The Inevitable Waltz – Medical-Legal Partnership

The natural progression of birth is to end life with death. Along the journey from birth to death, there will be health issues. It cannot be denied that social problems can exacerbate poor health. Predictably, the root causes of such social problems could be linked to legal related woes. Consequently, this article advocates for the creation of an upstream approach to community lawyering, by augmenting primary medical care in our medical institutions such as polyclinics, to address health-harming related legal problems.

A Medical-Legal Partnership (MLP) is not an innovative or novel concept. It was conceptualised and has existed since 1993 at Boston Medical Center.¹Legal Key Partnership for Health and Justice, <https://legalkeypartnership.org/our-story/> (Accessed 10 March 2025)

MLPs was conceived to plug the disconnect between a diagnosis of poor health and the legal solutions to improve the underlying legal currents that contributed to poor health.

Attorneys were hospital employees who attended to patients’ pressing legal issues. Over time, it blossomed into an important key in preventive medicine and law.²Legal Key Partnership for Health and Justice, <https://legalkeypartnership.org/our-story/> (Accessed 10 March 2025)

A typical model in MLP involves a lawyer being placed upstream into the healthcare system to work in tandem with the primary healthcare professionals. Root causes of poor health are identified by the medical professionals and the appropriate referrals are made for the patients to see the lawyer, who is residing on the same premises. Drop-in services to see the lawyers are available as well if the medical professionals made no referrals.

Conditions in one’s environment irrefutably affect one’s health. These conditions are known as social determinants of health (SDOH).³U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion, < https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health> (Accessed 10 March 2025) Some examples of SDOH include abuse, employment related matters, insolvency worries and various community disputes.⁴U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion, < https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health> (Accessed 10 March 2025) Inevitably, those various discomforts of life will lead to stress.

The precipitation of stress-related disorders or chronic diseases from health-harming related legal issues⁵Kate Marple, “Framing Legal Care as Health Care”. National Centre for Medical-Legal Partnership (January 2015) < https://medical-legalpartnership.org/wp-content/uploads/2015/01/Framing-Legal-Care-as-Health-Care-Messaging-Guide.pdf> (Accessed on 13 March 2025) can be better managed through MLPs.⁶Teufel J, Heller SM, Dausey DJ. Medical-legal partnerships as a strategy to improve social causes of stress and disease. Am J Public Health. 2014 Dec;104(12):e6-7. doi: 10.2105/AJPH.2014.302268. Epub 2014 Oct 16. PMID: 25320880; PMCID: PMC4232103.

MLPs has since been institutionalised in the United States of America (U.S.).⁷National Center for Medical Legal Partnerships, < https://medical-legalpartnership.org/partnerships/> (Accessed 3 March 2025) 450 health organisations, including hospitals, across 49 states of U.S. integrate MLPs into their medical practice.

Canada has also implemented MLPs, albeit in a smaller scale, through their Health Justice Program.⁸Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care: The Health Justice Program. Can Fam Physician. 2019 Apr;65(4):246-248. PMID: 30979753; PMCID: PMC6467680. India has aptly promoted a variation of the MLPs in its National Institution of Mental Health and Neurosciences, Bengaluru.⁹Math SB, Kumar NC, Harish T. Legal aid in hospitals: an innovative approach. Indian J Med Res. 2013 Mar;137(3):440-1. PMID: 23640549; PMCID: PMC3705650. The legal aid clinic parked in the hospital premises provided free legal services to all patients. An Indian study further concluded that patients benefited from free legal aid in mental health hospitals.¹⁰Kadiveti S, Vajawat B, Kumar CN, Hegde PR, Moirangthem S, Math SB. Free legal aid in hospitals for persons with mental illness: Is it helpful? An Indian prospective study. Indian J Psychiatry. 2022 May-Jun;64(3):322-325. doi: 10.4103/indianjpsychiatry.indianjpsychiatry_510_21. Epub 2022 Jun 8. PMID: 35859558; PMCID: PMC9290419.

Though Singapore has first-class primary healthcare facilities such as our polyclinics and a robust community lawyering system, the logical step of integrating both influential foundations have not been substantially studied and explored. That is an enigma.

Benefits

Firstly, the collaboration of both medical and legal practitioners serves to provide a holistic solution to societal issues. Both services should not work in silos and the chasm could be bridged through MLP.¹¹Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care: The Health Justice Program. Can Fam Physician. 2019 Apr;65(4):246-248. PMID: 30979753; PMCID: PMC6467680.

Undeniably, law is pervasive and permeates the entirety of a person’s life. Everyone at some point in their lives will have legal needs. A needs assessment conducted by clinicians in Canada revealed that more than half of patients that are referred to social workers had at least one legal issue.¹²Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care: The Health Justice Program. Can Fam Physician. 2019 Apr;65(4):246-248. PMID: 30979753; PMCID: PMC6467680.

