Professional Documents
Culture Documents
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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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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.
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).
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.
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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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.
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.
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.
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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
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.
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.
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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.
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.
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.
2. To understand which of the two applies in the case, consider first the
LEGAL RELATIONSHIPS involved (infra)
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
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.
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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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)
there is inflammation (swelling, redness) none, usually “maga” only, minimal swelling
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
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