Ethics and human rights in South African medicine

John R. Williams

CMAJ 2000;162(8):1167-70

• Introduction
• The medical profession under apartheid
• Transformation in the profession
• Conclusions
• References

The transformation of South African society and its institutions from apartheid to racial equality has been a long and arduous process, one that is far from complete. South Africans themselves have been the major agents of change, but other countries and international agencies have played important roles, often more negative than positive. Canada's support for successive apartheid regimes has been well documented,¹ and our active recruitment of South African physicians to meet our rural and remote needs undercuts South Africa's attempts to solve its own physician shortage.² South Africans might well ask what Canada will provide in exchange for all that we have taken from their country.

The role of the South African medical profession in apartheid is now acknowledged as generally shameful. However, the profession has been one of the more active participants in the transformation of South African society during the past decade. As indirect beneficiaries of apartheid and direct beneficiaries of the South African "brain drain," Canadians might wish to become better acquainted with the country and establish a more equal partnership with it.

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In November 1997 the South African Truth and Reconciliation Commission released its 3500-page report on the human rights abuses perpetrated under apartheid. One chapter in this report deals with the health sector — the subject of Truth and Reconciliation Commission hearings in June of 1997.³ Numerous individuals and groups made presentations at these hearings; these were supplemented by written submissions, including a detailed survey of apartheid health care by the Health and Human Rights Project, a joint initiative of the Trauma Centre for Survivors of Violence and the Department of Community Health, University of Cape Town.⁴ These submissions and the commission's conclusions present major challenges to the medical profession, not just in South Africa, but also in countries such as Canada.

The failings of the medical profession that were revealed at the Truth and Reconciliation Commission's hearings were of 2 kinds: toleration or active promotion of inequities in health care and complicity in gross violations of human rights. The basis of inequity was a racially segregated health care system in which the facilities and services for nonwhites were vastly inferior to those for whites. In 1985 per capita spending on health care was over 3 times greater for whites than for blacks. Even ambulances were segregated; "[i]f an ambulance of the 'wrong colour' arrived at the scene of an accident, the driver would leave and another ambulance would have to be summoned."⁵ Government policy severely hindered blacks from attending white medical schools and treating patients in white hospitals; as a result between 1968 and 1977 only 3% of newly qualified physicians were black.

The medical profession's acquiescence in these inequities was acknowledged in the submission of the Medical Association of South Africa (MASA) to the Truth and Reconciliation Commission. From its establishment in 1927 until 1981 "MASA was relatively silent on human rights initiatives and was part of the apartheid system.... The period [1982­1988] started with justification and defence of apartheid medicine."⁶ The commission's report condemns MASA for failing to draw attention to: "(a) the effects of the socioeconomic consequences of apartheid on the health of black South Africans, (b) the fact that segregated health care facilities were detrimental to the provision of health, (c) the negative impact on the health of millions of South Africans of unequal budgetary allocations for the health care of different 'racial' groups, (d) the fact that solitary confinement is a form of torture and (e) the severe impact of detention on the health of children."⁷ The report is equally critical of similar failings on the part of the South African Medical and Dental Council, the body responsible for licensing, ethics and standards of practice.

The Truth and Reconciliation Commission hearings witnessed numerous accounts of gross human rights violations in the health care sector. The best known is the death of Steve Biko while in custody; his physicians were eventually found guilty of professional misconduct for failing to diagnose and treat his injuries. Many other examples of misconduct of the district surgeons who were responsible for the health care of prisoners were reported, especially complicity in torture by police interrogators. This involved, among other things, advising torturers on how not to leave telltale signs on their victims and falsifying medical reports and death certificates to omit any mention of the effects of torture. Other physicians who worked in emergency wards of hospitals routinely broke patient confidentiality by reporting patients with gunshot wounds to the police.

