Rosit vs. Davao Doctors Hospital and Dr. Rolando G. Gestuvo

In a medical negligence case, the doctrine of res ipsa loquitur may dispense with expert medical testimony where the injury itself provides proof of negligence, and a physician breaches the doctrine of informed consent when he withholds material information about available alternative treatment that would have altered the patient's decision to undergo the procedure. An affidavit of a physician who never took the witness stand is hearsay and cannot be considered as expert testimony.

Nilo B. Rosit was a patient at Davao Doctors Hospital, where he was referred to Dr. Rolando G. Gestuvo, a specialist in mandibular injuries, after a motorcycle accident. The dispute concerns the surgical management of Rosit's fractured jaw. Philippine law recognizes medical negligence as a claim for bodily harm caused by a medical professional, requiring proof of duty, breach, injury, and proximate causation, with expert testimony generally required except when res ipsa loquitur applies; the doctrine of informed consent imposes on physicians a duty to disclose material risks and alternatives.

On January 15, 1999, Nilo B. Rosit figured in a motorcycle accident. The X-ray taken the next day at Davao Doctors Hospital showed that he fractured his jaw. Rosit was referred to Dr. Rolando G. Gestuvo, a specialist in mandibular injuries, who operated on him on January 19, 1999.

During the operation, Dr. Gestuvo used a metal plate fastened to the jaw with metal screws to immobilize the mandible. Because the operation required the smallest screws available, Dr. Gestuvo cut the screws on hand to make them smaller. He knew that smaller titanium screws were available in Manila but did not inform Rosit, supposing that Rosit would not be able to afford them.

Following the procedure, Rosit could not properly open and close his mouth and was in pain. X-rays done two days after the operation showed that the fracture in his jaw was aligned but the screws used touched his molar. Given the X-ray results, Dr. Gestuvo referred Rosit to a dentist. The dentist who checked Rosit, Dr. Pangan, opined that another operation was necessary and that it was to be performed in Cebu.

Alleging that the dentist told him that the operation conducted on his mandible was improperly done, Rosit went back to Dr. Gestuvo to demand a loan to defray the cost of the additional operation as well as the expenses of the trip to Cebu. Dr. Gestuvo gave Rosit P4,500. Rosit went to Cebu on February 19, 1999, still suffering from pain and could hardly open his mouth. In Cebu, Dr. Pangan removed the plate and screws installed by Dr. Gestuvo and replaced them with smaller titanium plate and screws. Dr. Pangan also extracted Rosit's molar that was hit with a screw and some bone fragments. Three days after the operation, Rosit was able to eat and speak well and could open and close his mouth normally.

On his return to Davao, Rosit demanded that Dr. Gestuvo reimburse him for the cost of the operation and the expenses he incurred in Cebu amounting to ₱140,000, as well as for the ₱50,000 that Rosit would have to spend for the removal of the plate and screws that Dr. Pangan installed. Dr. Gestuvo refused to pay. Rosit then filed a civil case for damages and attorney's fees with the RTC against Dr. Gestuvo and DDH.

The CA, in reversing the RTC, found that post-operative pain is not unusual after surgery; that there was no proof the molar Dr. Pangan removed was the same molar hit by Dr. Gestuvo's screw; that the second operation was conducted within the five-week usual healing period of the mandibular fracture; and that the X-ray examination prior to the first surgery suggested chronic inflammatory lung disease compatible, implying the injury may have been due to Rosit's peculiar condition.

• Res Ipsa Loquitur: Whether the Court of Appeals correctly ruled that the doctrine of res ipsa loquitur is inapplicable and that expert medical testimony is necessary to establish Dr. Gestuvo's negligence.
• Informed Consent: Whether Dr. Gestuvo breached the doctrine of informed consent by failing to disclose the availability of smaller titanium screws and the risks of using larger screws.
• Admissibility of Dr. Pangan's Affidavit: Whether the Court of Appeals erred in relying on Dr. Pangan's affidavit despite Dr. Pangan never having taken the witness stand.
• Damages: Whether Rosit is entitled to the damages awarded by the Regional Trial Court.

