LEGAL MEDICINE

Preliminary Period Lecture Notes

Introduction: The Filipino Physician

1. College of Medicine (4 years)

2. Professional Regulation Commission (PRC)
3. General Practice
4. Residency/Specialty Training (3-4 years depending on the program)
5. Specialist (e.g. Pediatrician)
6. Subspecialty training (2-3 years depending on the program)
7. Subspecialist (e.g. Pediatrician that specializes on babies/neonatologist)
- Takes around 10 years to be a doctor

Q: What is merely given to specialist/subspecialists?

A: Only certifications (no special license)

Republic Act No. 2382: The Medical Act of 1959

Two (2) agencies:

1. Board of Medical Examiners under the Professional Regulation Commission (PRC)
2. Board of Medical Education under the Commission on Higher Education (CHED)

CHED regulates medical education in the Philippines (curriculum, requirements, regulatory body, etc.)
 CHED can close a medical school for non-performance (particularly in board exams)
 CHED can order schools to release student credentials

Board of Medical Education vs. Alfonso, G.R. No. 88259, 10 August 1989
Facts:
The, College, a private educational institution, was founded in 1981 for the avowed purpose of producing
physicians who will “emancipate Muslim citizens from age-old attitudes on health.” The, unstable peace and order
situation in Mindanao led to the establishment of the College in Antipolo, Rizal, which granted it a temporary
permit to operate in the municipality, instead of in Zamboanga City where the school was first proposed to be
located. It has since adopted Antipolo as its permanent site and changed its name to the Rizal College of Medicine.

In 1985, the Department of Education, Culture and Sports (DECS) and the Board of Medical Education (BME)
authorized the Commission on Medical Education to conduct a study of all medical schools in the Philippines. The
report of the Commission showed that the College fell very much short of the minimum standards set for medical
schools.  The team of inspectors recommended the closure of the school upon the following findings, to wit:

(a) the College was not fulfilling the purpose for which it had been created because of its inappropriate
location and the absence in its curriculum of subjects relating to Muslim culture and welfare;
(b) its lack of university affiliation hindered its students from obtaining a “balanced humanistic and
scientific” education;
(c) it did not have its philosophy base hospital for the training of its students in the major clinical disciplines,
as required by the DECS;
(d) more than 60% of the college faculty did not teach in the College full-time, resulting in shortened and
irregular class hours, subject overloading, and in general, poor quality teaching.

The school disputed these findings as biased and discriminatory. Four (4) other surveys were thereafter made by
as many different committees or teams, at the school’s instance or otherwise, all of which basically confirmed the
results of that first survey.

In her letter of June 23, 1988, Secretary Quisumbing informed the Chairman of the College’s Board of Trustees,
Mr. Victor Sumulong, of the decision of the Board of Medical Education to close the College. Mr. Sumulong
instead proposed a gradual phase-out starting the school year 1989-1990 in order not to dislocate the students
and staff and to minimize financial loss. The Board subsequently allowed the College to continue its operations
but only until May 1989, after which it was to be closed, this decision being “final and unappealable.”

LEGMED | MOJICA 1
LEGAL MEDICINE
Preliminary Period Lecture Notes

The College appealed the decision to the Office of the President, imputing grave abuse of discretion to the
Secretary. On February 16, 1989, Executive Secretary Catalino Macaraig, Jr., finding “no reason to disturb” the
contested decision, affirmed it.

On March 2, 1989, the College went to court. It filed Civil Case No. 1385 in the court of respondent Judge Daniel
P. Alfonso against Secretary Quisumbing in her capacity as Secretary of Education, Culture and Sports,
questioning the decision as illegal, oppressive, arbitrary and discriminatory and applied for a writ of preliminary
injunction to restrain its implementation. The writ was issued as prayed for, by order of the respondent Judge
dated May 10, 1989, ruled that the inspection of June 18, 1988 was the principal basis of the closure order, and on
such basis sustained the claim of the College that the inspection was done in an “arbitrary and haphazard manner”
by a team of inspectors who had already prejudged the school.

Issue:  
Whether or not the order of injunction dated May 10, 1989 was issued with grave abuse of discretion and a
restraining order against its enforcement as well as for the dismissal of the action may be instituted in the court a
quo.

Ruling:
The petition is hereby granted and the temporary restraining order issued by the Court is made permanent. The
questioned writ of preliminary injunction dated May 10, 1989 is set aside and respondent Judge is ordered to
dismiss Civil Case No. 1385.

Respondent Judge gravely abused his discretion in substituting his judgment for theirs. It is well-settled doctrine
that courts of justice should not generally interfere with purely administrative and discretionary functions; that
courts have no supervisory power over the proceedings and actions of the administrative departments of the
government; involving the exercise of judgment and findings of facts, because by reason of their special knowledge
and expertise over matters falling under their jurisdiction, the latter are in a better position to pass judgment on
such matters and in their findings of facts in that regard are generally accorded respect, if not finality, by the
courts. There are, to be sure, exceptions to this general rule but none of them obtains in this case.

PRC vs. De Guzman, G.R. No. 144681, 21 June 2004

Mostly circumstantial evidence is accepted in administrative cases.

Q: Is it ministerial for Board of Medicine to administer their oath?

A: The Board of Medicine says they must have passed “satisfactorily” for it to be ministerial for the Board to
administer the oath. The Board says there was cheating involved.

PRC vs. De Guzman, G.R. No. 144681, 21 June 2004

Facts: 
After the Professional Regulations Commission (PRC) released the names of successful examinees in the Medical
Licensure Examination, the Board of Medicine observed that the grades of the 79 Fatima College of Medicine
successful examinees were unusually and exceptionally high in the two (2) most difficult subjects of the exam, i.e.,
Biochemistry and Obstetrics and Gynecology.

The Board then issued Resolution No. 19 withholding the registration as physicians of all the examinees from
Fatima College of Medicine. As noted by PRC’s statistician consultant, Fr. Nebres of ADMU, compared with other
examinees from other schools, the results of those from Fatima were not only incredibly high but unusually
clustered close to each other. The NBI Investigation concluded that the Fatima examinees gained early access to
the test questions.

On July 5, 1993, the respondents-examinees filed a petition for mandamus before the RTC of Manila to compel
the PRC to give them their licenses to practice medicine. Meanwhile on July 21, 1993, the Board of Medicine
issued Resolution No. 21 charging the respondents of immorality, dishonest conduct, fraud and deceit and
recommended that the test results of the Fatima Examinees be nullified.

LEGMED | MOJICA 2
LEGAL MEDICINE
Preliminary Period Lecture Notes

On December 19, 1994, the RTC of Manila promulgated its decision ordering the PRC to allow the respondents to
take the physician’s oath and to register them as physicians. The same was appealed by the PRC to the Court of
Appeals which sustained the RTC decision. Hence, this petition.

