A healthcare professional’s duty to advise: legislation and case law governing medical advice in Singapore

The legal landscape governing medical advice in Singapore has evolved over the years. Prior to 2017, a more “doctor-centric” test was in place (i.e. the Bolam-Bolitho test), which then evolved to a more “patient-centric” test established by the Court of Appeal in the landmark case of Hii Chii Kok v Ooi Peng Jin London Lucien [2017] SGCA 38. Effective from 1 July 2022, the standard of care in relation to a healthcare professional’s duty to advise was then codified under section 37 of the Civil Law Act 1909, with the statutory provision aiming to strike a balance between the two.

Section 37 of the Civil Law Act 1909

Section 37 was introduced following recommendations made by the Ministry of Health’s Workgroup to Review the Taking of Informed Consent and SMC Disciplinary Process, which was set up following a series of high-profile disciplinary actions. For example, in Singapore Medical Council v Dr Lim Lian Arn [2018] SMCDT 9, Dr Lim was at first instance fined $100,000 for failing to inform a patient about risks associated with a relatively routine and simple steroid injection. This conviction was overturned by the Court of Three Judges, who with reference to an earlier Court of Appeal judgment observed “that a doctor is not under a duty to convey to his patient every conceivable risk.”

The Workgroup’s report, dated 28 November 2019, highlighted uncertainty among medical professionals about informed consent requirements, and some admitted to practising defensively to err on the side of caution. The legislative intent of section 37 (as discussed in Parliament) is to frame a legal test which strives to preserve the principle of patient autonomy while upholding the principle of self-regulation in the medical profession (see Opening Speech for Second Reading of the Civil Law (Amendment) Bill and Medical Registration (Amendment Bill) by Mr Edwin Tong, Second Minister for Law, on 6 October 2020). In brief, section 37(1) provides that there are two conditions to be satisfied in relation to the duty to advise:

1. First, the healthcare professional must act in a manner accepted by a respectable body of medical opinion (also known as “peer professional opinion”).
2. Second, the peer professional opinion must be logical.

Additionally, section 37(2) also prescribes the standard by which the peer professional opinion must assess the information:

1. The patient must be given information which a person “in the same circumstances as the patient (which circumstances the healthcare professional knows or ought to know) would reasonably require to make an informed decision about whether to undergo a treatment or follow a medical advice”.
2. The patient must be given information which “the healthcare professional knows or ought to know” is “material” to that particular patient.
3. If material information is not given to the patient, there must be reasonable justification for not doing so.

Section 37(3) elaborates on the assessment of what information is material for the purpose of making an informed decision. This could relate to concerns/queries that “the patient expressly communicates to the healthcare professional”, or information which is not expressly communicated by the patient “but which ought to be apparent to the healthcare professional from the patient’s medical records”.

While it remains to be seen how cases will be decided following section 37, it is likely that certain principles from previous cases will remain instructive.

The standard will likely be calibrated based on the nature and complexity of the procedure

First, the court is likely to have regard to the nature and complexity of the procedure in determining the standard of care in relation to the duty to advise. This was illustrated in Cheng Shi Ying Cherissa v Khoo Chong Kiat [2025] SGHC 53 (Cherissa Cheng), where the patient alleged that her doctor failed to obtain her informed consent before performing cervical sweeps, an episiotomy, applying manual fundal pressure during delivery and repairing a rectovaginal tear.

The court found that no material or relevant information was withheld from the patient. In doing so, the court stressed that “medical procedures often involve numerous steps and routine actions” and “[r]equiring doctors to obtain explicit consent for each individual act within a medical procedure is impractical and would place an unreasonable burden on them.” The court added that doctors in Singapore are not required to obtain formal consent for an episiotomy or manual fundal pressure, which are considered “routine procedures of natural vaginal deliveries”. The court accepted that the purpose and process of a cervical sweep had been explained to the patient beforehand, and that at the material time, the baby’s head was crowning and there were signs of foetal distress. While it would have been good to let the patient know before a episiotomy is performed and before applying manual fundal pressure, failing to do so is not a breach of the standard of care.

Similarly, in Singapore Medical Council v Lim Lian Arn [2019] SGHC 172, the Court of Three Judges also took into account that the matter involved “a one-off failing committed in the course of a routine procedure”, in finding that Dr Lim’s conduct could not be said to be sufficiently serious to constitute professional misconduct under the Medical Registration Act.

The standard of care will likely be calibrated based on specialisation

Second, the healthcare practitioner’s specialisation may also be relevant in determining the scope of the duty to advise. This may be derived from Noor Azlin Bte Abdul Rahman v Changi General Hospital Pte Ltd & Ors [2019] SGCA 13 (Noor Azlin), which involved the delayed diagnosis of lung cancer.

In that case, the Court of Appeal emphasised that the standard of care must reflect the realities of each medical specialty’s working conditions. For instance, emergency medicine doctors are expected to see many patients in a day and to “make decisions at short notice in a highly pressurised environment”. It would therefore be unreasonable to expect emergency doctors “to review cases in as much breadth, depth or specificity as a GP or specialist in an outpatient clinic”. Instead, they may adopt a “targeted approach”, and “reasonably prioritise the diagnosis and treatment of the patient’s presenting symptoms and the elimination of life-threatening conditions”.

By contrast, the Court found that the respiratory specialist, who was the “last in line” to diagnose the lung opacity, was held to a higher standard and expected to conduct a more thorough follow-up. Although Noor Azlin did not concern the duty to advise, it is arguable that the scope and detail of medical advice should be tailored to the practitioner’s specialty, and the demands of their role.

Comment

Codification of the duty to advise under section 37 is a significant development in Singapore’s medical law. Crucially, section 37 applies not only to doctors but also other “healthcare professionals” including dentists or oral health therapists and potentially Traditional Chinese Medicine practitioners who give “medical advice”.

While it remains to be seen how the courts will interpret and apply section 37, it is likely that they will adopt a nuanced approach taking into account factors such as the nature and complexity of the medical procedures as well as the context that different healthcare practitioners operate in (as demonstrated by Cherissa Cheng and Noor Azlin). Expert opinion will continue to remain crucial in the determination of what is the reasonable standard of care in different factual matrices.

Overall, section 37 provides a more structured and transparent standard to the duty to advise. It balances  patient autonomy while acknowledging the practical demands of medical practice, and leaves room for self-regulation within the medical practice.