Reyes vs. Sisters of Mercy Hospital

2/28/2021 SUPREME COURT REPORTS ANNOTATED VOLUME 341
760 SUPREME COURT REPORTS ANNOTATED

Reyes vs. Sisters of Mercy Hospital
*
G.R. No. 130547. October 3, 2000.
LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and

minors LLOYD and KRISTINE, all surnamed REYES,
represented by their mother, LEAH ALESNA REYES,
petitioners, vs. SISTERS OF MERCY HOSPITAL, SISTER
ROSE PALACIO, DR. MARVIE BLANES, and DR.
MARLYN RICO, respondents.
Medical Malpractice; Elements; Words and Phrases; Medical

malpractice is a particular form of negligence which consists in the
failure of a physician or surgeon to apply to his practice of
medicine that degree of care and skill which is ordinarily
employed by the profession generally, under similar conditions,
and in like surrounding circumstances; There are four elements
involved in medical negligence cases, namely: duty, breach, injury
and proximate causation.—Petitioner’s action is for medical
malpractice. This is a particular form of negligence which consists
in the failure of a physician or surgeon to apply to his practice of
employed by the profession generally, under similar conditions,
and in like surrounding circumstances. In order to successfully
pursue such a claim, a patient must prove that the physician or
surgeon either failed to do something which a reasonably prudent
physician or surgeon would have done, or that he or she did
something that a reasonably prudent physician or surgeon would
not have done, and that the failure or action caused injury to the
patient. There are thus four elements involved in medical
negligence cases, namely: duty, breach, injury, and proximate
causation.
_______________
* SECOND DIVISION.
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VOL. 341, OCTOBER 3, 2000 761
Same; Evidence; Expert Witnesses; Inasmuch as the causes of

the injuries involved in malpractice actions are determinable only
in the light of scientific knowledge, it has been recognized that
expert testimony is usually necessary to support the conclusion as
to causation.—In the present case, there is no doubt that a
physician-patient relationship existed between respondent doctors
and Jorge Reyes. Respondents were thus duty-bound to use at
least the same level of care that any reasonably competent doctor
would use to treat a condition under the same circumstances. It is
breach of this duty which constitutes actionable malpractice. As to
this aspect of medical malpractice, the determination of the
reasonable level of care and the breach thereof, expert testimony
is essential. Inasmuch as the causes of the injuries involved in
malpractice actions are determinable only in the light of scientific
knowledge, it has been recognized that expert testimony is
usually necessary to support the conclusion as to causation.
Same; Same; Same; Res Ipsa Loquitur; There is a case when
expert testimony may be dispensed with, and that is under the
doctrine of res ipsa loquitur; Where res ipsa loquitur is applicable,
the court is permitted to find a physician negligent upon proper
proof of injury to the patient, without the aid of expert testimony,
where the court from its fund of common knowledge can determine
the proper standard of care.—There is a case when expert
testimony may be dispensed with, and that is under the doctrine
of res ipsa loquitur. As held in Ramos v. Court of Appeals :
Although generally, expert medical testimony is relied upon in
malpractice suits to prove that a physician has done a negligent
act or that he has deviated from the standard medical procedure,
when the doctrine of res ipsa loquitur is availed by the plaintiff,
the need for expert medical testimony is dispensed with because
the injury itself provides the proof of negligence. The reason is
that the general rule on the necessity of expert testimony applies
only to such matters clearly within the domain of medical science,
and not to matters that are within the common knowledge of
mankind which may be testified to by anyone familiar with the
facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has
been treated or operated upon with a reasonable degree of skill
and care. However, testimony as to the statements and acts of
physicians and surgeons, external appearances, and manifest
conditions which are observable by any one may be given by non-
expert witnesses. Hence, in cases where the res ipsa loquitur is
applicable, the court is permitted to find a physician negligent
upon proper proof of injury to the patient, without the aid of
expert testimony, where the court from its fund of common

knowledge can determine the proper standard of care. Where
common knowledge and experience teach that a resulting injury
would not have occurred to the patient if due care had been
exercised,
762
an inference of negligence may be drawn giving rise to an

application of the doctrine of res ipsa loquitur without medical
evidence, which is ordinarily required to show not only what
occurred but how and why it occurred. When the doctrine is
appropriate, all that the patient must do is prove a nexus between
the particular act or omission complained of and the injury
sustained while under the custody and management of the
defendant without need to produce expert medical testimony to
establish the standard of care. Resort to res ipsa loquitur is
allowed because there is no other way, under usual and ordinary
conditions, by which the patient can obtain redress for injury
suffered by him.
Same; Same; Same; Same; Requisites for Application of Res
Ipsa Loquitur.—Petitioners now contend that all requisites for the
application of res ipsa loquitur were present, namely: (1) the
accident was of a kind which does not ordinarily occur unless
someone is negligent; (2) the instrumentality or agency which
caused the injury was under the exclusive control of the person in
charge; and (3) the injury suffered must not have been due to any
voluntary action or contribution of the person injured.
Same; Same; Same; Same; Res ipsa loquitur is not a rigid or
ordinary doctrine to be perfunctorily used but a rule to be
cautiously applied, depending upon the circumstances of each case
—the doctrine of res ipsa loquitur can have no application in a suit
against a physician or a surgeon which involves the merits of a
diagnosis or of a scientific treatment; The physician or surgeon is
not required at his peril to explain why any particular diagnosis
was not correct, or why any particular scientific treatment did not
produce the desired result.—-Respondents alleged failure to
observe due care was not immediately apparent to a layman so as
to justify application of res ipsa loquitur. The question required
expert opinion on the alleged breach by respondents of the
standard of care required by the circumstances. Furthermore, on
the issue of the correctness of her diagnosis, no presumption of
negligence can be applied to Dr. Marlyn Rico. As held in Ramos:. .

