DR. RUBI LI, Petitioner, v. SPOUSES REYNALDO and LINA SOLIMANFACTS:

OnJuly 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the mass located in her lower extremity at the St. Lukes Medical Center (SLMC).Results showed that Angelica was suffering fromosteosarcoma,osteoblastic type,a high-grade (highly malignant) cancer of the bone which usually afflicts teenage children.Following this diagnosis and as primary intervention, Angelicas right leg was amputated by Dr. Jaime Tamayo in order to remove the tumor.As adjuvant treatment to eliminate any remaining cancer cells, and hence minimize the chances of recurrence and prevent the disease from spreading to other parts of the patients body (metastasis), chemotherapy was suggested by Dr. Tamayo.Dr. Tamayo referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.OnAugust 18, 1993, Angelica was admitted to SLMC.However, she died onSeptember 1, 1993, just eleven (11) days after the (intravenous) administration of the first cycle of the chemotherapy regimen.Because SLMC refused to release a death certificate without full payment of their hospital bill, respondents brought the cadaver of Angelica to the Philippine National Police (PNP) Crime Laboratory atCampCramefor post-mortem examination.The Medico-Legal Report issued by said institution indicated the cause of death as "Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation."OnFebruary 21, 1994, respondents filed a damage suitagainst petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them with negligence and disregard of Angelicas safety, health and welfare by their careless administration of the chemotherapy drugs, their failure to observe the essential precautions in detecting early the symptoms of fatal blood platelet decrease and stopping early on the chemotherapy, which bleeding led to hypovolemic shock that caused Angelicas untimely demise.On her part, Dr. Balmaceda declared that it is the physicians duty to inform and explain to the patient or his relatives every known side effect of the procedure or therapeutic agents to be administered, before securing the consent of the patient or his relatives to such procedure or therapy.The physician thus bases his assurance to the patient on his personal assessment of the patients condition and his knowledge of the general effects of the agents or procedure that will be allowed on the patient.Dr. Balmaceda stressed that the patient or relatives must be informed of all known side effects based on studies and observations, even if such will aggravate the patients condition.In dismissing the complaint, the trial court held that petitioner was not liable for damages as she observed the best known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on Angelica but despite all efforts said patient died.ISSUE: Whether the petitioner can be held liable for failure to fully disclose serious side effects to the parents of the child patient who died while undergoing chemotherapy, despite the absence of finding that petitioner was negligent in administering the said treatmentHELD. NoMedical Malpractice; Medical malpractice, or more appropriately, medical negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm.—The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health care provider would have done, or that he or she did something that a reasonably prudent provider would not have done; and that that failure or action caused injury to the patient.SAME; Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the SAME general neighborhood and in the SAME general line of practice as defendant physician or surgeon.—This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the SAME general neighborhood and in the SAME

general line of practice as defendant physician or surgeon. The deference of courts to the expert opinion of qualified physicians stems from the former’s realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating, hence the indispensability of expert testimonies.SAME; Doctrine of Informed Consent; Informed consent evolved into a general principle of law that 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.—The doctrine of informed consent within the context of physician-patient relationships goes far back into English common law. As early as 1767, doctors were charged with the tort of “battery” (i.e., an unauthorized physical contact with a patient) if they had not gained the consent of their patients prior to performing a surgery or procedure. In the United States, the seminal case was Schoendorff v. Society of New York Hospital which involved unwanted treatment performed by a doctor. Justice Benjamin Cardozo’s oft-quoted opinion upheld the basic right of a patient to give consent to any medical procedure or treatment: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent, commits an assault, for which he is liable in damages.” From a purely ethical norm, informed consent evolved into a general principle of law that 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.SAME; SAME; Proficiency in diagnosis and therapy is not the full measure of a physician’s responsibility; The physician is not expected to give the patient a short medical education, the disclosure rule only requires of him a reasonable explanation, which means generally informing the patient in nontechnical terms as to what is at stake, the therapy alternatives open to him, the goals expectably to be achieved, and the risks that may ensure from particular treatment or no treatment.—The scope of disclosure is premised on the fact that patients ordinarily are persons unlearned in the medical sciences. Proficiency in diagnosis and therapy is not the full measure of a physician’s responsibility. It is also his duty to warn of the dangers lurking in the proposed treatment and to impart information which the patient has every right to expect. Indeed, the patient’s reliance upon the physician is a trust of the kind which traditionally has exacted obligations beyond those associated with armslength transactions. The physician is not expected to give the patient a short medical education, the disclosure rule only requires of him a reasonable explanation, which means generally informing the patient in nontechnical terms as to what is at stake; the therapy alternatives open to him, the goals expectably to be achieved, and the risks that may ensue from particular treatment or no treatment. As to the issue of demonstrating what risks are considered material necessitating disclosure, it was held that experts are unnecessary to a showing of the materiality of a risk to a patient’s decision on treatment, or to the reasonably, expectable effect of risk disclosure on the decision. Such unrevealed risk that should have been made known must further materialize, for otherwise the omission, however unpardonable, is without legal consequence. And, as in malpractice actions generally, there must be a causal relationship between the physician’s failure to divulge and damage to the patient.SAME; SAME; Four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent.—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.CARPIO, J., Dissenting Opinion:Medical Malpractice; Doctrine of Informed Consent; The doctrine of informed consent requires doctors, before administering treatment to their patients, to disclose adequately the material risks and side effects of the proposed treatment; it is distinct from the doctor’s duty to skillfully diagnose and treat the patient.—The doctrine of informed consent requires doctors, before administering treatment to their patients, to disclose adequately the material risks and side effects of the proposed treatment. The duty to obtain the patient’s informed consent is distinct from the doctor’s duty to skillfully diagnose and treat the patient.SAME; SAME; Two standards by which courts determine what constitutes adequate disclosure of associated risks and side effects of a proposed treatment: the physician standard, and the patient standard of materiality.—There are two standards by which courts determine what constitutes adequate disclosure of associated risks and side effects of a proposed treatment: the physician standard, and the patient standard of materiality. Under the physician standard, a doctor is obligated to disclose that information which a reasonable doctor in the SAME field of expertise would have disclosed to his or her patient. x x x Under the patient standard of materiality, a doctor is obligated to disclose that information which a reasonable patient would deem material in deciding whether to proceed with a proposed treatment.SAME; SAME; In order to determine what the associated risks and side effects of proposed treatment are, testimony by an expert witness is necessary because these are beyond the common knowledge of ordinary people.—In order to determine what the associated risks and side effects of a proposed treatment are, testimony by an expert witness is necessary because these are beyond the common knowledge of ordinary people. In Canterbury, the Court held that, “There are obviously important roles for medical testimony in [nondisclosure] cases, and some roles which only medical evidence can fill. Experts are ordinarily indispensable to identify and elucidate for the fact-finder the risks of therapy.” The Court also held that, “medical facts are for medical experts.”SAME; SAME; Under the patient standard of materiality, a doctor obligated to disclose that information which a reasonable patient would deem material in deciding whether to proceed with a proposed treatment.—Again, under the patient standard of materiality, a doctor is obligated to disclose that information which a reasonable patient would deem material in deciding whether to proceed with a proposed treatment. Stated differently, what should be disclosed depends on what a reasonable person, in the SAME or similar situation as the patient, would deem material in deciding whether to proceed with the proposed treatment.SAME; SAME; Dr. Li impliedly admits that she failed to disclose to Reynaldo and Lina many of the other associated risks and side effects of chemotherapy, including the most material—infection, sepsis and death.—Dr. Li impliedly admits that she failed to disclose to Reynaldo and Lina many of the other associated risks and side effects of chemotherapy, including the most material—infection, sepsis and death. She impliedly admits that she failed to disclose as risks and side effects (1) rashes; (2) difficulty in breathing; (3) fever; (4) excretion of blood in the mouth; (5) excretion of blood in the anus; (6) development of ulcers in the mouth; (7) sloughing off of skin; (8) systemic lupus erythematosus; (9) carpo-pedal spasm; (10) loose bowel movement; (11) infection; (12) gum bleeding; (13) hypovolemic shock; (14) sepsis; and (15) death in 13 days.SAME; SAME; Infection, sepsis and death are material risks and side effects of chemotherapy.—Clearly, infection, sepsis and death are material risks and side effects of chemotherapy. To any reasonable person, the risk of death is one of the most important, if not the most important, consideration in deciding whether to undergo a proposed treatment. Thus, Dr. Li should have disclosed to Reynaldo and Lina that there was a chance that their 11-year old daughter could die as a result of chemotherapy as, in fact, she did after only 13 days of treatment.BRION, J., Separate Opinion:Medical Malpractice; Philippine jurisprudence tells us that expert testimony is crucial, if not determinative of a physician’s liability in a medical negligence case; Expert testimony is, therefore,

essential since the factual issue of whether a physician or surgeon exercised the requisite degree of skill and care in the treatment of his patient is  generally a matter of expert opinion.—Philippine jurisprudence tells us that expert testimony is crucial, if not determinative of a physician’s liability in a medical negligence case. In litigations involving medical negligence as in any civil action, we have consistently ruled that the burden to prove by preponderance of evidence the essential elements—i.e., duty, breach, injury and proximate causation—rests with the plaintiff. Expert testimony is, therefore, essential since the factual issue of whether a physician or surgeon exercised the requisite degree of skill and care in the treatment of his patient is generally a matter of expert opinion.SAME; In the present case, expert testimony is required in determining the risks and or side effects of chemotherapy that the attending physician should have considered and disclosed as these are clearly beyond the knowledge of a layperson to testify on.—In the present case, expert testimony is required in determining the risks and or side effects of chemotherapy that the attending physician should have considered and disclosed as these are clearly beyond the knowledge of a layperson to testify on. In other words, to prevail in their claim of lack of informed consent, the respondents must present expert supporting testimony to establish the scope of what should be disclosed and the significant risks attendant to chemotherapy that the petitioner should have considered and disclosed; the determination of the scope of disclosure, and the risks and their probability are matters a medical expert must determine and testify on since these are beyond the knowledge of laypersons.SAME; Dr. Balmaceda’s testimony failed to establish the existence of the risks or side-effects the petitioner should have disclosed to them in the use of chemotherapy in the treatment of osteosarcoma.—Unfortunately for the respondents, Dr. Balmaceda’s testimony failed to establish the existence of the risks or side-effects the petitioner should have disclosed to them in the use of chemotherapy in the treatment of osteosarcoma; the witness, although a medical doctor, could not have testified as an expert on these points for the simple reason that she is not an oncologist nor a qualified expert on the diagnosis and treatment of cancers. Neither is she a pharmacologist who can properly advance an opinion on the toxic side effects of chemotherapy, particularly the effects of Cisplatin, Doxorubicin and Cosmegen—the drugs administered to Angelica. As a doctor whose specialty encompasses hospital management and administration, she is no different from a layperson for purposes of testifying on the risks and probabilities that arise from chemotherapy.SAME; Sufficiency of disclosure can be made only after determination and assessment of risks have been made.—The ponencia concludes that “there was adequate disclosure of material risks of the [chemotherapy administered] with the consent of Angelica’s parents” in view of the fact that the petitioner informed the respondents of the side effects of chemotherapy, such as low white and red blood cell and platelet count, kidney or heart damage and skin darkening. I cannot agree with this conclusion because it was made without the requisite premises. As heretofore discussed, sufficiency of disclosure can be made only after a determination and assessment of risks have been made. As discussed above, no evidence exists showing that these premises have been properly laid and proven. Hence, for lack of basis, no conclusion can be made on whether sufficient disclosure followed. In other words, the disclosure cannot be said to be sufficient in the absence of evidence of what, in the first place, should be disclosed.SAME; Specific disclosures such as life expectancy probabilities are not legally necessary or required to be disclosed in informed consent situations.—A third consideration is that specific disclosures such as life expectancy probabilities are not legally necessary or “required to be disclosed in informed consent situations,” thus the respondent Lina Soliman’s testimony on this point cannot be given any probative value. Thus, in the landmark case of Arato v. Avedon, —where family members of a patient who died of pancreatic cancer brought an informed consent action against defendant physicians who failed to provide the patient material information (statistical life expectancy) necessary for his informed consent to undergo chemotherapy and radiation treatment—the Supreme Court of California “rejected the mandatory disclosure of life expectancy probabilities” on account “of the variations among doctor-patient interactions and the intimacy of the relationship itself.”ABAD, J., Concurring Opinion:

