Judges question if rules were breached, as medical council appeals for lower fine for surgeon

SINGAPORE — A panel of three judges presiding over a high profile case — which received an airing in Parliament — questioned on Thursday (May 9) if an orthopaedic surgeon had even committed professional misconduct in the first place, as it heard the Singapore Medical Council’s (SMC) appeal to reduce his fine to no more than S$20,000.

Dr Lim Lian Arn was hit with the maximum fine of S$100,000 by a disciplinary tribunal last November for failing to inform a patient of the risks or complications that could arise from a steroid injection.

The penalty sparked outrage among doctors here, who questioned whether they were expected to list every possible risk of treatments or drugs when dealing with patients and warned of escalating costs from the practice of defensive medicine.

On Thursday, the Court of Three Judges grappled with several points, including whether the threshold for professional misconduct had been crossed.

It will issue its decision at a later date.

Chief Justice (CJ) Sundaresh Menon noted the tribunal’s finding that Dr Lim’s patient had not suffered permanent or debilitating harm, and it was an “isolated one-off incident” and an honest omission on Dr Lim’s part.

“Nothing that Dr Lim did in this case caused the harm… the harm was a consequence of treatment,” added CJ Menon, who heard the case with Judges of Appeal Judith Prakash and Andrew Phang.

The patient developed “paper-thin skin” with discolouration and loss of fat and muscle on her wrist from the injection, which was the appropriate treatment.

The SMC’s lawyer Chia Voon Jiet said the medical watchdog — which regulates doctors here — considered these reasons in filing an appeal:

• The views of the Ministry of Health which, following the outcry, tasked the SMC to apply to the court to review the S$100,000 fine.

• The recent case of Dr Wong Meng Hang, who was struck off the register of approved medical practitioners after causing the death of a patient who underwent liposuction. The SMC is now able to refer to the sentencing framework that arose out of the case, which concluded on the same day Dr Lim was sent the notice of the S$100,000 fine.

• The tribunal had agreed that Dr Lim had low culpability, and his patient had retained most of her autonomy.

• The outcry from the medical community.

• The wider implications of a shift towards defensive medicine in Singapore.

“We want to show how it was erroneous and how it could have negative consequences in the practice of medicine here,” Mr Chia said.

Chief Justice Menon questioned why these reasons were not considered before initially sentencing Dr Lim.

Mr Chia acknowledged that the SMC should have considered the issue of defensive medicine and the risk of a large fine then, but has now reviewed the decision and decided it “may have an unintended effect”.

Dr Lim’s lawyer, Mr Eric Tin Keng Seng, told the court that he did not have any points to make, and that his client does not object to the appeal.

BACKGROUND

Dr Lim treated the patient in October 2014, and she lodged a complaint in January 2016.

During the disciplinary tribunal hearing, the SMC had sought a five-month suspension while Dr Lim’s lawyer had asked for the maximum S$100,000 fine in lieu of suspension, or a three-month suspension if warranted.

After the tribunal’s ruling, fellow orthopaedic surgeon Tho Kam San started a petition calling for the MOH to clarify its stand on the need for doctors to obtain informed consent from patients for minor procedures.

Shortly after, the SMC clarified that doctors need to convey only “relevant and material” information to their patients and do not need to inform them of all possible complications of a treatment or procedure.

But the uproar continued and Senior Minister of State for Health Lam Pin Min said in Parliament that doctors do not have to lay out “every possible side effect and potential complications” of a drug or treatment.

The MOH then asked the SMC to apply to the court to review Dr Lim’s fine “and for the appropriate revisions to be made”.

By the end of this year, a sentencing guidelines committee appointed by the SMC will develop a framework to guide disciplinary tribunals in handing down consistent and fair sentences to errant medical practitioners.