1. Carillo v. People of the Philippines GR 86890, January 21, 1994 Facts: 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. 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 Pea. Dra. Pea called for Dr. Emilio Madrid and the latter examined Catherine Acosta. According to Dr. Madrid, his findings might be appendicitis. Then Dr. Pea 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. According to the childs mother, 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. 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. Catherine was transferred to her room . afterwards, her mother noticed that her heartbeat was not normal. According to the dr Madrid, it was due to the lesion of the child. Few mins after they revived the heartbeat of the child, Dr Madrid and Dr. Carillo left. At about 15-30 minutes after, the child developed convulsion and stiffening of the body. The nurse called on Dr dela Pena, which in turn called dr. Madrid and the cardiologist. The cardiologist informed the mother that that she suffered from severe infection which went up to her head. 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. A case was filed against Dr. Madrid and Dr. Carillo. The lower court as well as the appellate court rendered them both liable for criminal negligence . Petiotioner contends that 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, 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. Issue: WON Dr. Carillo failed to exercise the diligence required by the standards of his profession. Held: Yes. Both doctors failed to appreciate the serious condition of their patient whose adverse physical signs were quite manifest right after surgery. 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. 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. 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. 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." 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. 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. Also,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. 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. Hence, the above mentioned incident presupposes that Dr. Madrid failed to exercise the appropriate and necessary degree off care and diligence to prevent the sudden decline in the condition of Catherine Acosta. 2. Batiquin v. CA GR 118231, July 5, 1996 Facts: Petitioner is a resident physician at the Negros Occidental Provincial Hospital, Dumaguete City. Sometime in September 21, 1988 Mrs Villegas submitted herself to petitioner for prenatal care. Petitioner performed a simple cesarean operation to respondent in the morning of September 21, 1988. On the 27th of september, petitioner was discharged . During the period of confinement, dr. Batiquin regularly visit respondent. Soon after leaving the hospital, respondent began to suffer 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 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 and despite the medications administered by Dr. Batiquin. The pains became unbearable , thus prompted her to consult Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete City on January 20, 1989. Upon examination she felt an abdominal mass one finger below the umbilicus which she suspected to be either a tumor of the uterus or an ovarian cyst, either of which could be cancerous. 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 result 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 materials on the right side of the uterus embedded on 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 also appeared also as "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 During trial, there were two versions of the offending rubber. The trial court ruled in favor of the petitioners, however, the court of appeals reversed its ruling, holding Dr. Batiquin liable for negligence. Petitioner contends that the appellate court committed error in appreciating the testimony of Dr. Kho, in favor of the respondents. They further contend that there were falsities and contradictory statements of Dr. Kho. Hence should not be relied upon by the court. Issue: WON the presence of the rubber inside the cavity of the respondents render petitioner liable for negligence? Held. Yes. Dr. Khos positive testimony prevails over the negative testimony in favor of the petitioners. 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 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." Or as Black's Law Dictionary puts it: Res ipsa loquitur. 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 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 beprima 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 cesarean 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' body, which, needless to say, does not occur unless through the intervention of negligence. Second, since aside from the cesarean 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 cesarean 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' abdomen and for all the adverse effects thereof. 3. Garcia-Rueda v. Pascasio GR 118141, September 5, 1997 Facts: Florencio V. Rueda, husband of petitioner Leonila GarciaRueda, underwent surgical operation at the UST hospital for the removal of a stone blocking his ureter. He was attended by Dr. Domingo Antonio, Jr. who was the surgeon, while Dr. Erlinda Balatbat-Reyes was the anaesthesiologist. Six hours after the surgery, however, Florencio died of complications of unknown cause, according to officials of the UST Hospital. Not satisfied with the findings of the hospital, petitioner requested the National Bureau of Investigation (NBI) to conduct an autopsy on her husbands body. Consequently, the NBI ruled that Florencios death was due to lack of care by the attending physician in administering anaesthesia. Pursuant to its findings, the NBI recommended that Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor. During the preliminary investigation, what transpired was a confounding series of events. 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. Aggrieved, petitioner filed graft charges specifically for violation of Section 3(e) of Republic Act No. 3019 [3] against Prosecutors Guerrero, Macaraeg, and Arizala for manifest partiality in favor of Dr. Reyes before the Office of the Ombudsman. However, on July 11, 1994, the Ombudsman issued the assailed resolution dismissing the complaint for lack of evidence. Issue: WON the dismissal of the complaint by the prosecution against the two physician concludes the absence of medical malpractice. Held: No. 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 partys accusation and defenses are better ventilated at the trial proper than at the preliminary investigation. A word on medical malpractice or negligence cases. In its simplest terms, the type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is

that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. 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 doctors actions in fact caused the harm to the patient and whether these were the proximate cause of the patients injury.[18] Indeed here, a causal connection is discernible from the occurrence of the victims death after the negligent act of the anaesthesiologist in administering the anesthesia, a fact which, if confirmed, should warrant the filing of the appropriate criminal case. To be sure, the allegation of negligence is not entirely baseless. 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. 4. DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI,respondents. 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, 1991. [11] 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 City 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 reoperated 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 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] Issue: WON petitioner is liable for reckless imprudence resulting to homicide. No. 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. 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 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 casual 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 occurred.'' 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] 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] This court has no recourse but to rely on the expert testimonies rendered by both prosecution and defense witnesses that substantiate rather than contradict petitioner's allegation that the cause of Lydia's death was DIC which, as attested to by an expert witness, cannot be attributed to the petitioner's fault or negligence. The probability that Lydia's death was caused by DIC was unrebutted during trial and has engendered in the mind of this Court a reasonable doubt as to the petitioner's guilt. Thus, the acquittal of petitioner of the crime reckless imprudence. 5. Ramos vs CA GR 124354, December 28, 1999 FACTS: Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, wasadvised to undergo an operation for the removal of a stone in her gall bladder (cholecystectomy).She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation on her. Theoperation was scheduled for June 17, 1985 at 9:00 in the morning at private respondent De LosSantos Medical Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka recommended to them the services of Dr.Gutierrez.Petitioner Erlinda

was admitted to the DLSMC the day before the scheduled operation. By 7:30in the morning of the following day, petitioner Erlinda was already being prepared for operation.Upon the request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who was then Dean of the College of Nursing at the Capitol Medical Center, was allowed to accompany her inside theoperating room. At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get intouch with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the operation might bedelayed due to the late arrival of Dr. Hosaka. In the meantime, the patient, petitioner Erlinda saidto Cruz, "Mindy, inip na inip na ako,ikuha mo ak o ng ibang Doctor ."By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio alreadywanted to pull out his wife from the operating room. He met Dr. Garcia, who remarked that hewas also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived at the hospital at around12:10 in the afternoon, or more than three (3)hours after the scheduled operation. Cruz, who was then still inside the operating room, heard about Dr. Hosakas arrival. While sheheld the hand of Erlinda, Cruz saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr.Gutierrez utter: "ang hir ap ma-int ubate nito,mali yata ang pagkakapasok ko.o lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlindas nailbeds on her left hand. She (Cruz)then heard Dr. Hosaka instruct someone to call Dr. Calderon, another anesthesiologist. When hearrived, Dr. Calderon attempted to intubate the patient. The nailbeds of the patient remained bluish, thus, she was placed in a trendelenburg position a position where the head of the patientis placed in a position lower than her feet. At this point, Cruz went out of the operating room toexpress her concern to petitioner Rogelio that Erlindas operation was not going well.Cruz quickly rushed back to the operating room and saw that the patient was still intrendelenburg position. At almost 3:00 in the afternoon, she saw Erlinda being wheeled to theIntensive Care Unit (ICU). The doctors explained to petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained incomatose condition until she died on August 3, 1999.1 Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private respondents.After due trial, the courta quo rendered judgment in favor of petitioners.Essentially, the trial court found that private respondents were negligent in the performance of their duties to Erlinda. On appeal by private respondents, the Court of A ppeals reversed the trialcourts decision and directed petitioners to pay their "unpaid medical bills" to privaterespondents.Petitioners filed with this Court a petition for review on certiorari. The private respondents werethen required to submit their respective comments thereon. On December 29, 1999, this Court promulgated the decision which private respondents now seek to be reconsidered. ISSUES: 1. WHETHER OR NOT DR. ORLINO HOSAKA(SURGEON)IS LIABLE FOR NEGLIGENCE 2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (A NESTHESIOLOGIST) IS LIABLE FOR NEGLIGENCE? 3. WHETHER OR NOT THE HOSPITAL (DELOS SA NTOS MEDICAL CENTER )IS LIABLE FOR A NY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITINGCONSULTA NT SURGEON A ND ANESTHESIOLOGIST. HELD: RULING: In the case at bar, the following issues were resolved as follows: 1) Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitionerErlinda is violative, not only of his duty as a physician "to serve the interest of his patients with thegreatest solicitude, giving them always his best talent and skill,but also of Article 19 of the Civil Codewhich requires a person, in the performance of his duties, to act with justice and give everyone his due. 2) Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has beensufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Dr. Gutierrez omitted to perform a thorough preoperative evaluation onErlinda. Further, there is no cogent reason for the Court to reverse its

