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7/30/2019 Professional Serv vs Argana
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G.R. No. 126297 January 31, 2007
PROFESSIONAL SERVICES, INC., Petitioner,
vs.
NATIVIDAD and ENRIQUE AGANA, Respondents.
x - - - - - - - - - - - - - - - - - - - - - - - x
G.R. No. 126467 January 31, 2007
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE
AGANA, JR., EMMA AGANA ANDAYA, JESUS AGANA, and RAYMUND AGANA)
and ENRIQUE AGANA, Petitioners,
vs.
JUAN FUENTES, Respondent.
x- - - - - - - - - - - - - - - - - - - -- - - - x
G.R. No. 127590 January 31, 2007
MIGUEL AMPIL, Petitioner,
vs.
NATIVIDAD AGANA and ENRIQUE AGANA, Respondents.
D E C I S I O N
SANDOVAL-GUTIERREZ, J.:
Hospitals, having undertaken one of mankinds most important and delicate
endeavors, must assume the grave responsibility of pursuing it with appropriate
care. The care and service dispensed through this high trust, however technical,
complex and esoteric its character may be, must meet standards of responsibility
commensurate with the undertaking to preserve and protect the health, andindeed, the very lives of those placed in the hospitals keeping.
1
Assailed in these three consolidated petitions for review on certiorari is the Court
of Appeals Decision2dated September 6, 1996 in CA-G.R. CV No. 42062 and CA-
G.R. SP No. 32198 affirming with modification the Decision3dated March 17, 1993
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of the Regional Trial Court (RTC), Branch 96, Quezon City in Civil Case No. Q-43322
and nullifying its Order dated September 21, 1993.
The facts, as culled from the records, are:
On April 4, 1984, Natividad Agana was rushed to the Medical City General
Hospital (Medical City Hospital) because of difficulty of bowel movement and
bloody anal discharge. After a series of medical examinations, Dr. Miguel Ampil,
petitioner in G.R. No. 127590, diagnosed her to be suffering from "cancer of the
sigmoid."
On April 11, 1984, Dr. Ampil, assisted by the medical staff4of the Medical City
Hospital, performed an anterior resection surgery on Natividad. He found that the
malignancy in her sigmoid area had spread on her left ovary, necessitating theremoval of certain portions of it. Thus, Dr. Ampil obtained the consent of
Natividads husband, Enrique Agana, to permit Dr. Juan Fuentes, respondent in
G.R. No. 126467, to perform hysterectomy on her.
After Dr. Fuentes had completed the hysterectomy, Dr. Ampil took over,
completed the operation and closed the incision.
However, the operation appeared to be flawed. In the corresponding Record of
Operation dated April 11, 1984, the attending nurses entered these remarks:
"sponge count lacking 2
"announced to surgeon searched (sic) done but to no avail continue for closure."
On April 24, 1984, Natividad was released from the hospital. Her hospital and
medical bills, including the doctors fees, amounted to P60,000.00.
After a couple of days, Natividad complained of excruciating pain in her anal
region. She consulted both Dr. Ampil and Dr. Fuentes about it. They told her that
the pain was the natural consequence of the surgery. Dr. Ampil then
recommended that she consult an oncologist to examine the cancerous nodes
which were not removed during the operation.
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On May 9, 1984, Natividad, accompanied by her husband, went to the United
States to seek further treatment. After four months of consultations and
laboratory examinations, Natividad was told she was free of cancer. Hence, she
was advised to return to the Philippines.
On August 31, 1984, Natividad flew back to the Philippines, still suffering from
pains. Two weeks thereafter, her daughter found a piece of gauze protruding
from her vagina. Upon being informed about it, Dr. Ampil proceeded to her house
where he managed to extract by hand a piece of gauze measuring 1.5 inches in
width. He then assured her that the pains would soon vanish.
Dr. Ampils assurance did not come true. Instead, the pains intensified, prompting
Natividad to seek treatment at the Polymedic General Hospital. While confined
there, Dr. Ramon Gutierrez detected the presence of another foreign object in her
vagina -- a foul-smelling gauze measuring 1.5 inches in width which badly infected
her vaginal vault. A recto-vaginal fistula had formed in her reproductive organs
which forced stool to excrete through the vagina. Another surgical operation was
needed to remedy the damage. Thus, in October 1984, Natividad underwent
another surgery.
