICA,
NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners,
vs.
CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR. JOEL
ENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondents.

DECISION

CARPIO, J.:
The Case
This petition for review1 assails the 6 February 1998 Decision 2 and 21 March 2000 Resolution3 of the Court of Appeals in
CA-G.R. CV No. 45641. The Court of Appeals affirmed in toto the 22 November 1993 Decision4 of the Regional Trial Court
of Manila, Branch 33, finding Dr. Oscar Estrada solely liable for damages for the death of his patient, Corazon Nogales,
while absolving the remaining respondents of any liability. The Court of Appeals denied petitioners' motion for
reconsideration.
The Facts
Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was under the exclusive
prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of pregnancy or as early as December
1975. While Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood pressure and
development of leg edema5 indicating preeclampsia,6 which is a dangerous complication of pregnancy.7
Around midnight of 25 May 1976, Corazon started to experience mild labor pains prompting Corazon and Rogelio
Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised her
immediate admission to the Capitol Medical Center ("CMC").
On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the written admission
request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales ("Rogelio") executed and signed the
"Consent on Admission and Agreement"9 and "Admission Agreement."10 Corazon was then brought to the labor room of
the CMC.
Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal examination of Corazon. Dr.
Uy then called up Dr. Estrada to notify him of her findings.

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Based on the Doctor's Order Sheet,11 around 3:00 a.m., Dr. Estrada ordered for 10 mg. of valium to be administered
immediately by intramuscular injection. Dr. Estrada later ordered the start of intravenous administration of syntocinon
admixed with dextrose, 5%, in lactated Ringers' solution, at the rate of eight to ten micro-drops per minute.
According to the Nurse's Observation Notes,12 Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist at CMC, was
notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he needed the services of an anesthesiologist,
Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observe Corazon's condition.
At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10 a.m., Corazon's bag of water ruptured
spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m., Corazon started to experience convulsions.
At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely Villaflor ("Dr.
Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium sulfate.
At 6:22 a.m., Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In the process, a 1.0 x
2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and injured condition.
Consequently, the baby had to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo.
At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse. Corazon's blood
pressure dropped from 130/80 to 60/40 within five minutes. There was continuous profuse vaginal bleeding. The
assisting nurse administered hemacel through a gauge 19 needle as a side drip to the ongoing intravenous injection of
dextrose.
At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. It took approximately 30 minutes
for the CMC laboratory, headed by Dr. Perpetua Lacson ("Dr. Lacson"), to comply with Dr. Estrada's order and deliver
the blood.
At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of the CMC, was
apprised of Corazon's condition by telephone. Upon being informed that Corazon was bleeding profusely, Dr. Espinola
ordered immediate hysterectomy. Rogelio was made to sign a "Consent to Operation." 13
Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an ambulance, arrived at the
CMC about an hour later or at 9:00 a.m. He examined the patient and ordered some resuscitative measures to be
administered. Despite Dr. Espinola's efforts, Corazon died at 9:15 a.m. The cause of death was "hemorrhage, post
partum."14
On 14 May 1980, petitioners filed a complaint for damages 15 with the Regional Trial Court16 of Manila against CMC, Dr.
Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr. Lacson, Dr. Espinola, and a certain Nurse J. Dumlao for the death of
Corazon. Petitioners mainly contended that defendant physicians and CMC personnel were negligent in the treatment
and management of Corazon's condition. Petitioners charged CMC with negligence in the selection and supervision of
defendant physicians and hospital staff.
For failing to file their answer to the complaint despite service of summons, the trial court declared Dr. Estrada, Dr.
Enriquez, and Nurse Dumlao in default.17 CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their respective
answers denying and opposing the allegations in the complaint. Subsequently, trial ensued.
After more than 11 years of trial, the trial court rendered judgment on 22 November 1993 finding Dr. Estrada solely liable
for damages. The trial court ruled as follows:
The victim was under his pre-natal care, apparently, his fault began from his incorrect and inadequate
management and lack of treatment of the pre-eclamptic condition of his patient. It is not disputed that he
misapplied the forceps in causing the delivery because it resulted in a large cervical tear which had caused the
profuse bleeding which he also failed to control with the application of inadequate injection of magnesium sulfate
by his assistant Dra. Ely Villaflor. Dr. Estrada even failed to notice the erroneous administration by nurse
Dumlao of hemacel by way of side drip, instead of direct intravenous injection, and his failure to consult a senior
obstetrician at an early stage of the problem.
On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr. Espinola, nurse J.
Dumlao and CMC, the Court finds no legal justification to find them civilly liable.

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On the part of Dra. Ely Villaflor, she was only taking orders from Dr. Estrada, the principal physician of Corazon
Nogales. She can only make suggestions in the manner the patient maybe treated but she cannot impose her will
as to do so would be to substitute her good judgment to that of Dr. Estrada. If she failed to correctly diagnose the
true cause of the bleeding which in this case appears to be a cervical laceration, it cannot be safely concluded by
the Court that Dra. Villaflor had the correct diagnosis and she failed to inform Dr. Estrada. No evidence was
introduced to show that indeed Dra. Villaflor had discovered that there was laceration at the cervical area of the
patient's internal organ.
On the part of nurse Dumlao, there is no showing that when she administered the hemacel as a side drip, she did
it on her own. If the correct procedure was directly thru the veins, it could only be because this was what was
probably the orders of Dr. Estrada.
While the evidence of the plaintiffs shows that Dr. Noe Espinola, who was the Chief of the Department of
Obstetrics and Gynecology who attended to the patient Mrs. Nogales, it was only at 9:00 a.m. That he was able to
reach the hospital because of typhoon Didang (Exhibit 2). While he was able to give prescription in the manner
Corazon Nogales may be treated, the prescription was based on the information given to him by phone and he
acted on the basis of facts as presented to him, believing in good faith that such is the correct remedy. He was not
with Dr. Estrada when the patient was brought to the hospital at 2:30 o'clock a.m. So, whatever errors that Dr.
Estrada committed on the patient before 9:00 o'clock a.m. are certainly the errors of Dr. Estrada and cannot be
the mistake of Dr. Noe Espinola. His failure to come to the hospital on time was due to fortuitous event.
On the part of Dr. Joel Enriquez, while he was present in the delivery room, it is not incumbent upon him to call
the attention of Dr. Estrada, Dra. Villaflor and also of Nurse Dumlao on the alleged errors committed by them.
Besides, as anesthesiologist, he has no authority to control the actuations of Dr. Estrada and Dra. Villaflor. For
the Court to assume that there were errors being committed in the presence of Dr. Enriquez would be to dwell on
conjectures and speculations.
On the civil liability of Dr. Perpetua Lacson, [s]he is a hematologist and in-charge of the blood bank of the CMC.
The Court cannot accept the theory of the plaintiffs that there was delay in delivering the blood needed by the
patient. It was testified, that in order that this blood will be made available, a laboratory test has to be conducted
to determine the type of blood, cross matching and other matters consistent with medical science so, the lapse of
30 minutes maybe considered a reasonable time to do all of these things, and not a delay as the plaintiffs would
want the Court to believe.
Admittedly, Dra. Rosa Uy is a resident physician of the Capitol Medical Center. She was sued because of her
alleged failure to notice the incompetence and negligence of Dr. Estrada. However, there is no evidence to
support such theory. No evidence was adduced to show that Dra. Rosa Uy as a resident physician of Capitol
Medical Center, had knowledge of the mismanagement of the patient Corazon Nogales, and that notwithstanding
such knowledge, she tolerated the same to happen.
In the pre-trial order, plaintiffs and CMC agreed that defendant CMC did not have any hand or participation in
the selection or hiring of Dr. Estrada or his assistant Dra. Ely Villaflor as attending physician[s] of the deceased.
In other words, the two (2) doctors were not employees of the hospital and therefore the hospital did not have
control over their professional conduct. When Mrs. Nogales was brought to the hospital, it was an emergency
case and defendant CMC had no choice but to admit her. Such being the case, there is therefore no legal ground
to apply the provisions of Article 2176 and 2180 of the New Civil Code referring to the vicarious liability of an
employer for the negligence of its employees. If ever in this case there is fault or negligence in the treatment of
the deceased on the part of the attending physicians who were employed by the family of the deceased, such civil
liability should be borne by the attending physicians under the principle of "respondeat superior".
WHEREFORE, premises considered, judgment is hereby rendered finding defendant Dr. Estrada of Number 13
Pitimini St. San Francisco del Monte, Quezon City civilly liable to pay plaintiffs: 1) By way of actual damages in
the amount of P105,000.00; 2) By way of moral damages in the amount of P700,000.00; 3) Attorney's fees in the
amount of P100,000.00 and to pay the costs of suit.
For failure of the plaintiffs to adduce evidence to support its [sic] allegations against the other defendants, the
complaint is hereby ordered dismissed. While the Court looks with disfavor the filing of the present complaint
against the other defendants by the herein plaintiffs, as in a way it has caused them personal inconvenience and
slight damage on their name and reputation, the Court cannot accepts [sic] however, the theory of the remaining
defendants that plaintiffs were motivated in bad faith in the filing of this complaint. For this reason defendants'
counterclaims are hereby ordered dismissed.

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Page 46

SO ORDERED.18
Petitioners appealed the trial court's decision. Petitioners claimed that aside from Dr. Estrada, the remaining
respondents should be held equally liable for negligence. Petitioners pointed out the extent of each respondent's alleged
liability.
On 6 February 1998, the Court of Appeals affirmed the decision of the trial court. 19 Petitioners filed a motion for
reconsideration which the Court of Appeals denied in its Resolution of 21 March 2000. 20
Hence, this petition.
Meanwhile, petitioners filed a Manifestation dated 12 April 2002 21 stating that respondents Dr. Estrada, Dr. Enriquez,
Dr. Villaflor, and Nurse Dumlao "need no longer be notified of the petition because they are absolutely not involved in the
issue raised before the [Court], regarding the liability of [CMC]."22 Petitioners stressed that the subject matter of this
petition is the liability of CMC for the negligence of Dr. Estrada. 23
The Court issued a Resolution dated 9 September 200224 dispensing with the requirement to submit the correct and
present addresses of respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao. The Court stated that with
the filing of petitioners' Manifestation, it should be understood that they are claiming only against respondents CMC, Dr.
Espinola, Dr. Lacson, and Dr. Uy who have filed their respective comments. Petitioners are foregoing further claims
against respondents Dr. Estrada, Dr. Enriquez, Dr. Villaflor, and Nurse Dumlao.
The Court noted that Dr. Estrada did not appeal the decision of the Court of Appeals affirming the decision of the
Regional Trial Court. Accordingly, the decision of the Court of Appeals, affirming the trial court's judgment, is already
final as against Dr. Oscar Estrada.
Petitioners filed a motion for reconsideration 25 of the Court's 9 September 2002 Resolution claiming that Dr. Enriquez,
Dr. Villaflor and Nurse Dumlao were notified of the petition at their counsels' last known addresses. Petitioners
reiterated their imputation of negligence on these respondents. The Court denied petitioners' Motion for Reconsideration
in its 18 February 2004 Resolution.26
The Court of Appeals' Ruling
In its Decision of 6 February 1998, the Court of Appeals upheld the trial court's ruling. The Court of Appeals rejected
petitioners' view that the doctrine in Darling v. Charleston Community Memorial Hospital 27 applies to this case.
According to the Court of Appeals, the present case differs from the Darling case since Dr. Estrada is an independent
contractor-physician whereas the Darling case involved a physician and a nurse who were employees of the hospital.
Citing other American cases, the Court of Appeals further held that the mere fact that a hospital permitted a physician to
practice medicine and use its facilities is not sufficient to render the hospital liable for the physician's negligence. 28 A
hospital is not responsible for the negligence of a physician who is an independent contractor. 29
The Court of Appeals found the cases of Davidson v. Conole30 and Campbell v. Emma Laing Stevens Hospital31applicable
to this case. Quoting Campbell, the Court of Appeals stated that where there is no proof that defendant physician was an
employee of defendant hospital or that defendant hospital had reason to know that any acts of malpractice would take
place, defendant hospital could not be held liable for its failure to intervene in the relationship of physician-patient
between defendant physician and plaintiff.
On the liability of the other respondents, the Court of Appeals applied the "borrowed servant" doctrine considering that
Dr. Estrada was an independent contractor who was merely exercising hospital privileges. This doctrine provides that
once the surgeon enters the operating room and takes charge of the proceedings, the acts or omissions of operating room
personnel, and any negligence associated with such acts or omissions, are imputable to the surgeon. 32 While the assisting
physicians and nurses may be employed by the hospital, or engaged by the patient, they normally become the temporary
servants or agents of the surgeon in charge while the operation is in progress, and liability may be imposed upon the
surgeon for their negligent acts under the doctrine of respondeat superior.33
The Court of Appeals concluded that since Rogelio engaged Dr. Estrada as the attending physician of his wife, any
liability for malpractice must be Dr. Estrada's sole responsibility.

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While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest could be imposed
on unliquidated claims or damages.
The Issue
Basically, the issue in this case is whether CMC is vicariously liable for the negligence of Dr. Estrada. The resolution of
this issue rests, on the other hand, on the ascertainment of the relationship between Dr. Estrada and CMC. The Court
also believes that a determination of the extent of liability of the other respondents is inevitable to finally and completely
dispose of the present controversy.
The Ruling of the Court
The petition is partly meritorious.
On the Liability of CMC
Dr. Estrada's negligence in handling the treatment and management of Corazon's condition which ultimately resulted in
Corazon's death is no longer in issue. Dr. Estrada did not appeal the decision of the Court of Appeals which affirmed the
ruling of the trial court finding Dr. Estrada solely liable for damages. Accordingly, the finding of the trial court on Dr.
Estrada's negligence is already final.
Petitioners maintain that CMC is vicariously liable for Dr. Estrada's negligence based on Article 2180 in relation to Article
2176 of the Civil Code. These provisions pertinently state:
Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts or omissions, but
also for those of persons for whom one is responsible.
xxxx
Employers shall be liable for the damages caused by their employees and household helpers acting within the
scope of their assigned tasks, even though the former are not engaged in any business or industry.
xxxx
The responsibility treated of in this article shall cease when the persons herein mentioned prove that they
observed all the diligence of a good father of a family to prevent damage.
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay
for the damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties,
is called a quasi-delict and is governed by the provisions of this Chapter.
Similarly, in the United States, a hospital which is the employer, master, or principal of a physician employee, servant, or
agent, may be held liable for the physician's negligence under the doctrine of respondeat superior.34
In the present case, petitioners maintain that CMC, in allowing Dr. Estrada to practice and admit patients at CMC, should
be liable for Dr. Estrada's malpractice. Rogelio claims that he knew Dr. Estrada as an accredited physician of CMC,
though he discovered later that Dr. Estrada was not a salaried employee of the CMC. 35 Rogelio further claims that he was
dealing with CMC, whose primary concern was the treatment and management of his wife's condition. Dr. Estrada just
happened to be the specific person he talked to representing CMC.36 Moreover, the fact that CMC made Rogelio sign a
Consent on Admission and Admission Agreement37 and a Consent to Operation printed on the letterhead of CMC
indicates that CMC considered Dr. Estrada as a member of its medical staff.
On the other hand, CMC disclaims liability by asserting that Dr. Estrada was a mere visiting physician and that it
admitted Corazon because her physical condition then was classified an emergency obstetrics case. 38
CMC alleges that Dr. Estrada is an independent contractor "for whose actuations CMC would be a total stranger." CMC
maintains that it had no control or supervision over Dr. Estrada in the exercise of his medical profession.

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The Court had the occasion to determine the relationship between a hospital and a consultant or visiting physician and
the liability of such hospital for that physician's negligence in Ramos v. Court of Appeals,39 to wit:
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct
of their work within the hospital premises. Doctors who apply for "consultant" slots, visiting or attending, are
required to submit proof of completion of residency, their educational qualifications; generally, evidence of
accreditation by the appropriate board (diplomate), evidence of fellowship in most cases, and references. These
requirements are carefully scrutinized by members of the hospital administration or by a review committee set
up by the hospital who either accept or reject the application. This is particularly true with respondent hospital.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to attend
clinico-pathological conferences, conduct bedside rounds for clerks, interns and residents, moderate grand
rounds and patient audits and perform other tasks and responsibilities, for the privilege of being able to maintain
a clinic in the hospital, and/or for the privilege of admitting patients into the hospital. In addition to these, the
physician's performance as a specialist is generally evaluated by a peer review committee on the basis of
mortality and morbidity statistics, and feedback from patients, nurses, interns and residents. A consultant remiss
in his duties, or a consultant who regularly falls short of the minimum standards acceptable to the hospital or its
peer review committee, is normally politely terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting "consultant"
staff. While "consultants" are not, technically employees, a point which respondent hospital
asserts in denying all responsibility for the patient's condition, the control exercised, the hiring,
and the right to terminate consultants all fulfill the important hallmarks of an employeremployee relationship, with the exception of the payment of wages. In assessing whether such a
relationship in fact exists, the control test is determining. Accordingly, on the basis of the
foregoing, we rule that for the purpose of allocating responsibility in medical negligence cases,
an employer-employee relationship in effect exists between hospitals and their attending and
visiting physicians. This being the case, the question now arises as to whether or not respondent hospital is
solidarily liable with respondent doctors for petitioner's condition.
The basis for holding an employer solidarily responsible for the negligence of its employee is found in Article
2180 of the Civil Code which considers a person accountable not only for his own acts but also for those of others
based on the former's responsibility under a relationship of patria potestas. x x x 40(Emphasis supplied)
While the Court in Ramos did not expound on the control test, such test essentially determines whether an employment
relationship exists between a physician and a hospital based on the exercise of control over the physician as to details.
Specifically, the employer (or the hospital) must have the right to control both the means and the details of the process by
which the employee (or the physician) is to accomplish his task.41
After a thorough examination of the voluminous records of this case, the Court finds no single evidence pointing to
CMC's exercise of control over Dr. Estrada's treatment and management of Corazon's condition. It is undisputed that
throughout Corazon's pregnancy, she was under the exclusive prenatal care of Dr. Estrada. At the time of Corazon's
admission at CMC and during her delivery, it was Dr. Estrada, assisted by Dr. Villaflor, who attended to Corazon. There
was no showing that CMC had a part in diagnosing Corazon's condition. While Dr. Estrada enjoyed staff privileges at
CMC, such fact alone did not make him an employee of CMC. 42 CMC merely allowed Dr. Estrada to use its
facilities43 when Corazon was about to give birth, which CMC considered an emergency. Considering these circumstances,
Dr. Estrada is not an employee of CMC, but an independent contractor.
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada is an independent
contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician. There is, however, an
exception to this principle. The hospital may be liable if the physician is the "ostensible" agent of the hospital. 44This
exception is also known as the "doctrine of apparent authority." 45 In Gilbert v. Sycamore Municipal Hospital,46 the
Illinois Supreme Court explained the doctrine of apparent authority in this wise:
[U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the negligent acts of a
physician providing care at the hospital, regardless of whether the physician is an independent contractor, unless
the patient knows, or should have known, that the physician is an independent contractor. The elements of the
action have been set out as follows:

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"For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that: (1) the hospital,
or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was
alleged to be negligent was an employee or agent of the hospital; (2) where the acts of the agent create the
appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them;
and (3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care
and prudence."
The element of "holding out" on the part of the hospital does not require an express representation by the
hospital that the person alleged to be negligent is an employee. Rather, the element is satisfied if the hospital
holds itself out as a provider of emergency room care without informing the patient that the care is provided by
independent contractors.
The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies upon the hospital to
provide complete emergency room care, rather than upon a specific physician.
The doctrine of apparent authority essentially involves two factors to determine the liability of an independent-contractor
physician.
The first factor focuses on the hospital's manifestations and is sometimes described as an inquiry whether the hospital
acted in a manner which would lead a reasonable person to conclude that the individual who was alleged to be negligent
was an employee or agent of the hospital.47 In this regard, the hospital need not make express representations
to the patient that the treating physician is an employee of the hospital; rather a representation may be
general and implied.48
The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil Code provides that
"[t]hrough estoppel, an admission or representation is rendered conclusive upon the person making it, and cannot be
denied or disproved as against the person relying thereon." Estoppel rests on this rule: "Whenever a party has, by his own
declaration, act, or omission, intentionally and deliberately led another to believe a particular thing true, and to act upon
such belief, he cannot, in any litigation arising out of such declaration, act or omission, be permitted to falsify it." 49
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. Through CMC's acts, CMC
clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales to believe that Dr. Estrada was an
employee or agent of CMC. CMC cannot now repudiate such authority.
First, CMC granted staff privileges to Dr. Estrada. CMC extended its medical staff and facilities to Dr. Estrada. Upon Dr.
Estrada's request for Corazon's admission, CMC, through its personnel, readily accommodated Corazon and updated Dr.
Estrada of her condition.
Second, CMC made Rogelio sign consent forms printed on CMC letterhead. Prior to Corazon's admission and supposed
hysterectomy, CMC asked Rogelio to sign release forms, the contents of which reinforced Rogelio's belief that Dr. Estrada
was a member of CMC's medical staff.50 The Consent on Admission and Agreement explicitly provides:
KNOW ALL MEN BY THESE PRESENTS:
I, Rogelio Nogales, of legal age, a resident of 1974 M. H. Del Pilar St., Malate Mla., being the
father/mother/brother/sister/spouse/relative/ guardian/or person in custody of Ma. Corazon, and representing
his/her family, of my own volition and free will, do consent and submit said Ma. Corazon to Dr. Oscar Estrada
(hereinafter referred to as Physician) for cure, treatment, retreatment, or emergency measures, that the
Physician, personally or by and through the Capitol Medical Center and/or its staff, may use,
adapt, or employ such means, forms or methods of cure, treatment, retreatment, or emergency
measures as he may see best and most expedient; that Ma. Corazon and I will comply with any
and all rules, regulations, directions, and instructions of the Physician, the Capitol Medical
Center and/or its staff; and, that I will not hold liable or responsible and hereby waive and forever discharge
and hold free the Physician, the Capitol Medical Center and/or its staff, from any and all claims of whatever kind
of nature, arising from directly or indirectly, or by reason of said cure, treatment, or retreatment, or emergency
measures or intervention of said physician, the Capitol Medical Center and/or its staff.
x x x x51 (Emphasis supplied)
While the Consent to Operation pertinently reads, thus:

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I, ROGELIO NOGALES, x x x, of my own volition and free will, do consent and submit said CORAZON
NOGALES to Hysterectomy, by the Surgical Staff and Anesthesiologists of Capitol Medical
Centerand/or whatever succeeding operations, treatment, or emergency measures as may be necessary and
most expedient; and, that I will not hold liable or responsible and hereby waive and forever discharge and hold
free the Surgeon, his assistants, anesthesiologists, the Capitol Medical Center and/or its staff, from any and all
claims of whatever kind of nature, arising from directly or indirectly, or by reason of said operation or operations,
treatment, or emergency measures, or intervention of the Surgeon, his assistants, anesthesiologists, the Capitol
Medical Center and/or its staff.52 (Emphasis supplied)
Without any indication in these consent forms that Dr. Estrada was an independent contractor-physician, the Spouses
Nogales could not have known that Dr. Estrada was an independent contractor. Significantly, no one from CMC informed
the Spouses Nogales that Dr. Estrada was an independent contractor. On the contrary, Dr. Atencio, who was then a
member of CMC Board of Directors, testified that Dr. Estrada was part of CMC's surgical staff. 53
Third, Dr. Estrada's referral of Corazon's profuse vaginal bleeding to Dr. Espinola, who was then the Head of the
Obstetrics and Gynecology Department of CMC, gave the impression that Dr. Estrada as a member of CMC's medical
staff was collaborating with other CMC-employed specialists in treating Corazon.
The second factor focuses on the patient's reliance. It is sometimes characterized as an inquiry on whether the plaintiff
acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence. 54
The records show that the Spouses Nogales relied upon a perceived employment relationship with CMC in accepting Dr.
Estrada's services. Rogelio testified that he and his wife specifically chose Dr. Estrada to handle Corazon's delivery not
only because of their friend's recommendation, but more importantly because of Dr. Estrada's "connection with a
reputable hospital, the [CMC]."55 In other words, Dr. Estrada's relationship with CMC played a significant role in the
Spouses Nogales' decision in accepting Dr. Estrada's services as the obstetrician-gynecologist for Corazon's delivery.
Moreover, as earlier stated, there is no showing that before and during Corazon's confinement at CMC, the Spouses
Nogales knew or should have known that Dr. Estrada was not an employee of CMC.
Further, the Spouses Nogales looked to CMC to provide the best medical care and support services for Corazon's delivery.
The Court notes that prior to Corazon's fourth pregnancy, she used to give birth inside a clinic. Considering Corazon's age
then, the Spouses Nogales decided to have their fourth child delivered at CMC, which Rogelio regarded one of the best
hospitals at the time.56 This is precisely because the Spouses Nogales feared that Corazon might experience complications
during her delivery which would be better addressed and treated in a modern and big hospital such as CMC. Moreover,
Rogelio's consent in Corazon's hysterectomy to be performed by a different physician, namely Dr. Espinola, is a clear
indication of Rogelio's confidence in CMC's surgical staff.
CMC's defense that all it did was "to extend to [Corazon] its facilities" is untenable. The Court cannot close its eyes to the
reality that hospitals, such as CMC, are in the business of treatment. In this regard, the Court agrees with the observation
made by the Court of Appeals of North Carolina in Diggs v. Novant Health, Inc., 57 to wit:
"The conception that the hospital does not undertake to treat the patient, does not undertake to act through its
doctors and nurses, but undertakes instead simply to procure them to act upon their own responsibility, no
longer reflects the fact. Present day hospitals, as their manner of operation plainly demonstrates, do
far more than furnish facilities for treatment. They regularly employ on a salary basis a large
staff of physicians, nurses and internes [sic], as well as administrative and manual workers, and
they charge patients for medical care and treatment, collecting for such services, if necessary, by
legal action. Certainly, the person who avails himself of 'hospital facilities' expects that the
hospital will attempt to cure him, not that its nurses or other employees will act on their own
responsibility." x x x (Emphasis supplied)
Likewise unconvincing is CMC's argument that petitioners are estopped from claiming damages based on the Consent on
Admission and Consent to Operation. Both release forms consist of two parts. The first part gave CMC permission to
administer to Corazon any form of recognized medical treatment which the CMC medical staff deemed advisable. The
second part of the documents, which may properly be described as the releasing part, releases CMC and its employees
"from any and all claims" arising from or by reason of the treatment and operation.
The documents do not expressly release CMC from liability for injury to Corazon due to negligence during her treatment
or operation. Neither do the consent forms expressly exempt CMC from liability for Corazon's death due to negligence
during such treatment or operation. Such release forms, being in the nature of contracts of adhesion, are construed

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Page 51

strictly against hospitals. Besides, a blanket release in favor of hospitals "from any and all claims," which includes claims
due to bad faith or gross negligence, would be contrary to public policy and thus void.
Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only mitigate
liability depending on the circumstances.58 When a person needing urgent medical attention rushes to a hospital, he
cannot bargain on equal footing with the hospital on the terms of admission and operation. Such a person is literally at
the mercy of the hospital. There can be no clearer example of a contract of adhesion than one arising from such a dire
situation. Thus, the release forms of CMC cannot relieve CMC from liability for the negligent medical treatment of
Corazon.
On the Liability of the Other Respondents
Despite this Court's pronouncement in its 9 September 2002 59 Resolution that the filing of petitioners' Manifestation
confined petitioners' claim only against CMC, Dr. Espinola, Dr. Lacson, and Dr. Uy, who have filed their comments, the
Court deems it proper to resolve the individual liability of the remaining respondents to put an end finally to this more
than two-decade old controversy.
a) Dr. Ely Villaflor
Petitioners blame Dr. Ely Villaflor for failing to diagnose the cause of Corazon's bleeding and to suggest the correct
remedy to Dr. Estrada.60 Petitioners assert that it was Dr. Villaflor's duty to correct the error of Nurse Dumlao in the
administration of hemacel.
The Court is not persuaded. Dr. Villaflor admitted administering a lower dosage of magnesium sulfate. However, this was
after informing Dr. Estrada that Corazon was no longer in convulsion and that her blood pressure went down to a
dangerous level.61 At that moment, Dr. Estrada instructed Dr. Villaflor to reduce the dosage of magnesium sulfate from 10
to 2.5 grams. Since petitioners did not dispute Dr. Villaflor's allegation, Dr. Villaflor's defense remains uncontroverted.
Dr. Villaflor's act of administering a lower dosage of magnesium sulfate was not out of her own volition or was in
contravention of Dr. Estrada's order.
b) Dr. Rosa Uy
Dr. Rosa Uy's alleged negligence consisted of her failure (1) to call the attention of Dr. Estrada on the incorrect dosage of
magnesium sulfate administered by Dr. Villaflor; (2) to take corrective measures; and (3) to correct Nurse Dumlao's
wrong method of hemacel administration.
The Court believes Dr. Uy's claim that as a second year resident physician then at CMC, she was merely authorized to
take the clinical history and physical examination of Corazon.62 However, that routine internal examination did not ipso
facto make Dr. Uy liable for the errors committed by Dr. Estrada. Further, petitioners' imputation of negligence rests on
their baseless assumption that Dr. Uy was present at the delivery room. Nothing shows that Dr. Uy participated in
delivering Corazon's baby. Further, it is unexpected from Dr. Uy, a mere resident physician at that time, to call the
attention of a more experienced specialist, if ever she was present at the delivery room.
c) Dr. Joel Enriquez
Petitioners fault Dr. Joel Enriquez also for not calling the attention of Dr. Estrada, Dr. Villaflor, and Nurse Dumlao about
their errors.63 Petitioners insist that Dr. Enriquez should have taken, or at least suggested, corrective measures to rectify
such errors.
The Court is not convinced. Dr. Enriquez is an anesthesiologist whose field of expertise is definitely not obstetrics and
gynecology. As such, Dr. Enriquez was not expected to correct Dr. Estrada's errors. Besides, there was no evidence of Dr.
Enriquez's knowledge of any error committed by Dr. Estrada and his failure to act upon such observation.
d) Dr. Perpetua Lacson
Petitioners fault Dr. Perpetua Lacson for her purported delay in the delivery of blood Corazon needed. 64Petitioners claim
that Dr. Lacson was remiss in her duty of supervising the blood bank staff.

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As found by the trial court, there was no unreasonable delay in the delivery of blood from the time of the request until the
transfusion to Corazon. Dr. Lacson competently explained the procedure before blood could be given to the
patient.65 Taking into account the bleeding time, clotting time and cross-matching, Dr. Lacson stated that it would take
approximately 45-60 minutes before blood could be ready for transfusion.66 Further, no evidence exists that Dr. Lacson
neglected her duties as head of the blood bank.
e) Dr. Noe Espinola
Petitioners argue that Dr. Espinola should not have ordered immediate hysterectomy without determining the underlying
cause of Corazon's bleeding. Dr. Espinola should have first considered the possibility of cervical injury, and advised a
thorough examination of the cervix, instead of believing outright Dr. Estrada's diagnosis that the cause of bleeding was
uterine atony.
Dr. Espinola's order to do hysterectomy which was based on the information he received by phone is not negligence. The
Court agrees with the trial court's observation that Dr. Espinola, upon hearing such information about Corazon's
condition, believed in good faith that hysterectomy was the correct remedy. At any rate, the hysterectomy did not push
through because upon Dr. Espinola's arrival, it was already too late. At the time, Corazon was practically dead.
f) Nurse J. Dumlao
In Moore v. Guthrie Hospital Inc.,67 the US Court of Appeals, Fourth Circuit, held that to recover, a patient complaining
of injuries allegedly resulting when the nurse negligently injected medicine to him intravenously instead of
intramuscularly had to show that (1) an intravenous injection constituted a lack of reasonable and ordinary care; (2) the
nurse injected medicine intravenously; and (3) such injection was the proximate cause of his injury.
In the present case, there is no evidence of Nurse Dumlao's alleged failure to follow Dr. Estrada's specific instructions.
Even assuming Nurse Dumlao defied Dr. Estrada's order, there is no showing that side-drip administration of hemacel
proximately caused Corazon's death. No evidence linking Corazon's death and the alleged wrongful hemacel
administration was introduced. Therefore, there is no basis to hold Nurse Dumlao liable for negligence.
On the Award of Interest on Damages
The award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which states that in crimes
and quasi-delicts, interest as a part of the damages may, in a proper case, be adjudicated in the discretion of the court. 68
WHEREFORE, the Court PARTLY GRANTS the petition. The Court finds respondent Capitol Medical Center
vicariously liable for the negligence of Dr. Oscar Estrada. The amounts of P105,000 as actual damages andP700,000 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 6 February 1998 and Resolution dated 21
March 2000 of the Court of Appeals in CA-G.R. CV No. 45641.
SO ORDERED.

G.R. No. 126297

January 31, 2007

PROFESSIONAL SERVICES, INC., Petitioner,


vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x
G.R. No. 126467

January 31, 2007

NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA
AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.

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Page 53

x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590

January 31, 2007

MIGUEL AMPIL, Petitioner,


vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
DECISION
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most important and delicate endeavors, must assume the grave
responsibility of pursuing it with appropriate care. The care and service dispensed through this high trust, however
technical, complex and esoteric its character may be, must meet standards of responsibility commensurate with the
undertaking to preserve and protect the health, and indeed, the very lives of those placed in the hospitals keeping. 1
Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals Decision 2 dated September
6, 1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with modification the Decision 3 dated March 17,
1993 of the Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322 and nullifying its Order dated
September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because of
difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil,
petitioner in G.R. No. 127590, diagnosed her to be suffering from "cancer of the sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City Hospital, performed an anterior resection
surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the
removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividads husband, Enrique Agana, to permit
Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of Operation dated April 11, 1984, the
attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including the doctors fees,
amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted both Dr. Ampil and
Dr. Fuentes about it. They told her that the pain was the natural consequence of the surgery. Dr. Ampil then
recommended that she consult an oncologist to examine the cancerous nodes which were not removed during the
operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment. After four
months of consultations and laboratory examinations, Natividad was told she was free of cancer. Hence, she was advised
to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks thereafter, her daughter
found a piece of gauze protruding from her vagina. Upon being informed about it, Dr. Ampil proceeded to her house
where he managed to extract by hand a piece of gauze measuring 1.5 inches in width. He then assured her that the pains
would soon vanish.

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Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting Natividad to seek treatment at the
Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected the presence of another foreign object
in her vagina -- a foul-smelling gauze measuring 1.5 inches in width which badly infected her vaginal vault. A rectovaginal fistula had formed in her reproductive organs which forced stool to excrete through the vagina. Another surgical
operation was needed to remedy the damage. Thus, in October 1984, Natividad underwent another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a complaint for damages
against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as
Civil Case No. Q-43322. They alleged that the latter are liable for negligence for leaving two pieces of gauze inside
Natividads body and malpractice for concealing their acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint
for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes, docketed as Administrative Case No. 1690. The
PRC Board of Medicine heard the case only with respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr.
Ampil who was then in the United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly substituted by her abovenamed children (the Aganas).
On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable
for negligence and malpractice, the decretal part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL SERVICES,
INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and severally, except in respect of
the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampil and Dr.
Fuentes only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of P21.60-US$1.00, as
reimbursement of actual expenses incurred in the United States of America;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic Hospital, medical
fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorneys fees, the sum of P250,000.00;
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the complaint until full
payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as CA-G.R. CV No.
42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its Decision, which was
granted in an Order dated May 11, 1993. Thereafter, the sheriff levied upon certain properties of Dr. Ampil and sold them
for P451,275.00 and delivered the amount to the Aganas.

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Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to indefinitely
suspend any further execution of the RTC Decision. However, not long thereafter, the Aganas again filed a motion for an
alias writ of execution against the properties of PSI and Dr. Fuentes. On September 21, 1993, the RTC granted the motion
and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and
prohibition, with prayer for preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the Court of
Appeals issued a Resolution5 dated October 29, 1993 granting Dr. Fuentes prayer for injunctive relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision 6 in Administrative Case No. 1690
dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to show that Dr. Fuentes was the one
who left the two pieces of gauze inside Natividads body; and that he concealed such fact from Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV No. 42062 and CAG.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes is hereby
DISMISSED, and with the pronouncement that defendant-appellant Dr. Miguel Ampil is liable to reimburse defendantappellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees, the
decision appealed from is hereby AFFIRMED and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-appellant Dr. Juan
Fuentes in CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of the respondent judge dated
September 21, 1993, as well as the alias writ of execution issued pursuant thereto are hereby NULLIFIED and SET
ASIDE. The bond posted by the petitioner in connection with the writ of preliminary injunction issued by this Court on
November 29, 1993 is hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution 7 dated December 19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is estopped from
raising the defense that Dr. Ampil is not its employee; (2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled to
its counterclaim against the Aganas. PSI contends that Dr. Ampil is not its employee, but a mere consultant or
independent contractor. As such, he alone should answer for his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of
negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They contend that the pieces of gauze are
prima facie proofs that the operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for negligence and
malpractice sans evidence that he left the two pieces of gauze in Natividads vagina. He pointed to other probable causes,
such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy; (2) the attending nurses failure to
properly count the gauzes used during surgery; and (3) the medical intervention of the American doctors who examined
Natividad in the United States of America.
For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr. Ampil liable for
negligence and malpractice; second, whether the Court of Appeals erred in absolving Dr. Fuentes of any liability; and
third, whether PSI may be held solidarily liable for the negligence of Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.

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Page 56

Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other possible causes of Natividads detriment.
He argues that the Court should not discount either of the following possibilities: first, Dr. Fuentes left the gauzes in
Natividads body after performing hysterectomy; second, the attending nurses erred in counting the gauzes; and third,
the American doctors were the ones who placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and without basis. Records show that he did not present any evidence to
prove that the American doctors were the ones who put or left the gauzes in Natividads body. Neither did he submit
evidence to rebut the correctness of the record of operation, particularly the number of gauzes used. As to the alleged
negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr. Fuentes) work and found it in order.
The glaring truth is that all the major circumstances, taken together, as specified by the Court of Appeals, directly point to
Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient during the
surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery noted in their report that the
sponge count (was) lacking 2; that such anomaly was announced to surgeon and that a search was done but to
no avail prompting Dr. Ampil to continue for closure x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs. Agana where the
surgery was performed.
An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed, and
it is settled that the leaving of sponges or other foreign substances in the wound after the incision has been closed is at
least prima facie negligence by the operating surgeon.8 To put it simply, such act is considered so inconsistent with due
care as to raise an inference of negligence. There are even legions of authorities to the effect that such act is negligence
per se.9
Of course, the Court is not blind to the reality that there are times when danger to a patients life precludes a surgeon
from further searching missing sponges or foreign objects left in the body. But this does not leave him free from any
obligation. Even if it has been shown that a surgeon was required by the urgent necessities of the case to leave a sponge in
his patients abdomen, because of the dangers attendant upon delay, still, it is his legal duty to so inform his patient
within a reasonable time thereafter by advising her of what he had been compelled to do. This is in order that she might
seek relief from the effects of the foreign object left in her body as her condition might permit. The ruling in Smith v.
Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to remove a sponge
he has placed in his patients body that should be removed as part of the operation, he thereby leaves his operation
uncompleted and creates a new condition which imposes upon him the legal duty of calling the new condition to his
patients attention, and endeavoring with the means he has at hand to minimize and avoid untoward results likely to
ensue therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain
she was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have
taken the immediate and appropriate medical remedy to remove the gauzes from her body. To our mind, what was
initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.
This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this kind of
case, a patient must only prove that a health care provider either failed to do something which a reasonably prudent
health care provider would have done, or that he did something that a reasonably prudent provider would not have done;
and that failure or action caused injury to the patient.11 Simply put, the elements are duty, breach, injury and proximate
causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividads
body before closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil
breached both duties. Such breach caused injury to Natividad, necessitating her further examination by American doctors
and another surgery. That Dr. Ampils negligence is the proximate cause 12 of Natividads injury could be traced from his
act of closing the incision despite the information given by the attending nurses that two pieces of gauze were still
missing. That they were later on extracted from Natividads vagina established the causal link between Dr. Ampils
negligence and the injury. And what further aggravated such injury was his deliberate concealment of the missing gauzes
from the knowledge of Natividad and her family.

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Page 57

II - G.R. No. 126467


Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it is contrary to the
doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze were left inside Natividads body is a
prima facie evidence of Dr. Fuentes negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the occurrence of an injury,
taken with the surrounding circumstances, may permit an inference or raise a presumption of negligence, or make out a
plaintiffs prima facie case, and present a question of fact for defendant to meet with an explanation. 13 Stated differently,
where the thing which caused the injury, without the fault of the injured, is under the exclusive control of the defendant
and the injury is such that it should not have occurred if he, having such control used proper care, it affords reasonable
evidence, in the absence of explanation that the injury arose from the defendants want of care, and the burden of proof is
shifted to him to establish that he has observed due care and diligence. 14
From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur are: (1)
the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who had
control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing
requisites, the most instrumental is the "control and management of the thing which caused the injury." 15
We find the element of "control and management of the thing which caused the injury" to be wanting. Hence, the
doctrine of res ipsa loquitur will not lie.
It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the
assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her sigmoid
area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr.
Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr.
Ampil then resumed operating on Natividad. He was about to finish the procedure when the attending nurses informed
him that two pieces of gauze were missing. A "diligent search" was conducted, but the misplaced gauzes were not found.
Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating
room and had, in fact, left the hospital.
Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the surgery room and all
personnel connected with the operation. Their duty is to obey his orders. 16 As stated before, Dr. Ampil was the lead
surgeon. In other words, he was the "Captain of the Ship." That he discharged such role is evident from his following
conduct: (1) calling Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order;
(3) granting Dr. Fuentes permission to leave; and (4) ordering the closure of the incision. To our mind, it was this act of
ordering the closure of the incision notwithstanding that two pieces of gauze remained unaccounted for, that caused
injury to Natividads body. Clearly, the control and management of the thing which caused the injury was in the hands of
Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an
independent or separate ground of liability, being a mere evidentiary rule.17 In other words, mere invocation and
application of the doctrine does not dispense with the requirement of proof of negligence. Here, the negligence was
proven to have been committed by Dr. Ampil and not by Dr. Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospitals and the resulting theories concerning
their liability for the negligence of physicians.

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Page 58

Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical services to the
lowest classes of society, without regard for a patients ability to pay. 18 Those who could afford medical treatment were
usually treated at home by their doctors.19 However, the days of house calls and philanthropic health care are over. The
modern health care industry continues to distance itself from its charitable past and has experienced a significant
conversion from a not-for-profit health care to for-profit hospital businesses. Consequently, significant changes in health
law have accompanied the business-related changes in the hospital industry. One important legal change is an increase in
hospital liability for medical malpractice. Many courts now allow claims for hospital vicarious liability under the theories
of respondeat superior, apparent authority, ostensible authority, or agency by estoppel. 20
In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code, which reads:
Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for the
damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties, is called a
quasi-delict and is governed by the provisions of this Chapter.
A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of respondeat
superior, thus:
ART. 2180. The obligation imposed by Article 2176 is demandable not only for ones own acts or omissions, but also for
those of persons for whom one is responsible.
x x x

x x x

The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their
employees in the service of the branches in which the latter are employed or on the occasion of their functions.
Employers shall be liable for the damages caused by their employees and household helpers acting within the scope of
their assigned tasks even though the former are not engaged in any business or industry.
x x x

x x x

The responsibility treated of in this article shall cease when the persons herein mentioned prove that they observed all
the diligence of a good father of a family to prevent damage.
A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and
pharmacists, are not "employees" under this article because the manner in which they perform their work is not within
the control of the latter (employer). In other words, professionals are considered personally liable for the fault or
negligence they commit in the discharge of their duties, and their employer cannot be held liable for such fault or
negligence. In the context of the present case, "a hospital cannot be held liable for the fault or negligence of a physician or
surgeon in the treatment or operation of patients."21
The foregoing view is grounded on the traditional notion that the professional status and the very nature of the
physicians calling preclude him from being classed as an agent or employee of a hospital, whenever he acts in a
professional capacity.22 It has been said that medical practice strictly involves highly developed and specialized
knowledge,23 such that physicians are generally free to exercise their own skill and judgment in rendering medical
services sans interference.24 Hence, when a doctor practices medicine in a hospital setting, the hospital and its employees
are deemed to subserve him in his ministrations to the patient and his actions are of his own responsibility. 25
The case of Schloendorff v. Society of New York Hospital26 was then considered an authority for this view. The
"Schloendorff doctrine" regards a physician, even if employed by a hospital, as an independent contractor because of the
skill he exercises and the lack of control exerted over his work. Under this doctrine, hospitals are exempt from the
application of the respondeat superior principle for fault or negligence committed by physicians in the discharge of their
profession.
However, the efficacy of the foregoing doctrine has weakened with the significant developments in medical care. Courts
came to realize that modern hospitals are increasingly taking active role in supplying and regulating medical care to
patients. No longer were a hospitals functions limited to furnishing room, food, facilities for treatment and operation,
and attendants for its patients. Thus, in Bing v. Thunig, 27 the New York Court of Appeals deviated from the Schloendorff
doctrine, noting that modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly
employ, on a salaried basis, a large staff of physicians, interns, nurses, administrative and manual workers. They charge

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Page 59

patients for medical care and treatment, even collecting for such services through legal action, if necessary. The court
then concluded that there is no reason to exempt hospitals from the universal rule of respondeat superior.
In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view
of our categorical pronouncement in Ramos v. Court of Appeals 28 that for purposes of apportioning responsibility in
medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and
visiting physicians. This Court held:
"We now discuss the responsibility of the hospital in this particular incident. The unique practice (among private
hospitals) of filling up specialist staff with attending and visiting "consultants," who are allegedly not hospital employees,
presents problems in apportioning responsibility for negligence in medical malpractice cases. However, the difficulty is
more apparent than real.
In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their
work within the hospital premises. Doctors who apply for consultant slots, visiting or attending, are required to submit
proof of completion of residency, their educational qualifications, generally, evidence of accreditation by the appropriate
board (diplomate), evidence of fellowship in most cases, and references. These requirements are carefully scrutinized by
members of the hospital administration or by a review committee set up by the hospital who either accept or reject the
application. x x x.
After a physician is accepted, either as a visiting or attending consultant, he is normally required to attend clinicopathological conferences, conduct bedside rounds for clerks, interns and residents, moderate grand rounds and patient
audits and perform other tasks and responsibilities, for the privilege of being able to maintain a clinic in the hospital,
and/or for the privilege of admitting patients into the hospital. In addition to these, the physicians performance as a
specialist is generally evaluated by a peer review committee on the basis of mortality and morbidity statistics, and
feedback from patients, nurses, interns and residents. A consultant remiss in his duties, or a consultant who regularly
falls short of the minimum standards acceptable to the hospital or its peer review committee, is normally politely
terminated.
In other words, private hospitals, hire, fire and exercise real control over their attending and visiting consultant staff.
While consultants are not, technically employees, x x x, the control exercised, the hiring, and the right to terminate
consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment
of wages. In assessing whether such a relationship in fact exists, the control test is determining. Accordingly, on the basis
of the foregoing, we rule that for the purpose of allocating responsibility in medical negligence cases, an employeremployee relationship in effect exists between hospitals and their attending and visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSIs liability. Its liability is also anchored upon the
agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained
acceptance in the determination of a hospitals liability for negligent acts of health professionals. The present case serves
as a perfect platform to test the applicability of these doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel,29 has its origin from the law of agency. It imposes
liability, not as the result of the reality of a contractual relationship, but rather because of the actions of a principal or an
employer in somehow misleading the public into believing that the relationship or the authority exists. 30 The concept is
essentially one of estoppel and has been explained in this manner:
"The principal is bound by the acts of his agent with the apparent authority which he knowingly permits the agent to
assume, or which he holds the agent out to the public as possessing. The question in every case is whether the principal
has by his voluntary act placed the agent in such a situation that a person of ordinary prudence, conversant with business
usages and the nature of the particular business, is justified in presuming that such agent has authority to perform the
particular act in question.31
The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. Doctor
Hospital of Lake Worth, Inc.32 There, it was explicitly stated that "there does not appear to be any rational basis for
excluding the concept of apparent authority from the field of hospital liability." Thus, in cases where it can be shown that
a hospital, by its actions, has held out a particular physician as its agent and/or employee and that a patient has accepted
treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital
will be liable for the physicians negligence.

Reyes, Hazel

Page 60

Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code reads:
ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack of action, or his
failure to repudiate the agency, knowing that another person is acting on his behalf without authority.
In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the
physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of
Appeals conclusion that it "is now estopped from passing all the blame to the physicians whose names it proudly paraded
in the public directory leading the public to believe that it vouched for their skill and competence." Indeed, PSIs act is
tantamount to holding out to the public that Medical City Hospital, through its accredited physicians, offers quality
health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital
created the impression that they were its agents, authorized to perform medical or surgical services for its patients. As
expected, these patients, Natividad being one of them, accepted the services on the reasonable belief that such were being
rendered by the hospital or its employees, agents, or servants. The trial court correctly pointed out:
x x x regardless of the education and status in life of the patient, he ought not be burdened with the defense of absence of
employer-employee relationship between the hospital and the independent physician whose name and competence are
certainly certified to the general public by the hospitals act of listing him and his specialty in its lobby directory, as in the
case herein. The high costs of todays medical and health care should at least exact on the hospital greater, if not broader,
legal responsibility for the conduct of treatment and surgery within its facility by its accredited physician or surgeon,
regardless of whether he is independent or employed."33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of acting only
through other individuals, such as physicians. If these accredited physicians do their job well, the hospital succeeds in its
mission of offering quality medical services and thus profits financially. Logically, where negligence mars the quality of
its services, the hospital should not be allowed to escape liability for the acts of its ostensible agents.
We now proceed to the doctrine of corporate negligence or corporate responsibility.
One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI as owner, operator
and manager of Medical City Hospital, "did not perform the necessary supervision nor exercise diligent efforts in the
supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns who assisted Drs.
Ampil and Fuentes in the performance of their duties as surgeons." 34 Premised on the doctrine of corporate negligence,
the trial court held that PSI is directly liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating hospitals
liability for the negligent acts of health practitioners, absent facts to support the application of respondeat superior or
apparent authority. Its formulation proceeds from the judiciarys acknowledgment that in these modern times, the duty
of providing quality medical service is no longer the sole prerogative and responsibility of the physician. The modern
hospitals have changed structure. Hospitals now tend to organize a highly professional medical staff whose competence
and performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide
quality medical care.35
The doctrine has its genesis in Darling v. Charleston Community Hospital.36 There, the Supreme Court of Illinois held
that "the jury could have found a hospital negligent, inter alia, in failing to have a sufficient number of trained nurses
attending the patient; failing to require a consultation with or examination by members of the hospital staff; and failing
to review the treatment rendered to the patient." On the basis of Darling, other jurisdictions held that a hospitals
corporate negligence extends to permitting a physician known to be incompetent to practice at the hospital. 37 With the
passage of time, more duties were expected from hospitals, among them: (1) the use of reasonable care in the
maintenance of safe and adequate facilities and equipment; (2) the selection and retention of competent physicians; (3)
the overseeing or supervision of all persons who practice medicine within its walls; and (4) the formulation, adoption and
enforcement of adequate rules and policies that ensure quality care for its patients. 38 Thus, in Tucson Medical Center, Inc.
v. Misevich,39 it was held that a hospital, following the doctrine of corporate responsibility, has the duty to see that it
meets the standards of responsibilities for the care of patients. Such duty includes the proper supervision of the members
of its medical staff. And in Bost v. Riley,40 the court concluded that a patient who enters a hospital does so with the
reasonable expectation that it will attempt to cure him. The hospital accordingly has the duty to make a reasonable effort
to monitor and oversee the treatment prescribed and administered by the physicians practicing in its premises.