Issues:
1. Whether or not it is a ministerial duty for the Board of Medicine to issue certificates of registration as
physicians under Republic Act No. 2382
2. Whether or not the respondent-examinees have the right to be registered as physicians

Ruling:
1. A careful reading of Section 20 of the Medical Act of 1959 discloses that the law uses the word “shall” with
respect to the issuance of certificates of registration. Thus, the petitioners “shall sign and issue certificates of
registration to those who have satisfactorily complied with the requirements of the Board.” In statutory
construction the term “shall” is a word of command. It is given imperative meaning. Thus, when an examinee
satisfies the requirements for the grant of his physician’s license, the Board is obliged to administer to him his
oath and register him as a physician, pursuant to Section 20 and par. (1) of Section 22 of the Medical Act of 1959.

However, the surrounding circumstances in this case call for serious inquiry concerning the satisfactory
compliance with the Board requirements by the respondents.

Section 8 of Republic Act No. 2382 prescribes, among others, that a person who aspires to practice medicine in
the Philippines, must have “satisfactorily passed the corresponding Board Examination.” Section 22, in turn,
provides that the oath may only be administered “to physicians who qualified in the examinations.” The operative
word here is “satisfactorily,” defined as “sufficient to meet a condition or obligation” or “capable of dispelling
doubt or ignorance.” Gleaned from Board Resolution No. 26, the licensing authority apparently did not find that
the respondents “satisfactorily passed” the licensure examinations. The Board instead sought to nullify the
examination results obtained by the respondents.

Hence, until the moral and mental fitness of the respondents could be ascertained, the Board has discretion to
hold in abeyance the administration of the Hippocratic Oath and the issuance of the certificates to them. The writ
of mandamus does not lie to compel performance of an act which is not duly authorized.

2. It is long established rule that a license to practice medicine is a privilege or franchise granted by the
government. 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.

In the present case, Republic Act No. 2382, as amended, prescribed the requirements for admission to the practice
of medicine, the qualifications of candidates for the board examinations, the scope and conduct of the
examinations, the grounds for denying the issuance of a physician’s license, or revoking a license that has been
issued. Verily, to be granted the privilege to practice medicine, the applicant must show that he possesses all the
qualifications and none of the disqualifications. Furthermore, it must appear that he has fully complied with all
the conditions and requirements imposed by the law and the licensing authority. Should doubt taint or mar the
compliance as being less than satisfactory, then the privilege will not issue. For said privilege is distinguishable
from a matter of right, which may be demanded if denied. Thus, without a definite showing that the aforesaid
requirements and conditions have been satisfactorily met, the courts may not grant the writ of mandamus to
secure said privilege without thwarting the legislative will.

Professional Regulation Commission through the Board of Medicine

 The PRC, through the BOM, regulates practice of medicine from the time they take the med examination.
 They are the ones who prepare the examinations.
 Medical examinations date should be 6 months apart (Section 18, R.A. No. 2382)

LEGMED | MOJICA 3
LEGAL MEDICINE
Preliminary Period Lecture Notes

Section 18. Dates of Examinations. The Board of Medical Examiners shall give examinations for
the registration of physicians, twice a year on dates to be determined by it provided that the interval
between the first and the second examinations in a year shall be six months, in the City of Manila or
any of its suburbs after giving not less than ten days’ notice to each candidate who had filed his name
and address with the Secretary of the Board.

 They conduct administrative investigations, complaints against physicians

o They can hear and decide administrative cases filed against the doctor.
o The Board can dismiss the complaint OR they can file the physician as administratively liable
▪ Either reprimand, suspend, or revoke the certificate of registration of physician (if found
to be administratively liable)

Section 24. Grounds for reprimand, suspension or revocation of registration

certificate. Any of the following shall be sufficient ground for reprimanding a physician, or for
suspending or revoking a certificate of registration as physician:
(1) Conviction by a court of competent jurisdiction of any criminal offense involving moral
turpitude;
(2) Immoral or dishonorable conduct;
(3) Insanity;
(4) Fraud in the acquisition of the certificate of registration;
(5) Gross negligence, ignorance or incompetence in the practice of his or her profession resulting in
an injury to or death of the patient;
(6) Addiction to alcoholic beverages or to any habit forming drug rendering him or her
incompetent to practice his or her profession, or to any form of gambling;
(7) False or extravagant or unethical advertisements wherein other things than his name,
profession, limitation of practice, clinic hours, office and home address, are mentioned.
(8) Performance of or aiding in any criminal abortion;
(9) Knowingly issuing any false medical certificate;
(10)Issuing any statement or spreading any news or rumor which is derogatory to the character
and reputation of another physician without justifiable motive;
(11) Aiding or acting as a dummy of an unqualified or unregistered person to practice medicine;
(12)Violation of any provision of the Code of Ethics as approved by the Philippine Medical
Association.

Refusal of a physician to attend a patient in danger of death is not a sufficient ground for revocation or
suspension of his registration certificate if there is a risk to the physician’s life.

 The Board of Medicine has NO civil and criminal jurisdiction; only administrative.
o No authority to award damages or rule on the criminal aspects of the complaint.
 Accessory/incidental powers of the Board of Medicine (Section 24, R.A. No. 2382):
o Contempt of court
o Issuing of subpoenas
 Decision of the Board of Medicine can be appealed to PRC
o PRC’s decision can be appealed to Court of Appeals
o Court of Appeals’ decision can be appealed to Supreme Court
 Appeal to Civil Service/Office of President is NO longer applicable
o Since PRC is no longer under the Office of the President

Lasam vs. Ramolete, G.R. No. 159132, 18 December 2008

Sec. 1, Rule 43 of the Rules of Court provides:

Section 1. Scope. - This Rule shall apply to appeals from judgments or final orders of the Court of Tax
Appeals, and from awards, judgments, final orders or resolutions of or authorized by any quasi-
judicial agency in the exercise of its quasi-judicial functions. Among these agencies are the Civil Service
Commission, Central Board of Assessment Appeals, Securities and Exchange Commission, Office of the President,

LEGMED | MOJICA 4
LEGAL MEDICINE
Preliminary Period Lecture Notes

Land Registration Authority, Social Security Commission, Civil Aeronautics Board, Bureau of Patents,
Trademarks and Technology Transfer, National Electrification Administration, Energy Regulatory Board,
National Telecommunications Commission, Department of Agrarian Reform under Republic Act No. 6657,
Government Service Insurance System, Employees Compensation Commission, Agricultural Inventions Board,
Insurance Commission, Philippine Atomic Energy Commission, Board of Investments, Construction Industry
Arbitration Commission, and voluntary arbitrators authorized by law.

Indeed, the PRC is not expressly mentioned as one of the agencies which are expressly enumerated under Section
1, Rule 43 of the Rules of Court. However, its absence from the enumeration does not, by this fact alone, imply its
exclusion from the coverage of said Rule. The Rule expressly provides that it should be applied to appeals from
awards, judgments final orders or resolutions of any quasi-judicial agency in the exercise of its quasi-judicial
functions. The phrase “among these agencies” confirms that the enumeration made in the Rule is not exclusive to
the agencies therein listed.

 Rule 43, Rules of Court – when you appeal decisions of quasi-judicial agency (e.g. PRC)
 Rule 45, Rules of Court – Court of Appeals decisions, final orders or resolutions may be
appealed to the Supreme Court by filing a petition for review.

