NATURE OF MEDICAL PRACTICE

Supreme Court of Indiana.HURLEY v. EDDINGFIELD.April 4, 1901.

Appeal from circuit court, Montgomery county; Jere West, Judge.

Action by George D. Hurley, as administrator, against George W. Eddingfield. Froma judgment in favor of the defendant, the plaintiff appeals. Affirmed.

BAKER, J.

The appellant sued appellee for $10,000 damages for wrongfully causing the death of his intestate. The court sustained appellee's demurrer to the complaint, and this ruling is assigned as error.

The material facts alleged may be summarized thus: At and for years before decedent's death appellee was a practicing physician at Mace, in Montgomery county, duly licensed under the laws of the state. He held himself out to the public as a general practitioner of medicine. He had been decedent's family physician. Decedent became dangerously ill, and sent for appellee. The messenger informed appellee of decedent's violent sickness, tendered him his fee for his services, and stated to him that no other physician was procurable in time, and that decedent relied on him for attention. No other physician was procurable in time to be of any use, and decedent did rely on appellee for medical assistance.Without any reason whatever, appellee refused to render aid to decedent. No other patients were requiring appellee's immediate service, and he could have gone to the relief of decedent if he had been willing to do so. Death ensued, without decedent's fault, and wholly from appellee's wrongful act. The alleged wrongful act was appellee's refusal to enter into a contract of employment. Counsel do not contend that, before the enactment of the law regulating the practice of medicine, physicians were bound to render professional service to every one who applied.Whart. Neg. s 731. The act regulating the practice of medicine provides for a board of examiners, standards of qualification, examinations, licenses to those found qualified, and penalties for practicing without license. Acts 1897, p. 255; Acts 1899, p. 247. The act is a preventive, not a compulsive, measure. In obtaining the state's license (permission) to practice medicine, the state does not require, and the licensee does not engage, that he will practice at all or on other terms than he may choose to accept. Counsel's analogies, drawn from the obligations to the public on the part of innkeepers, common carriers, and the like, are beside the mark. Judgment affirmed.

G.R. No. 88265 December 21, 1989SANTIAGO A. DEL ROSARIO, GEORGE G. GACULA, EDGARDO G. SANTOS, ALBANO S. SIBAL, ALBERTO C. REYES, NONITO P. ARROYO, EMMANUEL F. TERENCIO, DOMINGO S. DE LEON, MODESTO O. LLAMAS, FARIDA U. ALONTO, ZENAIDA A. FLOIRENDO, ISABEL A. MEJIA, LUZ P. MABANAG, RAMON H. RABAGO, JR., SAMUEL D. TROCIO and OSCAR M. BRION,petitioners,vs.HON. ALFREDO R. BENGZON, in his capacity as Secretary of the Department of Health,respondent.Facundo T. Bautista for petitioners.GRIO-AQUINO,J.:This is a class suit filed by officers of the Philippine Medical Association, the national organization of medical doctors in the Philippines, on behalf of their professional brethren who are of kindred persuasion, wherein this Court is asked to declare as unconstitutional, hence, null and void, some provisions of the Generics Act of 1988 (Rep. Act No. 6675), and of the implementing Administrative Order No. 62 issued pursuant thereto, specifically:(a) Section 6, Pars. (a) and (b) of the Generics Act which provide:a) All government health agencies and their personnel as well as other government agencies shall use generic terminology or generic names in all transactions related to purchasing, prescribing, dispensing and administering of drugs and medicines.b) All medical, dental and veterinary practitioners, including private practitioners, shall write prescriptions using the generic name. The brand name may be included if so desired. (p. 6, Rollo.)(b) Section 12, Pars. (b), (c) and (d) of the same law which provide:b) For the second conviction, the penalty of file in the amount of not less than two thousand pesos (P2,000.00) but not exceeding five thousand pesos (P5,000.00) at the discretion of the court.c) For the third conviction, the penalty of fine in the amount of not less than five thousand pesos (P5,000.00) but not exceeding ten thousand pesos (P10,000.00) and suspension of his license to practice his profession for thirty (30) days at the discretion of the court.d) For the fourth and subsequent convictions, the penalty of fine of not less than ten thousand pesos (P10,000.00) and suspension of his license to practice his profession for one year or longer at the discretion of the court. (pp. 6-7, Rollo.) and(c) Sections 4 and 7, Phase 3 of Administrative Order No. 62, Series of 1989 dated March 9, 1989, of the respondent Secretary of Health, which read as follows:Section 4. Violative Erroneous, and Impossible Prescriptions.4.1. Violative Prescriptions:4.1.1 Where the generic name is not written;4.1.2 Where the generic name is not legible and a brand name which is legible is written;4.1.3 Where the brand name is indicated and instructions added, such as the phase 'No Substitution' which tend to obstruct, hinder or prevent proper generic dispensing.4.2 What to do with Violative Prescriptions.Violative prescriptions shall not be filled. They shall be kept and reported by the pharmacist of the drug outlet or any other interested party to the nearest DOH Officer for appropriate action. The pharmacist shall advise the prescriber of the problem and/or instruct the customer to get the proper prescription.4.3 Erroneous Prescriptions:4.3.1 When the brand name precedes the generic name.4.3.2 Where the generic name is the one in parenthesis.4.3.3 Where the brand name in (sic) not in parenthesis.4.3.4 Where more than one drug product is prescribed in one prescription form.4.4 What to do with erroneous prescriptions.Erroneous prescriptions shall be filled. Such prescriptions shall also be kept and reported by the pharmacist of the drug outlet or any other interested party to the nearest DOH Office for appropriate action.xxx xxx xxxSection 7. Timetable of Implementation.In order to give all affected parties adequate time for learning and adjustment, the implementation of these Rules and Regulations shall be in three phases, as follows:Phase 1 Education Drive ...Phase 2 Monitoring of Compliancexxx xxx xxxPhase 3 Implementation.Beginning September 1, 1989 the DOH and the other relevant agencies of government shall monitor compliance with these Rules and Regulations and all violations shall be subject to the appropriate sanctions and penalties provided for under these Rules and Regulations and the Generics Act of 1988. (pp. 7-9, Rollo.)On March 15, 1989, the full text of Republic Act No. 6675 was published in two newspapers of general circulation in the Philippines. The law took effect on March 30, 1989, fifteen (15) days after its publication, as provided in Section 15 thereof.Section 7, Phase 3 of Administrative Order No. 62 was amended by Administrative Order No. 76 dated August 28, 1989 by postponing to January 1, 1990 the effectivity of the sanctions and penalties for violations of the law, provided in Sections 6 and 12 of the Generics Act and Sections 4 and 7 of the Administrative Order.The petitioners allege that "as of this date, there is no breach or violation yet" of the law (p. 9, Rollo), which took effect on March 30, 1989. However, as the penal provisions will only take effect on January 1, 1990, it would have been more accurate to state that "as of this date, no breaches or violations of the law have been punished yet" (p. 9, Rollo).The petition is captioned as an action for declaratory relief, over which this Court does not exercise jurisdiction. Nevertheless, in view of the public interest involved, we decided to treat it as a petition for prohibition instead.The petitioner's main argument against paragraphs (a) and (b), Section 6 of the law, is the alleged unequal treatment of government physicians, dentists, and veterinarians, on one hand, and those in private practice on the other hand, in the manner of prescribing generic drugs, for, while the former are allegedly required to use only generic terminology in their prescriptions, the latter may write the brand name of the drug in parenthesis below the generic name. The favored treatment of private doctors, dentists and veterinarians under the law is allegedly a specie of invalid class legislation.There is no merit in that argument for it proceeds from a misreading and misinterpretation of the letter and intent of paragraphs (a) and (b), Section 6 of the Generics Act. Indeed, as explained by the public respondent:... while paragraph (a) enumerates the government transactions ('Purchasing, prescribing, dispensing and administering of drugs and medicines') where the sole use of generic terminology has been required, the 'prescription' of drugs is further governed by paragraph (b).And the use of the word 'all' in the latter provision emphasizes the absence of any distinction between government and private physicians. In other words, in prescribing drugs, physicians, whether in government service or in private practice, are both governed by exactly the same rules, and thus, are both authorized to include the brand name in their respective prescriptions. (p. 44, Rollo.)Furthermore, it may be observed that while paragraph (a) refers to "all government health agencies, and their personnel as well as other government agencies" (not necessarily physicians, dentists and veterinarians), paragraph (b) refers to"all medical, dental and veterinary practitioners, including private practitioners."Petitioners concede that the requirement for doctors, dentists, and veterinarians to use the generic terminology in writing their prescriptions, followed by the brand name in parenthesis, is "well and good" (p. 12, Rollo). However, they complain that under paragraph (d) of the law which reads:(d) Drug outlets, including drugstores, hospital and non-hospital pharmacies and non-traditional outlets such as supermarkets and stores, shall inform any buyer about any and all other drug products having the same generic name, together with their corresponding prices so that the buyer may adequately exercise his option. Within one (1) year after approval of this Act, the drug outlets referred to herein, shall post in conspicuous places in their establishments, a list of drug products with the same generic name and their corresponding prices. (Annex A, p. 23, Rollo.)the salesgirl at the drugstore counter is authorized to "substitute the prescribed medicine with another medicine belonging to the same generic group." Since doctors are not allowed to instruct the druggist not to substitute the prescription, or to "Dispense only as Prescribed" (per Sec. 4, Adm. Order No. 62), the petitioners argue that "the act of prescribing the correct medicine for the patient becomes the act of the salesgirl at the drugstore counter, no longer the act of the physician, dentist, or veterinarian" (p. 12, Rollo).Here again, the petitioners have distorted the