A research report submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Arts in Applied Ethics For Professionals, July 2017 / Health and, by extension, healthcare is accepted to be a valuable and important social good that is both a good in and of itself, as well as necessary to achieve life’s goals. Its fair distribution is therefore properly the subject of ethical concern and in the era of modern medicine where costs and potentially limitless treatments exceed available resources, rationing healthcare has become an unavoidable necessity. Since such rationing implies that not everyone’s needs or preferences can be met, a fair and just way of rationing healthcare is a widely debated and controversial topic that, to date, remains unresolved. Where third-party private funding organisations are tasked with these rationing responsibilities, the ethical complexities are compounded by perceived conflicts between the ethical frameworks that govern corporate organisations versus those that govern healthcare. Given the apparent inability of normative theories to resolve the problem of how to ration healthcare fairly, there has been a shift in thinking to considerations of procedural justice and a dominant model, Accountability for Reasonableness (AFR), has emerged as the favoured procedure for healthcare decision-making. The report shows why health is an important social value and examines the key models and principles that dominate the rationing debate as well as why the conflict between healthcare ethics and organisational ethics create additional complexities that must be considered when making these funding decisions. Furthermore it explores the rationales for resorting to procedural accounts with specific emphasis on the parameters and validity of AFR. The report concludes that even though the AFR framework may be a legitimate and just process that can effectively frame decision-making and provide a platform to drive transparency and consistency, like most procedural accounts, it does not guarantee that the outcomes it produces are necessarily fair or just. Therefore a straightforward application of AFR cannot resolve the healthcare rationing debate which should, given its ethical complexity, continue to appeal to the important ethical principles that currently govern the field. / XL2018

