Standards of Care
Republic of the Philippines
SUPREME COURT
Manila
FIRST DIVISION
G.R. No. 126297 February 11, 2008
PROFESSIONAL SERVICES, INC., petitioner,
vs.
THE COURT OF APPEALS and NATIVIDAD and ENRIQUE AGANA, respondents,
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G.R. No. 126467 February 11, 2008
NATIVIDAD (Substituted by her children MARCELINO AGANA III, ENRIQUE AGANA, JR., EMMA AGANA
ANDAYA, JESUS AGANA, and RAYMUND AGANA) and ENRIQUE AGANA, petitioners,
vs.
THE COURT OF APPEALS and JUAN FUENTES, respondents,
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G.R. No. 127590 February 11, 2008
MIGUEL AMPIL, petitioner,
vs.
THE COURT OF APPEALS and NATIVIDAD AGANA and ENRIQUE AGANA, respondents.
RESOLUTION
SANDOVAL-GUTIERREZ, J.:
As the hospital industry changes, so must the laws and jurisprudence governing hospital liability. The immunity
from medical malpractice traditionally accorded to hospitals has to be eroded if we are to balance the interest of
the patients and hospitals under the present setting.
Before this Court is a motion for reconsideration filed by Professional Services, Inc. (PSI), petitioner in G.R. No.
126297, assailing the Courts First Division Decision dated January 31, 2007, finding PSI and Dr. Miguel Ampil,
petitioner in G.R. No. 127590, jointly and severally liable for medical negligence.
A brief revisit of the antecedent facts is imperative.
On April 4, 1984, Natividad Agana was admitted at the Medical City General Hospital (Medical City) because of
difficulty of bowel movement and bloody anal discharge. Dr. Ampil diagnosed her to be suffering from "cancer of
the sigmoid." Thus, on April 11, 1984, Dr. Ampil, assisted by the medical staff1 of Medical City, performed an
anterior resection surgery upon her. During the surgery, he found that the malignancy in her sigmoid area had
spread to her left ovary, necessitating the removal of certain portions of it. Thus, Dr. Ampil obtained the consent
of Atty. Enrique Agana, Natividads husband, to permit Dr. Juan Fuentes, respondent in G.R. No. 126467, to
perform hysterectomy upon Natividad.
Dr. Fuentes performed and completed the hysterectomy. Afterwards, 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 done (sic) but to no avail continue for closure.
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 surgical operation
performed upon her. Dr. Ampil recommended that Natividad consult an oncologist to treat the cancerous nodes
which were not removed during the operation.
On May 9, 1984, Natividad, accompanied by her husband, went to the United States to seek further treatment.
After four (4) months of consultations and laboratory examinations, Natividad was told that 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 (2) weeks thereafter,
her daughter found a piece of gauze protruding from her vagina. Dr. Ampil was immediately informed. He
proceeded to Natividads house where he managed to extract by hand a piece of gauze measuring 1.5 inches in
width. Dr. Ampil then assured Natividad that the pains would soon vanish.
Despite Dr. Ampils assurance, the pains intensified, prompting Natividad to seek treatment at the Polymedic
General Hospital. While confined thereat, Dr. Ramon Gutierrez detected the presence of a foreign object in her
vagina -- a foul-smelling gauze measuring 1.5 inches in width. The gauze had badly infected her vaginal vault. A
recto-vaginal fistula had formed in her reproductive organ which forced stool to excrete through the vagina.
Another surgical operation was needed to remedy the situation. Thus, in October 1984, Natividad underwent
another surgery.
On November 12, 1984, Natividad and her husband filed with the Regional Trial Court, Branch 96, Quezon City a
complaint for damages against PSI (owner of Medical City), Dr. Ampil and Dr. Fuentes.
On February 16, 1986, pending the outcome of the above case, Natividad died. She was duly substituted by her
above-named children (the Aganas).
On March 17, 1993, the trial court rendered judgment in favor of spouses Agana finding PSI, Dr. Ampil and Dr.
Fuentes jointly and severally liable. On appeal, the Court of Appeals, in its Decision dated September 6, 1996,
affirmed the assailed judgment with modification in the sense that the complaint against Dr. Fuentes was
dismissed.
PSI, Dr. Ampil and the Aganas filed with this Court separate petitions for review on certiorari. On January 31, 2007,
the Court, through its First Division, rendered a Decision holding that PSI is jointly and severally liable with Dr.
