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I. Standard of Care

RAMOS vs CA
Petitioner: Rogelio Ramos, Erlinda Ramos, Rommel Ramos, Roy
Roderick Ramos, and Ron Raymond Ramos
Respondents: Court of Appeals, Delos Santos Medical Center, Dr.
Orlino Hosaka and Dra. Perfecta Gutierrez
Date of Promulgation: September 5, 1997
Citation: G.R. No. 124354
Ponente: Kapunan, J.

FACTS
1. Dr. Hosaka was hired as a surgeon to conduct the surgery
removing stone from the gall bladder of Erlinda Ramos. The
operation was conducted at the De Los Santos Medical Center.
2. On the day of the operation, Dr. Hosaka was three hours late for
the procedure.
- Dr. Gutierrez, the anesthesiologist botched the administration
of the anesthesia causing Erlinda to go into a coma and suffer brain
damage
- the botched operation was witnessed by Herminda Cruz, the
victim's sister-in-law and Dean of College of Nursing of Capitol
Medical Center, so she went out of the operating room to tell the
victims husband that something is wrong.
3. Later that night, Erlinda was taken to the Intensive Care Unit due
to bronochospasm. She stayed there for a month comatosed.
- she suffered brain damage as a result of the absence of
oxygen in her brain for four to five minutes
- she was also diagnosed to be suffering from diffuse cerebral
parenchymal damage.
3. A complaint was filed against the hospital, the surgeon and the
anesthesiologist for damages.
- they showed expert testimony showing that Erlinda's
condition was caused by the anesthesiologist in not exercising
reasonable care in "intubating" Erlinda; Eyewitnesses heard Dr.
Gutierrez saying, "Ang hirap ma-intubate nito, mali yata
pagkakapasok. O lumalaki ang tiyan."
- test before the surgery proved that Erlinda was robust and fit
to undergo surgery
4. The RTC held that the anesthesiologist omitted to exercise due
care in intubating the patient, the surgeon was remissed in his
obligation to provide a "good anesthesiologist" and for arriving 3
hours late and the hospital liable for the negligence of the two
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doctors and not cancelling the operation after the surgeon failed to
arrive on time.
5. The CA reversed the decision of the RTC.

ISSUE
Whether or not the physicians were proven to be negligent and
caused the comatose condition of Ramos.

HELD
Yes. The Decision of the CA was modified in favor of petitioners.

The doctrine of Res Ipsa Loquitor is a procedure or evidentiary

rule which means that "the thing or the transaction speaks for
itself." It is a maxim for the rule that the fact of the
occurrence of the injury, taken with the surrounding
circumstances, may permit an inference or raise a
presumption of negligence, or make out a plaintiff's prima facie
case and present a question of fact for defendant to meet with an
explanation, where ordinarily in a medical malpractice case, the
complaining party must present expert testimony to prove that the
attending physician was negligent.
- it does not, however, dispense the requirement of
proof of negligence.
- before resort to the doctrine may be allowed, the following
requisites must be satisfactorily shown:
1. The accident is of a kind which ordinarily does
not occur in the absence of someone's negligence;
2. It is caused by an instrumentality within the
exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which
would make the plaintiff responsible is eliminated.

In the above requisites, the fundamental element is the

"control of instrumentality" which caused the damage. Such
element of control must be shown to be within the dominion
of the defendant. In order to have the benefit of the rule, a
plaintiff, in addition to proving injury or damage, must show a
situation where it is applicable, and must establish that the
essential elements of the doctrine were present in a particular
incident.

Although generally, expert medical testimony is relied upon in

malpractice suits to prove that a physician has done a
negligent act or that he has deviated from the standard medical
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procedure, when the doctrine of Res Ipsa Loquitur is availed
by the plaintiff, the need for expert medical testimony is
dispensed with because the injury itself provides the proof
of negligence.

This doctrine finds application in this case. On the day of the

operation, Erlinda Ramos already surrendered her person to the
private respondents who had complete and exclusive control over
her. Apart from the gallstone problem, she was neurologically sound
and fit. Then, after the procedure, she was comatose and brain
damagedres ipsa loquitur!the thing speaks for itself!

