Case Details
- Citation: [2025] SGHC 129
- Title: Lee Pheng Lip Ian v Singapore Medical Council
- Court: High Court of the Republic of Singapore (Court of 3 Judges of the General Division)
- Originating Application No: Originating Application No 11 of 2024
- Date of Judgment: 8 July 2025
- Date Judgment Reserved: 21 January 2025
- Judges: Sundaresh Menon CJ; Tay Yong Kwang JCA; Judith Prakash SJ
- Applicant/Appellant: Lee Pheng Lip Ian (Dr Ian Lee Pheng Lip)
- Respondent: Singapore Medical Council
- Legal Area: Professions — Medical profession and practice (professional conduct)
- Statutes Referenced: Medical Registration Act (Cap. 174, 2014 Rev Ed) (“MRA”)
- Ethical Instruments Referenced: SMC Ethical Code and Ethical Guidelines 2002 Edition (“ECEG”); SMC Ethical Code
- Key Disciplinary Body: Disciplinary Tribunal (“DT”) appointed by the SMC
- Complaints Bodies: Complaints Panel; Complaints Committee (“CC”)
- Procedural History (high level): Judicial review of CC’s decision dismissed (HC/OS 514/2018 dismissed 4 March 2019; CA appeal dismissed 10 February 2020); disciplinary proceedings stayed pending judicial review; stay lifted in 2020
- Charges: 21 charges under s 53(1)(d) MRA; DT convicted on 17 charges; 4 charges withdrawn by SMC during DT proceedings; 1 charge acquitted (18th charge)
- Sentence: Suspension for an aggregate term of 18 months
- Judgment Length: 79 pages; 23,310 words
- Expert Evidence: Prof C Rajasoorya (endocrinologist, Sengkang General Hospital) for SMC
- Related Expert Evidence: Dr Eng Soo Kiang (expert opinion requested by SMC)
Summary
In Lee Pheng Lip Ian v Singapore Medical Council [2025] SGHC 129, the High Court (Court of 3 Judges) dismissed Dr Ian Lee’s appeal against his convictions and sentence arising from disciplinary proceedings for professional misconduct under s 53(1)(d) of the Medical Registration Act (Cap. 174). The case concerned Dr Lee’s prescribing of various hormone replacement therapies (“HRT”), including thyroid hormone preparations (Erfa), compounded oestrogen formulations (Biest and Triest), and prescriptions of testosterone and progesterone to multiple patients.
The disciplinary tribunal had convicted Dr Lee on 17 of 21 charges and imposed an aggregate suspension of 18 months. The High Court’s decision is significant for its application of the two-limb framework for “professional misconduct” under s 53(1)(d) as articulated in Low Cze Hong v Singapore Medical Council [2008] 3 SLR(R) 612. It also illustrates how the SMC Ethical Code and Ethical Guidelines operate in practice: even where medicines are legally available (or later shown to have been imported with approval), prescribing may still be found “generally inappropriate”, unsupported by evidence, or lacking clear medical grounds.
What Were the Facts of This Case?
Dr Lee practised from a private clinic known as the Integrated Medicine Clinic (“IMC”). The SMC’s case against him centred on the clinical appropriateness of his hormone prescriptions over a period spanning late 2011 to early 2014. The judgment usefully begins by setting out the specific prescriptions that formed the basis of the charges, together with expert descriptions of the medications. The parties did not challenge the endocrinology expert’s observations on the nature and composition of the relevant hormones.
Four hormone categories were particularly relevant. First, Erfa, a thyroid hormone preparation derived from desiccated pig thyroid glands containing both thyroxine (T4) and triiodothyronine (T3), was prescribed on 41 occasions to eight patients (P2, P3, P6, P8, P9, P10, P11 and P19) between late 2011 and early 2014. Second, Biest and Triest were custom-compounded oestrogen mixtures: Biest contained estradiol (E2) and estriol (E3), while Triest contained E2, E3 and estrone (E1). Dr Lee prescribed Biest on 11 occasions to two patients (P11 and P24) and Triest on three occasions to two patients (P10 and P25) in the same general timeframe.
Third, the SMC brought two charges relating to Dr Lee’s prescriptions of testosterone to two patients (P17 and P21). Fourth, Dr Lee faced two charges relating to progesterone prescriptions to two women (P20 and P23) who had undergone hysterectomies. The judgment clarifies that HRT generally refers to prescribing hormones to replace hormone deficiencies, while “bio-identical hormone replacement therapy” (“BHRT”) refers to hormones structurally identical to those naturally produced by endocrine glands. Importantly, the court noted that nothing in the appeal turned on whether the treatments were technically BHRT; the focus remained on whether the prescriptions were clinically justified and professionally appropriate.
