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Republic of the Philippines

G.R. No. 165279 June 7, 2011
DR. RUBI LI, Petitioner,
SPOUSES REYNLDO !n" LIN SOLIMN, !# $!%en&#'(e)%# o* "e+e!#e" n,e-)+! So-).!n,
/ILLRM, JR., J.:
Challen!ed in this petition for revie" on certiorari is the Decision
dated $une #%, &''( as "ell as the
dated Septe)ber #, &''( of the Court of Appeals *CA+ in CA,-.R. C. No. %/'#0 "hich
)odified the Decision
dated Septe)ber %, #112 of the Re!ional 3rial Court of 4e!a5pi Cit6, Branch
/ in Civil Case No. /1'(.
3he factual antecedents7
n $ul6 2, #110, respondents8 ##,6ear old dau!hter, An!elica Soli)an, under"ent a biops6 of the
)ass located in her lo"er e9tre)it6 at the St. 4u:e8s Medical Center *S4MC+. Results sho"ed that
An!elica "as sufferin! fro) osteosarco)a, osteoblastic t6pe,
a hi!h,!rade *hi!hl6 )ali!nant+
cancer of the bone "hich usuall6 afflicts teena!e children. ;ollo"in! this dia!nosis and as pri)ar6
intervention, An!elica8s ri!ht le! "as a)putated b6 Dr. $ai)e 3a)a6o in order to re)ove the tu)or.
As ad<uvant treat)ent to eli)inate an6 re)ainin! cancer cells, and hence )ini)i5e the chances of
recurrence and prevent the disease fro) spreadin! to other parts of the patient8s bod6 *)etastasis+,
che)otherap6 "as su!!ested b6 Dr. 3a)a6o. Dr. 3a)a6o referred An!elica to another doctor at
S4MC, herein petitioner Dr. Rubi 4i, a )edical oncolo!ist.
n Au!ust #/, #110, An!elica "as ad)itted to S4MC. =o"ever, she died on Septe)ber #, #110,
<ust eleven *##+ da6s after the *intravenous+ ad)inistration of the first c6cle of the che)otherap6
re!i)en. Because S4MC refused to release a death certificate "ithout full pa6)ent of their hospital
bill, respondents brou!ht the cadaver of An!elica to the Philippine National Police *PNP+ Cri)e
4aborator6 at Ca)p Cra)e for post,)orte) e9a)ination. 3he Medico,4e!al Report issued b6 said
institution indicated the cause of death as >=6povole)ic shoc: secondar6 to )ultiple or!an
he)orrha!es and Disse)inated Intravascular Coa!ulation.>
n the other hand, the Certificate of Death
issued b6 S4MC stated the cause of death as follo"s7
I))ediate cause 7 a. steosarco)a, Status Post A@A
Antecedent cause 7 b. *above :nee a)putation+
Anderl6in! cause 7 c. Status Post Che)otherap6
n ;ebruar6 &#, #11(, respondents filed a da)a!e suit
a!ainst petitioner, Dr. 4eo Marbella, Mr.
$ose 4edes)a, a certain Dr. Arriete and S4MC. Respondents char!ed the) "ith ne!li!ence and
disre!ard of An!elica8s safet6, health and "elfare b6 their careless ad)inistration of the
che)otherap6 dru!s, their failure to observe the essential precautions in detectin! earl6 the
s6)pto)s of fatal blood platelet decrease and stoppin! earl6 on the che)otherap6, "hich bleedin!
led to h6povole)ic shoc: that caused An!elica8s unti)el6 de)ise. ;urther, it "as specificall6 averred
that petitioner assured the respondents that An!elica "ould recover in vie" of 1%B chance of
healin! "ith che)otherap6 *>Ma!i!in! nor)al na an! ana: n6o basta )a,che)o. 1%B an! healin!>+
and "hen as:ed re!ardin! the side effects, petitioner )entioned onl6 sli!ht vo)itin!, hair loss and
"ea:ness *>Ma!susu:a n! :aunti. Malulu!as an! buho:. Man!hihina>+. Respondents thus clai)ed
that the6 "ould not have !iven their consent to che)otherap6 had petitioner not falsel6 assured
the) of its side effects.
In her ans"er,
petitioner denied havin! been ne!li!ent in ad)inisterin! the che)otherap6 dru!s to
An!elica and asserted that she had full6 e9plained to respondents ho" the che)otherap6 "ill affect
not onl6 the cancer cells but also the patient8s nor)al bod6 parts, includin! the lo"erin! of "hite and
red blood cells and platelets. She clai)ed that "hat happened to An!elica can be attributed to
)ali!nant tu)or cells possibl6 left behind after sur!er6. ;e" as the6 )a6 be, these have the
capacit6 to co)pete for nutrients such that the bod6 beco)es so "ea: structurall6 *cache9ia+ and
functionall6 in the for) of lo"er resistance of the bod6 to co)bat infection. Such infection beco)es
uncontrollable and tri!!ers a chain of events *sepsis or septice)ia+ that )a6 lead to bleedin! in the
for) of Disse)inated Intravascular Coa!ulation *DIC+, as "hat the autops6 report sho"ed in the
case of An!elica.
