II. SOUTH AFRICA

The histories of medicine and of medical ethics in South Africa are intimately linked to political, social, and economic aspects of that country's development, dominant components of which include racial discrimination and social segregation. A brief review of some key political events will provide an illuminating backdrop to a description of the evolution of medical services and the ethics of medical practice in this controversial country, which typifies in microcosm many of the world's diverse human problems and arguably poses the most challenging contemporary opportunity to demonstrate human ability to resolve conflict peacefully.

Political Background

During the period of the Dutch settlers (1652–1820) the indigenous Khoi-Khoi (pastoral people) and the San (huntergatherers) were treated with the arrogance and paternalism that for subsequent centuries epitomized European domination over blacks and exploitation through enslavement and colonial/cultural imperialism. These attitudes, together with warfare and the introduction of new diseases (e.g., smallpox in 1713), led to the decimation and destruction of the organized cultures of these indigenous peoples (Burrows; Laidler and Gelfand).

British annexation of the Cape (1795) and the arrival of British immigrants in Algoa Bay were followed by ninety years of conflict that included devastating wars between rival black tribes, the freeing of slaves (1833), the "importation" of Indians to work in the cane fields of Natal (1860), the first Anglo-Boer War (1880), several wars against the Zulus, and the bitter second Anglo-Boer War (1899–1902), during which twenty-six thousand Afrikaner women and children died in British concentration camps.

The British Parliamentary Act of Union (1910), which gave whites the right to self-determination, and the subsequent failure of the British to exercise their veto powers to restrain the Union Parliament from enacting oppressive racial laws (Native Land Act of 1913, depriving blacks of their land, and the Native Administration Act of 1927, depriving them of their right to self-determination), set the scene for the growth of Afrikaner political and economic dominance. The rise to power of the Nationalist Party in 1948 was followed by proliferation of apartheid policies, relentlessly entrenched through legislation that oppressed and dehumanized the black people of South Africa.

Black opposition evolved from powerless peaceful protest into a politically powerful process of potentially peaceful progress. It was hampered, however, by a growing culture of individual and group violence, fueled by brutal elements within the state security forces and by internal sources of conflict that horrified the world (Schlemmer). Intensification of black resistance, more clearly articulated demands for human rights globally, and changing foreign policy agendas progressively isolated South Africa from its previous friends and from international markets. By the 1980s economic decline, rapid population growth, urbanization, destabilization in the neighboring states, and collapse of communism in eastern Europe and the Soviet retreat from regional conflicts constituted the matrix from which arose the Nationalist Party's acceptance of the need to seek, with the black opposition parties, a negotiated settlement as a step toward developing a democratic South Africa (Benatar, 1992).

Legislative changes since the "unbanning" of the black opposition movements in February 1990 have included repeal of the 1913 Native Land Act, the 1927 Native Administration Act, the 1950 Population Registration Act, and the 1950 Group Areas Act, which together formed a powerful core of statutory discriminatory policies. While the transition period abounds with ironies and ambiguities, optimism that peaceful and constructive pathways to progress could and would be found followed the December 1991 Convention for a Democratic South Africa (CODESA) Conference and the March 1992 referendum. It is against this background that the history of medicine and medical ethics in South Africa can now be briefly reviewed.

History of Medicine

The first manifestation of any formalized medical service was the erection of hospital tents following a smallpox epidemic introduced by a visiting fleet in 1713. Further episodes of smallpox (1751 and 1755) led to the construction of two rudimentary hospitals, one for poor Europeans and the other for slaves, the well-to-do being treated at home.

Medical practice developed in two directions: a private commercial venture predominantly for those who could afford to pay, and a public service for the poor, to which the mission medical service (introduced by the Missionary Society of London) made a major contribution in rural areas for well over a century. Concern for public health, stimulated by the 1918 influenza epidemic, generated decades of successful research on infections in close collaboration with the World Health Organization (WHO). Public health services of a high standard were developed through the creation of medical schools with public teaching hospitals open to all—on a segregated basis; ostensibly separate but equal.

