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LEGAL MEDICINE PHYSICIAN-PATIENT RELATIONSHIP NOTES:

In case where a boy of tender age was hit by a taxicab, who was eventually brought to Manila Doctors Hospital, the Supreme Court dedicated a substantial discussion on when exactly does physician-patient relationship ensues. The Honorable Court explained in detail, to wit:
xxx In the case of Lucas v. Tuao,[20] the Court wrote that [w]hen a patient engages the services of a physician, a physician-patient relationship is generated. And in accepting a case, the physician, for all intents and purposes, represents that he has the needed training and skill possessed by physicians and surgeons practicing in the same field; and that he will employ such training, care, and skill in the treatment of the patient. Thus, in treating his patient, a physician is under a duty to exercise that degree of care, skill and diligence which physicians in the same general neighborhood and in the same general line of practice ordinarily possess and exercise in like cases. Stated otherwise, the physician has the obligation to use at least the same level of care that any other reasonably competent physician would use to treat the condition under similar circumstances.

Notably, the latter and his mother went to the ER for an immediate medical attention. The petitioners allegedly passed by and were requested to attend to the victim (contrary to the testimony of Dr. Tacata that they were, at that time, residents on duty at the ER).[21] They obliged and examined the victim, and later assured the mother that everything was fine and that they could go home. Clearly, a physicianpatient relationship was established between the petitioners and the patient Roy Jr.
To repeat for clarity and emphasis, if these doctors knew from the start that they were not in the position to attend to Roy Jr., a vehicular accident victim, with the degree of diligence and commitment expected of every doctor in a case like this, they should have not made a baseless assurance that everything was all right. By doing so, they deprived Roy Jr. of adequate medical attention that placed him in a more dangerous situation than he was already in. What petitioners should have done, and could have done, was to refer Roy Jr. to another doctor who could competently and thoroughly examine his injuries. All told, the petitioners were, indeed, negligent but only civilly, and not criminally, liable as the facts show. Article II, Section 1 of the Code of Medical Ethics of the Medical Profession in the Philippines states:

Indubitably, a physician-patient relationship exists between the petitioners and patient Roy Jr.

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LEGAL MEDICINE
A physician should attend to his patients faithfully and conscientiously. He should secure for them all possible benefits that may depend upon his professional skill and care. As the sole tribunal to adjudge the physicians failure to fulfill his obligation to his patients is, in most cases, his own conscience, violation of this rule on his part is discreditable and inexcusable.[22] Established medical procedures and practices,

without fee or contract. I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly appointed and sworn and to none other. I will use my power to help the sick to the best of my ability and judgment. I will abstain from harming or wrong doing any man by it. I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing. Neither will I give a woman means to procure an abortion. I will be chaste and religious in my life and in my practice. I will not cut, even for the stone, but I will leave such procedures to the practitioners of that craft. Whenever I go into a house I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men whether they be freemen or slaves. Whatever I see or hear, whether professionally or privately which ought not to be divulged I will keep secret and tell no one. If therefore, I observe this oath and do not violate it, may I prosper both in my life and in my profession, earning good repute among all men for all time. If I transgress and foreswear this oath, may my lot be otherwise. (SOURCE: www.philippinemedicalassociation.org)

though in constant instability, are devised for the purpose of preventing complications. In this case, the petitioners failed to observe the most prudent medical procedure under the circumstances to prevent the complications suffered by a child of tender age. XXX (DR. EMMANUEL JARCIA, JR.and DR. MARILOU BASTAN vs, PEOPLE OF THE PHILIPPINES)

THE OATH OF HIPPOCRATES (HIPPOCRATIC OATH)

I swear by Apollo the Healer, by Aesculapius, by Health and all the powers of healing and to call witness all the Gods and Goddesses that I may keep this oath and promise to the best of my ability and judgment. I will pay the same respect to my master in the science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the science, if they desire to learn it,

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LEGAL MEDICINE CODE OF ETHICS OF THE PHILIPPINE MEDICAL ASSOCIATION ARTICLE 1

GENERAL PRINCIPLES Section 1. The primary objective of the practice of medicine is service to mankind irrespective of race, age, disease, disability, gender, sexual orientation, social standing, creed or political affiliation. In medical practice, reward or financial gain should be a subordinate consideration. Section 2. On entering the profession, a physician assumes the obligation of maintaining the honorable tradition that confers the well-deserved title of a friend of mankind. The physician should cherish a proper pride in the calling and conduct himself/herself in accordance with this Code and in the generally accepted principles of the International Code of Medical Ethics. Section 3. Physicians should fulfill the civic duties of a good citizen, must conform to the laws and cooperate with the proper authorities in the application of medical knowledge for the promotion of the common welfare. Section 4. Physicians should work together in harmony and mutual respect. Section 5. Physicians should cooperate with and safeguard the interest, reputation and dignity of paramedical and other health professionals. Section 6. Physicians should be upright, diligent, sober, modest and well versed in both the science and the art of the profession. Section 7. The promotion and advancement of the health of the patients should be prioritized over the benefits of the physicians and the health products industries. DUTIES OF A PHYSICIAN (continuation of CODE OF ETHICS) ARTICLE II