Since the )edical records of An!elica "ere not produced in court, the trial and appellate courts had
to rel6 on testi)onial evidence, principall6 the declarations of petitioner and respondents
the)selves. 3he follo"in! chronolo!6 of events "as !athered7
n $ul6 &0, #110, petitioner sa" the respondents at the hospital after An!elica8s sur!er6 and
discussed "ith the) An!elica8s condition. Petitioner told respondents that An!elica should be !iven
t"o to three "ee:s to recover fro) the operation before startin! che)otherap6. Respondents "ere
apprehensive due to financial constraints as Re6naldo earns onl6 fro) P2','''.'' to P#%','''.'' a
6ear fro) his <e"elr6 and "atch repairin! business.
Petitioner, ho"ever, assured the) not to "orr6
about her professional fee and told the) to <ust save up for the )edicines to be used.
Petitioner clai)ed that she e9plained to respondents that even "hen a tu)or is re)oved, there are
still s)all lesions undetectable to the na:ed e6e, and that ad<uvant che)otherap6 is needed to clean
out the s)all lesions in order to lessen the chance of the cancer to recur. She did not !ive the
respondents an6 assurance that che)otherap6 "ill cure An!elica8s cancer. Durin! these
consultations "ith respondents, she e9plained the follo"in! side effects of che)otherap6 treat)ent
to respondents7 *#+ fallin! hairC *&+ nausea and vo)itin!C *0+ loss of appetiteC *(+ lo" count of "hite
blood cells DEBCF, red blood cells DRBCF and plateletsC *%+ possible sterilit6 due to the effects on
An!elica8s ovar6C *?+ da)a!e to the heart and :idne6sC and *2+ dar:enin! of the s:in especiall6 "hen
e9posed to sunli!ht. She actuall6 tal:ed "ith respondents four ti)es, once at the hospital after the
sur!er6, t"ice at her clinic and the fourth ti)e "hen An!elica8s )other called her throu!h lon!
3his "as disputed b6 respondents "ho countered that petitioner !ave the) assurance
that there is 1%B chance of healin! for An!elica if she under!oes che)otherap6 and that the onl6
side effects "ere nausea, vo)itin! and hair loss.
3hose "ere the onl6 side,effects of che)otherap6
treat)ent )entioned b6 petitioner.
n $ul6 &2, #110, S4MC dischar!ed An!elica, "ith instruction fro) petitioner that she be read)itted
after t"o or three "ee:s for the che)otherap6.
n Au!ust #/, #110, respondents brou!ht An!elica to S4MC for che)otherap6, brin!in! "ith the)
the results of the laborator6 tests reGuested b6 petitioner7 An!elica8s chest 9,ra6, ultrasound of the
liver, creatinine and co)plete liver function tests.
Petitioner proceeded "ith the che)otherap6 b6
first ad)inisterin! h6dration fluids to An!elica.
3he follo"in! da6, Au!ust #1, petitioner be!an ad)inisterin! three che)otherap6 dru!s H Cisplatin,
and Cos)e!en
H intravenousl6. Petitioner "as supposedl6 assisted b6 her trainees
Dr. 4eo Marbella
and Dr. -race Arriete.
In his testi)on6, Dr. Marbella denied havin! an6
participation in ad)inisterin! the said che)otherap6 dru!s.
n the second da6 of che)otherap6, Au!ust &', respondents noticed reddish discoloration on
An!elica8s face.
3he6 as:ed petitioner about it, but she )erel6 Guipped, >Eala 6an. Epe:to n!
Petitioner recalled noticin! the s:in rashes on the nose and chee: area of An!elica. At that
)o)ent, she entertained the possibilit6 that An!elica also had s6ste)ic lupus and consulted Dr.
.ictoria Abesa)is on the )atter.
n the third da6 of che)otherap6, Au!ust &#, An!elica had difficult6 breathin! and "as thus
provided "ith o96!en inhalation apparatus. 3his ti)e, the reddish discoloration on An!elica8s face
had e9tended to her nec:, but petitioner dis)issed it a!ain as )erel6 the effect of )edicines.

Petitioner testified that she did not see an6 discoloration on An!elica8s face, nor did she notice an6
difficult6 in the child8s breathin!. She clai)ed that An!elica )erel6 co)plained of nausea and "as
!iven ice chips.
1avvphi 1
n Au!ust &&, #110, at around ten o8cloc: in the )ornin!, upon seein! that their child could not
an6)ore bear the pain, respondents pleaded "ith petitioner to stop the che)otherap6. Petitioner
supposedl6 replied7 >Dapat #% Cos)e!en pa i6an. :a6, let8s observe. If p"ede na, bi!6an uli n!
che)o.> At this point, respondents as:ed petitioner8s per)ission to brin! their child ho)e. 4ater in
the evenin!, An!elica passed blac: stool and reddish urine.
Petitioner countered that there "as no
record of blac:enin! of stools but onl6 an episode of loose bo"el )ove)ent *4BM+. Petitioner also
testified that "hat An!elica co)plained of "as carpo,pedal spas), not convulsion or epileptic attac:,
as respondents call it *petitioner described it in the vernacular as >nanini!as an! :a)a6 at paa>+.
She then reGuested for a seru) calciu) deter)ination and stopped the che)otherap6. Ehen
An!elica "as !iven calciu) !luconate, the spas) and nu)bness subsided.
