EDITORIAL I VAN DIE REDAKSIE We1cotne back many of our authors ate told by the editor, the Africa and a bitter opponent of apartheid, he was SAMJ has limited space, and often articles require banned in 1968, and the terms of this order were so A shortening ifthey are to have any chance ofbeing restrictive that he was forced to leave this country. A accepted for publication. It may therefore seem strange measure of his stature is that having taken up residence that in this issue of the SAMJ we appear to be going in the UK, he eventually became President of the Royal against our own policy by devoting over 4 pages to a talk College of Physicians of London and President of given at the University of Cape Town on 22 June 1993, Wolfson College, Oxford. What was most remarkable particularly since papers intended for oral delivery are about his talk was that there was no apparent bitterness, often not suitable for publication in the medium of although he had good reason to be bitter, and no print. attempt to pay back old scores, although he could cer­ The reason for the apparent disregard of our tainly have done so. Instead, his talk concentrated on usual practice is that the speaker was Sir Raymond the ethical principles of our profession which had in the Hoffenberg, and his subject was 'Doctors and society'. past become so sadly compromised, and without which The importance and relevance to the South African our profession still runs a grave risk ofsinking into being medical profession of what he had to say on that occa­ a mere trade or business. sion led to a decision to publish his talk, and because of It is tempting to speculate on the contribution Bill the significance of the occasion to publish it practically Hoffenberg might have made to medicine in South in full. Africa had he been allowed to stay here. However, even though his recent stay was all too short, I shall simply Sir Raymond Hoffenberg is well placed to give a talk confine myselfto saying - welcome back! on 'Doctors and society', with particular reference to the profession in South Africa. A staunch upholder of the N. C. LEE principles of academic equity for all races in South Emeritus Editor Doctors and society - the Biko Lecture t is nice to be back. When I left over 25 years ago, I reason for the public to respect doctors for the skill and expected never to rerum, as I left on an exit permit learning they possessed. Second, the lack of regulation I and did not foresee the change of circumstances of doctors - no training requirements, no testing, no that would allow me re-entry. I now advise you all to go certification - allowed easy infiltration by quacks and away for 25 years and then to come back, just for the charlatans of all descriptions. The public found it diffi­ immense pleasure ofdoing so. cult to distinguish the real thing from the bogus and To my great regret I never knew Steve Biko; he devised ways of testing their medical attendants by appeared on the scene just as I was retiring from it. But, attempting to deceive them. as Chairman of the Advisory Board of NUSAS I Naked-eye examination of the urine was at the time remember the effect he had in 1967 at the time of its an integral pan ofthe diagnostic process, and the doctor annual meeting at Rhodes University when he chal­ was meant to infer from this not only the nature of the lenged the imposed separate residential requirements, illness, but the age and sex of the patient. It was not and I recall the discussions that took place when he and uncommon for someone else's urine to be substituted Barney Pityana founded SASO, not conceived as an - or that of an animal - to test whether the doctor anti-white student organisation - or anti-NUSAS, sim­ knew his stuff. Texts of the time advised doctors how to ply as a black organisation more appropriate to repre­ overcome such challenges and I quote from one:' CVery sent the views ofblack students. I was aware at the time possibly you gather nothing from inspection of the that NUSAS held Steve Biko and his opinions in the urine; very well, then, say the patient is suffering from highest regard, and I am, of course, familiar with his life obstruction of the liver. Be sure to use the word and at least some ofhis writings. I feel honoured to help "obstruction" for they don't understand it, and it is to commemorate him this evening. often exceedingly useful that people should not under­ The manner of his death shocked the world and his stand what you say.' name has become a symbol of South African oppression Although Hippocrates tried to suggest that medicine in the same way as 'Sharpeville'. It brought into lurid . was a science, we can skip through the centuries and the relief the brutality and inhumanity of the security police long dominant influence of Galen to the Renaissance and