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Page 61

In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose and under the
concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise reasonable
care to protect from harm all patients admitted into its facility for medical treatment. Unfortunately, PSI failed to
perform such duty. The findings of the trial court are convincing, thus:
x x x PSIs liability is traceable to its failure to conduct an investigation of the matter reported in the nota bene of the
count nurse. Such failure established PSIs part in the dark conspiracy of silence and concealment about the gauzes.
Ethical considerations, if not also legal, dictated the holding of an immediate inquiry into the events, if not for the benefit
of the patient to whom the duty is primarily owed, then in the interest of arriving at the truth. The Court cannot accept
that the medical and the healing professions, through their members like defendant surgeons, and their institutions like
PSIs hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or negligence by
refusing or failing to investigate a report of such seriousness as the one in Natividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the Medical City
Hospitals staff, composed of resident doctors, nurses, and interns. As such, it is reasonable to conclude that PSI, as the
operator of the hospital, has actual or constructive knowledge of the procedures carried out, particularly the report of the
attending nurses that the two pieces of gauze were missing. In Fridena v. Evans,41 it was held that a corporation is bound
by the knowledge acquired by or notice given to its agents or officers within the scope of their authority and in reference
to a matter to which their authority extends. This means that the knowledge of any of the staff of Medical City Hospital
constitutes knowledge of PSI. Now, the failure of PSI, despite the attending nurses report, to investigate and inform
Natividad regarding the missing gauzes amounts to callous negligence. Not only did PSI breach its duties to oversee or
supervise all persons who practice medicine within its walls, it also failed to take an active step in fixing the negligence
committed. This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the Civil
Code, but also directly liable for its own negligence under Article 2176. In Fridena, the Supreme Court of Arizona held:
x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The emerging trend is to
hold the hospital responsible where the hospital has failed to monitor and review medical services being provided within
its walls. See Kahn Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In
Purcell, the hospital argued that it could not be held liable for the malpractice of a medical practitioner because he was an
independent contractor within the hospital. The Court of Appeals pointed out that the hospital had created a professional
staff whose competence and performance was to be monitored and reviewed by the governing body of the hospital, and
the court held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using the
facilities was employing a method of treatment or care which fell below the recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain inherent responsibilities
regarding the quality of medical care furnished to patients within its walls and it must meet the standards of
responsibility commensurate with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153
(1972). This court has confirmed the rulings of the Court of Appeals that a hospital has the duty of supervising the
competence of the doctors on its staff. x x x.
x

x x

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with its knowledge,
aid, and assistance, and that the negligence of the defendants was the proximate cause of the patients injuries. We find
that such general allegations of negligence, along with the evidence produced at the trial of this case, are sufficient to
support the hospitals liability based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be emphasized that PSI,
apart from a general denial of its responsibility, failed to adduce evidence showing that it exercised 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 last paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily
liable with Dr. Ampil. Moreover, as we have discussed, PSI is also directly liable to the Aganas.
One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on him certain
obligations. In order to escape liability, he must possess that reasonable degree of learning, skill and experience required
by his profession. At the same time, he must apply reasonable care and diligence in the exercise of his skill and the
application of his knowledge, and exert his best judgment.

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Page 62

WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of Appeals in CA-G.R. CV
No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
G.R. No. 160889

April 27, 2007

DR. MILAGROS L. CANTRE, Petitioner,


vs.
SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.
DECISION
QUISUMBING, J.:
For review on certiorari are the Decision 1 dated October 3, 2002 and Resolution2 dated November 19, 2003 of the Court
of Appeals in CA-G.R. CV No. 58184, which affirmed with modification the Decision 3 dated March 3, 1997 of the Regional
Trial Court of Quezon City, Branch 98, in Civil Case No. Q-93-16562.
The facts, culled from the records, are as follows:
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr. Jesus Delgado Memorial
Hospital. She was the attending physician of respondent Nora S. Go, who was admitted at the said hospital on April 19,
1992.
At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around 3:30 a.m., Nora
suffered profuse bleeding inside her womb due to some parts of the placenta which were not completely expelled from
her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to
"40" over "0." Petitioner and the assisting resident physician performed various medical procedures to stop the bleeding
and to restore Noras blood pressure. Her blood pressure was frequently monitored with the use of a
sphygmomanometer. While petitioner was massaging Noras uterus for it to contract and stop bleeding, she ordered a
droplight to warm Nora and her baby.4 Nora remained unconscious until she recovered.
While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping wound two and a half (2
) by three and a half (3 ) inches in the inner portion of her left arm, close to the armpit. 5 He asked the nurses what
caused the injury. He was informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital, called petitioner and the assisting
resident physician to explain what happened. Petitioner said the blood pressure cuff caused the injury.
On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical examination, which was
conducted by medico-legal officer Dr. Floresto Arizala, Jr.7 The medico-legal officer later testified that Noras injury
appeared to be a burn and that a droplight when placed near the skin for about 10 minutes could cause such burn. 8 He
dismissed the likelihood that the wound was caused by a blood pressure cuff as the scar was not around the arm, but just
on one side of the arm.9
On May 22, 1992, Noras injury was referred to a plastic surgeon at the Dr. Jesus Delgado Memorial Hospital for skin
grafting.10 Her wound was covered with skin sourced from her abdomen, which consequently bore a scar as well. About a
year after, on April 30, 1993, scar revision had to be performed at the same hospital. 11 The surgical operation left a healed
linear scar in Noras left arm about three inches in length, the thickest portion rising about one-fourth (1/4) of an inch
from the surface of the skin. The costs of the skin grafting and the scar revision were shouldered by the hospital. 12
Unfortunately, Noras arm would never be the same.1a\^/phi1.net Aside from the unsightly mark, the pain in her left arm
remains. When sleeping, she has to cradle her wounded arm. Her movements now are also restricted. Her children
cannot play with the left side of her body as they might accidentally bump the injured arm, which aches at the slightest
touch.

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Page 63

Thus, on June 21, 1993, respondent spouses filed a complaint13 for damages against petitioner, Dr. Abad, and the
hospital. Finding in favor of respondent spouses, the trial court decreed:
In view of the foregoing consideration, judgment is hereby rendered in favor of the plaintiffs and against the defendants,
directing the latters, (sic) jointly and severally
(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary damages;
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
(d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorneys fees; and
(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
SO ORDERED.14
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which affirmed with modification the trial
court decision, thus:
WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed Decision dated March 3, 1997
of Branch 98 of the Regional Trial Court of Quezon City in Civil Case No. Q-93-16562, the same is hereby AFFIRMED,
with the following MODIFICATIONS:
1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees John David Go and
Nora S. Go the sum of P200,000.00 as moral damages;
2. Deleting the award [of] exemplary damages, attorneys fees and expenses of litigation;1awphi1.nt
3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad and Delgado Clinic, Inc.;
4. Dismissing the counterclaims of defendants-appellants for lack of merit; and
5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.
SO ORDERED.15
Petitioners motion for reconsideration was denied by the Court of Appeals. Hence, the instant petition assigning the
following as errors and issues:
I.
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF THEIR
DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES HAVE RESTED THEIR RESPECTIVE CASES,
THE LOWER COURT ADMITTED THE ADDITIONAL EXHIBITS FURTHER OFFERED BY RESPONDENTS NOT
TESTIFIED TO BY ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT OF
APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
II.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT RULED THAT THE PETITIONER HAS
NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT TOUCH THE BODY OF MRS. NORA GO, AND THIS
DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE
ABUSE OF DISCRETION;
III.

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Page 64

WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT RULED THAT PETITIONER DRA.
CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE INJURY (BLISTERS) IN THE LEFT INNER ARM OF
RESPONDENT MRS. GO CAME ABOUT;
IV.
WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN IT MADE
A RULING ON THE RESPONDENTS INJURY QUOTING THE TESTIMONY OF SOMEONE WHO WAS NOT PRESENT
AND HAS NOT SEEN THE ORIGINAL, FRESH INJURY OF RESPONDENT MRS. NORA GO;
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED THAT PETITIONER
DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO SAVE THE LIFE OF RESPONDENT MRS.
GO;
VI.
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED GRAVE ABUSE OF
DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES DONE BY PETITIONER, BOTH RULED THAT
THE RESPONDENT WAS LEFT TO THE CARE OF THE NURSING STAFF;
VII.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO
THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT THE COSMETIC SURGERY MADE THE
SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC SURGERY A FAILURE;
VIII.
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN, CONTRARY TO
RESPONDENTS CONTRARY TESTIMONIES AND THE ABSENCE OF ANY TESTIMONY, IT RULED THAT THEY ARE
ENTITLED TO DAMAGES AND WHICH WAS UPHELD, ALTHOUGH MODIFIED, BY THE COURT OF APPEALS
LIKEWISE ABUSING ITS DISCRETION.16
Petitioner contends that additional documentary exhibits not testified to by any witness are inadmissible in evidence
because they deprived her of her constitutional right to confront the witnesses against her. Petitioner insists the droplight
could not have touched Noras body. She maintains the injury was due to the constant taking of Noras blood pressure.
Petitioner also insinuates the Court of Appeals was misled by the testimony of the medico-legal officer who never saw the
original injury before plastic surgery was performed. Finally, petitioner stresses that plastic surgery was not intended to
restore respondents injury to its original state but rather to prevent further complication.
Respondents, however, counter that the genuineness and due execution of the additional documentary exhibits were duly
admitted by petitioners counsel. Respondents point out that petitioners blood pressure cuff theory is highly improbable,
being unprecedented in medical history and that the injury was definitely caused by the droplight. At any rate, they
argue, even if the injury was brought about by the blood pressure cuff, petitioner was still negligent in her duties as
Noras attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional exhibits admissible in evidence? (2)
Is petitioner liable for the injury suffered by respondent Nora Go? Thereafter, the inquiry is whether the appellate court
committed grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible in evidence. We note that the
questioned exhibits consist mostly of Noras medical records, which were produced by the hospital during trial pursuant
to a subpoena duces tecum. Petitioners counsel admitted the existence of the same when they were formally offered for
admission by the trial court. In any case, given the particular circumstances of this case, a ruling on the negligence of
petitioner may be made based on the res ipsa loquitur doctrine even in the absence of such additional exhibits.

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Page 65

Petitioners contention that the medico-legal officer who conducted Noras physical examination never saw her original
injury before plastic surgery was performed is without basis and contradicted by the records. Records show that the
medico-legal officer conducted the physical examination on May 7, 1992, while the skin grafting and the scar revision
were performed on Nora on May 22, 1992 and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the well-being of their patients. If a doctor
fails to live up to this precept, he is accountable for his acts. This notwithstanding, courts face a unique restraint in
adjudicating medical negligence cases because physicians are not guarantors of care and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in negligence cases because where negligence
exists and is proven, it automatically gives the injured a right to reparation for the damage caused. 17
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an injury to justify a
presumption of negligence on the part of the person who controls the instrument causing the injury, provided that the
following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someones negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. 18
As to the first requirement, the gaping wound on Noras arm is certainly not an ordinary occurrence in the act of
delivering a baby, far removed as the arm is from the organs involved in the process of giving birth. Such injury could not
have happened unless negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both instruments
are deemed within the exclusive control of the physician in charge under the "captain of the ship" doctrine. This doctrine
holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those
assistants are under the surgeons control.19 In this particular case, it can be logically inferred that petitioner, the senior
consultant in charge during the delivery of Noras baby, exercised control over the assistants assigned to both the use of
the droplight and the taking of Noras blood pressure. Hence, the use of the droplight and the blood pressure cuff is also
within petitioners exclusive control.
Third, the gaping wound on Noras left arm, by its very nature and considering her condition, could only be caused by
something external to her and outside her control as she was unconscious while in hypovolemic shock. Hence, Nora could
not, by any stretch of the imagination, have contributed to her own injury.
Petitioners defense that Noras wound was caused not by the droplight but by the constant taking of her blood pressure,
even if the latter was necessary given her condition, does not absolve her from liability. As testified to by the medico-legal
officer, Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately after each use. Otherwise,
the inflated band can cause injury to the patient similar to what could have happened in this case. Thus, if Noras wound
was caused by the blood pressure cuff, then the taking of Noras blood pressure must have been done so negligently as to
have inflicted a gaping wound on her arm,20 for which petitioner cannot escape liability under the "captain of the ship"
doctrine.
Further, petitioners argument that the failed plastic surgery was not intended as a cosmetic procedure, but rather as a
measure to prevent complication does not help her case. It does not negate negligence on her part.
Based on the foregoing, the presumption that petitioner was negligent in the exercise of her profession stands
unrebutted. In this connection, the Civil Code provides:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for
the damage done.
ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched reputation,
wounded feelings, moral shock, social humiliation, and similar injury. Though incapable of pecuniary computation,
moral damages may be recovered if they are the proximate result of the defendants wrongful act or omission.

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Page 66

Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the latter as a proximate result of
petitioners negligence.
We note, however, that petitioner has served well as Noras obstetrician for her past three successful deliveries. This is
the first time petitioner is being held liable for damages due to negligence in the practice of her profession. The fact that
petitioner promptly took care of Noras wound before infection and other complications set in is also indicative of
petitioners 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 petitioners 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 (P200,000) as moral damages in favor of respondents and against petitioner is just and equitable. 21
WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolution dated November 19, 2003
of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.
No pronouncement as to costs.
SO ORDERED.

CONCEPCION ILAO-ORETA,
Petitioner,

G.R. No. 172406


Present:
QUISUMBING, J., Chairperson,
CARPIO,
CARPIO MORALES,
TINGA, and
VELASCO, JR., JJ.

- versus -

SPOUSES EVA MARIE and BENEDICTO


NOEL RONQUILLO,
Respondents.

Promulgated:
October 11, 2007

x - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
CARPIO MORALES, J.:
Respondents,

spouses

Eva

Marie

Ronquillo

(Eva

Marie)

and

Noel

Benedicto

(Noel) Ronquillo (the Ronquillo spouses or the spouses), had not been blessed with a child despite several years of
marriage. They thus consulted petitioner, Dr. Concepcion Ilao-Oreta (Dr. Ilao-Oreta), an obstetrician-gynecologistconsultant at the St. Lukes Medical Center where she was, at the time material to the case, the chief of the Reproductive
Endocrinology and Infertility Section.
Upon Dr. Ilao-Oretas advice, Eva Marie agreed to undergo a laparoscopic procedure whereby
a laparascope would be inserted through the patients abdominal wall to get a direct view of her internal reproductive
organ in order to determine the real cause of her infertility.

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Page 67

The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be performed by Dr. Ilao-Oreta. At around 7:00
a.m. of said date, Eva Marie, accompanied by her husband Noel, checked in at the St. Lukes Medical Center and
underwent pre-operative procedures including the administration of intravenous fluid and enema.
Dr. Ilao-Oreta did not arrive at the scheduled time for the procedure, however, and no prior notice of its
cancellation was received. It turned out that the doctor was on a return flight from Hawaii to, and arrived at 10:00
p.m. of April 5, 1999 in, Manila.
On May 18, 1999, the Ronquillo spouses filed a complaint [1] against Dr. Ilao-Oreta and the St.
Lukes Medical Center for breach of professional and service contract and for damages before the Regional Trial Court
(RTC) of Batangas City. They prayed for the award of actual damages including alleged loss of income of Noel while
accompanying his wife to the hospital, moral damages, exemplary damages, the costs of litigation, attorneys fees, and
other available reliefs and remedies. [2]
In her Answer,[3] Dr. Ilao-Oreta gave her side of the case as follows: She went on a honeymoon to Hawaii and was
scheduled to leave Hawaii at 3:00 p.m. of April 4, 1999 for Manila. Aware that her trip from Hawaii to Manila would take
about 12 hours, inclusive of a stop-over at the Narita Airport in Japan, she estimated that she would arrive in Manila in
the early morning ofApril 5, 1999. She thus believed in utmost good faith that she would be back in Manila in time for the
scheduled conduct of the laparoscopic procedure. She failed to consider the time difference between Hawaii and
the Philippines, however.
In its Answer,[4] the St. Lukes Medical Center contended that the spouses have no cause of action against it since
it performed the pre-operative procedures without delay, and any cause of action they have would be against Dr. IlaoOreta.
By Decision[5] of March 9, 2001, Branch 84 of the Batangas RTC, finding that the failure of the doctor to arrive on
time was not intentional, awarded Eva Marie only actual damages in the total amount of P9,939 and costs of suit. It
found no adequate proof that Noel had been deprived of any job contract while attending to his wife in the hospital.
On appeal by the spouses, the Court of Appeals, by Decision [6] of April 21, 2006, finding Dr. IlaoOreta grossly negligent,[7] modified the trial courts decision as follows:
WHEREFORE, the trial Courts decision dated March 9, 2001 is affirmed, subject to the
modification that the amount of actual damages, for which both defendants-appellees are jointly and
severally liable to plaintiffs-appellants, is increased to P16,069.40. Furthermore, defendant-appellee Dr.
Ilao-Oreta is also held liable to pay plaintiff-appellants the following:
(a) P50,000.00 as moral damages;
(b) P25,000.00 as exemplary damages; and
(c) P20,000.00 as attorneys fees.
SO ORDERED.[8] (Underscoring supplied)

Reyes, Hazel

Page 68

Hence, the present Petition for Review[9] of Dr. Ilao-Oreta raising the following arguments:
THE COURT A QUO ERRED IN FINDING PETITIONER TO HAVE ACTED WITH GROSS
NEGLIGENCE AND AWARDING MORAL DAMAGES TO RESPONDENTS. [10]
THE COURT A QUO ERRED IN AWARDING EXEMPLARY DAMAGES TO RESPONDENTS. [11]
THE COURT A QUO [ERRED] IN AWARDING ATTORNEYS FEES TO RESPONDENTS. [12]
THE COURT A QUO ERRED IN INCREASING THE AWARD OF ACTUAL DAMAGES IN
FAVOR OF RESPONDENTS.[13]

Gross negligence implies a want or absence of or failure to exercise slight care or diligence, or the entire
absence of care. It evinces a thoughtless disregard of consequences without exerting any effort to avoid them. [14] It is
characterized by want of even slight care, acting or omitting to act in a situation where there is a duty to act, not
inadvertently but willfully and intentionally with a conscious indifference to consequences in so far as other persons may
be affected.[15]
The records show that before leaving for Hawaii, Dr. Ilao-Oreta left an admitting order with her secretary for one
of the spouses to pick up, apprised Eva Marie of the necessary preparations for the procedure, and instructed the hospital
staff to perform pre-operative treatments. [16] These acts of the doctor reflect an earnest intention to perform the
procedure on the day and time scheduled.
The records also show that on realizing that she missed the scheduled procedure, Dr. Ilao-Oreta, upon arrival
in Manila, immediately sought to rectify the same, thus:
[ATTY SINJAN] Q: So, can you tell us the reason why you missed that operation?
[DR. ILAO-ORETA] A: When I scheduled her for the surgery, I looked at my ticket and so I was to leave
Hawaii on April 4 at around 4:00 oclock in the afternoon, so I was computing 12 hours of travel
including stop-over, then probably I would be in Manila early morning of April 5, then I have so
much time and I can easily do the case at 2:00 oclock, you know it skipped my mind the change
in time.
Q:

So when you arrived at 10:00 [PM] in Manila, what did you do?

A:

I called immediately the hospital and I talked with the nurses, I asked about the patient, Mrs.
Ronquillo, and they told me that she has already left at around 7:00.

Q:

And after calling the hospital, what happened?

A:

I wanted to call the plaintiffs, but I didnt have their number at that time, so in the morning I went
to my office early at 8:00 and looked for her chart, because her telephone number was written in
the chart. So, I called them right away.

Q:

Were you able to contact them?

A:

I was able to reach Mr. Ronquillo.

Reyes, Hazel

Page 69

Q:

In the course of your conversation, what did you tell Mr. Ronquillo?

A:

I apologized to him, I said I was sorry about the time that I missed the surgery, and I told him that
I can do the case right that same day without Mrs. Ronquillo having to undergo another
[b]arium enema.

Q:

What else did you tell him, if any?

A:

I asked him whether I can talk with Mrs. Ronquillo because I wanted to apologize to her
personally.

Q:

And what did he say?

A:

I could hear on the background that Mrs. Ronquillo was shouting angrily that she didnt want to
talk to me, and that she didnt want re-scheduling of the surgery . . .

ATTY LONTOK: May we move, your Honor, for the striking out of the answer, this is purely hearsay.
COURT: Remain on the record.
WITNESS [DR. ILAO-ORETA]: . . . and then Mr. Ronquillo told me Im sorry, Dra., we cannot reschedule the surgery.[17] (Underscoring supplied)

Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in Manila as related by her.[18]
The evidence then shows that Dr. Ilao-Oreta, who had traveled more than twice to the United States where she
obtained a fellowship in Reproductive Endocrinology and Infertility was indeed negligent when she scheduled to perform
professional

service

at 2:00

p.m. on April

5,

1999 without

considering

the

time

difference

between

the Philippines and Hawaii.


The doctors act did not, however, reflect gross negligence as defined above. Her argument that
Although petitioner failed to take into consideration the time difference between
the Philippines and Hawaii, the situation then did not present any clear and apparent harm or injury that
even a careless person may perceive. Unlike in situations where the Supreme Court had found gross
negligence to exist, petitioner could not have been conscious of any foreseeable danger that may occur
since she actually believed that she would make it to the operation that was elective in nature, the only
purpose of which was to determine the real cause of infertility and not to treat and cure a life threatening
disease. Thus, in merely fixing the date of her appointment with respondent Eva Marie Ronquillo,
petitioner was not in the pursuit or performance of conduct which any ordinary person may deem to
probably and naturally result in injury,[19] (Underscoring in original)

thus persuades.
It bears noting that when she was scheduling the date of her performance of the procedure, Dr. Ilao-Oreta had
just gotten married and was preparing for her honeymoon, [20] and it is of common human knowledge that excitement
attends its preparations. Her negligence could then be partly attributed to human frailty which rules out its
characterization as gross.
The doctors negligence not being gross, the spouses are not entitled to recover moral damages.

Reyes, Hazel

Page 70

Neither are the spouses entitled to recover exemplary damages in the absence of a showing that Dr. Ilao-Oreta
acted in a wanton, fraudulent, reckless, oppressive or malevolent manner, [21] nor to award of attorneys fees as, contrary
to the finding of the Court of Appeals that the spouses were compelled to litigate and incur expenses to protect their
interest,[22] the records show that they did not exert enough efforts to settle the matter before going to court. Eva Marie
herself testified:
ATTY. SINJIAN:
Q:
Isnt it true that before instituting this present case, you did not make any demand on Dr. IlaoOreta regarding the claims which you have allegedly incurred, because of the failed laparoscopic
surgery operation?
A [EVA MARIE]: I will tell the truth. Dr. Augusto Reyes of St. Lukes . . .
Q:

But did you demand?

A:

No, I did not demand because

ATTY. SINJIAN: That will be all, your Honor.


ATTY. LONTOK: The witness is still explaining.
WITNESS: Im explaining first. Dr. Augusto Reyes told me that he will hold the meeting for me and Dr.
Oreta to settle things and reimburse all the money that I spent from the hospital, and he even
suggested Dr. Oreta to personally talk to me.
ATTY. SINJIAN:
Q:
So it was to Dr. Augusto Reyes that you talked?
A:
Yes.
Q:

But you did not demand anything or write to Dr. Oreta?

A:

No.

Q:

Before instituting this case?

A:

No.[23] (Underscoring supplied)

Finally, Dr. Ilao-Oretas prayer for the reduction of actual damages is well-taken. Article 2201 of the Civil Code
provides:
In contracts and quasi-contracts, the damages for which the obligor who acted in good faith is
liable shall be those which are the natural and probable consequences of the breach of the obligation, and
which the parties have foreseen or could have reasonably foreseen at the time the obligation was
constituted.

In fixing the amount of actual damages, the Court of Appeals and the trial court included expenses which the spouses
incurred priorto April 5, 1999 when the breach of contract complained of occurred. [24] The Court of Appeals also included
the alleged P300 spent on fuel consumption from the spouses residence at San Pascual, Batangas to the St.
Lukes Medical Center in Quezon Cityand the alleged P500 spent on food in the hospital canteen, both of which are
unsubstantiated by independent or competent proof.[25] The only piece of documentary evidence supporting the food and

Reyes, Hazel

Page 71

fuel expenses is an unsigned listing.[26] As the fuel and food expenses are not adequately substantiated, they cannot be
included in the computation of the amount of actual damages. So Premiere Development Bank v. Court of
Appeals[27] instructs:
In the instant case, the actual damages were proven through the sole testimony
of Themistocles Ruguero, the vice president for administration of Panacor. In his testimony, the witness
affirmed that Panacor incurred losses, specifically, in terms of training and seminars, leasehold
acquisition, procurement of vehicles and office equipment without, however, adducing receipts to
substantiate the same. The documentary evidence marked as Exhibit W, which was an ordinary
private writing allegedly itemizing the capital expenditures and losses from the failed operation
of Panacor, was not testified to by any witness to ascertain the veracity of its content. Although the lower
court fixed the sum of P4,520,000.00 as the total expenditures incurred by Panacor, it failed to show
how and in what manner the same were substantiated by the claimant with reasonable
certainty. Hence, the claim for actual damages should be received with extreme caution since it is only
based on bare assertion without support from independent evidence. Premieres failure to prove actual
expenditure consequently conduces to a failure of its claim. In determining actual damages, the court
cannot rely on mere assertions, speculations, conjectures or guesswork but must depend on competent
proof and on the best evidence obtainable regarding the actual amount of loss.[28] (Underscoring
supplied)

The list of expenses cannot replace receipts when they should have been issued as a matter of course in business
transactions[29] as in the case of purchase of gasoline and of food.
The documented claim for hospital and medical expenses of the spouses is detailed in the Statement of Account
issued by the hospital, the pertinent entries of which read:
xxxx
4/5/1999

GROSS HOSPITAL CHARGES


1699460 DEPOSITOFFICIAL
RECEIPT

2,416.50
(5,000.00)
(5,000.00)

________
4/5/1999 SECOND 0284893 UNUSED MED 0439534 (65.55)
FLOOR
HINOX 500 MG CAP
SECOND 0284894 UNUSED MED 0439893 (62.25)
FLOOR
PHENERGAN 2 ML
50MG
______ (127.80)
BALANCE DUE
(2,711.30)[30]
=======
As extrapolated from the above-quoted entries in the Statement of Account, P2,288.70 (the gross hospital charges
of P2,416.50 less the unused medicine in the amount of P127.80) was debited from the P5,000 deposit[31] to thus leave a
balance of the deposit in the amount of P2,711.30, which the trial court erroneously denominated as confinement
fee. The remaining balance of P2,711.30 was the amount refundable to the spouses.
Following Eastern Shipping Lines, Inc. v. Court of Appeals,[32] this Court awards interest on the actual damages to
be paid by Dr. Ilao-Oreta at the rate of 6% per annum from the time of the filing of the complaint on May 18, 1999, and at
12% per annumfrom the finality of this judgment until its satisfaction.

Reyes, Hazel

Page 72

WHEREFORE, the petition is GRANTED.


1) the

award

to

The decision appealed from is MODIFIED in that

respondents-spouses

Noel

and

Eva

Marie Ronquillo of

actual

damages

is REDUCED to P2,288.70, to bear interest at a rate of 6% per annum from the time of the filing of the complaint on May
18, 1999 and, upon finality of this judgment, at the rate of 12% per annum until satisfaction; and
2.

The award of moral and exemplary damages and attorneys fees is DELETED.

SO ORDERED.
SPOUSES FREDELICTO FLORES
(deceased) and FELICISIMA
FLORES,
Petitioners,
-

G.R. No. 158996


Present:
QUISUMBING, J., Chairperson,
CARPIO MORALES,
TINGA,
VELASCO, JR., and
BRION, JJ.

versus -

SPOUSES DOMINADOR PINEDA and


VIRGINIA SACLOLO, and
FLORENCIO, CANDIDA, MARTA,
GODOFREDO, BALTAZAR and
LUCENA, all surnamed PINEDA, as
heirs of the deceased TERESITA S.
PINEDA, and UNITED DOCTORS
MEDICAL CENTER, INC.,
Respondents.

Promulgated:
November 14, 2008

x -------------------------------------------------------------------------------------------x

DECISION

BRION, J.:

This petition involves a medical negligence case that was elevated to this Court through an appeal
by certiorari under Rule 45 of the Rules of Court. The petition assails the Decision [1] of the Court of Appeals (CA) in CA
G.R. CV No. 63234, which affirmed with modification the Decision [2] of the Regional Trial Court (RTC) of Nueva Ecija,
Branch 37 in Civil Case No. SD-1233. The dispositive portion of the assailed CA decision states:
WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of Baloc,
Sto. Domingo, Nueva Ecija, Branch 37 is hereby AFFIRMED but with modifications as follows:
1)

Reyes, Hazel

Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors
Medical Center, Inc. to jointly and severally pay the plaintiff-appellees heirs of Teresita
Pineda, namely, Spouses Dominador Pineda and Virginia Saclolo and Florencio, Candida,

Page 73

Marta, Godofredo, Baltazar and Lucena, all surnamed Pineda, the sum of P400,000.00 by
way of moral damages;
2)

Ordering the above-named defendant-appellants to jointly and severally pay the abovenamed plaintiff-appellees the sum ofP100,000.00 by way of exemplary damages;

3)

Ordering the above-named defendant-appellants to jointly and severally pay the abovenamed plaintiff-appellees the sum ofP36,000.00 by way of actual and compensatory
damages; and

4)

Deleting the award of attorneys fees and costs of suit.

SO ORDERED.
While this case essentially involves questions of facts, we opted for the requested review in light of questions we have on
the findings of negligence below, on the awarded damages and costs, and on the importance of this type of ruling on
medical practice.[3]
BACKGROUND FACTS
Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo, Nueva Ecija. She consulted
on April 17, 1987 her townmate, Dr. Fredelicto Flores, regarding her medical condition. She complained of general body
weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto initially
interviewed the patient and asked for the history of her monthly period to analyze the probable cause of the vaginal
bleeding. He advised her to return the following week or to go to the United Doctors Medical Center ( UDMC) in Quezon
City for a general check-up. As for her other symptoms, he suspected that Teresita might be suffering from diabetes and
told her to continue her medications. [4]
Teresita did not return the next week as advised. However, when her condition persisted, she went to further
consult Dr. Flores at his UDMC clinic on April 28, 1987, travelling for at least two hours from Nueva Ecija to Quezon
City with her sister, Lucena Pineda. They arrived at UDMC at around 11:15 a.m.. Lucena later testified that her sister was
then so weak that she had to lie down on the couch of the clinic while they waited for the doctor. When Dr. Fredelicto
arrived, he did a routine check-up and ordered Teresitas admission to the hospital. In the admission slip, he directed the
hospital staff to prepare the patient for an on call D&C[5] operation to be performed by his wife, Dr. Felicisima Flores
(Dr. Felicisima). Teresita was brought to her hospital room at around 12 noon; the hospital staff forthwith took her blood
and urine samples for the laboratory tests[6] which Dr. Fredelicto ordered.
At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then that she met Dr.
Felicisima, an obstetrician and gynecologist. The two doctors Dr. Felicisima and Dr. Fredelicto, conferred on the
patients medical condition, while the resident physician and the medical intern gave Dr. Felicisima their own
briefings. She also interviewed and conducted an internal vaginal examination of the patient which lasted for about 15
minutes. Dr. Felicisima thereafter called up the laboratory for the results of the tests. At that time, only the results for
the blood sugar (BS), uric acid determination, cholesterol determination, and complete blood count (CBC) were
available. Teresitas BS count was 10.67mmol/l[7] and her CBC was 109g/l.[8]

Reyes, Hazel

Page 74

Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr. Fredelicto administering
the general anesthesia. The D&C operation lasted for about 10 to 15 minutes. By 3:40 p.m., Teresita was wheeled back to
her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound examination as a
confirmatory procedure. The results showed that she had an enlarged uterus and myoma uteri.[9] Dr. Felicisima,
however, advised Teresita that she could spend her recovery period at home. Still feeling weak, Teresita opted for
hospital confinement.
Teresitas complete laboratory examination results came only on that day (April 29, 1987). Teresitas urinalysis
showed a three plus sign (+++) indicating that the sugar in her urine was very high. She was then placed under the care
of Dr. Amado Jorge, an internist.
By April 30, 1987, Teresitas condition had worsened. She experienced difficulty in breathing and was rushed to
the intensive care unit. Further tests confirmed that she was suffering from Diabetes Mellitus Type II.[10] Insulin was
administered on the patient, but the medication might have arrived too late. Due to complications induced by diabetes,
Teresita died in the morning ofMay 6, 1987.[11]
Believing that Teresitas death resulted from the negligent handling of her medical needs, her family
(respondents) instituted an action for damages against Dr. Fredelicto Flores and Dr. Felicisima Flores (collectively
referred to as the petitioner spouses) before the RTC of Nueva Ecija.
The RTC ruled in favor of Teresitas family and awarded actual, moral, and exemplary damages, plus attorneys
fees and costs.[12] The CA affirmed the judgment, but modified the amount of damages awarded and deleted the award
for attorneys fees and costs of suit.[13]
Through this petition for review on certiorari, the petitioner spouses Dr. Fredelicto (now deceased) and Dr.
Felicisima Flores allege that the RTC and CA committed a reversible error in finding them liable through negligence for
the death of Teresita Pineda.
ASSIGNMENT OF ERRORS
The petitioner spouses contend that they exercised due care and prudence in the performance of their duties as
medical professionals. They had attended to the patient to the best of their abilities and undertook the management of
her case based on her complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on record shows
that the death of Teresita could have been averted had they employed means other than what they had adopted in the
ministration of the patient.

THE COURTS RULING


We do not find the petition meritorious.

Reyes, Hazel

Page 75

The respondents claim for damages is predicated on their allegation that the decision of the petitioner spouses to
proceed with the D&C operation, notwithstanding Teresitas condition and the laboratory test results, amounted to
negligence. On the other hand, the petitioner spouses contend that a D&C operation is the proper and accepted
procedure to address vaginal bleeding the medical problem presented to them. Given that the patient died after the
D&C, the core issue is whether the decision to proceed with the D&C operation was an honest mistake of judgment or one
amounting to negligence.
Elements of a Medical Negligence Case
A medical negligence case is a type of claim to redress a wrong committed by a medical professional, that has
caused bodily harm to or the death of a patient. There are four elements involved in a medical negligence case,
namely: duty, breach, injury, and proximate causation.[14]
Duty refers to the standard of behavior which imposes restrictions on ones conduct. [15] The standard in turn refers
to the amount of competence associated with the proper discharge of the profession. A physician is expected to use at
least the same level of care that any other reasonably competent doctor would use under the same circumstances. Breach
of duty occurs when the physician fails to comply with these professional standards. If injury results to the patient as a
result of this breach, the physician is answerable for negligence. [16]
As in any civil action, the burden to prove the existence of the necessary elements rests with the plaintiff. [17] To
successfully pursue a claim, the plaintiff must prove by preponderance of evidence that, one, the physician either failed
to do something which a reasonably prudent health care provider would have done, or that he did something that a
reasonably prudent provider would not have done; and two, the failure or action caused injury to the patient.
[18]

Expert testimony is therefore essential since the factual issue of whether a physician or surgeon has exercised the

requisite degree of skill and care in the treatment of his patient is generally a matter of expert opinion. [19]
Standard of Care and Breach of Duty
D&C is the classic gynecologic procedure for the evaluation and possible therapeutic treatment for abnormal vaginal
bleeding.[20] That this is the recognized procedure is confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado
(Dr. Mercado), the expert witnesses presented by the respondents:
DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what we call D&C
for diagnostic purposes.
xxx

xxx

xxx

Q:

So are you trying to tell the Court that D&C can be a diagnostic treatment?

A:

Yes, sir. Any doctor knows this.[21]

Dr. Mercado, however, objected with respect to the time the D&C operation should have been conducted in Teresitas
case. He opined that given the blood sugar level of Teresita, her diabetic condition should have been addressed first:
Q:

Why do you consider the time of performance of the D&C not appropriate?

Reyes, Hazel

Page 76

A:

Because I have read the record and I have seen the urinalysis, [there is] spillage in the
urine, and blood sugar was 10.67

Q:

What is the significance of the spillage in the urine?

A:

It is a sign that the blood sugar is very high.

Q:

Does it indicate sickness?

A:

80 to 95% it means diabetes mellitus. The blood sugar was 10.67.


xxx

xxx

xxx

COURT:
In other words, the operation conducted on the patient, your opinion, that it is
inappropriate?
A:

The timing of [when] the D&C [was] done, based on the record, in my personal opinion,
that D&C should be postponed a day or two.[22]

The petitioner spouses countered that, at the time of the operation, there was nothing to indicate that Teresita
was afflicted with diabetes: a blood sugar level of 10.67mmol/l did not necessarily mean that she was a diabetic
considering that this wasrandom blood sugar;[23] there were other factors that might have caused Teresitas blood
sugar to rise such as the taking of blood samples during lunchtime and while patient was being given intra-venous
dextrose.[24] Furthermore, they claim that their principal concern was to determine the cause of and to stop the vaginal
bleeding.
The petitioner spouses contentions, in our view, miss several points. First, as early as April 17, 1987, Teresita
was already suspected to be suffering from diabetes. [25] This suspicion again arose right before the D&C operation
on April 28, 1987 when the laboratory result revealed Teresitas increased blood sugar level. [26] Unfortunately, the
petitioner spouses did not wait for the full medical laboratory results before proceeding with the D&C, a fact that was
never considered in the courts below. Second, the petitioner spouses were duly advised that the patient was
experiencing general body weakness, loss of appetite, frequent urination, and thirst all of which are classic symptoms
of diabetes.[27] When a patient exhibits symptoms typical of a particular disease, these symptoms should, at the very
least, alert the physician of the possibility that the patient may be afflicted with the suspected disease:
[Expert testimony for the plaintiff showed that] tests should have been ordered immediately on
admission to the hospital in view of the symptoms presented, and that failure to recognize the existence
of diabetes constitutes negligence.[28]
Third, the petitioner spouses cannot claim that their principal concern was the vaginal bleeding and should not
therefore be held accountable for complications coming from other sources. This is a very narrow and self-serving view
that even reflects on their competence.
Taken together, we find that reasonable prudence would have shown that diabetes and its complications were
foreseeable harm that should have been taken into consideration by the petitioner spouses. If a patient suffers from
some disability that increases the magnitude of risk to him, that disability must be taken into account so
long as it is or should have been known to the physician. [29] And when the patient is exposed to an increased
risk, it is incumbent upon the physician to take commensurate and adequate precautions.

Reyes, Hazel

Page 77

Taking into account Teresitas high blood sugar, [30] Dr. Mendoza opined that the attending physician should have
postponed the D&C operation in order to conduct a confirmatory test to make a conclusive diagnosis of diabetes and to
refer the case to an internist or diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and
gynecologist, who stated that the patients diabetes should have been managed by an internist prior to, during, and
after the operation.[31]
Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so heavy and life-threatening
that urgent first-aid measures are required. [32] Indeed, the expert witnesses declared that a D&C operation on a
hyperglycemic patient may be justified only when it is an emergency case when there is profuse vaginal bleeding. In
this case, we choose not to rely on the assertions of the petitioner spouses that there was profuse bleeding, not only
because the statements were self-serving, but also because the petitioner spouses were inconsistent in their
testimonies. Dr. Fredelicto testified earlier that on April 28, he personally saw the bleeding, [33] but later on said that he
did not see it and relied only on Teresitas statement that she was bleeding. [34] He went on to state that he scheduled the
D&C operation without conducting any physical examination on the patient.
The likely story is that although Teresita experienced vaginal bleeding on April 28, it was not sufficiently profuse
to necessitate an immediate emergency D&C operation. Dr. Tan[35] and Dr. Mendoza[36] both testified that the medical
records of Teresita failed to indicate that there was profuse vaginal bleeding. The claim that there was profuse vaginal
bleeding although this was not reflected in the medical records strikes us as odd since the main complaint is vaginal
bleeding. A medical record is the only document that maintains a long-term transcription of patient care and as such, its
maintenance is considered a priority in hospital practice. Optimal record-keeping includes all patient inter-actions. The
records should always be clear, objective, and up-to-date. [37] Thus, a medical record that does not indicate profuse
medical bleeding speaks loudly and clearly of what it does not contain.
That the D&C operation was conducted principally to diagnose the cause of the vaginal bleeding further leads us
to conclude that it was merely an elective procedure, not an emergency case. In an elective procedure, the physician must
conduct a thorough pre-operative evaluation of the patient in order to adequately prepare her for the operation and
minimize possible risks and complications. The internist is responsible for generating a comprehensive evaluation of all
medical problems during the pre-operative evaluation.[38]
The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, but rather
to identify and quantify comorbidity that may impact on the operative outcome. This evaluation is
driven by findings on history and physical examination suggestive of organ system dysfunction The
goal is to uncover problem areas that may require further investigation or be amenable to
preoperative optimization.
If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an
underlying disease process, consultation with an internist or medical specialist may be required to
facilitate the work-up and direct management. In this process, communication between the surgeons
and the consultants is essential to define realistic goals for this optimization process and to expedite
surgical management.[39] [Emphasis supplied.]
Significantly, the evidence strongly suggests that the pre-operative evaluation was less than complete as the laboratory
results were fully reported only on the day following the D&C operation. Dr. Felicisima only secured a telephone report
of the preliminary laboratory result prior to the D&C. This preliminary report did not include the 3+ status of sugar in
the patients urine[40] a result highly confirmatory of diabetes.

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Page 78

Because the D&C was merely an elective procedure, the patients uncontrolled hyperglycemia presented a far
greater risk than her on-and-off vaginal bleeding. The presence of hyperglycemia in a surgical patient is associated with
poor clinical outcomes, and aggressive glycemic control positively impacts on morbidity and mortality. [41] Elective
surgery in people with uncontrolled diabetes should preferably be scheduled after acceptable glycemic control has been
achieved.[42] According to Dr. Mercado, this is done by administering insulin on the patient.[43]
The management approach in this kind of patients always includes insulin therapy in
combination with dextrose and potassium infusion. Insulin xxx promotes glucose uptake by the muscle
and fat cells while decreasing glucose production by the liver xxx. The net effect is to lower blood glucose
levels.[44]
The prudent move is to address the patients hyperglycemic state immediately and promptly before any other procedure
is undertaken. In this case, there was no evidence that insulin was administered on Teresita prior to or during the D&C
operation. Insulin was only administered two days after the operation.
As Dr. Tan testified, the patients hyperglycemic condition should have been managed not only before and
during the operation, but also immediately after. Despite the possibility that Teresita was afflicted with diabetes, the
possibility was casually ignored even in the post-operative evaluation of the patient; the concern, as the petitioner
spouses expressly admitted, was limited to the complaint of vaginal bleeding. Interestingly, while the ultrasound test
confirmed that Teresita had a myoma in her uterus, she was advised that she could be discharged a day after the
operation and that her recovery could take place at home. This advice implied that a day after the operation and even
after the complete laboratory results were submitted, the petitioner spouses still did not recognize any post-operative
concern that would require the monitoring of Teresitas condition in the hospital.
The above facts, point only to one conclusion that the petitioner spouses failed, as medical professionals, to
comply with their duty to observe the standard of care to be given to hyperglycemic/diabetic patients undergoing
surgery. Whether this breach of duty was the proximate cause of Teresitas death is a matter we shall next determine.
Injury and Causation
As previously mentioned, the critical and clinching factor in a medical negligence case is proof of the causal
connectionbetween the negligence which the evidence established and the plaintiffs injuries; [45] the plaintiff must plead
and prove not only that he had been injured and defendant has been at fault, but also that the defendants fault caused
the injury. A verdict in a malpractice action cannot be based on speculation or conjecture. Causation must be proven
within a reasonable medical probability based upon competent expert testimony.[46]
The respondents contend that unnecessarily subjecting Teresita to a D&C operation without adequately preparing
her, aggravated her hyperglycemic state and caused her untimely demise. The death certificate of Teresita lists down the
following causes of death:
Immediate cause:
Antecedent cause:
Underlying cause:

Reyes, Hazel

Cardiorespiratory arrest
Septicemic shock, ketoacidocis
Diabetes Mellitus II

Page 79

Other significant conditions


contributing to death:

Renal Failure Acute[47]

Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a form of
physical stress. Dr. Mendoza explained how surgical stress can aggravate the patients hyperglycemia: when stress occurs,
the diabetics body, especially the autonomic system, reacts by secreting hormones which are counter-regulatory; she can
have prolonged hyperglycemia which, if unchecked, could lead to death. [48] Medical literature further explains that if the
blood sugar has become very high, the patient becomes comatose (diabetic coma). When this happens over several days,
the body uses its own fat to produce energy, and the result is high levels of waste products (called ketones) in the blood
and urine (called diabetic ketoacidiosis, a medical emergency with a significant mortality). [49] This was apparently
what happened in Teresitas case; in fact, after she had been referred to the internist Dr. Jorge, laboratory test showed
that her blood sugar level shot up to 14.0mmol/l, way above the normal blood sugar range. Thus, between the D&C and
death was the diabetic complication that could have been prevented with the observance of standard medical
precautions. The D&C operation and Teresitas death due to aggravated diabetic condition is therefore sufficiently
established.
The trial court and the appellate court pinned the liability for Teresitas death on both the petitioner spouses and
this Court finds no reason to rule otherwise. However, we clarify that Dr. Fredelictos negligence is not solely the act of
ordering an on call D&C operation when he was mainly an anaesthesiologist who had made a very cursory
examination of the patients vaginal bleeding complaint. Rather, it was his failure from the very start to identify and
confirm, despite the patients complaints and his own suspicions, that diabetes was a risk factor that should be guarded
against, and his participation in the imprudent decision to proceed with the D&C operation despite his early suspicion
and the confirmatory early laboratory results. The latter point comes out clearly from the following exchange during the
trial:
Q:

On what aspect did you and your wife consult [with] each other?

A:

We discussed on the finding of the laboratory [results] because the hemoglobin was below
normal, the blood sugar was elevated, so that we have to evaluate these laboratory results what
it means.

Q:

So it was you and your wife who made the evaluation when it was phoned in?

A:

Yes, sir.

Q:

Did your wife, before performing D&C ask your opinion whether or not she can proceed?

A:

Yes, anyway, she asked me whether we can do D&C based on my experience.

Q:

And your answer was in the positive notwithstanding the elevation of blood sugar?

A:

Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.][50]

If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an internist or a diabetologist (for
which reason he referred Teresita to Dr. Jorge), [51] he should have likewise refrained from making a decision to proceed
with the D&C operation since he was niether an obstetrician nor a gynecologist.

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These findings lead us to the conclusion that the decision to proceed with the D&C operation, notwithstanding
Teresitas hyperglycemia and without adequately preparing her for the procedure, was contrary to the standards observed
by the medical profession. Deviation from this standard amounted to a breach of duty which resulted in the patients
death. Due to this negligent conduct, liability must attach to the petitioner spouses.
Liability of the Hospital
In the proceedings below, UDMC was the spouses Flores co-defendant. The RTC found the hospital jointly and
severally liable with the petitioner spouses, which decision the CA affirmed. In a Resolution dated August 28, 2006, this
Court however denied UDMCs petition for review on certiorari. Since UDMCs appeal has been denied and they are not
parties to this case, we find it unnecessary to delve on the matter. Consequently, the RTCs decision, as affirmed by the
CA, stands.
Award of Damages
Both the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the
respondents suffered. The loss was presented in terms of the hospital bills and expenses the respondents incurred on
account of Teresitas confinement and death. The settled rule is that a plaintiff is entitled to be compensated for proven
pecuniary loss.[52] This proof the respondents successfully presented. Thus, we affirm the award of actual
damages of P36,000.00 representing the hospital expenses the patient incurred.
In addition to the award for actual damages, the respondent heirs of Teresita are likewise entitled to P50,000.00
as death indemnity pursuant to Article 2206 of the Civil Code, which states that the amount of damages for death
caused by a xxx quasi-delict shall be at least three thousand pesos, [53] even though there may have been mitigating
circumstances xxx. This is a question of law that the CA missed in its decision and which we now decide in the
respondents favor.
The same article allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates
the spouse, legitimate or illegitimate ascendants or descendants as the persons entitled thereto. Moral damages are
designed to compensate the claimant for the injury suffered, that is, for the mental anguish, serious anxiety, wounded
feelings which the respondents herein must have surely felt with the unexpected loss of their daughter. We affirm the
appellate courts award of

P400,000.00 by way of moral damages to the respondents.

We similarly affirm the grant of exemplary damages. Exemplary damages are imposed by way of example or
correction for the public good.[54] Because of the petitioner spouses negligence in subjecting Teresita to an operation
without first recognizing and addressing her diabetic condition, the appellate court awarded exemplary damages to
the respondents in the amount ofP100,000.00. Public policy requires such imposition to suppress the wanton acts of an
offender.[55] We therefore affirm the CAs award as an example to the medical profession and to stress that the public
good requires stricter measures to avoid the repetition of the type of medical malpractice that happened in this case.

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Page 81

With the award of exemplary damages, the grant of attorneys fees is legally in order. [56] We therefore reverse the
CA decision deleting these awards, and grant the respondents the amount of P100,000.00 as attorneys fees taking
into consideration the legal route this case has taken.
WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No. 63234 finding
petitioner spouses liable for negligent medical practice. We likewise AFFIRM the awards of actual and compensatory
damages ofP36,000.00; moral damages of P400,000.00; and exemplary damages of P100,000.00.
We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death indemnity and by
reversing the deletion of the award of attorneys fees and costs and restoring the award of P100,000.00 as attorneys
fees. Costs of litigation are adjudged against petitioner spouses.
To summarize, the following awards shall be paid to the family of the late Teresita Pineda:
1.

The sum of P36,000.00 by way of actual and compensatory damages;

2.

The sum of P50,000.00 by way of death indemnity;

3.

The sum of P400,000.00 by way of moral damages;

4.

The sum of P100,000.00 by way of exemplary damages;

5.

The sum of P100,000.00 by way of attorneys fees; and

6.

Costs.

SO ORDERED.

FE CAYAO-LASAM,
Petitioner,

G.R. No. 159132


Present:

- versus -

YNARES-SANTIAGO, J.,
Chairperson,
AUSTRIA-MARTINEZ,
CHICO-NAZARIO,
NACHURA, and
REYES, JJ.

SPOUSES CLARO and


EDITHA RAMOLETE,
Promulgated:
Respondents.*
December 18, 2008
x-------------------------- -------------------------------x
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 CayaoLasam (petitioner) seeking to annul the Decision[1] dated July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP No. 62206.

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Page 82

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 sonogram[2] was then conducted on Editha revealing the fetus weak cardiac pulsation.[3] The
following day, Edithas repeat pelvic sonogram[4] showed that aside from the fetus weak cardiac pulsation, no fetal movement was also
appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure
(D&C) or raspa.
On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the hospital the following day.
On September 16, 1994, Editha was once again brought at the LMC, as she was suffering from vomiting and severe abdominal
pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly
informed Editha that there was a dead fetus in the latters womb. After, Editha underwent laparotomy,[5] she was found to have a
massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy [6] and as a
result, she has no more chance to bear a child.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a Complaint[7] for Gross Negligence and
Malpractice against petitioner before the Professional Regulations Commission (PRC).
Respondents alleged that Edithas hysterectomy was caused by petitioners unmitigated negligence and professional
incompetence in conducting the D&C procedure and the petitioners failure to remove the fetus inside Edithas womb.[8] Among the
alleged acts of negligence were: first, petitioners failure to check up, visit or administer medication on Editha during her first day of
confinement at the LMC;[9] second, petitioner recommended that a D&C procedure be performed on Editha without conducting any
internal examination prior to the procedure;[10]third, petitioner immediately suggested a D&C procedure instead of closely monitoring
the state of pregnancy of Editha.[11]
In her Answer,[12] petitioner denied the allegations of negligence and incompetence with the following explanations:
upon Edithasconfirmation that she would seek admission at the LMC, petitioner immediately called the hospital to anticipate the arrival
of Editha and ordered through the telephone the medicines Editha needed to take, which the nurses carried out; petitioner
visited Editha on the morning of July 28, 1994 during her rounds; on July 29, 1994, she performed an internal examination
on Editha and she discovered that the latters cervix was already open, thus, petitioner discussed the possible D&C procedure, should the
bleeding become more profuse; on July 30 1994, she conducted another internal examination on Editha, which revealed that the latters
cervix was still open; Editha persistently complained of her vaginal bleeding and her passing out of some meaty mass in the process of
urination and bowel movement; thus, petitioner advised Editha to undergo D&C procedure which the respondents consented to;
petitioner was very vocal in the operating room about not being able to see an abortus;[13]taking the words of Editha to mean that she
was passing out some meaty mass and clotted blood, she assumed that the abortus must have been expelled in the process of bleeding; it
was Editha who insisted that she wanted to be discharged; petitioner agreed, but she advised Editha to return for check-up on August 5,
1994, which the latter failed to do.

