Legmed Medical Jurisprudence

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MEDICAL  JURISPRUDENCE   A/y.  Edwin  L.  Dimatatac,  MD    

•  Health  Profession  under  PRC  

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Health  Professions     under  PRC   •  •  •  •  •  •  • 

DenDstry    (R.A.  No.  9484)   Medical  Technology    (R.A.  No.  5527)   Medicine    (R.A.  No.  2383,  as  amended)   Midwifery  (R.A.  No.  7392)   Nursing    (R.A.  No.  9173)   NutriDon  and  DieteDcs    (P.D.  No.  1286)   Optometry  (R.A.  No.  8050)  

Health  Professions     under  PRC   •  Pharmacy    (R.A.  No.  5921)   •  Physical  Therapy  and  OccupaDonal  Therapy   (R.A.  5680)   •  Radiologic  and  X-­‐Ray  Technology  (R.A.  No.   7431)   •  Sanitary  Engineering    (R.A.  No.  1364)   •  Social  Workers    (R.A.  No.  4373)   •  Veterinary  Medicine  (R.A.  9268)  

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•  Health  related  professions  are  generally   regulated  by  law  and  have  a  Code  of  Ethics   applicable  to  the  profession   •  Law  and  Code  of  Ethics  embody  the  ideals   expected  of  the  health  professional,  and  serve   basis  for  self-­‐regulaDon  and  administraDve   liability.        

PRIVACY/MEDICAL  PRIVACY/ CONFIDENTIALITY  

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MEDICAL  PRIVACY   •  Privacy   -­‐   the   state   of   being   free   from   intrusion   or   disturbance  in  one's  private  life  or  affairs   •  Confiden.ality   -­‐   privacy   of   informaDon   and   its   protecDon  against  unauthorized  disclosure   •  Medical   or   Health   Privacy   –   protecDon   of   the   confidenDal   nature   of   personal   health   informaDon,   includes   communicaDons   between   health   provider   and   paDent,     personal   data   and   informaDon   about   disease   or   paDent’s   condiDon   as   contained   in   medical  records  

Rules  of  Court,  Rule  128  Sec.  24  

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Rules  of  Court,  Rule  128  Sec.  24   •  DisqualificaDon  by  reason  of  privileged   communicaDon.  —  The  following  persons  cannot   tesDfy  as  to  ma/ers  learned  in  confidence  in  the   following  cases:  xxx     •  (c)  A  person  authorized  to  pracDce  medicine,  surgery   or  obstetrics  cannot  in  a  civil  case,  without  the   consent  of  the  paDent,  be  examined  as  to  any  advice   or  treatment  given  by  him  or  any  informaDon  which   he  may  have  acquired  in  a/ending  such  paDent  in  a   professional  capacity,  which  informaDon  was   necessary  to  enable  him  to  act  in  capacity,  and  which   would  blacken  the  reputaDon  of  the  paDent.  xxx  

Medical  Records  

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Medical  Records   •  Medical  Records  –  owned  by  hospital  or  physician   but  personal  data  contained  therein  belongs  to   paDent   •  Custodian  of  records  have  a  duty  not  to  disclose  or   release  contents  of  medical  records  unless   authorized  by  law  or  ordered  by  court  unless  paDent   consents   •  Electronic  Medical  Records,  Telemedicine  –  poses   challenges  to  health  informaDon  privacy  

•  The  Electronic  Commerce  Act  of  2000  (See   R.A.  8792  §§  5,  7,  31-­‐33)  provides  that  any   person  with  access  to  electronic  data   messages  or  documents  has  the  obligaDon  of   confidenDality  or  the  duty  not  to  convey  the   informaDon  to,  or  share  it  with,  any  other   person.    Under  this  law,  unauthorized  access   to  computer  systems  is  punishable  by  a  fine   and  mandatory  imprisonment.  

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•  The  anD-­‐wiretapping  law  (See  R.A.  No.  4200   §§  1-­‐2)  may  also  be  applied  where  a  person   who  is  not  authorized  by  parDes  to  a  private   communicaDon  record  or  communicate  its   contents.  The  act  would  probably  cover   doctor-­‐paDent  communicaDon  which  is   privileged  and  confidenDal,  and  which   therefore  should  not  be  recorded  or  disclosed   without  consent.  

