For clinical consent mavens - Singapore just passed into law an effective enshrinement of the Hii Chi Kok (aka modified Montgomery) standard on medical advice. Clarifies some issues, complicates others. Quick thread, 1/n https://www.straitstimes.com/singapore/politics/parliament-new-test-introduced-for-doctors-to-take-informed-consent-from-patients

It's a short read, but if you're impatient, you might be forgiven for thinking after looking at the very first section 37(1) this is a rollback to Bolam-Bolitho. Advice must be in line with "peer professional opinion" + logic. 2/n https://sso.agc.gov.sg/Bills-Supp/33-2020/Published/20200903?DocDate=20200903

Not so! Very next section 37(2) defines away the relativism of peer opinion, by essentially prescribing what that opinion must be - two delineating what information must be given, the third concerning when it's ok not to provide certain otherwise-required information. 3/n

This is rather conceptually confusing, obscuring the extent to which patient perspectives are really dominant in the law's framework, not physician perspectives. 4/n

That aside, we can move onto the first limb of information that must be provided (37.2.a.i)): info the patient would reasonably need to make an informed decision. No illustrations or explanations of what this means are provided. 5/n

While the Ministerial speech on the law claimed this law would resolve ambiguities in Hii Chi Kok/modified Montgomery, as far as I can tell this language preserves or (given brevity) even exacerbates those issues. 6/n https://www.moh.gov.sg/news-highlights/details/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

The law goes further to clarify things in the second limb (37.2.a.ii), where info is 'material' to the particular patient (over and above what's required for a generic patient, per first limb). 7/n

(as an aside, the law confusingly only references materiality in relation to the second limb, though again, conceptually it appears to apply to the first limb as well) 8/n

On its face that's also ambiguous, but a later section of the law, 37.3, clarifies: this means either the patient has asked for the info, or it's evident from the patient's readily-accessible medical record. Helpful illustrations are provided. Improvement over HCK, imho. 9/n

Third limb is something of a step back, a large amplification of ambiguity concerning when it's ok not to disclose info that's met the first or second limb. Just says, when there's "reasonable justification." 10/n

There's two examples at 37.3.b are given of legally acceptable non-disclosure justifications. One is unconsciousness. Other is express patient request not to hear info they've already heard from a different doc. Sensible, but very obvious - not much help in hard cases. 11/n

A negative example in the law shows what's not a reasonable justification - that if they gave the info, the patient would decline care. Ok, but again, leaves open a whole host of questions. What about therapeutic privilege? Diminished capacity? Public interest? etc. 12/n

Hii Chi Kok as well as the Singapore Medical Council's Ethical Code and Ethical Guidelines/Handbook on Medical Ethics at least goes further in specifying conditions of non-disclosure, and elaborate further on the first limb as well. 13/n

All things considered, it's good to have the principles of the Hii Chi Kok/modified Montgomery standard enshrined in legislation, not just common law, and some issues of materiality clarified. But the central ambiguities of that standard remain, or are even enlarged. 14/end