Republic of the Philippines On 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation.
Peter saw Dr. Tuaño for a follow-up consultation. After examining both of Peter’s eyes, Dr.
SUPREME COURT
Manila
THIRD DIVISION
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 conjunctivitis 5 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.
Tuaño instructed the former to taper down10 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.
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, Blephamide12 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 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
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
Timolol37 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.
45
Claiming to have steroid-induced glaucoma 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:
[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 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 RESPONDENT ON
THE GROUND OF INSUFFICIENCY OF EVIDENCE;
II.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN DISMISSING THE PETITIONERS’
COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT ON THE GROUND THAT NO MEDICAL EXPERT
WAS PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM FOR MEDICAL NEGLIGENCE AGAINST THE
RESPONDENT; AND
III.
THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN NOT FINDING THE RESPONDENT
LIABLE TO THE PETITIONERS’ FOR ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE FROM
ATTORNEY’S FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS NEGLIGENCE.69
A reading of the afore-quoted reversible errors supposedly committed by the Court of Appeals in its Decision and
Resolution would reveal that petitioners are fundamentally assailing the finding of the Court of Appeals that the
evidence on record is insufficient to establish petitioners’ entitlement to any kind of damage. Therefore, it could be said
that the sole issue for our resolution in the Petition at bar 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, their claim for
damages against Dr. Tuaño.
Evidently, said issue constitutes a question of fact, as we are asked to revisit anew 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
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 determination of which is not within the ambit of this Court’s power of
review under Rule 45 of the 1997 Rules Civil Procedure, as amended. 70
Elementary is the principle that this Court is not a trier of facts; only errors of law are generally reviewed in petitions for
review on certiorari criticizing decisions of the Court of Appeals. Questions of fact are not entertained.71
Nonetheless, the general rule that only questions of law may be raised on appeal in a 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 premised on the supposed absence of evidence, but is contradicted by the evidence on record. Although
petitioners may not explicitly invoke said exception, it may be gleaned from their allegations and arguments in the
instant Petition.1avvphi1.zw+
Petitioners contend, that "[c]ontrary to the findings of the Honorable Court of Appeals, [they] were more than able to
establish that: Dr. Tuaño ignored the standard medical procedure for ophthalmologists, administered medication with
recklessness, and exhibited an absence of competence and skills expected from him." 72 Petitioners reject the necessity
of presenting expert and/or medical testimony to establish (1) the standard of care respecting the treatment of the
disorder affecting Peter’s eye; and (2) whether or not negligence attended Dr. Tuaño’s treatment of Peter, because, in
their words –
That Dr. Tuaño was grossly negligent in the treatment of Peter’s simple eye ailment 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.
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 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
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.
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 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.
SO ORDERED.
 Republic of the Philippines To recall the salient facts, PSI, together with Dr. Miguel Ampil (Dr. Ampil) and Dr. Juan Fuentes (Dr. Fuentes), was
SUPREME COURT impleaded by Enrique Agana and Natividad Agana (later substituted by her heirs), in a complaint 10 for damages filed
Manila in the Regional Trial Court (RTC) of Quezon City, Branch 96, for the injuries suffered by Natividad when Dr. Ampil and
Dr. Fuentes neglected to remove from her body two gauzes 11 which were used in the surgery they performed on her
on April 11, 1984 at the Medical City General Hospital. PSI was impleaded as owner, operator and manager of the
EN BANC
hospital.

G.R. No. 126297 February 2, 2010

In a decision12 dated March 17, 1993, the RTC held PSI solidarily liable with Dr. Ampil and Dr. Fuentes for
damages.13 On appeal, the Court of Appeals (CA), absolved Dr. Fuentes but affirmed the liability of Dr. Ampil and PSI,
PROFESSIONAL SERVICES, INC., Petitioner, subject to the right of PSI to claim reimbursement from Dr. Ampil.141avvphi1
vs.
THE COURT OF APPEALS and NATIVIDAD and ENRIQUE AGANA, Respondents.
On petition for review, this Court, in its January 31, 2007 decision, affirmed the CA decision. 15 PSI filed a motion for
reconsideration16 but the Court denied it in a resolution dated February 11, 2008.17
x - - - - - - - - - - - - - - - - - - - - - - -x
The Court premised the direct liability of PSI to the Aganas on the following facts and law:
G.R. No. 126467
First, there existed between PSI and Dr. Ampil an employer-employee relationship as contemplated in the December
NATIVIDAD [substituted by her children Marcelino Agana III, Enrique Agana, Jr., Emma Agana-Andaya, 29, 1999 decision in Ramos v. Court of Appeals18 that "for purposes of allocating responsibility in medical negligence
Jesus Agana and Raymund Agana] and ENRIQUE AGANA, Petitioners, cases, an employer-employee relationship exists between hospitals and their consultants." 19 Although the Court
vs. in Ramos later issued a Resolution dated April 11, 200220 reversing its earlier finding on the existence of an
THE COURT OF APPEALS and JUAN FUENTES, Respondents. employment relationship between hospital and doctor, a similar reversal was not warranted in the present case
because the defense raised by PSI consisted of a mere general denial of control or responsibility over the actions of
Dr. Ampil.21
x - - - - - - - - - - - - - - - - - - - - - - -x

Second, by accrediting Dr. Ampil and advertising his qualifications, PSI created the public impression that he was its
G.R. No. 127590
agent.22 Enrique testified that it was on account of Dr. Ampil's accreditation with PSI that he conferred with said doctor
about his wife's (Natividad's) condition.23 After his meeting with Dr. Ampil, Enrique asked Natividad to personally
MIGUEL AMPIL, Petitioner, consult Dr. Ampil.24 In effect, when Enrigue and Natividad engaged the services of Dr. Ampil, at the back of their minds
vs. was that the latter was a staff member of a prestigious hospital. Thus, under the doctrine of apparent authority applied
NATIVIDAD and ENRIQUE AGANA, Respondents. in Nogales, et al. v. Capitol Medical Center, et al.,25 PSI was liable for the negligence of Dr. Ampil.

RESOLUTION
CORONA, J.:
With prior leave of court,1 petitioner Professional Services, Inc. (PSI) filed a second motion for reconsideration2 urging
referral thereof to the Court en banc and seeking modification of the decision dated January 31, 2007 and resolution
dated February 11, 2008 which affirmed its vicarious and direct liability for damages to respondents Enrique Agana
and the heirs of Natividad Agana (Aganas).
Manila Medical Services, Inc. (MMSI),3 Asian Hospital, Inc. (AHI),4 and Private Hospital Association of the Philippines
(PHAP)5 all sought to intervene in these cases invoking the common ground that, unless modified, the assailed
decision and resolution will jeopardize the financial viability of private hospitals and jack up the cost of health care.
The Special First Division of the Court granted the motions for intervention of MMSI, AHI and PHAP (hereafter
intervenors),6 and referred en consulta to the Court en banc the motion for prior leave of court and the second motion
for reconsideration of PSI.7
Finally, as owner and operator of Medical City General Hospital, PSI was bound by its duty to provide comprehensive
medical services to Natividad Agana, to exercise reasonable care to protect her from harm, 26 to oversee or supervise
all persons who practiced medicine within its walls, and to take active steps in fixing any form of negligence committed
within its premises.27 PSI committed a serious breach of its corporate duty when it failed to conduct an immediate
investigation into the reported missing gauzes.28
PSI is now asking this Court to reconsider the foregoing rulings for these reasons:
I
The declaration in the 31 January 2007 Decision vis-a-vis the 11 February 2009 Resolution that the ruling in Ramos
vs. Court of Appeals (G.R. No. 134354, December 29, 1999) that "an employer-employee relations exists between
hospital and their consultants" stays should be set aside for being inconsistent with or contrary to the import of the
resolution granting the hospital's motion for reconsideration in Ramos vs. Court of Appeals (G.R. No. 134354, April 11,
2002), which is applicable to PSI since the Aganas failed to prove an employer-employee relationship between PSI
and Dr. Ampil and PSI proved that it has no control over Dr. Ampil. In fact, the trial court has found that there is no
employer-employee relationship in this case and that the doctor's are independent contractors.

