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TOM Notes on Medical Jurisprudence & Legal Medicine (2015)

OUTLINE
I. Theoretical Framework & Key Ideas
II. The Medical Act of 1959 (RA 2382)
III. Medical Negligence Cases
A. Doctrine of Res Ipsa Loquitur (DRIL)
B. Captain of the Ship Doctrine (CSD)
C. Doctrine of Informed Consent (DIC)
D. Medical Malpractice (MM)
IV. Liability of Hospitals vis-a-vis Physicians
A. Doctrine of Vicarious Liability (DVL) or Principle of Respondeat
Superior (PRS)
B. Doctrine of Ostensible Agency (DOA) or Principle Apparent
Authority (PAA)
C. Principle of Corporate Negligence (PCN)
V. Legal Medicine matters
A. Significance of the study for lawyers
B. The human body
C. Examination of the human body
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THEORETICAL FRAMEWORK & KEY IDEAS

A. On the Medical Profession


1. Medical Act
2. PMA Code of Ethics

B. Medical Negligence Cases


1. Res Ipsa Loquitur (RIL): remedial in nature, not substantive.
Three requisites:
a. the accident would not have ordinarily occurred were it not
for the negligence of the physician;
b. it was caused by an instrumentality within the exclusive
control of the physician (NB: Exclusive control is under the CAPTAIN OF
THE SHIP DOCTRINE)
c. there is no contributory negligence on the part of the
patient.

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2. Captain of the Ship Doctrine (CSD)
a. This is a species of the Doctrine of Vicarious Liability
(infra). EG: The surgeon, as head of the surgical operation, can be held
liable for the acts of the other members of the team. This refers only to
civil liability as criminal liability is non-transferable (i.e., civil
liability can be transferred to the captain of the ship).
b. cf. Ramos case where CSD was questioned as it does not
apply anymore abroad (i.e., the trend is to scrap the doctrine based on the
recent developments in the field of medicine). SC said it still applies in
PH for practical purposes.

3. Doctrine of Informed Consent: 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. Four essential elements:
a. the physician had a duty to disclose material risks;
b. he failed to disclose or inadequately disclosed those risks;
c. as a direct and proximate result of the failure to disclose,
the patient consented to treatment she otherwise would not have
consented to; and
d. plaintiff was injured by the proposed treatment.

4. Elements/Requisites for Medical Negligence cases per se.


a. Duty. Determine first if there is a physician-patient
relationship.
b. Breach of the duty.
c. There’s injury on the patient.
d. There’s a causal connection between the breach & injury.

5. Instances when negligence is not automatic


a. Mistake in diagnosis. This cannot be auto-equated to
medical negligence, not even to RIL.
b. Physician’s discretion as to the management of the
patient. Failure to apply the correct management is not equated to medical
negligence.

6. Proving medical negligence


a. Mainly: that the physician failed to follow the standard
level of care followed in his field of specialisation and in the
neighbourhood where he practices.
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b. How? Present an expert witness to identify:
i. standard level of care
ii. if the physician followed such standard
iii. and to establish all the requisites of medical
negligence (4a-d, supra).
c. Who is an expert witness?
i. someone within the same specialty and same general
neighbourhood (locality rule): because standard of care may vary from
specialty-to-specialty, and locality-to-locality.
ii. However, in the case of Casumpang vs. Cortejo (11
March 2015), the Court seemed to ‘flip-flop’ as it allowed the presentation
of an expert witness who comes from a different specialty. The court
cited jurisprudence to justify that the witness has the requisite
qualifications: the trend abroad is that as long as the expert witness is
knowledgeable as to the practice, he can be admitted as one. However,
according to Sir, this is not yet final. It is subject to M/R.

C. Doctrines as to the Liability of Hospitals vis-a-vis the physicians


1. Doctrine of Vicarious Liability (DVL)
a. There must be ER-ER relationship for this to apply, where
ER is held liable for the acts of his EE (NB: essence of vicarious liability:
when one person is held liable for the acts of another person).
b. Legal basis: The ER’s failure to supervise, not the fault of
the EE.
c. This may not apply to many physicians who are considered as
independent contractors vs. nurses. Hence:
i. Nurses/Doctors who are EEs = hospital is liable.
ii. Doctors who are independent contractors = hospital is
not liable; doctors carry their own responsibility.

2. Doctrine of Ostensible Agency (DOA)


a. The principal can be held liable for the acts of his agent.

3. Doctrine of Corporate Negligence (DCN)


a. The relationship between the patient and the hospital is
contractual in nature, like that between the patient and the doctor.
Hence, a violation/breach can lead to civil liability.
b. As a corporation, it is the hospital’s duty to ensure safety
inside the hospital. Without it, it incurs civil liability.
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c. TheHospital has its own established standard of
conduct as a corporation and it failed to follow such standard, and
there is resulting injury or death to the patient.
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THE MEDICAL ACT of 1959 (RA 2382)

A. Main purpose of the act: regulates the practice of medicine in PH

B. Who enforces the regulatory role/duty?


1. Commission on Higher Education (CHED): it assumed the role of
the Board of Medical Education mentioned in the Act.
a. For the regulation of medical education
b. accreditation of hospitals, medical education curricula,
student-faculty ratio, etc.

2. Board of Medicine (BOM) of the Philippine Regulatory


Commission (PRC): assumed the role of the Board of Medical Examiners in
the Act.
a. For the regulation of medical practice
b. Board is composed of medical doctors appointed by the
President from a shortlist made by PMA.
c. Gatekeeper of the medical profession (they control who
comes in)
d. Other functions: prepare medical board exams (August &
Feb); set the passing rate; administer Hippocratic Oath; sign/issue
certificates of registration (COR); power to investigate for any violation of
the Medical Act.

C. BOM as a Quasi-Judicial (QJ) Agency/Body


a. Powers of BOM as a QJA
i. Power to hear & decide cases (on Administrative cases)
ii. Power to issue subpoenas
iii. Power to hold somebody in contempt for discourteous acts
directed against the court.

b. Three-levels of administrative complaints that prosper; their


effects are:
i. Reprimand
ii. Revocation of the COR (surrender the PRC card)
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iii. Suspension from practice.

D. The physician
1. Practice of Medicine (definition)
[] RA 4224: Sec. 10. Acts constituting practice of medicine. A
person shall be considered as engaged in the practice of medicine
(a) who shall, for compensation, fee, salary or reward in any
form paid to him directly or through another, or even without the same,
physically examine any person, and diagnose, treat, operate or
prescribe any remedy for human disease, injury, deformity, physical,
mental, psychical condition or any ailment, real or imaginary, regardless
of the nature of the remedy or treatment administered, prescribed or
recommended; or
(b) who shall by means of signs, cards, advertisements,
written or printed matter, or through the radio, television or any other
means of communication, either offer or undertake by any means or
method to diagnose, treat, operate or prescribe any remedy for any human
disease, injury, deformity, physical, mental or psychical condition; or
(c) who shall falsely use the title of M.D. after his name.
*Avoid people from being defrauded
*Scenarios:
i. If you get someone’s temperature or blood pressure?
The mere act is not practice of medicine.
ii. However, if after measuring one’s bp, you say that the
patient has high blood, advised him to take medicines and return to you,
that’s already an act of diagnosing and prescribing medicines.

