Proving medical malpractice
A medical malpractice case against a doctor is a generic term for what may technically be an administrative complaint, a civil suit for damages (under Article 2176 of the Civil Code), a criminal case (under Article 365 of the Revised Penal Code), or all three.
How is medical malpractice proven? Conversely, how does a doctor defend herself from such a charge?
Jurisprudence on the Liabilities of Doctors
The rulings of the Supreme Court on the liabilities of doctors outline how to prove medical malpractice or negligence. They lay down the standards of evidence for proving whether a complaint for medical malpractice should be upheld or dismissed.
For one, the mere fact of an unfortunate or even tragic outcome is often insufficient proof of a doctor’s negligence.
In 1997, the Supreme Court affirmed that:
Doctors are protected by a special rule of law. They are not guarantors of care. They do not even warrant a good result. They are not insurers against mishaps or unusual consequences. Furthermore they are not liable for honest mistakes of judgment . . .
Dr. Ninevetch Cruz vs. Court of Appeals and Lydia Umali, G.R. No. 122445, November 18, 1997
Other cases show how a medical malpractice case is proven. We see from these cases that Courts tend to defer to evidence presented by experts — medical physicians or surgeons — about whether the actions of a doctor were in line with professional standards and practices.
The type of lawsuit which has been called medical malpractice or, more appropriately, medical negligence, is that type of claim which a victim has available to him or her to redress a wrong committed by a medical professional which has caused bodily harm. In order to successfully pursue such a claim, a patient must prove that a health care provider, in most cases a physician, either failed to do something which a reasonably prudent health care provider would have done, or that he or she did something that a reasonably prudent provider would not have done; and that that failure or action caused injury to the patient.
This Court has recognized that medical negligence cases are best proved by opinions of expert witnesses belonging in the same general neighborhood and in the same general line of practice as defendant physician or surgeon. The deference of courts to the expert opinion of qualified physicians stems from the former’s realization that the latter possess unusual technical skills which laymen in most instances are incapable of intelligently evaluating, hence the indispensability of expert testimonies.
Dr. Rubli Li vs. Spouses Soliman, G.R. No. 165279, June 7, 2011
Whether or not a physician has committed an “inexcusable lack of precaution” in the treatment of his patient is to be determined according to the standard of care observed by other members of the profession in good standing under similar circumstances bearing in mind the advanced state of the profession at the time of treatment or the present state of medical science. In the recent case of Leonila Garcia-Rueda v. Wilfred L. Pascasio, et al., this Court stated that in accepting a case, a doctor in effect represents that, having the needed training and skill possessed by physicians and surgeons practicing in the same field, he will employ such training, care and skill in the treatment of his patients. He therefore has a duty to use at least the same level of care that any other reasonably competent doctor would use to treat a condition under the same circumstances. It is in this aspect of medical malpractice that expert testimony is essential to establish not only the standard of care of the profession but also that the physician’s conduct in the treatment and care falls below such standard. Further, 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.
Dr. Ninevetch Cruz vs. Court of Appeals and Lydia Umali, G.R. No. 122445, November 18, 1997
Proof of Medical Malpractice
As a rule, Courts do not favor mere allegations as proof of liability. More is required for proof.
What this means in practice is that, in order to prove a case of medical malpractice against a doctor, evidence of these medical, professional standards need to be presented in Court. A layman’s evidence is not enough. The evidence required typically takes the form of testimony by other doctors in the same or related fields of practice, and of medical literature and regulations have duly proven before the Court. Evidence should also be presented to prove that the doctor failed to abide by these standards. Absent these, a finding of liability can be difficult to sustain.
Conversely, a doctor defending herself from a complaint of medical malpractice or negligence would be well advised to show proof of the standards and particular procedures required by the situation. She should present proof that she followed these standards of care.
An Exception to the Rule of Evidence Against a Doctor (Res Ipsa Loquitur)
There is, however, a strain of Supreme Court rulings which have held a doctor liable for negligence even without medical experts or evidence presented against a defendant doctor.
In these cases, simply the fact of the injury was proven and from this the Court inferred that the doctor is liable for negligence. To do this, the Supreme Court applied the rule of evidence known as res ipsa loquitur, whereby “the thing speaks of itself”. In such cases,
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 anyone 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, 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.
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-plaintiff was under the influence of anesthetic, during or following an operation for appendicitis, among others.
Ramos vs. Court of Appeals, G.R. No. 124354, December 29, 1999, 321 SCRA 584, 599, cited in DR. FERNANDO P. SOLIDUM vs. PEOPLE OF THE PHILIPPINES, G.R. No. 192123, March 10, 2014.
But it must be borne in mind that the application of the res ipsa loquitur doctrine in medical malpractice cases is an exception to the general rule that evidence from medical experts should be presented to prove a doctor’s liability.
Three Conditions for Res Ipsa Loquitur to Apply
In the same case of Dr. Fernando P. Solidum vs. People of the Philippines, the Supreme Court ruled that in order for res ipsa loquitur to apply, three essential requisites must be present:
In order to allow resort to the doctrine, therefore, the following essential requisites must first be satisfied, to wit: (1) the accident was of a kind that does not ordinarily occur unless someone is negligent; (2) the instrumentality or agency that caused the injury was under the exclusive control of the person charged; and (3) the injury suffered must not have been due to any voluntary action or contribution of the person injured.
Because of the complexity inherent in many medical cases, a Court would often be at sea in determining whether these conditions all exist in a given case, thus requiring recourse to expert medical testimony.
Indeed, in Dr. Solidum, the Supreme Court ruled against relying on res ipsa loquitur and, ultimately, acquitted Dr. Solidum of both criminal and civil liability because the balance of evidence was not against him.
In the medical profession, specific norms or standards to protect the patient against unreasonable risk, commonly referred to as standards of care, set the duty of the physician to act in respect of the patient. Unfortunately, no clear definition of the duty of a particular physician in a particular case exists. Because most medical malpractice cases are highly technical, witnesses with special medical qualifications must provide guidance by giving the knowledge necessary to render a fair and just verdict. As a result, the standard of medical care of a prudent physician must be determined from expert testimony in most cases; and in the case of a specialist (like an anesthesiologist), the standard of care by which the specialist is judged is the care and skill commonly possessed and exercised by similar specialists under similar circumstances. The specialty standard of care may be higher than that required of the general practitioner.
The standard of care is an objective standard by which the conduct of a physician sued for negligence or malpractice may be measured, and it does not depend, therefore, on any individual physician’s own knowledge either. In attempting to fix a standard by which a court may determine whether the physician has properly performed the requisite duty toward the patient, expert medical testimony from both plaintiff and defense experts is required. The judge, as the trier of fact, ultimately determines the standard of care, after listening to the testimony of all medical experts.
Here, the Prosecution presented no witnesses with special medical qualifications in anesthesia to provide guidance to the trial court on what standard of care was applicable. It would consequently be truly difficult, if not impossible, to determine whether the first three elements of a negligence and malpractice action were attendant.
These are considerations to keep in mind when preparing for a medical malpractice case.
The diligence with which the proper standards of care are presented to the tribunal, and the evidence showing how well these standards were followed, are usually determinative of the case.