Professional Documents
Culture Documents
By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio
already wanted to pull out his wife from the operating room. He met Dr. Garcia, who
ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural remarked that he was also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived
guardians of the minors, ROMMEL RAMOS, ROY RODERICK RAMOS, and RON at the hospital at around 12:10 in the afternoon, or more than three (3) hours after
RAYMOND RAMOS, petitioners, the scheduled operation.
vs.
COURT OF APPEALS, DE LOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and Cruz, who was then still inside the operating room, heard about Dr. Hosaka’s arrival.
DR. PERFECTA GUTIERREZ, respondents. While she held the hand of Erlinda, Cruz saw Dr. Gutierrez trying to intubate the
patient. Cruz heard Dr. Gutierrez utter: "ang hirap ma-intubate nito, mali yata ang
RESOLUTION pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlinda’s
nailbeds on her left hand. She (Cruz) then heard Dr. Hosaka instruct someone to call
KAPUNAN, J.: Dr. Calderon, another anesthesiologist. When he arrived, Dr. Calderon attempted to
intubate the patient. The nailbeds of the patient remained bluish, thus, she was
placed in a trendelenburg position – a position where the head of the patient is
Private respondents De Los Santos Medical Center, Dr. Orlino Hosaka and Dr.
placed in a position lower than her feet. At this point, Cruz went out of the operating
Perfecta Gutierrez move for a reconsideration of the Decision, dated December 29,
room to express her concern to petitioner Rogelio that Erlinda’s operation was not
1999, of this Court holding them civilly liable for petitioner Erlinda Ramos’ comatose
going well.
condition after she delivered herself to them for their professional care and
management.
Cruz quickly rushed back to the operating room and saw that the patient was still in
trendelenburg position. At almost 3:00 in the afternoon, she saw Erlinda being
For better understanding of the issues raised in private respondents’ respective
wheeled to the Intensive Care Unit (ICU). The doctors explained to petitioner Rogelio
motions, we will briefly restate the facts of the case as follows:
that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was
released from the hospital only four months later or on November 15, 1985. Since
Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help,
the ill-fated operation, Erlinda remained in comatose condition until she died on
was advised to undergo an operation for the removal of a stone in her gall bladder
August 3, 1999.1
(cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform
the operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the
Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages
morning at private respondent De Los Santos Medical Center (DLSMC). Since neither
against private respondents. After due trial, the court a quo rendered judgment in
petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist,
favor of petitioners. Essentially, the trial court found that private respondents were
Dr. Hosaka recommended to them the services of Dr. Gutierrez.
negligent in the performance of their duties to Erlinda. On appeal by private
respondents, the Court of Appeals reversed the trial court’s decision and directed
Petitioner Erlinda was admitted to the DLSMC the day before the scheduled
petitioners to pay their "unpaid medical bills" to private respondents.
operation. By 7:30 in the morning of the following day, petitioner Erlinda was already
being prepared for operation. Upon the request of petitioner Erlinda, her sister-in-
Petitioners filed with this Court a petition for review on certiorari. The private
law, Herminda Cruz, who was then Dean of the College of Nursing at the Capitol
respondents were then required to submit their respective comments thereon. On
Medical Center, was allowed to accompany her inside the operating room.
December 29, 1999, this Court promulgated the decision which private respondents
now seek to be reconsidered. The dispositive portion of said Decision states:
At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried
to get in touch with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the
WHEREFORE, the decision and resolution of the appellate court appealed
operation might be delayed due to the late arrival of Dr. Hosaka. In the meantime,
from are hereby modified so as to award in favor of petitioners, and
the patient, petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha mo ako
solidarily against private respondents the following: 1) P1,352,000.00 as
ng ibang Doctor."
actual damages computed as of the date of promulgation of this decision
plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda
Ramos expires or miraculously survives; 2) P2,000,000.00 as moral damages, D. THE SUPREME COURT MAY HAVE INADVERTENTLY DISREGARDED THE
3) P1,500,000.00 as temperate damages; 4) P100,000.00 each exemplary EXPERT TESTIMONY OF DR. JAMORA AND DRA. CALDERON
damages and attorney’s fees; and 5) the costs of the suit.2 E. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY
AWARDED DAMAGES TO PETITIONERS DESPITE THE FACT THAT THERE WAS
In his Motion for Reconsideration, private respondent Dr. Hosaka submits the NO NEGLIGENCE ON THE PART OF RESPONDENT DOCTOR. 4
following as grounds therefor: Private respondent De Los Santos Medical Center likewise moves for reconsideration
on the following grounds:
I I
THE HONORABLE SUPREME COURT COMMITTED REVERSIBLE ERROR WHEN IT HELD THE HONORABLE COURT ERRED IN GIVING DUE COURSE TO THE INSTANT PETITION
RESPONDENT DR. HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-THE-SHIP" AS THE DECISION OF THE HONORABLE COURT OF APPEALS HAD ALREADY BECOME
DOCTRINE. FINAL AND EXECUTORY
II II
THE HONORABLE SUPREME COURT ERRED IN HOLDING RESPONDENT DR. HOSAKA THE HONORABLE SUPREME COURT ERRED IN FINDING THAT AN EMPLOYER-
LIABLE DESPITE THE FACT THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO HIM. EMPLOYEE [RELATIONSHIP] EXISTS BETWEEN RESPONDENT DE LOS SANTOS