DUTIES OF PHYSICIANS TO THEIR PATIENTS

Section 1. A physician should be dedicated to provide competent medical care with full professional skill in accordance with the current standards of care, compassion, independence and respect for human dignity. Section 2. A physician should be free to choose patients. Section 3. In an emergency, provided there is no risk to his or

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LEGAL MEDICINE
her safety, a physician should administer at least first aid treatment 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. Section 5. A physician should exercise good faith and honesty in expressing opinion/s as to the diagnosis, prognosis, and treatment of a case under his/her care. A physician shall respect the right of the patient to refuse medical treatment. Timely notice of the worsening of the disease should be given to the patient and/or family. A physician shall not conceal nor exaggerate the patients condition except when it is to the latters best interest. A physician shall obtain from the patient a voluntary informed consent. In case of unconsciousness or in a state of mental deficiency the informed consent may be given by a spouse or immediate relatives and in the absence of both, by the party authorized by an advanced directive of the patient. Informed consent in the case of minor should be given by the parents or guardian, members of the immediate family that are of legal age. Section 6. The physician should hold as sacred and highly Section 2. A physician shall assist the government in the administration of justice in accordance with law. He/she maybe accorded a fair and just remuneration when called upon as an expert witness. Section 1. A physician should cooperate with the duly constituted health authorities in the education and enforcement of laws and regulations for the promotion of health. Furthermore, in times of epidemic and public calamity, except when his or her personal safety is at stake, the physician must attend to the victims, alert the public and duly constituted health authorities on the dangers of communicable diseases and enforce measures for prevention and cure in accordance with existing laws, rules and regulations. ARTICLE III DUTIES OF PHYSICIANS TO THE COMMUNITY confidential whatever may be discovered or learned pertinent to the patient even after death, except when required in the promotion of justice, safety and public health. Section 7. Professional fees should be commensurate to the services rendered with due consideration to the patients financial status, nature of the case, time consumed and the professional standing and skill of the physician in the community.

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LEGAL MEDICINE
Section 3. A physician is encouraged to expose and report to the proper authorities unlicensed medical practitioners, charlatans and quacks in as much as their nefarious practices may cause injury to health and life. A physician should never condone nor connive with such fake health providers. Section 4. A physician shall not employ agents in the solicitation and recruitment of patients. For the promotion of medical practice, a physician may use professional cards, classified advertising, publications, internet, directories and signboards. Signboards shall not exceed one by two (1x2) meters in size. Except in internet web sites, only the name of the physician, field of specialty, office hours or office or residential addresses may appear. The act of the physician in publishing his or her personal superiority, special certificates or diplomas, post graduate training, specific methods of treatment, operative techniques or former connections with hospitals or clinics is not allowed. However, these matters may be placed by a physician within the confines of his clinic or residence. For internet web sites, recognizing the right of a patient to know the capabilities and qualifications of his doctor, special certificates or diplomas, post graduate training and former connections with hospitals or clinics may be posted. Section 5. A physician involved in multi media must be well informed of the matter under discussion. Only the name of the ARTICLE IV DUTIES OF PHYSICIANS TO THEIR COLLEAGUES AND TO THE PROFESSION Section 1. A physician shall waive his professional fees to a colleague, his or her spouse, children and parents who are financially dependent on him. Section 2. When necessary, the attending physician should always seek consultation from an available appropriate specialist. Section 3. The primary and consultant physicians should always observe the proper protocol of the referral system. The consultant may make another referral but should seek permission from the primary physician. In making a referral, a physician should forward a clinical abstract and specify the purpose as to whether the case is for opinion/evaluation, for physician and membership to a society or institution may be mentioned or posted. A physician should only make a general opinion and shall refrain from making a specific diagnosis, therapy or projection to individual cases in his appearances in the broadcast media. An article written by a physician must be evidence-based and disclose connections with pharmaceutical or health product companies. A physician shall not commercially endorse any medical or health product.

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LEGAL MEDICINE
co-management, or for transfer of service. Section 4. With the consent of the patient, in cases where a physician has to suspend service during temporary absences, the substitute physician shall treat the patient with the same dedication and quality of care extended to his/her own patient. The patient should be returned to the care of the primary physician as soon as possible. Section 10. Continuing medical education conferences and Section 5. Whenever a physician makes a social or business call on a patient under the care of another, making comments pertaining to the case is unethical unless if an emergency arises. Section 6. Whenever there is an irreconcilable difference of opinion in the management of a case, the matter should be referred to the Philippine Medical Association or the specialty society concerned. Section 12. Physicians may accept reasonable subsidies from Section 7. Members of the editorial board of medical journals should possess adequate qualifications. Written articles and scientific presentations in scientific conferences should include full disclosure of any pharmaceutical support and should be independent of any commercial influence. Section 8. A physician shall not receive any commission for referring patients to a colleague, third person or institution. Section 13. The faculty/speaker/consultant of conferences or meetings is allowed to accept from health industries honoraria and reimbursement for reasonable transportation, lodging and meal expenses. health and other industries to support their participation in CME events. Section 11. Funds from commercial sources may be accepted for the benefit of the association or society. professional meetings must contribute to improve and optimize patients care or address the educational needs of the targeted medical audience. They must be organized by a medical society on its own or in cooperation with sponsoring entities. Section 9. A physician is encouraged to report to the Philippine Medical Association or the Board of Medicine personal knowledge of any corrupt or dishonest conduct of the members of the profession. However, nominal gifts during occasions may be received by a physician.

