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RepublicofthePhilippines
SUPREMECOURT
Manila

FIRSTDIVISION

G.R.No.126297January31,2007

PROFESSIONALSERVICES,INC.,Petitioner,
vs.
NATIVIDADandENRIQUEAGANA,Respondents.

xx

G.R.No.126467January31,2007

NATIVIDAD(SubstitutedbyherchildrenMARCELINOAGANAIII,ENRIQUEAGANA,JR.,EMMAAGANA
ANDAYA,JESUSAGANA,andRAYMUNDAGANA)andENRIQUEAGANA,Petitioners,
vs.
JUANFUENTES,Respondent.

xx

G.R.No.127590January31,2007

MIGUELAMPIL,Petitioner,
vs.
NATIVIDADAGANAandENRIQUEAGANA,Respondents.

DECISION

SANDOVALGUTIERREZ,J.:

Hospitals,havingundertakenoneofmankindsmostimportantanddelicateendeavors,mustassumethegrave
responsibility of pursuing it with appropriate care. The care and service dispensed through this high trust,
however technical, complex and esoteric its character may be, must meet standards of responsibility
commensuratewiththeundertakingtopreserveandprotectthehealth,andindeed,theverylivesofthoseplaced
inthehospitalskeeping.1

Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals Decision2 dated
September 6, 1996 in CAG.R. CV No. 42062 and CAG.R. SP No. 32198 affirming with modification the
Decision3datedMarch17,1993oftheRegionalTrialCourt(RTC),Branch96,QuezonCityinCivilCaseNo.Q
43322andnullifyingitsOrderdatedSeptember21,1993.

Thefacts,asculledfromtherecords,are:

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.
MiguelAmpil,petitionerinG.R.No.127590,diagnosedhertobesufferingfrom"cancerofthesigmoid."

On April 11, 1984, Dr. Ampil, assisted by the medical staff4of the Medical City Hospital, performed an anterior
resectionsurgeryonNatividad.Hefoundthatthemalignancyinhersigmoidareahadspreadonherleftovary,
necessitatingtheremovalofcertainportionsofit.Thus,Dr.AmpilobtainedtheconsentofNatividadshusband,
EnriqueAgana,topermitDr.JuanFuentes,respondentinG.R.No.126467,toperformhysterectomyonher.

AfterDr.Fuenteshadcompletedthehysterectomy,Dr.Ampiltookover,completedtheoperationandclosedthe
incision.

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However,theoperationappearedtobeflawed.InthecorrespondingRecordofOperationdatedApril11,1984,
theattendingnursesenteredtheseremarks:

"spongecountlacking2

"announcedtosurgeonsearched(sic)donebuttonoavailcontinueforclosure."

OnApril24,1984,Natividadwasreleasedfromthehospital.Herhospitalandmedicalbills,includingthedoctors
fees,amountedtoP60,000.00.

Afteracoupleofdays,Natividadcomplainedofexcruciatingpaininheranalregion.SheconsultedbothDr.Ampil
andDr.Fuentesaboutit.Theytoldherthatthepainwasthenaturalconsequenceofthesurgery.Dr.Ampilthen
recommended that she consult an oncologist to examine the cancerous nodes which were not removed during
theoperation.

On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment.
After four months of consultations and laboratory examinations, Natividad was told she was free of cancer.
Hence,shewasadvisedtoreturntothePhilippines.

OnAugust31,1984,NatividadflewbacktothePhilippines,stillsufferingfrompains.Twoweeksthereafter,her
daughterfoundapieceofgauzeprotrudingfromhervagina.Uponbeinginformedaboutit,Dr.Ampilproceeded
to her house where he managed to extract by hand a piece of gauze measuring 1.5 inches in width. He then
assuredherthatthepainswouldsoonvanish.

Dr.Ampilsassurancedidnotcometrue.Instead,thepainsintensified,promptingNatividadtoseektreatmentat
the Polymedic General Hospital. While confined there, 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
vaginalvault.Arectovaginalfistulahadformedinherreproductiveorganswhichforcedstooltoexcretethrough
the vagina. Another surgical operation was needed to remedy the damage. Thus, in October 1984, Natividad
underwentanothersurgery.

OnNovember12,1984,NatividadandherhusbandfiledwiththeRTC,Branch96,QuezonCityacomplaintfor
damages against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr.
Fuentes,docketedasCivilCaseNo.Q43322.Theyallegedthatthelatterareliablefornegligenceforleavingtwo
piecesofgauzeinsideNatividadsbodyandmalpracticeforconcealingtheiractsofnegligence.

Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative
complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes, docketed as Administrative
CaseNo.1690.ThePRCBoardofMedicineheardthecaseonlywithrespecttoDr.Fuentesbecauseitfailedto
acquirejurisdictionoverDr.AmpilwhowasthenintheUnitedStates.

OnFebruary16,1986,pendingtheoutcomeoftheabovecases,Natividaddiedandwasdulysubstitutedbyher
abovenamedchildren(theAganas).

OnMarch17,1993,theRTCrendereditsDecisioninfavoroftheAganas,findingPSI,Dr.AmpilandDr.Fuentes
liablefornegligenceandmalpractice,thedecretalpartofwhichreads:

WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL
SERVICES, INC., DR. MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and severally,
except in respect of the award for exemplary damages and the interest thereon which are the liabilities of
defendantsDr.AmpilandDr.Fuentesonly,asfollows:

1.Asactualdamages,thefollowingamounts:

a.TheequivalentinPhilippineCurrencyofthetotalofUS$19,900.00attherateofP21.60US$1.00,
asreimbursementofactualexpensesincurredintheUnitedStatesofAmerica

b.ThesumofP4,800.00astraveltaxesofplaintiffsandtheirphysiciandaughter

c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic Hospital,
medicalfees,andcostofthesalinesolution

2.Asmoraldamages,thesumofP2,000,000.00

3.Asexemplarydamages,thesumofP300,000.00

4.Asattorneysfees,thesumofP250,000.00

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5.Legalinterestonitems1(a),(b),and(c)2and3hereinabove,fromdateoffilingofthecomplaintuntil
fullpaymentand

6.Costsofsuit.