• Res Ipsa Loquitur: Yes. The doctrine applies, and expert testimony was not required. The injury—a screw striking the molar—does not ordinarily occur absent negligence, the instrumentality was under Dr. Gestuvo's exclusive control, and the injury was not due to Rosit's voluntary action or contribution.
• Informed Consent: Yes. Dr. Gestuvo breached the doctrine of informed consent. He had the duty to disclose material risks and the availability of smaller titanium screws; his failure proximately caused Rosit to consent to the operation and to suffer injury.
• Admissibility of Dr. Pangan's Affidavit: No. The Court of Appeals erred in relying on Dr. Pangan's affidavit. An affidavit of an affiant who did not take the witness stand is hearsay and inadmissible.
• Damages: Yes. Rosit is entitled to actual, moral, and exemplary damages, attorney's fees, and costs as awarded by the Regional Trial Court.

• Res Ipsa Loquitur: Medical negligence requires duty, breach, injury, and proximate causation. Expert testimony is generally required to define the standard of behavior, but res ipsa loquitur supplies an exception where the injury itself proves negligence. The requisites are: (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 was not due to any voluntary action or contribution of the person injured. The first requisite was established because one of the screws installed by Dr. Gestuvo struck Rosit's molar; Dr. Gestuvo himself referred Rosit to Dr. Pangan, and Dr. Pangan's affidavit stated that the same molar struck by the screw was examined and operated on. Had Dr. Gestuvo used the proper size and length of screws and placed them properly, they would not have struck Rosit's teeth. Dr. Gestuvo knew the screws were too large, cut them with a saw, knew smaller screws were available locally, and still used the larger screws; even assuming proper length after cutting, he negligently placed one screw in the wrong area. The second requisite was satisfied because the operation that resulted in the screw hitting Rosit's molar was performed by Dr. Gestuvo; no other doctor caused that fact. The CA's finding of contributory negligence was misplaced because Dr. Gestuvo himself referred Rosit to Dr. Pangan, and Dr. Pangan's participation could not have contributed to the screw hitting the molar. The third requisite was satisfied because it was not shown that Rosit's lung disease contributed to the pain; what was clear was that he suffered because one of Dr. Gestuvo's screws hit his molar.

• Informed Consent: The doctrine of informed consent imposes on a physician the duty to disclose what a reasonably prudent physician in the medical community would disclose as to grave risks of injury from a proposed course of treatment, so that the patient may intelligently balance probable risks against probable benefits. The four essential elements are: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) the plaintiff was injured by the proposed treatment. The gravamen requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered the decision to undergo it. All four elements were present. Dr. Gestuvo had the duty to disclose the risks of using the larger screws. He failed to disclose those risks, deciding by himself that Rosit could not afford the more expensive titanium screws. Had Rosit been informed that the larger screws were inappropriate and that an additional operation might be required, he would not have agreed; Rosit was in fact able to afford the smaller titanium screws later used by Dr. Pangan. As a result of using the larger screws, Rosit experienced pain and could not heal properly because one screw hit his molar; three days after Dr. Pangan's corrective operation, Rosit was pain-free and could speak, compared to the one month of pain and inability to use his mouth after Dr. Gestuvo's operation. Dr. Gestuvo was thus guilty of withholding material information vital to Rosit's decision.

• Admissibility of Dr. Pangan's Affidavit: The CA anchored its absolution of Dr. Gestuvo on Dr. Pangan's letter or affidavit opining that Dr. Gestuvo did not commit gross negligence. An affidavit is merely hearsay evidence where its affiant or maker did not take the witness stand. Dr. Pangan never took the witness stand to affirm the contents of his affidavit; thus, the affidavit is inadmissible and cannot be given any weight. The CA erred in considering it, more so in treating it as expert testimony. Even if the affidavit were admissible and considered expert testimony, courts are not bound by expert testimonies; they may place whatever weight they choose in accordance with the facts. The relative weight and sufficiency of expert testimony is within the province of the trial court, considering the witness's ability and character, actions on the witness stand, reasoning, possible bias, and other matters. Dr. Pangan's belief on whether Dr. Gestuvo was negligent does not bind the Court; the Court must weigh and examine such testimony and decide for itself.

