First Cause of Action: Medical Malpractice (Failure to Warn)

● In the direct exam, show that AD did not mean physical harm to negate duty to inform IG
● “Ms. Gonzalez’s murder resulted from the Defendant’s failure to warn.”
○ For cross examination, negate this claim. Show the disconnect. This is non-sequitur, a big
jump in logic.

Second Cause of Action: Medical Malpractice (Negligent Treatment/Diagnosis)

● A cause of action has 3 elements. These state that the plaintiff must have a legal right violated by
the defendant. Thus, in an ​established physician-patient relationship​, the physician must have
violated the right of a patient. In this case the plaintiff is not even the patient. Negligent treatment,
if one does exist, must have been experienced by the patient himself. Plaintiff MG does not have
a legal right that was violated by Defendant EM. They do not have a relationship. No cause of
action exists.

Arguments

On Negligence
Duty: Does it extend? If it so, to what extent?
● Failure to warn? Not something absolute and should be done only within the capacity of the
doctor
● Was there threat to harm? No. it was too abstract
● Goal should be to preserve confidentiality

Proximate Cause
● Suggest the idea of intervening factors
● Standard of care? RESEARCH what is usually done for this kind of Px
● Voluntary admission
○ Meaning there is self-awareness and help-seeking behavior
● No reason to believe that he would harm someone

Dereliction? ​No
Damage?​ Yes

Objections
● Irrelevant
● Hearsay
● Direct - leading questions
● Badgering the witness

Opening Argument
● Introduce facts
● Summary of arguments
On Confidentiality
● Based on code of ethics
● When can it be broken?

On credibility
● Gail
○ Experience in past medicolegal cases
○ Adult psychiatrist is more relevant
● Penny
○ Adolescent psych
○ Patient is 23 years old. Adolescent psych no longer applies to this patient EVEN IF his
symptoms started at the age of 15.
○ Erikson: 15 y.o. focus on IDENTITY but 23 y.o. focus on LOVE & COMPANIONSHIP,
which the case is pertaining more to, making adolescent psychology no longer relevant in
this case.

Script
First Witness - Monica and Edric
Second Witness - Jaco and Kurt
Third Witness - Penny and Gail

Opening Statement
Good afternoon, your Honor. I’m Bianca Villanueva with my colleagues, appearing for the respondent of
this case, Edric Morales. The respondent stands wrongfully charged of medical negligence and by the end
of this trial, we will have proven him not liable of the accusations against him.

The respondent was the psychiatrist of Airon Dominguez and, following the events of May 23, 2017, was
accused of medical negligence by failing to warn Ivy Gonzales of Airon’s declining mental state and
capability to kill. But was it really medical negligence? [pause] All Dr. Morales did, and he will tell you
this himself, was assess Airon, a man with depression and suicidal ideations, then admitted him
voluntarily for 3 days and prescribed him Prozac. Airon was then discharged as an out-patient after
having fulfilled the criteria, under Dr. Morales’ ​BEST​ judgement as is ​REASONABLY expected​ of his
psychiatrist. Airon was meant to be treated with “a follow-up of 2 weeks and, if unresponsive to
medications, an increased dosage of antidepressants.” Dr. Morales worked within those standards. This
establishes Dr. Morales’ sole duty in this case: the utmost care for his patient and the preservation of
confidentiality.

In cases of medical negligence, the plaintiff has the burden of proof to establish the following elements:
Duty, Proximate Cause, Dereliction, and Damage. [pause]

Your Honor, you will find that there was no duty of Dr. Morales to the plaintiff as no patient-doctor
relationship exists between them. Now, we must ask, does his duty extend? And was there a duty to warn
Ivy Gonzales? According to Philippine Medical Association of the Code of Ethics, Article II, Section 6:
“The physician should hold as ​sacred a​ nd ​highly confidential​ whatever may be discovered or learned
pertinent to the patient even after death, except when required in the promotion of safety.” [pause] Your
Honor, this establishes confidentiality as not just essential to the doctor-patient relationship, but
something sacred even after death. Was something as arbitrary as anger towards an ex-girlfriend
something worth breaking that for?

To establish Dr. Morales’ duty to warn, two elements must be fulfilled: an identifiable target and serious
risk posed to him/her. We concede to the fact Airon had named Ivy and that Dr. Morales knew who she
was and her relation to him. [pause] [Now, I would like to quote Alana v Magud-Logmao (2014):
“Doctors are not, and are not supposed to be, ​omniscient of the future​.”] Had there been a threat, surely
Dr. Morales, an ​experienced professional​, would have warned Ivy but he did not because he did not
suspect one nor could he have known what was to come that night of May 23. Therefore, it follows that
the facts of the case do ​NOT​ fulfill the needed criteria to breach confidentiality.

