circumstance when the finding of fact of the Court of Appeals

is premised on the supposed absence of evidence, but is

contradicted by the evidence on record. Although petitioners
may not explicitly invoke said exception, it may be gleaned
from their allegations and arguments in the instant Petition.

 
_______________
SO ORDERED.

Ynares-Santiago (Chairperson), Chico-Nazario, * THIRD DIVISION.

Nachura and Peralta, JJ., concur.

174
Judgment rendered in accordance with compromise
agreement.
174 SUPREME COURT REPORTS ANNOTATED
Note.—A petition for review may be dismissed in
view of the compromise agreement entered into by the Lucas vs. Tuaño
parties. (Ayala Land, Inc. vs. Navarro, 428 SCRA 361
[2004])
——o0o—— Physicians; Medical Malpractice; Negligence; Damages;
Burden of Proof; The present controversy is a classic
  illustration of a medical negligence case against a physician
based on the latter’s professional negligence, and in this type
G.R. No. 178763. April 21, 2009.* of suit, the patient or his heirs, in order to prevail, is required
to prove by preponderance of evidence that the physician
PETER PAUL PATRICK LUCAS, FATIMA GLADYS failed to exercise that degree of skill, care, and learning
LUCAS, ABBEYGAIL LUCAS AND GILLIAN LUCAS, possessed by other persons in the same profession, and that as
petitioners, vs. DR. PROSPERO MA. C. TUAÑO, a proximate result of such failure, the patient or his heirs
respondent. suffered damages.—Petitioners’ position, in sum, is that
Peter’s glaucoma is the direct result of Dr. Tuaño’s
negligence in his improper administration of the drug
Appeals; Elementary is the principle that the Supreme
Maxitrol; “thus, [the latter] should be liable for all the
Court is not a trier of facts—only errors of law are generally
damages suffered and to be suffered by [petitioners].”
reviewed in petitions for review on certiorari criticizing
Clearly, the present controversy is a classic illustration of a
decisions of the Court of Appeals.—Elementary is the
medical negligence case against a physician based on the
principle that this Court is not a trier of facts; only errors of
latter’s professional negligence. In this type of suit, the
law are generally reviewed in petitions for review on
patient or his heirs, in order to prevail, is required to prove
certiorari criticizing decisions of the Court of Appeals.
by preponderance of evidence that the physician failed to
Questions of fact are not entertained. Nonetheless, the
exercise that degree of skill, care, and learning possessed by
general rule that only questions of law may be raised on
other persons in the same profession; and that as a
appeal in a petition for review under Rule 45 of the Rules of
proximate result of such failure, the patient or his heirs
Court admits of certain exceptions, including the
suffered damages.
 Same; Same; Same; Elements; For lack of a specific law testimony, because the standard of care in a medical
geared towards the type of negligence committed by members malpractice case is a matter peculiarly within the knowledge
of the medical profession, such claim for damages is almost of experts in the field.—When a patient engages the services
always anchored on the alleged violation of Article 2176 of the of a physician, a physician-patient relationship is generated.
Civil Code; In medical negligence cases, also called medical And in accepting a case, the physician, for all intents and
malpractice suits, there exist a physician-patient relationship purposes, represents that he has the needed training and
between the doctor and the victim.—For lack of a specific law skill possessed by physicians and surgeons practicing in the
geared towards the type of negligence committed by members same field; and that he will employ such training, care, and
of the medical profession, such claim for damages is almost skill in the treatment of the patient. Thus, in treating his
always anchored on the alleged violation of Article 2176 of patient, a physician is under a duty to [the former] to
the Civil Code, which states that: ART. 2176. Whoever by act exercise that degree of care, skill and diligence which
or omission causes damage to another, there being fault or physicians in the same general neighborhood and in the
negligence, is obliged to pay for the damage done. Such fault same general line of practice ordinarily possess and exercise
or negligence, if there is no pre-existing contractual relation in like cases. Stated otherwise, the physician has the duty to
between the parties, is called a quasi-delict and is governed use at least the same level of care that any other reasonably
by the provisions of this Chapter. In medical negligence competent physician would use to treat the condition under
cases, also called medical malpractice suits, there exist a similar circumstances. This standard level of care, skill and
physician-patient relationship between the doctor and the diligence is a matter best addressed by expert medical
victim. But just like any other proceeding for damages, four testimony, because the standard of care in a medical
essential (4) elements i.e., (1) duty; (2) breach; (3) injury; and malpractice case is a matter peculiarly within the knowledge
(4) proximate causation, must be established by the of experts in the field.
plaintiff/s. All the Same; Same; Same; There is breach of duty of care, skill
and diligence, or the improper performance of such duty, by
175 the attending physician when the patient is injured in body or
in health [and this] constitutes the actionable malpractice; In
order that there may be a recovery for an injury, it must be
VOL. 586, APRIL 21, 2009 175
shown that the “injury for which recovery is sought must be
Lucas vs. Tuaño the legitimate consequence of the wrong done; the connection
between the negligence and the injury must be a direct and
natural sequence of events, unbroken by intervening efficient
four (4) elements must co-exist in order to find the physician
causes”—that is, the negligence must be the proximate cause
negligent and, thus, liable for damages.
of the injury.—There is breach of duty of care, skill and
Same; Same; Same; When a patient engages the services diligence, or the improper performance of such duty, by the
of a physician, a physician-patient relationship is generated; attending physician when the patient is injured in body or in
In treating his patient, a physician is under a duty to the health [and this] constitutes the
former to exercise that degree of care, skill and diligence
which physicians in the same general neighborhood and in 176
the same general line of practice ordinarily possess and
exercise in like cases, which standard level of care, skill and
diligence is a matter best addressed by expert medical 176 SUPREME COURT REPORTS ANNOTATED
 Lucas vs. Tuaño expert witnesses belonging in the same general neighborhood
and in the same general line of practice as defendant
actionable malpractice. Proof of such breach must likewise physician or surgeon. The deference of courts to the expert
rest upon the testimony of an expert witness that the opinion of qualified physicians [or surgeons] stems from the
treatment accorded to the patient failed to meet the standard former’s realization that the latter possess unusual technical
level of care, skill and diligence which physicians in the same skills which laymen in most instances are incapable of
general neighborhood and in the same general line of intelligently evaluating; hence, the indispensability of expert
practice ordinarily possess and exercise in like cases. Even testimonies.
so, proof of breach of duty on the part of the attending 177
physician is insufficient, for there must be a causal
connection between said breach and the resulting injury
sustained by the patient. Put in another way, in order that VOL. 586, APRIL 21, 2009 177
there may be a recovery for an injury, it must be shown that
Lucas vs. Tuaño
the “injury for which recovery is sought must be the
legitimate consequence of the wrong done; the connection
between the negligence and the injury must be a direct and Same; Same; Same; The mere fact that the patient does
natural sequence of events, unbroken by intervening efficient not get well or that a bad result occurs does not in itself
causes”; that is, the negligence must be the proximate cause indicate failure to exercise due care.—We cannot but agree
of the injury. And the proximate cause of an injury is that with Dr. Tuaño’s assertion that when a doctor sees a patient,
cause, which, in the natural and continuous sequence, he cannot determine immediately whether the latter would
unbroken by any efficient intervening cause, produces the react adversely to the use of steroids; all the doctor can do is
injury, and without which the result would not have map out a course of treatment recognized as correct by the
occurred. standards of the medical profession. It must be remembered
Same; Same; Same; Evidence; Expert Witnesses; Medical that a physician is not an insurer of the good result of
negligence cases are best proved by opinions of expert treatment. The mere fact that the patient does not get well or
witnesses belonging in the same general neighborhood and in that a bad result occurs does not in itself indicate failure to
the same general line of practice as defendant physician or exercise due care.The result is not determinative of the
surgeon.—Just as with the elements of duty and breach of performance [of the physician] and he is not required to be
the same, in order to establish the proximate cause [of the infallible.
injury] by a preponderance of the evidence in a medical Same; Same; Same; The critical and clinching factor in a
