LEGAL MEDICINE

DR. RUBI LI vs SPOUSES REYNALDO and LINA SOLIMAN

GR NO. 165279 | JUNE 7, 2011
VILLARAMA ,JR.,J

FACTS: 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. Lukes Medical Center (SLMC). Results showed that Angelica was suffering from osteosaucoma,
ostiobiostic type, a high-grade (highly malignant) cancer of the bone which usually affects teenage children. Following this
diagnosis, Angelica’s right leg was amputated by Dr. Tamayo in order to remove the tumor. As an adjuvant treatment to eliminate
any remaining cancer cells, and hence minimizing the chances of recurrence and prevent the decease from spreading to other
parts of the patient’s body, chemotherapy was suggested by Dr. Tamayo and referred Angelica to another doctor at SLMC, herein
petitioner Dr. Rubi Li, a medical oncologist.

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 2-3 weeks to recover from the operation before starting the
chemotherapy. Respondents were apprehensive due to financial constraints as Reynaldo earns only from P70,000-150,000 a
year from his jewelry and watching repair business. Petitioner, however, assured them not to worry about her professional fee
and told them to just save up for medicines to be used.

On August 18, 1993, Angelica was admitted to SLMC. As the chemotherapy session started, day by day, Angelica experience
worsening condition and other physical effect on the body such as discoloration, nausea, and vomiting.
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 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 WBC, RBC, and platelets; 5.) possible sterility due to the effects
on Angelica’s ovary; 6.) Damage to kidney and heart; 7.) darkening of the skin especially when exposed to sunlight. She actually
talked to the respondents four times, once at the hospital after the surgery, twice at her clinic and fourth when Angelica’s mother
called her through long distance. 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. Those were the only side effects of chemotherapy mentioned by petitioner.

On September 1, 1993, Angelica died, just eleven days after the administration of the first cycle of chemotherapy regimen.
Because SLMC refused to release a death certificate without full payment of their hospital bills, respondents brought the cadaver
to PNP Crime Lab 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.”
On the other hand, the medical certificate issued by SLMC stated the cause of death as: osteosarcoma (immediate cause),
amputation (antecedent cause), status post chemotherapy (underlying cause).

On February 21, respondents filed a damage suit against petitioner , Dr. Leo Marbella, Mr. Jose Ledesma, and Dr. Arriete and
SLMC charging them with NEGLIGENCE and DISREGARD of Angelica’s safety, health and welfare citing their careless
administration of drugs, among others. They claimed that they would not have consented to chemotherapy had petitioner not
falsely assured them of its side effects.

Trial court: dismissed the complaint and 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. 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.

CA: find Dr. Rubi Li negligent which would be entitle respondents to their claim for damages. at 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.
 LEGAL MEDICINE

Petition then filed a motion for partial reconsideration which the CA denied. Hence, this petition.

ISSUE: Whether or not petitioner committed medical malpractice.

Whether the petitioner can be held liable for failure to fully disclose serious side effects to the parents of the child
patient

RULING: No. 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 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 health care provider would not have done; and that failure or action caused injury to the patient.

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 layman in most instances are
incapable of intelligently evaluating, hence the indispensability of expert testimonies.

The doctrine of informed consent within the context of physician-patient relationships goes as far back into english common law.
As early as 1767, doctors were charged with the tort of battery if they have not gained the consent of their patients prior to
performing a surgery or procedure. In the United States, the seminal case was Schoendorff vs Society of New York Hospital which
involved unwanted treatment performed by a doctor. Justice Bejamin Cardozo oft-quoted opinion upheld the basic right of a patient
to give consent to any medical procedure or treatment; every human being of adult year 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. 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 risk of injury might be incurred from a proposed course of treatment, so that a
patient, exercising ordinary care for her own welfare and faced with a choice of undergoing the proposed treatment, as alternative
treatment, or none at all, may intelligently exercise his judgement by reasonably balancing the probable risk against the probable
benefits.

There are four essential elements a plaintiff must proved 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 requires the plaintiff to point to significant
undisclosed information relating to the treatment which could have altered her decision to undergo it.

