Legal Medicine Finals

LEGAL MEDICINE The Filipino Physician

2.

Discuss the journey a person must thread to become a physician.

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A person must have a college degree, with the requisite subject units. He must have passed the National Medical Admissions Test (NMAT) to qualify to be admitted into a medical school. Under NMAT rules, “[a] student shall be allowed only three (3) chances to take the NMAT. After three (3) successive failures, a student shall not be allowed to take the NMAT for the fourth time.” In DECS vs San Diego, the Supreme Court upheld the validity of the three-flunk rule, saying that: “the medical profession directly affects the very lives of the people, unlike other careers which, for this reason, do not require more vigilant regulation.” The Doctor of Medicine (M.D.) degree is a five year graduate program intended to teach students the essentials of being a Medical Doctor. The program consists of three years of academic instruction, one year of clinical clerkship and one year of post-graduate internship. After passing the board exam, one can now be considered a licensed doctor. But from there, he is considered a general practitioner. He may also take specializations and sub specializations.

RA No. 2382 or the Medical Act of 1959; PMA Code of Ethics What are the objectives of the Medical Act? -

It provides for and shall govern the following: 1. Standardization and regulation of Medical Education; 2. Examination for registration of physicians; 3. Supervision, control and regulation of the practice of medicine in the Philippines

4. 5. 6. 7. 8.

What are the requirements for admission into medical school? 1. 2.

2.

1. 2. 3.

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Board of Medical Education (Duties are now assumed by the Commission on Higher Education) Board of Medical Examiners (Duties are now assumed by the Board of Medicine under PRC)

2. 3. 4. 5. 6. 7.

Secretary of Education or duly authorized representative; Secretary of Health or duly authorized representative; Director of Bureau of Private schools or his duly authorized representative; Chairman of the Board of Medicine or his duly authorized representative; Dean of UP Med; Council of Dean of Med Schools; Representative chosen by PACU

What are the functions of the Board of Medical Education? 1.

Prescribes the minimum requisites for admission to a medical school;

At least 21 years of age; Must have passed the medical board exams; and Must be a holder of a valid, certificate of registration issued by the Board of Medicine

Q: Once a person has passed the medical board exams, is the issuance of the certificate of registration ministerial on the part of the Board of Medicine?

Who comprise the Board of Medical Education? 1.

Must not have been convicted of a crime involving moral turpitude; Must be able to present the following: a. Bachelor’s degree; b. Certification of eligibility for entrance to a med school from the Board of Medical Education; c. Certification of GMC from at least two professors; and d. Birth certificate

What are the prerequisites for the practice of medicine?

What are the two agencies created by virtue of the Medical Act? 1.

Prescribes the minimum physical facilities required of a medical school; Prescribes the minimum number and minimum qualification of teaching personnel; Prescribes the minimum required curriculum; To authorize the implementation of experimental medical curriculum in a medical school that has exceptional faculty and instrumental facilities; To accept applications for certification for admission to a medical school and to keep a register of medical students; To select training hospitals; and To promulgate rules necessary for the enforcement of the above mentioned functions;

No. Section 8 of the Medical Act provides that “No person shall engage in the practice of medicine in the Philippines unless he is at least twenty-one years of age, has satisfactorily passed the corresponding Board Examination…” The operative word is “satisfactorily.” Hence, if the Board is not satisfied with the circumstances surrounding the examinee’s passing, it has the discretion of postponing or refusing to issue a certificate of registration. The duty to issue such certificate is not ministerial and hence not compellable by a petition for mandamus. (PRC vs De Guzman)

What are the qualifications candidates for board exams must possess? 1. 2. 3. 4. 5. 6.

Filipino citizen/foreigner (who must prove that his country allows reciprocal rights to Filipinos in practicing medicine); Good moral character; Of sound mind; Not convicted of a crime involving moral turpitude; Must be a holder of the degree of doctor of medicine; and He must have completed a calendar year of technical training known as internship

What constitutes the practice of medicine?

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A person shall be considered as engaged in the practice of medicine if he: 1. For compensation, fee, salary or reward (CFSR) in any form paid to him directly or through another, or even without the same, physically examine any person, and diagnose, treat, operate or prescribe (PeDTOP) any remedy for human disease, injury, deformity, physical, mental or psychological (DIDPMP) condition or ailment, real or imaginary, regardless of the value of the remedy administered, prescribed or recommended; 2. By means of signs, cards, advertisements, written or printed matter, or through the radio, TV or any other means of telecommunication, either offer or undertake by any means or method to diagnose, treat, operate or prescribe any remedy for any human disease, injury, deformity, physical, mental or psychological condition; and 3. Falsely use the title of MD after his name

What are the instances wherein a certificate of registrations is not required? 1.

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3.

4.

What are the exceptions to Sec. 10 regarding acts constituting practice of medicine? 1.

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3.

4.

5.

6. 7.

8.