. . Res ipsa loquitur is not a rigid or ordinary doctrine to be
perfunctorily used but a rule to be cautiously applied, depending
upon the circumstances of each case. It is generally restricted to
situations in malpractice cases where a layman is able to say, as a
matter of common knowledge and observation, that the
consequences of professional care were not as such as would
ordinarily have followed if due care had been exercised. A
distinction must be made between the failure to secure results,
and the occurrence of something more unusual and not ordinarily
found if the service or treatment rendered followed the usual
procedure of those skilled in that particular practice. It must be
conceded that the doctrine of res ipsa loquitur can have no
application in a. suit against a physician or a
763
VOL. 341, OCTOBER 3, 2000 763
surgeon which involves the merits of a diagnosis or of a scientific

treatment. The physician or surgeon is not required at his peril to
explain why any particular diagnosis was not correct, or why any
particular scientific treatment did not produce the desired result .
Same; Same; Same; The standard contemplated is not what is
actually the average merit among all known practitioners from the
best to the worst and from the most to the least experienced, but the
reasonable average merit among the ordinarily good physicians.—
The standard contemplated is not what is actually the average
merit among all known practitioners from the best to the worst
and from the most to the least experienced, but the reasonable
average merit among the ordinarily good physicians. Here, Dr.
Marlyn Rico did not depart from the reasonable standard
recommended by the experts as she in fact observed the due care
required under the circumstances. Though the Widal test is not
conclusive, it remains a standard diagnostic test for typhoid fever
and, in the present case, greater accuracy through repeated
testing was rendered unobtainable by the early death of the
patient. The results of the Widal test and the patient’s history of
fever with chills for five days, taken with the fact that typhoid
fever was then prevalent as indicated by the fact that the clinic
had been getting about 15 to 20 typhoid cases a month, were
sufficient to give upon any doctor of reasonable skill the
impression that Jorge Reyes had typhoid fever.
Same; Same; Negligence; The medical profession is one which,

like the business of a common carrier, is affected with public
interest; The standard of extraordinary diligence is peculiar to
common carriers.—Petitioners correctly observe that the medical
profession is one which, like the business of a common carrier, is
affected with public interest. Moreover, they assert that since the
law imposes upon common carriers the duty of observing
extraordinary diligence in the vigilance over the goods and for the
safety of the passengers, physicians and surgeons should have the
same duty toward their patients. They also contend that the
Court of Appeals erred when it allegedly assumed that the level of
medical practice is lower in Iligan City, thereby reducing the
standard of care and degree of diligence required from physicians
and surgeons in Iligan City. The standard of extraordinary
diligence is peculiar to common carriers. The Civil Code provides:
Art. 1733. Common carriers, from the nature of their business
and for reasons of public policy, are bound to observe
extraordinary diligence in the vigilance over the goods and for the
safety of the passengers transported by them, according to the
circumstances of each case. . . .
764
Same; Same; Same; Given the safeguards present in the

medical profession, there is no need to expressly require of doctors
the observance of “extraordinary” diligence—the standard
contemplated for doctors is simply the reasonable average merit
among ordinarily good physicians, that is, the reasonable skill and
competence that a physician in the same or similar locality should
apply.—The practice of medicine is a profession engaged in only
by qualified individuals. It is a right earned through years of
education, training, and by first obtaining a license from the state
through professional board examinations. Such license may, at
any time and for cause, be revoked by the government. In addition
to state regulation, the conduct of doctors is also strictly governed
by the Hippocratic Oath, an ancient code of discipline and ethical
rules which doctors have imposed upon themselves in recognition
and acceptance of their great responsibility to society. Given these
safeguards, there is no need to expressly require of doctors the
observance of “extraordinary” diligence. As it is now, the practice
of medicine is already conditioned upon the highest degree of
diligence. And, as we have already noted, the standard
contemplated for doctors is simply the reasonable average merit
among ordinarily good physicians. That is reasonable diligence for
doctors or, as the Court of Appeals called it, the reasonable “skill
and competence . . . that a physician in the same or similar
locality . . . should apply.”
PETITION for review on certiorari of a decision of the

Court of Appeals.
The facts are stated in the opinion of the Court.

Abbas, Abundiente and Associates Law Offices for
petitioners.
Arsenio C. Pascual, Jr. for respondents Sisters of
Mercy Hospital, Sister R. Palacio and Dr. M. Blanes.
Fernan, Mercado, Cordero, Dela Torre & Bael for
private respondent Dr. M. Rico.
MENDOZA, J .:
1
This is a petition for review of the decision of the Court of
Appeals in CA-G.R. CV No. 36551 affirming the decision of
the Re-
_______________
1 Per Associate Justice Hilarion L. Aquino, with concurrence of