Practice of Medicine

Section 8. Prerequisite to the Practice of Medicine. No person shall engage in the practice of medicine in
the Philippines unless he is:
1. at least twenty-one years of age;
2. has satisfactorily passed the corresponding Board of Examination; and
3. is a holder of a valid Certificate of Registration duly issued to him by the Board of Medical Examiners
[serves as proof of authority of doctor to practice]

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;
2. He shall be of good moral character;
3. He shall be of sound mind;
4. He shall not have been convicted by a court of competent jurisdiction of any offense involving moral
turpitude;
5. He shall be a holder of the degree of doctor of Medicine or its equivalent conferred by a college of
medicine duly recognized by the government; and
6. He must have completed a calendar year of technical training known as internship the nature of which
shall be prescribed by the Board of Medical Education undertaken in hospitals and health centers
approved by the Board

NOTE: The Medical Act does not mention PRC license but simply Certificate of Registration
 PRC will simply not issue certification of registration when the requirements are not complied with.
 Reinstatement into practice – after 2 years from finality of decision of disqualification
o Not ministerial. Only discretionary

Q: Can a foreigner practice medicine in Philippines? YES

Board of Medicine vs. Ona, G.R. No. 166097, 14 July 2008

Supreme Court: The requirement of the Medical Act is merely that the foreign country allows Filipinos,
even if there are no Filipinos practicing in that country, provided there is reciprocity
▪ If Filipinos are allowed to practice med in foreign country, foreigner can practice medicine in the
Philippines.

LEGMED | MOJICA 5
LEGAL MEDICINE
Preliminary Period Lecture Notes

▪ Requirements to practice in Philippines and in home country of foreigner must also be substantially the
same.

Consequence of Practice of Medicine without Certificate of Registration

Practicing medicine without certificate of registration constitutes illegal practice of medicine.

 P1,000.00 to P10,000.00 penalty
 1-5-year imprisonment in case of insolvency

Exceptions:
 Temporary practice of medicine by foreigners; Foreigners attached to certain international organizations; or
Exchange professors
○ Upon authorization of the Board of Medicine
 Medical personnel of the US Armed Forces
○ Only for the members of the said armed forces & within the limits of their respective jurisdiction.
 Medicine students (limited practice of medicine – without certificate of registration)
○ Completed the first 4 years of medical course, graduates of medicine [+ registered nurses]
○ Given by the Secretary of Health to render services during epidemics or national emergencies
whenever the services of duly registered physicians are not available.
○ Until the epidemic or national emergency is declared terminated by the Secretary of Health.

What constitutes Practice of Medicine?

 Physically examine, diagnose, treat, operate or prescribe any remedy for human disease, injury, condition or
ailment.
 Offering to perform services

Doctor-Patient Relationship

 Based on the general provisions of the Civil Code.

 May be based on a Contract
○ Express or implied
 The doctor and/or the patient need not secure a written agreement for their relationship since it may
also be implied.
○ Requires the consent of a valid contract → needs consent; premised on the mutual trust of the parties.
 Consent of the patient and the doctor.
 Patient’s consent must be an informed consent.

Rubi Li vs. Soliman, G.R. No. 165279, 7 June 2011

Facts: 
On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a biopsy of the mass located in
her lower extremity at the St. Luke’s Medical Center (SLMC). Results showed that Angelica was suffering from
osteosarcoma, osteoblastic type,a high-grade (highly malignant) cancer of the bone which usually afflicts teenage
children. Following this diagnosis and as primary intervention, Angelicas right leg was amputated by Dr. Jaime
Tamayo in order to remove the tumor. As adjuvant treatment to eliminate any remaining cancer cells, and hence
minimize the chances of recurrence and prevent the disease from spreading to other parts of the patient’s body
(metastasis), chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred Angelica to another doctor at
SLMC, herein petitioner Dr. Rubi Li, a medical oncologist.

On August 18, 1993, Angelica was admitted to SLMC. However, she died on September 1, 1993, just eleven (11)
days after the (intravenous) administration of the first cycle of the chemotherapy regimen. Because SLMC refused
to release a death certificate without full payment of their hospital bill, respondents brought the cadaver of
Angelica to the Philippine National Police (PNP) Crime Laboratory at Camp Crame for post-mortem examination.
The Medico-Legal Report issued by said institution indicated the cause of death as “Hypovolemic shock secondary
to multiple organ hemorrhages and Disseminated Intravascular Coagulation.”

On February 21, 1994, respondents filed a damage suit against petitioner, Dr. Leo Marbella, Mr. Jose Ledesma, a
certain Dr. Arriete and SLMC. Respondents charged them with negligence and disregard of Angelicas safety,

LEGMED | MOJICA 6
LEGAL MEDICINE
Preliminary Period Lecture Notes

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 Angelicas untimely demise.

On her part, Dr. Balmaceda declared that it is the physician’s duty to inform and explain to the patient or his
relatives every known side effect of the procedure or therapeutic agents to be administered, before securing the
consent of the patient or his relatives to such procedure or therapy. The physician thus bases his assurance to the
patient on his personal assessment of the patient’s condition and his knowledge of the general effects of the agents
or procedure that will be allowed on the patient. Dr. Balmaceda stressed that the patient or relatives must be
informed of all known side effects based on studies and observations, even if such will aggravate the patient’s
condition.

In dismissing the complaint, the trial court held that petitioner was not liable for damages as she observed the
best known procedures and employed her highest skill and knowledge in the administration of chemotherapy
drugs on Angelica but despite all efforts said patient died.

Issue:
Whether the petitioner can be held liable for failure to fully disclose serious side effects to the parents of the child
patient who died while undergoing chemotherapy, despite the absence of finding that petitioner was negligent in
administering the said treatment

Ruling:
NO. 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.”

Examining the evidence on record, we hold that there was adequate disclosure of material risks inherent in the
chemotherapy procedure performed with the consent of Angelica’s parents. Respondents could not have been
unaware in the course of initial treatment and amputation of Angelicas lower extremity, that her immune system
was already weak on account of the malignant tumor in her knee. When petitioner informed the respondents
beforehand of the side effects of chemotherapy which includes lowered counts of white and red blood cells,
decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation
on the part of the doctor that the respondents understood very well that the severity of these side effects will not
be the same for all patients undergoing the procedure. In other words, by the nature of the disease itself, each
patient’s reaction to the chemical agents even with pre-treatment laboratory tests cannot be precisely determined
by the physician. That death can possibly result from complications of the treatment or the underlying cancer
itself, immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled out,
as with most other major medical procedures, but such conclusion can be reasonably drawn from the general side
effects of chemotherapy already disclosed.

As a physician, petitioner can reasonably expect the respondents to have considered the variables in the
recommended treatment for their daughter afflicted with a life-threatening illness. On the other hand, it is
difficult to give credence to respondents claim that petitioner told them of 95% chance of recovery for their
daughter, as it was unlikely for doctors like petitioner who were dealing with grave conditions such as cancer to
have falsely assured patients of chemotherapy's success rate. Besides, informed consent laws in other countries
generally require only a reasonable explanation of potential harms, so specific disclosures such as statistical data,
may not be legally necessary.