Examining the evidence, we hold that there was adequate disclosure of material risks inherent in 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 patients
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.
 LEGAL MEDICINE

PROFESSIONAL SERVICES, INC. vs COURT OF APPEALS and NATIVIDAD and ENRIQUE AGANA
GR 126297 | JANUARY 21, 2007
AGANA vs CA and JUAN FUENTES (GR 126467)
MIGUEL AMPIL vs NATIVIDAD and ENRIQUE AGANA (GR 127590)

FACTS: Natividad Agana was rushed to Medical City Hospital because of difficulty of bowel movement and bloody anal discharge.
After a series of medical examinations, Dr. Miguel Ampil, diagnosed her to be suffering from “cancer of the sigmoid”. Dr. Ampil
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 to permit Dr. Fuentes to perform hysterectomy on her. After
Dr. Fuentes completed the hysterectomy, Dr. Ampil took over, completed the operation and closed the incision. However, the
operation appeared to be flawed.

Natividad was released from the hospital. After a couple of days, Natividad complained of excruciating pain in her anal region.
They consulted Ampil and Fuentes and they told her that the pain was the natural consequence of the surgery. Dr. Ampil
recommended that she consult an oncologist to examine the cancerous nodes which were not removed. Natividad accompanied
by her husband went to the U.S. to seek further treatment. After several consultations, Natividad was told that she is free from
cancer.

Natividad went back to the Phil. Still experiencing pains. Her daughter found a gauze from her vagina. After being informed, Dr.
Ampil proceeded to her house and removed the gauze and assured her that she will no longer experience pain. The pains
intensified, prompting Natividad to seek treatment at the Polymedic General Hospital. While confined there, Dr. Gutierrez detected
the presence of another foreign object in her vagina – a foul smelling gauze 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.

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. 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. Pending the
outcome of the above cases, Natividad died and was duly substituted by her above-named children (the Aganas).

RTC – ruled in favor of Aganas, awarded actual, moral, exemplary damages and attorney’s fees.
CA – affirmed.

ISSUES :
1. WON CA erred in holding Dr. Ampil liable for negligence and malpractice.
2. WON CA erred in absolving Dr. Fuentes of any liability. NO
3. WON PSI may be held solidarily liable for Dr. Ampil's negligence.

RULING:

DR. AMPIL IS LIABLE FOR NEGLIGENCE AND MALPRACTICE

His arguments are without basis [did not prove that the American doctors were the ones who put / left the gauzes; did not submit
evidence to rebut the correctness of the operation record (re: number of gauzes used); re: Dr. Fuentes' alleged negligence, Dr.
Ampil examined his work and found it in order].

Leaving foreign substances in the wound after incision has been closed is at least prima facie negligence by the
operating surgeon. Even if it has been shown that a surgeon was required to leave a sponge in his patient's abdomen because
of the dangers attendant upon delay, still, it is his legal duty to inform his patient within a reasonable time by advising her of what
he had been compelled to do, so she can seek relief from the effects of the foreign object left in her body as her condition might
permit. What's worse in this case is that he misled her by saying that the pain was an ordinary consequence of her operation.

Medical negligence; standard of diligence

 LEGAL MEDICINE

To successfully pursue this case of medical negligence, a patient must only prove that a health care provider either failed to do
something [or did something] which a reasonably prudent health care provider would have done [or wouldn't have done], and that
the failure or action caused injury to the patient.
 Duty - to remove all foreign objects from the body before closure of the incision; if he fails to do so, it was his duty to inform
the patient about it
 Breach - failed to remove foreign objects; failed to inform patient
 Injury - suffered pain that necessitated examination and another surgery
 Proximate Causation - breach caused this injury; could be traced from his act of closing the incision despite information given
by the attendant nurses that 2 pieces of gauze were still missing; what established causal link: gauze pieces later extracted
from patient's vagina

DR. FUENTES NOT LIABLE

The res ipsa loquitur [thing speaks for itself] argument of the Aganas' does not convince the court. Mere invocation and application
of this doctrine does not dispense with the requirement of proof of negligence.