Specific  Health  Privacy  LegislaDon   •  Republic   Act   No.   8504   (handling   of   informaDon,   both   the   idenDty   and   status,   of   persons  with  HIV)     •  Republic   Act   No.   9165   (confidenDality   of   records   of   those   who   have   undergone   drug   rehabilitaDon)    

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Specific  Health  Privacy  LegislaDon   •  Republic   Act   No.   9262   (confidenDality   of   records   pertaining   to   cases   of   violence   against   women  and  their  children)   •  Republic   Act   No.   8595   (ensuring   privacy   and   safety  of  rape  vicDms)   •  Duty   of   confidenDality   may   extend   to   those   who   may   have   access   to   the   private   informaDon,  including  custodian  of  records.  

•  Under  the  Philippine  AIDS  PrevenDon  and   Control  Act  of  1998,  the  duty  of  maintaining   paDent  confidenDality  is  imposed  on  all   persons  involved  in  handling  and  maintaining   paDent  records.  The  law  extends  the  duty  not   just  to  health  professionals  but  also  to  health   instructors,  co-­‐workers,  employers,   recruitment  agencies,  insurance  companies,   data  encoders,  and  other  custodians  of   medical  records.  

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•  R.A.  No.  8504  “Philippine  AIDS  PrevenDon  and   Control  Act  of  1998":  See  §§  15-­‐17,  30-­‐42   •  Wri/en  informed  consent  -­‐  requisite  for  HIV   tesDng   •  Compulsory  HIV  tesDng  unlawful   •  Medical  confidenDality  of  all  medical   informaDon   •  ViolaDon  of  ConfidenDality  and  discriminatory   acts  and  policies  penalized  

•  SOURCES  OF  OBLIGATION  

PHYSICIAN  AND  HOSPITAL   LIABILITY  

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Sources  of  ObligaDon   •  •  •  •   

Delict   Quasi-­‐delict   Contract   Quasi-­‐contract  

•  Who  is  considered  to  be  pracDcing  medicine?   A.  A  medical  student  diagnosing  and  treaDng  a   paDent  under  the  supervision  of  the  doctor   B.  A  denDst  because  we  call  him/her  a  doctor   C.  Someone  interviewed  by  Anthony  Taberna   on  his  show  who  offers  to  treats  AIDS  with  a   miracle  drug  for  free   D.  An  optometrist  who  examines  the  eye  and   provides  eyeglasses      

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PracDce  of  Medicine  

A  person  shall  be  considered  as  engaged  in  the  pracDce  of  medicine     (a)  who  shall,  for  compensaDon,  fee,  salary  or  reward  in  any  form,  paid   to  him  directly  or  through  another,  or  even  without  the  same,   physical  examine  any  person,  and  diagnose,  treat,  operate  or   prescribe  any  remedy  for  any  human  disease,  injury,  deformity,   physical,  mental  or  physical  condiDon  or  any  ailment,  real  or   imaginary,  regardless  of  the  nature  of  the  remedy  or  treatment   administered,  prescribed  or  recommended;  or     (b)  who  shall,  by  means  of  signs,  cards,  adverDsements,  wri/en  or   printed  ma/er,  or  through  the  radio,  television  or  any  other  means   of  communicaDon,  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  physical   condiDon;  or     (c)  who  shall  use  the  Dtle  M.D.  aqer  his  name.  (Republic  Act  No.  2382,   §10)  

The  following  are  NOT  acts   consDtuDng  the  pracDce  of  medicine   (a) any medical student duly   enrolled in an approved

medical college or school under training, serving without any professional fee in any government or private hospital, provided that he renders such service under the direct supervision and control of a registered physician; (b) 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;

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(d) 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 eye glasses, spectacles and lenses; (e) 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; (f) any person who administers or recommends any household remedy as per classification of existing Pharmacy Laws; and (g) any psychologist or mental hygienist in the performance of his duties, provided such performance is done in conjunction with a duly registered physician. (Republic Act No. 2382, §11)