SOORDERED.

Aggrieved,PSI,Dr.FuentesandDr.AmpilinterposedanappealtotheCourtofAppeals,docketedasCAG.R.CV
No.42062.

Incidentally,onApril3,1993,theAganasfiledwiththeRTCamotionforapartialexecutionofitsDecision,which
wasgrantedinanOrderdatedMay11,1993.Thereafter,thesherifflevieduponcertainpropertiesofDr.Ampil
andsoldthemforP451,275.00anddeliveredtheamounttotheAganas.

Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to
indefinitelysuspendanyfurtherexecutionoftheRTCDecision.However, not long thereafter, the Aganas again
filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes. On September 21,
1993,theRTCgrantedthemotionandissuedthecorrespondingwrit,promptingDr.FuentestofilewiththeCourt
ofAppealsapetitionforcertiorariandprohibition,withprayerforpreliminaryinjunction,docketedasCAG.R.SP
No.32198.Duringitspendency,theCourtofAppealsissuedaResolution5datedOctober29,1993grantingDr.
Fuentesprayerforinjunctiverelief.

OnJanuary24,1994,CAG.R.SPNo.32198wasconsolidatedwithCAG.R.CVNo.42062.

Meanwhile,onJanuary23,1995,thePRCBoardofMedicinerendereditsDecision6in Administrative Case No.


1690 dismissing the case against Dr. Fuentes. The Board held that the prosecution failed to show that Dr.
FuenteswastheonewholeftthetwopiecesofgauzeinsideNatividadsbodyandthatheconcealedsuchfact
fromNatividad.

OnSeptember6,1996,theCourtofAppealsrendereditsDecisionjointlydisposingofCAG.R.CVNo.42062and
CAG.R.SPNo.32198,thus:

WHEREFORE,exceptforthemodificationthatthecaseagainstdefendantappellantDr.JuanFuentesishereby
DISMISSED, and with the pronouncement that defendantappellant Dr. Miguel Ampil is liable to reimburse
defendantappellantProfessionalServices,Inc.,whateveramountthelatterwillpayorhadpaidtotheplaintiffs
appellees,thedecisionappealedfromisherebyAFFIRMEDandtheinstantappealDISMISSED.

Concomitantwiththeabove,thepetitionforcertiorariandprohibitionfiledbyhereindefendantappellantDr.Juan
FuentesinCAG.R.SPNo.32198isherebyGRANTEDandthechallengedorderoftherespondentjudgedated
September 21, 1993, as well as the alias writ of execution issued pursuant thereto are hereby NULLIFIED and
SETASIDE.Thebondpostedbythepetitionerinconnectionwiththewritofpreliminaryinjunctionissuedbythis
CourtonNovember29,1993isherebycancelled.

CostsagainstdefendantsappellantsDr.MiguelAmpilandProfessionalServices,Inc.

SOORDERED.

OnlyDr.Ampilfiledamotionforreconsideration,butitwasdeniedinaResolution7datedDecember19,1996.

Hence,theinstantconsolidatedpetitions.

InG.R.No.126297,PSIallegedinitspetitionthattheCourtofAppealserredinholdingthat:(1)itisestopped
fromraisingthedefensethatDr.Ampilisnotitsemployee(2)itissolidarilyliablewithDr.Ampiland(3)itisnot
entitled to its counterclaim against the Aganas. PSI contends that Dr. Ampil is not its employee, but a mere
consultantorindependentcontractor.Assuch,healoneshouldanswerforhisnegligence.

InG.R.No.126467,theAganasmaintainthattheCourtofAppealserredinfindingthatDr.Fuentesisnotguiltyof
negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. They contend that the pieces of
gauzeareprimafacieproofsthattheoperatingsurgeonshavebeennegligent.

Finally,inG.R.No.127590,Dr.AmpilassertsthattheCourtofAppealserredinfindinghimliablefornegligence
and malpractice sans evidence that he left the two pieces of gauze in Natividads vagina. He pointed to other
probable causes, such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy (2) the
attendingnursesfailuretoproperlycountthegauzesusedduringsurgeryand(3)themedicalinterventionofthe
AmericandoctorswhoexaminedNatividadintheUnitedStatesofAmerica.

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Forourresolutionarethesethreevitalissues:first,whethertheCourtofAppealserredinholdingDr.Ampilliable
for negligence and malpractice second, whether the Court of Appeals erred in absolving Dr. Fuentes of any
liabilityandthird,whetherPSImaybeheldsolidarilyliableforthenegligenceofDr.Ampil.

IG.R.No.127590

WhethertheCourtofAppealsErredinHoldingDr.Ampil

LiableforNegligenceandMalpractice.

Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other possible causes of Natividads
detriment.HearguesthattheCourtshouldnotdiscounteitherofthefollowingpossibilities:first,Dr.Fuentesleft
thegauzesinNatividadsbodyafterperforminghysterectomysecond,theattendingnurseserredincountingthe
gauzesandthird,theAmericandoctorsweretheoneswhoplacedthegauzesinNatividadsbody.

Dr. Ampils arguments are purely conjectural and without basis. Records show that he did not present any
evidencetoprovethattheAmericandoctorsweretheoneswhoputorleftthegauzesinNatividadsbody.Neither
did he submit evidence to rebut the correctness of the record of operation, particularly the number of gauzes
used.AstotheallegednegligenceofDr.Fuentes,wearemindfulthatDr.Ampilexaminedhis(Dr.Fuentes)work
andfounditinorder.

Theglaringtruthisthatallthemajorcircumstances,takentogether,asspecifiedbytheCourtofAppeals,directly
pointtoDr.Ampilasthenegligentparty,thus:

First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient
duringthesurgicaloperation.