On November 12, 1984, Natividad and her husband filed with the RTC, Branch 96,
Quezon City a complaint for damages against the Professional Services, Inc. (PSI),
owner of the Medical City Hospital, Dr. Ampil, and Dr. Fuentes, docketed as Civil
Case No. Q-43322. They alleged that the latter are liable for negligence for leaving
two pieces ofgauze inside Natividads body and malpractice for concealing their
acts of negligence.
Meanwhile, Enrique Agana also filed with the Professional Regulation Commission
(PRC) an administrative complaint for gross negligence and malpractice against
Dr. Ampil and Dr. Fuentes, docketed as Administrative Case No. 1690. The PRCBoard of Medicine heard the case only with respect to Dr. Fuentes because it
failed to acquire jurisdiction over Dr. Ampil who was then in the United States.
On February 16, 1986, pending the outcome of the above cases, Natividad died
and was duly substituted by her above-named children (the Aganas).
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On March 17, 1993, the RTC rendered its Decision in favor of the Aganas, finding
PSI, Dr. Ampil and Dr. Fuentes liable for negligence and malpractice, the decretal
part of which reads:
WHEREFORE, judgment is hereby rendered for the plaintiffs ordering thedefendants 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 only, as follows:
1. As actual damages, the following amounts:
a. The equivalent in Philippine Currency of the total of US$19,900.00 at the rate of
P21.60-US$1.00, as reimbursement of actual expenses incurred in the UnitedStates of America;
b. The sum of P4,800.00 as travel taxes of plaintiffs and their physician daughter;
c. The total sum of P45,802.50, representing the cost of hospitalization at
Polymedic Hospital, medical fees, and cost of the saline solution;
2. As moral damages, the sum of P2,000,000.00;
3. As exemplary damages, the sum of P300,000.00;
4. As attorneys fees, the sum of P250,000.00;
5. Legal interest on items 1 (a), (b), and (c); 2; and 3 hereinabove, from date of
filing of the complaint until full payment; and
6. Costs of suit.
SO ORDERED.
Aggrieved, PSI, Dr. Fuentes and Dr. Ampil interposed an appeal to the Court of
Appeals, docketed as CA-G.R. CV No. 42062.
Incidentally, on April 3, 1993, the Aganas filed with the RTC a motion for a partial
execution of its Decision, which was granted in an Order dated May 11, 1993.
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Thereafter, the sheriff levied upon certain properties of Dr. Ampil and sold them
for P451,275.00 and delivered the amount to the Aganas.
Following their receipt of the money, the Aganas entered into an agreement with
PSI and Dr. Fuentes to indefinitely suspend any further execution of the RTCDecision. However, not long thereafter, the Aganas again filed a motion for an
alias writ of execution against the properties of PSI and Dr. Fuentes. On
September 21, 1993, the 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, docketed as CA-
G.R. SP No. 32198. During its pendency, the Court of Appeals issued a
Resolution5dated October 29, 1993 granting Dr. Fuentes prayer for injunctive
relief.
On January 24, 1994, CA-G.R. SP No. 32198 was consolidated with CA-G.R. CV No.
42062.
Meanwhile, on January 23, 1995, the PRC Board of Medicine rendered its
Decision6in Administrative Case No. 1690 dismissing the case against Dr. Fuentes.
The Board held that the prosecution failed to show that Dr. Fuentes was the one
who left the two pieces of gauze inside Natividads body; and that he concealed
such fact from Natividad.
On September 6, 1996, the Court of Appeals rendered its Decision jointly
disposing of CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198, thus:
WHEREFORE, except for the modification that the case against defendant-
appellant Dr. Juan Fuentes is hereby DISMISSED, and with the pronouncement
that defendant-appellant 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, the decision appealed from is hereby AFFIRMED
and the instant appeal DISMISSED.