III MEDICAL CENTER AND DRS. ORLINO HOSAKA AND PERFECTA GUTIERREZ
ASSUMING WITHOUT ADMITTING THAT RESPONDENT DR. HOSAKA IS LIABLE, THE III
HONORABLE SUPREME COURT ERRED IN AWARDING DAMAGES THAT WERE CLEARLY THE HONORABLE SUPREME COURT ERRED IN FINDING THAT RESPONDENT DE LOS
EXCESSIVE AND WITHOUT LEGAL BASIS.3 SANTOS MEDICAL CENTER IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORS
Private respondent Dr. Gutierrez, for her part, avers that: IV
A. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY THE HONORABLE SUPREME COURT ERRED IN INCREASING THE AWARD OF DAMAGES
OVERLOOKED THE FACT THAT THE COURT OF APPEAL’S DECISION DATED 29 IN FAVOR OF PETITIONERS.5
MAY 1995 HAD ALREADY BECOME FINAL AND EXECUTORY AS OF 25 JUNE
1995, THEREBY DEPRIVING THIS HONORABLE COURT OF JURISDICTION In the Resolution of February 21, 2000, this Court denied the motions for
OVER THE INSTANT PETITION; reconsideration of private respondents Drs. Hosaka and Gutierrez. They then filed
B. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY their respective second motions for reconsideration. The Philippine College of
OVERLOOKED SEVERAL MATERIAL FACTUAL CIRCUMSTANCES WHICH, IF Surgeons filed its Petition-in-Intervention contending in the main that this Court
PROPERLY CONSIDERED, WOULD INDUBITABLY LEAD TO NO OTHER erred in holding private respondent Dr. Hosaka liable under the captain of the ship
CONCLUSION BUT THAT PRIVATE RESPONDENT DOCTORS WERE NOT doctrine. According to the intervenor, said doctrine had long been abandoned in the
GUILTY OF ANY NEGLIGENCE IN RESPECT OF THE INSTANT CASE; United States in recognition of the developments in modern medical and hospital
B.1 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS practice.6 The Court noted these pleadings in the Resolution of July 17, 2000.7
SUFFICIENTLY DISCHARGED THE BURDEN OF EVIDENCE BY
SUBSTANTIAL PROOF OF HER COMPLIANCE WITH THE STANDARDS On March 19, 2001, the Court heard the oral arguments of the parties, including the
OF DUE CARE EXPECTED IN HER RESPECTIVE FIELD OF MEDICAL intervenor. Also present during the hearing were the amicii curiae: Dr. Felipe A.
SPECIALIZATION. Estrella, Jr., Consultant of the Philippine Charity Sweepstakes, former Director of the
B.2 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS Philippine General Hospital and former Secretary of Health; Dr. Iluminada T.
SUFFICIENTLY DISCHARGED THE BURDEN OF EVIDENCE BY Camagay, President of the Philippine Society of Anesthesiologists, Inc. and Professor
SUBSTANTIAL PROOF OF HER HAVING SUCCESSFULLY INTUBATED and Vice-Chair for Research, Department of Anesthesiology, College of Medicine-
PATIENT ERLINDA RAMOS Philippine General Hospital, University of the Philippines; and Dr. Lydia M. Egay,
C. THE SUPREME COURT MAY HAVE INADVERTENTLY PLACED TOO MUCH Professor and Vice-Chair for Academics, Department of Anesthesiology, College of
RELIANCE ON THE TESTIMONY OF PETITIONER’S WITNESS HERMINDA CRUZ, Medicine-Philippine General Hospital, University of the Philippines.
DESPITE THE EXISTENCE OF SEVERAL FACTUAL CIRCUMSTANCES WHICH
RENDERS DOUBT ON HER CREDIBILITY The Court enumerated the issues to be resolved in this case as follows:
1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR operative, pain management if appropriate, special issues for this particular
NEGLIGENCE; patient. There are needs for special care after surgery and if it so it must be
written down there and a request must be made known to proper
2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS authorities that such and such care is necessary. And the request for medical
LIABLE FOR NEGLIGENCE; AND evaluation if there is an indication. When we ask for a cardio-pulmonary
clearance it is not in fact to tell them if this patient is going to be fit for
3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS anesthesia, the decision to give anesthesia rests on the anesthesiologist.
LIABLE FOR ANY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITING What we ask them is actually to give us the functional capacity of certain
CONSULTANT SURGEON AND ANESTHESIOLOGIST.8 systems which maybe affected by the anesthetic agent or the technique that
we are going to use. But the burden of responsibility in terms of selection of
agent and how to administer it rest on the anesthesiologist. 10
We shall first resolve the issue pertaining to private respondent Dr. Gutierrez. She
maintains that the Court erred in finding her negligent and in holding that it was the
faulty intubation which was the proximate cause of Erlinda’s comatose condition. The The conduct of a preanesthetic/preoperative evaluation prior to an operation,
following objective facts allegedly negate a finding of negligence on her part: 1) That whether elective or emergency, cannot be dispensed with.11 Such evaluation is
the outcome of the procedure was a comatose patient and not a dead one; 2) That necessary for the formulation of a plan of anesthesia care suited to the needs of the
the patient had a cardiac arrest; and 3) That the patient was revived from that cardiac patient concerned.
arrest.9 In effect, Dr. Gutierrez insists that, contrary to the finding of this Court, the
intubation she performed on Erlinda was successful. Pre-evaluation for anesthesia involves taking the patient’s medical history, reviewing
his current drug therapy, conducting physical examination, interpreting laboratory
Unfortunately, Dr. Gutierrez’ claim of lack of negligence on her part is belied by the data, and determining the appropriate prescription of preoperative medications as
records of the case. It has been sufficiently established that she failed to exercise the necessary to the conduct of anesthesia.12
standards of care in the administration of anesthesia on a patient. Dr. Egay
enlightened the Court on what these standards are: Physical examination of the patient entails not only evaluating the patient’s central
nervous system, cardiovascular system and lungs but also the upper airway.
