Lee Pheng Lip Ian v Singapore Medical Council

Facts

Dr Ian Lee Pheng Lip practised at the Integrated Medicine Clinic. Between late-2011 and early-2014 he prescribed Erfa, a thyroid preparation made from pig thyroid glands, on 41 occasions to eight patients, and Biest and Triest, custom-compounded estrogen mixtures, to four patients. He also prescribed testosterone to two patients and progesterone to two women who had had hysterectomies. In 2013 the Ministry of Health raised concerns about his use of bio-identical hormone replacement therapy, and in 2015 it declined to renew his clinic licence.

The Singapore Medical Council brought 21 charges of professional misconduct under s 53(1)(d) of the Medical Registration Act, alleging breaches of Guidelines 4.1.3 and 4.1.4 of its 2002 Ethical Code, which require clear medical grounds for prescriptions and methods generally accepted by the profession. Proceedings were delayed by his unsuccessful judicial review. A disciplinary tribunal convicted him on 17 charges, acquitted him of a charge of breaching an undertaking to the Ministry, and suspended him for an aggregate of 18 months. He appealed against conviction and sentence to the Court of 3 Judges in Originating Application No 11 of 2024. He argued that the expert's concerns were only about quality control, that his patients asked for these treatments, that other doctors prescribed them, and that standards were unclear at the time.

Issues

1. What the applicable standard of conduct was for each category of hormone prescribed
2. Whether Dr Lee intentionally departed from that standard and, if so, whether the departure was justified
3. Whether the 18-month suspension was manifestly excessive and whether a discount for delay was warranted

Holding

The Court of 3 Judges dismissed the appeal, upholding the 17 convictions, the aggregate suspension of 18 months and the tribunal's costs orders. It ordered Dr Lee to pay costs of the appeal fixed at $50,000 and directed that the suspension begin two weeks from the judgment.

Reasoning

Applying Ang Yong Guan v Singapore Medical Council and another matter [2024] 4 SLR 1364, once a departure from the standard is shown, the doctor must show it was justified: that he weighed the standard's rationale, that his conduct was objectively defensible, and in some cases that the patient gave informed consent.

For Erfa, the standard was synthetic thyroxine. Erfa was unlicensed, the expert evidence supported the standard, and Dr Lee conceded it. The court accepted that he considered the risks and sourced Erfa through a licensed compounding pharmacy, but the key concern was Erfa's relative excess of T3, which quality control could not cure. Patient preference required real informed consent about those risks, and his records showed none. The analogy with Low Chai Ling v Singapore Medical Council [2013] 1 SLR 83 failed: unlike aesthetic medicine then, there was no uncertainty about how to treat hypothyroidism.

For Biest and Triest, the standard was registered estradiol. He called no expert to show these mixtures worked, compounding did not remove dosing risks, and generic consent forms did not show patients knew they were departing from standard treatment. A patient's request cannot justify a treatment that is not medically indicated. Progesterone was not indicated for women without a uterus, and testosterone was given despite normal test results and no qualifying diagnosis.

On sentence, harm was slight but potential harm was real, and culpability was medium given the many prescriptions over four years. No discount for delay was due, as the case was complex and about three years of delay was his own doing.

From the judgment