Republic of the Philippines

SUPREME COURT
Manila
FIRST DIVISION

G.R. No. 124354 December 29, 1999

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own
behalf and as natural guardians of the minors, ROMMEL
RAMOS, ROY RODERICK RAMOS and RON RAYMOND
RAMOS, petitioners,
vs.
COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER,
DR. ORLINO HOSAKA and DRA. PERFECTA
GUTIERREZ, respondents.

KAPUNAN, J.:
The Hippocratic Oath mandates physicians to give primordial
consideration to the health and welfare of their patients. If a
doctor fails to live up to this precept, he is made accountable for
his acts. A mistake, through gross negligence or incompetence or
plain human error, may spell the difference between life and
death. In this sense, the doctor plays God on his patient's fate. 1
In the case at bar, the Court is called upon to rule whether a
surgeon, an anesthesiologist and a hospital should be made
liable for the unfortunate comatose condition of a patient
scheduled for cholecystectomy. 2
Petitioners seek the reversal of the decision 3 of the Court of
Appeals, dated 29 May 1995, which overturned the decision 4 of the
Regional Trial Court, dated 30 January 1992, finding private
respondents liable for damages arising from negligence in the
performance of their professional duties towards petitioner Erlinda
Ramos resulting in her comatose condition.

The antecedent facts as summarized by the trial court are

reproduced hereunder:
Plaintiff Erlinda Ramos was, until the afternoon
of June 17, 1985, a 47-year old (Exh. "A") robust
woman (TSN, October 19, 1989, p. 10). Except
for occasional complaints of discomfort due to
pains allegedly caused by the presence of a
stone in her gall bladder (TSN, January 13,
1988, pp. 4-5), she was as normal as any other
woman. Married to Rogelio E. Ramos, an
executive of Philippine Long Distance Telephone
Company, she has three children whose names
are Rommel Ramos, Roy Roderick Ramos and
Ron Raymond Ramos (TSN, October 19, 1989,
pp. 5-6).
Because the discomforts somehow interfered
with her normal ways, she sought professional
advice. She was advised to undergo an
operation for the removal of a stone in her gall
bladder (TSN, January 13, 1988, p. 5). She
underwent a series of examinations which
included blood and urine tests (Exhs. "A" and
"C") which indicated she was fit for surgery.
Through the intercession of a mutual friend, Dr.
Buenviaje (TSN, January 13, 1988, p. 7), she
and her husband Rogelio met for the first
time Dr. Orlino Hozaka (should be
Hosaka; see TSN, February 20, 1990, p. 3), one
of the defendants in this case, on June 10, 1985.
They agreed that their date at the operating table
at the DLSMC (another defendant), would be on
June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided
that she should undergo a "cholecystectomy"
operation after examining the documents
(findings from the Capitol Medical Center, FEU
Hospital and DLSMC) presented to him. Rogelio
E. Ramos, however, asked Dr. Hosaka to look
for a good anesthesiologist. Dr. Hosaka, in turn,
assured Rogelio that he will get a good
anesthesiologist. Dr. Hosaka charged a fee of

P16,000.00, which was to include the

anesthesiologist's fee and which was to be paid
after the operation (TSN, October 19, 1989, pp.
14-15, 22-23, 31-33; TSN, February 27, 1990, p.
13; and TSN, November 9, 1989, pp. 3-4, 10,
17).
A day before the scheduled date of operation,
she was admitted at one of the rooms of the
DLSMC, located along E. Rodriguez Avenue,
Quezon City (TSN, October 19,1989, p. 11).
At around 7:30 A.M. of June 17, 1985 and while still in
her room, she was prepared for the operation by the
hospital staff. Her sister-in-law, Herminda Cruz, who
was the Dean of the College of Nursing at the Capitol
Medical Center, was also there for moral support. She
reiterated her previous request for Herminda to be with
her even during the operation. After praying, she was
given injections. Her hands were held by Herminda as
they went down from her room to the operating room
(TSN, January 13, 1988, pp. 9-11). Her husband,
Rogelio, was also with her (TSN, October 19, 1989, p.
18). At the operating room, Herminda saw about two or
three nurses and Dr. Perfecta Gutierrez, the other
defendant, who was to administer anesthesia. Although
not a member of the hospital staff, Herminda
introduced herself as Dean of the College of Nursing at
the Capitol Medical Center who was to provide moral
support to the patient, to them. Herminda was allowed
to stay inside the operating room.
At around 9:30 A.M., Dr. Gutierrez reached a
nearby phone to look for Dr. Hosaka who was
not yet in (TSN, January 13, 1988, pp. 11-12).
Dr. Gutierrez thereafter informed Herminda Cruz
about the prospect of a delay in the arrival of Dr.
Hosaka. Herminda then went back to the patient
who asked, "Mindy, wala pa ba ang Doctor"? The
former replied, "Huwag kang mag-alaala,
darating na iyon" (Ibid.).

Thereafter, Herminda went out of the operating room and

informed the patient's husband, Rogelio, that the doctor was
not yet around (id., p. 13). When she returned to the
operating room, the patient told her, "Mindy, inip na inip na
ako, ikuha mo ako ng ibang Doctor." So, she went out again
and told Rogelio about what the patient said (id., p. 15).
Thereafter, she returned to the operating room.
At around 10:00 A.M., Rogelio E. Ramos was
"already dying [and] waiting for the arrival of the
doctor" even as he did his best to find somebody
who will allow him to pull out his wife from the
operating room (TSN, October 19, 1989, pp. 1920). He also thought of the feeling of his wife,
who was inside the operating room waiting for
the doctor to arrive (ibid.). At almost 12:00 noon,
he met Dr. Garcia who remarked that he (Dr.
Garcia) was also tired of waiting for Dr. Hosaka
to arrive (id., p. 21). While talking to Dr. Garcia at
around 12:10 P.M., he came to know that Dr.
Hosaka arrived as a nurse remarked, "Nandiyan
na si Dr. Hosaka, dumating na raw." Upon
hearing those words, he went down to the lobby
and waited for the operation to be completed (id.,
pp. 16, 29-30).
At about 12:15 P.M., Herminda Cruz, who was
inside the operating room with the patient, heard
somebody say that "Dr. Hosaka is already here."
She then saw people inside the operating room
"moving, doing this and that, [and] preparing the
patient for the operation" (TSN, January 13,
1988, p. 16). As she held the hand of Erlinda
Ramos, she then saw Dr. Gutierrez intubating
the hapless patient. She thereafter heard Dr.
Gutierrez say, "ang hirap ma-intubate nito, mali
yata ang pagkakapasok. O lumalaki ang tiyan"
(id., p. 17). Because of the remarks of Dra.
Gutierrez, she focused her attention on what Dr.
Gutierrez was doing. She thereafter noticed
bluish discoloration of the nailbeds of the left
hand of the hapless Erlinda even as Dr. Hosaka
approached her. She then heard Dr. Hosaka

issue an order for someone to call Dr. Calderon,

another anesthesiologist (id., p. 19). After Dr.
Calderon arrived at the operating room, she saw
this anesthesiologist trying to intubate the
patient. The patient's nailbed became bluish and
the patient was placed in a trendelenburg
position a position where the head of the
patient is placed in a position lower than her feet
which is an indication that there is a decrease of
blood supply to the patient's brain (Id., pp. 1920). Immediately thereafter, she went out of the
operating room, and she told Rogelio E. Ramos
"that something wrong was . . . happening"
(Ibid.). Dr. Calderon was then able to intubate
the patient (TSN, July 25, 1991, p. 9).
Meanwhile, Rogelio, who was outside the
operating room, saw a respiratory machine being
rushed towards the door of the operating room.
He also saw several doctors rushing towards the
operating room. When informed by Herminda
Cruz that something wrong was happening, he
told her (Herminda) to be back with the patient
inside the operating room (TSN, October 19,
1989, pp. 25-28).
Herminda Cruz immediately rushed back, and
saw that the patient was still in trendelenburg
position (TSN, January 13, 1988, p. 20). At
almost 3:00 P.M. of that fateful day, she saw the
patient taken to the Intensive Care Unit (ICU).
About two days thereafter, Rogelio E. Ramos
was able to talk to Dr. Hosaka. The latter
informed the former that something went wrong
during the intubation. Reacting to what was told
to him, Rogelio reminded the doctor that the
condition of his wife would not have happened,
had he (Dr. Hosaka) looked for a good
anesthesiologist (TSN, October 19, 1989, p. 31).
Doctors Gutierrez and Hosaka were also asked
by the hospital to explain what happened to the

patient. The doctors explained that the patient

had bronchospasm (TSN, November 15, 1990,
pp. 26-27).
Erlinda Ramos stayed at the ICU for a month.
About four months thereafter or on November
15, 1985, the patient was released from the
hospital.
During the whole period of her confinement, she
incurred hospital bills amounting to P93,542.25
which is the subject of a promissory note and
affidavit of undertaking executed by Rogelio E.
Ramos in favor of DLSMC. Since that fateful
afternoon of June 17, 1985, she has been in a
comatose condition. She cannot do anything.
She cannot move any part of her body. She
cannot see or hear. She is living on mechanical
means. She suffered brain damage as a result of
the absence of oxygen in her brain for four to five
minutes (TSN, November 9, 1989, pp. 21-22).
After being discharged from the hospital, she has
been staying in their residence, still needing
constant medical attention, with her husband
Rogelio incurring a monthly expense ranging
from P8,000.00 to P10,000.00 (TSN, October 19,
1989, pp. 32-34). She was also diagnosed to be
suffering from "diffuse cerebral parenchymal
damage" (Exh. "G"; see also TSN, December 21,
1989,
p. 6). 5
Thus, on 8 January 1986, petitioners filed a civil case 6 for
damages with the Regional Trial Court of Quezon City against herein
private respondents alleging negligence in the management and care of
Erlinda Ramos.

During the trial, both parties presented evidence as to the

possible cause of Erlinda's injury. Plaintiff presented the
testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to
prove that the sustained by Erlinda was due to lack of oxygen in
her brain caused by the faulty management of her airway by
private respondents during the anesthesia phase. On the other

hand, private respondents primarily relied on the expert

testimony of Dr. Eduardo Jamora, a pulmonologist, to the effect
that the cause of brain damage was Erlinda's allergic reaction to
the anesthetic agent, Thiopental Sodium (Pentothal).
After considering the evidence from both sides, the Regional Trial
Court rendered judgment in favor of petitioners, to wit:
After evaluating the evidence as shown in the
finding of facts set forth earlier, and applying the
aforecited provisions of law and jurisprudence to
the case at bar, this Court finds and so holds that
defendants are liable to plaintiffs for damages.
The defendants were guilty of, at the very least,
negligence in the performance of their duty to
plaintiff-patient Erlinda Ramos.
On the part of Dr. Perfecta Gutierrez, this Court
finds that she omitted to exercise reasonable
care in not only intubating the patient, but also in
not repeating the administration of atropine
(TSN, August 20, 1991, pp. 5-10), without due
regard to the fact that the patient was inside the
operating room for almost three (3) hours. For
after she committed a mistake in intubating [the]
patient, the patient's nailbed became bluish and
the patient, thereafter, was placed in
trendelenburg position, because of the decrease
of blood supply to the patient's brain. The
evidence further shows that the hapless patient
suffered brain damage because of the absence
of oxygen in her (patient's) brain for
approximately four to five minutes which, in turn,
caused the patient to become comatose.
On the part of Dr. Orlino Hosaka, this Court finds
that he is liable for the acts of Dr. Perfecta
Gutierrez whom he had chosen to administer
anesthesia on the patient as part of his obligation
to provide the patient a good anesthesiologist',
and for arriving for the scheduled operation
almost three (3) hours late.