finding that it was the faultyintubation on Erlinda that caused her comatose Condition. There is no question that Erlinda becamecomatose after Dr. Gutierrez performed a medical procedure on her. 3)After a careful consideration of the arguments raised by DLSMC, the Court finds thatrespondent hospitals position on this issue is meritorious. There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMCsolidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the CivilCode. urther, no evidence was adduced to show that the injury suffered by petitioner Erlindawas due to a failure on the part of respondent DLSMC to provide for hospital facilities and staff necessary for her treatment. For these reasons, the Supreme Cord reverse the finding of liabilityon the part of DLSMC for the injury suffered by petitioner Erlinda. 6. REYES vs. Sisters of mercy Facts: 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 theirchildren. Five days before his death on January 8, 1987, Jorge had been suffering from arecurring 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 seethe doctor.On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He wasattended to by respondent Dr. Marlyn Rico, resident physician and admitting physicianon duty, who gave Jorge a physical examination and took his medical history. She notedthat at the time of his admission, Jorge was conscious, ambulatory, oriented, coherent,and with respiratory distress. Typhoid fever was then prevalent in the locality, as theclinic had been getting from 15 to 20 cases of typhoid per month Suspecting that Jorgecould be suffering from this disease, Dr. Rico ordered a Widal Test, a standard test fortyphoid fever, to be performed on Jorge. Blood count, routine urinalysis, stoolexamination, and malarial smear were also made After about an hour, the medicaltechnician 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 Jorgeshistory 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, sheordered that a compatibility test with the antibiotic chloromycetin be done on Jorge. Saidtest 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 administeredon Jorge at around 9:00 p.m. A second dose was administered on Jorge about threehours later just before midnight. At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorges temperature roseto 41C. The patient also experienced chills and exhibited respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction machine,and administered hydrocortisone, temporarily easing the patients convulsions. When heregained consciousness, the patient was asked by Dr. Blanes whether he had a previousheart ailment or had suffered from chest pains in the past. Jorge replied he did not Afterabout 15 minutes, however, Jorge again started to vomit, showed restlessness, and hisconvulsions returned. Dr. Blanes re-applied the emergency measures taken before and, inaddition, valium was administered. Jorge, however, did not respond to the treatment andslipped 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 toHyperpyrexia and typhoid fever. Issue: Whether or not petitioner is entitled to damage applying res ipsa loquitur? Held: No. There is a case when expert testimony may be dispensed with, and that is under thedoctrine of res ipsa loquitur. Thus, courts of other jurisdictions have applied the doctrinein the following situations: leaving of a foreign object in the body of the patient after anoperation, injuries sustained on a healthy part of the body which was not under,

or in thearea, of treatment, removal of the wrong part of the body when another part wasintended, knocking out a tooth while a patients jaw was under anesthetic for the removalof 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.Petitioners now contend that all requisites for the application of res ipsaloquitur 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 theinjury was under the exclusive control of the person in charge; and (3) the injury sufferedmust not have been due to any voluntary action or contribution of the person injured. The contention is without merit. We agree with the ruling of the Court of Appeals. Inthe Ramos case, the question was whether a surgeon, an anesthesiologist, and a hospitalshould be made liable for the comatose condition of a patient scheduled forcholecystectomy. 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 Courtapplied the doctrine of res ipsa loquitur as mental brain damage does not normally occurin 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 hoursafter professional medical assistance was rendered, there is really nothing unusual orextraordinary about his death. Prior to his admission, the patient already had recurring fevers and chills for five days unrelieved by the analgesic, antipyretic, and antibioticsgiven him by his wife. This shows that he had been suffering from a serious illness andprofessional medical help came too late for him.Respondents alleged failure to observe due care was not immediately apparent to alayman so as to justify application of res ipsa loquitur. The question required expertopinion on the alleged breach by respondents of the standard of care required by thecircumstances. Furthermore, on the issue of the correctness of her diagnosis, nopresumption of negligence can be applied to Dr. Marlyn Rico. 7. RAMOS VS. CA FACTS: Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, was advised to undergo an operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at private respondent De Los Santos Medical Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka recommended to them the services of Dr. Gutierrez. Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. At the day of the operation Dr. Gutierrez informed Cruz that the operation might be delayed due to the late arrival of Dr. Hosaka. The latter finally arrived at the hospital at around 12:10 in the afternoon, or more than three (3) hours after the scheduled operation. Thereafter, Herminda Cruz, sister-in-law of Erlinda Ramos saw Dr. Gutierrez trying to intubate the patient and noticed a bluish discoloration of Erlindas nailbeds on her left hand, thus, she was placed in a trendelenburg position a position where the head of the patient is placed in a position lower than her feet. almost 3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit (ICU). The doctors explained to petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained in comatose condition until she died on August 3, 1999. Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private respondents. After due trial, the court a quo rendered judgment in favor of petitioners. Essentially, the trial court found that private respondents were negligent in the performance of their duties to Erlinda. On appeal by private respondents, the Court of Appeals reversed the trial courts decision and directed petitioners to pay their "unpaid medical bills" to private respondents. ISSUE: WHETHER OR NOT RESPONDENTS ARE LIABLE FOR

NEGLIGENCE. HELD: DR. Gutierrez liability. Yes. Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has been sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Pre-evaluation for anesthesia involves taking the patients medical history, reviewing his current drug therapy, conducting physical examination, interpreting laboratory data, and determining the appropriate prescription of preoperative medications as necessary to the conduct of anesthesia. Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. As she herself admitted, she saw Erlinda for the first time on the day of the operation itself, one hour before the scheduled operation. She auscultated the patients heart and lungs and checked the latters blood pressure to determine if Erlinda was indeed fit for operation. However, she did not proceed to examine the patients airway. Had she been able to check petitioner Erlindas airway prior to the operation, Dr. Gutierrez would most probably not have experienced difficulty in intubating the former, and thus the resultant injury could have been avoided. Dr. Hosaka's liability. Yes. There is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does not mean that this Court will ipso facto follow said trend. Due regard for the peculiar factual circumstances obtaining in this case justify the application of the Captain-of-the-Ship doctrine. From the facts on record it can be logically inferred that Dr. Hosaka exercised a certain degree of, at the very least, supervision over the procedure then being performed on Erlinda. First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In effect, he represented to petitioners that Dr. Gutierrez possessed the necessary competence and skills. Drs. Hosaka and Gutierrez had worked together since 1977. Whenever Dr. Hosaka performed a surgery, he would always engage the services of Dr. Gutierrez to administer the anesthesia on his patient. Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus, when Erlinda showed signs of cyanosis, it was Dr. Hosaka who gave instructions to call for another anesthesiologist and cardiologist to help resuscitate Erlinda. Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka and Gutierrez worked as a team. Their work cannot be placed in separate watertight compartments because their duties intersect with each other. While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their performance of acts within their respective fields of expertise for the treatment of petitioner Erlinda, and that one does not exercise control over the other, they were certainly not completely independent of each other so as to absolve one from the negligent acts of the other physician. That they were working as a medical team is evident from the fact that Dr. Hosaka was keeping an eye on the intubation of the patient by Dr. Gutierrez, and while doing so, he observed that the patients nails had become dusky and had to call Dr. Gutierrezs attention thereto. The Court also notes that the counsel for Dr. Hosaka admitted that in practice, the anesthesiologist would also have to observe the surgeons acts during the surgical process and calls the attention of the surgeon whenever necessary in the course of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the treatment of petitioner Erlinda are therefore not as clear-cut as respondents claim them to be. It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to petitioner Erlinda promptly, for he arrived more than three (3) hours late for the scheduled operation. The unreasonable delay in petitioner Erlindas scheduled operation subjected her to continued starvation and consequently, to the risk of acidosis, or the condition of decreased alkalinity of the blood and tissues, marked by sickly sweet breath, headache, nausea and vomiting, and visual disturbances. The long period that Dr. Hosaka made Erlinda wait for him certainly aggravated the anxiety that she must have been feeling at the time. It could be safely said that her anxiety adversely affected the administration of anesthesia on her.

