Letters to the Editor
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"Providing medical care at reasonable cost, a relevant ethical consideration although not explicitly stated in the pledge, is another responsibility that has become increasingly difficult to discharge during the past 50 years." - Emeritus Professor K Shanmugaratnam
The Reaffirmation of the Singapore Physician Pledge was made by the newly appointed medical officers of 1998 on 2 May 1998. We reproduce the address given by Emeritus Prof K Shanmugaratnam, Guest of Honour and Dr Lee Suan Yew, Member, Singapore Medical Council.
Address by Emeritus Professor K Shanmugaratnam
I feel honoured to take part in this Pledge Affirmation Ceremony. Being here also gives me a sense of nostalgia because it was in this very hall that I took my final qualifying examinations in 1947. It was also in this hall that our graduation ceremony was held with the Principal and professors of the then King Edward VII College of Medicine on the stage, the graduates on two rows of chairs at the side (there were only 13 medical graduates that year) and an audience consisting mainly of medical students.
There was no formal pledge affirmation ceremony when I became a medical practitioner more than 50 years ago _ which was before the formulation of pledge that we now affirm. We were of course aware of the Hippocratic Oath of which the origins trace back to more than 2,000 years ago but this oath, although cherished by virtue of its antiquity, contained some pledges that were so anachronistic that I doubt if it will ever be affirmed or administered in modern times as a condition for entering medical practice.
The Hippocratic Oath however did contain elements of some important ethical principles in the practice of Medicine. These principles were updated and incorporated in the Declaration of Geneva by the World Medical Association in 1949. The Singapore Medical Council Pledge is based on this Declaration.
This pledge is applicable to all registered medical practitioners regardless of their fields of work; it applies not only to general practitioners and specialists who deal directly with patients but also to physicians working in areas such as laboratory medicine, the diagnostic services or community health programmes. The pledge refers to the ethical obligations of physicians to one another, their ethical obligations to the sick, and several other ethical considerations relevant to the practice of medicine. The most important items in the pledge are those that concern the physicians obligations to their patients and to the community.
Sick patients and the community in general would justifiably expect physicians to use their professional knowledge and skills to cure their illnesses or at least minimise their effects, to respect the confidentiality of information gained from their consultations and investigations, to provide medical care at reasonable cost, and to participate in programmes for the prevention of diseases. These are fairly universal expectations. I shall not discuss any of them in detail but would limit myself to saying a few words on some developments in the practice of medicine during the past 50 years that have influenced the discharge of these expectations and obligations.
One of these developments has been the range and pace of medical advances during the past half century: these have led to new knowledge on the causation and manifestations of some diseases, the evolution of new medications, improved methods of therapy and, the use of sophisticated technology in the diagnosis and treatment of diseases. We are now able to do much more for our patients in terms of accuracy of diagnosis and efficacy of treatment.
But the magnitude of the information gathered and rapidly disseminated through a profusion of new books and medical journals has made it more difficult to keep up with all these advances. Some of this information is also available, often in considerable detail, to the lay public through the Internet and through review articles in popular weekly magazines. These circumstances have made it more important than ever before for physicians to keep adding to their knowledge and skills by continuing their medical education throughout their working lives however arduous the undertaking may be. They owe it to their patients and to themselves to do so.
Protecting medical confidentiality, another obligation that is spelt out in the pledge, was a relatively manageable proposition 50 years ago when a few physicians were involved in the treatment of individual patients and when medical reports and communications between them were sent in envelopes marked "Confidential". It has now become more problematic and demanding, especially in big institutions where the management of individual patients involves a much larger team of physicians and supporting staff representing various medical specialities, and where confidential medical reports are often sent through fax machines or transmitted electronically.
It is essential for everyone involved in the diagnosis and care of patients to respect medical confidentiality. The identity of patients should not be disclosed at "open" conferences. Fax machines and computer records must be protected from unauthorised access. The doctor-patient relationship is based on absolute trust and patients have every right to expect their physicians to protect the confidentiality of information gained through their consultations and investigative procedures _ except of course when disclosure of such information is required by law.
Providing medical care at reasonable cost, a relevant ethical consideration although not explicitly stated in the pledge, is another responsibility that has become increasingly difficult to discharge during the past 50 years.
Physicians can help reduce costs by avoiding unnecessary investigative procedures and extremely expensive modes of treatment as far as possible. But even their best efforts may not always succeed in bringing costs down to generally acceptable levels because it is difficult to circumvent some of the factors that have contributed to the steady rise in costs over the past 50 years, viz: the high cost of some medications, the use of highly advanced technology and expensive equipment in the investigation and treatment of some diseases, and increasing professional costs related to an expansion in the range of medical specialties and an increase in the proportion of physicians, working as specialists compared to those working as general practitioners or primary care providers.
The increase in medical costs has been complicated and aggravated in many countries by an upsurge of commercial interests in the delivery of health care, and by social and economic changes in society. More patients now ask for and are willing to pay for highly advanced forms of investigation and treatment for their complaints. Health care under such circumstances tends to get focused on patients who can afford to pay rather than on those who need it.
There is also a danger that some physicians can be tempted by mercantile considerations. They may allow themselves to be guided by the ethos of the market-place, rather than the pledge to uphold the noble traditions of the medical profession. Patients of course have the right to afford better or more sophisticated health care like any other service or commodity according to their priorities. And it is quite legitimate and justifiable for physicians, to be rewarded according to their competence like professionals in other industries.
But there is more to being a good physician than competence and industry: physicians have the obligation to fulfil a pledge to make the health of patients their first consideration. They must not, in the pursuit of their personal goals, allow themselves to be influenced primarily by motives of profit.
We are frequently made aware, through press reports from many countries, of physicians whose professional practices have been unethical or fraudulent physicians who over-service, prescribe unnecessary medications, undertake unnecessary surgery for personal profit or who abuse and defraud national health insurance programmes.
It is important to recognise that such physicians represent but a small minority in the profession. The majority of physicians are socially responsible practitioners who have made enduring contributions to the health and welfare of their communities through hard work and commitment to their vocation. Many among them are not only highly competent professionally but have also dedicated themselves to the welfare of their patients, the betterment of the health of the community or the advancement of their profession.
SMC PHYSICIANS PLEDGE
"I solemnly pledge to: