Legal Medicine First 26 Cases

1. Carillo vs. People of the PhilippinesG.R. No. 86890, January 21, 1994

Facts:Petitioner filed a petition for review on certiorari on the decision of the Court of Appeals affirming his conviction by the RTC of the crime of simple negligence resulting in homicide, for the death of his 13 year old patient Catherine Acosta after an appendectomy procedure conducted on the patient.Catherine Acosta, a 13 year old girl, daughter of spouses Domingo and Yolanda Acosta, complained to her father at about 10:30 o'clock in the morning of May 31, 1981 of pains 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. The appellant Dr. Emilio Madrid, a surgeon, operated on Catherine. He was assisted by appellant, Dr. Leandro Carillo, anesthesiologists. After operation, Catherine remained unconscious until noontime the next day, a neurologist examined her and she was diagnosed as comatose. Three (3) days later, Catherine died without regaining consciousness.

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. 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. The Court of Appeals identified such cardiac arrest as the immediate cause of Catherine's death.

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; that it was "a bit rash" on the part of the accused Dr. Carillo "to have administered Nubain without first weighing Catherine"; 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.

Issue:Whether or not Dr. Carillo is guilty of the crime of simple negligence resulting in homicide.

Held:Simple negligence, penalized under what is now Article 365 of the Revised Penal Code, is defined as "a mere lack of prevision in a situation where either the threatened harm is not immediate or the danger not openly visible." Put in a slightly different way, the gravamen of the offense of simple negligence is the failure to exercise the diligence necessitated or called for the situation which was not immediately life-destructive but which culminated in the present case, in the death of a human being three (3) days later.

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.

2. DR. VICTORIA L. BATIQUIN and ALLAN BATIQUIN, petitioners, vs. COURT OF APPEALS, SPOUSES QUEDO D. ACOGIDO and FLOTILDE G. VILLEGAS, respondents.G.R. No. 118231. July 5, 1996

Facts:The petitioner Dr. Batiquin was a Resident Physician at the Negros Oriental Provincial Hospital, Dumaguete City from January 9, 1978 to September 1989. And 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. The latter was submitted to a simple cesarean operation by herein petitioner to deliver her first child. 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.

In the meantime, Mrs. Villegas was given a Medical Certificate by Dr. Batiquin certifying to her physical fitness to return to her work and indeed soon after she returned back to her work. But still the abdominal pains and fever kept on recurring and bothered Mrs. Villegas no end and despite the medications administered by Dr. Batiquin. When the pains become 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. Dr. Kho 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 materials on the right side of the uterus embedded on 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 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. And this prompted Mrs. Villegas to file this present case against Dr. Batiquin. The CA ruled against the petitioner, hence, this petition.

Issue:Whether or not petitioner, Dr. Batiquin should be held liable for her negligence in leaving behind the piece of rubber from Mrs. Villegas’ abdomen.

Held:Yes.Dr. Batiquin is liable for negligently leaving behind a piece of rubber in private respondent Villegas' abdomen and for all the adverse effects thereof.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:

This doctrine [res ipsa loquitur] is stated thus: "Where the thing which causes injury is shown to be under the management of the defendant, and the accident is such as in the ordinary course of things does not happen if 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:

Res ipsa loquitur. The thing speaks for itself. Rebuttable presumption or 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 . . . 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.

In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the cesarean 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' body, which, needless to say, does not occur unless through the intervention of negligence. Second, since aside from the cesarean 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 cesarean 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.

As a final word, this Court reiterates its recognition of the vital role the medical profession plays in the lives of the people, and 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." 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." 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 the general, and members of the medical profession, in particular.

3. LEONILA GARCIA-RUEDA, petitioner, vs. WILFREDO L. PASCASIO, RAUL R. ARNAU, ABELARDO L. APORTADERA JR., Honorable CONDRADO M. VASQUEZ, all of the Office of the Ombudsman; JESUS F. GUERRERO, PORFIRIO MACARAEG, and GREGORIO A. ARIZALA, all of the Office of the City Prosecutor, Manila, respondents.G.R. No. 118141. September 5, 1997

Facts:Florencio V. Rueda, husband of petitioner Leonila Garcia-Rueda, underwent surgical operation at the UST hospital for the removal of a stone blocking his ureter. He was attended by Dr. Domingo Antonio, Jr. who was the surgeon, while Dr. Erlinda Balatbat-Reyes was the anaesthesiologist. Six hours after the surgery, however, Florencio died of complications of “unknown cause,” according to officials of the UST Hospital.Not satisfied with the findings of the hospital, petitioner requested the National Bureau of Investigation (NBI) to conduct an autopsy on her husband’s body. Consequently, the NBI ruled that Florencio’s death was due to lack of care by the attending physician in administering anaesthesia. Pursuant to its findings, the NBI recommended that Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor.

Issue:(1) Whether or not Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes should be charged for Homicide through Reckless Imprudence before the Office of the City Prosecutor.

(2) Whether or not a medical malpractice committed by Dr. Domingo Antonio and Dr. Erlinda Balatbat-Reyes indeed transpired.

Held:(1) No. In this instant case, no less than the NBI pronounced after conducting an autopsy that there was indeed negligence on the part of the attending physicians in administering the anaesthesia. The fact of want of competence or diligence is evidentiary in nature, the veracity of which can best be passed upon after a full-blown trial for it is virtually impossible to ascertain the merits of a medical negligence case without extensive investigation, research, evaluation and consultations with medical experts. Clearly,the City Prosecutors are not in a competent position to pass judgment on such a technical matter, especially when there are conflicting evidence and findings. The bases of a party’s accusation and defenses are better ventilated at the trial proper than at the preliminary investigation.

(2) Yes. “In its simplest terms, the type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health care provider would have done, or that he or she did something that a reasonably prudent provider would not have done; and that that failure or action caused injury to the patient.”

Hence, there are four elements involved in medical negligence cases: duty, breach, injury and proximate causation.

Evidently, when the victim employed the services of Dr. Antonio and Dr. Reyes, a physician-patient relationship was created. In accepting the case, Dr. Antonio and Dr. Reyes in effect represented that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, they will employ such training, care and skill in the treatment of their patients. They have a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a condition under the same circumstances. The breach of these professional duties of skill and care, or their improper performance, by a physician surgeon whereby the patient is injured in body or in health, constitutes actionable malpractice. Consequently, in the event that any injury results to the patient from want of due care or skill during the operation, the surgeons may be held answerable in damages for negligence.

Moreover, in malpractice or negligence cases involving the administration of anaesthesia, the necessity of expert testimony and the availability of the charge of res ipsa loquitur to the plaintiff, have been applied in actions against anaesthesiologists to hold the defendant liable for the death or injury of a patient under excessive or improper anaesthesia. Essentially, it requires two-pronged evidence: evidence as to the recognized standards of the medical community in the particular kind of case, and a showing that the physician in question negligently departed from this standard in his treatment.

Another element in medical negligence cases is causation which is divided into two inquiries: whether the doctor’s actions in fact caused the harm to the patient and whether these were the proximate cause of the patient’s injury. Indeed here, a causal connection is discernible from the occurrence of the victim’s death after the negligent act of the anaesthesiologist in administering the anesthesia, a fact which, if confirmed, should warrant the filing of the appropriate criminal case. To be sure, the allegation of negligence is not entirely baseless. Moreover, the NBI deduced that the attending surgeons did not conduct the necessary interview of the patient prior to the operation. It appears that the cause of the death of the victim could have been averted had the proper drug been applied to cope with the symptoms of malignant hyperthermia. Also, we cannot ignore the fact that an antidote was readily available to counteract whatever deleterious effect the anaesthesia might produce. Why these precautionary measures were disregarded must be sufficiently explained. Absent otherwise, the attending medical expert should have been held liable therein.

4. DR. NINEVETCH CRUZ, petitioner, vs. COURT OF APPEALS and LYDIA UMALI, respondents.G.R. No. 122445. November 18, 1997

Facts:On March 22, 1991, prosecution witness, Rowena Umali De Ocampo, accompanied her mother to the Perpetual Help Clinic and General Hospital situated in Balagtas Street, San Pablo City, Laguna. They arrived at the said hospital at around 4:30 in the afternoon of the same day. Prior to March 22, 1991, Lydia was examined by the petitioner who found a "myoma" in her uterus, and scheduled her for a hysterectomy operation on March 23, 1991.

According to Rowena, she noticed that the clinic was untidy and the window and the floor were very dusty prompting her to ask the attendant for a rag to wipe the window and the floor with. Because of the untidy state of the clinic, Rowena tried to persuade her mother not to proceed with the operation. The following day, before her mother was wheeled into the operating room, Rowena asked the petitioner if the operation could be postponed. The petitioner called Lydia into her office and the two had a conversation. Lydia then informed Rowena that the petitioner told her that she must be operated on as scheduled. The operation nevertheless happened with these circumstances attending:a. The relatives of Umali were asked to buy tagamet ampules by Dr. Ercillo.b. They were asked to buy blood for Umali, Type “A”.c. When asked again to buy blood, nowhere blodd available at the Blood Bank of the Hospital.d. The condition of Umali became worse that she has to be transferred to another Hospital, San Pablo District hospital.

Upon Lydia's arrival at the San Pablo District Hospital, she was wheeled into the operating room and the petitioner and Dr. Ercillo re-operated on her because there was blood oozing from the abdominal incision. While petitioner was closing the abdominal wall, the patient died. Thus, on March 24, 1991, Lydia Umali was pronounced dead. Her death certificate states "shock" as the immediate cause of death and "Disseminated Intravascular Coagulation (DIC)" as the antecedent cause.

In convicting the petitioner, the MTCC found her to be negligent in the performance of the operation.The RTC reiterated the abovementioned findings of the MTCC and upheld the latter's declaration of "incompetency, negligence and lack of foresight and skill of appellant (herein petitioner) in handling the subject patient before and after the operation." And likewise affirming the petitioner's conviction, the Court of Appeals echoed similar observations, thus:

"x x x. While we may grant that the untidiness and filthiness of the clinic may not by itself indicate negligence, it nevertheless shows the absence of due care and supervision over her subordinate employees. Did this unsanitary condition permeate the operating room? Were the surgical instruments properly sterilized? Could the conditions in the OR have contributed to the infection of the patient? Only the petitioner could answer these, but she opted not to testify. This could only give rise to the presumption that she has nothing good to testify on her defense. Anyway, the alleged "unverified statement of the prosecution witness" remains unchallenged and unrebutted.

Issue:Whether or not a physician has committed an "inexcusable lack of precaution" in the treatment of his patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science.

Held:The attending physician may have committed the lack of precaution if duly proven with concrete evidence supporting such claim. But absence of the same will lead such allegations as mere hearsay.In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pacasio, et. al., this Court stated that in accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, care and skill in the treatment of

his patients. He therefore has a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a condition under the same circumstances. It is in this aspect of medical malpractice that expert testimony is essential to establish not only the standard of care of the profession but also that the physician's conduct in the treatment and care falls below such standard. Further, inasmuch as the causes of the injuries involved in malpractice actions are determinable only in the light of scientific knowledge, it has been recognized that expert testimony is usually necessary to support the conclusion as to causation.