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Page 83

Petitioner contended that it was Edithas gross negligence and/or omission in insisting to be discharged on July 31, 1994 against
doctors advice and her unjustified failure to return for check-up as directed by petitioner that contributed to her life-threatening
condition on September 16, 1994; that Edithas hysterectomy was brought about by her very abnormal pregnancy known
as placenta increta, which was an extremely rare and very unusual case of abdominal placental implantation. Petitioner argued that
whether or not a D&C procedure was done by her or any other doctor, there would be no difference at all because at any stage of
gestation before term, the uterus would rupture just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision, [14] exonerating petitioner from the
charges filed against her. The Board held:
Based on the findings of the doctors who conducted the laparotomy on Editha, hers is a case
of Ectopic Pregnancy Interstitial. This type ofectopic pregnancy is one that is being protected by the uterine muscles
and manifestations may take later than four (4) months and only attributes to two percent (2%) of ectopic pregnancy
cases.
When complainant Editha was admitted at Lorma Medical Center on July 28, 1994 due to vaginal
bleeding, an ultra-sound was performed upon her and the result of the Sonogram Test reveals a morbid fetus but did
not specify where the fetus was located. Obstetricians will assume that the pregnancy is within the uterus unless so
specified by the Sonologist who conducted the ultra-sound. Respondent (Dr. Lasam) cannot be faulted if she was not
able to determine that complainant Editha is having an ectopic pregnancy interstitial. The D&C conducted
on Editha is necessary considering that her cervix is already open and so as to stop the profuse bleeding. Simple
curettage cannot remove a fetus if the patient is having an ectopic pregnancy, since ectopicpregnancy is pregnancy
conceived outside the uterus and curettage is done only within the uterus. Therefore, a more extensive operation
needed in this case of pregnancy in order to remove the fetus.[15]
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000, the PRC rendered a Decision[16] reversing
the findings of the Board and revoking petitioners authority or license to practice her profession as a physician.[17]
Petitioner brought the matter to the CA in a Petition for Review under Rule 43 of the Rules of Court. Petitioner also dubbed her
petition as one for certiorari[18] under Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review under Rule 43 of the Rules of Court was an
improper remedy, as the enumeration of the quasi-judicial agencies in Rule 43 is exclusive.[19] PRC is not among the quasi-judicial
bodies whose judgment or final orders are subject of a petition for review to the CA, thus, the petition for review of the PRC Decision,
filed at the CA, was improper. The CA further held that should the petition be treated as a petition for certiorari under Rule 65, the
same would still be dismissed for being improper and premature. Citing Section 26[20] of Republic Act (R.A.) No. 2382 or the Medical
Act of 1959, the CA held that the plain, speedy and adequate remedy under the ordinary course of law which petitioner should have
availed herself of was to appeal to the Office of the President.[21]
Hence, herein petition, assailing the decision of the CA on the following grounds:
1.

THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN HOLDING THAT THE


PROFESSIONAL REGULATION[S] COMMISSION (PRC) WAS EXCLUDED AMONG THE QUASIJUDICIAL AGENCIES CONTEMPLATED UNDER RULE 43 OF THE RULES OF CIVIL PROCEDURE;

2.

EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE PURVIEW
OF RULE 43 OF THE RULES OF CIVIL PROCEDURE, THE PETITIONER WAS NOT PRECLUDED
FROM FILING A PETITION FOR CERTIORARI WHERE THE DECISION WAS ALSO ISSUED IN
EXCESS OF OR WITHOUT JURISDICTION, OR WHERE THE DECISION WAS A PATENT NULLITY;

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Page 84

3.

HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO APPEAL FROM


THE DECISION OF THE BOARD OF MEDICINE TO THE PROFESSIONAL REGULATION[S]
COMMISSION;

4.

THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF DISCRETION IN


DENYING FOR IMPROPER FORUM THE PETITION FOR REVIEW/PETITION FOR CERTIORARI
WITHOUT GOING OVER THE MERITS OF THE GROUNDS RELIED UPON BY THE PETITIONER;

5.

PRCS GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE TO BE


HEARD ON APPEAL IS A CLEAR VIOLATION OF HER CONSTITUTIONAL RIGHT TO DUE PROCESS
AND HAS THE EFFECT OF RENDERING THE JUDGMENT NULL AND VOID;

6.

COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED GRAVE


ABUSE OF DISCRETION, AMOUNTING TO LACK OF JURISDICTION, IN ACCEPTING AND
CONSIDERING THE MEMORANDUM ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN
PETITIONER, AND IN VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND REGULATIONS
GOVERNING THE REGULATION AND PRACTICE OF PROFESSIONALS;

7.

PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING PETITIONERS


LICENSE TO PRACTICE MEDICINE WITHOUT AN EXPERT TESTIMONY TO SUPPORT ITS
CONCLUSION AS TO THE CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETES INJURY;

8.

PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN TOTALLY


DISREGARDING THE FINDING OF THE BOARD OF MEDICINE, WHICH HAD THE NECESSARY
COMPETENCE AND EXPERTISE TO ESTABLISH THE CAUSE OF RESPONDENT EDITHAS INJURY,
AS WELL AS THE TESTIMONY OF THE EXPERT WITNESS AUGUSTO MANALO, M.D. ;[AND]

9.

PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING CONCLUSIONS OF FACTS THAT


WERE NOT ONLY UNSUPPORTED BY EVIDENCE BUT WERE ACTUALLY CONTRARY TO EVIDENCE
ON RECORD.[22]

The Court will first deal with the procedural issues.


Petitioner claims that the law does not allow complainants to appeal to the PRC from the decision of the Board. She invokes
Article IV, Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals, which provides:
Sec. 35. The respondent may appeal the decision of the Board within thirty days from receipt thereof to the
Commission whose decision shall be final. Complainant, when allowed by law, may interpose an appeal
from the Decision of the Board within the same period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while the respondent, as a matter of right, may appeal
the Decision of the Board to the Commission, the complainant may interpose an appeal from the decision of the Board only when so
allowed by law.[23] Petitioner cited Section 26 of Republic Act No. 2382 or The Medical Act of 1959, to wit:
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners (now Medical Board)
shall automatically become final thirty days after the date of its promulgation unless the respondent, during the same
period, has appealed to the Commissioner of Civil Service (now Professional Regulations Commission) and later to
the Office of the President of the Philippines. If the final decision is not satisfactory, the respondent may ask for a
review of the case, or may file in court a petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the respondent in an administrative case to file an
appeal with the Commission while the complainant is not allowed to do so is double jeopardy. Petitioner is of the belief that the
revocation of license to practice a profession is penal in nature.[24]

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Page 85

The Court does not agree.


For one, the principle of double jeopardy finds no application in administrative cases. Double jeopardy attaches only: (1) upon a
valid indictment; (2) before a competent court; (3) after arraignment; (4) when a valid plea has been entered; and (5) when the
defendant was acquitted or convicted, or the case was dismissed or otherwise terminated without the express consent of the accused.
[25]

These elements were not present in the proceedings before the Board of Medicine, as the proceedings involved in the instant case

were administrative and not criminal in nature. The Court has already held that double jeopardy does not lie in administrative cases.[26]
Moreover, Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals cited by petitioner was
subsequently amended to read:
Sec. 35. The complainant/respondent may appeal the order, the resolution or the decision of the
Board within thirty (30) days from receipt thereof to the Commission whose decision shall be final
and executory. Interlocutory order shall not be appealable to the Commission. (Amended by Res. 174, Series of
1990).[27] (Emphasis supplied)
Whatever doubt was created by the previous provision was settled with said amendment. It is axiomatic that the
right to appeal is not a natural right or a part of due process, but a mere statutory privilege that may be exercised only in
the manner prescribed by law.[28] In this case, the clear intent of the amendment is to render the right to appeal from a
decision of the Board available to both complainants and respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No. 06-342(A), or the New Rules of
Procedure in Administrative Investigations in the Professional Regulations Commission and the Professional Regulatory Boards, which
provides for the method of appeal, to wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the Board shall be final
and executory after the lapse of fifteen (15) days from receipt of the decision, order or resolution without an appeal
being perfected or taken by either the respondent or the complainant. A party aggrieved by the decision, order
or resolution may file a notice of appeal from the decision, order or resolution of the Board to the
Commission within fifteen (15) days from receipt thereof, and serving upon the adverse party a notice of
appeal together with the appellants brief or memorandum on appeal, and paying the appeal and legal research fees.
x x x[29]
The above-stated provision does not qualify whether only the complainant or respondent may file an appeal; rather, the new
rules provide that a party aggrieved may file a notice of appeal. Thus, either the complainant or the respondent who has been
aggrieved by the decision, order or resolution of the Board may appeal to the Commission. It is an elementary rule that when the law
speaks in clear and categorical language, there is no need, in the absence of legislative intent to the contrary, for any interpretation.
[30]

Words and phrases used in the statute should be given their plain, ordinary, and common usage or meaning.[31]
Petitioner also submits that appeals from the decisions of the PRC should be with the CA, as Rule 43[32] of the Rules of Court

was precisely formulated and adopted to provide for a uniform rule of appellate procedure for quasi-judicial agencies. [33] Petitioner
further contends that a quasi-judicial body is not excluded from the purview of Rule 43 just because it is not mentioned therein.[34]

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Page 86

On this point, the Court agrees with the petitioner.


Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments or final orders of the Court of Tax
Appeals, and from awards, judgments, final orders or resolutions of or authorized by any quasijudicial agency in the exercise of its quasi-judicial functions. Among these agencies are the Civil Service
Commission, Central Board of Assessment Appeals, Securities and Exchange Commission, Office of the President,
Land Registration Authority, Social Security Commission, Civil Aeronautics Board, Bureau of Patents, Trademarks
and Technology Transfer, National Electrification Administration, Energy Regulatory Board, National
Telecommunications Commission, Department of Agrarian Reform under Republic Act No. 6657, Government
Service Insurance System, Employees Compensation Commission, Agricultural Inventions Board, Insurance
Commission, Philippine Atomic Energy Commission, Board of Investments, Construction Industry Arbitration
Commission, and voluntary arbitrators authorized by law. (Emphasis supplied)
Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly enumerated under Section 1, Rule 43 of
the Rules of Court. However, its absence from the enumeration does not, by this fact alone, imply its exclusion from the coverage of said
Rule.[35] The Rule expressly provides that it should be applied to appeals from awards, judgments final orders or resolutions of
any quasi-judicial agency in the exercise of its quasi-judicial functions. The phrase among these agencies confirms that the
enumeration made in the Rule is not exclusive to the agencies therein listed.[36]
Specifically, the Court, in Yang v. Court of Appeals,[37] ruled that Batas Pambansa (B.P.) Blg. 129[38] conferred upon the CA
exclusive appellate jurisdiction over appeals from decisions of the PRC. The Court held:
The law has since been changed, however, at least in the matter of the particular court to which appeals from
the Commission should be taken. OnAugust 14, 1981, Batas Pambansa Bilang 129 became effective and in its Section
29, conferred on the Court of Appeals exclusive appellate jurisdiction over all final judgments, decisions, resolutions,
orders or awards of Regional Trial Courts and quasi-judicial agencies, instrumentalities, boards or commissions
except those falling under the appellate jurisdiction of the Supreme Court. x x x. In virtue of BP 129, appeals
from the Professional Regulations Commission are now exclusively cognizable by the Court of
Appeals.[39] (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of Civil Procedure, [40] lodged with the CA such
jurisdiction over the appeals of decisions made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC decision for being without an expert testimony to support
its conclusion and to establish the cause of Edithas injury. Petitioner avers that in cases of medical malpractice, expert testimony is
necessary to support the conclusion as to the cause of the injury.[41]
Medical malpractice is a particular form of negligence which consists in the failure of a physician or surgeon to apply to his
practice of medicine that degree of care and skill which is ordinarily employed by the profession generally, under similar conditions, and
in like surrounding circumstances.[42] In order to successfully pursue such a claim, a patient must prove that the physician or surgeon
either failed to do something which a reasonably prudent physician or surgeon would not have done, and that the failure or action
caused injury to the patient.[43]
There are four elements involved in medical negligence cases: duty, breach, injury and proximate causation.[44]

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Page 87

A physician-patient relationship was created when Editha employed the services of the petitioner. As Edithas physician,
petitioner was duty-bound to use at least the same level of care that any reasonably competent doctor would use to treat a condition
under the same circumstances.[45] The breach of these professional duties of skill and care, or their improper performance by a physician
surgeon, whereby the patient is injured in body or in health, constitutes actionable malpractice. [46] As to this aspect of medical
malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential. [47] Further,
inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has
been recognized that expert testimony is usually necessary to support the conclusion as to causation.[48]
In the present case, respondents did not present any expert testimony to support their claim that petitioner failed to do
something which a reasonably prudent physician or surgeon would have done.

Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who was clearly an expert on the subject.
Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject matter about which he or
she is to testify, either by the study of recognized authorities on the subject or by practical experience.[49]
Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored various publications on the subject, and is a
professor at the University of the Philippines.[50] According to him, his diagnosis of Edithas case was Ectopic Pregnancy Interstitial
(also referred to asCornual), Ruptured.[51] In stating that the D&C procedure was not the proximate cause of the rupture
of Edithas uterus resulting in her hysterectomy, Dr. Manalo testified as follows:
Atty. Hidalgo:
Q:
Doctor, we want to be clarified on this matter. The complainant had testified here that the D&C was the
proximate cause of the rupture of the uterus. The condition which she found herself in on the second
admission. Will you please tell us whether that is true or not?
A:
Yah, I do not think so for two reasons. One, as I have said earlier, the instrument cannot reach the site
of the pregnancy, for it to further push the pregnancy outside the uterus. And, No. 2, I was thinking a while
ago about another reason- well, why I dont think so, because it is the triggering factor for the rupture, it could
havethe rupture could have occurred much earlier, right after the D&C or a few days after the D&C.
Q:

A:

In this particular case, doctor, the rupture occurred to have happened minutes prior to the hysterectomy or
right upon admission on September 15, 1994 which is about 1 months after the patient was discharged,
after the D&C was conducted. Would you tell us whether there is any relation at all of the D&C and the
rupture in this particular instance?
I dont think so for the two reasons that I have just mentioned- that it would not be possible
for the instrument to reach the site of pregnancy. And, No. 2, if it is because of the D&C that rupture
could have occurred earlier.[52] (Emphases supplied)

Clearly, from the testimony of the expert witness and the reasons given by him, it is evident that the D&C procedure was not the
proximate cause of the rupture of Edithas uterus.
During his cross-examination, Dr. Manalo testified on how he would have addressed Edithas condition should he be placed in
a similar circumstance as the petitioner. He stated:

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Atty. Ragonton:
Q:
Doctor, as a practicing OB-Gyne, when do you consider that you have done a good, correct and ideal
dilatation and curettage procedure?
A:
Well, if the patient recovers. If the patient gets well. Because even after the procedure, even after the
procedure you may feel that you have scraped everything, the patient stops bleeding, she feels well, I think
you should still have some reservations, and wait a little more time.
Q:
A:

If you were the OB-Gyne who performed the procedure on patient Editha Ramolete, would it be your
standard practice to check the fetal parts or fetal tissues that were allegedly removed?
From what I have removed, yes. But in this particular case, I think it was assumed that it was part of the
meaty mass which was expelled at the time she was urinating and flushed in the toilet. So theres no way.

Q:
A:

There was [sic] some portions of the fetal parts that were removed?
No, it was described as scanty scraping if I remember it rightscanty.

Q:
A:

And you would not mind checking those scant or those little parts that were removed?
Well, the fact that it was described means, I assume that it was checked, no. It was described as
scanty and the color also, I think was described. Because it would be very unusual, even
improbable that it would not be examined, because when you scrape, the specimens are
right there before your eyes. Its in front of you. You can touch it. In fact, some of them will
stick to the instrument and therefore to peel it off from the instrument, you have to touch
them. So, automatically they are examined closely.
As a matter of fact, doctor, you also give telephone orders to your patients through telephone?
Yes, yes, we do that, especially here in Manila because you know, sometimes a doctor can also be tied-up
somewhere and if you have to wait until he arrive at a certain place before you give the order, then it would be
a lot of time wasted. Because if you know your patient, if you have handled your patient, some of the
symptoms you can interpret that comes with practice. And, I see no reason for not allowing
telephone orders unless it is the first time that you will be encountering the patient. That you
have no idea what the problem is.

Q:
A:

Q:
A:

But, doctor, do you discharge patients without seeing them?


Sometimes yes, depending on how familiar I am with the patient. We are on the question of telephone
orders. I am not saying that that is the idle [sic] thing to do, but I think the reality of present day
practice somehow justifies telephone orders. I have patients whom I have justified and then all of a
sudden, late in the afternoon or late in the evening, would suddenly call they have decided that they will go
home inasmuch as they anticipated that I will discharge them the following day. So, I just call and ask our
resident on duty or the nurse to allow them to go because I have seen that patient and I think I have full grasp
of her problems. So, thats when I make this telephone orders. And, of course before giving that order I ask
about how she feels.[53] (Emphases supplied)

From the foregoing testimony, it is clear that the D&C procedure was conducted in accordance with the standard practice, with
the same level of care that any reasonably competent doctor would use to treat a condition under the same circumstances, and that there
was nothing irregular in the way the petitioner dealt with Editha.
Medical malpractice, in our jurisdiction, is often brought as a civil action for damages under Article 2176 [54] of the Civil
Code. The defenses in an action for damages, provided for under Article 2179 of the Civil Code are:
Art. 2179. When the plaintiffs own negligence was the immediate and proximate cause of his
injury, he cannot recover damages. But if his negligence was only contributory, the immediate and proximate
cause of the injury being the defendants lack of due care, the plaintiff may recover damages, but the courts shall
mitigate the damages to be awarded.
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient intervening
cause, produces injury, and without which the result would not have occurred. [55] An injury or damage is proximately caused by an act or
a failure to act, whenever it appears from the evidence in the case that the act or omission played a substantial part in bringing about or

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actually causing the injury or damage; and that the injury or damage was either a direct result or a reasonably probable consequence of
the act or omission.[56]
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994, herein respondent advised her to return
on August 4, 1994 or four (4) days after the D&C. This advise was clear in complainants Discharge
Sheet. However, complainant failed to do so. This being the case, the chain of continuity as required in order
that the doctrine of proximate cause can be validly invoked was interrupted. Had she returned, the respondent
could have examined her thoroughly.[57] x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that there was in fact a misdiagnosis, the same would
have been rectified if Editha followed the petitioners order to return for a check-up on August 4, 1994. Dr. Manalo stated:
Granting that the obstetrician-gynecologist has been misled (justifiably) up to thus point
that there would have been ample opportunity to rectify the misdiagnosis, had the patient returned,
as instructed for her follow-up evaluation. It was one and a half months later that the patient sought
consultation with another doctor. The continued growth of an ectopic pregnancy, until its eventual rupture, is a
dynamic process. Much change in physical findings could be expected in 1 months, including the emergence of
suggestive ones.[58]
It is undisputed that Editha did not return for a follow-up evaluation, in defiance of the petitioners advise. Editha omitted the
diligence required by the circumstances which could have avoided the injury. The omission in not returning for a follow-up evaluation
played a substantial part in bringing about Edithas own injury. Had Editha returned, petitioner could have conducted the proper
medical tests and procedure necessary to determine Edithas health condition and applied the corresponding treatment which could
have prevented the rupture of Edithasuterus. The D&C procedure having been conducted in accordance with the standard medical
practice, it is clear that Edithas omission was the proximate cause of her own injury and not merely a contributory negligence on her
part.
Contributory negligence is the act or omission amounting to want of ordinary care on the part of the person injured, which,
concurring with the defendants negligence, is the proximate cause of the injury.[59] Difficulty seems to be apprehended in deciding which
acts of the injured party shall be considered immediate causes of the accident. [60] Where the immediate cause of an accident resulting in
an injury is the plaintiffs own act, which contributed to the principal occurrence as one of its determining factors, he cannot recover
damages for the injury.[61] Again, based on the evidence presented in the present case under review, in which no
negligence can be attributed to the petitioner, the immediate cause of the accident resulting in Edithas injury was
her own omission when she did not return for a follow-up check up, in defiance of petitioners orders. The
immediate cause of Edithas injury was her own act; thus, she cannot recover damages from the injury.
Lastly, petitioner asserts that her right to due process was violated because she was never informed by either respondents or by
the PRC that an appeal was pending before the PRC. [62] Petitioner claims that a verification with the records section of the PRC revealed
that on April 15, 1999, respondents filed a Memorandum on Appeal before the PRC, which did not attach the actual registry receipt but
was merely indicated therein.[63]
Respondents, on the other hand avers that if the original registry receipt was not attached to the Memorandum on Appeal, PRC
would not have entertained the appeal or accepted such pleading for lack of notice or proof of service on the other party. [64] Also, the

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registry receipt could not be appended to the copy furnished to petitioners former counsel, because the registry receipt was already
appended to the original copy of the Memorandum of Appeal filed with PRC.[65]
It is a well-settled rule that when service of notice is an issue, the rule is that the person alleging that the notice was served must
prove the fact of service. The burden of proving notice rests upon the party asserting its existence. [66] In the present case, respondents
did not present any proof that petitioner was served a copy of the Memorandum on Appeal. Thus, respondents were not able to satisfy
the burden of proving that they had in fact informed the petitioner of the appeal proceedings before the PRC.
In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,[67] in which the National Labor Relations
Commission failed to order the private respondent to furnish the petitioner a copy of the Appeal Memorandum, the Court held that said
failure deprived the petitioner of procedural due process guaranteed by the Constitution, which could have served as basis for the
nullification of the proceedings in the appeal. The same holds true in the case at bar. The Court finds that the failure of the respondents
to furnish the petitioner a copy of the Memorandum of Appeal submitted to the PRC constitutes a violation of due process. Thus, the
proceedings before the PRC were null and void.
All told, doctors are protected by a special rule of law. They are not guarantors of care. They are not insurers against mishaps or
unusual consequences[68] specially so if the patient herself did not exercise the proper diligence required to avoid the injury.
WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of Appeals dated July 4, 2003 in CA-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.

PETER PAUL PATRICK LUCAS, FATIMA


GLADYS LUCAS, ABBEYGAIL LUCAS
AND GILLIAN LUCAS,
Petitioners,

- versus -

DR. PROSPERO MA. C. TUAO,


Respondent.

G. R. No. 178763
Present:
YNARES-SANTIAGO, J.,
Chairperson,
AUSTRIA-MARTINEZ,
CHICO-NAZARIO,
NACHURA, and
PERALTA, JJ.

Promulgated:

April 21, 2009


x--------------------------------------------------x
DECISION
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CHICO-NAZARIO, J.
In this petition for review on certiorari[1] under Rule 45 of the Revised Rules of Court, petitioners Peter Paul
Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas seek the reversal of the 27 September
2006 Decision[2] and 3 July 2007Resolution,[3] both of the Court of Appeals in CA-G.R. CV No. 68666, entitled Peter
Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C. Tuao.
In the questioned decision and resolution, the Court of Appeals affirmed the 14 July 2000 Decision of the
Regional Trial Court (RTC), Branch 150, Makati City, dismissing the complaint filed by petitioners in a civil case
entitled, Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C.
Tuao, docketed as Civil Case No. 92-2482.
From the record of the case, the established factual antecedents of the present petition are:
Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter) contracted sore eyes in his right eye.
On 2 September 1988, complaining of a red right eye and swollen eyelid, Peter made use of his health care
insurance issued by Philamcare Health Systems, Inc. (Philamcare), for a possible consult. The Philamcare Coordinator,
Dr. Edwin Oca, M.D., referred Peter to respondent, Dr. Prospero Ma. C. Tuao, M.D. (Dr. Tuao), an ophthalmologist at
St. Lukes Medical Center, for an eye consult.
Upon consultation with Dr. Tuao, Peter narrated that it had been nine (9) days since the problem with his right
eye began; and that he was already taking Maxitrol to address the problem in his eye. According to Dr. Tuao, he
performed ocular routine examination on Peters eyes, wherein: (1) a gross examination of Peters eyes and their
surrounding area was made; (2) Peters visual acuity were taken; (3) Peters eyes were palpated to check the intraocular
pressure of each; (4) the motility of Peters eyes was observed; and (5) the ophthalmoscopy [4] on Peters eyes was used. On
that particular consultation, Dr. Tuao diagnosed that Peter was suffering from conjunctivitis[5] or sore eyes. Dr. Tuao
then prescribed Spersacet-C[6] eye drops for Peter and told the latter to return for follow-up after one week.
As instructed, Peter went back to Dr. Tuao on 9 September 1988. Upon examination, Dr. Tuao told Peter that
the sore eyes in the latters right eye had already cleared up and he could discontinue the Spersacet-C. However, the
same eye developedEpidemic Kerato Conjunctivitis (EKC),[7] a viral infection. To address the new problem with Peters
right eye, Dr. Tuao prescribed to the former a steroid-based eye drop called Maxitrol,[8] a dosage of six (6) drops per
day.[9] To recall, Peter had already been using Maxitrol prior to his consult with Dr. Tuao.
On 21 September 1988, Peter saw Dr. Tuao for a follow-up consultation. After examining both of Peters eyes,
Dr. Tuao instructed the former to taper down [10] the dosage of Maxitrol, because the EKC in his right eye had already
resolved. Dr. Tuao specifically cautioned Peter that, being a steroid, Maxitrol had to be withdrawn gradually; otherwise,
the EKC might recur.[11]

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Complaining of feeling as if there was something in his eyes, Peter returned to Dr. Tuao for another check-up
on 6 October 1988. Dr. Tuao examined Peters eyes and found that the right eye had once more developed EKC . So, Dr.
Tuao instructed Peter to resume the use of Maxitrol at six (6) drops per day.
On his way home, Peter was unable to get a hold of Maxitrol, as it was out of stock. Consequently, Peter was told
by Dr. Tuano to take, instead, Blephamide[12] another steroid-based medication, but with a lower concentration, as
substitute for the unavailable Maxitrol, to be used three (3) times a day for five (5) days; two (2) times a day for five (5)
days; and then just once a day.[13]
Several days later, on 18 October 1988, Peter went to see Dr. Tuao at his clinic, alleging severe eye pain, feeling
as if his eyes were about to pop-out, a headache and blurred vision. Dr. Tuao examined Peters eyes and discovered
that the EKC was again present in his right eye. As a result, Dr. Tuao told Peter to resume the maximum dosage
of Blephamide.
Dr. Tuao saw Peter once more at the formers clinic on 4 November 1988. Dr. Tuaos examination showed that
only the periphery of Peters right eye was positive for EKC; hence, Dr. Tuao prescribed a lower dosage of Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peters spouse, read the accompanying literature
of Maxitroland found therein the following warning against the prolonged use of such steroids:
WARNING:
Prolonged use may result in glaucoma, with damage to the optic nerve, defects in visual acuity
and fields of vision, and posterior, subcapsular cataract formation. Prolonged use may suppress the host
response and thus increase the hazard of secondary ocular infractions, in those diseases causing thinning
of the cornea or sclera, perforations have been known to occur with the use of topical steroids. In acute
purulent conditions of the eye, steroids may mask infection or enhance existing infection. If these
products are used for 10 days or longer, intraocular pressure should be routinely monitored even though
it may be difficult in children and uncooperative patients.
Employment of steroid medication in the treatment of herpes simplex requires great caution.
xxxx
ADVERSE REACTIONS:
Adverse reactions have occurred with steroid/anti-infective combination drugs which can be
attributed to the steroid component, the anti-infective component, or the combination. Exact incidence
figures are not available since no denominator of treated patients is available.
Reactions occurring most often from the presence of the anti-infective ingredients are allergic
sensitizations. The reactions due to the steroid component in decreasing order to frequency are elevation
of intra-ocular pressure (IOP) with possible development of glaucoma, infrequent optic nerve damage;
posterior subcapsular cataract formation; and delayed wound healing.
Secondary infection: The development of secondary has occurred after use of combination
containing steroids and antimicrobials. Fungal infections of the correa are particularly prone to develop
coincidentally with long-term applications of steroid. The possibility of fungal invasion must be
considered in any persistent corneal ulceration where steroid treatment has been used.

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Secondary bacterial ocular infection following suppression of host responses also occurs.

On 26 November 1988, Peter returned to Dr. Tuaos clinic, complaining of feeling worse. [14] It appeared that
the EKC had spread to the whole of Peters right eye yet again. Thus, Dr. Tuao instructed Peter to resume the use
of Maxitrol. Petitioners averred that Peter already made mention to Dr. Tuao during said visit of the above-quoted
warning against the prolonged use of steroids, but Dr. Tuao supposedly brushed aside Peters concern as mere paranoia,
even assuring him that the former was taking care of him (Peter).
Petitioners further alleged that after Peters 26 November 1988 visit to Dr. Tuao, Peter continued to suffer pain
in his right eye, which seemed to progress, with the ache intensifying and becoming more frequent.
Upon waking in the morning of 13 December 1988, Peter had no vision in his right eye. Fatima observed that
Peters right eye appeared to be bloody and swollen. [15] Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuao.
Peter reported to Dr. Tuao that he had been suffering from constant headache in the afternoon and blurring of vision.
Upon examination, Dr. Tuao noted the hardness of Peters right eye. With the use of a tonometer[16] to verify the
exactintraocular pressure[17] (IOP) of Peters eyes, Dr. Tuao discovered that the tension in Peters right eye was 39.0
Hg, while that of his left was 17.0 Hg. [18] Since the tension in Peters right eye was way over the normal IOP, which
merely ranged from 10.0 Hg to 21.0 Hg,[19] Dr. Tuao ordered[20] him to immediately discontinue the use
of Maxitrol and prescribed to the latter Diamox[21]and Normoglaucon, instead.[22] Dr. Tuao also required Peter to go for
daily check-up in order for the former to closely monitor the pressure of the latters eyes.
On 15 December 1988, the tonometer reading of Peters right eye yielded a high normal level, i.e., 21.0
Hg. Hence, Dr. Tuao told Peter to continue using Diamox and Normoglaucon. But upon Peters complaint of stomach
pains and tingling sensation in his fingers,[23] Dr. Tuao discontinued Peters use of Diamox.[24]
Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal (Dr. Batungbacal), on 21 December 1988,
who allegedly conducted a complete ophthalmological examination of Peters eyes. Dr. Batungbacals diagnosis
was Glaucoma[25] O.D.[26] He recommended Laser Trabeculoplasty[27] for Peters right eye.
When Peter returned to Dr. Tuao on 23 December 1988,[28] the tonometer measured the IOP of Peters right eye
to be 41.0 Hg,[29] again, way above normal. Dr. Tuao addressed the problem by advising Peter to resume
taking Diamox along withNormoglaucon.
During the Christmas holidays, Peter supposedly stayed in bed most of the time and was not able to celebrate the
season with his family because of the debilitating effects of Diamox.[30]
On 28 December 1988, during one of Peters regular follow-ups with Dr. Tuao, the doctor conducted another
ocular routine examination of Peters eyes. Dr. Tuao noted the recurrence of EKC in Peters right eye. Considering,
however, that the IOP of Peters right eye was still quite high at 41.0 Hg, Dr. Tuao was at a loss as to how to balance the

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treatment of Peters EKC vis--visthe presence of glaucoma in the same eye. Dr. Tuao, thus, referred Peter to Dr.
Manuel B. Agulto, M.D. (Dr. Agulto), another ophthalmologist specializing in the treatment of glaucoma. [31] Dr. Tuaos
letter of referral to Dr. Agulto stated that:
Referring to you Mr. Peter Lucas for evaluation & possible management. I initially saw him Sept.
2, 1988 because of conjunctivitis. The latter resolved and he developed EKC for which I gave Maxitrol.
The EKC was recurrent after stopping steroid drops. Around 1 month of steroid treatment, he noted
blurring of vision & pain on the R. however, I continued the steroids for the sake of the EKC. A month
ago, I noted iris atrophy, so I took the IOP and it was definitely elevated. I stopped the steroids
immediately and has (sic) been treating him medically.
It seems that the IOP can be controlled only with oral Diamox, and at the moment, the EKC has
recurred and Im in a fix whether to resume the steroid or not considering that the IOP is still
uncontrolled.[32]

On 29 December 1988, Peter went to see Dr. Agulto at the latters clinic. Several tests were conducted thereat to
evaluate the extent of Peters condition. Dr. Agulto wrote Dr. Tuao a letter containing the following findings and
recommendations:
Thanks for sending Peter Lucas. On examination conducted vision was 20/25 R and 20/20L.
Tension curve 19 R and 15 L at 1210 H while on Normoglaucon BID OD & Diamox tab every 6h po.
Slit lamp evaluation[33] disclosed subepithelial corneal defect outer OD. There
circumferential peripheral iris atrophy, OD. The lenses were clear.
Funduscopy[34] showed vertical cup disc of 0.85 R and 0.6 L with temporal slope R>L.

was

Zeiss gonioscopy[35] revealed basically open angles both eyes with occasional PAS,[36] OD.
Rolly, I feel that Peter Lucas has really sustained significant glaucoma damage. I suggest that we
do a baseline visual fields and push medication to lowest possible levels. If I may suggest further, I think
we should prescribe Timolol[37] BID[38] OD in lieu of Normoglaucon. If the IOP is still inadequate, we may
try Depifrin[39] BID OD (despite low PAS). Im in favor of retaining Diamox or similar CAI. [40]
If fields show further loss in say 3 mos. then we should consider trabeculoplasty.
I trust that this approach will prove reasonable for you and Peter.[41]

Peter went to see Dr. Tuao on 31 December 1988, bearing Dr. Agultos aforementioned letter. Though Peters
right and left eyes then had normal IOP of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuao still gave him a prescription
for Timolol B.I.D. so Peter could immediately start using said medication. Regrettably, Timolol B.I.D. was out of stock, so
Dr. Tuao instructed Peter to just continue using Diamox and Normoglaucon in the meantime.
Just two days later, on 2 January 1989, the IOP of Peters right eye remained elevated at 21.0 Hg,[42] as he had
been withoutDiamox for the past three (3) days.

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On 4 January 1989, Dr. Tuao conducted a visual field study[43] of Peters eyes, which revealed that the latter
had tubularvision[44] in his right eye, while that of his left eye remained normal. Dr. Tuao directed Peter to religiously
use the Diamox andNormoglaucon, as the tension of the latters right eye went up even further to 41.0 Hg in just a
matter of two (2) days, in the meantime that Timolol B.I.D. and Depifrin were still not available in the market. Again, Dr.
Tuao advised Peter to come for regular check-up so his IOP could be monitored.
Obediently, Peter went to see Dr. Tuao on the 7 th, 13th, 16th and 20th of January 1989 for check-up and IOP
monitoring.
In the interregnum, however, Peter was prodded by his friends to seek a second medical opinion. On 13 January
1989, Peter consulted Dr. Jaime Lapuz, M.D. (Dr. Lapuz), an ophthalmologist, who, in turn, referred Peter to Dr. Mario
V. Aquino, M.D. (Dr. Aquino), another ophthalmologist who specializes in the treatment of glaucoma and who could
undertake the long term care of Peters eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation of Peters eyes, the said doctor
informed Peter that his eyes were relatively normal, though the right one sometimes manifested maximum borderline
tension. Dr. Aquino also confirmed Dr. Tuaos diagnosis of tubular vision in Peters right eye. Petitioners claimed that
Dr. Aquino essentially told Peter that the latters condition would require lifetime medication and follow-ups.
In May 1990 and June 1991, Peter underwent two (2) procedures of laser trabeculoplasty to attempt to control
the high IOP of his right eye.
Claiming to have steroid-induced glaucoma[45] and blaming Dr. Tuao for the same, Peter, joined by: (1) Fatima,
his spouse[46]; (2) Abbeygail, his natural child [47]; and (3) Gillian, his legitimate child [48] with Fatima, instituted on 1
September 1992, a civil complaint for damages against Dr. Tuao, before the RTC, Branch 150, Quezon City. The case was
docketed as Civil Case No. 92-2482.
In their Complaint, petitioners specifically averred that as the direct consequence of [Peters] prolonged use
of Maxitrol, [he] suffered from steroid induced glaucoma which caused the elevation of his intra-ocular pressure. The
elevation of the intra-ocular pressure of [Peters right eye] caused the impairment of his vision which impairment is not
curable and may even lead to total blindness. [49]
Petitioners additionally alleged that the visual impairment of Peters right eye caused him and his family so much
grief. Because of his present condition, Peter now needed close medical supervision forever; he had already
undergone two (2) laser surgeries, with the possibility that more surgeries were still needed in the future; his career in
sports casting had suffered and was continuing to suffer; [50] his anticipated income had been greatly reduced as a result of
his limited capacity; he continually suffered from headaches, nausea, dizziness, heart palpitations, rashes, chronic
rhinitis, sinusitis,[51] etc.; Peters relationships with his spouse and children continued to be strained, as his condition
made him highly irritable and sensitive; his mobility and social life had suffered; his spouse, Fatima, became the

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breadwinner in the family;[52] and his two children had been deprived of the opportunity for a better life and educational
prospects. Collectively, petitioners lived in constant fear of Peter becoming completely blind. [53]
In the end, petitioners sought pecuniary award for their supposed pain and suffering, which were ultimately
brought about byDr. Tuaos grossly negligent conduct in prescribing to Peter the medicine Maxitrol for a period of three
(3) months, without monitoring Peters IOP, as required in cases of prolonged use of said medicine, and notwithstanding
Peters constant complaint of intense eye pain while using the same. Petitioners particularly prayed that Dr. Tuao be
adjudged liable for the following amounts:
1.
The amount of P2,000,000.00 to plaintiff Peter Lucas as
of compensation for his impaired vision.

and by way

2.
The amount of P300,000.00 to spouses Lucas as and by
actual damages plus such additional amounts that
may be proven during trial.

way of

3.

The amount of P1,000,000.00 as and by way of moral

damages.

4.

The amount of P500,000.00 as and by way of exemplary

damages.

5.
costs of suit.[54]

The amount of P200,000.00 as and by way of attorneys

fees plus

In rebutting petitioners complaint, Dr. Tuao asserted that the treatment made by [him] more than three years
ago has no causal connection to [Peters] present glaucoma or condition. [55] Dr. Tuao explained that [d]rug-induced
glaucoma is temporary and curable, steroids have the side effect of increasing intraocular pressure. Steroids are
prescribed to treat Epidemic Kerato Conjunctivitis or EKC which is an infiltration of the cornea as a result of
conjunctivitis or sore eyes.[56] Dr. Tuao also clarified that (1) [c]ontrary to [petitioners] fallacious claim, [he] did NOT
continually prescribe the drug Maxitrol which contained steroids for any prolonged period [57] and [t]he truth was the
Maxitrol was discontinued x x x as soon as EKC disappeared and was resumed only when EKC reappeared [58]; (2) the
entire time he was treating Peter, he continually monitored the intraocular pressure of [Peters eyes] by palpating the
eyes and by putting pressure on the eyeballs, and no hardening of the same could be detected, which meant that there
was no increase in the tension or IOP, a possible side reaction to the use of steroid medications; and (3) it was only on 13
December 1988 that Peter complained of a headache and blurred vision in his right eye, and upon measuring the IOP of
said eye, it was determined for the first time that the IOP of the right eye had an elevated value.
But granting for the sake of argument that the steroid treatment of [Peters] EKC caused the steroid induced
glaucoma,[59]Dr. Tuao argued that:
[S]uch condition, i.e., elevated intraocular pressure, is temporary. As soon as the intake of steroids is
discontinued, the intraocular pressure automatically is reduced. Thus, [Peters] glaucoma can only be
due to other causes not attributable to steroids, certainly not attributable to [his] treatment of more than
three years ago x x x.

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From a medical point of view, as revealed by more current examination of [Peter], the latters
glaucoma can only be long standing glaucoma, open angle glaucoma, because of the large C:D ratio. The
steroids provoked the latest glaucoma to be revealed earlier as [Peter] remained asymptomatic prior to
steroid application. Hence, the steroid treatment was in fact beneficial to [Peter] as it revealed the
incipient open angle glaucoma of [Peter] to allow earlier treatment of the same. [60]

In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-2482 for insufficiency of
evidence.[61] The decretal part of said Decision reads:
Wherefore, premises considered, the instant complaint is dismissed for insufficiency of evidence.
The counter claim (sic) is likewise dismissed in the absence of bad faith or malice on the part of plaintiff
in filing the suit.[62]

The RTC opined that petitioners failed to prove by preponderance of evidence that Dr. Tuao was negligent in his
treatment of Peters condition. In particular, the record of the case was bereft of any evidence to establish that the steroid
medication and its dosage, as prescribed by Dr. Tuao, caused Peters glaucoma. The trial court reasoned that the
recognized standards of the medical community has not been established in this case, much less has causation been
established to render [Tuao] liable.[63] According to the RTC:
[Petitioners] failed to establish the duty required of a medical practitioner against which Peter
Pauls treatment by defendant can be compared with. They did not present any medical expert or even a
medical doctor to convince and expertly explain to the court the established norm or duty required of a
physician treating a patient, or whether the non taking (sic) by Dr. Tuao of Peter Pauls pressure a
deviation from the norm or his non-discovery of the glaucoma in the course of treatment constitutes
negligence. It is important and indispensable to establish such a standard because once it is established,
a medical practitioner who departed thereof breaches his duty and commits negligence rendering him
liable. Without such testimony or enlightenment from an expert, the court is at a loss as to what is then
the established norm of duty of a physician against which defendants conduct can be compared with to
determine negligence.[64]

The RTC added that in the absence of any medical evidence to the contrary, this court cannot accept [petitioners]
claim that the use of steroid is the proximate cause of the damage sustained by [Peters] eye. [65]
Correspondingly, the RTC accepted Dr. Tuaos medical opinion that Peter Paul must have been suffering from
normal tension glaucoma, meaning, optic nerve damage was happening but no elevation of the eye pressure is
manifested, that the steroid treatment actually unmasked the condition that resulted in the earlier treatment of the
glaucoma. There is nothing in the record to contradict such testimony. In fact, plaintiffs Exhibit S even tends to support
them.
Undaunted, petitioners appealed the foregoing RTC decision to the Court of Appeals. Their appeal was docketed
as CA-G.R. CV No. 68666.

Reyes, Hazel

Page 98

On 27 September 2006, the Court of Appeals rendered a decision in CA-G.R. CV No. 68666 denying petitioners
recourse and affirming the appealed RTC Decision. The fallo of the judgment of the appellate court states:
WHEREFORE, the Decision appealed from is AFFIRMED.[66]

The Court of Appeals faulted petitioners because they


[D]id not present any medical expert to testify that Dr. Tuanos prescription of Maxitrol and Blephamide
for the treatment of EKC on Peters right eye was not proper and that his palpation of Peters right eye
was not enough to detect adverse reaction to steroid. Peter testified that Dr. Manuel Agulto told him that
he should not have used steroid for the treatment of EKC or that he should have used it only for two (2)
weeks, as EKC is only a viral infection which will cure by itself. However, Dr. Agulto was not presented by
[petitioners] as a witness to confirm what he allegedly told Peter and, therefore, the latters testimony is
hearsay. Under Rule 130, Section 36 of the Rules of Court, a witness can testify only to those facts which
he knows of his own personal knowledge, x x x. Familiar and fundamental is the rule that hearsay
testimony is inadmissible as evidence.[67]

Like the RTC, the Court of Appeals gave great weight to Dr. Tuaos medical judgment, specifically the latters
explanation that:
[W]hen a doctor sees a patient, he cannot determine whether or not the latter would react adversely to
the use of steroids, that it was only on December 13, 1989, when Peter complained for the first time of
headache and blurred vision that he observed that the pressure of the eye of Peter was elevated, and it
was only then that he suspected that Peter belongs to the 5% of the population who reacts adversely to
steroids.[68]

Petitioners Motion for Reconsideration was denied by the Court of Appeals in a Resolution dated 3 July 2007.
Hence, this Petition for Review on Certiorari under Rule 45 of the Revised Rules of Court premised on the
following assignment of errors:
I.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN AFFIRMING THE
DECISION OF THE TRIAL COURT DISMISSING THE PETITIONERS COMPLAINT FOR DAMAGES
AGAINST THE RESPONDENT ON THE GROUND OF INSUFFICIENCY OF EVIDENCE;
II.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN DISMISSING THE
PETITIONERS COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT ON THE GROUND
THAT NO MEDICAL EXPERT WAS PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM
FOR MEDICAL NEGLIGENCE AGAINST THE RESPONDENT; AND
III.

Reyes, Hazel

Page 99

THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN NOT FINDING THE
RESPONDENT LIABLE TO THE PETITIONERS FOR ACTUAL, MORAL AND EXEMPLARY
DAMAGES, ASIDE FROM ATTORNEYS FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS
NEGLIGENCE.[69]

A reading of the afore-quoted reversible errors supposedly committed by the Court of Appeals in
its Decision and Resolutionwould reveal that petitioners are fundamentally assailing the finding of the Court of Appeals
that the evidence on record is insufficient to establish petitioners entitlement to any kind of damage. Therefore, it could
be said that the sole issue for our resolution in the Petition at bar is whether the Court of Appeals committed reversible
error in affirming the judgment of the RTC that petitioners failed to prove, by preponderance of evidence, their claim for
damages against Dr. Tuao.
Evidently, said issue constitutes a question 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 would have us sift through the evidence on record and pass
upon whether there is sufficient basis to establish Dr. Tuaos negligence in his treatment of Peters eye condition. This
question clearly involves a factual inquiry, the determination of which is not within the ambit of this Courts power of
review under Rule 45 of the 1997 Rules Civil Procedure, as amended. [70]
Elementary is the principle that this Court is not a trier of facts; only errors of law are generally reviewed in
petitions for review on certiorari criticizing decisions of the Court of Appeals. Questions of fact are not entertained. [71]
Nonetheless, the general rule that only questions of law may be raised on appeal in a petition for review under
Rule 45 of the Rules of Court admits of certain exceptions, including the circumstance when the finding of fact of the
Court of Appeals is premised on the supposed absence of evidence, but is contradicted by the evidence on record.
Although petitioners may not explicitly invoke said exception, it may be gleaned from their allegations and arguments in
the instant Petition.
Petitioners contend, that [c]ontrary to the findings of the Honorable Court of Appeals, [they] were more than
able to establish that: Dr. Tuao ignored the standard medical procedure for ophthalmologists, administered medication
with recklessness, and exhibited an absence of competence and skills expected from him. [72] Petitioners reject the
necessity of presenting expert and/or medical testimony to establish (1) the standard of care respecting the treatment of
the disorder affecting Peters eye; and (2) whether or not negligence attended Dr. Tuaos treatment of Peter, because, in
their words
That Dr. Tuao was grossly negligent in the treatment of Peters simple eye ailment is a simple
case of cause and effect. With mere documentary evidence and based on the facts presented by the
petitioners, respondent can readily be held liable for damages even without any expert testimony. In any
case, however, and contrary to the finding of the trial court and the Court of Appeals, there was a medical
expert presented by the petitioner showing the recklessness committed by [Dr. Tuao] Dr. Tuao
himself. [Emphasis supplied.]

Reyes, Hazel

Page 100

They insist that Dr. Tuao himself gave sufficient evidence to establish his gross negligence that ultimately
caused the impairment of the vision of Peters right eye, [73] i.e., that [d]espite [Dr. Tuaos] knowledge that 5% of the
population reacts adversely to Maxitrol, [he] had no qualms whatsoever in prescribing said steroid to Peter without first
determining whether or not the (sic) Peter belongs to the 5%.[74]
We are not convinced. The judgments of both the Court of Appeals and the RTC are in accord with the evidence
on record, and we are accordingly bound by the findings of fact made therein.
Petitioners position, in sum, is that Peters glaucoma is the direct result of Dr. Tuaos negligence in his
improper administration of the drug Maxitrol; thus, [the latter] should be liable for all the damages suffered and to be
suffered by [petitioners].[75] Clearly, the present controversy is a classic illustration of a medical negligence case against a
physician based on the latters professional negligence. In this type of suit, the patient or his heirs, in order to prevail, is
required to prove by preponderance of evidence that the physician failed to exercise that degree of skill, care, and
learning possessed by other persons in the same profession; and that as a proximate result of such failure, the patient or
his heirs suffered damages.

For lack of a specific law geared towards the type of negligence committed by members of the medical profession,
such claim for damages is almost always anchored on the alleged violation of Article 2176 of the Civil Code, which states
that:
ART. 2176. Whoever by act or omission causes damage to another, there being fault or
negligence, is obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing
contractual relation between the parties, is called a quasi-delict and is governed by the provisions of this
Chapter.

In medical negligence cases, also called medical malpractice suits, there exist a physician-patient relationship
between the doctor and the victim. But just like any other proceeding for damages, four essential (4) elements i.e., (1)
duty; (2) breach; (3) injury; and (4) proximate causation, [76] must be established by the plaintiff/s. All the four (4)
elements must co-exist in order to find the physician negligent and, thus, liable for damages.

When a patient engages the services of a physician, a physician-patient relationship is generated. And in
accepting a case, the physician, for all intents and purposes, represents that he has the needed training and skill
possessed by physicians and surgeons practicing in the same field; and that he will employ such training, care, and skill
in the treatment of the patient.[77] Thus, in treating his patient, a physician is under a duty to [the former] to exercise that
degree of care, skill and diligence which physicians in the same general neighborhood and in the same general line of
practice ordinarily possess and exercise in like cases. [78] Stated otherwise, the physician has the duty to use at least the
same level of care that any other reasonably competent physician would use to treat the condition under similar
circumstances.

Reyes, Hazel

Page 101

This standard level of care, skill and diligence is a matter best addressed by expert medical testimony, because
the standard of care in a medical malpractice case is a matter peculiarly within the knowledge of experts in the field. [79]
There is breach of duty of care, skill and diligence, or the improper performance of such duty, by the attending
physician when the patient is injured in body or in health [and this] constitutes the actionable malpractice. [80] Proof of
such breach must likewise rest upon the testimony of an expert witness that the treatment accorded to the patient failed
to meet the standard level of care, skill and diligence which physicians in the same general neighborhood and in the same
general line of practice ordinarily possess and exercise in like cases.
Even so, proof of breach of duty on the part of the attending physician is insufficient, for there must be a causal
connection between said breach and the resulting injury sustained by the patient. Put in another way, in order that there
may be a recovery for an injury, it must be shown that the injury for which recovery is sought must be the legitimate
consequence of the wrong done; the connection between the negligence and the injury must be a direct and natural
sequence of events, unbroken by intervening efficient causes; [81] that is, the negligence must be the proximate
cause of the injury. And the proximate cause of an injury is that cause, which, in the natural and continuous sequence,
unbroken by any efficient intervening cause, produces the injury, and without which the result would not have occurred.
[82]

Just as with the elements of duty and breach of the same, in order to establish the proximate cause [of the injury]
by a preponderance of the evidence in a medical malpractice action, [the patient] must similarly use expert testimony,
because the question of whether the alleged professional negligence caused [the patients] injury is generally one for
specialized expert knowledge beyond the ken of the average layperson; using the specialized knowledge and training of
his field, the experts role is to present to the [court] a realistic assessment of the likelihood that [the physicians] alleged
negligence caused [the patients] injury.[83]
From the foregoing, it is apparent that medical negligence cases are best proved by opinions of expert witnesses
belonging in the same general neighborhood and in the same general line of practice as defendant physician or surgeon.
The deference of courts to the expert opinion of qualified physicians [or surgeons] stems from the formers realization
that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating;
[84]

hence, the indispensability of expert testimonies.


