Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
126297 February 11, 2008 After a couple of days, Natividad complained of excruciating
pain in her anal region. She consulted both Dr. Ampil and Dr.
PROFESSIONAL SERVICES, INC., petitioner,
Fuentes about it. They told her that the pain was the natural
vs.
consequence of the surgical operation performed upon her. Dr.
THE COURT OF APPEALS and NATIVIDAD and ENRIQUE
Ampil recommended that Natividad consult an oncologist to
AGANA, respondents,
treat the cancerous nodes which were not removed during the
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - x operation.
G.R. No. 126467 February 11, 2008 On May 9, 1984, Natividad, accompanied by her husband, went
to the United States to seek further treatment. After four (4)
NATIVIDAD (Substituted by her children MARCELINO months of consultations and laboratory examinations, Natividad
AGANA III, ENRIQUE AGANA, JR., EMMA AGANA ANDAYA, was told that she was free of cancer. Hence, she was advised
JESUS AGANA, and RAYMUND AGANA) and ENRIQUE to return to the Philippines.
AGANA, petitioners,
vs. On August 31, 1984, Natividad flew back to the Philippines, still
THE COURT OF APPEALS and JUAN suffering from pains. Two (2) weeks thereafter, her daughter
FUENTES, respondents, found a piece of gauze protruding from her vagina. Dr. Ampil
was immediately informed. He proceeded to Natividad’s house
x- - - - - - - - - - - - - - - - - - - - - - - - - - - - x where he managed to extract by hand a piece of gauze
G.R. No. 127590 February 11, 2008 measuring 1.5 inches in width. Dr. Ampil then assured Natividad
that the pains would soon vanish.
MIGUEL AMPIL, petitioner,
vs. Despite Dr. Ampil’s assurance, the pains intensified, prompting
THE COURT OF APPEALS and NATIVIDAD AGANA and Natividad to seek treatment at the Polymedic General Hospital.
ENRIQUE AGANA, respondents. While confined thereat, Dr. Ramon Gutierrez detected the
presence of a foreign object in her vagina -- a foul-smelling
RESOLUTION gauze measuring 1.5 inches in width. The gauze had badly
infected her vaginal vault. A recto-vaginal fistula had formed in
SANDOVAL-GUTIERREZ, J.:
her reproductive organ which forced stool to excrete through the
As the hospital industry changes, so must the laws and vagina. Another surgical operation was needed to remedy the
jurisprudence governing hospital liability. The immunity from situation. Thus, in October 1984, Natividad underwent another
medical malpractice traditionally accorded to hospitals has to be surgery.
eroded if we are to balance the interest of the patients and
On November 12, 1984, Natividad and her husband filed with
hospitals under the present setting.
the Regional Trial Court, Branch 96, Quezon City a complaint
Before this Court is a motion for reconsideration filed by for damages against PSI (owner of Medical City), Dr. Ampil and
Professional Services, Inc. (PSI), petitioner in G.R. No. 126297, Dr. Fuentes.
assailing the Court’s First Division Decision dated January 31,
On February 16, 1986, pending the outcome of the above case,
2007, finding PSI and Dr. Miguel Ampil, petitioner in G.R. No.
Natividad died. She was duly substituted by her above-named
127590, jointly and severally liable for medical negligence.
children (the Aganas).
A brief revisit of the antecedent facts is imperative.
On March 17, 1993, the trial court rendered judgment in favor of
On April 4, 1984, Natividad Agana was admitted at the Medical spouses Agana finding PSI, Dr. Ampil and Dr. Fuentes jointly
City General Hospital (Medical City) because of difficulty of and severally liable. On appeal, the Court of Appeals, in its
bowel movement and bloody anal discharge. Dr. Ampil Decision dated September 6, 1996, affirmed the assailed
diagnosed her to be suffering from "cancer of the sigmoid." judgment with modification in the sense that the complaint
Thus, on April 11, 1984, Dr. Ampil, assisted by the medical against Dr. Fuentes was dismissed.
staff1 of Medical City, performed an anterior resection surgery
PSI, Dr. Ampil and the Aganas filed with this Court separate
upon her. During the surgery, he found that the malignancy in
petitions for review on certiorari. On January 31, 2007, the
her sigmoid area had spread to her left ovary, necessitating the
Court, through its First Division, rendered a Decision holding
removal of certain portions of it. Thus, Dr. Ampil obtained the
that PSI is jointly and severally liable with Dr. Ampil for the
consent of Atty. Enrique Agana, Natividad’s husband, to permit
following reasons: first, there is an employer-employee
Dr. Juan Fuentes, respondent in G.R. No. 126467, to perform
relationship between Medical City and Dr. Ampil. The Court
hysterectomy upon Natividad.
