the legal profession, the ethical and professional standards of the medical
profession are to a large extent, self-regulated. In order to retain public
confidence in the profession, these standards are exacting and are scrupulously
enforced. In this article, Francis Xavier provides an overview of the
disciplinary process involved and the applicable standards in the light of the
changes that came into effect in April 1998. This article also examines the
impact of the duty of patient confidentiality.
disciplinary powers of the profession rest chiefly with the Singapore Medical
Council (‘SMC’). The SMC possesses adjudicatory and punitive powers.
addition to the SMC, the Singapore Medical Association (‘SMA’) and the
Ministry of Health (‘MOH’) can and do receive complaints from the public.
These, bodies, however, have limited powers of investigation and punishment.
Also, the individual hospitals invariably have an internal disciplinary process
SMC was established under the Medical Registration Act (‘MRA’). Its
functions include maintaining a register of practitioners and making
recommendations on the training and education of medical professionals.
5(f) of the MRA provides that the SMC is ‘to determine and regulate the
conduct and ethics of the registered medical practitioners’. In fulfilling its
role, the SMC can make regulations ‘regulating the professional practice,
etiquette, conduct and discipline of registered medical practitioners’
(section 58(2)(e), MRA).1
SMA was formed in 1959 by the profession itself. It represents the majority of
the medical practitioners in Singapore and has its own constitution. Part of the
objectives of the SMA is to maintain the honour of the medical profession and to
support a higher standard of medical ethics and conduct.
public perception is that the SMA is the key body regulating the disciplinary
process within the profession. Indeed, in recent times, the majority of
complaints against doctors are lodged with the SMA and not the SMC.2
to popular perception, the SMA has no investigative or punitive powers. Even
where the conduct of the practitioner concerned falls short of expected
standards, the SMA is powerless to impose sanctions. The SMA’s power to
regulate the conduct of medical practitioners has aptly been described as being
upon receiving a complaint, the SMA plays the role of mediator. Where the
complaint cannot be resolved or the complainant remains dissatisfied, the SMA
usually recommends that the complainant obtain legal assistance or lodges an
official complaint with the SMC (see, for instance, the Ethics Committee Report
as contained at p 47 of the ‘Annual Report of the Singapore Medical
MOH has no direct disciplinary control over members of the profession. While
there is nothing to prevent the MOH from conducting its own investigation into a
complaint against a practitioner, in practice, it usually refers such complaints
to the SMA or SMC.
regulatory powers of the MOH lie in its control over hospitals and other medical
establishments. These powers are contained in the Private Hospitals and Medical
Clinics Act (Cap 248) (‘PHMCA’). With the exception of Alexandra Hospital
and the Institute of Mental Health, the PHMCA applies to all hospitals as well
as to private clinics, clinical laboratories and healthcare establishments.
to the powers set out in the PHMCA, the MOH oversees the licensing, quality and
appropriateness of the services provided and the practices and procedures
Hospital and the Institute of Mental Health come under the purview of the MOH by
virtue of the Government Hospitals Act (‘GHA’).
speaking, the MOH is concerned with the practice of these establishments as
opposed to that of the individual practitioner.
hospitals governed by the PHMCA are obliged to set up a quality assurance
programme to ‘[m]onitor and evaluate the quality and appropriateness of
patient care … and to identify and resolve problems’ (section 30, PHMCA).
The inquiry is an internal exercise within the hospital and will be governed by
the internal disciplinary practices of the hospitals concerned. There are no
specific standards or guidelines governing such disciplinary processes, apart
from the general law.
disgruntled complainant may in fact refer the conduct of the hospital’s
reviewing committee to the SMC (‘Annual Report of the Singapore Medical
Association, 1993–1994’, p 13).
is a need for a standard set of guidelines or minimum standards governing the
operation of such quality assurance programmes to be implemented.
is interesting to note that no similar obligation as set out above is provided
for in respect of hospitals governed by the GHA.
Proceedings by the SMC
proceedings by the SMC are governed by the MRA and the Medical Registration
Regulations (‘MRR’), both of which were amended in April 1998.
disciplinary proceedings comprise two main stages: a review by the Complaints
Committee (‘CC’), which may be followed by a formal inquiry by the
Disciplinary Committee (‘DC’).
primary role of the CC is to inquire into a complaint and determine if the
matter should be formally inquired into by the DC.4
The CC cannot inquire into matters beyond those raised in the complaint.5
CC has fairly wide powers. For example, it can, while conducting its inquiry,
require any person ‘to assist’ in the inquiry and any documents or records
to be produced. It can even compel a medical practitioner to disclose all
information relating to such documents or records (section 40(16), MRA). A
person withholds such information or documents on pain of imprisonment and/or
the imposition of a fine (section 40(17), MRA: maximum fine of S$5,000 and
imprisonment for up to 12 months). The patient confidentiality issue in this
context is discussed below.
medical practitioner whose conduct is being investigated has no right to be
heard by the CC (section 40(21), MRA) .
the event that the CC decides that no formal inquiry be made but that the
practitioner be issued with a letter of advice or warned, the aggrieved
practitioner has the right of appeal to the Minister of Health, whose decision
shall be final.
Grounds for Liability
to the 1998 amendments to the MRA, a practitioner facing a DC would be liable
for professional misconduct if he was either:
of a heinous offence; or
to have been guilty of infamous conduct in a professional respect (section
23(1) of the now revoked MRA, 1970).
SMC Ethical Code of 1995 (the ‘Code’) is a publication of the SMC which sets
out what the SMC regards as the minimum standards applicable to practitioners in
the discharge of their professional duties and responsibilities. The Code
defines a ‘heinous offence’ as ‘a conviction in the criminal courts of
Singapore of an offence involving moral turpitude affecting a practitioner’s
fitness to practise’ (the Code, para 16).
Code also defines ‘infamous conduct in a professional respect’ as a
‘serious professional misconduct judged according to the rules, written and
unwritten, which govern the medical profession’ (the Code, para 18). English
judges have construed this phrase to mean acts which ‘would be reasonably
regarded as disgraceful or dishonourable by his professional brethren of good
repute and competency’ (Allinson v General Council of Medical Education and
Registration  1 QB 750).
language was done away with by the 1998 amendments. Under the amended MRA, the
substantive grounds on which the DC may find a practitioner liable include the
convicted in Singapore or elsewhere of any offence involving fraud or
dishonesty or implying a defect in character which makes him unfit for his
guilty of such improper act or conduct which brings disrepute to his
guilty of professional misconduct.
MRA does not offer any assistance as to the meaning of the above phrases.
Further, the Code has not been updated by the SMC to reflect the 1998
amendments. The extent to which the old definitions will be applied remains
unclear. No doubt, some oblique guidance can be obtained from the conduct of
disciplinary proceedings in the legal profession in the cases interpreting
section 83 of the Legal Profession Act.
appeal lies to a Court of three Judges from an order made by a DC (section
45(12), MRA).6 In such an appeal, the High
Court will accept as final and conclusive any finding of the DC relating to
issues of medical ethics or standards of professional conduct, unless the Court
takes the view that such a finding is ‘unsafe, unreasonable or contrary to the
Confidentiality in the Context of Disciplinary Proceedings before the SMC
fundamental element of the medical profession is doctor-patient confidentiality.
It is enshrined in the Hippocratic oath which requires the doctor to ‘respect
the secrets that are confided in [him], even after the patient has died’. That
a doctor owes his patient a duty of confidentiality is undoubted in equity (Hunter
v Mann  QB 767, W v Egdell  Ch 359). It is also embodied
in the Code which forms the SMC’s guide to a doctor’s proper conduct (the
Code, para 20(b)(ii)).
question, therefore, is whether a practitioner seeking to defend himself in
medical disciplinary proceedings would, as a result of the duty of
doctor-patient confidentiality, find himself barred from adducing confidential
information as evidence.
with any other duty of confidentiality, doctor-patient confidentiality is
subject to exceptions. Two recognised exceptions or limitations which have
established roots in the duty of confidence are where there has been an implied
waiver to the right of confidentiality, and the limitation of self-interest.
Unfortunately, neither has been tested in the arena of doctor-patient
is accepted in relation to lawyers that a lawyer may utilise confidential
information of his client’s where his client has brought a claim against him.
The exception is founded on the basis that by instituting proceedings and
putting the lawyer’s conduct in issue, the client implicitly waives his right
of confidentiality (Lilicrap v Nalder  1 WLR 94). The position as
regards legal proceedings commenced against a doctor for medical negligence by a
patient is the same: in instituting proceedings, the patient puts his health in
issue and thereby implicitly consents to the breach of confidentiality (see Hay
v University of Alberta Hospital  2 Med LR 204 and Powers and Harris,
Medical Negligence (2nd ed, 1994), p 133). There would seem to be no good reason
why the courts should treat disciplinary proceedings any differently.
position as regards claims or complaints brought by a patient would, therefore,
seem to be relatively clear in equity. However, a complaint against a doctor may
be brought by someone else other than the patient. This may arise where the
patient has passed away or is no longer mentally competent. Or a third party,
such as the MOH, may decide to raise a complaint. In such a case, as it is not
the patient that has raised the issue, the exception of implied waiver would not
apply. In those instances, however, it is suggested that the exception of
self-interest would apply.
exception of self-interest essentially provides that the duty of confidentiality
is limited where the interests of the duty-bound party requires disclosure of
the confidential information. The duty was first formulated in banker-client
relationships (Tournier v National Provincial and Union Bank of England
 1 KB 461, Sunderland v Barclays Bank Ltd (The Times, 24 November
1938). However, the duty was expressed in general terms and it is suggested that
the doctor-patient relationship of confidentiality should be treated no
differently. Support for this proposition in relation to doctors may be found in
the case of Duncan v Medical Practitioners Disciplinary Committee 
1 NZLR 513, where the Wellington High Court stated in dicta that ‘a doctor may
reveal confidences and secrets if he is required to defend himself, or others,
against accusations of wrongful conduct’.