DLSMC's liability. No. Neither is there any showing that it is DLSMC which pays any of its consultants for medical services rendered by the latter to their respective patients. Moreover, the contract between the consultant in respondent hospital and his patient is separate and distinct from the contract between respondent hospital and said patient. 8. RUEZ, JR. vs. Dr. JURADO FACTS: On January 12, 2005, at around 4:20 p.m., Ruez, Sr. arrived by himself at this Courts clinic complaining of dizziness. Ruez, Jr. alleged that despite his fathers medical condition, he was merely advised to go to a hospital and then allowed to walk out of the clinic on his own. After being informed of his fathers condition, he rushed him to the Manila Doctors Hospital. There, Ruez, Sr. was treated in the emergency room for approximately four hours before he was discharged at around 8:30 p.m. and allowed to go home. However, prior to reaching their house in Balintawak, Caloocan City, Ruez, Sr. began experiencing nausea, abnormal palpitation and uneasiness and had to be brought back to the hospital and arrived at the emergency room of the Manila Doctors Hospital at around 10:00 p.m. after which Ruez, Sr. underwent a C.T. Scan. The C.T. Scan revealed a blood clot necessitating him to be admitted for treatment and observation. Unfortunately, Ruez Sr. never recovered from his ailment and, on September 12, 2005, he passed away due to medical complications Ruez, Jr. filed a letter-complaint with the Office of the Chief Justice regarding the alleged lack of attention given to his father by Dr. Jurado. Specifically, he claims that Dr. Jurado merely advised his father to go to the hospital and then allowed him to travel to Manila Doctors Hospital despite the availability of an ambulance at the disposal of the clinic. Ruez, Jr. submits that his father would not have suffered a stroke if not for the neglect of Dr. Jurado. Atty. Candelaria, Deputy Clerk of Court and Chief of Administrative Services submitted her report on June 17, 2005. The report gave credence to the account of Dr. Jurado that Ruez, Sr. was given Capoten, informed that he should be hospitalized and that the ambulance was placed on standby to take him there. These factual findings of Atty. Candelaria appear to be supported by the affidavits of the clinics personnel, including the ambulance driver, who witnessed the events that happened between Ruez, Sr. and Dr. Jurado. ISSUE: Whether there is cause to hold Dr. Jurado administratively liable. HELD: NO. A doctors duty to his patient is not required to be extraordinary. The standard contemplated for doctors is simply the reasonable average merit among ordinarily good physicians, i.e. reasonable skill and competence. We are persuaded that Dr. Jurado fulfilled such a standard when she treated Ruez, Sr. inside the clinic. But what of Dr. Jurados conduct after Ruez, Sr. left the clinic and failed to return? It has been held that a patient cannot attribute to a physician damages resulting from his own failure to follow his advice, even though he was ignorant of the consequences which would result from his failure. If a patient leaves the hospital contrary to instructions, the physician is not liable for subsequent events. 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. Dr. Jurado may have allowed Ruez, Sr. to walk out of the clinic despite her earlier diagnosis of his condition. By that time Ruez, Sr.s condition had temporarily stabilized and she did not have the authority to stop him just as other doctors have no power, save in certain instances (such as when the law makes treatment compulsory due to some communicable disease or when consent is withheld by a minor but non-treatment would be detrimental or when the court of competent jurisdiction orders the treatment), to force patients into staying under their care. Dr. Jurado relied on Ruez, Sr.s representation that he would return in order to be brought to the hospital but made no undertaking to wait for him beyond the clinic hours or to look for him if he did not return. Thus, when Ruez, Sr. failed to show up as of closing time, and could not be found by the

male nurse who looked for him at her instructions, Dr. Jurado had reason to think that he had decided to disregard her medical advice, which he in fact did when he and Ruez, Jr. decided to go to the hospital on their own. Ruez, Sr., still of sound mind, had the right to accept or ignore his doctors recommendation. Dr. Jurado was obligated to care for Ruez, Sr. when the latter asked for medical treatment, which she did, but when he left on his own accord Dr. Jurado was not expected, much less duty-bound, to seek out her patient and continue being his doctor. 9. Nogales vs. Capitol Medical Center FACTS: Corazon Nogales ("Corazon"), 37 years old pregnant with her fourth child, under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada"). The Doctor noted an increase in her blood pressure and development of leg edema indicating preeclampsia. Corazon started to experience mild labor pains Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC"). The staff nurse noted the written admission request of Dr. Estrada. Due to the "Consent on Admission and Agreement" and "Admission Agreement" signed by Corazons husband she was then brought to the labor room of the CMC. Corazon manifest moderate vaginal bleeding which rapidly became profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign consent to Operation. Due to the inclement weather, Dr. Espinola arrived an hour late. He examined the patient and ordered some resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon died the cause of death was "hemorrhage, post partum." Petitioners filed a complaint for damages with the Regional Trial Court of Manila contending that defendant physicians and CMC personnel were negligent in the treatment and management of Corazon's condition also in the selection and supervision of defendant physicians and hospital staff. The defendant fail to file their answer to the complaint the trial court declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default. CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint. The trial court rendered judgment finding Dr. Estrada solely liable for damages. Petitioners appealed the trial court's decision, The Court of Appeals affirmed the decision of the trial court. Petitioners filed a motion for reconsideration which was denied in its resolution. Hence, petitioners filed a Manifestation that respondents "need no longer be notified of the petition because they are not involved in the issue raised before the [Court], regarding the liability of [CMC]." 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. Hence this petition. ISSUE: Whether or not CMC is vicariously liable for the negligence? HELD: YES.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. CMC merely allowed Dr. Estrada to use its facilities 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 contractorphysician. 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. This exception is also known as the "doctrine of apparent authority." In Gilbert v. Sycamore Municipal Hospital, 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 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. 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. 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." 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. 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. 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]." 10. PSI vs. AGANA

FACTS: On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because of difficulty of bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil, diagnosed her to be suffering from "cancer of the sigmoid." Then, Dr. Ampil, assisted by the medical staff of the Medical City Hospital, performed an anterior resection surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividads husband, Enrique Agana, to permit Dr. Juan Fuentes to perform hysterectomy on her. Natividad was released from the hospital. 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. They went to US for further treatment and came after four months however 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 but never came true prompting natividad to seek treatment from Polymedic General Hospital, Dr. Ramon Gutierrez detected the presence of another foreign object in her vagina -- a foulsmelling 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 underwent by Natividad 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. Q43322. They alleged that the latter are liable for negligence for leaving two pieces of gauze inside Natividads body and malpractice for concealing their acts of negligence. ISSUE: Whether PSI is liable for malpractice and negligence. HELD: YES.The ruling in Smith v. Zeagler is explicit, thus: The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to remove a sponge he has placed in his patients body that should be removed as part of the operation, he thereby leaves his operation uncompleted and creates a new condition which imposes upon him the legal duty of calling the new condition to his patients attention, and endeavoring with the means he has at hand to minimize and avoid untoward results likely to ensue therefrom. Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient. This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this kind of case, a patient must only prove that a health care provider either failed to do something which a reasonably prudent health care provider would have done, or that he did something that a reasonably prudent provider would not have done; and that failure or action caused injury to the patient. Simply put, the elements are duty, breach, injury and proximate causation. Dr, Ampil, as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividads body before closure of the incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil breached both duties. Such breach caused injury to Natividad, necessitating her further examination by American doctors and another surgery. That Dr. Ampils negligence is the proximate cause of Natividads injury could be traced from his act of closing the incision despite the information given by the attending nurses that two pieces of gauze were still missing. That they were later on extracted from Natividads vagina established the causal link between Dr. Ampils negligence and the