Thesis (MPhil)--Stellenbosch University, 2000. / Some digitised pages may appear illegible due to the condition of the original hard copy. / ENGLISH ABSTRACT: Medicine in our country is under severe stress, brought about by internal and external forces that need a response from the medical profession. The profession's attempts and response will fall short unless the profession itself is aligned with the new social ethos and the responses are based on the profession's inherent values. Problem Statement: Medical doctors have always been highly valued in society because of the duty they have when illness and disease set in. As individuals, doctors have fulfilled other important roles in the communities where they work. These include giving advice to young people on career choices, counseling on various matters and provision of material help where there is need. This profession has for a long time been shrouded in mystery, being a trade learnt by a few. All these factors contributed to their social standing increasing phenomenally. There is a view that this has also led to public perceptions that doctors are the rich untouchable elite who have no interest or are unconcerned about problems faced by society. The medical profession faces a challenge that is more significant because of the value placed on it by society. The numerous submissions by the victims of human rights abuses to the Truth and Reconciliation Commission have cast a shadow of doubt on the medical profession for its complicity in these acts. The present government has declared transformation of health care as one of its top priorities. The response of the medical profession to this initiative has so far not led to any significant changes of public perception that the profession is unwilling to participate in the transformation of our society. The challenge and subject of discussion in this thesis therefore is: "What is the ideal role of the medical profession in a transforming South African society?" The medical profession, being the nerve centre of health care, has a big responsibility in social transformation. Doctors stand accused as a collective for failing to protect the human rights of patients and not living up to the standards of ethics required of them when patients' rights were violated. The Truth and Reconciliation Commission record of the hearings into the role of the professional organisations in health is used in this thesis to illustrate how serious society views the medical profession's role in the human rights abuses of the past. Based on the T. R. C's report and the assumption that society traditionally places high value on the medical profession, I conducted a survey among South African doctors to test their attitudes towards a range of policy and transformational issues. The unit of analysis was the medical doctors who are in active practice in South Africa in whatever mode of practice. The survey sought to explore the awareness of the respondents about a range of transformation policy changes and invite their comments on the role that they envisage for the medical profession in the process of transformation of society. There is unfortunately scarcity or a lack of applicable South African literature on this topic thus limiting local material for referencing. The search of international literature only yielded the subject of the study of professional values and not necessarily the role of a medical profession in a transforming society. The medical profession has to re-visit its foundations, analyse its history and map out its future in the context of the South African realities. It must find a way of aligning itself with the new ethos and diverse cultures South Africa possesses. Medicine has its own traditional goals and values derived and adapted from society's diverse cultural value systems. With its national and international networks, the inherent knowledge and skills that it possesses, guided by an ethical code, the Hippocratic Oath that serves as a public promise, it influences policy on the country's health care system - a mechanism that government uses to provide a basic human need. The medical profession therefore has to be responsive to the needs of society as much as society needs to support the profession. This thesis explores the role that the profession should play in a transforming South African society. The argument is that this can only be done through the profession examining its values and aligning itself with broader societal value systems, the moral and social norms. It is further argued that visible realistic commitment by the profession to public health will lead to an improvement in its public image. It is the actions or non-actions of the majority that the public notices. The majority of respondents to the survey have indicated that they approve of the transformation policies in health but that they may differ in the way they were introduced. / AFRIKAANSE OPSOMMING: Die geneeskunde in ons land is onder geweldige druk as gevolg van interne en eksterne faktore en dit is nodig dat die mediese beroep reageer. Dit sal die beroep egter nie help om te reageer indien sy lede hulle nie met die nuwe maatskaplike etos vereenselwig nie en die reaksie op die inherente waardes van die mediese beroep geskoei word nie. Probleemstelling Mediese dokters is nog altyd baie hoog geag deur die gemeenskap as gevolg van die verpligting wat hulle het om na mense om te sien wanneer hulle siek word. In hulle individuele hoedanigheid het dokters ook ander belangrike bydraes tot hulle gemeenskappe gelewer. Dit sluit in: advies aan jong mense oor loopbaankeuses, berading en die verskaffing van finansiele hulp waar nodig. Die beroep as sulks was egter vir baie lank ietwat van 'n misterie omdat dit 'n vakrigting is waarin baie min mense hulle kon bekwaam. Al hierdie faktore het die maatskaplike aansien/waarde van dokters geweldig verhoog. Daar is ook diegene wat van mening is dat hierdie faktore aanleiding gegee het tot die openbare mening dat dokters 'n ryk en onaantasbare elite is en glad nie in die probleme van die gemeenskap belangstel nie. Die etlike voorleggings deur die slagoffers van menseregtevergrype aan die Waarheids- en Versoeningskommissie het ook vrae rondom die beroep se betrokkenheid by sodanige gevalle laat ontstaan. Die huidige regering het die transformasie van gesondheidsorg as een van sy grootste prioriteite verklaar. Die reaksie van die beroep hierop het tot dusver nie tot enige noemenswaardige veranderinge in die openbare mening dat dokters nie bereid is om aan die transformasie van ons gemeenskap deel te neem gelei nie. Wat is die ideale rol van die mediese beroep in die transformasie van die Suid- Afrikaanse gemeenskap? As die senusentrum van gesondheidsorg het die mediese beroep 'n groot verantwoordelikheid in maatskaplike transformasie. Dokters word kollektief beskuldig dat hulle nagelaat het om die menseregte van pasiente te beskerm en nie voldoen het aan die nodige etiese standaarde wat van hulle verwag word in die tyd toe pasienteregte geskend is nie. Die rekord van die verhore van die Waarheids- en Versoeningskommissie oor die rol van professionele gesondheidsorganisasies is vir die doeleindes van hierdie tesis gebruik om te illustreer hoe ernstig die gemeenskap voeloor die mediese beroep se rol in die menseregte vergrype van die verlede. Gegrond op die WVK-verslag en die aanname dat die gemeenskap die mediese beroep hoog ag, het ek 'n meningsopname onder 300 Suid-Afrikaanse dokters gedoen om hulle houding jeens 'n aantal beleids- en transformasiekwessies te toets. Die eenheid van analise was mediese dokters wat in die aktiewe praktyk staan, ongeag hulle praktykgebied. Die opname het gepoog om te bepaal wat die vlak van bewustheid by die respondente oor 'n aantal beleidsveranderinge gerig op transformasie is, en hulle uit te nooi om kommentaar te lewer op die rol wat hulle meen die mediese beroep behoort in die proses te speel. Ongelukkig is daar nie toepaslike Suid-Afrikaanse literatuur oor die onderwerp beskikbaar me. 'n Internasionale literatuursoektog het net studies rondom waardes opgelewer, en nie oor die rol van 'n mediese beroep in die transformasie van 'n gemeenskap nie. Die mediese beroep moet die grondslag van sy wese in oenskou neem, die geskiedenis analiseer en sy toekoms in die konteks van die Suid-Afrikaanse realiteite uitstippel. Die beroep moet 'n manier vind om homself met die nuwe etos en uiteenlopende kulture van Suid-Afrika te vereenselwig. Die geneeskunde het sy eie tradisionele doelwitte en waardes gekry en aangepas vanuit die uiteenlopende kulturele waardestelsels van die gemeenskap. Deur middel van sy nasionale en internasionale netwerke, inherente kennis en vaardighede, die leiding van 'n etiese kode, die Eed van Hippokrates wat as 'n belofte aan die publiek dien, beinvloed die mediese beroep die land se gesondheidsorgstelsel - 'n meganisme van die regering om in 'n basiese menslike behoefte te voorsien. Die mediese beroep moet daarom ingestel wees op die behoeftes van die gemeenskap in dieselfde mate as wat die gemeenskap die beroep behoort te ondersteun. Hierdie tesis ondersoek die rol wat die mediese beroep behoort te vervul in 'n Suid-Afrikaanse gemeenskap waar transformasie besig is om plaas te vind. Daar word geargumenteer dat dit net gedoen kan word indien die beroep sy waardes ondersoek en hom met die breer maatskaplike waardestelsels vereenselwig. Daar word verder geargumenteer dat 'n sigbare realistiese verbintenis van die mediese beroep tot openbare gesondheid tot die verbetering van sy openbare beeld sal lei. Dit is die optrede of nie-optrede van die meerderheid wat die publiek raaksien. Die meerderheid respondente in die meningsopname het aangedui dat hulle die transformasiebeleid vir gesondheid ondersteun, maar dat hulle verskil van die wyse waarop dit in werking gestel is.

