Rubi Li vs Spouses Soliman

GR No. 165279, June 7, 2011

FACTS:

Angelica Soliman, respondents’ 11-year old daughter, was suffering from osteosarcoma, osteoblastic type, 4 a high-
grade (highly malignant) cancer of the bone which usually afflicts teenage children. Following this diagnosis and as
primary intervention, Angelica’s right leg was amputated by Dr.Tamayo in order to remove the tumor. As adjuvant
treatment to eliminate any remaining cancer cells chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred
Angelica to another doctor at St. Luke’s Medical Center (SLMC), herein petitioner Dr. Rubi Li, a medical oncologist.

Just 11 days after the (intravenous) administration of the first cycle of the chemotherapy regimen, Angelica died.
Because SLMC refused to release a death certificate without full payment of their hospital bill, respondents brought
the cadaver of Angelica to the Philippine National Police (PNP) Crime Laboratory at Camp Crame for post-mortem
examination. The Medico-Legal Report issued by said institution indicated the cause of death as "Hypovolemic shock
secondary to multiple organ hemorrhages and Disseminated Intravascular Coagulation. Certificate of Death issued by
SLMC stated the cause of death as follows: Immediate cause: Osteosarcoma and Antecedent cause: above knee
amputation.

Respondents filed a damage suit against petitioner, Dr Marbella, Mr. Ledesma, a certain Dr. Arriete and SLMC.
Respondents charged them with negligence and disregard of Angelica’s safety, health and welfare by their careless
administration of the chemotherapy drugs, their failure to observe the essential precautions in detecting early the
symptoms of fatal blood platelet decrease and stopping early on the chemotherapy, which bleeding led to
hypovolemic shock that caused Angelica’s untimely demise. They also averred that petitioner assured the
respondents that Angelica would recover in view of 95% chance of healing with chemotherapy and when asked
regarding the side effects, petitioner mentioned only slight vomiting, hair loss and weakness. Respondents thus
claimed that they would not have given their consent to chemotherapy had petitioner not falsely assured them of its
side effects.

Petitioner denied having been negligent in administering the chemotherapy drugs to Angelica and asserted that she
had fully explained to respondents how the chemotherapy will affect not only the cancer cells but also the patient’s
normal body parts, including the lowering of white and red blood cells and platelets. She claimed that what happened
to Angelica can be attributed to malignant tumor cells possibly left behind after surgery.

Respondents presented as witnesses Dr. Jesusa Nieves-Vergara, Medico-Legal Officer of the PNP-Crime
Laboratory who conducted the autopsy on Angelica’s cadaver, and Dr. Melinda Vergara Balmaceda who is a Medical
Specialist employed at the Department of Health (DOH) Operations and Management Services. Dr. Vergara noted
the following: (1) there were fluids recovered from the abdominal cavity, which is not normal, and was due to
hemorrhagic shock secondary to bleeding; (2) there was hemorrhage at the left side of the heart; (3) bleeding at the
upper portion of and areas adjacent to, the esophagus; (4) lungs were heavy with bleeding at the back and lower
portion, due to accumulation of fluids; (4) yellowish discoloration of the liver; (5) kidneys showed appearance of facial
shock on account of hemorrhages; and (6) reddishness on external surface of the spleen. All these were the end
result of "hypovolemic shock secondary to multiple organ hemorrhages and disseminated intravascular coagulation."
Dr. Vergara opined that this can be attributed to the chemical agents in the drugs given to the victim, which caused
platelet reduction resulting to bleeding sufficient to cause the victim’s death. Dr. Balmaceda declared that it is the
physician’s duty to inform and explain to the patient or his relatives every known side effect of the procedure or
therapeutic agents to be administered, before securing the consent of the patient or his relatives to such procedure or
therapy. Dr. Balmaceda also stressed that the patient or relatives must be informed of all known side effects based
on studies and observations, even if such will aggravate the patient’s condition.