injury. And what further aggravated such injury was his deliberate concealment of the missing gauzes from the knowledge of Natividad and her family. 11. DR. CANTRE vs. SPS. Go FACTS: 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. The following day, 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. While petitioner was massaging Noras uterus for it to contract and stop bleeding, she ordered a droplight to warm Nora and her baby. Nora remained unconscious until she recovered however respondent John David Z. Go noticed a fresh gaping wound two and a half (2 ) by three and a half (3 ) inches in the inner portion of her left arm, close to the armpit. 5 He asked the nurses what caused the injury. He was informed it was a burn. On April 22, 1992, John David filed a request for investigation. 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. 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.The medico-legal officer later testified that Noras injury appeared to be a burn and that a droplight when placed near the skin for about 10 minutes could cause such burn. 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. 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. ISSUE: Is petitioner liable for the injury suffered by respondent Nora Go? HELD: YES. Whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both instruments are deemed within the exclusive control of the physician in charge under the "captain of the ship" doctrine. This doctrine holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those assistants are under the surgeons control. In this particular case, it can be logically inferred that petitioner, the senior consultant in charge during the delivery of Noras baby, exercised control over the assistants assigned to both the use of the droplight and the taking of Noras blood pressure. Hence, the use of the droplight and the blood pressure cuff is also within petitioners exclusive control. Third, the gaping wound on Noras left arm, by its very nature and considering her condition, could only be caused by something external to her and outside her control as she was unconscious while in hypovolemic shock. Hence, Nora could not, by any stretch of the imagination, have contributed to her own injury. 12 . ILAO-ORETA vs. SPS. RONQUILLO FACTS: Spouses Ronquillo had not been blessed with a child despite several years of marriage. They thus consulted petitioner, Dr. Concepcion Ilao-Oreta (Dr. Ilao-Oreta), an obstetrician-gynecologistconsultant at the St. Lukes Medical Center where she was, at the time material to the case, the chief of the Reproductive Endocrinology and Infertility Section. Upon Dr. Ilao-Oretas advice, Eva Marie agreed to undergo a laparoscopic procedure whereby a laparascope would be inserted through the patients abdominal wall to get a direct view of her internal reproductive organ in order to determine the real cause of her infertility. The procedure was scheduled on April 5, 1999 at 2:00 p.m., to be

performed by Dr. Ilao-Oreta. At around 7:00 a.m. of said date, Eva Marie, accompanied by her husband Noel, checked in at the St. Lukes Medical Center and underwent pre-operative procedures including the administration of intravenous fluid and enema. Dr. IlaoOreta did not arrive at the scheduled time for the procedure, however, and no prior notice of its cancellation was received. It turned out that the doctor was on a return flight from Hawaii to, and arrived at 10:00 p.m. of April 5, 1999 in, Manila. On May 18, 1999, the Ronquillo spouses filed a complaint against Dr. Ilao-Oreta and the St. Lukes Medical Center for breach of professional and service contract and for damages before the Regional Trial Court (RTC) of Batangas City. ISSUE: Whether Petitioner committed Gross Negligence in the performance of her duty. HELD: NO. The evidence then shows that Dr. Ilao-Oreta, who had traveled more than twice to the United States where she obtained a fellowship in Reproductive Endocrinology and Infertility was indeed negligent when she scheduled to perform professional service at 2:00 p.m. on April 5, 1999 without considering the time difference between the Philippines and Hawaii. The doctors act did not, however, reflect gross negligence as defined above. Her argument that Although petitioner failed to take into consideration the time difference between the Philippines and Hawaii, the situation then did not present any clear and apparent harm or injury that even a careless person may perceive. Unlike in situations where the Supreme Court had found gross negligence to exist, petitioner could not have been conscious of any foreseeable danger that may occur since she actually believed that she would make it to the operation that was elective in nature, the only purpose of which was to determine the real cause of infertility and not to treat and cure a life threatening disease. Thus, in merely fixing the date of her appointment with respondent Eva Marie Ronquillo, petitioner was not in the pursuit or performance of conduct which any ordinary person may deem to probably and naturally result in injury, (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, and it is of common human knowledge that excitement attends its preparations. Her negligence could then be partly attributed to human frailty which rules out its characterization as gross. The doctors negligence not being gross, the spouses are not entitled to recover moral damages. 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, nor to award of attorneys fees as, contrary to the finding of the Court of Appeals that the spouses "were compelled to litigate and incur expenses to protect their interest," the records show that they did not exert enough efforts to settle the matter before going to court. 13. Sps. Flores v. Sps. Pineda, et. al. GR 158996, November 2008 Facts: Teresita Pineda, 51, consulted Dr. Flores about her medical condition saying she was experiencing general body weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. The latter advised her to go to UDMC for a general checkup because she was suspected to have diabetes. April 28, 1987, Teresita went to UDMC (she was very weak). After Dr. Flores did a routine check-up, he ordered her admission to the hospital and directed the staff to prepare her for an on call D&C operation (dilatation and curettage)to be performed by his wife, Dr. Felicisima Flores. Samples were taken for lab test. April 29, 1987, results of blood tests showed that the sugar in her urine was very high and further results showed she was suffering from Diabetes Mellitus Type II. Insulin was given but it might have been too late because she died on May 6, 1987 due to complications induced by diabetes.

