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An overview of key aspects of Singapore

medical law
Calvin WL Ho and Peter Loke

What is the supreme law of Singapore?

The Constitution is the supreme law of the land, so that any law that is inconsistent with any
of its provisions shall be void. It also vests judicial power in the Supreme Court, which
consists of the High Court and the Court of Appeal. The institution of law (principally, the
judiciary) is one of the key organs of state under the Constitution, together with the
legislature (i.e., Parliament) and the executive.

What is the common law?

The common law is judge-made law, where the law is based on legal principles laid down
from past cases (precedence). Judges play a key role in defining and making the law. There
are a number of statutes relating to the medical profession and the practice of medicine in
Singapore. Examples include, but are not limited to, the Medical Registration Act, the Private
Hospital and Medical Clinic Act, the Infectious Diseases Act, the Mental Capacity Act and
the Health Products Act, and even the Penal Code where serious injury or death might have
occurred due to negligent practice. The law relating to day-to-day practice issues is drawn in
large part from tort law, which is mainly based on common law. Tort law defines many of the
rights of a patient. It helps to define the legal expectations of the doctors responsibility to the
patient, such as setting the legal standard of care for medical diagnosis, treatment and advice.
In contrast to the common law, the laws and legal principles are codified in civil law
countries (which include many continental European countries). In these countries, judges are
not recognised to have a role in law-making.

What is case law?

Statutes are laws laid down in Parliament, and generally they outline broad principles. The
interpretation that judges give to statutory provisions in cases provides guidance on the
meaning and application of statutes. If there is no statute governing a specific issue, the law
can be defined according to the decision of the court. Within each decision, there is one main
reason or principle for the judgement that is laid down. If there has been an earlier decision
relating to the same context, a judge will usually be expected to follow that. Previous
decisions are always binding on lower courts, but courts of the same jurisdiction can
sometimes choose to depart from principles laid down in previous decisions. These judicial
interpretations and decisions that are found in cases constitute case law.

What professional guidelines apply?

Standards of professional conduct expected of doctors are set out by the Singapore Medical
Council (SMC) in its Ethical Code and Ethical Guidelines (SMC Code & Guidelines). The
SMC is empowered under the Medical Registration Act which gives it statutory responsibility
for the professional regulation of doctors.
The SMC is the professional self-regulatory body of medical profession in Singapore. Their
decisions have no legal standing, but provide the guidelines for how the profession expects
itself to behave. The strongest sanctions that the SMC can impose are fines or suspension or
even revocation of the doctors licence to practice. As opposed to a tortious claim where any
award against the doctor goes to the party taking action, fines by the SMC revert to the SMC.

The SMC Code and Guidelines capture important values within a doctorpatient relationship
that if anything can exceed those recognised in law. These include requirements relating to
standard of care, conflict of interest, advertisements, consent, truth-telling, confidentiality and
patient privacy.

Does a patient have a right to informed consent?

The requirement of consent arises from the recognition in law that a patient should be able to
exercise autonomous choice in making decisions about his medical care. Obtaining consent is
a communicative process that could occur at different points in the relationship between the
doctor and her patient. It is not limited to accepting a proposed treatment, but can relate to a
patients choice of different treatment options and refusing treatment. In order for consent to
be legally valid, it must have been obtained:

1. From a patient with the requisite capacity or from another person legally empowered
to make decisions on behalf of the patient;
2. After the patient has been provided with information that is sufficient for decision-
making; and
3. Voluntarily, in that the patient should not have provided consent under conditions of
coercion, duress or manipulation.

Treating a patient without his consent is a civil wrong that is actionable in law as battery. A
failure to adequately inform the patient when obtaining consent could amount to negligence,
which is also actionable in law. In addition, these failings violate professional requirements
under the SMC Code & Guidelines, which requires a doctor to ensure that her patient is
adequately informed of his medical condition, as well as treatment options, so that the patient
is able to participate in decisions about his treatment. Thus a doctor could also be brought
before the SMC Disciplinary Committee for failing to obtain adequate consent.

Are there exceptions to informed consent?

There are some exceptions to this requirement, such as during an emergency when treatment
must be administered immediately in order to save the patients life or to prevent serious
harm that the patient would have reasonably wanted to avoid. Other exceptions to the consent
requirement include a waiver by the patient (whether implicit or explicit), incompetency, and
other exceptions provided defined by statutes law. For instance, the law legislates for certain
individuals who are assessed as a danger to self or others to be provided institutionalised care.
The law requires medical care to be provided in ways that advance the best interests of these
patients who are deemed to not have the capability of exercising individual autonomy.