Any medical student duly enrolled in an approved medical college or school, or graduate under training, serving without any professional fee in any government or private hospital, provided that he render such service under the direct supervision and control of a registered physician; Any legally registered dentist engaged exclusively in the practice of dentistry; (c) any duly registered masseur or physiotherapist, provided that he applies massage or other physical means upon written order or prescription of a duly registered physician, or provided that such application of massage or physical means shall be limited to physical or muscular development; Any duly registered masseur or physiotherapist, provided that he applies massage or other physical means upon written order or prescription of a duly registered physician, or provided that such application of massage or physical means shall be limited to physical or muscular development; who fit artificial limbs under the supervision of a registered physician. Any duly registered optometrist who mechanically fits or sells lenses, artificial eyes, limbs or other similar appliances or who is engaged in the mechanical examination of eyes for the purpose of constructing or adjusting eyeglasses, spectacles and lenses; Any person who renders any service gratuitously in cases of emergency, or in places where the services of a duly registered physician, nurse or midwife are not available; Any person who administers or recommends any household remedy as per classification of existing Pharmacy Laws; Any clinical psychologist, or mental hygienist, in the performance of his duties in regard to patients with psychiatric problems, provided such performance is done with the prescription and direct supervision of a duly registered physician, and Prosthetists who fit artificial limbs under the supervision of a registered physician.

Physicians and surgeons from other countries called in consultation only and exclusively in specific and definite case, or those attached to international bodies or organizations assigned to perform certain definite work in the Philippines, provided they shall limit their practice to the specific work assigned to them and provided further they shall secure a previous authorization from the Board of Medical Examiners; Commissioned medical officers of the United States Armed Forces stationed in the Philippines while rendering service as such only for the members of the said armed forces and within the limit of their own respective territorial jurisdiction; Foreign physicians employed as exchange professors in special branches of medicine or surgery whose service may, upon previous authorization of the Board of Medical Examiners, be necessary; Medical students who have completed the first four years of medical course, graduates of medicine and registered nurses who may be given limited and special authorization by the Secretary of Health to render services during epidemics or national emergencies whenever the services of duly registered physicians are not available. Such authorization shall automatically cease when the epidemic or national emergency is declared terminated by the Secretary of Health.

What are the qualifications to be a member of the Board of Medicine and how are they appointed? -

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He must 1. 2. 3.

be: A natural born Filipino citizen; A physician practicing for at least 10 years; One who is of good moral character and of good standing in the medical profession; 4. Not a member of any medical school nor has a pecuniary interest, directly or indirectly in any medical school The Board of Medicine shall be composed of six members to be appointed by the President of the Philippines from a list of not more than twelve names approved and submitted by the Executive Council of the Philippine Medical Association, after due consultation with other medical association during the month of September each year. The chairman of the Board shall be elected from among themselves by the members at a meeting called for the purpose. The President of the Philippines shall fill any vacancy that may occur during any examination from the list of names submitted by the Philippine Medical Association in accordance with the provisions of this Act.

What are the duties of the Board of Medicine? -

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They promulgate rules and regulations, subject to the approval of the CSC, as may be necessary for the proper conduct of exams, correction of exam papers, and registration of physicians; Administer oaths to physicians; Study conditions affecting the practice of medicine in the Philippines; Exercise powers conferred by law with the view of maintaining the ethical and professional standards of the medical profession;

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Subpoena testifcandum / duces tecum; and Promulgate rules and regulations as may be necessary

What are the grounds for the reprimand, suspension or revocation of a physician’s certificate of registration? 1.

Conviction by a court of competent jurisdiction of any criminal offense involving moral turpitude; 2. Immoral or dishonorable conduct; 3. Insanity; 4. Fraud in the acquisition of the certificate of registration; 5. Gross negligence, ignorance or incompetence in the practice of his or her profession resulting in an injury to or death of the patient; 6. Addiction to alcoholic beverages or to any habit forming drug rendering him or her incompetent to practice his or her profession, or to any form of gambling; 7. False or extravagant or unethical advertisements wherein other things than his name, profession, limitation of practice, clinic hours, office and home address, are mentioned. 8. Performance of or aiding in any criminal abortion; 9. Knowingly issuing any false medical certificate; 10. Issuing any statement or spreading any news or rumor which is derogatory to the character and reputation of another physician without justifiable motive; 11. Aiding or acting as a dummy of an unqualified or unregistered person to practice medicine; 12. Violation of any provision of the Code of Ethics as approved by the Philippine Medical Association. *Refusal of a physician to attend a patient in danger of death is not a sufficient ground for revocation or suspension of his registration certificate if there is a risk to the physician's life.

acted in an exemplary manner in the community wherein he resides and has not committed any illegal, immoral or dishonorable act. Liabilities of a Physician What are the three fold liabilities of a physician? -

Do the regular courts have the authority to suspend or revoke the license of a physician? -

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Within five days after the filling of written charges under oath, the respondent physician shall be furnished a copy thereof, without requiring him or her to answer the same, and the Board shall conduct the investigation within five days after the receipt of such copy by the respondent. The investigation shall be completed as soon as practicable. Administrative investigations must be conducted by at least two members of the Board of Medicine, with one legal officer sitting during the investigation. The respondent physician shall be entitled to be represented by counsel or be heard by himself or herself, to have a speedy and public hearing, to confront and to cross-examine witnesses against him or her, and to all other rights guaranteed by the Constitution and provided for in the Rules of Court. The decision of the Board of Medical Examiners shall automatically become final thirty days after the date of its promulgation unless the respondent, during the same period, has appealed to the Commissioner of Civil Service and later to the Office of the President of the Philippines. If the final decision is not satisfactory, the respondent may ask for a review of the case, or may file in court a petition for certiorari. After two years, the Board may order the reinstatement of any physicians whose certificate of registration has been revoked, if the respondent has

No, it is the Board of Medicine that is vested with such authority. Administrative complaints against an erring physician must be filed with the Board of Medicine.