In the case at bar, there is no question that a physician-patient relationship developed between Dr. Tuao and

Peter when Peter went to see the doctor on 2 September 1988, seeking a consult for the treatment of his sore eyes.
Admittedly, Dr. Tuao, an ophthalmologist, prescribed Maxitrol when Peter developed and had recurrent
EKC. Maxitrol or neomycin/polymyxin B sulfates/dexamethasone ophthalmic ointment is a multiple-dose anti-infective
steroid combination in sterile form for topical application. [85] It is the drug which petitioners claim to have caused Peters
glaucoma.

Reyes, Hazel

Page 102

However, as correctly pointed out by the Court of Appeals, [t]he onus probandi was on the patient to establish
before the trial court that the physicians ignored standard medical procedure, prescribed and administered medication
with recklessness and exhibited an absence of the competence and skills expected of general practitioners similarly
situated.[86] Unfortunately, in this case, there was absolute failure on the part of petitioners to present any expert
testimony to establish: (1) the standard of care to be implemented by competent physicians in treating the same
condition as Peters under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuao failed in his duty to
exercise said standard of care that any other competent physician would use in treating the same condition as Peters
under similar circumstances; and (3) that the injury or damage to Peters right eye, i.e., his glaucoma, was the result of
his use of Maxitrol, as prescribed by Dr. Tuao. Petitioners failure to prove the first element alone is already fatal to
their cause.
Petitioners maintain that Dr. Tuao failed to follow in Peters case the required procedure for the prolonged use
of Maxitrol. But what is actually the required procedure in situations such as in the case at bar? To be precise, what is the
standard operating procedure when ophthalmologists prescribe steroid medications which, admittedly, carry some
modicum of risk?
Absent a definitive standard of care or diligence required of Dr. Tuao under the circumstances, we have no
means to determine whether he was able to comply with the same in his diagnosis and treatment of Peter. This Court has
no yardstick upon which to evaluate or weigh the attendant facts of this case to be able to state with confidence that the
acts complained of, indeed, constituted negligence and, thus, should be the subject of pecuniary reparation.
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuao should have determined first whether Peter was a
steroid responder.[87] Yet again, petitioners did not present any convincing proof that such determination is actually
part of the standard operating procedure which ophthalmologists should unerringly follow prior to prescribing steroid
medications.
In contrast, Dr. Tuao was able to clearly explain that what is only required of ophthalmologists, in cases such as
Peters, is the conduct of standard tests/procedures known as ocular routine examination, [88] composed of five (5)
tests/procedures specifically, gross examination of the eyes and the surrounding area; taking of the visual acuity of the
patient; checking the intraocular pressure of the patient; checking the motility of the eyes; and using ophthalmoscopy on
the patients eye and he did all those tests/procedures every time Peter went to see him for follow-up consultation
and/or check-up.
We cannot but agree with Dr. Tuaos assertion that when a doctor sees a patient, he cannot determine
immediately whether the latter would react adversely to the use of steroids; all the doctor can do is map out a course of
treatment recognized as correct by the standards of the medical profession. It must be remembered that a physician is
not an insurer of the good result of treatment. The mere fact that the patient does not get well or that a bad result occurs
does not in itself indicate failure to exercise due care. [89] The result is not determinative of the performance [of the
physician] and he is not required to be infallible.[90]

Reyes, Hazel

Page 103

Moreover, that Dr. Tuao saw it fit to prescribe Maxitrol to Peter was justified by the fact that the latter was
already using the same medication when he first came to see Dr. Tuao on 2 September 1988 and had exhibited no
previous untoward reaction to that particular drug. [91]
Also, Dr. Tuao categorically denied petitioners claim that he never monitored the tension of Peters eyes while
the latter was on Maxitrol. Dr. Tuao testified that he palpated Peters eyes every time the latter came for a check-up as
part of the doctors ocular routine examination, a fact which petitioners failed to rebut. Dr. Tuaos regular conduct of
examinations and tests to ascertain the state of Peters eyes negate the very basis of petitioners complaint for damages.
As to whether Dr. Tuaos actuations conformed to the standard of care and diligence required in like circumstances, it is
presumed to have so conformed in the absence of evidence to the contrary.
Even if we are to assume that Dr. Tuao committed negligent acts in his treatment of Peters condition, the
causal connection between Dr. Tuaos supposed negligence and Peters injury still needed to be established. The critical
and clinching factor in a medical negligence case is proof of the causal connection between the negligence which the
evidence established and the plaintiffs injuries. [92] The plaintiff must plead and prove not only that he has been injured
and defendant has been at fault, but also that the defendants fault caused the injury. A verdict in a malpractice action
cannot be based on speculation or conjecture. Causation must be proven within a reasonable medical probability based
upon competent expert testimony.[93]
The causation between the physicians negligence and the patients injury may only be established by the
presentation of proof that Peters glaucoma would not have occurred but for Dr. Tuaos supposed negligent
conduct. Once more, petitioners failed in this regard.
Dr. Tuao does not deny that the use of Maxitrol involves the risk of increasing a patients IOP. In fact, this was
the reason why he made it a point to palpate Peters eyes every time the latter went to see him -- so he could monitor the
tension of Peters eyes. But to say that said medication conclusively caused Peters glaucoma is purely speculative. Peter
was diagnosed with open-angle glaucoma. This kind of glaucoma is characterized by an almost complete absence of
symptoms and a chronic, insidious course. [94] In open-angle glaucoma, halos around lights and blurring of vision do not
occur unless there has been a sudden increase in the intraocular vision. [95] Visual acuity remains good until late in the
course of the disease. [96] Hence, Dr. Tuao claims that Peters glaucoma can only be long standing x x x because of the
large C:D[97] ratio, and that [t]he steroids provoked the latest glaucoma to be revealed earlier was a blessing in disguise
as [Peter] remained asymptomatic prior to steroid application.
Who between petitioners and Dr. Tuao is in a better position to determine and evaluate the necessity of
using Maxitrol to cure Peters EKC vis--vis the attendant risks of using the same?
That Dr. Tuao has the necessary training and skill to practice his chosen field is beyond cavil. Petitioners do not
dispute Dr. Tuaos qualifications that he has been a physician for close to a decade and a half at the time Peter first
came to see him; that he has had various medical training; that he has authored numerous papers in the field of

Reyes, Hazel

Page 104

ophthalmology, here and abroad; that he is aDiplomate of the Philippine Board of Ophthalmology; that he occupies
various teaching posts (at the time of the filing of the present complaint, he was the Chair of the Department of
Ophthalmology and an Associate Professor at the University of the Philippines-Philippine General Hospital and St.
Lukes Medical Center, respectively); and that he held an assortment of positions in numerous medical organizations like
the Philippine Medical Association, Philippine Academy of Ophthalmology, Philippine Board of Ophthalmology,
Philippine Society of Ophthalmic Plastic and Reconstructive Surgery, Philippine Journal of Ophthalmology, Association
of Philippine Ophthalmology Professors, et al.
It must be remembered that when the qualifications of a physician are admitted, as in the instant case, there is an
inevitable presumption that in proper cases, he takes the necessary precaution and employs the best of his knowledge
and skill in attending to his clients, unless the contrary is sufficiently established. [98] In making the judgment call of
treating Peters EKC with Maxitrol, Dr. Tuao took the necessary precaution by palpating Peters eyes to monitor their
IOP every time the latter went for a check-up, and he employed the best of his knowledge and skill earned from years of
training and practice.
In contrast, without supporting expert medical opinions, petitioners bare assertions of negligence on Dr. Tuaos
part, which resulted in Peters glaucoma, deserve scant credit.
Our disposition of the present controversy might have been vastly different had petitioners presented a medical
expert to establish their theory respecting Dr. Tuaos so-called negligence. In fact, the record of the case reveals that
petitioners counsel recognized the necessity of presenting such evidence. Petitioners even gave an undertaking to the
RTC judge that Dr. Agulto or Dr. Aquino would be presented. Alas, no follow-through on said undertaking was made.
The plaintiff in a civil case has the burden of proof as he alleges the affirmative of the issue. However, in the
course of trial in a civil case, once plaintiff makes out a prima facie case in his favor, the duty or the burden of evidence
shifts to defendant to controvert plaintiffs prima facie case; otherwise, a verdict must be returned in favor of plaintiff.
[99]

The party having the burden of proof must establish his case by a preponderance of evidence. [100] The concept of

preponderance of evidence refers to evidence which is of greater weight or more convincing than that which is offered
in opposition to it;[101] in the last analysis, it means probability of truth. It is evidence which is more convincing to the
court as worthy of belief than that which is offered in opposition thereto. [102] Rule 133, Section 1 of the Revised Rules of
Court provides the guidelines for determining preponderance of evidence, thus:
In civil cases, the party having the burden of proof must establish his case by a preponderance of
evidence. In determining where the preponderance or superior weight of evidence on the issues involved
lies the court may consider all the facts and circumstances of the case, the witnesses manner of
testifying, their intelligence, their means and opportunity of knowing the facts to which they are
testifying, the nature of the facts to which they testify, the probability or improbability of their testimony,
their interest or want of interest, and also their personal credibility so far as the same legitimately appear
upon the trial. The court may also consider the number of witnesses, though the preponderance is not
necessarily with the greater number.

Reyes, Hazel

Page 105

Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the lower court, to establish their case by
a preponderance of evidence showing a reasonable connection between Dr. Tuaos alleged breach of duty and the
damage sustained by Peters right eye. This, they did not do. In reality, petitioners complaint for damages is merely
anchored on a statement in the literature of Maxitrol identifying the risks of its use, and the purported comment of Dr.
Agulto another doctor not presented as witness before the RTC concerning the prolonged use of Maxitrol for the
treatment of EKC.
It seems basic that what constitutes proper medical treatment is a medical question that should have been
presented to experts. If no standard is established through expert medical witnesses, then courts have no standard by
which to gauge the basic issue of breach thereof by the physician or surgeon. The RTC and Court of Appeals, and even
this Court, could not be expected to determine on its own what medical technique should have been utilized for a certain
disease or injury. Absent expert medical opinion, the courts would be dangerously engaging in speculations.
All told, we are hard pressed to find Dr. Tuao liable for any medical negligence or malpractice where there is no
evidence, in the nature of expert testimony, to establish that in treating Peter, Dr. Tuao failed to exercise reasonable
care, diligence and skill generally required in medical practice. Dr. Tuaos testimony, that his treatment of Peter
conformed in all respects to standard medical practice in this locality, stands unrefuted. Consequently, the RTC and the
Court of Appeals correctly held that they had no basis at all to rule that petitioners were deserving of the various damages
prayed for in their Complaint.
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 herebyAFFIRMED. No cost.
SO ORDERED.
PROFESSIONAL SERVICES,
INC.,
Petitioner,

G.R. No. 126297


Present:
PUNO, C.J.,
CARPIO,

- versus -

Reyes, Hazel

CORONA,
CARPIO MORALES,
VELASCO, JR.,
NACHURA,
LEONARDO-DE CASTRO,
BRION,
PERALTA,
BERSAMIN,*
DEL CASTILLO,
ABAD,
VILLARAMA, JR.,
PEREZ and
MENDOZA, JJ.*

Page 106

THE COURT OF APPEALS and NATIVIDAD and ENRIQUE


AGANA,
Respondents.
x-------------------x
NATIVIDAD [substituted by her
children Marcelino Agana III,
Enrique Agana, Jr.,
Emma Agana-Andaya,
Jesus Agana and Raymund
Agana] and ENRIQUE AGANA,
Petitioners,

G.R. No. 126467

versus -

THE COURT OF APPEALS and JUAN FUENTES,


Respondents.
x-------------------x
MIGUEL AMPIL,
Petitioner,

G.R. No. 127590

- versus -

NATIVIDAD and ENRIQUE


AGANA,
Respondents.
Promulgated:
February 2, 2010
x - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
RESOLUTION
CORONA, J.:

With prior leave of court,[1] petitioner Professional Services, Inc. (PSI) filed a second motion for
reconsideration[2] urging referral thereof to the Court en banc and seeking modification of the
decision dated January 31, 2007 and resolution dated February 11, 2008 which affirmed its
vicarious and direct liability for damages to respondents Enrique Agana and the heirs of
Natividad Agana (Aganas).
Manila Medical Services, Inc. (MMSI),[3] Asian Hospital, Inc. (AHI),[4] and Private Hospital
Association of the Philippines (PHAP) [5] all sought to intervene in these cases invoking the
common ground that, unless modified, the assailed decision and resolution will jeopardize the
financial viability of private hospitals and jack up the cost of health care.

Reyes, Hazel

Page 107

The Special First Division of the Court granted the motions for intervention of MMSI, AHI and
PHAP (hereafter intervenors),[6] and referred en consulta to the Court en banc the motion for prior
leave of court and the second motion for reconsideration of PSI. [7]
Due to paramount public interest, the Court en banc accepted the referral[8] and heard the
parties on oral arguments on one particular issue: whether a hospital may be held liable for the
negligence of physicians-consultants allowed to practice in its premises. [9]
To recall the salient facts, PSI, together with Dr. Miguel Ampil (Dr. Ampil) and Dr. Juan Fuentes
(Dr. Fuentes), was impleaded by Enrique Agana and Natividad Agana (later substituted by her
heirs), in a complaint[10] for damages filed in the Regional Trial Court (RTC) of Quezon City, Branch
96, for the injuries suffered by Natividad when Dr. Ampil and Dr. Fuentes neglected to remove
from her body two gauzes[11] which were used in the surgery they performed on her on April 11,
1984 at the Medical City General Hospital. PSI was impleaded as owner, operator and manager
of the hospital.
In a decision[12] dated March 17, 1993, the RTC held PSI solidarily liable with Dr. Ampil and
Dr. Fuentes for damages.[13]On appeal, the Court of Appeals (CA), absolved Dr. Fuentes but affirmed the
liability of Dr. Ampil and PSI, subject to the right of PSI to claim reimbursement from Dr. Ampil. [14]
On petition for review, this Court, in its January 31, 2007 decision, affirmed the CA
decision.[15] PSI filed a motion for reconsideration [16] but the Court denied it in a resolution
dated February 11, 2008.[17]
The Court premised the direct liability of PSI to the Aganas on the following facts and law:
First, there existed between PSI and Dr. Ampil an employer-employee relationship as
contemplated in the December 29, 1999decision in Ramos v. Court of Appeals[18] that for
purposes of allocating responsibility in medical negligence cases, an employer-employee
relationship exists between hospitals and their consultants. [19] Although the Court in Ramos later
issued a Resolution dated April 11, 2002[20] reversing its earlier finding on the existence of an
employment relationship between hospital and doctor, a similar reversal was not warranted in
the present case because the defense raised by PSI consisted of a mere general denial of
control or responsibility over the actions of Dr. Ampil. [21]
Second, by accrediting Dr. Ampil and advertising his qualifications, PSI created the public
impression that he was its agent.[22] Enrique testified that it was on account of Dr. Ampil's
accreditation with PSI that he conferred with said doctor about his wife's (Natividad's) condition.
[23]
After his meeting with Dr. Ampil, Enrique asked Natividad to personally consult Dr. Ampil. [24] In
effect, when Enrigue and Natividad engaged the services of Dr. Ampil, at the back of their minds
was that the latter was a staff member of a prestigious hospital. Thus, under the doctrine of
apparent authority applied in Nogales, et al. v. Capitol MedicalCenter, et al.,[25] PSI was liable for
the negligence of Dr. Ampil.
Finally, as owner and operator of Medical City General Hospital, PSI was bound by its duty to
provide comprehensive medical services to Natividad Agana, to exercise reasonable care to
protect her from harm,[26] to oversee or supervise all persons who practiced medicine within its
walls, and to take active steps in fixing any form of negligence committed within its premises.
[27]
PSI committed a serious breach of its corporate duty when it failed to conduct an immediate
investigation into the reported missing gauzes. [28]
PSI is now asking this Court to reconsider the foregoing rulings for these reasons:
I
The declaration in the 31 January 2007 Decision vis-a-vis the 11 February 2009
Resolution that the ruling in Ramos vs. Court of Appeals (G.R. No. 134354, December 29, 1999)
Reyes, Hazel

Page 108

that an employer-employee relations exists between hospital and their consultants stays
should be set aside for being inconsistent with or contrary to the import of the resolution
granting the hospital's motion for reconsideration in Ramos vs. Court of Appeals (G.R. No.
134354, April 11, 2002), which is applicable to PSI since the Aganas failed to prove an employeremployee relationship between PSI and Dr. Ampil and PSI proved that it has no control over Dr.
Ampil. In fact, the trial court has found that there is no employer-employee relationship in this
case and that the doctor's are independent contractors.
II
Respondents Aganas engaged Dr. Miguel Ampil as their doctor and did not primarily and
specifically look to the Medical City Hospital (PSI) for medical care and support; otherwise
stated, respondents Aganas did not select Medical City Hospital (PSI) to provide medical care
because of any apparent authority of Dr. Miguel Ampil as its agent since the latter was chosen
primarily and specifically based on his qualifications and being friend and neighbor.
III
PSI cannot be liable under doctrine of corporate negligence since the proximate cause of
Mrs. Agana's injury was the negligence of Dr. Ampil, which is an element of the principle of
corporate negligence.[29]
In their respective memoranda, intervenors raise parallel arguments that the Court's ruling on
the existence of an employer-employee relationship between private hospitals and consultants
will force a drastic and complex alteration in the long-established and currently prevailing
relationships among patient, physician and hospital, with burdensome operational and financial
consequences and adverse effects on all three parties. [30]
The Aganas comment that the arguments of PSI need no longer be entertained for they have all
been traversed in the assailed decision and resolution. [31]
After gathering its thoughts on the issues, this Court holds that PSI is liable to the Aganas,
not under the principle ofrespondeat superior for lack of evidence of an employment relationship
with Dr. Ampil but under the principle of ostensible agency for the negligence of Dr. Ampil
and, pro hac vice, under the principle of corporate negligence for its failure to perform its duties
as a hospital.
While in theory a hospital as a juridical entity cannot practice medicine, [32] in reality it utilizes
doctors, surgeons and medical practitioners in the conduct of its business of facilitating medical
and surgical treatment.[33] Within that reality, three legal relationships crisscross: (1) between the
hospital and the doctor practicing within its premises; (2) between the hospital and the patient
being treated or examined within its premises and (3) between the patient and the doctor. The
exact nature of each relationship determines the basis and extent of the liability of the hospital
for the negligence of the doctor.
Where an employment relationship exists, the hospital may be held vicariously liable under
Article 2176[34] in relation to Article 2180[35] of the Civil Code or the principle of respondeat
superior. Even when no employment relationship exists but it is shown that the hospital holds
out to the patient that the doctor is its agent, the hospital may still be vicariously liable under
Article 2176 in relation to Article 1431[36] and Article 1869[37] of the Civil Code or the principle of
apparent authority.[38] Moreover, regardless of its relationship with the doctor, the hospital may
be held directly liable to the patient for its own negligence or failure to follow established
standard of conduct to which it should conform as a corporation. [39]
This Court still employs the control test to determine the existence of an employer-employee
relationship between hospital and doctor. In Calamba Medical Center, Inc. v. National Labor
Relations Commission, et al.[40] it held:
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Page 109

Under the "control test", an employment relationship exists between a physician and a hospital
if the hospital controls both the means and the details of the process by which the physician is
to accomplish his task.
xx xx xx
As priorly stated, private respondents maintained specific work-schedules, as
determined by petitioner through its medical director, which consisted of 24-hour shifts totaling
forty-eight hours each week and which were strictly to be observed under pain of administrative
sanctions.
That petitioner exercised control over respondents gains light from the undisputed
fact that in the emergency room, the operating room, or any department or ward for
that matter, respondents' work is monitored through its nursing supervisors, charge
nurses and orderlies. Without the approval or consent of petitioner or its medical
director, no operations can be undertaken in those areas. For control test to apply, it
is not essential for the employer to actually supervise the performance of duties of
the employee, it being enough that it has the right to wield the power. (emphasis
supplied)
Even in its December 29, 1999 decision[41] and April 11, 2002 resolution[42] in Ramos, the Court
found the control test decisive.
In the present case, it appears to have escaped the Court's attention that both the RTC and the
CA found no employment relationship between PSI and Dr. Ampil, and that the Aganas did not
question such finding. In its March 17, 1993 decision, the RTC found that defendant doctors
were not employees of PSI in its hospital, they being merely consultants without any employeremployee relationship and in the capacity of independent contractors. [43] The Aganas never
questioned such finding.
PSI, Dr. Ampil and Dr. Fuentes appealed [44] from the RTC decision but only on the issues of
negligence, agency and corporate liability. In its September 6, 1996 decision, the CA mistakenly
referred to PSI and Dr. Ampil as employer-employee, but it was clear in its discussion on the
matter that it viewed their relationship as one of mere apparent agency. [45]
The Aganas appealed from the CA decision, but only to question the exoneration of
Dr. Fuentes.[46] PSI also appealed from the CA decision, and it was then that the issue of
employment, though long settled, was unwittingly resurrected.
In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no employeremployee relationship, such finding became final and conclusive even to this Court. [47] There was
no reason for PSI to have raised it as an issue in its petition. Thus, whatever discussion on the
matter that may have ensued was purely academic.
Nonetheless, to allay the anxiety of the intervenors, the Court holds that, in this
particular instance, the concurrent finding of the RTC and the CA that PSI was not the employer
of Dr. Ampil is correct. Control as a determinative factor in testing the employer-employee
relationship between doctor and hospital under which the hospital could be held vicariously
liable to a patient in medical negligence cases is a requisite fact to be established by
preponderance of evidence. Here, there was insufficient evidence that PSI exercised the power
of control or wielded such power over the means and the details of the specific process by which
Dr. Ampil applied his skills in the treatment of Natividad. Consequently, PSI cannot be held
vicariously liable for the negligence of Dr. Ampil under the principle of respondeat superior.
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Page 110

There is, however, ample evidence that the hospital (PSI) held out to the patient (Natividad)
[48]
that the doctor (Dr. Ampil) was its agent. Present are the two factors that determine apparent
authority: first, the hospital's implied manifestation to the patient which led the latter to
conclude that the doctor was the hospital's agent; and second, the patients reliance upon the
conduct of the hospital and the doctor, consistent with ordinary care and prudence. [49]
Enrique testified that on April 2, 1984, he consulted Dr. Ampil regarding the condition of his
wife; that after the meeting and as advised by Dr. Ampil, he asked [his] wife to go to Medical
City to be examined by [Dr. Ampil]; and that the next day, April 3, he told his daughter to
take her mother to Dr. Ampil.[50] This timeline indicates that it was Enrique who actually made
the decision on whom Natividad should consult and where, and that the latter merely acceded
to it. It explains the testimony of Natividad that she consulted Dr. Ampil at the instigation of her
daughter.[51]
Moreover, when asked what impelled him to choose Dr. Ampil, Enrique testified:
Atty. Agcaoili
On that particular occasion, April 2, 1984, what was your reason for choosing Dr. Ampil to
contact with in connection with your wife's illness?
A.
First, before that, I have known him to be a specialist on that part of the body as a
surgeon, second, I have known him to be a staff member of the Medical City which is
a prominent and known hospital. And third, because he is a neighbor, I expect more than the
usual medical service to be given to us, than his ordinary patients. [52] (emphasis supplied)
Clearly, the decision made by Enrique for Natividad to consult Dr. Ampil was significantly
influenced by the impression that Dr. Ampil was a staff member of Medical City General Hospital,
and that said hospital was well known and prominent. Enrique looked upon Dr. Ampil not as
independent of but as integrally related to Medical City.
PSI's acts tended to confirm and reinforce, rather than negate, Enrique's view. It is of
record that PSI required a consent for hospital care [53] to be signed preparatory to the surgery
of Natividad. The form reads:
Permission is hereby given to the medical, nursing and laboratory staff of
the Medical City General Hospital to perform such diagnostic procedures and to administer such
medications and treatments as may be deemed necessary or advisable by the physicians
of this hospital for and during the confinement of xxx. (emphasis supplied)
By such statement, PSI virtually reinforced the public impression that Dr. Ampil was
a physician of its hospital, rather than one independently practicing in it; that the medications
and treatments he prescribed were necessary and desirable; and that the hospital staff was
prepared to carry them out.
PSI pointed out in its memorandum that Dr. Ampil's hospital affiliation was not the exclusive
basis of the Aganas decision to have Natividad treated in Medical City General Hospital,
meaning that, had Dr. Ampil been affiliated with another hospital, he would still have been
chosen by the Aganas as Natividad's surgeon.[54]
The Court cannot speculate on what could have been behind the Aganas decision
but would rather adhere strictly to the fact that, under the circumstances at that time,
Enrique decided to consult Dr. Ampil for he believed him to be a staff member of a prominent
and known hospital. After his meeting with Dr. Ampil, Enrique advised his wife Natividad to go to
the Medical CityGeneral Hospital to be examined by said doctor, and the hospital acted in a way
that fortified Enrique's belief.
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Page 111

This Court must therefore maintain the ruling that PSI is vicariously liable for the negligence of
Dr. Ampil as its ostensible agent.
Moving on to the next issue, the Court notes that PSI made the following admission
in its Motion for Reconsideration:
51.
Clearly, not being an agent or employee of petitioner PSI, PSI [sic] is not liable for Dr.
Ampil's acts during the operation. Considering further that Dr. Ampil was personally engaged as
a doctor by Mrs. Agana, it is incumbent upon Dr. Ampil, as Captain of the Ship, and as
the Agana's doctor to advise her on what to do with her situation vis-a-vis the two missing
gauzes. In addition to noting the missing gauzes, regular check-ups were made and no
signs of complications were exhibited during her stay at the hospital, which could
have alerted petitioner PSI's hospital to render and provide post-operation services
to and tread on Dr. Ampil's role as the doctor of Mrs. Agana. The absence of
negligence of PSI from the patient's admission up to her discharge is borne by the
finding of facts in this case. Likewise evident therefrom is the absence of any
complaint from Mrs. Agana after her discharge from the hospital which had she
brought to the hospital's attention, could have alerted petitioner PSI to act
accordingly and bring the matter to Dr. Ampil's attention. But this was not the case.
Ms. Agana complained ONLY to Drs. Ampil and Fuentes, not the hospital. How then
could PSI possibly do something to fix the negligence committed by Dr. Ampil when it
was not informed about it at all.[55](emphasis supplied)
PSI reiterated its admission when it stated that had Natividad Agana informed the hospital of
her discomfort and pain, the hospital would have been obliged to act on it.[56]
The significance of the foregoing statements is critical.
First, they constitute judicial admission by PSI that while it had no power to control the means or
method by which Dr. Ampil conducted the surgery on Natividad Agana, it had the power to
review or cause the review of what may have irregularly transpired within its walls strictly for
the purpose of determining whether some form of negligence may have attended any procedure
done inside its premises, with the ultimate end of protecting its patients.
Second, it is a judicial admission that, by virtue of the nature of its business as well as its
prominence[57] in the hospital industry, it assumed a duty to tread on the captain of the ship
role of any doctor rendering services within its premises for the purpose of ensuring the safety
of the patients availing themselves of its services and facilities.
Third, by such admission, PSI defined the standards of its corporate conduct under the
circumstances of this case, specifically: (a) that it had a corporate duty to Natividad even after
her operation to ensure her safety as a patient; (b) that its corporate duty was not limited to
having its nursing staff note or record the two missing gauzes and (c) that its corporate duty
extended to determining Dr. Ampil's role in it, bringing the matter to his attention,
and correcting his negligence.
And finally, by such admission, PSI barred itself from arguing in its second motion for
reconsideration that the concept of corporate responsibility was not yet in existence at the time
Natividad underwent treatment;[58] and that if it had any corporate responsibility, the same was
limited to reporting the missing gauzes and did not include taking an active step in fixing the
negligence committed.[59] An admission made in the pleading cannot be controverted by the
party making such admission and is conclusive as to him, and all proofs submitted by him
contrary thereto or inconsistent therewith should be ignored, whether or not objection is
interposed by a party.[60]

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Page 112

Given the standard of conduct that PSI defined for itself, the next relevant inquiry is whether
the hospital measured up to it.
PSI excuses itself from fulfilling its corporate duty on the ground that Dr. Ampil assumed
the personal responsibility of informing Natividad about the two missing gauzes. [61] Dr. Ricardo
Jocson, who was part of the group of doctors that attended to Natividad, testified that toward
the end of the surgery, their group talked about the missing gauzes but Dr. Ampil assured them
that he would personally notify the patient about it. [62] Furthermore, PSI claimed that there was
no reason for it to act on the report on the two missing gauzes because Natividad Agana showed
no signs of complications. She did not even inform the hospital about her discomfort. [63]
The excuses proffered by PSI are totally unacceptable.
To begin with, PSI could not simply wave off the problem and nonchalantly delegate to Dr. Ampil
the duty to review what transpired during the operation. The purpose of such review would have
been to pinpoint when, how and by whom two surgical gauzes were mislaid so that necessary
remedial measures could be taken to avert any jeopardy to Natividads recovery. Certainly, PSI
could not have expected that purpose to be achieved by merely hoping that the person likely to
have mislaid the gauzes might be able to retrace his own steps. By its own standard of
corporate conduct, PSI's duty to initiate the review was non-delegable.
While Dr. Ampil may have had the primary responsibility of notifying Natividad about
the missing gauzes, PSI imposed upon itself the separate and independent responsibility of
initiating the inquiry into the missing gauzes. The purpose of the first would have been to
apprise Natividad of what transpired during her surgery, while the purpose of the second would
have been to pinpoint any lapse in procedure that led to the gauze count discrepancy, so as to
prevent a recurrence thereof and to determine corrective measures that would ensure the safety
of Natividad. That Dr. Ampil negligently failed to notify Natividad did not release PSI from its
self-imposed separate responsibility.
Corollary to its non-delegable undertaking to review potential incidents of negligence committed
within its premises, PSI had the duty to take notice of medical records prepared by its own staff
and submitted to its custody, especially when these bear earmarks of a surgery gone awry.
Thus, the record taken during the operation of Natividad which reported a gauze count
discrepancy should have given PSI sufficient reason to initiate a review. It should not have
waited for Natividad to complain.
As it happened, PSI took no heed of the record of operation and consequently did not initiate a
review of what transpired during Natividads operation. Rather, it shirked its responsibility and
passed it on to others to Dr. Ampil whom it expected to inform Natividad, and to Natividad
herself to complain before it took any meaningful step. By its inaction, therefore, PSI failed its
own standard of hospital care. It committed corporate negligence.
It should be borne in mind that the corporate negligence ascribed to PSI is different from the
medical negligence attributed to Dr. Ampil. The duties of the hospital are distinct from those of
the doctor-consultant practicing within its premises in relation to the patient; hence, the failure
of PSI to fulfill its duties as a hospital corporation gave rise to a direct liability to the Aganas
distinct from that of Dr. Ampil.
All this notwithstanding, we make it clear that PSIs hospital liability based on ostensible agency
and corporate negligence applies only to this case, pro hac vice. It is not intended to set a
precedent and should not serve as a basis to hold hospitals liable for every form of negligence
of their doctors-consultants under any and all circumstances. The ruling is unique to this case,
for the liability of PSI arose from an implied agency with Dr. Ampil and an admitted corporate
duty to Natividad.[64]
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Page 113

Other circumstances peculiar to this case warrant this ruling, [65] not the least of which being that
the agony wrought upon the Aganas has gone on for 26 long years, with Natividad coming to
the end of her days racked in pain and agony. Such wretchedness could have been avoided had
PSI simply done what was logical: heed the report of a guaze count discrepancy, initiate a
review of what went wrong and take corrective measures to ensure the safety of
Nativad. Rather, for 26 years, PSI hemmed and hawed at every turn, disowning any such
responsibility to its patient. Meanwhile, the options left to the Aganas have all but dwindled, for
the status of Dr. Ampil can no longer be ascertained. [66]
Therefore, taking all the equities of this case into consideration, this Court believes P15 million
would be a fair and reasonable liability of PSI, subject to 12% p.a. interest from the finality of
this resolution to full satisfaction.
WHEREFORE, the second motion for reconsideration is DENIED and the motions for
intervention are NOTED.
Professional Services, Inc. is ORDERED pro hac vice to pay Natividad (substituted
by her children Marcelino Agana III, Enrique Agana, Jr., Emma Agana-Andaya, Jesus Agana and
Raymund Agana) and Enrique Agana the total amount of P15 million, subject to 12% p.a. interest
from the finality of this resolution to full satisfaction.
No further pleadings by any party shall be entertained in this case.
Let the long-delayed entry of judgment be made in this case upon receipt by all
concerned parties of this resolution.
SO ORDERED.
DR. RUBI LI,
Petitioner,

G.R. No. 165279


Present:

- versus -

CORONA, C.J.,
CARPIO,
CARPIO MORALES,
VELASCO, JR.,
NACHURA,
LEONARDO-DE CASTRO,
BRION,
PERALTA,
BERSAMIN,
DEL CASTILLO,*
ABAD,
VILLARAMA, JR.,
PEREZ,
MENDOZA, and
SERENO, JJ.

SPOUSES
REYNALDO
and
LINA
Promulgated:
SOLIMAN, as parents/heirs of deceased
Angelica Soliman,
June 7, 2011
Respondents.
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -x
DECISION
VILLARAMA, JR., J.:

Reyes, Hazel

Page 114

Challenged in this petition for review on certiorari is the Decision [1] dated June 15, 2004 as well as the
Resolution[2] datedSeptember 1, 2004 of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which modified the
Decision[3] dated September 5, 1997 of the Regional Trial Court of Legazpi City, Branch 8 in Civil Case No. 8904.
The factual antecedents:
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the mass located in her
lower extremity at the St. Lukes Medical Center (SLMC). Results showed that Angelica was suffering
from osteosarcoma, osteoblastic type,[4] a high-grade (highly malignant) cancer of the bone which usually afflicts teenage
children. Following this diagnosis and as primary intervention, Angelicas right leg was amputated by Dr. Jaime Tamayo
in order to remove the tumor. As adjuvant treatment to eliminate any remaining cancer cells, and hence minimize the
chances of recurrence and prevent the disease from spreading to other parts of the patients body ( metastasis),
chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to another doctor at SLMC, herein
petitioner Dr. Rubi Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on September 1, 1993, just eleven (11) days
after the (intravenous) administration of the first cycle of the chemotherapy regimen. Because SLMC refused to release a
death certificate without full payment of their hospital bill, respondents brought the cadaver of Angelica to the Philippine
National Police (PNP) Crime Laboratory at Camp Crame for post-mortem examination. The Medico-Legal Report issued
by said institution indicated the cause of death as Hypovolemic shock secondary to multiple organ hemorrhages and
Disseminated Intravascular Coagulation.[5]
On the other hand, the Certificate of Death[6] issued by SLMC stated the cause of death as follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c.
Status Post Chemotherapy

On February 21, 1994, respondents filed a damage suit [7] against petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a
certain Dr. Arriete and SLMC. Respondents charged them with negligence and disregard of Angelicas safety, health and
welfare by their careless administration of the chemotherapy drugs, their failure to observe the essential precautions in
detecting early the symptoms of fatal blood platelet decrease and stopping early on the chemotherapy, which bleeding led
to hypovolemic shock that caused Angelicas untimely demise. Further, it was specifically averred that petitioner assured
the respondents that Angelica would recover in view of 95% chance of healing with chemotherapy (Magiging normal na
ang anak nyo basta ma-chemo. 95% ang healing) and when asked regarding the side effects, petitioner mentioned only
slight vomiting, hair loss and weakness (Magsusuka ng kaunti. Malulugas ang buhok. Manghihina). Respondents
thus claimed that they would not have given their consent to chemotherapy had petitioner not falsely assured them of its
side effects.
In her answer,[8] petitioner denied having been negligent in administering the chemotherapy drugs to Angelica and
asserted that she had fully explained to respondents how the chemotherapy will affect not only the cancer cells but also
the patients normal body parts, including the lowering of white and red blood cells and platelets. She claimed that what

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Page 115

happened to Angelica can be attributed to malignant tumor cells possibly left behind after surgery. Few as they may be,
these have the capacity to compete for nutrients such that the body becomes so weak structurally (cachexia) and
functionally in the form of lower resistance of the body to combat infection. Such infection becomes uncontrollable and
triggers a chain of events (sepsis or septicemia) that may lead to bleeding in the form of Disseminated Intravascular
Coagulation (DIC), as what the autopsy report showed in the case of Angelica.
Since the medical records of Angelica were not produced in court, the trial and appellate courts had to rely on
testimonial evidence, principally the declarations of petitioner and respondents themselves. The following chronology of
events was gathered:
On July 23, 1993, petitioner saw the respondents at the hospital after Angelicas surgery and discussed with them
Angelicas condition. Petitioner told respondents that Angelica should be given two to three weeks to recover from the
operation before starting chemotherapy. Respondents were apprehensive due to financial constraints as Reynaldo earns
only from P70,000.00 toP150,000.00 a year from his jewelry and watch repairing business. [9] Petitioner, however,
assured them not to worry about her professional fee and told them to just save up for the medicines to be used.
Petitioner claimed that she explained to respondents that even when a tumor is removed, there are still small
lesions undetectable to the naked eye, and that adjuvant chemotherapy is needed to clean out the small lesions in order to
lessen the chance of the cancer to recur. She did not give the respondents any assurance that chemotherapy will cure
Angelicas cancer. During these consultations with respondents, she explained the following side effects of chemotherapy
treatment to respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells
[WBC], red blood cells [RBC] and platelets; (5) possible sterility due to the effects on Angelicas ovary; (6) damage to the
heart and kidneys; and (7) darkening of the skin especially when exposed to sunlight. She actually talked with
respondents four times, once at the hospital after the surgery, twice at her clinic and the fourth time when Angelicas
mother called her through long distance. [10] This was disputed by respondents who countered that petitioner gave them
assurance that there is 95% chance of healing for Angelica if she undergoes chemotherapy and that the only side effects
were nausea, vomiting and hair loss. [11] Those were the only side-effects of chemotherapy treatment mentioned by
petitioner.[12]
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that she be readmitted after two or
three weeks for the chemotherapy.
On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, bringing with them the results of
the laboratory tests requested by petitioner: Angelicas chest x-ray, ultrasound of the liver, creatinine and complete liver
function tests.[13] Petitioner proceeded with the chemotherapy by first administering hydration fluids to Angelica. [14]
The following day, August 19, petitioner began administering three chemotherapy drugs Cisplatin,
[15]

Doxorubicin[16]and Cosmegen[17] intravenously. Petitioner was supposedly assisted by her trainees Dr. Leo

Marbella[18] and Dr. Grace Arriete. [19] In his testimony, Dr. Marbella denied having any participation in administering
the said chemotherapy drugs.[20]
On the second day of chemotherapy, August 20, respondents noticed reddish discoloration on Angelicas face.
[21]

They asked petitioner about it, but she merely quipped, Wala yan. Epekto ng gamot.[22] Petitioner recalled

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Page 116

noticing the skin rashes on the nose and cheek area of Angelica. At that moment, she entertained the possibility that
Angelica also had systemic lupus and consulted Dr. Victoria Abesamis on the matter. [23]
On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was thus provided with
oxygen inhalation apparatus. This time, the reddish discoloration on Angelicas face had extended to her neck, but
petitioner dismissed it again as merely the effect of medicines. [24] Petitioner testified that she did not see any
discoloration on Angelicas face, nor did she notice any difficulty in the childs breathing. She claimed that Angelica
merely complained of nausea and was given ice chips. [25]
On August 22, 1993, at around ten oclock in the morning, upon seeing that their child could not anymore bear
the pain, respondents pleaded with petitioner to stop the chemotherapy. Petitioner supposedly replied: Dapat 15
Cosmegen pa iyan. Okay, lets observe. If pwede na, bigyan uli ng chemo. At this point, respondents asked petitioners
permission to bring their child home. Later in the evening, Angelica passed black stool and reddish urine. [26] Petitioner
countered that there was no record of blackening of stools but only an episode of loose bowel movement
(LBM). Petitioner also testified that what Angelica complained of was carpo-pedal spasm, not convulsion or epileptic
attack, as respondents call it (petitioner described it in the vernacular asnaninigas ang kamay at paa). She then
requested for a serum calcium determination and stopped the chemotherapy. When Angelica was given calcium
gluconate, the spasm and numbness subsided.[27]
The following day, August 23, petitioner yielded to respondents request to take Angelica home. But prior to
discharging Angelica, petitioner requested for a repeat serum calcium determination and explained to respondents that
the chemotherapy will be temporarily stopped while she observes Angelicas muscle twitching and serum calcium
level. Take-home medicines were also prescribed for Angelica, with instructions to respondents that the serum calcium
test will have to be repeated after seven days. Petitioner told respondents that she will see Angelica again after two weeks,
but respondents can see her anytime if any immediate problem arises. [28]
However, Angelica remained in confinement because while still in the premises of SLMC, her convulsions
returned and she also had LBM. Angelica was given oxygen and administration of calcium continued. [29]
The next day, August 24, respondents claimed that Angelica still suffered from convulsions. They also noticed
that she had a fever and had difficulty breathing. [30] Petitioner insisted it was carpo-pedal spasm, not convulsions. She
verified that at around 4:50that afternoon, Angelica developed difficulty in breathing and had fever. She then requested for
an electrocardiogram analysis, and infused calcium gluconate on the patient at a stat dose. She further ordered that
Angelica be given Bactrim,[31] a synthetic antibacterial combination drug,[32] to combat any infection on the childs body.[33]
By August 26, Angelica was bleeding through the mouth. Respondents also saw blood on her anus and urine.
When Lina asked petitioner what was happening to her daughter, petitioner replied, Bagsak ang platelets ng anak
mo. Four units of platelet concentrates were then transfused to Angelica. Petitioner prescribed Solucortef. Considering
that Angelicas fever was high and her white blood cell count was low, petitioner prescribed Leucomax. About four to
eight bags of blood, consisting of packed red blood cells, fresh whole blood, or platelet concentrate, were transfused to
Angelica. For two days (August 27 to 28), Angelica continued bleeding, but petitioner claimed it was lesser in amount
and in frequency. Petitioner also denied that there were gadgets attached to Angelica at that time.[34]

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Page 117

On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood clots that should not be
removed. Respondents claimed that Angelica passed about half a liter of blood through her anus at around seven
oclock that evening, which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and nasogastric tubes were
inserted into her weakened body. An aspiration of the nasogastric tube inserted to Angelica also revealed a bloody
content. Angelica was given more platelet concentrate and fresh whole blood, which petitioner claimed improved her
condition. Petitioner told Angelica not to remove the endotracheal tube because this may induce further bleeding.
[35]

She was also transferred to the intensive care unit to avoid infection.
The next day, respondents claimed that Angelica became hysterical, vomited blood and her body turned black.

Part of Angelicas skin was also noted to be shredding by just rubbing cotton on it. Angelica was so restless she removed
those gadgets attached to her, saying Ayaw ko na; there were tears in her eyes and she kept turning her
head. Observing her daughter to be at the point of death, Lina asked for a doctor but the latter could not answer her
anymore.[36] At this time, the attending physician was Dr. Marbella who was shaking his head saying that Angelicas
platelets were down and respondents should pray for their daughter. Reynaldo claimed that he was introduced to a
pediatrician who took over his daughters case, Dr. Abesamis who also told him to pray for his daughter. Angelica
continued to have difficulty in her breathing and blood was being suctioned from her stomach. A nurse was posted inside
Angelicas room to assist her breathing and at one point they had to revive Angelica by pumping her chest. Thereafter,
Reynaldo claimed that Angelica already experienced difficulty in urinating and her bowel consisted of blood-like
fluid. Angelica requested for an electric fan as she was in pain. Hospital staff attempted to take blood samples from
Angelica but were unsuccessful because they could not even locate her vein. Angelica asked for a fruit but when it was
given to her, she only smelled it. At this time, Reynaldo claimed he could not find either petitioner or Dr. Marbella. That
night, Angelica became hysterical and started removing those gadgets attached to her. At three oclock in the morning of
September 1, a priest came and they prayed before Angelica expired. Petitioner finally came back and supposedly told
respondents that there was malfunction or bogged-down machine. [37]
By petitioners own account, Angelica was merely irritable that day (August 31). Petitioner noted though that
Angelicas skin was indeed sloughing off. [38] She stressed that at 9:30 in the evening, Angelica pulled out her
endotracheal tube.[39] On September 1, exactly two weeks after being admitted at SLMC for chemotherapy, Angelica died.
[40]

The cause of death, according to petitioner, was septicemia, or overwhelming infection, which caused Angelicas

other organs to fail.[41] Petitioner attributed this to the patients poor defense mechanism brought about by the cancer
itself.[42]
While he was seeking the release of Angelicas cadaver from SLMC, Reynaldo claimed that petitioner acted
arrogantly and called him names. He was asked to sign a promissory note as he did not have cash to pay the hospital bill.
[43]

Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer of the PNP-Crime
Laboratory who conducted the autopsy on Angelicas cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical
Specialist employed at the Department of Health (DOH) Operations and Management Services.
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the following: (1) there were fluids
recovered from the abdominal cavity, which is not normal, and was due to hemorrhagic shock secondary to bleeding; (2)

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there was hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and areas adjacent to, the
esophagus; (4) lungs were heavy with bleeding at the back and lower portion, due to accumulation of fluids; (4) yellowish
discoloration of the liver; (5) kidneys showed appearance of facial shock on account of hemorrhages; and (6) reddishness
on external surface of the spleen. All these were the end result of hypovolemic shock secondary to multiple organ
hemorrhages and disseminated intravascular coagulation. Dr. Vergara opined that this can be attributed to the
chemical agents in the drugs given to the victim, which caused platelet reduction resulting to bleeding sufficient to cause
the victims death. The time lapse for the production of DIC in the case of Angelica (from the time of diagnosis of
sarcoma) was too short, considering the survival rate of about 3 years. The witness conceded that the victim will also die
of osteosarcoma even with amputation or chemotherapy, but in this case Angelicas death was not caused by
osteosarcoma. Dr. Vergara admitted that she is not a pathologist but her statements were based on the opinion of an
oncologist whom she had interviewed. This oncologist supposedly said that if the victim already had DIC prior to the
chemotherapy, the hospital staff could have detected it.[44]
On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain to the patient or his
relatives every known side effect of the procedure or therapeutic agents to be administered, before securing the consent
of the patient or his relatives to such procedure or therapy. The physician thus bases his assurance to the patient on his
personal assessment of the patients condition and his knowledge of the general effects of the agents or procedure that
will be allowed on the patient. Dr. Balmaceda stressed that the patient or relatives must be informed of all known side
effects based on studies and observations, even if such will aggravate the patients condition. [45]
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelicas lower extremity, testified for the
defendants. He explained that in case of malignant tumors, there is no guarantee that the ablation or removal of the
amputated part will completely cure the cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the
time of modern chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths occur from metastasis, or
spread of the cancer to other vital organs like the liver, causing systemic complications. The modes of therapy available
are the removal of the primary source of the cancerous growth and then the residual cancer cells or metastasis should be
treated with chemotherapy. Dr. Tamayo further explained that patients with osteosarcoma have poor defense mechanism
due to the cancer cells in the blood stream. In the case of Angelica, he had previously explained to her parents that after
the surgical procedure, chemotherapy is imperative so that metastasis of these cancer cells will hopefully be
addressed. He referred the patient to petitioner because he felt that petitioner is a competent oncologist. Considering
that this type of cancer is very aggressive and will metastasize early, it will cause the demise of the patient should there be
no early intervention (in this case, the patient developed sepsis which caused her death). Cancer cells in the
blood cannot be seen by the naked eye nor detected through bone scan. On cross-examination, Dr. Tamayo stated that of
the more than 50 child patients who had osteogenic sarcoma he had handled, he thought that probably all of them died
within six months from amputation because he did not see them anymore after follow-up; it is either they died or had
seen another doctor.[46]
In dismissing the complaint, the trial court held that petitioner was not liable for damages as she observed the best
known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on
Angelica but despite all efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he considered
petitioner one of the most proficient in the treatment of cancer and that the patient in this case was afflicted with a very
aggressive type of cancer necessitating chemotherapy as adjuvant treatment. Using the standard of negligence laid down
in Picart v. Smith,[47] the trial court declared that petitioner has taken the necessary precaution against the adverse effect

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of chemotherapy on the patient, adding that a wrong decision is not by itself negligence. Respondents were ordered to
pay their unpaid hospital bill in the amount of P139,064.43.[48]
Respondents appealed to the CA which, while concurring with the trial courts finding that there was no negligence
committed by the petitioner in the administration of chemotherapy treatment to Angelica, found that petitioner as her
attending physician failed to fully explain to the respondents all the known side effects of chemotherapy. The appellate
court stressed that since the respondents have been told of only three side effects of chemotherapy, they readily
consented thereto. Had petitioner made known to respondents those other side effects which gravely affected their child
-- such as carpo-pedal spasm, sepsis, decrease in the blood platelet count, bleeding, infections and eventual death -respondents could have decided differently or adopted a different course of action which could have delayed or prevented
the early death of their child.
The CA thus declared:
Plaintiffs-appellants child was suffering from a malignant disease. The attending physician
recommended that she undergo chemotherapy treatment after surgery in order to increase her chances
of survival. Appellants consented to the chemotherapy treatment because they believed in Dr. Rubi Lis
representation that the deceased would have a strong chance of survival after chemotherapy and also
because of the representation of appellee Dr. Rubi Li that there were only three possible side-effects of
the treatment. However, all sorts of painful side-effects resulted from the treatment including the
premature death of Angelica. The appellants were clearly and totally unaware of these other
side-effects which manifested only during the chemotherapy treatment. This was shown
by the fact that every time a problem would take place regarding Angelicas condition (like
an unexpected side-effect manifesting itself), they would immediately seek explanation
from Dr. Rubi Li. Surely, those unexpected side-effects culminating in the loss of a love[d] one caused
the appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle
plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is
hereby modified to the extent that defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffsappellants the following amounts:
1.

Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;

2.

Moral damages of P200,000.00;

3.

Exemplary damages of P50,000.00;

4.

Attorneys fee of P30,000.00.

SO ORDERED.[49] (Emphasis supplied.)