Due to paramount public interest, the Court en banc accepted the referral8 and heard the parties on oral arguments on II
one particular issue: whether a hospital may be held liable for the negligence of physicians-consultants allowed to
practice in its premises.9
Respondents Aganas engaged Dr. Miguel Ampil as their doctor and did not primarily and specifically look to the Medical
City Hospital (PSI) for medical care and support; otherwise stated, respondents Aganas did not select Medical City
Hospital (PSI) to provide medical care because of any apparent authority of Dr. Miguel Ampil as its agent since the
latter was chosen primarily and specifically based on his qualifications and being friend and neighbor.
III
PSI cannot be liable under doctrine of corporate negligence since the proximate cause of Mrs. Agana's injury was the
negligence of Dr. Ampil, which is an element of the principle of corporate negligence. 29
In their respective memoranda, intervenors raise parallel arguments that the Court's ruling on the existence of an
employer-employee relationship between private hospitals and consultants will force a drastic and complex alteration
in the long-established and currently prevailing relationships among patient, physician and hospital, with burdensome
operational and financial consequences and adverse effects on all three parties.30
The Aganas comment that the arguments of PSI need no longer be entertained for they have all been traversed in the
assailed decision and resolution.31
After gathering its thoughts on the issues, this Court holds that PSI is liable to the Aganas, not under the principle
of respondeat superior for lack of evidence of an employment relationship with Dr. Ampil but under the principle of
ostensible agency for the negligence of Dr. Ampil and, pro hac vice, under the principle of corporate negligence for its
failure to perform its duties as a hospital.
While in theory a hospital as a juridical entity cannot practice medicine, 32 in reality it utilizes doctors, surgeons and
medical practitioners in the conduct of its business of facilitating medical and surgical treatment.33 Within that reality,
three legal relationships crisscross: (1) between the hospital and the doctor practicing within its premises; (2) between
the hospital and the patient being treated or examined within its premises and (3) between the patient and the doctor.
The exact nature of each relationship determines the basis and extent of the liability of the hospital for the negligence
of the doctor.
Where an employment relationship exists, the hospital may be held vicariously liable under Article 217634 in relation to
Article 218035 of the Civil Code or the principle of respondeat superior. Even when no employment relationship exists
but it is shown that the hospital holds out to the patient that the doctor is its agent, the hospital may still be vicariously
liable under Article 2176 in relation to Article 143136 and Article 186937 of the Civil Code or the principle of apparent
authority.38 Moreover, regardless of its relationship with the doctor, the hospital may be held directly liable to the patient
for its own negligence or failure to follow established standard of conduct to which it should conform as a corporation. 39
This Court still employs the "control test" to determine the existence of an employer-employee relationship between
hospital and doctor. In Calamba Medical Center, Inc. v. National Labor Relations Commission, et al.40 it held:
Under the "control test", an employment relationship exists between a physician and a hospital if the hospital controls
both the means and the details of the process by which the physician is to accomplish his task.
xxx xxx xxx
As priorly stated, private respondents maintained specific work-schedules, as determined by petitioner through its
medical director, which consisted of 24-hour shifts totaling forty-eight hours each week and which were strictly to be
observed under pain of administrative sanctions.
That petitioner exercised control over respondents gains light from the undisputed fact that in the emergency
room, the operating room, or any department or ward for that matter, respondents' work is monitored through
its nursing supervisors, charge nurses and orderlies. Without the approval or consent of petitioner or its
medical director, no operations can be undertaken in those areas. For control test to apply, it is not essential
for the employer to actually supervise the performance of duties of the employee, it being enough that it has
the right to wield the power. (emphasis supplied)
Even in its December 29, 1999 decision41 and April 11, 2002 resolution42 in Ramos, the Court found the control test
decisive.
In the present case, it appears to have escaped the Court's attention that both the RTC and the CA found no
employment relationship between PSI and Dr. Ampil, and that the Aganas did not question such finding. In its
March 17, 1993 decision, the RTC found "that defendant doctors were not employees of PSI in its hospital, they being
merely consultants without any employer-employee relationship and in the capacity of independent contractors."43 The
Aganas never questioned such finding.
PSI, Dr. Ampil and Dr. Fuentes appealed44 from the RTC decision but only on the issues of negligence, agency and
corporate liability. In its September 6, 1996 decision, the CA mistakenly referred to PSI and Dr. Ampil as employer-
employee, but it was clear in its discussion on the matter that it viewed their relationship as one of mere apparent
agency.45
The Aganas appealed from the CA decision, but only to question the exoneration of Dr. Fuentes. 46 PSI also appealed
from the CA decision, and it was then that the issue of employment, though long settled, was unwittingly resurrected.
In fine, as there was no dispute over the RTC finding that PSI and Dr. Ampil had no employer-employee relationship,
such finding became final and conclusive even to this Court. 47 There was no reason for PSI to have raised it as an
issue in its petition. Thus, whatever discussion on the matter that may have ensued was purely academic.
Nonetheless, to allay the anxiety of the intervenors, the Court holds that, in this particular instance, the concurrent
finding of the RTC and the CA that PSI was not the employer of Dr. Ampil is correct. Control as a determinative factor
in testing the employer-employee relationship between doctor and hospital under which the hospital could be held
vicariously liable to a patient in medical negligence cases is a requisite fact to be established by preponderance of
evidence. Here, there was insufficient evidence that PSI exercised the power of control or wielded such power over
the means and the details of the specific process by which Dr. Ampil applied his skills in the treatment of Natividad.
Consequently, PSI cannot be held vicariously liable for the negligence of Dr. Ampil under the principle of respondeat
superior.
There is, however, ample evidence that the hospital (PSI) held out to the patient (Natividad) 48 that the doctor (Dr.
Ampil) was its agent. Present are the two factors that determine apparent authority: first, the hospital's implied
manifestation to the patient which led the latter to conclude that the doctor was the hospital's agent; and second, the
patient’s reliance upon the conduct of the hospital and the doctor, consistent with ordinary care and prudence. 49
Enrique testified that on April 2, 1984, he consulted Dr. Ampil regarding the condition of his wife; that after the meeting
and as advised by Dr. Ampil, he "asked [his] wife to go to Medical City to be examined by [Dr. Ampil]"; and that the
next day, April 3, he told his daughter to take her mother to Dr. Ampil.50 This timeline indicates that it was Enrique who
actually made the decision on whom Natividad should consult and where, and that the latter merely acceded to it. It
explains the testimony of Natividad that she consulted Dr. Ampil at the instigation of her daughter. 51
Moreover, when asked what impelled him to choose Dr. Ampil, Enrique testified:
Atty. Agcaoili
On that particular occasion, April 2, 1984, what was your reason for choosing Dr. Ampil to contact with in connection
with your wife's illness?
A. First, before that, I have known him to be a specialist on that part of the body as a surgeon, second, I have known First, they constitute judicial admission by PSI that while it had no power to control the means or method by which Dr.
him to be a staff member of the Medical City which is a prominent and known hospital. And third, because he is a Ampil conducted the surgery on Natividad Agana, it had the power to review or cause the review of what may have
neighbor, I expect more than the usual medical service to be given to us, than his ordinary patients.52 (emphasis irregularly transpired within its walls strictly for the purpose of determining whether some form of negligence may have
supplied) attended any procedure done inside its premises, with the ultimate end of protecting its patients.

Clearly, the decision made by Enrique for Natividad to consult Dr. Ampil was significantly influenced by the impression Second, it is a judicial admission that, by virtue of the nature of its business as well as its prominence57 in the hospital
that Dr. Ampil was a staff member of Medical City General Hospital, and that said hospital was well known and industry, it assumed a duty to "tread on" the "captain of the ship" role of any doctor rendering services within its
prominent. Enrique looked upon Dr. Ampil not as independent of but as integrally related to Medical City. premises for the purpose of ensuring the safety of the patients availing themselves of its services and facilities.

PSI's acts tended to confirm and reinforce, rather than negate, Enrique's view. It is of record that PSI required a Third, by such admission, PSI defined the standards of its corporate conduct under the circumstances of this case,
"consent for hospital care"53 to be signed preparatory to the surgery of Natividad. The form reads: specifically: (a) that it had a corporate duty to Natividad even after her operation to ensure her safety as a patient; (b)
that its corporate duty was not limited to having its nursing staff note or record the two missing gauzes and (c) that its
corporate duty extended to determining Dr. Ampil's role in it, bringing the matter to his attention, and correcting his
Permission is hereby given to the medical, nursing and laboratory staff of the Medical City General Hospital to perform
negligence.
such diagnostic procedures and to administer such medications and treatments as may be deemed necessary or
advisable by the physicians of this hospital for and during the confinement of xxx. (emphasis supplied)
And finally, by such admission, PSI barred itself from arguing in its second motion for reconsideration that the concept
of corporate responsibility was not yet in existence at the time Natividad underwent treatment; 58 and that if it had any
By such statement, PSI virtually reinforced the public impression that Dr. Ampil was a physician of its hospital, rather
corporate responsibility, the same was limited to reporting the missing gauzes and did not include "taking an active
than one independently practicing in it; that the medications and treatments he prescribed were necessary and
step in fixing the negligence committed."59 An admission made in the pleading cannot be controverted by the party
desirable; and that the hospital staff was prepared to carry them out.1avvphi1
making such admission and is conclusive as to him, and all proofs submitted by him contrary thereto or inconsistent
therewith should be ignored, whether or not objection is interposed by a party. 60
PSI pointed out in its memorandum that Dr. Ampil's hospital affiliation was not the exclusive basis of the Aganas’
decision to have Natividad treated in Medical City General Hospital, meaning that, had Dr. Ampil been affiliated with
Given the standard of conduct that PSI defined for itself, the next relevant inquiry is whether the hospital measured up
another hospital, he would still have been chosen by the Aganas as Natividad's surgeon. 54
to it.

The Court cannot speculate on what could have been behind the Aganas’ decision but would rather adhere strictly to
PSI excuses itself from fulfilling its corporate duty on the ground that Dr. Ampil assumed the personal responsibility of
the fact that, under the circumstances at that time, Enrique decided to consult Dr. Ampil for he believed him to be a
informing Natividad about the two missing gauzes.61 Dr. Ricardo Jocson, who was part of the group of doctors that
staff member of a prominent and known hospital. After his meeting with Dr. Ampil, Enrique advised his wife Natividad
attended to Natividad, testified that toward the end of the surgery, their group talked about the missing gauzes but Dr.
to go to the Medical City General Hospital to be examined by said doctor, and the hospital acted in a way that fortified
Ampil assured them that he would personally notify the patient about it. 62 Furthermore, PSI claimed that there was no
Enrique's belief.
reason for it to act on the report on the two missing gauzes because Natividad Agana showed no signs of
complications. She did not even inform the hospital about her discomfort.63
This Court must therefore maintain the ruling that PSI is vicariously liable for the negligence of Dr. Ampil as its
ostensible agent.
The excuses proffered by PSI are totally unacceptable.