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LEGAL MEDICINE
Section 14. Scholarships for physicians and medical students are permissible as long as the selection of scholars are made by the organizers or academic institutions concerned. Section 15. Generic names shall be used during the course of CME activities. However, after the lectures, the sponsoring entity may promote or indicate their branded products. Section 3. Only gifts of reasonable value that primarily entail Section 16. When commercial exhibits are part of the overall program, arrangements for these should not influence the planning nor interfere with the CME activities. Only relevant information of the product should be included in the exhibit area. Article V DUTIES OF PHYSICIANS TO ALLIED PROFESSIONALS Section 1. Physicians should never pay nor receive commission to or from any allied health worker for cases referred. ARTICLE VI RELATIONSHIP OF PHYSICIANS WITH THE HEALTH PRODUCTS INDUSTRY Section 1. The physician shall not derive any form of material gain from product samples. ARTICLE VII - AMENDMENTS Section 4. Physicians may request donations for a charitable purpose for as long as it does not redound to his or her personal benefit. Section 5. Research activities shall be ethically defensible, socially responsible, and scientifically valid. Any remuneration should be reasonable and should not constitute an enticement. Section 6 Research trials conducted by physicians for an industry should be done in accordance with the national or institutional guidelines for the protection of human subjects. benefit to patient care or related to physicians work may be accepted by a physician from a health product company. Section 2. Physicians may participate in post-marketing or similar activities where they are asked to try new products on patients provided that the patients are properly informed and have given their informed consent. Physicians are encouraged to report or share the result of such activities to the duly constituted authorities.

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LEGAL MEDICINE
Section 1. The Board of Governors of the Association, upon recommendation of the Commission on Ethics may amend or repeal this code by a 2/3 vote of the members of the Board. Amendments shall be subsequently ratified by the General Assembly following the approval by the Board.

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LEGAL MEDICINE
PHILIPPINE MEDICAL ASSOCIATION North Avenue, Quezon City PHILIPPINE MEDICAL ASSOCIATION DECLARATION ON THE RIGHTS AND OBLIGATIONS OF THE PATIENT INTRODUCTION The time honored relationship between Filipino physicians, their patients and the community has undergone significant changes in recent times. The physician should always act according to his conscience, for the best interest of the patient, and must exert equal effort to guarantee patient autonomy, justice and participation in the decision making. The following Declaration represents some of the principal rights and obligations of the patient which the medical profession endorses and promotes, Physicians and other persons or bodies involved in the provision of health care have a joint responsibility to recognize and uphold these rights. Whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them. On the other hand, legislating these rights will erode the basic foundation that welds the patients and the physicians together trust and respect, running counter to the best interests of the patients. RIGHTS 1. Right to Good Quality Health Care and Humane Treatment a. Every person has a right to good quality health care without any discrimination and within the limits of the resources available for health and medical care. b. In the course of such care, his human dignity, culture, convictions and integrity shall be respected. c. If the patient has to wait for care, he shall be informed by the health professionals of the reason for the delay. d. The patient shall always be treated in accordance with his best interests. The treatment applied shall be in accordance with generally accepted medical principles.

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e. The patient has the right of continuity of health care. f. An emergency patient who is immediate threat of dying or losing life or limb shall be extended immediate medical care and treatment without any pecuniary consideration until the emergency situation is over. 2. Right to Dignity a. The patient's dignity, culture and value shall be respected at all times in medical care and teaching. b. Terminal ill patients are entitled to humane terminal care to make dying as dignified and comfortable as possible. 3. Right to Be Informed of His Rights and Obligations as a Patient Every person has the right to be informed of his rights and obligations as a patient. The Philippine Medical Association (PMA) in coordination with health care providers, professionals and civic groups, the medical people's organizations, local government units, and other government agencies and nongovernmental organizations shall conduct a nationwide information and education to make known to people their rights as patients as provided in this Declaration. The health care institutions shall inform patients of their rights as well as of the institution's rules and regulations that apply to the conduct of the patient while in the care of such institution. 4. Right to Choose His Physician a. The patient is free to avail of the services of a physician or health institution of his choice except when he chooses to be confined in a service ward. In this case, his attending physician shall be the one who was on duty and who made the admitting orders at the time of admission as appearing in the Doctor's Order Sheet of the Medical Record. b.

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The patient has the right to seek a second opinion. c. The patient has the right to change his physician or other health care provider. 5. Right to Informed Consent a. The patient has the right to self-determination, to make free decisions regarding himself. The physician shall inform the patient of the consequences of his decisions. b. Patient who is mentally competent and of legal age or in his incapacity or age of minority his legal representative, has a right to a clear explanation, in layperson's terms, of all proposed or contemplated procedures whether diagnostic or therapeutic, including the identity and professional circumstances of the person or persons who will perform the said procedure or procedures. The explanation shall include that amount of information necessary and indispensable for him to intelligently give his consent which may include, but may not be limited to the benefits, risk and side effects, and the probability of success or failure, as a possible consequence of said proposed procedure or procedures, including the implications of withholding consent. In the explanation of the proposed procedure or procedures, the comprehensive ability of the patient shall also be considered taking into account his level of education, the dialect or language that he speaks and understands and if possible, the use of anatomic sketch, or otherwise the use of those materials or visual aids that may aid the patient or his legal representative, in fully understanding the proposed procedure or procedures. The right to informed consent shall likewise consider the voluntariness in which the patient or his legal representative has given his consent seeing to it that the patient or his legal representative was allowed to ask questions, or that he is given the chance to consult his kins, or to seek another expert opinion. c. The unconscious patient 1) If the patient is unconscious or unable to express his will, informed consent must be obtained whenever possible from a legal representative. 2)

