G.R. No.

165279               June 7, 2011

DR. RUBI LI, Petitioner,

vs.
SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of deceased Angelica Soliman, Respondents.

DECISION

VILLARAMA, JR., J.:

Challenged in this petition for review on certiorari is the Decision1 dated June 15, 2004 as well as the Resolution2 dated
September 1, 2004 of the Court of Appeals (CA) in CA-G.R. CV No. 58013 which modified the Decision3 dated September 5,
1997 of the Regional Trial Court of Legazpi City, Branch 8 in Civil Case No. 8904.

The factual antecedents:

On July 7, 1993, respondents’ 11-year old daughter, Angelica Soliman, underwent a biopsy of the mass located in her lower
extremity at the St. Luke’s Medical Center (SLMC). Results showed that Angelica was suffering from osteosarcoma,
osteoblastic 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 right leg was amputated by Dr. Jaime Tamayo in order to remove the tumor.
As adjuvant treatment to eliminate any remaining cancer cells, and hence minimize the chances of recurrence and prevent the
disease from spreading to other parts of the patient’s body (metastasis), chemotherapy was suggested by Dr. Tamayo. Dr.
Tamayo referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.

On August 18, 1993, Angelica was admitted to SLMC. However, she died on September 1, 1993, just eleven (11) days after the
(intravenous) administration of the first cycle of the chemotherapy regimen. Because SLMC refused to release a death
certificate without full payment of their hospital bill, respondents brought the cadaver of Angelica to the Philippine National
Police (PNP) Crime Laboratory at Camp 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

On the other hand, the Certificate of Death6 issued by SLMC stated the cause of death as follows:

Immediate cause : a. Osteosarcoma, Status Post AKA

Antecedent cause : b. (above knee amputation)

Underlying cause : c. Status Post Chemotherapy

On February 21, 1994, respondents filed a damage suit7 against petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a certain Dr.
Arriete and SLMC. Respondents charged them 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. Further, it was specifically averred that petitioner assured the respondents that
Angelica would recover in view of 95% chance of healing with chemotherapy ("Magiging normal na ang anak nyo basta ma-
chemo. 95% ang healing") and when asked regarding the side effects, petitioner mentioned only slight vomiting, hair loss and
weakness ("Magsusuka ng kaunti. Malulugas ang buhok. Manghihina"). Respondents thus claimed that they would not have
given their consent to chemotherapy had petitioner not falsely assured them of its side effects.

In her answer,8 petitioner denied having been negligent in administering the chemotherapy drugs to Angelica and asserted
that she had fully explained to respondents how the chemotherapy will affect not only the cancer cells but also the patient’s
normal body parts, including the lowering of white and red blood cells and platelets. She claimed that what happened to
Angelica can be attributed to malignant tumor cells possibly left behind after surgery. Few as they may be, these have the
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. Such 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.

Since the medical records of Angelica were not produced in court, the trial and appellate courts had to rely on testimonial
evidence, principally the declarations of petitioner and respondents themselves. The following chronology of events was
gathered:

On July 23, 1993, petitioner saw the respondents at the hospital after Angelica’s surgery and discussed with them Angelica’s
condition. Petitioner told respondents that Angelica should be given two to three weeks to recover from the operation before
starting chemotherapy. Respondents were apprehensive due to financial constraints as Reynaldo earns only from ₱70,000.00
to ₱150,000.00 a year from his jewelry and watch repairing business.9 Petitioner, however, assured them not to worry about
her professional fee and told them to just save up for the medicines to be used.

Petitioner claimed that she explained to respondents that even when a tumor is removed, there are still small lesions
undetectable to the naked eye, and that adjuvant chemotherapy is needed to clean out the small lesions in order to lessen the
chance of the cancer to recur. She did not give the respondents any assurance that chemotherapy will cure Angelica’s cancer.
During these consultations with respondents, she explained the following side effects of chemotherapy treatment to
respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of appetite; (4) low count of white blood cells [WBC], red blood
cells [RBC] and platelets; (5) possible sterility due to the effects on Angelica’s ovary; (6) damage to the heart and kidneys; and
(7) darkening of the skin especially when exposed to sunlight. She actually talked with respondents four times, once at the
hospital after the surgery, twice at her clinic and the fourth time when Angelica’s mother called her through long
distance.10 This was disputed by respondents who countered that petitioner gave them assurance that there is 95% chance of
healing for Angelica if she undergoes chemotherapy and that the only side effects were nausea, vomiting and hair loss.11 Those
were the only side-effects of chemotherapy treatment mentioned by petitioner.12

On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that she be readmitted after two or three weeks
for the chemotherapy.

On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy, bringing with them the results of the
laboratory tests requested by petitioner: Angelica’s chest x-ray, ultrasound of the liver, creatinine and complete liver function
tests.13 Petitioner proceeded with the chemotherapy by first administering hydration fluids to Angelica.14

The following day, August 19, petitioner began administering three chemotherapy drugs – Cisplatin,15 Doxorubicin16 and
Cosmegen17 – intravenously. Petitioner was supposedly assisted by her trainees Dr. Leo Marbella18 and Dr. Grace Arriete.19 In
his testimony, Dr. Marbella denied having any participation in administering the said chemotherapy drugs.20

On the second day of chemotherapy, August 20, respondents noticed reddish discoloration on Angelica’s face.21 They asked
petitioner about it, but she merely quipped, "Wala yan. Epekto ng gamot."22 Petitioner recalled noticing the skin rashes on the
nose and cheek area of Angelica. At that moment, she entertained the possibility that Angelica also had systemic lupus and
consulted Dr. Victoria Abesamis on the matter.23

On the third day of chemotherapy, August 21, Angelica had difficulty breathing and was thus provided with oxygen inhalation
apparatus. This time, the reddish discoloration on Angelica’s face had extended to her neck, but petitioner dismissed it again
as merely the effect of medicines.24 Petitioner testified that she did not see any discoloration on Angelica’s face, nor did she
notice any difficulty in the child’s breathing. She claimed that Angelica merely complained of nausea and was given ice
chips.251avvphi1

On August 22, 1993, at around ten o’clock in the morning, upon seeing that their child could not anymore bear the pain,
respondents pleaded with petitioner to stop the chemotherapy. Petitioner supposedly replied: "Dapat 15 Cosmegen pa iyan.
Okay, let’s observe. If pwede na, bigyan uli ng chemo." At this point, respondents asked petitioner’s permission to bring their
child home. Later in the evening, Angelica passed black stool and reddish urine.26 Petitioner countered that there was no
record of blackening of stools but only an episode of loose bowel movement (LBM). Petitioner also testified that what
Angelica complained of was carpo-pedal spasm, not convulsion or epileptic attack, as respondents call it (petitioner described
it in the vernacular as "naninigas ang kamay at paa"). She then requested for a serum calcium determination and stopped the
chemotherapy. When Angelica was given calcium gluconate, the spasm and numbness subsided.27
The following day, August 23, petitioner yielded to respondents’ request to take Angelica home. But prior to discharging
Angelica, petitioner requested for a repeat serum calcium determination and explained to respondents that the
chemotherapy will be temporarily stopped while she observes Angelica’s muscle twitching and serum calcium level. Take-
home medicines were also prescribed for Angelica, with instructions to respondents that the serum calcium test will have to
be repeated after seven days. Petitioner told respondents that she will see Angelica again after two weeks, but respondents
can see her anytime if any immediate problem arises.28

However, Angelica remained in confinement because while still in the premises of SLMC, her "convulsions" returned and she
also had LBM. Angelica was given oxygen and administration of calcium continued.29

The next day, August 24, respondents claimed that Angelica still suffered from convulsions. They also noticed that she had a
fever and had difficulty breathing.30 Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at around
4:50 that afternoon, Angelica developed difficulty in breathing and had fever. She then requested for an electrocardiogram
analysis, and infused calcium gluconate on the patient at a "stat dose." She further ordered that Angelica be given Bactrim,31 a
synthetic antibacterial combination drug,32 to combat any infection on the child’s body.33

By August 26, Angelica was bleeding through the mouth. Respondents also saw blood on her anus and urine. When Lina asked
petitioner what was happening to her daughter, petitioner replied, "Bagsak ang platelets ng anak mo." Four units of platelet
concentrates were then transfused to Angelica. Petitioner prescribed Solucortef. Considering that Angelica’s fever was high
and her white blood cell count was low, petitioner prescribed Leucomax. About four to eight bags of blood, consisting of
packed red blood cells, fresh whole blood, or platelet concentrate, were transfused to Angelica. For two days (August 27 to
28), Angelica continued bleeding, but petitioner claimed it was lesser in amount and in frequency. Petitioner also denied that
there were gadgets attached to Angelica at that time.34

On August 29, Angelica developed ulcers in her mouth, which petitioner said were blood clots that should not be removed.
Respondents claimed that Angelica passed about half a liter of blood through her anus at around seven o’clock that evening,
which petitioner likewise denied.

On August 30, Angelica continued bleeding. She was restless as endotracheal and nasogastric tubes were inserted into her
weakened body. An aspiration of the nasogastric tube inserted to Angelica also revealed a bloody content. Angelica was given
more platelet concentrate and fresh whole blood, which petitioner claimed improved her condition. Petitioner told Angelica
not to remove the endotracheal tube because this may induce further bleeding.35 She was also transferred to the intensive
care unit to avoid infection.

The next day, respondents claimed that Angelica became hysterical, vomited blood and her body turned black. Part of
Angelica’s skin was also noted to be shredding by just rubbing cotton on it. Angelica was so restless she removed those
gadgets attached to her, saying "Ayaw ko na"; there were tears in her eyes and she kept turning her head. Observing her
daughter to be at the point of death, Lina asked for a doctor but the latter could not answer her anymore.36 At this time, the
attending physician was Dr. Marbella who was shaking his head saying that Angelica’s platelets were down and respondents
should pray for their daughter. Reynaldo claimed that he was introduced to a pediatrician who took over his daughter’s case,
Dr. Abesamis who also told him to pray for his daughter. Angelica continued to have difficulty in her breathing and blood was
being suctioned from her stomach. A nurse was posted inside Angelica’s room to assist her breathing and at one point they
had to revive Angelica by pumping her chest. Thereafter, Reynaldo claimed that Angelica already experienced difficulty in
urinating and her bowel consisted of blood-like fluid. Angelica requested for an electric fan as she was in pain. Hospital staff
attempted to take blood samples from Angelica but were unsuccessful because they could not even locate her vein. Angelica
asked for a fruit but when it was given to her, she only smelled it. At this time, Reynaldo claimed he could not find either
petitioner or Dr. Marbella. That night, Angelica became hysterical and started removing those gadgets attached to her. At
three o’clock in the morning of September 1, a priest came and they prayed before Angelica expired. Petitioner finally came
back and supposedly told respondents that there was "malfunction" or bogged-down machine.37

By petitioner’s own account, Angelica was merely irritable that day (August 31). Petitioner noted though that Angelica’s skin
was indeed sloughing off.38 She stressed that at 9:30 in the evening, Angelica pulled out her endotracheal tube.39 On
September 1, exactly two weeks after being admitted at SLMC for chemotherapy, Angelica died.40 The cause of death,
according to petitioner, was septicemia, or overwhelming infection, which caused Angelica’s other organs to fail.41 Petitioner
attributed this to the patient’s poor defense mechanism brought about by the cancer itself.42
While he was seeking the release of Angelica’s cadaver from SLMC, Reynaldo claimed that petitioner acted arrogantly and
called him names. He was asked to sign a promissory note as he did not have cash to pay the hospital bill.43

Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer of the PNP-Crime Laboratory who
conducted the autopsy on Angelica’s cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical Specialist employed at the
Department of Health (DOH) Operations and Management Services.

Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the following: (1) there were fluids recovered
from the abdominal cavity, which is not normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was
hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and areas adjacent to, the esophagus; (4) lungs
were heavy with bleeding at the back and lower portion, due to accumulation of fluids; (4) yellowish discoloration of the liver;
(5) kidneys showed appearance of facial shock on account of hemorrhages; and (6) reddishness on external surface of the
spleen. All these were the end result of "hypovolemic shock secondary to multiple organ hemorrhages and disseminated
intravascular coagulation." Dr. Vergara opined that this 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 in the case of Angelica (from the time of diagnosis of sarcoma) was too short, considering the survival rate
of about 3 years. The witness conceded that the victim will also die of osteosarcoma even with amputation or chemotherapy,
but in this case Angelica’s death was not caused by osteosarcoma. Dr. Vergara admitted that she is not a pathologist but her
statements were based on the opinion of an oncologist whom she had interviewed. This oncologist supposedly said that if the
victim already had DIC prior to the chemotherapy, the hospital staff could have detected it.44

On her part, Dr. Balmaceda declared that it is the physician’s duty to inform and explain to the patient or his relatives every
known side effect of the procedure or therapeutic agents to be administered, before securing the consent of the patient or his
relatives to such procedure or therapy. The physician thus bases his assurance to the patient on his personal assessment of
the patient’s condition and his knowledge of the general effects of the agents or procedure that will be allowed on the
patient. Dr. Balmaceda stressed that the patient or relatives must be informed of all known side effects based on studies and
observations, even if such will aggravate the patient’s condition.45

Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelica’s lower extremity, testified for the defendants. He
explained that in case of malignant tumors, there is no guarantee that the ablation or removal of the amputated part will
completely cure the cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at the time of modern
chemotherapy and early diagnosis still remains at 80% to 90%. Usually, deaths occur from metastasis, or spread of the cancer
to other vital organs like the liver, causing systemic complications. The modes of therapy available are the removal of the
primary source of the cancerous growth and then the residual cancer cells or metastasis should be treated with
chemotherapy. Dr. Tamayo further explained that patients with osteosarcoma have poor defense mechanism due to the
cancer cells in the blood stream. In the case of Angelica, he had previously explained to her parents that after the surgical
procedure, chemotherapy is imperative so that metastasis of these cancer cells will hopefully be addressed. He referred the
patient to petitioner because he felt that petitioner is a competent oncologist. Considering that this type of cancer is very
aggressive and will metastasize early, it will cause the demise of the patient should there be no early intervention (in this case,
the patient developed sepsis which caused her death). Cancer cells in the blood cannot be seen by the naked eye nor detected
through bone scan. On cross-examination, Dr. Tamayo stated that of the more than 50 child patients who had osteogenic
sarcoma he had handled, he thought that probably all of them died within six months from amputation because he did not
see them anymore after follow-up; it is either they died or had seen another doctor.46

In dismissing the complaint, the trial court held that petitioner was not liable for damages as she observed the best known
procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on Angelica but
despite all efforts said patient died. It cited the testimony of Dr. Tamayo who testified that he considered petitioner one of the
most proficient in the treatment of cancer and that the patient in this case was afflicted with a very aggressive type of cancer
necessitating chemotherapy as adjuvant treatment. Using the standard of negligence laid down in Picart v. Smith,47 the trial
court declared that petitioner has taken the necessary precaution against the adverse effect of chemotherapy on the patient,
adding that a wrong decision is not by itself negligence. Respondents were ordered to pay their unpaid hospital bill in the
amount of ₱139,064.43.48

Respondents appealed to the CA which, while concurring with the trial court’s finding that there was no negligence committed
by the petitioner in the administration of chemotherapy treatment to Angelica, found that petitioner as her attending
physician failed to fully explain to the respondents all the known side effects of chemotherapy. The appellate court stressed
that since the respondents have been told of only three side effects of chemotherapy, they readily consented thereto. Had
petitioner made known to respondents those other side effects which gravely affected their child -- such as carpo-pedal
spasm, sepsis, decrease in the blood platelet count, bleeding, infections and eventual death -- respondents could have
decided differently or adopted a different course of action which could have delayed or prevented the early death of their
child.

The CA thus declared:

Plaintiffs-appellants’ child was suffering from a malignant disease. The attending physician recommended that she undergo
chemotherapy treatment after surgery in order to increase her chances of survival. Appellants consented to the
chemotherapy treatment because they believed in Dr. Rubi Li’s representation that the deceased would have a strong chance
of survival after chemotherapy and also because of the representation of appellee Dr. Rubi Li that there were only three
possible side-effects of the treatment. However, all sorts of painful side-effects resulted from the treatment including the
premature death of Angelica. The appellants were clearly and totally unaware of these other side-effects which manifested
only during the chemotherapy treatment. This was shown by the fact that every time a problem would take place regarding
Angelica’s condition (like an unexpected side-effect manifesting itself), they would immediately seek explanation from Dr.
Rubi Li. Surely, those unexpected side-effects culminating in the loss of a love[d] one caused the appellants so much trouble,
pain and suffering.

On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which would entitle plaintiffs-appellants to their
claim for damages.

xxxx

WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed decision is hereby modified to the extent that
defendant-appellee Dr. Rubi Li is ordered to pay the plaintiffs-appellants the following amounts:

1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;

2. Moral damages of P200,000.00;

3. Exemplary damages of P50,000.00;

4. Attorney’s fee of P30,000.00.

SO ORDERED.49 (Emphasis supplied.)

Petitioner filed a motion for partial reconsideration which the appellate court denied.

Hence, this petition.

Petitioner assails the CA in finding her guilty of negligence in not explaining to the respondents all the possible side effects of
the chemotherapy on their child, and in holding her liable for actual, moral and exemplary damages and attorney’s fees.
Petitioner emphasized that she was not negligent in the pre-chemotherapy procedures and in the administration of
chemotherapy treatment to Angelica.

On her supposed non-disclosure of all possible side effects of chemotherapy, including death, petitioner argues that it was
foolhardy to imagine her to be all-knowing/omnipotent. While the theoretical side effects of chemotherapy were explained by
her to the respondents, as these should be known to a competent doctor, petitioner cannot possibly predict how a particular
patient’s genetic make-up, state of mind, general health and body constitution would respond to the treatment. These are
obviously dependent on too many known, unknown and immeasurable variables, thus requiring that Angelica be, as she was,
constantly and closely monitored during the treatment. Petitioner asserts that she did everything within her professional
competence to attend to the medical needs of Angelica.
Citing numerous trainings, distinctions and achievements in her field and her current position as co-director for clinical affairs
of the Medical Oncology, Department of Medicine of SLMC, petitioner contends that in the absence of any clear showing or
proof, she cannot be charged with negligence in not informing the respondents all the side effects of chemotherapy or in the
pre-treatment procedures done on Angelica.

As to the cause of death, petitioner insists that Angelica did not die of platelet depletion but of sepsis which is a complication
of the cancer itself. Sepsis itself leads to bleeding and death. She explains that the response rate to chemotherapy of patients
with osteosarcoma is high, so much so that survival rate is favorable to the patient. Petitioner then points to some probable
consequences if Angelica had not undergone chemotherapy. Thus, without chemotherapy, other medicines and supportive
treatment, the patient might have died the next day because of massive infection, or the cancer cells might have spread to the
brain and brought the patient into a coma, or into the lungs that the patient could have been hooked to a respirator, or into
her kidneys that she would have to undergo dialysis. Indeed, respondents could have spent as much because of these
complications. The patient would have been deprived of the chance to survive the ailment, of any hope for life and her
"quality of life" surely compromised. Since she had not been shown to be at fault, petitioner maintains that the CA erred in
holding her liable for the damages suffered by the respondents.50

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 undergoing chemotherapy, despite the absence of finding that petitioner was
negligent in administering the said treatment.

The petition is meritorious.

The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of
claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused
bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a
physician, either failed to do something which a reasonably prudent health care provider would have done, or that he or she
did something that a reasonably prudent provider would not have done; and that that failure or action caused injury to the
patient.51

This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the
same general neighborhood and in the same general line of practice as defendant physician or surgeon. The deference of
courts to the expert opinion of qualified physicians stems from the former’s realization that the latter possess unusual
technical skills which laymen in most instances are incapable of intelligently evaluating, hence the indispensability of expert
testimonies.52

In this case, both the trial and appellate courts concurred in finding that the alleged negligence of petitioner in the
administration of chemotherapy drugs to respondents’ child was not proven considering that Drs. Vergara and Balmaceda, not
being oncologists or cancer specialists, were not qualified to give expert opinion as to whether petitioner’s lack of skill,
knowledge and professional competence in failing to observe the standard of care in her line of practice was the proximate
cause of the patient’s death. Furthermore, respondents’ case was not at all helped by the non-production of medical records
by the hospital (only the biopsy result and medical bills were submitted to the court). Nevertheless, the CA found petitioner
liable for her failure to inform the respondents on all possible side effects of chemotherapy before securing their consent to
the said treatment.

The doctrine of informed consent within the context of physician-patient relationships goes far back into English common law.
As early as 1767, doctors were charged with the tort of "battery" (i.e., an unauthorized physical contact with a patient) if they
had not gained the consent of their patients prior to performing a surgery or procedure. In the United States, the seminal case
was Schoendorff v. Society of New York Hospital53 which involved unwanted treatment performed by a doctor. Justice
Benjamin Cardozo’s oft-quoted opinion upheld the basic right of a patient to give consent to any medical procedure or
treatment: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body;
and a surgeon who performs an operation without his patient’s consent, commits an assault, for which he is liable in
damages."54 From a purely ethical norm, informed consent evolved into a general principle of law that a physician has a duty
to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care would disclose
to his patient as to whatever grave risks of injury might be incurred from a proposed course of treatment, so that a patient,
exercising ordinary care for his own welfare, and faced with a choice of undergoing the proposed treatment, or alternative
treatment, or none at all, may intelligently exercise his judgment by reasonably balancing the probable risks against the
probable benefits.55

Subsequently, in Canterbury v. Spence56 the court observed that the duty to disclose 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
particular therapy demands a standard set by law for physicians rather than one which physicians may or may not impose
upon themselves.57 The scope of disclosure is premised on the fact that patients ordinarily are persons unlearned in the
medical sciences. Proficiency in diagnosis and therapy is not the full measure of a physician’s responsibility. It is also his duty
to warn of the dangers lurking in the proposed treatment and to impart information which the patient has every right to
expect. Indeed, the patient’s reliance upon the physician is a trust of the kind which traditionally has exacted obligations
beyond those associated with armslength transactions.58 The physician is not expected to give the patient a short medical
education, the disclosure rule only requires of him a reasonable explanation, which means generally informing the patient in
nontechnical terms as to what is at stake; the therapy alternatives open to him, the goals expectably to be achieved, and the
risks that may ensue from particular treatment or no treatment.59 As to the issue of demonstrating what risks are considered
material necessitating disclosure, it was held that experts are unnecessary to a showing of the materiality of a risk to a
patient’s decision on treatment, or to the reasonably, expectable effect of risk disclosure on the decision. Such unrevealed risk
that should have been made known must further materialize, for otherwise the omission, however unpardonable, is without
legal consequence. And, as in malpractice actions generally, there must be a causal relationship between the physician’s
failure to divulge and damage to the patient.60

Reiterating the foregoing considerations, Cobbs v. Grant61 deemed it as integral part of physician’s overall obligation to
patient, the duty of reasonable disclosure of available choices with respect to proposed therapy and of dangers inherently and
potentially involved in each. However, the physician is not obliged to discuss relatively minor risks inherent in common
procedures when it is common knowledge that such risks inherent in procedure of very low incidence. Cited as exceptions to
the rule that the patient should not be denied the opportunity to weigh the risks of surgery or treatment are emergency cases
where it is evident he cannot evaluate data, and where the patient is a child or incompetent.62 The court thus concluded that
the patient’s right of self-decision can only be effectively exercised if the patient possesses adequate information to enable
him in making an intelligent choice. The 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. The test therefore for determining
whether a potential peril must be divulged is its materiality to the patient’s decision.63

Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that for liability of the physician for failure to
inform patient, there must be causal relationship between physician’s failure to inform and the injury to patient and such
connection arises only if it is established that, had revelation been made, consent to treatment would not have been given.

There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent:
"(1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a
direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have
consented to; and (4) plaintiff was injured by the proposed treatment." The gravamen in an informed consent case requires
the plaintiff to "point to significant undisclosed information relating to the treatment which would have altered her decision
to undergo it.64

Examining the evidence on record, we hold that there was adequate disclosure of material risks inherent in the chemotherapy
procedure performed with the consent of Angelica’s parents. Respondents could not have been unaware in the course of
initial treatment and amputation of Angelica’s lower extremity, that her immune system was already weak on account of the
malignant tumor in her knee. When petitioner informed the respondents beforehand of the side effects of chemotherapy
which includes lowered counts of white and red blood cells, 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. In other words, by the nature of
the disease itself, each patient’s reaction to the chemical agents even with pre-treatment laboratory tests cannot be precisely
determined by the physician. That death can possibly result from complications of the treatment or the underlying cancer
itself, immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled out, as with
most other major medical procedures, but such conclusion can be reasonably drawn from the general side effects of
chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered the variables in the recommended
treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to give credence to
respondents’ claim that petitioner told them of 95% chance of recovery for their daughter, as it 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, informed consent laws in other countries generally require only a reasonable explanation of potential harms, so
specific disclosures such as statistical data, may not be legally necessary.65

The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to one
simplistic formula applicable in all instances. Further, 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.66 Such expert testimony must show
the customary standard of care of physicians in the same practice as that of the defendant doctor.67

In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical Specialist of the DOH’s Operational and
Management Services charged with receiving complaints against hospitals, does not qualify as expert testimony to establish
the standard of care in obtaining consent for chemotherapy treatment. In the absence of expert testimony in this regard, the
Court feels hesitant in defining the scope of mandatory disclosure in cases of malpractice based on lack of informed consent,
much less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be an evolving one.

