LEGAL MEDICINE NOTES FINALS 2019

Asphyxia - lack of oxygen or excess of carbon dioxide in the body. Asphyxia may lead to unconsciousness,
seizures, damage to various sensory systems and death.

The term 'asphyxia' literally means lack of oxygen, though etymologically, asphyxia means [1]'absence of
pulsations'. Serious deprivation of oxygen for 5-10 minutes can result in permanent damage to CNS and CVS,
resulting death. Manner of death by mechanical asphyxia include: Suicidal, homicidal or accidental.

Choking. This is when food or an object gets stuck in your airway and blocks air from getting to your lungs. The
elderly have a greater chance of this happening to them, especially those who live alone, wear dentures, or
have trouble swallowing. Babies and toddlers also have higher odds of choking on large pieces of food or
things they put in their mouths.

Aspiration. It's different from choking. Aspiration happens when something you eat or drink "goes down the
wrong pipe" and enters your airway or lungs. The substance crowds out the air in your body. Drowning is the
most common type of aspiration.

Suffocation (smothering). Suffocation happens when something heavy covers the face or chest and prevents
you from breathing. It also occurs when you are in a place where oxygen runs out, such as a closed-in, airtight
space.

Strangulation. If a cord or rope or other object long enough to go around your neck presses on the airway, it
blocks air from getting to your lungs.

Drug overdose. Opioids affect your breathing. When you take too high a dose, it can slow down your breathing
to the point that your body does not take in enough oxygen.

Birth asphyxia. Sometimes, an unborn child may get too little oxygen during pregnancy. This might happen, for
example, because of a lack of oxygen in the mother's blood, or problems with the placenta. During delivery, the
baby can also not get oxygen because of umbilical cord problems or a long labor.

Seizure. It can cause asphyxia in several ways. Epileptic seizures may make your breathing suddenly pause
(also called apnea), and lower oxygen in your body to life-threatening levels. Also, during a seizure, your body
may move in such a way that your airway gets covered, blocking your breathing.

Illnesses or injuries, like heart failure, a broken neck, or an allergic reaction that causes airways to swell and
close, can also cause physical asphyxia.

Chemical Asphyxia - another type of asphyxia is called "chemical." In this type, a chemical keeps oxygen from
reaching your cells.

Chemicals that can cause asphyxia include:

Carbon monoxide. This is a colorless, odorless gas that comes from burning different types of fuel. If you
breathe in too much of it, the gas builds up in your body and replaces the oxygen in your blood.

Cyanide. It keeps cells from taking oxygen in. You're at risk of cyanide poisoning if you breathe smoke during a
fire, have contact with certain industrial chemicals, or work in jobs like mining or metalworking.
Hydrogen sulfide. This gas smells like a rotten egg. It can come from sewage, liquid manure, sulfur hot springs,
and natural gas. If you breathe in too much, it can prevent oxygen from entering your cells, much like cyanide
does.

RAPE
Hymen - Thin membrane, in females, that separates the external genitalia from the vagina. The outer surface
is a dry, squamous epithelium, and the inner surface is a moist mucous membrane.
Virgin – A woman who has had no carnal knowledge of man. Her genital organs have not been altered by
carnal connection.

Virginity - A condition of a female who has not experience sexual intercourse and whose genital organs have
not been altered by carnal connection and whose hymen is still intact.

Kinds of Virginity:

1. Moral virginity – the state of not knowing the nature of sexual life and not having experience sexual relations.
2. Physical Virginity – A condition whereby a woman is conscious of the nature of sexual life but has not
experienced sexual intercourse.
3. Demi–virginity – This term refers to a condition of a woman who permits any form of sexual liberties as long
as they abstain from rupturing the hymen by the sexual act. The woman allows sexual intercourse, but only
inter femora or even inter labia, but not to the extent of rupturing the hymen.
4. Virgo intacta – A truly virgin woman. There is no structural change in her organ, notwithstanding the fact of
previous sexual intercourse.

Carnal Knowledge - is the act of a man in having a sexual bodily connection with a woman. There is carnal
knowledge if there is the slightest penetration in the sexual organ of the female by the sexual organ of the
male.

Virtuous Female - If her body is pure and if she has never had any sexual intercourse with another through her
mind and heart is impure.

