SINGAPORE — There is “an objective ethical limit” on medical fees in both private and public healthcare that operates outside of contractual and market forces, said the Court of Three Judges yesterday, as it dismissed an appeal by prominent surgeon Susan Lim (picture) against her professional misconduct conviction from the Singapore Medical Council (SMC).

Given a doctor’s specialised knowledge and training — and his or her “corresponding duty” to utilise these skills with conscience and dignity in the patient’s best interests — the court opined that a doctor has an ethical obligation not to take advantage of his or her patient, whether monetarily or otherwise.

“In the circumstances, excessive overcharging would be a breach of this ethical obligation,” said the court, which comprised Judges of Appeal Andrew Phang and V K Rajah, as well as Justice Tan Lee Meng.

It added: “A doctor’s ethical obligation to charge a fair and reasonable fee for services rendered is not superseded by a valid agreement between the doctor and his or her patient. Unlike the present approach in the law of contract, in the context of disciplinary proceedings against a medical practitioner, ethical obligations are not only procedural but also substantive in nature.”

In their 109-page judgment, the three Judges called the episode “one of the most serious (if not the most serious so far) cases of overcharging in the medical profession” here. They affirmed the sentence meted out by the SMC disciplinary committee, noting that Dr Lim failed to show any remorse over her actions even though the court said she did not deliberately falsify the invoices and had “displayed exceptional care” to the patient.

In July last year, Dr Lim was suspended from practice for three years, fined S$10,000 and censured, after she was found guilty by an SMC disciplinary committee of 94 charges of professional misconduct for overcharging and making false representations in her invoices.

She had charged S$24 million for half a year’s care, before halving it to S$12.1 million with a discount after the Brunei Ministry of Health alerted its Singaporean counterpart on the magnitude of Dr Lim’s bills.

The court yesterday ruled that the discounted amount would still be “several times” what Dr Lim ought to have invoiced the patient for her services, even taking into account certain costs. The SMC had argued that a reasonable amount was S$2 million.

In January’s appeal before the court, Dr Lim’s lawyer, Senior Counsel Lee Eng Beng, argued there was no rule in the SMC Ethical Code which limited the quantum of fees a doctor may charge.

However, the doctor’s contention that she can charge whatever she wishes because it is a “free market” fails to appreciate the issue as a matter of ethics, argued the SMC’s lawyer, Senior Counsel Alvin Yeo.

Although there is no provision in the Code which refers precisely to an ethical obligation to charge a fair and reasonable fee for services rendered, the court noted that the Code contains relevant provisions which support the existence of such an obligation. “In particular, it is important for the honour and integrity of the medical profession that doctors charge fairly and reasonably, lest the profession becomes or be seen as one motivated by mere personal gain or financial considerations,” said Justice Phang, who delivered the court’s decision.

Further, the court felt that a doctor — who is deemed to be a professional — cannot rely “solely on the morals of the marketplace”. “As a member of an honourable profession which is rooted in the ideal of public service, a doctor has higher ethical obligations which are founded on a relationship of trust and confidence,” said Justice Phang.

“Viewed in this light, such ethical obligations necessarily trump contractual or commercial obligations where there is a conflict between the two.”

This, however, does not mean that contractual obligations are irrelevant, the Judges opined.

“Depending on the particular factual matrix, there will often (but not always) be an overlap between ethical obligations and contractual obligations. But, one thing is clear: Ethical obligations are fundamental and both characterise as well as justify the special status of a ‘profession’ that is conferred on the medical profession,” Justice Phang said.

It is not known when Dr Lim will begin her suspension. Contacted yesterday for comment, Mr Lee said he did not have any instructions to respond to media queries on behalf of his client.

The court said: “If the parties are unable to agree on the date of commencement of the appellant’s suspension, they are at liberty to apply to this court for directions.”

More on the Judges' ruling on Susan Lim's appeal: http://tdy.sg/12hWKib