I would like to respond to the article, “TPA Instructs Panel Hospitals To Prioritise Local Over General Anaesthesia”, by Boo Su-Lyn, published by CodeBlue on October 2, 2025.
The recent “instruction” by MediExpress (Malaysia) Sdn Bhd, which seeks to dictate whether procedures should be performed under local anaesthesia (LA) or general anaesthesia (GA), represents an overreach into the clinical space and undermines the doctor–patient relationship. Such interference cannot be justified on clinical and ethical grounds.
The choice between LA and GA is not merely a simplistic clerical or financial decision. It is a complex clinical judgment. It requires consideration of:
- The patient’s medical history, comorbidities, and risk profile.
- The type of surgery, anticipated pain, and intraoperative requirements.
- The patient’s psychological state, including anxiety or trauma associated with undergoing a procedure awake.
Non-medical third party administrators (TPAs) lack the expertise to evaluate these nuances. The arrogance in attempting to override clinical decision-making exposes patients to unnecessary harm and disregards the professional obligations of surgeons and anaesthesiologists.
Therefore, clinical decisions must be decided by clinicians, and only clinicians, in conjunction with patients after proper advice and consultation.
The “instruction” from the TPA also violates medical ethical principles.
Principle of Autonomy: Patients have the right to be involved in decisions about their care, including anaesthesia options. If a patient is fearful or psychologically distressed under LA, forcing them into it for cost reasons violates their autonomy and disregards informed consent. Autonomy is not negotiable, and it should not be subordinated to corporate financial policies.
Principle of Beneficence: Clinicians are duty-bound to act in the best interest of the patient. In certain cases, choosing GA over LA may maximise patient comfort, reduces psychological trauma, and ensure the success of the procedure.. A blanket cost-driven policy directly conflicts with the principle of beneficence.
Principle of Non-Maleficence: The “first, do no harm” dictum applies here. Purposely subjecting patients to procedures under LA when they are unsuitable, or when the patient is likely to suffer psychological harm, inflicts avoidable injury. When clinicians are forced to comply with such restrictions, this could result in harm that is both physical and psychological.
Principle of Justice: All patients, regardless of who pays for their care, should have access to clinically appropriate treatments. MediExpress’ policy creates an unjust system where financial considerations override medical necessity, disadvantaging patients covered under their schemes compared to others who receive proper, ethical clinician-led care.
If TPAs are permitted to dictate clinical choices, the precedent is dangerous. Medical practice risks being reduced to cost-driven algorithms, rather than individualised care.
The clinician’s professional autonomy is eroded, and his accountability is compromised. Patient trust in the health care system is undermined when they realize that decisions are made by short-sighted, penny-pinching insurers, rather than their treating doctors.
MediExpress’ conduct represents an intrusion into medical decision-making that is both clinically unsafe and ethically indefensible. Clinical judgment must remain with qualified clinical professionals, guided by patient needs and ethical principles of medicine, not financial directives.
I urge the Ministry of Health and professional bodies, such as the Malaysian Medical Association (MMA), Malaysian Society of Anesthesiologists (MSA), Academy of Medicine of Malaysia (AMM), College of Anaesthesiology (COA), College of Surgery (COS), as well as the various bodies representing the surgical disciplines, to issue a strongly worded statement to safeguard the integrity of medical decision-making against such commercial encroachments.
This preposterous overreach has to be decisively nipped in the bud.
Dr P is a consultant anaesthesiologist at a private hospital in Penang. CodeBlue is giving the author anonymity due to their fear of reprisal from their hospital and insurance companies.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