Private respondents were not able to disprove the

presumption of negligence on their part in the care of
Erlinda and their negligence was the proximate cause of her
condition. One need not be an anesthesiologist in order to tell
whether or not the intubation was a success. The Supreme Court
also found that the anesthesiologist only saw Erlinda for the first
time on the day of the operation which indicates unfamiliarity with
the patient and which is an act of negligence and irresponsibility.
- Obviously, brain damage, which Erlinda sustained, is an
injury which does not normally occur in the process of a gall bladder
operation. In fact, this kind of situation does not in the absence of
negligence of someone in the administration of anesthesia and in
the use of endotracheal tube. Normally, a person being put under
anesthesia is not rendered decerebrate as a consequence of
administering such anesthesia if the proper procedure was followed.
Furthermore, the instruments used in the administration of
anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents, who are the physicians-in-
charge.

The head surgeon, Dr. Hosaka was also negligent. He failed to

exercise the proper authority as the captain of the ship in
determining if the anesthesiologist observed the proper protocols.
Also, because he was late, he did not have time to confer with the
anesthesiologist regarding the anesthesia delivery.

The basis for holding an employer solidarily responsible for the

negligence of its employee is found in Article 2180 of the Civil Code
which considers a person accountable not only for his own acts but
also for those of others based on the former's responsibility under a
relationship of patria potestas. Such responsibility ceases when the
persons or entity concerned prove that they have observed the
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diligence of a good father of the family to prevent damage. In other
words, while the burden of proving negligence rests on the
plaintiffs, once negligence is shown, the burden shifts to the
respondents (parent, guardian, teacher or employer) who
should prove that they observed the diligence of a good
father of a family to prevent damage.
- The hospital failed to adduce evidence showing that it
exercised the diligence of a good father of the family in
hiring and supervision of its doctors (Art. 2180). The hospital
was negligent since they are the one in control of the hiring and
firing of their consultants. While these consultants are not
employees, hospitals still exert significant controls on the
selection and termination of doctors who work there which
is one of the hallmarks of an employer-employee
relationship. Thus, the hospital was allocated a share in the
liability.

Critique: Ramos vs CA

The facts of this case gives rise to the issue of whether or not the
application of the doctrine of res ipsa loquitur is proper, and I would
have to answer in the affirmative. I am totally in agreement with the
Supreme Courts decision.

The doctrine of res ipsa loquitur is applicable only when the injury is
undoubtedly evident as to have been a result of an act of
negligence, with such act exclusively performed by and within the
control of the accused, and the victim has in no way inflicted the
injury himself. It is well-settled that anesthesia is a safe and helpful
tool in the medical field. Only negligence in its utilization would give
rise to its harmful effects in the human body. Erlinda Ramos was
found to be healthy prior to the surgery, and cholecystectomy is not
a new medical procedure as to have high risks, so it is startling that
in the middle of the procedure she was sent to the Intensive Care
Unit in a state of a coma. These facts clearly establish the
negligence that was exhibited by the anesthesiologist, Dr. Guiterrez.

Dr. Hosaka also fell short of the standard of care healthcare

professionals are expected to exhibit. His failure to introduce the
anesthesiologist to the patient is one thing, but it is his tardiness
that really inculpated him. Because of his tardiness there was no
conference between him and the anesthesiologist prior to the
procedure, and no one supervised the administration of the
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anesthesia, which as the captain of the ship is his duty. He failed
to exercise due diligence and competence that is supposed to be
exhibited by a prudent healthcare professional.

From the foregoing, a reasonable mind would deduce that the

Supreme Courts decision is apt and sound.

II. Doctrine of Informed Consent

DR. RUBI LI vs SOLIMAN SPOUSES

Petitioner: Dr. Rubi Li
Respondent: Spouses Reynaldo and Lina Soliman, as parents/heirs of deceased
Angelica Soliman
Date of promulgation: June 7, 2011
Citation: G.R. No. 165279
Ponente: Villarama, Jr., J.