On the part of DLSMC (the hospital), this Court

finds that it is liable for the acts of negligence of
the doctors in their "practice of medicine" in the
operating room. Moreover, the hospital is liable
for failing through its responsible officials, to
cancel the scheduled operation after Dr. Hosaka
inexcusably failed to arrive on time.
In having held thus, this Court rejects the
defense raised by defendants that they have
acted with due care and prudence in rendering
medical services to plaintiff-patient. For if the
patient was properly intubated as claimed by
them, the patient would not have become
comatose. And, the fact that another
anesthesiologist was called to try to intubate the
patient after her (the patient's) nailbed turned
bluish, belie their claim. Furthermore, the
defendants should have rescheduled the
operation to a later date. This, they should have
done, if defendants acted with due care and
prudence as the patient's case was an elective,
not an emergency case.
xxx xxx xxx
WHEREFORE, and in view of the foregoing,
judgment is rendered in favor of the plaintiffs and
against the defendants. Accordingly, the latter
are ordered to pay, jointly and severally, the
former the following sums of money, to wit:
1) the sum of P8,000.00 as
actual monthly expenses for the
plaintiff Erlinda Ramos reckoned
from November 15, 1985 or in
the total sum of P632,000.00 as
of April 15, 1992, subject to its
being updated;
2) the sum of P100,000.00 as
reasonable attorney's fees;

3) the sum of P800,000.00 by

way of moral damages and the
further sum of P200,000,00 by
way of exemplary damages;
and,
4) the costs of the suit.
SO ORDERED. 7
Private respondents seasonably interposed an appeal to the
Court of Appeals. The appellate court rendered a Decision, dated
29 May 1995, reversing the findings of the trial court. The
decretal portion of the decision of the appellate court reads:
WHEREFORE, for the foregoing premises the
appealed decision is hereby REVERSED, and
the complaint below against the appellants is
hereby ordered DISMISSED. The counterclaim
of appellant De Los Santos Medical Center is
GRANTED but only insofar as appellees are
hereby ordered to pay the unpaid hospital bills
amounting to P93,542.25, plus legal interest for
justice must be tempered with mercy.
SO ORDERED. 8
The decision of the Court of Appeals was received on 9 June
1995 by petitioner Rogelio Ramos who was mistakenly
addressed as "Atty. Rogelio Ramos." No copy of the decision,
however, was sent nor received by the Coronel Law Office, then
counsel on record of petitioners. Rogelio referred the decision of
the appellate court to a new lawyer, Atty. Ligsay, only on 20 June
1995, or four (4) days before the expiration of the reglementary
period for filing a motion for reconsideration. On the same day,
Atty. Ligsay, filed with the appellate court a motion for extension
of time to file a motion for reconsideration. The motion for
reconsideration was submitted on 4 July 1995. However, the
appellate court denied the motion for extension of time in its
Resolution dated 25 July 1995. 9Meanwhile, petitioners engaged the
services of another counsel, Atty. Sillano, to replace Atty. Ligsay. Atty.
Sillano filed on 7 August 1995 a motion to admit the motion for
reconsideration contending that the period to file the appropriate

pleading on the assailed decision had not yet commenced to run as the
Division Clerk of Court of the Court of Appeals had not yet served a copy
thereof to the counsel on record. Despite this explanation, the appellate
court still denied the motion to admit the motion for reconsideration of
petitioners in its Resolution, dated 29 March 1996, primarily on the
ground that the fifteen-day (15) period for filing a motion for
reconsideration had already expired, to wit:

We said in our Resolution on July 25, 1995, that

the filing of a Motion for Reconsideration cannot
be extended; precisely, the Motion for Extension
(Rollo, p. 12) was denied. It is, on the other
hand, admitted in the latter Motion that
plaintiffs/appellees received a copy of the
decision as early as June 9, 1995. Computation
wise, the period to file a Motion for
Reconsideration expired on June 24. The Motion
for Reconsideration, in turn, was received by the
Court of Appeals already on July 4, necessarily,
the 15-day period already passed. For that
alone, the latter should be denied.
Even assuming admissibility of the Motion for the
Reconsideration, but after considering the
Comment/Opposition, the former, for lack of
merit, is hereby DENIED.
SO ORDERED. 10
A copy of the above resolution was received by Atty. Sillano on
11 April 1996. The next day, or on 12 April 1996, Atty. Sillano filed
before this Court a motion for extension of time to file the present
petition for certiorari under Rule 45. The Court granted the
motion for extension of time and gave petitioners additional thirty
(30) days after the expiration of the fifteen-day (15) period
counted from the receipt of the resolution of the Court of Appeals
within which to submit the petition. The due date fell on 27 May
1996. The petition was filed on 9 May 1996, well within the
extended period given by the Court.
Petitioners assail the decision of the Court of Appeals on the
following grounds:

I
IN PUTTING MUCH RELIANCE ON THE
TESTIMONIES OF RESPONDENTS DRA.
GUTIERREZ, DRA. CALDERON AND DR.
JAMORA;
II
IN FINDING THAT THE NEGLIGENCE OF THE
RESPONDENTS DID NOT CAUSE THE
UNFORTUNATE COMATOSE CONDITION OF
PETITIONER ERLINDA RAMOS;
III
IN NOT APPLYING THE DOCTRINE OF RES
IPSA LOQUITUR. 11
Before we discuss the merits of the case, we shall first dispose of
the procedural issue on the timeliness of the petition in relation to
the motion for reconsideration filed by petitioners with the Court
of Appeals. In their
Comment, 12 private respondents contend that the petition should not
be given due course since the motion for reconsideration of the
petitioners on the decision of the Court of Appeals was validly dismissed
by the appellate court for having been filed beyond the reglementary
period. We do not agree.

A careful review of the records reveals that the reason behind the
delay in filing the motion for reconsideration is attributable to the
fact that the decision of the Court of Appeals was not sent to then
counsel on record of petitioners, the Coronel Law Office. In fact,
a copy of the decision of the appellate court was instead sent to
and received by petitioner Rogelio Ramos on 9 June 1995
wherein he was mistakenly addressed as Atty. Rogelio Ramos.
Based on the other communications received by petitioner
Rogelio Ramos, the appellate court apparently mistook him for
the counsel on record. Thus, no copy of the decision of the
counsel on record. Petitioner, not being a lawyer and unaware of
the prescriptive period for filing a motion for reconsideration,
referred the same to a legal counsel only on 20 June 1995.

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. Moreover,
since the Court of Appeals already issued a second Resolution,
dated 29 March 1996, which superseded the earlier resolution
issued on 25 July 1995, and denied the motion for
reconsideration of petitioner, we believed that the receipt of the
former should be considered in determining the timeliness of the
filing of the present petition. Based on this, the petition before us
was submitted on time.
After resolving the foregoing procedural issue, we shall now look
into the merits of the case. For a more logical presentation of the
discussion we shall first consider the issue on the applicability of
the doctrine of res ipsa loquitur to the instant case. Thereafter,
the first two assigned errors shall be tackled in relation to the res
ipsa loquitur doctrine.
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 faciecase, and present a question of fact for
defendant to meet with an explanation. 13 Where the thing which
caused the injury complained of is shown to be under the management
of the defendant 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. 14

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. 15 It is grounded in the superior logic of ordinary human

Medical malpractice 24 cases do not escape the application of this

experience and on the basis of such experience or common knowledge,

negligence may be deduced from the mere occurrence of the accident
itself. 16 Hence, res ipsa loquitur is applied in conjunction with the
doctrine of common knowledge.

doctrine. Thus, res ipsa loquitur has been applied when the
circumstances attendant upon the harm are themselves of such a
character as to justify an inference of negligence as the cause of that
harm. 25 The application of res ipsa loquitur in medical negligence cases
presents a question of law since it is a judicial function to determine
whether a certain set of circumstances does, as a matter of law, permit a
given inference. 26

However, 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. 17 Instead, it is
considered as merely evidentiary or in the nature of a procedural
rule. 18 It is regarded as a mode of proof, or a mere procedural of
convenience since it furnishes a substitute for, and relieves a plaintiff of,
the burden of producing specific proof of negligence. 19 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. 20 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. 21
In the above requisites, the fundamental element is the "control
of instrumentality" which caused the damage. 22Such element of
control must be shown to be within the dominion of the defendant. In
order to have the benefit of the rule, a plaintiff, in addition to proving
injury or damage, must show a situation where it is applicable, and must
establish that the essential elements of the doctrine were present in a
particular incident. 23

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. 27 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. 28 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. 29 Hence, in cases where theres ipsa loquitur is
applicable, the court is permitted to find a physician negligent upon
proper proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine the
proper standard of care. 30 Where common knowledge and experience
teach that a resulting injury would not have occurred to the patient if due
care had been exercised, an inference of negligence may be drawn
giving rise to an application of the doctrine of res ipsa loquitur without
medical evidence, which is ordinarily required to show not only what
occurred but how and why it occurred. 31 When the doctrine is
appropriate, all that the patient must do is prove a nexus between the
particular act or omission complained of and the injury sustained while
under the custody and management of the defendant without need to
produce expert medical testimony to establish the standard of care.
Resort to res ipsa loquitur is allowed because there is no other way,
under usual and ordinary conditions, by which the patient can obtain
redress for injury suffered by him.

Thus, courts of other jurisdictions have applied the doctrine in the

following situations: leaving of a foreign object in the body of the
patient after an operation, 32 injuries sustained on a healthy part of the
body which was not under, or in the area, of treatment, 33 removal of the

wrong part of the body when another part was intended, 34 knocking out
a tooth while a patient's jaw was under anesthetic for the removal of his
tonsils, 35 and loss of an eye while the patient plaintiff was under the
influence of anesthetic, during or following an operation for
appendicitis, 36 among others.

Nevertheless, 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. 37 A distinction must be made between the failure to secure
results, and the occurrence of something more unusual and not
ordinarily found if the service or treatment rendered followed the usual
procedure of those skilled in that particular practice. 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. 38 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 produce the desired
result. 39 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. 40 The real question, therefore, is whether or not in the
process of the operation any extraordinary incident or unusual event
outside of the routine performance occurred which is beyond the regular
scope of customary professional activity in such operations, which, if
unexplained would themselves reasonably speak to the average man as
the negligent cause or causes of the untoward consequence. 41 If there
was such extraneous interventions, the doctrine of res ipsa loquitur may
be utilized and the defendant is called upon to explain the matter, by
evidence of exculpation, if he could. 42

We find the doctrine of res ipsa loquitur appropriate in the case at

bar. As will hereinafter be explained, the damage sustained by
Erlinda in her brain prior to a scheduled gall bladder operation
presents a case for the application of res ipsa loquitur.

A case strikingly similar to the one before us is Voss

vs. Bridwell, 43 where the Kansas Supreme Court in applying theres

Indeed, the principles enunciated in the aforequoted case apply

with equal force here. In the present case, Erlinda submitted
ipsa loquitur stated:
herself for cholecystectomy and expected a routine general
surgery to be performed on her gall bladder. On that fateful day
she delivered her person over to the care, custody and control of
The plaintiff herein submitted himself for a
mastoid operation and delivered his person over private respondents who exercised complete and exclusive
control over her. At the time of submission, Erlinda was
to the care, custody and control of his physician
neurologically sound and, except for a few minor discomforts,
who had complete and exclusive control over
was likewise physically fit in mind and body. However, during the
him, but the operation was never performed. At
administration of anesthesia and prior to the performance of
the time of submission he was neurologically
sound and physically fit in mind and body, but he cholecystectomy she suffered irreparable damage to her brain.
suffered irreparable damage and injury rendering Thus, without undergoing surgery, she went out of the operating
room already decerebrate and totally incapacitated. Obviously,
him decerebrate and totally incapacitated. The
injury was one which does not ordinarily occur in brain damage, which Erlinda sustained, is an injury which does
not normally occur in the process of a gall bladder operation. In
the process of a mastoid operation or in the
absence of negligence in the administration of an fact, this kind of situation does not in the absence of negligence
anesthetic, and in the use and employment of an of someone in the administration of anesthesia and in the use of
endotracheal tube. Normally, a person being put under
endoctracheal tube. Ordinarily a person being
anesthesia is not rendered decerebrate as a consequence of
put under anesthesia is not rendered
administering such anesthesia if the proper procedure was
decerebrate as a consequence of administering
followed. Furthermore, the instruments used in the administration
such anesthesia in the absence of negligence.
Upon these facts and under these circumstances of anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents, who are the physiciansa layman would be able to say, as a matter of
in-charge. Likewise, petitioner Erlinda could not have been guilty
common knowledge and observation, that the
of contributory negligence because she was under the influence
consequences of professional treatment were
of anesthetics which rendered her unconscious.
not as such as would ordinarily have followed if
due care had been exercised.
Considering that a sound and unaffected member of the body
(the brain) is injured or destroyed while the patient is
Here the plaintiff could not have been guilty of
unconscious and under the immediate and exclusive control of
contributory negligence because he was under
the physicians, we hold that a practical administration of justice
the influence of anesthetics and unconscious,
dictates the application of res ipsa loquitur. Upon these facts and
and the circumstances are such that the true
under these circumstances the Court would be able to say, as a
explanation of event is more accessible to the
matter of common knowledge and observation, if negligence
defendants than to the plaintiff for they had the
attended the management and care of the patient. Moreover, the
exclusive control of the instrumentalities of
liability of the physicians and the hospital in this case is not
anesthesia.
predicated upon an alleged failure to secure the desired results
Upon all the facts, conditions and circumstances of an operation nor on an alleged lack of skill in the diagnosis or
treatment as in fact no operation or treatment was ever
alleged in Count II it is held that a cause of
performed on Erlinda. Thus, upon all these initial determination a
action is stated under the doctrine of res ipsa
44
case is made out for the application of the doctrine of res ipsa
loquitur.
loquitur.

