1
DR. RUBI LI, Petitioner,
vs.
SPOUSES REYNALDO and LINA SOLIMAN, as parents/heirs of deceased
Angelica Soliman, Respondents.
DECISION
VILLARAMA, JR., J.:
Challenged in this petition for review on certiorari is the Decision 1 dated June 15,
2004 as well as the Resolution2 dated September 1, 2004 of the Court of Appeals
(CA) in CA-G.R. CV No. 58013 which modified the Decision3 dated September 5,
1997 of the Regional Trial Court of Legazpi City, Branch 8 in Civil Case No. 8904.
The factual antecedents:
On July 7, 1993, respondents’ 11-year old daughter, Angelica Soliman, underwent a
biopsy of the mass located in her lower extremity at the St. Luke’s Medical Center
(SLMC). Results showed that Angelica was suffering from osteosarcoma,
osteoblastic type,4 a high-grade (highly malignant) cancer of the bone which usually
afflicts teenage children. Following this diagnosis and as primary intervention,
Angelica’s right leg was amputated by Dr. Jaime Tamayo in order to remove the
tumor. As adjuvant treatment to eliminate any remaining cancer cells, and hence
minimize the chances of recurrence and prevent the disease from spreading to other
parts of the patient’s body (metastasis), chemotherapy was suggested by Dr.
Tamayo. Dr. Tamayo referred Angelica to another doctor at SLMC, herein
petitioner Dr. Rubi Li, a medical oncologist.
On August 18, 1993, Angelica was admitted to SLMC. However, she died on
September 1, 1993, just eleven (11) days after the (intravenous) administration of
the first cycle of the chemotherapy regimen. Because SLMC refused to release a
death certificate without full payment of their hospital bill, respondents brought the
cadaver of Angelica to the Philippine National Police (PNP) Crime Laboratory at
Camp Crame for post-mortem examination. The Medico-Legal Report issued by
said institution indicated the cause of death as "Hypovolemic shock secondary to
multiple organ hemorrhages and Disseminated Intravascular Coagulation." 5
On the other hand, the Certificate of Death6 issued by SLMC stated the cause of
death as follows:
Immediate cause : a. Osteosarcoma, Status Post AKA
Antecedent cause : b. (above knee amputation)
Underlying cause : c. Status Post Chemotherapy
On February 21, 1994, respondents filed a damage suit 7 against petitioner, Dr. Leo
Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged
them with negligence and disregard of Angelica’s safety, health and welfare by their
careless administration of the chemotherapy drugs, their failure to observe the
essential precautions in detecting early the symptoms of fatal blood platelet
decrease and stopping early on the chemotherapy, which bleeding led to
hypovolemic shock that caused Angelica’s untimely demise. Further, it was
specifically averred that petitioner assured the respondents that Angelica would
recover in view of 95% chance of healing with chemotherapy ("Magiging normal na
ang anak nyo basta ma-chemo. 95% ang healing") and when asked regarding the
side effects, petitioner mentioned only slight vomiting, hair loss and weakness
("Magsusuka ng kaunti. Malulugas ang buhok. Manghihina"). Respondents thus
claimed that they would not have given their consent to chemotherapy had
petitioner not falsely assured them of its side effects.
In her answer,8 petitioner denied having been negligent in administering the
chemotherapy drugs to Angelica and asserted that she had fully explained to
respondents how the chemotherapy will affect not only the cancer cells but also the

patient’s normal body parts, including the lowering of white and red blood cells and
platelets. She claimed that what happened to Angelica can be attributed to
malignant tumor cells possibly left behind after surgery. Few as they may be, these
have the capacity to compete for nutrients such that the body becomes so weak
structurally (cachexia) and functionally in the form of lower resistance of the body
to combat infection. Such infection becomes uncontrollable and triggers a chain of
events (sepsis or septicemia) that may lead to bleeding in the form of Disseminated
Intravascular Coagulation (DIC), as what the autopsy report showed in the case of
Angelica.
Since the medical records of Angelica were not produced in court, the trial and
appellate courts had to rely on testimonial evidence, principally the declarations of
petitioner and respondents themselves. The following chronology of events was
gathered:
On July 23, 1993, petitioner saw the respondents at the hospital after Angelica’s
surgery and discussed with them Angelica’s condition. Petitioner told respondents
that Angelica should be given two to three weeks to recover from the operation
before starting chemotherapy. Respondents were apprehensive due to financial
constraints as Reynaldo earns only from ₱70,000.00 to ₱150,000.00 a year from his
jewelry and watch repairing business.9 Petitioner, however, assured them not to
worry about her professional fee and told them to just save up for the medicines to
be used.
Petitioner claimed that she explained to respondents that even when a tumor is
removed, there are still small lesions undetectable to the naked eye, and that
adjuvant chemotherapy is needed to clean out the small lesions in order to lessen the
chance of the cancer to recur. She did not give the respondents any assurance that
chemotherapy will cure Angelica’s cancer. During these consultations with
respondents, she explained the following side effects of chemotherapy treatment to
respondents: (1) falling hair; (2) nausea and vomiting; (3) loss of appetite; (4) low
count of white blood cells [WBC], red blood cells [RBC] and platelets; (5) possible
sterility due to the effects on Angelica’s ovary; (6) damage to the heart and kidneys;
2
and (7) darkening of the skin especially when exposed to sunlight. She actually
talked with respondents four times, once at the hospital after the surgery, twice at
her clinic and the fourth time when Angelica’s mother called her through long
distance.10 This was disputed by respondents who countered that petitioner gave
them assurance that there is 95% chance of healing for Angelica if she undergoes
chemotherapy and that the only side effects were nausea, vomiting and hair loss. 11
Those were the only side-effects of chemotherapy treatment mentioned by
petitioner.12
On July 27, 1993, SLMC discharged Angelica, with instruction from petitioner that
she be readmitted after two or three weeks for the chemotherapy.
On August 18, 1993, respondents brought Angelica to SLMC for chemotherapy,
bringing with them the results of the laboratory tests requested by petitioner:
Angelica’s chest x-ray, ultrasound of the liver, creatinine and complete liver
function tests.13 Petitioner proceeded with the chemotherapy by first administering
hydration fluids to Angelica.14
The following day, August 19, petitioner began administering three chemotherapy
drugs – Cisplatin,15 Doxorubicin16 and Cosmegen17 – intravenously. Petitioner was
supposedly assisted by her trainees Dr. Leo Marbella18 and Dr. Grace Arriete.19 In
his testimony, Dr. Marbella denied having any participation in administering the
said chemotherapy drugs.20
On the second day of chemotherapy, August 20, respondents noticed reddish
discoloration on Angelica’s face.21 They asked petitioner about it, but she merely
quipped, "Wala yan. Epekto ng gamot." 22 Petitioner recalled noticing the skin rashes
on the nose and cheek area of Angelica. At that moment, she entertained the
possibility that Angelica also had systemic lupus and consulted Dr. Victoria
Abesamis on the matter.23

On the third day of chemotherapy, August 21, Angelica had difficulty breathing and
was thus provided with oxygen inhalation apparatus. This time, the reddish
discoloration on Angelica’s face had extended to her neck, but petitioner dismissed
it again as merely the effect of medicines.24 Petitioner testified that she did not see
any discoloration on Angelica’s face, nor did she notice any difficulty in the child’s
breathing. She claimed that Angelica merely complained of nausea and was given
ice chips.251avvphi1
On August 22, 1993, at around ten o’clock in the morning, upon seeing that their
child could not anymore bear the pain, respondents pleaded with petitioner to stop
the chemotherapy. Petitioner supposedly replied: "Dapat 15 Cosmegen pa iyan.
Okay, let’s observe. If pwede na, bigyan uli ng chemo." At this point, respondents
asked petitioner’s permission to bring their child home. Later in the evening,
Angelica passed black stool and reddish urine.26 Petitioner countered that there was
no record of blackening of stools but only an episode of loose bowel movement
(LBM). Petitioner also testified that what Angelica complained of was carpo-pedal
spasm, not convulsion or epileptic attack, as respondents call it (petitioner described
it in the vernacular as "naninigas ang kamay at paa"). She then requested for a
serum calcium determination and stopped the chemotherapy. When Angelica was
given calcium gluconate, the spasm and numbness subsided. 27
The following day, August 23, petitioner yielded to respondents’ request to take
Angelica home. But prior to discharging Angelica, petitioner requested for a repeat
serum calcium determination and explained to respondents that the chemotherapy
will be temporarily stopped while she observes Angelica’s muscle twitching and
serum calcium level. Take-home medicines were also prescribed for Angelica, with
instructions to respondents that the serum calcium test will have to be repeated after
seven days. Petitioner told respondents that she will see Angelica again after two
weeks, but respondents can see her anytime if any immediate problem arises. 28
However, Angelica remained in confinement because while still in the premises of
SLMC, her "convulsions" returned and she also had LBM. Angelica was given
oxygen and administration of calcium continued.29
3
The next day, August 24, respondents claimed that Angelica still suffered from
convulsions. They also noticed that she had a fever and had difficulty breathing. 30
Petitioner insisted it was carpo-pedal spasm, not convulsions. She verified that at
around 4:50 that afternoon, Angelica developed difficulty in breathing and had fever.
She then requested for an electrocardiogram analysis, and infused calcium
gluconate on the patient at a "stat dose." She further ordered that Angelica be given
Bactrim,31 a synthetic antibacterial combination drug,32 to combat any infection on
the child’s body.33
By August 26, Angelica was bleeding through the mouth. Respondents also saw
blood on her anus and urine. When Lina asked petitioner what was happening to her
daughter, petitioner replied, "Bagsak ang platelets ng anak mo." Four units of
platelet concentrates were then transfused to Angelica. Petitioner prescribed
Solucortef. Considering that Angelica’s fever was high and her white blood cell
count was low, petitioner prescribed Leucomax. About four to eight bags of blood,
consisting of packed red blood cells, fresh whole blood, or platelet concentrate,
were transfused to Angelica. For two days (August 27 to 28), Angelica continued
bleeding, but petitioner claimed it was lesser in amount and in frequency. Petitioner
also denied that there were gadgets attached to Angelica at that time. 34
On August 29, Angelica developed ulcers in her mouth, which petitioner said were
blood clots that should not be removed. Respondents claimed that Angelica passed
about half a liter of blood through her anus at around seven o’clock that evening,
which petitioner likewise denied.
On August 30, Angelica continued bleeding. She was restless as endotracheal and
nasogastric tubes were inserted into her weakened body. An aspiration of the
nasogastric tube inserted to Angelica also revealed a bloody content. Angelica was
given more platelet concentrate and fresh whole blood, which petitioner claimed
improved her condition. Petitioner told Angelica not to remove the endotracheal
tube because this may induce further bleeding.35 She was also transferred to the
intensive care unit to avoid infection.

The next day, respondents claimed that Angelica became hysterical, vomited blood
and her body turned black. Part of Angelica’s skin was also noted to be shredding
by just rubbing cotton on it. Angelica was so restless she removed those gadgets
attached to her, saying "Ayaw ko na"; there were tears in her eyes and she kept
turning her head. Observing her daughter to be at the point of death, Lina asked for
a doctor but the latter could not answer her anymore. 36 At this time, the attending
physician was Dr. Marbella who was shaking his head saying that Angelica’s
platelets were down and respondents should pray for their daughter. Reynaldo
claimed that he was introduced to a pediatrician who took over his daughter’s case,
Dr. Abesamis who also told him to pray for his daughter. Angelica continued to
have difficulty in her breathing and blood was being suctioned from her stomach. A
nurse was posted inside Angelica’s room to assist her breathing and at one point
they had to revive Angelica by pumping her chest. Thereafter, Reynaldo claimed
that Angelica already experienced difficulty in urinating and her bowel consisted of
blood-like fluid. Angelica requested for an electric fan as she was in pain. Hospital
staff attempted to take blood samples from Angelica but were unsuccessful because
they could not even locate her vein. Angelica asked for a fruit but when it was given
to her, she only smelled it. At this time, Reynaldo claimed he could not find either
petitioner or Dr. Marbella. That night, Angelica became hysterical and started
removing those gadgets attached to her. At three o’clock in the morning of
September 1, a priest came and they prayed before Angelica expired. Petitioner
finally came back and supposedly told respondents that there was "malfunction" or
bogged-down machine.37
By petitioner’s own account, Angelica was merely irritable that day (August 31).
Petitioner noted though that Angelica’s skin was indeed sloughing off. 38 She
stressed that at 9:30 in the evening, Angelica pulled out her endotracheal tube.39 On
September 1, exactly two weeks after being admitted at SLMC for chemotherapy,
Angelica died.40 The cause of death, according to petitioner, was septicemia, or
overwhelming infection, which caused Angelica’s other organs to fail. 41 Petitioner
attributed this to the patient’s poor defense mechanism brought about by the cancer
itself.42
4
While he was seeking the release of Angelica’s cadaver from SLMC, Reynaldo
claimed that petitioner acted arrogantly and called him names. He was asked to sign
a promissory note as he did not have cash to pay the hospital bill. 43
Respondents also presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal
Officer of the PNP-Crime Laboratory who conducted the autopsy on Angelica’s
cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical Specialist employed
at the Department of Health (DOH) Operations and Management Services.
Testifying on the findings stated in her medico-legal report, Dr. Vergara noted the
following: (1) there were fluids recovered from the abdominal cavity, which is not
normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was
hemorrhage at the left side of the heart; (3) bleeding at the upper portion of and
areas adjacent to, the esophagus; (4) lungs were heavy with bleeding at the back and
lower portion, due to accumulation of fluids; (4) yellowish discoloration of the liver;
(5) kidneys showed appearance of facial shock on account of hemorrhages; and (6)
reddishness on external surface of the spleen. All these were the end result of
"hypovolemic shock secondary to multiple organ hemorrhages and disseminated
intravascular coagulation." Dr. Vergara opined that this can be attributed to the
chemical agents in the drugs given to the victim, which caused platelet reduction
resulting to bleeding sufficient to cause the victim’s death. The time lapse for the
production of DIC in the case of Angelica (from the time of diagnosis of sarcoma)
was too short, considering the survival rate of about 3 years. The witness conceded
that the victim will also die of osteosarcoma even with amputation or chemotherapy,
but in this case Angelica’s death was not caused by osteosarcoma. Dr. Vergara
admitted that she is not a pathologist but her statements were based on the opinion
of an oncologist whom she had interviewed. This oncologist supposedly said that if
the victim already had DIC prior to the chemotherapy, the hospital staff could have
detected it.44
On her part, Dr. Balmaceda declared that it is the physician’s duty to inform and
explain to the patient or his relatives every known side effect of the procedure or
therapeutic agents to be administered, before securing the consent of the patient or

