Patients’ Rights in Singapore & What to Do If They are Violated
With greater access to healthcare, you may experience more encounters with healthcare professionals, whether as a patient or as a caretaker. You may then wonder what rights patients have in Singapore, and what your avenues of recourse are should these be violated.
This article will cover, with regard to patients’ rights:
- The right to informed consent
- Whether a patient can refuse to consent to medical treatment
- Whether a family member can request a doctor to withhold information from their loved one who is ill
- The right to adequate medical leave
- The right to confidentiality of medical information
- Other rights as specified in a hospital’s policy
- What can a patient do if his or her rights have been violated?
Right to informed consent
According to the 2016 edition of the Singapore Medical Council’s (SMC) Ethical Code and Ethical Guidelines (ECEG), patients have a right to informed consent in Singapore.
Informed consent refers to patients agreeing to go ahead with a medical treatment or procedure after they have been given sufficient and accurate information on it. This includes information on the benefits of the procedure, its significant limitations, the risks involved, and any alternatives available.
For low-risk procedures, oral consent or implied consent through compliance is sufficient. For complex, invasive or risky procedures, the patient’s consent must be adequately documented. If there are any language barriers, the doctor must engage an interpreter.
Doctors must be clear about the scope of the patients’ consent. For example, if the patient has consented to undergoing only a certain medical treatment but further treatment may be required later on, then the doctor should obtain the patient’s consent for the later treatment in advance as well.
Can a patient refuse to consent to medical treatment?
Patients have the right to reject, or not consent to, proposed treatment options, but doctors must ensure that patients have sufficient information to understand the consequences of their decisions.
Doctors must inform patients that they may withdraw or modify their consent at any time. The patient’s decisions to do so must be respected unless there is reason to believe that their judgement is impaired by illness, anaesthesia or temporary mental incapacity.
Doctors may only proceed with treatment without consent in emergency situations where the patient is incapable of consenting and where treatment is deemed to be necessary in the patient’s best interests.
However, in the case of patients with diminished mental capacity, doctors must first obtain the consent of the patient’s legal representative. This is unless they are uncontactable during emergency situations.
Can a family member request a doctor to withhold information from their loved one who is ill?
The patient’s right to make decisions with informed consent means that even if their family members request to withhold information from the patient (for example, not telling the patient that they have been diagnosed with a terminal illness), the doctor must not do so.
This is unless he assesses that the information will cause the patient to react in an extreme way which would cause them serious harm. For example, the patient may self-harm or experience psychological trauma.
The test for whether information can be legally withheld from the patient is the “modified-Montgomery test” (MM test). This test involves a 3-stage inquiry regarding any information which the doctor has failed to disclose to the patient:
- Is the withheld information important?: Is the information that the doctor knows important to the particular patient in question?
- Did the doctor have the information?: Did the doctor have the withheld information at the material time?
- Was withholding the information justified?: If the doctor had the information, was the doctor reasonably justified in withholding the information from the patient?
However, the MM test is set to change. In 2018, the case of Dr. Lim Lian Arn, who failed to inform a patient of risks associated with a steroid injection, sparked off a fierce debate within the healthcare industry on what constitutes informed consent. This was because the consensus at the time was that steroid injections were a common procedure with rare and transient side effects.
Many doctors thus considered Dr. Lim’s conduct to be acceptable and were worried about having to advise patients on all the risks associated with simple procedures. This led to the setting up of a Workgroup in March 2019 to review, amongst other issues, the applicable standard of care when taking informed consent and how that standard is to be judged.
The Workgroup made extensive recommendations relating to informed consent, including a new legal test in Annex E of the Workgroup’s recommendations at page 84.
Under the new suggested test, the extent of information that must be disclosed to the patient has to be in line with that of the professional opinion of the doctor’s peers, provided that such the court deems such opinion to be logical.
The Workgroup considered this standard to be easier to follow than the MM test, which was instead based on a variable and uncertain measure of how important the particular patient felt the information was, and led to many doctors overwhelming their patients with information in order to avoid liability.
Right to adequate medical leave
Medical Certificates (MCs) are issued either to promote patients’ recovery from medical conditions, or to protect third-parties against possible harm from the patients’ medical conditions. Unless there are clinical reasons for issuing MCs, patients who are well should only be given certificates of attendance (more commonly known as “time chits”) for their employers.
MCs must cover an appropriate duration and, where relevant, must provide an accurate account of patients’ limitations during the periods covered.
It is wrong for doctors to consider any factors outside of medical considerations when deciding whether to issue an MC, such as who pays for the consultation, what benefits the patients may receive or what employers’ preferences may be.
It is not explicitly stated in the 2016 ECEG whether patients are entitled to extended medical leave beyond what was initially given.
