LegMed: Medical Jurisprudence

A. Doctor Patient Relationship1 damages, alleging negligence by their

careless administration of the
Consent Rubi Li vs. Soliman chemotherapy drugs, their failure to
G.R. No. 165279, June 7, 2011. observe the essential precautions in
detecting early the symptoms of fatal
Facts: blood platelet decrease and failure to
Respondents’ 11-year old fully inform them of the possible side
daughter, Angelica Soliman, effects of its administration.
underwent a biopsy of the mass
located in her lower extremity at the Petitioner denied having been
St. Luke’s Medical Center (SLMC). negligent in administering the
Results showed that she was suffering chemotherapy drugs to Angelica and
from osteosarcoma, osteoblastic type, asserted that she had fully explained
a high-grade (highly malignant) to respondents how the chemotherapy
cancer of the bone. Following this will affect not only the cancer cells but
diagnosis, Angelica’s right leg was also the patient’s normal body parts,
amputated and her doctor suggested including the lowering of white and red
that she undergo chemotherapy to blood cells and platelets. She claimed
eliminate any remaining cancer cells. that Angelica died of sepsis which is a
She was then referred to herein complication of the cancer itself.
petitioner Dr. Rubi Li, a medical
oncologist. The trial court dismissed the
complaint; CA concurred, but found
On August 18, 1993, Angelica petitioner negligent in failing to fully
was admitted to SLMC, and died on explain all the known side effects of
September 1, 1993, just eleven days chemotherapy which entitled
after the administration of the first respondents to their claim for
cycle of the chemotherapy regimen. damages.
The post-mortem examination of the
PNP Crime Laboratory indicated the Issue: Whether or not the petitioner
cause of death as “Hypovolemic shock can be held liable for failure to fully
secondary to multiple organ disclose serious side effects to the
hemorrhages and Disseminated parents of the child patient who died
Intravascular Coagulation.” SLMC while undergoing chemotherapy.
issued its own Certificate of Death
showing the cause of death as Ruling: From a purely ethical norm,
Osteosarcoma, Status Post AKA. the doctrine of informed consent
evolved into a general principle of law
Respondents sued the petitioner that a physician has a duty to disclose
(among others) and SLMC for what a reasonably prudent physician
in the medical community in the
1 Duty means that there is a professional relationship exercise of reasonable care would
between the doctor and the patient. This relationship is disclose to his patient as to whatever
created when the patient engages the services of the grave risks of injury might be incurred
doctor and the doctor agrees to provide care to the from a proposed course of treatment,
patient.
so that a patient, exercising ordinary
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 LegMed: Medical Jurisprudence