Moving on to the next issue, the Court notes that PSI made the following admission in its Motion for Reconsideration:
To begin with, PSI could not simply wave off the problem and nonchalantly delegate to Dr. Ampil the duty to review
what transpired during the operation. The purpose of such review would have been to pinpoint when, how and by
51. Clearly, not being an agent or employee of petitioner PSI, PSI [sic] is not liable for Dr. Ampil's acts during the whom two surgical gauzes were mislaid so that necessary remedial measures could be taken to avert any jeopardy to
operation. Considering further that Dr. Ampil was personally engaged as a doctor by Mrs. Agana, it is incumbent upon Natividad’s recovery. Certainly, PSI could not have expected that purpose to be achieved by merely hoping that the
Dr. Ampil, as "Captain of the Ship", and as the Agana's doctor to advise her on what to do with her situation vis-a-vis person likely to have mislaid the gauzes might be able to retrace his own steps. By its own standard of corporate
the two missing gauzes. In addition to noting the missing gauzes, regular check-ups were made and no signs conduct, PSI's duty to initiate the review was non-delegable.
of complications were exhibited during her stay at the hospital, which could have alerted petitioner PSI's
hospital to render and provide post-operation services to and tread on Dr. Ampil's role as the doctor of Mrs.
While Dr. Ampil may have had the primary responsibility of notifying Natividad about the missing gauzes, PSI imposed
Agana. The absence of negligence of PSI from the patient's admission up to her discharge is borne by the
upon itself the separate and independent responsibility of initiating the inquiry into the missing gauzes. The purpose
finding of facts in this case. Likewise evident therefrom is the absence of any complaint from Mrs. Agana after
of the first would have been to apprise Natividad of what transpired during her surgery, while the purpose of the second
her discharge from the hospital which had she brought to the hospital's attention, could have alerted petitioner
would have been to pinpoint any lapse in procedure that led to the gauze count discrepancy, so as to prevent a
PSI to act accordingly and bring the matter to Dr. Ampil's attention. But this was not the case. Ms. Agana
recurrence thereof and to determine corrective measures that would ensure the safety of Natividad. That Dr. Ampil
complained ONLY to Drs. Ampil and Fuentes, not the hospital. How then could PSI possibly do something to
negligently failed to notify Natividad did not release PSI from its self-imposed separate responsibility.
fix the negligence committed by Dr. Ampil when it was not informed about it at all.55 (emphasis supplied)

Corollary to its non-delegable undertaking to review potential incidents of negligence committed within its premises,
PSI reiterated its admission when it stated that had Natividad Agana "informed the hospital of her discomfort and pain,
PSI had the duty to take notice of medical records prepared by its own staff and submitted to its custody, especially
the hospital would have been obliged to act on it."56
when these bear earmarks of a surgery gone awry. Thus, the record taken during the operation of Natividad which
reported a gauze count discrepancy should have given PSI sufficient reason to initiate a review. It should not have
The significance of the foregoing statements is critical. waited for Natividad to complain.
As it happened, PSI took no heed of the record of operation and consequently did not initiate a review of what transpired Republic of the Philippines
during Natividad’s operation. Rather, it shirked its responsibility and passed it on to others – to Dr. Ampil whom it SUPREME COURT
expected to inform Natividad, and to Natividad herself to complain before it took any meaningful step. By its inaction, Manila
therefore, PSI failed its own standard of hospital care. It committed corporate negligence.
THIRD DIVISION
It should be borne in mind that the corporate negligence ascribed to PSI is different from the medical negligence
attributed to Dr. Ampil. The duties of the hospital are distinct from those of the doctor-consultant practicing within its
G.R. No. 86890 January 21, 1994
premises in relation to the patient; hence, the failure of PSI to fulfill its duties as a hospital corporation gave rise to a
direct liability to the Aganas distinct from that of Dr. Ampil.
LEANDRO CARILLO, petitioner,
vs.
All this notwithstanding, we make it clear that PSI’s hospital liability based on ostensible agency and corporate
PEOPLE OF THE PHILIPPINES, respondent.
negligence applies only to this case, pro hac vice. It is not intended to set a precedent and should not serve as a basis
to hold hospitals liable for every form of negligence of their doctors-consultants under any and all circumstances. The
ruling is unique to this case, for the liability of PSI arose from an implied agency with Dr. Ampil and an admitted Balane, Tamase, Alampay Law Office for petitioner.
corporate duty to Natividad.64
The Solicitor General for the people.
Other circumstances peculiar to this case warrant this ruling, 65 not the least of which being that the agony wrought
upon the Aganas has gone on for 26 long years, with Natividad coming to the end of her days racked in pain and
agony. Such wretchedness could have been avoided had PSI simply done what was logical: heed the report of a guaze
count discrepancy, initiate a review of what went wrong and take corrective measures to ensure the safety of Nativad.
Rather, for 26 years, PSI hemmed and hawed at every turn, disowning any such responsibility to its patient. Meanwhile, FELICIANO, J.:
the options left to the Aganas have all but dwindled, for the status of Dr. Ampil can no longer be ascertained. 66
Petitioner Dr. Leandro Carillo, an anesthetist, seeks review of the Decision of the Court of Appeals dated 28 November
Therefore, taking all the equities of this case into consideration, this Court believes ₱15 million would be a fair and 1988, which affirmed his conviction by the Regional Trial Court of the crime of simple negligence resulting in homicide,
reasonable liability of PSI, subject to 12% p.a. interest from the finality of this resolution to full satisfaction. for the death of his thirteen (13) year old patient
Catherine Acosta. The trial court had sentenced him to suffer the penalty of arresto mayor in its medium period (four
WHEREFORE, the second motion for reconsideration is DENIED and the motions for intervention are NOTED. [4] months' imprisonment), as well as to pay the heirs of his patient an indemnity of P30,000.00 for her death,
P10,000.00 as reimbursement for actual expenses incurred, P50,000.00 as moral damages and to pay the costs of
the suit.1
Professional Services, Inc. is ORDERED pro hac vice to pay Natividad (substituted by her children Marcelino Agana
III, Enrique Agana, Jr., Emma Agana-Andaya, Jesus Agana and Raymund Agana) and Enrique Agana the total amount
of ₱15 million, subject to 12% p.a. interest from the finality of this resolution to full satisfaction. The information filed against petitioner and his co-accused, the surgeon Dr. Emilio Madrid, alleged the following:

No further pleadings by any party shall be entertained in this case. That on or about the 31st of May 1981, in the municipality of Parañaque, Metro Manila, Philippines
and within the jurisdiction of this Honorable Court, the above-named accused, conspiring and
confederating together and mutually helping and aiding with one another, without taking the
Let the long-delayed entry of judgment be made in this case upon receipt by all concerned parties of this resolution. necessary care and precaution to avoid injury to person, did then and there willfully, unlawfully
and feloniously operate, in a reckless, careless and imprudent manner and neglected to exercise
their respective medical knowhow and tasks and/or departed from the recognized standard in their
SO ORDERED.
treatment, diagnosis of the condition, and operation of the patient, one Catherine Acosta, 13 years
old, which negligence caused the death of the said Catherine Acosta. 2

Petitioner and Dr. Emilio Madrid entered pleas of not guilty at arraignment and the case proceeded to trail with Judge
Job B. Madayag presiding.3

The prosecution presented as its principal evidence the testimony of four (4) witnesses, namely: 1) Yolanda Acosta,
Catherine's mother, who was able to observe the conduct of the accused outside the operating theater before, during
and after the appendectomy procedure carried out on her daughter; 4 2) Domingo Acosta, Catherine's father, who
corroborated some parts of his wife's
testimony;5 3) Dr. Horacio Buendia, an expert witness who described before the trial court the relationship between a
surgeon and an anesthetist in the course of a surgical operation, as well as define the likelihood of cardiac arrest as a
post operative complication;6 and 4) Dr. Nieto Salvador, an expert witness who analyzed and explained the significance
of the results of the pathological study and autopsy conducted on Catherine's body by one Dr. Alberto Reyes. 7
After the prosecution had rested its case, the defense was granted leave to file a demurrer to the evidence. 8 After
failing to file the demurrer within the reglementary period, Judge Manuel Yuzon, who had in the meantime taken over
as presiding judge of the sala where this case was pending, denied the defense motion for extension of time to file
demurrer and declared the case submitted for decision.9
10
On 19 September 1985, the trial court promulgated its decision convicting both the accused of the crime charged.
On appeal, the Court of Appeals affirmed the judgment of conviction, and specified that the civil liability of the two (2)
accused was solidary in nature. 11
Petitioner Dr. Carillo alone filed the present Petition for Review with the Court, seeking reversal of his conviction, or in
the alternative, the grant of a new trial. Dr. Madrid did not try to appeal further the Court of Appeals Decision.
Accordingly, the judgment of conviction became final insofar as the accused surgeon Dr. Madrid is concerned.
It has also been established that the deceased was not weighed before the administration of
anesthesia on her.
The operation was finished at 7:00 o'clock in the evening and when the child was brought out from
the operating room, she was observed to be shivering (nanginginig); her heart beat was not
normal; she was asleep and did not wake up; she was pale; and as if she had difficulty in breathing
and Dr. Emilio Madrid suggested that she placed under oxygen tank; that oxygen was
administered to the child when she was already in the room.
Witness Yolanda Acosta further testified that shortly before the child was transferred from the
operating room to her room, she (witness) was requested by the anesthesiologist to go home and
get a blanket.
A portion of Yolanda Acosta's testimony on what happened when she returned to the hospital are
reproduced hereunder as follows:

The facts of the case as established by the Court of Appeals are as follows:
Q What happened afterward?

The deceased, Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and Yolanda
A When I arrived in the hospital, my child was being
Acosta, complained to her father at about 10:30 o'clock in the morning of May 31, 1981 of pains
transferred to her bed.
in the lower part of her abdomen. Catherine was then brought to Dr. Elva Peña. Dra. Peña called
for Dr. Emilio Madrid and the latter examined Catherine Acosta. According to Dr. Madrid, his
findings might be appendicitis. Then Dr. Peña told Catherine's parents to bring the child to the Q What else happened?
hospital in Baclaran so that the child will be observed.
Q I noticed that the heartbeat of my daughter was not
At the Baclaran General Hospital, a nurse took blood sample form the child. The findings became normal. And I noticed that her hospital gown is rising up
known at around 3:00 o'clock in the afternoon and the child was scheduled for operation at 5:00 and down.
o'clock in the afternoon. The operation took place at 5:45 p.m. because Dr. Madrid arrived only at
that time.
Q What transpired after that?

When brought inside the operating room, the child was feeling very well and they did not subject
A I asked Dr. Madrid why it was like that, that the
the child to ECG (electrocardiogram) and
heartbeat of my daughter is not normal.
X-ray.

Q And did the doctor make any reply?