Associate Justice (now Supreme Court Justice) Minerva P. Gonzaga-Reyes
and Associate Justice Eubulo G. Verzola.
765
VOL. 341, OCTOBER 3, 2000 765

gional Trial Court, Branch IX, Cebu City which dismissed a

complaint for damages filed by petitioners against
respondents.
The facts are as follows:
Petitioner Leah Alesna Reyes is the wife of the late
Jorge Reyes. The other petitioners, namely, Rose Nahdja,
Johnny, Lloyd, and Kristine, all surnamed Reyes, were
their children. Five days before his death on January 8,
1987, Jorge had been suffering from a recurring fever with
chills. After he failed to get relief from some home
medication he was taking, which consisted of analgesic,
antipyretic, and antibiotics, he decided to see the doctor.
On January 8, 1987, he was taken to the Mercy
Community Clinic by his wife. He was attended to by
respondent Dr. Marlyn Rico, resident physician and
admitting physician on duty, who gave Jorge a physical
examination and took his medical history. She noted that
at the time of his admission, Jorge was conscious,

ambulatory,
2
oriented, coherent, and with respiratory
distress. Typhoid fever was then prevalent in the locality,
as the clinic3 had been getting from 15 to 20 cases of typhoid
per month. Suspecting that Jorge could be suffering from
this disease, Dr. Rico ordered a Widal Test, a standard test
for typhoid fever, to be performed on Jorge. Blood count,
routine urinalysis,4 stool examination, and malarial smear
were also made. After about an hour, the medical
technician submitted the results of the test from which Dr.
Rico concluded that Jorge was positive for typhoid fever. As
her shift was only up to 5:00 p.m., Dr. Rico indorsed Jorge
to respondent Dr. Marvie Blanes.
Dr. Marvie Blanes attended to Jorge at around six in the
evening. She also took Jorge’s history and gave him a
physical examination. Like Dr. Rico, her impression was
that Jorge had typhoid fever. Antibiotics being the accepted
treatment for typhoid fever, she ordered that a
compatibility test with the antibiotic chloromycetin be done
on Jorge. Said test was administered by nurse Josephine
Pagente who also gave the patient a dose of triglobe. As she
_______________
2 TSN, p. 18, Aug. 14, 1990.

3 TSN, p. 18, Aug. 19, 1990.
4 TSN, p. 19, Aug. 14, 1990.
766

did not observe any adverse reaction by the patient to

chloromycetin, Dr. Blanes ordered the first five hundred
milligrams of said antibiotic to be administered on Jorge at
around 9:00 p.m. A second dose was administered on Jorge
about three hours later just before midnight.
At around 1:00 a.m. of January 9, 1987, Dr. Blanes was
called as Jorge’s temperature rose to 41°C. The patient also
experienced chills and exhibited respiratory distress,
nausea, vomiting, and convulsions. Dr. Blanes put him
under oxygen, used a suction machine, and administered
hydrocortisone, temporarily easing the patient’s
convulsions. When he regained consciousness, the patient
was asked by Dr. Blanes whether he had a previous heart
ailment or had suffered
5
from chest pains in the past. Jorge
replied he did not. After about 15 minutes, however, Jorge
again started to vomit, showed restlessness, and his

convulsions returned. Dr. Blanes re-applied the emergency
measures taken before and, in addition, valium was
administered. Jorge, however, did not respond to the
treatment and slipped into cyanosis, a bluish or purplish
discoloration of the skin or mucous membrane due to
deficient oxygenation of the blood. At around 2:00 a.m.,
Jorge died. He was forty years old. The cause of his death
was “Ventricular Arrythemia Secondary to Hyperpyrexia
and typhoid fever.”
On June 3, 1987, petitioners filed6 before the Regional
Trial Court of Cebu City a complaint for damages against
respondents Sisters of Mercy, Sister Rose Palacio, Dr.
Marvie Blanes, Dr. Marlyn Rico, and nurse Josephine
Pagente. On September 24, 1987, petitioners amended
their complaint to implead respondent Mercy Community
Clinic as additional defendant and to drop the name of
Josephine Pagente as defendant since she was no longer
connected with respondent hospital. Their principal7
contention was that Jorge did not die of typhoid fever.
Instead, his death was due to the wrongful administration
of chloromycetin. They contended that had respondent
doctors exercised due care and diligence, they would not
have recommended and rushed the performance of the
_______________
5 TSN, pp. 42-43, Oct. 19, 1990.

6 Records, p. 1.
7 Amended complaint, p. 6; Records, p. 61.
767
VOL. 341, OCTOBER 3, 2000 767

Widal Test, hastily concluded that Jorge was suffering from

typhoid fever, and administered chloromycetin without
first conducting sufficient tests on the patient’s
compatibility with said drug. They charged respondent
clinic and its directress, Sister Rose Palacio, with
negligence in failing to provide adequate
8
facilities and in
hiring negligent doctors and nurses.
Respondents denied the charges. During the pre-trial
conference, the parties agreed to limit the issues on the
following: (1) whether the death of Jorge Reyes was due to
or caused by the negligence, carelessness, imprudence, and
lack of skill or foresight on the part of defendants; (2)
whether respondent Mercy Community Clinic was