x x x What are the standards of care that an anesthesiologist should do Examination of the upper airway would in turn include an analysis of the patient’s
before we administer anesthesia? The initial step is the preparation of the cervical spine mobility, temporomandibular mobility, prominent central incisors,
patient for surgery and this is a pre-operative evaluation because the deceased or artificial teeth, ability to visualize uvula and the thyromental distance. 13
anesthesiologist is responsible for determining the medical status of the
patient, developing the anesthesia plan and acquainting the patient or the Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation
responsible adult particularly if we are referring with the patient or to adult on Erlinda. As she herself admitted, she saw Erlinda for the first time on the day of
patient who may not have, who may have some mental handicaps of the the operation itself, one hour before the scheduled operation. She auscultated 14 the
proposed plans. We do pre-operative evaluation because this provides for patient’s heart and lungs and checked the latter’s blood pressure to determine if
an opportunity for us to establish identification and personal acquaintance Erlinda was indeed fit for operation.15 However, she did not proceed to examine the
with the patient. It also makes us have an opportunity to alleviate anxiety, patient’s airway. Had she been able to check petitioner Erlinda’s airway prior to the
explain techniques and risks to the patient, given the patient the choice and operation, Dr. Gutierrez would most probably not have experienced difficulty in
establishing consent to proceed with the plan. And lastly, once this has been intubating the former, and thus the resultant injury could have been avoided. As we
agreed upon by all parties concerned the ordering of pre-operative have stated in our Decision:
medications. And following this line at the end of the evaluation we usually
come up on writing, documentation is very important as far as when we In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda
train an anesthesiologist we always emphasize this because we need for the first time on the day of the operation itself, on 17 June 1985. Before
records for our protection, well, records. And it entails having brief summary this date, no prior consultations with, or pre-operative evaluation of Erlinda
of patient history and physical findings pertinent to anesthesia, plan, was done by her. Until the day of the operation, respondent Dra. Gutierrez
organize as a problem list, the plan anesthesia technique, the plan post was unaware of the physiological make-up and needs of Erlinda. She was
likewise not properly informed of the possible difficulties she would face What is left to be determined therefore is whether Erlinda’s hapless condition was
during the administration of anesthesia to Erlinda. Respondent Dra. due to any fault or negligence on the part of Dr. Gutierrez while she (Erlinda) was
Gutierrez’ act of seeing her patient for the first time only an hour before the under the latter’s care. Dr. Gutierrez maintains that the bronchospasm and cardiac
scheduled operative procedure was, therefore, an act of exceptional arrest resulting in the patient’s comatose condition was brought about by the
negligence and professional irresponsibility. The measures cautioning anaphylactic reaction of the patient to Thiopental Sodium (pentothal). 18 In the
prudence and vigilance in dealing with human lives lie at the core of the Decision, we explained why we found Dr. Gutierrez’ theory unacceptable. In the first
physician’s centuries-old Hippocratic Oath. Her failure to follow this medical place, Dr. Eduardo Jamora, the witness who was presented to support her (Dr.
procedure is, therefore, a clear indicia of her negligence.16 Gutierrez) theory, was a pulmonologist. Thus, he could not be considered an
authority on anesthesia practice and procedure and their complications. 19
Further, there is no cogent reason for the Court to reverse its finding that it was the
faulty intubation on Erlinda that caused her comatose condition. There is no question Secondly, there was no evidence on record to support the theory that Erlinda
that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on developed an allergic reaction to pentothal. Dr. Camagay enlightened the Court as to
her. Even the counsel of Dr. Gutierrez admitted to this fact during the oral arguments: the manifestations of an allergic reaction in this wise:
G.R. No. 126467 To recall the salient facts, PSI, together with Dr. Miguel Ampil (Dr. Ampil) and Dr. Juan
Fuentes (Dr. Fuentes), was impleaded by Enrique Agana and Natividad Agana (later
NATIVIDAD [substituted by her children Marcelino Agana III, Enrique Agana, Jr., substituted by her heirs), in a complaint10 for damages filed in the Regional Trial Court
Emma Agana-Andaya, Jesus Agana and Raymund Agana] and ENRIQUE (RTC) of Quezon City, Branch 96, for the injuries suffered by Natividad when Dr. Ampil
AGANA, Petitioners, and Dr. Fuentes neglected to remove from her body two gauzes11 which were used
vs. in the surgery they performed on her on April 11, 1984 at the Medical City General
THE COURT OF APPEALS and JUAN FUENTES, Respondents. Hospital. PSI was impleaded as owner, operator and manager of the hospital.
x - - - - - - - - - - - - - - - - - - - - - - -x In a decision12 dated March 17, 1993, the RTC held PSI solidarily liable with Dr. Ampil
and Dr. Fuentes for damages.13 On appeal, the Court of Appeals (CA), absolved Dr.
G.R. No. 127590 Fuentes but affirmed the liability of Dr. Ampil and PSI, subject to the right of PSI to
claim reimbursement from Dr. Ampil.141avvphi1
On petition for review, this Court, in its January 31, 2007 decision, affirmed the CA import of the resolution granting the hospital's motion for reconsideration in Ramos
decision.15 PSI filed a motion for reconsideration 16 but the Court denied it in a vs. Court of Appeals (G.R. No. 134354, April 11, 2002), which is applicable to PSI since
resolution dated February 11, 2008.17 the Aganas failed to prove an employer-employee relationship between PSI and Dr.
Ampil and PSI proved that it has no control over Dr. Ampil. In fact, the trial court has
The Court premised the direct liability of PSI to the Aganas on the following facts and found that there is no employer-employee relationship in this case and that the
law: doctor's are independent contractors.
