FE CAYAO-LASAM, PETITIONER, VS. SPOUSES CLARO AND EDITHA RAMOLETE, RESPONDENTS.

Cayao-Lasam versus Ramolete

The Case

This is a petition for review on certiorari brought by Dr. Fe Cayao-Lasam against the spouses Claro and Editha Ramolete. The petitioner is a physician whose license to practice medicine was revoked by the Professional Regulations Commission after the respondents, her former patients, charged her with gross negligence and malpractice arising from a dilatation and curettage procedure that preceded Editha Ramolete's hysterectomy. The case matters for two reasons: it settles the procedural route by which a decision of the Professional Regulations Commission may be taken to the Court of Appeals, and it restates the substantive requirements of a medical malpractice claim, particularly the necessity of expert testimony on the standard of care and on causation.

Procedural History

The respondents filed a complaint for gross negligence and malpractice against the petitioner before the Professional Regulations Commission. The Board of Medicine rendered a decision exonerating the petitioner from the charges. The respondents appealed to the Professional Regulations Commission, which reversed the Board and revoked the petitioner's authority or license to practice her profession as a physician. The petitioner then went to the Court of Appeals, dubbing her petition both as a petition for review under Rule 43 and as a petition for certiorari under Rule 65. The Court of Appeals dismissed the petition. It held that the petition for review under Rule 43 was an improper remedy because the enumeration of quasi-judicial agencies in that Rule is exclusive, and the Professional Regulations Commission is not among the agencies listed. It further held that treating the petition as one for certiorari under Rule 65 would not save it, because the plain, speedy and adequate remedy was an appeal to the Office of the President under the Medical Act of 1959. The petitioner then filed the present petition for review on certiorari under Rule 45, assailing the decision of the Court of Appeals.

Facts

On July 28, 1994, Editha Ramolete, then three months pregnant, was brought to the Lorma Medical Center in San Fernando, La Union because of vaginal bleeding. Upon the petitioner's advice relayed by telephone, Editha was admitted the same day. A pelvic sonogram showed the fetus had a weak cardiac pulsation. The following day, a repeat sonogram showed the weak cardiac pulsation and no fetal movement. Because of persistent and profuse vaginal bleeding, the petitioner advised Editha to undergo a dilatation and curettage procedure. On July 30, 1994, the petitioner performed the procedure, and Editha was discharged the following day.

On September 16, 1994, Editha was again brought to the Lorma Medical Center, suffering from vomiting and severe abdominal pains. She was attended by other physicians. After a laparotomy, she was found to have a massive intra-abdominal hemorrhage and a ruptured uterus. She underwent a hysterectomy and, as a result, could no longer bear a child.

On November 7, 1994, the spouses Ramolete filed a complaint for gross negligence and malpractice against the petitioner before the Professional Regulations Commission. They alleged that the hysterectomy was caused by the petitioner's unmitigated negligence and professional incompetence in conducting the dilatation and curettage and in failing to remove the fetus inside Editha's womb. The petitioner denied the allegations. She explained that she had given telephone orders, visited Editha during her rounds, performed internal examinations, and advised the procedure only after Editha persistently complained of bleeding and passed out a meaty mass. She contended that Editha's own insistence on being discharged against medical advice and her failure to return for check-up contributed to her condition, and that the hysterectomy was brought about by an extremely rare and unusual abdominal placental implantation known as placenta increta. The Board of Medicine exonerated the petitioner, finding that Editha's case was an ectopic pregnancy interstitial, that the petitioner could not be faulted for failing to detect it, and that the dilatation and curettage was necessary to stop the profuse bleeding. The Professional Regulations Commission reversed and revoked the petitioner's license.

Issues

• Whether or not the Professional Regulations Commission is excluded from the quasi-judicial agencies covered by Rule 43 of the Rules of Court, so that a petition for review of its decision may be filed with the Court of Appeals.
• Whether or not the complainant in an administrative case before the Board of Medicine may appeal the Board's decision to the Professional Regulations Commission.
• Whether or not the Professional Regulations Commission committed grave abuse of discretion in revoking the petitioner's license to practice medicine without expert testimony to support its conclusion as to the cause of Editha Ramolete's injury.

Applicable Provisions

Section 1 of Rule 43 of the Rules of Court provides:

Section 1. Scope. This Rule shall apply to appeals from judgments or final orders of the Court of Tax Appeals, and from awards, judgments, final orders or resolutions of or authorized by any quasi-judicial agency in the exercise of its quasi-judicial functions. Among these agencies are the Civil Service Commission, Central Board of Assessment Appeals, Securities and Exchange Commission, Office of the President, Land Registration Authority, Social Security Commission, Civil Aeronautics Board, Bureau of Patents, Trademarks and Technology Transfer, National Electrification Administration, Energy Regulatory Board, National Telecommunications Commission, Department of Agrarian Reform under Republic Act Number 6657, Government Service Insurance System, Employees Compensation Commission, Agricultural Inventions Board, Insurance Commission, Philippine Atomic Energy Commission, Board of Investments, Construction Industry Arbitration Commission, and voluntary arbitrators authorized by law.