2. Who are not covered by the definition of practice of medicine?


[] RA 4224: Sec. 11. Exemptions. The preceding section shall
not be construed to affect
(a) any medical student duly enrolled in an approved
medical college or school, or graduate under training, serving without any
professional fee in any government or private hospital, provided that he
render such service under the direct supervision and control of a registered
physician;
*a student cannot disguise himself as a professional
doctor; he cannot charge a fee
(b) any legally registered dentist engaged exclusively in the
practice of dentistry;
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*dentists, nurses, optometrists, etc. are governed by their
own licensing laws (gives them authority to diagnose, treat, prescribe… as
in the case of dentists); includes vets.
(c) any duly registered masseur or physiotherapist,
provided that he applies massage or other physical means upon written
order or prescription of a duly registered physician, or provided that such
application of massage or physical means shall be limited to physical or
muscular development;
(d) any duly registered optometrist who mechanically fits or
sells lenses, artificial eyes, limbs or other similar appliances or who is
engaged in the mechanical examination of eyes for the purpose of
constructing or adjusting eyeglasses, spectacles and lenses;
(e) any person who renders any service gratuitously in cases
of emergency, or in places where the services of a duly registered
physician, nurse or midwife are not available;
*nagmamagandang loob lang po! This is called the
GOOD SAMARITAN LAW in American Jurisprudence.
(f ) any person who administers or recommends any
household remedy as per classification of existing Pharmacy Laws;
(g) any clinical psychologist, or mental hygienist, in the
performance of his duties in regard to patients with psychiatric problems,
provided such performance is done with the prescription and direct
supervision of a duly registered physician, and
(h) prosthetists who fit artificial limbs under the supervision
of a registered physician.

3. Instances when no Certificate of Registration (COR) is required


[] Sec. 12. Limited practice without any certificate of
registration. Certificates of registration shall not be required of the
following persons:
"(a) Physicians and surgeons from other countries called in
consultation only and exclusively in specific and definite case, or those
attached to international bodies or organizations assigned to perform
certain definite work in the Philippines, provided they shall limit their
practice to the specific work assigned to them and provided further they
shall secure a previous authorization from the Board of Medical
Examiners.
"(b) Commissioned medical officers of the United States Armed
Forces stationed in the Philippines while rendering service as such only
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for the members of the said armed forces and within the limit of their own
respective territorial jurisdiction.
"(c) Foreign physicians employed as exchange professors in special
branches of medicine or surgery whose service may, upon previous
authorization of the Board of Medical Examiners, be necessary.
“(d) Medical students who have completed the first four years of
medical course, graduates of medicine and registered nurses who may
be given limited and special authorization by the Secretary of Health to
render services during epidemics or national emergencies whenever
the services of duly registered physicians are not available. Such
authorization shall automatically cease when the epidemic or national
emergency is declared terminated by the Secretary of Health.

4. Kinds of MDs.
*Below are all called Doctors of Medicine or MDs (as a lawyer,
you have to know what type of MD they are; knowing the difference will
help win a case, say, the one who signed the medical certificate is only a
clerk vs. a specialist):
a. Clerk
b. Intern
c. Resident
d. Specialist
e. Sub-specialist
*An MD is not necessarily a licensed doctor; after
graduating from the college of medicine, one is granted an MD degree and
it can be affixed after one’s name (see the MDs in the UST hospital who
have not yet taken the board).

5. Qualifications (three basic requirements)


a. Age: 21 y/o
b. Pass the board exam
c. Holder of a valid Certificate of Registration (COR): BEST
EVIDENCE that a person is a physician and can engage in the practice of
medicine. Without COR, one is engaged in an illegal practice of medicine.
*NB: There is no requirement of holding a PRC license. Hence,
say a doctor who is about to operate on a patient realises that his PRC
license has expired. Can he still operate? Yes, as long as he has a valid COR.
[] Section 8. Prerequisite to the practice of medicine. No
person shall engage in the practice of medicine in the Philippines unless
he is at least twenty-one years of age, has satisfactorily passed the
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corresponding Board Examination, and is a holder of a valid
Certificate of Registration duly issued to him by the Board of Medical
Examiners.

6. Duty of BOM to issued COR is discretionary, not ministerial.


Fatima case: They passed the exam but did not satisfactorily meet all the
requirements. Hence, the BOM can prevent them from taking the oath.
a. Hence BOM CANNOT BE COMPELLED BY MANDAMUS
because
i. IT IS DISCRETIONARY on the part of the board. They
grant it only when the candidate SATISFACTORY QUALIFIED to the
MENTAL and MORAL standards set by the law.
ii. The FUNCTION of mandamus is NOT TO ESTABLISH
A RIGHT BUT TO ENFORCE ONE that has been established by law. And a
LICENSE to PRACTICE MEDICINE is a PRIVILEGE or FRANCHISE
granted by the Government, NOT A RIGHT.
b. For mandamus to prosper, there must be a showing that
(PRC vs. De Guzman 2004):
i. the officer, board, or official concerned, has a CLEAR
LEGAL DUTY, NOT INVOLVING DISCRETION
ii. there must be STATUTORY AUTHORITY for the
performance of the act, and
iii. the performance of the duty has been REFUSED.
c. PRC has no “duty to administer the Hippocratic Oath and
register respondents as physicians under the Medical Act of 1959” until
the MORAL AND MENTAL FITNESS of the respondents could be
ascertained, according to petitioners, the BOARD HAS DISCRETION to
hold in ABEYANCE the administration of the Hippocratic Oath and the
issuance of the certificates to them. The writ of mandamus does not lie to
compel performance of an act which is not duly authorized.
d. On resolving the PRC vs. De Guzman case, legal bases:
[] Section 20: the Board shall not issue a certificate of
registration only in the following instances:
(1) to any candidate who has been convicted by a court of
competent jurisdiction of any criminal offense involving moral turpitude;
(2) or has been found guilty of immoral or dishonorable
conduct after the investigation by the Board; or
(3) has been declared to be of unsound mind.
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[] Section 8[30] of Rep. Act No. 2382 prescribes, among others,
that a person who aspires to practice medicine in the Philippines, must
have “satisfactorily passed the corresponding Board Examination.”
[] Section 22, in turn, provides that the oath may only be
administered “to physicians who qualified in the examinations.”
e. The operative word here is “SATISFACTORILY,” defined as
“SUFFICIENT to meet a condition or obligation” or “capable of
dispelling doubt or ignorance.” Gleaned from Board Resolution No. 26,
the licensing authority apparently did not find that the respondents
“satisfactorily passed” the licensure examinations. The Board instead
sought to nullify the examination results obtained by the respondents.
f. PRC vs. De Guzman 2004: Mandamus is a command issuing
from a court of competent jurisdiction, in the name of the state or the
sovereign, directed to some inferior court, tribunal, or board, or to some
corporation or person requiring the performance of a particular duty
therein specified, which duty results from the official station of the party to
whom the writ is directed, or from operation of law.
g. Section 3 of Rule 65[18] of the 1997 Rules of Civil Procedure
outlines two situations when a writ of mandamus may issue, when any
tribunal, corporation, board, officer or person unlawfully
(1) neglects the performance of an act which the law
specifically enjoins as a duty resulting from an office, trust, or station; or
(2) excludes another from the use and enjoyment of a
right or office to which the other is entitled.

7. PRACTICE OF MEDICINE IS A PRIVILEGE, NOT A RIGHT. The


function of mandamus is not to establish a right but to enforce one that
has been established by law. If no legal right has been violated, there can
be no application of a legal remedy, and the writ of mandamus is a legal
remedy for a legal right. There must be a well-defined, clear and certain
legal right to the thing demanded. It is long established rule that a license
to practice medicine is a privilege or franchise granted by the government.

8. Can a physician choose his patients? Yes. But in case of


emergency, he has to administer first aide (if there is no risk to his life)
a. Article II PMA Code of Ethics:
Section 2. A physician should be free to choose patients.
Section 3. In an emergency, provided there is no risk to his
or her safety, a physician should administer at least first aid treatment
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and then refer the patient to the primary physician and/or to a more
competent health provider and appropriate facility if necessary.
Section 4. In serious/difficult cases, or when the
circumstances of the patient or the family so demand or justify, the
attending physician should seek the assistance of the appropriate
specialist.