his relatives to such procedure or therapy. The physician thus bases his assurance to
the patient on his personal assessment of the patient’s condition and his knowledge
of the general effects of the agents or procedure that will be allowed on the patient.
Dr. Balmaceda stressed that the patient or relatives must be informed of all known
side effects based on studies and observations, even if such will aggravate the
patient’s condition.45
Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelica’s lower
extremity, testified for the defendants. He explained that in case of malignant
tumors, there is no guarantee that the ablation or removal of the amputated part will
completely cure the cancer. Thus, surgery is not enough. The mortality rate of
osteosarcoma at the time of modern chemotherapy and early diagnosis still remains
at 80% to 90%. Usually, deaths occur from metastasis, or spread of the cancer to
other vital organs like the liver, causing systemic complications. The modes of
therapy available are the removal of the primary source of the cancerous growth and
then the residual cancer cells or metastasis should be treated with chemotherapy. Dr.
Tamayo further explained that patients with osteosarcoma have poor defense
mechanism due to the cancer cells in the blood stream. In the case of Angelica, he
had previously explained to her parents that after the surgical procedure,
chemotherapy is imperative so that metastasis of these cancer cells will hopefully be
addressed. He referred the patient to petitioner because he felt that petitioner is a
competent oncologist. Considering that this type of cancer is very aggressive and
will metastasize early, it will cause the demise of the patient should there be no
early intervention (in this case, the patient developed sepsis which caused her death).
Cancer cells in the blood cannot be seen by the naked eye nor detected through bone
scan. On cross-examination, Dr. Tamayo stated that of the more than 50 child
patients who had osteogenic sarcoma he had handled, he thought that probably all of
them died within six months from amputation because he did not see them anymore
after follow-up; it is either they died or had seen another doctor. 46
In dismissing the complaint, the trial court held that petitioner was not liable for
damages as she observed the best known procedures and employed her highest skill
and knowledge in the administration of chemotherapy drugs on Angelica but despite
5
all efforts said patient died. It cited the testimony of Dr. Tamayo who testified that
he considered petitioner one of the most proficient in the treatment of cancer and
that the patient in this case was afflicted with a very aggressive type of cancer
necessitating chemotherapy as adjuvant treatment. Using the standard of negligence
laid down in Picart v. Smith,47 the trial court declared that petitioner has taken the
necessary precaution against the adverse effect of chemotherapy on the patient,
adding that a wrong decision is not by itself negligence. Respondents were ordered
to pay their unpaid hospital bill in the amount of ₱139,064.43. 48
Respondents appealed to the CA which, while concurring with the trial court’s
finding that there was no negligence committed by the petitioner in the
administration of chemotherapy treatment to Angelica, found that petitioner as her
attending physician failed to fully explain to the respondents all the known side
effects of chemotherapy. The appellate court stressed that since the respondents
have been told of only three side effects of chemotherapy, they readily consented
thereto. Had petitioner made known to respondents those other side effects which
gravely affected their child -- such as carpo-pedal spasm, sepsis, decrease in the
blood platelet count, bleeding, infections and eventual death -- respondents could
have decided differently or adopted a different course of action which could have
delayed or prevented the early death of their child.
The CA thus declared:
Plaintiffs-appellants’ child was suffering from a malignant disease. The attending
physician recommended that she undergo chemotherapy treatment after surgery in
order to increase her chances of survival. Appellants consented to the chemotherapy
treatment because they believed in Dr. Rubi Li’s representation that the deceased
would have a strong chance of survival after chemotherapy and also because of the
representation of appellee Dr. Rubi Li that there were only three possible
side-effects of the treatment. However, all sorts of painful side-effects resulted from
the treatment including the premature death of Angelica. The appellants were
clearly and totally unaware of these other side-effects which manifested only during
the chemotherapy treatment. This was shown by the fact that every time a problem

would take place regarding Angelica’s condition (like an unexpected side-effect
manifesting itself), they would immediately seek explanation from Dr. Rubi Li.
Surely, those unexpected side-effects culminating in the loss of a love[d] one caused
the appellants so much trouble, pain and suffering.
On this point therefore, [w]e find defendant-appellee Dr. Rubi Li negligent which
would entitle plaintiffs-appellants to their claim for damages.
xxxx
WHEREFORE, the instant appeal is hereby GRANTED. Accordingly, the assailed
decision is hereby modified to the extent that defendant-appellee Dr. Rubi Li is
ordered to pay the plaintiffs-appellants the following amounts:
1. Actual damages of P139,064.43, plus P9,828.00 for funeral expenses;
2. Moral damages of P200,000.00;
3. Exemplary damages of P50,000.00;
4. Attorney’s fee of P30,000.00.
SO ORDERED.49 (Emphasis supplied.)
Petitioner filed a motion for partial reconsideration which the appellate court
denied.
Hence, this petition.
Petitioner assails the CA in finding her guilty of negligence in not explaining to the
respondents all the possible side effects of the chemotherapy on their child, and in
holding her liable for actual, moral and exemplary damages and attorney’s fees.
6
Petitioner emphasized that she was not negligent in the pre-chemotherapy
procedures and in the administration of chemotherapy treatment to Angelica.
On her supposed non-disclosure of all possible side effects of chemotherapy,
including death, petitioner argues that it was foolhardy to imagine her to be
all-knowing/omnipotent. While the theoretical side effects of chemotherapy were
explained by her to the respondents, as these should be known to a competent
doctor, petitioner cannot possibly predict how a particular patient’s genetic make-up,
state of mind, general health and body constitution would respond to the treatment.
These are obviously dependent on too many known, unknown and immeasurable
variables, thus requiring that Angelica be, as she was, constantly and closely
monitored during the treatment. Petitioner asserts that she did everything within her
professional competence to attend to the medical needs of Angelica.
Citing numerous trainings, distinctions and achievements in her field and her
current position as co-director for clinical affairs of the Medical Oncology,
Department of Medicine of SLMC, petitioner contends that in the absence of any
clear showing or proof, she cannot be charged with negligence in not informing the
respondents all the side effects of chemotherapy or in the pre-treatment procedures
done on Angelica.
As to the cause of death, petitioner insists that Angelica did not die of platelet
depletion but of sepsis which is a complication of the cancer itself. Sepsis itself
leads to bleeding and death. She explains that the response rate to chemotherapy of
patients with osteosarcoma is high, so much so that survival rate is favorable to the
patient. Petitioner then points to some probable consequences if Angelica had not
undergone chemotherapy. Thus, without chemotherapy, other medicines and
supportive treatment, the patient might have died the next day because of massive
infection, or the cancer cells might have spread to the brain and brought the patient
into a coma, or into the lungs that the patient could have been hooked to a respirator,
or into her kidneys that she would have to undergo dialysis. Indeed, respondents
could have spent as much because of these complications. The patient would have
been deprived of the chance to survive the ailment, of any hope for life and her

"quality of life" surely compromised. Since she had not been shown to be at fault,
petitioner maintains that the CA erred in holding her liable for the damages suffered
by the respondents.50
The issue to be resolved is whether the petitioner can be held liable for failure to
fully disclose serious side effects to the parents of the child patient who died while
undergoing chemotherapy, despite the absence of finding that petitioner was
negligent in administering the said treatment.
The petition is meritorious.
The type of lawsuit which has been called medical malpractice or, more
appropriately, medical negligence, is that type of claim which a victim has available
to him or her to redress a wrong committed by a medical professional which has
caused bodily harm. In order to successfully pursue such a claim, a patient must
prove that a health care provider, in most cases a physician, either failed to do
something which a reasonably prudent health care provider would have done, or
that he or she did something that a reasonably prudent provider would not have
done; and that that failure or action caused injury to the patient. 51
This Court has recognized that medical negligence cases are best proved by
opinions of expert witnesses belonging in the same general neighborhood and in the
same general line of practice as defendant physician or surgeon. The deference of
courts to the expert opinion of qualified physicians stems from the former’s
realization that the latter possess unusual technical skills which laymen in most
instances are incapable of intelligently evaluating, hence the indispensability of
expert testimonies.52
In this case, both the trial and appellate courts concurred in finding that the alleged
negligence of petitioner in the administration of chemotherapy drugs to
respondents’ child was not proven considering that Drs. Vergara and Balmaceda,
not being oncologists or cancer specialists, were not qualified to give expert opinion
7
as to whether petitioner’s lack of skill, knowledge and professional competence in
failing to observe the standard of care in her line of practice was the proximate
cause of the patient’s death. Furthermore, respondents’ case was not at all helped by
the non-production of medical records by the hospital (only the biopsy result and
medical bills were submitted to the court). Nevertheless, the CA found petitioner
liable for her failure to inform the respondents on all possible side effects of
chemotherapy before securing their consent to the said treatment.
The doctrine of informed consent within the context of physician-patient
relationships goes far back into English common law. As early as 1767, doctors
were charged with the tort of "battery" (i.e., an unauthorized physical contact with a
patient) if they had not gained the consent of their patients prior to performing a
surgery or procedure. In the United States, the seminal case was Schoendorff v.
Society of New York Hospital53 which involved unwanted treatment performed by a
doctor. Justice Benjamin Cardozo’s oft-quoted opinion upheld the basic right of a
patient to give consent to any medical procedure or treatment: "Every human being
of adult years and sound mind has a right to determine what shall be done with his
own body; and a surgeon who performs an operation without his patient’s consent,
commits an assault, for which he is liable in damages." 54 From a purely ethical norm,
informed consent evolved into a general principle of law that a physician has a duty
to disclose what a reasonably prudent physician in the medical community in the
exercise of reasonable care would disclose to his patient as to whatever grave risks
of injury might be incurred from a proposed course of treatment, so that a patient,
exercising ordinary care for his own welfare, and faced with a choice of undergoing
the proposed treatment, or alternative treatment, or none at all, may intelligently
exercise his judgment by reasonably balancing the probable risks against the
probable benefits.55
Subsequently, in Canterbury v. Spence56 the court observed that the duty to disclose
should not be limited to medical usage as to arrogate the decision on revelation to
the physician alone. Thus, respect for the patient’s right of self-determination on
particular therapy demands a standard set by law for physicians rather than one
which physicians may or may not impose upon themselves. 57 The scope of

disclosure is premised on the fact that patients ordinarily are persons unlearned in
the medical sciences. Proficiency in diagnosis and therapy is not the full measure of
a physician’s responsibility. It is also his duty to warn of the dangers lurking in the
proposed treatment and to impart information which the patient has every right to
expect. Indeed, the patient’s reliance upon the physician is a trust of the kind which
traditionally has exacted obligations beyond those associated with armslength
transactions.58 The physician is not expected to give the patient a short medical
education, the disclosure rule only requires of him a reasonable explanation, which
means generally informing the patient in nontechnical terms as to what is at stake;
the therapy alternatives open to him, the goals expectably to be achieved, and the
risks that may ensue from particular treatment or no treatment. 59 As to the issue of
demonstrating what risks are considered material necessitating disclosure, it was
held that experts are unnecessary to a showing of the materiality of a risk to a
patient’s decision on treatment, or to the reasonably, expectable effect of risk
disclosure on the decision. Such unrevealed risk that should have been made known
must further materialize, for otherwise the omission, however unpardonable, is
without legal consequence. And, as in malpractice actions generally, there must be a
causal relationship between the physician’s failure to divulge and damage to the
patient.60
Reiterating the foregoing considerations, Cobbs v. Grant61 deemed it as integral part
of physician’s overall obligation to patient, the duty of reasonable disclosure of
available choices with respect to proposed therapy and of dangers inherently and
potentially involved in each. However, the physician is not obliged to discuss
relatively minor risks inherent in common procedures when it is common
knowledge that such risks inherent in procedure of very low incidence. Cited as
exceptions to the rule that the patient should not be denied the opportunity to weigh
the risks of surgery or treatment are emergency cases where it is evident he cannot
evaluate data, and where the patient is a child or incompetent.62 The court thus
concluded that the patient’s right of self-decision can only be effectively exercised
if the patient possesses adequate information to enable him in making an intelligent
choice. The scope of the physician’s communications to the patient, then must be
measured by the patient’s need, and that need is whatever information is material to
8
the decision. The test therefore for determining whether a potential peril must be
divulged is its materiality to the patient’s decision.63
Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that
for liability of the physician for failure to inform patient, there must be causal
relationship between physician’s failure to inform and the injury to patient and such
connection arises only if it is established that, had revelation been made, consent to
treatment would not have been given.
There are four essential elements a plaintiff must prove in a malpractice action
based upon the doctrine of informed consent: "(1) the physician had a duty to
disclose material risks; (2) he failed to disclose or inadequately disclosed those risks;
(3) as a direct and proximate result of the failure to disclose, the patient consented to
treatment she otherwise would not have consented to; and (4) plaintiff was injured
by the proposed treatment." The gravamen in an informed consent case requires the
plaintiff to "point to significant undisclosed information relating to the treatment
which would have altered her decision to undergo it.64
Examining the evidence on record, we hold that there was adequate disclosure of
material risks inherent in the chemotherapy procedure performed with the consent
of Angelica’s parents. Respondents could not have been unaware in the course of
initial treatment and amputation of Angelica’s lower extremity, that her immune
system was already weak on account of the malignant tumor in her knee. When
petitioner informed the respondents beforehand of the side effects of chemotherapy
which includes lowered counts of white and red blood cells, decrease in blood
platelets, possible kidney or heart damage and skin darkening, there is reasonable
expectation on the part of the doctor that the respondents understood very well that
the severity of these side effects will not be the same for all patients undergoing the
procedure. In other words, by the nature of the disease itself, each patient’s reaction
to the chemical agents even with pre-treatment laboratory tests cannot be precisely
determined by the physician. That death can possibly result from complications of
the treatment or the underlying cancer itself, immediately or sometime after the
administration of chemotherapy drugs, is a risk that cannot be ruled out, as with

most other major medical procedures, but such conclusion can be reasonably drawn
from the general side effects of chemotherapy already disclosed.
As a physician, petitioner can reasonably expect the respondents to have considered
the variables in the recommended treatment for their daughter afflicted with a
life-threatening illness. On the other hand, it is difficult to give credence to
respondents’ claim that petitioner told them of 95% chance of recovery for their
daughter, as it was unlikely for doctors like petitioner who were dealing with grave
conditions such as cancer to have falsely assured patients of chemotherapy’s
success rate. Besides, informed consent laws in other countries generally require
only a reasonable explanation of potential harms, so specific disclosures such as
statistical data, may not be legally necessary.65
The element of ethical duty to disclose material risks in the proposed medical
treatment cannot thus be reduced to one simplistic formula applicable in all
instances. Further, in a medical malpractice action based on lack of informed
consent, "the plaintiff must prove both the duty and the breach of that duty through
expert testimony.66 Such expert testimony must show the customary standard of
care of physicians in the same practice as that of the defendant doctor. 67
In this case, the testimony of Dr. Balmaceda who is not an oncologist but a Medical
Specialist of the DOH’s Operational and Management Services charged with
receiving complaints against hospitals, does not qualify as expert testimony to
establish the standard of care in obtaining consent for chemotherapy treatment. In
the absence of expert testimony in this regard, the Court feels hesitant in defining
the scope of mandatory disclosure in cases of malpractice based on lack of informed
consent, much less set a standard of disclosure that, even in foreign jurisdictions,
has been noted to be an evolving one.
As society has grappled with the juxtaposition between personal autonomy and the
medical profession's intrinsic impetus to cure, the law defining "adequate"
disclosure has undergone a dynamic evolution. A standard once guided solely by
the ruminations of physicians is now dependent on what a reasonable person in the
9
patient’s position regards as significant. This change in perspective is especially
important as medical breakthroughs move practitioners to the cutting edge of
technology, ever encountering new and heretofore unimagined treatments for
currently incurable diseases or ailments. An adaptable standard is needed to account
for this constant progression. Reasonableness analyses permeate our legal system
for the very reason that they are determined by social norms, expanding and
contracting with the ebb and flow of societal evolution.
As we progress toward the twenty-first century, we now realize that the legal
standard of disclosure is not subject to construction as a categorical imperative.
Whatever formulae or processes we adopt are only useful as a foundational starting
point; the particular quality or quantity of disclosure will remain inextricably bound
by the facts of each case. Nevertheless, juries that ultimately determine whether a
physician properly informed a patient are inevitably guided by what they perceive
as the common expectation of the medical consumer—"a reasonable person in the
patient’s position when deciding to accept or reject a recommended medical
procedure."68 (Emphasis supplied.)
WHEREFORE, the petition for review on certiorari is GRANTED. The Decision
dated June 15, 2004 and the Resolution dated September 1, 2004 of the Court of
Appeals in CA-G.R. CV No. 58013 are SET ASIDE.
The Decision dated September 5, 1997 of the Regional Trial Court of Legazpi City,
Branch 8, in Civil Case No. 8904 is REINSTATED and UPHELD.
 10

ETER PAUL PATRICK LUCAS, et al. vs. DR. PROSPERO MA. C. TUAÑO
G.R. NO. 178763 21 April 2009
Chico-Nazario, J.

DOCTRINES:

In a medical negligence suit, the patient or his heirs, in order to prevail, is required
to prove by preponderance of evidence that the physician failed to exercise that
degree of skill, care, and learning possessed by other persons in the same
profession; and that as a proximate result of such failure, the patient or his heirs
suffered damages.

There is breach of duty of care, skill and diligence, or the improper performance of
such duty, by the attending physician when the patient is injured in body or in health
constitutes the actionable malpractice.