Ampil for the following reasons: first, there is an employer-employee relationship between Medical City and Dr.
Ampil. The Court relied on Ramos v. Court of Appeals,2 holding that for the purpose of apportioning responsibility
in medical negligence cases, an employer-employee relationship in effect exists between hospitals and their
attending and visiting physicians; second, PSIs act of publicly displaying in the lobby of the Medical City the
names and specializations of its accredited physicians, including Dr. Ampil, estopped it from denying the
existence of an employer-employee relationship between them under the doctrine of ostensible agency or
agency by estoppel; and third, PSIs 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 directly liable under the doctrine of corporate
negligence.
In its motion for reconsideration, PSI contends that the Court erred in finding it liable under Article 2180 of the
Civil Code, there being no employer-employee relationship between it and its consultant, Dr. Ampil. PSI stressed
that the Courts Decision in Ramos holding that "an employer-employee relationship in effect exists between
hospitals and their attending and visiting physicians for the purpose of apportioning responsibility" had been
reversed in a subsequent Resolution.3 Further, PSI argues that the doctrine of ostensible agency or agency by
estoppel cannot apply because spouses Agana failed to establish one requisite of the doctrine, i.e., that Natividad
relied on the representation of the hospital in engaging the services of Dr. Ampil. And lastly, PSI maintains that
the doctrine of corporate negligence is misplaced because the proximate cause of Natividads injury was Dr.
Ampils negligence.
The motion lacks merit.
As earlier mentioned, the First Division, in its assailed Decision, ruled that an employer-employee relationship "in
effect" exists between the Medical City and Dr. Ampil. Consequently, both are jointly and severally liable to the
Aganas. This ruling proceeds from the following ratiocination in Ramos:
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 only 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. This is particularly true with respondent hospital.
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 employees, a point which respondent
hospital asserts in denying all responsibility for the patients condition, 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. This being the case, the question now arises as to whether or not respondent hospital is
solidarily liable with respondent doctors for petitioners condition.
The basis for holding an employer solidarily responsible for the negligence of its employee is found in
Article 2180 of the Civil Code which considers a person accountable not only for his own acts but also for
those of others based on the formers responsibility under a relationship of partia ptetas.
Clearly, in Ramos, the Court considered the peculiar relationship between a hospital and its consultants on the
bases of certain factors. One such factor is the "control test" wherein the hospital exercises control in the hiring
and firing of consultants, like Dr. Ampil, and in the conduct of their work.
Actually, contrary to PSIs contention, the Court did not reverse its ruling in Ramos. What it clarified was that the
De Los Santos Medical Clinic did not exercise control over its consultant, hence, there is no employer-employee
relationship between them. Thus, despite the granting of the said hospitals motion for reconsideration, the
doctrine in Ramos stays, i.e., for the purpose of allocating responsibility in medical negligence cases, an employer-
employee relationship exists between hospitals and their consultants.
In the instant cases, PSI merely offered a general denial of responsibility, maintaining that consultants, like Dr.
Ampil, are "independent contractors," not employees of the hospital. Even assuming that Dr. Ampil is not an
employee of Medical City, but an independent contractor, still the said hospital is liable to the Aganas.
In Nograles, et al. v. Capitol Medical Center, et al.,4 through Mr. Justice Antonio T. Carpio, the Court held:
The question now is whether CMC is automatically exempt from liability considering that Dr. Estrada is
an independent contractor-physician.
In general, a hospital is not liable for the negligence of an independent contractor-physician. There is,
however, an exception to this principle. The hospital may be liable if the physician is the "ostensible" agent of
the hospital. (Jones v. Philpott, 702 F. Supp. 1210 [1988]) This exception is also known as the "doctrine of
apparent authority." (Sometimes referred to as the apparent or ostensible agency theory. [King v. Mitchell, 31
A.D.3rd 958, 819 N.Y. S.2d 169 (2006)].
xxx
The doctrine of apparent authority essentially involves two factors to determine the liability of an
independent contractor-physician.
The first factor focuses on the hospitals manifestations and is sometimes described as an inquiry whether the
hospital acted in a manner which would lead a reasonable person to conclude that the individual who was
alleged to be negligent was an employee or agent of the hospital. (Diggs v. Novant Health, Inc., 628 S.E.2d
851 (2006) citing Hylton v. Koontz, 138 N.C. App. 629 (2000). In this regard, the hospital need not make
express representations to the patient that the treating physician is an employee of the hospital; rather
a representation may be general and implied. (Id.)