Can the Board of Medicine imprison or impose a fine on an erring physician? -

No. Only the regular courts can do that.

What are the duties of physician under the PMA Code of Ethics? 1.

2.

3.

What are the procedures to observe in case of administrative investigations by the Board of Medicine? -

(1) Administrative, (2) Civil, and (3) Criminal

4.

5.

A physician should be dedicated to provide competent medical care with full professional skill in accordance with the current standards of care, compassion, independence and respect for human dignity. A physician should be free to choose patients.  Rationale: You cannot force a doctor to examine a patient whose illness is not within his competence. In an emergency, provided there is no risk to his or her safety, a physician should administer at least first aid treatment and then refer the patient to the primary physician and/or to a more competent health provider and appropriate facility if necessary.  Elements: i. There must be an emergency; and ii. There must be no risk to the physician’s safety. In serious/difficult cases, or when the circumstances of the patient or the family so demand or justify, the attending physician should seek the assistance of the appropriate specialist.  ‘Wag dapat ma-pride. Pag hindi kaya, humingi ng tulong. A physician should exercise good faith and honesty in expressing opinion/s as to the diagnosis, prognosis, and treatment of a case under his/her care. A physician shall respect the right of the patient to refuse medical treatment. Timely notice of the worsening of the disease should be given to the patient and/or family. A physician shall not conceal nor exaggerate the patient’s condition except when it is to the latter’s best interest. A physician shall obtain from the patient a voluntary informed consent. In case of unconsciousness or in a state of mental deficiency the informed consent may be given by a spouse or immediate relatives and in the absence of both, by the party authorized by an advanced directive of the patient. Informed consent in the case of minor should be given by the parents or guardian, members of the immediate family that are of legal age.  Good faith and honest opinion;

Respect the right of the patient to refuse medical treatment;  Give timely notice of the worsening of the disease;  Must not conceal nor exaggerate the patient’s condition, except when it is to the latter’s best interest; and  Voluntary informed consent. The physician should hold as sacred and highly confidential whatever may be discovered or learned pertinent to the patient even after death, except when required in the promotion of justice, safety and public health. Professional fees should be commensurate to the services rendered with due consideration to the patient’s financial status, nature of the case, time consumed and the professional standing and skill of the physician in the community 

6.

7.

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How can a physician qualify to testify as an expert witness? -

Can an aggrieved patient institute administrative, civil and criminal actions against a physician simultaneously? -

Yes, there is no prohibition to that effect.

What is the remedy of a party from an unfavorable decision of the Board of Medicine? -

Board of Medicine  PRC  (via Rule 43) CA  (via Rule 45)  SC

There must be a Doctor-Patient Relationship; There must be a duty; There is a breach of such duty; Damage to the patient resulted from that breach; and 5. The breach must be the proximate cause of the damage to the patient;  Jurisprudence:  If the proximate cause of the patient’s damage was his own failure to heed the instructions of his doctor, there is no medical negligence. (Lasam vs Ramolete, 2008) What is the usual if not the only cause of action against a doctor in a civil suit? -

Art. 2176 of the Civil Code: “Article 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 preexisting contractual relation between the parties, is called a quasi-delict and is governed by the provisions of this Chapter.”

Cite instances where there is no Doctor-Patient relationship? -

Company doctor set-up, pre-employment check ups, insurance, where physician is forced by the court to examine a patient.

How can a plaintiff or complainant prove the breach of duty and the proximate causation? -

He needs to procure a testimony of an expert witness.

The Supreme Court had been consisted in ruling that the doctor must be a specialist in the case concerned. But in Casumpang vs Cortejo (2015), the Court ruled that to qualify a witness as a medical expert, it must be shown that the witness: 1. Has the required professional knowledge, learning and skill of the subject under inquiry sufficient to qualify him to speak with authority on the subject; and 2. Is familiar with the standard required of a physician under similar circumstances; Where a witness has disclosed sufficient knowledge of the subject to entitle his opinion to go to the jury, the question of the degree of his knowledge goes more to the weight of the evidence than to its admissibility.

What are the elements of Medical Negligence? 1. 2. 3. 4.