E. Grounds to hold a physician liable


*NB: the last ground makes the list non-exclusive
[] Section 24. Grounds for reprimand, suspension or revocation of
registration certificate. Any of the following shall be sufficient ground for
reprimanding a physician, or for suspending or revoking a certificate
of registration as physician: (CIdI-FG-AAA-KIA-Code)
(1) Conviction by a court of competent jurisdiction of any criminal
offense involving moral turpitude;
*Moral turpitude: ENCOMPASSES EVERYTHING DONE
CONTRARY TO JHG: JUSTICE, HONESTY, GOOD MORALS
- In Villaber v. Commision on Elections: As to the meaning of
"moral turpitude," we have consistently adopted the definition in Black's
Law Dictionary as "an act of baseness, vileness, or depravity in the
private duties which a man owes his fellow men, or to society in general,
contrary to the accepted and customary rule of right and duty between
man and woman, or conduct contrary to justice, honesty, modesty, or good
morals."
- In In re Vinzon, the term "moral turpitude" is considered as
encompassing "everything which is done contrary to justice, honesty, or
good morals.”
(2) Immoral or dishonorable conduct;
(3) Insanity;
(4) Fraud in the acquisition of the certificate of registration;
(5) Gross negligence, ignorance or incompetence in the practice
of his or her profession resulting in an injury to or death of the patient;
(6) Addiction to alcoholic beverages or to any habit forming drug
rendering him or her incompetent to practice his or her profession, or to
any form of gambling;
(7) False or extravagant or unethical advertisements wherein other
things than his name, profession, limitation of practice, clinic hours, office
and home address, are mentioned.
(8) Performance of or aiding in any criminal abortion;
(9) Knowingly issuing any false medical certificate;
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(10) Issuing any statement or spreading any news or rumor which is
derogatory to the character and reputation of another physician without
justifiable motive;
(11) Aiding or acting as a dummy of an unqualified or unregistered
person to practice medicine;
(12) Violation of any provision of the Code of Ethics as approved by
the Philippine Medical Association.
*Refusal of a physician to attend a patient in danger of death is not a
sufficient ground for revocation or suspension of his registration
certificate if there is a risk to the physician's life.

F. Three-fold liabilities of a physician


1. Administrative
a. According to the Medical Act; Violation of grounds may lead
to mere reprimand/admonishment, suspension, revocation of
license/COR.
b. Procedure:
i. File before BOM-PRC, which has exclusive
jurisdiction (not CSC; neither PMA); not even the court can revoke a
physician’s license at the first instance.
ii. Adverse ruling is appealable directly with the
commission (PRC).
iii. From PRC to CA via Rule 43 ROC (Appeal to
decisions of QJAs). There is no need to go to the Office of the President
(OP). PRC is not anymore under the OP; it is now under SOLE. NB: in
one case, the R43 route was questioned because PRC was not in the list of
QJAs under the rule. SC said that the enumeration is not exclusive.
iv. From CA to SC under Rule 45
v. NB: Rule 65 is last resort!

2. Civil
a. refers to DAMAGES: certain amount of money
b. File before regular court depending on the amount of
damages: MTC: up to 300K (400K in MM), the rest at RTC (including
those incapable of pecuniary estimation).

3. Criminal
a. file at the regular court depending on the crime; if
punishable up to 6 years, MTC; the rest at RTC.
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ON PRC AS A QUASI-JUDICIAL AGENCY.
a. ALTHOUGH NOT EXPRESSLY MENTIONED UNDER SEC 1, R43
ROC. In virtue of BP 129, appeals from the Professional Regulations
Commission are now exclusively cognizable by the Court of Appeals.
b. Lasam v. Ramolete 2008: Indeed, the PRC is not expressly
mentioned as one of the agencies which are expressly enumerated under
Section 1, Rule 43 of the Rules of Court. However, its absence from the
enumeration does not, by this fact alone, imply its exclusion from the
coverage of said Rule. The Rule expressly provides that it should be applied
to appeals from awards, judgments final orders or resolutions of any quasi-
judicial agency in the exercise of its quasi-judicial functions. The phrase
"among these agencies" confirms that the enumeration made in the Rule is
not exclusive to the agencies therein listed.
c. Specifically, the Court, in Yang v. Court of Appeals, ruled that Batas
Pambansa (B.P.) Blg. 129 conferred upon the CA exclusive appellate
jurisdiction over appeals from decisions of the PRC. The Court held: The
law has since been changed, however, at least in the matter of the
particular court to which appeals from the Commission should be taken.
On August 14, 1981, Batas Pambansa Bilang 129 became effective and in its
Section 29, conferred on the Court of Appeals "exclusive appellate
jurisdiction over all final judgments, decisions, resolutions, orders or
awards of Regional Trial Courts and quasi-judicial agencies,
instrumentalities, boards or commissions except those falling under the
appellate jurisdiction of the Supreme Court. x x x." In virtue of BP 129,
appeals from the Professional Regulations Commission are now exclusively
cognizable by the Court of Appeals.
d. Clearly, the enactment of B.P. Blg. 129, the precursor of the present
Rules of Civil Procedure, lodged with the CA such jurisdiction over the
appeals of decisions made by the PRC.

G. Penalties for illegal practice of medicine:


[] Section 28. Penalties. Any person found guilty of "illegal practice of
medicine" shall be punished by a fine of not less than one thousand pesos
nor more than ten thousand pesos with subsidiary imprisonment in
case of insolvency, or by imprisonment of not less than one year nor
more than five years, or by both such fine and imprisonment, in the
discretion of the court.
*why is five (5) years significant? It’s PROBATIONABLE!

H. Remedies (what a lawyer should know):


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a. lawyering against a physician:
i. File the case at the BOM-PRC. Never filed it before the CSC!
That’s the old procedure (old lawyers still follow this because they base it
on the old Act). And never before the PMA!
ii. Appellate route: from PRC to CA under Rule 43, since BOM is
a QJA. In the old rule, it was from the Board to CSC to the O.P. before
going to CA.

b. lawyering for a physician accused & held liable by the BOM


(license revoked, for example):
i. file M/R at the BOM level
ii. Then to PRC level
iii. What if you failed to file an M/R and the decision has
become final? Don’t despair. File a PETITION FOR REINSTATEMENT
after two (2) years before the BOM. Show proof that he is not
disqualified anymore; that he is a good member of society, etc. Decision is
discretionary on the BOM.

I. The Philippine Medical Association (PMA).


a. Two roles:
i. Submit list to the President for the appointment of the
board members of BOM-PRC.
ii. Approve the Code of Ethics for physicians.
b. It’s only an accredited professional organization (APO) of
medical doctors. It does not have an authority to decide on administrative
cases against physicians. It’s a private entity. It cannot sanction/suspend
physicians; cannot revoke their license; cannot even reprimand them.
c. Besides, PMA membership is optional, unlike IBP for lawyers.
Non-membership in PMA does not lessen one’s authority to practice
medicine.

J. Other Information about the act:


1. Amended twice but in both cases, it did not affect the regulation of
the practice of medicine.
2. There is now a pending bill in congress: the Physicians License Act
but it’s still at the committee level, since the year 2000.
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DOCTRINE OF RES IPSA LOQUITUR [DRIL]

1. ELEMENTS [Cantre v. Go]


*DRIL allows the MERE EXISTENCE OF AN INJURY to JUSTIFY A
PRESUMPTION OF NEGLIGENCE
a. The ACCIDENT is of a KIND which ORDINARILY DOES NOT
OCCUR IN THE ABSENCE OF someone's NEGLIGENCE;
b. It is CAUSED BY AN INSTRUMENTALITY within the EXCLUSIVE
CONTROL of the defendant/s; and
*Exclusive control is under the CAPTAIN OF THE SHIP
DOCTRINE [Cantre v. Go] (infra)
c. The POSSIBILITY OF CONTRIBUTING CONDUCT which would
make the plaintiff responsible IS ELIMINATED.
*As applied to Batiquin v. CA: First, the entire proceedings of the
caesarean section were under the EXCLUSIVE CONTROL of Dr. Batiquin.
In this light, the private respondents were bereft of direct evidence as to
the actual culprit or the exact cause of the foreign object finding its way
into private respondent Villegas's body, which, needless to say, does not
occur unless through the intersection of negligence. Second, since aside
from the caesarean section, private respondent Villegas UNDERWENT NO
OTHER OPERATION which could have caused the offending piece of
rubber to appear in her uterus, it stands to reason that such could only
have been a by-product of the caesarean section performed by Dr.
Batiquin.

