Medical Negligence, what do you need to prove for your action to prosper?

Dr. Fernando P. Solidum vs. People, G.R. No. 192123, 10 March 2014, gives the requisites for an action based on medical negligence, whether civil, criminal, or administrative, to prosper.

Specifically, the Supreme Court explained that it is necessary to prove by competent evidence the following elements:

1. the duty owed by the physician to the patient, as created by the physician-patient relationship, to act in accordance with the specific norms or standards established by his profession (standards of care);
2. the breach of duty by the physician's failing to act in accordance with the applicable standard of care;
3. the causation (i.e., there must be a reasonably close and casual connection between the negligent act or omission and the resulting injury); and
4. the damages suffered by the patient.

Standard of care, in the medical profession, refers to the specific norms or standards to protect the patient against unreasonable risk. As noted by the Supreme Court itself, no clear definition of the duty of a particular physician in a particular case exists and this standard must be determined in every case, with the judge weighing the testimonies of experts on both sides to ultimately determine the standard, as the trier of fact.

The discussion of the Supreme Court, which I find very clear, is quoted below for reference, thus -

"An action upon medical negligence — whether criminal, civil or administrative — calls for the plaintiff to prove by competent evidence each of the following four elements, namely: (a) the duty owed by the physician to the patient, as created by the physician-patient relationship, to act in accordance with the specific norms or standards established by his profession; (b) the breach of the duty by the physician's failing to act in accordance with the applicable standard of care; (3) the causation, i.e., there must be a reasonably close and causal connection between the negligent act or omission and the resulting injury; and (4) the damages suffered by the patient.

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." (Emphasis and underscoring supplied)

As can be seen from above, in Dr. Fernando P. Solidum, the prosecution was not able to prove the foregoing requisites beyond reasonable doubt, as it did not even establish the first three elements, namely, the duty on the part of Dr. Solidum to his patient; Dr. Solidum's breach thereof by failing to act in accordance with the standard of care appropriate for his particular profession in that particular situation; and the causation between Dr. Solidum's alleged negligent act and the untimely demise of the patient.

The Supreme Court thus reversed both the Court of Appeals and the trial court and acquitted Dr. Solidum of all charges.

x x x x x x

Note that, as an exception to the foregoing, the Supreme Court explained that in some cases of medical negligence, the doctrine of res ipsa loquitur is applicable.

The Supreme Court recognized that there are certain cases which are such of a character as to justify an inference of negligence as the cause for that harm. In these case, expert testimony on the standard of care applicable is not necessary, especially "when common knowledge and experience teach that a resulting injury would not have occurred to the patient if due care has been exercised" (citing Ramos vs. Court of Appeals, G.R. No. 124354, 29 December 1999)

The doctrine of res ipsa loquitur, however, while recognized, should be applied cautiously and depends upon the circumstances of each case.

I am quoting again the discussion of the Supreme Court on this doctrine, as it presents an important caveat on the applicability of the said doctrine to medical malpractice cases, to wit -

"Medical malpractice cases do not escape the application of this doctrine. Thus, res ipsa loquitur has been applied when the circumstances attendant upon the harm are themselves of such a character as to justify an inference of negligence as the cause of that harm. The application of res ipsa loquitur in medical negligence cases presents a question of law since it is a judicial function to determine whether a certain set of circumstances does, as a matter of law, permit a given inference. 

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, 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. 

Nevertheless, despite the fact that the scope of res ipsa loquitur has been measurably enlarged, it does not automatically apply to all cases of medical negligence as to mechanically shift the burden of proof to the defendant to show that he is not guilty of the ascribed negligence. 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 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. Thus, res ipsa loquitur is not available in a malpractice suit if the only showing is that the desired result of an operation or treatment was not accomplished. The real question, therefore, is whether or not in the process of the operation any extraordinary incident or unusual event outside of the routine performance occurred which is beyond the regular scope of customary professional activity in such operations, which, if unexplained would themselves reasonably speak to the average man as the negligent cause or causes of the untoward consequence. If there was such extraneous intervention, the doctrine of res ipsa loquitur may be utilized and the defendant is called upon to explain the matter, by evidence of exculpation, if he could." (citing Ramos vs. Court of Appeals, G.R. No. 124354, 29 December 1999; emphasis and underscoring supplied)