Medical Malpractice; Doctrine of Informed Consent; The claim that Dr. Li gave assurance that Angelica had 95% chance of recovery after chemotherapy cannot be believed—it would be most unlikely for someone of Dr. Li’s expertise to make such a grossly reckless claim to a patient who actually had only a 20% chance of surviving the first year. She would literally be inviting a malpractice suit.—The claim that Dr. Li gave assurance that Angelica had a 95% chance of recovery after chemotherapy cannot be believed. The Solimans knew that their daughter had bone cancer. Having consulted with other doctors from four medical institutions, the Ago Medical and Educational Center in Bicol, the UERM Medical Center in Manila, the National Children’s Hospital in Quezon City, and finally the St. Luke’s hospital, all of whom gave the SAME dire opinion, it would be quite unlikely for the Solimans to accept Dr. Li’s supposed assurance that their daughter had 95% chance of returning to normal health after chemotherapy. In fact, it would be most unlikely for someone of Dr. Li’s expertise to make such a grossly reckless claim to a patient who actually had only a 20% chance of surviving the first year. She would literary be inviting a malpractice suit.SAME; SAME; Respondents are arguing from hindsight. The fact is that they were willing to assume huge risks on the chance that their daughter could cheat death.—The Solimans are arguing from hindsight. The fact is that they were willing to assume huge risks on the chance that their daughter could cheat death. They did not mind that their young daughter’s left leg would be amputated from above the knee for a 50% chance of preventing the spread of the cancer. There is probably no person on this planet whose family members, relatives, or close friends have not been touched by cancer. Every one knows of the travails and agonies of chemotherapy, yet it is rare indeed for a cancer patient or his relatives not to take a chance with this treatment, which had proved successful in extending the lives of some. Unfortunately for the Solimans, their daughter did not number among the successful cases.SAME; SAME; Respondents accepted the risks that chemotherapy offered with full knowledge of its effects on their daughter.—The Solimans accepted the risks that chemotherapy offered with full knowledge of its effects on their daughter. It is not fair that they should blame Dr. Li for Angelica’s suffering and death brought about by a decease that she did not wish upon her. Indeed, it was not Dr. Li, according to Reynaldo, who convinced him to agree to submit his daughter to chemotherapy but Dr. Tamayo. The latter explained to him the need for her daughter to undergo chemotherapy to increase the chance of containing her cancer. This consultation took place even before the Solimans met Dr. Li. [Li vs. Soliman, 651 SCRA 32(2011)]

Professional Services Inc. (PSI) v. Natividad and Enrique AganaFACTSNatividad Agana was rushed to Medical City because of difficulty of bowel movement and bloody anal discharge. Dr. Ampil diagnosed her to be suffering from cancer of the sigmoid. Dr. Ampil performed an anterior resection surgery on her, and finding that the malignancy spread on her left ovary, he obtained the consent of her husband, Enrique, to permit Dr. Fuentes to perform hysterectomy on her. After the hysterectomy, Dr. Fuentes showed his work to Dr. Ampil, who examined it and found it in order, so he allowed Dr. Fuentes to leave the operating room. Dr. Ampil was about to complete the procedure when the attending nurses made some remarks on the Record of Operation: “sponge count lacking 2; announced to surgeon search done but to no avail continue for closure” (two pieces of gauze were missing). A “diligent search” was conducted but they could not be found. Dr. Ampil then directed that the incision be closed.

A couple of days after, she complained of pain in her anal region, but the doctors told her that it was just a natural consequence of the surgery. Dr. Ampil recommended that she consult an oncologist to examine the cancerous nodes which were not removed during the operation. After months of consultations and examinations in the US, she was told that she was free of cancer. Weeks after coming back, her daughter found a piece of gauze (1.5 in) protruding from her vagina, so Dr. Ampil manually extracted this, assuring Natividad that the pains will go away. However, the pain worsened, so she sought treatment at a hospital, where another 1.5 in piece of gauze was found in her vagina. She underwent another surgery.

Sps. Agana filed a complaint for damages against PSI (owner of Medical City), Dr. Ampil, and Dr. Fuentes, alleging that the latter are liable for negligence for leaving 2 pieces of gauze in Natividad’s body, and malpractice for concealing their acts of negligence. Enrique Agana also filed an administrative complaint for gross negligence and malpractice against the two doctors with the PRC (although only the case against Dr. Fuentes was heard since Dr. Ampil was abroad). Pending the outcome of the cases, Natividad died (now substituted by her children). RTC found PSI and the two doctors liable for negligence and malpractice. PRC dismissed the case against Dr. Fuentes. CA dismissed only the case against Fuentes.

ISSUE AND HOLDINGWON CA erred in holding Dr. Ampil liable for negligence and malpractice. NO; DR. AMPIL IS GUILTYWON CA erred in absolving Dr. Fuentes of any liability. NOWON PSI may be held solidarily liable for Dr. Ampil’s negligence. YESCivil Law; Damages; Negligence; The leaving of sponges or other foreign substances in the wound after the incision has been closed is at least prima facie negligence by the operating surgeon.— An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed, and it is settled that the leaving of sponges or other foreign substances in the wound after the incision has been closed is at least prima facie negligence by the operating surgeon. 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 authorities to the effect that such act is negligence per se.SAME; SAME; SAME; To the mind of the Court, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.—Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain she was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have taken the immediate and appropriate medical remedy to remove the gauzes from her body. To our mind, what was initially an act of negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.SAME; SAME; SAME; Doctrine of Res Ipsa Loquitur; Requisites for the Applicability of the Doctrine.—Literally, res ipsa loquitur means “the thing speaks for itself.” It is the rule that the fact of the occurrence of an 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. Stated differently, where the thing which caused the injury, without the fault of the injured, is under the exclusive control of the defendant and the injury is such that it should not have occurred if he, having such control used proper care, it affords reasonable evidence, in the absence of explanation that the injury arose from the defendant’s want of care, and the burden of proof is shifted to him to establish that he has observed due care and diligence. From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the thing which caused the injury was under the control and management of the defendant; (3) the occurrence was such that in the ordinary course of things, would not have happened if those who had control or management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most instrumental is the “control and management of the thing which caused the injury.”SAME; SAME; SAME; SAME; Res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an independent or separate ground of liability, being a mere evidentiary rule.—In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an independent or separate ground of liability, being a mere evidentiary rule. In other words, mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. Here, the negligence was proven to have been committed by Dr. Ampil and not by Dr. Fuentes.SAME; SAME; SAME; Professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties and their employer cannot be held liable for such fault or negligence.—A prominent civilist commented that professionals engaged by an employer, such as

physicians, dentists, and pharmacists, are not “employees” under this article because the manner in which they perform their work is not within the control of the latter (employer). In other words, professionals are considered personally liable for the fault or negligence they commit in the discharge of their duties, and their employer cannot be held liable for such fault or negligence. In the context of the present case, “a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or operation of patients.”SAME; SAME; SAME; In this jurisdiction, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of the pronouncement in Ramos vs. Court of Appeals, 321 SCRA 584 (1999), that for purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.—In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of our categorical pronouncement in Ramos v. Court of Appeals, 321 SCRA 584 (1999), that for purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.SAME;SAME; SAME; PSI’s liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence.—But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also anchored upon the agency principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained acceptance in the determination of a hospital’s liability for negligent acts of health professionals. The present case serves as a perfect platform to test the applicability of these doctrines, thus, enriching our jurisprudence. Apparent authority, or what is sometimes referred to as the “holding out” theory, or doctrine of ostensible agency or agency by estoppel, has its origin from the law of agency. It imposes liability, not as the result of the reality of a contractual relationship, but rather because of the actions of a principal or an employer in somehow misleading the public into believing that the relationship or the authority exists. The concept is essentially one of estoppel and has been explained in this manner: “The principal is bound by the acts of his agent with the apparent authority which he knowingly permits the agent to assume, or which he holds the agent out to the public as possessing. The question in every case is whether the 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 agent has authority to perform the particular act in question.SAME; SAME; SAME; In cases where it can be shown that a hospital, by its actions, has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence.—The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. Doctor Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982). There, it was explicitly stated that “there does not appear to be any rational basis for excluding the concept of apparent authority from the field of hospital liability.” Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s negligence.SAME; SAME; SAME; By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its agents, authorized to perform medical or surgical services for its patients.—In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of Appeals’ conclusion that it “is now estopped from passing all the blame to the physicians whose names it proudly paraded in the public directory leading the public to believe that it vouched for their skill and competence.” Indeed, PSI’s act is tantamount to holding out to the public that Medical City Hospital, through its accredited physicians, offers quality health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its agents, authorized to perform

medical or surgical services for its patients. As expected, these patients, Natividad being one of them, accepted the services on the reasonable belief that such were being rendered by the hospital or its employees, agents, or servants. [Professional Services, Inc. vs. Agana, 513 SCRA 478(2007)]