Concomitant with the above, the petition for certiorari and prohibition filed by
herein defendant-appellant Dr. Juan Fuentes in CA-G.R. SP No. 32198 is hereby
GRANTED and the challenged order of the respondent judge dated September 21,
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1993, as well as the alias writ of execution issued pursuant thereto are hereby
NULLIFIED and SET ASIDE. The bond posted by the petitioner in connection with
the writ of preliminary injunction issued by this Court on November 29, 1993 is
hereby cancelled.
Costs against defendants-appellants Dr. Miguel Ampil and Professional Services,
Inc.
SO ORDERED.
Only Dr. Ampil filed a motion for reconsideration, but it was denied in a
Resolution7dated December 19, 1996.
Hence, the instant consolidated petitions.
In G.R. No. 126297, PSI alleged in its petition that the Court of Appeals erred in
holding that: (1) it is estopped from raising the defense that Dr. Ampil is not its
employee; (2) it is solidarily liable with Dr. Ampil; and (3) it is not entitled to its
counterclaim against the Aganas. PSI contends that Dr. Ampil is not its employee,
but a mere consultant or independent contractor. As such, he alone should
answer for his negligence.
In G.R. No. 126467, the Aganas maintain that the Court of Appeals erred in findingthat Dr. Fuentes is not guilty of negligence or medical malpractice, invoking the
doctrine of res ipsa loquitur. They contend that the pieces of gauze are prima
facie proofs that the operating surgeons have been negligent.
Finally, in G.R. No. 127590, Dr. Ampil asserts that the Court of Appeals erred in
finding him liable for negligence and malpractice sans evidence that he left the
two pieces of gauze in Natividads vagina. He pointed to other probable causes,
such as: (1) it was Dr. Fuentes who used gauzes in performing the hysterectomy;
(2) the attending nurses failure to properly count the gauzes used during surgery;
and (3) the medical intervention of the American doctors who examined
Natividad in the United States of America.
For our resolution are these three vital issues: first, whether the Court of Appeals
erred in holding Dr. Ampil liable for negligence and malpractice; second, whether
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the Court of Appeals erred in absolving Dr. Fuentes of any liability; and third,
whether PSI may be held solidarily liable for the negligence of Dr. Ampil.
I - G.R. No. 127590
Whether the Court of Appeals Erred in Holding Dr. Ampil
Liable for Negligence and Malpractice.
Dr. Ampil, in an attempt to absolve himself, gears the Courts attention to other
possible causes of Natividads detriment. He argues that the Court should not
discount either of the following possibilities: first, Dr. Fuentes left the gauzes in
Natividads body after performing hysterectomy; second, the attending nurses
erred in counting the gauzes; and third, the American doctors were the ones who
placed the gauzes in Natividads body.
Dr. Ampils arguments are purely conjectural and without basis. Records show
that he did not present any evidence to prove that the American doctors were the
ones who put or left the gauzes in Natividads body. Neither did he 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.
The glaring truth is that all the major circumstances, taken together, as specified
by the Court of Appeals, directly point to Dr. Ampil as the negligent party, thus:
First, it is not disputed that the surgeons used gauzes as sponges to control the
bleeding of the patient during the surgical operation.
Second, immediately after the operation, the nurses who assisted in the surgery
noted in their report that the sponge count (was) lacking 2; that such anomaly
was announced to surgeon and that a search was done but to no avail
prompting Dr. Ampil to continue for closure x x x.
Third, after the operation, two (2) gauzes were extracted from the same spot of
the body of Mrs. Agana where the surgery was performed.
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An operation requiring the placing of sponges in the incision is not complete until
the sponges are properly removed, and it is settled that the leaving of sponges or
other foreign substances in the wound after the incision has been closed is at
least prima facie negligence by the operating surgeon.8To put it simply, such act
is considered so inconsistent with due care as to raise an inference of negligence.
There are even legions of authorities to the effect that such act is negligence per
se.9
Of course, the Court is not blind to the reality that there are times when danger
to a patients life precludes a surgeon from further searching missing sponges or
foreign objects left in the body. But this does not leave him free from any
obligation. Even if it has been shown that a surgeon was required by the urgent
necessities of the case to leave a sponge in his patients abdomen, because of thedangers attendant upon delay, still, it is his legal duty to so inform his patient
within a reasonable time thereafter by advising her of what he had been
compelled to do. This is in order that she might seek relief from the effects of the
foreign object left in her body as her condition might permit. The ruling in Smith
v. Zeagler10
is explicit, thus:
The removal of all sponges used is part of a surgical operation, and when a
physician or surgeon fails to remove a sponge he has placed in his patients bodythat should be removed as part of the operation, he thereby leaves his operation
uncompleted and creates a new condition which imposes upon him the legal duty
of calling the new condition to his patients attention, and endeavoring with the
means he has at hand to minimize and avoid untoward results likely to ensue
therefrom.