•  Can  a  person  pracDce  medicine  without  a  duly   issued  medical  license  from  PRC?   •  What  is  “illegal  pracDce  of  medicine”?   •  Physician  Liability   •  Grounds  for  reprimand,  suspension  or   revoca.on  of  registra.on  cer.ficate  

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Physician  Liability   •  Administra@ve  Liability   •  Civil  Liability   •  Criminal  Liability  

The Code of Medical Ethics Ü Duties of Physicians to their patients Ü Duties of Physicians to the Community Ü Duties of Physicians to their colleagues and to the profession Ü Duties of Physicians to allied professionals Ü Relationship of Physicians with the Health Products Industry

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DUTIES OF PHYSICIANS TO THEIR PATIENTS •  Competence based on current standards •  Free to choose patients except if emergency •  Refer when needed •  Good faith and Strict honesty •  Preserve confidential information •  Reasonable fees

DUTIES OF PHYSICIANS TO THE COMMUNITY Ü Cooperate  with  proper  authoriDes  for  health   promoDon  or  with  government  in  administraDon   of  jusDce   Ü A/end  to  vicDms  of  epidemic  and  public   calamity,  except  if  personal  safety  is  at  stake   Ü Report  unlicensed  medical  pracDDoners   Ü SoliciDng  paDents  unethical   Ü Physicians  in  mulDmedia  must  be  well  informed   Ü Shall  not  endorse  medical  or  health  product  

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DUTIES OF PHYSICIANS TO THEIR COLLEAGUES AND TO THE PROFESSION •  Gratuitous service to a colleague, his or her spouse, children and parents •  Consultation with colleague when necessary, Observe proper protocol of referral system •  Full Disclosure of any pharmaceutical support in case of articles and presentations •  Report corrupt or dishonest conduct to proper forum •  May accept funds for CME but CME should be free from commercial influence

DUTIES OF PHYSICIANS TO ALLIED PROFESSIONALS •  No payment of receipt of commissions from allied health worker for cases referred

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RELATIONSHIP OF PHYSICIANS WITH THE HEALTH PRODUCTS INDUSTRY Ü No  material  gain  from  product  samples  by  may   try  new  products  on  paDents  provided  they   consent   Ü Giqs  of  reasonable  value  that  would  benefit   paDent  may  be  accepted  from  health  product   company;  donaDons  for  charitable  purpose  may   be  requested   Ü Research  acDviDes  should  be  ethical,  responsible   and  valid  

Which is a Ground for reprimand/ suspension/revocation of license to practice medicine? A.  Doctor  taking  videos  of  himself  having  sexual   intercourse  with  a  woman  but  the  taking  of   videos  is  without  the  woman’s  consent   B.  Doctor  adverDsing  his  name,  profession,  clinic   address  and  clinic  hours   C.  Issuing  a  medical  cerDficate  when  the  diagnosis   indicated  in  the  medical  cerDficate  is  later   proven  to  be  wrong   D.  AssisDng  the  aborDon  of  a  woman  with  an   ectopic  pregnancy  

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Grounds  for  reprimand,  suspension  or   revoca.on  of  registra.on  cer.ficate   (1)  ConvicDon  by  a  court  of  competent  jurisdicDon  of  any   criminal  offense  involving  moral  turpitude;   (2)  Immoral  or  dishonorable  conduct;   (3)  Insanity;   (4)  Fraud  in  the  acquisiDon  of  the  cerDficate  of  registraDon;   (5)  Gross  negligence,  ignorance  or  incompetence  in  the   pracDce  of  his  or  her  profession  resulDng  in  an  injury  to  or   death  of  the  paDent;   (6)  AddicDon  to  alcoholic  beverages  or  to  any  habit  forming   drug  rendering  him  or  her  incompetent  to  pracDce  his  or   her  profession,  or  to  any  form  of  gambling;  

(7)  False  or  extravagant  or  unethical  adverDsements  wherein   other  things  than  his  name,  profession,  limitaDon  of   pracDce,  clinic  hours,  office  and  home  address,  are   menDoned.   (8)  Performance  of  or  aiding  in  any  criminal  aborDon;   (9)  Knowingly  issuing  any  false  medical  cerDficate;   (10)  Issuing  any  statement  or  spreading  any  news  or  rumor   which  is  derogatory  to  the  character  and  reputaDon  of   another  physician  without  jusDfiable  moDve;   (11)  Aiding  or  acDng  as  a  dummy  of  an  unqualified  or   unregistered  person  to  pracDce  medicine;   (12)  Viola@on  of  any  provision  of  the  Code  of  Ethics  as   approved  by  the  Philippine  Medical  Associa@on.  