There is also no ​direct causal connection​ existent. We recognize the loss of life is a stressful event and
people can be quick to blame. However, Your Honor, you will find none here. Instead, the plaintiff is
desperately trying to connect two remotely unrelated events to place blame on, not just a man, but a
doctor​ as the direct cause of death of another human life.

We will be calling on three witnesses to show that the foregoing elements of medical negligence are
wanting in this case. [pause] Our first two witnesses are Edric Morales who is Airon’s psychiatrist and
respondent in this case, and Kurt Tinio who was a medical intern of the respondent. Both will testify on
Airon’s assessment and treatment plan. [pause] Our third witness is Gail Tesorio, our medical expert who
will testify on the standard course of care in cases such as this.

Your Honor, under law, our client is innocent until proven guilty. During this trial, you will hear no real
evidence against my client because, in terms of dereliction, he followed standard of care. [pause] In terms
of duty to warn, it did not extend in the case of Ivy Gonzales. [pause] Finally, in terms of proximate
cause, we find the alleged negligent act and the damage suffered by plaintiff unrelated. [pause] By the end
of this trial, we will have proven the respondent not liable for the charges against him. Thank you.

Cross Examination of Complainant’s First Witness

If they bring up this, what will we do?
● Good morning your honor, may I proceed with cross-examining the witnesses?
● Ms. Gonzalez, I’m so sorry for your loss. I may ask some difficult questions, so if you need a
moment, just let me know
● How do you know Dr Edric Morales?
○ Did your daughter have any professional relationship to Dr Edric Morales?
○ Did you contract a professional relationship with Dr. Morales?
○ Have you ever seen Dr. Morales in a professional setting?
○ Did your daughter ever see Dr. Morales in a professional setting?
● You mentioned in your affidavit that Mr. Domingues had “threatened” her, yes or no?
 ○ Do you know of any particular threat by Mr. Domingues against your daughter?
○ You also called your daughter a “victim of domestic violence.” Prior to May 23, 2017,
had Mr. Domingues ever physically harmed your daughter?
○ Isn’t it true that his previous threats had always related to his committing suicide and the
anguish she would feel resulting from that?
○ So there is no evidence of Mr. Domingues making physical threats or commiting physical
violence toward your daughter?
● You mentioned your daughter went to Pasig Science High School and was an honor student —
would you say that she was intelligent?
○ Because of that, would you say she would know if something was dangerous?
○ Would you agree?
● You also “she assumed the doctors treating him would have warned her if he were dangerous,”
but isn’t it true that Ms. Gonzalez had not spoken to Mr. Domingo in a week?
○ So how would she have known that he went to the hospital also?
● You said you and your daughter were close, is that correct?
○ That you spoke and texted a lot, is that right?
○ Would you say Ms. Gonzalez was an obedient daughter?
○ And would it be fair to assume you would give her advice?
○ On May 23, 2017 — did you tell Ms. Gonzalez that you were concerned about her going
to Mr. Domingues’ apartment?
■ So you’re saying that despite the warning from a trusted figure, she was still
going to go to the apartment?
■ If you thought Mr. Domingues was such an intense threat, wouldn’t you have
done everything in your power to dissuade him?

Cross Examination of Complainant’s Second Witness (Jaco)

If they bring up this, what will we do?
● Good morning your honor, may I proceed with the cross examination of the witness?
● Dr. Barrios, you were with Dr. Morales as well during his interview with Mr. Domingues, yes?
● But you did not document the encounter?
● So the only evidence we have is the encounter notes of Dr. Kurt Tinio, correct?
● So that means that your testimony is solely based on your personal recollection of the events that
happened 2 years ago?
● And at the time you were still a medical intern, not a psychiatry resident yet, am I correct?
● Would you agree with me that a psychiatrist of 19 years is more knowledgeable than a medical
intern?
● Based on your affidavit, it seems that you believed that Aaron needed more intensive
inpatient treatment. Why is that so?
○ Physical harm
● So you thought that Mr. Domingues was a serious threat against Ivy?
○ Yes
● Isn't it the duty of any doctor to fulfill their responsibility to warn in this case?
○ Yes
 ● So what did you do?
○ I raised this to my superior but he did not take my suggestion seriously.
● And then what did you do after that?
○ I told my group mates to try and contact Ivy. But they did not contact her.
● Did ​you​ contact her afterwards?
● And did you not say in your affidavit that you merely wanted to contact Ivy to interview her and
not specifically warn her about the alleged threat of Mr. Domingues?
● If you felt that there was a serious threat, would you not want to do everything in your power to
warn Ms. Ivy Gonzales about the alleged serious threat?
● So in the end, you did not contact Ms. Ivy Gonzalez. Either it wasn't a serious threat after all or
you failed in your duty as a medical professional. So do you still think there was a serious threat
to Ms. Ivy Gonzales?
○ If yes - Then you failed in your duty as a medical professional.
○ If no, - Then there was no serious threat after all.
● That is all your honor.