Dr. Ninevetch Cruz v. CA and Lydia UmaliFACTSLydia Umali was examined by Dr. Cruz who found a myoma [benign tumor] in her uterus, and scheduled her for a hysterectomy operation [removal of uterus] on 23 Mar 1991. Rowena Umali de Ocampo accompanied her mother to the hospital a day before the operation, and they spent the night there. Rowena noticed that the clinic was untidy, so she tried to persuade her mother not to proceed with the operation. The following day, Rowena asked Dr. Cruz if the operation could be postponed, but Lydia told her daughter that Dr. Cruz said that the operation must go on as scheduled. While Lydia’s relatives were waiting, Dr. Ercillo (anesthesiologist) told them to buy tagamet ampules, and Rowena’s sister went out to buy some. An hour later, Dr. Ercillo asked them to buy blood for Lydia, so they did. A few hours later, the operation was finished, but later, Dr. Cruz asked the family to buy additional blood, but there was no more type A blood available in the blood bank. A person arrived to donate blood which was later transfused to Lydia. Rowena noticed that her mother was gasping for breath–apparently, the oxygen supply had run out, so the family went out to buy oxygen. Later in the evening, she went into shock and her blood pressure dropped. She was then transferred to another hospital so she could be connected to a respirator and further examined. However, this transfer was without the consent of the relatives, who only found out about it when an ambulance came to take Lydia to the other hospital.In the new hospital, she was re-operated upon by Dr. Cruz and Dr. Ercillo because blood was oozing out from her incision. They summoned Dr. Angeles, Ob-Gyne head of the new hospital, but when he arrived, Lydia was already in shock and possibly dead (BP: 0/0). Dr. Angeles told Drs. Cruz and Ercillo that there was nothing he could do. Lydia died while Dr. Cruz was closing her abdominal wall. Immediate cause of death is shock; disseminated intravascular coagulation (DIC) as antecedent cause.Dr. Cruz and Dr. Ercillo were charged with reckless imprudence and negligence resulting in homicide of Lydia Umali. The Municipal Trial Court in Cities (MTCC) found Dr. Ercillo not guilty for insufficiency of evidence against her, but held Dr. Cruz responsible for Umali’s death. RTC and CA affirmed MTCC.Manifestation of negligenceuntidiness of cliniclack of provision of suppliesthe fact that the transfer was needed meant that there was something wrong in the way Dr. Cruz conducted operationno showing that pre-surgery procedure (clearance, blood typing/tests) was conducted

ISSUE AND HOLDINGWON the circumstances are sufficient to sustain a judgment of conviction against Dr. Cruz for reckless imprudence resulting in homicide. NO. DR. CRUZ IS ACQUITTED, BUT SHE IS STILL CIVILLY LIABLE (50K civil liability; 100k moral damages, 50k exemplary damages).

HeldPhysicians; Medical Malpractice; Criminal Law; Reckless Imprudence; Elements.—This Court, however, holds differently and finds the foregoing circumstances insufficient to sustain a judgment of conviction against the petitioner for the crime of reckless imprudence resulting in homicide. The elements of reckless imprudence are: (1) that the offender does or fails to do an act; (2) that the doing or the failure to do that act is voluntary; (3) that it be without malice; (4) that material damage results from the reckless imprudence; and (5) that there is inexcusable lack of precaution on the part of the offender, taking into consideration his employment or occupation, degree of intelligence, physical condition, and other circumstances regarding persons, time and place.

SAME; SAME; SAME; Evidence; Witnesses; Expert Testimony; Whether or not a physician has committed an “inexcusable lack of precaution” in the treatment of his patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science; Inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that exp ert testimony is usually necessary to support the conclusion as to causation.—Whether or not a physician has committed an “inexcusable lack of precaution” in the treatment of his patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et al., this Court stated that in accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the SAME field, he will employ such training, care and skill in the treatment of his patients. He therefore has a duty to use at least the SAME level of care that any other reasonably competent doctor would use to treat a condition under the SAME circumstances. It is in this aspect of medical malpractice that expert testimony is essential to establish not only the standard of care of the profession but also that the physician’s conduct in the treatment and care falls below such standard. Further, inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually necessary to support the conclusion as to causation.SAME; SAME; SAME; SAME; SAME; SAME; While it may be true that certain circumstances pointed out by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, such conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion.—All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure to subject the patient to a cardio-pulmonary test prior to the operation; the omission of any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed about by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion. The deference of courts to the expert opinion of qualified physicians stems from its realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling below the standard of care employed by other physicians in good standing when performing the SAME operation. It must be remembered that when the qualifications of a physician are admitted, as in the instant case, there is an inevitable presumption that in proper cases he takes the necessary precaution and employs the best of his knowledge and skill in attending to his clients, unless the contrary is sufficiently established. This presumption is rebuttable by expert opinion which is so sadly lacking in the case at bench.SAME; SAME; SAME; SAME; Burden of Proof; In litigations involving medical negligence, the plaintiff has the burden of establishing the defendant’s negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a causal connection of such breach and the resulting death of his patient.—In litigations involving medical negligence, the plaintiff has the burden of establishing appellant’s negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a causal connection of such breach and the resulting death of his patient. In Chan Lugay v. St. Luke’s Hospital, Inc., where the attending physician was

absolved of liability for the death of the complainant’s wife and newborn baby, this Court held that: “In order that there may be a recovery for an injury, however, it must be shown that the ‘injury for which recovery is sought must be the legitimate consequence of the wrong done; the connection between the negligence and the injury must be a direct and natural sequence of events, unbroken by intervening efficient causes.’ In other words, the negligence must be the proximate cause of the injury. For, ‘negligence, no matter in what it consists, cannot create a right of action unless it is the proximate cause of the injury complained of.’ And ‘the proximate cause of an injury is that cause, which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces the injury, and without which the result would not have occurred.’ ” (Italics supplied.)SAME; SAME; SAME; Evidence; Damages; While a conviction of a crime requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability, thus, even as the Court was not able to render a sentence of conviction for insufficiency of evidence, the Court is not blind to the reckless and imprudent manner in which the surgeon carried out her duties.—Nevertheless, this Court finds the petitioner civilly liable for the death of Lydia Umali, for while a conviction of a crime requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability. The petitioner is a doctor in whose hands a patient puts his life and limb. For insufficiency of evidence this Court was not able to render a sentence of conviction but it is not blind to the reckless and imprudent manner in which the petitioner carried out her duties. A precious life has been lost and the circumstances leading thereto exacerbated the grief of those left behind. The heirs of the deceased continue to feel the loss of their mother up to the present time and this Court is aware that no amount of compassion and commiseration nor words of bereavement can suffice to assuage the sorrow felt for the loss of a loved one. Certainly, the award of moral and exemplary damages in favor of the heirs of Lydia Umali are proper in the instant case. [Cruz vs. Court of Appeals, 282 SCRA 188(1997)]

Flores vs. Pineda, 571 SCRA 83(2008)Teresita Pineda consulted Dr. Fredelicto Flores for her medical condition, where the latter ordered the former to undergo an “on call” D&C operation to be performed by Dr. Felicisima Flores, Fredelicto’s wife. After the operation, Teresita’s condition worsened and she died eventually. Believing that it was the negligence of Dr. Felicisima and Dr. Fredelicto, Teresita’s family filed a medical negligence case against the doctors.The trial court and the Court of Appeals ruled in favour of Teresita’s family. The spouses appealed. UMDC, the spouses’ co-defendant, filed a petition for a review on certiorari. The factual settings of the case presented that Teresita Pineda consulted Dr. Fredelicto Flores, where she complained of general body weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto interviewed Teresita and subsequently advised her to return the next week for a general check-up. She failed to return the next week as advised, but when her condition persisted, she further consulted Dr. Fredelicto at his UMDC clinic. The latter did a routine check-up and ordered her to undergo an “on-call” D&C operation to be performed by his wife, Dr. Felisima Flores. Teresita was taken to the operating room and had undergone a series of medical examinations. The preliminary laboratory results indicated that her blood sugar was high. After the operation, Teresita’s condition worsened. She had difficulty in breathing and was rushed to the intensive care unit. Tests confirmed that she was suffering from Diabetes Mellitus Type H. Insulin was administered on her but the medications were already too late and Teresita died eventually.IssueWhether or not spouses Dr. Fredelicto Flores and Dr. Felisima Flores are guilty of medical negligence.Ruling Yes. Dr. Fredelicto Flores and Dr. Felisima Flores are guilty of medical negligenceCivil Law; Negligence; Medical Negligence; A medical negligence is a type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to or the death of a patient; Elements Involved in a Medical Negligence Case; A physician is expected to use at least the SAME level of care that any other reasonably competent doctor would use under the SAME circumstances; Breach of duty occurs when the physician fails to comply with these professional standards.—A medical negligence case is a

type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to or the death of a patient. There are four elements involved in a medical negligence case, namely: duty, breach, injury, and proximate causation. Duty refers to the standard of behavior which imposes restrictions on one’s conduct. The standard in turn refers to the amount of competence associated with the proper discharge of the profession. A physician is expected to use at least the SAME level of care that any other reasonably competent doctor would use under the SAME circumstances. Breach of duty occurs when the physician fails to comply with these professional standards. If injury results to the patient as a result of this breach, the physician is answerable for negligence.SAME; SAME; SAME; To successfully pursue a claim, the plaintiff must prove by preponderance of evidence that, one, the physician either failed to do something which a reasonable prudent health care provider would have done, or that he did something that a reasonably prudent provider would not have done and two, the failure or action caused injury to the patient; Expert testimony is therefore essential.—As in any civil action, the burden to prove the existence of the necessary elements rests with the plaintiff. To successfully pursue a claim, the plaintiff must prove by preponderance of evidence that, one, the physician either failed to do something which a reasonably prudent health care provider would have done, or that he did something that a reasonably prudent provider would not have done; and two, the failure or action caused injury to the patient. Expert testimony is therefore essential since the factual issue of whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is generally a matter of expert opinion.SAME; SAME; SAME; If a patient suffers from some disability that increases the magnitude of risk to him, that disability must be taken into account so long as it is or should have been known to the physician.—Taken together, we find that reasonable prudence would have shown that diabetes and its complications were foreseeable harm that should have been taken into consideration by the petitioner spouses. If a patient suffers from some disability that increases the magnitude of risk to him, that disability must be taken into account so long as it is or should have been known to the physician. And when the patient is exposed to an increased risk, it is incumbent upon the physician to take commensurate and adequate precautions.SAME; SAME; SAME; The critical and clinching factor in a medical negligence case is proof of the causal connection between the negligence which the evidence established and the plaintiff’s injuries; Causation must be proven within a reasonable medical probability based upon competent expert testimony.—The critical and clinching factor in a medical negligence case is proof of the causal connection between the negligence which the evidence established and the plaintiff’s injuries; the plaintiff must plead and prove not only that he had been injured and defendant has been at fault, but also that the defendant’s fault caused the injury. A verdict in a malpractice action cannot be based on speculation or conjecture. Causation must be proven within a reasonable medical probability based upon competent expert testimony.SAME; SAME; Damages; The settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss.—Both the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the respondents suffered. The loss was presented in terms of the hospital bills and expenses the respondents incurred on account of Teresita’s confinement and death. The settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss. This proof the respondents successfully presented. Thus, we affirm the award of actual damages of P36,000.00 representing the hospital expenses the patient incurred.SAME; SAME; SAME; Article 2206 of the Civil Code allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or descendants as the persons entitled thereto.—The SAME article allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates the spouse, legitimate or illegitimate ascendants or descendants as the persons entitled thereto. Moral damages are designed to compensate the claimant for the injury suffered, that is, for the mental anguish, serious anxiety, wounded feelings which the respondents herein must have surely felt with the unexpected loss of their daughter. We affirm the appellate court’s award of P400,000.00 by way of moral damages to the respondents.