FACTS:

Herein petitioner, Peter Lucas, first consulted respondent, Dr. Tuaño, on a

complaint of soreness and redness on his right eye. The respondent, after a series of
examinations, found that the former was suffering from conjunctivitis or “sore eyes”
and prescribed the use of the Spersacet-C. However, after the petitioner’s
condition seemed to have worsened, he sought for the respondent’s second finding
wherein the latter said that his condition had progressed to Epidemic Kerato
Conjunctivitis (EKC), a viral infection. The respondent then prescribed the use of
Maxitrol, a steroid-based eye drop. The petitioner’s condition worsened overtime,
yet he obediently complied with all the prescriptions and orders of the respondent.

Four months later and after the petitioner suffered from significant swelling of his
right eyeball, headaches, nausea and blindness on this right eye, he sought for the
opinion of another doctor, Dr. Aquino. Dr. Aquino found that the petitioner had
been suffering from glaucoma and needed to undergo laser surgery, lest he might
suffer from total blindness.
 11

After reading the literature on the use of the medicine Maxitrol, Fatima, one of the
petitioners herein and Peter Lucas’ wife, read that one of the adverse effects of
prolonged use of steroid-based eye drops could possibly be glaucoma. Peter,
Fatima, and their two children instituted a civil case for damages against herein
respondent for medical malpractice.
[and this] constitutes the actionable malpractice. Hence, proof of breach of duty on
the part of the attending physician is insufficient. Rather, the negligence of the
physician must be the proximate cause of the injury.

ISSUE:

Whether or not the petitioners amply proved that Dr. Tuaño failed to exercise
diligence in the performance of his duty as petitioner Peter Lucas’ physician.

RULING:

No. Absent a definitive standard of care or diligence required of Dr. Tuaño under
the circumstances, the Court has no yardstick upon which to evaluate the attendant
facts of the case at hand to be able to state with confidence that the acts complained
of, indeed, constituted negligence and, thus, should be the subject of pecuniary
reparation.

In medical negligence cases, also called medical malpractice suits, there exist a
physician-patient relationship between the doctor and the victim. But just like any
other proceeding for damages, four essential (4) elements i.e., (1) duty; (2) breach;
(3) injury; and (4) proximate causation, must be established by the plaintiff/s. All
the four (4) elements must co-exist in order to find the physician negligent and,
thus, liable for damages.

As the physician has the duty to use at least the same level of care as that of any
other reasonably competent physician would use in the treatment of his patient, said
standard level of care, skill and diligence must likewise be proven by expert medical
testimony, because the standard of care in a medical malpractice case is a matter
peculiarly within the knowledge of experts in the field. The same is outside the ken
of the average layperson.

There is breach of duty of care, skill and diligence, or the improper performance of
such duty, by the attending physician when the patient is injured in body or in health
 12

G.R. No. 178763 April 21, 2009

PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS,

ABBEYGAIL LUCAS AND GILLIAN LUCAS, Petitioners,
vs.
DR. PROSPERO MA. C. TUAÑO, Respondent.

DECISION

CHICO-NAZARIO, J.:

In this petition for review on certiorari1 under Rule 45 of the Revised Rules of Court,
petitioners Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and
Gillian Lucas seek the reversal of the 27 September 2006 Decision2 and 3 July 2007
Resolution,3 both of the Court of Appeals in CA-G.R. CV No. 68666, entitled
"Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian
Lucas v. Prospero Ma. C. Tuaño."

In the questioned decision and resolution, the Court of Appeals affirmed the 14 July
2000 Decision of the Regional Trial Court (RTC), Branch 150, Makati City,
dismissing the complaint filed by petitioners in a civil case entitled, "Peter Paul
Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas and Gillian Lucas v.
Prospero Ma. C. Tuaño," docketed as Civil Case No. 92-2482.

From the record of the case, the established factual antecedents of the present
petition are:

Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter) contracted
"sore eyes" in his right eye.

On 2 September 1988, complaining of a red right eye and swollen eyelid, Peter
made use of his health care insurance issued by Philamcare Health Systems, Inc.

(Philamcare), for a possible consult. The Philamcare Coordinator, Dr. Edwin Oca,
M.D., referred Peter to respondent, Dr. Prospero Ma. C. Tuaño, M.D. (Dr. Tuaño),
an ophthalmologist at St. Luke’s Medical Center, for an eye consult.
Upon consultation with Dr. Tuaño, Peter narrated that it had been nine (9) days
since the problem with his right eye began; and that he was already taking Maxitrol
to address the problem in his eye. According to Dr. Tuaño, he performed "ocular
routine examination" on Peter’s eyes, wherein: (1) a gross examination of Peter’s
eyes and their surrounding area was made; (2) Peter’s visual acuity were taken; (3)
Peter’s eyes were palpated to check the intraocular pressure of each; (4) the motility
of Peter’s eyes was observed; and (5) the ophthalmoscopy4 on Peter’s eyes was used.
On that particular consultation, Dr. Tuaño diagnosed that Peter was suffering from
conjunctivitis5 or "sore eyes." Dr. Tuaño then prescribed Spersacet-C6 eye drops for
Peter and told the latter to return for follow-up after one week.
As instructed, Peter went back to Dr. Tuaño on 9 September 1988. Upon
examination, Dr. Tuaño told Peter that the "sore eyes" in the latter’s right eye had
already cleared up and he could discontinue the Spersacet-C. However, the same
eye developed Epidemic Kerato Conjunctivitis (EKC),7 a viral infection. To address
the new problem with Peter’s right eye, Dr. Tuaño prescribed to the former a
steroid-based eye drop called Maxitrol,8 a dosage of six (6) drops per day.9 To recall,
Peter had already been using Maxitrol prior to his consult with Dr. Tuaño.
On 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation. After
examining both of Peter’s eyes, Dr. Tuaño instructed the former to taper down 10 the
dosage of Maxitrol, because the EKC in his right eye had already resolved. Dr.
Tuaño specifically cautioned Peter that, being a steroid, Maxitrol had to be
withdrawn gradually; otherwise, the EKC might recur.11
Complaining of feeling as if there was something in his eyes, Peter returned to Dr.
Tuaño for another check-up on 6 October 1988. Dr. Tuaño examined Peter’s eyes
and found that the right eye had once more developed EKC. So, Dr. Tuaño
instructed Peter to resume the use of Maxitrol at six (6) drops per day.
13
On his way home, Peter was unable to get a hold of Maxitrol, as it was out of stock.
Consequently, Peter was told by Dr. Tuano to take, instead, Blephamide 12 another
steroid-based medication, but with a lower concentration, as substitute for the
unavailable Maxitrol, to be used three (3) times a day for five (5) days; two (2)
times a day for five (5) days; and then just once a day.13
Several days later, on 18 October 1988, Peter went to see Dr. Tuaño at his clinic,
alleging severe eye pain, feeling as if his eyes were about to "pop-out," a headache
and blurred vision. Dr. Tuaño examined Peter’s eyes and discovered that the EKC
was again present in his right eye. As a result, Dr. Tuaño told Peter to resume the
maximum dosage of Blephamide.
Dr. Tuaño saw Peter once more at the former’s clinic on 4 November 1988. Dr.
Tuaño’s examination showed that only the periphery of Peter’s right eye was
positive for EKC; hence, Dr. Tuaño prescribed a lower dosage of Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peter’s spouse, read
the accompanying literature of Maxitrol and found therein the following warning
against the prolonged use of such steroids:
WARNING:
Prolonged use may result in glaucoma, with damage to the optic nerve, defects in
visual acuity and fields of vision, and posterior, subcapsular cataract formation.
Prolonged use may suppress the host response and thus increase the hazard of
secondary ocular infractions, in those diseases causing thinning of the cornea or
sclera, perforations have been known to occur with the use of topical steroids. In
acute purulent conditions of the eye, steroids may mask infection or enhance
existing infection. If these products are used for 10 days or longer, intraocular
pressure should be routinely monitored even though it may be difficult in children
and uncooperative patients.

Employment of steroid medication in the treatment of herpes simplex requires great
caution.
xxxx
ADVERSE REACTIONS:
Adverse reactions have occurred with steroid/anti-infective combination drugs
which can be attributed to the steroid component, the anti-infective component, or
the combination. Exact incidence figures are not available since no denominator of
treated patients is available.
Reactions occurring most often from the presence of the anti-infective ingredients
are allergic sensitizations. The reactions due to the steroid component in decreasing
order to frequency are elevation of intra-ocular pressure (IOP) with possible
development of glaucoma, infrequent optic nerve damage; posterior subcapsular
cataract formation; and delayed wound healing.
Secondary infection: The development of secondary has occurred after use of
combination containing steroids and antimicrobials. Fungal infections of the correa
are particularly prone to develop coincidentally with long-term applications of
steroid. The possibility of fungal invasion must be considered in any persistent
corneal ulceration where steroid treatment has been used.
Secondary bacterial ocular infection following suppression of host responses also
occurs.
On 26 November 1988, Peter returned to Dr. Tuaño’s clinic, complaining of
"feeling worse."14 It appeared that the EKC had spread to the whole of Peter’s right
eye yet again. Thus, Dr. Tuaño instructed Peter to resume the use of Maxitrol.
Petitioners averred that Peter already made mention to Dr. Tuaño during said visit
of the above-quoted warning against the prolonged use of steroids, but Dr. Tuaño
14
supposedly brushed aside Peter’s concern as mere paranoia, even assuring him that
the former was taking care of him (Peter).
Petitioners further alleged that after Peter’s 26 November 1988 visit to Dr. Tuaño,
Peter continued to suffer pain in his right eye, which seemed to "progress," with the
ache intensifying and becoming more frequent.
Upon waking in the morning of 13 December 1988, Peter had no vision in his right
eye. Fatima observed that Peter’s right eye appeared to be bloody and swollen. 15
Thus, spouses Peter and Fatima rushed to the clinic of Dr. Tuaño. Peter reported to
Dr. Tuaño that he had been suffering from constant headache in the afternoon and
blurring of vision.
Upon examination, Dr. Tuaño noted the hardness of Peter’s right eye. With the use
of a tonometer16 to verify the exact intraocular pressure17 (IOP) of Peter’s eyes, Dr.
Tuaño discovered that the tension in Peter’s right eye was 39.0 Hg, while that of his
left was 17.0 Hg.18 Since the tension in Peter’s right eye was way over the normal
IOP, which merely ranged from 10.0 Hg to 21.0 Hg,19 Dr. Tuaño ordered20 him to
immediately discontinue the use of Maxitrol and prescribed to the latter Diamox21
and Normoglaucon, instead.22 Dr. Tuaño also required Peter to go for daily
check-up in order for the former to closely monitor the pressure of the latter’s eyes.
On 15 December 1988, the tonometer reading of Peter’s right eye yielded a high
normal level, i.e., 21.0 Hg. Hence, Dr. Tuaño told Peter to continue using Diamox
and Normoglaucon. But upon Peter’s complaint of "stomach pains and tingling
sensation in his fingers,"23 Dr. Tuaño discontinued Peter’s use of Diamox.24
Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal (Dr.
Batungbacal), on 21 December 1988, who allegedly conducted a complete
ophthalmological examination of Peter’s eyes. Dr. Batungbacal’s diagnosis was
Glaucoma25 O.D.26 He recommended Laser Trabeculoplasty27 for Peter’s right eye.

When Peter returned to Dr. Tuaño on 23 December 1988, 28 the tonometer measured
the IOP of Peter’s right eye to be 41.0 Hg,29 again, way above normal. Dr. Tuaño
addressed the problem by advising Peter to resume taking Diamox along with
Normoglaucon.
During the Christmas holidays, Peter supposedly stayed in bed most of the time and
was not able to celebrate the season with his family because of the debilitating
effects of Diamox.30
On 28 December 1988, during one of Peter’s regular follow-ups with Dr. Tuaño, the
doctor conducted another ocular routine examination of Peter’s eyes. Dr. Tuaño
noted the recurrence of EKC in Peter’s right eye. Considering, however, that the
IOP of Peter’s right eye was still quite high at 41.0 Hg, Dr. Tuaño was at a loss as to
how to balance the treatment of Peter’s EKC vis-à-vis the presence of glaucoma in
the same eye. Dr. Tuaño, thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr.
Agulto), another ophthalmologist specializing in the treatment of glaucoma. 31 Dr.
Tuaño’s letter of referral to Dr. Agulto stated that:
Referring to you Mr. Peter Lucas for evaluation & possible management. I initially
saw him Sept. 2, 1988 because of conjunctivitis. The latter resolved and he
developed EKC for which I gave Maxitrol. The EKC was recurrent after stopping
steroid drops. Around 1 month of steroid treatment, he noted blurring of vision &
pain on the R. however, I continued the steroids for the sake of the EKC. A month
ago, I noted iris atrophy, so I took the IOP and it was definitely elevated. I stopped
the steroids immediately and has (sic) been treating him medically.
It seems that the IOP can be controlled only with oral Diamox, and at the moment,
the EKC has recurred and I’m in a fix whether to resume the steroid or not
considering that the IOP is still uncontrolled.32
15
On 29 December 1988, Peter went to see Dr. Agulto at the latter’s clinic. Several
tests were conducted thereat to evaluate the extent of Peter’s condition. Dr. Agulto
wrote Dr. Tuaño a letter containing the following findings and recommendations:
Thanks for sending Peter Lucas. On examination conducted vision was 20/25 R and
20/20L. Tension curve 19 R and 15 L at 1210 H while on Normoglaucon BID OD
& Diamox ½ tab every 6h po.
Slit lamp evaluation33 disclosed subepithelial corneal defect outer OD. There was
circumferential peripheral iris atrophy, OD. The lenses were clear.
Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L with temporal slope
R>L.
Zeiss gonioscopy35 revealed basically open angles both eyes with occasional PAS, 36
OD.
Rolly, I feel that Peter Lucas has really sustained significant glaucoma damage. I
suggest that we do a baseline visual fields and push medication to lowest possible
levels. If I may suggest further, I think we should prescribe Timolol 37 BID38 OD in
lieu of Normoglaucon. If the IOP is still inadequate, we may try D’epifrin39 BID
OD (despite low PAS). I’m in favor of retaining Diamox or similar CAI.40
If fields show further loss in say – 3 mos. then we should consider trabeculoplasty.
I trust that this approach will prove reasonable for you and Peter.41
Peter went to see Dr. Tuaño on 31 December 1988, bearing Dr. Agulto’s
aforementioned letter. Though Peter’s right and left eyes then had normal IOP of
21.0 Hg and 17.0 Hg, respectively, Dr. Tuaño still gave him a prescription for
Timolol B.I.D. so Peter could immediately start using said medication. Regrettably,

