Peter Paul Patrick Lucas, et al. v. Dr. Prospero Ma. C. Tuaño

[2009] PHSC 420
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The petitioner, Peter Lucas first consulted the respondent, Dr. Tuano who was an ophthalmologist, for treatment of soreness and redness in his right eye. The respondent, after a series of examinations found that Peter was suffering from conjunctivitis and prescribed Spersacet-C eye-drops. However, after a few days Peter’s eye condition worsened and he approached the respondent for a second finding. The respondent found that even though conjunctivitis had cleared, but Peter had developed Epidemic Kerato Conjunctivitis (EKC), a viral infection in the same eye. Dr. Tuano then prescribed Maxitrol to treat this, and upon resolution of the Peter’s EKC, he advised Peter to withdraw his use of Maxitrol gradually. Peter’s condition worsened overtime yet he complied with all the prescriptions and orders of the respondent. Peter’s wife had read that one of the adverse effects of prolonged use of steroid based eye drops could induce glaucoma. Peter alleged that when he mentioned this to Dr. Tuano, he simply brushed this concern off as paranoia.

Four months later, when Peter had suffered from significant swelling of his right eyeball, headaches, nausea and blindness on his right eye, he consulted another ophthalmologist, Dr. Aquino who diagnosed him with glaucoma. According to Peter, Dr. Aquino told him that his condition would require lifetime medication and follow-ups. Peter underwent laser surgery twice in order. Peter underwent two procedures of laser trabeculoplasty.

Peter then brought a medical malpractice action against the Dr. Tuano for causing steroid-induced glaucoma.

The trial court dismissed the case for insufficiency of evidence and opined that the petitioner had failed to prove by preponderance that Dr. Tuano was negligent in his treatment of Peter’s condition. The trial court reasoned that the there was no medical evidence to establish that steroids prescribed by Dr. Tuano were the proximate cause of glaucoma. Peter appealed to the Court of Appeal for reconsideration, however that was also denied. Peter then appealed to the Supreme Court of Philippines.

The central issue in this case was whether the petitioner failed to prove by preponderance of evidence to support his claim and allegation of medical negligence by Dr. Tuano.

The Supreme Court upheld the trial court and Court of Appeals decision. The Court found that Peter had failed to establish that the respondent, Dr. Tuano had breached the standard of care and diligence as there was no expert medical opinion or evidence to prove so.

The court stated that it would consider only questions of law that may be raised under the Rules of Court as that court was not a trier of facts. The court stated that the fact of want of competence or diligence is evidentiary in nature and it would be virtually impossible to ascertain the merit of a medical negligence case without extensive investigation, research, evaluation and consultation with the medical experts. The court stated that in a suit of medical negligence such as this, the patient or his heirs are required to prove by preponderance of evidence that the physician failed to exercise a degree of skill, care and learning possessed by other persons in the same profession and that as a proximate result of such failure the patient or his heirs suffered damages. The court laid down the four elements to establish medical negligence which are: duty of care, breach of that duty, a direct injury and the proximate cause for such injury and all four elements must co-exist to find the physician liable.

The court set out that the burden of proof lay with the plaintiff, whose case rested largely on statements in the literature of Maxitrol use. The plaintiff failed to bring forth expert testimony to determine what would be reasonable care, diligence, and skill as generally required within the defendant’s field. The Court found they could not be expected to determine on their own what medical techniques the respondent could have used. The court accepted the respondent’s argument that his work conformed to the standards of medical practice in his locality and he did conduct standard tests/ procedures when Peter came for his consultation.

The court stated that even if it assumed that the respondent committed negligent acts in his treatment of Peter's condition, the connection between the respondent supposed negligence and Peter's injury still needed to be established. The critical and clinching factor in a medical negligence case is the proof of causal connection between the negligent act and the plaintiff's injuries.  The court thus, found that the plaintiff failed to establish that his injury was the result of the use of Maxitrol as prescribed by the respondent.

“In medical negligence cases, also called medical malpractice suits, there exist a physician-patient relationship between the doctor and the victim. But just like any other proceeding for damages, four essential (4) elements i.e., (1) duty; (2) breach; (3) injury; and (4) proximate causation, must be established by the plaintiffs.  All the four (4) elements must co-exist in order to find the physician negligent and, thus, liable for damages.” (page 15)

“Unfortunately, in this case, there was absolute failure on the part of petitioners to present any expert testimony to establish: (1) the standard of care to be implemented by competent physicians in treating the same condition as Peter’s under similar circumstances; (2) that, in his treatment of Peter, Dr. Tuaño failed in his duty to exercise said standard of care that any other competent physician would use in treating the same condition as Peter’s under similar circumstances; and (3) that the injury or damage to Peter’s right eye, i.e., his glaucoma, was the result of his use of Maxitrol, as prescribed by Dr. Tuaño.” (page 17)

“It seems basic that what constitutes proper medical treatment is a medical question that should have been presented to experts. If no standard is established through expert medical witnesses, then courts have no standard by which to gauge the basic issue of breach thereof by the physician or surgeon.” (page 21-22)

“All told, we are hard pressed to find Dr. Tuaño liable for any medical negligence or malpractice where there is no evidence, in the nature of expert testimony, to establish that in treating Peter, Dr. Tuaño failed to exercise reasonable care, diligence and skill generally required in medical practice.” (page 22)

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