SAME; SAME; SAME; Damages; Exemplary Damages.—The Supreme Court similarly affirms the grant of exemplary damages. Exemplary damages are imposed by way of example or correction for the public good. Because of the petitioner spouses’ negligence in subjecting Teresita to an operation without first recognizing and addressing her diabetic condition, the appellate court awarded exemplary damages to the respondents in the amount of P100,000.00. Public policy requires such imposition to suppress the wanton acts of an offender. We therefore affirm the CA’s award as an example to the medical profession and to stress that the public good requires stricter measures to avoid the repetition of the type of medical malpractice that happened in this case. [Flores vs. Pineda, 571 SCRA 83(2008)]

Solidum vs. People, 718 SCRA 263(2014)On May 17, 1995, Gerald, then three years old, was admitted at the Ospital ng Maynila for a pull-through operation.[5] Dr. Leandro Resurreccion headed the surgical team, and was assisted by Dr. Joselito Luceño, Dr. Donatella Valeña and Dr. Joseph Tibio. The anesthesiologists included Dr. Marichu Abella, Dr. Arnel Razon and petitioner Dr. Fernando Solidum (Dr. Solidum).[6] During the operation, Gerald experienced bradycardia,[7] and went into a coma.[8] His coma lasted for two weeks,[9] but he regained consciousness only after a month.[10] He could no longer see, hear or move.[11]Agitated by her son’s helpless and unexpected condition, Ma. Luz Gercayo (Luz) lodged a complaint for reckless imprudence resulting in serious physical injuries with the City Prosecutor’s Office of Manila against the attending physicians.[12]Upon a finding of probable cause, the City Prosecutor’s Office filed an information solely against Dr. Solidum,[13] alleging: —That on or about May 17, 1995, in the City of Manila, Philippines, the said accused, being then an anesthesiologist at the Ospital ng Maynila, Malate, this City, and as such was tasked to administer the anesthesia on three-year old baby boy GERALD ALBERT GERCAYO, represented by his mother, MA. LUZ GERCAYO, the former having been born with an imperforate anus [no anal opening] and was to undergo an operation for anal opening [pull through operation], did then and there willfully, unlawfully and feloniously fail and neglect to use the care and diligence as the best of his judgment would dictate under said circumstance, by failing to monitor and regulate properly the levels of anesthesia administered to said GERALD ALBERT GERCAYO and using 100% halothane and other anesthetic medications, causing as a consequence of his said carelessness and negligence, said GERALD ALBERT GERCAYO suffered a cardiac arrest and consequently a defect  called hypoxic encephalopathy meaning insufficient oxygen supply in the brain, thereby rendering said GERALD ALBERT GERCAYO incapable of moving his body, seeing, speaking or hearing, to his damage and prejudice.ISSUE:(a) whether or not the doctrine of res ipsa loquitur was applicable herein; and (b) whether or not Dr. Solidum was liable for criminal negligence.RulingThe appeal is meritorious. [Solidum vs. People, 718 SCRA 263(2014)]HeldCivil Law; Quasi-Delicts; Res Ipsa Loquitur; The doctrine res ipsa loquitur means that “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.”—Res ipsa loquitur is literally translated as “the thing or the transaction speaks for itself.” The doctrine res ipsa loquitur means that “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.” It is simply “a recognition of the postulate that, as a matter of common knowledge and experience, the very nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the instrumentality causing the injury in the absence of some explanation by the defendant who is charged with negligence. It is grounded in the superior logic of ordinary human experience and on the

basis of such experience or common knowledge, negligence may be deduced from the mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge.”SAME; SAME; SAME; Essential Requisites Before Resorting to the Doctrine of Res Ipsa Loquitur.—In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1) the accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured.SAME; SAME; Negligence; Words and Phrases; Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care, precaution, and vigilance that the circumstances justly demand, whereby such other person suffers injury.—Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care, precaution, and vigilance that the circumstances justly demand, whereby such other person suffers injury. Reckless imprudence, on the other hand, consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform such act. Dr. Solidum’s conviction by the RTC was primarily based on his failure to monitor and properly regulate the level of anesthetic agent administered on Gerald by overdosing at 100% halothane.SAME; SAME; SAME; Medical Negligence; An action upon medical negligence — whether criminal, civil or administrative — calls for the plaintiff to prove by competent evidence each of the four elements.—An action upon medical negligence — whether criminal, civil or administrative — calls for the plaintiff to prove by competent evidence each of the following four elements, namely: (a) the duty owed by the physician to the patient, as created by the physician-patient relationship, to act in accordance with the specific norms or standards established by his profession; (b) the breach of the duty by the physician’s failing to act in accordance with the applicable standard of care; (3) the causation, i.e., there must be a reasonably close and causal connection between the negligent act or omission and the resulting injury; and (4) the damages suffered by the patient.SAME; SAME; SAME; SAME; In the medical profession, specific norms or standards to protect the patient against unreasonable risk, commonly referred to as standards of care, set the duty of the physician to act in respect of the patient.—In the medical profession, specific norms or standards to protect the patient against unreasonable risk, commonly referred to as standards of care, set the duty of the physician to act in respect of the patient. Unfortunately, no clear definition of the duty of a particular physician in a particular case exists. Because most medical malpractice cases are highly technical, witnesses with special medical qualifications must provide guidance by giving the knowledge necessary to render a fair and just verdict. As a result, the standard of medical care of a prudent physician must be determined from expert testimony in most cases; and in the case of a specialist (like an anesthesiologist), the standard of care by which the specialist is judged is the care and skill commonly possessed and exercised by similar specialists under similar circumstances. The specialty standard of care may be higher than that required of the general practitioner.SAME; SAME; SAME; SAME; In attempting to fix a standard by which a court may determine whether the physician has properly performed the requisite duty toward the patient, expert medical testimony from both plaintiff and defense experts is required.—The standard of care is an objective standard by which the conduct of a physician sued for negligence or malpractice may be measured, and it does not depend, therefore, on any individual physician’s own knowledge either. In attempting to fix a standard by which a court may determine whether the physician has properly performed the requisite duty toward the patient, expert medical testimony from both plaintiff and defense experts is required. The judge, as the trier of fact, ultimately determines the standard of care, after listening to the testimony of all medical experts.Remedial Law; Criminal Procedure; Prosecution of Offenses; Civil Liability; In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with the criminal action refers only

to that arising from the offense charged.—In criminal prosecutions, the civil action for the recovery of civil liability that is deemed instituted with the criminal action refers only to that arising from the offense charged. It is puzzling, therefore, how the RTC and the CA could have adjudged Ospital ng Maynila jointly and severally liable with Dr. Solidum for the damages despite the obvious fact that Ospital ng Maynila, being an artificial entity, had not been charged along with Dr. Solidum. The lower courts thereby acted capriciously and whimsically, which rendered their judgment against Ospital ng Maynila void as the product of grave abuse of discretion amounting to lack of jurisdiction.SAME; SAME; SAME; SAME; Ospital ng Maynila could be held civilly liable only when subsidiary liability would be properly enforceable pursuant to Article 103 of the Revised Penal Code.—Ospital ng Maynila could be held civilly liable only when subsidiary liability would be properly enforceable pursuant to Article 103 of the Revised Penal Code. But the subsidiary liability seems far-fetched here. The conditions for subsidiary liability to attach to Ospital ng Maynila should first be complied with. Firstly, pursuant to Article 103 of the Revised Penal Code, Ospital ng Maynila must be shown to be a corporation “engaged in any kind of industry.” The term industry means any department or branch of art, occupation or business, especially one that employs labor and capital, and is engaged in industry. However, Ospital ng Maynila, being a public hospital, was not engaged in industry conducted for profit but purely in charitable and humanitarian work. Secondly, assuming that Ospital ng Maynila was engaged in industry for profit, Dr. Solidum must be shown to be an employee of Ospital ng Maynila acting in the discharge of his duties during the operation on Gerald. Yet, he definitely was not such employee but a consultant of the hospital. And, thirdly, assuming that civil liability was adjudged against Dr. Solidum as an em- ployee (which did not happen here), the execution against him was unsatisfied due to his being insolvent. [Solidum vs. People, 718 SCRA 263(2014)]

Cayao-Lasam vs. Ramolete, 574 SCRA 439(2008)

On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner relayed via telephone, Editha was admitted to the LMC on the SAME day. A pelvic sonogram2 was then conducted on Editha revealing the fetus’ weak cardiac pulsation.3The following day, Editha’s repeat pelvic sonogram4 showed that aside from the fetus’ weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or “raspa.”On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged from the hospital the following day.On September 16, 1994, Editha was once again brought at the LMC, as she was suffering from vomiting and severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in the latter’s womb. After, Editha underwent laparotomy,5 she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy6 and as a result, she has no more chance to bear a child.On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed a Complaint7 for Gross Negligence and Malpractice against petitioner before the Professional Regulation Commission (PRC).Respondents alleged that Editha’s hysterectomy was caused by petitioner’s unmitigated negligence and professional incompetence in conducting the D&C procedure and the petitioner’s failure to remove the fetus inside Editha’s womb.8 Among the alleged acts of negligence were: first, petitioner’s failure to check up, visit or administer medication on Editha during her first day of confinement at the LMC;9 second, petitioner recommended that a D&C procedure be performed on Editha without conducting any internal examination prior to the procedure;10 third, petitioner immediately suggested a D&C procedure instead of closely monitoring the state of pregnancy of Editha.11

