EDITORIAL

Ethics replaced by politics at the patient's bedside: Sad and dark times in our post-1994 trajectory

The practice of healthcare has always been and continues to be a moral enterprise - a social contract between the profession and the public. This applies at all levels of healthcare - from policy decisionmaking down to the practitioner-patient relationship. I recall when, in 2017, as ethics witness during the Life Esidimeni arbitration, I underscored that the politicians at the Gauteng Department of Health who had made decisions for the patients had conducted themselves with impunity similar to what had occurred during the period of the previous apartheid regime. Unfortunately that moral pathology continues, with politics replacing ethics at the patient's bedside, as seen by the conduct of the MEC of Health, Limpopo Province, despite her taking an oath at the completion of her medical training to uphold the principles and values of medical ethics in all interactions with her patients. She also took an oath when sworn into her office to defend the values of the Constitution of South Africa (SA).^[1]

On 23 August, a video that was taken during MEC Dr Phophi Ramathuba's visit to a Bela Bela Hospital project called Rural Health Matters went viral on social media.^[2] The project was established to clear surgical backlogs in the province. In the video, the MEC is seen demeaning a patient because she is a foreign national. She disparagingly informs the patient that she should have been with Zimbabwean President Emmerson Mnangagwa, that he does not give her (the MEC) money to operate and that she is operating her department within her limited budget. She continues berating her, and informs her that she is aware that healthcare facilities in her province are considered a charity department by citizens from Zimbabwe, and that she will not be discharged until she settles her bill. Her manner is cold, insensitive and totally devoid of compassion. Dr Ramathuba is accompanied by an entourage that responds to her pitiless antics with laughter, further humiliating the defenceless and vulnerable patient.

Dr Ramathuba, a graduate of MEDUNSA, now Sefako Makgatho University (SMU), took an Oath, as all graduates do, which starts off with:

'Above all else my first consideration will be the well-being of my patients irrespective of race, gender, religious and political persuasion, affiliations, etc.'

She also pledged to 'actively guard against all human rights abuses', and to 'strive for good relationships with my patients based on respect, communication and trust'.

Similar to the Hippocratic Oath, the SMU Oath emphasises the duty of the doctor to help and not harm patients. While some have argued that she was not in a doctor-patient relationship with the patient, she is a doctor addressing a patient lying in a hospital bed, and her duty not to exploit the patient's vulnerabilities cannot be disregarded. Blatantly discounting the Oath that she took, she abused her power to unleash a political attack on the patient, being fully aware that the latter was in no position to retaliate. Oaths and codes serve as a source of moral authority, and are used among professionals and laypersons to set standards for ethical conduct, to define new ethical issues and to support one position or another in ethical discoursed Professional codes in healthcare are as old as antiquity, and despite the Hippocratic Oath being over 2 500 years old, the principles have survived the test of time and have been included in modern versions of the Oath internationally and locally within our health sciences faculties.

The Health Professions Council of SA (HPCSA) in its Booklet 1: General Ethical Guidelines for Health Care Professionals^[4]affirms in its introduction (s1) that being registered as a healthcare professional with the HPCSA confers the right and privilege to practitioners to practise their professions. Therefore, practitioners have corresponding moral or ethical duties to others and society in keeping with the principles of the SA Constitution and the obligations imposed on healthcare practitioners by the law. The booklet contains value-oriented principles, and expresses the most honourable ideals to which members of the profession should subscribe in terms of their conduct. Specific core ethical values and standards that underlie professional and ethical practice are highlighted. It underscores that everything ethically required of a professional to maintain good professional practice is grounded in these core ethical values and standards. In particular, practitioners should abide by the value of respect for persons, which means that practitioners should respect patients as persons, and acknowledge their intrinsic worth, dignity and sense of value. They should not harm or act against the best interests of patients, even when patients' best interests conflict with their own self-interest. In addition, they need to recognise and respect the human rights of all individuals, and by inference, not just SA citizens. Compassion, also a core value, means that practitioners need to be sensitive to and empathise with the individual and social needs of their patients. This places an obligation on them to seek and create mechanisms for providing comfort and support where appropriate and possible. Compassion, a crucial trait for the delivery of morally good care, is closely linked to caring, a natural striving healthcare practitioners ought to have to relieve sorrow and misery. Caring requires an attitude of empathy towards patients. Caring practitioners are able to put themselves in the patient's situation of pain and suffering to such an extent that they can perceive accurately the patient's care needs.^[5] What is clear is that Dr Ramathuba's arrogant and offensive ranting replaced moral principles and ethical values in our regulations and codes with political insult at the patient's bedside. The SA Medical Association has formally complained to the HPCSA regarding Dr Ramathuba's conduct. Several other entities and individuals have done so as well. It is left to be seen whether the regulator, which has been silent thus far, will react and respond to its mandate of protecting the patient and guiding the profession.

At the time of writing this editorial, there has been evasion by SA's leadership, including the president of the country and the Minister of Health, in addressing this flagrant disrespect of not only medical ethical values, but also our Constitutional values by an office-bearer in the government. Dr Ramathuba, as MEC, was required to take an oath (or solemn affirmation) in line with schedule 2, section 5 of the Constitution of the Republic of SA^[1] when sworn in to 'obey, respect and uphold the Constitution'. The Bill of Rights, our cornerstone of democracy, in section 7 stipulates that it enshrines the rights of all people in our country, and affirms inter alia everyone's right to human dignity. This patient's right to human dignity has unambiguously been infringed. Silence or hedging of the issues implies that our leadership, too, merely pays lip service to the oath they took to uphold the Constitution, hence insinuating collusion with the MEC.

These are definitely sad and dark times in our post-1994 trajectory. This unethical and dishonourable conduct needs to end, but it must also be recorded in our scholarly writings, as it forms part of our history. History can do much to enrich the understanding of how, why and under what circumstances issues in medical ethics and human rights come to the fore and achieve national or even international prominence, as well as how some issues fade away from view, only to surface again and be rediscovered by later observers.^[3] History has recorded human rights abuses by the country's previous oppressive regime, including the abuse of Biko. History has recorded the Life Esidimeni tragedy as well. History will also record how Dr Ramathuba replaced ethics at the bedside with politics and, should the silence continue, history will also record the complicity of the rest of the leadership.

Ames Dhai

Editor-in-Chief ames.dhai@wits.ac.za

References

1. Constitution of the Republic of South Africa, 1996. http://www.gov.za/sites/ www.gov.za/files/Act108of1996s.pdf (accessed 1 September 2022).

2. Ho U. Limpopo Health MEC Dr Phophi Ramathuba's xenophobic, dehumanising diatribe against Zimbabwean patient. Daily Maverick, 24 August 2022. https://www.dailymaverick.co.za/article/2022-08-24-limpopo-health-mec-ramathubas-xenophobic-rant-against-zimbabwean-patient-polarises-sa/ (accessed 1 September 2022).

3. Sugarman J, Sulmasy D. Methods in Medical Ethics. 2nd edition. Washington, DC: Georgetown University Press, 2019.         [ Links ]

4. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Care Professions. Pretoria: HPCSA, 2014. http://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_1_ guidelines_good_prac.pdf (accessed 1 September 2022).         [ Links ]

5. Vanlaere L, Gastmans C. Ethics in nursing education: Learning to reflect on care practices. Nurs Ethics 2007;14(6):758-766. https://doi.org/10.1191/0969733002ne557oa