Here, Dr. Ampil did not inform Natividad about the missing two pieces of gauze.
Worse, he even misled her that the pain she was experiencing was the ordinary
consequence of her operation. Had he been more candid, Natividad could have
taken the immediate and appropriate medical remedy to remove the gauzes from
her body. To our mind, what was initially an act of negligence by Dr. Ampil has
ripened into a deliberate wrongful act of deceiving his patient.
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This is a clear case of medical malpractice or more appropriately, medical
negligence. To successfully pursue this kind of case, a patient must only prove
that a health care provider either failed to do something which a reasonably
prudent health care provider would have done, or that he did something that a
reasonably prudent provider would not have done; and that failure or action
caused injury to the patient.11
Simply put, the elements are duty, breach, injury
and proximate causation. Dr, Ampil, as the lead surgeon, had the duty to remove
all foreign objects, such as gauzes, from Natividads body before closure of the
incision. When he failed to do so, it was his duty to inform Natividad about it. Dr.
Ampil breached both duties. Such breach caused injury to Natividad, necessitating
her further examination by American doctors and another surgery. That Dr.
Ampils negligence is the proximate cause12
of Natividads injury could be traced
from his act of closing the incision despite the information given by the attending
nurses that two pieces of gauze were still missing. That they were later on
extracted from Natividads vagina established the causal link between Dr. Ampils
negligence and the injury. And what further aggravated such injury was his
deliberate concealment of the missing gauzes from the knowledge of Natividad
and her family.
II - G.R. No. 126467
Whether the Court of Appeals Erred in Absolving
Dr. Fuentes of any Liability
The Aganas assailed the dismissal by the trial court of the case against Dr. Fuentes
on the ground that it is contrary to the doctrine of res ipsa loquitur. According to
them, the fact that the two pieces of gauze were left inside Natividads body is a
prima facie evidence of Dr. Fuentes negligence.
We are not convinced.
Literally, res ipsa loquitur means "the thing speaks for itself." It is the rule that the
fact of the occurrence of an injury, taken with the surrounding circumstances,
may permit an inference or raise a presumption of negligence, or make out a
plaintiffs prima facie case, and present a question of fact for defendant to meet
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with an explanation.13
Stated differently, where the thing which caused the injury,
without the fault of the injured, is under the exclusive control of the defendant
and the injury is such that it should not have occurred if he, having such control
used proper care, it affords reasonable evidence, in the absence of explanation
that the injury arose from the defendants want of care, and the burden of proof
is shifted to him to establish that he has observed due care and diligence.14
From the foregoing statements of the rule, the requisites for the applicability of
the doctrine of res ipsa loquitur are: (1) the occurrence of an injury; (2) the thing
which caused the injury was under the control and management of the
defendant; (3) the occurrence was such that in the ordinary course of things,
would not have happened if those who had control or management used proper
care; and (4) the absence of explanation by the defendant. Of the foregoingrequisites, the most instrumental is the "control and management of the thing
which caused the injury."15
We find the element of "control and management of the thing which caused the
injury" to be wanting. Hence, the doctrine of res ipsa loquitur will not lie.
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.
Under the "Captain of the Ship" rule, the operating surgeon is the person in
complete charge of the surgery room and all personnel connected with the
operation. Their duty is to obey his orders.16
As stated before, Dr. Ampil was the
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lead surgeon. In other words, he was the "Captain of the Ship." That he
discharged such role is evident from his following conduct: (1) calling Dr. Fuentes
to perform a hysterectomy; (2) examining the work of Dr. Fuentes and finding it in
order; (3) granting Dr. Fuentes permission to leave; and (4) ordering the closure
of the incision. To our mind, it was this act of ordering the closure of the incision
notwithstanding that two pieces of gauze remained unaccounted for, that caused
injury to Natividads body. Clearly, the control and management of the thing
which caused the injury was in the hands of Dr. Ampil, not Dr. Fuentes.