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When medical intervention is urgently needed, consent of the patient may be presumed. 3) Physicians should always try to save the life of a patient unconscious due to a suicide attempt. d. The legally incompetent patient 1) If a patient is a minor or legally incompetent the consent of a legally representative is required. Nevertheless the patient must be involved in the decision making to the fullest extent allowed by his mental capacity. A patient, who is eighteen years of age and above, shall be considered, for purposes of this declaration, to be of legal age. 2) If the legally incompetent patient can make rational decisions, his decisions must be respected, and he has the right to forbid the disclosure of information to his legally representative. 3) If the patient's legal representative, forbids treatment but, in the opinion of the physician contrary to the patient's best interest, the physician may challenge this decision in court. In case of emergency, the physician will act in the patient's best interest. e. In case of emergency, when there is no one who can give consent in his behalf, the physician can perform any emergency diagnostic or treatment procedure in the best interests of the patient. 6. Right to REFUSE DIAGNOSTIC AND MEDICAL TREATMENT a. The patient has the right to refuse diagnostic and medical treatment procedures, provided that the following conditions are satisfied: 1) He is of age twenty one and above, and mentally competent;

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2) He is informed of the medical consequences of his refusal; 3) He releases those involved in his care from any obligation relative to the consequences of his decision; and 4) His refusal will not jeopardize public health and safety. b. An adult with a sound mind may execute an advance directive for physicians not to put him on prolonged life support if, in the future, his condition is such that there is little or no hope of reasonable recovery and the physician shall therefore allow the natural course to happen. The qualifications listed as 1, 2, 3, and 4, of the preceding provision 6,a., shall be considered as satisfied if a patient whose condition makes him unable to express his will, has executed an advance directive. 7. Right to Refuse Participation in Medical Research The patient has the right to be advised of plans to involve him in medical research that may affect the care or treatment of his condition. The proposed research shall be performed only upon the written informed consent of the patient. 8. Right to Religious Belief and Assistance The patient has the right to receive spiritual and moral comfort including the help of a minister of his chosen religion. 9. Right to Privacy and Confidentiality The patient has the right to privacy and protection from unwarranted publicity. This right to privacy shall include the patient's right not to be subjected to exposure, private or public, either by photography, publications, video-taping, discussion, medical teaching or by any other means that would otherwise tend to reveal his person and identity and the circumstances under which he was, he is, or he will be, under medical or surgical care or treatment.

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a. All identifiable information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind, must be kept confidential, even after death. Except, in cases when descendants may have a right of access to information that would inform them of their health risks. b. All identifiable patient data must be protected. The protection of the data must be appropriate as to the manner of its storage. Human substance from which identifiable data can be derived must be likewise protected. c. Confidential information can be disclosed in the following cases: (1) when his mental or physical condition is in controversy in a court litigation and the court in its discretion orders him to submit to physical or mental examination by a physician; (2) when the public health and safety so demand; (3) when the patient or, in his incapacity, his legal representative expressly gives the consent; (4) when his medical or surgical condition, without revealing his identity, is discussed in a medical or scientific forum for expert discussion for his benefit or for the advancement of science and medicine. (5) when it is otherwise required by law. 10. Right to Disclosure of, and Access to Information a. In the course of his treatment and hospital care, the patient has the right to be informed of the result of the evaluation of the nature and extent of his disease. Any other additional or further contemplated medical treatment and surgical procedure or procedures.

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b. Disclosure of information maybe withheld if the information to the patient will cause mental suffering or further impair his health. Such disclosure may be withheld or deferred at some future opportune time upon due consultation with the patient's immediate family. c. Information must be given in a way appropriate to the local culture and in waiver the patient can understand. d. The patient has the right not to be informed on his explicit request, unless required for the protection of another person's life. e. The patient has the right to choose who, if anyone, should be informed on his behalf. f. The patient has the right to examine and be given an itemized bill of the hospital and medical services rendered. g. The patient or his legal representative, has the right to be informed by the physician or his delegate of his continuing health care requirements following discharge, including instructions about home medications, diet, physical activity and all other pertinent information. 11. Right to Correspondence and to Receive Visitors The patient has the right to communicate with relatives and other persons and to receive visitors subject to reasonable limits prescribed by the rules and regulations of the health care institution. 12. Right to Medical Records The health care institution and the physician shall ensure and safeguard the integrity and authenticity of the medical records. a.