Dr. Jaime Tamayo, the orthopaedic surgeon who operated on Angelica’s lower extremity, testified for the
defendants. He explained that in case of malignant tumors, there is no guarantee that the ablation or removal of the
amputated part will completely cure the cancer. Thus, surgery is not enough. The mortality rate of osteosarcoma at
the time of modern chemotherapy and early diagnosis still remains at 80% to 90%. In the case of Angelica, he had
previously explained to her parents that after the surgical procedure, chemotherapy is imperative so that metastasis
of these cancer cells will hopefully be addressed. He referred the patient to petitioner because he felt that petitioner is
a competent oncologist. Considering that this type of cancer is very aggressive and will metastasize early, it will
cause the demise of the patient should there be no early intervention

Trial Court dismissed the complaint and held that petitioner was not liable for damages as she observed the best
known procedures and employed her highest skill and knowledge in the administration of chemotherapy drugs on
Angelica but despite all efforts said patient died. Using the standard of negligence laid down in Picart v. Smith, the
trial court declared that petitioner has taken the necessary precaution against the adverse effect of chemotherapy on
the patient, adding that a wrong decision is not by itself negligence.

CA find defendant Dr. Rubi Li negligent which would entitle plaintiffs-appellants to their claim for damages.

ISSUES:

Whether or not Defendant is negligent

HELD:

NO. Defendant is not negligent.

In medical negligence lawsuit, 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.

Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the
same general neighborhood and in the same general line of practice as defendant physician or surgeon. The
deference of courts to the expert opinion of qualified physicians stems from the former’s realization that the latter
possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating, hence the
indispensability of expert testimonies. In this case, both the trial and appellate courts concurred in finding that the
alleged negligence of petitioner in the administration of chemotherapy drugs to respondents’ child was not proven
considering that Drs. Vergara and Balmaceda, not being oncologists or cancer specialists, were not qualified to give
expert opinion as to whether petitioner’s lack of skill, knowledge and professional competence in failing to observe
the standard of care in her line of practice was the proximate cause of the patient’s death. Furthermore, respondents’
case was not at all helped by the non-production of medical records by the hospital (only the biopsy result and
medical bills were submitted to the court).

In malpractice actions generally, there must be a causal relationship between the physician’s failure to divulge and
damage to the patient. 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.

In the case at bar, the SC held that there was adequate disclosure of material risks inherent in the chemotherapy
procedure performed with the consent of Angelica’s parents. Respondents could not have been unaware in the
course of initial treatment and amputation of Angelica’s lower extremity, that her immune system was already weak
on account of the malignant tumor in her knee. When petitioner informed the respondents beforehand of the side
effects of chemotherapy, there is reasonable expectation on the part of the doctor that the respondents understood
very well that the severity of these side effects will not be the same for all patients undergoing the procedure.

As a physician, petitioner can reasonably expect the respondents to have considered the variables in the
recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is difficult to
give credence to respondents’ claim that petitioner told them of 95% chance of recovery for their daughter, as it was
unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to have falsely assured
patients of chemotherapy’s success rate.

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 who is not an oncologist but a Medical Specialist of the DOH’s
Operational and Management Services charged with receiving complaints against hospitals, does not qualify as
expert testimony to establish the standard of care in obtaining consent for chemotherapy treatment. In the absence of
expert testimony in this regard, the Court feels hesitant in defining the scope of mandatory disclosure in cases of
malpractice based on lack of informed consent, much less set a standard of disclosure that, even in foreign
jurisdictions, has been noted to be an evolving one. Legal standard of disclosure is not subject to construction as a
categorical imperative. Whatever formulae or processes we adopt are only useful as a foundational starting point; the
particular quality or quantity of disclosure will remain inextricably bound by the facts of each case. Nevertheless,
juries that ultimately determine whether a physician properly informed a patient are inevitably guided by what they
perceive as the common expectation of the medical consumer—"a reasonable person in the patient’s position when
deciding to accept or reject a recommended medical procedure."

Therefore, SC reinstated the decision of the RTC and held petitioner not liable.