Petitioner filed a motion for partial reconsideration which the appellate court denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not explaining to the respondents all the possible
side effects of the chemotherapy on their child, and in holding her liable for actual, moral and exemplary damages and

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attorneys fees. Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures and in the
administration of chemotherapy treatment to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy, including death, petitioner argues that
it was foolhardy to imagine her to be all-knowing/omnipotent. While the theoretical side effects of chemotherapy were
explained by her to the respondents, as these should be known to a competent doctor, petitioner cannot possibly predict
how a particular patients genetic make-up, state of mind, general health and body constitution would respond to the
treatment. These are obviously dependent on too many known, unknown and immeasurable variables, thus requiring
that Angelica be, as she was, constantly and closely monitored during the treatment. Petitioner asserts that she did
everything within her professional competence to attend to the medical needs of Angelica.
Citing numerous trainings, distinctions and achievements in her field and her current position as co-director for
clinical affairs of the Medical Oncology, Department of Medicine of SLMC, petitioner contends that in the absence of any
clear showing or proof, she cannot be charged with negligence in not informing the respondents all the side effects of
chemotherapy or in the pre-treatment procedures done on Angelica.
As to the cause of death, petitioner insists that Angelica did not die of platelet depletion but of sepsis which is a
complication of the cancer itself. Sepsis itself leads to bleeding and death. She explains that the response rate to
chemotherapy of patients with osteosarcoma is high, so much so that survival rate is favorable to the patient. Petitioner
then points to some probable consequences if Angelica had not undergone chemotherapy. Thus, without chemotherapy,
other medicines and supportive treatment, the patient might have died the next day because of massive infection, or the
cancer cells might have spread to the brain and brought the patient into a coma, or into the lungs that the patient could
have been hooked to a respirator, or into her kidneys that she would have to undergo dialysis. Indeed, respondents could
have spent as much because of these complications. The patient would have been deprived of the chance to survive the
ailment, of any hope for life and her quality of life surely compromised. Since she had not been shown to be at fault,
petitioner maintains that the CA erred in holding her liable for the damages suffered by the respondents. [50]
The issue to be resolved is whether the petitioner can be held liable for failure to fully disclose serious side effects to
the parents of the child patient who died while undergoing chemotherapy, despite the absence of finding that petitioner
was negligent in administering the said treatment.
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that
type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which
has caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in
most cases a physician, either failed to do something which a reasonably prudent health care provider would have done,
or that he or she did something that a reasonably prudent provider would not have done; and that that failure or action
caused injury to the patient.[51]
This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging
in the same general neighborhood and in the same general line of practice as defendant physician or surgeon. The

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deference of courts to the expert opinion of qualified physicians stems from the formers realization that the latter
possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating, hence the
indispensability of expert testimonies.[52]
In this case, both the trial and appellate courts concurred in finding that the alleged negligence of petitioner in the
administration of chemotherapy drugs to respondents child was not proven considering that Drs. Vergara and
Balmaceda, not being oncologists or cancer specialists, were not qualified to give expert opinion as to whether petitioners
lack of skill, knowledge and professional competence in failing to observe the standard of care in her line of practice was
the proximate cause of the patients death. Furthermore, respondents case was not at all helped by the non-production
of medical records by the hospital (only the biopsy result and medical bills were submitted to the court). Nevertheless,
the CA found petitioner liable for her failure to inform the respondents on all possible side effects of chemotherapy before
securing their consent to the said treatment.
The doctrine of informed consent within the context of physician-patient relationships goes far back into English
common law. As early as 1767, doctors were charged with the tort of battery (i.e., an unauthorized physical contact with
a patient) if they had not gained the consent of their patients prior to performing a surgery or procedure. In the United
States, the seminal case wasSchoendorff v. Society of New York Hospital [53] which involved unwanted treatment
performed by a doctor. Justice Benjamin Cardozos oft-quoted opinion upheld the basic right of a patient to give consent
to any medical procedure or treatment: Every human being of adult years and sound mind has a right to determine
what shall be done with his own body; and a surgeon who performs an operation without his patients consent, commits
an assault, for which he is liable in damages. [54] From a purely ethical norm, informed consent evolved into a general
principle of law that a physician has a duty to disclose what a reasonably prudent physician in the medical community in
the exercise of reasonable care would disclose to his patient as to whatever grave risks of injury might be incurred from a
proposed course of treatment, so that a patient, exercising ordinary care for his own welfare, and faced with a choice of
undergoing the proposed treatment, or alternative treatment, or none at all, may intelligently exercise his judgment by
reasonably balancing the probable risks against the probable benefits.[55]
Subsequently, in Canterbury v. Spence[56] the court observed that the duty to disclose should not be limited to
medical usage as to arrogate the decision on revelation to the physician alone. Thus, respect for the patients right of selfdetermination on particular therapy demands a standard set by law for physicians rather than one which physicians may
or may not impose upon themselves.[57] The scope of disclosure is premised on the fact that patients ordinarily are
persons unlearned in the medical sciences. Proficiency in diagnosis and therapy is not the full measure of a physicians
responsibility. It is also his duty to warn of the dangers lurking in the proposed treatment and to impart information
which the patient has every right to expect. Indeed, the patients reliance upon the physician is a trust of the kind which
traditionally has exacted obligations beyond those associated with armslength transactions. [58] The physician is not
expected to give the patient a short medical education, the disclosure rule only requires of him a reasonable explanation,
which means generally informing the patient in nontechnical terms as to what is at stake; the therapy alternatives open to
him, the goals expectably to be achieved, and the risks that may ensue from particular treatment or no treatment. [59] As
to the issue of demonstrating what risks are considered material necessitating disclosure, it was held that experts are
unnecessary to a showing of the materiality of a risk to a patients decision on treatment, or to the reasonably, expectable
effect of risk disclosure on the decision. Such unrevealed risk that should have been made known must further
materialize, for otherwise the omission, however unpardonable, is without legal consequence. And, as in malpractice

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actions generally, there must be a causal relationship between the physicians failure to divulge and damage to the
patient.[60]
Reiterating the foregoing considerations, Cobbs v. Grant[61] deemed it as integral part of physicians overall
obligation to patient, the duty of reasonable disclosure of available choices with respect to proposed therapy and of
dangers inherently and potentially involved in each. However, the physician is not obliged to discuss relatively minor
risks inherent in common procedures when it is common knowledge that such risks inherent in procedure of very low
incidence. Cited as exceptions to the rule that the patient should not be denied the opportunity to weigh the risks of
surgery or treatment are emergency cases where it is evident he cannot evaluate data, and where the patient is a child or
incompetent.[62] The court thus concluded that the patients right of self-decision can only be effectively exercised if the
patient possesses adequate information to enable him in making an intelligent choice. The scope of the physicians
communications to the patient, then must be measured by the patients need, and that need is whatever information is
material to the decision. The test therefore for determining whether a potential peril must be divulged is its materiality to
the patients decision.[63]
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for liability of the physician for
failure to inform patient, there must be causal relationship between physicians failure to inform and the injury to patient
and such connection arises only if it is established that, had revelation been made, consent to treatment would not have
been given.
There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed
consent: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those
risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise
would not have consented to; and (4) plaintiff was injured by the proposed treatment. The gravamen in an informed
consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would
have altered her decision to undergo it.[64]
Examining the evidence on record, we hold that there was adequate disclosure of material risks inherent in the
chemotherapy procedure performed with the consent of Angelicas parents. Respondents could not have been unaware
in the course of initial treatment and amputation of Angelicas lower extremity, that her immune system was already
weak on account of the malignant tumor in her knee. When petitioner informed the respondents beforehand of the side
effects of chemotherapy which includes lowered counts of white and red blood cells, decrease in blood platelets, possible
kidney or heart damage and skin darkening, there is reasonable expectation on the part of the doctor that the
respondents understood very well that the severity of these side effects will not be the same for all patients undergoing
the procedure. In other words, by the nature of the disease itself, each patients reaction to the chemical agents even with
pre-treatment laboratory tests cannot be precisely determined by the physician. That death can possibly result from
complications of the treatment or the underlying cancer itself, immediately or sometime after the administration of
chemotherapy drugs, is a risk that cannot be ruled out, as with most other major medical procedures, but such conclusion
can be reasonably drawn from the general side effects of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the variables in the
recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to
give credence to respondents claim that petitioner told them of 95% chance of recovery for their daughter, as it was

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unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured patients
of chemotherapys success rate. Besides, informed consent laws in other countries generally require only a reasonable
explanation of potential harms, so specific disclosures such as statistical data, may not be legally necessary. [65]
The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to
one simplistic formula applicable in all instances. Further, in a medical malpractice action based on lack of informed
consent, the plaintiff must prove both the duty and the breach of that duty through expert testimony. [66] Such expert
testimony must show the customary standard of care of physicians in the same practice as that of the defendant doctor.
[67]

In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical Specialist of the DOHs
Operational and Management Services charged with receiving complaints against hospitals, does not qualify as expert
testimony to establish the standard of care in obtaining consent for chemotherapy treatment. In the absence of expert
testimony in this regard, the Court feels hesitant in defining the scope of mandatory disclosure in cases of malpractice
based on lack of informed consent, much less set a standard of disclosure that, even in foreign jurisdictions, has been
noted to be an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the medical
profession's intrinsic impetus to cure, the law defining adequate disclosure has undergone a dynamic
evolution. A standard once guided solely by the ruminations of physicians is now dependent on what a
reasonable person in the patients position regards as significant. This change in perspective is especially
important as medical breakthroughs move practitioners to the cutting edge of technology, ever
encountering new and heretofore unimagined treatments for currently incurable diseases or ailments.
An adaptable standard is needed to account for this constant progression. Reasonableness analyses
permeate our legal system for the very reason that they are determined by social norms, expanding and
contracting with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal standard of
disclosure is not subject to construction as a categorical imperative. 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 consumera reasonable person in the
patients position when deciding to accept or reject a recommended medical procedure. [68] (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 isREINSTATED and UPHELD.
No costs.
SO ORDERED.

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RICO ROMMEL ATIENZA,

G.R. No. 177407

Petitioner,
Present:

NACHURA,
Acting Chairperson,
PERALTA,

- versus -

DEL CASTILLO,*
VILLARAMA, JR.,** and
MENDOZA, JJ.

BOARD OF MEDICINE and EDITHA SIOSON,

Promulgated:

Respondents.
February 9, 2011

x------------------------------------------------------------------------------------x

DECISION

NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of Court, assailing the Decision [1] dated
September 22, 2006 of the Court of Appeals (CA) in CA-G.R. SP No. 87755. The CA dismissed the petition
for certiorari filed by petitioner Rico Rommel Atienza (Atienza), which, in turn, assailed the Orders [2] issued by public
respondent Board of Medicine (BOM) in Administrative Case No. 1882.
The facts, fairly summarized by the appellate court, follow.
Due to her lumbar pains, private respondent Editha Sioson went to Rizal Medical Center (RMC)
for check-up on February 4, 1995. Sometime in 1999, due to the same problem, she was referred to Dr.
Pedro Lantin III of RMC who, accordingly, ordered several diagnostic laboratory tests. The tests revealed
that her right kidney is normal. It was ascertained, however, that her left kidney is non-functioning and
non-visualizing. Thus, she underwent kidney operation in September, 1999.
On February 18, 2000, private respondents husband, Romeo Sioson (as complainant), filed a
complaint for gross negligence and/or incompetence before the [BOM] against the doctors who allegedly

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participated in the fateful kidney operation, namely: Dr. Judd dela Vega, Dr. Pedro Lantin, III, Dr.
Gerardo Antonio Florendo and petitioner Rico Rommel Atienza.
It was alleged in the complaint that the gross negligence and/or incompetence committed by the
said doctors, including petitioner, consists of the removal of private respondents fully functional right
kidney, instead of the left non-functioning and non-visualizing kidney.
The complaint was heard by the [BOM]. After complainant Romeo Sioson presented his evidence,
private respondent Editha Sioson, also named as complainant there, filed her formal offer of
documentary evidence. Attached to the formal offer of documentary evidence are her Exhibits A to D,
which she offered for the purpose of proving that her kidneys were both in their proper anatomical
locations at the time she was operated. She described her exhibits, as follows:
EXHIBIT A the certified photocopy of the X-ray Request form dated
December 12, 1996, which is also marked as Annex 2 as it was actually originally the
Annex to x x x Dr. Pedro Lantin, IIIs counter affidavit filed with the City Prosecutor of
Pasig City in connection with the criminal complaint filed by [Romeo Sioson] with the
said office, on which are handwritten entries which are the interpretation of the results
of the ultrasound examination. Incidentally, this exhibit happens to be the same as or
identical to the certified photocopy of the document marked as Annex 2 to the CounterAffidavit dated March 15, 2000, filed by x x x Dr. Pedro Lantin, III, on May 4, 2000, with
this Honorable Board in answer to this complaint;
EXHIBIT B the certified photo copy of the X-ray request form dated January
30, 1997, which is also marked as Annex 3 as it was actually likewise originally an
Annex to x x x Dr. Pedro Lantin, IIIs counter-affidavit filed with the Office of the City
Prosecutor of Pasig City in connection with the criminal complaint filed by the herein
complainant with the said office, on which are handwritten entries which are the
interpretation of the results of the examination. Incidentally, this exhibit happens to be
also the same as or identical to the certified photo copy of the document marked as
Annex 3 which is likewise dated January 30, 1997, which is appended as such Annex 3
to the counter-affidavit dated March 15, 2000, filed by x x x Dr. Pedro Lantin, III on May
4, 2000, with this Honorable Board in answer to this complaint.
EXHIBIT C the certified photocopy of the X-ray request form dated March 16,
1996, which is also marked as Annex 4, on which are handwritten entries which are the
interpretation of the results of the examination.
EXHIBIT D the certified photocopy of the X-ray request form dated May 20,
1999, which is also marked as Annex 16, on which are handwritten entries which are
the interpretation of the results of the examination. Incidentally, this exhibit appears to
be the draft of the typewritten final report of the same examination which is the
document appended as Annexes 4 and 1 respectively to the counter-affidavits filed by x
x x Dr. Judd dela Vega and Dr. Pedro Lantin, III in answer to the complaint. In the case
of Dr. dela Vega however, the document which is marked as Annex 4 is not a certified
photocopy, while in the case of Dr. Lantin, the document marked as Annex 1 is a
certified photocopy. Both documents are of the same date and typewritten contents are
the same as that which are written on Exhibit D.
Petitioner filed his comments/objections to private respondents [Editha Siosons] formal offer of
exhibits. He alleged that said exhibits are inadmissible because the same are mere photocopies, not
properly identified and authenticated, and intended to establish matters which are hearsay. He added
that the exhibits are incompetent to prove the purpose for which they are offered.

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Dispositions of the Board of Medicine


The formal offer of documentary exhibits of private respondent [Editha Sioson] was admitted by
the [BOM] per its Order dated May 26, 2004. It reads:
The Formal Offer of Documentary Evidence of [Romeo Sioson], the
Comments/Objections of [herein petitioner] Atienza, [therein respondents] De la Vega
and Lantin, and the Manifestation of [therein] respondent Florendo are hereby
ADMITTED by the [BOM] for whatever purpose they may serve in the resolution of this
case.
Let the hearing be set on July 19, 2004 all at 1:30 p.m. for the reception of the
evidence of the respondents.
SO ORDERED.
Petitioner moved for reconsideration of the abovementioned Order basically on the same reasons
stated in his comment/objections to the formal offer of exhibits.
The [BOM] denied the motion for reconsideration of petitioner in its Order dated October 8,
2004. It concluded that it should first admit the evidence being offered so that it can determine its
probative value when it decides the case. According to the Board, it can determine whether the evidence
is relevant or not if it will take a look at it through the process of admission. x x x. [3]

Disagreeing with the BOM, and as previously adverted to, Atienza filed a petition for certiorari with the CA,
assailing the BOMs Orders which admitted Editha Siosons (Edithas) Formal Offer of Documentary Evidence. The CA
dismissed the petition for certiorari for lack of merit.
Hence, this recourse positing the following issues:
I.

PROCEDURAL ISSUE:
WHETHER PETITIONER ATIENZA AVAILED OF THE PROPER REMEDY WHEN HE FILED
THE PETITION FORCERTIORARI DATED 06 DECEMBER 2004 WITH THE COURT OF
APPEALS UNDER RULE 65 OF THE RULES OF COURT TO ASSAIL THE ORDERS DATED 26
MAY 2004 AND 08 OCTOBER 2004 OF RESPONDENT BOARD.

II.

SUBSTANTIVE ISSUE:
WHETHER THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR AND
DECIDED A QUESTION OF SUBSTANCE IN A WAY NOT IN ACCORDANCE WITH LAW AND
THE APPLICABLE DECISIONS OF THE HONORABLE COURT WHEN IT UPHELD THE
ADMISSION OF INCOMPETENT AND INADMISSIBLE EVIDENCE BY RESPONDENT
BOARD, WHICH CAN RESULT IN THE DEPRIVATION OF PROFESSIONAL LICENSE A
PROPERTY RIGHT OR ONES LIVELIHOOD.[4]

We find no reason to depart from the ruling of the CA.

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Petitioner is correct when he asserts that a petition for certiorari is the proper remedy to assail the Orders of the
BOM, admitting in evidence the exhibits of Editha. As the assailed Orders were interlocutory, these cannot be the subject
of an appeal separate from the judgment that completely or finally disposes of the case. [5] At that stage, where there is no
appeal, or any plain, speedy, and adequate remedy in the ordinary course of law, the only and remaining remedy left to
petitioner is a petition forcertiorari under Rule 65 of the Rules of Court on the ground of grave abuse of discretion
amounting to lack or excess of jurisdiction.
However, the writ of certiorari will not issue absent a showing that the BOM has acted without or in excess of
jurisdiction or with grave abuse of discretion. Embedded in the CAs finding that the BOM did not exceed its jurisdiction
or act in grave abuse of discretion is the issue of whether the exhibits of Editha contained in her Formal Offer of
Documentary Evidence are inadmissible.
Petitioner argues that the exhibits formally offered in evidence by Editha: (1) violate the best evidence rule; (2)
have not been properly identified and authenticated; (3) are completely hearsay; and (4) are incompetent to prove their
purpose. Thus, petitioner contends that the exhibits are inadmissible evidence.
We disagree.
To begin with, it is well-settled that the rules of evidence are not strictly applied in proceedings before
administrative bodies such as the BOM. [6] Although trial courts are enjoined to observe strict enforcement of the rules of
evidence,[7] in connection with evidence which may appear to be of doubtful relevancy, incompetency, or admissibility, we
have held that:
[I]t is the safest policy to be liberal, not rejecting them on doubtful or technical grounds, but admitting
them unless plainly irrelevant, immaterial or incompetent, for the reason that their rejection places them
beyond the consideration of the court, if they are thereafter found relevant or competent; on the other
hand, their admission, if they turn out later to be irrelevant or incompetent, can easily be remedied by
completely discarding them or ignoring them.[8]

From the foregoing, we emphasize the distinction between the admissibility of evidence and the probative weight to
be accorded the same pieces of evidence. PNOC Shipping and Transport Corporation v. Court of Appeals[9] teaches:
Admissibility of evidence refers to the question of whether or not the circumstance (or evidence) is to be
considered at all. On the other hand, the probative value of evidence refers to the question of whether or
not it proves an issue.

Second, petitioners insistence that the admission of Edithas exhibits violated his substantive rights leading to
the loss of his medical license is misplaced. Petitioner mistakenly relies on Section 20, Article I of the Professional
Regulation Commission Rules of Procedure, which reads:
Section 20. Administrative investigation shall be conducted in accordance with these Rules. The Rules of Court
shall only apply in these proceedings by analogy or on a suppletory character and whenever practicable and convenient.

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Technical errors in the admission of evidence which do not prejudice the substantive rights of either party shall not
vitiate the proceedings.[10]
As pointed out by the appellate court, the admission of the exhibits did not prejudice the substantive rights of
petitioner because, at any rate, the fact sought to be proved thereby, that the two kidneys of Editha were in their proper
anatomical locations at the time she was operated on, is presumed under Section 3, Rule 131 of the Rules of Court:
Sec. 3. Disputable presumptions. The following presumptions are satisfactory if uncontradicted,
but may be contradicted and overcome by other evidence:
xxxx
(y) That things have happened according to the ordinary course of nature and the ordinary habits
of life.

The exhibits are certified photocopies of X-ray Request Forms dated December 12, 1996, January 30, 1997,
March 16, 1996, and May 20, 1999, filed in connection with Edithas medical case. The documents contain handwritten
entries interpreting the results of the examination. These exhibits were actually attached as annexes to Dr. Pedro Lantin
IIIs counter affidavit filed with the Office of the City Prosecutor of Pasig City, which was investigating the criminal
complaint for negligence filed by Editha against the doctors of Rizal Medical Center (RMC) who handled her surgical
procedure. To lay the predicate for her case, Editha offered the exhibits in evidence to prove that her kidneys were both
in their proper anatomical locations at the time of her operation.
The fact sought to be established by the admission of Edithas exhibits, that her kidneys were both in their
proper anatomical locations at the time of her operation, need not be proved as it is covered by mandatory judicial
notice.[11]
Unquestionably, the rules of evidence are merely the means for ascertaining the truth respecting a matter of fact.
[12]

Thus, they likewise provide for some facts which are established and need not be proved, such as those covered by

judicial notice, both mandatory and discretionary. [13] Laws of nature involving the physical sciences, specifically biology,
[14]

include the structural make-up and composition of living things such as human beings. In this case, we may take

judicial notice that Edithas kidneys before, and at the time of, her operation, as with most human beings, were in their
proper anatomical locations.
Third, contrary to the assertion of petitioner, the best evidence rule is inapplicable. Section 3 of Rule 130 provides:
1.

Best Evidence Rule

Sec. 3. Original document must be produced; exceptions. When the subject of inquiry is the
contents of a document, no evidence shall be admissible other than the original document itself, except
in the following cases:
(a)
When the original has been lost or destroyed, or cannot be produced in court, without bad
faith on the part of the offeror;

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Page 129

(b)
When the original is in the custody or under the control of the party against whom the
evidence is offered, and the latter fails to produce it after reasonable notice;
(c)
When the original consists of numerous accounts or other documents which cannot be
examined in court without great loss of time and the fact sought to be established from them is only the
general result of the whole; and
(d)
When the original is a public record in the custody of a public officer or is recorded in a
public office.

The subject of inquiry in this case is whether respondent doctors before the BOM are liable for gross negligence in
removing the right functioning kidney of Editha instead of the left non-functioning kidney, not the proper anatomical
locations of Edithas kidneys. As previously discussed, the proper anatomical locations of Edithas kidneys at the time of
her operation at the RMC may be established not only through the exhibits offered in evidence.
Finally, these exhibits do not constitute hearsay evidence of the anatomical locations of Edithas kidneys. To
further drive home the point, the anatomical positions, whether left or right, of Edithas kidneys, and the removal of one
or both, may still be established through a belated ultrasound or x-ray of her abdominal area.
In fact, the introduction of secondary evidence, such as copies of the exhibits, is allowed. [15] Witness Dr. Nancy
Aquino testified that the Records Office of RMC no longer had the originals of the exhibits because [it] transferred from
the previous building, x x x to the new building. [16] Ultimately, since the originals cannot be produced, the BOM properly
admitted Edithas formal offer of evidence and, thereafter, the BOM shall determine the probative value thereof when it
decides the case.
WHEREFORE, the petition is DENIED. The Decision of the Court of Appeals in CA-G.R. SP No. 87755
is AFFIRMED. Costs against petitioner.

SO ORDERED.

DR. EMMANUEL JARCIA, JR.and DR.


MARILOU BASTAN,
Petitioners,

- versus -

G.R. No. 187926


Present:
CARPIO,* J.,
PERALTA,** Acting Chairperson,
ABAD,
PEREZ,*** and
MENDOZA, JJ.
Promulgated:

PEOPLE OF THEPHILIPPINES,

Reyes, Hazel

February 15, 2012

Page 130

Respondent.
x --------------------------------------------------------------------------------------- x

DECISION
MENDOZA, J.:
Even early on, patients have consigned their lives to the skill of their doctors. Time and again,
it can be said that the most important goal of the medical profession is the preservation of life and
health of the people. Corollarily, when a physician departs from his sacred duty and endangers instead
the life of his patient, he must be made liable for the resulting injury. This Court, as this case would
show, cannot and will not let the act go unpunished.[1]
This is a petition for review under Rule 45 of the Rules of Court challenging the August 29, 2008 Decision [2] of
the Court of Appeals (CA), and its May 19, 2009 Resolution[3] in CA-G.R. CR No. 29559, dismissing the appeal and
affirming in toto the June 14, 2005 Decision [4] of the Regional Trial Court, Branch 43, Manila (RTC), finding the accused
guilty beyond reasonable doubt of simple imprudence resulting to serious physical injuries.

THE FACTS

Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the
petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect of
professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon
investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an
emergency medical treatment; that an X-ray of the victims ankle was ordered; that the X-ray result showed no fracture
as read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own examination of
the victim, informed Mrs. Santiago that since it was only the ankle that was hit, there was no need to examine the upper
leg; that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg and misalignment of the right foot; that
Mrs. Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial fracture and a linear
hairline fracture in the shaft of the bone.
The NBI indorsed the matter to the Office of the City Prosecutor of Manila for preliminary investigation.
Probable cause was found and a criminal case for reckless imprudence resulting to serious physical injuries, was filed
against Dr. Jarcia, Dr. Bastan and Dr. Pamittan, [5] before the RTC, docketed as Criminal Case No. 01-196646.
On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple
Imprudence Resulting to Serious Physical Injuries. The decretal portion of the RTC decision reads:
WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA,
JR. and DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE
IMPRUDENCE RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced to suffer the
penalty of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to indemnify MRS.

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Page 131

BELINDA SANTIAGO the amount of 3,850.00 representing medical expenses without subsidiary
imprisonment in case of insolvency and to pay the costs.
It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite
warrant issued for her arrest, let warrant be issued for her arrest and the case against her be ARCHIVED,
to be reinstated upon her apprehension.
SO ORDERED.[6]

The RTC explained:


After a thorough and in depth evaluation of the evidence adduced by the prosecution and the
defense, this court finds that the evidence of the prosecution is the more credible, concrete and sufficient
to create that moral certainty in the mind of the Court that accused herein [are] criminally
responsible. The Court believes that accused are negligent when both failed to exercise the necessary and
reasonable prudence in ascertaining the extent of injury of Alfonso Santiago, Jr.

However, the negligence exhibited by the two doctors does not approximate negligence of a
reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the lack of
precaution displayed in those cases in which the damage impending to be caused is not the immediate
nor the danger clearly manifest. The elements of simple imprudence are as follows.
1.
2.

that there is lack of precaution on the part of the offender; and


that the damage impending to be caused is not immediate of the danger is not
clearly manifest.

Considering all the evidence on record, The Court finds the accused guilty for simple imprudence
resulting to physical injuries. Under Article 365 of the Revised Penal Code, the penalty provided for is
arresto mayor in its minimum period.[7]

Dissatisfied, the petitioners appealed to the CA.


As earlier stated, the CA affirmed the RTC decision in toto. The August 29, 2008 Decision of the CA
pertinently reads:
This Court holds concurrently and finds the foregoing circumstances sufficient to sustain a
judgment of conviction against the accused-appellants for the crime of simple imprudence resulting in
serious physical injuries. The elements of imprudence are: (1) that the offender does or fails to do an
act; (2) that the doing or the failure to do that act is voluntary; (3) that it be without malice; (4) that
material damage results from the imprudence; and (5) that there is inexcusable lack of precaution on the
part of the offender, taking into consideration his employment or occupation, degree of intelligence,
physical condition, and other circumstances regarding persons, time and place.
Whether or not Dr. Jarcia and Dr. Bastan had committed an inexcusable lack of precaution in
the treatment of their patient is to be determined according to the standard of care observed by other
members of the profession in good standing under similar circumstances, bearing in mind the advanced
state of the profession at the time of treatment or the present state of medical science. In the case
of Leonila Garcia-Rueda v. Pascasio, the Supreme Court stated that, in accepting a case, a doctor in

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Page 132

effect represents that, having the needed training and skill possessed by physicians and surgeons
practicing in the same field, he will employ such training, care and skill in the treatment of his
patients. He therefore has a duty to use at least the same level of care that any other reasonably
competent doctor would use to treat a condition under the same circumstances.
In litigations involving medical negligence, the plaintiff has the burden of establishing accusedappellants negligence, and for a reasonable conclusion of negligence, there must be proof of breach of
duty on the part of the physician as well as a causal connection of such breach and the resulting injury of
his patient. The connection between the negligence and the injury must be a direct and natural sequence
of events, unbroken by intervening efficient causes. In other words, the negligence must be the
proximate cause of the injury. Negligence, no matter in what it consists, cannot create a right of action
unless it is the proximate cause of the injury complained of. The proximate cause of an injury is that
cause which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces
the injury and without which the result would not have occurred.
In the case at bench, the accused-appellants questioned the imputation against them and argued
that there is no causal connection between their failure to diagnose the fracture and the injury sustained
by Roy.
We are not convinced.
The prosecution is however after the cause which prolonged the pain and suffering of Roy and not
on the failure of the accused-appellants to correctly diagnose the extent of the injury sustained by Roy.
For a more logical presentation of the discussion, we shall first consider the applicability of the
doctrine of res ipsa loquitur to the instant case. Res ipsa loquitur is a Latin phrase which literally
means the thing or the transaction speaks for itself. The doctrine of res ipsa loquitur is simply a
recognition of the postulate that, as a matter of common knowledge and experience, the very nature of
certain types of occurrences may justify an inference of negligence on the part of the person who controls
the instrumentality causing the injury in the absence of some explanation by the accused-appellant who
is charged with negligence. It is grounded in the superior logic of ordinary human experience and, on the
basis of such experience or common knowledge, negligence may be deduced from the mere occurrence of
the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common
knowledge.
The specific acts of negligence was narrated by Mrs. Santiago who accompanied her son during
the latters ordeal at the hospital. She testified as follows:
Fiscal Formoso:
Q:
A:

Q:
A:

Now, he is an intern did you not consult the doctors, Dr. Jarcia or Dra. Pamittan
to confirm whether you should go home or not?
Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let us go
home and you dont even clean the wounds of my son.
And what did she [tell] you?
They told me they will call a resident doctor, sir.
xxx

Q:
A:
Q:
A:

Reyes, Hazel

xxx

xxx

Was there a resident doctor [who] came?


Yes, Sir. Dra. Bastan arrived.
Did you tell her what you want on you to be done?
Yes, sir.

Page 133

Q:
A:

What did you [tell] her?


I told her, sir, while she was cleaning the wounds of my son, are you not going to
x-ray up to the knee because my son was complaining pain from his ankle up to
the middle part of the right leg.

Q:
A:

And what did she tell you?


According to Dra. Bastan, there is no need to x-ray because it was the ankle part
that was run over.

Q:
A:

What did you do or tell her?


I told her, sir, why is it that they did not examine[x] the whole leg. They just lifted
the pants of my son.

Q:
A:

So you mean to say there was no treatment made at all?


None, sir.
xxx

A:

xxx

xxx

I just listened to them, sir. And I just asked if I will still return my son.
xxx

xxx

xxx

Q:
A:

And you were present when they were called?


Yes, sir.

Q:
A:

And what was discussed then by Sis. Retoria?


When they were there they admitted that they have mistakes, sir.

Still, before resort to the doctrine may be allowed, the following requisites must be satisfactorily shown:
1.

The accident is of a kind which ordinarily does not occur in the absence of
someones negligence;

2.

It is caused by an instrumentality within the exclusive control of the defendant or


defendants; and

3. The possibility of contributing conduct which would make the plaintiff responsible is
eliminated.
In the above requisites, the fundamental element is the control of the instrumentality which
caused the damage. Such element of control must be shown to be within the dominion of the accusedappellants. In order to have the benefit of the rule, a plaintiff, in addition to proving injury or damage,
must show a situation where it is applicable and must establish that the essential elements of the
doctrine were present in a particular incident. The early treatment of the leg of Roy would have lessen
his suffering if not entirely relieve him from the fracture. A boy of tender age whose leg was hit by a
vehicle would engender a well-founded belief that his condition may worsen without proper medical
attention. As junior residents who only practice general surgery and without specialization with the case
consulted before them, they should have referred the matter to a specialist. This omission alone
constitutes simple imprudence on their part. When Mrs. Santiago insisted on having another x-ray of
her child on the upper part of his leg, they refused to do so. The mother would not have asked them if
they had no exclusive control or prerogative to request an x-ray test. Such is a fact because a radiologist
would only conduct the x-ray test upon request of a physician.

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Page 134

The testimony of Mrs. Santiago was corroborated by a bone specialist Dr. Tacata. He further
testified based on his personal knowledge, and not as an expert, as he examined himself the child Roy.
He testified as follows:
Fiscal Macapagal:
Q:
A:

Q:
A:

And was that the correct respon[se] to the medical problem that was presented to
Dr. Jarcia and Dra. Bastan?
I would say at that stage, yes. Because they have presented the patient and the
history. At sabi nila, nadaanan lang po ito. And then, considering their year of
residency they are still junior residents, and they are not also orthopedic
residents but general surgery residents, its entirely different thing. Because if
you are an orthopedic resident, I am not trying to saybut if I were an
orthopedic resident, there would be more precise and accurate decision compare
to a general surgery resident in so far as involved.
You mean to say there is no supervisor attending the emergency room?
At the emergency room, at the Manila Doctors Hospital, the supervisor there is a
consultant that usually comes from a family medicine. They see where a certain
patient have to go and then if they cannot manage it, they refer it to the
consultant on duty. Now at that time, I dont [know] why they dont.Because at
that time, I think, it is the decision. Since the x-rays.

Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to
whether a patient has been treated or operated upon with a reasonable degree of skill and care. However,
testimony as to the statements and acts of physicians, external appearances, and manifest conditions
which are observable by any one may be given by non-expert witnesses. Hence, in cases where the res
ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of
injury to the patient, without the aid of expert testimony, where the court from its fund of common
knowledge can determine the proper standard of care. Where common knowledge and experience teach
that a resulting injury would not have occurred to the patient if due care had been exercised, an inference
of negligence may be drawn giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what occurred but how and why it
occurred. In the case at bench, we give credence to the testimony of Mrs. Santiago by applying the
doctrine of res ipsa loquitur.
Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case. It is generally restricted to situations
in malpractice cases where a layman is able to say, as a matter of common knowledge and observation,
that the consequences of professional care were not as such as would ordinarily have followed if due care
had been exercised. A distinction must be made between the failure to secure results and the occurrence
of something more unusual and not ordinarily found if the service or treatment rendered followed the
usual procedure of those skilled in that particular practice. The latter circumstance is the primordial
issue that confronted this Court and we find application of the doctrine of res ipsa loquitur to be in
order.
WHEREFORE, in view of the foregoing, the appeal in this case is hereby DISMISSED and the
assailed decision of the trial court finding accused-appellants guilty beyond reasonable doubt of simple
imprudence resulting in serious physical injuries is hereby AFFIRMED in toto.
SO ORDERED.[8]

Reyes, Hazel

Page 135

The petitioners filed a motion for reconsideration, but it was denied by the CA in its May 19,
2009 Resolution.
Hence, this petition.

The petitioners pray for the reversal of the decision of both the RTC and the CA anchored on the following
GROUNDS1.
IN AFFIRMING ACCUSED-PETITIONERS CONVICTION, THE COURT OF
APPEALS ERRED IN NOT HOLDING THAT THE ACTUAL, DIRECT, IMMEDIATE, AND
PROXIMATE CAUSE OF THE PHYSICAL INJURY OF THE PATIENT (FRACTURE OF THE
LEG BONE OR TIBIA), WHICH REQUIRED MEDICAL ATTENDANCE FOR MORE THAN
THIRTY (30) DAYS AND INCAPACITATED HIM FROM PERFORMING HIS CUSTOMARY
DUTY DURING THE SAME PERIOD OF TIME, WAS THE VEHICULAR ACCIDENT
WHERE THE PATIENTS RIGHT LEG WAS HIT BY A TAXI, NOT THE FAILURE OF THE
ACCUSED-PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY
EXAMINATION.
2.
THE COURT OF APPEALS ERRED IN DISREGARDING ESTABLISHED
FACTS CLEARLY NEGATING PETITIONERS ALLEGED NEGLIGENCE OR IMPRUDENCE.
SIGNIFICANTLY, THE COURT OF APPEALS UNJUSTIFIABLY DISREGARDED THE
OPINION OF THE PROSECUTIONS EXPERT WITNESS, DR. CIRILO TACATA, THAT
PETITIONERS WERE NOT GUILTY OF NEGLIGENCE OR IMPRUDENCE COMPLAINED
OF.
3.
THE COURT OF APPEALS ERRED IN HOLDING THAT THE FAILURE OF
PETITIONERS TO SUBJECT THE PATIENTS WHOLE LEG TO AN X-RAY EXAMINATION
PROLONGED THE PAIN AND SUFFERING OF THE PATIENT, SUCH CONCLUSION
BEING UNSUPPORTED BY, AND EVEN CONTRARY TO, THE EVIDENCE ON RECORD.
4.
ASSUMING ARGUENDO THAT THE PATIENT EXPERIENCED PROLONGED
PAIN AND SUFFERING, THE COURT OF APPEALS ERRED IN NOT HOLDING THAT THE
ALLEGED PAIN AND SUFFERING WERE DUE TO THE UNJUSTIFIED FAILURE OF THE
PATIENTS MOTHER, A NURSE HERSELF, TO IMMEDIATELY BRING THE PATIENT
BACK TO THE HOSPITAL, AS ADVISED BY THE PETITIONERS, AFTER HE
COMPLAINED OF SEVERE PAIN IN HIS RIGHT LEG WHEN HE REACHED HOME AFTER
HE WAS SEEN BY PETITIONERS AT THE HOSPITAL. THUS, THE PATIENTS ALLEGED
INJURY (PROLONGED PAIN AND SUFFERING) WAS DUE TO HIS OWN MOTHERS ACT
OR OMISSION.
5.
THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO PHYSICIANPATIENT RELATIONSHIP EXISTED BETWEEN PETITIONERS AND PATIENT ALFONSO
SANTIAGO, JR., PETITIONERS NOT BEING THE LATTERS ATTENDING PHYSICIAN AS
THEY WERE MERELY REQUESTED BY THE EMERGENCY ROOM (ER) NURSE TO SEE
THE PATIENT WHILE THEY WERE PASSING BY THE ER FOR THEIR LUNCH.
6.
THE COURT OF APPEALS GRAVELY ERRED IN NOT ACQUITTING
ACCUSED-PETITIONERS OF THE CRIME CHARGED.[9]

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Page 136

The foregoing can be synthesized into two basic issues: [1] whether or not the doctrine of res ipsa loquitur is
applicable in this case; and [2] whether or not the petitioners are liable for criminal negligence.

THE COURTS RULING

The CA is correct in finding that there was negligence on the part of the petitioners. After a perusal of the records,
however, the Court is not convinced that the petitioners are guilty of criminal negligence complained of. The Court is also
of the view that the CA erred in applying the doctrine of res ipsa loquitur in this particular case.

As to the Application of
The Doctrine of Res Ipsa Loquitur

This doctrine of res ipsa loquitur means "Where the thing which causes injury is shown to be under the
management of the defendant, and the accident is such as in the ordinary course of things does not happen if those who
have the management use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant,
that the accident arose from want of care." The Black's Law Dictionary defines the said doctrine. Thus:
The thing speaks for itself. Rebuttable presumption or inference that defendant was negligent,
which arises upon proof that the instrumentality causing injury was in defendant's exclusive control, and
that the accident was one which ordinarily does not happen in absence of negligence. Res ipsa
loquitur is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the
mere fact that the accident happened provided the character of the accident and circumstances attending
it lead reasonably to belief that in the absence of negligence it would not have occurred and that thing
which caused injury is shown to have been under the management and control of the alleged wrongdoer.
Under this doctrine, the happening of an injury permits an inference of negligence where plaintiff
produces substantial evidence that the injury was caused by an agency or instrumentality under the
exclusive control and management of defendant, and that the occurrence was such that in the ordinary
course of things would not happen if reasonable care had been used. [10]

The doctrine of res ipsa loquitur as a rule of evidence is unusual to the law of negligence which recognizes
that prima facienegligence may be established without direct proof and furnishes a substitute for specific proof of
negligence. The doctrine, however, is not a rule of substantive law, but merely a mode of proof or a mere procedural
convenience. The rule, when applicable to the facts and circumstances of a given case, is not meant to and does not
dispense with the requirement of proof of culpable negligence on the party charged. It merely determines and regulates
what shall be prima facie evidence thereof and helps the plaintiff in proving a breach of the duty. The doctrine can be
invoked when and only when, under the circumstances involved, direct evidence is absent and not readily available. [11]

The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was of a kind which
does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was

Reyes, Hazel

Page 137

under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary
action or contribution of the person injured.[12]

In this case, the circumstances that caused patient Roy Jr.s injury and the series of tests that were supposed to
be undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. Jarcia
and Bastan. It was established that they are mere residents of the Manila Doctors Hospital at that time who attended to
the victim at the emergency room.[13] While it may be true that the circumstances pointed out by the courts below seem
doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not
through the scholarly assumptions of a layman like the patients mother, but by the unquestionable knowledge of expert
witness/es. As to whether the petitioners have exercised the requisite degree of skill and care in treating patient Roy, Jr.
is generally a matter of expert opinion.
As to Dr. Jarcia and
Dr. Bastans negligence
The totality of the evidence on record clearly points to the negligence of the petitioners. At the risk of being
repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are criminally negligent in this case.
Negligence is defined as the failure to observe for the protection of the interests of another person that degree of
care, precaution, and vigilance which the circumstances justly demand, whereby such other person suffers injury. [14]

Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material
damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform
such act.[15]

The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender, and (2) that
the damage impending to be caused is not immediate or the danger is not clearly manifest.[16]

In this case, the Court is not convinced with moral certainty that the petitioners are guilty of reckless imprudence
or simple negligence. The elements thereof were not proved by the prosecution beyond reasonable doubt.
The testimony of Dr. Cirilo R. Tacata (Dr. Tacata), a specialist in pediatric orthopedic, although pointing to some
medical procedures that could have been done by Dr. Jarcia and Dr. Bastan, as physicians on duty, was not clear as to
whether the injuries suffered by patient Roy Jr. were indeed aggravated by the petitioners judgment call and their
diagnosis or appreciation of the condition of the victim at the time they assessed him. Thus:
Q:
A:

Will you please tell us, for the record, doctor, what is your specialization?
At present I am the chairman department of orthopedic in UP-PGH and I had special training in
pediatric orthopedic for two (2) years.

Reyes, Hazel

Page 138

Q:
A:

In June 1998, doctor, what was your position and what was your specialization at that time?
Since 1980, I have been specialist in pediatric orthopedic.

Q:

When Alfonso Santiago, Jr. was brought to you by his mother, what did you do by way of physicians
as first step?
As usual, I examined the patient physically and, at that time as I have said, the patient could not
walk so I [began] to suspect that probably he sustained a fracture as a result of a vehicular
accident. So I examined the patient at that time, the involved leg, I dont know if that is left or
right, the involved leg then was swollen and the patient could not walk, so I requested for the x-ray
of [the] lower leg.

A:

Q:
A:

What part of the leg, doctor, did you request to be examined?


If we refer for an x-ray, usually, we suspect a fracture whether in approximal, middle
or lebistal tinial, we usually x-ray the entire extremity.

Q:
A:

And what was the result?


Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger bone of the leg.

Q:
A:

And when you say spiral, doctor, how long was this fracture?
When we say spiral, it is a sort of letter S, the length was about six (6) to eight (8) centimeters.

Q:

Mid-tibial, will you please point to us, doctor, where the tibial is?
(Witness pointing to his lower leg)
The tibial is here, there are two bones here, the bigger one is the tibial and the smaller one is the
fibula. The bigger one is the one that get fractured.

A:
Q:
A:

And in the course of your examination of Alfonso Santiago, Jr. did you ask for the history of such
injury?
Yes, actually, that was a routine part of our examination that once a patient comes in, before we
actually examine the patient, we request for a detailed history. If it is an accident, then, we request
for the exact mechanism of injuries.

Q:
A:

And as far as you can recall, Doctor, what was the history of that injury that was told to you?
The patient was sideswiped, I dont know if it is a car, but it is a vehicular accident.

Q:
A:

Who did you interview?


The mother.

Q:
A:

How about the child himself, Alfonso Santiago, Jr.?


Normally, we do not interview the child because, usually, at his age, the answers are not accurate.
So, it was the mother that I interviewed.

Q:
A:

And were you informed also of his early medication that was administered on Alfonso Santiago, Jr.?
No, not actually medication. I was informed that this patient was seen initially at the emergency
room by the two (2) physicians that you just mentioned, Dr. Jarcia and Dra. Bastan, that time who
happened to be my residents who were [on] duty at the emergency room.
xxxx

A:

At the emergency room, at the Manila Doctors Hospital, the supervisor there is a consultant that
usually comes from a family medicine. They see where a certain patient have to go and then if they
cannot manage it, they refer it to the consultant on duty. Now at that time, I dont why they dont
Because at that time, I think, it is the decision. Since the x-rays
xxx

Q:
A:

You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an orthopedic specialist.
They are general surgeon residents. You have to man[x] the emergency room,
including neurology, orthopedic, general surgery, they see everything at the
emergency room.
xxxx

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Q:
A:

But if initially, Alfonso Santiago, Jr. and his case was presented to you at the
emergency room, you would have subjected the entire foot to x-ray even if the history
that was given to Dr. Jarcia and Dra. Bastan is the same?
I could not directly say yes, because it would still depend on my examination, we
cannot subject the whole body for x-ray if we think that the damaged was only the
leg.

Q:
A:

Not the entire body but the entire leg?


I think, if my examination requires it, I would.

Q:
A:

So, you would conduct first an examination?


Yes, sir.

Q:

And do you think that with that examination that you would have conducted you
would discover the necessity subjecting the entire foot for x-ray?
It is also possible but according to them, the foot and the ankle were swollen and not
the leg, which sometimes normally happens that the actual fractured bone do not get
swollen.

A:

xxxx
Q:
A:

Doctor, if you know that the patient sustained a fracture on the ankle and on the foot
and the history that was told to you is the region that was hit is the region of the foot,
will the doctor subject the entire leg for x-ray?
I am an orthopedic surgeon, you have to subject an x-ray of the leg. Because you have
to consider the kind of fracture that the patient sustained would you say the exact
mechanism of injury. For example spiral, paikot yung bale nya, so it was possible
that the leg was run over, the patient fell, and it got twisted. Thats why the leg seems
to be fractured.[17] [Emphases supplied]

It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not performed on Roy Jr. As
residents on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected to know the medical protocol in
treating leg fractures and in attending to victims of car accidents. There was, however, no precise evidence and scientific
explanation pointing to the fact that the delay in the application of the cast to the patients fractured leg because of failure
to immediately diagnose the specific injury of the patient, prolonged the pain of the child or aggravated his condition or
even caused further complications. Any person may opine that had patient Roy Jr. been treated properly and given the
extensive X-ray examination, the extent and severity of the injury, spiral fracture of the mid-tibial part or the bigger bone
of the leg, could have been detected early on and the prolonged pain and suffering of Roy Jr. could have been prevented.
But still, that opinion, even how logical it may seem would not, and could not, be enough basis to hold one criminally
liable; thus, a reasonable doubt as to the petitioners guilt.
Although the Court sympathizes with the plight of the mother and the child in this case, the Court is bound by the
dictates of justice which hold inviolable the right of the accused to be presumed innocent until proven guilty beyond
reasonable doubt. The Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently attend to Roy
Jr.s medical needs when the latter was rushed to the ER, for while a criminal conviction requires proof beyond
reasonable doubt, only a preponderance of evidence is required to establish civil liability. Taken into account also was the
fact that there was no bad faith on their part.
Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the victim. It may be true that the
actual, direct, immediate, and proximate cause of the injury (fracture of the leg bone or tibia) of Roy Jr. was the vehicular

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accident when he was hit by a taxi. The petitioners, however, cannot simply invoke such fact alone to excuse themselves
from any liability. If this would be so, doctors would have a ready defense should they fail to do their job in attending to
victims of hit-and-run, maltreatment, and other crimes of violence in which the actual, direct, immediate, and proximate
cause of the injury is indubitably the act of the perpetrator/s.
In failing to perform an extensive medical examination to determine the extent of Roy Jr.s injuries, Dr. Jarcia
and Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for the sake of argument that
they did not have the capacity to make such thorough evaluation at that stage, they should have referred the patient to
another doctor with sufficient training and experience instead of assuring him and his mother that everything was all
right.
This Court cannot also stamp its imprimatur on the petitioners contention that no physician-patient relationship
existed between them and patient Roy Jr., since they were not his attending physicians at that time. They claim that they
were merely requested by the ER nurse to see the patient while they were passing by the ER for their lunch. Firstly, this
issue was never raised during the trial at the RTC or even before the CA. The petitioners, therefore, raise the want of
doctor-patient relationship for the first time on appeal with this Court. It has been settled that issues raised for the first
time on appeal cannot be considered because a party is not permitted to change his theory on appeal. To allow him to do
so is unfair to the other party and offensive to the rules of fair play, justice and due process. [18] Stated differently, basic
considerations of due process dictate that theories, issues and arguments not brought to the attention of the trial court
need not be, and ordinarily will not be, considered by a reviewing court.[19]
Assuming again for the sake of argument that the petitioners may still raise this issue of no physicianpatient
relationship, the Court finds and so holds that there was a physicianpatient relationship in this case.

In the case of Lucas v. Tuao,[20] the Court wrote that [w]hen a patient engages the services of a physician, a
physician-patient relationship is generated. And in accepting a case, the physician, for all intents and purposes,
represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same field;
and that he will employ such training, care, and skill in the treatment of the patient. Thus, in treating his patient, a
physician is under a duty to exercise that degree of care, skill and diligence which physicians in the same general
neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. Stated otherwise, the
physician has the obligation to use at least the same level of care that any other reasonably competent physician would
use to treat the condition under similar circumstances.

Indubitably, a physician-patient relationship exists between the petitioners and patient Roy Jr. Notably, the
latter and his mother went to the ER for an immediate medical attention. The petitioners allegedly passed by and were
requested to attend to the victim (contrary to the testimony of Dr. Tacata that they were, at that time, residents on duty
at the ER).[21] They obliged and examined the victim, and later assured the mother that everything was fine and that they
could go home. Clearly, a physician-patient relationship was established between the petitioners and the patient Roy Jr.

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To repeat for clarity and emphasis, if these doctors knew from the start that they were not in the position to
attend to Roy Jr., a vehicular accident victim, with the degree of diligence and commitment expected of every doctor in a
case like this, they should have not made a baseless assurance that everything was all right. By doing so, they deprived
Roy Jr. of adequate medical attention that placed him in a more dangerous situation than he was already in. What
petitioners should have done, and could have done, was to refer Roy Jr. to another doctor who could competently and
thoroughly examine his injuries.
All told, the petitioners were, indeed, negligent but only civilly, and not criminally, liable as the facts show.

Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:

A physician should attend to his patients faithfully and conscientiously. He should secure for
them all possible benefits that may depend upon his professional skill and care. As the sole tribunal to
adjudge the physicians failure to fulfill his obligation to his patients is, in most cases, his own
conscience, violation of this rule on his part is discreditable and inexcusable. [22]

Established medical procedures and practices, though in constant instability, are devised for the purpose of
preventing complications. In this case, the petitioners failed to observe the most prudent medical procedure under
the circumstances to prevent the complications suffered by a child of tender age.

As to the Award of
Damages

While no criminal negligence was found in the petitioners failure to administer the necessary medical attention
to Roy Jr., the Court holds them civilly liable for the resulting damages to their patient. While it was the taxi driver who
ran over the foot or leg of Roy Jr., their negligence was doubtless contributory.

It appears undisputed that the amount of 3,850.00, as expenses incurred by patient Roy Jr., was adequately
supported by receipts. The Court, therefore, finds the petitioners liable to pay this amount by way of actual damages.

The Court is aware that no amount of compassion can suffice to ease the sorrow felt by the family of the child at
that time. Certainly, the award of moral and exemplary damages in favor of Roy Jr. in the amount of 100,000.00 and
50,000.00, respectively, is proper in this case.

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It is settled that moral damages are not punitive in nature, but are designed to compensate and alleviate in some
way the physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral
shock, social humiliation, and similar injury unjustly inflicted on a person. Intended for the restoration of the
psychological or emotional status quo ante, the award of moral damages is designed to compensate emotional injury
suffered, not to impose a penalty on the wrongdoer. [23]

The Court, likewise, finds the petitioners also liable for exemplary damages in the said amount. Article 2229 of
the Civil Code provides that exemplary damages may be imposed by way of example or correction for the public good.

WHEREFORE, the petition is PARTLY GRANTED. The Decision of the Court of Appeals dated August 29,
2008 isREVERSED and SET ASIDE. A new judgment is entered ACQUITTING Dr. Emmanuel Jarcia, Jr. and Dr.
Marilou Bastan of the crime of reckless imprudence resulting to serious physical injuries but declaring them civilly liable
in the amounts of:

(1) 3,850.00 as actual damages;


(2) 100,000.00 as moral damages;
(3) 50,000.00 as exemplary damages; and
(4) Costs of the suit.

with interest at the rate of 6% per annum from the date of the filing of the Information. The rate shall be 12% interest per
annumfrom the finality of judgment until fully paid.

SO ORDERED.