negligent in the hiring of its employees; and (3) whether
either party was entitled to damages. The case was then
heard by the trial court during which, in addition to the
testimonies of the parties, the testimonies of doctors as
expert witnesses were presented.
Petitioners offered the testimony of Dr. Apolinar
Vacalares, Chief Pathologist at the Northern Mindanao
Training Hospital, Cagayan de Oro City. On January 9,
1987, Dr. Vacalares performed an autopsy on Jorge Reyes
to determine the cause of his death. However, he9 did not
open the skull to examine the brain. His findings showed
that the gastrointestinal tract was normal and without any
ulceration or enlargement of the nodules. Dr. Vacalares
testified that Jorge did not die of typhoid fever. He also
stated that he had not seen a patient die of typhoid fever
within five days from the onset of the disease.
For their part, respondents offered the testimonies of Dr.
Peter Gotiong and Dr. Ibarra Panopio, Dr. Gotiong is a
diplomate in internal medicine whose expertise is
microbiology and infectious diseases. He is also a
consultant at the Cebu City Medical Center and an
associate professor of medicine at the South Western
University College of Medicine in Cebu City. He had
treated over a thousand cases of typhoid patients.
According to Dr. Gotiong, the patient’s history and positive
Widal Test results ratio of 1:320 would make him suspect
that the patient had typhoid fever. As to
_______________
8 Id. at 7.
9 Exh. A.
768

Dr. Vacalares’ observation regarding the absence of

ulceration in Jorge’s gastrointestinal tract, Dr. Gotiong
said that such hyperplasia in the intestines of a typhoid
victim may be microscopic. He noted that since the toxic
effect of typhoid fever may lead to meningitis, Dr.
Vacalares’10autopsy should have included an examination of
the brain.
The other doctor presented was Dr. Ibarra Panopio, a
member of the American Board of Pathology, examiner of
the Philippine Board of Pathology from 1978 to 1991, fellow

of the Philippine Society of Pathologist, associate professor
of the Cebu Institute of Medicine, and chief pathologist of
the Andres Soriano Jr. Memorial Hospital in Toledo City.
Dr. Panopio stated that although he was partial to the use
of the culture test for its greater reliability in the diagnosis
of typhoid fever, the Widal Test may also be used. Like Dr.
Gotiong, he agreed that the 1:320 ratio in Jorge’s case was
already the maximum by which a conclusion of typhoid
fever may be made. No additional11 information may be
deduced from a higher dilution. He said that Dr.
Vacalares’ autopsy on Jorge was incomplete and thus
inconclusive.
On September 12, 1991, the trial court rendered its
decision absolving respondents from the charges of
negligence and dismissing petitioners’ action for damages.
The trial court likewise dismissed respondents’
counterclaim, holding that, in seeking damages from
respondents, petitioners were impelled by the honest belief
that Jorge’s death was due to the latter’s negligence.
Petitioners brought the matter to the Court of Appeals.
On July 31, 1997, the Court of Appeals affirmed the
decision of the trial court.
Hence this petition.
Petitioners raise the following assignment of errors:
I. THE HONORABLE COURT OF APPEALS COMMITTED A

REVERSIBLE ERROR WHEN IT RULED THAT THE
DOCTRINE OF RES IPSA LOQUITUR IS NOT APPLICABLE
IN THE INSTANT CASE.
_______________
10 TSN, pp. 4-14, Dec. 17, 1990.

11 TSN, p. 18, March 8, 1991.
769
VOL. 341, OCTOBER 3, 2000 769

II. THE HONORABLE COURT OF APPEALS

COMMITTED REVERSIBLE ERROR WHEN IT
MADE AN UNFOUNDED ASSUMPTION THAT
THE LEVEL OF MEDICAL PRACTICE IS LOWER
IN ILIGAN CITY.
III. THE HONORABLE COURT OF APPEALS
GRAVELY ERRED WHEN IT RULED FOR A
LESSER STANDARD OF CARE AND DEGREE

OF DILIGENCE FOR MEDICAL PRACTICE IN
ILIGAN CITY WHEN IT APPRECIATE[D] NO
DOCTOR’S NEGLIGENCE IN THE TREATMENT
OF JORGE REYES.
Petitioner’s action is for medical malpractice. This is a

particular form of negligence which consists in the failure
of a physician or surgeon to apply to his practice of
employed by the profession generally, under similar 12
conditions, and in like surrounding circumstances. In
order to successfully pursue such a claim, a patient must
prove that the physician or surgeon either failed to do
something which a reasonably prudent physician or
surgeon would have done, or that he or she did something
that a reasonably prudent physician or surgeon would not
have done, and
13
that the failure or action caused injury to
the patient. There are thus four elements involved in
medical negligence cases, namely: duty, breach, injury, and
proximate causation.
In the present case, there is no doubt that a physician-
patient relationship existed between respondent doctors
and Jorge Reyes. Respondents were thus duty-bound to use
at least the same level of care that any reasonably
competent doctor would use to treat a condition under the
same circumstances. It is breach14 of this duty which
constitutes actionable malpractice. As to this aspect of
medical malpractice, the determination of the reasonable
level of care and the breach thereof, expert testimony is
essential. Inasmuch as the causes of the injuries involved
in malpractice actions are determinable only in the light of
scientific knowledge, it has
_______________
12 61 Am. Jur. 2d 337, §205 on Physicians, Surgeons, etc.