Her family, believing that negligence caused her death, filed an action for damages against Dr. Flores and Felicisima. FAMILY: They should have waited for lab results before performing D&C. Since she is already suspected of diabetes, it should have been given more attention. DOCTORS: D&C is the immediate answer to vaginal bleeding. And that operation on a hypoglycemic patient, such as Teresita who is suffering from diabetes, is justified if shown to be life-threatening. Both RTC and CA ruled in favor of the relatives of Teresita. Issue(s): W/N the negligence of the doctors caused her death thus rendering them liable to pay damages? Held: YES, their decision to proceed with the operation, notwithstanding her hypoglycemia and without preparing her for the procedure, was contrary to the standards observed by the medical profession. Deviation from this standard led to a breach of duty resulting to death, thus, the spouses are liable. Ratio: 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; 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. Medical Negligence is a wrong committed by a medical professional causing harm or death to a patient. The elements of which are: duty, breach, injury and proximate causation. Duty: Standard behavior which imposes restrictions on ones conduct (the amount of competence associated with the proper discharge of a profession) Breach: When physician fails to comply with these professional standards. If injury results from this, he is liable for negligence. It must be proven that: 1) Physician either failed to do something which a reasonably prudent health care provider would have done, or did something a reasonably prudent provider would not have done. 2) This failure or action caused injury to the patient. (best shown through expert testimony) In this case: 1) Felicisima did not even check on her patient or talk to her before the operation (I think the SC is wrong here, because the case was an emergency and usually someone else does it for them but then again, thats just me J) 2) The spouses were not able to prove that the bleeding was lifethreatening. Dr. Flores should not have made the decision to operate on her because he was not an expert in the field of gynecology. 14. Cayao-Lasam v. Ramolete GR 159132, December 18, 2008 Facts: Ramolete underwent raspa (D&C procedure ) under Caya0Lasam and was discharged the following day. She was brought to the hospital again for severe abdominal pains and vomiting. She was informed that there is a dead fetus in her womd. She underwent laparatomy and she was found to have massive intraabdominal hemorrhage and a ruptured uterus. She had to undergo hysterectormy and as a result she cant bear a child anymore. Ramolete says that the hysterectomy is due to the negligence of Cayao-Lasam in performing raspa (not knowing that what she had was an ectopic pregnancy). Cayao-Lasam says that it was because of Ramoletes insistence to be discharged immediately and failing to go to her check up. Held: Ramolete did not present any expert testimony to support their claim. Cayao-Lasam presented an expert on the subject who stated D&C was not the proximate cause of the rupture of Edithas uterus resulting in her hysterectomy. The D&C 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. Assuming that there was in fact a misdiagnosis, the same would have been rectified if Ramolete followed the order to return for a check-up. She 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 her injury. Had she returned, Cayao-Lasam could have conducted the proper medical tests and procedure necessary to determine her health condition and applied the corresponding treatment which could have prevented the rupture of her uterus. DOCTRINE: Medical malpractice is a particular form of negligence which consists in the failure of a physician or surgeon to apply use at least the same level of care that any reasonably competent doctor would use to treat a condition under the same circumstances. As to this aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential. 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. All told, doctors are protected by a special rule of law. They are not guarantors of care. They are not insurers against mishaps or unusual consequences specially so if the patient herself did not exercise the proper diligence required to avoid the injury. 15. Lucas v. Tuano GR 178763, April 21, 2009 Facts: Lucas had a sore eye and used maxitrol (steroid based) for it. He then consulted Dr. Tuano (opthal) on October 1988. He was prescribed a different medicine. The sore eyes was cured but the eye developed EKC (a viral infection) and he was told to use maxitrol. EKC tapered down and Lucas was told gradually reduce the dosage of maxitrol otherwise EKC might recur. His EKC recurred and he was told to resume the orig dosage of maxitrol. Blephamide (also steroid based) was used when maxitrol is unavailable. Lucas discovered that prolonged used of maxitrol is dangerous to the eyes (may develop glaucoma). He told Tuano about it but the doctor just brushed it aside. By December his right eye was blind and he was told to stop the use of maxitrol and was prescribed different medicines. Tuano referred Lucas to another Doctor for the treatment of glaucoma and Tuano treated him according to the advice of that doctor. Lucas consulted Dr. Aquino on his own initiative and was told that his condition needs lifetime med and follow ups. Lucas underwent two operations (1990 and 1991) of laser trabeculoplasty. He said that what he had is steroid-induced glaucoma and sued Tuano. Tuano says that Lucas glaucoma is not steroid induced for if it were, it would disappear with the discontinue of the use of maxitrol. Held: No expert testimony was presented. Absent a definitive standard of care or diligence required of the Dr. Tuano under the circumstances, the Court cant determine whether he was able to comply with the same in his diagnosis and treatment of Lucas. There is no causation between use of maxitrol and glaucoma. Lucas failed to prove by preponderance of evidence that Tuani failed to exercise that degree of skill, care and learning possessed by other persons in the same profession; and that as a proximate result if such failure, the patient or his heirs suffered damages. The mere fact that the patient does not get well or that a bad result is not determinative of the performance of the physician and he is not required to be infallible. When a patient engages the services of a physician, a physicianpatient 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 [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. 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. 16. PSI v. Agana (Resolution) GR 126297, February 2, 2010 Facts: PSI, together with Dr. Miguel Ampil (Dr. Ampil) and Dr. Juan Fuentes (Dr. Fuentes), was impleaded by Enrique Agana and Natividad Agana (later substituted by her heirs), in a complaint for damages filed in the Regional Trial Court (RTC) of Quezon City, Branch 96, for the injuries suffered by Natividad when Dr. Ampil and Dr. Fuentes neglected to remove from her body two gauzes which were used in the surgery they performed on her on April 11, 1984 at the Medical City General Hospital. PSI was impleaded as owner, operator and manager of the hospital. In a decision dated March 17, 1993, the RTC held PSI solidarily liable with Dr. Ampil and Dr. Fuentes for damages. On appeal, the Court of Appeals (CA), absolved Dr. Fuentes but affirmed the liability of Dr. Ampil and PSI, subject to the right of PSI to claim reimbursement from Dr. Ampil. On petition for review, this Court, in its January 31, 2007 decision, affirmed the CA decision. PSI filed a motion for reconsideration but the Court denied it in a resolution dated February 11, 2008. Issue: Whether the hospital is liable for damages? Held: YES, Nonetheless, to allay the anxiety of the intervenors, the Court holds that, in this particular instance, the concurrent finding of the RTC and the CA that PSI was not the employer of Dr. Ampil is correct. Control as a determinative factor in testing the employeremployee relationship between doctor and hospital under which the hospital could be held vicariously liable to a patient in medical negligence cases is a requisite fact to be established by preponderance of evidence. Here, there was insufficient evidence that PSI exercised the power of control or wielded such power over the means and the details of the specific process by which Dr. Ampil applied his skills in the treatment of Natividad. Consequently, PSI cannot be held vicariously liable for the negligence of Dr. Ampil under the principle of respondeat superior. PSI could not simply wave off the problem and nonchalantly delegate to Dr. Ampil the duty to review what transpired during the operation. The purpose of such review would have been to pinpoint when, how and by whom two surgical gauzes were mislaid so that necessary remedial measures could be taken to avert any jeopardy to Natividads recovery. Certainly, PSI could not have expected that purpose to be achieved by merely hoping that the person likely to have mislaid the gauzes might be able to retrace his own steps. By its own standard of corporate conduct, PSI's duty to initiate the review was non-delegable. While Dr. Ampil may have had the primary responsibility of notifying Natividad about the missing gauzes, PSI imposed upon itself the separate and independent responsibility of initiating the inquiry into the missing gauzes. The purpose of the first would have been to apprise Natividad of what transpired during her surgery, while the purpose of the second would have been to pinpoint any lapse in procedure that led to the gauze count discrepancy, so as to prevent a recurrence thereof and to determine corrective measures that would ensure the safety of Natividad. That Dr. Ampil negligently failed to notify Natividad did not release PSI from its self-imposed separate responsibility. Corollary to its non-delegable undertaking to review potential incidents of negligence committed within its premises, PSI had the duty to take notice of medical records prepared by its own staff and submitted to its custody, especially when these bear earmarks of a surgery gone awry. Thus, the record taken during the operation of Natividad which reported a gauze count discrepancy should have given PSI sufficient reason to initiate a review. It should not have waited for Natividad to complain.

As it happened, PSI took no heed of the record of operation and consequently did not initiate a review of what transpired during Natividads operation. Rather, it shirked its responsibility and passed it on to others to Dr. Ampil whom it expected to inform Natividad, and to Natividad herself to complain before it took any meaningful step. By its inaction, therefore, PSI failed its own standard of hospital care. It committed corporate negligence. It should be borne in mind that the corporate negligence ascribed to PSI is different from the medical negligence attributed to Dr. Ampil. The duties of the hospital are distinct from those of the doctorconsultant practicing within its premises in relation to the patient; hence, the failure of PSI to fulfill its duties as a hospital corporation gave rise to a direct liability to the Aganas distinct from that of Dr. Ampil. All this notwithstanding, we make it clear that PSIs hospital liability based on ostensible agency and corporate negligence applies only to this case, pro hac vice. It is not intended to set a precedent and should not serve as a basis to hold hospitals liable for every form of negligence of their doctors-consultants under any and all circumstances. The ruling is unique to this case, for the liability of PSI arose from an implied agency with Dr. Ampil and an admitted corporate duty to Natividad 17. Li v Soliman Villarama, Jr., J. June 7, 2001 RATIO DECIDENDI: In a malpractice action based upon the doctrine of informed consent, four essential elements must be proven: The physician had a duty to disclose material risks S/he failed to disclose or inadequately disclosed those risks As a direct and proximate result of the failure to disclose, the patient consented to treatment s/he otherwise would not have consented to Plaintiff was injured by the proposed treatment QUICK FACTS: Spouses Solimans daughter underwent knee amputation, which necessitated adjuvant chemotherapy to minimize the chances of recurrence and prevent the disease from spreading to other parts of the body. 11 days after the administration of the first cycle of the chemotherapy regimen, spouses Solimans daughter died. FACTS: Name of petitioner- Dr. Rubi Li Name of respondent- Spouses Reynaldo and Lina Soliman Spouses Solimans daughter, Angelica Soliman, was found to be suffering from osteosarcoma, osteoblastic type, a high-grade (highly malignant) cancer of the bone which usually affects teenage children. Following this diagnosis, Angelicas right leg was amputated by Dr. Jaime Tamayo in order to remove the tumor. As adjuvant treatment, chemotherapy was suggested. Angelica was referred to Dr. Li, a medical oncologist. She was discharged four days after the surgery but was instructed to return after two or three weeks for the chemotherapy. On August 18, 1993, she was readmitted to St. Lukes Medical Center (SLMC). She died 11 days later. SLMC refused to release a death certificate without payment of the hospital bill. Hence, the spouses brought their daughters cadaver to the PNP Crime Laboratory for post-mortem examination. The Medico-Legal Report indicated the cause of death as Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation. On the other hand, the Certificate of Death issued by SLMC indicated that the immediate cause of death was osteosarcoma. The spouses filed a damage suit against Dr. Li, Dr. Marbella and Dr. Ledesma (Dr. Lis assistants in handling Angelicas case), Dr. Arriete, and SLMC. They were charged with negligence and disregard of Angelicas safety, health, and welfare by their careless administration of the chemotherapy drugs, their failure to observe the essential precautions in detecting early the symptoms of fatal blood platelet decrease and

