The Supreme Court held that a doctor was liable for medical negligence for failing to inform his patient about the availability of smaller, more appropriate surgical screws and for using improperly sized screws during a jaw surgery, which resulted in the patient experiencing pain and needing a second corrective surgery. This decision underscores the importance of informed consent and the application of the res ipsa loquitur doctrine in medical malpractice cases, ensuring that healthcare providers are held accountable for substandard care that directly harms patients. It reinforces patient autonomy by requiring physicians to disclose all material risks and available treatment options so patients can make informed decisions about their medical care.

Screwed Up: When a Doctor’s Oversight Leads to Surgical Suffering

This case, Nilo B. Rosit v. Davao Doctors Hospital and Dr. Rolando G. Gestuvo, revolves around a medical negligence claim against Dr. Rolando Gestuvo, a specialist in mandibular injuries. The core legal question is whether Dr. Gestuvo breached his duty of care to his patient, Nilo B. Rosit, during a jaw surgery, and whether the principle of res ipsa loquitur and the doctrine of informed consent are applicable in determining liability. The factual background involves Rosit’s motorcycle accident, which led to a fractured jaw and subsequent surgery performed by Dr. Gestuvo at Davao Doctors Hospital (DDH).

During the operation, Dr. Gestuvo used a metal plate fastened with metal screws to immobilize Rosit’s mandible. Knowing smaller titanium screws were available in Manila, he opted to use larger screws, which he cut to size. He did not inform Rosit about the availability of the smaller screws, assuming Rosit could not afford them. Post-surgery, Rosit experienced pain and difficulty opening his mouth. X-rays revealed the screws touched his molar, prompting Dr. Gestuvo to refer Rosit to a dentist, Dr. Pangan, who recommended a second operation in Cebu. This second operation involved removing the improperly placed screws and replacing them with smaller titanium screws, after which Rosit’s condition significantly improved.

The Regional Trial Court (RTC) found Dr. Gestuvo negligent, applying the principle of res ipsa loquitur, which suggests negligence can be inferred from the nature of the injury itself. This principle posits that certain events typically do not occur without negligence, making it unnecessary to provide expert medical testimony. The RTC awarded damages to Rosit, including reimbursement for medical expenses, attorney’s fees, moral damages, and exemplary damages. However, the Court of Appeals (CA) reversed the RTC’s decision, arguing that res ipsa loquitur was inapplicable and that expert testimony was necessary to prove negligence. The CA also gave weight to a letter from Dr. Pangan, stating that Dr. Gestuvo did not commit gross negligence in his management of Rosit’s case.

The Supreme Court (SC) disagreed with the Court of Appeals and reinstated the RTC’s decision, finding Dr. Gestuvo liable for medical negligence. The Court emphasized the elements necessary to establish medical negligence: duty, breach, injury, and proximate causation. The SC explained that a physician has a duty to provide a standard level of care expected from a reasonably competent doctor under similar circumstances. Breach of this duty occurs when the physician fails to meet these professional standards, resulting in injury to the patient. The Court found that the doctrine of res ipsa loquitur was applicable because the injury (screws hitting the molar) would not have occurred without negligence, the instrumentality (the screws) was under Dr. Gestuvo’s exclusive control, and the injury was not due to Rosit’s voluntary action.

The Supreme Court also underscored the importance of the doctrine of informed consent, which requires physicians to disclose material risks and alternative treatments to patients, enabling them to make informed decisions. This doctrine is crucial to patient autonomy and the ethical practice of medicine. In Li v. Soliman, the Court articulated that informed consent is based on the duty to disclose:

…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 a patient, exercising ordinary care for his own welfare, and faced with a choice of undergoing the proposed treatment, or alternative treatment, or none at all, may intelligently exercise his judgment by reasonably balancing the probable risks against the probable benefits.

The Court noted that Dr. Gestuvo failed to inform Rosit about the availability of smaller titanium screws and the risks associated with using larger screws. By not providing this information, Dr. Gestuvo deprived Rosit of the opportunity to make an informed decision about his treatment. The Court emphasized that the four elements of a malpractice action based on informed consent were present: Dr. Gestuvo had a duty to disclose material risks, he failed to do so, Rosit consented to treatment he otherwise would not have, and Rosit was injured as a result.