We may or may not use this:

● Dr. Barrios, can you please read line 11 from your affidavit.
● At the time of your twin brother’s suicide, he was 17 years old. Were you already a practicing
medical doctor at this time?
● So would you say that your analysis of your brother’s context included medical expertise?
● Regarding the insurance and Dr. Morales’ being careful about admitting patients:
○ He still admitted the patient!

Cross Examination of Complainant’s Third Witness ​- Tony

● Good morning your honor, may I proceed with the cross-examination of the witnesses?
● According to your CV, you are an adolescent psychiatrist by profession, am I correct?
● From the term itself, adolescent psychiatry focuses primarily on adolescents, am I correct?
● So on a daily basis, the patients that seek consult in your clinic are adolescents, right?
●
● And according to the WHO definition, adolescents are classified as individuals aged 10-19, am I
correct?
● Are you aware that Mr. Domingues is 24 years old during the happenings of this case?
● Therefore, Mr. Domingues does not fall under the adolescent age group, yes or no?
● And therefore, Mr. Domingues and his case is outside your area of expertise, am I correct?

● In medicine, are doctors trained to handle two patients who present with two very different
backgrounds, two different symptomatologies, as if they were the same?
● Let me break it down for you, psychiatry is a study of the brain and how it functions, am I
correct?
● And is an adult brain similar to that of an adolescent’s, yes or no?
● Mr. Domingues is an adult patient with an adult brain and is therefore different from an
adolescent patient having an adolescent brain?
 ● And since you are used to encountering adolescent brains for the most part in your specialization,
isn’t it possible that you were looking at

● Based on your expertise, would you agree that the brain of an adolescent is one that is undergoing
a lot of changes?
● And that these changes make them particularly vulnerable to mental health problems such as
suicidal ideation, right?
● Therefore, you as an ADOLESCENT psychiatrist is very much well-trained and very sharp in
looking for these specific ideations and risks?
● Isn’t there a possibility that the conclusions you have drawn from your interpretation of Mr.
Domingues’ statement was due to this very training of looking for these ideations?

● In your affidavit, what is your basis for coming to the conclusion that Mr. Domingues meant
“hurt” in the physical sense of the word?
● It has been repeated. What is the most important part of your patient encounter?
● History??
● Is there putting on the notes would have changed?
● Were you there when they recollected?

