MEDJUR

FINALS
REVIEWER

HERNANDEZ

MANGALINDAN

PARUNGAO SAGUINSIN

MODULE 9: INFANCY AND CHILDHOOD

Anatomy and Physiology of Breast
Definition: The breast of an adult woman is a milk-producing, tear-shaped gland. It is supported by and
attached to the front of the chest wall on either side of the sternum by ligaments. Positioned over the
pectoral muscles of the chest wall and attached to the chest wall by fibrous strands called Coopers
ligaments.
Composition: The breast is a mass of glandular, fatty, and fibrous tissues and contains no muscle tissue. A
layer of fat surrounds the gland and extends throughout the breast. A layer of fatty tissue surrounds the
breast glands and extends throughout the breast. The fatty tissue gives the breast a soft consistency.
Composition:
- milk glands (lobules) that produce milk
- ducts that transport milk from the milk glands (lobules) to the nipple
nipple
- areola (pink or brown pigmented region surrounding the nipple)
- connective (fibrous) tissue that surrounds the lobules and ducts
- fat
Initial Breast Development: Human breast tissue begins to develop in the 6th week of fetal life. Breast
tissue initially develops along the lines of the armpits and extends to the groin (this is called the milk
ridge). By the 9th week of fetal life, it regresses (goes back) to the chest area, leaving two breast buds on
the upper half of the chest. In females, columns of cells grow inward from each breast bud, becoming
separate sweat glands with ducts leading to the nipple. Both male and female infants have very small
breasts and actually experience some nipple discharge during the first few days after birth.
Gross Anatomy of the Normal Breast
Developmental stages:
At birth, the breasts of men and women are the same and are not well developed at this stage. In early
puberty, the areola becomes a prominent bud, and breasts begin to fill out. In late puberty, glandular
tissue and fat increase in the breast, and the areola becomes flat.
Male vs. Female Anatomy
Male breasts are composed of fat, with some glandular tissue. They also show areolas and nipples. Female
breasts have similar structures, but, in addition, contain:
glandular tissue (lobes, lobules)
acini,
ducts,
Coopers ligaments,
Montgomerys glands
Development: Female breasts do not begin growing until pubertythe period in life when the body
undergoes a variety of changes to prepare for reproduction. Puberty usually begins for women around age
10 or 11. After pubic hair begins to grow, the breasts will begin responding to hormonal changes in the
body. Specifically, the production of two hormones, estrogen and progesterone, signal the development of
the glandular breast tissue. This initial growth of the breast may be somewhat painful for some girls.
During this time, fat and fibrous breast tissue becomes more elastic. The breast ducts begin to grow and
this growth continues until menstruation begins (typically one to two years after breast development has
begun). Menstruation prepares the breasts and ovaries for potential pregnancy.
Breast size, Appearance, and Changes Over Time: The size and shape of womens breasts varies
considerably. Some women have a large amount of breast tissue, and therefore, have large breasts. Other
women have a smaller amount of tissue with little breast fat.

Factors that may influence a womans breast size include:

-Volume of breast tissue
-History of pregnancies and lactation
-Thickness and elasticity of the breast skin
-Degree of hormonal influences on the breast (particularly estrogen and progesterone)
-Menopause
Size and Appearance: A womans breasts are rarely balanced (symmetrical). Usually, one breast is slightly
larger or smaller, higher or lower, or shaped differently than the other. The size and characteristics of the
nipple also vary greater from one woman to another. In some women, the nipples are constantly erect. In
others, they will only become erect when stimulated by cold or touch. Some women also have inverted
(
the condition is a new change.
Since there are hair follicles around the nipple, hair on the breast is not uncommon.
Nipple and Areola: The color of the nipple is determined by the thinness and pigmentation of its skin. The
nipple and areola (pigmented region surrounding the nipple) contain specialized muscle fibers that
respond to stimulation to make the nipple erect. The areola also houses the Montgomerys gland that may
appear as tiny, raised bumps on the surface of the areola. The Montgomerys gland helps lubricate the
areola. When the nipple is stimulated, the muscle fibers will contract, the areola will pucker, and the
nipples become hard.
Breast Shape: Breast shape and appearance undergo a number of changes as a woman ages. In young
women, the breast skin stretches and expands as the breasts grow, creating a rounded appearance. Young
women tend to have denser breasts (more glandular tissue) than older women

Gross Anatomy of the Normal Breast

External Anatomy consists of:
- the nipple
- areola,
- Montgomerys glands,
- Morgagnis tubercles,
- skin,
- axillary tail,
- inframammary fold, and
- the margin of the pectoralis major muscle.
Internal anatomy consists of:
- fascial layers,
retromammary space,
- fibrous tissues,
- glandular tissues/lobes: lobules &terminal ductal lobular unit (TDLU)
adipose tissues,
Coopers ligaments,
Pectoral muscle,
circulatory system, and
lymphatic channels.
Let-down reflex: Milk ejection is initiated in the mother's breast by the act of suckling by the baby. The
milk ejection reflex (also called let-down reflex) is not always consistent, especially at first. Once a woman
is conditioned to nursing, let-down can be triggered by a variety of stimuli, including the sound of any
baby. Even thinking about breastfeeding can stimulate this reflex, causing unwanted leakage, or both

breasts may give out milk when an infant is feeding from one breast. However, this and other problems
often settle after two weeks of feeding. Stress or anxiety can cause difficulties with breastfeeding. The
release of the hormone oxytocin leads to the milk ejection or let-down reflex. Oxytocin stimulates the
muscles surrounding the breast to squeeze out the milk. Breastfeeding mothers describe the sensation
differently. Some feel a slight tingling, others feel immense amounts of pressure or slight pain/discomfort,
and still others do not feel anything different.
10 Facts on Breastfeeding
1.

WHO recommends exclusive breastfeeding for the first six months of life. At six months, solid
foods, such as mashed fruits and vegetables, should be introduced to complement breastfeeding
for up to two years or more. In addition:
a. breastfeeding should begin within one hour of birth
b. breastfeeding should be "on demand", as often as the child wants day and night; and
c. bottles or pacifiers should be avoided.

2. Breast milk is the ideal food for newborns and infants. It gives infants all the nutrients they need
for healthy development. It is safe and contains antibodies that help protect infants from common
childhood illnesses such as diarrhoea and pneumonia, the two primary causes of child mortality
worldwide. Breast milk is readily available and affordable, which helps to ensure that infants get
adequate nutrition.
3. Breastfeeding also benefits mothers. Exclusive breastfeeding is associated with a natural (though
not fail-safe) method of birth control (98% protection in the first six months after birth). It
reduces risks of breast and ovarian cancer later in life, helps women return to their pre-pregnancy
weight faster, and lowers rates of obesity.
4. Beyond the immediate benefits for children, breastfeeding contributes to a lifetime of good health.
Adolescents and adults who were breastfed as babies are less likely to be overweight or obese.
They are less likely to have type-2 diabetes and perform better in intelligence tests.
5. Infant formula does not contain the antibodies found in breast milk. When infant formula is not
properly prepared, there are risks arising from the use of unsafe water and unsterilized
equipment or the potential presence of bacteria in powdered formula. Malnutrition can result
from over-diluting formula to "stretch" supplies. While frequent feeding maintains breast milk
supply, if formula is used but becomes unavailable, a return to breastfeeding may not be an
option due to diminished breast milk production.
6. An HIV-infected mother can pass the infection to her infant during pregnancy, delivery and
through breastfeeding. Antiretroviral (ARV) drugs given to either the mother or HIV-exposed
infant reduces the risk of transmission. Together, breastfeeding and ARVs have the potential to
significantly improve infants' chances of surviving while remaining HIV uninfected. WHO
recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow
WHO guidance for infant feeding.
7.

An international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It
calls for:
a. all formula labels and information to state the benefits of breastfeeding and the health
risks of substitutes;
b. no promotion of breast-milk substitutes;
c. no free samples of substitutes to be given to pregnant women, mothers or their families;
and
d. no distribution of free or subsidized substitutes to health workers or facilities.

8. Breastfeeding has to be learned and many women encounter difficulties at the beginning. Nipple
pain, and fear that there is not enough milk to sustain the baby are common. Health facilities that

support breastfeedingby making trained breastfeeding counsellors available to new mothers

encourage higher rates of the practice. To provide this support and improve care for mothers and
newborns, there are "baby-friendly" facilities in about 152 countries thanks to the WHO-UNICEF
Baby-friendly Hospital initiative.
9. Many mothers who return to work abandon breastfeeding partially or completely because they do
not have sufficient time, or a place to breastfeed, express and store their milk. Mothers need a
safe, clean and private place in or near their workplace to continue breastfeeding. Enabling
conditions at work, such as paid maternity leave, part-time work arrangements, on-site crches,
facilities for expressing and storing breast milk, and breastfeeding breaks, can help.
10. To meet the growing needs of babies at six months of age, mashed solid foods should be
introduced as a complement to continued breastfeeding. Foods for the baby can be specially
prepared or modified from family meals. WHO notes that:
a. breastfeeding should not be decreased when starting on solids;
b. food should be given with a spoon or cup, not in a bottle;
c. food should be clean, safe and locally available; and
d. ample time is needed for young children to learn to eat solid foods.
Anatomy and Physiology of infants and Children
Fetal Circulation:
-Ductus venosus
-Foramen Ovale
-Ductus arteriosus
Changes at Birth: First breath generates negative pressure. Blood flows from right ventricle through lungs.
Oxygen stimulates ductal constriction.
Neonatal physiology
Cardiovascular system: Right ventricle = left ventricle; there is higher ratio of connective tissue to
contractile tissue.
Lungs: bronchial tree is fully developed. Alveoli develop fully after birth. Compliant chest wall.
Diaphragmatic breathing
Kidneys: # of nephrons complete by birth
Liver: immature enzymes
Central Nervous System: pathways complete at birth
Temperature control: less subcutaneous fat, non-shivering thermogenesis, high surface area to
body weight ratio
Parricide
(Latin: parricida, killer of parents or another close relative) is defined as: the act of killing one's father
(patricide), or less usually mother (matricide) or other close relative, but usually not children (infanticide),
the act of killing a person (such as the ruler of one's country) who stands in a relationship resembling that
of a father, a person who commits such an act, a related adjective ("parricide treason", "parricide
brothers").
Infanticide
Infanticide (or infant homicide) is the intentional killing of infants. Neonaticide, killing within 24 hours of
a child's birth, is most commonly done by the mother whereas infanticide of a child more than one day old
is slightly more likely to be committed by the father
Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) also known as cot death or crib death is the sudden death of
an infant that is not predicted by medical history and remains unexplained after a thorough
forensic autopsy and detailed death scene investigation. Infants are at the highest risk for SIDS during
sleep. Typically the infant is found dead after having been put to bed, and exhibits no signs of having
struggled.
The cause of SIDS is unknown, but some characteristics associated with the syndrome have been
identified and appear to interact with other characteristics: A triple-risk model states that SIDS occurs
when an infant with an underlying, biological vulnerability who is at a critical developmental age is
exposed to an external trigger. SIDS prevention strategies include: putting the infant to sleep on his/her
back, a firm mattress separate from but close to caregivers, no loose bedding, a relatively cool sleeping
environment, using a pacifier, and avoidance of exposure to tobacco smoke. The "Safe to Sleep" campaign
is considered a significant public health success, credited with leading to a measurable reduction in SIDS
rates.
SIDS was the third leading cause of infant mortality in the U.S. in 2011 and rates have been declining
since 1988.
Infanticide and child abuse cases may be misdiagnosed as SIDS due to lack of evidence, and caretakers of
infant with SIDS are sometimes falsely accused. Accidental suffocations are also sometimes misdiagnosed
as SIDS and vice versa. Grief support for families impacted by SIDS is particularly important because the
death of the infant is typically sudden, without witnesses, and requires an investigation.
Shaken Baby Syndrome
Shaken baby syndrome (SBS) is a triad of medical findings: subdural hematoma,retinal hemorrhage,
and cerebral edema from which some doctors, consistent with current medical understanding, infer child
abuse caused by intentional shaking. In a majority of cases there is no visible sign of external trauma.
SBS is often fatal and can cause severe brain damage, resulting in lifelong disability. Estimated death rates
(mortality) among infants with SBS range from 15% to 38%; the median is 20%25%. Up to half of deaths
related to child abuse are reportedly due to shaken baby syndrome. Nonfatal consequences of SBS include
varying degrees of visual impairment (including blindness), motor impairment (e.g. cerebral palsy)
and cognitive impairments
RA 10028
Private enterprises as well as government agencies, including government-owned and controlled
corporations, are required to put up lactation stations.
Expenses incurred by private health and non-health facilities, establishments or institutions in complying
with the law will now be deductible expenses (for income tax purposes) that can be up to twice the actual
amount incurred.
The law requires lactation periods for breastfeeding employees, in addition to time-off for meals, to
allow them time to express their breast milk. This period should be less no less than a total of 40 minutes
for every eight-hour working period.
Health institutions are encouraged to put up breast milk banks to store pasteurized breast milk donated
by breastfeeding mothers.
Breastfeeding will now be included in the curriculum of schools (under relevant subjects).
Health Institutions are encouraged to set up Milk Banks for storage of breastmilk. The stored breastmilk
will be given to children in neonatal intensive care units.
The law now requires Health Institutions, Public Places (i.e. schools, public transportation terminals,
shopping malls, etc.) and Work Places (i.e. work premises, whether private enterprises or government
agencies) to establish Lactation Stations.

Lactation Stations should be private, clean, sanitary and well-ventilated rooms or areas where nursing
mothers can wash up, breastfeed or express their milk comfortably and store afterwards.
Important Things to remember:
1. These places have to have Lactation Stations:
Hospitals
Infirmaries
Health Centers
Lying-In Clinics
Schools
Public Transportation Terminals
Shopping Malls
Your office
If not, you can report this matter to the Department of Health (651-7801 or 651-7800 loc. 1105) and the
violating institution can be fined from P50,000.00 to P200,000.00.
2. A Lactation Station should have:
Lavatory for hand-washing
Refrigeration for storing breastmilk
Electrical outlets for breast pumps
A small table
Comfortable seats
If not, you can report this matter to the Department of Health (651-7801 or 651-7800 loc. 1105) and the
violating institution can be fined from P50,000.00 to P200,000.00.
3. A Lactation Station should NOT be in a toilet or a rest room.
4. Employees who are breastfeeding have a right to be granted breaks so that they can breastfeed. A
nursing employee is entitled to at least 40 minutes for breastfeeding for every 8-hour work period
Convention on the Rights of the Child
Considering that, in accordance with the principles proclaimed in the Charter of the United Nations,
recognition of the inherent dignity and of the equal and inalienable rights of all members of the human
family is the foundation of freedom, justice and peace in the world
Recognizing that the child, for the full and harmonious development of his or her personality, should
grow up in a family environment, in an atmosphere of happiness, love and understanding,
Considering that the child should be fully prepared to live an individual life in society, and brought up in
the spirit of the ideals proclaimed in the Charter of the United Nations, and in particular in the spirit of
peace, dignity, tolerance, freedom, equality and solidarity,
Bearing in mind that the need to extend particular care to the child has been stated in the Geneva
Declaration of the Rights of the Child of 1924 and in the Declaration of the Rights of the Child adopted by
the General Assembly on 20 November 1959 and recognized in the Universal Declaration of Human
Rights, in the International Covenant on Civil and Political Rights (in particular in articles 23 and 24), in
the International Covenant on Economic, Social and Cultural Rights (in particular in article 10) and in the
statutes and relevant instruments of specialized agencies and international organizations concerned with
the welfare of children,
Bearing in mind that, as indicated in the Declaration of the Rights of the Child, "the child, by reason of his
physical and mental immaturity, needs special safeguards and care, including appropriate legal protection,
before as well as after birth

Recalling the provisions of the Declaration on Social and Legal Principles relating to the Protection and
Welfare of Children, with Special Reference to Foster Placement and Adoption Nationally and
Internationally; the United Nations Standard Minimum Rules for the Administration of Juvenile Justice
(The Beijing Rules) ; and the Declaration on the Protection of Women and Children in Emergency and
Armed Conflict, Recognizing that, in all countries in the world, there are children living in exceptionally
difficult conditions, and that such children need special consideration
RA 7610
provide special protection to children from all firms of abuse, neglect, cruelty exploitation and
discrimination and other conditions, prejudicial their development; provide sanctions for their
commission and carry out a program for prevention and deterrence of and crisis intervention in situations
of child abuse, exploitation and discrimination. The State shall intervene on behalf of the child when the
parent, guardian, teacher or person having care or custody of the child fails or is unable to protect the
child against abuse, exploitation and discrimination or when such acts against the child are committed by
the said parent, guardian, teacher or person having care and custody of the same.1awphi1@alf
It shall be the policy of the State to protect and rehabilitate children gravely threatened or endangered by
circumstances which affect or will affect their survival and normal development and over which they have
no control.
The best interests of children shall be the paramount consideration in all actions concerning them,
whether undertaken by public or private social welfare institutions, courts of law, administrative
authorities, and legislative bodies, consistent with the principle of First Call for Children as enunciated in
the United Nations Convention of the Rights of the Child. Every effort shall be exerted to promote the
welfare of children and enhance their opportunities for a useful and happy life.
Re child prostitution:
The penalty of reclusion temporal in its medium period to reclusion perpetua shall be imposed upon the
following:
(a)
Those who engage in or promote, facilitate or induce child prostitution which include, but are not
limited to, the following:
(1)

Acting as a procurer of a child prostitute;

(2)
Inducing a person to be a client of a child prostitute by means of written or oral advertisements or
other similar means;
(3)

Taking advantage of influence or relationship to procure a child as prostitute;

(4)

Threatening or using violence towards a child to engage him as a prostitute; or

(5)
Giving monetary consideration goods or other pecuniary benefit to a child with intent to engage
such child in prostitution.
(b)
Those who commit the act of sexual intercourse of lascivious conduct with a child exploited in
prostitution or subject to other sexual abuse; Provided, That when the victims is under twelve (12) years of
age, the perpetrators shall be prosecuted under Article 335, paragraph 3, for rape and Article 336 of Act
No. 3815, as amended, the Revised Penal Code, for rape or lascivious conduct, as the case may be:
Provided, That the penalty for lascivious conduct when the victim is under twelve (12) years of age shall be
reclusion temporal in its medium period; and
(c)
Those who derive profit or advantage therefrom, whether as manager or owner of the
establishment where the prostitution takes place, or of the sauna, disco, bar, resort, place of

entertainment or establishment serving as a cover or which engages in prostitution in addition to the

activity for which the license has been issued to said establishment.
Penalty for child trafficking:
A penalty lower two (2) degrees than that prescribed for the consummated felony under Section 7 hereof
shall be imposed upon the principals of the attempt to commit child trafficking under this Act.
Re Acts of neglect, Abuse, Cruelty or Exploitation:
(a)
Any person who shall commit any other acts of child abuse, cruelty or exploitation or to be
responsible for other conditions prejudicial to the child's development including those covered by Article
59 of Presidential Decree No. 603, as amended, but not covered by the Revised Penal Code, as amended,
shall suffer the penalty of prision mayor in its minimum period.
(b)
Any person who shall keep or have in his company a minor, twelve (12) years or under or who in
ten (10) years or more his junior in any public or private place, hotel, motel, beer joint, discotheque,
cabaret, pension house, sauna or massage parlor, beach and/or other tourist resort or similar places shall
suffer the penalty of prision mayor in its maximum period and a fine of not less than Fifty thousand pesos
(P50,000): Provided, That this provision shall not apply to any person who is related within the fourth
degree of consanguinity or affinity or any bond recognized by law, local custom and tradition or acts in the
performance of a social, moral or legal duty.
(c)
Any person who shall induce, deliver or offer a minor to any one prohibited by this Act to keep or
have in his company a minor as provided in the preceding paragraph shall suffer the penalty of prision
mayor in its medium period and a fine of not less than Forty thousand pesos (P40,000); Provided,
however, That should the perpetrator be an ascendant, stepparent or guardian of the minor, the penalty to
be imposed shall be prision mayor in its maximum period, a fine of not less than Fifty thousand pesos
(P50,000), and the loss of parental authority over the minor.
(d)
Any person, owner, manager or one entrusted with the operation of any public or private place of
accommodation, whether for occupancy, food, drink or otherwise, including residential places, who allows
any person to take along with him to such place or places any minor herein described shall be imposed a
penalty of prision mayor in its medium period and a fine of not less than Fifty thousand pesos (P50,000),
and the loss of the license to operate such a place or establishment.
(e)

Any person who shall use, coerce, force or intimidate a street child or any other child to;

(1)

Beg or use begging as a means of living;

(2)

Act as conduit or middlemen in drug trafficking or pushing; or

(3)
Conduct any illegal activities, shall suffer the penalty of prision correccional in its medium period
to reclusion perpetua.
For purposes of this Act, the penalty for the commission of acts punishable under Articles 248, 249, 262,
paragraph 2, and 263, paragraph 1 of Act No. 3815, as amended, the Revised Penal Code, for the crimes of
murder, homicide, other intentional mutilation, and serious physical injuries, respectively, shall be
reclusion perpetua when the victim is under twelve (12) years of age. The penalty for the commission of
acts punishable under Article 337, 339, 340 and 341 of Act No. 3815, as amended, the Revised Penal Code,
for the crimes of qualified seduction, acts of lasciviousness with the consent of the offended party,
corruption of minors, and white slave trade, respectively, shall be one (1) degree higher than that imposed
by law when the victim is under twelve (12) years age.
anctions of Establishments or Enterprises which Promote, Facilitate, or Conduct Activities Constituting
Child Prostitution and Other Sexual Abuse, Child Trafficking, Obscene Publications and Indecent Shows,
and Other Acts of Abuse. All establishments and enterprises which promote or facilitate child
prostitution and other sexual abuse, child trafficking, obscene publications and indecent shows, and other

acts of abuse shall be immediately closed and their authority or license to operate cancelled, without
prejudice to the owner or manager thereof being prosecuted under this Act and/or the Revised Penal Code,
as amended, or special laws. A sign with the words "off limits" shall be conspicuously displayed outside
the establishments or enterprises by the Department of Social Welfare and Development for such period
which shall not be less than one (1) year, as the Department may determine. The unauthorized removal of
such sign shall be punishable by prision correccional.
Any person who discriminate against children of indigenous cultural communities shall suffer a penalty of
arresto mayor in its maximum period and a fine of not less than Five thousand pesos (P5,000) more than
Ten thousand pesos (P10,000).
Common Penal Provisions.
(a)
The penalty provided under this Act shall be imposed in its maximum period if the offender has
been previously convicted under this Act;
(b)
When the offender is a corporation, partnership or association, the officer or employee thereof
who is responsible for the violation of this Act shall suffer the penalty imposed in its maximum period;
(c)
The penalty provided herein shall be imposed in its maximum period when the perpetrator is an
ascendant, parent guardian, stepparent or collateral relative within the second degree of consanguinity or
affinity, or a manager or owner of an establishment which has no license to operate or its license has
expired or has been revoked;
(d)
When the offender is a foreigner, he shall be deported immediately after service of sentence and
forever barred from entry to the country;
(e)
The penalty provided for in this Act shall be imposed in its maximum period if the offender is a
public officer or employee: Provided, however, That if the penalty imposed is reclusion perpetua or
reclusion temporal, then the penalty of perpetual or temporary absolute disqualification shall also be
imposed: Provided, finally, That if the penalty imposed is prision correccional or arresto mayor, the
penalty of suspension shall also be imposed; and
(f)
A fine to be determined by the court shall be imposed and administered as a cash fund by the
Department of Social Welfare and Development and disbursed for the rehabilitation of each child victim,
or any immediate member of his family if the latter is the perpetrator of the offense.
CASE: SANCHEZ v. PEOPLE
FACTS:
Leonilo Nilo Sanchez was charged with the crime of Other Acts of Child Abuse in an Information dated
August 29, 2001. He was accused of hitting VVV, a 16 year old minor, in the upper part of her legs, thus
prejudicial to the childs development.
Nilo argues that the injuries inflicted by him were minor in nature that it is not prejudicial to VVVs
development and therefore P.D. No. 603 is not applicable. Nilo avers that he should be charged under the
RPC instead for slight physical injuries.
ISSUE: WON P.D. 603 as amended is applicable to the case at hand.
HELD:
In this case, the applicable laws are Article 59 of P.D. No. 603 and Section 10(a) of R.A. No. 7610. Section
10(a) of R.A. No. 7610 provides:
SECTION 10. Other Acts of Neglect, Abuse, Cruelty or Exploitation and Other Conditions Prejudicial to
the Child's Development.

