Lim v CA
- confidentiality of the physician-patient relationship Issues:
1. Lim (petitioner) and Sim (private respondent) are married to each other.
Sim filed for an annulment on the ground that Lim has been allegedly
suffering from schizophrenia.
2. Sim's counsel issued a subpoena so that Dr. Acampado, a Doctor
specializing in Psychiatry, would be a witness.
3. Lim’s counsel opposed this on the ground that the testimony to be
elicited is privileged since Dr. Acampado had examined the Lim in a
professional capacity and had diagnosed her to be suffering from
schizophrenia. Stating that Dr. Acampado should be barred from
testifying based in the rule of confidentiality of the physician-patient
relationship. The subpoena was still issued.
4. Counsel for Sim contended that Dr. Acampado would be presented as an
expert witness and would not testify on any information acquired while
attending to the petitioner in a professional capacity.
5. The TC allowed the witness to testify. Dr. Acampado was asked
hypothetical questions related to her field of expertise. She neither
revealed the illness she examined and treated the petitioner for nor
disclosed the results of her examination and the medicines she had
prescribed.
6. Lim filed a petition to annul the order and to prohibit the court from
proceeding with the reception of Dr. Acampado’s testimony because the
judge acted with GAD.
7. The CA denied it because Lim failed in establishing the confidential
nature of the testimony given by Dr. Acampado when she testified.
8. Dr. Acampado's testimony did not touch or disclose any information
which she has acquired from her patient. Although she testified that she
examined and interviewed the patient, she did not disclose anything she
obtained in the course of her examination, interview and treatment of
her patient.
9. A physician is not disqualified to testify as an expert concerning a
patient's ailment, when he can disregard knowledge acquired in
attending such patient and make answer solely on facts related in the
hypothetical question. (Butler vs. Role)
10. Expert testimony of a physician based on hypothetical question as to
cause of illness of a person whom he has attended is not privileged,
provided the physician does not give testimony tending to disclose
confidential information related to him in his professional capacity
while attending to the patient. (Crago vs. City of Cedar Rapids)
Lim appealed on the grounds that the CA seriously erred:
a. In not finding that all the essential elements of the rule on physician-
patient privileged communication exist in the case at bar.
b. In believing that Dr. Acampado ‘was summoned as an expert witness and
not as an attending physician of petitioner.
c. In concluding that Dr. Acampado made 'no declaration that disclosed any
information which she has acquired from her patient.
d. In declaring that Lim failed in establishing the confidential nature of the
testimony given by or obtained from Dr. Acampado.
Held:
The petition is devoid of any merit. The CA committed no reversible error in its
challenged resolution.
In order that the privilege may be successfully claimed, the following requisites
must concur:
(a) the privilege is claimed in a civil case;
(b) the person against whom the privilege is claimed is one duly authorized
to practice medicine, surgery or obstetrics;
(c) such person acquired the information while he was attending to the
patient in his professional capacity;
(d) the information was necessary to enable him to act in that capacity; and
(e) the information was confidential, and, if disclosed, would blacken the
reputation (formerly character) of the patient.
The physician may be considered to be acting in his professional capacity when he
attends to the patient for curative, preventive, or palliative treatment. Only
disclosures which would have been made to the physician to enable him "safely
and efficaciously to treat his patient" are covered by the privilege. It is to be
emphasized that "it is the tenor only of the communication that is privileged.
The mere fact of making a communication, as well as the date of a consultation
and the number of consultations, are therefore not privileged from disclosure,
so long as the subject communicated is not stated.”
One who claims this privilege must prove the presence of these aforementioned
requisites.
1. Dr. Acampado was presented and qualified as an expert witness. Her
expert opinion excluded whatever information or knowledge she had
about the petitioner which was acquired by reason of the physician-
patient relationship existing between them. As an expert witness, her
testimony before the trial court cannot then be excluded.
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 2. Dr. Acampado's interviews were always conducted in the presence of a
third party. Information elicited in the presence of third parties removes
such information from the mantle of the privilege.
