Cape Town — The discriminatory practices of the apartheid era had a negative impact on the medical education of
black students, the care of black patients in private as well as public institutions, and the careers of black medical doctors. Medical student training programmes at most universities ensured that white patients were not examined by black medical students either in life or after death. Post-mortems on white patients were conducted in the presence of white students only; students of colour were permitted to view the organs only after they were removed from the corpse.
Public and private hospitals reflected the mores of apartheid South Africa. Ambulance services were segregated, and even in emergencies a designated “white ambulance” could not treat and transport critically ill or injured patients of colour. Public hospitals had separate wings for white and black patients and medical staff. Many private practices had separate entrances and waiting rooms for patients with medical insurance and those paying cash, effectively segregating white and black. Doctors treating political prisoners faced dual loyalties on a regular basis. Some, like Dr Wendy Orr, resisted the gross human rights violations, while many were complicit. In particular, the abhorrent treatment of medical student and political activist Steve Biko received international attention.
The conduct of district surgeon Dr Ivor Lang and chief district surgeon Dr Benjamin Tucker in the Biko affair was indefensible. They failed to examine Biko adequately, did not attempt to elicit even a basic history from him, and did not provide adequate care or treatment. Instead, they acquiesced to the instructions of the security police, neglecting to place the best interests of their patient above all other considerations. This unprofessional conduct may be explained by the conflict of the doctors caught in a classical “dual-loyalty” situation — one in which their duty to their patient, Biko, conflicted with their (perceived) duty to the state. In fact, Tucker subsequently admitted: “I had become too closely identified with the interest of the organs of the state, especially the police force, with which I dealt practically on a daily basis… I have come to realise that a medical practitioner’s primary consideration is the well-being of his patient.”
GR McLean and Trefor Jenkins make the point that the Biko case is an example of a difficult ethics case not because it is difficult to know what the morally correct course of action is, but “because it is hard to do what one ought to do”. The duty of the doctors involved in Biko’s case was clear, but performing that duty was difficult. They had become so accustomed to working with the security police and regarding the detainees as dangerous terrorists rather than patients that they had disengaged from the duties and the responsibilities of their profession. Neither the Medical Association of South Africa (Masa) nor the South African Medical and Dental Council (SAMDC) supported charges of misconduct or unethical conduct against the doctors involved in the Biko case.
The Biko affair marked a moral threshold in public life. The reputation of the medical profession had never sunk as low. Confidence had evaporated. It was no longer just a matter of moral wrongdoing by a few medical practitioners. Through the actions of Masa and the SAMDC, the whole organised medical profession became implicated in that wrongdoing. It was only after a small group of doctors (Frances Ames, Edward Barker, Trefor Jenkins, Leslie Robertson, and Phillip Tobias) successfully obtained a Supreme Court ruling to force the SAMDC to re-open the case against the Biko doctors that the council did so in 1985. Ultimately, Lang was found guilty of improper conduct and received a caution and a reprimand; Tucker was found guilty of improper and disgraceful conduct and was later struck from the medical roll.
Other human rights violations occurred at the hands of physicians, many of them in prisons and the military. In particular, Dr Wouter Basson joined the South African Defence Force as head of Project Coast — the chemical and biological warfare programme of the apartheid government. It was only in 1998, during the Truth and Reconciliation Commission (TRC) hearings, that the details of the activities of Project Coast emerged: the manufacture of biological weapons, secret stockpiles of lethal bacteria to kill people with pigmented skin selectively, and chemicals and drugs developed specifically for use against enemies of the apartheid South African government. Although Basson gave evidence at the TRC hearings for 12 hours in 1998, he did not apologise, he did not show remorse, and he did not request amnesty. Finally, after a 13-year-long case with the Health Professions Council of South Africa (HPCSA), Basson was found guilty of unethical conduct in December 2013. Although he argued that he had acted as a soldier and not a doctor, that medical ethics were different for military doctors, and that he had no doctor-patient relationship with those he harmed, among other arguments, a long-awaited guilty verdict was reached.
Although the Sama issued a statement in support of this verdict, Basson retains his membership in the organisation Apartheid corrupted the moral fibre of South African society in a manner that permeated and broke the core ethical covenants of the medical profession. Separation between the profession and the state became opaque and ambiguous. Through this dense veil of confusion, a minority of health professionals were able to see their way clear and rebel against injustices in health care in the prisons and security forces. However, the stance of many was one of indifference or, worse still, complicity. Public hospitals are now fully integrated. HPCSA mandated that ethics training for all registered professionals become compulsory. All medical schools are now compelled to provide training in ethics, law, and human rights as a compulsory part of their curricula.
Medical undergraduate training ensures equity in student intake and training, except for a minority of apartheid institutions that continue to use language as a barrier to entry, thereby denying access to non-Afrikaans-speaking students, who are typically black. We hope that this bleak chapter of medical history will never be repeated. * This is an edited extract from a paper Dual Loyalties, Human Rights Violations, and Physician Complicity in Apartheid South Africa first published in the AMA Journal of Ethics. Story originated here: Apartheid corrupted the medical profession October 6 2015 at 03:44pm