Direct Testimony of Defendant’s First Witness

What do we make Edric say?
● Your honor, I will present our first witness, Dr. Edric Morales, defendant in his case.
○ The purpose of his testimony is to disprove the allegations in this case
○ We will show that Dr. Morales fulfilled his duty to his patient, that there is no direct
relationship between Dr. Morales and Ms. Gonzalez, that there was no dereliction of care
of his patient, and that Dr. Morales’ actions were not a direct cause of Ms. Gonzalez’s
death.
● Do you swear to tell the truth
● Your honor may I proceed?
● Thank you your honor
● Mr. Witness, can you please state your name? ​Edric Morales
● What is your profession? ​Psychiatrist
● In relation to this case, did you execute any affidavit? ​Yes
● I will show to you an affidavit with three annexes signed on July 20, 2019 signed by one Edric
Morales. Is this the affidavit you were referring to? ​Yes
● Is this signature appearing above the name Edric Morales, is this your signature? ​Yes
● Your honor I would like this affidavit to be marked as exhibit 1 and his signature as exhibit 1-A
for the defendant.
● Who is your patient in this case? ​Aaron Domingues
○ Do you know of Ivy Gonzalez? ​Yes
■ Can you describe how you came to know her? ​I only know her by name, because
my patient would mention her name on our therapy sessions.
 ■ Can you explain to us how your patient described his relationship with Ms.
Gonzales?​ My patient would refer to her as his on-and-off girlfriend.
■ What about Monica Gonzalez? Do you have a relationship with her? ​I do not
have any relationship with Monica Gonzalez because I have not interacted with
her in any way.
■ Because you did not interact with Ms. Ivy Gonzalez nor Ms. Monica Gonzalez,
would you say that there is no doctor-patient relationship between you and the
two aforementioned persons? ​That is correct, there is no doctor-patient
relationship because they are not my patients.
○ As a professional you are aware of the code of ethics of PMA? ​Yes
■ Do you have a duty to take care of your patient? ​Yes
■ Do you have any duty to any third party related to your patient? ​No
● Based on your affidavit, How long have you been a psychiatrist? ​19 years
○ How many suicidal or violent patients have you seen in 19 years? ​Many
○ Based on this, would you say you have built up a considerable experience on clinical
judgement on suicidal and violent patients? ​Yes
● In your affidavit, you noted that Mr. Domingues had been admitted to the hospital 4 times prior
for suicide attempts, correct? ​Yes
○ You also noted that all these emergency psychiatric admissions were non-voluntary, is
that also correct? ​Yes
○ But on May 15, 2017 — Mr. Domingues actually voluntarily presented himself at the
hospital emergency room because of suicidal ideations? ​Yes
○ If Dr. Ramirez has already spoken:​ Dr. Ramirez is alleging that Aaron’s suicidal ideations
were becoming more frequent and this was a result of the mental deterioration. Would
you agree with this? ​No
■ In fact, wouldn’t you say that Mr. Domingues presenting himself to the hospital
with ideations, and in fact did not make a suicide attempt, show that he was
improving in terms of managing his depression? ​Yes, it is likely that the prozac
was helping him.
○ If Dr. Ramirez hasn’t spoken: ​ Would you say that Mr. Domingues presenting himself to
the hospital with ideations, and in fact did not make a suicide attempt, show that he was
improving in terms of managing his depression? ​Yes, it is likely that the prozac was
helping him
● During your discussion with Mr. Domingues, what did he say about how he was feeling?
Depressed
○ What did he say about his girlfriend, Ms. Gonzalez?
■ He said that she was unsupportive of his depression, and during his suicide
attempt the prior month, he thought about hurting her
○ What is your basis for believing this was emotional hurt?
■ When I pressed him, he said that while he was ingesting the drugs, he thought
about hurting his girlfriend because she hurt him. In all of his descriptions of his
girlfriend, it was always clear that she was emotionally hurting him with her lack
of support.
 ○ You noted that he mentioned he had these thoughts during his previous suicide attempt,
why is that important?
■ It is quite common for suicidal patients to believe that by committing suicide,
they will inflict emotional harm upon those who they believe are emotionally
harming them.
○ In fact, hadn’t Mr. Domingues done many times before?
■ Yes, and with every suicide attempt, it would bring about a reunion of the couple.
○ Upon your assessment and review of Mr. Domingues’ history, had he ever previously
been violent to others?
■ No
● Dr. Ramirez is alleging that you may have lied about following up about asking these questions.
Is there any truth in that? ​No
● At the time of admission, did you think he was suicidal? ​Yes
○ What did you do? ​Admitted him immediately for observation and also increased his
medication dosage
○ After that what was your assessment
■ Suicidal ideations decreased
○ How long did it take to subside? ​Two days
● At the time of discharge, what was your assessment ​That the patient’s suicidal ideations had
decreased
○ What else did you do?
■ O​rdered him to follow up after 5 days
● Why 5 days?
○ Based on the clinical practice guidelines and my judegement
■ Was there any verbalization that he wants to hurt Ivy?
● No doesn’t appear anymore
● Do you think that the Prozac medication you prescribed him may have caused his violent
behavior?
○ No, it did not cause the violent behavior of Mr. Domingues as Prozac is the first-line
drug for depression. The studies that said that Prozac does cause violent behavior are
few and not established. Also, this side effect of Prozac is usually seen only after a few
days of not taking the medicine.
● Mr. Domingues did not come to his follow up appointment on the morning of May 23, 2017.
○ Was this concerning to you?
■ Managing psychiatric patients is a fine line between caring for them and hassling
them, and I felt it wasn’t urgent, given that he had been discharged with a good
record. Also, according to the NICE guidelines, Mr. Domingues’ case warrants a
follow-up after 2 weeks, but I decided to see him after 5 days.
● What was your professional relationship with Dr. Barrios? ​He was my intern during his medical
school years.
○ Was Dr. Barrios a proactive person? ​Yes.
■ If he truly felt that the patient was at such risk, couldn’t he have approached the
authorities or Ms. Gonzalez? ​Yes.
 ○ He alleged that you would warn you residents about the costs of inpatient treatment.
Hypothetically (if Jaco not first) ​was the fact that the patient was uninsured a factor in
your decision of treatment? ​No.