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

LEGMED | MOJICA 7
LEGAL MEDICINE
Preliminary Period Lecture Notes

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. PETITION DENIED.
Introduction to Medical Negligence

- Medical malpractice
- Professional medical liability

Medical Negligence is defined as negligence on the part of the physician resulting to injury to the patient or a
breach of a doctor-patient relationship contract.

No specific law for medical malpractice in the Philippines but we rely on general provisions of other
laws, depending on the cause of action of the patient.

So if you’re patient was injured on the ground of negligence of the physician, there are three possible
liabilities that may arise:

1. Administrative Liability

This would refer to the license of the doctor to practice. If a physician is found to be administratively liable,
his license may be revoked. This is under the Board of Medicine (BOM), the Professional Regulation
Commission (PRC) which has jurisdiction to do this.

The grounds will be based on Section 24 of the Republic Act No. 2382: The Medical Act of 1959.

Section 24. Grounds for reprimand, suspension or revocation of registration certificate. Any of

the following shall be sufficient ground for reprimanding a physician, or for suspending or revoking a certificate of
registration as physician:
(1) Conviction by a court of competent jurisdiction of any criminal offense involving moral turpitude;
(2) Immoral or dishonorable conduct;
(3) Insanity;
(4) Fraud in the acquisition of the certificate of registration;
(5) Gross negligence, ignorance or incompetence in the practice of his or her profession resulting in an injury
to or death of the patient;
(6) Addiction to alcoholic beverages or to any habit forming drug rendering him or her incompetent to
practice his or her profession, or to any form of gambling;
(7) False or extravagant or unethical advertisements wherein other things than his name, profession,
limitation of practice, clinic hours, office and home address, are mentioned.
(8) Performance of or aiding in any criminal abortion;
(9) Knowingly issuing any false medical certificate;
(10)Issuing any statement or spreading any news or rumor which is derogatory to the character and
reputation of another physician without justifiable motive;
(11) Aiding or acting as a dummy of an unqualified or unregistered person to practice medicine
(12)Violation of any provision of the Code of Ethics as approved by the Philippine Medical Association.

Refusal of a physician to attend a patient in danger of death is not a sufficient ground for revocation or suspension
of his registration certificate if there is a risk to the physician’s life.

The jurisdiction of the Board of Medicine is only limited to administrative liability.

2. Civil Liability

Another option of the patient would be to file a suit for damages against the doctor, that is, to claim for
money against the physician. The Board of Medicine has no such authority, so it is lodged before the courts.
The court has the jurisdiction to award damages to the patient.

LEGMED | MOJICA 8
LEGAL MEDICINE
Preliminary Period Lecture Notes

3. Criminal Liability

Another cause of action of the part of the patient would be to file a criminal case against the doctor for the
injury that he suffered. Also, this is lodged before the courts of justices.

So, depending now on the intention of the patient, we [the physicians] always ask the patients when cases of
malpractice suits. We [the physicians] the patient, what is your intention? What do you want to happen? Do you
want to revoke the license of the physician? Do you want to ask for money or damages? Or do you want to put him
in prison? Or all of the above, or any of the above? It would depend on what is the intention.

If the intention is to just revoke the license, we [the physician and the patient-complainant] go to PRC, to the
Board of Medicine. What are the grounds here? These are in Section 24 of the Republic Act No. 2382:
The Medical Act of 1959: gross negligence or incompetence of the physician resulting to injury or
death of the patient.

Or if the intention of the patient is to recover money, we [the physician and the patient-complainant] go now to
court and file an action for damages. What is the basis there? It is either 1) breach of doctor-patient
contractual relationship; (2) breach of contract; or (3) torts, quasi-delicts under Article 2176 of
the New Civil Code.

Quasi-delicts (torts)
Anyone who causes injury to another, there being fault or negligence shall pay for the damage done. So it
depends now on the counsel on what will be his strategy to recover damages.

(4) Or he [counsel] can go against the physician’s freedom or liberty and file a criminal case for the
imprisonment of the doctor and the payment of fine. He would also have to file that in court, and it is the
court that will decide that, after the necessary preliminary investigation with the fiscal [prosecutor].
Eventually, it will be lodged to court if there is probable cause. It is now the court that has jurisdiction to put a
physician in prison or payment of fine. What is the basis here? It is Article 365 of the R evised Penal Code on
criminal negligence. So it depends on what the patient wants; it can be any of the above. But the point here is
we do not have particular law for medical malpractice. It is scattered in The Medical Act of 1959
[administrative liability], in the provisions of the New Civil Code [civil liability], and also in the provisions of
the Revised Penal Code [criminal liability]. So it is as the case may be, depending on the intention of the
complainant-patient.

Introduction to Medical Negligence

Elements of Medical Negligence/Medical Malpractice:

1. Duty
2. Breach/dereliction of duty
3. Injury to the complainant-patient
4. Direct Causation/proximate cause

Case: Ramos vs. Court of Appeals, G.R. No. 124354, 29 December 1999 [landmark case on medical negligence]

1. Duty

First, we have to prove that there is duty on the part of the doctor, that is, the duty to the patient. That duty will
arise on the basis of the doctor-patient relationship. Therefore, it is important to first prove the existence of
the doctor-patient relationship. This is the first thing to establish in a doctor-patient relationship case,
because if there is none, then there is no need to proceed to the other elements.

Most of the time, this is no longer contentious because the doctor-patient relationship can be implied on
the acts of the parties. Most of the time, this [duty as an element] is no longer an issue and they already
stipulate and admit the fact that the physician had a relationship with the patient. But it is important to establish
this because from that relationship, that would mean that there is already a duty on the part of the physician and

LEGMED | MOJICA 9
LEGAL MEDICINE
Preliminary Period Lecture Notes

on the part of the patient [since it is a contractual relationship, it gives rise to the duty both on the part of the
physician and that of the patient].

Once the doctor-patient relationship has been established, we now go to breach/dereliction of duty.

2. Breach/dereliction of duty

For us to say that the physician breached his obligations to the patient, we must first establish this
standard of care to the practice. What is the standard that is to be practiced by a physician? How can you say
that a physician breached his duty if you do not know what is his duty? And what are the standards of this
physician? What is the standard that he is supposed to follow?

You have to establish the standard of care of a physician by presenting an expert witness. There must be
an expert witness here. That is why, as a general rule, there must be an expert witness in malpractice cases.
And what is the role of that witness? That is to establish that standard of care because how will you know if
there is a breach of contract if you do not know what is the standard to be followed by the physician. And
who will tell us what this standard is? The Supreme Court said, it is not the courts, it is not the parties, it is not the
judges; it must an expert witness, and which case, it must be another physician. This physician will tell the
court that this doctor-respondent should have established this standard. He is supposed to prove to the court that
this physician failed to follow the standard—this is the standard, and he failed to follow this standard. And as a
result, his patient suffered injury.

It must be a physician that is an expert witness because we are talking here of standard of practice. But
not any physician can be an expert witness. What are the rules?