In her Answer,12 petitioner denied the allegations of negligence and incompetence with the following explanations: upon Editha’s confirmation that she would seek admission at the LMC, petitioner immediately called the hospital to anticipate the arrival of Editha and ordered through the telephone the medicines Editha needed to take, which the nurses carried out; petitioner visited Editha on the morning of July 28, 1994 during her rounds; on July 29, 1994, she performed an internal examination on Editha and she discovered that the latter’s cervix was already open, thus, petitioner discussed the possible D&C procedure, should the bleeding become more profuse; on July 30 1994, she conducted another internal examination on Editha, which revealed that the latter’s cervix was still open; Editha persistently complained of her vaginal bleeding and her passing out of some meaty mass in the process of urination and bowel movement; thus, petitioner advised Editha to undergo D&C procedure which the respondents consented to; petitioner was very vocal in the operating room about not being able to see an abortus;13 taking the words of Editha to mean that she was passing out some meaty mass and clotted blood, she assumed that the abortus must have been expelled in the process of bleeding; it was Editha who insisted that she wanted to be discharged; petitioner agreed, but she advised Editha to return for check-up on August 5, 1994, which the latter failed to do.Petitioner contended that it was Editha’s gross negligence and/or omission in insisting to be discharged on July 31, 1994 against doctor’s advice and her unjustified failure to return for check-up as directed by petitioner that contributed to her life-threatening condition on September 16, 1994; that Editha’s hysterectomy was brought about by her very abnormal pregnancy known as placenta increta, which was an extremely rare and very unusual case of abdominal placental implantation. Petitioner argued that whether or not a D&C procedure was done by her or any other doctor, there would be no difference at all because at any stage of gestation before term, the uterus would rupture just the SAME. [Cayao-Lasam vs. Ramolete, 574 SCRA 439(2008)]Issue: BOM not guilty- PRC Revoke license- CA improper venueHELD:Administrative Law; Double Jeopardy; Requisites; The principle of double jeopardy finds no application in administrative cases.—The principle of double jeopardy finds no application in administrative cases. Double jeopardy attaches only: (1) upon a valid indictment; (2) before a competent court; (3) after arraignment; (4) when a valid plea has been entered; and (5) when the defendant was acquitted or convicted, or the case was dismissed or otherwise terminated without the express consent of the accused. These elements were not present in the proceedings before the Board of Medicine, as the proceedings involved in the instant case were administrative and not criminal in nature. The Court has already held that double jeopardy does not lie in administrative cases.SAME; Physicians; Board of Medicine; Appeals; The right to appeal from a decision of the Board of Medicine to the Professional Regulation Commission is available to both complainants and respondents.—Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals cited by petitioner was subsequently amended to read: Sec. 35. The complainant/respondent may appeal the order, the resolution or the decision of the Board within thirty (30) days from receipt thereof to the Commission whose decision shall be final and executory. Interlocutory order shall not be appealable to the Commission. (Amended by Res. 174, Series of 1990). Whatever doubt was created by the previous provision was settled with said amendment. It is axiomatic that the right to appeal is not a natural right or a part of due process, but a mere statutory privilege that may be exercised only in the manner prescribed by law. In this case, the clear intent of the amendment is to render the right to appeal from a decision of the Board available to both complainants and respondents.SAME; Statutory Construction; It is an elementary rule that when the law speaks in clear and categorical language, there is no need, in the absence of legislative intent to the contrary, for any interpretation.—Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No. 06-342(A), or the New Rules of Procedure in Administrative Investigations in the Professional Regulation Commission and the Professional Regulatory Boards, which provides for the method of appeal, to wit: Sec. 1. Appeal; Period Non-Extendible.—The decision, order or resolution of the Board shall be final and executory after the lapse of fifteen (15) days from receipt of the decision, order or resolution without an appeal being

perfected or taken by either the respondent or the complainant. A party aggrieved by the decision, order or resolution may file a notice of appeal from the decision, order or resolution of the Board to the Commission within fifteen (15) days from receipt thereof, and serving upon the adverse party a notice of appeal together with the appellant’s brief or memorandum on appeal, and paying the appeal and legal research fees. x x x The above-stated provision does not qualify whether only the complainant or respondent may file an appeal; rather, the new rules provide that “a party aggrieved” may file a notice of appeal. Thus, either the complainant or the respondent who has been aggrieved by the decision, order or resolution of the Board may appeal to the Commission. It is an elementary rule that when the law speaks in clear and categorical language, there is no need, in the absence of legislative intent to the contrary, for any interpretation. Words and phrases used in the statute should be given their plain, ordinary, and common usage or meaning.SAME; SAME; Jurisdiction; Batas Pambansa (B.P.) Blg. 129 conferred upon the Court of Appeals (CA) exclusive appellate jurisdiction over appeals from decisions of the Professional Regulation Commission (PRC).—The PRC is not expressly mentioned as one of the agencies which are expressly enumerated under Section 1, Rule 43 of the Rules of Court. However, its absence from the enumeration does not, by this fact alone, imply its exclusion from the coverage of said Rule. The Rule expressly provides that it should be applied to appeals from awards, judgments final orders or resolutions of any quasi-judicial agency in the exercise of its quasi-judicial functions. The phrase “among these agencies” confirms that the enumeration made in the Rule is not exclusive to the agencies therein listed. Specifically, the Court, in Yang v. Court of Appeals, 186 SCRA 287 (1990), ruled that Batas Pambansa (B.P.) Blg. 129 conferred upon the CA exclusive appellate jurisdiction over appeals from decisions of the PRC.Physicians; Medical Malpractice; Words and Phrases; Medical malpractice is a particular form of negligence which consists in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed by the profession generally, under similar conditions, and in like surrounding circumstances; There are four elements involved in medical negligence cases—duty, breach, injury and proximate causation.—Anent the substantive merits of the case, petitioner questions the PRC decision for being without an expert testimony to support its conclusion and to establish the cause of Editha’s injury. Petitioner avers that in cases of medical malpractice, expert testimony is necessary to support the conclusion as to the cause of the injury. Medical malpractice is a particular form of negligence which consists in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill which is ordinarily employed by the profession generally, under similar conditions, and in like surrounding circumstances. In order to successfully pursue such a claim, a patient must prove that the physician or surgeon either failed to do something which a reasonably prudent physician or surgeon would not have done, and that the failure or action caused injury to the patient. There are four elements involved in medical negligence cases: duty, breach, injury and proximate causation.SAME; SAME; Witnesses; Expert Witnesses; The breach of professional duties of skill and care, or their improper performance by a physician surgeon, whereby the patient is injured in body or in health, constitutes actionable malpractice, and as to this aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential.—A physician-patient relationship was created when Editha employed the services of the petitioner. As Editha’s physician, petitioner was duty-bound to use at least the SAME level of care that any reasonably competent doctor would use to treat a condition under the SAME circumstances. The breach of these professional duties of skill and care, or their improper performance by a physician surgeon, whereby the patient is injured in body or in health, constitutes actionable malpractice. As to this aspect of medical malpractice, the determination of the reasonable level of care and the breach thereof, expert testimony is essential. Further, inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually necessary to support the conclusion as to causation.SAME; SAME; SAME; SAME; Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject matter about which he or she is to testify, either by the study of recognized

authorities on the subject or by practical experience.—In the present case, respondents did not present any expert testimony to support their claim that petitioner failed to do something which a reasonably prudent physician or surgeon would have done. Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo, who was clearly an expert on the subject. Generally, to qualify as an expert witness, one must have acquired special knowledge of the subject matter about which he or she is to testify, either by the study of recognized authorities on the subject or by practical experience. Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored various publications on the subject, and is a professor at the University of the Philippines.SAME; SAME; Negligence; Proximate Cause; Words and Phrases; Medical malpractice, in our jurisdiction, is often brought as a civil action for damages under Article 2176 of the Civil Code, and the defenses in an action for damages are provided for under Article 2179; Proximate cause is that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred.—Medical malpractice, in our jurisdiction, is often brought as a civil action for damages under Article 2176 of the Civil Code. The defenses in an action for damages, provided for under Article 2179 of the Civil Code are: Art. 2179. When the plaintiff’s own negligence was the immediate and proximate cause of his injury, he cannot recover damages. But if his negligence was only contributory, the immediate and proximate cause of the injury being the defendant’s lack of due care, the plaintiff may recover damages, but the courts shall mitigate the damages to be awarded. Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred. An injury or damage is proximately caused by an act or a failure to act, whenever it appears from the evidence in the case that the act or omission played a substantial part in bringing about or actually causing the injury or damage; and that the injury or damage was either a direct result or a reasonably probable consequence of the act or omission.SAME; SAME; SAME; SAME; SAME; Where the immediate cause of an accident resulting in an injury is the plaintiff’s own act, which contributed to the principal occurrence as one of its determining factors, he cannot recover damages for the injury; Contributory negligence is the act or omission amounting to want of ordinary care on the part of the person injured, which, concurring with the defendant’s negligence, is the proximate cause of the injury.—Contributory negligence is the act or omission amounting to want of ordinary care on the part of the person injured, which, concurring with the defendant’s negligence, is the proximate cause of the injury. Difficulty seems to be apprehended in deciding which acts of the injured party shall be considered immediate causes of the accident. Where the immediate cause of an accident resulting in an injury is the plaintiff’s own act, which contributed to the principal occurrence as one of its determining factors, he cannot recover damages for the injury. Again, based on the evidence presented in the present case under review, in which no negligence can be attributed to the petitioner, the immediate cause of the accident resulting in Editha’s injury was her own omission when she did not return for a follow-up check up, in defiance of petitioner’s orders. The immediate cause of Editha’s injury was her own act; thus, she cannot recover damages from the injury.Actions; Pleadings and Practice; Service of Notice; Burden of Proof; It is a well-settled rule that when service of notice is an issue, the rule is that the person alleging that the notice was served must prove the fact of service—the burden of proving notice rests upon the party asserting its existence.—It is a well-settled rule that when service of notice is an issue, the rule is that the person alleging that the notice was served must prove the fact of service. The burden of proving notice rests upon the party asserting its existence. In the present case, respondents did not present any proof that petitioner was served a copy of the Memorandum on Appeal. Thus, respondents were not able to satisfy the burden of proving that they had in fact informed the petitioner of the appeal proceedings before the PRC.SAME; SAME; SAME; Due Process; Failure of the appellant to furnish the appellee a copy of the Memorandum of Appeal submitted to the Professional Regulation Commission (PRC) constitutes a violation of due process.—In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission, 537 SCRA 409 (2007), in which the National Labor Relations Commission failed to order the private respondent to furnish the petitioner a copy of the Appeal Memorandum, the Court held that said

failure deprived the petitioner of procedural due process guaranteed by the Constitution, which could have served as basis for the nullification of the proceedings in the appeal. The SAME holds true in the case at bar. The Court finds that the failure of the respondents to furnish the petitioner a copy of the Memorandum of Appeal submitted to the PRC constitutes a violation of due process. Thus, the proceedings before the PRC were null and void.Physicians; Doctors are protected by a special rule of law—they are not guarantors of care and they are not insurers against mishaps or unusual consequences.—Doctors are protected by a special rule of law. They are not guarantors of care. They are not insurers against mishaps or unusual consequences specially so if the patient herself did not exercise the proper diligence required to avoid the injury. [Cayao-Lasam vs. Ramolete, 574 SCRA 439(2008)]