FACTS
1. Angelica Soliman, daughter of Reynaldo and Lina Soliman, underwent a biopsy of
the mass located in her lower extremity at St. Luke's Medical Center.
- results showed that Angelica was suffering fromosteosarcoma, osteoblastic
type, a high-grade (highly malignant) cancer of the bone which usually afflicts
teenage children
- as primary intervention, the tumor was removed and Angelica's right leg was
amputated by Dr. Jaime Tamayo
2. Dr. Tamayo suggested chemotherapy to eliminate any remaining cancer cells, to
minimize the chances of the recurrence of the cancer, and to prevent the disease from
spreading.
- Angelica was referred to Dr. Rubi Li, another doctor of St. Luke's Medical
Center
3. Chemotherapy drugs were administered intravenously on August 19, 1993.
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- (August 20) the next day, the Soliman spouses noticed reddish discoloration
on Angelica's face. Petitioner mentioned, "Wala yan. Epekto ng gamot"
- (August 21) Angelica had difficulty breathing and was provided with oxygen
inhalation apparatus. The red discoloration extended to her neck
- (August 22) Angelica could not bear the pain and respondents pleaded to stop
the chemotherapy. Angelica's stool was black and urine was reddish
- (August 23) Angelica was supposed to be taken home per the request of her
parents, but her convulsions returned
- (August 24) Respondents claimed that Angelica still suffered from
convulsions--fever and heavy breathing, but petitioner insisted it was carpo-pedal
spasm.
- In the coming days, Angelica suffered ulcers in the mouth, low platelet count,
restlessness, bleeding of the anus, and vomiting blood.
4. On September 1, 1993, Angelica died, 2 weeks after being admitted for
chemotherapy.
- St. Luke's Medical Center refused to release a death certificate without full
payment of the bills incurred.
5. The Soliman spouses brought Angelica's cadaver to the Philippine National
Police's Crime Laboratory for post-mortem examination.
- the Medico-Legal Report indicated "Hypovolemic shock secondary to
multiple organ hemorrhages and Disseminated Intravascular Coagulation" as the
cause of death.
6. On February 21, 1994, the Soliman spouses filed charges against the hospital and
the physicians involved for negligence and failure to observe the essential precautions
to prevent Angelica's untimely death.
7. The trial court dismissed the complaint and held that petitioner is not liable for
damages as she observed best known procedures and employed highest skill and
knowledge in the administration of chemotherapy drugs on Angelica.
8. The Soliman spouses appealed the case with the Court of Appeals. The court, while
concurring with the trial courts finding that there was no negligence committed by the
petitioner in the administration of chemotherapy treatment to Angelica, found that
petitioner as her attending physician failed to fully explain to the respondents all the
known side effects of chemotherapy. The appellate court stressed that since the
respondents have been told of only three side effects of chemotherapy, they readily
consented thereto.
- The appellants were clearly and totally unaware of these other side-
effects which manifested only during the chemotherapy treatment. This was
shown by the fact that every time a problem would take place regarding
Angelicas condition (like an unexpected side-effect manifesting itself), they
would immediately seek explanation from Dr. Rubi Li
- Dr. Rubi Li was found negligent and the Soliman spouses were entitled to
their claim for damages.

ISSUE
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Whether or not the Court of Appeals was correct in finding Dr. Rubi Li negligent in
her failure to disclose all possible side-effects of the procedure.

HELD
No. The petition of Dr. Rubi Li was granted.

The Court was in the opinion that there was adequate disclosure of material risks
inherent in the chemotherapy procedure performed with the consent of Angelica's
parents.
- 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.

There are four essential elements a plaintiff must prove in a malpractice action
based upon the doctrine of informed consent:
(1) the physician had a duty to disclose material risks;
(2) he failed to disclose or inadequately disclosed those risks;
(3) as a direct and proximate result of the failure to disclose, the patient
consented to treatment she otherwise would not have consented to; and
(4) plaintiff was injured by the proposed treatment.
The gravamen in an informed consent case requires the plaintiff to point to significant
undisclosed information relating to the treatment which would have altered her
decision to undergo it.