malpractice action, [the patient] must similarly use expert medical negligence case is proof of the causal connection
testimony, because the question of whether the alleged between the negligence which the evidence established and the
professional negligence caused [the patient’s] injury is plaintiff’s injuries.—Even if we are to assume that Dr. Tuaño
generally one for specialized expert knowledge beyond the committed negligent acts in his treatment of Peter’s
ken of the average layperson; using the specialized condition, the causal connection between Dr. Tuaño’s
knowledge and training of his field, the expert’s role is to supposed negligence and Peter’s injury still needed to be
present to the [court] a realistic assessment of the likelihood established. The critical and clinching factor in a medical
that [the physician’s] alleged negligence caused [the negligence case is proof of the causal connection between the
patient’s] injury. From the foregoing, it is apparent that negligence which the evidence established and the plaintiff’s
medical negligence cases are best proved by opinions of
injuries. The plaintiff must plead and prove not only that he presumption that in proper cases, he takes the necessary
has been injured and defendant has been at fault, but also precaution and employs the best of his knowledge and skill in
that the defendant’s fault caused the injury. A verdict in a attending to his clients, unless the contrary is sufficiently
malpractice action cannot be based on speculation or established.—It must be remembered that when the
conjecture. Causation must be proven within a reasonable qualifications of a physician are admitted, as in the instant
medical probability based upon competent expert testimony. case, there is an inevitable presumption that in proper cases,
Same; Same; Same; Glaucoma; Words and Phrases; In he takes the necessary precaution and employs the best of
Open-angle glaucoma, which is characterized by an almost his knowledge and skill in attending to his clients, unless the
complete absence of symptoms and a chronic, insidious contrary is sufficiently established. In making the judgment
course, halos around lights and blurring of vision do not call of treating Peter’s EKC with Maxitrol, Dr. Tuaño took
occur unless there has been a sudden increase in the the necessary precaution by palpating Peter’s eyes to monitor
intraocular vision.—Dr. Tuaño does not deny that the use of their IOP every time the latter went for a check-up, and he
Maxitrol involves the risk of increasing a patient’s IOP. In employed the best of his knowledge and skill earned from
fact, this was the reason why he made it a point to palpate years of training and practice.
Peter’s eyes every time the latter went to see him—so he Same; Same; Same; Civil Law; Evidence; Quantum of
could monitor the tension of Peter’s eyes. But to say that said Proof; Preponderance of Evidence; Words and Phrases; The
medication conclusively caused Peter’s glaucoma is purely concept of “preponderance of evidence” refers to evidence
speculative. Peter was diagnosed with open-angle glaucoma. which is of greater weight or more convincing than that which
This kind of glaucoma is characterized by an almost complete is offered in opposition to it—in the last analysis, it means
absence of symptoms and a chronic, insidious course. In probability of truth, it is evidence which is more convincing to
open-angle glaucoma, halos around lights and the court as worthy of belief than that which is offered in
opposition thereto.—The plaintiff in a civil case has the
178 burden of proof as he alleges the affirmative of the issue.
However, in the course of trial in a civil case, once plaintiff
makes out a prima facie case in his favor, the duty or the
178 SUPREME COURT REPORTS ANNOTATED
burden of evidence shifts to defendant to controvert
Lucas vs. Tuaño plaintiff’s prima facie case; otherwise, a verdict must be
returned in favor of plaintiff. The party having the burden of
proof must establish his case by a preponderance of evidence.
blurring of vision do not occur unless there has been a
The concept of “preponderance of evidence” refers to evidence
sudden increase in the intraocular vision. Visual acuity
which is of greater weight or more convincing than that
remains good until late in the course of the disease. Hence,
which is offered in opposition to it; in the last analysis, it
Dr. Tuaño claims that Peter’s glaucoma “can only be long
means probability of truth. It is evidence which is more
standing x x x because of the large C:D ratio,” and that “[t]he
convincing to the court as worthy
steroids provoked the latest glaucoma to be revealed earlier”
was a blessing in disguise “as [Peter] remained
179
asymptomatic prior to steroid application.”
Same; Same; Same; Presumptions; It must be
remembered that when the qualifications of a physician are VOL. 586, APRIL 21, 2009 179
admitted, as in the instant case, there is an inevitable Lucas vs. Tuaño
 180
of belief than that which is offered in opposition thereto. Rule
133, Section 1 of the Revised Rules of Court provides the
180 SUPREME COURT REPORTS ANNOTATED
guidelines for determining preponderance of evidence, thus:
In civil cases, the party having the burden of proof must Lucas vs. Tuaño
establish his case by a preponderance of evidence. In
determining where the preponderance or superior weight of CHICO-NAZARIO, J.:
evidence on the issues involved lies the court may consider In this petition for review on certiorari1 under Rule
all the facts and circumstances of the case, the witnesses’ 45 of the Revised Rules of Court, petitioners Peter Paul
manner of testifying, their intelligence, their means and Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas
opportunity of knowing the facts to which they are testifying, and Gillian Lucas seek the reversal of the 27
the nature of the facts to which they testify, the probability September 2006 Decision2 and 3 July 2007 Resolution,3
or improbability of their testimony, their interest or want of both of the Court of Appeals in CA-G.R. CV No. 68666,
interest, and also their personal credibility so far as the same entitled “Peter Paul Patrick Lucas, Fatima Gladys
legitimately appear upon the trial. The court may also Lucas, Abbeygail Lucas and Gillian Lucas v. Prospero
consider the number of witnesses, though the preponderance Ma. C. Tuaño.”
is not necessarily with the greater number. In the questioned decision and resolution, the Court
Same; Same; Same; Evidence; Expert Witnesses; It seems of Appeals affirmed the 14 July 2000 Decision of the
basic that what constitutes proper medical treatment is a Regional Trial Court (RTC), Branch 150, Makati City,
medical question that should have been presented to experts— dismissing the complaint filed by petitioners in a civil
if no standard is established through expert medical case entitled, “Peter Paul Patrick Lucas, Fatima
witnesses, then courts have no standard by which to gauge the Gladys Lucas, Abbeygail Lucas and Gillian Lucas v.
basic issue of breach thereof by the physician or surgeon.—It Prospero Ma. C. Tuaño,” docketed as Civil Case No. 92-
seems basic that what constitutes proper medical treatment 2482.
is a medical question that should have been presented to From the record of the case, the established factual
experts. If no standard is established through expert medical antecedents of the present petition are:
witnesses, then courts have no standard by which to gauge Sometime in August 1988, petitioner Peter Paul
the basic issue of breach thereof by the physician or surgeon. Patrick Lucas (Peter) contracted “sore eyes” in his
The RTC and Court of Appeals, and even this Court, could right eye.
not be expected to determine on its own what medical On 2 September 1988, complaining of a red right
technique should have been utilized for a certain disease or eye and swollen eyelid, Peter made use of his health
injury. Absent expert medical opinion, the courts would be care insurance issued by Philamcare Health Systems,
dangerously engaging in speculations. Inc. (Philamcare), for a possible consult. The
Philamcare Coordinator, Dr. Edwin Oca, M.D.,
PETITION for review on certiorari of the decision and referred Peter to respondent, Dr. Prospero Ma. C.
resolution of the Court of Appeals. Tuaño, M.D. (Dr. Tuaño), an ophthalmologist at St.
   The facts are stated in the opinion of the Court. Luke’s Medical Center, for an eye consult.
  Fortun and Narvasa Law Offices for petitioners. Upon consultation with Dr. Tuaño, Peter narrated that
  K.V. Faylona and Associates for respondent. it had been nine (9) days since the problem with his
right eye
_______________ 4  Ophthalmoscopy is a test that allows a health professional to
see inside the back of the eye (called the fundus) and other
1 Rollo, pp. 9-48.
structures using a magnifying instrument (ophthalmoscope) and a
2 Penned by Court of Appeals Associate Justice Marina L. Buzon light source. It is done as part of an eye examination and may be
with Associate Justices Regalado E. Maambong and Japar B. done as part of a routine physical examination
Dimaampao concurring; Annex “A” of the Petition; id., at pp. 49-69. (http://www.webmd.com/eye-health/ophthalmoscopy).
3 Annex “B” of the Petition; id., at pp. 70-72. 5 Conjunctivitis, also known as pinkeye, is an inflammation of the
conjunctiva, the thin, clear tissue that lies over the white part of the
181
eye and lines the inside of the eyelid (http://www.webmd.com
/eye-health/eye-health-conjunctivitis).
VOL. 586, APRIL 21, 2009 181 6 The generic name of Spersacet-C ophthalmic drops is

