LEGAL MED CASES
said institution and excluded petitioner.
Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. L-24119 August 8, 1925
FELIX MARQUEZ, petitioner,
vs.
THE BOARD OF MEDICAL EXAMINERS and THE SECRETARY-
TREASURER OF THE BOARD OF MEDICAL
EXAMINERS, respondent.
STREET, J.:
This is an original proceeding in this court by which the petitioner, Felix
Marquez, seeks to obtain a writ of mandamus against the respondents, the
Board of Medical Examiners, requiring them to admit the petitioner to the
physicians' examinations conducted, or to be conducted by the respondents in
the City of Manila. To the original complaint the respondents answered, and
to the answer a demurrer was interposed in behalf of the petitioner.
It appears that petitioner is a graduate of the Chicago Medical College, having
received the degree of M.D. from said institution on June 8, of the year 1922.
No question appears to have been made by the respondents with respect to the
petitioner's qualifications of the physician's examinations in other respects,
but they have denied him admission to the examinations on the grounds that
the Chicago Medical College, where the petitioner was graduated, has been
classified as a Class C medical college by the National Medical State Board
of the United States. For this reason the respondents, in accordance with the
regulations of the board now in effect, have denied the requisite standing to
It is not denied by the respondents that prior to the adoption of the present
regulations, and prior to the date when the Chicago Medical School was
classified as a Class C medical college, the Board of Medical Examiners for
the Philippine Islands had accepted diplomas of graduation from said medical
college as sufficient proof of proficiency in medical knowledge to admit a
graduate to the examinations held in these Islands; and as late as October 29,
1923, said board accepted favorably upon the application of one Dr. Mariano
M. Lazatin, who was graduated from said school in the year 1921. At the time
said candidate was admitted, however, the regulations denying the requisite
status to the Chicago Medical College had not been made effective, and they
had been made effective by proper authority before the present petitioner had
submitted his application.
In the argument for the petitioner it is admitted that under Act No. 3111, and
the regulations now in force, the petitioner is disqualified to take the
examinations; but it is pointed out that at the time he began and even when he
conducted his course in the Chicago Medical School, said institution was still
recognized as a reputable medical institution; and the question submitted is
whether the petitioner's case should be governed by the law and regulations
in force at the time of his enrollment in and graduation from the Chicago
Medical School, or by those in force at the time he filed his application for
admission, on or about September 26, 1924. It is submitted for the petitioner
that his case should be governed by the law and regulations at the time of his
graduation. To hold otherwise, it is insisted, is to make the law retroactive in
effect and to do irreparable damage to the petitioner, who has pursued his
work in the institution referred to in good faith, believing that said school had
the status necessary to qualify him from examination.
The position taken by the petitioner is, we think, untenable. The question
whether a medical institution is "a reputable medical school," in the sense
intended by the law, is vested in the Board of Medical Examiners, and Republic of the Philippines
although the action taken by them may conceivably, in isolated cases, result SUPREME COURT
in hardship, nevertheless the interests of the public require that the board Manila
should be free to exercise its judgment and discretion without reference to the
effect of the determination of the question in particular instances. There can EN BANC
in the nature of things be no vested right in an existing law, which would
preclude its change or repeal. No one who has commenced preparation in a G.R. No. L-32441 March 29, 1930
particular institution has any inchoate right on account of that fact. If the law
were otherwise upon this point, it would be impossible for the Board of DOMINADOR GOMEZ, plaintiff-appellant,
Medical Examiners to give effect to the knowledge which they from time to vs.
time acquire as to the standing of medical schools; and an intending physician, HONORIO VENTURA, Secretary of the Interior of the Government of
upon matriculating in a particular college, takes upon himself the risk of the Philippine Islands, and the
changes that may be made in the standing of the institution by the board. BOARD OF MEDICAL EXAMINERS OF THE PHILIPPINE
ISLANDS, defendants-appellees.
The demurrer to the answer is not well taken. The answer is therefore declared
sufficient, and the petition dismissed, with costs, So ordered. ROMUALDEZ, J.:

In this cause, the plaintiff prays for judgment, as follows:

1. Annulling and setting aside the aforementioned investigation proceedings,

and particularly the decision of the Board of Medical Examiners of the
Philippine Islands dated March 30, 1926, forever revoking the plaintiff's
license to practice medicine and surgery.

2. Ordering the defendants to restore the plaintiff to his status before the
investigation and the decision of March 30, 1926, that is, as if there had never
been an investigation and an adverse decision.

3. Ordering said defendants to issue in favor of the plaintiff a license for the
practice of medicine and surgery in the Philippine Islands, such as he had prior
to the investigation and adverse decision.
4. Granting the plaintiff any proper legal remedy. (Pages 5 and 6, bill of
exemptions.)
The defendants answered with a general denial and prayed that the complaint
be dismissed.
After trial the Court of First Instance of Manila dismissed the complaint with
costs against the plaintiff.
Counsel for plaintiff contends that the court below erred:
1. In holding that Assistant Fiscal Alfonso Felix of the City of Manila was
authorized to appear and institute administrative proceedings against Dr.
Dominador Gomez before the Board of Medical Examiners of the Philippines.
2. In not holding that Assistant Fiscal Alfonso Felix, of the City of Manila,
had personality nor power to institute administrative proceedings against Dr.
Dominador Gomez before the Board of Medical Examiners of the Philippines.
3. In admitting in its decision that section 9 of Act No. 2381, known as the
Opium Law, is valid.
4. In not holding that section 9 of Act No. 2381, known as the Opium Law, is
unconstitutional, and therefore null and void.
5. In holding that section 9 Act No. 2381, known as the Opium Law, is in
force.
6. In not holding that section 9 Act No. 2381 has been repealed, even on the
supposition that it was valid.
7. In rendering the judgment appealed from.
8. In denying the motion for avoidance, and for a new trial, filed by appellant.
The first two assignments of error relate to the validity of the charges against
the plaintiff, preferred by Assistant Fiscal Alfonso Felix of the City of Manila,
who, according to the plaintiff is not authorized by law to file charges with
the Board of Medical Examiners, which therefore acquired no jurisdiction
over the matter.
According to section 780 of Administrative Code, as amended by Act No.
3111, the procedure to be observed in revoking a certificate of registration is
the following:
Proceedings for revocation of a certificate of registration shall be begun by
filing a written charge or charges against the accused. These charges may be
preferred by any person or persons, firm or corporation, or the Board of
Medical Examiners itself may direct its executive officer to prepare said
charges. Said charges shall be filed with the executive officer of the Board of
Medical Examiners and a copy thereof, together with written notice of the
time and place when they will be heared and determined, shall be served upon
the accused or his counsel, at least two weeks before the date actually fixed
for said hearing. (Sec. 12, Act No. 3111.)
The law does not require that the charges be preferred by a public officer or
by any specified person; it even permits the Board of Medical Examiners itself
to require its executive officer to prefer said charges. From the wording of the
law we infer that any person, including a public officer, may prefer the
charges referred to in the above-quoted provision. Wherefore, the fact that the
charges were filed by Assistant Fiscal Alfonso Felix of the City of Manila,
does not deprive the Board of Medical Examiners of jurisdiction to hear said
charges and to take the proper action according to law.
The appellant contends in his third and fourth assignments of error that section
9 of Act No. 2381 is null and void on the ground of unconstitutionality, since
said section is foreign to the subject of said Act, in violation of section 3 of
the Jones Law prohibiting the enactment of any bill embracing more than one
subject and providing that the subject be expressed in the title of the bill.
Our opinion is that the matter contained in section 9 of Act No. 2381 is not
foreign to the end pursued in said Act, and that in view in the provision of
said section it cannot be maintained that Act No. 2381 includes more than one
subject. The penalty provided in said section for the physician or dentist who
prescribes opium for a patient whose physical condition does not require the
use of said drug, is one of the means employed by the Legislature to attain the
purpose of Act No. 2381, which is, to prohibit unnecessary use of opium; it is
one of the details subordinate to the purpose in view. Such punishment is not
the end contemplated in Act No. 2381, but, as we have just said, it is a means
employed to regulate the use of opium.
In passing said Act No. 2381, the Legislature merely exercised the police
power expressly granted by the Act of Congress of March 3, 1905, for the
protection of the health, comfort, and general welfare of the people of the
Philippine Islands.
ID.; ID.; POWER OF PHILIPPINE LEGISLATURE TO LEGISLATE
UPON THE SUBJECT. — The Philippine Legislature is expressly authorized
by the Act of Congress of March 3, 1905, to adopt legislation upon the
importation and sale of opium in the Philippine Islands. The purpose of such
legislation was to protect the health, comfort, and general welfare of the
people of the Philippine Islands. Such legislation was an exercise of the police
power of the State. (United States vs. Wayne Shoup, 35 Phil., 56.)
And, as we have stated, the provisions contained in section 9 of Act No. 2381
relative to the physicians and dentist are simply detailes and means conducive
to the ultimate purpose of said Act, which details and means need not be stated
in the title of the Act for the very reason that properly speaking, they are not
foreign matter.
The general purpose of these provisions is accomplished when a law has but
one general object, which is fairly indicated by its title. To require every end
and means necessary or convenient for the accomplishment of this general
object to be provided for by a separate act relating to that alone, would not
only be unreasonable, but would actually render legislation impossible.
(Cooley on Constitutional Limitations, pp. 296-297.)
The constitutional requirement is addressed to the subject, not to the details
of the act. The subject must be single; the provisions, to accomplished the
object involved in that subject, may be multifarious. . . . None of the
provisions of a statute will be held unconstitutional when they all relate,
directly or indirectly, to the same subject, have natural connection, and are
not foreign to the subject expressed in the title. As very frequently expressed
by the courts, any provisions that are germane to the subject expressed in the
title may properly be included in the act. (I Sutherland on Stat. Const., par.
118.)
In order to hold that section 9 of Act No. 2381 is unconstitutional on the
ground alleged by the plaintiff, the violation of the constitutional provision
must be substantial and manifest. It is not so in the case at bar.
2. To warrant the setting aside of statutes because their subjects are not
expressed in the titles, the violation of the rule must be substantial and plain.
(Posadas vs. Menzi, Decision of the United States Supreme Court, page 388,
No. 11, May 15, 1929, United States Supreme Court Advance Opinions.)
At all events the validity of this Opium Law, Act No. 2381, has already been
upheld by this court, not only in the above cited case, United States vs. Wayne
Shoup, supra, but also in the subsequent case of United States vs. Jao Li Sing
(37 Phil., 211).
Passing to the fifth and sixth assignments of error, wherein counsel for
appellant contends that even granting that section 9 of Act No. 2381 is valid,
it was repealed by Act No. 2493 and later by section 780 of the Administrative
Code, we note, first, that there is no express repeal of section 9 of Act No.
2381. Secondly, it cannot be held that it has been impliedly repealed, for the
reason that the provisions of section 9, Act No. 2381, are neither contrary to,
nor incompatible with, the provisions of section 780 of the Administrative
Code, as amended. Upon this point, we approve and adopt the following
statements made by the trial judge:
Counsel contends, in support of the above, that Act No. 2493 being complete,
and "covering the field" by implication repealed all laws relating to the
practice of medicine, powers of the Board of Medical Examiners and allied
matters; hence, the said law, expressly providing the causes for revocation of
medical licenses, necessarily excluded all others, even though embodied in
prior enactments.
Act No. 310 provided that the Board of medical Examiners could revoke
licenses for "unprofessional conduct," without defining the term. Act No.
1761 (the Opium Law) provided that illegaly prescribing opium should be
cause for revocation of medical licenses. Clearly, the Opium Law did not
repeal Act No. 310. Act No. 2381 — also an Opium Law — in its section 9,
repeated the provision as to doctors and dentists. The repetition did not repeal
Act No. 310. Act No. 2493, section 11 (Ad. Code, sec. 780), provided that
certificates of physicians are revocable for "unprofessional conduct," without
defining the phrase. In other words, so far as revocation of licenses is
concerned, Act No. 2493 is mere reenactment of Act No. 310. The
reenactment of the said portion of Act No. 310 did not repeal section 9 of the
Opium Law. If said section 9 has been repealed, it must be by Act No. 3111,
which amends Act No. 2493 (Ad. Code, sec. 780), by an addition after the
words "unprofessional conduct" of the following:
"The words "unprofessional conduct, immoral, or dishonorable conduct" as
used in this chapter shall be construed to include the following acts: (1)
Procuring, aiding or abeting a criminal abortion; (2) advertising, either in his
own name or in the name of any other person, firm, association, or
corporation, in any written or printed paper, or document, of medical business
in which untruthful or improbable promises are made, or being employed by,
or in the service of any person, firm, association or corporation so advertising,
or advertising in any obscene manner derogatory to good morals; (3) habitual
intemperance or addition to the use of morphine, opium, cocaine or other
drugs having a similar effect; (4) conviction of a crime or misdemeanor
involving dishonorable conduct; and (5) willfully betraying a professional
secret."
It cannot be seriously contended that aside from the five examples specified
there can be no other conduct of a physician deemed "unprofessional" conduct
theretofore deemed grounds for revocation licenses. The maxim expressio
unius est exclussio alterius should be applied only as a means of discovering
legislative intent and should not be permitted to defeat the plain indicated
purpose of the Legislature. It does not apply when words are mentioned by
way of example, or to remove doubts. (See Cyc., 1122.) If, therefore, there
exists, "unprofessional conduct" not specified in the laws, with more reason
does the criminal use of opium remain a specific cause for revocation of
license. (Pages 11, 12 and 13, bill of exceptions.)
As to the seventh and eighth assignments of error, we find the judgment and
appealed from correctly rendered, and the motion of avoidance and new trial
properly denied.
As the Attorney-General correctly observes, the powers vested in the Board
of Medical Examiners to suspend or revoke a physician's certificate of
registration and the authority granted the Secretary of the Interior of
confirming or reversing the decision of said board of examiners, partake of a
quasi-judicial character, that is, involve the use of discretion. For this reason,
the exercise thereof cannot be reviewed by mandamus, which is the nature of
this cause on its merits.
As in the case of courts and judicial officers, it is a rule of general application
that mandamus will not lie to review or control the acts of executive officers
and boards of state and federal governments in respect of matters as to which
they are vested with discretion. In other words, they cannot be compelled to
act or render a decision in any particular way, and this is so, even though the
exercise of this discretion requires the construction and interpretation of
statutes. Where public officials exercise their discretion, it is said that their
conclusions, although disputable, are impregnable to mandamus. (38 C. J.,
659-660.)
That this action is really a mandamus proceeding, appears clearly from the
terms of the complaint filed herein.
Finding no merit in the assignments of error, the judgment appealed from is
affirmed, with costs against the appellant. So ordered.
Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. 89572 December 21, 1989
DEPARTMENT OF EDUCATION, CULTURE AND SPORTS (DECS)
and DIRECTOR OF CENTER FOR EDUCATIONAL
MEASUREMENT, petitioners,
vs.
ROBERTO REY C. SAN DIEGO and JUDGE TERESITA DIZON-
CAPULONG, in her capacity as Presiding Judge of the Regional Trial
Court of Valenzuela, Metro Manila, Branch 172, respondents.
CRUZ, J.:
The issue before us is mediocrity. The question is whether a person who has
thrice failed the National Medical Admission Test (NMAT) is entitled to take
it again.
The petitioner contends he may not, under its rule that-
h) A student shall be allowed only three (3) chances to take the NMAT. After
three (3) successive failures, a student shall not be allowed to take the NMAT
for the fourth time.
The private respondent insists he can, on constitutional grounds.
But first the facts.
The private respondent is a graduate of the University of the East with a
degree of Bachelor of Science in Zoology. The petitioner claims that he took
the NMAT three times and flunked it as many times.1 When he applied to take
it again, the petitioner rejected his application on the basis of the aforesaid
rule. He then went to the Regional Trial Court of Valenzuela, Metro Manila,
to compel his admission to the test.
In his original petition for mandamus, he first invoked his constitutional rights
to academic freedom and quality education. By agreement of the parties, the
private respondent was allowed to take the NMAT scheduled on April 16,
1989, subject to the outcome of his petition. 2 In an amended petition filed
with leave of court, he squarely challenged the constitutionality of MECS
Order No. 12, Series of 1972, containing the above-cited rule. The additional
grounds raised were due process and equal protection.
After hearing, the respondent judge rendered a decision on July 4, 1989,
declaring the challenged order invalid and granting the petition. Judge
Teresita Dizon-Capulong held that the petitioner had been deprived of his
right to pursue a medical education through an arbitrary exercise of the police
power. 3
We cannot sustain the respondent judge. Her decision must be reversed.
In Tablarin v. Gutierrez, 4 this Court upheld the constitutionality of the
NMAT as a measure intended to limit the admission to medical schools only
to those who have initially proved their competence and preparation for a
medical education. Justice Florentino P. Feliciano declared for a unanimous
Court:
Perhaps the only issue that needs some consideration is whether there is some
reasonable relation between the prescribing of passing the NMAT as a
condition for admission to medical school on the one hand, and the securing
of the health and safety of the general community, on the other hand. This
question is perhaps most usefully approached by recalling that the regulation
of the pratice of medicine in all its branches has long been recognized as a
reasonable method of protecting the health and safety of the public. That the
power to regulate and control the practice of medicine includes the power to
regulate admission to the ranks of those authorized to practice medicine, is
also well recognized. Thus, legislation and administrative regulations
requiring those who wish to practice medicine first to take and pass medical
board examinations have long ago been recognized as valid exercises of
governmental power. Similarly, the establishment of minimum medical
educational requirements-i.e., the completion of prescribed courses in a
recognized medical school-for admission to the medical profession, has also
been sustained as a legitimate exercise of the regulatory authority of the state.
What we have before us in the instant case is closely related: the regulation of
access to medical schools. MECS Order No. 52, s. 1985, as noted earlier,
articulates the rationale of regulation of this type: the improvement of the
professional and technical quality of the graduates of medical schools, by
upgrading the quality of those admitted to the student body of the medical
schools. That upgrading is sought by selectivity in the process of admission,
selectivity consisting, among other things, of limiting admission to those who
exhibit in the required degree the aptitude for medical studies and eventually
for medical practice. The need to maintain, and the difficulties of maintaining,
high standards in our professional schools in general, and medical schools in
particular, in the current state of our social and economic development, are
widely known.
We believe that the government is entitled to prescribe an admission test like
the NMAT as a means of achieving its stated objective of "upgrading the
selection of applicants into [our] medical schools" and of "improv[ing] the
quality of medical education in the country." Given the widespread use today
of such admission tests in, for instance, medical schools in the United States
of America (the Medical College Admission Test [MCAT] and quite
probably, in other countries with far more developed educational resources
than our own, and taking into account the failure or inability of the petitioners
to even attempt to prove otherwise, we are entitled to hold that the NMAT is
reasonably related to the securing of the ultimate end of legislation and
regulation in this area. That end, it is useful to recall, is the protection of 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.
However, the respondent judge agreed with the petitioner that the said case
was not applicable. Her reason was that it upheld only the requirement for the
admission test and said nothing about the so-called "three-flunk rule."
We see no reason why the rationale in the Tablarin case cannot apply to the
case at bar. The issue raised in both cases is the academic preparation of the
applicant. This may be gauged at least initially by the admission test and,
indeed with more reliability, by the three-flunk rule. The latter cannot be
regarded any less valid than the former in the regulation of the medical
profession.
There is no need to redefine here the police power of the State. Suffice it to
repeat that the power is validly exercised if (a) the interests of the public
generally, as distinguished from those of a particular class, require the
interference of the State, and (b) the means employed are reasonably
necessary to the attainment of the object sought to be accomplished and not
unduly oppressive upon individuals.5
In other words, the proper exercise of the police power requires the
concurrence of a lawful subject and a lawful method.
The subject of the challenged regulation is certainly within the ambit of the
police power. It is the right and indeed the responsibility of the State to insure
that the medical profession is not infiltrated by incompetents to whom patients
may unwarily entrust their lives and health.
The method employed by the challenged regulation is not irrelevant to the
purpose of the law nor is it arbitrary or oppressive. The three-flunk rule is
intended to insulate the medical schools and ultimately the medical profession
from the intrusion of those not qualified to be doctors.
While every person is entitled to aspire to be a doctor, he does not have a
constitutional right to be a doctor. This is true of any other calling in which
the public interest is involved; and the closer the link, the longer the bridge to
one's ambition. The State has the responsibility to harness its human resources
and to see to it that they are not dissipated or, no less worse, not used at all.
These resources must be applied in a manner that will best promote the
common good while also giving the individual a sense of satisfaction.
A person cannot insist on being a physician if he will be a menace to his
patients. If one who wants to be a lawyer may prove better as a plumber, he
should be so advised and adviced. Of course, he may not be forced to be a
plumber, but on the other hand he may not force his entry into the bar. By the
same token, a student who has demonstrated promise as a pianist cannot be
shunted aside to take a course in nursing, however appropriate this career may
be for others.
The right to quality education invoked by the private respondent is not
absolute. The Constitution also provides that "every citizen has the right to
choose a profession or course of study, subject to fair, reasonable and
equitable admission and academic requirements.6
The private respondent must yield to the challenged rule and give way to those
better prepared. Where even those who have qualified may still not be
accommodated in our already crowded medical schools, there is all the more
reason to bar those who, like him, have been tested and found wanting.
The contention that the challenged rule violates the equal protection clause is
not well-taken. A law does not have to operate with equal force on all persons
or things to be conformable to Article III, Section 1 of the Constitution.
There can be no question that a substantial distinction exists between medical
students and other students who are not subjected to the NMAT and the three-
flunk rule. The medical profession directly affects the very lives of the people,
unlike other careers which, for this reason, do not require more vigilant
regulation. The accountant, for example, while belonging to an equally
respectable profession, does not hold the same delicate responsibility as that "swamped with mediocrity," in the words of Justice Holmes, not because we
of the physician and so need not be similarly treated. are lacking in intelligence but because we are a nation of misfits.

There would be unequal protection if some applicants who have passed the WHEREFORE, the petition is GRANTED. The decision of the respondent
tests are admitted and others who have also qualified are denied entrance. In court dated January 13, 1989, is REVERSED, with costs against the private
other words, what the equal protection requires is equality among equals. respondent. It is so ordered.

The Court feels that it is not enough to simply invoke the right to quality
education as a guarantee of the Constitution: one must show that he is entitled
to it because of his preparation and promise. The private respondent has failed
the NMAT five times. 7 While his persistence is noteworthy, to say the least,
it is certainly misplaced, like a hopeless love.

No depreciation is intended or made against the private respondent. It is

stressed that a person who does not qualify in the NMAT is not an absolute
incompetent unfit for any work or occupation. The only inference is that he is
a probably better, not for the medical profession, but for another calling that
has not excited his interest.

In the former, he may be a bungler or at least lackluster; in the latter, he is

more likely to succeed and may even be outstanding. It is for the appropriate
calling that he is entitled to quality education for the full harnessing of his
potentials and the sharpening of his latent talents toward what may even be a
brilliant future. Republic of the Philippines
SUPREME COURT
We cannot have a society of square pegs in round holes, of dentists who Manila
should never have left the farm and engineers who should have studied
banking and teachers who could be better as merchants. SECOND DIVISION

It is time indeed that the State took decisive steps to regulate and enrich our G.R. No. 144681 June 21, 2004
system of education by directing the student to the course for which he is best
suited as determined by initial tests and evaluations. Otherwise, we may be PROFESSIONAL REGULATION COMMISSION (PRC),
CHAIRMAN HERMOGENES P. POBRE, ASSOCIATE
COMMISSIONER ARMANDO PASCUAL, BOARD OF MEDICINE,
CHAIRMAN RODOLFO P. DE GUZMAN, JOSE S. RAMIREZ,
JUANITO B. BILLOTE, RUBEN R. POLICARPIO, EDGARDO T.
FERNANDO and RICARDO D. FULGENCIO II, petitioners,
vs.
ARLENE V. DE GUZMAN, VIOLETA V. MENESES, CELERINA S.
NAVARRO, JOSE RAMONCITO P. NAVARRO, ARNEL V.
HERRERA and GERALDINE ELIZABETH M. PAGILAGAN,
ELNORA R. RAQUENO, MARISSA A. REGODON, LAURA M.
SANTOS, KARANGALAN D. SERRANO, DANILO A. VILLAVER,
MARIA ROSARIO L. LEONOR, ALICIA S. LIZANO, MARITEL M.
ECHIVERRI, BERNADETTE T. MENDOZA, FERNANDO F.
MANDAPAT, ALELI A. GOLLAYAN, ELCIN C. ARRIOLA,
HERMINIGILDA E. CONEJOS, SALLY B. BUNAGAN, ROGELIO
B. ANCHETA, OSCAR H. PADUA, JR., EVELYN D. GRAJO,
EVELYN S. ACOSTA, MARGARITA BELINDA L. VICENCIO,
VALENTINO P. ARBOLEDA, EVELYN O. RAMOS, ACHILLES J.
PERALTA, CORAZON M. CRUZ, LEUVINA P. CHICO, JOSEPH A.
JAO, MA. LUISA S. GUTIERREZ, LYDIA C. CHAN, OPHELIA C.
HIDALGO, FERNANDO T. CRUZ, MELVIN M. USITA, RAFAEL I.
TOLENTINO, GRACE E. UY, CHERYL R. TRIGUERO, MICHAEL
L. SERRANO, FEDERICO L. CASTILLO, MELITA J. CAÑEDO,
SAMUEL B. BANGOY, BERNARDITA B. SY, GLORIA T.
JULARBAL, FREDERICK D. FRANCISCO, CARLOS M.
BERNARDO, JR., HUBERT S. NAZARENO, CLARISSA B. BACLIG,
DAYMINDA G. BONTUYAN, BERNADETTE H. CABUHAT,
NANCY J. CHAVEZ, MARIO D. CUARESMA, ERNESTO L. CUE,
EVELYN C. CUNDANGAN, RHONEIL R. DEVERATURDA,
DERILEEN D. DORADO, SAIBZUR N. EDDING, VIOLETA C.
FELIPE, HERMINIO V. FERNANDEZ, JR., MARIA VICTORIA M.
LACSAMANA, NORMA G. LAFAVILLA, RUBY B. LANTIN, MA.
ELOISA Q. MALLARI, CLARISA SJ. NICOLAS, PERCIVAL H.
PANGILINAN, ARNULFO A. SALVADOR, ROBERT B. SANCHEZ,
MERLY D. STA. ANA and YOLANDA P. UNICA, respondents.
DECISION
TINGA, J.:
This petition for review under Rule 45 of the 1997 Rules of Civil Procedure
seeks to nullify the D E C I S I O N,1dated May 16, 2000, of the Court of
Appeals in CA-G.R. SP No. 37283. The appellate court affirmed the
judgment2dated December 19, 1994, of the Regional Trial Court (RTC) of
Manila, Branch 52, in Civil Case No. 93-66530. The trial court allowed the
respondents to take their physician’s oath and to register as duly licensed
physicians. Equally challenged is the R E S O L U T I O N3 promulgated on
August 25, 2000 of the Court of Appeals, denying petitioners’ Motion for
Reconsideration.
The facts of this case are as follows:
The respondents are all graduates of the Fatima College of Medicine,
Valenzuela City, Metro Manila. They passed the Physician Licensure
Examination conducted in February 1993 by the Board of Medicine (Board).
Petitioner Professional Regulation Commission (PRC) then released their
names as successful examinees in the medical licensure examination.
Shortly thereafter, the Board observed that the grades of the seventy-nine
successful examinees from Fatima College in the two most difficult subjects
in the medical licensure exam, Biochemistry (Bio-Chem) and Obstetrics and
Gynecology (OB-Gyne), were unusually and exceptionally high. Eleven
Fatima examinees scored 100% in Bio-Chem and ten got 100% in OB-Gyne,
another eleven got 99% in Bio-Chem, and twenty-one scored 99% in OB-
Gyne. The Board also observed that many of those who passed from Fatima
got marks of 95% or better in both subjects, and no one got a mark lower than
90%. A comparison of the performances of the candidates from other schools
was made. The Board observed that strangely, the unusually high ratings were
true only for Fatima College examinees. It was a record-breaking
phenomenon in the history of the Physician Licensure Examination.
On June 7, 1993, the Board issued Resolution No. 19, withholding the
registration as physicians of all the examinees from the Fatima College of
Medicine.4 The PRC asked the National Bureau of Investigation (NBI) to
investigate whether any anomaly or irregularity marred the February 1993
Physician Licensure Examination.
Prior to the NBI investigation, the Board requested Fr. Bienvenido F. Nebres,
S.J., an expert mathematician and authority in statistics, and later president of
the Ateneo de Manila University, to conduct a statistical analysis of the results
in Bio-Chem and Ob-Gyne of the said examination.
On June 10, 1993, Fr. Nebres submitted his report. He reported that a
comparison of the scores in Bio-Chem and Ob-Gyne, of the Fatima College
examinees with those of examinees from De La Salle University and
Perpetual Help College of Medicine showed that the scores of Fatima College
examinees were not only incredibly high but unusually clustered close to each
other. He concluded that there must be some unusual reason creating the
clustering of scores in the two subjects. It must be a cause "strong enough to
eliminate the normal variations that one should expect from the examinees [of
Fatima College] in terms of talent, effort, energy, etc."5
For its part, the NBI found that "the questionable passing rate of Fatima
examinees in the [1993] Physician Examination leads to the conclusion that
the Fatima examinees gained early access to the test questions."6
On July 5, 1993, respondents Arlene V. De Guzman, Violeta V. Meneses,
Celerina S. Navarro, Jose Ramoncito P. Navarro, Arnel V. Herrera, and
Geraldine Elizabeth M. Pagilagan (Arlene V. De Guzman et al., for brevity)
filed a special civil action for mandamus, with prayer for preliminary
mandatory injunction docketed as Civil Case No. 93-66530 with the Regional
Trial Court (RTC) of Manila, Branch 52. Their petition was adopted by the
other respondents as intervenors.
Meanwhile, the Board issued Resolution No. 26, dated July 21, 1993,
charging respondents with "immorality, dishonest conduct, fraud, and deceit"
in connection with the Bio-Chem and Ob-Gyne examinations. It
recommended that the test results of the Fatima examinees be nullified. The
case was docketed as Adm. Case No. 1687 by the PRC.
On July 28, 1993, the RTC issued an Order in Civil Case No. 93-66530
granting the preliminary mandatory injunction sought by the respondents. It
ordered the petitioners to administer the physician’s oath to Arlene V. De
Guzman et al., and enter their names in the rolls of the PRC.
The petitioners then filed a special civil action for certiorari with the Court of
Appeals to set aside the mandatory injunctive writ, docketed as CA-G.R. SP
No. 31701.
On October 21, 1993, the appellate court decided CA-G.R. SP No. 31701,
with the dispositive portion of the Decision ordaining as follows:
WHEREFORE, this petition is GRANTED. Accordingly, the writ of
preliminary mandatory injunction issued by the lower court against
petitioners is hereby nullified and set aside.
SO ORDERED.7
Arlene V. de Guzman, et al., then elevated the foregoing Decision to this
Court in G.R. No. 112315. In our Resolution dated May 23, 1994, we denied
the petition for failure to show reversible error on the part of the appellate
court.
Meanwhile, on November 22, 1993, during the pendency of the instant
petition, the pre-trial conference in Civil Case No. 93-66530 was held. Then,
the parties, agreed to reduce the testimonies of their respective witnesses to
sworn questions-and-answers. This was without prejudice to cross-
examination by the opposing counsel.
On December 13, 1993, petitioners’ counsel failed to appear at the trial in the
mistaken belief that the trial was set for December 15. The trial court then
ruled that petitioners waived their right to cross-examine the witnesses.
On January 27, 1994, counsel for petitioners filed a Manifestation and
Motion stating the reasons for her non-appearance and praying that the cross-
examination of the witnesses for the opposing parties be reset. The trial court
denied the motion for lack of notice to adverse counsel. It also denied
the Motion for Reconsideration that followed on the ground that adverse
counsel was notified less than three (3) days prior to the hearing.
Meanwhile, to prevent the PRC and the Board from proceeding with Adm.
Case No. 1687, the respondents herein moved for the issuance of a restraining
order, which the lower court granted in its Order dated April 4, 1994.
The petitioners then filed with this Court a petition for certiorari docketed as
G.R. No. 115704, to annul the Orders of the trial court dated November 13,
1993, February 28, 1994, and April 4, 1994. We referred the petition to the
Court of Appeals where it was docketed as CA-G.R. SP No. 34506.
On August 31, 1994, the appellate court decided CA-G.R. SP No. 34506 as
follows:
WHEREFORE, the present petition for certiorari with prayer for temporary
restraining order/preliminary injunction is GRANTED and the Orders of
December 13, 1993, February 7, 1994, February 28, 1994, and April 4, 1994
of the RTC-Manila, Branch 52, and all further proceedings taken by it in
Special Civil Action No. 93-66530 are hereby DECLARED NULL and
VOID. The said RTC-Manila is ordered to allow petitioners’ counsel to cross-
examine the respondents’ witnesses, to allow petitioners to present their
evidence in due course of trial, and thereafter to decide the case on the merits
on the basis of the evidence of the parties. Costs against respondents.
IT IS SO ORDERED.8
The trial was then set and notices were sent to the parties.
A day before the first hearing, on September 22, 1994, the petitioners filed
an Urgent Ex-Parte Manifestation and Motion praying for the partial
reconsideration of the appellate court’s decision in CA-G.R. SP No. 34506,
and for the outright dismissal of Civil Case No. 93-66530. The petitioners
asked for the suspension of the proceedings.
In its Order dated September 23, 1994, the trial court granted the aforesaid
motion, cancelled the scheduled hearing dates, and reset the proceedings to
October 21 and 28, 1994.
Meanwhile, on October 25, 1994, the Court of Appeals denied the partial
motion for reconsideration in CA-G.R. SP No. 34506. Thus, petitioners filed
with the Supreme Court a petition for review docketed as G.R. No. 117817,
entitled Professional Regulation Commission, et al. v. Court of Appeals, et al.
On November 11, 1994, counsel for the petitioners failed to appear at the trial
of Civil Case No. 93-66530. Upon motion of the respondents herein, the trial
court ruled that herein petitioners waived their right to cross-examine the
herein respondents. Trial was reset to November 28, 1994.
On November 25, 1994, petitioners’ counsel moved for the inhibition of the
trial court judge for alleged partiality. On November 28, 1994, the day
the Motion to Inhibit was to be heard, petitioners failed to appear. Thus, the
trial court denied the Motion to Inhibit and declared Civil Case No. 93-66530
deemed submitted for decision.
On December 19, 1994, the trial court handed down its judgment in Civil Case
No. 93-66530, the fallo of which reads:
WHEREFORE, judgment is rendered ordering the respondents to allow the
petitioners and intervenors (except those with asterisks and footnotes in pages
1 & 2 of this decision) [sic],9 to take the physician’s oath and to register them
as physicians.
It should be made clear that this decision is without prejudice to any
administrative disciplinary action which may be taken against any of the
petitioners for such causes and in the manner provided by law and consistent
with the requirements of the Constitution as any other professionals.
No costs.
SO ORDERED.10
As a result of these developments, petitioners filed with this Court a petition
for review on certiorari docketed as G.R. No. 118437, entitled Professional
Regulation Commission v. Hon. David G. Nitafan, praying inter alia, that (1)
G.R. No. 118437 be consolidated with G.R. No. 117817; (2) the decision of
the Court of Appeals dated August 31, 1994 in CA-G.R. SP No. 34506 be
nullified for its failure to decree the dismissal of Civil Case No. 93-66530,
and in the alternative, to set aside the decision of the trial court in Civil Case
No. 93-66530, order the trial court judge to inhibit himself, and Civil Case
No. 93-66530 be re-raffled to another branch.
On December 26, 1994, the petitioners herein filed their Notice of Appeal11 in
Civil Case No. 93-66530, thereby elevating the case to the Court of Appeals,
where it was docketed as CA-G.R. SP No. 37283.
In our Resolution of June 7, 1995, G.R. No. 118437 was consolidated with
G.R. No. 117817.
On July 9, 1998, we disposed of G.R. Nos. 117817 and 118437 in this wise:
WHEREFORE, the petition in G.R. No. 117817 is DISMISSED for being
moot. The petition in G.R. No. 118437 is likewise DISMISSED on the ground
that there is a pending appeal before the Court of Appeals. Assistant Solicitor
General Amparo M. Cabotaje-Tang is advised to be more circumspect in her
dealings with the courts as a repetition of the same or similar acts will be dealt
with accordingly.
SO ORDERED.12
While CA-G.R. SP No. 37283 was awaiting disposition by the appellate court,
Arnel V. Herrera, one of the original petitioners in Civil Case No. 93-66530,
joined by twenty-seven intervenors, to wit: Fernando F. Mandapat, Ophelia
C. Hidalgo, Bernadette T. Mendoza, Ruby B. Lantin-Tan, Fernando T. Cruz,
Marissa A. Regodon, Ma. Eloisa Q. Mallari-Largoza, Cheryl R. Triguero,
Joseph A. Jao, Bernadette H. Cabuhat, Evelyn S. Acosta-Cabanes, Laura M.
Santos, Maritel M. Echiverri, Bernadette C. Escusa, Carlosito C. Domingo,
Alicia S. Lizano, Elnora R. Raqueno-Rabaino, Saibzur N. Edding, Derileen
D. Dorado-Edding, Robert B. Sanchez, Maria Rosario L. Leonor-Lacandula,
Geraldine Elizabeth M. Pagilagan-Palma, Margarita Belinda L. Vicencio-
Gamilla, Herminigilda E. Conejos, Leuvina P. Chico-Paguio, Elcin C.
Arriola-Ocampo, and Jose Ramoncito P. Navarro, manifested that they were
no longer interested in proceeding with the case and moved for its dismissal.
A similar manifestation and motion was later filed by intervenors Mary Jean
I. Yeban-Merlan, Michael L. Serrano, Norma G. Lafavilla, Arnulfo A.
Salvador, Belinda C. Rabara, Yolanda P. Unica, Dayminda G. Bontuyan,
Clarissa B. Baclig, Ma. Luisa S. Gutierrez, Rhoneil R. Deveraturda, Aleli A.
Gollayan, Evelyn C. Cundangan, Frederick D. Francisco, Violeta V. Meneses,
Melita J. Cañedo, Clarisa SJ. Nicolas, Federico L. Castillo, Karangalan D.
Serrano, Danilo A. Villaver, Grace E. Uy, Lydia C. Chan, and Melvin M.
Usita. The Court of Appeals ruled that its decision in CA-G.R. SP No. 37283
would not apply to them.
On May 16, 2000, the Court of Appeals decided CA-G.R. SP No. 37283, with
the following fallo, to wit:
WHEREFORE, finding no reversible error in the decision appealed from, We
hereby AFFIRM the same and DISMISS the instant appeal.
No pronouncement as to costs.
SO ORDERED.13
In sustaining the trial court’s decision, the appellate court ratiocinated that the
respondents complied with all the statutory requirements for admission into
the licensure examination for physicians in February 1993. They all passed
the said examination. Having fulfilled the requirements of Republic Act No.
2382,14 they should be allowed to take their oaths as physicians and be
registered in the rolls of the PRC.
Hence, this petition raising the following issues:
I Resolution dated May 24, 1994 in G.R. No. 112315 held that there was no
WHETHER OR NOT RESPONDENTS HAVE A VALID CAUSE OF
ACTION FOR MANDAMUS AGAINST PETITIONERS IN THE LIGHT
OF THE RESOLUTION OF THIS HONORABLE COURT IN G.R. NO.
112315 AFFIRMING THE COURT OF APPEALS’ DECISION
DECLARING THAT IF EVER THERE IS SOME DOUBT AS TO THE
MORAL FITNESS OF EXAMINEES, THE ISSUANCE OF LICENSE TO
PRACTICE MEDICINE IS NOT AUTOMATICALLY GRANTED TO THE
SUCCESSFUL EXAMINEES.
II
WHETHER OR NOT THE PETITION FOR MANDAMUS COULD
PROCEED DESPITE THE PENDENCY OF ADMINISTRATIVE CASE
NO. 1687, WHICH WAS PRECISELY LODGED TO DETERMINE THE
MORAL FITNESS OF RESPONDENTS TO BECOME DOCTORS.15
To our mind, the only issue is: Did the Court of Appeals commit a reversible
error of law in sustaining the judgment of the trial court that respondents are
entitled to a writ of mandamus?
The petitioners submit that a writ of mandamus will not lie in this case. They
point out that for a writ of mandamus to issue, the applicant must have a well-
defined, clear and certain legal right to the thing demanded and it is the duty
of the respondent to perform the act required. Thus, mandamus may be
availed of only when the duty sought to be performed is a ministerial and not
a discretionary one. The petitioners argue that the appellate court’s decision
in CA-G.R. SP No. 37283 upholding the decision of the trial court in Civil
Case No. 93-66530 overlooked its own pronouncement in CA-G.R. SP No.
31701. The Court of Appeals held in CA-G.R. SP No. 31701 that the issuance
of a license to engage in the practice of medicine becomes discretionary on
the PRC if there exists some doubt that the successful examinee has not fully
met the requirements of the law. The petitioners stress that this Court’s
showing "that the Court of Appeals had committed any reversible error in
rendering the questioned judgment" in CA-G.R. SP No. 31701. The
petitioners point out that our Resolution in G.R. No. 112315 has long become
final and executory.
Respondents counter that having passed the 1993 licensure examinations for
physicians, the petitioners have the obligation to administer to them the oath
as physicians and to issue their certificates of registration as physicians
pursuant to Section 2016 of Rep. Act No. 2382. The Court of Appeals in CA-
G.R. SP No. 37283, found that respondents complied with all the
requirements of Rep. Act No. 2382. Furthermore, respondents were admitted
by the Medical Board to the licensure examinations and had passed the same.
Hence, pursuant to Section 20 of Rep. Act No. 2382, the petitioners had the
obligation to administer their oaths as physicians and register them.
Mandamus is a command issuing from a court of competent jurisdiction, in
the name of the state or the sovereign, directed to some inferior court, tribunal,
or board, or to some corporation or person requiring the performance of a
particular duty therein specified, which duty results from the official station
of the party to whom the writ is directed, or from operation of law.17 Section
3 of Rule 6518 of the 1997 Rules of Civil Procedure outlines two situations
when a writ of mandamus may issue, when any tribunal, corporation, board,
officer or person unlawfully (1) neglects the performance of an act which the
law specifically enjoins as a duty resulting from an office, trust, or station; or
(2) excludes another from the use and enjoyment of a right or office to which
the other is entitled.
We shall discuss the issues successively.
1. On The Existence of a Duty of the Board of Medicine To Issue
Certificates of Registration as Physicians under Rep. Act No. 2382.
For mandamus to prosper, there must be a showing that the officer, board, or
official concerned, has a clear legal duty, not involving
discretion.19 Moreover, there must be statutory authority for the performance
of the act,20 and the performance of the duty has been refused.21 Thus, it must
be pertinently asked now: Did petitioners have the duty to administer the
Hippocratic Oath and register respondents as physicians under the Medical
Act of 1959?
As found by the Court of Appeals, on which we agree on the basis of the
records:
It bears emphasizing herein that petitioner-appellees and intervenor-appellees
have fully complied with all the statutory requirements for admission into the
licensure examinations for physicians conducted and administered by the
respondent-appellants on February 12, 14, 20 and 21, 1993. Stress, too, must
be made of the fact that all of them successfully passed the same
examinations.22
The crucial query now is whether the Court of Appeals erred in concluding
that petitioners should allow the respondents to take their oaths as physicians
and register them, steps which would enable respondents to practice the
medical profession23 pursuant to Section 20 of the Medical Act of 1959?
The appellate court relied on a single provision, Section 20 of Rep. Act No.
2382, in concluding that the petitioners had the ministerial obligation to
administer the Hippocratic Oath to respondents and register them as
physicians. But it is a basic rule in statutory construction that each part of a
statute should be construed in connection with every other part to produce a
harmonious whole, not confining construction to only one section.24 The
intent or meaning of the statute should be ascertained from the statute taken
as a whole, not from an isolated part of the provision. Accordingly, Section
20, of Rep. Act No. 2382, as amended should be read in conjunction with the
other provisions of the Act. Thus, to determine whether the petitioners had
the ministerial obligation to administer the Hippocratic Oath to respondents
and register them as physicians, recourse must be had to the entirety of the
Medical Act of 1959.
A careful reading of Section 20 of the Medical Act of 1959 discloses that the
law uses the word "shall" with respect to the issuance of certificates of
registration. Thus, the petitioners "shall sign and issue certificates of
registration to those who have satisfactorily complied with the requirements
of the Board." In statutory construction the term "shall" is a word of
command. It is given imperative meaning. Thus, when an examinee satisfies
the requirements for the grant of his physician’s license, the Board is obliged
to administer to him his oath and register him as a physician, pursuant to
Section 20 and par. (1) of Section 2225 of the Medical Act of 1959.
However, the surrounding circumstances in this case call for serious inquiry
concerning the satisfactory compliance with the Board requirements by the
respondents. The unusually high scores in the two most difficult subjects was
phenomenal, according to Fr. Nebres, the consultant of PRC on the matter,
and raised grave doubts about the integrity, if not validity, of the tests. These
doubts have to be appropriately resolved.
Under the second paragraph of Section 22, the Board is vested with the power
to conduct administrative investigations and "disapprove applications for
examination or registration," pursuant to the objectives of Rep. Act No. 2382
as outlined in Section 126 thereof. In this case, after the investigation, the
Board filed before the PRC, Adm. Case No. 1687 against the respondents to
ascertain their moral and mental fitness to practice medicine, as required by
Section 927 of Rep. Act No. 2382. In its Decision dated July 1, 1997, the
Board ruled:
WHEREFORE, the BOARD hereby CANCELS the respondents[’]
examination papers in the Physician Licensure Examinations given in
February 1993 and further DEBARS them from taking any licensure
examination for a period of ONE (1) YEAR from the date of the promulgation
of this DECISION. They may, if they so desire, apply for the scheduled
examinations for physicians after the lapse of the period imposed by the
BOARD.
SO ORDERED.28
Until the moral and mental fitness of the respondents could be ascertained,
according to petitioners, the Board has discretion to hold in abeyance the
administration of the Hippocratic Oath and the issuance of the certificates to
them. The writ of mandamus does not lie to compel performance of an act
which is not duly authorized.
The respondents nevertheless argue that under Section 20, the Board shall not
issue a certificate of registration only in the following instances: (1) to any
candidate who has been convicted by a court of competent jurisdiction of any
criminal offense involving moral turpitude; (2) or has been found guilty of
immoral or dishonorable conduct after the investigation by the Board; or (3)
has been declared to be of unsound mind. They aver that none of these
circumstances are present in their case.
Petitioners reject respondents’ argument. We are informed that in Board
Resolution No. 26,29 dated July 21, 1993, the Board resolved to file charges
against the examinees from Fatima College of Medicine for "immorality,
dishonesty, fraud, and deceit in the Obstetrics-Gynecology and Biochemistry
examinations." It likewise sought to cancel the examination results obtained
by the examinees from the Fatima College.
Section 830 of Rep. Act No. 2382 prescribes, among others, that a person who
aspires to practice medicine in the Philippines, must have "satisfactorily
passed the corresponding Board Examination." Section 22, in turn, provides
that the oath may only be administered "to physicians who qualified in the
examinations." The operative word here is "satisfactorily," defined as
"sufficient to meet a condition or obligation" or "capable of dispelling doubt
or ignorance."31 Gleaned from Board Resolution No. 26, the licensing
authority apparently did not find that the respondents "satisfactorily passed"
the licensure examinations. The Board instead sought to nullify the
examination results obtained by the respondents.
2. On the Right Of The Respondents To Be Registered As Physicians
The function of mandamus is not to establish a right but to enforce one that
has been established by law. If no legal right has been violated, there can be
no application of a legal remedy, and the writ of mandamus is a legal remedy
for a legal right.32 There must be a well-defined, clear and certain legal right
to the thing demanded.33 It is long established rule that a license to practice
medicine is a privilege or franchise granted by the government.34
It is true that this Court has upheld the constitutional right35 of every citizen
to select a profession or course of study subject to a fair, reasonable, and
equitable admission and academic requirements.36 But like all rights and
freedoms guaranteed by the Charter, their exercise may be so regulated
pursuant to the police power of the State to safeguard health, morals, peace,
education, order, safety, and general welfare of the people.37 Thus, persons
who desire to engage in the learned professions requiring scientific or
technical knowledge may be required to take an examination as a prerequisite
to engaging in their chosen careers. This regulation takes particular pertinence
in the field of medicine, to protect the public from the potentially deadly
effects of incompetence and ignorance among those who would practice
medicine. In a previous case, it may be recalled, this Court has ordered the
Board of Medical Examiners to annul both its resolution and certificate
authorizing a Spanish subject, with the degree of Licentiate in Medicine and
Surgery from the University of Barcelona, Spain, to practice medicine in the
Philippines, without first passing the examination required by the Philippine
Medical Act.38 In another case worth noting, we upheld the power of the State
to upgrade the selection of applicants into medical schools through admission
tests.39
It must be stressed, nevertheless, that the power to regulate the exercise of a
profession or pursuit of an occupation cannot be exercised by the State or its
agents in an arbitrary, despotic, or oppressive manner. A political body that
regulates the exercise of a particular privilege has the authority to both forbid
and grant such privilege in accordance with certain conditions. Such
conditions may not, however, require giving up ones constitutional rights as
a condition to acquiring the license.40 Under the view that the legislature
cannot validly bestow an arbitrary power to grant or refuse a license on a
public agency or officer, courts will generally strike down license legislation
that vests in public officials discretion to grant or refuse a license to carry on
some ordinarily lawful business, profession, or activity without prescribing
definite rules and conditions for the guidance of said officials in the exercise
of their power.41
In the present case, the aforementioned guidelines are provided for in Rep.
Act No. 2382, as amended, which prescribes the requirements for admission
to the practice of medicine, the qualifications of candidates for the board
examinations, the scope and conduct of the examinations, the grounds for
denying the issuance of a physician’s license, or revoking a license that has
been issued. Verily, to be granted the privilege to practice medicine, the
applicant must show that he possesses all the qualifications and none of the
disqualifications. Furthermore, it must appear that he has fully complied with
all the conditions and requirements imposed by the law and the licensing
authority. Should doubt taint or mar the compliance as being less than
satisfactory, then the privilege will not issue. For said privilege is
distinguishable from a matter of right, which may be demanded if denied.
Thus, without a definite showing that the aforesaid requirements and
conditions have been satisfactorily met, the courts may not grant the writ of
mandamus to secure said privilege without thwarting the legislative will.
3. On the Ripeness of the Petition for Mandamus
Lastly, the petitioners herein contend that the Court of Appeals should have
dismissed the petition for mandamus below for being premature. They argue
that the administrative remedies had not been exhausted. The records show
that this is not the first time that petitioners have sought the dismissal of Civil
Case No. 93-66530. This issue was raised in G.R. No. 115704, which petition
we referred to the Court of Appeals, where it was docketed as CA-G.R. SP
No. 34506. On motion for reconsideration in CA-G.R. SP No. 34506, the
appellate court denied the motion to dismiss on the ground that the prayers
for the nullification of the order of the trial court and the dismissal of Civil
Case No. 93-66530 were inconsistent reliefs. In G.R. No. 118437, the
petitioners sought to nullify the decision of the Court of Appeals in CA-G.R.
SP No. 34506 insofar as it did not order the dismissal of Civil Case No. 93-
66530. In our consolidated decision, dated July 9, 1998, in G.R. Nos. 117817
& 118437, this Court speaking through Justice Bellosillo opined that:
Indeed, the issue as to whether the Court of Appeals erred in not ordering the
dismissal of Civil Case No. 93-66530 sought to be resolved in the instant
petition has been rendered meaningless by an event taking place prior to the
filing of this petition and denial thereof should follow as a logical
consequence.42 There is no longer any justiciable controversy so that any
declaration thereon would be of no practical use or value.43 It should be
recalled that in its decision of 19 December 1994 the trial court granted the
writ of mandamus prayed for by private respondents, which decision was
received by petitioners on 20 December 1994. Three (3) days after, or on 23
December 1994, petitioners filed the instant petition. By then, the remedy
available to them was to appeal the decision to the Court of Appeals, which
they in fact did, by filing a notice of appeal on 26 December 1994.44
The petitioners have shown no cogent reason for us to reverse the aforecited
ruling. Nor will their reliance upon the doctrine of the exhaustion of
administrative remedies in the instant case advance their cause any.
Section 2645 of the Medical Act of 1959 provides for the administrative and
judicial remedies that respondents herein can avail to question Resolution No.
26 of the Board of Medicine, namely: (a) appeal the unfavorable judgment to
the PRC; (b) should the PRC ruling still be unfavorable, to elevate the matter
on appeal to the Office of the President; and (c) should they still be
unsatisfied, to ask for a review of the case or to bring the case to court viaa
special civil action of certiorari. Thus, as a rule, mandamus will not lie when
administrative remedies are still available.46 However, the doctrine of
exhaustion of administrative remedies does not apply where, as in this case, a
pure question of law is raised.47 On this issue, no reversible error may, thus,
be laid at the door of the appellate court in CA-G.R. SP No. 37283, when it
refused to dismiss Civil Case No. 93-66530.
As we earlier pointed out, herein respondents Arnel V. Herrera, Fernando F.
Mandapat, Ophelia C. Hidalgo, Bernadette T. Mendoza, Ruby B. Lantin-Tan,
Fernando T. Cruz, Marissa A. Regodon, Ma. Eloisa Q. Mallari-Largoza,
Cheryl R. Triguero, Joseph A. Jao, Bernadette H. Cabuhat, Evelyn S. Acosta-
Cabanes, Laura M. Santos, Maritel M. Echiverri, Bernadette C. Escusa,
Carlosito C. Domingo, Alicia S. Lizano, Elnora R. Raqueno-Rabaino, Saibzur
N. Edding, Derileen D. Dorado-Edding, Robert B. Sanchez, Maria Rosario
Leonor-Lacandula, Geraldine Elizabeth M. Pagilagan-Palma, Margarita
Belinda L. Vicencio-Gamilla, Herminigilda E. Conejos, Leuvina P. Chico-
Paguio, Elcin C. Arriola-Ocampo, and Jose Ramoncito P. Navarro manifested
to the Court of Appeals during the pendency of CA-G.R. SP No. 37283, that
they were no longer interested in proceeding with the case and moved for its
dismissal insofar as they were concerned. A similar manifestation and motion
were later filed by intervenors Mary Jean I. Yeban-Merlan, Michael L.
Serrano, Norma G. Lafavilla, Arnulfo A. Salvador, Belinda C. Rabarra,
Yolanda P. Unica, Dayminda G. Bontuyan, Clarissa B. Baclig, Ma. Luisa S.
Gutierrez, Rhoneil R. Deveraturda, Aleli A. Gollayan, Evelyn C. Cundangan,
Frederick D. Francisco, Violeta V. Meneses, Melita J. Cañedo, Clarisa SJ.
Nicolas, Federico L. Castillo, Karangalan D. Serrano, Danilo A. Villaver,
Grace E. Uy, Lydia C. Chan, and Melvin M. Usita. Following these
manifestations and motions, the appellate court in CA-G.R. SP No. 37283
decreed that its ruling would not apply to them. Thus, inasmuch as the instant
case is a petition for review of the appellate court’s ruling in CA-G.R. SP No.
37283, a decision which is inapplicable to the aforementioned respondents
will similarly not apply to them.
As to Achilles J. Peralta, Evelyn O. Ramos, Sally B. Bunagan, Rogelio B.
Ancheta, Oscar H. Padua, Jr., Evelyn D. Grajo, Valentino P. Arboleda, Carlos
M. Bernardo, Jr., Mario D. Cuaresma, Violeta C. Felipe, Percival H.
Pangilinan, Corazon M. Cruz and Samuel B. Bangoy, herein decision shall
not apply pursuant to the Orders of the trial court in Civil Case No. 93-66530,
dropping their names from the suit.
Consequently, this Decision is binding only on the remaining respondents,
namely: Arlene V. de Guzman, Celerina S. Navarro, Rafael I. Tolentino,
Bernardita B. Sy, Gloria T. Jularbal, Hubert S. Nazareno, Nancy J. Chavez,
Ernesto L. Cue, Herminio V. Fernandez, Jr., Maria Victoria M. Lacsamana
and Merly D. Sta. Ana, as well as the petitioners.
WHEREFORE, the instant petition is GRANTED. Accordingly, (1) the
assailed decision dated May 16, 2000, of the Court of Appeals, in CA-G.R.
SP No. 37283, which affirmed the judgment dated December 19, 1994, of the
Regional Trial Court of Manila, Branch 52, in Civil Case No. 93-66530,
ordering petitioners to administer the physician’s oath to herein respondents
as well as the resolution dated August 25, 2000, of the appellate court,
denying the petitioners’ motion for reconsideration, are REVERSED and SET
ASIDE; and (2) the writ of mandamus, issued in Civil Case No. 93-66530,
and affirmed by the appellate court in CA-G.R. SP No. 37283 is NULLIFIED
AND SET ASIDE. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 166097 July 14, 2008
BOARD OF MEDICINE, DR. RAUL FLORES (now DR. JOSE S.
RAMIREZ), in his capacity as Chairman of the Board,
PROFESSIONAL REGULATION COMMISSION, through its
Chairman, HERMOGENES POBRE (now DR. ALCESTIS M.
GUIANG), Petitioners,
vs.
YASUYUKI OTA, Respondent.
DECISION
AUSTRIA-MARTINEZ, J.:
Before the Court is a Petition for Review on Certiorari assailing the
Decision1 of the Court of Appeals (CA) in CA-G.R. SP No. 849452 dated
November 16, 2004 which affirmed the Decision3 of the Regional Trial Court
(RTC), Branch 22, Manila, dated October 19, 2003.4
The facts are as follows:
Yasuyuki Ota (respondent) is a Japanese national, married to a Filipina, who
has continuously resided in the Philippines for more than 10 years. He
graduated from Bicol Christian College of Medicine on April 21, 1991 with a
degree of Doctor of Medicine.5 After successfully completing a one-year post
graduate internship training at the Jose Reyes Memorial Medical Center, he
filed an application to take the medical board examinations in order to obtain
a medical license. He was required by the Professional Regulation
Commission (PRC) to submit an affidavit of undertaking, stating among
others that should he successfully pass the same, he would not practice
medicine until he submits proof that reciprocity exists between Japan and the
Philippines in admitting foreigners into the practice of medicine.6
Respondent submitted a duly notarized English translation of the Medical
Practitioners Law of Japan duly authenticated by the Consul General of the
Philippine Embassy to Japan, Jesus I. Yabes;7 thus, he was allowed to take
the Medical Board Examinations in August 1992, which he subsequently
passed.8
In spite of all these, the Board of Medicine (Board) of the PRC, in a letter
dated March 8, 1993, denied respondent's request for a license to
practice medicine in the Philippines on the ground that the Board "believes
that no genuine reciprocity can be found in the law of Japan as there is no
Filipino or foreigner who can possibly practice there."9
Respondent then filed a Petition for Certiorari and Mandamus against the
Board before the RTC of Manila on June 24, 1993, which petition was
amended on February 14, 1994 to implead the PRC through its Chairman.10
In his petition before the RTC, respondent alleged that the Board and the PRC,
in refusing to issue in his favor a Certificate of Registration and/or license to
practice medicine, had acted arbitrarily, in clear contravention of the
provision of Section 20 of Republic Act (R.A.) No. 2382 (The Medical Act
of 1959), depriving him of his legitimate right to practice his profession in the
Philippines to his great damage and prejudice.11
On October 19, 2003, the RTC rendered its Decision finding that respondent
had adequately proved that the medical laws of Japan allow foreigners like
Filipinos to be granted license and be admitted into the practice of medicine
under the principle of reciprocity; and that the Board had a ministerial duty of
issuing the Certificate of Registration and license to respondent, as it was
shown that he had substantially complied with the requirements under the
law.12 The RTC then ordered the Board to issue in favor of respondent the
corresponding Certificate of Registration and/or license to practice medicine
in the Philippines.13
The Board and the PRC (petitioners) appealed the case to the CA, stating that
while respondent submitted documents showing that foreigners are allowed
to practice medicine in Japan, it was not shown that the conditions for the
practice of medicine there are practical and attainable by a foreign applicant,
hence, reciprocity was not established; also, the power of the PRC and the
Board to regulate and control the practice of medicine is discretionary and not
ministerial, hence, not compellable by a writ of mandamus.14
The CA denied the appeal and affirmed the ruling of the RTC.15
Hence, herein petition raising the following issue:
WHETHER THE COURT OF APPEALS COMMITTED A REVERSIBLE
ERROR IN FINDING THAT RESPONDENT HAD ESTABLISHED THE
EXISTENCE OF RECIPROCITY IN THE PRACTICE OF MEDICINE
BETWEEN THE PHILIPPINES AND JAPAN.16
Petitioners claim that: respondent has not established by competent and
conclusive evidence that reciprocity in the practice of medicine exists
between the Philippines and Japan. While documents state that foreigners are
allowed to practice medicine in Japan, they do not similarly show that the
conditions for the practice of medicine in said country are practical and
attainable by a foreign applicant. There is no reciprocity in this case, as the
requirements to practice medicine in Japan are practically impossible for a
Filipino to comply with. There are also ambiguities in the Medical
Practitioners Law of Japan, which were not clarified by respondent, i.e., what
are the provisions of the School Educations Laws, what are the criteria of the
Minister of Health and Welfare of Japan in determining whether the academic
and technical capability of foreign medical graduates are the same or better
than graduates of medical schools in Japan, and who can actually qualify to
take the preparatory test for the National Medical Examination. Consul
General Yabes also stated that there had not been a single Filipino who was
issued a license to practice medicine by the Japanese Government. The
publication showing that there were foreigners practicing medicine in Japan,
which respondent presented before the Court, also did not specifically show
that Filipinos were among those listed as practicing said
profession.17 Furthermore, under Professional Regulation Commission v. De
Guzman,18the power of the PRC and the Board to regulate and control the
practice of medicine includes the power to regulate admission to the ranks of
those authorized to practice medicine, which power is discretionary and not
ministerial, hence, not compellable by a writ of mandamus.19
Petitioners pray that the CA Decision dated November 16, 2004 be reversed
and set aside, that a new one be rendered reinstating the Board Order dated
March 8, 1993 which disallows respondent to practice medicine in the
Philippines, and that respondent's petition before the trial court be dismissed
for lack of merit.20
In his Comment, respondent argues that: Articles 2 and 11 of the Medical
Practitioners Law of Japan and Section 9 of the Philippine Medical Act of
1959 show that reciprocity exists between the Philippines and Japan
concerning the practice of medicine. Said laws clearly state that both countries
allow foreigners to practice medicine in their respective jurisdictions as long
as the applicant meets the educational requirements, training or residency in
hospitals and pass the licensure examination given by either country. Consul
General Yabes in his letter dated January 28, 1992 stated that "the Japanese
Government allows a foreigner to practice medicine in Japan after complying
with the local requirements." The fact that there is no reported Filipino who
has successfully penetrated the medical practice in Japan does not mean that
there is no reciprocity between the two countries, since it does not follow that
no Filipino will ever be granted a medical license by the Japanese
Government. It is not the essence of reciprocity that before a citizen of one of
the contracting countries can demand its application, it is necessary that the
interested citizen’s country has previously granted the same privilege to the
citizens of the other contracting country.21 Respondent further argues that
Section 20 of the Medical Act of 195922 indicates the mandatory character of
the statute and an imperative obligation on the part of the Board inconsistent
with the idea of discretion. Thus, a foreigner, just like a Filipino citizen, who
successfully passes the examination and has all the qualifications and none of
the disqualifications, is entitled as a matter of right to the issuance of a
certificate of registration or a physician’s license, which right is enforceable
by mandamus.23
Petitioners filed a Reply24 and both parties filed their respective
memoranda25 reiterating their arguments.1avvphi1
The Court denies the petition for lack of merit.
There is no question that a license to practice medicine is a privilege or
franchise granted by the government.26 It is a right that is earned through years
of education and training, and which requires that one must first secure a
license from the state through professional board examinations.27
Indeed,
[T]he regulation of the practice of medicine in all its branches has long been
recognized as a reasonable method of protecting the health and safety of the
public. That the power to regulate and control the practice of medicine
includes the power to regulate admission to the ranks of those authorized to
practice medicine, is also well recognized. Thus, legislation and
administrative regulations requiring those who wish to practice medicine first
to take and pass medical board examinations have long ago been recognized
as valid exercises of governmental power. Similarly, the establishment of
minimum medical educational requirements – i.e., the completion of
prescribed courses in a recognized medical school – for admission to the
medical profession, has also been sustained as a legitimate exercise of the
regulatory authority of the state."28
It must be stressed however that the power to regulate the exercise of a
profession or pursuit of an occupation cannot be exercised by the State or its
agents in an arbitrary, despotic, or oppressive manner. A political body which
regulates the exercise of a particular privilege has the authority to both forbid
and grant such privilege in accordance with certain conditions. As the
legislature cannot validly bestow an arbitrary power to grant or refuse a
license on a public agency or officer, courts will generally strike down license
legislation that vests in public officials discretion to grant or refuse a license
to carry on some ordinarily lawful business, profession, or activity without
prescribing definite rules and conditions for the guidance of said officials in
the exercise of their power.29
R.A. No. 2382 otherwise known as the Medical Act of 1959 states in Section
9 thereof that:
Section 9. Candidates for Board Examinations.- Candidates for Board
examinations shall have the following qualifications:
1. He shall be a citizen of the Philippines or a citizen of any foreign country
who has submitted competent and conclusive documentary evidence,
confirmed by the Department of Foreign Affairs, showing that his country’s
existing laws permit citizens of the Philippines to practice medicine under the
same rules and regulations governing citizens thereof;
xxxx
30
Presidential Decree (P.D.) No. 223 also provides in Section (j) thereof that:
j) The [Professional Regulation] Commission may, upon the recommendation
of the Board concerned, approve the registration of and authorize the issuance
of a certificate of registration with or without examination to a foreigner who
is registered under the laws of his country: Provided, That the requirement for
the registration or licensing in said foreign state or country are substantially
the same as those required and contemplated by the laws of the Philippines
and that the laws of such foreign state or country allow the citizens of the
Philippines to practice the profession on the same basis and grant the same
privileges as the subject or citizens of such foreign state or country: Provided,
finally, That the applicant shall submit competent and conclusive
documentary evidence, confirmed by the Department of Foreign Affairs,
showing that his country's existing laws permit citizens of the Philippines to
practice the profession under the rules and regulations governing citizens
thereof. The Commission is also hereby authorized to prescribe additional
requirements or grant certain privileges to foreigners seeking registration in
the Philippines if the same privileges are granted to or some additional
requirements are required of citizens of the Philippines in acquiring the same
certificates in his country;
xxxx
As required by the said laws, respondent submitted a copy of the Medical
Practitioners Law of Japan, duly authenticated by the Consul General of the
Embassy of the Philippines in Japan, which provides in Articles 2 and 11,
thus:
Article 2. Anyone who wants to be medical practitioner must pass the national
examination for medical practitioner and get license from the Minister of
Health and Welfare.
xxxx
Article 11. No one can take the National Medical Examination except persons
who conform to one of the following items:
1. Persons who finished regular medical courses at a university based on the
School Education Laws (December 26, 1947) and graduated from said
university.
2. Persons who passed the preparatory test for the National Medical
Examination and practiced clinics and public sanitation more than one year
after passing the said test.
3. Persons who graduated from a foreign medical school or acquired medical
practitioner license in a foreign country, and also are recognized to have the
same or more academic ability and techniques as persons stated in item 1 and
item 2 of this article.31
Petitioners argue that while the Medical Practitioners Law of Japan allows
foreigners to practice medicine therein, said document does not show that
conditions for the practice of medicine in said country are practical and
attainable by a foreign applicant; and since the requirements are practically
impossible for a Filipino to comply with, there is no reciprocity between the
two countries, hence, respondent may not be granted license to practice
medicine in the Philippines.
The Court does not agree.
R.A. No. 2382, which provides who may be candidates for the medical board
examinations, merely requires a foreign citizen to submit competent and
conclusive documentary evidence, confirmed by the Department of Foreign
Affairs (DFA), showing that his country’s existing laws permit citizens of the
Philippines to practice medicine under the same rules and regulations
governing citizens thereof.
Section (j) of P.D. No. 223 also defines the extent of PRC's power to grant
licenses, i.e., it may, upon recommendation of the board, approve the
registration and authorize the issuance of a certificate of registration with or
without examination to a foreigner who is registered under the laws of his
country, provided the following conditions are met: (1) that the requirement
for the registration or licensing in said foreign state or country are
substantially the same as those required and contemplated by the laws of the
Philippines; (2) that the laws of such foreign state or country allow the citizens
of the Philippines to practice the profession on the same basis and grant the
same privileges as the subject or citizens of such foreign state or country; and
(3) that the applicant shall submit competent and conclusive documentary
evidence, confirmed by the DFA, showing that his country's existing laws
permit citizens of the Philippines to practice the profession under the rules
and regulations governing citizens thereof.
The said provision further states that the PRC is authorized to prescribe
additional requirements or grant certain privileges to foreigners seeking
registration in the Philippines if the same privileges are granted to or some
additional requirements are required of citizens of the Philippines in acquiring
the same certificates in his country.
Nowhere in said statutes is it stated that the foreign applicant must show that
the conditions for the practice of medicine in said country are practical and
attainable by Filipinos. Neither is it stated that it must first be proven that a
Filipino has been granted license and allowed to practice his profession in said
country before a foreign applicant may be given license to practice in the
Philippines. Indeed, the phrase used in both R.A. No. 2382 and P.D. No. 223
is that:
[T]he applicant shall submit] competent and conclusive documentary
evidence, confirmed by the Department of Foreign Affairs, showing that his
country's existing laws permit citizens of the Philippines to practice the
profession [of medicine] under the [same] rules and regulations governing
citizens thereof. x x x (Emphasis supplied)
It is enough that the laws in the foreign country permit a Filipino to get license
and practice therein. Requiring respondent to prove first that a Filipino has
already been granted license and is actually practicing therein unduly expands
the requirements provided for under R.A. No. 2382 and P.D. No. 223.
While it is true that respondent failed to give details as to the conditions stated
in the Medical Practitioners Law of Japan -- i.e., the provisions of the School
Educations Laws, the criteria of the Minister of Health and Welfare of Japan
in determining whether the academic and technical capability of foreign
medical graduates are the same as or better than that of graduates of medical
schools in Japan, and who can actually qualify to take the preparatory test for
the National Medical Examination – respondent, however, presented proof
that foreigners are actually practicing in Japan and that Filipinos are not
precluded from getting a license to practice there.
Respondent presented before the trial court a Japanese Government
publication, Physician-Dentist-Pharmaceutist Survey, showing that there are
a number of foreign physicians practicing medicine in Japan.32 He also
presented a letter dated January 28, 1992 from Consul General Yabes,33 which
states:
Sir:
With reference to your letter dated 12 January 1993, concerning your request
for a Certificate of Confirmation for the purpose of establishing a reciprocity
with Japan in the practice of medical profession relative to the case of Mr.
Yasuyuki Ota, a Japanese national, the Embassy wishes to inform you that
inquiries from the Japanese Ministry of Foreign Affairs, Ministry of Health
and Welfare as well as Bureau of Immigration yielded the following
information:
1. They are not aware of a Filipino physician who was granted a license by
the Japanese Government to practice medicine in Japan;
2. However, the Japanese Government allows a foreigner to practice medicine
in Japan after complying with the local requirements such as holding a valid
visa for the purpose of taking the medical board exam, checking the
applicant's qualifications to take the examination, taking the national board
examination in Japanese and filing an application for the issuance of the
medical license.
Accordingly, the Embassy is not aware of a single Filipino physician who was
issued by the Japanese Government a license to practice medicine, because it
is extremely difficult to pass the medical board examination in the Japanese
language. Filipino doctors here are only allowed to work in Japanese hospitals
as trainees under the supervision of a Japanese doctor. On certain occasions,
they are allowed to show their medical skills during seminars for
demonstration purposes only. (Emphasis supplied)
Very truly yours,
Jesus I. Yabes
Minister Counsellor &
Consul General
From said letter, one can see that the Japanese Government allows foreigners
to practice medicine therein provided that the local requirements are complied
with, and that it is not the impossibility or the prohibition against Filipinos
that would account for the absence of Filipino physicians holding licenses and
practicing medicine in Japan, but the difficulty of passing the board
examination in the Japanese language. Granting that there is still no Filipino
who has been given license to practice medicine in Japan, it does not mean
that no Filipino will ever be able to be given one.
Petitioners next argue that as held in De Guzman, its power to issue licenses
is discretionary, hence, not compellable by mandamus.
The Court finds that the factual circumstances of De Guzman are different
from those of the case at bar; hence, the principle applied therein should be
viewed differently in this case. In De Guzman, there were doubts about the
integrity and validity of the test results of the examinees from a particular
school which garnered unusually high scores in the two most difficult
subjects. Said doubts called for serious inquiry concerning the applicants’
satisfactory compliance with the Board requirements.34 And as there was no
definite showing that the requirements and conditions to be granted license to has not committed any reversible error in rendering its Decision dated
practice medicine had been satisfactorily met, the Court held that the writ November 16, 2004 and Resolution dated October 19, 2003.
of mandamus may not be granted to secure said privilege without thwarting
the legislative will.35 WHEREFORE, the petition is hereby DENIED for lack of merit.