Timolol B.I.D. was out of stock, so Dr. Tuaño instructed Peter to just continue using
Diamox and Normoglaucon in the meantime.
Just two days later, on 2 January 1989, the IOP of Peter’s right eye remained
elevated at 21.0 Hg,42 as he had been without Diamox for the past three (3) days.
On 4 January 1989, Dr. Tuaño conducted a visual field study43 of Peter’s eyes,
which revealed that the latter had tubular vision44 in his right eye, while that of his
left eye remained normal. Dr. Tuaño directed Peter to religiously use the Diamox
and Normoglaucon, as the tension of the latter’s right eye went up even further to
41.0 Hg in just a matter of two (2) days, in the meantime that Timolol B.I.D. and
D’epifrin were still not available in the market. Again, Dr. Tuaño advised Peter to
come for regular check-up so his IOP could be monitored.
Obediently, Peter went to see Dr. Tuaño on the 7th, 13th, 16th and 20th of January
1989 for check-up and IOP monitoring.
In the interregnum, however, Peter was prodded by his friends to seek a second
medical opinion. On 13 January 1989, Peter consulted Dr. Jaime Lapuz, M.D. (Dr.
Lapuz), an ophthalmologist, who, in turn, referred Peter to Dr. Mario V. Aquino,
M.D. (Dr. Aquino), another ophthalmologist who specializes in the treatment of
glaucoma and who could undertake the long term care of Peter’s eyes.
According to petitioners, after Dr. Aquino conducted an extensive evaluation of
Peter’s eyes, the said doctor informed Peter that his eyes were relatively normal,
though the right one sometimes manifested maximum borderline tension. Dr.
Aquino also confirmed Dr. Tuaño’s diagnosis of tubular vision in Peter’s right eye.
Petitioners claimed that Dr. Aquino essentially told Peter that the latter’s condition
would require lifetime medication and follow-ups.
In May 1990 and June 1991, Peter underwent two (2) procedures of laser
trabeculoplasty to attempt to control the high IOP of his right eye.
16
Claiming to have steroid-induced glaucoma45 and blaming Dr. Tuaño for the same,
Peter, joined by: (1) Fatima, his spouse46; (2) Abbeygail, his natural child47; and (3)
Gillian, his legitimate child48 with Fatima, instituted on 1 September 1992, a civil
complaint for damages against Dr. Tuaño, before the RTC, Branch 150, Quezon
City. The case was docketed as Civil Case No. 92-2482.
In their Complaint, petitioners specifically averred that as the "direct consequence
of [Peter’s] prolonged use of Maxitrol, [he] suffered from steroid induced glaucoma
which caused the elevation of his intra-ocular pressure. The elevation of the
intra-ocular pressure of [Peter’s right eye] caused the impairment of his vision
which impairment is not curable and may even lead to total blindness."49
Petitioners additionally alleged that the visual impairment of Peter’s right eye
caused him and his family so much grief. Because of his present condition, Peter
now needed close medical supervision forever; he had already undergone two (2)
laser surgeries, with the possibility that more surgeries were still needed in the
future; his career in sports casting had suffered and was continuing to suffer;50 his
anticipated income had been greatly reduced as a result of his "limited" capacity; he
continually suffered from "headaches, nausea, dizziness, heart palpitations, rashes,
chronic rhinitis, sinusitis,"51 etc.; Peter’s relationships with his spouse and children
continued to be strained, as his condition made him highly irritable and sensitive;
his mobility and social life had suffered; his spouse, Fatima, became the
breadwinner in the family;52 and his two children had been deprived of the
opportunity for a better life and educational prospects. Collectively, petitioners lived
in constant fear of Peter becoming completely blind. 53
In the end, petitioners sought pecuniary award for their supposed pain and suffering,
which were ultimately brought about by Dr. Tuaño’s grossly negligent conduct in
prescribing to Peter the medicine Maxitrol for a period of three (3) months, without
monitoring Peter’s IOP, as required in cases of prolonged use of said medicine, and
notwithstanding Peter’s constant complaint of intense eye pain while using the same.
Petitioners particularly prayed that Dr. Tuaño be adjudged liable for the following
amounts:

1. The amount of ₱2,000,000.00 to plaintiff Peter Lucas as and by way of
compensation for his impaired vision.
2. The amount of ₱300,000.00 to spouses Lucas as and by way of actual damages
plus such additional amounts that may be proven during trial.
3. The amount of ₱1,000,000.00 as and by way of moral damages.
4. The amount of ₱500,000.00 as and by way of exemplary damages.
5. The amount of ₱200,000.00 as and by way of attorney’s fees plus costs of suit. 54
In rebutting petitioners’ complaint, Dr. Tuaño asserted that the "treatment made by
[him] more than three years ago has no causal connection to [Peter’s] present
glaucoma or condition."55 Dr. Tuaño explained that "[d]rug-induced glaucoma is
temporary and curable, steroids have the side effect of increasing intraocular
pressure. Steroids are prescribed to treat Epidemic Kerato Conjunctivitis or EKC
which is an infiltration of the cornea as a result of conjunctivitis or sore eyes." 56 Dr.
Tuaño also clarified that (1) "[c]ontrary to [petitioners’] fallacious claim, [he] did
NOT continually prescribe the drug Maxitrol which contained steroids for any
prolonged period"57 and "[t]he truth was the Maxitrol was discontinued x x x as
soon as EKC disappeared and was resumed only when EKC reappeared" 58; (2) the
entire time he was treating Peter, he "continually monitored the intraocular pressure
of [Peter’s eyes] by palpating the eyes and by putting pressure on the eyeballs," and
no hardening of the same could be detected, which meant that there was no increase
in the tension or IOP, a possible side reaction to the use of steroid medications; and
(3) it was only on 13 December 1988 that Peter complained of a headache and
blurred vision in his right eye, and upon measuring the IOP of said eye, it was
determined for the first time that the IOP of the right eye had an elevated value.
But granting for the sake of argument that the "steroid treatment of [Peter’s] EKC
caused the steroid induced glaucoma,"59 Dr. Tuaño argued that:
17
[S]uch condition, i.e., elevated intraocular pressure, is temporary. As soon as the
intake of steroids is discontinued, the intraocular pressure automatically is reduced.
Thus, [Peter’s] glaucoma can only be due to other causes not attributable to steroids,
certainly not attributable to [his] treatment of more than three years ago x x x.
From a medical point of view, as revealed by more current examination of [Peter],
the latter’s glaucoma can only be long standing glaucoma, open angle glaucoma,
because of the large C:D ratio. The steroids provoked the latest glaucoma to be
revealed earlier as [Peter] remained asymptomatic prior to steroid application.
Hence, the steroid treatment was in fact beneficial to [Peter] as it revealed the
incipient open angle glaucoma of [Peter] to allow earlier treatment of the same. 60
In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-2482 "for
insufficiency of evidence."61 The decretal part of said Decision reads:
Wherefore, premises considered, the instant complaint is dismissed for insufficiency
of evidence. The counter claim (sic) is likewise dismissed in the absence of bad
faith or malice on the part of plaintiff in filing the suit. 62
The RTC opined that petitioners failed to prove by preponderance of evidence that
Dr. Tuaño was negligent in his treatment of Peter’s condition. In particular, the
record of the case was bereft of any evidence to establish that the steroid medication
and its dosage, as prescribed by Dr. Tuaño, caused Peter’s glaucoma. The trial court
reasoned that the "recognized standards of the medical community has not been
established in this case, much less has causation been established to render [Tuaño]
liable."63 According to the RTC:
[Petitioners] failed to establish the duty required of a medical practitioner against
which Peter Paul’s treatment by defendant can be compared with. They did not
present any medical expert or even a medical doctor to convince and expertly
explain to the court the established norm or duty required of a physician treating a
patient, or whether the non taking (sic) by Dr. Tuaño of Peter Paul’s pressure a

deviation from the norm or his non-discovery of the glaucoma in the course of
treatment constitutes negligence. It is important and indispensable to establish such
a standard because once it is established, a medical practitioner who departed
thereof breaches his duty and commits negligence rendering him liable. Without
such testimony or enlightenment from an expert, the court is at a loss as to what is
then the established norm of duty of a physician against which defendant’s conduct
can be compared with to determine negligence.64
The RTC added that in the absence of "any medical evidence to the contrary, this
court cannot accept [petitioners’] claim that the use of steroid is the proximate cause
of the damage sustained by [Peter’s] eye." 65
Correspondingly, the RTC accepted Dr. Tuaño’s medical opinion that "Peter Paul
must have been suffering from normal tension glaucoma, meaning, optic nerve
damage was happening but no elevation of the eye pressure is manifested, that the
steroid treatment actually unmasked the condition that resulted in the earlier
treatment of the glaucoma. There is nothing in the record to contradict such
testimony. In fact, plaintiff’s Exhibit ‘S’ even tends to support them."
Undaunted, petitioners appealed the foregoing RTC decision to the Court of
Appeals. Their appeal was docketed as CA-G.R. CV No. 68666.
On 27 September 2006, the Court of Appeals rendered a decision in CA-G.R. CV
No. 68666 denying petitioners’ recourse and affirming the appealed RTC Decision.
The fallo of the judgment of the appellate court states:
WHEREFORE, the Decision appealed from is AFFIRMED. 66
The Court of Appeals faulted petitioners because they –
[D]id not present any medical expert to testify that Dr. Tuano’s prescription of
Maxitrol and Blephamide for the treatment of EKC on Peter’s right eye was not
18
proper and that his palpation of Peter’s right eye was not enough to detect adverse
reaction to steroid. Peter testified that Dr. Manuel Agulto told him that he should
not have used steroid for the treatment of EKC or that he should have used it only
for two (2) weeks, as EKC is only a viral infection which will cure by itself.
However, Dr. Agulto was not presented by [petitioners] as a witness to confirm
what he allegedly told Peter and, therefore, the latter’s testimony is hearsay. Under
Rule 130, Section 36 of the Rules of Court, a witness can testify only to those facts
which he knows of his own personal knowledge, x x x. Familiar and fundamental is
the rule that hearsay testimony is inadmissible as evidence.67
Like the RTC, the Court of Appeals gave great weight to Dr. Tuaño’s medical
judgment, specifically the latter’s explanation that:
[W]hen a doctor sees a patient, he cannot determine whether or not the latter would
react adversely to the use of steroids, that it was only on December 13, 1989, when
Peter complained for the first time of headache and blurred vision that he observed
that the pressure of the eye of Peter was elevated, and it was only then that he
suspected that Peter belongs to the 5% of the population who reacts adversely to
steroids.68
Petitioners’ Motion for Reconsideration was denied by the Court of Appeals in a
Resolution dated 3 July 2007.
Hence, this Petition for Review on Certiorari under Rule 45 of the Revised Rules of
Court premised on the following assignment of errors:
I.
THE COURT OF APPEALS COMMITTED GRAVE
REVERSIBLE ERROR IN AFFIRMING THE DECISION OF
THE TRIAL COURT DISMISSING THE PETITIONERS’
COMPLAINT FOR DAMAGES AGAINST THE
 19

RESPONDENT ON THE GROUND OF INSUFFICIENCY OF Evidently, said issue constitutes a question of fact, as we are asked to revisit anew
EVIDENCE; the factual findings of the Court of Appeals, as well as of the RTC. In effect,
petitioners would have us sift through the evidence on record and pass upon
II. whether there is sufficient basis to establish Dr. Tuaño’s negligence in his treatment
of Peter’s eye condition. This question clearly involves a factual inquiry, the
THE COURT OF APPEALS COMMITTED GRAVE determination of which is not within the ambit of this Court’s power of review
REVERSIBLE ERROR IN DISMISSING THE PETITIONERS’ under Rule 45 of the 1997 Rules Civil Procedure, as amended.70
COMPLAINT FOR DAMAGES AGAINST THE
RESPONDENT ON THE GROUND THAT NO MEDICAL Elementary is the principle that this Court is not a trier of facts; only errors of law
EXPERT WAS PRESENTED BY THE PETITIONERS TO are generally reviewed in petitions for review on certiorari criticizing decisions of
PROVE THEIR CLAIM FOR MEDICAL NEGLIGENCE the Court of Appeals. Questions of fact are not entertained. 71
AGAINST THE RESPONDENT; AND
Nonetheless, the general rule that only questions of law may be raised on appeal in a
III. petition for review under Rule 45 of the Rules of Court admits of certain exceptions,
including the circumstance when the finding of fact of the Court of Appeals is
THE COURT OF APPEALS COMMITTED GRAVE premised on the supposed absence of evidence, but is contradicted by the evidence
REVERSIBLE ERROR IN NOT FINDING THE RESPONDENT on record. Although petitioners may not explicitly invoke said exception, it may be
LIABLE TO THE PETITIONERS’ FOR ACTUAL, MORAL gleaned from their allegations and arguments in the instant Petition.1avvphi1.zw+
AND EXEMPLARY DAMAGES, ASIDE FROM
ATTORNEY’S FEES, COSTS OF SUIT, AS A RESULT OF Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of
HIS GROSS NEGLIGENCE.69 Appeals, [they] were more than able to establish that: Dr. Tuaño ignored the
standard medical procedure for ophthalmologists, administered medication with
A reading of the afore-quoted reversible errors supposedly committed by the Court recklessness, and exhibited an absence of competence and skills expected from
of Appeals in its Decision and Resolution would reveal that petitioners are him."72 Petitioners reject the necessity of presenting expert and/or medical
fundamentally assailing the finding of the Court of Appeals that the evidence on testimony to establish (1) the standard of care respecting the treatment of the
record is insufficient to establish petitioners’ entitlement to any kind of damage. disorder affecting Peter’s eye; and (2) whether or not negligence attended Dr.
Therefore, it could be said that the sole issue for our resolution in the Petition at bar Tuaño’s treatment of Peter, because, in their words –
is whether the Court of Appeals committed reversible error in affirming the
judgment of the RTC that petitioners failed to prove, by preponderance of evidence, That Dr. Tuaño was grossly negligent in the treatment of Peter’s simple eye ailment
their claim for damages against Dr. Tuaño. is a simple case of cause and effect. With mere documentary evidence and based on
the facts presented by the petitioners, respondent can readily be held liable for
damages even without any expert testimony. In any case, however, and contrary to
the finding of the trial court and the Court of Appeals, there was a medical expert

presented by the petitioner showing the recklessness committed by [Dr. Tuaño] – Dr.
Tuaño himself. [Emphasis supplied.]
They insist that Dr. Tuaño himself gave sufficient evidence to establish his gross
negligence that ultimately caused the impairment of the vision of Peter’s right eye, 73
i.e., that "[d]espite [Dr. Tuaño’s] knowledge that 5% of the population reacts
adversely to Maxitrol, [he] had no qualms whatsoever in prescribing said steroid to
Peter without first determining whether or not the (sic) Peter belongs to the 5%." 74
We are not convinced. The judgments of both the Court of Appeals and the RTC are
in accord with the evidence on record, and we are accordingly bound by the
findings of fact made therein.
Petitioners’ position, in sum, is that Peter’s glaucoma is the direct result of Dr.
Tuaño’s negligence in his improper administration of the drug Maxitrol; "thus, [the
latter] should be liable for all the damages suffered and to be suffered by
[petitioners]."75 Clearly, the present controversy is a classic illustration of a medical
negligence case against a physician based on the latter’s professional negligence. In
this type of suit, the patient or his heirs, in order to prevail, is required to prove by
preponderance of evidence that the physician failed to exercise that degree of skill,
care, and learning possessed by other persons in the same profession; and that as a
proximate result of such failure, the patient or his heirs suffered damages.
For lack of a specific law geared towards the type of negligence committed by
members of the medical profession, such claim for damages is almost always
anchored on the alleged violation of Article 2176 of the Civil Code, which states
that:
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.
20
In medical negligence cases, also called medical malpractice suits, there exist a
physician-patient relationship between the doctor and the victim. But just like any
other proceeding for damages, four essential (4) elements i.e., (1) duty; (2) breach;
(3) injury; and (4) proximate causation,76 must be established by the plaintiff/s. All
the four (4) elements must co-exist in order to find the physician negligent and, thus,
liable for damages.
When 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.77 Thus, in treating his patient, a physician is
under a duty to [the former] 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.78 Stated otherwise, the
physician has the duty to use at least the same level of care that any other
reasonably competent physician would use to treat the condition under similar
circumstances.
This standard level of care, skill and diligence is a matter best addressed by expert
medical testimony, because the standard of care in a medical malpractice case is a
matter peculiarly within the knowledge of experts in the field. 79
There is breach of duty of care, skill and diligence, or the improper performance of
such duty, by the attending physician when the patient is injured in body or in health
[and this] constitutes the actionable malpractice.80 Proof of such breach must
likewise rest upon the testimony of an expert witness that the treatment accorded to
the patient failed to meet the standard level 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.
Even so, proof of breach of duty on the part of the attending physician is insufficient,
for there must be a causal connection between said breach and the resulting injury