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Upon the request of patient, the physician shall issue a medical certificate, a clinical abstract to the patient upon discharge from the institution. Any relevant document that the patient may require for insurance claims shall also be made available to him within a reasonable period of time. b. He has the right to view the contents of his medical records with the attending physician explaining contents thereof and at his expense. c. The patient may obtain from the health care institution a reproduction of his medical record at his expense. 13. Right to Health Education Every person has the right to health education that will assist him in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his own health should be stressed. Physicians should have an obligation to participate actively in educational efforts. 14. Right to Express Grievances The patient has the right to express only valid complaints and grievances about the care and services received. Patients may express their complaints and grievances with the Ethics Committee of the Philippine Medical Association through its component societies which shall afford all parties concerned with the opportunity to settle amicably all grievances. Societal Rights of Patients In addition to the individual rights of patients, patients have societal rights which are as follows: 1. Right to Health The patient has the right to access quality health care and to physicians who are free to render clinical and ethical judgment without interference or outside pressure. The patient has the right to regain and/or acquire the highest attainable standard of health, in a non- discriminatory, gender sensitive, and equal manner, which health authorities and health practitioner must progressively contribute to realize.

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2. Right to Access to Quality Public Health Care The patient has a right from the national and local government a comprehensive and integrated health care delivery system, providing the necessary manpower and facility resources. The patient has the right to functioning public health and health care facilities, goods and services and programs needed and sufficient quantity. They shall likewise be provided with health facilities and services with adequate provision of essential drugs, regular screening program, appropriate treatment of prevalent diseases, illnesses, injuries and disabilities, including provision of public health insurance. Towards this end, the government shall approximate the international standard allocation for the health sector as set by the World Health Organization. 3. Right to Healthy and Safe Workplace The patient has the right to a healthy natural workplace environment with adequate supply of safe and potable water and basic sanitation, industrial hygiene, prevention and reduction of exposure to harmful substances, preventive measures for occupational accidents and diseases, and an environment that discourages abuse of alcohol, tobacco use, drug use and other harmful substances. 4. Right to Medical and Education Information and Programs the patient has the right to prevention, medical information and education programs on immunization, prevention, treatment and control of diseases, behavior-related concerns, and disaster relief and emergency situations during epidemics and similar health hazards. The government shall endeavor to provide these information through lectures, symposia, tri-media, posters and the like. 5. Right to Participate in Policy Decisions the patient has the right to participate in policy decisions relating to patient's right to health at the community and national levels. 6. Right to Access to Health Facilities The patient has the right to be admitted to any primary, secondary, tertiary and other specialty hospitals when appropriate and necessary. 7. Right to Equitable and Economic Use of Resources

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The patient has the right to demand that government health facility resources must be equitably distributed in all regions of the country. 8. Right to Continuing Health Care The patient has the right from the national and local government programs to ensure continuity of care in the form of hospice care, rehabilitation, chemotherapy, and radiotherapy and similar modalities. 9. Right to Be Provided Quality Health Care in Times of Insolvency The patients who are paupers have the right from the national and local government provisions for quality medical care in spite of insolvency. The national and local government must provide for a system of payment to health care facilities and providers for all the valid and necessary medical expenses of their poor and marginalized citizens. Declaration of Obligations The Obligation of Patients Patients shall at all times fulfill their obligations and responsibilities regarding medical care and their personal behavior. 1. Obligation to Know Rights the patient shall ensure that he/she knows and understands what the patients' rights are and shall exercise those rights responsibly and reasonably. 2. Obligation to Provide Adequate, Accurate and Complete Information the patient shall provide, to the best of his knowledge, adequate, accurate and complete information about all matters pertaining to his/her health, including medications and past or present medical problems, ailments, medical history, consultation with other physicians, results of Diagnostic work-up and treatment to his/her health care provider. 3. Obligation to Report Unexpected Health Changes It shall be the duty of every patient to report unexpected changes to his/her condition or symptoms, including pain, to a member of the health care team.

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4. Obligation to Understand Purpose and Cost of Treatment The patient shall ensure that he/she understands the purpose and cost of any proposed treatment or procedure before deciding to accept it. He/she shall notify the health care provider or practitioner if he/she does not understand any information about his/her care or treatment. The patient shall insist upon explanations until adequately informed and consult with all relevant persons before reaching a decision. 5. Obligation to Accept Consequences of Own Informed Consent the patient shall accept all the consequences of the patient's own informed consent. If he/she refuses treatment or do not follow the instructions or advice of the health care provider or practitioner, he/she must accept the consequences of his/her decision. He is obligated to forever free the physician of liability in his exercise of his right to self determination. 6. Obligation to Settle Financial Obligations the patient shall ensure that financial obligations of his/her health care fulfilled as promptly as possible, otherwise he/she shall make appropriate arrangements to settle unpaid bills in the hospital and/or professional fees of the health care provider. Failure is considered estafa. Patients must seek support from the national and local government to provide a system of payment to health workers and facilities. 7. Obligation to Respect the Rights of Health Care Providers Patients are required to give due respect to the rights of health care providers most especially their human rights. He is under obligation that his actions must be considerate, cooperative and must never infringe on the rights and property of the health care provider. 8. Obligation to Respect the Rights of Health Institutions The patients are required to give due respect to rights of health care provider institutions and must never infringe upon their rights. This includes the obligation to know and follow the health institution's policies, rules and regulations. 9. Obligation to Respect the Rights of Other Patients the patient is obligated to conduct himself/herself