clear provisions of the law and the implementing administrative order. For it is plain to see that neither paragraph (d) of Section 6 of the Generics Act, nor Section 4 of Administrative Order No. 62, gives the salesgirl and/or druggist the discretionto substitutethe doctor's prescription.On the contrary, Section 4, par. 4.1, of Administrative Order No. 62 directs the pharmacistnot to fill"violative prescriptions" (where the generic name is not written, or illegibly written, and the prescription of a brand name is accompanied by the doctor's instruction not to substitute it), as well as"impossible prescriptions"(par. 4.5). Even a doctor's "erroneous" prescriptions "shall be filled," not substituted (par. 4.3, Adm. Order No. 62). And, Sections 3 and 5 of Adm. Order No. 63 enjoin the drug outlets not (to) favor or suggest" or "impose" a particular brand or product on the customer. The administrative older provides:In order to ensure the informed choice and use of drugs by the patient/ buyer,the drug outlet is required to:3.1.1 Inform the patient/buyer of all available drug products generically equivalent to the one prescribed with their corresponding prices. In so doing,the drug outlet shall not favor or suggest any particular product so that the patient/buyer may fully and adequately exercise his option to choose(Sec. 3, Adm. Order No. 63 s. 1989).xxx xxx xxxThe following acts or omissions are considered violations of these rules and regulations:5.1 Imposing a particular brand or product on the buyer. ... (pp. 46-47, Rollo.)The salesgirl at the drugstore counter, merelyinformsthe customer, but does not determine (for she is incompetent to do so) all the other drug products or brands that have the same generic name, and their corresponding prices. That information she may obtain from the list of drug products determined by the Bureau of Food and Drugs to have the same generic name, or which are the chemical, biological, and therapeutic equivalent of the generic drug. All drugstores or drug outlets are required by the law to post such list in a conspicuous place in their premises for the information of the customers, for the choice of whether to buy the expensive brand name drug, or the less expensive generic, should be exercised by the customer alone.The purpose of the Generics Act is to carry out the policy of the State:To promote, encourage and require the use of generic terminology in the importation, manufacture, distribution, marketing, advertising and promotion, prescription and dispensing of drugs;To ensure the adequate supply of drugs with generic names at the lowest possible cost and endeavor to make them available for free to indigent patients;To encourage the extensive use of drugs with generic names through a rational system of procurement and distribution;To emphasize the scientific basis for the use of drugs, in order that health professionals may become more aware and cognizant of their therapeutic effectiveness; andTo promote drug safety by minimizing duplication in medications and/or use of drugs with potentially adverse drug interactions. (pp. 3839, Rollo.)or, as stated by the public respondent, "to promote and require the use of generic drug products that are therapeutically equivalent to their brand-name counter-parts" (p. 39, Rollo) for"the therapeutic effect of a drug does not depend on its 'brand' but on the 'active ingredients' which it contains." The medicine that cures is the "active ingredient" of the drug, and not the brand name by which it has been baptized by the manufacturer.The public respondent points out that the institution of generics in the Philippines will compel physicians to prescribe drugs based on their therapeutic or "active ingredient," instead of their well-known brand names. Multiple medications which may produce potentially adverse, even lethal, chemical reactions in the patient will thereby be avoided. Patients with limited means will be able to buy generic drugs that cost less but possess the same active ingredients, dosage form, and strength as brand names, many of which are priced beyond the reach of the common tao because the high costs of advertising, packaging, royalties, and other inputs of production determine their pricing for the market.The Court has been unable to find any constitutional infirmity in the Generics Act. It, on the contrary, implements the constitutional mandate for the State "to protect and promote the right to health of the people" and "to make essential goods, health and other social services available to all the peopleat affordable cost"(Section 15, Art. II and Section 11, Art. XIII, 1987 Constitution).The prohibition against the use by doctors of "no substitution" and/or words of similar import in their prescription, is a valid regulation to prevent the circumvention of the law. It secures to the patient the right to choose between the brand name and its generic equivalent since his doctor is allowed to write both the generic and the brand name in his prescription form. If a doctor is allowed to prescribe a brand-name drug with "no substitution," the patient's option to buy a lower-priced, but equally effective, generic equivalent would thereby be curtailed. The law aims to benefit the impoverished (and often sickly) majority of the population in a still developing country like ours, not the affluent and generally healthy minority.There is no merit in the petitioners' theory that the Generics Act impairs the obligation of contract between a physician and his patient, for no contract ever results from a consultation between patient and physician. A doctor may take in or refuse a patient, just as the patient may take or refuse the doctor's advice or prescription. As aptly observed by the public respondent, no doctor has ever filed an action for breach of contract against a patient who refused to take prescribed medication, undergo surgery, or follow a recommended course treatment by his doctor ( p. 53, Rollo). In any event, no private contract between doctor and patient may be allowed to override the power of the State to enact laws that are reasonably necessary to secure the health, safety, good order, comfort, or general welfare of the community. This power can neither be abdicated nor bargained away. All contractual and property rights are held subject to its fair exercise (Anglo-Fil Trading Corporation vs. Lazaro, 124 SCRA 495.)Petitioners have also assailed Section 12, paragraphs b, c and d, of the Generics Act prescribing graduated penalties (ranging from a reprimand to a fine of not less that P10,000 and the suspension of the physician's license to practice his profession for one [1]) year or longer, at the discretion of the court) for violations of its provisions. Petitioners' allegation that these penalties violate the constitutional guarantee against excessive fines and cruel and degrading punishment, has no merit. Penal sanctions are indispensable if the law is to be obeyed. They are the "teeth" of the law. Without them, the law would be toothless, not worth the paper it is printed on, for physicians, dentists and veterinarians may freely ignore its prescriptions and prohibitions. The penalty of suspension or cancellation of the physician's license is neither cruel, inhuman, or degrading. It is no different from the penalty of suspension or disbarment that this Court inflicts on lawyers and judges who misbehave or violate the laws and the Codes of Professional and Judicial Conduct. We hold that the Generics Act and the implementing administrative orders of the Secretary of Health are constitutional. In light of its beneficial provisions, we cannot heed the petitioners' plea to kill it aborning, i.e., before it has had a chance to prove its value to our people as envisioned by its makers. WHEREFORE, the petition is dismissed for lack of merit. Costs against the petitioners. SO ORDERED. Fernan, C.J., Narvasa, Cruz, Paras, Feliciano, Gancayco, Padilla, Bidin, Sarmiento, Cortes, Medialdea and Regalado, JJ., concur.Melencio-Herrera, J.,concurs in the result.G.R. No. 124354 April 11, 2002ROGELIO E. RAMOS and ERLINDA RAMOS, in their own behalf and as natural guardians of the minors, ROMMEL RAMOS, ROY RODERICK RAMOS, and RON RAYMOND RAMOS,petitioners,vs.COURT OF APPEALS, DE LOS SANTOS MEDICAL CENTER, DR. ORLINO HOSAKA and DR. PERFECTA GUTIERREZ,respondents.R E S O L U T I O NKAPUNAN,J.:Private respondents De Los Santos Medical Center, Dr. Orlino Hosaka and Dr. Perfecta Gutierrez move for a reconsideration of the Decision, dated December 29, 1999, of this Court holding them civilly liable for petitioner Erlinda Ramos comatose condition after she delivered herself to them for their professional care and management.For better understanding of the issues raised in private respondents respective motions, we will briefly restate the facts of the case as follows:Sometime in 1985, petitioner Erlinda Ramos, after seeking professional medical help, was advised to undergo an operation for the removal of a stone in her gall bladder (cholecystectomy). She was referred to Dr. Hosaka, a surgeon, who agreed to perform the operation on her. The operation was scheduled for June 17, 1985 at 9:00 in the morning at private respondent De Los Santos Medical Center (DLSMC). Since neither petitioner Erlinda nor her husband, petitioner Rogelio, knew of any anesthesiologist, Dr. Hosaka recommended to them the services of Dr. Gutierrez.Petitioner Erlinda was admitted to the DLSMC the day before the scheduled operation. By 7:30 in the morning of the following day, petitioner Erlinda was already being prepared for operation. Upon the request of petitioner Erlinda, her sister-in-law, Herminda Cruz, who was then Dean of the College of Nursing at the Capitol Medical Center, was allowed to accompany her inside the operating room.At around 9:30 in the morning, Dr. Hosaka had not yet arrived so Dr. Gutierrez tried to get in touch with him by phone. Thereafter, Dr. Gutierrez informed Cruz that the operation might be delayed due to the late arrival of Dr. Hosaka. In the meantime, the patient, petitioner Erlinda said to Cruz, "Mindy,inip na inip na ako, ikuha mo ako ng ibang Doctor."By 10:00 in the morning, when Dr. Hosaka was still not around, petitioner Rogelio already wanted to pull out his wife from the operating room. He met Dr. Garcia, who remarked that he was also tired of waiting for Dr. Hosaka. Dr. Hosaka finally arrived at the hospital at around 12:10 in the afternoon, or more than three (3) hours after the scheduled operation.Cruz, who was then still inside the operating room, heard about Dr. Hosakas arrival. While she held the hand of Erlinda, Cruz saw Dr. Gutierrez trying to intubate the patient. Cruz heard Dr. Gutierrez utter: "ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." Cruz noticed a bluish discoloration of Erlindas nailbeds on her left hand. She (Cruz) then heard Dr. Hosaka instruct someone to call Dr. Calderon, another anesthesiologist. When he arrived, Dr. Calderon attempted to intubate the patient. The nailbeds of the patient remained bluish, thus, she was placed in a trendelenburg position a