G.R. No. 167366

September 26, 2012

DR. PEDRO DENNIS CERENO, and DR. SANTOS ZAFE, Petitioners,


vs.
COURT OF APPEALS, SPOUSES DIOGENES S. OLAVERE and FE R. SERRANO, Respondents.
DECISION
PEREZ, J.:

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Before the Court is a Petition for Review on Certiorari 1 under Rule 45 of the Rules of Court seeking the annulment and
setting aside of the 21 February 2005 decision 2 of the Court of Appeals (CA) in CA-G.R. CV No. 65800. In the assailed
decision, the CA affirmed in toto the decision of the Regional Trial Court (R TC), Branch 22, Nag a City finding herein
petitioners Dr. Pedro Dennis Cereno (Dr. Cereno) and Dr. Santos Zafe (Dr. Zafe) liable for damages.
Culled from the records are the following antecedent facts:
At about 9:15 in the evening of 16 September 1995, Raymond S. Olavere (Raymond), a victim of a stabbing incident, was
rushed to the emergency room of the Bicol Regional Medical Center (BRMC). There, Raymond was attended to by Nurse
Arlene Balares (Nurse Balares) and Dr. Ruel Levy Realuyo (Dr. Realuyo) the emergency room resident physician.
Subsequently, the parents of Raymondthe spouses Deogenes Olavere (Deogenes) and Fe R. Serranoarrived at the
BRMC. They were accompanied by one Andrew Olavere, the uncle of Raymond.
After extending initial medical treatment to Raymond, Dr. Realuyo recommended that the patient undergo "emergency
exploratory laparotomy." Dr. Realuyo then requested the parents of Raymond to procure 500 cc of type "O" blood
needed for the operation. Complying with the request, Deogenes and Andrew Olavere went to the Philippine National
Red Cross to secure the required blood.
At 10:30 P.M., Raymond was wheeled inside the operating room. During that time, the hospital surgeons, Drs. Zafe and
Cereno, were busy operating on gunshot victim Charles Maluluy-on. Assisting them in the said operation was Dr.
Rosalina Tatad (Dr. Tatad), who was the only senior anesthesiologist on duty at BRMC that night. Dr. Tatad also
happened to be the head of Anesthesiology Department of the BRMC.
Just before the operation on Maluluy-on was finished, another emergency case involving Lilia Aguila, a woman who was
giving birth to triplets, was brought to the operating room.
At 10:59 P.M., the operation on Charles Maluluy-on was finished. By that time, however, Dr. Tatad was already working
with the obstetricians who will perform surgery on Lilia Aguila. There being no other available anesthesiologist to assist
them, Drs. Zafe and Cereno decided to defer the operation on Raymond.
Drs. Zafe and Cereno, in the meantime, proceeded to examine Raymond and they found that the latters blood pressure
was normal and "nothing in him was significant."3 Dr. Cereno reported that based on the xray result he interpreted, the
fluid inside the thoracic cavity of Raymond was minimal at around 200-300 cc.
At 11:15 P.M., Deogenes and Andrew Olavere returned to the BRMC with a bag containing the requested 500 cc type "O"
blood. They handed over the bag of blood to Dr. Realuyo.
After Dr. Tatad finished her work with the Lilia Aguila operation, petitioners immediately started their operation on
Raymond at around 12:15 A.M. of 17 September 1995. Upon opening of Raymonds thoracic cavity, they found that 3,200
cc of blood was stocked therein. The blood was evacuated and petitioners found a puncture at the inferior pole of the left
lung.
In his testimony, Dr. Cereno stated that considering the loss of blood suffered by Raymond, he did not immediately
transfuse blood because he had to control the bleeders first.4
Blood was finally transfused on Raymond at 1:40 A.M. At 1:45 A.M., while the operation was on-going, Raymond suffered
a cardiac arrest. The operation ended at 1:50 A.M. and Raymond was pronounced dead at 2:30 A.M.
Raymonds death certificate5 indicated that the immediate cause of death was "hypovolemic shock" or the cessation of the
functions of the organs of the body due to loss of blood. 6
Claiming that there was negligence on the part of those who attended to their son, the parents of Raymond, on 25
October 1995, filed before the RTC, Branch 22, Naga City a complaint for damages 7 against Nurse Balares, Dr. Realuyo
and attending surgeons Dr. Cereno and Dr. Zafe.
During trial, the parents of Raymond testified on their own behalf. They also presented the testimonies of Andrew
Olavere and one Loira Oira, the aunt of Raymond. On the other hand, Dr. Cereno, Dr. Realuyo, Nurse Balares and

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Security Guard Diego Reposo testified for the defense. On rebuttal, the parents of Raymond presented Dr. Tatad, among
others.
On 15 October 1999, the trial court rendered a decision 8 the dispositive portion of which reads:
WHEREFORE, premises considered, this Court hereby renders judgment:
1. Dismissing the case against Dr. Ruel Levy Realuyo and Arlene Balares for lack of merit;
2. Ordering defendants Dr. Santos Zafe and Dr. Dennis Cereno to pay the heirs of Raymond Olavere, jointly and
severally the following amounts:
1. P 50,000.00 for the death of the victim;
2. P 150,000.00 as moral damages;
3. P 100,000.00 as exemplary damages;
4. P 30,000.00 for attorneys fees; and
5. Cost of suit.9
x x x x.
The trial court found petitioners negligent in not immediately conducting surgery on Raymond. It noted that petitioners
have already finished operating on Charles Maluluy-on as early as 10:30 in the evening, and yet they only started the
operation on Raymond at around 12:15 early morning of the following day. The trial court held that had the surgery been
performed promptly, Raymond would not have lost so much blood and, therefore, could have been saved. 10
The trial court also held that the non-availability of Dr. Tatad after the operation on Maluluy-on was not a sufficient
excuse for the petitioners to not immediately operate on Raymond. It called attention to the testimony of Dr. Tatad
herself, which disclosed the possibility of calling a standby anesthesiologist in that situation. The trial court opined that
the petitioners could have just requested for the standby anesthesiologist from Dr. Tatad, but they did not.
Lastly, the trial court faulted petitioners for the delay in the transfusion of blood on Raymond.
On appeal, the CA in a decision dated 21 February 2005 affirmed in toto the judgment rendered by the RTC finding
herein petitioners guilty of gross negligence in the performance of their duties and awarding damages to private
respondents.
Hence, this petition for review on certiorari under Rule 45 of the Rules of Court assailing the CA decision on the
following grounds:
1. THAT THE CA ERRED IN RULING THAT PETITIONERS WERE GROSSLY NEGLIGENT IN THE
PERFORMANCE OF THEIR DUTIES;
2. THAT THE CA ERRED IN NOT CONSIDERING THE BICOL REGIONAL MEDICAL CENTER AS AN
INDISPENSABLE PARTY AND SUBSIDIARILY LIABLE SHOULD PETITIONERS BE FOUND LIABLE FOR
DAMAGES; and
3. THAT THE CA ERRED IN NOT FINDING THE AWARD OF MORAL AND EXEMPLARY DAMAGES AS
WELL AS ATTORNEYS FEES EXORBITANT OR EXCESSIVE.
We grant the petition
It is well-settled that under Rule 45 of the Rules of Court, only questions of law may be raised. The reason behind this is
that this Court is not a trier of facts and will not re-examine and re-evaluate the evidence on record. 11Factual findings of
the CA, affirming that of the trial court, are therefore generally final and conclusive on this Court. This rule is subject to

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the following exceptions: (1) the conclusion is grounded on speculations, surmises or conjectures; (2) the inference is
manifestly mistaken, absurd or impossible; (3) there is grave abuse of discretion; (4) the judgment is based on a
misapprehension of facts; (5) the findings of fact are conflicting; (6) there is no citation of specific evidence on which the
factual findings are based; (7) the findings of absence of fact are contradicted by the presence of evidence on record; (8)
the findings of the CA are contrary to those of the trial court; (9) the CA manifestly overlooked certain relevant and
undisputed facts that, if properly considered, would justify a different conclusion; (10) the findings of the CA are beyond
the issues of the case; and (11) such findings are contrary to the admissions of both parties. 12 In this case, We find
exceptions (1) and (4) to be applicable.
The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of
claim which a victim has available to him or her to redress a wrong committed by a medical professional which has
caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in
most cases a physician, either failed to do something which a reasonably prudent health care provider
would have done, or that he or she did something that a reasonably prudent provider would not have
done; and that the failure or action caused injury to the patient.13 Stated otherwise, the complainant must prove:
(1) that the health care provider, either by his act or omission, had been negligent, and (2) that such act or omission
proximately caused the injury complained of.
The best way to prove these is through the opinions of expert witnesses belonging in the same neighborhood and in the
same general line of practice as defendant physician or surgeon. The deference of courts to the expert opinion of qualified
physicians stems from the formers realization that the latter possess unusual technical skills which laymen in most
instances are incapable of intelligently evaluating, hence, the indispensability of expert testimonies. 14
Guided by the foregoing standards, We dissect the issues at hand.
Petitioners Not Negligent
The trial court first imputed negligence on the part of the petitioners by their failure to perform the operation on
Raymond immediately after finishing the Maluluy-on operation. It rejected as an excuse the nonavailability of Dr. Tatad.
The trial court relied on the testimony of Dr. Tatad about a "BRMC protocol" that introduces the possibility that a
standby anesthesiologist could have been called upon. The pertinent portions of the testimony of Dr. Tatad provides:
Q: Aside from you and Dr. Rebancos, who was the standby anesthesiologist?
A: We have a protocol at the Bicol Medical Center to have a consultant who is on call.
Q: How many of them?
A: One.
Q: Who is she?
A: Dra. Flores.
Q: What is the first name?
A: Rosalina Flores.
Q: Is she residing in Naga City?
A: In Camaligan.
Q: She is on call anytime when there is an emergency case to be attended to in the Bicol Medical Center?
A: Yes sir.15
Dr. Tatad further testified:

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Q: Alright (sic), considering that you said you could not attend to Raymond Olavere because another patient was coming
in the person of Lilia Aguila, did you not suggest to Dr. Cereno to call the standby anesthesiologist?
A: They are not ones to do that. They have no right to call for the standby anesthesiologist.
Q: Then, who should call for the standby anesthesiologist?
A: It is me if the surgeon requested.
Q: But in this case, the surgeon did not request you?
A: No. It is their prerogative.
Q: I just want to know that in this case the surgeon did not request you to call for the standby anesthesiologist?
A: No sir.16
From there, the trial court concluded that it was the duty of the petitioners to request Dr. Tatad to call on Dr. Rosalina
Flores, the standby anesthesiologist. Since petitioners failed to do so, their inability to promptly perform the operation on
Raymond becomes negligence on their part.
This Court does not agree with the aforesaid conclusion.
First. There is nothing in the testimony of Dr. Tatad, or in any evidence on the record for that matter, which shows that
the petitioners were aware of the "BRMC protocol" that the hospital keeps a standby anesthesiologist available on call.
Indeed, other than the testimony of Dr. Tatad, there is no evidence that proves that any such "BRMC protocol" is being
practiced by the hospitals surgeons at all.
Evidence to the effect that petitioners knew of the "BRMC protocol" is essential, especially in view of the contrary
assertion of the petitioners that the matter of assigning anesthesiologists rests within the full discretion of the BRMC
Anesthesiology Department. Without any prior knowledge of the "BRMC protocol," We find that it is quite reasonable for
the petitioners to assume that matters regarding the administration of anesthesia and the assignment of anesthesiologists
are concerns of the Anesthesiology Department, while matters pertaining to the surgery itself fall under the concern of
the surgeons. Certainly, We cannot hold petitioners accountable for not complying with something that they, in the first
place, do not know.
Second. Even assuming ex gratia argumenti that there is such "BRMC protocol" and that petitioners knew about it, We
find that their failure to request for the assistance of the standby anesthesiologist to be reasonable when taken in the
proper context. There is simply no competent evidence to the contrary.
From the testimony of Dr. Tatad herself, it is clear that the matter of requesting for a standby anaesthesiologist is not
within the full discretion of petitioners. The "BRMC protocol" described in the testimony requires the petitioners to
course such request to Dr. Tatad who, as head of the Department of Anesthesiology, has the final say of calling the
standby anesthesiologist.
As revealed by the facts, however, after the Maluluy-on operation, Dr. Tatad was already assisting in the Lilia Aguila
operation. Drs. Zafe and Cereno then proceeded to examine Raymond and they found that the latters blood pressure was
normal and "nothing in him was significant."17 Dr. Cereno even concluded that based on the x-ray result he interpreted,
the fluid inside the thoracic cavity of Raymond was minimal at around 200-300 cc. Such findings of Drs. Cereno and Zafe
were never challenged and were unrebutted.
Given that Dr. Tatad was already engaged in another urgent operation and that Raymond was not showing any symptom
of suffering from major blood loss requiring an immediate operation, We find it reasonable that petitioners decided to
wait for Dr. Tatad to finish her surgery and not to call the standby anesthesiologist anymore. There is, after all, no
evidence that shows that a prudent surgeon faced with similar circumstances would decide otherwise.
Here, there were no expert witnesses presented to testify that the course of action taken by petitioners were not in accord
with those adopted by other reasonable surgeons in similar situations. Neither was there any testimony given, except that
of Dr. Tatads, on which it may be inferred that petitioners failed to exercise the standard of care, diligence, learning and

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skill expected from practitioners of their profession. Dr. Tatad, however, is an expert neither in the field of surgery nor of
surgical practices and diagnoses. Her expertise is in the administration of anesthesia and not in the determination of
whether surgery ought or not ought to be performed.
Another ground relied upon by the trial court in holding petitioners negligent was their failure to immediately transfuse
blood on Raymond. Such failure allegedly led to the eventual death of Raymond through "hypovolemic shock." The trial
court relied on the following testimony of Dr. Tatad:
Q: In this case of Raymond Olavere was blood transfused to him while he was inside the operating room?
A: The blood arrived at 1:40 a.m. and that was the time when this blood was hooked to the patient.
xxxx
Q: Prior to the arrival of the blood, you did not request for blood?
A: I requested for blood.
Q: From whom?
A: From the attending physician, Dr. Realuyo.
Q: What time was that?
xxxx
A: 9:30.
xxxx
Q: Had this blood been given to you before the operation you could have transfused the blood to the patient?
A: Of course, yes.
Q: And the blood was transfused only after the operation?
A: Because that was the time when the blood was given to us.
xxxx
Q: Have you monitored the condition of Raymond Olavere?
A: I monitored the condition during the time when I would administer anesthesia.
Q: What time was that?
A: 11:45 already.
Q: What was the condition of the blood pressure at that time?
A: 60/40 initial.
Q: With that kind of blood pressure the patient must have been in critical condition?
A: At the time when the blood pressure was 60/40 I again told Dr. Cereno that blood was already needed.

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Q: With that condition, Doctor, that the patient had 60/40 blood pressure you did not decide on transfusing blood to
him?
A: I was asking for blood but there was no blood available.
Q: From whom did you ask?
A: From the surgeon. According to Dr. Zafe there was only 500 cc but still for cross-matching. 18
From the aforesaid testimony, the trial court ruled that there was negligence on the part of petitioners for their failure to
have the blood ready for transfusion. It was alleged that at 11:15 P.M., the 500 cc of blood was given to Dr. Realuyo by
Raymonds parents. At 11:45 P.M., when Dr. Tatad was asking for the blood, 30 minutes had passed. Yet, the blood was
not ready for transfusion as it was still being cross-matched. 19 It took another two hours before blood was finally
transfused to Raymond at 1:40 A.M. of 17 September 1995.
Again, such is a mistaken conclusion.
First, the alleged delay in the cross-matching of the blood, if there was any, cannot be attributed as the fault of the
petitioners. The petitioners were never shown to be responsible for such delay. It is highly unreasonable and the height of
injustice if petitioners were to be sanctioned for lapses in procedure that does not fall within their duties and beyond
their control.
Second, Dr. Cereno, in his unchallenged testimony, aptly explained the apparent delay in the transfusion of blood on
Raymond before and during the operation.
Before the operation, Dr. Cereno explained that the reason why no blood transfusion was made on Raymond was because
they did not then see the need to administer such transfusion, viz:
Q: Now, you stated in your affidavit that prior to the operation you were informed that there was 500 cc of blood
available and was still to be cross-matched. What time was that when you were informed that 500 cc of blood was due for
crossmatching?
A: I am not sure of the time.
Q: But certainly, you learned of that fact that there was 500 cc of blood, which was due for crossmatching immediately
prior to the operation?
A: Yes, sir.
Q: And the operation was done at 12:15 of September 17?
A: Yes, sir.
Q: And that was the reason why you could not use the blood because it was being crossmatched?
A: No, sir. That was done only for a few minutes. We did not transfuse at that time because there was no need.There is a
necessity to transfuse blood when we saw there is gross bleeding inside the body. 20(Emphasis supplied)
During the operation, on the other hand, Dr. Cereno was already able to discover that 3,200 cc of blood was stocked in
the thoracic cavity of Raymond due to the puncture in the latters left lung. Even then, however, immediate blood
transfusion was not feasible because:
Q: Now considering the loss of blood suffered by Raymund Olavere, why did you not immediately transfuse blood to the
patient and you waited for 45 minutes to elapse before transfusing the blood?
A: I did not transfuse blood because I had to control the bleeders. If you will transfuse blood just the
same the blood that you transfuse will be lost. After evacuation of blood and there is no more bleeding

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Q: It took you 45 minutes to evacuate the blood?


A: The evacuation did not take 45 minutes.
Q: So what was the cause of the delay why you only transfuse blood after 45 minutes?
A: We have to look for some other lesions. It does not mean that when you slice the chest you will see the
lesions already.21
(Emphasis supplied)
Again, the foregoing testimonies of Dr. Cereno went unchallenged or unrebutted. The parents of Raymond were not able
to present any expert witness to dispute the course of action taken by the petitioners.
Causation Not Proven
In medical negligence cases, it is settled that the complainant has the burden of establishing breach of duty on the part of
the doctors or surgeons. It must be proven that such breach of duty has a causal connection to the resulting death of the
patient.22 A verdict in malpractice action cannot be based on speculation or conjecture. Causation must be proven within
a reasonable medical probability based upon competent expert testimony.
The parents of Raymond failed in this respect. Aside from their failure to prove negligence on the part of the petitioners,
they also failed to prove that it was petitioners fault that caused the injury. Their cause stands on the mere assumption
that Raymonds life would have been saved had petitioner surgeons immediately operated on him; had the blood been
cross-matched immediately and had the blood been transfused immediately. There was, however, no proof presented
that Raymonds life would have been saved had those things been done. Those are mere assumptions and cannot
guarantee their desired result. Such cannot be made basis of a decision in this case, especially considering that the name,
reputation and career of petitioners are at stake.
The Court understands the parents grief over their sons death.1wphi1 That notwithstanding, it cannot hold petitioners
liable. It was noted that Raymond, who was a victim of a stabbing incident, had multiple wounds when brought to the
hospital. Upon opening of his thoracic cavity, it was discovered that there was gross bleeding inside the body. Thus, the
need for petitioners to control first what was causing the bleeding. Despite the situation that evening i.e. numerous
patients being brought to the hospital for emergency treatment considering that it was the height of the Peafrancia
Fiesta, it was evident that petitioners exerted earnest efforts to save the life of Raymond. It was just unfortunate that the
loss of his life was not prevented.
In the case of Dr. Cruz v. CA, it was held that "[d]octors are protected by a special law. They are not guarantors of care.
They do not even warrant a good result. They are not insurers against mishaps or unusual consequences. Furthermore,
they are not liable for honest mistake of judgment"23
This Court affirms the ruling of the CA that the BRMC is not an indispensible party. The core issue as agreed upon by the
parties and stated in the pre-trial order is whether petitioners were negligent in the performance of their duties. It
pertains to acts/omissions of petitioners for which they could be held liable. The cause of action against petitioners may
be prosecuted fully and the determination of their liability may be arrived at without impleading the hospital where they
are employed. As such, the BRMC cannot be considered an indispensible party without whom no final determination can
be had of an action.24
IN THE LIGHT OF THE FOREGOING, the instant Petition for Review on Certiorari is hereby GRANTED. The
Court of Appeals decision dated 21 February 2005 in CA-G.R. CV No. 65800 is hereby REVERSED and SET
ASIDE. No costs.
SO ORDERED.

G.R. No. 163753

Reyes, Hazel

January 15, 2014

Page 150

DR. ENCARNACION C. LUMANTAS, M.D., Petitioner,


vs.
HANZ CALAPIZ, REPRESENTED BY HIS PARENTS, HILARIO CALAPIZ, JR. and HERLITA
CALAPIZ,Respondent.
DECISION
BERSAMIN, J.:
The acquittal of the accused does not necessarily mean his absolution from civil liability.
The Case
In this appeal, an accused desires the reversal of the decision promulgated on February 20, 2003, 1 whereby the Court of
Appeals (CA) affirmed the judgment rendered on August 6, 1999 by the Regional Trial Court (RTC), Branch 13, in
Oroquieta City ordering him to pay moral damages despite his acquittal of the crime of reckless imprudence resulting in
serious physical injuries charged against him.2
Antecedents
On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought their 8-year-old son, Hanz Calapiz (Hanz),
to the Misamis Occidental Provincial Hospital, Oroquieta City, for an emergency appendectomy. Hanz was attended to by
the petitioner, who suggested to the parents that Hanz also undergo circumcision at no added cost to spare him the pain.
With the parents consent, the petitioner performed the coronal type of circumcision on Hanz after his appendectomy. On
the following day, Hanz complained of pain in his penis, which exhibited blisters. His testicles were swollen. The parents
noticed that the child urinated abnormally after the petitioner forcibly removed the catheter, but the petitioner dismissed
the abnormality as normal. On January 30, 1995, Hanz was discharged from the hospital over his parents protestations,
and was directed to continue taking antibiotics.
On February 8, 1995, Hanz was confined in a hospital because of the abscess formation between the base and the shaft of
his penis. Presuming that the ulceration was brought about by Hanzs appendicitis, the petitioner referred him to Dr.
Henry Go, an urologist, who diagnosed the boy to have a damaged urethra. Thus, Hanz underwent cystostomy, and
thereafter was operated on three times to repair his damaged urethra.
When his damaged urethra could not be fully repaired and reconstructed, Hanzs parents brought a criminal charge
against the petitioner for reckless imprudence resulting to serious physical injuries. On April 17, 1997, the
information3 was filed in the Municipal Trial Court in Cities of Oroquieta City (MTCC), to which the latter pleaded not
guilty on May 22, 1998.4 Under the order of April 30, 1999, the case was transferred to the RTC pursuant to Supreme
Court Circular No. 11-99.5
At the trial, the Prosecution presented several witnesses, including Dr. Rufino Agudera as an expert witness and as the
physician who had operated on Hanz twice to repair the damaged urethra. Dr. Agudera testified that Hanz had been
diagnosed to have urethral stricture and cavernosal injury left secondary to trauma that had necessitated the conduct of
two operations to strengthen and to lengthen the urethra. Although satisfactorily explaining that the injury to the urethra
had been caused by trauma, Dr. Agudera could not determine the kind of trauma that had caused the injury.
In his defense, the petitioner denied the charge. He contended that at the time of his examination of Hanz on January 16,
1995, he had found an accumulation of pus at the vicinity of the appendix two to three inches from the penis that had
required immediate surgical operation; that after performing the appendectomy, he had circumcised Hanz with his
parents consent by using a congo instrument, thereby debunking the parents claim that their child had been cauterized;
that he had then cleared Hanz on January 27, 1995 once his fever had subsided; that he had found no complications when
Hanz returned for his follow up check-up on February 2, 1995; and that the abscess formation between the base and the
shaft of the penis had been brought about by Hanzs burst appendicitis.
Ruling of the RTC
In its decision rendered on August 6, 1999,6 the RTC acquitted the petitioner of the crime charged for insufficiency of the
evidence. It held that the Prosecutions evidence did not show the required standard of care to be observed by other
members of the medical profession under similar circumstances. Nonetheless, the RTC ruled that the petitioner was

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liable for moral damages because there was a preponderance of evidence showing that Hanz had received the injurious
trauma from his circumcision by the petitioner. The decision disposed as follows:
WHEREFORE, for insufficiency of evidence, this court renders judgment acquitting the accused, Dr. Encarnacion
Lumantas, of reckless imprudence resulting in serious physical injuries, but ordering him to pay Hanz
CalapizP50,000.00 as moral damages. No costs.
SO ORDERED.
Ruling of the CA
On appeal, the CA affirmed the RTC,7 sustaining the award of moral damages. It opined that even if the petitioner had
been acquitted of the crime charged, the acquittal did not necessarily mean that he had not incurred civil liability
considering that the Prosecution had preponderantly established the sufferings of Hanz as the result of the circumcision.
The petitioner moved for reconsideration, but the CA denied the motion on April 28, 2004. 8
Hence, this appeal.
Issue
Whether the CA erred in affirming the petitioners civil liability despite his acquittal of the crime of reckless imprudence
resulting in serious physical injuries.
Ruling
The petition for review lacks merit.
It is axiomatic that every person criminally liable for a felony is also civilly liable. 9 Nevertheless, the acquittal of an
accused of the crime charged does not necessarily extinguish his civil liability. In Manantan v. Court of Appeals, 10the
Court elucidates on the two kinds of acquittal recognized by our law as well as on the different effects of acquittal on the
civil liability of the accused, viz:
Our law recognizes two kinds of acquittal, with different effects on the civil liability of the accused.1wphi1 First is an
acquittal on the ground that the accused is not the author of the act or omission complained of. This instance closes the
door to civil liability, for a person who has been found to be not the perpetrator of any act or omission cannot and can
never be held liable for such act or omission. There being no delict, civil liability ex delicto is out of the question, and the
civil action, if any, which may be instituted must be based on grounds other than the delict complained of. This is the
situation contemplated in Rule 111 of the Rules of Court. The second instance is an acquittal based on reasonable doubt
on the guilt of the accused. In this case, even if the guilt of the accused has not been satisfactorily established, he is not
exempt from civil liability which may be proved by preponderance of evidence only.
The Rules of Court requires that in case of an acquittal, the judgment shall state "whether the evidence of the prosecution
absolutely failed to prove the guilt of the accused or merely failed to prove his guilt beyond reasonable doubt. In either
case, the judgment shall determine if the act or omission from which the civil liability might arise did not exist." 11
Conformably with the foregoing, therefore, the acquittal of an accused does not prevent a judgment from still being
rendered against him on the civil aspect of the criminal case unless the court finds and declares that the fact from which
the civil liability might arise did not exist.
Although it found the Prosecutions evidence insufficient to sustain a judgment of conviction against the petitioner for the
crime charged, the RTC did not err in determining and adjudging his civil liability for the same act complained of based
on mere preponderance of evidence.12 In this connection, the Court reminds that the acquittal for insufficiency of the
evidence did not require that the complainants recovery of civil liability should be through the institution of a separate
civil action for that purpose.13
The petitioners contention that he could not be held civilly liable because there was no proof of his negligence deserves
scant consideration. The failure of the Prosecution to prove his criminal negligence with moral certainty did not forbid a
finding against him that there was preponderant evidence of his negligence to hold him civilly liable. 14 With the RTC and

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Page 152

the CA both finding that Hanz had sustained the injurious trauma from the hands of the petitioner on the occasion of or
incidental to the circumcision, and that the trauma could have been avoided, the Court must concur with their uniform
findings. In that regard, the Court need not analyze and weigh again the evidence considered in the proceedings a quo.
The Court, by virtue of its not being a trier of facts, should now accord the highest respect to the factual findings of the
trial court as affirmed by the CA in the absence of a clear showing by the petitioner that such findings were tainted with
arbitrariness, capriciousness or palpable error.
Every person is entitled to the physical integrity of his body.1wphi1 Although we have long advocated the view that any
physical injury, like the loss or diminution of the use of any part of ones body, is not equatable to a pecuniary loss, and is
not susceptible of exact monetary estimation, civil damages should be assessed once that integrity has been violated. The
assessment is but an imperfect estimation of the true value of ones body. The usual practice is to award moral damages
for the physical injuries sustained. 15 In Hanzs case, the undesirable outcome of the circumcision performed by the
petitioner forced the young child to endure several other procedures on his penis in order to repair his damaged urethra.
Surely, his physical and moral sufferings properly warranted the amount of P50,000.00 awarded as moral damages.
Many years have gone by since Hanz suffered the injury. Interest of 6% per annum should then be imposed on the award
as a sincere means of adjusting the value of the award to a level that is not only reasonable but just and commensurate.
Unless we make the adjustment in the permissible manner by prescribing legal interest on the award, his sufferings
would be unduly compounded. For that purpose, the reckoning of interest should be from the filing of the criminal
information on April 17, 1997, the making of the judicial demand for the liability of the petitioner.
WHEREFORE, the Court AFFIRMS the decision promulgated on February 20, 2003, with the modification that legal
interest of 6% per annum to start from April 17, 1997 is imposed on the award of:P50,000.00 as moral damages; and
ORDERS the petitioner to pay the costs of suit.
SO ORDERED.

G.R. No. 192123

March 10, 2014

DR. FERNANDO P. SOLIDUM, Petitioner,


vs.
PEOPLE OF THE PHILIPPINES, Respondent.
DECISION
BERSAMIN, J.:
This appeal is taken by a physician-anesthesiologist who has been pronounced guilty of reckless imprudence resulting in
serious physical injuries by the Regional Trial Court (RTC) and the Court of Appeals (CA). He had been part of the team
of anesthesiologists during the surgical pull-through operation conducted on a three-year old patient born with an
imperforate anus.1
The antecedents are as follows:
Gerald Albert Gercayo (Gerald) was born on June 2, 19922 with an imperforate anus. Two days after his birth, Gerald
underwent colostomy, a surgical procedure to bring one end of the large intestine out through the abdominal
wall,3 enabling him to excrete through a colostomy bag attached to the side of his body.4
On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pull-through operation. 5 Dr.
Leandro Resurreccion headed the surgical team, and was assisted by Dr. Joselito Luceo, Dr. Donatella Valea and Dr.
Joseph Tibio. The anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and petitioner Dr. Fernando Solidum
(Dr. Solidum).6 During the operation, Gerald experienced bradycardia, 7 and went into a coma.8 His coma lasted for two
weeks,9 but he regained consciousness only after a month.10 He could no longer see, hear or move.11
Agitated by her sons helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint for reckless
imprudence resulting in serious physical injuries with the City Prosecutors Office of Manila against the attending
physicians.12

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Page 153

Upon a finding of probable cause, the City Prosecutors Office filed an information solely against Dr. Solidum, 13alleging:
That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an anesthesiologist at the
Ospital ng Maynila, Malate, this City, and as such was tasked to administer the anesthesia on three-year old baby boy
GERALD ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former having been born with an
imperforate anus [no anal opening] and was to undergo an operation for anal opening [pull through operation], did then
and there willfully, unlawfully and feloniously fail and neglect to use the care and diligence as the best of his judgment
would dictate under said circumstance, by failing to monitor and regulate properly the levels of anesthesia administered
to said GERALD ALBERT GERCAYO and using 100% halothane and other anesthetic medications, causing as a
consequence of his said carelessness and negligence, said GERALD ALBERT GERCAYO suffered a cardiac arrest and
consequently a defect called hypoxic encephalopathy meaning insufficient oxygen supply in the brain, thereby rendering
said GERALD ALBERT GERCAYO incapable of moving his body, seeing, speaking or hearing, to his damage and
prejudice.
Contrary to law.14
The case was initially filed in the Metropolitan Trial Court of Manila, but was transferred to the RTC pursuant to Section
5 of Republic Act No. 8369 (The Family Courts Act of 1997),15 where it was docketed as Criminal Case No. 01-190889.
Judgment of the RTC
On July 19, 2004, the RTC rendered its judgment finding Dr. Solidum guilty beyond reasonable doubt of reckless
imprudence resulting to serious physical injuries,16 decreeing:
WHEREFORE, premises considered, the Court finds accused DR. FERNANDO P. SOLIDUM GUILTY beyond reasonable
doubt as principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of TWO (2)
MONTHS and ONE (1) DAY of arresto mayor as minimum to ONE (1) YEAR, ONE (1) MONTH and TEN (10) DAYS of
prision correccional as maximum and to indemnify, jointly and severally with the Ospital ng Maynila, Dr. Anita So and
Dr. Marichu Abella, private complainant Luz Gercayo, the amount of P500,000.00 as moral damages and P100,000.00
as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby CANCELLED.
SO ORDERED.17
Upon motion of Dr. Anita So and Dr. Marichu Abella to reconsider their solidary liability, 18 the RTC excluded them from
solidary liability as to the damages, modifying its decision as follows:
WHEREFORE, premises considered, the Court finds accused Dr. Fernando Solidum, guilty beyond reasonable doubt as
principal of the crime charged and is hereby sentenced to suffer the indeterminate penalty of two (2) months and one (1)
day of arresto mayor as minimum to one (1) year, one (1) month and ten (10) days of prision correccional as maximum
and to indemnify jointly and severally with Ospital ng Maynila, private complainant Luz Gercayo the amount
of P500,000.00 as moral damages and P100,000 as exemplary damages and to pay the costs.
Accordingly, the bond posted by the accused for his provisional liberty is hereby cancelled. 19
Decision of the CA
On January 20, 2010, the CA affirmed the conviction of Dr. Solidum, 20 pertinently stating and ruling:
The case appears to be a textbook example of res ipsa loquitur.
xxxx
x x x [P]rior to the operation, the child was evaluated and found fit to undergo a major operation. As noted by the OSG,
the accused himself testified that pre-operation tests were conducted to ensure that the child could withstand the surgery.
Except for his imperforate anus, the child was healthy. The tests and other procedures failed to reveal that he was
suffering from any known ailment or disability that could turn into a significant risk. There was not a hint that the nature
of the operation itself was a causative factor in the events that finally led to hypoxia.

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In short, the lower court has been left with no reasonable hypothesis except to attribute the accident to a failure in the
proper administration of anesthesia, the gravamen of the charge in this case. The High Court elucidates in Ramos vs.
Court of Appeals 321 SCRA 584
In cases where the res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of
injury to the patient, without the aid of expert testimony, where the court from its fund of common knowledge can
determine the proper standard of care.
Where common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care
had been exercised, an inference of negligence may be drawn giving rise to an application of the doctrine of res ipsa
loquitur without medical evidence, which is ordinarily required to show not only what occurred but how and why it
occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the particular act or
omission complained of and the injury sustained while under the custody and management of the defendant without
need to produce expert medical testimony to establish the standard of care. Resort to res ipsa loquitur is allowed because
there is no other way, under usual and ordinary conditions, by which the patient can obtain redress for injury suffered by
him.
The lower court has found that such a nexus exists between the act complained of and the injury sustained, and in line
with the hornbook rules on evidence, we will afford the factual findings of a trial court the respect they deserve in the
absence of a showing of arbitrariness or disregard of material facts that might affect the disposition of the case. People v.
Paraiso 349 SCRA 335.
The res ipsa loquitur test has been known to be applied in criminal cases. Although it creates a presumption of
negligence, it need not offend due process, as long as the accused is afforded the opportunity to go forward with his own
evidence and prove that he has no criminal intent. It is in this light not inconsistent with the constitutional presumption
of innocence of an accused.
IN VIEW OF THE FOREGOING, the modified decision of the lower court is affirmed.
SO ORDERED.21
Dr. Solidum filed a motion for reconsideration, but the CA denied his motion on May 7, 2010. 22
Hence, this appeal.
Issues
Dr. Solidum avers that:
I.
THE HONORABLE COURT OF APPEALS ERRED IN AFFIRMING THE DECISION OF THE LOWER COURT
IN UPHOLDING THE PETITIONERS CONVICTION FOR THE CRIME CHARGED BASED ON THE TRIAL
COURTS OPINION, AND NOT ON THE BASIS OF THE FACTS ESTABLISHED DURING THE TRIAL. ALSO,
THERE IS A CLEAR MISAPPREHENSION OF FACTS WHICH IF CORRECTED, WILL RESULT TO THE
ACQUITTAL OF THE PETITIONER. FURTHER, THE HONORABLE COURT ERRED IN AFFIRMING THE
SAID DECISION OF THE LOWER COURT, AS THIS BREACHES THE CRIMINAL LAW PRINCIPLE THAT
THE PROSECUTION MUST PROVE THE ALLEGATIONS OF THE INFORMATION BEYOND REASONABLE
DOUBT, AND NOT ON THE BASIS OF ITS PRESUMPTIVE CONCLUSION.
II.
THE HONORABLE COURT OF APPEALS ERRED IN APPLYING THE PRINCIPLE OF RES IPSA LOQUITOR
(sic) WHEN THE DEFENSE WAS ABLE TO PROVE THAT THERE IS NO NEGLIGENCE ON THE PART OF
THE PETITIONER, AND NO OVERDOSING IN THE APPLICATION OF THE ANESTHETIC AGENT BECAUSE
THERE WAS NO 100% HALOTHANE ADMINISTERED TO THE CHILD, BUT ONLY ONE (1%) PERCENT AND
THE APPLICATION THEREOF, WAS REGULATED BY AN ANESTHESIA MACHINE. THUS, THE
APPLICATION OF THE PRINCIPLE OF RES IPSA LOQUITOR (sic) CONTRADICTED THE ESTABLISHED
FACTS AND THE LAW APPLICABLE IN THE CASE.

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Page 155

III.
THE AWARD OF MORAL DAMAGES AND EXEMPLARY DAMAGES IS NOT JUSTIFIED THERE BEING NO
NEGLIGENCE ON THE PART OF THE PETITIONER. ASSUMING THAT THE CHILD IS ENTITLED TO
FINANCIAL CONSIDERATION, IT SHOULD BE ONLY AS A FINANCIAL ASSISTANCE, BECAUSE THERE
WAS NO NEGLIGENCE, AND NO OVERDOSING OF ANESTHETIC AGENT AND AS SUCH, THE AWARD IS
SO EXCESSIVE, AND NO FACTUAL AND LEGAL BASIS.23
To simplify, the following are the issues for resolution, namely: (a) whether or not the doctrine of res ipsa loquitur was
applicable herein; and (b) whether or not Dr. Solidum was liable for criminal negligence.
Ruling
The appeal is meritorious.
Applicability of the Doctrine of Res Ipsa Loquitur
Res ipsa loquitur is literally translated as "the thing or the transaction speaks for itself." The doctrine res ipsa loquitur
means that "where the thing which causes injury is shown to be under the management of the defendant, and the
accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it
affords reasonable evidence, in the absence of an explanation by the defendant, that the accident arose from want of
care."24 It is simply "a recognition of the postulate that, as a matter of common knowledge and experience, the very
nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the
instrumentality causing the injury in the absence of some explanation by the defendant who is charged with negligence. It
is grounded in the superior logic of ordinary human experience and on the basis of such experience or common
knowledge, negligence may be deduced from the mere occurrence of the accident itself.
Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge." 25
Jarcia, Jr. v. People26 has underscored that the doctrine is not a rule of substantive law, but merely a mode of proof or a
mere procedural convenience. The doctrine, when applicable to the facts and circumstances of a given case, is not meant
to and does not dispense with the requirement of proof of culpable negligence against the party charged. It merely
determines and regulates what shall be prima facie evidence thereof, and helps the plaintiff in proving a breach of the
duty. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is absent and
not readily available.27
The applicability of the doctrine of res ipsa loquitur in medical negligence cases was significantly and exhaustively
explained in Ramos v. Court of Appeals,28 where the Court said
Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa loquitur has been applied when
the circumstances attendant upon the harm are themselves of such a character as to justify an inference of negligence as
the cause of that harm. The application of res ipsa loquitur in medical negligence cases presents a question of law since it
is a judicial function to determine whether a certain set of circumstances does, as a matter of law, permit a given
inference.
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard medical procedure, when the doctrine of res ipsa loquitur is
availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides the
proof of negligence. The reason is that the general rule on the necessity of expert testimony applies only to such matters
clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind
which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of
skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and
manifest conditions which are observable by any one may be given by non-expert witnesses. Hence, in cases where the
res ipsa loquitur is applicable, the court is permitted to find a physician negligent upon proper proof of injury to the
patient, without the aid of expert testimony, where the court from its fund of common knowledge can determine the
proper standard of care. Where common knowledge and experience teach that a resulting injury would not have occurred
to the patient if due care had been exercised, an inference of negligence may be drawn giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is ordinarily required to show not only what occurred but
how and why it occurred. When the doctrine is appropriate, all that the patient must do is prove a nexus between the

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Page 156

particular act or omission complained of and the injury sustained while under the custody and management of the
defendant without need to produce expert medical testimony to establish the standard of care. Resort to res ipsa loquitur
is allowed because there is no other way, under usual and ordinary conditions, by which the patient can obtain redress for
injury suffered by him.
Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in the
body of the patient after an operation, injuries sustained on a healthy part of the body which was not under, or in the
area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a tooth while a
patients jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient plaintiff was under
the influence of anesthetic, during or following an operation for appendicitis, among others.
Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does not automatically
apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant to show that he is
not guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a
rule to be cautiously applied, depending upon the circumstances of each case. It is generally restricted to situations in
malpractice cases where a layman is able to say, as a matter of common knowledge and observation, that the
consequences of professional care were not as such as would ordinarily have followed if due care had been exercised. A
distinction must be made between the failure to secure results, and the occurrence of something more unusual and not
ordinarily found if the service or treatment rendered followed the usual procedure of those skilled in that particular
practice. It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a physician or
surgeon which involves the merits of a diagnosis or of a scientific treatment. The physician or surgeon is not required at
his peril to explain why any particular diagnosis was not correct, or why any particular scientific treatment did not
produce the desired result. Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is that the
desired result of an operation or treatment was not accomplished. The real question, therefore, is whether or not in the
process of the operation any extraordinary incident or unusual event outside of the routine performance occurred which
is beyond the regular scope of customary professional activity in such operations, which, if unexplained would themselves
reasonably speak to the average man as the negligent cause or causes of the untoward consequence. If there was such
extraneous intervention, the doctrine of res ipsa loquitur may be utilized and the defendant is called upon to explain the
matter, by evidence of exculpation, if he could.
In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1) the
accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency that
caused the injury was under the exclusive control of the person charged; and (3) the injury suffered must not have been
due to any voluntary action or contribution of the person injured. 29
The Court considers the application here of the doctrine of res ipsa loquitur inappropriate. Although it should be
conceded without difficulty that the second and third elements were present, considering that the anesthetic agent and
the instruments were exclusively within the control of Dr. Solidum, and that the patient, being then unconscious during
the operation, could not have been guilty of contributory negligence, the first element was undeniably wanting. Luz
delivered Gerald to the care, custody and control of his physicians for a pull-through operation. Except for the
imperforate anus, Gerald was then of sound body and mind at the time of his submission to the physicians. Yet, he
experienced bradycardia during the operation, causing loss of his senses and rendering him immobile. Hypoxia, or the
insufficiency of oxygen supply to the brain that caused the slowing of the heart rate, scientifically termed as bradycardia,
would not ordinarily occur in the process of a pull-through operation, or during the administration of anesthesia to the
patient, but such fact alone did not prove that the negligence of any of his attending physicians, including the
anesthesiologists, had caused the injury. In fact, the anesthesiologists attending to him had sensed in the course of the
operation that the lack of oxygen could have been triggered by the vago-vagal reflex, prompting them to administer
atropine to the patient.30
This conclusion is not unprecedented. It was similarly reached in Swanson v. Brigham, 31 relevant portions of the decision
therein being as follows:
On January 7, 1973, Dr. Brigham admitted 15-year-old Randall Swanson to a hospital for the treatment of infectious
mononucleosis. The patient's symptoms had included a swollen throat and some breathing difficulty. Early in the
morning of January 9 the patient was restless, and at 1:30 a.m. Dr. Brigham examined the patient. His inspection of the
patient's air passage revealed that it was in satisfactory condition. At 4:15 a.m. Dr. Brigham received a telephone call from
the hospital, advising him that the patient was having respiratory difficulty. The doctor ordered that oxygen be
administered and he prepared to leave for the hospital. Ten minutes later, 4:25 a.m., the hospital called a second time to
advise the doctor that the patient was not responding. The doctor ordered that a medicine be administered, and he
departed for the hospital. When he arrived, the physician who had been on call at the hospital had begun attempts to
revive the patient. Dr. Brigham joined him in the effort, but the patient died.

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The doctor who performed the autopsy concluded that the patient died between 4:25 a.m. and 4:30 a.m. of asphyxia, as a
result of a sudden, acute closing of the air passage. He also found that the air passage had been adequate to maintain life
up to 2 or 3 minutes prior to death. He did not know what caused the air passage to suddenly close.
xxxx
It is a rare occurrence when someone admitted to a hospital for the treatment of infectious mononucleosis dies of
asphyxiation. But that is not sufficient to invoke res ipsa loquitur. The fact that the injury rarely occurs does not in itself
prove that the injury was probably caused by someone's negligence. Mason v. Ellsworth, 3 Wn. App. 298, 474 P.2d 909
(1970). Nor is a bad result by itself enough to warrant the application of the doctrine. Nelson v. Murphy, 42 Wn.2d 737,
258 P.2d 472 (1953). See 2 S. Speiser, The Negligence Case Res Ipsa Loquitur 24:10 (1972). The evidence presented is
insufficient to establish the first element necessary for application of res ipsa loquitur doctrine. The acute closing of the
patients air passage and his resultant asphyxiation took place over a very short period of time. Under these
circumstances it would not be reasonable to infer that the physician was negligent. There was no palpably negligent act.
The common experience of mankind does not suggest that death would not be expected without negligence. And there is
no expert medical testimony to create an inference that negligence caused the injury.
Negligence of Dr. Solidum
In view of the inapplicability of the doctrine of res ipsa loquitur, the Court next determines whether the CA correctly
affirmed the conviction of Dr. Solidum for criminal negligence.
Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care,
precaution, and vigilance that the circumstances justly demand, whereby such other person suffers injury. 32Reckless
imprudence, on the other hand, consists of voluntarily doing or failing to do, without malice, an act from which material
damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform
such act.33
Dr. Solidums conviction by the RTC was primarily based on his failure to monitor and properly regulate the level of
anesthetic agent administered on Gerald by overdosing at 100% halothane. In affirming the conviction, the CA observed:
On the witness stand, Dr. Vertido made a significant turnaround. He affirmed the findings and conclusions in his report
except for an observation which, to all intents and purposes, has become the storm center of this dispute. He wanted to
correct one piece of information regarding the dosage of the anesthetic agent administered to the child. He declared that
he made a mistake in reporting a 100% halothane and said that based on the records it should have been 100% oxygen.
The records he was relying on, as he explains, are the following:
(a) the anesthesia record A portion of the chart in the record was marked as Exhibit 1-A and 1-B to indicate the
administration at intervals of the anesthetic agent.
(b) the clinical abstract A portion of this record that reads as follows was marked Exhibit 3A. 3B
Approximately 1 hour and 45 minutes through the operation, patient was noted to have bradycardia (CR = 70)
and ATSO4 0.2 mg was immediately administered. However, the bradycardia persisted, the inhalational agent
was shut off, and the patient was ventilated with 100% oxygen and another dose of ATSO4 0.2 mg was given.
However, the patient did not respond until no cardiac rate can be auscultated and the surgeons were immediately
told to stop the operation. The patient was put on a supine position and CPR was initiated. Patient was given 1
amp of epinephrine initially while continuously doing cardiac massage still with no cardiac rate appreciated;
another ampule of epinephrine was given and after 45 secs, patients vital signs returned to normal. The entire
resuscitation lasted approximately 3-5 mins. The surgeons were then told to proceed to the closure and the
childs vital signs throughout and until the end of surgery were: BP = 110/70; CR = 116/min and RR = 20-22
cycles/min (on assisted ventilation).
Dr. Vertido points to the crucial passage in the clinical abstract that the patient was ventilated with 100% oxygen and
another dose of ATSO4 when the bradycardia persisted, but for one reason or another, he read it as 100% halothane. He
was asked to read the anesthesia record on the percentage of the dosage indicated, but he could only sheepishly note I
cant understand the number. There are no clues in the clinical abstract on the quantity of the anesthetic agent used. It
only contains the information that the anesthetic plan was to put the patient under general anesthesia using a
nonrebreathing system with halothane as the sole anesthetic agent and that 1 hour and 45 minutes after the operation
began, bradycardia occurred after which the inhalational agent was shut off and the patient administered with 100%

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oxygen. It would be apparent that the 100% oxygen that Dr. Vertido said should be read in lieu of 100% halothane was
the pure oxygen introduced after something went amiss in the operation and the halothane itself was reduced or shut off.
The key question remains what was the quantity of halothane used before bradycardia set in?
The implication of Dr. Vertidos admission is that there was no overdose of the anesthetic agent, and the accused Dr.
Solidum stakes his liberty and reputation on this conclusion. He made the assurance that he gave his patient the utmost
medical care, never leaving the operating room except for a few minutes to answer the call of nature but leaving behind
the other members of his team Drs. Abella and Razon to monitor the operation. He insisted that he administered only a
point 1% not 100% halothane, receiving corroboration from Dr. Abella whose initial MA in the record should be enough
to show that she assisted in the operation and was therefore conversant of the things that happened. She revealed that
they were using a machine that closely monitored the concentration of the agent during the operation.
But most compelling is Dr. Solidums interpretation of the anesthesia record itself, as he takes the bull by the horns, so to
speak. In his affidavit, he says, reading from the record, that the quantity of halothane used in the operation is one
percent (1%) delivered at time intervals of 15 minutes. He studiedly mentions the concentration of halothane as
reflected in the anesthesia record (Annex D of the complaint-affidavit) is only one percent (1%) The numbers indicated
in 15 minute increments for halothane is an indication that only 1% halothane is being delivered to the patient Gerard
Gercayo for his entire operation; The amount of halothane delivered in this case which is only one percent cannot be
summated because halothane is constantly being rapidly eliminated by the body during the entire operation.
xxxx
In finding the accused guilty, despite these explanations, the RTC argued that the volte-face of Dr. Vertido on the
question of the dosage of the anesthetic used on the child would not really validate the non-guilt of the anesthesiologist.
Led to agree that the halothane used was not 100% as initially believed, he was nonetheless unaware of the implications
of the change in his testimony. The court observed that Dr. Vertido had described the condition of the child as hypoxia
which is deprivation of oxygen, a diagnosis supported by the results of the CT Scan. All the symptoms attributed to a
failing central nervous system such as stupor, loss of consciousness, decrease in heart rate, loss of usual acuity and
abnormal motor function, are manifestations of this condition or syndrome. But why would there be deprivation of
oxygen if 100% oxygen to 1% halothane was used? Ultimately, to the court, whether oxygen or halothane was the object of
mistake, the detrimental effects of the operation are incontestable, and they can only be led to one conclusion if the
application of anesthesia was really closely monitored, the event could not have happened. 34
The Prosecution did not prove the elements of reckless imprudence beyond reasonable doubt because the circumstances
cited by the CA were insufficient to establish that Dr. Solidum had been guilty of inexcusable lack of precaution in
monitoring the administration of the anesthetic agent to Gerald. The Court aptly explained in Cruz v. Court of
Appeals35 that:
Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his patient is to be
determined according to the standard of care observed by other members of the profession in good standing under
similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state
of medical science. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., this Court stated that in
accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and
surgeons practicing in the same field, he will employ such training, care and skill in the treatment of his patients. He
therefore has a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a
condition under the same circumstances. It is in this aspect of medical malpractice that expert testimony is essential to
establish not only the standard of care of the profession but also that the physician's conduct in the treatment and care
falls below such standard. Further, inasmuch as the causes of the injuries involved in malpractice actions are
determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually necessary to
support the conclusion as to causation.
xxxx
In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's negligence and for a
reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a causal
connection of such breach and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital, Inc., where the
attending physician was absolved of liability for the death of the complainants wife and newborn baby, this Court held
that:

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"In order that there may be a recovery for an injury, however, it must be shown that the injury for which recovery is
sought must be the legitimate consequence of the wrong done; the connection between the negligence and the injury
must be a direct and natural sequence of events, unbroken by intervening efficient causes. In other words, the negligence
must be the proximate cause of the injury. For, negligence, no matter in what it consists, cannot create a right of action
unless it is the proximate cause of the injury complained of. And the proximate cause of an injury is that cause, which, in
natural and continuous sequence, unbroken by any efficient intervening cause, produces the injury, and without which
the result would not have occurred."
An action upon medical negligence whether criminal, civil or administrative calls for the plaintiff to prove by
competent evidence each of the following four elements, namely: (a) the duty owed by the physician to the patient, as
created by the physician-patient relationship, to act in accordance with the specific norms or standards established by his
profession; (b) the breach of the duty by the physicians failing to act in accordance with the applicable standard of care;
(3) the causation, i.e., there must be a reasonably close and causal connection between the negligent act or omission and
the resulting injury; and (4) the damages suffered by the patient.36
In the medical profession, specific norms or standards to protect the patient against unreasonable risk, commonly
referred to as standards of care, set the duty of the physician to act in respect of the patient. Unfortunately, no clear
definition of the duty of a particular physician in a particular case exists. Because most medical malpractice cases are
highly technical, witnesses with special medical qualifications must provide guidance by giving the knowledge necessary
to render a fair and just verdict. As a result, the standard of medical care of a prudent physician must be determined from
expert testimony in most cases; and in the case of a specialist (like an anesthesiologist), the standard of care by which the
specialist is judged is the care and skill commonly possessed and exercised by similar specialists under similar
circumstances. The specialty standard of care may be higher than that required of the general practitioner. 37
The standard of care is an objective standard by which the conduct of a physician sued for negligence or malpractice may
be measured, and it does not depend, therefore, on any individual physicians own knowledge either. In attempting to fix
a standard by which a court may determine whether the physician has properly performed the requisite duty toward the
patient, expert medical testimony from both plaintiff and defense experts is required. The judge, as the trier of fact,
ultimately determines the standard of care, after listening to the testimony of all medical experts. 38
Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to provide guidance to the
trial court on what standard of care was applicable. It would consequently be truly difficult, if not impossible, to
determine whether the first three elements of a negligence and malpractice action were attendant.
Although the Prosecution presented Dr. Benigno Sulit, Jr., an anesthesiologist himself who served as the Chairman of the
Committee on Ethics and Malpractice of the Philippine Society of Anesthesiologists that investigated the complaint
against Dr. Solidum, his testimony mainly focused on how his Committee had conducted the investigation. 39 Even then,
the report of his Committee was favorable to Dr. Solidum,40 to wit:
Presented for review by this committee is the case of a 3 year old male who underwent a pull-thru operation and was
administered general anesthesia by a team of anesthesia residents. The patient, at the time when the surgeons was
manipulating the recto-sigmoid and pulling it down in preparation for the anastomosis, had bradycardia. The
anesthesiologists, sensing that the cause thereof was the triggering of the vago-vagal reflex, administered atropine to
block it but despite the administration of the drug in two doses, cardiac arrest ensued. As the records show, prompt
resuscitative measures were administered and spontaneous cardiac function re-established in less than five (5) minutes
and that oxygen was continuously being administered throughout, unfortunately, as later become manifest, patient
suffered permanent irreversible brain damage.
In view of the actuations of the anaesthesiologists and the administration of anaesthesia, the committee find that the
same were all in accordance with the universally accepted standards of medical care and there is no evidence of any fault
or negligence on the part of the anaesthesiologists.
Dr. Antonio Vertido, a Senior Medico-Legal Officer of the National Bureau of Investigation, was also presented as a
Prosecution witness, but his testimony concentrated on the results of the physical examination he had conducted on
Gerald, as borne out by the following portions of his direct examination, to wit:
FISCAL CABARON Doctor, what do you mean by General Anesthetic Agent?
WITNESS General Anesthetic Agent is a substance used in the conduction of Anesthesia and in this case, halothane was
used as a sole anesthetic agent.