As society has grappled with the juxtaposition between personal autonomy and the medical profession's intrinsic impetus to
cure, the law defining "adequate" disclosure has undergone a dynamic evolution. A standard once guided solely by the
ruminations of physicians is now dependent on what a reasonable person in the patient’s position regards as significant. This
change in perspective is especially important as medical breakthroughs move practitioners to the cutting edge of technology,
ever encountering new and heretofore unimagined treatments for currently incurable diseases or ailments. An adaptable
standard is needed to account for this constant progression. Reasonableness analyses permeate our legal system for the very
reason that they are determined by social norms, expanding and contracting with the ebb and flow of societal evolution.

As we progress toward the twenty-first century, we now realize that the legal standard of disclosure is not subject to
construction as a categorical imperative. Whatever formulae or processes we adopt are only useful as a foundational starting
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 physician properly informed a patient are inevitably guided by what they perceive
as the common expectation of the medical consumer—"a reasonable person in the patient’s position when deciding to accept
or reject a recommended medical procedure."68 (Emphasis supplied.)

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.

G.R. No. 126297             January 31, 2007

PROFESSIONAL SERVICES, INC., Petitioner,

vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x-----------------------x

G.R. No. 126467            January 31, 2007

NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, JESUS
AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.

x- - - - - - - - - - - - - - - - - - - -- - - - x

G.R. No. 127590            January 31, 2007

MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.

DECISION

SANDOVAL-GUTIERREZ, J.:

Hospitals, having undertaken one of mankind’s most important and delicate endeavors, must assume the grave responsibility
of pursuing it with appropriate care. The care and service dispensed through this high trust, however technical, complex and
esoteric its character may be, must meet standards of responsibility commensurate with the undertaking to preserve and
protect the health, and indeed, the very lives of those placed in the hospital’s keeping.1

Assailed in these three consolidated petitions for review on certiorari is the Court of Appeals’ Decision2 dated September 6,
1996 in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198 affirming with modification the Decision3 dated March 17, 1993 of the
Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322 and nullifying its Order dated September 21,
1993.

The facts, as culled from the records, are:

On April 4, 1984, Natividad Agana was rushed to the Medical City General Hospital (Medical City Hospital) because of difficulty
of bowel movement and bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil, petitioner in G.R. No.
127590, diagnosed her to be suffering from "cancer of the sigmoid."

On April 11, 1984, Dr. Ampil, assisted by the medical staff4 of the Medical City Hospital, performed an anterior resection
surgery on Natividad. He found that the malignancy in her sigmoid area had spread on her left ovary, necessitating the
removal of certain portions of it. Thus, Dr. Ampil obtained the consent of Natividad’s husband, Enrique Agana, to permit Dr.
Juan Fuentes, respondent in G.R. No. 126467, to perform hysterectomy on her.

After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision.

However, the operation appeared to be flawed. In the corresponding Record of Operation dated April 11, 1984, the attending
nurses entered these remarks:

"sponge count lacking 2

"announced to surgeon searched (sic) done but to no avail continue for closure."

On April 24, 1984, Natividad was released from the hospital. Her hospital and medical bills, including the doctors’ fees,
amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal region. She consulted both Dr. Ampil and Dr.
Fuentes about it. They told her that the pain was the natural consequence of the surgery. Dr. Ampil then recommended that
she consult an oncologist to examine the cancerous nodes which were not removed during the operation.

On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment. After four
months of consultations and laboratory examinations, Natividad was told she was free of cancer. Hence, she was advised to
return to the Philippines.

On August 31, 1984, Natividad flew back to the Philippines, still suffering from pains. Two weeks thereafter, her daughter
found a piece of gauze protruding from her vagina. Upon being informed about it, Dr. Ampil proceeded to her house where he
managed to extract by hand a piece of gauze measuring 1.5 inches in width. He then assured her that the pains would soon
vanish.

Dr. Ampil’s assurance did not come true. Instead, the pains intensified, prompting Natividad to seek treatment at the
Polymedic General Hospital. While confined there, Dr. Ramon Gutierrez detected the presence of another foreign object in
her vagina -- a foul-smelling gauze measuring 1.5 inches in width which badly infected her vaginal vault. A recto-vaginal fistula
had formed in her reproductive organs which forced stool to excrete through the vagina. Another surgical operation was
needed to remedy the damage. Thus, in October 1984, Natividad underwent another surgery.

On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96, Quezon City a complaint for damages
against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil
Case No. Q-43322. They alleged that the latter are liable for negligence for leaving two pieces of gauze inside Natividad’s body
and malpractice for concealing their acts of negligence.

Meanwhile, Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross
negligence and malpractice against Dr. Ampil and Dr. Fuentes, docketed as Administrative Case No. 1690. The PRC Board of
Medicine heard the case only with respect to Dr. Fuentes because it failed to acquire jurisdiction over Dr. Ampil who was then
in the United States.

On February 16, 1986, pending the outcome of the above cases, Natividad died and was duly substituted by her above-named
children (the Aganas).

On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for
negligence and malpractice, the decretal part of which reads:

WHEREFORE, judgment is hereby rendered for the plaintiffs ordering the defendants PROFESSIONAL SERVICES, INC., DR.
MIGUEL AMPIL and DR. JUAN FUENTES to pay to the plaintiffs, jointly and severally, except in respect of the award for
exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes only, as follows:

1. As actual damages, the following amounts:

a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of P21.60-US$1.00, as reimbursement of
actual expenses incurred in the United States of America;

b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;

c. The total sum of P45,802.50, representing the cost of hospitalization at Polymedic Hospital, medical fees, and cost of the
saline solution;

2. As moral damages, the sum of P2,000,000.00;

3. As exemplary damages, the sum of P300,000.00;

4. As attorney’s fees, the sum of P250,000.00;

5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of filing of the complaint until full payment; and

6. Costs of suit.

SO ORDERED.

Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, docketed as CA-G.R. CV No. 42062.

Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial execution of its Decision, which was granted
in an Order dated May 11, 1993. Thereafter, the sheriff levied upon certain properties of Dr. Ampil and sold them for
P451,275.00 and delivered the amount to the Aganas.

Following their receipt of the money, the Aganas entered into an agreement with PSI and Dr. Fuentes to indefinitely suspend
any further execution of the RTC Decision. However, not long thereafter, the Aganas again filed a motion for an alias writ of
execution against the properties of PSI and Dr. Fuentes. On September 21, 1993, the RTC granted the motion and issued the
corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with
prayer for preliminary injunction, docketed as CA-G.R. SP No. 32198. During its pendency, the Court of Appeals issued a
Resolution5 dated October 29, 1993 granting Dr. Fuentes’ prayer for injunctive relief.

On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No. 42062.

Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its Decision6 in Administrative Case No. 1690 dismissing
the case against Dr. Fuentes. The Board held that the prosecution failed to show that Dr. Fuentes was the one who left the
two pieces of gauze inside Natividad’s body; and that he concealed such fact from Natividad.

On September 6, 1996, the Court of Appeals rendered its Decision jointly disposing of CA-G.R. CV No. 42062 and CA-G.R. SP
No. 32198, thus:

WHEREFORE, except for the modification that the case against defendant-appellant Dr. Juan Fuentes is hereby DISMISSED,
and with the pronouncement that defendant-appellant Dr. Miguel Ampil is liable to reimburse defendant-appellant
Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees, the decision appealed
from is hereby AFFIRMED and the instant appeal DISMISSED.

Concomitant with the above, the petition for certiorari and prohibition filed by herein defendant-appellant Dr. Juan Fuentes in
CA-G.R. SP No. 32198 is hereby GRANTED and the challenged order of the respondent judge dated September 21, 1993, as
well as the alias writ of execution issued pursuant thereto are hereby NULLIFIED and SET ASIDE. The bond posted by the
petitioner in connection with the writ of preliminary injunction issued by this Court on November 29, 1993 is hereby
cancelled.

Costs against defendants-appellants Dr. Miguel Ampil and Professional Services, Inc.

SO ORDERED.

Only Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution7 dated December 19, 1996.

Hence, the instant consolidated petitions.

In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in holding that: (1) it is estopped from raising the
defense that Dr. Ampil is not its employee; (2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled to its counterclaim
against the Aganas. PSI contends that Dr. Ampil is not its employee, but a mere consultant or independent contractor. As
such, he alone should answer for his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of negligence
or medical malpractice, invoking the doctrine of res ipsa loquitur. They contend that the pieces of gauze are prima facie proofs
that the operating surgeons have been negligent.

Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in finding him liable for negligence and
malpractice sans evidence that he left the two pieces of gauze in Natividad’s vagina. He pointed to other probable causes,
such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy; (2) the attending nurses’ failure to properly
count the gauzes used during surgery; and (3) the medical intervention of the American doctors who examined Natividad in
the United States of America.

For our resolution are these three vital issues: first, whether the Court of Appeals erred in holding Dr. Ampil liable for
negligence and malpractice; second, whether the Court of Appeals erred in absolving Dr. Fuentes of any liability; and third,
whether PSI may be held solidarily liable for the negligence of Dr. Ampil.

I - G.R. No. 127590

Whether the Court of Appeals Erred in Holding Dr. Ampil

Liable for Negligence and Malpractice.

Dr. Ampil, in an attempt to absolve himself, gears the Court’s attention to other possible causes of Natividad’s detriment. He
argues that the Court should not discount either of the following possibilities: first, Dr. Fuentes left the gauzes in Natividad’s
body after performing hysterectomy; second, the attending nurses erred in counting the gauzes; and third, the American
doctors were the ones who placed the gauzes in Natividad’s body.

Dr. Ampil’s arguments are purely conjectural and without basis. Records show that he did not present any evidence to prove
that the American doctors were the ones who put or left the gauzes in Natividad’s body. Neither did he submit evidence to
rebut the correctness of the record of operation, particularly the number of gauzes used. As to the alleged negligence of Dr.
Fuentes, we are mindful that Dr. Ampil examined his (Dr. Fuentes’) work and found it in order.

The glaring truth is that all the major circumstances, taken together, as specified by the Court of Appeals, directly point to Dr.
Ampil as the negligent party, thus:

First, it is not disputed that the surgeons used gauzes as sponges to control the bleeding of the patient during the surgical
operation.

Second, immediately after the operation, the nurses who assisted in the surgery noted in their report that the ‘sponge count
(was) lacking 2’; that such anomaly was ‘announced to surgeon’ and that a ‘search was done but to no avail’ prompting Dr.
Ampil to ‘continue for closure’ x x x.

Third, after the operation, two (2) gauzes were extracted from the same spot of the body of Mrs. Agana where the surgery
was performed.

An operation requiring the placing of sponges in the incision is not complete until the sponges are properly removed, and it is
settled that the leaving of sponges or other foreign substances in the wound after the incision has been closed is at least prima
facie negligence by the operating surgeon.8 To put it simply, such act is considered so inconsistent with due care as to raise an
inference of negligence. There are even legions of authorities to the effect that such act is negligence per se.9

Of course, the Court is not blind to the reality that there are times when danger to a patient’s life precludes a surgeon from
further searching missing sponges or foreign objects left in the body. But this does not leave him free from any obligation.
Even if it has been shown that a surgeon was required by the urgent necessities of the case to leave a sponge in his patient’s
abdomen, because of the dangers attendant upon delay, still, it is his legal duty to so inform his patient within a reasonable
time thereafter by advising her of what he had been compelled to do. This is in order that she might seek relief from the
effects of the foreign object left in her body as her condition might permit. The ruling in Smith v. Zeagler10 is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a physician or surgeon fails to remove a sponge he
has placed in his patient’s body that should be removed as part of the operation, he thereby leaves his operation
uncompleted and creates a new condition which imposes upon him the legal duty of calling the new condition to his patient’s
attention, and endeavoring with the means he has at hand to minimize and avoid untoward results likely to ensue therefrom.

Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze. Worse, he even misled her that the pain she
was experiencing was the ordinary consequence of her operation. Had he been more candid, Natividad could have taken the
immediate and appropriate medical remedy to remove the gauzes from her body. To our mind, what was initially an act of
negligence by Dr. Ampil has ripened into a deliberate wrongful act of deceiving his patient.

This is a clear case of medical malpractice or more appropriately, medical negligence. To successfully pursue this kind of case,
a patient must only prove that a health care provider either failed to do something which a reasonably prudent health care
provider would have done, or that he did something that a reasonably prudent provider would not have done; and that failure
or action caused injury to the patient.11 Simply put, the elements are duty, breach, injury and proximate causation. Dr, Ampil,
as the lead surgeon, had the duty to remove all foreign objects, such as gauzes, from Natividad’s body before closure of the
incision. When he failed to do so, it was his duty to inform Natividad about it. Dr. Ampil breached both duties. Such breach
caused injury to Natividad, necessitating her further examination by American doctors and another surgery. That Dr. Ampil’s
negligence is the proximate cause12 of Natividad’s injury could be traced from his act of closing the incision despite the
information given by the attending nurses that two pieces of gauze were still missing. That they were later on extracted from
Natividad’s vagina established the causal link between Dr. Ampil’s negligence and the injury. And what further aggravated
such injury was his deliberate concealment of the missing gauzes from the knowledge of Natividad and her family.

II - G.R. No. 126467

Whether the Court of Appeals Erred in Absolving

Dr. Fuentes of any Liability

The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes on the ground that it is contrary to the
doctrine of res ipsa loquitur. According to them, the fact that the two pieces of gauze were left inside Natividad’s body is a
prima facie evidence of Dr. Fuentes’ negligence.

We are not convinced.

Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the fact of the occurrence of an injury, taken
with the surrounding circumstances, may permit an inference or raise a presumption of negligence, or make out a plaintiff’s
prima facie case, and present a question of fact for defendant to meet with an explanation.13 Stated differently, where the
thing which caused the injury, without the fault of the injured, is under the exclusive control of the defendant and the injury is
such that it should not have occurred if he, having such control used proper care, it affords reasonable evidence, in the
absence of explanation that the injury arose from the defendant’s want of care, and the burden of proof is shifted to him to
establish that he has observed due care and diligence.14

From the foregoing statements of the rule, the requisites for the applicability of the doctrine of res ipsa loquitur are: (1) the
occurrence of an injury; (2) the thing which caused the injury was under the control and management of the defendant; (3)
the occurrence was such that in the ordinary course of things, would not have happened if those who had control or
management used proper care; and (4) the absence of explanation by the defendant. Of the foregoing requisites, the most
instrumental is the "control and management of the thing which caused the injury."15

We find the element of "control and management of the thing which caused the injury" to be wanting. Hence, the doctrine of
res ipsa loquitur will not lie.

It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of
Dr. Fuentes only to perform hysterectomy when he (Dr. Ampil) found that the malignancy in her sigmoid area had spread to
her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. The latter
examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed
operating on Natividad. He was about to finish the procedure when the attending nurses informed him that two pieces of
gauze were missing. A "diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed
that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the
hospital.

Under the "Captain of the Ship" rule, the operating surgeon is the person in complete charge of the surgery room and all
personnel connected with the operation. Their duty is to obey his orders.16 As stated before, Dr. Ampil was the lead surgeon.
In other words, he was the "Captain of the Ship." That he discharged such role is evident from his following conduct: (1) calling
Dr. Fuentes to perform a hysterectomy; (2) examining the work of Dr. Fuentes and finding it in order; (3) granting Dr. Fuentes’
permission to leave; and (4) ordering the closure of the incision. To our mind, it was this act of ordering the closure of the
incision notwithstanding that two pieces of gauze remained unaccounted for, that caused injury to Natividad’s body. Clearly,
the control and management of the thing which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.

In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does not per se create or constitute an
independent or separate ground of liability, being a mere evidentiary rule.17 In other words, mere invocation and application
of the doctrine does not dispense with the requirement of proof of negligence. Here, the negligence was proven to have been
committed by Dr. Ampil and not by Dr. Fuentes.

III - G.R. No. 126297

Whether PSI Is Liable for the Negligence of Dr. Ampil

The third issue necessitates a glimpse at the historical development of hospitals and the resulting theories concerning their
liability for the negligence of physicians.

Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical services to the lowest
classes of society, without regard for a patient’s ability to pay.18 Those who could afford medical treatment were usually
treated at home by their doctors.19 However, the days of house calls and philanthropic health care are over. The modern
health care industry continues to distance itself from its charitable past and has experienced a significant conversion from a
not-for-profit health care to for-profit hospital businesses. Consequently, significant changes in health law have accompanied
the business-related changes in the hospital industry. One important legal change is an increase in hospital liability for medical
malpractice. Many courts now allow claims for hospital vicarious liability under the theories of respondeat superior, apparent
authority, ostensible authority, or agency by estoppel. 20

In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code, which reads:

Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay for the
damage done. Such fault or negligence, if there is no pre-existing contractual relation between the parties, is called a quasi-
delict and is governed by the provisions of this Chapter.

A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of respondeat superior,
thus:

ART. 2180. The obligation imposed by Article 2176 is demandable not only for one’s own acts or omissions, but also for those
of persons for whom one is responsible.

x x x x x x

The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their employees
in the service of the branches in which the latter are employed or on the occasion of their functions.

Employers shall be liable for the damages caused by their employees and household helpers acting within the scope of their
assigned tasks even though the former are not engaged in any business or industry.
 x x x x x x

The responsibility treated of in this article shall cease when the persons herein mentioned prove that they observed all the
diligence of a good father of a family to prevent damage.

A prominent civilist commented that professionals engaged by an employer, such as physicians, dentists, and pharmacists, are
not "employees" under this article because the manner in which they perform their work is not within the control of the latter
(employer). In other words, professionals are considered personally liable for the fault or negligence they commit in the
discharge of their duties, and their employer cannot be held liable for such fault or negligence. In the context of the present
case, "a hospital cannot be held liable for the fault or negligence of a physician or surgeon in the treatment or operation of
patients."21

The foregoing view is grounded on the traditional notion that the professional status and the very nature of the physician’s
calling preclude him from being classed as an agent or employee of a hospital, whenever he acts in a professional capacity.22 It
has been said that medical practice strictly involves highly developed and specialized knowledge,23 such that physicians are
generally free to exercise their own skill and judgment in rendering medical services sans interference.24 Hence, when a doctor
practices medicine in a hospital setting, the hospital and its employees are deemed to subserve him in his ministrations to the
patient and his actions are of his own responsibility.25

The case of Schloendorff v. Society of New York Hospital26 was then considered an authority for this view. The "Schloendorff
doctrine" regards a physician, even if employed by a hospital, as an independent contractor because of the skill he exercises
and the lack of control exerted over his work. Under this doctrine, hospitals are exempt from the application of the
respondeat superior principle for fault or negligence committed by physicians in the discharge of their profession.

However, the efficacy of the foregoing doctrine has weakened with the significant developments in medical care. Courts came
to realize that modern hospitals are increasingly taking active role in supplying and regulating medical care to patients. No
longer were a hospital’s functions limited to furnishing room, food, facilities for treatment and operation, and attendants for
its patients. Thus, in Bing v. Thunig,27 the New York Court of Appeals deviated from the Schloendorff doctrine, noting that
modern hospitals actually do far more than provide facilities for treatment. Rather, they regularly employ, on a salaried basis,
a large staff of physicians, interns, nurses, administrative and manual workers. They charge patients for medical care and
treatment, even collecting for such services through legal action, if necessary. The court then concluded that there is no
reason to exempt hospitals from the universal rule of respondeat superior.

In our shores, the nature of the relationship between the hospital and the physicians is rendered inconsequential in view of
our categorical pronouncement in Ramos v. Court of Appeals28 that for purposes of apportioning responsibility in medical
negligence cases, an employer-employee relationship in effect exists between hospitals and their attending and visiting
physicians. This Court held:

"We now discuss the responsibility of the hospital in this particular incident. The unique practice (among private hospitals) of
filling up specialist staff with attending and visiting "consultants," who are allegedly not hospital employees, presents
problems in apportioning responsibility for negligence in medical malpractice cases. However, the difficulty is more apparent
than real.

In the first place, hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work
within the hospital premises. Doctors who apply for ‘consultant’ slots, visiting or attending, are required to submit proof of
completion of residency, their educational qualifications, generally, evidence of accreditation by the appropriate board
(diplomate), evidence of fellowship in most cases, and references. These requirements are carefully scrutinized by members
of the hospital administration or by a review committee set up by the hospital who either accept or reject the application. x x
x.

After a physician is accepted, either as a visiting or attending consultant, he is normally required to attend clinico-pathological
conferences, conduct bedside rounds for clerks, interns and residents, moderate grand rounds and patient audits and perform
other tasks and responsibilities, for the privilege of being able to maintain a clinic in the hospital, and/or for the privilege of
admitting patients into the hospital. In addition to these, the physician’s performance as a specialist is generally evaluated by
a peer review committee on the basis of mortality and morbidity statistics, and feedback from patients, nurses, interns and
residents. A consultant remiss in his duties, or a consultant who regularly falls short of the minimum standards acceptable to
the hospital or its peer review committee, is normally politely terminated.

In other words, private hospitals, hire, fire and exercise real control over their attending and visiting ‘consultant’ staff. While
‘consultants’ are not, technically employees, x x x, 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. "

But the Ramos pronouncement is not our only basis in sustaining PSI’s liability. Its liability is also anchored upon the agency
principle of apparent authority or agency by estoppel and the doctrine of corporate negligence which have gained acceptance
in the determination of a hospital’s liability for negligent acts of health professionals. The present case serves as a perfect
platform to test the applicability of these doctrines, thus, enriching our jurisprudence.

Apparent authority, or what is sometimes referred to as the "holding out" theory, or doctrine of ostensible agency or agency
by estoppel,29 has its origin from the law of agency. It imposes liability, not as the result of the reality of a contractual
relationship, but rather because of the actions of a principal or an employer in somehow misleading the public into believing
that the relationship or the authority exists.30 The concept is essentially one of estoppel and has been explained in this
manner:

"The principal is bound by the acts of his agent with the apparent authority which he knowingly permits the agent to assume,
or which he holds the agent out to the public as possessing. The question in every case is whether the principal has by his
voluntary act placed the agent in such a situation that a person of ordinary prudence, conversant with business usages and
the nature of the particular business, is justified in presuming that such agent has authority to perform the particular act in
question.31

The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v. Doctor Hospital of
Lake Worth, Inc.32 There, it was explicitly stated that "there does not appear to be any rational basis for excluding the concept
of apparent authority from the field of hospital liability." Thus, in cases where it can be shown that a hospital, by its actions,
has held out a particular physician as its agent and/or employee and that a patient has accepted treatment from that
physician in the reasonable belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the
physician’s negligence.

Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code reads:

ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack of action, or his failure to
repudiate the agency, knowing that another person is acting on his behalf without authority.

In this case, PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians
associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. We concur with the Court of Appeals’ conclusion
that it "is now estopped from passing all the blame to the physicians whose names it proudly paraded in the public directory
leading the public to believe that it vouched for their skill and competence." Indeed, PSI’s act is tantamount to holding out to
the public that Medical City Hospital, through its accredited physicians, offers quality health care services. By accrediting Dr.
Ampil and Dr. Fuentes and publicly advertising their qualifications, the hospital created the impression that they were its
agents, authorized to perform medical or surgical services for its patients. As expected, these patients, Natividad being one of
them, accepted the services on the reasonable belief that such were being rendered by the hospital or its employees, agents,
or servants. The trial court correctly pointed out:

x x x regardless of the education and status in life of the patient, he ought not be burdened with the defense of absence of
employer-employee relationship between the hospital and the independent physician whose name and competence are
certainly certified to the general public by the hospital’s act of listing him and his specialty in its lobby directory, as in the case
herein. The high costs of today’s medical and health care should at least exact on the hospital greater, if not broader, legal
responsibility for the conduct of treatment and surgery within its facility by its accredited physician or surgeon, regardless of
whether he is independent or employed."33
The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of acting only through
other individuals, such as physicians. If these accredited physicians do their job well, the hospital succeeds in its mission of
offering quality medical services and thus profits financially. Logically, where negligence mars the quality of its services, the
hospital should not be allowed to escape liability for the acts of its ostensible agents.

We now proceed to the doctrine of corporate negligence or corporate responsibility.

One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI as owner, operator and
manager of Medical City Hospital, "did not perform the necessary supervision nor exercise diligent efforts in the supervision of
Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns who assisted Drs. Ampil and Fuentes in the
performance of their duties as surgeons."34 Premised on the doctrine of corporate negligence, the trial court held that PSI is
directly liable for such breach of duty.

We agree with the trial court.

Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating hospital’s
liability for the negligent acts of health practitioners, absent facts to support the application of respondeat superior or
apparent authority. Its formulation proceeds from the judiciary’s acknowledgment that in these modern times, the duty of
providing quality medical service is no longer the sole prerogative and responsibility of the physician. The modern hospitals
have changed structure. Hospitals now tend to organize a highly professional medical staff whose competence and
performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide quality
medical care.35

The doctrine has its genesis in Darling v. Charleston Community Hospital.36 There, the Supreme Court of Illinois held that "the
jury could have found a hospital negligent, inter alia, in failing to have a sufficient number of trained nurses attending the
patient; failing to require a consultation with or examination by members of the hospital staff; and failing to review the
treatment rendered to the patient." On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence
extends to permitting a physician known to be incompetent to practice at the hospital.37 With the passage of time, more
duties were expected from hospitals, among them: (1) the use of reasonable care in the maintenance of safe and adequate
facilities and equipment; (2) the selection and retention of competent physicians; (3) the overseeing or supervision of all
persons who practice medicine within its walls; and (4) the formulation, adoption and enforcement of adequate rules and
policies that ensure quality care for its patients.38 Thus, in Tucson Medical Center, Inc. v. Misevich,39 it was held that a hospital,
following the doctrine of corporate responsibility, has the duty to see that it meets the standards of responsibilities for the
care of patients. Such duty includes the proper supervision of the members of its medical staff. And in Bost v. Riley,40 the court
concluded that a patient who enters a hospital does so with the reasonable expectation that it will attempt to cure him. The
hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment prescribed and
administered by the physicians practicing in its premises.

In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose and under the concept
of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise reasonable care to protect
from harm all patients admitted into its facility for medical treatment. Unfortunately, PSI failed to perform such duty. The
findings of the trial court are convincing, thus:

x x x PSI’s liability is traceable to its failure to conduct an investigation of the matter reported in the nota bene of the count
nurse. Such failure established PSI’s part in the dark conspiracy of silence and concealment about the gauzes. Ethical
considerations, if not also legal, dictated the holding of an immediate inquiry into the events, if not for the benefit of the
patient to whom the duty is primarily owed, then in the interest of arriving at the truth. The Court cannot accept that the
medical and the healing professions, through their members like defendant surgeons, and their institutions like PSI’s hospital
facility, can callously turn their backs on and disregard even a mere probability of mistake or negligence by refusing or failing
to investigate a report of such seriousness as the one in Natividad’s case.

It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the Medical City Hospital’s
staff, composed of resident doctors, nurses, and interns. As such, it is reasonable to conclude that PSI, as the operator of the
hospital, has actual or constructive knowledge of the procedures carried out, particularly the report of the attending nurses
that the two pieces of gauze were missing. In Fridena v. Evans,41 it was held that a corporation is bound by the knowledge
acquired by or notice given to its agents or officers within the scope of their authority and in reference to a matter to which
their authority extends. This means that the knowledge of any of the staff of Medical City Hospital constitutes knowledge of
PSI. Now, the failure of PSI, despite the attending nurses’ report, to investigate and inform Natividad regarding the missing
gauzes amounts to callous negligence. Not only did PSI breach its duties to oversee or supervise all persons who practice
medicine within its walls, it also failed to take an active step in fixing the negligence committed. This renders PSI, not only
vicariously liable for the negligence of Dr. Ampil under Article 2180 of the Civil Code, but also directly liable for its own
negligence under Article 2176. In Fridena, the Supreme Court of Arizona held:

x x x In recent years, however, the duty of care owed to the patient by the hospital has expanded. The emerging trend is to
hold the hospital responsible where the hospital has failed to monitor and review medical services being provided within its
walls. See Kahn Hospital Malpractice Prevention, 27 De Paul . Rev. 23 (1977).

Among the cases indicative of the ‘emerging trend’ is Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972). In Purcell,
the hospital argued that it could not be held liable for the malpractice of a medical practitioner because he was an
independent contractor within the hospital. The Court of Appeals pointed out that the hospital had created a professional
staff whose competence and performance was to be monitored and reviewed by the governing body of the hospital, and the
court held that a hospital would be negligent where it had knowledge or reason to believe that a doctor using the facilities
was employing a method of treatment or care which fell below the recognized standard of care.

Subsequent to the Purcell decision, the Arizona Court of Appeals held that a hospital has certain inherent responsibilities
regarding the quality of medical care furnished to patients within its walls and it must meet the standards of responsibility
commensurate with this undertaking. Beeck v. Tucson General Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court
has confirmed the rulings of the Court of Appeals that a hospital has the duty of supervising the competence of the doctors on
its staff. x x x.

x x x x x x

In the amended complaint, the plaintiffs did plead that the operation was performed at the hospital with its knowledge, aid,
and assistance, and that the negligence of the defendants was the proximate cause of the patient’s injuries. We find that such
general allegations of negligence, along with the evidence produced at the trial of this case, are sufficient to support the
hospital’s liability based on the theory of negligent supervision."

Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for damages, let it be emphasized that PSI, apart
from a general denial of its responsibility, failed to adduce evidence showing that it exercised the diligence of a good father of
a family in the accreditation and supervision of the latter. In neglecting to offer such proof, PSI failed to discharge its burden
under the last paragraph of Article 2180 cited earlier, and, therefore, must be adjudged solidarily liable with Dr. Ampil.
Moreover, as we have discussed, PSI is also directly liable to the Aganas.

One final word. Once a physician undertakes the treatment and care of a patient, the law imposes on him certain obligations.
In order to escape liability, he must possess that reasonable degree of learning, skill and experience required by his
profession. At the same time, he must apply reasonable care and diligence in the exercise of his skill and the application of his
knowledge, and exert his best judgment.

WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of the Court of Appeals in CA-G.R. CV No. 42062
and CA-G.R. SP No. 32198.

Costs against petitioners PSI and Dr. Miguel Ampil. SO ORDERED.

G.R. No. 122445 November 18, 1997

DR. NINEVETCH CRUZ, petitioner,

vs.
COURT OF APPEALS and LYDIA UMALI, respondents.

FRANCISCO, J.:
Doctors are protected by a special rule of law. They are not guarantors of care. They do not even warrant a good result. They are not
insurers against mishaps or unusual consequences. Furthermore they are not liable for honest mistakes of judgment . . . 1

The present case against petitioner is in the nature of a medical malpractice suit, which in simplest terms is the type of claim which a
victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. 2 In this
jurisdiction, however, such claims are most often brought as a civil action for damages under Article 2176 of the Civil Code, 3 and in
some instances, as a criminal case under Article 365 of the Revised Penal Code 4 with which the civil action for damages is impliedly
instituted. It is via the latter type of action that the heirs of the deceased sought redress for the petitioner's alleged imprudence and
negligence in treating the deceased thereby causing her death. The petitioner and one Dr. Lina Ercillo who was the attending
anaesthesiologist during the operation of the deceased were charged with "reckless imprudence and negligence resulting to (sic)
homicide" in an information which reads:

That on or about March 23, 1991, in the City of San Pablo, Republic of the Philippines and within the jurisdiction of this Honorable
Court, the accused above named, being then the attending anaesthesiologist and surgeon, respectively, did then and there, in a
negligence (sic), careless, imprudent, and incompetent manner, and failing to supply or store sufficient provisions and facilities
necessary to meet any and all exigencies apt to arise before, during and/or after a surgical operation causing by such negligence,
carelessness, imprudence, and incompetence, and causing by such failure, including the lack of preparation and foresight needed to
avert a tragedy, the untimely death of said Lydia Umali on the day following said surgical operation. 5

Trial ensued after both the petitioner and Dr. Lina Ercillo pleaded not guilty to the above-mentioned charge. On March 4, 1994, the
Municipal Trial Court in Cities (MTCC) of San Pablo City rendered a decision, the dispositive portion of which is hereunder quoted as
follows:

WHEREFORE, the court finds the accused Dra. Lina Ercillo not guilty of the offense charged for insufficiency of evidence while her co-
accused Dra. Ninevetch Cruz is hereby held responsible for the death of Lydia Umali on March 24, 1991, and therefore guilty under
Art. 365 of the Revised Penal Code, and she is hereby sentenced to suffer the penalty of 2 months and 1 day imprisonment of
arresto mayor with costs. 6

The petitioner appealed her conviction to the Regional Trial Court (RTC) which affirmed in toto the decision of the MTCC 7 prompting
the petitioner to file a petition for review with the Court of Appeals but to no avail. Hence this petition for review
on certiorari assailing the decision promulgated by the Court of Appeals on October 24, 1995 affirming petitioner's conviction with
modification that she is further directed to pay the heirs of Lydia Umali P50,000.00 as indemnity for her death.8

In substance, the petition brought before this Court raises the issue of whether or not 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.

First the antecedent facts.

On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her mother to the Perpetual Help Clinic and
General Hospital situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said hospital at around 4:30 in the afternoon
of the same day. 9 Prior to
March 22, 1991, Lydia was examined by the petitioner who found a "myoma" 10 in her uterus, and scheduled her for a hysterectomy
operation on March 23,
1991. 11 Rowena and her mother slept in the clinic on the evening of March 22, 1991 as the latter was to be operated on the next day
at 1:00 o'clock in the afternoon. 12 According to Rowena, she noticed that the clinic was untidy and the window and the floor were
very dusty prompting her to ask the attendant for a rag to wipe the window and the floor with. 13 Because of the untidy state of the
clinic, Rowena tried to persuade her mother not to proceed with the operation. 14 The following day, before her mother was
wheeled into the operating room, Rowena asked the petitioner if the operation could be postponed. The petitioner called Lydia into
her office and the two had a conversation. Lydia then informed Rowena that the petitioner told her that she must be operated on as
scheduled. 15

Rowena and her other relatives, namely her husband, her sister and two aunts waited outside the operating room while Lydia
underwent operation. While they were waiting, Dr. Ercillo went out of the operating room and instructed them to buy tagamet
ampules which Rowena's sister immediately bought. About one hour had passed when Dr. Ercillo came out again this time to ask
them to buy blood for Lydia. They bought type "A" blood from the St. Gerald Blood Bank and the same was brought by the attendant
into the operating room. After the lapse of a few hours, the petitioner informed them that the operation was finished. The operating
staff then went inside the petitioner's clinic to take their snacks. Some thirty minutes after, Lydia was brought out of the operating
room in a stretcher and the petitioner asked Rowena and the other relatives to buy additional blood for Lydia. Unfortunately, they
were not able to comply with petitioner's order as there was no more type "A" blood available in the blood bank. Thereafter, a
person arrived to donate blood which was later transfused to Lydia. Rowena then noticed her mother, who was attached to an
oxygen tank, gasping for breath. Apparently the oxygen supply had run out and Rowena's husband together with the driver of the
accused had to go to the San Pablo District Hospital to get oxygen. Lydia was given the fresh supply of oxygen as soon as it
arrived. 16 But at around 10:00 o'clock P.M. she went into shock and her blood pressure dropped to 60/50. Lydia's unstable condition
necessitated her transfer to the San Pablo District Hospital so she could be connected to a respirator and further examined. 17 The
transfer to the San Pablo District Hospital was without the prior consent of Rowena nor of the other relatives present who found out
about the intended transfer only when an ambulance arrived to take Lydia to the San Pablo District Hospital. Rowena and her other
relatives then boarded a tricycle and followed the ambulance. 18

Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating room and the petitioner and Dr. Ercillo re-
operated on her because there was blood oozing from the abdominal incision. 19 The attending physicians summoned Dr. Bartolome
Angeles, head of the Obstetrics and Gynecology Department of the San Pablo District Hospital. However, when Dr. Angeles arrived,
Lydia was already in shock and possibly dead as her blood pressure was already 0/0. Dr. Angeles then informed petitioner and Dr.
Ercillo that there was nothing he could do to help save the patient. 20 While the petitioner was closing the abdominal wall, the
patient died. 21 Thus, on March 24, 1991, at 3:00 o'clock in the morning, Lydia Umali was pronounced dead. Her death certificate
states "shock" as the immediate cause of death and "Disseminated Intravascular Coagulation (DIC)" as the antecedent cause. 22

In convicting the petitioner, the MTCC found the following circumstances as sufficient basis to conclude that she was indeed
negligent in the performance of the operation:

. . . , the clinic was untidy, there was lack of provision like blood and oxygen to prepare for any contingency that might happen
during the operation. The manner and the fact that the patient was brought to the San Pablo District Hospital for reoperation
indicates that there was something wrong in the manner in which Dra. Cruz conducted the operation. There was no showing that
before the operation, accused Dra. Cruz had conducted a cardio pulmonary clearance or any typing of the blood of the patient. It
was (sic) said in medical parlance that the "the abdomen of the person is a temple of surprises" because you do not know the whole
thing the moment it was open (sic) and surgeon must be prepared for any eventuality thereof. The patient (sic) chart which is a
public document was not presented because it is only there that we could determine the condition of the patient before the surgery.
The court also noticed in Exh. "F-1" that the sister of the deceased wished to postpone the operation but the patient was prevailed
upon by Dra. Cruz to proceed with the surgery. The court finds that Lydia Umali died because of the negligence and carelessness of
the surgeon Dra. Ninevetch Cruz because of loss of blood during the operation of the deceased for evident unpreparedness and for
lack of skill, the reason why the patient was brought for operation at the San Pablo City District Hospital. As such, the surgeon should
answer for such negligence. With respect to Dra. Lina Ercillo, the anaesthesiologist, there is no evidence to indicate that she should
be held jointly liable with Dra. Cruz who actually did the operation. 23

The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's declaration of "incompetency, negligence and
lack of foresight and skill of appellant (herein petitioner) in handling the subject patient before and after the operation." 24 And
likewise affirming the petitioner's conviction, the Court of Appeals echoed similar observations, thus:

. . . While we may grant that the untidiness and filthiness of the clinic may not by itself indicate negligence, it nevertheless shows the
absence of due care and supervision over her subordinate employees. Did this unsanitary condition permeate the operating room?
Were the surgical instruments properly sterilized? Could the conditions in the OR have contributed to the infection of the patient?
Only the petitioner could answer these, but she opted not to testify. This could only give rise to the presumption that she has
nothing good to testify on her defense. Anyway, the alleged "unverified statement of the prosecution witness" remains
unchallenged and unrebutted.