Immediately apparent from a review of the records of this case is the absence of any expert testimony on the matter of the standard of care employed by other physicians of good standing in the conduct of similar operations. The prosecution's expert witnesses in the persons of Dr. Floresto Arizala and Dr. Nieto Salvador, Jr. of the National Bureau of Investigation (NBI) only testified as to the possible cause of death but did not venture to illuminate the court on the matter of the standard of care that petitioner should have exercised.

All three courts below bewail the inadequacy of the facilities of the clinic and its untidiness; the lack of provisions such as blood, oxygen, and certain medicines; the failure to subject the patient to a cardio-pulmonary test prior to the operation; the omission of any form of blood typing before transfusion; and even the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner. But while it may be true that the circumstances pointed out by the courts below seemed beyond cavil to constitute reckless imprudence on the part of the surgeon, this conclusion is still best arrived at not through the educated surmises nor conjectures of laymen, including judges, but by the unquestionable knowledge of expert witnesses. For whether a physician or surgeon has exercised the requisite degree of skill and care in the treatment of his patient is, in the generality of cases, a matter of expert opinion. The deference of courts to the expert opinion of qualified physicians stems from its realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating. Expert testimony should have been offered to prove that the circumstances cited by the courts below are constitutive of conduct falling below the standard of care employed by other physicians in good standing when performing the same operation. 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 sufficientlyestablished. This presumption is rebuttable by expert opinion which is so sadly lacking in the case at bench.

Even granting arguendo that the inadequacy of the facilities and untidiness of the clinic; the lack of provisions; the failure to conduct pre-operation tests on the patient; and the subsequent transfer of Lydia to the San Pablo Hospital and the reoperation performed on her by the petitioner do indicate, even without expert testimony, that petitioner was recklessly imprudent in the exercise of her duties as a surgeon, no cogent proof exists that any of these circumstances caused petitioner's death. Thus, the absence of the fourth element of reckless imprudence: that the injury to the person or property was a consequence of the reckless imprudence.

In litigations involving medical negligence, the plaintiff has the burden of establishing appellant's negligence and for a reasonable conclusion of negligence, there must be proof of breach of duty on the part of the surgeon as well as a casual connection of such breach and the resulting death of his patient. In Chan Lugay v. St Luke's Hospital, Inc., where the attending physician was absolved of liability for the death of the complainant's wife and newborn baby, this court held that:

"In order that there may be a recovery for an injury, however, 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.' In other words, the negligence must be the proximate cause of the injury. For, 'negligence, no matter in what it consists, cannot create a right of action unless it is the proximate cause of the injury complained of.' And 'the proximate cause of an injury is that cause, which, in natural and

continuous sequence, unbroken by any efficient intervening cause, produces the injury, and without which the result would not have occurred.''' (Underscoring supplied.)

The petitioner is a doctor in whose hands a patient puts his life and limb. For insufficiency of evidence this Court was not able to render a sentence of conviction but it is not blind to the reckless and imprudent manner in which the petitioner carried out her duties. A precious life has been lost and the circumstances leading thereto exacerbated the grief of those left behind. The heirs of the deceased continue to feel the loss of their mother up to the present time and this Court is aware that no amount of compassion and commiseration nor words of bereavement can suffice to assuage the sorrow felt for the loss of a loved one. Certainly, the award of moral and exemplary damages in favor of the heirs of Lydia Umali are proper in the instant case.

Hence, petitioner DR. NINEVETCH CRUZ is hereby ACQUITTED of the crime of reckless imprudence resulting in homicide but is ordered to pay the heirs of the deceased Lydia Umali the amount of FIFTY THOUSAND PESOS (P50,000.00) as civil liability, ONE HUNDRED THOUSAND PESOS (P100,000.00) as moral damages, and FIFTY THOUSAND PESOS (P50,000.00) as exemplary damages.

5. ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of the minors, ROMMEL RAMOS, ROY RODERICK RAMOS and RON RAYMOND RAMOS, petitioners, vs. COURT OF APPEALS, DELOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DRA. PERFECTA GUTIERREZ, respondents.G.R. No. 124354 December 29, 1999

Facts:Plaintiff Erlinda Ramos was, until the afternoon of June 17, 1985, a 47-year old was a robust woman. Except for occasional complaints of discomfort due to pains allegedly caused by the presence of a stone in her gall bladder, she was as normal as any other woman. Married to Rogelio E. Ramos, an executive of Philippine Long Distance Telephone Company, she has three children whose names are Rommel Ramos, Roy Roderick Ramos and Ron Raymond Ramos.

Because the discomforts somehow interfered with her normal ways, she sought professional advice. She was advised to undergo an operation for the removal of a stone in her gall bladder. She underwent a series of examinations which included blood and urine tests indicated she was fit for surgery.Through the intercession of a mutual friend, Dr. Buenviaje, she and her husband Rogelio met for the first time Dr. Orlino Hozaka, one of the defendants in this case, on June 10, 1985. They agreed that their date at the operating table at the DLSMC (another defendant), would be on June 17, 1985 at 9:00 A.M.. Dr. Hosaka decided that she should undergo a "cholecystectomy" operation after examining the documents presented to him. Rogelio E. Ramos, however, asked Dr. Hosaka to look for a good anesthesiologist.After the operation, unfortunately, she suffered brain damage as a result of the absence of oxygen in her brain for four to five minutes. After being discharged from the hospital, she has been staying in their residence, still needing constant medical attention, with her husband Rogelio incurring a monthly expense ranging from P8,000.00 to P10,000.00. She was also diagnosed to be suffering from "diffuse cerebral parenchymal damage".

Thus, on 8 January 1986, petitioners filed a civil case for damages with the Regional Trial Court of Quezon City against herein private respondents alleging negligence in the management and care of Erlinda Ramos.

After considering the evidence from both sides, the Regional Trial Court rendered judgment in favor of petitioners. Private respondents seasonably interposed an appeal to the Court of Appeals. The appellate court rendered a Decision, dated 29 May 1995, reversing the findings of the trial court.

Issue:Whether a surgeon, an anesthesiologist and a hospital should be made liable for the unfortunate comatose condition of a patient scheduled for cholecystectomy.

Held:Yes. We hold that private respondents were unable to disprove the presumption of negligence on their part in the care of Erlinda and their negligence was the proximate cause of her piteous condition.We do not agree with the reasoning of the appellate court. Although witness Cruz is not an anesthesiologist, she can very well testify upon matters on which she is capable of observing such as, the statements and acts of the physician and surgeon, external appearances, and manifest conditions which are observable by any one. This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. It is the accepted rule that expert testimony is not necessary for the proof of negligence in non-technical matters or those of which an ordinary person may be expected to have knowledge, or where the lack of skill or want of care is so obvious as to render expert testimony unnecessary. We take judicial notice of the fact that anesthesia procedures have become so common, that even an ordinary person can tell if it was administered properly. As such, it would not be too difficult to tell if the tube was properly inserted. This kind of observation, we believe, does not require a medical degree to be acceptable.

The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common knowledge and experience, the very nature of certain types of occurrences may justify an inference of negligence on the part of the person who controls the instrumentality causing the injury in the absence of some explanation by the defendant who is charged with negligence. It is grounded in the superior logic of ordinary human experience and on the basis of such experience or common knowledge, negligence may be deduced from the mere occurrence of the accident itself. Hence, res ipsa loquitur is applied in conjunction with the doctrine of common knowledge.

Established medical procedures and practices, though in constant flux are devised for the purpose of preventing complications. A physician's experience with his patients would sometimes tempt him to deviate from established community practices, and he may end a distinguished career using unorthodox methods without incident. However, when failure to follow established procedure results in the evil precisely sought to be averted by observance of the procedure and a nexus is made between the deviation and the injury or damage, the physician would necessarily be called to account for it. In the case at bar, the failure to observe pre-operative assessment protocol which would have influenced the intubation in a salutary way was fatal to private respondents' case.

WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to award in favor of petitioners, and solidarily against private respondents the following: 1) P1,352,000.00 as actual damages computed as of the date of promulgation of this decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each as exemplary damages and attorney's fees; and, 5) the costs of the suit.

6. Reyes v Sisters of Mercy HospitalG.R. 130547 October 3, 2000

Facts:Petitioner Leah Alesna Reyes is the wife of the late Jorge Reyes. The other petitioners, namely, Rose Nahdja, Johnny, Lloyd, and Kristine, all surnamed Reyes, were their children. Five days before his death on January 8, 1987, Jorge had been suffering from are curring fever with chills. After he failed to get relief from some home medication he was taking, which consisted of analgesic, antipyretic, and antibiotics, he decided to see the doctor. On January 8, 1987, he was taken to the Mercy Community Clinic by his wife. He was attended to by respondent Dr. Marlyn Rico, resident physician and admitting physician on duty, who gave Jorge a physical examination and took his medical history. She noted that atthe time of his admission, Jorge was conscious, ambulatory, oriented, coherent, and with respiratory distress. Typhoid fever was then prevalent in the locality, as the clinic had been getting from 15 to 20 cases of typhoid per month Suspecting that Jorge could be suffering from this disease, Dr. Rico ordered a Widal Test, a standard test for typhoid fever, to be performed on Jorge. Blood count, routine urinalysis,

stool examination, and malarial smear were also made after about an hour, the medical technician submitted the results of the test from which Dr. Rico concluded that Jorge was positive for typhoid fever. As her shift was only up to 5:00 p.m., Dr. Rico indorsed Jorge to respondent Dr. Marvie Blanes.Dr. Marvie Blanes attended to Jorge at around six in the evening. She also took Jorge’s history and gave him a physical examination. Like Dr. Rico, her impression was that Jorge had typhoid fever. Antibiotics being the accepted treatment for typhoid fever, she ordered that a compatibility test with the antibiotic chloromycetin be done on Jorge. Said test was administered by nurse Josephine Pagente who also gave the patient a dose of triglobe.

As she did not observe any adverse reaction by the patient to chloromycetin,Dr. Blanes ordered the first five hundred milligrams of said antibiotic to be administered on Jorge at around 9:00 p.m. A second dose was administered on Jorge about three hours later just before midnight. At around 1:00 a.m. of January 9, 1987, Dr. Blanes was called as Jorge’s temperature roseto 41°C. The patient also experienced chills and exhibited respiratory distress, nausea, vomiting, and convulsions. Dr. Blanes put him under oxygen, used a suction machine, and administered hydrocortisone, temporarily easing the patient’s convulsions. When here gained consciousness, the patient was asked by Dr. Blanes whether he had a previous heart ailment or had suffered from chest pains in the past. Jorge replied he did not After about 15 minutes, however, Jorge again started to vomit, showed restlessness, and his convulsions returned. Dr. Blanes re-applied the emergency measures taken before and, in addition, valium was administered. Jorge, however, did not respond to the treatment and slipped into cyanosis, a bluish or purplish discoloration of the skin or mucous membrane due to deficient oxygenation of the blood. At around 2:00 a.m., Jorge died. He was forty years old. The cause of his death was “Ventricular Arrythemia Secondary to Hyperpyrexia and typhoid fever.”

Issue:Whether or not petitioner is entitled to damage applying res ipsa loquitur?