(a)
Any person who shall commit any other acts of child abuse, cruelty or exploitation or be
responsible for other conditions prejudicial to the child's development including those covered by Article
59 of Presidential Decree No. 603, as amended, but not covered by the Revised Penal Code, as amended,
shall suffer the penalty of prision mayor in its minimum period.
As gleaned from the foregoing, the provision punishes not only those enumerated under Article 59, PD
603, but also four distinct acts, i.e.:
(a)
(b)
(c)
(d)

child abuse
Child cruelty
Child exploitation and
Being responsible for conditions prejudicial to the childs development

The Rules and Regulations of the questioned statute distinctly and separately defined child abuse, cruelty
and exploitation just to show that these three acts are different from one another and from the act
prejudicial to the childs development. Contrary to Nilos assertion, an accused can be prosecuted and be
convicted under Section 10(a), Article VI of RA. 7610 if he commits any of the four acts therein.
The prosecution need not prove that the acts of child abuse, child cruelty and child exploitation have
resulted in the prejudice of the child because an act prejudicial to the development of the child is different
from the former acts.
Moreover, it is a rule in statutory construction that the word or is a disjunctive term signifying
dissociation and independence of one thing from other things enumerated. It should, as a rule, be
construed in the sense which it ordinarily implies. Hence, the use of or in Section 10(a) of RA 7610
before the phrase be responsible for other conditions prejudicial to the childs development supposes
that there are four punishable acts therein. First, the act of child abuse; second, child cruelty; third, child
exploitation; and fourth, being responsible for conditions prejudicial to the childs development. The
fourth penalized act cannot be interpreted, as petitioner suggests, as a qualifying condition for the three
other acts, because an analysis of the entire context of the questioned provision does not warrant such
construal.
Nilo contends that, after proof, the act should not be considered as child abuse but merely as slight
physical injuries defined and punishable under Article 266 of the Revised Penal Code. Nilo conveniently
forgets that when the incident happened, VVV was a child entitled to the protection extended by R.A. No.
7610, as mandated by the Constitution. As defined in the law, child abuse includes physical abuse of the
child, whether the same is habitual or not. The act of Nilo falls squarely within this definition.

Anti-Child Pornography
Problems before RA 9775 was passed:
Only those who used/employed children can be prosecuted under R.A. 7610.
It excludes those who publish, access, transmit, sell, distribute, etc,. child pornographic materials
Under the Revised Penal Code of the Philippines, publication is punished but it is a too general definition
under obscene publication.
RA 9775
Answers the lack of a law of the Philippines to combat online sexual exploitation of children
Child Pornography- refers to any representation, whether visual, audio, or written combination thereof,
by electronic, mechanical, digital, optical, magnetic or any other means, of child engaged or involved in
real or simulated explicit sexual activities

Explicit Sexual Activity- includes actual or simulated

(1) As to form:
(i) sexual intercourse or lascivious act including, but not limited to, contact involving genital to genital,
oral to genital, anal to genital, or oral to anal, whether between persons of the same or opposite sex
(2) bestiality;
(3) masturbation;
(4) sadistic or masochistic abuse;
(5) lascivious exhibition of the genitals, buttocks, breasts, pubic area and/or anus; or
(6) use of any object or instrument for lascivious acts
Anti-Bullying Law
This law characterizes bullying as any severe or repeated use by one or more students of a written, verbal
or electronic expression, or a physical act or gesture, or any combination thereof, directed at another
student that has the effect of actually causing or placing the latter in reasonable fear of physical or
emotional harm or damage to his property; creating a hostile environment at school for the other student;
infringing on the rights of the other student at school; or materially and substantially disrupting the
education process or the orderly operation of a school.
Bullying is not limited to the usual physical confrontation like punching and fighting. Bullying includes
any act that causes damage to a victims psyche and/or emotional well-being, as well as any slanderous
statement or accusation that causes the victim undue emotional distress like directing foul language or
profanity at the target, name-calling, tormenting and commenting negatively on victims looks, clothes
and body. Call someone a jologs and youre probably in for bullying. Also includes cyber-bullying
theres no imprisonment provided under the Anti-Bullying Act. Government social workers already have
their hands full with children in conflict with the law or CICL. This law does not impose any criminal
penalty for bullying, but requires schools to promulgate rules and regulations which must include
disciplinary actions. This is, of course, without prejudice to criminal liability under other laws, like
physical injuries under the Revised Penal Code.

MODULE 10: INSANITY AND PSYCHOLOGICAL INCAPACITY

Brain Anatomy and Function
Much of the brain's job involves receiving information from the rest of the body, interpreting that
information, and then guiding the body's response to it. Types of input the brain interprets include odors,
light, sounds, and pain. The brain also helps perform vital operations such as breathing, maintaining
blood pressure, and releasing hormones.
The brain is divided into sections. These sections include the cerebrum, the cerebellum, the diencephalon,
and the brain stem.
Each of these parts is responsible for portions of the brain's overall job. The larger parts are, in turn,
divided into smaller areas that handle smaller portions of the work. Different areas often share
responsibility for the same task.
The cerebrum is the largest part of the brain. It handles memory, speech, the senses, emotional response,
and more. It is divided into several sections called lobes. These lobes are the frontal, temporal, parietal,
and occipital; each handles portions of the cerebrum's jobs.
The cerebellum is below and behind the cerebrum and is attached to the brain stem. It controls motor
function, the body's ability to balance, and its ability to interpret information sent to the brain by the eyes,
ears, and other sensory organs.
The functions the brain stem governs include respiration, blood pressure, some reflexes, and the changes
that happen in the body during what is called the fight or flight response. The brain stem is also divided
into several distinct sections: the midbrain, pons, and medulla oblongata.
The diencephalon is inside the cerebrum above the brain stem. Its jobs include sensory function, food
intake control, and the body's ability to sleep. As with the other parts of the brain, it is divided into
sections. These include the thalamus, hypothalamus, and epithalamus.
The brain is protected from damage by several layers of defenses. Outermost are the bones of the skull.
Beneath the skull are the meninges, a series of sturdy membranes that surround the brain and spinal cord.
Inside the meninges the brain is cushioned by fluid.
Still, the brain can suffer damage, become diseased, or malfunction. These problems may include cancer,
physical injuries such as skull fractures, and ruptures of blood vessels that supply the brain.
Insanity
Insanity under article 12 of the Revised Penal Code means that the accused must be deprived completely
of reason or discernment and freedom of the will at the time of committing the crime.
Insanity exists when there is complete deprivation of intelligence in committing the act, that is, the
accused is deprived of reason, he acts without the least discernment because there is complete absence of
the power to discern, or that there is total deprivation of freedom of the will. Mere abnormality of the
mental faculties will not exclude imputability (People vs. Puno)
CASES:
PEOPLE v. BASCOS
19 Dec. 1922| J. Malcolm
Facts
Donato Bascos was charged in an information filed in CFI with the murder of Victoriano Romero. On
arraignment, he entered a plea of not guilty. the proof for the prosecution established that the accused
was the one who had killed Victoriano Romero, while the latter was sleeping. The defense was that of
insanity.
CFI found Bascos guilty and sentencing him to seventeen years, four months, and one day of reclusion
temporal, with the accessory penalties, to indemnify the heirs of Victoriano Romero in the sum of P1,000,
and to pay the costs, provided, however, that the execution of the sentence should be suspended in

accordance with Art. 100 of the Penal Code, and the accused placed in a hospital for the insane, there to
remain until such time as his mental condition shall be determined.
Issue: Is the plea of insanity sustainable under Art. 8 (par. 1), Penal Code, or does the case fall under Art.
100?
Held:
Art. 8, (par. 1):
An imbecile or lunatic, unless the latter has acted during a lucid interval.
When the imbecile or lunatic has committed an act which the law defines as a grave felony, the court
shall order his confinement in one of the asylums established for persons thus afflicted, which he shall
not be permitted to leave without first obtaining the permission of the same court.
Article 100 of the Penal Code applies when the convict shall become insane or an imbecile after final
sentence has been pronounced.
When the defense of insanity is interposed, there are two fundamental propositions: authority exists. At
least, all the authorities are in harmony with reference to two fundamental propositions: First, that the
burden is on the prosecution to prove beyond a reasonable doubt the defendant committed the crime; and
secondly, that the law presumes every man to be sane. The conflict in the decisions arises by reason of the
fact that the courts differ in their opinion as to how much evidence is necessary to overthrow this original
presumption of sanity, and as to What quantum of evidence is sufficient to enable the court to say that the
burden of proving the crime beyond a reasonable doubt has been sufficiently borne.
The strict doctrine "that when a defendant in a criminal case interposes the defense of mental incapacity,
the burden of establishing that fact rests upon him," has been adopted in a series of decisions by this court.
The wife of the accused and his cousin testified that the accused had been more or less continuously out of
his mind for many years. Doctor Gonzalo Montemayor, assistant district health officer, who, by order of
the judge, examined the accused and conducted an investigation, found that the accused is a violent
maniac, and that from the information he had received from the neighbors of the accused, the latter had
been insane for some time. The physician expressed the opinion that the accused was probably insane
when Victoriano Romero was killed. The official declaration of Doctor Montemayor in his capacity as
acting district health officer was "that this accused, according to a physical examination and investigation,
is a violent maniac, and that this mental state has continued through many years, constituting a danger
both for himself and for the community." The total lack of motive of Bascos to kill Romero bears out the
assumption that the former was insane.
PEOPLE v. BONOAN
17 Feb. 1937 | J. Laurel
Facts:
Celestino Bonoan is charged with the crime of murder for stabbing Carlos Guison with a knife, which
caused his death three days afterwards. An arraignment was then called, but the defense objected on the
ground that the defendant was mentally deranged and was at the time confined at the Psychopatic
Hospital. After several months of summons for doctors, production of the defendants complete record of
mental condition from the hospital and defendants admission to the hospital for personal observation,
assistant alienist Dr. Jose Fernandez finally reported to the court that Bonoan may be discharged for
being a recovered case. After trial, the lower court found Bonoan guilty and sentenced him to life
imprisonment.

The defense now appeals, claiming the lower court made errors in finding Bonoan suffered dementia only
occasionally and intermittently, did not show any kind of abnormality, that the defense did not establish
the defendants insanity and finding accused guilty.
Issue:
W/N the lower court erred in finding the accused guilty
Held:
Yes. The Court finds the accused demented at the time he perpetrated the crime, which consequently
exempts him from criminal liability, and orders for his confinement in San Lazaro Hospital or other
hospital for the insane. This ruling was based on the following evidence:
Uncontradicted evidence that accused was confined in the insane department of San Lazaro Hospital and
diagnosed with dementia praecox long before the commission of the offense and recurrence of ailments
were not entirely lacking of scientific foundation.
Persons with dementia praecox are disqualified from legal responsibility because they have no control of
their acts; dementia praecox symptoms similar to manic depression psychosis.
Accused had an insomnia attack, a symptom leading to dementia praecox, four days prior to act according
to Dr. Francisco.
Accused was sent the Psychopatic hospital on the same day of crime and arrest, indicating the polices
doubt of his mental normalcy
Defendant suffered from manic depressive psychosis according to Dr. Joson
Dissenting (Justices Imperial, Diaz and Concepcion):
The dissenting opinions pose that the accused committed the crime when he was sane, or at least, during
a lucid interval.
The legal presumption is always in favor of sanity; no positive evidence of accused mental state was
established
Based on expert testimonies, accused was cured of dementia praecox and later manic depressive psychosis
Based on observance of arresting officer Damaso Arnoco, corrobating statement of Benjamin Cruz, and
other witnesses, accused appear sane at the time immediately after commission
There is a motive of aggression on part of accused is real and positive fact: deceaseds failure to pay
borrowed money.
PEOPLE v. FORMIGONES
29 November 1950
FACTS:
From November to December 1946, defendant Abelardo Formigones together with his wife Julia Agricola,
and his five children lived in the house of his half-brother, Zacarias Formigones to find employment as
harvesters. One afternoon, the accused, without any previous quarrel or provocation whatsoever, took his
bolo from the wall of the house and stabbed his wife at the back, the blade penetrating the right lung
which latter caused her death. When she fall ont he ground the defendant carried her up the house, laid
her on the floor of the living room and then lay down beside her. He was convicted of parricide and was
sentenced to prison. The defendant entered a plea of not guilty. His counsel presented testimonies of two
guards of the provincial jail where defendant was confined. They said that he behaved like an insane
person, that sometimes he would remove his clothes in front of others, would not take a bath, and
remained silent and indifferent to his surroundings. His counsel claimed that e is an imbecile therefore
exempt from criminal liability. Dr. Francisco Gomez told that Abelardo was suffering only from
feeblemindedness and not imbecility and that he could distinguish right from wrong. An imbecile so as to

be exempt from criminal liability, he must be deprived completely of reason or discernment and freedom
of the will at the time of committing the crime.
ISSUE: WON the defendant who is suffering from feeblemindedness is exempt from criminal liability.
HELD:
No. In order that an exempting circumstance may be taken into account, it is necessary that there be a
complete deprivation of intelligence in committing the act, that is, that the accused be deprived of reason;
that there be no responsibility for his own acts; that he acts without the least discernment; that there be a
complete absence of the power to discern, or that there be a total deprivation of freedom of the will. As to
the strange behaviour of the accused during his confinement, assuming that it was not feigned to
stimulate insanity, it may be attributed either to his being feebleminded or eccentric, or to a morbid
mental condition produced by remorse at having killed his wife. He could distinguish right from wrong.
PEOPLE v. PUNO
29 June 1981| J. Aquino
Facts
Ernesto Puno, 28, jeepney driver, entered the bedroom of Francisca Col (Aling Kikay), 72, widow. The
house was located in the area known as Little Baguio, Barrio Tinajeros Malabon, Rizal.
On seeing Aling Kikay sitting in bed, Puno insulted her by saying: "Mangkukulam ka mambabarang
mayroon kang bubuyog". Then, he repeatedly slapped her and struck her several times on the head with a
hammer until she was dead.
The assault was witnessed by Hilaria de la Cruz, 23, who was in the bedroom with the old woman, and by
Lina Pajes, 27, a tenant of the adjoining room. They testified that Puno's eyes were reddish. His look was
baleful and menacing. Puno was a neighbor of Aling Kikay.
After the killing, Puno went to the room of Lina, where Hilaria had taken refuge, and made the following
confession and threat: "Huwag kayong magkakamaling tumawag ng pulis at sabihin ninyo na umalis kayo
ng bahay at hindi ninyo alam kung sino ang pumatay sa matanda." Or, according to Lina, Puno said:
"Pinatay ko na iyong matanda. Huwag kayong tumawag ng pulis. Pag tumawag kayo ng pulis, kayo ang
paghihigantihan ko. "
Puno fled to his parents' house at Barrio Tugatog, Malabon and then went to the house of his second
cousin, Teotimo Puno, located at Barrio San Jose, Calumpit, Bulacan, reaching that place in the evening.
Lina, after noting that he had left, notified the Malabon police of the killing. Corporal Daniel B. Cruz
answered the call. He found Aling Kikay sprawled on her bed already dead, Her head was bloody. Her
blanket and pillows were bloodstained. He took down the statements of Lina and Hilaria at the police
station. They pointed to Puno as the killer.
Puno's father surrendered him to the police. Two Malabon policemen brought him to the National Mental
Hospital in Mandaluyong, Rizal. He was charged with murder in the municipal court. He waived the
second stage of the preliminary investigation.
Alleged in the information as aggravating circumstances were evident premeditation, abuse of superiority
and disregard of sex.
Zenaida Gabriel, 30, Puno's wife, testified that on the night before the murder, Puno's eyes were reddish.
He complained of a headache. The following day while he was feeding the pigs, he told Zenaida that a
bumble bee was coming towards him and he warded it off with his hands. Zenaida did not see any bee.

Puno then went upstairs and took the cord of the religious habit of his mother. He wanted to use that cord
in tying his dog. He asked for another rope when Zenaida admonished him not to use that cord. Puno tied
the dog to a tree by looping the rope through its mouth and over its head. He repeatedly boxed the dog.
Aida Gabriel, Zenaida's elder sister, saw Puno while he was boxing that dog. Aida observed that Puno's
eyes were bloodshot and his countenance had a ferocious expression.
Teotimo Puno testified that on the night of September 8, 1970, Ernesto Puno came to their house in
Barrio San Jose, Calumpit. Ernesto was soaking wet as there was a flood in that place. He was cuddling a
puppy that he called "Diablo". He called for Teotimo's mother who invited him to eat. Ernesto did not eat.
Instead, he fed the puppy.
Ernesto introduced Teotimo to his puppy. Then, he sang an English song. When Teotimo asked him to
change his wet clothes, Ernesto refused. Later, he tried on the clothes of Teotimo's father. When told that
Teotimo's father had been dead for a couple of years already, Ernesto just looked at Teotimo.
While he was lying down, Ernesto began singing again. Then he emitted a moaning sound until he fell
asleep. Ernesto was awakened the next morning by the noise caused by persons wading in the flood.
Ernesto thought they were his fellow cursillistas.
Medical experts testified that Puno acted with discernment:
Dr. Maravilla to whom Puno was referred for treatment ten times testified that Puno was an out-patient
who could very well live with society, although he was afflicted with "schizophrenic reaction"; that Puno
knew what he was doing and that he had psychosis, a slight destruction of the ego. Puno admitted to
Doctor Maravilia that one cause of his restlessness, sleeplessness and irritability was his financial problem.
Dr. Robles testified that Puno was first brought to that hospital on July 28, 1962 because his parents
complained that he laughed alone and exhibited certain eccentricities such as kneeling, praying and
making his body rigid. Doctor Robles observed that while Puno was suffering from "schizophrenic
reaction", his symptoms were "not socially incapacitating" and that he could adjust himself to his
environment.
Dr. Vicente testified that from his examination of Puno, he gathered that Puno acted with discernment
when he committed the killing and that Puno could distinguish between right and wrong. He also
concluded that Puno was not suffering from any delusion and that he was not mentally deficient;
otherwise, he would not have reached third year high school.
The doctors concluded in their report that Ernesto Puno, who previously was suffering from a mental
illness called schizophrenia, is presently free from any social incapacitating psychotic symptoms. Persons
who recover from an acute episode of mental illness like schizophrenia may retain some residual
symptoms impairing their judgment but not necessarily their discernment of right from wrong of the
offense committed.
TC concluded that Puno knew that the killing of Francisca Col was wrong and that he would be punished
for it, as shown by the threats which he made to Hilaria de la Cruz and Lina Pajes, the old woman's
companions who witnessed his dastardly deed.
The trial court also concluded that if Puno was a homicidal maniac who had gone berserk, he would have
killed also Hilaria and Lina. The fact that he singled out Aling Kikay signified that he really disposed of
her because he thought that she was a witch.
He was convicted of murder and sentenced to death.
Issue: WON Puno was actually insane.
Held

Insanity under article 12 of the Revised Penal Code means that the accused must be deprived completely
of reason or discernment and freedom of the will at the time of committing the crime.
Insanity exists when there is complete deprivation of intelligence in committing the act, that is, the
accused is deprived of reason, he acts without the least discernment because there is complete absence of
the power to discern, or that there is total deprivation of freedom of the will. Mere abnormality of the
mental faculties will not exclude imputability."
Puno was not legally insane when he killed the hapless and helpless victim. The facts and the findings of
the psychiatrists reveal that on that tragic occasion he was not completely deprived of reason and freedom
of will.
In the instant case, the trial court correctly characterized the killing as murder. The qualifying
circumstance is abuse of superiority. In liquidating Francisco Col, Puno, who was armed with a hammer,
took advantage of his superior natural strength over that of the unarmed septuagenarian female victim
who was unable to offer any resistance and who could do nothing but exclaim " Diyos ko ".
Thus, it was held that "an attack made by a man with a deadly weapon upon an unarmed and defenseless
woman constitutes the circumstance of abuse of that superiority and the weapon used in the act afforded
him, and from which the woman was unable to defend herself"
Evident premeditation (premeditacion conocida) cannot be appreciated because the evidence does not
show (a) the time when the offender determined to commit the crime, (b) an act manifestly indicating that
the culprit had clung to his determination and (c) a sufficient interval of time between the determination
and the execution of the crime to allow him to reflect upon the consequences of his act.
However, those two aggravating circumstances are off-set by the mitigating circumstances of voluntary
surrender to the authorities and, as contended by counsel de oficio, the offender's mental illness (mild
psychosis or schizophrenic reaction) which diminished his will-power without however depriving him of
consciousness of his acts.
Dissenting, J. Makasiar:
Puno was mentally ill when he committed the alleged killing of Francisca Col.
His medical records, as properly evaluated and confirmed by the expert testimony of the three
physicians/psychiatrists who examined and treated him, undeniably establish the fact that Puno had been
ailing with a psychotic disorder medically known as chronic schizophrenia of the paranoid type.
Schizophrenia is a chronic mental disorder characterized by inability to distinguish between fantasy and
reality, and often accompanied by hallucinations and delusions. Formerly called dementia praecox, it is
the most common form of psychosis and usually develops between the ages of 15 and 30.
For a clear appreciation of Puno's mental condition, quoted hereunder are pertinent portions of the
discussion on the paranoid type of schizophrenia:
Paranoid Types. The features that tend to be most evident in this type or phase are delusions, which are
often numerous, illogical, and disregardful of reality, hallucinations, and the usual schizophrenic
disturbance of associations and of affect, together with negativism.
Frequently the prepsychotic personality of the paranoid schizophrenic is characterized by poor
interpersonal rapport. Often he is cold, withdrawn, distrustful, and resentful of other persons. Many are
truculent, have a chip-on-the-shoulder attitude, and are argumentative, scornful, sarcastic, defiant,
resentful of suggestions or of authority, and given to caustic remarks. Sometimes flippnant, facetious
responses cover an underlying hostility.