Nonetheless, in holding that res ipsa loquitur is available to the

present case we are not saying that the doctrine is applicable in
any and all cases where injury occurs to a patient while under
anesthesia, or to any and all anesthesia cases. Each case must
be viewed in its own light and scrutinized in order to be within
the res ipsa loquitur coverage.
Having in mind the applicability of the res ipsa loquitur doctrine
and the presumption of negligence allowed therein, the Court
now comes to the issue of whether the Court of Appeals erred in
finding that private respondents were not negligent in the care of
Erlinda during the anesthesia phase of the operation and, if in the
affirmative, whether the alleged negligence was the proximate
cause of Erlinda's comatose condition. Corollary thereto, we shall
also determine if the Court of Appeals erred in relying on the
testimonies of the witnesses for the private respondents.
In sustaining the position of private respondents, the Court of
Appeals relied on the testimonies of Dra. Gutierrez, Dra.
Calderon and Dr. Jamora. In giving weight to the testimony of
Dra. Gutierrez, the Court of Appeals rationalized that she was
candid enough to admit that she experienced some difficulty in
the endotracheal intubation 45 of the patient and thus, cannot be said
to be covering her negligence with falsehood. The appellate court
likewise opined that private respondents were able to show that the
brain damage sustained by Erlinda was not caused by the alleged faulty
intubation but was due to the allergic reaction of the patient to the drug
Thiopental Sodium (Pentothal), a short-acting barbiturate, as testified on
by their expert witness, Dr. Jamora. On the other hand, the appellate
court rejected the testimony of Dean Herminda Cruz offered in favor of
petitioners that the cause of the brain injury was traceable to the
wrongful insertion of the tube since the latter, being a nurse, was
allegedly not knowledgeable in the process of intubation. In so holding,
the appellate court returned a verdict in favor of respondents physicians
and hospital and absolved them of any liability towards Erlinda and her
family.

We disagree with the findings of the Court of Appeals. We hold

that private respondents were unable to disprove the
presumption of negligence on their part in the care of Erlinda and
their negligence was the proximate cause of her piteous
condition.

In the instant case, the records are helpful in furnishing not only
the logical scientific evidence of the pathogenesis of the injury
but also in providing the Court the legal nexus upon which liability
is based. As will be shown hereinafter, private respondents' own
testimonies which are reflected in the transcript of stenographic
notes are replete of signposts indicative of their negligence in the
care and management of Erlinda.
With regard to Dra. Gutierrez, we find her negligent in the care of
Erlinda during the anesthesia phase. As borne by the records,
respondent Dra. Gutierrez failed to properly intubate the patient.
This fact was attested to by Prof. Herminda Cruz, Dean of the
Capitol Medical Center School of Nursing and petitioner's sisterin-law, who was in the operating room right beside the patient
when the tragic event occurred. Witness Cruz testified to this
effect:
ATTY. PAJARES:
Q: In particular, what did Dra.
Perfecta Gutierrez do, if any on
the patient?

stretcher holding the left hand of

the patient and all of a sudden
heard some remarks coming
from Dra. Perfecta Gutierrez
herself. She was saying "Ang
hirap ma-intubate nito, mali yata
ang pagkakapasok. O lumalaki
ang tiyan.
xxx xxx xxx
ATTY. PAJARES:
Q: From whom did you hear
those words "lumalaki ang
tiyan"?
A: From Dra. Perfecta Gutierrez.
xxx xxx xxx

A: He made an order to call on

the anesthesiologist in the
person of Dr. Calderon.
Q: Did Dr. Calderon, upon being
called, arrive inside the
operating room?
A: Yes sir.
Q: What did [s]he do, if any?
A: [S]he tried to intubate the
patient.
Q: What happened to the
patient?
A: When Dr. Calderon try (sic) to
intubate the patient, after a while
the patient's nailbed became
bluish and I saw the patient was
placed in trendelenburg position.

A: In particular, I could see that

she was intubating the patient.

Q: After hearing the phrase

"lumalaki ang tiyan," what did
you notice on the person of the
patient?

Q: Do you know what happened

to that intubation process
administered by Dra. Gutierrez?

A: I notice (sic) some bluish

discoloration on the nailbeds of
the left hand where I was at.

Q: Do you know the reason why

the patient was placed in that
trendelenburg position?

ATTY. ALCERA:

Q: Where was Dr. Orlino

Ho[s]aka then at that particular
time?

A: As far as I know, when a

patient is in that position, there
is a decrease of blood supply to
the brain. 46

She will be incompetent Your

Honor.
COURT:

A: I saw him approaching the

patient during that time.

Witness may answer if she

knows.

Q: When he approached the

patient, what did he do, if any?

A: As have said, I was with the

patient, I was beside the

xxx xxx xxx

xxx xxx xxx

The appellate court, however, disbelieved Dean Cruz's testimony

in the trial court by declaring that:
A perusal of the standard nursing curriculum in
our country will show that intubation is not taught

as part of nursing procedures and techniques.

Indeed, we take judicial notice of the fact that
nurses do not, and cannot, intubate. Even on the
assumption that she is fully capable of
determining whether or not a patient is properly
intubated, witness Herminda Cruz, admittedly,
did not peep into the throat of the patient. (TSN,
July 25, 1991, p. 13). More importantly, there is
no evidence that she ever auscultated the
patient or that she conducted any type of
examination to check if the endotracheal tube
was in its proper place, and to determine the
condition of the heart, lungs, and other organs.
Thus, witness Cruz's categorical statements that
appellant Dra. Gutierrez failed to intubate the
appellee Erlinda Ramos and that it was Dra.
Calderon who succeeded in doing so clearly
suffer from lack of sufficient factual bases. 47
In other words, what the Court of Appeals is trying to impress is
that being a nurse, and considered a layman in the process of
intubation, witness Cruz is not competent to testify on whether or
not the intubation was a success.
We do not agree with the above reasoning of the appellate court.
Although witness Cruz is not an anesthesiologist, she can very
well testify upon matters on which she is capable of observing
such as, the statements and acts of the physician and surgeon,
external appearances, and manifest conditions which are
observable by any one. 48 This is precisely allowed under the doctrine
of res ipsa loquitur where the testimony of expert witnesses is not
required. It is the accepted rule that expert testimony is not necessary
for the proof of negligence in non-technical matters or those of which an
ordinary person may be expected to have knowledge, or where the lack
of skill or want of care is so obvious as to render expert testimony
unnecessary. 49 We take judicial notice of the fact that anesthesia
procedures have become so common, that even an ordinary person can
tell if it was administered properly. As such, it would not be too difficult to
tell if the tube was properly inserted. This kind of observation, we
believe, does not require a medical degree to be acceptable.

At any rate, without doubt, petitioner's witness, an experienced

clinical nurse whose long experience and scholarship led to her
appointment as Dean of the Capitol Medical Center School at

Nursing, was fully capable of determining whether or not the

intubation was a success. She had extensive clinical experience
starting as a staff nurse in Chicago, Illinois; staff nurse and
clinical instructor in a teaching hospital, the FEU-NRMF; Dean of
the Laguna College of Nursing in San Pablo City; and then Dean
of the Capitol Medical Center School of Nursing. 50Reviewing

A: "Mahirap yata itong iintubate," that was the patient.

witness Cruz' statements, we find that the same were delivered in a

straightforward manner, with the kind of detail, clarity, consistency and
spontaneity which would have been difficult to fabricate. With her clinical
background as a nurse, the Court is satisfied that she was able to
demonstrate through her testimony what truly transpired on that fateful
day.

A: Yes, because of (sic) my first

attempt, I did not see right
away. 51

Most of all, her testimony was affirmed by no less than

respondent Dra. Gutierrez who admitted that she experienced
difficulty in inserting the tube into Erlinda's trachea, to wit:
ATTY. LIGSAY:
Q: In this particular case,
Doctora, while you were
intubating at your first attempt
(sic), you did not immediately
see the trachea?
DRA. GUTIERREZ:
A: Yes sir.
Q: Did you pull away the tube
immediately?
A: You do not pull the . . .
Q: Did you or did you not?
A: I did not pull the tube.
Q: When you said "mahirap yata
ito," what were you referring to?

Q: So, you found some difficulty

in inserting the tube?

Curiously in the case at bar, respondent Dra. Gutierrez made the

haphazard defense that she encountered hardship in the
insertion of the tube in the trachea of Erlinda because it was
positioned more anteriorly (slightly deviated from the normal
anatomy of a person) 52 making it harder to locate and, since Erlinda is
obese and has a short neck and protruding teeth, it made intubation
even more difficult.

The argument does not convince us. If this was indeed observed,
private respondents adduced no evidence demonstrating that
they proceeded to make a thorough assessment of Erlinda's
airway, prior to the induction of anesthesia, even if this would
mean postponing the procedure. From their testimonies, it
appears that the observation was made only as an afterthought,
as a means of defense.
The pre-operative evaluation of a patient prior to the
administration of anesthesia is universally observed to lessen the
possibility of anesthetic accidents. Pre-operative evaluation and
preparation for anesthesia begins when the anesthesiologist
reviews the patient's medical records and visits with the patient,
traditionally, the day before elective surgery. 53 It includes taking the
patient's medical history, review of current drug therapy, physical
examination and interpretation of laboratory data. 54 The physical
examination performed by the anesthesiologist is directed primarily
toward the central nervous system, cardiovascular system, lungs
and upper airway. 55 A thorough analysis of the patient's airway normally
involves investigating the following: cervical spine mobility,
temporomandibular mobility, prominent central incisors, diseased or
artificial teeth, ability to visualize uvula and the thyromental
distance. 56 Thus, physical characteristics of the patient's upper airway
that could make tracheal intubation difficult should be studied. 57 Where
the need arises, as when initial assessment indicates possible problems
(such as the alleged short neck and protruding teeth of Erlinda) a

thorough examination of the patient's airway would go a long way

towards decreasing patient morbidity and mortality.