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in harmony with, respect to and must not interfere with the rights and property of other patients. 10. Obligation to Self The patient is obligated to maintain a state of wellness. 11. Obligation to Have Adequate Health Information and Actively Participate in His Treatment The patient is obligated to know the basic health information. This adequate knowledge is subsumed when a patient signs an informed consent. Patients are obligated to actively obtain the necessary information to enable him to actively participate in the formulation of his diagnostic and treatment plans. 12. Obligation to Respect the Right to Privacy of Health Workers and Institutions Patients have the obligation to address grievances to the proper authorities or venue and not resort to unwarranted publicity in the media. Patients shall not disclose to the public any alleged complain against health provider and institution not fully decided by a court or administrative tribunal of proper jurisdiction. 13. Obligation to Exercise Fidelity on Privileged Communication A patient-physician relationship is a fiduciary one where mutual trust, respect and confidence is executed. All communications are privileged and the patient is obligated not to breech this privileged communication especially if it involves a third party.

14. Obligation Not to Force Physicians to Treat Him/Her While patients have the right to choose their physicians, these patients are likewise obligated to respect the physician's decision to choose whom he is going to serve or to treat.

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15. Obligation to Respect the Physician's Decision on Medical Reasons on His Right to Religious Beliefs Patients are obligated to respect and obey the health care provider's decision on matters referable to medical reasons on his children not yet of legal age but whose lives and health are affected by the parents' rights to religious belief. Patients are obligated to respect the physician's religious beliefs. 16. Obligation to Medical Records Patients are obligated to ensure the integrity and authenticity of his medical records. Any attempt to alter his records is a criminal offense subject to the provisions to this bill and to the Revised Penal Code. 17. Obligation to Participate in the Training of Competent Future Physicians Training of competent future physicians is a necessary development in the health care delivery system of the country. Patients are, therefore, obligated to participate in the training of these future health workers provided the necessary information are provided him and the necessary ethical considerations employed. 18. Obligation to Inform Patients are obligated to inform the health worker to any perceived or alleged infraction of his rights by the health worker or institution through proper channels. This is to provide a system of immediate rectification to promote mutual trust, respect and confidence between the doctor and patient. 19. Obligation to Use Due Process and Exhaust Grievance Mechanisms All grievances of patients must be coursed through proper channels and process. The patient shall exhaust the grievance mechanism provided in this Act before filing any administrative or legal action. Grievance Mechanism Mediation Any written complaint arising from violation of any of the right and obligations of patients shall first be submitted to mediation with the Ethics Committee of the Philippine Medical Association

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through its component societies which shall afford all parties concerned with the opportunity to settle all grievances amicably. The hearing procedure shall not be adversarial in nature. The patient and the health care provider or practitioner shall be given the opportunity to discuss the cause of complaint and efforts shall be made for its amicable settlement. No monetary compensation shall be involved during this stage and neither shall a legal counsel be present. The ethics committee of the local component societies shall be constituted by three members of the said society, 3 members of the specialty society corresponding to the case and one representative from the public or private or religious sector. The aggrieved party shall be given sixty (60) days from occurrence of incident to file his/her written complaint to the appropriate grievance mechanism level. Upon receipt of written complaint, the Chairperson shall give notice to the respondent. Upon receipt of the written complaint, due notice to the respondent and conciliation meeting, the Mediation Committee shall be given thirty (30) days to resolve the said complaint. Otherwise, the complainant shall have the option to proceed to the next level of grievance system. The Committee shall now constitute themselves into an arbitration committee to hear and resolve the complaint. Arbitration if and when the complaint is not resolved through mediation within the prescribed period, the complainant shall file a case of arbitration. Only complaints with physical injuries shall proceed to the arbitration process. The Committee shall base its decision on documentary evidence including depositions. The Committee shall render a decision within thirty (30) days from receipt of the position papers of both parties. The decision is binding to all parties. Process The Philippine Medical Association shall ensure the establishment of these grievance mechanism and issue the necessary rules and regulations for its proper operation and implementation. These grievance mechanisms shall be seniquanon before filing any complaint with the judicial body. All parties to the complaint shall be bound by the rules on confidentiality on all levels of the Grievance Mechanism. All minutes of the committee shall not be disclosed to any party unless authorized by the court of law. Prescriptive Period the time during which the case is submitted for mediation shall toll the running of the prescriptive period for the filing of a civil or criminal case under the Revised Penal Code or any

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administrative case. Miscellaneous Provisions Inclusion in School Curriculum and Licensure Examinations the provisions of the Act shall be included in the medical and medical related school curriculum and licensure examinations. Rules and Regulations The Philippine Medical Association, in consultation with the Secretary of Health, Philippine Hospital Association and concerned people's organizations like the People's Health Watch, shall promulgate the rules and regulations for its implementation. Presented and submitted during the public hearing at the House of Representative on August 16, 2005.