Nogales vs. Capitol Medical CenterCarpio, J.:G.R. No. 142625, Dec. 19, 2006 | 511 SCRA 204

FACTS:Pregnant with her fourth child, Corazon Nogales ("Corazon"), who was then 37 years old, was under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada") beginning on her fourth month of pregnancy or as early as December 1975. While Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood pressure and development of leg edema5 indicating preeclampsia, which is a dangerous complication of pregnancy. Around midnight of 25 May 1976, Corazon started to experience mild labor painsprompting Corazon and Rogelio Nogales ("Spouses Nogales") to see Dr. Estrada at his home. After examining Corazon, Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC"). On 26 May 1976, Corazon was admitted at 2:30 a.m. at the CMC after the staff nurse noted the written admission request8 of Dr. Estrada. Upon Corazon's admission at the CMC, Rogelio Nogales ("Rogelio") executed and signed the "Consent on Admission Agreement” and “Admission Agreement.” Corazon was then bought to the labor room of the CMC. Dr. Rosa Uy ("Dr. Uy"), who was then a resident physician of CMC, conducted an internal examination of Corazon. Dr. Uy then called up Dr. Estrada to notify him of her findings. Based on the Doctor's Order Sheet, around 3:00 a.m., Dr. Estrada ordered for 10 mg.of valium to be administered immediately by intramuscular injection. Dr. Estrada later ordered the start of intravenous administration of syntocinon admixed with dextrose,5%, in lactated Ringers' solution, at the rate of eight to ten micro-drops per minute. According to the Nurse's Observation Notes, Dr. Joel Enriquez ("Dr. Enriquez"), an anesthesiologist at CMC, was notified at 4:15 a.m. of Corazon's admission. Subsequently, when asked if he needed the services of an anesthesiologist, Dr. Estrada refused. Despite Dr. Estrada's refusal, Dr. Enriquez stayed to observeCorazon’s condition. At 6:00 a.m., Corazon was transferred to Delivery Room No. 1 of the CMC. At 6:10a.m., Corazon's bag of water ruptured spontaneously. At 6:12 a.m., Corazon's cervix was fully dilated. At 6:13 a.m., Corazon started to experience convulsions. At 6:15 a.m., Dr. Estrada ordered the injection of ten grams of magnesium sulfate. However, Dr. Ely Villaflor ("Dr. Villaflor"), who was assisting Dr. Estrada, administered only 2.5 grams of magnesium sulphate. At 6:22 a.m. Dr. Estrada, assisted by Dr. Villaflor, applied low forceps to extract Corazon's baby. In the process, a 1.0 x 2.5 cm. piece of cervical tissue was allegedly torn. The baby came out in an apnic, cyanotic, weak and injured condition. Consequently, the baby had to be intubated and resuscitated by Dr. Enriquez and Dr. Payumo. At 6:27 a.m., Corazon began to manifest moderate vaginal bleeding which rapidly became profuse. Corazon's blood pressure dropped from 130/80 to 60/40 within five minutes. There was continuous profuse vaginal bleeding. The assisting nurse administered hemacel through a gauge 19 needle as a side drip to the ongoing intravenous injection of dextrose. At 7:45 a.m., Dr. Estrada ordered blood typing and cross matching with bottled blood. Ittook approximately 30 minutes for the CMC laboratory, headed by Dr. Perpetua Lacson("Dr. Lacson"), to comply with Dr. Estrada's order and deliver the blood. At 8:00 a.m., Dr. Noe Espinola ("Dr. Espinola"), head of the Obstetrics-Gynecology Department of the CMC, was apprised of Corazon's condition by telephone. Upon being informed that Corazon was bleeding profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign a "Consent to Operation."13 Due to the inclement weather then, Dr. Espinola, who was fetched from his residence by an ambulance, arrived at the CMC about an hour later or at 9:00 a.m. He examined the patient and ordered some resuscitative measures to be administered. Despite Dr.Espinola's efforts,

Corazon died at 9:15 a.m. The cause of death was "hemorrhage, postpartum."14 On 14 May 1980, petitioners filed a complaint for damages15 with the Regional TrialCourt16 of Manila against CMC, Dr. Estrada, Dr. Villaflor, Dr. Uy, Dr. Enriquez, Dr.Lacson, Dr. Espinola, and a certain Nurse J. Dumlao for the death of Corazon. Petitioners mainly contended that defendant physicians and CMC personnel were negligent in the treatment and management of Corazon's condition. Petitioners charged CMC with negligence in the selection and supervision of defendant physicians and hospital staff.ISSUES & ARGUMENTS •W/N CMC should be held liableHospitals; Medical Malpractice; Employer-Employee Relationship; The control test essentially determines whether an employment relationship exists between a physician and a hospital based on the exercise of control over the physician as to details.—While the Court in Ramos did not expound on the control test, such test essentially determines whether an employment relationship exists between a physician and a hospital based on the exercise of control over the physician as to details. Specifically, the employer (or the hospital) must have the right to control both the means and the details of the process by which the employee (or the physician) is to accomplish his task.SAME; SAME; SAME; Doctrine of Apparent Authority; Words and Phrases; An exception to the general rule that a hospital is not liable for the negligence of an independent contractor-physician is when the physician is the “ostensible” agent of the hospital, which exception is also known as the “doctrine of apparent authority.”—In general, a hospital is not liable for the negligence of an independent contractor-physician. There is, however, an exception to this principle. The hospital may be liable if the physician is the “ostensible” agent of the hospital. This exception is also known as the “doctrine of apparent authority.” In Gilbert v. Sycamore Municipal Hospital, the Illinois Supreme Court explained the doctrine of apparent authority in this wise: [U]nder the doctrine of apparent authority a hospital can be held vicariously liable for the negligent acts of a physician providing care at the hospital, regardless of whether the physician is an independent contractor, unless the patient knows, or should have known, that the physician is an independent contractor. The elements of the action have been set out as follows: “For a hospital to be liable under the doctrine of apparent authority, a plaintiff must show that: (1) the hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital; (2) where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and (3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence.” The element of “holding out” on the part of the hospital does not require an express representation by the hospital that the person alleged to be negligent is an employee. Rather, the element is satisfied if the hospital holds itself out as a provider of emergency room care without informing the patient that the care is provided by independent contractors. The element of justifiable reliance on the part of the plaintiff is satisfied if the plaintiff relies upon the hospital to provide complete emergency room care, rather than upon a specific physician.SAME; SAME; SAME; SAME; Estoppel; The doctrine of apparent authority is a species of the doctrine of estoppel.—The doctrine of apparent authority is a species of the doctrine of estoppel. Article 1431 of the Civil Code provides that “[t]hrough estoppel, an admission or representation is rendered conclusive upon the person making it, and cannot be denied or disproved as against the person relying thereon.” Estoppel rests on this rule: “Whenever a party has, by his own declaration, act, or omission, intentionally and deliberately led another to believe a particular thing true, and to act upon such belief, he cannot, in any litigation arising out of such declaration, act or omission, be permitted to falsify it.”SAME; SAME; SAME; SAME; The Court cannot close its eyes to the reality that hospitals are in the business of treatment.—CMC’s defense that all it did was “to extend to [Corazon] its facilities” is untenable. The Court cannot close its eyes to the reality that hospitals, such as CMC, are in the business of treatment. In this regard, the Court agrees with the observation made by the Court of Appeals of North Carolina in Diggs v. Novant Health, Inc., to wit: “The conception that the hospital does not undertake to treat the patient, does not undertake to act through its doctors and nurses, but undertakes instead simply to procure them to act upon their own responsibility, no longer reflects the fact. Present day hospitals, as their manner of operation plainly demonstrates, do far more than furnish facilities for treatment. They

regularly employ on a salary basis a large staff of physicians, nurses and internes [sic], as well as administrative and manual workers, and they charge patients for medical care and treatment, collecting for such services, if necessary, by legal action. Certainly, the person who avails himself of ‘hospital facilities’ expects that the hospital will attempt to cure him, not that its nurses or other employees will act on their own responsibility.” x x xSAME; SAME; SAME; SAME; Contracts of Adhesion; Consent and Release Forms; A blanket release in favor of hospitals “from any and all claims,” which includes claims due to bad faith or gross negligence, would be contrary to public policy and thus void.—Likewise unconvincing is CMC’s argument that petitioners are estopped from claiming damages based on the Consent on Admission and Consent to Operation. Both release forms consist of two parts. The first part gave CMC permission to administer to Corazon any form of recognized medical treatment which the CMC medical staff deemed advisable. The second part of the documents, which may properly be described as the releasing part, releases CMC and its employees “from any and all claims” arising from or by reason of the treatment and operation. The documents do not expressly release CMC from liability for injury to Corazon due to negligence during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability for Corazon’s death due to negligence during such treatment or operation. Such release forms, being in the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a blanket release in favor of hospitals “from any and all claims,” which includes claims due to bad faith or gross negligence, would be contrary to public policy and thus void.SAME; SAME; SAME; SAME; SAME; SAME; Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only mitigate liability depending on the circumstances.—Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only mitigate liability depending on the circumstances. When a person needing urgent medical attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of admission and operation. Such a person is literally at the mercy of the hospital. There can be no clearer example of a contract of adhesion than one arising from such a dire situation. Thus, the release forms of CMC cannot relieve CMC from liability for the negligent medical treatment of Corazon.

