AMA Journal of Ethics. October 2015, Volume 17, Number 10: 966-972.
History of Medicine
Dual Loyalties, Human Rights Violations, and Physician Complicity in Apartheid South Africa
The gross negligence of the physicians who cared for Steve Biko, an apartheid-era South African political activist who died of injuries inflicted while in police custody, illustrates how dual loyalty—toward patients and, in this case, the state—makes performance of professional duties difficult.
Keymanthri Moodley, MBChB, MFam Med, DPhil, and Sharon Kling, MBChB, MMed, MPhil
From 1948 to 1994, South Africans were subjected to a period of sociopolitical segregation and discrimination based on race, a social experiment known as apartheid. South African history was tainted by a minority Afrikaner Nationalist Party that sought to plunder, exploit, divide, and rule. When that party took power in 1948, human rights abuses permeated all levels of society, including the medical profession, which was to a large extent complicit in various human rights violations.
These discriminatory practices 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 programs at most universities ensured that white patients were not examined by black medical students either in life or after death. Postmortems on white patients were conducted in the presence of white students only; students of color 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 color . 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 [1, 2]. 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 Case of Steve Biko
Steve Biko was a political activist, founder of the Black Consciousness Movement in South Africa, and a fierce opponent of the apartheid regime. As a medical student at the University of Natal, he established the South African Students Organisation (SASO) for “nonwhite” students in 1968. He was instrumental in encouraging self-respect and a desire for liberation among black youth in particular and black people more generally in South Africa. In 1973, he was “banned” by the South African government, that is, his freedom of movement and freedom of speech were curtailed, and there was a severe restriction on his political activities with the intent to silence his opposition to the apartheid regime. Steve Biko was hence restricted to a single magisterial district, his birthplace, King Williams Town in the Eastern Cape . On August 19, 1977, he was detained by the security police in the Eastern Cape Province; Section 6 of the Terrorism Act of 1967 permitted his detention for an unspecified time period. Nineteen days later, he was moved to security police headquarters in Port Elizabeth for interrogation, and the following day, Dr. Ivor Lang, the district surgeon, was asked to examine Biko because he was acting strangely and refused to respond to questions [2, 4]. Examining Biko in the presence of the security police, Dr. Lang found him to be ataxic, with slurred speech, a swollen upper lip, and various bruises. Nevertheless, he issued a medical certificate, stating, “I have found no evidence of any abnormality or pathology on the patient” .
The following day, Dr. Lang, accompanied by his superior, Dr. Benjamin Tucker, the chief district surgeon in Port Elizabeth, examined Biko again. Biko complained of “a vague pain in his head and back” , and this time Dr. Lang found signs suggesting a possible brain injury. A neurologist in private practice saw Biko at the prison hospital the next day and found signs of left-sided weakness and difficult speech; a lumbar puncture (LP) revealed blood-stained cerebrospinal fluid (CSF). His report did not refer to any brain injury, but he told the security police that there were signs of nervous system damage and recommended referral to a neurosurgeon. Dr. Lang’s recommendation that Biko be transferred to another hospital was refused by the security police. Dr. Lang informed Dr. Tucker of the neurologist’s findings, but nothing further was done and no treatment was initiated .
On September 10, a neurosurgeon was consulted and agreed that the neurological findings and bloody CSF were indications of brain damage and recommended close observation. Dr. Lang visited Biko and found his physical condition unchanged. Consistent with the medical certificate he had issued, he made a note in the medical record that he and the neurologist had not found any pathology and that the LP was normal. Despite the neurosurgeon’s recommendation that Biko required observation in hospital—and his own previous recommendation that he be transferred to another hospital—Dr. Lang permitted Biko to be transferred back to the police cells, where he was left lying on a mat on the floor . Although Dr. Lang consistently found pathology, he repeatedly acted in contradiction to his findings. It seems unlikely that such behavior could be explained by simple incompetence. Rather, what appears evident is a total violation of the most basic rules of medical professionalism and a complete disregard for the life of a black political prisoner.
