Lim Mey Lee Susan v Singapore Medical Council

• Jurisdiction: Singapore
• Judge: Andrew Phang Boon Leong JA
• Judgment Date: 28 June 2013
• Neutral Citation: [2013] SGHC 122
• Court: High Court (Singapore)
• Docket Number: Originating Summons No 780 of 2012
• Year: 2013
• Published date: 10 July 2013
• Hearing Date: 15 January 2013
• Plaintiff Counsel: Lee Eng Beng SC, Paul Tan, Elizabeth Wu, Amy Seow and Jonathan Cheong (Rajah & Tann LLP)
• Defendant Counsel: Alvin Yeo SC, Ho Pei Shien Melanie, Lim Wei Lee, Sim Mei Ling, Jolyn Francisca de Roza and Liu Xueyuan Alvis (WongPartnership LLP)
• Subject Matter: Professions,Medical profession and practice,Professional Conduct,Disciplinary Proceedings,Medical Registration Act
• Citation: [2013] SGHC 122

Andrew Phang Boon Leong JA (delivering the judgment of the court): Introduction

This is an appeal by the appellant (“the Appellant”), a registered medical practitioner, against her conviction by a Disciplinary Committee (“the DC”) appointed by the respondent (“the Respondent”), the Singapore Medical Council, of 94 charges of professional misconduct under s 45(1)(d) of the Medical Registration Act (Cap 174, 2004 Rev Ed) (“the Medical Registration Act”). As the Appellant’s alleged professional misconduct occurred before the amendments made by the Medical Registration (Amendment) Act 2010 (Act 1 of 2010) (“the 2010 Amendment Act”) came into effect, it is the Medical Registration Act as it stood prior to the 2010 Amendment Act (“the MRA”) which applies to the disciplinary proceedings against the Appellant as well as this appeal, and not the Medical Registration Act as it currently stands (“the current Medical Registration Act”). This appeal raises several related issues of fundamental importance. In particular, is there an ethical obligation on the part of all doctors who practise medicine in Singapore to charge a fair and reasonable fee for their services? If so, is such an obligation an inherent one, or must it first be embodied within published legislation or rules before it can be enforced? If such an ethical obligation exists, is it inoperative in the face of a binding contract between a doctor and his or her patient (assuming that the contract in question is not otherwise rendered invalid under the general principles of contract law)? These questions raise, in turn, an even more fundamental question – what does it mean to be a professional? More specifically, is a professional bound by ethical obligations which trump his or her commercial obligations and interests? If so, should a distinction be drawn between lawyers on the one hand and doctors on the other, given that for lawyers, the answer to the last-mentioned question is in the affirmative, whilst counsel for the Appellant has argued that the contrary should obtain for his client instead?

There are also numerous important issues of application as well. The issues referred to in the preceding paragraph do not operate in a vacuum. The charges against the Appellant relate, in the main, to fees of approximately $24m which the Appellant invoiced for services which she (and other doctors) provided to Pengiran Anak Hajah Damit Pg Pemancha Pg Anak Mohd Alam (“the Patient”), a member of the royal family of Brunei, over 110 treatment days from January to June 2007. In its decision dated 17 July 2012 (“the DC decision”), the DC ordered that the Appellant be suspended from practice for a period of three years, pay a financial penalty of $10,000 and be censured in writing. It further ordered the Appellant to undertake, on her return to practice, not to charge her patients more than a fair and reasonable fee for her services. The DC also ordered the Appellant to pay the costs of the disciplinary proceedings. The present appeal relates, in the final analysis, to the Appellant’s status as a professional doctor. That is why all the charges brought against her must – as the DC itself acknowledged – be proved by the Respondent beyond reasonable doubt (see the DC decision at [3.3.1]).

The factual background The Appellant’s treatment of the Patient beginning in 2001

The material facts, as summarised by the DC in its decision, are as follows. The Appellant’s primary area of practice is general surgery, and she was at the material time registered as practising at Susan Lim Surgery Pte Ltd at Gleneagles Medical Centre. The Appellant is also the chairman and chief executive officer of a number of other clinics, including Group Surgical Practice Pte Ltd, Centre for Weight Management Pte Ltd, Centre for Cancer Surgery Pte Ltd and Centre for Breast Screening and Surgery Pte Ltd (which, together with Susan Lim Surgery Pte Ltd, shall hereinafter be collectively referred to as “the Appellant’s clinics”).