2. INTENT IS IMMATERIAL IN NEGLIGENCE CASES: where negligence


exists and is proven, it automatically gives the injured a right to
reparation for the damage caused

3. How to word it best: The physician failed to overcome the


PRESUMPTION OF NEGLIGENCE ARISING FROM THE DRIL. He is,
therefore, liable for negligently “put the act here” and for ALL THE
ADVERSE EFFECTS thereof.

4. THE DOCTRINE
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*Batiquin v. CA: “Where the thing which causes injury is shown to be
under the management of the defendant, and the accident is such as in
the ordinary course of things does not happen in those who have the
management use proper care, it affords reasonable evidence, in the
absence of an explanation by the defendant, that the accident arose
from want of care.”

5. WHAT IT IS
a. a RULE OF EVIDENCE that is PECULIAR TO THE LAW OF
NEGLIGENCE
b. It recognizes that PRIMA FACIE NEGLIGENCE may be
ESTABLISHED WITHOUT DIRECT PROOF and
c. it furnishes a SUBSTITUTE FOR SPECIFIC PROOF OF
NEGLIGENCE.
d. It is NOT A RULE OF SUBSTANTIVE LAW, but merely a mode of
proof or a MERE PROCEDURAL CONVENIENCE.
e. When applicable, it is NOT INTENDED TO AND DOES NOT
DISPENSE WITH the REQUIREMENT OF PROOF OF CULPABLE
NEGLIGENCE on the party charged.
*It merely determines and regulates what shall be prima facie
evidence thereof and facilitates the burden of plaintiff of proving a
breach of the duty of due care.
f. It can be INVOKED WHEN AND ONLY WHEN, under the
circumstances involved, DIRECT EVIDENCE IS ABSENT AND NOT
READILY AVAILABLE.
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CAPTAIN OF THE SHIP DOCTRINE [CSD]

1. WHAT IT IS
a. PATIENT IS UNDER THE EXCLUSIVE CONTROL OF THE
PHYSICIAN, HE BEING THE LEADER OF THE TEAM THAT ATTENDS
TO THE PATIENT.
b. PHYSICIAN EXERCISED A CERTAIN DEGREE OF CONTROL, OR
AT THE VERY LEAST, SUPERVISION OVER THE ENTIRE PROCEDURE
c. IT DOES NOT MEAN ONE EXERCISES CONTROL OVER
A N O T H E R . T H E Y J U S T N E E D T O H AV E A C O M M O N
RESPONSIBILITY TO TREAT THE PATIENT
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*Applied in Ramos v. CA: From the facts on record it can be logically
inferred that Dr. Hosaka exercised a certain degree of, at the very least,
supervision over the procedure then being performed on Erlinda.
First, it was Dr. Hosaka who RECOMMENDED to petitioners THE
SERVICES of Dr. Gutierrez. In effect, he REPRESENTED to petitioners
that Dr. Gutierrez possessed the necessary competence and skills. Drs.
Hosaka and Gutierrez had worked together since 1977. Whenever Dr.
Hosaka performed a surgery, he would always engage the services of Dr.
Gutierrez to administer the anesthesia on his patient.
Second, Dr. Hosaka himself ADMITTED THAT HE WAS THE
ATTENDING PHYSICIAN of Erlinda. Thus, when Erlinda showed signs of
cyanosis, IT WAS DR. HOSAKA WHO GAVE INSTRUCTIONS TO CALL
FOR ANOTHER anesthesiologist and cardiologist to help resuscitate
Erlinda.
Third, it is conceded that in performing their responsibilities to the
patient, Drs. Hosaka and Gutierrez WORKED AS A TEAM. THEIR WORK
CANNOT BE PLACED IN SEPARATE WATERTIGHT COMPARTMENTS
because their DUTIES INTERSECT with each other.
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.

2. REJECTION OF U.S. OF CSD DOES NOT MEAN WE FELLOW THE


TREND (infra)
*Ramos v. CA: 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.

3. REJECTED IN THE US SUPREME COURT DUE TO THE FIELD OF


MEDICINE HAVING BECOME SPECIALIZED, SUCH THAT SURGEONS
CAN NO LONGER DEEMED TO HAVE CONTROL OVER OTHER
PERSONNEL IN THE OPERATING ROOM
*Thomas v. Raleigh General Hospital: suit filed by a patient who lost
his voice due to the wrongful insertion of the endotracheal tube
preparatory to the administration of anesthesia in connection with the
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laparotomy to be conducted on him. The patient sued both the
anesthesiologist and the surgeon for the injury suffered by him.
The Supreme Court of Appeals of West Virginia held that the
surgeon could not be held liable for the loss of the patient’s voice,
considering that the surgeon did not have a hand in the intubation of the
patient. The court rejected the application of the “Captain-of-the-Ship
Doctrine,” citing the fact that the field of medicine has become specialized
such that surgeons can no longer be deemed as having control over the
other personnel in the operating room. It held that “[a]n assignment of
liability based on actual control more realistically reflects the actual
relationship which exists in a modern operating room.”
Hence, only the anesthesiologist who inserted the endotracheal tube
into the patient’s throat was held liable for the injury suffered by the latter.

4. TWO MINOR VIOLATIONS


a. VIOLATION OF PHYSICIAN’S DUTY TO SERVE HIS PATIENT
WITH GREATEST SOLICITUDE, BEST TALENT & SKILL
b. ARTICLE 19: ACT WITH JUSTICE, GIVE EVERYONE HIS DUE
*Ramos v. CA: 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, giving them always his best talent and skill,”[Batiquin v.
CA; Carillo v. PP] 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.
i. ARRIVED LATE: MORE THAN 3 HOURS AFTER
SCHEDULE. It is equally important to point out that Dr. Hosaka was
remiss in his duty of attending to petitioner Erlinda promptly, for he
arrived more than three (3) hours late for the scheduled operation. The
cholecystectomy was set
for June 17, 1985 at 9:00 a.m., but he arrived at DLSMC only at around 12:10
p.m.
ii. RECKLESS DISREGARD FOR PATIENT’S WELL-BEING:
SCHEDULED TWO PROCEDURES ON THE SAME MORNING IN TWO
DIFFERENT HOSPITALS. In reckless disregard for his patient’s well
being, Dr. Hosaka scheduled two procedures on the same day, just thirty
minutes apart from each other, at different hospitals. Thus, when the first
procedure (protoscopy) at the Sta. Teresita Hospital did not proceed on
time, Erlinda was kept in a state of uncertainty at the DLSMC.
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iii. DELAY & RECKLESS DISREGARD BROUGHT HARM TO
PATIENT. The unreasonable delay in petitioner Erlinda’s scheduled
operation subjected her to continued starvation and consequently, to the
risk of acidosis, or the condition of decreased alkalinity of the blood and
tissues, marked by sickly sweet breath, headache, nausea and vomiting,
and visual disturbances. The long period that Dr. Hosaka made Erlinda
wait for him certainly aggravated the anxiety that she must have been
feeling at the time. It could be safely said that her anxiety adversely
affected the administration of anesthesia on her. As explained by Dr.
Camagay, the patient’s anxiety usually causes the outpouring of adrenaline
which in turn results in high blood pressure or disturbances in the heart
rhythm
————————————————————————————————

DOCTRINE OF INFORMED CONSENT (DIC) [Li vs. Sps. Soliman 2011]

1. What DIC means: 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.

2. There are four essential elements a plaintiff must prove in a


malpractice action based upon the doctrine of informed consent:
a. the physician had a duty to disclose material risks;
b. he failed to disclose or inadequately disclosed those risks;
c. as a direct and proximate result of the failure to disclose, the
patient consented to treatment she otherwise would not have consented
to; and
d. plaintiff was injured by the proposed treatment.

