Code of Ethics
The Code of Ethics (“the Code”) of The Chiropractors Association (Singapore) sets out standards of conduct and practice expected of its Doctors of Chiropractic (hereafter known as chiropractors). The Code is not an exhaustive set of rules and conduct not specifically covered will be judged in relation to what is considered the current sound practice of a reasonable and competent chiropractor.
The Code is founded on the principle that the welfare of the patient is paramount. It also assumes that chiropractors are personally responsible for their actions regardless of the clinical environment in which they work. In terms of practice, any action must demonstrate competency and safety to be deemed acceptable practice in the care of patients. Actions must also be considerate of environmental, societal and cultural values prevailing at the time.
Outline of the Code
The Code is divided into three main sections:
A. Duties owed to patient
B. Duties owed to the public
C. Duties owed to the profession
A. Duties owed to Patient
- Freedom to choose patients
- Chiropractors are free to choose who they accept or reject as patients
- If a patient presents as an acute case and the chiropractor is unable to undertake treatment or care, the chiropractor should make whatever onward referral is necessary as soon as is practicable.
- Chiropractors shall listen to patients and shall respect their views and opinions in respect of their health. They will treat patients with courtesy and consideration.
- Chiropractors shall at all times observe patient confidentiality. This duty extends to the communication of information verbally, electronically and in writing. Chiropractors shall take all steps to preserve confidentially by adopting such practice procedures as are necessary, including training of staff members.
- Any release of information should be expressly permitted by the patient and chiropractors are strongly encouraged to obtain consent for disclosure in writing.
- There are exceptions to this rule of confidentiality: (a) when the chiropractor believes it is in the patient’s best interests to disclose information to another health professional or relevant agency; (b) if the chiropractor believes that disclosure to someone other than a health professional is essential for the sake of the patient’s health; (c) if the disclosure is ordered by someone having the legal power to order it; (d) the chiropractor is advised that disclosure is required in the public interest. In all cases, other than when disclosure might endanger the chiropractor’s personal safety, the patient should be informed that disclosure will be made.
- Chiropractors shall respect the privacy and dignity of patients. This includes a patient’s right to be treated in private and the provision of private changing facilities. When an open plan clinic is in use, a private treatment room must be provided upon request or the doctor must make a referral to a clinic that does provide private treatment rooms. Gowns should be provided for use by patients should they wish to use one. Dignity should be maintained at all times when assessing or caring for patients. This includes using appropriate language and respect for cultural or religious sensitivities or needs. A chaperone or appropriate third party should be considered wherever the proposed assessment or care may involve intimate areas or where the patient is a child under the age of 16 years.
- Chiropractors shall treat patients equally regardless of their gender, lifestyle, culture, sexuality, religion, political views, social status or country of origin. At no time will they endeavour to exert influence by imposing their own views, beliefs or prejudices on a patient.
- Chiropractors shall be open with their patients and encourage patients to be responsible for their health.
- They shall not do anything which may be seen as placing undue influence on a patient to choose a particular style of treatment and must respect a patient’s right to make his/her own decision.
- They will be open with patients as to the risks and benefits of care.
- Prior to assessing or caring for a competent legally adult patient, a chiropractor shall ensure that appropriate consent is obtained. All adult patients are deemed to be competent unless demonstrated otherwise. It should be recognised that patients give consent to some procedures and not others. The giving of consent is a process, not a one-off event. If the chiropractor is in doubt he/she should always check that consent from the patient is still valid.
- Patients need to be given adequate information to decide whether they will give their consent; this should include information on reasonably foreseeable risks and likely benefits, and appropriate alternatives to chiropractic treatment.
- Consent may be given in writing, verbally or non-verbally. Regardless of how consent is obtained, chiropractors are encouraged to record the fact that consent has been given. It is not appropriate to seek written consent prior to assessment, treatment or care being explained fully to the patient. Where appropriate, separate consents to assessment and treatment should be recorded.
- Children who are able to fully understand the proposed procedure are able to give their consent, although ideally the parent of the child should be involved. If a competent child gives their consent, it cannot be over-ridden by the parent.
- Except in rare circumstances, patients are able to refuse care, even if this means that it may cause harm to the patient.
- No one is able to give consent on behalf of an incompetent adult; however, a patient may still be treated if it is considered in their best interests.
- Chiropractors must be honest in their dealings with patients.
- In particular, chiropractors shall not overstate the gravity of a condition, nor encourage a patient to pursue a programme of care against their will or not in their best interests.
