Martin Young
Martin Young

Has Mandela’s medical treatment created a bad precedent?

If Madiba is recovering in a manner consistent with the public announcements of being able to go home “soon” I will be the first to admit that my expectation that his days were severely numbered was wrong, and be very pleased that I was. Because it really did not sound good. Being “critical but stable” for so long could easily be doctor-speak for “we’ve started something we cannot stop”. When a sick, elderly person is put onto a ventilator it is very, very difficult to wean that person off the machine and have him/her breathing normally again. Medical consensus is that medical interventions like that are often best never started.

And so I joined many of my medical colleagues in raising my eyebrows when I heard the scanty details of his treatment. I was almost, almost prepared to declare via Twitter my readiness to tattoo the word “Wrong” on my forehead if Madiba recovered. The optimistic reports that have since been released by his family and other spokespersons would now make me nervous that I would lose what at the time seemed to be a very safe bet, and that I would have to keep my word. So I sensibly didn’t make the bet. Who would want to see a surgeon with “Wrong” tattooed on his forehead?

Nevertheless, if Madiba gets to go home it will be a combination of the man’s dogged determination to survive, excellent medical care, and a whole lot of luck. Make that “luck against all the odds”. Or perhaps even a “miracle”.

It would be wrong to speculate too much on the details of Madiba’s care because they have not been released to the public. Nor should they be. This is private information on a private individual’s health. We have no right to know. So no one other than family and medical team knows what might have set the latter on an unusual path of treatment. There might have been exceptional circumstances. What would be unethical however is to base medical treatment on the patient himself being an exceptional person. That goes against every modern and traditional dictum for doctors that states all patients should be treated equally without regard for their position or status.

And so we have a problem. If Madiba’s care is successful against such high odds, there will be an expectation that the same treatment considerations should apply to all frail 95-year-olds. Or frail 65-year-olds, and all the ages in between. It will not matter that we do not know the nuances of his condition nor his treatment. It will be enough to know that a highly qualified team of doctors decided — or were told — to treat Nelson Mandela against all the odds and went ahead.

The biggest question in this is: “Who pays?” Intensive-care treatment, especially on ventilation, can be as high as R25 000 a day. If the money is the individual’s own there is no problem.

I am unable to find out who pays for ex-presidents’ medical care. It may be private medical aids, the SADF medical aid, or private income. I have no idea. It may be a free gift from the hospital group and doctors in this case. It’s equally unlikely that anyone from the Presidency or the Mandela family will ever tell me. But let’s assume for argument’s sake that the biggest and most successful medical aid in South Africa, Discovery, is paying.

As recently as this month Discovery bemoaned the fact that very sick people use up most of the medical-aid benefits . The comments at the end of this article are very informative and put the executives’ complaints into an uneasy perspective.

Nevertheless, for a medical aid the prospect of a patient spending an extended time in ICU is their worst nightmare. Nothing generates cost as rapidly, and in many cases to no avail as the mortality rates for pneumonia requiring ventilation are well in excess of 30%. In Madiba’s case, with the information at our disposal, even to begin treatment of that nature would be money poorly spent, a bad investment. I am convinced that every medical adviser, case officer and medical-aid executive in the country would agree with me.

Yup. Insurers and medical aids don’t like it when you claim. Of course you are entitled to make use of the product you purchased, but they still don’t like it, especially if you are sick and frail and expected to die soon.

And here is the precedent. Assume Madiba is a Discovery client, and assume that his care is successful. What is to stop every Discovery patient in the same situation claiming the same benefits as Madiba, even if the likelihood of a successful outcome is equally low? If Madiba’s treatment has been covered by a medical aid, that medical aid has no right to give preferential treatment to a patient based on who that person is. That would break every ethical medical convention and principle of equality under the law and under our Constitution. It is a human-rights issue. One life is not more important than another. What is good enough for Madiba should be good enough for every citizen. A clear precedent has been set.

It doesn’t really matter to me who is paying for Mandela’s care. Perhaps he does deserve more than the rest of us. But all over South Africa, as we speak, there are people younger, less frail, with higher chances of survival, and more years of potential life ahead of them, being allowed, or even forced, to die because of economic considerations by government health departments due to financial constraints, and by medical aids and insurances based on statistically low likelihoods of survival, and yet they have a chance of further life still higher than that of our beloved icon.

I somehow don’t think Madiba would approve.

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    • Zola

      Compelling argument. The ethical question will have to be answered by HPCSA and most probably the National Health Minister himself.