Likewise undisputed is the prosecution's version indicating the following facts: that the accused asked the patient's relatives to buy
Tagamet capsules while the operation was already in progress; that after an hour, they were also asked to buy type "A" blood for the
patient; that after the surgery, they were again asked to procure more type "A" blood, but such was not anymore available from the
source; that the oxygen given to the patient was empty; and that the son-in-law of the patient, together with a driver of the
petitioner, had to rush to the San Pablo City District Hospital to get the much-needed oxygen. All these conclusively show that the
petitioner had not prepared for any unforeseen circumstances before going into the first surgery, which was not emergency in
nature, but was elective or pre-scheduled; she had no ready antibiotics, no prepared blood, properly typed and cross-matched, and
no sufficient oxygen supply.
Moreover, there are a lot of questions that keep nagging Us. Was the patient given any cardio-pulmonary clearance, or at least a
clearance by an internist, which are standard requirements before a patient is subjected to surgery. Did the petitioner determine as
part of the pre-operative evaluation, the bleeding parameters of the patient, such as bleeding time and clotting time? There is no
showing that these were done. The petitioner just appears to have been in a hurry to perform the operation, even as the family
wanted a postponement to April 6, 1991. Obviously, she did not prepare the patient; neither did she get the family's consent to the
operation. Moreover, she did not prepare a medical chart with instructions for the patient's care. If she did all these, proof thereof
should have been offered. But there is none. Indeed, these are overwhelming evidence of recklessness and imprudence. 25

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

Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his patient is to be determined
according to the standard of care observed by other members of the profession in good standing under similar circumstances
bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science. 26 In the
recent case of Leonila Garcia-Rueda v.  Wilfred L. Pascasio, et al., 27 this Court stated that in accepting a case, a doctor in effect
represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will
employ such training, care and skill in the treatment of his patients. He therefore has a duty to use at least the same level of care
that any other reasonably competent doctor would use to treat a condition under the same circumstances. It is in this aspect of
medical malpractice that expert testimony is essential to establish not only the standard of care of the profession but also that the
physician's conduct in the treatment and care falls below such standard. 28 Further, inasmuch as the causes of the injuries involved in
malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually
necessary to support the conclusion as to causation. 29

Immediately apparent from a review of the records of this case is the absence of any expert testimony on the matter of the standard
of care employed by other physicians of good standing in the conduct of similar operations. The prosecution's expert witnesses in
the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified as to the
possible cause of death but did not venture to illuminate the court on the matter of the standard of care that petitioner should have
exercised.

All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood,
oxygen, and certain medicines; the failure to subject the patient to a cardio-pulmonary test prior to the operation; the omission of
any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the
reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed out by the courts below
seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through
the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For
whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality
of cases, a matter of expert opinion. 30 The deference of courts to the expert opinion of qualified physicians stems from its realization
that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. 31 Expert
testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling
below the standard of care employed by other physicians in good standing when performing the same operation. It must be
remembered that when the qualifications of a physician are admitted, as in the instant case, there is an inevitable presumption that
in proper cases he takes the necessary precaution and employs the best of his knowledge and skill in attending to his clients, unless
the contrary is sufficiently established. 32 This presumption is rebuttable by expert opinion which is so sadly lacking in the case at
bench.

Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of provisions; the failure to conduct
pre-operation tests on the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on
her by the petitioner do indicate, even without expert testimony, that petitioner was recklessly imprudent in the exercise of her
duties as a surgeon, no cogent proof exists that any of these circumstances caused petitioner's death. Thus, the absence of the
fourth element of reckless imprudence: that the injury to the person or property was a consequence of the reckless imprudence.

In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's negligence and for a reasonable
conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a causal connection of such
breach and the resulting death of his patient.  33 In Chan Lugay v.  St.  Luke's Hospital, Inc., 34 where the attending physician was
absolved of liability for the death of the complainant's wife and newborn baby, this Court held that:

In order that there may be a recovery for an injury, however, it must be shown that the "injury for which recovery is sought must be
the legitimate consequence of the wrong done; the connection between the negligence and the injury must be a direct and natural
sequence of events, unbroken by intervening efficient causes." In other words, the negligence must be the proximate cause of the
injury.  For, "negligence, no matter in what it consists, cannot create a right of action unless it is the proximate cause of the injury
complained of ." And "the proximate cause of an injury is that cause, which, in natural and continuous sequence, unbroken by any
efficient intervening cause, produces the injury, and without which the result would not have occurred." 35 (Emphasis supplied.)

Dr. Arizala who conducted an autopsy on the body of the deceased summarized his findings as follows:
Atty. Cachero:
Q. You mentioned about your Autopsy Report which has been marked as Exh. "A-1-b". There appears here a signature above the typewritten name
Floresto Arizala, Jr., whose signature is that?
A. That is my signature, sir.
Q. Do you affirm the truth of all the contents of Exh. "A-1-b"?
A. Only as to the autopsy report no. 91-09, the time and place and everything after the post mortem findings, sir.
Q. You mentioned on your "Post Mortem Findings" about surgical incision, 14:0 cm., infraumbilical area, anterior abdominal area, midline, will you
please explain that in your own language?
A. There was incision wound (sic) the area just below the navel, sir.
Q. And the last paragraph of the postmortem findings which I read: Uterus, pear-shaped and pale measuring 7.5 x 5.5 x 5.0 cm. with some surface
nodulation of the fundic area posteriorly. Cut-section shows diffusely pale myometrium with areas of streak induration. The ovaries and adnexal
structures are missing with the raw surfaces patched with clotted blood. Surgical sutures were noted on the operative site.
Intestines and mesenteries are pale with blood clots noted between the mesentric folds.
Hemoperitoneum: 300 s.s.,
right paracolic gutter,
50 c.c., left paracolic gutter
200 c.c., mesentric area,
100 c.c., right pelvic gutter
stomach empty.
Other visceral organs, pale.,
will you please explain that on (sic) your own language or in ordinary. . . . . . . . . . . .
A. There was a uterus which was not attached to the adnexal structures namely ovaries which were not present and also sign of previous surgical
operation and there were (sic) clotted blood, sir.
Q. How about the ovaries and adnexal structures?
A. They are missing, sir.
Q. You mean to say there are no ovaries?
A. During that time there are no ovaries, sir.
Q. And there were likewise sign of surgical sutures?
A. Yes, sir.
Q. How about the intestines and mesenteries are place (sic) with blood clots noted between the mesenteric folds, will you please explain on (sic)
this?
A. In the peritoneal cavity, they are mostly perritonial blood . . . . . . . .
Q. And what could have caused this blood?
A. Well, ordinarily blood is found inside the blood vessel. Blood were (sic) outside as a result of the injuries which destroyed the integrity of the
vessel allowing blood to sip (sic) out, sir.
Q. By the nature of the postmortem findings indicated in Exh.  A-1-B, can you tell the court the cause of death?
A. Yes, sir. The cause of death is: Gross findings are compatible with hemorrhagic shock.
Q. Can you tell the us what could have caused this hemorrhagic shock?
A. Well hemorrhagic shock is the result of blood loss.
Q. What could have the effect of that loss of blood?
A. Unattended hemorrhage, sir. 36 (Emphasis supplied.)
The foregoing was corroborated by Dr. Nieto Salvador:
Q. And were you able to determine the cause of death by virtue of the examination of the specimen submitted by Dr. Arizala?
A. Without knowledge of the autopsy findings it would be difficult for me to determine the cause of death, sir.
Q. Have you also examined the post mortem of Dr. Arizala?
A. Yes, sir, and by virtue of the autopsy report in connection with your pathology report.
Q. What could have caused the death of the victim?
A. This pathologic examination are (sic) compatible with the person who died, sir.
Q. Will you explain to us the meaning of hemorrhagic compatible?
A. It means that a person died of blood loss. Meaning a person died of non-replacement of blood and so the victim before she died there was shock
of diminish of blood of the circulation.  She died most probably before the actual complete blood loss, sir.
Court: Is it possible doctor that the loss of the blood was due on (sic) operation?
A. Based on my pathologist finding, sir.
Q. What could have caused this loss of blood?
A. Many, sir. A patient who have undergone surgery.  Another may be a blood vessel may be cut while on operation and this cause (sic) bleeding, or
may be set in the course of operation, or may be (sic) he died after the operation.  Of course there are other cause (sic).
Atty. Cachero:
Q. Especially so doctor when there was no blood replacement?
A. Yes, sir. 37 (Emphasis supplied.)
The testimonies of both doctors 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. Thus, Dr. Salvador's
elaboration on the matter:
Atty. Pascual:
Q. Doctor, among the causes of hemorrhage that you mentioned you said that it could be at the moment of operation when one losses (sic) control
of the presence, is that correct? During the operation there is lost (sic) of control of the cut vessel?
A. Yes, sir.
Q. Or there is a failure to ligate a vessel of considerable size?
A. Yes, sir.
Q. Or even if the vessel were ligated the knot may have slipped later on?
A. Yes, sir.
Q. And you also mentioned that it may be possible also to some clotting defect, is that correct?
A. May be (sic). 38 (Emphasis supplied).
Defense witness, Dr. Bu C. Castro also gave the following expert opinion:
Q. Doctor even a patient after an operations (sic) would suffer hemorrage what would be the possible causes of such hemorrage (sic)?
A. Among those would be what we call Intravascular Coagulation and this is the reason for the bleeding, sir, which cannot be prevented by anyone,
it will happen to anyone, anytime and to any persons (sic), sir.
COURT:
What do you think of the cause of the bleeding, the cutting or the operations done in the body?
A. Not related to this one, the bleeding here is not related to any cutting or operation that I (sic) have done.
Q. Aside from the DIC what could another causes (sic) that could be the cause for the hemorrhage or bleeding in a patient by an operations (sic)?
A. In general sir, if there was an operations (sic) and it is possible that the ligature in the suture was (sic) become (sic) loose, it is (sic) becomes loose
if proven..
x x x           x x x          x x x
Q. If the person who performed an autopsy does not find any untight (sic) clot (sic) blood vessel or any suture that become (sic) loose the cause of
the bleeding could not be attributed to the fault of the subject?
A. Definitely, sir. 39 (Emphasis supplied.)
According to both doctors, the possible causes of hemorrhage during an operation are: (1) the failure of the surgeon to tie or suture a cut blood
vessel; (2) allowing a cut blood vessel to get out of control; (3) the subsequent loosening of the tie or suture applied to a cut blood vessel; and (4)
and a clotting defect known as DIC. It is significant to state at this juncture that the autopsy conducted by Dr. Arizala on the body of Lydia 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. 40 Hence the following pertinent portion of Dr. Arizala's testimony:
Q: Doctor, in examining these structures did you know whether these were sutured ligature or plain ligature
A: Ligature, sir.
Q: We will explain that later on. Did you recall if the cut structures were tied by first suturing it and then tying a knot or the tie was merely placed
around the cut structure and tied?
A: I cannot recall, sir.
Q: As a matter of fact, you cannot recall because you did not even bothered (sic) to examine, is that correct?
A: Well, I bothered enough to know that they were sutured, sir.
Q: So, therefore, Doctor, you would not know whether any of the cut structures were not sutured or tied neither were you able to determine
whether any loose suture was found in the peritoneal cavity?
A: I could not recall any loose sutured (sic), sir. 41
On the other hand, the findings of all three doctors do not preclude the probability that DIC caused the hemorrhage and consequently, Lydia's
death. DIC which is a clotting defect creates a serious bleeding tendency and when massive DIC occurs as a complication of surgery leaving raw
surface, major hemorrhage occurs. 42 And as testified to by defense witness, Dr. Bu C. Castro, hemorrhage due to DIC "cannot be prevented, it will
happen to anyone,
anytime." 43 He testified further:
Q. Now, under that circumstance one of the possibility as you mentioned in (sic) DIC?
A. Yes, sir.
Q. And you mentioned that this cannot be prevented?
A. Yes, sir.
Q. Can you even predict if it really happen (sic)?
A. Possible, sir.
Q. Are there any specific findings of autopsy that will tell you whether this patient suffered among such things as DIC?
A. Well, I did reserve because of the condition of the patient.
Q. Now, Doctor you said that you went through the record of the deceased Lydia Umali looking for the chart, the operated (sic) records, the post
mortem findings on the histophanic (sic) examination based on your examination of record, doctor, can you more or less says (sic) what part are
(sic) concerned could have been the caused (sic) of death of this Lydia Umali?
A. As far as the medical record is concern (sic) the caused (sic) of death is dessimulated (sic) Intra Vascular Coagulation or the DIC which resulted to
hemorrhage or bleedings, sir.
Q. Doctor based on your findings then there is knowing (sic) the doctor would say whether the doctor her (sic) has been (sic) fault?
ATTY. MALVEDA:
We will moved (sic) to strike out the (sic) based on finding they just read the chart as well as the other record.
ATTY. PASCUAL:
Precisely based on this examination.
ATTY. MALVEDA:
Not finding, there was no finding made.
COURT:
He is only reading the record.
ATTY. PASCUAL:
Yes, sir.
A. No,  sir, there is no fault on the part of the surgeon, sir. 44