3he follo"in! da6, Au!ust &0, petitioner 6ielded to respondents8 reGuest to ta:e An!elica ho)e. But
prior to dischar!in! An!elica, petitioner reGuested for a repeat seru) calciu) deter)ination and
e9plained to respondents that the che)otherap6 "ill be te)poraril6 stopped "hile she observes
An!elica8s )uscle t"itchin! and seru) calciu) level. 3a:e,ho)e )edicines "ere also prescribed for
An!elica, "ith instructions to respondents that the seru) calciu) test "ill have to be repeated after
seven da6s. Petitioner told respondents that she "ill see An!elica a!ain after t"o "ee:s, but
respondents can see her an6ti)e if an6 i))ediate proble) arises.
=o"ever, An!elica re)ained in confine)ent because "hile still in the pre)ises of S4MC, her
>convulsions> returned and she also had 4BM. An!elica "as !iven o96!en and ad)inistration of
calciu) continued.
3he ne9t da6, Au!ust &(, respondents clai)ed that An!elica still suffered fro) convulsions. 3he6
also noticed that she had a fever and had difficult6 breathin!.
Petitioner insisted it "as carpo,pedal
spas), not convulsions. She verified that at around (7%' that afternoon, An!elica developed difficult6
in breathin! and had fever. She then reGuested for an electrocardio!ra) anal6sis, and infused
calciu) !luconate on the patient at a >stat dose.> She further ordered that An!elica be !iven
a s6nthetic antibacterial co)bination dru!,
to co)bat an6 infection on the child8s bod6.
B6 Au!ust &?, An!elica "as bleedin! throu!h the )outh. Respondents also sa" blood on her anus
and urine. Ehen 4ina as:ed petitioner "hat "as happenin! to her dau!hter, petitioner replied,
>Ba!sa: an! platelets n! ana: )o.> ;our units of platelet concentrates "ere then transfused to
An!elica. Petitioner prescribed Solucortef. Considerin! that An!elica8s fever "as hi!h and her "hite
blood cell count "as lo", petitioner prescribed 4euco)a9. About four to ei!ht ba!s of blood,
consistin! of pac:ed red blood cells, fresh "hole blood, or platelet concentrate, "ere transfused to
An!elica. ;or t"o da6s *Au!ust &2 to &/+, An!elica continued bleedin!, but petitioner clai)ed it "as
lesser in a)ount and in freGuenc6. Petitioner also denied that there "ere !ad!ets attached to
An!elica at that ti)e.
n Au!ust &1, An!elica developed ulcers in her )outh, "hich petitioner said "ere blood clots that
should not be re)oved. Respondents clai)ed that An!elica passed about half a liter of blood
throu!h her anus at around seven o8cloc: that evenin!, "hich petitioner li:e"ise denied.
n Au!ust 0', An!elica continued bleedin!. She "as restless as endotracheal and naso!astric
tubes "ere inserted into her "ea:ened bod6. An aspiration of the naso!astric tube inserted to
An!elica also revealed a blood6 content. An!elica "as !iven )ore platelet concentrate and fresh
"hole blood, "hich petitioner clai)ed i)proved her condition. Petitioner told An!elica not to re)ove
the endotracheal tube because this )a6 induce further bleedin!.
She "as also transferred to the
intensive care unit to avoid infection.
3he ne9t da6, respondents clai)ed that An!elica beca)e h6sterical, vo)ited blood and her bod6
turned blac:. Part of An!elica8s s:in "as also noted to be shreddin! b6 <ust rubbin! cotton on it.
An!elica "as so restless she re)oved those !ad!ets attached to her, sa6in! >A6a" :o na>C there
"ere tears in her e6es and she :ept turnin! her head. bservin! her dau!hter to be at the point of
death, 4ina as:ed for a doctor but the latter could not ans"er her an6)ore.
At this ti)e, the
attendin! ph6sician "as Dr. Marbella "ho "as sha:in! his head sa6in! that An!elica8s platelets "ere
do"n and respondents should pra6 for their dau!hter. Re6naldo clai)ed that he "as introduced to a
pediatrician "ho too: over his dau!hter8s case, Dr. Abesa)is "ho also told hi) to pra6 for his
dau!hter. An!elica continued to have difficult6 in her breathin! and blood "as bein! suctioned fro)
her sto)ach. A nurse "as posted inside An!elica8s roo) to assist her breathin! and at one point
the6 had to revive An!elica b6 pu)pin! her chest. 3hereafter, Re6naldo clai)ed that An!elica
alread6 e9perienced difficult6 in urinatin! and her bo"el consisted of blood,li:e fluid. An!elica
reGuested for an electric fan as she "as in pain. =ospital staff atte)pted to ta:e blood sa)ples fro)
An!elica but "ere unsuccessful because the6 could not even locate her vein. An!elica as:ed for a
fruit but "hen it "as !iven to her, she onl6 s)elled it. At this ti)e, Re6naldo clai)ed he could not
find either petitioner or Dr. Marbella. 3hat ni!ht, An!elica beca)e h6sterical and started re)ovin!
those !ad!ets attached to her. At three o8cloc: in the )ornin! of Septe)ber #, a priest ca)e and
the6 pra6ed before An!elica e9pired. Petitioner finall6 ca)e bac: and supposedl6 told respondents
that there "as >)alfunction> or bo!!ed,do"n )achine.