stopping early on the chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely demise. Dr. Li assured the spouses that Angelica would recover in view of 95% chance of healing with chemotherapy and enumerated the side effects as: (1) slight vomiting; (2) hair loss; and (3) weakness. Spouses claim that they would not have given their consent to chemotherapy had Dr. Li not falsely assured them of its side effects. Dr. Li denied having been negligent in administering the chemotherapy drugs to Angelica and asserted that she had fully explained to the spouses how the chemotherapy will affect not only the cancer cells but also the patients normal body parts, including the white and red blood cells and platelets. 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. This 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. Witnesses presented by spouses: Dr. Vergara (medico-legal): the DIC can be attributed to the chemical agents in the drugs given to the victim, which caused platelet reduction resulting to bleeding sufficient to cause the victims death. The time lapse for the production of DIC (from the time of diagnosis of sarcoma) was too short, considering the survival rate of about 3 years. Dr. Vergara admitted that she is not a pathologist but her statements were based on the opinion of an oncologist whom she had interviewed. Dr. Balmaceda: it is the physicians duty to inform and explain to the patient or his relatives every known side effect of the procedure or therapeutic agents to be administered, before securing the consent of the patient or his relatives to such procedure or therapy. He stressed that the patient or relatives must be informed of all known side effects based on studies and observations, even if such will aggravate the patients condition. Dr. Tamayo (who performed the amputation) testified for Dr. Li : Dr. Li was one of the most proficient in the treatment of cancer and the patient was afflicted with a very aggressive type of cancer necessitating chemotherapy as adjuvant treatment RTC- Dr. Li is 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. Citing Picart v Smith, declared that Li has taken the necessary precaution against the adverse effect of chemotherapy on Angelica. A wrong decision is not by itself negligence. CA- awarded damages; while there was no negligence on her part, Dr. Li as her attending physician failed to fully explain to the spouses all the known side effects of chemotherapy (doctrine of informed consent) ISSUE: WoN Dr. Li can be liable for failure to fully disclose serious side effects of chemotherapy, despite the absence of finding that Dr. Li was negligent in administering said treatment. DECISION: No. 1) There was adequate disclosure of material risks and 2) the spouses failed to present expert testimony. RATIO: The doctrine of informed consent within the context of physicianpatient relationships goes far back into English common law. As early as 1767, doctors were charged with battery (unauthorized physical contact with a patient) if they had not gained the consent of their patients prior to performing a surgery or procedure. Schoendorff v Society of New York Hospital: 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 consent, commits and assault, for which he is liable in damages. Canterbury v Spence: (as to scope of disclosure) The disclosure rule only requires of the physician a reasonable explanation, which means generally informing the patient in nontechnical terms as to what is at stake, the therapy alternatives available to him, the goals expectably

to be achieved, and the risks that may ensue from particular treatment or no treatment. The patients right of self-decision can only be effectively exercised if the patient possesses adequate information to enable him in making an intelligent choice. The test therefore for determining whether a potential peril must be divulged is its materiality to the patients decision. Four essential elements to prove in a malpractice action based upon the doctrine of informed consent: (1) The physician had a duty to disclose material risks; (2) S/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 s/he otherwise would not have consented to and (4) Plaintiff was injured by the proposed treatment Plaintiff is required to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it. On disclosure of material risks There was adequate disclosure of material risks inherent in the chemotherapy procedure performed with the consent of Angelicas parents. When Dr. Li informed the spouses beforehand of the side effects which include lowered counts of WBC and RBC, 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. By the very nature of the disease, the physician cannot precisely determine each patients reaction to the chemical agents. That death can possibly result from complications of the treatment or the underlying cancer itself is a risk that cannot be ruled out, as with most other major medical procedures, but conclusion can be reasonably drawn from the general side effects of chemotherapy already disclosed. On failure to present expert testimony 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. Such testimony must show the customary standard of care of physicians in the same practice as that of the defendant doctor. The testimony of Dr. Balmaceda, who is not an oncologist, does not qualify as expert testimony to establish the standard of care in obtaining consent for chemotherapy treatment. Carpio, dissenting. There are two standards by which courts determine what constitutes adequate disclosure of associated risks and side effects of a proposed treatment: Physician standard- a doctor is obligated to disclose that information which a reasonable doctor in the same field of expertise would have disclosed to his/her patient Patient standard- a doctor is obligated to disclose that information which a reasonable patient would deem material in deciding whether to proceed with a proposed treatment Historically, courts used the physician standard. However, modern prevailing trend among courts is to use the patient standard of materiality. Any definition of scope in terms of a professional standard is at odds with the patients prerogative to decide on projected therapy himself. In order to determine what risks and side effects of a proposed treatment are material and should be disclosed to the patient, testimony by an expert witness is unnecessary (Canterbury). Dr. Li admitted that she assured the spouses that there was an 80%b chance that Angelicas cancer would be controlled and that she disclosed to them only some of the associated risks and side effects of chemotherapy. Thus, Dr. Li impliedly admits that she failed to disclose many of the other associated risks and side effects of chemotherapy, including the most materialinfection, sepsis, and death. Clearly, infection, sepsis, and death are material risks and side effects of chemotherapy. To any reasonable person, the risk of death is one of the most important, if not the most important, consideration in deciding whether to undergo a proposed treatment. Had the spouses fully known the severity of the risks and side effects

of chemotherapy, they may have opted not to go through with the treatment of their daughter. In fact, after some of the side effects of chemotherapy manifested, they asked Dr. Li to stop the treatment. Brion, concurring and dissenting. Concurs in the result and its conclusion that the respondents failed to prove by preponderance of evidence the essential elements of a cause of action based on the doctrine of informed consent. Disagrees with the ponencias conclusion that there was adequate disclosure of material risks of the chemotherapy administered in view of a complete absence of competent expert testimony establishing a medical disclosure standard in the case. Rather, the conclusion is based on spouses failure to prove by competent expert testimony the first and fourth elements of a prima facie case for lack of informed consent, specifically: The scope of the duty to disclose and the violation of this duty (i.e., failure to define what should be disclosed and to disclose the required material risks or side effects of chemotherapy that allow the patient and/or her parents to properly decide whether to undergo chemotherapy That the chemotherapy administered by Dr. Li proximately caused the death of Angelica Soliman. 18. Dr. Jarcia and Bastan vs People of the Philippines GR 187926, February 15, 2012 Facts: Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the victims ankle was ordered; that the Xray 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. CA affirmed. Issues: [1] whether or not the doctrine of res ipsa loquitur is applicable in this case; [2] whether or not the petitioners are liable for criminal negligence. Held: 1. NO, 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. 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. While it may be true that the circumstances pointed out by the courts below seem

doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not through the scholarly assumptions of a layman like the patients mother, but by the unquestionable knowledge of expert witness/es 2. NO, 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. 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. 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). 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. 19. Manila Doctors Hospital vs. Chua and Ty (Note: pasensya na kung mahaba, importante lahat e, mahirap bawasan) Facts: Respondent Chua, mother of Ty, was admitted to petitioner hospital for hypertension and diabetes. While Chua was confined, another daughter Judith Chua was admitted for treatment of injuries sustained after a vehicular accident. Ty shouldered the hospital bills for the two. After Judith was discharged, respondent Chua remained confined. Ty was able to pay P435,800.00. The hospital bills eventually totaled P1,075,592.95. When Ty was unable to pay the bills, the hospital allegedly pressured her, by cutting off the telephone line in her room and removing the air-conditioning unit, television set, and refrigerator, refusing to render medical attendance and to change the hospital gown and bed sheets, and barring the private nurses or midwives from assisting the patient, to settle the same through the signing of a promissory note. Ty issued postdated checks to pay the note. The checks bounced. The petitioner alleged that that as early as one week after respondent Chua had been admitted to its hospital, Dr. Rody Sy, her attending physician, had already given instructions for her to be discharged, but respondents insisted that Chua remain in confinement. It also alleged that Ty voluntarily signed the agreement that she will pay the bills and that no undue pressure was exerted by them; and that the cutting-off of the telephone line and removal of the air-conditioning unit, television set, and refrigerator cannot constitute unwarranted actuations, for the same were resorted to as cost-cutting measures and to minimize respondents' charges that were already piling up, especially after respondent Ty refused to settle the balance notwithstanding frequent demands. Finally it alleged that this case was instituted by Ty to provide leverage against the hospital for filing criminal charges against the latter for violation of BP 22. Both the trial court and the CA rendered decisions in favor of the respondents finding that the removal of the facilities led to the worsening of Chuas condition. Issue: Whether or not the hospital is liable for damages. Ruling: No. The operation of private pay hospitals and medical clinics is impressed with public interest and imbued with a heavy social responsibility. But the hospital is also a business, and, as a business, it has a right to institute all measures of efficiency commensurate to