This Court has no recourse but to rely on the expert testimonies rendered by both prosecution and defense witnesses that
substantiate rather than contradict petitioner's allegation that the cause of Lydia's death was DIC which, as attested to by an expert
witness, cannot be attributed to the petitioner's fault or negligence. 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. While we condole with the family of Lydia Umali, our hands are
bound by the dictates of justice and fair dealing which hold inviolable the right of an accused to be presumed innocent until proven
guilty beyond reasonable doubt. Nevertheless, this Court finds the petitioner civilly liable for the death of Lydia Umali, for while a
conviction of a crime requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil
liability. 45

The petitioner is a doctor in whose hands a patient puts his life and limb. For insufficiency of evidence this Court was not able to
render a sentence of conviction but it is not blind to the reckless and imprudent manner in which the petitioner carried out her
duties. A precious life has been lost and the circumstances leading thereto exacerbated the grief of those left behind. The heirs of
the deceased continue to feel the loss of their mother up to the present time 46 and this Court is aware that no amount of
compassion and commiseration nor words of bereavement can suffice to assuage the sorrow felt for the loss of a loved one.
Certainly, the award of moral and exemplary damages in favor of the heirs of Lydia Umali are proper in the instant case.

WHEREFORE, premises considered, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED of the crime of reckless imprudence
resulting in homicide but is ordered to pay the heirs of the deceased Lydia Umali the amount of FIFTY THOUSAND PESOS
(P50,000.00) as civil liability, ONE HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND PESOS
(P50,000.00) as exemplary damages.

Let a copy of this decision be furnished to the Professional Regulation Commission (PRC) for appropriate action.

SO ORDERED.

G.R. No. 158996             November 14, 2008

SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners,

vs.
SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and
LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA S. PINEDA, and UNITED DOCTORS MEDICAL CENTER,
INC., respondents.
DECISION

BRION, J.:

This petition involves a medical negligence case that was elevated to this Court through an appeal by certiorari  under Rule 45 of the
Rules of Court. The petition assails the Decision1 of the Court of Appeals (CA) in CA G.R. CV No. 63234, which affirmed with
modification the Decision2 of the Regional Trial Court (RTC) of Nueva Ecija, Branch 37 in Civil Case No. SD-1233. The dispositive
portion of the assailed CA decision states:

WHEREFORE, premises considered, the assailed Decision of the Regional Trial Court of Baloc, Sto. Domingo, Nueva Ecija, Branch 37 is
hereby AFFIRMED but with modifications as follows:

1) Ordering defendant-appellants Dr. and Dra. Fredelicto A. Flores and the United Doctors Medical Center, Inc. to jointly and
severally pay the plaintiff-appellees - heirs of Teresita Pineda, namely, Spouses Dominador Pineda and Virginia Saclolo and Florencio,
Candida, Marta, Godofredo, Baltazar and Lucena, all surnamed Pineda, the sum of P400,000.00 by way of moral damages;

2) Ordering the above-named defendant-appellants to jointly and severally pay the above-named plaintiff-appellees the sum
of P100,000.00 by way of exemplary damages;

3) Ordering the above-named defendant-appellants to jointly and severally pay the above-named plaintiff-appellees the sum
of P36,000.00 by way of actual and compensatory damages; and

4) Deleting the award of attorney's fees and costs of suit.

SO ORDERED.

While this case essentially involves questions of facts, we opted for the requested review in light of questions we have on the
findings of negligence below, on the awarded damages and costs, and on the importance of this type of ruling on medical practice.3

BACKGROUND FACTS

Teresita Pineda (Teresita) was a 51-year old unmarried woman living in Sto. Domingo, Nueva Ecija. She consulted on April 17, 1987
her townmate, Dr. Fredelicto Flores, regarding her medical condition. She complained of general body weakness, loss of appetite,
frequent urination and thirst, and on-and-off vaginal bleeding. Dr. Fredelicto initially interviewed the patient and asked for the
history of her monthly period to analyze the probable cause of the vaginal bleeding. He advised her to return the following week or
to go to the United Doctors Medical Center (UDMC) in Quezon City for a general check-up. As for her other symptoms, he suspected
that Teresita might be suffering from diabetes and told her to continue her medications.4

Teresita did not return the next week as advised. However, when her condition persisted, she went to further consult Dr. Flores at
his UDMC clinic on April 28, 1987, travelling for at least two hours from Nueva Ecija to Quezon City with her sister, Lucena Pineda.
They arrived at UDMC at around 11:15 a.m.. Lucena later testified that her sister was then so weak that she had to lie down on the
couch of the clinic while they waited for the doctor. When Dr. Fredelicto arrived, he did a routine check-up and ordered Teresita's
admission to the hospital. In the admission slip, he directed the hospital staff to prepare the patient for an "on call" D&C5 operation
to be performed by his wife, Dr. Felicisima Flores (Dr. Felicisima). Teresita was brought to her hospital room at around 12 noon; the
hospital staff forthwith took her blood and urine samples for the laboratory tests6 which Dr. Fredelicto ordered.

At 2:40 p.m. of that same day, Teresita was taken to the operating room. It was only then that she met Dr. Felicisima, an obstetrician
and gynecologist. The two doctors - Dr. Felicisima and Dr. Fredelicto, conferred on the patient's medical condition, while the resident
physician and the medical intern gave Dr. Felicisima their own briefings. She also interviewed and conducted an internal vaginal
examination of the patient which lasted for about 15 minutes. Dr. Felicisima thereafter called up the laboratory for the results of the
tests. At that time, only the results for the blood sugar (BS), uric acid determination, cholesterol determination, and complete blood
count (CBC) were available. Teresita's BS count was 10.67mmol/l7 and her CBC was 109g/l.8

Based on these preparations, Dr. Felicisima proceeded with the D&C operation with Dr. Fredelicto administering the general
anesthesia. The D&C operation lasted for about 10 to 15 minutes. By 3:40 p.m., Teresita was wheeled back to her room.
A day after the operation (or on April 29, 1987), Teresita was subjected to an ultrasound examination as a confirmatory procedure.
The results showed that she had an enlarged uterus and myoma uteri.9 Dr. Felicisima, however, advised Teresita that she could
spend her recovery period at home. Still feeling weak, Teresita opted for hospital confinement.

Teresita's complete laboratory examination results came only on that day (April 29, 1987). Teresita's urinalysis showed a three plus
sign (+++) indicating that the sugar in her urine was very high. She was then placed under the care of Dr. Amado Jorge, an internist.

By April 30, 1987, Teresita's condition had worsened. She experienced difficulty in breathing and was rushed to the intensive care
unit. Further tests confirmed that she was suffering from Diabetes Mellitus Type II.10 Insulin was administered on the patient, but
the medication might have arrived too late. Due to complications induced by diabetes, Teresita died in the morning of May 6, 1987.11

Believing that Teresita's death resulted from the negligent handling of her medical needs, her family (respondents) instituted an
action for damages against Dr. Fredelicto Flores and Dr. Felicisima Flores (collectively referred to as the petitioner spouses) before
the RTC of Nueva Ecija.

The RTC ruled in favor of Teresita's family and awarded actual, moral, and exemplary damages, plus attorney's fees and costs.12 The
CA affirmed the judgment, but modified the amount of damages awarded and deleted the award for attorney's fees and costs of
suit.13

Through this petition for review on certiorari, the petitioner spouses -Dr. Fredelicto (now deceased) and Dr. Felicisima Flores - allege
that the RTC and CA committed a reversible error in finding them liable through negligence for the death of Teresita Pineda.

ASSIGNMENT OF ERRORS

The petitioner spouses contend that they exercised due care and prudence in the performance of their duties as medical
professionals. They had attended to the patient to the best of their abilities and undertook the management of her case based on
her complaint of an on-and-off vaginal bleeding. In addition, they claim that nothing on record shows that the death of Teresita
could have been averted had they employed means other than what they had adopted in the ministration of the patient.

THE COURT'S RULING

We do not find the petition meritorious.

The respondents' claim for damages is predicated on their allegation that the decision of the petitioner spouses to proceed with the
D&C operation, notwithstanding Teresita's condition and the laboratory test results, amounted to negligence. On the other hand,
the petitioner spouses contend that a D&C operation is the proper and accepted procedure to address vaginal bleeding - the medical
problem presented to them. Given that the patient died after the D&C, the core issue is whether the decision to proceed with the
D&C operation was an honest mistake of judgment or one amounting to negligence.

Elements of a Medical Negligence Case

A medical negligence case is a type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to
or the death of a patient. There are four elements involved in a medical negligence case, namely: duty, breach, injury, and proximate
causation.14

Duty refers to the standard of behavior which imposes restrictions on one's conduct.15 The standard in turn refers to the amount of
competence associated with the proper discharge of the profession. A physician is expected to use at least the same level of care
that any other reasonably competent doctor would use under the same circumstances. Breach of duty occurs when the physician
fails to comply with these professional standards. If injury results to the patient as a result of this breach, the physician is answerable
for negligence.16

As in any civil action, the burden to prove the existence of the necessary elements rests with the plaintiff.17 To successfully pursue a
claim, the plaintiff must prove by preponderance of evidence that, one, the physician either failed to do something which a
reasonably prudent health care provider would have done, or that he did something that a reasonably prudent provider would not
have done; and two, the failure or action caused injury to the patient.18 Expert testimony is therefore essential since the factual issue
of whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is generally a
matter of expert opinion.19

Standard of Care and Breach of Duty

D&C is the classic gynecologic procedure for the evaluation and possible therapeutic treatment for abnormal vaginal bleeding.20 That
this is the recognized procedure is confirmed by Drs. Salvador Nieto (Dr. Nieto) and Joselito Mercado (Dr. Mercado), the expert
witnesses presented by the respondents:

DR. NIETO: [W]hat I know among obstetricians, if there is bleeding, they perform what we call D&C for diagnostic purposes.

xxx xxx xxx

Q: So are you trying to tell the Court that D&C can be a diagnostic treatment?

A: Yes, sir. Any doctor knows this.21

Dr. Mercado, however, objected with respect to the time the D&C operation should have been conducted in Teresita's case. He
opined that given the blood sugar level of Teresita, her diabetic condition should have been addressed first:

Q: Why do you consider the time of performance of the D&C not appropriate?

A: Because I have read the record and I have seen the urinalysis, [there is] spillage in the urine, and blood sugar was 10.67

Q: What is the significance of the spillage in the urine?

A: It is a sign that the blood sugar is very high.

Q: Does it indicate sickness?

A: 80 to 95% it means diabetes mellitus. The blood sugar was 10.67.

xxx xxx xxx

COURT: In other words, the operation conducted on the patient, your opinion, that it is inappropriate?

A: The timing of [when] the D&C [was] done, based on the record, in my personal opinion, that D&C should be postponed a day or
two.22

The petitioner spouses countered that, at the time of the operation, there was nothing to indicate that Teresita was afflicted with
diabetes: a blood sugar level of 10.67mmol/l did not necessarily mean that she was a diabetic considering that this was random
blood sugar;23 there were other factors that might have caused Teresita's blood sugar to rise such as the taking of blood samples
during lunchtime and while patient was being given intra-venous dextrose.24 Furthermore, they claim that their principal concern
was to determine the cause of and to stop the vaginal bleeding.

The petitioner spouses' contentions, in our view, miss several points. First, as early as April 17, 1987, Teresita was already suspected
to be suffering from diabetes.25 This suspicion again arose right before the D&C operation on April 28, 1987 when the laboratory
result revealed Teresita's increased blood sugar level.26 Unfortunately, the petitioner spouses did not wait for the full medical
laboratory results before proceeding with the D&C, a fact that was never considered in the courts below. Second, the petitioner
spouses were duly advised that the patient was experiencing general body weakness, loss of appetite, frequent urination, and thirst -
all of which are classic symptoms of diabetes.27 When a patient exhibits symptoms typical of a particular disease, these symptoms
should, at the very least, alert the physician of the possibility that the patient may be afflicted with the suspected disease:

Expert testimony for the plaintiff showed that] tests should have been ordered immediately on admission to the hospital in view of the symptoms presented, and that failure to recognize the existence of diabetes constitutes

negligence.28
Third, the petitioner spouses cannot claim that their principal concern was the vaginal bleeding and should not therefore be held
accountable for complications coming from other sources. This is a very narrow and self-serving view that even reflects on their
competence.