Indeed, to be granted the privilege to practice medicine, the applicant must SO ORDERED.
show that he possesses all the qualifications and none of the disqualifications.
It must also appear that he has fully complied with all the conditions and
requirements imposed by the law and the licensing authority.36

In De Guzman itself, the Court explained that:

Republic of the Philippines
A careful reading of Section 2037 of the Medical Act of 1959 discloses that SUPREME COURT
the law uses the word "shall" with respect to the issuance of certificates of Manila
registration. Thus, the petitioners [PRC] "shall sign and issue certificates of
registration to those who have satisfactorily complied with the requirements EN BANC
of the Board." In statutory construction the term "shall" is a word of
command. It is given imperative meaning. Thus, when an examinee satisfies G.R. No. L-15079 January 31, 1962
the requirements for the grant of his physician's license, the Board is obliged
to administer to him his oath and register him as a physician, pursuant to THE PEOPLE OF THE PHILIPPINES, plaintiff-appellee,
Section 20 and par. (1) of Section 22 of the Medical Act of 1959.38 vs.
GUILLERMO I. VENTURA, defendant-appellant.
In this case, there is no doubt as to the competence and qualifications of
respondent. He finished his medical degree from Bicol Christian College of BENGZON, C.J.:
Medicine. He completed a one-year post graduate internship training at the
Jose Reyes Memorial Medical Center, a government hospital. Then he passed Statement. —This is an appeal from the decision of the Court of First Instance
the Medical Board Examinations which was given on August 8, 1992 with a of Rizal finding Guillermo I. Ventura guilty of illegal practice of medicine
general average of 81.83, with scores higher than 80 in 9 of the 12 subjects. under Section 770 in connection with Section 2678 of the Revised
Administrative Code, and sentencing him, this being his second offense, to
In fine, the only matter being questioned by petitioners is the alleged failure pay a fine in the sum of P500.00, with the corresponding subsidiary
of respondent to prove that there is reciprocity between the laws of Japan and imprisonment in case of insolvency and to pay costs.
the Philippines in admitting foreigners into the practice of medicine.
Respondent has satisfactorily complied with the said requirement and the CA
Appellant, the accused, was charged with the above offense in an information
which alleged that in February, 1955, he did, .
"willfully, unlawfully and feloniously, and for compensation and reward,
practice medicine in the said City (Pasay) by treating and applying electrical
appliances to patients for the purpose of curing them with their ailments,
diseases, pains, and physical defects from which they are suffering and by
holding out himself to the public by means of signs, advertisements, and other
means, to be a Doctor of Medicine."
Facts. — lower court found, as facts, the following:
"... in the year 1949, the accused herein, Guillermo I. Ventura, was convicted
by the court of first instance of Rizal of a 'similar offense' or illegal practice
of medicine in the municipality of Pasay, now Pasay City and sentenced to
pay a fine of P200.00 under the same legal provisions, or Section 770 in
connection with Section 2678 of the Revised Administrative Code.
"... by reason of certain complaints the National Bureau of Investigation had
received from the President of the Philippine Federation of Private Medical
Practitioners and from the Chairman of the Board of Medical Examiners, the
National Bureau of Investigation on December 16, 1955, sent its morgue
attendant Jose Natayan to the clinic of the accused at No. 2454 M. de la Cruz
Street, Pasay City. Natayan was at that time suffering from pains in his back
and he asked the accused to see his sickness. The accused attended to
Natayan; wrote something on a piece of paper; and then he told him that he
(Natayan) 'was sick of lumbago'. Thereupon, the accused asked Natayan to
pay P5.00 and then asked him to pay the amount to a lady employee in the
clinic which Natayan did. At the request of the accused, Natayan, then went
around the other side of the clinic where he was given an enema of hot water
by a male attendant. Then Natayan was asked to lie down on a table where his
back was exposed to a big bulb for around fifteen minutes and afterwards to
a red colored bulb for another ten minutes. Thereafter Natayan went back to
the accused, who told him to come back to his clinic for six consecutive days.
After that Natayan went back on the same day or December 16, 1955 to his
office in the National Bureau of Investigation.
The following day, Natayan returned to the clinic of the accused with the
National Bureau of Investigation raiding party composed of two agents, two
attorneys and one photographer. After he was dropped by the National Bureau
of Investigation agents about seven meters away from the clinic of the
accused, Natayan proceeded to the office of the accused, who then and there
told him that another treatment would be applied to him and that he would
pay P3.00. After paying this amount and while Natayan was lying on a table
about to be given treatment the National Bureau of Investigation agents raided
the place.
The accused herein, Guillermo I. Ventura, is not a duly registered masseur or
a physician qualified to practice medicine.
Issues. —Appellant seeks a reversal here of aforementioned judgment of
conviction on the grounds: (1) that the offense charged in the information had
already prescribed; (2) that the laws involved are unconstitutional and void;
(3) that granting that the said laws are valid, the accused should not have been
prosecuted thereunder because he was not engaged in the practice of
medicine; (4) that Congress, in passing House Bills Nos. 2405 and 357
recognized and believed in the efficacy of the drugless systems of healing and
although said bills were vetoed by the President of the Philippines and thereby
did not become regular statutes, they may be considered as concurrent
resolutions formally establishing the drugless system of healing as a separate
and distinct profession, not covered by Section 770 of the Medical Law; (5)
that the complainants and the Government are estopped from prosecuting the
accused under Section 770 because they were the ones who induced him to
practice drugless healing after his conviction in 1949; and (6) that the accused
has an implied license to practice drugless healing from the people of the
Philippines and the Chairman of the Medical Board of Examiners.
Discussion. — Appellant, testifying on his behalf admitted that for the past
35 years, he had been practicing as a naturopathic physician, "treating human
ailments without the use of drugs and medicines" and employing in his
practice "electricity, water and hand" without a license to practice medicine;
that during this time he had treated 500,000 patients, more or less about 90%
of whom were healed, and that he had studied drugless healing in the
American University, Chicago, Illinois for about four years.
Invoking prescription, he argues that in view of the fact that he had begun the
alleged practice of medicine thirty five years ago without the required license,
the crime charged in the information had already prescribed.1
The records reveal that the accused began practicing his method of drugless
healing 35 years ago. This practice was first discovered by the authorities in
1949. He was prosecuted and convicted therefor the same year. Sometime
after he again set up a clinic. He had a lucrative clientele and nobody bothered
him.1äwphï1.ñët
However, at about February, 1955, the President of the Philippine Federation
of Private Medical Practitioners, complained to the National Bureau of
Investigation that appellant was advertising himself as capable of treating
human ailments without drugs. Upon investigation, appellant was found to be
without certificate of registration to practice such profession either from the
Board of Medical Examiners or from the Committee of Examiners of
Masseurs. So, this prosecution started in 1956. It is clear that the four-year
period of prescription of the offense charged should be computed from
February, 1955 when the National Bureau of Investigation discovered
appellant's alleged illegal practice of Medicine.
Appellant also questions the constitutionality of Section 770 in relation to
Section 775 of the Revised Administrative Code. It is appellant's theory that
to require, of any person whose business is merely to stimulate by mechanical
means the nerves of the body, many years of study in medical schools, taking
up obstetrics, general surgery, gynecology, bacteriology and many other
sciences, is curtailment of the exercise of one's calling, a violation of the
constitutional principle that all men have the right to life, liberty, and the
pursuit of happiness and are entitled to the equal protection of the law. It is
furthermore theorized that inasmuch as drugless healing is not taught in any
of the medical schools prescribed, how could the members of the Medical
Board of Examiners pass on the competence of these drugless healers? .
This same contention was presented to and settled by this Court in the case
of People vs. Buenviaje who was convicted of illegal practice of medicine for
practicing chiropractor.2 It held:
There is very little force in this argument. The subjects in which an
examination is required relate to matters of which a thorough knowledge
seems necessary for the proper diagnosis of diseases of the human body and
it is within the police power of the State to require that persons who devote
themselves to the curing of human ills should possess such knowledge.
In the instant case, we must again uphold these immutable concepts of the
police power of the State. Under this power, the State may prescribe such
regulations as in its judgment will secure or tend to secure the general welfare
of the people, to protect them against the consequences of ignorance and
incapacity as well as of deception and fraud. As one means to this end, it has
been the practice of different States, from time immemorial to exact in any
pursuit, profession or trade, a certain degree of skill and learning upon which
the community may confidently rely, their possession being generally
ascertained in an examination of parties by competent persons, or inferred
from a certificate to them in the form of a diploma or license from an
institution established for instruction on the subjects, scientific or otherwise,
with which such pursuits have to deal.3
Appellant claims that his act of stimulating the affected nerves of the patients
without use of any drug or medicine is not practice of medicine; that "practice
of medicine" is confined only to the systems taught by the medical schools,
namely, the regular, the homeopathic and the eclectic schools or systems.
Section 770 of the Revised Administrative Code in no uncertain terms covers
appellant's acts. The statutory definition as to what acts constitute illegal
practice of medicine its provided in said Section 770 includes the acts and
practices performed by appellant, By his own statements, he admitted to have
continuously diagnosed and treated more or less 500,000 instances of
different kinds of human ailments and to have prescribed remedies therefor.
As regards the contention that there are at least two concurrent resolutions
declaring formally that Congress has recognized the drugless methods of
healing, we need not elaborate further than to say that not until such
recognition is actually embodied in a statute, shall we extend consideration of
such method.
Appellant pleads that the lower court erred in not holding that the
complainants and the government are estopped from prosecuting him because
they were the ones who induced him to practice drugless healing after his
conviction in 1949. He tried to show that medical practitioners, members of
Congress, provincial governors, city mayors and municipal board members
wrote to him requesting his help for persons suffering from all kinds of
ailments; that municipal ordinances and resolutions were also passed
authorizing him not only to practice his method of healing but also to put up
clinics in some of municipalities; that he was even extended free
transportation facilities to work in the Central Luzon Sanitarium in Tala,
Caloocan, Rizal.
Above plea cannot be sustained by this Court. The doctrine of estoppel does
not apply to the government.4 It is never stopped by mistakes or errors on the
part of its agents, even assuming without conceding that said municipalities
had encouraged appellant's practice. We cannot allow the bargaining away of
public health and safety for the semblance of benefit to a few government
officials, people or even municipalities.
Similarly, there is no such thing as implied license to practice drugless healing
by the mere fact that the Chairman of the Board of Medical Examiners had
permitted appellant to serve free in the Central Luzon Sanitarium in Tala,
Caloocan, Rizal, or that countless people persisted in engaging his services.
For one thing, these people might have contracted his services on the mistaken
notion that he was duly licensed to practice his profession; for another, a
repetition of illegal acts can never make them legal.
As additional argument, appellant urges acquittal under the new Medical Act
of 19595 wherein the practice of physiotherapy is recognized as a distinct
science. He claims coverage of said law on the ground that he practices
physiotherapy by massage through physical devices and upon the
recommendation of duly registered physicians.
The above argument has no merit because there is strong evidence to the effect
that appellant alone diagnoses his patients' ailments and applies the remedies
therefor6 without written order or prescription by a registered physician.
Judgment. — Wherefore, the decision appealed from is hereby affirmed in
all parts and respects. Costs against appellant.

Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. 88259 August 10, 1989
THE BOARD OF MEDICAL EDUCATION and the HON. LOURDES
R. QUISUMBING, in her capacity as Secretary of the Department of
Education, Culture and Sports and Chairman, Board of Medical
Education, petitioners,
vs.
HON. DANIEL P. ALFONSO, Presiding Judge of the Regional Trial
Court, Branch 74, Fourth Judicial Region, Antipolo, Rizal, and the
PHILIPPINE MUSLIM-CHRISTIAN COLLEGE OF MEDICINE
FOUNDATION, INC., respondents.
NARVASA, J.:
Petitioners, the Board of Medical Education, the government agency which
supervises and regulates the country's medical colleges, and Secretary
Lourdes R. Quisumbing of the Department of Education, Culture and Sports,
as Chairperson of the Board, pray for a writ of certiorari to nullify and set
aside the order issued by respondent Judge Daniel P. Alfonso, Regional Trial
Court, Antipolo, Rizal, in Civil Case No. 1385 restraining the enforcement of
petitioner Quisumbing's order of closure of the respondent Philippine
Muslim-Christian College of Medicine Foundation, Inc. (hereafter simply the
College).lâwphî1.ñèt
The, College, a private educational institution, was founded in 1981 for the
avowed purpose of producing physicians who will "emancipate Muslim
citizens from age-old attitudes on health." The, unstable peace and order
situation in Mindanao led to the establishment of the College in Antipolo,
Rizal, which granted it a temporary permit to operate in the municipality,
instead of in Zamboanga City where the school was first proposed to be
located. It has since adopted Antipolo as its permanent site and changed its
name to the Rizal College of Medicine.
In 1985, the Department of Education, Culture and Sports (DECS) and the
Board of Medical Education (BME) authorized the Commission on Medical
Education to conduct a study of all medical schools in the Philippines. The,
report of the Commission showed that the College fell very much short of the
minimum standards set for medical schools. 1 The, team of inspectors,
composed of Doctors Florentino Herrera, Jr., Elena Ines Cuyegkeng, Horacio
Estrada, Jose V. Silao, Jr. and Andres L. Reyes, recommended the closure of
the school 2 upon the following findings, to wit:
(a) the College was not fulfilling the purpose for which it had been created
because of its inappropriate location and the absence in its curriculum of
subjects relating to Muslim culture and welfare;
(b) its lack of university affiliation hindered its students from obtaining a
"balanced humanistic and scientific" education;
(c) it did not have its philosophy base hospital for the training of its students
in the major clinical disciplines, as required by the DECS;
(d) more than 60% of the college faculty did not teach in the College full-
time, resulting in shortened and irregular class hours, subject overloading, and
in general, poor quality teaching.
The, school disputed these findings as biased and discriminatory. At its
request, the Board of Medical Education, in May, 1987, sent another team of
doctors 3 for a re-evaluation of the College. After inspection, the team
confirmed the previous findings and recommended the phase-out of the
school. 4
The, first two reports were verified on June 23, 1987 by a third team of
inspectors. 5 A year thereafter, the College failed another test what was in
effect the fourth evaluation of its fitness to continue as a medical school
conducted on March 4 and 5, 1988 by a team from the Board of Medical
Education determining the eligibility of medical schools for government
recognition. The, College was adjudged "inadequate" in all aspects of the
survey, to wit, college, curriculum, facilities, teaching hospital, and
studentry. 6 The, inspectors, Doctors Nilo Rosas, Macario Tan and Elena Ines
Cuyegkeng, accordingly recommended denial of government; recognition.
Accordingly, the Board of Medical Education recommended to the DECS the
closure of the College, effective the end of the school year 1988-1989. The,
College however succeeded in having the Board form yet another team to
review the previous findings. Doctors Elena Ines Cuyegkeng, Alberto
Romualdez, Artemio Ordinaria Joven Cuanang and Nilo L. Rosas conducted
their inspection on June 18, 1988. Their findings: although there had been a
"major effort to improve the physical plant for classroom instructions and the
library, serious deficiencies remain(ed) in the areas of clinical facilities and
library operations;" "faculty continue(d) to be quite inadequate with no
prospects for satisfactory growth and development;" "student profile ... (was)
below par from the point of view of credentials (NMAT and transfer records)
as well as level knowledge and preparedness at various stages of medical
education," and "the most serious deficiency ... (was) the almost total lack of
serious development efforts in academic medicine — i.e., seeming lack of
philosophy of teaching, no serious effort to study curricula, almost non-
existent innovative approaches." Again, the recommendation was to close the
College with provisions for the dispersal of its students to other medical
schools. 7
In her letter of June 23, 1988, Secretary Quisumbing informed the Chairman
of the College's Board of Trustees, Mr. Victor Sumulong, of the decision of
the Board of Medical Education to close the College. Mr. Sumulong instead
proposed a gradual phase-out starting the school year 1989-1990 in order not
to dislocate the students and staff and to minimize financial loss. 8 The, Board
subsequently allowed the College to continue its operations but only until
May, 1989, after which it was to be closed, this decision being "final and
unappealable." The, College was, however, assured of assistance in the
relocation of its students and in its rehabilitation as an institution for health-
related and paramedical courses. 9
The, College appealed the decision to the Office of the President, imputing
grave abuse of discretion to the Secretary. 10 On February 16, 1989, Executive
Secretary Catalino Macaraig, Jr., finding "no reason to disturb" the contested
decision, affirmed it. 11
On March 2, 1989, the College went to court. It filed Civil Case No. 1385 in
the court of respondent Judge Daniel P. Alfonso against Secretary
Quisumbing in her capacity as Secretary of Education, Culture and Sports,
questioning the decision as illegal, oppressive, arbitrary and discriminatory
and applied for a writ of preliminary injunction to restrain its implementation.
The, writ issued as prayed for by order of the respondent Judge dated May 10,
1989. 12 His Honor ruled that the inspection of June 18, 1988 was the principal
basis of the closure order, and on such basis sustained the claim of the College
that the inspection was done in an "arbitrary and haphazard manner" by a team
of inspectors who had already prejudged the school. Judge Alfonso held that
there was no evidence supporting the findings in the report of June 18, 1988,
and declared that his philosophy ocular inspection of the College disclosed
that the deficiencies mentioned in the report were non-existent, and that on
the contrary, the laboratory and library areas were "big enough," and in the
operations of the proposed base hospital were going on smoothly at the time
of the ocular inspection."
The, school thereupon promptly advertised in major newspaper dailies for
enrollees in all levels of the medical college and in its pre-board review
classes. 13
Hence the present petition, assailing the order of injunction dated May 10,
1989 as having been issued with grave abuse of discretion, and praying for a
restraining order against its enforcement as well as for the dismissal of the
action instituted in the court a quo. The, Court on June 1, 1989 ordered the
respondent College to desist from advertising and admitting students, and the
respondent judge to refrain from enforcing his injunction order.
The, College in its Comment would justify its entitlement to the questioned
injunction on the ground that the closure order against which it was directed
was issued without factual basis and in violation of the right of the College to
due process of law, and that it violates MECS Order No. 5 (Series of 1986) to
the effect that the penalty of closure cannot be imposed earlier than three (3)
years from the last evaluation, which in this instance was made, on June 18,
1988.
Resort to the Courts to obtain a reversal of the determination by the Secretary
of Education, Culture and Sports that the College is unfit to continue its
operations is in this case clearly unavailing. There is, to begin with, no law
authorizing an appeal from decisions or orders of the Secretary of Education,
Culture and Sports to this Court or any other Court. It is not the function of
this Court or any other Court to review the decisions and orders of the
Secretary on the issue of whether or not an educational institution meets the
norms and standards required for permission to operate and to continue
operating as such. On this question, no Court has the power or prerogative to
substitute its opinion for that of the Secretary. Indeed, it is obviously not
expected that any Court would have the competence to do so.
The, only authority reposed in the Courts in the matter is the determination of
whether or not the Secretary of Education, Culture and Sports has acted within
the scope of powers granted him by law and the Constitution. As long as it
appears that he has done so, any decision rendered by him should not and will
not be subject to review and reversal by any court.
Of course, if it should be made, to appear to the Court that those powers were
in a case exercised so whimsically, capriciously, oppressively, despotically or
arbitrarily as to call for peremptory correction — or stated otherwise, that the
Secretary had acted with grave abuse of discretion, or had unlawfully
neglected the performance of an act which the law specifically enjoins as a
duty, or excluded another from the use or enjoyment of a right or office to
which such other is entitled — it becomes the Court's duty to rectify such
action through the extraordinary remedies of certiorari, prohibition,
or mandamus, whichever may properly apply. Yet even in these extreme
instances, where a Court finds that there has been abuse of powers by the
Secretary and consequently nullifies and/or forbids such an abuse of power,
or compliance whatever is needful to keep its exercise within bounds, the
Court, absent any compelling reason to do otherwise, should still leave to the
Secretary the ultimate determination of the issue of the satisfy action or
fulfillment by an educational institution of the standards set down for its
legitimate operation, as to which it should not ordinarily substitute its over
judgment for that of said office.
In any case, the recorded facts quite clearly fail to support the College's claim
of grave abuse of discretion containing the order of closure, and on the
contrary convincingly show the challenged decision to be correct. From 1985,
no less than five (5) surveys were conducted of respondent institution to
determine its compliance with the minimum standards established for a
medical college. The, first survey, that undertaken by the Commission on
Medical Education, disclosed such various and significant deficiencies in the
school as to constrain the inspectors to recommend its closure. Four (4) other
surveys were thereafter made by as many different committees or teams, at
the school's instance or otherwise, all of which basically confirmed the results
of that first survey. Moreover, the findings of all five (5) surveys were
affirmed by the Office of the President. Indeed, the petitioner, through the
Chairman of its Board of Trustees, to all intents and purposes accepted the
validity of the findings of those five (5) survey groups when it proposed, in
1988, a gradual phase-out of the school starting in 1989. The, respondent
College knew that the recommendation for its closure was made, as early as
1986, that recommendation was reiterated and reaffirmed four (4) times
thereafter until it was finally approved and acted upon by the Secretary, whose
action was confirmed by the Office of the President. Said respondent was
given notice in June 1988, that in consequence of all these, the time for its
definite closure had been unalterably set at May, 1989, a notice which was
accompanied by assurances of assistance in the relocation of its students
before June, 1989 and in its rehabilitation as a school for other courses. After
having resorted to the whole range of administrative remedies available to it,
without success, it sought to obtain from the respondent Court the relief it
could not obtain from those sources, and what can only be described as a
deliberate attempt to frustrate and obstruct implementation of the decision for
its closure as of June, 1989 openly solicited, by newspaper advertisements or
otherwise, enrollment of new and old students.
Given these facts, and it being a matter of law that the Secretary of Education,
Culture and Sports exercises the power to enjoin compliance with the
requirements laid down for medical schools and to mete out sanctions where
he finds that violations thereof have been committed, it was a grave abuse of
discretion for the respondent judge to issue the questioned injunction and
thereby thwart official action, in the premises correctly taken, allowing the
College to operate without the requisite government permit. A single ocular
inspection, done after the College had been pre-warned thereof, did not, in the
circumstances, warrant only the findings of more qualified inspectors about
the true state of the College, its faculty, facilities, operations, etc. The,
members of the evaluating team came from the different sectors in the fields
of education and medicine, 14 and their judgment in this particular area is
certainly better than that of the respondent Judge whose sole and only visit to
the school could hardly have given him much more to go on than a brief look
at the physical plant and facilities and into the conduct of the classes and other
school activities. Respondent Judge gravely abused his discretion in
substituting his judgment for theirs. It is well-settled doctrine that courts of
justice should not generally interfere with purely administrative and
discretionary functions; that courts have no supervisory power over the
proceedings and actions of the administrative departments of the government;
involving the exercise of judgment and findings of facts, because by reason
of their special knowledge and expertise over matters falling under their
jurisdiction, the latter are in a better position to pass judgment on such matters
andn their findings of facts in that regard are generally accorded respect, if
not finality, by the courts. 15 There are, to be sure, exceptions to this general
rule but none of them obtains in this case.
The, claim of denial of due process likewise holds no water, as the record
clearly shows that the College was given every opportunity to so improve
itself as to come up to requirements, but remained sadly sub-standard after the
inspections conducted by the evaluating teams. It had, in fact, admitted its
failure to have up to the desired standards when it proposed its gradual phase-
out in its letter dated June 27, 1988 to Secretary Quisumbing. It was also
precisely because of its complaints of bias and prejudice that the Board of
Medical Education dispatched new teams to survey and re-evaluate its
performance. It had even gone all the way up to the Office of the President to
seek a reversal of the order of closure. There is thus no reason for it to
complain of a lack of opportunity to be heard and to explain its side as well
as to seek reconsideration of the ruling complained of.
There is also no merit in respondent College's argument that the closure
violated NMCS ORDER No. 5, Series of 1986, because it was sought to be
effected before the lapse of the three-year period therein snowed, which in
this case is sought to be counted from June 18, 1988, or the date of the last
evaluation. The, provision referred to reads:
The following sanction shall be applied against any medical school, for failure
to comply with the specific requirements of the essentials, viz.:
c. Withdrawal or cancellation of the school's government; authority to
operate, for failure to fully comply with the prescribed requirements after
three (3) years from the last evaluation conducted on the school.
It must at once be obvious from a reading of the provision, paragraph c, that
the situation therein contemplated — where a school is found to have failed
to "fully comply with the prescribed requirements," i.e., has not complied with
some requirements and has failed to do so within three (3) years from the last
evaluation is quite distinct from that obtaining in the case at bar — where
respondent school was found to have deficiencies so serious as to warrant its
immediate closure. Said paragraph c should not be construed to prohibit
absolutely the withdrawal or cancellation of government; authority to operate
until after three (3) years from the last evaluation conducted on the school; or,
stated otherwise, it does not unexceptionally prescribe a three-year waiting
period before authority to operate may be withdrawn. Rather, it should be read
as giving the Secretary of Education the discretion, depending on the
seriousness of the discovered deficiencies, to afford an educational institution
which has failed to comply with some requirement or other, time not
exceeding three (3) years to correct the deficiencies before applying the
sanction of withdrawal or cancellation of the government; authority to
operate. The, circumstances in the case at bar are far from nominal and, to
repeat, are different from those obviously envisioned by the paragraph in
question. There had never been a recommendation that the College be granted
an opportunity to comply with certain requirements. From the outset, the
proposal had been that it be forthwith closed, its discovered deficiencies as a
medical college being of so serious a character as to be irremediable. The,
other four (4) surveys were conducted, not to determine if in the course of
time the petitioner school had already fully complied with all the prescribed
requisites, but rather, whether or not the original recommendation for its
closure was correct and should be sustained. And, as already mentioned, the
subsequent surveys, over a period of more than three (3) years, served but to
confirm the validity of that initial proposal for its closure. Under these
circumstances, therefore, even if it be assumed that the provision, paragraph
c, applied to petitioner school, it must be held that there has been substantial
compliance therewith.
Having thus disposed of the issues raised by the facts of the case, the Court
sees no useful purpose to be served by remanding the case to the Trial Court
for further proceedings. The, only acceptable reason for such a remand would
be so that the Trial Court may determine whether or not the petitioners' first
have acted within the scope of their powers or grossly abused them, a matter
that this Court has already passed upon here. Such a remand cannot be
justified on the theory that the Trial Court will make its philosophy
independent determination of whether or not respondent medical institution
has complied with the minimum standards laid down for its continued
operation, since, as here ruled, it has not that power.
WHEREFORE, premises considered, the petition is hereby granted and the
temporary restraining order issued by the Court is made, permanent. The,
questioned writ of preliminary injunction dated May 10, 1989 is set aside and
respondent Judge is ordered to dismiss Civil Case No. 1385.
SO ORDERED.

Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. 78164 July 31, 1987
TERESITA TABLARIN, MA, LUZ CIRIACO, MA NIMFA B.
ROVIRA, EVANGELINA S. LABAO, in their behalf and in behalf of
applicants for admission into the Medical Colleges during the school year
1987-88 and future years who have not taken or successfully hurdled tile
National Medical Admission Test (NMAT).petitioners,
vs.
THE HONORABLE JUDGE ANGELINA S. GUTIERREZ, Presiding
Judge of Branch XXXVII of the Regional Trial Court of the National
Capital Judicial Region with seat at Manila, THE HONORABLE
SECRETARY LOURDES QUISUMBING, in her capacity as Chairman
of the BOARD OF MEDICAL EDUCATION, and THE CENTER FOR
EDUCATIONAL MEASUREMENT (CEM), respondents.
FELICIANO, J.:
The petitioners sought admission into colleges or schools of medicine for the
school year 1987-1988. However, the petitioners either did not take or did not
successfully take the National Medical Admission Test (NMAT) required by
the Board of Medical Education, one of the public respondents, and
administered by the private respondent, the Center for Educational
Measurement (CEM).
On 5 March 1987, the petitioners filed with the Regional Trial Court, National
Capital Judicial Region, a Petition for Declaratory Judgment and Prohibition
with a prayer for Temporary Restraining Order and Preliminary Injunction.
The petitioners sought to enjoin the Secretary of Education, Culture and
Sports, the Board of Medical Education and the Center for Educational
Measurement from enforcing Section 5 (a) and (f) of Republic Act No. 2382,
as amended, and MECS Order No. 52, series of 1985, dated 23 August 1985
and from requiring the taking and passing of the NMAT as a condition for
securing certificates of eligibility for admission, from proceeding with
accepting applications for taking the NMAT and from administering the
NMAT as scheduled on 26 April 1987 and in the future. After hearing on the
petition for issuance of preliminary injunction, the trial court denied said
petition on 20 April 1987. The NMAT was conducted and administered as
previously scheduled.
Petitioners accordingly filed this Special Civil Action for certiorari with this
Court to set aside the Order of the respondent judge denying the petition for
issuance of a writ of preliminary injunction.
Republic Act 2382, as amended by Republic Acts Nos. 4224 and 5946, known
as the "Medical Act of 1959" defines its basic objectives in the following
manner:
Section 1. Objectives. — This Act provides for and shall govern
(a) the standardization and regulation of medical education (b) the
examination for registration of physicians; and (c) the supervision, control
and regulation of the practice of medicine in the Philippines. (Underscoring
supplied)
The statute, among other things, created a Board of Medical Education which
is composed of (a) the Secretary of Education, Culture and Sports or his duly
authorized representative, as Chairman; (b) the Secretary of Health or his duly
authorized representative; (c) the Director of Higher Education or his duly
authorized representative; (d) the Chairman of the Medical Board or his duly
authorized representative; (e) a representative of the Philippine Medical
Association; (f) the Dean of the College of Medicine, University of the
Philippines; (g) a representative of the Council of Deans of Philippine
Medical Schools; and (h) a representative of the Association of Philippine
Medical Colleges, as members. The functions of the Board of Medical
Education specified in Section 5 of the statute include the following:
(a) To determine and prescribe equirements for admission into a recognized
college of medicine;
(b) To determine and prescribe requirements for minimum physical facilities
of colleges of medicine, to wit: buildings, including hospitals, equipment and
supplies, apparatus, instruments, appliances, laboratories, bed capacity for
instruction purposes, operating and delivery rooms, facilities for outpatient
services, and others, used for didactic and practical instruction in accordance
with modern trends;
(c) To determine and prescribe the minimum number and minimum
qualifications of teaching personnel, including student-teachers ratio;
(d) To determine and prescribe the minimum required curriculum leading to
the degree of Doctor of Medicine;
(e) To authorize the implementation of experimental medical curriculum in a
medical school that has exceptional faculty and instrumental facilities. Such
an experimental curriculum may prescribe admission and graduation
requirements other than those prescribed in this Act; Provided, That only
exceptional students shall be enrolled in the experimental curriculum;
(f) To accept applications for certification for admission to a medical school
and keep a register of those issued said certificate; and to collect from said
applicants the amount of twenty-five pesos each which shall accrue to the
operating fund of the Board of Medical Education;
(g) To select, determine and approve hospitals or some departments of the
hospitals for training which comply with the minimum specific physical
facilities as provided in subparagraph (b) hereof; and
(h) To promulgate and prescribe and enforce the necessary rules and
regulations for the proper implementation of the foregoing functions.
(Emphasis supplied)
Section 7 prescribes certain minimum requirements for applicants to medical
schools:
Admission requirements. — The medical college may admit any student who
has not been convicted by any court of competent jurisdiction of any offense
involving moral turpitude and who presents (a) a record of completion of a
bachelor's degree in science or arts; (b) a certificate of eligibility for entrance
to a medical school from the Board of Medical Education; (c) a certificate of
good moral character issued by two former professors in the college of liberal
arts; and (d) birth certificate. Nothing in this act shall be construed to inhibit
any college of medicine from establishing, in addition to the preceding, other
entrance requirements that may be deemed admissible.
xxx xxx x x x (Emphasis supplied)
MECS Order No. 52, s. 1985, issued by the then Minister of Education,
Culture and Sports and dated 23 August 1985, established a uniform
admission test called the National Medical Admission Test (NMAT) as an
additional requirement for issuance of a certificate of eligibility for admission
into medical schools of the Philippines, beginning with the school year 1986-
1987. This Order goes on to state that:
2. The NMAT, an aptitude test, is considered as an instrument toward
upgrading the selection of applicants for admission into the medical schools
and its calculated to improve the quality of medical education in the
country. The cutoff score for the successful applicants, based on the scores on
the NMAT, shall be determined every year by the Board of Medical Education
after consultation with the Association of Philippine Medical Colleges. The
NMAT rating of each applicant, together with the other admission
requirements as presently called for under existing rules, shall serve as a
basis for the issuance of the prescribed certificate of elegibility for admission
into the medical colleges.
3. Subject to the prior approval of the Board of Medical Education, each
medical college may give other tests for applicants who have been issued a
corresponding certificate of eligibility for admission that will yield
information on other aspects of the applicant's personality to complement the
information derived from the NMAT.
xxx xxx xxx
8. No applicant shall be issued the requisite Certificate of Eligibility for
Admission (CEA), or admitted for enrollment as first year student in any
medical college, beginning the school year, 1986-87, without the required
NMAT qualification as called for under this Order. (Underscoring supplied)
Pursuant to MECS Order No. 52, s. 1985, the private respondent Center
conducted NMATs for entrance to medical colleges during the school year
1986-1987. In December 1986 and in April 1987, respondent Center
conducted the NMATs for admission to medical colleges during the school
year 1987.1988.1avvphi1
Petitioners raise the question of whether or not a writ of preliminary
injunction may be issued to enjoin the enforcement of Section 5 (a) and (f) of
Republic Act No. 2382, as amended, and MECS Order No. 52, s. 1985,
pending resolution of the issue of constitutionality of the assailed statute and
administrative order. We regard this issue as entirely peripheral in nature. It
scarcely needs documentation that a court would issue a writ of preliminary
injunction only when the petitioner assailing a statute or administrative order
has made out a case of unconstitutionality strong enough to overcome, in the
mind of the judge, the presumption of constitutionality, aside from showing a
clear legal right to the remedy sought. The fundamental issue is of course the
constitutionality of the statute or order assailed.
1. The petitioners invoke a number of provisions of the 1987 Constitution
which are, in their assertion, violated by the continued implementation of
Section 5 (a) and (f) of Republic Act 2381, as amended, and MECS Order No.
52, s. 1985. The provisions invoked read as follows:
(a) Article 11, Section 11: "The state values the dignity of every human person
and guarantees full respect of human rights. "
(b) ArticleII, Section l3: "The State recognizes the vital role of the youth in
nation building and shall promote and protect their physical, moral, spiritual,
intellectual and social well being. It shall inculcate in the youth patriotism and
nationalism, and encourage their involvement in public and civic affairs."
(c) Article II, Section 17: "The State shall give priority to education, science
and technology, arts, culture and sports to foster patriotism and nationalism,
accelerate social progress and to promote total human liberation and
development. "
(d) Article XIV, Section l: "The State shall protect and promote the right of
all citizens to quality education at all levels and take appropriate steps to make
such education accessible to all. "
(e) Article XIV, Section 5 (3): "Every citizen has a right to select a profession
or course of study, subject to fair, reasonable and equitable admission and
academic requirements."
Article II of the 1987 Constitution sets forth in its second half certain "State
policies" which the government is enjoined to pursue and promote. The
petitioners here have not seriously undertaken to demonstrate to what extent
or in what manner the statute and the administrative order they assail collide
with the State policies embodied in Sections 11, 13 and 17. They have not, in
other words, discharged the burden of proof which lies upon them. This
burden is heavy enough where the constitutional provision invoked is
relatively specific, rather than abstract, in character and cast in behavioral or
operational terms. That burden of proof becomes of necessity heavier where
the constitutional provision invoked is cast, as the second portion of Article
II is cast, in language descriptive of basic policies, or more precisely, of basic
objectives of State policy and therefore highly generalized in tenor. The
petitioners have not made their case, even a prima facie case, and we are not
compelled to speculate and to imagine how the legislation and regulation
impugned as unconstitutional could possibly offend the constitutional
provisions pointed to by the petitioners.
Turning to Article XIV, Section 1, of the 1987 Constitution, we note that once
more petitioners have failed to demonstrate that the statute and regulation they
assail in fact clash with that provision. On the contrary we may note-in
anticipation of discussion infra — that the statute and the regulation which
petitioners attack are in fact designed to promote "quality education" at the
level of professional schools. When one reads Section 1 in relation to Section
5 (3) of Article XIV as one must one cannot but note that the latter phrase of
Section 1 is not to be read with absolute literalness. The State is not really
enjoined to take appropriate steps to make quality education " accessible
to all who might for any number of reasons wish to enroll in a professional
school but rather merely to make such education accessible to all who qualify
under "fair, reasonable and equitable admission and academic requirements.
"
2. In the trial court, petitioners had made the argument that Section 5 (a) and
(f) of Republic Act No. 2382, as amended, offend against the constitutional
principle which forbids the undue delegation of legislative power, by failing
to establish the necessary standard to be followed by the delegate, the Board
of Medical Education. The general principle of non-delegation of legislative
power, which both flows from the reinforces the more fundamental rule of the
separation and allocation of powers among the three great departments of
government,1 must be applied with circumspection in respect of statutes
which like the Medical Act of 1959, deal with subjects as obviously complex
and technical as medical education and the practice of medicine in our present
day world. Mr. Justice Laurel stressed this point 47 years ago in Pangasinan
Transportation Co., Inc. vs. The Public Service Commission:2
One thing, however, is apparent in the development of the principle of
separation of powers and that is that the maxim of delegatus non potest
delegare or delegate potestas non potest delegare, adopted this practice
(Delegibus et Consuetudiniis Anglia edited by G.E. Woodbine, Yale
University Press, 1922, Vol. 2, p. 167) but which is also recognized in
principle in the Roman Law (d. 17.18.3) has been made to adapt itself to the
complexities of modern government, giving rise to the adoption, within certain
limits of the principle of "subordinate legislation," not only in the United
States and England but in practically all modern governments. (People vs.
Rosenthal and Osmena [68 Phil. 318, 1939]. Accordingly, with the growing
complexity of modern life, the multiplication of the subjects of governmental
regulation and the increased difficulty of administering the laws, there is a
constantly growing tendency toward the delegation of greater power by the
legislature, and toward the approval of the practice by the courts." 3
The standards set for subordinate legislation in the exercise of rule making
authority by an administrative agency like the Board of Medical Education
are necessarily broad and highly abstract. As explained by then Mr. Justice
Fernando in Edu v. Ericta4 —
The standard may be either expressed or implied. If the former, the non-
delegation objection is easily met. The standard though does not have to be
spelled out specifically. It could be implied from the policy and purpose of the
act considered as a whole. In the Reflector Law, clearly the legislative
objective is public safety. What is sought to be attained as in Calalang v.
Williams is "safe transit upon the roads. 5
We believe and so hold that the necessary standards are set forth in Section 1
of the 1959 Medical Act: "the standardization and regulation of medical
education" and in Section 5 (a) and 7 of the same Act, the body of the statute
itself, and that these considered together are sufficient compliance with the
requirements of the non-delegation principle.
3. The petitioners also urge that the NMAT prescribed in MECS Order No.
52, s. 1985, is an "unfair, unreasonable and inequitable requirement," which
results in a denial of due process. Again, petitioners have failed to specify just
what factors or features of the NMAT render it "unfair" and "unreasonable"
or "inequitable." They appear to suggest that passing the NMAT is an
unnecessary requirement when added on top of the admission requirements
set out in Section 7 of the Medical Act of 1959, and other admission
requirements established by internal regulations of the various medical
schools, public or private. Petitioners arguments thus appear to relate to utility
and wisdom or desirability of the NMAT requirement. But constitutionality
is essentially a question of power or authority: this Court has neither
commission or competence to pass upon questions of the desirability or
wisdom or utility of legislation or administrative regulation. Those questions
must be address to the political departments of the government not to the
courts.
There is another reason why the petitioners' arguments must fail: the
legislative and administrative provisions impugned by them constitute, to the
mind of the Court, a valid exercise of the police power of the state. The police
power, it is commonplace learning, is the pervasive and non-waivable power
and authority of the sovereign to secure and promote an the important interests
and needs — in a word, the public order — of the general community.6 An
important component of that public order is the health and physical safety and
well being of the population, the securing of which no one can deny is a
legitimate objective of governmental effort and regulation.7
Perhaps the only issue that needs some consideration is whether there is some
reasonable relation between the prescribing of passing the NMAT as a
condition for admission to medical school on the one hand, and the securing
of the health and safety of the general community, on the other hand. This
question is perhaps most usefully approached by recalling that the regulation
of the practice of medicine in all its branches has long been recognized as a
reasonable method of protecting the health and safety of the public.8 That the
power to regulate and control the practice of medicine includes the power to
regulate admission to the ranks of those authorized to practice medicine, is
also well recognized. thus, legislation and administrative regulations
requiring those who wish to practice medicine first to take and pass medical
board examinations have long ago been recognized as valid exercises of
governmental power.9 Similarly, the establishment of minimum medical
educational requirements — i.e., the completion of prescribed courses in a
recognized medical school — for admission to the medical profession, has
also been sustained as a legitimate exercise of the regulatory authority of the
state.10 What we have before us in the instant case is closely related: the
regulation of access to medical schools. MECS Order No. 52, s. 1985, as
noted earlier, articulates the rationale of regulation of this type: the
improvement of the professional and technical quality of the graduates of
medical schools, by upgrading the quality of those admitted to the student
body of the medical schools. That upgrading is sought by selectivity in the
process of admission, selectivity consisting, among other things, of limiting
admission to those who exhibit in the required degree the aptitude for medical
studies and eventually for medical practice. The need to maintain, and the
difficulties of maintaining, high standards in our professional schools in
general, and medical schools in particular, in the current stage of our social
and economic development, are widely known.
We believe that the government is entitled to prescribe an admission test like
the NMAT as a means for achieving its stated objective of "upgrading the
selection of applicants into [our] medical schools" and of "improv[ing] the
quality of medical education in the country." Given the widespread use today
of such admission tests in, for instance, medical schools in the United States
of America (the Medical College Admission Test [MCAT]11 and quite
probably in other countries with far more developed educational resources
than our own, and taking into account the failure or inability of the petitioners
to even attempt to prove otherwise, we are entitled to hold that the NMAT is
reasonably related to the securing of the ultimate end of legislation and
regulation in this area. That end, it is useful to recall, is the protection of 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.
4. Petitioners have contended, finally, that MECS Order No. 52, s. 1985, is in
conflict with the equal protection clause of the Constitution. More
specifically, petitioners assert that that portion of the MECS Order which
provides that
the cutoff score for the successful applicants, based on the scores on the
NMAT, shall be determined every-year by the Board of Medical 11
Education after consultation with the Association of Philippine Medical
Colleges. (Emphasis supplied)
infringes the requirements of equal protection. They assert, in other words,
that students seeking admission during a given school year, e.g., 1987-1988,
when subjected to a different cutoff score than that established for an, e.g.,
earlier school year, are discriminated against and that this renders the MECS
Order "arbitrary and capricious." The force of this argument is more apparent
than real. Different cutoff scores for different school years may be dictated by
differing conditions obtaining during those years. Thus, the appropriate cutoff
score for a given year may be a function of such factors as the number of
students who have reached the cutoff score established the preceding year; the
number of places available in medical schools during the current year; the
average score attained during the current year; the level of difficulty of the
test given during the current year, and so forth. To establish a permanent and
immutable cutoff score regardless of changes in circumstances from year to
year, may wen result in an unreasonable rigidity. The above language in
MECS Order No. 52, far from being arbitrary or capricious, leaves the Board
of Medical Education with the measure of flexibility needed to meet
circumstances as they change.
We conclude that prescribing the NMAT and requiring certain minimum
scores therein as a condition for admission to medical schools in the
Philippines, do not constitute an unconstitutional imposition.
WHEREFORE, the Petition for certiorari is DISMISSED and the Order of the
respondent trial court denying the petition for a writ of preliminary injunction
is AFFIRMED. Costs against petitioners.
SO ORDERED.

Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. L-22945 March 3, 1925
THE PEOPLE OF THE PHILIPPINE ISLANDS, plaintiff-appellee,
vs.
JOVITA V. BUENVIAJE, defendant-appellant.
Francisco and Lualhati and Ariston Rivera for appellant.
Attorney-General Villa-Real for appellee.
OSTRAND, J.:
The defendant is accused of the violation of the Medical Act, the information
alleging "that on or about the first day of June, 1923, and for some time prior
to said date, the said accused without having obtained from the Board of
Medical Examiners the corresponding certificate of registration for the
practice of medicine in the Philippine Islands, voluntarily, illegally and
criminally and for compensation, practiced medicine in the City of Manila,
Philippine Islands, assisting, treating and manipulating the head and body of
Regino Noble for the purpose of curing him of the ailments, diseases, pains
and physical defects from which he pretended to suffer, and advertising and
offering her services as a physician, by means of cards which she distributed
and by letterheads and signs which she exposed on the door of her office,
situated at No. 712 Calle Asuncion, and in newspapers which are published
and circulated in the City of Manila, in which cards, letterheads, signs and
advertising she added and prefixed to her name the letters `Dra.,' which is the
abbreviation of the word `doctor,' for the purpose of causing the public to
believe that she, the said defendant, had received the corresponding title of
doctor."
To this information the defendant demurred in the court below on the grounds:
(1) That it stated more than one offense, and (2) that it was not drawn in
accordance with the form prescribed by law. The demurrer was overruled and
the defendant pleaded not guilty.
At the trial of the case the defendant made the following admissions: "That
on the first of June, 1923, she had no certificate from the Board of Medical
Examiners authorizing her to practice medicine in the Philippine Islands; that
on that day she treated and manipulated the head and body of Regino Noble
in order to cure him of ailments from which he pretended to suffer, the
treatment consisting in a `thrust' by means of the application of the hand to
the spinal column; that she for such treatment received and collected from
said Regino Noble the sum of P1; that the said treatment took place in her
office situated at No. 712 Calle Asuncion, District of Binondo, City of Manila,
Philippine Islands; that she on or about the first day of June, 1923, and for
some time prior to that date, advertised herself as a `doctor of chiropractic,' in
said City of Manila, said advertisement appearing upon her business cards and
in the newspaper `El Debate,' in its issue of April 29, 1923, edited and
published in Manila and in which cards and newspaper advertisement the
defendant prefixed the abbreviation `Dra.' to her name; that she was graduated
a doctor in chiropractic on the 13th day of August, 1919, as evidenced by a
certificate marked Exhibit I and issued by the American University School of
Chiropractic of Chicago, Illinois."
Upon this admission and some other evidence to the same effect, the trial
court found the defendant guilty as charged in the information and, in
accordance with section 2678 of the Administrative Code, sentenced her to
pay a fine of P300, with subsidiary imprisonment in case of insolvency and
to pay the costs. From this judgment the defendant appeals to this court and
presents four assignments of error.
I. In the first assignment of error counsel contends that the demurrer to the
information should have been sustained on the ground that said information
charged more than one offense. The Medical Law is contained in sections 758
to 783 of the Administrative Code and it is argued that inasmuch as some of
the illegal acts with which the defendant is charged are prohibited by section
770 of the Code and others by section 783, the defendant is in reality accused
of two separate and distinct offenses, namely, illegal practice of medicine and
illegally representing oneself as a doctor.
We cannot accept this view. It may be noted that the Medical Law itself, as it
appears in the Administrative Code, does not declare any of the therein
prohibited acts penal offenses. The penal provisions relating thereto are
contained in section 2678 of the Code, which reads as follows:
SEC. 2678. Violation of Medical Law. — A person violating any provision of
the Medical Law shall, upon conviction, be punished by a fine of not more
than three hundred pesos or by imprisonment for not more than ninety days,
or both, in the discretion of the court.
The offense here penalized is "violation of the Medical Law." The statute
makes no distinction between illegal practice of medicine and illegally
advertising oneself as a doctor. Both are in violation of the Medical Law and
carry the same penalty. They are merely different ways or means of
committing the same offense and both of these means are closely related to
each other and usually employed together.
In these circumstances and where, as alleged in the information in the present
case, the various violations have taken place simultaneously, we do not think
it was the intention of the legislator that each single act should be regarded as
a separate offense and separate informations presented for each. The language
of this court in the case of United States vs. Poh Chi (20 Phil., 140), in regard
to the Opium Law, is opposite to the present case.
It is true that the Commission has provided a certain punishment for the
possession of a pipe used in the smoking of opium, for the smoking of opium,
as well as a punishment for the illegal possession of opium, but it is not
believed that it was the intention of the legislature to have separate complaints
filed against a person who was found in the illegal possession of opium and a
pipe at the same time. If that were true then every person who was found to
be smoking opium could be charged in three different complaints: First, with
the illegal possession of the pipe; second, the illegal possession of the opium;
and third, for smoking the opium. Certainly the legislature did not intend any
such consequences.
In the case of United States vs. Douglass (2 Phil., 461), the court said:
It is not objectionable, when a single offense may be committed by the use of
different means, to charge, in the alternative, the various means by which the
crime may have been committed. (U.S. vs. Potter, 27 Fed. Cases, 604;
Bishop's New Criminal Procedure, sec. 434.)
The same rule was followed in the case of United States vs. Dorr (2 Phil.,
332); United States vs. Tolentino (5 Phil., 682); and United States vs. Gustilo
(19 Phil., 208) and is in harmony with the views of the courts in other
jurisdictions. That the various means of committing the offense is described
in more than one section of the statute does not necessarily effect the general
principle involved; the subdivision of a statute into section is merely a matter
of convenience and while it sometimes may be of some aid in ascertaining the
legislative intent, it is, of course, not conclusive thereof.
II. Under the second assignment of error the appellant argues in substance that
chiropractic has nothing to do with medicine and that the practice of that
profession can therefore not be regarded as practice of medicine. There is no
merit whatever in this contention. Assuming without conceding that
chiropractic does not fall within the term "practice of medicine" in its ordinary
acceptation, we have the statutory definition contained in section 770 of the
Administrative Code and which clearly includes the manipulations employed
in chiropractic. The statutory definition necessarily prevails over the ordinary
one.
Under the same assignment of error the defendant also argues that the
examination prescribed by section 776 of the Administrative Code for
admission to the practice of medicine, embraces subjects which have no
connection with chiropractic and that to require chiropractors to take that
examination is unreasonable and, in effect amounts to prohibition of the
practice of their profession and therefore violates the constitutional principle
that all men have the right to life, liberty and the pursuit of happiness and are
entitled to the equal protection of the law.
There is very little force in this argument. The subjects in which an
examination is required by section 778 of the Administrative Code, as
amended by Act No. 3111, relate to matters of which a thorough knowledge
seems necessary for the proper diagnosis of diseases of the human body and
it is within the police power of the State to require that persons who devote
themselves to the curing of human ills should possess such knowledge.
(State vs. Edmunds, 127 Iowa, 333; 69 L.R.A., 504; Underwood vs. Scott, 43
Kan., 714; People vs. Blue Mountain Joe, 129 Ill., 370; State vs. Mylod, 20 R.
I., 632; 41 L.R.A., 428; Stewart vs. Raab, 55 Minn., 20; Matthei vs. Wooley,
69 Ill. App., 654; State vs. Buswell, 40 Neb., 158; 24 L.R.A., 68; O'Connor vs.
State, 46 Neb., 157; U. S. vs. Gomez Jesus, 31 Phil., 218.)
III. The third assignment of error is closely related to the foregoing. The
appellant contends that the prohibition in section 783 against the unauthorized
use of the title "doctor" must be understood to refer to "Doctor of Medicine"
and has no application to doctors of chiropractic. Under different
circumstances that might possibly be so, but where, as here, chiropractic is by
statute made a form of the practice of medicine, it necessarily follows that a
person holding himself out as a doctor of chiropractic in legal effect represents
himself as a doctor of medicine.
IV. In her fourth assignment of error the appellant attacks the constitutionality
of Act No. 3111, amending section 770 of the Administrative Code, on the
ground that the subject of the Act is not sufficiently expressed in its title and
that it embraces more than one subject. There is no merit in this contention.
The title of Act No. 3111 reads as follows:
An Act to amend sections seven hundred and fifty-nine, seven hundred and
sixty, seven hundred and sixty-one, seven hundred and sixty-two, seven
hundred and sixty-five, seven hundred and sixty-seven, seven hundred and
seventy, seven hundred and seventy-four, seven hundred and seventy-five,
seven hundred and seventy-six, seven hundred and seventy-eight, seven
hundred and eighty, seven hundred and eighty-two, seven hundred and eighty-
three, and twenty-six hundred and seventy-eight of Act Numbered Twenty-
seven hundred and eleven, known as the Administrative Code, increasing the
number of the members of the Board of Medical Examiners, conferring upon
the same certain additional powers and responsibilities and for other purposes.
All of the sections enumerated in the title quoted relate to the same general
subject, namely, defining and regulating the practice of medicine, and section
770 is expressly mentioned as one of the sections amended.
This is sufficient. Under constitutional provisions similar to ours the general
rule is that a title which declares the amendatory statute to be an act to amend
a designated section or the like of a specified Code is sufficient and the precise
nature of the amendatory Act need not be further stated. (Ross vs. Aguirre,
191 U.S., 60; Udell vs. Citizens Street R. Co., 152 Ind., 507; McGuire vs.
Chicago, etc., R. Co., 131 Iowa, 340; Lankford vs. County Commissioners of
Somerset County, 73 Md., 105; Tabor vs. State, 34 Tex. Crim., 631; Com. vs.
Brown, 91 Va., 762.) For a full and authoritative discussion of this subject,
see Note to Lewis vs. Dunne, 55 L.R.A., 833. See also Government of the
Philippine Islands vs. Municipality of Binalonan and Roman Catholic Bishop
of Nueva Segovia (32 Phil., 634) and Yu Cong Eng vs. Trinidad (p.
385, ante).
We find no error in the judgment appealed from and the same is therefore
affirmed, with the costs against the appellant. So ordered.
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. Nos. 78813-14 November 8, 1993
PEOPLE OF THE PHILIPPINES, plaintiff-appellee,
vs.
FARHAD HATANI y ABOLHASSAN, accused-appellant.
QUIASON, J.:
This is an appeal from the decisions of the Regional Trial Court, Branch 105,
Quezon City, convicting appellant in Criminal Cases No. Q-11867 and No.
Q-11868.
The dispositive portion of the decision in Criminal Case No. Q-11867 reads
as follows:
WHEREFORE, premises considered, the Court finds the accused Farhad
Hatani y Abolhassan, GUILTY beyond reasonable doubt of illegal practice of
medicine in violation of R.A. 2382 otherwise known as the Medical Act of
1959 (Secs. 8, 10) penalized by Section 28 thereof with "a fine of not less than
one thousand pesos nor more than ten thousand pesos with subsidiary
imprisonment in case of insolvency, or by imprisonment of not less than one
year nor more than five years, or by both such fine and imprisonment, in the
discretion of the court; and considering the circumstances of the case and the
ignominy caused by him to his two teen-aged, female, then unmarried victims,
this Court exercising its discretion granted under said Section 28 of the law,
hereby SENTENCES said accused FARHAD HATANI Y ABOLHASSAN
to pay a fine of ten thousand pesos (P10,000.00) with subsidiary
imprisonment in case of insolvency AND to suffer imprisonment of five (5)
years; and to pay the costs.
This Court further recommends that after service of his sentence the accused
be deported as undesirable alien (Rollo, p. 35).
The dispositive portion of the decision in Criminal Case No. Q-11868 reads
as follows:
WHEREFORE, premises considered, the Court finds the accused, FARHAD
HATANI y ABOLHASSAN, GUILTY beyond reasonable doubt of the crime
of rape punishable under Article 335 of the Revised Penal Code and hereby
SENTENCES said accused to suffer life imprisonment or reclusion perpetua;
and to indemnify the complainant, Precila Borja, in the sum of fifty thousand
pesos (P50,000.00) and to pay costs (Rollo, p. 41).
The information in Criminal Case No. Q-11867 charged appellant with illegal
practice of medicine, in violation of R.A. No. 2382, otherwise known as the
Medical Act of 1959, committed as follows:
That on or about the 6th day of July, 1979, in Quezon City, Philippines the
above named accused, knowing fully well that he has not satisfactorily passed
the corresponding Board Examination, neither is he a holder of a valid
Certificate of Registration duly issued by the Board of Medical Examiners, as
in fact he does not even appear to have taken or completed the course leading
to a medical degree, did, then and there, willfully, unlawfully and feloniously
for compensation, fee and salary, paid to him directly, physically examined
Priscila (sic) Borja Y Loquero and Wilma Borja Y Loquero, diagnosed,
treated and administer injections on the persons of Prescila (sic) Borja Y
Loquero and Wilma Borja Y Loquero, in Violation of Section 10, in relation
to Section 28, Republic Act No. 2382 (Records, Vol. I, p. 1).
The information in Criminal Case No. Q-11868, charged appellant with Rape,
committed as follows:
That on or about the 6th day of July, 1979, in Quezon City, Philippines, the
above-named accused, with lewd designs, and while she was deprived of
reason or unconscious after having been drugged or administered medicine,
did, then and there, willfully, unlawfully and feloniously have sexual
intercourse with the undersigned PRECILA BORJA Y LOQUERO without
her consent and against her will, to her damage and prejudice in such amount
as may be awarded under the provisions of the Civil Code (Records, Vol. II,
p. 1).
It appears that in the morning of July 6, 1979, Agustina Borja visited
her comadre, Maura Fontreras, and requested malunggay leaves as
medication for her 16-year old daughter, Precila, who had high fever and
loose bowel movement. Upon learning that Precila was sick, Marita, Maura's
daughter, introduced Agustina to her husband, appellant herein, whom she
said was a medical doctor. Marita suggested that her husband treat Precila and
Agustina agreed.
Appellant and Marita went to the Borja residence, where he examined Precila.
He gave her tablets to take and administered two injections (to her), one in
the morning and the second at noon. After each injection, Precila would feel
dizzy and fall asleep.
It was appellant's diagnosis that Precila was a drug addict and required further
observation and treatment. Appellant offered to attend to Precila at his house
and again, Agustina agreed in the belief that her daughter was a drug addict.
In the evening of the same day, Precila was fetched by appellant and Marita
and was brought to appellant's house. Again, Precila was given an injection
which caused her to sleep. When she awoke, she realized that she was naked
and her entire body was in pain. Appellant was seated on the bed and was
fondling her private parts. Shocked, Precila called for her mother and tried to
get up. Appellant, however, punched her on the chest and forced her to lie
down. He pressed a pillow on her face and injected her again, causing her to
fall asleep.
When Precila awoke the second time, she found appellant in bed with her. He
was naked and fondling her private parts. The pain all over her body lingered.
When Precila touched her private parts, she saw blood stains on her hand. She
tried to stand up but she was too weak. Appellant gave her another injection
rendering her unconscious.
The following morning, Agustina went to fetch Precila. Upon reaching the
Fontreras' residence, she went straight to the bedroom, where, to her great
dismay, she found Precila and appellant both asleep and naked. She hurriedly
dressed up Precila and brought her home.
When Precila woke up, she noticed she was already home and her mother was
crying. Precila remained dizzy, with throbbing pains all over her body. When
talked to, she was incoherent.
That evening, Precila's oldest sister, Josefina, a nurse by profession, came
home and saw Precila looking very weak. Her mother, who was crying
narrated what she had witnessed that morning. She also told Josefina that
appellant was in the other bedroom, treating another sister, Wilma whom he
also diagnosed as a drug addict. Josefina immediately proceeded to the
bedroom and saw appellant about to inject Wilma.
Josefina saw the open bag of appellant, which contained empty capsules of
dalmane and empty vials of valium. She inquired on the need of the injection
and appellant replied that a second shot of plain distilled water was required
to cure Wilma of her drug addiction. Josefina told appellant to stop but he
persisted. Only upon threat that she would call the police did appellant stop.
Appellant and his wife then left the Borja residence.
The following day, Agustina and Josefina brought Precila and Wilma to the
Philippine Constabulary Headquarters at Camp Crame, Quezon City, where
Josefina and Wilma gave their statements (Exhs. "D" and "F"). Precila was
physically examined by a doctor, whose medical report stated that Precila's
hymen and "deep, healing lacerations" and that "subject is in non-virgin state
physically" (Exh. A). Several needle puncture marks were also found on
Precila's arms and buttocks.
A physical examination was likewise done on Wilma, which showed that she
too had a needle puncture, as shown in the Medico-Legal Report (Exh. "L").
Acting on the complaint filed before the Constabulary Anti-Narcotics Unit
(CANU), a surveillance of appellant's residence was conducted.
Subsequently, a search warrant was secured from Judge Jose P. Castro of the
Court of First Instance of Quezon City. Armed with the warrant, CANU
agents raided appellant's residence on July 15, 1979.
Assorted drugs, such as dalmane, valium and mogadon, as well as prescription
pads in the name of Dr. Jesus Yap (Exhs. "H" "H-4") and other medical
instruments, such as a "thermometer, a "hygomonometer (sic), stethoscope,
syringes and needles, were seized.
The Handwriting Identification Report (Exh. "I") on the prescription slips
showed that these were written by the appellant himself. The report on the
chemistry examination of the seized tablets and capsules (Exhs. "J" "J-1")
confirmed the presence of mogadon, dalmane and valium.
After the preliminary investigation, separate informations for rape and
violation of R.A. No. 2382 were filed. Appellant pleaded not guilty to both
crimes.
The defense's version is that in the evening of July 6, 1976, Agustina and
Precila Borja visited the mother-in-law of the appellant, Maura Fontreras. In
the course of the conversation, Agustina asked Marita if she could help
Precila. Marita obliged and agreed to take care of Precila for the night and
allow her to sleep in her bedroom.
Precila and Marita chatted the whole night. Accordingly, Precila confessed
that she was not really sick. She merely related her personal problems,
involving her parents. She also admitted her vice, such as drinking, smoking
and taking drugs.
Their talk lasted until the wee hours of the morning and during their
conversation, appellant would occasionally enter the room but he never joined
their discussion.
Precila and Marita shared the same bed. Appellant; who was wearing only his
pajama pants, slept on the floor at the opposite end of the room.
The following morning Agustina arrived and Marita related some of Precila's
problems. Nothing untoward happened that day and Agustina headed for
home while Precila and Marita followed later.
At past midnight of July 15, 1979, a raid was conducted by CANU agents in
the house of the appellant under the supervision of C1C Agustin Timbol, Jr.
The raid was made upon Josefina's complaint for illegal possession of drugs.
Appellant and his wife were driven out of their bedroom, while three-men
remained. Later, appellant was called to join them in the bedroom and he was
shocked to see assorted drugs scattered around. Appellant denied owning
them. Photographs were taken of him with the drugs. A barangay official was
called to attest to the list of the confiscated drugs. Appellant, however, refused
to sign the said list.
C1C Timbol offered to fur the case in exchange of money. Instead of
acceding, appellant demanded to see the search warrant. C1C Timbol failed
to show a warrant on the pretext that they were military men without need of
any identification or search warrant. Appellant, his wife and brother-in-law
were forced to join C1C Timbol for questioning in Camp Crame. Upon
boarding the van, appellant saw Josefina aboard kissing C1C Timbol and both
exchanged victory signs.
The trial court rendered two separate decisions and convicted the appellant of
both crimes. In finding appellant guilty of illegal purchase of medicine,
considerable weight was given to the prosecution's exhibits.
The Professional Regulation Commission certified that appellant is not
among the list of registered physicians nor among those with special permit
to practice medicine in a limited scope (Exh. "K").
Appellant failed to refute the Handwriting Identification Report (Exh. "I")
released by the PC Crime Laboratory showing that the signature of Dr. Jesus
D. Yap (Exhs. "H" — "H-4") prescribing medicine belonged to him. The
pictures also taken during the raid (Exhs. "G" - "G-8'" undeniably reveal
several medical equipment used by practicing physicians.
Notwithstanding the trial court's finding that there was no direct evidence of
rape, it concluded that circumstantial evidence indicate that rape was
consummated by appellant considering the following:
1. The medico-legal examination of victim Precila, taken on July 8, 1979 at
10:25 in the morning or less than 48 hours from the evening of July 6, 1979
found "hymen with deep, healing lacerations at 4, 6 and 9 o'clock position";
thus indicating that the lacerations were recent as they are in the process of
healing; (Exh. "A-1")
2. The above undeniable findings of the expert confirms the statement of the
victim, a young girl of 16 or 17 years of age, that when she held private parts
which were painful then, she noticed blood. (tsn. Alma, Feb. 9, 1984, pp. 4-
5).
The fresh laceration of the hymen further confirms the carnal assault. (People
vs. Ocampo, L-47335, Aug. 13, 1986)
3. In the two short waking moments of the victim she noticed she was naked
and beside her on the same bed was the accused, also naked. (tsn. Alma, Feb.
9, 1984, pp. 3-5)
4. The accused, then 21 years of age was in the prime of youth, and the
unconscious girl beside him was just 16 or 17 years of age, thus in the full
bloom of womanhood. The sexual excitement on the part of the accused was
therefore exceedingly great.
5. When the mother, Agustina, came into the room of the accused that early
morning of July 7, 1979 she saw her daughter and the accused on the same
bed and both naked. (tsn., Rogato, Jan. 27, 1981, p. 9)
6. The medico-legal found several needle puncture marks on the arms and
buttocks of Precila (Exh. "A"); thus confirming Precila's testimony that she
had been injected by the accused, rendering her unconscious (tsn. Alma, Feb.
9, 1984, pp. 4-5; tsn., Nenita, May 21, 1984, pp. 3-6; also pp. 29-30).
7. The medico-legal found the victim "in non-virgin state physically." (Exh;
"A-i")
8. At the time of the medico-legal examination, i.e. morning of July 8, 1979,
the victim was found to be "incoherent." (Exh. A) — after effect of the
injections or drugs.
9. At the time of the incident (July 6, 1979) the Borjas and Frontreras (sic)
were "comadres" and neighbors. There is no enmity between and among
them.
10. Between accused and Marita on one hand, and the victim, her mother, and
sisters, on the other hand, there was no misunderstanding before the incident.
There is absolutely absence of any ulterior motive for the teen-aged victim or
her family to file the serious charge of rape which would expose her to
embarrassment of examination of her private parts and public trial (Rollo, pp.
38-39).
In his first assignment of error, appellant questions the credibility of the
prosecution witnesses.
Appellant faults complainant for recounting her ordeal only after four years
when she took the witness stand. This argument is misleading. The record
shows that the day after the rape, Josefina and Wilma Borja, accompanied by
their mother, Agustina, issued their statements at Camp Crame. Agustina gave
her statement twice on separate days. Precila did not give any statement due
to her weak condition but it cannot be denied that she was instead physically
examined. Suffice it to say, the Medico Legal Report (Exh. "A") indicates
swellings and lacerations and concludes that Precila was no longer a virgin.
Although the records fail to show any sworn statement by Precila, such is not
fatal where the sworn affidavits of her mother, her two sisters and the medico-
legal report are sufficient to show probable cause of rape (People v. Yambao,
193 SGRA 571 [1991]).
Precila was either dizzy or unconscious at the time she was sexually abused.
We find her testimony consistent and credible. While her testimony is limited
to the times when she would gain her consciousness, it is not unlikely that
such traumatic incidents would still be engraved on her mind even four years
after.
Appellant's assertion that Precila failed to inform her family of his misdeeds
is explainable. As correctly pointed out by the Solicitor General, Precila was
still dizzy and incoherent as a consequence of the injections administered by
appellant. In fact, when Precila was physically examined by the doctor the
day after, she was still sleepy and groggy (TSN, March 31, 1980, pp. 7-8).
Appellant also finds it strange that considering the acts allegedly committed
by him against Precila, the medico-legal report fails to specify any injuries on
the body of Precila. Appellant need not inflict heavy blows on Precila for the
simple reason that she was under sedation. The absence of the injuries does
not negate the commission of rape (People v. Torrevillas, 203 SCRA 576
[1991]; People v. Arenas, 198 172 [1991]) for rape may be committed after
rendering a woman unconscious (Art. 335, Revised Penal Code; People v.
Gerones, 193 SCRA 263 [1991]).
Appellant alleges that Precila was no longer a virgin on that fateful day and
that her bleeding was actually the start of her menstrual cycle. It is settled
jurisprudence that virginity is not an essential element of rape (People v.
Corro, 197 SCRA 121 [1991]; People v. Banayo, 195 SCRA 543 [1991]). To
claim that Precila's menstrual cycle began on that day is highly speculative.
Appellant claims that the sworn statements of the Borjas (Exhs. "D", "E" and
"F") were antedated and were prepared after the illegal search was conducted
in his residence. He also cites some inconsistencies in said statements. We
find the claim to be devoid of merit. It is only now on appeal that appellant
disputes the execution of these affidavits. When they were presented and
offered as evidence, appellant failed to raise such objections and to refute
them.
The alleged inconsistencies in the testimony of the prosecution witnesses
merely refer to minor details, which cannot destroy their credibility (People
v. Doctolero, 193 SCRA 632 [1991]). This is also true where statements made
while on the witness stand are claimed to be inconsistent with the affidavit,
which are generally incomplete (People v. Lagota, 194 SCRA 92 [1991];
People v. Avanzado, 158 SCRA 427 [1988]).
With regard to the second assignment of error, appellant insists that his
conviction arose from insufficient evidence and his failure to prove his
innocence.
Indeed, the circumstantial evidence established at the trial are more than
sufficient to prove the guilt of appellant. The Medico-Legal Report on Precila,
taken within 48 hours from the commission of rape confirmed that her hymen
had "deep, healing lacerations at 4, 6 and 9 o'clock position" and Precila was
"in non-virgin state physically" (Exh. "A"). Furthermore, the report confirms
that Precila had at least six needle puncture marks and swellings, which
confirm that appellant had injected her several times.
On the two occasions that Precila woke up, she positively stated that appellant
was with her on the bed and that they were both naked. She also tried to free
herself on both attempts from accused, but, he made her unconscious through
injections (TSN, February 9, 1984, pp. 3-5). This is corroborated by the
testimony of Agustina, who saw her daughter and accused together naked on
bed (TSN, January 27, 1981, p. 9). These unbroken chain of events leads one
to a fair and reasonable conclusion that accused actually raped Precila.
As held in People v. Yambao, supra, credence is given to the findings of the
trial court where the rape victim's testimony is buttressed by the corroborative
testimony of the mother and the medico-legal report, as well as the report of
the police investigator.
It must also be borne in mind that at the time of the commission of the crime,
Precila was just sixteen years old. No young lady at the prime of her youth
would concoct a story of defloration, allow an examination of her intimate
parts and later bare herself to the disgrace brought to her honor in a public
trial unless she was motivated solely by a desire to have the culprit
apprehended and brought to justice (People v. Patilan, 197 SCRA 354 [1991];
People v. Yambao, 193 SCRA 571 [1991]).
Appellant claims that his right to be presumed innocent was violated. He cites
the trial court's decision holding that it. —
. . . finds that with these circumstantial evidences (sic) pieced together the
prosecution has proved the crime of rape, and the burden shifted on the
defense to show the contrary (Rollo, p. 40).
Appellant was afforded a fair trial and in fact he availed of surrebuttal
evidence. The statement of the trial court, as correctly argued by the Solicitor
General, implies that the circumstantial evidence is sufficient to support
appellant's conviction unless the defense is able to provide evidence to the
contrary.
With respect to his conviction of illegal practice of medicine, appellant
presented inconsistent claims. On one hand, he claims that the drugs and other
paraphernalia were planted by the raiding team; while on the other hand, he
claims that these were seized without any warrant.
If indeed the evidence were all planted, how can appellant explain his
handwriting on the prescription pads in the name of Dr. Jesus Yap? A perusal
of the photographs showing accused during the raid, fails to indicate any
protestation by him. In fact, the other photographs (Exhs. "G-l", "G-2", "G-4"
— "G-8") do not bear any sign of disorder, in contrast to appellant's testimony
that his room was made into a mess during the raid.
The records fail to disclose a copy of a search warrant. However, the
prosecution was able to present its return (Exh. "ZZ") and we are satisfied that
indeed a lawful search warrant was obtained. Besides, the judge who granted
the search warrant was the same judge who initially heard both criminal cases.
It can therefore be presumed, that the search was made with a search warrant
and absent of any showing that it was procured maliciously, the items seized
are admissible in evidence (People v. Umali, 193 SCRA 493 [1991]).
The evidence is overwhelming that appellant actually treated and diagnosed
Precila and Wilma Borja. The positive testimony of Agustina, Precila, Wilma
and Josefina Borja; the medico-legal reports (Exhs. "A", "A-7", "C", "L" and
"L-1") which attest to the needle marks; the Handwriting Identification Report
(Exh. I); the photographs (Exhs. "G-l — "G-8") showing assorted drugs and
medical equipment in appellant's room; and the chemistry reports (Exhs. "J"
— "J-1") prove that appellant was engaged in the practice of medicine. And
as to his allegation that there was no proof of payment, the law specifically
punishes said act whether or not done for a fee.
Appellant claims that Precila admitted in her cross-examination that she was
in school the whole day of July 6, 1979 and it was therefore impossible for
him to have treated and diagnosed her on that date. An accurate reading of the
transcript, however, will show that Precila's testimony was in response to a
question regarding her school schedule for that day.
Finally, appellant claims that the ponente of both decisions was not the trial
judge, ergo said judge was thus deprived of the opportunity to assess the
credibility of the prosecution witnesses.
Admittedly, the ponente's participation was limited to the resolution of the
cases. The fact that the judge who heard the evidence is not the one who
rendered the judgment, and for that reason the latter did not have the
opportunity to observe the demeanor of the witnesses during the trial but
merely relied on the records of the case, does not render the judgment
erroneous (People v. Ramos, Jr., 203 SCRA 237 [1991]; People v.
Villamayor, 199 SCRA 472 [1991]), especially where the evidence on record
is sufficient to support its conclusion.
WHEREFORE, the judgments appealed from are AFFIRMED in toto.
Costs de oficio.
SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. Nos. 89095 & 89555 November 6, 1989
SIXTO P. CRISOSTOMO, petitioner,
vs.
SECURITIES AND EXCHANGE COMMISSION, SPOUSES SHOJI
YAMADA and MICHIYO YAMADA and SPOUSES TOMOTADA
ENATSU and EDITA ENATSU, respondents.
GRIÑO-AQUINO, J.:
In his petition for certiorari, 1 the petitioner seeks to annul and set aside the en
banc resolution dated February 14, 1989 of the Securities and Exchange
Commission in SEC EB Case No. 191 and the concurring opinions thereto
(Annexes F, G, and H, pp. 39-62, Rollo), as well as its orders dated June 27,
1989 and July 21, 1989 (Annexes M and 0, pp. 83-86, Rollo) directing the
corporate secretary of the United Doctors Medical Center, Inc. (hereafter
"UDMC") to call a special meeting of the stockholders to elect the officers
and directors in the implementation of the SEC's aforementioned en
banc resolution of February 14, 1989, which the Court of Appeals affirmed
in its decision dated June 8, 1989 in CA-G.R. SP No. 17435, entitled "Sixto
Crisostomo, petitioner vs. Securities and Exchange Commission, Spouses Dr.
Shoji Yamada and Michiyo Yamada, and Spouses Dr. Tomotada Enatsu and
Edita Enatsu, respondents." On August 1, 1989, the Court of Appeals denied
Crisostomo's motion for reconsideration of its decision. On August 24, 1989,
he filed a petition for review of said decision in this Court (G.R. No. 89555)
which was originally assigned to the Third Division, but was later
consolidated with G.R. No. 89095.
At first blush, the petitions sound like a patriotic defense of the Constitution,
but, at bottom they are only an artful scheme to defraud a group of foreign
investors who had been persuaded by the officers of UDMC to invest P57
million to save the corporation (its assets as well as those of the Crisostomo's)
from imminent foreclosure by the Development Bank of the Philippines
(DBP) to which UDMC was indebted in the sum of P55 million. It is the kind
of operation that sullies our collective image as a people and sets back our
government's heroic efforts to attract foreign investments to our country.
The antecedent facts, culled from the decision of the Court of Appeals, are as
follows:
Sixto Crisostomo, Felipe Crisostomo (deceased), Veronica Palanca, Juanito
Crisostomo, Carlos Crisostomo, Ricardo Alfonso, Regino Crisostomo and
Ernesto Crisostomo (known as the Crisostomo group) were the original
stockholders of the United Doctors Medical Center (UDMC) which was
organized in 1968 with an authorized capital stock of P1,000,000 (later
increased to P15,000,000 in 1972). They owned approximately 40% of
UDMC's outstanding capital stock, while the 60% majority belonged to the
members of the United Medical Staff Association (UMSA), numbering
approximately 150 doctors and medical personnel of UDMC.
Despite their minority status, the Crisostomo group has managed UDMC
from its inception, with Juanito Crisostomo as president, Ricardo Alfonso, Sr.
as chairman of the board, Carlos Crisostomo as corporate secretary and Sixto
Crisostomo as director and legal counsel.
In 1988, UDMC defaulted in paying its loan obligation of approximately P55
million to the DBP. In the last quarter of 1987, UDMC's assets (principally
its hospital) and those of the Crisostomos which had been given as collateral
to the DBP, faced foreclosure by the Asset Privatization' rust (APT), which
had taken over UDMC's loan obligation to the DBP.
To stave off the threatened foreclosure, UDMC, through its principal officers,
Ricardo Alfonso and Juanito Crisostomo, persuaded the Yamadas and Enatsu
(Shoji Yamada and Tomotada Enatsu are Japanese doctors) to invest fresh
capital in UDMC. The wife of Tomotada Enatsu, Edita Enatsu, is a Filipina.
They invested approximately P57 million in UDMC.
The investment was effected by means of: (1) a Stock Purchase Agreement;
and (2) an Amended Memorandum of Agreement whereby the group
subscribed to 82.09% of the outstanding shares of UDMC.
Both transactions were duly authorized by the board of directors and
stockholders of UDMC. They were submitted to, scrutinized by, and, finally,
approved by the Board of Investments, the Central Bank of the Philippines,
and the Securities and Exchange Commission. The elaborate governmental
approval process was done openly and with full knowledge of all concerned,
including Sixto Crisostomo, the corporate legal counsel. Upon the completion
of the governmental approval process, shares of stock, duly signed by
UDMC's authorized officers, were issued to the Yamadas and Enatsus.
This capital infusion not only saved the assets of the UDMC (especially the
hospital) from foreclosure but also freed the Crisostomos from their
individual and solidary liabilities as sureties for the DBP loan.
As it had been agreed in the Amended Memorandum of Agreement between
UDMC and the Japanese group that upon the latter's acquisition of the
controlling interest in UDMC, the corporation would be reorganized, a special
stockholders' meeting and board of directors' meeting were scheduled to be
held on August 20, 1988.
However, on the eve of the meetings, i.e., on August 19, 1988, Sixto
Crisostomo, supposedly acting for himself, filed SEC Case No. 3420 against
Juanito Crisostomo, Ricardo Alfonso, Shoji Yamada, Michiyo Yamada,
Tomotada Enatsu and Edita Enatsu, praying, among other things, (1) to stop
the holding of the stockholder's and board of directors' meetings; (2) to
disqualify the Japanese investors from holding a controlling interest in
UDMC and from being elected directors or officers of UDMC; and (3) to
annul the Memorandum of Agreement and Stock Purchase Agreement
because they allegedly did not express the true agreement of the parties (pp.
194-203, Rollo).
Two weeks later, on September 2, 1988, Crisostomo filed Civil Case No. 88-
1823 in the Regional Trial Court of Makati, Metro Manila, where he also
sought a preliminary injunction and the Identical reliefs prayed for by him in
SEC Case No. 3420 (pp. 317-335, Rollo). It was dismissed by the trial court
for lack of jurisdiction and is pending appeal in the Court of Appeals where it
is docketed as CA-G.R. No. 20285-CV.
On September 13, 1988, the hearing officer, Antonio Esteves, granted the
application for a writ of preliminary injunction enjoining the respondents —
... from holding the special meeting of the stockholders and of the Board of
Directors of United Doctors Medical Center, [Inc.] (UDMC) scheduled on
August 20, 1988 or any subsequent meetings; from adopting resolutions to
elect new directors and appoint new officers; from approving resolutions
directly or indirectly affecting the operations, organizational structure, and
financial condition of the corporation, ... and from disbursing funds of the said
corporation except those ordinary day-to-day expenses pending the final
termination of this case. (p. 30, Rollo.)
The private respondents' motion for reconsideration of this order was denied
by the hearing officer on November 16, 1988. In the same order, he created a
management committee to administer UDMC (pp. 32-35, Rollo).
The respondents appealed by certiorari to the SEC en banc. On February
14,1989, Commissioner Jose C. Laureta, with whom Commissioners Rosario
N. Lopez and Gonzalo T. Santos separately concurred, set aside the
preliminary injunction issued by Esteves and the management committee
which he created. The dispositive part of the decision reads:
Wherefore, premises considered, the instant petition for certiorari is
GRANTED and the Commission en banc ORDERS:
1. That the questioned orders of the hearing officer in SEC Case No. 3420 of
September 13, 1988 and November 16, 1988, be immediately vacated;
2. That a special stockholders' meeting of UDMC be held for the purpose of
allowing the stockholders of record of the corporation to elect a new board of
directors, which special meeting is hereby directed to be scheduled within 10
days from receipt of a copy of this resolution by the incumbent corporate
secretary or acting corporate secretary of UDMC, and to this end, that such
officer be, as he hereby is, directed: (a) to issue a call for such special meeting
and serve notice thereof on all stockholders of record of the corporation, in
accordance with section 6 of article VII of UDMC's by-laws; and (b) to submit
to the Commission, through the Commission Secretary, a written report of his
compliance with this particular order of the Commission, not later than 5 days
prior to the scheduled date of the proposed UDMC special stockholders'
meeting;
3. That upon the election of a new board of directors of UDMC, that such
board be, as it hereby is, enjoined to meet as promptly as possible for the
purpose of electing a new set of officers of the corporation in order to ensure
its proper management;
4. That the hearing officer be, as he hereby is, directed to continue with the
proceedings of SEC Case No. 3420, and to do so with all deliberate speed, for
the purpose of resolving the alleged violation of certain rights of Sixto
Crisostomo, as a stockholder of UDMC particularly, his right to inspect the
corporate books and records of UDMC, his preemptive right to subscribe to
the P60 million increase in the authorized capital of UDMC, and his appraisal
rights; and
5. That the board of directors and officers of UDMC be, as they hereby are,
ordered to submit to the Commission, through the Chairman, a written report
as to its plans as regards its nursing school, such report to be submitted at least
one month prior to the commencement of the school year 1989-1990.
SO ORDERED. (pp. 49-50, Rollo.)
Sixto Crisostomo sought a review of the SEC's en banc resolution in the Court
of Appeals (CA-G.R. SP No. 17435).
On June 8, 1989, the Court of Appeals dismissed his petition and lifted the
temporary restraining order that it had issued against the SEC's resolution
(Annex K, pp. 65-81, Rollo). Petitioner filed a motion for reconsideration (pp.
418-434, Rollo). The Court of Appeals required the private respondents to
comment but it denied the petitioner's motion to reinstate the writ of
preliminary injunction (Annex L, p. 82, Rollo),
On motion of the private respondents (Annex K, p. 413, Rollo), the SEC en
banc issued an order on June 27, 1989 directing the secretary of UDMC to
call a special stockholders' meeting to elect a new board of directors and
officers of the corporation (Annex F). Petitioner asked the SEC to recall that
order on account of his pending motion for reconsideration in the Court of
Appeals. The motion was opposed by the private respondents. On July 21,
1989, the SEC denied petitioner's motion (p. 86, Rollo). Whereupon, he filed
this petition for certiorari and prohibition with a prayer for preliminary
injunction alleging that the SEC en banc abused its discretion:
1. in setting aside Esteves' orders
2. in allowing the Japanese group to have control of UDMC for it will result
in culpable violation of Section 7, Article XII of the 1987 Constitution which
provides that no private lands shall be transferred or conveyed except to
individuals or corporations qualified to acquire or hold land of the public
domain, meaning corporations at least sixty per centum of whose capital is
owned by Filipino citizens (Sec. 2, Article XII, 1987 Constitution); and
3. in allowing the Japanese investors to own more than 40% of the capital
stock of UDMC (which operates a nursing and midwifery school) in violation
of Section 4 (2) Article XIV of the 1987 Constitution which provides that
educational institutions ... shall be owned solely by citizens of the Philippines
or corporations or associations at least sixty per centum of the capital of which
is owned by such citizens.
The public and private respondents, in their comments on the petition, asked
that the petition be dismissed and that the petitioner be cited for contempt for
forum-shopping.
We find no merit in the petition. The first allegation that the SEC en
banc erred in reversing the orders of the hearing officer, Esteves, is the same
ground raised by the petitioner in CA-G.R. No. SP 17435. The issue is
frivolous for the authority of the SEC en banc to review, revise, reverse, or
affirm orders of its hearing officers is too elementary to warrant any debate.
Equally unmeritorious are the second and third grounds of the petition — that
the P57 million investment of the Japanese group in UDMC violates the
constitutional provisions restricting the transfer or conveyance of private
lands (Art. XIII, Sec. 7, 1987 Constitution) and the ownership of educational
institutions (Art. XVI, Sec. 14[a], 1987 Constitution), to citizens of the
Philippines or corporations at least 60% of the capital of which is owned by
Filipino citizens. While 82% of UDMC's capital stock is indeed subscribed
by the Japanese group, only 30% (equivalent to 171,721 shares or P17,172.00)
is owned by the Japanese citizens, namely, the Yamada spouses and
Tomotada Enatsu. 52% is owned by Edita Enatsu, who is a Filipino.
Accordingly, in its application for approval/registration of the foreign equity
investments of these investors, UDMC declared that 70% of its capital stock
is owned by Filipino citizens, including Edita Enatsu. That application was
approved by the Central Bank on August 3, 1988 (p. 249, Rollo,).
The investments in UDMC of Doctors Yamada and Enatsu do not violate the
Constitutional prohibition against foreigners practising a profession in the
Philippines (Section 14, Article XII, 1987 Constitution) for they do not
practice their profession (medicine) in the Philippines, neither have they
applied for a license to do so. They only own shares of stock in a corporation
that operates a hospital. No law limits the sale of hospital shares of stock to
doctors only. The ownership of such shares does not amount to engaging
(illegally,) in the practice of medicine, or, nursing. If it were otherwise, the
petitioner's stockholding in UDMC would also be illegal.
The SEC's orders dated June 27, 1989 and July 21, 1989 (directing the
secretary of UDMC to call a stockholders' meeting, etc.) are not premature,
despite the petitioner's then pending motion for reconsideration of the
decision of the Court of Appeals. The lifting by the Court of Appeals of its
writ of preliminary injunction in CA-G.R. SP No. 17435 cleared the way for
the implementation by the SEC's en banc resolution in SEC EB Case No. 191.
The SEC need not wait for the Court of Appeals to resolve the petitioner's
motion for reconsideration for a judgment decreeing the dissolution of a
preliminary injunction is immediately executory. It "shall not be stayed after
its rendition and before an appeal is taken or during the pendency of an
appeal." (Sec. 4, Rule 39, Rules of Court; Marcelo Steel Corp. vs. Court of
Appeals, 54 SCRA 89 [1973]; Aguilar vs. Tan, 31 SCRA 205 [1970]; Sitia
Teco vs. Ventura, 1 Phil. 497 [1902]; Watson & Co., Ltd. vs. M. Enriquez, I
Phil. 480 [1902]).
We now address the public and private respondents' separate motions to
dismiss the petition and to cite Crisostomo and his counsel for contempt of
court for forum-shopping. The records show that Crisostomo had two actions
pending in the Court of Appeals (CA-G.R. No. SP 17435 and CA-G.R. No.
20285 CV) when he filed the petition for certiorari (G.R. No. 89095) in this
Court on July 27, 1989. The case docketed as CA-G.R. No. 20285-CV, is his
appeal from the decision of the Regional Trial Court of Makati, dismissing
his complaint for annulment of the Memorandum of Agreement and the Stock
Purchase Agreement between UDMC and the Japanese investors. CA-G.R.
No. SP 17435 is his petition for certiorari to review the SEC's en
banc resolution upholding those transactions and ordering the holding of a
stockholders meeting to elect the directors of the UDMC, and of a board of
directors meeting to elect the officers.
Notwithstanding the pendency of those two cases in the Court of Appeals,
Crisostomo filed this petition for certiorari 1 and prohibition on July 27, 1989
where he raises the same issues that he raised in the Court of Appeals.
The prayer of his petition in CA-G.R. No. SP 17435 reads thus:
3) After hearing on the merits, judgment be rendered:
a) Annulling and setting aside the questioned rulings of the respondent
COMMISSION 2for having been issued with grave abuse of discretion
tantamount to lack or excess of jurisdiction; and
b) Making permanent the preliminary injunction issued in this case against
the respondents. (p. 241, Rollo.)
In his petition for certiorari (G.R. No. 89095), he also prays that —
1. Upon the filing of this petition, a temporary restraining order issue
enjoining respondents, their representatives or agents from implementing or
executing the SEC opinions (Annexes "F", "G" and "H") and its June 27 and
July 21,1989 orders (Annexes "M" and "O") until further orders from the
Honorable Court.
xxx xxx xxx
3. After notice, this petition be given due course and a writ of preliminary
injunction be issued for the same purpose and effect upon such terms and
conditions the Honorable Court may impose; and thereafter, judgment be
rendered granting the writ prayed for and annulling and setting aside the said
opinions rendered by the SEC in their stead, affirming the orders of the
Hearing Officer (Annexes "A" and "B"). (pp. 27-28, Rollo.)
Additionally, in his petition for review (G.R. No. 89555) he prays this Court
to giant "all the reliefs" prayed for by him in CA-G.R. SP No. 17435. Here is
a clear case of forum-shopping.
There is forum-shopping whenever as a result of an adverse opinion in one
forum, a party seeks a favorable opinion (other than by appeal or certiorari)
in another. The principle applies not only with respect to suits filed in the
courts but also in connection with litigations commenced in the courts while
an administrative proceeding is pending, as in this case, in order to defeat
administrative processes and in anticipation of an unfavorable administrative
ruling and a favorable court ruling. This is specially so, as in this case, where
the court in which the second suit was brought, has no jurisdiction.
(Villanueva vs. Adre, G.R. No. 8063, April 27, 1989.) (p. 303, Rollo)
Forum-shopping is prohibited by the Interim Rules of Court for it trifles with
the courts and abuses their processes (E. Razon, Inc. vs. Phil. Port Authority,
101 SCRA 450). Section 17 of the Interim Rules of Courts provides:
17. Petitions for writs of certiorari, etc., — No petition for certiorari,
mandamus, prohibition, habeas corpus or quo warranto may be filed in the
Intermediate Appellate Court if another similar petition has been filed or is
still pending in the Supreme Court. Nor may such petition be filed in the
Supreme Court if a similar petition has been filed or is still pending in the
Intermediate Appellate Court, unless it be to review the action taken by the
Intermediate Appellate Court on the petition filed with it. A violation of this
rule shall constitute contempt of court and shall be a cause for the summary
dismissal of both petitions, without prejudice to the taking of appropriate
action against the counsel or party concerned. (Interim Rules of Court.)
Forum-shopping makes the petitioner subject to disciplinary action and
renders his petitions in this Court and in the Court of Appeals dismissible (E.
Razon, Inc. vs. Philippine Port Authority, et al., G.R. No. 75197, Resolution
dated July 31, 1986; Buan vs. Lopez, Jr., 145 SCRA 34, 38-39; Collado vs.
Hernando, L-43886, May 30, 1988). For this reason, if not for their lack of
merit, the petitions should be, as they are hereby, dismissed.
WHEREFORE, these petitions are dismissed for lack of merit. The temporary
restraining order which this Court issued on August 7, 1989 in G.R. No. 89095
is hereby lifted. The Court of Appeals is ordered to immediately dismiss CA-
G.R. CV No. 20285. The petitioner and his counsel are censured for engaging
in forum-shopping. The petitioner is further ordered to pay double costs in
this instance. SO ORDERED.
 Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. L-14160 June 30, 1960
PEOPLE OF THE PHILIPPINES, plaintiff-appellant,
vs.
ANUNCIACION VDA. DE GOLEZ, defendant-appellee.
REYES, J. B. L., J.:
On October 2, 1957, the provincial fiscal of Negros Occidental filed an
information in the Court of First Instance of that province charging
Anunciacion Vda. de Golez with the crime of homicide through reckless
imprudence, as follows:
That on or about the period comprised from December 12, 1956 to December
24, 1956, in the municipality of San Carlos, province of Negros Occidental,
Philippines, and within the jurisdiction of this Honorable Court, the herein
accused, without being duly licensed to practice medicine and with reckless
negligence and without taking due precaution, did, then and there, wilfully,
unlawfully, and feloniosly diagnose, prescribe, and treat one Susana Tam,
who had been suffering for sometime with bodily ailment, knowing fully well
that she is incompetent and not possessing the necessary technical or scientific
knowledge or skill, and as a consequence of such negligence and carelessness
and lack of medical skill, said Susana Tam died thereafter.
The accused pleaded not guilty to the information.
When the case was called for trial, the assistant fiscal made a manifestation
that the accused had also been charged with the crime of illegal practice of
medicine before another sala of the same court. In view of this manifestation,
the trial court motu proprio dismissed the information for being fatally
defective, without prejudice to the filing of the proper information against the
same accused. The grounds given for the dismissal were the following:
In view of the foregoing manifestation of the Fiscal, the Court finds that the
information is fatally defective and, therefore, should be dismissed under Par.
(a), Sec. 2 of Rule 113 of the Rules of Court inasmuch as the facts charged do
not constitute the offense of homicide thru reckless imprudence because
illegal practice of medicine is malicious per se, and when the accused
practiced medicine without academical preparation and without a license to
do so, then she is per se committing a criminal act for which the criminal
intent is presumed. Although the crime of homicide thru reckless imprudence
can be committed by a duly licensed physician when in the practice of his
profession he fails to exercise due care and diligence from which the criminal
act arises, this crime cannot be imputed to a person who has no authority to
practice this profession, which act is malicious per se. The crime described in
Article 365 of the Revised Penal Code results from the performance of a
lawful act which was done without exercising the care and diligence that is
required by the circumstances, and not from the performance of an unlawful
act which is the subject of the information in this case because a quack doctor
who practices medicine does so against the law, and, therefore, his act is
necessarily malicious and criminal.
From the above order, the provincial fiscal appealed to this Court, and,
through the Solicitor General, urges that the court below erred in dismissing
the information for being fatally defective because the facts charged therein
allegedly do not constitute the crime of homicide thru reckless imprudence.
We agree with appellant that the order of dismissal is erroneous, in that the
crime of illegal practice of medicine is a statutory offense wherein criminal
intent is taken for granted, so that a person may be convicted thereof
irrespective of his intention and in spite of his having acted in good faith and
without malice; i.e., even if he was not motivated by an evil desire to injure
or hurt another, but by an honest desire to cure or alleviate the pain of a
patient. In fact, as defined by Section 2678 of the Revised Administrative
Code (the law then in force), the offense consists in the mere act of practicing
medicine in violation of the Medical Law, even if no injury to another, much
less death, results from such malpractice. When, therefore, the patient dies,
the illegal practitioner should be equally responsible for the death of his
patient, an offense independent of and distinct from the illegal practice of
medicine.
The allegations in the information in this case that the accused acted with
reckless negligence in diagnosing, prescribing for, and treating the deceased
Susana Tam, knowing that she did not possess the necessary technical
knowledge or skill to do so, thus causing her death, sufficiently charge the
crime of homicide through reckless imprudence, since ordinary diligence
counsels one not to tamper with human life by trying to treat a sick man when
he knows that he does not have the special skill, knowledge, and competence
to attempt such treatment and cure, and may consequently reasonably foresee
harm or injury to the latter, said accused was found guilty and convicted by
this Court of physical injuries through imprudence under the old Penal Code
(U. S. vs. Feliciano Divino, 12 Phil., 175).
However, in view of the error of the lower court in dismissing the information,
we cannot sustain this appeal for the reason that it would place the accused in
double jeopardy. The present information being valid and sufficient in form
and substance to sustain a conviction, the dismissal thereof by the court after
the accused had pleaded not guilty to the charge and without his consent
constitutes jeopardy as to bar further proceedings upon the case (U. S vs. Yam
Tung Way, 21 Phil., 67; People vs. Hernandez, 94 Phil., 49; 49 Off. Gaz. No.
12, 5342; People vs. Ferrer, 100 Phil., 124; 55 Off. Gaz. [4] 620). The failure
of the accused to file a brief and raise the question of double jeopardy in this
appeal does not mean that section 2, Rule 118, providing that the People can
not appeal if the defendant would be placed in double jeopardy would no
longer apply (People vs. Bao, 106 Phil., 243; 56 Off. Gaz. [51] 7768).
The unfortunate result in this case could have been avoided if the trial court
had proceeded more deliberately, without allowing its judgment to be
influenced by preconceived notions or undue haste in dispatching cases.
The appeal is, therefore, dismissed, with costs de oficio.
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 86890 January 21, 1994
LEANDRO CARILLO, petitioner,
vs.
PEOPLE OF THE PHILIPPINES, respondent.
FELICIANO, J.:
Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the Decision of
the Court of Appeals dated 28 November 1988, which affirmed his conviction
by the Regional Trial Court of the crime of simple negligence resulting in
homicide, for the death of his thirteen (13) year old patient
Catherine Acosta. The trial court had sentenced him to suffer the penalty
of arresto mayor in its medium period (four [4] months' imprisonment), as
well as to pay the heirs of his patient an indemnity of P30,000.00 for her death,
P10,000.00 as reimbursement for actual expenses incurred, P50,000.00 as
moral damages and to pay the costs of the suit.1
The information filed against petitioner and his co-accused, the surgeon Dr.
Emilio Madrid, alleged the following:
That on or about the 31st of May 1981, in the municipality of Parañaque,
Metro Manila, Philippines and within the jurisdiction of this Honorable Court,
the above-named accused, conspiring and confederating together and
mutually helping and aiding with one another, without taking the necessary
care and precaution to avoid injury to person, did then and there willfully,
unlawfully and feloniously operate, in a reckless, careless and imprudent
manner and neglected to exercise their respective medical knowhow and tasks
and/or departed from the recognized standard in their treatment, diagnosis of
the condition, and operation of the patient, one Catherine Acosta, 13 years
old, which negligence caused the death of the said Catherine Acosta.2
Petitioner and Dr. Emilio Madrid entered pleas of not guilty at arraignment
and the case proceeded to trail with Judge Job B. Madayag presiding.3
The prosecution presented as its principal evidence the testimony of four (4)
witnesses, namely: 1) Yolanda Acosta, Catherine's mother, who was able to
observe the conduct of the accused outside the operating theater before,
during and after the appendectomy procedure carried out on her daughter;4 2)
Domingo Acosta, Catherine's father, who corroborated some parts of his
wife's
testimony;5 3) Dr. Horacio Buendia, an expert witness who described before
the trial court the relationship between a surgeon and an anesthetist in the
course of a surgical operation, as well as define the likelihood of cardiac arrest
as a post operative complication;6 and 4) Dr. Nieto Salvador, an expert
witness who analyzed and explained the significance of the results of the
pathological study and autopsy conducted on Catherine's body by one Dr.
Alberto Reyes.7
After the prosecution had rested its case, the defense was granted leave to file
a demurrer to the evidence.8 After failing to file the demurrer within the
reglementary period, Judge Manuel Yuzon, who had in the meantime taken
over as presiding judge of the sala where this case was pending, denied the
defense motion for extension of time to file demurrer and declared the case
submitted for decision.9
On 19 September 1985, the trial court promulgated its decision convicting
both the accused of the crime charged. 10
On appeal, the Court of Appeals affirmed the judgment of conviction, and
specified that the civil liability of the two (2) accused was solidary in nature. 11
Petitioner Dr. Carillo alone filed the present Petition for Review with the
Court, seeking reversal of his conviction, or in the alternative, the grant of a
new trial. Dr. Madrid did not try to appeal further the Court of Appeals
Decision. Accordingly, the judgment of conviction became final insofar as
the accused surgeon Dr. Madrid is concerned.
The facts of the case as established by the Court of Appeals are as follows:
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. Catherine was then brought to Dr. Elva Peña. Dra. Peña called for
Dr. Emilio Madrid and the latter examined Catherine Acosta. According to
Dr. Madrid, his findings might be appendicitis. Then Dr. Peña told Catherine's
parents to bring the child to the hospital in Baclaran so that the child will be
observed.
At the Baclaran General Hospital, a nurse took blood sample form the child.
The findings became known at around 3:00 o'clock in the afternoon and the
child was scheduled for operation at 5:00 o'clock in the afternoon. The
operation took place at 5:45 p.m. because Dr. Madrid arrived only at that time.
When brought inside the operating room, the child was feeling very well and
they did not subject the child to ECG (electrocardiogram) and
X-ray.
The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was
assisted by appellant, Dr. Leandro Carillo, an anesthesiologists.
During the operation, while Yolanda Acosta, Catherine's mother, was staying
outside the operating room, she "noticed something very unfamiliar." The
three nurses who assisted in the operation were going in and out of the
operating room, they were not carrying anything, but in going out of the
operating room, they were already holding something.
Yolanda asked one of the nurses if she could enter the operating room but she
was refused.
At around 6:30 p.m., Dr. Emilio Madrid went outside the operating room and
Yolanda Acosta was allowed to enter the first door.
The appendicitis (sic) was shown to them by Dr. Madrid, because, according
to Dr. Madrid, they might be wondering because he was going to install
drainage near the operating (sic) portion of the child.
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.
Witness Yolanda Acosta further testified that shortly before the child was
transferred from the operating room to her room, she (witness) was requested
by the anesthesiologist to go home and get a blanket.
A portion of Yolanda Acosta's testimony on what happened when she
returned to the hospital are reproduced hereunder as follows:
Q What happened afterward?
A When I arrived in the hospital, my child was being transferred to her bed.
Q What else happened?
Q I noticed that the heartbeat of my daughter was not normal. And I noticed
that her hospital gown is rising up and down.
Q What transpired after that?
A I asked Dr. Madrid why it was like that, that the heartbeat of my daughter
is not normal.
Q And did the doctor make any reply?
A The doctor said because of the lesion of the child.
Q What else happened?
A After they have revived the heartbeat of the child, Dr. Carillo and
Dr.Madrid left.
Q Now do you remember what time was it when Dr. Carillo stepped out?
A Only a minute after they have transferred the child to the bed.
Q What happened later on after Dr. Carillo and Dr. Madrid stepped out of
the hospital?
A After 15 or 30 minutes has lapsed at about 7:15 or 7:30, the child had
developed convulsion and stiffening of the body.
Q When you observed convulsion and stiffening of the body, did you do
anything?
A We requested the nurse who was attending to her to call for a doctor.
Q And the nurse who was attending to the patient called for a doctor?
A They called for Dra. Peña, their family physician.
Q What transpired afterwards?
A What Dra. Peña did was call for Dr. Madrid and the cardiologist.
Q Did this doctor arrived?
A Yes.
Q What transpired after the doctor arrived?
A They examined the child.
Q After they examined the child, did they inform you of the result of the
examination?
A The cardiologist was the one whom informed us after he stepped out of the
room when we followed him. The doctor told us that she suffered severe
infection which went up to her head.
Q After you were informed of the result of his examination, what transpired
next?
A According to them, they will do their best for the child and that they will
call for Dr. Carillo.
Q Did Dr. Carillo arrived?
A At around 10:30 in the evening.
Q Did Dr. Carillo do anything when he arrived on 31 May 1981?
A When he arrived, he noticed that there were two small bottles and big
bottles of dextrose which were hanging above the bed of the child. Then he
said, "What is this? Christmas tree or what?" He told us that one bottle of
dextrose be removed. And the big one will remain.
Q What happened after that?
A After that we talked to Dr. Carillo and asked him how did this happen to
the child.
Q What did Dr. Carillo reply (sic) to you?
A He answered "that is nothing, the child will regain consciousness and if the
child will not regain consciousness, I will resign (sic) as a doctor."12
(Emphasis supplied)
When Catherine remained unconscious until noontime the next day, a
neurologist examined her and she was diagnosed as comatose. 13 Three (3)
days later, Catherine died without regaining consciousness.14
The Court of Appeals held that Catherine had suffered from an overdose of,
or an adverse reaction to, anesthesia, particularly the arbitrary administration
of Nubain, a pain killer, without benefit of prior weighing of the patient's body
mass, which weight determines the dosage of Nubain which can safely be
given to a patient. 15 The Court of Appeals held that this condition triggered
off a heart attack as a post-operative complication, depriving Catherine's brain
of oxygen, leading to the brain's hemorrhage. 16 The Court of Appeals
identified such cardiac arrest as the immediate cause of Catherine's death. 17
The Court of Appeals found criminal negligence on the part of petitioner Dr.
Carillo and his co-accused Dr. Madrid, holding that both had failed to observe
the required standard of diligence in the examination of Catherine prior to the
actual administration of anesthesia; 18 that it was "a bit rash" on the part of the
accused Dr. Carillo "to have administered Nubain without first weighing
Catherine"; 19 and that it was an act of negligence on the part of both doctors
when, (a) they failed to monitor Catherine's heartbeat after the operation and
(b) they left the hospital immediately after reviving Catherine's heartbeat,
depriving the latter of immediate and expert medical assistance when she
suffered a heart attack approximately fifteen (15) to thirty (30) minutes
later. 20
Since neither petitioner nor his co-accused presented evidence in their own
behalf, the present Petition seeks to question the soundness of the factual
conclusions drawn by the Court of Appeals, upon which the affirmance of
petitioner's conviction was based.
Close examination of the instant Petition for Review shows that petitioner's
main arguments are two-fold: (1) the Court of Appeals "completely brushed
aside" and "misapprehended" Catherine's death certificate and biopsy report
which allegedly showed that the cause of death was a ruptured appendix,
which led to blood poisoning, 21 rather than faulty anesthetic treatment;
and (2) there was no direct evidence of record showing that Nubain was
administered to Catherine either during the appendectomy procedure or after
such operation. 22
Two (2) related issues are thus posed for the Court's consideration. The first
is whether the Court of Appeals so drastically "misapprehended" the relevant,
operative facts in this case as to compel this Court to examine and resolve
question(s) of fact which would have a decisive significance for the
disposition of the case. The rule is too firmly settled to require much
documentation that only questions of law may be raised before this Court in
a petition for review on certiorari, subject to certain well-known
exceptions. 23 After careful scrutiny of petitioner's contentions before us and
the record of this case, we do not believe that petitioner has shown
"misapprehension of facts" on the part of the Court of Appeals which would
require this Court to overturn the judgment reached by the former.
The second issue is 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. Our
review of the record leads us to an affirmative answer.
Petitioner contends that the Court of Appeals seriously erred in finding that
an overdose of, or an allergic reaction to, the anesthetic drug Nubain had led
to the death of Catherine Acosta and that the true cause of Catherine's death
was that set out in the death certificate of Catherine: "Septicemia (or blood
poisoning) due to perforated appendix with peritonitis." 24 The concept of
causation in general, and the cause of death in human beings in particular, are
complex and difficult notions. What is fairly clear is that death, understood as
a physical condition involving cessation of vital signs in the brain and heart,
is preceded by a series of physiological events, any one of which events can,
with equal cogency, be described as a "cause of death". The Court of Appeals
found that an overdose of, or an adverse reaction to, Nubain, an anesthetic or
pain-killing drug the appropriate dose of which depends on the body weight
or mass of the patient, had generated or triggered off cardiac arrest, which in
turn led to lack of oxygen in Catherine's brain, which then brought about
hemorrhaging in the brain. Vital activity in the brain thereupon ceased. The
medical evidence presented at the trial was quite consistent with the findings
of the Court of Appeals which concluded that cardiac arrest was the cause of
Catherine's death. 25
For his part, petitioner insists that cardiac arrest is not the only cause of
oxygen-starvation of the brain, that septicemia with peritonitis or severe
infection which had "gone up to the head" of Catherine was an equally
efficient cause of deprivation of the brain of oxygen and hence of brain
hemorrhage. The medical testimony of the expert witnesses for the
prosecution on which petitioner relies is also consistent with petitioner's
theory that septicemia with peritonitis was, or at least could have been, the
cause of Catherine's death. 26
Indeed, it appears to the Court that there was no medical proof submitted to
the trial court to show that one or the other "cause"
was necessarily an exclusive cause of death in the case of Catherine Acosta;
that an overdose or allergic reaction to Nubain could not have combined with
septicemia and peritonitis in bringing about Catherine's death.
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.
When the patient was wheeled out of the operating room after completion of
surgery, she manifested signs of medical instability (i.e., shivering, paleness,
irregular breathing and weak heart beat). 27 She was not brought to a properly
equipped recovery room, or intensive care until which the hospital
lacked. 28 Such facilities and their professional staffs, of which an anesthetist
is commonly a part, are essential for providing close observation and patient
care while a post-surgery patient is recovering from the effects of anesthesia
and while the normal protective mechanisms are still dull or
obtunded. 29 Instead, the patient was merely brought to her assigned hospital
bed and was provided oxygen on the instructions of Dr. Madrid then "revived"
her heartbeat. 30 Both doctors then left their patient and the hospital;
approximately fifteen minutes later, she suffered convulsions and cardiac
arrest. 31
The conduct of Dr. Madrid and of the petitioner constituted inadequate care
of their patient in view of her vulnerable condition. Both doctors failed to
appreciate the serious condition of their patient whose adverse physical signs
were quite manifest right after surgery. And after reviving her heartbeat, both
doctors failed to monitor their patient closely or extend further medical care
to her; such conduct was especially necessary in view of the inadequate,
post-operative facilities of the hospital. We do not, of course, seek to hold
petitioner responsible for the inadequate facilities of the Baclaran General
Hospital. We consider, however, that the inadequate nature of those facilities
did impose a somewhat higher standard of professional diligence upon the
accused surgeon and anesthetist personally than would have been called for
in a modern fully-equipped hospital.
While Dr. Madrid and a cardiologist were containing the patient's
convulsions, and after the latter had diagnosed that infection had reached the
patient's head, these two (2) apparently after consultation, decided to call-in
the petitioner. 32 There is here a strong implication that the patient's post-
operative condition must have been considered by the two (2) doctors as in
some way related to the anesthetic treatment she had received from the
petitioner either during or after the surgical procedure.
Once summoned, petitioner anesthesiologist could not be readily found.
When he finally appeared at 10:30 in the evening, he was evidently in a bad
temper, commenting critically on the dextrose bottles before ordering their
removal. 33 This circumstance indicated he was not disposed to attend to this
unexpected call, in violation of the canons of his profession that as a
physician, he should serve the interest of his patient "with the greatest of
solicitude, giving them always his best talent and skill." 34 Indeed, when
petitioner finally saw his patient, he offered the unprofessional bluster to the
parents of Catherine that he would resign if the patient will not regain
consciousness. 35 The canons of medical ethics require a physician to "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 physician's failure to fulfill his obligation to his
patient is, in most cases, his own conscience, violation of this rule on his part
is "discreditable and inexcusable". 36
Nubain was an experimental drug for anesthesia and post-operative pain and
the medical literature required that a patient be weighed first before it is
administered and warned that there was no (or inadequate) experience relating
to the administration thereof to a patient less that eighteen (18) ears of
age. 37 Yet, the doctor's order sheet (Exhibit "C") did not contain this
precaution but instead directed a reader to apply the drug only when warranted
by the circumstances. 38 During the offer of Exhibit "C" by the prosecution,
Dr. Madrid admitted that this prescription, which was unsigned, was made in
his own handwriting. 39 It must be observed that the instruction was open-
ended in that some other individual still had to determine if circumstances
existed warranting administration of the drug to the patient. The document
thus indicated the abdication of medical responsibility on an extremely
critical matter. Sincepetitioner anesthesiologist
entered subsequent prescriptions or orders in the same order sheet, which
were signed by him, at 7:15 p.m. on the same evening of 31 May 1981, he was
in a position to appreciate the dangers inherent in the prior prescription,
which was within his (petitioner's) area of specialization, and to order
measures to correct this anomaly and protect his patient's well-being. So far
as the condition of the evidence shows, he failed to do so. In sum, only a low
level of diligence was exhibited by petitioner and Dr. Madrid in the
prescription of medication for their patient.
As noted earlier, petitioner relied heavily in this proceeding on the testimony
on cross-examination of the expert witnesses for the prosecution to show that
blood poisoning resulting from a ruptured appendix could also be responsible
for the patient's death.
No suggestion has been made that the rupture of the patient's occurred prior
to surgery. After her blood sample was examined, the patient was merely
diagnosed as a case of appendicitis, without further
elaboration. 40 No intensive preoperative preparations, like the immediate
administration of antibiotics, was thereafter undertaken on the patient. This is
a standard procedure for patients who are, after being diagnosed, suspected of
suffering from a perforated appendix and consequent peritonitis. 41 The
mother also testified that petitioner anesthesiologist merely injected a drug,
"pre-anesthesia" intended to put the patient to sleep, into the container of
fluids being administered to her daughter intravenously at her room, prior to
surgery. 42 We note further that the surgeon Dr. Madrid was forty-five
minutes late in arriving at the operating theater. 43 Considering that delay in
treatment of appendicitis increases the morbidity of the patient, 44 Dr.
Madrid's conduct can only be explained by a pre-operative diagnosis on his
part that the condition of appendicitis was not yet attended by complications
(i.e., a ruptured appendix and peritonitis).
The above circumstances do strongly indicate that the rupture of the patient's
appendix occurred during the appendectomy procedure, that is, at a time and
place — the operating room — where the two (2) accused were in full control
of the situation and could determine decisively what needed to be done in
respect of the patient. 45 This circumstance must be considered in conjunction
with other related circumstances which the prosecution had proven: that the
patient was ambulatory when brought to the operating room; 46 that she left
the operating room two (2) hours later in obviously serious condition; and that
an appendectomy accompanied or followed by sustained antibiotic treatment
is a fairly common and generally accepted medical procedure for dealing with
ruptured appendix and peritonitis, 47 a fact of which judicial note may be
taken.
As early as in People v. Vistan, 48 the Court defined simple negligence,
penalized under what is now Article 365 of the Revised Penal Code, as "a
mere lack of prevision in a situation where either the threatened harm is
not immediate or the danger not openly visible." Put in a slightly different
way, the gravamen of the offense of simple negligence is the failure to
exercise the diligence necessitated or called for the situation which was not
immediately
life-destructive but which culminated, in the present case, in the death of a
human being three (3) days later. Such failure to exercise the necessary degree
of care and diligence is a negative ingredient of the offense charged. The rule
in such cases is that while the prosecution must prove the negative ingredient
of the offense, it needs only to present the best evidence procurable under the
circumstances, in order to shift the burden of disproving or countering the
proof of the negative ingredient to the accused, provided that such initial
evidence establishes at least on a prima facie basis the guilt of the
accused. 49 This rule is particularly applicable where the negative ingredient
of the offense is of such a nature or character as, under the circumstances, to
be specially within the knowledge or control of the accused. 50 In the instant
case, the Court is bound to observe that the events which occurred during the
surgical procedure (including whether or not Nubain had in fact been
administered as an anesthesia immediately before or during the surgery) were
peculiarly within the knowledge and control of Dr. Carillo and Dr. Madrid. It
was, therefore, incumbent upon the two (2) accused to overturn the prima
facie case which the prosecution had established, by reciting the measures
which they had actually taken to prevent or to counter the obviously serious
condition of Catherine Acosta which was evident right after surgery. This they
failed or refused to do so.
Still another circumstance of which account must be taken is that both
petitioner and Dr. Madrid failed to inform the parents of their minor patient
of the nature of her illness, or to explain to them either during the surgery
(if feasible) or at any time after the surgery, the events which comprised the
dramatic deterioration of her condition immediately after surgery as
compared with her pre-surgery condition. To give a truthful explanation to
the parents was a duty imposed upon them by the canons of their
profession. 51 Petitioner should have explained to Catherine's parents the
actual circumstances surrounding Catherine's death, how, in other words, a
simple appendectomy procedure upon an ambulatory patient could have led
to such fatal consequences.
By way of resume, in the case at bar, we consider that the chain of
circumstances above noted, namely: (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 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.
In addition to the main arguments raised by petitioner earlier, he also raised replaced
an ancillary, constitutional claim of denial of due process. He contends that Atty. Puerto as counsel only upon institution of the present petition. 57
he was deprived of his right to have competent representation at trial, and to
have his cause adequately heard, because his counsel of record, Atty. Jose B. Petitioner's constitutional objection is plainly an afterthought.
Puerto, was "incompetent" and exhibited "gross negligence" by manifesting
an intent to file a demurrer to the evidence, in failing to present evidence in WHEREFORE, the Decision of the Court of Appeals dated 28 November
his behalf and in omitting to file a defense memorandum for the benefit of 1988 is hereby AFFIRMED, subject only to the modification that the
Judge Yuzon, after the latter took over the case at the end of trial and before indemnity for the death of Catherine Acosta is hereby increased to
the Judge rendered his decision. 52Petitioner submits he is entitled to a new P50,000.00, in line with current jurisprudence. 58
trial. 53
SO ORDERED.
These contentions do not persuade. An examination of the record indicates
that Atty. Puerto represented petitioner during trial with reasonable
competence. Except for the two hearing sessions when witnesses Domingo
Acosta was cross-examined and recross-examined by Atty. Puerto, petitioner
was present during all the sessions when the other prosecution witnesses were
presented and during which Atty. Puerto extensively cross-examined them in Republic of the Philippines
behalf of petitioner and Dr. Madrid. This counsel elicited from the two (2) SUPREME COURT
expert witnesses for the prosecution testimony favorable to petitioner and Manila
which was relied upon by the latter in this proceeding. 54 The record further
indicates that if petitioner indeed entertained substantial doubts about the THIRD DIVISION
capability of Atty. Puerto, he could have easily terminated the services of that
counsel and retained a new one, or sought from the trial court the appointment
of counsel
de oficio, during the ample opportunity given from the time Atty. Puerto G.R. No. 118231 July 5, 1996
manifested his intent to file a demurrer on 16 October 1985, to the submission
of the case for decision on 25 June 1986 and before the promulgation of DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners,
judgment on 19 September 1986. 55 During all this time, petitioner could have vs.
obtained leave of court to present evidence in his behalf in lieu of a demurrer, COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and
or to submit a memorandum for the defense. After promulgation of the FLOTILDE G. VILLEGAS, respondents.
judgment of conviction, petitioner did not seek a new trial, but permitted Atty.
Puerto to obtain leave from the trial court to continue on bail during the DAVIDE, JR., J.:p
pendency of the proceedings before the Court of Appeals. 56 Indeed, petitioner
Throughout history, patients have consigned their fates and lives to the skill
of their doctors. For a breach of this trust, men have been quick to demand
retribution. Some 4,000 years ago, the Code of Hammurabi1 then already
provided: "If a physician make a deep incision upon a man with his bronze
lancet and cause the man's death, or operate on the eye socket of a man with
his bronze lancet and destroy the man's eyes, they shall cut off his
hand." 2 Subsequently, Hippocrates3wrote what was to become part of the
healer's oath: "I will follow that method of treatment which according to my
ability and judgment, I consider for the benefit of my patients, and abstain
from whatever is deleterious and mischievous. . . . While I continue to keep
this oath unviolated may it be granted me to enjoy life and practice the art,
respected by all men at all times but should I trespass and violate this oath,
may the reverse be my lot." At present, the primary objective of the medical
profession if the preservation of life and maintenance of the health of the
people.4
Needless to say then, when a physician strays from his sacred duty and
endangers instead the life of his patient, he must be made to answer therefor.
Although society today cannot and will not tolerate the punishment meted out
by the ancients, neither will it and this Court, as this case would show, let the
act go uncondemned.
The petitioners appeal from the decision5 of the Court of Appeals of 11 May
1994 in CA-G.R. CV No. 30851, which reversed the decision6 of 21
December 1990 of Branch 30 of the Regional Trial Court (RTC) of Negros
Oriental in Civil Case No. 9492.
The facts, as found by the trial court, are as follows:
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial
Hospital, Dumaguete City from January 9, 1978 to September 1989. Between
1987 and September, 1989 she was also the Actg. Head of the Department of
Obstetrics and Gynecology at the said Hospital.
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 who was also a Resident Physician at the same Hospital,
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. Thereafter, Plaintiff remained confined
at the Hospital until September 27, 1988 during which period of confinement
she was regularly visited by Dr. Batiquin. 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.
In the meantime, Mrs. Villegas was given a Medical Certificate by Dr.
Batiquin on October 31, 1988. . . certifying to her physical fitness to return to
her work on November 7, 1988. So, on the second week of November, 1988
Mrs. Villegas returned to her work at the Rural Bank of Ayungon, Negros
Oriental.
The abdominal pains and fever kept on recurring and bothered Mrs. Villegas
no end despite the medications administered by Dr. Batiquin. 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.
The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs.
Villegas at the Holy Child's Hospital on January 20, 1989 she found Mrs.
Villegas to be feverish, pale and was breathing fast. 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. She had an x-ray taken of Mrs. Villegas' chest, abdomen and
kidney. She also took blood tests of Plaintiff. A blood count showed that Mrs.
Villegas had [an] infection inside her abdominal cavity. The results of all
those 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,
1988.7
The piece of rubber allegedly found near private respondent Flotilde
Villegas's uterus was not presented in court, and although Dr. Ma. Salud Kho
Testified that she sent it to a pathologist in Cebu City for examination,8 it was
not mentioned in the pathologist's Surgical Pathology Report.9
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of
rubber are a Medical Certificate,10 a Progress Record,11 an Anesthesia
Record,12 a Nurse's Record,13 and a Physician's Discharge Summary.14 The
trial court, however, regarded these documentary evidence as mere hearsay,
"there being no showing that the person or persons who prepared them are
deceased or unable to testify on the facts therein stated. . . . Except for the
Medical Certificate (Exhibit "F"), all the above documents were allegedly
prepared by persons other than Dr. Kho, and she merely affixed her signature
on some of them to express her agreement thereto. . . ."15 The trial court also
refused to give weight to Dr. Kho's testimony regarding the subject piece of
rubber as Dr. Kho "may not have had first-hand knowledge" thereof,16 as
could be gleaned from her statement, thus:
A . . . I have heard somebody that [sic] says [sic] there is [sic] a foreign body
that goes with the tissues but unluckily I don't know where the rubber was. 17
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she
confronted Dr. Kho regarding the piece of rubber, "Dr. Kho answered that
there was rubber indeed but that she threw it away."18 This statement, the trial
court noted, was never denied nor disputed by Dr. Kho, leading it to conclude:
There are now two different versions on the whereabouts of that offending
"rubber" — (1) that it was sent to the Pathologist in Cebu as testified to in
Court by Dr. Kho and (2) that Dr. Kho threw it away as told by her to
Defendant. The failure of the Plaintiffs to reconcile these two different
versions serve only to weaken their claim against Defendant Batiquin.19
All told, the trial court held in favor of the petitioners herein.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even
without admitting the private respondents' documentary evidence, deemed
Dr. Kho's positive testimony to definitely establish that a piece of rubber was
found near private respondent Villegas's uterus. Thus, the Court of Appeals
reversed the decision of the trial court, holding:
4. The fault or negligence of appellee Dr. Batiquin is established by
preponderance of evidence. The trial court itself had narrated what happened
to appellant Flotilde after the caesarean operation made by appellee doctor. .
. . After the second operation, appellant Flotilde became well and healthy.
Appellant Flotilde's troubles were caused by the infection due to the "rubber"
that was left inside her abdomen. Both appellant; testified that after the
operation made by appellee doctor, they did not go to any other doctor until
they finally decided to see another doctor in January, 1989 when she was not
getting any better under the care of appellee Dr. Batiquin. . . . Appellee Dr.
Batiquin admitted on the witness stand that she alone decided when to close
the operating area; that she examined the portion she operated on before
closing the same. . . Had she exercised due diligence, appellee Dr. Batiquin
would have found the rubber and removed it before closing the operating
area.20
The appellate court then ruled:
Appellants' evidence show[s] that they paid a total of P17,000.00 [deposit of
P7,100.00 (Exh. G-1-A) plus hospital and medical expenses together with
doctor's fees in the total amount P9,900.00 (Exhs. G and G-2)] for the second
operation that saved her life.
For the miseries appellants endured for more than three (3) months, due to the
negligence of appellee Dr. Batiquin they are entitled to moral damages in the
amount of P100,000.00; exemplary damages in the amount of P20,000.00 and
attorney's fees in the amount of P25,000.00.
The fact that appellant Flotilde can no longer bear children because her uterus
and ovaries were removed by Dr. Kho is not taken into consideration as it is
not shown that the removal of said organs were the direct result of the rubber
left by appellee Dr. Batiquin near the uterus. What is established is that the
rubber left by appellee caused infection, placed the life of appellant Flotilde
in jeopardy and caused appellant fear, worry and anxiety. . . .
WHEREFORE, the appealed judgment, dismissing the complaint for
damages is REVERSED and SET ASIDE. Another judgment is hereby
entered ordering defendants-appellees to pay plaintiffs-appellants the
amounts of P17,000.00 as and for actual damages; P100,000.00 as and for
moral damages; P20,000.00 as and for exemplary damages; and P25,000.00
as and for attorney's fees plus the costs of litigation.
SO ORDERED.21
From the above judgment, the petitioners appealed to this Court claiming that
the appellate court: (1) committed grave abuse of discretion by resorting to
findings of fact not supported by the evidence on record, and (2) exceeded its
discretion, amounting to lack or excess of jurisdiction, when it gave credence
to testimonies punctured with contradictions and falsities.
The private respondents commented that the petition raised only questions of
fact, which were not proper for review by this Court.
While the rule is that only questions of law may be raised in a petition for
review on certiorari, there are exceptions, among which are when the factual
findings of the trial court and the appellate court conflict, when the appealed
decision is clearly contradicted by the evidence on record, or when the
appellate court misapprehended the facts.22
After deciphering the cryptic petition, we find that the focal point of the
instant appeal is the appreciation of Dr. Kho's testimony. The petitioners
contend that the Court of Appeals misappreciated the following portion of Dr.
Kho's testimony:
Q What is the purpose of the examination?
A Just in case, I was just thinking at the back of my mind, just in case this
would turn out to be a medico-legal
case, I have heard somebody that [sic] says [sic] there is [sic] a
foreign body that goes with the tissues but unluckily I don't know where the r
ubber was. It was not in the Lab, it was not in Cebu. 23 (emphasis supplied)
The petitioners prefer the trial court's interpretation of the above
testimony, i.e., that Dr. Kho's knowledge of the piece of rubber was based on
hearsay. The Court of Appeals, on the other hand, concluded that the
underscored phrase was taken out of context by the trial court. According to
the Court of Appeals, the trial court should have likewise considered the other
portions of Dr. Kho's testimony, especially the following:
Q So you did actually conduct the operation on her?
A Yes, I did.
Q And what was the result?
A Opening up her abdomen, there was whitish-yellow discharge inside the
abdomen, there was an ovarian cyst on the left and side and there was also an
ovarian cyst on the right which, on opening up or freeing it up from the uterus,
turned out to be pus. Both ovaries turned out. . . to have pus. And then,
cleaning up the uterus, at the back of the uterus it was very dirty, it was full
of pus. And there was a [piece of] rubber, we found a [piece of] rubber on the
right
side. 24
We agree with the Court of Appeals. The phrase relied upon by the trial court
does not negate the fact that 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.25 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 for, as she asserted before
the trial court:
Q But you are sure you have seen [the piece of rubber]?
A Oh yes. I was not the only one who saw it. 26
The petitioners emphasize that the private respondents never reconciled Dr.
Kho's testimony with Dr. Batiquin's claim on the witness stand that when Dr.
Batiquin confronted Dr. Kho about the foreign body, the latter said that there
was a piece of rubber but that she threw it away. Although hearsay, Dr.
Batiquin's claim was not objected to, and hence, the same is admissible27 but
it carries no probative value.28 Nevertheless, assuming otherwise, Dr.
Batiquin's statement 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. On this
score, it is perfectly reasonable to believe the testimony of a witness with
respect to some facts and disbelieve his testimony with respect to other facts.
And it has been aptly said that even when a witness is found to have
deliberately falsified in some material particulars, it is not required that the
whole of his uncorroborated testimony be rejected, but such portions thereof
deemed worthy of belief may be credited.29
It is here worth noting that the trial court paid heed to the following portions
of Dr. Batiquin's testimony: that no rubber drain was used in the
operation,30 and that there was neither any tear on Dr. Batiquin's gloves after
the operation nor blood smears on her hands upon removing her
gloves.31 Moreover, the trial court pointed out that the absence of a rubber
drain was corroborated by Dr. Doris Sy, Dr. Batiquin's assistant during the
operation on private respondent Villegas.32 But the trial court failed to
recognize that the assertions of Drs. Batiquin and Sy were denials or negative
testimonies. Well-settled is the rule that positive testimony is stronger than
negative testimony.33 Of course, as the petitioners advocate, such positive
testimony must come from a credible source, which leads us to the second
assigned error.
While the petitioners claim that contradictions and falsities punctured Dr.
Kho's testimony, a regarding of the said testimony reveals no such infirmity
and establishes Dr. Kho as a credible witness. Dr. Kho was frank throughout
her turn on the witness stand. Furthermore, no motive to state any untruth was
ever imputed against Dr. Kho, leaving her trustworthiness unimpaired.34 The
trial court's following declaration shows that while it was critical of the lack
of care with which Dr. Kho handled the piece of rubber, it was not prepared
to doubt Dr. Kho's credibility, thus only supporting our appraisal of Dr. Kho's
trustworthiness:
This is not to say that she was less than honest when she testified about her
findings, but it can also be said that she did not take the most appropriate
precaution to preserve that "piece of rubber" as an eloquent evidence of what
she would reveal should there be a "legal problem" which she claim[s] to have
anticipated.35
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. This
Court has had occasion to delve into the nature and operation of this doctrine:
This doctrine [res ipsa loquitur] is stated thus: "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 in 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." Or as Black's Law Dictionary puts it:
Res ipsa loquitur. The thing speaks for itself. Rebuctable 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 ordinary 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 [sic] was such that in the ordinary course
of things would not happen if reasonable care had been used.The doctrine of
[r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence
which recognizes that prima facie negligence may be established without
direct proof and furnishes a substitute for specific proof of negligence. The
doctrine 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 particular case, is not intended 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 facilitates the burden of plaintiff of proving a breach of the duty of due
care. The doctrine can be invoked when and only when, under the
circumstances involved, direct evidence is absent and not readily available.36
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,3 7 and the State's compelling interest to enact measures to
protect the public from "the potentially deadly effects of incompetence and
ignorance in those who would undertake to treat our bodies and minds for
disease or trauma."38 Indeed, a physician is bound to serve the interest of his
patients "with the greatest of solicitude, giving them always his best talent and
skill."39 Through her tortious conduct, the petitioner endangered the life of
Flotilde Villegas, in violation of her profession's rigid ethical code and in
contravention of the legal standards set forth for professionals, in
general,40 and members of the medical profession,41 in particular.
WHEREFORE, the challenged decision of 11 May 1994 of the Court of
Appeals in CA-G.R. CV No. 30851 is hereby AFFIRMED in toto. Costs
against the petitioners. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 118141 September 5, 1997
LEONILA GARCIA-RUEDA, petitioner,
vs.
WILFRED L. PASCASIO, RAUL R. ARNAU, ABELARDO L.
APORTADERA JR., Honorable CONRADO 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.
ROMERO, J.:
May this Court review the findings of the Office of the Ombudsman? The
general rule has been enunciated in Ocampo v. Ombudsman1 which
states:
In the exercise of its investigative power, this Court has consistently held
that courts will not interfere with the discretion of the fiscal or the
Ombudsman to determine the specificity and adequacy of the averments
of the offense charged. He may dismiss the complaint forthwith if he finds
it to be insufficient in form and substance or if he otherwise finds no
ground to continue with the inquiry; or he may proceed with the
investigation of the complaint if, in his view, it is in due and proper form.
Does the instant case warrant a departure from the foregoing general
rule? When a patient dies soon after surgery under circumstances which
indicate that the attending surgeon and anaesthesiologist may have been
guilty of negligence but upon their being charged, a series
of nine prosecutors toss the responsibility of conducting a preliminary
investigation to each other with contradictory recommendations, "ping-
pong" style, perhaps the distraught widow is not to be blamed if she
finally decides to accuse the City Prosecutors at the end of the line for
partiality under the Anti-Graft and Corrupt Practices Act. Nor may she
be entirely faulted for finally filing a petition before this Court against
the Ombudsman for grave abuse of discretion in dismissing her
complaint against said City Prosecutors on the ground of lack of
evidence. Much as we sympathize with the bereaved widow, however, this
Court is of the opinion that the general rule still finds application in
instant case. In other words, the respondent Ombudsman did not commit
grave abuse of discretion in deciding against filing the necessary
information against public respondents of the Office of the City
Prosecutor.
The following facts are borne out by the records.
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.2
Not satisfied with the findings of the hospital, petitioner requested the
National Bureau of Investigation (NBI) to conduct an autopsy on her
husband's body. Consequently, the NBI ruled that Florencio's 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.
During the preliminary investigation, what transpired was a confounding
series of events which we shall try to disentangle. 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.
The case took another perplexing turn when Assistant City Prosecutor
Josefina Santos Sioson, in the "interest of justice and peace of mind of the
parties," recommended that the case be re-raffled on the ground that
Prosecutor Carisma was partial to the petitioner. Thus, 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 petitioner's motion for reconsideration regarding
Prosecutor Dimagiba's resolution, the investigative "pingpong" continued
when 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. 30193 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.
Preliminarily, the powers and functions of the Ombudsman have generally
been categorized into the following: investigatory powers, prosecutory power,
public assistance function, authority to inquire and obtain information, and
function to adopt, institute and implement preventive measures.4
As protector of the people, the Office of the Ombudsman has the power,
function and duty "to act promptly on complaints filed in any form or manner
against public officials" and "to investigate any act or omission of any public
official when such act or omission appears to be illegal, unjust, improper or
inefficient."5
While the Ombudsman has the full discretion to determine whether or not a
criminal case should be filed, this Court is not precluded from reviewing the
Ombudsman's action when there is an abuse of discretion, in which case Rule
65 of the Rules of Court may exceptionally be invoked pursuant to Section I,
Article VIII of the 1987 Constitution.6
In this regard, "grave abuse of discretion" has been defined as "where a power
is exercised in an arbitrary or despotic manner by reason of passion or
personal hostility so patent and gross as to amount to evasion of positive duty
or virtual refusal to perform a duty enjoined by, or in contemplation of law.7
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
Ombudsmans should have been more vigilant and assiduous in determining
the reasons behind the "buckpassing" to ensure that no irregularity took place.
Whether such transfers were due to any outside pressure or ulterior motive is
a matter of evidence. One would have expected the Ombudsman, however, to
inquire into what could hardly qualify as "standard operating procedure,"
given the surrounding circumstances of the case.
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.8 Probable
cause has been defined as "the existence of such fact and circumstances as
would excite the belief, in a reasonable mind, acting on the facts within the
knowledge of the prosecution, that the person charged was guilty of the crime
for which he was prosecuted."9
"Probable cause is a reasonable ground of presumption that a matter is, or may
be, well founded, such a state of facts in the mind of the prosecutor as would
lead a person of ordinary caution and prudence to believe, or entertain an
honest or strong suspicion, that a thing is so." The term does not mean actual
and positive cause nor does it import absolute certainty. It is merely based on
opinion and reasonable belief. Thus, a finding of probable cause does not
require an inquiry into whether there is sufficient evidence to procure a
conviction. It is enough that it is believed that the act or omission complained
of constitutes the offense charged. Precisely, there is a trial for the reception
of evidence of the prosecution in support of the charge. 10
In the instant case, 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 party's 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.
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. 12
Hence, there are four elements involved in medical negligence cases: duty,
breach, injury and proximate causation.
Evidently, when the victim employed the services of Dr. Antonio and Dr.
Reyes, a physician-patient relationship was created. In accepting the case, 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. 15
Moreover, in malpractice or negligence cases involving the administration of
anaesthesia, the necessity of expert testimony and the availability of the
charge of res ipsa loquitur to the plaintiff; have been applied in actions
against anaesthesiologists to hold the defendant liable for the death or injury
of a patient under excessive or improper anaesthesia. 16 Essentially, it requires
two-pronged evidence: evidence as to the recognized standards of the medical
community in the particular kind of case, and a showing that the physician in
question negligently departed from this standard in his treatment. 17
Another element in medical negligence cases is causation which is divided
into two inquiries: whether the doctor's actions in fact caused the harm to the
patient and whether these were the proximate cause of the patient's
injury. 18 Indeed here, a causal connection is discernible from the occurrence
of the victim's 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. Moreover, the NBI deduced that the attending
surgeons did not conduct the necessary interview of the patient prior to the
operation. It appears that the cause of the death of the victim could have been
averted had the proper drug been applied to cope with the symptoms of
malignant hyperthermia. Also, we cannot ignore the fact that an antidote was
readily available to counteract whatever deleterious effect the anaesthesia
might produce. 19 Why these precautionary measures were disregarded must
be sufficiently explained.
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. 20
Why did the complainant, petitioner in instant case, elect to charge
respondents under the above law?
While a party who feels himself aggrieved is at liberty to choose the
appropriate "weapon from the armory," it is with no little surprise that this
Court views the choice made by the complainant widow.
To our mind, 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
Justice's Order No. 223, 21 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:
Sec. 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.
What action may the Secretary of Justice take on the appeal? Section 9 of
Order No. 223 states: "The Secretary of Justice may reverse, affirm or modify
the appealed resolution." On the other hand, "He may motu proprio or on
motion of the appellee, dismiss outright the appeal on specified grounds." 22
In exercising his discretion under the circumstances, the Ombudsman acted
within his power and authority in dismissing the complaint against the
Prosecutors and this Court will not interfere with the same.
WHEREFORE, in view of the foregoing, 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. No costs. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 122445 November 18, 1997
DR. NINEVETCH CRUZ, petitioner,
vs.
COURT OF APPEALS and LYDIA UMALI, respondents.
FRANCISCO, J.:
Doctors are protected by a special rule of 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 mistakes
of judgment . . . 1
The present case against petitioner is in the nature of a medical malpractice
suit, which in simplest terms is the 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. 2 In this jurisdiction, however, such claims are most
often brought as a civil action for damages under Article 2176 of the Civil
Code, 3 and in some instances, as a criminal case under Article 365 of the
Revised Penal Code 4 with which the civil action for damages is impliedly
instituted. It is via the latter type of action that the heirs of the deceased sought
redress for the petitioner's alleged imprudence and negligence in treating the
deceased thereby causing her death. The petitioner and one Dr. Lina Ercillo
who was the attending anaesthesiologist during the operation of the deceased
were charged with "reckless imprudence and negligence resulting to (sic)
homicide" in an information which reads:
That on or about March 23, 1991, in the City of San Pablo, Republic of the
Philippines and within the jurisdiction of this Honorable Court, the accused
above named, being then the attending anaesthesiologist and surgeon,
respectively, did then and there, in a negligence (sic), careless, imprudent, and
incompetent manner, and failing to supply or store sufficient provisions and
facilities necessary to meet any and all exigencies apt to arise before, during
and/or after a surgical operation causing by such negligence, carelessness,
imprudence, and incompetence, and causing by such failure, including the
lack of preparation and foresight needed to avert a tragedy, the untimely death
of said Lydia Umali on the day following said surgical operation. 5
Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty
to the above-mentioned charge. On March 4, 1994, the Municipal Trial Court
in Cities (MTCC) of San Pablo City rendered a decision, the dispositive
portion of which is hereunder quoted as follows:
WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty of the
offense charged for insufficiency of evidence while her co-accused Dra.
Ninevetch Cruz is hereby held responsible for the death of Lydia Umali on
March 24, 1991, and therefore guilty under Art. 365 of the Revised Penal
Code, and she is hereby sentenced to suffer the penalty of 2 months and 1 day
imprisonment of arresto mayor with costs. 6
The petitioner appealed her conviction to the Regional Trial Court (RTC)
which affirmed in toto the decision of the MTCC 7 prompting the petitioner
to file a petition for review with the Court of Appeals but to no avail. Hence
this petition for review on certiorari assailing the decision promulgated by
the Court of Appeals on October 24, 1995 affirming petitioner's conviction
with modification that she is further directed to pay the heirs of Lydia Umali
P50,000.00 as indemnity for her death.8
In substance, the petition brought before this Court raises the issue of whether
or not petitioner's conviction of the crime of reckless imprudence resulting in
homicide, arising from an alleged medical malpractice, is supported by the
evidence on record.
First the antecedent facts.
On March 22, 1991, prosecution witness, Rowena Umali De Ocampo,
accompanied her mother to the Perpetual Help Clinic and General Hospital
situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said
hospital at around 4:30 in the afternoon of the same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a
"myoma" 10 in her uterus, and scheduled her for a hysterectomy operation on
March 23,
11
1991. Rowena and her mother slept in the clinic on the evening of March
22, 1991 as the latter was to be operated on the next day at 1:00 o'clock in the
afternoon. 12 According to Rowena, she noticed that the clinic was untidy and
the window and the floor were very dusty prompting her to ask the attendant
for a rag to wipe the window and the floor with. 13 Because of the untidy state
of the clinic, Rowena tried to persuade her mother not to proceed with the
operation. 14 The following day, before her mother was wheeled into the
operating room, Rowena asked the petitioner if the operation could be
postponed. The petitioner called Lydia into her office and the two had a
conversation. Lydia then informed Rowena that the petitioner told her that she
must be operated on as scheduled. 15
Rowena and her other relatives, namely her husband, her sister and two aunts
waited outside the operating room while Lydia underwent operation. While
they were waiting, Dr. Ercillo went out of the operating room and instructed
them to buy tagamet ampules which Rowena's sister immediately bought.
About one hour had passed when Dr. Ercillo came out again this time to ask
them to buy blood for Lydia. They bought type "A" blood from the St. Gerald
Blood Bank and the same was brought by the attendant into the operating
room. After the lapse of a few hours, the petitioner informed them that the
operation was finished. The operating staff then went inside the petitioner's
clinic to take their snacks. 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. Unfortunately, they were not
able to comply with petitioner's order as there was no more type "A" blood
available in the blood bank. Thereafter, 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. 16 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. 17 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. Rowena and her other relatives then boarded
a tricycle and followed the ambulance. 18
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. 19 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. 20 While
the petitioner was closing the abdominal wall, the patient died. 21 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. 22
In convicting the petitioner, the MTCC found the following circumstances as
sufficient basis to conclude that she was indeed negligent in the performance
of the operation:
. . . , the clinic was untidy, there was lack of provision like blood and oxygen
to prepare for any contingency that might happen during the operation. The
manner and the fact that the patient was brought to the San Pablo District
Hospital for reoperation indicates that there was something wrong in the
manner in which Dra. Cruz conducted the operation. There was no showing
that before the operation, accused Dra. Cruz had conducted a cardio
pulmonary clearance or any typing of the blood of the patient. It was (sic) said
in medical parlance that the "the abdomen of the person is a temple of
surprises" because you do not know the whole thing the moment it was open
(sic) and surgeon must be prepared for any eventuality thereof. The patient
(sic) chart which is a public document was not presented because it is only
there that we could determine the condition of the patient before the surgery.
The court also noticed in Exh. "F-1" that the sister of the deceased wished to
postpone the operation but the patient was prevailed upon by Dra. Cruz to
proceed with the surgery. The court finds that Lydia Umali died because of
the negligence and carelessness of the surgeon Dra. Ninevetch Cruz because
of loss of blood during the operation of the deceased for evident
unpreparedness and for lack of skill, the reason why the patient was brought
for operation at the San Pablo City District Hospital. As such, the surgeon
should answer for such negligence. With respect to Dra. Lina Ercillo, the
anaesthesiologist, there is no evidence to indicate that she should be held
jointly liable with Dra. Cruz who actually did the operation. 23
The RTC reiterated the abovementioned findings of the MTCC and upheld
the latter's declaration of "incompetency, negligence and lack of foresight and
skill of appellant (herein petitioner) in handling the subject patient before and
after the operation." 24 And likewise affirming the petitioner's conviction, the
Court of Appeals echoed similar observations, thus:
. . . While we may grant that the untidiness and filthiness of the clinic may not
by itself indicate negligence, it nevertheless shows the absence of due care
and supervision over her subordinate employees. Did this unsanitary
condition permeate the operating room? Were the surgical instruments
properly sterilized? Could the conditions in the OR have contributed to the
infection of the patient? Only the petitioner could answer these, but she opted
not to testify. This could only give rise to the presumption that she has nothing
good to testify on her defense. Anyway, the alleged "unverified statement of
the prosecution witness" remains unchallenged and unrebutted.
Likewise undisputed is the prosecution's version indicating the following
facts: that the accused asked the patient's relatives to buy Tagamet capsules
while the operation was already in progress; that after an hour, they were also
asked to buy type "A" blood for the patient; that after the surgery, they were
again asked to procure more type "A" blood, but such was not anymore
available from the source; that the oxygen given to the patient was empty; and
that the son-in-law of the patient, together with a driver of the petitioner, had
to rush to the San Pablo City District Hospital to get the much-needed oxygen.
All these conclusively show that the petitioner had not prepared for any
unforeseen circumstances before going into the first surgery, which was not
emergency in nature, but was elective or pre-scheduled; she had no ready
antibiotics, no prepared blood, properly typed and cross-matched, and no
sufficient oxygen supply.
Moreover, there are a lot of questions that keep nagging Us. Was the patient
given any cardio-pulmonary clearance, or at least a clearance by an internist,
which are standard requirements before a patient is subjected to surgery. Did
the petitioner determine as part of the pre-operative evaluation, the bleeding
parameters of the patient, such as bleeding time and clotting time? There is
no showing that these were done. The petitioner just appears to have been in
a hurry to perform the operation, even as the family wanted a postponement
to April 6, 1991. Obviously, she did not prepare the patient; neither did she
get the family's consent to the operation. Moreover, she did not prepare a
medical chart with instructions for the patient's care. If she did all these, proof
thereof should have been offered. But there is none. Indeed, these are
overwhelming evidence of recklessness and imprudence. 25
This Court, however, holds differently and finds the foregoing 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.
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. 26 In the recent
case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et al., 27 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. 28 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. 29
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.
All three courts below bewail the inadequacy of the facilities of the clinic and
its untidiness; the lack of provisions such as blood, oxygen, and certain
medicines; the failure to subject the patient to a cardio-pulmonary test prior
to the operation; the omission of any form of blood typing before transfusion;
and even the subsequent transfer of Lydia to the San Pablo Hospital and the
reoperation performed on her by the petitioner. But while it may be true that
the circumstances pointed out by the courts below seemed beyond cavil to
constitute reckless imprudence on the part of the surgeon, this conclusion is
still best arrived at not through the educated surmises nor conjectures of
laymen, including judges, but by the unquestionable knowledge of expert
witnesses. For whether a physician or surgeon has exercised the requisite
degree of skill and care in the treatment of his patient is, in the generality of
cases, a matter of expert opinion. 30 The deference of courts to the expert
opinion of qualified physicians stems from its realization that the latter
possess unusual technical skills which laymen in most instances are incapable
of intelligently evaluating. 31 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. 33 In Chan Lugay v. St. Luke's Hospital, Inc., 34 where the attending
physician was absolved of liability for the death of the complainant's wife and
newborn baby, this Court held that:
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 Intestines and mesenteries are pale with blood clots noted between the
occurred." 35 (Emphasis supplied.) mesentric folds.