13 Garcia-Rueda v. Pascasio, 278 SCRA 769, 778 (1997).
14 Id. at 778-779.
770

been recognized that expert testimony is 15usually necessary

to support the conclusion as to causation.
Res Ipsa Loquitur
There is a case when expert testimony may be dispensed

with, and that is under the doctrine
16
of res ipsa loquitur. As
held in Ramos v. Court of Appeals:
Although generally, expert medical testimony is relied upon in

malpractice suits to prove that a physician has done a negligent
act or that he has deviated from the standard medical procedure,
when the doctrine of res ipsa loquitur is availed by the plaintiff,
the need for expert medical testimony is dispensed with because
the injury itself provides the proof of negligence. The reason is
that the general rule on the necessity of expert testimony applies
only to such matters clearly within the domain of medical science,
and not to matters that are within the common knowledge of
mankind which may be testified to by anyone familiar with the
facts. Ordinarily, only physicians and surgeons of skill and
experience are competent to testify as to whether a patient has
been treated or operated upon with a reasonable degree of skill
and care. However, testimony as to the statements and acts of
physicians and surgeons, external appearances, and manifest
conditions which are observable by any one may be given by
nonexpert witnesses.Hence, in cases where the res ipsa loquitur is
applicable, the court is permitted to find a physician negligent
upon proper proof of injury to the patient, without the aid of expert
testimony, where the court from its fund of common knowledge can
determine the proper standard of care. Where common knowledge
and experience teach that a resulting injury would not have
occurred to the patient if due care had been exercised, an inference
of negligence may be drawn giving rise to an application of the
doctrine of res ipsa loquitur without medical evidence, which is
ordinarily required to show not only what occurred but how and
why it occurred. When the doctrine is appropriate, all that the
patient must do is prove a nexus between the particular act or
omission complained of and the injury sustained while under the
custody and management of the defendant without need to produce
expert medical testimony to establish the standard of care. Resort
to res ipsa loquitur is allowed because there is no other way,
under usual and ordinary conditions, by which the patient can
obtain redress for injury suffered by him.
_______________
15 Id. at 200, citing 61 Am. Jur. 2d, 510.

16 G.R. No. 124354, Dec. 29, 1999, 321 SCRA 584.
771
VOL. 341, OCTOBER 3, 2000 771

Thus, courts of other jurisdictions have applied the doctrine in the

following situations: leaving of a foreign object in the body of the
patient after an operation, injuries sustained on a healthy part of
the body which was not under, or in the area, of treatment,
removal of the wrong part of the body when another part was
intended, knocking out a tooth while a patient’s jaw was under
anesthetic for the removal of his tonsils, and loss of an eye while
the patient was under the influence of anesthetic, during or
17
following an operation for appendicitis, among others.
Petitioners asserted in the Court of Appeals that the

doctrine of res ipsa loquitur applies to the present case
because Jorge Reyes was merely experiencing fever and
chills for five days and was fully conscious, coherent, and
ambulant when he went to the hospital. Yet, he died after
only ten hours from the time of his admission.
This contention was rejected by the appellate court.
Petitioners now contend that all requisites for the
application of res ipsa loquitur were present, namely: (1)
the accident was of a kind which does not ordinarily occur
unless someone is negligent; (2) the instrumentality or
agency which caused the injury was under the exclusive
control of the person in charge; and (3) the injury suffered
must not have been due to any 18
voluntary action or
contribution of the person injured.
The contention is without merit. We agree with the
ruling of the Court of Appeals. In the Ramos case, the
question was whether a surgeon, an anesthesiologist, and a
hospital should be made liable for the comatose
19
condition of
a patient scheduled for cholecystectomy. In that case, the
patient was given anesthesia prior to her operation. Noting
that the patient was neurologically sound at the time of her
operation, the Court applied the doctrine of res ipsa
loquitur as mental brain damage does not normally occur
in a gallbladder operation in the absence of negligence of
the anesthesiologist. Taking judicial notice that anesthesia
procedures had become so common that even an ordinary
person could tell if it was administered properly, we
allowed the testimony of a witness who was not an expert.
In this case, while it is true that the patient
_______________
17 Id. (Citations omitted; emphasis added).

18 Petition, p. 9; Rollo, p. 12.
19 The surgical excision of the gallbladder.
772

died just a few hours after professional medical assistance

was rendered, there is really nothing unusual or
extraordinary about his death. Prior to his admission, the
patient already had recurring fevers and chills for five days
unrelieved by the analgesic, antipyretic, and antibiotics
given him by his wife. This shows that he had been
suffering from a serious illness and professional medical
help came too late for him.
Respondents alleged failure to observe due care was not
immediately apparent to a layman so as to justify
application of res ipsa loquitur. The question required
expert opinion on the alleged breach by respondents of the
standard of care required by the circumstances.
Furthermore, on the issue of the correctness of her
diagnosis, no presumption of negligence can be applied to
Dr. Marlyn Rico. As held in Ramos:
. . . . Res ipsa loquitur is not a rigid or ordinary doctrine to be

perfunctorily used but a rule to be cautiously applied, depending
upon the circumstances of each case. It is generally restricted to
situations in malpractice cases where a layman is able to say, as a
matter of common knowledge and observation, that the
consequences of professional care were not as such as would
ordinarily have followed if due care had been exercised. A
distinction must be made between the failure to secure results,
and the occurrence of something more unusual and not ordinarily
found if the service or treatment rendered followed the usual
procedure of those skilled in that particular practice. It must be
conceded that the doctrine of res ipsa loquitur can have no
application in a suit against a physician or a surgeon which
involves the merits of a diagnosis or of a scientific treatment. The
physician or surgeon is not required at his peril to explain why any
particular diagnosis was not correct, or why any particular
scientific treatment did not produce the desired result.20
Specific Acts of Negligence
We turn to the question whether petitioners have