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Can  a  physician  refuse  to  a/end  an  emergency?  

Refusal  of  a  physician  to  a/end  a  paDent  in   danger  of  death  is  not  a  sufficient  ground  for   revocaDon  or  suspension  of  his  registraDon   cerDficate  if  there  is  a  risk  to  the  physician's   life.    

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AdministraDve  Liability   •  ViolaDon  of  Code  of  Ethics   •  ViolaDon  of  Medical  Act  of  1959  Sec.  24    (but   some  of  those  enumerated  are  also  grounds   for  civil  and/or  criminal  liability)   •  E.O.  No.  212  (July  10,  1987)  –  ReporDng  of   treatment  of  Serious  and  Less  Serious  Physical   Injuries  to  nearest  government  health   authority  

PRC  Procedure   Formal  complaints  should  be  submi/ed  in   person  at  the  PRC  office.  Formal  complaints   undergo  four  stages:   • Docke@ng  and  Calendar  -­‐  this  starts  from  the   date  of  filing  of  the  complaint  to  when  the   noDce  of  pre-­‐trial  is  sent  to  the  parDes.   • Pre-­‐trial  and  Deposi@ons  –  covers  the  pre-­‐trial,   deposiDons,  and  other  pracDces  designed  to   dispense  with,  or  limit  Dme  for  the  recepDon  of   evidence  

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PRC  Procedure   •  Recep@on  of  Evidence  –  evidence  for  both  the   complainant  and  for  the  respondent  are   presented  as  well  as  the  rebu/al  evidence.   •  Decision-­‐making  –  discussions  and  vote  on   the  case  and  the  preparaDon  and  signing  of   the  decision.  

 

CRIMINAL  LIABILITY  

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Can  the  fact  of  being  a  doctor  be   considered  an  aggravaDng     circumstance?  

CRIMINAL  LIABILITY   *  Degree  of  InstrucDon  as  an  AlternaDve   Circumstance   • Illegal  PracDce  of  Medicine   • False  Medical  CerDficate   • AborDon  pracDced  by  a  physician  or  midwife   •   SimulaDon  of  births,  subsDtuDon  of  one  child   for  another  and  concealment  or  abandonment   of  a  legiDmate  child.     • Criminal  Negligence  

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Reckless  Imprudence   •  The  elements  of  reckless  imprudence  are:     (1) that  the  offender  does  or  fails  to  do  an  act;     (2) that  the  doing  or  the  failure  to  do  that  act  is  voluntary;     (3) that  it  be  without  malice;     (4) that  material  damage  results  from  the  reckless   imprudence;  and     (5) that  there  is  inexcusable  lack  of  precauDon  on  the  part   of  the  offender,  taking  into  consideraDon  his   employment  or  occupaDon,  degree  of  intelligence,   physical  condiDon,  and  other  circumstances  regarding   persons,  Dme  and  place.  

Reckless  Imprudence  

The allegations in the information in this case that the accused acted with reckless negligence in diagnosing, prescribing for, and treating the deceased Susana Tam, knowing that she did not possess the necessary technical knowledge or skill to do so, thus causing her death, sufficiently charge the crime of homicide through reckless imprudence, since ordinary diligence counsels one not to tamper with human life by trying to treat a sick man when he knows that he does not have the special skill, knowledge, and competence to attempt such treatment and cure, and may consequently reasonably foresee harm or injury to the latter. In a similar case wherein the accused, not being a regular practitioner, undertook to render medical assistance to another, causing physical injuries to the latter, said accused was found guilty and convicted by this Court of physical injuries through imprudence under the old Penal Code (U. S. vs. Feliciano Divino, 12 Phil., 175). [People vs. Vda. de Golez, 108 Phil. 855, 859(1960)]

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•  Whether or not a physician has committed an “inexcusable lack of precaution” in the treatment of his patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science [Cruz vs. Court of Appeals, 282 SCRA 188, 199-200(1997)(This case involves a hysterectomy performed for myoma allegedly in a hospital with inadequate facilities and untidy surroundings. The accused was acquitted because of lack of expert testimony to establish standard of care.]