The developing systems of medical practice and of medical education mirrored the diverse characteristics of South African society. Undisputedly high standards of medical education in the Western tradition, dedication of generations of practitioners to high standards of medical practice and patient care, considerable goodwill between doctors and patients of all races, extensive public-health facilities—including teaching centers of excellence and well-funded private medicine—reflect the successes. Privileged access to medical education; fragmentation and duplication of health services; lack of planning; wide disparities in health and in access to healthcare (predominantly on a racially discriminatory and unequal basis); focus on curative hospital-based medicine; paucity of preventive, promotive, and rehabilitative services; paternalistic attitudes to patients; and dismissive attitudes to African traditional medicine reflect the racist and oppressive aspects of a system doomed to failure through its institutionalized neglect of civil and social justice (Van Rensburg and Benatar).

Deficiencies in the healthcare system were clearly articulated in the 1940s, and the case for reform toward a unitary health service has been the subject of intense debate since the 1980s (Benatar, 1986, 1990b, 1991). Traditional African medicine continues to be practiced, particularly in rural areas. While black Africans have increasingly accepted Western medicine, they eclectically choose varying combinations of modern and traditional medical advice (Edwards).

Medical Ethics

The South African Medical and Dental Council (SAMDC), a statutory body, was established in 1929 with the primary purpose of protecting the public through maintenance of high professional (including ethical) standards of practice and with a view to serving the interests of the medical and dental professions—insofar as these interests are compatible with high standards. The wide range of powers vested in SAMDC included the power to institute inquiries into any complaint, charge, or allegation of improper or disgraceful conduct of its members and to exercise disciplinary power over them.

As in most other Western countries in the first sixty years of the twentieth century, discussions on medical ethics in South Africa largely took place within the framework of the authoritarian, paternalistic behavior expected of professionals supposedly adhering to the Hippocratic Oath and similar codes. The first South African text on medical ethics (Elliott) was limited to discussion of ethical codes, professional secrecy, advertising, the conduct of consultations, fees and financial matters, and upholding the "traditions" of medicine, with only brief reference to abortion and sterilization, and to the ethics of investigative medicine. This text, based on Guy Elliott's experience of deliberations on ethical matters by the Medical Association of South Africa (MASA) and the SAMDC, provides a succinct outline of accepted medical ethics in South Africa (and in many Western countries) in the first half of the twentieth century.

Issues of bioethics have usually been stimulated by the widespread application of technological advances in everyday medical practice, the social changes that challenge many traditional professional values, cost considerations, uncertainty regarding the effectiveness of innovative treatments, and increasing concern for individual autonomy and shared decision making in the United States and Europe.

The pace of social change, and of change in medicine and bioethics in South Africa (a middle-income country—per capita gross national product (GNP) less than one-tenth that in the United States and falling), has been much slower. Expenditure on health has increased only marginally and, despite their high profile, modern lifesaving medical treatments are available only on a limited scale. Public and even professional debates on ethical issues in medicine have been very limited in a repressive, authoritarian society lacking a patients' rights movement and unaccustomed to public discourse on civil and political liberties (Benatar, 1988).

