LEGAL MEDICINE

The Filipino Physician

2.

Discuss the journey a person must thread to become a

physician.

3.

A person must have a college degree, with the requisite

subject units.
He must have passed the National Medical Admissions
Test (NMAT) to qualify to be admitted into a medical
school. Under NMAT rules, [a] student shall be
allowed only three (3) chances to take the NMAT. After
three (3) successive failures, a student shall not be
allowed to take the NMAT for the fourth time. In DECS
vs San Diego, the Supreme Court upheld the validity of
the three-flunk rule, saying that: the medical
profession directly affects the very lives of the people,
unlike other careers which, for this reason, do not
require more vigilant regulation.
The Doctor of Medicine (M.D.) degree is a five year
graduate program intended to teach students the
essentials of being a Medical Doctor. The program
consists of three years of academic instruction, one
year of clinical clerkship and one year of post-graduate
internship.
After passing the board exam, one can now be
considered a licensed doctor. But from there, he is
considered a general practitioner. He may also take
specializations and sub specializations.

RA No. 2382 or the Medical Act of 1959; PMA Code of Ethics

What are the objectives of the Medical Act?
-

It provides for and shall govern the following:

1. Standardization and regulation of Medical
Education;
2. Examination for registration of physicians;
3. Supervision, control and regulation of the
practice of medicine in the Philippines

4.
5.
6.
7.
8.

What are the requirements for admission into medical

school?
1.
2.

2.

1.
2.
3.

Board of Medical Education (Duties are now assumed

by the Commission on Higher Education)
Board of Medical Examiners (Duties are now assumed
by the Board of Medicine under PRC)

2.
3.
4.
5.
6.
7.

Secretary of Education or duly authorized

representative;
Secretary of Health or duly authorized representative;
Director of Bureau of Private schools or his duly
authorized representative;
Chairman of the Board of Medicine or his duly
authorized representative;
Dean of UP Med;
Council of Dean of Med Schools;
Representative chosen by PACU

What are the functions of the Board of Medical

Education?
1.

Prescribes the minimum requisites for admission to a

medical school;

At least 21 years of age;

Must have passed the medical board exams; and
Must be a holder of a valid, certificate of registration
issued by the Board of Medicine

Q: Once a person has passed the medical board exams,

is the issuance of the certificate of registration
ministerial on the part of the Board of Medicine?

Who comprise the Board of Medical Education?

1.

Must not have been convicted of a crime involving

moral turpitude;
Must be able to present the following:
a. Bachelors degree;
b. Certification of eligibility for entrance to a med
school from the Board of Medical Education;
c. Certification of GMC from at least two
professors; and
d. Birth certificate

What are the prerequisites for the practice of medicine?

What are the two agencies created by virtue of the

Medical Act?
1.

Prescribes the minimum physical facilities required of a

medical school;
Prescribes the minimum number and minimum
qualification of teaching personnel;
Prescribes the minimum required curriculum;
To authorize the implementation of experimental
medical curriculum in a medical school that has
exceptional faculty and instrumental facilities;
To accept applications for certification for admission to
a medical school and to keep a register of medical
students;
To select training hospitals; and
To promulgate rules necessary for the enforcement of
the above mentioned functions;

No. Section 8 of the Medical Act provides that No

person shall engage in the practice of medicine in the
Philippines unless he is at least twenty-one years of
age, has satisfactorily passed the corresponding Board
Examination The operative word is satisfactorily.
Hence, if the Board is not satisfied with the
circumstances surrounding the examinees passing, it
has the discretion of postponing or refusing to issue a
certificate of registration. The duty to issue such
certificate is not ministerial and hence not compellable
by a petition for mandamus. (PRC vs De Guzman)

What are the qualifications candidates for board exams

must possess?
1.
2.
3.
4.
5.
6.

Filipino citizen/foreigner (who must prove that his

country allows reciprocal rights to Filipinos in practicing
medicine);
Good moral character;
Of sound mind;
Not convicted of a crime involving moral turpitude;
Must be a holder of the degree of doctor of medicine;
and
He must have completed a calendar year of technical
training known as internship

What constitutes the practice of medicine?

A person shall be considered as engaged in the practice

of medicine if he:
1. For compensation, fee, salary or reward
(CFSR) in any form paid to him directly or
through another, or even without the same,
physically examine any person, and diagnose,
treat, operate or prescribe (PeDTOP) any
remedy for human disease, injury, deformity,
physical, mental or psychological (DIDPMP)
condition or ailment, real or imaginary,
regardless of the value of the remedy
administered, prescribed or recommended;
2. By means of signs, cards, advertisements,
written or printed matter, or through the
radio, TV or any other means of
telecommunication, either offer or undertake
by any means or method to diagnose, treat,
operate or prescribe any remedy for any
human disease, injury, deformity, physical,
mental or psychological condition; and
3. Falsely use the title of MD after his name

What are the instances wherein a certificate of

registrations is not required?
1.

2.

3.

4.

What are the exceptions to Sec. 10 regarding acts

constituting practice of medicine?
1.

2.

3.

4.

5.

6.
7.

8.