•  The crime is committed if a person undergoes to treat a patient even if he is not qualified, and in the process causes injury to the patient. •  Inexcusable lack of precaution is determined based on accepted standard of care of the medical profession.

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  Negligence  of  a  doctor  resulDng  to  injury  to  a   paDent  may  be  ground  for  criminal  liability.    It  is   also  basis  for  civil  liability  and  award  of  damages   under  what  law?            

NEGLIGENCE  CAUSING  INJURY  TO  A   PATIENT   •  The Medical Act imposes the penalty of imprisonment, fine, or both for any person found guilty of illegal practice of medicine. This refers to the act of engaging in the practice of medicine (defined in §10) without complying with the prerequisites provided by the same act (as provided in §8). There is no penalty under the Medical Act of 1959 for gross negligence, ignorance or incompetence other than administrative liability. (Republic Act No. 2382, §§8,10 and 28)

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¨ Gross  negligence,  ignorance,  or   incompetence  in  the  pracDce  of  Medicine   resulDng  in  an  injury  to  or  death  of  the   paDent  may  be  basis  for  award  of  damages   under  the  Civil  Code  which  makes  every   person  who  negligently  causes  damage  to   another  liable  to  indemnify  the  la/er  for  the   same.  (New  Civil  Code,  ,  arts.  19-­‐21,  2176.)    

Civil  Liability   •  Direct  Liability  under  arDcle  2176   •  Vicarious  Liability,  arDcle  2180  in  relaDon  to   arDcle  2176  

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

•  Culpable  Act  or  Negligence   •  Damage  to  another     •  Causal  rela@on  between  the  culpable  act  or   negligence  and  the  damage  to  another  

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•  Elements  of  Medical  Negligence  

Elements  of  Medical  Negligence   •  •  •  • 

duty     breach     injury     proximate  causaDon    

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•  TEST  to  determine  negligence:  Did  the  defendant  in   doing  the  alleged  negligent  act  use  that  reasonable   care  and  cau@on  which  an  ordinarily  prudent  person   would  have  used  in  the  same  situa@on?  If  not,  he  is   guilty  of  negligence.   •  Conduct  is  said  to  be  negligent  when  a  prudent  man   in  the  posi@on  of  the  torSeasor  would  have  foreseen   that  an  effect  harmful  to  another  was  sufficiently   probable  to  warrant  his  foregoing  the  conduct  or   guarding  against  its  consequences.  

•  Negligence  –  Conduct  which  creates  undue  risk  of   harm  to  others;  risk  means  a  danger  which  is   apparent  or  should  be  apparent,  to  one  in  the   posi@on  of  the  actor;  determina@on  of  negligence  is  a   ques@on  of  foresight  on  the  part  of  the  actor   (FORSEEABILITY);  effect  harmful  to  other  was   sufficiently  probable  to  warrant  his  conduct  or   guarding  against  its  consequence  (PROBABILITY)   •  The  fault  or  negligence  of  the  obligor  consists  in  the   omission  of  that  diligence  which  is  required  by  the   nature  of  the  obliga@on  and  corresponds  with  the   circumstances  of  the  persons,  of  the  @me  and  of  the   place.  

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•  PROXIMATE  CAUSE:    that  cause,  which,  in   natural  and  con@nuous  sequence,  unbroken   by  any  efficient  intervening  cause,  produces   the  injury,  and  without  which  the  result   would  not  have  occurred.  

•  Burden  of  Proof   •  Proof  Required  

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Burden  of  Proof   •  BURDEN  OF  PROOF:  duty  of  a  party  to  present  evidence   on  the  facts  in  issue  necessary  to  establish  his  claim  or   defenses  by  the  amount  of  evidence  required  by  law   •  Plain@ff  alleging  DAMAGE  because  of  the  negligent  act  of   defendant  has  the  burden  of  proving  such  negligence   •  It  is  even  presumed  that  a  person  takes  ordinary  care  of   his  concerns   •  Quantum  of  proof  required  is  preponderance  of  evidence   •  Excep@on:  when  rules  or  the  laws  provide  for  cases  when   negligence  is  presumed  

•  Doctrine  of  Res  Ipsa  Loquitur  

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Doctrine  of  Res  Ipsa  Loquitur   •  the  accident    was  of  a  kind  which  does  not   ordinarily  occur  unless  someone  is  negligent;   and     •  that  the  instrumentality  or  agency  which  caused   the  injury  was  under  the  exclusive  control  of  the   person  charged  with  negligence.   •  the  injury  suffered  must  not  have  been  due  to   any  voluntary  acDon  or  contribuDon  on  the  part   of  the  person  injured  

•  The  doctrine  of  res  ipsa  loquitur,  operates   more  as  a  rule  of  evidence  than  a  substanDal   basis  of  a  cause  of  acDon.   •  The  doctrine  of  res  ipsa  loquitur  warrants  a   presumpDon  or  inference  of  negligence  on  the   part  of  the  person  having  charge  of  the   instrumentality  causing  damage.   •  Direct  evidence  as  to  specific  act  of  negligence   causing  injury  absent  or  not  readily  available  

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Elements  of  Medical  Negligence   •  •  •  • 

duty     breach     injury     proximate  causaDon    

Doctrine  of  Informed  Consent     based  upon  the   Elements  in  a  malpracDce  acDon  

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  paDent  consented  to  treatment  she   otherwise  would  not  have  consented  to;  and       (4) plainDff  was  injured  by  the  proposed  treatment.     The  paDent  must  point  to  significant  undisclosed   informaDon  relaDng  to  the  treatment  which  would   have  altered  her  decision  to  undergo  it.     [Li  v.  Soliman,  G.R.  No.  165279,  June  7,  2011]    

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•  Possible  defenses  of  Physician  

Possible  Defenses  of  a  Physician   1.  No negligence 2.  Plaintiff’s Own Negligence is cause of injury 3.  Assumption of risk (related to informed consent) 4.  Act of God/Accident/Force Majeur

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PaDent’s  own  Negligence   Doctrine  of  Contributory  Negligence     plainDff’s  own   •  Art. 2179. When  the  

negligence  was  the  immediate  and  proximate   cause  of  his  injury,  he  cannot  recover   damages.  But  if  his  negligence  was  only   contributory,  the  immediate  and  proximate   cause  of  the  injury  being  the  defendant’s  lack   of  due  care,  the  plainDff  may  recover   damages,  but  the  courts  shall  miDgate  the   damages  to  be  awarded.  (See  also  Cayao-­‐ Lasam  vs.  Ramolete,  574  SCRA  439(2008)]  

VICARIOUS  LIABILITY   •  ArDcle  2180  -­‐  The  obligaDon  imposed  by   ArDcle  2176  is  demandable  not  only  for  one's   own  acts  or  omissions,  but  also  for  those  of   persons  for  whom  one  is  responsible.  Xxx     •  The  owners  and  managers  of  an   establishment  or  enterprise  are  likewise   responsible  for  damages  caused  by  their   employees  in  the  service  of  the  branches  in   which  the  la/er  are  employed  or  on  the   occasion  of  their  funcDons.       •  Employers  shall  be  liable  for  the  damages   caused  by  their  employees  and  household   helpers  acDng  within  the  scope  of  their   assigned  tasks,  even  though  the  former  are   not  engaged  in  any  business  or  industry.  

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VICARIOUS  LIABILITY    Employers  shall  be  liable  for  the  damages   caused  by  their  employees  and  household   helpers  acDng  within  the  scope  of  their  assigned   tasks,  even  though  the  former  are  not  engaged   in  any  business  or  industry.xxx   The  responsibility  treated  of  in  this  arDcle  shall   cease  when  the  persons  herein  menDoned   prove  that  they  observed  all  the  diligence  of  a   good  father  of  a  family  to  prevent  damage.      