position where the head of the patient is placed in a position lower than her feet. At this point, Cruz went out of the operating room to express her concern to petitioner Rogelio that Erlindas operation was not going well.Cruz quickly rushed back to the operating room and saw that the patient was still in trendelenburg position. At almost 3:00 in the afternoon, she saw Erlinda being wheeled to the Intensive Care Unit (ICU). The doctors explained to petitioner Rogelio that his wife had bronchospasm. Erlinda stayed in the ICU for a month. She was released from the hospital only four months later or on November 15, 1985. Since the ill-fated operation, Erlinda remained in comatose condition until she died on August 3, 1999.1Petitioners filed with the Regional Trial Court of Quezon City a civil case for damages against private respondents. After due trial, the courta quorendered judgment in favor of petitioners. Essentially, the trial court found that private respondents were negligent in the performance of their duties to Erlinda. On appeal by private respondents, the Court of Appeals reversed the trial courts decision and directed petitioners to pay their "unpaid medical bills" to private respondents.Petitioners filed with this Court a petition for review on certiorari. The private respondents were then required to submit their respective comments thereon. On December 29, 1999, this Court promulgated the decision which private respondents now seek to be reconsidered. The dispositive portion of said Decision states:WHEREFORE, the decision and resolution of the appellate court appealed from are hereby modified so as to award in favor of petitioners, and solidarily against private respondents the following: 1) P1,352,000.00 as actual damages computed as of the date of promulgation of this decision plus a monthly payment of P8,000.00 up to the time that petitioner Erlinda Ramos expires or miraculously survives; 2) P2,000,000.00 as moral damages, 3) P1,500,000.00 as temperate damages; 4) P100,000.00 each exemplary damages and attorneys fees; and 5) the costs of the suit.2In his Motion for Reconsideration, private respondent Dr. Hosaka submits the following as grounds therefor:ITHE HONORABLE SUPREME COURT COMMITTED REVERSIBLE ERROR WHEN IT HELD RESPONDENT DR. HOSAKA LIABLE ON THE BASIS OF THE "CAPTAIN-OF-THE-SHIP" DOCTRINE.IITHE HONORABLE SUPREME COURT ERRED IN HOLDING RESPONDENT DR. HOSAKA LIABLE DESPITE THE FACT THAT NO NEGLIGENCE CAN BE ATTRIBUTABLE TO HIM.IIIASSUMING WITHOUT ADMITTING THAT RESPONDENT DR. HOSAKA IS LIABLE, THE HONORABLE SUPREME COURT ERRED IN AWARDING DAMAGES THAT WERE CLEARLY EXCESSIVE AND WITHOUT LEGAL BASIS.3Private respondent Dr. Gutierrez, for her part, avers that:A. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED THE FACT THAT THE COURT OF APPEALS DECISION DATED 29 MAY 1995 HAD ALREADY BECOME FINAL AND EXECUTORY AS OF 25 JUNE 1995, THEREBY DEPRIVING THIS HONORABLE COURT OF JURISDICTION OVER THE INSTANT PETITION;B. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY OVERLOOKED SEVERAL MATERIAL FACTUAL CIRCUMSTANCES WHICH, IF PROPERLY CONSIDERED, WOULD INDUBITABLY LEAD TO NO OTHER CONCLUSION BUT THAT PRIVATE RESPONDENT DOCTORS WERE NOT GUILTY OF ANY NEGLIGENCE IN RESPECT OF THE INSTANT CASE;B.1 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER COMPLIANCE WITH THE STANDARDS OF DUE CARE EXPECTED IN HER RESPECTIVE FIELD OF MEDICAL SPECIALIZATION.B.2 RESPONDENT DOCTOR PERFECTA GUTIERREZ HAS SUFFICIENTLY DISCHARGED THE BURDEN OF EVIDENCE BY SUBSTANTIAL PROOF OF HER HAVING SUCCESSFULLY INTUBATED PATIENT ERLINDA RAMOSC. THE SUPREME COURT MAY HAVE INADVERTENTLY PLACED TOO MUCH RELIANCE ON THE TESTIMONY OF PETITIONERS WITNESS HERMINDA CRUZ, DESPITE THE EXISTENCE OF SEVERAL FACTUAL CIRCUMSTANCES WHICH RENDERS DOUBT ON HER CREDIBILITYD. THE SUPREME COURT MAY HAVE INADVERTENTLY DISREGARDED THE EXPERT TESTIMONY OF DR. JAMORA AND DRA. CALDERONE. THE HONORABLE SUPREME COURT MAY HAVE INADVERTENTLY AWARDED DAMAGES TO PETITIONERS DESPITE THE FACT THAT THERE WAS NO NEGLIGENCE ON THE PART OF RESPONDENT DOCTOR.4Private respondent De Los Santos Medical Center likewise moves for reconsideration on the following grounds:ITHE HONORABLE COURT ERRED IN GIVING DUE COURSE TO THE INSTANT PETITION AS THE DECISION OF THE HONORABLE COURT OF APPEALS HAD ALREADY BECOME FINAL AND EXECUTORYIITHE HONORABLE SUPREME COURT ERRED IN FINDING THAT AN EMPLOYER-EMPLOYEE [RELATIONSHIP] EXISTS BETWEEN RESPONDENT DE LOS SANTOS MEDICAL CENTER AND DRS. ORLINO HOSAKA AND PERFECTA GUTIERREZIIITHE HONORABLE SUPREME COURT ERRED IN FINDING THAT RESPONDENT DE LOS SANTOS MEDICAL CENTER IS SOLIDARILY LIABLE WITH RESPONDENT DOCTORSIVTHE HONORABLE SUPREME COURT ERRED IN INCREASING THE AWARD OF DAMAGES IN FAVOR OF PETITIONERS.5In the Resolution of February 21, 2000, this Court denied the motions for reconsideration of private respondents Drs. Hosaka and Gutierrez. They then filed their respective second motions for reconsideration. The Philippine College of Surgeons filed its Petition-in-Intervention contending in the main that this Court erred in holding private respondent Dr. Hosaka liable under the captain of the ship doctrine. According to the intervenor, said doctrine had long been abandoned in the United States in recognition of the developments in modern medical and hospital practice.6The Court noted these pleadings in the Resolution of July 17, 2000.7On March 19, 2001, the Court heard the oral arguments of the parties, including the intervenor. Also present during the hearing were the amicii curiae: Dr. Felipe A. Estrella, Jr., Consultant of the Philippine Charity Sweepstakes, former Director of the Philippine General Hospital and former Secretary of Health; Dr. Iluminada T. Camagay, President of the Philippine Society of Anesthesiologists, Inc. and Professor and Vice-Chair for Research, Department of Anesthesiology, College of Medicine-Philippine General Hospital, University of the Philippines; and Dr. Lydia M. Egay, Professor and Vice-Chair for Academics, Department of Anesthesiology, College of Medicine-Philippine General Hospital, University of the Philippines.The Court enumerated the issues to be resolved in this case as follows:1. WHETHER OR NOT DR. ORLINO HOSAKA (SURGEON) IS LIABLE FOR NEGLIGENCE;2. WHETHER OR NOT DR. PERFECTA GUTIERREZ (ANESTHESIOLOGIST) IS LIABLE FOR NEGLIGENCE; AND3. WHETHER OR NOT THE HOSPITAL (DELOS SANTOS MEDICAL CENTER) IS LIABLE FOR ANY ACT OF NEGLIGENCE COMMITTED BY THEIR VISITING CONSULTANT SURGEON AND ANESTHESIOLOGIST.8We shall first resolve the issue pertaining to private respondent Dr. Gutierrez. She maintains that the Court erred in finding her negligent and in holding that it was the faulty intubation which was the proximate cause of Erlindas comatose condition. The following objective facts allegedly negate a finding of negligence on her part: 1) That the outcome of the procedure was a comatose patient and not a dead one; 2) That the patient had a cardiac arrest; and 3) That the patient was revived from that cardiac arrest.9In effect, Dr. Gutierrez insists that, contrary to the finding of this Court, the intubation she performed on Erlinda was successful.Unfortunately, Dr. Gutierrez claim of lack of negligence on her part is belied by the records of the case. It has been sufficiently established that she failed to exercise the standards of care in the administration of anesthesia on a patient. Dr. Egay enlightened the Court on what these standards are:x x x What are the standards of care that an anesthesiologist should do before we administer anesthesia? The initial step is the preparation of the patient for surgery and this is a pre-operative evaluation because the anesthesiologist is responsible for determining the medical status of the patient, developing the anesthesia plan and acquainting the patient or the responsible adult particularly if we are referring with the patient or to adult patient who may not have, who may have some mental handicaps of the proposed plans. We do pre-operative evaluation because this provides for an opportunity for us to establish identification and personal acquaintance with the patient. It also makes us have an opportunity to alleviate anxiety, explain techniques and risks to the patient, given the patient the choice and establishing consent to proceed with the plan. And lastly, once this has been agreed upon by all parties concerned the ordering of pre-operative medications. And following this line at the end of the evaluation we usually come up on writing, documentation is very important as far as when we train an anesthesiologist we always emphasize this because we need records for our protection, well, records. And it entails having brief summary of patient history and physical findings pertinent to anesthesia, plan, organize as a problem list, the plan anesthesia technique, the plan post operative, pain management if appropriate, special issues for this particular patient. There are needs for special care after surgery and if it so it must be written down there and a request must be made known to proper authorities that such and such care is necessary. And the request for medical evaluation if there is an indication. When we ask for a cardio-pulmonary clearance it is not in fact to tell them if this patient is going to be fit for anesthesia, the decision to give anesthesia rests on the anesthesiologist. What we ask them is actually to give us the functional capacity of certain systems which maybe affected by the anesthetic agent or the technique that we are going to use. But the burden of responsibility in terms of selection of agent and how to administer it rest on the anesthesiologist.10The conduct of a preanesthetic/preoperative evaluation prior to an operation, whether elective or emergency, cannot be dispensed with.11Such evaluation is necessary for the formulation of a plan of anesthesia care suited to the needs of the patient concerned.Pre-evaluation for anesthesia involves taking the patients medical history, reviewing his current drug therapy, conducting physical examination, interpreting laboratory data, and determining the appropriate prescription of preoperative medications as necessary to the conduct of anesthesia.12Physical examination of the patient entails not only evaluating the patients central nervous system, cardiovascular system and lungs but also the upper airway. Examination of the upper airway would in turn include an analysis of the patients cervical spine mobility, temporomandibular mobility, prominent central incisors, deceased or artificial teeth, ability to visualize uvula and the thyromental distance.13Nonetheless, Dr. Gutierrez omitted to perform a thorough preoperative evaluation on Erlinda. As she herself admitted, she saw Erlinda for the first time on the day of the operation itself, one hour before the scheduled operation. She auscultated14the patients heart and lungs and checked the latters blood pressure to determine if Erlinda was indeed fit for operation.15However, she did not proceed to examine the patients airway. Had she been able to check petitioner Erlindas airway