Lucas vs. Tuaño Sulfacetamide. It is prescribed for the treatment and prophylaxis of
conjunctivitis due to susceptible organisms; corneal ulcers;
adjunctive treatment with systemic sulfonamides for therapy of
began; and that he was already taking Maxitrol to
trachoma
address the problem in his eye. According to Dr.
(http://www.merck.com/mmpe/lexicomp/sulfacetamide.html).
Tuaño, he performed “ocular routine examination” on
7 Epidemic kerato conjunctivitis is a type of adenovirus ocular
Peter’s eyes, wherein: (1) a gross examination of
infection. (http://emedicine.medscape.com/article/1192751-overview).
Peter’s eyes and their surrounding area was made; (2)
Peter’s visual acuity were taken; (3) Peter’s eyes were 182
palpated to check the intraocular pressure of each; (4)
the motility of Peter’s eyes was observed; and (5) the
ophthalmoscopy4 on Peter’s eyes was used. On that 182 SUPREME COURT REPORTS ANNOTATED
particular consultation, Dr. Tuaño diagnosed that Lucas vs. Tuaño
Peter was suffering from conjunctivitis5 or “sore eyes.”
Dr. Tuaño then prescribed Spersacet-C6 eye drops for called Maxitrol,8 a dosage of six (6) drops per day.9 To
Peter and told the latter to return for follow-up after recall, Peter had already been using Maxitrol prior to
one week. his consult with Dr. Tuaño.
As instructed, Peter went back to Dr. Tuaño on 9 On 21 September 1988, Peter saw Dr. Tuaño for a
September 1988. Upon examination, Dr. Tuaño told follow-up consultation. After examining both of Peter’s
Peter that the “sore eyes” in the latter’s right eye had eyes, Dr. Tuaño instructed the former to taper down10
already cleared up and he could discontinue the the dosage of Maxitrol, because the EKC in his right
Spersacet-C. However, the same eye developed eye had already resolved. Dr. Tuaño specifically
Epidemic Kerato Conjunctivitis (EKC),7 a viral cautioned Peter that, being a steroid, Maxitrol had to
infection. To address the new problem with Peter’s be withdrawn gradually; otherwise, the EKC might
right eye, Dr. Tuaño prescribed to the former a steroid- recur.11
based eye drop Complaining of feeling as if there was something in
his eyes, Peter returned to Dr. Tuaño for another
_______________ check-up on 6 October 1988. Dr. Tuaño examined
Peter’s eyes and found that the right eye had once
more developed EKC. So, Dr. Tuaño instructed Peter to present in his right eye. As a result, Dr. Tuaño told
resume the use of Maxitrol at six (6) drops per day. Peter to resume the maximum dosage of Blephamide.
On his way home, Peter was unable to get a hold of Dr. Tuaño saw Peter once more at the former’s clinic
Maxitrol, as it was out of stock. Consequently, Peter on 4 November 1988. Dr. Tuaño’s examination showed
was told by Dr. Tuano to take, instead, Blephamide12 that only the periphery of Peter’s right eye was
another steroid-based medication, but with a lower positive for EKC; hence, Dr. Tuaño prescribed a lower
concentration, as substitute for the unavailable dosage of Blephamide.
Maxitrol, to be used three (3) times a It was also about this time that Fatima Gladys
Lucas (Fatima), Peter’s spouse, read the accompanying
_______________ literature of Maxitrol and found therein the following
warning against the prolonged use of such steroids:
8 Neomycin/polymyxin B sulfates/dexamethasone is the generic
name of Maxitrol Ophthalmic Ointment. It is a multiple dose anti- WARNING:
infective steroid combination in sterile form for topical application Prolonged use may result in glaucoma, with damage to the
(http://www.druglib.com/druginfo/maxitrol/). optic nerve, defects in visual acuity and fields of vision, and
9 Exhibit “A”; Records, p. 344. posterior, subcapsular cataract formation. Prolonged use may
10 Apply 5-6 drops for 5 days; then 3 drops for 3 days; and then a suppress the host response and thus increase the hazard of
minimum of 1 drop per day. secondary ocular infractions, in those diseases causing
11 TSN, 27 September 1993, pp. 18-19. thinning of the cornea or sclera, perforations have been
12 Blephamide Ophthalmic Suspenion contains known to occur with the use of topical steroids. In acute
Sulfacetamide/Prednisolone. This medication contains an antibiotic purulent conditions of the eye, steroids may mask infection
(sulfacetamide) that stops the growth of bacteria and a corticosteroid
or enhance existing infection. If these products are used for
10 days or longer, intraocular pressure should be routinely
(prednisolone) that reduces inflammation
monitored even though it may be difficult in children and
(http://www.webmd.com/drugs/drug-6695-Blephamide+Opht.aspx?
uncooperative patients.
drugid=6695&drugname=Blephamide+Opht).
Employment of steroid medication in the treatment of
183 herpes simplex requires great caution.
xxxx