Despite many complaints, the South African Medical and Dental Council habitually failed to discipline or even investigate physicians involved in state-sanctioned violations of human rights. MASA was equally reluctant to criticize the police and their political masters. In 1980 the Executive Committee of MASA expressed full support of the South African Medical and Dental Council's exoneration of Biko's physicians. However, pressure from some of its members and from medical organizations outside the country forced MASA to reconsider the Biko case and eventually admit that the medical care of prisoners needed to be improved. Still, MASA was extremely reluctant to criticize the authorities for their mistreatment of physicians who opposed apartheid, such as Dr. Neil Aggett who died in suspicious circumstances while in police custody. Right up to the end of apartheid in 1990, white-dominated medical organizations such as the South African Medical and Dental Council and MASA were complicit in human rights abuses by their failure to criticize those responsible or even acknowledge that such abuses were widespread.

The medical profession's complicity in apartheid cannot be explained by ignorance of the human rights abuses that were being perpetrated. Numerous writers, including the physicians Trefor Jenkins⁸ and Max Price,⁹ published critiques of apartheid medicine, and few physicians could have ignored the publicity given to the negligent medical treatment of Steve Biko. It is harder to determine whether physicians realized that apartheid medicine was contrary to the basic principles of medical ethics, however. In attempting to answer this question, the Truth and Reconciliation Commission concluded that, "[d]uring the period under review, ethics was taught on an ad hoc basis and, for the most part, students were not examined on these topics. There was, therefore, no uniformity in the way in which health professionals were made aware of, or given guidance on, incorporating issues of medical ethics and human rights into daily practice."¹⁰ The commission was especially critical of the Department of Health, the South African Defence Force and the South African police and prisons for failing to provide adequate training, support and ethical guidance to health professionals in their employ on matters such as conflicts between their responsibilities to employers and to patients.

Although individual physicians may not be to blame for ignorance of the basic principles of medical ethics, the same cannot be said for the medical profession as a whole. Except for the years 1976­1981, MASA was a member in good standing of the World Medical Association and presumably subscribed to their core ethical statements. These include the 1948 Declaration of Geneva, which states, "I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patients," the 1975 Declaration of Tokyo, which forbids physician participation in torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment, and the 1981 Resolution on Physician Participation in Capital Punishment, which states that "it is unethical for physicians to participate in capital punishment...." MASA, the South African Medical and Dental Council, the medical schools and the military and prison medical authorities failed to adequately promote these ethical principles, either within the medical profession or in public.

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Throughout the entire apartheid era there were individual physicians who protested against inequities and human rights abuses in health care. It was only in the late 1980s, however, when apartheid was in its death throes, that MASA seriously questioned its complicity in the system. In 1989 the MASA Federal Council unanimously approved a policy statement calling for "the abolition of all discriminatory measures in South Africa to ensure the disappearance of the practice of apartheid."¹¹ In 1994 it adopted a new Code of Conduct that highlights the social responsibility of physicians to promote equity in health care; and in 1995 it issued a public apology for remaining silent about "race-based public policies affecting the medical profession, the restriction of medical school admissions on race, segregation of hospitals and other health facilities, the maintenance of separate waiting rooms by members of the profession, [and] the involvement of medical physicians in the treatment of prisoners and detainees...."¹² MASA repeated this apology in its submission to the Truth and Reconciliation Commission. However, the submissions of 2 other medical organizations, the Interim National Medical and Dental Council (successor to South African Medical and Dental Council) and the South African (military) Medical Services, refused to accept blame for any of the abuses that occurred under apartheid.¹³

Another sign of the transformation of the medical profession in South Africa was the 1998 merger of MASA and the predominantly black Progressive Doctors Group to form the South African Medical Association (SAMA). The Progressive Doctors Group was the successor to the National Medical and Dental Association, which was founded in 1982 because of dissatisfaction with MASA's response to the death of Steve Biko. In 1999 the National Medical Alliance, a group of 5 medical organizations, joined SAMA to complete the unity process. Although MASA was by far the largest of the uniting groups, it occupied only 50% of the board positions.