First, there existed between PSI and Dr. Ampil an employer-employee relationship as II
contemplated in the December 29, 1999 decision in Ramos v. Court of Appeals18 that
"for purposes of allocating responsibility in medical negligence cases, an employer- Respondents Aganas engaged Dr. Miguel Ampil as their doctor and did not primarily
employee relationship exists between hospitals and their consultants." 19Although and specifically look to the Medical City Hospital (PSI) for medical care and support;
the Court in Ramos later issued a Resolution dated April 11, 200220 reversing its otherwise stated, respondents Aganas did not select Medical City Hospital (PSI) to
earlier finding on the existence of an employment relationship between hospital and provide medical care because of any apparent authority of Dr. Miguel Ampil as its
doctor, a similar reversal was not warranted in the present case because the defense agent since the latter was chosen primarily and specifically based on his qualifications
raised by PSI consisted of a mere general denial of control or responsibility over the and being friend and neighbor.
actions of Dr. Ampil.21
III
Second, by accrediting Dr. Ampil and advertising his qualifications, PSI created the
public impression that he was its agent.22 Enrique testified that it was on account of PSI cannot be liable under doctrine of corporate negligence since the proximate
Dr. Ampil's accreditation with PSI that he conferred with said doctor about his wife's cause of Mrs. Agana's injury was the negligence of Dr. Ampil, which is an element of
(Natividad's) condition.23 After his meeting with Dr. Ampil, Enrique asked Natividad the principle of corporate negligence.29
to personally consult Dr. Ampil.24 In effect, when Enrigue and Natividad engaged the
services of Dr. Ampil, at the back of their minds was that the latter was a staff In their respective memoranda, intervenors raise parallel arguments that the Court's
member of a prestigious hospital. Thus, under the doctrine of apparent authority ruling on the existence of an employer-employee relationship between private
applied in Nogales, et al. v. Capitol Medical Center, et al.,25 PSI was liable for the hospitals and consultants will force a drastic and complex alteration in the long-
negligence of Dr. Ampil. established and currently prevailing relationships among patient, physician and
hospital, with burdensome operational and financial consequences and adverse
Finally, as owner and operator of Medical City General Hospital, PSI was bound by its effects on all three parties.30
duty to provide comprehensive medical services to Natividad Agana, to exercise
reasonable care to protect her from harm, 26 to oversee or supervise all persons who The Aganas comment that the arguments of PSI need no longer be entertained for
practiced medicine within its walls, and to take active steps in fixing any form of they have all been traversed in the assailed decision and resolution. 31
negligence committed within its premises.27 PSI committed a serious breach of its
corporate duty when it failed to conduct an immediate investigation into the
After gathering its thoughts on the issues, this Court holds that PSI is liable to the
reported missing gauzes.28
Aganas, not under the principle of respondeat superior for lack of evidence of an
employment relationship with Dr. Ampil but under the principle of ostensible agency
PSI is now asking this Court to reconsider the foregoing rulings for these reasons: for the negligence of Dr. Ampil and, pro hac vice, under the principle of corporate
negligence for its failure to perform its duties as a hospital.
I
While in theory a hospital as a juridical entity cannot practice medicine, 32 in reality it
The declaration in the 31 January 2007 Decision vis-a-vis the 11 February 2009 utilizes doctors, surgeons and medical practitioners in the conduct of its business of
Resolution that the ruling in Ramos vs. Court of Appeals (G.R. No. 134354, December facilitating medical and surgical treatment.33 Within that reality, three legal
29, 1999) that "an employer-employee relations exists between hospital and their relationships crisscross: (1) between the hospital and the doctor practicing within its
consultants" stays should be set aside for being inconsistent with or contrary to the premises; (2) between the hospital and the patient being treated or examined within
its premises and (3) between the patient and the doctor. The exact nature of each that the Aganas did not question such finding. In its March 17, 1993 decision, the
relationship determines the basis and extent of the liability of the hospital for the RTC found "that defendant doctors were not employees of PSI in its hospital, they
negligence of the doctor. being merely consultants without any employer-employee relationship and in the
capacity of independent contractors."43 The Aganas never questioned such finding.
Where an employment relationship exists, the hospital may be held vicariously liable
under Article 217634 in relation to Article 218035 of the Civil Code or the principle PSI, Dr. Ampil and Dr. Fuentes appealed44 from the RTC decision but only on the
of respondeat superior. Even when no employment relationship exists but it is shown issues of negligence, agency and corporate liability. In its September 6, 1996 decision,
that the hospital holds out to the patient that the doctor is its agent, the hospital may the CA mistakenly referred to PSI and Dr. Ampil as employer-employee, but it was
still be vicariously liable under Article 2176 in relation to Article 1431 36 and Article clear in its discussion on the matter that it viewed their relationship as one of mere
186937 of the Civil Code or the principle of apparent authority. 38 Moreover, apparent agency.45
regardless of its relationship with the doctor, the hospital may be held directly liable
to the patient for its own negligence or failure to follow established standard of The Aganas appealed from the CA decision, but only to question the exoneration of
conduct to which it should conform as a corporation.39 Dr. Fuentes.46 PSI also appealed from the CA decision, and it was then that the issue
of employment, though long settled, was unwittingly resurrected.
This Court still employs the "control test" to determine the existence of an employer-
employee relationship between hospital and doctor. In Calamba Medical Center, Inc. In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no
v. National Labor Relations Commission, et al.40 it held: employer-employee relationship, such finding became final and conclusive even to
this Court.47 There was no reason for PSI to have raised it as an issue in its petition.