Held:There is a case when expert testimony may be dispensed with, and that is under the doctrine of res ipsa loquitur. Thus, courts of other jurisdictions have applied the doctrine in the following situations: leaving of a foreign object in the body of the patient after an operation, injuries sustained on a healthy part of the body which was not under, or in the area, of treatment, removal of the wrong part of the body when another part was intended, knocking out a tooth while a patient’s jaw was under anesthetic for the removal of his tonsils, and loss of an eye while the patient was under the influence of anesthetic, during or following an operation for appendicitis, among others. Petitioners now contend that all requisites for the application of res ipsa loquitur were present, namely: (1) the accident was of a kind which does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency which caused the injury was under the exclusive control of the person in charge; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured. The contention is without merit. We agree with the ruling of the Court of Appeals. In the Ramos case, the question was whether a surgeon, an anesthesiologist, and a hospital should be made liable for the comatose condition of a patient scheduled for cholecystectomy. In that case, the patient was given anesthesia prior to her operation.

Noting that the patient was neurologically sound at the time of her operation, the Courtapplied the doctrine of res ipsa loquitur as mental brain damage does not normally occurin a gall blader operation in the absence of negligence of the anesthesiologist.

Taking judicial notice that anesthesia procedures had become so common that even an ordinary person could tell if it was administered properly, we allowed the testimony of a witness who was not an expert. In this case, while it is true that the patient died just a few hours after professional medical assistance was rendered, there is really nothing unusual or extraordinary about his death. Prior to his admission, the patient already had recurring fevers and chills for five days unrelieved by the analgesic, antipyretic, and antibiotics given him by his wife. This shows that he had been suffering from a serious illness and professional medical help came too late for him. Respondents alleged failure to observe due care was not immediately apparent to a layman so as to justify application of res ipsa loquitur. The question

required expert opinion on the alleged breach by respondents of the standard of care required by th circumstances. Furthermore, on the issue of the correctness of her diagnosis, no presumption of negligence can be applied to Dr. Marlyn Rico.

7. Ramos vs. CA;GR No. 124354 ; April 11, 2001

Facts:After seeking professional help, Erlinda Ramos was advised to undergo an operation for the removal of a stone in her gallbladder. She was referred to Dr. Hosaka who agreed to do the operation and was further recommended to an anaesthesiologist, Dr. Gutierrez.On the day of the scheduled operation at De Los Santos Medical Center, around 9:30 in the morning Dr. Hosaka had not yet arrived so Dr. Gutierres tried to get in touch with him by phone and informed Hermina Cruz, sister-in-law of Erlina who accompanied Erlinda to the operating room, that the operation might be delayed. Dr. Hosaka arrived around 12:20 in the afternoon, or more than three hours after the scheduled operation.

Cruz, who was then still inside the operation room while still holding the hand of Erlinda saw Dr. Gutierrez trying to intubate the patient and heard Dr. Gutierrez utter “and hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan.” Cruz then noticed bluish discoloration of Erlinda’s nailbeds on her left hand. She then hear Osaka instructed someone to call another anestheologist in the name of Dr. Calderon. Dr. Calderon then attempted to intubate the patient but still the nailbeds of the patient remained bluish thus she was placed in a trendelenburg position.At almost 3:00 in the afternoon, Cruz saw Erlinda being wheeled to the ICU and the doctors explained to Rogelio that Erlinda his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was then released from the hospital after four months and since then she remained in a comatose condition and died on August 1999.

Petitioner then filed with the RTC a civil case for damages against private respondents. After due trial, RTC rendered judgment in favor of petitioners and found the respondent negiligent in the performance of their duties to Erlinda. On appeal, the CA reversed the RTC’s decision and directed the petitioners to pay their “unpaid medical bills”.

Issue:Whether Dr. Hosaka and Gutierrez were liable for negligence.

Held:Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the greatest solicitude, giving them always his best talent and skill," but also of Article 19 of the Civil Code which requires a person, in the performance of his duties, to act with justice and give everyone his due. Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has been sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that caused her comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on her.

8. Ruñez Jr. vs. Dr. JuradoA.M. No. 2005-08-SC, December 9, 2005(To follow by Gladys Chua)

9. ROGELIO P. NOGALES, for himself and on behalf of the minors, ROGER ANTHONY, ANGELICA,NANCY, and MICHAEL CHRISTOPHER, all surnamed NOGALES, petitioners, vs. CAPITOL MEDICAL CENTER, DR. OSCAR ESTRADA, DR. ELY VILLAFLOR, DR. ROSA UY, DR. JOELENRIQUEZ, DR. PERPETUA LACSON, DR. NOE ESPINOLA, and NURSE J. DUMLAO, respondents.G.R. No. 142625 December 19, 2006

Facts:Corazon Nogales ("Corazon"), 37 years old pregnant with her fourth child, under the exclusive prenatal care of Dr. Oscar Estrada ("Dr. Estrada"). The Doctor noted an increase in her blood pressure and development of leg edema indicating preeclampsia. Corazon started to experience mild labor pains Dr. Estrada advised her immediate admission to the Capitol Medical Center ("CMC"). The staff nurse noted the written admission request of Dr. Estrada. Due to the "Consent on Admission and Agreement" and "Admission Agreement" signed by Corazon’s husband she was then brought to the labor room of the CMC. Corazon manifest moderate vaginal bleeding which rapidly became profusely, Dr. Espinola ordered immediate hysterectomy. Rogelio was made to sign. Consent to Operation."Due to the inclement weather, Dr. Espinola arrived an hour late. He examined the patient and ordered some resuscitative measures to be administered. Despite Dr. Espinola's efforts, Corazon died the cause of death was "hemorrhage, post partum."Petitioners filed a complaint for damages with the Regional Trial Court of Manila contending that defendant physicians and CMC personnel were negligent in the treatment and management of Corazon's condition also in the selection and supervision of defendant physicians and hospital staff. The defendant fail to file their answer to the complaint the trial court declared Dr. Estrada, Dr. Enriquez, and Nurse Dumlao in default. CMC, Dr. Villaflor, Dr. Uy, Dr. Espinola, and Dr. Lacson filed their respective answers denying and opposing the allegations in the complaint. The trial court rendered judgment finding Dr. Estrada solely liable for damages.

Petitioners appealed the trial court's decision, The Court of Appeals affirmed the decision of the trial court. Petitioners filed a motion for reconsideration which was denied in its Resolution. Hence, petitioners filed a Manifestation that respondents "need no longer be notified of the petition because they are not involved in the issue raised before the [Court], regarding the liability of [CMC]." The Court of Appeals concluded that since Rogelio engaged Dr.Estrada as the attending physician of his wife, any liability for malpractice must be Dr. Estrada's sole responsibility. While it found the amount of damages fair and reasonable, the Court of Appeals held that no interest could be imposed on unliquidated claims or damages. Hence this petition.

Issue:Whether or not CMC is vicariously liable for the negligence?

Held:On the Liability of CMCCMC is vicariously liable for Dr. Estrada's negligence based on Article 2180 in relation to Article2176 of the Civil Code. Art. 2180. The obligation imposed by article 2176 is demandable not only for one's own acts or omissions, but also for those of persons for whom one is responsible. Employers shall be liable for the damages caused by their employees. The records show that Rogelio testified that he and his wife specifically chose Dr. Estrada to handle Corazon's delivery not only because of their friend's recommendation, but more importantly because of Dr.Estrada's "connection with a reputable hospital, to provide the best medical care and support services for Corazon's delivery.

On the Liability of the other RespondentsThere was no evidence showing that the other respondents are liable for negligent act. The records show that all are acting with good faith.

On the Award of interest on DamagesThe award of interest on damages is proper and allowed under Article 2211 of the Civil Code, which states that in crimes and quasi-delicts, interest as a part of the damages may, in a proper case, be adjudicated in the discretion of the court. The Court partly grants the petition finds respondent Capitol

Medical Center vicariously liable for the negligence of Dr. Oscar Estrada. The actual damages and moral damages should each earn legal interest at the rate of six percent (6%) per annum computed from the date of the judgment of the trial court.

10. PROFESSIONAL SERVICES, INC. VS. NATIVIDAD and ENRIQUE AGANAG.R. no. 126297 January 31, 2007NATIVIDAD and ENRIQUE AGANAVS JUAN FUENTESG.R. no. 127590 January 31, 2007

Facts:Natividad Agana was rushed to the Medical City Hospital Dr. Miguel Ampil diagnosed her to be suffering from cancer of the sigmoid. Dr. Ampil performed the surgery and found the malignancy in her sigmoid necessitating the removal. Dr. Juan Fuentes performs hysterectomy Dr. Ampil took over, completed the operation and closed the incision. The attending nurse entered the remarks that the sponge count lacking 2. Since nowhere to be found the surgeon avail to continue closure. After a couple of days, Natividad complained of excruciating pain she consulted both the doctors about it but they told that it was natural consequence of the surgery. Dr. Ampil. Natividad, went to the United States after four months of consultation and laboratory examinations, she was free of cancer. Natividad flew back to the Philippines, still suffering from pains, her daughter found gauze protruding from her Vagina. Then after the pain intensified, prompting Natividad to seek treatment. Dr. Ramon Gutierez detected the presence of another foreign object in her vagina a foul-smelling gauze which badly infected her vaginal vault. Natividad underwent another surgery to remedy the damage.

Natividad and her husband filed with the RTC, Quezon City a complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes. Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr. Fuentes. The PRC Board of Medicine heard the case but it failed to acquire jurisdiction over Dr. Ampil who was then in the United States. The case was pending; Natividad died and was duly substituted by her above-named children (the Aganas). RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice, ordering the defendants PROFESSIONAL SERVICES, INC., Dr Miguel Ampil and Dr. Juan Fuentes to pay to the plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampil and Dr. Fuentes.

Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals, Aganas filed with the RTC a motion for a partial execution of its Decision. Aganas again filed a motion for an alias writ of execution against the properties of PSI and Dr. Fuentes. RTC granted the motion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for preliminary injunction. During its pendency, the Court of Appeals issued a Resolution granting Dr. Fuentes prayer for injunctive relief. PRC Board of Medicine rendered its Decision in Administrative Case dismissing the case against Dr. Fuentes. The prosecution failed to show that Dr. Fuentes was the one who left the two pieces of gauze inside Natividad’s body.

The Court of Appeals rendered its Decision Dr.Miguel Ampil is liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees. Dr. Ampil filed a motion for reconsideration, but it was denied in a Resolution Aganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guilty of negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. Dr. Ampilasserts that the Court of Appeals erred in finding him liable for negligence and malpractice.

Issues:(1) Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence and malpractice(2) Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability(3) Whether PSI may be held solidarily liable for the negligence of Dr. Ampil.

Held:(1) Dr. Ampil is liable for Negligence and Malpractice, an attempt to absolve himself, gears the Court’s attention to other possible causes of Natividad’s detriment. His arguments are purely conjectural and without basis. He did not present any evidence to prove that the American doctors were the ones who put or left the gauzes in Natividad’s body. Neither submit evidence to rebut the correctness of the record of operation, particularly the number of gauzes used. As to the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr.Fuentes) work and found it in order.