3. Except for the petitioner's sweeping claim which is based on a wrong
premise, nothing specific or concrete was offered to show that indeed,
the information obtained from Dr. Acampado would blacken the
former's "character ". Dr. Acampado never disclosed any information
obtained from Lim regarding the latter’s ailment and the treatment
recommended therefor.
4. Though Lim’s counsel opposed the oral request for the issuance of
a subpoena and filed a quashal, Lim’s counsel had not objected to any
question asked of the witness on the ground that it elicited an answer
that would violate the privilege, despite the trial court's advise that said
counsel may interpose his objection to the testimony once it becomes
apparent that the testimony, sought to be elicited is covered by the
privileged communication rule.
a. Even granting ex gratia that the testimony of Dr. Acampado
could be covered by the privilege, the failure to seasonably
object thereto amounted to a waiver thereof.
Cruz v. CA
- Medical malpractice
1. Rowena Umali De Ocampo, accompanied her mother, Lydia Umali, to the
clinic where Lydia, examined by Dr. Cruz, was found to have a myoma in
her uterus. She was scheduled for a hysterectomy operation the next
day. Rowena and Lydia slept in the clinic, and according to Rowena, the
clinic was untidy even making her ask the attendant for a rag to wipe the
window and the floor with.
2. Because of the untidy state of the clinic, Rowena tried to dissuade her
mother with the operation. The following day, Rowena asked Dr. Cruz if
the operation could be postponed. Dr. Cruz talked to Lydia, and then
Lydia informed Rowena that Dr. Cruz told her that she must be operated
on as scheduled.
3. Rowena and her other relatives waited outside the operating room while
Lydia underwent operation. During the operation, Dr. Ercillo went out of
the operating room and instructed them to buy tagamet ampoules. She
emerged twice asking them to buy blood.
4. After a few hours, Dr. Cruz informed them that the operation was
finished. Lydia was then brought out of the operating room, but Dr. Cruz
still asked Rowena to buy more blood for Lydia.
5. Being unable to buy as it was out of stock, a donor arrived with the
blood. While it was being transfused, Rowena noticed her mother was
gasping for breath.
6. Rowena’s husband bought oxygen, but Lydia’s BP still dropped. Lydia had
to be rushed to the hospital to be connected to a respirator without the
consent of Rowena or any of her relatives.
7. Lydia was immediately wheeled into the operating room and Dr. Cruz
and Dr. Ercillo re-operated on her because there was blood oozing from
the abdominal incision. The attending physicians summoned Dr.
Bartolome Angeles, head of the Obstetrics and Gynecology Department
8. When Dr. Angeles arrived, Lydia was already in shock and possibly dead.
Dr. Angeles then informed Dr. Cruz and Dr. Ercillo that there was nothing
he could do to help save the patient. While Dr. Cruz was closing the
abdominal wall, the patient died.
9. The MTCC found the untidiness of the clinic, lack of blood and oxygen,
and unpreparedness as sufficient basis to conclude that she was indeed
negligent in the performance of the operation. With respect to Dr.
Ercillo, the anaesthesiologist, there is no evidence to indicate that she
should be held jointly liable with Dr. Cruz.
10. The RTC reiterated the findings of the MTCC, and so did the CA.
Issue:
Whether petitioner's conviction of the crime of reckless imprudence resulting
in homicide, arising from an alleged medical malpractice, is supported by the
evidence on record
Held:
1. NO. While there is no showing that clearance was obtained and that she
did not prepare the patient, get the family's consent to the operation,
nor prepare a medical chart, the SC finds the foregoing circumstances
insufficient to sustain a judgment of conviction against the petitioner for
the crime of reckless imprudence resulting in homicide.
2. The elements of reckless imprudence are: xxx and (5) that there is
inexcusable lack of precaution on the part of the offender,xxx.
3. Whether a physician has committed an "inexcusable lack of precaution"
is to be determined according to the standard of care observed by other
members of the profession in good standing under similar circumstances.
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 4. Without expert testimony that Dr. Cruz was recklessly imprudent in the
exercise of her duties as a surgeon, no cogent proof exists that any of
these circumstances caused Lydia's death.
5. The testimonies of Dr. Salvador and Dr. Arizala establish hemorrhage or
hemorrhagic shock as the cause of death. However, as likewise testified
to by the expert witnesses in open court, hemorrhage or hemorrhagic
shock during surgery may be caused by several different factors.
