INFECTIOUS DISEASES (AMENDMENT) BILL

Debate resumed.

Dr Lily Neo (Kreta Ayer-Tanglin): Mr Speaker, Sir, I would like to declare that I am a medical practitioner.

I stand to support the Infectious Diseases (Amendment) Bill. In my opinion, the amendments in this Bill will give better protection of the public with regard to Human Immunodeficiency Virus (or HIV) infection. We know that there is no cure at present for those suffering from Acquired Immunodeficiency Syndrome (or AIDS) because of HIV infection. Therefore, any improvement towards protecting innocent people, through no fault of their own, from getting the deadly HIV infection, is welcome news. Indeed, I believe that having stringent measures in place to deter inconsiderate or ignorant people from harming others through HIV infection is prudent and timely. I agree with my parliamentary colleague, Mr Bernard Chen, that the action by such people amounts to giving their victims the death sentence and such action, whether intentional or inadvertent, must be considered illegal, to say the least. Sir, I would like to contribute the following concerning the amendments:

Insertion of new section 10A

The insertion of this section 10A to create an offence when blood donors supply false or misleading information and to set a maximum penalty under this section as a fine of $20,000 or a term of imprisonment of two years or both is necessary and timely. It is necessary because there is this window period' when presently available tests cannot detect an early HIV infection. Although with new technology, this window period' will become shorter, it is extremely important that blood donors give truthful information, through detailed questionnaires. This is, unfortunately, still the only way to minimise the risks of innocent blood recipients from being infected. It is timely because any means of deterring a repeat of that tragic incident in 1997, as mentioned earlier by the Senior Minister of State, when two blood recipients contracted HIV infection because a blood donor had lied about his promiscuous habits, is most welcome.

Sir, some people may argue that such strict deterrents will result in fewer much needed blood donors. However, much as we need blood donors, the safety of blood recipients must be protected as a matter of highest priority. The majority of blood donors volunteer as good Samaritans. They want to be contributing a good service to the society. They want to be saving someone's life. With such good intentions at heart, the severe penalty imposed on errant donors will not interfere with their willingness to continue as blood donors. It is necessary, however, for the public to be assured that the intent is not to penalise blood donors liberally but to dissuade those with high risks to abstain from blood donation. I hope the Ministry of Health can step up in its campaign in this area. Amendment to section 20C

Sir, this section provides an enhanced penalty of up to $50,000 in fine where a person who knows that he has HIV infection or AIDS donates blood or does any act that is likely to result in the spreading or transmission of those diseases. Although it is good to have this clause, the resultant effects would depend on the next task for the Ministry of Health. This task would be to ensure that the targeted group gets the message. For example, the warning about the penalty may need to be prominently marked on the blood transfusion registration forms; the warning may have to be posted in the wards of the Communicable Disease Hospital and the same warning may need to be clearly explained to newly diagnosed HIV patients. Sir, my question to the Senior Minister of State is, in those recalcitrant cases that do not heed any warning and are callous in their behaviour within society, what further preventive measures can be meted out? Could these offenders be made discretely identifiable to the relevant authorities or persons? Could these offenders be forcibly put behind bars? Since confidentiality will be an issue here, who with the privileged information can report them?

Amendment of section 20D

The amendments here include the addition of four more exceptions to medical confidentiality for HIV infected patients in subsection 1 and the insertion of new subsection (12) to provide for medical confidentiality and disclosure of the identity of infected patients. Mr Speaker, Sir, such a large list of new provisos indicates the tremendous difficulties involved in this very sensitive issue.

The newly inserted subsection (6) allows medical practitioners to disclose information identifying the infected person to his spouse, former spouse or other persons who have experienced a significant risk by being in contact with him. This is welcome news especially when these contacts of the inflicted may generally be the highest at risk of being infected. Among 90% of the known cases in Singapore are males. In 1998, there were 830 males with HIV infection and in the past two years, eight children were detected to have HIV infection. Sir, I feel this amendment may help lessen the number of females and children from potential infection. The argument against this new subsection may be that people who suspect they themselves may have HIV infection would be reluctant to come forward for fear of being disclosed. This, however, has been addressed through certain safeguards. One of them is the requirement for the medical practitioner to counsel and inform the infected person of his intent to make such disclosure to the spouse, former spouse, or other contacts. Otherwise the medical practitioner shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $2,000 or to imprisonment for a term not exceeding three months or to both.

Mr Speaker, Sir, I would like to ask if the Senior Minister of State would consider three further aspects on this Bill.