VOL. 586, APRIL 21, 2009 183

_______________
Lucas vs. Tuaño
13 Exhibit “H”; Records, p. 346.

day for five (5) days; two (2) times a day for five (5) 184
days; and then just once a day.13
Several days later, on 18 October 1988, Peter went 184 SUPREME COURT REPORTS ANNOTATED
to see Dr. Tuaño at his clinic, alleging severe eye pain,
Lucas vs. Tuaño
feeling as if his eyes were about to “pop-out,” a
headache and blurred vision. Dr. Tuaño examined
Peter’s eyes and discovered that the EKC was again ADVERSE REACTIONS:
Adverse reactions have occurred with steroid/anti-
infective combination drugs which can be attributed to the
steroid component, the anti-infective component, or the 185
combination. Exact incidence figures are not available since
no denominator of treated patients is available.
VOL. 586, APRIL 21, 2009 185
Reactions occurring most often from the presence of the
anti-infective ingredients are allergic sensitizations. The Lucas vs. Tuaño
reactions due to the steroid component in decreasing order to
frequency are elevation of intra-ocular pressure (IOP) with Upon waking in the morning of 13 December 1988,
possible development of glaucoma, infrequent optic nerve Peter had no vision in his right eye. Fatima observed
damage; posterior subcapsular cataract formation; and that Peter’s right eye appeared to be bloody and
delayed wound healing. swollen.15 Thus, spouses Peter and Fatima rushed to
Secondary infection: The development of secondary has the clinic of Dr. Tuaño. Peter reported to Dr. Tuaño
occurred after use of combination containing steroids and that he had been suffering from constant headache in
antimicrobials. Fungal infections of the correa are the afternoon and blurring of vision.
particularly prone to develop coincidentally with long-term Upon examination, Dr. Tuaño noted the hardness of
applications of steroid. The possibility of fungal invasion Peter’s right eye. With the use of a tonometer16 to
must be considered in any persistent corneal ulceration verify the exact intraocular pressure17 (IOP) of Peter’s
where steroid treatment has been used. eyes, Dr. Tuaño discovered that the tension in Peter’s
Secondary bacterial ocular infection following suppression right eye was 39.0 Hg, while that of his left was 17.0
of host responses also occurs.” Hg.18 Since the tension in Peter’s right eye was way
over the normal IOP, which merely ranged from 10.0
On 26 November 1988, Peter returned to Dr. Hg to 21.0 Hg,19 Dr. Tuaño ordered20 him to
Tuaño’s clinic, complaining of “feeling worse.”14 It immediately discontinue the use of Maxitrol and
appeared that the EKC had spread to the whole of prescribed to the latter Diamox21 and Normoglaucon,
Peter’s right eye yet again. Thus, Dr. Tuaño instructed instead.22 Dr. Tuaño also required Peter to go for daily
Peter to resume the use of Maxitrol. Petitioners check-up in order for the former to closely monitor the
averred that Peter already made mention to Dr. Tuaño pressure of the latter’s eyes.
during said visit of the above-quoted warning against
the prolonged use of steroids, but Dr. Tuaño
_______________
supposedly brushed aside Peter’s concern as mere
paranoia, even assuring him that the former was 15 TSN, 3 May 1995, p. 14.
taking care of him (Peter). 16 A tonometer is an instrument for measuring the tension or
Petitioners further alleged that after Peter’s 26 pressure, particularly intraocular pressure (http://medical-
November 1988 visit to Dr. Tuaño, Peter continued to dictionary. thefreedictionary.com/tonometer).
suffer pain in his right eye, which seemed to 17 Intraocular Pressure (IOP) is the pressure created by the
“progress,” with the ache intensifying and becoming continual renewal of fluids within the eye (http://www.medterms.
more frequent. com/script/main/art.asp?articlekey=4014).
18 Exhibit “1-a”; Records, p. 618-A.
_______________ 19 Normal IOP is measured in millimeters of Mercury (Hg).
20 See note 19.
14 TSN, 27 September 1993, p. 40.
 21 The generic name of Diamox, for oral administration, is called the intraocular pressure, can damage the optic nerve, which
acetazolamide. This medication is a potent carbonic anhydrase inhi- transmits images to the brain. If the damage to the optic nerve from
bitor, effective in the control of fluid secretion (http://www.drugs. high eye pressure continues, glaucoma will cause loss of vision
com/pro/diamox.html). (http://www.webmd.com/eye-health/glaucoma-eyes).
22 The active ingredient of Normoglaucon is Metipranolol 26 O.D. is the abbreviation for oculus dexter, a Latin phrase
hydrochloride. It is used for the reduction of intraocular pressure in meaning “right eye” (http://medical-dictionary.thefreedictionary.com/
patients with glaucoma (open, closed angle) in situations in which O.D).
monotherapy with pilocarpine or beta-blockers are insufficient 27 Laser Trabeculoplasty is a kind of surgery which uses a very
(http://www.angelini.it/public/schedepharma/normoglaucon.htm). focused beam of light to treat the drainage angle of the eye. This
surgery makes it easier for fluid to flow out of the front part of the
186
eye, decreasing pressure in the eye (http://www.med.nyu.edu/health
wise).
186 SUPREME COURT REPORTS ANNOTATED 28 According to Peter, after seeing Dr. Tuaño on the 15th of
December 1988, he next saw him on the 17th of the same month. Per
Lucas vs. Tuaño
Exhibit 1-a, the patient’s index card, however, after the 15th of
December 1988, Peter’s next visit was on the 23rd of the same
On 15 December 1988, the tonometer reading of month.
Peter’s right eye yielded a high normal level, i.e., 29 Exhibit “1-a”; Records, p. 618-A.
21.0 Hg. Hence, Dr. Tuaño told Peter to continue using
Diamox and Normoglaucon. But upon Peter’s 187
complaint of “stomach pains and tingling sensation in
his fingers,”23 Dr. Tuaño discontinued Peter’s use of VOL. 586, APRIL 21, 2009 187
Diamox.24
Peter went to see another ophthalmologist, Dr. Lucas vs. Tuaño
Ramon T. Batungbacal (Dr. Batungbacal), on 21
December 1988, who allegedly conducted a complete problem by advising Peter to resume taking Diamox
ophthalmological examination of Peter’s eyes. Dr. along with Normoglaucon.
Batungbacal’s diagnosis was Glaucoma25 O.D.26 He During the Christmas holidays, Peter supposedly
recommended Laser Trabeculoplasty27 for Peter’s right stayed in bed most of the time and was not able to
eye. celebrate the season with his family because of the
When Peter returned to Dr. Tuaño on 23 December debilitating effects of Diamox.30
1988,28 the tonometer measured the IOP of Peter’s On 28 December 1988, during one of Peter’s regular
right eye to be 41.0 Hg,29 again, way above normal. Dr. follow-ups with Dr. Tuaño, the doctor conducted
Tuaño addressed the another ocular routine examination of Peter’s eyes. Dr.
Tuaño noted the recurrence of EKC in Peter’s right
_______________ eye. Considering, however, that the IOP of Peter’s
right eye was still quite high at 41.0 Hg, Dr. Tuaño
23 TSN, 11 October 1993, p. 7. was at a loss as to how to balance the treatment of
24 Exhibit “1-a”; Records, p. 618-A. Peter’s EKC vis-à-vis the presence of glaucoma in the
25  Glaucoma is an eye condition which develops when too much same eye. Dr. Tuaño, thus, referred Peter to Dr.
fluid pressure builds up inside of the eye. The increased pressure,
Manuel B. Agulto, M.D. (Dr. Agulto), another “Thanks for sending Peter Lucas. On examination
ophthalmologist specializing in the treatment of conducted vision was 20/25 R and 20/20L. Tension curve 19 R
glaucoma.31 Dr. Tuaño’s letter of referral to Dr. Agulto and 15 L at 1210 H while on Normoglaucon BID OD &
stated that: Diamox ½ tab every 6h po.
Slit lamp evaluation33 disclosed subepithelial corneal
“Referring to you Mr. Peter Lucas for evaluation & defect outer OD. There was circumferential peripheral iris
possible management. I initially saw him Sept. 2, 1988 atrophy, OD. The lenses were clear.
because of conjunctivitis. The latter resolved and he Funduscopy34 showed vertical cup disc of 0.85 R and 0.6 L
developed EKC for which I gave Maxitrol. The EKC was with temporal slope R>L.
recurrent after stopping steroid drops. Around 1 month of Zeiss gonioscopy35 revealed basically open angles both
steroid treatment, he noted blurring of vision & pain on the eyes with occasional PAS,36 OD.
R. however, I continued the steroids for the sake of the EKC. Rolly, I feel that Peter Lucas has really sustained significant
A month ago, I noted iris atrophy, so I took the IOP and it glaucoma damage. I suggest that we do a baseline visual
was definitely elevated. I stopped the steroids immediately fields and push medication to lowest possible levels. If I may
and has (sic) been treating him medically. suggest further, I think we should prescribe Timolol37 BID38
It seems that the IOP can be controlled only with oral OD in lieu of Normoglau-
Diamox, and at the moment, the EKC has recurred and I’m
in a fix whether to resume the steroid or not considering that
_______________
the IOP is still uncontrolled.”32
33 The slit-lamp evaluation/examination looks at structures that are at
On 29 December 1988, Peter went to see Dr. Agulto the front of the eye using a slit-lamp, a low-powered microscope combined
at the latter’s clinic. Several tests were conducted with a high-intensity light source that can be focused to shine in a thin beam
thereat to evaluate the extent of Peter’s condition. Dr. (http://www.nlm.nih.gov/medline
Agulto wrote Dr. plus/ency/article/003880.htm).
34 Funduscopy is the examination of the back part of the eye’s interior
_______________ (fundus); also known as ophthalmoscopy.
35  Zeiss Gonioscopy (indirect gonioscopy) is the visualization of the
30 TSN, 11 October 1993, pp. 16-17.
anterior chamber angle of the eyes undertaken using a Zeiss lens. It is
31 Id., at p. 18.
essential to determine the mechanism responsible for impeding aqueous flow
32 Exhibit “C”; Records, p. 352. (http://www.glaucomaworld.net/english/019/e019a01.html).
36 Peripheral Anterior Synechiae.
188
37 Timolol Maleate is a generic name of a drug in ophthalmic dosage form
used in treatment of elevated intraocular pressure by reducing aqueous
188 SUPREME COURT REPORTS ANNOTATED humor production or possibly outflow

Lucas vs. Tuaño (http://www.umm.edu/altmed/drugs/timolol-125400.htm).

38 B.I.D. is the abbreviation of the Latin phrase bis in di´e, meaning
“twice a day” (http://medical-dictionary.thefreedictionary.com/B.I.D).
Tuaño a letter containing the following findings and
recommendations: 189