The 2016 ECEG merely states that “medical certificates must be issued to patients only on proper medical grounds arrived at through good clinical assessment”. Therefore, it seems that whether patients are entitled to extended medical leave depends on the doctor’s professional judgement.
Right to confidentiality of medical information
Generally, patients have a right to confidentiality of their medical records. Disclosure of their medical records may only be made with their consent. However, doctors are allowed to disclose patients’ information without consent if there are sound reasons for doing so. These include situations where disclosure is:
- Required by law
- Necessary in order to protect the patient or others from harm
- Needed because the patient is a minor, and disclosure to their parents would benefit the patient
- In the patient’s best interests.
If the patient is deceased, requests for information by next-of-kin or personal representatives of estates may also be acceded to if the doctor has no reason to believe that this would be against the patient’s wishes.
If you wish to access your loved one’s medical records without his or her consent, the doctor has a duty to verify your identity against the patient’s records to check that you are indeed the patient’s next-of-kin. The exact steps to be taken would depend on the context of the case.
For example, in the case of Singapore Medical Council v Soo Shuenn Chiang, a man called the doctor under the pretense that he was the patient’s husband. He said that the patient was about to commit suicide and requested for the doctor to write a letter containing the patient’s medical information so that the ambulance/police could bring her to IMH.
However, the man turned out to be the patient’s brother, who then used the patient’s medical information, to support his application for a personal protection order against her, on behalf of her son.
The court found that the doctor was not at fault for disclosing the medical information because he took reasonable steps to verify the identity of the caller in the context of the case.
Given that the doctor was under the impression that it was an emergency situation, and the patient was apparently at risk of suicide, it was sufficient for the doctor to have verified the caller’s identity through his ability to provide the patient’s information – specifically, her name, identification number, and medical history.
Other rights as specified in the hospital’s policy
Different hospitals may have different policies on the rights and responsibilities of their patients. Patients’ rights may include, for instance:
- The right to refuse visitors
- The right to know the names of his or her healthcare providers
- The right to know the estimated costs for investigations, procedures and treatments.
What Can a Patient Do If His or Her Rights Have been Violated?
There are several avenues of recourse if you believe your or your loved one’s rights as a patient have been violated. You may:
- Communicate with the healthcare institution/doctor concerned;
- File a complaint with other regulators;
- Mediate under the Healthcare Medication Scheme and Small Case Mediation Scheme by the Ministry of Health Holdings;
- File a civil claim;
- Make a police report; or
- Submit a complaint to the Singapore Medical Council (SMC).
There are several factors that you should consider before deciding whether to lodge a complaint with the SMC or to consider alternative avenues.
First, the SMC can only handle complaints against doctors. It does not handle complaints directed against a healthcare institution, healthcare professionals other than doctors (such as nurses) or Traditional Chinese medicine practitioners.
Second, the SMC is unable to provide certain forms of redress. These are:
- A refund of monies or a bill reduction;
- Compensation or damages for any harm caused as a result of the doctor’s misconduct or negligence;
- Retrieval of medical records on a patient’s behalf;
- An explanation from the doctor(s) and/or healthcare institution(s) in respect of a treatment or procedure;
- An order that the doctor(s) perform a particular procedure or offer a certain treatment;
- An apology from the doctor(s) or healthcare institution(s);
- Revocation of the licence of the healthcare institution(s); and
- Criminal sanctions against the doctor(s) and/or healthcare institution(s).
Therefore, it is recommended that you consider who the subject of the complaint will be (such as a doctor, nurse or healthcare institution) and what form of redress you wish to seek before deciding on which of the following courses of action to adopt.
You should carefully consider the merits of your complaint before filing it with the SMC. Currently there are no fees to file a complaint with the SMC, but in the future, patients who make frivolous or vexatious complaints may have to pay to any person costs that have been reasonably incurred by that person during the proceedings.
However, where the case involves serious allegations of misconduct or serious defects in the quality of services provided, SMC encourages you to report the matter to them as soon as possible. Otherwise, errant doctors could continue to practise and possibly harm other patients. Situations which the SMC has the power to investigate include misdiagnosis, breach of confidentiality by a doctor, and inadequate explanation after a procedure or treatment.
1) Communicate with the doctor or healthcare institution concerned
You should first attempt to resolve the matter with the doctor and/or the healthcare institution directly. This is because the situation could be due to a simple misunderstanding that can be easily resolved through direct communication between both parties, compared to going straight to the SMC which may be a more time-consuming process.
However, if the issue cannot be resolved informally between both parties, you can ask for it to be considered as an official complaint.
You can lodge a complaint with the healthcare institution either in writing by letter or email. You should include your full particulars in the complaint, i.e. your name, NRIC number, gender, age, contact address and contact number. It would also be helpful to define the cause of your dissatisfaction. If you are not satisfied with the person who you are dealing with, ask to escalate it to the person’s reporting officer.