Expert witnesses are very important in medical negligence cases. They have therein a two-fold role: 1. To establish the standard of care; and 2. To state whether or not the defendant physician has followed such proper standard of care. Jurisprudence:  To be sure, the Court cannot give much weight to the complainant’s own opinion and assessment of what the doctor should have and should not have done. (Lucas vs Tuano, 2009)

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Also, in Ramos vs CA (1999), the Court held: “Although witness Cruz is not an anesthesiologist, she can very well testify upon matters on which she is capable of observing such as, the statements and acts of the physician and surgeon, external appearances, and manifest conditions which are observable by any one. 48 This is precisely allowed under the doctrine of res ipsa loquitur where the testimony of expert witnesses is not required. It is the accepted rule that expert testimony is not necessary for the proof of negligence in non-technical matters or those of which an ordinary person may be expected to have knowledge, or where the lack of skill or want of care is so obvious as to render expert testimony unnecessary. We take judicial notice of the fact that anesthesia procedures have become so common, that even an ordinary person can tell if it was administered properly. As such, it would not be too difficult to tell if the tube was properly inserted. This kind of observation, we believe, does not require a medical degree to be acceptable. At any rate, without doubt, petitioner's witness, an experienced clinical nurse whose long experience and scholarship led to her appointment as Dean of the Capitol Medical Center School at Nursing, was fully capable of determining whether or not the intubation was a success. She had extensive clinical experience starting as a staff nurse in Chicago, Illinois; staff nurse and clinical instructor in a teaching hospital, the FEU-NRMF; Dean of the Laguna College of Nursing in San Pablo City; and then Dean of the Capitol Medical Center School of Nursing.”

What is the principle of res ipsa loquitur and how is it relevant in medical negligence? -

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"Where the thing which causes injury is shown to be under the management of the defendant, and the accident is such as in the ordinary course of things does not happen if those who have the management use proper care, it affords reasonable evidence, in the absence of an explanation by the defendant, that the accident arose from want of care." The doctrine of [r]es ipsa loquitur as a rule of evidence is peculiar to the law of negligence which recognizes that prima facie negligence may be established without direct proof and furnishes a substitute for specific proof of negligence. The doctrine is not a rule of substantive law, but merely a mode of proof or a mere procedural convenience. The rule, when applicable to the facts and circumstances of a particular case, is not intended to and does not dispense with the requirement of proof of culpable negligence on the party charged. It merely determines and regulates what shall be prima facie evidence thereof and facilitates the burden of plaintiff of proving a breach of the duty of due care. The doctrine can be invoked when and only when, under the circumstances involved, direct evidence is absent and not readily available. In other words, in the absence of direct evidence or a testimony of an expert witness, the complainant’s cause of action may be saved by the application of res ipsa loquitur.

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What are the elements of res ipsa loquitur in the context of medical negligence? 1.

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The accident is of a kind which ordinarily does not occur in the absence of someone's negligence; 2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and 3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated. Jurisprudence:  “In the instant case, all the requisites for recourse to the doctrine are present. First, the entire proceedings of the caesarean section were under the exclusive control of Dr. Batiquin. In this light, the private respondents were bereft of direct evidence as to the actual culprit or the exact cause of the foreign object finding its way into private respondent Villegas's body, which, needless to say, does not occur unless through the intersection of negligence. Second, since aside from the caesarean section, private respondent Villegas underwent no other operation which could have caused the offending piece of rubber to appear in her uterus, it stands to reason that such could only have been a by-product of the caesarean section performed by Dr. Batiquin.” (Batiquin vs CA, 1996)  “Relative to the case, res ipsa loquitor does not apply since the circumstances that caused patient Roy Jr.’s injury and the series of tests that were supposed to be undergone by him to determine the extent of the injury suffered were not under the exclusive control of Drs. Jarcia and Bastan. It was established that they are mere residents of the Manila Doctors Hospital at that time who

attended to the victim at the emergency room. While it may be true that the circumstances pointed out by the courts below seem doubtless to constitute reckless imprudence on the part of the petitioners, this conclusion is still best achieved, not through the scholarly assumptions of a layman like the patient’s mother, but by the unquestionable knowledge of expert witness/es. As to whether the petitioners have exercised the requisite degree of skill and care in treating patient Roy, Jr. is generally a matter of expert opinion.” (Jarcia vs People, 2012) Luz delivered Gerald to the care, custody and control of his physicians for a pull-through operation. Except for the imperforate anus, Gerald was then of sound body and mind at the time of his submission to the physicians. Yet, he experienced bradycardia during the operation, causing loss of his senses and rendering him immobile. Hypoxia, or the insufficiency of oxygen supply to the brain that caused the slowing of the heart rate, scientifically termed as bradycardia, would not ordinarily occur in the process of a pullthrough operation, or during the administration of anesthesia to the patient, but such fact alone did not prove that the negligence of any of his attending physicians, including the anesthesiologists, had caused the injury. In fact, the anesthesiologists attending to him had sensed in the course of the operation that the lack of oxygen could have been triggered by the vagovagal reflex, prompting them to administer atropine to the patient. (Solidum vs People, 2014)

Discuss the liability of a hospital with respect to the acts of its physicians. 1.

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3.

If an Employer-Employee Relationship is established, then the hospital, unless it can prove diligence of a good father in the selection of employees, is solidarily liable with the doctor by virtue of vicarious liability under Article 2180 of the Civil Code.  It should be noted that in light of recent jurisprudence, it is almost impossible to prove an employment relationship, because it is recognized in this jurisdiction that the relationship between a physician and a hospital is merely contractual.  Under the Schloendorff Doctrine, a physician, even if employed by a hospital, is considered 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. There is, however, what is called as the Doctrine of Apparent Authority or Doctrine of Ostensible Agency, which would still allow the complainant to invoke the hospital’s vicarious liability. The hospital may also be held liable under the Doctrine of Corporate Negligence.

Discuss the Doctrine of Apparent Authority.