- Chiropractors shall be honest about the realistic prospects of success and will not make claims that cannot be substantiated.
- Use of the doctor title is permitted provided that a chiropractor makes it clear that they are a doctor of chiropractic.
- Chiropractors should be honest in their financial and commercial dealings.
- Chiropractors must remember that the relationship between chiropractors and their patients is based on trust and that the welfare of the patient is paramount. They should not exploit the trust and dependence of a patient on their care.
- In particular, they should not use their position to pursue any inappropriate relationship with a patient or any close relative of a patient. While friendships may develop between the chiropractor and the patient and their family, such trust shall not be abused and confidence shall be preserved.
- Chiropractors must communicate clearly with their patients in a way which they can understand. They must be particularly careful when communicating information about their condition and proposed care so that the patient is able to give valid consent. They must be aware of language difficulties in the region. Consideration should also be given to disability and communication difficulties arising from this.
- Chiropractors should communicate their findings from ongoing assessments, treatment and care. They should recognise that communication is a two-way process and be perceptive to patient behaviour that might suggest further investigation might be necessary.
- Written communication should be clear, unambiguous and must contain all relevant detail to assist another health professional to make decisions about the patient’s health care.
- Record keeping
- Chiropractors shall make legible, accurate and attributable records which are an accurate reflection of every patient interaction. Such records may include (but not be limited to) appropriate documentation in relation to the case history, examination findings, progress, examination and assessment findings, treatment undertaken, advice and recommendations and a plan of management.
- Such records should be made promptly and in a form that allows the patient to be readily identified. Consent to assessment, treatment and care should be recorded.
- Assessment and care of patients
- Prior to starting a programme of care, a chiropractor must ensure that they have undertaken such a clinical assessment as is necessary to determine the nature of the presenting condition, the prognosis, the foreseeable risks and benefits, any factors that may affect that patient’s response to care. This will involve the taking of a thorough case history which shall be recorded in the case records.
- Such physical examination methods will be used as are necessary to determine more thoroughly the nature of the presenting complaint. Any referral for further investigations (e.g. diagnostic imaging) will be undertaken with due consideration for the patient’s best interests and the relative risks and benefits of any given investigation. Chiropractors shall not undertake repeated x-ray investigations without adequate clinical justification.
- A diagnosis, clinical impression or rationale for care shall be documented in the case record in language that is understandable to another chiropractor.
- Chiropractors shall consider all of the information about a patient and make ongoing decisions about their prospects for improvement, risks and benefits of care, need for referral and long term health goals. Chiropractors are encouraged to document these decisions.
- Chiropractors shall regularly review and reassess their patients at intervals not less frequently than every twelve treatment sessions. This review shall be recorded in the patient’s records.
- Access to records
- Where requested by a patient or by a third party but with the patient’s written consent, records should be made available. This disclosure should be made within a reasonable time (in most cases this will be less than 21 days from the date of the request).
- Chiropractors are encouraged not to disclose original records but to make photocopies.
- Chiropractors must keep records securely and must retain them for a period in accordance with the Singapore law.
- Chiropractors should make contingency for the safe keeping of their records in the event of sale or closure of their practice.
- Termination of Care
- Prior to terminating patient care, a chiropractor must ensure that a patient is fit to be discharged or, in the case of patients still requiring care, that all reasonable attempts have been made to refer a patient to another health professional. Case records should be provided promptly if requested.
- All chiropractors are encouraged to maintain professional indemnity insurance.
B. Duties owed to the Public
- Health promotion
- Chiropractors should act as health care professionals and take responsibility for the promotion of health, the prevention of illness and the alleviation of suffering within the wider community.
- Chiropractors shall act at all times in a manner that will not adversely affect public confidence. In particular, they shall comply with all laws, orders and regulations of Singapore that shall at any time be in force.
- Chiropractors shall act in a manner consistent with their place in society and reasonable and responsible citizens and shall not engage in any activity that may be considered contrary to the public’s best interests.
- Chiropractors shall not engage in any marketing or advertising activities that are contrary to existing codes or guidelines.
- Chiropractors shall not engage in any activity which may undermine the public’s confidence in the profession.
- Chiropractors shall be liable for any marketing and advertising activities by third parties engaged on their behalf that are contrary to the existing codes or guidelines.
- Chiropractors who act as expert witnesses must recognise that their duty is to the Court and act with impartiality and professionalism at all times.
