SINGAPORE - All doctors in Singapore have an ethical obligation to charge fair and reasonable fees, the Court of Three Judges ruled on Tuesday.
This responsibility comes over and above contractual and market forces - including any existing agreement with the patient - it said in its judgment in the Susan Lim case. The main issue before the court was whether there is an ethical limit on how much a doctor can charge.
Yes, said lawyers for regulatory watchdog the Singapore Medical Council, which alleged that Dr Lim was guilty of professional misconduct.
No, said her lawyers, arguing that she had a fee agreement with the patient and was not ethically obliged to charge a fair and reasonable rate.
The court agreed with the Singapore Medical Council.
"The idea that the practice of medicine is, above all, a calling of the highest order is a historical cornerstone of the medical profession," it said.
Given doctors' specialised knowledge and training, they have a responsibility not to take advantage of patients. "Such ethical obligations necessarily trump contractual or commercial obligations where there is a conflict between the two," said the court.
Overcharging is an abuse of patients' trust and confidence, it ruled. This, in turn, constitutes professional misconduct.
As for what is a fair and reasonable fee, this depends on the relevant facts as well as the views of experts in that particular field.
In Dr Lim's case, the court found she had no fee agreement with her royal patient from Brunei. Even if she had, this would not have justified the bill of around $24 million.
The three judges found that there was clearly enough proof to justify the 94 charges against Dr Lim. "Fees charged by the appellant were, in any objective view, grossly excessive and unreasonable," said the court.
"It was also clear... that the invoices were issued in an unsystematic, arbitrary and, ultimately, opportunistic manner."
Dr Lim's $24 million bill was for treating Pengiran Anak Hajah Damit between January and June 2007. Before this, the Bruneian government - which ultimately paid for the treatment - had no complaints. For example, in 2001 - the year Dr Lim started treating her royal patient for breast cancer - the bill was about $670,000.
On Tuesday, several specialists told The Straits Times that there is an ambiguity over the ethical limits on medical fees.
"While most will agree that the $24 million bill does seem excessive, many doctors are also apprehensive and unclear what this 'ethical limit' should be," said Dr Lam Pin Min, who chairs the Government Parliamentary Committee for Health.
"There are really no clear guidelines at the moment. What the health-care industry needs is a better definition of what this ethical limit is so as to avoid any ambiguity in future."
An eye doctor in private practice, who spoke on condition of anonymity, asked: "Where then will the court draw the line? What is the amount that constitutes overcharging?"
Other doctors felt the medical profession should not be singled out for overcharging.
Colonoscopist Francis Seow- Choen said: "It is a little bit unfair for specialists... In every line of work... there are always people who are specialists. I am not sure that it (should) apply to only doctors."
But he added that the ruling will not affect most doctors.
"We are not in it for the money. If we are, we would have become businessmen."
How a $24m bill got surgeon in trouble
The saga began in 2007 when the Health Ministry filed a complaint against Dr Susan Lim.
It concerned her $24 million bill for six months of treatment given in 2007 to a royal patient from Brunei.
Dr Lim, a prominent general surgeon in private practice, started treating Pengiran Anak Hajah Damit for cancer in 2001.
Her bills in previous years had been paid by the Brunei government. After the patient's death in August 2007, Brunei's Health Ministry asked its Singapore counterpart if her $24 million bill was reasonable.
Then, in January 2010, the Singapore Medical Council (SMC) started a disciplinary hearing against her.
It ended in July that year with no verdict after members of the disciplinary committee voluntarily stood down over accusations by her lawyers that they had pre-judged the case.
When the SMC took steps to set up a second disciplinary committee, she challenged the move in the High Court.
In May 2011, the High Court dismissed her bid.
And in November that year, the Court of Appeal turned down her appeal to block the inquiry.
The disciplinary hearing went ahead.
In July last year, Dr Lim was found guilty of all 94 charges.
She appealed to a Court of Three Judges, which has endorsed the disciplinary committee's decision.
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