Cross Examination of Defendant’s First Witness

● The treatment of Aaron was improper
○ According to the NICE guidelines on major depressive disorder, if the starting prozac
dosage of 20 mg is inadequate, they suggest increasing the dose, which we did up to 40
mg. In additionally, it usually recommends a follow up of two weeks. Based on Mr.
Domingues’ case, I decided to have his follow-up after 5 days.
● On what basis did you discharge a suicidal and violent patient?
○ In psychiatry, there’s no one diagnostic test or imaging that diagnoses a patient, to
diagnose we need to see the patient clinically and also rely on our knowledge and
experience
● Why were the notes incomplete? Isn’t that part of your doctor’s duty?
○ In our opinion, the threat was purely emotional. Had we thought at any point that Mr.
Domingues was violent towards others, we certainly would have noted that.
○ In addition, adjusting the notation to include the words emotional harm would not have
changed my management of the patient.
● Why did you not probe more?
○ In my experience, my assessment was appropriate and cleared any concerns he would be
violent towards himself or others.
● In your discharge summary, you noted that unlike in previous occurrences, she was not present,
and he seemed angrier toward her in the past?
○ Unlike his previous involuntary admissions, I thought the fact that Mr. Domingues came
in of his own volition due to suicidal ideations was a major improvement in his
management of his depression. In addition, I also noted in the discharge that he
responded well to psychotherapy and the increased dose to Prozac.

Direct Testimony of Defendant’s Second Witness

A. Your honor, I will present our second witness, Dr. Kurt Tinio, another doctor who was assigned
to Mr. Domingues’ case.
B. The purpose of the testimony of Dr. Kurt Tinio is to corroborate the testimony of Dr. Edric
Morales regarding the events of the admission of Mr. Aaron Domingues on May 15, 2017 until
his discharge on May 18, 2017.
C. Swearing of oath
D. Mr. Witness, please state your full name and occupation for the court.
a. My name is Kurt Tinio, I am a licensed psychiatrist in the Philippines, currently working
in the Pasig Memorial Hospital.
E. Dr. Tinio do you remember submitting an affidavit in relation to this case?
a. Yes.
F. I will show you an affidavit signed on July 19, 2019 signed by one Kurt Tinio. Is this the affidavit
you were referring to? On page 2 of the affidavit, there is a signature above a name. Whose
signature is that?
a. That is my signature.
G. Your honor I would like this affidavit to be marked as Exhibit 2.
H. Dr. Tinio, what is your relation to Dr. Edric Morales?
a. Dr. Edric Morales is my resident advisor for the psychiatry program in Pasig Memorial
Hospital.
I. Do you have any conflict of interest to declare pertinent to this case?
a. Right now there is potential conflict of interest. I am applying to Dr. Morales’ private
group clinic. The results have yet to be released. But to avoid conflict of interest related
to the case, I will ask that Dr. Morales not be included in the decision making regarding
my application.
J. OK. So how do you know Mr. Aaron Domingues?
a. I was doing rounds in Pasig Memorial on May 16, 2017 when I came across Mr. Aaron
Domingues. He complained of having the feeling of wanting to commit suicide but he
chose to admit himself into the hospital. Dr. Morales evaluated him and I was assigned to
take notes regarding his case.
K. You mentioned that you have notes regarding the case. Do you have a copy of these notes?
a. Yes.
L. I am showing you encounter notes signed by one Kurt Tinio. Is this the note that you are referring
to?
a. Yes
M. In this document, it states, “Patient was thinking of hurting his girlfriend also since she is hurting
him” is this correct?
a. Yes
N. When Aaron Domingues mentioned that he was thinking of hurting his girlfriend, based on your
recollection, what did Dr. Morales do?
a. Dr. Morales clarified Aaron’s remark. He specifically asked Aaron, “What do you
mean?” and “Why would you want to do that?”
O. And do you recall what Mr. Domingues replied to those questions?
a. Yes. Mr. Domingues said that he was saddened and frustrated that his girlfriend was not
more supportive while he was depressed. He thought that his girlfriend just wanted him to
snap out of it, be happy, and that really made him feel bad. And because of that, ​Mr.
Domingues wanted his girlfriend to feel the same pain that he was feeling.
P. And what type or form of pain was that, Dr. Tinio?
a. Emotional pain.
Q. So what exactly did you mean by “hurt” in your encounter notes, Dr. Tinio?
a. I meant that Aaron Domingues had thoughts about possibly causing​ emotional harm​ to
his girlfriend.
R. Would there be any other form of harm that you felt Mr. Domingues meant with these
statements?
 a. No other form except the emotional harm similar to the emotional pain he felt from his
girlfriend.
S. And why is that?
a. Well, it seemed very clear to me at the time that Aaron Domingues was pertaining to
emotional harm. And I thought that he could not be a threat to his girlfriend because (1)
he was consistently expressing concern about losing his girlfriend and (2) there was no
history of any form of physical abuse in their relationship
T. No further questions Your Honor. The witness is now ready for cross-examination.