This provision governs the procedural question, because the petitioner invoked Rule 43 as the proper route from the Professional Regulations Commission to the Court of Appeals.

Section 26 of Republic Act Number 2382, the Medical Act of 1959, provides:

Section 26. Appeal from judgment. The decision of the Board of Medical Examiners (now Medical Board) shall automatically become final thirty days after the date of its promulgation unless the respondent, during the same period, has appealed to the Commissioner of Civil Service (now Professional Regulations Commission) and later to the Office of the President of the Philippines. If the final decision is not satisfactory, the respondent may ask for a review of the case, or may file in court a petition for certiorari.

This provision was invoked by the petitioner to argue that only the respondent, and not the complainant, may appeal the Board's decision to the Commission.

Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals, as amended, provides:

Section 35. The complainant/respondent may appeal the order, the resolution or the decision of the Board within thirty (30) days from receipt thereof to the Commission whose decision shall be final and executory. Interlocutory order shall not be appealable to the Commission. (Amended by Res. 174, Series of 1990).

This amended provision settles who may appeal from the Board to the Commission.

Ruling

On the first issue, the Court agreed with the petitioner. The Professional Regulations Commission is not expressly mentioned in Section 1 of Rule 43, but its absence from the enumeration does not, by that fact alone, imply its exclusion from the coverage of the Rule. The Rule expressly applies to appeals from awards, judgments, final orders or resolutions of any quasi-judicial agency in the exercise of its quasi-judicial functions, and the phrase "among these agencies" confirms that the enumeration is not exclusive. The Court recalled its earlier ruling that Batas Pambansa Bilang 129 conferred upon the Court of Appeals exclusive appellate jurisdiction over appeals from decisions of the Professional Regulations Commission. The Court quoted that ruling:

The law has since been changed, however, at least in the matter of the particular court to which appeals from the Commission should be taken. On August 14, 1981, Batas Pambansa Bilang 129 became effective and in its Section 29, conferred on the Court of Appeals "exclusive appellate jurisdiction over all final judgments, decisions, resolutions, orders or awards of Regional Trial Courts and quasi-judicial agencies, instrumentalities, boards or commissions except those falling under the appellate jurisdiction of the Supreme Court. x x x." In virtue of BP 129, appeals from the Professional Regulations Commission are now exclusively cognizable by the Court of Appeals.

On the second issue, the Court did not agree with the petitioner. Double jeopardy finds no application in administrative cases; it attaches only upon a valid indictment, before a competent court, after arraignment, when a valid plea has been entered, and when the defendant was acquitted or convicted or the case was dismissed or otherwise terminated without the express consent of the accused. None of these elements were present in the proceedings before the Board of Medicine, which were administrative and not criminal in nature. Moreover, the earlier Section 35 was amended so that the complainant or respondent may appeal the order, resolution or decision of the Board to the Commission. The clear intent of the amendment is to render the right to appeal available to both complainants and respondents. The Court added that the right to appeal is not a natural right or part of due process, but a mere statutory privilege that may be exercised only in the manner prescribed by law.

On the third issue, the Court held that expert testimony is essential in medical malpractice cases. Medical malpractice is a particular form of negligence consisting in the failure of a physician or surgeon to apply to the 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 which a reasonably prudent physician would have done, or did something which a reasonably prudent physician would not have done, and that the failure or action caused injury to the patient. The four elements are duty, breach, injury and proximate causation. The determination of the reasonable level of care and the breach thereof, and the conclusion as to causation, ordinarily require expert testimony. In this case, the respondents presented no expert testimony, while the petitioner presented Dr. Augusto M. Manalo, a specialist in gynecology and obstetrics, who testified that the dilatation and curettage was not the proximate cause of the rupture of Editha's uterus, because the instrument could not reach the site of the pregnancy and because, had the procedure been the cause, the rupture would have occurred much earlier.

Doctrine

First, the enumeration of quasi-judicial agencies in Section 1 of Rule 43 of the Rules of Court is not exclusive. The phrase "among these agencies" means that other quasi-judicial bodies, including the Professional Regulations Commission, fall within the Rule, and appeals from their decisions lie with the Court of Appeals. Second, the right to appeal is not a natural right or part of due process but a mere statutory privilege, and under the amended Section 35 of the Rules and Regulations Governing the Regulation and Practice of Professionals, both the complainant and the respondent may appeal the decision of the Board of Medicine to the Professional Regulations Commission. Third, double jeopardy does not lie in administrative cases. Fourth, in medical malpractice, the patient must prove duty, breach, injury and proximate causation, and expert testimony is essential both to establish the reasonable level of care and its breach and to support the conclusion as to causation.

Disposition

The petition was granted, the decision of the Court of Appeals was reversed and set aside, and the case was remanded to the Court of Appeals for resolution of the merits of the petition.

Remember This

Remember that the list of quasi-judicial agencies in Rule 43 is not exclusive, so appeals from the Professional Regulations Commission go to the Court of Appeals, and that a medical malpractice claim cannot succeed without expert testimony on the standard of care and on causation. Examiners use this case for the procedural question of the proper remedy from a Professional Regulations Commission decision and for the four elements of medical negligence.