Mrs Khoo

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This case concerns a single parent with a previous history of drug addiction who has completed a programme of drug rehabilitation and is working in a halfway house. The patient is seeing her GP periodically as follow-up to specialist treatment for hepatitis. The patient’s mother, who helps with childcare while her daughter is at work, phones the GP with a problematic request.

Ms Khoo: A patient with a history of drug addiction seeks treatment from a family physician

Early one morning, as Dr Jeya arrived at his family practice in a HDB estate, he encountered two visibly anxious women standing in front of the locked aluminium sliding doors of the clinic. The older of the women stepped forward.

‘Are you the GP?’

‘Yes, but we’re not open yet. Do you have an appointment for this morning?’

‘No, but… ‘

Unsure about them, Dr Jeya answered, ‘Madam, my appointment book is full today. You might want to walk two blocks down and try the polyclinic.’

‘Doctor, if we can have just a moment of your time – that’s why we came so early. We don’t mean to cause any trouble.’

Observing their distress, Dr Jeya said, ‘All right, I have a little time before my first appointment – 15 minutes, no more.’ He unlocked the doors and showed the women into his office.

‘Please, take a seat. Now, what’s the trouble?’

The older woman spoke first.

‘Doctor, I’m Bertha Khoo and this is my daughter Annie. Annie is 22, she’s got a lovely little boy, here’s his photo—’

‘Mrs Khoo, I have very little time— ‘

‘Mum, I’ll tell him… sorry, Doctor. I’m losing weight and feeling sick all the time. I’ve had a fever on and off for two weeks.’

‘Have you ever had anything like this happen before—any sort of GI infection, something like that?’

Annie took a deep breath.

‘I’ll be very honest with you, Doctor. I’m an ex-drug offender. Two years in prison for heroin. That’s why we came so early… I didn’t know if I could say this with other people around. I was released early for good behaviour, and I’ve done a rehab programme. I know what you’re thinking, but I’m clean, I swear. I even have a job at a halfway house – we supply laundry services. Everything I do is for my son, he’s in kindy. My mum looks after him while I’m at work. I just want to support my son, but I’m so weak I can’t keep up at work. Just when I’m getting back my life proper…’

‘Miss Khoo, thank you for telling me this. I’m sure it wasn’t easy. Let me do a quick exam and see if we can figure out what’s going on.’

Dr Jeya observed on examination that Annie had a tinge of jaundice, but no other clinical signs of infection or other disease. He took a blood sample, and told Annie to register with the receptionist at the front counter so that he could contact her when the test results came back, adding, ‘You don’t have to tell her everything you told me. Just tell her that you came to clinic early and I fitted you in as a new patient.’

Based on the patient’s jaundice and symptoms as described, and on her history of heroin use, Dr Jeya ordered tests for blood counts, liver function, Hepatitis A, B, and C, and HIV. When the test results came back the following day, they were negative except for Hepatitis B; that, together with evidence of moderately abnormal liver function, suggested ongoing infective hepatitis.  Dr Jeya called Annie that evening to explain that she had tested positive for Hepatitis B and needed to follow up with a gastroenterologist.

After visiting the gastroenterologist and taking a month of anti-viral treatment, Annie, accompanied by her mother, turned up at Dr Jeya’s clinic for a scheduled appointment.

‘Hi, Dr Jeya! I’m feeling so much better than the last time I was here! I’m back at work, I can keep up with my little boy – everything’s good. The GI specialist told me to follow up with my regular GP for the Hep B surveillance bloodwork – I hope it’s okay that I came back here?’

‘Of course, Annie. I’m very glad that you’re feeling better and that you stuck with the treatment. We’ll do your bloodwork today, and then, if everything is going well, I’ll see you in three months.’

Three months after Annie’s first follow-up appointment,  Dr Jeya receives a phone call from Bertha Khoo:

“Doctor, it’s about Annie.”

‘What’s wrong? Has something happened to her?’