Re-direct Examination of Defendant’s Second Witness

Possible ways they can attack Kurt:
● How can you say that your recollection of the events is accurate? How are you sure that he meant
EMOTIONAL pain and not physical?
○ In my notes it states that Mr. Domingues wanted his girlfriend to experience the same
pain that he was feeling. And it was never mentioned in the notes or Dr. Morales’ notes
that there was intention to physically harm. If there was potential for physical harm I
would have written it down because that is considered a serious threat. Because of these,
as far as I know, no physical harm was mentioned or implied.

Direct Testimony of Defendant’s Third Witness ​- Tony

Counsel Your honor, the defense would like to present its third witness. The purpose of her
testimony is to prove that the standard of care was exhibited throughout this case and
that any physician, given the same circumstances, would do the same thing done by Dr.
Edric Morales.

Counsel Do you swear to tell the whole truth and nothing but the truth before this Honorable
Court?

Witness Yes, I swear.

Counsel Your Honor, may I proceed? Thank you, your Honor. Ms. Witness, can you please state
your name?

Witness Gail Tesoro

Counsel And your profession is?

Witness I’ve been a full time consulting psychiatrist for five years now, in the same field as Dr.
Morales, routinely providing care for patients like Aaron Domingues.

Counsel In relation to this case, do you remember having executed any affidavit relevant to this
case?
Witness Yes, sir.

Counsel Now, I’m showing you a document signed by one Gail Tesoro on July 20, 2019. What is
the relation of this document to the one you said earlier?

Witness This is my judicial affidavit.

Counsel On the last page of this document, there’s a signature on top of a name Gail Tesoro.
Whose signature is that?

Witness That is my signature.

Counsel Your Honor, the witness has just identified her judicial affidavit and signature. The
defense would like to mark it as Exhibit 1 and 1-A for the defendant. Dr. Tesoro, what is
your educational background?

Witness I graduated Cum Laude from Rizal University and graduated with honors from Rizal
Medical School before completing my residency in psychiatry.

Counsel Are you a member of any professional organizations?

Witness Yes, the Philippine Board of Psychiatry and Philippine Medical Association.

Counsel Your CV also states that you provide psychiaty forensic and malpractice consultations.
Could you tell us how many cases you’ve done this for?

Witness I can’t give you an exact number but I’ve provided expert opinions on several occasions,
in defense of the defendant psychiatrists involved. I’ve never been discredited as an
expert witness in any of those cases.

Counsel Alright. Given your experience in this field, can you tell us about the disorder Mr.
Domingues was diagnosed with.

Witness He was diagnosed with recurrent major depressive episodes without psychotic features.
These patients experience low mood and loss of interest in normal activities, also
interfering with relationships. Aaron was also diagnosed with a dependent personality
disorder, putting him at increased risk for both depression and suicide.

Counsel In handling these patients, what guidelines do you follow?

Witness There are several guidelines but in this case, I think the most applicable one is the one by
the National Institute for Healthcare and Excellence (NICE), which is also recognized by
the Philippine Academy of Family Physicians for Depression in Primary Care.

Counsel Based on that guideline, what would be the proper course of action at the time Mr.
Domingues presented at the hospital.

Witness For major depressive disorders, usually we provide a combination of pharmacotherapy

and psychotherapy. When patients present with ​significant​ risk to self or others, like Mr.
 Domingues, we do in-patient treatment to monitor them.

Counsel When you say pharmacotherapy, what exactly do you mean?

Witness The first-line for these patients, to this day, are usually SSRIs such as Fluoxetine or
Prozac, started at a dose of 20 mg, which can be later adjusted based on its effect on the
patient.

Counsel Does Prozac have any side effects?

Witness It is thought, but ​not​ proven, that Prozac is associated with a very small increased risk of
suicide. There is also a risk of violent behavior but that’s more likely several days after
stopping the drug.

Counsel What about psychotherapy?

Witness Normally, in psychotherapy, we assess the patient by asking them about their
perceptions and thoughts, to know where the patient is coming from, and help them be
able to process those things. To know the causes of depression and how to address them.

Counsel And then, how do you know when to discharge a patient diagnosed with this disorder?

Witness As long as the patient is compliant with prescribed medications, is self-aware at the time
of discharge, can take care of themselves, and have no ideations or violent behavior
towards themselves and others, there is no more need for in-patient treatment.

Counsel So in this case, it appears from the records that Aaron was exhibiting all of this behavior,
correct?

Witness Yes.

Counsel In your opinion, should Dr. Morales have discharged the patient?

Witness Yes.

Counsel What would be your other interventions upon discharge?

Witness Based on the NICE guidelines, patients on antidepressants not considered to be at risk of
suicide, we see them after two weeks. Those with increased risk of suicide are seen
within 1 week.