Requisites for the applicability of res ipsa loquitur

1. Occurrence of injury
2. Thing which caused injury was under the control and management of the defendant [DR. FUENTES] -
- LACKING SINCE CTRL+MGT WAS WITH DR. AMPIL
3. Occurrence was such that in the ordinary course of things, would not have happened if those who had control
or management used proper care
4. Absence of explanation by defendant
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. That Dr. Ampil discharged such role is evident from the following:
 He called Dr. Fuentes to perform a hysterectomy
 He examined Dr. Fuentes' work and found it in order
 He granted Dr. Fuentes permission to leave
 He ordered the closure of the incision

HOSPITAL OWNER PSI SOLIDARILY LIABLE WITH DR. AMPIL [NCC 2180], AND DIRECTLY LIABLE TO SPS. AGANAS
[NCC 2176]
Previously, employers cannot be held liable for the fault or negligence of its professionals. However, this doctrine has weakened
since courts came to realize that modern hospitals are taking a more active role in supplying and regulating medical care to its
patients, by employing staff of physicians, among others. Hence, there is no reason to exempt hospitals from the universal rule
of respondeat superior. Here are the Court's bases for sustaining PSI's liability:

Ramos v. CA doctrine on E-E relationship

For purposes of apportioning responsibility in medical negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians. [LABOR LESSON: power to hire, fire, power of control]
Agency principle of apparent authority / agency by estoppel
Imposes liability because of the actions of a principal or employer in somehow misleading the public into believing that the
relationship or the authority exists [see NCC 1869]
PSI publicly displays in the Medical City lobby the names and specializations of their physicians. Hence, PSI 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.

If doctors do well, hospital profits financially, so when negligence mars the quality of its services, the hospital should not be allowed
to escape liability for its agents' acts.
Doctrine of corporate negligence / corporate responsibility
 LEGAL MEDICINE

This is 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.
This provides for the duties expected [from hospitals]. In this case, PSI failed to perform the duty of exercising reasonable care to
protect from harm all patients admitted into its facility for medical treatment. PSI failed to conduct an investigation of the matter
reported in the note of the count nurse, and this established PSI's part in the dark conspiracy of silence and concealment
about the gauzes.

PSI has actual / constructive knowledge of the matter, through the report of the attending nurses + the fact that the operation was
carried on with the assistance of various hospital staff
It also breached its duties to oversee or supervise all persons who practice medicine within its walls and take an active step in
fixing the negligence committed

PSI also liable under NCC 2180. It failed to adduce evidence to show that it exercised the diligence of a good father of the family in
the accreditation and supervision of Dr. Ampil
 LEGAL MEDICINE

PROFESSIONAL SERVICES, INC. vs COURT OF APPEALS and NATIVIDAD and ENRIQUE AGANA
GR 126297 | FEBRUARY 2, 2010
AGANA vs CA and JUAN FUENTES (GR 126467)
MIGUEL AMPIL vs NATIVIDAD and ENRIQUE AGANA (GR 127590)
CORONA, J.

FACTS: PSI, together with Dr. Miguel Ampil and Dr. Juan Fuentes, was impleaded by Enrique Agana and Natividad Agana (later
substituted by her heirs), in a complaint for damages filed in the Regional Trial Court (RTC) of Quezon City, Branch 96, for the
injuries suffered by Natividad when Dr. Ampil and Dr. Fuentes neglected to remove from her body two gauzes which were used
in the surgery they performed on her on April 11, 1984 at the Medical City General Hospital. PSI was impleaded as owner, operator
and manager of the hospital.

The RTC held PSI solidarily liable with Dr. Ampil and Dr. Fuentes for damages. On appeal, the Court of Appeals, absolved Dr.
Fuentes but affirmed the liability of Dr. Ampil and PSI, subject to the right of PSI to claim reimbursement from Dr. Ampil. On
petition for review, this Court, in its January 31, 2007 decision, affirmed the CA decision. PSI filed a motion for reconsideration but
the Court denied it in a resolution dated February 11, 2008. It premised the direct liability of PSI to Aganas on he ff: first,tehre
exist and employer- employee relationship; second, under the doctrine of apparent authority PSI was liable for the negligence of
Dr. Ampil; finally, PSI committed a serious breach of its corporate duty to provide comprehensive service to Natividad.

ISSUES: (won PSI is liable for damages)