Any medical student duly enrolled in an approved

medical college or school, or graduate under training,
serving without any professional fee in any government
or private hospital, provided that he render such
service under the direct supervision and control of a
registered physician;
Any legally registered dentist engaged exclusively in
the practice of dentistry; (c) any duly registered
masseur or physiotherapist, provided that he applies
massage or other physical means upon written order
or prescription of a duly registered physician, or
provided that such application of massage or physical
means shall be limited to physical or muscular
development;
Any duly registered masseur or physiotherapist,
provided that he applies massage or other physical
means upon written order or prescription of a duly
registered physician, or provided that such application
of massage or physical means shall be limited to
physical or muscular development; who fit artificial
limbs under the supervision of a registered physician.
Any duly registered optometrist who mechanically fits
or sells lenses, artificial eyes, limbs or other similar
appliances or who is engaged in the mechanical
examination of eyes for the purpose of constructing or
adjusting eyeglasses, spectacles and lenses;
Any person who renders any service gratuitously in
cases of emergency, or in places where the services of
a duly registered physician, nurse or midwife are not
available;
Any person who administers or recommends any
household remedy as per classification of existing
Pharmacy Laws;
Any clinical psychologist, or mental hygienist, in the
performance of his duties in regard to patients with
psychiatric problems, provided such performance is
done with the prescription and direct supervision of a
duly registered physician, and
Prosthetists who fit artificial limbs under the
supervision of a registered physician.

Physicians and surgeons from other countries called in

consultation only and exclusively in specific and
definite case, or those attached to international bodies
or organizations assigned to perform certain definite
work in the Philippines, provided they shall limit their
practice to the specific work assigned to them and
provided further they shall secure a previous
authorization from the Board of Medical Examiners;
Commissioned medical officers of the United States
Armed Forces stationed in the Philippines while
rendering service as such only for the members of the
said armed forces and within the limit of their own
respective territorial jurisdiction;
Foreign physicians employed as exchange professors
in special branches of medicine or surgery whose
service may, upon previous authorization of the Board
of Medical Examiners, be necessary;
Medical students who have completed the first four
years of medical course, graduates of medicine and
registered nurses who may be given limited and special
authorization by the Secretary of Health to render
services during epidemics or national emergencies
whenever the services of duly registered physicians are
not available. Such authorization shall automatically
cease when the epidemic or national emergency is
declared terminated by the Secretary of Health.

What are the qualifications to be a member of the Board

of Medicine and how are they appointed?
-

He must
1.
2.
3.

be:
A natural born Filipino citizen;
A physician practicing for at least 10 years;
One who is of good moral character and of
good standing in the medical profession;
4. Not a member of any medical school nor has
a pecuniary interest, directly or indirectly in
any medical school
The Board of Medicine shall be composed of six
members to be appointed by the President of the
Philippines from a list of not more than twelve names
approved and submitted by the Executive Council of
the Philippine Medical Association, after due
consultation with other medical association during the
month of September each year. The chairman of the
Board shall be elected from among themselves by the
members at a meeting called for the purpose. The
President of the Philippines shall fill any vacancy that
may occur during any examination from the list of
names submitted by the Philippine Medical Association
in accordance with the provisions of this Act.

What are the duties of the Board of Medicine?

-

They promulgate rules and regulations, subject to the

approval of the CSC, as may be necessary for the
proper conduct of exams, correction of exam papers,
and registration of physicians;
Administer oaths to physicians;
Study conditions affecting the practice of medicine in
the Philippines;
Exercise powers conferred by law with the view of
maintaining the ethical and professional standards of
the medical profession;

Subpoena testifcandum / duces tecum; and

Promulgate rules and regulations as may be necessary

What are the grounds for the reprimand, suspension or

revocation of a physicians certificate of registration?
1.

Conviction by a court of competent jurisdiction of any

criminal offense involving moral turpitude;
2. Immoral or dishonorable conduct;
3. Insanity;
4. Fraud in the acquisition of the certificate of
registration;
5. Gross negligence, ignorance or incompetence in the
practice of his or her profession resulting in an injury
to or death of the patient;
6. Addiction to alcoholic beverages or to any habit
forming drug rendering him or her incompetent to
practice his or her profession, or to any form of
gambling;
7. False or extravagant or unethical advertisements
wherein other things than his name, profession,
limitation of practice, clinic hours, office and home
address, are mentioned.
8. Performance of or aiding in any criminal abortion;
9. Knowingly issuing any false medical certificate;
10. Issuing any statement or spreading any news or rumor
which is derogatory to the character and reputation of
another physician without justifiable motive;
11. Aiding or acting as a dummy of an unqualified or
unregistered person to practice medicine;
12. Violation of any provision of the Code of Ethics as
approved by the Philippine Medical Association.
*Refusal of a physician to attend a patient in danger of
death is not a sufficient ground for revocation or
suspension of his registration certificate if there is a risk
to the physician's life.

acted in an exemplary manner in the community

wherein he resides and has not committed any illegal,
immoral or dishonorable act.
Liabilities of a Physician
What are the three fold liabilities of a physician?
-

Do the regular courts have the authority to suspend or

revoke the license of a physician?
-

Within five days after the filling of written charges

under oath, the respondent physician shall be
furnished a copy thereof, without requiring him or her
to answer the same, and the Board shall conduct the
investigation within five days after the receipt of such
copy by the respondent. The investigation shall be
completed as soon as practicable.
Administrative investigations must be conducted by at
least two members of the Board of Medicine, with one
legal officer sitting during the investigation.
The respondent physician shall be entitled to be
represented by counsel or be heard by himself or
herself, to have a speedy and public hearing, to
confront and to cross-examine witnesses against him
or her, and to all other rights guaranteed by the
Constitution and provided for in the Rules of Court.
The decision of the Board of Medical Examiners shall
automatically become final thirty days after the date of
its promulgation unless the respondent, during the
same period, has appealed to the Commissioner of Civil
Service and later to the Office of the President of the
Philippines. If the final decision is not satisfactory, the
respondent may ask for a review of the case, or may
file in court a petition for certiorari.
After two years, the Board may order the
reinstatement of any physicians whose certificate of
registration has been revoked, if the respondent has

No, it is the Board of Medicine that is vested with such

authority.
Administrative complaints against an erring physician
must be filed with the Board of Medicine.