sustained by the patient. Put in another way, in order that there may be a recovery
for an injury, it must be shown that the "injury for which recovery is sought must be
the legitimate consequence of the wrong done; the connection between the
negligence and the injury must be a direct and natural sequence of events, unbroken
by intervening efficient causes";81 that is, the negligence must be the proximate
cause of the injury. And the proximate cause of an injury is that cause, which, in the
natural and continuous sequence, unbroken by any efficient intervening cause,
produces the injury, and without which the result would not have occurred.82
Just as with the elements of duty and breach of the same, in order to establish the
proximate cause [of the injury] by a preponderance of the evidence in a medical
malpractice action, [the patient] must similarly use expert testimony, because the
question of whether the alleged professional negligence caused [the patient’s] injury
is generally one for specialized expert knowledge beyond the ken of the average
layperson; using the specialized knowledge and training of his field, the expert’s
role is to present to the [court] a realistic assessment of the likelihood that [the
physician’s] alleged negligence caused [the patient’s] injury.83
From the foregoing, it is apparent that medical negligence cases are best proved by
opinions of expert witnesses belonging in the same general neighborhood and in the
same general line of practice as defendant physician or surgeon. The deference of
courts to the expert opinion of qualified physicians [or surgeons] stems from the
former’s realization that the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating;84 hence, the indispensability
of expert testimonies.
In the case at bar, there is no question that a physician-patient relationship
developed between Dr. Tuaño and Peter when Peter went to see the doctor on 2
September 1988, seeking a consult for the treatment of his sore eyes. Admittedly,
Dr. Tuaño, an ophthalmologist, prescribed Maxitrol when Peter developed and had
recurrent EKC. Maxitrol or neomycin/polymyxin B sulfates/dexamethasone
ophthalmic ointment is a multiple-dose anti-infective steroid combination in sterile
21
form for topical application.85 It is the drug which petitioners claim to have caused
Peter’s glaucoma.
However, as correctly pointed out by the Court of Appeals, "[t]he onus probandi
was on the patient to establish before the trial court that the physicians ignored
standard medical procedure, prescribed and administered medication with
recklessness and exhibited an absence of the competence and skills expected of
general practitioners similarly situated." 86 Unfortunately, in this case, there was
absolute failure on the part of petitioners to present any expert testimony to
establish: (1) the standard of care to be implemented by competent physicians in
treating the same condition as Peter’s under similar circumstances; (2) that, in his
treatment of Peter, Dr. Tuaño failed in his duty to exercise said standard of care that
any other competent physician would use in treating the same condition as Peter’s
under similar circumstances; and (3) that the injury or damage to Peter’s right eye,
i.e., his glaucoma, was the result of his use of Maxitrol, as prescribed by Dr. Tuaño.
Petitioners’ failure to prove the first element alone is already fatal to their cause.
Petitioners maintain that Dr. Tuaño failed to follow in Peter’s case the required
procedure for the prolonged use of Maxitrol. But what is actually the required
procedure in situations such as in the case at bar? To be precise, what is the standard
operating procedure when ophthalmologists prescribe steroid medications which,
admittedly, carry some modicum of risk?
Absent a definitive standard of care or diligence required of Dr. Tuaño under the
circumstances, we have no means to determine whether he was able to comply with
the same in his diagnosis and treatment of Peter. This Court has no yardstick upon
which to evaluate or weigh the attendant facts of this case to be able to state with
confidence that the acts complained of, indeed, constituted negligence and, thus,
should be the subject of pecuniary reparation.
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuaño should have
determined first whether Peter was a "steroid responder." 87 Yet again, petitioners
did not present any convincing proof that such determination is actually part of the

standard operating procedure which ophthalmologists should unerringly follow
prior to prescribing steroid medications.
In contrast, Dr. Tuaño was able to clearly explain that what is only required of
ophthalmologists, in cases such as Peter’s, is the conduct of standard
tests/procedures known as "ocular routine examination," 88 composed of five (5)
tests/procedures – specifically, gross examination of the eyes and the surrounding
area; taking of the visual acuity of the patient; checking the intraocular pressure of
the patient; checking the motility of the eyes; and using ophthalmoscopy on the
patient’s eye – and he did all those tests/procedures every time Peter went to see
him for follow-up consultation and/or check-up.
We cannot but agree with Dr. Tuaño’s assertion that when a doctor sees a patient,
he cannot determine immediately whether the latter would react adversely to the use
of steroids; all the doctor can do is map out a course of treatment recognized as
correct by the standards of the medical profession. It must be remembered that a
physician is not an insurer of the good result of treatment. The mere fact that the
patient does not get well or that a bad result occurs does not in itself indicate failure
to exercise due care.89 The result is not determinative of the performance [of the
physician] and he is not required to be infallible.90
Moreover, that Dr. Tuaño saw it fit to prescribe Maxitrol to Peter was justified by
the fact that the latter was already using the same medication when he first came to
see Dr. Tuaño on 2 September 1988 and had exhibited no previous untoward
reaction to that particular drug. 91
Also, Dr. Tuaño categorically denied petitioners’ claim that he never monitored the
tension of Peter’s eyes while the latter was on Maxitrol. Dr. Tuaño testified that he
palpated Peter’s eyes every time the latter came for a check-up as part of the
doctor’s ocular routine examination, a fact which petitioners failed to rebut. Dr.
Tuaño’s regular conduct of examinations and tests to ascertain the state of Peter’s
eyes negate the very basis of petitioners’ complaint for damages. As to whether Dr.
Tuaño’s actuations conformed to the standard of care and diligence required in like
22
circumstances, it is presumed to have so conformed in the absence of evidence to
the contrary.
Even if we are to assume that Dr. Tuaño committed negligent acts in his treatment
of Peter’s condition, the causal connection between Dr. Tuaño’s supposed
negligence and Peter’s injury still needed to be established. The critical and
clinching factor in a medical negligence case is proof of the causal connection
between the negligence which the evidence established and the plaintiff’s injuries.92
The plaintiff must plead and prove not only that he has been injured and defendant
has been at fault, but also that the defendant’s fault caused the injury. A verdict in a
malpractice action cannot be based on speculation or conjecture. Causation must be
proven within a reasonable medical probability based upon competent expert
testimony.93
The causation between the physician’s negligence and the patient’s injury may only
be established by the presentation of proof that Peter’s glaucoma would not have
occurred but for Dr. Tuaño’s supposed negligent conduct. Once more, petitioners
failed in this regard.
Dr. Tuaño does not deny that the use of Maxitrol involves the risk of increasing a
patient’s IOP. In fact, this was the reason why he made it a point to palpate Peter’s
eyes every time the latter went to see him -- so he could monitor the tension of
Peter’s eyes. But to say that said medication conclusively caused Peter’s glaucoma
is purely speculative. Peter was diagnosed with open-angle glaucoma. This kind of
glaucoma is characterized by an almost complete absence of symptoms and a
chronic, insidious course.94 In open-angle glaucoma, halos around lights and
blurring of vision do not occur unless there has been a sudden increase in the
intraocular vision.95 Visual acuity remains good until late in the course of the
disease.96 Hence, Dr. Tuaño claims that Peter’s glaucoma "can only be long
standing x x x because of the large C:D97 ratio," and that "[t]he steroids provoked
the latest glaucoma to be revealed earlier" was a blessing in disguise "as [Peter]
remained asymptomatic prior to steroid application."

Who between petitioners and Dr. Tuaño is in a better position to determine and
evaluate the necessity of using Maxitrol to cure Peter’s EKC vis-à-vis the attendant
risks of using the same?
That Dr. Tuaño has the necessary training and skill to practice his chosen field is
beyond cavil. Petitioners do not dispute Dr. Tuaño’s qualifications – that he has
been a physician for close to a decade and a half at the time Peter first came to see
him; that he has had various medical training; that he has authored numerous papers
in the field of ophthalmology, here and abroad; that he is a Diplomate of the
Philippine Board of Ophthalmology; that he occupies various teaching posts (at the
time of the filing of the present complaint, he was the Chair of the Department of
Ophthalmology and an Associate Professor at the University of the
Philippines-Philippine General Hospital and St. Luke’s Medical Center,
respectively); and that he held an assortment of positions in numerous medical
organizations like the Philippine Medical Association, Philippine Academy of
Ophthalmology, Philippine Board of Ophthalmology, Philippine Society of
Ophthalmic Plastic and Reconstructive Surgery, Philippine Journal of
Ophthalmology, Association of Philippine Ophthalmology Professors, et al.
It must be remembered that when the qualifications of a physician are admitted, as
in the instant case, there is an inevitable presumption that in proper cases, he takes
the necessary precaution and employs the best of his knowledge and skill in
attending to his clients, unless the contrary is sufficiently established.98 In making
the judgment call of treating Peter’s EKC with Maxitrol, Dr. Tuaño took the
necessary precaution by palpating Peter’s eyes to monitor their IOP every time the
latter went for a check-up, and he employed the best of his knowledge and skill
earned from years of training and practice.
In contrast, without supporting expert medical opinions, petitioners’ bare assertions
of negligence on Dr. Tuaño’s part, which resulted in Peter’s glaucoma, deserve
scant credit.
23
Our disposition of the present controversy might have been vastly different had
petitioners presented a medical expert to establish their theory respecting Dr.
Tuaño’s so-called negligence. In fact, the record of the case reveals that petitioners’
counsel recognized the necessity of presenting such evidence. Petitioners even gave
an undertaking to the RTC judge that Dr. Agulto or Dr. Aquino would be presented.
Alas, no follow-through on said undertaking was made.1avvphi1
The plaintiff in a civil case has the burden of proof as he alleges the affirmative of
the issue. However, in the course of trial in a civil case, once plaintiff makes out a
prima facie case in his favor, the duty or the burden of evidence shifts to defendant
to controvert plaintiff’s prima facie case; otherwise, a verdict must be returned in
favor of plaintiff.99 The party having the burden of proof must establish his case by
a preponderance of evidence.100 The concept of "preponderance of evidence" refers
to evidence which is of greater weight or more convincing than that which is offered
in opposition to it;101 in the last analysis, it means probability of truth. It is evidence
which is more convincing to the court as worthy of belief than that which is offered
in opposition thereto.102 Rule 133, Section 1 of the Revised Rules of Court provides
the guidelines for determining preponderance of evidence, thus:
In civil cases, the party having the burden of proof must establish his case by a
preponderance of evidence. In determining where the preponderance or superior
weight of evidence on the issues involved lies the court may consider all the facts
and circumstances of the case, the witnesses’ manner of testifying, their intelligence,
their means and opportunity of knowing the facts to which they are testifying, the
nature of the facts to which they testify, the probability or improbability of their
testimony, their interest or want of interest, and also their personal credibility so far
as the same legitimately appear upon the trial. The court may also consider the
number of witnesses, though the preponderance is not necessarily with the greater
number.
Herein, the burden of proof was clearly upon petitioners, as plaintiffs in the lower
court, to establish their case by a preponderance of evidence showing a reasonable
connection between Dr. Tuaño’s alleged breach of duty and the damage sustained
 24

by Peter’s right eye. This, they did not do. In reality, petitioners’ complaint for
damages is merely anchored on a statement in the literature of Maxitrol identifying
the risks of its use, and the purported comment of Dr. Agulto – another doctor not
presented as witness before the RTC – concerning the prolonged use of Maxitrol for
the treatment of EKC.

It seems basic that what constitutes proper medical treatment is a medical question
that should have been presented to experts. If no standard is established through
expert medical witnesses, then courts have no standard by which to gauge the basic
issue of breach thereof by the physician or surgeon. The RTC and Court of Appeals,
and even this Court, could not be expected to determine on its own what medical
technique should have been utilized for a certain disease or injury. Absent expert
medical opinion, the courts would be dangerously engaging in speculations.

All told, we are hard pressed to find Dr. Tuaño liable for any medical negligence or
malpractice where there is no evidence, in the nature of expert testimony, to
establish that in treating Peter, Dr. Tuaño failed to exercise reasonable care,
diligence and skill generally required in medical practice. Dr. Tuaño’s testimony,
that his treatment of Peter conformed in all respects to standard medical practice in
this locality, stands unrefuted. Consequently, the RTC and the Court of Appeals
correctly held that they had no basis at all to rule that petitioners were deserving of
the various damages prayed for in their Complaint.

WHEREFORE, premises considered, the instant petition is DENIED for lack of

merit. The assailed Decision dated 27 September 2006 and Resolution dated 3 July
2007, both of the Court of Appeals in CA-G.R. CV No. 68666, are hereby
AFFIRMED. No cost.
 25

Lasam vs. Sps. Ramolete G.R. No. 159132 December 8, 2008

Facts:

On July 1994, respondent three months pregnant Editha Ramolete was brought to
the Lorma Medical Center (LMC) to vaginal bleeding. A pelvic sonogram was then
conducted on Editha revealing the fetus weak cardiac pulsation. Editha’s repeat
pelvic sonogram showed that aside from the fetus weak cardiac pulsation, no fetal
movement was also appreciated. Due to persistent and profuse vaginal bleeding,
petitioner Dr. Fe Cayao-Lasam advised Editha to undergo a Dilatation and
Curettage Procedure (D&C) or raspa which the petitioner performed.

On September 1994, Editha was brought again to LMC due to vomiting and severe
abdominal pains. One of the attending physician, Dr. Mayo allegedly informed
Editha that there was a dead fetus in her womb. Editha underwent laparotomy where
she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus.
Editha had to undergo a procedure for hysterectomy and as a result, she has no more
chance to bear a child.

On November 1994, Editha and her husband Claro Ramolete filed a Complaint for
Gross Negligence and Malpractice against petitioner before the PRC.

Respondents alleged that Editha’s hysterectomy was caused by petitioners

unmitigated negligence and professional incompetence in conducting the D&C
procedure and the petitioners failure to remove the fetus inside Editha’s womb.
Petitioner denied the allegations of negligence and incompetence

On March 1999, Board of Medicine of the PRC exonerated petitioner from the
charges filed against her. Feeling aggrieved, respondents went to the PRC on appeal.
On November 2000, the PRC reversed the findings of the Board and revoked
petitioners authority or license to practice her profession as a physician. Petitioner
 26

brought the matter to the CA but was dismissed on the ground of being improper
and premature.
Issue: WON there was medical malpractice in the case?
Art. 2179. When the plaintiffs own negligence was the immediate and proximate
cause of his injury, he cannot recover damages. But if his negligence was only
contributory, the immediate and proximate cause of the injury being the defendants
lack of due care, the plaintiff may recover damages, but the courts shall mitigate the
damages to be awarded.

Held: There was no medical malpractice in the case.

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.
There are four elements involved in medical negligence cases: duty, breach, injury
and proximate causation.
It is also undisputed that Editha did not return for a follow-up evaluation, in
defiance of the petitioners advise. Editha omitted the diligence required by the
circumstances which could have avoided the injury. The omission in not returning
for a follow-up evaluation played a substantial part in bringing about Editha’s own
injury. Had Editha returned, petitioner could have conducted the proper medical
tests and procedure necessary to determine Editha’s health condition and applied the
corresponding treatment which could have prevented the rupture of Editha’s uterus.
The D&C procedure having been conducted in accordance with the standard
medical practice, it is clear that Editha’s omission was the proximate cause of her
own injury and not merely a contributory negligence on her part.

From the testimony of the expert witness and the reasons given by him, it is evident
that the D&C procedure was not the proximate cause of the rupture of Editha’s
uterus. Further in the testimony, it is clear that the D&C procedure was conducted in
accordance with the standard practice, with the same level of care that any
reasonably competent doctor would use to treat a condition under the same
circumstances, and that there was nothing irregular in the way the petitioner dealt
with Editha.

Medical malpractice is often brought as a civil action for damages under Article
2176 of the Civil Code. The defenses in an action for damages, provided for under
Article 2179 of the Civil Code are:
 27

.R. No. 159132 December 18, 2008

FE CAYAO-LASAM, petitioner,
vs.
SPOUSES CLARO and EDITHA RAMOLETE, respondents.*

DECISION

AUSTRIA-MARTINEZ, J.:

Before the Court is a Petition for Review on Certiorari under Rule 45 of the Rules
of Court filed by Dr. Fe Cayao-Lasam (petitioner) seeking to annul the Decision1
dated July 4, 2003 of the Court of Appeals (CA) in CA-G.R. SP No. 62206.

The antecedent facts:

On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was
brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to
vaginal bleeding. Upon advice of petitioner relayed via telephone, Editha was
admitted to the LMC on the same day. A pelvic sonogram2 was then conducted on
Editha revealing the fetus’ weak cardiac pulsation.3 The following day, Editha’s
repeat pelvic sonogram4 showed that aside from the fetus’ weak cardiac pulsation,
no fetal movement was also appreciated. Due to persistent and profuse vaginal
bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure
(D&C) or "raspa."

On July 30, 1994, petitioner performed the D&C procedure. Editha was discharged
from the hospital the following day.