(2) The court is not convinced, that the Court of Appeals Erred in Absolving Dr. Fuentes of any Liability. It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he(Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr. Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. The latter examined it and finding everything to be in order, allowed Dr. Fuentes to leave the operating room. Dr. Ampil then resumed operating on Natividad. He was about to finish the procedure when the attending nurses informed him that two pieces of gauze were missing. A"diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil then directed that the incision be closed. During this entire period, Dr. Fuentes was no longer in the operating room and had, in fact, left the hospital.

(3) The issue of whether PSI is solidarily liable with Dr. Ampil for damages, that PSI, failed to adduce evidence showing that it exercised the diligence of a good father of a family in the accreditation and supervision of the latter. Moreover PSI is also directly liable to the Aganas. When a doctor practices medicine in a hospital setting, the hospital and its employees are deemed to sub serve him in his ministrations to the patient and his actions are of his own responsibility. The nature of the relationship between the hospital and the physicians is an employer-employee relationship the hospitals exercise significant control in the hiring and firing of consultants and in the conduct of their work within the hospital premises. Doctors who apply for consultant slots, are required to submit proof of completion of residency, their educational qualifications, evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in most cases, and references. These requirements in other words, private hospitals, hire, fire and exercise real control over their attending and visiting consultant staff. The hiring, and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment of wages. PSI publicly displays in the lobby of the Medical City Hospital the names and specializations of the physicians associated or accredited by it, including those of Dr. Ampil and Dr. Fuentes. PSI failed to discharge its burden under the last paragraph of Article 2180 cited must be adjudged solidarily liable with Dr. Ampil.

11. DR. MILAGROS L. CANTRE, Petitioner, vs. SPS. JOHN DAVID Z. GO and NORA S. GO, Respondents.

Facts: 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 suffered profuse bleeding inside her womb due to some parts of the placenta which were not completely expelled from her womb after delivery. Consequently, Nora suffered hypovolemic shock, resulting in a drop in her blood pressure to "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 droplight to warm Nora and her baby.4 Nora remained unconscious until she recovered.

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. Respondent spouses filed a complaint13 for damages against petitioner, Dr. Abad, and the hospital.

Issue:Is petitioner liable for the injury suffered by respondent Nora Go??

Held: The Court ruled 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.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.

12. ILAO-ORETA vs. RONQUILLOGR G.R. No. 172406 October 17, 2007

Facts:Despite several years of marriage, Spouses Ronquillo is still childless. They consulted Dr. Concepcion Ilao-Oreta, an obstetrician gynecologist-consultant at St. Luke’s and Chief of the Reproductive Endocrinology and Infertility Section. Eva Marie agreed to undergo alaparoscopic procedure where a laparoscope would be inserted through her abdominal wall to get a direct view of her internal reproductive organ in order to determine the real cause of her infertility.The procedure was scheduled on April 5, 1999 at 2 pm. Dr. Ilao-Oreta did not arrive at the schedules time and no prior notice of its cancellation was received by the Ronquillos. Dr. Ilao-Oreta was on her honeymoon in Hawaii.

She estimated that she would arrive in Manila in the early morning of April5. However, she failed to consider the time difference between Hawaii and Philippines. Ronquillos filed a complaint against Dr. Ilao-Oreta and St. Luke’s for breach of professional and service contract and for damages.RTC: awarded Eva Marie only actual damages upon finding that the doctor’s failure to arrive on time was not intentional

CA: found Dr. Ilao-Oreta grossly negligent

Issue:WON Dr. Ilao-Oreta was grossly negligent in not arriving on time for the scheduled laparoscopy

Held:Records show that Dr- Ilao-Oreta left an admitting order with her secretary for one of the spouses to pick up, apprised Eva Marie of the necessary preparations for the procedure and instructed the hospital staff to perform pre-operative treatments before leaving for Hawaii. These acts reflect an earnest intention to perform the procedure on the day and time scheduled.

On realizing that she missed the scheduled procedure, Dr. Ilao Oreta, upon arrival in Manila, immediately called the hospital and asked the nurses about Eva Marie. She also wanted to call the Ronquillos but she didn’t have their number at that time. So the next morning, shewent to her office to get the Ronquillos contact number, which is written on Eva Marie’s chart, and called them right away.

Noel admitted that indeed Dr. Ilao-Oreta called him up after she arrived in Manila. Although Dr. Ilao-Oreta’s act is not grossly negligent, she was negligent when she scheduled to perform professional service at 2 pm without considering the time difference between Philippines and Hawaii. Having travelled to the US, where she obtained a fellowship in Reproductive Endocrinology and Infertility, more than twice, she should have been mindful of said difference.

The procedure to be conducted on Eva Marie was only elective in nature thus the situation did not present any clear and apparent harm or injury that even a careless person may perceive.

According to the SC, it bears noting that when Dr. Ilao-Oreta was scheduling the date of her performance of the procedure, she had just gotten married and was preparing for her honeymoon. It is common knowledge that excitement attends its preparations. Her negligence could then be partly attributed to human frailty which rules out its characterization as gross.

13. SPOUSES FREDELICTO FLORES (deceased) and FELICISIMA FLORES, petitioners, vs. SPOUSES DOMINADOR PINEDA and VIRGINIA SACLOLO, and FLORENCIO, CANDIDA, MARTA, GODOFREDO, BALTAZAR and LUCENA, all surnamed PINEDA, as heirs of the deceased TERESITA S. PINEDA, and UNITED DOCTORS MEDICAL CENTER, INC., respondents.

Facts: Teresita was a 51-year old unmarried woman living in Sto. Domingo, Nueva Ecija. She consulted on April 17, 1987 her townmate, Dr. Fredelicto Flores, regarding her medical condition. She complained of general body weakness, loss of appetite, frequent urination and thirst, and on-and-off vaginal bleeding. He advised her to return the following week or to go to the United Doctors Medical Center (UDMC) in Quezon City for a general check-up. As for her other symptoms, he suspected that Teresita might be suffering from diabetes and told her to continue her medications. They went to United Doctors Medical Center (UDMC) in Quezon City. Teresita was taken to the operating room. It was only then that she met Dr. Felicisima, an obstetrician and gynecologist. Upon Teresita's complete laboratory examination results came only on that day . Teresita's urinalysis showed a three plus sign (+++) indicating that the sugar in her urine was very high. She was then placed under the care of Dr. Amado Jorge, an internist. Teresita's condition had worsened. She experienced difficulty in breathing and was rushed to the intensive care unit. Further tests confirmed that she was suffering from Diabetes Mellitus Type II. Insulin was administered on the patient, but the medication might have arrived too late. Due to complications induced by diabetes, Teresita died.

Believing that Teresita's death resulted from the negligent handling of her medical needs, her family (respondents) instituted an action for damages against Dr. Fredelicto Flores and Dr. Felicisima Flores (collectively referred to as the petitioner spouses) before the RTC of Nueva Ecija.

Issue: Whether the said doctors can be held liable for negligence?

Held: A medical negligence case is a type of claim to redress a wrong committed by a medical professional, that has caused bodily harm to or the death of a patient. There are four elements involved in a medical negligence case, namely: duty, breach, injury, and proximate causation. We clarify that Dr. Fredelicto's negligence is not solely the act of ordering an "on call" D&C operation when he was mainly ananaesthesiologist who had made a very cursory examination of the patient's vaginal bleeding complaint. Rather, it was his failure from the very start to identify and confirm, despite the patient's complaints and his own suspicions, that diabetes was a risk factor that should be guarded against, and his participation in the imprudent decision to proceed with the D&C operation despite his early suspicion and the confirmatory early laboratory results. If Dr. Fredelicto believed himself to be incompetent to treat the diabetes, not being an internist or a diabetologist (for which reason he referred Teresita to Dr. Jorge), he should have likewise refrained from making a decision to proceed with the D&C operation

since he was niether an obstetrician nor a gynecologist. These findings lead us to the conclusion that the decision to proceed with the D&C operation, notwithstanding Teresita's hyperglycemia and without adequately preparing her for the procedure, was contrary to the standards observed by the medical profession. Deviation from this standard amounted to a breach of duty which resulted in the patient's death. Due to this negligent conduct, liability must attach to the petitioner spouses

14. FE CAYAO-LASAM, PETITIONER, VS. SPOUSES CLARO AND EDITHA RAMOLETE, RESPONDENTS.

Facts:On July 28, 1994, respondent, three months pregnant Editha Ramolete (Editha) was brought to the Lorma Medical Center (LMC) in San Fernando, La Union due to vaginal bleeding. Upon advice of petitioner relayed via telephone, Editha was admitted to the LMC on the same day. A pelvic sonogram was then conducted on Editha revealing the fetus' weak cardiac pulsation.

The following day, Editha's repeat pelvic sonogram showed that aside from the fetus' weak cardiac pulsation, no fetal movement was also appreciated. Due to persistent and profuse vaginal bleeding, petitioner advised Editha to undergo a Dilatation and Curettage Procedure (D&C) or "raspa."

Petitioner performed the D&C procedure. Editha was discharged from the hospital the following day.Editha was once again brought at the LMC, as she was suffering from vomiting and severe abdominal pains. Editha was attended by Dr. Beatriz de la Cruz, Dr. Victor B. Mayo and Dr. Juan V. Komiya. Dr. Mayo allegedly informed Editha that there was a dead fetus in the latter's womb. After, Editha underwent laparotomy, she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. Thus, Editha had to undergo a procedure for hysterectomy and as a result, she has no more chance to bear a child. Editha and her husband Claro Ramolete (respondents) filed a Complaint for Gross Negligence and Malpractice against petitioner before the Professional Regulations Commission (PRC).

Petitioner contended that it was Editha's gross negligence and/or omission in insisting to be discharged on such day against doctor's advice and her unjustified failure to return for check-up as directed by petitioner that contributed to her life-threatening condition on September 16, 1994; that Editha's hysterectomy was brought about by her very abnormal pregnancy known as placenta increta, which was an extremely rare and very unusual case of abdominal placental implantation.

On March 4, 1999, the Board of Medicine (the Board) of the PRC rendered a Decision, exonerating petitioner from the charges filed against her. On appeal, the PRC rendered a Decision reversing the findings of the Board and revoking petitioner's authority or license to practice her profession as a physician. Hence, this petition.

Issue:Whether the petitioner is liable for malpractice?

Held:When complainant was discharged on July 31, 1994, herein respondent advised her to return on August 4, 1994 or four (4) days after the D&C. This advise was clear in complainant's Discharge Sheet. However, complainant failed to do so. This being the case, the chain of continuity as required in order that the doctrine of proximate cause can be validly invoked was interrupted. Had she returned, the respondent could have examined her thoroughly.

No negligence can be attributed to the petitioner, the immediate cause of the accident resulting in Editha's injury was her own omission when she did not return for a follow-up check up, in defiance of petitioner's orders. The immediate cause of Editha's injury was her own act; thus, she cannot recover damages from the injury.

The Decision of the Board of Medicine dated March 4, 1999 exonerating petitioner is AFFIRMED.

15. PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS, ABBEYGAIL LUCAS AND GILLIAN LUCAS, Petitioners, vs. DR. PROSPERO MA. C. TUAÑO,

Facts: Petitioner Peter Paul Patrick Lucas (Peter) contracted "sore eyes" in his right eye. 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. Dr. Tuaño diagnosed that Peter was suffering from conjunctivitis5 or "sore eyes." Dr. Tuaño then prescribed Spersacet-C6 eye drops for Peter and told the latter to return for follow-up after one week. As instructed, Peter went back to Dr. Tuañ. 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, a dosage of six (6) drops per day. To recall, Peter had already been using Maxitrol prior to his consult with Dr. Tuaño. Peter saw Dr. Tuaño for a follow-up consultation. After examining both of Peter’s eyes, Dr. Tuaño instructed the former to taper down 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. Complaining of feeling as if there was something in his eyes, Peter returned to Dr. Tuaño for another check-up on . 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. Several days later, 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. 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. 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.

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. A civil complaint for damages against Dr. Tuaño on the ground of 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.

Issue: Whether Dr. Tuano was negligent?

Held: 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. 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.

16. PSI vs AGANA

Facts:Natividad Agana was rushed to the Medical City Hospital Dr. Miguel Ampil diagnosed her to be suffering from “cancer of the sigmoid”. Dr. Ampil performed the surgery and found the malignancy in her sigmoid necessitating the removal. Dr. Juan Fuentes performs hysterectomyDr. Ampil took over, completed the operation and closed the incision. The attending nurse entered the remarks that the sponge count lacking 2. Since nowhere to be found the surge on avail to continue closure. After a couple of days, Natividad complained of excruciating pain she consulted both the doctors about it but they told that it was natural consequence of the surgery. Dr. Ampil Natividad, went to the United States after four months of consultation and laboratory examinations, she was free of cancer. Natividad flew back to the Philippines, still suffering from pains, her daughter found gauze protruding from her Vagina. Then after the pain intensified, prompting Natividad to seek treatment. Dr. Ramon Gutierez detected the presence of another foreign object in her vagina – a foul-smelling gauze which badly infected her vaginal vault. Natividad underwent another surgery to remedy the damage. Natividad and her husband filed with the RTC, Quezon City a complaint for damages against the Professional Services, Inc. (PSI), owner of the Medical City Hospital, Dr. Ampil, andDr. Fuentes. Enrique Agana also filed with the Professional Regulation Commission (PRC) an administrative complaint for gross negligence and malpractice against Dr. Ampil and Dr.Fuentes. The PRC Board of Medicine heard the case but it failed to acquire jurisdiction over Dr.Ampil who was then in the United States. The case was pending; Natividad died and was dulysubstituted by her above-named children (the Aganas).

RTC rendered its Decision in favor of the Aganas, finding PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice,ordering the defendants PROFESSIONAL SERVICES, INC., Dr Miguel Ampil and Dr. JuanFuentes to pay to the plaintiffs, jointly and severally, except in respect of the award for exemplary damages and the interest thereon which are the liabilities of defendants Dr. Ampiland Dr. Fuentes.Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of Appeals,Aganas filed with the RTC a motion for a partial execution of its Decision. Aganas again filed amotion for an alias writ of execution against the properties of PSI and Dr. Fuentes. RTC grantedthemotion and issued the corresponding writ, prompting Dr. Fuentes to file with the Court of Appeals a petition for certiorari and prohibition, with prayer for preliminary injunction. During itspendency, the Court of Appeals issued a Resolution granting Dr. Fuentes’ prayer for injunctiverelief.

PRC Board of Medicine rendered its Decision in Administrative Case dismissing thecase against Dr. Fuentes. The prosecution failed to show that Dr. Fuentes was the one who leftthe two pieces of gauze inside Natividad’s body. The Court of Appeals rendered its Decision Dr.Miguel Ampil is liable to reimburse defendant-appellant Professional Services, Inc., whatever amount the latter will pay or had paid to the plaintiffs-appellees. Dr. Ampil filed a motion for reconsideration, but it was denied in a ResolutionAganas maintain that the Court of Appeals erred in finding that Dr. Fuentes is not guiltyof negligence or medical malpractice, invoking the doctrine of res ipsa loquitur. Dr. Ampilasserts that the Court of Appeals erred in finding him liable for negligence and malpractice.

Issues:(1) Whether the Court of Appeals erred in holding Dr. Ampil liable for negligence andmalpractice(2) Whether the Court of Appeals erred in absolving Dr. Fuentes of any liability

Held:Dr. Ampil is liable for Negligence and Malpractice, an attempt to absolve himself, gears theCourt’s attention to other possible causes of Natividad’s detriment. His arguments are purelyconjectural and without basis. He did not present any evidence to prove that the Americandoctors were the ones who

put or left the gauzes in Natividad’s body. Neither submit evidenceto rebut the correctness of the record of operation, particularly the number of gauzes used. Asto the alleged negligence of Dr. Fuentes, we are mindful that Dr. Ampil examined his (Dr.Fuentes’) work and found it in order. The court is not convinced, that the Court of Appeals Erred in Absolving Dr. Fuentes of anyLiability. It was duly established that Dr. Ampil was the lead surgeon during the operation of Natividad. He requested the assistance of Dr. Fuentes only to perform hysterectomy when he(Dr. Ampil) found that the malignancy in her sigmoid area had spread to her left ovary. Dr.Fuentes performed the surgery and thereafter reported and showed his work to Dr. Ampil. Thelatter examined it and finding everything to be in order, allowed Dr. Fuentes to leave theoperating room. Dr. Ampil then resumed operating on Natividad. He was about to finish theprocedure when the attending nurses informed him that two pieces of gauze were missing. A"diligent search" was conducted, but the misplaced gauzes were not found. Dr. Ampil thendirected that the incision be closed. During this entire period, Dr. Fuentes was no longer in theoperating room and had, in fact, left the hospital.

17. Dr Li vs Sps Soliman

Facts: This case involved the death of Angelica Soliman, respondents’ 11-year old daughter. Previously, Angelica was diagnosed withosteosarcoma, osteoblastic type, a highly malignant cancer of the [thigh] bone. To remove the tumor, her right leg was amputated. And to eliminate any remaining cancer cells and minimize the chances of recurrence and prevent the disease from spreading to other parts of herbody (metastasis), she subsequently underwent chemotherapy. The chemotherapy was administered by petitioner Dr. Rubi Li, an oncologist at St. Luke’s Medical Center (SLMC) upon consent by her parents, herein respondents. Angelica died just eleven days after the administration of the first cycle of the chemotherapy regimen. The parents of the child thereafter sued the doctor for damages before the RTC, charging the latter (along with other doctors and the SLMC itself) with negligence in causing Angelica’s untimely demise. It was specifically averred in the complaint that the doctor assured the parents that Angelica would recover in view of 95% chance of healing with chemotherapy (“Magiging normal na ang anak nyo basta ma-chemo. 95% ang healing”), and when asked regarding the side effects, petitioner mentioned only slight vomiting, hair loss and weakness (“Magsusuka ng kaunti. Malulugas ang buhok. Manghihina”). The parents thus claimed that they would not have given their consent to chemotherapy had the doctor not falsely assured them of its side effects.

The trial court however dismissed the case. It found that the doctor was not liable for damages as she observed the best known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on Angelica [though] despite all efforts said patient died.

The parents appealed to the Court of Appeals (CA). While concurring with the trial court’s finding that there was no negligence committed by the petitioner in the administration of chemotherapy treatment to Angelica, the CA found that the doctor failed to fully explain to the parents of the patient all the known side effects of chemotherapy. The CA thus adjudged the doctor liable for damages. The doctor then appealed to the Supreme Court (SC), raising the following issue Under the facts, can she be held liable [of failing] to fully disclose serious side effects of chemotherapy to the parents of her patient despite the absence of finding that she was negligent in administering the said treatment.

Issue: Whether or not there is malpractice

Held: As indicated above, Justice Villarama ruled that there are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed treatment. The gravamen in an

informed consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it. There was adequate disclosure of material risk inherent in the chemotherapy procedure performed with the consent of Angelica’s parents. [The parents] could not have been unaware in the course of initial treatment and amputation of Angelica’s lower extremity, that her immune system was already weak on account of the malignant tumor in her knee. When [the doctor] informed the [parents] beforehand of the side effects of chemotherapy[,] which includes lowered counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on the part of the doctor that the parents understood very well that the severity of these side effects will not be the same for all patients undergoing the procedure. As a physician, petitioner can reasonably expect the parents to have considered the variables in the recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to give credence to respondent’s claim that petitioner told them of 95% chance of recovery for their daughter, as it was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured patients of chemotherapy’s success rate. Besides, informed consent laws in other countries generally require only a reasonable explanation of potential harms, so specific disclosures such as statistical data, may not be legally necessary. The element of ethical duty to disclose material risks in the proposed medical treatment cannot thus be reduced to one simplistic formula applicable in all instances. Further, in a medical malpractice action based on lack of informed consent, the plaintiff must prove both the duty and the breach of that duty through expert testimony. Such expert testimony must show the customary standard of care of physicians in the same practice as that of the defendant doctor. In this case, the testimony of Dr. Balmaceda [witness for the girl’s parents] who is not an oncologist but a Medical Specialist of the DOH’s Operational and Management Services charged with receiving complaints against hospitals, does not qualify as expert testimony to establish thestandard of care in obtaining consent for chemotherapy treatment. In the absence of expert testimony in this regard, the Court felt hesitant defining the scope of mandatory disclosure in cases of malpractice based on lack of informed consent, much less set a standard of disclosure that, even in foreign jurisdictions, has been noted to be an evolving one.

18. Dr Jarcia vs Bastan

Facts: Belinda Santiago (Mrs. Santiago) lodged a complaint with the National Bureau of Investigation (NBI) against the petitioners, Dr. Emmanuel Jarcia, Jr. (Dr. Jarcia) and Dr. Marilou Bastan (Dr. Bastan), for their alleged neglect of professional duty which caused her son, Roy Alfonso Santiago (Roy Jr.), to suffer serious physical injuries. Upon investigation, the NBI found that Roy Jr. was hit by a taxicab; that he was rushed to the Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the victim’s ankle was ordered; that the X-ray result showed no fracture as read by Dr. Jarcia; that Dr. Bastan entered the emergency room (ER) and, after conducting her own examination of the victim, informed Mrs. Santiago that since it was only the ankle that was hit, there was no need to examine the upper leg; that eleven (11) days later, Roy Jr. developed fever, swelling of the right leg and misalignment of the right foot; that Mrs. Santiago brought him back to the hospital; and that the X-ray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone.

On June 14, 2005, the RTC found the petitioners guilty beyond reasonable doubt of the crime of Simple Imprudence Resulting to Serious Physical Injuries. The Court believes that accused are negligent when both failed to exercise the necessary and reasonable prudence in ascertaining the extent of injury of Alfonso Santiago, Jr. However, the negligence exhibited by the two doctors does not approximate negligence of a reckless nature but merely amounts to simple imprudence. Simple imprudence consists in the lack of precaution displayed in those cases in which the damage impending to be caused is not the immediate nor the danger clearly manifest. The elements of simple imprudence are as follows. 1. that there is lack of precaution on the part of the offender; and 2. that the damage impending to be caused is not immediate of the danger is not clearly manifest.