Can the Board of Medicine imprison or impose a fine on

an erring physician?
-

No. Only the regular courts can do that.

What are the duties of physician under the PMA Code of

Ethics?
1.

2.

3.

What are the procedures to observe in case of

administrative investigations by the Board of Medicine?
-

(1) Administrative, (2) Civil, and (3) Criminal

4.

5.

A physician should be dedicated to provide competent

medical care with full professional skill in accordance
with the current standards of care, compassion,
independence and respect for human dignity.
A physician should be free to choose patients.
Rationale: You cannot force a doctor to
examine a patient whose illness is not within
his competence.
In an emergency, provided there is no risk to his or her
safety, a physician should administer at least first aid
treatment and then refer the patient to the primary
physician and/or to a more competent health provider
and appropriate facility if necessary.
Elements:
i. There must be an emergency; and
ii. There must be no risk to the
physicians safety.
In serious/difficult cases, or when the circumstances of
the patient or the family so demand or justify, the
attending physician should seek the assistance of the
appropriate specialist.
Wag dapat ma-pride. Pag hindi kaya, humingi
ng tulong.
A physician should exercise good faith and honesty in
expressing opinion/s as to the diagnosis, prognosis,
and treatment of a case under his/her care. A physician
shall respect the right of the patient to refuse medical
treatment. Timely notice of the worsening of the
disease should be given to the patient and/or family. A
physician shall not conceal nor exaggerate the patients
condition except when it is to the latters best interest.
A physician shall obtain from the patient a voluntary
informed consent. In case of unconsciousness or in a
state of mental deficiency the informed consent may
be given by a spouse or immediate relatives and in the
absence of both, by the party authorized by an
advanced directive of the patient. Informed consent in
the case of minor should be given by the parents or
guardian, members of the immediate family that are of
legal age.
Good faith and honest opinion;

Respect the right of the patient to refuse

medical treatment;
Give timely notice of the worsening of the
disease;
Must not conceal nor exaggerate the patients
condition, except when it is to the latters best
interest; and
Voluntary informed consent.
The physician should hold as sacred and highly
confidential whatever may be discovered or learned
pertinent to the patient even after death, except when
required in the promotion of justice, safety and public
health.
Professional fees should be commensurate to the
services rendered with due consideration to the
patients financial status, nature of the case, time
consumed and the professional standing and skill of the
physician in the community

6.

7.

How can a physician qualify to testify as an expert

witness?
-

Can an aggrieved patient institute administrative, civil

and
criminal
actions
against
a
physician
simultaneously?
-

Yes, there is no prohibition to that effect.

What is the remedy of a party from an unfavorable

decision of the Board of Medicine?
-

Board of Medicine PRC (via Rule 43) CA (via

Rule 45) SC

There must be a Doctor-Patient Relationship;

There must be a duty;
There is a breach of such duty;
Damage to the patient resulted from that breach;
and
5. The breach must be the proximate cause of the
damage to the patient;
Jurisprudence:
If the proximate cause of the patients
damage was his own failure to heed the
instructions of his doctor, there is no medical
negligence. (Lasam vs Ramolete, 2008)
What is the usual if not the only cause of action against
a doctor in a civil suit?
-

Art. 2176 of the Civil Code: Article 2176. Whoever by

act or omission causes damage to another, there being
fault or negligence, is obliged to pay for the damage
done. Such fault or negligence, if there is no preexisting contractual relation between the parties, is
called a quasi-delict and is governed by the provisions
of this Chapter.

Cite instances where there is no Doctor-Patient

relationship?
-

Company doctor set-up, pre-employment check ups,

insurance, where physician is forced by the court to
examine a patient.

How can a plaintiff or complainant prove the breach of

duty and the proximate causation?
-

He needs to procure a testimony of an expert witness.

The Supreme Court had been consisted in ruling that

the doctor must be a specialist in the case concerned.
But in Casumpang vs Cortejo (2015), the Court ruled
that to qualify a witness as a medical expert, it must
be shown that the witness:
1. Has the required professional knowledge,
learning and skill of the subject under inquiry
sufficient to qualify him to speak with
authority on the subject; and
2. Is familiar with the standard required of a
physician under similar circumstances;
Where a witness has disclosed sufficient
knowledge of the subject to entitle his opinion to
go to the jury, the question of the degree of his
knowledge goes more to the weight of the
evidence than to its admissibility.

What are the elements of Medical Negligence?

1.
2.
3.
4.