PSI is now asking this Court to reconsider the foregoing rulings for these reasons:
1. The declaration in the 31 January 2007 Decision vis-a-vis the 11 February 2009 Resolution that the ruling in Ramos vs.
Court of Appeals (G.R. No. 134354, December 29, 1999) that "an employer-employee relations exists between hospital
and their consultants" stays should be set aside for being inconsistent with or contrary to the import of the resolution
granting the hospital's motion for reconsideration in Ramos vs. Court of Appeals (G.R. No. 134354, April 11, 2002), which
is applicable to PSI since the Aganas failed to prove an employer-employee relationship between PSI and Dr.
Ampil and PSI proved that it has no control over Dr. Ampil. In fact, the trial court has found that there is no employer-
employee relationship in this case and that the doctor's are independent contractors.
2. Respondents Aganas engaged Dr. Miguel Ampil as their doctor and did not primarily and specifically look to the Medical
City Hospital (PSI) for medical care and support; otherwise stated, respondents Aganas did not select Medical City
Hospital (PSI) to provide medical care because of any apparent authority of Dr. Miguel Ampil as its agent since
the latter was chosen primarily and specifically based on his qualifications and being friend and neighbor.
3. PSI cannot be liable under doctrine of corporate negligence since the proximate cause of Mrs. Agana's injury was
the negligence of Dr. Ampil, which is an element of the principle of corporate negligence

RULING:
PSI is liable to the Aganas, not under the principle of respondeat superior for lack of evidence of an employment
relationship with Dr. Ampil but under the principle of ostensible agency for the negligence of Dr. Ampil and, pro hac
vice, under the principle of corporate negligence for its failure to perform its duties as a hospital.

In the present case, the Aganas did not question the finding of the RTC and the CA that there is no employment relationship
between PSI and Dr. Ampil. In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no employer-
employee relationship, such finding became final and conclusive even to this Court. There was no reason for PSI to have raised
it as an issue in its petition. Thus, whatever discussion on the matter that may have ensued was purely academic. onsequently,
PSI cannot be held vicariously liable for the negligence of Dr. Ampil under the principle of respondeat superior.

There is, however, ample evidence that the hospital (PSI) held out to the patient (Natividad) that the doctor (Dr. Ampil) was its
agent. Present are the two factors that determine apparent authority: first, the hospital's implied manifestation to the patient which
led the latter to conclude that the doctor was the hospital's agent; and second, the patient’s reliance upon the conduct of the
hospital and the doctor, consistent with ordinary care and prudence.
 LEGAL MEDICINE

Enrique looked upon Dr. Ampil not as independent of but as integrally related to Medical City.

When asked what impelled him (Enrique) to choose Dr. Ampil, Enrique testified that, “[he] have known him to be a specialist on
that part of the body as a surgeon, second, I have known him to be a staff member of the Medical City which is a prominent and
known hospital. And third, because he is a neighbor, I expect more than the usual medical service to be given to us, than his
ordinary patients.” Clearly, the decision made by Enrique for Natividad to consult Dr. Ampil was significantly influenced by the
impression that Dr. Ampil was a staff member of Medical City General Hospital, and that said hospital was well known and
prominent. Enrique looked upon Dr. Ampil not as independent of but as integrally related to Medical City.

The Court cannot speculate on what could have been behind the Aganas’ decision but would rather adhere strictly to the fact that,
under the circumstances at that time, Enrique decided to consult Dr. Ampil for he believed him to be a staff member of a prominent
and known hospital. After his meeting with Dr. Ampil, Enrique advised his wife Natividad to go to the Medical City General Hospital
to be examined by said doctor, and the hospital acted in a way that fortified Enrique's belief.

This Court must therefore maintain the ruling that PSI is vicariously liable for the negligence of Dr. Ampil as its ostensible agent.

PSI, by its inaction, failed it owned standard of hospital care. It committed corporate negligence.

PSI made judicial admission, which barred itself from arguing in its second motion for reconsideration that the concept of corporate
responsibility was not yet in existence at the time Natividad underwent treatment; and that if it had any corporate responsibility,
the same was limited to reporting the missing gauzes and did not include "taking an active step in fixing the negligence committed.

PSI’s judicial admission imposes upon itself that it had the power to review or cause the review of what may have irregularly
transpired within its walls strictly for the purpose of determining whether some form of negligence may have attended any procedure
done inside its premises, with the ultimate end of protecting its patients. It likewise established that virtue of the nature of its business
as well as its prominence in the hospital industry, it assumed a duty to "tread on" the "captain of the ship" role of any doctor rendering
services within its premises for the purpose of ensuring the safety of the patients availing themselves of its services and facilities.
Further, such admission PSI defined the standards of its corporate conduct under the circumstances of this case, specifically: (a)
that it had a corporate duty to Natividad even after her operation to ensure her safety as a patient; (b) that its corporate duty was not
limited to having its nursing staff note or record the two missing gauzes and (c) that its corporate duty extended to determining Dr.
Ampil's role in it, bringing the matter to his attention, and correcting his negligence.

