Tag Archives: medical ethics

Doctor, Bill Thyself

Bring up the subject of doctors’ bills and many patients will have their anecdotes, but an interesting court trial is currently shaping up in Singapore regarding the way doctors there charge for their services.

A well-known surgeon in Singapore is fighting in the High Court there to disallow the Singapore Medical Council from setting up a disciplinary committee to investigate charges that the surgeon had over-charged her patient from Brunei, who happened to be the Brunei Queen’s sister.

Dr Susan Lim and doctors' charges - how much is too much?


The surgeon, Dr Susan Lim, had begun treatment for breast cancer on the patient in 2001 right till her death in 2007. In the process, she had referred the patient to several colleagues who had their bills directed to her for onward transmission. Here are some astounding facts that were heard in court last week:

The Bill Mark-Ups (courtesy of Straits Times,Singapore,24 Feb 2011)

  • The overall bill for the year 2007 alone came to USD 19.5 million.
  • She charged as high as USD 354,000 per day for her services.
  • The surgeon would inflate her colleagues’ bills dramatically and bill the patient. For instance, doctors’ bill for USD 315 forwarded to her was bumped up to USD 166,000.

When the patient eventually passed away in 2007, the Ministry of Health of Brunei, alarmed at the high fees, complained to their Singapore counterparts. It was alleged the surgeon then gave a 25% discount of the bills accompanied by an apology on “inadvertent mistakes made by her office”; but when this did not work, she then offered to waive all her bills in return for a “letter of good standing” to state that the matter would not be pursued further. The Brunei government did not respond.

In her defence, the lady surgeon said that the patient had been forewarned on her fees of between USD 79,000-168,000 per day and that the patient had agreed to it, saying that the Palace would pay. In addition, the patient had become so dependent on her that no other doctors could provide treatment without her physical presence.

The above anecdote makes grim reading and raises several questions related to medical ethics and human psychology. Can a doctor justify such charges no matter what challenges are faced? Can a patient, assuming he or she is in a mentally fit state, make a financial undertaking  on behalf of  the body paying for the bills? The issue is made complicated by some of the doctors backing the surgeon on the inflated bills. See here.

It also calls attention as to why a developed country like Singapore does not have an approved fixed fee schedule upon which doctors’ charges are based. Most countries have one in place that makes such charges transparent.

Whichever way  you look at it,  healthcare has become an industry; like all industries, standard-operating procedures and adequate legislation must be in place to protect the consumer. This includes a transparent doctors’ fee schedule. Until this is done, Singapore’s credibility as a medical hub is seriously affected.

Choosing To Die..Australia Bans Euthanasia Ad

Take a look at this TV advert..its about a terminally-ill man sitting on a hospital bed talking about the choices he made in life, including the choice to die. But this advert will not see the light of day in Australia where it was made because the regulatory authority which decides what is fit for screening on free-to-air commercial stations has decided that “material which promotes or encourages suicide will invariably be unsuitable for television.”

Australia’s Northern Territory introduced the world’s first voluntary euthanasia legislation in 1995 but it was overturned by the federal government and euthanasia remains a crime in the country. Euthanasia advocates appear unfazed and are pressing for the ad to be released on TV. You decide…

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The Right To Die..The Way You Want It

Walking out of the ICU the other day, my mind was occupied by the thought of the patient who had just passed away . A proud, self-made man, he had leapt from obscurity to popularity on his own blood,sweat and tears. Surrounded by drips,  lines and pumps he laid helplessly in the ICU bed, knowing  that the end was nigh and that his will to survive had drawn on the last straw. The nurses sensed that and the doctors knew that; but we were all trained to keep him going. Deep inside, we were wondering if he knew about  living wills

A Living Will determines how medical staff will manage end-of-life care

A living will is quite different from a last will and testament which specifies beneficiaries and funeral arrangements. Quite simply, a living will speaks on your behalf when you are medically seriously ill and unable to communicate,such as when in a coma, and is a healthcare directive made in advance instructing medical personnel and family as to what medical treatment you wish to receive at end of life, including matters such as organ donation.

For doctors in attendance and family members, this relieves them from making agonizing decisions like when to turn off the respirator at end of life; or for that matter, whether to use that life support machine in the first place.

Living wills can also stipulate whether blood transfusions can be used, artificial feeding implemented or even the use of organ transplantation.

To make your living will legally binding:

* It must be witnessed by two people who are legal adults

* Witnesses must not be related to you in any way

* They cannot be beneficiaries of your estate

* They are not directly involved with your health care providers

* They have not been named as your agent in a medical power of attorney document or in your living will.