Law / LL.M.

Law / LL.M.

The therapeutic privilege is a defence in terms of which a doctor may withhold information from a patient if disclosure of such information could harm the patient. This study explores the defence of therapeutic privilege and provides a critical evaluation. A comparative investigation is undertaken, while arguments springing from a variety of disciplines are also incorporated. A number of submissions are made for limiting the ambit of the defence. The main submission is that the therapeutic privilege should comply with all the requirements of the defence of necessity. In addition, it should contain some of the safeguards afforded to the patient by the requirements of the defence of negotiorum gestio so that therapeutic privilege is out of the question if medical treatment is administered against the patient's will, or the doctor has reason to believe (or knows) that the patient will refuse to undergo an intended intervention once properly informed. / Jurisprudence / L.L.M. (Jurisprudence)

Thesis (M.Phil.)--Stellenbosch University, 2000. / ENGLISH ABSTRACT: The aim of this research is to identify the various levels of health care units, their relationships and the problems hindering an effective referral system. To achieve this goal, use is made of a case study of the West Rand area in Gauteng. The standpoint is that, to achieve Primary Health for all South Africans referral systems within health care units and levels must be reciprocal. It is argued that for Primary Health Care to be successful, it must satisfy the goal of affordability appropriateness and accessibility. Results from the research revealed that four health care levels, namely traditional healers, health NGOs, Clinics, and Hospitals. Though there is some degree of referral in the study area, it was observed that referrals in the study area were not reciprocal. Amongst the major problems identified as hindering an effective referral system in the study area, include lack of cooperation between health institutions, poor health infrastructure and communication network as well as lack of other health paraphernalia. The research also found that government policy towards some of the health institutions (Traditional healers) contributes to the inefficiency of proper referrals in the study area. / AFRIKAANSE OPSOMMING: Die oogmerk van hierdie ondersoek is om die verskillende vlakke van gesondheidsorgeenhede, hulonderlinge verbande en die probleme wat doeltreffende verwysings in die wiele ry, te identifiseer. Dit word gedoen aan die hand van 'n gevallestudie van die Wes-Randarea in Gauteng. Die uitgangspunt is dat doeltreffende Primêre Gesondheid vir alle Suid- Afrikaners afhang van resiprokale verwysingsisteme tussen gesondheidsorgeenhede en -vlakke. Suksesvolle Primêre Gesondheidsorg vereis bekostigbaarheid, toepaslikheid en toeganklikheid. Die ondersoek het vier gesondheidsorgvlakke aan die lig gebring: tradisionele genesers, gesondheids-nie-regerings-organisasies, klinieke en hospitale. Hoewel daar 'n mate van onderfinge verwysing in die studie-area bestaan, was dit nie wederkerig nie. Onder die vernaamste struikelblokke vir 'n doeltreffende verwysingsisteem tel swak samewerking tussen gesondheidsinstellings, gebrekkige gesondheidsinfrastruktuur en kommunikasienetwerk, en 'n skaarste aan ander gesondheidsmiddelle. Die ondersoek het ook bevind dat regeringsbeleid aangaande sommige van die gesondheidsinstellings (tradisionele genesers) bydra tot die ondoeltreffendheid van verwysings in die studie-area.

The therapeutic privilege is a defence in terms of which a doctor may withhold information from a patient if disclosure of such information could harm the patient. This study explores the defence of therapeutic privilege and provides a critical evaluation. A comparative investigation is undertaken, while arguments springing from a variety of disciplines are also incorporated. A number of submissions are made for limiting the ambit of the defence. The main submission is that the therapeutic privilege should comply with all the requirements of the defence of necessity. In addition, it should contain some of the safeguards afforded to the patient by the requirements of the defence of negotiorum gestio so that therapeutic privilege is out of the question if medical treatment is administered against the patient's will, or the doctor has reason to believe (or knows) that the patient will refuse to undergo an intended intervention once properly informed. / Jurisprudence / L.L.M. (Jurisprudence)

Increasing numbers of medicines are being used by pregnant South African women in the public sector during pregnancy, for the treatment of different biomedical and supernatural disease states and conditions. The motivation for the research is to support the development of more local pregnancy registries in order to strengthen evidence for the safety and efficacy of medicines used in pregnancy. A mixed methods approach was used. Women in their ninth month of pregnancy in a public sector setting, and four community pharmacists were identified. The women who met the inclusion criteria were recruited. One in-depth semi-structured interview was conducted with each woman before giving birth and data on their pregnancy outcomes were collected after labour. Coincidentally, the mother of one of the participants was found to be a traditional healer. She was also interviewed on the topic. A structured questionnaire was administered to the pharmacists. Ten pregnant women between the ages of 19 to 39 who had used or were using a traditional medicine during the pregnancy were recruited. All the participants had had at least one antenatal check up during their pregnancy with one having attended five times. No abnormal results were reported from any of the check ups or tests done during the visits. All of them had been to school and had at least Standard 8/Grade 10 education. Ten babies were seen between one and four days postpartum and no birth defects were obvious or were reported for any of them. The traditional healer did not provide additional information to what the women had said and confirmed that some of the practices the women reported were known to her as traditional medicine practices. All four pharmacists indicated that they considered complementary and alternative medicines (CAMs) to be “somewhat effective” and sold them at their pharmacies although none of them were aware of whether or not they were registered with the MCC. None of the pharmacists appeared to have an in-depth knowledge of traditional, complementary and alternative medicines (TCAMs). All four pharmacists said that it is important to have a basic understanding of TCAMs before using them, although they did not agree on the reasons for this. All of them felt that pharmacists have a professional responsibility to provide information on TCAMs (especially herbal preparations) and two felt that providing this information is part of a medical doctors’ responsibility. No harm from taking TCAMs could be shown. However herbal medicines have numerous ingredients some of which are unknown and taking these medicines is risky. The pharmacists in this sample were unsure whether they were accessing unreliable CAM information. Reliable sources of information and reference materials on CAMs to assist pharmacists and other healthcare professionals are needed. The apparent widespread use of TCAM in pregnancy indicates a need for documentation about its efficacy and safety. The establishing of TCAM pregnancy registries should seriously be considered. Due to the increase in CAM use, CAM education during pharmacists’ training as well as continuing professional development (CPD) in CAM for pharmacists in practice should be encouraged.

Law / LL.M.

The dissertation critically examines and compares the decisions of the Constitutional Court and the High Courts in cases dealing with the right to life, as contained in section 11 of the Constitution of South Africa Act 108 of 1996. The dissertation analysis the issues of adjudication and the concept of justice in perspective. The main question is as follows: Are the Constitutional Court decisions objective, based on the interpretation of the constitutional text, or do they rather reflect the individual judge(s) personal perspective(s) or preference(s). The purpose of this dissertation is to undertake a comparative study and analysis of the Constitutional Court decisions on the right to life, same aspect from different perspective, and show that the right to life is not given proper effect to on account of the subjective approach to its interpretation undertaken by the judges. It examines and scrutinises the Constitutional Court’s adjudication process. It found that the law is indeterminable, because the court’s decisions are not based on the interpretation of the law, but on the individual judges’ background and personal preferences. This is so because the court uses the majority rule principle in its decisions: The perception of the majority of the judges becomes a decision of the court. It is argued that when taking a decision a judge does not apply the law but instead uses the law to justify his predetermined decision on the matter. The conclusion supports the critical legal scholars’ theory relating to the indeterminacy of the law. It tests the objectivity of the judges using their own previous decisions. / Criminal & Procedural Law / LLM