On September 16, 1994, Editha was once again brought at the LMC, as she was
suffering from vomiting and severe abdominal pains. Editha was attended by Dr.
Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo

allegedly informed Editha that there was a dead fetus in the latter’s womb. After,
Editha underwent laparotomy,5 she was found to have a massive intra-abdominal
hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for
hysterectomy6 and as a result, she has no more chance to bear a child.
On November 7, 1994, Editha and her husband Claro Ramolete (respondents) filed
a Complaint7 for Gross Negligence and Malpractice against petitioner before the
Professional Regulations Commission (PRC).
Respondents alleged that Editha’s hysterectomy was caused by petitioner’s
unmitigated negligence and professional incompetence in conducting the D&C
procedure and the petitioner’s failure to remove the fetus inside Editha’s womb. 8
Among the alleged acts of negligence were: first, petitioner’s failure to check up,
visit or administer medication on Editha during her first day of confinement at the
LMC;9 second, petitioner recommended that a D&C procedure be performed on
Editha without conducting any internal examination prior to the procedure; 10 third,
petitioner immediately suggested a D&C procedure instead of closely monitoring
the state of pregnancy of Editha.11
In her Answer,12 petitioner denied the allegations of negligence and incompetence
with the following explanations: upon Editha’s confirmation that she would seek
admission at the LMC, petitioner immediately called the hospital to anticipate the
arrival of Editha and ordered through the telephone the medicines Editha needed to
take, which the nurses carried out; petitioner visited Editha on the morning of July
28, 1994 during her rounds; on July 29, 1994, she performed an internal
examination on Editha and she discovered that the latter’s cervix was already open,
thus, petitioner discussed the possible D&C procedure, should the bleeding become
more profuse; on July 30 1994, she conducted another internal examination on
Editha, which revealed that the latter’s cervix was still open; Editha persistently
complained of her vaginal bleeding and her passing out of some meaty mass in the
process of urination and bowel movement; thus, petitioner advised Editha to
undergo D&C procedure which the respondents consented to; petitioner was very
vocal in the operating room about not being able to see an abortus;13 taking the
28
words of Editha to mean that she was passing out some meaty mass and clotted
blood, she assumed that the abortus must have been expelled in the process of
bleeding; it was Editha who insisted that she wanted to be discharged; petitioner
agreed, but she advised Editha to return for check-up on August 5, 1994, which the
latter failed to do.
Petitioner contended that it was Editha’s gross negligence and/or omission in
insisting to be discharged on July 31, 1994 against doctor’s advice and her
unjustified failure to return for check-up as directed by petitioner that contributed to
her life-threatening condition on September 16, 1994; that Editha’s hysterectomy
was brought about by her very abnormal pregnancy known as placenta increta,
which was an extremely rare and very unusual case of abdominal placental
implantation. Petitioner argued that whether or not a D&C procedure was done by
her or any other doctor, there would be no difference at all because at any stage of
gestation before term, the uterus would rupture just the same.
On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a
Decision,14 exonerating petitioner from the charges filed against her. The Board
held:
Based on the findings of the doctors who conducted the laparotomy on Editha, hers
is a case of Ectopic Pregnancy Interstitial. This type of ectopic pregnancy is one that
is being protected by the uterine muscles and manifestations may take later than
four (4) months and only attributes to two percent (2%) of ectopic pregnancy cases.
When complainant Editha was admitted at Lorma Medical Center on July 28, 1994
due to vaginal bleeding, an ultra-sound was performed upon her and the result of the
Sonogram Test reveals a morbid fetus but did not specify where the fetus was
located. Obstetricians will assume that the pregnancy is within the uterus unless so
specified by the Sonologist who conducted the ultra-sound. Respondent (Dr. Lasam)
cannot be faulted if she was not able to determine that complainant Editha is having
an ectopic pregnancy interstitial. The D&C conducted on Editha is necessary
considering that her cervix is already open and so as to stop the profuse bleeding.

Simple curettage cannot remove a fetus if the patient is having an ectopic pregnancy,
since ectopic pregnancy is pregnancy conceived outside the uterus and curettage is
done only within the uterus. Therefore, a more extensive operation needed in this
case of pregnancy in order to remove the fetus.15
Feeling aggrieved, respondents went to the PRC on appeal. On November 22, 2000,
the PRC rendered a Decision16 reversing the findings of the Board and revoking
petitioner’s authority or license to practice her profession as a physician. 17
Petitioner brought the matter to the CA in a Petition for Review under Rule 43 of
the Rules of Court. Petitioner also dubbed her petition as one for certiorari18 under
Rule 65 of the Rules of Court.
In the Decision dated July 4, 2003, the CA held that the Petition for Review under
Rule 43 of the Rules of Court was an improper remedy, as the enumeration of the
quasi-judicial agencies in Rule 43 is exclusive.19 PRC is not among the
quasi-judicial bodies whose judgment or final orders are subject of a petition for
review to the CA, thus, the petition for review of the PRC Decision, filed at the CA,
was improper. The CA further held that should the petition be treated as a petition
for certiorari under Rule 65, the same would still be dismissed for being improper
and premature. Citing Section 2620 of Republic Act (R.A.) No. 2382 or the Medical
Act of 1959, the CA held that the plain, speedy and adequate remedy under the
ordinary course of law which petitioner should have availed herself of was to appeal
to the Office of the President.21
Hence, herein petition, assailing the decision of the CA on the following grounds:
1. THE COURT OF APPEALS ERRED ON A QUESTION OF LAW IN
HOLDING THAT THE PROFESSIONAL REGULATION[S] COMMISSION
(PRC) WAS EXCLUDED AMONG THE QUASI-JUDICIAL AGENCIES
CONTEMPLATED UNDER RULE 43 OF THE RULES OF CIVIL
PROCEDURE;
29
2. EVEN ASSUMING, ARGUENDO, THAT PRC WAS EXCLUDED FROM THE
PURVIEW OF RULE 43 OF THE RULES OF CIVIL PROCEDURE, THE
PETITIONER WAS NOT PRECLUDED FROM FILING A PETITION FOR
CERTIORARI WHERE THE DECISION WAS ALSO ISSUED IN EXCESS OF
OR WITHOUT JURISDICTION, OR WHERE THE DECISION WAS A PATENT
NULLITY;
3. HEREIN RESPONDENTS-SPOUSES ARE NOT ALLOWED BY LAW TO
APPEAL FROM THE DECISION OF THE BOARD OF MEDICINE TO THE
PROFESSIONAL REGULATION[S] COMMISSION;
4. THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF
DISCRETION IN DENYING FOR IMPROPER FORUM THE PETITION FOR
REVIEW/PETITION FOR CERTIORARI WITHOUT GOING OVER THE
MERITS OF THE GROUNDS RELIED UPON BY THE PETITIONER;
5. PRC’S GRAVE OMISSION TO AFFORD HEREIN PETITONER A CHANCE
TO BE HEARD ON APPEAL IS A CLEAR VIOLATION OF HER
CONSTITUTIONAL RIGHT TO DUE PROCESS AND HAS THE EFFECT OF
RENDERING THE JUDGMENT NULL AND VOID;
6. COROLLARY TO THE FOURTH ASSIGNED ERROR, PRC COMMITTED
GRAVE ABUSE OF DISCRETION, AMOUNTING TO LACK OF
JURISDICTION, IN ACCEPTING AND CONSIDERING THE MEMORANDUM
ON APPEAL WITHOUT PROOF OF SERVICE TO HEREIN PETITIONER,
AND IN VIOLATION OF ART. IV, SEC. 35 OF THE RULES AND
REGULATIONS GOVERNING THE REGULATION AND PRACTICE OF
PROFESSIONALS;
7. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN REVOKING
PETITIONER’S LICENSE TO PRACTICE MEDICINE WITHOUT AN EXPERT

TESTIMONY TO SUPPORT ITS CONCLUSION AS TO THE CAUSE OF
RESPONDENT EDITHAT [SIC] RAMOLETE’S INJURY;
8. PRC COMMITTED AN EVEN GRAVER ABUSE OF DISCRETION IN
TOTALLY DISREGARDING THE FINDING OF THE BOARD OF MEDICINE,
WHICH HAD THE NECESSARY COMPETENCE AND EXPERTISE TO
ESTABLISH THE CAUSE OF RESPONDENT EDITHA’S INJURY, AS WELL
AS THE TESTIMONY OF THE EXPERT WITNESS AUGUSTO MANALO,
M.D. ;[and]
9. PRC COMMITTED GRAVE ABUSE OF DISCRETION IN MAKING
CONCLUSIONS OF FACTS THAT WERE NOT ONLY UNSUPPORTED BY
EVIDENCE BUT WERE ACTUALLY CONTRARY TO EVIDENCE ON
RECORD.22
The Court will first deal with the procedural issues.
Petitioner claims that the law does not allow complainants to appeal to the PRC
from the decision of the Board. She invokes Article IV, Section 35 of the Rules and
Regulations Governing the Regulation and Practice of Professionals, which
provides:
Sec. 35. The respondent may appeal the decision of the Board within thirty days
from receipt thereof to the Commission whose decision shall be final. Complainant,
when allowed by law, may interpose an appeal from the Decision of the Board
within the same period. (Emphasis supplied)
Petitioner asserts that a careful reading of the above law indicates that while the
respondent, as a matter of right, may appeal the Decision of the Board to the
Commission, the complainant may interpose an appeal from the decision of the
Board only when so allowed by law.23 Petitioner cited Section 26 of Republic Act
No. 2382 or "The Medical Act of 1959," to wit:
30
Section 26. Appeal from judgment. The decision of the Board of Medical Examiners
(now Medical Board) shall automatically become final thirty days after the date of
its promulgation unless the respondent, during the same period, has appealed to the
Commissioner of Civil Service (now Professional Regulations Commission) and
later to the Office of the President of the Philippines. If the final decision is not
satisfactory, the respondent may ask for a review of the case, or may file in court a
petition for certiorari.
Petitioner posits that the reason why the Medical Act of 1959 allows only the
respondent in an administrative case to file an appeal with the Commission while
the complainant is not allowed to do so is double jeopardy. Petitioner is of the belief
that the revocation of license to practice a profession is penal in nature. 24
The Court does not agree.
For one, the principle of double jeopardy finds no application in administrative
cases. Double jeopardy attaches only: (1) upon a valid indictment; (2) before a
competent court; (3) after arraignment; (4) when a valid plea has been entered; and
(5) when the defendant was acquitted or convicted, or the case was dismissed or
otherwise terminated without the express consent of the accused. 25 These elements
were not present in the proceedings before the Board of Medicine, as the
proceedings involved in the instant case were administrative and not criminal in
nature. The Court has already held that double jeopardy does not lie in
administrative cases.26
Moreover, Section 35 of the Rules and Regulations Governing the Regulation and
Practice of Professionals cited by petitioner was subsequently amended to read:
Sec. 35. The complainant/respondent may appeal the order, the resolution or the
decision of the Board within thirty (30) days from receipt thereof to the
Commission whose decision shall be final and executory. Interlocutory order shall

not be appealable to the Commission. (Amended by Res. 174, Series of 1990).27
(Emphasis supplied)
Whatever doubt was created by the previous provision was settled with said
amendment. It is axiomatic that the right to appeal is not a natural right or a part of
due process, but a mere statutory privilege that may be exercised only in the manner
prescribed by law.28 In this case, the clear intent of the amendment is to render the
right to appeal from a decision of the Board available to both complainants and
respondents.
Such conclusion is bolstered by the fact that in 2006, the PRC issued Resolution No.
06-342(A), or the New Rules of Procedure in Administrative Investigations in the
Professional Regulations Commission and the Professional Regulatory Boards,
which provides for the method of appeal, to wit:
Sec. 1. Appeal; Period Non-Extendible.- The decision, order or resolution of the
Board shall be final and executory after the lapse of fifteen (15) days from receipt of
the decision, order or resolution without an appeal being perfected or taken by either
the respondent or the complainant. A party aggrieved by the decision, order or
resolution may file a notice of appeal from the decision, order or resolution of
the Board to the Commission within fifteen (15) days from receipt thereof, and
serving upon the adverse party a notice of appeal together with the appellant’s brief
or memorandum on appeal, and paying the appeal and legal research fees. x x x 29
The above-stated provision does not qualify whether only the complainant or
respondent may file an appeal; rather, the new rules provide that "a party aggrieved"
may file a notice of appeal. Thus, either the complainant or the respondent who has
been aggrieved by the decision, order or resolution of the Board may appeal to the
Commission. It is an elementary rule that when the law speaks in clear and
categorical language, there is no need, in the absence of legislative intent to the
contrary, for any interpretation.30 Words and phrases used in the statute should be
given their plain, ordinary, and common usage or meaning. 31
31
Petitioner also submits that appeals from the decisions of the PRC should be with
the CA, as Rule 4332 of the Rules of Court was precisely formulated and adopted to
provide for a uniform rule of appellate procedure for quasi-judicial agencies.33
Petitioner further contends that a quasi-judicial body is not excluded from the
purview of Rule 43 just because it is not mentioned therein.34
On this point, the Court agrees with the petitioner.
Sec. 1, Rule 43 of the Rules of Court provides:
Section 1. Scope. - This Rule shall apply to appeals from judgments or final
orders of the Court of Tax Appeals, and from awards, judgments, final orders or
resolutions of or authorized by any quasi-judicial agency in the exercise of its
quasi-judicial functions. Among these agencies are the Civil Service Commission,
Central Board of Assessment Appeals, Securities and Exchange Commission,
Office of the President, Land Registration Authority, Social Security Commission,
Civil Aeronautics Board, Bureau of Patents, Trademarks and Technology Transfer,
National Electrification Administration, Energy Regulatory Board, National
Telecommunications Commission, Department of Agrarian Reform under Republic
Act No. 6657, Government Service Insurance System, Employees Compensation
Commission, Agricultural Inventions Board, Insurance Commission, Philippine
Atomic Energy Commission, Board of Investments, Construction Industry
Arbitration Commission, and voluntary arbitrators authorized by law. (Emphasis
supplied)
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.35 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.36

Specifically, the Court, in Yang v. Court of Appeals,37 ruled that Batas Pambansa
(B.P.) Blg. 12938 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.39 (Emphasis supplied)
Clearly, the enactment of B.P. Blg. 129, the precursor of the present Rules of Civil
Procedure,40 lodged with the CA such jurisdiction over the appeals of decisions
made by the PRC.
Anent the substantive merits of the case, petitioner questions the PRC decision for
being without an expert testimony to support its conclusion and to establish the
cause of Editha’s injury. Petitioner avers that in cases of medical malpractice, expert
testimony is necessary to support the conclusion as to the cause of the injury. 41
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. 42 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.43
32
There are four elements involved in medical negligence cases: duty, breach, injury
and proximate causation.44
A physician-patient relationship was created when Editha employed the services of
the petitioner. As Editha’s physician, petitioner was duty-bound to use at least the
same level of care that any reasonably competent doctor would use to treat a
condition under the same circumstances.45 The breach of these professional duties
of skill and care, or their improper performance by a physician surgeon, whereby
the patient is injured in body or in health, constitutes actionable malpractice. 46 As to
this aspect of medical malpractice, the determination of the reasonable level of care
and the breach thereof, expert testimony is essential.47 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.48
In the present case, respondents did not present any expert testimony to support
their claim that petitioner failed to do something which a reasonably prudent
physician or surgeon would have done.
Petitioner, on the other hand, presented the testimony of Dr. Augusto M. Manalo,
who was clearly an expert on the subject.
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. 49
Dr. Manalo specializes in gynecology and obstetrics, authored and co-authored
various publications on the subject, and is a professor at the University of the
Philippines.50 According to him, his diagnosis of Editha’s case was "Ectopic
Pregnancy Interstitial (also referred to as Cornual), Ruptured." 51 In stating that the
D&C procedure was not the proximate cause of the rupture of Editha’s uterus
resulting in her hysterectomy, Dr. Manalo testified as follows:

Atty. Hidalgo:
Q: Doctor, we want to be clarified on this matter. The complainant had testified
here that the D&C was the proximate cause of the rupture of the uterus. The
condition which she found herself in on the second admission. Will you please tell
us whether that is true or not?
A: Yah, I do not think so for two reasons. One, as I have said earlier, the
instrument cannot reach the site of the pregnancy, for it to further push the
pregnancy outside the uterus. And, No. 2, I was thinking a while ago about another
reason- well, why I don’t think so, because it is the triggering factor for the rupture,
it could have–the rupture could have occurred much earlier, right after the D&C or a
few days after the D&C.
Q: In this particular case, doctor, the rupture occurred to have happened minutes
prior to the hysterectomy or right upon admission on September 15, 1994 which is
about 1 ½ months after the patient was discharged, after the D&C was conducted.
Would you tell us whether there is any relation at all of the D&C and the rupture in
this particular instance?
A: I don’t think so for the two reasons that I have just mentioned- that it
would not be possible for the instrument to reach the site of pregnancy. And,
No. 2, if it is because of the D&C that rupture could have occurred earlier. 52
(Emphases supplied)
Clearly, from the testimony of the expert witness and the reasons given by him, it is
evident that the D&C procedure was not the proximate cause of the rupture of
Editha’s uterus.
During his cross-examination, Dr. Manalo testified on how he would have
addressed Editha’s condition should he be placed in a similar circumstance as the
petitioner. He stated:
33
Atty. Ragonton:
Q: Doctor, as a practicing OB-Gyne, when do you consider that you have done a
good, correct and ideal dilatation and curettage procedure?
A: Well, if the patient recovers. If the patient gets well. Because even after the
procedure, even after the procedure you may feel that you have scraped everything,
the patient stops bleeding, she feels well, I think you should still have some
reservations, and wait a little more time.
Q: If you were the OB-Gyne who performed the procedure on patient Editha
Ramolete, would it be your standard practice to check the fetal parts or fetal tissues
that were allegedly removed?
A: From what I have removed, yes. But in this particular case, I think it was
assumed that it was part of the meaty mass which was expelled at the time she was
urinating and flushed in the toilet. So there’s no way.
Q: There was [sic] some portions of the fetal parts that were removed?
A: No, it was described as scanty scraping if I remember it right–scanty.
Q: And you would not mind checking those scant or those little parts that were
removed?
A: Well, the fact that it was described means, I assume that it was checked,
‘no. It was described as scanty and the color also, I think was described. Because it
would be very unusual, even improbable that it would not be examined,
because when you scrape, the specimens are right there before your eyes. It’s
in front of you. You can touch it. In fact, some of them will stick to the
instrument and therefore to peel it off from the instrument, you have to touch
them. So, automatically they are examined closely.

Q: As a matter of fact, doctor, you also give telephone orders to your patients
through telephone?
A: Yes, yes, we do that, especially here in Manila because you know, sometimes
a doctor can also be tied-up somewhere and if you have to wait until he arrive at a
certain place before you give the order, then it would be a lot of time wasted.
Because if you know your patient, if you have handled your patient, some of the
symptoms you can interpret that comes with practice. And, I see no reason for not
allowing telephone orders unless it is the first time that you will be
encountering the patient. That you have no idea what the problem is.
Q: But, doctor, do you discharge patients without seeing them?
A: Sometimes yes, depending on how familiar I am with the patient. We are on
the question of telephone orders. I am not saying that that is the idle [sic] thing to do,
but I think the reality of present day practice somehow justifies telephone
orders. I have patients whom I have justified and then all of a sudden, late in the
afternoon or late in the evening, would suddenly call they have decided that they
will go home inasmuch as they anticipated that I will discharge them the following
day. So, I just call and ask our resident on duty or the nurse to allow them to go
because I have seen that patient and I think I have full grasp of her problems. So,
that’s when I make this telephone orders. And, of course before giving that order I
ask about how she feels.53 (Emphases supplied)
From the foregoing testimony, it is clear that the D&C procedure was conducted in
accordance with the standard practice, with the same level of care that any
reasonably competent doctor would use to treat a condition under the same
circumstances, and that there was nothing irregular in the way the petitioner dealt
with Editha.
34
Medical malpractice, in our jurisdiction, is often brought as a civil action for
damages under Article 217654 of the Civil Code. The defenses in an action for
damages, provided for under Article 2179 of the Civil Code are:
Art. 2179. When the plaintiff’s own negligence was the immediate and
proximate cause of his injury, he cannot recover damages. But if his negligence
was only contributory, the immediate and proximate cause of the injury being the
defendant’s lack of due care, the plaintiff may recover damages, but the courts shall
mitigate the damages to be awarded.
Proximate cause has been defined as that which, in natural and continuous sequence,
unbroken by any efficient intervening cause, produces injury, and without which the
result would not have occurred.55 An injury or damage is proximately caused by an
act or a failure to act, whenever it appears from the evidence in the case that the act
or omission played a substantial part in bringing about or actually causing the injury
or damage; and that the injury or damage was either a direct result or a reasonably
probable consequence of the act or omission.56
In the present case, the Court notes the findings of the Board of Medicine:
When complainant was discharged on July 31, 1994, herein respondent advised
her to return on August 4, 1994 or four (4) days after the D&C. This advise
was clear in complainant’s Discharge Sheet. However, complainant failed to do
so. This being the case, the chain of continuity as required in order that the doctrine
of proximate cause can be validly invoked was interrupted. Had she returned, the
respondent could have examined her thoroughly.57 x x x (Emphases supplied)
Also, in the testimony of Dr. Manalo, he stated further that assuming that there was
in fact a misdiagnosis, the same would have been rectified if Editha followed the
petitioner’s order to return for a check-up on August 4, 1994. Dr. Manalo stated:

Granting that the obstetrician-gynecologist has been misled (justifiably) up to
thus point that there would have been ample opportunity to rectify the
misdiagnosis, had the patient returned, as instructed for her follow-up
evaluation. It was one and a half months later that the patient sought
consultation with another doctor. The continued growth of an ectopic pregnancy,
until its eventual rupture, is a dynamic process. Much change in physical findings
could be expected in 1 ½ months, including the emergence of suggestive ones. 58
It is undisputed that Editha did not return for a follow-up evaluation, in defiance of
the petitioner’s advise. Editha omitted the diligence required by the circumstances
which could have avoided the injury. The omission in not returning for a follow-up
evaluation played a substantial part in bringing about Editha’s own injury. Had
Editha returned, petitioner could have conducted the proper medical tests and
procedure necessary to determine Editha’s health condition and applied the
corresponding treatment which could have prevented the rupture of Editha’s uterus.
The D&C procedure having been conducted in accordance with the standard
medical practice, it is clear that Editha’s omission was the proximate cause of her
own injury and not merely a contributory negligence on her part.
Contributory negligence is the act or omission amounting to want of ordinary care
on the part of the person injured, which, concurring with the defendant’s negligence,
is the proximate cause of the injury.59 Difficulty seems to be apprehended in
deciding which acts of the injured party shall be considered immediate causes of the
accident.60 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.61 Again, based on
the evidence presented in the present case under review, in which no negligence
can be attributed to the petitioner, the immediate cause of the accident
resulting in Editha’s injury was her own omission when she did not return for
a follow-up check up, in defiance of petitioner’s orders. The immediate cause
of Editha’s injury was her own act; thus, she cannot recover damages from the
injury.
35
Lastly, petitioner asserts that her right to due process was violated because she was
never informed by either respondents or by the PRC that an appeal was pending
before the PRC.62 Petitioner claims that a verification with the records section of the
PRC revealed that on April 15, 1999, respondents filed a Memorandum on Appeal
before the PRC, which did not attach the actual registry receipt but was merely
indicated therein.63
Respondents, on the other hand avers that if the original registry receipt was not
attached to the Memorandum on Appeal, PRC would not have entertained the
appeal or accepted such pleading for lack of notice or proof of service on the other
party.64 Also, the registry receipt could not be appended to the copy furnished to
petitioner’s former counsel, because the registry receipt was already appended to the
original copy of the Memorandum of Appeal filed with PRC. 65
It is a well-settled rule that when service of notice is an issue, the rule is that the
person alleging that the notice was served must prove the fact of service. The
burden of proving notice rests upon the party asserting its existence.66 In the present
case, respondents did not present any proof that petitioner was served a copy of the
Memorandum on Appeal. Thus, respondents were not able to satisfy the burden of
proving that they had in fact informed the petitioner of the appeal proceedings
before the PRC.
In EDI-Staffbuilders International, Inc. v. National Labor Relations Commission,67
in which the National Labor Relations Commission failed to order the private
respondent to furnish the petitioner a copy of the Appeal Memorandum, the Court
held that said failure deprived the petitioner of procedural due process guaranteed
by the Constitution, which could have served as basis for the nullification of the
proceedings in the appeal. The same holds true in the case at bar. The Court finds
that the failure of the respondents to furnish the petitioner a copy of the
Memorandum of Appeal submitted to the PRC constitutes a violation of due process.
Thus, the proceedings before the PRC were null and void.
 36

All told, doctors are protected by a special rule of law. They are not guarantors of
care. They are not insurers against mishaps or unusual consequences 68 specially so
if the patient herself did not exercise the proper diligence required to avoid the
injury.

WHEREFORE, the petition is GRANTED. The assailed Decision of the Court of

Appeals dated July 4, 2003 in CA-GR SP No. 62206 is hereby REVERSED and
SET ASIDE. The Decision of the Board of Medicine dated March 4, 1999
exonerating petitioner is AFFIRMED. No pronouncement as to costs.

SO ORDERED.
 37

THIRD DIVISION

G.R. No. 179786 July 24, 2013

JOSIELENE LARA CHAN, Petitioner,

vs.
JOHNNY T. CHAN, Respondent.

DECISION

ABAD, J.:

This case is about the propriety of issuing a subpoena duces tecum for
the production and submission in court of the respondent husband's
hospital record in a case for declaration of nullity of marriage where one
of the issues is his mental fitness as a husband.

The Facts and the Case

On February 6, 2006 petitioner Josielene Lara Chan (Josielene) filed

before the Regional Trial Court (RTC) of Makati City, Branch 144 a
petition for the declaration of nullity of her marriage to respondent Johnny
Chan (Johnny), the dissolution of their conjugal partnership of gains, and
the award of custody of their children to her. Josielene claimed that
Johnny failed to care for and support his family and that a psychiatrist
diagnosed him as mentally deficient due to incessant drinking and
excessive use of prohibited drugs. Indeed, she had convinced him to
undergo hospital confinement for detoxification and rehabilitation.

Johnny resisted the action, claiming that it was Josielene who failed in
her wifely duties. To save their marriage, he agreed to marriage

counseling but when he and Josielene got to the hospital, two men
forcibly held him by both arms while another gave him an injection. The
marriage relations got worse when the police temporarily detained
Josielene for an unrelated crime and released her only after the case
against her ended. By then, their marriage relationship could no longer
be repaired.
During the pre-trial conference, Josielene pre-marked the Philhealth
Claim Form1 that Johnny attached to his answer as proof that he was
forcibly confined at the rehabilitation unit of a hospital. The form carried a
physician’s handwritten note that Johnny suffered from
"methamphetamine and alcohol abuse." Following up on this point, on
August 22, 2006 Josielene filed with the RTC a request for the issuance
of a subpoena duces tecum addressed to Medical City, covering
Johnny’s medical records when he was there confined. The request was
accompanied by a motion to "be allowed to submit in evidence" the
records sought by subpoena duces tecum.2
Johnny opposed the motion, arguing that the medical records were
covered by physician-patient privilege. On September 13, 2006 the RTC
sustained the opposition and denied Josielene’s motion. It also denied
her motion for reconsideration, prompting her to file a special civil action
of certiorari before the Court of Appeals (CA) in CA-G.R. SP 97913,
imputing grave abuse of discretion to the RTC.
On September 17, 2007 the CA3 denied Josielene’s petition. It ruled that,
if courts were to allow the production of medical records, then patients
would be left with no assurance that whatever relevant disclosures they
may have made to their physicians would be kept confidential. The
prohibition covers not only testimonies, but also affidavits, certificates,
and pertinent hospital records. The CA added that, although Johnny can
38
waive the privilege, he did not do so in this case. He attached the
Philhealth form to his answer for the limited purpose of showing his
alleged forcible confinement.
Question Presented
The central question presented in this case is:
Whether or not the CA erred in ruling that the trial court correctly denied
the issuance of a subpoena duces tecum covering Johnny’s hospital
records on the ground that these are covered by the privileged character
of the physician-patient communication.
The Ruling of the Court
Josielene requested the issuance of a subpoena duces tecum covering
the hospital records of Johnny’s confinement, which records she wanted
to present in court as evidence in support of her action to have their
marriage declared a nullity. Respondent Johnny resisted her request for
subpoena, however, invoking the privileged character of those records.
He cites Section 24(c), Rule 130 of the Rules of Evidence which reads:
SEC. 24. Disqualification by reason of privileged communication.— The
following persons cannot testify as to matters learned in confidence in the
following cases:
xxxx
(c) A person authorized to practice medicine, surgery or obstetrics cannot
in a civil case, without the consent of the patient, be examined as to any
advice or treatment given by him or any information which he may have

acquired in attending such patient in a professional capacity, which
information was necessary to enable him to act in that capacity, and
which would blacken the reputation of the patient.
The physician-patient privileged communication rule essentially means
that a physician who gets information while professionally attending a
patient cannot in a civil case be examined without the patient’s consent
as to any facts which would blacken the latter’s reputation. This rule is
intended to encourage the patient to open up to the physician, relate to
him the history of his ailment, and give him access to his body, enabling
the physician to make a correct diagnosis of that ailment and provide the
appropriate cure. Any fear that a physician could be compelled in the
future to come to court and narrate all that had transpired between him
and the patient might prompt the latter to clam up, thus putting his own
health at great risk.4
1. The case presents a procedural issue, given that the time to object to
the admission of evidence, such as the hospital records, would be at the
time they are offered. The offer could be made part of the physician’s
testimony or as independent evidence that he had made entries in those
records that concern the patient’s health problems.
Section 36, Rule 132, states that objections to evidence must be made
after the offer of such evidence for admission in court. Thus:
SEC. 36. Objection.— Objection to evidence offered orally must be made
immediately after the offer is made.
Objection to a question propounded in the course of the oral examination
of a witness shall be made as soon as the grounds therefor shall become
reasonably apparent.
39
An offer of evidence in writing shall be objected to within three (3) days
after notice of the offer unless a different period is allowed by the court.
In any case, the grounds for the objections must be specified.
Since the offer of evidence is made at the trial, Josielene’s request for
subpoena duces tecum is premature. She will have to wait for trial to
begin before making a request for the issuance of a subpoena duces
tecum covering Johnny’s hospital records. It is when those records are
produced for examination at the trial, that Johnny may opt to object, not
just to their admission in evidence, but more so to their disclosure.
Section 24(c), Rule 130 of the Rules of Evidence quoted above is about
non-disclosure of privileged matters.
2. It is of course possible to treat Josielene’s motion for the issuance of a
subpoena duces tecum covering the hospital records as a motion for
production of documents, a discovery procedure available to a litigant
prior to trial. Section 1, Rule 27 of the Rules of Civil Procedure provides:
SEC. 1. Motion for production or inspection; order.— Upon motion of any
party showing good cause therefor, the court in which an action is
pending may (a) order any party to produce and permit the inspection
and copying or photographing, by or on behalf of the moving party, of any
designated documents, papers, books, accounts, letters, photographs,
objects or tangible things, not privileged, which constitute or contain
evidence material to any matter involved in the action and which are in
his possession, custody or control; or (b) order any party to permit entry
upon designated land or other property in his possession or control for
the purpose of inspecting, measuring, surveying, or photographing the
property or any designated relevant object or operation thereon. The
order shall specify the time, place and manner of making the inspection

and taking copies and photographs, and may prescribe such terms and
conditions as are just. (Emphasis supplied)
But the above right to compel the production of documents has a
limitation: the documents to be disclosed are "not privileged."
Josielene of course claims that the hospital records subject of this case
are not privileged since it is the "testimonial" evidence of the physician
that may be regarded as privileged. Section 24(c) of Rule 130 states that
the physician "cannot in a civil case, without the consent of the patient,
be examined" regarding their professional conversation. The privilege,
says Josielene, does not cover the hospital records, but only the
examination of the physician at the trial.
To allow, however, the disclosure during discovery procedure of the
hospital records—the results of tests that the physician ordered, the
diagnosis of the patient’s illness, and the advice or treatment he gave
him—would be to allow access to evidence that is inadmissible without
the
patient’s consent. Physician memorializes all these information in the
patient’s records. Disclosing them would be the equivalent of compelling
the physician to testify on privileged matters he gained while dealing with
the patient, without the latter’s prior consent.
3. Josielene argues that since Johnny admitted in his answer to the
petition before the RTC that he had been confined in a hospital against
his will and in fact attached to his answer a Philhealth claim form covering
that confinement, he should be deemed to have waived the privileged
character of its records. Josielene invokes Section 17, Rule 132 of the
Rules of Evidence that provides:
40
SEC. 17. When part of transaction, writing or record given in evidence,
the remainder admissible.— When part of an act, declaration,
conversation, writing or record is given in evidence by one party, the
whole of the same subject may be inquired into by the other, and when a
detached act, declaration, conversation, writing or record is given in
evidence, any other act, declaration, conversation, writing or record
necessary to its understanding may also be given in evidence. 1âwphi1
But, trial in the case had not yet begun. Consequently, it cannot be said
that Johnny had already presented the Philhealth claim form in evidence,
the act contemplated above which would justify Josielene into requesting
an inquiry into the details of his hospital confinement. Johnny was not yet
bound to adduce evidence in the case when he filed his answer. Any
request for disclosure of his hospital records would again be premature.
For all of the above reasons, the CA and the RTC were justified in
denying Josielene her request for the production in court of Johnny’s
hospital records.
ACCORDINGLY, the Court DENIES the petition and AFFIRMS the
Decision of the Court of Appeals in CA-G.R. SP 97913 dated September
17, 2007.
SO ORDERED.
ROBERTO A. ABAD
Associate Justice
WE CONCUR:
 41

.R. No. 108854 June 14, 1994

MA. PAZ FERNANDEZ KROHN, petitioner,

vs.
COURT OF APPEALS and EDGAR KROHN, JR., respondents.