Case: Ramos vs. Court of Appeals, G.R. No. 124354, 29 December 1999

The Court said that the expert witness preferably must belong to the same field of expertise/specialty as
that of the respondent-doctor/defendant-doctor. The Court also said that preferably, they [expert witness
and the respondent-doctor] must also belong to the same locality, preferably, practicing in that same
locality, because you cannot say that the practice here in the city maybe different from the practice in an
isolated island or the practice in the mountains, so the standard of care would be different [sometimes
referred to as the locality rule]. But primarily, the first that is very important is this one [that the expert witness
belongs to the same field of expertise/specialty].

In the case of Ramos vs. Court of Appeals, the patient was operated for cholecystectomy [surgical excision of
the gall bladder]. There was wrongful insertion of the tube, and this was proven in Court. The faulty
intubation was the proximate cause of the patient’s comatose condition.

Case excerpt:
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken by any
efficient intervening cause, produces injury, and without which the result would not have occurred.  An
injury or damage is proximately caused by an act or a failure to act, whenever it appears from the
evidence in the case, that the act or omission played a substantial part in bringing about or actually
causing the injury or damage; and that the injury or damage was either a direct result or a reasonably
probable consequence of the act or omission. It is the dominant, moving or producing cause.

Applying the above definition in relation to the evidence at hand, faulty intubation is undeniably the
proximate cause which triggered the chain of events leading to Erlinda’s brain damage and, ultimately,
her comatosed condition.

So the respondent-anesthesiologist said that he did not commit any mistake, and to prove that, he presented
an expert witness that is a pulmonologist. Although this is a well-known pulmonologist, the Court did not give
weight or credence to the testimony of the pulmonologist. Why? Because how can a pulmonologist establish this
standard of care of an anesthesiologist? How can the pulmonologist tell the Court that this anesthesiologist
followed the standard of care of an anesthesiologist? If they do not belong to the same field, they cannot establish

LEGMED | MOJICA 10
LEGAL MEDICINE
Preliminary Period Lecture Notes

the standard of care, and concomitantly, the Court will have no way of determining whether the physician
breached this contract which is his duty towards his patient.

But we have an exception to this rule, as held in the case of Casumpang vs. Cortejo, G.R. No. 171127, 11 March
2015. In this case, the expert witness was admittedly not a pediatrician but a practicing physician who specializes
in pathology. The counsels for the pediatrician said that that is a wrong witness; you cannot present that as a
witness because how can a pediatrician establish a standard of care for dengue in children. But the Supreme Court
made a different decision in the case at bar. The Court said that even if that doctor is not a pediatrician, he has
undergone several trainings already. He attended at least 30 conferences pertaining to pediatricians. He has seen
several dengue cases. He even conducted several autopsies on dengue cases. In other words, he is sufficiently
familiar with the disease that is being questioned. He is sufficiently familiar to handle dengue cases. He is
sufficiently familiar in the findings in dengue cases. So in that case, even if the expert witness presented there
does not belong to the same field of expertise, as a matter of exception, the Court said the testimony of that
witness can still be given weight because he is sufficiently familiar with the practice of this pediatrician, especially
in the handling of dengue cases.

The Doctrine of Res ipsa loquitur [the injury of the patient speaks for itself] applies in this element. The
injury of the patient would already establish that there is negligence. The injury would be sufficient already, as
a matter of common knowledge.

Other examples of res ipsa loquitur: leaving scissors inside the patient, operating on the wrong organ, inserting
a tube on a wrong place, operating on the wrong eye, etc. In those instances, as a matter of common knowledge,
there would already be negligence—the injury of the patient would speak for itself.

In the application of the doctrine of res ipsa loquitur, the physician is prima facie deemed to have been
negligent. Common knowledge will tell you that there is already negligence of the part of the physician.

In medical negligence cases, res ipsa loquitur can be invoked only when:
(1) the patient suffers an injury that is not an expected complication of medical care;
(2) the injury does not normally occur unless someone has been negligent; and
(3) the defendant was responsible for the patient’s well-being at the time of the injury.

Reference: https://biotech.law.lsu.edu/map/ResIpsaLoquitur.html (retrieved 30 September 2021)

Does the doctrine of res ipsa loquitur apply to medical negligence cases where expert testimony is required to
establish possible causes of an injury, and there may be more than one health care provider who was responsible
for that injury? With some qualifications, the answer is yes.

In general, res ipsa loquitur (literally, “the thing speaks for itself”) permits the finder of fact to infer both
negligence and causation from the mere occurrence of an event if:
(1) the occurrence producing the injury is of a kind which does not ordinarily happen in the absence
of someone’s negligence,
(2) the injury is caused by an agency or instrumentality within the exclusive control of the defendant,
and
(3) the injury-causing occurrence was not due to any contribution on the part of the plaintiff.

The doctrine casts upon the defendant the duty to come forward with an exculpatory explanation to rebut the
presumption or inference of negligence on his or her part.

Reference: https://cmglaw.com/articles/res-ipsa-loquitur-in-medical-negligence-cases/ (retrieved 30

September 2021)

Ordinarily, there would be no injury in the absence of negligence.

3. Injury to the complainant-patient

LEGMED | MOJICA 11
LEGAL MEDICINE
Preliminary Period Lecture Notes

Whether administrative, civil, or criminal liability, injury has to be proven.

4. Direct Causation/proximate cause

In the case of Ramos vs. Court of Appeals, the patient was operated for cholecystectomy [surgical excision of
the gall bladder]. There was wrongful insertion of the tube, and this was proven in Court. The faulty
intubation was the proximate cause of the patient’s comatose condition.

Case excerpt:
Proximate cause has been defined as that which, in natural and continuous sequence, unbroken
by any efficient intervening cause, produces injury, and without which the result would
not have occurred.  An injury or damage is proximately caused by an act or a failure to act,
whenever it appears from the evidence in the case, that the act or omission played a substantial part in
bringing about or actually causing the injury or damage; and that the injury or damage was either a
direct result or a reasonably probable consequence of the act or omission. It is the dominant, moving or
producing cause.

Applying the above definition in relation to the evidence at hand, faulty intubation is undeniably the
proximate cause which triggered the chain of events leading to Erlinda’s brain damage and, ultimately,
her comatosed condition.

There must be a direct connection between the breach of the duty and the injury to the complainant-
patient.

Case: Professional Services vs. Agana, G.R. No. 126297, 2 February 2010

The injury is the direct result of the negligence of the surgeon.

Classification of Hospitals

Pursuant to Republic Act No. 4226, otherwise known as the Hospital Licensure Act of 1965, the
Department of Health (DOH) issued Administrative Order No. 2012-0012 in order to stipulate the “Rules
and Regulations Governing the New Classification of Hospitals and Other Health Facilities in
the Philippines.” According to the Administrative Order, the classification of hospitals all over the Philippines
according to service capability (Level I, Level II, or Level III) is based on the availability of certain
structures and services within the hospital, as well as on the hospital’s capability to train
physicians under accredited residency training programs in Internal Medicine, Obstetrics-Gynecology,
Pediatrics, and Surgery.

According to Ownership

1. Government
The hospital is created by law.

A government health facility may be under the National Government, DOH, Local Government Unit (LGU),
Department of Justice (DOJ), State Universities and Colleges (SUCs), Government-owned and controlled
corporations (GOCC) and others.

2. Private
Owned, established, and operated with funds from donation, principal, investment, or other means by any
individual, corporation, association, or organization.