prior to the operation, Dr. Gutierrez would most probably not have experienced difficulty in intubating the former, and thus the resultant injury could have been avoided. As we have stated in our Decision:In the case at bar, respondent Dra. Gutierrez admitted that she saw Erlinda for the first time on the day of the operation itself, on 17 June 1985. Before this date, no prior consultations with, or pre-operative evaluation of Erlinda was done by her. Until the day of the operation, respondent Dra. Gutierrez was unaware of the physiological make-up and needs of Erlinda. She was likewise not properly informed of the possible difficulties she would face during the administration of anesthesia to Erlinda. Respondent Dra. Gutierrez act of seeing her patient for the first time only an hour before the scheduled operative procedure was, therefore, an act of exceptional negligence and professional irresponsibility. The measures cautioning prudence and vigilance in dealing with human lives lie at the core of the physicians centuries-old Hippocratic Oath. Her failure to follow this medical procedure is, therefore, a clearindiciaof her negligence.16Further, there is no cogent reason for the Court to reverse its finding that it was the faulty intubation on Erlinda that caused her comatose condition. There is no question that Erlinda became comatose after Dr. Gutierrez performed a medical procedure on her. Even the counsel of Dr. Gutierrez admitted to this fact during the oral arguments:CHIEF JUSTICE:Mr. Counsel, you started your argument saying that this involves a comatose patient?ATTY. GANA:Yes, Your Honor.CHIEF JUSTICE:How do you mean by that, a comatose, a comatose after any other acts were done by Dr. Gutierrez or comatose before any act was done by her?ATTY. GANA:No, we meant comatose as a final outcome of the procedure.CHIEF JUSTICE:Meaning to say, the patient became comatose after some intervention, professional acts have been done by Dr. Gutierrez?ATTY. GANA:Yes, Your Honor.CHIEF JUSTICE:In other words, the comatose status was a consequence of some acts performed by D. Gutierrez?ATTY. GANA:It was a consequence of the well, (interrupted)CHIEF JUSTICE:An acts performed by her, is that not correct?ATTY. GANA:Yes, Your Honor.CHIEF JUSTICE:Thank you.17What is left to be determined therefore is whether Erlindas hapless condition was due to any fault or negligence on the part of Dr. Gutierrez while she (Erlinda) was under the latters care. Dr. Gutierrez maintains that the bronchospasm and cardiac arrest resulting in the patients comatose condition was brought about by the anaphylactic reaction of the patient to Thiopental Sodium (pentothal).18In the Decision, we explained why we found Dr. Gutierrez theory unacceptable. In the first place, Dr. Eduardo Jamora, the witness who was presented to support her (Dr. Gutierrez) theory, was a pulmonologist. Thus, he could not be considered an authority on anesthesia practice and procedure and their complications.19Secondly, there was no evidence on record to support the theory that Erlinda developed an allergic reaction to pentothal. Dr. Camagay enlightened the Court as to the manifestations of an allergic reaction in this wise:DR. CAMAGAY:All right, let us qualify an allergic reaction. In medical terminology an allergic reaction is something which is not usual response and it is further qualified by the release of a hormone called histamine and histamine has an effect on all the organs of the body generally release because the substance that entered the body reacts with the particular cell, the mass cell, and the mass cell secretes this histamine. In a way it is some form of response to take away that which is not mine, which is not part of the body. So, histamine has multiple effects on the body. So, one of the effects as you will see you will have redness, if you have an allergy you will have tearing of the eyes, you will have swelling, very crucial swelling sometimes of the larynges which is your voice box main airway, that swelling may be enough to obstruct the entry of air to the trachea and you could also have contraction, constriction of the smaller airways beyond the trachea, you see you have the trachea this way, we brought some visual aids but unfortunately we do not have a projector. And then you have the smaller airways, the bronchi and then eventually into the mass of the lungs you have the bronchus. The difference is that these tubes have also in their walls muscles and this particular kind of muscles is smooth muscle so, when histamine is released they close up like this and that phenomenon is known as bronco spasm. However, the effects of histamine also on blood vessels are different. They dilate blood vessel open up and the patient or whoever has this histamine release has hypertension or low blood pressure to a point that the patient may have decrease blood supply to the brain and may collapse so, you may have people who have this.20These symptoms of an allergic reaction were not shown to have been extant in Erlindas case. As we held in our Decision, "no evidence of stridor, skin reactions, or wheezing some of the more common accompanying signs of an allergic reaction appears on record. No laboratory data were ever presented to the court."21Dr. Gutierrez, however, insists that she successfully intubated Erlinda as evidenced by the fact that she was revived after suffering from cardiac arrest. Dr. Gutierrez faults the Court for giving credence to the testimony of Cruz on the matter of the administration of anesthesia when she (Cruz), being a nurse, was allegedly not qualified to testify thereon. Rather, Dr. Gutierrez invites the Courts attention to her synopsis on what transpired during Erlindas intubation:12:15 p.m. Patient was inducted with sodium pentothal 2.5% (250 mg) given by slow IV. 02 was started by mask. After pentothal injection this was followed by IV injection of Norcuron 4mg. After 2 minutes 02 was given by positive pressure for about one minute. Intubation with endotracheal tube 7.5 m in diameter was done with slight difficulty (short neck & slightly prominent upper teeth) chest was examined for breath sounds & checked if equal on both sides. The tube was then anchored to the mouth by plaster & cuff inflated. Ethrane 2% with 02 4 liters was given. Blood pressure was checked 120/80 & heart rate regular and normal 90/min.12:25 p.m. After 10 minutes patient was cyanotic. Ethrane was discontinued & 02 given alone. Cyanosis disappeared. Blood pressure and heart beats stable.12:30 p.m. Cyanosis again reappeared this time with sibilant and sonorous rales all over the chest. D_5%_H20 & 1 ampule of aminophyline by fast drip was started. Still the cyanosis was persistent. Patient was connected to a cardiac monitor. Another ampule of of [sic] aminophyline was given and solu cortef was given.12:40 p.m. There was cardiac arrest. Extra cardiac massage and intercardiac injection of adrenalin was given & heart beat reappeared in less than one minute. Sodium bicarbonate & another dose of solu cortef was given by IV. Cyanosis slowly disappeared & 02 continuously given & assisted positive pressure. Laboratory exams done (see results in chart).Patient was transferred to ICU for further management.22From the foregoing, it can be allegedly seen that there was no withdrawal (extubation) of the tube. And the fact that the cyanosis allegedly disappeared after pure oxygen was supplied through the tube proved that it was properly placed.The Court has reservations on giving evidentiary weight to the entries purportedly contained in Dr. Gutierrez synopsis. It is significant to note that the said record prepared by Dr. Gutierrez was made only after Erlinda was taken out of the operating room. The standard practice in anesthesia is that every single act that the anesthesiologist performs must be recorded. In Dr. Gutierrez case, she could not account for at least ten (10) minutes of what happened during the administration of anesthesia on Erlinda. The following exchange between Dr. Estrella, one of the amicii curiae, and Dr. Gutierrez is instructive:DR. ESTRELLAQ You mentioned that there were two (2) attempts in the intubation period?DR. GUTIERREZYes.Q There were two attempts. In the first attempt was the tube inserted or was the laryngoscope only inserted, which was inserted?A All the laryngoscope.Q All the laryngoscope. But if I remember right somewhere in the re-direct, a certain lawyer, you were asked that you did a first attempt and the question was did you withdraw the tube? And you said you never withdrew the tube, is that right?A Yes.Q Yes. And so if you never withdrew the tube then there was no, there was no insertion of the tube during that first attempt. Now, the other thing that we have to settle here is when cyanosis occurred, is it recorded in the anesthesia record when the cyanosis, in your recording when did the cyanosis occur?A (sic)Q Is it a standard practice of anesthesia that whatever you do during that period or from the time of induction to the time that you probably get the patient out of the operating room that every single action that you do is so recorded in your anesthesia record?A I was not able to record everything I did not have time anymore because I did that after the, when the patient was about to leave the operating room. When there was second cyanosis already that was the (interrupted)Q When was the first cyanosis?A The first cyanosis when I was (interrupted)Q What time, more or less?A I think it was 12:15 or 12:16.Q Well, if the record will show you started induction at 12:15?A Yes, Your Honor.Q And the first medication you gave was what?A The first medication, no, first the patient was oxygenated for around one to two minutes.Q Yes, so, that is about 12:13?A Yes, and then, I asked the resident physician to start giving the pentothal very slowly and that was around one minute.Q So, that is about 12:13 no, 12:15, 12:17?A Yes, and then, after one minute another oxygenation was given and after (interrupted)Q 12:18?A Yes, and then after giving the oxygen we start the menorcure which is a relaxant. After that relaxant (interrupted)Q After that relaxant, how long do you wait before you do any manipulation?A Usually you wait for two minutes or three minutes.Q So, if our estimate of the time is accurate we are now more or less 12:19, is that right?A Maybe.Q 12:19. And at that time, what would have been done to this patient?A After that time you examine the, if there is relaxation of the jaw which you push it downwards and when I saw that the patient was relax because that monorcure is a relaxant, you cannot intubate the patient or insert the laryngoscope if it is not keeping him relax. So, my first attempt when I put the laryngoscope on I saw the trachea was deeply interiorly. So, what I did ask "mahirap ata ito ah." So, I removed the laryngoscope and oxygenated again the patient.Q So, more or less you attempted to do an intubation after the first attempt as you claimed that it was only the laryngoscope that was inserted.A Yes.Q And in the second attempt you inserted the laryngoscope and now possible