6. The possible causes of hemorrhage during an operation are: (1) failure of
the surgeon to tie or suture a cut blood vessel; (2) allowing a cut blood
vessel to get out of control; (3) subsequent loosening of the tie or suture
applied to a cut blood vessel; and (4) and a clotting defect known as DIC.
7. The autopsy conducted by Dr. Arizala did not reveal any untied or
unsutured cut blood vessel nor was there any indication that the tie or
suture of a cut blood vessel had become loose thereby causing the
hemorrhage
8. The findings of all three doctors do not preclude the probability that DIC
caused the hemorrhage and consequently, Lydia's death. According to
Dr. Castro, hemorrhage due to DIC "cannot be prevented, it will happen
to anyone, anytime."
9. The probability that Lydia's death was caused by DIC was unrebutted
during trial and has engendered in the mind of this Court a reasonable
doubt as to the petitioner's guilt. Thus, her acquittal of the crime of
reckless imprudence resulting in homicide.
Cayao – Lasam v. Spouses Claro and Editha Ramolete
1. 3-months pregnant Editha was brought to LMC due to vaginal bleeding
and then underwent a Dilatation and Curettage Procedure (D&C) or
"raspa." Lasam performed the D&C procedure. Editha was discharged
from the hospital the following day.
2. 2 months after, Editha was again brought at the LMC, as she was
suffering from vomiting and severe abdominal pains. She was told that
there was a dead fetus in her womb. Editha had to undergo a procedure
for hysterectomy and as a result, she has no more chance to bear a child.
3. Spouses Ramolete filed a Complaint for Gross Negligence and
Malpractice against Lasam before the PRC.
4. Spouses Ramolete alleged that Editha’s hysterectomy was caused by
Lasam’s unmitigated negligence and professional incompetence in
conducting the D&C procedure and the petitioner’s failure to remove the
fetus inside Editha’s womb.
5. Lasam denied the allegations. She claimed that it was Editha who
insisted that she wanted to be discharged; Lasam agreed, but she
advised Editha to return for check-up, which the latter failed to do.
Lasam contended that it was Editha’s gross negligence that brought her
to undergo hysterectomy.
6. The PRC exonerated Lasam from the charges filed against her. The Board
held that Dr. Lasam cannot be faulted if she was not able to determine
that complainant Editha is having an ectopic pregnancy interstitial. The
D&C conducted on Editha is necessary.
7. Spouses Ramolete went to the PRC on appeal. PRC reversed the decision.
Lasam raised it to the CA.
Issues:
1. PRC committed GAD in revoking petitioner’s license to practice medicine
without an expert testimony to support its conclusion as to the cause of
Editha’s injury;
2. PRC committed an even graver abuse of discretion in totally disregarding
the finding of the Board of Medicine, which had the necessary
competence and expertise to establish the cause of Editha’s injury, as
well as the testimony of the expert witness Dr. Manalo;
3. PRC committed GAD in making conclusions of facts that were not only
unsupported by evidence but were actually contrary to evidence on
record.
Held:
1. Lasam questions the PRC decision for being without an expert testimony
to support its conclusion and to establish the cause of Editha’s injury.
Petitioner avers that in cases of medical malpractice, expert testimony is
necessary to support the conclusion as to the cause of the injury.
2. Medical malpractice is a particular form of negligence which consists in
the failure of a physician or surgeon to apply to his practice of medicine
that degree of care and skill which is ordinarily employed by the
profession generally, under similar conditions, and in like surrounding
circumstances. In order to successfully pursue such a claim, a patient
must prove that the physician or surgeon either failed to do something
which a reasonably prudent physician or surgeon would not have done,
and that the failure or action caused injury to the patient.
3. There are four elements involved in medical negligence cases: duty,
breach, injury and proximate causation.
4. In the present case, respondents did not present any expert testimony to
support their claim that petitioner failed to do something which a
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 reasonably prudent physician or surgeon would have done. Lasam
presented the testimony of Dr. Manalo, who was clearly an expert on the
subject.
5. 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.
6. From the testimony of the expert witness and the reasons given by him,
it is evident that the D&C procedure was not the proximate cause of the
rupture of Editha’s uterus. It is clear that the D&C procedure was
conducted in accordance with the standard practice.
7. Dr. Manalo, stated further that assuming that there was in fact a
misdiagnosis, the same would have been rectified if Editha followed the
petitioner’s order to return for a check-up.
Layugan v IAC
FACTS:
A truck bumped into the plaintiff while he and a companion were
repairing the tire of their parked truck along the right side of the highway. He
sustained injuries. Defendant contends that the proximate cause was the failure
of the driver of the parked truck to install an early warning device. IAC concluded
that under the doctrine, the plaintiff was negligent. The question is whether the
doctrine was applicable.
HELD:
Res ipsa loquitor (the thing speaks for itself) –Where the thing which causes the
injury is shown to be under the management of the defendant, and the accident
is such as in the ordinary course of things does not happen if those who have he
management use proper care, it affords reasonable evidence, in the absence of
an explanation by the defendant, that the accident arose from want of care. It is
not rule of substantive law but merely a mode of proof or a mere procedural
convenience. It can be involved when and only when, under the circumstances
involved, direct evidence is absent and not readily available. It cannot be availed
of when the plaintiff has knowledge and testifies or presents evidence as to the
specific act of negligence which is the cause of injury complained of or where
there is direct evidence as to the precise cause of the accident and all the facts
and circumstances attendant to the occurrence appear. The absence of want of
care of the driver has been established by clear and convincing evidence. The
doctrine does not apply.
RULE:
Res ipsa can be involved when and only when, under the circumstances involved,
direct evidence is absent and not readily available
Ramos v CA
1. Erlinda Ramos, a 47-year old robust woman, was normal except for her
experiencing occasional pain due to the presence of stone in her gall
bladder.
2. She was advised to undergo an operation for its removal. The results in
the examinations she underwent indicate that she was fit for the
operation. She and her husband Rogelio met Dr. Hosaka, one of the
defendants, who advised that she should undergo cholecystectomy. Dr.
Hosaka assured them that he will get a good anaesthesiologist.
3. 7:30am, On the day of the operation at Delos Santos Medical Center,
Herminda Cruz, Erlinda’s sister-in-law and the dean of the College of
Nursing in Capitol Medical Center, was there to provide moral support
4. Dr. Perfecta Gutierrez was to administer the anaesthesia. Dr. Hosaka
arrived only at 12:15 p. m. Herminda saw Dr. Gutierrez intubating the
patient, and heard the latter say “Ang hirap ma-intubate nito, mali yata
ang pagkakapasok. O, lumalaki ang tiyan.” Herminda saw bluish
discoloration of the nailbeds of the patient.
5. She heard Dr. Hosaka issue an order for someone to call Dr. Calderon.
The doctor arrived and placed the patient in trendelenburg position,
wherein the head of the patient is positioned lower than the feet, which
indicates a decrease of blood supply in the brain. Herminda knew and
told Rogelio that something wrong was happening. Dr. Calderon was able
to intubate the patient. Erlinda was taken to the ICU and became
comatose.
6. Rogelio filed a civil case for damages. The trial court ruled in his favor,
finding Dr. Gutierrez, Dr. Hosaka, and the hospital, guilty of negligence,
but the Court of Appeals reversed the decision. Hence, petitioner filed a
Motion for Reconsideration, which the Court of Appeals denied for
having been filed beyond the reglementary period. However, it was
found that the notice of the decision was never sent to the petitioner’s
counsel. Rather, it was sent to the petitioner, addressing him as Atty.
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 Rogelio Ramos, as if he was the legal counsel. The petitioner filed the
instant petition for certiorari. On the procedural issue, the Supreme
Court rules that since the notice did not reach the petitioner’s then legal
counsel, the motion was filed on time.