The patient's previous negative attitudes become more marked, and misinterpretations are common.
Ideas of reference are among the first symptoms. Disorders of association appear. Many patients show an
unpleasant emotional aggressiveness, Through displacement, the patient may begin to act out his hostile
impulses. His grip on reality begins to loosen. At first his delusions are limited, but later they become
numerous and changeable ... Delusions of persecution are the most prominent occurrences in paranoid
schizophrenia, but expansive and obviously wish- fulfilling Ideas and hypochondriacal and depressive
delusions are not uncommon. With increasing personality disorganization, delusional beliefs become less
logical. Verbal expressions may be inappropriate and neologistic. The patient is subjected to vague
magical forces, and his explanations become extremely vague and irrational. Imaginative fantasy may
become extreme but take on the value of reality. Repressed aggressive tendencies may be released in a
major outburst some inarticulate paranoids may manifest an unpredictable assaultiveness. Many
paranoid schizophrenics are irritable, discontented, resentful, and angrily suspicious and show a surely
aversion to being interviewed. Some manifest an unapproachable, aggressively hostile attitude and may
have in a bitter aloofness"
When Puno was examined and treated for the first time on July 28, 1962, his father revealed the patient's
initial symptoms of laughing alone and making gestures, poor sleep and appetite, praying and kneeling
always and making his body rigid (per consultation chart, p. 154, CCC rec.). Upon interview on aforesaid
date, Puno stated that "he could see God" and "That a neighbor is bewitching her" ("pinapakulam ako")
Why? "hindi ko alam kung bakit"
Puno underwent eighteen (18) treatments and checkups from July 28, 1962 to July 24, 1970 which
covered eight (8) years before the alleged crime was committed.
It should be stressed that between July 24, 1970 when Puno suffered from his last attack or relapse and
September 8, 1970 when he committed the alleged crime, barely 1 month and 15 days had elapsed.
Medically speaking, the interval was not sufficient time for Puno's full recovery nor did such time give any
guaranty for his mental disease to be "cured."
Puno was still mentally sick at the time he attacked the victim. He previously suffered from a
"displacement of aggressive and hostile behavior" when he got angry with his wife and when he tied and
boxed their dog. He had the mental delusion that a "mangkukulam" was inflicting harm on him. This
delusion found its mark on the victim whom he believed was the "mangkukulam" and fearing that she
would harm him, Puno had to kill her in self-defense. Simply stated, the victim was a mere consequence of
his mental delusion. He killed the "mangkukulam" as personified by the victim; he did not kin Aling Kikay
herself. And the said fatal act was made by Puno in defending himself from the "mangkukulam".
While it has been established that Puno was "manageable" and was "presently free from any social
incapacitating psychotic symptoms" during the trial, the fact remains that at the very moment of the
commission of the alleged crime, he was still a mentally sick person. No evidence was produced to prove
otherwise against the bulk of Puno's medical history for 8 years clearly indicative of his mental psychosis.
PEOPLE v. MORALES
20 April 1983| Per Curiam
Facts
Manuel Morales was charged with the rape of his own 14 year old daughter, Maria Morales in December
1974 and another charge of infanticide by burying alive his baby girl, Mary Morales March 1976. Maria is
Mary's mother.
Morales pleaded guilty. TC found Morales guilty of rape (Art. 335, RPC) for which he was imposed the
penalty of reclusion perpetual. As to infanticide (Art. 255, RPC), Morales was sentenced to death.
Morales only appeals the death penalty in the infanticide case.

Issue: Was Maria alive when Morales buried her?

Held:
The post mortem findings on baby Mary stated:
'I.EXTERNAL FINDINGS:
a)A dead new born baby girl with the placenta still attached was dug up approximately 100 meters
away from the residence of Manuel Morales under a banana tree.
b)Purplish black cynosis of the face, neck and all parts of the body were clearly observed.
c)At the early stage of decomposition, there is still the evidence of the caput succedanum and the baby is
covered with vernix cascosa. The head is covered with fine lanuge hair and the nails projected from the
fingers.
d)CHEST There is arching of the chest.
IIINTERNAL FINDINGS:
a)Lungs filled the thoracic cavity and overlaps the heart. Edges are rounded and vermillion red (pinkish
mottled color) in color. It crepitates on pressure: On section it exudes froth. A piece of the lungs floated
on water showing that air had probably entered in the lungs air sacs. It is spongy. It weighs more or
less 900 gms.
b)Stomach and intestines contains mucus and air bubbles and saliva.
IIICONCLUSION:
MOST PROBABLY CARDIO-RESPIRATORY FAILURE DUE TO ASPHYXIATION CAUSED THE DEATH
OF THE CHILD".
Morales himself admitted the killing of baby Mary in his extrajudicial confession, given two days after the
incident. This was reiterated on the witness stand.
The sworn statement of Maria Dolores further disclosed that the baby girl she delivered on that night of
March 19, 1976, without her father calling a "hilot" despite her request, was "buhay po at mabilog at
malakas ang uha na malusog"; that her father, the accused, took away said baby from her; and that,
thereafter, she was not able to see her baby anymore.
The accused's testimony that he had suffered a mental blackout and did not know what he was doing at
the time he buried his daughter, which condition, it is alleged, should have impelled the lower Court to
order his confinement in a hospital for treatment and for determination of whether or not he was insane,
is untenable. The act of the accused in refusing to call a "hilot" to help his daughter deliver, and his
insistence to act as such himself, betrays a conscious and deliberate intent to hide the fact of birth from
other eyes. The act of the accused in building a fire over the grave where he buried his infant daughter in
order to camouflage it and to deflect it from suspicion belies his protestations that he had suffered a
mental blackout at the time. On the contrary, they show deliberateness and full possession of his mental
faculties to prevent discovery of a dastardly crime. It is more likely that the accused was wavering between
remorse of conscience and a lurking desire to disown the crime and go scot-free if it could be proven that
the child had been born dead and lifeless. Besides, the law presumes every man to be sane. When a
defendant in a criminal case interposes the defense of mental incapacity, the burden of establishing that
fact rests upon him.

PEOPLE vs. MEDINA

Facts: (May 20, 1992) Alberto Medina was convicted of murder for stabbing Andres Dalisay.
Defense:
On several occasions before the crime, Medina had exhibited unusual behaviours. His sister Lorna
testified that she brought her brother to the National Mental Hospital after the latter had shown unusual
conduct, such as looking blankly at a distance, hitting his wife or banging her head on the wall for no
reason and for having sleepless nights.
(June-October 1982) Medina was confined at the National Mental Hospital. The Records Officer of the
National Center for Mental Health (formerly NMH) testified on the documents issued by their office
relative to Medinas confinement for schizophreniform disorder during that period.
After his release from the hospital, Medina lived with his mother and 2 children. His condition did not
seem to improve. Her sister testified that in January 1992, Medina again exhibited the same unusual
behaviour she had observed from him in 1982. This prompted her to refer her brothers case to Dr.
Teresita Adigue, a psychologist-friend.
Dr. Teresita Adigue, a Doctor of Psychology and a holder of a Masters Degree in Clinical and Industrial
Psychology and another Masters Degree in guidance and Counselling and an accredited psychologist of
the PNP testified that she administered a psychological evaluation on Medina.
Dr. Teresita Adigue testified that based on the evaluation of Medina, the latter has been shown to be
suffering from depression and was exhibiting homicidal tendencies and that he did not know the
difference between right and wrong. On cross-examination, Dr. Adigue affirmed that a person suffering
from depression may be insane.
Dr. Adigue stated that the psychological evaluation made on Medina was based on the behavioural history
furnished by his sister, a case study based on Medinas family background and on a series of
psychological tests (draw a person test, the card test wherein the emotions of the subject are represented
by cards and the thematic perception test where the subject creates stories from pictures presented to
him).
RTC: rejected the defense of insanity.
Dr. Adigue was not properly qualified as an expert witness because (1) she did not have Medinas
complete behavioural history; (2) she failed to demonstrate satisfactorily how she arrived at her
conclusions; (3) her method of testing was incomplete and inconclusive; (4) her examination lasted only
for a few hours without any follow up evaluation; (5) the university from where she allegedly obtained her
doctoral degree is not known to specialize in psychology or psychiatry; (6) she is not known as a
psychiatrist; and (7) she reported that the mental activity of Medina was functioning on the normal level
at the time of the evaluation, that he comprehended instructions fast, and that he was suffering only from
mild depression.
The testimony of Medinas sister that she had observed unusual behaviour on the part of Medina did not
constitute sufficient proof of his insanity, because not every aberration of the mind or mental deficiency
constitutes insanity. That Medina was released from confinement at the National Center for Mental
health on October 1982 and was not readmitted for any mental disorder for about 10 years militated
against his alleged lunacy. Additionally, the trial judge observed that, during the hearings, Medina was
attentive, well-behaved, and responsive to the questions propounded to him in English without
translation.
SC: Medinas Insanity Not Proven

When Medina tried to prove that Dr. Adigue is qualified as an expert witness, the SC ruled that what
mattered most were the results of the psychological examination:
Psychological test results revealed that subjects mental activity is functioning on the normal level at the
time of evaluation. He can comprehend instructions fast and [was] never hesitant to take the said
examinations.
With regards to some dominant personality factors, test results revealed also the fact that subject is
suffering only from mild depression because of problems he had encountered in life and in things around
him. He had also developed negative reactions and outlook in life, therefore the undersigned concluded
that he has some emotional disturbances.
These results do not prove the alleged insanity of Medina. Article 12, par. 1 of the RPC requires a complete
deprivation of rationality in committing the act, i.e., that the accused be deprived of reason, that there be
no consciousness of responsibility for his acts, or that there be complete absence of the power to discern.
More relevantly, the psychological report does not support the claim that Medina could not distinguish
right from wrong.
The presumption of law, per Art. 800 of the Civil Code, always lies in favor of sanity, and, in the absence
of proof to the contrary, every person is presumed to be of sound mind.
The defense of insanity or imbecility must be clearly proved, for there is a presumption that acts penalized
by law are voluntary. Hence, in the absence of positive evidence that the accused had previously lost his
reason or was demented moments prior to or during the perpetration of the crime, the courts will always
presume that he was in a normal state of mind.
Before the defense of insanity may be accepted as an exempting circumstance, PH case law shows a
common reliance on the test of cognition, which requires a complete deprivation of intelligence not only
of the will in committing the criminal act.
In Rafanan, the fact that appellant threatened the victim with death in case she reported her ravishment
indicated that he was aware of the reprehensible moral depravity of that assault and that he was not
deprived of intelligence. In Dungo, that the accused knew the nature of what he had done negated his
claim that he was insane when he fatally stabbed his victim.
In Aquino, appellant, who took 120 cc of cough syrup and consumed three sticks of marijuana before
raping his victim and hitting her head with a stone, had some form of mental illness which did not totally
deprive him of intelligence. The presence of his reasoning faculties, enabling him to exercise sound
judgment and to satisfactorily articulate the aforesaid matters, sufficiently discounted any intimation of
insanity when he committed the felony. It has been held that mere abnormality of the mental faculties
does not exclude criminal culpability.
In the present case, Dr. Adigues testimony did not establish complete deprivation of Medinas reason.
Consequently, Medina cannot claim exemption from criminal liability under Art. 12, par. 1 of the RPC.
On the alternative argument that Medinas condition should at least merit the accpreciation of a
mitigating circumstance under Art. 13, par. 9: NOPE
In Formigones, the Court found the feeblemindedness of the accused to be a mitigating circumstance,
noting that his faculties were not fully developed. After stabbing his wife, the accused in said case took
her dead body up their house, put her on the floor and lay beside her for hours, showing remorse at
having killed her. The accused was suffering [from] some physical defect which thus restrict[ed] his
means of action, defense or communication with his fellow beings, or such illness as would diminish the
exercise of his will power.

In Rafanan, schizophrenic reaction, although not exempting because it does not completely deprive the
offender of the consciousness of his acts, was considered a mitigating circumstance which diminished the
exercise of the offenders will power without, however, depriving him of the consciousness of his acts.
Here, the defense miserably failed to establishthe deprivation of Medinas will when he stabbed his victim.
Medina testified that he thought the victim was going to pull out a weapon, thus he beat him to the draw
(Inunahan ko na siya) and stabbed him with his balisong. This statement shows that he did not suffer any
deprivation of reason or discernment. While the victim appeared to him as a devil with horns, such
perceptual distortion occurred only after he had dealt the fatal blows on the victim. The Court cannot,
therefore, appreciate this mitigating circumstance in his favor.
Others:
Treachery was present: Treachery can be gleaned from the fact that Medina waited behind a chico tree
and then, all of a sudden, jumped on the victim. Medinas attack was not only sudden and unexpected; it
was also vicious and relentless. After delivering the first stab, Medina chased his victim and stabbed him
seven more times. These seven additional stabs were inflicted when the victim was helpless, as he fell
down several times during the pursuit. Counterattack and escape proved futile because of the injuries
that the victim sustained. The medico-legal officer reported that of the eight stab wounds on the victim,
six were fatal. Clearly, in killing his victim, Medina employed means which ensured its execution without
risk to himself arising from any defense which the victim might make. Treachery which qualified the
killing as murder was properly appreciated by the trial court.
No evident premeditation
Mitigating circumstance of voluntary surrender

PEOPLE vs. POLICARPIO RAFANAN, JR. (1991)

Facts: Rafanan was convicted of raping his mothers househelper Estelita Ronaya.
At 11:00 o'clock in the evening, the accused called the complainant to help him close the door of the store
and as the latter complied and went near him, he suddenly pulled the complainant inside the store and
said, "Come, let us have sexual intercourse," to which Estelita replied, "I do not like," and struggled to free
herself and cried. The accused held a bolo measuring 1-1/2 feet including the handle which he pointed to
the throat of the complainant threatening her with said bolo should she resist. Then, he forced her to lie
down on a bamboo bed, removed her pants and after unfastening the zipper of his own pants, went on top
of complainant and succeeded having carnal knowledge of her inspite of her resistance and struggle. After
the sexual intercourse, the accused cautioned the complainant not to report the matter to her mother or
anybody in the house, otherwise he would kill her.
Defense: Rafanan was suffering from a mental aberration characterized as schizophrenia when he
inflicted his violent intentions upon Estelita.
RTC suspended trial and ordered Rafanas confinement at the National Mental Hospital for observation
and treatment.
During his confinement, the hospital prepared four (4) clinical reports on the mental and physical
condition of Rafanan, all signed by Dr. Simplicio N. Masikip and Dr. Arturo E. Nerit, physician-in-charge
and chief, Forensic Psychiatry Service, respectively.
Report 1:
On admission he was sluggish in movements, indifferent to interview, would just look up whenever
questioned but refused to answer.

On subsequent examinations and observations he was carelessly attired, with dishevelled hair, would
stare vacuously through the window, or look at people around him. He was indifferent and when
questioned, he would just smile inappropriately. He refused to verbalize, even when persuaded, and was
emotionally dull and mentally inaccessible. He is generally seclusive, at times would pace the floor,
seemingly in deep thought. Later on when questioned his frequent answers are "Aywan ko, hindi ko
alam." His affect is dull, he claimed to hear strange voices "parang ibon, tinig ng ibon," but cannot
elaborate. He is disoriented to 3 spheres and has no idea why he was brought here.
In view of the foregoing examinations and observations, Policarpio Rafanan, Jr. y Gambawa is found
suffering from a mental disorder called schizophrenia, manifested by carelessness in grooming,
sluggishness in movements, staring vacuously, indifferen[ce], smiling inappropriately, refusal to verbalize,
emotional dullness, mental inaccessibility, seclusiveness, preoccupation, disorientation, and perceptual
aberrations of hearing strange sounds. He is psychotic or insane, hence cannot stand court trial. He needs
further hospitalization and treatment.
Report 2:
At present he is still seclusive, undertalkative and retarded in his reponses. There is dullness of his affect
and he appeared preoccupied. He is observed to mumble alone by himself and would show periods of
being irritable saying "oki naman" with nobody in particular. He claim he does not know whether or not
he was placed in jail and does not know if he has a case in court. Said he does not remember having
committed any wrong act.
In view of the foregoing examinations and observations Policarpio Rafanan, Jr. y Gambawa is at present
time still psychotic or insane, manifested by periods of irritability cursing nobody in particular,
seclusive, underactive, undertalkative, retarded in his response, dullness of his affect, mumbles alone by
himself, preoccupied and lack of insight.
He is not yet in a condition to stand court trial. He needs further hospitalization and treatment.
Report 3:
He has become "better behaved, responsive" and "neat in person," and "adequate in his emotional tone, in
touch with his surroundings and . . . free from hallucinatory experiences." During the preceding period,
appellant had been allowed to leave the hospital temporarily; he stayed with a relative in Manila while
coming periodically to the hospital for check-ups. During this period, he was said to have been helpful in
the doing of household chores, conversed and as freely with other members of the household and slept
well, although, occasionally, appellant smiled while alone. Appellant complained that at times he heard
voices of small children, talking in a language he could not understand. The report concluded by saying
that while appellant had improved in his mental condition, he was not yet in a position to stand trial since
he needed further treatment, medication and check-ups.
Report 4:
He was behaved, helpful in household chores and no longer talking while alone. He was "fairly groomed"
and "oriented" and as denying having hallucinations. He was in a "much improved condition" and "in a
mental condition to stand court trial."
Trial of the case thus resumed. The defense first presented Dr. Arturo Nerit who suggested that Rafanan
was sick one or two years before his admission into the hospital, in effect implying that he was already
suffering from schizophrenia when he raped complainant. The defense next presented Raquel Jovellano, a
psychiatrist engaged in private practice, who testified that she had examined and treated Rafanan.
SC: Insanity not proven

Although the Court has ruled many times in the past on the insanity defense, it was only in People vs.
Formigones that the Court elaborated on the required standards of legal insanity, quoting extensively
from the Commentaries of Judge Guillermo Guevara on the Revised Penal Code:
In order that this exempting circumstance may be taken into account, it is necessary that there be a
complete deprivation of intelligence in committing the act, that is, that the accused be deprived of
reason; that there be no responsibility for his own acts; that he acts without the least discernment; that
there be a complete absence of the power to discern, or that there be a total deprivation of freedom of the
will. Imbecility or insanity at the time of the commission of the act should absolutely deprive a person of
intelligence or freedom of will, because mere abnormality of his mental faculties does not exclude
imputability.
The allegation of insanity or imbecility must be clearly proved. Without positive evidence that the
defendant had previously lost his reason or was demented, a few moments prior to or during the
perpetration of the crime, it will be presumed that he was in a normal condition. Acts penalized by law
are always reputed to be voluntary, and it is improper to conclude that a person acted unconsciously, in
order to relieve him from liability, on the basis of his mental condition, unless his insanity and absence of
will are proved.
TESTS ESTABLISHED in Formigones:
(a) the test of cognition "complete deprivation of intelligence in committing the [criminal] act,"
(b) the test of volition "or that there be a total deprivation freedom of the will."
PH case law shows common reliance on the test of cognition, rather than on a test relating to "freedom of
the will;" examination of our caselaw has failed to turn up any case where this Court has exempted an
accused on the sole ground that he was totally deprived of "freedom of the will," i.e., without an
accompanying "complete deprivation of intelligence." This is perhaps to be expected since a person's
volition naturally reaches out only towards that which is presented as desirable by his intelligence,
whether that intelligence be diseased or healthy. In any case, where the accused failed to show complete
impairment or loss of intelligence, the Court has recognized at most a mitigating, not an exempting,
circumstance in accord with Article 13(9) of the Revised Penal Code: "Such illness of the offender as would
diminish the exercise of the will-power of the offender without however depriving him of the
consciousness of his acts."
Schizophrenia pleaded by Rafanan has been described as a chronic mental disorder characterized by
inability to distinguish between fantasy and reality, and often accompanied by hallucinations and
delusions. Formerly called dementia praecox, it is said to be the most common form of psychosis an
usually develops between the ages 15 and 30.
In previous cases where schizophrenia was interposed as an exempting circumtance, it has mostly been
rejected by the Court. In each of these cases, the evidence presented tended to show that if there was
impairment of the mental faculties, such impairment was not so complete as to deprive the accused of
intelligence or the consciousness of his acts.
Dr. Jovellanos testimony negates complete destruction of intelligence at the time of the commission of
the act charged which, in the current state of our caselaw, is critical if the defense of insanity is to be
sustained. The fact that appellant Rafanan threatened complainant Estelita with death should she reveal
she had been sexually assaulted by him, indicates, to the mind of the Court, that Rafanan was aware of the
reprehensible moral quality of that assault.
Q And would you say that condition that ability of a person to plan a rape and to perform all the acts
preparatory to the actual intercourse could be done by an insane person?
A Yes, it could be done.
Q Now, you are talking of insanity in its broadest sense, is it not?
A Yes, sir.
Q Now, is this insane person also capable of knowing what is right and what is wrong?

A Well, there is no weakness on that part of the individual. They may know what is wrong but yet there
is no inhibition on the individual.
Q Yes, but actually, they are mentally equipped with knowledge that an act they are going to commit is
wrong?
A Yeah, they are equipped but the difference is, there is what we call they lost the inhibition. The
reasoning is weak and yet they understand but the volition is [not] there, the drive is [not]
there.
The law presumes every man to be sane. A person accused of a crime has the burden of proving his
affirmative allegation of insanity. Here, Rafanan failed to present clear and convincing evidence regarding
his state of mind immediately before and during the sexual assault on Estelita. It has been held that
inquiry into the mental state of the accused should relate to the period immediately before or at the very
moment the act is committed. Rafanan rested his case on the testimonies of two (2) physicians (Dr.
Jovellano and Dr. Nerit) which, however, did not purport to characterize his mental condition during that
critical period of time. They did not specifically relate to circumstances occurring on or immediately
before the day of the rape. Their testimonies consisted of broad statements based on general behavioral
patterns of people afflicted with schizophrenia. Curiously, while it was Dr. Masikip who had actually
observed and examined Rafanan during his confinement at the National Mental Hospital, the defense
chose to present Dr. Nerit.