established specific acts of negligence allegedly committed
by respondent doctors.
Petitioners contend that: (1) Dr. Marlyn Rico hastily and

erroneously relied upon the Widal test, diagnosed Jorge’s
illness as ty-
_______________
20 Ramos v. Court of Appeals, supra.
773
VOL. 341, OCTOBER 3, 2000 773

phoid fever, and immediately prescribed

21
the administration
of the antibiotic chloromycetin; and (2) Dr. Marvie Blanes
erred in ordering the administration of the second dose of
500 milligrams of 22 chloromycetin barely three hours after
the first was given. Petitioners presented the testimony of
Dr. Apolinar Vacalares, Chief Pathologist of the Northern
Mindanao Training Hospital, Cagayan de Oro City, who
performed an autopsy on the body of Jorge Reyes. Dr.
Vacalares testified that, based on his findings during the
autopsy, Jorge Reyes did not die of typhoid fever but of
shock undetermined, which could be due to allergic
reaction or chloromycetin overdose. We are not persuaded.
First. While petitioners presented Dr. Apolinar
Vacalares as an expert witness, we do not find him to be so
as he is not a specialist on infectious diseases like typhoid
fever. Furthermore, although he may have had extensive
experience in performing autopsies, he admitted that he
had yet to do one on the body of a typhoid victim at the
time he conducted the postmortem on Jorge Reyes. It is
also plain from his testimony that he has treated only 23
about three cases of typhoid fever. Thus, he testified that:
ATTY. PASCUAL:
Q Why? Have you not testified earlier that you have never
seen a patient who died of typhoid fever?
A In autopsy. But, that was when I was a resident
physician yet.
Q But you have not performed an autopsy of a patient who
died of typhoid fever?
A I have not seen one.
Q And you testified that you have never seen a patient
who died of typhoid fever within five days?
A I have not seen one.
Q How many typhoid fever cases had you seen while you
were in the general practice of medicine?
A In our case we had no widal test that time so we cannot
consider that the typhoid fever is like this and like that.
And the widal test does not specify the time of the
typhoid fever.
_______________
21 Petition, p. 10; Rollo, p. 13.

22 Id. at p. 17.
23 TSN, pp. 33-35, Sept. 20, 1989.
774

Q The question is: how many typhoid fever cases had you
seen in your general practice regardless of the cases now
you practice ?
A I had only seen three cases .
Q And that was way back in 1964 ?
A Way back after my training in UP .
Q Clinically?
A Way back before my training.
He is thus not qualified to prove that Dr. Marlyn Rico erred

in her diagnosis. Both lower courts were therefore correct
in discarding his testimony, which is really inadmissible.
In Ramos, the defendants presented the testimony of a
pulmonologist to prove that brain injury was due to oxygen 24
deprivation after the patient had bronchospasms25
triggered by her allergic response to a drug, and not due
to faulty intubation by the anesthesiologist. As the issue
was whether the intubation was properly performed by an
anesthesiologist, we rejected the opinion of the
pulmonologist on the ground that he was not: (1) an
anesthesiologist who could enlighten the court about
anesthesia practice, procedure, and their complications; nor
(2) an allergologist who could properly advance expert
opinion on allergic mediated processes; nor (3) a
pharmacologist who could explain the pharmacologic and
toxic effects of the drug allegedly responsible for the
bronchospasms.
Second. On the other hand, the two doctors presented by

respondents clearly were experts on the subject. They
vouched for the correctness of Dr. Marlyn Rico’s diagnosis.
Dr. Peter Gotiong, a diplomate whose specialization is
infectious diseases and microbiology and an associate
professor at the Southwestern University College of
Medicine and the Gullas College of Medicine, testified that
he has26
already treated over a thousand cases of typhoid
fever. According to him, when a case of typhoid fever is
suspected,
_______________
24 The constriction of air passages in the lungs by spasmodic

contraction of the bronchial muscles.
25 Thiopental Sodium.
26 TSN, p. 6, Dec. 17, 1990.
775
VOL. 341, OCTOBER 3, 2000 775

27
the Widal test is normally used, and if the 1:320 results of
the Widal test on Jorge Reyes had been presented to him
along with the patient’s history, his impression would
28
also
be that the patient was suffering from typhoid fever. As to
the treatment of the disease,
29
he stated that chloromycetin
was the drug of choice. He also explained that despite the
measures taken by respondent doctors and the intravenous
administration of two doses of chloromycetin, complications
of the disease
30
could not be discounted. His testimony is as
follows:
ATTY. PASCUAL:
Q If with that count with the test of positive for 1 is to
320, what treatment if any would be given?
A If those are the findings that would be presented to me,
the first thing I would consider would be typhoid fever .
Q And presently what are the treatments commonly used?
A Drug of choice of chloramphenical.
Q Doctor, if given the same patient and after you have
administered chloramphenical about 3 1/2 hours later,
the patient associated with chills, temperature—41°C,
what could possibly come to your mind?
A Well, when it is change in the clinical finding, you have
to think of complication.
Q And what will you consider on the complication of
typhoid?
A One must first understand that typhoid fever is toximia.
The problem is complications are caused by toxins
produced by the bacteria . . . whether you have suffered
complications to think of—heart toxic myocardities;
then you can consider a toxic meningitis and other
complications and perforations and bleeding in the
ilium.
Q Even that 40-year old married patient who received
medication of chloromycetin of 500 milligrams
intravenous, after the skin test, and received a second
dose of chloromycetin of 500 miligrams, 3 hours later,
the patient developed chills . . . rise in temperature to
41°C, and then about 40 minutes later the
_______________
27 Id.
28 Id. at 9.
29 Id.
30 Id. at 9-12.
776

temperature rose to 100°F, cardiac rate of 150 per

minute who appeared to be coherent, restless,
nauseating, with seizures: what significance could you
attach to these clinical changes?
A I would then think of toxemia, which was toxic
meningitis and probably a toxic meningitis because of
the high cardiac rate.
Q Even if the same patient who, after having given
intramuscular valium, became conscious and coherent
about 20 minutes later, have seizure and cyanosis and
rolling of eyeballs and vomitting . . . and death: what
significance would you attach to this development?
A We are probably dealing with typhoid to meningitis.
Q In such case, Doctor, what finding if any could you
expect on the post-mortem examination?
A No, the finding would be more on the meninges or
covering of the brain.
Q And in order to see those changes would it require

opening the skull?
A Yes.
As regards Dr. Vacalares’ finding during the autopsy that

the deceased’s gastro-intestinal tract
31
was normal, Dr. Rico
explained that, while hyperplasia in the payer’s patches
or layers of the small intestines is present in typhoid fever,
the same may not always be grossly visible and 32
a
microscope was needed to see the texture of the cells.
Respondents also presented the testimony of Dr. Ibarra
T. Panopio who is a member of the Philippine and
American Board of Pathology, an examiner of the
Philippine Board of Pathology, and chief pathologist at the
MetroCebu Community Hospital, Perpetual Succor
Hospital, and the Andres Soriano Jr. Memorial Medical
Center. He stated that, as a clinical pathologist, he
recognized that the Widal test is used for typhoid patients,
although he did not encourage its use because a single test
would only give a presumption necessitating that the test
be repeated, becoming more 33
conclusive at the second and
third weeks of the disease. He corroborated
_______________
31 An abnormal or unusual increase in the component cells.

32 TSN, p. 12, Dec. 17, 1990.
33 TSN, pp. 37-40, March 8, 1991.
777
VOL. 341, OCTOBER 3, 2000 777

Dr. Gotiong’s testimony that the danger with typhoid fever

is really the possible complications which could develop like
perforation, hemorrhage,
34
as well as liver and cerebral
complications. As regards the 1:320 results of the Widal
test on Jorge Reyes, Dr. Panopio stated that no additional
35
information could be obtained from a higher ratio. He also
agreed with Dr. Gotiong that 36
hyperplasia in the payer’s
patches may be microscopic.
Indeed, the standard contemplated is not what is
actually the average merit among all known practitioners
from the best to the worst and from the most to the least
experienced, but the reasonable
37
average merit among the
ordinarily good physicians. Here, Dr. Marlyn Rico did not
depart from the reasonable standard recommended by the

experts as she in fact observed the due care required under
the circumstances. Though the Widal test is not conclusive,
it remains a standard diagnostic test for typhoid fever and,
in the present case, greater accuracy through repeated
testing was rendered unobtainable by the early death of
the patient. The results of the Widal test and the patient’s
history of fever with chills for five days, taken with the fact
that typhoid fever was then prevalent as indicated by the
fact that the clinic had been getting about 15 to 20 typhoid
cases a month, were sufficient to give upon any doctor of
reasonable skill the impression that Jorge Reyes had
typhoid fever.
Dr. Rico was also justified in recommending the
administration of the drug chloromycetin, the drug of
choice for typhoid fever. The burden of proving that Jorge
Reyes was suffering from any other illness rested with the
petitioners. As they failed to present expert opinion on this,
preponderant evidence to support their contention is
clearly absent.
Third. Petitioners contend that respondent Dr. Marvie
Blanes, who took over from Dr. Rico, was negligent in
ordering the intravenous administration of two doses of 500
milligrams of chloromycetin at an interval of less than
three hours. Petitioners claim that
_______________
34 Id. at 27-30.
35 Id. at 18.
36 Id. at 30.
37 61 Am. Jur. 2d 338.
778

38
Jorge Reyes died of anaphylactic shock or possibly from
overdose as the second dose should have been administered
five to six hours after the first, per instruction of Dr.
Marlyn Rico. As held by the Court of Appeals, however:
That chloromycetin was likewise a proper prescription is best

established by medical authority. Wilson, et al., in Harrison’s
Principle of Internal Medicine, 12th ed. write that chlorampenicol
(which is the generic of chloromycetin) is the drug of choice for
typhoid fever and that no drug has yet proven better in promoting
a favorable clinical response. “Chlorampenicol (Chloromycetin) is