In essence, these legal needs when unmet lead to complications and stress. Visting healthcare professionals for primary care will treat superficial physiological difficulties but does not address the underlying and unmet legal needs of the populace.

Secondly, provision of upstream legal solutions through the healthcare system is arguably the best approach to prostrate before the ideology of “Access to Justice”.

The efforts of community lawyering are commendable.¹³Grace Yeoh, “From a small container at a Hougang temple, this lawyer and her team bring legal access to the vulnerable”. Channel News Asia Lifestyle (30 June 2024) < https://cnalifestyle.channelnewsasia.com/women/cai-chengying-pro-bono-community-lawyer-hougang-temple-392401> (Accessed 11 March 2025). Presently, there are legal clinics located on different Community Development Council sites, community clubs, centres and various organisations.¹⁴List of legal Clinics in Singapore < https://www.probono.sg/get-legal-help/legal-guidance/the-general-public/legal-clinics-in-singapore/> (Accessed 11 March 2025) Integrating MLPs into healthcare centres such as our polyclinics will serve to enhance and strengthen the available network and opportunities for the said segment of society to seek help. The legal community will then truly be accountable to our ideology as we tackle the roots of health-harming legal problems.

For example, a patient is suffering from depression due to unfair employment practices and is experiencing physical symptoms such as headaches and insomnia. If MLPs are in place, the patient can be treated holistically at the healthcare facility. Without MLPs, the patient will visit the healthcare facility to treat the physical symptoms while the health-harming legal problems continue to plague the patient’s life. The patient would then need to navigate the web and search for a convenient location at an appropriate time to seek legal advice and guidance. The delay could be costly if the patient is suicidal. Further, the patient may not be able to take leave from work due to the same employment practices that caused depression.

It is further argued that the same segment of society that will visit the healthcare facilities such as polyclinics is possibly the same segment of society that is vulnerable.¹⁵Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care: The Health Justice Program. Can Fam Physician. 2019 Apr;65(4):246-248. PMID: 30979753; PMCID: PMC6467680. They could have been facing medical and legal challenges with great stoicism that the better endowed segments of society would hardly fathom. Therefore, by empowering the vulnerable segments of society with legal knowledge and tools upstream would possibly aid to balance social inequality and build confidence in the vulnerable segments of our society.

Thirdly, some studies have shown the efficacy of MLP.¹⁶Nerlinger AL, Alberti PM, Gilbert AL, Goodman TL, Fair MA, Johnson SB, Pettignano R. Evaluating the Efficacy of Medical-Legal Partnerships that Address Social Determinants of Health. Prog Community Health Partnersh. 2021;15(2):255-264. doi: 10.1353/cpr.2021.0027. PMID: 34248069; PMCID: PMC8729181. Healthcare costs will foreseeably be reduced as there should be fewer medical visits and hospitalisations of the populace. Further, by arresting legal issues at its infancy could prevent downstream escalation into senseless litigation.

Fourthly, empirical research can be conducted with ease at such facilities to further chart the directions of MLP to conquer new frontiers in medical intervention and provide guidance for better policy making. MLP has even ventured into a neonatal intensive care unit¹⁷Gievers L, Mutrie L, Klawetter S. Novel perinatal medical-legal partnership development and pilot implementation to address health-harming legal needs. J Perinatol. 2024 Jan;44(1):136-141. doi: 10.1038/s41372-023-01829-8. Epub 2023 Nov 25. PMID: 38007591; PMCID: PMC10872264. in a study. That study concluded that the early intervention with legal services for the young and vulnerable patients is a promising direction to take to improve short and long-term health outcomes. This clearly exhibits that the possibilities are boundless but the foundation in Singapore must first be built.

Fifthly, there must be a paradigm shift in how medicine and law are traditionally taught in universities. Delivery of knowledge must be purpose driven and education must be meaningful to the community.

MLPs have progressed into studies on the efficacy of curricula and innovative practices jointly crafted by doctors and lawyers.¹⁸Cohen E, Fullerton DF, Retkin R, Weintraub D, Tames P, Brandfield J, Sandel M. Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med. 2010 May;25 Suppl 2(Suppl 2):S136-9. doi: 10.1007/s11606-009-1239-7. PMID: 20352508; PMCID: PMC2847107. With an MLP curricula, it becomes crucial for healthcare professionals to screen and diagnose medical conditions as well as to identify the health-harming antecedent legal problems and refer them to the lawyers to help educate the patients on their rights and holistically treat them.¹⁹Cohen E, Fullerton DF, Retkin R, Weintraub D, Tames P, Brandfield J, Sandel M. Medical-legal partnership: collaborating with lawyers to identify and address health disparities. J Gen Intern Med. 2010 May;25 Suppl 2(Suppl 2):S136-9. doi: 10.1007/s11606-009-1239-7. PMID: 20352508; PMCID: PMC2847107. Lawyers will effectively become an integral facet of healthcare systems. Further, the MLPs could also provide career opportunities for allied legal professionals. These proposed outcomes should arguably complement the recommendations to reform legal education in Singapore.²⁰“Joint Press Release: Recommendations to Legal Education and Training in Singapore to Keep Pace with Evolving Industry Needs” (8 January 2024) < https://www.judiciary.gov.sg/news-and-resources/news/news-details/joint-press-release-recommendations-to-legal-education-and-training-in-singapore-to-keep-pace-with-evolving-industry-needs> (Accessed 11 March 2025)