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Under the Doctrine of Apparent Authority, a hospital can be held vicariously liable for the negligent acts of a physician providing care at the hospital, regardless of whether the physician is an independent contractor, unless the patient knows, or should have known, that the physician is an independent contractor. Elements: 1. The hospital, or its agent, acted in a manner that would lead a reasonable person to conclude that the individual who was alleged to be negligent was an employee or agent of the hospital; 2. Where the acts of the agent create the appearance of authority, the plaintiff must also prove that the hospital had knowledge of and acquiesced in them; and 3. The plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent with ordinary care and prudence. Jurisprudence:  There is ample evidence that the hospital (PSI) held out to the patient (Natividad) that the doctor (Dr. Ampil) was its agent. Present are the two factors that determine apparent authority: first, the hospital's implied manifestation to the patient which led the latter to conclude that the doctor was the hospital's agent; and second, the patient’s reliance upon the conduct of the hospital and the doctor, consistent with ordinary care and prudence. (PSI vs Agana, 2010)

Discuss the Doctrine of Corporate Negligence. -

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Recent years have seen the doctrine of corporate negligence as the judicial answer to the problem of allocating hospital’s liability for the negligent acts of health practitioners, absent facts to support the application of respondeat superior or apparent authority. Its formulation proceeds from the judiciary’s acknowledgment that in these modern times, the duty of providing quality medical service is no longer the sole prerogative and responsibility of the physician. The modern hospitals have changed structure. Hospitals now tend to organize a highly professional medical staff whose competence and performance need to be monitored by the hospitals commensurate with their inherent responsibility to provide quality medical care. The doctrine has its genesis in Darling v. Charleston Community Hospital. There, the Supreme Court of Illinois held that “the jury could have found a hospital negligent, inter alia, in failing to have a sufficient number of trained nurses attending the patient; failing to require a consultation with or examination by members of the hospital staff; and failing to review the treatment rendered to the patient.” On the basis of Darling, other jurisdictions held that a hospital’s corporate negligence extends to permitting a physician known to be incompetent to practice at the hospital. With the passage of time, more duties were expected from hospitals, among them: (1) the use of reasonable care in the maintenance of safe and adequate facilities and equipment; (2) the selection and retention of competent physicians; (3) the overseeing or supervision of all persons who practice medicine within its walls; and (4) the formulation, adoption and

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

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Under the Doctrine of Captain of the Ship, it is the surgeon's responsibility to see to it that those under him perform their task in the proper manner. Invocation of this doctrine against a doctor means that the liability of the doctor stems from the negligence of supervising the other doctors performing their task under him—whether or not the “captain” doctor himself was also negligent in the surgery. Although in the US, this doctrine is starting to be discarded, it is still well applicable here in the Philippines (Ramos vs CA, 1999)

Discuss the Doctrine of Informed Consent -

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A physician has a duty to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care would disclose to his patient as to whatever grave risks of injury might be incurred from a proposed course of treatment, so that a patient, exercising ordinary care for his own welfare, and faced with a choice of undergoing the proposed treatment, or alternative treatment, or none at all, may intelligently exercise his judgment by reasonably balancing the probable risks against the probable benefits. Four essential elements a plaintiff must prove in a malpractice suit based on the Doctrine of Informed Consent: 1. the physician had a duty to disclose material risks; 2. he failed to disclose or inadequately disclosed those risks; 3. as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and 4. plaintiff was injured by the proposed treatment. The gravamen in an informed consent case requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered her decision to undergo it. Jurisprudence:  “When petitioner informed the respondents beforehand of the side effects of chemotherapy which includes lowered counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on the part of the doctor that the respondents understood very well that the

severity of these side effects will not be the same for all patients undergoing the procedure. In other words, by the nature of the disease itself, each patients reaction to the chemical agents even with pre-treatment laboratory tests cannot be precisely determined by the physician. That death can possibly result from complications of the treatment or the underlying cancer itself, immediately or sometime after the administration of chemotherapy drugs, is a risk that cannot be ruled out, as with most other major medical procedures, but such conclusion can be reasonably drawn from the general side effects of chemotherapy already disclosed.” (Li vs Sps Soliman, 2011) What are some of the criminal offenses that may be committed by a physician? -

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Article 174. False medical certificates, false certificates of merits or service, etc. Article 259. Abortion practiced by a physician or midwife and dispensing of abortives Article 347. Simulation of births, substitution of one child for another and concealment or abandonment of a legitimate child. Criminal Negligence (Reckless Imprudence)  Reckless imprudence consists in voluntary, but without malice, doing or falling to do an act from which material damage results by reason of inexcusable lack of precaution on the part of the person performing of failing to perform such act, taking into consideration his employment or occupation, degree of intelligence, physical condition and other circumstances regarding persons, time and place.  Simple imprudence consists in the lack of precaution displayed in those cases in which the damage impending to be caused is not immediate nor the danger clearly manifest.

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d) e) f) g)

Q: What is the different between a Post-Mortem Examination and an Autopsy? A post-mortem examination is limited to the orifices, while an autopsy also examines the organs. Note: In practice, both terms seem to be used interchangeably. Q: What is the difference between a Medicolegal Certificate and a Medical Certificate? A medicolegal certificate is one issued by a medicolegal officer, while a medical certificate is one issued by a physician. Both have the same evidentiary value. But, the important thing to remember is to make sure that the one who signs the certificate is one authorized to document injuries. Q: What are the two types of injuries? 1. 2.

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Q: What is the significance of proper documentation of injuries? As far as lawyers are concerned, they rely on documents. It is the best evidence. And it prevails over oral testimonies. Thus, if there are discrepancies in the documents, it can destroy or diminish the credibility of the witness.

2. 3.

Q: What do you do when you see a dead body lying around?

c)

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Observe surroundings. Examine the clothes.  Look particularly for stains. If there’s a red stain there, we do not immediately conclude that it is blood. It might be a paint, ketchup, etc. And if there is blood, we further qualify whether it is human blood or not. The point is, ‘wag assuming! Try to ascertain identity of the person.

Find another source material for studying anatomy. I’m not competent enough to make one.

Open; and Closed

I. Closed Injuries are those which involve no tear on the skin. Examples:

The Human Body1

a) b)

Interview people, but do not take their word as gospel truth. Check for IDs, dog tags, etc.  Know the gender of the person. Identify the position of the dead body. Identify the color of the person. Ascertain the approximate time of death. Check the orifices.  Are there foreign objects, secretions, etc.?

Fractures (which may also be open or closed depending on whether there is a break on the skin); a. Linear: a fracture that extends parallel to the long axis of a bone but does not displace the bone tissue b. Comminuted (a fracture in which the bone fragments into several pieces) c. Greenstick (an incomplete fracture in which the bone is bent. This type of fracture occurs most often in children)2 d. Transverse: a fracture at a right angle to the bone’s axis e. Oblique: a fracture in which the break is at an angle to the bone’s axis. f. Impacted: one whose ends are driven into each other. Hematoma – Blood cyst/ commonly referred to as “bukol” Contusion – A bruise, or contusion, is caused when blood vessels are damaged or broken as the result of a blow to the skin3

Note: Be sure not to confuse hematoma with contusion. In hematoma, you can extract the blood with a syringe, but you cannot do that with contusion, because blood is scattered in the tissues. II. Open Wounds are injuries involving an external or internal break in body tissue, usually involving the skin. Examples:

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Only the first three were discussed by Atty. Logronio

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Stab Wound  Caused by a sharp edge (e.g. knife, sword, etc.) Perforated Wound  Cause by a pointed instrument (e.g. ice pick, ball pen, etc.) Lacerated Wound  Caused by a blunt instrument (e.g. baseball bat, Manny Pacquio’s fists, etc.) Incised Wound  Caused by a sharp-edged object in slashing or slicing motion. Abrasion  An abrasion is a wound caused by superficial damage to the skin, no deeper than the epidermis. Also known as “gasgas” Gunshot Wound  a form of physical trauma sustained from the discharge of arms or munitions

It is also possible that there is only one bullet but more than one entrance wound. There are a lot of possibilities, given the advancement of technological warfare.

Q: What are the important differences between a lacerated wound and an incised wound?

When the bullet or projectile penetrates the epithelial tissue, there is friction between the skin and the projectile. This friction results in an abraded area of tissue which surrounds the entry wound and is known as an abrasion collar.4

2. 3. 4. 5.

6.

1. 2. 3. 4.

Lacerated Wound Cut is clean There is swelling There is no cut of hair Heals slower

1. 2. 3. 4.

Incised Wound Cut is not clean There is no swelling There is a cut of hair Heals faster

Q: What are the stuff that come out when you fire a gun? 1. 2. 3. 4.

Bullet; Flame (reaches up to 6 inches) - Singeing; Smoke (reaches up to 12 inches) – Soot/Smudging; Unburnt Powder (reaches up to 24 inches) – Peppering/Stippling.

Q: What is the importance of knowing the stuff, aside from bullets, that come from a gun? The presence of one or more of them may be determinative of the distance of the assailant. For example, if the gunshot wound includes all the four, there is a high probability that the assailant was very near when he fired the gun. Likewise, if it is just a gunshot wound, then the assailant most likely fired from a distance. Q: What are the two types of gunshot wound (GSW)? 1. 2.

Entry Wound Exit Wound

The usual scenario is that there are even numbers of GSW. This is what is known as the “Odd-Even Rule.” So, if you were shot thrice, there should be six GSW. But of course, it is possible to have an odd number of GSW. In such case, there would be a presumption that one or more bullets are still inside the body.

4

http://what-when-how.com/forensic-sciences/evaluationof-gunshot-wounds/

Bullet movement is described to be any of the following: spinning, tumbling and tail-wagging. Q: What are the differences between an entry wound and an exit wound? Entry Wound 1. Usually round in shape.

2. Inverted (papasok) 3. You can find an abrasion/contusion collar

Exit Wound 1. No particular shape. (This is why newbies usually make a mistake of considering this as a stab wound.) 2. Everted (palabas) 3. You can’t find them

Q: What is an Abrasion Collar?