According to Scope of Services

1. General Hospital

LEGMED | MOJICA 12
LEGAL MEDICINE
Preliminary Period Lecture Notes

General Hospitals are those that provide services for all kinds of illnesses, diseases, injuries or deformities. They
provide medical and surgical care to the sick and injured, maternity, newborn and child care.

They shall be equipped with the service capabilities needed to support board certified/ eligible medical specialists
and other licensed physicians rendering services in, but not limited to the following:
 Clinical Services (Family Medicine, Pediatrics, Internal Medicine, Obstetrics and Gynecology, Surgery)
 Emergency Services
 Outpatient Services
 Ancillary and Support Services (Clinical Laboratory, Imaging Facility, Pharmacy)

2. Specialty
Specializes in a particular disease or condition or in one type of patient

A specialized hospital may be devoted to the treatment of the following:

 Treatment of a particular type of illness or for a particular condition requiring a range of treatment
 Treatment of patients suffering from a particular disease of a particular organ or group of organs
 Treatment of patients belonging to a group such as children, women, elderly or others

According to Functional Capacity

Level 1

A level 1 General Hospital shall have as minimum:

1. A staff of qualified, medical, allied medical and administrative personnel headed by a physician duly
licensed by the PRC

LEGMED | MOJICA 13
LEGAL MEDICINE
Preliminary Period Lecture Notes

2. Bed space for its authorized bed capacity, in accordance with DOH Guidelines in the Planning and Design
of Hospitals
3. An operating room with standard equipment and provisions for sterilization of equipment and supplies in
accordance with:
a. DOH Reference Plan in the Planning and Design of an Operating Room or Theater 
b. DOH Guidelines on Cleaning, Disinfection, and Sterilization of Reusable Medical Devices in
Hospital Facilities in the Philippines
4. A post-operative Recovery Room
5. Maternity Facilities consisting of Ward(s), Room(s), a Delivery Room, exclusively for maternity patients
and newborns
6. Isolation facilities with proper procedures for the care and control of infection and communicable
diseases as well as for the prevention of cross infection
7. A separate dental section/ clinic
8. Provision for blood donation
9. A DOH-licensed secondary clinical laboratory with the services of a consulting pathologist
10. A DOH licensed Level 1 imaging facility with the services of a consulting radiologist
11. A DOH licensed pharmacy

Level 2

A level 2 General Hospital has departmentalized services. Patients here are already segregated. There is also
presence of Intensive Care Unit (ICU), as well as additional facilities like an ICU for critically-ill patients and
specialist doctors for gynecology and pediatric services.

A level 2 General Hospital shall have as minimum:

As minimum, all of Level 1 capacity, including but not limited to:

1. An organized staff of qualified and competent personnel with Chief of Hospital/Medical Director and
appropriate board certified Clinical Department Heads
2. Departmentalized and equipped with the service capabilities needed to support board certified/ eligible
medical specialties and other licensed physicians rendering services in the specialties of Medicine,
Pediatrics, Obstetrics and Gynecology, Surgery, their subspecialties, and other ancillary services
3. Provision for general ICU for critically ill patients
4. Provision for NICU
5. Provision for HRPU
6. Provision for Respiratory Therapy Services
7. A DOH licensed tertiary clinical laboratory
8. A DOH licensed level 2 imaging facility with mobile X-ray inside the institution and with capability for
contrast examinations

Level 3

A level 3 General Hospital has a high-level specialty intervention like physical rehabilitation or dialysis
treatment. Accredited residency or specialty training programs can also be found in level 3 General Hospitals.

A level 3 General Hospital shall have as minimum:

As minimum, all of Level 2 capacity, including but not limited to:

1. Teaching and/or Training Hospital with accredited residency training program for physicians in the four
major specialties namely: Medicine, Pediatrics, Obstetrics and Gynecology, and Surgery
2. Provision for physical medicine and rehabilitation unit
3. Provision for ambulatory surgical clinic
4. Provision for dialysis facility
5. Provision for blood bank
6. A DOH licensed level 3 imaging facility with interventional radiology

References:

LEGMED | MOJICA 14
LEGAL MEDICINE
Preliminary Period Lecture Notes

 Republic of the Philippines. An Act Requiring the Licensure of All Hospitals in the Philippines and
Authorizing the Bureau of Medical Services to Serve as the Licensing Agency, Republic Act No. 4226 (19
June 1965).
 Ona ET. Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities
in the Philippines, Department of Health Administrative Order No. 2012-0012 (18 July 2012).

Hospital Liability

A hospital can be held liable for the negligence of its employees through the legal concept of vicarious liability,
which holds employers liable for the negligent actions of their employees, which could include:
 Physicians
 Nurses
 Physical therapists
 Occupational therapists
 Other health care providers

If the individual was employed by the hospital and was completing work-related duties when the malpractice
occurred, the hospital may be held liable for the negligent acts of its employee. Some common medical errors the
hospital could be held liable for include:
 Failing to monitor a patient
 Failing to take a patient’s vital signs when appropriate
 Failing to consult the patient’s record for important information
 Administering the wrong type of medication or giving the wrong dose
 Making a surgical error
 Failing to properly diagnose a patient
 Failing to respond to a patient’s call
 Failing to check a bedridden patient for bedsores or to periodically rotate the patient

Health Care Providers Who Are Not Employees

While hospitals can be held liable when their employees are negligent, many hospital workers are not actually
employees. For example, many doctors are independent contractors. They may work in more than one hospital
and in their own practice. Even if medical malpractice occurred at the hospital, the hospital itself may be off the
hook when a health care provider is an independent contractor.

Determining whether a hospital is the employer of the doctor depends on the extent of control the hospital had
over this person. Some factors that may indicate an employment relationship include:
 The hospital determines the fees the doctor can charge.
 The hospital exercises significant control over the health care provider’s payment.
 The hospital controls the doctor’s working hours.
 The hospital exercises significant control over the health care provider’s job conditions.

If a hospital employee commits medical malpractice when a non-employee doctor is supervising him or her, the
doctor may be the only one held legally responsible for the malpractice. An employee is under the supervision of a
doctor when the doctor is present and has control to prevent the employee’s negligence.

Hospital Negligence
Medical malpractice claims can also be grounded on acts of the hospital and administration. Some ways that a
hospital may be held liable include:
 Negligent hiring – Hospitals are responsible for hiring qualified health care providers who can properly
perform their work duties. They must carefully review their background and any history of complaints
against them. They must ensure that they are currently licensed and retain their credentials during their
employment.
 Failing to remove an incompetent health care provider – If a health care provider does not have
the required skills or cannot competently perform his or her work duties, the hospital has a responsibility
to remove the person.

LEGMED | MOJICA 15
LEGAL MEDICINE
Preliminary Period Lecture Notes

 Understaffing – Hospitals are required to hire adequate staff to provide proper care for their patients.
When hospitals are understaffed, patients may suffer as a result.

Reference:
https://www.oal-law.com/blog/can-a-hospital-be-held-liable-for-medical-malpractice/ (retrieved 30
September 2021)

1. Doctrine of vicarious liability (imputed liability) or respondeat-superior doctrine

The doctor can be held responsible for the acts of another, in its capacity as an employee. The basis of the liability
of a hospital is as an employer.