intubation?A Yes.Q And at that point, you made a remark, what remark did you make?A I said "mahirap ata ito" when the first attempt I did not see the trachea right away. That was when I (interrupted)Q That was the first attempt?A Yes.Q What about the second attempt?A On the second attempt I was able to intubate right away within two to three seconds.Q At what point, for purposes of discussion without accepting it, at what point did you make the comment "na mahirap ata to intubate, mali ata ang pinasukan"A I did not say "mali ata ang pinasukan" I never said that.Q Well, just for the information of the group here the remarks I am making is based on the documents that were forwarded to me by the Supreme Court. That is why for purposes of discussion I am trying to clarify this for the sake of enlightenment. So, at what point did you ever make that comment?A Which one, sir?Q The "mahirap intubate ito" assuming that you (interrupted)A Iyon lang, that is what I only said "mahirap intubate(interrupted)Q At what point?A When the first attempt when I inserted the laryngoscope for the first time.Q So, when you claim that at the first attempt you inserted the laryngoscope, right?A Yes.Q But in one of the recordings somewhere at the, somewhere in the transcript of records that when the lawyer of the other party try to inquire from you during the first attempt that was the time when "mayroon ba kayong hinugot sa tube, I do not remember the page now, but it seems to me it is there. So, that it was on the second attempt that (interrupted)A I was able to intubate.Q And this is more or less about what time 12:21?A Maybe, I cannot remember the time, Sir.Q Okay, assuming that this was done at 12:21 and looking at the anesthesia records from 12:20 to 12:30 there was no recording of the vital signs. And can we presume that at this stage there was already some problems in handling the patient?A Not yet.Q But why are there no recordings in the anesthesia record?A I did not have time.Q Ah, you did not have time, why did you not have time?A Because it was so fast, I really (at this juncture the witness is laughing)Q No, I am just asking. Remember I am not here not to pin point on anybody I am here just to more or less clarify certainty more ore less on the record.A Yes, Sir.Q And so it seems that there were no recording during that span of ten (10) minutes. From 12:20 to 12:30, and going over your narration, it seems to me that the cyanosis appeared ten (10) minutes after induction, is that right?A Yes.Q And that is after induction 12:15 that is 12:25 that was the first cyanosis?A Yes.Q And that the 12:25 is after the 12:20?A We cannot (interrupted)Q Huwag ho kayong makuwan, we are just trying to enlighten, I am just going over the record ano,kung mali ito kuwan eh di ano. So,ganoon po ano, that it seems to me that there is no recording from 12:20 to 12:30, so, I am just wondering why there were no recordings during the period and then of course the second cyanosis, after the first cyanosis. I think that was the time Dr. Hosaka came in?A No, the first cyanosis (interrupted).23We cannot thus give full credence to Dr. Gutierrez synopsis in light of her admission that it does not fully reflect the events that transpired during the administration of anesthesia on Erlinda. As pointed out by Dr. Estrella, there was a ten-minute gap in Dr. Gutierrez synopsis, i.e., the vital signs of Erlinda were not recorded during that time. The absence of these data is particularly significant because, as found by the trial court, it was the absence of oxygen supply for four (4) to five (5) minutes that caused Erlindas comatose condition.On the other hand, the Court has no reason to disbelieve the testimony of Cruz. As we stated in the Decision, she is competent to testify on matters 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.24Cruz, Erlindas sister-in-law, was with her inside the operating room. Moreover, being a nurse and Dean of the Capitol Medical Center School of Nursing at that, she is not entirely ignorant of anesthetic procedure. Cruz narrated that she heard Dr. Gutierrez remark, "Ang hirap ma-intubate nito, mali yata ang pagkakapasok. O lumalaki ang tiyan." She observed that the nailbeds of Erlinda became bluish and thereafter Erlinda was placed in trendelenburg position.25Cruz further averred that she noticed that the abdomen of Erlinda became distended.26The cyanosis (bluish discoloration of the skin or mucous membranes caused by lack of oxygen or abnormal hemoglobin in the blood) and enlargement of the stomach of Erlinda indicate that the endotracheal tube was improperly inserted into the esophagus instead of the trachea. Consequently, oxygen was delivered not to the lungs but to the gastrointestinal tract. This conclusion is supported by the fact that Erlinda was placed in trendelenburg position. This indicates that there was a decrease of blood supply to the patients brain. The brain was thus temporarily deprived of oxygen supply causing Erlinda to go into coma.The injury incurred by petitioner Erlinda does not normally happen absent any negligence in the administration of anesthesia and in the use of an endotracheal tube. As was noted in our Decision, the instruments used in the administration of anesthesia, including the endotracheal tube, were all under the exclusive control of private respondents Dr. Gutierrez and Dr. Hosaka.27InVoss vs. Bridwell,28which involved a patient who suffered brain damage due to the wrongful administration of anesthesia, and even before the scheduled mastoid operation could be performed, the Kansas Supreme Court applied the doctrine ofres ipsa loquitur, reasoning that the injury to the patient therein was one which does not ordinarily take place in the absence of negligence in the administration of an anesthetic, and in the use and employment of an endotracheal tube. The court went on to say that "[o]rdinarily a person being put under anesthesia is not rendered decerebrate as a consequence of administering such anesthesia in the absence of negligence. Upon these facts and under these circumstances, a layman would be able to say, as a matter of common knowledge and observation, that the consequences of professional treatment were not as such as would ordinarily have followed if due care had been exercised."29Considering the application of the doctrine ofres ipsa loquitur, the testimony of Cruz was properly given credence in the case at bar.For his part, Dr. Hosaka mainly contends that the Court erred in finding him negligent as a surgeon by applying the Captain-of-the-Ship doctrine.30Dr. Hosaka argues that the trend in United States jurisprudence has been to reject said doctrine in light of the developments in medical practice. He points out that anesthesiology and surgery are two distinct and specialized fields in medicine and as a surgeon, he is not deemed to have control over the acts of Dr. Gutierrez. As anesthesiologist, Dr. Gutierrez is a specialist in her field and has acquired skills and knowledge in the course of her training which Dr. Hosaka, as a surgeon, does not possess.31He states further that current American jurisprudence on the matter recognizes that the trend towards specialization in medicine has created situations where surgeons do not always have the right to control all personnel within the operating room,32especially a fellow specialist.33Dr. Hosaka cites the case ofThomas v. Raleigh General Hospital,34which involved a suit filed by a patient who lost his voice due to the wrongful insertion of the endotracheal tube preparatory to the administration of anesthesia in connection with the laparotomy to be conducted on him. The patient sued both the anesthesiologist and the surgeon for the injury suffered by him. The Supreme Court of Appeals of West Virginia held that the surgeon could not be held liable for the loss of the patients voice, considering that the surgeon did not have a hand in the intubation of the patient. The court rejected the application of the "Captain-of-the-Ship Doctrine," citing the fact that the field of medicine has become specialized such that surgeons can no longer be deemed as having control over the other personnel in the operating room. It held that "[a]n assignment of liability based on actual control more realistically reflects the actual relationship which exists in a modern operating room."35Hence, only the anesthesiologist who inserted the endotracheal tube into the patients throat was held liable for the injury suffered by the latter.This contention fails to persuade.That there is a trend in American jurisprudence to do away with the Captain-of-the-Ship doctrine does not mean that this Court willipso factofollow said trend. Due regard for the peculiar factual circumstances obtaining in this case justify the application of the Captain-of-the-Ship doctrine. From the facts on record it can be logically inferred that Dr. Hosaka exercised a certain degree of, at the very least, supervision over the procedure then being performed on Erlinda.First, it was Dr. Hosaka who recommended to petitioners the services of Dr. Gutierrez. In effect, he represented to petitioners that Dr. Gutierrez possessed the necessary competence and skills. Drs. Hosaka and Gutierrez had worked together since 1977. Whenever Dr. Hosaka performed a surgery, he would always engage the services of Dr. Gutierrez to administer the anesthesia on his patient.36Second, Dr. Hosaka himself admitted that he was the attending physician of Erlinda. Thus, when Erlinda showed signs of cyanosis, it was Dr. Hosaka who gave instructions to call for another anesthesiologist and cardiologist to help resuscitate Erlinda.37Third, it is conceded that in performing their responsibilities to the patient, Drs. Hosaka and Gutierrez worked as a team. Their work cannot be placed in separate watertight compartments because their duties intersect with each other.38While the professional services of Dr. Hosaka and Dr. Gutierrez were secured primarily for their performance of acts within their respective fields of expertise for the treatment of petitioner Erlinda, and that one does not exercise control over the other, they were certainly not completely independent of each other so as to absolve one from the negligent acts of the other physician.That they were working as a medical team is evident from the fact that Dr. Hosaka was keeping an eye on the intubation of the patient by Dr. Gutierrez, and while doing so, he observed that the patients nails had become dusky and had to call Dr. Gutierrezs attention thereto. The Court also notes that the counsel for Dr. Hosaka admitted that in practice, the anesthesiologist would also have to observe the surgeons acts during the surgical process and calls the attention of the surgeon whenever necessary39in the course of the treatment. The duties of Dr. Hosaka and those of Dr. Gutierrez in the treatment of petitioner Erlinda are therefore not as clear-cut as respondents claim them to be. On the contrary, it is quite apparent that they have a common responsibility to treat the patient, which responsibility necessitates that they call each