relied on Ramos v. Court of Appeals,2 holding that for the
Dr. Fuentes performed and completed the hysterectomy. purpose of apportioning responsibility in medical negligence
Afterwards, Dr. Ampil took over, completed the operation and cases, an employer-employee relationship in effect
closed the incision. However, the operation appeared to be exists between hospitals and their attending and visiting
flawed. In the corresponding Record of Operation dated April physicians; second, PSI’s act of publicly displaying in the lobby
11, 1984, the attending nurses entered these remarks: of the Medical City the names and specializations of its
accredited physicians, including Dr. Ampil, estopped it from
sponge count lacking 2 denying the existence of an employer-employee relationship
announced to surgeon searched done (sic) but to no avail between them under the doctrine of ostensible agency or
continue for closure. agency by estoppel;and third, PSI’s failure to supervise Dr.
Ampil and its resident physicians and nurses and to take an
active step in order to remedy their negligence rendered it While "consultants" are not, technically employees, a point
directly liable under the doctrine of corporate negligence. which respondent hospital asserts in denying all
responsibility for the patient’s condition, the control
In its motion for reconsideration, PSI contends that the Court
exercised, the hiring, and the right to terminate consultants
erred in finding it liable under Article 2180 of the Civil Code,
all fulfill the important hallmarks of an employer-employee
there being no employer-employee relationship between it and
relationship, with the exception of the payment of wages. In
its consultant, Dr. Ampil. PSI stressed that the Court’s Decision
assessing whether such a relationship in fact exists, the
in Ramos holding that "an employer-employee relationship in
control test is determining. Accordingly, on the basis of the
effect exists between hospitals and their attending and visiting
foregoing, we rule that for the purpose of allocating
physicians for the purpose of apportioning responsibility" had
responsibility in medical negligence cases, an employer-
been reversed in a subsequent Resolution.3 Further, PSI argues
employee relationship in effect exists between hospitals
that the doctrine of ostensible agency or agency by
and their attending and visiting physicians.This being the
estoppelcannot apply because spouses Agana failed to
case, the question now arises as to whether or not respondent
establish one requisite of the doctrine, i.e., that Natividad relied
hospital is solidarily liable with respondent doctors for
on the representation of the hospital in engaging the services of
petitioner’s condition.
Dr. Ampil. And lastly, PSI maintains that the doctrine of
corporate negligence is misplaced because the proximate The basis for holding an employer solidarily responsible for the
cause of Natividad’s injury was Dr. Ampil’s negligence. negligence of its employee is found in Article 2180 of the Civil
Code which considers a person accountable not only for his own
The motion lacks merit.
acts but also for those of others based on the former’s
As earlier mentioned, the First Division, in its assailed Decision, responsibility under a relationship of partia ptetas.
ruled that an employer-employee relationship "in effect" exists
Clearly, in Ramos, the Court considered the peculiar
between the Medical City and Dr. Ampil. Consequently, both are
relationship between a hospital and its consultants on the bases
jointly and severally liable to the Aganas. This ruling proceeds
of certain factors. One such factor is the "control test" wherein
from the following ratiocination in Ramos:
the hospital exercises control in the hiring and firing of
We now discuss the responsibility of the hospital in this consultants, like Dr. Ampil, and in the conduct of their work.
particular incident. The unique practice (among private
Actually, contrary to PSI’s contention, the Court did not reverse
hospitals) of filling up specialist staff with attending and visiting
its ruling in Ramos. What it clarified was that the De Los Santos
"consultants," who are allegedly not hospital employees,
Medical Clinic did not exercise control over its consultant,
presents problems in apportioning responsibility for negligence
hence, there is no employer-employee relationship between
in medical malpractice cases. However, the difficulty is only
them. Thus, despite the granting of the said hospital’s motion for
more apparent than real.
reconsideration, the doctrine in Ramos stays, i.e., for the
In the first place, hospitals exercise significant control in the purpose of allocating responsibility in medical negligence cases,
hiring and firing of consultants and in the conduct of their an employer-employee relationship exists between hospitals
work within the hospital premises. Doctors who apply for and their consultants.