VOL. 586, APRIL 21, 2009 189

 Lucas vs. Tuaño 43 A test to determine the total area in which objects can be seen
in the peripheral vision while the eye is focused on a central point
con. If the IOP is still inadequate, we may try D’epifrin39 BID (http://www.healthline.com/ adamcontent/visual-field).
OD (despite low PAS). I’m in favor of retaining Diamox or 44 A centrally constricted field of vision that is like what you can
similar CAI.40 see through a tube (http://www.medterms.com/script/main/art.
If fields show further loss in say—3 mos. then we should asp?articlekey=24516).
consider trabeculoplasty.
190
I trust that this approach will prove reasonable for you
and Peter.”41
190 SUPREME COURT REPORTS ANNOTATED
Peter went to see Dr. Tuaño on 31 December 1988,
bearing Dr. Agulto’s aforementioned letter. Though Lucas vs. Tuaño
Peter’s right and left eyes then had normal IOP of 21.0
Hg and 17.0 Hg, respectively, Dr. Tuaño still gave him right eye went up even further to 41.0 Hg in just a
a prescription for Timolol B.I.D. so Peter could matter of two (2) days, in the meantime that Timolol
immediately start using said medication. Regrettably, B.I.D. and D’epifrin were still not available in the
Timolol B.I.D. was out of stock, so Dr. Tuaño market. Again, Dr. Tuaño advised Peter to come for
instructed Peter to just continue using Diamox and regular check-up so his IOP could be monitored.
Normoglaucon in the meantime. Obediently, Peter went to see Dr. Tuaño on the 7th,
Just two days later, on 2 January 1989, the IOP of 13th, 16th and 20th of January 1989 for check-up and
Peter’s right eye remained elevated at 21.0 Hg,42 as he IOP monitoring.
had been without Diamox for the past three (3) days. In the interregnum, however, Peter was prodded by
On 4 January 1989, Dr. Tuaño conducted a visual his friends to seek a second medical opinion. On 13
field study43 of Peter’s eyes, which revealed that the January 1989, Peter consulted Dr. Jaime Lapuz, M.D.
latter had tubular vision44 in his right eye, while that (Dr. Lapuz), an ophthalmologist, who, in turn, referred
of his left eye remained normal. Dr. Tuaño directed Peter to Dr. Mario V. Aquino, M.D. (Dr. Aquino),
Peter to religiously use the Diamox and Normoglaucon, another ophthalmologist who specializes in the
as the tension of the latter’s treatment of glaucoma and who could undertake the
long term care of Peter’s eyes.
_______________ According to petitioners, after Dr. Aquino conducted
an extensive evaluation of Peter’s eyes, the said doctor
39 The generic name of the medication D’epifrin is dipivefrin informed Peter that his eyes were relatively normal,
ophthalmic. It is used to treat open-angle glaucoma or ocular though the right one sometimes manifested maximum
hypertension by reducing the amount of fluid in the eye thereby borderline tension. Dr. Aquino also confirmed Dr.
decreasing intraocular pressure Tuaño’s diagnosis of tubular vision in Peter’s right eye.
(http://www.drugs.com/mtmdipivefrin-ophthalmic.html). Petitioners claimed that Dr. Aquino essentially told
40 Carbon Anhydrase Inhibitor. Peter that the latter’s condition would require lifetime
41 Exhibit “D”; Records, pp. 356-357. medication and follow-ups.
42 Exhibit “1-a”; id., at p. 618-A. In May 1990 and June 1991, Peter underwent two
(2) procedures of laser trabeculoplasty to attempt to
control the high IOP of his right eye.
 Claiming to have steroid-induced glaucoma45 and and was continuing to suffer;50 his anticipated income
blaming Dr. Tuaño for the same, Peter, joined by: (1) had been greatly reduced as a result of his “limited”
Fatima, his spouse;46 (2) Abbeygail, his natural child;47 capacity; he continually suffered from “headaches,
and (3) Gillian, his nausea, dizziness, heart palpitations, rashes, chronic
rhinitis, sinusitis,”51 etc.; Peter’s relationships with his
_______________ spouse and children continued to be strained, as his
condition made him highly irritable and sensitive; his
45 A form of open-angle glaucoma that usually is associated with mobility and social life had suffered; his spouse,
topical steroid use, but it may develop with inhaled, oral, Fatima, became the breadwinner in the family;52 and
intravenous, periocular, or intravitreal steroid administration (http:// his two children had been deprived of the opportunity
emedicine.medscape.com/article/1205298-print). for a better life
46 As evidenced by a Marriage Contract between Peter and
Fatima; Records, p. 340.
_______________
47 As evidenced by the child’s Certificate of Live Birth; id., at p.
341. 48 As evidenced by the child’s Certificate of Live Birth; id., at p.
342.
191
49 Amended Complaint, p. 4; id., at p. 79.
50 Peter alleged that due to is impaired vision, he was ‘forced’ to
VOL. 586, APRIL 21, 2009 191 decline several opportunities to cover international and regional
sports events, i.e., the 1988 and 1992 Olympics as well as various
Lucas vs. Tuaño
Asian Games; and he could not cover fast-paced games, i.e.,
basketball.
legitimate child48 with Fatima, instituted on 1 51 Amended Complaint, p. 4; Records, p. 79.
September 1992, a civil complaint for damages against 52 Id.
Dr. Tuaño, before the RTC, Branch 150, Quezon City.
The case was docketed as Civil Case No. 92-2482. 192
In their Complaint, petitioners specifically averred
that as the “direct consequence of [Peter’s] prolonged
192 SUPREME COURT REPORTS ANNOTATED
use of Maxitrol, [he] suffered from steroid induced
glaucoma which caused the elevation of his intra- Lucas vs. Tuaño
ocular pressure. The elevation of the intra-ocular
pressure of [Peter’s right eye] caused the impairment and educational prospects. Collectively, petitioners
of his vision which impairment is not curable and may lived in constant fear of Peter becoming completely
even lead to total blindness.”49 blind.53
Petitioners additionally alleged that the visual In the end, petitioners sought pecuniary award for
impairment of Peter’s right eye caused him and his their supposed pain and suffering, which were
family so much grief. Because of his present condition, ultimately brought about by Dr. Tuaño’s grossly
Peter now needed close medical supervision forever; he negligent conduct in prescribing to Peter the medicine
had already undergone two (2) laser surgeries, with Maxitrol for a period of three (3) months, without
the possibility that more surgeries were still needed in monitoring Peter’s IOP, as required in cases of
the future; his career in sports casting had suffered
prolonged use of said medicine, and notwithstanding eyes.”56 Dr. Tuaño also clarified that (1) “[c]ontrary to
Peter’s constant complaint of intense eye pain while [petitioners’] fallacious claim, [he] did NOT continually
using the same. Petitioners particularly prayed that prescribe the drug Maxitrol which contained steroids
Dr. Tuaño be adjudged liable for the following for any prolonged period”57 and “[t]he truth was the
amounts: Maxitrol was discontinued x x x as soon as EKC
disappeared and was resumed only when EKC
“1. The amount of P2,000,000.00 to plaintiff Peter Lucas reappeared”58; (2) the entire time he was treating
as and by way of compensation for his impaired vision. Peter, he “continually monitored the intraocular
2. The amount of P300,000.00 to spouses Lucas as and pressure of [Peter’s eyes] by palpating the eyes and by
by way of actual damages plus such additional amounts that putting pressure on the eyeballs,” and no hardening of
may be proven during trial. the same could be detected, which meant that there
3. The amount of P1,000,000.00 as and by way of moral was no increase in the tension or IOP, a possible side
damages. reaction to the use of steroid medications; and (3) it
4. The amount of P500,000.00 as and by way of was only on 13 December 1988 that Peter complained
exemplary damages. of a headache and blurred vision in his right eye, and
5. The amount of P200,000.00 as and by way of upon measuring the IOP of said eye, it was determined
attorney’s fees plus costs of suit.”54 for the first time that the IOP of the right eye had an
elevated value.
In rebutting petitioners’ complaint, Dr. Tuaño
But granting for the sake of argument that the
asserted that the “treatment made by [him] more than
“steroid treatment of [Peter’s] EKC caused the steroid
three years ago has no causal connection to [Peter’s]
induced glaucoma,”59 Dr. Tuaño argued that:
present glaucoma or condition.”55 Dr. Tuaño explained
that “[d]rug-induced glaucoma is temporary and “[S]uch condition, i.e., elevated intraocular pressure, is
curable, steroids have the side effect of increasing temporary. As soon as the intake of steroids is discontinued,
intraocular pressure. Steroids are prescribed to treat the intraocular pressure automatically is reduced. Thus,
Epidemic Kerato Conjunctivitis or EKC which is an [Peter’s] glaucoma can only be due to other causes not
infiltration of the cornea as a result of conjunctivitis or attributable to steroids, certainly not attributable to [his]
sore treatment of more than three years ago x x x.
From a medical point of view, as revealed by more current
_______________ examination of [Peter], the latter’s glaucoma can only be long
standing glaucoma, open angle glaucoma, because of the
53 Id.
large C:D ratio. The steroids provoked the latest glaucoma to
54 Id., at p. 82. be revealed earlier as [Peter] remained asymptomatic prior
55 Answer, p. 6; id., at p. 38. to steroid application. Hence, the steroid treatment was in
fact beneficial to [Peter] as it revealed the incipient open
193
angle glaucoma of [Peter] to allow earlier treatment of the
same.”60
VOL. 586, APRIL 21, 2009 193
Lucas vs. Tuaño _______________

56 Id.
 57 Id. and indispensable to establish such a standard because once
58 Id. it is established, a medical practitioner who departed thereof
59 Answer, p. 13; id., at p. 45. breaches his duty and commits negligence rendering him
60 Id. liable. Without such testimony or enlightenment from an
expert, the court is at a loss as to what is then the
194 established norm of duty of a physician against which
defendant’s conduct can be compared with to determine
negligence.”64
194 SUPREME COURT REPORTS ANNOTATED
Lucas vs. Tuaño
_______________

In a Decision dated 14 July 2000, the RTC 61 Id., at pp. 722-734.