care for his own welfare, and faced expectation on the part of the doctor
with a choice of undergoing the that the respondents understood very
proposed treatment, or alternative well that the severity of these side
treatment, or none at all, may effects will not be the same for all
intelligently exercise his judgment by patients undergoing the procedure. In
reasonably balancing the probable other words, by the nature of the
risks against the probable benefits. disease itself, each patient’s reaction
to the chemical agents even with pre-
There are four essential treatment laboratory tests cannot be
elements a plaintiff must prove in a precisely determined by the physician.
malpractice action based upon the That death can possibly result from
doctrine of informed consent: “(1) the complications of the treatment or the
physician had a duty to disclose underlying cancer itself, immediately
material risks; (2) he failed to disclose or sometime after the administration
or inadequately disclosed those risks; of chemotherapy drugs, is a risk that
(3) as a direct and proximate result of cannot be ruled out, as with most
the failure to disclose, the patient other major medical procedures, but
consented to treatment she otherwise such conclusion can be reasonably
would not have consented to; and (4) drawn from the general side effects of
plaintiff was injured by the proposed chemotherapy already disclosed.
treatment.” The gravamen in an
informed consent case requires the Borromeo vs. Family Care Hospital
plaintiff to point to significant G.R. No. 191018, January 25, 2016.
undisclosed information relating to the
treatment which would have altered Facts:
her decision to undergo it. The patient was complaining of
acute pain and fever for two days. The
Examining the evidence on doctor suspected that the patient
record, we hold that there was might be suffering from acute
adequate disclosure of material risks appendicitis. After several inconclusive
inherent in the chemotherapy tests, the doctor decided to perform
procedure performed with the consent an exploratory laparotomy. After the
of Angelica’s parents. Respondents surgery, the patient’s blood pressure
could not have been unaware in the suddenly dropped. Furthermore, the
course of initial treatment and patient developed petechiae in various
amputation of Angelica’s lower parts of her body. The doctor
extremity, that her immune system suspected that the patient has
was already weak on account of the Disseminated Intravascular
malignant tumor in her knee. When Coagulation, which is a blood disorder.
petitioner informed the respondents Unfortunately, attempts to resuscitate
beforehand of the side effects of the patient failed.
chemotherapy which includes lowered
counts of white and red blood cells, Issue: Whether or not there is
decrease in blood platelets, possible medical malpractice.
kidney or heart damage and skin
darkening, there is reasonable
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Ruling: The Supreme Court held that Rowena and her other relatives,
there is no medical malpractice since namely her husband, her sister and
the cause of the uncontrollable two aunts waited outside the operating
bleeding was a medical disorder, room while Lydia underwent
Disseminated Intravascular operation. While they were waiting,
Coagulation. In this case there is no Dr. Ercillo (anaesthesiologist) went out
proof that the doctor fell short of the of the operating room and instructed
expected standard required under the them to buy tagamet ampules which
circumstances. Rowena's sister immediately bought.
About one hour had passed when Dr.
Standard of Breach — The breach Ercillo came out again this time to ask
referred to in medical malpractice them to buy blood for Lydia. They
cases is the breach of the standard of bought type "A" blood from the St.
care expected of other similarly Gerald Blood Bank and the same was
trained medical professionals acting brought by the attendant into the
under the same circumstances. operating room. After the lapse of a
few hours, Dr. Cruz informed them
B. Medical Negligence that the operation was finished. The
operating staff then went inside the
Cruz vs. C.A. petitioner's clinic to take their snacks.
G.R. No. 122445, November 18, 1997. Some thirty minutes after, Lydia was
brought out of the operating room in a
Facts: stretcher and the petitioner asked
Lydia Umali was Diagnosed by Rowena and the other relatives to buy
Dr. Cruz to have a myoma in her additional blood for Lydia.
uterus and scheduled her for a Unfortunately, they were not able to
hysterectomy operation. According to comply with petitioner's order as there
Rowena (Lydia’s daughter), she was no more type "A" blood available
noticed that the clinic was untidy and in the blood bank. Thereafter, a
the window and the floor were very person arrived to donate blood which
dusty prompting her to ask the was later transfused to Lydia. Rowena
attendant for a rag to wipe the window then noticed her mother, who was
and the floor with. Because of the attached to an oxygen tank, gasping
untidy state of the clinic, Rowena tried for breath. Apparently the oxygen
to persuade her mother not to proceed supply had run out and Rowena's
with the operation. The following day, husband together with the driver of
before her mother was wheeled into the accused had to go to the San
the operating room, Rowena asked Dr. Pablo District Hospital to get oxygen.
Cruz if the operation could be Lydia was given the fresh supply of
postponed. Dr. Cruz called Lydia into oxygen as soon as it arrived. But at
her office and the two had a around 10:00 o'clock P.M. she went
conversation. Lydia then informed into shock and her blood pressure
Rowena that the petitioner told her dropped to 60/50. Lydia's unstable
that she must be operated on as condition necessitated her transfer to
scheduled. the San Pablo District Hospital so she
could be connected to a respirator and
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further examined. The transfer to the Ruling: Petitioner is hereby

San Pablo District Hospital was without ACQUITTED of the crime of reckless
the prior consent of Rowena nor of the imprudence resulting in homicide but
other relatives present who found out is ordered to pay the heirs of the
about the intended transfer only when deceased Lydia Umali the amount of
an ambulance arrived to take Lydia to P50,000.00 as civil liability,
the San Pablo District Hospital. P100,000.00 as moral damages, and
Rowena and her other relatives then P50,000.00 as exemplary damages.
boarded a tricycle and followed the
ambulance. The elements of reckless
imprudence are: (1) that the offender
Upon Lydia's arrival at the San does or fails to do an act; (2) that the
Pablo District Hospital, she was doing or the failure to do that act is
wheeled into the operating room and voluntary; (3) that it be without
the petitioner and Dr. Ercillo re- malice; (4) that material damage
operated on her because there was results from the reckless imprudence;
blood oozing from the abdominal and (5) that there is inexcusable lack
incision. The attending physicians of precaution on the part of the
summoned Dr. Bartolome Angeles, offender, taking into consideration his
head of the Obstetrics and Gynecology employment or occupation, degree of
Department of the San Pablo District intelligence, physical condition, and
Hospital. However, when Dr. Angeles other circumstances regarding
arrived, Lydia was already in shock persons, time and place.
and possibly dead as her blood
pressure was already 0/0. Dr. Angeles Whether or not a physician has
then informed petitioner and Dr. committed an "inexcusable lack of
Ercillo that there was nothing he could precaution" in the treatment of his
do to help save the patient. While Dr. patient is to be determined according
Cruz was closing the abdominal wall, to the standard of care observed by
the patient died. Thus, on March 24, other members of the profession in
1991, at 3:00 o'clock in the morning, good standing under similar
Lydia Umali was pronounced dead. circumstances bearing in mind the
advanced state of the profession at
Dr. Cruz was charged with the time of treatment or the present
reckless imprudence and negligence state of medical science.
resulting to homicide. The MTC, RTC
and CA found Dr. Cruz guilty. Hence Expert testimony is essential to
this petition. establish not only the standard of care
of the profession but also that the
Issue: W/N petitioner's conviction of physician's conduct in the treatment
the crime of reckless imprudence and care falls below such standard.
resulting in homicide, arising from an Further, inasmuch as the causes of the
alleged medical malpractice, is injuries involved in malpractice actions
supported by the evidence on record. are determinable only in the light of
scientific knowledge, it has been
recognized that expert testimony is
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usually necessary to support the right of an accused to be presumed