ROMEO G. ENCANTO, M.D., MEM, FPCS, FPSGS Chairman, Commission on Legislation MODESTO O. LLAMAS, M.D. President

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LEGAL MEDICINE RIGHT TO REFUSE TREATMENT EXCEPTION IS IN RA 8344

Republic of the Philippines Congress of the Philippines Metro Manila Tenth Congress

Republic Act No. 8344

August 25, 1997

AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN EMERGENCY OR SERIOUS CASES, AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG 702, OTHERWISE KNOWN AS "AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES"

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled::
Section 1. Section 1 of Batas Pambansa Bilang 702 is hereby amended to read as follows: "SECTION 1. In emergency or serious cases, it shall be unlawful for any proprietor, president, director,manager or any other officer, and/or medical practitioner or employee of a hospital or medical clinic to request, solicit, demand or accept any deposit or any other form of advance payment as a prerequisite for confinement or medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability: Provided, That by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility where the appropriate care can be given, after the patient or his next of kin consents to said transfer and after the receiving hospital or medical clinic agrees to the transfer: Provided, however, That when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient even without his consent: Provided, further, That such transfer shall be done only after necessary emergency treatment and support have been administered to stabilize the patient and after it has been established that such transfer entails less risks than the patient's continued confinement: Provided, furthermore, That no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to receive the patient nor demand from the patient or his next of kin any deposit or advance payment: Provided, finally, That strict compliance with the foregoing

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procedure on transfer shall not be construed as a refusal made punishable by this Act." Section 2. Section 2 of Batas Pambansa Bilang 702 is hereby deleted and in place thereof, new sections

2, 3 and 4 are added, to read as follows:

"SEC. 2. For purposes of this Act, the following definitions shall govern: "(a) 'Emergency' - a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initialsupport and treatment may cause loss of life or cause permanent disability to the patient. "(b) 'Serious case' - refers to a condition of a patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient. "(c) 'Confinement' - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing, and treatment consistent with the capability and available facilities of the hospital or clinic. "(d) 'Hospital' - a facility devoted primarily to the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical and nursing care. It shall also be construed as any institution, building or place where there are facilities and personnel for the continued and prolonged care of patients. "(e) 'Emergency treatment and support' - any medical or surgical measure within the capability of the hospital or medical clinic that is administered by qualified health care professionals to prevent thedeath or permanent disability of a patient. "(f) 'Medical clinic' - a place in which patients can avail of medical consultation or treatment on an outpatient basis. "(g) 'Permanent disability' - a condition of physical disability as defined under Article 192-C and Article 193-B and C of Presidential Decree No 442; as amended, otherwise known as the Labor Code of the Philippines. "(h) 'Stabilize' - the provision of necessary care until such time that the patient may be discharged or transferred to another hospital or clinic with a reasonable probability that no physical deterioration would result from or occur during such discharge or transfer. "SEC. 3. After the hospital or medical clinic mentioned above shall have administered medical treatment and support, it may cause the transfer of the patient to an appropriate hospital consistent with the

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needs of the patient, preferably to a government hospital, specially in the case of poor or indigent patients. "SEC. 4. Any official, medical practitioner or employee of the hospital or medical clinic who violates the provisions of this Act shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1) day but not more than two (2) years and four (4) months, or a fine of not less than Twenty thousand pesos (P20,000.00), but not more than One hundred thousand pesos (P100,000.00) or both, at the discretion of the court: Provided, however, That if such violation was committed pursuant to an established policy of the hospital or clinic or upon instruction of its management, the director or officer of such hospital or clinic responsible for the formulation and implementation of such policy shall, upon conviction by final judgment, suffer imprisonment of four (4) to six (6) years, or a fine of not less than One hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos (P500,000.00) or both, at the discretion of the court." Section 3. Section 3 of Batas Pambansa Bilang 702 is hereby repealed. Section 4. Section 4 of Batas Pambansa Bilang 702 shall become Section 5 thereof and shall be

amended to read as follows:

"SEC. 5. The Department of Health shall promulgate the necessary rules and regulations to carry out the provisions of this Act." Section 5. This Act shall take effect fifteen (15) days after its publication in two (2) national newspapers

of general circulation.
Approved: August 25, 1997

The Lawphil Project - Arellano Law Foundation

IMPLEMENTING RULES AND REGULATIONS OF REPUBLIC ACT NO. 8344, OTHERWISE KNOWN AS "AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN EMERGENCY OR SERIOUS CASES, AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG

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702, OTHERWISE KNOWN AS AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES" WHEREAS, the Tenth Congress of the Republic of the Philippines enacted Republic Act No. 8344 on June 05, 1997; WHEREAS, the President of the Republic of the Philippines signed into law R.A. 8344 on August 25, 1997; WHEREAS, under Section 5 of R.A. 8344, the Department of Health (DOH) is mandated to promulgate the necessary rules and regulations to carry out the provisions of the aforementioned law. NOW THEREFORE, pursuant to the provisions of R.A. 8344 authorizing the Department of Health to promulgate the necessary rules and regulations, the following are hereby issued: 1. Section 1 of said Act provides: "In emergency or serious cases, it shall be unlawful for any proprietor, president, director, manager or any other officer, and/or medical practitioner or employee of a hospital or medical clinic to request, solicit, demand or accept any deposit or any other form of advance payment as a prerequisite for confinement or medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability: Provided, That by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility where appropriate care can be given, after the patient or his next of kin consents to said transfer: Provided, however, That when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient even without his consent, Provided, further, That such transfer shall be done only after the necessary emergency treatment and support have been administered to stabilize the patient and after it has been established that such transfer entails less risks than the patient's continued confinement: Provided, finally, That strict compliance with the foregoing procedure on transfer shall not be construed as a refusal made punishable by this Act." 2. For the purpose of implementing the above, the following definitions are provided: 2.1 Emergency - A condition or state of patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or cause permanent disability to the patient. 2.2 Serious Case - refers to a condition of a patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient.