• Damages: The trial court properly awarded actual damages after Rosit proved the actual expenses he incurred due to Dr. Gestuvo's negligence. A claimant is entitled to actual damages when the damage sustained is the natural and probable consequence of the negligent act and the amount is adequately proved. Rosit is also entitled to moral damages under Article 2217 of the Civil Code given the unnecessary physical suffering he endured for one month. Attorney's fees and costs of suit were properly awarded under Article 2208 of the Civil Code because Rosit was compelled to litigate due to Dr. Gestuvo's refusal to pay. Exemplary damages were also properly affirmed. The requisites are: first, exemplary damages may be imposed by way of example or correction only in addition to compensatory damages and cannot be recovered as a matter of right; second, the claimant must first establish his right to moral, temperate, liquidated, or compensatory damages; third, the wrongful act must be accompanied by bad faith, and the award is allowed only if the guilty party acted in a wanton, fraudulent, reckless, oppressive, or malevolent manner. Dr. Gestuvo's actions were clearly negligent, and he acted in bad faith or in a wanton, fraudulent, reckless, oppressive manner when he breached the doctrine of informed consent by concealing the correct medical procedure of using smaller titanium screws due to his erroneous belief that Rosit could not afford them.

• Medical negligence — A medical negligence case is a claim to redress a wrong committed by a medical professional that has caused bodily harm to or the death of a patient. It has four elements: duty, breach, injury, and proximate causation. Duty refers to the standard of behavior imposing restrictions on conduct, measured by the competence associated with the proper discharge of the profession; a physician is expected to use at least the same level of care that any other reasonably competent doctor would use under the same circumstances. Breach occurs when the physician fails to comply with professional standards. If injury results from the breach, the physician is answerable for negligence. In this case, Dr. Gestuvo breached his duty by using larger screws, cutting them, and placing one screw so that it struck Rosit's molar, causing injury.

• Res ipsa loquitur in medical negligence — Generally, expert medical testimony is required to prove that a physician committed a negligent act or deviated from standard medical procedure. When res ipsa loquitur is availed of, expert testimony is dispensed with because the injury itself provides proof of negligence. The doctrine applies where the matter is within common knowledge rather than solely within the domain of medical science. The essential requisites are: (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 was not due to any voluntary action or contribution of the person injured. All three requisites were present: the screw striking the molar would not ordinarily occur absent negligence; the operation was performed by Dr. Gestuvo; and Rosit's lung disease was not shown to have contributed to the pain.

• Informed consent — The doctrine imposes on a physician a duty to disclose what a reasonably prudent physician in the medical community, in the exercise of reasonable care, would disclose to the patient as to grave risks of injury from a proposed course of treatment, so that the patient may intelligently exercise judgment by balancing probable risks against probable benefits. The four essential elements are: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) the plaintiff was injured by the proposed treatment. The gravamen requires the plaintiff to point to significant undisclosed information relating to the treatment which would have altered the decision to undergo it. Dr. Gestuvo breached this doctrine by not informing Rosit that smaller titanium screws were available and by concealing the risks of using larger screws.

• Hearsay affidavit — An affidavit is merely hearsay evidence where its affiant or maker did not take the witness stand. Such an affidavit is inadmissible and cannot be given any weight. Dr. Pangan never took the witness stand to affirm the contents of his affidavit, so the CA erred in relying on it and in treating it as expert testimony.

• Expert testimony in medical negligence — Expert testimony is generally required to define the standard of behavior by which the court may determine whether the physician properly performed the requisite duty. However, courts are not bound by expert testimonies; they may place whatever weight they choose upon such testimonies in accordance with the facts. The relative weight and sufficiency of expert testimony is peculiarly within the province of the trial court to decide, considering the ability and character of the witness, his actions upon the witness stand, the weight and process of reasoning by which he supported his opinion, his possible bias, and other matters. The trial court's ruling on evaluation of expert testimony is not reviewable absent an abuse of discretion. Even if Dr. Pangan's affidavit were admissible expert testimony, his opinion on negligence would not bind the Court.