Further, the Supreme Court dismissed the appellate court’s reliance on Dr. Pangan’s letter, which stated that Dr. Gestuvo did not commit gross negligence. The Court deemed this letter inadmissible as hearsay evidence since Dr. Pangan did not testify in court to affirm the contents of the affidavit. The Court cited Dantis v. Maghinang, Jr.:

an affidavit is merely hearsay evidence where its affiant/maker did not take the witness stand.

The Supreme Court affirmed the trial court’s award of damages, including actual damages for medical expenses, moral damages for physical suffering, attorney’s fees, and exemplary damages. The Court explained that actual damages are warranted when the claimant proves the damage sustained as a natural and probable consequence of the negligent act. Moral damages are justified given the unnecessary physical suffering Rosit endured due to Dr. Gestuvo’s negligence, as outlined in Article 2217 of the Civil Code:

Moral damages include physical suffering, mental anguish, fright, serious anxiety, besmirched reputation, wounded feelings, moral shock, social humiliation, and similar injury. Though incapable of pecuniary computation, moral damages may be recovered if they are the proximate result of the defendant’s wrongful act for omission.

The Court found that 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 compensate him for the damages. The award of exemplary damages was also affirmed, based on the finding that Dr. Gestuvo acted in bad faith or in a wanton, fraudulent, reckless, or oppressive manner when he breached the doctrine of informed consent. The court relied on Mendoza v. Spouses Gomez, where the requisites for exemplary damages were laid out:

First, they may be imposed by way of example or correction only in addition, among others, to compensatory damages, and cannot be recovered as a matter of right, their determination depending upon the amount of compensatory damages that may be awarded to the claimant. 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 would be allowed only if the guilty party acted in a wanton, fraudulent, reckless, oppressive or malevolent manner.

FAQs

What was the key issue in this case?	The key issue was whether the doctor was liable for medical negligence for using improperly sized screws during surgery and failing to obtain informed consent from the patient regarding alternative treatment options.
What is the res ipsa loquitur doctrine?	Res ipsa loquitur is a legal principle that allows negligence to be inferred from the nature of an injury, especially when the injury would not ordinarily occur without negligence and the instrumentality causing the injury was under the exclusive control of the defendant. In this case, the screws hitting the molar during surgery invoked this doctrine.
What is informed consent?	Informed consent is a legal and ethical principle that requires a physician to disclose all material risks and alternative treatments to a patient, enabling the patient to make an informed decision about their medical care. The physician must provide enough information for the patient to understand the potential benefits and risks of the proposed treatment.
Why was the doctor found negligent?	The doctor was found negligent because he failed to inform the patient about the availability of smaller titanium screws, used larger screws that he had to cut, and improperly placed one of the screws, causing it to hit the patient’s molar. This constituted a breach of his duty of care.
What damages did the patient receive?	The patient received actual damages for medical expenses, moral damages for physical suffering, attorney’s fees, and exemplary damages. These damages were awarded to compensate the patient for the harm caused by the doctor’s negligence.
Why was Dr. Pangan’s letter not considered?	Dr. Pangan’s letter was not considered because it was deemed hearsay evidence. Dr. Pangan did not testify in court to affirm the contents of the affidavit.
What is the significance of exemplary damages in this case?	Exemplary damages were awarded because the doctor acted in bad faith by concealing the correct medical procedure and failing to inform the patient about the risks of using the larger screws. The Court used this to encourage the medical field to be more transparent.
What should doctors learn from this case?	Doctors should learn the importance of obtaining informed consent from patients, providing them with all necessary information to make informed decisions about their treatment, and adhering to the standard of care expected from a reasonably competent physician. This case reinforces ethical behavior.

This case serves as a crucial reminder of the responsibilities healthcare providers have to their patients. By prioritizing informed consent and adhering to established standards of care, medical professionals can safeguard patient rights and avoid liability for negligence. The decision underscores the importance of transparency and ethical conduct in medical practice, ensuring that patients are empowered to make informed decisions about their health.

For inquiries regarding the application of this ruling to specific circumstances, please contact ASG Law through contact or via email at frontdesk@asglawpartners.com.

Disclaimer: This analysis is provided for informational purposes only and does not constitute legal advice. For specific legal guidance tailored to your situation, please consult with a qualified attorney.
Source: NILO B. ROSIT, VS. DAVAO DOCTORS HOSPITAL AND DR. ROLANDO G. GESTUVO, G.R. No. 210445, December 07, 2015