PEOPLE vs. FERNANDO MADARANG (2000)

What distinguishes man from beast is his intellect. Man's action is guided and controlled by his mind.
Law is designed for rational beings as it is based on our inherent sense of right which is inseparable from
reason. Thus, when man's reasoning is so distorted by disease that he is totally incapable of distinguishing
right from wrong, he loses responsibility before the law.
Facts: Madarang was charged of parricide for killing his wife Lilia (inflicting upon her stab wound 4 1/2
inches by 1 1/2 inch(es)long and 3/16 of an inch wide, located just below the left clavicle 1 3/4 inch(es)
lateral to the supra-sternal notch, and plowed along the interpace slightly coursing upward and
posteriorly and stab wound 1 inch in length, gaping and 3 1/2 inch(es) deep, located at the right arm at its
medial aspect, coursing upwards and medially towards the apex of the right axilla which caused her
instantaneous death).
At the initial hearing, Madarangs counsel manifested that his client had been observed behaving in an
abnormal manner inside the provincial jail. Thus, the Court called Madarang to the stand but he refused
to answer any of the questions propounded by the court. Hence, on the same date, the Court issued an
Order directing the transfer of Madarang to the National Center for Mental Health (NCMH) for
psychiatric evaluation to determine his fitness to stand trial.
The initial examination of Madarang at the NCMH revealed that he was suffering from a form of
psychosis known as schizophrenia. He was detained at the hospital and was administered medication for
his illness. On June 19, 1996, after more than two (2) years of confinement, he was discharged from the
NCMH and recommitted to the provincial jail as he was already found fit to face the charges against him.
Defense: The accused declared that he has absolutely no recollection of the stabbing incident. He could
not remember where he was on that fateful day. He did not know the whereabouts of his wife. It was only
during one of the hearings when his mother-in-law showed him a picture of his wife in a coffin that he
learned about her death. He, however, was not aware of the cause of her demise. He claimed that he did
not know whether he suffered from any mental illness and did not remember being confined at the NCMH
for treatment.

DR. WILSON S. TIBAYAN, a resident doctor of the National Center for Mental Health (NCMH), declared
that the accused was committed to the NCMH on July 4, 1994 upon order of the court. The NCMH
conducted three (3) medical and psychiatric evaluations of the accused during his confinement therein.
Report 1: Medina was found to be suffering from insanity or psychosis, classified as schizophrenia. Dr.
Tibayan explained that schizophrenia is a mental abnormality characterized by impaired fundamental
reasoning, delusions, hallucinations, preoccupation with one's thoughts, poor self-care, insight and
judgment, and impaired cognitive, social and occupational functions. The patient may be incapable of
distinguishing right from wrong or know what he is doing. He may become destructive or have a
propensity to attack any one if his hallucinations were violent. A schizophrenic, however, may have lucid
intervals during which he may be able to distinguish right from wrong. Dr. Tibayan opined that the
accused's mental illness may have begun even prior to his admission to the NCMH and it was highly
possible that he was already suffering from schizophrenia prior to his commission of the crime.
Report 2: Madarang was still suffering from schizophrenia.
Report 3: Madarangs mental condition considerably improved due to continuous medication. He was
recommended to be discharged from the NCMH and recommitted to jail to stand trial.
MADARANG insists that at the time he stabbed his wife, he was completely deprived of intelligence,
making his criminal act involuntary. His unstable state of mind could allegedly be deduced from the
following:
1.

He had no recollection of the stabbing incident. Hence he was completely unaware of his acts that
fateful day and must have committed the crime without the least discernment.
2. His behavior at the time of the stabbing proved he was then afflicted with schizophrenia. He cited
the testimony of Dr. Tibayan that a schizophrenic may go into extremes -- he may be violent and
destructive, or very silent and self-focused. The appellant exhibited his violent tendencies on that
fateful day. He killed his wife and Avelina and her nephew were so frightened that they ran away
at the sight of him holding a bolo. He did not seem to recognize anybody and could have turned to
anyone and inflicted further injury. He avers that this is peculiar only to persons who are mentally
deranged for a sane person who just committed a crime would have appeared remorseful and
repentant after realizing that what he did was wrong.
3. Dr. Tibayan opined that there was a high possibility that he was already suffering from insanity
prior to his commission of the crime on September 3, 1993. The defense posits that his mental
illness may have been caused by his loss of fortune. His hardware business, which he started
through 16 years of working as a seaman, went bankrupt. He ended up virtually dependent on his
mother-in-law for his family's support and all these may have been beyond his capacity to handle.
Madarang further contended the fact that he and his wife never engaged in a fight prior to that
fateful day should be considered. The marked change in his behavior when he uncharacteristically
quarreled with his wife on that day and suddenly turned violent on her confirms that he was
mentally disturbed when he committed the crime.
4. He had no motive to kill Lilia who was scheduled to give birth to their eighth child three (3) days
prior to the killing. Unless overpowered by something beyond his control, nobody in his right
mind would kill his wife who was carrying his child. Jealousy, the appellant posits, is not a
sufficient reason to kill a pregnant spouse.
SC: Insanity not proven
In all civilized nations, an act done by a person in a state of insanity cannot be punished as an offense. The
insanity defense is rooted on the basic moral assumption of criminal law. Man is naturally endowed with
the faculties of understanding and free will. The consent of the will is that which renders human actions
laudable or culpable. Hence, where there is a defect of the understanding, there can be no free act of the
will. An insane accused is not morally blameworthy and should not be legally punished. No purpose of
criminal law is served by punishing an insane accused because by reason of his mental state, he would
have no control over his behavior and cannot be deterred from similar behavior in the future.

TESTS to determine insanity in Anglo-American jurisprudence:

1.

MNaghten Rule (1843): To establish a defense on the ground of insanity, it must be clearly
proved that, at the time of committing the act, the party accused was laboring under such a defect
of reason from disease of the mind, as not to know the nature and quality of the act he was doing,
or, if he did know it, that he did not know he was doing what was wrong.
This is a cognitive measure of insanity.
Accused is required to know 2 things: the nature and the quality of the act, and that the act was
wrong.
Criticized for ambiguity
Debate as to whether the word wrong referred to moral or legal wrong
Condemned as based on an obsolete and misleading concept of the nature of insanity as insanity
does not only affect the intellectual faculties but also affects the whole personality of the patient,
including his will and emotions. It was argued that reason is only one of the elements of a
personality and does not solely determine man's conduct.

2. Irresistible impulse test: Assuming defendants knowledge of the nature and quality of his act
and knowledge that the act is wrong, if, by reason of disease of the mind, defendant has been
deprived of or lost the power of his will which would enable him to prevent himself from doing
the act, then he cannot be found guilty."
Thus, even if the accused knew that what he was doing was wrong, he would be acquitted by
reason of insanity if his mental illness kept him from controlling his conduct or resisting the
impulse to commit the crime.
Rule rests on the assumption that there are mental illnesses that impair volition or self-control,
even while there is cognition or knowledge of what is right and wrong.
Criticism: (1) the impulse requirement is too restrictive as it covers only impulsive acts; (2) the
irresistible requirement is also restrictive as it requires absolute impairment of the freedom of
the will which cases are very rare; (3) it will not serve the purpose of criminal law to deter
criminals as the will to resist commission of the crime will not be encouraged and; (4) it is
difficult to prove whether the act was the result of an insane, irresistible impulse.
3. Durham product test (1954): An accused is not criminally responsible if his unlawful act was
the product of mental disease or defect.
Critics argued that the test gave too much protection to the accused. It placed the prosecution in a
difficult position of proving accuseds sanity beyond reasonable doubt as a mere testimony of a
psychiatrist that accuseds act was the result of a mental disease leaves the judge with no choice
but to accept it as a fact
Case becomes completely dependent on the testimonies of experts
4. The American Law Institutes (ALIs) substantial capacity test: A person is not responsible for
his criminal act if, as a result of the mental disease or defect, he lacks substantial capacity to
appreciate the criminality of his act or to conform his conduct to the requirements of the law.
Improved on the MNaghten and irresistible impulse tests
Criticized for its use of ambiguous words like "substantial capacity" and "appreciate" as there
would be differences in expert testimonies whether the accused's degree of awareness was
sufficient.
Objections were also made to the exclusion of psychopaths or persons whose abnormalities are
manifested only by repeated criminal conduct. Critics observed that psychopaths cannot be
deterred and thus undeserving of punishment.
5. Appreciation test
Made applicable in all federal courts in 1984 when US Congress enacted the Comprehensive
Crime Control Act
Similar to MNaghten as it relies on the cognitive test
Similar to ALI test in that the accused is not required to prove lack of control

Shifted the burden of proof to the defense, limited the scope of expert testimony, eliminated the
defense of diminished capacity and provided for commitment of accused found to be insane

In the Philippines, the courts have established a more stringent criterion for insanity to be exempting as it
is required that there must be a complete deprivation of intelligence in committing the act, i.e., the
accused is deprived of reason; he acted without the least discernment because there is a complete absence
of the power to discern, or that there is a total deprivation of the will. Mere abnormality of the mental
faculties will not exclude imputability.
The issue of insanity is a question of fact for insanity is a condition of the mind, not susceptible of the
usual means of proof. As no man can know what is going on in the mind of another, the state or condition
of a person's mind can only be measured and judged by his behavior. Establishing the insanity of an
accused requires opinion testimony which may be given by a witness who is intimately acquainted with
the accused, by a witness who has rational basis to conclude that the accused was insane based on the
witness' own perception of the accused, or by a witness who is qualified as an expert, such as a psychiatrist.
The testimony or proof of the accused's insanity must relate to the time preceding or coetaneous with the
commission of the offense with which he is charged.
In the case at bar, the appellant was diagnosed to be suffering from schizophrenia when he was
committed to the NCMH months after he killed his wife. Medical books describe schizophrenia as a
chronic mental disorder characterized by inability to distinguish between fantasy and reality and often
accompanied by hallucinations and delusions. Formerly called dementia pracecox, it is the most common
form of psychosis.
Symptomatically, schizophrenic reactions are recognizable through odd and bizarre behavior apparent in
aloofness or periods of impulsive destructiveness and immature and exaggerated emotionality, often
ambivalently directed. The interpersonal perceptions are distorted in the more serious states by delusions
and hallucinations. In the most disorganized form of schizophrenic living, withdrawal into a fantasy life
takes place and is associated with serious thought disorder and profound habit deterioration in which the
usual social customs are disregarded.
During the initial stage, the common early symptom is aloofness, a withdrawal behind barriers of
loneliness, hopelessness, hatred and fear. Frequently, the patient would seem preoccupied and dreamy
and may appear "faraway." He does not empathize with the feelings of others and manifests little concern
about the realities of life situations. The schizophrenic suffers from a feeling of rejection and an
intolerable lack of self-respect. He withdraws from emotional involvement with other people to protect
himself from painful relationships. There is shallowness of affect, a paucity of emotional responsiveness
and a loss of spontaneity. Frequently, he becomes neglectful of personal care and cleanliness.
A variety of subjective experiences, associated with or influenced by mounting anxiety and fears precede
the earliest behavioral changes and oddities. He becomes aware of increasing tension and confusion and
becomes distracted in conversation manifested by his inability to maintain a train of thought in his
conversations. Outwardly, this will be noticed as blocks or breaks in conversations. The schizophrenic
may not speak or respond appropriately to his companions. He may look fixedly away, or he may appear
to stare, as he does not regularly blink his eyes in his attempt to hold his attention.
None of the witnesses presented by the appellant declared that he exhibited any of the myriad symptoms
associated with schizophrenia immediately before or simultaneous with the stabbing incident. To be sure,
the record is bereft of even a single account of abnormal or bizarre behavior on the part of the
appellant prior to that fateful day. Although Dr. Tibayan opined that there is a high possibility that the
appellant was already suffering from schizophrenia at the time of the stabbing, he also declared
that schizophrenics have lucid intervals during which they are capable of distinguishing right from wrong.
Hence the importance of adducing proof to show that the appellant was not in his lucid interval at the
time he committed the offense. Although the appellant was diagnosed with schizophrenia a few
months after the stabbing incident, the evidence of insanity after the fact of commission of the offense

may be accorded weight only if there is also proof of abnormal behavior immediately before or
simultaneous to the commission of the crime. Evidence on the alleged insanity must refer to the time
preceding the act under prosecution or to the very moment of its execution.
In the present case, the evidence adduced by the defense is insufficient to establish Madarangs claim of
insanity at the time he killed his wife.
There is a dearth of evidence on record to show that the appellant was completely of unsound mind prior
to or coetaneous with the commission of the crime. The arguments advanced by the appellant to prove his
insanity are speculative and non-sequitur. For one, his claim that he has absolutely no recollection of the
stabbing incident amounts to a mere general denial that can be made with facility. The fact that Avelina
and her nephew were frightened at the sight of the appellant holding a bolo after he killed his wife does
not, by any stretch of imagination, prove that the appellant has lost his grip on reality on that occasion.
Neither is the appellant's seemingly non-repentant attitude immediately after he stabbed his wife an
indicium of his alleged insanity. Even criminals of stable mental condition take this non-remorseful
stance. Similarly, that the appellant and his wife were never seen quarrelling prior to that fateful day does
not by itself prove the appellant's unstable mental condition. Neither can it be said that jealousy is not a
sufficient reason to kill a pregnant spouse. Our jurisprudence is replete with cases where lives had been
terminated for the flimsiest reason.
The appellant attributes his loss of sanity to the fact that he lost his business and became totally
dependent on his mother-in-law for support. We find this, however, purely speculative and unsupported
by record. To be sure, there was no showing of any odd or bizarre behavior on the part of the
appellant after he lost his fortune and prior to his commission of the crime that may be symptomatic of
his mental illness. In fact, the appellant's mother-in-law declared that during the time that she knew the
appellant and while he lived in her house, she did not notice anything irregular or abnormal in the
appellant's behavior that could have suggested that he was suffering from any mental illness.
An accused invoking the insanity defense pleads not guilty by reason thereof. He admits committing the
crime but claims that he is not guilty because he was insane at the time of its commission. Hence, the
accused is tried on the issue of sanity alone and if found to be sane, a judgment of conviction is rendered
without any trial on the issue of guilt as he had already admitted committing the crime.

PEOPLE vs. ROSALINO DUNGO (1991)

Facts: Dungo was charged of murder for the killing of Belen Sigua. Witnesses stated that they saw him go
to the place where Mrs. Sigua was holding office at the Department of Agrarian Reform, Apalit, Pampanga.
After a brief talk, the accused drew a knife from the envelope he was carrying and stabbed Mrs. Sigua
several times. Accomplishing the morbid act, he went down the staircase and out of the DAR's office with
blood stained clothes, carrying along a bloodied bladed weapon.
Rodolfo Sigua, the husband of the deceased, testified that, sometime in the latter part of February, 1987,
the accused Rosalino Dungo inquired from him concerning the actuations of his wife (the victim) in
requiring so many documents from the accused. Rodolfo Sigua explained to the accused the procedure in
the Department of Agrarian Reform but the latter just said "never mind, I could do it my own way."
Defense:
Testimony of Dungos wife, Andrea
Dungo had been engaged in farming up to 1982 when he went to Lebanon for six (6) months. Later, in
December 1983, her husband again left for Saudi Arabia and worked as welder. Her husband did not
finish his two-year contract because he got sick. Upon his arrival, he underwent medical treatment.

He was confined for one week at the Macabali Clinic. Thereafter he had his monthly check-up. Because of
his sickness, he was not able to resume his farming. The couple, instead, operated a small store which her
husband used to tend.
Two weeks prior to March 16, 1987, she noticed her husband to be in deep thought always; maltreating
their children when he was not used to it before; demanding another payment from his customers even if
the latter had paid; chasing any child when their children quarrelled with other children. There were also
times when her husband would inform her that his feet and head were on fire when in truth they were
not.
On the fateful day of March 16, 1987, at around noon time, her husband complained to her of stomach
ache; however, they did not bother to buy medicine as he was immediately relieved of the pain therein.
Thereafter, he went back to the store. When Andrea followed him to the store, he was no longer there. She
got worried as he was not in his proper mind. She looked for him. She returned home only when she was
informed that her husband had arrived. While on her way home, she heard from people the words
"mesaksak" and "menaksak" (translated as "stabbing" and "has stabbed"). She saw her husband in her
parents-in-law's house with people milling around, including the barangay officials. She instinctively
asked her husband why he did such act, but he replied, "that is the only cure for my ailment. I have a
cancer in my heart." Her husband further said that if he would not be able to kill the victim in a number of
days, he would die, and that he chose to live longer even in jail.
Testimony of Dra. Sylvia Santiago and Dr. Nicanor Echavez of the National Center for Mental Health
Dungo was confined in the mental hospital, as per order of the trial court dated August 17, 1987, on
August 25, 1987. Based on the reports of their staff, they concluded that Rosalino Dungo was psychotic or
insane long before, during and after the commission of the alleged crime and that his insanity was
classified under organic mental disorder secondary to cerebro-vascular accident or stroke.
Testimony of Dungo himself
He once worked in Saudi Arabia as welder. However, he was not able to finish his two-year contract when
he got sick. He had undergone medical treatment at Macabali Clinic. However, he claimed that he was not
aware of the stabbing incident nor of the death of Mrs. Belen Sigua. He only came to know that he was
accused of the death of Mrs. Sigua when he was already in jail.
Testimony of the prosecutions rebuttal witnesses
Dr. Vicente Balatbat testified that the accused was his patient. He treated the accused for ailments
secondary to a stroke. While Dr. Ricardo Lim testified that the accused suffered from oclusive disease of
the brain resulting in the left side weakness. Both attending physicians concluded that Rosalino Dungo
was somehow rehabilitated after a series of medical treatment in their clinic. Dr. Leonardo Bascara
further testified that the accused is functioning at a low level of intelligence.
SC: Insanity not proven
One who suffers from insanity at the time of the commission of the offense charged cannot in a legal sense
entertain a criminal intent and cannot be held criminally responsible for his acts. His unlawful act is the
product of a mental disease or a mental defect. In order that insanity may relieve a person from criminal
responsibility, it is necessary that there be a complete deprivation of intelligence in committing the act,
that is, that the accused be deprived of cognition; that he acts without the least discernment; that there be
complete absence or deprivation of the freedom of the will.
It is difficult to distinguish sanity from insanity. There is no definite defined border between sanity and
insanity.
3 major criteria in determining the existence of insanity in foreign jurisprudence

1.

Delusion test: Insane delusion is manifested by a false belief for which there is no reasonbale
basis and which would be incredible under the given circumstances to the same person if he is of
compos mentis. Under the delusion test, an insane person believes in a state of things, the
existence of which no rational person would believe.
2. Irresistible impulse test: A person acts under an irresistible impulse when, by reason of duress or
mental disease, he has lost the power to choose between right and wrong, to avoid the act in
question, his free agency being at the time destroyed.
3. Right and wrong test: A person is insane when he suffers from such perverted condition of the
mental and moral faculties as to render him incapable of distinguishing between right and wrong.
So far, under our jurisdiction, there has been no case that lays down a definite test or criterion for
insanity.
However, Court applied as test or criterion the definition of insanity under Section 1039 of the Revised
Administrative Code, which states that insanity is "a manifestation in language or conduct, of disease or
defect of the brain, or a more or less permanently diseased or disordered condition of the mentality,
functional or organic, and characterized by perversion, inhibition, or by disordered function of the
sensory or of the intellective faculties, or by impaired or disordered volition." Insanity as defined above is
evinced by a deranged and perverted condition of the mental faculties which is manifested in language or
conduct. An insane person has no full and clear understanding of the nature and consequence of his act.
Thus, insanity may be shown by surrounding circumstances fairly throwing light on the subject, such as
evidence of the alleged deranged person's general conduct and appearance, his acts and conduct
inconsistent with his previous character and habits, his irrational acts and beliefs, and his improvident
bargains.
Evidence of insanity must have reference to the mental condition of the person whose sanity is in issue, at
the very time of doing the act which is the subject of inquiry. However, it is permissible to receive
evidence of his mental condition for a reasonable period both before and after the time of the act in
question. Direct testimony is not required nor the specific acts of derangement essential to establish
insanity as a defense. The vagaries of the mind can only be known by outward acts: thereby we read the
thoughts, motives and emotions of a person; and through which we determine whether his acts conform
to the practice of people of sound mind.
In the case at bar, defense's expert witnesses, who are doctors of the National Center for Mental Health,
concluded that the accused was suffering from psychosis or insanity classified under organic mental
disorder secondary to cerebro-vascular accident or stroke before, during and after the commission of the
crime charged.
Accordingly, the mental illness of the accused was characterized by perceptual disturbances manifested
through impairment of judgment and impulse control, impairment of memory and disorientation, and
hearing of strange voices. The accused allegedly suffered from psychosis which was organic. The defect of
the brain, therefore, is permanent.
Dr. Echavez, defense's expert witness, admitted that the insanity of the accused was permanent and did
not have a period for normal thinking. (Considering the nature of the organic mental disorder, the lucid
intervals are unfortunately not present.) However, Dr. Echavez disclosed that the manifestation or the
symptoms of psychosis may be treated with medication. Thus, although the defect of the brain is
permanent, the manifestation of insanity is curable.
Dr. Echavez further testified that the accused was suffering from psychosis since January of 1987. Patient
had a stroke in Riyadh about seven (7) months before his contract expired and he was brought home.
Sometime in January of 1987, the first manifestation is noted on the behavioral changes. He was noted to
be in deep thought, pre-occupied self, complaining of severe headache, deferment of sleep and loss of
appetite.

The defense reposed their arguments on the findings of the doctors of the National Center for Mental
Health, specifically on Dr. Echavez's assessment that the accused has been insane since January of 1987
or three (3) months before the commission of the crime charged. The doctors arrived at this conclusion
based on the testimonies of the accused's wife and relatives, and after a series of medical and
psychological examinations on the accused when he was confined therein.
The prosecution aptly rebutted the defense proposition, that the accused, though he may be insane, has no
lucid intervals. It is an undisputed fact that a month or few weeks prior to the commission of the crime
charged the accused confronted the husband of the victim concerning the actuations of the latter. He
complained against the various requirements being asked by the DAR office, particularly against the
victim.
If We are to believe the contention of the defense, the accused was supposed to be mentally ill during this
confrontation. However, it is not usual for an insane person to confront a specified person who may have
wronged him. Be it noted that the accused was supposed to be suffering from impairment of the memory,
We infer from this confrontation that the accused was aware of his acts. This event proves that the
accused was not insane or if insane, his insanity admitted of lucid intervals.
The testimony of defense witness Dr. Nicanor Echavez is to the effect that the appellant could have been
aware of the nature of his act at the time he committed it:
A Having examined a particular patient, in this particular case, I made a laboratory examination, in short
all the assessment necessary to test the behavior of the patient, like for example praying for postponement
and fleeing from the scene of the crime is one situation to consider if the patient is really insane or not. If I
may elaborate to explain the situation of the accused, the nature of the illness, the violent behavior, then
he appears normal he can reason out and at the next moment he burst out into violence regardless
motivated or unmotivated. This is one of the difficulties we have encountered in this case. When we
deliberated because when we prepared this case we have really deliberation with all the members of the
medical staff so those are the things we considered. Like for example he shouted out "Napatay ko si Mrs.
Sigua!" at that particular moment he was aware of what he did, he knows the criminal case.
Q With that statement of yours that he was aware when he shouted that he killed the victim in this case,
Mrs. Sigua, do we get it that he shouted those words because he was aware when he did the act?
A The fact that he shouted, Your Honor, awareness is there.
Insanity in law exists when there is a complete deprivation of intelligence. The statement of one of the
expert witnesses presented by the defense, Dr. Echavez, that the accused knew the nature of what he had
done makes it highly doubtful that accused was insane when he committed the act charged.
Generally, in criminal cases, every doubt is resolved in favor of the accused. However, in the defense of
insanity, doubt as to the fact of insanity should be resolved in fervor of sanity. The burden of proving the
affirmative allegation of insanity rests on the defense. In considering the plea of insanity as a defense in a
prosecution for crime, the starting premise is that the law presumes all persons to be of sound
mind. therwise stated, the law presumes all acts to be voluntary, and that it is improper to presume that
acts were done unconsciously. Whoever, therefore, invokes insanity as a defense has the burden of
proving its existence.
The quantum of evidence required to overthrow the presumption of sanity is proof beyond reasonable
doubt. Insanity is a defense in a confession and avoidance and as such must be proved beyond reasonable
doubt. Insanity must be clearly and satisfactorily proved in order to acquit an accused on the ground of
insanity. Appellant has not successfully discharged the burden of overcoming the presumption that he
committed the crime as charged freely, knowingly, and intelligently.
Lastly, the State should guard against sane murderer escaping punishment through a general plea of
insanity.