B6 petitioner8s o"n account, An!elica "as )erel6 irritable that da6 *Au!ust 0#+. Petitioner noted
thou!h that An!elica8s s:in "as indeed slou!hin! off.
She stressed that at 170' in the evenin!,
An!elica pulled out her endotracheal tube.
n Septe)ber #, e9actl6 t"o "ee:s after bein!
ad)itted at S4MC for che)otherap6, An!elica died.
3he cause of death, accordin! to petitioner,
"as septice)ia, or over"hel)in! infection, "hich caused An!elica8s other or!ans to fail.
attributed this to the patient8s poor defense )echanis) brou!ht about b6 the cancer itself.
Ehile he "as see:in! the release of An!elica8s cadaver fro) S4MC, Re6naldo clai)ed that
petitioner acted arro!antl6 and called hi) na)es. =e "as as:ed to si!n a pro)issor6 note as he did
not have cash to pa6 the hospital bill.
Respondents also presented as "itnesses Dr. $esusa Nieves,.er!ara, Medico,4e!al fficer of the
PNP,Cri)e 4aborator6 "ho conducted the autops6 on An!elica8s cadaver, and Dr. Melinda .er!ara
Bal)aceda "ho is a Medical Specialist e)plo6ed at the Depart)ent of =ealth *D=+ perations
and Mana!e)ent Services.
3estif6in! on the findin!s stated in her )edico,le!al report, Dr. .er!ara noted the follo"in!7 *#+ there
"ere fluids recovered fro) the abdo)inal cavit6, "hich is not nor)al, and "as due to he)orrha!ic
shoc: secondar6 to bleedin!C *&+ there "as he)orrha!e at the left side of the heartC *0+ bleedin! at
the upper portion of and areas ad<acent to, the esopha!usC *(+ lun!s "ere heav6 "ith bleedin! at the
bac: and lo"er portion, due to accu)ulation of fluidsC *(+ 6ello"ish discoloration of the liverC *%+
:idne6s sho"ed appearance of facial shoc: on account of he)orrha!esC and *?+ reddishness on
e9ternal surface of the spleen. All these "ere the end result of >h6povole)ic shoc: secondar6 to
)ultiple or!an he)orrha!es and disse)inated intravascular coa!ulation.> Dr. .er!ara opined that
this can be attributed to the che)ical a!ents in the dru!s !iven to the victi), "hich caused platelet
reduction resultin! to bleedin! sufficient to cause the victi)8s death. 3he ti)e lapse for the
production of DIC in the case of An!elica *fro) the ti)e of dia!nosis of sarco)a+ "as too short,
considerin! the survival rate of about 0 6ears. 3he "itness conceded that the victi) "ill also die of
osteosarco)a even "ith a)putation or che)otherap6, but in this case An!elica8s death "as not
caused b6 osteosarco)a. Dr. .er!ara ad)itted that she is not a patholo!ist but her state)ents "ere
based on the opinion of an oncolo!ist "ho) she had intervie"ed. 3his oncolo!ist supposedl6 said
that if the victi) alread6 had DIC prior to the che)otherap6, the hospital staff could have detected
n her part, Dr. Bal)aceda declared that it is the ph6sician8s dut6 to infor) and e9plain to the
patient or his relatives ever6 :no"n side effect of the procedure or therapeutic a!ents to be
ad)inistered, before securin! the consent of the patient or his relatives to such procedure or
therap6. 3he ph6sician thus bases his assurance to the patient on his personal assess)ent of the
patient8s condition and his :no"led!e of the !eneral effects of the a!ents or procedure that "ill be
allo"ed on the patient. Dr. Bal)aceda stressed that the patient or relatives )ust be infor)ed of all
:no"n side effects based on studies and observations, even if such "ill a!!ravate the patient8s
Dr. $ai)e 3a)a6o, the orthopaedic sur!eon "ho operated on An!elica8s lo"er e9tre)it6, testified for
the defendants. =e e9plained that in case of )ali!nant tu)ors, there is no !uarantee that the
ablation or re)oval of the a)putated part "ill co)pletel6 cure the cancer. 3hus, sur!er6 is not
enou!h. 3he )ortalit6 rate of osteosarco)a at the ti)e of )odern che)otherap6 and earl6
dia!nosis still re)ains at /'B to 1'B. Asuall6, deaths occur fro) )etastasis, or spread of the
cancer to other vital or!ans li:e the liver, causin! s6ste)ic co)plications. 3he )odes of therap6
available are the re)oval of the pri)ar6 source of the cancerous !ro"th and then the residual
cancer cells or )etastasis should be treated "ith che)otherap6. Dr. 3a)a6o further e9plained that
patients "ith osteosarco)a have poor defense )echanis) due to the cancer cells in the blood
strea). In the case of An!elica, he had previousl6 e9plained to her parents that after the sur!ical
procedure, che)otherap6 is i)perative so that )etastasis of these cancer cells "ill hopefull6 be
addressed. =e referred the patient to petitioner because he felt that petitioner is a co)petent
oncolo!ist. Considerin! that this t6pe of cancer is ver6 a!!ressive and "ill )etastasi5e earl6, it "ill
cause the de)ise of the patient should there be no earl6 intervention *in this case, the patient
developed sepsis "hich caused her death+. Cancer cells in the blood cannot be seen b6 the na:ed
e6e nor detected throu!h bone scan. n cross,e9a)ination, Dr. 3a)a6o stated that of the )ore than
%' child patients "ho had osteo!enic sarco)a he had handled, he thou!ht that probabl6 all of the)
died "ithin si9 )onths fro) a)putation because he did not see the) an6)ore after follo",upC it is
either the6 died or had seen another doctor.