The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was assisted by appellant,
Dr. Leandro Carillo, an anesthesiologists.
A The doctor said because of the lesion of the child.
During the operation, while Yolanda Acosta, Catherine's mother, was staying outside the operating
room, she "noticed something very unfamiliar." The three nurses who assisted in the operation Q What else happened?
were going in and out of the operating room, they were not carrying anything, but in going out of
the operating room, they were already holding something.
A After they have revived the heartbeat of the child,
Dr. Carillo and Dr. Madrid left.
Yolanda asked one of the nurses if she could enter the operating room but she was refused.
Q Now do you remember what time was it when
At around 6:30 p.m., Dr. Emilio Madrid went outside the operating room and Yolanda Acosta was Dr. Carillo stepped out?
allowed to enter the first door.
A Only a minute after they have transferred the child to
The appendicitis (sic) was shown to them by Dr. Madrid, because, according to Dr. Madrid, they the bed.
might be wondering because he was going to install drainage near the operating (sic) portion of
the child.
Q What happened later on after Dr. Carillo and
Dr. Madrid stepped out of the hospital?
When asked, the doctor told them the child was already out of danger but the operation was not
yet finished.
A After 15 or 30 minutes has lapsed at about 7:15 or
7:30, the child had developed convulsion and stiffening
of the body.
Q When you observed convulsion and stiffening of the
body, did you do anything?
A We requested the nurse who was attending to her to
call for a doctor.
Q And the nurse who was attending to the patient called
for a doctor?
A They called for Dra. Peña, their family physician.
Q What transpired afterwards?
A What Dra. Peña did was call for Dr. Madrid and the
cardiologist.
Q Did this doctor arrived?
A Yes.
Q What transpired after the doctor arrived?
A They examined the child.
Q After they examined the child, did they inform you of
the result of the examination?
A The cardiologist was the one whom informed us after
he stepped out of the room when we followed him. The
doctor told us that she suffered severe infection which
went up to her head.
Q After you were informed of the result of his
examination, what transpired next?
A According to them, they will do their best for the child
and that they will call for Dr. Carillo.
Q Did Dr. Carillo arrived?
A At around 10:30 in the evening.
Q Did Dr. Carillo do anything when he arrived on 31 May
1981?
A When he arrived, he noticed that there were two small
bottles and big bottles of dextrose which were hanging
above the bed of the child. Then he said, "What is this?
Christmas tree or what?" He told us that one bottle of
dextrose be removed. And the big one will remain.
Q What happened after that?
A After that we talked to Dr. Carillo and asked him how
did this happen to the child.
Q What did Dr. Carillo reply (sic) to you?
A He answered "that is nothing, the child will regain
consciousness and if the child will not regain
consciousness, I will resign (sic) as a doctor."12
(Emphasis supplied)
When Catherine remained unconscious until noontime the next day, a neurologist examined her and she was
diagnosed as comatose. 13 Three (3) days later, Catherine died without regaining consciousness. 14
The Court of Appeals held that Catherine had suffered from an overdose of, or an adverse reaction to, anesthesia,
particularly the arbitrary administration of Nubain, a pain killer, without benefit of prior weighing of the patient's body
mass, which weight determines the dosage of Nubain which can safely be given to a patient. 15 The Court of Appeals
held that this condition triggered off a heart attack as a post-operative complication, depriving Catherine's brain of
oxygen, leading to the brain's hemorrhage. 16 The Court of Appeals identified such cardiac arrest as the immediate
cause of Catherine's death. 17
The Court of Appeals found criminal negligence on the part of petitioner Dr. Carillo and his co-accused Dr. Madrid,
holding that both had failed to observe the required standard of diligence in the examination of Catherine prior to the
actual administration of anesthesia; 18 that it was "a bit rash" on the part of the accused Dr. Carillo "to have administered
Nubain without first weighing Catherine"; 19 and that it was an act of negligence on the part of both doctors when, (a)
they failed to monitor Catherine's heartbeat after the operation and
(b) they left the hospital immediately after reviving Catherine's heartbeat, depriving the latter
of immediate and expert medical assistance when she suffered a heart attack approximately fifteen (15) to thirty (30)
minutes later. 20
Since neither petitioner nor his co-accused presented evidence in their own behalf, the present Petition seeks to
question the soundness of the factual conclusions drawn by the Court of Appeals, upon which the affirmance of
petitioner's conviction was based.
Close examination of the instant Petition for Review shows that petitioner's main arguments are two-fold: (1) the Court
of Appeals "completely brushed aside" and "misapprehended" Catherine's death certificate and biopsy report which
allegedly showed that the cause of death was a ruptured appendix, which led to blood poisoning, 21 rather than faulty
anesthetic treatment;
and (2) there was no direct evidence of record showing that Nubain was administered to Catherine either during the
appendectomy procedure or after such operation. 22
Two (2) related issues are thus posed for the Court's consideration. The first is whether the Court of Appeals so
drastically "misapprehended" the relevant, operative facts in this case as to compel this Court to examine and resolve
question(s) of fact which would have a decisive significance for the disposition of the case. The rule is too firmly settled
to require much documentation that only questions of law may be raised before this Court in a petition for review
on certiorari, subject to certain well-known exceptions. 23 After careful scrutiny of petitioner's contentions before us and
the record of this case, we do not believe that petitioner has shown "misapprehension of facts" on the part of the Court
of Appeals which would require this Court to overturn the judgment reached by the former.
The second issue is whether or not the findings of fact of the Court of Appeals adequately support the conclusion that
petitioner Dr. Carillo was, along with Dr. Madrid, guilty of simple negligence which resulted in homicide. Our review of
the record leads us to an affirmative answer.
Petitioner contends that the Court of Appeals seriously erred in finding that an overdose of, or an allergic reaction to,
the anesthetic drug Nubain had led to the death of Catherine Acosta and that the true cause of Catherine's death was
that set out in the death certificate of Catherine: "Septicemia (or blood poisoning) due to perforated appendix with
peritonitis." 24 The concept of causation in general, and the cause of death in human beings in particular, are complex
and difficult notions. What is fairly clear is that death, understood as a physical condition involving cessation of vital
signs in the brain and heart, is preceded by a series of physiological events, any one of which events can, with equal
cogency, be described as a "cause of death". The Court of Appeals found that an overdose of, or an adverse reaction
to, Nubain, an anesthetic or
pain-killing drug the appropriate dose of which depends on the body weight or mass of the patient, had generated or
triggered off cardiac arrest, which in
turn led to lack of oxygen in Catherine's brain, which then brought about hemorrhaging in the brain. Vital activity in the
brain thereupon ceased. The medical evidence presented at the trial was quite consistent with the findings of the Court
of Appeals which concluded that cardiac arrest was the cause of Catherine's death. 25
For his part, petitioner insists that cardiac arrest is not the only cause of oxygen-starvation of the brain, that septicemia
with peritonitis or severe infection which had "gone up to the head" of Catherine was an equally efficient cause of
deprivation of the brain of oxygen and hence of brain hemorrhage. The medical testimony of the expert witnesses for
the prosecution on which petitioner relies is also consistent with petitioner's theory that septicemia with peritonitis was,
or at least could have been, the cause of Catherine's death. 26
Indeed, it appears to the Court that there was no medical proof submitted to the trial court to show that one or the other
"cause" was necessarily an exclusive cause of death in the case of Catherine Acosta; that an overdose or allergic
reaction to Nubain could not have combined with septicemia and peritonitis in bringing about Catherine's death.
What is of critical importance for present purposes is not so much the identification of the "true cause" or "real cause"
of Catherine's death but rather the set of circumstances which both the trial court and the Court of Appeals found
constituted simple (as distinguished from reckless) negligence on the part of the two accused Dr. Madrid and Dr. Carillo
leading to the death of Catherine.
When the patient was wheeled out of the operating room after completion of surgery, she manifested signs of medical
instability (i.e., shivering, paleness, irregular breathing and weak heart beat). 27 She was not brought to a properly
equipped recovery room, or intensive care until which the hospital lacked. 28 Such facilities and their professional staffs,
of which an anesthetist is commonly a part, are essential for providing close observation and patient care while a post-
surgery patient is recovering from the effects of anesthesia and while the normal protective mechanisms are still dull
or obtunded. 29 Instead, the patient was merely brought to her assigned hospital bed and was provided oxygen on the
instructions of Dr. Madrid then "revived" her heartbeat. 30 Both doctors then left their patient and the hospital;
approximately fifteen minutes later, she suffered convulsions and cardiac arrest. 31
The conduct of Dr. Madrid and of the petitioner constituted inadequate care of their patient in view of her vulnerable
condition. Both doctors failed to appreciate the serious condition of their patient whose adverse physical signs were
quite manifest right after surgery. And after reviving her heartbeat, both doctors failed to monitor their patient closely
or extend further medical care to her; such conduct was especially necessary in view of the inadequate,
post-operative facilities of the hospital. We do not, of course, seek to hold petitioner responsible for the inadequate
facilities of the Baclaran General Hospital. We consider, however, that the inadequate nature of those facilities did
impose a somewhat higher standard of professional diligence upon the accused surgeon and anesthetist personally
than would have been called for in a modern fully-equipped hospital.
While Dr. Madrid and a cardiologist were containing the patient's convulsions, and after the latter had diagnosed that
infection had reached the patient's head, these two (2) apparently after consultation, decided to call-in the
petitioner. 32 There is here a strong implication that the patient's post-operative condition must have been considered
by the two (2) doctors as in some way related to the anesthetic treatment she had received from the petitioner either
during or after the surgical procedure.
Once summoned, petitioner anesthesiologist could not be readily found. When he finally appeared at 10:30 in the
evening, he was evidently in a bad temper, commenting critically on the dextrose bottles before ordering their
removal. 33 This circumstance indicated he was not disposed to attend to this unexpected call, in violation of the canons
of his profession that as a physician, he should serve the interest of his patient "with the greatest of solicitude, giving
them always his best talent and skill." 34 Indeed, when petitioner finally saw his patient, he offered the unprofessional
bluster to the parents of Catherine that he would resign if the patient will not regain consciousness. 35 The canons of
medical ethics require a physician to "attend to his patients faithfully and conscientiously." He should secure for them
all possible benefits that may depend upon his professional skill and care. As the sole tribunal to adjudge the
physician's failure to fulfill his obligation to his patient is, in most cases, his own conscience, violation of this rule on his
part is "discreditable and inexcusable". 36
Nubain was an experimental drug for anesthesia and post-operative pain and the medical literature required that a
patient be weighed first before it is administered and warned that there was no (or inadequate) experience relating to
the administration thereof to a patient less that eighteen (18) ears of age. 37 Yet, the doctor's order sheet (Exhibit "C")
did not contain this precaution but instead directed a reader to apply the drug only when warranted by the
circumstances. 38 During the offer of Exhibit "C" by the prosecution, Dr. Madrid admitted that this prescription, which
was unsigned, was made in his own handwriting. 39 It must be observed that the instruction was open-ended in that
some other individual still had to determine if circumstances existed warranting administration of the drug to the patient.
The document thus indicated the abdication of medical responsibility on an extremely critical matter.
Since petitioner anesthesiologist entered subsequent prescriptions or orders in the same order sheet, which were
signed by him, at 7:15 p.m. on the same evening of 31 May 1981, he was in a position to appreciate the dangers
inherent in the prior prescription, which was within his (petitioner's) area of specialization, and to order measures to
correct this anomaly and protect his patient's well-being. So far as the condition of the evidence shows, he failed to do
so. In sum, only a low level of diligence was exhibited by petitioner and Dr. Madrid in the prescription of medication for
their patient.
As noted earlier, petitioner relied heavily in this proceeding on the testimony on cross-examination of the expert
witnesses for the prosecution to show that blood poisoning resulting from a ruptured appendix could also be
responsible for the patient's death.
No suggestion has been made that the rupture of the patient's occurred prior to surgery. After her blood sample was
examined, the patient was merely diagnosed as a case of appendicitis, without further elaboration. 40 No intensive
preoperative preparations, like the immediate administration of antibiotics, was thereafter undertaken on the patient.
This is a standard procedure for patients who are, after being diagnosed, suspected of suffering from a perforated
appendix and consequent peritonitis. 41 The mother also testified that petitioner anesthesiologist merely injected a
drug, "pre-anesthesia" intended to put the patient to sleep, into the container of fluids being administered to her
daughter intravenously at her room, prior to surgery. 42 We note further that the surgeon Dr. Madrid was forty-five
minutes late in arriving at the operating theater. 43 Considering that delay in treatment of appendicitis increases the
morbidity of the patient, 44 Dr. Madrid's conduct can only be explained by a pre-operative diagnosis on his part that the
condition of appendicitis was not yet attended by complications (i.e., a ruptured appendix and peritonitis).
The above circumstances do strongly indicate that the rupture of the patient's appendix occurred during the
appendectomy procedure, that is, at a time and place — the operating room — where the two (2) accused were in full
control of the situation and could determine decisively what needed to be done in respect of the patient. 45 This
circumstance must be considered in conjunction with other related circumstances which the prosecution had proven:
that the patient was ambulatory when brought to the operating room; 46 that she left the operating room two (2) hours
later in obviously serious condition; and that an appendectomy accompanied or followed by sustained antibiotic
treatment is a fairly common and generally accepted medical procedure for dealing with ruptured appendix and
peritonitis, 47 a fact of which judicial note may be taken.
As early as in People v. Vistan, 48 the Court defined simple negligence, penalized under what is now Article 365 of the behalf in lieu of a demurrer, or to submit a memorandum for the defense. After promulgation of the judgment of
Revised Penal Code, as "a mere lack of prevision in a situation where either the threatened harm is conviction, petitioner did not seek a new trial, but permitted Atty. Puerto to obtain leave from the trial court to continue
not immediate or the danger not openly visible." Put in a slightly different way, the gravamen of the offense of simple on bail during the pendency of the proceedings before the Court of Appeals. 56 Indeed, petitioner replaced
negligence is the failure to exercise the diligence necessitated or called for the situation which was not immediately Atty. Puerto as counsel only upon institution of the present petition. 57
life-destructive but which culminated, in the present case, in the death of a human being three (3) days later. Such
failure to exercise the necessary degree of care and diligence is a negative ingredient of the offense charged. The rule
Petitioner's constitutional objection is plainly an afterthought.
in such cases is that while the prosecution must prove the negative ingredient of the offense, it needs only to present
the best evidence procurable under the circumstances, in order to shift the burden of disproving or countering the proof
of the negative ingredient to the accused, provided that such initial evidence establishes at least on a prima facie basis WHEREFORE, the Decision of the Court of Appeals dated 28 November 1988 is hereby AFFIRMED, subject only to
the guilt of the accused. 49 This rule is particularly applicable where the negative ingredient of the offense is of such a the modification that the indemnity for the death of Catherine Acosta is hereby increased to P50,000.00, in line with
nature or character as, under the circumstances, to be specially within the knowledge or control of the accused. 50 In current jurisprudence. 58
the instant case, the Court is bound to observe that the events which occurred during the surgical procedure (including
whether or not Nubain had in fact been administered as an anesthesia immediately before or during the surgery) were
SO ORDERED.
peculiarly within the knowledge and control of Dr. Carillo and Dr. Madrid. It was, therefore, incumbent upon the two (2)
accused to overturn the prima facie case which the prosecution had established, by reciting the measures which they
had actually taken to prevent or to counter the obviously serious condition of Catherine Acosta which was evident right
after surgery. This they failed or refused to do so.