PSI could not simply wave off the problem and nonchalantly delegate to Dr. Ampil the duty to review what transpired during the
operation. While Dr. Ampil may have had the primary responsibility of notifying Natividad about the missing gauzes, PSI imposed
upon itself the separate and independent responsibility of initiating the inquiry into the missing gauzes.

As it happened, PSI took no heed of the record of operation and consequently did not initiate a review of what transpired during
Natividad’s operation. Rather, it shirked its responsibility and passed it on to others – to Dr. Ampil whom it expected to inform
Natividad, and to Natividad herself to complain before it took any meaningful step. By its inaction, therefore, PSI failed its own
standard of hospital care. It committed corporate negligence.

It should be borne in mind that the corporate negligence ascribed to PSI is different from the medical negligence attributed to Dr.
Ampil. The duties of the hospital are distinct from those of the doctor-consultant practicing within its premises in relation to the
patient; hence, the failure of PSI to fulfill its duties as a hospital corporation gave rise to a direct liability to the Aganas distinct from
that of Dr. Ampil.

***
All this notwithstanding, we make it clear that PSI’s hospital liability based on ostensible agency and corporate negligence applies
only to this case, pro hac vice. It is not intended to set a precedent and should not serve as a basis to hold hospitals liable for
every form of negligence of their doctors-consultants under any and all circumstances. The ruling is unique to this case, for the
liability of PSI arose from an implied agency with Dr. Ampil and an admitted corporate duty to Natividad.
 LEGAL MEDICINE

ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of the minors, ROMMEL
RAMOS, ROY RODERICK RAMOS and RON RAYMOND RAMOS, vs. COURT OF APPEALS, DELOS SANTOS
MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA GUTIERREZ
G.R. No. 124354 | APRIL 11, 2002
KAPUNAN, J

FACTS: Petitioner Erlinda Ramos, after seeking professional medical help, was advised to undergo an operation for the removal
of a stone in her gall bladder (cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation
on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at private respondent De Los Santos Medical
Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka
recommended to them the services of Dr. Gutierrez. Petitioner Erlinda was admitted to the DLSMC the day before the scheduled
operation. Upon the request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who was then Dean of the College of Nursing
at the Capitol Medical Center, was allowed to accompany her inside the operating room.

Dr. Gutierrez informed Cruz that the operation might be delayed due to the late arrival of Dr. Hosaka. In the meantime, the patient,
petitioner Erlinda said to Cruz, "Mindy, inip na inip na ako, ikuha mo ako ng ibang Doctor." Dr. Hosaka finally arrived at the
hospital at around 12:10 in the afternoon, or more than three (3) hours after the scheduled operation.Cruz, who was then still
inside the operating room, saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr. Gutierrez utter: "ang hirap ma-intubate
nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlinda’s nailbeds on her left hand.
She (Cruz) then heard Dr. Hosaka instruct someone to call Dr. Calderon, another anesthesiologist. Who attempted to intubate
the patient. The nailbeds of the patient remained bluish, thus, she was placed in a trendelenburg position – a position where the
head of the patient is placed in a position lower than her feet.

At almost 3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit (ICU). The doctors explained to petitioner
Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital only four
months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained in comatose condition until she died on
August 3, 1999.

Petitioners filed with the QC RTC a civil case for damages against private respondents. The RTC rendered judgment in favor of
petitioners and found that private respondents were negligent in the performance of their duties to Erlinda.

On appeal by private respondents, the Court of Appeals reversed the trial court’s decision and directed petitioners to pay their
"unpaid medical bills" to private respondents.

Petitioners filed with this Court a petition for review on certiorari. On December 29, 1999, this Court hold respondents civilly liable
for petitioner Erlinda Ramos’ comatose condition:
WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to award in favor of
petitioners, and solidarily against private respondents the following: 1) P1,352,000.00 as actual damages computed as of the date of
promulgation of this decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos expires or miraculously
survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each exemplary damages
and attorney’s fees; and 5) the costs of the suit.

Hence this motion for reconsideration by DLSMC, Dr. Hosaka, and Dr. Gutierrez.