In or around 2001, the Appellant began treating the Patient for cancer of the left breast. The Appellant was the Patient’s principal physician, and was responsible for the Patient’s overall care as well as for the coordination of her treatment. For services rendered to the Patient in 2001, Susan Lim Surgery Pte Ltd issued invoices amounting to $671,827.80. The Appellant did not attend to the Patient in 2002 and 2003, and resumed her treatment of the Patient in 2004, providing medical services to the Patient during the following periods: from around May 2004 to August 2004, for which period the Appellant’s clinics issued invoices amounting to $2,708,895; from around January 2005 to December 2005, for which period the Appellant’s clinics issued invoices amounting to $3,790,237.50; from around January 2006 to November 2006, for which period the Appellant’s clinics issued invoices amounting to $7,501,357.50; and from around January 2007 to June 2007, for which period the Appellant’s clinics issued invoices amounting to $26,042,112.50 inclusive of Goods and Services Tax (“GST”) (the sum is approximately $24m before GST). The arrangement between the parties was that the Appellant’s clinics would address their invoices to the High Commission of Brunei in Singapore, and the invoices would ultimately be approved and paid by the Bruneian government.

On 19 August 2007, the Patient passed away. For services rendered in 2007, to which the charges brought against the Appellant largely relate, the total quantum of the invoices issued by the Appellant’s clinics amounted (as noted above) to approximately $24m. The services which the Appellant provided in 2007 concerned, in the main, palliative care and the coordination of the treatment of a patient in the advanced stages of breast cancer. As the DC observed in its decision, in 2007, the Appellant did not perform on the Patient any surgical procedures which would have required her to utilise her considerable surgical skills and expertise (see the DC decision at [2.2.4] and [5.1.4]). There is some dispute as to the number of days of treatment provided in 2007. The Respondent asserts, and the DC in its decision accepted, that the Appellant’s invoices for 2007 covered 110 treatment days from 15 January 2007 to 14 June 2007. However, the Appellant contends that invoices were issued in relation to 153 treatment days from 15 January 2007 to 16 July 2007, and included services which she and her staff provided to the Patient in Brunei in June 2007 and July 2007. We shall proceed on the basis that the Appellant’s invoices covered 110 treatment days up to 14 June 2007, as the services provided by the Appellant and her medical team to the Patient after the latter’s repatriation to Brunei in June 2007 are not the subject of any invoices. This conclusion is supported by the Appellant’s own letter dated 12 November 2007 to the Permanent Secretary of the Ministry of Health of Brunei (“MOHB”), where she referred to “billings during the period of 110 days between 15 January to 14 June 2007”.¹

MOHB contacts the Ministry of Health of Singapore

In May 2007, the High Commission of Brunei in Singapore alerted MOHB to the magnitude of the Appellant’s bills. On 18 July 2007, MOHB’s Director-General of Medical Services, Dr Affendy bin Pehin Orang Kaya Saiful Mulok Dato Seri Paduka Haji Awang Abidin, met with the Director of Medical Services of the Ministry of Health of Singapore (“MOHS”), Prof K Satku (“Prof Satku”), to review the bills issued by the Appellant in 2007. Prof Satku invited MOHB to write in officially to MOHS so that MOHS could investigate the matter.

On 20 July 2007, officials of MOHB met with Dr Lim Cheok Peng (“Dr C P Lim”), the chief executive officer of the Parkway Group (which operates Gleneagles Hospital, where one of the Appellant’s clinics is located), and informed him that MOHB found the Appellant’s bills excessive. Dr C P Lim conveyed the Bruneian government’s dissatisfaction with the bills to the Appellant on the same day, and subsequently informed MOHB that he had spoken with the Appellant.

Invoices annulled, withdrawn or discounted

In a letter dated 1 August 2007, the Appellant informed the Permanent Secretary of MOHB that 43 invoices which she had issued in 2007 “should be disregarded”² and treated as “null and void”.³ The Appellant offered her apologies, explaining that her office was “not used to handling such bills over such a long period of time”.⁴ The Appellant further offered to reduce the amount set out in the remaining invoices by 25% and to withdraw another two invoices “as a gesture of goodwill”.⁵ This had the combined effect of reducing the Appellant’s fees for services rendered to the Patient in 2007 to about $12.6m. The invoices which the Appellant chose to withdraw or annul mainly related to services provided by other doctors, radiotherapy services and the coordination of medical conferences with other specialists to discuss the Patient’s treatment.

In a letter dated 18 August 2007, the Appellant apologised to the Minister of Health of Brunei for what she described as “inadvertent mistakes”⁶ made by her office in respect of the invoices due to the complexity of the billings. On 27 August 2007, after the death of the Patient on 19 August 2007, MOHB responded to the Appellant restating its position that “[t]he Ministry of Health of Brunei finds the charges to be extremely high”.⁷ Also by a letter dated 27 August 2007, MOHB wrote to MOHS expressing its view that the Appellant’s charges for the services rendered in 2007 were “unacceptable and extremely high”.⁸ In its letter to MOHS, MOHB referred to the Appellant’s letter of 1 August 2007, asserting that notwithstanding the withdrawal of the 45 invoices and the 25% discount, MOHB still found the Appellant’s charges “unacceptable”.⁹ The letter then proceeded to seek the intervention of MOHS in the matter.

By way of a letter...