Still another circumstance of which account must be taken is that both petitioner and Dr. Madrid failed to inform the
parents of their minor patient of the nature of her illness, or to explain to them either during the surgery
(if feasible) or at any time after the surgery, the events which comprised the dramatic deterioration of her condition
immediately after surgery as compared with her pre-surgery condition. To give a truthful explanation to the parents
was a duty imposed upon them by the canons of their profession. 51 Petitioner should have explained to Catherine's
parents the actual circumstances surrounding Catherine's death, how, in other words, a simple appendectomy
procedure upon an ambulatory patient could have led to such fatal consequences.

By way of resume, in the case at bar, we consider that the chain of circumstances above noted, namely: (1) the failure
of petitioner and Dr. Madrid to appreciate the serious post-surgery condition of their patient and to monitor her condition
and provide close patient care to her; (2) the summons of petitioner by Dr. Madrid and the cardiologist after the patient's
heart attack on the very evening that the surgery was completed; (3) the low level of care and diligence exhibited by
petitioner in failing to correct Dr. Madrid's prescription of Nubain for post-operative pain; (4) the extraordinary failure or
refusal of petitioner and Dr. Madrid to inform the parents of Catherine Acosta of her true condition after surgery, in
disregard of the requirements of the Code of Medical Ethics; and (5) the failure of petitioner and Dr. Madrid to prove
that they had in fact exercised the necessary and appropriate degree of care and diligence to prevent the sudden
decline in the condition of Catherine Acosta and her death three (3) days later, leads the Court to the conclusion, with
moral certainty, that petitioner and Dr. Madrid were guilty of simple negligence resulting in homicide.

In addition to the main arguments raised by petitioner earlier, he also raised an ancillary, constitutional claim of denial
of due process. He contends that he was deprived of his right to have competent representation at trial, and to have
his cause adequately heard, because his counsel of record, Atty. Jose B. Puerto, was "incompetent" and exhibited
"gross negligence" by manifesting an intent to file a demurrer to the evidence, in failing to present evidence in his
behalf and in omitting to file a defense memorandum for the benefit of
Judge Yuzon, after the latter took over the case at the end of trial and before the Judge rendered his
decision. 52 Petitioner submits he is entitled to a new trial. 53