Dr. Arizala who conducted an autopsy on the body of the deceased Hemoperitoneum: 300 s.s.,
summarized his findings as follows: right paracolic gutter,
50 c.c., left paracolic gutter
Atty. Cachero: 200 c.c., mesentric area,
100 c.c., right pelvic gutter
Q. You mentioned about your Autopsy Report which has been marked as Exh. stomach empty.
"A-1-b". There appears here a signature above the typewritten name Floresto
Arizala, Jr., whose signature is that? Other visceral organs, pale.,

A. That is my signature, sir.
Q. Do you affirm the truth of all the contents of Exh. "A-1-b"?
A. Only as to the autopsy report no. 91-09, the time and place and everything
after the post mortem findings, sir.
will you please explain that on (sic) your own language or in ordinary. . . . . .
......
A. There was a uterus which was not attached to the adnexal structures namely
ovaries which were not present and also sign of previous surgical operation
and there were (sic) clotted blood, sir.

Q. You mentioned on your "Post Mortem Findings" about surgical incision, Q. How about the ovaries and adnexal structures?
14:0 cm., infraumbilical area, anterior abdominal area, midline, will you
please explain that in your own language? A. They are missing, sir.

A. There was incision wound (sic) the area just below the navel, sir. Q. You mean to say there are no ovaries?

Q. And the last paragraph of the postmortem findings which I read: Uterus,
pear-shaped and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface
nodulation of the fundic area posteriorly. Cut-section shows diffusely pale
myometrium with areas of streak induration. The ovaries and adnexal
structures are missing with the raw surfaces patched with clotted blood.
Surgical sutures were noted on the operative site.
A. During that time there are no ovaries, sir.
Q. And there were likewise sign of surgical sutures?
A. Yes, sir.
Q. How about the intestines and mesenteries are place (sic) with blood clots
noted between the mesenteric folds, will you please explain on (sic) this?
A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
Q. And what could have caused this blood?
A. Well, ordinarily blood is found inside the blood vessel. Blood were (sic)
outside as a result of the injuries which destroyed the integrity of the vessel
allowing blood to sip (sic) out, sir.
Q. By the nature of the postmortem findings indicated in Exh. A-1-B, can you
tell the court the cause of death?
A. Yes, sir. The cause of death is: Gross findings are compatible with
hemorrhagic shock.
Q. Can you tell the us what could have caused this hemorrhagic shock?
A. Well hemorrhagic shock is the result of blood loss.
Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
The foregoing was corroborated by Dr. Nieto Salvador:
Q. And were you able to determine the cause of death by virtue of the
examination of the specimen submitted by Dr. Arizala?
A. Without knowledge of the autopsy findings it would be difficult for me to
determine the cause of death, sir.
Q. Have you also examined the post mortem of Dr. Arizala?
A. Yes, sir, and by virtue of the autopsy report in connection with your
pathology report.
Q. What could have caused the death of the victim?
A. This pathologic examination are (sic) compatible with the person who
died, sir.
Q. Will you explain to us the meaning of hemorrhagic compatible?
A. It means that a person died of blood loss. Meaning a person died of non-
replacement of blood and so the victim before she died there was shock of
diminish of blood of the circulation. She died most probably before the actual
complete blood loss, sir.
Court: Is it possible doctor that the loss of the blood was due on (sic)
operation?
A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery. Another may be a blood
vessel may be cut while on operation and this cause (sic) bleeding, or may be
set in the course of operation, or may be (sic) he died after the operation. Of
course there are other cause (sic).
Atty. Cachero:
Q. Especially so doctor when there was no blood replacement?
A. Yes, sir. 37 (Emphasis supplied.)
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. Thus, Dr. Salvador's elaboration on the
matter:
Atty. Pascual:
Q. Doctor, among the causes of hemorrhage that you mentioned you said that
it could be at the moment of operation when one losses (sic) control of the
presence, is that correct? During the operation there is lost (sic) of control of
the cut vessel?
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size?
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped later on?
A. Yes, sir.
Q. And you also mentioned that it may be possible also to some clotting defect,
is that correct?
A. May be (sic). 38 (Emphasis supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert opinion:
Q. Doctor even a patient after an operations (sic) would suffer hemorrage
what would be the possible causes of such hemorrage (sic)?
A. Among those would be what we call Intravascular Coagulation and this is
the reason for the bleeding, sir, which cannot be prevented by anyone, it will
happen to anyone, anytime and to any persons (sic), sir.
COURT:
What do you think of the cause of the bleeding, the cutting or the operations
done in the body?
A. Not related to this one, the bleeding here is not related to any cutting or
operation that I (sic) have done.
Q. Aside from the DIC what could another causes (sic) that could be the cause
for the hemorrhage or bleeding in a patient by an operations (sic)?
A. In general sir, if there was an operations (sic) and it is possible that the
ligature in the suture was (sic) become (sic) loose, it is (sic) becomes loose if
proven..
xxx xxx xxx
Q. If the person who performed an autopsy does not find any untight (sic) clot
(sic) blood vessel or any suture that become (sic) loose the cause of the
bleeding could not be attributed to the fault of the subject?
A. Definitely, sir. 39 (Emphasis supplied.)
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. 40 Hence the following pertinent portion of Dr. Arizala's
testimony:
Q: Doctor, in examining these structures did you know whether these were
sutured ligature or plain ligature
A: Ligature, sir.
Q: We will explain that later on. Did you recall if the cut structures were tied
by first suturing it and then tying a knot or the tie was merely placed around
the cut structure and tied?
A: I cannot recall, sir.
Q: As a matter of fact, you cannot recall because you did not even bothered
(sic) to examine, is that correct?
A: Well, I bothered enough to know that they were sutured, sir.
Q: So, therefore, Doctor, you would not know whether any of the cut
structures were not sutured or tied neither were you able to determine
whether any loose suture was found in the peritoneal cavity?
A: I could not recall any loose sutured (sic), sir. 41
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. 42 And as testified to by defense witness, Dr. Bu C.
Castro, hemorrhage due to DIC "cannot be prevented, it will happen to
anyone,
anytime." 43 He testified further:
Q. Now, under that circumstance one of the possibility as you mentioned in
(sic) DIC?
A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
A. Yes, sir.
Q. Can you even predict if it really happen (sic)?
A. Possible, sir.
Q. Are there any specific findings of autopsy that will tell you whether this
patient suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient.
Q. Now, Doctor you said that you went through the record of the deceased
Lydia Umali looking for the chart, the operated (sic) records, the post mortem
findings on the histophanic (sic) examination based on your examination of
record, doctor, can you more or less says (sic) what part are (sic) concerned
could have been the caused (sic) of death of this Lydia Umali?
A. As far as the medical record is concern (sic) the caused (sic) of death is
dessimulated (sic) Intra Vascular Coagulation or the DIC which resulted to
hemorrhage or bleedings, sir.
Q. Doctor based on your findings then there is knowing (sic) the doctor would
say whether the doctor her (sic) has been (sic) fault?
ATTY. MALVEDA: until proven guilty beyond reasonable doubt. Nevertheless, this Court finds
the petitioner civilly liable for the death of Lydia Umali, for while a
We will moved (sic) to strike out the (sic) based on finding they just read the conviction of a crime requires proof beyond reasonable doubt, only a
chart as well as the other record. preponderance of evidence is required to establish civil liability. 45

ATTY. PASCUAL: The petitioner is a doctor in whose hands a patient puts his life and limb. For
insufficiency of evidence this Court was not able to render a sentence of
Precisely based on this examination. conviction but it is not blind to the reckless and imprudent manner in which
the petitioner carried out her duties. A precious life has been lost and the
ATTY. MALVEDA: circumstances leading thereto exacerbated the grief of those left behind. The
heirs of the deceased continue to feel the loss of their mother up to the present
Not finding, there was no finding made. time 46 and this Court is aware that no amount of compassion and
commiseration nor words of bereavement can suffice to assuage the sorrow
COURT: felt for the loss of a loved one. Certainly, the award of moral and exemplary
damages in favor of the heirs of Lydia Umali are proper in the instant case.
He is only reading the record.
WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is
ATTY. PASCUAL: hereby ACQUITTED of the crime of reckless imprudence resulting in
homicide but is ordered to pay the heirs of the deceased Lydia Umali the
Yes, sir. amount of FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE
HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and
A. No, sir, there is no fault on the part of the surgeon, sir. 44 FIFTY THOUSAND PESOS (P50,000.00) as exemplary damages.

This Court has no recourse but to rely on the expert testimonies rendered by Let a copy of this decision be furnished to the Professional Regulation
both prosecution and defense witnesses that substantiate rather than contradict Commission (PRC) for appropriate action.
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 SO ORDERED.
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. While we condole with the Republic of the Philippines
family of Lydia Umali, our hands are bound by the dictates of justice and fair SUPREME COURT
dealing which hold inviolable the right of an accused to be presumed innocent Manila
 FIRST DIVISION
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 APPEALS, DELOS SANTOS MEDICAL CENTER, DR.
ORLINO HOSAKA and DRA. PERFECTA GUTIERREZ, respondents.
KAPUNAN, J.:
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, 22-23, 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.).
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
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.
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;
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
loquiturto the instant case. Thereafter, the first two assigned errors shall be
tackled in relation to the res ipsa loquiturdoctrine.
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 facie case, 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;
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 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. 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. 40The 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
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 the res 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.
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 Witness may answer if she knows.
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 A: As have said, I was with the patient, I was beside the stretcher holding the
piteous condition. 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,
In the instant case, the records are helpful in furnishing not only the logical mali yata ang pagkakapasok. O lumalaki ang tiyan.
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 xxx xxx xxx
hereinafter, private respondents' own testimonies which are reflected in the
transcript of stenographic notes are replete of signposts indicative of their ATTY. PAJARES:
negligence in the care and management of Erlinda.
Q: From whom did you hear those words "lumalaki ang tiyan"?
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. A: From Dra. Perfecta Gutierrez.
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 xxx xxx xxx
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: Q: After hearing the phrase "lumalaki ang tiyan," what did you notice on the
person of the patient?
ATTY. PAJARES:
A: I notice (sic) some bluish discoloration on the nailbeds of the left hand
Q: In particular, what did Dra. Perfecta Gutierrez do, if any on the patient? where I was at.

