Que vs. Philippine Heart Center

A physician is not liable for medical malpractice where expert evidence shows that the patient's death was an inherent risk of the chosen procedure, the physician disclosed the material risks, and the patient gave valid informed consent; bare allegations of a defective device do not establish proximate causation.

Quintin Que, Elpidio Que's father, consulted Dr. Aventura, Head of the Department of Surgery at the PHC, for an aortic arch aneurysm. The PHC is governed by Presidential Decree No. 673, which allows it to invite foreign heart specialists and similar experts in various medical fields to train the personnel, trainees, or residents of the PHC.

In May 1999, Quintin Que was brought to Dr. Avelino P. Aventura, Head of the Department of Surgery at the Philippine Heart Center, for medical consultation because of an aneurysm in the aortic arch that affected Quintin's vocal cords. Dr. Aventura advised Quintin to undergo a spinal CT scan at the Makati Medical Center; the CT scan confirmed the aneurysm and showed that it would require open-method surgery since it could burst and be fatal. Dr. Aventura also advised Quintin to undergo an angiogram and aortogram at the PHC. In June 1999, Quintin underwent the angiogram and aortogram, and Dr. Aventura performed a three-vessel coronary aorta bypass surgery on him. Dr. Aventura told the Que family that an open-method surgery would be performed after a month, depending on Quintin's condition. Quintin was thereafter discharged and had regular check-ups with Dr. Aventura, who updated the family about Quintin's progress and the need for open-method surgery.

Sometime in October 1999, Dr. Aventura recommended a new non-invasive treatment for an aneurysm, a "state-of-the-art" procedure using a custom-built gadget called a stent, as an alternative to open-method surgery. The Que family had reservations, but Dr. Aventura assured them that the operation would be less risky than the traditional open-method surgery because there was less risk of bleeding or rupture of the aneurysm and a smaller chance of paralysis. The family eventually decided to proceed because Dr. Aventura told them that Quintin's aneurysm was fatal and the stenting procedure was "virtually risk-free." According to Dr. Aventura, however, after the successful bypass operation in June 1999, he advised Quintin on July 19, 1999 to return for a follow-up check-up after a month for his aneurysm, but Quintin returned only after three months, on October 27, 1999. By then, Dr. Aventura observed that Quintin's hoarseness had worsened, indicating that the aneurysm had grown. He reiterated that the aneurysm put Quintin's life at risk and gave the family two options, which, like any other medical procedure, had no guarantee of success: aneurysmectomy and replacement, a rigorous operation requiring the chest to be reopened and the adhesions from the triple bypass to be removed; or endovascular stenting, a less invasive procedure where the chest need not be reopened but which would expose Quintin to the risk of death. Dr. Aventura emphasized that he would not be the one to do the procedure. Quintin expressed interest in stenting, and after being informed of the risks and introduced to Dr. Verhoeven, Quintin consented to the stenting procedure.

Quintin was admitted to the PHC on February 12, 2000. On the scheduled operation on February 14, 2000, Dr. Aventura introduced Dr. Eric Verhoeven to the Que family as the Belgian doctor specializing in stenting procedures. With Dr. Verhoeven was Daphne Sim, who was introduced as a product specialist of Medtronic International Limited of Singapore, the distributor in Asia of World Medical Mfg. Corporation of Florida, United States of America, the manufacturer of the Talent brand of stent graft system to be used on Quintin. Three representatives from FAMED were also present, and FAMED was introduced as the Philippine distributor of Talent. Dr. Verhoeven showed the Que family a long catheter and three stents labeled "Quintin Que" and "Custom Built." He announced the system product as state-of-the-art and said it would be the first time it would be used in Asia. He demonstrated how the stents would be deployed into Quintin's body, remarking that it would be his first time to deploy a stent into a curve like the aortic arch. Quintin signed the Consent for Endovascular Stenting and the Consent to Operation, Administration of Anesthesia, and the Rendering of Other Medical Services. At noon, Dr. Verhoeven came out of the operating room "looking sad and tired." When the Que family inquired about the result, he responded that he could not complete the operation because he could not go through the bend or curve where the stent should have been deployed, and the device on hand was "faulty." According to Dr. Aventura, Dr. Verhoeven performed the procedure in the presence of Dr. Aventura, Dr. Juvenal Quitiquit, Dr. Ramon Ribu, and other medical staff of the PHC; Dr. Verhoeven was unable to deploy the stent in the desired location despite three attempts, and Quintin eventually suffered a brain infarction. Dr. Aventura said this was possibly caused by manipulating the device to place the stent, one of the risks involved in stenting that could have been the result even if the stent had been successfully placed, and that he could not interfere with Dr. Verhoeven because he was not the surgeon operating on Quintin and had no experience in stenting.

