DR. LI V.

SPOUSES SOLIMAN
FACTS:
- On July 7, 1993, respondents 11-year old daughter, Angelica Soliman, underwent a
biopsy of the mass located in her lower extremity at the St. Lukes Medical Center
(SLMC). Results showed that Angelica was suffering from osteosarcoma, osteoblastic
type, a type of bone cancer usually afflicting teenage children
- Following this diagnosis and as primary intervention, Angelicas right leg was amputated
by Dr. Jaime Tamayo in order to remove the tumor. As adjuvant treatment to eliminate
any remaining cancer cells, and hence minimize the chances of recurrence and prevent
the disease from spreading to other parts of the patients body (metastasis), chemotherapy
was suggested by Dr. Tamayo.
- Dr. Tamayo referred Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a
medical oncologist.
- On August 18, 1993, Angelica was admitted to SLMC. However, she died on September
1, 1993, just eleven (11) days after the (intravenous) administration of the first cycle of
the chemotherapy regimen.
- Because SLMC refused to release a death certificate without full payment of their
hospital bill, respondents brought the cadaver of Angelica to the Philippine National
Police (PNP) Crime Laboratory at Camp Crame for post-mortem examination. The
Medico-Legal Report issued by said institution indicated the cause of death as
Hypovolemic shock secondary to multiple organ hemorrhages and Disseminated
Intravascular Coagulation
- On February 21, 1994, respondents filed a damage suit against petitioner, Dr. Leo
Marbella, Mr. Jose Ledesma, a certain Dr. Arriete and SLMC. Respondents charged them
with negligence and disregard of Angelicas safety, health and welfare by their careless
administration of the chemotherapy drugs, their failure to observe the essential
precautions in detecting early the symptoms of fatal blood platelet decrease and stopping
early on the chemotherapy, which bleeding led to hypovolemic shock that caused
Angelicas untimely demise.
- Further, it was specifically averred that petitioner assured the respondents that Angelica
would recover in view of 95% chance of healing with chemotherapy (Magiging normal
na ang anak nyo basta ma-chemo. 95% ang healing) and when asked regarding the side
effects, petitioner mentioned only slight vomiting, hair loss and weakness (Magsusuka ng
kaunti. Malulugas ang buhok. Manghihina). Respondents thus claimed that they would
not have given their consent to chemotherapy had petitioner not falsely assured them of
its side effects.
- PETITIONER: denied negligence; contends that she fully explained how chemo
wors and what side effects it can produce; cause of what happened may be left over
malignant cells no assurance that chemo will completely cure Angelica
- TC: medical records not produced; relied on testimonial evidence
- OTHER FACTS:

1. Second day of chemo respondents noticed reddish discoloration on Angelicas

face pet: epekto lang yan ng gamut, but entertained the possibility that he patient
had systemic lupus, thus consulted with a certain Dr. Abesamis
2. 3rd day: patient had trouble breathing; she was then provided with an oxygen
breathing apparatus reddish discoloration extended to patients neck
3. On August 22, 1993, at around ten oclock in the morning, upon seeing that their child
could not anymore bear the pain, respondents pleaded with petitioner to stop the
chemotherapy. Petitioner supposedly replied: Dapat 15 Cosmegen pa iyan. Okay, lets
observe. If pwede na, bigyan uli ng chemo. At this point, respondents asked
petitioners permission to bring their child home. Later in the evening, Angelica
passed black stool and reddish urine petitioner countered this, again
4. The following day, August 23, petitioner yielded to respondents request to take
Angelica home. But prior to discharging Angelica, petitioner requested for a repeat
serum calcium determination and explained to respondents that the chemotherapy will
be temporarily stopped while she observes Angelicas muscle twitching and serum
calcium level but the patient remained in the hospital because of convulsions and
LBM
5. She even began bleeding from the mouth; blood also was found in her anus and urine;
she developed ulcers around the mouth; she continued bleeding and vomiting blood
became hysterical, and then she died
6. RESPONDENTS PRESENTED DR. NIEVES-VERGARA, PNPS MEDICOLEGAL OFFICER: (1) there were fluids recovered from the abdominal cavity, which is not
normal, and was due to hemorrhagic shock secondary to bleeding; (2) there was hemorrhage at the left
side of the heart; (3) bleeding at the upper portion of and areas adjacent to, the esophagus; (4) lungs
were heavy with bleeding at the back and lower portion, due to accumulation of fluids; (4) yellowish
discoloration of the liver; (5) kidneys showed appearance of facial shock on account of hemorrhages;
and (6) reddishness on external surface of the spleen. All these were the end result of hypovolemic
shock secondary to multiple organ hemorrhages and disseminated intravascular coagulation. Dr.
Vergara opined that this can be attributed to the chemical agents in the drugs given to the victim, which
caused platelet reduction resulting to bleeding sufficient to cause the victims death. The time lapse for
the production of DIC in the case of Angelica (from the time of diagnosis of sarcoma) was too short,
considering the survival rate of about 3 years. The witness conceded that the victim will also die of
osteosarcoma even with amputation or chemotherapy, but in this case Angelicas death was not caused
by osteosarcoma. Dr. Vergara admitted that she is not a pathologist but her statements were based on
the opinion of an oncologist whom she had interviewed. This oncologist supposedly said that if the
victim already had DIC prior to the chemotherapy, the hospital staff could have detected it