(1) Not included for a further consideration with these amendments is the subject of consent for diagnostic investigations for HIV infection or AIDS. I feel that a responsible approach together with these amendments in place should provide sufficient protection from breach of confidentiality of a person with HIV infection or AIDS. Sir, on the other hand, it is important to protect those who are at risk of exposure and it is important to protect the public by keeping the infectious disease from spreading. The ease to diagnose, to identify and to treat the infected and their contacts would be the key to effectively deal with these aspects. HIV infection or AIDS should be treated like any other infectious diseases. The consent for diagnostic tests should be implied when a person gives general consent for medical or surgical treatment. There should not be a need for specific consent. Only then, Sir, can all those involved in the management of the disease feel at ease to handle the condition in a normal way. Only then, perhaps, can the infectious disease be effectively managed and contained.

(2) Each country deals with this disease in its own way and the solutions for one country may not be relevant to another or to us here. Sir, though fortunately not an endemic problem, the incidence of HIV infection or AIDS is increasing in Singapore. We should take every measure possible to keep it in check. Our population and our problems are unique to us and there is scope for us to take more stringent and radical steps to combat the increase of the disease.

(3) There is a need to inform and advise all doctors and healthcare workers on new regulations pertaining to their profession in simple terms. Many of them would not know about the amendments to this Bill and the details contained therein. Perhaps the Ministry of Health would keep all relevant parties well informed.

I hope the Senior Minister of State would enlighten me in these areas. Sir, I support the Infectious Diseases (Amendment) Bill.

Mr Shriniwas Rai: Thank you, Mr Speaker, Sir, for giving me this opportunity to speak.

Mr Speaker, Sir, having listened to the very moving speech by the Senior Minister of State in which she painted the picture of the AIDS patients, and having heard Mr Bernard Chen who also graphically painted the picture that is emerging, I have no doubt that this House would support this Amendment Bill.

Sir, we have moved from the days when we had malaria as an infectious disease. In fact, the first legislation was introduced in 1915 when Singapore was largely a seaport. Today, she has become one of the largest airports in this part of the world. We are getting people from all over the world and our citizens are also travelling. It is therefore important that we should legislate and take care.

Mr Speaker, Sir, what is required is social education. We have to inform the public at large the need to take preventive measures. Sir, section 10A, which is a new piece of legislation, lays down that any person who supplies any material information which he knows to be false or misleading may be fined up to $20,000 or imprisonment for a term not exceeding two years or both. I think the existing Penal Code does not have the severity which this Bill introduces. I support this amendment because the Penal Code provisions are really inadequate. And it is very important for us to have enough deterrents.

But when I move to section 20C, Sir, I am a bit apprehensive. From $10,000, we are increasing to $50,000. This is too drastic and I hope the Senior Minister of State will explain to the House the necessity of taking such a large quantum move.

Sir, Members have spoken on the other details and I do not want to belabour the points. Generally, it is important that we should have a legal framework for medical practitioners and other officials to work within the framework of law and it is important that we lay it down. I share Dr Tan Cheng Bock's concern. As a lawyer, I find difficulty in comprehending this piece of legislation. We are moving to plain language, and I hope that our draftsmen will try to make it as easy as possible. If we have difficulty, what about the man-in-the-street, Sir? I know the Attorney-General has been trying his level best to have simple plain English and I would again urge the draftsmen to have mercy on us.

Sir, with these words, I support this Bill.

Dr Aline Wong: I would like to thank the Members of the House who spoke in such strong support of this Bill. We all realise that Singapore is open to the world trend of increase in AIDS/HIV infection, and therefore we must do our utmost to try to contain the problem, to prevent its spread among the population and to educate people to avoid the risk of infection. I agree completely with Mr Bernard Chen, Dr Lily Neo and also Mr Shriniwas Rai that public education is very, very important. We will do our best in this respect to help prevent the disease and its spread.

Now, let me address some of the specific points brought up by my colleagues here. Dr Tan Cheng Bock talked about the Explanatory Statement where "any other sexually transmitted disease" is mentioned. He said that he could not find this phrase in this Amendment Bill and he was concerned that this is too blanket a statement which would seem to allow the disclosure of a whole range of sexually transmitted diseases on the same ground or at par with HIV infection. Actually this Amendment Bill is an extension of the 1992 Amendment Act where, in section 20D, it is mentioned "or is suffering from a sexually transmitted disease" which is any other STD. I would like to point out that there is a reason for this. By inserting "any other sexually transmitted disease" is to cater for a situation when, apart from HIV, some time in the future, we may discover another very deadly disease that we have to control on the same ground and use the same measures as we control HIV. So that is a contingency. But, in practice, as Dr Tan mentioned, in the Notification of Infectious Diseases form, which is gazetted and which every medical doctor receives, it is clearly stated that for the other sexually transmitted diseases, such as gonorrhoea, syphilis, non-gonococco urethritis and so on, there is no need to disclose the full name, the identity card or passport number, address, etc, of the patient. The only exception for full information is on HIV. I am not sure about the STD that Dr Tan mentioned. I could ask my officers to look into this and whether it is specifically mentioned in the form.