enough, the position in equity seems to be contradicted by the Code, as
paragraph 29 of the Code provides that:
… confidential information in respect of patients should not be disclosed, even in situations where the practitioner wishes to rely upon it in his defence in a disciplinary proceeding. If such information is relevant, the patient’s identity must not under any circumstances be disclosed.7
is trite law that the common law (including equity) can only be changed by the
legislature and even then, only through express wording. A review of the MRA and
the MRR does not reveal any express (or even implied) curtailment of the
exception. The Code itself occupies an odd position under the law. It is not a
creature of statute in that it has not been passed by the legislature, or even
promulgated under any power vested in the SMC by the legislature to create
subsidiary legislation. Its impact on established case law may, therefore, be
nub, however, is of course that there has been no decision in respect of
doctor-patient confidentiality in the area of disciplinary proceedings in
Singapore. The position, therefore, remains unclear.
is suggested, however, that there are compelling reasons why a doctor should be
able to bring exonerating evidence even if in doing so he would be breaching
doctor-patient confidentiality and that the exceptions discussed above in the
various cases should prevail:
a patient has raised a complaint against the doctor, doctor-patient
confidentiality should not be in issue as the patient has arguably waived
his right to confidentiality. In the face of a waiver or consent (albeit
implied), the issue of ethics ceases to be relevant. The only issue left is
the extent of the waiver. Arguably, while the facts immediately relevant to
the medical case have ceased to be covered by the duty of confidence, other
related facts in respect of other medical cases of the patient may not be.
Any consideration of protecting the client from an excessive disclosure of
medical information may arguably be protected by limiting the extent of the
there is much to be said for preventing doctors from using confidential
information in their possession that may be potentially embarrassing and
damaging to the patient, this must be balanced against the doctor’s own
rights. As a matter of natural justice and morality, the doctor should be
entitled to defend his good name with the evidence available. This must be
the case where a third party not covered by a duty of confidentiality
selectively utilises evidence supportive of his case, but leaves out
evidence detrimental to it.
is nothing intrinsic to medical information that should cause it to be
treated on a higher scale from say, legal information provided to a lawyer,
or credit information provided to a bank.
is no compelling reason why disciplinary proceedings against a practitioner
should be treated any differently from civil proceedings against him.9
Under section 13(2) of the PHMCA, any medical information in the possession of the MOH is not to be disclosed except under specified exceptions. Disciplinary proceedings under the MRA constitute one of those exceptions. If the MOH may disclose a patient’s medical information in disciplinary proceedings, it is suggested that a doctor should be entitled to do so as well.
Rajah & Tann
is similar to the powers of the Law Society in its disciplinary proceedings
under section 71 of the Legal Profession Act (Cap 161). However, in the case
of the legal profession, the Chief Justice must approve these rules before
they come into effect.
Between 1994 to 1997, the SMA received a total of 417 complaints as compared
with 216 complaints received by the SMC. See Appendices 1 and 2 of
Medico-Legal Responsibility in Singapore by Dr Yeo Khee Quan (2000).
3 Medico-Legal Responsibility in Singapore, p 108.
4 Where the complaint
touches on the physical or mental fitness of the practitioner, the CC must
order an inquiry to be held by the Health Committee who will determine if
the practitioner’s fitness to practise is impaired.
5 Tan Tiang Hin Jerry v Singapore Medical Council  1 SLR 105 and
Pong Tshai  1 SLR 399. This is also the position in lawyers’
disciplinary proceedings — Re Seah Pong Tshai  1 SLR 399.
6 For some examples of where the High Court did interfere, see
David Tan Boon Chee v Medical Council of Singapore  2 MLJ 116 (where
some DC members were absent on some days of the hearing or were
apathetically walking in and out of proceedings), Re Chuang Wei Ping 
1 SLR 176 (where reasonable suspicion of bias arose as a DC member was also
member of the complainant, MOH), Tan Sek Ho v Singapore Dental Board 
4 SLR 757 (where in the court’s opinion, the punishment imposed was
7 Although it is difficult to see how the patient’s identity is to be kept a
secret where the complaint relates to a specific case of the doctor’s
conduct vis-a-vis a patient.
8 While the SMC does have a power to make regulations regulating the
professional practice, etiquette, conduct and discipline of registered
medical practitioners under section 58(2)(e), the Code has not been made as
a regulation pursuant to this section. Furthermore, it should be noted that
the scope of section 58(2) is confined to regulating the practice,
etiquette, conduct and discipline of a practitioner; it does not empower the
SMC to change the law as such.
Disciplinary proceedings aside, it may be of interest to note that, the MOH
possesses wide powers under the PHMCA. An analysis of the PHMCA reveals that
the MOH is virtually unfettered by the rules of doctor-patient
confidentiality in its conduct of investigations pursuant to the Act. See,
for example, sections 12(2) and (3) of the PHMCA.
The author would like to thank Lim Wee Teck and Trevor Ivan D’cruz for their valuable assistance in the preparation of this article.