The dispute also had a regulatory background. In 2013, the Ministry of Health (“MOH”) corresponded with Dr Lee expressing concern about BHRT provision. The MOH informed Dr Lee that IMC’s clinic licence would be renewed for six months subject to a licensing condition that BHRT would not be carried out at the clinic. The MOH also notified the SMC. After further clarifications, the SMC issued a formal letter of complaint in February 2014. The MOH then granted short extensions of the clinic licence to allow Dr Lee to make arrangements for patients, and Dr Lee wrote to request further renewal so that patient care would not be affected, while stating he would cease prescribing BHRT forthwith. The MOH renewed the licence multiple times while monitoring compliance.
On 15 April 2014, the MOH issued a circular prohibiting the prescription of BHRT by licensed healthcare institutions outside the context of a formal clinical trial approved by the Health Sciences Authority (“HSA”). When IMC’s licence expired in March 2015, the MOH did not renew it, citing inspection findings that Dr Lee did not intend to wean patients off BHRT. The MOH also discovered testosterone prescriptions despite normal testosterone levels and the absence of proper documentation of clinical indications. These matters formed the basis of a second SMC complaint in April 2015, which was brought before a Complaints Committee (“CC”).
Dr Lee responded by submitting written explanations under s 44(2) of the MRA. He also sought to challenge the CC’s decision to hold an inquiry by filing HC/OS 514/2018. That application was dismissed by the High Court on 4 March 2019, and his appeal to the Court of Appeal was dismissed on 10 February 2020. The disciplinary proceedings were stayed pending the judicial review, and later resumed after the stay was lifted. The SMC then obtained expert opinions, including from Prof Rajasoorya and Dr Eng, with reports signed and submitted in April 2021.
What Were the Key Legal Issues?
The central legal question was whether Dr Lee’s conduct amounted to “professional misconduct” under s 53(1)(d) of the Medical Registration Act. The provision requires an assessment of whether the practitioner’s conduct falls within the statutory concept of professional misconduct, which the Court of Three Judges in Low Cze Hong described as capable of being established through two distinct but related limbs: (a) an intentional, deliberate departure from the standards observed by members of the profession of good repute and competency (the “First Limb”); or (b) serious negligence that objectively portrays an abuse of the privileges which accompany registration as a medical practitioner (the “Second Limb”).
Accordingly, the court had to determine whether the tribunal was correct to find that Dr Lee either intentionally departed from professional standards or, alternatively, was seriously negligent in a manner that objectively portrayed abuse of professional privileges. This required the court to examine the clinical grounds for the prescriptions, the evidence (or lack thereof) supporting their use, and the circumstances in which the prescriptions were made.
A further issue concerned the relevance of regulatory availability and licensing. Some original charges had alleged that certain medications were “not legally available for prescription in Singapore”, but those allegations were withdrawn once it became apparent that the medicines had been imported with HSA approval. The court therefore had to consider how the “legally available” status of medicines affects (or does not affect) the professional misconduct analysis, particularly in light of the SMC Ethical Code provisions requiring clear medical grounds and reasonable quantities.
How Did the Court Analyse the Issues?
The court’s analysis begins with the prescriptions themselves, because the charges were patient-specific and depended on the particular hormone and clinical context. The judgment emphasises that the expert evidence on the nature and composition of the hormones was not contested. This allowed the court to focus on whether the prescriptions were clinically appropriate and whether they were supported by evidence and medical grounds.
In relation to the ethical framework, the court considered the SMC Ethical Code and Ethical Guidelines 2002 Edition, in particular Guideline 4.1.3. The guideline provides that a doctor may only prescribe medicines legally available in Singapore and must comply with statutory requirements governing their use. It also requires that a doctor prescribe, dispense or supply medicines only on clear medical grounds and in reasonable quantities as appropriate to the patient’s needs, and that patients be appropriately informed about purpose, contraindications and possible side effects. The court treated these requirements as relevant benchmarks for professional standards, even where the “legally available” aspect was no longer in dispute.
Although some charges originally alleged illegality or lack of availability, the SMC withdrew those allegations. The court therefore did not treat regulatory availability as determinative. Instead, it examined whether the hormones prescribed were generally inappropriate, whether there was a lack of evidence to support their use, and whether the prescriptions were given in circumstances where there were no medical grounds to do so. This approach reflects a key principle: professional misconduct can arise not only from prescribing medicines that are unlawful, but also from prescribing lawful medicines in an unjustified, unsupported, or negligent manner.