conclusion as to causation. innocent until proven guilty beyond
reasonable doubt. Nevertheless, this
In order that there may be a Court finds the petitioner civilly liable
recovery for an injury, however, it for the death of Lydia Umali, for while
must be shown that the "injury for a conviction of a crime requires proof
which recovery is sought must be the beyond reasonable doubt, only a
legitimate consequence of the wrong preponderance of evidence is required
done; the connection between the to establish civil liability.
negligence and the injury must be a
direct and natural sequence of events, The petitioner is a doctor in
unbroken by intervening efficient whose hands a patient puts his life and
causes." In other words, the limb. For insufficiency of evidence this
negligence must be the proximate Court was not able to render a
cause of the injury. For, "negligence, sentence of conviction but it is not
no matter in what it consists, cannot blind to the reckless and imprudent
create a right of action unless it is the manner in which the petitioner carried
proximate cause of the injury out her duties. A precious life has
complained of ." And "the proximate been lost and the circumstances
cause of an injury is that cause, which, leading thereto exacerbated the grief
in natural and continuous sequence, of those left behind. The heirs of the
unbroken by any efficient intervening deceased continue to feel the loss of
cause, produces the injury, and their mother up to the present time
without which the result would not and this Court is aware that no
have occurred." amount of compassion and
commiseration nor words of
This Court has no recourse but bereavement can suffice to assuage
to rely on the expert testimonies the sorrow felt for the loss of a loved
rendered by both prosecution and one. Certainly, the award of moral and
defense witnesses that substantiate exemplary damages in favor of the
rather than contradict petitioner's heirs of Lydia Umali are proper in the
allegation that the cause of Lydia's instant case.
death was DIC which, as attested to
by an expert witness, cannot be
attributed to the petitioner's fault or
negligence. The probability that
Lydia's death was caused by DIC was
unrebutted during trial and has Ramos vs. C.A.
engendered in the mind of this Court a G.R. No. 124354, April 11, 2002.
reasonable doubt as to the petitioner's
guilt. Thus, her acquittal of the crime Facts:
of reckless imprudence resulting in Erlinda Ramos, a 47-year old
homicide. While we condole with the robust woman, was normal except for
family of Lydia Umali, our hands are her experiencing occasional pain due
bound by the dictates of justice and to the presence of stone in her gall
fair dealing which hold inviolable the bladder. She was advised to undergo
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an operation for its removal. The beyond the reglementary period.

results in the examinations she However, it was found that the notice
underwent indicate that she was fit for of the decision was never sent to the
the operation. She and her husband petitioner’s counsel. Rather, it was
Rogelio met Dr. Hosaka, one of the sent to the petitioner, addressing him
defendants, who advised that she as Atty. Rogelio Ramos, as if he was
should undergo cholecystectomy. Dr. the legal counsel. The petitioner filed
Hosaka assured them that he will get the instant petition for certiorari. On
a good anaesthesiologist. At 7:30 a.m. the procedural issue, the Supreme
on the day of the operation at Delos Court rules that since the notice did
Santos Medical Center, Herminda not reach the petitioner’s then legal
Cruz, Erlinda’s sister-in-law and the counsel, the motion was filed on time.
dean of the College of Nursing in
Capitol Medical Center, was there to Issue: Whether or not a surgeon, an
provide moral support. Dr. Perfecta anaesthesiologist, and a hospital,
Gutierrez was to administer the should be made liable for the
anaesthesia. Dr. Hosaka arrived only unfortunate comatose condition of a
at 12:15 p. m. Herminda saw Dr. patient scheduled for cholecystectomy.
Gutierrez intubating the patient, and
heard the latter say “Ang hirap ma- Ruling: Res Ipsa Loquitor is a Latin
intubate nito, mali yata ang phrase which literally means "the thing
pagkakapasok. O, lumalaki ang tiyan.” or the transaction speaks for itself."
Herminda saw bluish discoloration of The phrase "res ipsa loquitur'' is a
the nailbeds of the patient. She heard maxim for the rule that the fact of the
Dr. Hosaka issue an order for someone occurrence of an injury, taken with the
to call Dr. Calderon. The doctor arrived surrounding circumstances, may
and placed the patient in permit an inference or raise a
trendelenburg position, wherein the presumption of negligence, or make
head of the patient is positioned lower out a plaintiff's prima facie case, and
than the feet, which indicates a present a question of fact for
decrease of blood supply in the brain. defendant to meet with an
Herminda knew and told Rogelio that explanation. Where the thing which
something wrong was happening. Dr. caused the injury complained of is
Calderon was able to intubate the shown to be under the management of
patient. Erlinda was taken to the ICU the defendant or his servants and the
and became comatose. accident is such as in ordinary course
of things does not happen if those who
Rogelio filed a civil case for have its management or control use
damages. The trial court ruled in his proper care, it affords reasonable
favor, finding Dr. Gutierrez, Dr. evidence, in the absence of
Hosaka, and the hospital, guilty of explanation by the defendant, that the
negligence, but the Court of Appeals accident arose from or was caused by
reversed the decision. Hence, the defendant's want of care. It is
petitioner filed a Motion for grounded in the superior logic of
Reconsideration, which the Court of ordinary human experience and on the
Appeals denied for having been filed basis of such experience or common
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knowledge, negligence may be from the standard medical procedure,