Do doctors have an obligation to tell the truth?

Truth-telling is entailed in the requirement for a patient to be adequately informed of his


condition and treatment options. In consent taking, the law generally expects the
communication between a doctor and her patient to be accurate, open and honest. The SMC
Code & Guidelines outlines a patients right to information and self-determination. There
may be exceptions to disclosure, such as when non-disclosure of bad news is necessary to
protect the patient from serious harm. However, a patient is usually assumed to have the
ability to cope with information disclosed to him about his health unless there are clear
indications to the contrary. Often, the cause of distress is not so much from the information
disclosed, but from how the disclosure was done. Another challenge in the practice of truth-
telling is in determining the extent of disclosure that is appropriate. For instance, to what
extent is there a legal duty to disclose unexpected or remote outcomes of care? A doctor
could be held to be legally negligent for failing to inform her patient of a risk associated with
a proposed procedure. The courts determine this by deciding if the doctor has fallen below
the minimum acceptable legal standard of care.

What is medical negligence?

Medical negligence is a specialised area of law concerned with standard of medical conduct
that is considered acceptable in law. It imposes a duty on doctors to take reasonable care to
avoid injury to those under their care. A duty of care generally exists in law on a doctor
looking after her patient, the latter being someone who has relied on the formers expertise.
For doctors in general, the law in Singapore has primarily deferred to professional medical
knowledge in the determination of an appropriate standard of care relating to medical
diagnosis and advice, including obtaining consent and treatment. In Singapore, the legal
standard, which is not necessarily the SMC standard, is that a doctor is not guilty of
negligence if he has acted in accordance with a practice accepted as proper and responsible
by a responsible body of medical practitioners skilled in that particular art, subject to the test
of logical reasoning. So a doctor would not be legally negligent for a diagnosis, advice or
treatment if it is supported by a respectable body of medical opinion, so long that opinion can
be logically defended. For instance, a doctor could decide as a matter of medical judgement
whether it would be appropriate to disclose a particular risk to her patient based on such a
body of knowledge and usual practice. A doctor could be negligent for failing to disclose a
particular risk that was substantial and where there was no cogent clinical reason for non-
disclosure.

Does a patient have a right to medical confidentiality?

Communication on treatment between the doctor and her patient is confidential. Ethical
guidelines including the SMC Ethical Codes and Guidelines have clearly enunciated this, as
have SMC cases. The law on this is conjectured from English law, which while not binding is
considered highly influential where no similar cases exist in Singapore. It is noted that the
Data Protection Act, which is scheduled to come into force in the middle of 2014, formalises
in statute many of the principles relating to confidentiality. Communicative details should not
be disclosed to a third party unless this is done for the therapeutic benefit of the patient or if
the patients consent has first been obtained (or is otherwise waived or inapplicable). Medical
confidentiality is not absolute and could be overridden by legislation (e.g., notification
requirements in the Infectious Diseases Act), a court order, or a greater public interest in
disclosure (e.g., clear danger of harm to an innocent third party or the public at large). If the
doctor makes a disclosure in breach of patient confidentiality, she must be prepared to
explain and justify her decision if asked to do so.
Does a patient have a right to privacy?

A patient has a legal right to informational privacy. Medical information that identifies a
person, whether living or dead, is protected by law as personal information. Healthcare
institutions should ensure that medical information collected is accurate and complete. They
should make reasonable security arrangements to prevent unauthorised access, use or
disclosure, and ensure that medical information transferred outside of Singapore is likewise
protected by a recipient individual or organisation. In addition, the patient has a right to
access his or her medical information, to obtain information about its use, and to require any
inaccurate personal information to be corrected.

References:

Singapore Academy of Law, History of the Singapore Legal System

Singapore Statutes: Medical Registration Act, Cap 174 of Singapore, Revised Edition 2004

Singapore Medical Council, Ethical Code and Ethical Guidelines. Singapore: Singapore
Medical Council, January 2002

Yeo Khee Quan, Leslie Chew, Goh Lee Gan, Terry Kaan, Kuah Boon Theng and Edwin
Tong, Essentials of Medical Law. Singapore: Sweet & Maxwell Asia, 2004.

Citation

Calvin WL Ho and Peter Loke, "An overview of key aspects of Singapore medical law" in
Jacqueline Chin, Nancy Berlinger, Michael C Dunn, Calvin WL Ho, Michael K Gusmano
(eds.) Making Difficult Decisions with Patients and Families: A Singapore Casebook.
Singapore: National University of Singapore, 2014. http://www.bioethicscasebook.sg.

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