3. Gravamen: Burden of Proof lies on the plaintiff (the patient): 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.

4. As applied to the case of Dr. Rubi Li vs. Spouses Soliman 2011: 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
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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 pretreatment 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.
————————————————————————————————

ON MEDICAL MALPRACTICE
*a PARTICULAR FORM OF NEGLIGENCE

1. FOUR ELEMENTS
a. DUTY
i. show PHYSICIAN-PATIENT RELATIONSHIP
ii. PHYSICIAN: bound to use AT LEAST THE SAME LEVEL OF
CARE that any REASONABLE COMPETENT DOCTOR would use to
TREAT A CONDITION UNDER THE SAME CIRCUMSTANCES
b. BREACH
i. BREACH of these PROFESSIONAL DUTIES of SKILL & CARE
ii. or their IMPROPER PERFORMANCE
c. INJURY
i. The breach caused INJURY in BODY or in HEALTH to the
PATIENT, which constitutes ACTIONABLE MALPRACTICE
ii. Causes of INJURY
d. PROXIMATE CAUSATION

2. EXPERT TESTIMONY is ESSENTIAL in the:


a. DETERMINATION of the REASONABLE LEVEL of CARE
b. and the BREACH THEREOF
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c. CAUSES of INJURY (since they are determinable only in the
LIGHT of SCIENTIFIC KNOWLEDGE)
d. and to SUPPORT THE CONCLUSION as to CAUSATION (given
the INJURY and the expected REASONABLE LEVEL OF CARE)

3. QUALIFICATIONS of an EXPERT:
a. Prof’s emphasis:
i. within the same specialization
ii. within the same general neighborhood (locality rule)
*because standard of care may vary from specialty-to-specialty,
and locality-to-locality.

b. Case: Expertise ACQUIRED SPECIAL KNOWLEDGE OF THE


SUBJECT MATTER, EITHER BY
i. STUDY of recognised authorities on the subject
ii. or by PRACTICAL EXPERIENCE
*Lasam v. Ramolete: Generally, to qualify as an expert witness,
one must have acquired special knowledge of the subject matter about
which he or she is to testify, either by the study of recognized authorities
on the subject or by practical experience.
c. However, in the case of Casumpang vs. Cortejo (11 March 2015),
the Court seemed to ‘flip-flop’ as it allowed the presentation of an expert
witness who comes from a different specialty. The court cited
jurisprudence to justify that the witness has the requisite qualifications:
the trend abroad is that as long as the expert witness is knowledgeable as
to the practice, he can be admitted as one. However, according to Sir, this
is not yet final. It is subject to M/R.
d. EFFECT of FAILURE TO bring expert testimony: case will be
dismissed.

4. FAULT OF THE PATIENT


a. PROXIMATE CAUSE of injury/death
b. CONTRIBUTORY NEGLIGENCE: the ACT OR OMISSION
amounting to WANT OF ORDINARY CARE on the part of the person
i n j u re d , wh i c h , CO N C U R R I N G W I T H T H E D E F E N DA N T ’ S
NEGLIGENCE, is the PROXIMATE CAUSE of the injury.
*Lasam v. Remolete: Editha’s omission was the proximate cause of
her own injury and not merely a contributory negligence on her part.
c. EFFECT if acts of patient were the IMMEDIATE CAUSE: HE
CANNOT RECOVER DAMAGES FOR THE INJURY
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*Difficulty seems to be apprehended in deciding which acts of the
injured party shall be considered immediate causes of the accident. Where
the immediate cause of an accident resulting in an injury is the plaintiff’s
own act, which contributed to the principal occurrence as one of its
determining factors, he cannot recover damages for the injury.

5. RELATED CASES
a. Lasam v. Ramolete: Medical malpractice is a particular form of
negligence which consists in the failure of a physician or surgeon to apply
to his practice of medicine that degree of care and skill which is ordinarily
employed by the profession generally, under similar conditions, and in like
surrounding circumstances. In order to successfully pursue such a claim, a
patient must prove that the physician or surgeon either failed to do
something which a reasonably prudent physician or surgeon would not
have done, and that the failure or action caused injury to the patient.
As to this aspect of medical malpractice, the determination of The
reasonable level of care and the breach thereof, expert testimony is
essential. 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.
————————————————————————————————

DOCTRINE OF VICARIOUS LIABILITY (DVL) or RESPONDEAT


SUPERIOR (DRS)

1. Summary:
a. ER-ER relationship must be established
b. Legal basis: The ER’s failure to supervise, not the fault of the
EE; ER is held liable for the acts of his EE (NB: essence of vicarious
liability: when one person is held liable for the acts of another person).
c. This may not apply to many physicians who are considered as
independent contractors vs. nurses.

2. PRINCIPLE OF RESPONDEAT SUPERIOR. HOSPITAL: VICARIOUSLY


LIABLE UNDER Art 2176 irt Art 2180
*Where an EMPLOYMENT RELATIONSHIP EXISTS, the hospital
may be held vicariously liable under Article 2176 in relation to Article 2180
of the Civil Code or the principle of respondeat superior.
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[] 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. (1902a)
[] 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.
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.
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. (1903a)
————————————————————————————————

DOCTRINE OF OSTENSIBLE AGENCY (DOA) or PRINCIPLE OF


APPARENT AUTHORITY (PAA)

1. Summary:
a. No ER-EE relationship exists
b. But the hospital holds itself out to the patient that the doctor is its
agent.
c. And the patient relied on such representation.

2. Check presence of TWO FACTORS. If both are present, hospital is


VICARIOUSLY LIABLE
*PSI v. Agana: Two factors that determine apparent authority:
(1) first, the HOSPITAL’S IMPLIED MANIFESTATION to the patient
which LED THE LATTER TO CONCLUDE THAT THE DOCTOR WAS THE
HOSPITAL’S AGENT; and
(2) second, the PATIENT’S RELIANCE UPON THE CONDUCT OF
THE HOSPITAL AND THE DOCTOR, CONSISTENT WITH ORDINARY
CARE AND PRUDENCE.
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*Application PSI vs. Agana: While there is no employer-employee
relationship between the hospital and doctor, there is ample evidence that
PSI held out to the patient that the doctor was its agent. Present are the
two factors that determine apparent authority… Hence, PSI is vicariously
liable for the negligence of Dr. Ampil as its ostensible agent.

3. HOSPITAL: VICARIOUSLY LIABLE UNDER Art 2176 it Art 1431 and Art
1869
a. Even WHEN NO EMPLOYMENT RELATIONSHIP EXISTS BUT it
is shown that THE HOSPITAL HOLDS OUT TO THE PATIENT THAT
THE DOCTOR IS ITS AGENT, the hospital may still be VICARIOUSLY
LIABLE under Article 2176 in relation to Article1431 and Article 1869 of the
Civil Code or the principle of apparent authority.
[] Art. 1431. Through estoppel an admission or representation is
rendered conclusive upon the person making it, and cannot be denied or
disproved as against the person relying thereon.
[] 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.
Agency may be oral, unless the law requires a specific form.

4. Application in NOGALES v. CMC: In general, a hospital is not liable


for the negligence of an independent contractor-physician. There is,
however, an exception to this principle. The hospital may be liable if the
physician is the “OSTENSIBLE” agent of the hospital. This exception is
also known as the "doctrine of apparent authority."
a. ON THE HOSPITAL’S LIABILITY. Gilbert v. Sycamore Municipal
Hospital: a hospital can be held VICARIOUSLY LIABLE for the negligent
acts of a physician providing care at the hospital, regardless of whether the
physician is an independent contractor, UNLESS THE PATIENT KNOWS,
OR SHOULD HAVE KNOWN, that the physician is an independent
contractor. ELEMENTS (a plaintiff must show that):
(i) the hospital, or its agent, ACTED IN A MANNER That
would LEAD A REASONABLE PERSON TO CONCLUDE that the
individual who was alleged to be negligent was an employee or agent of the
hospital;
*The element of “HOLDING OUT” on the part of the
hospital DOES NOT REQUIRE AN EXPRESS REPRESENTATION by the
hospital that the person alleged to be negligent IN AN EMPLOYEE. Rather,
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the element is SATISFIED IF THE HOSPITAL HOLDS ITSELF OUT AS A
PROVIDER of EMERGENCY ROOM CARE WITHOUT INFORMING the
p a t i e n t t h a t t h e C A R E I S PROV I D E D BY I N D E PE N D E N T
CONTRACTORS.
(ii) where the ACTS OF THE AGENT CREATE THE
APPEARANCE OF AUTHORITY, the plaintiff must also PROVE THAT
THE HOSPITAL HAD KNOWLEDGE OF AND ACQUIESCED IN THEM;
and
(iii) the PLAINTIFF ACTED IN RELIANCE upon the conduct
of the hospital or its agent, consistent with ordinary care and prudence."
*The element of justifiable reliance on the part of the
plaintiff is SATISFIED if the plaintiff RELIES UPON THE HOSPITAL TO
PROVIDE COMPLETE EMERGENCY ROOM CARE, RATHER THAN
UPON A SPECIFIC PHYSICIAN.

