From the survey of palliative care personal at the HPCA AGM at Rustenburg, a number of ethical issues were identified (Table 23):

Table 23 Identified ethical issues

Rustenburg survey 2004 ¹⁰⁷

Some of these issues are amplified below:

South Africa has a very liberal constitution, probably one of the most liberal constitutions in the world, and a very advanced human rights constitution. We have abortion on demand, and the euthanasia debate is going to come up within the next ten years – and the northern European, the Dutch model, I could foresee being proposed. That’s speculation on my part. But they’ve made the transition from at the beginning of life to permit abortion on demand, and so I see no reason that the human rights lobby might not push for euthanasia on demand or some version of that in due course. That will be a major ethical issue. The issues of confidentiality and disclosure with regard to HIV are really topical - not new because they have applied to tuberculosis in the past and have been negotiated. We’ve got models for these things and I think we should explore our history before we develop new ways to deal with this.¹⁰⁸ Dr Alan Barnard – palliative care physician, St Luke’s Hospice, Cape Town

I really think that the major ethical issue has been access to care and access to antiretrovirals; and then, the place of women in society that have made them the kind of victims, as it were, in Africa, of the epidemic. Then we need to look at the children’s rights because our social services are not as strong as our health care services, and children are being abandoned to really horrific circumstances when their parents die from the AIDS epidemic … And one of the issues that I’ve discovered in my career as a GP - and also in hospice - is

that medical care, and also traditional life, has been very autocratic. So it’s the doctor telling you what’s good for you, you know, ‘Take this medicine,’ and it’s the chief and the traditional leaders saying, ‘This is what we’ll do’¹⁰⁹ Dr Liz Gwyther – education and research co-ordinator, HPCA.

I think the ethical issues are beginning to be appreciated now with the impact of HIV/AIDS on hospice care in this country. Historically, hospices in this country were primarily established to provide care for the terminally ill cancer patient, and there was genuine support from the public for this. I think the onset of the HIV/AIDS pandemic has eroded the donor base, you know, that is why it’s become dependent now on overseas funding to take care of the HIV/AIDS aspect of hospice work in this country.¹¹⁰ Dr CN Pillay, president, Chatsworth Hospice.