There is no need to add the word "designated" before "sexually transmitted diseases" in this amendment or in the law itself because it is fully understood that the list of diseases will be gazetted and that the law will apply to these gazetted conditions.

Two Members have complained about the language of this Bill. I will feedback this to the Attorney-General's Chambers. In fact, I also spent quite a lot of time trying to read through this Bill.

May I address some of Dr Lily Neo's points. Again, I thank her for supporting this Bill. As for her point about the severity of the new penalties on blood donors who give false information or wilfully donate blood even though they know of their own HIV status, my Ministry will revise the Donor's Health Assessment questionnaire to include the new provisions of the amended Act. Even in the existing blood Donor Health Assessment Questionnaire, we have already warned them about the danger of donating contaminated blood which is not suitable for transfusion and if they do so, they would be liable to prosecution and would face serious consequences. We will update our Donor's Health Assessment Questionnaire to include the new penalties and so on, that we have amended today.

HIV patients at the Communicable Disease Centre (CDC) are always warned during the counselling sessions that it is an offence to carry out any act that may transmit HIV infection to others, such as sexual intercourse, without first informing their partner of the status, or to donate blood. Again, in our counselling at the CDC, we would make sure the counsellers, doctors and nurses will inform the patients of the new provisions in this Bill. In the event of a HIV patient who behaves carelessly and most irresponsibly, then this amendment Bill allows the Minister for Health to disclose the identity of the HIV infected person to relevant persons, including the public, so as to ensure that public health and safety is preserved. It is a preventive measure to publish information which leads to the identification of the person but it will call for the Minister's authorisation and it would be done only under extreme circumstances when the person behaves carelessly and most irresponsibly.

On Dr Neo's comment that there is no need for specific consent for HIV testing when a person seeks medical or surgical treatment, I would like to emphasise that HIV infection is different from any other infectious diseases in that there is at present no cure and that it carries a very strong social stigma. Therefore, HIV testing and its outcome have a very traumatic impact on the person. It is almost like a pronouncement of a death sentence, as some Members have put it. Persons undergoing such tests should therefore be fully aware of the nature of the test and be counselled before and after the HIV test is carried out. Counselling is crucial because it will help the patient cope with the situation and help him change his risk behaviour and lifestyle to prevent further spreading of the disease.

Under the law, it is necessary in all circumstances to obtain consent of the person before taking his blood for laboratory testing. This includes testing the blood for HIV. This act, if done without the patient's consent, constitutes a battery of tort and an offence of voluntarily causing hurt under section 323 of the Penal Code. From the medical ethical point of view, when a patient seeks medical attention, doctors have a duty to inform him what tests are being done and what is the nature of this test. So this is in the spirit of a good doctor-patient relationship. In the case of HIV testing, informed consent is required to also protect the doctor in case there is a denial by the patient later. HIV testing is put on par with a surgical operation as it has serious implications should a positive result turn out.

Finally, on her point about the need for more stringent and radical steps to control the spread of AIDS in Singapore, we should not be complacent about the situation but it is a fact that the extent of the AIDS epidemic in Singapore is comparatively smaller than many other countries in the region, because we took steps to control the situation very early, from the day go in 1985, shortly after AIDS itself was identified. So, we have taken the necessary AIDS control measures and we have been reviewing and fine-tuning the strategies based on the changing trends of the HIV infection over the years. I am confident that with this amendment Bill, we would be able to further tighten the AIDS control situation for public health purposes in Singapore. Of course, we will inform all the medical practitioners and health care workers of the new provisions and keep them updated.

Finally, let me come to Mr Shriniwas Rai's point about the severity of the penalty. I think he agrees with the new section 10A, that is, for people who give false information when they give blood donation, the penalty will be raised to $20,000 or to imprisonment of two years or both. But he does not quite agree with section 20C that raises the present penalty for a person who knows that he is HIV-infected but he still insists on giving blood at our blood bank. Mr Rai does not agree with raising the penalty from $10,000 to $50,000. He said that it is too severe. I think the heavy penalty underscores the seriousness of the crime. This person has already been counselled against giving blood. He knows about his own HIV status. He knows it himself and he still persists in donating blood. When he goes to the blood centre, he is made to understand the consequences. He is given the blood donor's health assessment form where he has to sign a declaration about his blood donation. If he knows that he is HIV infected, he is supposed to refrain from donating blood and there are legal penalties involved and he knows. He is supposed to read this form, and be counselled before signing the form. But he still does it. It is very dangerous because this could cause the death of the person who receives his blood. Of course, if the the blood is infected, we are able to detect it because of our stringent tests. But in the extreme case, if it escapes detection, the consequences would be too heavy. If he does it wilfully, with his eyes open, then I must question what is the motive. We must guard ourselves against such irresponsible behaviour. I think I have addressed all the points.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Dr Aline Wong].

Bill considered in Committee; Bill reported without amendment; read a Third time and passed.