Expert witnesses are very important in medical

negligence cases. They have therein a two-fold role:
1. To establish the standard of care; and
2. To state whether or not the defendant
physician has followed such proper standard
of care.
Jurisprudence:
To be sure, the Court cannot give much
weight to the complainants own opinion and
assessment of what the doctor should have
and should not have done. (Lucas vs Tuano,
2009)

Also, in Ramos vs CA (1999), the Court held: Although

witness Cruz is not an anesthesiologist, she can very
well testify upon matters on which she is capable of
observing such as, the statements and acts of the
physician and surgeon, external appearances, and
manifest conditions which are observable by any one.
48 This is precisely allowed under the doctrine of res
ipsa loquitur where the testimony of expert witnesses
is not required. It is the accepted rule that expert
testimony is not necessary for the proof of negligence
in non-technical matters or those of which an ordinary
person may be expected to have knowledge, or where
the lack of skill or want of care is so obvious as to
render expert testimony unnecessary. We take judicial
notice of the fact that anesthesia procedures have
become so common, that even an ordinary person can
tell if it was administered properly. As such, it would
not be too difficult to tell if the tube was properly
inserted. This kind of observation, we believe, does not
require a medical degree to be acceptable. At any rate,
without doubt, petitioner's witness, an experienced
clinical nurse whose long experience and scholarship
led to her appointment as Dean of the Capitol Medical
Center School at Nursing, was fully capable of
determining whether or not the intubation was a
success. She had extensive clinical experience starting
as a staff nurse in Chicago, Illinois; staff nurse and
clinical instructor in a teaching hospital, the FEU-NRMF;
Dean of the Laguna College of Nursing in San Pablo
City; and then Dean of the Capitol Medical Center
School of Nursing.

What is the principle of res ipsa loquitur and how is it

relevant in medical negligence?
-

"Where the thing which causes injury is shown to be

under the management of the defendant, and the
accident is such as in the ordinary course of things does
not happen if those who have the management use
proper care, it affords reasonable evidence, in the
absence of an explanation by the defendant, that the
accident arose from want of care."
The doctrine of [r]es ipsa loquitur as a rule of evidence
is peculiar to the law of negligence which recognizes
that prima facie negligence may be established without
direct proof and furnishes a substitute for specific proof
of negligence. The doctrine is not a rule of substantive
law, but merely a mode of proof or a mere procedural
convenience. The rule, when applicable to the facts
and circumstances of a particular case, is not intended
to and does not dispense with the requirement of proof
of culpable negligence on the party charged. It merely
determines and regulates what shall be prima facie
evidence thereof and facilitates the burden of plaintiff
of proving a breach of the duty of due care. The
doctrine can be invoked when and only when, under
the circumstances involved, direct evidence is absent
and not readily available.
In other words, in the absence of direct evidence or a
testimony of an expert witness, the complainants
cause of action may be saved by the application of res
ipsa loquitur.

What are the elements of res ipsa loquitur in the context

of medical negligence?
1.

The accident is of a kind which ordinarily does not

occur in the absence of someone's negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or defendants;
and
3. The possibility of contributing conduct which
would make the plaintiff responsible is eliminated.
Jurisprudence:
In the instant case, all the requisites for recourse
to the doctrine are present. First, the entire
proceedings of the caesarean section were under
the exclusive control of Dr. Batiquin. In this light,
the private respondents were bereft of direct
evidence as to the actual culprit or the exact cause
of the foreign object finding its way into private
respondent Villegas's body, which, needless to
say, does not occur unless through the
intersection of negligence. Second, since aside
from the caesarean section, private respondent
Villegas underwent no other operation which could
have caused the offending piece of rubber to
appear in her uterus, it stands to reason that such
could only have been a by-product of the
caesarean section performed by Dr. Batiquin.
(Batiquin vs CA, 1996)
Relative to the case, res ipsa loquitor does not
apply since 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.
As to whether the petitioners have exercised the
requisite degree of skill and care in treating patient
Roy, Jr. is generally a matter of expert opinion.
(Jarcia vs People, 2012)
Luz delivered Gerald to the care, custody and
control of his physicians for a pull-through
operation. Except for the imperforate anus, Gerald
was then of sound body and mind at the time of
his submission to the physicians. Yet, he
experienced bradycardia during the operation,
causing loss of his senses and rendering him
immobile. Hypoxia, or the insufficiency of oxygen
supply to the brain that caused the slowing of the
heart rate, scientifically termed as bradycardia,
would not ordinarily occur in the process of a
pullthrough
operation,
or
during
the
administration of anesthesia to the patient, but
such fact alone did not prove that the negligence
of any of his attending physicians, including the
anesthesiologists, had caused the injury. In fact,
the anesthesiologists attending to him had sensed
in the course of the operation that the lack of
oxygen could have been triggered by the vagovagal reflex, prompting them to administer
atropine to the patient. (Solidum vs People, 2014)

Discuss the liability of a hospital with respect to the acts

of its physicians.
1.

2.

3.

If an Employer-Employee Relationship is established,

then the hospital, unless it can prove diligence of a
good father in the selection of employees, is solidarily
liable with the doctor by virtue of vicarious liability
under Article 2180 of the Civil Code.
It should be noted that in light of recent
jurisprudence, it is almost impossible to prove
an employment relationship, because it is
recognized in this jurisdiction that the
relationship between a physician and a
hospital is merely contractual.
Under the Schloendorff Doctrine, a physician,
even if employed by a hospital, is considered
an independent contractor, because of the
skill he exercises and the lack of control
exerted over his work. Under this doctrine,
hospitals are exempt from the application of
the respondeat superior principle for fault or
negligence committed by physicians in the
discharge of their profession.
There is, however, what is called as the Doctrine of
Apparent Authority or Doctrine of Ostensible Agency,
which would still allow the complainant to invoke the
hospitals vicarious liability.
The hospital may also be held liable under the Doctrine
of Corporate Negligence.

Discuss the Doctrine of Apparent Authority.