"consultant" slots, visiting or attending, are required to submit
In the instant cases, PSI merely offered a general denial of
proof of completion of residency, their educational qualifications;
responsibility, maintaining that consultants, like Dr. Ampil, are
generally, evidence of accreditation by the appropriate board
"independent contractors," not employees of the hospital. Even
(diplomate), evidence of fellowship in most cases, and
assuming that Dr. Ampil is not an employee of Medical City, but
references. These requirements are carefully scrutinized by
an independent contractor, still the said hospital is liable to the
members of the hospital administration or by a review
Aganas.
committee set up by the hospital who either accept or reject the
application. This is particularly true with respondent hospital. In Nograles, et al. v. Capitol Medical Center, et al.,4 through Mr.
Justice Antonio T. Carpio, the Court held:
After a physician is accepted, either as a visiting or
attending consultant, he is normally required to attend The question now is whether CMC is automatically exempt from
clinico-pathological conferences, conduct bedside rounds liability considering that Dr. Estrada is an independent
for clerks, interns and residents, moderate grand rounds contractor-physician.
and patient audits and perform other tasks and
In general, a hospital is not liable for the negligence of an
responsibilities, for the privilege of being able to maintain
independent contractor-physician. There is, however, an
a clinic in the hospital, and/or for the privilege of admitting
exception to this principle. The hospital may be liable if the
patients into the hospital. In addition to these, the
physician is the "ostensible" agent of the hospital. (Jones v.
physician’s performance as a specialist is generally
Philpott, 702 F. Supp. 1210 [1988]) This exception is also known
evaluated by a peer review committee on the basis of
as the "doctrine of apparent authority." (Sometimes referred to
mortality and morbidity statistics, and feedback from
as the apparent or ostensible agency theory. [King v. Mitchell,
patients, nurses, interns and residents. A consultant
31 A.D.3rd 958, 819 N.Y. S.2d 169 (2006)].
remiss in his duties, or a consultant who regularly falls
short of the minimum standards acceptable to the hospital xxx
or its peer review committee, is normally politely
terminated. The doctrine of apparent authority essentially involves two
factors to determine the liability of an independent contractor-
In other words, private hospitals hire, fire and exercise real physician.
control over their attending and visiting "consultant" staff.
The first factor focuses on the hospital’s manifestations and is expect more than the usual medical service to be given to us,
sometimes described as an inquiry whether the hospital acted than his ordinary patients.5
in a manner which would lead a reasonable person to conclude
Clearly, PSI is estopped from passing the blame solely to Dr.
that the individual who was alleged to be negligent was an
Ampil. Its act of displaying his name and those of the other
employee or agent of the hospital. (Diggs v. Novant Health, Inc.,
physicians in the public directory at the lobby of the hospital
628 S.E.2d 851 (2006) citing Hylton v. Koontz, 138 N.C. App.
amounts to holding out to the public that it offers quality medical
629 (2000). In this regard, the hospital need not make
service through the listed physicians. This justifies Atty. Agana’s
express representations to the patient that the treating
belief that Dr. Ampil was a member of the hospital’s staff. It
physician is an employee of the hospital; rather a
must be stressed that under the doctrine of apparent
representation may be general and implied. (Id.)
authority, the question in every case is whether the
The doctrine of apparent authority is a specie of the doctrine of principal has by his voluntary act placed the agent in such
estoppel. Article 1431 of the Civil Code provides that "[t]hrough a situation that a person of ordinary prudence, conversant
estoppel, an admission or representation is rendered conclusive with business usages and the nature of the particular
upon the person making it, and cannot be denied or disproved business, is justified in presuming that such agent has
as against the person relying thereon." Estoppel rests on this authority to perform the particular act in question.6 In these
rule: "Whether a party has, by his own declaration, act, or cases, the circumstances yield a positive answer to the
omission, intentionally and deliberately led another to believe a question.
particular thing true, and to act upon such belief, he cannot, in
The challenged Decision also anchors its ruling on the doctrine
any litigation arising out of such declaration, act or omission, be
permitted to falsify it. (De Castro v. Ginete, 137 Phil. 453 [1969], of corporate responsibility.7 The duty of providing quality
medical service is no longer the sole prerogative and
citing Sec. 3, par. A, Rule 131 of the Rules of Court. See
responsibility of the physician. This is because the modern
also King v. Mitchell, 31 A.D.3rd 958, 819 N.Y.S.2d 169 [2006]).