Issue:
Whether a surgeon, an anaesthesiologist, and a hospital, should be made liable
for the unfortunate comatose condition of a patient scheduled for
cholecystectomy
Held:
Res Ipsa Loquitor
Res ipsa loquitur is a Latin phrase which literally means "the thing or the
transaction speaks for itself." The phrase "res ipsa loquitur'' is a maxim for the
rule that the fact of the occurrence of an injury, taken with the surrounding
circumstances, may permit an inference or raise a presumption of negligence, or
make out a plaintiff's prima facie case, and present a question of fact for
defendant to meet with an explanation. Where the thing which caused the injury
complained of is shown to be under the management of the 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. It is grounded
in the superior logic of ordinary human experience and on the basis of such
experience or common knowledge, negligence may be deduced from the mere
occurrence of the accident itself. 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. Mere invocation and application of
the doctrine does not dispense with the requirement of proof of negligence. It is
simply a step in the process of such proof, permitting the plaintiff to present
along with the proof of the accident, enough of the attending circumstances to
invoke the doctrine, creating an inference or presumption of negligence, and to
thereby place on the defendant the burden of going forward with the proof. Still,
before resort to the doctrine may be allowed, the following requisites must be
satisfactorily shown.
(1) The accident is of a kind which ordinarily does not occur in the absence of
someone's negligence;
(2) It is caused by an instrumentality within the exclusive control of the defendant
or defendants; and
(3) The possibility of contributing conduct which would make the plaintiff
responsible is eliminated.
Medical malpractice cases do not escape the application of this 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. 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.
Hence, in cases where the res 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. 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.
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. 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. 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.
We find the doctrine of res ipsa loquitur appropriate in the case at bar. Erlinda
submitted 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 private respondents who exercised
complete and exclusive control over her. At the time of submission, Erlinda was
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neurologically sound and, except for a few minor discomforts, was likewise
physically fit in mind and body. However, during the administration of anesthesia
and prior to the performance of cholecystectomy she suffered irreparable
damage to her brain. Thus, without undergoing surgery, she went out of the
operating room already decerebrate and totally incapacitated. Obviously, brain
damage, which Erlinda sustained, is an injury which does not normally occur in
the process of a gall bladder operation. In fact, this kind of situation does not in
the absence of negligence of someone in the administration of anesthesia and in
the use of endotracheal tube. Furthermore, the instruments used in the
administration of anesthesia, including the endotracheal tube, were all under the
exclusive control of private respondents, who are the physicians-in-charge.
Likewise, petitioner Erlinda could not have been guilty of contributory negligence
because she was under the influence of anesthetics which rendered her
unconscious.
Negligence of the Anaesthesiologist
The pre-operative evaluation of a patient prior to the administration of
anesthesia is universally observed to lessen the possibility of anesthetic accidents.
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. Her failure to follow this
medical procedure is, therefore, a clear indicia of her negligence. 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.
Opinion of Expert Witness
An anesthetic accident caused by a rare drug-induced bronchospasm properly
falls within the fields of anesthesia, internal medicine-allergy, and clinical
pharmacology. The resulting anoxic encephalopathy belongs to the field of
neurology. While admittedly, many bronchospastic-mediated pulmonary diseases
are within the expertise of pulmonary medicine, Dr. Jamora's field, the anesthetic
drug-induced, allergic mediated bronchospasm alleged in this case is within the
disciplines of anesthesiology, allergology and pharmacology. On the basis of the
foregoing transcript, in which the pulmonologist himself admitted that he could
not testify about the drug with medical authority, it is clear that the appellate
court erred in giving weight to Dr. Jamora's testimony as an expert in the
administration of Thiopental Sodium. 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. 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.
Proximate Cause
Proximate cause has been defined as that which, in natural and continuous
sequence, unbroken by any efficient intervening cause, produces injury, and
without which the result would not have occurred. An injury or damage is
proximately caused by an act or a failure to act, whenever it appears from the
evidence in the case, that the act or omission played a substantial part in bringing
about or actually causing the injury or damage; and that the injury or damage was
either a direct result or a reasonably probable consequence of the act or
omission. 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.
Responsibility of the Surgeon
As the so-called "captain of the ship," 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 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.
