Protecting patients' welfare while being fair to the doctors

Latest medical ethics guidelines guard against overcharging and over-treatment

The latest edition of the Singapore Medical Council's (SMC) Ethical Code and Ethical Guidelines (ECEG) and its accompanying resource document, The Handbook of Medical Ethics, were released last September.

Medical ethics guidelines seek to ensure that patients' welfare is protected.

The guidelines emphasise to doctors the importance of providing the required standard of clinical care through good practices; building excellent relationships with patients and colleagues; maintaining competency and fitness to practise; ensuring proper sharing of information with patients and the public; and avoiding conflicts of interest.

The public will want to know how well their interests are being protected by the ECEG and how well justice is served when doctors do wrong.

My own view is that the ECEG is a balanced document that protects patients comprehensively while being fair to doctors and that the SMC's disciplinary processes are rigorous enough to ensure justice is not only done, but seen to be done.

First, it is helpful to discuss a few areas of the ECEG that in recent years have generated heightened public interest.

One of the biggest areas of concern relates to financial conflicts of interest that doctors face. The sources of such conflicts mainly arise from new organisational and business models as medical practice becomes more commercialised.

Ultimately, doctors should never regard patients as potential complainants or litigants, but as "a fellow creature in pain", as the ancient Oath of Maimonides expresses it. Patients, for their part, should not approach doctors with an attitude of mistrust that could lead to defensive medical practices that do not benefit them and escalate healthcare costs.

OVERCHARGING

One issue that arises is overcharging. There has been recent publicity on this, especially regarding the landmark appeal of Dr Susan Lim versus SMC, heard before the Court of Three Judges in 2013. In fact, the judgment delivered in this case underwrote much of the new Ethical Guidelines on doctors' fees.

While it remains forbidden by the Competition Commission of Singapore to publish prescribed ranges of fees, the ECEG now requires "the fees that you charge must be fair and reasonable and commensurate with the work actually done and the circumstances in which it is done".

A further requirement is: "You must not charge fees of a level that would bring the profession into disrepute... The appropriateness of your fees is subject to the review of peers."

In case doctors think that caveat emptor (buyer beware) applies, the ECEG states: "Your ethical obligation to charge fair and reasonable fees for services rendered operates over and above contractual and market forces and is not superseded by any agreement between you and your patients."

Doctors are not exempt from business costs.

Other factors that influence fees include the complexity of the case, the intensity and duration of service, the training, skills and expertise brought to bear and the specific circumstances in which care is delivered. Hence, doctors' charges will inevitably vary.

While the guidelines still leave a wide range of fees that are legitimate for doctors to charge, the ECEG seeks to prevent charging of fees that are disproportionate, arbitrary, have no relation to the actual services provided or are clearly opportunistic.

GUARDING AGAINST OVER-TREATMENT

A second related issue is "over-servicing" of patients for financial gain. Would doctors prescribe more medicines out of their own dispensaries or recommend more procedures than necessary?

Patients nowadays are more educated and keen to be active participants in their personal healthcare, so the risk of unknowingly accepting unnecessary or excessive treatment is reduced.

Still, the ECEG requires that "you must provide a standard of medical care that is rational and based on a balance of evidence and accepted good clinical practice".

Also: "You must prescribe, dispense or supply medicines only on clear medical grounds arrived at through sufficient clinical information and after considering the available evidence and what is accepted by the profession as good clinical practice."

Once again, should there be any allegation of over-treatment, it is the opinion of peers that will decide whether a doctor has practised within acceptable limits.

STANDARDS FOR TELEMEDICINE

Another area of concern arises from the evolution of medical practice, with advancing technologies and many innovative treatments.

With the advent of telemedicine, one of the biggest risks is the depersonalisation of medical interactions, with consequent degradation of care.

However, the ECEG states: "If you engage in telemedicine, you must endeavour to provide the same quality and standard of care as in-person medical care." This is as much a challenge for the development of sound technological platforms for good information exchange, as it is for doctors to retain the personal touch.

As for new modes of treatments, those "not generally accepted must be offered to patients only in the context of formal and approved clinical trials which would be subject to the ethics of research". This is to protect patients from being subject to all manner of unverified therapies and being made to pay for them.

Next, complementary and alternative medicine (CAM) seem to offer economical alternatives to conventional therapies. Yet, many come with very little, if any scientific evidence.

The ECEG warns doctors who practise CAM that "you must not, through taking advantage of patients' trust in your medical qualifications... mislead patients as to the appropriateness of use and expected benefits of CAM".

For many illnesses or injuries, "alternative" treatments are not truly alternative in an equal sense. The ECEG specifies that "harm caused to patient through failure to offer necessary conventional medical treatment is not defensible on the grounds that your management is legitimate under an alternative health system or philosophy".

SELF-REGULATION REGIME TRUSTWORTHY

The public deserves to know that the enforcement of the Ethical Guidelines will be fair and just - that it is not a case of "doctors protecting doctors". This is a legitimate concern wherever there is professional self-regulation.

In some places where self-regulation has failed to protect the public, this has been rescinded by governments and professional discipline has been placed in the hands of government-appointed lay persons. This has not happened in Singapore, because our self-regulation regime remains rigorous and trustworthy.

Finally, a word about SMC's disciplinary processes. Self-regulation means that peer review is pivotal, where it will be the opinion of fair and reasonably minded doctors of suitable qualifications and experience that will decide whether an accused doctor has crossed the line.

Yet, every step of the SMC's disciplinary processes, from complaints committees to disciplinary tribunals, involves lay persons who represent society at large. They cast an impartial eye on the deliberations or evidence of the medical peers, and actively participate by assessing evidence for themselves.

Lay persons are appointed from a list of persons of good repute from a wide variety of occupations including accountants, architects, businessmen and lawyers.

It may well be asked what purpose lay members serve, if doctors hold all the cards in terms of knowledge and experience.

But the lay persons are able to check the opinions of their medical peers to see if they stand up to logical scrutiny, or make sense to the reasonable lay person's mind.

Any system that involves human judgment is necessarily imperfect.

This is why, just like in civil and criminal court cases, there are appeal pathways for both complainants and respondent doctors, who are dissatisfied with judgments rendered, all the way up to the appellate Court of Three Judges.

Ultimately, doctors should never regard patients as potential complainants or litigants, but as "a fellow creature in pain", as the ancient Oath of Maimonides expresses it.

Patients, for their part, should not approach doctors with an attitude of mistrust that could lead to defensive medical practices that do not benefit them and escalate healthcare costs.

Mutual trust and respect are required of all parties.

• The writer is a gastroenterologist at Gleneagles Medical Centre. He is chairman of the Medical Ethics Committee of the Singapore Medical Council, and chairman of the Working Committee for the review of the Ethical Code and Guidelines.

A version of this article appeared in the print edition of The Straits Times on April 27, 2017, with the headline 'Protecting patients' welfare while being fair to the doctors'. Print Edition | Subscribe