Under the Doctrine of Apparent Authority, a hospital

can be held vicariously liable for the negligent acts of
a physician providing care at the hospital, regardless of
whether the physician is an independent contractor,
unless the patient knows, or should have known, that
the physician is an independent contractor.
Elements:
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.
Jurisprudence:
There is ample evidence that the hospital (PSI)
held out to the patient (Natividad) that the doctor
(Dr. Ampil) was its agent. Present are the two
factors that determine apparent authority: first,
the hospital's implied manifestation to the patient
which led the latter to conclude that the doctor
was the hospital's agent; and second, the patients
reliance upon the conduct of the hospital and the
doctor, consistent with ordinary care and
prudence. (PSI vs Agana, 2010)

Discuss the Doctrine of Corporate Negligence.

-

Recent years have seen the doctrine of corporate

negligence as the judicial answer to the problem of
allocating hospitals liability for the negligent acts of
health practitioners, absent facts to support the
application of respondeat superior or apparent
authority. Its formulation proceeds from the judiciarys
acknowledgment that in these modern times, the duty
of providing quality medical service is no longer the
sole prerogative and responsibility of the physician.
The modern hospitals have changed structure.
Hospitals now tend to organize a highly professional
medical staff whose competence and performance
need to be monitored by the hospitals commensurate
with their inherent responsibility to provide quality
medical care.
The doctrine has its genesis in Darling v. Charleston
Community Hospital. There, the Supreme Court of
Illinois held that the jury could have found a hospital
negligent, inter alia, in failing to have a sufficient
number of trained nurses attending the patient; failing
to require a consultation with or examination by
members of the hospital staff; and failing to review the
treatment rendered to the patient. On the basis of
Darling, other jurisdictions held that a hospitals
corporate negligence extends to permitting a physician
known to be incompetent to practice at the hospital.
With the passage of time, more duties were expected
from hospitals, among them: (1) the use of reasonable
care in the maintenance of safe and adequate facilities
and equipment; (2) the selection and retention of
competent physicians; (3) the overseeing or
supervision of all persons who practice medicine within
its walls; and (4) the formulation, adoption and

enforcement of adequate rules and policies that ensure

quality care for its patients. Thus, in Tucson Medical
Center, Inc. v. Misevich, it was held that a hospital,
following the doctrine of corporate responsibility, has
the duty to see that it meets the standards of
responsibilities for the care of patients. Such duty
includes the proper supervision of the members of its
medical staff. And in Bost v. Riley, the court concluded
that a patient who enters a hospital does so with the
reasonable expectation that it will attempt to cure him.
The hospital accordingly has the duty to make a
reasonable effort to monitor and oversee the treatment
prescribed and administered by the physicians
practicing in its premises.
Discuss the Captain of the Ship Doctrine.
-

Under the Doctrine of Captain of the Ship, it is the

surgeon's responsibility to see to it that those under
him perform their task in the proper manner.
Invocation of this doctrine against a doctor means that
the liability of the doctor stems from the negligence of
supervising the other doctors performing their task
under himwhether or not the captain doctor
himself was also negligent in the surgery.
Although in the US, this doctrine is starting to be
discarded, it is still well applicable here in the
Philippines (Ramos vs CA, 1999)

Discuss the Doctrine of Informed Consent

-

A physician has a duty to disclose what a reasonably

prudent physician in the medical community in the
exercise of reasonable care would disclose to his
patient as to whatever grave risks of injury might be
incurred from a proposed course of treatment, so that
a patient, exercising ordinary care for his own welfare,
and faced with a choice of undergoing the proposed
treatment, or alternative treatment, or none at all, may
intelligently exercise his judgment by reasonably
balancing the probable risks against the probable
benefits.
Four essential elements a plaintiff must prove in a
malpractice suit based on the Doctrine of Informed
Consent:
1. the physician had a duty to disclose material
risks;
2. he failed to disclose or inadequately disclosed
those risks;
3. as a direct and proximate result of the failure
to disclose, the patient consented to
treatment she otherwise would not have
consented to; and
4. plaintiff was injured by the proposed
treatment.
The gravamen in an informed consent case requires
the plaintiff to point to significant undisclosed
information relating to the treatment which would have
altered her decision to undergo it.
Jurisprudence:
When petitioner informed the respondents
beforehand of the side effects of chemotherapy
which includes lowered counts of white and red
blood cells, decrease in blood platelets, possible
kidney or heart damage and skin darkening, there
is reasonable expectation on the part of the doctor
that the respondents understood very well that the

severity of these side effects will not be the same

for all patients undergoing the procedure. In other
words, by the nature of the disease itself, each
patients reaction to the chemical agents even with
pre-treatment laboratory tests cannot be precisely
determined by the physician. That death can
possibly result from complications of the treatment
or the underlying cancer itself, immediately or
sometime
after
the
administration
of
chemotherapy drugs, is a risk that cannot be ruled
out, as with most other major medical procedures,
but such conclusion can be reasonably drawn from
the general side effects of chemotherapy already
disclosed. (Li vs Sps Soliman, 2011)
What are some of the criminal offenses that may be
committed by a physician?
-

Article 174. False medical certificates, false certificates

of merits or service, etc.
Article 259. Abortion practiced by a physician or
midwife and dispensing of abortives
Article 347. Simulation of births, substitution of one
child for another and concealment or abandonment of
a legitimate child.
Criminal Negligence (Reckless Imprudence)
Reckless imprudence consists in voluntary,
but without malice, doing or falling to do an
act from which material damage results by
reason of inexcusable lack of precaution on
the part of the person performing of failing to
perform such act, taking into consideration
his employment or occupation, degree of
intelligence, physical condition and other
circumstances regarding persons, time and
place.
Simple imprudence consists in the lack of
precaution displayed in those cases in which
the damage impending to be caused is not
immediate nor the danger clearly manifest.

d)
e)
f)
g)

Q: What is the different between a Post-Mortem

Examination and an Autopsy?
A post-mortem examination is limited to the orifices, while an
autopsy also examines the organs.
Note: In practice, both terms seem to be used interchangeably.
Q: What is the difference between a Medicolegal
Certificate and a Medical Certificate?
A medicolegal certificate is one issued by a medicolegal officer,
while a medical certificate is one issued by a physician. Both
have the same evidentiary value. But, the important thing to
remember is to make sure that the one who signs the certificate
is one authorized to document injuries.
Q: What are the two types of injuries?
1.
2.