‘I think she’s back on heroin. She just can’t – or won’t – get out of bed. She can’t keep track of her medication for the hepatitis. I’m afraid she’s going to lose her job; she’s missed work or been late so many times lately. And I’m not sure if I can leave her alone with my grandson.’

‘Mrs Khoo, I’m very sorry to hear this. I’m not sure what I can do – I’m Annie’s GP, not a specialist in addiction. And there could be other explanations.’

‘Dr Jeya, I need your help. Annie trusts you. Her next appointment is tomorrow. I want you to test her for drugs. I don’t feel right leaving my grandson with her until I know whether it’s safe.’

Dr Jeya pauses to think about how to respond.

Who has the right to know?

Commentary by Nancy Berlinger

What a caregiver needs to know

The ethical question that Dr Jeya faces does not, at first glance, seem difficult. Should he perform a drug test on an adult patient at the request of someone other than the patient, without the patient’s consent? Mrs Bertha Khoo did not explicitly ask for Dr Jeya to test Annie Khoo without Annie’s consent. However, calling Dr Jeya in advance of Annie’s visit and stating, in effect, ‘I want to know,’ implies that Bertha wants this information for herself, so she can assess whether it is safe for Annie to be left alone with Annie’s own young son. Dr Jeya may know that he cannot administer a test for drugs without a patient’s informed consent. Nor can he disclose a patient’s health information to another person without the patient’s informed consent. Patient privacy, the confidentiality of health information, and the expectation that physicians will deal directly and truthfully with their patients are fundamental to ethical practice. Neither the consent that Annie has provided to date for other medical treatment and testing, nor Mrs Khoo’s history of participating in Annie’s healthcare, justifies undermining these rights and expectations.

What healthcare providers need to know

A person in Annie’s situation has probably undergone mandatory drug testing, as a condition of her probation, rehabilitation, and employment. Drug testing may sometimes be part of medical treatment, but it is a controversial practice.

On the one hand, evidence that a patient is misusing or abusing drugs would be relevant to the physician­–patient relationship in several ways. To avoid harmful interactions, a physician needs to know what drugs are in a patient’s system. Ongoing use of drugs or alcohol may rule out some forms of medical treatment, such as organ transplants.

Knowing whom and when to trust

A physician may reasonably be concerned that a patient with a history of drug addiction may be likely to conceal or lie about drug misuse or abuse. However, as far as Dr Jeya knows, Annie has been truthful about her past drug use and its effect on her life and her health.

On the other hand, drug testing within the physician–patient relationship introduces surveillance into that relationship. It conveys the message that the physician expects that this patient will not be truthful, and the truth must be obtained by other means. It may be stigmatising, suggesting that a patient with a known history of addiction should expect less privacy than other patients. And it may be unfairly applied, if patients who have been more truthful about past or continuing drug use are placed under greater scrutiny than patients who have concealed these activities.

Dr Jeya, by his own admission, is not a specialist in the treatment of addiction, and he may well be unsure where these issues fit into everyday GP practice. As a GP, he should know that any physician may be in a position to consider whether a patient poses a danger to herself or to others, or is in an unsafe situation. He should also know that patient privacy, confidentiality, and informed decision-making are legal and ethical standards for good care, and that breaking patient confidentiality, deceiving a patient, or treating a patient without consent are unethical under most circumstances and require stringent justification.

Respecting patients as persons

At this point, Dr Jeya has no information about Annie Khoo’s current situation other than her mother’s perceptions. While Annie clearly relies on her mother, and while Mrs Khoo is clearly concerned about her daughter and her grandson, Dr Jeya’s primary responsibility is to Annie, his patient. He owes it to Annie to try to find out, from Annie, what is going on in her life, as part of providing good medical care to Annie as a person. This will be challenging, as he is unlikely to forget what Bertha Khoo has told him, and this may introduce bias or other communication problems into his next meeting with Annie. Caring for Annie and respecting her privacy, while supporting Bertha and taking her observations and concerns seriously, will be continuing challenges for Dr Jeya.