Quintin never woke up and suffered a stroke after the incomplete stenting procedure. From February 15, 2000 until Quintin's death on February 27, 2000, the Que family constantly communicated with Dr. Aventura, but he "turned his back" on them. Suspecting that human error caused Quintin's death, the family had Quintin's body autopsied by Dr. Raquel B. Del Rosario-Fortun, who issued a Report stating that "Autopsy findings show multiple hemorrhagic infarcts of the brain due to thrombotic/atheromatous emboli probably arising from the aortic aneurysm and triggered by the catheterization. Based on available information on the circumstances surrounding death and the autopsy findings, death is due to complications of hypertensive atherosclerotic cardiovascular disease and the manner of death is therefore classified as natural." The Que family also discovered that Dr. Verhoeven was not qualified or admitted to practice medicine in the Philippines. On March 18, 2002, Elpidio filed a Complaint for Damages against the PHC, FAMED, Medtronic, Dr. Aventura, and Dr. Verhoeven.

The trial court found that Dr. Aventura openly disclosed to the Que family that he was not a specialist in stenting and that a foreign doctor specializing in stenting would perform the procedure on Quintin. It also found that Quintin signed the two consent forms and that Elpidio did not categorically dispute the veracity of Quintin's signature. The trial court noted the autopsy report's classification of the death as natural and due to complications of hypertensive atherosclerotic cardiovascular disease, and found that Elpidio failed to show that FAMED participated in the stent used on Quintin or had a hand in manufacturing it even if the stent was faulty. The CA also noted that the parties stipulated during pre-trial that stenting as the "new non-invasive approach" has been used in the United States and Europe and entails "much less risk."

• Informed Consent and Risk Disclosure: Elpidio argued that Dr. Aventura assured the Que family that the stenting procedure was "virtually risk-free" and that the family was not informed of the risks inherent in the procedure; had they known Quintin would die, they would not have agreed to it.
• Medical Negligence and Proximate Cause: Elpidio maintained that the collective negligence of respondents was the proximate cause of Quintin's death and that the lower court erred in ruling that neither medical negligence nor medical malpractice was sustainable and that the stent/stenting procedure was not the proximate cause.
• Validity of Consent Forms: Elpidio questioned the validity and authenticity of the consent forms allegedly signed by Quintin because they did not bear the signature of a witness.
• FAMED and the Faulty Stent: Elpidio posited that FAMED was responsible for the faulty stent that it distributed without approval for use by the United States Food and Drug Administration.
• Autopsy and Expert Evidence: Elpidio argued that the lower court erred in disregarding the autopsy report and the expert testimony of Dr. Raquel B. Del Rosario-Fortun, who personally conducted the autopsy, and in relying on Dr. Peter R. Figueroa, who was a friend and colleague of Dr. Aventura and had no personal knowledge of the facts and circumstances surrounding Quintin's death.

• Rule 45 and Factual Questions: The PHC countered that the Petition should be dismissed for raising factual questions outside the SC's jurisdiction under a Rule 45 petition; Dr. Aventura echoed that the Petition presented issues of fact not proper in a Rule 45 petition for review.
• Medical Negligence: The PHC averred that the CA and the trial court correctly held that there was no medical negligence or liability for damages because Quintin's death was one of the risks involved in a stenting procedure, not because of the negligence of respondents; Dr. Aventura insisted that the trial and appellate courts properly found him innocent of medical malpractice.
• Due Diligence and Good Faith: Dr. Aventura maintained that he acted with due diligence, care, and utmost good faith in treating Quintin.

• Rule 45 and Questions of Fact: Whether the Petition raises questions of fact that are outside the scope of a Rule 45 petition for review on certiorari.
• Medical Negligence: Whether respondents are liable for medical negligence or malpractice for Quintin's death.
• Informed Consent: Whether Dr. Aventura validly disclosed the material risks of the stenting procedure and obtained Quintin's informed consent.
• Res Ipsa Loquitur: Whether the doctrine of res ipsa loquitur applies to establish negligence.
• Dr. Verhoeven's Authority: Whether the PHC and Dr. Aventura were negligent in allowing Dr. Verhoeven to operate on Quintin.
• FAMED and the Stent: Whether FAMED is liable for the allegedly faulty stent used on Quintin.

• Rule 45 and Questions of Fact: No. The consent forms and the "faultiness" of the stent are factual matters beyond the SC's power of review under Rule 45, which permits only questions of law.
• Medical Negligence: No. Respondents are not liable for medical negligence; expert evidence showed that Quintin's stroke and death were inherent risks of stenting and not the proximate result of Dr. Aventura's acts or omissions.
• Informed Consent: Yes. Dr. Aventura disclosed the material risks, including death, and that another physician would perform the procedure; Quintin signed the consent forms, and the lack of witness signatures did not invalidate them.
• Res Ipsa Loquitur: No. The doctrine does not apply because the cause of Quintin's death was an inherent risk of the stenting procedure, not an accident that ordinarily occurs only through negligence.
• Dr. Verhoeven's Authority: No. Section 5 of Presidential Decree No. 673 allows the PHC to invite foreign heart specialists and similar experts, and a certification listed Dr. Verhoeven as one of the experts in his field to have operated in the PHC.
• FAMED and the Stent: No. Elpidio failed to prove that the stent was defective or that FAMED caused any defect; bare allegations are not proof.

• Rule 45 and Questions of Fact: Under Rule 45, a petition for review on certiorari shall only raise questions of law; the SC is not a trier of facts and does not analyze and weigh evidence already passed upon by the lower courts. A question of law arises when there is doubt as to the applicable law and jurisprudence on a certain set of facts and its resolution does not involve an examination of the probative value of the evidence; a question of fact exists when there is controversy as to the truth or falsity of the alleged facts. Elpidio asked the SC to evaluate anew the consent forms signed by Quintin and the "faultiness" of the stent used during the operation; these are factual matters beyond the SC's power of review under Rule 45. On this basis alone, the Petition should be dismissed. Nonetheless, the SC found no reason to depart from the trial court's ruling, as affirmed by the CA.
• Medical Negligence: Medical malpractice is a particular form of negligence consisting in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill ordinarily employed by the profession generally, under similar conditions, and in like surrounding circumstances. A medical professional has the duty to observe the standard of care and exercise the degree of skill, knowledge, and training ordinarily expected of other similarly trained medical professionals acting under the same circumstances; a breach of the accepted standard of care constitutes negligence or malpractice and renders the defendant liable for the resulting injury to his patient. To successfully pursue such a claim, a patient must prove that the physician or surgeon either failed to do something that a reasonably prudent physician or surgeon would have done or did something that a reasonably prudent physician or surgeon would not have done and that the failure or action caused injury to the patient. Here, Dr. Aventura informed the Que family, most especially Quintin, of the material risks inherent in the stenting procedure, including death, and informed them that another physician would operate because he did not specialize in stenting. The trial court found that Dr. Aventura openly disclosed that he was not a specialist in stenting and that a foreign doctor specializing in stenting would perform the procedure; his qualifications were admitted, and jurisprudence provides that when the qualifications of a physician are admitted, there is a presumption that in proper cases he takes the necessary precautions and employs the best of his knowledge and skill in attending to his clients. Expert witnesses Dr. Tuazon and Dr. Figueroa, both experts in cardiovascular and endovascular surgery, testified that stenting was the sound medical advice and treatment for Quintin rather than open-method surgery considering his underlying condition, and that the stroke and death were inherent risks of the stenting procedure. Dr. Figueroa testified that Quintin did not die from the stenting per se directo but from complications during the procedure, and that even if the stent had been successfully deployed, Quintin would have had a cerebrovascular accident because the catheter manipulation could dislodge cholesterol clots. Elpidio failed to present an expert witness to refute Dr. Tuazon and Dr. Figueroa; Dr. Fortun, as a forensic pathologist, could not qualify as an expert witness to determine whether Dr. Aventura exercised the norm observed by other reasonably competent members of the profession, because the expert witness must be a similarly trained and experienced physician. Thus, the preponderance of evidence tilted in favor of respondents, and negligence was not the proximate cause of Quintin's death.
• Informed Consent: In a lack of informed consent litigation, the plaintiff must prove the following: (1) the physician had a duty to disclose material risks; (2) the physician failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to the treatment they otherwise would not have consented to; and (4) the patient was injured by the proposed treatment. The SC explained the doctrine of informed consent in Li vs. Spouses Soliman: a physician has a duty to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care would disclose to his patient as to whatever grave risks of injury might be incurred from a proposed course of treatment, so that the patient may intelligently exercise judgment by reasonably balancing the probable risks against the probable benefits; the scope of disclosure is measured by the patient's need, and the test for determining whether a potential peril must be divulged is its materiality to the patient's decision; there must be a causal relationship between the physician's failure to divulge and damage to the patient, and such connection arises only if it is established that, had revelation been made, consent to treatment would not have been given. Here, Dr. Aventura informed the Que family of the material risks inherent in the stenting procedure, including death, and informed them that another physician would operate because he did not specialize in stenting. Quintin signed the Consent for Endovascular Stenting and the Consent to Operation, Administration of Anesthesia, and the Rendering of Other Medical Services; Elpidio did not categorically dispute the veracity of Quintin's signature, and absent proof that the signature was forged or that Quintin was incapable of giving intelligent consent when he signed the two documents, the SC upheld the validity of the consent forms. Accordingly, the lack of signatures of witnesses was irrelevant.
• Res Ipsa Loquitur: The doctrine of res ipsa loquitur, translated as "the thing speaks for itself," requires the concurrence of the following elements: (1) the accident was of a kind that 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 charged with negligence; and (3) the injury suffered must not have been due to any voluntary action or contribution from the injured person. The cause of Quintin's death was not due to the negligence of Dr. Aventura but was due to one of the inherent risks of the stenting procedure; thus, the doctrine does not apply.
• Dr. Verhoeven's Authority: Section 5 of Presidential Decree No. 673 allows the PHC to "invite foreign heart specialists and similar experts in the various medical fields to train the personnel or trainees or residents of the [PHC]." Dr. Ludgerio D. Torres, former director of the PHC, issued a Certification dated January 25, 2013, listing Dr. Verhoeven as one of the experts in his field to have operated in the PHC. Thus, there was no fault or negligence on the part of the answering defendants in allowing Dr. Verhoeven to operate on Quintin.
• FAMED and the Stent: The SC could not subscribe to Elpidio's claim that the "faulty" stent hastened the death of his father. Bare allegations are not proof. The trial court noted that other than the testimonies of Elpidio and his sister, Elisa Que, the records do not show how faulty the stent used on Quintin was. Dr. Verhoeven's purported statement that the stent was "faulty" was not enough, as there was no other evidence to ascertain the existence of the defect. Besides, the expert witnesses testified that even if the stent had been successfully deployed, Quintin would have had a cerebrovascular accident. Thus, no liability could be attributed to FAMED.

• Medical malpractice — A particular form of negligence consisting in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and skill ordinarily employed by the profession generally, under similar conditions, and in like surrounding circumstances. The patient must prove that the physician either failed to do something a reasonably prudent physician would have done or did something a reasonably prudent physician would not have done, and that the failure or action caused injury. The SC applied this rule and found no breach because expert evidence showed Dr. Aventura met the standard and Quintin's death was an inherent risk of stenting.
• Informed consent — A physician has a duty to disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care would disclose as to grave risks of injury that might be incurred from a proposed course of treatment, so that the patient may intelligently exercise judgment by balancing probable risks against probable benefits. In a lack of informed consent litigation, the plaintiff must prove: (1) the physician had a duty to disclose material risks; (2) the physician failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to the treatment they otherwise would not have consented to; and (4) the patient was injured by the proposed treatment. The SC applied this rule and upheld the consent forms because Dr. Aventura disclosed material risks including death and Quintin signed the forms; lack of witness signatures was irrelevant.
• Proximate cause — That which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, without which the result would not have occurred. An injury or damage is proximately caused by an act or failure to act whenever it appears from the evidence that the act or omission played a substantial part in bringing about or actually causing the injury or damage and that the injury or damage was either a direct result or a reasonably probable consequence of the act or omission. The SC applied this rule and found that Quintin's death was an inherent risk of stenting, not the proximate result of negligence.
• Res ipsa loquitur — "The thing speaks for itself." The doctrine requires: (1) the accident was of a kind that 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 charged with negligence; and (3) the injury suffered must not have been due to any voluntary action or contribution from the injured person. The SC applied this rule and held the doctrine inapplicable because the cause of death was an inherent risk of the procedure, not negligence.
• Question of law vs. question of fact under Rule 45 — A Rule 45 petition for review on certiorari shall only raise questions of law; the SC is not a trier of facts. A question of law arises when there is doubt as to the applicable law and jurisprudence on a certain set of facts and its resolution does not involve an examination of the probative value of the evidence; a question of fact exists when there is controversy as to the truth or falsity of the alleged facts. The SC applied this rule and held that the consent forms and the faultiness of the stent were factual matters outside Rule 45.
• Expert witness qualification in medical negligence — The expert witness must be a similarly trained and experienced physician. A forensic pathologist is not qualified to testify as to whether a physician exercised the norm observed by other reasonably competent members of the profession. The SC applied this rule and held that Dr. Fortun was not qualified to testify on the standard of care required of Dr. Aventura.
• Presumption of physician skill — When the qualifications of a physician are admitted, there is a presumption that in proper cases he takes the necessary precautions and employs the best of his knowledge and skill in attending to his clients. The SC applied this rule in favor of Dr. Aventura, whose qualifications were not rebutted.
• Bare allegations are not proof — A claim must be supported by evidence; mere allegations do not establish a fact. The SC applied this rule and rejected Elpidio's claim that the stent was faulty and hastened Quintin's death.

• "A medical professional has the duty to observe the standard of care and exercise the degree of skill, knowledge, and training ordinarily expected of other similarly trained medical professionals acting under the same circumstances. A breach of the accepted standard of care constitutes negligence or malpractice and renders the defendant liable for the resulting injury to his patient." — This defines the standard of care and the basis for medical malpractice liability, which the SC applied to find no breach by Dr. Aventura.
• "In a lack of informed consent litigation, the plaintiff must prove the following: (1) the physician had a duty to disclose material risks; (2) the physician failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to the treatment they otherwise would not have consented to; and (4) the patient was injured by the proposed treatment." — This sets out the requisites for an informed consent claim, which the SC applied in upholding the consent forms.
• "The doctrine requires the concurrence of the following elements: (1) the accident was of a kind that 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 charged with negligence; and (3) the injury suffered must not have been due to any voluntary action or contribution from the injured person." — This states the elements of res ipsa loquitur, which the SC held inapplicable because the death was an inherent risk of stenting.
• "Bare allegations are not proof." — This is the SC's basis for rejecting Elpidio's claim that the stent was faulty and hastened Quintin's death.

• Borromeo vs. Family Care Hospital, Inc., 779 Phil. 1 (2016) — Followed; quoted the standard of care for medical professionals and breach as negligence or malpractice.
• Li vs. Spouses Soliman, 666 Phil. 29 (2011) — Followed; explained the doctrine of informed consent, including materiality and causal relationship.
• Cayao-Lasam vs. Spouses Ramolete, 595 Phil. 56 (2008) — Followed; defined medical malpractice and proximate cause.
• Ramos vs. Court of Appeals, 378 Phil. 1198 (1999) — Followed; held a pulmonologist not qualified to testify on the standard of care of an anesthesiologist.
• Reyes vs. Sisters of Mercy Hospital, 396 Phil. 87 (2000) — Followed; held an autopsy expert not qualified to testify as a specialist in infectious diseases.
• Child Learning Center Inc. vs. Tagorio, 512 Phil. 618 (2005) — Followed; enumerated the elements of res ipsa loquitur.
• De Jesus vs. Uyloan, 919 Phil. 878 (2022) — Followed; stated the proof required to pursue a medical negligence claim.
• Far Eastern Surety and Insurance Co., Inc. vs. People, 721 Phil. 760 (2013) — Followed; distinguished a question of law from a question of fact.

• Rule 45, Rules of Court — A petition for review on certiorari shall only raise questions of law; applied to reject Elpidio's factual challenges to the consent forms and the faultiness of the stent.
• Section 5, Presidential Decree No. 673 — Allows the PHC to invite foreign heart specialists and similar experts in various medical fields to train the personnel, trainees, or residents of the PHC; applied to hold that Dr. Verhoeven was authorized to operate in the PHC.

• Justice Leonen (Concurring) — Separate opinion; its text is not included.