deduced from the mere occurrence of when the doctrine of res ipsa loquitur
the accident itself. However, much has is availed by the plaintiff, the need for
been said that res ipsa loquitur is not expert medical testimony is dispensed
a rule of substantive law and, as such, with because the injury itself provides
does not create or constitute an the proof of negligence. Hence, in
independent or separate ground of cases where the res ipsa loquitur is
liability. Mere invocation and applicable, the court is permitted to
application of the doctrine does not find a physician negligent upon proper
dispense with the requirement of proof proof of injury to the patient, without
of negligence. It is simply a step in the the aid of expert testimony, where the
process of such proof, permitting the court from its fund of common
plaintiff to present along with the knowledge can determine the proper
proof of the accident, enough of the standard of care. When the doctrine is
attending circumstances to invoke the appropriate, all that the patient must
doctrine, creating an inference or do is prove a nexus between the
presumption of negligence, and to particular act or omission complained
thereby place on the defendant the of and the injury sustained while
burden of going forward with the under the custody and management of
proof. Still, before resort to the the defendant without need to produce
doctrine may be allowed, the following expert medical testimony to establish
requisites must be satisfactorily the standard of care. Resort to res
shown: ipsa loquitur is allowed because there
is no other way, under usual and
(1) The accident is of a kind which ordinary conditions, by which the
ordinarily does not occur in the patient can obtain redress for injury
absence of someone's negligence; suffered by him.
(2) It is caused by an instrumentality
within the exclusive control of the Res ipsa loquitur is not a rigid or
defendant or defendants; ordinary doctrine to be perfunctorily
(3) The possibility of contributing used but a rule to be cautiously
conduct which would make the applied, depending upon the
plaintiff responsible is eliminated. circumstances of each case. A
distinction must be made between the
Medical malpractice cases do not failure to secure results, and the
escape the application of this doctrine. occurrence of something more unusual
Thus, res ipsa loquitur has been and not ordinarily found if the service
applied when the circumstances or treatment rendered followed the
attendant upon the harm are usual procedure of those skilled in that
themselves of such a character as to particular practice. The real question,
justify an inference of negligence as therefore, is whether or not in the
the cause of that harm. Although process of the operation any
generally, expert medical testimony is extraordinary incident or unusual
relied upon in malpractice suits to event outside of the routine
prove that a physician has done a performance occurred which is beyond
negligent act or that he has deviated the regular scope of customary
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professional activity in such of anesthetics, which rendered her

operations, which, if unexplained unconscious.
would themselves reasonably speak to
the average man as the negligent Negligence of the Anesthesiologist
cause or causes of the untoward
consequence. The pre-operative evaluation of
a patient prior to the administration of
We find the doctrine of res ipsa anesthesia is universally observed to
loquitur appropriate in the case at bar. lessen the possibility of anesthetic
Erlinda submitted herself for accidents. Respondent Dra. Gutierrez'
cholecystectomy and expected a act of seeing her patient for the first
routine general surgery to be time only an hour before the
performed on her gall bladder. On that scheduled operative procedure was,
fateful day she delivered her person therefore, an act of exceptional
over to the care, custody and control negligence and professional
of private respondents who exercised irresponsibility. Her failure to follow
complete and exclusive control over this medical procedure is, therefore, a
her. At the time of submission, Erlinda clear indicia of her negligence.
was neurologically sound and, except Erlinda's case was elective and this
for a few minor discomforts, was was known to respondent Dra.
likewise physically fit in mind and Gutierrez. Thus, she had all the time
body. However, during the to make a thorough evaluation of
administration of anesthesia and prior Erlinda's case prior to the operation
to the performance of cholecystectomy and prepare her for anesthesia.
she suffered irreparable damage to However, she never saw the patient at
her brain. Thus, without undergoing the bedside. She herself admitted that
surgery, she went out of the operating she had seen petitioner only in the
room already decerebrate and totally operating room, and only on the actual
incapacitated. Obviously, brain date of the cholecystectomy. She
damage, which Erlinda sustained, is an negligently failed to take advantage of
injury which does not normally occur this important opportunity. As such,
in the process of a gall bladder her attempt to exculpate herself must
operation. In fact, this kind of fail.
situation does not in the absence of
negligence of someone in the Opinion of Expert Witness
administration of anesthesia and in the
use of endotracheal tube. An anesthetic accident caused
Furthermore, the instruments used in by a rare drug-induced bronchospasm
the administration of anesthesia, properly falls within the fields of
including the endotracheal tube, were anesthesia, internal medicine-allergy,
all under the exclusive control of and clinical pharmacology. The
private respondents, who are the resulting anoxic encephalopathy
physicians-in-charge. Likewise, belongs to the field of neurology.
petitioner Erlinda could not have been While admittedly, many
guilty of contributory negligence bronchospastic-mediated pulmonary
because she was under the influence diseases are within the expertise of
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pulmonary medicine, Dr. Jamora's either a direct result or a reasonably