The doctrine of apparent authority is a specie of the doctrine of estoppel. Article 1431 of the Civil Code
provides that "[t]hrough estoppel, an admission or representation is rendered conclusive upon the person
making it, and cannot be denied or disproved as against the person relying thereon." Estoppel rests on this
rule: "Whether a party has, by his own declaration, act, or omission, intentionally and deliberately led another
to believe a particular thing true, and to act upon such belief, he cannot, in any litigation arising out of such
declaration, act or omission, be permitted to falsify it. (De Castro v. Ginete, 137 Phil. 453 [1969], citing Sec. 3,
par. A, Rule 131 of the Rules of Court. See also King v. Mitchell, 31 A.D.3rd 958, 819 N.Y.S.2d 169 [2006]).
xxx
The second factor focuses on the patients reliance. It is sometimes characterized as an inquiry on whether
the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and
prudence. (Diggs v. Novant Health, Inc.)
PSI argues that the doctrine of apparent authority cannot apply to these cases because spouses Agana failed to
establish proof of their reliance on the representation of Medical City that Dr. Ampil is its employee.
The argument lacks merit.
Atty. Agana categorically testified that one of the reasons why he chose Dr. Ampil was that he knew him to be a
staff member of Medical City, a prominent and known hospital.
Q Will you tell us what transpired in your visit to Dr. Ampil?
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 and he asked me to bring my wife over so she could be examined. Prior to that,
I have known Dr. Ampil, first, he was staying in front of our house, he was a neighbor, second, my
daughter was his student in the University of the East School of Medicine at Ramon Magsaysay; and
when my daughter opted to establish a hospital or a clinic, Dr. Ampil was one of our consultants on how
to establish that hospital. And from there, I have known that he was a specialist when it comes to that
illness.
Atty. Agcaoili
On that particular occasion, April 2, 1984, what was your reason for choosing to contact Dr. Ampil in
connection with your wifes illness?
A First, before that, I have known him to be a specialist on that 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 and known
hospital. And third, because he is a neighbor, I expect more than the usual medical service to be given to
us, than his ordinary patients.5
Clearly, PSI is estopped from passing the blame solely to Dr. Ampil. Its act of displaying his name and those of the
other physicians in the public directory at the lobby of the hospital amounts to holding out to the public that it
offers quality medical service through the listed physicians. This justifies Atty. Aganas belief that Dr. Ampil was a
member of the hospitals staff. It must be stressed that under the doctrine of apparent authority, 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. 6 In these cases,
the circumstances yield a positive answer to the question.
The challenged Decision also anchors its ruling on the doctrine of corporate responsibility.7 The duty of
providing quality medical service is no longer the sole prerogative and responsibility of the physician. This is
because the modern hospital now tends to organize a highly-professional medical staff whose competence and
performance need also to be monitored by the hospital commensurate with its inherent responsibility to provide
quality medical care.8 Such responsibility includes the proper supervision of the members of its medical staff.
Accordingly, the hospital has the duty to make a reasonable effort to monitor and oversee the treatment
prescribed and administered by the physicians practicing in its premises.
Unfortunately, PSI had been remiss in its duty. It did not conduct an immediate investigation on the reported
missing gauzes to the great prejudice and agony of its patient. Dr. Jocson, a member of PSIs medical staff, who
testified on whether the hospital conducted an investigation, was evasive, thus:
Q We go back to the operative technique, this was signed by Dr. Puruganan, was this submitted to
the hospital?
A Yes, sir, this was submitted to the hospital with the record of the patient.
Q Was the hospital immediately informed about the missing sponges?
A That is the duty of the surgeon, sir.
Q As a witness to an untoward incident in the operating room, was it not your obligation, Dr., to
also report to the hospital because you are under the control and direction of the hospital?
A The hospital already had the record of the two OS missing, sir.
Q If you place yourself in the position of the hospital, how will you recover.
A You do not answer my question with another question.
Q Did the hospital do anything about the missing gauzes?
A The hospital left it up to the surgeon who was doing 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. Jocsons lack of concern for the patients. Such conduct is reflective of
the hospitals 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 courts finding that the failure of PSI to conduct an investigation "established
PSIs 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 PSIs motion for reconsideration with finality.
SO ORDERED.
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