In dis)issin! the co)plaint, the trial court held that petitioner "as not liable for da)a!es as she
observed the best :no"n procedures and e)plo6ed her hi!hest s:ill and :no"led!e in the
ad)inistration of che)otherap6 dru!s on An!elica but despite all efforts said patient died. It cited the
testi)on6 of Dr. 3a)a6o "ho testified that he considered petitioner one of the )ost proficient in the
treat)ent of cancer and that the patient in this case "as afflicted "ith a ver6 a!!ressive t6pe of
cancer necessitatin! che)otherap6 as ad<uvant treat)ent. Asin! the standard of ne!li!ence laid
do"n in Picart v. S)ith,
the trial court declared that petitioner has ta:en the necessar6 precaution
a!ainst the adverse effect of che)otherap6 on the patient, addin! that a "ron! decision is not b6
itself ne!li!ence. Respondents "ere ordered to pa6 their unpaid hospital bill in the a)ount of
Respondents appealed to the CA "hich, "hile concurrin! "ith the trial court8s findin! that there "as
no ne!li!ence co))itted b6 the petitioner in the ad)inistration of che)otherap6 treat)ent to
An!elica, found that petitioner as her attendin! ph6sician failed to full6 e9plain to the respondents all
the :no"n side effects of che)otherap6. 3he appellate court stressed that since the respondents
have been told of onl6 three side effects of che)otherap6, the6 readil6 consented thereto. =ad
petitioner )ade :no"n to respondents those other side effects "hich !ravel6 affected their child ,,
such as carpo,pedal spas), sepsis, decrease in the blood platelet count, bleedin!, infections and
eventual death ,, respondents could have decided differentl6 or adopted a different course of action
"hich could have dela6ed or prevented the earl6 death of their child.
3he CA thus declared7
Plaintiffs,appellants8 child "as sufferin! fro) a )ali!nant disease. 3he attendin! ph6sician
reco))ended that she under!o che)otherap6 treat)ent after sur!er6 in order to increase her
chances of survival. Appellants consented to the che)otherap6 treat)ent because the6 believed in
Dr. Rubi 4i8s representation that the deceased "ould have a stron! chance of survival after
che)otherap6 and also because of the representation of appellee Dr. Rubi 4i that there "ere onl6
three possible side,effects of the treat)ent. =o"ever, all sorts of painful side,effects resulted fro)
the treat)ent includin! the pre)ature death of An!elica. 3he appellants "ere clearl6 and totall6
una"are of these other side,effects "hich )anifested onl6 durin! the che)otherap6 treat)ent. 3his
"as sho"n b6 the fact that ever6 ti)e a proble) "ould ta:e place re!ardin! An!elica8s condition
*li:e an une9pected side,effect )anifestin! itself+, the6 "ould i))ediatel6 see: e9planation fro) Dr.
Rubi 4i. Surel6, those une9pected side,effects cul)inatin! in the loss of a loveDdF one caused the
appellants so )uch trouble, pain and sufferin!.
n this point therefore, D"Fe find defendant,appellee Dr. Rubi 4i ne!li!ent "hich "ould entitle
plaintiffs,appellants to their clai) for da)a!es.
9 9 9 9
E=ERE;RE, the instant appeal is hereb6 -RAN3ED. Accordin!l6, the assailed decision is hereb6
)odified to the e9tent that defendant,appellee Dr. Rubi 4i is ordered to pa6 the plaintiffs,appellants
the follo"in! a)ounts7
#. Actual da)a!es of P#01,'?(.(0, plus P1,/&/.'' for funeral e9pensesC
&. Moral da)a!es of P&'','''.''C
0. E9e)plar6 da)a!es of P%','''.''C
(. Attorne68s fee of P0','''.''.
*E)phasis supplied.+
Petitioner filed a )otion for partial reconsideration "hich the appellate court denied.
=ence, this petition.
Petitioner assails the CA in findin! her !uilt6 of ne!li!ence in not e9plainin! to the respondents all
the possible side effects of the che)otherap6 on their child, and in holdin! her liable for actual,
)oral and e9e)plar6 da)a!es and attorne68s fees. Petitioner e)phasi5ed that she "as not
ne!li!ent in the pre,che)otherap6 procedures and in the ad)inistration of che)otherap6 treat)ent
to An!elica.
n her supposed non,disclosure of all possible side effects of che)otherap6, includin! death,
petitioner ar!ues that it "as foolhard6 to i)a!ine her to be all,:no"in!Io)nipotent. Ehile the
theoretical side effects of che)otherap6 "ere e9plained b6 her to the respondents, as these should
be :no"n to a co)petent doctor, petitioner cannot possibl6 predict ho" a particular patient8s !enetic
)a:e,up, state of )ind, !eneral health and bod6 constitution "ould respond to the treat)ent. 3hese
are obviousl6 dependent on too )an6 :no"n, un:no"n and i))easurable variables, thus reGuirin!
that An!elica be, as she "as, constantl6 and closel6 )onitored durin! the treat)ent. Petitioner
asserts that she did ever6thin! "ithin her professional co)petence to attend to the )edical needs of
Citin! nu)erous trainin!s, distinctions and achieve)ents in her field and her current position as co,
director for clinical affairs of the Medical ncolo!6, Depart)ent of Medicine of S4MC, petitioner
contends that in the absence of an6 clear sho"in! or proof, she cannot be char!ed "ith ne!li!ence
in not infor)in! the respondents all the side effects of che)otherap6 or in the pre,treat)ent
procedures done on An!elica.