field, the anesthetic drug-induced, probable consequence of the act or
allergic mediated bronchospasm omission. Instead of the intended
alleged in this case is within the endotracheal intubation what actually
disciplines of anesthesiology, took place was an esophageal
allergology and pharmacology. On the intubation. During intubation, such
basis of the foregoing transcript, in distention indicates that air has
which the pulmonologist himself entered the gastrointestinal tract
admitted that he could not testify through the esophagus instead of the
about the drug with medical authority, lungs through the trachea. Entry into
it is clear that the appellate court the esophagus would certainly cause
erred in giving weight to Dr. Jamora's some delay in oxygen delivery into the
testimony as an expert in the lungs as the tube which carries oxygen
administration of Thiopental Sodium. is in the wrong place. That abdominal
Generally, to qualify as an expert distention had been observed during
witness, one must have acquired the first intubation suggests that the
special knowledge of the subject length of time utilized in inserting the
matter about which he or she is to endotracheal tube (up to the time the
testify, either by the study of tube was withdrawn for the second
recognized authorities on the subject attempt) was fairly significant. Due to
or by practical experience. Clearly, Dr. the delay in the delivery of oxygen in
Jamora does not qualify as an expert her lungs Erlinda showed signs of
witness based on the above standard cyanosis.
since he lacks the necessary
knowledge, skill, and training in the Responsibility of the Surgeon
field of anesthesiology. Oddly, apart
from submitting testimony from a As the so-called "captain of the
specialist in the wrong field, private ship," it is the surgeon's responsibility
respondents' intentionally avoided to see to it that those under him
providing testimony by competent and perform their task in the proper
independent experts in the proper manner. Respondent Dr. Hosaka's
areas. negligence can be found in his failure
to exercise the proper authority in not
Proximate Cause has been determining if his anesthesiologist
defined as that which, in natural and observed proper anesthesia protocols.
continuous sequence, unbroken by any In fact, no evidence on record exists
efficient intervening cause, produces to show that respondent Dr. Hosaka
injury, and without which the result verified if respondent Dra. Gutierrez
would not have occurred. An injury or properly intubated the patient.
damage is proximately caused by an Furthermore, it does not escape us
act or a failure to act, whenever it that respondent Dr. Hosaka had
appears from the evidence in the case, scheduled another procedure in a
that the act or omission played a different hospital at the same time as
substantial part in bringing about or Erlinda's cholecystectomy, and was in
actually causing the injury or damage; fact over three hours late for the
and that the injury or damage was latter's operation. Because of this, he
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had little or no time to confer with his father of the family to prevent
anesthesiologist regarding the damage. In the instant case,
anesthesia delivery. This indicates that respondent hospital, apart from a
he was remiss in his professional general denial of its responsibility over
duties towards his patient. Thus, he respondent physicians, failed to
shares equal responsibility for the adduce evidence showing that it
events which resulted in Erlinda's exercised the diligence of a good
condition. father of a family in the hiring and
supervision of the latter. It failed to
Responsibility of the Hospital adduce evidence with regard to the
degree of supervision, which it
Hospitals hire, fire and exercise exercised over its physicians. In
real control over their attending and neglecting to offer such proof, or proof
visiting "consultant" staff. While of a similar nature, respondent
"consultants" are not, technically hospital thereby failed to discharge its
employees, a point which respondent burden under the last paragraph of
hospital asserts in denying all Article 2180. Having failed to do this,
responsibility for the patient's respondent hospital is consequently
condition, the control exercised, the solidarily responsible with its
hiring, and the right to terminate physicians for Erlinda's condition.
consultants all fulfill the important
hallmarks of an employer-employee Damages
relationship, with the exception of the
payment of wages. In assessing At current levels, the
whether such a relationship in fact P8000/monthly amount established by
exists, the control test is determining. the trial court at the time of its
Accordingly, on the basis of the decision would be grossly inadequate
foregoing, we rule that for the purpose to cover the actual costs of home-
of allocating responsibility in medical based care for a comatose individual.
negligence cases, an employer- The calculated amount was not even
employee relationship in effect exists arrived at by looking at the actual cost
between hospitals and their attending of proper hospice care for the patient.
and visiting physicians. What it reflected were the actual
expenses incurred and proved by the
The basis for holding an petitioners after they were forced to
employer solidarily responsible for the bring home the patient to avoid
negligence of its employee is found in mounting hospital bills. And yet
Article 2180 of the Civil Code which ideally, a comatose patient should
considers a person accountable not remain in a hospital or be transferred
only for his own acts but also for those to a hospice specializing in the care of
of others based on the former's the chronically ill for the purpose of
responsibility under a relationship of providing a proper milieu adequate to
patria potestas. Such responsibility meet minimum standards of care.
ceases when the persons or entity Given these considerations, the
concerned prove that they have amount of actual damages recoverable
observed the diligence of a good in suits arising from negligence should
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at least reflect the correct minimum compensatory damages on the