In the case at bar, respondent Dra. Gutierrez admitted that she

saw Erlinda for the first time on the day of the operation itself, on
17 June 1985. Before this date, no prior consultations with, or
pre-operative evaluation of Erlinda was done by her. Until the day
of the operation, respondent Dra. Gutierrez was unaware of the
physiological make-up and needs of Erlinda. She was likewise
not properly informed of the possible difficulties she would face
during the administration of anesthesia to Erlinda. Respondent
Dra. Gutierrez' act of seeing her patient for the first time only an
hour before the scheduled operative procedure was, therefore,
an act of exceptional negligence and professional irresponsibility.
The measures cautioning prudence and vigilance in dealing with
human lives lie at the core of the physician's centuries-old
Hippocratic Oath. Her failure to follow this medical procedure is,
therefore, a clear indicia of her negligence.
Respondent Dra. Gutierrez, however, attempts to gloss over this
omission by playing around with the trial court's ignorance of
clinical procedure, hoping that she could get away with it.
Respondent Dra. Gutierrez tried to muddle the difference
between an elective surgery and an emergency surgery just so
her failure to perform the required pre-operative evaluation would
escape unnoticed. In her testimony she asserted:
ATTY. LIGSAY:

with elective cases and normal

cardio-pulmonary clearance like
that, I usually don't do it except
on emergency and on cases that
have an abnormalities (sic). 58
However, the exact opposite is true. In an emergency procedure,
there is hardly enough time available for the fastidious demands
of pre-operative procedure so that an anesthesiologist is able to
see the patient only a few minutes before surgery, if at all.
Elective procedures, on the other hand, are operative procedures
that can wait for days, weeks or even months. Hence, in these
cases, the anesthesiologist possesses the luxury of time to be at
the patient's beside to do a proper interview and clinical
evaluation. There is ample time to explain the method of
anesthesia, the drugs to be used, and their possible hazards for
purposes of informed consent. Usually, the pre-operative
assessment is conducted at least one day before the intended
surgery, when the patient is relaxed and cooperative.
Erlinda's case was elective and this was known to respondent
Dra. Gutierrez. Thus, she had all the time to make a thorough
evaluation of Erlinda's case prior to the operation and prepare
her for anesthesia. However, she never saw the patient at the
bedside. She herself admitted that she had seen petitioner only
in the operating room, and only on the actual date of the
cholecystectomy. She negligently failed to take advantage of this
important opportunity. As such, her attempt to exculpate herself
must fail.

Q: Would you agree, Doctor, that

it is good medical practice to see
the patient a day before so you
can introduce yourself to
establish good doctor-patient
relationship and gain the trust
and confidence of the patient?

Having established that respondent Dra. Gutierrez failed to

perform pre-operative evaluation of the patient which, in turn,
resulted to a wrongful intubation, we now determine if the faulty
intubation is truly the proximate cause of Erlinda's comatose
condition.

DRA. GUTIERREZ:

Private respondents repeatedly hammered the view that the

cerebral anoxia which led to Erlinda's coma was due to
bronchospasm 59 mediated by her allergic response to the drug,

A: As I said in my previous
statement, it depends on the
operative procedure of the
anesthesiologist and in my case,

Thiopental Sodium, introduced into her system. Towards this end, they
presented Dr. Jamora, a Fellow of the Philippine College of Physicians
and Diplomate of the Philippine Specialty Board of Internal Medicine,
who advanced private respondents' theory that the oxygen deprivation

which led to anoxic encephalopathy, 60 was due to an unpredictable drug

reaction to the short-acting barbiturate. We find the theory of private
respondents unacceptable.

First of all, Dr. Jamora cannot be considered an authority in the

field of anesthesiology simply because he is not an
anesthesiologist. Since Dr. Jamora is a pulmonologist, he could
not have been capable of properly enlightening the court about
anesthesia practice and procedure and their complications. Dr.
Jamora is likewise not an allergologist and could not therefore
properly advance expert opinion on allergic-mediated processes.
Moreover, he is not a pharmacologist and, as such, could not
have been capable, as an expert would, of explaining to the court
the pharmacologic and toxic effects of the supposed culprit,
Thiopental Sodium (Pentothal).
The inappropriateness and absurdity of accepting Dr. Jamora's
testimony as an expert witness in the anesthetic practice of
Pentothal administration is further supported by his own
admission that he formulated his opinions on the drug not from
the practical experience gained by a specialist or expert in the
administration and use of Sodium Pentothal on patients, but only
from reading certain references, to wit:
ATTY. LIGSAY:
Q: In your line of expertise on
pulmonology, did you have any
occasion to use pentothal as a
method of management?
DR. JAMORA:
A: We do it in conjunction with
the anesthesiologist when they
have to intubate our patient.
Q: But not in particular when you
practice pulmonology?
A: No.

Q: In other words, your

knowledge about pentothal is
based only on what you have
read from books and not by your
own personal application of the
medicine pentothal?
A: Based on my personal
experience also on pentothal.
Q: How many times have you
used pentothal?
A: They used it on me. I went
into bronchospasm during my
appendectomy.
Q: And because they have used
it on you and on account of your
own personal experience you
feel that you can testify on
pentothal here with medical
authority?
A: No. That is why I used
references to support my
claims. 61

The provision in the rules of evidence

62

regarding expert witnesses

states:

Sec. 49. Opinion of expert witness. The

opinion of a witness on a matter requiring special
knowledge, skill, experience or training which he
is shown to possess, may be received in
evidence.
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.63 Clearly, Dr. Jamora does
not qualify as an expert witness based on the above standard since he
lacks the necessary knowledge, skill, and training in the field of
anesthesiology. Oddly, apart from submitting testimony from a specialist
in the wrong field, private respondents' intentionally avoided providing
testimony by competent and independent experts in the proper areas.

Moreover, private respondents' theory, that Thiopental Sodium

may have produced Erlinda's coma by triggering an allergic
mediated response, has no support in evidence. No evidence of
stridor, skin reactions, or wheezing some of the more common
accompanying signs of an allergic reaction appears on record.
No laboratory data were ever presented to the court.

In any case, private respondents themselves admit that

Thiopental induced, allergic-mediated bronchospasm happens
only very rarely. If courts were to accept private respondents'
An anesthetic accident caused by a rare drug-induced
hypothesis without supporting medical proof, and against the
bronchospasm properly falls within the fields of anesthesia,
weight of available evidence, then every anesthetic accident
internal medicine-allergy, and clinical pharmacology. The
would be an act of God. Evidently, the Thiopental-allergy theory
resulting anoxic encephalopathy belongs to the field of neurology. vigorously asserted by private respondents was a mere
While admittedly, many bronchospastic-mediated pulmonary
afterthought. Such an explanation was advanced in order to
diseases are within the expertise of pulmonary medicine, Dr.
advanced in order to absolve them of any and all responsibility
Jamora's field, the anesthetic drug-induced, allergic mediated
for the patient's condition.
bronchospasm alleged in this case is within the disciplines of
anesthesiology, allergology and pharmacology. On the basis of
In view of the evidence at hand, we are inclined to believe
the foregoing transcript, in which the pulmonologist himself
petitioners' stand that it was the faulty intubation which was the
admitted that he could not testify about the drug with medical
proximate cause of Erlinda's comatose condition.
authority, it is clear that the appellate court erred in giving weight
to Dr. Jamora's testimony as an expert in the administration of
Proximate cause has been defined as that which, in natural and
Thiopental Sodium.
continuous sequence, unbroken by any efficient intervening

cause, produces injury, and without which the result would not
have occurred. 64 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. 65 It is the dominant, moving or producing cause.

Applying the above definition in relation to the evidence at hand,

faulty intubation is undeniably the proximate cause which
triggered the chain of events leading to Erlinda's brain damage
and, ultimately, her comatosed condition.
Private respondents themselves admitted in their testimony that
the first intubation was a failure. This fact was likewise observed
by witness Cruz when she heard respondent Dra. Gutierrez
remarked, "Ang hirap ma-intubate nito, mali yata ang
pagkakapasok. O lumalaki ang tiyan." Thereafter, witness Cruz
noticed abdominal distention on the body of Erlinda. The
development of abdominal distention, together with respiratory
embarrassment indicates that the endotracheal tube entered the
esophagus instead of the respiratory tree. In other words, instead
of the intended endotracheal intubation what actually took place
was an esophageal intubation. During intubation, such distention
indicates that air has entered the gastrointestinal tract through
the esophagus instead of the lungs through the trachea. Entry
into the esophagus would certainly cause some delay in oxygen
delivery into the lungs as the tube which carries oxygen is in the
wrong place. That abdominal distention had been observed
during the first intubation suggests that the length of time utilized
in inserting the endotracheal tube (up to the time the tube was
withdrawn for the second attempt) was fairly significant. Due to
the delay in the delivery of oxygen in her lungs Erlinda showed
signs of cyanosis. 66 As stated in the testimony of Dr. Hosaka, the lack
of oxygen became apparent only after he noticed that the nailbeds of
Erlinda were already blue. 67 However, private respondents contend that
a second intubation was executed on Erlinda and this one was
successfully done. We do not think so. No evidence exists on record,
beyond private respondents' bare claims, which supports the contention
that the second intubation was successful. Assuming that the
endotracheal tube finally found its way into the proper orifice of the
trachea, the same gave no guarantee of oxygen delivery, the hallmark of
a successful intubation. In fact, cyanosis was again observed
immediately after the second intubation. Proceeding from this event

(cyanosis), it could not be claimed, as private respondents insist, that

the second intubation was accomplished. Even granting that the tube
was successfully inserted during the second attempt, it was obviously
too late. As aptly explained by the trial court, Erlinda already suffered
brain damage as a result of the inadequate oxygenation of her brain for
about four to five minutes. 68

We now discuss the responsibility of the hospital in this particular

incident. The unique practice (among private hospitals) of filling
up specialist staff with attending and visiting "consultants," 74 who

The above conclusion is not without basis. Scientific studies point

out that intubation problems are responsible for one-third (1/3) of
deaths and serious injuries associated with
anesthesia. 69 Nevertheless, ninety-eight percent (98%) or the vast

In the first place, hospitals exercise significant control in the

hiring and firing of consultants and in the conduct of their work
within the hospital premises. Doctors who apply for "consultant"
slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications;
generally, evidence of accreditation by the appropriate board
(diplomate), evidence of fellowship in most cases, and
references. These requirements are carefully scrutinized by
members of the hospital administration or by a review committee
set up by the hospital who either accept or reject the
application. 75 This is particularly true with respondent hospital.

majority of difficult intubations may be anticipated by performing a

thorough evaluation of the patient's airway prior to the operation. 70 As
stated beforehand, respondent Dra. Gutierrez failed to observe the
proper pre-operative protocol which could have prevented this
unfortunate incident. Had appropriate diligence and reasonable care
been used in the pre-operative evaluation, respondent physician could
have been much more prepared to meet the contingency brought about
by the perceived anatomic variations in the patient's neck and oral area,
defects which would have been easily overcome by a prior knowledge of
those variations together with a change in technique. 71 In other words,
an experienced anesthesiologist, adequately alerted by a thorough preoperative evaluation, would have had little difficulty going around the
short neck and protruding teeth. 72 Having failed to observe common
medical standards in pre-operative management and intubation,
respondent Dra. Gutierrez' negligence resulted in cerebral anoxia and
eventual coma of Erlinda.

We now determine the responsibility of respondent Dr. Orlino

Hosaka as the head of the surgical team. As the so-called
"captain of the ship," 73 it is the surgeon's responsibility to see to it that
those under him perform their task in the proper manner. Respondent
Dr. Hosaka's negligence can be found in his failure to exercise the
proper authority (as the "captain" of the operative team) in not
determining if his anesthesiologist observed proper anesthesia
protocols. In fact, no evidence on record exists to show that respondent
Dr. Hosaka verified if respondent Dra. Gutierrez properly intubated the
patient. Furthermore, it does not escape us that respondent Dr. Hosaka
had scheduled another procedure in a different hospital at the same time
as Erlinda's cholecystectomy, and was in fact over three hours late for
the latter's operation. Because of this, he had little or no time to confer
with his anesthesiologist regarding the anesthesia delivery. This
indicates that he was remiss in his professional duties towards his
patient. Thus, he shares equal responsibility for the events which
resulted in Erlinda's condition.

are allegedly not hospital employees, presents problems in apportioning

responsibility for negligence in medical malpractice cases. However, the
difficulty is only more apparent than real.

After a physician is accepted, either as a visiting or attending

consultant, he is normally required to attend clinico-pathological
conferences, conduct bedside rounds for clerks, interns and
residents, moderate grand rounds and patient audits and perform
other tasks and responsibilities, for the privilege of being able to
maintain a clinic in the hospital, and/or for the privilege of
admitting patients into the hospital. In addition to these, the
physician's performance as a specialist is generally evaluated by
a peer review committee on the basis of mortality and morbidity
statistics, and feedback from patients, nurses, interns and
residents. A consultant remiss in his duties, or a consultant who
regularly falls short of the minimum standards acceptable to the
hospital or its peer review committee, is normally politely
terminated.
In other words, 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 employeremployee 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. 76
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. 77 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.78 In other words, while the burden of proving
negligence rests on the plaintiffs, once negligence is shown, the burden
shifts to the respondents (parent, guardian, teacher or employer) who
should prove that they observed the diligence of a good father of a
family to prevent damage.