the ends for which it is designed, especially to ensure its economic viability and survival. And in the legitimate pursuit of economic considerations, the extent to which the public may be served and cured is expanded, the pulse and life of the medical sector quickens, and the regeneration of the people as a whole becomes more visibly attainable. In the institution of cost-cutting measures, the hospital has a right to reduce the facilities and services that are deemed to be nonessential, such that their reduction or removal would not be detrimental to the medical condition of the patient. The lower courts decisions are results of misappreciation of the uncorroborated and self-serving evidence presented by the respondents. The evidence in the record firmly establishes that the staff of the petitioner took proactive steps to inform the relatives of respondent Chua of the removal of facilities prior thereto, and to carry out the necessary precautionary measures to ensure that her health and well-being would not be adversely affected. Also, the medical condition of respondent Chua, as consistently and indisputably confirmed by her attending physician, Dr. Rody Sy, a cardiologist, who was called as witness for both parties, whom even respondent Chua repeatedly praised to be "my doctor" and "a very good doctor" at that, and whose statements at times had been corroborated by other competent witnesses, had been "relatively well," "ambulatory," "walking around in the room," and that she was "able to leave the hospital on her own without any assistance;" that although she complained of symptoms such as dizziness, weakness, and abdominal discomfort, Dr. Sy requested several medical examinations, such as the laboratory tests, renal tests, MRI, ultrasound, and CT scan, all of which were administered after procuring the consent of respondent Chua's family as admitted by respondent Ty herself, and even called on other specialists, such as a neurologist, endocrinologist, and gastroenterologist, to look into her condition and conduct other tests as well according to their fields of specialty, all of which yielded no serious finding. Finally, her illnesses were "lifelong illnesses" at a stage where they cannot be totally removed or abolished, making it clear to her family that "one hundred percent recovery is not possible" despite being given daily medication in the hospital. Her condition, nonetheless, is not serious, as the blood pressure is more or less controlled and within acceptable limits, "not that critical to precipitate any acute attack," nor likely to fall into any emergency, nor yet does she require continuous or prolonged hospitalization since she was stable enough to be treated at home and on an "out-patient" basis, so much so that Dr. Sy encouraged her to exercise and avoid resting all the time, and recommended that "anytime she may be discharged" even in just "two weeks after confinement," the propriety of his order of discharge concurred upon by the other specialists as well, had it not been for respondents' insistence to stay in the hospital in view of their hope for absolute recovery despite the admission of respondent Chua herself that she cannot anymore be totally cured. Authorities explicitly declare that a patient cannot be detained in a hospital for non-payment of the hospital bill. If the patient cannot pay the hospital or physician's bill, the law provides a remedy for them to pursue, that is, by filing the necessary suit in court for the recovery of such fee or bill. If the patient is prevented from leaving the hospital for his inability to pay the bill, any person who can act on his behalf can apply in court for the issuance of the writ of habeas corpus. The form of restraint must be total; movement must be restrained in all directions. If restraint is partial, e.g., in a particular direction with freedom to proceed in another, the restraint on the person's liberty is not total. However, the hospital may legally detain a patient against his will when he is a detained or convicted prisoner, or when the patient is suffering from a very contagious disease where his release will be prejudicial to public health, or when the patient is mentally ill such that his release will endanger public safety, or in other exigent cases as may be provided by law. Moreover, under the common law doctrines on tort, it does not constitute a trespass to the person to momentarily prevent him from leaving the premises or any part thereof because he refuses to comply with some reasonable condition subject to which he entered them. In all cases, the condition of this kind of restraint must be reasonable in the light of the circumstances. At any rate, as stated above, the patient is free to leave the premises, even in the ostensible violation of these conditions, after being momentarily interrupted by the hospital staff for purposes of informing him of those reasonable conditions or simply for purposes of

making a demand to settle the bill. If the patient chooses to abscond or leave without the consent of the hospital in violation of any of the conditions deemed to be reasonable under the circumstances, the hospital may nonetheless register its protest and may choose to pursue the legal remedies available under law, provided that the hospital may not physically detain the patient, unless the case falls under the exceptions abovestated. Authorities are of the view that, ordinarily, a hospital, especially if it is a private pay hospital, is entitled to be compensated for its services, by either an express or an implied contract, and if no express contract exists, there is generally an implied agreement that the patient will pay the reasonable value of the services rendered; when a hospital treats a patient's injuries, it has an enforceable claim for full payment for its services, regardless of the patient's financial status. The requirement to have the relative of respondent Chua to execute a promissory note as part of the arrangement to settle the unpaid obligations is a formality that converts any implied contract into written form and, moreover, amounts to a reasonable condition, the non-fulfillment of which, in itself, however, as discussed, cannot allow the hospital to detain the patient. Contrary to the findings of the courts a quo, that such an agreement embodied in a promissory note, as well as the Contract for Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990, do not become contracts of adhesion simply because the person signing it was under stress that was not the result of the actions of the hospital, especially taking into account that there is testimony to the effect that respondent Ty signed the Promissory Note dated June 5, 1992 in the presence of counsel and acting under his advise. 20. RCAP vs. Executive Secretary Ermita Facts: There was a report that handwritten copies of two sets of 2006 Nursing Board examination were circulated during the examination period among examinees reviewing at the R.A. Gapuz Review Center and Inress Review Center. The examinees were provided with a list of 500 questions and answers in two of the examinations five subjects, particularly Tests III (Psychiatric Nursing) and V (Medical-Surgical Nursing). The PRC later admitted the leakage and traced it to two Board of Nursing members. Exam results came out but Court of Appeals restrained the PRC from proceeding with the oath-taking of the successful examinees. President GMA ordered for a re-examination and issued EO 566 which authorized the CHED to supervise the establishment and operation of all review centers and similar entities in the Philippines. CHED Chairman Puno approved CHED Memorandum Order No. 49 series of 2006 (Implementing Rules and Regulations). Review Center Association of the Philippines (petitioner), an organization of independent review centers, asked the CHED to "amend, if not withdraw" the IRR arguing, among other things, that giving permits to operate a review center to Higher Education Institutions (HEIs) or consortia of HEIs and professional organizations will effectively abolish independent review centers. CHED Chairman Puno however believed that suspending the implementation of the IRR would be inconsistent with the mandate of EO 566. A dialogue between the petitioner and CHED took place. Revised IRR was approved. Petitioner filed before the CHED a Petition to Clarify/Amend RIRR praying to exclude independent review center from the coverage of the CHED; to clarify the meaning of the requirement for existing review centers to tie-up with HEIs; to revise the rules to make it conform with RA 7722 limiting the CHEDs coverage to public and private institutions of higher. In 2007, then CHED Chairman Neri responded to the petitioner that: to exclude the operation of independent review centers from the coverage of CHED would clearly contradict the intention of the said Executive Order No. 566; As to the request to clarify what is meant by tie-up/be integrated with an HEI, tie-up/be integrated simply means, to be in partner with an HEI. Petitioner filed a petition for Prohibition and Mandamus before this Court praying for the annulment of the RIRR, the declaration of EO 566 as invalid and unconstitutional exercise of legislative power, and the prohibition against CHED from implementing the RIRR. Motion to intervene filed by other organizations/institutions were granted by the Court. On 21 May 2008, CHED issued CHED Memorandum Order No. 21, Series of 2008 (CMO 21, s. 2008) extending the deadline for