    • Tofolux

      I cannot distinguish what you are lamenting about. Could it be that lo and behold, Madiba enjoyed the best of the best attention of highly qualified medical practitioners or are you complaining about medical aids and their terrible practises when it comes to the health of the nation. Firstly I want to appreciate and congratulate the doctors for a job well done. I also want to once again pay humble respect to my esteemed leader, Nelson Rolihlahla Mandela who once again despite his age continue to lead society by showing us how to continue to fight the good fight. Of course, we were drilled by persons such as yourself with all your fears (eish do you ever stop?). And again and again, he proves you wrong much like he has done throughout his life with his revolutionary fights and his revolutionary life, Wow. we are truly blessed. Personally, this non-sense that you raise is a non-issue. If you go out on the roads in the Kasi where we live, we dont care how much it costs to bring him back to health. I can promise you that this nation who fought so hard to get access to proper health services will take their last penny to collectively pay OFF all his bills. In fact we are indebted to him much more than you could possibly imagin so no task to repay him would be too great. Inasmuch as he has said he would die for our nation, we will walk to the end of the earth for him. If you got an issue with medical aids, raise them properly and do not mis-use Madiba to make a particular point.

    • Reginald Dwight

      Buddy, this utilitarian approach sounds awfully like the views of a certain russian gentleman of history’s recent acquaintance. He suggested that people over 50 be euthanised since they could no longer be productive members of the state.

    • Momma Cyndi

      To the best of my knowledge, all presidents and past presidents were always treated at One Military Hospital. Unfortunately, the deterioration of One Mil has made it impossible this time. I would imagine that the military will be picking up the tab as it is their faulty hospital which necessitated Madiba going to a private one.

      Medical aids are like gambling casinos. They are betting that you won’t get sick and you are betting that you will. We all know that the house never loses

    • jacob

      the way i look at this SITUATION.. of MR NELSON MANDELA.. I do believe SUM CITIZENS OF THIS COUNTRY ,.DONT want to be REALISTIC ,.about MADIBA state of HEALTH., First POINT., when we as HUMAN BEINGS ,REACH A CERTAIN AGE,. our BODY start to BECOME VERY weak,. this is A FACT OF LIFE., This is aBIG PART OF NATURE,. EVERY BODY KNOWS THIS? we will EVENTUAL PASS AWAY; LIKE it OR NOT ,.This how nature WORKS; WE will not LIVE forever; BUT LETS pray FOR a miracle

    • Nguni

      Yes, he may be going home, but he’s not speaking. Means he’s probably going home being ventilated via a tracheotomy. Means we won’t get to see him again without a nice big scarf around his neck or a high-collared shirt in the summer..

    • Kwame Obonomaba

      You right every health care system in the world must treat all patients equally just as we expect our judiciary to treat every one equal before the law. The reality is this is not the case. One’ s station in life coupled with access to financial resources has huge bearing on how health care is dispensed. How do we place value on the lives of citizens who desire the most in the face of life and death decisions? In essence, if we are confronted with the decision to keep Joe Carpenter and Joe President of Country or big corporation alive what criteria must be used to make decision? Or better still, who desire most, a 35 year old unemployed citizen and 75 year old productive pensioner all need in kidney transplant? I am sure compelling case could be made to give the kidney to either the unemployed citizen or the pensioner. The point here is there are no clear cut answers. In the case of Mr Mandela, there are more factors at play than who pays what. As alluded to in one of the commentaries, Mr. Mandela’ s iconic status in the world makes it difficult to place monetary value on his life. And therefore keeping him alive is not only national aspiration but a global desire. His continued existence keeps the project of developing a rainbow nation alive. A united South Africa is a project in the making and to the extent that Mandela is the glue and the hope that keeps this dream, every cent to keep him alive is worth it. We need Mr Mandela alive than dead and cost is immaterial for…

    • Martin Young

      Dear Tofolux

      I am aware that you are terribly upset about Madiba – your comment on my earlier post makes it obvious.

      I am also aware that you do not get my point. You appear to think it is possible to bring a sick elderly man with a chronic illness ‘back to health.’ It is very, very unlikely.

      This is different to saying we cannot ‘keep him alive.’ That we can do – keep him breathing and his heart beating using machines. But is he comfortable? Is he aware of what is going on? Is he suffering? How long will this last?

      Would he, Madiba, not rather slip off this Earth peacefully? What would he want? Can we ask him?

      Madiba probably no longer has any say in the matter, and it is too easy to use him for our own purposes – family purposes, political purposes etc. That is using someone, not loving them. To love someone in this situation is to let them go, to do the kindest thing even if it hurts us the most.

      My point is that, if a medical aid is paying Madiba’s bills, it cannot then deny the same treatment to someone else just because it is Madiba. That is unethical and against the Constitution.

      You say the ‘nation fought so hard to access proper health services.’ The nation still hasn’t achieved that. You would be a fool to believe anything has improved in access to healthcare. We have disproportionately high infant and maternal mortality rates, HIV infection rates, TB rates, and just plain simple shocking service delivery due to greed, corruption…

    • billyC

      @Neil: I’m supprised that you seem unaware that, amongst those who are more equal than ordinary citizens, are Judges, MP’s, MPL’s, MEC’s and Presidents, who belong to the exclusive medical Aid called PARMED, even into retirement. Parmed puts Discovery to shame with nearly unlimited benefits and will happily pay for Madiba’s respirator until some time near the election next year, when the ANC will need his passing, to creature a tsunami of grief, that will guarantee the desired 67% majority.

    • OneFlew

      I suspect you’re right: Mandela (and egalitarians generally) are unlikely to approve.

    • Sipho

      I seem to recall that Mr Ariel Sharon (former Israeli Prime Minister) has been in coma since 2005 – after eight years he’s still receiving medical care around the clock. I know, I know it’s Israeli taxpayers who are picking up the tab, but my point is that not every Israeli will now demand the same medical treatment as their leaders. Mr Sharon is just one example. My point is, everywhere in the world leaders both in government and business enjoy better facilities compared to ordinary citizens. A CEO of a JSE listed company is most likely to enjoy better medical care than the majority of his/her company shareholders (and it’s acceptable).

    • Martin Young

      Sipho, I agree. But that care is not as highly publicized. If there ever was a ‘test’ case for extended, highly optimistic and expensive care, this is it. The identity of the person should not matter.

      BillyC’s slant on it is interesting. ‘They’ wouldn’t, surely not? Surely not!

      But then I think of Nkandla and realize every option is open.

    • BillyC

      @Sipho: Zuma’s Nkandla Compound reportedly includes miltary facilty grade bomb proof bunkers,, bullet proof glass, a fully equiped mini hospital and helipad for doctors flown in from 2 Military Hospital at a moments notice. Thats his private residence! If one considers these facilities are probably duplicated at the other 3 official presidential resiidences, even (or especially) one of the the richest man on earth,, Warren Buffet, would refuse to be be treated like such a banana republic kleptocrat ;

    • http://none Lyndall Beddy

      The idea that a man in his 90s might be kept breathing for political expediency makes my flesh crawl. But would doctors do that?

      And isn’t your conclusion based on the long period of “stable but critical” reports from the presidency, which might have been over cautious?

      Surely someone is not sent home with a tracheotomy? Ariel Sharon is in hospital isn’t he?

    • Uffa

      If President Mandela is on a life support machine and is being kept alive for political purposes it is wicked and unethical. If he is able to sustain life by breathing on his own and just needs time in hospital to recover that is laudable. Shall we ever know ?Medical confidentiality precludes his team from informing the public , the politicians feed us what they want us to hear, and the media can’t seem to give us the facts.

    • Mtshayisa

      Mhh, such a difficult question to consider. In a sense, though I love Mandela so much, just like many South Africans do, my comments would be a direct stir of the situation, as I may say If he dies, what does the nation lose? and so goes the question for the international peoples of the world” Doesn’t this help that even at the remotest ability prove that we seem not to have taken into our own peace that He has contributed enormously, for us to take over from him. We should be ready to take from his brevity, his courage and greatness. The most peaceful thing we should be doing is to take the next step in life, that of living with the fact that he passed on, and that we are capable of reaping from his life’s endeavours – a world at peace with his works and with what nature provides.

    • Peter Jansen

      Martin
      You raise very important moral, medical, ethical and economic points.

      Do you know that the biggest single cause of personal banruptcy in the USA is medical expenses?

      (Rich and middle class) Elderly people in the USA are often kept on life support, given very expensive life extending treatment when terminally ill, and given the best medical treatment that modern technlogy can supply and money can buy.
      The result is crippling bills, estates that are wiped out, and people living to a (overly?) ripe old age with very questionable quality of life.
      The fear by Doctors of potential medical malpractice suits for “letting Ma or pa die” or actining a DNR must also play some part.

      Apparently, some people born today (in first world countries) will live to the age of 150.
      The questin is – would you want to?

      If I could look like I did when I was 24, hell, yes.

      But to look like I do now – getting worse every year – for the next 90 years?
      No thanks!

      As for Madiba, for goodness sake let him die with peace and dignity.

      There is NO WAY he is leaving hospital in anything other than a wooden box.

      We are being told very little (“critical but stable”) – what are we NOT being told?

    • http://saman-koushik.livejournal.com Siripala

      we cant just judge whether his treatmenat was good or bad but one thing we know he lived 95 years.. which means he lived a good full life…, and life to the fullest..To all who do kno much about mandela grab a book about him and get to know the great personality : some best books, biographies and Conversation by Madiba. : http://saman-koushik.livejournal.com/1517.html

    • http://www.mzansilife.co.za Paul Scott

      RIP Rholihlahla.

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