These contentions do not persuade. An examination of the record indicates that Atty. Puerto represented petitioner
during trial with reasonable competence. Except for the two hearing sessions when witnesses Domingo Acosta was
cross-examined and recross-examined by Atty. Puerto, petitioner was present during all the sessions when the other
prosecution witnesses were presented and during which Atty. Puerto extensively cross-examined them in behalf of
petitioner and Dr. Madrid. This counsel elicited from the two (2) expert witnesses for the prosecution testimony
favorable to petitioner and which was relied upon by the latter in this proceeding. 54 The record further indicates that if
petitioner indeed entertained substantial doubts about the capability of Atty. Puerto, he could have easily terminated
the services of that counsel and retained a new one, or sought from the trial court the appointment of counsel
de oficio, during the ample opportunity given from the time Atty. Puerto manifested his intent to file a demurrer on 16
October 1985, to the submission of the case for decision on 25 June 1986 and before the promulgation of judgment
on 19 September 1986. 55 During all this time, petitioner could have obtained leave of court to present evidence in his
 Republic of the Philippines
SUPREME COURT
Manila
THIRD DIVISION
G.R. No. 118231 July 5, 1996
DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners,
vs.
COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS, respondents.
DAVIDE, JR., J.:p
Throughout history, patients have consigned their fates and lives to the skill of their doctors. For a breach of this trust,
men have been quick to demand retribution. Some 4,000 years ago, the Code of Hammurabi 1 then already provided:
"If a physician make a deep incision upon a man with his bronze lancet and cause the man's death, or operate on the
eye socket of a man with his bronze lancet and destroy the man's eyes, they shall cut off his hand." 2 Subsequently,
Hippocrates3 wrote what was to become part of the healer's oath: "I will follow that method of treatment which according
to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and
mischievous. . . . While I continue to keep this oath unviolated may it be granted me to enjoy life and practice the art,
respected by all men at all times but should I trespass and violate this oath, may the reverse be my lot." At present,
the primary objective of the medical profession if the preservation of life and maintenance of the health of the people.4
Needless to say then, when a physician strays from his sacred duty and endangers instead the life of his patient, he
must be made to answer therefor. Although society today cannot and will not tolerate the punishment meted out by the
ancients, neither will it and this Court, as this case would show, let the act go uncondemned.
The petitioners appeal from the decision5 of the Court of Appeals of 11 May 1994 in CA-G.R. CV No. 30851, which
reversed the decision6 of 21 December 1990 of Branch 30 of the Regional Trial Court (RTC) of Negros Oriental in Civil
Case No. 9492.
The facts, as found by the trial court, are as follows:
Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City
from January 9, 1978 to September 1989. Between 1987 and September, 1989 she was also the
Actg. Head of the Department of Obstetrics and Gynecology at the said Hospital.
Mrs. Villegas is a married woman who submitted to Dr. Batiquin for prenatal care as the latter's
private patient sometime before September 21, 1988.
In the morning of September 21, 1988 Dr. Batiquin, with the assistance of Dr. Doris Teresita Sy
who was also a Resident Physician at the same Hospital, C.I. and O.R. Nurse Arlene Diones and
some student nurses performed a simple caesarean section on Mrs. Villegas at the Negros
Oriental Provincial Hospital and after 45 minutes Mrs. Villegas delivered her first child, Rachel
Acogido, at about 11:45 that morning. Thereafter, Plaintiff remained confined at the Hospital until
September 27, 1988 during which period of confinement she was regularly visited by Dr. Batiquin.
On September 28, 1988 Mrs. Villegas checked out of the Hospital. . . and on that same day she
paid Dr. Batiquin, thru the latter's secretary, the amount of P1,500.00 as "professional fee". . . .
Soon after leaving the Hospital Mrs. Villegas began to suffer abdominal pains and complained of
being feverish. She also gradually lost her appetite, so she consulted Dr. Batiquin at the latter's
polyclinic who prescribed for her certain medicines. . . which she had been taking up to December,
1988.
In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin on October 31,
1988. . . certifying to her physical fitness to return to her work on November 7, 1988. So, on the
second week of November, 1988 Mrs. Villegas returned to her work at the Rural Bank of Ayungon,
Negros Oriental.
The abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end despite the
medications administered by Dr. Batiquin. When the pains became unbearable and she was
rapidly losing weight she consulted Dr. Ma. Salud Kho at the Holy Child's Hospital in Dumaguete
City on January 20, 1989.
The evidence of Plaintiffs show that when Dr. Ma. Salud Kho examined Mrs. Villegas at the Holy
Child's Hospital on January 20, 1989 she found Mrs. Villegas to be feverish, pale and was
breathing fast. Upon examination she felt an abdominal mass one finger below the umbilicus which
she suspected to be either a tumor of the uterus or an ovarian cyst, either of which could be
cancerous. She had an x-ray taken of Mrs. Villegas' chest, abdomen and kidney. She also took
blood tests of Plaintiff. A blood count showed that Mrs. Villegas had [an] infection inside her
abdominal cavity. The results of all those examinations impelled Dr. Kho to suggest that Mrs.
Villegas submit to another surgery to which the latter agreed.
When Dr. Kho opened the abdomen of Mrs. Villegas she found whitish-yellow discharge inside,
an ovarian cyst on each of the left and right ovaries which gave out pus, dirt and pus behind the
uterus, and a piece of rubber material on the right side of the uterus embedded on [sic] the ovarian
cyst, 2 inches by 3/4 inch in size. This piece of rubber material which Dr. Kho described as a
"foreign body" looked like a piece of a "rubber glove". . . and which is [sic] also "rubber-drain like".
. . . It could have been a torn section of a surgeon's gloves or could have come from other sources.
And this foreign body was the cause of the infection of the ovaries and consequently of all the
discomfort suffered by Mrs. Villegas after her delivery on September 21, 1988. 7
The piece of rubber allegedly found near private respondent Flotilde Villegas's uterus was not presented in court, and
although Dr. Ma. Salud Kho Testified that she sent it to a pathologist in Cebu City for examination,8 it was not mentioned
in the pathologist's Surgical Pathology Report.9
Aside from Dr. Kho's testimony, the evidence which mentioned the piece of rubber are a Medical Certificate, 10 a
Progress Record,11 an Anesthesia Record,12 a Nurse's Record,13 and a Physician's Discharge Summary.14 The trial
court, however, regarded these documentary evidence as mere hearsay, "there being no showing that the person or
persons who prepared them are deceased or unable to testify on the facts therein stated. . . . Except for the Medical
Certificate (Exhibit "F"), all the above documents were allegedly prepared by persons other than Dr. Kho, and she
merely affixed her signature on some of them to express her agreement thereto. . . ." 15 The trial court also refused to
give weight to Dr. Kho's testimony regarding the subject piece of rubber as Dr. Kho "may not have had first-hand
knowledge" thereof,16 as could be gleaned from her statement, thus:
A . . . I have heard somebody that [sic] says [sic] there is [sic] a foreign body
that goes with the tissues but unluckily I don't know where the rubber was. 17
The trial court deemed vital Dr. Victoria Batiquin's testimony that when she confronted Dr. Kho regarding the piece of
rubber, "Dr. Kho answered that there was rubber indeed but that she threw it away." 18 This statement, the trial court
noted, was never denied nor disputed by Dr. Kho, leading it to conclude:
 There are now two different versions on the whereabouts of that offending "rubber" — (1) that it
was sent to the Pathologist in Cebu as testified to in Court by Dr. Kho and (2) that Dr. Kho threw
it away as told by her to Defendant. The failure of the Plaintiffs to reconcile these two different
versions serve only to weaken their claim against Defendant Batiquin. 19
All told, the trial court held in favor of the petitioners herein.
The Court of Appeals reviewed the entirety of Dr. Kho's testimony and, even without admitting the private respondents'
documentary evidence, deemed Dr. Kho's positive testimony to definitely establish that a piece of rubber was found
near private respondent Villegas's uterus. Thus, the Court of Appeals reversed the decision of the trial court, holding:
4. The fault or negligence of appellee Dr. Batiquin is established by preponderance of evidence.
The trial court itself had narrated what happened to appellant Flotilde after the caesarean
operation made by appellee doctor. . . . After the second operation, appellant Flotilde became well
and healthy. Appellant Flotilde's troubles were caused by the infection due to the "rubber" that
was left inside her abdomen. Both appellant; testified that after the operation made by appellee
doctor, they did not go to any other doctor until they finally decided to see another doctor in
January, 1989 when she was not getting any better under the care of appellee Dr. Batiquin. . . .
Appellee Dr. Batiquin admitted on the witness stand that she alone decided when to close the
operating area; that she examined the portion she operated on before closing the same. . . Had
she exercised due diligence, appellee Dr. Batiquin would have found the rubber and removed it
before closing the operating area.20
The appellate court then ruled:
Appellants' evidence show[s] that they paid a total of P17,000.00 [deposit of P7,100.00 (Exh. G-
1-A) plus hospital and medical expenses together with doctor's fees in the total amount P9,900.00
(Exhs. G and G-2)] for the second operation that saved her life.
For the miseries appellants endured for more than three (3) months, due to the negligence of
appellee Dr. Batiquin they are entitled to moral damages in the amount of P100,000.00; exemplary
damages in the amount of P20,000.00 and attorney's fees in the amount of P25,000.00.
The fact that appellant Flotilde can no longer bear children because her uterus and ovaries were
removed by Dr. Kho is not taken into consideration as it is not shown that the removal of said
organs were the direct result of the rubber left by appellee Dr. Batiquin near the uterus. What is
established is that the rubber left by appellee caused infection, placed the life of appellant Flotilde
in jeopardy and caused appellant fear, worry and anxiety. . . .
WHEREFORE, the appealed judgment, dismissing the complaint for damages is REVERSED and
SET ASIDE. Another judgment is hereby entered ordering defendants-appellees to pay plaintiffs-
appellants the amounts of P17,000.00 as and for actual damages; P100,000.00 as and for moral
damages; P20,000.00 as and for exemplary damages; and P25,000.00 as and for attorney's fees
plus the costs of litigation.
SO ORDERED.21
From the above judgment, the petitioners appealed to this Court claiming that the appellate court: (1) committed grave
abuse of discretion by resorting to findings of fact not supported by the evidence on record, and (2) exceeded its
discretion, amounting to lack or excess of jurisdiction, when it gave credence to testimonies punctured with
contradictions and falsities.
The private respondents commented that the petition raised only questions of fact, which were not proper for review
by this Court.
While the rule is that only questions of law may be raised in a petition for review on certiorari, there are exceptions,
among which are when the factual findings of the trial court and the appellate court conflict, when the appealed decision
is clearly contradicted by the evidence on record, or when the appellate court misapprehended the facts. 22
After deciphering the cryptic petition, we find that the focal point of the instant appeal is the appreciation of Dr. Kho's
testimony. The petitioners contend that the Court of Appeals misappreciated the following portion of Dr. Kho's
testimony:
Q What is the purpose of the examination?
A Just in case, I was just thinking at the back of my mind, just in case this
would turn out to be a medico-legal
case, I have heard somebody that [sic] says [sic] there is [sic] a
foreign body that goes with the tissues but unluckily I don't know where the r
ubber was. It was not in the Lab, it was not in Cebu. 23 (emphasis supplied)
The petitioners prefer the trial court's interpretation of the above testimony, i.e., that Dr. Kho's knowledge of
the piece of rubber was based on hearsay. The Court of Appeals, on the other hand, concluded that the
underscored phrase was taken out of context by the trial court. According to the Court of Appeals, the trial
court should have likewise considered the other portions of Dr. Kho's testimony, especially the following:
Q So you did actually conduct the operation on her?
A Yes, I did.
Q And what was the result?
A Opening up her abdomen, there was whitish-yellow discharge inside the
abdomen, there was an ovarian cyst on the left and side and there was also
an ovarian cyst on the right which, on opening up or freeing it up from the
uterus, turned out to be pus. Both ovaries turned out. . . to have pus. And
then, cleaning up the uterus, at the back of the uterus it was very dirty, it was
full of pus. And there was a [piece of] rubber, we found a [piece of] rubber on
the right
side. 24
We agree with the Court of Appeals. The phrase relied upon by the trial court does not negate the fact that Dr. Kho
saw a piece of rubber in private respondent Villegas's abdomen, and that she sent it to a laboratory and then to Cebu
City for examination by a pathologist.25 Not even the Pathologist's Report, although devoid of any mention of a piece
of rubber, could alter what Dr. Kho saw. Furthermore, Dr. Kho's knowledge of the piece of rubber could not be based
on other than first-hand knowledge for, as she asserted before the trial court:
Q But you are sure you have seen [the piece of rubber]?
26
A Oh yes. I was not the only one who saw it.
The petitioners emphasize that the private respondents never reconciled Dr. Kho's testimony with Dr. Batiquin's claim
on the witness stand that when Dr. Batiquin confronted Dr. Kho about the foreign body, the latter said that there was
a piece of rubber but that she threw it away. Although hearsay, Dr. Batiquin's claim was not objected to, and hence,
the same is admissible27 but it carries no probative value.28 Nevertheless, assuming otherwise, Dr. Batiquin's
statement cannot belie the fact that Dr. Kho found a piece of rubber near private respondent Villegas's uterus. And
even if we were to doubt Dr. Kho as to what she did to the piece of rubber, i.e., whether she threw it away or sent it to
Cebu City, we are not justified in distrusting her as to her recovery of a piece of rubber from private respondent
Villegas's abdomen. On this score, it is perfectly reasonable to believe the testimony of a witness with respect to some
facts and disbelieve his testimony with respect to other facts. And it has been aptly said that even when a witness is
found to have deliberately falsified in some material particulars, it is not required that the whole of his uncorroborated
testimony be rejected, but such portions thereof deemed worthy of belief may be credited. 29
It is here worth noting that the trial court paid heed to the following portions of Dr. Batiquin's testimony: that no rubber
drain was used in the operation,30 and that there was neither any tear on Dr. Batiquin's gloves after the operation nor
blood smears on her hands upon removing her gloves. 31 Moreover, the trial court pointed out that the absence of a
rubber drain was corroborated by Dr. Doris Sy, Dr. Batiquin's assistant during the operation on private respondent
Villegas.32 But the trial court failed to recognize that the assertions of Drs. Batiquin and Sy were denials or negative
testimonies. Well-settled is the rule that positive testimony is stronger than negative testimony.33 Of course, as the
petitioners advocate, such positive testimony must come from a credible source, which leads us to the second assigned
error.
While the petitioners claim that contradictions and falsities punctured Dr. Kho's testimony, a regarding of the said
testimony reveals no such infirmity and establishes Dr. Kho as a credible witness. Dr. Kho was frank throughout her
turn on the witness stand. Furthermore, no motive to state any untruth was ever imputed against Dr. Kho, leaving her
trustworthiness unimpaired.34 The trial court's following declaration shows that while it was critical of the lack of care
with which Dr. Kho handled the piece of rubber, it was not prepared to doubt Dr. Kho's credibility, thus only supporting
our appraisal of Dr. Kho's trustworthiness:
This is not to say that she was less than honest when she testified about her findings, but it can
also be said that she did not take the most appropriate precaution to preserve that "piece of rubber"
as an eloquent evidence of what she would reveal should there be a "legal problem" which she
claim[s] to have anticipated.35
. . . the happening of an injury permits an inference of negligence where
plaintiff produces substantial evidence that [the] injury was caused by an
agency or instrumentality under [the] exclusive control and management of
defendant, and that the occurrence [sic] was such that in the ordinary course
of things would not happen if reasonable care had been used.
xxx xxx xxx
The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law
of negligence which recognizes that prima facie negligence may be
established without direct proof and furnishes a substitute for specific proof
of negligence. The doctrine is not a rule of substantive law, but merely a mode
of proof or a mere procedural convenience. The rule, when applicable to the
facts and circumstances of a particular case, is not intended to and does not
dispense with the requirement of proof of culpable negligence on the party
charged. It merely determines and regulates what shall be prima
facie evidence thereof and facilitates the burden of plaintiff of proving a
breach of the duty of due care. The doctrine can be invoked when and only
when, under the circumstances involved, direct evidence is absent and not
readily available.36
In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the
caesarean section were under the exclusive control of Dr. Batiquin. In this light, the private respondents were bereft of
direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent
Villegas's body, which, needless to say, does not occur unless through the intersection of negligence. Second, since
aside from the caesarean section, private respondent Villegas underwent no other operation which could have caused
the offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product
of the caesarean section performed by Dr. Batiquin. The petitioners, in this regard, failed to overcome the presumption
of negligence arising from resort to the doctrine of res ipsa loquitur. Dr. Batiquin is therefore liable for negligently
leaving behind a piece of rubber in private respondent Villegas's abdomen and for all the adverse effects thereof.