In this jurisdiction, res ipsa loquitur is not a rule of substantive law, hence, does
not per se create or constitute an independent or separate ground of liability,
being a mere evidentiary rule.17
In other words, mere invocation and application
of the doctrine does not dispense with the requirement of proof of negligence.Here, the negligence was proven to have been committed by Dr. Ampil and not by
Dr. Fuentes.
III - G.R. No. 126297
Whether PSI Is Liable for the Negligence of Dr. Ampil
The third issue necessitates a glimpse at the historical development of hospitals
and the resulting theories concerning their liability for the negligence ofphysicians.
Until the mid-nineteenth century, hospitals were generally charitable institutions,
providing medical services to the lowest classes of society, without regard for a
patients ability to pay.18
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
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claims for hospital vicarious liability under the theories of respondeat superior,
apparent authority, ostensible authority, or agency by estoppel.20
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
ones own acts or omissions, but also for those of persons for whom one is
responsible.
x x x x x x
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.
x x x x x x
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.
A prominent civilist commented that 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
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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."21
The foregoing view is grounded on the traditional notion that the professional
status and the very nature of the physicians calling preclude him from being
classed as an agent or employee of a hospital, whenever he acts in a professional
capacity.22
It has been said that medical practice strictly involves highly developed
and specialized knowledge,23
such that physicians are generally free to exercise
their own skill and judgment in rendering medical services sans
interference.24
Hence, when a doctor practices medicine in a hospital setting, the
hospital and its employees are deemed to subserve him in his ministrations to thepatient and his actions are of his own responsibility.
25
The case of Schloendorff v. Society of New York Hospital26
was then considered an
authority for this view. 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.
However, the efficacy of the foregoing doctrine has weakened with the significant
developments in medical care. Courts came to realize that modern hospitals are
increasingly taking active role in supplying and regulating medical care to
patients. No longer were a hospitals functions limited to furnishing room, food,
facilities for treatment and operation, and attendants for its patients. Thus, in
Bing v. Thunig,27
the New York Court of Appeals deviated from the Schloendorff
doctrine, noting that modern hospitals actually do far more than provide facilities
for treatment. Rather, they regularly employ, on a salaried basis, a large staff of
physicians, interns, nurses, administrative and manual workers. They charge
patients for medical care and treatment, even collecting for such services through
legal action, if necessary. The court then concluded that there is no reason to
exempt hospitals from the universal rule of respondeat superior.
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In our shores, the nature of the relationship between the hospital and the
physicians is rendered inconsequential in view of our categorical pronouncement
in Ramos v. Court of Appeals28
that for purposes of apportioning responsibility in
medical negligence cases, an employer-employee relationship in effect exists
between hospitals and their attending and visiting physicians. This Court held:
"We now discuss the responsibility of the hospital in this particular incident. 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. x x x.
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 physicians 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
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employees, x x x, 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. "
But the Ramos pronouncement is not our only basis in sustaining PSIs liability. Its
liability is also anchored upon the agency principle of apparent authority or
agency by estoppel and the doctrine of corporate negligence which have gained
acceptance in the determination of a hospitals liability for negligent acts of
health professionals. The present case serves as a perfect platform to test theapplicability of these doctrines, thus, enriching our jurisprudence.
Apparent authority, or what is sometimes referred to as the "holding
out" theory, or doctrine of ostensible agency or agency by estoppel,29
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.30The 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 theparticular act in question.
31
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.32
There, it was
explicitly stated that "there does not appear to be any rational basis for excluding
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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 physicians
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, PSIs 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:
x x x regardless of the education and status in life of the patient, he ought not beburdened 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 hospitals act of
listing him and his specialty in its lobby directory, as in the case herein. The high
costs of todays medical and health care should at least exact on the hospital
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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."33
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.
We now proceed to the doctrine of corporate negligence or 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."34
Premised on the doctrine of corporate negligence, the trial
court held that PSI is directly liable for such breach of duty.
We agree with the trial court.