dismissed Civil Case No. 92-2482 “for insufficiency of 62 Id., at p. 734.
evidence.”61 The decretal part of said Decision reads: 63 Id.
64 Id., at p. 731.
“Wherefore, premises considered, the instant complaint is
dismissed for insufficiency of evidence. The counter claim 195
(sic) is likewise dismissed in the absence of bad faith or
malice on the part of plaintiff in filing the suit.”62
VOL. 586, APRIL 21, 2009 195
The RTC opined that petitioners failed to prove by Lucas vs. Tuaño
preponderance of evidence that Dr. Tuaño was
negligent in his treatment of Peter’s condition. In
The RTC added that in the absence of “any medical
particular, the record of the case was bereft of any
evidence to the contrary, this court cannot accept
evidence to establish that the steroid medication and
[petitioners’] claim that the use of steroid is the
its dosage, as prescribed by Dr. Tuaño, caused Peter’s
proximate cause of the damage sustained by [Peter’s]
glaucoma. The trial court reasoned that the
eye.”65
“recognized standards of the medical community has
Correspondingly, the RTC accepted Dr. Tuaño’s
not been established in this case, much less has
medical opinion that “Peter Paul must have been
causation been established to render [Tuaño] liable.”63
suffering from normal tension glaucoma, meaning,
According to the RTC:
optic nerve damage was happening but no elevation of
“[Petitioners] failed to establish the duty required of a the eye pressure is manifested, that the steroid
medical practitioner against which Peter Paul’s treatment by treatment actually unmasked the condition that
defendant can be compared with. They did not present any resulted in the earlier treatment of the glaucoma.
medical expert or even a medical doctor to convince and There is nothing in the record to contradict such
expertly explain to the court the established norm or duty testimony. In fact, plaintiff’s Exhibit ‘S’ even tends to
required of a physician treating a patient, or whether the non support them.”
taking (sic) by Dr. Tuaño of Peter Paul’s pressure a deviation Undaunted, petitioners appealed the foregoing RTC
from the norm or his non-discovery of the glaucoma in the decision to the Court of Appeals. Their appeal was
course of treatment constitutes negligence. It is important docketed as CA-G.R. CV No. 68666.
 On 27 September 2006, the Court of Appeals the latter’s explanation that:
rendered a decision in CA-G.R. CV No. 68666 denying
petitioners’ recourse and affirming the appealed RTC “[W]hen a doctor sees a patient, he cannot determine
Decision. The fallo of the judgment of the appellate whether or not the latter would react adversely to the use of
court states: steroids, that it was only on December 13, 1989, when Peter
complained for the first time of headache and blurred vision
“WHEREFORE, the Decision appealed from is that he observed that the pressure of the eye of Peter was
AFFIRMED.”66 elevated, and it was only then that he suspected that Peter
belongs to the 5% of the population who reacts adversely to
The Court of Appeals faulted petitioners because steroids.”68
they—
Petitioners’ Motion for Reconsideration was denied
“[D]id not present any medical expert to testify that Dr. by the Court of Appeals in a Resolution dated 3 July
Tuano’s prescription of Maxitrol and Blephamide for the 2007.
treatment of EKC on Peter’s right eye was not proper and Hence, this Petition for Review on Certiorari under
that his palpation of Peter’s right eye was not enough to Rule 45 of the Revised Rules of Court premised on the
detect adverse reaction to steroid. Peter testified that Dr. following assignment of errors:
Manuel Agulto told him that he should not have used steroid
for the treatment of EKC or that he should have used it only I.
for two (2) weeks, as EKC is only a viral infection which will THE COURT OF APPEALS COMMITTED GRAVE
cure by itself. However, Dr. Agulto was not presented by REVERSIBLE ERROR IN AFFIRMING THE DECISION OF
[petitioners] as a witness to confirm what he allegedly told THE TRIAL COURT DISMISSING THE PETITIONERS’
Peter and, therefore, the latter’s testimony is hearsay. Under COMPLAINT FOR DAMAGES AGAINST THE
Rule 130, Section 36 of the Rules of Court, a witness can RESPONDENT ON THE GROUND OF INSUFFICIENCY
testify only to those facts which he OF EVIDENCE;
II.
_______________ THE COURT OF APPEALS COMMITTED GRAVE
REVERSIBLE ERROR IN DISMISSING THE
65 Id.
PETITIONERS’ COMPLAINT FOR DAMAGES AGAINST
66 Rollo, p. 68.
THE RESPONDENT ON THE GROUND THAT NO
196
MEDICAL EXPERT WAS PRESENTED BY THE
PETITIONERS TO PROVE THEIR CLAIM FOR MEDICAL
NEGLIGENCE AGAINST THE RESPONDENT; AND
196 SUPREME COURT REPORTS ANNOTATED
Lucas vs. Tuaño _______________

knows of his own personal knowledge, x x x. Familiar and 67 Id., at p. 67.

fundamental is the rule that hearsay testimony is 68 Id., at p. 66.

inadmissible as evidence.”67
197

Like the RTC, the Court of Appeals gave great

weight to Dr. Tuaño’s medical judgment, specifically VOL. 586, APRIL 21, 2009 197
 Lucas vs. Tuaño 69 Id., at p. 23.
70  Civil Service Commission v. Maala, G.R. No. 165253, 18
III. August 2005, 467 SCRA 390, 398.
THE COURT OF APPEALS COMMITTED GRAVE 71 Alfaro v. Court of Appeals, 416 Phil. 310, 317; 363 SCRA 799,
REVERSIBLE ERROR IN NOT FINDING THE 806 (2001).
RESPONDENT LIABLE TO THE PETITIONERS’ FOR
198
ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE
FROM ATTORNEY’S FEES, COSTS OF SUIT, AS A
RESULT OF HIS GROSS NEGLIGENCE.69 198 SUPREME COURT REPORTS ANNOTATED

A reading of the afore-quoted reversible errors Lucas vs. Tuaño

supposedly committed by the Court of Appeals in its
Decision and Resolution would reveal that petitioners Nonetheless, the general rule that only questions of
are fundamentally assailing the finding of the Court of law may be raised on appeal in a petition for review
Appeals that the evidence on record is insufficient to under Rule 45 of the Rules of Court admits of certain
establish petitioners’ entitlement to any kind of exceptions, including the circumstance when the
damage. Therefore, it could be said that the sole issue finding of fact of the Court of Appeals is premised on
for our resolution in the Petition at bar is whether the the supposed absence of evidence, but is contradicted
Court of Appeals committed reversible error in by the evidence on record. Although petitioners may
affirming the judgment of the RTC that petitioners not explicitly invoke said exception, it may be gleaned
failed to prove, by preponderance of evidence, their from their allegations and arguments in the instant
claim for damages against Dr. Tuaño. Petition.
Evidently, said issue constitutes a question of fact, Petitioners contend, that “[c]ontrary to the findings
as we are asked to revisit anew the factual findings of of the Honorable Court of Appeals, [they] were more
the Court of Appeals, as well as of the RTC. In effect, than able to establish that: Dr. Tuaño ignored the
petitioners would have us sift through the evidence on standard medical procedure for ophthalmologists,
record and pass upon whether there is sufficient basis administered medication with recklessness, and
to establish Dr. Tuaño’s negligence in his treatment of exhibited an absence of competence and skills expected
Peter’s eye condition. This question clearly involves a from him.”72 Petitioners reject the necessity of
factual inquiry, the determination of which is not presenting expert and/or medical testimony to
within the ambit of this Court’s power of review under establish (1) the standard of care respecting the
Rule 45 of the 1997 Rules Civil Procedure, as treatment of the disorder affecting Peter’s eye; and (2)
amended.70 whether or not negligence attended Dr. Tuaño’s
Elementary is the principle that this Court is not a treatment of Peter, because, in their words—
trier of facts; only errors of law are generally reviewed
“That Dr. Tuaño was grossly negligent in the treatment of
in petitions for review on certiorari criticizing decisions
Peter’s simple eye ailment is a simple case of cause and effect.
of the Court of Appeals. Questions of fact are not
With mere documentary evidence and based on the facts
entertained.71
presented by the petitioners, respondent can readily be held
liable for damages even without any expert testimony. In any
_______________
case, however, and contrary to the finding of the trial court
and the Court of Appeals, there was a medical expert and learning possessed by other persons in the same
presented by the petitioner showing the recklessness profession; and that as a proximate result of such
committed by [Dr. Tuaño]—Dr. Tuaño himself.” [Emphasis failure, the patient or his heirs suffered damages.
supplied.] For lack of a specific law geared towards the type of
negligence committed by members of the medical
They insist that Dr. Tuaño himself gave sufficient profession, such claim for damages is almost always
evidence to establish his gross negligence that anchored on the alleged violation of Article 2176 of the
ultimately caused the impairment of the vision of Civil Code, which states that:
Peter’s right eye,73 i.e., that “[d]espite [Dr. Tuaño’s]
knowledge that 5% of the population “ART. 2176. Whoever by act or omission causes damage
to another, there being fault or negligence, is obliged to pay
_______________ for the damage done. Such fault or negligence, if there is no
pre-existing contractual relation between the parties, is
72 Petition, p. 16; Rollo, p. 24. called a quasi-delict and is governed by the provisions of this
73 Id. Chapter.”

199 In medical negligence cases, also called medical

malpractice suits, there exist a physician-patient
relationship between the doctor and the victim. But
VOL. 586, APRIL 21, 2009 199
just like any other proceeding for damages, four
Lucas vs. Tuaño essential (4) elements i.e., (1) duty;