In the instant case, respondent hospital, apart from a general

denial of its responsibility over respondent physicians, failed to
adduce evidence showing that it exercised the diligence of a
good father of a family in the hiring and supervision of the latter. It
failed to adduce evidence with regard to the degree of
supervision which it exercised over its physicians. In neglecting
to offer such proof, or proof of a similar nature, respondent
hospital thereby failed to discharge its burden under the last
paragraph of Article 2180. Having failed to do this, respondent
hospital is consequently solidarily responsible with its physicians
for Erlinda's condition.
Based on the foregoing, we hold that the Court of Appeals erred
in accepting and relying on the testimonies of the witnesses for
the private respondents. Indeed, as shown by the above
discussions, private respondents were unable to rebut the
presumption of negligence. Upon these disquisitions we hold that
private respondents are solidarily liable for damages under
Article 2176 79 of the Civil Code.
We now come to the amount of damages due petitioners. The
trial court awarded a total of P632,000.00 pesos (should be

P616,000.00) in compensatory damages to the plaintiff, "subject

to its being updated" covering the period from 15 November 1985
up to 15 April 1992, based on monthly expenses for the care of
the patient estimated at P8,000.00.

compensation only for such pecuniary loss

suffered by him as he has duly proved. Such
compensation is referred to as actual or
compensatory damages.

At current levels, the P8000/monthly amount established by the

trial court at the time of its decision would be grossly inadequate
to cover the actual costs of home-based care for a comatose
individual. The calculated amount was not even arrived at by
looking at the actual cost of proper hospice care for the patient.
What it reflected were the actual expenses incurred and proved
by the petitioners after they were forced to bring home the patient
to avoid mounting hospital bills.

Our rules on actual or compensatory damages generally assume

that at the time of litigation, the injury suffered as a consequence
of an act of negligence has been completed and that the cost can
be liquidated. However, these provisions neglect to take into
account those situations, as in this case, where the resulting
injury might be continuing and possible future complications
directly arising from the injury, while certain to occur, are difficult
to predict.

And yet ideally, a comatose patient should remain in a hospital or

be transferred to a hospice specializing in the care of the
chronically ill for the purpose of providing a proper milieu
adequate to meet minimum standards of care. In the instant case
for instance, Erlinda has to be constantly turned from side to side
to prevent bedsores and hypostatic pneumonia. Feeding is done
by nasogastric tube. Food preparation should be normally made
by a dietitian to provide her with the correct daily caloric
requirements and vitamin supplements. Furthermore, she has to
be seen on a regular basis by a physical therapist to avoid
muscle atrophy, and by a pulmonary therapist to prevent the
accumulation of secretions which can lead to respiratory
complications.

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. 80 In other

Given these considerations, the amount of actual damages

recoverable in suits arising from negligence should at least
reflect the correct minimum cost of proper care, not the cost of
the care the family is usually compelled to undertake at home to
avoid bankruptcy. However, the provisions of the Civil Code on
actual or compensatory damages present us with some
difficulties.
Well-settled is the rule that actual damages which may be
claimed by the plaintiff are those suffered by him as he has duly
proved. The Civil Code provides:
Art. 2199. Except as provided by law or by
stipulation, one is entitled to an adequate

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.

As it would not be equitable and certainly not in the best

interests of the administration of justice for the victim in such
cases to constantly come before the courts and invoke their aid
in seeking adjustments to the compensatory damages previously
awarded temperate damages are appropriate. The amount
given as temperate damages, though to a certain extent
speculative, should take into account the cost of proper care.
In the instant case, petitioners were able to provide only homebased nursing care for a comatose patient who has remained in
that condition for over a decade. Having premised our award for
compensatory damages on the amount provided by petitioners at
the onset of litigation, it would be now much more in step with the
interests of justice if the value awarded for temperate damages
would allow petitioners to provide optimal care for their loved one
in a facility which generally specializes in such care. They should

not be compelled by dire circumstances to provide substandard

care at home without the aid of professionals, for anything less
would be grossly inadequate. Under the circumstances, an award
of P1,500,000.00 in temperate damages would therefore be
reasonable. 81
In Valenzuela vs. Court of Appeals, 82 this Court was confronted with
a situation where the injury suffered by the plaintiff would have led to
expenses which were difficult to estimate because while they would
have been a direct result of the injury (amputation), and were certain to
be incurred by the plaintiff, they were likely to arise only in the future. We
awarded P1,000,000.00 in moral damages in that case.

Describing the nature of the injury, the Court therein stated:

As a result of the accident, Ma. Lourdes
Valenzuela underwent a traumatic amputation of
her left lower extremity at the distal left thigh just
above the knee. Because of this, Valenzuela will
forever be deprived of the full ambulatory
functions of her left extremity, even with the use
of state of the art prosthetic technology. Well
beyond the period of hospitalization (which was
paid for by Li), she will be required to undergo
adjustments in her prosthetic devise due to the
shrinkage of the stump from the process of
healing.
These adjustments entail costs, prosthetic
replacements and months of physical and
occupational rehabilitation and therapy. During
the lifetime, the prosthetic devise will have to be
replaced and readjusted to changes in the size
of her lower limb effected by the biological
changes of middle-age, menopause and aging.
Assuming she reaches menopause, for example,
the prosthetic will have to be adjusted to respond
to the changes in bone resulting from a
precipitate decrease in calcium levels observed
in the bones of all post-menopausal women. In
other words, the damage done to her would not
only be permanent and lasting, it would also be
permanently changing and adjusting to the

physiologic changes which her body would

normally undergo through the years. The
replacements, changes, and adjustments will
require corresponding adjustive physical and
occupational therapy. All of these adjustments, it
has been documented, are painful.
xxx xxx xxx
A prosthetic devise, however technologically
advanced, will only allow a reasonable amount of
functional restoration of the motor functions of
the lower limb. The sensory functions are forever
lost. The resultant anxiety, sleeplessness,
psychological injury, mental and physical pain
are inestimable.83

patient. They, not the respondents, are charged with the moral
responsibility of the care of the victim. The family's moral injury and
suffering in this case is clearly a real one. For the foregoing reasons, an
award of P2,000,000.00 in moral damages would be appropriate.

SO ORDERED.
Davide, Jr., C.J., Puno, Pardo and Ynares-Santiago, JJ., concur.

Finally, by way of example, exemplary damages in the amount of

P100,000.00 are hereby awarded. Considering the length and
nature of the instant suit we are of the opinion that attorney's fees
valued at P100,000.00 are likewise proper.
Our courts face unique difficulty in adjudicating medical
negligence cases because physicians are not insurers of life and,
they rarely set out to intentionally cause injury or death to their
patients. However, intent is immaterial in negligence cases
because where negligence exists and is proven, the same
automatically gives the injured a right to reparation for the
damage caused.

The injury suffered by Erlinda as a consequence of private

respondents' negligence is certainly much more serious than the
amputation in the Valenzuela case.

Established medical procedures and practices, though in

constant flux are devised for the purpose of preventing
complications. A physician's experience with his patients would
sometimes tempt him to deviate from established community
Petitioner Erlinda Ramos was in her mid-forties when the incident
practices, and he may end a distinguished career using
occurred. She has been in a comatose state for over fourteen
unorthodox methods without incident. However, when failure to
years now. The burden of care has so far been heroically
follow established procedure results in the evil precisely sought
shouldered by her husband and children, who, in the intervening
to be averted by observance of the procedure and a nexus is
years have been deprived of the love of a wife and a mother.
made between the deviation and the injury or damage, the
physician would necessarily be called to account for it. In the
Meanwhile, the actual physical, emotional and financial cost of
case at bar, the failure to observe pre-operative assessment
the care of petitioner would be virtually impossible to quantify.
protocol which would have influenced the intubation in a salutary
Even the temperate damages herein awarded would be
way was fatal to private respondents' case.
inadequate if petitioner's condition remains unchanged for the
next ten years.
WHEREFORE, the decision and resolution of the appellate court
appealed from are hereby modified so as to award in favor of
We recognized, in Valenzuela that a discussion of the victim's
petitioners, and solidarily against private respondents the
actual injury would not even scratch the surface of the resulting
following: 1) P1,352,000.00 as actual damages computed as of
moral damage because it would be highly speculative to estimate the date of promulgation of this decision plus a monthly payment
the amount of emotional and moral pain, psychological damage
of P8,000.00 up to the time that petitioner Erlinda Ramos expires
and injury suffered by the victim or those actually affected by the or miraculously survives; 2) P2,000,000.00 as moral damages, 3)
victim's condition. 84The husband and the children, all petitioners in this P1,500,000.00 as temperate damages; 4) P100,000.00 each as
case, will have to live with the day to day uncertainty of the patient's
exemplary damages and attorney's fees; and, 5) the costs of the
illness, knowing any hope of recovery is close to nil. They have
suit.
fashioned their daily lives around the nursing care of petitioner, altering
their long term goals to take into account their life with a comatose

Republic of the Philippines

SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 150355

July 31, 2006

MANILA DOCTORS HOSPITAL, petitioner,

vs.
SO UN CHUA and VICKY TY, respondents.
DECISION
AUSTRIA-MARTINEZ, J.:
Before this Court is a Petition for Review on Certiorari under Rule
45 questioning the Decision1 dated October 2, 2001 promulgated

by the Court of Appeals (CA) in CA-G.R. CV No. 61581, which

affirmed the Decision dated September 30, 1997 of the Regional
Trial Court (RTC), Branch 159, Pasig City, but which reduced the
award of damages.

In its Answer, Amended Answer, and Rejoinder, petitioner

specifically denied the material averments of the Complaint and
Reply, and interposed its counterclaims arguing that as early as
one week after respondent Chua had been admitted to its
hospital, Dr. Rody Sy, her attending physician, had already given
instructions for her to be discharged, but respondents insisted
This case originated from an action for damages filed with the
RTC by respondents So Un Chua and Vicky Ty against petitioner that Chua remain in confinement; that, through its staff, petitioner
accordingly administered medical examinations, all of which
Manila Doctors Hospital.2 The complaint is premised on the
yielded negative results; that respondent Ty voluntarily
alleged unwarranted actuations of the petitioner towards its
undertook, jointly and severally, to pay the hospital bills for both
patient, respondent So Un Chua (Chua), who was confined for
patients; that although respondent Ty paid up to P435,000.00,
hypertension, diabetes, and related illnesses.
more or less, she reneged on her commitment to pay the balance
in violation of the Contract for Admission and Acknowledgment of
The antecedents of the case follow:
Responsibility for Payment dated October 30, 1990 which she
voluntarily executed; that she signed a Promissory Note on June
On December 13, 1993, respondents filed a Complaint averring
5, 1992 for the unpaid balance of P1,075,592.95 and issued
that on October 30, 1990, respondent Chua, the mother of
postdated checks to cover the same; that no such undue
respondent Vicky Ty, was admitted in petitioner's hospital for
pressure had been imposed upon respondent Chua to settle the
hypertension and diabetes; that while respondent Chua was
bills, the truth being that, as a matter of standard procedure, the
confined, Judith Chua, the sister of respondent Ty, had been
reminders to settle the bills were transmitted not to the patients
likewise confined for injuries suffered in a vehicular accident; that but to their relatives who usually undertook to pay the same; that
partial payments of the hospital bills were made, totaling
respondent Ty deliberately evaded the staff of the Credit and
P435,800.00; that after the discharge of Judith Chua, respondent Collection Department; that the cutting-off of the telephone line
Chua remained in confinement and the hospital bills for both
and removal of the air-conditioning unit, television set, and
patients accumulated; that respondent Chua was pressured by
refrigerator cannot constitute unwarranted actuations, for the
the petitioner, through its Credit and Collection Department, to
same were resorted to as cost-cutting measures and to minimize
settle the unpaid bills; that respondent Ty represented that she
respondents' charges that were already piling up, especially after
will settle the bills as soon as the funds become available; that
respondent Ty refused to settle the balance notwithstanding
respondent Ty pleaded to the management that in view of the
frequent demands; that respondent Ty evaded the staff when the
physical condition of her mother, respondent Chua, the
latter attempted to inform her that the room facilities will be cut off
correspondences relating to the settlement of the unpaid hospital to minimize the rising charges; and that respondents instituted
bills should be relayed to the former; that these pleas were
the present civil case purposely as leverage against the petitioner
unheeded by the petitioner; that petitioner threatened to
after the latter had filed criminal charges for violation of Batas
implement unpleasant measures unless respondent Ty
Pambansa (B.P.) Blg. 22 against respondent Ty for issuing
undertakes her mother's obligation as well as the obligation of
checks, later dishonored, totaling P1,075,592.95, the amount
her sister, Judith Chua, to pay the hospitalization expenses; that
referring to the unpaid hospital bills. In its compulsory
petitioner made good its threat and employed unethical,
counterclaim, petitioner prayed, among other items, for the award
unpleasant and unlawful methods which allegedly worsened the
of no less than P1,000,000.00 as compensatory damages due to
condition of respondent Chua, particularly, by (i) cutting off the
the filing of a malicious and unfounded suit, and, in its permissive
telephone line in her room and removing the air-conditioning unit, counterclaim, petitioner prayed for respondents to pay
television set, and refrigerator, (ii) refusing to render medical
P1,075,592.95, the amount representing the due and
attendance and to change the hospital gown and bed sheets, and demandable obligation under the Promissory Note dated June 5,
(iii) barring the private nurses or midwives from assisting the
1992, including the stipulated interest therein and the 25 percent
patient. Respondents thus prayed for the award of moral
of the total amount due as attorney's fees.
damages, exemplary damages, and attorney's fees.

