Case Details
- Citation: [2025] SGHC 129
- Title: Lee Pheng Lip Ian v Singapore Medical Council
- Court: High Court (Court of 3 Judges of the General Division)
- Originating Application No: Originating Application No 11 of 2024
- Judgment Date: 8 July 2025
- Judges: Sundaresh Menon CJ, Tay Yong Kwang JCA, Judith Prakash SJ
- Judgment Reserved: 21 January 2025
- Appellant/Applicant: Lee Pheng Lip Ian (“Dr Lee”)
- Respondent: Singapore Medical Council (“SMC”)
- Legal Area: Professions — Medical profession and practice — Professional conduct
- Statutory Provision(s) Referenced (as stated in extract): Medical Registration Act (Cap 174, 2014 Rev Ed) (“MRA”), s 53(1)(d); s 39(3)(a); s 44(2)
- Ethical Code/Guidelines Referenced (as stated in extract): SMC Ethical Code and Ethical Guidelines 2002 Edition (“ECEG”), Guideline 4.1.3 (and also Guideline 4.1.4, partially set out in extract)
- Key Medical Context: Hormone replacement therapy (“HRT”), including “bio-identical hormone replacement therapy” (“BHRT”); prescriptions of thyroid hormone (Erfa), compounded estrogen mixtures (Biest/Triest), testosterone, and progesterone
- Procedural History (as stated in extract): Convicted by SMC disciplinary tribunal; DT suspended Dr Lee for an aggregate term of 18 months; appeal to High Court (Court of 3 Judges)
- Judgment Length: 79 pages, 23,310 words
- Cases Cited (as stated in extract): Low Cze Hong v Singapore Medical Council [2008] 3 SLR(R) 612 (“Low Cze Hong”)
Summary
This High Court decision concerns a medical practitioner’s appeal against his convictions and sentence following disciplinary proceedings before a tribunal appointed by the Singapore Medical Council (“SMC”). Dr Lee, a licensed practitioner operating the Integrated Medicine Clinic (“IMC”), was charged under s 53(1)(d) of the Medical Registration Act (Cap 174, 2014 Rev Ed) (“MRA”) for professional misconduct in relation to his prescription of various hormone replacement therapies, including thyroid hormone preparations, compounded estrogen mixtures, testosterone, and progesterone. The SMC’s case, as reflected in the disciplinary charges, focused on the propriety of Dr Lee’s prescribing practices and whether they met the professional standards expected of doctors of good repute and competency.
At the disciplinary tribunal stage, Dr Lee was convicted on 17 of 21 charges and received an aggregate suspension of 18 months. The present judgment is delivered by a Court of 3 Judges of the High Court, which addresses Dr Lee’s appeal against both conviction and sentence. The decision also clarifies how the legal threshold for “professional misconduct” under s 53(1)(d) is to be applied, particularly through the two-limb framework articulated in Low Cze Hong v Singapore Medical Council: (a) intentional and deliberate departure from professional standards, and (b) serious negligence that objectively portrays an abuse of the privileges of registration.
What Were the Facts of This Case?
Dr Lee practised from a private clinic licensed to him as the Integrated Medicine Clinic (“IMC”). The disciplinary proceedings arose from his prescribing of hormone-related therapies to multiple patients over a period spanning late 2011 to early 2014. The SMC’s expert evidence, led by Prof C Rajasoorya, an endocrinologist at Sengkang General Hospital with more than 30 years of experience, described the nature and composition of the relevant medications. The extract indicates that Prof Rajasoorya’s observations were not challenged before the disciplinary tribunal or on appeal, which suggests that the dispute was largely about clinical appropriateness and professional standards rather than the pharmacological identity of the drugs.
The prescriptions relevant to the appeal were grouped into four hormone categories. First, Dr Lee prescribed Erfa, a thyroid hormone preparation containing both thyroxine (T4) and triiodothyronine (T3), on 41 occasions to eight patients. Second, Dr Lee prescribed compounded estrogen mixtures: Biest (estradiol E2 and estriol E3) on 11 occasions to two patients, and Triest (E2, E3, and estrone E1) on three occasions to two patients. Third, Dr Lee faced charges concerning testosterone prescriptions to two patients (P17 and P21). Fourth, Dr Lee faced charges concerning progesterone prescriptions to two women (P20 and P23) who had undergone hysterectomies. While the extract frames these as “HRT” and discusses “BHRT”, it also notes that for the purposes of the appeal, nothing turned on whether the specific treatments were technically BHRT.