A: In particular, I could see that she was intubating the patient. Q: Where was Dr. Orlino Ho[s]aka then at that particular time?

Q: Do you know what happened to that intubation process administered by A: I saw him approaching the patient during that time.
Dra. Gutierrez?
Q: When he approached the patient, what did he do, if any?
ATTY. ALCERA:
A: He made an order to call on the anesthesiologist in the person of Dr.
She will be incompetent Your Honor. Calderon.

COURT: Q: Did Dr. Calderon, upon being called, arrive inside the operating room?
A: Yes sir. 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.
Q: What did [s]he do, if any? 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
A: [S]he tried to intubate the patient. factual bases. 47

Q: What happened to the patient? 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
A: When Dr. Calderon try (sic) to intubate the patient, after a while the not competent to testify on whether or not the intubation was a success.
patient's nailbed became bluish and I saw the patient was placed in
trendelenburg position. 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
xxx xxx xxx on which she is capable of observing such as, the statements and acts of the
physician and surgeon, external appearances, and manifest conditions which
Q: Do you know the reason why the patient was placed in that trendelenburg are observable by any one. 48 This is precisely allowed under the doctrine
position? 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
A: As far as I know, when a patient is in that position, there is a decrease of negligence in non-technical matters or those of which an ordinary person may
blood supply to the brain. 46 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
xxx xxx xxx 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
The appellate court, however, disbelieved Dean Cruz's testimony in the trial would not be too difficult to tell if the tube was properly inserted. This kind
court by declaring that: of observation, we believe, does not require a medical degree to be acceptable.

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
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
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. 56Thus, 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 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. 63Clearly, 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 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 one-third (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.
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 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
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.
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.
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. 84 The 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.
damages computed as of the date of promulgation of this decision plus a
monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos
expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3)
P1,500,000.00 as temperate damages; 4) P100,000.00 each as exemplary
damages and attorney's fees; and, 5) the costs of the suit. SO ORDERED.

Finally, by way of example, exemplary damages in the amount of Republic of the Philippines
P100,000.00 are hereby awarded. Considering the length and nature of the SUPREME COURT
instant suit we are of the opinion that attorney's fees valued at P100,000.00 Manila
are likewise proper.
SECOND DIVISION
Our courts face unique difficulty in adjudicating medical negligence cases
because physicians are not insurers of life and, they rarely set out to G.R. No. 130547 October 3, 2000
intentionally cause injury or death to their patients. However, intent is
immaterial in negligence cases because where negligence exists and is proven, LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and minors
the same automatically gives the injured a right to reparation for the damage LLOYD and KRISTINE, all surnamed REYES, represented by their
caused. mother, LEAH ALESNA REYES, petitioners,
vs.
Established medical procedures and practices, though in constant flux are SISTERS OF MERCY HOSPITAL, SISTER ROSE PALACIO, DR.
devised for the purpose of preventing complications. A physician's experience MARVIE BLANES, and DR. MARLYN RICO, respondents.
with his patients would sometimes tempt him to deviate from established
community practices, and he may end a distinguished career using DECISION
unorthodox methods without incident. However, when failure to follow
established procedure results in the evil precisely sought to be averted by MENDOZA, J.:
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 This is a petition for review of the decision1 of the Court of Appeals in CA-
it. In the case at bar, the failure to observe pre-operative assessment protocol G.R. CV No. 36551 affirming the decision of the Regional Trial Court,
which would have influenced the intubation in a salutary way was fatal to Branch IX, Cebu City which dismissed a complaint for damages filed by
private respondents' case. petitioners against respondents.

WHEREFORE, the decision and resolution of the appellate court appealed The facts are as follows:
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
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 Jorge’s 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 Jorge’s
temperature rose to 41°C. 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 patient’s 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 complaint6 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 patient’s 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.
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 findings9 showed that the gastro-intestinal 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
patient’s 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 Jorge’s 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 Jorge’s 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 Jorge’s death was due to the latter’s 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 DOCTOR’S NEGLIGENCE IN THE
TREATMENT OF JORGE REYES.
Petitioner’s 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
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
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 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 patient’s 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 in Ramos:
. . . . 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 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 Q But you have not performed an autopsy of a patient who died of typhoid
fever?
We turn to the question whether petitioners have established specific acts of
negligence allegedly committed by respondent doctors. A I have not seen one.

Petitioners contend that: (1) Dr. Marlyn Rico hastily and erroneously relied Q And you testified that you have never seen a patient who died of typhoid
upon the Widal test, diagnosed Jorge’s illness as typhoid fever, and fever within five days?
immediately prescribed the administration of the antibiotic
chloromycetin;21 and (2) Dr. Marvie Blanes erred in ordering the A I have not seen one.
administration of the second dose of 500 milligrams of chloromycetin barely
three hours after the first was given.22 Petitioners presented the testimony of Q How many typhoid fever cases had you seen while you were in the general
Dr. Apolinar Vacalares, Chief Pathologist of the Northern Mindanao Training practice of medicine?
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 A In our case we had no widal test that time so we cannot consider that the
autopsy, Jorge Reyes did not die of typhoid fever but of shock undetermined, typhoid fever is like this and like that. And the widal test does not specify the
which could be due to allergic reaction or chloromycetin overdose. We are time of the typhoid fever.
not persuaded.
Q The question is: how many typhoid fever cases had you seen in your general
First. While petitioners presented Dr. Apolinar Vacalares as an expert practice regardless of the cases now you practice?
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 A I had only seen three cases.
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 Q And that was way back in 1964?
Reyes. It is also plain from his testimony that he has treated only about three
cases of typhoid fever. Thus, he testified that:23 A Way back after my training in UP.

ATTY. PASCUAL: Q Clinically?

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.
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
bronchospasms24 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.
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
Rico’s 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 patient’s 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 41oC, and then about 40 minutes
later the temperature rose to 100oF, 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 deceased’s
gastro-intestinal tract was normal, Dr. Rico explained that, while
hyperplasia31 in the payer’s 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. Gotiong’s
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 payer’s patches may be microscopic.36
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 patient’s 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 shock38 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 Harrison’s 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 o’clock 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, O’Nick, 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,40physicians 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. . . .
The practice of medicine is a profession engaged in only by qualified
individuals.1âwphi1 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 Dental Services. All three were working for the Court at the time of the
conditioned upon the highest degree of diligence. And, as we have already incident in issue.
noted, the standard contemplated for doctors is simply the reasonable average
merit among ordinarily good physicians. That is reasonable diligence for The parties agree that on January 12, 2005, at around 4:20 p.m., Ruñez, Sr.
doctors or, as the Court of Appeals called it, the reasonable "skill and arrived by himself at this Court’s clinic complaining of dizziness. His blood
competence . . . that a physician in the same or similar locality . . . should pressure and pulse rate were taken by the reception nurse and were registered
apply." at 210/100 mmHg and 112 beats a minute, respectively. What transpired next
is disputed. Ruñez, Jr. alleged that despite his father’s medical condition, he
WHEREFORE, the instant petition is DENIED and the decision of the Court was merely advised to go to a hospital and then allowed to walk out of the
of Appeals is AFFIRMED. SO ORDERED. clinic on his own. Dr. Jurado, on the other hand, maintained that after being
informed of Ruñez, Sr.’s blood pressure and heart rate, she instructed the
Republic of the Philippines nurse to administer one tablet of Capoten 25mg, an emergency drug that
SUPREME COURT quickly lowers a patient’s blood pressure. She then informed Ruñez, Sr. that
he will be taken to the hospital, after which she immediately instructed the
EN BANC ambulance driver, Mr. Jacinto, to stand by for hospital conduction. Minutes
later, after having taken Capoten and being given a chance to rest, Ruñez, Sr.
A.M. No. 2005-08-SC December 9, 2005 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
SAMUEL R. RUÑEZ, JR., Complainant, asked Mr. Almarza, a nurse at the clinic, to look for Ruñez, Sr. but he was
vs. unable to locate him.
MARYBETH V. JURADO, Respondent.
According to Ruñez, Jr., after being informed of his father’s condition, he
DECISION rushed him to the Manila Doctors Hospital. There, Ruñez, Sr. was treated in
the emergency room for approximately four hours before he was discharged
AZCUNA, J.: at around 8:30 p.m. and allowed to go home. However, prior to reaching their
house in Balintawak, Caloocan City, Ruñez, Sr. began experiencing nausea,
It is unfortunate that this administrative case involves co-workers in this abnormal palpitation and uneasiness and had to be brought back to the
Court. Complainant, Samuel R. Ruñez, Jr. (Ruñez, Jr.), is Chief of the hospital.
Clearance Section, Checks Disbursement Division of the FMO-OCA and is
the son of the aggrieved party, Samuel V. Ruñez, Sr. (Ruñez, Sr.), Driver I Ruñez, Sr. and Ruñez, Jr.1 arrived at the emergency room of the Manila
for the Motorpool, Property Division of the OCA. Respondent is Dr. Doctors Hospital at around 10:00 p.m. after which Ruñez, Sr. underwent a
Marybeth V. Jurado (Dr. Jurado), Medical Officer IV of the Medical and 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,
Ruñez Sr. never recovered from his ailment and, on September 12, 2005, he
passed away due to medical complications.2
On February 15, 2005, Ruñez, 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. Ruñez,
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 respondent’s witnesses. This was followed by Ruñez, Jr.’s
reply to the comment on April 12, 2005 and Dr. Jurado’s 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 Ruñez, 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 clinic’s personnel, including the
ambulance driver, who witnessed the events that happened between Ruñez,
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 Ruñez, Sr. proper treatment inside the
clinic. However, in her opinion, Dr. Jurado’s actions after Ruñez, Sr. had left
were less than the required diligence of a good father of a family. We quote
below the analysis of Atty. Candelaria:
. . . Records will clearly show that minutes after Mr. Ruñez, 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. Ruñez, 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. Ruñez 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]
didn’t materialize and [she] put [the] blame on Mr. Ruñez, Sr. As admitted by
complainant, Mr. Ruñez, 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 indifference4 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
court’s 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. Candelaria’s 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 Ruñez, 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 physician’s
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 doctor’s 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
persuaded that Dr. Jurado fulfilled such a standard when she treated Ruñez,
Sr. inside the clinic. But what of Dr. Jurado’s conduct after Ruñez, 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 Ruñez, Sr. to walk out of the clinic despite her
earlier diagnosis of his condition. By that time Ruñez, 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 disease13 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 Ruñez, 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 Ruñez, 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 Ruñez, Jr. decided to go
to the hospital on their own. Ruñez, Sr., still of sound mind, had the right to
accept or ignore his doctor’s recommendation. Dr. Jurado was obligated to
care for Ruñez, 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. Jurado’s inaction as indifference, while others
may view the same as just proper. Some would applaud Dr. Jurado’s
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 Ruñez, 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 Court
and Chief of Administrative Services, Dr. Prudencio Banzon, Senior Staff
Officer, Medical and Dental Services, is DIRECTED 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.
Republic of the Philippines
SUPREME COURT
THIRD DIVISION
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 Decision2 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.
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 damages15 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.
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.
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 200221 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.
25
Petitioners filed a motion for reconsideration 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 Hospital27 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.
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.
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 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.
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
x40 (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.44 This 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:
"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:
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 Center and/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 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 200259 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.64 Petitioners claim that Dr. Lacson was remiss in
her duty of supervising the blood bank staff.
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
and P700,000 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. Hospitals, having undertaken one of mankind’s 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
Republic of the Philippines standards of responsibility commensurate with the undertaking to preserve
SUPREME COURT and protect the health, and indeed, the very lives of those placed in the
Manila hospital’s keeping.1

FIRST DIVISION Assailed in these three consolidated petitions for review on certiorari is the
Court of Appeals’ Decision2 dated September 6, 1996 in CA-G.R. CV No.
G.R. No. 126297 January 31, 2007 42062 and CA-G.R. SP No. 32198 affirming with modification the
Decision3dated March 17, 1993 of the Regional Trial Court (RTC), Branch
PROFESSIONAL SERVICES, INC., Petitioner, 96, Quezon City in Civil Case No. Q-43322 and nullifying its Order dated
vs. September 21, 1993.
NATIVIDAD and ENRIQUE AGANA, Respondents.
The facts, as culled from the records, are:
G.R. No. 126467 January 31, 2007
On April 4, 1984, Natividad Agana was rushed to the Medical City General
NATIVIDAD (Substituted by her children MARCELINO AGANA III, Hospital (Medical City Hospital) because of difficulty of bowel movement
ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA, and bloody anal discharge. After a series of medical examinations, Dr. Miguel
and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners, Ampil, petitioner in G.R. No. 127590, diagnosed her to be suffering from
vs. "cancer of the sigmoid."
JUAN FUENTES, Respondent.
On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical
G.R. No. 127590 January 31, 2007 City Hospital, performed an anterior resection surgery on Natividad. He found
that the malignancy in her sigmoid area had spread on her left ovary,
MIGUEL AMPIL, Petitioner, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained
vs. the consent of Natividad’s husband, Enrique Agana, to permit Dr. Juan
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents. Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.

DECISION After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision.
SANDOVAL-GUTIERREZ, J.:
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.
Dr. Ampil’s 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 recto-vaginal 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 Natividad’s 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 above-named 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 attorney’s 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.
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
Decision6 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 Natividad’s 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 CA-G.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 defendant-appellant 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
Resolution7 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 Natividad’s 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.
Dr. Ampil, in an attempt to absolve himself, gears the Court’s attention to
other possible causes of Natividad’s detriment. He argues that the Court
should not discount either of the following possibilities: first, Dr. Fuentes left
the gauzes in Natividad’s 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 Natividad’s body.
Dr. Ampil’s 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 Natividad’s 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 patient’s 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 patient’s 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 patient’s
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 patient’s 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 Natividad’s 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. Ampil’s negligence is the proximate cause12 of
Natividad’s 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 Natividad’s vagina
established the causal link between Dr. Ampil’s 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.
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
Natividad’s 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 plaintiff’s 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 defendant’s 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 Natividad’s 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.
Until the mid-nineteenth century, hospitals were generally charitable
institutions, providing medical services to the lowest classes of society,
without regard for a patient’s 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 one’s 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 physician’s 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 hospital’s 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 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 Appeals28 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 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, 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 employer-
employee relationship in effect exists between hospitals and their attending
and visiting physicians. "
But the Ramos pronouncement is not our only basis in sustaining PSI’s
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 hospital’s 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 physician’s negligence.
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, PSI’s
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 hospital’s act
of listing him and his specialty in its lobby directory, as in the case herein.
The high costs of today’s 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 hospital’s 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 judiciary’s
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 hospital’s 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.
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 PSI’s 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
PSI’s 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 PSI’s 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 Natividad’s case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad
with the assistance of the Medical City Hospital’s 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 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 patient’s 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 hospital’s
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.
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.
Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
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 Decision1 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 Decision3 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 Nora’s blood pressure. Her blood pressure
was frequently monitored with the use of a sphygmomanometer. While
petitioner was massaging Nora’s 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 ½) by three and a half (3 ½)
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 Nora’s 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, Nora’s 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 Nora’s 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, Nora’s 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.
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 attorney’s 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, attorney’s fees and expenses
of litigation;1awphi1.nét
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
Petitioner’s 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.
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
RESPONDENT’S 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 Nora’s body. She maintains the injury was
due to the constant taking of Nora’s 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
respondent’s 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 petitioner’s counsel.
Respondents point out that petitioner’s 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 Nora’s 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 Nora’s medical records, which were produced by the hospital during trial
pursuant to a subpoena duces tecum. Petitioner’s 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.
Petitioner’s contention that the medico-legal officer who conducted Nora’s
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
someone’s 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 Nora’s 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 surgeon’s control.19 In this particular case, it can be logically inferred that
petitioner, the senior consultant in charge during the delivery of Nora’s baby,
exercised control over the assistants assigned to both the use of the droplight
and the taking of Nora’s blood pressure. Hence, the use of the droplight and
the blood pressure cuff is also within petitioner’s exclusive control.
Third, the gaping wound on Nora’s 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.
Petitioner’s defense that Nora’s 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 Nora’s wound was caused by the blood pressure cuff, then the
taking of Nora’s 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, petitioner’s 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 WHEREFORE, the petition is DENIED. The Decision dated October 3,
exercise of her profession stands unrebutted. In this connection, the Civil 2002 and Resolution dated November 19, 2003 of the Court of Appeals in
Code provides: CA-G.R. CV No. 58184 are AFFIRMED.

ART. 2176. Whoever by act or omission causes damage to another, there No pronouncement as to costs.
being fault or negligence, is obliged to pay for the damage done.…
SO ORDERED
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 defendant’s wrongful act or omission.

Clearly, under the law, petitioner is obliged to pay Nora for moral damages
suffered by the latter as a proximate result of petitioner’s negligence.

We note, however, that petitioner has served well as Nora’s obstetrician for Republic of the Philippines
her past three successful deliveries. This is the first time petitioner is being SUPREME COURT
held liable for damages due to negligence in the practice of her profession. Manila
The fact that petitioner promptly took care of Nora’s wound before infection
and other complications set in is also indicative of petitioner’s good SECOND DIVISION
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 G.R. No. 172406 October 11, 2007
petitioner’s elemental concern. Nonetheless, it should be stressed that all these
could not justify negligence on the part of petitioner. CONCEPCION ILAO-ORETA, Petitioner,
vs.
Hence, considering the specific circumstances in the instant case, we find no SPOUSES EVA MARIE and BENEDICTO NOEL
grave abuse of discretion in the assailed decision and resolution of the Court RONQUILLO, Respondents.
of Appeals. Further, we rule that the Court of Appeals’ award of Two Hundred
Thousand Pesos (₱200,000) as moral damages in favor of respondents and DECISION
against petitioner is just and equitable.21
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-gynecologist-
consultant at the St. Luke’s Medical Center where she was, at the time
material to the case, the chief of the Reproductive Endocrinology and
Infertility Section.
Upon Dr. Ilao-Oreta’s advice, Eva Marie agreed to undergo a laparoscopic
procedure whereby a laparascope would be inserted through the patient’s
abdominal wall to get a direct view of her internal reproductive organ in order
to determine the real cause of her infertility.
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. Luke’s 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 complaint1 against Dr. Ilao-
Oreta and the St. Luke’s 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, attorney’s 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 of April 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. Luke’s 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. Ilao-
Oreta.
By Decision5 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 ₱9,939 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 Decision6 of April 21,
2006, finding Dr. Ilao-Oreta grossly negligent,7 modified the trial court’s
decision as follows:
WHEREFORE, the trial Court’s 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 attorney’s fees.
SO ORDERED.8 (Underscoring supplied)
Hence, the present Petition for Review9 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 Attorney’s 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 o’clock 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 o’clock, 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 didn’t 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.
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 didn’t want to talk to me, and that she didn’t 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 "I’m
sorry, Dra., we cannot re-schedule 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 doctor’s 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 doctor’s negligence not being gross, the spouses are not entitled to
recover moral damages.
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 attorney’s 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: Isn’t it true that before instituting this present case, you did not make any
demand on Dr. Ilao-Oreta 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. Luke’s . . .
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: I’m 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-Oreta’s 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 prior to April 5, 1999
when the breach of contract complained of occurred.24 The Court of Appeals
also included the alleged ₱300 spent on fuel consumption from the spouses’
residence at San Pascual, Batangas to the St. Luke’s Medical Center in
Quezon City and the alleged ₱500 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 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
Appeals27 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
4/5/1999 SECOND 284893 UNUSED MED 43
Panacor, it failed to show how and in what manner the same were
substantiated by the claimant with reasonable certainty. Hence, the claim for
FLOOR HINOX 500 MG CAP
actual damages should be received with extreme caution since it is only based
on bare assertion without support from independent evidence. Premiere’s
failure to prove actual expenditure consequently conduces to a failure of its
claim. In determining actual damages, the court cannot rely on mere SECOND 284894 UNUSED MED 43
assertions, speculations, conjectures or guesswork but must depend FLOOR PHENERGAN 2 ML
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 transactions29 as in the case of
50MG ____
purchase of gasoline and of food.1âwphi1

The documented claim for hospital and medical expenses of the spouses is
detailed in the Statement of Account issued by the hospital, the pertinent BALANCE DUE
entries of which read:

xxxx

As extrapolated from the above-quoted entries in the Statement of Account,

GROSS HOSPITAL₱2,288.70
CHARGES(the gross hospital charges of ₱2,416.50 less the unused
2,416.50
medicine
in the amount of ₱127.80) was debited from the ₱5,000 deposit to thus leave
31

a balance of the deposit in the amount of ₱2,711.30, which the trial court
4/5/1999 1699460 DEPOSIT–OFFICIAL
erroneously denominated as "confinement fee." The remaining balance of
₱2,711.30 was the amount refundable to the spouses.

RECEIPT
Following Eastern
(5,000.00)
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
(5,000.00)
of 6% per annum from the time of the filing of the complaint on May 18,
1999, and at 12% per annum from the finality of this judgment until its
satisfaction.
WHEREFORE, the petition is GRANTED. The decision appealed from
is MODIFIED in that
1) the award to respondents-spouses Noel and Eva Marie Ronquillo of actual
damages is REDUCED to ₱2,288.70, 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
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 Decision1 of the Court of Appeals (CA) in CA G.R.
CV No. 63234, which affirmed with modification the Decision2 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:

2) The award of moral and exemplary damages and attorney’s fees is WHEREFORE, premises considered, the assailed Decision of the Regional
DELETED. Trial Court of Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is hereby
AFFIRMED but with modifications as follows:
SO ORDERED.
1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the
Republic of the Philippines United Doctors Medical Center, Inc. to jointly and severally pay the plaintiff-
SUPREME COURT appellees - heirs of Teresita Pineda, namely, Spouses Dominador Pineda and
Manila Virginia Saclolo and Florencio, Candida, Marta, Godofredo, Baltazar and
Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral
SECOND DIVISION damages;

G.R. No. 158996 November 14, 2008 2) Ordering the above-named defendant-appellants to jointly and severally
pay the above-named plaintiff-appellees the sum of P100,000.00 by way of
SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA exemplary damages;
FLORES, petitioners,
vs. 3) Ordering the above-named defendant-appellants to jointly and severally
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and pay the above-named plaintiff-appellees the sum of P36,000.00 by way of
FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and actual and compensatory damages; and
LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA
S. PINEDA, and UNITED DOCTORS MEDICAL CENTER, 4) Deleting the award of attorney's fees and costs of suit.
INC., respondents.
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 Teresita's admission
to the hospital. In the admission slip, he directed the hospital staff to prepare
the patient for an "on call" D&C5 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 tests6 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 patient's
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.
Teresita's BS count was 10.67mmol/l7 and her CBC was 109g/l.8
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.9Dr. Felicisima, however,
advised Teresita that she could spend her recovery period at home. Still
feeling weak, Teresita opted for hospital confinement.
Teresita's complete laboratory examination results came only on that day
(April 29, 1987). Teresita's 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, Teresita's 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
of May 6, 1987.11
Believing that Teresita's 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 Teresita's family and awarded actual, moral, and
exemplary damages, plus attorney's fees and costs.12 The CA affirmed the
judgment, but modified the amount of damages awarded and deleted the
award for attorney's 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 COURT'S RULING
We do not find the petition meritorious.
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 Teresita's 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 one's
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 Teresita's 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?
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 was random blood sugar;23 there were other factors that
might have caused Teresita's 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 Teresita's 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.
Taking into account Teresita's 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
patient's 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 Teresita's 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. Tan35 and Dr. Mendoza36 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 patient's urine40 - a result
highly confirmatory of diabetes.
Because the D&C was merely an elective procedure, the patient's
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 patient's 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 patient's 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 Teresita's 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 Teresita's
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 connection between the negligence
which the evidence established and the plaintiff's 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 defendant's 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 level shot up to 14.0mmol/l, way above the normal blood sugar range. Thus,
down the following causes of death: 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 Teresita's death due to aggravated diabetic condition is
Immediate cause: Cardiorespiratory arrest
therefore sufficiently established.

The trial court and the appellate court pinned the liability for Teresita's death
Antecedent cause: Septicemic shock, ketoacidocis
on both the petitioner spouses and this Court finds no reason to rule otherwise.
However, we clarify that Dr. Fredelicto's negligence is not solely the act of
ordering an "on call" D&C operation when he was mainly
Underlying cause: Diabetes Mellitus II
an anaesthesiologist who had made a very cursory examination of the
patient's vaginal bleeding complaint. Rather, it was his failure from the very
Other significant conditions start to identify and confirm, despite the patient's 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
contributing to death: despite his- early
Renal Failure Acute suspicion
47 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?

Stress, whether physical or emotional, is a factor that can aggravate diabetes;

A: We discussed on the finding of the laboratory [results] because the
a D&C operation is a form of physical stress. Dr. Mendoza explained how
hemoglobin was below normal, the blood sugar was elevated, so that we have
surgical stress can aggravate the patient's hyperglycemia: when stress occurs,
to evaluate these laboratory results - what it means.
the diabetic's body, especially the autonomic system, reacts by secreting
hormones which are counter-regulatory; she can have prolonged
Q: So it was you and your wife who made the evaluation when it was phoned
hyperglycemia which, if unchecked, could lead to death.48 Medical literature
in?
further explains that if the blood sugar has become very high, the patient
becomes comatose (diabetic coma). When this happens over several days, the
A: Yes, sir.
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
Q: Did your wife, before performing D&C ask your opinion whether or not
ketoacidiosis, a medical emergency with a significant mortality).49 This was
she can proceed?
apparently what happened in Teresita's case; in fact, after she had been
referred to the internist Dr. Jorge, laboratory test showed that her blood sugar
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.
These findings lead us to the conclusion that the decision to proceed with the
D&C operation, notwithstanding Teresita's 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 patient's 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 UDMC's petition for review on certiorari.
Since UDMC's appeal has been denied and they are not parties to this case,
we find it unnecessary to delve on the matter. Consequently, the RTC's
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 Teresita's 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,53even
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 court's 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
of P100,000.00. Public policy requires such imposition to suppress the
wanton acts of an offender.55 We therefore affirm the CA's award as an
example to the medical profession and to stress that the public good requires 6. Costs.
stricter measures to avoid the repetition of the type of medical malpractice
that happened in this case. SO ORDERED.

With the award of exemplary damages, the grant of attorney's 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 attorney's fees taking
into consideration the legal route this case has taken.

WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003

Republic of the Philippines
in CA G.R. CV No. 63234 finding petitioner spouses liable for negligent
SUPREME COURT
medical practice. We likewise AFFIRM the awards of actual and
Manila
compensatory damages of P36,000.00; moral damages of P400,000.00; and
exemplary damages of P100,000.00.
THIRD DIVISION

We MODIFY the CA Decision by additionally granting an award

G.R. No. 159132 December 18, 2008
of P50,000.00 as death indemnity and by reversing the deletion of the award
of attorney's fees and costs and restoring the award of P100,000.00 as
FE CAYAO-LASAM, petitioner,
attorney's fees. Costs of litigation are adjudged against petitioner spouses.
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.*
To summarize, the following awards shall be paid to the family of the late
Teresita Pineda:
DECISION
1. The sum of P36,000.00 by way of actual and compensatory damages;
AUSTRIA-MARTINEZ, J.:
2. The sum of P50,000.00 by way of death indemnity;
Before the Court is a Petition for Review on Certiorari under Rule 45 of the
Rules of Court filed by Dr. Fe Cayao-Lasam (petitioner) seeking to annul the
3. The sum of P400,000.00 by way of moral damages;
Decision1 dated July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP
No. 62206.
4. The sum of P100,000.00 by way of exemplary damages;

The antecedent facts:

5. The sum of P100,000.00 by way of attorney's fees; and
On July 28, 1994, respondent, three months pregnant Editha Ramolete
(Editha) was brought to the Lorma Medical Center (LMC) in San Fernando,
La Union due to vaginal bleeding. Upon advice of petitioner
relayed via telephone, Editha was admitted to the LMC on the same day. A
pelvic sonogram2 was then conducted on Editha revealing the fetus’ weak
cardiac pulsation.3 The following day, Editha’s repeat pelvic
sonogram4 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 latter’s
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 hysterectomy6 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 Complaint7 for Gross Negligence and Malpractice against petitioner
before the Professional Regulations Commission (PRC).
Respondents alleged that Editha’s hysterectomy was caused by petitioner’s
unmitigated negligence and professional incompetence in conducting the
D&C procedure and the petitioner’s failure to remove the fetus inside Editha’s
womb.8 Among the alleged acts of negligence were: first, petitioner’s 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 Editha’s confirmation
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 latter’s 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 latter’s 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.
Petitioner contended that it was Editha’s gross negligence and/or omission in
insisting to be discharged on July 31, 1994 against doctor’s 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
Editha’s 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 of ectopic 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 ectopic
pregnancy 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 Decision16 reversing the findings of the Board and
revoking petitioner’s 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 certiorari18 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
2620 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 QUASI-
JUDICIAL 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;
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. PRC’S 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
PETITIONER’S LICENSE TO PRACTICE MEDICINE WITHOUT AN
EXPERT TESTIMONY TO SUPPORT ITS CONCLUSION AS TO THE
CAUSE OF RESPONDENT EDITHAT [SIC] RAMOLETE’S 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
EDITHA’S 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
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 appellant’s brief or memorandum
on appeal, and paying the appeal and legal research fees. x x x29
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 4332 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
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 quasi-judicial 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. 12938 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. On
August 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 Editha’s 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
A physician-patient relationship was created when Editha employed the
services of the petitioner. As Editha’s 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 Editha’s
case was "Ectopic Pregnancy Interstitial (also referred to as Cornual),
Ruptured."51 In stating that the D&C procedure was not the proximate cause
of the rupture of Editha’s 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 don’t think so, because it is the triggering factor
for the rupture, it could have–the rupture could have occurred much earlier,
right after the D&C or a few days after the D&C.
Q: 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 ½ 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?
A: I don’t 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 Editha’s uterus.
During his cross-examination, Dr. Manalo testified on how he would have
addressed Editha’s condition should he be placed in a similar circumstance as
the petitioner. He stated:
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: 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?
A: 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 there’s no way.
Q: There was [sic] some portions of the fetal parts that were removed?
A: No, it was described as scanty scraping if I remember it right–scanty.
Q: And you would not mind checking those scant or those little parts that
were removed?
A: 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. It’s 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.
Q: As a matter of fact, doctor, you also give telephone orders to your
patients through telephone?
A: 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: But, doctor, do you discharge patients without seeing them?
A: 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, that’s 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 217654 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 plaintiff’s 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 defendant’s 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 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 complainant’s 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 petitioner’s 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 ½ 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 petitioner’s 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
Editha’s own injury. Had Editha returned, petitioner could have conducted
the proper medical tests and procedure necessary to determine Editha’s health
condition and applied the corresponding treatment which could have
prevented the rupture of Editha’s uterus. The D&C procedure having been
conducted in accordance with the standard medical practice, it is clear that
Editha’s 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 defendant’s
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.60Where the immediate cause of an accident
resulting in an injury is the plaintiff’s 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 Editha’s
injury was her own omission when she did not return for a follow-up
check up, in defiance of petitioner’s orders. The immediate cause of
Editha’s 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 registry receipt could not be appended to the copy
furnished to petitioner’s 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
consequences68 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.
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 178763 April 21, 2009
PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS,
ABBEYGAIL LUCAS AND GILLIAN LUCAS,Petitioners,
vs.
DR. PROSPERO MA. C. TUAÑO, Respondent.
 DECISION
CHICO-NAZARIO, J.:
In this petition for review on certiorari1 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 Decision2 and 3 July 2007 Resolution,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. Tuaño."
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. Tuaño," 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. Tuaño, M.D. (Dr. Tuaño), an ophthalmologist at St. Luke’s Medical
Center, for an eye consult.
Upon consultation with Dr. Tuaño, 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. Tuaño,
he performed "ocular routine examination" on Peter’s eyes, wherein: (1) a
gross examination of Peter’s eyes and their surrounding area was made; (2)
Peter’s visual acuity were taken; (3) Peter’s eyes were palpated to check the
intraocular pressure of each; (4) the motility of Peter’s eyes was observed;
and (5) the ophthalmoscopy4 on Peter’s eyes was used. On that particular
consultation, Dr. Tuaño diagnosed that Peter was suffering from
conjunctivitis5 or "sore eyes." Dr. Tuaño then prescribed Spersacet-C6 eye
drops for Peter and told the latter to return for follow-up after one week.
As instructed, Peter went back to Dr. Tuaño on 9 September 1988. Upon
examination, Dr. Tuaño told Peter that the "sore eyes" in the latter’s right eye
had already cleared up and he could discontinue the Spersacet-C. However,
the same eye developed Epidemic Kerato Conjunctivitis (EKC),7 a viral
infection. To address the new problem with Peter’s right eye, Dr. Tuaño
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. Tuaño.
On 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation.
After examining both of Peter’s eyes, Dr. Tuaño instructed the former to taper
down10 the dosage of Maxitrol, because the EKC in his right eye had already
resolved. Dr. Tuaño specifically cautioned Peter that, being a steroid,
Maxitrol had to be withdrawn gradually; otherwise, the EKC might recur.11
Complaining of feeling as if there was something in his eyes, Peter returned
to Dr. Tuaño for another check-up on 6 October 1988. Dr. Tuaño examined
Peter’s eyes and found that the right eye had once more developed EKC. So,
Dr. Tuaño 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,
Blephamide12 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. Tuaño at his
clinic, alleging severe eye pain, feeling as if his eyes were about to "pop-out,"
a headache and blurred vision. Dr. Tuaño examined Peter’s eyes and
discovered that the EKC was again present in his right eye. As a result, Dr.
Tuaño told Peter to resume the maximum dosage of Blephamide.
Dr. Tuaño saw Peter once more at the former’s clinic on 4 November 1988.
Dr. Tuaño’s examination showed that only the periphery of Peter’s right eye
was positive for EKC; hence, Dr. Tuaño prescribed a lower dosage of
Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peter’s spouse,
read the accompanying literature of Maxitrol and 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.
Secondary bacterial ocular infection following suppression of host responses
also occurs.
On 26 November 1988, Peter returned to Dr. Tuaño’s clinic, complaining of
"feeling worse."14 It appeared that the EKC had spread to the whole of Peter’s
right eye yet again. Thus, Dr. Tuaño instructed Peter to resume the use of
Maxitrol. Petitioners averred that Peter already made mention to Dr. Tuaño
during said visit of the above-quoted warning against the prolonged use of
steroids, but Dr. Tuaño supposedly brushed aside Peter’s concern as mere
paranoia, even assuring him that the former was taking care of him (Peter).
Petitioners further alleged that after Peter’s 26 November 1988 visit to Dr.
Tuaño, 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 Peter’s right eye appeared to be bloody and
swollen.15 Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuaño.
Peter reported to Dr. Tuaño that he had been suffering from constant headache
in the afternoon and blurring of vision.
Upon examination, Dr. Tuaño noted the hardness of Peter’s right eye. With
the use of a tonometer16 to verify the exact intraocular pressure17 (IOP) of
Peter’s eyes, Dr. Tuaño discovered that the tension in Peter’s right eye
was 39.0 Hg, while that of his left was 17.0 Hg.18 Since the tension in Peter’s
right eye was way over the normal IOP, which merely ranged from 10.0 Hg
to 21.0 Hg,19 Dr. Tuaño ordered20 him to immediately discontinue the use of
Maxitrol and prescribed to the latter Diamox21 and Normoglaucon,
instead.22 Dr. Tuaño also required Peter to go for daily check-up in order for
the former to closely monitor the pressure of the latter’s eyes.
On 15 December 1988, the tonometer reading of Peter’s right eye yielded
a high normal level, i.e., 21.0 Hg. Hence, Dr. Tuaño told Peter to continue
using Diamox and Normoglaucon. But upon Peter’s complaint of "stomach
pains and tingling sensation in his fingers,"23 Dr. Tuaño discontinued Peter’s
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 Peter’s eyes. Dr. Batungbacal’s diagnosis
was Glaucoma25 O.D.26 He recommended Laser Trabeculoplasty27 for Peter’s
right eye.
When Peter returned to Dr. Tuaño on 23 December 1988,28 the tonometer
measured the IOP of Peter’s right eye to be 41.0 Hg,29 again, way above
normal. Dr. Tuaño addressed the problem by advising Peter to resume taking
Diamox along with Normoglaucon.
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 Peter’s regular follow-ups with Dr.
Tuaño, the doctor conducted another ocular routine examination of Peter’s
eyes. Dr. Tuaño noted the recurrence of EKC in Peter’s right eye.
Considering, however, that the IOP of Peter’s right eye was still quite high
at 41.0 Hg, Dr. Tuaño was at a loss as to how to balance the treatment of
Peter’s EKC vis-à-vis the presence of glaucoma in the same eye. Dr. Tuaño,
thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), another
ophthalmologist specializing in the treatment of glaucoma.31 Dr. Tuaño’s
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 I’m 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 latter’s clinic.
Several tests were conducted thereat to evaluate the extent of Peter’s
condition. Dr. Agulto wrote Dr. Tuaño 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 ½ tab every 6h po.
33
Slit lamp evaluation disclosed subepithelial corneal defect outer OD. There
was circumferential peripheral iris atrophy, OD. The lenses were clear.
Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L with temporal
slope R>L.
Zeiss gonioscopy35 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
Timolol37 BID38 OD in lieu of Normoglaucon. If the IOP is still inadequate,
we may try D’epifrin39 BID OD (despite low PAS). I’m 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. Tuaño on 31 December 1988, bearing Dr. Agulto’s
aforementioned letter. Though Peter’s right and left eyes then had normal IOP
of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuaño 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. Tuaño instructed Peter
to just continue using Diamox and Normoglaucon in the meantime.
Just two days later, on 2 January 1989, the IOP of Peter’s right eye remained
elevated at 21.0 Hg,42 as he had been without Diamox for the past three (3)
days.
On 4 January 1989, Dr. Tuaño conducted a visual field study43 of Peter’s eyes,
which revealed that the latter had tubular vision44 in his right eye, while that
of his left eye remained normal. Dr. Tuaño directed Peter to religiously use
the Diamox and Normoglaucon, as the tension of the latter’s 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 D’epifrin were still not available in the market. Again,
Dr. Tuaño advised Peter to come for regular check-up so his IOP could be
monitored.
Obediently, Peter went to see Dr. Tuaño on the 7th, 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 Peter’s eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation
of Peter’s 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. Tuaño’s diagnosis of tubular vision
in Peter’s right eye. Petitioners claimed that Dr. Aquino essentially told Peter
that the latter’s 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 glaucoma45 and blaming Dr. Tuaño for the
same, Peter, joined by: (1) Fatima, his spouse46; (2) Abbeygail, his natural
child47; and (3) Gillian, his legitimate child48 with Fatima, instituted on 1
September 1992, a civil complaint for damages against Dr. Tuaño, 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 [Peter’s] 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 [Peter’s 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 Peter’s 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.;
Peter’s 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 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 by Dr. Tuaño’s grossly
negligent conduct in prescribing to Peter the medicine Maxitrol for a period
of three (3) months, without monitoring Peter’s IOP, as required in cases of
prolonged use of said medicine, and notwithstanding Peter’s constant
complaint of intense eye pain while using the same. Petitioners particularly
prayed that Dr. Tuaño be adjudged liable for the following amounts:
1. The amount of ₱2,000,000.00 to plaintiff Peter Lucas as and by way of
compensation for his impaired vision.
2. The amount of ₱300,000.00 to spouses Lucas as and by way of actual
damages plus such additional amounts that may be proven during trial.
3. The amount of ₱1,000,000.00 as and by way of moral damages.
4. The amount of ₱500,000.00 as and by way of exemplary damages.
5. The amount of ₱200,000.00 as and by way of attorney’s fees plus costs of
suit.54
In rebutting petitioners’ complaint, Dr. Tuaño asserted that the "treatment
made by [him] more than three years ago has no causal connection to [Peter’s]
present glaucoma or condition."55 Dr. Tuaño 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. Tuaño 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 [Peter’s
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 [Peter’s]
EKC caused the steroid induced glaucoma,"59 Dr. Tuaño 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, [Peter’s] 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.
From a medical point of view, as revealed by more current examination of
[Peter], the latter’s 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. Tuaño was negligent in his treatment of Peter’s 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. Tuaño, caused
Peter’s 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 [Tuaño] liable."63 According to the RTC:
[Petitioners] failed to establish the duty required of a medical practitioner
against which Peter Paul’s 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. Tuaño of
Peter Paul’s 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 defendant’s 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 [Peter’s] eye."65
Correspondingly, the RTC accepted Dr. Tuaño’s 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, plaintiff’s 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.
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:
66
WHEREFORE, the Decision appealed from is AFFIRMED.
The Court of Appeals faulted petitioners because they –
[D]id not present any medical expert to testify that Dr. Tuano’s prescription
of Maxitrol and Blephamide for the treatment of EKC on Peter’s right eye
was not proper and that his palpation of Peter’s 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 latter’s 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. Tuaño’s medical
judgment, specifically the latter’s 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.
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 ATTORNEY’S 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 Resolution would 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.
Tuaño.
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. Tuaño’s negligence in
his treatment of Peter’s eye condition. This question clearly involves a factual
inquiry, the determination of which is not within the ambit of this Court’s
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.1avvphi1.zw+
Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of
Appeals, [they] were more than able to establish that: Dr. Tuaño 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 Peter’s eye; and (2) whether or not
negligence attended Dr. Tuaño’s treatment of Peter, because, in their words –
That Dr. Tuaño was grossly negligent in the treatment of Peter’s 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. Tuaño] – Dr. Tuaño himself. [Emphasis
supplied.]
They insist that Dr. Tuaño himself gave sufficient evidence to establish his
gross negligence that ultimately caused the impairment of the vision of Peter’s
right eye,73 i.e., that "[d]espite [Dr. Tuaño’s] 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 Peter’s glaucoma is the direct result of
Dr. Tuaño’s 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
latter’s 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.
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 patient’s] 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 expert’s role is to present to the [court] a realistic
assessment of the likelihood that [the physician’s] alleged negligence caused
[the patient’s] 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 former’s 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. Tuaño 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. Tuaño, 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 Peter’s glaucoma.
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 Peter’s under similar
circumstances; (2) that, in his treatment of Peter, Dr. Tuaño failed in his duty
to exercise said standard of care that any other competent physician would
use in treating the same condition as Peter’s under similar circumstances; and
(3) that the injury or damage to Peter’s right eye, i.e., his glaucoma, was the
result of his use of Maxitrol, as prescribed by Dr. Tuaño. Petitioners’ failure
to prove the first element alone is already fatal to their cause.
Petitioners maintain that Dr. Tuaño failed to follow in Peter’s 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. Tuaño 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. Tuaño 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. Tuaño was able to clearly explain that what is only required
of ophthalmologists, in cases such as Peter’s, 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 patient’s 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. Tuaño’s 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
Moreover, that Dr. Tuaño 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. Tuaño on 2 September 1988 and had exhibited no previous
untoward reaction to that particular drug. 91
Also, Dr. Tuaño categorically denied petitioners’ claim that he never
monitored the tension of Peter’s eyes while the latter was on Maxitrol. Dr.
Tuaño testified that he palpated Peter’s eyes every time the latter came for a
check-up as part of the doctor’s ocular routine examination, a fact which
petitioners failed to rebut. Dr. Tuaño’s regular conduct of examinations and
tests to ascertain the state of Peter’s eyes negate the very basis of petitioners’
complaint for damages. As to whether Dr. Tuaño’s 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. Tuaño committed negligent acts in his
treatment of Peter’s condition, the causal connection between Dr. Tuaño’s
supposed negligence and Peter’s 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
plaintiff’s 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 defendant’s 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 physician’s negligence and the patient’s injury
may only be established by the presentation of proof that Peter’s glaucoma
would not have occurred but for Dr. Tuaño’s supposed negligent conduct.
Once more, petitioners failed in this regard.
Dr. Tuaño does not deny that the use of Maxitrol involves the risk of
increasing a patient’s IOP. In fact, this was the reason why he made it a point
to palpate Peter’s eyes every time the latter went to see him -- so he could
monitor the tension of Peter’s eyes. But to say that said medication
conclusively caused Peter’s 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. Tuaño claims that Peter’s glaucoma "can only be long
standing x x x because of the large C:D97 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. Tuaño is in a better position to determine
and evaluate the necessity of using Maxitrol to cure Peter’s EKC vis-à-vis the
attendant risks of using the same?
That Dr. Tuaño has the necessary training and skill to practice his chosen field
is beyond cavil. Petitioners do not dispute Dr. Tuaño’s 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 ophthalmology, here and abroad; that he is a
Diplomate 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. Luke’s 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 Peter’s EKC
with Maxitrol, Dr. Tuaño took the necessary precaution by palpating Peter’s
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. Tuaño’s part, which resulted in Peter’s
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. Tuaño’s 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.1avvphi1
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 plaintiff’s 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.
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. Tuaño’s alleged breach of duty and the
damage sustained by Peter’s 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. Tuaño 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. Tuaño failed to exercise
reasonable care, diligence and skill generally required in medical practice. Dr.
Tuaño’s 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 hereby AFFIRMED. No cost. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
EN BANC
G.R. No. 165279 June 7, 2011
DR. RUBI LI, Petitioner,
vs.
SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of
deceased Angelica Soliman, Respondents.
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision1 dated June
15, 2004 as well as the Resolution2dated September 1, 2004 of the Court of
Appeals (CA) in CA-G.R. CV No. 58013 which modified the Decision3dated
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.
Luke’s 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, Angelica’s 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
patient’s 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 Death6 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 suit7 against petitioner, Dr.
Leo Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC.
Respondents charged them with negligence and disregard of Angelica’s
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 Angelica’s 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 patient’s normal body parts, including the lowering of white and red
blood cells and platelets. She claimed that what 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
Angelica’s surgery and discussed with them Angelica’s 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
₱70,000.00 to ₱150,000.00 a year from his jewelry and watch repairing
business.9Petitioner, 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 Angelica’s 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
Angelica’s 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 Angelica’s 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: Angelica’s 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 Doxorubicin16and Cosmegen17 –
intravenously. Petitioner was supposedly assisted by her trainees Dr. Leo
Marbella18 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 Angelica’s face.21They asked petitioner about it, but she
merely quipped, "Wala yan. Epekto ng gamot."22 Petitioner recalled 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 Angelica’s 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 Angelica’s face, nor did she
notice any difficulty in the child’s breathing. She claimed that Angelica
merely complained of nausea and was given ice chips.251avvphi1
On August 22, 1993, at around ten o’clock 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, let’s observe. If pwede na, bigyan uli ng chemo."
At this point, respondents asked petitioner’s 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
as "naninigas 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 Angelica’s
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 4:50 that 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 child’s 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 Angelica’s 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
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
o’clock 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.35She
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 Angelica’s 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 Angelica’s platelets were down and respondents
should pray for their daughter. Reynaldo claimed that he was introduced to a
pediatrician who took over his daughter’s 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 Angelica’s 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 o’clock 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 petitioner’s own account, Angelica was merely irritable that day (August
31). Petitioner noted though that Angelica’s 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
Angelica’s other organs to fail.41 Petitioner attributed this to the patient’s poor
defense mechanism brought about by the cancer itself.42
While he was seeking the release of Angelica’s 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
Angelica’s 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) 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 victim’s 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 Angelica’s 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 physician’s 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 patient’s 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 patient’s
condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelica’s
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 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 ₱139,064.43.48
Respondents appealed to the CA which, while concurring with the trial court’s
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
Li’s 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 Angelica’s 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 plaintiffs-appellants 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. Attorney’s 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
attorney’s 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 patient’s
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
deference of courts to the expert opinion of qualified physicians stems from
the former’s 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 petitioner’s 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 patient’s 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
was Schoendorff v. Society of New York Hospital53 which involved
unwanted treatment performed by a doctor. Justice Benjamin Cardozo’s 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 patient’s 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. Spence56 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 patient’s right of self-
determination 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 physician’s 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
patient’s 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 patient’s 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 actions generally, there
must be a causal relationship between the physician’s failure to divulge and
damage to the patient.60
61
Reiterating the foregoing considerations, Cobbs v. Grant deemed it as
integral part of physician’s 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 patient’s
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 physician’s communications to the patient, then must be measured by
the patient’s 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 patient’s 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 physician’s 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 Angelica’s parents. Respondents could not have been unaware in
the course of initial treatment and amputation of Angelica’s 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 patient’s 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 unlikely for doctors like petitioner who
were dealing with grave conditions such as cancer to have falsely assured
patients of chemotherapy’s 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 DOH’s 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 patient’s 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 consumer—"a reasonable person in the patient’s 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 is REINSTATED and UPHELD. No
costs. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 177407 February 9, 2011
RICO ROMMEL ATIENZA, Petitioner,
vs.
BOARD OF MEDICINE and EDITHA SIOSON, Respondents.
DECISION
NACHURA, J.:
Before us is a petition for review on certiorari under Rule 45 of the Rules of
Court, assailing the Decision1 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 Orders2 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 respondent’s husband, Romeo Sioson (as
complainant), filed a complaint for gross negligence and/or incompetence
before the [BOM] against the doctors who allegedly 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 respondent’s 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, III’s 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
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 ‘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, III’s 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 respondent’s [Editha
Sioson’s] 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.
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 BOM’s Orders which
admitted Editha Sioson’s (Editha’s) 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 FOR CERTIORARI 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 ONE’S LIVELIHOOD.4
We find no reason to depart from the ruling of the CA.
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 for certiorari 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 CA’s 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,7in 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
Appeals9 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, petitioner’s insistence that the admission of Editha’s 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. 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:
(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 Editha’s medical case. The documents contain
handwritten entries interpreting the results of the examination. These exhibits
were actually attached as annexes to Dr. Pedro Lantin III’s 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 Editha’s 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.12Thus, 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 Editha’s 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.1awphil 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;
(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 Editha’s kidneys.
As previously discussed, the proper anatomical locations of Editha’s 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 Editha’s kidneys. To further
drive home the point, the anatomical positions, whether left or right, of
Editha’s 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 Editha’s 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.
Republic of the Philippines
SUPREME COURT
Manila
G.R. No. 187926 February 15, 2012
Dr. EMMANUEL JARCIA, Jr. and Dr. MARILOU
BASTAN, Petitioners,
vs.
PEOPLE OF THE PHILIPPINES, Respondent.
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 Decision2 of the Court of Appeals (CA), and its May 19,
2009 Resolution3 in CA-G.R. CR No. 29559, dismissing the appeal and
affirming in toto the June 14, 2005 Decision4 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 victim’s 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. 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. that there is lack of precaution on the part of the offender; and
2. 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 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 accused-appellants’ 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 latter’s ordeal at the hospital. She testified as
follows:
Fiscal Formoso:
Q: 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?
A: Dra. Pamittan was inside the cubicle of the nurses and I asked her, you let
us go home and you don’t even clean the wounds of my son.
Q: And what did she [tell] you?
A: They told me they will call a resident doctor, sir.
Q: Was there a resident doctor [who] came?
A: Yes, Sir. Dra. Bastan arrived.
Q: Did you tell her what you want on you to be done?
A: Yes, sir.
Q: What did you [tell] her?
A: 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: And what did she tell you?
A: According to Dra. Bastan, there is no need to x-ray because it was the
ankle part that was run over.
Q: What did you do or tell her?
A: 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: So you mean to say there was no treatment made at all?
A: None, sir.
A: I just listened to them, sir. And I just asked if I will still return my son.
Q: And you were present when they were called?
A: Yes, sir.
Q: And what was discussed then by Sis. Retoria?
A: 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 someone’s 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 accused-appellants. 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.
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: And was that the correct respon[se] to the medical problem that was
presented to Dr. Jarcia and Dra. Bastan?
A: 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, it’s entirely different thing.
Because if you are an orthopedic resident, I am not trying to say…but 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.
Q: You mean to say there is no supervisor attending the emergency room?
A: At the emergency room, at the Manila Doctor’s 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 don’t [know] why they
don’t….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
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
GROUNDS-
1. 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 PATIENT’S RIGHT LEG
WAS HIT BY A TAXI, NOT THE FAILURE OF THE ACCUSED-
PETITIONERS TO SUBJECT THE PATIENT’S 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 PROSECUTION’S 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 PATIENT’S
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
PATIENT’S 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
PATIENT’S ALLEGED INJURY (PROLONGED PAIN AND
SUFFERING) WAS DUE TO HIS OWN MOTHER’S ACT OR
OMISSION.
5. THE COURT OF APPEALS ERRED IN NOT HOLDING THAT NO
PHYSICIAN-PATIENT RELATIONSHIP EXISTED BETWEEN
PETITIONERS AND PATIENT ALFONSO SANTIAGO, JR.,
PETITIONERS NOT BEING THE LATTER’S 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
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 COURT’S 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 facie negligence 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 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 patient’s 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. Bastan’s 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: Will you please tell us, for the record, doctor, what is your specialization?
A: At present I am the chairman department of orthopedic in UP-PGH and I
had special training in pediatric orthopedic for two (2) years.
Q: In June 1998, doctor, what was your position and what was your
specialization at that time?
A: 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?
A: 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 don’t 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.
Q: What part of the leg, doctor, did you request to be examined?
A: 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: And what was the result?
A: Well, I can say that it was a spiral fracture of the mid-tibial, it is the bigger
bone of the leg.
Q: And when you say spiral, doctor, how long was this fracture?
A: 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)
A: 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.
Q: And in the course of your examination of Alfonso Santiago, Jr. did you ask
for the history of such injury?
A: 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: And as far as you can recall, Doctor, what was the history of that injury
that was told to you?
A: The patient was sideswiped, I don’t know if it is a car, but it is a vehicular
accident.
Q: Who did you interview?
A: The mother.
Q: How about the child himself, Alfonso Santiago, Jr.?
A: 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: And were you informed also of his early medication that was administered
on Alfonso Santiago, Jr.?
A: 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.
A: At the emergency room, at the Manila Doctor’s 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 don’t why they don’t …
Because at that time, I think, it is the decision. Since the x-rays…
Q: You also said, Doctor, that Dr. Jarcia and Dra. Bastan are not even an
orthopedic specialist.
A: 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.
Q: 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?
A: 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: Not the entire body but the entire leg?
A: I think, if my examination requires it, I would.
Q: So, you would conduct first an examination?
A: 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?
A: 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.
xxxx
Q: 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?
A: 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. That’s 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 patient’s
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 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 physician–patient relationship," the Court finds and so holds
that there was a "physician–patient" relationship in this case.
In the case of Lucas v. Tuaño,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.
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 physician’s
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.
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 is REVERSED 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 annum from the finality of
judgment until fully paid.
SO ORDERED.

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

Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
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.:
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 decision2 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 Raymond—the spouses Deogenes Olavere
(Deogenes) and Fe R. Serrano—arrived 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 latter’s 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 Raymond’s 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.
Raymond’s 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 damages7 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
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 decision8 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. ₱ 50,000.00 for the death of the victim;
2. ₱ 150,000.00 as moral damages;
3. ₱ 100,000.00 as exemplary damages;
4. ₱ 30,000.00 for attorney’s 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 ATTORNEY’S 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.11 Factual
findings of the CA, affirming that of the trial court, are therefore generally
final and conclusive on this Court. This rule is subject to 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 Q: What is the first name?
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 A: Rosalina Flores.
opinion of qualified physicians stems from the former’s realization that the
latter possess unusual technical skills which laymen in most instances are Q: Is she residing in Naga City?
incapable of intelligently evaluating, hence, the indispensability of expert
testimonies.14 A: In Camaligan.

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: 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:
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: How many of them? Q: But in this case, the surgeon did not request you?

A: One. A: No. It is their prerogative.

Q: Who is she? Q: I just want to know that in this case the surgeon did not request you to call
for the standby anesthesiologist?
A: Dra. Flores.
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
hospital’s 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 latter’s 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. Tatad’s, on which it may be inferred that petitioners
failed to exercise the standard of care, diligence, learning and 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: Because that was the time when the blood was given to us.
xxxx
Q: Have you monitored the condition of Raymond Olavere?

A: The blood arrived at 1:40 a.m. and that was the time when this blood was A: I monitored the condition during the time when I would administer
hooked to the patient. anesthesia.

xxxx Q: What time was that?

Q: Prior to the arrival of the blood, you did not request for blood? A: 11:45 already.

A: I requested for blood. Q: What was the condition of the blood pressure at that time?

Q: From whom? A: 60/40 initial.

A: From the attending physician, Dr. Realuyo. Q: With that kind of blood pressure the patient must have been in critical
condition?
Q: What time was that?
A: At the time when the blood pressure was 60/40 I again told Dr. Cereno that
xxxx blood was already needed.

A: 9:30. Q: With that condition, Doctor, that the patient had 60/40 blood pressure you
did not decide on transfusing blood to him?
xxxx
A: I was asking for blood but there was no blood available.
Q: Had this blood been given to you before the operation you could have
transfused the blood to the patient? Q: From whom did you ask?