Republic Act 8353 The Anti-Rape Law of 1997

"AN ACT EXPANDING THE DEFINITION OF THE CRIME OF RAPE, RECLASSIFYING THE SAME AS A
CRIME AGAINST PERSONS, AMENDING FOR THE PURPOSE ACT NO. 3815, AS AMENDED,
OTHERWISE KNOWN AS THE REVISED PENAL CODE, AND FOR THE PURPOSES"

Section 1. Short Title. - This Act shall be known as "The Anti-Rape Law of 1997."
Sec. 2. Rape as a Crime Against Persons. - The crime of rape shall hereafter be classified as a Crime Against
Persons under Title Eight of Act No. 3815, as amended, otherwise known as the Revised Penal Code.
Accordingly, there shall be incorporated into Title Eight of the same Code a new chapter to be known as
Chapter Three on Rape, to read as follows:

"Chapter Three"
"Rape"

"Article 266-A. Rape: When And How Committed. - Rape is committed:

"1) By a man who shall have carnal knowledge of a woman under any of the following circumstances:

"a) Through force, threat, or intimidation;

"b) When the offended party is deprived of reason or otherwise unconscious;

"c) By means of fraudulent machination or grave abuse of authority; and

"d) When the offended party is under twelve (12) years of age or is demented, even though none of
the circumstances mentioned above be present.

"2) By any person who, under any of the circumstances mentioned in paragraph 1 hereof, shall commit an act
of sexual assault by inserting his penis into another person's mouth or anal orifice, or any instrument or object,
into the genital or anal orifice of another person.
"Article 266-B. Penalty. - Rape under paragraph 1 of the next preceding article shall be punished by reclusion
perpetua.

"Whenever the rape is committed with the use of a deadly weapon or by two or more persons, the penalty shall
be reclusion perpetua to death.

"When by reason or on the occasion of the rape, the victim has become insane, the penalty shall become
reclusion perpetua to death.

"When the rape is attempted and a homicide is committed by reason or on the occasion thereof, the penalty
shall be reclusion perpetua to death.

"When by reason or on the occasion ofthe rape, homicide is committed, the penalty shall be death.

"The death penalty shall also be imposed if the crime of rape is committed with any of the following
aggravating/qualifying circumstances:

"l) When the victim is under eighteen (18) years of age and the offender is a parent, ascendant, step-parent,
guardian, relative by consanguinity or affinity within the third civil degree, or the common-law spouse of the
parent of the victim;

"2) When the victim is under the custody of the police or military authorities or any law enforcement or penal
institution;

"3) When the rape is committed in full view of the spouse, parent, any of the children or other relatives within
the third civil degree of consanguinity;

"4) When the victim is a religious engaged in legitimate religious vocation or calling and is personally known to
be such by the offender before or at the time of the commission of the crime;

"5) When the victim is a child below seven (7) years old;

"6) When the offender knows that he is afflicted with the Human Immuno-Deficiency Virus (HIV)/Acquired
Immune Deficiency Syndrome (AIDS) or any other sexually transmissible disease and the virus or disease is
transmitted to the victim;

"7) When committed by any member of the Armed Forces of the Philippines or para-military units thereof or the
Philippine National Police or any law enforcement agency or penal institution, when the offender took
advantage of his position to facilitate the commission of the crime;

"8) When by reason or on the occasion of the rape, the victim has suffered permanent physical mutilation or
disability;

"9) When the offender knew of the pregnancy of the offended party at the time of the commission of the crime;
and

"10) When the offender knew of the mental disability, emotional disorder and/or physical handicap of the
offended party at the time of the commission of the crime.

"Rape under paragraph 2 of the next preceding article shall be punished by prision mayor.

"Whenever the rape is committed with the use of a deadly weapon or by two or more persons, the penalty shall
be prision mayor to reclusion temporal.

"When by reason or on the occasion of the rape, the victim has become insane, the penalty shall be reclusion
temporal.
"When the rape is attempted and a homicide is committed by reason or on the occasion thereof, the penalty
shall be reclusion temporal to reclusion perpetua.

"When by reason or on the occasion ofthe rape, homicide is committed, the penalty shall be reclusion
perpetua.

"Reclusion temporal shall be imposed if the rape is committed with any of the ten aggravating/ qualifying
circumstances mentioned in this article.

"Article 266-C. Effect of Pardon. - The subsequent valid marriage between the offended party shall extinguish
the criminal action or the penalty imposed.

"In case it is the legal husband who is the offender, the subsequent forgiveness by the wife as the offended
party shall extinguish the criminal action or the penalty: Provided, That the crime shall not be extinguished or
the penalty shall not be abated if the marriage is void ab initio.