As to the cause of death, petitioner insists that An!elica did not die of platelet depletion but of sepsis
"hich is a co)plication of the cancer itself. Sepsis itself leads to bleedin! and death. She e9plains
that the response rate to che)otherap6 of patients "ith osteosarco)a is hi!h, so )uch so that
survival rate is favorable to the patient. Petitioner then points to so)e probable conseGuences if
An!elica had not under!one che)otherap6. 3hus, "ithout che)otherap6, other )edicines and
supportive treat)ent, the patient )i!ht have died the ne9t da6 because of )assive infection, or the
cancer cells )i!ht have spread to the brain and brou!ht the patient into a co)a, or into the lun!s
that the patient could have been hoo:ed to a respirator, or into her :idne6s that she "ould have to
under!o dial6sis. Indeed, respondents could have spent as )uch because of these co)plications.
3he patient "ould have been deprived of the chance to survive the ail)ent, of an6 hope for life and
her >Gualit6 of life> surel6 co)pro)ised. Since she had not been sho"n to be at fault, petitioner
)aintains that the CA erred in holdin! her liable for the da)a!es suffered b6 the respondents.
3he issue to be resolved is "hether the petitioner can be held liable for failure to full6 disclose
serious side effects to the parents of the child patient "ho died "hile under!oin! che)otherap6,
despite the absence of findin! that petitioner "as ne!li!ent in ad)inisterin! the said treat)ent.
3he petition is )eritorious.
3he t6pe of la"suit "hich has been called )edical )alpractice or, )ore appropriatel6, )edical
ne!li!ence, is that t6pe of clai) "hich a victi) has available to hi) or her to redress a "ron!
co))itted b6 a )edical professional "hich has caused bodil6 har). In order to successfull6 pursue
such a clai), a patient )ust prove that a health care provider, in )ost cases a ph6sician, either
failed to do so)ethin! "hich a reasonabl6 prudent health care provider "ould have done, or that he
or she did so)ethin! that a reasonabl6 prudent provider "ould not have doneC and that that failure
or action caused in<ur6 to the patient.
3his Court has reco!ni5ed that )edical ne!li!ence cases are best proved b6 opinions of e9pert
"itnesses belon!in! in the sa)e !eneral nei!hborhood and in the sa)e !eneral line of practice as
defendant ph6sician or sur!eon. 3he deference of courts to the e9pert opinion of Gualified ph6sicians
ste)s fro) the for)er8s reali5ation that the latter possess unusual technical s:ills "hich la6)en in
)ost instances are incapable of intelli!entl6 evaluatin!, hence the indispensabilit6 of e9pert
In this case, both the trial and appellate courts concurred in findin! that the alle!ed ne!li!ence of
petitioner in the ad)inistration of che)otherap6 dru!s to respondents8 child "as not proven
considerin! that Drs. .er!ara and Bal)aceda, not bein! oncolo!ists or cancer specialists, "ere not
Gualified to !ive e9pert opinion as to "hether petitioner8s lac: of s:ill, :no"led!e and professional
co)petence in failin! to observe the standard of care in her line of practice "as the pro9i)ate cause
of the patient8s death. ;urther)ore, respondents8 case "as not at all helped b6 the non,production of
)edical records b6 the hospital *onl6 the biops6 result and )edical bills "ere sub)itted to the court+.
Nevertheless, the CA found petitioner liable for her failure to infor) the respondents on all possible
side effects of che)otherap6 before securin! their consent to the said treat)ent.
3he doctrine of infor)ed consent "ithin the conte9t of ph6sician,patient relationships !oes far bac:
into En!lish co))on la". As earl6 as #2?2, doctors "ere char!ed "ith the tort of >batter6> *i.e., an
unauthori5ed ph6sical contact "ith a patient+ if the6 had not !ained the consent of their patients prior
to perfor)in! a sur!er6 or procedure. In the Anited States, the se)inal case "as Schoendorff v.
Societ6 of Ne" Jor: =ospital
"hich involved un"anted treat)ent perfor)ed b6 a doctor. $ustice
Ben<a)in Cardo5o8s oft,Guoted opinion upheld the basic ri!ht of a patient to !ive consent to an6
)edical procedure or treat)ent7 >Ever6 hu)an bein! of adult 6ears and sound )ind has a ri!ht to
deter)ine "hat shall be done "ith his o"n bod6C and a sur!eon "ho perfor)s an operation "ithout
his patient8s consent, co))its an assault, for "hich he is liable in da)a!es.>
;ro) a purel6 ethical
nor), infor)ed consent evolved into a !eneral principle of la" that a ph6sician has a dut6 to
disclose "hat a reasonabl6 prudent ph6sician in the )edical co))unit6 in the e9ercise of
reasonable care "ould disclose to his patient as to "hatever !rave ris:s of in<ur6 )i!ht be incurred
fro) a proposed course of treat)ent, so that a patient, e9ercisin! ordinar6 care for his o"n "elfare,
and faced "ith a choice of under!oin! the proposed treat)ent, or alternative treat)ent, or none at
all, )a6 intelli!entl6 e9ercise his <ud!)ent b6 reasonabl6 balancin! the probable ris:s a!ainst the
probable benefits.