reacts adversely to Maxitrol, [he] had no qualms _______________

whatsoever in prescribing said steroid to Peter without
first determining whether or not the (sic) Peter belongs 74 Id., at p. 26.
to the 5%.”74 75 Amended Complaint, p. 6; Records, p. 81.
We are not convinced. The judgments of both the
200
Court of Appeals and the RTC are in accord with the
evidence on record, and we are accordingly bound by
the findings of fact made therein. 200 SUPREME COURT REPORTS ANNOTATED
Petitioners’ position, in sum, is that Peter’s
Lucas vs. Tuaño
glaucoma is the direct result of Dr. Tuaño’s negligence
in his improper administration of the drug Maxitrol;
“thus, [the latter] should be liable for all the damages (2) breach; (3) injury; and (4) proximate causation,76
suffered and to be suffered by [petitioners].”75 Clearly, must be established by the plaintiff/s. All the four (4)
the present controversy is a classic illustration of a elements must co-exist in order to find the physician
medical negligence case against a physician based on negligent and, thus, liable for damages.
the latter’s professional negligence. In this type of suit, When a patient engages the services of a physician,
the patient or his heirs, in order to prevail, is required a physician-patient relationship is generated. And in
to prove by preponderance of evidence that the accepting a case, the physician, for all intents and
physician failed to exercise that degree of skill, care, purposes, represents that he has the needed training
and skill possessed by physicians and surgeons
practicing in the same field; and that he will employ general neighborhood and in the same general line of
such training, care, and skill in the treatment of the practice ordinarily possess and exercise in like cases.
patient.77 Thus, in treating his patient, a physician is Even so, proof of breach of duty on the part of the
under a duty to [the former] to exercise that degree of attending physician is insufficient, for there must be a
care, skill and diligence which physicians in the same causal connection between said breach and the
general neighborhood and in the same general line of resulting injury sustained by the patient. Put in
practice ordinarily possess and exercise in like cases.78 another way, in order that there may be a recovery for
Stated otherwise, the physician has the duty to use at an injury, it must be shown that the “injury for which
least the same level of care that any other reasonably recovery is sought must be the legitimate consequence
competent physician would use to treat the condition of the wrong done; the connection between the
under similar circumstances. negligence and the injury must be a direct and natural
This standard level of care, skill and diligence is a sequence of events, unbroken by intervening efficient
matter best addressed by expert medical testimony, causes”;81 that is, the negligence must be the
because the standard of care in a medical malpractice proximate cause of the injury. And the proximate
case is a matter peculiarly within the knowledge of cause of an injury is that cause, which, in the natural
experts in the field.79 and continuous sequence, unbroken by any efficient
There is breach of duty of care, skill and diligence, intervening cause, produces the injury, and without
or the improper performance of such duty, by the which the result would not have occurred.82
attending physician when the patient is injured in Just as with the elements of duty and breach of the
body or in health [and this] constitutes the actionable same, in order to establish the proximate cause [of the
malpractice.80 Proof of such breach must likewise rest injury] by a preponderance of the evidence in a medical
upon the testimony of an expert witness that the malpractice action, [the patient] must similarly use
treatment accorded to the patient failed to meet the expert testimony, because the question of whether the
standard level of care, skill and diligence which alleged professional negligence caused [the patient’s]
physicians in the same injury is generally one for specialized expert
knowledge beyond the ken of the average layperson;
_______________ using the specialized knowledge and training of his
field, the expert’s role is to present to the [court] a
76 Garcia-Rueda v. Pascasio, et al., 278 SCRA 769, 778 (1997). realistic assessment of the likelihood that [the
77 Id. physician’s] alleged negligence caused [the patient’s]
78 Snyder v. Pantaleo (1956), 143 Conn 290, 122 A2d 21. injury.83
79 Johnson v. Superior Court, 49 Cal. Rptr. 3d 52 (Cal. App. 3d From the foregoing, it is apparent that medical
Dist. 2006). negligence cases are best proved by opinions of expert
80 Garcia-Rueda v. Pascasio, supra note 76 at p. 779. witnesses belong-

201
_______________

81  Chan Lugay v. St. Luke’s Hospital, Inc., 10 CA Reports 415

VOL. 586, APRIL 21, 2009 201
(1966).
Lucas vs. Tuaño
 82 Calimutan v. People of the Philippines, G.R. No. 152133, 9 testimony to establish: (1) the standard of care to be
February 2006, 482 SCRA 44, 60, citing Vda. de Bataclan v. Medina, implemented by competent physicians in treating the
102 Phil. 181, 186 (1957). same condition as Peter’s under similar circumstances;
83 Barngrover v. Hins, 657 S.E.2d 14 (Ga. Ct. App. 2008). (2) that, in his treatment of Peter, Dr. Tuaño failed in
his duty to exercise said standard of care that any
202 other competent physician would use in treating the
same condition as Peter’s under similar circumstances;
202 SUPREME COURT REPORTS ANNOTATED and (3) that the injury or damage to Peter’s right eye,
i.e., his glaucoma,
Lucas vs. Tuaño

_______________
ing in the same general neighborhood and in the same
general line of practice as defendant physician or 84 Dr. Cruz v. Court of Appeals, 346 Phil. 872, 884-885; 282 SCRA
surgeon. The deference of courts to the expert opinion 188, 201 (1997).
of qualified physicians [or surgeons] stems from the 85 http://www.druglib.com/druginfo/maxitrol/.
former’s realization that the latter possess unusual 86 Court of Appeals Decision, p. 17; Rollo, p. 66.
technical skills which laymen in most instances are
incapable of intelligently evaluating;84 hence, the 203

indispensability of expert testimonies.

In the case at bar, there is no question that a VOL. 586, APRIL 21, 2009 203
physician-patient relationship developed between Dr.
Lucas vs. Tuaño
Tuaño and Peter when Peter went to see the doctor on
2 September 1988, seeking a consult for the treatment
of his sore eyes. Admittedly, Dr. Tuaño, an was the result of his use of Maxitrol, as prescribed by
ophthalmologist, prescribed Maxitrol when Peter Dr. Tuaño. Petitioners’ failure to prove the first
developed and had recurrent EKC. Maxitrol or element alone is already fatal to their cause.
neomycin/polymyxin B sulfates/dexamethasone Petitioners maintain that Dr. Tuaño failed to follow
ophthalmic ointment is a multiple-dose anti-infective in Peter’s case the required procedure for the
steroid combination in sterile form for topical prolonged use of Maxitrol. But what is actually the
application.85 It is the drug which petitioners claim to required procedure in situations such as in the case at
have caused Peter’s glaucoma. bar? To be precise, what is the standard operating
However, as correctly pointed out by the Court of procedure when ophthalmologists prescribe steroid
Appeals, “[t]he onus probandi was on the patient to medications which, admittedly, carry some modicum of
establish before the trial court that the physicians risk?
ignored standard medical procedure, prescribed and Absent a definitive standard of care or diligence
administered medication with recklessness and required of Dr. Tuaño under the circumstances, we
exhibited an absence of the competence and skills have no means to determine whether he was able to
expected of general practitioners similarly situated.”86 comply with the same in his diagnosis and treatment
Unfortunately, in this case, there was absolute failure of Peter. This Court has no yardstick upon which to
on the part of petitioners to present any expert evaluate or weigh the attendant facts of this case to be
able to state with confidence that the acts complained
of, indeed, constituted negligence and, thus, should be standards of the medical profession. It must be
the subject of pecuniary reparation. remembered that a physician is not an insurer of the
Petitioners assert that prior to prescribing Maxitrol, good result of treatment. The mere fact that the
Dr. Tuaño should have determined first whether Peter patient does not get well or that a bad result occurs
was a “steroid responder.”87 Yet again, petitioners did does not in itself indicate failure to exercise due care.89
not present any convincing proof that such The result is not determinative of the performance [of
determination is actually part of the standard the physician] and he is not required to be infallible.90
operating procedure which ophthalmologists should Moreover, that Dr. Tuaño saw it fit to prescribe
unerringly follow prior to prescribing steroid Maxitrol to Peter was justified by the fact that the
medications. latter was already using the same medication when he
In contrast, Dr. Tuaño was able to clearly explain first came to see Dr. Tuaño on 2 September 1988 and
that what is only required of ophthalmologists, in cases had exhibited no previous untoward reaction to that
such as Peter’s, is the conduct of standard particular drug. 91
tests/procedures known as “ocular routine Also, Dr. Tuaño categorically denied petitioners’
examination,”88 composed of five (5) tests/procedures— claim that he never monitored the tension of Peter’s
specifically, gross examination of the eyes and the eyes while the latter was on Maxitrol. Dr. Tuaño
surrounding area; taking of the visual acuity of the pa- testified that he palpated Peter’s eyes every time the
latter came for a check-up as part of the doctor’s ocular
_______________ routine examination, a fact which petitioners failed to
rebut. Dr. Tuaño’s regular conduct of examinations
87  Steroid responders are people whose intraocular pressure and tests to ascertain the state of Peter’s eyes negate
(IOP) goes up very high when they use steroids (http://www. the very basis of petitioners’ complaint for damages. As
willsglaucoma.org/supportgroup/20030827.php). to whether Dr. Tuaño’s actuations conformed to the
88 TSN, 7 February 1997, p. 17; Rollo, p. 66. standard of care and
204
_______________

