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Non-Medical Chair, Medical Disciplinary Tribunal?

Country: 
Singapore
Partner Institute: 
Department of Epidemiology and Public Health, National University of Singapore
Survey no: 
(14) 2009
Author(s): 
Lim Meng Kin
Health Policy Issues: 
Others
Others: 
Regulation
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Abstract

Among several changes being proposed to streamline existing disciplinary processes within the medical profession is a controversial provision for a senior lawyer, legal officer or retired judge to be appointed as chairperson of the medical disciplinary tribunal which hears and determines disciplinary proceedings brought against medical practitioners.

Purpose of health policy or idea

The Ministry of Health (MOH) and the Singapore Medical Council (SMC) are proposing to make several amendments to the Medical Registration Act. One particularly contentious provision is the proposal to allow a senior lawyer, legal officer or retired judge as chairperson of the SMC Disciplinary Tribunal. 

MOH's stated reasons for amending the Act are to keep up with the new developments in the practice of medicine in Singapore and to further strengthen and streamline existing disciplinary processes within the medical profession. It is also clear that the aim is directed at promoting greater transparency and accountability, and thus foster greater public trust in the disciplinary process within the medical profession. MOH has explained that allowing a senior lawyer or judge with professional legal or judicial expertise to serve as chairperson of disciplinary tribunals inquiring into complaints filed against doctors, will improve the process by:  

  • avoiding potential conflicts in the medical community in high profile cases;
  • contributing authoritative written judgments that are capable of withstanding rigorous judicial scrutiny in complex cases; and,
  • helping the Tribunal achieve greater parity in legal knowledge and expertise in cases where the prosecution and defence have formidable legal teams. 

MOH also said that the move was prompted by "significant public feedback that doctors may be sympathetic and partial towards their own colleagues in passing judgment. The fact that proceedings are not held in public does not help." It further noted that such views, if allowed to grow, will erode the position and influence of the doctor in society and the trust that patients have in the medical profession.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low high very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

The Medical Registration Act governs the registration of medical practitioners and regulates the conduct and ethics of doctors. It was last amended in 2002.  

Under the current regime, complaints of professional misconduct against a doctor are handled by the Singapore Medical Council which comprises entirely of medical doctors. A complaint, to be considered, will have to be in written form and accompanied by a statutory Declaration, unless the complainant is a public officer. The Chairman of the Complaints Panel will appoint a Complaints Committee comprising 3 doctors and a layperson, who will investigate the complaint and decide if a formal inquiry is necessary - in which case the order for the inquiry can be held by the Health Committee or a Disciplinary Committee (the latter being for the most serious of cases).  

The Disciplinary Committee (which MOH proposes to rename "Tribunal") comprises of 3 doctors (2 of whom must be Council members), and a non-voting fourth layperson.

The Disciplinary Committee must be chaired by a member of the Medical Council. Under the proposed amendments, the new Disciplinary Tribunal could be chaired by a senior doctor, or the Medical Council could exercise its discretion to appoint a senior lawyer, legal officer or retired judge for certain cases, in which case the Disciplinary Tribunal need not have a layperson.  

A point of note is that under the proposal, the appointment of a chairperson with a legal background will not be the rule; it will only occur when the Medical Council deems it appropriate or necessary - e.g. in cases involving complex legalities and when it is in the best interest of the public or the profession to do so. The SMC, comprising entirely of medical doctors, retains the power to appoint the chairperson, or indeed, decide on the need for a Disciplinary Tribunal. Hence the Disciplinary Tribunal is expected to continue to be chaired by medical practitioners, except in rare situations. The decisions of a Tribunal will be based on the majority vote of its members. Should a chairperson with a non-medical background be appointed, there will still be two doctors with voting rights in the Tribunal who will decide on the judgment together with the chairperson.  

Nevertheless, the proposal has stirred controversy, with protestations coming mainly from the medical profession.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Initiators of idea/main actors

  • Government
  • Patients, Consumers
  • Scientific Community
  • Media

Stakeholder positions

The MOH argues that professional self-regulation is intended primarily for the benefit of the public. In assessing whether the proposed amendment is appropriate, the main consideration should be whether the proposed change ensures fair outcomes for the public, the complainant and the doctor, and engenders greater public trust in the profession. It also stresses that the inclusion of non-medical practitioners such as senior lawyers as chairmen in such tribunals is not unusual. It is practised in New Zealand and Victoria in Australia whereas in Britain, it is not stipulated that the chairman of the panel needs to be a doctor.  