Cantre vs. Go, 522 SCRA 547(2007)

Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr. Jesus Delgado Memorial Hospital. She was the attending physician of respondent Nora S. Go, who was admitted at the said hospital on April 19, 1992.At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around 3:30 a.m., Nora suffered profuse bleeding inside her womb due to some parts of the placenta which were not completely expelled from her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to “40” over “0.” Petitioner and the assisting resident physician performed various medical procedures to stop the bleeding and to restore Nora’s blood pressure. Her blood pressure was frequently monitored with the use of a sphygmomanometer. While petitioner was massaging Nora’s uterus for it to contract and stop bleeding, she ordered a droplight to warm Nora and her baby.4 Nora remained unconscious until she recovered.While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping wound two and a half (2 1/2) by three and a half (3 1/2) inches in the inner portion of her left arm, close to the armpit.5 He asked the nurses what caused the injury. He was informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital, called petitioner and the assisting resident physician to explain what happened. Petitioner said the blood pressure cuff caused the injury.On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical examination, which was conducted by medico-legal officer Dr. Floresto Arizala, Jr.7 The medico-legal officer later testified that Nora’s injury appeared to be a burn and that a droplight when placed near the

skin for about 10 minutes could cause such burn.8 He dismissed the likelihood that the wound was caused by a blood pressure cuff as the scar was not around the arm, but just on one side of the arm.9On May 22, 1992, Nora’s injury was referred to a plastic surgeon at the Dr. Jesus Delgado Memorial Hospital for skingrafting.10 Her wound was covered with skin sourced from her abdomen, which consequently bore a scar as well. About a year after, on April 30, 1993, scar revision had to be performed at the SAME hospital.11 The surgical operation left a healed linear scar in Nora’s left arm about three inches in length, the thickest portion rising about one-fourth (1/4) of an inch from the surface of the skin. The costs of the skin grafting and the scar revision were shouldered by the hospital.12Unfortunately, Nora’s arm would never be the SAME. Aside from the unsightly mark, the pain in her left arm remains. When sleeping, she has to cradle her wounded arm. Her movements now are also restricted. Her children cannot play with the left side of her body as they might accidentally bump the injured arm, which aches at the slightest touch. Thus, on June 21, 1993, respondent spouses filed a complaint13 for damages against petitioner, Dr. Abad, and the hospital. Finding in favor of respondent spouses, the trial court decreed: Petitioner contends that additional documentary exhibits not testified to by any witness are inadmissible in evidence because they deprived her of her constitutional right to confront the witnesses against her. Petitioner insists the droplight could not have touched Nora’s body. She maintains the injury was due to the constant taking of Nora’s blood pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of the medico-legal officer who never saw the original injury before plastic surgery was performed. Finally, petitioner stresses that plastic surgery was not intended to restore respondent’s injury to its original state but rather to prevent further complication.Respondents, however, counter that the genuineness and due execution of the additional documentary exhibits were duly admitted by petitioner’s counsel. Respondents point out that petitioner’s blood pressure cuff theory is highly improbable, being unprecedented in medical history and that the injury was definitely caused by the droplight. At any rate, they argue, even if the injury was brought about by the blood pressure cuff, petitioner was still negligent in her duties as Nora’s attending physician.Simply put, the threshold issues for resolution are: (1) Are the questioned additional exhibits admissible in evidence? (2) Is petitioner liable for the injury suffered by respondent Nora Go? Thereafter, the inquiry is whether the appellate court committed grave abuse of discretion in its assailed issuances. [Cantre vs. Go, 522 SCRA 547(2007)]Civil Law; Negligence; Damages; Intent is immaterial in negligence cases because where negligence exists and is proven, it automatically gives the injured a right to reparation for the damages caused.—The Hippocratic Oath mandates physicians to give primordial consideration to the well-being of their patients. If a doctor fails to live up to this precept, he is accountable for his acts. This notwithstanding, courts face a unique restraint in adjudicating medical negligence cases because physicians are not guarantors of care and, they never set out to intentionally cause injury to their patients. However, intent is immaterial in negligence cases because where negligence exists and is proven, it automatically gives the injured a right to reparation for the damage caused.SAME; SAME; SAME; Requisites in Order for the Doctrine of Res Ipsa Loquitur to Apply in Cases Involving Medical Negligence.—In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an injury to justify a presumption of negligence on the part of the person who controls the instrument causing the injury, provided that the following requisites concur: 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.SAME; SAME; SAME; Captain of the Ship Doctrine; The doctrine holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those assistants are under the surgeon’s control.—Whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both instruments are deemed within the exclusive control of the physician in charge under the “captain of the ship” doctrine. This doctrine holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those assistants are under the surgeon’s control. In this

particular case, it can be logically inferred that petitioner, the senior consultant in charge during the delivery of Nora’s baby, exercised control over the assistants assigned to both the use of the droplight and the taking of Nora’s blood pressure. Hence, the use of the droplight and the blood pressure cuff is also within petitioner’s exclusive control.SAME; SAME; SAME; Petitioner is obliged to pay Nora for moral damages suffered by the latter as a proximate result of petitioner’s negligence.—Based on the foregoing, the presumption that petitioner was negligent in the exercise of her profession stands unrebutted. In this connection, the Civil Code provides: ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for the damage done. . . . ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though incapable of pecuni-ary computation, moral damages may be recovered if they are the proximate result of the defendant’s wrongful act or omission. Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the latter as a proximate result of petitioner’s negligence.

Ramos v. CAFacts:

Erlinda Ramos, a 47-year old robust woman, was normal except for her experiencing occasional pain due to the presence of stone in her gall bladder. She was advised to undergo an operation for its removal. The results in the examinations she underwent indicate that she was fit for the operation. She and her husband Rogelio met Dr. Hosaka, one of the defendants, who advised that she should undergo cholecystectomy. Dr. Hosaka assured them that he will get a good anaesthesiologist. At 7:30 a.m. on the day of the operation at Delos Santos Medical Center, Herminda Cruz, Erlinda’s sister-in-law and the dean of the College of Nursing in Capitol Medical Center, was there to provide moral support. Dr. Perfecta Gutierrez was to administer the anaesthesia. Dr. Hosaka arrived only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating the patient, and heard the latter say “Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O, lumalaki ang tiyan.” Herminda saw bluish discoloration of the nailbeds of the patient. She heard Dr. Hosaka issue an order for someone to call Dr. Calderon. The doctor arrived and placed the patient in trendelenburg position, wherein the head of the patient is positioned lower than the feet, which indicates a decrease of blood supply in the brain. Herminda knew and told Rogelio that something wrong was happening. Dr. Calderon was able to intubate the patient. Erlinda was taken to the ICU and became comatose.Rogelio filed a civil case for damages. The trial court ruled in his favor, finding Dr. Gutierrez, Dr. Hosaka, and the hospital, guilty of negligence, but the Court of Appeals reversed the decision. Hence, petitioner filed a Motion for Reconsideration, which the Court of Appeals denied for having been filed beyond the reglementary period. However, it was found that the notice of the decision was never sent to the petitioner’s counsel. Rather, it was sent to the petitioner, addressing him as Atty. Rogelio Ramos, as if he was the legal counsel. The petitioner filed the instant petition for certiorari. On the procedural issue, the Supreme Court rules that since the notice did not reach the petitioner’s then legal counsel, the motion was filed on time.Issue:Whether a surgeon, an anaesthesiologist, and a hospital, should be made liable for the unfortunate comatose condition of a patient scheduled for cholecystectomy Held:Remedial Law; Pleadings and Practice; When a party is represented by counsel, all notices should be sent to the party’s lawyer at his given address.—It is elementary that when a party is represented by counsel, all notices should be sent to the party’s lawyer at his given address. With a few exceptions, notice to a litigant without notice to his counsel on record is no notice at all. In the present case, since a copy of the decision of the appellate court was not sent to the counsel on record of petitioner, there can be no sufficient notice to speak of. Hence, the delay in the filing of the motion for reconsideration cannot be taken against petitioner.

SAME; Evidence; Res Ipsa Loquitur; Doctrine of Res Ipsa Loquitur.—Res ipsa loquitur is a Latin phrase which literally means “the thing or the transaction speaks for itself.” The phrase “res ipsa loquitur” is a maxim for the rule that the fact of the occurrence of an 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 the thing which caused the injury complained of is shown to be under the management of the defen-dant or his servants and the accident is such as in ordinary course of things does not happen if those who have its management or control use proper care, it affords reasonable evidence, in the absence of explanation by the defendant, that the accident arose from or was caused by the defendant’s want of care.SAME; SAME; SAME; SAME; Res Ipsa Loquitur is applied in conjunction with the doctrine of common knowledge.—The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common knowledge and experience, the very nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the instrumentality causing the injury in the absence of some explanation by the defendant who is charged with negligence. It is grounded in the superior logic of ordinary human experience and on the basis of such experience or common knowledge, negligence may be deduced from the mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge.SAME; SAME; SAME; SAME; Mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence; Requisites before resort to the doctrine may be allowed.—Much has been said that res ipsa loquitur is not a rule of substantive law and, as such, does not create or constitute an independent or separate ground of liability. Instead, it is considered as merely evidentiary or in the nature of a procedural rule. It is regarded as a mode of proof, or a mere procedural convenience since it furnishes a substitute for, and relieves a plaintiff of, the burden of producing specific proof of negligence. In other words, mere invocation and application of the doctrine does not dispense with the requirement of proof of negligence. It is simply a step in the process of such proof, permitting the plaintiff to present along with the proof of the accident, enough of the attending circumstances to invoke the doctrine, creating an inference or presumption of negligence, and to thereby place on the defendant the burden of going forward with the proof. Still, 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.SAME; SAME; SAME; SAME; When the doctrine of res ipsa loqui-tur is availed by the plaintiff, the need for expert medical testimony is dispensed with because the injury itself provides the proof of negligence.—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 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. The reason is that the general rule on the necessity of expert testimony applies only to such matters clearly within the domain of medical science, and not to matters that are within the common knowledge of mankind which may be testified to by anyone familiar with the facts. Ordinarily, only physicians and surgeons of skill and experience are competent to testify as to whether a patient has been treated or operated upon with a reasonable degree of skill and care. However, testimony as to the statements and acts of physicians and surgeons, external appearances, and manifest conditions which are observable by any one may be given by non-expert witnesses.SAME; SAME; SAME; SAME; Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied depending upon the circumstances of each case.—Despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does not automatically apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant to show that he is not guilty of the ascribed negligence. Res ipsa loquitur is not a rigid or ordinary doctrine to be perfunctorily used but a rule to be cautiously applied, depending upon the circumstances of each case. It is generally

restricted to situations in malpractice cases where a layman is able to say, as a matter of common knowledge and observation, that the consequences of professional care were not as such as would ordinarily have followed if due care had been exercised.SAME; SAME; SAME; SAME; Res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not accomplished.—It must be conceded that the doctrine of res ipsa loquitur can have no application in a suit against a physician or surgeon which involves the merits of a diagnosis or of a scientific treatment. The physician or surgeon is not required at his peril to explain why any particular diagnosis was not correct, or why any particular scientific treatment did not producethe desired result. Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not accomplished.Hospitals; Damages; Proximate Cause Defined.—Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred. An injury or damage is proximately caused by an act or a failure to act, whenever it appears from the evidence in the case, that the act or omission played a substantial part in bringing about or actually causing the injury or damage; and that the injury or damage was either a direct result or a reasonably probable consequence of the act or omission. It is the dominant, moving or producing cause.SAME; SAME; For the purpose of allocating responsibility in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians.—Private hospitals, hire, fire and exercise real control over their attending and visiting “consultant” staff. While “consultants” are not, technically employees, a point which respondent hospital asserts in denying all responsibility for the patient’s condition, the control exercised, the hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of 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 negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting physicians. This being the case, the question now arises as to whether or not respondent hospital is solidarily liable with respondent doctors for petitioner’s condition.SAME; SAME; The basis for holding an employer solidarily responsible for the negligence of its employee is found in Article 2180 of the Civil Code.—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 diligence of a good father of the family to prevent damage. In other words, while the burden of proving negligence restson 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.SAME; SAME; Amount of damages awarded may be a continuing one where the injury is chronic and continuing, as when the patient is comatose.—In these cases, the amount of damages which should be awarded, if they are to adequately and correctly respond to the injury caused, should be one which compensates for pecuniary loss incurred and proved, up to the time of trial; and one which would meet pecuniary loss certain to be suffered but which could not, from the nature of the case, be made with certainty. In other words, temperate damages can and should be awarded on top of actual or compensatory damages in instances where the injury is chronic and continuing. And because of the unique nature of such cases, no incompatibility arises when both actual and temperate damages are provided for. The reason is that these damages cover two distinct phases. [Ramos vs. Court of Appeals, 321 SCRA 584(1999)]