six months from 27 May 2008 for all existing independent review centers to tie-up or be integrated with HEIs in accordance with the RIRR. On 25 November 2008 Resolution, SC resolved to require the parties to observe the status quo prevailing before the issuance of EO 566, the RIRR, and CMO 21, s. 2008. Issues: 1. Whether EO 566 is an unconstitutional exercise by the Executive of legislative power as it expands the CHEDs jurisdiction [Yes, it expands CHEDs jurisdiction, hence unconsititutional]; and 2. Whether the RIRR is an invalid exercise of the Executives rule-making power. [Yes, it is invalid.] Ruling: 1. The scopes of EO 566 and the RIRR clearly expand the CHEDs coverage under RA 7722. The CHEDs coverage under RA 7722 is limited to public and private institutions of higher education and degreegranting programs in all public and private post-secondary educational institutions. EO 566 directed the CHED to formulate a framework for the regulation of review centers and similar entities. The definition of a review center under EO 566 shows that it refers to one which offers "a program or course of study that is intended to refresh and enhance the knowledge or competencies and skills of reviewees obtained in the formal school setting in preparation for the licensure examinations" given by the PRC. It does not offer a degree granting program that would put it under the jurisdiction of the CHED. A review course is only intended to "refresh and enhance the knowledge or competencies and skills of reviewees." Thus, programs given by review centers could not be considered "programs x x x of higher learning" that would put them under the jurisdiction of the CHED. "Higher education," is defined as "education beyond the secondary level or "education provided by a college or university." Further, the "similar entities" in EO 566 cover centers providing "review or tutorial services" in areas not covered by licensure examinations given by the PRC, which include, although not limited to, college entrance examinations, Civil Services examinations, and tutorial services. These review and tutorial services hardly qualify as programs of higher learning. 2. ) The exercise of the Presidents residual powers under Section 20, Title I of Book III of EO (invoked by the OSG to justify GMAs action) requires legislation; as the provision clearly states that the exercise of the Presidents other powers and functions has to be "provided for under the law." There is no law granting the President the power to amend the functions of the CHED. The President has no inherent or delegated legislative power to amend the functions of the CHED under RA 7722. The line that delineates Legislative and Executive power is not indistinct. Legislative power is "the authority, under the Constitution, to make laws, and to alter and repeal them." The Constitution, as the will of the people in their original, sovereign and unlimited capacity, has vested this power in the Congress of the Philippines. Any power, deemed to be legislative by usage and tradition, is necessarily possessed by Congress, unless the Constitution has lodged it elsewhere. The President has control over the executive department, bureaus and offices. Meaning, he has the authority to assume directly the functions of the executive department, bureau and office, or interfere with the discretion of its officials. Corollary to the power of control, he is granted administrative power. Administrative power is concerned with the work of applying policies and enforcing orders as determined by proper governmental organs. It enables the President to fix a uniform standard of administrative efficiency and check the official conduct of his agents. To this end, he can issue administrative orders, rules and regulations. An administrative order is an ordinance issued by the President which relates to specific aspects in the administrative operation of government. It must be in harmony with the law and should be for the sole purpose of implementing the law and carrying out the legislative policy. Since EO 566 is an invalid exercise of legislative power, the RIRR is also an invalid exercise of the CHEDs quasi-legislative power. Administrative agencies exercise their quasi-legislative or rule-making power through the promulgation of rules and regulations. The CHED may only exercise its rule-making power within the confines of its jurisdiction under RA 7722. But The RIRR covers review centers and similar entities. On the issue of whether RA 8981 as the appropriate law, the PRC has the power to adopt measures to preserve the integrity and inviolability

of licensure examinations. However, this power should properly be interpreted to refer to the conduct of the examinations. The power to preserve the integrity and inviolability of licensure examinations should be read together with these functions. These powers of the PRC have nothing to do at all with the regulation of review centers. 21. Phil. Medical Assoc. vs. Board of Medical Examiners and Torres Facts: The Board of Medical Examiners granted Jose Ma. Torres, a resident of Basilan City, a Spanish subject and a member of the Missionary Sons of the Immaculate Heart of Mary, otherwise known as the Claretian Missionaries, a license to practice medicine in the Philippines without taking any examination. The Philippine Medical Association questioned the resolution that granted such authority. Respondent was earlier granted special authority to practice medicine in Lamitan, Basilan City pursuant to Section 771(e) of the Revised Administrative Code. This authority has been granted and revoked several times in the past depending on the existence of the circumstances referred to in the law. The Board defends its grant by invoking The Treaty on the Validity of Academic Degrees and The Exercise of the Professions between the Republic of the Philippines and the Spanish State specifically Article I thereof which states: The nationals of both countries who shall have obtained degrees or diplomas to practice the liberal professions in either of the Contracting States, issued by competent national authorities, shall be deemed competent to exercise said professions in the territory of the Other, subject to the laws and regulations of the latter. When the degree or diploma of Bachelor, issued by competent national authorities allows its holder without requiring further evidence of proficiency to pursue normally higher courses of study, he shall also be deemed qualified to continue his studies in the territory of either Party in conformity with the applicable laws and regulations of the State which recognizes the validity of the title or diploma in question, and with the rules and regulations of the particular educational institution in which he intends to pursue his studies. Issue: Whether or not the grant of authority to practice medicine in the country is valid. Ruling: No. The theory of respondent cannot be accepted without placing graduates from our own educational institutions at a disadvantage vis-a-vis Spanish graduates from Spanish schools, colleges or universities. Indeed, the latter could under respondent's pretense engage in the practice of medicine in the Philippines without taking the examination prescribed in Republic Act No. 2882, whereas the former would have to take and pass said examination. Worse still, since as we ruled in the Garcia case the benefits of the aforementioned Treaty cannot be availed of in the Philippines except by Spanish subjects, the result would be should respondent's contention be sustained that graduates from Spanish schools of medicine would be entitled to practice medicine in the Philippines without examination, if they were Spanish subjects, but not if they are Filipinos. Said Treaty merely extended to diplomas issued or degrees conferred by educational institutions of Spain the same recognition and treatment that we accord to similar diplomas or degrees from local institutions of learning; that holders of said Spanish diplomas or degrees must take the examination prescribed by our laws for holders of similar diplomas or degrees from educational institutions in the Philippines. 22. Tablarin et al. vs. Judge Gutierrez, et al. Facts: The petitioners herein are questioning the constitutionality of administering the National Medical Admission Test (NMAT) by the Center for Educational Measurement and as required by the Board of Medical Education. They claim that the continued implementation of the law requiring the test violates the following provisions of the 1987 Constitution: (a) Article II, Section 11: "The state values the dignity of every human person and guarantees full respect of human rights." (b) Article II, 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;" that the implementation is a violation of the constitutional principle which forbids the undue delegation of legislative power; that it is an "unfair, unreasonable and inequitable requirement," which results in a denial of due process; and that is in conflict with the equal protection clause of the Constitution. Issue: Whether or not the implementation of the NMAT is unconstitutional. Ruling: No. Petitioners 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 of Article II. They also failed to demonstrate that the statute and regulation they assail in fact clash with the Sections referred to under Article XIV. 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. Onto the next point, 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. ` 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 nor 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. 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. 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. 23. The Board of Medical Education vs. Alfonso Facts: Philippine Muslim-Christian College of Medicine Foundation, Inc. failed several inspections regarding the adequacy of their school to operate a medical school. A total of five teams of inspectors ruled the school to be inadequate in all aspects of the inspection namely: college, curriculum, facilities, teaching hospital, and studentry. Accordingly, the Board of Medical Education recommended to the

DECS the closure of the College. The Department followed the recommendation. 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 was issued. The Board of Medical Education then assailed the writ as being issued with grave abuse of discretion. Issue: Whether or not the issuance was tainted with grave abuse of discretion. Ruling: Yes. 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 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. 24. DECS vs. San Diego Facts: San Diego took the NMAT three times and flunked all three takes. He contends that he is constitutionally entitled to take the test for the fourth time. He invokes his constitutional rights to academic freedom and quality education. By agreement of the parties, San Diego was allowed to take the NMAT again, subject to the outcome of his petition. In an amended petition filed with leave of court, he squarely challenged the constitutionality of MECS Order No. 12, Series of 1972, containing the rule that an aspiring med student who flunks the test 3 times in a row is barred from taking a fourth one. The additional grounds raised were due process and equal protection. After hearing, the respondent judge declared the challenged order invalid and granting the petition. The Decision held that the petitioner had been deprived of his right to pursue a medical education through an arbitrary exercise of the police power. Issue: Whether or not the challenged order is invalid. Ruling: No. 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. 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. 25. PRC vs. De Guzman et al. Facts: 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 (OBGyne), 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. 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. The respondents were constrained from taking oath as licensed medical doctors. Issue: Was the act pursuant to R.A. 2382 a valid exercise of police power? Ruling: Yes, it is true that this Court has upheld the constitutional right of every citizen to select a profession or course of study subject to a fair, reasonable, and equitable admission and academic requirements. 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. 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. 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 physicians 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. Section 8 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. 26. Board of Medicine vs. Yasuyuki Ota Facts: Yasuyuki Ota 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 with a degree of Doctor of Medicine. 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 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. Ota 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 thus, he was allowed to take the Medical Board Examinations, which he subsequently passed. 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. Ota filed a Petition for Certiorari and Mandamus against the Board and PRC alleging that the they, 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. 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 RTC ruled in Otas favor and added that the Board had the ministerial duty to issue the certificate Ota seeks. The CA affirmed the ruling. Issue: Whether or not the respondent had sufficiently proven the existence of reciprocity between the Philippines and Japan. Ruling: Yes. R.A. No. 2382 and P.D. No. 223 allows a foreigner 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 (Sec. 9, RA 2382) to be a candidate to take the board examinations. 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.

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. 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. 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. The doctrine enunciated in PRC vs. De Guzman cannot apply in this case.

3.