Cruz, Durian, Agabin, Atienza, Alday and Tuason for petitioner.

Oscar F. Martinez for private respondent.

BELLOSILLO, J.:

A confidential psychiatric evaluation report is being presented in

evidence before the trial court in a petition for annulment of marriage
grounded on psychological incapacity. The witness testifying on the
report is the husband who initiated the annulment proceedings, not the
physician who prepared the report.

The subject of the evaluation report, Ma. Paz Fernandez Krohn, invoking
the rule on privileged communication between physician and patient,
seeks to enjoin her husband from disclosing the contents of the report.
After failing to convince the trial court and the appellate court, she is now
before us on a petition for review on certiorari.

On 14 June 1964, Edgar Krohn, Jr., and Ma. Paz Fernandez were
married at the Saint Vincent de Paul Church in San Marcelino, Manila.
The union produced three children, Edgar Johannes, Karl Wilhelm and
Alexandra. Their blessings notwithstanding, the relationship between the
couple developed into a stormy one. In 1971, Ma. Paz underwent
psychological testing purportedly in an effort to ease the marital strain.
The effort however proved futile. In 1973, they finally separated in fact.

In 1975, Edgar was able to secure a copy of the confidential psychiatric
report on Ma. Paz prepared and signed by Drs. Cornelio Banaag, Jr., and
Baltazar Reyes. On 2 November 1978, presenting the report among
others, he obtained a decree ("Conclusion") from the Tribunal
Metropolitanum Matrimoniale in Manila nullifying his church marriage
with Ma. Paz on the ground of "incapacitas assumendi onera conjugalia
due to lack of due discretion existent at the time of the wedding and
thereafter." On 10 July 1979, the decree was confirmed and pronounced
1
"Final and Definite."2
Meanwhile, on 30 July 1982, the then Court of First Instance (now
Regional Trial Court) of Pasig, Br. II, issued an order granting the
voluntary dissolution of the conjugal partnership.
On 23 October 1990, Edgar filed a petition for the annulment of his
marriage with Ma. Paz before the trial court. In his petition, he cited the
3
Confidential Psychiatric Evaluation Report which Ma. Paz merely denied
in her Answer as "either unfounded or irrelevant." 4
At the hearing on 8 May 1991, Edgar took the witness stand and tried to
testify on the contents of the Confidential Psychiatric Evaluation Report.
This was objected to on the ground that it violated the rule on privileged
communication between physician and patient. Subsequently, Ma. Paz
filed a Manifestation expressing her "continuing objection" to any
evidence, oral or documentary, "that would thwart the physician-patient
privileged communication rule," and thereafter submitted a Statement
5
for the Record asserting among others that "there is no factual or legal
basis whatsoever for petitioner (Edgar) to claim 'psychological incapacity'
to annul their marriage, such ground being completely false, fabricated
and merely an afterthought." Before leaving for Spain where she has
6
since resided after their separation, Ma. Paz also authorized and
42
instructed her counsel to oppose the suit and pursue her counterclaim
even during her absence.
On 29 May 1991, Edgar opposed Ma. Paz' motion to disallow the
introduction of the confidential psychiatric report as evidence, and 7
afterwards moved to strike out Ma. Paz' Statement for the Record. 8
On 4 June 1991, the trial court issued an Order admitting the Confidential
Psychiatric Evaluation Report in evidence and ruling that —
. . . the Court resolves to overrule the objection and to sustain the
Opposition to the respondent's Motion; first, because the very issue in
this case is whether or not the respondent had been suffering from
psychological incapacity; and secondly, when the said psychiatric report
was referred to in the complaint, the respondent did not object thereto on
the ground of the supposed privileged communication between patient
and physician. What was raised by the respondent was that the said
psychiatric report was irrelevant. So, the Court feels that in the interest of
justice and for the purpose of determining whether the respondent as
alleged in the petition was suffering from psychological incapacity, the
said psychiatric report is very material and may be testified to by
petitioner (Edgar Krohn, Jr.) without prejudice on the part of the
respondent to dispute the said report or to cross-examination first the
petitioner and later the psychiatrist who prepared the same if the latter
will be presented. 9
On 27 November 1991, the trial court denied the Motion to Reconsider
Order dated June 4, 1991, and directed that the Statement for the Record
filed by Ma. Paz be stricken off the record. A subsequent motion for
reconsideration filed by her counsel was likewise denied.

Counsel of Ma. Paz then elevated the issue to respondent Court of
Appeals. In a Decision promulgated 30 October 1992, the appellate court
dismissed the petition for certiorari. On 5 February 1993, the motion to
10
reconsider the dismissal was likewise denied. Hence, the instant petition
for review.
Petitioner now seeks to enjoin the presentation and disclosure of the
contents of the psychiatric report and prays for the admission of her
Statement for the Record to form part of the records of the case. She
argues that since
Sec. 24, par. (c), Rule 130, of the Rules of Court prohibits a physician
11
from testifying on matters which he may have acquired in attending to a
patient in a professional capacity, "WITH MORE REASON should be
third person (like respondent-husband in this particular instance) be
PROHIBITED from testifying on privileged matters between a physician
and patient or from submitting any medical report, findings or evaluation
prepared by a physician which the latter has acquired as a result of his
confidential and privileged relation with a patient." She says that the
12
reason behind the prohibition is —
. . . to facilitate and make safe, full and confidential disclosure by a
patient to his physician of all facts, circumstances and symptoms,
untrammeled by apprehension of their subsequent and enforced
disclosure and publication on the witness stand, to the end that the
physician may form a correct opinion, and be enabled safely and
efficaciously to treat his patient.
13
She further argues that to allow her husband to testify on the contents of
the psychiatric evaluation report "will set a very bad and dangerous
precedent because it abets circumvention of the rule's intent in
preserving the sanctity, security and confidence to the relation of
43
physician and his patient." Her thesis is that what cannot be done
14
directly should not be allowed to be done indirectly.
Petitioner submits that her Statement for the Record simply reiterates
under oath what she asserted in her Answer, which she failed to verify as
she had already left for Spain when her Answer was filed. She maintains
that her "Statement for the Record is a plain and simple pleading and is
not as it has never been intended to take the place of her testimony;" 15
hence, there is no factual and legal basis whatsoever to expunge it from
the records.
Private respondent Edgar Krohn, Jr., however contends that "the rules
are very explicit: the prohibition applies only to a physician. Thus . . . the
legal prohibition to testify is not applicable to the case at bar where the
person sought to be barred from testifying on the privileged
communication is the husband and not the physician of the petitioner." 16
In fact, according to him, the Rules sanction his testimony considering
that a husband may testify against his wife in a civil case filed by one
against the other.
Besides, private respondent submits that privileged communication may
be waived by the person entitled thereto, and this petitioner expressly did
when she gave her unconditional consent to the use of the psychiatric
evaluation report when it was presented to the Tribunal Metropolitanum
Matrimoniale which took it into account among others in deciding the
case and declaring their marriage null and void. Private respondent
further argues that petitioner also gave her implied consent when she
failed to specifically object to the admissibility of the report in her Answer
where she merely described the evaluation report as "either unfounded
or irrelevant." At any rate, failure to interpose a timely objection at the

earliest opportunity to the evidence presented on privileged matters may
be construed as an implied waiver.
With regard to the Statement for the Record filed by petitioner, private
respondent posits that this in reality is an amendment of her Answer and
thus should comply with pertinent provisions of the Rules of Court, hence,
its exclusion from the records for failure to comply with the Rules is
proper.
The treatise presented by petitioner on the privileged nature of the
communication between physician and patient, as well as the reasons
therefor, is not doubted. Indeed, statutes making communications
between physician and patient privileged are intended to inspire
confidence in the patient and encourage him to make a full disclosure to
his physician of his symptoms and condition. 17
Consequently, this
prevents the physician from making public information that will result in
humiliation, embarrassment, or disgrace to the patient. For, the patient
18
should rest assured with the knowledge that the law recognizes the
communication as confidential, and guards against the possibility of his
feelings being shocked or his reputation tarnished by their subsequent
disclosure. The physician-patient privilege creates a zone of privacy,
19
intended to preclude the humiliation of the patient that may follow the
disclosure of his ailments. Indeed, certain types of information
communicated in the context of the physician-patient relationship fall
within the constitutionally protected zone of privacy, including a
20
patient's interest in keeping his mental health records confidential. Thus,
21
it has been observed that the psychotherapist-patient privilege is founded
upon the notion that certain forms of antisocial behavior may be
prevented by encouraging those in need of treatment for emotional
problems to secure the services of a psychotherapist.
44
Petitioner's discourse while exhaustive is however misplaced. Lim v.
Court of Appeals clearly lays down the requisites in order that the
22
privilege may be successfully invoked: (a) the privilege is claimed in a
civil case; (b) the person against whom the privilege is claimed is one
duly authorized to practice medicine, surgery or obstetrics; (c) such
person acquired the information while he was attending to the patient in
his professional capacity; (d) the information was necessary to enable
him to act in that capacity; and, (e) the information was confidential and, if
disclosed, would blacken the reputation (formerly character) of the
patient.
In the instant case, the person against whom the privilege is claimed is
not one duly authorized to practice medicine, surgery or obstetrics. He is
simply the patient's husband who wishes to testify on a document
executed by medical practitioners. Plainly and clearly, this does not fall
within the claimed prohibition. Neither can his testimony be considered a
circumvention of the prohibition because his testimony cannot have the
force and effect of the testimony of the physician who examined the
patient and executed the report.
Counsel for petitioner indulged heavily in objecting to the testimony of
private respondent on the ground that it was privileged. In his
Manifestation before the trial court dated 10 May 1991, he invoked the
rule on privileged communications but never questioned the testimony as
hearsay. It was a fatal mistake. For, in failing to object to the testimony on
the ground that it was hearsay, counsel waived his right to make such
objection and, consequently, the evidence offered may be admitted.
The other issue raised by petitioner is too trivial to merit the full attention
of this Court. The allegations contained in the Statement for the Records
 45

are but refutations of private respondent's declarations which may be

denied or disproved during the trial.

The instant appeal has taken its toll on the petition for annulment. Three
years have already lapsed and private respondent herein, as petitioner
before the trial court, has yet to conclude his testimony thereat. We thus
enjoin the trial judge and the parties' respective counsel to act with
deliberate speed in resolving the main action, and avoid any and all
stratagems that may further delay this case. If all lawyers are allowed to
appeal every perceived indiscretion of a judge in the course of trial and
include in their appeals depthless issues, there will be no end to
litigations, and the docket of appellate courts will forever be clogged with
inconsequential cases. Hence, counsel should exercise prudence in
appealing lower court rulings and raise only legitimate issues so as not to
retard the resolution of cases. Indeed, there is no point in unreasonably
delaying the resolution of the petition and prolonging the agony of the
wedded couple who after coming out from a storm still have the right to a
renewed blissful life either alone or in the company of each other. 23

WHEREFORE, the instant petition for review is DENIED for lack of merit.
The assailed Decision of respondent Court of Appeals promulgated on
30 October 1992 is AFFIRMED.

SO ORDERED.

Cruz, Davide, Jr., Quiason and Kapunan, JJ., concur.

 46

NELLY LIM, Petitioner, v. THE COURT OF APPEALS, HON. MANUEL D.

VICTORIO, as Presiding Judge of RTC-Rosales, Pangasinan, Branch 53, and
JUAN SIM, Respondents.

Quisumbing, Torres & Evangelista for Petitioner.

Bince, Oficiana & Dancel for Private Respondent.

SYLLABUS

1. REMEDIAL LAW; ACTIONS; EVIDENCE; PRIVILEGED COMMUNICATIONS;

PHYSICIAN-PATIENT PRIVILEGE; RATIONAL BEHIND THE RULE. — This rule on the
physician-patient privilege is intended to facilitate and make safe full and confidential
disclosure by the patient to the physician of all facts, circumstances and symptoms,
untrammeled by apprehension of their subsequent and enforced disclosure and
publication on the witness stand, to the end that the physician may form a correct
opinion, and be enabled safely and efficaciously to treat his patient. It rests in public
policy and is for the general interest of the community.

2. ID.; ID.; ID.; ID.; ID.; SUBJECT TO WAIVER. — Since the object of the privilege is
 47

disclosure and publication on the witness stand, to the end that the physician may
form a correct opinion, and be enabled safely and efficaciously to treat his patient. 11
It rests in public policy and is for the general interest of the community. 12

Since the object of the privilege is to protect the patient, it may be waived if no timely
objection is made to the physician’s testimony. 13

In order that the privilege may be successfully claimed, the following requisites must
concur: jgc:chanroble s.com.p h

"1. the privilege is claimed in a civil case;

2. the person against whom the privilege is claimed is one duly authorized to practice
medicine, surgery or obstetrics;

3. such person acquired the information while he was attending to the patient in his
professional capacity;

4. the information was necessary to enable him to act in that capacity; and

5. the information was confidential, and, if disclosed, would blacken the reputation
(formerly character) of the patient." 14

These requisites conform with the four (4) fundamental conditions necessary for the
establishment of a privilege against the disclosure of certain communications, to
wit:jgc:chan rob les.com. ph

"1. The communications must originate in a confidence that they will not be disclosed.

2. This element of confidentiality must be essential to the full and satisfactory

maintenance of the relation between the parties.

3. The relation must be one which in the opinion of the community ought to be
sedulously fostered

4. The injury that would inure to the relation by the disclosure of the communications
must be greater than the benefit thereby gained for the correct disposal of litigation."
15

The physician may be considered to be acting in his professional capacity when he

attends to the patient for curative, preventive, or palliative treatment. Thus, only
disclosures which would have been made to the physician to enable him "safely and
efficaciously to treat his patient" are covered by the privilege. 16 It is to be
emphasized that "it is the tenor only of the communication that is privileged. The
mere fact of making a communication, as well as the date of a consultation and the
number of consultations, are therefore not privileged from disclosure, so long as the
subject communicated is not stated." 17

One who claims this privilege must prove the presence of these aforementioned
requisites. 18

Our careful evaluation of the submitted pleadings leads Us to no other course of