Under the "control test", an employment relationship exists between a physician and Thus, whatever discussion on the matter that may have ensued was purely academic.
a hospital if the hospital controls both the means and the details of the process by
which the physician is to accomplish his task. Nonetheless, to allay the anxiety of the intervenors, the Court holds that, in this
particular instance, the concurrent finding of the RTC and the CA that PSI was not the
xxx xxx xxx employer of Dr. Ampil is correct. Control as a determinative factor in testing the
employer-employee relationship between doctor and hospital under which the
As priorly stated, private respondents maintained specific work-schedules, as hospital could be held vicariously liable to a patient in medical negligence cases is a
determined by petitioner through its medical director, which consisted of 24-hour requisite fact to be established by preponderance of evidence. Here, there was
shifts totaling forty-eight hours each week and which were strictly to be observed insufficient evidence that PSI exercised the power of control or wielded such power
under pain of administrative sanctions. over the means and the details of the specific process by which Dr. Ampil applied his
skills in the treatment of Natividad. Consequently, PSI cannot be held vicariously
That petitioner exercised control over respondents gains light from the undisputed liable for the negligence of Dr. Ampil under the principle of respondeat superior.
fact that in the emergency room, the operating room, or any department or ward
for that matter, respondents' work is monitored through its nursing supervisors, There is, however, ample evidence that the hospital (PSI) held out to the patient
charge nurses and orderlies. Without the approval or consent of petitioner or its (Natividad)48 that the doctor (Dr. Ampil) was its agent. Present are the two factors
medical director, no operations can be undertaken in those areas. For control test that determine apparent authority: first, the hospital's implied manifestation to the
to apply, it is not essential for the employer to actually supervise the performance patient which led the latter to conclude that the doctor was the hospital's agent; and
of duties of the employee, it being enough that it has the right to wield the second, the patient’s reliance upon the conduct of the hospital and the doctor,
power. (emphasis supplied) consistent with ordinary care and prudence.49
Even in its December 29, 1999 decision41 and April 11, 2002 Enrique testified that on April 2, 1984, he consulted Dr. Ampil regarding the condition
resolution42 in Ramos, the Court found the control test decisive. of his wife; that after the meeting and as advised by Dr. Ampil, he "asked [his] wife
to go to Medical City to be examined by [Dr. Ampil]"; and that the next day, April 3,
In the present case, it appears to have escaped the Court's attention that both the he told his daughter to take her mother to Dr. Ampil.50 This timeline indicates that it
RTC and the CA found no employment relationship between PSI and Dr. Ampil, and was Enrique who actually made the decision on whom Natividad should consult and
where, and that the latter merely acceded to it. It explains the testimony of Natividad The Court cannot speculate on what could have been behind the Aganas’ decision
that she consulted Dr. Ampil at the instigation of her daughter.51 but would rather adhere strictly to the fact that, under the circumstances at that
time, Enrique decided to consult Dr. Ampil for he believed him to be a staff member
Moreover, when asked what impelled him to choose Dr. Ampil, Enrique testified: of a prominent and known hospital. After his meeting with Dr. Ampil, Enrique advised
his wife Natividad to go to the Medical City General Hospital to be examined by said
Atty. Agcaoili doctor, and the hospital acted in a way that fortified Enrique's belief.
On that particular occasion, April 2, 1984, what was your reason for choosing Dr. This Court must therefore maintain the ruling that PSI is vicariously liable for the
Ampil to contact with in connection with your wife's illness? negligence of Dr. Ampil as its ostensible agent.
A. First, before that, I have known him to be a specialist on that part of the body as a Moving on to the next issue, the Court notes that PSI made the following admission
surgeon, second, I have known him to be a staff member of the Medical City which in its Motion for Reconsideration:
is a prominent and known hospital. And third, because he is a neighbor, I expect
more than the usual medical service to be given to us, than his ordinary 51. Clearly, not being an agent or employee of petitioner PSI, PSI [sic] is not liable for
patients.52 (emphasis supplied) Dr. Ampil's acts during the operation. Considering further that Dr. Ampil was
personally engaged as a doctor by Mrs. Agana, it is incumbent upon Dr. Ampil, as
Clearly, the decision made by Enrique for Natividad to consult Dr. Ampil was "Captain of the Ship", and as the Agana's doctor to advise her on what to do with her
significantly influenced by the impression that Dr. Ampil was a staff member of situation vis-a-vis the two missing gauzes. In addition to noting the missing gauzes,
Medical City General Hospital, and that said hospital was well known and prominent. regular check-ups were made and no signs of complications were exhibited during
Enrique looked upon Dr. Ampil not as independent of but as integrally related to her stay at the hospital, which could have alerted petitioner PSI's hospital to render
Medical City. and provide post-operation services to and tread on Dr. Ampil's role as the doctor
of Mrs. Agana. The absence of negligence of PSI from the patient's admission up to
her discharge is borne by the finding of facts in this case. Likewise evident
PSI's acts tended to confirm and reinforce, rather than negate, Enrique's view. It is of
therefrom is the absence of any complaint from Mrs. Agana after her discharge
record that PSI required a "consent for hospital care" 53 to be signed preparatory to
from the hospital which had she brought to the hospital's attention, could have
the surgery of Natividad. The form reads:
alerted petitioner PSI to act accordingly and bring the matter to Dr. Ampil's
attention. But this was not the case. Ms. Agana complained ONLY to Drs. Ampil and
Permission is hereby given to the medical, nursing and laboratory staff of the Medical
Fuentes, not the hospital. How then could PSI possibly do something to fix the
City General Hospital to perform such diagnostic procedures and to administer such
negligence committed by Dr. Ampil when it was not informed about it at
medications and treatments as may be deemed necessary or advisable by
all.55 (emphasis supplied)
the physicians of this hospital for and during the confinement of xxx. (emphasis
supplied)
PSI reiterated its admission when it stated that had Natividad Agana "informed the
hospital of her discomfort and pain, the hospital would have been obliged to act on
By such statement, PSI virtually reinforced the public impression that Dr. Ampil was
it."56
a physician of its hospital, rather than one independently practicing in it; that the
medications and treatments he prescribed were necessary and desirable; and that
The significance of the foregoing statements is critical.
the hospital staff was prepared to carry them out.1avvphi1
First, they constitute judicial admission by PSI that while it had no power to control
PSI pointed out in its memorandum that Dr. Ampil's hospital affiliation was not the
the means or method by which Dr. Ampil conducted the surgery on Natividad Agana,
exclusive basis of the Aganas’ decision to have Natividad treated in Medical City
it had the power to review or cause the review of what may have irregularly
General Hospital, meaning that, had Dr. Ampil been affiliated with another hospital,
transpired within its walls strictly for the purpose of determining whether some form
he would still have been chosen by the Aganas as Natividad's surgeon.54
of negligence may have attended any procedure done inside its premises, with the
ultimate end of protecting its patients.