the system they represented. before we find the first real attempts to establish a scien­ As a subtheme in this ghastly story there was the tific basis for medical practice. The 16th century anato­ behaviour of the Biko doctors - Lang, Tucker, and mical studies of Vesalius were followed by Harvey's one or two others who seem lucky to have escaped demonstration of the circulation and, in relatively quick closer scrutiny. I shall return to them in the context of succession, scientists like Malpighi and van Leeuwenhoek the broader subject I wish to discuss this evening: the inspired the great clinicians - Boerhaave and the role of d,octors in society; their responsibilities to indi­ Scottish School stand out - to introduce scientific con­ vidual patients on one hand and to society on the other; cepts into practice. New respect for medicine began to and the dilemma that arises at times when there is a emerge. conflicting interest between these two responsibilities. This was greatly enhanced by the simultaneous The standing of doctors in society - and therefore efforts ofthe medical profession to regulate itself, by set­ the influence they have been able to exert - has ting entry requirements, establishing standards of prac­ changed over the centuries. In the Middle Ages doctors tice and introducing ce.rtification. In Britain the Royal were understandably held in very low esteem. First, College of Physicians, founded in 1518, initiated these because medicine had no defined rational or scientific ideas. The public could now distinguish the professional base; it was compounded of magic, superstition and from the impostor, the trained practitioner from the metaphysics with a flavour of religion. There was little charlatan. VOl84 MEl1994 EDITORIAL I VAN DIE REDAKSIE The status of doctors began to change. Suspicion terest? Once this conflict of interests becomes apparent and mistrust gave way to respect and confidence and to the patient, there is erosion of an essential feature of doctors began to enjoy some recognition in society of good clinical practice - trust. Without this we return to their learning and professionalism. (Surgeons and the era ofdoubt and suspicion that dominated medicine apothecaries lagged behind physicians - thus deference in the middle ages. This, 1 fear, is happening in the USA was paid to 'the profession of physic' but less flattering and explains, in part, the high prevalence of litigation reference was made to 'the craft of surgery' and 'the there. apothecary's trade'.) Respect for doctors - and its lack To let die - personal choice or legal By the beginning of this century doctors in Britain constraint? enjoyed considerable prestige. The great physicians In this annosphere of doubt, doctors are no longer seen and surgeons of the time became fashionable, treated as the patients' advocate, purring their interests above all royalty, gained wealth and influence - and authority. others. Panicularly in matters oflife and death the hege­ When authority merged into authoritarianism critical mony of doctors has been challenged. Whereas at one voices began to be heard. One of the most trenchant time doctors were free to decide - and their decisions was that of G. B. Shaw who, in his preface to The were not questioned - that a badly deformed newborn Doctors' Dilemma in 1920, wrote: '... the medical pro­ baby should be allowed to die or that an elderly patient fession has not a high character; it has an infamous should not be resuscitated or that a life support system character. 1 do not know a single thoughtful and well­ should be switched off, today such decisions often informed person who does not feel that the tragedy of require the consent of patients, relatives, hospital illness at present is that it delivers you helplessly into the authorities and, at times, courts of law. We .iaw this hands ofa profession which you deeply mistrust .. .'. recendy in Britain in the case of Tony Bland, a young Notwithstanding, the reputation of doctors contin­ man who had been in a persistent vegetative sta.te since ued to climb. Paul Starr in The Social Transformation of being injured when a football stadium collapsed some American Medicine recognised that the medical profes­ 3 112 years ago. After considering a petition from his sion has an especially persuasive claim to authority. parents, the Law Lords agreed to allow his feeding tubes First, because - unlike the law and the clergy - it to be removed, and Tony Bland was allowed slowly to enjoys close bonds with medical science (and science die. In their judgement, the Lords warned that future has a special place in our society); second, because doc­ similar cases should not be decided by doctors, that tors are brought into direct and intimate contact with each decision needed the authority ofthe law.