Recent years have seen the doctrine of corporate negligence as the judicial
answer to the problem of allocating hospitals 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 judiciarys
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.35
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The doctrine has its genesis in Darling v. Charleston Community Hospital.36
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 hospitals
corporate negligence extends to permitting a physician known to be incompetent
to practice at the hospital.37
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.38
Thus, in Tucson Medical Center, Inc. v. Misevich,39
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 v.
Riley,40
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 treatmentprescribed 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:
x x x PSIs 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
PSIs 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
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primarily 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 PSIs 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 Natividads case.
It is worthy to note that Dr. Ampil and Dr. Fuentes operated on Natividad with the
assistance of the Medical City Hospitals 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 v. Evans,41it was held that a corporation is bound by theknowledge 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:
x x x 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. See Kahn Hospital Malpractice Prevention, 27 De Paul .Rev. 23 (1977).
Among the cases indicative of the emerging trend is Purcell v. Zimbelman, 18
Ariz. App. 75,500 P. 2d 335 (1972). In Purcell, the hospital argued that it could not
be held liable for the malpractice of a medical practitioner because he was an
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independent contractor within the hospital. The Court of Appeals pointed out
that the hospital had created a professional staff whose competence and
performance was to be monitored and reviewed by the governing body of the
hospital, and the court held that a hospital would be negligent where it had
knowledge or reason to believe that a doctor using the facilities was employing a
method of treatment or care which fell below the recognized standard of care.
Subsequent to the Purcell decision, the Arizona Court of Appeals held that a
hospital has certain inherent responsibilities regarding the quality of medical care
furnished to patients within its walls and it must meet the standards of
responsibility commensurate with this undertaking. Beeck v. Tucson General
Hospital, 18 Ariz. App. 165, 500 P. 2d 1153 (1972). This court has confirmed the
rulings of the Court of Appeals that a hospital has the duty of supervising thecompetence of the doctors on its staff. x x x.
x x x x x x
In the amended complaint, the plaintiffs did plead that the operation was
performed at the hospital with its knowledge, aid, and assistance, and that the
negligence of the defendants was the proximate cause of the patients injuries.
We find that such general allegations of negligence, along with the evidence
produced at the trial of this case, are sufficient to support the hospitals liability
based on the theory of negligent supervision."
Anent the corollary issue of whether PSI is solidarily liable with Dr. Ampil for
damages, let it be emphasized that PSI, apart from a general denial of its
responsibility, 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. In
neglecting to offer such proof, PSI failed to discharge its burden under the last
paragraph of Article 2180 cited earlier, and, therefore, must be adjudgedsolidarily liable with Dr. Ampil. Moreover, as we have discussed, PSI is also directly
liable to the Aganas.
One final word. 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
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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.
WHEREFORE, we DENY all the petitions and AFFIRM the challenged Decision of
the Court of Appeals in CA-G.R. CV No. 42062 and CA-G.R. SP No. 32198.
Costs against petitioners PSI and Dr. Miguel Ampil.
SO ORDERED.
ANGELINA SANDOVAL-GUTIERREZ
Associate Justice
WE CONCUR:
REYNATO S. PUNO
Chief Justice
Chairperson
RENATO C. CORONA
Associate Justice
ADOLFO S. AZCUNA
Asscociate Justice
(No Part)
CANCIO C. GARCIA
Associate Justice
C E R T I F I C A T I O N
Pursuant to Article VIII, Section 13 of the Constitution, it is hereby certified that
the conclusions in the above Decision were reached in consultation before the
case was assigned to the writer of the opinion of the Courts Division.
REYNATO S. PUNO
Chief Justice
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Footnotes
*No part. Ponente of the assailed Decision in the Court of Appeals.
1Beeck v. Tucson General Hospital, 500 P. 2d 1153 (1972), citing Darling v.
Charleston Community Memorial Hospital, 33 Ill. 2d 326, 211 N.E. 2d 253.
2Penned by Associate Justice Cancio C. Garcia (now a member of the Supreme
Court) and concurred in by Associate Justices Eugenio S. Labitoria and Artemio G.
Tuquero (both retired), Rollo, G.R. Nos. 126297, pp. 36-51; 126467, pp. 27-42;
127590, pp. 23-38.