5. ON THE INDEPENDENT-CONTRACTOR PHYSICIAN’S LIABILITY.


The doctrine of apparent authority essentially involves two factors to
determine the liability of an independent-contractor physician.
(1) The first factor focuses on the HOSPITAL’S MANIFESTATIONS
manifestations and is sometimes described as an inquiry whether the
HOSPITAL ACTED IN A MANNER WHICH WOULD LEAD A
REASONABLE PERSON TO CONCLUDE THAT THE INDIVIDUAL WHO
WAS ALLEGED TO BE NEGLIGENT WAS AN EMPLOYEE OR AGENT OF
THE HOSPITAL. In this regard, the hospital NEED NOT MAKE EXPRESS
REPRESENTATIONS TO THE PATIENT that the treating physician is an
employee of the hospital; rather a REPRESENTATION MAY BE GENERAL
AND IMPLIED.
(2) The second factor focuses on the PATIENT’S RELIANCE. It is
sometimes characterized as an inquiry on whether the PATIENT ACTED
IN RELIANCE UPON THE CONDUCT OF THE HOSPITAL OR ITS
AGENT, CONSISTENT WITH ORDINARY CARE AND PRUDENCE.

6. DAA (PAA) IS A SPECIES OF THE DOCTRINE OF ESTOPPEL


a. The doctrine of apparent authority is a species of the doctrine of
estoppel. Article 1431 of the Civil Code provides that "[t]hrough estoppel,
an admission or representation is rendered conclusive upon the person
making it, and cannot be denied or disproved as against the person
relying thereon."
b. Estoppel rests on this rule: "Whenever a party has, by his own
declaration, act, or omission, intentionally and deliberately led another to
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believe a particular thing true, and to act upon such belief, he cannot, in
any litigation arising out of such declaration, act or omission, be permitted
to falsify it."
————————————————————————————————

RESPONDEAT SUPERIOR vs. APPARENT AUTHORITY


1. PSI v. Agana: 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.

2. To understand which of the two applies in the case, consider first the
LEGAL RELATIONSHIPS involved (infra)

LEGAL RELATIONSHIPS THAT CRISS-CROSS AMONG THE


HOSPITAL, PHYSICIAN & PARIENT
*PSI v. Agana: While in theory a hospital as a juridical entity cannot
practice medicine, in reality it utilizes doctors, surgeons and medical
practitioners in the conduct of its business of facilitating medical and
surgical treatment. Within that reality, three legal relationships crisscross:
(1) between the HOSPITAL AND THE DOCTOR practicing within
its premises;
(2) between the HOSPITAL AND THE PATIENT being treated or
examined within its premises and (3) between the PATIENT AND THE
DOCTOR.
*The exact nature of each relationship determines the basis and
extent of the liability of the hospital for the negligence of the doctor.
————————————————————————————————

PRINCIPLE OF CORPORATE NEGLIGENCE. HOSPITAL: DIRECTLY


LIABLE

1. Summary:
a. No ER-ER relationship exists
b. Hospital has its own established standard of conduct as a
corporation
c. Hospital fails to follow such standard, and there is resulting
injury or death to the patient.
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2. THERE IS A DEFINED STANDARD OF CONDUCT AND THE
HOSPITAL WAS FOUND WANTING IN OBSERVING IT.
*Applied to PSI v. Agana: That Dr. Ampil negligently failed to notify
Natividad did not release PSI from its self-imposed separate responsibility.
* Moreover, REGARDLESS OF ITS RELATIONSHIP WITH THE
DOCTOR, the hospital may be held DIRECTLY LIABLE to the patient FOR
ITS OWN NEGLIGENCE OR FAILURE TO FOLLOW ESTABLISHED
STANDARD OF CONDUCT TO WHICH IT SHOULD CONFORM AS A
CORPORATION

3. The DUTY TO INITIATE REVIEW on what transpired in the hospital is


NON-DELEGABLE.
*Corollary to its non-delegable undertaking to review potential
incidents of negligence committed within its premises, PSI had the duty to
take notice of medical records prepared by its own staff and submitted to
its custody, especially when these bear earmarks of a surgery gone awry.

4. CORPORATE NEGLIGENCE IS DIFFERENT FROM MEDICAL


NEGLIGENCE OF PHYSICIANS
*DIRECTLY LIABILITY

5. Summary: HOSPITAL CAN BE LIABLE BASED ON BOTH:


a. OSTENSIBLE AGENCY: due to IMPLIED AGENCY with the
physician
b. CORPORATE NEGLIGENCE: due to neglect of ADMITTED
corporate duty
*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 PSIs hospital
liability based on ostensible agency and corporate negligence applies only
to this case, pro hac vice… 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.

6. More on PSI v. Agana


*PSI has defined for itself its STANDARD OF CONDUCT. PSI
admitted that had Natividad Agana informed the hospital of her
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discomfort and pain, the hospital would have been obliged to act on it.
Such statement constitutes JUDICIAL ADMISSION that:
(1) it has 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;
(2) by 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;
(3) 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; and
(4) PSI barred itself from arguing in its second M/R 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.

SUMMARY: ON THE LIABILITY OF A HOSPITAL


1. CHECK FIRST ER-EE RELATIONSHIP.
- Yes: apply PRINCIPLE OF RESPONDEAT SUPERIOR
- No: check if PRINCIPLE OF APPARENT AUTHORITY applies
2. LIABILITIES
a. PRS: Vicariously liable
b. PAA: Vicariously liable
c. PCN: Directly liable
————————————————————————————————
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V. Legal Medicine matters

A. Relevance of studying the human body for lawyers


1. Legal Medicine: the application of medical knowledge & skill to the
uses and purposes of law [Lee, Legal Medicine at Harvard University, J. of
Criminal Law & Criminology, 1952]

2. A documentary evidence is more important than oral testimony.


Hence, documenting correctly the human body (say, for homicide cases) is
important to prove your case.

3. It is a way of “destroying” the credibility of a physician who may be


careless is making his medical report: his testimony may be stricken down
by the court. If you are not aware of these terms, you lose this area of the
legal battle which may be critical for you to win a case.

4. Post mortem vs. autopsy: post-mortem deals only with the external
parts of the dead body (up to the orifices), while autopsy cuts through
the study of individual organs.

5. A medical certificate can be issued by any licensed physician: make


sure that he is authorised to practice medicine and is trained to document
injuries, for example (if he is not in the right specialization, you may have a
point to raise as to his credibility) vs. medico-legal certificate which is
issued by the NBI.