Dr. ORLINO HOSAKA Dr. PERFECTA GUTIERREZ DLSMC

 SC erred when it held Dr. Hosaka liable on the
basis of the “CAPTAIN-OF-THE-SHIP” doctrine
 SC erred in holding Dr. Hosaka liable despite the
fact that no negligence can be attributed to him
 Award for damages were excessive and w/o legal
basis
 SC overlooked the decision that CA decision had
already become final and executory
 SC overlooked several material factual
circumstances w/c, if considered, would lead to
conclusion that respondents were not negligent
- compliance w/ the standard of due care
- successfully intubated the patient
 SC placed too much reliance on the testimony of
Herminda Cruz
 SC disregard the expert testimony of Dr. Jamora
and Dra. Calderon
 SC inadvertently awarded damages despite
absence of negligence
 SC erred in giving due course to instant petition as
the CA decision had already become final and
executory
 SC erred in finding that an employer-employee
relationship exists between DLSMC and
respondent doctors
 SC erred in finding that DLSMC is solidarily liable
w/ respondent doctors
 SC erred in increasing the award of damages
 LEGAL MEDICINE

In the Resolution of February 21, 2000, this Court denied the motions for reconsideration of private respondents Drs. Hosaka and
Gutierrez. They then filed their respective second motions for reconsideration. The Philippine College of Surgeons filed its Petition-
in-Intervention contending in the main that this Court erred in holding private respondent Dr. Hosaka liable under the captain of
the ship doctrine. According to the intervenor, said doctrine had long been abandoned in the United States in recognition of the
developments in modern medical and hospital practice. On March 19, 2001, the Court heard the oral arguments of the parties,
including the intervenor.

ISSUES:
1. Whether or not Dr. Orlino Hosaka (surgeon) is liable for negligence - YES
2. Whether or not Dr. Perfecta Gutierrez (anesthesiologist) is liable for negligence - YES
3. Whether or not the hospital (DELOS SANTOS MEDICAL CENTER) is liable for any act of negligence committed by their visiting
consultant surgeon and anesthesiologist - NO

RULING:
Dr. Gutirrez is liable for negligence
The conduct of a preanesthetic/preoperative evaluation prior to an operation, whether elective or emergency, cannot be dispensed
with. Such evaluation is necessary for the formulation of a plan of anesthesia care suited to the needs of the patient concerned.
Clearly, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. As she herself admitted, she saw Erlinda
for the first time on the day of the operation itself, one hour before the scheduled operation. Had she been able to check petitioner
Erlinda’s airway prior to the operation, Dr. Gutierrez would most probably not have experienced difficulty in intubating the former,
and thus the resultant injury could have been avoided.

Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that caused her
comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on
her. In the first place, Dr. Eduardo Jamora, the witness who was presented to support her (Dr. Gutierrez) theory, was a
pulmonologist. Thus, he could not be considered an authority on anesthesia practice and procedure and their complications.
Secondly, there was no evidence on record to support the theory that Erlinda developed an allergic reaction to pentothal.

The Court also has no reason to disbelieve the testimony of Cruz. As we stated in the Decision, she is competent to testify on
matters which she is capable of observing such as, the statements and acts of the physician and surgeon, external appearances
and manifest conditions which are observable by any one. Cruz, Erlinda’s sister-in-law, was with her inside the operating room.
Moreover, being a nurse and Dean of the Capitol Medical Center School of Nursing at that, she is not entirely ignorant of anesthetic
procedure. The injury incurred by petitioner Erlinda does not normally happen absent any negligence in the administration of
anesthesia and in the use of an endotracheal tube. In Voss vs. Bridwell, which involved a patient who suffered brain damage due
to the wrongful administration of anesthesia, and even before the scheduled mastoid operation could be performed, the Kansas
Supreme Court applied the doctrine of res ipsa loquitur, reasoning that the injury to the patient therein was one which does not
ordinarily take place in the absence of negligence in the administration of an anesthetic, and in the use and employment of an
endotracheal tube. Considering the application of the doctrine of res ipsa loquitur, the testimony of Cruz was properly given
credence in the case at bar.

The application of res ipsa loquitur in medical negligence cases presents a question of law since it is a judicial function to determine
whether a certain set of circumstances does, as a matter of law, permit a given inference. It is availed by the plaintiff, the need for
expert medical testimony is dispensed with because the injury itself provides the proof of negligence - applicable in this case. The
doctrine of res ipsa loquitur can have no application in a suit against a physician or surgeon which involves the merits of a diagnosis
or of a scientific treatment.