3Penned by Judge Lucas P. Bersamin (now Justice of the Court of Appeals), Rollo,
G.R. No. 126647, pp. 69-83.
4The medical staff was composed of physicians, both residents and interns, as
well as nurses.
5The dispositive portion reads:
"WHEREFORE, let a writ of preliminary injunction be issued upon petitionersposting of bond in the amount of P20,000.00, ENJOINING public respondents
from implementing the questioned order dated September 21, 1993 and from
further taking any action in Civil Case No. Q-43322 entitled Natividad G. Agana, et
al., plaintiffs, versus Professional Services, Inc., et al., defendants pending
resolution of the instant petition.
SO ORDERED." See Rollo, G.R. No. 126297, p. 42.
6Rollo of G.R. No. 126467, pp. 84-89.
7Rollo of G.R. No. 127590, p. 40.
8Rule v. Cheeseman, 317 P. 2d 472 (1957), citing Russel v. Newman, 116 Kan. 268
P. 752; Bernsden v. Johnson, 174 Kan. 230, 255 P. 2d 1033.
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9Smith v. Zeagler, 157 So. 328 Fla. (1934), citing Ruth v. Johnson, (C.C.A.) 172 F.
191; Reeves v. Lutz, 179 Mo. App. 61, 162 S.W. 280; Rayburn v. Day, 126 Or.
135,268 P. 1002, 59 A.L.R. 1062; Wynne v. Harvey, 96 Wash. 379, 165 P. 67; Harris
v. Fall (C.C.A.) 177 F. 79, 27 L.R.A. (N.S.) 1174; Moore v. Ivey, (Tex. Civ. App.) 264
S.W. 283; 21 R.C. L. 388.
10157 So. 328 Fla. (1934)
11Garcia-Rueda v. Pascasio, G.R. No. 118141, September 5, 1997, 278 SCRA 769.
12In the leading case of Vda. de Bataclan v. Medina, (102 Phil. 181 [1957]), this
Court laid down the following definition of proximate cause in this jurisdiction as
follows:
[T]hat 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. And more comprehensively, the proximate cause is that
acting first and producing the injury, either immediately or by setting other events
in motion, all constituting a natural and continuous chain of events, each having a
close causal connection with the immediate predecessor, the final event in the
chain immediately effecting the injury as a natural and probable result of the
cause which first acted, under which circumstances that the person responsiblefor the first event should, as an ordinarily prudent and intelligent person, have
reasonable ground to expect at the moment of his act or default that an injury to
some person might probably result therefrom.
13Ramos v. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA 584.
14Africa v. Caltex (Phils.) Inc., 123 Phil. 280 (1966).
15Ranos v. Court of Appeals, supra. In Ramos, the phrase used is "control of the
instrumentality which caused the damage," citing St. Johns Hospital and School
of Nursing v. Chapman, 434 P2d 160 (1967).
16Rural Educational Assn v. Bush, 42 Tenn. App. 34, 298 S.W. 2d 761 (1956).
17Ramos v. Court of Appeals, supra at footnote 13.
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18Levin, Hospital Vicarious Liability for Negligence by Independent Contractor
Physicians: A New Rule for New Times, October 17, 2005.
19Id.
20Id.
21Tolentino, The Civil Code of the Philippines, Volume V, 1992 Ed., p. 616.
22Arkansas M.R. Co. v. Pearson, 98 Ark. 442, 153 SW 595 (1911); Runyan v.
Goodrum, 147 Ark. 281, 228 SW 397, 13 ALR 1403 (1921); Rosane v. Senger, 112
Colo. 363, 149 P. 2d 372 (superseded by statute on other grounds); Moon v.
Mercy Hosp., 150 Col. 430, 373 P. 2d 944 (1962); Austin v. Litvak, 682 P. 2d 41, 50
ALR 4th 225 (1984); Western Ins. Co. v. Brochner, 682 P. 2d 1213 (1983);
Rodriguez v. Denver, 702 P. 2d 1349 (1984).