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2.3 Confinement - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing, and treatment consistent with the capability and available facilities of the hospital or clinic. 2.4 Hospital - a facility devoted primarily to the diagnosis, treatment and care of individuals or other medical and nursing care. It shall also be construed as any institution, building or place where there are facilities and personnel for the continued and prolonged care of patients. The hospital shall be duly licensed by the Bureau of Licensing and Regulation of the DOH. 2.5 Emergency Treatment and Support - any medical or surgical measure within the capability of a hospital or medical clinic that is administer by qualified health care professionals to prevent the death or permanent disability of a patient. (In determining the capability of a hospital or clinic, the standards and the classification of these facilities set by the DOH Bureau of Licensing and Regulation shall be used). 2.6 Medical Clinic - a place in which patients can avail of medical consultation or treatment on an outpatient basis. 2.7 Permanent Disability - a condition of physical disability as defined under Article 192-C and Article 193-B and C of Presidential Decree No. 442, as amended, otherwise known as the Labor Code of the Philippines. 2.8 Stabilize - the provision of necessary care until such time that the patient may be discharged or transferred to another hospital or clinic with a reasonable probability that no physical deterioration would result from or occur during such discharge or transfer. 3. Transfer of Patients - Section 3 of R.A. 8344 provides: "After the hospital or medical clinic mentioned above shall have administered medical treatment and consistent with the needs of the patients preferably to a government hospital, specially in the case of poor or indigent patients." 3.1 The transferring and receiving hospital, shall be as much as practicable, be within ten (10) kilometer radius of each other. 3.2 The transfer of patients contemplated under this Act shall at all times be properly documented. 3.3 Hospitals may require a deposit or advance payment when the patient is no longer under the state of emergency and he/she refuses to be transferred. 4. All hospitals shall use a Uniform Discharge/Transfer Slip for cases covered by RA 8344 which shall include the following information:

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4.1 Admission Form of transferring hospital. 4.2 Transfer Form of Transferring Hospital, to include but not necessarily limited to the following information: 4.2.1 Vital signs 4.2.2 Name of Attending Physician 4.2.3 Treatment given to patient 4.2.4 Name of receiving hospital 4.2.5 Name of contact person and approving official at receiving hospital 4.2.6 Consent of the patient or companion. In case of an unaccompanied minor or patient, they may be transferred without consent provided that the provisions of Section 1 of RA 8344 is strictly observed. The hospital shall endeavor to use all forms of media to contact the next of kin of the unaccompanied minor or patient. 4.2.7 In case of refusal of transfer, the name of the hospital, the name(s) of persons who refused and the reason(s) for the refusal. A copy of the Uniform Discharge/Transfer Slip is hereto attached as Annex A*. 5. Penal Provisions - any official, medical practitioner or employee of the hospital or medical clinic who violates the provisions of RA 8344 shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1) day but not more than two (2) years and four months, or a fine of not less than Twenty Thousand Pesos (P20,000.00) but not more than One Hundred Thousand Pesos (P100,000.00) or both at the discretion of the court: Provided, however, That if such violation was committed pursuant to an established policy of the hospital or clinic or upon instruction of its management, the director or officer of such hospital or clinic responsible for the formulation and imprisonment of four (4) to six (6) years, or a fine of not less than One Hundred Thousand Pesos (P100,000.00), but not more than Five Hundred Thousand Pesos (P500,000.00) or both, at the discretion of the court. 6. In order to demonstrate compliance with the Act's provisions, all hospitals and medical clinics are instructed to institute the following measures: 6.1 A copy of the law and this implementing rules and regulations should be displayed prominently at hospital emergency rooms, hospital admission, counters and medical clinic premises.

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6.2 Hospital and clinic managers shall establish billing and collection procedure for treatment or confinement of emergency and serious cases which shall not commence until the essential appropriate treatment of such cases has been completed. 6.3 Hospital and clinic managers shall instruct their personnel to provide prompt and immediate medical attention to emergency and serious cases without any prior requirements for payment or deposit. 6.4 It is clarified that the law and this administrative order covers only the provision of medical and surgical goods and services, and do not cover the provision of non-medical amenities which have nothing to do with the treatment of the emergency or serious case. The provisions of and payment for these non-medical amenities shall be subject to appropriate institutional business practice. 6.5 Alleged violations of the Act and this Order may be reported to the Bureau of Licensing and Regulations, Office for Standards and Regulations, Department of Health, Sta. Cruz, Manila, or to the nearest Regional Health Office which shall immediately conduct a fact-finding investigation. The findings shall be referred to the appropriate fiscal for criminal prosecution. Persons convicted of violation shall be punished in accordance with the Act. 6.6 At the instance of the Bureau of Licensing and Regulation, Administrative proceedings may also be pursued against erring clinics or hospitals that could lead to either suspension or revocation of appropriate licenses. These Rules and Regulations shall take effect fifteen (15) days after publication in the Official Gazette or in a newspaper of general circulation. Adopted: February 18, 1998

(SGD.) CARMENCITA NORIEGA-REODICA, MD

Secretary of Health
* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Q.C.

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