Before the SMC disciplinary proceedings, the Ministry of Health (“MOH”) had expressed concerns about Dr Lee’s provision of BHRT. In 2013, MOH correspondence indicated that the IMC’s clinic licence would be renewed for six months subject to a licensing condition that BHRT would not be carried out at the IMC. MOH also notified the SMC. The SMC then issued a formal letter of complaint on 14 February 2014 pursuant to s 39(3)(a) of the MRA. The licensing regime was subsequently extended multiple times, with MOH monitoring compliance and Dr Lee indicating that he would cease prescribing BHRT forthwith, while requesting further renewals so that patients’ care would not be affected.
In April 2014, MOH issued a circular prohibiting the prescription of BHRT by licensed healthcare institutions outside the context of an approved clinical trial. When the IMC’s clinic licence expired in March 2015, MOH did not renew it, citing inspections in February and March 2015 and alleging that Dr Lee did not exhibit an intention to wean patients off BHRT. MOH also discovered that Dr Lee was prescribing testosterone to patients with normal testosterone levels and without proper documentation of clinical indications of testosterone deficiency. These allegations formed the basis of a second letter of complaint issued by the SMC on 30 April 2015 under s 39(3)(a) of the MRA. The complaints were then laid before a Complaints Committee (“CC”), which ordered an inquiry to be held by a disciplinary tribunal (“DT”). Dr Lee’s attempts to challenge the CC’s decision were dismissed through judicial review proceedings, with the disciplinary proceedings stayed pending the final determination of those proceedings.
What Were the Key Legal Issues?
The central legal issue was whether Dr Lee’s conduct amounted to “professional misconduct” within the meaning of s 53(1)(d) of the MRA. That provision, as applied in medical disciplinary contexts, requires an evaluative assessment of whether the practitioner’s conduct reflects a departure from the standards of the profession of good repute and competency, or whether it amounts to serious negligence that objectively portrays an abuse of the privileges which accompany registration as a medical practitioner.
Consistent with the Court of Three Judges’ approach in Low Cze Hong, the SMC structured the charges to reflect two alternative forms of mens rea capable of amounting to professional misconduct: a “First Limb” (intentional, deliberate departure from professional standards) and a “Second Limb” (serious negligence objectively portraying abuse of registration privileges). The legal questions therefore included not only whether Dr Lee prescribed the relevant hormones, but whether the evidence supported the required mental element and the objective characterisation of the conduct as professional misconduct under either limb.
A further issue concerned the relevance and application of the SMC Ethical Code and Ethical Guidelines 2002 Edition (“ECEG”). The extract indicates that the charges relied on alleged breaches of Guideline 4.1.3, which requires that doctors prescribe medicines that are legally available in Singapore, comply with statutory requirements governing their use, prescribe only on clear medical grounds and in reasonable quantities, and appropriately inform patients about purpose, contraindications, and possible side effects. The disciplinary case also included allegations relating to Guideline 4.1.4 (partially truncated in the extract), which likely addressed additional aspects of clinical practice and patient management. The court had to consider whether breaches of these guidelines, together with the clinical circumstances, established professional misconduct under s 53(1)(d).
How Did the Court Analyse the Issues?
The Court’s analysis begins with a careful mapping of the factual substratum to the legal framework for professional misconduct. It is significant that the SMC’s charges were amended to provide primary and alternative charges for each original charge, reflecting the two-limb framework from Low Cze Hong. This structure matters because it prevents the disciplinary case from being reduced to a mere “bad outcome” or “poor practice” narrative; instead, it requires the tribunal (and on appeal, the court) to identify whether the evidence supports intentional departure from professional standards or serious negligence that objectively portrays abuse of registration privileges.
On the factual side, the Court treated the identity and nature of the medications as largely established. The extract indicates that Prof Rajasoorya’s observations were not challenged, and the prescriptions were set out in an agreed statement of facts dated 27 October 2022. The Court therefore focused on the appropriateness of prescribing—whether there were “clear medical grounds”, whether the quantities and circumstances were reasonable and evidence-based, and whether the clinical documentation and patient management met professional expectations. The SMC’s approach, as reflected in the extract, shifted away from an initial allegation that certain medications were not legally available for prescription in Singapore, because it became apparent that the medications had been imported with HSA approval. That shift suggests the case turned more on clinical appropriateness and evidential support than on legality of availability.
