Under the knife
By Toh Hsien Min
I'm not a doctor. I have many friends who are doctors, and a first cousin training to be one, but my direct medical knowledge is effectively zero. Fortunately, I've so far had a robust constitution, but when the day comes that I do need to consult a doctor, I should like the decisions on my care to be guided by unbiased expertise along the principle of what is overall in my best interests. Assuming I am in Singapore, I will have this consultation in full confidence that the medical infrastructure and support is top notch. Articles in economic journals and the press of the developed world often remark upon the balance that has been struck in Singapore healthcare, achieving some of the highest quality medical care in the world through a blend of government-run universal healthcare and a strong private healthcare sector. Meanwhile, this healthcare system is kept affordable to society at large, through a combination of co-payments, compulsory savings, national healthcare insurance, and means-tested direct government subsidies, which are nevertheless calibrated so that healthcare costs do not consume an ever expanding proportion of the government budget and require a fiscal interventions such as raising taxes. In 2014, Bloomberg ranked Singapore's healthcare system the most efficient in the world.
But in recent days I have wondered whether this is as good as it gets, and whether we have started on the road towards American healthcare paralysis. The trigger is a S$100,000 fine handed out by the Singapore Medical Council to an orthopaedic specialist, Dr Lim Lian Arn, over an injection. A summary of the case: an experienced senior doctor gives an everyday injection to a patient, who suffers some side effects, allegedly involving more pain than the condition that the injection was intended to resolve, and who lodges a complaint against the doctor. The SMC throws the book at the doctor, saying that consent to administer the injection was not taken properly. It is important that there is no medical negligence or competence issue at all. The injection is a well established practice for the affliction in question, and is so commonly administered that formal written consent is virtually never done; many GPs perform it in their clinics. The bone of contention appears to be that the potential side effect was not sufficiently explained. There are prisoner's dilemma choices involved in arriving at the quantum of fine, as apparently the doctor offered the SMC the maximum fine possible as a fully rational and tactical decision to avoid a suspension. However, for the SMC to accept, in effect setting a precedent of a S$100,000 fine for minor procedural lapses in a $100 injection, implies sequelae that will shake the foundation of healthcare in Singapore. Every medical intervention - any pill, any injection - has potential side effects. Are doctors going make you read and sign Montgomery-test-driven 3-page disclosures for everything that they do? (In effect, transferring at least some of the responsibility for the decision to us non-medically-trained patients.) Or will the medical profession here practice more and more defensively, prioritising CYA over exercising their best judgement? Will this translate towards every medical consultation involving fifteen different tests just so the doctor can prove to a tribunal that everything possible was evaluated, rather than the two or three tests that might deliver a diagnosis with high enough probability? Will all of this snowball into an avalanche of costs that are useless for medical outcomes but purely about pricing for risk?
One senior doctor I know thinks that what is needed is common sense heads on the SMC; but for common sense to work, there needs to be a common sense consensus, otherwise the outlying party practising common sense is vulnerable to all the other parties - whether the SMC lawyer or the doctor or the disciplinary tribunal - covering themselves against liability. When everyone acts in his or her own rational interest and this leads to outcomes that are irrational for society as a whole, this is pretty much the definition of a market failure. And in cases of market failure, what needs to be done is for an enlightened government standing apart from the monetary and professional considerations in the market to intervene and reset the market. Otherwise, we should all go and quintuple our health insurance coverage now.
I suppose I've had medical issues on my mind also because the process of putting together this issue was interrupted by having to think about healthcare, and then the end of healthcare, for some people proximate to me. I had wondered, for a while, if I would be able to put out the issue at its usual size and quality and on time, but I suppose we have managed to cure its ailments. Adam Aitken may have been describing the healthcare developments above when in his poem he writes that "Fundamentally my fundamentals / make money // but no sense", but the themes in among the poems have circled around the arts rather than the sciences. Among the short stories, Patrick Sagaram's story offers another account of unintended consequences. Our reviews continue to offer their usual blend of encouraging and constructive support for Singapore books. In short: the diagnosis for this issue is a clean bill of health.QLRS Vol. 18 No. 1 Jan 2019