The element of ethical duty to disclose material risks in the proposed medical
treatment cannot thus be reduced to one simplistic formula applicable in all instances.
Further, in a medical malpractice action based on lack of informed consent, the
plaintiff must prove both the duty and the breach of that duty through expert
testimony. Such expert testimony must show the customary standard of care of
physicians in the same practice as that of the defendant doctor.
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Critique: Dr. Rubi Li vs Soliman Spouses

The issue in this case is whether or not the Dr. Rubi Li can be held
liable for damages in failing to fully disclose the side effects of
chemotherapy despite the absence negligence in administering the
said treatment. The Supreme Court held no but I do not agree.

Jurisprudence seemed to have applied the doctrine of informed

consent as to find liable only doctors who have completely
undisclosed information relating to the treatment. But it is clear in
the essential elements of the doctrine that inadequate disclosure of
information is included.

It is true that nothing can be found in this case as to render Dr. Rubi
Li negligent in any of the medical procedures she let Angelica go
through. However, the Soliman spouses, being laymen, could not
have grasped that the side-effects mentioned by Dr. Rubi Li imply
the possibility of death. A prudent lawyer would explain documents,
procedures, and the like to clients in a manner that they would
understand. This is to ensure that a client would know what is
actually going on and what could actually happen. The same should
be applicable to healthcare professionals. In providing possible
outcome regarding a certain procedure, a prudent healthcare
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professional should be straightforward and open about all the risks
and benefits. This would ensure that a patient is going through the
procedure fully aware of what might happen, bad or good.

The facts and the laws that apply to the same, in my viewpoint at
least, should have found Dr. Rubi Li liable for damages.

III. DNA as evidence

PEOPLE vs VALLEJO
Plaintiff: People of the Philippines
Accused: Gerrico Vallejo
Date of Promulgation: May 9, 2002
Citation: G.R. No. 144656
Per Curiam

FACTS
1. On July 10, 1999, Daisy Diolola was sent by her mother, Ma. Nida Diolola to go to
their neighbor's house so that Aimee Vallejo, the sister of the accused, may help
Daisy with her lessons.
- later that day, Ma. Nida noticed Daisy was not yet home so she went to
Aimee's house. Aimee's mother told Ma. Nida that Daisy wasn't there and that Aimee
wasn't feeling well so she was not able to help Daisy
- Ma. Nida went to look for her daughter in he brothers' and sister's houses, but
she was not there either
- Ma. Nida went back to her neighbor's house where Gerrico told her that
Daisy went to her classmate's house. But when she went there, she was told Daisy
had not been there
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2. The search for Daisy went on until early morning the following day but their
search proved futile. On July 12, she was then informed that the dead body of her
daughter was found tied to the root of an aroma tree by the river.
- Daisy's cadaver was brought to the barangay hall. She was wearing her pink
shorts with her sleeveless shirt tied around her neck.
3. Ma. Nida pointed at Gerrico as the probable suspect since he was with the victim
when was last seen alive.
- Jessiemin, another witness, testified that Gerrico came and told Daisy
something, and the latter went with him. She also testified that she saw Gerrico later
that day with wet shorts on and a wet shirt in his hand
- Charito also testified that she saw Gerrico that day near the place where
Daisy's dead body was found and the former looked troubled.
4. Gerrico was invited by policemen for questioning and was asked to submit the
clothes he wore the day the victim disappeared. The shirt and shorts of the victim,
which were bloodstained, were turned over to the NBI for laboratory examination.
5. The autopsy revealed that Daisy was raped and that the cause of death was
asphyxia by manual strangulation.
6. Mayor Abutan visited Gerrico in prison, who admitted to him that he killed Daisy.
Atty. Leyva was tasked to become Gerrico's counsel.
7. Pet Byron Buan, Forensic Biologist of the NBI, testified that on July 12, 1999, he
took blood samples from Gerrico in his office for laboratory examination to
determine his blood type.
- his blood type is O
- the victim's clothes and the surrendered clothes of Gerrico had bloodstains
that were blood type A.
8. Gerrico executed a sworn statement admitting that he not only killed the victim but
also raped her.
- he was informed that it can be used against him and that he could be
convicted of the case, but Gerrico said that he had freely and voluntarily executed the
document because he was bothered by his conscience
9. During trial however, Gerrico claimed that he was coerced into executing the
sworn statement. He also argued that the DNA samples should be inadmissible
because the body and the clothing of Daisy were already soaked in smirchy waters,
hence contaminated.
10. The trial court rendered a decision finding Gerrico guilty of the offense charged.