others attention to the condition of the patient while the other physician is performing the necessary medical procedures.It is equally important to point out that Dr. Hosaka was remiss in his duty of attending to petitioner Erlinda promptly, for he arrived more than three (3) hours late for the scheduled operation. Thecholecystectomywas set for June 17, 1985 at 9:00 a.m., but he arrived at DLSMC only at around 12:10 p.m. In reckless disregard for his patients well being, Dr. Hosaka scheduled two procedures on the same day, just thirty minutes apart from each other, at different hospitals. Thus, when the first procedure (protoscopy) at the Sta. Teresita Hospital did not proceed on time, Erlinda was kept in a state of uncertainty at the DLSMC.The unreasonable delay in petitioner Erlindas scheduled operation subjected her to continued starvation and consequently, to the risk of acidosis,40or the condition of decreased alkalinity of the blood and tissues, marked by sickly sweet breath, headache, nausea and vomiting, and visual disturbances.41The long period that Dr. Hosaka made Erlinda wait for him certainly aggravated the anxiety that she must have been feeling at the time. It could be safely said that her anxiety adversely affected the administration of anesthesia on her. As explained by Dr. Camagay, the patients anxiety usually causes the outpouring of adrenaline which in turn results in high blood pressure or disturbances in the heart rhythm:DR. CAMAGAY:x x x Pre-operative medication has three main functions: One is to alleviate anxiety. Second is to dry up the secretions and Third is to relieve pain. Now, it is very important to alleviate anxiety because anxiety is associated with the outpouring of certain substances formed in the body called adrenalin. When a patient is anxious there is an outpouring of adrenalin which would have adverse effect on the patient. One of it is high blood pressure, the other is that he opens himself to disturbances in the heart rhythm, which would have adverse implications. So, we would like to alleviate patients anxiety mainly because he will not be in control of his body there could be adverse results to surgery and he will be opened up; a knife is going to open up his body. x x x42Dr. Hosaka cannot now claim that he was entirely blameless of what happened to Erlinda. His conduct clearly constituted a breach of his professional duties to Erlinda:CHIEF JUSTICE:Two other points. The first, Doctor, you were talking about anxiety, would you consider a patient's stay on the operating table for three hours sufficient enough to aggravate or magnify his or her anxiety?DR. CAMAGAY:Yes.CHIEF JUSTICE:In other words, I understand that in this particular case that was the case, three hours waiting and the patient was already on the operating table (interrupted)DR. CAMAGAY:Yes.CHIEF JUSTICE:Would you therefore conclude that the surgeon contributed to the aggravation of the anxiety of the patient?DR. CAMAGAY:That this operation did not take place as scheduled is already a source of anxiety and most operating tables are very narrow and that patients are usually at risk of falling on the floor so there are restraints that are placed on them and they are never, never left alone in the operating room by themselves specially if they are already pre-medicated because they may not be aware of some of their movement that they make which would contribute to their injury.CHIEF JUSTICE:In other words due diligence would require a surgeon to come on time?DR. CAMAGAY:I think it is not even due diligence it is courtesy.CHIEF JUSTICE:Courtesy.DR. CAMAGAY:And care.CHIEF JUSTICE:Duty as a matter of fact?DR. CAMAGAY:Yes, Your Honor.43Dr. Hosaka's irresponsible conduct of arriving very late for the scheduled operation of petitioner Erlinda is violative, not only of his duty as a physician "to serve the interest of his patients with the greatest solicitude, giving them always his best talent and skill,"44but also of Article 19 of the Civil Code which requires a person, in the performance of his duties, to act with justice and give everyone his due.Anent private respondent DLSMCs liability for the resulting injury to petitioner Erlinda, we held that respondent hospital is solidarily liable with respondent doctors therefor under Article 2180 of the Civil Code45since there exists an employer-employee relationship between private respondent DLSMC and Drs. Gutierrez and Hosaka:In other words, private hospitals, hire, fire and exercise real control over their attending and visiting "consultant" staff. While "consultants" are not, technically employees, x x x the control exercised, the hiring and the right to terminate consultants all fulfill the important hallmarks of an employer-employee relationship, with the exception of the payment of wages. In assessing whether such a relationship in fact exists, the control test is determining. x x x46DLSMC however contends that applying the four-fold test in determining whether such a relationship exists between it and the respondent doctors, the inescapable conclusion is that DLSMC cannot be considered an employer of the respondent doctors.It has been consistently held that in determining whether an employer-employee relationship exists between the parties, the following elements must be present: (1) selection and engagement of services; (2) payment of wages; (3) the power to hire and fire; and (4) the power to control not only the end to be achieved, but the means to be used in reaching such an end.47DLSMC maintains that first, a hospital does not hire or engage the services of a consultant, but rather, accredits the latter and grants him or her the privilege of maintaining a clinic and/or admitting patients in the hospital upon a showing by the consultant that he or she possesses the necessary qualifications, such as accreditation by the appropriate board (diplomate), evidence of fellowship and references.48Second, it is not the hospital but the patient who pays the consultants fee for services rendered by the latter.49Third, a hospital does not dismiss a consultant; instead, the latter may lose his or her accreditation or privileges granted by the hospital.50Lastly, DLSMC argues that when a doctor refers a patient for admission in a hospital, it is the doctor who prescribes the treatment to be given to said patient. The hospitals obligation is limited to providing the patient with the preferred room accommodation, the nutritional diet and medications prescribed by the doctor, the equipment and facilities necessary for the treatment of the patient, as well as the services of the hospital staff who perform the ministerial tasks of ensuring that the doctors orders are carried out strictly.51After a careful consideration of the arguments raised by DLSMC, the Court finds that respondent hospitals position on this issue is meritorious. There is no employer-employee relationship between DLSMC and Drs. Gutierrez and Hosaka which would hold DLSMC solidarily liable for the injury suffered by petitioner Erlinda under Article 2180 of the Civil Code.As explained by respondent hospital, that the admission of a physician to membership in DLSMCs medical staff as active or visiting consultant is first decided upon by the Credentials Committee thereof, which is composed of the heads of the various specialty departments such as the Department of Obstetrics and Gynecology, Pediatrics, Surgery with the department head of the particular specialty applied for as chairman. The Credentials Committee then recommends to DLSMC's Medical Director or Hospital Administrator the acceptance or rejection of the applicant physician, and said director or administrator validates the committee's recommendation.52Similarly, in cases where a disciplinary action is lodged against a consultant, the same is initiated by the department to whom the consultant concerned belongs and filed with the Ethics Committee consisting of the department specialty heads. The medical director/hospital administrator merely acts as ex-officio member of said committee.Neither is there any showing that it is DLSMC which pays any of its consultants for medical services rendered by the latter to their respective patients. Moreover, the contract between the consultant in respondent hospital and his patient is separate and distinct from the contract between respondent hospital and said patient. The first has for its object the rendition of medical services by the consultant to the patient, while the second concerns the provision by the hospital of facilities and services by its staff such as nurses and laboratory personnel necessary for the proper treatment of the patient.Further, no evidence was adduced to show that the injury suffered by petitioner Erlinda was due to a failure on the part of respondent DLSMC to provide for hospital facilities and staff necessary for her treatment.For these reasons, we reverse the finding of liability on the part of DLSMC for the injury suffered by petitioner Erlinda.Finally, the Court also deems it necessary to modify the award of damages to petitioners in view of the supervening event of petitioner Erlindas death. In the assailed Decision, the Court awarded actual damages of One Million Three Hundred Fifty Two Thousand Pesos (P1,352,000.00) to cover the expenses for petitioner Erlindas treatment and care from the date of promulgation of the Decision up to the time the patient expires or survives.53In addition thereto, the Court awarded temperate damages of One Million Five Hundred Thousand Pesos (P1,500,000.00) in view of the chronic and continuing nature of petitioner Erlindas injury and the certainty of further pecuniary loss by petitioners as a result of said injury, the amount of which, however, could not be made with certainty at the time of the promulgation of the decision. The Court justified such award in this manner:Our rules on actual or compensatory damages generally assume that at the time of litigation, the injury suffered as a consequence of an act of negligence has been completed and that the cost can be liquidated. However, these provisions neglect to take into account those situations, as in this case, where the resulting injury might be continuing and possible future complications directly arising from the injury, while certain to occur, are difficult to predict.In these cases, the amount of damages which should be awarded, if they are to adequately and correctly respond to the injury caused, should be one which compensates for pecuniary loss incurred and proved, up to the time of trial;andone which would meet pecuniary loss certain to be suffered but which could not, from the nature of the case, be made with certainty. In other words, temperate damages can and should be awarded on top of actual or compensatory damages in instances where the injury is chronic and continuing. And because of the unique nature of such cases, no incompatibility arises when both actual and temperate damages are provided for. The reason is that these damages cover two distinct phases.As it would not be equitableand certainly not in the best interests of the