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06 Oct 2020

6th Oct 2020

1.     The Workgroup to Review the Taking of Informed Consent and the Singapore Medical Council’s (SMC) Disciplinary Process issued its Report on Recommendations on 29 November 2019, which the Ministry of Health (MOH) accepted in full in December 2019. Some of the Workgroup’s recommendations require legislative amendments, to be effected by way of the Civil Law (Amendment) Bill and the Medical Registration (Amendment) Bill.
 
2.     The doctor-patient relationship is built on trust. Patients need to be able to trust that their doctors will do their best for them. Correspondingly, doctors also need to be able to trust that the disciplinary system they operate in is a fair and transparent one which produces consistent outcomes, and which sets and applies clear standards on what is required of doctors.
 
3.     During the Workgroup’s many townhalls and consultations, doctors raised concerns over the uncertainty in the standards by which informed consent taking was to be judged.  The amendments to the Civil Law Act (CLA) will provide clarity, certainty and consistency on the standards expected of doctors, through the codification of a new statutory test. At the same time, the changes to the Medical Registration Act (MRA) seek to establish an effective and robust self-regulatory system which acts expeditiously, and is consistent, proportionate, fair and independent.
 
A. Clarity, Certainty and Consistency in the Taking of Informed Consent 
 
4.     The Civil Law (Amendment) Bill sets out a new statutory test for a healthcare professional’s duty in giving medical advice to his patient. The new CLA test should not be characterised as one that is binary in being either doctor- or patient-centric. Instead, the new test acknowledges and promotes the reality that doctor and patient are in fact on the same side, working towards the same outcome: the good health and recovery of the patient.
 
5.     Under the new test, a healthcare professional will meet the required standard if he acts in a manner which is accepted by peer professional opinion (i.e. a body of the healthcare professional’s peers) as reasonable professional practice in the circumstances. A doctor can therefore be assured that his conduct in providing medical advice to the patient will be assessed by his fellow doctors. The peer professional opinion must also be logical, i.e. the risks and benefits of the relevant matter have been assessed and compared by the peers holding the opinion, and the opinion itself is internally consistent and does not contradict relevant facts.
 
6.     At the same time, the new test will also preserve patient autonomy as the peer professional opinion assesses that the healthcare professional provided information that the patient reasonably requires, or is material to the patient for the purpose of making an informed decision. The assessment of what information is material is based on two factors.
 
i) If the patient expressly communicates a specific concern or query to the healthcare professional, information relating to that is material;
 
ii) Even if the patient does not expressly communicate a specific concern or query, if that ought to be apparent from medical records that the healthcare professional has reasonable access to and ought reasonably to review, information relating to that concern or query is also material. There must be reasonable justification if information is not provided to the patient.
 
B. Changes to Strengthen the Medical Disciplinary Process
 
7. The Medical Registration (Amendment) Bill aims to strengthen the medical disciplinary process through more effective enforcement of professional standards, more expeditious resolution of complaints, and increased transparency of the disciplinary process. The amendments aim to:
 
i) Improve the quality and consistency of processes and outcomes in the system;
ii) Reduce delays and facilitating the more expeditious resolution of complaints;
iii) Protect patients more effectively;
iv) Provide for greater representation within the SMC; and
v) Encourage the amicable resolution of complaints and facilitate a less adversarial disciplinary process.
 
The key amendments are listed in Annex A. A flowchart with an overview of the revised medical disciplinary process is in Appendix 1.
 
8.     The MRA amendments also include other amendments arising from the holistic review of the MRA, for better administration of and to streamline and strengthen the disciplinary process. These changes are in line with the spirit of the Workgroup’s recommendations.
 
9.     The co-chairpersons of the Workgroup welcome the amendments made to the CLA and MRA. Ms Kuah Boon Theng, SC, Managing Director of Legal Clinic LLC, said, “The amendments will guide doctors on how to provide information to their patients, in a way that will better serve patients’ needs. Ultimately, we hope that this will benefit all parties concerned, and strengthen the doctor-patient partnership.”
 
10.     Associate Professor Ng Wai Hoe, Chief Executive Officer of Changi General Hospital, said, “We believe that greater clarity to the legal test for medical advice and various improvements to the disciplinary process will serve the interests of patients, doctors and society at large; leading to stronger doctor-patient relationships and trust.”
 
11.     While the legislative changes will ensure a disciplinary process that is clearer, fairer, more timely and robust, and bring clarity, certainty and consistency to the taking of informed consent, these outcomes also require a culture shift in the medical fraternity. The self-regulating system requires the continued contribution and involvement of all healthcare professionals, such as by participating as members of the committees or as experts in the disciplinary process.
 
12.     MOH will continue to work with SMC, the medical community and other relevant stakeholders on the implementation of the changes based on the Workgroup recommendations, and the legislative amendments to the CLA and MRA.