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xxxx
Q Now under paragraph two of page 1 of your report you mentioned that after one hour and 45 minutes after the
operation, the patient experienced a bradycardia or slowing of heart rate, now as a doctor, would you be able to tell this
Honorable Court as to what cause of the slowing of heart rate as to Gerald Gercayo?
WITNESS Well honestly sir, I cannot give you the reason why there was a bradycardia of time because is some reason one
way or another that might caused bradycardia.
FISCAL CABARON What could be the possible reason?
A Well bradycardia can be caused by anesthetic agent itself and that is a possibility, were talking about possibility here.
Q What other possibility do you have in mind, doctor?
A Well, because it was an operation, anything can happen within that situation.
FISCAL CABARON Now, this representation would like to ask you about the slowing of heart rate, now what is the
immediate cause of the slowing of the heart rate of a person?
WITNESS Well, one of the more practical reason why there is slowing of the heart rate is when you do a vagal reflex in
the neck wherein the vagal receptors are located at the lateral part of the neck, when you press that, you produce the
slowing of the heart rate that produce bradycardia.
Q I am pro[p]ounding to you another question doctor, what about the deficiency in the supply of oxygen by the patient,
would that also cause the slowing of the heart rate?
A Well that is a possibility sir, I mean not as slowing of the heart rate, if there is a hypoxia or there is a low oxygen level in
the blood, the normal thing for the heart is to pump or to do not a bradycardia but a to counter act the Hypoxia that is
being experienced by the patient
(sic).
xxxx
Q Now, you made mention also doctor that the use of general anesthesia using 100% halothane and other anesthetic
medications probably were contributory to the production of hypoxia.
A Yes, sir in general sir.41
On cross-examination, Dr. Vertido expounded more specifically on his interpretation of the anesthesia record and the
factors that could have caused Gerald to experience bradycardia, viz:
ATTY. COMIA I noticed in, may I see your report Doctor, page 3, will you kindly read to this Honorable court your last
paragraph and if you will affirm that as if it is correct?
A "The use of General Anesthesia, that is using 100% Halothane probably will be contributory to the production of
Hypoxia and - - - -"
ATTY COMIA And do you affirm the figure you mentioned in this Court Doctor?
WITNESS Based on the records, I know the - - Q 100%?
A 100% based on the records.

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Q I will show you doctor a clinical record. I am a lawyer I am not a doctor but will you kindly look at this and tell me
where is 100%, the word "one hundred" or 1-0-0, will you kindly look at this Doctor, this Xerox copy if you can show to
this Honorable Court and even to this representation the word "one hundred" or 1-0-0 and then call me.
xxxx
ATTY. COMIA Doctor tell this Honorable Court where is that 100, 1-0-0 and if there is, you just call me and even the
attention of the Presiding Judge of this Court. Okay, you read one by one.
WITNESS Well, are you only asking 100%, sir?
ATTY. COMIA Im asking you, just answer my question, did you see there 100% and 100 figures, tell me, yes or no?
WITNESS Im trying to look at the 100%, there is no 100% there sir.
ATTY. COMIA Okay, that was good, so you Honor please, may we request also temporarily, because this is just a xerox
copy presented by the fiscal, that the percentage here that the Halothane administered by Dr. Solidum to the patient is 1%
only so may we request that this portion, temporarily your Honor, we are marking this anesthesia record as our Exhibit 1
and then this 1% Halothane also be bracketed and the same be marked as our Exhibit "1-A".
xxxx
ATTY. COMIA Doctor, my attention was called also when you said that there are so many factors that contributed to
Hypoxia is that correct?
WITNESS Yes, sir.
Q I remember doctor, according to you there are so many factors that contributed to what you call hypoxia and according
to you, when this Gerald suffered hypoxia, there are other factors that might lead to this Hypoxia at the time of this
operation is that correct?
WITNESS The possibility is there, sir.
Q And according to you, it might also be the result of such other, some or it might be due to operations being conducted
by the doctor at the time when the operation is being done might also contribute to that hypoxia is that correct?
A That is a possibility also.
xxxx
ATTY. COMIA How will you classify now the operation conducted to this Gerald, Doctor?
WITNESS Well, that is a major operation sir.
Q In other words, when you say major operation conducted to this Gerald, there is a possibility that this Gerald might
[be] exposed to some risk is that correct?
A That is a possibility sir.
Q And which according to you that Gerald suffered hypoxia is that correct?
A Yes, sir.
Q And that is one of the risk of that major operation is that correct?
A That is the risk sir.42

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At the continuation of his cross-examination, Dr. Vertido maintained that Geralds operation for his imperforate anus,
considered a major operation, had exposed him to the risk of suffering the same condition. 43 He then corrected his earlier
finding that 100% halothane had been administered on Gerald by saying that it should be 100% oxygen. 44
Dr. Solidum was criminally charged for "failing to monitor and regulate properly the levels of anesthesia administered to
said Gerald Albert Gercayo and using 100% halothane and other anesthetic medications." 45However, the foregoing
circumstances, taken together, did not prove beyond reasonable doubt that Dr. Solidum had been recklessly imprudent in
administering the anesthetic agent to Gerald. Indeed, Dr. Vertidos findings did not preclude the probability that other
factors related to Geralds major operation, which could or could not necessarily be attributed to the administration of
the anesthesia, had caused the hypoxia and had then led Gerald to experience bradycardia. Dr. Vertido revealingly
concluded in his report, instead, that "although the anesthesiologist followed the normal routine and precautionary
procedures, still hypoxia and its corresponding side effects did occur." 46
The existence of the probability about other factors causing the hypoxia has engendered in the mind of the Court a
reasonable doubt as to Dr. Solidums guilt, and moves us to acquit him of the crime of reckless imprudence resulting to
serious physical injuries. "A reasonable doubt of guilt," according to United States v. Youthsey: 47
x x x is a doubt growing reasonably out of evidence or the lack of it. It is not a captious doubt; not a doubt engendered
merely by sympathy for the unfortunate position of the defendant, or a dislike to accept the responsibility of convicting a
fellow man. If, having weighed the evidence on both sides, you reach the conclusion that the defendant is guilty, to that
degree of certainty as would lead you to act on the faith of it in the most important and crucial affairs of your life, you
may properly convict him. Proof beyond reasonable doubt is not proof to a mathematical demonstration. It is not proof
beyond the possibility of mistake.
We have to clarify that the acquittal of Dr. Solidum would not immediately exempt him from civil liability.1wphi1 But
we cannot now find and declare him civilly liable because the circumstances that have been established here do not
present the factual and legal bases for validly doing so. His acquittal did not derive only from reasonable doubt. There
was really no firm and competent showing how the injury to Gerard had been caused. That meant that the manner of
administration of the anesthesia by Dr. Solidum was not necessarily the cause of the hypoxia that caused the bradycardia
experienced by Gerard. Consequently, to adjudge Dr. Solidum civilly liable would be to speculate on the cause of the
hypoxia. We are not allowed to do so, for civil liability must not rest on speculation but on competent evidence.
Liability of Ospital ng Maynila
Although the result now reached has resolved the issue of civil liability, we have to address the unusual decree of the RTC,
as affirmed by the CA, of expressly holding Ospital ng Maynila civilly liable jointly and severally with Dr. Solidum. The
decree was flawed in logic and in law.
In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with the criminal
action refers only to that arising from the offense charged. 48 It is puzzling, therefore, how the RTC and the CA could have
adjudged Ospital ng Maynila jointly and severally liable with Dr. Solidum for the damages despite the obvious fact that
Ospital ng Maynila, being an artificial entity, had not been charged along with Dr. Solidum. The lower courts thereby
acted capriciously and whimsically, which rendered their judgment against Ospital ng Maynila void as the product of
grave abuse of discretion amounting to lack of jurisdiction.
Not surprisingly, the flawed decree raises other material concerns that the RTC and the CA overlooked. We deem it
important, then, to express the following observations for the instruction of the Bench and Bar.
For one, Ospital ng Maynila was not at all a party in the proceedings. Hence, its fundamental right to be heard was not
respected from the outset. The R TC and the CA should have been alert to this fundamental defect. Verily, no person can
be prejudiced by a ruling rendered in an action or proceeding in which he was not made a party. Such a rule would
enforce the constitutional guarantee of due process of law.
Moreover, Ospital ng Maynila could be held civilly liable only when subsidiary liability would be properly enforceable
pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability seems far-fetched here. The conditions for
subsidiary liability to attach to Ospital ng Maynila should first be complied with. Firstly, pursuant to Article 103 of the
Revised Penal Code, Ospital ng Maynila must be shown to be a corporation "engaged in any kind of industry." The term
industry means any 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 work.50Secondly, assuming that Ospital ng Maynila was

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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 AND SETS ASIDE the decision
promulgated on January 20, 2010; ACQUITS Dr. Fernando P. Solidum of the crime of reckless imprudence resulting to
serious physical injuries; and MAKES no pronouncement on costs of suit.
SO ORDERED.

State Regulation of Hospital Operation

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Licensure:
the granting of permission by a competent authority (usually a government agency) to anorganization o
r individual to engage in a practice or activity that would otherwise be illegal. Kindsof licensure in
clude the issuing of licenses for general hospitals or nursing homes, for healthprofessionals such
as physicians, and for the production or distribution of biologic products.Licensure is usually gra
nted on the basis of education and examination rather than performance.It is usually permanent,
but a periodic fee, demonstration of competence, or continuingeducation may be required. Licens
ure may be revoked by the granting agency for incompetence,criminal acts, or other reasons stip
ulated in the rules governing the specific area of licensure.
(http://medicaldictionary.thefreedictionary.com/licensure)

Accreditation:
a process whereby a professional association or nongovernmental agency grants recognition toa school or health care inst
itution for demonstrated ability to meet predetermined criteria forestablished standards, such as the accreditation of hos
pitals by the Joint Commission onAccreditation of Healthcare Organizations or of schools of nursing by the NLNAC. (htt
p://medical-dictionary.thefreedictionary.com/accreditation)
Certification:
a process in which the professional organization or association verifies that aperson who is licensed has met the standard
s for specialty practice specified by the profession.The purpose of certification is to assure other professionals and the pu
blic that the person hasmastered the skills necessary to practice a particular specialty and has acquired the standardbody
of knowledge common to that specialty. (http://medical-dictionary.thefreedictionary.com/certification)

REPUBLIC ACT NO. 4226 - AN ACT REQUIRING THE LICENSURE OF ALL HOSPITALS IN THE PHILIPPINES AND
AUTHORIZING THE BUREAU OF MEDICAL SERVICES TO SERVE AS THE LICENSING AGENCY
Section 1. This Act shall also be known as the Hospital Licensure Act.
Sec. 2. Definitions. As used in this Act
(a) 'Hospital' means a place devoted primarily to the maintenance and operation of facilities for the diagnosis,
treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other
medical and nursing care. The term 'hospital shall also be construed as any institution, building or place where there are
installed beds, or cribs, or bassinets for twenty-four-hour use or longer by patients in the treatment of diseases, diseasedconditions, injuries, deformities, or abnormal physical and mental states, maternity cases, and all institutions such as
those for convalescence, sanitarial or sanitarial care, infirmities, nurseries, dispensaries and such other names by which
they may designated.
(b) 'Government hospital' means a hospital operated and maintained either partially or wholly by the national,
provincial, municipal or city government or other political subdivision, or by any department, division, board or other
agency thereof.
(c) 'Private hospital' means one which is privately owned, established and operated with funds raised or contributed
through donations, or by private capital or other means, by private individuals, association, corporation, religious
organization, firm, company or joint stock association.
(d) 'Clinic' means a place in which patients avail of medical consultations or treatments on an out-patient basis.
However, any clinic or dispensary where there is at least six beds or cribs or bassinets installed for twenty-four-hour use
by patients shall be construed to fall within the definition of a hospital as described in this Act.

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(e) 'Licensee' is the person or persons granted a license to operate and maintain a hospital according to an approved
minimum standard.
Sec. 3. Construction Permit. No hospital, government or private, shall be constructed unless plans have been
approved and construction permit issued by the licensing agency as defined in this Act.
Sec. 4. Registration and license. No hospital shall operate or be opened to the public unless it shall have been
registered and a license for its operation obtained from the licensing agency provided in this Act.
Sec. 5. Licensing Agency. For purposes of setting standards in hospital construction and operation, the Bureau of
Medical Services in addition to its present duties shall act as the licensing agency. The Secretary of Health shall
reorganize this Bureau to include a staff of hospital architects, hospital administrators, sanitary engineers and such
personnel as may be necessary to carry out the purposes of this Act without necessarily increasing the present personnel
strength of this Bureau.
Sec. 6. Powers and duties of the licensing agency. The Bureau of Medical Services, or the licensing agency shall have
the following powers and duties:
a. To conduct an ocular survey of all existing hospitals in the Philippines, government or private, with a view to
determine their fitness to operate considering their facilities and physical plant.
b. To prescribe standard plans for government hospital plants in consultation with the Division of Architecture, Bureau
of Public Works.
c. To approve plans for hospital plants, government or private, and to issue permits or authority to construct hospitals
in accordance with the provisions of this Act.
d. To keep a permanent register of approved hospitals or those issued licenses to operate indicating the name of the
hospital, address or location, type of hospital, name of the director or administrator, ownership, number of authorized
beds and bassinets and such other pertinent data as may be necessary.
e. To grant licenses for the operation and maintenance of hospitals or revoke the same in accordance with the
provisions of this Act.
f. To make periodic inspection of all hospitals so as to check compliance with rules and regulations legally promulgated
or with the provisions of this Act and to make recommendations to directors or administrators of hospitals for the
correction of defects found during such inspections.
g. To publish yearly a list of all approved hospitals indicating the name, location, type, authorized beds, and name of the
director or administrator.
h. To submit yearly reports to the Secretary of Health, the Speaker of the House of Representatives, the President of the
Senate and the chairmen and members of the Committees on Health of both Houses of Congress, such reports to include
a list of approved hospitals indicating the name of the hospital, location, bed capacity and name of the director or
administrator and make recommendations on hospital needs or requirements for hospital service in certain communities
that do not enjoy such hospital services.
Sec. 7. Filing of Application for Construction Permit. Application for a permit to construct a hospital shall be
submitted to the Office of the Director, Bureau of Medical Services in a form prescribed by the latter and accompanied by
a plan of the hospital plant proposed to be constructed. The application shall state the name of the hospital, ownership,
number of beds proposed to be operated, location and type of hospital to be constructed.
Sec. 8. Minimum Standards of Construction. In order that a permit to construct a hospital can be issued the hospital
plan shall provide sufficient bed space for the hospital bed capacity proposed, a laboratory room, an operating room,
including work rooms for sterilization, anesthesia preparation, etc., an X-ray or radiology room, pharmacy, dispensary or
out-patient department, delivery room, isolation rooms, autopsy room or morgue, sufficient quarters for residents,
nurses, attendants and helpers and sufficient number of toilet facilities.
Wards shall be constructed such that segregation of the sexes is observed and as far as practicable classified as to the type
of cases to be confined.

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Sec. 9. Application for Registration and Issuance of License. Application for registration of a hospital and for the
issuance of a license for its operation and maintenance shall be filed with the Bureau of Medical Services on a form
prescribed by it. Registration may be made and license issued upon compliance with the provisions of Section eight
hereof and the rules and regulations prescribed by the licensing agency pursuant to the provisions of this Act.
SECTION 10. Inspection. Permit to construct a hospital or a major portion thereof and license to operate and
maintain the same shall be issued by the licensing agency only after a representative of the licensing agency has
conducted an ocular inspection and certified that the applicant has satisfactorily complied with requisites prescribed in
this Act. The license to operate and maintain a hospital shall be renewed every year upon payment of the prescribed fees.
SECTION 11. Revocation of License. The licensing agency may suspend or revoke a license already issued for any of
the following grounds: (a) repeated violation by the licensee of any provision of this Act or of any other existing law; (b)
repeated violation of rules and regulations prescribed in the implementation of this Act; or (c) repeated failure to make
necessary corrections or adjustments required by the licensing agency in the improvement of facilities and services.
SECTION 12. Hearing. Any person, association, corporation, or any other private entity who has been refused a
license to operate and maintain a hospital or whose license for such hospital has been suspended or revoked shall be
entitled to an administrative hearing to be conducted by the Secretary of Health and his two undersecretaries to
determine the justifiability of such denial, suspension or revocation of the license: provided, that the licensee may resort
to the courts, as in other cases provided by law.
SECTION 13. Separate Licenses Required. Separate licenses shall be required for hospitals or branches thereof
maintained in separate premises, even though they are operated under the same management: provided, however, that
separate licenses shall not be required for separate buildings in the same compound: provided, further, that permits for
construction or alteration of buildings within the same compound shall also be secured from the licensing agency to
determine compliance with standards and requirements herein authorized.
SECTION 14. License not transferable. License for the operation of hospitals shall not be transferable. The licensing
agency shall be notified of any change in ownership, change of name of the hospital, and transfer of location and in the
latter case, an application for a new license should be submitted.
SECTION 15. Rules and Regulations. The Bureau of Medical Services acting as a licensing agency and subject to the
approval of the Secretary of Health, shall promulgate rules and regulations to implement the provisions of this Act.
SECTION 16. Classification of Hospitals. The licensing agency shall study and adopt a system of classifying hospitals
in the Philippines as to: (1) general or special; (2) hospital services capabilities; (3) size or bed capacity and (4) class of
hospital whether training or not.
SECTION 17. Fees. Each applicant for a permit to construct a hospital shall pay the amount of five pesos as permit
fee. A registration fee of five pesos and an annual license fee of ten pesos shall likewise be collected for each hospital and
for each approved license: provided, that a government hospital shall be exempt from the payment of such fees. The
amount herein collected shall be officially receipted by the licensing agency and shall constitute as a revolving fund for
the use of the licensing agency.
SECTION 18. Penalties. Any person, partnership, association, or corporation who establishes, operates, conducts,
manages or maintains a hospital or hospital clinic within the meaning of this Act without first obtaining a license as
provided for in this Act or violates any provision hereof shall be guilty of a misdemeanor, and upon conviction thereof
shall be liable to a fine of not more than five hundred pesos for the first offense and not more than one thousand pesos
for each subsequent offense, and each day that the hospital shall operate after the first conviction shall be considered a
subsequent offense.
SECTION 19. Repeal. Any law or laws or parts thereof inconsistent with the provisions of this Act are hereby
repealed.
Sec. 20. Effectivity. This Act shall take effect upon its approval.
Executive Order 292, Title IX
SECTION 3. Powers and Functions.The Department shall:

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(1) Define the national health policy and formulate and implement a national health plan within the framework of the
governments general policies and plans, and present proposals to appropriate authorities on national issues which have
health implications;
(2) Provide for health programs, services, facilities and other requirements as may be needed, subject to availability of
funds and administrative rules and regulations;
(3) Coordinate or collaborate with, and assist local communities, agencies and interested groups including international
organizations in activities related to health;
(4) Administer all laws, rules and regulations in the field of health, including quarantine laws and food and drug safety
laws;
(5) Collect, analyze and disseminate statistical and other relevant information on the countrys health situation, and
require the reporting of such information from appropriate sources;
(6) Propagate health information and educate the population on important health, medical and environmental matters
which have health implications;
(7) Undertake health and medical research and conduct training in support of its priorities, programs and activities;
(8) Regulate the operation of and issue licenses and permits to government and private hospitals, clinics and
dispensaries, laboratories, blood banks, drugstores and such other establishments which by the nature of their functions
are required to be regulated by the Department;
(9) Issue orders and regulations concerning the implementation of established health policies; and
(10) Perform such other functions as may be provided by law.
SECTION 14. Office for Hospital and Facilities Services.The Office for Hospital and Facilities Services, headed by an
Undersecretary who shall be supported by an Assistant Secretary, shall include four (4) staff services involved in policy
formulation, standards development, program monitoring and provision of specialized assistance in the operations of
hospitals and the management of facilities, which are as follows:
(1) Hospital Operations and Management Service which shall formulate and implement plans, programs, policies,
standards and techniques related to management improvement and quality control of hospital operations; provide
consultative, training and advisory services to field offices in relation to the supervision and management of hospital
components; and conduct studies and research related to hospital operations and management;
(2) Radiation Health Service which shall formulate and implement plans, programs, policies, standards and techniques
to ensure radiation health safety; provide consultative, monitoring, training and advisory services to private and
government facilities with radiation-emitting apparatus; and conduct studies and research related to radiation health;
(3) Hospital Maintenance Service which shall formulate and implement plans, programs, policies, standards and
techniques related to assuring the proper maintenance of Department equipment; provide consultative, training and
advisory services to implementing agencies in relation to preservation, repair and maintenance of medical and nonmedical equipment of the Department; and conduct studies and research related to equipment and facility maintenance;
(4) Health Infrastructure Service which shall formulate and implement plans, policies, programs, standards and
techniques related to development and preservation of health infrastructure; provide consultative, training and advisory
services to implementing agencies in relation to infrastructure projects to assure economical and efficient
implementation; and conduct studies and research related to infrastructure development and utilization.
SECTION 15. Office for Standards and Regulations.The Office for Standards and Regulations, headed by an
Undersecretary and supported by an Assistant Secretary, shall include three (3) bureaus and one (1) national office that
shall be responsible for the formulation of regulatory policies and standards over the various areas of concern in the
health sector, whose implementation shall be the general responsibility of the Departments regional field offices. The
same bureaus shall also be responsible for those areas of activity covered by regulatory policy to provide the Secretary
with current information on the status of these regulated areas of activity and to provide the Secretary with a basis for
preliminary evaluation of the efficiency of the Departments field offices in performing their regulatory functions. The
same bureaus shall conduct studies and research pertinent to their areas of responsibility. In certain instances the
bureaus may also perform consultative, training and advisory services to the practitioners and institutions in the area of
regulated activity. The same bureaus and national office are the following:
(1) Bureau of Research and Laboratories which shall develop and formulate plans, standards and policies, for the
establishment and accreditation and licensing of laboratories; blood banks and entities handling biological products;
provide consultative, training and advisory services to public and private laboratories; and conduct studies and research
related to laboratory procedures and operations;
(2) Bureau of Food and Drugs which shall act as the policy formulation and sector monitoring arm of the Secretary on
matters pertaining to foods, drugs, traditional medicines, cosmetics and household products containing hazardous
substances, and the formulation of rules, regulations and standards in accordance with Republic Act 3720 (1963), as
amended by Executive Order No. 175, s. 1987, and other pertinent laws for their proper enforcement; prescribe general

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standards and guidelines with respect to the veracity of nutritional and medicinal claims in the advertisement of food,
drugs and cosmetics in the various media, to monitor such advertisements; advise the Departments field offices to call
upon any erring manufacturer, distributor, or advertiser to desist from such inaccurate or misleading nutritional or
medicinal claims in their advertising; should such manufacturer, distributor, or advertiser refuse or fail to obey the
desistance order issued by the Bureau, he shall be subject to the applicable penalties as may be prescribed by law and
regulations; the Bureau shall provide consultative, training and advisory services to all agencies and organizations
involved in food and drug manufacturing and distribution with respect to assuring safety and efficacy of food and drugs;
conduct studies and research related to food and drug safety; maintain a corps of specially trained food and drugs
inspectors for assignment to the various field offices of the Department; while these inspectors shall be under the
technical supervision and guidance of the Bureau, they shall be under the administrative supervision of the head of the
field offices to which they shall be assigned, the latter being responsible for regulatory program implementation within
the geographic area of his jurisdiction;
(3) Bureau of Licensing and Regulation which shall formulate policies and establish the standards for the licensing and
regulation of hospitals, clinics and other health facilities; establish standards that shall be the basis of inspections and
licensure procedures of the Departments field offices; and provide consultative, training and advisory services to field
offices on the conduct of licensing and regulatory functions over hospitals, clinics and other health facilities.
(4) National Quarantine Office which shall formulate and implement quarantine laws and regulations and, through its
field offices, exercise supervision over rat-proof zones in designated international ports and airports and over medical
examination of aliens for immigration purposes.
Republic of the Philippines
Congress of the Philippines
Metro Manila
Thirteenth Congress
Third Regular Session
Begun and held in Metro Manila, on Monday, the nineteenth day of February, two thousand seven.
REPUBLIC ACT NO. 9439
April 27, 2007
AN ACT PROHIBITING THE DETENTION OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS ON
GROUNDS OF NONPAYMENT OF HOSPITAL BILLS OR MEDICAL EXPENSES
Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:
SECTION 1. It shall be unlawful for any hospital or medical clinic in the country to detain or to otherwise cause, directly
or indirectly, the detention of patients who have fully or partially recovered or have been adequately attended to or who
may have died, for reasons of nonpayment in part or in full of hospital bills or medical expenses.
SEC. 2. Patients who have fully or partially recovered and who already wish to leave the hospital or medical clinic but are
financially incapable to settle, in part or in full, their hospitalization expenses, including professional fees and medicines,
shall be allowed to leave the hospital or medical clinic, with a right to demand the issuance of the corresponding medical
certificate and other pertinent papers required for the release of the patient from the hospital or medical clinic upon the
execution of a promissory note covering the unpaid obligation. The promissory note shall be secured by either a mortgage
or by a guarantee of a co-maker, who will be jointly and severally liable with the patient for the unpaid obligation. In the
case of a deceased patient, the corresponding death certificate and other documents required for interment and other
purposes shall be released to any of his surviving relatives requesting for the same: Provided, however, That patients who
stayed in private rooms shall not be covered by this Act.
SEC. 3. Any officer or employee of the hospital or medical clinic responsible for releasing patients, who violates the
provisions of this Act shall be punished by a fine of not less than Twenty thousand pesos (P20,000.00), but not more
than Fifty thousand pesos (P50,000.00), or imprisonment of not less than one month, but not more than six months, or
both such fine and imprisonment, at the discretion of the proper court.
SEC. 4. The Department of Health shall promulgate the necessary rules and regulations to carry out the provisions of
this Act.
SEC. 5. If any provision of this Act is declared void and unconstitutional the remaining provisions hereof not affected
thereby shall remain in full force and effect.
SEC. 6. All laws, decrees, orders, rules and regulations or part thereof inconsistent with this Act are hereby repealed or
amended accordingly.
SEC. 7. This Act shall take effect fifteen (15) days after its publication in two national newspapers of general circulation.
Approved,
MANNY VILLAR
JOSE DE VENECIA JR.
President of the Senate
Speaker of the House of
Representatives

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This Act which originated in the House of Representatives was finally passed by the House of Representatives and the
Senate on June 7, 2005 and February 19, 2007, respectively.
OSCAR G. YABES
ROBERTO P. NAZARENO
Secretary of Senate
Secretary General
House of Represenatives
Approved: April 27, 2007
GLORIA MACAPAGAL-ARROYO
President of the Philippines
Republic Act No. 8344
August 25, 1997
AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER
APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN EMERGENCY OR SERIOUS CASES,
AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG 702, OTHERWISE KNOWN AS "AN ACT
PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR
TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES"
Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled::
Section 1. Section 1 of Batas Pambansa Bilang 702 is hereby amended to read as follows:
"SECTION 1. In emergency or serious cases, it shall be unlawful for any proprietor, president, director, manager or any
other officer, and/or medical practitioner or employee of a hospital or medical clinic to request, solicit, demand or accept
any deposit or any other form of advance payment as a prerequisite for confinement or medical treatment of a patient in
such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of
medicine to prevent death or permanent disability: Provided, That by reason of inadequacy of the medical capabilities of
the hospital or medical clinic, the attending physician may transfer the patient to a facility where the appropriate care can
be given, after the patient or his next of kin consents to said transfer and after the receiving hospital or medical clinic
agrees to the transfer: Provided, however, That when the patient is unconscious, incapable of giving consent and/or
unaccompanied, the physician can transfer the patient even without his consent: Provided, further, That such transfer
shall be done only after necessary emergency treatment and support have been administered to stabilize the patient and
after it has been established that such transfer entails less risks than the patient's continued confinement: Provided,
furthermore, That no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to
receive the patient nor demand from the patient or his next of kin any deposit or advance payment: Provided, finally,
That strict compliance with the foregoing procedure on transfer shall not be construed as a refusal made punishable by
this Act."
Section 2. Section 2 of Batas Pambansa Bilang 702 is hereby deleted and in place thereof, new sections 2, 3 and 4 are
added, to read as follows:
"SEC. 2. For purposes of this Act, the following definitions shall govern:
"(a) 'Emergency' - a condition or state of a patient wherein based on the objective findings of a prudent medical officer on
duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or
cause permanent disability to the patient.
"(b) 'Serious case' - refers to a condition of a patient characterized by gravity or danger wherein based on the objective
findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause
permanent disability to the patient.
"(c) 'Confinement' - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing,
and treatment consistent with the capability and available facilities of the hospital or clinic.
"(d) 'Hospital' - a facility devoted primarily to the diagnosis, treatment and care of individuals suffering from illness,
disease, injury or deformity, or in need of obstetrical or other medical and nursing care. It shall also be construed as any
institution, building or place where there are facilities and personnel for the continued and prolonged care of patients.
"(e) 'Emergency treatment and support' - any medical or surgical measure within the capability of the hospital or medical
clinic that is administered by qualified health care professionals to prevent the death or permanent disability of a patient.
"(f) 'Medical clinic' - a place in which patients can avail of medical consultation or treatment on an outpatient basis.
"(g) 'Permanent disability' - a condition of physical disability as defined under Article 192-C and Article 193-B and C of
Presidential Decree No 442; as amended, otherwise known as the Labor Code of the Philippines.
"(h) 'Stabilize' - the provision of necessary care until such time that the patient may be discharged or transferred to
another hospital or clinic with a reasonable probability that no physical deterioration would result from or occur during
such discharge or transfer.
"SEC. 3. After the hospital or medical clinic mentioned above shall have administered medical treatment and support, it
may cause the transfer of the patient to an appropriate hospital consistent with the needs of the patient, preferably to a
government hospital, specially in the case of poor or indigent patients.
"SEC. 4. Any official, medical practitioner or employee of the hospital or medical clinic who violates the provisions of this
Act shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1)
day but not more than two (2) years and four (4) months, or a fine of not less than Twenty thousand pesos (P20,000.00),

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but not more than One hundred thousand pesos (P100,000.00) or both, at the discretion of the court: Provided, however,
That if such violation was committed pursuant to an established policy of the hospital or clinic or upon instruction of its
management, the director or officer of such hospital or clinic responsible for the formulation and implementation of such
policy shall, upon conviction by final judgment, suffer imprisonment of four (4) to six (6) years, or a fine of not less than
One hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos (P500,000.00) or both, at
the discretion of the court."
Section 3. Section 3 of Batas Pambansa Bilang 702 is hereby repealed.
Section 4. Section 4 of Batas Pambansa Bilang 702 shall become Section 5 thereof and shall be amended to read as
follows:
"SEC. 5. The Department of Health shall promulgate the necessary rules and regulations to carry out the provisions of
this Act."
Section 5. This Act shall take effect fifteen (15) days after its publication in two (2) national newspapers of general
circulation.
Approved: August 25, 1997
The Lawphil Project - Arellano Law Foundation

IMPLEMENTING RULES AND REGULATIONS OF REPUBLIC ACT NO. 8344,


OTHERWISE KNOWN AS "AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL
CLINICS TO ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN
EMERGENCY OR SERIOUS CASES, AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG 702,
OTHERWISE KNOWN AS AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE
PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL
CLINICS IN CERTAIN CASES"
WHEREAS, the Tenth Congress of the Republic of the Philippines enacted Republic Act No. 8344 on June 05, 1997;
WHEREAS, the President of the Republic of the Philippines signed into law R.A. 8344 on August 25, 1997;
WHEREAS, under Section 5 of R.A. 8344, the Department of Health (DOH) is mandated to promulgate the necessary
rules and regulations to carry out the provisions of the aforementioned law.
NOW THEREFORE, pursuant to the provisions of R.A. 8344 authorizing the Department of Health to promulgate the
necessary rules and regulations, the following are hereby issued:
1. Section 1 of said Act provides: "In emergency or serious cases, it shall be unlawful for any proprietor, president,
director, manager or any other officer, and/or medical practitioner or employee of a hospital or medical clinic to request,
solicit, demand or accept any deposit or any other form of advance payment as a prerequisite for confinement or medical
treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as
dictated by good practice of medicine to prevent death or permanent disability: Provided, That by reason of inadequacy
of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility
where appropriate care can be given, after the patient or his next of kin consents to said transfer: Provided, however, That
when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the
patient even without his consent, Provided, further, That such transfer shall be done only after the necessary emergency
treatment and support have been administered to stabilize the patient and after it has been established that such transfer
entails less risks than the patient's continued confinement: Provided, finally, That strict compliance with the foregoing
procedure on transfer shall not be construed as a refusal made punishable by this Act."
2. For the purpose of implementing the above, the following definitions are provided:
2.1 Emergency - A condition or state of patient wherein based on the objective findings of a prudent medical officer on
duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or
cause permanent disability to the patient.
2.2 Serious Case - refers to a condition of a patient characterized by gravity or danger wherein based on the objective
findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause
permanent disability to the patient.
2.3 Confinement - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing, and
treatment consistent with the capability and available facilities of the hospital or clinic.
2.4 Hospital - a facility devoted primarily to the diagnosis, treatment and care of individuals or other medical and nursing
care. It shall also be construed as any institution, building or place where there are facilities and personnel for the
continued and prolonged care of patients. The hospital shall be duly licensed by the Bureau of Licensing and Regulation
of the DOH.
2.5 Emergency Treatment and Support - any medical or surgical measure within the capability of a hospital or medical
clinic that is administer by qualified health care professionals to prevent the death or permanent disability of a patient.
(In determining the capability of a hospital or clinic, the standards and the classification of these facilities set by the DOH
Bureau of Licensing and Regulation shall be used).

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2.6 Medical Clinic - a place in which patients can avail of medical consultation or treatment on an outpatient basis.
2.7 Permanent Disability - a condition of physical disability as defined under Article 192-C and Article 193-B and C of
Presidential Decree No. 442, as amended, otherwise known as the Labor Code of the Philippines.
2.8 Stabilize - the provision of necessary care until such time that the patient may be discharged or transferred to another
hospital or clinic with a reasonable probability that no physical deterioration would result from or occur during such
discharge or transfer.
3. Transfer of Patients - Section 3 of R.A. 8344 provides: "After the hospital or medical clinic mentioned above shall have
administered medical treatment and consistent with the needs of the patients preferably to a government hospital,
specially in the case of poor or indigent patients."
3.1 The transferring and receiving hospital, shall be as much as practicable, be within ten (10) kilometer radius of each
other.
3.2 The transfer of patients contemplated under this Act shall at all times be properly documented.
3.3 Hospitals may require a deposit or advance payment when the patient is no longer under the state of emergency and
he/she refuses to be transferred.
4. All hospitals shall use a Uniform Discharge/Transfer Slip for cases covered by RA 8344 which shall include the
following information:
4.1 Admission Form of transferring hospital.
4.2 Transfer Form of Transferring Hospital, to include but not necessarily limited to the following information:
4.2.1 Vital signs
4.2.2 Name of Attending Physician
4.2.3 Treatment given to patient
4.2.4 Name of receiving hospital
4.2.5 Name of contact person and approving official at receiving hospital
4.2.6 Consent of the patient or companion. In case of an unaccompanied minor or patient, they may be transferred
without consent provided that the provisions of Section 1 of RA 8344 is strictly observed.
The hospital shall endeavor to use all forms of media to contact the next of kin of the unaccompanied minor or patient.
4.2.7 In case of refusal of transfer, the name of the hospital, the name(s) of persons who refused and the reason(s) for the
refusal.
A copy of the Uniform Discharge/Transfer Slip is hereto attached as Annex A*.
5. Penal Provisions - any official, medical practitioner or employee of the hospital or medical clinic who violates the
provisions of RA 8344 shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6)
months and one (1) day but not more than two (2) years and four months, or a fine of not less than Twenty Thousand
Pesos (P20,000.00) but not more than One Hundred Thousand Pesos (P100,000.00) or both at the discretion of the
court: Provided, however, That if such violation was committed pursuant to an established policy of the hospital or clinic
or upon instruction of its management, the director or officer of such hospital or clinic responsible for the formulation
and imprisonment of four (4) to six (6) years, or a fine of not less than One Hundred Thousand Pesos (P100,000.00), but
not more than Five Hundred Thousand Pesos (P500,000.00) or both, at the discretion of the court.
6. In order to demonstrate compliance with the Act's provisions, all hospitals and medical clinics are instructed to
institute the following measures:
6.1 A copy of the law and this implementing rules and regulations should be displayed prominently at hospital emergency
rooms, hospital admission, counters and medical clinic premises.
6.2 Hospital and clinic managers shall establish billing and collection procedure for treatment or confinement of
emergency and serious cases which shall not commence until the essential appropriate treatment of such cases has been
completed.
6.3 Hospital and clinic managers shall instruct their personnel to provide prompt and immediate medical attention to
emergency and serious cases without any prior requirements for payment or deposit.
6.4 It is clarified that the law and this administrative order covers only the provision of medical and surgical goods and
services, and do not cover the provision of non-medical amenities which have nothing to do with the treatment of the
emergency or serious case. The provisions of and payment for these non-medical amenities shall be subject to
appropriate institutional business practice.
6.5 Alleged violations of the Act and this Order may be reported to the Bureau of Licensing and Regulations, Office for
Standards and Regulations, Department of Health, Sta. Cruz, Manila, or to the nearest Regional Health Office which shall
immediately conduct a fact-finding investigation. The findings shall be referred to the appropriate fiscal for criminal
prosecution. Persons convicted of violation shall be punished in accordance with the Act.
6.6 At the instance of the Bureau of Licensing and Regulation, Administrative proceedings may also be pursued against
erring clinics or hospitals that could lead to either suspension or revocation of appropriate licenses.
These Rules and Regulations shall take effect fifteen (15) days after publication in the Official Gazette or in a newspaper
of general circulation.
Adopted: February 18, 1998
(SGD.) CARMENCITA NORIEGA-REODICA, MD
Secretary of Health

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REPUBLIC ACT NO. 6615 - AN ACT REQUIRING GOVERNMENT AND PRIVATE HOSPITALS AND
CLINICS TO EXTEND MEDICAL ASSISTANCE IN EMERGENCY CASES
Section 1. All government and private hospitals or clinic duly licensed to operate as such are hereby required to render
immediate emergency medical assistance and to provide facilities and medicine within its capabilities to patients in
emergency cases who are in danger of dying and/or who may have suffered serious physical injuries.
Sec. 2. The expenses and losses of earnings incurred by a private hospital of clinic for medicines, facilities and services
beyond first aid extended to emergency cases as required herein, and not to exceed fifty thousand pesos per year, shall be
deductible expenses and losses for income tax purposes which may be carried over for a period of five years, any
provision of law or regulation to the contrary notwithstanding.
Sec. 3. Any hospital director, administrator, officer-in-charge or physician in the hospital, medical center or clinic, who
shall refuse or fail without good cause to render the appropriate assistance pursuant to the requirements of section one
after said case had been brought to his attention, or any nurse, midwife or medical attendant who shall refuse to extend
the appropriate assistance, subject to existing rules, or neglect to notify or call a physician shall be punished by
imprisonment of one month and one day to one year and one day, and a fine of three hundred pesos to one thousand
pesos, without prejudice to the provisions of Republic Act Numbered Twenty-three hundred eighty-two in the case of
physicians.
In the case of Government hospitals, the imposition of the penalty upon the person or persons guilty of the violations
shall be without prejudice to the administrative action that might be proper.
In the case of private hospitals, aside from the imposition of penalty upon the person or persons guilty of the violations,
the license of the hospital to operate shall, whenever justified, be suspended or revoked.
Sec. 4. Subject to the approval of the Secretary of Health, the Bureau of Medical Services shall promulgate the necessary
rules and regulations to carry out the provisions of this Act.
Sec. 5. Any law or laws or parts thereof inconsistent with the provisions of this Act is hereby repealed.
Sec. 6. This Act shall take effect upon its approval.
Approved: October 23, 1972

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Page 173

MA NI LA DOC TOR S HOS PI TA L,


Pet it io ner,

G. R . No . 150355
Present :

- v ersu s -

S O UN C HUA and VIC K Y TY,


R espo ndent s.

PA NG A NIB A N, C. J. ,
( Ch ai rpe rs o n)
YNAR ES - S A NTI A G O,
A US TR IA - MA R TI NEZ,
CA LL EJ O, S R . and
C HI C O- NA ZA RI O, JJ .

Pro m u lga t ed:


Ju ly 31, 2006
x - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - x
D E C I S I O N
A US TR I A - MA R TI NEZ, J .:
Bef ore t his Cou rt is a Pet it ion for Rev iew on Cert i o rari under Rul e 45 qu est ioning the
Decision [ 1 ] dat edO ct ober 2, 2 001 promu l gat ed by t he Cou rt of Appeal s ( CA) in CA- G.R. CV N o.
6 158 1, w hich af f irmed t he Decision dat ed Sept ember 30, 199 7 of t he Regional T rial Cou rt (RT C) ,
Branch 159 , Pasig Cit y, bu t w hich redu ced t he aw ard of damages.
T his case originat ed from an act ion for damage s f il ed w it h t he RT C by respondent s So U n
Chu a and V ick y T y against pet it ioner M anil a Doctors Hospit al . [ 2 ] T he compl aint is premise d on the
al l eged u nw arrant ed actu at ions of t he pet it ioner t ow ards it s pat ient , responde nt So Un Chu a
( Chu a) , w ho w as conf ined f or hypert ension, diabet es, and rel at ed il l nesses.
T he ant ecedent s of t he case foll ow :
On December 13, 19 9 3, respondent s f il ed a Compl aint av erring t hat on Oct ober 30, 199 0,
respondent Chu a, the mot her of responde nt V ick y T y, w as admit t ed in pet it ioner s hospit al f or
hypert ension and diabet es; that w hil e respondent Chu a w as conf ined, Ju dit h Chu a, t he sist er of
respondent T y, had been l ik ew ise conf ined f or inju ries suf f ered in a v ehicu l ar acci dent ; t hat part ial
payment s of t he hospit al bil l s w ere made, t ot al ing P 4 35 ,8 00.00 ; t hat aft er the discharg e of Ju dit h
Chu a, respondent Chu a remained in conf inement and t he hospit al bil l s for bot h pat ient s
accu mu l at ed; that respondent Chu a w as pressu red by t he pet it ioner, throu gh it s Credit and
Col l ect ion Depart ment , to sett l e the u npaid bill s; t hat respondent T y represent ed t hat she w il l
set tl e t he bill s as soon as the fu nds become av ail abl e; that respondent T y pl eade d t o t he
manageme nt t hat in v iew of t he physical condit ion of her mot her, respondent Chu a, t he
correspond ence s rel at ing to the set tl ement of t he unpaid hospit al bil l s shou l d be rel ayed to the
f ormer; t hat t hese pl eas w ere unheede d by the pet it ioner; that pet it ioner threat ened t o impl ement
u npl easant measu res u nl ess respondent T y undert ak es her mot her s obl igat ion as w el l as t he
obl igat ion of her sist er, J u dit h Chu a, t o pay the hospit al izat ion expens es; t hat pet it ioner made
good it s threat and empl oyed unet hical , u npl easant and unl awf u l met hods w hich al l egedl y
w orsened t he condit ion of respondent Chu a, part icu l arl y, by ( i) cu tt ing of f t he t el ephone l ine in her
room and remov ing t he air- condit ioning unit , t el ev ision set , and ref rigerat or, (ii) refu sing t o
render medic al at t endance and to change the hospit al gow n and bed sheet s, and ( iii) barring t he
priv at e nu rses or midw iv es from assist ing the pat ient . Responde nt s t hu s prayed f or the aw ard of
moral damage s, exempl ary damages, and att orney s f ees.
In it s Answ er, Amended Answ er, and Rejoind er, pet it ioner specif ical l y denie d t he
mat erial av erment s of the Compl aint and Repl y, and int erposed it s cou nt ercl aims argu ing t hat
as earl y as one w eek af t er respondent Chu a had been admit t ed to it s hospit al , Dr. Rody Sy, her
at t ending physi cian, had al ready giv en inst ru ct ions for her to be discharge d, bu t respondent s
insist ed t hat Chu a remain in conf inement ; that , t hrou gh it s st af f , pet it ioner accordingl y
admini st ered medic al examinat ions, all of w hich yiel de d negat iv e resul t s; t hat respondent T y
v ol u nt aril y undert ook , joint l y and sev eral l y, t o pay the hospit al bil l s for bot h pat ient s; t hat
al t hou gh respondent T y paid u p t o P 435 ,000.0 0, more or l ess, she reneged on her commit ment

Reyes, Hazel

Page 174

t o pay the bal ance in v iol at ion of t he Cont ract for Admission and Ack now l edgment of
Responsib il it y f or Payment dat ed Oct ober 30, 19 9 0 w hich she v olu nt aril y execu t ed; t hat she
signed a Promissory N ot e on Ju ne 5, 19 9 2 for t he u npaid bal ance of P 1,075 ,5 9 2 .9 5 and issu ed
post dat ed check s to cov er t he same; t hat no su ch undu e pressu re had been imposed u pon
respondent Chu a to set t l e t he bil l s, the trut h being t hat , as a mat t er of st andar d procedu re, t he
reminder s to sett l e the bil l s w ere transmit t ed not to the pat ient s bu t t o t heir rel at iv es w ho
u su all y u ndert ook to pay t he same; that respondent T y del iberat el y ev aded the st af f of t he
Credit and Col l ect ion Depart ment ; t hat the cut t ing-off of the t el ephone l ine and remov al of t he
air- condit ioning u nit , t el ev ision set , and ref rigerat or cannot const it ut e u nw arrant ed act u at ions,
f or t he same w ere resort ed to as cost - cut t ing measu res and to minimize respondent s charges
t hat w ere al ready pil ing u p, especial l y aft er respondent T y ref u sed t o set t l e the bal ance
not w it hst anding frequ ent demands ; t hat respondent T y ev aded t he st aff w hen the l at t er
at t empt ed to inf orm her that t he room f acil it ies w il l be cu t of f to minimiz e t he rising charges ;
and that respondent s inst itu t ed t he present civ il case pu rposel y as l ev erage against the
pet it ioner aft er the l at t er had f il ed criminal charges f or v iol at ion of Bat as Pambans a ( B.P.) Bl g.
2 2 against respondent T y f or issu ing check s, l at er dishonored, tot al ing P 1,075 ,5 9 2 .9 5 , t he
amou nt ref erring t o t he u npaid hospit al bil l s. In it s compu l sory cou nt ercl aim, pet it ioner
prayed, among ot her it ems, for t he aw ard of no l ess than P 1,000,00 0.00 as compensat ory
damage s du e to the f il ing of a mal iciou s and u nf ou nded su it , and, in it s permissiv e
cou nt ercl aim, pet it ioner praye d for respondent s to pay P 1,075 ,5 92 .9 5 , t he amou nt represent ing
t he du e and demandabl e obl igat ion u nder t he Promissory Not e dat ed J u ne 5 , 19 9 2 , incl u ding
t he st ipu l at ed int erest t herein and the 25 percent of t he t ot al amou nt du e as att orney s f ees.
Du ring pre- trial , t he part ies st ipul at ed on t he foll ow ing issu es: Fi rst , w het her t he
respondent s are liabl e t o t he pet it ioner t o pay t he hospit al bill s arising f rom t he hospit al izat ion
o f respondent Chu a and J u dit h Chu a; and seco nd , w het her t he part ies are ent it l ed t o t heir
respect iv e cl aims for damage s. [ 3 ] Fu rt hermore, t he part ies st ipu l at ed on t he f ol l ow ing f act s: a)
J u dit h Chu a w as conf ined f rom J u ne 14 , 19 9 1 t o M ay 2 , 19 9 2 ; b) responde nt s f ail ed to pay t he
bal ance despit e repeat ed reminders ; c) t he said reminders ref erred to the hospit al bil l s of
respondent Chu a and Ju dit h Chu a; d) one of t he at t ending physici ans of respondent Chu a w as
Dr. Rody Sy; and e) the pet it ioner ordered the remov al of t he facil it ies in qu est ion f rom the
room of it s pat ient , respondent Chu a, w it h t he qu al if icat ion that they w ere const rained to
discont inu e the same aft er the represent at iv e of respondent Chu a refu sed to u pdat e t he hospit al
bil l s or refu sed to t ransf er her to semi- del u xe room or w ard t o l essen cost s. [ 4 ]
On Sept ember 30, 199 7, t he RT C rendered it s Decision in f avor of t he respondent s, t he
disposit iv e port ion of w hich st at es:
W H EREFORE, premises considere d, ju dgment on the compl aint is hereby
rendere d in f av or of t he [responde nt s] as against t he [ pet it ioner] as foll ow s:
[ O] rdering t he [ pet it ioner] to pay t he [ respondent s] t he foll ow ing, t o w it :
a)

P 2 00,00 0.00 as moral damages;

b)

P 100,000. 00 as exempl ar y damages ; and

c)

P 5 0,000. 00 as at t orney s f ees and t he amou nt of P 5 0,000.00 as


l it igat ion cost s.