hospital now tends to organize a highly-professional medical
xxx staff whose competence and performance need also to be
monitored by the hospital commensurate with its inherent
The second factor focuses on the patient’s reliance. It is
responsibility to provide quality medical care.8 Such
sometimes characterized as an inquiry on whether the plaintiff
responsibility includes the proper supervision of the
acted in reliance upon the conduct of the hospital or its agent,
members of its medical staff. Accordingly, the hospital has
consistent with ordinary care and prudence. (Diggs v. Novant
the duty to make a reasonable effort to monitor and oversee
Health, Inc.)
the treatment prescribed and administered by the
PSI argues that the doctrine of apparent authority cannot physicians practicing in its premises.
apply to these cases because spouses Agana failed to establish
Unfortunately, PSI had been remiss in its duty. It did not conduct
proof of their reliance on the representation of Medical City that
an immediate investigation on the reported missing gauzes to
Dr. Ampil is its employee. the great prejudice and agony of its patient. Dr. Jocson, a
The argument lacks merit. member of PSI’s medical staff, who testified on whether the
hospital conducted an investigation, was evasive, thus:
Atty. Agana categorically testified that one of the reasons why
he chose Dr. Ampil was that he knew him to be a staff Q We go back to the operative technique, this was signed
member of Medical City, a prominent and known hospital. by Dr. Puruganan, was this submitted to the hospital?
Q Will you tell us what transpired in your visit to Dr. Ampil? A Yes, sir, this was submitted to the hospital with the
record of the patient.
A Well, I saw Dr. Ampil at the Medical City, I know him to be
a staff member there, and I told him about the case of my wife Q Was the hospital immediately informed about the
and he asked me to bring my wife over so she could be missing sponges?
examined. Prior to that, I have known Dr. Ampil, first, he was
A That is the duty of the surgeon, sir.
staying in front of our house, he was a neighbor, second, my
daughter was his student in the University of the East School of Q As a witness to an untoward incident in the operating
Medicine at Ramon Magsaysay; and when my daughter opted room, was it not your obligation, Dr., to also report to the
to establish a hospital or a clinic, Dr. Ampil was one of our hospital because you are under the control and direction of
consultants on how to establish that hospital. And from there, I the hospital?
have known that he was a specialist when it comes to that
illness. A The hospital already had the record of the two OS
missing, sir.
Atty. Agcaoili
Q If you place yourself in the position of the hospital, how
On that particular occasion, April 2, 1984, what was your reason will you recover.
for choosing to contact Dr. Ampil in connection with your wife’s
A You do not answer my question with another question.
illness?
Q Did the hospital do anything about the missing
A First, before that, I have known him to be a specialist on that
gauzes?
part of the body as a surgeon; second, I have known him to
be a staff member of the Medical City which is a prominent A The hospital left it up to the surgeon who was doing
and known hospital. And third, because he is a neighbor, I the operation, sir.
Q Did the hospital investigate the surgeon who did the
operation?
A I am not in the position to answer that, sir.
Q You never did hear the hospital investigating the
doctors involved in this case of those missing sponges, or
did you hear something?
xxxxxx
A I think we already made a report by just saying that two
sponges were missing, it is up to the hospital to make the
move.
Atty. Agana
Precisely, I am asking you if the hospital did a move, if the
hospital did a move.
A I cannot answer that.
Court
By that answer, would you mean to tell the Court that you
were aware if there was such a move done by the hospital?
A I cannot answer that, your honor, because I did not
have any more follow-up of the case that happened until
now.9
The above testimony obviously shows Dr. Jocson’s lack of
concern for the patients. Such conduct is reflective of the
hospital’s manner of supervision. Not only did PSI breach
its duty 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.
Moreover, there is merit in the trial court’s finding that the failure
of PSI to conduct an investigation "established PSI’s part in
the dark conspiracy of silence and concealment about the
gauzes." The following testimony of Atty. Agana supports such
findings, thus:
Q You said you relied on the promise of Dr. Ampil and despite
the promise you were not able to obtain the said record. Did you
go back to the record custodian?
A I did not because I was talking to Dr. Ampil. He
promised me.
Q After your talk to Dr. Ampil, you went to the record
custodian?
A I went to the record custodian to get the clinical record
of my wife, and I was given a portion of the records
consisting of the findings, among them, the entries of the
dates, but not the operating procedure and operative
report.10
In sum, we find no merit in the motion for reconsideration.
WHEREFORE, we DENY PSI’s motion for reconsideration with
finality.