specifically indicated for bacterial meningitis, typhoid fever,
rickettsial infections, bacteriodes infections, etc.” (PIMS Annual,
1994, p. 211) The dosage likewise including the first
administration of five hundred milligrams (500 mg.) at around
nine o’clock in the evening and the second dose at around 11:30 the
same night was still within medically acceptable limits, since the
recommended dose of chloromycetin is one (1) gram every six (6)
hours, (cf. Pediatric Drug Handbook, 1st Ed., Philippine Pediatric
Society, Committee on Therapeutics and Toxicology, 1996). The
intravenous route is likewise correct. (Mansser, O’Nick,
Pharmacology and Therapeutics) Even if the test was not
administered by the physician-on-duty, the evidence introduced
that it was Dra. Blanes who interpreted the results remain
uncontroverted. (Decision pp. 16-17) Once more, this Court rejects
any claim of professional negligence in this regard.
....
As regards anaphylactic shock, the usual way of guarding
against it prior to the administration of a drug, is the skin test of
which, however, it has been observed: “Skin testing with haptenic
drugs is generally not reliable. Certain drugs cause nonspecific
histamine release, producing a weal-and-flare reaction in normal
individuals. Immunologic activation of mast cells requires a
polyvalent allergen, so a negative skin test to a univalent
haptenic drug does not rule out anaphylactic sensitivity to that
drug.” (Terr, “Anaphylaxis and Urticaria” in Basic and Clinical
Immunology, p. 349) What all this means legally is that even if
the deceased suffered from an anaphylactic shock, this, of itself,
would not yet establish
_______________
38 A state of shock resulting from injection or more rarely ingestion of

sensitizing antigen or hapten and due mainly to contraction of smooth muscle and
increased capillary permeability caused by release in the tissues and circulation of
histamine, heparin, and perhaps acetylcholin and serotonin.
779
VOL. 341, OCTOBER 3, 2000 779

the negligence of the appellee-physicians for all that the law

requires of them is that they perform the standard tests and
perform standard procedures. The law cannot require them to
predict every possible reaction to all drugs administered. The
onus probandi was on the appellants to establish, before the trial
court, that the appellee-physicians ignored standard medical
procedure, prescribed and administered medication with

recklessness and exhibited an absence of the competence and
39
skills expected of general practitioners similarly situated.
Fourth. Petitioners correctly observe that the medical

profession is one which, like the business of a common
carrier, is affected with public interest. Moreover, they
assert that since the law imposes upon common carriers
the duty of observing extraordinary diligence in the
vigilance over
40
the goods and for the safety of the
passengers, physicians and surgeons 41
should have the
same duty toward their patients. They also contend that
the Court of Appeals erred when it allegedly assumed that
the level of medical practice is lower in Iligan City, thereby
reducing the standard of care and degree of diligence
required from physicians and surgeons in Iligan City.
The standard of extraordinary diligence is peculiar to
common carriers. The Civil Code provides:
Art. 1733. Common carriers, from the nature of their business and
for reasons of public policy, are bound to observe extraordinary
diligence in the vigilance over the goods and for the safety of the
passengers transported by them, according to the circumstances
of each case. . . .
The practice of medicine is a profession engaged in only by

qualified individuals. It is a right earned through years of
education, training, and by first obtaining a license from
the state through professional board examinations. Such
license may, at any time and for cause, be revoked by the
government. In addition to state regulation, the conduct of
doctors is also strictly governed by the Hippocratic Oath,
an ancient code of discipline and ethical rules which
doctors have imposed upon themselves in recognition and
_______________
39 CA Decision, pp. 5-7; Rollo, pp. 31-33. (Italics supplied)

40 THE CIVIL CODE, ART. 1733.
41 Petition, pp. 19-20; Rollo, pp. 22-23.
780

acceptance of their great responsibility to society. Given

these safeguards, there is no need to expressly require of
doctors the observance of “extraordinary” diligence. As it is
now, the practice of medicine is already conditioned upon

the highest degree of diligence. And, as we have already
noted, the standard contemplated for doctors is simply the
reasonable average merit among ordinarily good
physicians. That is reasonable diligence for doctors or, as
the Court of Appeals called it, the reasonable “skill and
competence . . . that a physician in the same or similar
locality . . . should apply.”
WHEREFORE, the instant petition is DENIED and the
decision of the Court of Appeals is AFFIRMED.
SO ORDERED.
Bellosillo (Chairman), Quisumbing, Buena and De

Leon, Jr., JJ. , concur.
Petition denied, judgment affirmed.
Notes.—Needless to say then, when a physician strays

from his sacred duty and endangers instead the life of his
patient, he must be made to answer therefore. Although
society today cannot and will not tolerate the punishment
meted out by the ancients, neither will it and this Court, as
this case would show, let the act go uncondemned.
(Batiquin vs. Court of Appeals, 258 SCRA 334 [1996])
In malpractice or negligence cases involving the
administration of anaesthesia, the necessity of expert
testimony and the availability of the charge of res ipsa
loquitur to the plaintiff, have been applied in actions
against anaesthesiologists to hold the defendant liable for
the death or injury of a patient under excessive or improper
anaesthesia. (Garcia-Rueda vs. Pascasio, 278 SCRA 769
[1997])
While it may be true that certain circumstances pointed
out by the courts below seemed beyond cavil to constitute
reckless imprudence on the part of the surgeon, such
conclusion is still best arrived at not through the educated
surmises nor conjectures of laymen, including judges, but
by the unquestionable knowledge of expert witnesses. For
whether a physician or surgeon has exercised
781
VOL. 341, OCTOBER 3, 2000 781

Security Bank and Trust Company, Inc. vs. Cuenca
is, in the generality of cases, a matter of expert opinion.

(Cruz vs. Court of Appeals, 282 SCRA 188 [1997])
——o0o——
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2/28/2021 SUPREME COURT REPORTS ANNOTATED VOLUME 341

760 SUPREME COURT REPORTS ANNOTATED

LEAH ALESNA REYES, ROSE NAHDJA, JOHNNY, and

Medical Malpractice; Elements; Words and Phrases; Medical

VOL. 341, OCTOBER 3, 2000 761