Second,immediatelyaftertheoperation,thenurseswhoassistedinthesurgerynotedintheirreportthat
thespongecount(was)lacking2thatsuchanomalywasannouncedtosurgeonandthatasearchwas
donebuttonoavailpromptingDr.Ampiltocontinueforclosurexxx.

Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs. Agana
wherethesurgerywasperformed.

An operation requiring the placing of sponges in the incision is not complete until the sponges are properly
removed,anditissettledthattheleavingofspongesorotherforeignsubstancesinthewoundaftertheincision
has been closed is at least prima facie negligence by the operating surgeon.8 To put it simply, such act is
considered so inconsistent with due care as to raise an inference of negligence. There are even legions of
authoritiestotheeffectthatsuchactisnegligenceperse.9

Of course, the Court is not blind to the reality that there are times when danger to a patients life precludes a
surgeon from further searching missing sponges or foreign objects left in the body. But this does not leave him
freefromanyobligation.Evenifithasbeenshownthatasurgeonwasrequiredbytheurgentnecessitiesofthe
casetoleaveaspongeinhispatientsabdomen,becauseofthedangersattendantupondelay,still,itishislegal
dutytosoinformhispatientwithinareasonabletimethereafterbyadvisingherofwhathehadbeencompelledto
do.Thisisinorderthatshemightseekrelieffromtheeffectsoftheforeignobjectleftinherbodyashercondition
mightpermit.TherulinginSmithv.Zeagler10isexplicit,thus:

Theremovalofallspongesusedispartofasurgicaloperation,andwhenaphysicianorsurgeonfailstoremove
aspongehehasplacedinhispatientsbodythatshouldberemovedaspartoftheoperation,hetherebyleaves
hisoperationuncompletedandcreatesanewconditionwhichimposesuponhimthelegaldutyofcallingthenew
condition to his patients attention, and endeavoring with the means he has at hand to minimize and avoid
untowardresultslikelytoensuetherefrom.

Here,Dr.AmpildidnotinformNatividadaboutthemissingtwopiecesofgauze.Worse,heevenmisledherthat
the pain she was experiencing was the ordinary consequence of her operation. Had he been more candid,
Natividadcouldhavetakentheimmediateandappropriatemedicalremedytoremovethegauzesfromherbody.
To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of
deceivinghispatient.

Thisisaclearcaseofmedicalmalpracticeormoreappropriately,medicalnegligence.Tosuccessfullypursuethis
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
providerwouldnothavedoneandthatfailureoractioncausedinjurytothepatient.11Simplyput,theelements
are duty, breach, injury and proximate causation. Dr, Ampil, as the lead surgeon, had the duty to remove all
foreignobjects,suchasgauzes,fromNatividadsbodybeforeclosureoftheincision.Whenhefailedtodoso,it
washisdutytoinformNatividadaboutit.Dr.Ampilbreachedbothduties.SuchbreachcausedinjurytoNatividad,
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necessitatingherfurtherexaminationbyAmericandoctorsandanothersurgery.ThatDr.Ampilsnegligenceisthe
proximatecause12ofNatividadsinjurycouldbetracedfromhisactofclosingtheincisiondespitetheinformation
givenbytheattendingnursesthattwopiecesofgauzewerestillmissing.Thattheywerelateronextractedfrom
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
andherfamily.

IIG.R.No.126467

WhethertheCourtofAppealsErredinAbsolving

Dr.FuentesofanyLiability

The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it is
contrary to the doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze were left
insideNatividadsbodyisaprimafacieevidenceofDr.Fuentesnegligence.

Wearenotconvinced.

Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the occurrence of an
injury,takenwiththesurroundingcircumstances,maypermitaninferenceorraiseapresumptionofnegligence,
or make out a plaintiffs prima facie case, and present a question of fact for defendant to meet with an
explanation.13Stateddifferently,wherethethingwhichcausedtheinjury,withoutthefaultoftheinjured,isunder
the exclusive control of the defendant and the injury is such that it should not have occurred if he, having such
controlusedpropercare,itaffordsreasonableevidence,intheabsenceofexplanationthattheinjuryarosefrom
thedefendantswantofcare,andtheburdenofproofisshiftedtohimtoestablishthathehasobservedduecare
anddiligence.14

From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur
are:(1)theoccurrenceofaninjury(2)thethingwhichcausedtheinjurywasunderthecontrolandmanagement
ofthedefendant(3)theoccurrencewassuchthatintheordinarycourseofthings,wouldnothavehappenedif
thosewhohadcontrolormanagementusedpropercareand(4)theabsenceofexplanationbythedefendant.
Oftheforegoingrequisites,themostinstrumentalisthe"controlandmanagementofthethingwhichcausedthe
injury."15

Wefindtheelementof"controlandmanagementofthethingwhichcausedtheinjury"tobewanting.Hence,the
doctrineofresipsaloquiturwillnotlie.

ItwasdulyestablishedthatDr.AmpilwastheleadsurgeonduringtheoperationofNatividad.Herequestedthe
assistance of Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her
sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and
showedhisworktoDr.Ampil.Thelatterexamineditandfindingeverythingtobeinorder,allowedDr.Fuentesto
leavetheoperatingroom.Dr.AmpilthenresumedoperatingonNatividad.Hewasabouttofinishtheprocedure
when the attending nurses informed him that two pieces of gauze were missing. A "diligent search" was
conducted,butthemisplacedgauzeswerenotfound.Dr.Ampilthendirectedthattheincisionbeclosed.During
thisentireperiod,Dr.Fuenteswasnolongerintheoperatingroomandhad,infact,leftthehospital.

Underthe"CaptainoftheShip"rule,theoperatingsurgeonisthepersonincompletechargeofthesurgeryroom
and all personnel connected with the operation. Their duty is to obey his orders.16As stated before, Dr. Ampil
wastheleadsurgeon.Inotherwords,hewasthe"CaptainoftheShip."Thathedischargedsuchroleisevident
from his following conduct: (1) calling Dr. Fuentes to perform a hysterectomy (2) examining the work of Dr.
Fuentesandfindingitinorder(3)grantingDr.Fuentespermissiontoleaveand(4)orderingtheclosureofthe
incision. To our mind, it was this act of ordering the closure of the incision notwithstanding that two pieces of
gauzeremainedunaccountedfor,thatcausedinjurytoNatividadsbody.Clearly,thecontrolandmanagementof
thethingwhichcausedtheinjurywasinthehandsofDr.Ampil,notDr.Fuentes.