cost of proper care, not the cost of the amount provided by petitioners at the
care the family is usually compelled to onset of litigation, it would be now
undertake at home to avoid much more in step with the interests
bankruptcy. of justice if the value awarded for
temperate damages would allow
Our rules on actual or petitioners to provide optimal care for
compensatory damages generally their loved one in a facility which
assume that at the time of litigation, generally specializes in such care.
the injury suffered as a consequence They should not be compelled by dire
of an act of negligence has been circumstances to provide substandard
completed and that the cost can be care at home without the aid of
liquidated. However, these provisions professionals, for anything less would
neglect to take into account those be grossly inadequate. Under the
situations, as in this case, where the circumstances, an award of
resulting injury might be continuing P1,500,000.00 in temperate damages
and possible future complications would therefore be reasonable.
directly arising from the injury, while
certain to occur, are difficult to Petitioner Erlinda Ramos was in
predict. Temperate damages can and her mid-forties when the incident
should be awarded on top of actual or occurred. She has been in a comatose
compensatory damages in instances state for over fourteen years now. The
where the injury is chronic and burden of care has so far been
continuing. And because of the unique heroically shouldered by her husband
nature of such cases, no and children, who, in the intervening
incompatibility arises when both actual years have been deprived of the love
and temperate damages are provided of a wife and a mother. Meanwhile,
for. The reason is that these damages the actual physical, emotional and
cover two distinct phases. As it would financial cost of the care of petitioner
not be equitable - and certainly not in would be virtually impossible to
the best interests of the administration quantify. Even the temperate damages
of justice - for the victim in such cases herein awarded would be inadequate if
to constantly come before the courts petitioner's condition remains
and invoke their aid in seeking unchanged for the next ten years. The
adjustments to the compensatory husband and the children, all
damages previously awarded - petitioners in this case, will have to
temperate damages are appropriate. live with the day to day uncertainty of
The amount given as temperate the patient's illness, knowing any hope
damages, though to a certain extent of recovery is close to nil. They have
speculative, should take into account fashioned their daily lives around the
the cost of proper care. In the instant nursing care of petitioner, altering
case, petitioners were able to provide their long term goals to take into
only home-based nursing care for a account their life with a comatose
comatose patient who has remained in patient. They, not the respondents,
that condition for over a decade. are charged with the moral
Having premised our award for responsibility of the care of the victim.
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The family's moral injury and suffering fever but did not have any colds or
in this case is clearly a real one. For cough.
the foregoing reasons, an award of
P2,000,000.00 in moral damages The following day, the mother of
would be appropriate. the patient informed the doctor that
there were traces of blood in her son’s
Finally, by way of example, sputum. However, the doctor simply
exemplary damages in the amount of nodded and reassured them that it
P100,000.00 are hereby awarded. was due to bronchopneumonia. Later
Considering the length and nature of that morning, the patient vomited
the instant suit we are of the opinion phlegm with blood streaks. He was
that attorney's fees valued at attended to by one of the resident
P100,000.00 are likewise proper. physicians. Several tests were ordered
done on the patient. When the tests
WHEREFORE, the decision and came out, the results showed that the
resolution of the appellate court patient was suffering from Dengue
appealed from are hereby modified so Hemorrhagic Fever.
as to award in favor of petitioners, and
solidarily against private respondents Issue: Whether or not the negligence
the following: 1) P1,352,000.00 as of the doctor is the proximate cause
actual damages computed as of the for the patient’s death.
date of promulgation of this decision
plus a monthly payment of P8,000.00 Ruling: The Supreme Court held that
up to the time that petitioner Erlinda the doctor is liable for medical
Ramos expires or miraculously malpractice. In determining whether
survives; 2) P2,000,000.00 as moral or not the negligence of the doctor is
damages, 3) P1,500,000.00 as the proximate cause for the patient’s
temperate damages; 4) P100,000.00 death, the court looked at the nature
each as exemplary damages and of Dengue. The court considered
attorney's fees; and, 5) the costs of expert testimony stating that with
the suit. correct and timely diagnosis and
proper medical management, dengue
Casumpang vs. Cortejo fever is not a life threatening disease
G.R. No. 171127, March 11, 2015. and could easily be cured. In fact, the
mortality rate of dengue fever should
Facts: fall to less than 2%. Thus, the
The patient is an 11-year old proximate cause of patient’ death is
boy who initially complained of the failure of the doctor to timely
difficulty in breathing, chest pain, diagnose dengue, despite the presence
stomach pain and fever. The doctor of its characteristic symptoms.
who examined the patient diagnosed
him with bronchopneumonia. Proximate causation refers to the
However, the mother of the patient relation between the negligence or
raised her doubts with the doctor’s breach of the doctor and the resulting
diagnosis since her son had a high injury of the patient. The negligence or
breach must have played an integral
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 LegMed: Medical Jurisprudence