Counsel Okay, so do you think that Dr. Morales was negligent in the case of Mr. Domingues
when he discharged the patient and instructed him to follow up in 5 days?

Witness No. Two weeks is standard. Even if he was hypothetically at increased risk for suicide, 5
days still falls within what is standard.

Counsel So it can be safely assumed that ​provided that​ the patient has exhibited the behavior
you mentioned earlier upon discharge, there is no tendency to relapse after at least 1 to 2
 weeks?

Witness No. ​Unless​, there are certain triggering or intervening factors.

Counsel So you’re saying that ​there may be other factors​ that could have contributed to the
violent behavior of Mr. Domingues ​after​ discharge?

Witness Yes, I think in my expert opinion, that the reason why he could have done this is because
there was an intervening factor that could have triggered this behavior which is ​beyond
the control of the physician.

Counsel What then is ​within​ the control or the responsibility of the physician to his patient?

Witness Doctors must respond to their patients’ needs and recognize potentially dangerous
behavior, ​if​ there are any, and to warn those at serious risk for harm. This is the ​only
instance where physician-patient confidentiality may be broken based on the Code of
Ethics.

Counsel So what would aid the physician in determining whether ​there is​ a ​serious​ risk?

Witness The physician’s clinical judgment plays a big role here, especially in psychiatry where
there aren’t really tests like labs that can help us. However, a physician can ​never​ be
omniscient​ and so the decision that there’s no risk must be evaluated in terms of what he
knew ​at that time,​ and cannot be criticized based on knowledge of what was to come.

Counsel So, if you were in Dr. Morales’ shoes, given the information you had ​at that time​, how
would you have assessed this case?

Witness It is my opinion, to a reasonable degree of medical certainty, that Domingues’ statement

can ​only​ be interpreted as him wanting to hurt Gonzales ​emotionally​, as he had done
repetitively​ in the past for her to return to him. He was talking about hurting her ​just as
she had hurt him​, which was ​only emotionally​. He also has no history of violence or
threatened violence towards others. That was also just ​one​ statement in his 3 days of
admission. A statement like that should not be overanalyzed given his history.

Counsel If that’s your assessment, does your duty as a physician to protect your patient’s
confidentiality hold?

Witness Yes.

Counsel Now, what are the possible consequences if this confidentiality was wrongfully broken?

Witness This may potentially cause distrust between the patient and doctor which may hinder the
patient from trusting him or any other physicians in providing him proper medical care.

Counsel Lastly, in your expert opinion, did Dr. Morales meet the standard of care in treating Mr.
Domingues?

Witness Yes.
 Counsel Thank you. No further questions, your honor.

Re-direct Examination of Defendant’s Third Witness ​- Tony

You serviced defendants only

● I’ve always been retained
● If this was a concern, i wouldn’t have been chosen for this
● I’m a practicing physician
● Even if I’m not the defendant, the CPG will not change

If you know prozac has risk, wouldn’t you be able to know there’s a risk for him being violent
● It’s still what in the guidelines
● Prozac still has more benefits than a small risk, any drug would have its adverse effects
● And we assessed how he responded to it during his stay which he responded well to
● It’s improving his stay cos he went voluntarily

Did the increase in dose harm him

● Initial 20 worked
● Max is 80g
● Follow up is earlier for any adverse effects
● We started the 40 so we got to monitor while he was admitted

Why didn’t you follow up

● You have to balance between harassing them and checking up on them, at most you have to give
them and/or their family to contact you
● Again, we are not omniscient
● He could have been late for any number of reasons

Aren’t CPGs just guidelines

● We’re talking about standard of care right
● That is the standard
● Based on my judgment, i’m a practicing psychiatrist
● It’s still risk benefit

Don’t you have to contact or identify family or source of support before discharge?
● Not on affidavit about aaron’s family if ever??
● Maybe they did or did not but in that case shouldn’t airon’s family be suing us now lol

Closing Statement

Good morning, Your Honor. I am Nikolai Mappatao, one of the defense lawyers of Dr. Morales. We
appreciate your attention throughout this matter, and we thank you for listening to both sides equally.
I would like to remind everyone today why we were all gathered here. We are here because of two
reckless allegations by the plaintiff. First, they claim that

“Ms. Gonzalez’s murder resulted from the Defendant’s failure to warn.”​;

And,

“As a result of the Defendants’ negligence in releasing Mr. Domingues, Mr. Domingues was in a
position to harm Ms. Gonzales (as well as himself).”

To prove a prima facie case of negligence, a plaintiff must demonstrate the existence of a duty, a breach
of that duty, and that the breach of such duty was a direct cause of his or her injuries.