It is the gasgas caused by the bullet where the bullet is angulated which would make gasgas before making an entrance to the skin. This is important for purposes of giving an idea as to the position of the assailant when he fired the gun. Q: How do we document rape cases? First, we must look for injuries around the legs first and other body parts (particularly the wrists), which would indicate that rape was probably committed. For example: A struggling woman being raped would usually sustain bruises in some of her body parts. In rape, there are usually hymenal lacerations which are distinguished and determined by using the face of the clock: 1. 2. 3.

Incomplete Laceration (around 3 o’clock) Complete Laceration (around 6 o’clock onwards) Compound Laceration (outside the hymen)

The healing period of hymenal laceration is from four to 10 days. Q: How do we know that a person is already dead? We can’t just say “Hindi na gumagalaw eh, kaya patay na.” There are two machines that that determine whether a person is already dead: 1.

Electroencephalogram (EEG) – test that measures and records the electrical activity of your brain. Special sensors electrodes are attached to your head and hooked by wires to a computer. The computer records your brain's electrical activity on the screen or on paper as wavy lines. Certain conditions, such as seizures, can be seen by the changes in the normal pattern of the brain's electrical activity.

2.

Electrocardiogram (ECG) - a test that records the electrical activity of the heart. It is used to measure the rate and regularity of heartbeats as well as the size and position of the chambers, the presence of any damage to the heart, and the effects of drugs or devices used to regulate the heart (such as a pacemaker)

In the Philippines, it is the ECG that is commonly used, because most hospitals cannot afford EEG machines. Q: What are the vital signs of a person? 1. 2. 3. 4.

Blood Pressure Respiratory Rate Pulse Rate Body Temperature

The first three are used to pronounce a person clinically dead. Clinical death is the medical term for cessation of blood circulation and breathing, the two necessary criteria to sustain human and many other organisms' lives.[1] It occurs when the heart stops beating in a regular rhythm, a condition called cardiac arrest. The term is also sometimes used in resuscitation research. On the other hand, brain/biological death occurs four to six minutes after clinical death. This is due to the fact that the heart is the main pumping machine of the body, and without the blood coming from the heart, the brain will gradually cease to function until it achieves irreversible damage. This is when the doctor will formally or legally declare that the person is dead as the neurological damage to the person is really impossible to reverse. A person can be clinically dead but can still exist with the help of artificial life support. This is the best time to consider the option of organ donation. Technically, the patient is already dead but the organs are still functioning. Once the life support is taken off, the whole body will start to deteriorate and cease its functions permanently. Brain death, either of the whole brain or the brain stem, is used as a legal indicator of death in many jurisdictions.5 Q: What are the three stages which the muscles of the body pass through after death? 1. 2. 3.

Primary Flacidity Rigor Mortis Secondary Flacidity

1. Primary Flacidity (usually happens within the first three (3) hours after death) At the moment of death, the muscles relax completely—a condition called "primary flaccidity." The muscles then stiffen, perhaps due to coagulation of muscle proteins or a shift in the muscle's energy containers (ATP-ADP), into a condition known as rigor mortis. All of the body's muscles are affected.6 2. Rigor Mortis (Usually happens 3 hours after death and lasts up to 12 hours)

5

http://www.nursebuff.com/2012/01/clinical-death-versusbrain-death-which-comes-first/ http://www.deathreference.com/Py-Se/Rigor-Mortis-andOther-Postmortem-Changes.html#ixzz3snOTsK51 6

This is a state of stiffening of muscles, sometimes with slight shortening of fibers. Individual cell death takes place in this stage. The body becomes completely rigid on the 12th hour: Complete Rigor Mortis. Rigor mortis begins within two to six hours of death, starting with the eyelids, neck, and jaw. This sequence may be due to the difference in lactic acid levels among different muscles, which corresponds to the difference in glycogen levels and to the different types of muscle fibers. Over the next four to six hours, rigor mortis spreads to the other muscles, including those in the internal organs such as the heart. The onset of rigor mortis is more rapid if the environment is cold and if the decedent had performed hard physical work just before death. Its onset also varies with the individual's age, sex, physical condition, and muscular build.7 3. Secondary Flacidity (24 – 36 hours later) After being in this rigid condition for twenty-four to eightyfour hours, the muscles relax and secondary laxity (flaccidity) develops, usually in the same order as it began. The length of time rigor mortis lasts depends on multiple factors, particularly the ambient temperature. The degree of rigor mortis can be determined by checking both the finger joints and the larger joints and ranking their degree of stiffness on a one- to threeor four-point scale. Many infant and child corpses will not exhibit perceptible rigor mortis. This decreased perceptible stiffness may be due to their smaller muscle mass. During this period, the body gradually cools in a process called algor mortis. The best way to accurately assess a corpse's temperature is with a core (tympanic membrane, liver, or rectal) thermometer. Rectal insertion may be difficult and cause postmortem injury.8 Q: What is Putrefaction? During the Secondary Flacidity, body will also start to decay. This is what is known as “Putrefaction.” In the absence of embalming or relatively rapid cremation, the body putrefies. The first sign of putrefaction is a greenish skin discoloration appearing on the right lower abdomen about the second or third day after death. This coloration then spreads over the abdomen, chest, and upper thighs and is usually accompanied by a putrid odor. Sulphur-containing intestinal gas and a breakdown product of red blood cells produce both the color and smell. The ancient Greeks and the Etruscans paid homage to this well-recognized stage of decomposition by coloring a prominent god aqua-marine, considered the color of rotting flesh. Bacteria normally residing in the body, especially the colon, play an important part in digestion of food during life. They also contribute mightily to decomposition after death—the process of putrefaction. The smell, rather than the sight, is the most distinctive thing about a putrefying body. Under normal conditions, the intestinal bacteria in a corpse produce large amounts of foul-smelling gas that flows into the blood vessels and tissues. It is this gas that bloats the body, turns the skin from green to purple to black, makes the tongue and eyes protrude, and often pushes the intestines out through the vagina and rectum. The gas also causes large amounts of foulsmelling bloodstained fluid to exude from the nose, mouth, and other body orifices. Two of the chemicals produced during 7 8