The SMA accepts the option of lay-persons on the Disciplinary Tribunal and acknowledges that their expertise may be welcome in some instances as ad-hoc members or resource members, but objects to the specific proposal to allow the option of appointing a judge, legal officer or senior lawyer as Chairman. It insists that the Chairman should still be a SMC member and cites, in support of this view, a landmark case in which Singapore's ex-Chief Justice stated in his judgment: "We often enough tell doctors not to play god; it seems only fair that, similarly, judges and lawyers should not play at being doctors…A judge, unschooled and unskilled in the art of medicine, has no business adjudicating matters over which medical experts themselves cannot come to agreement. This is especially where, as in this case, the medical dispute is complex and resolvable only by long-term research and empirical observation. Furthermore, the lawyer/judge in 'playing doctor' at the frontiers of medical science might distort or even hamper its proper development. Excessive judicial interference raises the spectre of defensive medicine, with the attendant evils of higher medical costs and wastage of precious medical resources."  

SMA further argues that the entire rationale of the existence of the SMC is to have a self-regulatory body, and that having non-doctors as the Chairman of the Disciplinary Tribunal completely defeats this purpose.  

The Law Society of Singapore responded on other points of the the legislation but was conspicuosly silent on the matter of the chair of the Tribunal. Rather, it was more concerned with the fact that the  provision allows that an employee of MOH may be a member of a Complaints Committee or Disciplinary Tribunal or Health Committee. It noted that "a not insignificant number of complaints made agaist doctors are in fact filed by the MOH" and went on to say that clearly in such cases, no employee of the MOH should be involved in considering the complaint since that would offend the Rules of Natural Justice besides vitiating the peer review mechanism and eroding the objective of self-regulation.  

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivesupportive strongly opposed
Singapore Medical Councilvery supportivevery supportive strongly opposed
Patients, Consumers
General Publicvery supportivesupportive strongly opposed
Scientific Community
Singapore Medical Associationvery supportiveopposed strongly opposed
College of Family Physiciansvery supportiveopposed strongly opposed
Law Society of Singaporevery supportiveneutral strongly opposed
Media
Mediavery supportivevery supportive strongly opposed

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongvery strong none
Singapore Medical Councilvery strongstrong none
Patients, Consumers
General Publicvery strongweak none
Scientific Community
Singapore Medical Associationvery strongstrong none
College of Family Physiciansvery strongstrong none
Law Society of Singaporevery strongstrong none
Media
Mediavery strongstrong none
Singapore Medical Council, MediaGeneral PublicMinistry of HealthLaw Society of SingaporeSingapore Medical Association, College of Family Physicians

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

A month-long public consultation was held in January 2009. But when results were reported on MOH's website as being favorable, and having been obtained from members of the public and the medical profession, the validity of this claim was vigorously challenged, both by individual doctors writing in to the Press and the SMA itself. The questions raised were about the relatively small numbers from which the feedback were derived, as well as the way Professional Bodies were counted in deriving these numbers. The Academy of Medicine, Singapore (AMS), College of Family Physicians Singapore (CFPS) and Singapore Medical Association (SMA) had either expressed reservations or disagreed with the proposed amendment to allow a layman to chair Singapore Medical Council (SMC) disciplinary committees.  

The SMA Council then conducted its own survey among its members in June, which apparently showed a different result.  

Expected outcome

The topic has become a matter of public debate in the media, through forum letters, editorials and online discussions. A number of letters from members of the public and online discussions have focused on the need for greater transparency and accountability of the medical profession, putting the doctors on the defensive.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable four system more equitable
Cost Efficiency very low neutral very high

Because of the controversy surrounding the issue, the matter remained unresolved for several months as the MOH met up with key leaders of the Singapore Medical Association, College Of Family Physicians Singapore, the Academy of Medicine and the Singapore Medical Council to seek a better understanding of the medical community's concerns.

In the end, however, MOH announced in October 2009 that the Bill, with the controversial amendments intact, would be introduced in Parliament for debate within the next few weeks. In a letter to all registered medical practitioners, MOH emphasized that "the provision of allowing legally-trained persons in the tribunal should not be viewed as an indictment that the medical fraternity has failed to self-regulate. Rather, it is to prevent legal errors when dealing with complex issues of law.

References

Sources of Information

  • Karen Tan. Medical Act: Did feedback reflect docs' views? The Straits Times . 09 Jun 2009, http://www.moh.gov.sg/mohcorp/mediaforums.aspx?id=22104
  • Law Society's Feedback in Public Consultation on Proposed Amendments to the Medical Registration Act - Submitted on 12 March 2009
  • Submission by the Singapore Medical Association - Response to public consultation on proposed amendments to Medical Registration Act. SMA News, page 10, March 2009
  • Ministry of Health.Medical Registration (Amendment) Bill. MOH Circular CF 78:02/8, 13 October 2009

Author/s and/or contributors to this survey

Lim Meng Kin

National University of Singapore

Suggested citation for this online article

Lim Meng Kin. "Non-Medical Chair, Medical Disciplinary Tribunal?". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/sg/a14/3