6. Anatomical positions (jargons); Position of the human body = palm


facing forward. Knowing the external parts of the body & the internal
organs that correspond to them will help you see the accuracy of the
medical certificate submitted as evidence.
a. anterior = front
b. posterior = back
c. lateral = outer side
d. medial = inner side
—————————
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B. The human body


1. Regions of the body for medico-legal purposes
a. Head
b. Trunk
i. Upper trunk: Thorax
ii. Lower trunk: Abdomen
d. Back
e. Extremities
i. Upper extremities: arm-forearm-hand/palm-digits (1: thumb)
ii. Lower extremities: thigh-leg-foot-digits (1: toe)

2. The Head/Skull/Brain
a. Some nuances
i. frontal bone is the bone in the frontal area;
ii. zygomatic region = pisngi; hence, right zygomatic area: right
cheek.
iii. orbit: butas ng mata
iv. temporal region: above the ear
v. occipital region: “batok"
vi. parietal region: between frontal & occipital regions.
vii. top view: right/left parietal regions
b. lobes of the brain: correspond to the names of the regions of the
skull
i. cerebellum: below cerebrum: balance
ii. cerebrum (contains the frontal lobe, occipital lobe, temporal
lobe, parietal lobe): biggest part: sensation, voluntary movement, memory
(a) frontal lobe: voluntary movement: if hit: can’t move
(b) occipital lobe: back
(c) temporal lobe: side
(d) parietal lobe: top: interprets sensation; if hit, one may
become numb: may not feel any sensation.
iii. medulla oblongata (brain stem): smallest; called “tangkay”;
contains VITAL CENTERS: cardiovascular, respiratory; injuries here are
FATAL.
c. Application:
i. locate a fracture in the frontal area
ii. what’s an orbital fracture?

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3. Trunk
a. Thorax: 12 pairs of ribs (1o front; 2 floating ribs at the back);
sternum = flat bone
*The ribs or the spaces between them (intercostal spaces) are
reference points when describing injuries.
*you start counting from the 2nd rib because you cannot
palpate the first rib.
*the heart is in the 5th intercostal space (“ics” in the medical
certificate): best sound of the stethoscope is in this area; since the heart is
rotated to the left, hitting that area is dangerous; if you hit the right, you
may hit the lungs.
*if client is hit in the RUQ and the liver was damaged, injury is
fatal; it may be bloody: he may bleed to death (massive blood loss)

b. Abdomen: “nasaksak sa tiyan/sikmura”; see the 4 quadrants and
take note of the internal organs in the areas; RUQ means right upper
quadrant, etc.
*two regions of the abdomen
i. epigastric region (upper), aka, sikmura; if your client is hit
here, acid may be spilled and it can be harmful to the other organs;
ii. umbilical region: small intestine area; if hit here, digested
food will come out.
iii. periphery: if hit here, large intestines may be damaged and
fecal matter released: dangerous—may cause sepsis (infection)
*this can be the PROXIMATE CAUSE of the death of
your client.
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4. Back
1. Vertebral column: spine; protects the spinal cord
2. The two floating ribs can be found at the back region: added
protection to the kidneys: vascular organ & so one may bleed to death if
they are hit.


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5. Circulatory system
a. essence: circulate blood around the body
b. heart: keeps the blood flowing
c. arteries: from the heart to other parts of the body: bring blood rich
in nutrients & oxygen; high pressure (you get the pulse from arteries): in
spurts; hence if blood spurts, what was hit could be an artery; deeply-set.
d. veins: carry unoxygenated blood from the other parts of the body
to the heart; low pressure (can be zero); if a vein is hit, blood will just flow;
superficial.
e. dangerous areas if hit, may bleed to death: ‘singit' (branch from
aorta); temporal artery (head)


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C. Examination of the human body: what to do as an investigator:

1. Observe the surroundings first: this is part of the preliminary exam!


Observe the furnitures, for example, persons present, circumstance
surrounding the death of the victim;

2. Only then will you go to examine the body:


a. first, do EXTERNAL observation: look at the clothes: could be
transvestite, for example;
b. check for STAINS: record their color, nature; if red: not conclusive
that its blood (it can be paint, ink, ketchup, or blood); if it’s blood, it can b
human or animal blood. Check its physical appearance & have its chemical
composition determined.
c. check the BODY SURFACE: identity of the person (interview the
people around; do not believe what they say right away); check for tattoo
marks, ornamentations, dog tags; check for fingerprints; get his
fingerprints; look for identification cards; determine the gender (from the
clothing, for example; there are only two genders in medico-legal practice:
male 0r female).
d. record the POSITION of the dead body: right side up, back side
down, side ways.
e. note the COLOR of the body: complexion; any discolouration of
the skin, etc.
f. check ORIFICES (butas): ears, mouth, etc; check for foreign
objects, secretions, any deformation/injury; EG: bleeding on the nose:
there might be a fracture on the frontal bone (anterior cranial fossa);
vaginal opening: might be a victim of rape; impact on the mouth: check
position of the tongue.

3. Note approximate TIME of death

4. Inside of the body: AUTOPSY: check for internal organs.

5. The dead body undergoes several changes: how to document them:


Importance: GIVES YOU AN IDEA OF THE TIME OF DEATH:
a. Best test is an EEG machine but it’s expensive and so we use ECG
machines in PH: the person is not dead if there are fluctuations; result
should be a flat line; ECG measures the activity of the heart; since the
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heart movement produces electric currents, there will be a flat line when
there is no more activity. (don’t just present as proof of death the
statement that he is not moving anymore; show ECG results!)
b. early signs of death: check vital signs: zero bp; zero respiratory
rate; zero pulse rate; drop in temperature (no more energy production;
no heat production). This is called CLINICAL DEATH. However,
individual cells are still alive and muscles can still be stimulated (if you
apply current into them).
c. When individual cells start to die: 3 hours after death: COOLING
OF THE BODY; after 3 hours, cells start to die and the body gets cold.
d. MUSCULAR CHANGES: at the start, muscles are still relaxed, even
the sphincters (hence, fecal matter and urine come out). This is the
PRIMARY STAGE OF FLACCIDITY (first 3 hours)
e. RIGOR MORTIS: when muscles stiffen, usually 3 hours from the
time of death; this is gradual and it reaches its peak on the 12th hour when
the entire body becomes stiff (complete rigor mortis).
f. SECONDARY STAGE OF FLACCIDITY: from 24-36 hours after
death. (if someone got drowned, wait the next day, it will float)
g. PUTREFACTION: decay of the body; muscles/organs start to
decay; starts to smell; fluids come out (hence, they put cotton on the
orifices); body becomes bloated; microorganisms decompose the body
h. Changes in the blood: blood settles down to the most dependent
part (LIVIDITY: Livor mortis (Latin: livor—"bluish color," mortis—"of
death"), postmortem lividity (Latin: postmortem—"after death", lividity
—"black and blue”). EG: if it was right side up, you find bluish coloration
in the body at the back. This happens within 3 hours after death
g. Stomach: it takes 3h to vacate its contents; if upon autopsy, food is
found, he must have been killed less than 3h earlier: TRIANGULATE!
h. Presence of insects: if there are maggots already, he must have
died more than 24h earlier (takes 24h for a maggot to form); if find fleas in
a person who drowned, he must have drowned less than 24h earlier
because it takes 24h for fleas to die underwater.

*Importance: GIVES YOU AN IDEA OF THE TIME OF DEATH. EG: if


body is still warm, he may have died within 3 hours; if cold, more than 3h;
if entirely rigid, 12h; if blood is completely settled, at least 3h.
BODY CHANGES APPROX TIME AFTER DEATH
Flat ECG; zero bp; zero respiratory rate; Clinical death
zero pulse rate; drop in temperature
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BODY CHANGES APPROX TIME AFTER DEATH
cooling of the body: individual cells start to 3 hours after death
die
Primary stage of flaccidity: muscles begin to first 3 hours
disintegrate: muscles are relaxed, even the
sphincters (hence, fecal matter and urine
come out)
Livor mortis: lividity: settling of blood to a within 3 hours after death
part of the body depending on its position
Initial stage of rigor mortis: muscles start to 3 hours from the time of death
stiffen
Complete rigor mortis: entire body stiffens after 12 hours
Secondary stage of flaccidity 24-36 hours after death.
Putrefaction: decay of the body; muscles/ after 24-26 hours
organs start to decay; starts to smell; fluids
come out (hence, they put cotton on the
orifices); body becomes bloated;
microorganisms decompose the body
presence of food in the stomach person died within 3h after eating
Presence of insects like maggots person must have died at least 24h earlier