204 SUPREME COURT REPORTS ANNOTATED 89  Solis, Pedro P., Medical Jurisprudence, 1988, Garcia
Publishing, Co., Philippines.
Lucas vs. Tuaño
90 Domina v. Pratt, 13 A 2d 198 Vt. 1940.
91 TSN, 7 February 1997, pp. 18-19.
tient; checking the intraocular pressure of the patient;
checking the motility of the eyes; and using 205
ophthalmoscopy on the patient’s eye—and he did all
those tests/procedures every time Peter went to see
VOL. 586, APRIL 21, 2009 205
him for follow-up consultation and/or check-up.
We cannot but agree with Dr. Tuaño’s assertion that Lucas vs. Tuaño
when a doctor sees a patient, he cannot determine
immediately whether the latter would react adversely diligence required in like circumstances, it is presumed
to the use of steroids; all the doctor can do is map out a to have so conformed in the absence of evidence to the
course of treatment recognized as correct by the contrary.
 Even if we are to assume that Dr. Tuaño committed 206
negligent acts in his treatment of Peter’s condition, the
causal connection between Dr. Tuaño’s supposed
206 SUPREME COURT REPORTS ANNOTATED
negligence and Peter’s injury still needed to be
established. The critical and clinching factor in a Lucas vs. Tuaño
medical negligence case is proof of the causal
connection between the negligence which the evidence vision.95 Visual acuity remains good until late in the
established and the plaintiff’s injuries.92 The plaintiff course of the disease.96 Hence, Dr. Tuaño claims that
must plead and prove not only that he has been injured Peter’s glaucoma “can only be long standing x x x
and defendant has been at fault, but also that the because of the large C:D97 ratio,” and that “[t]he
defendant’s fault caused the injury. A verdict in a steroids provoked the latest glaucoma to be revealed
malpractice action cannot be based on speculation or earlier” was a blessing in disguise “as [Peter] remained
conjecture. Causation must be proven within a asymptomatic prior to steroid application.”
reasonable medical probability based upon competent Who between petitioners and Dr. Tuaño is in a
expert testimony.93 better position to determine and evaluate the necessity
The causation between the physician’s negligence of using Maxitrol to cure Peter’s EKC vis-à-vis the
and the patient’s injury may only be established by the attendant risks of using the same?
presentation of proof that Peter’s glaucoma would not That Dr. Tuaño has the necessary training and skill
have occurred but for Dr. Tuaño’s supposed negligent to practice his chosen field is beyond cavil. Petitioners
conduct. Once more, petitioners failed in this regard. do not dispute Dr. Tuaño’s qualifications—that he has
Dr. Tuaño does not deny that the use of Maxitrol been a physician for close to a decade and a half at the
involves the risk of increasing a patient’s IOP. In fact, time Peter first came to see him; that he has had
this was the reason why he made it a point to palpate various medical training; that he has authored
Peter’s eyes every time the latter went to see him—so numerous papers in the field of ophthalmology, here
he could monitor the tension of Peter’s eyes. But to say and abroad; that he is a Diplomate of the Philippine
that said medication conclusively caused Peter’s Board of Ophthalmology; that he occupies various
glaucoma is purely speculative. Peter was diagnosed teaching posts (at the time of the filing of the present
with open-angle glaucoma. This kind of glaucoma is complaint, he was the Chair of the Department of
characterized by an almost complete absence of Ophthalmology and an Associate Professor at the
symptoms and a chronic, insidious course.94 In open- University of the Philippines-Philippine General
angle glaucoma, halos around lights and blurring of Hospital and St. Luke’s Medical Center, respectively);
vision do not occur unless there has been a sudden and that he held an assortment of positions in
increase in the intraocular numerous medical organizations like the Philippine
Medical Association, Philippine Academy of
_______________ Ophthalmology, Philippine Board of Ophthalmology,
Philippine Society of Ophthalmic Plastic and
92 61 Am. Jur. 2d. §359, p. 527. Reconstructive Surgery, Philippine Journal of
93 Id. Ophthalmology, Association of Philippine
94 Newell, Frank W., Ophthalmology, Principles and Concepts, Ophthalmology Professors, et al.
6th ed., 1986, C.V. Mosby Company, Missouri.
 It must be remembered that when the qualifications the course of trial in a civil case, once plaintiff makes
of a physician are admitted, as in the instant case, out a prima facie case in his favor, the duty or the
there is an inevitable presumption that in proper burden of evidence shifts to defendant to controvert
cases, he takes the plaintiff’s prima facie case; otherwise, a verdict must
be returned in favor of plaintiff.99 The party having the
_______________ burden of proof must establish his case by a
preponderance of evidence.100 The concept of
95 Id. “preponderance of evidence” refers to evidence which is
96 Id. of greater weight or more convincing than that which
97 Cup to Disc ratio. is offered in opposition to

207
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VOL. 586, APRIL 21, 2009 207 98 Dr. Cruz v. Court of Appeals, supra note 84 at pp. 884-885; p.
201.
Lucas vs. Tuaño
99 Prudential Guarantee and Assurance Inc. v. Trans-Asia
Shipping Lines, Inc., G.R. No. 151890, 20 June 2006, 491 SCRA 411,
necessary precaution and employs the best of his 433.
knowledge and skill in attending to his clients, unless 100 Bank of the Philippine Islands v. Royeca, G.R. No. 176664, 21
the contrary is sufficiently established.98 In making July 2008, 559 SCRA 207, 215.
the judgment call of treating Peter’s EKC with
Maxitrol, Dr. Tuaño took the necessary precaution by 208
palpating Peter’s eyes to monitor their IOP every time
the latter went for a check-up, and he employed the
208 SUPREME COURT REPORTS ANNOTATED
best of his knowledge and skill earned from years of
training and practice. Lucas vs. Tuaño
In contrast, without supporting expert medical
opinions, petitioners’ bare assertions of negligence on it;101 in the last analysis, it means probability of truth.
Dr. Tuaño’s part, which resulted in Peter’s glaucoma, It is evidence which is more convincing to the court as
deserve scant credit. worthy of belief than that which is offered in opposition
Our disposition of the present controversy might thereto.102 Rule 133, Section 1 of the Revised Rules of
have been vastly different had petitioners presented a Court provides the guidelines for determining
medical expert to establish their theory respecting Dr. preponderance of evidence, thus:
Tuaño’s so-called negligence. In fact, the record of the
case reveals that petitioners’ counsel recognized the “In civil cases, the party having the burden of proof must
necessity of presenting such evidence. Petitioners even establish his case by a preponderance of evidence. In
gave an undertaking to the RTC judge that Dr. Agulto determining where the preponderance or superior weight of
or Dr. Aquino would be presented. Alas, no follow- evidence on the issues involved lies the court may consider
through on said undertaking was made. all the facts and circumstances of the case, the witnesses’
The plaintiff in a civil case has the burden of proof manner of testifying, their intelligence, their means and
as he alleges the affirmative of the issue. However, in opportunity of knowing the facts to which they are testifying,
the nature of the facts to which they testify, the probability physician or surgeon. The RTC and Court of Appeals,
or improbability of their testimony, their interest or want of and even this Court, could not be expected to
interest, and also their personal credibility so far as the same determine on its own what medical technique should
legitimately appear upon the trial. The court may also have been utilized for a certain disease or injury.
consider the number of witnesses, though the preponderance Absent expert medical opinion, the courts would be
is not necessarily with the greater number.” dangerously engaging in speculations.
All told, we are hard pressed to find Dr. Tuaño
Herein, the burden of proof was clearly upon liable for any medical negligence or malpractice where
petitioners, as plaintiffs in the lower court, to establish there is no evidence, in the nature of expert testimony,
their case by a preponderance of evidence showing a to establish that in treating Peter, Dr. Tuaño failed to
reasonable connection between Dr. Tuaño’s alleged exercise reasonable care, diligence and skill generally
breach of duty and the damage sustained by Peter’s required in medical practice. Dr. Tuaño’s testimony,
right eye. This, they did not do. In reality, petitioners’ that his treatment of Peter conformed in all respects to
complaint for damages is merely anchored on a standard medical practice in this locality, stands
statement in the literature of Maxitrol identifying the unrefuted. Consequently, the RTC and the Court of
risks of its use, and the purported comment of Dr. Appeals correctly held that they had no basis at all to
Agulto—another doctor not presented as witness rule that petitioners were deserving of the various
before the RTC—concerning the prolonged use of damages prayed for in their Complaint.
Maxitrol for the treatment of EKC. WHEREFORE, premises considered, the instant
It seems basic that what constitutes proper medical petition is DENIED for lack of merit. The assailed
treatment is a medical question that should have been Decision dated 27 September 2006 and Resolution
presented to experts. If no standard is established dated 3 July 2007, both of the Court of Appeals in CA-
through expert medi- G.R. CV No. 68666, are hereby AFFIRMED. No cost.
SO ORDERED.
_______________
Ynares-Santiago (Chairperson), Austria-Martinez,
101 Jison v. Court of Appeals, 350 Phil. 138, 173; 286 SCRA 495, Nachura and Peralta, JJ., concur.
532 (1998), citing Vicente J. Francisco, REVISED RULES OF COURT IN

THE PHILIPPINES, EVIDENCE (Part II, Rules 131-134). Petition denied, judgment and resolution affirmed.
102 Go v. Court of Appeals, 403 Phil. 883, 890-891; 351 SCRA 145,
152-153 (2001), citing 20 Am. Jur. 1100-1101 as cited in Francisco,
REVISED RULES OF COURT. 

209

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VOL. 586, APRIL 21, 2009 209
Lucas vs. Tuaño

cal witnesses, then courts have no standard by which

to gauge the basic issue of breach thereof by the