part in causing the injury or damage. "sponge count lacking 2 "announced to

In other words, the injury to the surgeon searched (sic) done but to no
patient is either a direct result or a avail continue for closure."
reasonably probable consequence of
the negligence or breach of the doctor. On April 24, 1984, Natividad was
released from the hospital. Her
D. Hospital Liability hospital and medical bills, including
the doctors’ fees, amounted to
Professional Services vs. Agana P60,000.00. After a couple of days,
G.R. No. 126297, February 2, 2010. Natividad complained of excruciating
pain in her anal region. She consulted
Facts: both Dr. Ampil and Dr. Fuentes about
it. They told her that the pain was the
On April 4, 1984, Natividad natural consequence of the surgery.
Agana was rushed to the Medical City Dr. Ampil then recommended that she
General Hospital because of difficulty consult an oncologist to examine the
of bowel movement and bloody anal cancerous nodes which were not
discharge. After a series of medical removed during the operation.
examinations, Dr. Miguel Ampil,
petitioner in G.R. No. 127590, On May 9, 1984, Natividad,
diagnosed her to be suffering from accompanied by her husband, went to
"cancer of the sigmoid." the United States to seek further
treatment. After four months of
On April 11, 1984, Dr. Ampil, consultations and laboratory
assisted by the medical staff of the examinations, Natividad was told she
Medical City Hospital, performed an was free of cancer. Hence, she was
anterior resection surgery on advised to return to the Philippines.
Natividad. He found that the
malignancy in her sigmoid area had On August 31, 1984, Natividad
spread on her left ovary, necessitating flew back to the Philippines, still
the removal of certain portions of it. suffering from pains. Two weeks
Thus, Dr. Ampil obtained the consent thereafter, her daughter found a piece
of Natividad’s husband, Enrique of gauze protruding from her vagina.
Agana, to permit Dr. Juan Fuentes, Upon being informed about it, Dr.
respondent in G.R. No. 126467, to Ampil proceeded to her house where
perform hysterectomy on her. he managed to extract by hand a
piece of gauze measuring 1.5 inches in
After Dr. Fuentes had completed width. He then assured her that the
the hysterectomy, Dr. Ampil took pains would soon vanish.
over, completed the operation and
closed the incision. However, the Dr. Ampil’s assurance did not
operation appeared to be flawed. In come true. Instead, the pains
the corresponding Record of Operation intensified, prompting Natividad to
dated April 11, 1984, the attending seek treatment at the Polymedic
nurses entered these remarks: General Hospital. While confined there,
Dr. Ramon Gutierrez detected the
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 LegMed: Medical Jurisprudence

presence of another foreign object in (2) W/N PSI as owner of the

her vagina -- a foul-smelling gauze Hospital should also be held
measuring 1.5 inches in width which liable.
badly infected her vaginal vault. A
recto-vaginal fistula had formed in her Ruling: Petition Denied. Professional
reproductive organs which forced stool Services, Inc. is ORDERED pro hac
to excrete through the vagina. Another vice to pay and Enrique Agana the
surgical operation was needed to total amount of P15 million, subject
remedy the damage. Thus, in October to 12% p.a. interest from the finality
1984, Natividad underwent another of this resolution to full satisfaction.
surgery.
After gathering its thoughts on
On November 12, 1984, the issues, this Court holds that PSI is
Natividad and her husband filed with liable to the Aganas, not under the
the RTC a complaint for damages principle of respondeat superior for
against the Professional Services, Inc. lack of evidence of an employment
(PSI), owner of the Medical City relationship with Dr. Ampil but under
Hospital, Dr. Ampil, and Dr. Fuentes. the principle of ostensible agency for
They alleged that the latter are liable the negligence of Dr. Ampil and, pro
for negligence for leaving two pieces hac vice, under the principle of
of gauze inside Natividad’s body and corporate negligence for its failure to
malpractice for concealing their acts of perform its duties as a hospital.
negligence.
While in theory a hospital as a
Meanwhile, Enrique Agana also juridical entity cannot practice
filed with the Professional Regulation medicine, in reality it utilizes doctors,
Commission (PRC) an administrative surgeons and medical practitioners in
complaint for gross negligence and the conduct of its business of
malpractice against Dr. Ampil and Dr. facilitating medical and surgical
Fuentes. The RTC rendered its treatment. Within that reality, three
Decision in favor of the Aganas, legal relationships crisscross: (1)
finding PSI, Dr. Ampil and Dr. Fuentes between the hospital and the doctor
liable for negligence and malpractice. practicing within its premises; (2)
Aggrieved, PSI, Dr. Fuentes and Dr. between the hospital and the patient
Ampil interposed an appeal to the being treated or examined within its
Court of Appeals. The CA ruled that premises and (3) between the patient
only Dr. Ampil should be held liable and the doctor. The exact nature of
and he should reimburse PSI for each relationship determines the basis
whatever the latter had paid or is and extent of the liability of the
going to pay the Aganas. hospital for the negligence of the
doctor.
Issue(s):
Where an employment
(1) W/N the CA erred in ruling relationship exists, the hospital may
that only Dr. Ampil is liable. be held vicariously liable under Article
2176 in relation to Article 2180 of the
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 LegMed: Medical Jurisprudence