TC: DISMISSED COMPLAINT; PETITIONER OBSERVED THE BEST NOWN

PROCEDURES AND EMPLOYED HER HIGHEST SKILL OF KNOWLEDGE
petitioner has taken the necessary precaution against the adverse effect of chemotherapy
on the patient, adding that a wrong decision is not by itself negligence
CA: while concurring with the trial courts finding that there was no negligence
committed by the petitioner in the administration of chemotherapy treatment to Angelica,
found that petitioner as her attending physician failed to fully explain to the respondents
all the known side effects of chemotherapy. The appellate court stressed that since the
respondents have been told of only three side effects of chemotherapy, they readily
consented thereto DR. LI LIABLE FOR DAMAGES

WHETHER THE PETITIONER CAN BE HELD LIABLE FOR FAILURE TO FULLY DISCLOSE
SERIOUS SIDE EFFECTS TO THE PARENTS OF THE CHILD PATIENT WHO DIED WHILE
UNDERGOING CHEMOTHERAPY, DESPITE THE ABSENCE OF FINDING THAT
PETITIONER WAS NEGLIGENT IN ADMINISTERING THE SAID TREATMENT?
SUPREME COURT: THE PETITION IS MERITORIOUS.
In this case, both the trial and appellate courts concurred in finding that the alleged negligence of
petitioner in the administration of chemotherapy drugs to respondents child was not proven
considering that Drs. Vergara and Balmaceda, not being oncologists or cancer specialists, were
not qualified to give expert opinion as to whether petitioners lack of skill, knowledge and
professional competence in failing to observe the standard of care in her line of practice was the
proximate cause of the patients death. Furthermore, respondents case was not at all helped by the
non-production of medical records by the hospital (only the biopsy result and medical bills were
submitted to the court). Nevertheless, the CA found petitioner liable for her failure to inform the
respondents on all possible side effects of chemotherapy before securing their consent to the said
treatment.
The doctrine of informed consent within the context of physician-patient relationships
goes far back into English common law. As early as 1767, doctors were charged with the tort of
battery (i.e., an unauthorized physical contact with a patient) if they had not gained the consent
of their patients prior to performing a surgery or procedure. In the United States, the seminal case
was Schoendorff v. Society of New York Hospital which involved unwanted treatment performed
by a doctor. Justice Benjamin Cardozos oft-quoted opinion upheld the basic right of a patient to
give consent to any medical procedure or treatment: Every human being of adult years and sound
mind has a right to determine what shall be done with his own body; and a surgeon who
performs an operation without his patients consent, commits an assault, for which he is liable in
damages. From a purely ethical norm, informed consent evolved into a general principle of law
that 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 duty to disclose should not be limited to medical usage as to arrogate the decision on
revelation to the physician alone
-

scope of disclosure is premised on the fact that patients ordinarily are persons unlearned
in the medical sciences

the physician is not expected to give the patient a short medical education, the disclosure
rule only requires of him a reasonable explanation, which means generally informing the
patient in nontechnical terms as to what is at stake; the therapy alternatives open to him,
the goals expectably to be achieved, and the risks that may ensue from particular
treatment or no treatment

AS TO THE ISSUE OF DEMONSTRATING WHAT RISKS ARE CONSIDERED

MATERIAL NECESSITATING DISCLOSURE, IT WAS HELD THAT EXPERTS ARE
UNNECESSARY TO A SHOWING OF THE MATERIALITY OF A RISK TO A
PATIENTS DECISION ON TREATMENT, OR TO THE REASONABLY,
EXPECTABLE EFFECT OF RISK DISCLOSURE ON THE DECISION. SUCH
UNREVEALED RISK THAT SHOULD HAVE BEEN MADE KNOWN MUST
FURTHER MATERIALIZE, FOR OTHERWISE THE OMISSION, HOWEVER
UNPARDONABLE, IS WITHOUT LEGAL CONSEQUENCE. AND, AS IN
MALPRACTICE ACTIONS GENERALLY, THERE MUST BE A CAUSAL
RELATIONSHIP BETWEEN THE PHYSICIANS FAILURE TO DIVULGE AND
DAMAGE TO THE PATIENT

Cobbs v. Grant further reiterated the pronouncement in Canterbury v. Spence that

for liability of the physician for failure to inform patient, there must be causal
relationship between physicians failure to inform and the injury to patient and such
connection arises only if it is established that, had revelation been made, consent to
treatment would not have been given.

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. The gravamen in an informed consent case requires the
plaintiff to point to significant undisclosed information relating to the treatment
which would have altered her decision to undergo it

IN THE CASE AT BAR, THERE WAS ADEQUATE DISCLOSURE

Respondents could not have been unaware in the course of initial treatment and amputation of Angelicas
lower extremity, that her immune system was already weak on account of the malignant tumor in her knee.
When petitioner informed the respondents beforehand of the side effects of chemotherapy which includes
lowered counts of white and red blood cells, decrease in blood platelets, possible kidney or heart damage and
skin darkening, there is reasonable expectation on the part of the doctor that the respondents understood very
well that the severity of these side effects will not be the same for all patients undergoing the procedure. In
other words, by the nature of the disease itself, each patients reaction to the chemical agents even with pretreatment laboratory tests cannot be precisely determined by the physician. That death can possibly result
from complications of the treatment or the underlying cancer itself, immediately or sometime after the
administration of chemotherapy drugs, is a risk that cannot be ruled out, as with most other major medical
procedures, but such conclusion can be reasonably drawn from the general side effects of chemotherapy
already disclosed.