Considering that we have assessed Dr. Kho to be a credible witness, her positive testimony [that a piece of rubber
was indeed found in private respondent Villega's abdomen] prevails over the negative testimony in favor of the
petitioners.
As such, the rule of res ipsa loquitur comes to fore. This Court has had occasion to delve into the nature and operation
of this doctrine:
As a final word, this Court reiterates its recognition of the vital role the medical profession plays in the lives of the
people,3 7 and the State's compelling interest to enact measures to protect the public from "the potentially deadly
effects of incompetence and ignorance in those who would undertake to treat our bodies and minds for disease or
trauma."38 Indeed, a physician is bound to serve the interest of his patients "with the greatest of solicitude, giving them
always his best talent and skill."39 Through her tortious conduct, the petitioner endangered the life of Flotilde Villegas,
in violation of her profession's rigid ethical code and in contravention of the legal standards set forth for professionals,
in general,40 and members of the medical profession,41 in particular.

This doctrine [res ipsa loquitur] is stated thus: "Where the thing which causes injury is shown to
WHEREFORE, the challenged decision of 11 May 1994 of the Court of Appeals in CA-G.R. CV No. 30851 is hereby
be under the management of the defendant, and the accident is such as in the ordinary course of
AFFIRMED in toto.
things does not happen in those who have the management use proper care, it affords reasonable
evidence, in the absence of an explanation by the defendant, that the accident arose from want
of care." Or as Black's Law Dictionary puts it: Costs against the petitioners.

Res ipsa loquitur. The thing speaks for itself. Rebuctable presumption or SO ORDERED.
inference that defendant was negligent, which arises upon proof that [the]
instrumentality causing injury was in defendant's exclusive control, and that
the accident was one which ordinary does not happen in absence of
negligence. Res ipsa loquitur is [a] rule of evidence whereby negligence of
[the] alleged wrongdoer may be inferred from [the] mere fact that [the]
accident happened provided [the] character of [the] accident and
circumstances attending it lead reasonably to belief that in [the] absence of
negligence it would not have occurred and that thing which caused injury is
shown to have been under [the] management and control of [the] alleged
wrongdoer. . . . Under [this] doctrine
 Republic of the Philippines Unfortunately, Nora’s arm would never be the same.1a\^/phi1.net Aside from the unsightly mark, the pain in her left
SUPREME COURT arm remains. When sleeping, she has to cradle her wounded arm. Her movements now are also restricted. Her children
Manila cannot play with the left side of her body as they might accidentally bump the injured arm, which aches at the slightest
touch.
SECOND DIVISION
Thus, on June 21, 1993, respondent spouses filed a complaint 13 for damages against petitioner, Dr. Abad, and the
hospital. Finding in favor of respondent spouses, the trial court decreed:
G.R. No. 160889 April 27, 2007

In view of the foregoing consideration, judgment is hereby rendered in favor of the plaintiffs and against the defendants,
DR. MILAGROS L. CANTRE, Petitioner,
directing the latters, (sic) jointly and severally –
vs.
SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.
(a) to pay the sum of Five Hundred Thousand Pesos (P500,000.00) in moral damages;
DECISION
(b) to pay the sum of One Hundred Fifty Thousand Pesos (P150,000.00) exemplary damages;
QUISUMBING, J.:
(c) to pay the sum of Eighty Thousand Pesos (P80,000.00) nominal damages;
For review on certiorari are the Decision1 dated October 3, 2002 and Resolution2 dated November 19, 2003 of the
Court of Appeals in CA-G.R. CV No. 58184, which affirmed with modification the Decision3 dated March 3, 1997 of the (d) to pay Fifty Thousand Pesos (P50,000.00) for and as attorney’s fees; and
Regional Trial Court of Quezon City, Branch 98, in Civil Case No. Q-93-16562.
(e) to pay Six Thousand Pesos (P6,000.00) litigation expenses.
The facts, culled from the records, are as follows:
SO ORDERED.14
Petitioner Dr. Milagros L. Cantre is a specialist in Obstetrics and Gynecology at the Dr. Jesus Delgado Memorial
Hospital. She was the attending physician of respondent Nora S. Go, who was admitted at the said hospital on April
Petitioner, Dr. Abad, and the hospital all appealed to the Court of Appeals, which affirmed with modification the trial
19, 1992.
court decision, thus:

At 1:30 a.m. of April 20, 1992, Nora gave birth to her fourth child, a baby boy. However, at around 3:30 a.m., Nora
WHEREFORE, in view of all the foregoing, and finding no reversible error in the appealed Decision dated March 3,
suffered profuse bleeding inside her womb due to some parts of the placenta which were not completely expelled from
1997 of Branch 98 of the Regional Trial Court of Quezon City in Civil Case No. Q-93-16562, the same is hereby
her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to
AFFIRMED, with the following MODIFICATIONS:
"40" over "0." Petitioner and the assisting resident physician performed various medical procedures to stop the bleeding
and to restore Nora’s blood pressure. Her blood pressure was frequently monitored with the use of a
sphygmomanometer. While petitioner was massaging Nora’s uterus for it to contract and stop bleeding, she ordered a 1. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay plaintiffs-appellees John David Go and
droplight to warm Nora and her baby.4 Nora remained unconscious until she recovered. Nora S. Go the sum of P200,000.00 as moral damages;

While in the recovery room, her husband, respondent John David Z. Go noticed a fresh gaping wound two and a half
(2 ½) by three and a half (3 ½) inches in the inner portion of her left arm, close to the armpit. 5 He asked the nurses
what caused the injury. He was informed it was a burn. Forthwith, on April 22, 1992, John David filed a request for
investigation.6 In response, Dr. Rainerio S. Abad, the medical director of the hospital, called petitioner and the assisting
resident physician to explain what happened. Petitioner said the blood pressure cuff caused the injury.
2. Deleting the award [of] exemplary damages, attorney’s fees and expenses of litigation;1awphi1.nét
3. Dismissing the complaint with respect to defendants-appellants Dr. Rainerio S. Abad and Delgado Clinic,
Inc.;

On May 7, 1992, John David brought Nora to the National Bureau of Investigation for a physical examination, which 4. Dismissing the counterclaims of defendants-appellants for lack of merit; and
was conducted by medico-legal officer Dr. Floresto Arizala, Jr.7 The medico-legal officer later testified that Nora’s injury
appeared to be a burn and that a droplight when placed near the skin for about 10 minutes could cause such burn.8 He 5. Ordering defendant-appellant Dra. Milagros [L.] Cantre only to pay the costs.
dismissed the likelihood that the wound was caused by a blood pressure cuff as the scar was not around the arm, but
just on one side of the arm.9
SO ORDERED.15