A: Of course, yes. A: From the surgeon. According to Dr. Zafe there was only 500 cc but still
for cross-matching.18
Q: And the blood was transfused only after the operation?
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 Raymond’s 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 latter’s 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…
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 Raymond’s 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 Raymond’s 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 son’s death.1âwphi1 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 Peñafrancia 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.
 Republic of the Philippines Provincial Hospital, Oroquieta City, for an emergency appendectomy. Hanz
SUPREME COURT was attended to by the petitioner, who suggested to the parents that Hanz also
Manila 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
FIRST DIVISION after his appendectomy. On the following day, Hanz complained of pain in
his penis, which exhibited blisters. His testicles were swollen. The parents
G.R. No. 163753 January 15, 2014 noticed that the child urinated abnormally after the petitioner forcibly
removed the catheter, but the petitioner dismissed the abnormality as normal.
DR. ENCARNACION C. LUMANTAS, M.D., Petitioner, On January 30, 1995, Hanz was discharged from the hospital over his parents’
vs. protestations, and was directed to continue taking antibiotics.
HANZ CALAPIZ, REPRESENTED BY HIS PARENTS, HILARIO
CALAPIZ, JR. and HERLITA CALAPIZ,Respondent. 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
DECISION ulceration was brought about by Hanz’s appendicitis, the petitioner referred
him to Dr. Henry Go, an urologist, who diagnosed the boy to have a damaged
BERSAMIN, J.: urethra. Thus, Hanz underwent cystostomy, and thereafter was operated on
three times to repair his damaged urethra.
The acquittal of the accused does not necessarily mean his absolution from
civil liability. When his damaged urethra could not be fully repaired and reconstructed,
Hanz’s parents brought a criminal charge against the petitioner for reckless
The Case imprudence resulting to serious physical injuries. On April 17, 1997, the
information3 was filed in the Municipal Trial Court in Cities of Oroquieta City
In this appeal, an accused desires the reversal of the decision promulgated on (MTCC), to which the latter pleaded not guilty on May 22, 1998.4 Under the
February 20, 2003,1 whereby the Court of Appeals (CA) affirmed the order of April 30, 1999, the case was transferred to the RTC pursuant to
judgment rendered on August 6, 1999 by the Regional Trial Court (RTC), Supreme Court Circular No. 11-99.5
Branch 13, in Oroquieta City ordering him to pay moral damages despite his
acquittal of the crime of reckless imprudence resulting in serious physical At the trial, the Prosecution presented several witnesses, including Dr. Rufino
injuries charged against him.2 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
Antecedents diagnosed to have urethral stricture and cavernosal injury left secondary to
trauma that had necessitated the conduct of two operations to strengthen and
On January 16, 1995, Spouses Hilario Calapiz, Jr. and Herlita Calapiz brought to lengthen the urethra. Although satisfactorily explaining that the injury to
their 8-year-old son, Hanz Calapiz (Hanz), to the Misamis Occidental
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 Hanz’s 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
Prosecution’s 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 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 Calapiz
₱50,000.00 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 petitioner’s 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.1âwphi1 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 Prosecution’s 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 complainant’s recovery of civil liability
should be through the institution of a separate civil action for that purpose.13
The petitioner’s 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.14With the RTC and 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.1âwphi1 Although we have long advocated the view that any physical
injury, like the loss or diminution of the use of any part of one’s 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
one’s body. The usual practice is to award moral damages for the physical
injuries sustained.15 In Hanz’s 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
₱50,000.00 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 Ynzon (Dr. Ynzon) of the crime of Reckless Imprudence Resulting to
20, 2003, with the modification that legal interest of 6% per annum to start Homicide.
from April 17, 1997 is imposed on the award of:₱50,000.00 as moral
damages; and ORDERS the petitioner to pay the costs of suit. SO ORDERED. The Information3 alleged –

Republic of the Philippines That on or about June 17, 2000in the City of Dagupan, Philippines, and within
SUPREME COURT the jurisdiction of this Honorable Court, the abovenamed accused, DR.
Manila ANTONIO P.CABUGAO and DR. CLENIO YNZON, being then the
attending physicians of one RODOLFO PALMA, JR., a minor 10 years old,
THIRD DIVISION confederating and acting jointly with one another, did, then and there,
willfully, unlawfully and feloniously fail through negligence, carelessness
G.R. No. 163879 July 30, 2014 and imprudence to perform immediate operation upon their patient,
RODOLFO PALMA, JR. of acute appendicitis, when they, the said
DR. ANTONIO P. CABUGAO, Petitioner, physicians, should have been done so considering that examinations
vs. conducted upon their patient Rodolfo Palma, Jr. seriously manifest todo so,
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M. causing by such negligence, carelessness, and imprudence the victim,
PALMA and ROSARIO F. PALMA, Respondents. RODOLFO PALMA JR., to die due to:

G.R. No. 165805 "CARDIORESPIRATORY ARREST, METABOLIC

DR. CLENIO YNZON, Petitioner,
vs.
PEOPLE OF THE PHILIPPINES and SPOUSES RODOLFO M.
PALMA AND ROSARIO F. PALMA, Respondents.
DECISION
PERALTA, J.:
1
Before this Court are appeals via Rule 45 from the Decision dated June 4,
2004 of the Court of Appeals in CA-G.R. CR No. 27293, affirming the
Decision2 dated February 28,2003 of the Regional Trial Court (RTC),
convicting appellant Dr. Antonio P. Cabugao (Dr. Cabugao) and Dr. Clenio
ENCEPHALOPATHY, SEPTICEMIA (ACUTE APPENDICITIS),
CEREBRAL ANEURYSM RUPTURED (?)"
As per Certificate of Death issued by accused Dr. Antonio P. Cabugao, to the
damage and prejudice of the legal heirs of said deceased RODOLFO
PALMA, JR. and other consequential damages relative thereto.
CONTRARY to Article 365, 1st par. of the Revised Penal Code.
Dagupan City, Philippines, January 29, 2001.
Arising from the same events, the Court resolved to consolidate these
cases.4 The facts, as culled from the records, are as follows:
On June 14, 2000, at around 4 o'clock in the afternoon, ten (10)-year old
Rodolfo F. Palma, Jr. (JR) complained of abdominal pain to his mother,
Rosario Palma. At 5 o’clock that sameafternoon, Palma's mother and father,
Atty. Rodolfo Palma Sr., brought JR to the clinic of accused Dr. Cabugao. Dr.
Cabugao, a general practitioner, specializing in familymedicine gave
medicines for the pain and told Palma's parents to call him up if his stomach
pains continue. Due to persistent abdominal pains, at 4:30 in the early
morning of June 15, 2000, they returnedto Dr. Cabugao, who advised them to
bring JR to the Nazareth General Hospital in Dagupan City, for confinement.
JR was admitted at the said hospital at 5:30 in the morning.5
Blood samples were taken from JR for laboratory testing. The complete blood
count conveyed the following result: wbc – 27.80 x 10 9/L; lymphocytes –
0.10 and neutrophils – 0.90. Diagnostic ultrasound was likewise conducted
on the patient's lower abdomen by radiologist, Dr. Ricky V. Querubin, with
the following findings:
Normal liver, bile ducts, gallbladder, pancreas, spleen, kidneys and urinary
bladder.
There is no free peritoneal fluid.
There is localized tenderness in the paraumbilical region, more so in the supra
and right paraumbilical areas.
There is a vague elongated hypoechoic focus in the right periumbilical region
roughly about 47 x 18 mm surrounded by undistended gas-filled bowels. This
is suggestive of an inflammatory process wherein appendiceal or
periappendiceal pathology cannot be excluded. Clinical correlation is
essential."6
Dr. Cabugao did a rectal examination noting the following: "rectal: good
sphincter, negative tenderness, negative mass." The initial impression was
Acute Appendicitis,7 and hence, he referred the case to his co-accused, Dr.
Ynzon, a surgeon.8 In the later part of the morning of June 15, 2000, Dr.
Ynzon went to the hospital and readthe CBC and ultrasound results. The
administration of massive antibiotics and pain reliever to JRwere ordered.
Thereafter, JR was placed on observation for twenty-four (24) hours.
In the morning of June 16, 2000, JR complained again of abdominal pain and
his parents noticeda swelling in his scrotum. In the afternoon of the same day,
JR vomitted out greenish stuff three (3) times and had watery bowels also
three (3) times. The nurses on-duty relayed JR's condition to Dr. Ynzon who
merely gaveorders via telephone.9Accused continued medications to alleviate
JR's abdominal spasms and diarrhea. By midnight, JR again vomitted twice,
had loose bowel movements and was unable to sleep. The following morning,
June 17,2000, JR's condition worsened, he had a running fever of 38°C. JR's
fever remained uncontrolled and he became unconscious, he was given
Aeknil (1 ampule) and Valium (1 ampule). JR's condition continued to
deteriorate that by 2 o'clock in the afternoon, JR's temperature soared to 42°C,
had convulsions and finally died.
The Death Certificate10 dated June 19, 2000 prepared by Dr. Cabugao
indicated the following causes of death:
Immediate cause: CARDIORESPIRATORY ARREST
Antecedent cause: METABOLIC ENCEPHALOPATHY
Underlying cause: SEPTICEMIA (ACUTE APPENDICITIS)
Other significant conditionscontributing to death:
CEREBRAL ANEURYSM RUPTURED (?)
No post-mortem examination was conducted on JR. On February 1, 2001, an
Information was filed against accused for reckless imprudence resulting to
homicide. At their arraignment, both accused, duly assisted by counsel,
pleaded not guilty to the charge.
On February 28, 2003, in convicting both the accused, the trial court found
the following circumstances as sufficient basis to conclude that accused were
indeed negligent in the performance of their duties:
It is unquestionable that JR was under the medical care of the accused from
the time of his admission for confinement at the Nazareth General Hospital
until his death. Upon his admission, the initial working diagnosis was to
consider acute appendicitis. To assist the accused in the consideration of acute
appendicitis, Dr. Cabugao requested for a complete blood count (CBC) and a
diagnostic ultrasound on JR. The findings of the CBC and ultrasound showed
that an inflammatory process or infection was going on inside the body of JR.
Said inflammatory process was happening in the periumbilical region where
the appendix could be located. The initial diagnosis of acute appendicitis
appears to be a distinct possibility. x x x.
Dr. Ynzon ordered medications to treat the symptoms being manifested by
JR. Thereafter, he ordered that JR be observed for 24 hours. However, the
accused, as the attending physicians, did not personally monitor JR in order
to check on subtle changes that may occur. Rather, they left the monitoring
and actual observation to resident physicians who are just on residency
training and in doing so, they substituted their own expertise, skill and
competence with those of physicians who are merely new doctors still on
training. Not having personally observed JR during this 24-hour critical
period of observation, the accused relinquished their duty and thereby were
unable to give the proper and correct evaluation as to the real condition of JR.
In situations where massive infection is going on as shown by the aggressive
medication of antibiotics, the condition of the patient is serious which
necessitated personal, not delegated, attention of attending physicians,
namely JR and the accused in this case.
xxxx
Throughout the course of the hospitalization and treatment of JR, the accused
failed to address the acute appendicitis which was the initial diagnosis. They
did not take steps to find out if indeed acute appendicitis was what was
causing the massive infection that was ongoing inside the body of JR even
when the inflammatory process was located at the paraumbilical region where
the appendix can be located. x x x
There may have been other diseases but the records do not show that the
accused took steps to find outwhat disease exactly was plaguing JR. It was
their duty to find out the disease causing the health problem of JR, but they
did not perform any process of elimination. Appendicitis, according to expert
testimonies, could be eliminated only by surgery but no surgery was done by
the accused. But the accused could not have found out the real disease of JR
because they were treating merely and exclusively the symptoms by means of
the different medications to arrest the manifested symptoms. In fact, by
treating the symptoms alone, the accused were recklessly and wantonly
ignoring the same as signs of the graver health problem of JR. This gross
negligence on the part of the accused allowed the infection to spread inside
the body of JR unabated. The infection obviously spread so fastand was so
massive that within a period of only two and a half (2 ½) days from the day
of admission to the hospital on June 15, 2000, JR who was otherwise healthy
died [of] Septicemia (Acute Appendicitis) on June 17, 2000.11
On June 4, 2004, in affirming the accused' conviction, the Court of Appeals
gave similar observations, to wit:
The foregoing expert testimony clearly revealed such want of reasonable skill
and care on the part of JR's attending physicians, appellants Dr. Cabugao and
Dr. Ynzon in neglecting to monitor effectively and sufficiently the
developments/changes during the observation period and act upon the
situation after said 24-hour period when his abdominal pain subsisted, his
condition even worsened with the appearance of more serious symptoms of
nausea, vomiting and diarrhea. Considering the brief visit only made on
regular rounds, the records clearly show such gross negligence in failing to
take appropriate steps to determine the real cause of JR's abdominal pain so
that the crucial decision to perform surgery (appendectomy) had even been
ruled out precisely because of the inexcusable neglect to undertake
suchefficient diagnosis by process of elimination, as correctly pointed out by
the trial court. As has been succinctly emphasized by Dr. Mateo, acute
appendicitis was the working diagnosis, and with the emergence of symptoms
after the 24-hour observation (high fever, vomiting, diarrhea) still, appellants
ruled out surgery, not even considering exploratory laparoscopy. Dr. Mateo
also expressed the opinion that the decision to operate could have been made
after the result of the ultrasound test, considering that acute appendicitis was
the initial diagnosis by Dr. Cabugao after he had conducted a rectal
examination.
Medical records buttress the trial court's finding that in treating JR, appellants
have demonstrated indifference and neglect of the patient's condition as a
serious case. Indeed, appendicitis remains a clinical emergencyand a surgical
disease, as correctly underscored by Dr. Mateo, a practicing surgeon who has
already performed over a thousand appendectomy. In fact, appendectomy is
the only rational therapy for acute appendicitis; it avoids clinical deterioration
and may avoid chronic or recurrent appendicitis. Although difficult, prompt
recognition and immediate treatment of the disease prevent complications.
Under the factual circumstances, the inaction, neglect and indifference of
appellants who, after the day of admission and after being apprised of the
ongoing infection from the CBC and initial diagnosis as acute appendicitis
from rectal examination and ultrasound testand only briefly visited JR once
during regular rounds and gave medication orders by telephone – constitutes
gross negligenceleading to the continued deterioration of the patient, his
infection having spread in sofast a pace that he died within just two and a half
(2 ½) days’ stay inthe hospital. Authorities state that if the clinical picture is
unclear a short period of 4 to 6 hours of watchful waiting and a CT scan may
improve diagnostic accuracy and help to hasten diagnosis.Even assuming that
JR's case had an atypical presentation in view of the location of his appendix,
laboratory tests could have helped to confirm diagnosis, as Dr. Mateo opined
thatthe possibility of JR having a retrocecal appendicitis should have been a
strong consideration. Lamentably, however, as found by the trial court,
appellants had not taken steps towards correct diagnosis and demonstrated
laxity even when JR was already running a high fever in the morning of June
17, 2000 and continued vomiting with diarrhea, his abdominal pain becoming
more intense. This is the reason why private complainants were not even
apprised of the progress of appellants' diagnosis – appellants have nothing to
report because they did nothing towards the end and merely gave medications
to address the symptoms.12
Thus, these appeals brought beforethis Court raising the following arguments:
I
WHETHER THE CAUSE OF ACCUSATION AS CONTAINED IN THE
INFORMATION IS "FAILURE TO PERFORM IMMEDIATE
OPERATION UPON THE PATIENT ROFOLFO PALMA JR. OF ACUTE
APPENDICITIS;
II
WHETHER THE SUBJECT INFORMATION APPEARS TO HAVE
ACCUSED BOTH ACCUSED DOCTORS OF CONSPIRACY AND THE
APPEALED DECISION SEEMS TO HAVE TREATED BOTH ACCUSED
DOCTORS TO BE IN CONSPIRACY;
III
WHETHER PETITIONER DR. CABUGAO IS A GENERAL
PRACTITIONER (NOT A SURGEON) AND HAVE EXCLUDED
SURGERY FROM THE LIMITS OFHIS PRACTICE, AND IT WAS NOT
AND NEVER HIS DUTY TO OPERATE THE PATIENT RODOLFO
PALMA JR., THAT WAS WHY HE REFERRED SUBJECT PATIENT TO
A SURGEON, DR. CLENIO YNZON;
IV
WHETHER THE DEFENSE NEVER STATED THAT THERE IS
GUARANTEE THAT DOING SURGERY WOULD HAVE SAVED THE
PATIENT;
V
WHETHER THE WITNESSES FOR THE PROSECUTION INCLUDING
PROSECUTION'S EXPERT WITNESSES EVER
DECLARED/TESTIFIED THAT PETITIONER DR. CABUGAO HAD
THE DUTY TO PERFORM IMMEDIATE OPERATION ON RODOLFO
PALMA, JR., AND THEY FAILED TO STATE/SHOW THAT THE
PROXIMATE CAUSE OF DEATH OF JR WAS ACUTE APPENDICITIS;
VI
WHETHER THE EXPERT WITNESSES PRESENTED BY THE
PROSECUTION EVER QUESTIONED THE MANAGEMENT AND
CARE APPLIED BY PETITIONER DR. CABUGAO;
VII
WHETHER THE EXPERT WITNESSES PRESENTED BY THE
DEFENSE ARE UNANIMOUS IN APPROVING THE METHOD OF
TREATMENT APPLIED BY BOTH ACCUSED DOCTORS ON SUBJECT
PATIENT, AND THEY DECLARED/AFFIRMED THAT THEY WOULD
FIRST PLACE SUBJECT THE PATIENT UNDER OBSERVATION, AND
WOULD NOT PERFORM IMMEDIATE OPERATION;
VIII
WHETHER THE CONVICTION OF PETITIONER DR. YNZON WAS
ESTABLISHED WITH THE REQUIRED QUANTUM OF PROOF
BEYOND REASONABLE DOUBT THAT THE PATIENT WAS
SPECIFICALLY SUFFERING FROM AND DIED OF ACUTE
APPENDICITIS; and
IX
WHETHER THE FAILURE TO CONDUCT THE SPECIFIC SURGICAL
OPERATION KNOWN AS APPENDECTOMY CONSTITUTED
CRIMINAL NEGLIGENCE.
In a nutshell, the petition brought before this Court raises the issue of whether
or not petitioners' conviction of the crime of reckless imprudence resulting in
homicide, arising from analleged medical malpractice, is supported by the
evidence on record.
Worth noting is that the assigned errors are actually factual in nature, which
as a general rule, findings of factof the trial court and the Court of Appeals
are binding and conclusiveupon this Court, and we will not normally disturb
such factual findings unless the findings of the court are palpably unsupported
by the evidence on record or unless the judgment itself is based on
misapprehension of facts. Inthe instant case, we find the need to make certain
exception.
AS TO DR. YNZON'S LIABILITY:
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 precautionon the part of the person performing or failing to perform
such act.13 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 bewithout 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.14
With respect to Dr. Ynzon, all the requisites of the offense have been clearly
established by the evidence on record. The court a quoand the appellate court
were one in concluding that Dr. Ynzon failed to observe the required standard
of care expected from doctors.
In the instant case, it was sufficiently established that to prevent certain death,
it was necessary to perform surgery on JR immediately. Even the
prosecution’s own expert witness, Dr. Antonio Mateo,15 testified during
cross-examination that he would perform surgery on JR:
ATTY. CASTRO:
Q. Given these data soft non-tender abdomen, ambulatory, watery diarrhea,
Exhibit C which is the ultrasound result, with that laboratory would you
operate the patient?
A Yes, I would do surgery.
Q And you should have done surgery with this particular case?"
A Yes, sir.16
xxxx
COURT:
Q You stated a while ago doctor thatyou are going to [do] surgery to the
patient, why doctor, if you are notgoing to do surgery, what will happen?
A If this would be appendicitis, the usual progress would be that it would be
ruptured and generalized peritonitis and eventually septicemia, sir.
Q What do you mean by that doctor?
A That means that infection would spread throughout the body, sir.
Q If unchecked doctor, what will happen?
A It will result to death.17
xxxx
Q And what would have you doneif you entertain other considerations from
the time the patient was admitted?
A From the time the patient was admitted until the report of the sonologist, I
would have made a decision by then.
Q And when to decide the surgery would it be a particular exact time, would
it be the same for all surgeons?
A If you are asking acute appendicitis, it would be about 24 hours because
acute appendicitis is a 24-hour disease, sir.
Q. And would it be correct to say that it depends on the changes on the
condition of the patient?
A. Yes, sir.
Q. So, are you saying more than 24 hours when there are changes?
A. If there are changes in the patient pointing towards appendicitis then you
have to decide right there and then, sir.
Q. So if there are changes in the patient pointing to appendicitis?
A. It depends now on what you are trying to wait for in the observation
period, sir.
Q. So precisely if the change is a condition which bring you in doubt that there
is something else other than appendicitis, would you extend over a period of
24 hours?
A. It depends on the emergent development, sir.
Q. That is the point, if you are the attending physician and there is a change
not pointing to appendicitis, would you extend over a period of 24 hours?
A. In 24 hours you have to decide, sir.
xxxx
Q. And that is based on the assessment of the attending physician?
A. Yes, sir.18
Dr. Mateo further testified on cross-examination:
ATTY. CASTRO:
Q: So you will know yourself, as far as the record is concerned, because if
you will agree with me, you did not even touch the patient?
A. Yes, I based my opinion on what is put on record, sir. The records show
that after the observation period, the abdominal pain is still there plus there
are already other signs and symptoms which are not seen or noted.
Q. But insofar as you yourself not having touched the abdomen of the patient,
would you give a comment on that?
A. Yes, based on the record, after 24 hours of observation, the pain apparently
was still there and there was more vomiting and there was diarrhea. In my
personal opinion, I think the condition of the patient was deteriorating.
Q. Even though you have not touched the patient?
A. I based on what was on the record, sir.19
From the foregoing, it is clear that if JR’s condition remained unchecked it
would ultimately result in his death, as what actually happened in the present
case. Another expert witness for the defense, Dr. Vivencio Villaflor, Jr.
testified on direct examination that he would perform a personal and thorough
physical examination of the patient as frequent as every 4 to 6 hours, to wit:
ATTY. CASTRO:
Q. As an expert doctor, if you were faced with a history of abdominal pain
with nausea, vomiting, fever, anurecia (sic), elevated white blood cell count,
physical examination of a positive psoas sign, observation of the sonologist
of abdominal tenderness and the ultrasound findings of the probability of
appendiceal (sic) pathology, what will you do if you have faced these
problems, Doctor?
A. I will examine the patient thoroughly and it will depend on my physical
examination and that isprobably every 4 to 6 hours, sir.20
On cross-examination, Dr. Villaflor affirmed:
Cross Exam. By Atty. Marteja:
Q. x x x However, there are corrections and admissions made at that time,
your Honor, do I understand thatT/C does not mean ruled out but rather to
consider the matter?
A. Yes, now that I have seen the records of the patient, it says here, impression
and T/C means to consider the appendicitis.
Q. Isn't it that it is worth then to say that the initial working diagnosis on
Rodolfo Palma, Jr., otherwise known as JR, to whom I shall now refer to as
JR, the primary consideration then is acute appendicitis, is that correct to say
Doctor?
A. I think so, that is the impression.
Q. x x x Now if it is to be considered as the primary consideration in the initial
working diagnosis, isn't it a fact that it has tobe ruled out in order to consider
it as not the disease of JR?
A. Yes. Sir.
Q. Isn't it a fact thatto rule out acute appendicitis as not the disease of JR,
surgery or operation must be done, isn't it Doctor?
A. You have to correlate all the findings.
Q. Is it yes or no, Doctor?
A. Yes.
Q. So, you are saying then that in order to rule out acute appendicitis there
must be an operation, that is right Doctor?
A. No, sir. If your diagnosis is toreally determine if it is an acute appendicitis,
you have to operate.21
xxxx
Q. Now Doctor, considering the infection, considering that there was a
[symptom] that causes pain, considering that JR likewise was feverish and
that he was vomiting, does that not show a disease of acute appendicitis
Doctor?
A. Its possible.
Q. So that if that is possible, are we getting the impression then Doctor what
you have earlier mentioned that the only way to rule out the suspect which is
acute appendicitis is by surgery, you have said that earlier Doctor, I just want
any confirmation of it?
A. Yes, sir.22
Verily, whether a physician or surgeon has exercised the requisite degree of
skill and care in the treatment of his patient is, in the generality of cases, a
matter of expert opinion. The deference of courts to the expert opinions of
qualified physicians stems from its realization that the latter possess unusual
technical skills which laymen in most instances are incapable of intelligently
evaluating.23 From the testimonies of the expert witnesses presented, it was
irrefutably proven that Dr. Ynzon failed to practice that degree of skill and
care required in the treatment of his patient.
As correctly observed by the appellate court, Dr. Ynzon revealed want of
reasonable skill and care in attending to the needs of JR by neglecting to
monitor effectively the developmentsand changes on JR's condition during
the observation period, and to act upon the situation after the 24-hour period
when his abdominal pain persisted and his condition worsened. Lamentable,
Dr. Ynzon appeared to have visited JRbriefly only during regular rounds in
the mornings. He was not there during the crucial times on June 16, 2000
when JR's condition started to deteriorate until JR's death. As the attending
surgeon, he should be primarily responsible in monitoring the condition of
JR, as he is in the best position considering his skills and experience to know
if the patient's condition had deteriorated. While the resident-doctors-onduty
could likewise monitor the patient’scondition, he is the one directly
responsible for the patient as the attending surgeon. Indeed, it is reckless and
gross negligence of duty to relegate his personal responsibility to observe the
condition of the patient. Again, acute appendicitis was the working diagnosis,
and with the emergence of graver symptoms after the 24-hour observation,
Dr. Ynzon ruled out surgery for no apparent reason. We, likewise, note that
the records are devoid of showing of any reasonable cause which would lead
Dr. Ynzon tooverrule appendectomy despite the initial diagnosis of
appendicitis. Neitherwas there any showing that he was entertaining another
diagnosis nor he took appropriate steps towards another diagnosis.
Among the elements constitutive of reckless imprudence, what perhaps is
most central to a finding of guilt is the conclusive determination that the
accused has exhibited, by his voluntary act without malice, an inexcusable
lack of precaution. It is that which supplies the criminal intent so
indispensable as tobring an act of mere negligence and imprudence under the
operation of the penal law. This is because a conscious indifference to the
consequences of the conduct is all that is required from the standpoint of the
frame of mind of the accused.24 Quasioffenses penalize the mental attitudeor
condition behind the act, the dangerous recklessness, the lack of care or
foresight, the "imprudencia punible," unlike willful offenses which punish the
intentional criminal act.25 This is precisely where this Court found Dr. Ynzon
to be guilty of - his seemingly indifference to the deteriorating condition of
JR that he as a consequence, failed to exercise lack of precaution which
eventually led to JR's death.
To be sure, 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 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.26 Sadly, Dr. Ynzon did not display that degree of care
and precaution demanded by the circumstances.
AS TO DR. CABUGAO'S LIABILITY:
Every criminal conviction requires of the prosecution to prove two things —
the fact of the crime, i.e., the presence of all the elements of the crime for
which the accused stands charged, and the fact that the accused is the
perpetrator of the crime. Based on the above disquisitions, however, the
prosecution failed to prove these two things. The Court is not convinced with
moral certainty that Dr. Cabugao isguilty of reckless imprudence as the
elements thereof were not proven by the prosecution beyond a reasonable
doubt.
Both the trial court and the appellate court bewail the failure to perform
appendectomy on JR, or the failure to determine the source of infection which
caused the deterioration of JR's condition. However, a review of the records
fail to show that Dr. Cabugao is in any position to perform the required
appendectomy.
Immediately apparent from a review of the records of this case is the fact that
Dr. Cabugao is not a surgeon,but a general practitioner specializing in family
medicine;27 thus, even if he wanted to, he cannot do an operation, much less
an appendectomy on JR. It is precisely for this reason why he referred JR to
Dr. Ynzon after he suspected appendicitis. Dr. Mateo, the prosecution’s
expert witness, emphasized the role of the surgeon during direct examination,
to wit:
ATTY. MARTEJA:
Q. You had mentioned that under this circumstances and condition, you have
mentioned that surgery is the solution, would you have allowed then a 24 hour
observation?
A. If there is a lingering doubt, inshort period of observation of 18-24 hours
can be allowed provided that there would be close monitoring of the patient,
sir.
Q. Would you please tell us who would be doing the monitoring doctor?
A. The best person should be the first examiner, the best surgeon, sir.
Q. So that would you say that it is incumbent on the surgeon attending to the
case to have been the one to observe within the period of observation?
A. Yes, because he will be in the best position to observe the sudden changes
in the condition of the patient, sir.
Q. And how often would in your experience doctor, how often would the
surgeon re-assist (sic) the condition of the patient during the period of
observation?
A. Most foreign authors would recommend every four (4) hours, some centers
will recommend hourly or every two hours but here in the Philippines, would
recommend for 4 to 6 hours, sir.28
Dr. Cabugao’s supervision does not cease upon his endorsement of his patient
to the surgeon. Here, Dr. Cabugao has shown to have exerted all efforts to
monitor his patient and under these circumstances he did not have any cause
to doubt Dr. Ynzon’s competence and diligence. Expert testimonies have been
offered to prove the circumstances surrounding the case of JR and the need to
perform an operation. Defense witness, Dr. Villaflor, on cross examination
testified, to wit:
Q. Isn't it a fact that torule out acute appendicitis as notthe disease of JR,
surgery or operation mustbe done, isn't it Doctor?
A. You have to [correlate] all the findings.
Q. Is it yes or no, Doctor?
A. Yes.
Q. So, you are saying then that in order to rule out acute appendicitis there
must be an operation, that is right Doctor?
A. No, sir. If your diagnosis is to really determine if it is an acute appendicitis,
you have to operate.29
xxxx
Q. Now Doctor, considering the infection, considering that there was a
[symptom] that causes pain, considering that JR likewise was feverish and
that he was vomitting, does that not show a disease of acute appendicitis
Doctor?
A. It’s possible.
Q. So that if that is possible, are we getting the impression then Doctor what
you have earlier mentioned that the only way to rule out the suspect which is
acute appendicitis is by surgery, you have said that earlier Doctor, I just want
any confirmation of it?
A. Yes, sir.30
Neither do we find evidence that Dr. Cabugao has been negligent or lacked
the necessary precaution in his performance of his duty as a family doctor. On
the contrary, a perusal ofthe medical records would show that during the 24-
hour monitoring on JR, it was Dr. Cabugao who frequently made orders on
the administration of antibiotics and pain relievers. There was also repetitive
instructions from Dr. Cabugao to refer JR to Dr. Ynzon as it appeared that he
is suspecting appendicitis. The referral of JR to Dr. Ynzon, a surgeon, is
actually an exercise of precaution as he knew that appendicitis is not within
his scope of expertise. This clearly showed that he employed the best of his
knowledge and skill in attending to JR's condition, even after the referral of
JR to Dr. Ynzon. To be sure, the calculated assessment of Dr. Cabugao to
refer JRto a surgeon who has sufficient training and experience to handle JR’s
case belies the finding that he displayed inexcusable lack of precaution in
handling his patient.31
We likewise note that Dr. Cabugao was out of town when JR's condition
began to deteriorate. Even so, before he left, he made endorsement and
notified the resident-doctor and nurses-on-duty that he will be on leave.
Moreover, while both appeared to be the attending physicians of JR during
his hospital confinement, it cannot be said that the finding of guilt on Dr.
Ynzon necessitates the same finding on the co-accused Dr. Cabugao.
Conspiracy is inconsistent with the idea of a felony committed by means of
culpa.32 Thus, the accused-doctors to be found guilty of reckless imprudence
resulting in homicide, it must be shown that both accused-doctors
demonstratedan act executed without malice or criminal intent – but with lack
of foresight, carelessness, or negligence. Noteworthy, the evidence on record
clearly points to the reckless imprudence of Dr. Ynzon; however, the same
cannot be said in Dr. Cabugao's case.
AS TO CIVIL LIABILITY
While this case is pending appeal, counsel for petitioner Dr. Ynzon informed
the Court that the latter died on December 23, 2011 due to "multiorgan
failure" as evidenced by a copy of death certificate.33 Thus, the effect of death,
pending appeal of his conviction of petitioner Dr. Ynzon with regard to his
criminal and pecuniary liabilities should be in accordance to People v.
Bayotas,34 wherein the Court laid down the rules in case the accused dies prior
to final judgment:
1. Death of the accused pending appeal of his conviction extinguishes his
criminal liability as well as the civil liability based solely thereon. As opined
by Justice Regalado, in this regard, "the death of the accused prior to final
judgment terminates his criminal liability and only the civil liability directly
arising from and based solely on the offense committed, i.e.,civil liability ex
delictoin senso strictiore."
2. Corollarily, the claim for civil liability survives notwithstanding the death
of accused, if the same may also be predicated on a source of obligation other
than delict. Article 1157 of the Civil Code enumerates these other sources of
obligation fromwhich the civil liability may arise as a result of the same act
or omission:
a) Law
b) Contracts
c) Quasi-contracts
d) x x x x x x x x x
e) Quasi-delicts
3. Where the civil liability survives, as explained in Number 2 above, an
action for recovery therefor may be pursued but only by way of filing a
separate civil action and subject to Section 1, Rule 111 of the 1985 Rules on
Criminal Procedure as amended. This separate civil action may be enforced
either againstthe executor/administrator or the estate of the accused,
depending on the source of obligation upon which the same is based as
explained above.
4. Finally, the private offended party need not fear a forfeiture of his right to
file this separate civil action by prescription, in cases where during the
prosecution of the criminal action and prior to its extinction, the private-
offended party instituted together therewith the civil action. In such case, the
statute of limitationson the civil liability is deemed interrupted during the
pendency of the criminal case, conformably with provisions of Article 1155
of the Civil Code, that should thereby avoid any apprehension on a possible
privation of right by prescription.35
In view of the foregoing, it is clear that the death of the accused Dr. Ynzon
pending appeal of his conviction extinguishes his criminal liability. However,
the recovery of civil liability subsists as the same is not based on delictbut by
contract and the reckless imprudence he was guilty of under Article 365 of
the Revised Penal Code.1âwphi1For this reason, a separate civil action may
be enforced either against the executor/administrator or the estate of the
accused, depending on the source of obligation upon which the same is
based,36 and in accordance with Section 4, Rule 111 of the Rules on Criminal
Procedure, we quote:
Sec. 4. Effect of death on civil actions. – The death of the accused after
arraignment and during the pendency of the criminal action shall extinguish
the civil liability arising from the delict. However, the independent civil action
instituted under section 3 of this Rule or which thereafter is instituted to
enforce liability arising from other sources of obligation may be continued
against the estate or legal representative of the accused after proper
substitution or against said estate, as the case may be. The heirs of the accused
may besubstituted for the deceased without requiring the appointment of an
executor or administrator and the court may appoint a guardian ad litem for
the minor heirs.
The court shall forthwith order said legal representative or representatives to
appear and be substituted within a period of thirty (30) days from notice.
A final judgment entered in favor of the offended party shall be enforced in
the manner especially provided in these rules for prosecuting claims against
the estate of the deceased.
If the accused dies before arraignment, the case shall be dismissed without
prejudice to any civil action the offended party may file against the estate of
the deceased. (Emphases ours)
In sum, upon the extinction of the criminal liability and the offended party
desires to recover damages from the same act or omission complained of, the
party may file a separate civil action based on the other sources of obligation
in accordance with Section 4, Rule 111.37 If the same act or omission
complained of arises from quasi-delict,as in this case, a separate civil action
must be filed against the executor or administrator of the estate of the accused,
pursuant to Section 1, Rule 87 of the Rules of Court:38
Section 1. Actions which may and which may not be brought against executor
or administrator. — No action upon a claim for the recovery of money or
debtor interest thereon shall be commenced against the executor or
administrator; but to recover real or personal property, or an interest therein,
from the estate, or to enforce a lien thereon, and actions to recover damages
for an injury to person or property, real or personal, may be commenced
against him. (Emphases ours)
action is brought against the executor or administrator, or the estate.39 The
heirs of JR must choose which of the available causes of action for damages
they will bring.
WHEREFORE, premises considered, petitioner DR. ANTONIO P.
CABUGAO is hereby ACQUITTEDof the crime of reckless imprudence
resulting to homicide.

Conversely, if the offended party desires to recover damages from the same Due to the death of accused Dr. Clenio Ynzon prior to the disposition of this
act or omission complained of arising from contract, the filing of a separate case, his criminal liability is extinguished; however, his civil liability subsists.
civil action must be filed against the estate, pursuant to Section 5, Rule 86 of A separate civil action may be filed either against the executor/administrator,
the Rules of Court, to wit: or the estateof Dr. Ynzon, depending on the source of obligation upon which
the same are based.
Section 5. Claims which must be filed under the notice. If not filed, barred;
exceptions. — All claims for money against the decent, arising from contract, SO ORDERED.
express or implied, whether the same be due, not due, or contingent, all claims
for funeral expenses and expense for the last sickness of the decedent, and
judgment for money against the decent, must be filed within the time limited
in the notice; otherwise they are barred forever, except that they may be set
forth as counterclaims in any action that the executor or administrator may
bring against the claimants. Where an executor or administrator
commencesan action, or prosecutes an action already commenced by the
deceased in his lifetime, the debtor may set forth by answer the claims he has
against the decedent, instead of presenting them independently to the court as
herein provided, and mutual claims may be set off against each other in such
action; and if final judgment is rendered in favor of the defendant, the amount
so determined shall be considered the true balance against the estate, as
Republic of the Philippines
though the claim had been presented directly beforethe court in the
SUPREME COURT
administration proceedings. Claims not yet due, or contingent, may be
Manila
approved at their present value.

SECOND DIVISION
As a final note, we reiterate thatthe policy against double recovery requires
that only one action be maintained for the same act or omission whether the
G.R. No. 171127 March 11, 2015 Factual Antecedents

NOEL CASUMPANG, RUBY SANGA-MIRANDA and SAN JUAN The common factual antecedents are briefly summarized below.
DEDIOS HOSPITAL, Petitioners,
vs. On April 22, 1988, at about 11:30 in the morning, Mrs. Jesusa Cortejo brought
NELSON CORTEJO, Respondent. her 11-year old son, Edmer Cortejo (Edmer), to the Emergency Room of the
San Juan de Dios Hospital (SJDH) because of difficulty in breathing, chest
G.R. No. 171217 pain, stomach pain, and fever.4

DRA. RUBY SANGA-MIRANDA, Petitioner, Dr. Ramoncito Livelo (Dr. Livelo) initially attended to and examined Edmer.
vs. In her testimony, Mrs. Cortejo narrated that in the morning of April 20, 1988,
NELSON CORTEJO, Respondent. Edmer had developed a slight fever that lasted for one day; a few hours upon
discovery, she brought Edmer to their family doctor; and two hours after
G.R. No. 171228 administering medications, Edmer’s fever had subsided.5