Psychological Incapacity
Psychological incapacity must be characterized by (a) gravity (b) juridical antecedence, and (c)
incurability. These guidelines do not require that a physician examine the person to be declared
psychologically incapacitated. In fact, the root cause may be medically or clinically identified. What is
important is the presence of evidence that can adequately establish the party's psychological condition. If
the totality of evidence presented is enough to sustain a finding of psychological incapacity, then actual
medical examination of the person concerned need not be resorted to
CASE: CYNTHIA YAMBAO vs. RP and PATRICIO YAMBAO (2011)
Facts: Cynthia and Patricio were married on December 21, 1968 in QC. On July 11, 2003, after 35 years of
marriage, Cynthia filed a petition before RTC Makati, praying that the marriage be declared null and void
by reason of Patricios psychological incapacity.
Petitioner:
Cynthia narrated that since the beginning, their married life had been marred by bickering, quarrels and
recrimination due to Patricios inability to comply with the essential obligations of married life.
Cynthia averred that through all the years of their married life, she was the only one who earned a living
and took care of the children. Patricio did nothing but eat and sleep all day, and spend time with friends.
When Patricio would find a job, he would not be able to stay in it long. Likewise, he went into several
business ventures, which all failed. In addition, he loved to gamble and gambled away whatever money
would come in his way.
Cynthia also claimed that, when their children were babies, Patricio did not ven help to change their
diapers or feed them, even while she was recovering from her caesarean operation, proffering the excuse
that he knew nothing about children. Later, he became insecure and jealous and would get mad every
time he would see Cynthia talking to other people, even to her relatives. When Patricio started threatening
to kill her, Cynthia decided to leave the conjugal abode and live separately from him.
She then consulted a psychiatrist who concluded that Patricio was indeed psychologically incapacitated to
comply with the essential marital obligations.
Respondent:
Patricio denied that he has refused to work. He claimed that he had been trying to find a decent job, but
was always unable to because of his old age and lack of qualifications. He also claimed that he did not stay
long in the jobs he had because the same could not support the needs of his family, and yielded benefits
that were not commensurate to the efforts he exerted. He had ventured into small businesses but they
failed due to various economic crises. He further claimed that he was not, in fact, contented with living
with Cynthias relatives since his every move was being watched with eagle eyes.
He denied that he gambled, positing that since he had no income, he would not have the funds for such
activity. He alleged that even without a steady source of income, he still shared in the payment of the
amortization of their house in BF Homes, Paraaque City.
As to the care of their children, respondent countered that no fault should be attributed to him because
that is the duty of the household help.
He also denied that he threatened to kill Cynthia, considering that there was never any evidence that he
had ever harmed or inflicted physical injury on petitioner to justify the latter having a nervous breakdown.
He further alleged that he never consulted any psychiatrist, and denied that he was psychologically
incapacitated to comply with the essential obligations of marriage.

SC:
Each case for declaration of nullity under the foregoing provision must be judged, not on the basis of a
priori assumptions, predilections, or generalizations, but according to its own facts. And, to repeat for
emphasis, courts should interpret the provision on a case-to-case basis, guided by experience, the findings
of experts and researchers in psychological disciplines, and by decisions of church tribunals. Judicial
understanding of psychological incapacity may be informed by evolving standards, taking into account the
particulars of each case, current trends in psychological and even canonical thought, and experience.
Santos vs. CA: Psychological incapacity must be characterized by (a) gravity (b) juridical antecedence, and
(c) incurability. These guidelines do not require that a physician examine the person to be declared
psychologically incapacitated. In fact, the root cause may be medically or clinically identified. What is
important is the presence of evidence that can adequately establish the party's psychological condition. If
the totality of evidence presented is enough to sustain a finding of psychological incapacity, then actual
medical examination of the person concerned need not be resorted to.
In the present case, the totality of Cynthias evidence did not establish Patricios psychological incapacity
to perform the essential obligations of marriage.
The intendment of the law has been to confine the application of Article 36 to the most serious cases of
personality disorders clearly demonstrative of an utter insensitivity or inability to give meaning and
significance to the marriage.Thus, for a marriage to be annulled under Article 36 of the Family Code, the
psychologically incapacitated spouse must be shown to suffer no less than a mental (not physical)
incapacity that causes him or her to be truly incognitive of the basic marital covenants. It is a malady so
grave and so permanent as to deprive one of awareness of the duties and responsibilities of the
matrimonial bond one is about to assume.
In this case, there is no showing that Patricio was suffering from a psychological condition so severe that
he was unaware of his obligations to his wife and family. On the contrary, his efforts, though few and far
between they may be, showed an understanding of his duty to provide for his family, albeit he did not
meet with much success. Whether his failure was brought about by his own indolence or irresponsibility,
or by some other external factors, is not relevant. What is clear is that Patricio, in showing an awareness
to provide for his family, even with his many failings, does not suffer from psychological incapacity.
Article 36 contemplates incapacity or inability to take cognizance of and to assume basic marital
obligations and not merely difficulty, refusal, or neglect in the performance of marital obligations or ill
will. This incapacity consists of the following:
(a) a true inability to commit oneself to the essentials of marriage;
(b) this inability to commit oneself must refer to the essential obligations of marriage: the conjugal act,
the community of life and love, the rendering of mutual help, the procreation and education of offspring;
and
(c) the inability must be tantamount to a psychological abnormality.
It is not enough to prove that a spouse failed to meet his responsibility and duty as a married person; it is
essential that he must be shown to be incapable of doing so due to some psychological illness.
That Patricio lacked effective sense of rational judgment and responsibility does not mean he is incapable
to meet his marital obligations. His refusal to help care for the children, his neglect for his business
ventures, and his alleged unbearable jealousy may indicate some emotional turmoil or mental difficulty,
but none have been shown to amount to a psychological abnormality.
Moreover, even assuming that Patricios faults amount to psychological incapacity, it has not been
established that the same existed at the time of the celebration of the marriage.
In his psychological report, Dr. Tolentino merely said, [b]ecause ones personality or character is formed
early in life, it has a clear ANTECEDENT and it has an enduring pattern of inner experience that deviates
from the expectations of the individuals culture, without explaining this antecedent. Even Cynthia, in her

allegations, never explained how the alleged psychological incapacity manifested itself prior to or at the
time of the celebration of their marriage.
Patricio may not have turned out to be the ideal husband, or may have failed to meet Cynthias exacting
standards. Yet this Court finds it impossible to believe that, as Cynthia alleges, there was nothing but
heartache and strife in their over 35 years (prior to filing the petition for declaration of nullity) of
marriage.
To be sure, Patricio, perhaps with a little more effort on his part, could have been more helpful and could
have made life that much easier for his wife. The fact that he did not, however, does not mean that he is
psychologically incapacitated to discharge his marital obligations, as to give the Court a reason to declare
the marriage null and void.
Certainly, the marriage was beset by difficulties, or as petitioner puts it, marred by bickerings, quarrels,
and recrimination. It is a fact, however, that all marriages suffer through the same trials at one point or
another, with some going through more rough patches than others. The Court concedes that Cynthia and
Patricios marriage, as characterized by the former, may indeed be problematic, even tumultuous.
However, that they had gone through 35 years together as husband and wife is an indication that the
parties can, should they choose to do so, work through their problems.

MODULE 11: DRUGS AND POISONS

DRUGS
Laws
1.

RA 6675 (An Act to Promote, Require and Ensure the Production of an Adequate Supply,
Distribution, Use and Acceptance of Drugs and Medicines Identified by their generic Names) or
Generics Act of 1988

Definitions
"Active Ingredient" is the chemical component responsible for the claimed therapeutic
effect of the pharmaceutical product. "Chemical Name" is the description of the chemical
structure of the drugs and medicine and serves as the complete identification of the
compound.
o "Drug Product" is the finished product form that contains the active ingredients,
generally but not necessarily in association with inactive ingredients.
o "Drug Establishment" is any organization or company involved in the manufacture,
importation, repacking and/or distribution of drugs or medicines.
o "Drug Outlets" means drugstores, pharmacist, and any other business establishment
which sell drugs or medicines.
o "Brand Name" is the proprietary name given by the manufacture to distinguish its
product from those of competitors.
o "Generic Drugs" are not covered by the patent protection and which are labelled solely by
their international non-proprietary or generic name.
The exclusive use of generic terminology in the manufacture, marketing and sales of drugs and
medicines, particularly those in the Essential Drug List, shall be promoted through such a system
of Incentive as the Board of Investments jointly with the Department of Health and other
government agencies.
Who shall use generic terminology? (Section 6)
o

(a) All government agencies and their personnel as well as other government agencies shall use generic
terminology or generic names in all transactions related to purchasing, prescribing, dispensing and
administering of all drugs and medicines.
(b) All medical, dental and veterinary practitioners, including private practitioners, shall write
prescriptions using generic name. The brand name maybe included if so desired.
(c) Any organization or company involved in the manufacture, importation, repacking, marketing and/or
distribution of drugs and medicine shall indicate prominently the generic name of the product labels as
well as in advertising and other promotional materials.
(d) Drug Outlets, including drugstores, hospital and non-hospital pharmacies and non-traditional outlets
such as supermarkets and stores shall inform any buyer about all other drug products having the same
generic name, together with their corresponding prices so that the buyer may adequately exercise his
option. Within one (1) year after approval of this Act, the drug outlets referred to herein. Shall post in
conspicuous places in their establishment, a list of drug products with the same generic name and their
corresponding prices.

In order to assure responsibility of drug quality in all instances, the label of drugs and medicine
shall have the following: name and country of manufacture, dates of manufacture and expiration.
The quality of such generically labelled drugs and medicines shall be duly certified by the
Department of Health.
Education drive (Section 11): DOH, DepEd, Philippine Information Agency and DILG shall
conduct a continuous information campaign for the public and a continuing education and

training for the medical and allied medical professions on drugs with generic names as an
alternative of equal efficacy to the more expensive brand name drug. Such educational campaign
shall include information on the illnesses or symptoms which each generically named drug is
supposed to cure or alleviate, as well as its contradiction.
CASE: DEL ROSARIO vs. SECRETARY OF HEALTH (1989)
Facts: This is a class suit filed by officers of the Philippine Medical Association, the national organization
of medical doctors in the PH, on behalf of their professional brethren who are of kindred persuasion.
They asked that some provisions of RA 6675 of the Generics Act of 1988 and of the implementing
Administrative Order no. 62 issued pursuant thereto be declared unconstitutional.
(a) Section 6, Paragraphs (a) and (b) of the Generics Act:
a) All government health agencies and their personnel as well as other government agencies
shall use generic terminology or generic names in all transactions related to purchasing,
prescribing, dispensing and administering of drugs and medicines.
b) All medical, dental and veterinary practitioners, including private practitioners, shall write
prescriptions using the generic name. The brand name may be included if so desired.
ARGUMENTS AND RULING:
1.

Del Rosario et als main argument against paragraphs (a) and (b), Section 6 of the law, is the
alleged unequal treatment of government physicians, dentists, and veterinarians, on one hand,
and those in private practice on the other hand, in the manner of prescribing generic drugs, for,
while the former are allegedly required to use only generic terminology in their prescriptions, the
latter may write the brand name of the drug in parenthesis below the generic name. The favored
treatment of private doctors, dentists and veterinarians under the law is allegedly a specie of
invalid class legislation.

SC:
No merit in Del Rosario et als argument as it proceeds from a misreading and misinterpretation of the
letter and intent of paragraphs (a) and (b), Section 6 of the Generics Act.
While paragraph (a) enumerates the government transactions ('Purchasing, prescribing, dispensing and
administering of drugs and medicines') where the sole use of generic terminology has been required, the
'prescription' of drugs is further governed by paragraph (b). And the use of the word 'all' in the latter
provision emphasizes the absence of any distinction between government and private physicians. In
other words, in prescribing drugs, physicians, whether in government service or in private practice, are
both governed by exactly the same rules, and thus, are both authorized to include the brand name in their
respective prescriptions.
Furthermore, it may be observed that while paragraph (a) refers to "all government health agencies, and
their personnel as well as other government agencies" (not necessarily physicians, dentists and
veterinarians), paragraph (b) refers to "all medical, dental and veterinary practitioners, including
private practitioners."
2. Petitioners concede that the requirement for doctors, dentists, and veterinarians to use the
generic terminology in writing their prescriptions, followed by the brand name in parenthesis, is
"well and good" (p. 12, Rollo). However, they complain that under paragraph (d) of the law which
reads:
(d)
Drug outlets, including drugstores, hospital and non-hospital pharmacies and non-traditional
outlets such as supermarkets and stores, shall inform any buyer about any and all other drug products
having the same generic name, together with their corresponding prices so that the buyer may adequately
exercise his option. Within one (1) year after approval of this Act, the drug outlets referred to herein, shall

post in conspicuous places in their establishments, a list of drug products with the same generic name and
their corresponding prices.
the salesgirl at the drugstore counter is authorized to "substitute the prescribed medicine with another
medicine belonging to the same generic group." Since doctors are not allowed to instruct the druggist not
to substitute the prescription, or to "Dispense only as Prescribed" (per Sec. 4, Adm. Order No. 62), the
petitioners argue that "the act of prescribing the correct medicine for the patient becomes the act of the
salesgirl at the drugstore counter, no longer the act of the physician, dentist, or veterinarian"
SC: Petitioners have distorted the clear provisions of the law and the implementing administrative order.
For it is plain to see that neither paragraph (d) of Section 6 of the Generics Act, nor Section 4 of
Administrative Order No. 62, gives the salesgirl and/or druggist the discretion to substitute the doctor's
prescription.
On the contrary, Section 4, par. 4.1, of Administrative Order No. 62 directs the pharmacist not to
fill "violative prescriptions" (where the generic name is not written, or illegibly written, and the
prescription of a brand name is accompanied by the doctor's instruction not to substitute it), as well
as "impossible prescriptions" (par. 4.5). Even a doctor's "erroneous" prescriptions "shall be filled," not
substituted (par. 4.3, Adm. Order No. 62). And, Sections 3 and 5 of Adm. Order No. 63 enjoin the drug
outlets not (to) favor or suggest" or "impose" a particular brand or product on the customer.
The salesgirl at the drugstore counter, merely informs the customer, but does not determine (for she is
incompetent to do so) all the other drug products or brands that have the same generic name, and their
corresponding prices. That information she may obtain from the list of drug products determined by the
Bureau of Food and Drugs to have the same generic name, or which are the chemical, biological, and
therapeutic equivalent of the generic drug. All drugstores or drug outlets are required by the law to post
such list in a conspicuous place in their premises for the information of the customers, for the choice of
whether to buy the expensive brand name drug, or the less expensive generic, should be exercised by the
customer alone.
Purpose of the Generic Act is to carry out the policy of the State:

To promote, encourage and require the use of generic terminology in the importation,
manufacture, distribution, marketing, advertising and promotion, prescription and dispensing of
drugs;
To ensure the adequate supply of drugs with generic names at the lowest possible cost and
endeavor to make them available for free to indigent patients;
To encourage the extensive use of drugs with generic names through a rational system of
procurement and distribution;
To emphasize the scientific basis for the use of drugs, in order that health professionals may
become more aware and cognizant of their therapeutic effectiveness; and
To promote drug safety by minimizing duplication in medications and/or use of drugs with
potentially adverse drug interactions.

or, as stated by the public respondent, "to promote and require the use of generic drug products that are
therapeutically equivalent to their brand-name counter-parts" (p. 39, Rollo) for "the therapeutic effect of
a drug does not depend on its 'brand' but on the 'active ingredients' which it contains." The medicine that
cures is the "active ingredient" of the drug, and not the brand name by which it has been baptized by the
manufacturer.
The institution of generics in the Philippines will compel physicians to prescribe drugs based on their
therapeutic or "active ingredient," instead of their well-known brand names. Multiple medications which
may produce potentially adverse, even lethal, chemical reactions in the patient will thereby be avoided.
Patients with limited means will be able to buy generic drugs that cost less but possess the same active
ingredients, dosage form, and strength as brand names, many of which are priced beyond the reach of the

common tao because the high costs of advertising, packaging, royalties, and other inputs of production
determine their pricing for the market.
The prohibition against the use by doctors of "no substitution" and/or words of similar import in their
prescription, is a valid regulation to prevent the circumvention of the law. It secures to the patient the
right to choose between the brand name and its generic equivalent since his doctor is allowed to write
both the generic and the brand name in his prescription form. If a doctor is allowed to prescribe a brandname drug with "no substitution," the patient's option to buy a lower-priced, but equally effective, generic
equivalent would thereby be curtailed. The law aims to benefit the impoverished (and often sickly)
majority of the population in a still developing country like ours, not the affluent and generally healthy
minority.
There is no merit in the petitioners' theory that the Generics Act impairs the obligation of contract
between a physician and his patient, for no contract ever results from a consultation between patient and
physician. A doctor may take in or refuse a patient, just as the patient may take or refuse the doctor's
advice or prescription. As aptly observed by the public respondent, no doctor has ever filed an action for
breach of contract against a patient who refused to take prescribed medication, undergo surgery, or follow
a recommended course treatment by his doctor ( p. 53, Rollo). In any event, no private contract between
doctor and patient may be allowed to override the power of the State to enact laws that are reasonably
necessary to secure the health, safety, good order, comfort, or general welfare of the community. This
power can neither be abdicated nor bargained away. All contractual and property rights are held subject
to its fair exercise.
2. RA 9502 (An Act providing for cheaper and quality medicines) or Universally Accessible Cheaper
and Quality Medicines Act of 2008
Definitions
o Drugs and medicines refers to any chemical compound or biological substance, other tha
food, intended for use in the treatment, prevention or diagnosis of disease in humans or
animals, including but not limited to:
any article recognized in the official United States Pharmacopoeia-National
Formulary (USP-NF), official Homeopathic Pharmacopoeia of the United States,
Philippine Pharmacopoeia, Philippine National Drug Formulary, British
Pharmacopoeia, European Pharmacopoeia, Japanese Pharmacopoeia, Indian
Pharmacopoeia, any national compendium or any supplement to any of them;
any article intended for use in the diagnosis, cure, mitigation, treatment, or
prevention of disease in humans or animals;
any article other than food intended to affect the structure or any function of the
human body or animals;
Any article intended for use as a component of any articles in the first 3 not
including devices or their components, parts or accessories
herbal and/or traditional drugs which are articles of plant or animal origin used
in folk medicine which are:
recognized in the PH National Drug Formulary
intended for use in the treatment or cure or mitigation of disease
symptoms, injury or body defects in humans
other than food, intended to affect the structure or any function of the
human body
in finished or ready-to-use dosage form
intended for use as a component of any of the articles specified in the
first 4
o "Essential drugs list or national drug formulary" refers to a list of drugs prepared and
periodically updated by the Department of Health on the basis of health conditions
obtaining in the Philippines as well as on internationally accepted criteria
Drugs and Medicines Price Regulation
o President has power to impose maximum retail prices over any or all drugs and
medicines. No court, except SC, shall issue any TRO or preliminary injunction or

preliminary mandatory injunction that will prevent immediate execution of the exercise
of this power of the President.
List of Drugs and medicines that are subject to Price Regulation

The list of drugs and medicines that are subject to price regulation shall include, inter alia:
(a) All drugs and medicines indicated for treatment of chronic illnesses and life threatening conditions,
such as, but not limited to, endocrine disorders, e.g., diabetes mellitus; gastrointestinal disorders, e.g.,
peptic ulcer; urologic disorders, e.g., benign prostatic hyperplasia (BPH); cardiovascular diseases, e.g.,
hypertension; pulmonary diseases, e.g., pulmonary tuberculosis (PTB), asthma; auto-immune diseases,
e.g., systemic lupus erythematosus (SLE); skin diseases, e.g., psoriasis; neuro-psychiatric disorders; other
infectious diseases, e.g., human immunodeficiency virus-acquired immune deficiency syndrome (HIVAIDS); and other conditions such as organ transplants and neoplasm;
(b) Drugs and medicines indicated for prevention of diseases, e.g., vaccines, immunoglobulin, anti-sera;
(c) Drugs and medicines indicated for prevention of pregnancy, e.g., oral contraceptives;
(d) Anesthetic agents;
(e) Intravenous fluids;
(f) Drugs and medicines that are included in the Philippine National Drug Formulary (PNDF) Essential
Drug List; and
(g) All other drugs and medicines which, from time to time, the Secretary of the Department of Health
determines to be in need of price regulation.

Illegal Acts of Price Manipulation: Without prejudice to the provisions of existing laws on goods
not covered by this Act, it shall be unlawful for any manufacturer, importer, trader, distributor,
wholesaler, retailer, or any person engaged in any method of disposition of drugs and medicines
to engage in acts of price manipulation such as hoarding, profiteering, or illegal combination or
forming cartel, as defined under Section 5 of Republic Act No. 7581, otherwise known as the Price
Act, and all other acts committed in restraint of trade.
Display of Maximum Retail Price Fixed and Approved by Order of the President of the Philippines
for Drugs and Medicines Subject to Price Regulation.
(a) Within a reasonable period as may be determined by the Secretary of the Department of Health,
and: Provided, That it conforms to existing drug product labeling requirements, every manufacturer,
importer, distributor, wholesaler, trader, or retailer of a drug and medicine intended for sale shall
display the retail price which shall not exceed the maximum retail price approved by order of the
President of the Philippines. The maximum retail price shall be printed on the label of the immediate
container of the drug and medicine and the minimum pack thereof offered for retail sale with the
words "RETAIL PRICE NOT TO EXCEED" preceding it, and "UNDER DRUG PRICE REGULATION"
on a red strip.
(b) Within a period as may be determined by the Secretary of the Department of Health from time to
time, every manufacturer, importer, or trader shall issue a price list to wholesalers, distributors,
retailers and to the Secretary of the Department of Health, indicating the retail price, the maximum
retail price, and such other information as may be required by the Secretary of the Department of
Health.