Jarcia, Jr. vs. People, 666 SCRA 336(2012)Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their

alleged neglect of professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the victim’s ankle was ordered; that the X-ray result showed no fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own examination of the victim, informed Mrs. Santiago that since it was only the ankle that was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg and misalignment of the right foot; that Mrs. Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone.The NBI indorsed the matter to the Office of the City Prosecutor of Manila for preliminary investigation. Probable cause was found and a criminal case for reckless imprudence resulting to serious physical injuries, was filed against Dr. Jarcia, Dr. Bastan and Dr. Pamittan,5 before the RTC, docketed as Criminal Case No. 01-196646.On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple Imprudence Resulting to Serious Physical Injuries. The decretal portion of the RTC decision reads:“WHEREFORE, premises considered, the Court finds accused DR. EMMANUEL JARCIA, JR. and DR. MARILOU BASTAN GUILTY beyond reasonable doubt of the crime of SIMPLE IMPRU-DENCE RESULTING TO SERIOUS PHYSICAL INJURIES and are hereby sentenced to suffer the penalty of ONE (1) MONTH and ONE (1) DAY to TWO (2) MONTHS and to indemnify MRS. BELINDA SANTIAGO the amount of P3,850.00 representing medical expenses without subsidiary imprisonment in case of insolvency and to pay the costs.It appearing that Dr. Pamittan has not been apprehended nor voluntarily surrendered despite warrant issued for her arrest, let warrant be issued for her arrest and the case against her be ARCHIVED, to be reinstated upon her apprehension.SO ORDERED.”6The RTC explained:“After a thorough and in depth evaluation of the evidence adduced by the prosecution and the defense, this court finds that the evidence of the prosecution is the more credible, concrete and sufficient to create that moral certainty in the mind of the Court that accused herein [are] criminally responsible. The Court believes that accused are negligent when both failed to exercise the necessary and reasonable prudence in ascertaining the extent of injury of Alfonso Santiago, Jr.However, the negligence exhibited by the two doctors does not approximate negligence of a reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the lack of precaution displayed in those cases in which the damage impending to be caused is not the immediate nor the danger clearly manifest. The elements of simple imprudence are as follows.1. that there is lack of precaution on the part of the offender; and2. that the damage impending to be caused is not immediate of the danger is not clearly manifest.Considering all the evidence on record, The Court finds the accused guilty for simple imprudence resulting to physical injuries. Under Article 365 of the Revised Penal Code, the penalty provided for is arresto mayor in its minimum period.”7As earlier stated, the CA affirmed the RTC decision HELD:Civil Law; Quasi-Delicts; Res Ipsa Loquitor; The doctrine of res ipsa loquitur means “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.”—This doctrine of res ipsa loquitur means “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 Black’s Law Dictionary defines the said doctrine. Thus: The thing speaks for itself. Rebuttable

presumption or inference that defendant was negligent, which arises upon proof that the instrumentality causing injury was in defendant’s exclusive control, and that the accident was one which ordinarily does not happen in absence of negligence. Res ipsa loquitur is a rule of evidence whereby negligence of the alleged wrongdoer may be inferred from the mere fact that the accident happened provided the character of the accident and circumstances attending it lead reasonably to belief that in the absence of negligence it would not have occurred and that thing which caused injury is shown to have been under the management and control of the alleged wrongdoer. Under this doctrine, the happening of an injury permits an inference of negligence where plaintiff produces substantial evidence that the injury was caused by an agency or instrumentality under the exclusive control and management of defendant, and that the occurrence was such that in the ordinary course of things would not happen if reasonable care had been used.SAME; SAME; SAME; The doctrine of res ipsa loquitur as a rule of evidence is unusual 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 of res ipsa loquitur as a rule of evidence is unusual 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, however, 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 given case, is not meant 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 helps the plaintiff in proving a breach of the duty. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is absent and not readily available.SAME; SAME; SAME; Requisites for the Application of the Doctrine of Res Ipsa Loquitur.—The requisites for the application of the doctrine of res ipsa loquitur are: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured.SAME; SAME; “Negligence,” Defined; Words and Phrases.—Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care, precaution, and vigilance which the circumstances justly demand, whereby such other person suffers injury.SAME; SAME; “Reckless Imprudence,” Defined; Words and Phrases.—Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform such act.SAME; SAME; Simple Negligence; Elements of Simple Negligence.—The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender, and (2) that the damage impending to be caused is not immediate or the danger is not clearly manifest.SAME; Reckless Imprudence; The Court finds the petitioners civilly liable for their failure to sufficiently attend to Roy Jr.’s medical needs when the latter was rushed to the ER, for while a criminal conviction requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability.—Although the Court sympathizes with the plight of the mother and the child in this case, the Court is bound by the dictates of justice which hold inviolable the right of the accused to be presumed innocent until proven guilty beyond reasonable doubt. The Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently attend to Roy Jr.’s medical needs when the latter was rushed to the ER, for while a criminal conviction requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability. Taken into account also was the fact that there was no bad faith on their part.Remedial Law; Civil Procedure; Appeals; Issues raised for the first time on appeal cannot be considered because a party is not permitted to change his theory on appeal.—This Court cannot also stamp its imprimatur on the petitioners’ contention that no physician-patient relationship existed between them and patient Roy Jr., since they were not his attending physicians at that time. They claim that they were merely requested by the ER nurse to see the patient while they were passing by the ER for their lunch.

Firstly, this issue was never raised during the trial at the RTC or even before the CA. The petitioners, therefore, raise the want of doctor-patient relationship for the first time on appeal with this Court. It has been settled that “issues raised for the first time on appeal cannot be considered because a party is not permitted to change his theory on appeal. To allow him to do so is unfair to the other party and offensive to the rules of fair play, justice and due process.” Stated differently, basic considerations of due process dictate that theories, issues and arguments not brought to the attention of the trial court need not be, and ordinarily will not be, considered by a reviewing court.Civil Law; Physician-Patient Relationship; When a patient engages the services of a physician, a physician-patient relationship is generated; Thus, in treating his patient, a physician is under a duty to exercise that degree of care, skill and diligence which physicians in the SAME general neighborhood and in the SAME general line of practice ordinarily possess and exercise in like cases.—In the case of Lucas v. Tuaño, 586 SCRA 173 (2009), the Court wrote that “[w]hen a patient engages the services of a physician, a physician-patient relationship is generated. And in accepting a case, the physician, for all intents and purposes, represents that he has the needed training and skill possessed by physicians and surgeons practicing in the SAME field; and that he will employ such training, care, and skill in the treatment of the patient. Thus, in treating his patient, a physician is under a duty to exercise that degree of care, skill and diligence which physicians in the SAME general neighborhood and in the SAME general line of practice ordinarily possess and exercise in like cases. Stated otherwise, the physician has the obligation to use at least the SAME level of care that any other reasonably competent physician would use to treat the condition under similar circumstances.”SAME; SAME; Medical Ethics; Established medical procedures and practices, though in constant instability, are devised for the purpose of preventing complications.—Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states: A physician should attend to his patients faithfully and conscientiously. He should secure for them all possible benefits that may depend upon his professional skill and care. As the sole tribunal to adjudge the physician’s failure to fulfill his obligation to his patients is, in most cases, his own conscience, violation of this rule on his part is discreditable and inexcusable. Established medical procedures and practices, though in constant instability, are devised for the purpose of preventing complications. In this case, the petitioners failed to observe the most prudent medical procedure under the circumstances to prevent the complications suffered by a child of tender age.SAME; Negligence; While no criminal negligence was found in the petitioners’ failure to administer the necessary medical attention to Roy Jr., the Court holds them civilly liable for the resulting damages to their patient.—While no criminal negligence was found in the petitioners’ failure to administer the necessary medical attention to Roy Jr., the Court holds them civilly liable for the resulting damages to their patient. While it was the taxi driver who ran over the foot or leg of Roy Jr., their negligence was doubtless contributory.SAME; Damages; Actual Damages; Claims for actual damages must be adequately supported by receipts.—It appears undisputed that the amount of P3,850.00, as expenses incurred by patient Roy Jr., was adequately supported by receipts. The Court, therefore, finds the petitioners liable to pay this amount by way of actual damages.SAME; SAME; Moral Damages; It is settled that moral damages are not punitive in nature, but are designed to compensate and alleviate in some way the physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury unjustly inflicted on a person.—The Court is aware that no amount of compassion can suffice to ease the sorrow felt by the family of the child at that time. Certainly, the award of moral and exemplary damages in favor of Roy Jr. in the amount of P100,000.00 and P50,000.00, respectively, is proper in this case. It is settled that moral damages are not punitive in nature, but are designed to compensate and alleviate in some way the physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury unjustly inflicted on a person. Intended for the restoration of the psychological or emotional status quo ante, the award of moral damages is designed to compensate emotional injury suffered, not to impose a penalty on the wrongdoer.

SAME; SAME; Exemplary Damages; Exemplary damages may be imposed by way of example or correction for the public good.—The Court, likewise, finds the petitioners also liable for exemplary dam-ages in the said amount. Article 2229 of the Civil Code provides that exemplary damages may be imposed by way of example or correction for the public good. [Jarcia, Jr. vs. People, 666 SCRA 336(2012)]