"Article 266-D. Presumptions. - Any physical overt act manifesting resistance against the act of rape in any
degree from the offended party, or where the offended party is so situated as to render her/him incapable of
giving valid consent, may be accepted as evidence in the prosecution of the acts punished under Article 266-
A."

Sec. 3. Separability Clause. - If any part, Sec., or provision of this Act is declared invalid or unconstitutional,
the other parts thereof not affected thereby shall remain valid.

Sec. 4. Repealing Clause. - Article 336 of Act No. 3815, as amended, and all laws, acts, presidential decrees,
executive orders, administrative orders, rules and regulations inconsistent with or contrary to the provisions of
this Act are deemed amended, modified or repealed accordingly.

Sec. 5. Effectivity. - This Act shall take effect fifteen (15) days after completion of its publication in two (2)
newspapers of general circulation. Approved: September 30, 1997.

Fortun Narvasa & Salazar

Medical Malpractice: 4 Elements to Understand
By: Paolo Miguel C. Gonzales

The most important goal of the medical profession is the preservation of life and health of the people. But what
happens when a medical professional causes bodily harm or even death to his or her patient? What is the
remedy available to the patient?
The remedy available is called a medical malpractice suit. In the Philippines, a medical malpractice suit is
primarily governed by the Civil Law concept of damages.

In order to successfully pursue a medical malpractice suit, the patient must prove the four (4) elements
of medical negligence. The four (4) elements are (1) duty; (2) breach; (3) injury; and (4) proximate
causation. Recent cases will illustrate how these 4 elements interact in order to pursue a successful medical
malpractice suit.

Is there a Physician-Patient Relationship?

Duty means that there is a professional relationship between the doctor and the patient. This relationship is
created when the patient engages the services of the doctor and the doctor agrees to provide care to the
patient.

To illustrate, let us take the case of Jarcia v. People of the Philippines (G.R. No. 187926, February 15,
2012). In Jarcia, the patient was hit by a taxicab and was rushed to the hospital. The two doctors who attended
the patient ordered an X-ray, which showed no fracture. The doctors informed the mother of the patient that
since it was only the ankle of the patient that was hit by the taxicab, there is no need to examine the upper leg.
Unfortunately, the patient subsequently developed fever, swelling of the right leg, and misalignment of the right
foot. A new X-ray revealed a mid tibial fracture and a linear hairline fracture in the shaft of the patient’s bone.

The two doctors raised the argument that there is no physician-patient relationship in this case. They claim that
they were merely passing by the emergency room for lunch when the nurse requested them to see the patient.
The Supreme Court struck down the arguments of the doctors and said that when they examined the victim
and gave assurances to the victim’s mother, a clear physician-patient relationship existed between the parties.
Thus, the two doctors were under a duty to exercise the same degree of care, skill and diligence which
physicians in the same line of practice ordinarily possess.

Standard of Breach
The breach referred to in medical malpractice cases is the breach of the standard of care expected of other
similarly trained medical professionals acting under the same circumstances.
Let us take the example of Borromeo v. Family Care Hospital, Inc. (G.R. No. 191018, January 25, 2016). In
Borromeo, the patient was complaining of acute pain and fever for two days. The doctor suspected that the
patient might be suffering from acute appendicitis. After several inconclusive tests, the doctor decided to
perform an exploratory laparotomy. After the surgery, the patient’s blood pressure suddenly dropped.
Furthermore, the patient developed petechiae in various parts of her body. The doctor suspected that the
patient has Disseminated Intravascular Coagulation, which is a blood disorder. Unfortunately, attempts to
resuscitate the patient failed.

The Supreme Court held that there is no medical malpractice since the cause of the uncontrollable bleeding
was a medical disorder, Disseminated Intravascular Coagulation. In this case there is no proof that the doctor
fell short of the expected standard required under the circumstances.

Injury as a Result of Breach

The element of injury to the patient in medical malpractice cases is straightforward – it is the direct result of the
doctor’s breach.

The case of Rosit v. Davao Doctors Hospital (G.R. No. 210445, December 7, 2015) perfectly illustrates how
an injury to the patient can take place. In Rosit, the patient figured in a motorcycle accident, which fractured his
jaw. During the operation, the doctor used a metal plate fastened to the jaw of the patient with metal screws to
immobilize his mandible. However, despite the doctor’s knowledge that the operation requires the smallest
screws available, the doctor simply cut the larger screws which were on hand. The doctor also knew that the
smaller screws were available in Manila, but he simply assumed that the patient would not be able to afford the
same.
Following the procedure, the patient could no longer properly open or close his mouth and was in constant
pain. X-rays done on the patient revealed that the modified screws placed by the doctor reached the molar of
the patient. The patient then had to seek the services of another doctor to undo the damage.