Non-discriminatory clause: It shall be unlawful for any retail drug outlet to refuse to carry either
by sale or by consignment, or offer for sale drugs and medicines brought into the country, as
allowed under Section 7 of this Act which amends Section 72.1 of the Intellectual Property Code of
the Philippines or Republic Act No. 8293, by the government or authorized third party which
have been previously approved for distribution or sale by the Bureau of Food and Drugs. For this
purpose, the said products shall be displayed with equal prominence as all other products sold in
the establishment.
Refusal to Sell Drugs and Medicines. - No manufacturer, importer, trader, distributor, wholesaler
shall withhold from sale or refuse to sell to a wholesaler or retailer any drug or medicine without
good and sufficient reasons.
Sale of medicine, pharmaceuticals, drugs and devices. - No medicine, pharmaceutical, or drug,
except for those which are non-prescription or over-the-counter, of whatever nature and kind or
device shall be compounded, dispensed, sold or resold, or otherwise be made available to the

consuming public except through a prescription drugstore or hospital pharmacy, duly established
in accordance with the provisions of this Act. Non-prescription or over-the-counter drugs may be
sold in their original packages, bottles, containers or in small quantities, not in their original
containers to the consuming public through supermarkets, convenience stores and other retail
establishments.
"Pharmaceutical, drug or biological manufacturing establishments, importers and wholesalers of
drugs, medicines, or biologic products, shall not sell their products for re-sale except only to retail
drug outlets, hospital pharmacies or to other drug wholesalers under the supervision of a
registered pharmacist, and supermarkets, convenience stores, other retail establishments for
over-the-counter drugs, duly licensed by the Bureau of Food and Drugs."

3. RA 9165 or Comprehensive Dangerous Drugs Act of 2002

Definitions

Dangerous Drugs. Include those listed in the Schedules annexed to the 1961 Single Convention
on Narcotic Drugs, as amended by the 1972 Protocol, and in the Schedules annexed to the 1971
Single Convention on Psychotropic Substances as enumerated in the attached annex which is an
integral part of this Act.
Cannabis or commonly known as "Marijuana" or "Indian Hemp" or by its any other name.
Embraces every kind, class, genus, or specie of the plant Cannabis sativa L. including, but not
limited to, Cannabis americana, hashish, bhang, guaza, churrus and ganjab, and embraces every
kind, class and character of marijuana, whether dried or fresh and flowering, flowering or fruiting
tops, or any part or portion of the plant and seeds thereof, and all its geographic varieties,
whether as a reefer, resin, extract, tincture or in any form whatsoever.
Methylenedioxymethamphetamine (MDMA) or commonly known as "Ecstasy", or by its any other
name. Refers to the drug having such chemical composition, including any of its isomers or
derivatives in any form.
Methamphetamine Hydrochloride or commonly known as "Shabu", "Ice", "Meth", or by its any
other name. Refers to the drug having such chemical composition, including any of its isomers
or derivatives in any form.
Opium. Refers to the coagulated juice of the opium poppy (Papaver somniferum L.) and
embraces every kind, class and character of opium, whether crude or prepared; the ashes or
refuse of the same; narcotic preparations thereof or therefrom; morphine or any alkaloid of
opium; preparations in which opium, morphine or any alkaloid of opium enters as an ingredient;
opium poppy; opium poppy straw; and leaves or wrappings of opium leaves, whether prepared for
use or not.
Opium Poppy. Refers to any part of the plant of the species Papaver somniferum L., Papaver
setigerum DC, Papaver orientale, Papaver bracteatum and Papaver rhoeas, which includes the
seeds, straws, branches, leaves or any part thereof, or substances derived therefrom, even for
floral, decorative and culinary purposes.

CASE: PEOPLE vs. CARDENAS

Facts: DSOD-CIDG conducted a buy-bust operation and arrested Cardenas for selling shabu. PO3 Palacio
recovered two (2) other clear plastic sachets from the accuseds right pocket. The three sachets were
marked CC-1, CC-2 and CC-3 CC representing the initials of the accused Cardenas. He was then
brought to Camp Crame, where he was booked and investigated. The plastic sachets recovered from him
were transmitted to the PNP Crime Laboratory for analysis upon the request of Police Chief Inspector.
The results of the Initial Laboratory Report showed that the white crystalline substance contained in the
three (3) heat-sealed plastic sachets tested positive for methylamphetamine hydrochloride, or shabu, with
a total weight of 0.05 gram.
RTC & CA found him guilty.

On appeal to the SC, Cardenas argued that he should be acquitted because the arresting officers did not
follow the required procedure for the handling of seized drugs in a buy-bust operation as stated in Section
21 of the IRR of R.A. 9165 (ie. arresting officers did not conduct a physical inventory of the items seized
and failed to photograph them in the presence of the accused and of other personalities specified).
SC affirmed the conviction.
Although the police officers did not strictly comply with the requirements of Section 21, Article II IRR of
R.A. 9165, the noncompliance did not affect the evidentiary weight of the drugs seized from the accused,
because the chain of custody of the evidence was shown to be unbroken under the circumstances of the
case.
Chain of Custody is defined by the IRR of RA 9165: means the duly recorded authorized movements and
custody of seized drugs or controlled chemicals or plant sources of dangerous drugs or laboratory
equipment of each stage, from the time of seizure/confiscation to receipt in the forensic laboratory to
safekeeping to presentation in court for destruction. Such record of movements and custody of seized item
shall include the identity and signature of the person who held temporary custody of the seized item, the
date and time when such transfer of custody were made in the course of safekeeping and used in court as
evidence, and the final disposition.
Mere substantial compliance with the procedural aspect of the chain of custody rule does not necessarily
render the seized drug items inadmissible.
In the instant case, the SC found that the chain of custody of the seized prohibited drugs was not broken.
The testimony of PO3 Palacio shows that he was the one who recovered from the accused the three plastic
sachets of shabu, together with the marked money. He also testified that he was the one who personally
brought the request for examination to the PNP Crime Laboratory and had the plastic sachets examined
there. This was corroborated by the other police officer who acted as poseur-buyer.
POISONS
Poisons: substances that cause disturbances to organisms, usually by chemical reaction or other activity
on the molecular scale, when a sufficient quantity is absorbed by an organism.
A. Arsenic

Arsenic: chemical element with symbol As and atomic number 33. In subtoxic doses, soluble
arsenic compounds act as stimulants, and were once popular in small doses as medicine by people
in the mid-18th century.
Arsenic poisoning is a medical condition caused by elevated levels of arsenic in the body. The
dominant basis of arsenic poisoning is from ground water that naturally contains high
concentrations of arsenic1
Poisoning can occur by ingestion, inhalation and dermal absorption. Inorganic compounds are
much more toxic than organic compounds. Elemental arsenic is least toxic. Arsine gas is highly
toxic. Toxicity is due to arsenic's effect on many cell enzymes, which affect metabolism and
DNA repair. Arsenic is excreted in urine, but can also accumulate in many body tissues. Arsenic
has been used in medicines, as a pigment, a pesticide, and as a weapon of murder. It shares many
toxic features with the other heavy metals like mercury and lead. It is used in the production of
glass and semiconductors. It is found in some water supplies and seafood, and is used in various
industries.2

B. Lead
1
2

http://en.wikipedia.org/wiki/Arsenic_poisoning
http://www.patient.co.uk/doctor/Arsenic-Poisoning.htm

Lead: chemical element in the carbon group with symbol Pb (from Latin: plumbum) and atomic
number 82.3
Lead poisoning (also known as plumbism, colica pictorum, saturnism, Devon colic, or painter's
colic) is a medical condition in humans and other vertebrates caused by increased levels of the
heavy metal lead in the body. Lead interferes with a variety of body processes and is toxic to many
organs and tissues including the heart, bones, intestines, kidneys, and reproductive and nervous
systems. It interferes with the development of the nervous system and is therefore particularly
toxic to children, causing potentially permanent learning and behavior disorders.
Symptoms include abdominal pain, confusion, headache, anemia, irritability, and in severe cases
seizures, coma, and death.4
Lead is a very strong poison. When a person swallows a lead object or breathes in lead dust, some
of the poison can stay in the body and cause serious health problems. Lead used to be very
common in gasoline and house paint in the U.S. Children living in cities with older houses are
more likely to have high levels of lead. Although gasoline and paint are no longer made with lead
in them, lead is still a health problem.
Lead is everywhere, including dirt, dust, new toys, and old house paint. Unfortunately, you can't
see, taste, or smell lead. There are many possible symptoms of lead poisoning.
Lead can affect many different parts of the body. A single high dose of lead can cause severe
emergency symptoms. However, it is more common for lead poisoning to build up slowly over
time. This occurs from repeated exposure to small amounts of lead. In this case, there may not be
any obvious symptoms.5

C. Mercury

Mercury: a chemical element with the symbol Hg and atomic number 80. It is commonly known
as quicksilver and was formerly named hydrargyrum.
Mercury in any form is poisonous, with mercury toxicity most commonly affecting the neurologic,
gastrointestinal (GI) and renal organ systems. Poisoning can result from mercury vapor
inhalation, mercury ingestion, mercury injection, and absorption of mercury through the skin. 6

2. TOXINS

Toxin: poisonous substance produced within living cells or organisms.7 Toxins also include
medications that are helpful in small doses but poisonous when used in an large amounts.
Most toxins that cause problems in humans are released by germs such as bacteria. For example,
cholera is due to a bacterial toxin.8

A. Snake Bites

Snakebite is an injury caused by a bite from a snake, often resulting in puncture wounds inflicted
by the animal's fangs and sometimes resulting in envenomation. Although the majority of snake
species are non-venomous and typically kill their prey with constriction rather than venom,
venomous snakes can be found on every continent except Antarctica.
Snakes often bite their prey as a method of hunting, but also for defensive purposes against
predators. Since the physical appearance of snakes may differ, there is often no practical way to
identify a species and professional medical attention should be sought.
The outcome of snake bites depends on numerous factors, including the species of snake, the area
of the body bitten, the amount of venom injected, and the health conditions of the person.

http://en.wikipedia.org/wiki/Lead
http://en.wikipedia.org/wiki/Lead_poisoning
5 http://www.nlm.nih.gov/medlineplus/ency/article/002473.htm
6 http://emedicine.medscape.com/article/1175560-overview
7 http://en.wikipedia.org/wiki/Toxin
8 http://www.nlm.nih.gov/medlineplus/ency/article/002331.htm
3

1.
2.
3.
4.
5.
6.

Feelings of terror and panic are common after a snakebite and can produce a characteristic set of
symptoms mediated by the autonomic nervous system, such as a racing heart and nausea. Bites
from non-venomous snakes can also cause injury, often due to lacerations caused by the snake's
teeth, or from a resulting infection. A bite may also trigger an anaphylactic reaction, which is
potentially fatal.
First aid recommendations for bites depend on the snakes inhabiting the region, as effective
treatments for bites inflicted by some species can be ineffective for others.9
Poisonous snake bites include bites by any of the following:
Cobra
Copperhead
Coral snake
Cottonmouth (water moccasin)
Rattlesnake
Various snakes found at zoos
All snakes will bite when threatened or surprised, but most will usually avoid people if possible
and only bite as a last resort.10

B. Spider bites

Spider bite is injury resulting from the bite of spiders. In technical literature such injury and its
consequences commonly are referred to as "arachnidism."11
Only a few spiders are dangerous to humans. Two that are present in the contiguous United States,
and more common in the Southern states, are the black widow spider and the brown recluse
spider. Both prefer warm climates and dark, dry places where flies are plentiful. They often live in
dry, littered, undisturbed areas, such as closets, woodpiles and under sinks.
1. Black widow spider: Although serious, a black widow bite is rarely lethal. You can identify this
spider by the red hourglass marking on its belly. The bite feels like a pinprick. You may not even
know you've been bitten. At first you may notice slight swelling and faint red marks. Within a few
hours, though, intense pain and stiffness begin. Other signs and symptoms include: Chills, Fever,
Nausea and vomiting and Severe abdominal pain
2. Brown recluse spider: You can identify this spider by the violin-shaped marking on its back.
The bite produces a mild stinging, followed by local redness and intense pain within eight hours.
A fluid-filled blister forms at the site and then sloughs off to leave a deep, enlarging ulcer.
Reactions from a brown recluse spider bite vary from a mild fever and rash to nausea and
listlessness. On rare occasions death results, more often in children.
C. Rabies

Rabies (Latin: rabies, "madness") is a viral disease that causes acute inflammation of the brain
in humans and other warm-blooded animals.
The time period between contacting the disease and the start of symptoms is usually one to three
months; however can be less than one week or more than one year. The time is dependent on the
distance the virus must travel to reach the central nervous system.
Early symptoms may include: fever and tingling at the site of exposure. This is then followed by
either violent movements, uncontrolled excitement, and fear of water or an inability to move parts
of the body and confusion that leads to loss of consciousness. In both cases once symptoms
appears it nearly always results in death.
The disease is spread to humans from another animal, commonly by a bite or scratch. Infected
saliva that comes into contact with any mucous membrane is also a risk.
Rodents are very rarely infected.
The rabies virus travels to the brain by following the peripheral nerves.

http://en.wikipedia.org/wiki/Snakebite
http://www.nlm.nih.gov/medlineplus/ency/article/000031.htm
11 http://en.wikipedia.org/wiki/Spider_bite
9

10

Immunizing people before they are exposed is recommended in those who are at high risk
including: those who work with bats or spend prolonged periods in areas of the world where the
disease is common.12

D. Jellyfishes and other sea animals

Many marine animals bite or sting. Some deliver venom through their teeth, tentacles, spines, or
skin. Others, such as sharks, arent venomous but can inflict serious bites with their large, sharp
teeth. Most creatures that sting or bite have developed these behaviors as defense mechanisms or
to help them hunt for food.13

E. Tetanus

Tetanus: medical condition characterized by a prolonged contraction of skeletal muscle fibers.14

Tetanus is caused by a type of bacteria called Clostridium tetani. The bacteria can live in many
different substances including: soil, house dust, animal and human waste, such as manure.
The tetanus bacteria usually enter the body through a wound in the skin or a serious burn. Once
inside, they multiply and release a powerful type of poison, known as a neurotoxin. The
neurotoxin disrupts the normal workings of the nerves, causing symptoms such as stiffness and
muscle spasms.15

3. ALCOHOL INTOXICATION

Alcohol intoxication: physiological state induced by the ingestion of ethyl alcohol (ethanol).16
Alcohol intoxication is the consequence of alcohol entering the bloodstream faster than it can be
metabolized by the liver, which breaks down the ethanol into non-intoxicating byproducts.

A. Types of Alcohol17
1. Methanol, or methyl alcohol: made from natural gas or biomass.
2. Ethanol: the alcohol that people drink. Sometimes referred to as ethyl alcohol, pure alcohol,
grain alcohol or spirits.
3. Denatured alcohol: ethanol to which additives have been mixed to discourage some fool from
drinking it.
B.
1.
2.
3.
4.
5.
6.
7.
8.

Signs and Symptoms of Alcohol Intoxication18

Confusion
Vomiting
Seizures
Slow breathing (less than eight breaths a minute)
Irregular breathing (a gap of more than 10 seconds between breaths)
Blue-tinged skin or pale skin
Low body temperature (hypothermia)
Passing out (unconsciousness) and can't be awakened

C. Complications19

http://en.wikipedia.org/wiki/Rabies
http://www.healthline.com/health/marine-animal-stings-or-bites#Overview
14 http://en.wikipedia.org/wiki/Tetanus
15 http://www.nhs.uk/conditions/Tetanus/Pages/Introduction.aspx
16 http://en.wikipedia.org/wiki/Alcohol_intoxication
17 http://lacrossetribune.com/tomahjournal/lifestyles/different-kinds-of-alcohol/article_633b4e0c-2c5011e3-ad71-0019bb2963f4.html
18 http://en.wikipedia.org/wiki/Alcohol_intoxication#Signs_and_symptoms
12
13

1.
2.
3.
4.
5.
6.
7.

Choking. Alcohol may cause vomiting. Because it depresses your gag reflex, this increases the
risk of choking on vomit if you've passed out.
Stopping breathing. Accidentally inhaling vomit into your lungs can lead to a dangerous or
fatal interruption of breathing (asphyxiation).
Severe dehydration. Vomiting can result in severe dehydration, leading to dangerously low
blood pressure and fast heart rate.
Seizures. Your blood sugar level may drop low enough to cause seizures.
Hypothermia. Your body temperature may drop so low that it leads to cardiac arrest.
Brain damage. Heavy drinking may cause irreversible brain damage.
Death. Any of the issues above can lead to death

http://www.mayoclinic.org/diseases-conditions/alcohol-poisoning/basics/complications/con20029020
19

MODULE 12: PHYSICAL INJURIES

1. Wound

break in continuity of tissues

is a type of injury in which skin is torn, cut, or punctured (an open wound), or where
blunt force trauma causes a contusion (a closed wound); it specifically refers to a sharp
injury which damages the dermis of the skin

2. Type of wound based on skin continuity

2.1 Open - is a break in the skin or mucous membrane
2.2 Closed - an injury in which no blood escapes from the body
3. Causative agents: nature of wound
3.1 Sharp instruments: incisions, cuts, slash, amputations
sharp instruments
smooth edges
generally, length is greater than width
generally, not life threatening
tends to gape
examples of sharp-edged objects are a knife, razor, or glass splinter.
incisions a clean cut in the skin, one caused by a cutting instrument
amputations - removal of a body extremity by trauma, prolonged constriction, or surgery
3.2 Blunt instruments: lacerations, contusion (bruise), hematoma, macerations, fractures
length (depth) usually greater than width (diameter)
generally more fatal due to involvement of internal organs
extent of injury not easily observable on ocular inspection
infection may go deeper
lacerations tear like wound
contusions - swollen bruises due to accumulation of blood and dead cells under skin
hematoma - a mass of usually clotted blood that forms in a tissue, organ, or body space as
a result of a broken blood vessels
fractures - break in the continuity of the bone
macerations - a situation in which the surrounding skin of a wound retains too much
moisture and thus causing it to turn white and soften
3.3 Pointed instruments: stabs, prick, puncture, spike
depth greater than width
more fatal
deeper infection
not too bloody but internal haemorrhage could be extensive
wounding instrument may be deduced from shape of point of entry
stab - specific form of penetrating trauma to the skin that results from a knife or a similar
pointed object that is "deeper than it is wide"
prick a puncture made to the skin that is caused by an instrument with a pointed end
3.4 Rough surface: abrasion, scrape, scratch, excoriate
abrasion - made when the skin is rubbed or scraped off; rope burns, floorburns, and
skinned knees or elbows are common examples of abrasions
this kind of wound can become infected quite easily because dirt and germs are usually
embedded in the tissues
3.5 Electricity: electrical burns
severity determined by voltage, current and resistance
a burn that results from electricity passing through the body causing rapid injury.
differs from thermal or chemical burns in that they cause much more subdermal damage.
can exclusively cause surface damage, but more often tissues deeper underneath the skin
have been severely damaged;

electrical burns are difficult to accurately diagnose, and many people underestimate the
severity of their burn; in extreme cases, electricity can cause shock to the brain, strain to
the heart, and injury to other organs.
3.6 Chemicals: chemical burn, poison injury
chemical burn are burns to internal or external organs of the body caused by contact,
ingestion, inhalation of noxious fumes of acids, alkalis or organic materials.); all chemical
burns are classified as major burn injuries
3.7 Explosives: blast injury, burns, avulsions, fractures
a complex type of physical trauma resulting from direct or indirect exposure to an
explosion
blast injuries occur with the detonation of high-order explosives as well as the
deflagration of low order explosives and these injuries are compounded when the
explosion occurs in a confined space
avulsion - an injury in which a body structure is forcibly detached from its normal point
of insertion by either trauma or surgery; the term most commonly refers to a surface
trauma where all layers of the skin have been torn away, exposing the underlying
structures (i.e., subcutaneous tissue, muscle, tendons, or bone); similar to an abrasion
but more severe, as body parts such as an eyelid or an ear can be partially or fully
detached from the body.
3.8 Gravitational force: contusions, hematoma, fractures, macerations
3.9 Stretching: avulsions
3.10 Poisons, chemicals: Chemical burns
3.11 Electricity: electrical burns
3.12 Cold: Hypothermia
Hypothermia - medical emergency that occurs when your body loses heat faster than it
can produce heat, causing a dangerously low body temperature; a potentially fatal
condition, occurs when body temperature falls below 95F (35C)
3.13 Hot: Hyperthermia
defined as a temperature greater than 37.538.3 C (99.5100.9 F), depending on the
reference used, that occurs without a change in the body's temperature set point
elevated body temperature due to failed thermoregulation that occurs when a body
produces or absorbs more heat than it dissipates.
extreme temperature elevation then becomes a medical emergency requiring immediate
treatment to prevent disability or death
most common causes of Hyperthermia include heat stroke and adverse reactions to drugs
3.14 Radiation: Radiation burns
damage to the skin or other biological tissue caused by exposure to radiation
radiation types of greatest concern are thermal radiation, radio frequency energy,
ultraviolet light and ionizing radiation.
most common type of radiation burn is a sunburn caused by UV radiation
high exposure to X-rays during diagnostic medical imaging or radiotherapy can also
result in radiation burns
radiation burns are often associated with radiation-induced cancer due to the ability of
ionizing radiation to interact with and damage DNA, occasionally inducing a cell to
become cancerous
3.15 Microwaves/radiowaves: microwave/radiowave injuries
microwave burns are burn injuries caused by thermal effects of microwave radiation
absorbed in a living organism
in comparison with radiation burns caused by ionizing radiation, where the dominant
mechanism of tissue damage is internal cell damage caused by free radicals, the primary
damage mechanism of microwave radiation is thermal, by dielectric heating
microwave damage can manifest with a delay; pain and/or signs of skin damage can show
some time after microwave exposure
3.16 Bacteria/viruses: Infections

is the invasion of a host organism's bodily tissues by disease-causing organisms, their

multiplication, and the reaction of host tissues to these organisms and the toxins they
produce
are caused by infectious agents such as viruses, viroids, and prions, microorganisms such
as bacteria, nematodes etc.
3.17 Bullets: Gunshot wounds (GSW): lacerations, cavitations
4. Other types of wounds
4.1 Defense wounds
sustained to avoid or minimize a blow or slashing
passive defense wounds are those sustained by the victim trying to protect his/her body,
usually the face and chest; exposed areas of the body (e.g. outer hands, arms, limbs, back)
are the usual sites
active defense wounds are those sustained when the victims actively wards off and grasps
the knife and sustained injuries as a result
4.2 Suicide wounds
throat, wrists, front of chest due to presence of vital organs or where blood flows more
profusely (e.g. pulse areas)
often multiple depending on the instrument or agent used for suicide
nature and site of injury maybe indicative of intent to commit suicide
suicide note may or may not be present but if found genuine, rules out murder
sooting is found on the hand of a suicide victim indicating that he is holding the gun when
it was fired
4.3 Self injuries mutilation of body parts found in superficial areas and shows repeated patters is not
indicative of suicide but rather of a psychiatric illness
4.4 Mutilations as defined by law refers to lopping off some part of the body
5. Gunshot wounds
5.1 Types of firearms
Medium velocity < 1,500 ft/sec
High velocity > 1,500 ft/sec
5.2 Distance
Contact abrasion rim/ring, muzzle imprint, stellate when located against a bone
Intermediate gunpowder tattooing
Distant no abrasion rim
5.3 Entry/exit
Entrance wound normally smaller and quite symmetrical
Exit wound bigger, more irregular, will often bleed profusely
Shoring produced when the outstretched skin is impaled, sandwiched, and crushed
between the outgoing bullet and the unyielding object over the exit site, thus leaving an
abrasion collar on the wound margin
Buckshots due to pellets in shotguns
Abrasion rim/collar annular area of abrasion caused by forward motion of a bullet
indenting the skin in an entrance wound

MODULE 13: MEDICAL MALPRACTICE

Definition
Failure of a physician to properly perform the duty which devolves upon him in his professional
relation to his patient which results to injury
Bad or unskilful practice of medicine resulting to injury of the patient or failure on the part of the
physician to exercise the degree of care, skill and diligence, as to treatment in a manner contrary
to accepted standards of medicine resulting to injury to the patient
Elements of medical malpractice
1.