During pre-trial, the parties stipulated on the following issues:

First, whether the respondents are liable to the petitioner to pay
the hospital bills arising from the hospitalization of respondent
Chua and Judith Chua; and second, whether the parties are
entitled to their respective claims for damages.3 Furthermore, the
parties stipulated on the following facts: a) Judith Chua was
confined from June 14, 1991 to May 2, 1992; b) respondents
failed to pay the balance despite repeated reminders; c) the said
reminders referred to the hospital bills of respondent Chua and
Judith Chua; d) one of the attending physicians of respondent
Chua was Dr. Rody Sy; and e) the petitioner ordered the removal
of the facilities in question from the room of its patient,
respondent Chua, with the qualification that they were
constrained to discontinue the same after the representative of
respondent Chua refused to update the hospital bills or refused
to transfer her to semi-deluxe room or ward to lessen costs. 4
On September 30, 1997, the RTC rendered its Decision in favor
of the respondents, the dispositive portion of which states:
WHEREFORE, premises considered, judgment on the
complaint is hereby rendered in favor of the
[respondents] as against the [petitioner] as follows:
[O]rdering the [petitioner] to pay the [respondents] the
following, to wit:
a) P200,000.00 as moral damages;
b) P100,000.00 as exemplary damages; and
c) P50,000.00 as attorney's fees and the amount
of P50,000.00 as litigation costs.
SO ORDERED.5
In brief, the RTC held that the removal of the facilities of the room
triggered the hypertension of respondent Chua; that the petitioner
acted in bad faith in removing the facilities without prior notice;
that her condition was aggravated by the pressure employed by
the administration upon her to pay the hospital bills; that the food
always came late as compared to the other patients; that the
beddings and clothes of respondent Chua were no longer
changed and, as a result, bed sores emerged on her body; that
there was an utter lack of medical attendance; that, because of

these, respondent Chua suffered from self-pity and depression;

that petitioner clearly discriminated against the respondents; that
respondent Ty had no choice but to sign the promissory notes in
order to secure the release of her mother, respondent Chua; that
the foregoing actuations constitute an abuse of rights; that
petitioner failed to establish the pecuniary loss it suffered and,
hence, it is not entitled to compensatory damages; and that,
since the promissory note is a contract of adhesion, the petitioner
is not entitled to the award of attorney's fees as stipulated
thereon.
On appeal to the CA, the petitioner assigned the following errors:
A.
THE HONORABLE TRIAL COURT COMMITTED
REVERSIBLE ERROR BY FINDING THE ACTUATIONS
OF THE ADMINISTRATION OF DEFENDANTAPPELLANT TO BE IN BAD FAITH, OPPRESSIVE AND
UNNECESSARY AS TO MAKE IT LIABLE TO
PLAINTIFFS-APPELLEES FOR DAMAGES AND
ATTORNEY'S FEES.
B.
THE HONORABLE TRIAL COURT COMMITTED
REVERSIBLE ERROR BY NOT RULING UPON THE
PERMISSIVE COUNTERCLAIM OF DEFENDANTAPPELLANT WITH RESPECT TO THE P1,075,592.95
REPRESENTING THE HOSPITAL BILL OF
PLAINTIFFS-APPELLEES, WHICH OBLIGATION IS
NOT DISPUTED AND WHICH AMOUNT WAS NEVER
CONTROVERTED BY PLAINTIFFS-APPELLEES.6
On October 2, 2001, the CA promulgated its Decision the
dispositive portion of which reads:
IN VIEW OF ALL THE FOREGOING, the appealed
Decision is hereby AFFIRMED with the modification that
the award of moral damages, exemplary damages as
well as attorney's fees is reduced to Seventy Five
Thousand Pesos (P75,000.00), Thirty Thousand Pesos
(P30,000.00) and Twenty Thousand Pesos (P20,000.00),
respectively. Litigation costs are hereby deleted. Costs
against appellant.

SO ORDERED.7
Apart from the reduction in the award of damages, the CA
affirmed all salient portions of the RTC Decision and declined to
disturb the findings of fact.
Petitioner is now before this Court raising essentially the same
grounds heard by the CA.
Incidentally, with respect to the related criminal case against
respondent Ty, this Court, on September 27, 2004, promulgated
its Decision entitled Ty v. People of the Philippines,8 which
affirmed the decisions of the lower courts finding respondent Ty
guilty of violating B.P. Blg. 22 and ordering her to pay the private
complainant, herein petitioner, the total amount of the dishonored
checks.

ventilation in the room.12 In view of the foregoing, the courts a

quo concluded that the actuations of the petitioner were
oppressive, unnecessary,13 and anti-social,14 done in bad faith
without proper notice,15 with no intention other than to harass or
irritate the respondents,16 all of which constitute an abuse of
rights.17
We do not agree. The conclusions of the courts a quo are either
haphazard conjectures, or founded on a misapprehension of
facts. The record is replete with evidence that justifies a different
conclusion.

Indeed the operation of private pay hospitals and medical clinics

is impressed with public interest and imbued with a heavy social
responsibility. But the hospital is also a business, and, as a
business, it has a right to institute all measures of efficiency
commensurate to the ends for which it is designed, especially to
ensure its economic viability and survival. And in the legitimate
The petition is impressed with merit.
pursuit of economic considerations, the extent to which the public
may be served and cured is expanded, the pulse and life of the
While, as a rule, only questions of law may be raised in a petition medical sector quickens, and the regeneration of the people as a
for review on certiorari under Rule 45, under certain exceptions,
whole becomes more visibly attainable. In the institution of costthe Court may re-examine the evidence presented by the parties cutting measures, the hospital has a right to reduce the facilities
during the trial. At least four exceptions exist in this case, namely: and services that are deemed to be non-essential, such that their
(a) when the conclusion is a finding grounded entirely on
reduction or removal would not be detrimental to the medical
speculation, surmises, or conjectures; (b) when the judgment is
condition of the patient.18 For the moment, the question to be
based on a misapprehension of facts; (c) when the findings of
considered is whether the subject facilities are indeed nonfact are premised on the supposed absence of evidence and
essential the air-conditioner, telephone, television, and
contradicted by the evidence on record; and (d) when the
refrigerator the removal of which would cause the adverse
courts a quo manifestly overlooked certain relevant facts not
health effects and emotional trauma the respondents so claimed.
disputed by the parties and which, if properly considered, would
Corollary to this question is whether the petitioner observed the
justify a different conclusion.9
diligence of a good father of the family19 in the course of
ascertaining the possible repercussions of the removal of the
The principal questions are, first, whether the actuations of the
facilities prior to the removal itself and for a reasonable time
petitioner amount to actionable wrongs, andsecond, whether the thereafter, with a view to prevent damage.20
counterclaims of the petitioner can be backed up by the measure
of preponderant evidence.
After an extensive analysis of the record, it becomes rather
In brief, the courts a quo concurred in the holding that the
petitioner and its staff failed to take into consideration the
physical condition of its patient, respondent Chua, when it
removed the facilities provided in her room;10 that the removal of
these facilities, namely, the air-conditioner, telephone lines,
television, and refrigerator, aggravated the condition of the
patient, triggered her hypertension, and caused her blood
pressure to fluctuate,11 considering that there was no proper

worrisome to this Court that the courts a quounreservedly drew

their conclusions from the self-serving and uncorroborated
testimonies of the respondents the probative value of which is
highly questionable.21 We hold that the respondents failed to
prove the damages so claimed.
The evidence in the record firmly establishes that the staff of the
petitioner took proactive steps to inform the relatives of
respondent Chua of the removal of facilities prior thereto, and to

carry out the necessary precautionary measures to ensure that

her health and well-being would not be adversely affected: as
early as around two weeks after her admission on October 30,
1990, to the time when the facilities had been removed sometime
in the middle of May 1992,22 and even up to the point when she
actually left the premises of the hospital three weeks later, or
during the first week of June 1992,23 the medical condition of
respondent Chua, as consistently and indisputably confirmed by
her attending physician, Dr. Rody Sy, a cardiologist, who was
called as witness for both parties,24 whom even respondent Chua
repeatedly praised to be "my doctor" and "a very good doctor" 25 at
that, and whose statements at times had been corroborated as
well by Sister Mary Philip Galeno, SPC, the Administrator of the
hospital and who also happens to be a registered nurse, had
been "relatively well,"26 "ambulatory,"27 "walking around in the
room,"28 and that she was "able to leave the hospital on her own
without any assistance;"29 that although she complained of
symptoms such as dizziness, weakness,30 and abdominal
discomfort,31 Dr. Sy requested several medical examinations,
such as the laboratory tests, renal tests, MRI, ultrasound, and CT
scan,32 all of which were administered after procuring the consent
of respondent Chua's family33 as admitted by respondent Ty
herself,34 and even called on other specialists, such as a
neurologist, endocrinologist, and gastroenterologist, to look into
her condition35 and conduct other tests as well36 according to their
fields of specialty, all of which yielded no serious finding; 37 that
her illnesses were "lifelong illnesses"38 at a stage where they
cannot be totally removed or abolished,39 making it clear to her
family that "one hundred percent recovery is not possible"
despite being given daily medication in the hospital; 40 but that her
condition, nonetheless, is not serious,41 as the blood pressure is
more or less controlled and within acceptable limits, 42 "not that
critical to precipitate any acute attack,"43 nor likely to fall into any
emergency,44 nor yet does she require continuous or prolonged
hospitalization45 since she was stable enough to be treated at
home and on an "out-patient" basis, so much so that Dr. Sy
encouraged her to exercise and avoid resting all the
time,46 and recommended that "anytime she may be discharged" 47
even in just "two weeks after confinement,"48 the propriety of his
order of discharge concurred upon by the other specialists as
well,49 had it not been for respondents' insistence to stay in the
hospital in view of their hope for absolute recovery50 despite the
admission of respondent Chua herself that she cannot anymore
be totally cured.51