SubseGuentl6, in Canterbur6 v. Spence
the court observed that the dut6 to disclose should not be
li)ited to )edical usa!e as to arro!ate the decision on revelation to the ph6sician alone. 3hus,
respect for the patient8s ri!ht of self,deter)ination on particular therap6 de)ands a standard set b6
la" for ph6sicians rather than one "hich ph6sicians )a6 or )a6 not i)pose upon the)selves.
scope of disclosure is pre)ised on the fact that patients ordinaril6 are persons unlearned in the
)edical sciences. Proficienc6 in dia!nosis and therap6 is not the full )easure of a ph6sician8s
responsibilit6. It is also his dut6 to "arn of the dan!ers lur:in! in the proposed treat)ent and to
i)part infor)ation "hich the patient has ever6 ri!ht to e9pect. Indeed, the patient8s reliance upon the
ph6sician is a trust of the :ind "hich traditionall6 has e9acted obli!ations be6ond those associated
"ith ar)slen!th transactions.
3he ph6sician is not e9pected to !ive the patient a short )edical
education, the disclosure rule onl6 reGuires of hi) a reasonable e9planation, "hich )eans !enerall6
infor)in! the patient in nontechnical ter)s as to "hat is at sta:eC the therap6 alternatives open to
hi), the !oals e9pectabl6 to be achieved, and the ris:s that )a6 ensue fro) particular treat)ent or
no treat)ent.
As to the issue of de)onstratin! "hat ris:s are considered )aterial necessitatin!
disclosure, it "as held that e9perts are unnecessar6 to a sho"in! of the )aterialit6 of a ris: to a
patient8s decision on treat)ent, or to the reasonabl6, e9pectable effect of ris: disclosure on the
decision. Such unrevealed ris: that should have been )ade :no"n )ust further )ateriali5e, for
other"ise the o)ission, ho"ever unpardonable, is "ithout le!al conseGuence. And, as in
)alpractice actions !enerall6, there )ust be a causal relationship bet"een the ph6sician8s failure to
divul!e and da)a!e to the patient.
Reiteratin! the fore!oin! considerations, Cobbs v. -rant
dee)ed it as inte!ral part of ph6sician8s
overall obli!ation to patient, the dut6 of reasonable disclosure of available choices "ith respect to
proposed therap6 and of dan!ers inherentl6 and potentiall6 involved in each. =o"ever, the ph6sician
is not obli!ed to discuss relativel6 )inor ris:s inherent in co))on procedures "hen it is co))on
:no"led!e that such ris:s inherent in procedure of ver6 lo" incidence. Cited as e9ceptions to the
rule that the patient should not be denied the opportunit6 to "ei!h the ris:s of sur!er6 or treat)ent
are e)er!enc6 cases "here it is evident he cannot evaluate data, and "here the patient is a child or
3he court thus concluded that the patient8s ri!ht of self,decision can onl6 be
effectivel6 e9ercised if the patient possesses adeGuate infor)ation to enable hi) in )a:in! an
intelli!ent choice. 3he scope of the ph6sician8s co))unications to the patient, then )ust be
)easured b6 the patient8s need, and that need is "hatever infor)ation is )aterial to the decision.
3he test therefore for deter)inin! "hether a potential peril )ust be divul!ed is its )aterialit6 to the
patient8s decision.
Cobbs v. -rant further reiterated the pronounce)ent in Canterbur6 v. Spence that for liabilit6 of the
ph6sician for failure to infor) patient, there )ust be causal relationship bet"een ph6sician8s failure
to infor) and the in<ur6 to patient and such connection arises onl6 if it is established that, had
revelation been )ade, consent to treat)ent "ould not have been !iven.
3here are four essential ele)ents a plaintiff )ust prove in a )alpractice action based upon the
doctrine of infor)ed consent7 >*#+ the ph6sician had a dut6 to disclose )aterial ris:sC *&+ he failed to
disclose or inadeGuatel6 disclosed those ris:sC *0+ as a direct and pro9i)ate result of the failure to
disclose, the patient consented to treat)ent she other"ise "ould not have consented toC and *(+
plaintiff "as in<ured b6 the proposed treat)ent.> 3he !rava)en in an infor)ed consent case reGuires
the plaintiff to >point to si!nificant undisclosed infor)ation relatin! to the treat)ent "hich "ould have
altered her decision to under!o it.
E9a)inin! the evidence on record, "e hold that there "as adeGuate disclosure of )aterial ris:s
inherent in the che)otherap6 procedure perfor)ed "ith the consent of An!elica8s parents.