Issue:Whether or not the Petitioners are guilty of negligence

Held: The Supreme Court reversed the decision of the lower court and the CA. The totality of the evidence on record clearly points to the negligence of the petitioners. At the risk of being repetitious, the Court, however, is not satisfied that Dr. Jarcia and Dr. Bastan are criminally negligent in this case. Negligence is defined as the failure to observe for the protection of the interests of another person that degree of care, precaution, and vigilance which the circumstances justly demand, whereby such other person suffers injury. Reckless imprudence consists of voluntarily doing or failing to do, without malice, an act from which material damage results by reason of an inexcusable lack of precaution on the part of the person performing or failing to perform such act.

The elements of simple negligence are: (1) that there is lack of precaution on the part of the offender, and (2) that the damage impending to be caused is not immediate or the danger is not clearly manifest. In this case, the Court is not convinced with moral certainty that the petitioners are guilty of reckless imprudence or simple negligence. The elements thereof were not proved by the prosecution beyond reasonable doubt It can be gleaned from the testimony of Dr. Tacata that a thorough examination was not performed on Roy Jr. As residents on duty at the emergency room, Dr. Jarcia and Dr. Bastan were expected to know the medical protocol in treating leg fractures and in attending to victims of car accidents.

There was, however, no precise evidence and scientific explanation pointing to the fact that the delay in the application of the cast to the patient’s fractured leg because of failure to immediately diagnose the specific injury of the patient, prolonged the pain of the child or aggravated his condition or even caused further complications. Any person may opine that had patient Roy Jr. been treated properly and given the extensive X-ray examination, the extent and severity of the injury, spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been detected early on and the prolonged pain and suffering of Roy Jr. could have been prevented. But still, that opinion, even how logical it may seem would not, and could not, be enough basis to hold one criminally liable; thus, a reasonable doubt as to the petitioners’ guilt.

The Court, nevertheless, finds the petitioners civilly liable for their failure to sufficiently attend to Roy Jr.’s medical needs when the latter was rushed to the ER, for while a criminal conviction requires proof beyond reasonable doubt, only a preponderance of evidence is required to establish civil liability. Taken into account also was the fact that there was no bad faith on their part.Dr. Jarcia and Dr. Bastan cannot pass on the liability to the taxi driver who hit the victim. It may be true that the actual, direct, immediate, and proximate cause of the injury (fracture of the leg bone or tibia) of Roy Jr. was the vehicular accident when he was hit by a taxi. The petitioners, however, cannot simply invoke such fact alone to excuse themselves from any liability. If this would be so, doctors would have a ready defense should they fail to do their job in attending to victims of hit-and-run, maltreatment, and other crimes of violence in which the actual, direct, immediate, and proximate cause of the injury is indubitably the act of the perpetrator/s. In failing to perform an extensive medical examination to determine the extent of Roy Jr.’s injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical profession. Assuming for the sake of argument that they did not have the capacity to make such thorough evaluation at that stage, they should have referred the patient to another doctor with sufficient training and experience instead of assuring him and his mother that everything was all right. If these doctors knew from the start that they were not in the position to attend to Roy Jr., a vehicular accident victim, with the degree of diligence and commitment expected of every doctor in a case like this, they should have not made a baseless assurance that everything was all right. By doing so, they deprived Roy Jr. of adequate medical attention that placed him in a more dangerous situation than he was already in. What petitioners should have done, and could have done, was to refer Roy Jr. to another doctor who could competently and thoroughly examine his injuries.

19. Manila Doctors Hospital vs Chua and Ty

Facts: On December 13, 1993, respondents filed a Complaint averring that on October 30, 1990, respondent Chua, the mother of respondent Vicky Ty, was admitted in petitioner's hospital for hypertension and diabetes; that while respondent Chua was confined, Judith Chua, the sister of respondent Ty, had been likewise confined for injuries suffered in a vehicular accident; that partial payments of the hospital bills were made, totaling P435,800.00; that after the discharge of Judith Chua, respondent Chua remained in confinement and the hospital bills for both patients accumulated; that respondent Chua was pressured by the petitioner, through its Credit and Collection Department, to settle the unpaid bills; that respondent Ty represented that she will settle the bills as soon as the funds become available; that respondent Ty pleaded to the management that in view of the physical condition of her mother, respondent Chua, the correspondences relating to the settlement of the unpaid hospital bills should be relayed to the former; that these pleas were unheeded by the petitioner; that petitioner threatened to implement unpleasant measures unless respondent Ty undertakes her mother's obligation as well as the obligation of her sister, Judith Chua, to pay the hospitalization expenses; that petitioner made good its threat and employed unethical, unpleasant and unlawful methods which allegedly worsened the condition of respondent Chua, particularly, by (i) cutting off the telephone line in her room and removing the air-conditioning unit, television set, and refrigerator, (ii) refusing to render medical attendance and to change the hospital gown and bed sheets, and (iii) barring the private nurses or midwives from assisting the patient. Respondents thus prayed for the award of moral damages, exemplary damages, and attorney's fees.

RTC held that the removal of the facilities of the room triggered the hypertension of respondent Chua; that the petitioner acted in bad faith in removing the facilities without prior notice; that her condition was aggravated by the pressure employed by the administration upon her to pay the hospital bills; that the food always came late as compared to the other patients; that the beddings and clothes of respondent Chua were no longer changed and, as a result, bed sores emerged on her body; that there was an utter lack of medical attendance; that, because of these, respondent Chua suffered from self-pity and depression; that petitioner clearly discriminated against the respondents; that respondent Ty had no choice but to sign the promissory notes in order to secure the release of her mother, respondent Chua; that the foregoing actuations constitute an abuse of rights; that petitioner failed to establish the pecuniary loss it suffered and, hence, it is not entitled to compensatory damages; and that, since the promissory note is a contract of adhesion, the petitioner is not entitled to the award of attorney's fees as stipulated thereon.

Issue:Whether or not the petitioner is liable

Held: The Supreme Court ruled that the petitioner is not liable. Indeed the operation of private pay hospitals and medical clinics is impressed with public interest and imbued with a heavy social responsibility. But the hospital is also a business, and, as a business, it has a right to institute all measures of efficiency commensurate to the ends for which it is designed, especially to ensure its economic viability and survival. And in the legitimate pursuit of economic considerations, the extent to which the public may be served and cured is expanded, the pulse and life of the medical sector quickens, and the regeneration of the people as a whole becomes more visibly attainable. In the institution of cost-cutting measures, the hospital has a right to reduce the facilities and services that are deemed to be non-essential, such that their reduction or removal would not be detrimental to the medical condition of the patient. For the moment, the question to be considered is whether the subject facilities are indeed non-essential – the air-conditioner, telephone, television, and refrigerator – the removal of which would cause the adverse health effects and emotional trauma the respondents so claimed.

Corollary to this question is whether the petitioner observed the diligence of a good father of the family in the course of ascertaining the possible repercussions of the removal of the facilities prior to the

removal itself and for a reasonable time thereafter, with a view to prevent damage. The evidence in the record overwhelmingly demonstrates that respondent Chua had been adequately attended to, and this Court cannot understand why the courts a quo had declared that there was an "utter lack of medical attendance," or that her health suffered during the period after the removal of the facilities. The Court finds that the facilities in question are non-essential for the care of respondent Chua and, hence, they may be lessened or removed by the petitioner for the sake of economic necessity and survival.

Authorities are of the view that, ordinarily, a hospital, especially if it is a private pay hospital, is entitled to be compensated for its services, by either an express or an implied contract, and if no express contract exists, there is generally an implied agreement that the patient will pay the reasonable value of the services rendered; when a hospital treats a patient's injuries, it has an enforceable claim for full payment for its services, regardless of the patient's financial status. At this juncture, it must be noted that there is testimony, though to a degree disputable, to the effect that the execution of the promissory note and the issuance of postdated checks were conditions imposed not by the petitioner but voluntarily offered by the counsel for respondents. At any rate, however, this Court holds, in view of the foregoing authorities, that the requirement to have the relative of respondent Chua to execute a promissory note as part of the arrangement to settle the unpaid obligations is a formality that converts any implied contract into written form and, moreover, amounts to a reasonable condition, the non-fulfillment of which, in itself, however, as discussed, cannot allow the hospital to detain the patient. It must also be stressed, contrary to the findings of the courts a quo, that such an agreement embodied in a promissory note, as well as the Contract for Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990, do not become contracts of adhesion simply because the person signing it was under stress that was not the result of the actions of the hospital,117 especially taking into account that there is testimony to the effect that respondent Ty signed the Promissory Note dated June 5, 1992 in the presence of counsel and acting under his advise.

20. RCAP vs Executive Secretary

Facts:On 11 and 12 June 2006, the Professional Regulation Commission (PRC) conducted the Nursing Board Examinations nationwide. In June 2006, licensure applicants wrote the PRC to report that handwritten copies of two sets of examinations were circulated during the examination period among the examinees reviewing at the R.A. Gapuz Review Center and Inress Review Center. George Cordero, Inress Review Center’s President, was then the incumbent President of the Philippine Nurses Association. The examinees were provided with a list of 500 questions and answers in two of the examinations’ five subjects, particularly Tests III (Psychiatric Nursing) and V (Medical-Surgical Nursing). The PRC later admitted the leakage and traced it to two Board of Nursing members.On 19 June 2006, the PRC released the results of the Nursing Board Examinations. On 18 August 2006, the Court of Appeals restrained the PRC from proceeding with the oath-taking of the successful examinees set on 22 August 2006. Consequently, President Gloria Macapagal-Arroyo (President Arroyo) replaced all the members of the PRC’s Board of Nursing. President Arroyo also ordered the examinees to re-take the Nursing Board Examinations. On 8 September 2006, President Arroyo issued EO 566 which authorized the CHED to supervise the establishment and operation of all review centers and similar entities in the Philippines. In a letter dated 24 November 2006, the Review Center Association of the Philippines (petitioner), an organization of independent review centers, asked the CHED to "amend, if not withdraw" the IRR arguing, among other things, that giving permits to operate a review center to Higher Education Institutions (HEIs) or consortia of HEIs and professional organizations will effectively abolish independent review centers. In a letter dated 3 January 2007, Chairman Puno wrote petitioner, through its President Jose Antonio Fudolig (Fudolig), that to suspend the implementation of the IRR would be inconsistent with the mandate of EO 566. Chairman Puno wrote that the IRR was presented to the stakeholders during a consultation process prior to its finalization and publication on 13 November 2006. Chairman Puno also wrote that petitioner’s comments and suggestions would be considered in the event of revisions to the IRR.