6

Responsibility of the Hospital
Hospitals hire, fire and exercise real control over their attending and visiting
"consultant" staff. While "consultants" are not, technically employees, a point
which respondent hospital asserts in denying all responsibility for the patient's
condition, the control exercised, the hiring, and the right to terminate consultants
all fulfill the important hallmarks of an employer-employee relationship, with the
exception of the payment of wages. In assessing whether such a relationship in
fact exists, the control test is determining. Accordingly, on the basis of the
foregoing, we rule that for the purpose of allocating responsibility in medical
negligence cases, an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians.
The basis for holding an employer solidarily responsible for the negligence of its
employee is found in Article 2180 of the Civil Code which considers a person
accountable not only for his own acts but also for those of others based on the
former's responsibility under a relationship of patria potestas. Such responsibility
ceases when the persons or entity concerned prove that they have observed the
diligence of a good father of the family to prevent damage. In 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.
Li v. Soliman
RATIO DECIDENDI: In a malpractice action based upon the doctrine of informed
consent In a malpractice action based upon the doctrine of informed consent ,
four essential elements must be proven, four essential elements must be proven:
1)The physician had a duty to disclose material risks.
2)S/he failed to disclose or inadequately disclosed those risks.
3)As a direct and proximate result of the failure to disclose, the patientconsented
to treatment s/he otherwise would not have consented to.
4)Plaintiff was injured by the proposed treatment.
Facts:
o Spouses Soliman’s daughter, Angelica Soliman, was found to be suffering
from osteosarcoma, osteoblastic type, a high-grade (highly malignant)
cancer of the bone which usually affects teenage children.
o Following this diagnosis, Angelica’s right leg was amputated by Dr. Jaime
Tamayo in order to remove the tumor. As adjuvant treatment,
chemotherapy was suggested. Angelica was referred to Dr. Li, a medical
oncologist.
o She was discharged four days after the surgery but was instructed to
return after two or three weeks for the chemotherapy.
o On August 18, 1993, she was readmitted to St. Luke’s Medical Center
(SLMC).She died 11 days later.
o SLMC refused to release a death certificate without payment of the
hospital
o bill. Hence, the spouses brought their daughter’s cadaver to the PNP
Crime Laboratory for post-mortem examination.
o The Medico-Legal Report indicated the cause of death as “Hypovolemic
shock secondary to multiple organ hemorrhages and Disseminated
Intravascular Coagulation.”
o On the other hand, the Certificate of Death issued by SLMC indicated
that the immediate cause of death was osteosarcoma.
o The spouses filed a damage suit against Dr. Li, Dr. Marbella and Dr.
Ledesma(Dr. Li’s assistants in handling Angelica’s case), Dr. Arriete, and
SLMC.
o They were charged with negligence and disregard of Angelica’s safety,
health, and welfare by their careless administration of the chemotherapy
drugs, their failure to observe the essential precautions in detecting early
the symptoms of fatal blood platelet decrease and stopping early on the
chemotherapy, which bleeding led to hypovolemic shock that caused
Angelica’s untimely demise.
o Dr. Li assured the spouses that Angelica would recover in view of
95%chance of healing with chemotherapy and enumerated the side
effects as: (1) slight vomiting; (2) hair loss; and (3) weakness.
o Spouses claim that they would not have given their consent to
chemotherapy had Dr. Li not falsely assured them of its side effects.
o Dr. Li denied having been negligent in administering the chemotherapy
drugs to Angelica and asserted that she had fully explained to the
spouses how the chemotherapy will affect not only the cancer cells but
also the patient’s normal body parts, including the white and red blood
cells and platelets.
o What happened to Angelica can be attributed to malignant tumor cells
possibly left behind after surgery. Few as they may be, these have the
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 capacity to compete for nutrients such that the body becomes so weak
structurally (cachexia) and functionally in the form of lower resistance of
the body to combat infection.
o This infection becomes uncontrollable and triggers a chain of
events(sepsis or septicemia) that may lead to bleeding in the form of
Disseminated Intravascular Coagulation (DIC), as what the autopsy report
showed in the case of Angelica.
o Witnesses presented by spouses:
o Dr. Vergara (medico-legal): the DIC can be attributed to the chemical
agents in the drugs given to the victim, which caused platelet reduction
resulting to bleeding sufficient to cause the victim’s death. The time
lapse for the production of DIC (from the time of diagnosis of sarcoma)
was too short, considering the survival rate of about 3 years. Dr. Vergara
admitted that she is not a pathologist but her statements were based on
the opinion of an oncologist whom she had interviewed.