Ibid. Ibid.

putrefaction are aptly named putrescine (1,4-diaminobutane) and cadaverine (1,5-pentanediamine). If a person dies from an overwhelming bacterial infection, marked changes from putrefaction can occur within as few as nine to twelve hours after death. By seven days after death, most of the body is discolored and giant blood-tinged blisters begin to appear. The skin loosens and any pressure causes the top layer to come off in large sheets (skin slip). As the internal organs and the fatty tissues decay, they produce large quantities of foul-smelling gas. By the second week after death, the abdomen, scrotum, breasts, and tongue swell; the eyes bulge out. A bloody fluid seeps out of the mouth and nose. After three to four weeks, the hair, nails, and teeth loosen and the grossly swollen internal organs begin to rupture and eventually liquefy. The internal organs decompose at different rates, with the resistant uterus and prostate often intact after twelve months, giving pathologists one way to determine an unidentified corpse's sex.

Cadaveric spasm, also known as postmortem spasm, instantaneous rigor, cataleptic rigidity, or instantaneous rigidity, is a rare form of muscular stiffening that occurs at the moment of death, persists into the period of rigor mortis and can be mistaken for rigor mortis. The cause is unknown, but is usually associated with violent deaths happening under extremely physical circumstances with intense emotion. It is usually used to determine whether injuries are suicidal or homicidal. For example, when you shoot yourself with a handgun, your wrist will stiffen. That is cadaveric spasm. Q: When a person’s throat is cut, how do you know if it is suicidal or homicidal? 1. 2.

Presence of maggots would indicate that the body has been dead for more than 24 hours.9

3.

Q: Discuss what happens when a person dies of drowning?

4.

The body tend to surface after 24 – 36 hours (during Secondary Flacidity) because of putrefaction wherein the body becomes bloated due to accumulation of gases.

Observe the angle and direction of the injury. In suicide, the incision will be diagonal, while in homicide, it will be horizontal. In suicide, there will be what are known as “hesitance cuts” (trial and error cuts), while in homicide, there is usually only one cut. In suicide, injury is usually above the Adam’s Apple, while in homicide, it is below. In suicide, there’s blood in front and in the hands, while in homicide, there is blood at the back.

Q: If you find a dead body and it is still warm, what does that tell you? That it has been dead for probably less than three hours. Q: If, during autopsy, food is found in the stomach, what can you conclude? It takes three hours for the stomach to vacate its contents. So, you can conclude that the victim was killed less than three hours ago. Q: What happens when the heart stops pumping? Lividity occurs. Lividity is the process through which the body's blood supply will stop moving after the heart has stopped pumping it around the inside of the deceased. What normally happens at this point is that the blood supply - or at least any blood that remains within the corpse depending on the nature of their death - will settle in direct response to gravity. For example an individual found lying on their stomach would be found with all the blood from their back heading towards the ground. Lividity also displays itself as a dark purple discolouration of the body and can also be referred to as Livor Mortis or Post Mortem Hypostasis. It is worth noting that lividity begins to work through the deceased within thirty minutes of their heart stopping and can last up to twelve hours. Only up to the first six hours of death can lividity be altered by moving the body. After the six hour mark lividity is fixed as blood vessels begin to break down within the body. Rigor mortis and lividity are some of the key factors that are used when Estimating the Time of Death. 10 Q: What is Cadaveric Spasm?

9

Ibid.

10

http://www.exploreforensics.co.uk/rigor-mortis-andlividity.html

Frontal Lobe – Responsible for voluntary movement. If you destroy this, the person would lose sense of movement.

Wound to the intestine? Expect food materials to spill out. Wound to the stomach? Expect spillage of acid, which could also destroy other organs. Wound to the large intestine? Expect spillage of fecal materials, which may cause the person to die due to infection. One of the purposes of the circulatory system is to deliver nutrients, extraction of waste materials, deliver oxygen. Circulatory Two types of blood vessels: artery and veins. What is the difference? Artery (high pressure) releases oxygen (away from the heart to the different parts of the body). Vein (low pressure) carries blood going back to the heart. Artery usually located deeper. Pulses are in the artery not in veins. Injury to the artery? Blood will spur out. Injury to the vein? Blood will pour out. Thank God liver and artery are hidden deep within the body. Because you can die instantly if those are injured. Brain

Parietal Lobe – Responsible for sensation. Loss of sensation. Magiging manhid ka. Cerebellum – Responsible for balance/equilibrium. Ito yung naapektuhan, pag naglasing ka. Brain Stem – Connected to vital sectors.