Vicarious liability is a legal doctrine under which parties can be held indirectly liable for an injury,
even though they did not cause it.

Article 2180 of the Civil Code provides that a person is not only liable for one's own quasi-delictual acts, but
also for those persons for whom one is responsible for. This liability is popularly known as vicarious or
imputed liability or, in the case at bar, the failure of the hospital to supervise its employees.

To sustain claims against employers for the acts of their employees, the following requisites must be established:
(1) That the employee was chosen by the employer personally or through another;
(2) That the service to be rendered in accordance with orders which the employer has the authority to give at
all times; and
(3) That the illicit act of the employee was on the occasion or by reason of the functions entrusted to him.

Significantly, to make the employee liable under paragraphs 5 and 6 of Article 2180, it must be established that
the injurious or tortuous act was committed at the time the employee was performing his functions.

Until the mid-nineteenth century, hospitals were generally charitable institutions, providing medical services to
the lowest classes of society, without regard for a patient’s ability to pay. Those who could afford medical
treatment were usually treated at home by their doctors. 19 However, the days of house calls and philanthropic
health care are over. The modern health care industry continues to distance itself from its charitable past and has
experienced a significant conversion from a not-for-profit health care to for-profit hospital businesses.
Consequently, significant changes in health law have accompanied the business-related changes in the hospital
industry. One important legal change is an increase in hospital liability for medical malpractice. Many courts now
allow claims for hospital vicarious liability under the theories of respondeat superior, apparent authority,
ostensible authority, or agency by estoppel.

In this jurisdiction, the statute governing liability for negligent acts is Article 2176 of the Civil Code, which reads:

Art. 2176. Whoever by act or omission causes damage to another, there being fault or negligence, is
obliged to pay for the damage done. Such fault or negligence, if there is no pre-existing contractual
relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.

A derivative of this provision is Article 2180, the rule governing vicarious liability under the doctrine of
respondeat superior, thus:

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.

The owners and managers of an establishment or enterprise are likewise responsible for damages caused by their
employees in the service of the branches in which the latter are employed or on the occasion of their functions.
Employers shall be liable for the damages caused by their employees and household helpers acting within the
scope of their assigned tasks even though the former are not engaged in any business or industry.

LEGMED | MOJICA 16
LEGAL MEDICINE
Preliminary Period Lecture Notes

The responsibility treated of in this article shall cease when the persons herein mentioned prove that they
observed all the diligence of a good father of a family to prevent damage.

Professionals engaged by an employer, such as physicians, dentists, and pharmacists, are not “employees” under
this article because the manner in which they perform their work is not within the control of the latter (employer).
In other words, professionals are considered personally liable for the fault or negligence they commit in the
discharge of their duties, and their employer cannot be held liable for such fault or negligence. In the context of
the present case, “a hospital cannot be held liable for the fault or negligence of a physician or
surgeon in the treatment or operation of patients.”

In practice, one may go to someone who has the deepest pocket (hospital) or the deep-pocket doctrine.

Deep-pocket doctrine
Under this principle, victims injured by the negligence of several others can collect 100 percent of the
damages from one person or company if the person or company is heavily insured and can afford to
pay, even if it was only 1 percent at fault.

Employer-employee Relationship
The unique practice (among private hospitals) of filling up specialist staff with attending and visiting
“consultants,” who are allegedly not hospital employees, presents problems in apportioning responsibility for
negligence in medical malpractice cases. However, the difficulty is more apparent than real.

In the first place, 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, visiting or
attending, are required to submit proof of completion of residency, their educational qualifications, generally,
evidence of accreditation by the appropriate board (diplomate), evidence of fellowship in most cases, and
references. These requirements are carefully scrutinized by members of the hospital administration or by a review
committee set up by the hospital who either accept or reject the application.

After a physician is accepted, either as a visiting or attending consultant, he is normally required to attend clinico-
pathological conferences, conduct bedside rounds for clerks, interns and residents, moderate grand rounds and
patient audits and perform other tasks and responsibilities, for the privilege of being able to maintain a clinic in
the hospital, and/or for the privilege of admitting patients into the hospital. In addition to these, the physician’s
performance as a specialist is generally evaluated by a peer review committee on the basis of mortality and
morbidity statistics, and feedback from patients, nurses, interns and residents. A consultant remiss in his duties,
or a consultant who regularly falls short of the minimum standards acceptable to the hospital or its peer review
committee, is normally politely terminated.

In other words, private hospitals, hire, fire and exercise real control over their attending and visiting
‘consultant’ staff. While ‘consultants’ are not, technically employees, the control exercised, 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. In assessing whether such a relationship in fact exists, the control test is
determining. Accordingly, on the basis of the foregoing, we rule that for the purpose of allocating responsibility in
medical negligence cases, an employer-employee relationship in effect exists between hospitals and their
attending and visiting physicians.

Q: What if the doctor is negligent? What is the remedy of the patient?

A: File a case for administrative, civil, or criminal liability, as the case may be.

In the case at bar, these doctors/physicians are not employees of the hospitals; they are only independent
contractors. Vicarious liability will not lie.

The “Schloendorff doctrine” regards a physician, even if employed by a hospital, as an independent

contractor because of the skill he exercises and the lack of control exerted over his work . Under
this doctrine, hospitals are exempt from the application of the respondeat superior principle for fault or
negligence committed by physicians in the discharge of their profession.

LEGMED | MOJICA 17
LEGAL MEDICINE
Preliminary Period Lecture Notes

Resident physicians or those who are doing their specialization (they are full-time in the hospital) are not
employees of the hospital. It has to be proven on the part of the hospital that the training program is
accredited.

How can the hospital then be held liable?

2. Doctrine of ostensible agency/ agency by estoppel

Apparent authority, or what is sometimes referred to as the “holding out” theory, or doctrine of
ostensible agency or agency by estoppel, has its origin from the law of agency. It imposes liability, not as
the result of the reality of a contractual relationship, but rather because of the actions of a principal or an
employer in somehow misleading the public into believing that the relationship or the authority exists. The
concept is essentially one of estoppel and has been explained in this manner:

The principal is bound by the acts of his agent with the apparent authority which he knowingly permits
the agent to assume, or which he holds the agent out to the public as possessing. The question in every
case is whether the principal has by his voluntary act placed the agent in such a situation that a person
of ordinary prudence, conversant with business usages and the nature of the particular business, is
justified in presuming that such agent has authority to perform the particular act in question.

The applicability of apparent authority in the field of hospital liability was upheld long time ago in Irving v.
Doctor Hospital of Lake Worth, Inc. There, it was explicitly stated that “there does not appear to be
any rational basis for excluding the concept of apparent authority from the field of hospital
liability.” Thus, in cases where it can be shown that a hospital, by its actions, has held out a particular physician
as its agent and/or employee and that a patient has accepted treatment from that physician in the reasonable
belief that it is being rendered in behalf of the hospital, then the hospital will be liable for the physician’s
negligence.