In this case, the Supreme Court held that the doctor is liable for at least three types of damages, namely:
actual, moral and exemplary damages. First, the patient was able to claim actual damages since he was able
to prove the definite expenses that he incurred due to the negligence of the doctor. Second, the patient was
likewise able to claim moral damages because of the unnecessary physical suffering he endured as a
consequence of the doctor’ negligence. Third, the patient was entitled to exemplary damages because the
doctor acted in bad faith or in a wanton, fraudulent, reckless, oppressive manner when he did not inform the
patient of the risks of using large screws for the operation.

Proximate Cause
Proximate causation refers to the relation between the negligence or breach of the doctor and the resulting
injury of the patient. The negligence or breach must have played an integral part in causing the injury or
damage. In other words, the injury to the patient is either a direct result or a reasonably probable consequence
of the negligence or breach of the doctor.
An illustration of proximate causation is provided for in the case of Casumpang v. Cortejo (G.R. No. 171127,
March 11, 2015).

In Casumpang, the patient is an 11-year old boy who initially complained of difficulty in breathing, chest pain,
stomach pain and fever. The doctor who examined the patient diagnosed him with bronchopneumonia.
However, the mother of the patient raised her doubts with the doctor’s diagnosis since her son had a high fever
but did not have any colds or cough.
The following day, the mother of the patient informed the doctor that there were traces of blood in her son’s
sputum. However, the doctor simply nodded and reassured them that it was due to bronchopneumonia. Later
that morning, the patient vomited phlegm with blood streaks. He was attended to by one of the resident
physicians. Several tests were ordered done on the patient. When the tests came out, the results showed that
the patient was suffering from Dengue Hemorrhagic Fever.

The Supreme Court held that the doctor is liable for medical malpractice. In determining whether or not the
negligence of the doctor is the proximate cause for the patient’s death, the court looked at the nature of
Dengue. The court considered expert testimony stating that with correct and timely diagnosis and proper
medical management, dengue fever is not a life threatening disease and could easily be cured. In fact, the
mortality rate of dengue fever should fall to less than 2%. Thus, the proximate cause of patient’ death is the
failure of the doctor to timely diagnose dengue, despite the presence of its characteristic symptoms.

Captain of the Ship Doctrine

Aside from the four (4) elements of Medical Malpractice cases, there are specific doctrines that should be
taken into consideration in determining physician’s liability.

Under the Captain of the Ship Doctrine, the operating surgeon is the person in complete charge of the surgery
room and all personnel connected with the operation. In Professional Services Inc. v. Agana (G.R. No.
126297, February 2, 2010), the patient was rushed to the hospital wherein a doctor diagnosed her to be
suffering from cancer of the sigmoid. While performing anterior resection surgery on the patient, the doctor
discovered that the malignancy in the patient’s sigmoid had already spread to her ovary. This prompted the
doctor to obtain the consent of the patient’s husband, to permit another doctor to perform hysterectomy.

After completion of the hysterectomy, the first doctor took over and decided to close the incision despite the
fact that the attending nurses informed him that there were missing gauzes. After her release from the hospital,
the patient complained of excruciating pain in her anal region. Subsequently, the patient’s daughter found a
piece of gauze protruding from her vagina. The doctor was able to remove the gauze but the pain did not
subside. Upon consulting other doctors, another gauze was found inside the patient’s vagina, which was
already causing infection.

The Supreme Court applied the Captain of the Ship Doctrine in upholding the liability of the doctor. The Court
stressed that as the lead surgeon, the doctor had the duty to remove all foreign objects from the patient’s body
before the closure of the incision. At the very least, the doctor should have informed the patient of his failure to
do so. The act of ordering the closure of the incision notwithstanding that the pieces of gauze remained
unaccounted for bolstered the application of the doctrine.

For victims of possible medical malpractice cases, we recommend that you immediately seek the advice of a
legal counsel. A legal counsel should be able to provide advice on the proper course of action to take, from
initial consultations to the possible filing of appropriate actions in court.

© 2019 Fortun Narvasa & Salazar.