Signed copies of the living will should be handed to one’s personal doctor as well as close family members and need to be seen by the attending doctors at any possible end-of-life scenario. Take a look at a typical living will here.

Doctors encountering patients with living wills vary. In New Jersey,USA 1 in 6 adults have one. In Asia, the exception is the rule. But with increasing awareness of patient rights, an egalitarian society and the rising costs of end-of-life care, it would not be surprising, in the near future, to see more patients with a living will in hand. The dying, not doctors, should have the final say in the type of treatment they receive.

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A Tale of Three Doctors

Woke up one day this week to read about how the medical profession was  put in a rather unfavorable light, in various parts of the globe.

In Los Angeles,USA, it was reported that the late Michael Jackson’s doctor, Dr Conrad Murray, who practises in Houston was going to be charged in a few days time  for involuntary manslaughter. It was alleged that the doctor had administered the powerful anaesthetic drug, propafol, plus two other sedatives in a concerted attempt to make the pop star go to sleep. Propafol needs to be administered intravenously by an anaesthesiologist in a hospital setting and requires continuous monitoring as the drug can cause suppression of breathing, lowering of heart-rate and blood pressure. See my earlier posting “MJ’s Death Explained for details.

Dr Daniel Ubani - still practising in Germany

In Cambridge,UK, a foreign-trained doctor, on his first work assignment for the NHS after arriving in the UK the day before, administered an injection of diamorphine (an opioid used for pain relief) of twenty times the recommended dose to an elderly patient at his home for relief of kidney pain. Not surprisingly, the patient stopped breathing soon after the doctor had left. At the coroner’s enquiry, it was discovered that the doctor, originally from Germany, had failed his English test earlier and had never given the drug before. It was also not possible to extradite the doctor from Germany to face charges, where latest reports say he is still practising.

Dr Suresh Nair -1991 Sydney Uni graduation pic

Meanwhile, in Sydney,Australia, a neurosurgeon has been charged over the cocaine-related deaths, in November 2009, of two young women who had visited his apartment. Post-mortem results showed both women had died of cocaine toxicity. Having been suspended by the New South Wales Medical Board, he now remains in custody pending trial. Some unanswered questions remain, like having been a known cocaine abuser since 2004, why was he still allowed to practise by the Medical Board?

Having read these stories, I just wonder whether this is a trend of things to come, or whether the virtues of a noble profession are being eroded in the face of changing times? Perhaps, most tellingly, when I asked a student who had aspirations of being a doctor, why he had chosen the profession, his answer was, So that I can make a lot of money!”

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For Those Studying Medicine..(5)

“A journey of a thousand miles begins with a single step.”

-Confucius (551-479 BC), Chinese philosopher and founder of Confucianism

Its often been said that studying to be a doctor is a calling, as opposed to many other professions when its just involves studying to obtain an occupation. To become a doctor not only involves studying hard but it involves a change in one’s lifestyle and attitude towards life, in the pursuit of the maxim ” to cure sometimes, to heal often and to comfort always”.

Many medical students appear daunted at the long tortuous years of study ahead of them but this is often made easier if, before taking that first step, that you have the right aptitude and attitude. In my book, you do need some brains (though not as much as a rocket scientist), but more important, the three paramount qualities that you need are :

  • a desire to help others
  • a love for learning
  • a curiosity towards how diseases affect people

If its money you’re after, there’s a lot of other careers which are more lucrative; minus the sacrifice, effort and responsibilities of becoming a doctor!

Patients Who Abuse Hospital Stays

A brash 30-year old man comes into the Emergency Department(ED) with low-grade fever and immediately demands hospital admission. Already annoyed at having made to wait (triaging rightly placed him low down on the wait-list), the patient was carefully examined by the duty doctor who then ordered some essential blood tests. Upon a few hours observation in the sick bay and on receipt of the blood test results, the doctor dutifully explained that there was no medical necessity for the patient to stay in and that outpatient treatment would more than suffice.

Whereupon, turning red in anger, he quickly whipped out his trendy mobile phone and made a call to his father who happened to be the President of a large company which used the hospital as its main referral centre.  In next to no time, the hospital CEO was on the scene and the doctor’s decision was overruled on the basis that the patient represented an important client of the hospital and the hospital needed to maintain ‘good relations’. He was then admitted for investigation of fever, without much justification for in-hospital stay based on mclinical grounds. While in hospital, the patient insisted on a whole battery of expensive tests, including heart-scans, confident that this would be taken care of by his private health insurance policy. Needless to say, upon the patient being discharged, the insurance company rejected the hospital’s bills on the basis that the tests were irrelevant to the illness. Finally, the hospital was forced to absorb the  costs.