- Chiropractors shall recognise their duty to the public by bringing to the attention of the association or public body any chiropractor who engages in illegal activity.
- Conflict of interest
- Chiropractors who hold any form of public office shall avoid any conduct which may be deemed a conflict of interest between their professional and public duties.
- Protection of reputation
- Chiropractors shall at all time act in a manner that does not lessen the reputation of the profession in the public eye. Conduct which may include illegal or irresponsible behaviour, whether or not that behaviour is related to their practice as a chiropractor, is likely to cause public alarm or concern in relation to the chiropractic profession.
- Health considerations
- Chiropractors have a duty to protect the public; should they, in the discharge of this duty, have concerns about their own or another chiropractor’s health they should report their concerns to the association, in the case of another chiropractor, after first discussing the issue with the chiropractor concerned.
- In accordance with Singapore law, all reportable / notifiable illnesses must be reported, overriding the patient's right to confidentiality.
- Health and safety
- Chiropractors shall manage their practices in accordance with any health and safety legislation that may at any time be in force. In doing so, they are encouraged to undertake and document a risk assessment and should have in place a procedure for dealing with any emergencies.
- Every attempt shall be made by the chiropractor to avoid the risk of spread of infection.
7. Protection from incompetence or misconduct
a. Chiropractors should protect the public by reporting to the association any chiropractor whose conduct or competence is in question after having made every attempt to establish the facts of any particular case upon which the belief is based.
C. Duties owed to the Profession
- Chiropractors shall at all times act with integrity and not participate in any activity which may adversely reflect on the association and profession. They shall at all times act in accordance with the principles and objects of the association.
- They shall recognise that at all times their conduct and competence may be subject to adverse public scrutiny and such will avoid all circumstances which may make it so.
- Chiropractors shall not publicly criticise the association nor allow or encourage a third party to do so.
- Public confidence
- Chiropractors shall respect and uphold high standards and maintain public confidence in the profession by not engaging in any act or omission likely to damage its reputation or interests.
- Chiropractors shall abstain from making bizarre or unsubstantiated claims about their treatment or its efficacy that if proven false may adversely affect public confidence.
- Chiropractors shall not make any uninvited approach to individual members of the public with a view to recruiting them as patients. They are permitted to advertise in accordance with the guidelines of the association and any public regulations in force at the time. They are also permitted to undertake lectures and presentations to schools, groups, societies of associations subject to compliance with the code of ethics.
- Working with colleagues
- Chiropractors shall work with colleagues in a way that respects diversity of style and culture. In particular, they shall not unjustly criticise a professional colleague or his /her style of practice.
- Chiropractors should recognise the need for lifelong learning and development. In facilitating this need they are encouraged to assist colleagues in acquiring and developing knowledge that they might better serve the public in the practice of chiropractic.
- Chiropractors shall not engage in the teaching of chiropractic skills to non-chiropractors. Chiropractors employed in chiropractic teaching faculties must ensure that they possess the skills necessary to undertake this activity, and that those students they teach are properly supervised and, where necessary, insured.
- Chiropractors should treat professional colleagues with respect and not engage in disputes that may potentially harm the interests of the association or the profession. Where differences of opinion exist, chiropractors are encouraged to engage in mature debate and promote constructive discussion for the benefit of the wider profession.
- To ensure the integrity of the profession, should a chiropractor believe that another chiropractor is practicing in breach of the code, it is suggested that they first approach the chiropractor in a constructive manner and discuss their concerns and provide the chiropractor with the opportunity to respond.
- Working with other health professions
- Chiropractors will be seen to represent the association when they work with other health professions. In doing so, they are encouraged to maintain the highest standards of professionalism and abstain from conduct that may reflect poorly on the association.
- Where a chiropractor is working as part of a healthcare team, he/she remains responsible for his/her acts or omissions in relation to patient care.
- Where a chiropractor delegates professional responsibility to a third party (e.g. a rehabilitation trainer, clinic receptionist or practice assistant), he/she should ensure that the third party is competent to undertake the delegated duties. Where the third party is not a chiropractor, responsibility for the third party lies with the chiropractor delegating the duties.
- Chiropractors employing chiropractic associates have a duty to satisfy themselves that they are properly qualified and have in place all employment papers to allow them to work legally in Singapore.
- Soliciting of patients
- Chiropractors shall not engage in any activity which might be seen to encourage a patient to leave their existing chiropractor (or any other related health professional) with the intention of persuading that patient to become the chiropractor’s patient.