     

Give  an  Example  of  a   Doctrine  that  makes  a  physician     vicariously  liable  

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VICARIOUS  LIABILITY     • Captain  of  Ship  Doctrine   • Borrowed  Servant  Doctrine  

CONSENT  FORMS  AND  WAIVER  OF   LIABILITY     expressly  specified   •  Art.  1174.  Except  in  cases  

by  the  law,  or  when  it  is  otherwise  declared   by  s@pula@on,  or  when  the  nature  of  the   obliga@on  requires  the  assump@on  of  risk,  no   person  shall  be  responsible  for  those  events   which  could  not  be  foreseen,  or  which,   though  foreseen,  were  inevitable.    

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• 

CONSENT  FORMS  AND  WAIVER  OF   LIABILITY     Admission and Consent Release Forms: Consent on

to Operation. “Both release forms consist of two parts. The first part gave CMC permission to administer to Corazon any form of recognized medical treatment which the CMC medical staff deemed advisable. The second part of the documents, which may properly be described as the releasing part, releases CMC and its employees “from any and all claims” arising from or by reason of the treatment and operation.”

•  The documents do not expressly release CMC from liability for injury to Corazon due to negligence during her treatment or operation. Neither do the consent forms expressly exempt CMC from liability for Corazon’s death due to negligence during such treatment or operation. Such release forms, being in the nature of contracts of adhesion, are construed strictly against hospitals. Besides, a blanket release in favor of hospitals “from any and all claims,” which includes claims due to bad faith or gross negligence, would be contrary to public policy and thus void.

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•  Even simple negligence is not subject to blanket release in favor of establishments like hospitals but may only mitigate liability depending on the circumstances. When a person needing urgent medical attention rushes to a hospital, he cannot bargain on equal footing with the hospital on the terms of admission and operation. Such a person is literally at the mercy of the hospital. There can be no clearer example of a contract of adhesion than one arising from such a dire situation. Thus, the release forms of CMC cannot relieve CMC from liability for the negligent medical treatment of Corazon. •  [Nogales vs. Capitol Medical Center, 511 SCRA 204, 228-29(2006)]

Hospital  Liability   •  Direct  Liability  under  arDcle  2176   Corporate  liabiliDes  -­‐  those  arising  from  the   failure  of  hospitals  to  furnish  accommodaDons   and  faciliDes  necessary  to  carry  out  its   purpose  or  to  follow  the  established  standard   of  conduct  to  which  it  should  conform.   •  Vicarious  Liability  

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•  Under  2176,  two  things  must  be  proven:  that   the  hospital  did  not  exercise  reasonable  care   and  cauDon  required  of  prudent  hospitals;  and   second,  that  this  failure  is  the  cause  of  injury   to  the  paDent.  

Elements  of  Medical  Negligence   •  •  •  • 

duty     breach     injury     proximate  causaDon    

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Give  an  example  of  a  hospital  duty     provided  by  law  

DuDes  of  Hospitals  provided  by   Law   1.  DUTY  TO  OBTAIN  LICENSE   2.  DUTY  TO  RENDER  IMMEDIATE  EMERGENCY   MEDICAL  ASSISTANCE   3.  DUTY  NOT  TO  REQUIRE  DEPOSIT  IN   EMERGENCY  AND  SERIOUS  CASES   4.  DUTY  NOT  TO  CAUSE  DETENTION  OF   PATIENTS  DUE  TO  NONPAYMENT  

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HOSPITAL  CODE  OF  ETHICS   •  The  Primary  objecDve  of  the  hospital  are  the   following:   •  1.2  To  provide  the  best  possible  faciliDes  for   the  care  of  the  sick  and  injured  at  all  Dmes;   •  1.3  To  constantly  upgrade  and  improve   methods  for  the  care,  the  cure,  amelioraDon   and  prevenDon  of  disease;  and  

HOSPITAL  CODE  OF  ETHICS   •  1.4  To  promote  the  pracDce  of  medicine  by   Physicians  within  the  insDtuDon  consistent   with  the  acceptable  quality  of  paDent  care.   •  These  objecDves  require  an  efficient   organizaDon,  a  competent  administrator,  a   qualified  medical  staff,  other  well-­‐trained   personnel  and  adequate  physical  faciliDes   with  all  of  which  services  are  made  available   at  all  Dmes  consistent  with  community  needs.  

