Sunday Times (Johannesburg) - Sunday 03 March 2002
Carmel Rickard

But, for many doctors, the conflict between government policy and their professional - even their constitutional - duty is proving too great.

That tension partly explains this week's unusual application in the Pretoria High Court by the Treatment Action Campaign and Dr Haroon Saloojee, when they asked that some of the content of last year's landmark decision by Judge Chris Botha be put into effect immediately, even though there is a Constitutional Court appeal pending.

In the earlier case, Judge Botha ruled that the state had an "ineluctable obligation" to provide a countrywide mother-to-child HIV/Aids prevention programme and outlined how the state should proceed to satisfy the court that it was taking that duty seriously.

The state immediately appealed, and that matter is now starting to make its way to the top of the Constitutional Court's roll.

But, in the meantime, says the Treatment Action Campaign, something must be done to prevent the loss of life of babies, caused by the limited scope of the state's use of nevirapine.

What the applicants asked for this week was that the state keep its hands off doctors who - moved to obey their Hippocratic oath, their conscience and their constitutional duty - prescribed nevirapine where medically indicated to prevent mother-to-child transmission of the virus at birth.

As a corollary, the Treatment Action Campaign also asked that the state make the medication available to fill the scripts written by these doctors.

The application was necessary to stop the state's continued, inexplicable, heavy-handed action against doctors who have permitted private organisations to fund medication for pregnant women, or who have themselves paid for nevirapine.

To read the court papers is to be reminded of the extraordinary facts behind the case - that doctors at state health institutions, outside a few selected pilot-project hospitals, are forbidden to facilitate the provision of drugs that they know will save the lives of many of their patients.

If they disobey official policy, following instead their consciences as physicians and as decent citizens, they can expect to be disciplined, even sacked.

Section 195 of the Constitution deals with basic values and principles guiding public administration, stating that these must be governed by the democratic values and principles enshrined in South Africa's supreme law.

And the very first value, spelt out in the very first section of the Constitution, is that of human dignity.

Just how it advances human dignity to bar doctors from giving mothers and babies the drugs they need to save their lives is beyond the understanding of most people.

The argument becomes all the more puzzling as, thanks to foreign assistance, the state can afford the medication, so the problem of cost cannot excuse the government's ban.

The dignity of the women, the babies and the doctors concerned must surely all be compromised.

To take one phrase of Section 195, it states that, as far as public administration is concerned, a "high standard of professional ethics" must be promoted and maintained.

Quite how it promotes a high standard of professional medical ethics to require that doctors put their pens back in their pockets and walk out of a ward without writing a script for medication that could save the lives of their patients, the court will have to decide.

However, the average observer will no doubt be at the least rather puzzled by how to reconcile these two requirements.

Saloojee told the court last year how this tension played itself out.

"As doctors who place the health of our patients first, we would act against our constitutional right to freedom of conscience and against our ethical duty of clinical independence if we were to deny women the right to use antiretroviral therapy to prevent mother-to-child transmission of HIV.

"The current policy that restricts provision of antiretroviral therapy to pregnant women to 'pilot' and 'research' sites denies women this right and undermines the doctor-patient relationship."

There is an obvious irony here.

During the apartheid years, some doctors were roundly criticised for blindly following state instructions in relation to the handling of their patients.

These doctors did as they were told, against the best interests of their patients, despite the requirements of their Hippocratic oath, the doctor-patient relationship and their consciences.

Once this became known, these doctors came in for a hammering: the public and professional bodies all found such behaviour completely unacceptable.

And in hearings before the truth commission, members of the medical profession said, effectively: "We are very sorry - we've learnt our lesson. From now on, we will act in accordance with the highest standards of our profession, and taking the best interests of our patients into account - regardless of whether the state likes it or not."

The series of cases on the provision of nevirapine at state hospitals and clinics therefore serves a number of purposes.

While the courts will be adjudicating on the policy and behaviour of the state, the medical profession is also under close scrutiny.

Once again, doctors stand in the spotlight - along with their ethical practices and the sincerity of their profession's declared intention to never again unquestioningly put state policy and instructions above the needs of patients.

020303
ST020302

Always watch for outdated information. This article first appeared in 2002. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2002. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .