IZINDABA

Stellenbosch University: Africa's first WHO Bioethics Collaborating Centre

Stellenbosch University (SU)'s Centre for Medical Ethics and Law became Africa's first World Health Organization (WHO) Bio-ethics Collaborating Centre in April this year, after several years of working with the global body in vital areas such as vaccine policies, bio-banking and research ethics.

It joins a prestigious international network of university bioethics centres in Toronto, New York, Zurich, Singapore, Miami and Melbourne which, among other things, informs the WHO's ethical understanding and response to global humanitarian crises such as the recent Ebola outbreak in West Africa. The collaboration will be renewable in 2019, with the current agreement being to cover ethical issues in neurological science and mental health (neuroimaging and dementia being of growing importance), and advising and developing guidelines on bio-banking and research ethics (with ongoing capacity-building workshops for the African region). The SU Centre has already played a pivotal role in developing WHO guidelines on ethical issues in public health surveillance. It will also monitor new issues in the local field as they arise.

Prof. Andreas Reis, strategy ambassador for strengthening and developing the WHO's regional institutional capacity and carrying out its mandated projects, said that the Ebola outbreak powerfully demonstrated the inherently global nature of ethics and the interconnectedness of all countries. 'We can learn a lot from SA's concept of Ubuntu -we'll only succeed globally if we build mutually beneficial partnerships.' He said that the Centre for Medical Ethics and Law, established in 2003, was one of the oldest and most prestigious in Africa, having built an excellent global reputation for empirical and conceptual research and medical ethics teaching, including a postgraduate diploma in research ethics, funded by the US National Institutes of Health. Prof. Jimmy Volmink, Dean in the Faculty of Medicine and Health Sciences, said that SU had a 'long and proud history' of partnership with the WHO, stretching over many decades. Its academic staff served on various WHO advisory boards and on several working groups, the most prominent being paediatric and drug-resistant tuberculosis (TB). Prof. Keymanthri Moodley, Director of the SU Centre for Medical Ethics and Law, was one of two SU academics in the WHO's Strategic Advisory Group of Experts (SAGE) on immunisation during humanitarian crises, and was currently part of the SAGE working group on Ebola vaccines. Other SU work that guided WHO policy formulation included the ongoing development of an HIV vaccine, health systems strengthening, prevention of mother-to-child HIV transmission and adherence to antiretroviral and TB drugs. Volmink singled out philosophy professor Anton van Niekerk, Director of SU's Centre for Applied Ethics, as 'one of the fathers of bioethics' in SA, saying he played a leading role in teaching and mentoring several clinicians/bioethicists who contribute to teaching in the Centre.

Van Niekerk told the gathering that bioethics had (belatedly) come a long way since Chris Barnard's heart transplant, which would have 'failed dismally' to clear today's ethical hurdles (i.e. the definition of death). 'Bioethics was not taken seriously before the 1980s [in SA]; the attitude was that it was important, but taught by the bedside with no serious need for the philosophical underpinnings - you could get around it by simply making it a practical subject.' The pivotal and founding local event for bioethics in SA was the death of Steve Biko in December 1977.

Together with the Soweto uprising in June 1976, these deaths made it clear that the rhetoric of government leaders about the intended justice of the homeland system and other alleged justifications for apartheid were bogus and that the system was morally corrupt with its demise 'a mere matter of time'. The Biko affair highlighted the importance of a moral orientation in the practice of medicine and directly contributed to a reorganisation of the institutionalised medical profession in SA. Greater attention to ethical responsibilities towards prisoners, detainees and hunger strikers ensued, while the public confession of guilt by the district surgeon who bore major responsibility for Biko's medical care emphasised the need to maintain professional independence in the face of state security and other coercive pressures. Biko's death highlighted the depths to which a society could sink when gross violations of human rights became commonplace, and illustrated the social and political impact that a severe violation of medical morals had on SA society.

Van Niekerk said the teaching of bio-ethics, while not progressing equally across medical faculties, had increased profoundly in the past 20 years, particularly since it was introduced into healthcare worker undergraduate education in the late 1990s. HIV/AIDS had raised a 'host' of bioethical issues, not to mention TB and malaria, making SA a leading international destination for biomedical researchers. He paid tribute to the contribution of Ethics SA's Prof. Willem Landman and his empirical research on the state of the medical profession in SA and the appalling conditions in several major hospitals, and said that Ethics SA had also changed the face of abortion in SA by helping introduce the Termination of Pregnancy Act (1996), which remained one of the most liberal laws in the world. The draft law on assisted death, tabled by the Law Commission in Parliament in 1998, was shelved by government but still contained 'some remarkable suggestions' which would have to be confronted 'sooner or later'. The National Research Ethics Council had produced outstanding and long-awaited revised guidelines for ethical research that had been 'signed off' by the health minister and his director-general, now probably due for publication next year.

Moodley said her journey to Director of the Centre began in 1997 when she was a new consultant to Prof. Pierre de Villiers, then head of the Department of Family Medicine at SU. 'He gave me a huge pile of folders and told me to prepare two ethics lectures for fifth-year medical students, unschooled as I was in medical ethics. I took it on as a challenge.' By the following year she realised she needed 'much greater depth of knowledge in ethics' and studied philosophy under Van Niekerk, 'thinking about value systems and morality', before going to Columbia University in New York as a Fogarty Fellow. In the midst of the Twin Towers 9/11 tragedy, she studied public health ethics with Prof. Ron Bayer (who now chairs the global network of WHO collaborating centres in bioethics). He encouraged her to start working on her doctorate. Upon her return to SA she approached Prof. Wynand van der Merwe, then Dean of SU's Faculty of Medicine, suggesting the establishment of a SU Centre for Bioethics. He and Prof. Barney de Villiers (now deceased) made the Centre into a reality. Together with Profs Willie Pienaar and Sharon Kling, Moodley has built a strong and dynamic undergraduate ethics programme, with several fifth-year medical students today regarding their ethics block as 'among the most stimulating' because it teaches them 'to think and challenge'.

Chris Bateman
chrisb@hmpg.co.za