Issue:Whether or not EO 566 is an unconstitutional exercise by the Executive of legislative power as it expands the CHED’s jurisdiction

Held:The President has no inherent or delegated legislative power to amend the functions of the CHED under RA 7722. Legislative power is the authority to make laws and to alter or repeal them, and this power is vested with the Congress. The line that delineates Legislative and Executive power is not indistinct. Legislative power is "the authority, under the Constitution, to make laws, and to alter and repeal them." The Constitution, as the will of the people in their original, sovereign and unlimited capacity, has vested this power in the Congress of the Philippines. The grant of legislative power to Congress is broad, general and comprehensive. The legislative body possesses plenary power for all purposes of civil government. Any power, deemed to be legislative by usage and tradition, is necessarily possessed by Congress, unless the Constitution has lodged it elsewhere. In fine, except as limited by the Constitution, either expressly or impliedly, legislative power embraces all subjects and extends to matters of general concern or common interest. While Congress is vested with the power to enact laws, the President executes the laws. The executive power is vested in the President. It is generally defined as the power to enforce and administer laws. It is the power of carrying the laws into practical operation and enforcing their due observance. As head of the Executive Department, the President is the Chief Executive. He represents the government as a whole and sees to it that all laws are enforced by the officials and employees of his department. He has control over the executive department, bureaus and offices. This means that he has the authority to assume directly the functions of the executive department, bureau and office, or interfere with the discretion of its officials. Corollary to the power of control, the President also has the duty of supervising the enforcement of laws for the maintenance of general peace and public order. Thus, he is granted administrative power over bureaus and offices under his control to enable him to discharge his duties effectively. Administrative power is concerned with the work of applying policies and enforcing orders as determined by proper governmental organs. It enables the President to fix a uniform standard of administrative efficiency and check the official conduct of his agents. To this end, he can issue administrative orders, rules and regulations.

21. PMA v. Board of Medical ExaminersG.R. L-25135 September 21, 1968

Facts:Respondent Jose Ma. Torres was granted a certificate to practice medicine in the Philippines without the examination required in Republic Act No. 2882, otherwise known as the Medical Act of 1959. Thereafter petitioner Philippine Medical Association filed an action contending that the grant of the respondent’s certificate for the general practice of medicine in the Philippines without the examination prescribed by law is violative of the law and that the respondent Board of Medical Examiners had exceeded its authority in passing the resolution that granted respondent Torres said certificate. Respondent contends that under the Treaty on the Validity of Academic Degrees and the Exercise of the Professions between the Republic of the Philippines and the Spanish State, she can be allowed to perform general practice of medicine in the country without taking the required examination.

Issue:Whether or not respondent should be allowed to perform the general practice of medicine in the Philippines even without taking the examination required by law.

Held:The SC held that the benefits of the aforementioned Treaty merely extended to diplomas issued or degrees conferred by educational institutions of Spain the same recognition and treatment that the Philippines accord to similar diplomas or degrees from local institutions of learning. Thus, holders of said Spanish diplomas or degrees must take the examination prescribed by the Philippines’ laws for holders of similar diplomas or degrees from educational institutions in the Philippines. The resolution No. 25,

series of 1965, of respondent Board is violative of Republic Act No. 2882 and hence, null and void; and that, respondent Board of Medical Examiners should be, as it is hereby ordered to cancel the certificate of registration, for the practice of medicine in the Philippines, issued in favor of respondent Jose Ma. Torres.

22. TABLARIN VS. GUTIERREZ 152 SCRA 730; G.R. No. 78164; 31 July 1987

Facts: The petitioners sought to enjoin the Secretary of Education, Culture and Sports, the Board of Medical Education and the Center for Educational Measurement from enforcing Section 5 (a) and (f) of Republic Act No. 2382, as amended, and MECS Order No. 52, series of 1985, dated 23 August 1985 and from requiring the taking and passing of the NMAT as a condition for securing certificates of eligibility for admission, from proceeding with accepting applications for taking the NMAT and from administering the NMAT as scheduled on 26 April 1987 and in the future. The trial court denied said petition on 20 April 1987. The NMAT was conducted and administered as previously scheduled. Republic Act 2382, as amended by Republic Acts Nos. 4224 and 5946, known as the "Medical Act of 1959" defines its basic objectives in the following manner: "SECTION 1. Objectives. — This Act provides for and shall govern (a) the standardization and regulation of medical education; (b) the examination for registration of physicians; and (c) the supervision, control and regulation of the practice of medicine in the Philippines."

The statute, among other things, created a Board of Medical Education. Its functions as specified in Section 5 of the statute include the following: "(a) To determine and prescribe requirements for admission into a recognized college of medicine; x x x (f) To accept applications for certification for admission to a medical school and keep a register of those issued said certificate; and to collect from said applicants the amount of twenty-five pesos each which shall accrue to the operating fund of the Board of Medical Education;”

Section 7 prescribes certain minimum requirements for applicants to medical schools: "Admission requirements. — The medical college may admit any student who has not been convicted by any court of competent jurisdiction of any offense involving moral turpitude and who presents (a) a record of completion of a bachelor's degree in science or arts; (b) a certificate of eligibility for entrance to a medical school from the Board of Medical Education; (c) a certificate of good moral character issued by two former professors in the college of liberal arts; and (d) birth certificate. Nothing in this act shall be construed to inhibit any college of medicine from establishing, in addition to the preceding, other entrance requirements that may be deemed admissible.”

MECS Order No. 52, s. 1985, issued by the then Minister of Education, Culture and Sports and dated 23 August 1985, established a uniform admission test called the National Medical Admission Test (NMAT) as an additional requirement for issuance of a certificate of eligibility for admission into medical schools of the Philippines, beginning with the school year 1986-1987. This Order goes on to state that: "2. The NMAT, an aptitude test, is considered as an instrument toward upgrading the selection of applicants for admission into the medical schools and its calculated to improve the quality of medical education in the country. The cutoff score for the successful applicants, based on the scores on the NMAT, shall be determined every year by the Board of Medical Education after consultation with the Association of Philippine Medical Colleges. The NMAT rating of each applicant, together with the other admission requirements as presently called for under existing rules, shall serve as a basis for the issuance of the prescribed certificate of eligibility for admission into the medical colleges.

Issue: Whether or not Section 5 (a) and (f) of Republic Act No. 2382, as amended, and MECS Order No. 52, s. 1985 are constitutional.

Held: Yes. We conclude that prescribing the NMAT and requiring certain minimum scores therein as a condition for admission to medical schools in the Philippines, do not constitute an unconstitutional imposition. The police power, it is commonplace learning, is the pervasive and non-waivable power and authority of the sovereign to secure and promote all the important interests and needs — in a word, the public order — of the general community. An important component of that public order is the health and physical safety and well being of the population, the securing of which no one can deny is a legitimate objective of governmental effort and regulation. Perhaps the only issue that needs some consideration is whether there is some reasonable relation between the prescribing of passing the NMAT as a condition for admission to medical school on the one hand, and the securing of the health and safety of the general community, on the other hand. This question is perhaps most usefully approached by recalling that the regulation of the practice of medicine in all its branches has long been recognized as a reasonable method of protecting the health and safety of the public.

MECS Order No. 52, s. 1985 articulates the rationale of regulation of this type: the improvement of the professional and technical quality of the graduates of medical schools, by upgrading the quality of those admitted to the student body of the medical schools. That upgrading is sought by selectivity in the process of admission, selectivity consisting, among other things, of limiting admission to those who exhibit in the required degree the aptitude for medical studies and eventually for medical practice. The need to maintain, and the difficulties of maintaining, high standards in our professional schools in general, and medical schools in particular, in the current stage of our social and economic development, are widely known. We believe that the government is entitled to prescribe an admission test like the NMAT as a means for achieving its stated objective of "upgrading the selection of applicants into [our] medical schools" and of "improv[ing] the quality of medical education in the country. We are entitled to hold that the NMAT is reasonably related to the securing of the ultimate end of legislation and regulation in this area. That end, it is useful to recall, is the protection of 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. WHEREFORE, the Petition for Certiorari is DISMISSED.

23. Board of Medical Education v. AlfonsoG.R. 88259 August 10, 1989

Facts:Upon finding, after conducting several inspections and evaluations, that the respondent Philippine Muslim-Christian College of Medicine Foundation, Inc. fell very much short of the minimum standards set for medical schools, the petitioner Board of Medical Education recommended to the DECS the closure of the said College. Secretary Lourdes Quisumbing of DECS ordered the closure of the said College. The College appealed to the Office of the President, however, the contested decision was affirmed. Thereafter, the College filed a case against Secretary Quisumbing in her capacity as Secretary of Education, Culture and Sports, questioning the decision as illegal, oppressive, arbitrary and discriminatory. The trial court ruled that there was no basis in ordering the closure of the College, as there was no evidence supporting such findings. It ordered a writ of injunction for the closure order made by Secretary Quisumbing. Hence, the petition.

Issue:Whether or not the Philippine Muslim-Christian College of Medicine Foundation, Inc. should be closed.

Held:There have been several evaluations conducted on the College and all yielded to the findings that it have failed to fully comply with the prescribed requirements by law. The discovered deficiencies as a medical college (i.e., the inadequate faculty with no prospects for satisfactory growth and development, and the total lack of serious development efforts in academic medicine) are so serious a character as to be irremediable. Under the law, the Secretary of Education, Culture and Sports have the power to enjoin compliance with the requirements laid down for medical schools and to mete out sanctions where he

finds that violations thereof have been committed. In the case at bar, Secretary Quisumbing correctly ordered the closure of the College after it had been given several opportunities to comply with certainrequirements yet it failed to do so. It was grave abuse of discretion for respondent judge to issue the questioned injunction and there by thwart official action.

24. DEPARTMENT OF EDUCATION, CULTURE AND SPORTS (DECS) and DIRECTOR OF CENTER FOR EDUCATIONAL MEASUREMENT vs. ROBERTO REY C. SAN DIEGOG.R. No. 89572 December 21, 1989

Facts:The private respondent Roberto Rey San Diego, is a graduate of the University of the East with a degree of Bachelor of Science in Zoology. The petitioner claims that he took the NMAT three times and flunked it as many times. When he applied to take it again, the petitioner rejected his application on the basis of the aforesaid rule. He then went to the Regional Trial Court of Valenzuela, Metro Manila, to compel his admission to the test. After hearing, the respondent judge rendered a decision on July 4, 1989, declaring the challenged order invalid and granting the petition. Judge Teresita Dizon-Capulong held that the petitioner had been deprived of his right to pursue a medical education through an arbitrary exercise of the police power.

Issue:Whether or not San Diego is entitled to take NMAT as requirement for admission to any medical school?

Held:The private respondent cannot take the NMAT again and pursue his medical profession because of the following grounds:1. For the purpose of gauging at least initially by the admission test and by the three-flunk rule, a student shall not be allowed to take the NMAT again after three successive failures.2. The State ensures that medical profession is not permeated by incompetents to whom patients may unwarily hand over their lives and health.3.It is not enough to simply invoke the right to quality education as a guarantee of the Constitution, while one has the right to aspire to be a doctor, he does not have the constitutional right to be a doctor; one must show that he is entitled to it because of his preparation and promise.4. The conflict that the challenged rule violates the equal protection clause is not well taken. Conformable to Article III, Section 1 of the Constitution, a law does not have to operate with equal force on all person or things.