To help develop a human rights ethos for the profession SAMA has undertaken the following initiatives:

• Its ethics committee has been renamed the Committee for Human Rights, Law and Ethics with an expanded mandate to deal with human rights issues.
• It established a Medical Ethics Education Subcommittee to promote the teaching of ethics and human rights in medical schools.
• It has participated in discussions with other health and human rights organizations to form a Steering Committee on Human Rights in South Africa, although efforts to obtain funding for committee activities have so far been unsuccessful.
• It has fostered the development of the Ethics Institute of South Africa, a soon-to-be-launched venture funded initially by the Merck Foundation. SAMA representatives have participated on a task team to determine the mission, structure and scope of operations of the institute. With an initial focus on organizational ethics in the health care sector, the Ethics Institute of South Africa will require considerable ongoing support from SAMA if it is to be successful.
• In response to the Medical and Dental Professional Board's regulation that the renewal of physicians' and dentists' licenses to practise is contingent on the fulfillment of a defined number of continuing professional development credits, including 10 in ethics, SAMA's Foundation for Professional Development is offering a correspondence course in medical ethics that will provide all South African physicians with the means of meeting this requirement.

The Truth and Reconciliation Commission report suggested numerous other initiatives for medical and health organizations to help overcome the legacy of apartheid in the health care professions and the health care system. Given the enormity of these tasks and the scarcity of resources to carry them out, it may take many years before respect for human rights is an integral part of health care in South Africa. Moreover, there is still a great deal of suspicion in South Africa about the sincerity of the medical profession's new commitment to an ethos of human rights and ethics. Critics note that "[m]any of the individuals implicated in complicity with human rights abuses are still working in the health sector; many even hold senior positions in professional organizations and in the public health services. Their failure to 'come clean' regarding their past activities may present the most serious obstacle to reconciliation within the profession and to the success of institutional reform directed at building a human rights culture."³ Another major obstacle to the transformation of the medical profession is a lack of funds for new initiatives in medical education due to the weakness of the South African economy and the national government's decision to reallocate health care spending in favour of primary care. SAMA itself is not immune from financial pressures; for example, it has not filled the vacancy created by the departure of its Manager of Ethics, and it recently suspended the part-time position of Medical Ombudsman, both for budgetary reasons. Finally, there is a shortage of medical ethics specialists to help overcome the deficiencies noted by the Truth and Reconciliation Commission in ethics education.

Despite these obstacles, human rights and ethics initiatives such as those SAMA has undertaken can contribute significantly to a heightened sensitivity to the ethical aspects of medicine and health care on the part of physicians, other health professionals and the general public. Much more will need to be done, but the process is well under way.

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Although Canadians may feel that apartheid had nothing to do with Canada, there are important lessons that we can learn from the South African struggle against this form of systemic racism.

• The current South African commitment to reduce these inequalities between white an nonwhite citizens might inspire a similar commitment to address aboriginal health issues in Canada.
• Ethics is still a marginal and poorly resourced subject in many Canadian medical schools, and there is nothing comparable here to the SAMA continuing professional development course on ethics for practising physicians who wish to upgrade their knowledge and skills in this area. Although the breeches of medical ethics observed in Canada are not on the level of those documented in South Africa, they still jeopardize the profession's ability to advocate on behalf of physicians and patients; these incidents might decline with increased ethical awareness.
• Canadians have benefitted from the immigration of South African physicians in the past. If we are in favour of the transformation of South African society, including the health care system, on the basis of racial equality, then we should be prepared to reciprocate with Canadian medical knowledge, resources and personnel.

Underlying these recommendations is a need for vigilance to ensure that the medical profession in Canada avoids both direct violations of human rights, such as those performed by some South African physicians under apartheid, and complicity in an unjust social system that violates the basic principles of human rights and medical ethics.

Competing interests: Dr. Williams' sabbatical work in South Africa, including research related to this article, was funded, in part, by a CIDA Professional Development Award administered by the Canadian Bureau of International Education. The South African Medical Association also provided logistical support for this work.

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Reprint requests to: Dr. John Williams, Director of Ethics, Canadian Medical Association, 1867 Alta Vista Dr., Ottawa ON K1G 5W8; fax 616 731-1779; willij@cma.ca

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