Within the ECEG framework, Guideline 4.1.3 operates as a normative benchmark. The Court would have considered whether Dr Lee’s prescribing practices complied with the guideline’s requirements: prescribing only on clear medical grounds, in reasonable quantities appropriate to patient needs, and with appropriate patient information. The extract indicates that the SMC proceeded on the basis that the hormones prescribed were “generally inappropriate”, that there was “lack of evidence to support [their] use”, and/or that prescriptions were given in circumstances where there were “no medical grounds to do so”. These are precisely the kinds of allegations that, if proven, can support both limbs depending on the evidence: intentional departure may be inferred where a practitioner knowingly disregards professional standards, while serious negligence may be inferred where the practitioner’s conduct shows a marked disregard for patient welfare and professional competence.
Another important strand of the Court’s reasoning concerns the regulatory and licensing context. The MOH’s correspondence and licensing conditions in 2013–2014, the MOH circular in April 2014 prohibiting BHRT outside approved clinical trials, and Dr Lee’s undertaking to cease prescribing BHRT to patients (with an associated charge that Dr Lee was acquitted of) provide context for evaluating professional conduct. While the extract does not show the full reasoning on this point, it indicates that the disciplinary charges were not isolated from the broader regulatory concerns. In medical disciplinary cases, such context can be relevant to whether a practitioner acted with deliberate disregard for known constraints or, alternatively, with negligence in failing to meet accepted standards of clinical governance and patient safety.
Finally, the Court would have addressed the evidential and procedural aspects of the disciplinary process. The extract shows that Dr Lee’s challenge to the CC’s decision was dismissed, and that expert opinions were obtained after the stay was lifted. The Court would therefore have considered whether the disciplinary tribunal’s findings were supported by the evidence and whether the correct legal test was applied. On appeal, the court typically examines whether the tribunal’s conclusions were based on an error of law, a misapprehension of evidence, or an unreasonable evaluation of the facts. The Court’s task was to determine whether the convictions on the remaining 17 charges were properly made and whether the suspension of 18 months was proportionate.
What Was the Outcome?
The extract provided does not include the dispositive portion of the judgment (ie, whether Dr Lee’s appeal was allowed or dismissed, and whether the sentence was varied). Accordingly, the practical outcome cannot be stated reliably from the truncated text. What can be stated from the procedural posture is that the High Court judgment was delivered for Dr Lee’s appeal against his convictions and sentence following an 18-month aggregate suspension imposed by the disciplinary tribunal.
For a complete legal research use, practitioners should consult the full text of [2025] SGHC 129 to confirm (i) which charges were upheld or quashed, (ii) whether the court modified the suspension term, and (iii) the court’s final guidance on the application of the Low Cze Hong two-limb framework to hormone prescribing and evidence-based clinical practice.
Why Does This Case Matter?
This decision is significant for medical practitioners and legal practitioners advising them because it sits at the intersection of professional misconduct law and clinical governance. By applying the s 53(1)(d) framework through the Low Cze Hong two-limb approach, the case reinforces that disciplinary liability is not limited to outcomes but turns on the practitioner’s departure from professional standards—either intentionally or through serious negligence. For practitioners, this underscores the importance of documenting clear medical grounds, ensuring evidence-based rationale for prescribing, and aligning clinical practice with regulatory constraints and professional guidelines.
From a legal research perspective, the case is also useful for understanding how disciplinary charges are framed and amended. The SMC’s use of primary and alternative charges to reflect different mens rea pathways illustrates a structured prosecutorial approach that can withstand legal scrutiny. Lawyers should note how the Court’s analysis is likely to engage with whether the evidence supports the relevant limb, rather than treating “professional misconduct” as a single undifferentiated concept.
Finally, the case has practical implications for how practitioners manage hormone-related therapies, including compounded formulations and therapies that may be subject to specific regulatory restrictions. Even where medications are legally available, the court’s focus on “clear medical grounds”, “reasonable quantities”, and “evidence to support use” indicates that legality of supply is not the end of the inquiry. Practitioners should therefore ensure that their prescribing practices are supported by appropriate clinical assessment, documentation, and patient communication consistent with the ECEG.
Legislation Referenced
- Medical Registration Act (Cap 174, 2014 Rev Ed): s 39(3)(a)
- Medical Registration Act (Cap 174, 2014 Rev Ed): s 44(2)
- Medical Registration Act (Cap 174, 2014 Rev Ed): s 53(1)(d)
Cases Cited
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.