Inthisjurisdiction,resipsaloquiturisnotaruleofsubstantivelaw,hence,doesnotpersecreateorconstitutean
independentorseparategroundofliability,beingamereevidentiaryrule.17Inotherwords,mereinvocationand
applicationofthedoctrinedoesnotdispensewiththerequirementofproofofnegligence.Here, the negligence
wasproventohavebeencommittedbyDr.AmpilandnotbyDr.Fuentes.

IIIG.R.No.126297

WhetherPSIIsLiablefortheNegligenceofDr.Ampil

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The third issue necessitates a glimpse at the historical development of hospitals and the resulting theories
concerningtheirliabilityforthenegligenceofphysicians.

Untilthemidnineteenthcentury,hospitalsweregenerallycharitableinstitutions,providingmedicalservicestothe
lowestclassesofsociety,withoutregardforapatientsabilitytopay.18Thosewhocouldaffordmedicaltreatment
wereusuallytreatedathomebytheirdoctors.19However,thedaysofhousecallsandphilanthropichealthcare
are over. The modern health care industry continues to distance itself from its charitable past and has
experienced a significant conversion from a notforprofit health care to forprofit hospital businesses.
Consequently,significantchangesinhealthlawhaveaccompaniedthebusinessrelatedchangesinthehospital
industry.Oneimportantlegalchangeisanincreaseinhospitalliabilityformedicalmalpractice.Manycourtsnow
allowclaimsforhospitalvicariousliabilityunderthetheoriesofrespondeatsuperior,apparentauthority,ostensible
authority,oragencybyestoppel.20

Inthisjurisdiction,thestatutegoverningliabilityfornegligentactsisArticle2176oftheCivilCode,whichreads:

Art.2176.Whoeverbyactoromissioncausesdamagetoanother,therebeingfaultornegligence,isobligedto
pay for the damage done. Such fault or negligence, if there is no preexisting contractual relation between the
parties,iscalledaquasidelictandisgovernedbytheprovisionsofthisChapter.

AderivativeofthisprovisionisArticle2180,therulegoverningvicariousliabilityunderthedoctrineofrespondeat
superior,thus:

ART.2180.TheobligationimposedbyArticle2176isdemandablenotonlyforonesownactsoromissions,but
alsoforthoseofpersonsforwhomoneisresponsible.

xxxxxx

The owners and managers of an establishment or enterprise are likewise responsible for damages caused by
their employees in the service of the branches in which the latter are employed or on the occasion of their
functions.

Employers shall be liable for the damages caused by their employees and household helpers acting within the
scopeoftheirassignedtaskseventhoughtheformerarenotengagedinanybusinessorindustry.

xxxxxx

The responsibility treated of in this article shall cease when the persons herein mentioned prove that they
observedallthediligenceofagoodfatherofafamilytopreventdamage.

A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and
pharmacists,arenot"employees"underthisarticlebecausethemannerinwhichtheyperformtheirworkisnot
within the control of the latter (employer). In other words, professionals are considered personally liable for the
faultornegligencetheycommitinthedischargeoftheirduties,andtheiremployercannotbeheldliableforsuch
faultornegligence.Inthecontextofthepresentcase,"ahospitalcannotbeheldliableforthefaultornegligence
ofaphysicianorsurgeoninthetreatmentoroperationofpatients."21

The foregoing view is grounded on the traditional notion that the professional status and the very nature of the
physicianscallingprecludehimfrombeingclassedasanagentoremployeeofahospital,wheneverheactsina
professionalcapacity.22It has been said that medical practice strictly involves highly developed and specialized
knowledge,23suchthatphysiciansaregenerallyfreetoexercisetheirownskillandjudgmentinrenderingmedical
servicessansinterference.24Hence,whenadoctorpracticesmedicineinahospitalsetting,thehospitalandits
employees are deemed to subserve him in his ministrations to the patient and his actions are of his own
responsibility.25

ThecaseofSchloendorffv.SocietyofNewYorkHospital26was then considered an authority for this view. The


"Schloendorff doctrine" regards a physician, even if employed by a hospital, as an independent contractor
becauseoftheskillheexercisesandthelackofcontrolexertedoverhiswork.Underthisdoctrine,hospitalsare
exemptfromtheapplicationoftherespondeatsuperiorprincipleforfaultornegligencecommittedbyphysicians
inthedischargeoftheirprofession.

However,theefficacyoftheforegoingdoctrinehasweakenedwiththesignificantdevelopmentsinmedicalcare.
Courts came to realize that modern hospitals are increasingly taking active role in supplying and regulating
medical care to patients. No longer were a hospitals functions limited to furnishing room, food, facilities for
treatmentandoperation,andattendantsforitspatients.Thus,inBingv.Thunig,27theNewYorkCourtofAppeals
deviatedfromtheSchloendorffdoctrine,notingthatmodernhospitalsactuallydofarmorethanprovidefacilities
for treatment. Rather, they regularly employ, on a salaried basis, a large staff of physicians, interns, nurses,
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administrativeandmanualworkers.Theychargepatientsformedicalcareandtreatment,evencollectingforsuch
servicesthroughlegalaction,ifnecessary.Thecourtthenconcludedthatthereisnoreasontoexempthospitals
fromtheuniversalruleofrespondeatsuperior.

