Law Seminar Raja Daryl Loh

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Law Seminar Raja Daryl Loh
24th June 2021
I just attended the webinar on Covid-19 and perspectives of consent by Raja, Daryl and Loh.
There was actually nothing new. It reaffirms most of what we already know.
Summary of the important discussions:
1. On my question to the panelists on off-label drug use:
a. can an off-label drug be given to a patient and is it illegal?
If the drug is not registered here, then it is illegal. Period.
b. If the drug is registered here, then off-label use must be VERY SPECIFIC based on the standard duty of care and consistent with the Bolam test. This means it must be supported by evidence AND “a practice accepted as proper by a responsible body of medical men”.
They gave 2 examples – Cytotec in labour and Ivermectin in Covid-19.
The off-label use of Cytotec in labour is very clear.
As for Ivermectin, it is illegal as Ivermectin is NOT registered for use here.
Now, IF and IF it is registered for use here, THEN the Bolam test is applicable and this must be supported by evidence AND “a practice accepted as proper by a responsible body of medical men”.
So, with MOH and experts here clearly stating the role of Ivermectin in our current situation, even if Ivermectin was to be registered here, we cannot be prescribing off-label Ivermectin.
The only exclusion is of course if this is done as a clinical trial with an ethical committee approval, and not by the whims and fancy of the treating clinician.
We are responsible to whomever we prescribe to, the Bolam test is applicable here, and we are bound by law and our responsibilities to our patients.
That should settle our current discussions on Ivermectin.
Without being supported by evidence AND “a practice accepted as proper by a responsible body of medical men”, it would currently be a breach of duty of care prescribing Ivermectin for Covid 19.
2. On another scenario – patients cannot dictate to a doctor on what to investigate and what is to be prescribed. I think this is a common occurence in private medical practice. The investigations and prescribing of treatment by a doctor should be based on a good scientific basis and be evidence-based. This is also bound by the Bolam test.
Hence no question should arise for doctors to prescribing Ivermectin just becos the patient demands for it, or has consented to be treated by it.
3. On a question about doctors being anti-vaxxers and having anti-vaxxer sentiments, healthcare professionals’ personal beliefs must be separated from medical facts. If they do have an anti-vaxxer stance, then they should not be exhibiting this as medical professionals. This can be considered a breach of duty of care by the healthcare professionals, and punitive actions can be taken against them based on the potential damage that they have caused.
4. As for spousal consent for procedures, in general a spousal consent is not neccessary, but consideration should be made on the Asian family dynamics.
As for the 2 landmark cases:
In the Abdul Razak case (2013), this was only specific to that case only. In that particular case, it was evident that the patient was dependant on the spouse to make decisions.
On the Gumit Kaur case (2012):
This is a bit different. The hospital consent form actually had a specific column for spousal consent, which was not signed by the spouse.
This case was only specific to that hospital only.
I would tend to agree on this.
The same with everyone who practices defensive medicine – you will be jeopardizing yourselves by doing unnecessary investigations and treatment. Always follow the standard duty of care, and you will be safe.
5. To a specific question I raised to the panelists, spousal consent is not necessary for vasectomy and tubal ligation (and even hysterectomy). The patient has the ultimate autonomy to decide.
The Abdul Razak and Gurmit Kaur cases are specific for those cases ONLY.
Note: there MAY be a different interpretation for Muslims who follow Syariah Law, for which spousal consent is necessary when dealing with reproductive organs.
6. On a scenario where a patient doesnt want to know the risks of the procedures when signing a consent, one can continue with the signing of the consent and proceed with the procedures becos it is ultimately the patient’s choice on whether disclosure is necessary or not. But the doctor MUST clearly document this in their case notes.
However, be aware of the patient who is likely to attach a significance of a certain risk to himself.
This deals with the explanation of material risks, which is explanation of risks a ‘reasonable’ person (in the same position) if warned of the risk is likely to attach significance to it, or, if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it.
7. This is not one format for consent taking. The same advice cannot be given for all patients. The advice of material risks is important in informed consent taking. The factors to consider include co-morbidity, locality, language, questions raised by the patient, age and social history. Most importantly, you have to know the details of the patients in very much detail to actually determine their material risks.
8. What if there are unknown risks?
The doctors’ duty is to advise on material risks and based on the knowledge at that period of time only. It deals with the standard duty of care at that particular period of time only.
9. Finally, on tackling misinformation, the following laws are applicable:
A. Communications and Multimedia Act 1998
B. Medicines (Advertisement and Sale) Act 1956
C. The Penal Code
D. Emergency (Essential Powers) Ordinance 2021.
This was basically a summary and the gist of it. Not all wordings or statements were exactly accurate by word during the webinar as we were not able to record the webinar.
However they seem correct and were consistent of my understanding as well.
Also one has to understand that many factors are involved in legal cases, and they depend on the intricate details of that particular case, as in the Abdul Razak and Gurmit Kaur cases. But the context of informed consent and the issues are all the same.
Thank you
Dr Rajeen
24th June 2021
3.40 pm

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