25. PRC vs. De Guzman et al.GR 144681 June 21, 2004

Facts:The respondents are all graduates of the Fatima College of Medicine, Valenzuela City, Metro Manila. They passed the Physician Licensure Examination conducted in February 1993 by the Board of Medicine (Board). Petitioner Professional Regulation Commission (PRC) then released their names as successful examinees in the medical licensure examination. Shortly thereafter, the Board observed that the grades of the seventy-nine successful examinees from Fatima College in the two most difficult subjects in the medical licensure exam, Biochemistry (Bio-Chem) and Obstetrics and Gynecology (OB-Gyne), were unusually and exceptionally high. Eleven Fatima examinees scored 100% in Bio-Chem and ten got 100% in OB-Gyne, another eleven got 99% in Bio-Chem, and twenty-one scored 99% in OB-Gyne. The Board also observed that many of those who passed from Fatima got marks of 95% or better in both subjects, and no one got a mark lower than 90%. A comparison of the performances of the candidates from other schools was made. The Board observed that strangely, the unusually high ratings were true only for Fatima College examinees. It was a record-breaking phenomenon in the history of the Physician Licensure Examination. On June 7, 1993, the Board issued Resolution No. 19, withholding the registration as physicians of all the examinees from the Fatima College of Medicine. The PRC asked the National

Bureau of Investigation (NBI) to investigate whether any anomaly or irregularity marred the February 1993 Physician Licensure Examination. For its part, the NBI found that “the questionable passing rate of Fatima examinees in the [1993] Physician Examination leads to the conclusion that the Fatima examinees gained early access to the test questions.”

Issue:Was the act pursuant to R.A. 2382 a valid exercise of police power

Held:Yes, it is true that this Court has upheld the constitutional right of every citizen to select a profession or course of study subject to a fair, reasonable, and equitable admission and academic requirements. But like all rights and freedoms guaranteed by the Charter, their exercise may be so regulated pursuant to the police power of the State to safeguard health, morals, peace, education, order, safety, and general welfare of the people. Thus, persons who desire to engage in the learned professions requiring scientific or technical knowledge may be required to take an examination as a prerequisite to engaging in their chosen careers. This regulation takes particular pertinence in the field of medicine, to protect the public from the potentially deadly effects of incompetence and ignorance among those who would practice medicine.

It must be stressed, nevertheless, that the power to regulate the exercise of a profession or pursuit of an occupation cannot be exercised by the State or its agents in an arbitrary, despotic, or oppressive manner. A political body that regulates the exercise of a particular privilege has the authority to both forbid and grant such privilege in accordance with certain conditions. Such conditions may not, however, require giving up ones constitutional rights as a condition to acquiring the license. Under the view that the legislature cannot validly bestow an arbitrary power to grant or refuse a license on a public agency or officer, courts will generally strike down license legislation that vests in public officials discretion to grant or refuse a license to carry on some ordinarily lawful business, profession, or activity without prescribing definite rules and conditions for the guidance of said officials in the exercise of their power.

26. BOARD OF MEDICINE, DR. RAUL FLORES (NOW DR. JOSE S. RAMIREZ), IN HIS CAPACITY AS CHAIRMAN OF THE BOARD, PROFESSIONAL REGULATION COMMISSION, THROUGH ITS CHAIRMAN, HERMOGENES POBRE (NOW DR. ALCESTIS M. GUIANG), PETITIONERS, VS. YASUYUKI OTA, RESPONDENT.G.R. No. 166097, July 14, 2008

Facts:Yasuyuki Ota (respondent) is a Japanese national, married to a Filipina, who has continuously resided in the Philippines for more than 10 years. He graduated from Bicol Christian College of Medicine on April 21, 1991 with a degree of Doctor of Medicine. After successfully completing a one-year post graduate internship training at the Jose Reyes Memorial Medical Center, he filed an application to take the medical board examinations in order to obtain a medical license. He was required by the Professional Regulation Commission (PRC) to submit an affidavit of undertaking, stating among others that should he successfully pass the same, he would not practice medicine until he submits proof that reciprocity exists between Japan and the Philippines in admitting foreigners into the practice of medicine. Respondent submitted a duly notarized English translation of the Medical Practitioners Law of Japan duly authenticated by the Consul General of the Philippine Embassy to Japan, Jesus I. Yabes; thus, he was allowed to take the Medical Board Examinations in August 1992, which he subsequently passed. In spite of all these, the Board of Medicine (Board) of the PRC, in a letter dated March 8, 1993, denied respondent's request for a license to practice medicine in the Philippines on the ground that the Board "believes that no genuine reciprocity can be found in the law of Japan as there is no Filipino or foreigner who can possibly practice there." Respondent then filed a Petition for Certiorari and Mandamus against the Board before the RTC of Manila on June 24, 1993. In his petition before the RTC, respondent alleged that the Board and the PRC, in refusing to issue in his favor a Certificate of Registration and/or license to practice medicine, had acted arbitrarily, in clear contravention of the provision of Section 20 of Republic

Act (R.A.) No. 2382 (The Medical Act of 1959), depriving him of his legitimate right to practice his profession in the Philippines to his great damage and prejudice.

The RTC decided in favor of the respondent and thereby ordering the Board to issue in favor of respondent the corresponding Certificate of Registration and/or license to practice medicine in the Philippines. However, the Board and the PRC (petitioners) appealed the case to the CA, stating that while respondent submitted documents showing that foreigners are allowed to practice medicine in Japan, it was not shown that the conditions for the practice of medicine there are practical and attainable by a foreign applicant, hence, reciprocity was not established; also, the power of the PRC and the Board to regulate and control the practice of medicine is discretionary and not ministerial, hence, not compellable by a writ of mandamus. The CA denied the appeal and affirmed the ruling of the RTC.

Issue:Whether or not reciprocity in the practice of medicine exists between the Philippines and Japan

Held:Yes. R.A. No. 2382 otherwise known as the Medical Act of 1959 states in Section 9 thereof that:Section 9. Candidates for Board Examinations. – Candidates for Board examinations shall have the following qualifications:1. He shall be a citizen of the Philippines or a citizen of any foreign country who has submitted competent and conclusive documentary evidence, confirmed by the Department of Foreign Affairs, showing that his country's existing laws permit citizens of the Philippines to practice medicine under the same rules and regulations governing citizens thereof;x x x x

Presidential Decree (P.D.) No. 223 also provides in Section (j) thereof that:j) The [Professional Regulation] Commission may, upon the recommendation of the Board concerned, approve the registration of and authorize the issuance of a certificate of registration with or without examination to a foreigner who is registered under the laws of his country: Provided, That the requirement for the registration or licensing in said foreign state or country are substantially the same as those required and contemplated by the laws of the Philippines and that the laws of such foreign state or country allow the citizens of the Philippines to practice the profession on the same basis and grant the same privileges as the subject or citizens of such foreign state or country: Provided, finally, That the applicant shall submit competent and conclusive documentary evidence, confirmed by the Department of Foreign Affairs, showing that his country's existing laws permit citizens of the Philippines to practice the profession under the rules and regulations governing citizens thereof. The Commission is also hereby authorized to prescribe additional requirements or grant certain privileges to foreigners seeking registration in the Philippines if the same privileges are granted to or some additional requirements are required of citizens of the Philippines in acquiring the same certificates in his country; x x x x

As required by the said laws, respondent submitted a copy of the Medical Practitioners Law of Japan, duly authenticated by the Consul General of the Embassy of the Philippines in Japan, which provides inArticles 2 and 11, thus:Article 2. Anyone who wants to be medical practitioner must pass the national examination for medical practitioner and get license from the Minister of Health and Welfare. xxxxArticle 11. No one can take the National Medical Examination except persons who conform to one of the following items:

Persons who finished regular medical courses at a university based on the School Education Laws (December 26, 1947) and graduated from said university.

Persons who passed the preparatory test for the National Medical Examination and practiced clinics and public sanitation more than one year after passing the said test.

Persons who graduated from a foreign medical school or acquired medical practitioner license in a foreign country, and also are recognized to have the same or more academic ability and techniques as persons stated in item 1 and item 2 of this article.

Petitioners argue that while the Medical Practitioners Law of Japan allows foreigners to practice medicine therein, said document does not show that conditions for the practice of medicine in said country are practical and attainable by a foreign applicant; and since the requirements are practically impossible for a Filipino to comply with, there is no reciprocity between the two countries, hence, respondent may not be granted license to practice medicine in the Philippines.

The Court does not agree. R.A. No. 2382, which provides who may be candidates for the medical board examinations, merely requires a foreign citizen to submit competent and conclusive documentary evidence, confirmed by the Department of Foreign Affairs (DFA), showing that his country's existing laws permit citizens of the Philippines to practice medicine under the same rules and regulations governing citizens thereof. Section (j) of P.D. No. 223 also defines the extent of PRC's power to grant licenses, i.e., it may, upon recommendation of the board, approve the registration and authorize the issuance of a certificate of registration with or without examination to a foreigner who is registered under the laws of his country, provided the following conditions are met:

that the requirement for the registration or licensing in said foreign state or country are substantially the same as those required and contemplated by the laws of the Philippines;

that the laws of such foreign state or country allow the citizens of the Philippines to practice the profession on the same basis and grant the same privileges as the subject or citizens of such foreign state or country; and

that the applicant shall submit competent and conclusive documentary evidence, confirmed by the DFA, showing that his country's existing laws permit citizens of the Philippines to practice the profession under the rules and regulations governing citizens thereof.

The said provision further states that the PRC is authorized to prescribe additional requirements or grant certain privileges to foreigners seeking registration in the Philippines if the same privileges are granted to or some additional requirements are required of citizens of the Philippines in acquiring the same certificates in his country. Nowhere in said statutes is it stated that the foreign applicant must show that the conditions for the practice of medicine in said country are practical and attainable by Filipinos. Neither is it stated that it must first be proven that a Filipino has been granted license and allowed to practice his profession in said country before a foreign applicant may be given license to practice in the Philippines.

Indeed, the phrase used in both R.A. No. 2382 and P.D. No. 223 is that: [T]he applicant shall submit] competent and conclusive documentary evidence, confirmed by the Department of Foreign Affairs, showing that his country's existing laws permit citizens of the Philippines to practice the profession [of medicine] under the [same] rules and regulations governing citizens thereof. x x x (Emphasis supplied) It is enough that the laws in the foreign country permit a Filipino to get license and practice therein.

Requiring respondent to prove first that a Filipino has already been granted license and is actually practicing therein unduly expands the requirements provided for under R.A. No. 2382 and P.D. No. 223. While it is true that respondent failed to give details as to the conditions stated in the Medical Practitioners Law of Japan -- i.e., the provisions of the School Educations Laws, the criteria of the Minister of Health and Welfare of Japan in determining whether the academic and technical capability of foreign medical graduates are the same as or better than that of graduates of medical schools in Japan, and who can actually qualify to take the preparatory test for the National Medical Examination –respondent, however, presented proof that foreigners are actually practicing in Japan and that Filipinos are not precluded from getting a license to practice there. In fine, the only matter being questioned by petitioners is the alleged failure of respondent to prove that there is reciprocity between the laws of Japan and the Philippines in admitting foreigners into the practice of medicine. Respondent has satisfactorily complied with the said requirement and the CA has not committed any reversible error in rendering its Decision dated November 16, 2004 and Resolution dated October 19, 2003.