Taken together, we find that reasonable prudence would have shown that diabetes and its complications were foreseeable harm
that should have been taken into consideration by the petitioner spouses. If a patient suffers from some disability that increases
the magnitude of risk to him, that disability must be taken into account so long as it is or should have been known to the
physician.29 And when the patient is exposed to an increased risk, it is incumbent upon the physician to take commensurate and
adequate precautions.

Taking into account Teresita's high blood sugar,30 Dr. Mendoza opined that the attending physician should have postponed the D&C
operation in order to conduct a confirmatory test to make a conclusive diagnosis of diabetes and to refer the case to an internist or
diabetologist. This was corroborated by Dr. Delfin Tan (Dr. Tan), an obstetrician and gynecologist, who stated that the patient's
diabetes should have been managed by an internist prior to, during, and after the operation.31

Apart from bleeding as a complication of pregnancy, vaginal bleeding is only rarely so heavy and life-threatening that urgent first-aid
measures are required.32 Indeed, the expert witnesses declared that a D&C operation on a hyperglycemic patient may be justified
only when it is an emergency case - when there is profuse vaginal bleeding. In this case, we choose not to rely on the assertions of
the petitioner spouses that there was profuse bleeding, not only because the statements were self-serving, but also because the
petitioner spouses were inconsistent in their testimonies. Dr. Fredelicto testified earlier that on April 28, he personally saw the
bleeding,33 but later on said that he did not see it and relied only on Teresita's statement that she was bleeding.34 He went on to
state that he scheduled the D&C operation without conducting any physical examination on the patient.

The likely story is that although Teresita experienced vaginal bleeding on April 28, it was not sufficiently profuse to necessitate an
immediate emergency D&C operation. Dr. Tan35 and Dr. Mendoza36 both testified that the medical records of Teresita failed to
indicate that there was profuse vaginal bleeding. The claim that there was profuse vaginal bleeding although this was not reflected
in the medical records strikes us as odd since the main complaint is vaginal bleeding. A medical record is the only document that
maintains a long-term transcription of patient care and as such, its maintenance is considered a priority in hospital practice. Optimal
record-keeping includes all patient inter-actions. The records should always be clear, objective, and up-to-date.37 Thus, a medical
record that does not indicate profuse medical bleeding speaks loudly and clearly of what it does not contain.

That the D&C operation was conducted principally to diagnose the cause of the vaginal bleeding further leads us to conclude that it
was merely an elective procedure, not an emergency case. In an elective procedure, the physician must conduct a thorough pre-
operative evaluation of the patient in order to adequately prepare her for the operation and minimize possible risks and
complications. The internist is responsible for generating a comprehensive evaluation of all medical problems during the pre-
operative evaluation.38

The aim of pre-operative evaluation is not to screen broadly for undiagnosed disease, but rather to identify and quantify comorbidity
that may impact on the operative outcome. This evaluation is driven by findings on history and physical examination suggestive of
organ system dysfunction…The goal is to uncover problem areas that may require further investigation or be amenable to
preoperative optimization.

If the preoperative evaluation uncovers significant comorbidity or evidence of poor control of an underlying disease process,
consultation with an internist or medical specialist may be required to facilitate the work-up and direct management. In this process,
communication between the surgeons and the consultants is essential to define realistic goals for this optimization process and to
expedite surgical management.39 [Emphasis supplied.]

Significantly, the evidence strongly suggests that the pre-operative evaluation was less than complete as the laboratory results were
fully reported only on the day following the D&C operation. Dr. Felicisima only secured a telephone report of the preliminary
laboratory result prior to the D&C. This preliminary report did not include the 3+ status of sugar in the patient's urine40 - a result
highly confirmatory of diabetes.

Because the D&C was merely an elective procedure, the patient's uncontrolled hyperglycemia presented a far greater risk than her
on-and-off vaginal bleeding. The presence of hyperglycemia in a surgical patient is associated with poor clinical outcomes, and
aggressive glycemic control positively impacts on morbidity and mortality.41 Elective surgery in people with uncontrolled
diabetes should preferably be scheduled after acceptable glycemic control has been achieved.42 According to Dr. Mercado, this is
done by administering insulin on the patient.43
The management approach in this kind of patients always includes insulin therapy in combination with dextrose and potassium
infusion. Insulin xxx promotes glucose uptake by the muscle and fat cells while decreasing glucose production by the liver xxx. The
net effect is to lower blood glucose levels.44

The prudent move is to address the patient's hyperglycemic state immediately and promptly before any other procedure is
undertaken. In this case, there was no evidence that insulin was administered on Teresita prior to or during the D&C operation.
Insulin was only administered two days after the operation.

As Dr. Tan testified, the patient's hyperglycemic condition should have been managed not only before and during the operation, but
also immediately after. Despite the possibility that Teresita was afflicted with diabetes, the possibility was casually ignored even in
the post-operative evaluation of the patient; the concern, as the petitioner spouses expressly admitted, was limited to the complaint
of vaginal bleeding. Interestingly, while the ultrasound test confirmed that Teresita had a myoma in her uterus, she was advised that
she could be discharged a day after the operation and that her recovery could take place at home. This advice implied that a day
after the operation and even after the complete laboratory results were submitted, the petitioner spouses still did not recognize any
post-operative concern that would require the monitoring of Teresita's condition in the hospital.

The above facts, point only to one conclusion - that the petitioner spouses failed, as medical professionals, to comply with their duty
to observe the standard of care to be given to hyperglycemic/diabetic patients undergoing surgery. Whether this breach of duty was
the proximate cause of Teresita's death is a matter we shall next determine.

Injury and Causation

As previously mentioned, the critical and clinching factor in a medical negligence case is proof of the causal connection between the
negligence which the evidence established and the plaintiff's injuries;45 the plaintiff must plead and prove not only that he had been
injured and defendant has been at fault, but also that the defendant's fault caused the injury. A verdict in a malpractice action
cannot be based on speculation or conjecture. Causation must be proven within a reasonable medical probability based upon
competent expert testimony.46

The respondents contend that unnecessarily subjecting Teresita to a D&C operation without adequately preparing her, aggravated
her hyperglycemic state and caused her untimely demise. The death certificate of Teresita lists down the following causes of death:

Immediate cause: Cardiorespiratory arrest

Antecedent cause: Septicemic shock, ketoacidocis

Underlying cause: Diabetes Mellitus II

Other significant conditions

contributing to death: Renal Failure - Acute47

Stress, whether physical or emotional, is a factor that can aggravate diabetes; a D&C operation is a form of physical stress. Dr.
Mendoza explained how surgical stress can aggravate the patient's hyperglycemia: when stress occurs, the diabetic's body,
especially the autonomic system, reacts by secreting hormones which are counter-regulatory; she can have prolonged
hyperglycemia which, if unchecked, could lead to death.48 Medical literature further explains that if the blood sugar has become very
high, the patient becomes comatose (diabetic coma). When this happens over several days, the body uses its own fat to produce
energy, and the result is high levels of waste products (called ketones) in the blood and urine (called diabetic ketoacidiosis, a
medical emergency with a significant mortality).49 This was apparently what happened in Teresita's case; in fact, after she had been
referred to the internist Dr. Jorge, laboratory test showed that her blood sugar level shot up to 14.0mmol/l, way above the normal
blood sugar range. Thus, between the D&C and death was the diabetic complication that could have been prevented with the
observance of standard medical precautions. The D&C operation and Teresita's death due to aggravated diabetic condition is
therefore sufficiently established.

The trial court and the appellate court pinned the liability for Teresita's death on both the petitioner spouses and this Court finds no
reason to rule otherwise. However, we clarify that Dr. Fredelicto's negligence is not solely the act of ordering an "on call" D&C
operation when he was mainly an anaesthesiologist who had made a very cursory examination of the patient's vaginal bleeding
complaint. Rather, it was his failure from the very start to identify and confirm, despite the patient's complaints and his own
suspicions, that diabetes was a risk factor that should be guarded against, and his participation in the imprudent decision to proceed
with the D&C operation despite his early suspicion and the confirmatory early laboratory results. The latter point comes out clearly
from the following exchange during the trial:

Q: On what aspect did you and your wife consult [with] each other?

A: We discussed on the finding of the laboratory [results] because the hemoglobin was below normal, the blood sugar was elevated,
so that we have to evaluate these laboratory results - what it means.

Q: So it was you and your wife who made the evaluation when it was phoned in?

A: Yes, sir.

Q: Did your wife, before performing D&C ask your opinion whether or not she can proceed?

A: Yes, anyway, she asked me whether we can do D&C based on my experience.

Q: And your answer was in the positive notwithstanding the elevation of blood sugar?

A: Yes, sir, it was both our disposition to do the D&C. [Emphasis supplied.]50

If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an internist or a diabetologist (for which reason
he referred Teresita to Dr. Jorge),51 he should have likewise refrained from making a decision to proceed with the D&C operation
since he was niether an obstetrician nor a gynecologist.

These findings lead us to the conclusion that the decision to proceed with the D&C operation, notwithstanding Teresita's
hyperglycemia and without adequately preparing her for the procedure, was contrary to the standards observed by the medical
profession. Deviation from this standard amounted to a breach of duty which resulted in the patient's death. Due to this negligent
conduct, liability must attach to the petitioner spouses.

Liability of the Hospital

In the proceedings below, UDMC was the spouses Flores' co-defendant. The RTC found the hospital jointly and severally liable with
the petitioner spouses, which decision the CA affirmed. In a Resolution dated August 28, 2006, this Court however denied UDMC's
petition for review on certiorari. Since UDMC's appeal has been denied and they are not parties to this case, we find it unnecessary
to delve on the matter. Consequently, the RTC's decision, as affirmed by the CA, stands.

Award of Damages

Both the trial and the appellate court awarded actual damages as compensation for the pecuniary loss the respondents suffered.
The loss was presented in terms of the hospital bills and expenses the respondents incurred on account of Teresita's confinement
and death. The settled rule is that a plaintiff is entitled to be compensated for proven pecuniary loss.52 This proof the respondents
successfully presented. Thus, we affirm the award of actual damages of P36,000.00 representing the hospital expenses the patient
incurred.

In addition to the award for actual damages, the respondent heirs of Teresita are likewise entitled to P50,000.00 as death
indemnity pursuant to Article 2206 of the Civil Code, which states that "the amount of damages for death caused by a xxx quasi-
delict shall be at least three thousand pesos,53 even though there may have been mitigating circumstances xxx." This is a question of
law that the CA missed in its decision and which we now decide in the respondents' favor.

The same article allows the recovery of moral damages in case of death caused by a quasi-delict and enumerates the spouse,
legitimate or illegitimate ascendants or descendants as the persons entitled thereto. Moral damages are designed to compensate
the claimant for the injury suffered, that is, for the mental anguish, serious anxiety, wounded feelings which the respondents herein
must have surely felt with the unexpected loss of their daughter. We affirm the appellate court's award of P400,000.00 by way
of moral damages to the respondents.
We similarly affirm the grant of exemplary damages. Exemplary damages are imposed by way of example or correction for the public
good.54 Because of the petitioner spouses' negligence in subjecting Teresita to an operation without first recognizing and addressing
her diabetic condition, the appellate court awarded exemplary damages to the respondents in the amount of P100,000.00. Public
policy requires such imposition to suppress the wanton acts of an offender.55 We therefore affirm the CA's award as an example to
the medical profession and to stress that the public good requires stricter measures to avoid the repetition of the type of medical
malpractice that happened in this case.

With the award of exemplary damages, the grant of attorney's fees is legally in order.56 We therefore reverse the CA decision
deleting these awards, and grant the respondents the amount of P100,000.00 as attorney's fees taking into consideration the legal
route this case has taken.

WHEREFORE, we AFFIRM the Decision of the CA dated June 20, 2003 in CA G.R. CV No. 63234 finding petitioner spouses liable for
negligent medical practice. We likewise AFFIRM the awards of actual and compensatory damages of P36,000.00; moral damages
of P400,000.00; and exemplary damages of P100,000.00.

We MODIFY the CA Decision by additionally granting an award of P50,000.00 as death indemnity and by reversing the deletion of
the award of attorney's fees and costs and restoring the award of P100,000.00 as attorney's fees. Costs of litigation are adjudged
against petitioner spouses.

To summarize, the following awards shall be paid to the family of the late Teresita Pineda:

1. The sum of P36,000.00 by way of actual and compensatory damages;

2. The sum of P50,000.00 by way of death indemnity;

3. The sum of P400,000.00 by way of moral damages;

4. The sum of P100,000.00 by way of exemplary damages;

5. The sum of P100,000.00 by way of attorney's fees; and

6. Costs.

SO ORDERED.