ISSUE
Whether or not the DNA samples obtained through Gerrico's and the victim's clothes
are admissible as evidence.

HELD
Yes. The trial court's decision was affirmed by the Supreme Court.
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The Supreme Court found Gerrico's contention that the bloodstains found on his
garments were not proven to have been that of the victim as the victims blood type
was not determined as devoid of merit.
- The examination conducted by Forensic Biologist Pet Byron Buan of both
accused-appellants and the victims clothing yielded bloodstains of the same blood
type A. Even if there was no direct determination as to what blood type the
victim had, it can reasonably be inferred that the victim was blood type A since
she sustained contused abrasions all over her body which would necessarily
produce the bloodstains on her clothing.

The DNA analysis conducted by NBI Forensic Chemist Aida Viloria-Magsipoc is

also questioned by accused-appellant. He argues that the prosecution failed to show
that all the samples submitted for DNA testing were not contaminated, considering
that these specimens were already soaked in smirchy waters before they were
submitted to the laboratory.
- When a crime is committed, material is collected from the scene of the
crime or from the victims body for the suspect's DNA. This is the evidence
sample. The evidence sample is then matched with the reference sample taken
from the suspect and the victim
- In assessing the probative value of DNA evidence, therefore, courts should
consider, among others things, the following data:
1) how the samples were collected,
2) how they were handled,
3) the possibility of contamination of the samples,
4) the procedure followed in analyzing the samples,
5) whether the proper standards and procedures were followed in
conducting the tests, and
6) the qualification of the analyst who conducted the tests.

The purpose of DNA testing is to ascertain whether an association exists between

the evidence sample and the reference sample. The samples collected are subjected
to various chemical processes to establish their profile. The test may yield three
possible results:
1) The samples are different and therefore must have originated from
different sources (exclusion). This conclusion is absolute and requires no further
analysis or discussion;
2) It is not possible to be sure, based on the results of the test, whether the
samples have similar DNA types (inconclusive). This might occur for a variety of
reasons including degradation, contamination, or failure of some aspect of the
protocol. Various parts of the analysis might then be repeated with the same or a
different sample, to obtain a more conclusive result; or
3) The samples are similar, and could have originated from the same source
(inclusion). In such a case, the samples are found to be similar, the analyst proceeds
to determine the statistical significance of the Similarity.
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The totality of the evidence points to no other conclusion than that accused-appellant
is guilty of the crime charged. Evidence is weighed not counted. When facts or
circumstances which are proved are not only consistent with the guilt of the accused
but also inconsistent with his innocence, such evidence, in its weight and probative
force, may surpass direct evidence in its effect upon the court.

Critique: People vs Vallejo

This is the first instance that DNA samples were admitted as evidence in a case and
that rouses the issue of whether or not such is a valid means of convicting a person. I
find that

DNA is described as being unique per person, except in the case of twins. This entails
that through DNA samples, it can be accurately surmised whether or not a person is
guilty of a crimeeither his DNA is in the crime scene/weapon/victim or not. I am
impressed with the intricate procedure in determining the DNAs validity and the
scrutinization of ascertaining whether an association exists between the evidence
sample and the reference sample. Such tests and procedures have been used in other
jurisdictions for quite some time and they and have proven to be helpful. I am glad
that our jurisdiction has started to utilize such in the speedy disposition of cases and
administration of justice.