We recognize that there was indeed an injury afflicted to the plaintiff, and we sincerely offer our deepest
condolences to her and her family.

However, to say that Ms. Gonzalez’s murder resulted from the Defendant’s failure to warn is a
non-sequitur argument, a fallacy, a big jump in logic.

First, the plaintiff had to prove that there existed an ​extension of duty ​of the defendant to the plaintiff’s
daughter, and that the defendant had a ​duty to warn​ her daughter. The plaintiff’s counsel​ failed to prove
the existence of both​.

Meanwhile, the defense have established, with the Philippine Medical Association Code of Ethics, and the
landmark case of Tarasoff v. Regents of University of California, that there was indeed no extension of
duty. In the hypothetical case that the defendant had an extension of duty, the case of Tedrick v.
Community Resource Center, Inc postulates ​two requirements to say that the defendant had the duty
to warn​ - that is, that the ​person to be warned is identifiable​, and that there exists a ​serious risk of
physical harm to that person.​ We acknowledge that the person to be warned is identifiable. However,
this serious risk of “physical harm” was based entirely on an ​emotionally-clouded inference​, and a h​asty
generalization from a supposedly expert testimony​.

Next, we want to dispute the accusation that “As a result of the Defendants’ negligence in releasing Mr.
Domingues, Mr. Domingues was in a position to harm Ms. Gonzales (as well as himself).” Again, the
conclusion does not follow the premise.

To start with, the premise presented by the plaintiff is not even sound. To say that the defendant has been
negligent in releasing Mr Dominguez, the plaintiff had to prove that the defendant violated the standards
of care elicited by the patient’s condition; that the defendant, despite seeing similar cases for 19 years,
decided to breach the Clinical Practice Guidelines and disregard his expert clinical judgment of the case.
The conclusion is even more absurd implying that the defendant put Mr. Domingues in a position to harm
the plaintiff’s daughter. A concurring opinion by Supreme Court Justice Leonen, in Alano vs Logmao,
stipulates that “​Reasonable men govern their conduct by the circumstances which are before them or
known to them. T ​ hey are not, and are not supposed to be, omniscient of the future.”​

Dr. Morales assessed, managed, and discharged this patient in accordance with the guidelines prescribed
for his patient, along with his clinical judgment, which is crucial to psychiatric cases. Even upon
discharge, the defendant diligently adhered to the clinical standards by prescribing a follow-up consult
with the patient. ​There was no logical way for the defendant to deduce or foresee that his patient will
commit murder and suicide three days after his discharge.

Here, the allegations in the complaint clearly elicit an emotional response, and the human desire that there
should be some recovery for this tragedy is understandable. Nevertheless, ​we cannot allow emotion to
govern the determination of legal liability.

Hence, we stand by the facts that the defendant exercised due diligence in performing his ​duty to care for
his patient and duty to preserve their doctor-patient confidentiality​, that there was ​no breach​, and
without breach there can be no liability.

Your Honor, we would like to ask you to render the only verdict that is fair - that is, ​Dr. Morales is not
guilty.

__________________________________________________________

November 23, 2019

● Opening Statement - confidentiality should not be broken, unless there is a serious risk. Their
burden is to prove the exception to the law
● Deflect their arguments, and then bring up our own arguments (For example, among the 4D’s, if
they don’t discuss Proximate Cause, we can bring it up kasi talo sila doon)

DUTY DERELICTION DIRECT CAUSE DAMAGE

There is no extension The doctor followed The discharge is not

of duty the guidelines and the direct cause of
standards of care Ivy’s death
https://caselaw.findlaw.
com/ca-supreme-court/ *Penny is an adolescent *Threat did not exist at
1829929.html psychiatrist the time of discharge.
**They could bring up *The evidence was
http://jaapl.org/content/ the lack of present ONLY at the
39/2/266​ (Identifiable, record-keeping time of admission.
serious risk) * The lack of * Monica: What actions
record-keeping would did she take despite
https://www.garyrosenb not be relevant to the being warned by her
erg-law.com/blog/2011/ death of Ivy mother
september/doctor-who-t
reated-mental-patient-o
wed-no-duty-t/

https://www.philippine
medicalassociation.org/
wp-content/uploads/201
7/10/FINAL-PMA-CO
DEOFETHICS2008.pd
f​ (fulfilled all duties)

*If they cite the

Tarasoft case, it’s
persuasive

Duty to preserve
doctor-patient
confidentiality

*Uphold confidentiality
*Only in your strict
judgment should you
break it if it will be a
matter of public safety

https://www.lawphil.net
/judjuris/juri2014/apr20
14/gr_175540_so_2014
.html​ (They are not, and
are not supposed to be,
omniscient of the
future.)