The 6ME FDW or Maid Check-up

The recent case of the tragic death of a Myanmese maid has led to calls for doctors to be tasked to report cases of maid abuse. Actually this requirement already exists, in small print, in the current form after the doctor ticks off the results for the VDRL and pregnancy tests:

“If you notice signs of abuse, refer the helper immediately to the Police or MOM for help”.

It was also noted that “the doctor had seen bruises around the maid’s eye sockets and cheeks, but Gaiyathiri (the late maid’s employer) claimed that the victim fell down frequently as she was clumsy” (CNA website, 25 Feb 2020; Myanmar maid’s death: MOM reviewing how doctors report potential abuse). It was also reported that Gaiyathiri turned down the doctor’s suggestion for further tests on the victim’s swollen legs in case of underlying conditions.

MOM said “Nothing adverse was flagged to the authorities’ attention on either occasion (when the doctor saw the deceased maid)”.

This hobbit is all for doctors’ playing a greater role in the detection of foreign domestic worker abuse. But to go beyond the present state of affairs, we need to answer a few questions.

The first question that needs to be answered is whether the doctor is supposed to detect abuse in this statutory medical examination using clinical examination or forensic examination methods?

Let us first talk about statutory medical examination. A statutory medical examination is simply a medical consultation and physical examination (and sometimes includes investigations) to demonstrate that the examinee is fit for a purpose as required by law (i.e. statute). Examples include heavy vehicle examination, pilot examination etc. The Six-monthly medical examination (6ME) for foreign domestic worker (FDW) required by MOM is another such example.

The purpose of this examination when it was first instituted was to detect if a FDW was pregnant or if the FDW had contracted sexually transmitted diseases. These questions can easily be answered objectively and in a binary fashion (yes or no) by simple laboratory tests.

Detecting abuse was a later addition to the 6ME that was added on only a few years ago. The case for detecting physical abuse is slightly different. There are no simple laboratory tests with binary outcomes for physical abuse. It is a matter of judgement and therefore more subjective.

Every doctor is trained to conduct a clinical examination. However the clinical examination is based on certain assumptions of a social compact between the patient and the doctor. A clinical examination entails history-taking and physical examination to elicit clinical signs and symptoms. Undergirding this is that the patient must cooperate by telling the truth. I think all doctors would have had the unfortunate experience of being waylaid to some extent by patients not telling the whole truth after many years of practice.

A forensic examination is different. The underlying principle here is that the doctor is trying detect some crime that has been committed. The patient should preferably cooperate with the doctor but the forensic examination is not dependent on this cooperation. After all, a forensic medical examination is a comprehensive examination looking for injuries and taking samples that may be used as evidence in a police investigation and any subsequent prosecution. Doctors will have to be trained to perform forensic examinations if this is the standard expected of them in the 6ME.

It would be helpful if MOM can state if they expect doctors to conduct a clinical or forensic examination when they carry out the 6ME FDW.

Be it clinical or forensic examination, a key point is that the employer or any other person should not be present, if the intent is to detect abuse. However, there is no such stated requirement now, despite the fact that the doctor is to refer the maid to the Police or MOM if the doctor notices “signs of abuse”. It is hard to do a proper examination to detect abuse when the criminal may be right there standing next to the abused. The doctor is also not empowered by statute to confirm his suspicions of abuse by ordering tests.

A second and equally difficult question is how will a doctor be judged? If there is truly abuse and a doctor missed it, to borrow a legal term, what is the “burden of proof” that will be applied to the doctor?

There are three common standards used:

• Prima facie, i.e. enough evidence to support a case
• On the balance of probabilities
• Beyond reasonable doubt

Is a doctor supposed to report abuse because

• There is just some evidence that the event happened? (“prima facie”)
• More likely than not that the event happened (50.1% probability that something happened)
• Very strong evidence that the event happened (beyond reasonable doubt)

If the doctor is informed beforehand what is the applicable standard, then the doctor will also likewise respond appropriately to the standard expected of him or her.

The third question is that of costs. Presently, a 6ME costs anything from the region of $25 to $45 (depending on whether you use urine or blood to detect HCG). In reality, most doctors do nothing more than a cursory physical examination and the whole process takes 5 to 10 minutes or so. A detailed clinical examination (let alone a forensic one) will entail far more time and resources than what is presented committed to the 6ME. It would also mean employers have to probably pay a higher price for the 6ME. But if society is determined is stamp out maid abuse, then it must be so.