As in the United States, theologians have played a pioneering role in reawakening interest in bioethics; several conferences were held in South Africa (in the 1960s and 1970s) under church or theological auspices. The first, stimulated by the historic heart transplant in Cape Town (December 1967), was on the ethics of tissue transplantation (Oosthuizen). Others followed on abortion (Oosthuizen et al., 1974), euthanasia (Oosthuizen et al., 1978), professional secrecy (Oosthuizen et al., 1983), and clinical experimentation (Oosthuizen et al., 1985). These provoked little ongoing public or professional debate. In the 1980s some medical schools began developing modern bioethics education programs, but progress has been slow and the programs remain (1) in a fledgling state, (2) dependent on enthusiastic physicians who have heavy professional responsibilities and minimal formal training in philosophical ethics, and (3) without the financial and institutional support to develop formal programs with committed support from other disciplines (e.g., philosophy, law). One medical faculty has published the proceedings of four symposia on bioethics (Benatar, 1985, 1986, 1988, 1992). These have encompassed theological, philosophical, and sociological debates on death and dying; resource allocation; the doctor–patient relationship; abortion and in vitro fertilization; research on humans; principles of biomedical ethics; moral reasoning; withholding and withdrawing treatment; healthcare of detainees; hospital ethics; the right to healthcare and the structure of health services; ethical considerations in relation to acquired immunodeficiency syndrome (AIDS); and teaching medical ethics. These proceedings reflect progressive movement toward the views being popularized in bioethics debates in the United Kingdom and the United States. By retaining a degree of "cultural sensitivity" they endeavor to avoid the pitfalls both of "ethical imperialism" and of "ethical double standards."

A milestone event in the history of medical ethics in South Africa was the inadequate SAMDC and MASA responses to the unethical manner in which state-employed medical practitioners provided professional attention to prominent black activist Steve Biko prior to his death during detention without trial in 1977. Failure of SAMDC to exercise its duty to protect the public by acknowledging the unethical behavior of Biko's doctors and taking appropriate disciplinary action against them, and MASA's response to SAMDC's deficient protection of the public met with resounding criticism nationally and internationally (Nightingale et al.). The sequence of events through which the efforts of a small group of rank-and-file members of the profession led to a Supreme Court injunction against SAMDC, which resulted in a reversal of its previous decisions and the imposition of disciplinary action, is well documented. The National Medical and Dental Association (NAMDA), formed in 1982 as a result of discontent with MASA's actions following the death of Steve Biko, has received international acclaim for its outspoken advocacy against discriminatory practices. MASA, which came under considerable criticism for its inadequate reactions to the Biko affair, has, to its credit, taken some sincere steps in an attempt to rectify its previous shortcomings. Its statements are now clearly on public record, and the challenge ahead is to ensure their further implementation in practice. Greater attention to ethical responsibilities toward prisoners, detainees, and hunger strikers has been a gratifying response to the Biko case (Benatar, 1990a; Kalk and Veriava). The public confession of guilt by the district surgeon who bore major responsibility for Biko's medical care, emphasizes the need to maintain professional independence in the face of state security and other coercive pressures.

Professional institutional responses intended to stimulate higher standards of ethical practice include the MASA and the Medical Research Council (MRC) guidelines on professional ethics and the ethics of medical research, respectively (both currently under further revision), and the publication by the College of Medicine of South Africa of its Credo. The long-standing requirement by some universities that all proposals for human and animal experimentation need approval by institutional ethics committees is spreading to other universities, and such prior approval has now become a requirement for all funding applications to the South African Medical Research Council.

Conclusion

In a period characterized by national economic attrition, real per capita expenditure on health of less than one-twentieth of what is spent in the United States, burgeoning population growth, rapid erosion of financial support for academic medicine, and political liberation with rapidly escalating human expectations, development of the discipline of bioethics in South Africa has been initiated and sustained more as a hobby by a few enthusiasts than as an integral component of medical education and practice. The need to include formal teaching of bioethics and clinical ethics in professional schools, which has gained widespread acceptance in the developed world, remains to be achieved in South Africa, as in other developing countries. Who should teach, what should be taught, how teaching of this discipline can be made most effective, and the ways in which such teaching can enrich medical and social education and practice are, as in any new discipline, matters of ongoing debate. If South Africa can learn from the developments in other countries and, with international support, use these lessons to build a national bioethics program and a better healthcare system in South Africa, this could contribute toward restructuring a new South Africa that could play a vital role in helping to rehabilitate southern Africa.

solomon r. benatar (1995)

bibliography revised

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