Our jurisdiction recognizes the concept of an agency by implication or estoppel. Article 1869 of the Civil Code
reads:

ART. 1869. Agency may be express, or implied from the acts of the principal, from his silence or lack of
action, or his failure to repudiate the agency, knowing that another person is acting on his behalf
without authority.

In this case, 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. We concur with the Court
of Appeals’ conclusion that it “is now estopped from passing all the blame to the physicians whose names it
proudly paraded in the public directory leading the public to believe that it vouched for their skill and
competence.” Indeed, PSI’s act is tantamount to holding out to the public that Medical City Hospital, through its
accredited physicians, offers quality health care services. By accrediting Dr. Ampil and Dr. Fuentes and publicly
advertising their qualifications, the hospital created the impression that they were its agents, authorized to
perform medical or surgical services for its patients. As expected, these patients, Natividad being one of them,
accepted the services on the reasonable belief that such were being rendered by the hospital or its employees,
agents, or servants. The trial court correctly pointed out:

Regardless of the education and status in life of the patient, he ought not be burdened with the defense of
absence of employer-employee relationship between the hospital and the independent physician whose
name and competence are certainly certified to the general public by the hospital’s act of listing him and
his specialty in its lobby directory, as in the case herein. The high costs of today’s medical and health
care should at least exact on the hospital greater, if not broader, legal responsibility for the conduct of
treatment and surgery within its facility by its accredited physician or surgeon, regardless of whether
he is independent or employed.

LEGMED | MOJICA 18
LEGAL MEDICINE
Preliminary Period Lecture Notes

The wisdom of the foregoing ratiocination is easy to discern. Corporate entities, like PSI, are capable of acting only
through other individuals, such as physicians. If these accredited physicians do their job well, the hospital
succeeds in its mission of offering quality medical services and thus profits financially. Logically, where negligence
mars the quality of its services, the hospital should not be allowed to escape liability for the acts of its ostensible
agents.

The hospital being the principal is accountable for the negligence of its surgeon, its agent. The hospital
cannot deny the negligence of the surgeon who is its agent.

3. Doctrine of corporate negligence/corporate responsibility

One allegation in the complaint in Civil Case No. Q-43332 for negligence and malpractice is that PSI as owner,
operator and manager of Medical City Hospital, “did not perform the necessary supervision nor exercise diligent
efforts in the supervision of Drs. Ampil and Fuentes and its nursing staff, resident doctors, and medical interns
who assisted Drs. Ampil and Fuentes in the performance of their duties as surgeons.” Premised on the doctrine of
corporate negligence, the trial court held that PSI is directly liable for such breach of duty.

The Supreme Court with the trial court.

Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating
hospital’s liability for the negligent acts of health practitioners, absent facts to support the application of
respondeat superior or apparent authority. Its formulation proceeds from the judiciary’s acknowledgment that in
these modern times, the duty of providing quality medical service is no longer the sole prerogative and
responsibility of the physician. The modern hospitals have changed structure. Hospitals now tend to organize a
highly professional medical staff whose competence and performance need to be monitored by the hospitals
commensurate with their inherent responsibility to provide quality medical care.

The doctrine has its genesis in Darling vs. Charleston Community Hospital. There, the Supreme Court of
Illinois held that “the jury could have found a hospital negligent, inter alia, in failing to have a sufficient number of
trained nurses attending the patient; failing to require a consultation with or examination by members of the
hospital staff; and failing to review the treatment rendered to the patient.” On the basis of Darling, other
jurisdictions held that a hospital’s corporate negligence extends to permitting a physician known to be
incompetent to practice at the hospital. 

With the passage of time, more duties were expected from hospitals, among them:
(1) the use of reasonable care in the maintenance of safe and adequate facilities and equipment;
(2) the selection and retention of competent physicians;
(3) the overseeing or supervision of all persons who practice medicine within its walls; and
(4) the formulation, adoption and enforcement of adequate rules and policies that ensure quality care for its
patients.

Thus, in Tucson Medical Center, Inc. vs. Misevich, it was held that a hospital, following the doctrine of
corporate responsibility, has the duty to see that it meets the standards of responsibilities for the care of patients.
Such duty includes the proper supervision of the members of its medical staff. And in Bost vs. Riley, the court
concluded that a patient who enters a hospital does so with the reasonable expectation that it will attempt to cure
him. The hospital accordingly has the duty to make a reasonable effort to monitor and oversee the treatment
prescribed and administered by the physicians practicing in its premises.

In the present case, it was duly established that PSI operates the Medical City Hospital for the purpose and under
the concept of providing comprehensive medical services to the public. Accordingly, it has the duty to exercise
reasonable care to protect from harm all patients admitted into its facility for medical treatment. Unfortunately,
PSI failed to perform such duty. The findings of the trial court are convincing, thus:

PSI’s liability is traceable to its failure to conduct an investigation of the matter reported in the nota
bene of the count nurse. Such failure established PSI’s part in the dark conspiracy of silence and
concealment about the gauzes. Ethical considerations, if not also legal, dictated the holding of an
immediate inquiry into the events, if not for the benefit of the patient to whom the duty is primarily

LEGMED | MOJICA 19
LEGAL MEDICINE
Preliminary Period Lecture Notes

owed, then in the interest of arriving at the truth. The Court cannot accept that the medical and the
healing professions, through their members like defendant surgeons, and their institutions like PSI’s
hospital facility, can callously turn their backs on and disregard even a mere probability of mistake or
negligence by refusing or failing to investigate a report of such seriousness as the one in Natividad’s
case.

It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the assistance of the Medical City
Hospital’s staff, composed of resident doctors, nurses, and interns. As such, it is reasonable to conclude that PSI,
as the operator of the hospital, has actual or constructive knowledge of the procedures carried out, particularly the
report of the attending nurses that the two pieces of gauze were missing.

In Fridena vs. Evans, it was held that a corporation is bound by the knowledge acquired by or notice given to
its agents or officers within the scope of their authority and in reference to a matter to which their authority
extends. This means that the knowledge of any of the staff of Medical City Hospital constitutes knowledge of PSI.
Now, the failure of PSI, despite the attending nurses’ report, to investigate and inform Natividad regarding the
missing gauzes amounts to callous negligence. Not only did PSI breach its duties to oversee or supervise all
persons who practice medicine within its walls, it also failed to take an active step in fixing the negligence
committed. This renders PSI, not only vicariously liable for the negligence of Dr. Ampil under Article 2180 of the
Civil Code, but also directly liable for its own negligence under Article 2176. In Fridena, the Supreme Court of
Arizona held:

In recent years, however, the duty of care owed to the patient by the hospital has expanded. The
emerging trend is to hold the hospital responsible where the hospital has failed to monitor and review
medical services being provided within its walls.

The hospital is duty bound to ensure the safety of their patients in the hospital premises. In the case at bar, the
hospital failed to conduct necessary investigation as to how it happened and how to avoid such incidence.

Once a physician undertakes the treatment and care of a patient, the law imposes on him certain
obligations. In order to escape liability, he must possess that reasonable degree of learning, skill and
experience required by his profession. At the same time, he must apply reasonable care and diligence in
the exercise of his skill and the application of his knowledge, and exert his best judgment.

LEGMED | MOJICA 20