It is also undisputed that the hospital administrator, Sister

establish any clear and direct link to the injury allegedly suffered
Galeno, prior to the removal of the facilities, consulted the
by the patient:
attending physician, Dr. Sy.52 To Sister Galeno, also a registered
nurse, the matter of removal and its possible repercussions on
Q You found it safe to remove these facilities from the
the health of the patient, as a matter of hospital policy, is a critical
room of the patient suffering from diabetes and
and sensitive maneuver, and, hence, it is carried out only after
hypertension?
discussing with the doctors to evaluate all important factors. 53 The
fact of prior consultation54 as well as the medical determination to
A Yes, Sir. Many hypertensive, diabetic patients do not
the effect that it was safe to remove the facilities and would
need air-conditioning, or T.V. or refrigerator.
cause no harmful effect55 had been amply corroborated by
respondent Chua's own doctor himself.56 When Dr. Sy testified as
Q Do you agree with me that hypertension is triggered
rebuttal witness for the respondents themselves and whose
sometimes by excitement, anger or (sic) a person
credibility respondents failed to impeach, he categorically stated
suffering from such illness?
that he consented to the removal since the removal of the said
facilities would not by itself be detrimental to the health of his
A Hypertension can be triggered by anything.
patient, respondent Chua.57 And in this respect, he had been
advising respondent Ty, the daughter of the patient, that the
facilities, such as the air-conditioner, television, refrigerator, and
Court:
telephone, are not absolutely necessary, and, that although they
may add to the comfort of the patient, if absent, they will not
Q And even in other words the discomfort can also
cause any significant deterioration of her condition, 58 given that,
trigger?
in his experience as a cardiologist, and after personally attending
respondent Chua on a daily basis before, during, and after the
A Sometimes mental stress can trigger.
removal and even up to the time of her actual discharge, 59 he
concluded that many hypertensive and diabetic patients, as in
xxxx
her case, do not at all need in particular an air-conditioning unit,
60
among the other facilities aforementioned. And, contrary to the
Court:
findings of the courts a quo and the self-serving testimonies of
respondents that the lack of ventilation, after the removal of the
air-conditioner, triggered her hypertension, Dr. Sy categorically
Q You mentioned earlier that this hypertension may be
stated that during his daily rounds with the patient he was certain
triggered mentally?
that, although admittedly the blood pressure in general would
fluctuate daily, there had been no adverse effect on her, and that
A Yes, Your Honor.
her blood pressure were within acceptable limits, 61 especially
considering that he treated the patient on a daily basis up to the
Court:
point of actual discharge,62 and accordingly, as confirmed by the
medical records, he made no change in the medications
Q Will the removal of these facilities not affect the
thereafter.63 In support of Dr. Sy's findings, Sister Galeno, testified
patient including the relatives?
that she knew the condition of the ventilation of the
patient's deluxe room, located at the fifth floor, even without the
air-conditioning, notably in times of brownout, and that there had
A It may to a certain extent. And well, maybe the days
been enough ventilation since the grilled window of that room
after the removal would prove that fluctuation in blood
was large enough which, if opened, would permit sufficient
pressure are within acceptable limits.65
ventilation.64 The Court finds that the premise of the RTC
judgment refers merely to hypothetical statements which fail to
With respect to the findings of the courts a quo that bed sores
appeared on the body of respondent Chua, that she suffered

from depression after the disconnection of the said facilities, that

her private midwives were barred, and that the delivery of food
was delayed, this Court holds, as above, that these conclusions
are bereft of sound evidentiary basis, self-serving and
uncorroborated as they are. Again, Dr. Sy affirmed that during the
daily rounds he would make on the patient, he did not detect any
skin lesion or any other abnormality up to the time she was
actually discharged.66 Nor did he find any sign of depression,
although, admittedly, he observed that she had been "very angry"
because of the removal of the facilities.67 All the while he did not
receive any complaint from respondent Chua indicating that she
suffered from the foregoing infirmities,68 considering that it is the
responsibility of the family of the patient to specifically inform the
attending physician or the nurses during their rounds whatever
they feel is important, or if there were any new developments
since the last visit.69 As corroborated by Sister Galeno,
throughout respondent Chua's confinement, she never received
any complaint from the latter or her relatives that she had not
been attended to by the nursing staff.70 Worth noting again is the
fact that the nursing staff and the attending physicians, which
included Dr. Sy, in accordance with hospital policy, would
routinely make their rounds on a daily basis, or would visit the
patient whenever they are called for any problem,71 and, in the
case of the specialists other than the attending physician, they
would visit the patient about once a week.72 The nurses, on the
other hand, would make their rounds more frequently, that is, at
least once per shift, or every eight hours.73 Apart from the selfserving statements of respondents, which by now have become
rather indicative of being mere afterthoughts, there is no clear
showing from the record that the petitioner and its medical staff
deviated from the foregoing policy and practice, nor had they
been called upon to look into the alleged physical reactions or
emotional trauma respondent Chua claims to have suffered
during and after the removal of the facilities. It must be
emphasized that, as stated above, respondent Chua herself
explicitly found Dr. Sy to be a "very good doctor" because he
personally attended to her "almost every hour." 74 And throughout
her confinement, Dr. Sy positively stated that her family
employed a private midwife who attended to her all the time. 75
The evidence in the record overwhelmingly demonstrates that
respondent Chua had been adequately attended to, and this
Court cannot understand why the courts a quo had declared that
there was an "utter lack of medical attendance," or that her health
suffered during the period after the removal of the facilities. The
Court finds that the facilities in question are non-essential for the

care of respondent Chua and, hence, they may be lessened or

removed by the petitioner for the sake of economic necessity and
survival.
Though human experience would show that the deactivation of
the air-conditioner may cause a temperature differential that may
trigger some physical discomfort, or that the removal of
entertainment facilities such as the television set, or the
disconnection of communication devices such as the telephone,
may cause some exasperation on the part of the one who
benefits from these, nevertheless, all things considered, and
given the degree of diligence the petitioner duly exerted, not
every suppression of the things that one has grown accustomed
to enjoy amounts to an actionable wrong, nor does every
physical or emotional discomfort amount to the kind of anguish
that warrants the award of moral damages under the general
principles of tort. The underlying basis for the award of tort
damages is the premise that an individual was injured in
contemplation of law. Thus, there must first be the breach of
some duty and the imposition of liability for that breach before
damages may be awarded; it is not sufficient to state that there
should be tort liability merely because the plaintiff suffered some
pain and suffering.76
Moreover, this Court must reiterate the standard of tort to arrive
at a proper award for damages premised on matters that suggest
the application of medical knowledge, especially in the
description of the causal link between external or environmental
factors, on one hand, and their effect unto the physical or
emotional health of the patient, on the other, expert opinion, as
discussed in Cruz v. Court of Appeals,77 is generally required:
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
out 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 opinions 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. 78
With respect to the propriety of the notice of removal of facilities,
the evidence shows that the hospital staff, accompanied by Sister
Gladys Lim, SPC, Finance Administrative Assistant of the
hospital,79 through written and verbal notices as per hospital
policy, forewarned the respondents, through respondent Ty and
her sister, Judith Chua, of the impending removal of the facilities
over a week beforehand80 in view of their obstinate refusal to
vacate and transfer to a lower rate room 81 or to update the
mounting hospital bills82 which, by then, had swollen to
approximately one million pesos.83 Respondent Ty refused to
read many of the written notices sent by the Credit
Department.84 After repeated attempts to contact respondent
Ty85 and before the actual removal of the facilities, the staff of the
petitioner tried to personally serve the final notice dated April 23,
1992,86 signed by Sister Gladys Lim, addressed to respondent Ty,
which adopted the tenor of the prior verbal warnings, and which
expressly and sternly warned the respondents that the hospital
shall be constrained to take legal action and that they shall be
compelled to transfer the patient, respondent Chua, to a lower
rate room unless the balance could be satisfied.87Respondent Ty,
for no justifiable reason, and sticking to her inclination to avoid
the staff, refused to receive or acknowledge this letter as
well.88 Worth noting is that Sister Galeno, testified that, as a
matter of hospital policy the tenor of which respondents, by virtue

of the Contract for Admission dated October 30, 1990, agreed to

comply with,89 the hospital can only cut off the non-essential
facilities and only in extreme cases90 if the patient occupies a
private room all to herself; had the room been semi-private
shared by other patients, or had it been the ward, the hospital
cannot disconnect the facilities since this would unduly prejudice
the other patients. But respondent Chua herself insisted on
staying in a private room despite her being fully aware of the
ballooning charges,91 and even if she could have freely gone
home anytime to her condominium unit which, as admitted, was
equipped with an air-conditioner.92 With respect to the "pressure"
and "harassment" respondents allegedly suffered daily whenever
the hospital staff would follow up the billing during odd hours, or
at 10pm, 11pm, 12 midnight, 1am, or 2am,93 this averment had
been convincingly refuted by the witnesses for the petitioner,
namely, Editha L. Vecino, the Head of Credit and Collection, and
Sister Galeno, in that the Credit and Collection Department would
only hold office hours from 8am to 5pm and, hence, it is
impossible to "harass" the respondents during the times they so
claimed.94
The courts a quo found that respondent Ty had "no choice but to
sign the promissory note in order for her mother to be released
from the hospital,"95 thus suggesting that the hospital refused to
actually discharge or bodily release its patient, respondent Chua,
until arrangements had been made to settle the charges.
While there are portions of the testimonies of the witnesses for
the petitioner which state that although, as per standard
procedure, the patient "cannot leave"96 the hospital without the
"discharge,"97 "clearance" or "gate pass" issued only after
arrangements on the settlement of bills had been made, 98 still, it
must be understood that these are only demonstrative of the
precondition that a patient cannot step out of the premises
"without the consent" of the hospital, or, in other words, that the
"clearance" merely indicates that the hospital expressly
consented to the actual release of the patient, 99 but, even without
its consent, the patient is still free to leave "anytime" as a matter
of policy, in spite of the refusal to issue a "clearance" or "gate
pass,"100 or even in cases where the accounts have not yet been
liquidated or settled,101 or yet even if no promissory note or postdated check were executed in favor of the petitioner, as testified
by no less than Sister Galeno,102 and corroborated by Editha
Vecino;103 and that, petitioner, a private hospital established for
profit,104 being also a business, by warning respondents that it

shall withhold clearance, is simply exercising its right to protest

against an absconding patient as a precursor to avail of other
appropriate legal remedies; that, on the contrary, the respondents
opted not to leave because of their own promise not to leave
unless the hospital bills were fully settled;105 that the accusations
found in the Demand Letter dated May 19, 1992, and signed by
the counsel for the respondents,106 particularly, that the petitioner
"refused to discharge the patient, [respondent Chua,] despite
orders from the attending physician, Dr. Rody Sy," had all been
refuted by Sister Galeno when she read its contents in front of
the counsel for respondents, emphatically telling him that "we are
not detaining his clients;" that "[respondent Ty] was the one who
told us that they are not going to leave the hospital unless they
have fully paid the hospital;"107 and that, most importantly, no
physical restraint upon the person of respondent Chua or upon
the person of her relatives had been imposed by the staff.

conditions, such as the assessment of whether the patient is fit to

leave, insane, or suffering from a contagious disease, etc., or
simply for purposes of making a demand to settle the bill. If the
patient chooses to abscond or leave without the consent of the
hospital in violation of any of the conditions deemed to be
reasonable under the circumstances, the hospital may
nonetheless register its protest and may choose to pursue the
legal remedies available under law, provided that the hospital
may not physically detain the patient, unless the case falls under
the exceptions abovestated.