SAN JUAN DEDIOS HOSPITAL, Petitioner,
vs.
NELSON CORTEJO, Respondent.
DECISION
BRION, J.:
We resolve the three (3) consolidated petitions for review on
Certiorari1 involving medical negligence, commonly assailing the October
29, 2004 decision2 and the January 12, 2006 resolution3 of the Court of
Appeals (CA) in CA-G.R. CV No. 56400. This CA decision affirmed en
totothe ruling of the Regional Trial Court (RTC), Branch 134, Makati City.
The RTC awarded Nelson Cortejo (respondent) damages in the total amount
of ₱595,000.00, for the wrongful death of his son allegedly due to the medical
negligence of the petitioning doctors and the hospital.
After taking Edmer’s medical history, Dr. Livelo took his vital signs, body
temperature, and blood pressure.6 Based on these initial examinations and the
chest x-ray test that followed, Dr. Livelo diagnosed Edmer with
"bronchopneumonia.7 " Edmer’s blood was also taken for testing, typing, and
for purposes of administering antibiotics. Afterwards, Dr. Livelo gave Edmer
an antibiotic medication to lessen his fever and to loosen his phlegm.
Mrs. Cortejo did not know any doctor at SJDH. She used her Fortune Care
card and was referred to an accredited Fortune Care coordinator, who was
then out of town. She was thereafter assigned to Dr. Noel Casumpang (Dr.
Casumpang), a pediatrician also accredited with Fortune Care.8
At 5:30 in the afternoon of the same day, Dr. Casumpang for the first time
examined Edmer in his room. Using only a stethoscope, he confirmed the
initial diagnosis of "Bronchopneumonia."9
At that moment, Mrs. Cortejo recalled entertaining doubts on the doctor’s
diagnosis. She immediately advised Dr. Casumpang that Edmer had a high
fever, and had no colds or cough10 but Dr. Casumpang merely told her that
her son’s "blood pressure is just being active,"11 and remarked that "that’s the
usual bronchopneumonia, no colds, no phlegm."12 Dr. Casumpang next
visited and examined Edmer at 9:00 in the morning the following day.13 Still
suspicious about his son’s illness, Mrs. Cortejo again called Dr. Casumpang’s
attention and stated that Edmer had a fever, throat irritation, as well as chest
and stomach pain. Mrs. Cortejo also alerted Dr. Casumpang about the traces
of blood in Edmer’s sputum. Despite these pieces of information, however,
Dr. Casumpang simply nodded, inquired if Edmer has an asthma, and
reassured Mrs. Cortejo that Edmer’s illness is bronchopneumonia.14
At around 11:30 in the morning of April 23, 1988, Edmer vomited "phlegm
with blood streak"15 prompting the respondent (Edmer’s father) to request for
a doctor at the nurses’ station.16 Forty-five minutes later, Dr. Ruby Miranda-
Sanga (Dr. Sanga), one of the resident physicians of SJDH, arrived. She
claimed that although aware that Edmer had vomited "phlegm with blood
streak," she failed to examine the blood specimen because the respondent
washed it away. She then advised the respondent to preserve the specimen for
examination.
Thereafter, Dr. Sanga conducted a physical check-up covering Edmer’s head,
eyes, nose, throat, lungs, skin and abdomen; and found that Edmer had a low-
grade non-continuing fever, and rashes that were not typical of dengue
fever.17 Her medical findings state:
the patient’s rapid breathing and then the lung showed sibilant and the
patient’s nose is flaring which is a sign that the patient is in respiratory
distress; the abdomen has negative finding; the patient has low grade fever
and not continuing; and the rashes in the patient’s skin were not
"Herman’s Rash" and not typical of dengue fever.18
At 3:00 in the afternoon, Edmer once again vomited blood. Upon seeing Dr.
Sanga, the respondent showed her Edmer’s blood specimen, and reported that
Edmer had complained of severe stomach pain and difficulty in moving his
right leg.19
Dr. Sanga then examined Edmer’s "sputum with blood" and noted that he was
bleeding. Suspecting that he could be afflicted with dengue, she inserted a
plastic tube in his nose, drained the liquid from his stomach with ice cold
normal saline solution, and gave an instruction not to pull out the tube, or give
the patient any oral medication.
Dr. Sanga thereafter conducted a tourniquet test, which turned out to be
negative.20 She likewise ordered the monitoring of the patient’s blood
pressure and some blood tests. Edmer’s blood pressure was later found to be
normal.21
At 4:40 in the afternoon, Dr. Sanga called up Dr. Casumpang at his clinic and
told him about Edmer’s condition.22Upon being informed, Dr. Casumpang
ordered several procedures done including: hematocrit, hemoglobin, blood
typing, blood transfusion and tourniquet tests.
The blood test results came at about 6:00 in the evening.
Dr. Sanga advised Edmer’s parents that the blood test results showed that
Edmer was suffering from "Dengue Hemorrhagic Fever." One hour later, Dr.
Casumpang arrived at Edmer’s room and he recommended his transfer to the
Intensive Care Unit (ICU), to which the respondent consented. Since the ICU
was then full, Dr. Casumpang suggested to the respondent that they hire a
private nurse. The respondent, however, insisted on transferring his son to
Makati Medical Center.
After the respondent had signed the waiver, Dr. Casumpang, for the last time,
checked Edmer’s condition, found that his blood pressure was stable, and
noted that he was "comfortable." The respondent requested for an ambulance
but he was informed that the driver was nowhere to be found. This prompted
him to hire a private ambulance that cost him ₱600.00.23
At 12:00 midnight, Edmer, accompanied by his parents and by Dr.
Casumpang, was transferred to Makati Medical Center.
Dr. Casumpang immediately gave the attending physician the patient’s
clinical history and laboratory exam results. Upon examination, the attending
physician diagnosed "Dengue Fever Stage IV" that was already in its
irreversible stage.
Edmer died at 4:00 in the morning of April 24, 1988.24 His Death Certificate
indicated the cause of death as "Hypovolemic Shock/hemorrhagic shock;"
"Dengue Hemorrhagic Fever Stage IV."
Believing that Edmer’s death was caused by the negligent and erroneous
diagnosis of his doctors, the respondent instituted an action for damages
against SJDH, and its attending physicians: Dr. Casumpang and Dr. Sanga
(collectively referred to as the "petitioners") before the RTC of Makati City.
The Ruling of the Regional Trial Court
25
In a decision dated May 30, 1997, the RTC ruled in favor of the respondent,
and awarded actual and moral damages, plus attorney's fees and costs.
In ruling that the petitioning doctors were negligent, the RTC found untenable
the petitioning doctors’ contention that Edmer’s initial symptoms did not
indicate dengue fever. It faulted them for heavily relying on the chest x-ray
result and for not considering the other manifestations that Edmer’s parents
had relayed. It held that in diagnosing and treating an illness, the physician’s
conduct should be judged not only by what he/she saw and knew, but also by
what he/she could have reasonably seen and known. It also observed that
based on Edmer’s signs and symptoms, his medical history and physical
examination, and also the information that the petitioning doctors gathered
from his family members, dengue fever was a reasonably foreseeable illness;
yet, the petitioning doctors failed to take a second look, much less, consider
these indicators of dengue.
The trial court also found that aside from their self-serving testimonies, the
petitioning doctors did not present other evidence to prove that they exercised
the proper medical attention in diagnosing and treating the patient, leading it
to conclude that they were guilty of negligence. The RTC also held SJDH
solidarily liable with the petitioning doctors for damages based on the
following findings of facts: first, Dr. Casumpang, as consultant, is an
ostensible agent of SJDH because before the hospital engaged his medical
services, it scrutinized and determined his fitness, qualifications, and
competence as a medical practitioner; and second, Dr. Sanga, as resident
physician, is an employee of SJDH because like Dr. Casumpang, the hospital,
through its screening committee, scrutinized and determined her
qualifications, fitness,and competence before engaging her services; the
hospital also exercised control over her work.
The dispositive portion of the decision reads:
WHEREFORE, judgment is hereby rendered in favor of the plaintiff and
against the defendants, ordering the latter to pay solidarily and severally
plaintiff the following:
(1) Moral damages in the amount of ₱500,000.00;
(2) Costs of burial and funeral in the amount of ₱45,000.00;
(3) Attorney’s fees of ₱50,000.00; and
(4) Cost of this suit.
SO ORDERED.
The petitioners appealed the decision to the CA.
The Ruling of the Court of Appeals
In its decision dated October 29, 2004, the CA affirmed en toto the RTC’s
ruling, finding that SJDH and its attending physicians failed to exercise the
minimum medical care, attention, and treatment expected of an ordinary
doctor under like circumstances.
The CA found the petitioning doctors’ failure to read even the most basic
signs of "dengue fever" expected of an ordinary doctor as medical negligence.
The CA also considered the petitioning doctors’ testimonies as self-serving,
noting that they presented no other evidence to prove that they exercised due
diligence in diagnosing Edmer’s illness.
The CA likewise found Dr. Rodolfo Jaudian’s (Dr. Jaudian) testimony
admissible. It gave credence to his opinion26that: (1) given the exhibited
symptoms of the patient, dengue fever should definitely be considered, and
bronchopneumonia could be reasonably ruled out; and (2) dengue fever could
have been detected earlier than 7:30 in the evening of April 23, 1988 because
the symptoms were already evident; and agreed with the RTC that the
petitioning doctors should not have solely relied on the chest-x-ray result, as
it was not conclusive.
On SJDH’s solidary liability, the CA ruled that the hospital’s liability is based
on Article 2180 of the Civil Code. The CA opined that the control which the
hospital exercises over its consultants, the hospital’s power to hire and
terminate their services, all fulfill the employer-employee relationship
requirement under Article 2180.
Lastly, the CA held that SJDH failed to adduce evidence showing that it
exercised the diligence of a good father of a family in the hiring and the
supervision of its physicians.
The petitioners separately moved to reconsider the CA decision, but the CA
denied their motion in its resolution of January 12, 2006; hence, the present
consolidated petitions pursuant to Rule 45 of the Rules of Court.
The Petitions
I. Dr. Casumpang’s Position (G.R. No. 171127)
Dr. Casumpang contends that he gave his patient medical treatment and care
to the best of his abilities, and within the proper standard of care required from
physicians under similar circumstances. He claims that his initial diagnosis of
bronchopneumonia was supported by the chest x-ray result.
Dr. Casumpang also contends that dengue fever occurs only after several days
of confinement. He alleged that when he had suspected that Edmer might be
suffering from dengue fever, he immediately attended and treated him.
Dr. Casumpang likewise raised serious doubts on Dr. Jaudian’s credibility,
arguing that the CA erred in appreciating his testimony as an expert witness
since he lacked the necessary training, skills, and experience as a specialist in
dengue fever cases.
II. Dr. Sanga’s Position (G.R. No. 171217)
In her petition, Dr. Sanga faults the CA for holding her responsible for
Edmer’s wrong diagnosis, stressing that the function of making the diagnosis
and undertaking the medical treatment devolved upon Dr. Casumpang, the
doctor assigned to Edmer, and who confirmed "bronchopneumonia."
Dr. Sanga also alleged that she exercised prudence in performing her duties
as a physician, underscoring that it was her professional intervention that led
to the correct diagnosis of "Dengue Hemorrhagic Fever." Furthermore,
Edmer’s Complete Blood Count (CBC) showed leukopenia and an increase
in balance as shown by the differential count, demonstrating that Edmer’s
infection, more or less, is of bacterial and not viral in nature.
Dr. Sanga as well argued that there is no causal relation between the alleged
erroneous diagnosis and medication for "Bronchopneumonia," and Edmer’s
death due to "Dengue Hemorrhagic Fever."
Lastly, she claimed that Dr. Jaudianis not a qualified expert witness since he
never presented any evidence of formal residency training and fellowship
status in Pediatrics.
III. SJDH’s Position (G.R. No. 171228)
SJDH, on the other hand, disclaims liability by asserting that Dr. Casumpang
and Dr. Sanga are mere independent contractors and "consultants" (not
employees) of the hospital. SJDH alleges that since it did not exercise control
or supervision over the consultants’ exercise of medical profession, there is
no employer-employee relationship between them, and consequently, Article
2180 of the Civil Code does not apply.
SJDH likewise anchored the absence of employer-employee relationship on
the following circumstances: (1) SJDH does not hire consultants; it only
grants them privileges to admit patients in the hospital through accreditation;
(2) SJDH does not pay the consultants wages similar to an ordinary employee;
(3) the consultants earn their own professional fees directly from their
patients; SJDH does not fire or terminate their services; and (4) SJDH does
not control or interfere with the manner and the means the consultants use in
the treatment of their patients. It merely provides them with adequate space
in exchange for rental payment.
Furthermore, SJDH claims that the CA erroneously applied the control test
when it treated the hospital’s practice of accrediting consultants as an exercise
of control. It explained that the control contemplated by law is that which the
employer exercises over the: (i) end result; and the (ii) manner and means to
be used to reach this end, and not any kind of control, however significant, in
accrediting the consultants.
SJDH moreover contends that even if the petitioning doctors are considered
employees and not merely consultants of the hospital, SJDH cannot still be
held solidarily liable under Article 2180 of the Civil Code because it observed
the diligence of a good father of a family in their selection and supervision as
shown by the following: (1) the adequate measures that the hospital
undertakes to ascertain the petitioning doctors’ qualifications and medical
competence; and (2) the documentary evidence that the petitioning doctors
presented to prove their competence in the field of pediatrics.27
SJDH likewise faults the CA for ruling that the petitioning doctors are its
agents, claiming that this theory, aside from being inconsistent with the CA’s
finding of employment relationship, is unfounded because: first, the
petitioning doctors are independent contractors, not agents of SJDH; and
second, as a medical institution, SJDH cannot practice medicine, much more,
extend its personality to physicians to practice medicine on its behalf.
Lastly, SJDH maintains that the petitioning doctors arrived at an intelligently
deduced and correct diagnosis. It claimed that based on Edmer's signs and
symptoms at the time of admission (i.e., one day fever,28 bacterial
infection,29 and lack of hemorrhagic manifestations30), there was no
reasonable indication yet that he was suffering from dengue fever, and
accordingly, their failure to diagnose dengue fever, does not constitute
negligence on their part.
The Case for the Respondent
In his comment, the respondent submits that the issues the petitioners raised
are mainly factual in nature, which a petition for review on certiorari under
Rule 45 of the Rules of Courts does not allow.
In any case, he contends that the petitioning doctors were negligent in
conducting their medical examination and diagnosis based on the following:
(1) the petitioning doctors failed to timely diagnose Edmer’s correct illness
due to their non-observance of the proper and acceptable standard of medical
examination; (2) the petitioning doctors’ medical examination was not
comprehensive, as they were always in a rush; and (3) the petitioning doctors
employed a guessing game in diagnosing bronchopneumonia.
The respondent also alleges that there is a causal connection between the
petitioning doctors’ negligence and Edmer’s untimely death, warranting the
claim for damages.
The respondent, too, asserted that SJDH is also negligent because it was not
equipped with proper paging system, has no bronchoscope, and its doctors are
not proportionate to the number of its patients. He also pointed out that out of
the seven resident physicians in the hospital, only two resident physicians
were doing rounds at the time of his son’s confinement.
The Issues
The case presents to us the following issues:
1. Whether or not the petitioning doctors had committed "inexcusable lack of
precaution" in diagnosing and in treating the patient;
2. Whether or not the petitioner hospital is solidarily liable with the petitioning
doctors;
3. Whether or not there is a causal connection between the petitioners’
negligent act/omission and the patient’s resulting death; and
4. Whether or not the lower courts erred in considering Dr. Rodolfo
Tabangcora Jaudian as an expert witness.
Our Ruling
We find the petition partly meritorious.
A Petition for Review on Certiorari
under Rule 45 of the Rules of Court
is Limited to Questions of Law.
The settled rule is that the Court’s jurisdiction in a petition for review on
certiorari under Rule 45 of the Rules of Court is limited only to the review of
pure questions of law. It is not the Court’s function to inquire on the veracity
of the appellate court’s factual findings and conclusions; this Court is not a
trier of facts.31
A question of law arises when there is doubt as to what the law is on a certain
state of facts, while there is a question of fact when the doubt arises as to the
truth or falsity of the alleged facts.32
These consolidated petitions before us involve mixed questions of fact and
law. As a rule, we do not resolve questions of fact. However, in determining
the legal question of whether the respondent is entitled to claim damages
under Article 2176 of the Civil Code for the petitioners’ alleged medical
malpractice, the determination of the factual issues – i.e., whether the
petitioning doctors were grossly negligent in diagnosing the patient’s illness,
whether there is causal relation between the petitioners’ act/omission and the
patient’s resulting death, and whether Dr. Jaudian is qualified as an expert
witness– must necessarily be resolved. We resolve these factual questions
solely for the purpose of determining the legal issues raised.
Medical Malpractice Suit as a
Specialized Area of Tort Law
The claim for damages is based on the petitioning doctors’ negligence in
diagnosing and treating the deceased Edmer, the child of the respondent. It is
a medical malpractice suit, an action available to victims to redress a wrong
committed by medical professionals who caused bodily harm to, or the death
of, a patient.33 As the term is used, the suit is brought whenever a medical
practitioner or health care provider fails to meet the standards demanded by
his profession, or deviates from this standard, and causes injury to the patient.
To successfully pursue a medical malpractice suit, the plaintiff (in this case,
the deceased patient’s heir) must prove that the doctor either failed to do what
a reasonably prudent doctor would have done, or did what a reasonably
prudent doctor would not have done; and the act or omission had caused injury
to the patient.34 The patient’s heir/s bears the burden of proving his/her cause
of action.
The Elements of a Medical Malpractice Suit
The elements of medical negligence are: (1) duty; (2) breach; (3) injury; and
(4) proximate causation.
Duty refers to the standard of behavior that imposes restrictions on one's
conduct.35 It requires proof of professional relationship between the physician
and the patient. Without the professional relationship, a physician owes no
duty to the patient, and cannot therefore incur any liability.
A physician-patient relationship is created when a patient engages the services
of a physician,36 and the latter accepts or agrees to provide care to the
patient.37 The establishment of this relationship is consensual,38 and the
acceptance by the physician essential. The mere fact that an individual
approaches a physician and seeks diagnosis, advice or treatment does not
create the duty of care unless the physician agrees.39
The consent needed to create the relationship does not always need to be
express.40 In the absence of an express agreement, a physician-patient
relationship may be implied from the physician’s affirmative action to
diagnose and/or treat a patient, or in his participation in such diagnosis and/or
treatment.41 The usual illustration would be the case of a patient who goes to
a hospital or a clinic, and is examined and treated by the doctor. In this case,
we can infer, based on the established and customary practice in the medical
community that a patient-physician relationship exists.
Once a physician-patient relationship is established, the legal duty of care
follows. The doctor accordingly becomes duty-bound to use at least the same
standard of care that a reasonably competent doctor would use to treat a
medical condition under similar circumstances.
Breach of duty occurs when the doctor fails to comply with, or improperly
performs his duties under professional standards. This determination is both
factual and legal, and is specific to each individual case.42
If the patient, as a result of the breach of duty, is injured in body or in health,
actionable malpractice is committed, entitling the patient to damages.43
To successfully claim damages, the patient must lastly prove the causal
relation between the negligence and the injury. This connection must be
direct, natural, and should be unbroken by any intervening efficient causes. In
other words, the negligence must be the proximate cause of the injury.44 The
injury or damage is proximately caused by the physician’s negligence when
it appears, based on the evidence and the expert testimony, that the negligence
played an integral part in causing the injury or damage, and that the injury or
damage was either a direct result, or a reasonably probable consequence of
the physician’s negligence.45
a. The Relationship Between Dr. Casumpang and Edmer
In the present case, the physician-patient relationship between Dr.
Casumpang and Edmer was created when the latter’s parents sought the
medical services of Dr. Casumpang, and the latter knowingly accepted Edmer
as a patient. Dr. Casumpang’s acceptance is implied from his affirmative
examination, diagnosis and treatment of Edmer. On the other hand, Edmer’s
parents, on their son’s behalf, manifested their consent by availing of the
benefits of their health care plan, and by accepting the hospital’s assigned
doctor without objections.
b. The Relationship Between Dr. Sanga and Edmer
With respect to Dr. Sanga, her professional relationship with Edmer arose
when she assumed the obligation to provide resident supervision over the
latter. As second year resident doctor tasked to do rounds and assist other
physicians, Dr. Sanga is deemed to have agreed to the creation of physician-
patient relationship with the hospital’s patients when she participated in the
diagnosis and prescribed a course of treatment for Edmer.
The undisputed evidence shows that Dr. Sanga examined Edmer twice (at
around 12:00 and 3:30 in the afternoon of April 23, 1988),and in both
instances, she prescribed treatment and participated in the diagnosis of
Edmer’s medical condition. Her affirmative acts amounted to her acceptance
of the physician-patient relationship, and incidentally, the legal duty of care
that went with it.
In Jarcia, Jr. v. People of the Philippines,46 the Court found the doctors who
merely passed by and were requested to attend to the patient, liable for
medical malpractice. It held that a physician-patient relationship was
established when they examined the patient, and later assured the mother that
everything was fine.
In the US case of Mead v. Legacy Health System,47 the Court also considered
the rendering of an opinion in the course of the patient’s care as the doctor’s
assent to the physician-patient relationship. It ruled that the relationship was
formed because of the doctor’s affirmative action. Likewise, in Wax v.
Johnson,48 the court found that a physician patient relationship was formed
between a physician who "contracts, agrees, undertakes, or otherwise
assumes" the obligation to provide resident supervision at a teaching hospital,
and the patient with whom the doctor had no direct or indirect contract.
Standard of Care and Breach of Duty
A determination of whether or not the petitioning doctors met the required
standard of care involves a question of mixed fact and law; it is factual as
medical negligence cases are highly technical in nature, requiring the
presentation of expert witnesses to provide guidance to the court on matters
clearly falling within the domain of medical science, and legal, insofar as the
Court, after evaluating the expert testimonies, and guided by medical
literature, learned treatises, and its fund of common knowledge, ultimately
determines whether breach of duty took place. Whether or not Dr. Casumpang
and Dr. Sanga committed a breach of duty is to be measured by the yardstick
of professional standards observed by the other members of the medical
profession in good standing under similar circumstances.49 It is in this aspect
of medical malpractice that expert testimony is essential to establish not only
the professional standards observed in the medical community, but also that
the physician’s conduct in the treatment of care falls below such standard.50
In the present case, expert testimony is crucial in determining first, the
standard medical examinations, tests, and procedures that the attending
physicians should have undertaken in the diagnosis and treatment of dengue
fever; and second, the dengue fever signs and symptoms that the attending
physicians should have noticed and considered.
Both the RTC and the CA relied largely on Dr. Jaudian’s expert testimony on
dengue diagnosis and management to support their finding that the petitioning
doctors were guilty of breach of duty of care.
Dr. Jaudian testified that Edmer’s rapid breathing, chest and stomach pain,
fever, and the presence of blood in his saliva are classic symptoms of dengue
fever. According to him, if the patient was admitted for chest pain, abdominal
pain, and difficulty in breathing coupled with fever, dengue fever should
definitely be considered;51 if the patient spits coffee ground with the presence
of blood, and the patient’s platelet count drops to 47,000, it becomes a clear
case of dengue fever, and bronchopneumonia can be reasonably ruled out.52
Furthermore, the standard of care according to Dr. Jaudian is to administer
oxygen inhalation, analgesic, and fluid infusion or dextrose.53 If the patient
had twice vomited fresh blood and thrombocytopenia has already occurred,
the doctor should order blood transfusion, monitoring of the patient every 30
minutes, hemostatic to stop bleeding, and oxygen if there is difficulty in
breathing.54
We find that Dr. Casumpang, as Edmer’s attending physician, did not act
according to these standards and, hence, was guilty of breach of duty. We do
not find Dr. Sanga liable for the reasons discussed below.
Dr. Casumpang’s Negligence
a. Negligence in the Diagnosis
At the trial, Dr. Casumpang declared that a doctor’s impression regarding a
patient’s illness is 90% based on the physical examination, the information
given by the patient or the latter’s parents, and the patient’s medical history.55
He testified that he did not consider either dengue fever or dengue
hemorrhagic fever because the patient’s history showed that Edmer had low
breath and voluntary submission, and that he was up and about playing
basketball.56He based his diagnosis of bronchopneumonia on the following
observations: "difficulty in breathing, clearing run nostril, harsh breath sound,
tight air, and sivilant sound."57
It will be recalled that during Dr. Casumpang’s first and second visits to
Edmer, he already had knowledge of Edmer’s laboratory test result (CBC),
medical history, and symptoms (i.e., fever, rashes, rapid breathing, chest and
stomach pain, throat irritation, difficulty in breathing, and traces of blood in
the sputum). However, these information did not lead Dr. Casumpang to the
possibility that Edmer could be suffering from either dengue fever, or dengue
hemorrhagic fever, as he clung to his diagnosis of broncho pneumonia. This
means that given the symptoms exhibited, Dr. Casumpang already ruled out
the possibility of other diseases like dengue.
In other words, it was lost on Dr. Casumpang that the characteristic symptoms
of dengue (as Dr. Jaudian testified) are: patient’s rapid breathing; chest and
stomach pain; fever; and the presence of blood in his saliva. All these
manifestations were present and known to Dr. Casumpang at the time of his
first and second visits to Edmer. While he noted some of these symptoms in
confirming bronchopneumonia, he did not seem to have considered the
patient’s other manifestations in ruling out dengue fever or dengue
hemorrhagic fever.58 To our mind, Dr. Casumpang selectively appreciated
some, and not all of the symptoms; worse, he casually ignored the pieces of
information that could have been material in detecting dengue fever. This is
evident from the testimony of Mrs. Cortejo:
TSN, Mrs. Cortejo, November 27, 1990
Q: Now, when Dr. Casumpang visited your son for the first time at 5:30
p.m., what did he do, if any?
A: He examined my son by using stethoscope and after that, he confirmed to
me that my son was suffering from broncho pneumonia.
Q: After he confirmed that your son was suffering broncho pneumonia, what
did you say if any?
A: Again, I told Dr. Casumpang, how come it was broncho pneumonia when
my son has no cough or colds.
Q: What was the answer of Dr. Casumpang to your statement?
xxxx
A: And then, Dr. Casumpang answered "THAT’S THE USUAL
BRONCHO PNEUMONIA, NO COLDS, NO PHLEGM."
Q: How long did Dr. Casumpang stay in your son’s room?
A: He stayed for a minute or 2.
xxxx
Q: When Dr. Casumpang arrived at 9:00 o’clock a.m. on April 23, what did
you tell him, if any?
xxxx
A: I told Dr. Casumpang… After examining my son using stethoscope and
nothing more, I told Dr. Casumpang about the traces of blood in my son’s
sputum and I told him what is all about and he has throat irritation.
Q: What did he tell you?
A: He just nodded his head but he did not take the initiative of looking at the
throat of my son.
Q: So what happened after that?
A: I also told Dr. Casumpang about his chest pain and also stomach pain.
Q: So what did Dr. Casumpang do after you have narrated all these
complaints of your son?
A: Nothing. He also noticed the rapid breathing of my son and my son was
almost moving because of rapid breathing and he is swaying in the bed.
Q: Do you know what action was taken by Dr. Casumpang when you told
him that your son is experiencing a rapid breathing?
A: No action. He just asked me if my son has an asthma but I said none.
Q: So how long did Dr. Casumpang stay and attended your son on April 23?
A: More or less two (2) minutes then I followed him up to the door and I
repeated about the fever of my son.
Q: What did he tell you, if any, regarding that information you gave him that
your son had a fever?
A: He said, that is broncho pneumonia, It’s only being active now.
[Emphasis supplied]
We also find it strange why Dr. Casumpang did not even bother to check
Edmer’s throat despite knowing that as early as 9:00 in the morning of April
23, 1988, Edmer had blood streaks in his sputum. Neither did Dr. Casumpang
order confirmatory tests to confirm the source of bleeding. The Physician’s
Progress Notes59 stated: "Blood streaks on phlegm can be due to bronchial
irritation or congestion," which clearly showed that Dr. Casumpang merely
assumed, without confirmatory physical examination, that
bronchopneumonia caused the bleeding.
Dr. Jaudian likewise opined that Dr. Casumpang’s medical examination was
not comprehensive enough to reasonably lead to a correct diagnosis.60 Dr.
Casumpang only used a stethoscope in coming up with the diagnosis that
Edmer was suffering from bronchopneumonia; he never confirmed this
finding with the use of a bronchoscope. Furthermore, Dr. Casumpang based
his diagnosis largely on the chest x-ray result that is generally inconclusive.61
Significantly, it was only at around 5:00 in the afternoon of April 23, 1988
(after Edmer’s third episode of bleeding) that Dr. Casumpang ordered the
conduct of hematocrit, hemoglobin, blood typing, blood transfusion and
tourniquet tests. These tests came too late, as proven by: (1) the blood test
results that came at about 6:00 in the evening, confirming that Edmer’s illness
had developed to "Dengue Hemorrhagic Fever;" and (2) Dr. Jaudian’s
testimony that "dengue fever could have been detected earlier than 7:30 in the
evening of April 23, 1988 because the symptoms were already evident."62
In Spouses Flores v. Spouses Pineda,63 a case involving a medical malpractice
suit, the Court ruled that the petitioner doctors were negligent because they
failed to immediately order tests to confirm the patient’s illness. Despite the
doctors’ suspicion that the patient could be suffering from diabetes, the former
still proceeded to the D&C operation. In that case, expert testimony showed
that tests should have been ordered immediately on admission to the hospital
in view of the symptoms presented. The Court held:
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.
The Court also ruled that reasonable prudence would have shown that diabetes
and its complications were foreseeable harm. However, the petitioner doctors
failed to take this into consideration and proceeded with the D&C operation.
Thus, the Court ruled that they failed to comply with their duty to observe the
standard of care to be given to hyperglycemic/diabetic patients.
Similarly, in Jarcia,64 involving the negligence of the doctors in failing to
exercise reasonable prudence in ascertaining the extent of the patient’s
injuries, this Court declared that:
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. [Emphasis supplied]
Even assuming that Edmer’s symptoms completely coincided with the
diagnosis of bronchopneumonia (so that this diagnosis could not be
considered "wrong"), we still find Dr. Casumpang guilty of negligence.
First, we emphasize that we do not decide the correctness of a doctor’s
diagnosis, or the accuracy of the medical findings and treatment. Our duty in
medical malpractice cases is to decide – based on the evidence adduced and
expert opinion presented– whether a breach of duty took place.
Second, we clarify that a wrong diagnosis is not by itself medical
malpractice.65 Physicians are generally not liable for damages resulting from
a bona fide error of judgment. Nonetheless, when the physician’s erroneous
diagnosis was the result of negligent conduct (e.g., neglect of medical history,
failure to order the appropriate tests, failure to recognize symptoms), it
becomes an evidence of medical malpractice.
Third, we also note that medicine is not an exact science;66 and doctors, or
even specialists, are not expected to give a 100% accurate diagnosis in treating
patients who come to their clinic for consultations. Error is possible as the
exercise of judgment is called for in considering and reading the exhibited
symptoms, the results of tests, and in arriving at definitive conclusions. But
in doing all these, the doctor must have acted according to acceptable medical
practice standards.
In the present case, evidence on record established that in confirming the
diagnosis of bronchopneumonia, Dr. Casumpang selectively appreciated
some and not all of the symptoms presented, and failed to promptly conduct
the appropriate tests to confirm his findings. In sum, Dr. Casumpang failed to
timely detect dengue fever, which failure, especially when reasonable
prudence would have shown that indications of dengue were evident and/or
foreseeable, constitutes negligence.
a. Negligence in the Treatment and Management of Dengue
Apart from failing to promptly detect dengue fever, Dr. Casumpang also
failed to promptly undertake the proper medical management needed for this
disease.
As Dr. Jaudian opined, the standard medical procedure once the patient had
exhibited the classic symptoms of dengue fever should have been: oxygen
inhalation, use of analgesic, and infusion of fluids or dextrose;67 and once the
patient had twice vomited fresh blood, the doctor should have ordered: blood
transfusion, monitoring of the patient every 30 minutes, hemostatic to stop
bleeding, and oxygen if there is difficulty in breathing.68
Dr. Casumpang failed to measure up to these standards. The evidence strongly
suggests that he ordered a transfusion of platelet concentrate instead of blood
transfusion. The tourniquet test was only conducted after Edmer’s second
episode of bleeding, and the medical management (as reflected in the records)
did not include antibiotic therapy and complete physical examination. Dr.
Casumpang’s testimony states:
Q: Now, after entertaining – After considering that the patient Edmer
Cortero was already suffering from dengue hemorrhagic fever, what did you
do, if any?
A: We ordered close monitoring of the blood pressure, the cardiac rate and
respiratory rate of the patient.
Q: Now, was your instructions carried on?
A: Yes, sir.
Q: What was the blood pressure of the patient?
A: During those times, the blood pressure of the patient was even normal
during those times.
Q: How about the respiratory rate?
A: The respiratory rate was fast because the patient in the beginning since
admission had difficulty in breathing.
Q: Then, after that, what did you do with the patient? Doctor?
A: We transfused platelet concentrate and at the same time, we monitor [sic]
the patient.
Q: Then, who monitor [sic] the patient?
A: The pediatric resident on duty at that time.
Q: Now, what happened after that?
Q: While monitoring the patient, all his vital signs were _____; his blood
pressure was normal so we continued with the supportive management at
that time.
Q: Now, after that?
A: In the evening of April 23, 1988, I stayed in the hospital and I was informed
by the pediatric resident on duty at around 11:15 in the evening that the blood
pressure of the patient went down to .60 palpatory.
Q: What did you do upon receipt of that information?
A: I immediately went up to the room of the patient and we changed the IV
fluid from the present fluid which was D5 0.3 sodium chloride to lactated
ringers solution.
Q: You mean to say you increased the dengue [sic] of the intervenus [sic]
fluid?
A: We changed the IV fluid because lactated ringers was necessary to resume
the volume and to bring back the blood pressure, to increase the blood
pressure. [Emphasis supplied]
Although Dr. Casumpang presented the testimonies of Dr. Rodolfo Jagonap
and Dr. Ellewelyn Pasion (Dr. Pasion), Personnel Officer and Medical
Director of SJDH, respectively as well as the testimonies of Dr. Livelo and
Dr. Reyes (the radiologist who read Edmer’s chest x-ray result), these
witnesses failed to dispute the standard of action that Dr. Jaudian established
in his expert opinion. We cannot consider them expert witnesses either for the
sole reason that they did not testify on the standard of care in dengue cases.69
On the whole, after examining the totality of the adduced evidence, we find
that the lower courts correctly did not rely on Dr. Casumpang’s claim that he
exercised prudence and due diligence in handling Edmer’s case. Aside from
being self-serving, his claim is not supported by competent evidence. As the
lower courts did, we rely on the uncontroverted fact that he failed, as a medical
professional, to observe the most prudent medical procedure under the
circumstances in diagnosing and treating Edmer.
Dr. Sanga is Not Liable for Negligence
In considering the case of Dr. Sanga, the junior resident physician who was
on-duty at the time of Edmer’s confinement, we see the need to draw
distinctions between the responsibilities and corresponding liability of Dr.
Casumpang, as the attending physician, and that of Dr. Sanga.
In his testimony, Dr. Pasion declared that resident applicants are generally
doctors of medicine licensed to practice in the Philippines and who would like
to pursue a particular specialty.70 They are usually the front line doctors
responsible for the first contact with the patient. During the scope of the
residency program,71 resident physicians (or "residents")72 function under the
supervision of attending physicians73 or of the hospital’s teaching staff. Under
this arrangement, residents operate merely as subordinates who usually defer
to the attending physician on the decision to be made and on the action to be
taken.
The attending physician, on the other hand, is primarily responsible for
managing the resident’s exercise of duties. While attending and resident
physicians share the collective responsibility to deliver safe and appropriate
care to the patients,74 it is the attending physician who assumes the principal
responsibility of patient care.75 Because he/she exercises a supervisory role
over the resident, and is ultimately responsible for the diagnosis and treatment
of the patient, the standards applicable to and the liability of the resident for
medical malpractice is theoretically less than that of the attending physician.
These relative burdens and distinctions, however, do not translate to immunity
from the legal duty of care for residents,76 or from the responsibility arising
from their own negligent act.
In Jenkins v. Clark,77 the Ohio Court of Appeals held that the applicable
standard of care in medical malpractice cases involving first-year residents
was that of a reasonably prudent physician and not that of interns. According
to Jenkins:
It is clear that the standard of care required of physicians is not an
individualized one but of physicians in general in the community. In order to
establish medical malpractice, it must be shown by a preponderance of the
evidence that a physician did some particular thing or things that a physician
or surgeon of ordinary skill, care and diligence would not have done under
like or similar conditions or circumstances, or that he failed or omitted to do
some particular thing or things that a physician or surgeon of ordinary skill,
care and diligence would have done under like or similar conditions or
circumstances, and that the inquiry complained of was the direct result of such
doing or failing to do such thing or things.
We note that the standard of instruction given by the court was indeed a proper
one. It clearly informed the jury that the medical care required is that of
reasonably careful physicians or hospital emergency room operators, not of
interns or residents. [Emphasis supplied]
A decade later, Centman v. Cobb,78 affirmed the Jenkins ruling and held that
interns and first-year residents are "practitioners of medicine required to
exercise the same standard of care applicable to physicians with unlimited
licenses to practice." The Indiana Court held that although a first-year resident
practices under a temporary medical permit, he/she impliedly contracts that
he/she has the reasonable and ordinary qualifications of her profession and
that he/she will exercise reasonable skill, diligence, and care in treating the
patient.
We find that Dr. Sanga was not independently negligent. Although she had
greater patient exposure, and was subject to the same standard of care
applicable to attending physicians, we believe that a finding of negligence
should also depend on several competing factors, among them, her authority
to make her own diagnosis, the degree of supervision of the attending
physician over her, and the shared responsibility between her and the
attending physicians.
In this case, before Dr. Sanga attended to Edmer, both Dr. Livelo and Dr.
Casumpang had diagnosed Edmer with bronchopneumonia. In her testimony,
Dr. Sanga admitted that she had been briefed about Edmer’s condition, his
medical history, and initial diagnosis;79 and based on these pieces of
information, she confirmed the finding of bronchopneumonia.
Dr. Sanga likewise duly reported to Dr. Casumpang, who admitted receiving
updates regarding Edmer’s condition.80There is also evidence supporting Dr.
Sanga’s claim that she extended diligent care to Edmer. In fact, when she
suspected – during Edmer’s second episode of bleeding– that Edmer could be
suffering from dengue fever, she wasted no time in conducting the necessary
tests, and promptly notified Dr. Casumpang about the incident. Indubitably,
her medical assistance led to the finding of dengue fever.
We note however, that during Edmer’s second episode of bleeding,81 Dr.
Sanga failed to immediately examine and note the cause of the blood
specimen. Like Dr. Casumpang, she merely assumed that the blood in
Edmer’s phlegm was caused by bronchopneumonia. Her testimony states:
TSN, June 8, 1993:
Q: Let us get this clear, you said that the father told you the patient cocked
[sic] out phlegm.
A: With blood streak.
Q: Now, you stated specimen, were you not able to examine the specimen?
A: No, sir, I did not because according to the father he wash [sic] his hands.
xxxx
Q: Now, from you knowledge, what does that indicate if the patient expels a
phlegm and blood streak?
A: If a patient cocked [sic] out phlegm then the specimen could have come
from the lung alone.82 [Emphasis supplied]
xxxx
TSN, June 17, 1993:
Q: Now, in the first meeting you had, when that was relayed to you by the
father that Edmer Cortejo had coughed out blood, what medical action did
you take?
A: I examined the patient and I thought that, that coughed out phlegm was a
product of broncho pneumonia.
xxxx
Q: So what examination did you specifically conduct to see that there was no
internal bleeding? A: At that time I did not do anything to determine the cause
of coughing of the blood because I presumed that it was a mucous (sic)
produced by broncho pneumonia, And besides the patient did not even show
any signs of any other illness at that time.83
Based on her statements we find that Dr. Sanga was not entirely faultless.
Nevertheless, her failure to discern the import of Edmer’s second bleeding
does not necessarily amount to negligence as the respondent himself admitted
that Dr. Sanga failed to examine the blood specimen because he wash edit
away. In addition, considering the diagnosis previously made by two doctors,
and the uncontroverted fact that the burden of final diagnosis pertains to the
attending physician (in this case, Dr. Casumpang), we believe that Dr. Sanga’s
error was merely an honest mistake of judgment influenced in no small
measure by her status in the hospital hierarchy; hence, she should not be held
liable for medical negligence.
Dr. Jaudian’s Professional Competence and Credibility
One of the critical issues the petitioners raised in the proceedings before the
lower court and before this Court was Dr. Jaudian’s competence and
credibility as an expert witness. The petitioners tried to discredit his expert
testimony on the ground that he lacked the proper training and fellowship
status in pediatrics.
● Criteria in Qualifying as an Expert Witness
The competence of an expert witness is a matter for the trial court to decide
upon in the exercise of its discretion. The test of qualification is necessarily a
relative one, depending upon the subject matter of the investigation, and the
fitness of the expert witness.84 In our jurisdiction, the criterion remains to be
the expert witness’ special knowledge experience and practical training that
qualify him/her to explain highly technical medical matters to the Court.
In Ramos v. Court of Appeals,85 the Court found the expert witness, who is a
pulmonologist, not qualified to testify on the field of anesthesiology.
Similarly, in Cereno v. Court of Appeals,86 a 2012 case involving medical
negligence, the Court excluded the testimony of an expert witness whose
specialty was anesthesiology, and concluded that an anesthesiologist cannot
be considered an expert in the field of surgery or even in surgical practices
and diagnosis.
Interestingly in this case, Dr. Jaudian, the expert witness was admittedly not
a pediatrician but a practicing physician who specializes in pathology.87 He
likewise does not possess any formal residency training in pediatrics.
Nonetheless, both the lower courts found his knowledge acquired through
study and practical experience sufficient to advance an expert opinion on
dengue-related cases.
We agree with the lower courts.
A close scrutiny of Ramos and Cereno reveals that the Court primarily based
the witnesses’ disqualification to testify as an expert on their incapacity to
shed light on the standard of care that must be observed by the defendant-
physicians. That the expert witnesses’ specialties do not match the physicians’
practice area only constituted, at most, one of the considerations that should
not be taken out of context. After all, the sole function of a medical expert
witness, regardless of his/her specialty, is to afford assistance to the courts on
medical matters, and to explain the medical facts in issue.
Furthermore, there was no reasonable indication in Ramos and Cereno that
the expert witnesses possess a sufficient familiarity with the standard of care
applicable to the physicians’ specialties. US jurisprudence on medical
malpractice demonstrated the trial courts’ wide latitude of discretion in
allowing a specialist from another field to testify against a defendant
specialist.
88
In Brown v. Sims, a neurosurgeon was found competent to give expert
testimony regarding a gynecologist's standard of pre-surgical care. In that
case, the court held that since negligence was not predicated on the
gynecologist’s negligent performance of the operation, but primarily on the
claim that the pre-operative histories and physicals were inadequate, the
neurosurgeon was competent to testify as an expert.
Frost v. Mayo Clinic89 also allowed an orthopedic surgeon to testify against a
neurologist in a medical malpractice action. The court considered that the
orthopedic surgeon’s opinion on the "immediate need for decompression"
need not come from a specialist in neurosurgery. The court held that:
It is well established that "the testimony of a qualified medical doctor cannot
be excluded simply because he is not a specialist x x x." The matter of "x x x
training and specialization of the witness goes to the weight rather than
admissibility x x x."
xxxx
It did not appear to the court that a medical doctor had to be a specialist in
neurosurgery to express the opinions permitted to be expressed by plaintiffs’
doctors, e.g., the immediate need for a decompression in the light of certain
neurological deficits in a post-laminectomy patient. As stated above, there
was no issue as to the proper execution of the neurosurgery. The medical
testimony supported plaintiffs’ theory of negligence and causation. (Citations
omitted)
In another case,90 the court declared that it is the specialist’s knowledge of the
requisite subject matter, rather than his/her specialty that determines his/her
qualification to testify.
Also in Evans v. Ohanesian,91 the court set a guideline in qualifying an expert
witness:
To qualify a witness as a medical expert, it must be shown that the witness (1)
has the required professional knowledge, learning and skill of the subject
under inquiry sufficient to qualify him to speak with authority on the subject;
and (2) is familiar with the standard required of a physician under similar
circumstances; where a witness has disclosed sufficient knowledge of the
subject to entitle his opinion to go to the jury, the question of the degree of
his knowledge goes more to the weight of the evidence than to its
admissibility.
xxxx
Nor is it critical whether a medical expert is a general practitioner or a
specialist so long as he exhibits knowledge of the subject. Where a duly
licensed and practicing physician has gained knowledge of the standard of
care applicable to a specialty in which he is not directly engaged but as to
which he has an opinion based on education, experience, observation, or
association wit that specialty, his opinion is competent.(Emphasis supplied)
Finally, Brown v. Mladineo92 adhered to the principle that the witness’
familiarity, and not the classification by title or specialty, which should
control issues regarding the expert witness’ qualifications:
The general rule as to expert testimony in medical malpractice actions is that
"a specialist in a particular branch within a profession will not be required."
Most courts allow a doctor to testify if they are satisfied of his familiarity with
the standards of a specialty, though he may not practice the specialty himself.
One court explained that "it is the scope of the witness’ knowledge and not
the artificial classification by title that should govern the threshold question
of admissibility. (Citations omitted)
● Application to the Present Case
In the case and the facts before us, we find that Dr. Jaudian is competent to
testify on the standard of care in dengue fever cases.1avvphi1
Although he specializes in pathology, it was established during trial that he
had attended not less than 30 seminars held by the Pediatric Society, had
exposure in pediatrics, had been practicing medicine for 16 years, and had
handled not less than 50 dengue related cases.
As a licensed medical practitioner specializing in pathology, who had
practical and relevant exposure in pediatrics and dengue related cases, we are
convinced that Dr. Jaudian demonstrated sufficient familiarity with the
standard of care to be applied in dengue fever cases. Furthermore, we agree
that he possesses knowledge and experience sufficient to qualify him to speak
with authority on the subject.
The Causation Between Dr. Casumpang’s
Negligent Act/Omission, and the Patient’s
Resulting Death was Adequately Proven
Dr. Jaudian’s testimony strongly suggests that due to Dr. Casumpang’s failure
to timely diagnose Edmer with dengue, the latter was not immediately given
the proper treatment. In fact, even after Dr. Casumpang had discovered
Edmer’s real illness, he still failed to promptly perform the standard medical
procedure. We agree with these findings.
As the respondent had pointed out, dengue fever, if left untreated, could be a
life threatening disease. As in any fatal diseases, it requires immediate
medical attention.93 With the correct and timely diagnosis, coupled with the
proper medical management, dengue fever is not a life threatening disease and
could easily be cured.94
Furthermore, as Dr. Jaudian testified, with adequate intensive care, the
mortality rate of dengue fever should fall to less than 2%. Hence, the survival
of the patient is directly related to early and proper management of the
illness.95
To reiterate, Dr. Casumpang failed to timely diagnose Edmer with dengue
fever despite the presence of its characteristic symptoms; and as a
consequence of the delayed diagnosis, he also failed to promptly manage
Edmer’s illness. Had he immediately conducted confirmatory tests, (i.e.,
tourniquet tests and series of blood tests)and promptly administered the
proper care and management needed for dengue fever, the risk of
complications or even death, could have been substantially reduced.
Furthermore, medical literature on dengue shows that early diagnosis and
management of dengue is critical in reducing the risk of complications and
avoiding further spread of the virus.96 That Edmer later died of "Hypovolemic
Shock/hemorrhagic shock," "Dengue Hemorrhagic Fever Stage IV," a severe
and fatal form of dengue fever, established the causal link between Dr.
Casumpang’s negligence and the injury.
Based on these considerations, we rule that the respondent successfully
proved the element of causation.
Liability of SJDH
We now discuss the liability of the hospital.
The respondent submits that SJDH should not only be held vicariously liable
for the petitioning doctors’ negligence but also for its own negligence. He
claims that SJDH fell short of its duty of providing its patients with the
necessary facilities and equipment as shown by the following circumstances:
(a) SJDH was not equipped with proper paging system;
(b) the number of its doctors is not proportionate to the number of patients;
(c) SJDH was not equipped with a bronchoscope;
(d) when Edmer’s oxygen was removed, the medical staff did not immediately
provide him with portable oxygen;
(e) when Edmer was about to be transferred to another hospital, SJDH’s was
not ready and had no driver; and
(f) despite Edmer’s critical condition, there was no doctor attending to him
from 5:30 p.m. of April 22, to 9:00 a.m. of April 23, 1988.
SJDH on the other hand disclaims liability by claiming that the petitioning
doctors are not its employees but are mere consultants and independent
contractors.
We affirm the hospital’s liability not on the basis of Article 2180 of the Civil
Code, but on the basis of the doctrine of apparent authority or agency by
estoppel.
There is No Employer-Employee Relationship
Between SJDH and the Petitioning Doctors
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.97
Control, which is the most crucial among the elements, is not present in this
case.
Based on the records, no evidence exists showing that SJDH exercised any
degree of control over the means, methods of procedure and manner by which
the petitioning doctors conducted and performed their medical profession.
SJDH did not control their diagnosis and treatment. Likewise, no evidence
was presented to show that SJDH monitored, supervised, or directed the
petitioning doctors in the treatment and management of Edmer’s case. In these
lights, the petitioning doctors were not employees of SJDH, but were mere
independent contractors.
SJDH is Solidarily Liable Based
on The Principle of Agency or Doctrine
of Apparent Authority
Despite the absence of employer-employee relationship between SJDH and
the petitioning doctors, SJDH is not free from liability.98
As a rule, hospitals are not liable for the negligence of its independent
contractors. However, it may be found liable if the physician or independent
contractor acts as an ostensible agent of the hospital. This exception is also
known as the "doctrine of apparent authority."99
The US case of Gilbert v. Sycamore Municipal Hospital100 abrogated the
hospitals’ immunity to vicarious liability of independent contractor
physicians. In that case, the Illinois Supreme Court held that under the
doctrine of apparent authority, hospitals could be found vicariously liable for
the negligence of an independent contractor:
Therefore, we hold that, under 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:
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. (Emphasis supplied)
The doctrine was applied in Nogales v. Capitol Medical Center101 where this
Court, through the ponencia of Associate Justice Antonio T. Carpio, discussed
the two factors in determining hospital liability as follows:
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. 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.
xxxx
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. (Citation omitted)
In sum, a hospital can be held vicariously liable for the negligent acts of a
physician (or an independent contractor) providing care at the hospital if the
plaintiff can prove these two factors: first, the hospital’s manifestations; and
second, the patient’s reliance.
a. Hospital’s manifestations
It involves an inquiry on whether the hospital acted in a manner that would
lead a reasonable person to conclude that the individual alleged to be
negligent was an employee or agent of the hospital. As pointed out in Nogales,
the hospital need not make express representations to the patient that the
physician or independent contractor is an employee of the hospital;
representation may be general and implied.102
In Pamperin v. Trinity Memorial Hospital,103 questions were raised on "what
acts by the hospital or its agent are sufficient to lead a reasonable person to
conclude that the individual was an agent of the hospital." In ruling that the
hospital’s manifestations can be proven without the express representation by
the hospital, the court relied on several cases from other jurisdictions, and
held that:
(1) the hospital, by providing emergency room care and by failing to advise
patients that they were being treated by the hospital’s agent and not its
employee, has created the appearance of agency; and
(2) patients entering the hospital through the emergency room, could properly
assume that the treating doctors and staff of the hospital were acting on its
behalf.1âwphi1
In this case, the court considered the act of the hospital of holding itself out
as provider of complete medical care, and considered the hospital to have
impliedly created the appearance of authority.
b. Patient’s reliance
It involves an inquiry on whether the plaintiff acted in reliance on the conduct
of the hospital or its agent, consistent with ordinary care and prudence.104
In Pamperin, the court held that the important consideration in determining
the patient’s reliance is: whether the plaintiff is seeking care from the hospital
itself or whether the plaintiff is looking to the hospital merely as a place for
his/her personal physician to provide medical care.105 Thus, this requirement
is deemed satisfied if the plaintiff can prove that he/she relied upon the
hospital to provide care and treatment, rather than upon a specific physician.
In this case, we shall limit the determination of the hospital’s apparent
authority to Dr. Casumpang, in view of our finding that Dr. Sanga is not liable
for negligence.
SJDH Clothed Dr. Casumpang With Apparent Authority
SJDH impliedly held out and clothed Dr. Casumpang with apparent authority
leading the respondent to believe that he is an employee or agent of the
hospital.
Based on the records, the respondent relied on SJDH rather than upon Dr.
Casumpang, to care and treat his son Edmer. His testimony during trial
showed that he and his wife did not know any doctors at SJDH; they also did
not know that Dr. Casumpang was an independent contractor. They brought
their son to SJDH for diagnosis because of their family doctor’s referral. The
referral did not specifically point to Dr. Casumpang or even to Dr. Sanga, but
to SJDH. Significantly, the respondent had relied on SJDH’s representation
of Dr. Casumpang’s authority. To recall, when Mrs. Cortejo presented her
Fortune Care card, she was initially referred to the Fortune Care coordinator,
who was then out of town. She was thereafter referred to Dr. Casumpang, who
is also accredited with Fortune Care. In both instances, SJDH through its
agent failed to advise Mrs. Cortejo that Dr. Casumpang is an independent
contractor.
Mrs. Cortejo accepted Dr. Casumpang’s services on the reasonable belief that
such were being provided by SJDH or its employees, agents, or servants. By
referring Dr. Casumpang to care and treat for Edmer, SJDH impliedly held
out Dr. Casumpang, not only as an accredited member of Fortune Care, but
also as a member of its medical staff. SJDH cannot now disclaim liability
since there is no showing that Mrs. Cortejo or the respondent knew, or should
have known, that Dr. Casumpang is only an independent contractor of the
hospital. In this case, estoppel has already set in.
We also stress that Mrs. Cortejo’s use of health care plan (Fortune Care) did
not affect SJDH’s liability. The only effect of the availment of her Fortune
Care card benefits is that her choice of physician is limited only to physicians
who are accredited with Fortune Care. Thus, her use of health care plan in this
case only limited the choice of doctors (or coverage of services, amount etc.)
and not the liability of doctors or the hospital.
WHEREFORE, premises considered, this Court PARTLY GRANTS the
consolidated petitions. The Court finds Dr. Noel Casumpang and San Juan de
Dios Hospital solidarily liable for negligent medical practice. We SET ASIDE
the finding of liability as to Dr. Ruby Miranda-Sanga. The amounts of
₱45,000.00 as actual damages and ₱500,000.00 as moral damages should
each earn legal interest at the rate of six percent (6%) per annum computed
from the date of the judgment of the trial court. The Court AFFIRMS the rest
of the Decision dated October 29, 2004 and the Resolution dated January 12,
2006 in CA-G.R. CV No. 56400. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
SECOND DIVISION
G.R. No. 204095 June 15, 2015
DR. JAIME T. CRUZ, Petitioner,
vs.
FELICISIMO V. AGAS, JR., Respondent.
DECISION
MENDOZA, J.:
This petition for review on certiorari under Rule 45 of the Rules of Court
assails the May 22, 2012 Decision1 and October 18, 2012 Resolution2 of the
Court of Appeals (CA), in CA-G.R. SP No. 111910, which affirmed the
March 2, 20073 and September 23, 20094 Resolutions of the Secretary of
Justice. The said resolutions let stand the February 16, 2004 Resolution of the
Office of the Prosecutor of Quezon City, dismissing the complaint of
petitioner Dr. Jaime T. Cruz (Dr. Cruz) for Serious Physical Injuries through
Reckless Imprudence and Medical Malpractice against respondent, Dr.
Felicisimo V. Agas, Jr. (Dr. Agas).
The Antecedents
In his Complaint-Affidavit5 for Serious Physical Injuries through Reckless
Imprudence and Medical Malpractice against Dr. Agas, Dr. Cruz alleged,
among others, that sometime in May 2003, he engaged the services of St.
Luke’s Medical Center (SLMC)for a medical check-up; that after being
admitted in SLMC on May 28, 2003,he underwent stool, urine, blood, and
other body fluid tests conducted by the employees and doctors of the said
hospital; that on May 29, 2003, he was sent to the Gastro-Enterology
Department for a scheduled gastroscopy and colonoscopy; that because the
specialist assigned to perform the procedure was nowhere to be found, he gave
the colonoscopy results to the attending female anesthesiologist for the
information and consideration of the assigned specialist; that, thereafter, he
was sedated and the endoscopic examination was carried out; that when he
regained consciousness, he felt that something went wrong during the
procedure because he felt dizzy, had cold clammy perspiration and
experienced breathing difficulty; that he could not stand or sit upright because
he felt so exhausted and so much pain in his abdomen; that when he was about
to urinate in the comfort room, he collapsed; that he tried to consult the
specialist who performed the colonoscopy but he was nowhere to be found;
and that his cardiologist, Dra. Agnes Del Rosario, was able to observe his
critical condition and immediately referred him to the surgical department
which suspected that he had hemorrhage in his abdomen and advised him to
undergo an emergency surgical operation.
Dr. Cruz further averred that he agreed to the operation and upon waking up
at the ICU on May 30, 2003, he found out that the doctors did an exploratory
laparatomy because of the internal bleeding; that he learned that the doctors
cut a portion of the left side of his colon measuring 6-8 inches because it had
a partial tear of the colonic wall which caused the internal bleeding; that
despite the painkillers, he was under tremendous pain in the incision area
during his recovery period in the ICU and had fever; and that he had
intravenous tubes attached to his arms, subclavian artery on the left part of his
chest and a nasogastric tube through his nose.
Dr. Cruz claimed that Dr. Agas admitted that he was the one who performed
the colonoscopy procedure but the latter insisted that nothing went wrong. On
June 7, 2003,he was discharged from SLMC. Nevertheless, he complained
that he had a hard time digesting his food; that he was frequently fed every
two hours because he easily got full; that he had fresh blood stools every time
he moved his bowel; that he had lost his appetite and had gastric acidity; that
he slept most of the day; and that he was in good physical condition before
the colonoscopy procedure. He asserted that at the time of the filing of the
complaint, he was still weak, tired and in pain.
Defense of Dr. Agas
Dr. Agas, on the other hand, countered that Dr. Cruz failed to prove the basic
elements of reckless imprudence or negligence. He averred that Dr. Cruz
unfairly made it appear that he did not know that he would perform the
procedure. He explained that before the start of the colonoscopy procedure,
he was able to confer with Dr. Cruz and review his medical history which was
taken earlier by a fellow gastrointestinal physician. He claimed that the
gastroscopy and colonoscopy procedures conducted on Dr. Cruz were
completely successful considering that the latter did not manifest any
significant adverse reaction or body resistance during the procedures and that
his vital signs were normal throughout the procedure.6
Dr. Agas added that certifications and sworn statements were submitted by
the Assistant Medical Director for Professional Services, the Director of the
Institute of Digestive Diseases, the anesthesiologist, and the hospital nurse
attesting to the fact that the intraperitonial bleeding which developed after the
colonoscopy procedure, was immediately recognized, evaluated, carefully
managed, and corrected; that he provided an adequate and reasonable standard
of care to Dr. Cruz; that the endoscopist followed all precautionary measures;
that the colonoscopy procedure was done properly; that he was not negligent
or reckless in conducting the colonoscopy procedure; that he did not deviate
from any standard medical norm, practice or procedure; and that he exercised
competence and diligence in rendering medical services to Dr. Cruz.7
Antecedents at the Prosecution Level
On February 16, 2004, the Office of the City Prosecutor (OCP) issued a
resolution dismissing the complaint for Serious Physical Injuries through
Reckless Imprudence and Medical Malpractice. Aggrieved, Dr. Cruz filed a
petition for review with the Department of Justice (DOJ)but the same was
dismissed in its March 2, 2007 Resolution. Dr. Cruz filed a motion for
reconsideration but it was denied by the DOJ in its September 23, 2009
Resolution.8
At the Court of Appeals
Not satisfied, Dr. Cruz filed a petition for certiorari before the CA questioning
the unfavorable DOJ resolutions. On May 22, 2012, the CA rendered a
decision affirming the said DOJ resolutions. The CA explained that, as a
matter of sound judicial policy, courts would not interfere with the public
prosecutor’s wide discretion of determining probable cause in a preliminary
investigation unless such executive determination was tainted with manifest
error or grave abuse of discretion. It stated that the public prosecutor’s finding
of lack of probable cause against Dr. Agas was in accordance with law and
that his alleged negligence was not adequately established by Dr. Cruz.
The CA also declared that Dr. Cruz failed to state in his Complaint-Affidavit
the specific procedures that Dr. Agas failed to do which a reasonable prudent
doctor would have done, or specific norms he failed to observe which a
reasonably prudent doctor would have complied with. The CA pointed out
that Dr. Agas was able to satisfactorily explain in his Counter-Affidavit that
the complications suffered by Dr. Cruz was not caused by his negligence or
was the result of medical malpractice. Dr. Agas explained as follows:
That the complication was due to the abnormal condition and configuration
of the digestive system, colon in particular, of the complainant and not from
any negligent act in connection with the conduct of colonoscopy. The surgical
findings (xxx) revealed marked adhesions in the sigmoid colon which is not
and never within my control. That the tear in the serosa (the outermost layer
of the colonic wall which has 4 layers) happened likely because of the marked
interloop adhesions and tortuousity of the sigmoid segment of the colon.
These adhesions that connect the serosa to the peritoneal lining of each loop
detached from the serosa during the procedure. It is not possible to detect the
presence of marked adhesions prior to the endoscopic procedure because no
clinical findings, laboratory tests or diagnostic imaging such as x-ray,
ultrasound or computed tomography (CT scan) of the abdomen can diagnose
these conditions. This can only be detected by surgically opening up the
abdomen. Moreover, marked adhesions and serosal tear, in particular, cannot
likewise be detected by colonoscopy because they are in the outer wall of the
colon and only the inner lining of the colon is within the view of the
colonoscope (camera).9
The CA further wrote that the counter-affidavit of Dr. Agas was supported by
the sworn affidavit of Dr. Jennifel S. Bustos, an anesthesiologist at the SLMC
and the affidavit of Evelyn E. Daulat, a nurse at SLMC, both swearing under
oath that Dr. Agas was not negligent in conducting a gastroscopy and
colonoscopy procedure on Dr. Cruz and the certification issued by the
Hospital Ethics Committee which stated that Dr. Cruz was given an adequate
and reasonable standard of care; that Dr. Agas followed all precautionary
measures in safeguarding Dr. Cruz from any possible complications; and that
the colonoscopy was done properly.
Hence, this petition.
ISSUE
WHETHER OR NOT THE CA WAS CORRECT IN AFFIRMING THE
DECISION OF THE DOJ THAT NO PROBABLE CAUSE EXISTS FOR
FILING AN INFORMATION AGAINST THE RESPONDENT, THAT THE
RESPONDENT WAS NOT NEGLIGENT AND THAT THERE WAS NO
DENIAL OF DUE PROCESS.
Non-interference with Executive
Determination of Probable Cause
in Preliminary Investigations
Under the doctrine of separation of powers, courts have no right to directly
decide on matters over which full discretionary authority has been delegated
to the Executive Branch of the Government, or to substitute their own
judgment for that of the Executive Branch, represented in this case by the
Department of Justice. The settled policy is that the courts will not interfere
with the executive determination of probable cause for the purpose of filing
an Information, in the absence of grave abuse of discretion. That abuse of
discretion must be so patent and gross as to amount to an evasion of a positive
duty or a virtual refusal to perform a duty enjoined by law or to act at all in
contemplation of law, such as where the power is exercised in an arbitrary
and despotic manner by reason of passion or hostility.
Medical Negligence and
Malpractice Not Established
In the case at bench, Dr. Cruz failed to show that the DOJ gravely abused its
discretion in finding that there was lack of probable cause and dismissing the
complaint against Dr. Agas for Serious Physical Injuries through Reckless
Imprudence and Medical Malpractice.
A medical negligence case can prosper if the patient can present solid proof
that the doctor, like in this case, either failed to do something which a
reasonably prudent doctor would have done, or that he did something that a
reasonably prudent doctor would not have done, and such failure or action
caused injury to the patient.
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. Simply put, the elements are duty, breach, injury
and proximate causation.10
In this case, Dr. Cruz has the burden of showing the negligence or
recklessness of Dr. Agas. Although there is no dispute that Dr. Cruz sustained
internal hemorrhage due to a tear in the serosa of his sigmoid colon, he failed
to show that it was caused by Dr. Agas’s negligent and reckless conduct of
the colonoscopy procedure. In other words, Dr. Cruz failed to show and
explain that particular negligent or reckless act or omission committed by Dr.
Agas. Stated differently, Dr. Cruz did not demonstrate that there was
"inexcusable lack of precaution" on the part of Dr. Agas.
Res Ipsa Loquitur Doctrine
Not Applicable Against Respondent
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 plaintiff’s prima facie case, and present a question of fact for
defendant to meet with an explanation.11
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.12
In this case, the Court agrees with Dr. Agas that his purported negligence in
performing the colonoscopy on Dr. Cruz was not immediately apparent to a
layman to justify the application of res ipsa loquitur doctrine.
Dr. Agas was able to establish that the internal bleeding sustained by Dr. Cruz
was due to the abnormal condition and configuration of his sigmoid colon
which was beyond his control considering that the said condition could not be
detected before a colonoscopic procedure. Dr. Agas adequately explained that
no clinical findings, laboratory tests, or diagnostic imaging, such as x-rays,
ultrasound or computed tomography (CT) scan of the abdomen, could have
detected this condition prior to an endoscopic procedure. Specifically, Dr.
Agas wrote:
On the other hand, in the present case, the correlation between petitioner’s
injury, i.e., tear in the serosa of sigmoid colon, and the colonoscopy conducted
by respondent to the petitioner clearly requires the presentation of an expert
opinion considering that no perforation of the sigmoid colon was ever noted
during the laparotomy. It cannot be overemphasized that the colonoscope
inserted by the respondent only passed through the inside of petitioner’s
sigmoid colon while the damaged tissue, i.e., serosa, which caused the
bleeding, is located in the outermost layer of the colon. It is therefore Resolution3 dated July 27, 2010 of the Court of Appeals (CA) in CA-G.R. CV
impossible for the colonoscope to touch, scratch, or even tear the serosa since No. 78534.
the said membrane is beyond reach of the colonoscope in the absence of
perforation on the colon.13 The case stemmed from a complaint4 for damages filed by Pedrito against
herein respondents Dr. ArturoImbuido and Dr. Norma Imbuido (Dr. Norma),
Dr. Cruz failed to rebut this. in their capacity as the ownersand operators of the Divine Spirit General
Hospital in Olongapo City, and Dr. Nestor Pasamba (Dr. Nestor)
WHEREFORE, the petition is DENIED. (respondents). Pedrito alleged in his complaint that he was married to one
Carmen Castillo Dela Torre(Carmen), who died while admitted at the Divine
Spirit General Hospital on February 13, 1992. Carmen was due to give birth
on February 2,1992 and was brought at around 11:30 p.m. on that day by
Pedrito to the Divine Spirit General Hospital. When Carmen still had not
delivered her baby at the expected time, Dr. Norma discussed with Pedrito the
Republic of the Philippines possibility of a caesarean section operation.5
SUPREME COURT
Manila At around 3:00 p.m. on February 3, 1992, Carmen was brought to the
hospital’s operating room for her caesarian section operation, which was to
THIRD DIVISION be performed by Dr. Nestor. By 5:30 p.m. of the same day, Pedrito was
informed of his wife’s delivery of a baby boy. In the early morning of
G.R. No. 192973 September 29, 2014 February 4, 1992, Carmen experienced abdominal pain and difficulty in
urinating. She was diagnosed to be suffering from urinary tract infection
PEDRITO DELA TORRE, Petitioner, (UTI), and was prescribed medications by Dr. Norma. On February 10, 1992,
vs. Pedrito noticed that Carmen’s stomach was getting bigger, but Dr. Norma
DR. ARTURO IMBUIDO, DRA. NORMA IMBUIDO in their capacity dismissed the patient’s condition as mere flatulence (kabag).6
as owners and operators of DIVINE SPIRIT GENERAL HOSPITAL
and/or DR. NESTOR PASAMBA, Respondents. When Carmen’s stomach still grewbigger despite medications, Dr. Norma
advised Pedrito of the possibility of a second operation on Carmen. Dr.
RESOLUTION Norma, however, provided no detailson its purpose and the doctor who would
perform it. At around 3:00 p.m. on February 12, 1992, Carmen had her second
REYES, J.: operation. Later in the evening, Dr. Norma informed Pedrito that "everything
was going on fine with [his] wife."7
This resolves the petition for review on certiorari1 filed by petitioner Pedrito
Dela Torre (Pedrito) assailing the Decision2 dated December 15, 2009 and
The condition of Carmen, however, did not improve. It instead worsened that
on February 13, 1992, she vomited dark red blood. At 9:30 p.m. on the same
day, Carmen died.8 Per her certificate of death upon information provided by
the hospital,the immediate cause of Carmen’s death was "cardio-respiratory
arrest secondary to cerebro vascular accident, hypertension and chronic
nephritis induced by pregnancy."9 An autopsy Report10 prepared by Dr.
Richard Patilano(Dr. Patilano), Medico-Legal Officer-Designate of Olongapo
City, however, provided that the cause of Carmen’s death was "shock due to
peritonitis, severe, with multiple intestinal adhesions; Status post C[a]esarian
Section and Exploratory Laparotomy."
Pedrito claimed in his complaint that the respondents "failed to exercise the
degree of diligence required of them" as members of the medical profession,
and were "negligent for practicing surgery on [Carmen] in the most unskilled,
ignorant and cruel manner, x x x[.]"11
In their answer12 to the complaint, the respondents argued that they "observed
the required standard of medical care in attending to the needs of
Carmen."13 The respondents explained that Carmen was admitted in Divine
Spirit General Hospital for "pregnancy in labor and pre-eclampsia." Her
condition was closely monitored during her confinement. A caesarian section
operation became necessary, as she manifested no significant progress for the
spontaneous delivery of her baby.14 No unusual events were observed during
the course of Carmen’s caesarian section operation. The second surgery,
however, became necessary due to suspected intestinal obstruction and
adhesions. This procedure was fully explained to Carmen and Pedrito prior to
its conduct. During the second operation, the diagnosis of intestinal
obstruction and adhesion was confirmed but resolved by her doctors. Despite
the observance of due care by the doctors, however, Carmen died on February
13, 1992.15
The respondents included in their answer a counterclaim for ₱48,515.58 as
unpaid hospital charges, professional fees and medicines, ₱3,000,000.00 for
moral damages, ₱1,500,000.00 for exemplary damages, and attorney’s fees.16
After the pre-trial conference, trial proper ensued. To support his claim,
Pedrito presented the testimony of Dr. Patilano, the medicolegal officer who
conducted an autopsy on the body of Carmen upon a telephone request made
by the City Health Officer of Olongapo City, Dr. Generoso Espinosa. Among
Dr. Patilano’s observations, as narrated in the lower court’s decision, were as
follows:
In the intestines, [Dr. Patilano] found outthat it was more reddish than the
normal condition which is supposed to bepinkish. There was presence of
adhesions, meaning, it sticks to each other and these areas were dilated. There
were constricted areas. He concluded that there might have been foreign
organic matters in the intestines. He did not see any swelling but assuming
that there was, it would be concomitant to the enlargement. x x x He came to
the conclusion that the cause of death was peritonitis, with the multiple
adhesions status in the post caesarian section. In connection with peritonitis,
this is the inflammation of the abdomen. This peritonitis in the abdominal
cavity may be caused by several conditions which are supposed to be
infections, entrance of foreign bodies in the intestines in connection with
ruptured peptic ulcer or [may be] somewhere in the spleen. The entrance of
foreign object in the abdominal cavities may cause severe infections of the
intra-abdominal cavities resulting [in] multiple adhesions of the intestines. In
cases of surgical operation, it [may be] due to the conditions of the
instruments used, the materials used in the operating room being not aseptic
and the ladies assisting the operation were not in uniform. x x x.17
Dr. Patilano claimed that peritonitis could have been prevented through
proper medical procedures and medicines. He also stated that if the cause of
Carmen’s death was actually cerebro-vascular accident, there would have
been ruptured blood vessels and blood clot in her head; but there were none
in Carmen’s case.18
Among those who testified to refutePedrito’s claim was Dr. Nestor. He
claimed that when Carmen was referred to him on February 3, 1992, she was
in full term uterine pregnancy, with pre-eclampsia, fetal distress and active
labor pains. A caesarian section operation became necessary to terminate the
pregnancy for her safety. Carmen was ready to go home four days after giving
birth, but was advised by the doctors to stay more because of her persistent
hypertension.19
The second surgery performed on Carmen was necessary after she showed
symptoms of intestinal obstruction, which happens as the intestines get
twisted due to adhesions and the normal flow of intestinal contents are
obstructed. For Dr. Nestor, this occurrence was not preventable since any
interference of the abdominal cavity would irritate the serosa of the intestines,
inviting adhesions that could cause obstruction. Surgery could remedy the
adhesions and obstruction.20 Both Carmen and Pedrito gave their written
consent to this second procedure.21
Dr. Bienvenido G. Torres (Dr. Torres), Chief of the Medico-Legal Division
of the Philippine National Police (PNP) Crime Laboratory Service,22 also
testified for the respondents.He claimed that based on Dr. Patilano’s report,
vital internal organs of Carmen, such as her brain, lungs, kidneys, liver and
adrenal glands, were not examined during the autopsy.23
On January 28, 2003, the Regional Trial Court (RTC) of Olongapo City,
Branch 75, rendered its Decision24 in favor of Pedrito. The trial court gave
greater weight to the testimony of Dr. Patilano and thus disposed of the case
as follows:
WHEREFORE, premises considered, judgment is hereby rendered in favor of
the plaintiff and against the defendants, ordering the latter to pay jointly and
severally, the former, the following sums of money, to wit:
1.) the sum of Php 28,759.46 as actual damages;
2.) the sum of Fifty Thousand (Php 50,000.00) Pesos as indemnity for the
death of Carmen dela Torre;
3.) the sum of Fifty Thousand (Php 50,000.00) Pesos as moral damages and
the further sum of Twenty Thousand (Php 20,000.00) Pesos as exemplary
damages;
4.) the sum of Twenty Thousand (Php 20,000.00) Pesos as attorney’s fees;
and
5.) the costs of [suit].
SO ORDERED.25
Dissatisfied with the RTC ruling, the respondents appealed to the CA. On
December 15, 2009, the CA rendered its Decision reversing and setting aside
the decision of the RTC. For the appellate court, it was not established that
the respondents failed to exercisethe degree of diligence required of them by
their profession as doctors. The CA also granted the respondents’
counterclaim for the amount of ₱48,515.58, as it held:
WHEREFORE, the Decision of the Regional Trial Court of Olongapo City
dated January 28, 2003 in Civil Case No. 165-0-92 is hereby REVERSED
AND SET ASIDE.
Plaintiff-appellee is directed to pay the unpaid balance for hospital bills,
professional fees and other expenses in the amount of [P]48,515.58.
SO ORDERED.26
Hence, this petition for review on certiorariin which Pedrito insists that the
respondents should be held liable for the death of Carmen.
The petition is denied.
"[M]edical 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 professionalwhich has caused bodily harm." In order
to successfully pursue such a claim, a patient, or his or her family as in this
case, "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 failure or action caused injury to the patient."27
The Court emphasized in Lucas, et al. v. Tuaño28 that in medical negligence
cases, there is a physician-patient relationship between the doctor and the
victim, but just like in any other proceeding for damages, four essential
elements must be established by the plaintiff, namely: (1) duty; (2) breach;
(3) injury; and (4) proximate causation. All four elements must be present in
order to find the physician negligent and, thus, liable for damages.29
It is settled that a physician’s duty tohis patient relates to his exercise of the
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. There is breach of this duty when the patient is injured
in body or in health. Proof of this breach rests 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. To justify an award of damages, the
negligence of the doctor must be established to be the proximate cause of the
injury.30
Through the instant petition, Pedritoseeks the reinstatement of the decision of
the RTC whose finding of the respondents’ medical negligence depended
mainly on the testimony of Dr. Patilano. Upon review, however, the Court
agrees with the CA that the report and testimony of Dr. Patilano failed to
justify Pedrito’s entitlement to the damages awarded by the RTC.
For the trial court to give weightto Dr. Patilano’s report, it was necessary to
show first Dr. Patilano’s specialization and competence to testify on the
degree of care, skill and diligence needed for the treatment of Carmen’s case.
Considering that it was not duly established that Dr. Patilano practiced and
was an expert inthe fields that involved Carmen’s condition, he could not have
accurately identified the said degree of care, skill, diligence and the medical
procedures that should have been applied by her attending physicians.
Similarly, such duty, degree of care, skill and diligence were not sufficiently
established in this case because the testimony of Dr. Patilano was based solely
on the results of his autopsy on the cadaver of Carmen. His study and
assessment were restrictedby limitations that denied his full evaluation of
Carmen’s case. He could have only deduced from the injuries apparent in
Carmen’s body, and in the condition when the body was examined. Judging
from his testimony, Dr. Patilano did not even take full consideration of the
medical history of Carmen, her actual health condition at the time of hospital
admission, and her condition as it progressed while she was being monitored
and treated by the respondents. There was also no reference to the
respondents’ defense that the emergency caesarian section operation had to
be performed in order to protect the lives and safety of Carmen and her then
unborn child. For lack of sufficient information on Carmen’s health condition
while still alive, Dr. Patilano could not have fully evaluated the suitability of
the respondents’ decisions in handling Carmen’s medical condition as it
turned critical.
On the other hand, the CA pointed out that Dr. Nestor, a surgeon, possessed
the reasonable degree of learning, skill and experience required by his
profession for the treatment ofCarmen. The respondents also emphasized in
their pleadings beforethe RTC that Dr. Nestor had his training and experience
in surgery and obstetrics since 1970.1âwphi1Without sufficient proof from
the claimant on a different degree of care, skill and diligence that should be
expected from the respondents, it could not be said with certainty that a
breachwas actually committed.
the amount of ₱48,515.58, incurred by plaintiff when the patient was confined
at said hospital from February 3 to 13, 1992.33
WHEREFORE, the petition is DENIED. The Decision dated December 15,
2009 and Resolution dated July 27, 2010 of the Court of Appeals in CA-G.R.
CV No. 78534 are AFFIRMED.