Respondents could not have been una"are in the course of initial treat)ent and a)putation of
An!elica8s lo"er e9tre)it6, that her i))une s6ste) "as alread6 "ea: on account of the )ali!nant
tu)or in her :nee. Ehen petitioner infor)ed the respondents beforehand of the side effects of
che)otherap6 "hich includes lo"ered counts of "hite and red blood cells, decrease in blood
platelets, possible :idne6 or heart da)a!e and s:in dar:enin!, there is reasonable e9pectation on
the part of the doctor that the respondents understood ver6 "ell that the severit6 of these side
effects "ill not be the sa)e for all patients under!oin! the procedure. In other "ords, b6 the nature
of the disease itself, each patient8s reaction to the che)ical a!ents even "ith pre,treat)ent
laborator6 tests cannot be precisel6 deter)ined b6 the ph6sician. 3hat death can possibl6 result
fro) co)plications of the treat)ent or the underl6in! cancer itself, i))ediatel6 or so)eti)e after
the ad)inistration of che)otherap6 dru!s, is a ris: that cannot be ruled out, as "ith )ost other
)a<or )edical procedures, but such conclusion can be reasonabl6 dra"n fro) the !eneral side
effects of che)otherap6 alread6 disclosed.
As a ph6sician, petitioner can reasonabl6 e9pect the respondents to have considered the variables
in the reco))ended treat)ent for their dau!hter afflicted "ith a life,threatenin! illness. n the other
hand, it is difficult to !ive credence to respondents8 clai) that petitioner told the) of 1%B chance of
recover6 for their dau!hter, as it "as unli:el6 for doctors li:e petitioner "ho "ere dealin! "ith !rave
conditions such as cancer to have falsel6 assured patients of che)otherap68s success rate. Besides,
infor)ed consent la"s in other countries !enerall6 reGuire onl6 a reasonable e9planation of potential
har)s, so specific disclosures such as statistical data, )a6 not be le!all6 necessar6.
3he ele)ent of ethical dut6 to disclose )aterial ris:s in the proposed )edical treat)ent cannot thus
be reduced to one si)plistic for)ula applicable in all instances. ;urther, in a )edical )alpractice
action based on lac: of infor)ed consent, >the plaintiff )ust prove both the dut6 and the breach of
that dut6 throu!h e9pert testi)on6.
Such e9pert testi)on6 )ust sho" the custo)ar6 standard of
care of ph6sicians in the sa)e practice as that of the defendant doctor.
In this case, the testi)on6 of Dr. Bal)aceda "ho is not an oncolo!ist but a Medical Specialist of the
D=8s perational and Mana!e)ent Services char!ed "ith receivin! co)plaints a!ainst hospitals,
does not Gualif6 as e9pert testi)on6 to establish the standard of care in obtainin! consent for
che)otherap6 treat)ent. In the absence of e9pert testi)on6 in this re!ard, the Court feels hesitant
in definin! the scope of )andator6 disclosure in cases of )alpractice based on lac: of infor)ed
consent, )uch less set a standard of disclosure that, even in forei!n <urisdictions, has been noted to
be an evolvin! one.
As societ6 has !rappled "ith the <u9taposition bet"een personal autono)6 and the )edical
professionKs intrinsic i)petus to cure, the la" definin! >adeGuate> disclosure has under!one a
d6na)ic evolution. A standard once !uided solel6 b6 the ru)inations of ph6sicians is no" dependent
on "hat a reasonable person in the patient8s position re!ards as si!nificant. 3his chan!e in
perspective is especiall6 i)portant as )edical brea:throu!hs )ove practitioners to the cuttin! ed!e
of technolo!6, ever encounterin! ne" and heretofore uni)a!ined treat)ents for currentl6 incurable
diseases or ail)ents. An adaptable standard is needed to account for this constant pro!ression.
Reasonableness anal6ses per)eate our le!al s6ste) for the ver6 reason that the6 are deter)ined
b6 social nor)s, e9pandin! and contractin! "ith the ebb and flo" of societal evolution.
As "e pro!ress to"ard the t"ent6,first centur6, "e no" reali5e that the le!al standard of disclosure
is not sub<ect to construction as a cate!orical i)perative. Ehatever for)ulae or processes "e adopt
are onl6 useful as a foundational startin! pointC the particular Gualit6 or Guantit6 of disclosure "ill
re)ain ine9tricabl6 bound b6 the facts of each case. Nevertheless, <uries that ulti)atel6 deter)ine
"hether a ph6sician properl6 infor)ed a patient are inevitabl6 !uided b6 "hat the6 perceive as the
co))on e9pectation of the )edical consu)erL>a reasonable person in the patient8s position "hen
decidin! to accept or re<ect a reco))ended )edical procedure.>
*E)phasis supplied.+
E=ERE;RE, the petition for revie" on certiorari is -RAN3ED. 3he Decision dated $une #%, &''(
and the Resolution dated Septe)ber #, &''( of the Court of Appeals in CA,-.R. C. No. %/'#0 are
3he Decision dated Septe)ber %, #112 of the Re!ional 3rial Court of 4e!a5pi Cit6, Branch /, in Civil
Case No. /1'( is REINS3A3ED and AP=E4D.
No costs.
Associate $ustice
Chief $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
*No Part+
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
Associate $ustice
C E R 3 I ; I C A 3 I N
Pursuant to Section #0, Article .III of the #1/2 Constitution, I certif6 that the conclusions in the
above Decision had been reached in consultation before the case "as assi!ned to the "riter of the
opinion of the Court.
Chief $ustice