Commentary by Berlinger, Nancy, ‘Who has the right to know?' in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),

Covert testing

Commentary by Calvin W. L. Ho

In this case, a key ethical and legal issue that confronts us is whether the clinician, Dr Jeya, should accede to a request from the patient’s mother, Mrs Bertha Khoo, to covertly test for drug use by the patient, Annie. There is arguably no legal basis for such a testing to be conducted, although a number of ethical implications would also be considered.

Informed consent and covert testing

The requirement of informed consent is explicitly recognised in the Ethical Code and Ethical Guidelines of the Singapore Medical Council. It requires a doctor to ensure that a patient under his care is adequately informed about her medical condition and options for treatment so that she is able to participate in decisions about her treatment. If a procedure needs to be performed, the patient shall be made aware of the benefits, risks and possible complications of the procedure and any alternatives available to her. In addition, the Medical Council indicates that the patient has a right to adequate information so that she can make informed choices about her medical management. A doctor must respect his patient’s choice of accepting or rejecting the medical advice or treatment, provided that the patient understands the consequences of her choice. There are exceptional situations where the requirement of informed consent could possibly be dispensed with. These situations are mainly concerned with preserving life, preventing suicide and protecting innocent third parties.

In the context of this case, there does not appear to be an immediate need to adopt drastic measures to preserve Annie’s life or to prevent suicide. In addition, it is unclear if Annie is a danger to anyone else, including her mother or her son. It is hence difficult to find a proper legal or ethical basis for covert testing for drug use, particularly since such an action would contravene fundamental legal principles of informed consent, the right to refuse treatment, and substantive and procedural due process rights. In the absence of a medical emergency and where Annie has the capacity to make decisions <link to BG on Medical decision-making>, Dr Jeya should attempt reasonable measures of open discussion and persuasion, rather than carry out covert testing. Failing to do so could amount to a civil wrong, in conducting a medical test without the patient’s consent, as well as a breach of ethical and professional duty.

If Annie’s behaviour strongly suggests a relapse of illicit drug use, every attempt should be made by Dr Jeya and Mrs Khoo to persuade Annie to seek help. As Dr Jeya has explained to Mrs Khoo, he is not a specialist in addiction. Even if Annie is tested positive for drug use, he would need to refer her to a specialist. Covert testing by Dr Jeya in a non-transparent manner is likely to contribute to an atmosphere of distrust between Annie and those who are concerned about her well-being.

Getting help

During the medical consultation, Dr Jeya could discuss with Annie the option of seeking help from the Institute of Mental Health’s National Addictions Management Service (NAMS) clinic which provides specialist treatment, or the Singapore Anti-Narcotic Association (SANA) which offers case management and a range of social services, if she suffered a relapse. He could likewise advise Bertha Khoo to get specialist counselling through these channels.

Doctors are required to report any relapse into drug use to the Central Narcotics Bureau (CNB). The CNB is the primary drug enforcement agency that is responsible for eradicating illicit drug use in Singapore. An officer of the CNB or a police officer has the power to require a person reasonably suspected of illicit drug use to undergo a urinalysis. The Director of the CNB is empowered by law to commit an illicit drug user for treatment and rehabilitation in a drug rehabilitation centre for between six and 36 months in duration. Repeat offenders of specific drugs could be subject to long-term imprisonment. Apart from enforcing the law on misuse of drugs and carrying out treatment and rehabilitation for addicts, the CNB is also concerned with preventive drug education, and aftercare and continued rehabilitation for former addicts with the goal of re-integrating them into society. It is highly likely that CNB already has had some follow-up with Annie after her initial release, and either Annie or Mrs Khoo could contact the Bureau for assistance.

There should already be a relationship of collaborative trust between Annie and Dr Jeya. After all, Annie was honest in disclosing to him that she had a problem with drug addiction. As his patient, the fiduciary duty that Dr Jeya has towards Annie requires him to be truthful in his communication with her. This should encompass honest discussion with Annie on what follow-up actions would be appropriate for Dr Jeya if she did or is likely to have suffered a relapse. Covert testing is not a viable solution. It is not only damaging to the relationships of trust that Annie has with Mrs Khoo and with Dr Jeya, but could potentially undermine the trustworthiness of the medical profession.