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Corporate  Negligence   •  (1)  A  duty  to  use  reasonable  care  in  the   maintenance  of  safe  and  adequate  faciliDes  and   equipment;     •  (2)  A  duty  to  select  and  retain  only  competent   physicians;     •  (3)  A  duty  to  oversee  all  persons  who  pracDce   medicine  within  its  walls  as  to  paDent  care;  and     •  (4)  A  duty  to  formulate,  adopt  and  enforce   adequate  rules  and  policies  to  ensure  quality  care   for  the  paDents  

   

What  doctrine  may  be  used  to   make  a  hospital  liable  for  acts  of  an     independent   contractor  such  as  a   physician  who  performs  a   negligent  act  causing  injury  to   paDent?  

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Vicarious  Liability   •  1.  vicarious  liability  for  acts  of  an  employee   •  2.  the  doctrine  of  apparent  authority  or   agency  by  estoppel      

Doctrine  of  Apparent  Authority   •  It  must  be  stressed  that  under  the  doctrine  of   apparent  authority,  the  ques@on  in  every   case  is  whether  the  principal  has  by  his   voluntary  act  placed  the  agent  in  such  a   situa@on  that  a  person  of  ordinary  prudence,   conversant  with  business  usages  and  the   nature  of  the  par@cular  business,  is  jus@fied   in  presuming  that  such  agent  has  authority  to   perform  the  par@cular  act  in  ques@on.  

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•  Hospital's  manifestaDons  -­‐  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.  

•  PaDent's  reliance  -­‐  as  an  inquiry  on  whether   the  plainDff  acted  in  reliance  upon  the   conduct  of  the  hospital  or  its  agent,  consistent   with  ordinary  care  and  prudence  

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CASE 1 •  13/F underwent an appendectomy. Apparently, patient was not weighed prior to the operation. •  The Operation was scheduled at 5PM but started 5:45PM because the surgeon arrived only at that time. Patient was finally brought out of the OR at 7PM and brought back to her room. Patient did not wake up and had a “weak heartbeat” but was apparently revived. Surgeon and anesthesiologist then left.

•  Approximately 15 minutes later, patient suffered convulsions. The family physician, surgeon and a cardiologist were called and after examining patient, doctors consulted with each other. •  The cardiologist then informed the parents that the “infection went up to her head” and that the anesthesiologist will be called. •  The anesthesiologist arrived only at 10:30PM.

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•  Upon arriving and aeeing 2 small bottles and a big bottle of dextrose hanging above the bed of the child, the anesthesiologist said, "What is this? Christmas tree or what?" •  When asked why the child is deteriorating, the anesthesiologist answered, "that is nothing, the child will regain consciousness and if the child will not regain consciousness, I will resign as a doctor.” •  Patient never regained consciousness and died 3 days later.

CASE 2 •  Elderly male consulted clinic and found to have BP 210/100 and HR 112. Patient was given Capoten 25mg and advised to go to a hospital. Physician instructed clinic ambulance to stand-by for conduction. After resting for a few minutes, patient said that he will just look for a companion. A nurse was asked to look for the patient but he could not be found. After a few minutes, the doctor left.

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•  Patient apparently went to the hospital and was treated in the emergency room for four hours. Upon being discharged and prior to arriving home, patient experienced nausea, abnormal palpitation and uneasiness and had to be brought back to the hospital. He was admitted for treatment but the following morning, he suffered a stroke. He never completely recovered and eventually died months later.

CASE 3 •  A video was uploaded in YouTube showing an operation wherein medical staff extracted a can of body spray lodged in a patient’s rectum. Throughout the entire operation, the staff were seen to laugh and jeer, and several of them exclaimed, “baby out!” when the spray can was finally removed. The hospital apparently asked the patient’s permission to take the video of the unusual case, and the patient agreed.

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CASE 4 •  Several sex videos found their way in the internet showing a physician having sex with various female partners. Videos were apparently taken without the knowledge and consent of the women, some of whom were his patients. Immorality complaints were filed against the physician before the Professional Regulations Commission.

•  The physician’s license was revoked as he was found guilty of immorality and dishonorable and/or unethical conduct offensive to the profession. Physicians are expected to show respect for women and their patients, and to uphold the honor, dignity and integrity of the medical profession.

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•  THANK  YOU  

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