Civil Code or the principle of Present are the two factors that
respondeat superior. Even when no determine apparent authority: first,
employment relationship exists but it the hospital's implied manifestation to
is shown that the hospital holds out to the patient which led the latter to
the patient that the doctor is its agent, conclude that the doctor was the
the hospital may still be vicariously hospital's agent; and second, the
liable under Article 2176 in relation to patient’s reliance upon the conduct of
Article 1431 and Article 1869 of the the hospital and the doctor, consistent
Civil Code or the principle of apparent with ordinary care and prudence.
authority. Moreover, regardless of its
relationship with the doctor, the To begin with, PSI could not
hospital may be held directly liable to simply wave off the problem and
the patient for its own negligence or nonchalantly delegate to Dr. Ampil the
failure to follow established standard duty to review what transpired during
of conduct to which it should conform the operation. The purpose of such
as a corporation. review would have been to pinpoint
when, how and by whom two surgical
Nonetheless, to allay the anxiety gauzes were mislaid so that necessary
of the intervenors, the Court holds remedial measures could be taken to
that, in this particular instance, the avert any jeopardy to Natividad’s
concurrent finding of the RTC and the recovery. Certainly, PSI could not
CA that PSI was not the employer of have expected that purpose to be
Dr. Ampil is correct. Control as a achieved by merely hoping that the
determinative factor in testing the person likely to have mislaid the
employer-employee relationship gauzes might be able to retrace his
between doctor and hospital under own steps. By its own standard of
which the hospital could be held corporate conduct, PSI's duty to
vicariously liable to a patient in initiate the review was non-delegable.
medical negligence cases is a requisite
fact to be established by While Dr. Ampil may have had
preponderance of evidence. Here, the primary responsibility of notifying
there was insufficient evidence that Natividad about the missing gauzes,
PSI exercised the power of control or PSI imposed upon itself the separate
wielded such power over the means and independent responsibility of
and the details of the specific process initiating the inquiry into the missing
by which Dr. Ampil applied his skills in gauzes. The purpose of the first would
the treatment of Natividad. have been to apprise Natividad of
Consequently, PSI cannot be held what transpired during her surgery,
vicariously liable for the negligence of while the purpose of the second would
Dr. Ampil under the principle of have been to pinpoint any lapse in
respondeat superior. procedure that led to the gauze count
discrepancy, so as to prevent a
There is, however, ample recurrence thereof and to determine
evidence that the hospital (PSI) held corrective measures that would ensure
out to the patient (Natividad) that the the safety of Natividad. That Dr. Ampil
doctor (Dr. Ampil) was its agent. negligently failed to notify Natividad
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 LegMed: Medical Jurisprudence

did not release PSI from its self- All this notwithstanding, we
imposed separate responsibility. make it clear that PSI’s hospital
liability based on ostensible agency
Corollary to its non-delegable and corporate negligence applies only
undertaking to review potential to this case, pro hac vice. It is not
incidents of negligence committed intended to set a precedent and
within its premises, PSI had the duty should not serve as a basis to hold
to take notice of medical records hospitals liable for every form of
prepared by its own staff and negligence of their doctors-consultants
submitted to its custody, especially under any and all circumstances. The
when these bear earmarks of a ruling is unique to this case, for the
surgery gone awry. Thus, the record liability of PSI arose from an implied
taken during the operation of agency with Dr. Ampil and an
Natividad which reported a gauze admitted corporate duty to Natividad.
count discrepancy should have given
PSI sufficient reason to initiate a Other circumstances peculiar to
review. It should not have waited for this case warrant this ruling, not the
Natividad to complain. least of which being that the agony
wrought upon the Aganas has gone on
As it happened, PSI took no for 26 long years, with Natividad
heed of the record of operation and coming to the end of her days racked
consequently did not initiate a review in pain and agony. Such wretchedness
of what transpired during Natividad’s could have been avoided had PSI
operation. Rather, it shirked its simply done what was logical: heed
responsibility and passed it on to the report of a guaze count
others – to Dr. Ampil whom it discrepancy, initiate a review of what
expected to inform Natividad, and to went wrong and take corrective
Natividad herself to complain before it measures to ensure the safety of
took any meaningful step. By its Nativad. Rather, for 26 years, PSI
inaction, therefore, PSI failed its own hemmed and hawed at every turn,
standard of hospital care. It disowning any such responsibility to its
committed corporate negligence. patient. Meanwhile, the options left to
the Aganas have all but dwindled, for
It should be borne in mind that the status of Dr. Ampil can no longer
the corporate negligence ascribed to be ascertained.
PSI is different from the medical
negligence attributed to Dr. Ampil. The The Supreme Court applied the
duties of the hospital are distinct from Captain of the Ship Doctrine in
those of the doctor-consultant upholding the liability of the doctor.
practicing within its premises in The Court stressed that as the lead
relation to the patient; hence, the surgeon, the doctor had the duty to
failure of PSI to fulfill its duties as a remove all foreign objects from the
hospital corporation gave rise to a patient’s body before the closure of
direct liability to the Aganas distinct the incision. At the very least, the
from that of Dr. Ampil. doctor should have informed the
patient of his failure to do so. The act
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 LegMed: Medical Jurisprudence

of ordering the closure of the incision

notwithstanding that the pieces of
gauze remained unaccounted for
bolstered the application of the
doctrine.

17