Duty to patient
a. To possess knowledge and skill

CASE: JARCIA vs. PEOPLE (2012)

Facts: Roy Jr. was hit by a taxi cab and rushed to the ER of Manila Doctors. The Drs were in the ER and
they ordered and X-ray of the ankle. They interpreted the X-ray results and found that there were no
fractures. They informed the mom that since it was only the ankle that was hit, there was no need to
examine the upper leg. 11 days later, Roy Jr. developed fever, swelling of the right leg and misalignment of
the right foot. Mrs. Santiago brought him back to the hospital and that the X-ray revealed a right midtibial fracture and a linear hairline fracture in the shaft of the bone (ie. an upper leg injury). The mom
filed a case against the doctors for reckless imprudence resulting to physical injuries.
RTC & CA found the doctors liable for SIMPLE imprudence.
SC: On appeal, SC said that the doctors are NOT criminally liable. But they were held civilly liable for
expenses and moral and exemplary damages (since there was preponderance of evidence).
Negligence is defined as the failure to observe for the protection of the interests of another person that
degree of care, precaution, and vigilance which the circumstances justly demand, whereby such other
person suffers injury. Reckless imprudence consists of voluntarily doing or failing to do, without malice,
an act from which material damage results by reason of an inexcusable lack of precaution on the part of
the person performing or failing to perform such act.The elements of simple negligence are: (1) that there
is lack of precaution on the part of the offender, and (2) that the damage impending to be caused is not
immediate or the danger is not clearly manifest.
The testimony of another doctor, a specialist in pediatric orthopedic, although pointing to some medical
procedures that could have been done by Drs, as physicians on duty, was not clear as to whether the
injuries suffered by patient were indeed aggravated by the petitioners judgment call and their diagnosis
or appreciation of the condition of the victim at the time they assessed him. Any person may opine that
had patient Roy Jr. been treated properly and given the extensive X-ray examination, the extent and
severity of the injury, spiral fracture of the mid-tibial part or the bigger bone of the leg, could have been
detected early on and the prolonged pain and suffering of Roy Jr. could have been prevented. But still,
that opinion, even how logical it may seem would not, and could not, be enough basis to hold one
criminally liable; thus, a reasonable doubt as to the petitioners guilt.
Nevertheless, the SC said that the doctors should have referred the patient to another doctor with
sufficient training and experience instead of assuring him and his mother that everything was all right.
b. To utilize such knowledge and skill with care and diligence
2. Dereliction of duty which may be due to (a) violation of law, (b) negligence, (c) ignorance, (d)
departure from accepted practice

CASE: LUCAS vs. TUAO (2009)

Facts:Lucas contracted sore eyes on his right eye. This began a series of consultations with Dr. Tuano.
Dr. Tuano prescribed the use of Maxitrol. Months later, Lucas woke up with no vision in his right eye and
it was found that he suffered from Glaucoma. He filed a civil case against Dr. Tuano, claiming that his
Glaucoma was steroid-induced (ie. caused by the Maxitrol Dr. Tuano prescribed) and that Dr. Tuano
was negligent in prescribing the same to him without monitoring the intra-ocular pressure in his eyes.
SC: Like any other proceeding for damages, four essential (4) elements i.e., (1) duty; (2) breach; (3) injury;
and (4) proximate causation. In order to establish the proximate cause of the injury by a preponderance of
the evidence in a medical malpractice action, the patient must similarly use expert testimony, because the
question of whether the alleged professional negligence caused the injury is generally one for specialized
expert knowledge beyond the ken of the average layperson. In this case, the complainants failed to present
any medical expert to prove that Dr. Tuanos actuations fell short of the required diligence from doctors.
Also, absent any medical opinion, to say that the Glaucoma was a result of the medication was purely
speculative.
3. Direct (proximate) cause of the damage is negligence
a. There is direct physical connection between the act or omission and injury
b. The wrongful act or omission must be efficient, effective and must not be too remote
c. The injury must be the natural and probable consequence of the act or omission
CASE: CAYAO-LASAM vs. RAMOLETE (2008)
Facts: Editha Ramolete, 3 months pregnant, was rushed to LMC in La Union due to vaginal bleeding. Dr.
Lasam was the attending physician for her pregnancy. Due to persistent and profuse vaginal bleeding, Dr.
Lasam performed D&C (Dilation and Curettage Procedure) or raspa. Editha was discharged. But
months later, she was rushed again to the hospital for severe abdominal pains and vomiting. It was found
that there was a dead fetus in her womb. She underwent laparotomy and hysterectomy, and as a result,
she can no longer bear a child.
The spouses filed a complaint with the PRC (Professional Regulations Commission) for gross negligence
and malpractice. The Board of Medicine of the PRC acquitted Dr. Lasam. But on appeal to the PRC, PRC
reversed the findings and revoked her license.
SC acquitted Dr. Lasam.
SC: The spouses did not present any expert testimony to support their claim that petitioner failed to do
something which a reasonably prudent physician or surgeon would have done. Dr Lasam, on the other
hand, presented the testimony of Dr. Manalo, who was clearly an expert on the subject. From the
testimony of Dr. Manalo and the reasons given by him, it is evident that the D&C procedure was not the
proximate cause of the rupture of Edithas uterus. Also, from his testimony, it was clear that the D&C
procedure was conducted in accordance with the standard practice, with the same level of care that any
reasonably competent doctor would use to treat a condition under the same circumstances, and that there
was nothing irregular in the way the petitioner dealt with Editha.
The immediate cause of the accident resulting in Edithas injury was her own omission when she did not
return for a follow-up check up, in defiance of Dr. Lasams orders. The immediate cause of Edithas injury
was her own act; thus, she cannot recover damages from the injury.

But for or Sine Qua Non test

Substantial factor test

Doctrine of Efficient independent intervening cause: In the causal connection between the
negligence of the physician and the injury sustained by the patient, there may be an efficient
intervening cause which is the proximate cause of the injury.

4. Damage sustained condition worsens

a. Diminished chances of recovery
b. Prolonged illness
c. Increase sufferings
(5) For criminal medical malpractice, the act or omission must be punishable by law.
Essential elements to prove malpractice action based upon the doctrine of informed consent
1. Duty to disclose material risks
2. Failure to dis close or inadequate disclosure of those risks
3. As a direct and proximate result of the failure to disclose, the patient consented to treatment
he/she would otherwise would not have consented to
4. Plaintiff was injured by the proposed treatment
CASE: DR. RUBI LI vs. SPS.TAMAYO (2011)
Facts: Spouses Tamayos 11-year old daughter, Angelica underwent a biopsy of the mass located in her
lower extremity at the St. Lukes. Results showed that Angelica was suffering from osteosarcoma,
osteoblastic type, a high- grade (highly malignant) cancer of the bone which usually afflicts teenage
children. Following this diagnosis and as primary intervention, Angelicas right leg was amputated by Dr.
Jaime Tamayo in order to remove the tumor. As adjuvant treatment to eliminate any remaining cancer
cells, and hence minimize the chances of recurrence and prevent the disease from spreading to other parts
of the patients body (metastasis), chemotherapy was suggested by Dr. Tamayo. Dr. Tamayo referred
Angelica to another doctor at SLMC, herein petitioner Dr. Rubi Li, a medical oncologist. On August 18,
Angelica was admitted to SLMC. However, she died on September 1, just 11 days after the intravenous
administration of the first cycle of the chemotherapy regimen.
Spouses filed a damage suit against the doctors. RTC dismissed the complaint, but on appeal, CA awarded
damages because Dr. Li, as attending physician, failed to fully explain to the spouses all the possible side
effects of chemotherapy before securing their consent to the treatment.
SC ruled in favor of Dr. Li.
SC: The doctrine of informed consent evolved into a general principle of law that a physician has a duty to
disclose what a reasonably prudent physician in the medical community in the exercise of reasonable care
would disclose to his patient as to whatever grave risks of injury might be incurred from a proposed
course of treatment, so that a patient, exercising ordinary care for his own welfare, and faced with a choice
of undergoing the proposed treatment, or alternative treatment, or none at all, may intelligently exercise
his judgment by reasonably balancing the probable risks against the probable benefits.
4 essential elements a plaintiff must prove in a malpractice action based upon the doctrine of informed
consent: (1) the physician had a duty to disclose material risks; (2) he failed to disclose or inadequately
disclosed those risks; (3) as a direct and proximate result of the failure to disclose, the patient consented
to treatment she otherwise would not have consented to; and (4) plaintiff was injured by the proposed
treatment. The gravamen in an informed consent case requires the plaintiff to point to significant
undisclosed information relating to the treatment which would have altered her decision to undergo it.
In this case, there was adequate disclosure of material risks inherent in the chemotherapy procedure
performed with the consent of Angelicas parents. The spouses could not have been unaware in the course
of initial treatment and amputation of Angelicas lower extremity, that her immune system was already
weak on account of the malignant tumor in her knee. When Dr. Li informed the spouses beforehand of the

side effects of chemotherapy which includes lowered counts of white and red blood cells, decrease in
blood platelets, possible kidney or heart damage and skin darkening, there is reasonable expectation on
the part of the doctor that the respondents understood very well that the severity of these side effects will
not be the same for all patients undergoing the procedure. In other words, by the nature of the disease
itself, each patients reaction to the chemical agents even with pre-treatment laboratory tests cannot be
precisely determined by the physician. That death can possibly result from complications of the treatment
or the underlying cancer itself, immediately or sometime after the administration of chemotherapy drugs,
is a risk that cannot be ruled out, as with most other major medical procedures, but such conclusion can
be reasonably drawn from the general side effects of chemotherapy already disclosed.
Doctrines and principles in medical malpractice
1.

Doctrine of vicarious liability: Responsibility of a person, who is not negligent, for the wrongful
conduct or negligence of another.
a. Ostensible agent doctrine
In cases where the employees are at the same time independent contractors of the hospital
Because of this peculiar situation, they are considered ostensible agents and therefore, the
hospital must be held liable for their negligent acts
Pathologist, radiologist, anesthesiologist

CASE: PSI vs. CA (2010)

Facts:
PSI together with Dr. Ampil and Dr. Fuentes were impleaded by Spouses Enrique and Natividad Agana
for damages because of the injuries suffered by Natividad when the two doctors neglected to remove from
her body two gauzes which were used in the surgery they performed on her. PSI was impleaded as owner,
operator and manager of the hospital. The pivotal issue in this case is whether a hospital may be held
liable for the negligence of physicians-consultants allowed to practice in its premises.
Ruling:
SC ruled PSI is vicariously liable for the negligence of Dr. Ampil as its ostensible agent. PSIs hospital
liability based on ostensible agency and corporate negligence applies only to this case, pro hac vice. It is
not intended to set a precedent and should not serve as a basis to hold hospitals liable for every form of
negligence of their doctors-consultants under any and all circumstances.
Even when no employment relationship exists but it is shown that the hospital holds out to the patient
that the doctor is its agent, the hospital may still be vicariously liable under Article 2176 in relation to
Article 1431 and Article 1869 of the Civil Code or the principle of apparent authority
There is, however, ample evidence that the hospital (PSI) held out to the patient (Natividad) that the
doctor (Dr. Ampil) was its agent. Present are the two factors that determine apparent authority: first, the
hospital's implied manifestation to the patient which led the latter to conclude that the doctor was the
hospital's agent; and second, the patients reliance upon the conduct of the hospital and the doctor,
consistent with ordinary care and prudence.
The decision made by Enrique for Natividad to consult Dr. Ampil was significantly influenced by the
impression that Dr. Ampil was a staff member of Medical City General Hospital, and that said hospital
was well known and prominent. Enrique looked upon Dr. Ampil not as independent of but as integrally
related to Medical City. PSI's acts tended to confirm and reinforce, rather than negate, Enrique's view. It
is of record that PSI required a consent for hospital care to be signed preparatory to the surgery of
Natividad. The form reads that permission is hereby given to the medical, nursing and laboratory staff of
the Medical City General Hospital to perform such diagnostic procedures and to administer such
medications and treatments as may be deemed necessary or advisable by the physicians of this hospital.
By such statement, PSI virtually reinforced the public impression that Dr. Ampil was a physician of its
hospital, rather than one independently practicing in it; that the medications and treatments he
prescribed were necessary and desirable; and that the hospital staff was prepared to carry them out.

b. Borrowed servant doctrine

Ordinarily, resident physicians, nurses and other personnel of the hospital are employees or
servants of the hospital
In some instances, they are under the temporary supervision and control of another other than
their employer while performing their duties
By fiction of law, they are deemed borrowed from the hospital by someone and for any wrongful
act committed by them during the period, their temporary employer must be held liable for the
discharge of their acts and duties
In the determination of whether one is a borrowed servant, it is necessary that he is not only
subjected to the control of another with regard to the work done and the manner of performing it
but also that the work to be done is for the benefit of the temporary employer.

CASE: NOGALES VS. CAPITOL MEDICAL CENTER (2006)

(Note: The Borrowed servant doctrine was discussed and mentioned by the Court of Appeals in this case)
Facts:
Pregnant with her fourth child, Corazon Nogales was under the exclusive prenatal care of Dr. Oscar
Estrada. While Corazon was on her last trimester of pregnancy, Dr. Estrada noted an increase in her blood
pressure and development of leg edema indicating preeclampsia, which is a dangerous complication of
pregnancy. Corazon started to experience mild labor pains prompting the Spouses Nogales to see Dr.
Estrada at his home. Dr. Estrada advised her immediate admission to the Capitol Medical Center, where
she was attended by different physicians aside from Dr. Estrada. After using forceps to deliver the baby,
Corazon died due hemorrhage post partum from a tear in her cervix. Dr. Estrada and the physicians who
assisted him were being sued for damages.
The Court of Appeals affirmed the trial court in holding Dr. Estrada solely liable and this was already final
became final. It is not disputed that he misapplied the forceps in causing the delivery because it resulted
in a large cervical tear which had caused the profuse bleeding which he also failed to control with the
application of inadequate injection of magnesium sulfate by his assistant Dra. Ely Villaflor. Dr. Estrada
even failed to notice the erroneous administration by nurse Dumlao of hemacel by way of side drip,
instead of direct intravenous injection, and his failure to consult a senior obstetrician at an early stage of
the problem. On the part however of Dra. Ely Villaflor, Dra. Rosa Uy, Dr. Joel Enriquez, Dr. Lacson, Dr.
Espinola, nurse J. Dumlao and CMC, the lower court found no legal justification to find them civilly liable.
The issue that was appealed to the Supreme Court was whether CMC is vicariously liable for the
negligence of Dr. Estrada and whether the other attending physicians are liable as well.
Ruling:
In the instant case, CMC impliedly held out Dr. Estrada as a member of its medical staff. Through CMCs
acts, CMC clothed Dr. Estrada with apparent authority thereby leading the Spouses Nogales to believe
that Dr. Estrada was an employee or agent of CMC. CMC cannot now repudiate such authority and is held
to be vicariously liable for the negligence of Dr. Oscar Estrada.
SC also absolved the respondent physicians of any liability, as was also held by the Court of Appeals. On
the liability of the other respondents, the Court of Appeals applied the borrowed servant doctrine
considering that Dr. Estrada was an independent contractor who was merely exercising hospital privileges.
This doctrine provides that once the surgeon enters the operating room and takes charge of the
proceedings, the acts or omissions of operating room personnel, and any negligence associated with such
acts or omissions, are imputable to the surgeon. While the assisting physicians and nurses may be
employed by the hospital, or engaged by the patient, they normally become the temporary servants or
agents of the surgeon in charge while the operation is in progress, and liability may be imposed upon the
surgeon for their negligent acts under the doctrine of respondeat superior. The Court of Appeals
concluded that since Rogelio engaged Dr. Estrada as the attending physician of his wife, any liability for
malpractice must be Dr. Estradas sole responsibility.

c. Captain of the ship doctrine

Liability of the surgeon not only for the wrongful acts of those who are under his physical control
but also those wherein he has extension of control

2. Res ipsa loquitur

The thing speaks for itself, the nature of the wrongful act or injury is suggestive of negligence
General Rule: Expert testimony is necessary to prove that a physician has done a negligent act or
that has deviated from the standard medical practice
Requisites:
(a) The accident must be of a kind which ordinarily does not occur in the absence of someones
negligence
(b) It must be caused by an agency or instrumentality within the exclusive control of the
defendant
(c) It must not have been due to any voluntary action or contribution on the part of the plaintiff

CASES:
RAMOS vs. CA (1999)
Facts:
Petitioner was admitted to the hospital for a cholecystectomy operation to remove a stone in her gall
bladder. She was waiting for almost three hours for Dr. Hosaka to arrive when the anesthesia was applied
to her. But the intubation went wrong and as a result she was admitted to the Intensive Care Unit. Doctors
Gutierrez and Hosaka explained that the patient had bronchospasm. Erlinda stayed at the ICU for a
month. About four months thereafter, the patient was released from the hospital. A civil case for damages
was filed against the hospital and the doctors. Both parties presented evidence as to the possible cause of
Erlindas injury. Plaintiff presented the testimonies of Dean Herminda Cruz and Dr. Mariano Gavino to
prove that the damage sustained by Erlinda was due to lack of oxygen in her brain caused by the faulty
management of her airway by private respondents during the anesthesia phase. On the other hand,
private respondents primarily relied on the expert testimony of Dr. Eduardo Jamora, a pulmonologist, to
the effect that the cause of brain damage was Erlindas allergic reaction to the anesthetic agent,
Thiopental Sodium (Pentothal). RTC ruled in favor of the petitioners but was reversed by CA. SC is called
upon to decide whether a surgeon, an anesthesiologist and a hospital should be made liable for the
unfortunate comatose condition of a patient scheduled for cholecystectomy.
Ruling:
SC held that the doctrine of res ipsa loquitur is appropriate in the case at bar and private respondents
were unable to disprove the presumption of negligence on their part in the care of Erlinda and their
negligence was the proximate cause of her piteous condition.
The doctrine of res ipsa loquitur is simply a recognition of the postulate that, as a matter of common
knowledge and experience, the very nature of certain types of occurrences may justify an inference of
negligence on the part of the person who controls the instrumentality causing the injury in the absence of
some explanation by the defendant who is charged with negligence.
Before resort to the doctrine may be allowed, the following requisites must be satisfactorily shown:
1. The accident is of a kind which ordinarily does not occur in the absence of someones negligence;
2. It is caused by an instrumentality within the exclusive control of the defendant or defendants; and
3. The possibility of contributing conduct which would make the plaintiff responsible is eliminated
Although generally, expert medical testimony is relied upon in malpractice suits to prove that a physician
has done a negligent act or that he has deviated from the standard medical procedure, when the doctrine

of res ipsa loquitur is availed by the plaintiff, the need for expert medical testimony is dispensed with
because the injury itself provides the proof of negligence.
In the present case, Erlinda submitted herself for cholecystectomy and expected a routine general surgery
to be performed on her gall bladder. At the time of submission, Erlinda was neurologically sound and,
except for a few minor discomforts, was likewise physically fit in mind and body. However, during the
administration of anesthesia and prior to the performance of cholecystectomy she suffered irreparable
damage to her brain. Thus, without undergoing surgery, she went out of the operating room already
decerebrate and totally incapacitated. Obviously, brain damage, which Erlinda sustained, is an injury
which does not normally occur in the process of a gall bladder operation. In fact, this kind of situation
does not happen in the absence of negligence of someone in the administration of anesthesia and in the
use of endotracheal tube.
MENDOZA vs. CASUMPANG ET AL (2012)
Facts:
Josephine underwent hysterectomy and myomectomy that Dr. Mendoza performed on her at the Iloilo
Doctors Hospital. After her operation, Josephine experienced recurring fever, nausea, and vomiting.
Three months after the operation, she noticed while taking a bath something protruding from her genital.
She tried calling Dr. Mendoza to report it but the latter was unavailable. Josephine instead went to see
another physician, Dr. Edna Jamandre-Gumban, who extracted a foul smelling, partially expelled rolled
gauze from her cervix. The discovery of the gauze and the illness she went through prompted Josephine to
file a damage suit against Dr. Mendoza. RTC and CA found Dr. Mendoza guilty of neglect that caused
Josephines illness and eventual death. Petitioner claims that no gauze or surgical material was left in
Josephines body after her surgery as evidenced by the surgical sponge count in the hospital record.
Ruling:
SC affirmed CA ruling. Josephine did not undergo any other surgical operation. And it would be much
unlikely for her or for any woman to inject a roll of gauze into her cervix. An operation requiring the
placing of sponges in the incision is not complete until the sponges are properly removed, and it is settled
that the leaving of sponges or other foreign substances in the wound after the incision has been closed is
at least prima facie negligence by the operating surgeon. To put it simply, such act is considered so
inconsistent with due care as to raise an inference of negligence.
A surgical operation is the responsibility of the surgeon performing it. He must personally ascertain that
the counts of instruments and materials used before the surgery and prior to sewing the patient up have
been correctly done. To provide an example to the medical profession and to stress the need for constant
vigilance in attending to a patients health, the award of exemplary damages in this case is in order.
3. Doctrine of common knowledge
notwithstanding the general prerequisite for expert testimony to establish the standard of care
and its breach in medical malpractice cases, such expert testimony is not required when the
subject matter of the allegedly substandard conduct is within the common knowledge of nonmedically-trained persons, or in other words, fully comprehensible to ordinary non-medical
members of the public.
The common knowledge question also arises frequently in the context of causation questions.
Here, too, expert testimony is the norm, but an exception is often recognized when the existence
of a causal connection between the alleged medical negligence and the plaintiffs injury is deemed
a matter of common knowledge
4. Doctrine of contributory negligence

Defined as conduct on the part of plaintiff or injured party, contributing as a legal cause to the
harm he has suffered, which falls below the standard which he is required to conform to his own
protection

Act or omission amounting to want of care on the part of the complaining party which, concurring
with the defendants negligence, is the proximate cause of the injury

5. Doctrine of continuing negligence If the physician, after a prolonged treatment of a patient

which normally produces alleviation of the condition, fails to investigate non-response, he may be
held liable if in the exercise of care and diligence he could have discovered the cause of nonresponse
6. Doctrine of assumption of risk

7.

