The Court of Three Judge’s decision in Singapore Medical Council v Soo Shuenn Chiang  SGHC 250 clarifies that the inquiry a doctor should undertake when faced with a request for a patient’s confidential medical information is context-specific
In a welcome move for the medical profession, the Court of Three Judges set aside the Singapore Medical Council’s conviction of a psychiatrist for giving out a patient’s confidential medical information to a next-of-kin in a medical emergency. The SMC’s conviction of the National University Hospital (NUH) psychiatrist for disclosing the patient’s medical information without verifying the requester’s identity sparked an outcry amongst members of the medical profession, who expressed concern that the Tribunal’s decision would fuel the practice of defensive medicine.
In 2015, Dr Soo received a call from his patient’s brother, posing as the patient’s husband, who claimed the patient was suicidal but refused an assessment at the IMH. The caller requested for a medical memo so that the police and/or the ambulance could take her to IMH. Dr Soo did not verify the caller’s identity by asking for his name, identity-card or contact numbers and comparing them against the hospital’s records. Dr Soo passed a memo containing the patient’s medical information to his clinic staff, to be provided to the patient’s husband, without obtaining the patient’s permission.
However, the brother later collected that memo and used it to support his application for a personal protection order against the patient. The protection order was granted. Subseqently, the patient filed a complaint with the SMC, and Dr Soo pleaded guilty to one charge of professional misconduct. The Disciplinary Tribunal found Dr Soo liable for failing to maintain the patient’s medical confidentiality by:
- failing to verify the caller’s identity; and
- failing to take appropriate steps to ensure that the patient’s confidential medical information in the memo was not accessible to unauthorised persons, in this case, the brother.
The Court’s Decision
The Court held that a doctor may disclose a patient’s confidential medical information without her consent when he reasonably regards it as necessary to protect the patient from potentially serious self-harm, disclosure is in the patient’s best interests, and the patient’s consent cannot be reasonably be obtained. In such circumstances, the disclosure should be made to those closest to the patient, such as her next of kin.
Every doctor who handles patients’ confidential information is under a duty to take reasonable care to ensure that such information is not mishandled or released negligently to unauthorised persons. The steps to be taken by a doctor to verify the identity of the person requesting a patient’s medical information will depend significantly on the context and the surrounding circumstances. Thus the duty of a doctor faced with an emergency request for confidential medical information of a patient who is reasonably believed by the doctor to be in imminent danger of self-harm would be different from that of another doctor who is for instance requested to provide such information to support an application for insurance.
In this case, the Court held that Dr Soo had done precisely what was called for in the circumstances. Upon receiving the call, Dr Soo had good reason to assess that there was a real risk the patient may commit suicide in the light of her past psychiatric history. Further, the caller had represented that he was the patient’s husband, had significant personal information about the patient which reasonably suggested to Dr Soo that the caller was indeed the patient’s husband, and had significant information about the patient’s past psychiatric condition, which information was consistent with Dr Soo’s knowledge and information on this.
Thus in choosing to prioritise acting promptly on information that he reasonably believed to be true, and in what he believed was the patient’s best interests, over taking unnecessary and potentially harmful steps such as trying to contact the patient directly, Dr Soo could not be faulted for acting as he did.
As regards the second facet of the charge, the Court held that Dr Soo could not be held liable for how the husband might choose to use or misuse the memo, if the memo had in fact been delivered to the husband as Dr Soo had instructed. Any administrative failings of the clinic staff in handing the memo to the brother contrary to Dr Soo’s instructions would fall outside the scope of Dr Soo’s duty to maintain the patient’s medical confidentiality.
Key takeaways from the decision
The Court’s decision should be lauded for aptly drawing the line between what the Court termed “defensive medicine” on the one hand and “appropriate medicine” on the other.
The SMC’s decision, which held that Dr Soo should have taken additional steps (e.g. verifying the caller’s identity, contacting the patient for consent etc.), before acting in the interests of the patient was the very epitome of defensive medicine. Such a course of action would have been driven by concern over the avoidance of perceived legal risks rather than the patient’s best interests. Delay necessitated by the taking of additional steps could have led to tragic circumstances for the patient and her family.
It may be gleaned from the Court’s decision that in assessing whether a patient’s confidential medical information should be disclosed in any given situation, doctors should be guided by, inter alia, the following factors:
- whether the patient is in imminent danger of harming herself seriously, and thus whether an urgent response is required;
- whether the caller has significant personal information about the patient, which would reasonably suggest that the caller is the patient’s next-of-kin;
- whether the caller has significant information about the patient’s past medical condition, and whether such information is consistent with the doctor’s knowledge and information on this; and
- whether the alleged symptoms the patient was manifesting (e.g. verbalising suicidal ideation) are similar to those presented in the patient’s recent medical history.
The case follows an earlier one in July this year (Singapore Medical Council v Lim Lian Arn  SGHC 172) where the High Court overturned the SMC’s conviction against a doctor and imposition of a hefty $100,000 fine for not informing his patient of all the side effects that could arise from a steroid injection. In that case, the Court observed that a departure from medical standards of conduct is not necessarily tantamount to professional misconduct.
Both cases saw members of the medical community protesting over what they viewed as unduly harsh decisions which could lead to the practice of defensive medicine and adversely impact patient safety and welfare. The Court’s decisions in both cases helpfully clarify the scope of a doctor’s duty and the applicable standard of care in situations requiring the obtaining of a patient’s informed consent and the disclosure of a patient’s confidential medical information.