Inourshores,thenatureoftherelationshipbetweenthehospitalandthephysiciansisrenderedinconsequential
in view of our categorical pronouncement in Ramos v. Court of Appeals28 that for purposes of apportioning
responsibilityinmedicalnegligencecases,anemployeremployeerelationshipineffectexistsbetweenhospitals
andtheirattendingandvisitingphysicians.ThisCourtheld:

"Wenowdiscusstheresponsibilityofthehospitalinthisparticularincident.Theuniquepractice(amongprivate
hospitals) of filling up specialist staff with attending and visiting "consultants," who are allegedly not hospital
employees, presents problems in apportioning responsibility for negligence in medical malpractice cases.
However,thedifficultyismoreapparentthanreal.

Inthefirstplace,hospitalsexercisesignificantcontrolinthehiringandfiringofconsultantsandintheconductof
theirworkwithinthehospitalpremises.Doctorswhoapplyforconsultantslots,visitingorattending,arerequired
tosubmitproofofcompletionofresidency,theireducationalqualifications,generally,evidenceofaccreditationby
theappropriateboard(diplomate),evidenceoffellowshipinmostcases,andreferences.Theserequirementsare
carefully scrutinized by members of the hospital administration or by a review committee set up by the hospital
whoeitheracceptorrejecttheapplication.xxx.

Afteraphysicianisaccepted,eitherasavisitingorattendingconsultant,heisnormallyrequiredtoattendclinico
pathologicalconferences,conductbedsideroundsforclerks,internsandresidents,moderategrandroundsand
patientauditsandperformothertasksandresponsibilities,fortheprivilegeofbeingabletomaintainaclinicinthe
hospital, and/or for the privilege of admitting patients into the hospital. In addition to these, the physicians
performance as a specialist is generally evaluated by a peer review committee on the basis of mortality and
morbiditystatistics,andfeedbackfrompatients,nurses,internsandresidents.Aconsultantremissinhisduties,
or a consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer review
committee,isnormallypolitelyterminated.

In other words, private hospitals, hire, fire and exercise real control over their attending and visiting consultant
staff.Whileconsultantsarenot,technicallyemployees,xxx, the control exercised, the hiring, and the right to
terminateconsultantsallfulfilltheimportanthallmarksofanemployeremployeerelationship,withtheexceptionof
the payment of wages. In assessing whether such a relationship in fact exists, the control test is determining.
Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating responsibility in medical
negligencecases,anemployeremployeerelationshipineffectexistsbetweenhospitalsandtheirattendingand
visitingphysicians."

ButtheRamospronouncementisnotouronlybasisinsustainingPSIsliability.Itsliabilityisalsoanchoredupon
theagencyprincipleofapparentauthorityoragencybyestoppelandthedoctrineofcorporatenegligencewhich
havegainedacceptanceinthedeterminationofahospitalsliabilityfornegligentactsofhealthprofessionals.The
present case serves as a perfect platform to test the applicability of these doctrines, thus, enriching our
jurisprudence.

Apparentauthority,orwhatissometimesreferredtoasthe"holding

out" theory, or doctrine of ostensible agency or agency by estoppel,29has its origin from the law of agency. It
imposesliability,notastheresultoftherealityofacontractualrelationship,butratherbecauseoftheactionsofa
principal or an employer in somehow misleading the public into believing that the relationship or the authority
exists.30Theconceptisessentiallyoneofestoppelandhasbeenexplainedinthismanner:

"Theprincipalisboundbytheactsofhisagentwiththeapparentauthoritywhichheknowinglypermitstheagent
toassume,orwhichheholdstheagentouttothepublicaspossessing.Thequestionineverycaseiswhetherthe
principal has by his voluntary act placed the agent in such a situation that a person of ordinary prudence,
conversant with business usages and the nature of the particular business, is justified in presuming that such
agenthasauthoritytoperformtheparticularactinquestion.31

TheapplicabilityofapparentauthorityinthefieldofhospitalliabilitywasupheldlongtimeagoinIrvingv.Doctor
HospitalofLakeWorth,Inc.32There,itwasexplicitlystatedthat"theredoesnotappeartobeanyrationalbasis
forexcludingtheconceptofapparentauthorityfromthefieldofhospitalliability."Thus,incaseswhereitcanbe
shownthatahospital,byitsactions,hasheldoutaparticularphysicianasitsagentand/oremployeeandthata
patienthasacceptedtreatmentfromthatphysicianinthereasonablebeliefthatitisbeingrenderedinbehalfof
thehospital,thenthehospitalwillbeliableforthephysiciansnegligence.

Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code
reads:

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ART.1869.Agencymaybeexpress,orimpliedfromtheactsoftheprincipal,fromhissilenceorlackofaction,or
hisfailuretorepudiatetheagency,knowingthatanotherpersonisactingonhisbehalfwithoutauthority.

Inthiscase,PSIpubliclydisplaysinthelobbyoftheMedicalCityHospitalthenamesandspecializationsofthe
physiciansassociatedoraccreditedbyit,includingthoseofDr.AmpilandDr.Fuentes.WeconcurwiththeCourt
of Appeals conclusion that it "is now estopped from passing all the blame to the physicians whose names it
proudlyparadedinthepublicdirectoryleadingthepublictobelievethatitvouchedfortheirskillandcompetence."
Indeed, PSIs act is tantamount to holding out to the public that Medical City Hospital, through its accredited
physicians,offersqualityhealthcareservices.ByaccreditingDr.AmpilandDr.Fuentesandpubliclyadvertising
theirqualifications,thehospitalcreatedtheimpressionthattheywereitsagents,authorizedtoperformmedicalor
surgicalservicesforitspatients.Asexpected,thesepatients,Natividadbeingoneofthem,acceptedtheservices
onthereasonablebeliefthatsuchwerebeingrenderedbythehospitaloritsemployees,agents,orservants.The
trialcourtcorrectlypointedout:

xxxregardlessoftheeducationandstatusinlifeofthepatient,heoughtnotbeburdenedwiththedefenseof
absence of employeremployee relationship between the hospital and the independent physician whose name
andcompetencearecertainlycertifiedtothegeneralpublicbythehospitalsactoflistinghimandhisspecialtyin
itslobbydirectory,asinthecaseherein.Thehighcostsoftodaysmedicalandhealthcareshouldatleastexact
onthehospitalgreater,ifnotbroader,legalresponsibilityfortheconductoftreatmentandsurgerywithinitsfacility
byitsaccreditedphysicianorsurgeon,regardlessofwhetherheisindependentoremployed."33

The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of acting
only through other individuals, such as physicians. If these accredited physicians do their job well, the hospital
succeedsinitsmissionofofferingqualitymedicalservicesandthusprofitsfinancially.Logically,wherenegligence
marsthequalityofitsservices,thehospitalshouldnotbeallowedtoescapeliabilityfortheactsofitsostensible
agents.