o Dr. Balmaceda: it is the physician’s duty to inform and explain to the
patient or his relatives every known side effect of the procedure
ortherapeutic agents to be administered, before securing the consent of
the patient or his relatives to such procedure or therapy. He stressed
that the patient or relatives must be informed of all known side effects
based on studies and observations, even if such will aggravate the
patient’s condition.
o Dr. Tamayo (who performed the amputation) testified for Dr. Li :Dr. Li
was one of the most proficient in the treatment of cancer and the
patient was afflicted with a very aggressive type of cancer necessitating
chemotherapy as adjuvant treatment
o RTC- Dr. Li is not liable for damages as she observed the best known
procedures and employed her highest skill and knowledge in the
administration of chemotherapy drugs on Angelica. Citing Picart v Smith,
declared that Li has taken the necessary precaution against the adverse
effect of chemotherapy on Angelica. A wrong decision is not by itself
negligence.
o CA- awarded damages; while there was no negligence on her part, Dr. Li
as her attending physician failed to fully explain to the spouses all the
known side effects of chemotherapy
Issue:
Whether Dr. Li can be liable for failure to fully disclose serious side effects of
chemotherapy, despite the absence of finding that Dr. Li was negligent in
administering said treatment.
Held:
No.
1) There was adequate disclosure of material risks and
2) the spouses failed to present expert testimony.
Ratio:
o The doctrine of informed consent within the context of physician-patient
relationships goes far back into English common law.
o As early as 1767, doctors were charged with “battery” (unauthorized
physical contact with a patient) if they had not gained the consent of
their patients prior to performing a surgery or procedure.
o Schoendorff v Society of New York Hospital: Every human being of adult
years and sound mind has a right to determine what shall be done with
his own body; and a surgeon who performs an operation without his
consent, commits and assault, for which he is liable in damages.
o Canterbury v Spence: (as to scope of disclosure) The disclosure rule only
requires of the physician a reasonable explanation, which means
generally informing the patient in nontechnical terms as to what is at
stake, the therapy alternatives available to him, the goals expectably to
be achieved, and the risks that may ensue from particular treatment or
no treatment.
o The patient’s right of self-decision can only be effectively exercised if
the patient possesses adequate information to enable him in makingan
intelligent choice. The test therefore for determining whether a
potential peril must be divulged is its materiality to the patient’s
decision.
o Four essential elements to prove in a malpractice action based upon the
doctrine of informed consent: (1) The physician had a duty to disclose
material risks; (2) S/he failed to disclose or inadequately disclosed those
risks; (3) As a direct and proximate result of the failure to disclose, the
patient consented to treatment s/he otherwise would not have
consented to and (4) Plaintiff was injured by the proposed treatment
o Plaintiff is required to point to significant undisclosed information
relating tothe treatment which would have altered her decision to
undergo it.
On disclosure of material risks
o There was adequate disclosure of material risks inherent in the
chemotherapy procedure performed with the consent of Angelica’s
parents.
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 o When Dr. Li informed the spouses beforehand of the side effects which
include lowered counts of WBC and RBC, decrease in blood platelets,
possible kidney or heart damage and skin darkening, there is reasonable
expectation on the part of the doctor that the respondents understood
very well that the severity of these side effects will not be the same for
all patients undergoing the procedure. By the very nature f the disease,
the physician cannot precisely determine each patient’s reaction to the
chemical agents.
o That death can possibly result from complications of the treatment or
the underlying cancer itself is a risk that cannot be ruled out, as with
most other major medical procedures, but conclusion can be reasonably
drawn from the general side effects of chemotherapy already disclosed.

On failure to present expert testimony

o In a medical malpractice action based on lack of informed consent, the
plaintiff must prove both the duty and the breach of that duty through
expert testimony. Such testimony must show the customary standard of
care of physicians in the same practice as that of the defendant doctor.
o The testimony of Dr. Balmaceda, who is not an oncologist, does not
qualify as expert testimony to establish the standard of care in obtaining
consent for chemotherapy treatment.