SO ORDERED. [ 5 ]
In brief , the RT C hel d t hat t he remov al of t he f acil it ies of the room triggered t he
hypert ension of respondent Chu a; t hat t he pet it ioner act ed in bad f ait h in remov ing t he f acil it ies
w it hou t prior not ice; t hat her condit ion w as aggrav at ed by the pressu re empl oyed by t he
admini st rat ion u pon her t o pay the hospit al bil l s; t hat t he f ood al w ays came l at e as compared to
t he ot her pat ient s; t hat t he beddings and cl ot hes of respondent Chu a w ere no longer changed and,
as a resul t , bed sores emerged on her body; t hat t here w as an u tt er l ack of medic al at t endance ;
t hat , becau se of these, respondent Chu a suf f ered from sel f -pit y and depression ; t hat pet it ioner
cl earl y discrim inat ed against t he respondent s; that respondent T y had no choice bu t to sign the
promissory not es in order to secu re t he rel ease of her mot her, respondent Chu a; that t he f oregoing
act u at ions const it ut e an abu se of right s; t hat pet it ioner fail ed to est abl ish t he pecu niary loss it

Reyes, Hazel

Page 175

su ff ered and, hence, it is not ent it l ed to compensat ory damages; and t hat , since t he promissory
not e is a cont ract of adhes ion, t he pet it ioner is not ent itl ed t o the aw ard of at t orney s f ees as
st ipu l at ed t hereon.
On appeal t o the CA, t he pet it ioner assigned the foll ow ing errors:
A.
T H E HON ORABLE T RIAL COU RT COM M IT T ED REV ERSIBLE ERROR BY FINDIN G
T H E ACTU AT ION S OF T H E ADM IN IST RAT ION OF DEFEN DAN T - APPELLAN T T O BE
IN BAD FAIT H , OPPRESSIV E AN D UN N ECESSARY AS T O MAKE IT LIABLE T O
PLAIN T IFFS- APPELLEES FOR DAM AG ES AN D AT T ORN EY S FEES.
B.
T H E H ON ORABLE T RIAL COU RT COM M IT T ED REV ERSIBLE ERROR BY N OT
RU LIN G U PON TH E PERM ISSIV E COU N T ERCLAIM OF DEFEN DAN T - APPELLAN T
W ITH RESPECT T O TH E P 1,075 ,5 9 2 .9 5 REPRESEN T IN G TH E H OSPIT AL BILL OF
PLAIN T IFFS- APPELLEES, WH ICH OBLIG AT ION IS N OT DISPUT ED AN D WH ICH
AM OU N T W AS N EV ER CON T ROV ERT ED BY PLAIN T IFFS- APPELLEES. [ 6 ]
On Oct ober 2 , 2 001, t he CA promu l gat ed it s Decision t he disposit iv e port ion of w hich reads:
IN
VIEW
OF
ALL
THE
FOREG OIN G ,
the
appeal e d
Decision
is
hereby AFFIRM ED w it h the modif icat ion t hat t he aw ard of moral damages, exempl ary
damage s as w ell as att orney s fees is redu ced to Sev ent y Fiv e T hou sand Pesos
( P 75 ,000.00) , T hirt y T hou sand Pesos ( P 30,00 0.00) and T w ent y T hou sand Pesos
( P 2 0,000.00) , respect iv el y. Lit igat ion cost s are hereby del et ed. Cost s against
appel l ant .
SO ORDERED. [ 7 ]
Apart f rom t he redu ct ion in the aw ard of damages, t he CA aff irmed al l sal ient port ions of t he
RT C Decision and decl ine d t o dist u rb the f indings of f act .
Pet it ioner is now bef ore t his Cou rt raising essent ial l y t he same grou nds heard by the CA.
Incident al l y, w it h respect t o the rel at ed crimin al case against respondent T y, this Cou rt ,
on Sept ember 2 7, 2 004 , promul gat ed it s Decision ent it l ed T y v. Peo pl e o f t he Phil i p p i nes, [ 8 ] w hich
af f irmed t he decis ions of t he low er cou rt s f inding respondent T y gu ilt y of v iol at ing B.P. Bl g. 22 and
ordering her to pay t he priv at e compl ainant , herein pet it ioner, t he tot al amou nt of t he dishonored
check s.
T he pet it ion is impressed w it h merit .
W hil e, as a rul e, onl y qu est ions of l aw may be raised in a pet it ion for rev iew
on cert i o rari under Rul e 45 , u nder cert ain except ions, the Cou rt may re- examine t he ev idenc e
present ed by t he part ies du ring t he trial . At l east f ou r exce pt ions exist in t his case, namel y: (a)
w hen the concl u sion is a finding grou nded ent irel y on specu l at ion, su rmises, or conject u res; ( b)
w hen t he ju dgment is based on a misappre hens ion of f act s; (c) w hen the f indings of f act are
premise d on t he su pposed absence of ev idence and cont radict ed by t he ev idence on record; and ( d)
w hen the cou rt s a q uo manif est l y ov erl ook ed cert ain rel ev ant f act s not dispu t ed by t he part ies and
w hich, if properl y considere d, w ou l d ju st if y a dif f erent concl u sion. [ 9 ]
T he princip al qu est ions are, fi rst , w het her the act u at ions of t he pet it ioner amou nt to
act ionabl e w rongs, and seco nd , w het her the cou nt ercl aims of the pet it ioner can be back ed u p by
t he measu re of preponderant ev idenc e.
In brief , the cou rt s a qu o concu rred in t he hol ding that the pet it ioner and it s st af f f ail ed t o
t ak e int o consider at ion the physic al condit ion of it s pat ient , respondent Chu a, w hen it remov ed the
f acil it ies prov ided in her room; [ 1 0 ] t hat t he remov al of these f acil it ies, namel y, t he air- condit ioner,
t el ephone l ines, t el ev ision, and ref rigerat or, aggrav at ed t he condit ion of the pat ient , t riggered her

Reyes, Hazel

Page 176

hypert ension, and cau sed her bl ood pressu re to fl u ct u at e, [ 1 1 ] considering t hat there w as no proper
v ent il at ion in the room. [ 1 2 ] In v iew of the f oregoing, the cou rt s a q uo concl u ded t hat the act u at ions
of t he pet it ioner w ere oppressiv e, unneces sary, [ 1 3 ] and ant i- social , [ 1 4 ] done in bad f ait h w it hout
proper not ice, [ 1 5 ] w it h no int ent ion ot her t han to harass or irrit at e t he respondent s, [ 1 6 ] al l of w hich
const it ut e an abu se of right s. [ 1 7 ]
W e do not agree. T he concl u sions of t he cou rt s a q uo are eit her hapha zard conject u res, or
f ou nded on a misapprehen sion of f act s. T he record is repl et e w it h ev idenc e that ju st if ies a
dif f erent concl u sion.
Indeed t he operat ion of priv at e pay hospit al s and medic al cl inics is impressed w it h pu bl ic
int erest and imbu ed w it h a heav y social responsibil it y. But t he hospit al is al so a bu siness, and, as
a bu siness, it has a right t o inst it ut e al l measu res of eff icien cy commensu rat e to the ends for w hich
it is designed, espec ial l y to ensu re it s economic v iabil it y and su rv iv al . And in t he legit imat e
pu rsu it of economic considerat ions, t he ext ent t o w hich the pu bl ic may be serv ed and cu red is
expan ded, t he pul se and l if e of t he medic al sect or qu ick ens, and t he regenerat ion of t he peopl e as a
w hol e becomes more v isibl y at t ainabl e. In t he inst it ut ion of cost -cu tt ing measu res, t he hospit al
has a right t o redu ce the f acil it ies and serv ice s that are deeme d to be no n-essent i al , su ch t hat t heir
redu ct ion or remov al w ou l d not be det riment al to t he medi cal condit ion of the pat ient . [ 1 8 ] For t he
moment , t he qu est ion t o be consider ed is w het her the su bject f acil it ies are indeed non- essent ial
t he air- condit ioner, t el ephone, t el ev ision, and ref rigerat or t he remov al of w hich w ou l d cau se t he
adv erse heal t h eff ect s and emot ional trau ma t he respondent s so cl aime d. Corol l ary t o t his
qu est ion is w het her the pet it ioner observ ed t he dil igenc e of a good fat her of t he f amil y [ 1 9 ] in t he
cou rse of ascert ai ning t he possibl e repercu ss ions of t he remov al of the f acil it ies prior t o the
remov al it sel f and for a reasonabl e t ime thereaf t er, w it h a v iew t o prev ent damage. [ 2 0 ]
Aft er an ext ensiv e anal ysis of t he record, it becomes rat her w orrisome t o t his Cou rt that t he
cou rt s a qu ou nreserv edl y drew t heir concl u sions from the sel f -serv ing and u ncorroborat ed
t est imonies of the respondent s t he probat iv e v al u e of w hich is highl y qu est ionabl e. [ 2 1 ] W e hol d t hat
t he respondent s f ail ed t o prov e t he damage s so cl aimed.
T he ev idenc e in the record f irml y est abl ishes t hat t he st aff of the pet it ioner t ook proact iv e
st eps t o inf orm t he rel at iv es of responde nt Chu a of t he remov al of f acil it ies prior theret o, and to
carry out t he necessary precau t ionary measu res to ensu re that her heal t h and w ell - being woul d not
be adv ersel y aff ect ed: as earl y as arou nd t w o w eek s aft er her admis sion on Oct ober 30, 19 9 0, t o t he
t ime w hen t he f acil it ies had been remov ed somet ime in t he middl e of M ay 199 2 , [ 2 2 ] and ev en up t o
t he point w hen she act u all y l eft t he premises of t he hospit al t hree w eek s l at er, or du ring t he f irst
w eek of Ju ne 19 9 2 , [ 2 3 ] t he medic al condit ion of respondent Chu a, as consist ent l y and indis pu t abl y
conf irmed by her at t ending physici an, Dr. Rody Sy, a cardiol ogist , w ho w as cal l ed as w it ness for
bot h part ies, [ 2 4 ] w hom ev en respondent Chu a repeat edl y praised to be my doct or and a v ery good
doct or [ 2 5 ] at that , and w hose st at ement s at t imes had been corroborat ed as w el l by Sist er M ary
Phil ip G al eno, SPC, t he Administ rat or of the hospit al and w ho al so happens t o be a regist ered
nu rse, had been rel at iv el y w el l , [ 2 6 ] ambu l at ory, [ 2 7 ] w alk ing arou nd in t he room, [ 2 8 ] and t hat
she w as abl e to leav e t he hospit al on her ow n w it hou t any assist ance ; [ 2 9 ] t hat al t hough she
compl aine d of sympt oms su ch as dizz ines s, w eak ness, [ 3 0 ] and abdominal discomf ort , [ 3 1 ] Dr. Sy
requ est ed sev eral medical examinat ion s, su ch as the l aborat ory t est s, renal t est s, MRI, ul t rasou nd,
and CT scan, [ 3 2 ] al l of w hich w ere administ ere d af t er procu ring the consent of respondent Chu a s
f amil y [ 3 3 ] as admit t ed by responde nt T y hersel f , [ 3 4 ] and ev en cal l ed on ot her speci al ist s, su ch as a
neu rol ogist , endocrinol ogist , and gast roent erol ogist , t o l ook int o her condit ion [ 3 5 ] and condu ct
ot her t est s as w ell [ 3 6 ] according to t heir f iel ds of special t y, al l of w hich yiel ded no seriou s finding;
[37]
that her il l nesses w ere l if el ong ill nesses [ 3 8 ] at a st age w here t hey cannot be t ot al l y remov ed or
abol ished, [ 3 9 ] mak ing it cl ear to her f amil y t hat one hu ndred percent recov ery is not possibl e
despit e being giv en dail y medicat ion in t he hospit al ; [ 4 0 ] but t hat her condit ion, nonet hel ess, is not
seriou s, [ 4 1 ] as t he bl ood pressu re is more or l ess cont rol l ed and w it hin accept abl e l imit s, [ 4 2 ] not
t hat crit ical t o precipit at e any acu t e at t ack , [ 4 3 ] nor l ik el y to f all int o any emergency, [ 4 4 ] nor yet
does she requ ire cont inu ou s or prol onged hospit al izat ion [ 4 5 ] since she w as st abl e enou gh to be
t reat ed
at
home
and
on
an
out -pat ient
basis,
so
mu ch
so
t hat
Dr. Sy encou raged her to exerc ise and av oid rest ing al l the
t ime, [ 4 6 ] and recommend ed that anyt ime she may be discharg ed [ 4 7 ]
ev en in ju st t wo w eek s aft er conf inement , [ 4 8 ] the propriet y of his order of disch arge concu rred
u pon by t he ot her speci al ist s as w ell , [ 4 9 ] had it not been for respondent s insist enc e to st ay in the
hospit al in v iew of t heir hope for absol ut e recov ery [ 5 0 ] despit e the admis sion of respondent Chu a
hersel f that she cannot anymore be t ot al l y cu red. [ 5 1 ]

Reyes, Hazel

Page 177

It is al so u ndispu t ed t hat the hospit al administ rat or, Sist er G al eno, prior t o t he remov al of
t he f acil it ies, consu l t ed t he at t ending physic ian, Dr. Sy. [ 5 2 ] T o Sist er G al eno, al so a regist ered
nu rse, t he matt er of remov al and it s possibl e repercu ssions on t he heal t h of t he pat ient , as a
mat t er of hospit al pol icy, is a crit ical and sensit iv e maneu v er, and, hence, it is carrie d out onl y
af t er discu ssing w it h the doct ors t o ev alu at e all import ant f act ors. [ 5 3 ] T he f act of prior
consu l t at ion [ 5 4 ] as w el l as the medical det erminat ion to t he ef f ect t hat it w as saf e to remov e the
f acil it ies and w oul d cau se no harmf ul eff ect [ 5 5 ] had been ampl y corroborat ed by respondent Chu a s
ow n doct or himsel f . [ 5 6 ] W hen Dr. Sy t est if ied as rebu tt al w it ness for the respondent s t hemsel v es
and w hose credibil it y respondent s f ail ed to impeach, he cat egoric al l y st at ed t hat he consent ed t o
t he remov al since t he remov al of the said f acil it ies w ou l d not by it sel f be det riment al t o the heal t h
of his pat ient , responde nt Chu a. [ 5 7 ] And in t his respect , he had been adv ising respondent T y, t he
dau ght er of t he pat ient , that the f acil it ies, su ch as t he air- condit ioner, tel ev ision, ref rigerat or, and
t el ephone, are not absolu t el y necessary, and, that alt hou gh they may add to the comf ort of t he
pat ient , if absent , they w il l not cau se any signif icant det eriorat ion of her condit ion, [ 5 8 ] giv en that ,
in his experien ce as a cardiol ogist , and aft er personal l y at t ending respondent Chu a on a dail y basis
bef ore, du ring, and aft er t he remov al and ev en up t o t he time of her actu al discharg e, [ 5 9 ] he
concl u ded t hat many hypert ensiv e and diabet ic pat ient s, as in her case, do not at al l need in
part icu l ar an air- condit ioning u nit , among t he ot her f acil it ies af orement ioned. [ 6 0 ] And, cont rary to
t he f indings of t he cou rt s a qu o and the sel f -serv ing test imonies of respondent s t hat t he l ack of
v ent il at ion, af t er t he remov al of t he air- condit ioner, triggered her hypert ension, Dr. Sy
cat egorical l y st at ed t hat du ring his dail y rou nds w it h t he pat ient he w as cert ain that , al t hou gh
admit t edl y t he bl ood pressu re in general w oul d fl u ct u at e dail y, t here had been no adv erse eff ect on
her, and that her bl ood pressu re w ere w it hin accept abl e l imit s, [ 6 1 ] espec ial l y consider ing t hat he
t reat ed t he pat ient on a dail y basis u p t o the point of act u al disch arge, [ 6 2 ] and accord ingl y, as
conf irmed by the medic al records, he made no change in the medic at ions t hereaf t er. [ 6 3 ] In su pport
of Dr. Sy s findings, Sist er G al eno, t est if ied t hat she k new t he condit ion of t he v ent il at ion of t he
pat ient s delu xe room, l ocat ed at t he f ift h f loor, ev en w it hout the air- condit ioning, not abl y in times
of brow nou t , and t hat t here had been enou gh v ent il at ion since the gril l ed w indow of t hat room w as
l arge enou gh w hich, if opened, woul d permit su ff icient v ent il at ion. [ 6 4 ] T he Cou rt f inds that t he
premise of t he RT C ju dgment ref ers merel y t o hypot het ical st at ement s w hich f ail to est abl ish any
cl ear and direct l ink to t he inju ry all egedl y su ff ered by the pat ient :
Q

Y ou f ou nd it saf e t o remov e t hese f acil it ies from the room of t he pat ient
su ff ering from diabet es and hypert ension?

Y es, Sir. M any hypert ensiv e, diabet ic pat ient s do not need air- condit ioning, or
T .V . or ref rigerat or.

Do you agree w it h me t hat hypert ension is t riggered somet imes by excit ement ,
anger or ( sic) a person su ff ering f rom su ch il l ness?

H ypert ension can be triggered by anyt hing.

Cou rt :
Q

And ev en in ot her w ords t he discomf ort can al so t rigger?

Somet imes ment al st ress can t rigger.


x x x x

Cou rt :
Q

Y ou ment ioned earl ier that t his hypert ension may be t riggered ment al l y?

Y es, Y ou r H onor.

Cou rt :
Q

W ill t he remov al of t hese f acil it ies not af f ect t he pat ient incl u ding t he rel at iv es?

Reyes, Hazel

Page 178

It may to a cert ain ext ent . And w el l , maybe t he days af t er the remov al w ou l d
prov e t hat f lu ctu at ion in blood pressu re are w it hin accept abl e limit s. [ 6 5 ]

W it h respect t o the findings of t he cou rt s a q uo that bed sores appeare d on the body of
respondent Chu a, that she su ff ered f rom depression aft er the disconne ct ion of the said f acil it ies,
t hat her priv at e midw iv es w ere barred, and t hat the del iv ery of food w as del ayed, t his Cou rt hol ds,
as abov e, t hat these concl u sions are beref t of sou nd ev ident iar y basis, sel f -serv ing and
u ncorroborat ed as they are. Again, Dr. Sy aff irmed t hat du ring t he dail y rou nds he w ou l d mak e on
t he pat ient , he did not det ect any sk in l esion or any ot her abnormal it y u p to t he t ime she w as
act u al l y disch arged. [ 6 6 ] Nor did he f ind any sign of depression, alt hou gh, admit t edl y, he observ ed
t hat she had been v ery angry becau se of the remov al of t he f acil it ies. [ 6 7 ] Al l the w hil e he did not
receiv e any compl aint from respondent Chu a indic at ing that she su ff ered from the f oregoing
inf irmit ies, [ 6 8 ] consid ering t hat it is the responsibil it y of the f amil y of the pat ient t o specif ical l y
inf orm t he at t ending physici an or the nu rses du ring t heir rou nds w hat ev er t hey feel is import ant ,
or if t here w ere any new dev el opment s since t he l ast v isit . [ 6 9 ] As corroborat ed by Sist er G al eno,
t hrou ghout responde nt Chu a s conf inement , she nev er receiv ed any compl aint f rom t he l at t er or
her rel at iv es t hat she had not been att ended t o by t he nu rsing st af f . [ 7 0 ] Wort h not ing again is t he
f act that t he nu rsing st aff and t he att ending physic ians, w hich incl u ded Dr. Sy, in acco rdan ce w it h
hospit al pol icy, w oul d rout inel y mak e t heir rou nds on a dail y basis, or w ou l d v isit the pat ient
w henev er t hey are cal l ed f or any probl em, [ 7 1 ] and, in t he case of t he speci al ist s ot her t han the
at t ending physici an, t hey woul d v isit t he pat ient abou t once a w eek . [ 7 2 ] T he nu rses, on t he ot her
hand, w ou l d mak e their rou nds more f requ ent l y, that is, at l east once per shift , or ev ery eight
hou rs. [ 7 3 ] Apart from the sel f -serv ing st at ement s of respondent s, w hich by now hav e become rat her
indic at iv e of being mere af t ert hou ght s, t here is no cl ear show ing f rom the record that t he
pet it ioner and it s medic al st af f dev iat ed f rom t he f oregoing pol icy and pract ice, nor had they been
cal l ed u pon to l ook int o t he al l eged physic al react ions or emot ional t rau ma respondent Chu a cl aims
t o hav e su ff ered du ring and aft er the remov al of t he f acil it ies. It mu st be emphasiz ed that , as
st at ed abov e, respondent Chu a hersel f expl icit l y f ou nd Dr. Sy to be a v ery good doct or becau se he
personal l y att ended t o her al most ev ery hou r. [ 7 4 ] And t hrou ghout her conf inement , Dr. Sy
posit iv el y st at ed t hat her f amil y empl oyed a priv at e midw if e w ho att ended to her all t he time. [ 7 5 ]
T he ev idence in t he record ov erw hel mingl y demonst rat es that respondent Chu a had been
adequ at el y att ende d t o, and this Cou rt cannot underst and w hy t he cou rt s a qu o had decl are d t hat
t here w as an ut t er l ack of medic al at t endance, or t hat her heal t h suf f ered du ring t he period af t er
t he remov al of t he f acil it ies. T he Cou rt f inds t hat t he f acil it ies in qu est ion are non- essent ial f or
t he care of respondent Chu a and, hence, t hey may be lessene d or remov ed by t he pet it ioner f or the
sak e of economic necess it y and su rv iv al .
T hou gh hu man experi enc e woul d show t hat t he deact iv at ion of the air- condit ioner may cau se
a t emperat u re dif f erent ial t hat may trigger some physical discomf ort , or that t he remov al of
ent ert ainment f acil it ies su ch as t he t el ev ision set , or the disconne ct ion of commu nicat ion dev ices
su ch as t he tel ephone, may cau se some exas perat ion on t he part of the one w ho benef it s f rom t hese,
nev ert hel ess, al l things consider ed, and giv en t he degree of dil igence t he pet it ioner du l y exert ed,
not ev ery su ppression of t he t hings that one has grow n accu st omed to enjoy amou nt s t o an
act ionabl e w rong, nor does ev ery physic al or emot ional discomf ort amou nt to the k ind of angu ish
t hat w arrant s t he aw ard of moral damage s under the general principl e s of tort. T he underl ying
basis f or t he aw ard of t ort damages is t he premise t hat an indiv idu al w as inju red in cont empl at ion
of l aw. T hu s, t here mu st f irst be t he breach of some dut y and t he imposit ion of l iabil it y f or t hat
breach bef ore damages may be aw arded; it is not suf f icient t o st at e that t here shoul d be t ort
l iabil it y merel y becau se the pl aint iff su ff ered some pain and suf f ering. [ 7 6 ]
M oreov er, this Cou rt mu st reit erat e the st andard of t ort to arriv e at a proper aw ard f or
damage s premised on matt ers t hat su gg est t he appl icat ion of medic al knowl edge, especi al l y in t he
descr ipt ion of the cau sal l ink bet w een ext ernal or env ironment al f act ors, on one hand, and t heir
ef f ect u nto t he physical or emot ional heal t h of the pat ient , on the ot her, expert opinion, as
discu ss ed in Cru z v . Co u rt of Ap p eal s, [ 7 7 ] is general l y requ ired:
Al l three cou rt s bel ow bew ail t he inadequ ac y of the f acil it ies of t he cl inic and
it s u nt idiness; t he l ack of prov isions su ch as bl ood, oxygen, and cert ain medicin es;
t he f ail u re t o su bject t he pat ient t o a cardio - pu l monary t est prior to t he operat ion;
t he omission of any form of bl ood t yping bef ore t ransf u sion; and ev en t he su bsequ ent
t ransf er of Lydia to t he San Pabl o H ospit al and the reoperat ion perf ormed on her by

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t he pet it ioner. But w hil e it may be tru e t hat t he circu mst ances point ed ou t by t he
cou rt s bel ow seemed beyond cav il to const itu t e reck l ess impru dence on the part of t he
su rgeon, t his concl u sion is st ill best arriv ed at not t hrou gh t he edu cat ed su rmises nor
conject u res of l aymen, incl u ding ju dges, but by the u nqu est ionabl e know l edge of
expert w it nesses. For w het her a physici an or su rgeon has exercis ed the requ isit e
degree of sk il l and care in t he t reat ment of his pat ient is, in t he general it y of cases, a
mat t er of expert opinion. T he def erence of cou rt s to t he expert opinions of qu al if ied
physic ians st ems from it s real izat ion t hat t he l at t er possess unu su al t echnical sk ill s
w hich l aymen in most inst ance s are incapabl e of int el l igentl y ev alu at ing. Expert
t est imony shou l d hav e been off ered to prov e t hat t he circu mst ance s cit ed by t he
cou rt s bel ow are const itu t iv e of condu ct f al l ing bel ow t he st andard of care empl oyed
by ot her physicia ns in good st anding w hen perf orming t he same operat ion. It mu st be
remembere d that w hen t he qu al if icat ions of a physician are admit t ed, as in the
inst ant case, t here is an inev it abl e presu mpt ion that in proper cases he t ak es t he
necess ary precau t ion and empl oys t he best of his know l edge and sk il l in att ending to
his cl ient s, unl ess the cont rary is suf f icient l y est abl ished. T his presu mpt ion is
rebu tt abl e by expert opinion w hich is so sadl y l ack ing in t he case at bench. [ 7 8 ]
W it h respect t o t he propriet y of t he not ice of remov al of f acil it ies, the ev idenc e show s that
t he hospit al st af f , accompan ied by Sist er Gl adys Lim, SPC, Finance Administ rat iv e Assist ant of t he
hospit al , [ 7 9 ] t hrou gh w ritt en and v erbal not ices as per hospit al pol icy, f orew arned t he respondent s,
t hrou gh respondent T y and her sist er, J u dit h Chu a, of t he impending remov al of the f acil it ies ov er
a w eek bef orehand [ 8 0 ] in v iew of t heir obst inat e ref u sal to v acat e and t ransf er t o a l ow er rat e
room [ 8 1 ] or to updat e the mou nt ing hospit al bil l s [ 8 2 ] w hich, by t hen, had sw ol l en to approximat el y
one mil l ion pesos. [ 8 3 ] Respondent T y ref u sed t o read many of t he w rit t en not ices sent by t he
Credit
Depart ment . [ 8 4 ] Af t er repeat ed att empt s to cont act respondent T y [ 8 5 ] and bef ore t he act u al remov al
of the f acil it ies, t he st aff of the pet it ioner t ried t o personal l y serv e t he f inal not ice dat ed April 2 3,
199 2 , [ 8 6 ] signed by Sist er Gl adys Lim, address ed to respondent T y, which adopt ed the t enor of t he
prior v erbal w arnings, and w hich expressl y and st ernl y w arned the respondent s t hat the hospit al
shal l be const rained to t ak e l egal act ion and that t hey shal l be compel l ed t o transf er the pat ient ,
respondent Chu a, to a low er rat e room unl ess t he bal ance cou l d be sat isf ied. [ 8 7 ] Respondent T y, f or
no ju st if iabl e reason, and st ick ing t o her incl inat ion t o av oid t he st aff , refu sed to receiv e or
ack now l edge t his l ett er as w el l . [ 8 8 ] W ort h not ing is t hat Sist er G al eno, t est if ied that , as a matt er of
hospit al pol icy t he tenor of w hich respondent s, by v irt u e of t he Cont ract for Admission dat ed
Oct ober 30, 19 9 0, agreed to compl y w it h, [ 8 9 ] t he hospit al can onl y cut of f t he non-essent ial
f acil it ies and onl y in ext reme case s [ 9 0 ] if the pat ient occu pies a priv at e room all to hersel f ; had
t he room been semi- priv at e shared by ot her pat ient s, or had it been the w ard, t he hospit al cannot
disconn ect t he f acil it ies since this w ou l d u ndul y preju dice the ot her pat ient s. But respondent Chu a
hersel f insist ed on st aying in a priv at e room despit e her being fu ll y aw are of t he ball ooning
charges, [ 9 1 ] and ev en if she cou l d hav e f r eel y gone home anyt ime t o her condominiu m u nit w hich, as
admit t ed, w as equ ipped w it h an air- condit ioner. [ 9 2 ] W it h respect t o t he pressu re and
harassm ent respondent s al l egedl y su ff ered dail y w henev er the hospit al st aff wou l d foll ow u p the
bil l ing du ring odd hou rs, or at 10pm, 11pm, 12 midnight , 1am, or 2 am, [ 9 3 ] this av erment had been
conv incingl y ref ut ed by t he w it nesses for t he pet it ioner, namel y, Edit ha L. V ecino, t he H ead of
Credit and Col l ect ion, and Sist er G al eno, in that t he Credit and Col l ect ion Depart ment w ou l d onl y
hol d off ice hou rs f rom 8 am t o 5 pm and, hence, it is impossibl e t o harass t he respondent s du ring
t he t imes t hey so cl aimed. [ 9 4 ]
T he cou rt s a qu o f ou nd that responde nt T y had no choice bu t to sign t he promissory not e in
order f or her mot her t o be rel eased from t he hospit al , [ 9 5 ] t hu s suggest ing t hat the hospit al refu sed
t o act u al l y discharge or bodil y rel ease it s pat ient , respondent Chu a, unt il arrangeme nt s had been
made to set tl e the charges.
W hil e t here are port ions of t he t est imonies of t he w it nesses f or the pet it ioner w hich st at e
t hat al t hough, as per st andard procedu re, t he pat ient cannot l eav e [ 9 6 ] t he hospit al w it hout
t he disch arge, [ 9 7 ] cl earance or gat e pass issu ed onl y aft er
arrangement s on t he set tl ement of bil l s had been made, [ 9 8 ] st il l , it mu st be underst ood t hat t hese
are onl y demonst rat iv e of t he precondit ion t hat a pat ient cannot st ep ou t of t he premises w it hou t
t he consent of t he hospit al , or, in ot her w ords, t hat t he cl earance merel y indicat es t hat the
hospit al expressl y consent ed to t he act u al rel ease of t he pat ient , [ 9 9 ] bu t , ev en w it hou t it s consent ,
t he pat ient is st ill free to leav e anyt ime as a mat t er of pol icy, in spit e of t he ref u sal to issu e a

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cl earanc e or gat e pass, [ 1 0 0 ] or ev en in cases where the accou nt s hav e not yet been l iqu idat ed or
set tl ed, [ 1 0 1 ] or yet ev en if no promissor y not e or post -dat ed check w ere execu t ed in f avor of t he
pet it ioner, as test if ied by no less t han Sist er G al eno, [ 1 0 2 ] and corroborat ed by Edit ha V ecino;
[103]
and t hat , pet it ioner, a priv at e hospit al est abl ished f or prof it , [ 1 0 4 ] being al so a bu siness, by
w arning respondent s t hat it shal l w it hhol d cl earance, is simpl y exerc ising it s right t o prot est
against an absconding pat ient as a precu rsor t o av ail of ot her appropriat e l egal remedie s; t hat , on
t he cont rary, t he respondent s opt ed not t o l eav e becau se of t heir ow n promise not t o l eav e u nl ess
t he hospit al bill s w ere f ul l y set tl ed; [ 1 0 5 ] t hat t he accu sat ions f ou nd in t he Demand Lett er dat ed M ay
19 , 19 92 , and signed by t he cou nsel f or t he respondent s, [ 1 0 6 ] part icu l arl y, t hat t he pet it ioner
ref u sed t o disch arge t he pat ient , [ respondent Chu a,] despit e orders f rom t he att ending physic ian,
Dr. Rody Sy, had al l been refu t ed by Sist er Gal eno w hen she read it s cont ent s in front of t he
cou nsel f or respondent s, emphat ic al l y tel l ing him that w e are not det aining his cl ient s; t hat
[ respondent T y] w as t he one w ho tol d u s t hat they are not going to l eav e t he hospit al u nl ess t hey
hav e f ul l y paid t he hospit al ; [ 1 0 7 ] and that , most import ant l y, no physic al rest raint u pon the person
of respondent Chu a or u pon t he person of her rel at iv es had been imposed by t he st af f .
Aut horit ies, incl u ding t hose of common l aw origin, expl icit l y decl are t hat a pat ient cannot be
det aine d in a hospit al for non- payment of t he hospit al bil l . If t he pat ient cannot pay t he hospit al
or physici an s bill , the l aw prov ides a remedy f or t hem to pu rsu e, t hat is, by f il ing the necess ary
su it in cou rt f or t he recov ery of su ch f ee or bill . [ 1 0 8 ] If t he pat ient is prev ent ed from l eav ing t he
hospit al for his inabil it y to pay t he bil l , any person w ho can act on his behal f can appl y in cou rt for
t he issu ance of the writ of habeas co rp u s . [ 1 0 9 ]
T he f orm of rest raint mu st be t ot al ; mov ement mu st be rest rained in all direct ions. If
rest raint is part ial , e.g ., in a part icu l ar direct ion w it h f reedom t o proceed in anot her, t he rest raint
on t he person s l ibert y is not tot al . [ 1 1 0 ] H ow ev er, t he hospit al may l egal l y det ain a pat ient against
his w il l w hen he is a det ained or conv ict ed prisoner, or w hen t he pat ient is suf f ering from a v ery
cont agiou s disease w here his rel ease w ill be preju dicial t o pu bl ic heal t h, or w hen the pat ient is
ment al l y ill su ch that his rel ease w ill endanger pu bl ic saf et y, [ 1 1 1 ] or in ot her exigent case s as may be
prov ided by l aw . Moreov er, u nder t he common l aw doct rines on tort , it does not const itu t e a
t respass t o t he person to moment aril y prev ent him from l eav ing t he premises or any part t hereof
becau se he ref u ses t o compl y w it h some reasonabl e condit ion su bject to w hich he ent ered them. In
al l case s, the condit ion of this k ind of rest raint mu st be reasonabl e in t he l ight of t he
circu mst anc es. [ 1 1 2 ] At any rat e, as st at ed abov e, the pat ient is free t o leav e t he premises, ev en in
t he ost ensibl e v iol at ion of t hese condit ions, af t er being moment aril y int erru pt ed by the hospit al
st aff f or pu rposes of inf orming him of t hose reasonabl e condit ions, su ch as the asses sment of
w het her t he pat ient is f it to l eav e, insane, or suf f ering f rom a cont agiou s diseas e, et c., or simpl y
f or pu rposes of mak ing a demand to set tl e t he bill . If t he pat ient chooses to abscond or l eav e
w it hou t t he consent of t he hospit al in v iol at ion of any of t he condit ions deeme d t o be reasonabl e
u nder t he circu mst ances, t he hospit al may nonet hel ess regist er it s prot est and may choose t o
pu rsu e the l egal remedies av ail abl e under l aw , prov ided that the hospit al may not physical l y det ain
t he pat ient , unl ess the case f all s under t he exce pt ions abov est at ed.
Aut horit ies are of the v iew t hat , ordinaril y, a hospit al , especial l y if it is a priv at e pay hospit al ,
is ent it l ed to be compensat ed for it s serv ices, by eit her an expre ss or an impl ied cont ract , and
if no expres s cont ract exist s, there is general l y an impl ied agreement t hat t he pat ient w il l pay the
reasonabl e v alu e of t he serv ices rendered ; [ 1 1 4 ] w hen a hospit al treat s a pat ient s inju ries, it has an
enf orceabl e cl aim f or fu ll payment for it s serv ices, regardl ess of t he pat ient s financi al st atu s.
[115]
At t his ju nctu re, it mu st be not ed t hat there is test imony, t hou gh t o a degree dispu t abl e, t o the
ef f ect t hat the execu t ion of t he promissory not e and t he issu ance of post dat ed check s w ere
condit ions imposed not by t he pet it ioner bu t v olu nt aril y of f ered by t he cou nsel f or responde nt s.
[116]
At any rat e, how ev er, t his Cou rt hol ds, in v iew of t he foregoing au t horit ies, t hat t he
requ irement t o hav e t he rel at iv e of respondent Chu a t o execu t e a promissory not e as part of t he
arrangement t o set tl e t he unpaid obl igat ions is a f ormal it y t hat conv ert s any impl ied cont ract int o
w ritt en form and, moreov er, amou nt s t o a reasonabl e condit ion, t he non-f ul f il l ment of w hich, in
it sel f , how ev er, as discu sse d, cannot all ow the hospit al t o det ain t he pat ient . It mu st al so be
st ressed, cont rary t o t he f indings of t he cou rt s a q uo , that su ch an agreement embodied in a
promissory not e, as w el l as the Cont ract for Admission and Ack nowl edgment of Responsib il it y for
Payment dat ed Oct ober 30, 19 9 0, do not become cont ract s of adhes ion simpl y becau se t he person
signing it w as u nder st ress t hat w as not the resu lt of t he act ions of t he hospit al , [ 1 1 7 ] especi al l y
t ak ing int o accou nt t hat t here is t est imony to t he eff ect that responde nt T y signed t he Promissory
N ot e dat ed J une 5 , 19 9 2 in t he presenc e of cou nsel and act ing under his adv ise. [ 1 1 8 ]
[113]

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Bu t as to the propriet y of t he circu mst ances su rrou nding t he issu ance of t he post dat ed
check s to cov er t he amou nt st at ed in t he Promissory N ot e dat ed J une 5 , 19 9 2 , this Cou rt mu st ref er
t o the discu ssion of t he recent case of T y v. Peo p l e o f t he Phil i p p i nes [ 1 1 9 ] w here t his Cou rt af f irmed
t he conv ict ion of respondent T y for t he issu ance of bou ncing check s addre sse d t o the pet it ioner
herein. W hil e t he inst ant case is t o be dist ingu ishe d from the T y case in nat u re, appl icabl e l aw ,
t he st andards of ev idenc e, and in t he def enses av ail abl e t o t he part ies, hence, t he ju dgment of
conv ict ion in that case shoul d not at all preju dice t he disposit ion of this case, ev en if t he fact s
coinci de, nonet hel ess, f or pu rposes of conv enienc e and inst ru ct iv e u til it y, t he Cou rt qu ot es t he
rel ev ant port ions:
In t his case, f ar f rom it , the f ear, if any, harbored by T y w as not real and
imminent . T y cl aims that she w as compel l ed to issu e the check s a condit ion the
hospit al all egedl y demand ed of her bef ore her mot her coul d be disch arged for f ear
t hat her mot her s heal t h might det eriorat e f urt her du e t o t he inhu mane treat ment of
t he hospit al or worse, her mot her might commit su icide. T his is specu l at iv e f ear; it is
not t he u ncont rol l abl e f ear cont empl at ed by l aw .
T o begin w it h, there w as no show ing t hat the mot her s ill ness w as so l if et hreat ening su ch t hat her cont inu ed st ay in t he hospit al suf f ering al l it s al l eged
u net hical t reat ment woul d indu ce a w ell - grou nded apprehens ion of her
deat h. Secondl y, it is not the l aw s int ent to say t hat any f ear exempt s one f rom
criminal l iabil it y mu ch l ess pet it ioner s fl imsy f ear t hat her mot her might commit
su icide. In ot her w ords, the f ear she inv ok es w as not impend ing or insu perabl e as t o
depriv e her of al l v ol it ion and to mak e her a mere inst ru ment w it hout w il l , mov ed
excl u siv el y by t he hospit al s t hreat s or demand s.
T y has al so f ail ed t o conv ince t he Cou rt t hat she w as l ef t w it h no choice bu t t o
commit a crime. She did not t ak e adv ant age of t he many opport u nit ies av ail abl e t o
her to av oid commit t ing one. By her v ery ow n words, she admit t ed t hat the coll at eral
or secu rit y t he hospit al requ ired prior to t he disc harge of her mot her may be in the
f orm of post dat ed check s or jew el ry. And if indeed she w as coerce d to open an
accou nt w it h t he bank and issu e t he check s, she had all the opport u nit y t o l eav e t he
scene to av oid inv olv ement .
M oreov er, pet it ioner had su ff icient know l edge t hat t he issu ance of check s
w it hou t f unds may resul t in a v iol at ion of B.P. 22 . She ev en t est if ied t hat her cou nsel
adv ise d her not t o open a cu rrent accou nt nor issu e post dat ed check s becau se the
moment I w il l not hav e f unds it w il l be a big probl em. Besi des, apart f rom
pet it ioner s bare assert ion, t he record is bereft of any ev idenc e to corroborat e and
bol st er her cl aim t hat she w as compel l ed or coerce d t o cooperat e w it h and giv e in to
t he hospit al s demands.
T y l ik ew ise su ggest s . . . t hat t he ju st if ying circu mst ance of st at e of necess it y
u nder par. 4 , Art . 11 of t he Rev ised Penal Code may f ind appl icat ion in t his case.
W e do not agree. T he l aw prescribe s the presenc e of three requ isit es t o exempt
t he act or from l iabil it y under t his paragrap h: ( 1) t hat t he ev il sou ght t o be av oided
act u al l y exist s; (2 ) t hat t he inju ry feared be great er t han t he one done to av oid it ; (3)
t hat t here be no ot her pract ical and l ess harmfu l means of prev ent ing it .
In t he inst ant case, t he ev il sou ght t o be av oided is merel y expe ct ed or
ant icipat e d. If t he ev il sou ght t o be av oided is merel y expect ed or ant icipat ed or may
happen in t he fu tu re, this def ense is not appl icabl e. T y cou l d hav e t ak en adv ant age of
an av ail abl e opt ion to av oid commit t ing a crime. By her ow n admis sion, she had t he
choice t o giv e jew el ry or ot her f orms of secu rit y inst ead of post dat ed check s to secu re
her obl igat ion.
M oreov er, f or the def ense of st at e of necess it y t o be av ail ing, the great er inju ry
f eared shou l d not hav e been brou ght abou t by t he negl igence or impru dence, more so,
t he w il lf ul inact ion of t he act or. In t his case, the issu ance of t he bou nced check s w as
brou ght abou t by T y s ow n f ailu re to pay her mot her s hospit al bil l s.

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T he Cou rt al so t hink s it rat her odd t hat T y has chosen t he exempt ing
circu mst anc e of uncont roll abl e f ear and t he ju st if ying circu mst anc e of st at e of
necess it y to absolv e her of l iabil it y. It w oul d not hav e been half as bizarre had T y
been abl e to prov e t hat t he issu ance of t he bou nced check s w as done w it hout her fu ll
v ol it ion. U nder t he circu mst anc es, how ev er, it is qu it e cl ear that neit her
u ncont rol l abl e f ear nor av oidanc e of a great er ev il or inju ry prompt ed t he issu ance of
t he bou nced check s.
Parent het ical l y, t he f indings of f act in t he Decision of t he trial cou rt in t he
Civ il Case for damage s f il ed by T y s mot her against t he hospit al is w holl y irrel ev ant
f or pu rposes of disposing the case at bench. W hil e t he f indings t herein may est abl ish
a cl aim for damages w hich, w e may add, need onl y be su pport ed by a preponderan ce
of ev idenc e, it does not necessar il y engender reasonabl e dou bt as to free T y f rom
l iabil it y. [ 1 2 0 ]
In v iew of t he f oregoing, t he Cou rt t heref ore hol ds t hat the cou rt s a q uo commit t ed seriou s
errors in f inding that the pet it ioner w as biase d, [ 1 2 1 ] discr iminat e d against t he respondent s,
[122]
and pu rposel y int ended t o irrit at e [ 1 2 3 ] or harass [ 1 2 4 ] t hem; t hat it act ed in bad f ait h in
remov ing the f acil it ies w it hou t prior not ice; [ 1 2 5 ] and that it s act s w ere ant i- social . [ 1 2 6 ] T he
af orequ ot ed decl arat ions of t he w it nesses, signif icant port ions of which t his Cou rt considers as
expert t est imony, are rel iabl e and remain consid erabl y t ru st w ort hy to cont rov ert respondent s
assert ions as w el l as to rev erse t he concl u sions of f act and l aw of t he CA and t he RT C that
respondent Chu a suf f ered the physical and emot ional angu ish so cl aimed, and so, for t hese reasons,
t he Cou rt hol ds t hat the pet it ioner inf l ict ed no act ionabl e w rong.
T his Cou rt observ es that the cou rt s a qu o aw arde d bot h respondent s moral damage s. But it is
w el l -set tl ed t hat in case of physic al inju ries, w it h some exce pt ions, [ 1 2 7 ] moral damages are
recov erabl e onl y by t he part y inju red and not by her spou se, next of k in, or rel at iv e w ho happened
t o sympat hize w it h the inju red part y. [ 1 2 8 ] H ence, ev en if t he cou rt s a q uo w ere correct in t heir basis
f or damages, they shoul d hav e decl ined to aw ard damages t o respondent T y.
T he l ast issu e t o be resol v ed is t he qu est ion w het her the cou nt ercl aims of t he pet it ioner are
su pport ed by a preponder anc e of ev idence.
W e agree w it h t he pet it ioner t hat the cou rt s a qu o seriou sl y erred in mist ak ing t he case of it s
compu l sory cou nt ercl aim f or it s permissiv e cou nt ercl aim and for f ail ing to consider t he ev iden ce
w hich impressiv el y su pport s the l at t er. Fi rst , for f ail u re w it hou t ju st if iabl e cau se of respondent s
cou nsel t o comment on the Part ial Formal Off er of Ev idenc e dat ed Febru ary 14 , 19 96 [ 1 2 9 ] f il ed by
t he pet it ioner, t he RT C issu ed an order du ring t he cou rse of t he t rial , w hich cou nsel f or
respondent s neit her cont est ed nor raise d on appeal , admit t ing Exhibit s 1 to 16 , toget her w it h
t heir su bmark ings and t he pu rposes for w hich t he same w ere off ered, [ 1 3 0 ] all of w hich had al so been
prev iou sl y aut hent icat ed and t heir cont ent s v erif ied by the w it nesses f or t he pet it ioner. [ 1 3 1 ] T hese
docu ment s incl u de the Cont ract for Admiss ion of respondent Chu a dat ed Oct ober 30, 19 9 0, du l y
execu t ed by respondent T y, incorporat ing t herein t he ru l es and regu l at ions of t he hospit al ,
incl u ding the du t y t o u nderst and t he same [ 1 3 2 ] as w el l as the u ndert ak ing of respondent T y t o be
joint l y and sev eral l y l iabl e f or t he payment of t he hospit al bil l s of respondent Chu a; [ 1 3 3 ] t he
Promissory N ot e dat ed J une 5 , 19 9 2 in t he amou nt of P 1,075 ,5 92 .9 5 dul y execu t ed by respondent T y
in f av or of t he pet it ioner agreeing to be jointl y and sev eral l y l iabl e to pay t he u npaid obl igat ions of
respondent Chu a and J u dit h Chu a, incl u ding int erest and at torney s fees in case of def aul t ; [ 1 3 4 ] t he
U ndert ak ings signed by respondent T y dat ed M arch 3, 199 2 and April 7, 19 9 2 to maint ain regu l ar
deposit s; [ 1 3 5 ] and t he credit memos and st at ement s of accou nt t hat su pport t he amou nt ref erring to
t he u npaid obl ig at ion. [ 1 3 6 ] Seco nd , the part ies st ipul at ed du ring pre- t rial t hat respondent s f ail ed to
pay the bal ance despit e repeat ed reminders. [ 1 3 7 ] And t hi rd , respondent T y in open cou rt ident if ied
and admit t ed t hat she signed t he Cont ract of Admission dat ed Oct ober 30, 199 0 as w el l as the
U ndert ak ings dat ed M arch 3, 199 2 and April 7, 19 9 2 but w hich, f or no ju st if iabl e reason, she did
not bot her to read, [ 1 3 8 ] and, w hat is more, she repeat edl y admit t ed du ring the cou rse of t he trial
t hat she f ail ed t o fu ll y set t l e t he f oregoing hospit al bil l s. [ 1 3 9 ] In f act , w hil e t he T y case cannot
cont rol the incident s of t he inst ant case as heret ofore st at ed, it is st ill w ort h ment ioning, at l east
f or inf ormat iv e pu rposes, t he f indings of t his Cou rt in T y w it h respect to respondent s obl igat ions
t o the pet it ioner :

Reyes, Hazel

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T y s mot her and sist er av ail ed of t he serv ices and the f acil it ies of t he hospit al . For
t he care giv en t o her k in, T y had a l egit imat e obl igat ion t o pay the hospit al by v irt u e
of her rel at ionship w it h t hem and by force of her signat u re on her mot her s Cont ract
of Admiss ion ack nowl edging responsibil it y for payment , and on t he promissory not e
she execu t ed in f av or of t he hospit al . [ 1 4 0 ]
In v iew of al l these f indings, t he Cou rt earnest l y disagrees w it h the sw eeping concl u sion of
t he CA that [ Pet it ioner] f ail ed to present any iot a of ev idenc e t o prov e his cl aim, [ 1 4 1 ] a st at ement
apparent l y ref erring to t he permiss iv e cou nt ercl aim of P 1,075 ,5 92 .9 5 . How ev er, w it h respect t o the
compu l sory cou nt ercl aim predic at ed on the f il ing of a basel ess su it and inju ry t o it s reput at ion,
pet it ioner did not raise t his mat t er on appeal and, hence, is deemed to hav e w aiv ed the same.
Bu t t he Cou rt in T y made a part ial f inding on t he civ il l iabil it y of respondent T y w it h respect
t o the amou nt cov ered by sev en of t he sev eral dishonored check s she issu ed equ iv al ent to
P 2 10,000. 00. [ 1 4 2 ] Since t his amou nt f orms a f ract ion of her tot al civ il l iabil it y, t hen this amou nt ,
in def erence to T y, shoul d be dedu ct ed theref rom.
T he cl aim for att orney s f ees, as st ipu l at ed under the Promissory N ot e dat ed J u ne 5, 19 9 2 ,
shou l d be redu ced for being unreasonabl e u nder t he circu mst ances, f rom 2 5 percent t o 12 percent
of the tot al amou nt du e. [ 1 4 3 ]
As a f inal word, t he Cou rt t ak es ju dicial not ice of t he pending Senat e Bil l No. 337, ent itl ed
An Act Prohibit ing t he Det ent ion of Pat ient s in Hospit al s and M edical Cl inics on Grou nds of N onPayment of Hospit al Bil l s or M edical Expense s, w hich decl ares, among ot hers, t hat it shal l be
u nl aw f ul f or any hospit al or medic al cl inic to cau se direct l y or indire ct l y the det ent ion of pat ient s
f or non-payment , in part or in f ul l, of t heir hospit al bill s, [ 1 4 4 ] and, f urt hermore, requ ires pat ient s
w ho hav e fu ll y recov ered and are f inancial l y incap abl e to sett l e the hospit al izat ion expens es t o
execu t e a promissory not e, co- signed by anot her indiv idu al , to t he ext ent of t he u npaid obl igat ion
bef ore l eav ing t he hospit al . [ 1 4 5 ] W hil e t his Cou rt may hav e tou ched u pon t hese matt ers in t he
adju dic at ion of the inst ant case, it mu st be st at ed t hat t his deci sion shoul d in no w ay preempt any
const it ut ional chal l enge to t he prov isions of Senat e Bill No. 337 if passed int o l aw , bearing in mind
t he st andard s f or the exercis e of t he pow er of ju dici al rev iew [ 1 4 6 ] as w ell as t he recognit ion t hat the
t enor of the bill may adju st w it h t he t imes, or t hat the bill it sel f may f ail to pass, accord ing t o the
dynami sm of the l egisl at iv e process, especial l y in l ight of t he object ions int erposed by int erest
grou ps t o dat e. [ 1 4 7 ]
W H EREFORE, t he pet it ion is GR A NTED . T he Decision of t he Cou rt of Appeal s
dat ed Oct ober 2 , 2 001, toget her w it h the Decision dat ed Sept ember 30, 19 9 7 of t he Regional T rial
Cou rt in Civ il Case No. 6 39 5 8, is R EVER S ED and S ET AS I DE . Anot her ju dgment is ent ered
dismis sing t he Compl aint and ordering respondent s, jointl y and sev eral l y, t o pay the pet it ioner t he
amou nt of P 86 5 ,59 2 .9 5 , w it h st ipul at ed int erest of 12 percent reck oned f rom t he dat e of
ext raju dic ial deman d u nt il f ul l payment , and 12 percent of the tot al amou nt du e as at t orney s f ees.
N o pronou ncement as t o cost s.
SO ORDERED.

Reyes, Hazel

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