Second, it is a judicial admission that, by virtue of the nature of its business as well as might be able to retrace his own steps. By its own standard of corporate conduct,
its prominence57 in the hospital industry, it assumed a duty to "tread on" the "captain PSI's duty to initiate the review was non-delegable.
of the ship" role of any doctor rendering services within its premises for the purpose
of ensuring the safety of the patients availing themselves of its services and facilities. While Dr. Ampil may have had the primary responsibility of notifying Natividad about
the missing gauzes, PSI imposed upon itself the separate and independent
Third, by such admission, PSI defined the standards of its corporate conduct under responsibility of initiating the inquiry into the missing gauzes. The purpose of the first
the circumstances of this case, specifically: (a) that it had a corporate duty to would have been to apprise Natividad of what transpired during her surgery, while
Natividad even after her operation to ensure her safety as a patient; (b) that its the purpose of the second would have been to pinpoint any lapse in procedure that
corporate duty was not limited to having its nursing staff note or record the two led to the gauze count discrepancy, so as to prevent a recurrence thereof and to
missing gauzes and (c) that its corporate duty extended to determining Dr. Ampil's determine corrective measures that would ensure the safety of Natividad. That Dr.
role in it, bringing the matter to his attention, and correcting his negligence. Ampil negligently failed to notify Natividad did not release PSI from its self-imposed
separate responsibility.
And finally, by such admission, PSI barred itself from arguing in its second motion for
reconsideration that the concept of corporate responsibility was not yet in existence Corollary to its non-delegable undertaking to review potential incidents of negligence
at the time Natividad underwent treatment;58 and that if it had any corporate committed within its premises, PSI had the duty to take notice of medical records
responsibility, the same was limited to reporting the missing gauzes and did not prepared by its own staff and submitted to its custody, especially when these bear
include "taking an active step in fixing the negligence committed."59 An admission earmarks of a surgery gone awry. Thus, the record taken during the operation of
made in the pleading cannot be controverted by the party making such admission Natividad which reported a gauze count discrepancy should have given PSI sufficient
and is conclusive as to him, and all proofs submitted by him contrary thereto or reason to initiate a review. It should not have waited for Natividad to complain.
inconsistent therewith should be ignored, whether or not objection is interposed by
a party.60 As it happened, PSI took no heed of the record of operation and consequently did
not initiate a review of what transpired during Natividad’s operation. Rather, it
Given the standard of conduct that PSI defined for itself, the next relevant inquiry is shirked its responsibility and passed it on to others – to Dr. Ampil whom it expected
whether the hospital measured up to it. to inform Natividad, and to Natividad herself to complain before it took any
meaningful step. By its inaction, therefore, PSI failed its own standard of hospital
PSI excuses itself from fulfilling its corporate duty on the ground that Dr. Ampil care. It committed corporate negligence.
assumed the personal responsibility of informing Natividad about the two missing
gauzes.61 Dr. Ricardo Jocson, who was part of the group of doctors that attended to It should be borne in mind that the corporate negligence ascribed to PSI is different
Natividad, testified that toward the end of the surgery, their group talked about the from the medical negligence attributed to Dr. Ampil. The duties of the hospital are
missing gauzes but Dr. Ampil assured them that he would personally notify the distinct from those of the doctor-consultant practicing within its premises in relation
patient about it.62 Furthermore, PSI claimed that there was no reason for it to act on to the patient; hence, the failure of PSI to fulfill its duties as a hospital corporation
the report on the two missing gauzes because Natividad Agana showed no signs of gave rise to a direct liability to the Aganas distinct from that of Dr. Ampil.
complications. She did not even inform the hospital about her discomfort. 63
All this notwithstanding, we make it clear that PSI’s hospital liability based on
The excuses proffered by PSI are totally unacceptable. ostensible agency and corporate negligence applies only to this case, pro hac vice. It
is not intended to set a precedent and should not serve as a basis to hold hospitals
To begin with, PSI could not simply wave off the problem and nonchalantly delegate liable for every form of negligence of their doctors-consultants under any and all
to Dr. Ampil the duty to review what transpired during the operation. The purpose circumstances. The ruling is unique to this case, for the liability of PSI arose from an
of such review would have been to pinpoint when, how and by whom two surgical implied agency with Dr. Ampil and an admitted corporate duty to Natividad. 64
gauzes were mislaid so that necessary remedial measures could be taken to avert any
jeopardy to Natividad’s recovery. Certainly, PSI could not have expected that purpose Other circumstances peculiar to this case warrant this ruling,65 not the least of which
to be achieved by merely hoping that the person likely to have mislaid the gauzes being that the agony wrought upon the Aganas has gone on for 26 long years, with
Natividad coming to the end of her days racked in pain and agony. Such wretchedness
could have been avoided had PSI simply done what was logical: heed the report of a The factual antecedents:
guaze count discrepancy, initiate a review of what went wrong and take corrective
measures to ensure the safety of Nativad. Rather, for 26 years, PSI hemmed and On July 7, 1993, respondents’ 11-year old daughter, Angelica Soliman, underwent a
hawed at every turn, disowning any such responsibility to its patient. Meanwhile, the biopsy of the mass located in her lower extremity at the St. Luke’s Medical Center
options left to the Aganas have all but dwindled, for the status of Dr. Ampil can no (SLMC). Results showed that Angelica was suffering from osteosarcoma, osteoblastic
longer be ascertained.66 type,4 a high-grade (highly malignant) cancer of the bone which usually afflicts
teenage children. Following this diagnosis and as primary intervention, Angelica’s
Therefore, taking all the equities of this case into consideration, this Court believes right leg was amputated by Dr. Jaime Tamayo in order to remove the tumor. As
₱15 million would be a fair and reasonable liability of PSI, subject to 12% p.a. interest adjuvant treatment to eliminate any remaining cancer cells, and hence minimize the
from the finality of this resolution to full satisfaction. chances of recurrence and prevent the disease from spreading to other parts of the
patient’s body (metastasis), chemotherapy was suggested by Dr. Tamayo. Dr.