Challenges

Firstly, there are considerations about funding and types of collaboration models. However, those are not indomitable obstacles that should impede the progress of law. Currently with the legal clinics operating in CDCs, CCs and other organisations, it is possible for some of them to move their operations to the polyclinics to integrate with the healthcare services of that precinct. That helps in the consolidation of the essential services through MLPs and provides a one-stop solution for the patients. Even if scalability is at an aphelion stage, it can be argued that at the very least, a pilot project in any of the primary care facility would be a move in the right direction.

Secondly, doctors and lawyers may have difficulties in integrating their services. Initially it may pose issues as the training of the two different professions is different. Fortunately, it is not an insurmountable hurdle. Doctors and Lawyers can conduct joint training in their own field to help alleviate any discomfort and perceived dissonance by fellow practitioners. In addition, as mentioned above, how medicine and law are conventionally taught in universities should be re-evaluated with the inclusion of credit bearing courses such as MLPs curricula.

Eventually, both doctors and lawyers will be equipped with community-based skills. Doctors will be better able to identify legal issues and make the necessary referrals. Lawyers will be able to intervene early through upstream lawyering and help prevent escalation of legal woes, physical and mental health of the patients.

Thirdly, there could be patient and client confidentiality issues. These are important ethical dilemmas that both medical and legal stalwarts must come together for a consensus. Confidentiality under the MLP framework should be legislated and a common code of ethics could be developed. Overall, such discussions could lead to a novel healthcare database that documents both medical and legal history. With informed consent from the patient and a possible waiver of privilege, a report generated from such a database could provide a compelling and strong evidential document to be used by the courts in decision-making.

Conclusion

Recently, there had been advocacy in the U.S. for a more advanced model of MLP to expand its ambit to include criminal legal needs.²¹Streltzov N, van Deventer E, Vanjani R, Tobin-Tyler E. A New Kind of Academic MLP: Addressing Clients’ Criminal Legal Needs to Promote Health Justice and Reduce Mass Incarceration. J Law Med Ethics. 2023;51(4):847-855. doi: 10.1017/jme.2024.3. Epub 2024 Mar 13. PMID: 38477263; PMCID: PMC10937173.

Unsurprisingly, there had also been a clarion call by the Ministry of Law of Singapore as well as professionals including lawyers to be more inclusive as well as to provide for offenders with invisible disabilities.²²Christine Tan and Claudia Tan, “MinLaw committed to task force to support those with unseen disabilities in legal system”. The Straits Times (26 March 2025) <https://www.straitstimes.com/singapore/courts-crime/minlaw-committed-to-taskforce-for-persons-with-invisible-disabilities-in-justice-system-edwin-tong> (accessed on 1 April 2025). Essentially, it is about brainstorming to develop solutions other than the traditional penal treatment for accused persons with mental health issues.

Naturally, it can be argued that MLPs would possibly serve as the ideal platform for the early detection, monitoring and tracking of potential accused persons to help arrest the growth of such social ills before they manifest into serious offences. MLPs would then be the envisioned upstream approach to plug the gaps in access to justice for the mentally ill.

Consequently, Lawyers can and should become important members of any healthcare system. Treatment of physical symptoms does not address health-harming legal issues.

A comprehensive approach to healthcare through MLPs will assist in improving population health and lower healthcare costs.²³Tobin Tyler E. Medical-Legal Partnership in Primary Care: Moving Upstream in the Clinic. Am J Lifestyle Med. 2017 Mar 23;13(3):282-291. doi: 10.1177/1559827617698417. PMID: 31105492; PMCID: PMC6506975. Patients will also benefit as the upstream approach will improve access to justice and reduce any perceived disparities in different social segments of the community.

In essence, legal education and community lawyering should indubitably be shifting toward a more predictive and preventive upstream practice rather than a traditional passive and reactive model.

The hard truth is that it will be wilful optimism to herald MLPs to be the panacea, but it will be profound folly for community lawyering to be caught in the slipstream of inertia.

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