Authorities are of the view that, ordinarily, a hospital, especially if

it is a private pay hospital,113 is entitled to be compensated for its
services, by either an express or an implied contract, and if no
express contract exists, there is generally an implied agreement
that the patient will pay the reasonable value of the services
rendered;114when a hospital treats a patient's injuries, it has an
Authorities, including those of common law origin, explicitly
enforceable claim for full payment for its services, regardless of
declare that a patient cannot be detained in a hospital for nonthe patient's financial status.115 At this juncture, it must be noted
payment of the hospital bill. If the patient cannot pay the hospital that there is testimony, though to a degree disputable, to the
or physician's bill, the law provides a remedy for them to pursue, effect that the execution of the promissory note and the issuance
that is, by filing the necessary suit in court for the recovery of
of postdated checks were conditions imposed not by the
such fee or bill.108 If the patient is prevented from leaving the
petitioner but voluntarily offered by the counsel for
hospital for his inability to pay the bill, any person who can act on respondents.116 At any rate, however, this Court holds, in view of
his behalf can apply in court for the issuance of the writ
the foregoing authorities, that the requirement to have the relative
of habeas corpus.109
of respondent Chua to execute a promissory note as part of the
arrangement to settle the unpaid obligations is a formality that
The form of restraint must be total; movement must be restrained converts any implied contract into written form and, moreover,
in all directions. If restraint is partial, e.g., in a particular direction amounts to a reasonable condition, the non-fulfillment of which,
in itself, however, as discussed, cannot allow the hospital to
with freedom to proceed in another, the restraint on the person's
detain the patient. It must also be stressed, contrary to the
liberty is not total.110However, the hospital may legally detain a
findings of the courts a quo, that such an agreement embodied in
patient against his will when he is a detained or convicted
a promissory note, as well as the Contract for Admission and
prisoner, or when the patient is suffering from a very contagious
Acknowledgment of Responsibility for Payment dated October
disease where his release will be prejudicial to public health, or
when the patient is mentally ill such that his release will endanger 30, 1990, do not become contracts of adhesion simply because
the person signing it was under stress that was not the result of
public safety,111 or in other exigent cases as may be provided by
the actions of the hospital,117 especially taking into account that
law. Moreover, under the common law doctrines on tort, it does
there is testimony to the effect that respondent Ty signed the
not constitute a trespass to the person to momentarily prevent
Promissory Note dated June 5, 1992 in the presence of counsel
him from leaving the premises or any part thereof because he
and acting under his advise.118
refuses to comply with some reasonable condition subject to
which he entered them. In all cases, the condition of this kind of
restraint must be reasonable in the light of the
But as to the propriety of the circumstances surrounding the
circumstances.112 At any rate, as stated above, the patient is free
issuance of the postdated checks to cover the amount stated in
to leave the premises, even in the ostensible violation of these
the Promissory Note dated June 5, 1992, this Court must refer to
conditions, after being momentarily interrupted by the hospital
the discussion of the recent case of Ty v. People of the
staff for purposes of informing him of those reasonable
Philippines119 where this Court affirmed the conviction of

respondent Ty for the issuance of bouncing checks addressed to

the petitioner herein. While the instant case is to be distinguished
from the Ty case in nature, applicable law, the standards of
evidence, and in the defenses available to the parties, hence, the
judgment of conviction in that case should not at all prejudice the
disposition of this case, even if the facts coincide, nonetheless,
for purposes of convenience and instructive utility, the Court
quotes the relevant portions:
In this case, far from it, the fear, if any, harbored by Ty
was not real and imminent. Ty claims that she was
compelled to issue the checks a condition the hospital
allegedly demanded of her before her mother could be
discharged for fear that her mother's health might
deteriorate further due to the inhumane treatment of the
hospital or worse, her mother might commit suicide. This
is speculative fear; it is not the uncontrollable fear
contemplated by law.
To begin with, there was no showing that the mother's
illness was so life-threatening such that her continued
stay in the hospital suffering all its alleged unethical
treatment would induce a well-grounded apprehension of
her death. Secondly, it is not the law's intent to say that
any fear exempts one from criminal liability much less
petitioner's flimsy fear that her mother might commit
suicide. In other words, the fear she invokes was not
impending or insuperable as to deprive her of all volition
and to make her a mere instrument without will, moved
exclusively by the hospital's threats or demands.
Ty has also failed to convince the Court that she was left
with no choice but to commit a crime. She did not take
advantage of the many opportunities available to her to
avoid committing one. By her very own words, she
admitted that the collateral or security the hospital
required prior to the discharge of her mother may be in
the form of postdated checks or jewelry. And if indeed
she was coerced to open an account with the bank and
issue the checks, she had all the opportunity to leave the
scene to avoid involvement.
Moreover, petitioner had sufficient knowledge that the
issuance of checks without funds may result in a violation
of B.P. 22. She even testified that her counsel advised
her not to open a current account nor issue postdated

checks "because the moment I will not have funds it will

be a big problem." Besides, apart from petitioner's bare
assertion, the record is bereft of any evidence to
corroborate and bolster her claim that she was
compelled or coerced to cooperate with and give in to the
hospital's demands.
Ty likewise suggests . . . that the justifying circumstance
of state of necessity under par. 4, Art. 11 of the Revised
Penal Code may find application in this case.

Parenthetically, the findings of fact in the Decision of the

trial court in the Civil Case for damages filed by Ty's
mother against the hospital is wholly irrelevant for
purposes of disposing the case at bench. While the
findings therein may establish a claim for damages
which, we may add, need only be supported by a
preponderance of evidence, it does not necessarily
engender reasonable doubt as to free Ty from liability.120

In view of the foregoing, the Court therefore holds that the

courts a quo committed serious errors in finding that the
petitioner was "biased,"121 "discriminated" against the
We do not agree. The law prescribes the presence of
respondents,122 and "purposely intended to irritate"123or
three requisites to exempt the actor from liability under
"harass"124 them; that it "acted in bad faith in removing the
this paragraph: (1) that the evil sought to be avoided
facilities without prior notice;"125 and that its acts were "antiactually exists; (2) that the injury feared be greater than
social."126 The aforequoted declarations of the witnesses,
the one done to avoid it; (3) that there be no other
significant portions of which this Court considers as expert
practical and less harmful means of preventing it.
testimony, are reliable and remain considerably trustworthy to
controvert respondents' assertions as well as to reverse the
In the instant case, the evil sought to be avoided is
conclusions of fact and law of the CA and the RTC that
merely expected or anticipated. If the evil sought to be
avoided is merely expected or anticipated or may happen respondent Chua suffered the physical and emotional anguish so
claimed, and so, for these reasons, the Court holds that the
in the future, this defense is not applicable. Ty could
petitioner inflicted no actionable wrong.
have taken advantage of an available option to avoid
committing a crime. By her own admission, she had the
This Court observes that the courts a quo awarded both
choice to give jewelry or other forms of security instead
respondents moral damages. But it is well-settled that in case of
of postdated checks to secure her obligation.
physical injuries, with some exceptions,127 moral damages are
recoverable only by the party injured and not by her spouse, next
Moreover, for the defense of state of necessity to be
of kin, or relative who happened to sympathize with the injured
availing, the greater injury feared should not have been
party.128 Hence, even if the courts a quo were correct in their
brought about by the negligence or imprudence, more
basis for damages, they should have declined to award damages
so, the willful inaction of the actor. In this case, the
to respondent Ty.
issuance of the bounced checks was brought about by
Ty's own failure to pay her mother's hospital bills.
The Court also thinks it rather odd that Ty has chosen
the exempting circumstance of uncontrollable fear and
the justifying circumstance of state of necessity to
absolve her of liability. It would not have been half as
bizarre had Ty been able to prove that the issuance of
the bounced checks was done without her full volition.
Under the circumstances, however, it is quite clear that
neither uncontrollable fear nor avoidance of a greater evil
or injury prompted the issuance of the bounced checks.

The last issue to be resolved is the question whether the

counterclaims of the petitioner are supported by a
preponderance of evidence.
We agree with the petitioner that the courts a quo seriously erred
in mistaking the case of its compulsory counterclaim for its
permissive counterclaim and for failing to consider the evidence
which impressively supports the latter. First, for failure without
justifiable cause of respondents' counsel to comment on the
Partial Formal Offer of Evidence dated February 14, 1996 129 filed
by the petitioner, the RTC issued an order during the course of
the trial, which counsel for respondents neither contested nor
raised on appeal, admitting Exhibits "1" to "16", together with

their submarkings and the purposes for which the same were
offered,130 all of which had also been previously authenticated and
their contents verified by the witnesses for the petitioner.131 These
documents include the Contract for Admission of respondent
Chua dated October 30, 1990, duly executed by respondent Ty,
incorporating therein the rules and regulations of the hospital,
including the duty to understand the same132 as well as the
undertaking of respondent Ty to be jointly and severally liable for
the payment of the hospital bills of respondent Chua;133 the
Promissory Note dated June 5, 1992 in the amount of
P1,075,592.95 duly executed by respondent Ty in favor of the
petitioner agreeing to be jointly and severally liable to pay the
unpaid obligations of respondent Chua and Judith Chua,
including interest and attorney's fees in case of default; 134 the
Undertakings signed by respondent Ty dated March 3, 1992 and
April 7, 1992 to maintain regular deposits;135 and the credit
memos and statements of account that support the amount
referring to the unpaid obligation.136 Second, the parties stipulated
during pre-trial that respondents failed to pay the balance despite
repeated reminders.137 Andthird, respondent Ty in open court
identified and admitted that she signed the Contract of Admission
dated October 30, 1990 as well as the Undertakings dated March
3, 1992 and April 7, 1992 but which, for no justifiable reason, she
"did not bother to read,"138 and, what is more, she repeatedly
admitted during the course of the trial that she failed to fully settle
the foregoing hospital bills.139 In fact, while the Ty case cannot
control the incidents of the instant case as heretofore stated, it is
still worth mentioning, at least for informative purposes, the
findings of this Court in Ty with respect to respondents'
obligations to the petitioner:
Ty's mother and sister availed of the services and the
facilities of the hospital. For the care given to her kin, Ty
had a legitimate obligation to pay the hospital by virtue of
her relationship with them and by force of her signature
on her mother's Contract of Admission acknowledging

responsibility for payment, and on the promissory note

she executed in favor of the hospital.140
In view of all these findings, the Court earnestly disagrees with
the sweeping conclusion of the CA that "[Petitioner] failed to
present any iota of evidence to prove his claim," 141 a statement
apparently referring to the permissive counterclaim of
P1,075,592.95. However, with respect to the compulsory
counterclaim predicated on the filing of a baseless suit and injury
to its reputation, petitioner did not raise this matter on appeal
and, hence, is deemed to have waived the same.
But the Court in Ty made a partial finding on the civil liability of
respondent Ty with respect to the amount covered by seven of
the several dishonored checks she issued equivalent to
P210,000.00.142 Since this amount forms a fraction of her total
civil liability, then this amount, in deference to Ty, should be
deducted therefrom.
The claim for attorney's fees, as stipulated under the Promissory
Note dated June 5, 1992, should be reduced for being
unreasonable under the circumstances, from 25 percent to 12
percent of the total amount due.143
As a final word, the Court takes judicial notice of the pending
Senate Bill No. 337, entitled "An Act Prohibiting the Detention of
Patients in Hospitals and Medical Clinics on Grounds of NonPayment of Hospital Bills or Medical Expenses," which declares,
among others, that it shall be unlawful for any hospital or medical
clinic to cause directly or indirectly the detention of patients for
non-payment, in part or in full, of their hospital bills, 144 and,
furthermore, requires patients who have fully recovered and are
financially incapable to settle the hospitalization expenses to
execute a promissory note, co-signed by another individual, to

the extent of the unpaid obligation before leaving the

hospital.145 While this Court may have touched upon these
matters in the adjudication of the instant case, it must be stated
that this decision should in no way preempt any constitutional
challenge to the provisions of Senate Bill No. 337 if passed into
law, bearing in mind the standards for the exercise of the power
of judicial review146 as well as the recognition that the tenor of the
bill may adjust with the times, or that the bill itself may fail to
pass, according to the dynamism of the legislative process,
especially in light of the objections interposed by interest groups
to date.147
WHEREFORE, the petition is GRANTED. The Decision of the
Court of Appeals dated October 2, 2001, together with the
Decision dated September 30, 1997 of the Regional Trial Court in
Civil Case No. 63958, is REVERSEDand SET ASIDE. Another
judgment is entered dismissing the Complaint and ordering
respondents, jointly and severally, to pay the petitioner the
amount of P865,592.95, with stipulated interest of 12 percent
reckoned from the date of extrajudicial demand until full payment,
and 12 percent of the total amount due as attorney's fees.
No pronouncement as to costs.
SO ORDERED.
Panganiban, C.J., Ynares-Santiago, Callejo, Sr., Chico-Nazario,
J.J., concur.