1.

Q: What is the significance of proper documentation of

injuries?
As far as lawyers are concerned, they rely on documents. It is
the best evidence. And it prevails over oral testimonies. Thus, if
there are discrepancies in the documents, it can destroy or
diminish the credibility of the witness.

2.
3.

Q: What do you do when you see a dead body lying

around?

c)

Observe surroundings.
Examine the clothes.
Look particularly for stains. If theres a red
stain there, we do not immediately conclude
that it is blood. It might be a paint, ketchup,
etc. And if there is blood, we further qualify
whether it is human blood or not. The point
is, wag assuming!
Try to ascertain identity of the person.

Find another source material for studying anatomy. Im not

competent enough to make one.

Open; and
Closed

I. Closed Injuries are those which involve no tear on the skin.

Examples:

The Human Body1

a)
b)

Interview people, but do not take their word

as gospel truth. Check for IDs, dog tags, etc.
Know the gender of the person.
Identify the position of the dead body.
Identify the color of the person.
Ascertain the approximate time of death.
Check the orifices.
Are there foreign objects, secretions, etc.?

Fractures (which may also be open or closed

depending on whether there is a break on the skin);
a. Linear: a fracture that extends parallel to the
long axis of a bone but does not displace the
bone tissue
b. Comminuted (a fracture in which the bone
fragments into several pieces)
c. Greenstick (an incomplete fracture in which
the bone is bent. This type of fracture occurs
most often in children)2
d. Transverse: a fracture at a right angle to the
bones axis
e. Oblique: a fracture in which the break is at an
angle to the bones axis.
f. Impacted: one whose ends are driven into
each other.
Hematoma Blood cyst/ commonly referred to as
bukol
Contusion A bruise, or contusion, is caused when
blood vessels are damaged or broken as the result of
a blow to the skin3

Note: Be sure not to confuse hematoma with contusion. In

hematoma, you can extract the blood with a syringe, but you
cannot do that with contusion, because blood is scattered in
the tissues.
II. Open Wounds are injuries involving an external or
internal break in body tissue, usually involving the skin.
Examples:

Only the first three were discussed by Atty. Logronio

1.

Stab Wound
Caused by a sharp edge (e.g. knife,
sword, etc.)
Perforated Wound
Cause by a pointed instrument (e.g. ice
pick, ball pen, etc.)
Lacerated Wound
Caused by a blunt instrument (e.g.
baseball bat, Manny Pacquios fists, etc.)
Incised Wound
Caused by a sharp-edged object in
slashing or slicing motion.
Abrasion
An abrasion is a wound caused by
superficial damage to the skin, no deeper
than the epidermis. Also known as
gasgas
Gunshot Wound
a form of physical trauma sustained from
the discharge of arms or munitions

It is also possible that there is only one bullet but more than one
entrance wound. There are a lot of possibilities, given the
advancement of technological warfare.

Q: What are the important differences between a

lacerated wound and an incised wound?

When the bullet or projectile penetrates the epithelial tissue,

there is friction between the skin and the projectile. This friction
results in an abraded area of tissue which surrounds the entry
wound and is known as an abrasion collar.4

2.
3.
4.
5.

6.

1.
2.
3.
4.

Lacerated Wound
Cut is clean
There is swelling
There is no cut of hair
Heals slower

1.
2.
3.
4.

Incised Wound
Cut is not clean
There is no swelling
There is a cut of hair
Heals faster

Q: What are the stuff that come out when you fire a gun?
1.
2.
3.
4.

Bullet;
Flame (reaches up to 6 inches) - Singeing;
Smoke (reaches up to 12 inches) Soot/Smudging;
Unburnt Powder (reaches up to 24 inches)
Peppering/Stippling.

Q: What is the importance of knowing the stuff, aside

from bullets, that come from a gun?
The presence of one or more of them may be determinative of
the distance of the assailant. For example, if the gunshot
wound includes all the four, there is a high probability that the
assailant was very near when he fired the gun. Likewise, if it is
just a gunshot wound, then the assailant most likely fired from
a distance.
Q: What are the two types of gunshot wound (GSW)?
1.
2.

Entry Wound
Exit Wound

The usual scenario is that there are even numbers of GSW. This
is what is known as the Odd-Even Rule. So, if you were shot
thrice, there should be six GSW.
But of course, it is possible to have an odd number of GSW. In
such case, there would be a presumption that one or more
bullets are still inside the body.

http://what-when-how.com/forensic-sciences/evaluationof-gunshot-wounds/

Bullet movement is described to be any of the following:

spinning, tumbling and tail-wagging.
Q: What are the differences between an entry wound
and an exit wound?
Entry Wound
1. Usually round in shape.

2. Inverted (papasok)
3. You can find an
abrasion/contusion collar

Exit Wound
1. No particular shape. (This
is why newbies usually make
a mistake of considering this
as a stab wound.)
2. Everted (palabas)
3. You cant find them

Q: What is an Abrasion Collar?