Dr. Hosaka is likewise liable for negligence; Captain of the Ship doctrine
That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does not mean that this Court
will ipso facto follow said trend. Due regard for the peculiar factual circumstances obtaining in this case justify the application of
the Captain-of-the-Ship doctrine. While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their
performance of acts within their respective fields of expertise for the treatment of petitioner Erlinda, and that one does not exercise
control over the other, they were certainly not completely independent of each other so as to absolve one from the negligent acts
of the other physician.

Dr. Hosaka cannot now claim that he was entirely blameless of what happened to Erlinda. His conduct clearly constituted a breach
of his professional duties to Erlinda. Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of
petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the greatest solicitude,
 LEGAL MEDICINE

giving them always his best talent and skill," but also of Article 19 of the Civil Code which requires a person, in the performance
of his duties, to act with justice and give everyone his due.

There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC
solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil Code
DLSMC however contends that applying the four-fold test in determining whether such a relationship exists between it and the
respondent doctors, the inescapable conclusion is that DLSMC cannot be considered an employer of the respondent doctors.

It has been consistently held that in determining whether an employer-employee relationship exists between the parties, the
following elements must be present: (1) selection and engagement of services; (2) payment of wages; (3) the power to hire and
fire; and (4) the power to control not only the end to be achieved, but the means to be used in reaching such an end.

DLSMC argues, among others, that when a doctor refers a patient for admission in a hospital, it is the doctor who prescribes the
treatment to be given to said patient. The hospital’s obligation is limited to providing the patient with the preferred room
accommodation, the nutritional diet and medications prescribed by the doctor, the equipment and facilities necessary for the
treatment of the patient, as well as the services of the hospital staff who perform the ministerial tasks of ensuring that the doctor’s
orders are carried out strictly.

Neither is there any showing that it is DLSMC which pays any of its consultants for medical services rendered by the latter to their
respective patients. Moreover, the contract between the consultant in respondent hospital and his patient is separate and distinct
from the contract between respondent hospital and said patient. The first has for its object the rendition of medical services by the
consultant to the patient, while the second concerns the provision by the hospital of facilities and services by its staff such as
nurses and laboratory personnel necessary for the proper treatment of the patient. Further, no evidence was adduced to show
that the injury suffered by petitioner Erlinda was due to a failure on the part of respondent DLSMC to provide for hospital facilities
and staff necessary for her treatment.

For these reasons, we reverse the finding of liability on the part of DLSMC for the injury suffered by petitioner Erlinda.

It necessary to modify the award of damages to petitioners in view of the supervening event of petitioner Erlinda’s death.
Our rules on actual or compensatory damages generally assume that at the time of litigation, the injury suffered as a consequence
of an act of negligence has been completed and that the cost can be liquidated. However, these provisions neglect to take into
account those situations, as in this case, where the resulting injury might be continuing and possible future complications directly
arising from the injury, while certain to occur, are difficult to predict.

In the instant case, petitioners were able to provide only home-based nursing care for a comatose patient who has remained in
that condition for over a decade. Having premised our award for compensatory damages on the amount provided by petitioners
at the onset of litigation, it would be now much more in step with the interests of justice if the value awarded for temperate damages
would allow petitioners to provide optimal care for their loved one in a facility which generally specializes in such care. Under the
circumstances, an award of P1,500,000.00 in temperate damages would therefore be reasonable.

However, subsequent to the promulgation of the Decision, the Court was informed by petitioner Rogelio that petitioner Erlinda
died on August 3, 1999.55 In view of this supervening event, the award of temperate damages in addition to the actual or
compensatory damages would no longer be justified since the actual damages awarded in the Decision are sufficient to cover the
medical expenses incurred by petitioners for the patient. Hence, only the amounts representing actual, moral and exemplary
damages, attorney’s fees and costs of suit should be awarded to petitioners.

WHEREFORE, the assailed Decision is hereby modified as follows:

(1) Private respondent De Los Santos Medical Center is hereby absolved from liability arising from the injury suffered by petitioner
Erlinda Ramos on June 17, 1985;
(2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta Gutierrez are hereby declared to be solidarily liable for the injury
suffered by petitioner Erlinda on June 17, 1985 and are ordered to pay petitioners—
(a) P1,352,000.00 as actual damages;
(b) P2,000,000.00 as moral damages;
(c) P100,000.00 as exemplary damages;
(d) P100,000.00 as attorney’s fees; and
(e) the costs of the suit