administration of justicefor the victim in such cases to constantly come before the courts and invoke their aid in seeking adjustments to the compensatory damages previously awardedtemperate damages are appropriate. The amount given as temperate damages, though to a certain extent speculative, should take into account the cost of proper care.In the instant case, petitioners were able to provide only home-based nursing care for a comatose patient who has remained in that condition for over a decade. Having premised our award for compensatory damages on the amount provided by petitioners at the onset of litigation, it would be now much more in step with the interests of justice if the value awarded for temperate damages would allow petitioners to provide optimal care for their loved one in a facility which generally specializes in such care. They should not be compelled by dire circumstances to provide substandard care at home without the aid of professionals, for anything less would be grossly inadequate. Under the circumstances, an award of P1,500,000.00 in temperate damages would therefore be reasonable.54However, subsequent to the promulgation of the Decision, the Court was informed by petitioner Rogelio that petitioner Erlinda died on August 3, 1999.55In view of this supervening event, the award of temperate damages in addition to the actual or compensatory damages would no longer be justified since the actual damages awarded in the Decision are sufficient to cover the medical expenses incurred by petitioners for the patient. Hence, only the amounts representing actual, moral and exemplary damages, attorneys fees and costs of suit should be awarded to petitioners.WHEREFORE, the assailed Decision is hereby modified as follows:(1) Private respondent De Los Santos Medical Center is hereby absolved from liability arising from the injury suffered by petitioner Erlinda Ramos on June 17, 1985;(2) Private respondents Dr. Orlino Hosaka and Dr. Perfecta Gutierrez are hereby declared to be solidarily liable for the injury suffered by petitioner Erlinda on June 17, 1985 and are ordered to pay petitioners(a) P1,352,000.00 as actual damages;(b) P2,000,000.00 as moral damages;(c) P100,000.00 as exemplary damages;(d) P100,000.00 as attorneys fees; and(e) the costs of the suit.SO ORDERED.Davide, Jr., C.J., (Chairman), Puno, and Ynares-Santiago, JJ.,concur.G.R. No. 150355 July 31, 2006MANILA DOCTORS HOSPITAL,petitioner,vs.SO UN CHUA and VICKY TY,respondents.D E C I S I O NAUSTRIA-MARTINEZ,J.:Before this Court is a Petition for Review onCertiorariunder Rule 45 questioning the Decision1dated October 2, 2001 promulgated by the Court of Appeals (CA) in CA-G.R. CV No. 61581, which affirmed the Decision dated September 30, 1997 of the Regional Trial Court (RTC), Branch 159, Pasig City, but which reduced the award of damages.This case originated from an action for damages filed with the RTC by respondents So Un Chua and Vicky Ty against petitioner Manila Doctors Hospital.2The complaint is premised on the alleged unwarranted actuations of the petitioner towards its patient, respondent So Un Chua (Chua), who was confined for hypertension, diabetes, and related illnesses.The antecedents of the case follow:On December 13, 1993, respondents filed a Complaint averring that on October 30, 1990, respondent Chua, the mother of respondent Vicky Ty, was admitted in petitioner's hospital for hypertension and diabetes; that while respondent Chua was confined, Judith Chua, the sister of respondent Ty, had been likewise confined for injuries suffered in a vehicular accident; that partial payments of the hospital bills were made, totaling P435,800.00; that after the discharge of Judith Chua, respondent Chua remained in confinement and the hospital bills for both patients accumulated; that respondent Chua was pressured by the petitioner, through its Credit and Collection Department, to settle the unpaid bills; that respondent Ty represented that she will settle the bills as soon as the funds become available; that respondent Ty pleaded to the management that in view of the physical condition of her mother, respondent Chua, the correspondences relating to the settlement of the unpaid hospital bills should be relayed to the former; that these pleas were unheeded by the petitioner; that petitioner threatened to implement unpleasant measures unless respondent Ty undertakes her mother's obligation as well as the obligation of her sister, Judith Chua, to pay the hospitalization expenses; that petitioner made good its threat and employed unethical, unpleasant and unlawful methods which allegedly worsened the condition of respondent Chua, particularly, by (i) cutting off the telephone line in her room and removing the air-conditioning unit, television set, and refrigerator, (ii) refusing to render medical attendance and to change the hospital gown and bed sheets, and (iii) barring the private nurses or midwives from assisting the patient. Respondents thus prayed for the award of moral damages, exemplary damages, and attorney's fees.In its Answer, Amended Answer, and Rejoinder, petitioner specifically denied the material averments of the Complaint and Reply, and interposed its counterclaims arguing that as early as one week after respondent Chua had been admitted to its hospital, Dr. Rody Sy, her attending physician, had already given instructions for her to be discharged, but respondents insisted that Chua remain in confinement; that, through its staff, petitioner accordingly administered medical examinations, all of which yielded negative results; that respondent Ty voluntarily undertook, jointly and severally, to pay the hospital bills for both patients; that although respondent Ty paid up to P435,000.00, more or less, she reneged on her commitment to pay the balance in violation of the Contract for Admission and Acknowledgment of Responsibility for Payment dated October 30, 1990 which she voluntarily executed; that she signed a Promissory Note on June 5, 1992 for the unpaid balance of P1,075,592.95 and issued postdated checks to cover the same; that no such undue pressure had been imposed upon respondent Chua to settle the bills, the truth being that, as a matter of standard procedure, the reminders to settle the bills were transmitted not to the patients but to their relatives who usually undertook to pay the same; that respondent Ty deliberately evaded the staff of the Credit and Collection Department; that the cutting-off of the telephone line and removal of the air-conditioning unit, television set, and refrigerator cannot constitute unwarranted actuations, for the same were resorted to as cost-cutting measures and to minimize respondents' charges that were already piling up, especially after respondent Ty refused to settle the balance notwithstanding frequent demands; that respondent Ty evaded the staff when the latter attempted to inform her that the room facilities will be cut off to minimize the rising charges; and that respondents instituted the present civil case purposely as leverage against the petitioner after the latter had filed criminal charges for violation of Batas Pambansa (B.P.) Blg. 22 against respondent Ty for issuing checks, later dishonored, totaling P1,075,592.95, the amount referring to the unpaid hospital bills. In its compulsory counterclaim, petitioner prayed, among other items, for the award of no less than P1,000,000.00 as compensatory damages due to the filing of a malicious and unfounded suit, and, in its permissive counterclaim, petitioner prayed for respondents to pay P1,075,592.95, the amount representing the due and demandable obligation under the Promissory Note dated June 5, 1992, including the stipulated interest therein and the 25 percent of the total amount due as attorney's fees.During pre-trial, the parties stipulated on the following issues: First, whether the respondents are liable to the petitioner to pay the hospital bills arising from the hospitalization of respondent Chua and Judith Chua; and second, whether the parties are entitled to their respective claims for damages.3Furthermore, the parties stipulated on the following facts: a) Judith Chua was confined from June 14, 1991 to May 2, 1992; b) respondents failed to pay the balance despite repeated reminders; c) the said reminders referred to the hospital bills of respondent Chua and Judith Chua; d) one of the attending physicians of respondent Chua was Dr. Rody Sy; and e) the petitioner ordered the removal of the facilities in question from the room of its patient, respondent Chua, with the qualification that they were constrained to discontinue the same after the representative of respondent Chua refused to update the hospital bills or refused to transfer her to semi-deluxe room or ward to lessen costs.4On September 30, 1997, the RTC rendered its Decision in favor of the respondents, the dispositive portion of which states:WHEREFORE, premises considered, judgment on the complaint is hereby rendered in favor of the [respondents] as against the [petitioner] as follows:[O]rdering the [petitioner] to pay the [respondents] the following, to wit:a) P200,000.00 as moral damages;b) P100,000.00 as exemplary damages; andc) P50,000.00 as attorney's fees and the amount of P50,000.00 as litigation costs.SO ORDERED.5In brief, the RTC held that the removal of the facilities of the room triggered the hypertension of respondent Chua; that the petitioner acted in bad faith in removing the facilities without prior notice; that her condition was aggravated by the pressure employed by the administration upon her to pay the hospital bills; that the food always came late as compared to the other patients; that the beddings and clothes of respondent Chua were no longer changed and, as a result, bed sores emerged on her body; that there was an utter lack of medical attendance; that, because of these, respondent Chua suffered from self-pity and depression; that petitioner clearly discriminated against the respondents; that respondent Ty had no choice but to sign the promissory notes in order to secure the release of her mother, respondent Chua; that the foregoing actuations constitute an abuse of rights; that petitioner failed to establish the pecuniary loss it suffered and, hence, it is not entitled to compensatory damages; and that, since the promissory note is a contract of adhesion, the petitioner is not entitled to the award of attorney's fees as stipulated thereon.On appeal to the CA, the petitioner assigned the following errors:A.THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY FINDING THE ACTUATIONS OF THE ADMINISTRATION OF DEFENDANT-APPELLANT TO BE IN BAD FAITH, OPPRESSIVE AND UNNECESSARY AS TO MAKE IT LIABLE TO PLAINTIFFS-APPELLEES FOR DAMAGES AND ATTORNEY'S FEES.B.THE HONORABLE TRIAL COURT COMMITTED REVERSIBLE ERROR BY NOT RULING UPON THE PERMISSIVE COUNTERCLAIM OF DEFENDANT-APPELLANT WITH RESPECT TO THE P1,075,592.95 REPRESENTING THE HOSPITAL BILL OF PLAINTIFFS-APPELLEES, WHICH OBLIGATION IS NOT DISPUTED AND WHICH AMOUNT WAS NEVER CONTROVERTED BY PLAINTIFFS-APPELLEES.6On October 2, 2001, the CA promulgated its