It is the gasgas caused by the bullet where the bullet is

angulated which would make gasgas before making an entrance
to the skin.
This is important for purposes of giving an idea as to the position
of the assailant when he fired the gun.
Q: How do we document rape cases?
First, we must look for injuries around the legs first and other
body parts (particularly the wrists), which would indicate that
rape was probably committed. For example: A struggling woman
being raped would usually sustain bruises in some of her body
parts.
In rape, there are usually hymenal lacerations which are
distinguished and determined by using the face of the clock:
1.
2.
3.

Incomplete Laceration (around 3 oclock)

Complete Laceration (around 6 oclock onwards)
Compound Laceration (outside the hymen)

The healing period of hymenal laceration is from four to 10 days.

Q: How do we know that a person is already dead?
We cant just say Hindi na gumagalaw eh, kaya patay na.
There are two machines that that determine whether a person
is already dead:
1.

Electroencephalogram (EEG) test that measures and

records the electrical activity of your brain. Special
sensors electrodes are attached to your head and
hooked by wires to a computer. The computer records
your brain's electrical activity on the screen or on paper
as wavy lines. Certain conditions, such as seizures, can
be seen by the changes in the normal pattern of the
brain's electrical activity.

2.

Electrocardiogram (ECG) - a test that records the

electrical activity of the heart. It is used to measure the
rate and regularity of heartbeats as well as the size and
position of the chambers, the presence of any damage
to the heart, and the effects of drugs or devices used
to regulate the heart (such as a pacemaker)

In the Philippines, it is the ECG that is commonly used, because

most hospitals cannot afford EEG machines.
Q: What are the vital signs of a person?
1.
2.
3.
4.

Blood Pressure
Respiratory Rate
Pulse Rate
Body Temperature

The first three are used to pronounce a person clinically dead.

Clinical death is the medical term for cessation of blood
circulation and breathing, the two necessary criteria to sustain
human and many other organisms' lives.[1] It occurs when the
heart stops beating in a regular rhythm, a condition called
cardiac arrest. The term is also sometimes used in resuscitation
research.
On the other hand, brain/biological death occurs four to six
minutes after clinical death. This is due to the fact that the heart
is the main pumping machine of the body, and without the blood
coming from the heart, the brain will gradually cease to function
until it achieves irreversible damage. This is when the doctor will
formally or legally declare that the person is dead as the
neurological damage to the person is really impossible to
reverse.
A person can be clinically dead but can still exist with the help
of artificial life support. This is the best time to consider the
option of organ donation. Technically, the patient is already
dead but the organs are still functioning. Once the life support
is taken off, the whole body will start to deteriorate and cease
its functions permanently. Brain death, either of the whole brain
or the brain stem, is used as a legal indicator of death in many
jurisdictions.5
Q: What are the three stages which the muscles of the
body pass through after death?
1.
2.
3.

Primary Flacidity
Rigor Mortis
Secondary Flacidity

1. Primary Flacidity (usually happens within the first three (3)

hours after death)
At the moment of death, the muscles relax completelya
condition called "primary flaccidity." The muscles then stiffen,
perhaps due to coagulation of muscle proteins or a shift in the
muscle's energy containers (ATP-ADP), into a condition known
as rigor mortis. All of the body's muscles are affected.6
2. Rigor Mortis (Usually happens 3 hours after death and lasts
up to 12 hours)

http://www.nursebuff.com/2012/01/clinical-death-versusbrain-death-which-comes-first/
http://www.deathreference.com/Py-Se/Rigor-Mortis-andOther-Postmortem-Changes.html#ixzz3snOTsK51
6

This is a state of stiffening of muscles, sometimes with slight

shortening of fibers. Individual cell death takes place in this
stage. The body becomes completely rigid on the 12th hour:
Complete Rigor Mortis.
Rigor mortis begins within two to six hours of death, starting
with the eyelids, neck, and jaw. This sequence may be due to
the difference in lactic acid levels among different muscles,
which corresponds to the difference in glycogen levels and to
the different types of muscle fibers. Over the next four to six
hours, rigor mortis spreads to the other muscles, including those
in the internal organs such as the heart. The onset of rigor
mortis is more rapid if the environment is cold and if the
decedent had performed hard physical work just before death.
Its onset also varies with the individual's age, sex, physical
condition, and muscular build.7
3. Secondary Flacidity (24 36 hours later)
After being in this rigid condition for twenty-four to eightyfour hours, the muscles relax and secondary laxity (flaccidity)
develops, usually in the same order as it began. The length of
time rigor mortis lasts depends on multiple factors, particularly
the ambient temperature. The degree of rigor mortis can be
determined by checking both the finger joints and the larger
joints and ranking their degree of stiffness on a one- to threeor four-point scale. Many infant and child corpses will not exhibit
perceptible rigor mortis. This decreased perceptible stiffness
may be due to their smaller muscle mass. During this period,
the body gradually cools in a process called algor mortis. The
best way to accurately assess a corpse's temperature is with a
core (tympanic membrane, liver, or rectal) thermometer. Rectal
insertion may be difficult and cause postmortem injury.8
Q: What is Putrefaction?
During the Secondary Flacidity, body will also start to decay.
This is what is known as Putrefaction.
In the absence of embalming or relatively rapid cremation, the
body putrefies. The first sign of putrefaction is a greenish skin
discoloration appearing on the right lower abdomen about the
second or third day after death. This coloration then spreads
over the abdomen, chest, and upper thighs and is usually
accompanied by a putrid odor. Sulphur-containing intestinal gas
and a breakdown product of red blood cells produce both the
color and smell. The ancient Greeks and the Etruscans paid
homage to this well-recognized stage of decomposition by
coloring a prominent god aqua-marine, considered the color of
rotting flesh. Bacteria normally residing in the body, especially
the colon, play an important part in digestion of food during life.
They also contribute mightily to decomposition after deaththe
process of putrefaction. The smell, rather than the sight, is the
most distinctive thing about a putrefying body. Under normal
conditions, the intestinal bacteria in a corpse produce large
amounts of foul-smelling gas that flows into the blood vessels
and tissues. It is this gas that bloats the body, turns the skin
from green to purple to black, makes the tongue and eyes
protrude, and often pushes the intestines out through the
vagina and rectum. The gas also causes large amounts of foulsmelling bloodstained fluid to exude from the nose, mouth, and
other body orifices. Two of the chemicals produced during
7
8