Moreover, while Dr. Patilano opined that Carmen died of peritonitis which SO ORDERED.
could be due to the poor state of the hospital equipment and medical supplies
used during her operation, there was no sufficient proof that any such fault
actually attended the surgery of Carmen, caused her illness and resulted in her
Republic of the Philippines
death. It is also significant that the Chief of the Medico-Legal Division of the
SUPREME COURT
PNP Crime Laboratory Service, Dr. Torres, testified before the trial court that
Manila
based on the autopsy report issued by Dr. Patilano, the latter did not comply
with the basic autopsy procedure when he examined the cadaver of Carmen.
FIRST DIVISION
Dr. Patilano did not appear to have thoroughly examined Carmen’s vital
organs such as her heart, lungs, uterus and brain during the autopsy. His GR No. 210445 Dec 07, 2015
findings were then inconclusive on the issue of the actual cause of Carmen's
death, and the claim of negligence allegedly committed by the respondents. NILO B. ROSIT

As the Court held in Spouses Flores v. Spouses Pineda, et al.,31 the critical
and clinching factor in a medical negligence case is proof of the causal
connection between the negligence and the injuries. The claimant must prove
not only the injury but also the defendant's fault, and that such 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,32 which the Court finds
absent in the case at bar. As regards the respondents' counterclaim, the CA's
award of ₱48,515.58 is sustained, considering that among the parties'
stipulations during the pre-trial indicated:
5. That at the time of the death of the patient Carmen C. dela Torrell there was
an unpaid balance for hospital bills, professional fees and other expenses in
v.
DAVAO DOCTORS HOSPITAL
VELASCO JR., J.:
The Case
This is a petition filed under Rule 45 of the Rules of Court assailing the
Decision and Resolution dated January 22, 2013[1] and November 7,
2013,[2] respectively, of the Court of Appeals, Cagayan De Oro City (CA),
in CA-G.R. CV No. 00911-MIN. The CA Decision reversed the Decision
dated September 14, 2004[3] of the Regional Trial Court, Branch 33 in Davao
City-(RTC) in Civil Case No. 27,354-99, a suit for damages thereat which
Nilo B. Rosit (Rosit) commenced against Dr. Rolando Gestuvo (Dr. Gestuvo).
Factual Antecedents
On January 15, 1999, Rosit figured in a motorcycle accident. The X-ray soon
taken the next day at the Davao Doctors Hospital (DDH) showed that he
fractured his jaw. Rosit was then referred to Dr. Gestuvo, a specialist in
mandibular injuries,[4] who, on January 19, 1999, operated on Rosit.
During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with
metal screws to immobilize the mandible. As the operation required the
smallest screws available, Dr. Gestuvo cut the screws on hand to make them
smaller. Dr. Gestuvo knew that there were smaller titanium screws available
in Manila, but did not so inform Rosit supposing that the latter would not be
able to afford the same.[5]
Following the procedure, Rosit could not properly open and close his mouth
and was in pain. X-rays done on Rosit two (2) days after the operation showed
that the fracture in his jaw was aligned but the screws used on him touched
his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist.
The dentist who checked Rosit, Dr. Pangan, opined that another operation is
necessary and that it is to be performed in Cebu.[6]
Alleging that the dentist told him that the operation conducted on his mandible
was improperly done, Rosit went back to Dr. Gestuvo to demand a loan to
defray the cost of the additional operation as well as the expenses of the trip
to Cebu. Dr. Gestuvo gave Rosit P4,500.
Rosit went to Cebu on February 19, 1999, still suffering from pain and could
hardly open his mouth.
In Cebu, Dr. Pangan removed the plate and screws thus installed by Dr.
Gestuvo and replaced them with smaller titanium plate and screws. Dr.
Pangan also extracted Rosit's molar that was hit with a screw and some bone
fragments. Three days after the operation, Rosit was able to eat and speak well
and could open and close his mouth normally.[7]
On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for
the cost of the operation and the expenses he incurred in Cebu amounting to
P140,000, as well as for the P50,000 that Rosit would have to spend for the
removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo refused
to pay.[8]
Thus, Rosit filed a civil case for damages and attorney's fees with the RTC
against Dr. Gestuvo and DDH, the suit docketed as Civil Case No. 27,354-99.
The Ruling of the Regional Trial Court
The RTC freed DDH from liability on the ground that it exercised the proper
diligence in the selection and supervision of Dr. Gestuvo, but adjudged Dr.
Gestuvo negligent and ruled, thus:
FOR ALL THE FOREGOING, finding the plaintiff Nilo B. Rosit to have
preponderantly established his cause of action in the complaint against
defendant Dr. Rolando G. Gestuvo only, judgment is hereby rendered for the
plaintiff and against said defendant, ordering the defendant DR. ROLANDO
G. GESTUVO to pay unto plaintiff NILO B. ROSIT the following:
the sum of ONE HUNDRED FORTY THOUSAND ONE HUNDRED NINETY N
a)
of actual expenses incurred by plaintiff in the operation and re-operation of his man
 The Ruling of the Court of Appeals
the sum of TWENTY NINE THOUSAND AND SIXTY EIGHT PESOS (P29,068.00) representing reimbursement of the filing fees and appearance
b) In its January 22, 2013 Decision, the CA modified the appealed judgment by
fees;
deleting the awards made by the trial court, disposing as follows:
WHEREFORE, the appeal filed by Gestuvo is GRANTED. The Decision
dated September 14, 2004 of the Regional Trial Court, Branch 33, Davao
c) the sum of ONE HUNDRED FIFTY THOUSAND PESOS (P150,000.00)City,
as andrendered in Civil
for attorney's fees;Case No. 27,354-99 is hereby MODIFIED. The
monetary awards adjudged in favor of Nilo B. Rosit are hereby DELETED
for lack of basis.

d) the amount of FIFTY THOUSAND PESOS (P50,000.00) as moral damages;

SO ORDERED.
Unlike the RTC, the CA ruled that the res ipsa loquitur principle is not
applicable and that the testimony of an expert witness is necessary for a
finding of negligence. The appellate court also gave credence to Dr. Pangan's
e) the amount of TEN THOUSAND PESOS (P10,000.00) as exemplary damages; and
letter stating the opinion that Dr. Gestuvo did not commit gross negligence in
his emergency management of Rosit's fractured mandible.

f) the costs of the suit. Rosit's motion for reconsideration was denied in the CA's November 7, 2013
Resolution.

For lack of merit, the complaint against defendant DAVAO DOCTORS Hence, the instant appeal.
HOSPITAL and the defendants' counterclaims are hereby ordered
DISMISSED. The Issue

Cost against Dr. Rolando G. Gestuvo. The ultimate issue for our resolution is whether the appellate court correctly
absolved Dr. Gestuvo from liability.
SO ORDERED.
In so ruling, the trial court applied the res ipsa loquitur principle holding that The Court's Ruling
"the need for expert, medical testimony may be dispensed with because the
injury itself provides the proof of negligence." The petition is impressed with merit.

Therefrom, both parties appealed to the CA. In Flores v. Pineda,[9] the Court explained the concept of a medical
negligence case and the elements required for its prosecution, viz:

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.
Duty refers to the standard of behavior which imposes restrictions on one's
conduct. 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.
(emphasis supplied)
An expert witness is not necessary as the res ipsa loquitur doctrine is
applicable
To establish medical negligence, this Court has held that an expert testimony
is generally required to define the standard of behavior by which the court
may determine whether the physician has properly performed the requisite
duty toward the patient. This is so considering that the requisite degree of skill
and care in the treatment of a patient is usually a matter of expert opinion.[10]
Solidum v. People of the Philippines[11] provides an exception. There, the
Court explained that where the application of the principle of res ipsa
loquitur is warranted, an expert testimony may be dispensed with in medical
negligence cases:
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. x x x
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 patient's 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.
We have further held that resort to the doctrine of res ipsa loquitur as an
exception to the requirement of an expert testimony in medical negligence
cases may be availed of if the following essential requisites are satisfied: (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.[12]
In its assailed Decision, the CA refused to acknowledge the application of
the res ipsa loquitur doctrine on the ground that the foregoing elements are
absent. In particular, the appellate court is of the position that post-operative
pain is not unusual after surgery and that there is no proof that the molar Dr.
Pangan removed is the same molar that was hit by the screw installed by Dr.
Gestuvo in Rosit's mandible. Further, a second operation was conducted
within the 5-week usual healing period of the mandibular fracture so that the
second element cannot be considered present. Lastly, the CA pointed out that
the X-ray examination conducted on Rosit prior to his first surgery suggests
that he had "chronic inflammatory lung disease compatible," implying that
the injury may have been due to Rosit's peculiar condition, thus effectively
negating the presence of the third element.[13]
After careful consideration, this Court cannot accede to the CA's findings as
it is at once apparent from the records that the essential requisites for the
application of the doctrine of res ipsa loquitur are present.
The first element was sufficiently established when Rosit proved that one of
the screws installed by Dr. Gestuvo struck his molar. It was for this issue that
Dr. Gestuvo himself referred Rosit to Dr. Pangan. In fact, the affidavit of Dr.
Pangan presented by Dr. Gestuvo himself before the trial court narrated that
the same molar struck with the screw installed by Dr. Gestuvo was examined
and eventually operated on by Dr. Pangan. Dr. Gestuvo cannot now go back
and say that Dr. Pangan treated a molar different from that which was affected
by the first operation.
Clearly, had Dr. Gestuvo used the proper size and length of screws and placed
the same in the proper locations, these would not have struck Rosit's teeth
causing him pain and requiring him to undergo a corrective surgery.
Dr. Gestuvo knew that the screws he used on Rosit were too large as, in fact,
he cut the same with a saw.[14] He also stated during trial that common sense
dictated that the smallest screws available should be used. More importantly,
he also knew that these screws were available locally at the time of the
operation.[15] Yet, he did not avail of such items and went ahead with the
larger screws and merely sawed them off. Even assuming that the screws were
already at the proper length after Dr. Gestuvo cut the same, it is apparent that
he negligently placed one of the screws in the wrong area thereby striking one
of Rosit's teeth.
In any event, whether the screw hit Rosit's molar because it was too long or
improperly placed, both facts are the product of Dr. Gestuvo's negligence. An
average man of common intelligence would know that striking a tooth with
any foreign object much less a screw would cause severe pain. Thus, the first
essential requisite is present in this case.
Anent the second element for the res ipsa loquitur doctrine application, it is
sufficient that the operation which resulted in the screw hitting Rosit's molar
was, indeed, performed by Dr. Gestuvo. No other doctor caused such fact.
The CA finds that Rosit is guilty of contributory negligence in having Dr.
Pangan operate on him during the healing period of his fractured mandible.
What the CA overlooked is that it was Dr. Gestuvo himself who referred Rosit
to Dr. Pangan. Nevertheless, Dr. Pangan's participation could not have
contributed to the reality that the screw that Dr. Gestuvo installed hit Rosit's
molar.
Lastly, the third element that the injury suffered must not have been due to
any voluntary action or contribution of the person injured was satisfied in this
case. It was not shown that Rosit's lung disease could have contributed to the
pain. What is clear is that he suffered because one of the screws that Dr.
Gestuvo installed hit Rosit's molar.
Clearly then, the res ipsa loquitur doctrine finds application in the instant
case and no expert testimony is required to establish the negligence of
defendant Dr. Gestuvo.
Petitioner was deprived of the opportunity to make an "informed
consent"
What is more damning for Dr. Gestuvo is his failure to inform Rosit that such
smaller screws were available in Manila, albeit at a higher price.[16] As
testified to by Dr. Gestuvo himself:
Court. This titanium materials according to you were already available in the
Witness Yes, your Honor. Witness Yes, that is true.

Li v. Soliman[17] made the following disquisition on the relevant Doctrine of

xxxx Informed Consent in relation to medical negligence cases, to wit:
The doctrine of informed consent within the context of physician-patient
relationships goes far back into English common law. x x x From a purely
ethical norm, informed consent evolved into a general principle of law
Court Did you inform Rosit about the existence of titanium screwsthat a physician
and plates has a duty
which according to isdisclose
to you what
the screws and aplates
reasonably prudent
of choice?
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,
Witness No, your Honor. 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
xxxx probable risks against the probable benefits.

xxxx

The reason I did not inform him anymore Judge because whatThere are he
I thought four
wasessential
already elements a plaintiff
hard up with the down must proveAnd
payment. in aifmalpractice
I will further
Witness action based upon the doctrine of informed consent: "(1) the physician
introduce him this screws, the more he will not be able to afford
had thea operation.
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
xxxx 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." (emphasis
supplied)
This titanium screws and plates were available then it is up to Rosit to decide whether to use it or not because after all the material you are
Court The four adverted essential elements above are present here.
using is paid by the patient himscll, is it not?
First, Dr. Gestuvo clearly had the duty of disclosing to Rosit the risks of using
the larger screws for the operation. This was his obligation as the physician
undertaking the operation.
Second, Dr. Gestuvo failed to disclose these risks to Rosit, deciding by
himself that Rosit could not afford to get the more expensive titanium screws.
Third, had Rosit been informed that there was a risk that the larger screws are
not appropriate for the operation and that an additional operation replacing
the screws might be required to replace the same, as what happened in this
case, Rosit would not have agreed to the operation. It bears pointing out that
Rosit was, in fact, able to afford the use of the smaller titanium screws that
were later used by Dr. Pangan to replace the screws that were used by Dr.
Gestuvo.
Fourth, as a result of using the larger screws, Rosit experienced pain and
could not heal properly because one of the screws hit his molar. This was
evident from the fact that just three (3) days after Dr. Pangan repeated the
operation conducted by Dr. Gestuvo, Rosit was pain-free and could already
speak. This is compared to the one (1) month that Rosit suffered pain and
could not use his mouth after the operation conducted by Dr. Gestuvo until
the operation of Dr. Pangan.
Without a doubt, Dr. Gestuvo is guilty of withholding material information
which would have been vital in the decision of Rosit in going through with
the operation with the materials at hand. Thus, Dr. Gestuvo is also guilty of
negligence on this ground.
Dr. Pangan's Affidavit is not admissible
The appellate court's Decision absolving Dr. Gestuvo of negligence was also
anchored on a letter signed by Dr. Pangan who stated the opinion that Dr.
Gestuvo did not commit gross negligence in his emergency management of
Mr. Rosit's fractured mandible.[18] Clearly, the appellate court overlooked
the elementary principle against hearsay evidence.
In Dantis v. Maghinang, Jr.,[19] the Court reiterated the oft-repeated rule that
"an affidavit is merely hearsay evidence where its affiant/maker did not take
the witness stand." Here, Dr. Pangan never took the witness stand to affirm
the contents of his affidavit. Thus, the affidavit is inadmissible and cannot be
given any weight. The CA, therefore, erred when it considered the affidavit
of Dr. Pangan, mpreso for considering the same as expert testimony.
Moreover, even if such affidavit is considered as admissible and the testimony
of an expert witness, the Court is not bound by such testimony. As ruled
in Ilao-Quianay v. Mapile:[20]
Indeed, courts are not bound by expert testimonies. They may place whatever
weight they choose upon such testimonies in accordance with the facts of the
case. The relative weight and sufficiency of expert testimony is peculiarly
within the province of the trial court to decide, considering the ability and
character of the witness, his actions upon the witness stand, the weight and
process of the reasoning by which he has supported his opinion, his possible
bias in favor of the side for whom he testifies, and any other matters which
serve to illuminate his statements. The opinion of an expert should be
considered by the court in view of all the facts and circumstances of the case.
The problem of the evaluation of expert testimony is left to the discretion of
the trial court whose ruling thereupon is not revicwable in the absence of an
abuse of that discretion.
Thus, the belief of Dr. Pangan whether Dr. Gestuvo is guilty of negligence or
not will not bind the Court. The Court must weigh and examine such
testimony and decide for itself the merits thereof.
As discussed above, Dr. Gestuvo's negligence is clearly demonstrable by the
doctrines of res ipsa loquitur and informed consent.
Damages

For the foregoing, the trial court properly awarded Rosit actual damages after
he was able to prove the actual expenses that he incurred due to the negligence
of Dr. Gestuvo. In Mendoza v. Spouses Gomez,[21] the Court explained that
a claimant is entitled to actual damages when the damage he sustained is the
natural and probable consequences of the negligent act and he adequately
proved the amount of such damage.
Rosit is also entitled to moral damages as provided under Article 2217 of the
Civil Code,[22] given the unnecessary physical suffering he endured as a
consequence of defendant's negligence.
To recall, from the time he was negligently operated upon by Dr. Gestuvo
until three (3) days from the corrective surgery performed by Dr. Pangan, or
for a period of one (1) month, Rosit suffered pain and could not properly use
his jaw to speak or eat.
The three (3) requisites are met. Dr. Gestuvo's actions are clearly negligent.
Likewise, Dr. Gestuvo acted in bad faith or in a wanton, fraudulent, reckless,
oppressive manner when he was in breach of the doctrine of informed consent.
Dr. Gestuvo had the duty to fully explain to Rosit the risks of using large
screws for the operation. More importantly, he concealed the correct medical
procedure of using the smaller titanium screws mainly because of his
erroneous belief that Rosit cannot afford to buy the expensive titanium
screws. Such concealment is clearly a valid basis for an award of exemplary
damages.
WHEREFORE, the instant petition is GRANTED. The CA Decision dated
January 22, 2013 and Resolution dated November 7, 2013 in CA-G.R. CV
No. 00911-MIN are hereby REVERSED and SET ASIDE. Further, the
Decision dated September 14, 2004 of the Regional Trial Court, Branch 33 in
Davao City in Civil Case No. 27,345-99 is
hereby REINSTATED and AFFIRMED. SO ORDERED.

The trial court also properly awarded attorney's fees and costs of suit under
Republic of the Philippines
Article 2208 of the Civil Code,[23] since Rosit was compelled to litigate due
SUPREME COURT
to Dr. Gestuvo's refusal to pay for Rosit's damages.
Manila

As to the award of exemplary damages, the same too has to be affirmed.

FIRST DIVISION
In Mendoza,[24] the Court enumerated the requisites for the award of
exemplary damages:
G.R. No. 192123 March 10, 2014
Our jurisprudence sets certain conditions when exemplary damages may be
awarded: First, they may be imposed by way of example or correction only in
DR. FERNANDO P. SOLIDUM, Petitioner,
addition, among others, to compensatory damages, and cannot be recovered
vs.
as a matter of right, their determination depending upon the amount of
PEOPLE OF THE PHILIPPINES, Respondent.
compensatory damages that may be awarded to the claimant. Second, the
claimant must first establish his right to moral, temperate, liquidated or
DECISION
compensatory damages. Third, the wrongful act must be accompanied by bad
faith, and the award would be allowed only if the guilty party acted in a
BERSAMIN, J.:
wanton, fraudulent, reckless, oppressive or malevolent manner.
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.5Dr. Leandro Resurreccion headed
the surgical team, and was assisted by Dr. Joselito Luceño, Dr. Donatella
Valeña 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.8His 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 son’s helpless and unexpected condition, Ma. Luz Gercayo
(Luz) lodged a complaint for reckless imprudence resulting in serious
physical injuries with the City Prosecutor’s Office of Manila against the
attending physicians.12
Upon a finding of probable cause, the City Prosecutor’s 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 ₱500,000.00 as moral damages and
₱100,000.00 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 ₱500,000.00 as moral damages and ₱100,000 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.
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
PETITIONER’S CONVICTION FOR THE CRIME CHARGED BASED
ON THE TRIAL COURT’S 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.
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 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 patient’s 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.
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 patient’s 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. Solidum’s 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,
patient’s 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 child’s 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 can’t 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% 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. Vertido’s 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. Solidum’s 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 complainant’s wife
and newborn baby, this Court held that:
"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 physician’s 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 physician’s 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.
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, we’re 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.
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 I’m asking you, just answer my question, did you see there
100% and 100 figures, tell me, yes or no?
WITNESS I’m 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
At the continuation of his cross-examination, Dr. Vertido maintained that
Gerald’s 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. Vertido’s findings did not preclude the
probability that other factors related to Gerald’s 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. Solidum’s
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.1âwphi1 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.50 Secondly, assuming that Ospital ng Maynila was
engaged in industry for profit, Dr. Solidum must be shown to be an employee
of Ospital ng Maynila acting in the discharge of his duties during the operation
on Gerald. Yet, he definitely was not such employee but a consultant of the
hospital. And, thirdly, assuming that civil liability was adjudged against Dr.
Solidum as an employee (which did not happen here), the execution against
him was unsatisfied due to his being insolvent.
WHEREFORE, the Court GRANTS the petition for review on certiorari;
REVERSES 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.
 Republic of the Philippines Johnny resisted the action, claiming that it was Josielene who failed in her
SUPREME COURT wifely duties. To save their marriage, he agreed to marriage counseling but
Manila when he and Josielene got to the hospital, two men forcibly held him by both
arms while another gave him an injection. The marriage relations got worse
THIRD DIVISION when the police temporarily detained Josielene for an unrelated crime and
released her only after the case against her ended. By then, their marriage
G.R. No. 179786 July 24, 2013 relationship could no longer be repaired.

JOSIELENE LARA CHAN, Petitioner,
vs.
JOHNNY T. CHAN, Respondent.
DECISION
ABAD, J.:
This case is about the propriety of issuing a subpoena duces tecum for the
production and submission in court of the respondent husband's hospital
record in a case for declaration of nullity of marriage where one of the issues
is his mental fitness as a husband.
The Facts and the Case
On February 6, 2006 petitioner Josielene Lara Chan (Josielene) filed before
the Regional Trial Court (RTC) of Makati City, Branch 144 a petition for the
declaration of nullity of her marriage to respondent Johnny Chan (Johnny),
the dissolution of their conjugal partnership of gains, and the award of custody
of their children to her. Josielene claimed that Johnny failed to care for and
support his family and that a psychiatrist diagnosed him as mentally deficient
due to incessant drinking and excessive use of prohibited drugs. Indeed, she
had convinced him to undergo hospital confinement for detoxification and
rehabilitation.
During the pre-trial conference, Josielene pre-marked the Philhealth Claim
Form1 that Johnny attached to his answer as proof that he was forcibly
confined at the rehabilitation unit of a hospital. The form carried a physician’s
handwritten note that Johnny suffered from "methamphetamine and alcohol
abuse." Following up on this point, on August 22, 2006 Josielene filed with
the RTC a request for the issuance of a subpoena duces tecum addressed to
Medical City, covering Johnny’s medical records when he was there confined.
The request was accompanied by a motion to "be allowed to submit in
evidence" the records sought by subpoena duces tecum.2
Johnny opposed the motion, arguing that the medical records were covered
by physician-patient privilege. On September 13, 2006 the RTC sustained the
opposition and denied Josielene’s motion. It also denied her motion for
reconsideration, prompting her to file a special civil action of certiorari before
the Court of Appeals (CA) in CA-G.R. SP 97913, imputing grave abuse of
discretion to the RTC.
On September 17, 2007 the CA3 denied Josielene’s petition. It ruled that, if
courts were to allow the production of medical records, then patients would
be left with no assurance that whatever relevant disclosures they may have
made to their physicians would be kept confidential. The prohibition covers
not only testimonies, but also affidavits, certificates, and pertinent hospital
records. The CA added that, although Johnny can waive the privilege, he did
not do so in this case. He attached the Philhealth form to his answer for the
limited purpose of showing his alleged forcible confinement.
 Question Presented
The central question presented in this case is:
Whether or not the CA erred in ruling that the trial court correctly denied the
issuance of a subpoena duces tecum covering Johnny’s hospital records on
the ground that these are covered by the privileged character of the physician-
patient communication.
The Ruling of the Court
Josielene requested the issuance of a subpoena duces tecum covering the
hospital records of Johnny’s confinement, which records she wanted to
present in court as evidence in support of her action to have their marriage
declared a nullity. Respondent Johnny resisted her request for subpoena,
however, invoking the privileged character of those records. He cites Section
24(c), Rule 130 of the Rules of Evidence which reads:
SEC. 24. Disqualification by reason of privileged communication.— The
following persons cannot testify as to matters learned in confidence in the
following cases:
xxxx
(c) A person authorized to practice medicine, surgery or obstetrics cannot in
a civil case, without the consent of the patient, be examined as to any advice
or treatment given by him or any information which he may have acquired in
attending such patient in a professional capacity, which information was
necessary to enable him to act in that capacity, and which would blacken the
reputation of the patient.
The physician-patient privileged communication rule essentially means that a
physician who gets information while professionally attending a patient
cannot in a civil case be examined without the patient’s consent as to any facts
which would blacken the latter’s reputation. This rule is intended to encourage
the patient to open up to the physician, relate to him the history of his ailment,
and give him access to his body, enabling the physician to make a correct
diagnosis of that ailment and provide the appropriate cure. Any fear that a
physician could be compelled in the future to come to court and narrate all
that had transpired between him and the patient might prompt the latter to
clam up, thus putting his own health at great risk.4
1. The case presents a procedural issue, given that the time to object to the
admission of evidence, such as the hospital records, would be at the time they
are offered. The offer could be made part of the physician’s testimony or as
independent evidence that he had made entries in those records that concern
the patient’s health problems.
Section 36, Rule 132, states that objections to evidence must be made after
the offer of such evidence for admission in court. Thus:
SEC. 36. Objection.— Objection to evidence offered orally must be made
immediately after the offer is made.
Objection to a question propounded in the course of the oral examination of a
witness shall be made as soon as the grounds therefor shall become reasonably
apparent.
An offer of evidence in writing shall be objected to within three (3) days after
notice of the offer unless a different period is allowed by the court.
In any case, the grounds for the objections must be specified.
Since the offer of evidence is made at the trial, Josielene’s request for
subpoena duces tecum is premature. She will have to wait for trial to begin
before making a request for the issuance of a subpoena duces tecum covering
Johnny’s hospital records. It is when those records are produced for
examination at the trial, that Johnny may opt to object, not just to their
admission in evidence, but more so to their disclosure. Section 24(c), Rule
130 of the Rules of Evidence quoted above is about non-disclosure of
privileged matters.
2. It is of course possible to treat Josielene’s motion for the issuance of a
subpoena duces tecum covering the hospital records as a motion for
production of documents, a discovery procedure available to a litigant prior
to trial. Section 1, Rule 27 of the Rules of Civil Procedure provides:
SEC. 1. Motion for production or inspection; order.— Upon motion of any
party showing good cause therefor, the court in which an action is pending
may (a) order any party to produce and permit the inspection and copying or
photographing, by or on behalf of the moving party, of any designated
documents, papers, books, accounts, letters, photographs, objects or tangible
things, not privileged, which constitute or contain evidence material to any
matter involved in the action and which are in his possession, custody or
control; or (b) order any party to permit entry upon designated land or other
property in his possession or control for the purpose of inspecting, measuring,
surveying, or photographing the property or any designated relevant object or
operation thereon. The order shall specify the time, place and manner of
making the inspection and taking copies and photographs, and may prescribe
such terms and conditions as are just. (Emphasis supplied)
But the above right to compel the production of documents has a limitation:
the documents to be disclosed are "not privileged."
Josielene of course claims that the hospital records subject of this case are not
privileged since it is the "testimonial" evidence of the physician that may be
regarded as privileged. Section 24(c) of Rule 130 states that the physician
"cannot in a civil case, without the consent of the patient, be examined"
regarding their professional conversation. The privilege, says Josielene, does
not cover the hospital records, but only the examination of the physician at
the trial.
To allow, however, the disclosure during discovery procedure of the hospital
records—the results of tests that the physician ordered, the diagnosis of the
patient’s illness, and the advice or treatment he gave him—would be to allow
access to evidence that is inadmissible without the
patient’s consent. Physician memorializes all these information in the
patient’s records. Disclosing them would be the equivalent of compelling the
physician to testify on privileged matters he gained while dealing with the
patient, without the latter’s prior consent.
3. Josielene argues that since Johnny admitted in his answer to the petition
before the RTC that he had been confined in a hospital against his will and in
fact attached to his answer a Philhealth claim form covering that confinement,
he should be deemed to have waived the privileged character of its records.
Josielene invokes Section 17, Rule 132 of the Rules of Evidence that provides:
SEC. 17. When part of transaction, writing or record given in evidence, the
remainder admissible.— When part of an act, declaration, conversation,
writing or record is given in evidence by one party, the whole of the same
subject may be inquired into by the other, and when a detached act,
declaration, conversation, writing or record is given in evidence, any other
act, declaration, conversation, writing or record necessary to its understanding
may also be given in evidence.1âwphi1
But, trial in the case had not yet begun. Consequently, it cannot be said that
Johnny had already presented the Philhealth claim form in evidence, the act
contemplated above which would justify Josielene into requesting an inquiry
into the details of his hospital confinement. Johnny was not yet bound to
adduce evidence in the case when he filed his answer. Any request for
disclosure of his hospital records would again be premature. For all of the
above reasons, the CA and the RTC were justified in denying Josielene her
request for the production in court of Johnny’s hospital records.
ACCORDINGLY, the Court DENIES the petition and AFFIRMS the
Decision of the Court of Appeals in CA-G.R. SP 97913 dated September 17,
2007. SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 108854 June 14, 1994
MA. PAZ FERNANDEZ KROHN, petitioner,
vs.
COURT OF APPEALS and EDGAR KROHN, JR., respondents.
BELLOSILLO, J.:
A confidential psychiatric evaluation report is being presented in evidence
before the trial court in a petition for annulment of marriage grounded on
psychological incapacity. The witness testifying on the report is the husband
who initiated the annulment proceedings, not the physician who prepared the
report.
The subject of the evaluation report, Ma. Paz Fernandez Krohn, invoking the
rule on privileged communication between physician and patient, seeks to
enjoin her husband from disclosing the contents of the report. After failing to
convince the trial court and the appellate court, she is now before us on a
petition for review on certiorari.
On 14 June 1964, Edgar Krohn, Jr., and Ma. Paz Fernandez were married at
the Saint Vincent de Paul Church in San Marcelino, Manila. The union
produced three children, Edgar Johannes, Karl Wilhelm and Alexandra. Their
blessings notwithstanding, the relationship between the couple developed into
a stormy one. In 1971, Ma. Paz underwent psychological testing purportedly
in an effort to ease the marital strain. The effort however proved futile. In
1973, they finally separated in fact.
In 1975, Edgar was able to secure a copy of the confidential psychiatric report
on Ma. Paz prepared and signed by Drs. Cornelio Banaag, Jr., and Baltazar
Reyes. On 2 November 1978, presenting the report among others, he obtained
a decree ("Conclusion") from the Tribunal Metropolitanum Matrimoniale in
Manila nullifying his church marriage with Ma. Paz on the ground of
"incapacitas assumendi onera conjugalia due to lack of due discretion
existent at the time of the wedding and thereafter." 1 On 10 July 1979, the
decree was confirmed and pronounced "Final and Definite." 2
Meanwhile, on 30 July 1982, the then Court of First Instance (now Regional
Trial Court) of Pasig, Br. II, issued an order granting the voluntary dissolution
of the conjugal partnership.
On 23 October 1990, Edgar filed a petition for the annulment of his marriage
with Ma. Paz before the trial court. 3 In his petition, he cited the Confidential
Psychiatric Evaluation Report which Ma. Paz merely denied in her Answer as
"either unfounded or irrelevant." 4
At the hearing on 8 May 1991, Edgar took the witness stand and tried to testify
on the contents of the Confidential Psychiatric Evaluation Report. This was
objected to on the ground that it violated the rule on privileged
communication between physician and patient. Subsequently, Ma. Paz filed a
Manifestation expressing her "continuing objection" to any evidence, oral or
documentary, "that would thwart the physician-patient privileged
communication rule," 5 and thereafter submitted a Statement for the Record
asserting among others that "there is no factual or legal basis whatsoever for
petitioner (Edgar) to claim 'psychological incapacity' to annul their marriage,
such ground being completely false, fabricated and merely an
afterthought." 6 Before leaving for Spain where she has since resided after
their separation, Ma. Paz also authorized and instructed her counsel to oppose
the suit and pursue her counterclaim even during her absence.
On 29 May 1991, Edgar opposed Ma. Paz' motion to disallow the introduction
of the confidential psychiatric report as evidence, 7 and afterwards moved to
strike out Ma. Paz' Statement for the Record. 8
On 4 June 1991, the trial court issued an Order admitting the Confidential
Psychiatric Evaluation Report in evidence and ruling that —
. . . the Court resolves to overrule the objection and to sustain the Opposition
to the respondent's Motion; first, because the very issue in this case is whether
or not the respondent had been suffering from psychological incapacity; and
secondly, when the said psychiatric report was referred to in the complaint,
the respondent did not object thereto on the ground of the supposed privileged
communication between patient and physician. What was raised by the
respondent was that the said psychiatric report was irrelevant. So, the Court
feels that in the interest of justice and for the purpose of determining whether
the respondent as alleged in the petition was suffering from psychological
incapacity, the said psychiatric report is very material and may be testified to
by petitioner (Edgar Krohn, Jr.) without prejudice on the part of the
respondent to dispute the said report or to cross-examination first the
petitioner and later the psychiatrist who prepared the same if the latter will be
presented. 9
On 27 November 1991, the trial court denied the Motion to Reconsider Order
dated June 4, 1991, and directed that the Statement for the Record filed by
Ma. Paz be stricken off the record. A subsequent motion for reconsideration
filed by her counsel was likewise denied.
Counsel of Ma. Paz then elevated the issue to respondent Court of Appeals.
In a Decision promulgated 30 October 1992, the appellate court dismissed the
petition for certiorari. 10 On 5 February 1993, the motion to reconsider the
dismissal was likewise denied. Hence, the instant petition for review.
Petitioner now seeks to enjoin the presentation and disclosure of the contents
of the psychiatric report and prays for the admission of her Statement for the
Record to form part of the records of the case. She argues that since
Sec. 24, par. (c), Rule 130, of the Rules of Court 11 prohibits a physician from
testifying on matters which he may have acquired in attending to a patient in
a professional capacity, "WITH MORE REASON should be third person (like
respondent-husband in this particular instance) be PROHIBITED from
testifying on privileged matters between a physician and patient or from
submitting any medical report, findings or evaluation prepared by a physician
which the latter has acquired as a result of his confidential and privileged
relation with a patient." 12 She says that the reason behind the prohibition is
—
. . . to facilitate and make safe, full and confidential disclosure by a patient to
his physician of all facts, circumstances and symptoms, untrammeled by
apprehension of their subsequent and enforced disclosure and publication on
the witness stand, to the end that the physician may form a correct opinion,
and be enabled safely and efficaciously to treat his patient. 13
She further argues that to allow her husband to testify on the contents of the
psychiatric evaluation report "will set a very bad and dangerous precedent
because it abets circumvention of the rule's intent in preserving the sanctity,
security and confidence to the relation of physician and his patient." 14 Her
thesis is that what cannot be done directly should not be allowed to be done
indirectly.
Petitioner submits that her Statement for the Record simply reiterates under
oath what she asserted in her Answer, which she failed to verify as she had
already left for Spain when her Answer was filed. She maintains that her
"Statement for the Record is a plain and simple pleading and is not as it has
never been intended to take the place of her testimony;" 15 hence, there is no
factual and legal basis whatsoever to expunge it from the records.
Private respondent Edgar Krohn, Jr., however contends that "the rules are very
explicit: the prohibition applies only to a physician. Thus . . . the legal
prohibition to testify is not applicable to the case at bar where the person
sought to be barred from testifying on the privileged communication is the
husband and not the physician of the petitioner." 16In fact, according to him,
the Rules sanction his testimony considering that a husband may testify
against his wife in a civil case filed by one against the other.
Besides, private respondent submits that privileged communication may be
waived by the person entitled thereto, and this petitioner expressly did when
she gave her unconditional consent to the use of the psychiatric evaluation
report when it was presented to the Tribunal Metropolitanum
Matrimoniale which took it into account among others in deciding the case
and declaring their marriage null and void. Private respondent further argues
that petitioner also gave her implied consent when she failed to specifically
object to the admissibility of the report in her Answer where she merely
described the evaluation report as "either unfounded or irrelevant." At any
rate, failure to interpose a timely objection at the earliest opportunity to the
evidence presented on privileged matters may be construed as an implied
waiver.
With regard to the Statement for the Record filed by petitioner, private
respondent posits that this in reality is an amendment of her Answer and thus
should comply with pertinent provisions of the Rules of Court, hence, its
exclusion from the records for failure to comply with the Rules is proper.
Petitioner's discourse while exhaustive is however misplaced. Lim v. Court of
Appeals 22 clearly lays down the requisites in order that the privilege may be
successfully invoked: (a) the privilege is claimed in a civil case; (b) the person
against whom the privilege is claimed is one duly authorized to practice
medicine, surgery or obstetrics; (c) such person acquired the information
while he was attending to the patient in his professional capacity; (d) the
information was necessary to enable him to act in that capacity; and, (e) the
information was confidential and, if disclosed, would blacken the reputation
(formerly character) of the patient.
In the instant case, the person against whom the privilege is claimed is not
one duly authorized to practice medicine, surgery or obstetrics. He is simply
the patient's husband who wishes to testify on a document executed by
medical practitioners. Plainly and clearly, this does not fall within the claimed
prohibition. Neither can his testimony be considered a circumvention of the
prohibition because his testimony cannot have the force and effect of the
testimony of the physician who examined the patient and executed the report.
Counsel for petitioner indulged heavily in objecting to the testimony of
private respondent on the ground that it was privileged. In his Manifestation
before the trial court dated 10 May 1991, he invoked the rule on privileged
communications but never questioned the testimony as hearsay. It was a fatal
mistake. For, in failing to object to the testimony on the ground that it was
hearsay, counsel waived his right to make such objection and, consequently,
the evidence offered may be admitted.
The other issue raised by petitioner is too trivial to merit the full attention of
this Court. The allegations contained in the Statement for the Records are but
refutations of private respondent's declarations which may be denied or
disproved during the trial.
The instant appeal has taken its toll on the petition for annulment. Three years
have already lapsed and private respondent herein, as petitioner before the
trial court, has yet to conclude his testimony thereat. We thus enjoin the trial
judge and the parties' respective counsel to act with deliberate speed in
resolving the main action, and avoid any and all stratagems that may further
delay this case. If all lawyers are allowed to appeal every perceived
indiscretion of a judge in the course of trial and include in their appeals
depthless issues, there will be no end to litigations, and the docket of appellate
courts will forever be clogged with inconsequential cases. Hence, counsel
should exercise prudence in appealing lower court rulings and raise only
legitimate issues so as not to retard the resolution of cases. Indeed, there is no
point in unreasonably delaying the resolution of the petition and prolonging
the agony of the wedded couple who after coming out from a storm still have
the right to a renewed blissful life either alone or in the company of each
other. 23
WHEREFORE, the instant petition for review is DENIED for lack of merit.
The assailed Decision of respondent Court of Appeals promulgated on 30
October 1992 is AFFIRMED.
SO ORDERED.
Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
[G.R. No. 91114. September 25, 1992.]
NELLY LIM, Petitioner,
v.
THE COURT OF APPEALS, HON. MANUEL D. VICTORIO, as
Presiding Judge of RTC-Rosales, Pangasinan, Branch 53, and JUAN
SIM, Respondents.
DAVIDE, JR., J.:
DECISION
This petition brings into focus the rule on the confidentiality of the physician-
patient relationship. Petitioner urges this Court to strike down as being
violative thereof the resolution of public respondent Court of Appeals in C.A.-
G.R. SP No. 16991 denying due course to a petition to annul the order of the
trial court allowing a Psychiatrist of the National Mental Hospital to testify as
an expert witness and not as an attending physician of petitioner.
The parties are in agreement as to the following facts:chanrob1es virtual 1aw
library
Petitioner and private respondent are lawfully married to each other.
On 25 November 1987, private respondent filed with Branch 53 of the
Regional Trial Court (RTC) of Pangasinan a petition for annulment of such
marriage on the ground that petitioner has been allegedly suffering from a
mental illness called schizophrenia "before, during and after the marriage and
until the present." After the issues were joined and the pre-trial was
terminated, trial on the merits ensued. Private respondent presented three (3)
witnesses before taking the witness stand himself to testify on his own behalf.
On 11 January 1989, private respondent’s counsel announced that he would
present as his next witness the Chief of the Female Services of the National
Mental Hospital, Dr. Lydia Acampado, a Doctor of Medicine who specializes
in Psychiatry. Said counsel forthwith orally applied for the issuance of a
subpoena ad testificandum requiring Dr. Acampado to testify on 25 January
1989. Petitioner’s counsel opposed the motion on the ground that the
testimony sought to be elicited from the witness is privileged since the latter
had examined the petitioner in a professional capacity and had diagnosed her
to be suffering from schizophrenia. Over such opposition, the subpoena was
issued on 12 January 1989.chanrobles virtualawlibrary
chanrobles.com:chanrobles.com.ph
On 24 January 1989, petitioner’s counsel filed an urgent omnibus motion to
quash the subpoena and suspend the proceedings pending resolution of the
motion.
Before Dr. Acampado took the witness stand on 25 January 1989, the court
heard this urgent motion. Movant argued that having seen and examined the
petitioner in a professional capacity, Dr. Acampado is barred from testifying
under the rule on the confidentiality of a physician-patient relationship.
Counsel for private respondent contended, however, that Dr. Acampado
would be presented as an expert witness and would not testify on any
information acquired while attending to the petitioner in a professional
capacity. The trial court, per respondent Judge, denied the motion and allowed
the witness to testify. Dr. Acampado thus took the witness stand, was qualified
by counsel for private respondent as an expert witness and was asked
hypothetical questions related to her field of expertise. She neither revealed
the illness she examined and treated the petitioner for nor disclosed the results
of her examination and the medicines she had prescribed.
Since petitioner’s counsel insisted that the ruling of the court on the motion
be reduced to writing, respondent Judge issued the following Order on the
same date:jgc:chanrobles.com.ph
"In his omnibus motion filed with the Court only yesterday, January 24, 1989,
petitioner seeks to prevent Dr. Lydia Acampado from testifying because she
saw and examined respondent Nelly Lim in her professional capacity perforce
her testimony is covered by the privileged (sic) communication rule.
Petitioner contends that Dr. Acampado is being presented as an expert witness
and that she will not testify on any information she acquired in (sic) attending
to Nelly Lim in her professional capacity.
Based on the foregoing manifestation of counsel for petitioner, the Court
denied the respondent’s motion and forthwith allowed Dr. Acampado to
testify. However, the Court advised counsel for respondent to interpose his
objection once it becomes apparent that the testimony sought to be elicited is
covered by the privileged communication rule.
On the witness box, Dr. Acampado answered routinary (sic) questions to
qualify her as an expert in psychiatry; she was asked to render an opinion as
to what kind of illness (sic) are stelazine tablets applied to; she was asked to
render an opinion on a (sic) hypothetical facts respecting certain behaviours
of a person; and finally she admitted she saw and treated Nelly Lim but she
never revealed what illness she examined and treated her (sic); nor (sic) the
result of her examination of Nelly Lim, nor (sic) the medicines she prescribed.
WHEREFORE, the omnibus motion dated January 19, 1989 is hereby
DENIED." 1
On 3 March 1989, petitioner filed with the public respondent Court of Appeals
a petition 2 for certiorariand prohibition, docketed therein as C.A.-G.R. SP
No. 16991, to annul the aforesaid order of respondent Judge on the ground
that the same was issued with grave abuse of discretion amounting to lack of
jurisdiction, and to prohibit him from proceeding with the reception of Dr.
Acampado’s testimony.chanrobles.com : virtual law library
On 18 September 1989, the Court of Appeals promulgated a resolution 3
denying due course to the petition on the ground that "the petitioner failed in
establishing the confidential nature of the testimony given by or obtained from
Dr. Acampado when she testified on January 25, 1989." Hence, the
respondent Judge committed no grave abuse of discretion. In support thereof,
the respondent Court discussed the conditions which would render as
inadmissible testimonial evidence between a physician and his patient under
paragraph (c), Section 24, Rule 130 of the Revised Rules of Court and made
the following findings:jgc:chanrobles.com.ph
"The present suit is a civil case for annulment of marriage and the person
whose testimony is sought to be stopped as a privileged communication is a
physician, who was summoned by the patient in her professional capacity for
curative remedy or treatment. The divergence in views is whether the
information given by the physician in her testimony in open court on January
25, 1989 was a privileged communication. We are of the opinion that they do
not fall within the realm of a privileged communication because the
information were (sic) not obtained from the patient while attending her in
her professional capacity and neither were (sic) the information necessary to
enable the physician to prescribe or give treatment to the patient Nelly Lim.
And neither does the information obtained from the physician tend to blacken
the character of the patient or bring disgrace to her or invite reproach. Dr.
Acampado is a Medical Specialist II and in-charge (sic) of the Female Service
of the National Center for Mental Health a fellow of the Philippine
Psychiatrist Association and a Diplomate of the Philippine Board of
Psychiatrists. She was summoned to testify as an expert witness and not as an
attending physician of petitioner.
After a careful scrutiny of the transcript of Dr. Acampado’s testimony, We
find no declaration that touched (sic) or disclosed any information which she
has acquired from her patient, Nelly Lim, during the period she attended her
patient in a professional capacity. Although she testified that she examined
and interviewed the patient, she did not disclose anything she obtained in the
course of her examination, interview and treatment of her patient. Given a set
of facts and asked a hypothetical question, Dr. Acampado rendered an opinion
regarding the history and behaviour of the fictitious character in the
hypothetical problem. The facts and conditions alleged in the hypothetical
problem did not refer and (sic) had no bearing to (sic) whatever information
or findings the doctor obtained from attending the (sic) patient. A physician
is not disqualified to testify as an expert concerning a patient’s ailment, when
he can disregard knowledge acquired in attending such patient and make
answer solely on facts related in (sic) the hypothetical question. (Butler v.
Role, 242 Pac. 436; Supreme Court of Arizona Jan. 7, 1926). Expert testimony
of a physician based on hypothetical question (sic) as to cause of illness of a
person whom he has attended is not privileged, provided the physician does
not give testimony tending to disclose confidential information related to him
in his professional capacity while attending to the patient. (Crago v. City of
Cedar Rapids, 98 NW 354, see Jones on Evidence, Vol. 3, p. 843, 3rd Ed.).
The rule on privilege (sic) communication in the relation of physician and
patient proceeds from the fundamental assumption that the communication to
deserve protection must be confidential in their origin. Confidentiality is not
to be blindly implied from the mere relation of physician and patient. It might
be implied according to circumstances of each case, taking into consideration
the nature of the ailment and the occasion of the consultation. The claimant
of the privilege has the burden of establishing in each instance all the facts
necessary to create the privilege, including the confidential nature of the
information given." 4
Her motion to reconsider the resolution having been denied, petitioner took
this recourse under Rule 45 of the Rules of Court. In her view, the respondent
Court of Appeals "seriously erred" :chanrob1es virtual 1aw library
"I.
. . . in not finding that all the essential elements of the rule on physician-patient
privileged communication under Section 21, Rule 130 of the Rules of Court
(Section 24, Rule 130 of the Revised Rules of Evidence) exist in the case at
bar.
 II.
. . . in believing that Dr. Acampado ‘was summoned as an expert witness and
not as an attending physician of petitioner.’
III.
. . . in concluding that Dr. Acampado made ‘no declaration that touched (sic)
or disclosed any information which she has acquired from her patient, Nelly
Lim, during the period she attended her patient in a professional capacity.’
IV.
. . . in declaring that ‘the petitioner failed in establishing the confidential
nature of the testimony given by or obtained from Dr. Acampado.’" 5
We gave due course to the petition and required the parties to submit their
respective Memoranda 6 after the private respondent filed his Comment 7 and
the petitioner submitted her reply 8 thereto. The parties subsequently filed
their separate Memoranda.
The petition is devoid of any merit. Respondent Court of Appeals committed
no reversible error in its challenged resolution.
The law in point is paragraph (c), Section 24 of the Revised Rules on Evidence
which reads:jgc:chanrobles.com.ph
"SECTION 24. Disqualification by reason of privileged communication. —
The following persons cannot testify as to matters learned in confidence in
the following cases:chanrob1es virtual 1aw library
x x x
(c) A person authorized to practice medicine, surgery or obstetrics cannot in
a civil case, without the consent of the patient, be examined as to any advice
or treatment given by him or any information which he may have acquired in
attending such patient in a professional capacity, which information was
necessary to enable him to act in that capacity, and which would blacken the
reputation of the patient." chanrobles virtual lawlibrary
This is a reproduction of paragraph (c), Section 21, Rule 130 of the 1964
Revised Rules of Court with two (2) modifications, namely: (a) the inclusion
of the phrase "advice or treatment given by him," and (b) substitution of the
word reputation for the word character. Said Section 21 in turn is a
reproduction of paragraph (f), Section 26, Rule 123 of the 1940 Rules of Court
with a modification consisting in the change of the phrase "which would tend
to blacken" in the latter to "would blacken." 9 Verily, these changes affected
the meaning of the provision. Under the 1940 Rules of Court, it was sufficient
if the information would tend to blacken the character of the patient. In the
1964 Rules of Court, a stricter requirement was imposed; it was imperative
that the information would blacken such character. With the advent of the
Revised Rules on Evidence on 1 July 1989, the rule was relaxed once more
by the substitution of the word character with the word reputation. There is a
distinction between these two concepts." ‘Character’ is what a man is, and
‘reputation’ is what he is supposed to be in what people say he is.’Character’
depends on attributes possessed, and ‘reputation’ on attributes which others
believe one to possess. The former signifies reality and the latter merely what
is accepted to be reality at present." 10
This rule on the physician-patient privilege is intended to facilitate and make
safe full and confidential disclosure by the patient to the physician of all facts,
circumstances and symptoms, untrammeled by apprehension of their
subsequent and enforced disclosure and publication on the witness stand, to
the end that the physician may form a correct opinion, and be enabled safely
and efficaciously to treat his patient. 11 It rests in public policy and is for the
general interest of the community. 12
Since the object of the privilege is to protect the patient, it may be waived if
no timely objection is made to the physician’s testimony. 13
In order that the privilege may be successfully claimed, the following
requisites must concur:jgc:chanrobles.com.ph
"1. the privilege is claimed in a civil case;
2. the person against whom the privilege is claimed is one duly authorized to
practice medicine, surgery or obstetrics;
3. such person acquired the information while he was attending to the patient
in his professional capacity;
4. the information was necessary to enable him to act in that capacity; and
5. the information was confidential, and, if disclosed, would blacken the
reputation (formerly character) of the patient." 14
These requisites conform with the four (4) fundamental conditions necessary
for the establishment of a privilege against the disclosure of certain
communications, to wit:jgc:chanrobles.com.ph
"1. The communications must originate in a confidence that they will not be
disclosed.
2. This element of confidentiality must be essential to the full and satisfactory
maintenance of the relation between the parties.
3. The relation must be one which in the opinion of the community ought to
be sedulously fostered
4. The injury that would inure to the relation by the disclosure of the
communications must be greater than the benefit thereby gained for the
correct disposal of litigation." 15
The physician may be considered to be acting in his professional capacity
when he attends to the patient for curative, preventive, or palliative treatment.
Thus, only disclosures which would have been made to the physician to
enable him "safely and efficaciously to treat his patient" are covered by the
privilege. 16 It is to be emphasized that "it is the tenor only of the
communication that is privileged. The mere fact of making a communication,
as well as the date of a consultation and the number of consultations, are
therefore not privileged from disclosure, so long as the subject communicated
is not stated." 17
One who claims this privilege must prove the presence of these
aforementioned requisites. 18
Our careful evaluation of the submitted pleadings leads Us to no other course
of action but to agree with the respondent Court’s observation that the
petitioner failed to discharge that burden. In the first place, Dr. Acampado
was presented and qualified as an expert witness. As correctly held by the
Court of Appeals, she did not disclose anything obtained in the course of her
examination, interview and treatment of the petitioner; moreover, the facts
and conditions alleged in the hypothetical problem did not refer to and had no
bearing on whatever information or findings the doctor obtained while
attending to the patient. There is, as well, no showing that Dr. Acampado’s
answers to the questions propounded to her relating to the hypothetical
problem were influenced by the information obtained from the petitioner.
Otherwise stated, her expert opinion excluded whatever information or
knowledge she had about the petitioner which was acquired by reason of the
physician-patient relationship existing between them. As an expert witness,
her testimony before the trial court cannot then be excluded. The rule on this
point is summarized as follows:chanrobles virtual lawlibrary
"The predominating view, with some scant authority otherwise, is that the
statutory physician-patient privilege, though duly claimed, is not violated by
permitting a physician to give expert opinion testimony in response to a
strictly hypothetical question in a lawsuit involving the physical mental
condition of a patient whom he has attended professionally, where his opinion
is based strictly upon the hypothetical facts stated, excluding and disregarding
any personal professional knowledge he may have concerning such patient.
But in order to avoid the bar of the physician-patient privilege where it is
asserted in such a case, the physician must base his opinion solely upon the
facts hypothesized in the question, excluding from consideration his personal
knowledge of the patient acquired through the physician and patient
relationship. If he cannot or does not exclude from consideration his personal
professional knowledge of the patient’s condition he should not be permitted
to testify as to his expert opinion." 19
Secondly, it is quite clear from Dr. Acampado’s testimony that the petitioner
was never interviewed alone. Said interviews were always conducted in the
presence of a third party, thus:jgc:chanrobles.com.ph
"Q I am asking you, doctor, whom did you interview?
A I interviewed the husband first, then the father and after having the history,
I interviewed the patient, Nelly.
Q How many times did Juan Sim and Nelly Lim go to your office?
A Now, the two (2) of them came three (3) times. As I have stated before,
once in the month of April of 1987 and two (2) times for the month of June
1987, and after that, since July of 1987, it was the father of Nelly, Dr. Lim,
who was bringing Nelly to me until November of 1987.
Q Now, Dr. Lim is a fellow physician?
A Yes, I understand.
Q Was there anything that he told you when he visited with you in a clinic?
A I would say that there was none. Even if I asked information about Nelly, I
could not get anything from Dr. Lim.
Q Now, when Dr. Lim and his daughter went to your clinic, was there any
doctor who was also present during that interview?
A No, sir, I don’t remember any." 20
There is authority to the effect that information elicited during consultation
with a physician in the presence of third parties removes such information
from the mantle of the privilege:jgc:chanrobles.com.ph
"Some courts have held that the casual presence of a third person destroys the
confidential nature of the communication between doctor and patient and thus
destroys the privilege, and that under such circumstances the doctor may
testify. Other courts have reached a contrary result." 21
Thirdly, except for the petitioner’s sweeping claim — that" (T)he information
given by Dr. Acampado brings disgrace and invite (sic) reproach to petitioner
by falsely making it appear in the eyes of the trial court and the public that the
latter was suffering from a mental disturbance called schizophrenia — which
caused, and continues to cause, irreparable injury to the name and reputation
of petitioner and her family," 22 — which is based on a wrong premise,
nothing specific or concrete was offered to show that indeed, the information
obtained from Dr. Acampado would blacken the former’s "character" (or
"reputation"). Dr. Acampado never disclosed any information obtained from
the petitioner regarding the latter’s ailment and the treatment recommended
therefor.chanrobles.com : virtual law library

Finally, while it may be true that counsel for the petitioner opposed the oral
request for the issuance of a subpoena ad testificandum to Dr. Acampado and .
filed a formal motion for the quashal of the said subpoena a day before the
witness was to testify, the petitioner makes no claim in any of her pleadings
that her counsel had objected to any question asked of the witness on the
ground that it elicited an answer that would violate the privilege, despite the
trial court’s advise that said counsel may interpose his objection to the
testimony "once it becomes apparent that the testimony, sought to be elicited
is covered by the privileged communication rule." The particular portions of
the stenographic notes of the testimony of Dr. Acampado quoted in the
petitioner’s Petition 23 and Memorandum, 24 and in the private respondent’s
Memorandum, 25 do not at all show that any objections were interposed. Even
granting ex gratia that the testimony of Dr. Acampado could be covered by
the privilege, the failure to seasonably object thereto amounted to a waiver
thereof.

WHEREFORE, the instant petition is DENIED for lack of merit.

Costs against petitioner.

SO ORDERED.