If you are not satisfied with the reply from the healthcare institution you complained against, you can write to the relevant regulatory agency. This will be discussed further below.
2) File a complaint with other regulators
If your complaint is against a healthcare institution or other healthcare professionals instead of a particular doctor, you may file a complaint with the relevant regulatory agency. In proceeding with this stage, you should furnish the regulatory agency with your original complaint and all the written correspondences between the healthcare institution and yourself.
These regulatory agencies include the:
- Singapore Nursing Board: for the professional conduct of a specific nurse
- Singapore Dental Council: for the professional conduct of a specific dentist
- Singapore Pharmacy Council: for the professional conduct of a specific pharmacist
For more information on the contact details and the usual response time of these healthcare institutions, you may visit the Ministry of Health’s Inquiries and Complaints Guide.
3) Mediate under the Healthcare Mediation Scheme (HMS) and Small Case Mediation Scheme by the Ministry of Health Holdings (SCMS)
The Healthcare Mediation Scheme (HMS) and Small Case Mediation Scheme (SCMS) promote the voluntary use of mediation to resolve disputes between patients and healthcare institutions. Such disputes include unhappiness over service quality, medical care and management, and billing and financial disputes.
SCMS offers mediation services to help parties resolve disputes where the claim amount is $10,000 or less. On the other hand, HMS applies to disputes where the claim amount exceeds $10,000.
Benefits of mediation as compared to filing a civil claim in court include savings in time and money, control over the results, not needing a lawyer, and case confidentiality. A mediated settlement agreement is also legally binding and parties are obliged to comply with its terms, which usually include keeping the outcome of the settlement a secret and giving up any legal claims with respect to the matter.
Mediation may not be suitable for you if your dispute involves an issue of public policy or a criminal offence (for example, in a case of alleged molest by a doctor), or if you require investigations of your claims. If your claim requires investigation, you are advised to submit a complaint to the SMC.
4) File a civil claim
If you wish to claim for compensation, you may file a civil claim in either the State Courts or the General Division of the High Court, depending on the amount of the claim. You may wish to consult a lawyer for further assistance on this matter.
5) Make a police report
In serious cases involving alleged criminal conduct on the part of a doctor, you are encouraged to lodge a police report as soon as possible.
6) Submit a complaint to the Singapore Medical Council (SMC)
If your complaint is against a doctor and the forms of redress listed above are not appropriate for your matter, you may file a complaint with the SMC. The SMC requires that you consider the other avenues of recourse stated above before lodging a complaint with them.
Detailed instructions on how to make a complaint are found on the SMC website.
Your complaint must be made in writing and must include information such as the full name of the doctor, the name of the healthcare institution, details of your allegations against the doctor, and copies of supporting documents.
You may refer to a sample letter of complaint provided by the SMC here. The complaint should be lodged within 6 years of the incident.
As the SMC is an independent administrator of the disciplinary process, the SMC is unable to obtain the name of the doctor for you. Thus, you will need to find out the full name of the doctor before making your complaint.
The complaint must be accompanied by an original Statutory Declaration. The Statutory Declaration must contain the full name of the doctor(s) complained against and his or her place of practice. You may find a copy of the Statutory Declaration here.
The Statutory Declaration must either be endorsed by a Commissioner for Oaths or be made by way of appointment at the SMC’s office after your complaint letter is ready.
Most SMC cases take at least 9 months to be investigated and concluded. For more complex matters, investigations may take more than a year. Your complaint will be reviewed by an independent Complaints Committee (CC).
You will not receive periodic updates on the status of the investigations as all complaints before the CC are confidential. However, you will be informed in writing of the outcome of the CC’s deliberations as soon as a decision has been reached.
After the investigations are completed, there are several possible outcomes. The CC may:
- Dismiss the complaint;
- Refer the matter for mediation between you and the doctor;
- Issue the doctor with a Letter of Advice;
- Issue the doctor with a Letter of Warning;
- Refer the doctor to a Disciplinary Tribunal for a formal inquiry;
- Refer the doctor to a Health Committee for a formal inquiry (if the complaint relates to the doctor’s physical or mental fitness to practice); or
- Order the doctor to undergo medical treatment or counselling, complete further education or training, or seek advice on the management of his medical practice.
If you are dissatisfied with the orders made by the CC, you may appeal to the Minister for Health in writing within 30 days after being notified of the decision. The Minister’s decision will be final.
We hope that the above has been helpful in helping you understand what rights a patient has in Singapore and how to seek redress if these have been violated.
If you have considered the above options and decide that you wish to file a civil claim, feel free to get in touch with one of our medical negligence lawyers should you need any assistance or advice.
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