On May 22, 1992, Nora’s injury was referred to a plastic surgeon at the Dr. Jesus Delgado Memorial Hospital for skin
grafting.10 Her wound was covered with skin sourced from her abdomen, which consequently bore a scar as well. Petitioner’s motion for reconsideration was denied by the Court of Appeals. Hence, the instant petition assigning the
About a year after, on April 30, 1993, scar revision had to be performed at the same hospital. 11 The surgical operation following as errors and issues:
left a healed linear scar in Nora’s left arm about three inches in length, the thickest portion rising about one-fourth (1/4)
of an inch from the surface of the skin. The costs of the skin grafting and the scar revision were shouldered by the I.
hospital.12
WHETHER OR NOT, THE LOWER COURT, AND THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF
THEIR DISCRETION WHEN, NOTWITHSTANDING THAT BOTH PARTIES HAVE RESTED THEIR RESPECTIVE
CASES, THE LOWER COURT ADMITTED THE ADDITIONAL EXHIBITS FURTHER OFFERED BY
RESPONDENTS NOT TESTIFIED TO BY ANY WITNESS AND THIS DECISION OF THE LOWER COURT WAS
UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING GRAVE ABUSE OF DISCRETION;
II.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT RULED THAT THE PETITIONER
HAS NOT AMPLY SHOWED THAT THE DROPLIGHT DID NOT TOUCH THE BODY OF MRS. NORA GO, AND THIS
DECISION OF THE LOWER COURT WAS UPHELD BY THE COURT OF APPEALS LIKEWISE COMMITTING
GRAVE ABUSE OF DISCRETION;
III.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN, CONTRARY
TO PREPONDERANCE OF EVIDENCE PRESENTED BY THE PETITIONER, IT RULED THAT PETITIONER DRA.
CANTRE WAS NOT ABLE TO AMPLY EXPLAIN HOW THE INJURY (BLISTERS) IN THE LEFT INNER ARM OF
RESPONDENT MRS. GO CAME ABOUT;
IV.
WHETHER OR NOT THE COURT OF APPEALS COMMITTED GRAVE ABUSE OF ITS DISCRETION WHEN IT
MADE A RULING ON THE RESPONDENT’S INJURY QUOTING THE TESTIMONY OF SOMEONE WHO WAS NOT
PRESENT AND HAS NOT SEEN THE ORIGINAL, FRESH INJURY OF RESPONDENT MRS. NORA GO;
V.
WHETHER OR NOT THE COURT OF APPEALS GRAVELY ABUSING ITS DISCRETION RULED THAT
PETITIONER DRA. CANTRE SHOULD HAVE INTENDED TO INFLICT THE INJURY TO SAVE THE LIFE OF
RESPONDENT MRS. GO;
VI.
WHETHER OR NOT THE LOWER COURT AND THE COURT [OF] APPEALS COMMITTED GRAVE ABUSE OF
DISCRETION WHEN, CONTRARY TO THE DETAILED PROCEDURES DONE BY PETITIONER, BOTH RULED
THAT THE RESPONDENT WAS LEFT TO THE CARE OF THE NURSING STAFF;
VII.
WHETHER OR NOT THE LOWER COURT COMMITTED GRAVE ABUSE OF DISCRETION WHEN, CONTRARY TO
THE MEDICAL PURPOSES OF COSMETIC SURGERY, IT RULED THAT THE COSMETIC SURGERY MADE THE
SCARS EVEN MORE UGLY AND DECLARED THE COSMETIC SURGERY A FAILURE;
VIII.
WHETHER OR NOT THE LOWER COURT GRAVELY ABUSE OF (SIC) DISCRETION WHEN, CONTRARY TO
RESPONDENTS’ CONTRARY TESTIMONIES AND THE ABSENCE OF ANY TESTIMONY, IT RULED THAT THEY
ARE ENTITLED TO DAMAGES AND WHICH WAS UPHELD, ALTHOUGH MODIFIED, BY THE COURT OF
APPEALS LIKEWISE ABUSING ITS DISCRETION.16
Petitioner contends that additional documentary exhibits not testified to by any witness are inadmissible in evidence
because they deprived her of her constitutional right to confront the witnesses against her. Petitioner insists the
droplight could not have touched Nora’s body. She maintains the injury was due to the constant taking of Nora’s blood
pressure. Petitioner also insinuates the Court of Appeals was misled by the testimony of the medico-legal officer who
never saw the original injury before plastic surgery was performed. Finally, petitioner stresses that plastic surgery was
not intended to restore respondent’s injury to its original state but rather to prevent further complication.
Respondents, however, counter that the genuineness and due execution of the additional documentary exhibits were
duly admitted by petitioner’s counsel. Respondents point out that petitioner’s blood pressure cuff theory is highly
improbable, being unprecedented in medical history and that the injury was definitely caused by the droplight. At any
rate, they argue, even if the injury was brought about by the blood pressure cuff, petitioner was still negligent in her
duties as Nora’s attending physician.
Simply put, the threshold issues for resolution are: (1) Are the questioned additional exhibits admissible in evidence?
(2) Is petitioner liable for the injury suffered by respondent Nora Go? Thereafter, the inquiry is whether the appellate
court committed grave abuse of discretion in its assailed issuances.
As to the first issue, we agree with the Court of Appeals that said exhibits are admissible in evidence. We note that the
questioned exhibits consist mostly of Nora’s medical records, which were produced by the hospital during trial pursuant
to a subpoena duces tecum. Petitioner’s counsel admitted the existence of the same when they were formally offered
for admission by the trial court. In any case, given the particular circumstances of this case, a ruling on the negligence
of petitioner may be made based on the res ipsa loquitur doctrine even in the absence of such additional exhibits.
Petitioner’s contention that the medico-legal officer who conducted Nora’s physical examination never saw her original
injury before plastic surgery was performed is without basis and contradicted by the records. Records show that the
medico-legal officer conducted the physical examination on May 7, 1992, while the skin grafting and the scar revision
were performed on Nora on May 22, 1992 and April 30, 1993, respectively.
Coming now to the substantive matter, is petitioner liable for the injury suffered by respondent Nora Go?
The Hippocratic Oath mandates physicians to give primordial consideration to the well-being of their patients. If a
doctor fails to live up to this precept, he is accountable for his acts. This notwithstanding, courts face a unique restraint
in adjudicating medical negligence cases because physicians are not guarantors of care and, they never set out to
intentionally cause injury to their patients. However, intent is immaterial in negligence cases because where negligence
exists and is proven, it automatically gives the injured a right to reparation for the damage caused. 17
In cases involving medical negligence, the doctrine of res ipsa loquitur allows the mere existence of an injury to justify
a presumption of negligence on the part of the person who controls the instrument causing the injury, provided that the
following requisites concur:
1. The accident is of a kind which ordinarily does not occur in the absence of someone’s negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. 18
As to the first requirement, the gaping wound on Nora’s arm is certainly not an ordinary occurrence in the act of
delivering a baby, far removed as the arm is from the organs involved in the process of giving birth. Such injury could
not have happened unless negligence had set in somewhere.
Second, whether the injury was caused by the droplight or by the blood pressure cuff is of no moment. Both instruments
are deemed within the exclusive control of the physician in charge under the "captain of the ship" doctrine. This doctrine
holds the surgeon in charge of an operation liable for the negligence of his assistants during the time when those
assistants are under the surgeon’s control.19 In this particular case, it can be logically inferred that petitioner, the senior
consultant in charge during the delivery of Nora’s baby, exercised control over the assistants assigned to both the use
of the droplight and the taking of Nora’s blood pressure. Hence, the use of the droplight and the blood pressure cuff is
also within petitioner’s exclusive control.

Third, the gaping wound on Nora’s left arm, by its very nature and considering her condition, could only be caused by
something external to her and outside her control as she was unconscious while in hypovolemic shock. Hence, Nora
could not, by any stretch of the imagination, have contributed to her own injury.

Petitioner’s defense that Nora’s wound was caused not by the droplight but by the constant taking of her blood
pressure, even if the latter was necessary given her condition, does not absolve her from liability. As testified to by the
medico-legal officer, Dr. Arizala, Jr., the medical practice is to deflate the blood pressure cuff immediately after each
use. Otherwise, the inflated band can cause injury to the patient similar to what could have happened in this case.
Thus, if Nora’s wound was caused by the blood pressure cuff, then the taking of Nora’s blood pressure must have
been done so negligently as to have inflicted a gaping wound on her arm,20 for which petitioner cannot escape liability
under the "captain of the ship" doctrine.

Further, petitioner’s argument that the failed plastic surgery was not intended as a cosmetic procedure, but rather as
a measure to prevent complication does not help her case. It does not negate negligence on her part.

Based on the foregoing, the presumption that petitioner was negligent in the exercise of her profession stands
unrebutted. In this connection, the Civil Code provides:

ART. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is obliged to pay
for the damage done.…

ART. 2217. Moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched reputation,
wounded feelings, moral shock, social humiliation, and similar injury. Though incapable of pecuniary computation,
moral damages may be recovered if they are the proximate result of the defendant’s wrongful act or omission.

Clearly, under the law, petitioner is obliged to pay Nora for moral damages suffered by the latter as a proximate result
of petitioner’s negligence.

We note, however, that petitioner has served well as Nora’s obstetrician for her past three successful deliveries. This
is the first time petitioner is being held liable for damages due to negligence in the practice of her profession. The fact
that petitioner promptly took care of Nora’s wound before infection and other complications set in is also indicative of
petitioner’s good intentions. We also take note of the fact that Nora was suffering from a critical condition when the
injury happened, such that saving her life became petitioner’s elemental concern. Nonetheless, it should be stressed
that all these could not justify negligence on the part of petitioner.

Hence, considering the specific circumstances in the instant case, we find no grave abuse of discretion in the assailed
decision and resolution of the Court of Appeals. Further, we rule that the Court of Appeals’ award of Two Hundred
Thousand Pesos (₱200,000) as moral damages in favor of respondents and against petitioner is just and equitable. 21

WHEREFORE, the petition is DENIED. The Decision dated October 3, 2002 and Resolution dated November 19, 2003
of the Court of Appeals in CA-G.R. CV No. 58184 are AFFIRMED.

No pronouncement as to costs.

SO ORDERED.