How will SMC ruling affect psychiatry and treatment of mental health patients?
Being acutely aware of the high levels of stigma that patients with mental illness face, it would not be a bold claim to say that psychiatrists face the need to protect sensitive medical information every single day more so than any other specialty in medicine, says the author.
I thank Dr Desmond Wai for his insightful commentary entitled “Why Singapore Medical Council’s ruling against NUH psychiatrist raises concerns”, which helps lay persons understand the implications the ruling has on the wider medical community.
SMC on Thursday (March 14) said that it will be appealing to reduce the S$50,000 fine imposed on psychiatrist Soo Shuenn Chiang.
There are specific nuances in this case that particularly affects the practice of psychiatry, and therefore has downstream effects on the care received by patients with mental illness.
Being acutely aware of the high levels of stigma that patients with mental illness face, it would not be a bold claim to say that psychiatrists face the need to protect sensitive medical information every single day more so than any other specialty in medicine.
In addition, they face ethical dilemmas routinely in their practice, needing to consider beneficence (do good), non-maleficence (do no harm), patient autonomy, and confidentiality.
These dilemmas are such that abiding by one principle means violating another.
A further complicating factor is that specific laws exist for the compulsory treatment of mental illness over-riding a person’s autonomy.
In Singapore, it is the Mental Health (Care & Treatment) Act. Aside from the Infectious Diseases Act, no other laws exist for the compulsory treatment of other medical illnesses against a person’s wishes.
Such is the environment that psychiatric trainees immerse themselves in from their junior years until mastery at resolving such ethical dilemmas becomes second nature when they qualify as specialists in psychiatry.
READ ALSO:
Singapore Medical Council ‘not aware’ of any action taken against man who deceived psychiatrist
Petition backing NUH psychiatrist went offline after drawing over 2,000 signatures
Dr Soo’s case is a classic example of what psychiatrists and even junior trainees face in routine practice.
In order to invoke the law and do good for the patient (beneficence), they violate the principles of confidentiality and autonomy, by revealing certain (not all) information to key crisis personnel who are able to put the wheels of the Mental Health Act in motion.
Hence, the ruling raises the following concerns for psychiatrists in particular.
First, it is inconceivable to conclude that Dr Soo, a qualified specialist, “showed a lack of concern for or appreciation for the required standards and indifference to the patient’s medical confidentiality”, as stated by SMC.
If he was providing standard care like all other psychiatrists as he was trained to do (which is already at a more sensitive level than other medical specialties as explained above), what then is SMC’s standard for concern for and appreciation of medical confidentiality?
Second, the SMC ruled that Dr Soo’s misstep was in failure to verify the identity of the caller before releasing the information and that was equated to “indifference to confidentiality”.
This is illogical because in order to furnish the memo, Dr Soo would have had to look back into the patient’s records for the clinical details, do a risk assessment based on the available information, and put some thought into writing essential information to a specified addressee with a specific recommendation for a plan of action.
In this case, the memo was addressed specifically to Ambulance or Police Officer in-charge, for the specific purpose of seeking their assistance to bring the suicidal patient to Institute of Mental Health for an assessment. In what way is this careful and considered act indifferent?
I believe that Dr Soo was on the contrary, considering and resolving the ethical dilemma in his mind exactly as he was trained to do. This was not a memo addressed “To Whom It May Concern” that gives it potential for abuse of the information it contained.
The clinical information was also not used for Dr Soo’s personal or selfish gains like other preceding cases of medical practitioners who intentionally breached medical confidentiality in situations that were clearly not ethical dilemmas in patient care.
If failure to verify caller’s identity in such an emergency situation is unprofessional and unethical behaviour, then I dare say every single psychiatrist in Singapore would have to be penalised as well.
Third, does SMC then imply through this ruling that the principle of confidentiality trumps over the other ethical principles in future similar cases where high-risk patients need to have the Mental Health Act invoked for their care?
Fourth, practically speaking, how then would psychiatrists practising outside the Institute of Mental Health invoke the Mental Health Act for their patients when required?
Fifth, will there be any legal consequences for psychiatrists if their high-risk patients come to harm through their inability to invoke the Mental Health Act?
Sixth, the caller in this case not only lied about his identity, he also lied about the purpose of requesting for the memo. Does the need for verification henceforth also mean that verification needs to be done for the purpose of such requests for memos seeking assistance for suicidal patients?
How does SMC suggest for this type of verification to be done in real life practice? Would a truly suicidal person verify that he/she is suicidal and needs to be brought to Institute of Mental Health?
Lastly, will this ruling mean that psychiatrists no longer practise in an environment of safety, but in an environment of ever-moving standards where we never know whether our best intentions in resolving these daily ethical dilemmas may be found to fall short at the whim of certain patients disgruntled enough to make formal complaints?
As psychiatrists, we are painfully aware that there already exists many barriers for sufferers to access professional help.
However, the ruling in this case has created yet another barrier by unnecessarily causing fear in us, preventing us from doing what we had hitherto believed to be best for our patients.
We want to continue to be able to do what Dr Soo did in psychiatric emergencies, but we fear being victimised and we fear being unjustly penalised.
The only way to remove this fear, to restore confidence among psychiatrists, and improve access to mental healthcare, is to convince us that we can trust our professional body, the SMC, to protect us when it can be demonstrated that we have practised in good faith, to the best of our expertise and with the resources available to us.
ABOUT THE AUTHOR:
Dr Chan Lai Gwen is a psychiatrist in public practice. She has been in this field for 13 years.
