Dr Ang Yong Guan v Singapore Medical Council

1 Dr Ang Yong Guan is a psychiatrist who issued a number of prescriptions to his former patient, the late Mr Quek Kiat Siong (“the Patient”), who he had been treating for various conditions including insomnia, depression, post-traumatic stress disorder, obsessional ruminations, and anxiety. In the course of treating the Patient over approximately two years as both an inpatient and outpatient, Dr Ang prescribed a series of medications intended to address the various conditions from which the Patient was suffering. Dr Ang’s final prescription to the Patient was issued on 31 July 2012, and the Patient passed away days later on 4 August 2012. The Patient’s final cause of death was certified as “multi-organ failure with pulmonary haemorrhage, due to mixed drug intoxication”, and his post-mortem blood concentrations of various drugs were found to be elevated beyond the therapeutic concentrations found in living subjects.

2 After the Patient’s demise, the Patient’s sister filed a suit against his insurers on behalf of his estate, the central issue in which being whether the Patient had deliberately consumed an overdose of his prescribed medication in circumstances where the probability of death was or ought to have been foreseen. In Quek Kwee Kee Victoria (executor of the estate of Quek Kiat Siong, deceased) and another v American International Assurance Co Ltd and another [2017] 1 SLR 461, the Court of Appeal found that the most likely scenario was that the Patient had taken his medication in accordance with the prescriptions given to him, without any intention or expectation of suffering injury resulting in death. Thereafter, the Patient’s sister filed a complaint against Dr Ang with the Singapore Medical Council (“SMC”), in relation to the prescriptions which he had issued to the Patient.

3 The SMC brought three charges against Dr Ang for professional misconduct under s 53(1)(d) of the MRA (the “professional misconduct charges”), and three alternative charges under s 53(1)(e) of the MRA for failure to provide professional services of the quality that was reasonable to expect of him (the “professional services charges”). The first professional misconduct and professional service charges pertained to prescriptions issued by Dr Ang between 8 February 2010 and 31 December 2011; the second pair of charges concerned prescriptions issued between 1 January 2012 and 31 July 2012; and the third pair concerned the prescription issued on 31 July 2012, which was Dr Ang’s last prescription to the Patient before the Patient’s death four days later. The key factual averments of each pair of charges are as follows:

4 It was not disputed that Dr Ang had made such prescriptions, and that these prescriptions were inconsistent with various standards of treatment applicable to him at the time, codified either in guidelines issued by the Ministry of Health, or package inserts in medication approved for use by the Health Sciences Authority.

5 The Disciplinary Tribunal of the SMC found that Dr Ang could not demonstrate that he had clear medical grounds for making any of the prescriptions described in the charges, as he could not prove that he had undertaken a risk-benefit analysis in respect of each prescription, discussed the risks and benefits with the Patient, and obtained the Patient’s consent to the course of action in question. However, the Disciplinary Tribunal was of the view that Dr Ang’s conduct did not amount to an international and deliberate departure from the standards of treatment applicable to him, as he had shown “care and concern” for the Patient and “attempted to meet the standard” expected of him. It thus declined to convict him on the professional misconduct charges, and instead convicted him of the professional services charges.

6 The following issues arose for the Court of Appeal’s determination:

a. What are the elements of the charges under s 53(1)(d) and s 53(1)(e) of the MRA;

b. What is test for determining whether a departure from codified standards of treatment applicable to a doctor were appropriate in the circumstances;

c. Whether Dr Ang had discharged his burden of proving that each departure was appropriate in the circumstances.

7 To demonstrate that a doctor’s departure from standards of conduct applicable to him was intentional and deliberate in connection with a charge under s 53(1)(d) of the MRA, all that must be shown is that the doctor knows of the applicable standard of conduct but chooses not to comply with it. The absence of malicious intent or financial motive, or the fact that a doctor might have shown “care and concern” for their patient, is ultimately irrelevant to this analysis: at [51].

8 The test for liability under s 53(1)(e) of the MRA is simply that articulated using the words of the MRA itself, ie. whether the doctor has failed to provide professional services of the quality which is reasonable to expect of them. There is no further requirement that the standard breached must have been a “minimum or elementary” standard. Where a failure or departure from such standards is of a less severe nature, the matter may instead be dealt with at various stages of the disciplinary process before it reaches a Disciplinary Tribunal or the court, or the lower degree of severity may be reflected in the type of sanctions that are imposed: at [52]–[54].

9 Standards set out in guidelines promulgated by the Ministry of Health or package inserts approved by the Health Sciences Authority represent codifications of standards observed or adopted by the medical profession, and form the compulsory starting point or a baseline standard of care for all doctors. While doctors may depart from these standards, the burden falls on them to demonstrate that the departure is justified or supported by good reasons: at [56]–[60].