Decision the dispositive portion of which reads:IN VIEW OF ALL THE FOREGOING, the appealed Decision is herebyAFFIRMEDwith the modification that the award of moral damages, exemplary damages as well as attorney's fees is reduced to Seventy Five Thousand Pesos (P75,000.00), Thirty Thousand Pesos (P30,000.00) and Twenty Thousand Pesos (P20,000.00), respectively. Litigation costs are hereby deleted. Costs against appellant.SO ORDERED.7Apart from the reduction in the award of damages, the CA affirmed all salient portions of the RTC Decision and declined to disturb the findings of fact.Petitioner is now before this Court raising essentially the same grounds heard by the CA.Incidentally, with respect to the related criminal case against respondent Ty, this Court, on September 27, 2004, promulgated its Decision entitledTy v. People of the Philippines,8which affirmed the decisions of the lower courts finding respondent Ty guilty of violating B.P. Blg. 22 and ordering her to pay the private complainant, herein petitioner, the total amount of the dishonored checks.The petition is impressed with merit.While, as a rule, only questions of law may be raised in a petition for review oncertiorariunder Rule 45, under certain exceptions, the Court may re-examine the evidence presented by the parties during the trial. At least four exceptions exist in this case, namely: (a) when the conclusion is a finding grounded entirely on speculation, surmises, or conjectures; (b) when the judgment is based on a misapprehension of facts; (c) when the findings of fact are premised on the supposed absence of evidence and contradicted by the evidence on record; and (d) when the courtsa quomanifestly overlooked certain relevant facts not disputed by the parties and which, if properly considered, would justify a different conclusion.9The principal questions are,first, whether the actuations of the petitioner amount to actionable wrongs, andsecond, whether the counterclaims of the petitioner can be backed up by the measure of preponderant evidence.In brief, the courtsa quoconcurred in the holding that the petitioner and its staff failed to take into consideration the physical condition of its patient, respondent Chua, when it removed the facilities provided in her room;10that the removal of these facilities, namely, the air-conditioner, telephone lines, television, and refrigerator, aggravated the condition of the patient, triggered her hypertension, and caused her blood pressure to fluctuate,11considering that there was no proper ventilation in the room.12In view of the foregoing, the courtsa quoconcluded that the actuations of the petitioner were oppressive, unnecessary,13and anti-social,14done in bad faith without proper notice,15with no intention other than to harass or irritate the respondents,16all of which constitute an abuse of rights.17We do not agree. The conclusions of the courtsa quoare either haphazard conjectures, or founded on a misapprehension of facts. The record is replete with evidence that justifies a different conclusion.Indeed the operation of private pay hospitals and medical clinics is impressed with public interest and imbued with a heavy social responsibility. But the hospital is also a business, and, as a business, it has a right to institute all measures of efficiency commensurate to the ends for which it is designed, especially to ensure its economic viability and survival. And in the legitimate pursuit of economic considerations, the extent to which the public may be served and cured is expanded, the pulse and life of the medical sector quickens, and the regeneration of the people as a whole becomes more visibly attainable. In the institution of cost-cutting measures, the hospital has a right to reduce the facilities and services that are deemed to be non-essential, such that their reduction or removal would not be detrimental to the medical condition of the patient.18For the moment, the question to be considered is whether the subject facilities are indeed non-essential the air-conditioner, telephone, television, and refrigerator the removal of which would cause the adverse health effects and emotional trauma the respondents so claimed. Corollary to this question is whether the petitioner observed the diligence of a good father of the family19in the course of ascertaining the possible repercussions of the removal of the facilities prior to the removal itself and for a reasonable time thereafter, with a view to prevent damage.20After an extensive analysis of the record, it becomes rather worrisome to this Court that the courtsa quounreservedly drew their conclusions from the self-serving and uncorroborated testimonies of the respondents the probative value of which is highly questionable.21We hold that the respondents failed to prove the damages so claimed.The evidence in the record firmly establishes that the staff of the petitioner took proactive steps to inform the relatives of respondent Chua of the removal of facilities prior thereto, and to carry out the necessary precautionary measures to ensure that her health and well-being would not be adversely affected: as early as around two weeks after her admission on October 30, 1990, to the time when the facilities had been removed sometime in the middle of May 1992,22and even up to the point when she actually left the premises of the hospital three weeks later, or during the first week of June 1992,23the medical condition of respondent Chua, as consistently and indisputably confirmed by her attending physician, Dr. Rody Sy, a cardiologist, who was called as witness for both parties,24whom even respondent Chua repeatedly praised to be "my doctor" and "a very good doctor"25at that, and whose statements at times had been corroborated as well by Sister Mary Philip Galeno, SPC, the Administrator of the hospital and who also happens to be a registered nurse, had been "relatively well,"26"ambulatory,"27"walking around in the room,"28and that she was "able to leave the hospital on her own without any assistance;"29that although she complained of symptoms such as dizziness, weakness,30and abdominal discomfort,31Dr. Sy requested several medical examinations, such as the laboratory tests, renal tests, MRI, ultrasound, and CT scan,32all of which were administered after procuring the consent of respondent Chua's family33as admitted by respondent Ty herself,34and even called on other specialists, such as a neurologist, endocrinologist, and gastroenterologist, to look into her condition35and conduct other tests as well36according to their fields of specialty, all of which yielded no serious finding;37that her illnesses were "lifelong illnesses"38at a stage where they cannot be totally removed or abolished,39making it clear to her family that "one hundred percent recovery is not possible" despite being given daily medication in the hospital;40but that her condition, nonetheless, is not serious,41as the blood pressure is more or less controlled and within acceptable limits,42"not that critical to precipitate any acute attack,"43nor likely to fall into any emergency,44nor yet does she require continuous or prolonged hospitalization45since she was stable enough to be treated at home and on an "out-patient" basis, so much so that Dr. Sy encouraged her to exercise and avoid resting all thetime,46and recommended that "anytime she may be discharged"47even in just "two weeks after confinement,"48the propriety of his order of discharge concurred upon by the other specialists as well,49had it not been for respondents' insistence to stay in the hospital in view of their hope for absolute recovery50despite the admission of respondent Chua herself that she cannot anymore be totally cured.51It is also undisputed that the hospital administrator, Sister Galeno, prior to the removal of the facilities, consulted the attending physician, Dr. Sy.52To Sister Galeno, also a registered nurse, the matter of removal and its possible repercussions on the health of the patient, as a matter of hospital policy, is a critical and sensitive maneuver, and, hence, it is carried out only after discussing with the doctors to evaluate all important factors.53The fact of prior consultation54as well as the medical determination to the effect that it was safe to remove the facilities and would cause no harmful effect55had been amply corroborated by respondent Chua's own doctor himself.56When Dr. Sy testified as rebuttal witness for the respondents themselves and whose credibility respondents failed to impeach, he categorically stated that he consented to the removal since the removal of the said facilities would not by itself be detrimental to the health of his patient, respondent Chua.57And in this respect, he had been advising respondent Ty, the daughter of the patient, that the facilities, such as the air-conditioner, television, refrigerator, and telephone, are not absolutely necessary, and, that although they may add to the comfort of the patient, if absent, they will not cause any significant deterioration of her condition,58given that, in his experience as a cardiologist, and after personally attending respondent Chua on a daily basis before, during, and after the removal and even up to the time of her actual discharge,59he concluded that many hypertensive and diabetic patients, as in her case, do not at all need in particular an air-conditioning unit, among the other facilities aforementioned.60And, contrary to the findings of the courtsa quoand the self-serving testimonies of respondents that the lack of ventilation, after the removal of the air-conditioner, triggered her hypertension, Dr. Sy categorically stated that during his daily rounds with the patient he was certain that, although admittedly the blood pressure in general would fluctuate daily, there had been no adverse effect on her, and that her blood pressure were within acceptable limits,61especially considering that he treated the patient on a daily basis up to the point of actual discharge,62and accordingly, as confirmed by the medical records, he made no change in the medications thereafter.63In support of Dr. Sy's findings, Sister Galeno, testified that she knew the condition of the ventilation of the patient'sdeluxeroom, located at the fifth floor, even without the air-conditioning, notably in times of brownout, and that there had been enough ventilation since the grilled window of that room was large enough which, if opened, would permit sufficient ventilation.64The Court finds that the premise of the RTC judgment refers merely to hypothetical statements which fail to establish any clear and direct link to the injury allegedly suffered by the patient:Q You found it safe to remove these facilities from the room of the patient suffering from diabetes and hypertension?A Yes, Sir. Many hypertensive, diabetic patients do not need air-conditioning, or T.V. or refrigerator.Q Do you agree with me that hypertension is triggered sometimes by excitement, anger or (sic) a person suffering from such illness?A Hypertension can be triggered by anything.Court:Q And even in other words the discomfort can also trigger?