D. Traumas & Injuries


1. Trauma: “bugbog" due to accident, not “shock” as in ordinary parlance.

2. Locate the injury (see parts of the body, supra); check whether injury is
suicidal or homicidal:
SUICIDAL HOMICIDAL
cut his own throat somebody else cut his throat
angle of injury: incise wound is diagonal horizontal
(from left ear downwards)
superficial wound with hesitance cuts usually just one incision that’s deep
above Adam’s apple; neck was raised up below Adam’s apple; neck bowed down
blood infront of the hand no blood or blood is at the back (assailant
from the back)
location: infront of the mirror bed
cadaveric spasms* are present absent
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*cadaveric spasms: present in those who died in extreme nervous
tension. EG if he pulls the trigger on his temple, expect cadaveric spasm
in the muscles of the area that held the gun: localised group of muscles
that are stiff while the rest are still in a state of flaccidity; EG: all those
who drowned have localised stiffening in their palms (tried to grasp onto
something)

3. Determine the type of injury suffered:


a. CLOSE WOUNDS: no tear in the continuity of the skin
b. OPEN WOUNDS:
i. stab wounds: caused by a sharp-edged instrument like a
knife;
ii. perforated wounds: caused by a sharp-pointed instrument
like an icepick, nail, pencil, screwdriver
*EG: counsel asks doctor: how can an icepick produce a
stab wound? doctor’s credibility may be destroyed.
iii. lacerated wounds: due to a blunt instrument like ‘dos por
dos’, tubo, ‘suntok’ ni Pacquiao; not clear cut; serrated (edge) wounds.
iv. incise wounds: slash/slice cut; caused by sharp-edged
instrument like a cutter/knife; clean cut (vs. serrated cut of lacerated
wounds)
v. abrasions: ‘gasgas’; imprints; friction marks.
LACERATED WOUNDS INCISE WOUNDS

instrument used is blunt sharp-edged

wound edges are serrated clean

there is inflammation (swelling, redness) none, usually “maga” only, minimal swelling

no hair bulbs cut cut includes hair bulbs (root of hair)

healing takes longer healing is faster; sometimes a scar may even be


absent, depending on the cut; minimal scar

c. FRACTURES: injury to the bones


(a) linear: ‘diretso’
(b) comminuted: ‘nadurog’ (trash injuries)
(c) green stick: only 1 side; ‘may lamat’
(d) open: if there’s a break in the skin
(e) close: no break in the skin
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d. HEMATOMA: ‘bukol’: blood cysts; results in elevation in the skin;
blood can be extracted from a hematoma using a syringe: cavity is formed
where blood accumulates; usually in the head
*EG: document says “1 x 1 hematoma in the right frontal area”
e. CONTUSIONS: discolouration of the skin; ‘pasa’; scattering of
blood in the tissues.
*EG: document says “contusion on the right zygomatic area”:
‘bukol na may kulay sa kanang pisngi’
f. GUNSHOT WOUNDS: due to firearms/bullet: when one pulls the
trigger, the following come out (may serve as a GUIDE in determining
the distance of the assailant)
i. flame: may cause singeing of the hair; flash burns; around 6
inches away;
ii. bullet: far away: produce gun-shot wounds (2 types): (a)
ENTRY WOUND: point of entry; (b) EXIT WOUND: point of exit:. Ideally
(a) & (b) should be even in number; if odd, it gives rise to a
PRESUMPTION that a bulled is lodged inside the body. This is called the
ODD-EVEN RULE in gunshot wound counting. NB: movement of the
bullet is in a spinning fashion, propelled by the barrel of the gun (vs. shot
gun: smooth board, no ridges). Mechanical failure: when there is tumbling
or tail-wagging of the bullet.

ENTRANCE WOUND EXIT WOUND


usually round in shape; takes the shape of never round, sometimes it is slit-shaped; it is
the bullet as it pierces the skin; body fats sometimes MISTAKEN FOR A STAB
keep the shape round; XPN: star-shaped on WOUND; if there are many exits wounds,
the skull if hit point-blank & if it hit a bony the bullet may have fragmented inside like
portion (the flat bones absorb the cases and when it hit a bone
so the entrance wound is not round)
inverted edges edges are everted (palabas)
there are usually smudges, peppering on the no smudges/peppering
skin
there are abrasions or contusion collars none

iii. smoke: may leave soot, smudges; around 12 inches away


iv. unburned powder (pulbura): may cause minute burns; cause
peppering/stippling on the skin; around 24 inches away
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SUMMARY OF EXTERNAL SIGNS & ESTIMATED DISTANCE


EXTERNAL SIGNS PRODUCED BY GUN SHOTS POSSIBLE DISTANCE

FLAME: burning/singeing of hair, flash burns around 6 inches away


SMOKE: soot (black powder) & smudges around 12 inches away
UNBURNED POWDER (pulbura): minute around 24 inches away
burns; peppering & stippling (small dots)
BULLET: gun shot wounds (see details, supra) far away

4. Documenting rape
a. Check injuries in the perineum: perineal area: the area between
the anus and the scrotum or vulva; there are three orifices: urethra, anal,
vaginal (hymenal injuries are classified as either complete (the entire
width) or incomplete, when partial; there could be compound laceration
for example in children; position of the laceration is described using the
position of a clock. EG: complete laceration at the 6 o’ clock position;
partial laceration at 7 o’clock position, compound laceration at 8 o’clock;
multiple lacerations at 3, 6 and 7 o’clock positions)
b. Look for other injuries: contusions in the legs, even up to the knee
area; abrasions
c. look for defense wounds: “kalmot”
d. check foreign objects; ejaculates/semen/pubic hair (may be used
to test if they belong to the accused)
*How do you document these? by measuring them, EG: 2 cm.
lacerated wound in the frontal area

————————————————————————————————

SOURCES FOR THESE NOTES



1. Discussions in the class of Atty. Logronio
2. Cases in the syllabus
3. Images from the Net.
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“THE UNIVERSAL PRAYER (attributed to Pope Clement XI)



Lord, I believe in you: increase my faith. my life well-ordered.
I trust in you: strengthen my trust. Put me on guard against my human weaknesses.
I love you: let me love you more and more. Let me cherish your love for me,
I am sorry for my sins: deepen my sorrow. keep your law,
I worship you as my first beginning, and come at last to your salvation.
I long for you as my last end, Teach me to realize that this world is passing,
I praise you as my constant helper, that my true future is the happiness of heaven,
and call on you as my loving protector. that life on earth is short,
Guide me by your wisdom, and the life to come eternal.
correct me with your justice, “Help me to prepare for death
comfort me with your mercy, with a proper fear of judgment,
protect me with your power. but a greater trust in your goodness.
I offer you, Lord, my thoughts: to be fixed on Lead me safely through death
you; to the endless joy of heaven.
my words: to have you for their theme; Grant this through Christ our Lord. Amen.”
my actions: to reflect my love for you;
my sufferings: to be endured for your greater Excerpt From: Charles Belmonte. “Handbook of
glory. Prayers.” iBooks.
I want to do what you ask of me:
in the way you ask,
for as long as you ask,
because you ask it.
Lord, enlighten my understanding,
strengthen my will,
purify my heart,
and make me holy.
Help me to repent of my past sins
and to resist temptation in the future.
Help me to rise above my human weakness
and to grow stronger as a Christian.
“Let me love you, my Lord and my God,
and see myself as I really am:
a pilgrim in this world,
a Christian called to respect and love
all whose lives I touch,
those in authority over me
or those under my authority,
my friends and my enemies.
Help me to conquer anger with gentleness,
greed by generosity, apathy by fervor.
Help me to forget myself
and reach out toward others.
Make me prudent in planning,
courageous in taking risks.
Make me patient in suffering,
unassuming in prosperity.
Keep me, Lord, attentive in prayer,
temperate in food and drink,
diligent in my work,
firm in my good intentions.
Let my conscience be clear,
my conduct without fault,
my speech blameless,

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