10 In order to discharge this burden, it is incumbent on the doctor to demonstrate that the departure was objectively justified in terms of the risks and benefits, and with reference to the rationale behind the codified standard which the doctor had departed from: at [65]–[75].

12 Dr Ang had shown that each discontinuation of antidepressants before the minimum period of four to six weeks was objectively justifiable. The rationale behind the minimum period was to allow for sufficient time to assess a medication’s effectiveness as an antidepressant. Where an antidepressant medication was causing a patient side effects, or where it was being used in order to help a patient achieve sleep and was assessed to be either unnecessary or ineffective in doing so, Dr Ang’s decision to depart from the guidelines did not offend against their underlying rationale, and was objectively justifiable. Similarly, Dr Ang’s discontinuation of Duloxetine before four to six weeks on several occasions had to be understood in light of the fact that the Patient had already been previously prescribed Duloxetine for a period of over six weeks, and that its effectiveness was known to Dr Ang. The discontinuations had been to allow Dr Ang to test the effectiveness of other antidepressants. There was also no evidence to suggest that premature discontinuation of an antidepressant in itself carried any inherent risk. In this context, these discontinuations were a justifiable part of Dr Ang’s ongoing attempts to calibrate the different medications the Patient was taking: at [94]–[106].

13  Dr Ang was unable to demonstrate that his concurrent prescription of multiple benzodiazepines or his concurrent prescription of benzodiazepines with opioid analgesics was objectively justifiable in terms of the risks and benefits. The rationale for these prohibitions was because of the risk of drug-drug interactions, which could lead to significant safety concerns such as central nervous system depression, increased risks of sedation, respiratory depression, or cardiovascular depression, slowed breathing, or even death. The fact that the Patient was a complex case did not suffice to justify undertaking risks of such a magnitude, and evidence on the extent to which close monitoring of the Patient would have ameliorated this risk was equivocal at best. In any event, there would have been no effective measures to detect the onset of adverse drug reactions in place while the Patient was being treated as an outpatient, and certainly nothing in the way of emergency care or other support measures to enable anything to be done about it, had they materialised then: at [107]–[116].

14 Dr Ang had shown that his prescription of benzodiazepines beyond the limits of short-term and intermittent use, and of a six-month supply of benzodiazepines, were objectively justifiable on the facts. The rationale behind the prohibition against doing so was to guard against the risk of drug dependence, which unlike the potential consequences of drug-drug interactions was not immediately life-threatening. In view of the Patient’s documented chronic insomnia, Dr Ang’s plan to wean the Patient off benzodiazepines once his primary stressors had been resolved, and Dr Ang’s evidence that the Patient had proven to be capable and responsible in managing his medications, the benefit of these prescriptions objectively outweighed the risks. There was also insufficient evidence that these risks were of such probability and magnitude that Dr Ang was obliged to inform the Patient of them. The six-month prescription of benzodiazepines was further to be seen in the context of the Patient’s aversion to coming to the clinic, which had resulted from a traumatic prior experience with a different psychiatrist: at [117]–[126].

15 Dr Ang was unable to demonstrate that his prescription of Mirtazapine and Zolpidem Controlled Release in excess of the maximum dosages set out in their package inserts was objectively justifiable. Dr Ang did not explain why this was warranted in terms of risks and benefits, even though he acknowledged that his prescription of 60mg of Mirtazapine was close to the “killing range”. It was difficult to accept at face value his explanation that he had done so to keep the Patient’s consumption of benzodiazepines low, given that he afterwards reintroduced a benzodiazepine that had earlier been discontinued. It was similarly difficult to accept his claim to have judiciously titrated the dosages of these two medications, when the record showed that he only exceeded the maximum stipulated dosages during the Patient’s very last hospital stay before his passing. Furthermore, while prescriptions of Mirtazapine or Zolpidem Controlled Release in dosages beyond their stipulated maximums posed little risk when taken alone, it had to be remembered that the Patient was also concurrently taking a variety of other medications: at [139]–[147].

16 As Dr Ang was fully aware of the standards applicable to him and nonetheless chose to depart from them, his departures were intentional and deliberate. It followed that those which he was unable to demonstrate to be justified amounted to professional misconduct: at [129], [134], and [149].

17 The C3J thus found that at least one of the factual averments contained in each of the charges was made out. It thus convicted Dr Ang of all three counts of professional misconduct, albeit that in the context of the first and second charges, this was only to the limited extent of those departures which he was unable to justify.