Predicate upon knowledge and informed consent, anyone who voluntarily assumes the risk of the
injury from a known danger, if injured, is barred from recovery
Violenti non fit injuria: a person who assents and was injured is not regarded by law to be injured
Doctrine of last clear chance
A physician who has the last clear chance of avoiding damage or injury but negligently fails to do
so is liable
It implies thought, appreciation, mental direction and lapse of sufficient time to effectually act
upon impulse to save the life or prevent injury to another.

8. Doctrine of foreseeability
A physician cannot be held accountable for negligence if the injury sustained by the patient is on
account of unforeseen conditions but if a physician fails to ascertain the condition of the patient
for want of the requisite skill and training, he is answerable for the injury sustained by the patient
if injury resulted thereto.
A physician owes duty of care to all persons who are foreseeably endangered by his conduct, with
respect to the risk which make the conduct unreasonably dangerous.
9. Fellow Servant Doctrine
If a servant (employee) is injured on account of the negligence of his fellow servant (employee),
the employer cannot be held liable.
10. Rescue doctrine
If a physician who went to rescue a victim of an accident was himself injured, the original
wrongdoer must be held liable for such injury.
Laws
1.

Medical Act of 1959 as amended by RA 4224

Included Legal Medicine (including Medical Jurisprudence) in the subjects required for medical
courses
What is the practice of medicine? It is a privilege or franchise granted by the State to any person
to perform medical acts upon compliance with law, that is the Medical Act of 1959, as amended,
which has been promulgated by the State in the exercise of police power to protect its citizenry
from unqualified practitioners of medicine.
What are the acts constituting practice of medicine? (Sec 10)

A person shall be considered as engaged in the practice of medicine

(a) who shall, for compensation, fee, salary or reward in any form paid to him directly or through
another, or even without the same, physically examine any person, and diagnose, treat, operate or
prescribe any remedy for human disease, injury, deformity, physical, mental, psychical condition
or any ailment, real or imaginary, regardless of the nature of the remedy or treatment
administered, prescribed or recommended; or

(b) who shall by means of signs, cards, advertisements, written or printed matter, or through the
radio, television or any other means of communication, either offer or undertake by any means or
method to diagnose, treat, operate or prescribe any remedy for any human disease, injury,
deformity, physical, mental or psychical condition; or
(c) who shall falsely use the title of M.D. after his name.

Exemptions to Section 10 (Section 11) meaning people not considered practicing medicine

The preceding section shall not be construed to affect

(a) any medical student duly enrolled in an approved medical college or school, or graduate under
training, serving without any professional fee in any government or private hospital, provided that he
render such service under the direct supervision and control of a registered physician;
(b) any legally registered dentist engaged exclusively in the practice of dentistry;
(c) any duly registered masseur or physiotherapist, provided that he applies massage or other physical
means upon written order or prescription of a duly registered physician, or provided that such
application of massage or physical means shall be limited to physical or muscular development;
(d) any duly registered optometrist who mechanically fits or sells lenses, artificial eyes, limbs or other
similar appliances or who is engaged in the mechanical examination of eyes for the purpose of
constructing or adjusting eyeglasses, spectacles and lenses;
(e) any person who renders any service gratuitously in cases of emergency, or in places where the
services of a duly registered physician, nurse or midwife are not available;
(f) any person who administers or recommends any household remedy as per classification of existing
Pharmacy Laws;
(g) any clinical psychologist, or mental hygienist, in the performance of his duties in regard to patients
with psychiatric problems, provided such performance is done with the prescription and direct
supervision of a duly registered physician, and
(h) prosthetists who fit artificial limbs under the supervision of a registered physician.

There is no provision in the medical act exempting faith healing from the definition of the acts
which constitute practice of medicine
Persons qualified to practice medicine: Those who have complied with the prerequisites to the
practice of medicine in accordance with Section 8: (a) 21 years old, (b) passed the Medical Board
Examination, (c) Holder of valid certificate of registration issued to him by the Board of Medicine,
(d) proper educational background meaning graduated from the college of medicine, holder of a
bachelors degree, not convicted of any crime involving moral turpitude, certificate of eligibility
from the Board of Medical Education and good moral character
Persons allowed limited practice without certificates of registration (Section 12)

(a) Physicians and surgeons from other countries called in consultation only and exclusively in
specific and definite case, or those attached to international bodies or organizations assigned to
perform certain definite work in the Philippines, provided they shall limit their practice to the
specific work assigned to them and provided further they shall secure a previous authorization
from the Board of Medical Examiners.
(b) Commissioned medical officers of the United States Armed Forces stationed in the Philippines
while rendering service as such only for the members of the said armed forces and within the limit
of their own respective territorial jurisdiction.
(c) Foreign physicians employed as exchange professors in special branches of medicine or surgery
whose service may, upon previous authorization of the Board of Medical Examiners, be necessary.
(d) Medical students who have completed the first four years of medical course, graduates of
medicine and registered nurses who may be given limited and special authorization by the
Secretary of Health to render services during epidemics or national emergencies whenever the
services of duly registered physicians are not available. Such authorization shall automatically
cease when the epidemic or national emergency is declared terminated by the Secretary of Health.
2. BP 702 as amended by RA 8344 (Act Prohibiting the demand of deposits or advance payments for
the confinement or treatment of patients in hospitals and medical clinics in certain cases)

Section 1: In emergency or serious cases, it shall be unlawful for any proprietor, president,
director, manager or any other officer, and/or medical practitioner or employee of a hospital or
medical clinic to request, solicit, demand or accept any deposit or any other form of
advance payment as a prerequisite for confinement or medical treatment of a
patient in such hospital or medical clinic or to refuse to administer medical
treatment and support as dictated by good practice of medicine to prevent death or
permanent disability: Provided, That by reason of inadequacy of the medical capabilities of
the hospital or medical clinic, the attending physician may transfer the patient to a facility where
the appropriate care can be given, after the patient or his next of kin consents to said transfer and
after the receiving hospital or medical clinic agrees to the transfer: Provided, however, That when
the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can
transfer the patient even without his consent: Provided, further, That such transfer shall be done
only after necessary emergency treatment and support have been administered to stabilize the
patient and after it has been established that such transfer entails less risks than the patient's
continued confinement: Provided, furthermore, That no hospital or clinic, after being informed of
the medical indications for such transfer, shall refuse to receive the patient nor demand from the
patient or his next of kin any deposit or advance payment: Provided, finally, That strict
compliance with the foregoing procedure on transfer shall not be construed as a refusal made
punishable by this Act.

Definition of terms
o

o
o

o
o
o

Emergency a condition or state of a patient wherein based on the objective findings of a

prudent medical officer on duty for the day there is immediate danger and where delay in
initial support and treatment may cause loss of life or cause permanent disability to the
patient
Serious case refers to a condition of a patient characterized by gravity or danger
wherein based on the objective findings of a prudent medical officer on duty for the day
when left unattended to, may cause loss of life or cause permanent disability to the
patient
Confinement a state of being admitted in a hospital or medical clinic for medical
observation, diagnosis, testing and treatment consistent with the capability and available
facilities of the hospital or clinic
Hospital a facility devoted primarily to the diagnosis, treatment and care of individuals
suffering from illness, disease, injury or deformity, or in need of obstetrical or other
medical and nursing care. It shall also be construed as any institution, building or place
where there are facilities and personnel for the continued and prolonged care of patients
Emergency treatment and support any medical or surgical measure within the
capability of the hospital or medical clinic that is administered by qualified health care
professionals to prevent the death or permanent disability of a patient
Permanent disability a ondition of physical disability as defined under Article 192-C
and Article 193-B and C of Presidential Decree No 442; as amended, otherwise known as
the Labor Code of the Philippines.
Stabilize the provision of necessary care until such time that the patient may be
discharged or transferred to another hospital or clinic with a reasonable probability that
no physical deterioration would result from or occur during such discharge or transfer

Penalties under the law (Section 4)

Imprisonment of not less than 6 months and 1 day but not more than 2 years and 4 months or
a fine of not less than P20,000 but not more than P100,000 or both
If violation was committed pursuant to an established policy of the hospital or clinic or upon
instruction of its management: Imprisonment of 4 to 6 years or a fine of not less than
P100,000 but not more than P500,000 or both

3. PRC Rules of Procedure

MODULE 14: DEATH AND DYING

Legal definition of death
Section 2 (j) of RA 7170
"Death" is the irreversible cessation of circulatory and respiratory functions or the irreversible cessation
of all functions of the entire brain, including the brain stem. A person shall be medically and legally dead
if either:
(1) In the opinion of the attending physician, based on the acceptable standards of medical practice,
there is an absence of natural respiratory and cardiac functions and, attempts at resuscitation
would not be successful in restoring those functions. In this case, death shall be deemed to have
occurred at the time these functions ceased; or
(2) In the opinion of the consulting physician, concurred in by the attending physician, that on the
basis of acceptable standards of medical practice, there is an irreversible cessation of all brain
functions; and considering the absence of such functions, further attempts at resuscitation or
continued supportive maintenance would not be successful in resorting such natural functions. In
this case, death shall be deemed to have occurred at the time when these conditions first appeared.
The death of the person shall be determined in accordance with the acceptable standards of medical
practice and shall be diagnosed separately by the attending physician and another consulting physician,
both of whom must be appropriately qualified and suitably experienced in the care of such parties. The
death shall be recorded in the patient's medical record.
1.

Cardiac arrest
the cessation of circulation of the blood due to failure of the heart to contract effectively (as
evidenced by the absence of a palpable pulse)
a medical emergency that, in certain situations, is potentially reversible if treated early
Cardiac causes:
o 60-70% of sudden cardiac death (SCD)
o Coronary heart disease
o Myocardial infarction (heart attack)
o Congestive heart disease
Non-cardiac causes:
o Trauma
o Internal haemorrhage

2. Respiratory arrest

Cessation of breathing due to the failure of the lungs to function effectively

Respiratory functions: delivers oxygen to the blood and removes carbon dioxide from the blood
Causes:
o Chemical (drug abuse)
o Physical (head injury)
o Infection (tetanus)
o Lack of oxygen (drowning, suffocation)

3. Brain death

Irreversible cessation of all functions of the entre brain, including the brain stem as determined
by the attending physician and consulting physician using acceptable standards of medical
malpractice and with the opinion that further resuscitation attempts or continued supportive
maintenance would not be successful to restore natural functions
Causes:
o Traumatic head injury

o
o
o

Brain haemorrhage
Lack of oxygen
Cardio-respiratory arrest

States of Consciousness

1.

Fully conscious

2. Minimally conscious state

Diagnostic criteria

Purposeful behaviour
Following command
Gestural or verbal yes/no response (regardless of accuracy)
Intelligible verbalization
Emergence from MCS is signalled by the return of functional communication or object
use
3. Vegetative state
o
o
o
o
o

Diagnostic criteria
o No evidence of awareness of self or environment and an inability to interact with others
o No evidence of sustained, reproducible, purposeful, or voluntary behavioural responses to
visual, auditory, tactile or noxious stimuli
o No evidence of language comprehension or expression
o Presence of sleep-wake cycles
o Sufficiently preserved hypothalamic and brainstem autonomic functions to permit
survival with medical and nursing care
o Bowel and bladder incontinence
o Variably preserved cranial-nerve and spinal reflexes

4. Persistent vegetative state

US
o
o
o

UK

After the lapse of one year

Considered as permanent vegetative state
A presumption exists that recovery is impossible so no need to prove impossibility of
recovery
o Only the diagnosis of the attending physician that the condition persisted for at least or
over a year is necessary to discontinue further life support without legal liability
Locked-in syndrome
o Etiology damage to specific portions of the lower brain and brain stem, with no damage
to the upper brain
o 90% die within 4 months
o Diagnostic criteria:
Presence of sustained eye opening (bilateral ptosis should be ruled out as a
complicatingfactor)
Aphonia or hypophonia
Quadriplegia or quadriparesis
Primary mode of communication that uses vertical or lateral eye movement or
blinking of the upper eyelid to signal yes/no responses
Preserved awareness of the environment
o Causes
Stroke or brain haemorrhage usually of the basilar artery
Traumatic brain injury
Drug or medication overdose
Amyotrophic lateral sclerosis aka Lou Gehrigs disease
Multiple sclerosis
o Coma
Diagnostic criteria
Absence of eye-opening on intense stimulation
No evidence of awareness of self or environment
At least 6 hours
Causes
o
o
o

After 4 weeks under vegetative state

May apply to court for discontinuance of artificial support
Need to prove by medical opinion that the recovery is impossible

Drug poisoning (40%)

Lack of oxygen due to cardiac arrest (25%)
Stroke (20%)
Trauma, excessive blood loss, malnutrition, hypothermia, abnormal
glucose levels, and many other biological disorders (15%)

3 the deepest level of coma; total unresponsiveness

3 to 8 severe injury (VS)
9 not in a coma, but not fully alert (MCS)
9 to 12 moderate injury
13 to 15 mild brain injury (or loss of consciousness for fewer than 20 minutes)
15 full consciousness
Death-related phenomena
1.

Cadaveric spasm
also known as post-mortem spasm, instantaneous rigor, cataleptic rigidity, or instantaneous
rigidity
rare form of muscular stiffening that occurs at the moment of death, persists into the period of
rigor mortis
usually associated with violent deaths happening under extremely physical circumstances with
intense emotion
may affect all muscles in the body, but typically only groups, such as the forearms, or hands
seen in cases of drowning victims when grass, weeds, roots or other materials are clutched, and
provides proof of life at the time of entry into the water
often crystallizes the last activity one did prior to death and is therefore significant in forensic
investigations, e.g. holding onto a knife tightly

cadaveric spasm vs. rigor mortis

o CS: instantaneous, RM: 2-3hours after death up to 12-24 hours
o CS: strong intensity, RM: moderate intensity
o CS: unknown but predisposing factors include fear, fatigue, muscle contraction at time of
death, RM: breakdown of ATP below critical levels
o CS: selected muscles, RM: all muscles affected

2. Lazarus sign

A reflex movement in brain--dead or brainstem failure patients which causes them to briefly
raise their arms and drop them crossed on their chests (in a position similar to some Egyptian
mummies)

3. Near-death experiences
Time of death
1.

Basis of determining time of death

When faced with the task of estimating a period of time since death, there are generally two known points
existing for the worker: the time at which the body was discovered and the last time the individual was
reliably known to be alive. The death occurred between these two points and the aim is to estimate when it
most probably took place.
This will be an estimate since, it is generally accepted that there is actually no scientific way to precisely
determine the exact period of time since death.
What is done in the case of entomology is an estimation of the period of insect activity on the body. This
period of insect activity will reflect the minimum period of time since death or postmortem interval (PMI)
but will not precisely determine the time of death.
2. Methods for estimating time of death
Post-mortem changes and decomposition
1.

Pallor mortis
A post mortem paleness
Evident in those with light skin almost instantly
Occurs 15-20 minutes after the death
Due to lack of capillary circulation throughout the body

2. Algor mortis

Once death has occurred, the body ceases to regulate its internal temperature and the internal
temperature begins to approximate the ambient temperature.
In most instances, this involves a cooling of the body until the ambient temperature is reached,
most often in a period of 18-20 hours.
The most useful single indicator of the time of death during the first 24 hours post-mortem
The cooling of a human body is best represented by a sigmoid curve when temperature is plotted
against time
There is an initial maintenance of body temperature which may last for some hours the socalled temperature plateau which may last from to 3-5 hours.
Followed by a relatively linear rate of cooling which subsequently slows rapidly as the body
approaches the environmental temperature
The most commonly used temperature in these calculations are from the liver although rectal
temperature may also be employed.

Causes
o Size of the body the bigger the body, the slower the cooling; the greater surface area
relative to its mass, the faster the cooling
o Clothing and covering slows cooling
o Movement of air more air movement, more rapid cooling
o Humidity more humid, more rapid cooling
o Immersion in water cooling is faster

3. Rigor mortis
Chemical change resulting in a stiffening of body muscles following death due to changes in the
myofibrils of the muscle tissues.
All muscles in the body are affected
2-6 hours begins with the eyelids, neck and jaw
6-12 hours spreads to the other muscles including the internal organs
Affected by the individuals age, sex, physical condition and the muscular build
The onset and duration of rigor is governed by 2 primary factors: temperature and the metabolic
state of the body.
Lower ambient temperatures tend to accelerate the onset of rigor and prolong its duration while
the opposite is found in warmer temperatures.
If the individual has been involved in vigorous activity immediately prior to death, the onset of
rigor is more rapid.
May not be perceivable in many infant and child corpses due to their smaller muscle mass
May be used to estimate the time of death
Ambient temperature affects the length of time from onset
As rigor disappears from the body, pattern is similar to that seen in onset, with the muscles of the
face relaxing first.
Position of corpse at the time of death
4. Livor mortis

While the individual is alive, the heart is functioning and circulating the blood, when death occurs,
circulation stops and the blood begins to settle, by gravity, to the lowest portions of the body.
Settling of the blood in the lower (dependent) portion of the body
Causing a purplish red discoloration of the skin
When the heart is no longer agitating the blood, heavy red blood cells sink through the serum by
action of gravity
Intensity of color depends upon the amount of reduced haemoglobin in the blood
Does not occur in the areas of the body that are in contact with the ground or another object, as
the capillaries are compressed
As the vessel wall become permeable due to decomposition, blood leaks through them and stains
the tissue. This is the reason for fixation of hypostasis.
First signs of livor mortis are typically observed after a period of approximately 1 hour following
the death with full development being observed 3-4 hours following the death. At this time, the
blood is still fluid and pressing on the skin will result in the blood being squeezed out of the area
(blanching), only to return once pressure is removed. This situation continues until 9-12 hours
following death, at which time the pattern will not change and the livor mortis is said to be fixed.

5. Putrefaction

Decomposition of proteins
Accelerated by anaerobic microorganisms found in the gastrointestinal tract
Broken down proteins excreted by the bacteria into gases and amines such as putrescine and
cadaverine
Gases lead to bloating

Stages:
o 2-3 days: Discoloration appears on the skin of the abdomen. The abdomen begins to swell
due to gas formation
o 3-4 days: The discoloration spreads and discoloured veins become visible.
o 5-6 days: the abdomen swells noticeably and the skin blisters.
o 2 weeks: the abdomen is bloated. Internal gas pressure nears maximum capacity.
o 3 weeks: Tissues have softened. Organs and cavities are bursting. The nails fall off.
o 4 weeks: Soft tissues begin to liquefy and the face become unrecognizable.

6. Skeletonization

Last stage of decomposition where last vestiges of soft tissues have decayed or dried exposing the
skeleton
By the end of the skeletonization process, all soft tissue will have been eliminated, leaving only
disarticulated bones
Acids in the soil destroy the bone

Other post-mortem changes (not in the module but in the assigned article)

Tache Noir
o French term for black line
o Following death, the eyes may remain open and the exposed part of the cornea will dry,
leaving a re-orange to black discoloration.
o May be misinterpreted as haemorrhage but unlike haemorrhage, this will have a
symmetrical distribution, corresponding to the position of the eyelids.

Greenish discoloration
o As the body decomposes, gases are produced in the abdomen and other parts of the body.
o A significant component of these gases is hydrogen sulphide. This gas is a small molecule
and readily diffuses through the body.
o Hydrogen sulphide will react with the haemoglobin in blood to form sulfhemoglobin. This
pigment is greenish and may be seen in blood vessels and in other areas of the body,
particularly where livor mortis has formed.
Marbling
o As the anaerobic bacteria from the abdomen spread via the blood vessels, the
subcutaneous vessels take on a purple to greenish discoloration, presenting a mosaic
appearance, similar to what is seen in cracking of old marble statuary.
o Typically seen on the trunk and extremities

Skin slippage
o Upon death, in moist or wet habitats, epidermis begins to separate from the underlying
dermis due to production of hydrolytic enzymes from cells at the junction between the
epidermis and the underlying dermis.
o This results in the separation of the epidermis which can be easily removed from the body.
o Slippage may first be observed as the formation of vesicle formation in dependent
portions of the body.
o Glove formation: The skin from the hand may separate from the underlying dermis as a
complete or relatively complete unit. Skin can be removed from the hand as an intact unit.
This skin can be used for finger printing, often with better results than if the skin remains
on the hand.

Mummification
o In a dry climate, a body will desiccate. The low level of humidity will serve to inhibit
bacterial action and typically there will be some exclusion of insects and other scavengers
from the body.
o The temperatures will be either very hot or very cold in this situation.
o The desiccated tissues and skin will have a leathery appearance and will survive for long
periods of time with minimal change.
o In hot, dry climates mummification can occur within a period of several weeks.

Saponification process of hydrolysis of fatty tissues in wet, anaerobic situations, such as

submersion or in flooded burials. The tissues take on a waxy appearance and consistency. This
period requires a period of several months to complete.

CASE: PEOPLE vs. OLIVA (2000)

Facts:
Avelino went out of the house to urinate. He saw Ferigel set the roof of their house on fire with a lighted
match. Awakened by the loud barking of dogs, Avelino's wife sensed danger and peeped through a hole in
their wall. She also saw Ferigel burn the roof of their house. She called out to the neighbors for help.
One of the neighbors, Benjamin went to the nearby river and fetched water with a pail. As Benjamin was
helping put out the fire, he was shot by Ferigel at close range. Benjamin tried to run, but he slumped and
fell to the ground. The gunshot wound caused Benjamin's death.
A post-mortem report was released stating:
"II POSTMORTEM FINDINGS:
"Cadaver is in a state of rigor mortis and with postmortem lividity at back.
"Gunshot wound of entrance 0.9 cm. at left lateral mid-scapular area going medially and
anterosuperiorily, 10 cms. deep without exit."

"III. CAUSE OF DEATH

"Internal Hemorrhage due to gunshot wound at back."
The trial court found Oliva to be guilty beyond reasonable doubt of the crime of murder and arson.
Ruling:
SC affirmed the ruling of the lower court. Whether or not Benjamin was shot while he was on the street or
when he was in the act of pouring water on the burning roof is irrelevant to the crime. The fact is that he
was shot; any act of his after he was shot would not change the shooting, which at that point was fait
accompli.
Equally insignificant is whether the gun used was a long firearm or a short firearm. Identification of the
weapon only becomes critical when there is doubt as to the identity of the assailant. In this case, the trial
court did not doubt the identity, and neither would we. The fact is that Benjamin was shot and that it was
Ferigel who shot him. This was the categorical, straightforward and unbiased testimony of the prosecution
witnesses.
Proof of corpus delicti is indispensable in prosecutions for felonies and offenses. Corpus delicti is the body
or substance of the crime. It refers to the fact that a crime has been actually committed. Corpus delicti is
the fact of the commission of the crime that may be proved by the testimonies of witnesses. In murder, the
fact of death is the corpus delicti. In arson, the corpus delicti rule is satisfied by proof of the bare
occurrence of the fire and of its having been intentionally caused. The uncorroborated testimony of a
single eyewitness, if credible, may be enough to prove the corpus delicti and to warrant conviction. Here,
corpus delicti of the arson and murder was duly proven beyond reasonable doubt.