The following afternoon, Biko was found “collapsed, glassy-eyed, hyperventilating, and frothing at the mouth” . Dr. Tucker examined him and opined that his condition was unchanged. He recommended transfer to the local provincial hospital, but, when the security police refused to allow this, he agreed to Biko’s being transferred to Pretoria, 1,100 kilometers away, by motor vehicle. Biko was transported to Central Pretoria Prison—a twelve-hour journey—without medical escort, handcuffed, and lying naked on the floor in the back of a police Land Rover .
Many hours later Biko was examined by the district surgeon in Pretoria, who had not been given any medical information regarding him, and the only treatment he received was intravenous fluids and vitamins. Six hours after arriving in Pretoria, Biko, who was left completely unattended, died on the floor of an empty cell on the evening of September 12, 1977 . It was in this way that South Africa was robbed of one of its foremost political thinkers.
Medical Professionalism and Dual Loyalties
The conduct of Drs. Lang and Tucker 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. Dr. Lang wrote a false medical certificate on September 6 and inaccurate notes in the medical record on September 10. He also made no effort to ensure Biko’s safety and allowed him to be transferred back to the prison cells. Dr. Tucker allowed Biko’s transfer to Pretoria to occur in a police vehicle rather than an ambulance and without an accompanying medical report to the receiving doctor.
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, Steve Biko, conflicted with their (perceived) duty to the state. In fact, Dr. 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” .
G. R. 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 Steve 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.
The Role of the Medical Association of South Africa (MASA)
The Medical Association of South Africa (MASA) was originally linked to the British Medical Association. It became known as the South African Medical Association (SAMA) in 1998 and was a voluntary association of doctors. The South African Medical and Dental Council (SAMDC) was the regulatory body controlling the medical and dental professions at the time Bike was imprisoned . Surprisingly, neither MASA nor SAMDC supported charges of misconduct or unethical conduct against the doctors involved in the Biko case. The professional organizations were derelict in their duty to uphold professional standards because they too allowed state security issues to subvert the profession’s responsibilities and ethical obligations to its patients. As N. Barney Pityana writes,
the Biko affair marked a moral threshold in public life in South Africa. 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, Dr. Lang was found guilty of improper conduct and received a caution and a reprimand; Dr. Tucker was found guilty of improper and disgraceful conduct and was later struck from the medical roll .
Other Ethical Violations
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 program of the apartheid government [11-14]. 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 poisoned weapons, secret stockpiles of lethal bacteria to selectively kill people with pigmented skin, 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 apologize, 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 of 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 [15, 16], a long-awaited guilty verdict was reached. Although the SAMA issued a statement in support of this verdict , Basson retains his membership in the organization .
Apartheid seriously corrupted the moral fiber 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.
The TRC Hearings in 1998 played a pivotal role in reversing the tide of discrimination and human rights abuses. Public hospitals are now fully integrated. The Health Professions Council of South Africa mandated that ethics training for all registered professionals become compulsory. All medical schools in South Africa are now compelled to provide training in ethics, law, and human rights as a compulsory part of their curricula [19, 20]. 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 fervently hope that this bleak chapter of medical history will never be repeated.
Keymanthri Moodley, MBChB, MFam Med, DPhil, is the director of the Centre for Medical Ethics and Law and a professor in the Department of Internal Medicine of the Faculty of Medicine and Health Sciences at Stellenbosch University in Cape Town, South Africa. Her research interests include biobanking, HIV and ethics, and neuroethics, and she has a strong interest in the constraints facing women in academia.
Sharon Kling, MBChB, MMed, MPhil, is the clinical unit head for general pediatrics and an associate professor in the Department of Paediatrics and Child Health of the Faculty of Medicine and Health Sciences at Stellenbosch University in Cape Town, South Africa, where she is also a part-time lecturer in the Centre for Medical Ethics and Law. Her areas of interest are clinical and pediatric ethics, allergy, and asthma.
Related in the AMA Journal of Ethics
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
© 2015 American Medical Association. All Rights Reserved. ISSN 2376-6980