Does the above story sound familiar? If you’re a hospital manager or an emergency room doctor, this incident is not unusual at all. Many a time, healthcare providers are faced with a situation like this, where there is abuse of the facilities between  either one (or more) of the three main stakeholders in healthcare delivery: the patient, healthcare provider and the payor (usually insurance companies).

In this particular case, the insurance company was the winner but a similar scenario could arise when a doctor, practising extreme defensive medicine, could have ordered ‘grey area’  investigative tests  at the behest of the patient. In which case, the insurance company would be the loser.

Whichever way it strikes, the ultimate loser is going to be the consumer because there’s no free lunch and everybody’s got to sing for their supper. So, the insurance premiums will keep on rising and consumers will have to dig deeper into their pockets.

Even so, insurance companies are facing huge problems containing costs, given that inflation within the healthcare industry is in double digits. Recently,  more heat occurred in the Oregon summer when an elderly woman with lung cancer was prescribed a $4000 a month cancer drug and was told that ” the Oregon Health Plan wouldn’t cover the treatment, but that it would cover palliative, or comfort, care, including, if she chose, doctor-assisted suicide.”

This is clearly an ethical conflict – denying chemotherapy to terminally ill patients while offering to pay the cost of helping them die.

A Deadly Decision

What do you do if an AIDS patient is dying but does not want the family members to know the diagnosis?

This was an ethical dilemma that I faced some time ago. This young man was admitted with pneumonia and expressly told the doctors not to disclose his illness to family and friends. As doctors, we were bound to uphold confidentiality.  Should this be absolute at all costs, no matter what?

As was expected, his condition quickly deteriorated and he lapsed into coma. Close friends and relatives soon arrived at the hospital, each one enquiring on what was wrong.

Needless to say, a decision had to be made quickly enough on what to reveal or, more important, what not to reveal. We decided that, as the patient had nominated a next-of-kin, that this person would be the proxy for determining the future management and course of action. The patient had voluntarily nominated a person to make decisions on his behalf, so, by inference, this person should be told of his actual disease.

However, after much discussion, the medical team agreed that, as it was unlikely that the patient would survive another 24 hours, telling the next-of-kin was not going to affect decisions on management anyway. It would have been different if there were possibilities that treatment could realistically prolong his life; then the next-of-kin would have needed to be told of the diagnosis in order to obtain permission for the next course of action.

The patient eventually passed on a few hours later and relatives were told that he died of pneumonia due to an underlying cause for which the doctors were not under the liberty to disclose.

In this case, the duty to maintain doctor-patient confidentiality was maintained. This duty is not absolute always as pointed out above. Also, as AIDS is a notifiable disease, health authorities needed to be informed and further action necessary if there is a suggestion that the patient had infected others.

Doctors play God, or don’t they?

Many years ago, as a junior resident in a large overcrowded public hospital, I chanced upon an elderly man lying in bed looking very pale and ill and surrounded by two younger men looking at their friend(the patient) as if he was in death’s throes. As I breezed past on the way home after a rather tough stint, the younger man stopped me in my tracks and said if we could do something to help the elderly man as they had been told earlier by another doctor that the patient was terminally ill, nothing could be done and that the best thing would be to take him home to spend his last days comfortably in his own bed.

It was already late night but as there was a bit of extra time left before the call-duty was over, I took a brief look at his case-notes and summarised that the working diagnosis was that of advanced cancer of the lungs.

Having promised the patient’s friends that we would take a second look the next morning with the team, I headed off for home.

To cut a long story short, the diagnosis turned out to be a lung infection called aspergillosis and in next to no time, the patient was cured and able to walk home quite well.

I was constantly reminded of this gentleman as he would faithfully turn up once a year outside my office during the main festivity season bringing a celebratory gift. Although he did not speak English, the words, gestures and smile spoke volumes in terms of gratitude. These visits went on for several years till my staff took his visits almost for granted.

One fine day, we all realised that his visit had stopped coming for some time and it wasn’t till much later that word got to us that this fine old man had finally succumbed at home to what was presumably old-age.

This whole episode really got me thinking whether we as doctors do actually determine the fate of fellow human-beings. Much as the Hippocrates Oath or the Geneva Declaration on Health determine our behaviour towards patients, doctors are subjected to various constraints sometimes beyond their control. A missed diagnosis, inadequate review, insufficient resources are some of the factors which may hinder appropriate treatment and consequently lead to a different fate than what God probably intended…

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