23Arkansas M.R. Co. v. Pearson, id.; Nieto v. State, 952 P. 2d 834 (1997). But see
Beeck v. Tucson General Hosp., 18 Ariz. App. 165, 500 P. 2d 1153 (1972);
Paintsville Hosp. Co., 683 SW 2d 255 (1985); Kelley v. Rossi, 395 Mass. 659, 481
NE 2d 1340 (1985) which held that a physicians professional status does not
prevent him or her from being a servant or agent of the hospital.
24
Fridena v. Evans, 127 Ariz. 516, 522 P. 2d 463 (1980).25
Kitto v. Gilbert, 39 Colo App 374, 570 P. 2d 544 (1977).
26211 N.Y. 125, 105 N.E. 92, 52 L.R.A., N.S., 505 (1914). The court in Schloendorff
opined that a hospital does not act through physicians but merely procures them
to act on their own initiative and responsibility. For subsequent application of the
doctrine, see for instance, Hendrickson v. Hodkin, 250 App. Div 649, 294 NYS 982,
revd on other grounds, 276 NY 252, 11 NE 2d 899 (1937); Necolayff v. Genesee
Hosp., 270 App. Div. 648, 61 NYS 2d 832, affd 296 NY 936, 73 NE2d 117 (1946);Davie v. Lenox Hill Hosp., Inc., 81 NYS 2d 583 (1948); Roth v. Beth El Hosp., Inc.,
279 App. Div 917, 110 NYS 2d 583 (1952); Rufino v. US, 126 F. Supp. 132 (1954);
Mrachek v. Sunshine Biscuit, Inc., 308 NY 116, 123 N.E. 2d 801 (1954).
272 NY 2d 656, 163 NYS 2d 3, 143 N.E. 2d 3 (1957).
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28Supra at footnote 13.
29Blacks Law Dictionary (6th Ed. 1990) 1100. The terms "ostensible agency,"
"agency by estoppel," "apparent authority," and "holding out" tend to be used
interchangeably by the courts to refer to this theory of liability. See for instance,Baker v. Werner, 654 P2d 263 (1982) and Adamski v. Tacoma Gen. Hosp., 20
Wash App. 98, 579 P2d 970 (1978). Agency by estoppel is defined as "one created
by operation of law and established by proof of such acts of the principal as
reasonably lead third persons to the conclusion of its existence. Arises where
principal by negligence in failing to supervise agents affairs, allows agent to
exercise powers not granted to him, thus justifying others in believing the agent
possesses requisite authority." Blacks, supra, p. 62. An ostensible agency is "an
implied or presumptive agency which exists where one, either intentionally orfrom want of ordinary care, induces another to believe that a third person is his
agent, though he never in fact, employed him. It is, strictly speaking, no agency at
all, but is in reality based entirely upon estoppel." Apparent authority refers to
"the power to affect the legal relations of another person by transactions with
third persons, professedly as agent for the other, arising from and in accordance
with the others manifestations to such third persons." Supra, p. 96.
30
Irving v. Doctors Hospital of Lake Worth, Inc., 415 So. 2d 55 (1982), quotingArthur v. St. Peters Hospital, 169 N.J. 575, 405 A. 2d 443 (1979).
31Id., citing Hudson v. C., Loan Assn., Inc. v. Horowytz, 116 N.J.L. 605, 608, 186 A
437 (Sup. Ct. 1936).
32Supra.
33RTC Decision, p. 9, Rollo of G.R. No. 126467, p. 127.
34RTC Decision, p. 2, Rollo of G.R. No. 126467, p. 120.
35Purcell v. Zimbelman, 18 Ariz. App. 75, 500 P2d 335 (1972).
36Supra at footnote 1.
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37Corleto v. Hospital, 138 N.J. Super. 302, 350 A. 2d 534 (Super. Ct. Law Div.1975);
Purcell v. Zimbelman, 18 Ariz. App. 75,500 P. 2d 335 (1972); Hospital Authority v.
Joiner, 229 Ga. 140,189 S.E. 2d 412 (1972).
38
Welsh v. Bulger, 548 Pa. 504, 698 A.2d 581 (1997).39
115 Ariz. 34, 545 P2d 958 (1976).
40262 S.E. 2d 391, cert denied 300 NC 194, 269 S.E. 2d 621 (1980).
41127 Ariz. 516, 622 P. 2d 463 (1980).
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