Commentary by Ho, Calvin W. L., ‘Covert Testing', in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),

Ethical dilemmas in family practice

Clinical perspective by Chong Poh Heng

The diversity of work never fails to excite a general practitioner (GP). Every day, there are situations not encountered in training. You never know who might walk through your doors or what challenges the day might bring! It forces this generalist to come out of his comfort zone and think out of the box.

A GP does not often get to meet someone like Annie Khoo, nor does he relish it. Facing a patient like this alone can be challenging at best and unnerving at worst – not to mention the unhappy patients in the waiting room if this consultation goes on for too long, or the impact a ‘difficult case’ might have on the already slim profit margins of a humble practice.

Practically, common sense and conventional wisdom would help in dealing with Bertha Khoo’s request. Conceptually, is there a cogent way to work out a moral answer here?

An ‘ex-drug offender’ should be recognised for what it is – a label. Immediately, a stereotyped image of a former convict comes to mind. The patient is thereby often stigmatised and discriminated against in other ways. If she ever asks for sedatives just for a decent night’s sleep, would you even prescribe them? I still clearly remember the sign a colleague of mine hung outside his clinic. ‘We do not stock Dormicum here.’ When I first started out, a senior colleague warned me that drug addicts could be devious and manipulative, ‘Never believe what they say. If you don’t want to have trouble, or to lose your other patients, have nothing to do with them.’

We have only recently understood a little more about the reward system in the limbic system of our brain. Is dependence or even addiction an illness or a crime? Should people with chemical dependence or addiction be given special medical attention, or shunned? Because dire social circumstances or dysfunctional families can be part of an addicted person’s struggle, the afflicted ought to receive treatment beyond just detoxification. The unanswered medical and policy question is, who should provide it? A dedicated team of trained specialists? A trusted family physician? Or an enforcement agency?

I believe that my specialist colleagues and I are duty bound to help people like Annie to rid themselves of their ‘disease’, so that they can regain their control and dignity. Additional justification for this commitment comes from my responsibilities to the institution of the family, and to the state.

Coming back to Annie and her mother Bertha, I see three dimensions of tension as Dr Jeya ponders what to do next.

Complexity of addiction disorders

We should learn to leave our preconceptions and prejudices behind as we attend to anyone who has come to us for help. Personal limitations in terms of knowledge and experience should be clear. Some cases are best left to the experts, using a structured team-based approach and drawing on what the evidence tells us about good care for patients who struggle with addiction.

Regulations for mandatory reporting

We must be familiar with these, so that we do not run afoul of the law, and so that we know how to get help in exceptional cases where we may be menacingly threatened by a desperate offender. If Dr Jeya has strong, independent reasons – beyond Bertha’s suspicions – to suspect that Annie has resumed her old ways, he would be obliged to report her to the authorities.

Balance of rights between the patient and her family

If Dr Jeya accedes to Bertha’s request, he risks compromising his professional ties to Annie. However, Annie has so far been truthful with him. For his part, Dr Jeya has not seen Annie in months, and should not take Bertha’s word for it that Annie is using drugs or is under narcotic influence to the extent that her capacity to make decisions has been seriously affected.

Therefore, in my view, Dr Jeya should urge Bertha to persuade Annie to come to the clinic and obtain from him a referral to specialist care for her current health problems and challenges. Dr Jeya should also check on Annie’s capacity to make her own decisions in this area. He might further explore with Annie the step of documenting an advance directive to designate certain persons to authorise a doctor to administer appropriate tests and treatments in the event that she loses capacity to make decisions due to narcotic influence. At the same time, he could advise Bertha to seek help and specialist counselling for family members through services such as the National Addiction Management Service clinic’s helpline.

Ultimately, the tension lies within the physician himself, to make these difficult decisions courageously.


Clinical Perspective by Chong, Poh Heng, ‘Ethical dilemmas in family practice', in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. i: Making Difficult Decisions with Patients and Families (Singapore: National University of Singapore, 2014; 2017),