• Damages in medical negligence — Actual damages are recoverable when the damage sustained is the natural and probable consequence of the negligent act and the amount is adequately proved. Moral damages under Article 2217 of the Civil Code include physical suffering and may be recovered if proximately resulting from the defendant's wrongful act or omission. Attorney's fees and expenses of litigation under Article 2208 may be recovered when the defendant's act or omission compelled the plaintiff to litigate or incur expenses to protect his interest. Exemplary damages may be imposed by way of example or correction only in addition to compensatory damages, cannot be recovered as a matter of right, require the claimant to first establish a right to moral, temperate, liquidated, or compensatory damages, and require the wrongful act to be accompanied by bad faith or to have been done in a wanton, fraudulent, reckless, oppressive, or malevolent manner. The RTC's awards were proper because Rosit proved actual expenses, suffered unnecessary physical suffering, was compelled to litigate due to Dr. Gestuvo's refusal to pay, and Dr. Gestuvo acted in bad faith or in a wanton, fraudulent, reckless, oppressive manner in breaching informed consent.

• "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." — This states the exception to the general requirement of expert medical testimony in medical negligence cases, which the Court applied to excuse the absence of an expert witness against Dr. Gestuvo.
• "We have further held that resort to the doctrine of res ipsa loquitur as an exception to the requirement of an expert testimony in medical negligence cases may be availed of if the following essential requisites are satisfied: (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." — This is the canonical formulation of the requisites of res ipsa loquitur in medical negligence, which the Court found all present.
• "There are four essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed consent: '(1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed treatment.'" — This defines the doctrine of informed consent and its elements, which the Court applied to hold Dr. Gestuvo liable for withholding the availability of smaller titanium screws.
• "an affidavit is merely hearsay evidence where its affiant/maker did not take the witness stand." — This is the rule the Court used to reject Dr. Pangan's affidavit, which the CA had relied upon to absolve Dr. Gestuvo.

• Flores vs. Pineda, G.R. No. 158996, November 14, 2008, 571 SCRA 83 — Explained the concept of a medical negligence case and its four elements: duty, breach, injury, and proximate causation. The Court relied on this to frame the negligence analysis.
• Solidum vs. People of the Philippines, G.R. No. 192123, March 10, 2014 — Held that when res ipsa loquitur is availed of, expert medical testimony may be dispensed with because the injury itself provides proof of negligence, and enumerated the doctrine's essential requisites. The Court applied this to find expert testimony unnecessary.
• Li vs. Soliman, G.R. No. 165279, June 7, 2011, 651 SCRA 32 — Discussed the doctrine of informed consent in medical negligence cases and its four essential elements. The Court used this to hold Dr. Gestuvo liable for failing to disclose material information.
• Dantis vs. Maghinang, Jr., G.R. No. 191606, April 10, 2013, 695 SCRA 599 — Reiterated that an affidavit is merely hearsay evidence where its affiant or maker did not take the witness stand. The Court applied this to reject Dr. Pangan's affidavit.
• Ilao-Quianay vs. Mapile, G.R. No. 154087, October 25, 2005, 474 SCRA 246 — Held that courts are not bound by expert testimonies and may place whatever weight they choose upon them in accordance with the facts. The Court cited this to hold that Dr. Pangan's opinion would not bind it even if admissible.
• Mendoza vs. Spouses Gomez, G.R. No. 1601 10, June 18, 2014, 726 SCRA 505 — Explained that a claimant is entitled to actual damages when the damage sustained is the natural and probable consequence of the negligent act and the amount is adequately proved, and enumerated the requisites for exemplary damages. The Court relied on this to affirm the RTC's damage awards.

• Article 2217, Civil Code — Provides that moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury, and may be recovered if the proximate result of the defendant's wrongful act or omission. The Court applied this to award moral damages for the unnecessary physical suffering Rosit endured for one month.
• Article 2208, Civil Code — Provides that, in the absence of stipulation, attorney's fees and expenses of litigation, other than judicial costs, cannot be recovered except in cases such as when the defendant's act or omission has compelled the plaintiff to litigate with third persons or to incur expenses to protect his interest. The Court applied this to affirm the award of attorney's fees and costs because Rosit was compelled to litigate due to Dr. Gestuvo's refusal to pay.
• Rule 45, Rules of Court — Governs petitions for review on certiorari. The case reached the Supreme Court through a petition filed under Rule 45 assailing the CA Decision and Resolution.

Peralta, Villarama, Jr., Reyes, and Jardeleza, JJ., concur.