Wenowproceedtothedoctrineofcorporatenegligenceorcorporateresponsibility.

OneallegationinthecomplaintinCivilCaseNo.Q43332fornegligenceandmalpracticeisthatPSIasowner,
operatorandmanagerofMedicalCityHospital,"didnotperformthenecessarysupervisionnorexercisediligent
efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns
whoassistedDrs.AmpilandFuentesintheperformanceoftheirdutiesassurgeons."34Premisedonthedoctrine
ofcorporatenegligence,thetrialcourtheldthatPSIisdirectlyliableforsuchbreachofduty.

Weagreewiththetrialcourt.

Recentyearshaveseenthedoctrineofcorporatenegligenceasthejudicialanswertotheproblemofallocating
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
commensuratewiththeirinherentresponsibilitytoprovidequalitymedicalcare.35

ThedoctrinehasitsgenesisinDarlingv.CharlestonCommunityHospital.36There,theSupremeCourtofIllinois
heldthat"thejurycouldhavefoundahospitalnegligent,interalia,infailingtohaveasufficientnumberoftrained
nursesattendingthepatientfailingtorequireaconsultationwithorexaminationbymembersofthehospitalstaff
andfailingtoreviewthetreatmentrenderedtothepatient."OnthebasisofDarling,otherjurisdictionsheldthata
hospitals corporate negligence extends to permitting a physician known to be incompetent to practice at the
hospital.37 With the passage of time, more duties were expected from hospitals, among them: (1) the use of
reasonablecareinthemaintenanceofsafeandadequatefacilitiesandequipment(2)theselectionandretention
ofcompetentphysicians(3)theoverseeingorsupervisionofallpersonswhopracticemedicinewithinitswalls
and(4)theformulation,adoptionandenforcementofadequaterulesandpoliciesthatensurequalitycareforits
patients.38Thus,inTucsonMedicalCenter,Inc.v.Misevich,39itwasheldthatahospital,followingthedoctrineof
corporateresponsibility,hasthedutytoseethatitmeetsthestandardsofresponsibilitiesforthecareofpatients.
Such duty includes the proper supervision of the members of its medical staff. And in Bost v. Riley,40the court
concludedthatapatientwhoentersahospitaldoessowiththereasonableexpectationthatitwillattempttocure
him. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment
prescribedandadministeredbythephysicianspracticinginitspremises.

Inthepresentcase,itwasdulyestablishedthatPSIoperatestheMedicalCityHospitalforthepurposeandunder
the concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise
reasonablecaretoprotectfromharmallpatientsadmittedintoitsfacilityformedicaltreatment.Unfortunately,PSI
failedtoperformsuchduty.Thefindingsofthetrialcourtareconvincing,thus:

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xxxPSIsliabilityistraceabletoitsfailuretoconductaninvestigationofthematterreportedinthenotabeneof
thecountnurse.SuchfailureestablishedPSIspartinthedarkconspiracyofsilenceandconcealmentaboutthe
gauzes.Ethicalconsiderations,ifnotalsolegal,dictatedtheholdingofanimmediateinquiryintotheevents,ifnot
forthebenefitofthepatienttowhomthedutyisprimarilyowed,thenintheinterestofarrivingatthetruth.The
Court cannot accept that the medical and the healing professions, through their members like defendant
surgeons,andtheirinstitutionslikePSIshospitalfacility,cancallouslyturntheirbacksonanddisregardevena
mereprobabilityofmistakeornegligencebyrefusingorfailingtoinvestigateareportofsuchseriousnessasthe
oneinNatividadscase.

ItisworthytonotethatDr.AmpilandDr.FuentesoperatedonNatividadwiththeassistanceoftheMedicalCity
Hospitalsstaff,composedofresidentdoctors,nurses,andinterns.Assuch,itisreasonabletoconcludethatPSI,
as the operator of the hospital, has actual or constructive knowledge of the procedures carried out, particularly
thereportoftheattendingnursesthatthetwopiecesofgauzeweremissing.InFridenav.Evans,41itwasheld
thatacorporationisboundbytheknowledgeacquiredbyornoticegiventoitsagentsorofficerswithinthescope
oftheirauthorityandinreferencetoamattertowhichtheirauthorityextends.Thismeansthattheknowledgeof
any of the staff of Medical City Hospital constitutes knowledge of PSI. Now, the failure of PSI, despite the
attending nurses report, to investigate and inform Natividad regarding the missing gauzes amounts to callous
negligence.NotonlydidPSIbreachitsdutiestooverseeorsuperviseallpersonswhopracticemedicinewithinits
walls,italsofailedtotakeanactivestepinfixingthenegligencecommitted.ThisrendersPSI,notonlyvicariously
liable for the negligence of Dr. Ampil under Article 2180 of the Civil Code, but also directly liable for its own
negligenceunderArticle2176.InFridena,theSupremeCourtofArizonaheld:

xxxInrecentyears,however,thedutyofcareowedtothepatientbythehospitalhasexpanded.Theemerging
trend is to hold the hospital responsible where the hospital has failed to monitor and review medical services
beingprovidedwithinitswalls.SeeKahnHospitalMalpracticePrevention,27DePaul.Rev.23(1977).

Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335
(1972).InPurcell,thehospitalarguedthatitcouldnotbeheldliableforthemalpracticeofamedicalpractitioner
becausehewasanindependentcontractorwithinthehospital.TheCourtofAppealspointedoutthatthehospital
hadcreatedaprofessionalstaffwhosecompetenceandperformancewastobemonitoredandreviewedbythe
governingbodyofthehospital,andthecourtheldthatahospitalwouldbenegligentwhereithadknowledgeor
reasontobelievethatadoctorusingthefacilitieswasemployingamethodoftreatmentorcarewhichfellbelow
therecognizedstandardofcare.

Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain inherent
responsibilities regarding the quality of medical care furnished to patients within its walls and it must meet the
standardsofresponsibilitycommensuratewiththisundertaking.Beeckv.TucsonGeneralHospital,18Ariz.App.
165,500P.2d1153(1972).ThiscourthasconfirmedtherulingsoftheCourtofAppealsthatahospitalhasthe
dutyofsupervisingthecompetenceofthedoctorsonitsstaff.xxx.

xxxxxx

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with its
knowledge, aid, and assistance, and that the negligence of the defendants was the proximate cause of the
patients injuries. We find that such general allegations of negligence, along with the evidence produced at the
trialofthiscase,aresufficienttosupportthehospitalsliabilitybasedonthetheoryofnegligentsupervision."

AnentthecorollaryissueofwhetherPSIissolidarilyliablewithDr.Ampilfordamages,letitbeemphasizedthat
PSI, apart from a general denial of its responsibility, failed to adduce evidence showing that it exercised the
diligenceofagoodfatherofafamilyintheaccreditationandsupervisionofthelatter.Inneglectingtooffersuch
proof, PSI failed to discharge its burden under the last paragraph of Article 2180 cited earlier, and, therefore,
mustbeadjudgedsolidarilyliablewithDr.Ampil.Moreover,aswehavediscussed,PSIisalsodirectlyliabletothe
Aganas.

Onefinalword.Onceaphysicianundertakesthetreatmentandcareofapatient,thelawimposesonhimcertain
obligations.Inordertoescapeliability,hemustpossessthatreasonabledegreeoflearning,skillandexperience
requiredbyhisprofession.Atthesametime,hemustapplyreasonablecareanddiligenceintheexerciseofhis
skillandtheapplicationofhisknowledge,andexerthisbestjudgment.

WHEREFORE,weDENYallthepetitionsandAFFIRMthechallengedDecisionoftheCourtofAppealsinCAG.R.
CVNo.42062andCAG.R.SPNo.32198.

CostsagainstpetitionersPSIandDr.MiguelAmpil.

SOORDERED.

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ANGELINASANDOVALGUTIERREZ
AssociateJustice

WECONCUR:

REYNATOS.PUNO
ChiefJustice
Chairperson

RENATOC.CORONA ADOLFOS.AZCUNA
AssociateJustice AsscociateJustice

(NoPart)
CANCIOC.GARCIA
AssociateJustice

CERTIFICATION

Pursuant to Article VIII, Section 13 of the Constitution, it is hereby certified that the conclusions in the above
Decision were reached in consultation before the case was assigned to the writer of the opinion of the Courts
Division.

REYNATOS.PUNO
ChiefJustice

Footnotes
*
Nopart.PonenteoftheassailedDecisionintheCourtofAppeals.
1 Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citing Darling v. Charleston Community
MemorialHospital,33Ill.2d326,211N.E.2d253.

2PennedbyAssociateJusticeCancioC.Garcia(nowamemberoftheSupremeCourt)andconcurredin
byAssociateJusticesEugenioS.LabitoriaandArtemioG.Tuquero(bothretired),Rollo,G.R.Nos.126297,
pp.3651126467,pp.2742127590,pp.2338.
3PennedbyJudgeLucasP.Bersamin(nowJusticeoftheCourtofAppeals),Rollo,G.R.No.126647,pp.
6983.

4Themedicalstaffwascomposedofphysicians,bothresidentsandinterns,aswellasnurses.

5Thedispositiveportionreads:

"WHEREFORE,letawritofpreliminaryinjunctionbeissueduponpetitionerspostingofbondinthe
amount of P20,000.00, ENJOINING public respondents from implementing the questioned order
dated September 21, 1993 and from further taking any action in Civil Case No. Q43322 entitled
Natividad G. Agana, et al., plaintiffs, versus Professional Services, Inc., et al., defendants pending
resolutionoftheinstantpetition.

SOORDERED."SeeRollo,G.R.No.126297,p.42.
6RolloofG.R.No.126467,pp.8489.

7RolloofG.R.No.127590,p.40.

8Rulev.Cheeseman,317P.2d472(1957),citingRusselv.Newman,116Kan.268P.752Bernsdenv.
Johnson,174Kan.230,255P.2d1033.

9 Smith v. Zeagler, 157 So. 328 Fla. (1934), citing Ruth v. Johnson, (C.C.A.) 172 F. 191 Reeves v. Lutz,
179 Mo. App. 61, 162 S.W. 280 Rayburn v. Day, 126 Or. 135,268 P. 1002, 59 A.L.R. 1062 Wynne v.
Harvey, 96 Wash. 379, 165 P. 67 Harris v. Fall (C.C.A.) 177 F. 79, 27 L.R.A. (N.S.) 1174 Moore v. Ivey,
(Tex.Civ.App.)264S.W.28321R.C.L.388.
10157So.328Fla.(1934)

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11GarciaRuedav.Pascasio,G.R.No.118141,September5,1997,278SCRA769.

12 In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181 [1957]), this Court laid down the
followingdefinitionofproximatecauseinthisjurisdictionasfollows:

[T]hatcause,which,innaturalandcontinuoussequenceunbrokenbyanyefficientinterveningcause,
produces the injury and without which the result would not have occurred. And more
comprehensively,theproximatecauseisthatactingfirstandproducingtheinjury,eitherimmediately
orbysettingothereventsinmotion,allconstitutinganaturalandcontinuouschainofevents,each
having a close causal connection with the immediate predecessor, the final event in the chain
immediatelyeffectingtheinjuryasanaturalandprobableresultofthecausewhichfirstacted,under
whichcircumstancesthatthepersonresponsibleforthefirsteventshould,asanordinarilyprudent
andintelligentperson,havereasonablegroundtoexpectatthemomentofhisactordefaultthatan
injurytosomepersonmightprobablyresulttherefrom.
13Ramosv.CourtofAppeals,G.R.No.124354,December29,1999,321SCRA584.