On the s 53(1)(d) analysis, the court applied the Low Cze Hong two-limb framework. The primary charges were framed under the First Limb (intentional, deliberate departure from professional standards), while alternative charges were framed under the Second Limb (serious negligence portraying abuse of professional privileges). The court’s task was to assess whether the tribunal’s findings were supported by the evidence and whether the tribunal correctly characterised Dr Lee’s conduct under one or both limbs.
In doing so, the court considered the broader regulatory history as context rather than as a substitute for clinical analysis. The MOH’s correspondence and licensing conditions, including the prohibition on BHRT outside approved clinical trials, showed that there were regulatory concerns about Dr Lee’s practice. However, the court’s reasoning remained anchored in the professional misconduct charges and the evidence about the prescriptions to individual patients. The fact that Dr Lee had undertaken to cease prescribing BHRT to patients (and was acquitted on the charge relating to breach of that undertaking) also underscored that the court’s conclusions depended on the tribunal’s assessment of the clinical and professional aspects of the remaining charges.
For the testosterone and progesterone charges, the court’s analysis necessarily involved whether there were proper clinical indications and documentation. The MOH had earlier found that testosterone was prescribed despite normal testosterone levels and without proper documentation of clinical indications. While the judgment extract provided does not reproduce the full patient-by-patient reasoning, the overall structure indicates that the court evaluated whether the prescriptions demonstrated either deliberate departure from professional standards or serious negligence. The same approach applied to the thyroid and compounded oestrogen prescriptions: the court assessed whether the prescriptions were supported by evidence and clear medical grounds, and whether the pattern of prescribing reflected professional competence and good-repute standards.
Finally, the court’s approach to expert evidence is notable. The SMC had obtained expert reports from an endocrinologist and another expert. The judgment indicates that the expert observations on medication composition were not challenged. The court therefore treated expert evidence as central to determining whether the prescriptions were appropriate and whether the absence of evidence or medical grounds could amount to professional misconduct under the statutory limbs.
What Was the Outcome?
The High Court dismissed Dr Lee’s appeal against his convictions and the sentence imposed by the disciplinary tribunal. The practical effect was that the convictions on 17 charges and the aggregate suspension of 18 months remained in force.
For practitioners, the decision confirms that appeals in medical disciplinary matters will turn on whether the tribunal correctly applied the statutory concept of professional misconduct and the Low Cze Hong two-limb framework, assessed against the evidence on clinical grounds, evidence support, and professional standards reflected in the SMC Ethical Code.
Why Does This Case Matter?
This case matters because it reinforces how “professional misconduct” under s 53(1)(d) is assessed in medical disciplinary proceedings. The court’s reliance on the Low Cze Hong framework demonstrates that the First Limb and Second Limb are not merely academic categories; they guide how tribunals and appellate courts evaluate intent, departure from professional standards, and serious negligence.
Equally important, the judgment illustrates that the legal availability of medicines is not the end of the inquiry. Even where medicines are legally available (and even where earlier allegations of illegality are withdrawn), prescribing may still be found professionally inappropriate if it lacks clear medical grounds, is not supported by evidence, or is administered in circumstances that objectively portray abuse of professional privileges. This is particularly relevant for cases involving therapies that may be controversial or whose evidence base is contested.
For lawyers and law students, the decision is also a useful study in disciplinary procedure and appellate review. The case includes a significant procedural history involving judicial review of the CC’s decision to hold an inquiry, followed by resumed disciplinary proceedings and expert evidence. The judgment therefore provides a coherent example of how procedural challenges may run in parallel with, and then give way to, substantive disciplinary adjudication.
Legislation Referenced
- Medical Registration Act (Cap. 174, 2014 Rev Ed) (“MRA”), including ss 39(3)(a), 44(2), and 53(1)(d)
- Medical Registration Act (Cap. 174) (as cited in metadata)
- SMC Ethical Code and Ethical Guidelines 2002 Edition (“ECEG”), including Guideline 4.1.3 (and other relevant provisions referenced in the judgment)
Cases Cited
- Low Cze Hong v Singapore Medical Council [2008] 3 SLR(R) 612
- [2025] SGHC 129 (the present case)
Source Documents
This article analyses [2025] SGHC 129 for legal research and educational purposes. It does not constitute legal advice. Readers should consult the full judgment for the Court's complete reasoning.