Ibid.
Ibid.

putrefaction are aptly named putrescine (1,4-diaminobutane)

and cadaverine (1,5-pentanediamine). If a person dies from an
overwhelming bacterial infection, marked changes from
putrefaction can occur within as few as nine to twelve hours
after death. By seven days after death, most of the body is
discolored and giant blood-tinged blisters begin to appear. The
skin loosens and any pressure causes the top layer to come off
in large sheets (skin slip). As the internal organs and the fatty
tissues decay, they produce large quantities of foul-smelling gas.
By the second week after death, the abdomen, scrotum,
breasts, and tongue swell; the eyes bulge out. A bloody fluid
seeps out of the mouth and nose. After three to four weeks, the
hair, nails, and teeth loosen and the grossly swollen internal
organs begin to rupture and eventually liquefy. The internal
organs decompose at different rates, with the resistant uterus
and prostate often intact after twelve months, giving
pathologists one way to determine an unidentified corpse's sex.

Cadaveric spasm, also known as postmortem spasm,

instantaneous rigor, cataleptic rigidity, or instantaneous rigidity,
is a rare form of muscular stiffening that occurs at the moment
of death, persists into the period of rigor mortis and can be
mistaken for rigor mortis. The cause is unknown, but is usually
associated with violent deaths happening under extremely
physical circumstances with intense emotion.
It is usually used to determine whether injuries are suicidal or
homicidal. For example, when you shoot yourself with a
handgun, your wrist will stiffen. That is cadaveric spasm.
Q: When a persons throat is cut, how do you know if it
is suicidal or homicidal?
1.
2.

Presence of maggots would indicate that the body has been

dead for more than 24 hours.9

3.

Q: Discuss what happens when a person dies of

drowning?

4.

The body tend to surface after 24 36 hours (during Secondary

Flacidity) because of putrefaction wherein the body becomes
bloated due to accumulation of gases.

Observe the angle and direction of the injury. In

suicide, the incision will be diagonal, while in homicide,
it will be horizontal.
In suicide, there will be what are known as hesitance
cuts (trial and error cuts), while in homicide, there is
usually only one cut.
In suicide, injury is usually above the Adams Apple,
while in homicide, it is below.
In suicide, theres blood in front and in the hands, while
in homicide, there is blood at the back.

Q: If you find a dead body and it is still warm, what does

that tell you?
That it has been dead for probably less than three hours.
Q: If, during autopsy, food is found in the stomach, what
can you conclude?
It takes three hours for the stomach to vacate its contents. So,
you can conclude that the victim was killed less than three hours
ago.
Q: What happens when the heart stops pumping?
Lividity occurs. Lividity is the process through which the body's
blood supply will stop moving after the heart has stopped
pumping it around the inside of the deceased. What normally
happens at this point is that the blood supply - or at least any
blood that remains within the corpse depending on the nature
of their death - will settle in direct response to gravity. For
example an individual found lying on their stomach would be
found with all the blood from their back heading towards the
ground. Lividity also displays itself as a dark purple
discolouration of the body and can also be referred to as Livor
Mortis or Post Mortem Hypostasis.
It is worth noting that lividity begins to work through the
deceased within thirty minutes of their heart stopping and can
last up to twelve hours. Only up to the first six hours of death
can lividity be altered by moving the body. After the six hour
mark lividity is fixed as blood vessels begin to break down within
the body. Rigor mortis and lividity are some of the key factors
that are used when Estimating the Time of Death. 10
Q: What is Cadaveric Spasm?

Ibid.

10

http://www.exploreforensics.co.uk/rigor-mortis-andlividity.html

Frontal Lobe Responsible for voluntary movement. If you

destroy this, the person would lose sense of movement.

Wound to the intestine? Expect food materials to spill out.

Wound to the stomach? Expect spillage of acid, which could also
destroy other organs.
Wound to the large intestine? Expect spillage of fecal materials,
which may cause the person to die due to infection.
One of the purposes of the circulatory system is to deliver
nutrients, extraction of waste materials, deliver oxygen.
Circulatory
Two types of blood vessels: artery and veins. What is the
difference? Artery (high pressure) releases oxygen (away from
the heart to the different parts of the body). Vein (low pressure)
carries blood going back to the heart. Artery usually located
deeper. Pulses are in the artery not in veins.
Injury to the artery? Blood will spur out. Injury to the vein?
Blood will pour out.
Thank God liver and artery are hidden deep within the body.
Because you can die instantly if those are injured.
Brain

Parietal Lobe Responsible for sensation. Loss of sensation.

Magiging manhid ka.
Cerebellum Responsible for balance/equilibrium. Ito yung
naapektuhan, pag naglasing ka.
Brain Stem Connected to vital sectors.