14Africav.Caltex(Phils.)Inc.,123Phil.280(1966).

15Ranos v. Court of Appeals, supra. In Ramos, the phrase used is "control of the instrumentality which
causedthedamage,"citingSt.JohnsHospitalandSchoolofNursingv.Chapman,434P2d160(1967).

16RuralEducationalAssnv.Bush,42Tenn.App.34,298S.W.2d761(1956).

17Ramosv.CourtofAppeals,supraatfootnote13.

18Levin,HospitalVicariousLiabilityforNegligencebyIndependentContractorPhysicians:ANewRulefor
NewTimes,October17,2005.

19Id.

20Id.

21Tolentino,TheCivilCodeofthePhilippines,VolumeV,1992Ed.,p.616.

22ArkansasM.R.Co.v.Pearson,98Ark.442,153SW595(1911)Runyanv.Goodrum,147Ark.281,228
SW397,13ALR1403(1921)Rosanev.Senger,112Colo.363,149P.2d372(supersededbystatuteon
othergrounds)Moonv.MercyHosp.,150Col.430,373P.2d944(1962)Austinv.Litvak,682P.2d41,50
ALR4th225(1984)WesternIns.Co.v.Brochner,682P.2d1213(1983)Rodriguezv.Denver,702P.2d
1349(1984).

23 Arkansas M.R. Co. v. Pearson, id. Nieto v. State, 952 P. 2d 834 (1997). But see Beeck v. Tucson
General Hosp., 18 Ariz. App. 165, 500 P. 2d 1153 (1972) Paintsville Hosp. Co., 683 SW 2d 255 (1985)
Kelley v. Rossi, 395 Mass. 659, 481 NE 2d 1340 (1985) which held that a physicians professional status
doesnotpreventhimorherfrombeingaservantoragentofthehospital.
24Fridenav.Evans,127Ariz.516,522P.2d463(1980).

25Kittov.Gilbert,39ColoApp374,570P.2d544(1977).

26211N.Y.125,105N.E.92,52L.R.A.,N.S.,505(1914).ThecourtinSchloendorffopinedthatahospital
doesnotactthroughphysiciansbutmerelyprocuresthemtoactontheirowninitiativeandresponsibility.
Forsubsequentapplicationofthedoctrine,seeforinstance,Hendricksonv.Hodkin,250App.Div649,294
NYS982,revdonothergrounds,276NY252,11NE2d899(1937)Necolayffv.GeneseeHosp.,270App.
Div.648,61NYS2d832,affd296NY936,73NE2d117(1946)Daviev.LenoxHillHosp.,Inc.,81NYS2d
583 (1948) Roth v. Beth El Hosp., Inc., 279 App. Div 917, 110 NYS 2d 583 (1952) Rufino v. US, 126 F.
Supp.132(1954)Mrachekv.SunshineBiscuit,Inc.,308NY116,123N.E.2d801(1954).

272NY2d656,163NYS2d3,143N.E.2d3(1957).

28Supraatfootnote13.

29 Blacks Law Dictionary (6th Ed. 1990) 1100. The terms "ostensible agency," "agency by estoppel,"
"apparentauthority,"and"holdingout"tendtobeusedinterchangeablybythecourtstorefertothistheory
ofliability.Seeforinstance,Bakerv.Werner,654P2d263(1982)andAdamskiv.TacomaGen.Hosp.,20
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WashApp.98,579P2d970(1978).Agencybyestoppelisdefinedas"onecreatedbyoperationoflawand
establishedbyproofofsuchactsoftheprincipalasreasonablyleadthirdpersonstotheconclusionofits
existence. Arises where principal by negligence in failing to supervise agents affairs, allows agent to
exercise powers not granted to him, thus justifying others in believing the agent possesses requisite
authority."Blacks, supra, p. 62. An ostensible agency is "an implied or presumptive agency which exists
whereone,eitherintentionallyorfromwantofordinarycare,inducesanothertobelievethatathirdperson
ishisagent,thoughheneverinfact,employedhim.Itis,strictlyspeaking,noagencyatall,butisinreality
based entirely upon estoppel." Apparent authority refers to "the power to affect the legal relations of
anotherpersonbytransactionswiththirdpersons,professedlyasagentfortheother,arisingfromandin
accordancewiththeothersmanifestationstosuchthirdpersons."Supra,p.96.
30Irvingv.DoctorsHospitalofLakeWorth,Inc.,415So.2d55(1982),quotingArthurv.St.PetersHospital,
169N.J.575,405A.2d443(1979).
31Id.,citingHudsonv.C.,LoanAssn.,Inc.v.Horowytz,116N.J.L.605,608,186A437(Sup.Ct.1936).

32Supra.

33RTCDecision,p.9,RolloofG.R.No.126467,p.127.

34RTCDecision,p.2,RolloofG.R.No.126467,p.120.

35Purcellv.Zimbelman,18Ariz.App.75,500P2d335(1972).

36Supraatfootnote1.

37Corletov.Hospital,138N.J.Super.302,350A.2d534(Super.Ct.LawDiv.1975)Purcellv.Zimbelman,
18Ariz.App.75,500P.2d335(1972)HospitalAuthorityv.Joiner,229Ga.140,189S.E.2d412(1972).

38Welshv.Bulger,548Pa.504,698A.2d581(1997).

39115Ariz.34,545P2d958(1976).

40262S.E.2d391,certdenied300NC194,269S.E.2d621(1980).

41127Ariz.516,622P.2d463(1980).

TheLawphilProjectArellanoLawFoundation

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