TRC Final Report

Volume 4

Chapter 5

Volume FOUR Chapter FIVE

Institutional Hearing:The Health Sector

■ ETHICS FOR HEALTH PROFESSIONALS

International ethical codes

1 Health professionals have an ethical obligation to place the well-being of their patients at the forefront of their professional commitments. From ancient times up until the present day, this has been codified in a number of oaths, codes of conduct and international declarations. In addition, since 1948, many ethical codes and international human rights instruments have been formulated concerning the treatment of patients, detainees, hunger strikers, mental health patients, and on the role of nurses and other related matters.¹

2 The greatest drawback of these codes and oaths is the difficulty of monitoring and enforcing compliance with them. Responsibility for upholding these principles is left, by default, to professional organisations and statutory regulatory bodies in each country. This can be problematic if these institutions are themselves under the influence of the state or if they have colluded with or been complicit in violating human rights. The international health care community can help reinforce these standards by putting pressure on countries that violate them, and especially on professional organisations within those countries. However, it is often difficult for the international community to make a significant impact, except over extended periods.

Requirements in South Africa at the time of reporting

3 In South Africa, most doctors are expected to take the Hippocratic Oath or the Declaration of Geneva (the modern equivalent of the Hippocratic Oath) upon qualifying (see Appendices 1 and 2). However, some medical schools require their students to take other oaths or develop their own. There is thus no uniformity in the codes of conduct or ethical pledges taken by health professionals. These codes are intended to provide the fundamental principles of the physician’s role as healer, including the obligation to maintain patient/doctor confidentiality and to undertake measures that are in the best interest of the patient. If different schools take different pledges, one cannot expect consistency within the profession.

4 Nurses take the ‘Nurses’ Pledge of Service’ (a local adaptation of the Florence Nightingale Pledge) when they graduate. However, the submission of the Democratic Nurses Organisation of South Africa (DENOSA) noted that: “it was confirmed during interviews that an individual could, theoretically, decide not to say the pledge. Also, those who are absent from the ceremony do not take the pledge.” The same could obviously apply to graduating doctors. No system ensured or enforced the making of a commitment to ethical practice.

5 Mental health professionals are not required to take any sort of pledge or oath on qualifying or registering; their statutory obligations are outlined in the Mental Health Act.² Although the Psychology Board (a sub-section of the South African Medical and Dental Council or SAMDC) has a code of conduct, psychologists are only made aware of this (that is, sent a copy of it) when they register to practice.

6 Issues of ethics and human rights are not usually included in the teaching curriculum of psychology masters’ degree students. Similarly, there are no uniform guidelines for the teaching of ethics in South African health science faculties. DENOSA had the following to say about the teaching of ethics to nursing students:

Ethics content has always been included in nursing curricula. However, it seems that educators largely did not succeed in teaching this subject so that it had everyday application.

While provision is made for the teaching of ethics in the curriculum, nurses do not seem to identify it as significant to their professional role. In one particular study, it was found that 87 per cent of the research sample indicated that they did not regard the subject Ethos as necessary to their work as registered nurses.

It also appeared from interviews that, in teaching the subject, more attention was given to the history of nursing and etiquette than to ethics and professional conduct, and that students perceived the subject as a list of ‘do’s and don’ts’.

7 During the period under review, ethics was taught on an ad hoc basis and, for the most part, students were not examined on these topics. There was, therefore, no uniformity in the way in which health professionals were made aware of, or given guidance on, incorporating issues of medical ethics and human rights into daily practice.

8 The SAMDC is responsible for disciplinary action and has a code of conduct and guidelines for ethical practice. The Council does not, however, ensure that all registered health professionals are informed of these. Health professionals who are not interested or do not themselves take the initiative to familiarise themselves with the code of conduct and guidelines may not be aware of their obligations.

9 The value of oaths and professional declarations in ensuring a human rights consciousness in clinical practice has been questioned by a variety of sources. If oaths and declarations are merely repeated and signed at the end of a period of training or study, they are unlikely to have any meaningful impact on the life and practice of health professionals. Ethics and human rights need to be incorporated holistically into the overall curriculum to ensure that these principles govern the activities of health professionals.