WHEREFORE, the second motion for reconsideration is DENIED and the motions for Tamayo referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a
intervention are NOTED. medical oncologist.
Professional Services, Inc. is ORDERED pro hac vice to pay Natividad (substituted by On August 18, 1993, Angelica was admitted to SLMC. However, she died on
her children Marcelino Agana III, Enrique Agana, Jr., Emma Agana-Andaya, Jesus September 1, 1993, just eleven (11) days after the (intravenous) administration of
Agana and Raymund Agana) and Enrique Agana the total amount of ₱15 million, the first cycle of the chemotherapy regimen. Because SLMC refused to release a
subject to 12% p.a. interest from the finality of this resolution to full satisfaction. death certificate without full payment of their hospital bill, respondents brought the
cadaver of Angelica to the Philippine National Police (PNP) Crime Laboratory at Camp
No further pleadings by any party shall be entertained in this case. Crame for post-mortem examination. The Medico-Legal Report issued by said
institution indicated the cause of death as "Hypovolemic shock secondary to multiple
organ hemorrhages and Disseminated Intravascular Coagulation."5
Let the long-delayed entry of judgment be made in this case upon receipt by all
concerned parties of this resolution.
On the other hand, the Certificate of Death6 issued by SLMC stated the cause of death
as follows:
SO ORDERED.
Hence, this petition. The issue to be resolved is whether the petitioner can be held liable for failure to fully
disclose serious side effects to the parents of the child patient who died while
Petitioner assails the CA in finding her guilty of negligence in not explaining to the undergoing chemotherapy, despite the absence of finding that petitioner was
respondents all the possible side effects of the chemotherapy on their child, and in negligent in administering the said treatment.
holding her liable for actual, moral and exemplary damages and attorney’s fees.
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or, more of injury might be incurred from a proposed course of treatment, so that a patient,
appropriately, medical negligence, is that type of claim which a victim has available exercising ordinary care for his own welfare, and faced with a choice of undergoing
to him or her to redress a wrong committed by a medical professional which has the proposed treatment, or alternative treatment, or none at all, may intelligently
caused bodily harm. In order to successfully pursue such a claim, a patient must prove exercise his judgment by reasonably balancing the probable risks against the
that a health care provider, in most cases a physician, either failed to do something probable benefits.55
which a reasonably prudent health care provider would have done, or that he or she
did something that a reasonably prudent provider would not have done; and that Subsequently, in Canterbury v. Spence56 the court observed that the duty to disclose
that failure or action caused injury to the patient.51 should not be limited to medical usage as to arrogate the decision on revelation to
the physician alone. Thus, respect for the patient’s right of self-determination on
This Court has recognized that medical negligence cases are best proved by opinions particular therapy demands a standard set by law for physicians rather than one
of expert witnesses belonging in the same general neighborhood and in the same which physicians may or may not impose upon themselves.57 The scope of disclosure
general line of practice as defendant physician or surgeon. The deference of courts is premised on the fact that patients ordinarily are persons unlearned in the medical
to the expert opinion of qualified physicians stems from the former’s realization that sciences. Proficiency in diagnosis and therapy is not the full measure of a physician’s
the latter possess unusual technical skills which laymen in most instances are responsibility. It is also his duty to warn of the dangers lurking in the proposed
incapable of intelligently evaluating, hence the indispensability of expert treatment and to impart information which the patient has every right to expect.
testimonies.52 Indeed, the patient’s reliance upon the physician is a trust of the kind which
traditionally has exacted obligations beyond those associated with armslength
In this case, both the trial and appellate courts concurred in finding that the alleged transactions.58 The physician is not expected to give the patient a short medical
negligence of petitioner in the administration of chemotherapy drugs to education, the disclosure rule only requires of him a reasonable explanation, which
respondents’ child was not proven considering that Drs. Vergara and Balmaceda, not means generally informing the patient in nontechnical terms as to what is at stake;
being oncologists or cancer specialists, were not qualified to give expert opinion as the therapy alternatives open to him, the goals expectably to be achieved, and the
to whether petitioner’s lack of skill, knowledge and professional competence in risks that may ensue from particular treatment or no treatment.59 As to the issue of
failing to observe the standard of care in her line of practice was the proximate cause demonstrating what risks are considered material necessitating disclosure, it was
of the patient’s death. Furthermore, respondents’ case was not at all helped by the held that experts are unnecessary to a showing of the materiality of a risk to a
non-production of medical records by the hospital (only the biopsy result and medical patient’s decision on treatment, or to the reasonably, expectable effect of risk
bills were submitted to the court). Nevertheless, the CA found petitioner liable for disclosure on the decision. Such unrevealed risk that should have been made known
her failure to inform the respondents on all possible side effects of chemotherapy must further materialize, for otherwise the omission, however unpardonable, is
before securing their consent to the said treatment. without legal consequence. And, as in malpractice actions generally, there must be a
causal relationship between the physician’s failure to divulge and damage to the
The doctrine of informed consent within the context of physician-patient patient.60
relationships goes far back into English common law. As early as 1767, doctors were
charged with the tort of "battery" (i.e., an unauthorized physical contact with a Reiterating the foregoing considerations, Cobbs v. Grant61 deemed it as integral part
patient) if they had not gained the consent of their patients prior to performing a of physician’s overall obligation to patient, the duty of reasonable disclosure of
surgery or procedure. In the United States, the seminal case was Schoendorff v. available choices with respect to proposed therapy and of dangers inherently and
Society of New York Hospital53 which involved unwanted treatment performed by a potentially involved in each. However, the physician is not obliged to discuss
doctor. Justice Benjamin Cardozo’s oft-quoted opinion upheld the basic right of a relatively minor risks inherent in common procedures when it is common knowledge
patient to give consent to any medical procedure or treatment: "Every human being that such risks inherent in procedure of very low incidence. Cited as exceptions to
of adult years and sound mind has a right to determine what shall be done with his the rule that the patient should not be denied the opportunity to weigh the risks of
own body; and a surgeon who performs an operation without his patient’s consent, surgery or treatment are emergency cases where it is evident he cannot evaluate
commits an assault, for which he is liable in damages."54 From a purely ethical norm, data, and where the patient is a child or incompetent. 62 The court thus concluded
informed consent evolved into a general principle of law that a physician has a duty that the patient’s right of self-decision can only be effectively exercised if the patient
to disclose what a reasonably prudent physician in the medical community in the possesses adequate information to enable him in making an intelligent choice. The
exercise of reasonable care would disclose to his patient as to whatever grave risks scope of the physician’s communications to the patient, then must be measured by
the patient’s need, and that need is whatever information is material to the decision. informed consent laws in other countries generally require only a reasonable
The test therefore for determining whether a potential peril must be divulged is its explanation of potential harms, so specific disclosures such as statistical data, may
materiality to the patient’s decision.63 not be legally necessary.65
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that The element of ethical duty to disclose material risks in the proposed medical
for liability of the physician for failure to inform patient, there must be causal treatment cannot thus be reduced to one simplistic formula applicable in all
relationship between physician’s failure to inform and the injury to patient and such instances. Further, in a medical malpractice action based on lack of informed consent,
connection arises only if it is established that, had revelation been made, consent to "the plaintiff must prove both the duty and the breach of that duty through expert
treatment would not have been given. testimony.66 Such expert testimony must show the customary standard of care of
physicians in the same practice as that of the defendant doctor.67
There are four essential elements a plaintiff must prove in a malpractice action based
upon the doctrine of informed consent: "(1) the physician had a duty to disclose In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a Specialist of the DOH’s Operational and Management Services charged with receiving
direct and proximate result of the failure to disclose, the patient consented to complaints against hospitals, does not qualify as expert testimony to establish the
treatment she otherwise would not have consented to; and (4) plaintiff was injured standard of care in obtaining consent for chemotherapy treatment. In the absence of
by the proposed treatment." The gravamen in an informed consent case requires the expert testimony in this regard, the Court feels hesitant in defining the scope of
plaintiff to "point to significant undisclosed information relating to the treatment mandatory disclosure in cases of malpractice based on lack of informed consent,
which would have altered her decision to undergo it.64 much less set a standard of disclosure that, even in foreign jurisdictions, has been
noted to be an evolving one.
Examining the evidence on record, we hold that there was adequate disclosure of
material risks inherent in the chemotherapy procedure performed with the consent As society has grappled with the juxtaposition between personal autonomy and the
of Angelica’s parents. Respondents could not have been unaware in the course of medical profession's intrinsic impetus to cure, the law defining "adequate" disclosure
initial treatment and amputation of Angelica’s lower extremity, that her immune has undergone a dynamic evolution. A standard once guided solely by the
system was already weak on account of the malignant tumor in her knee. When ruminations of physicians is now dependent on what a reasonable person in the
petitioner informed the respondents beforehand of the side effects of chemotherapy patient’s position regards as significant. This change in perspective is especially
which includes lowered counts of white and red blood cells, decrease in blood important as medical breakthroughs move practitioners to the cutting edge of
platelets, possible kidney or heart damage and skin darkening, there is reasonable technology, ever encountering new and heretofore unimagined treatments for
expectation on the part of the doctor that the respondents understood very well that currently incurable diseases or ailments. An adaptable standard is needed to account
the severity of these side effects will not be the same for all patients undergoing the for this constant progression. Reasonableness analyses permeate our legal system
procedure. In other words, by the nature of the disease itself, each patient’s reaction for the very reason that they are determined by social norms, expanding and
to the chemical agents even with pre-treatment laboratory tests cannot be precisely contracting with the ebb and flow of societal evolution.
determined by the physician. That death can possibly result from complications of
the treatment or the underlying cancer itself, immediately or sometime after the As we progress toward the twenty-first century, we now realize that the legal
administration of chemotherapy drugs, is a risk that cannot be ruled out, as with most standard of disclosure is not subject to construction as a categorical imperative.
other major medical procedures, but such conclusion can be reasonably drawn from Whatever formulae or processes we adopt are only useful as a foundational starting
the general side effects of chemotherapy already disclosed. point; the particular quality or quantity of disclosure will remain inextricably bound
by the facts of each case. Nevertheless, juries that ultimately determine whether a
As a physician, petitioner can reasonably expect the respondents to have considered physician properly informed a patient are inevitably guided by what they perceive as
the variables in the recommended treatment for their daughter afflicted with a life- the common expectation of the medical consumer—"a reasonable person in the
threatening illness. On the other hand, it is difficult to give credence to respondents’ patient’s position when deciding to accept or reject a recommended medical
claim that petitioner told them of 95% chance of recovery for their daughter, as it procedure."68 (Emphasis supplied.)
was unlikely for doctors like petitioner who were dealing with grave conditions such
as cancer to have falsely assured patients of chemotherapy’s success rate. Besides,
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision dated
June 15, 2004 and the Resolution dated September 1, 2004 of the Court of Appeals
in CA-G.R. CV No. 58013 are SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City,
Branch 8, in Civil Case No. 8904 is REINSTATED and UPHELD.
No costs.
SO ORDERED.