The battle between primary health care needs and the=20 right of the individual to expensive transplant=20 operations has forced a government policy decision on the issue, writes Pat Sidley
A NATIONAL policy on transplants is being thrashed out=20 — with a draft at the moment before Minister of Health=20 Nkosazana Zuma. Talks leading to the policy began=20 earlier this year — but the process has been speeded=20 up by events of the past two weeks in the heart=20 transplant world.
The policy is expected to provide guidelines on who=20 will be able to receive an organ and under what=20 conditions, in the private and public health sectors.=20 Donor organs may be treated as a national resource=20 (which is not the case at present) and their use could=20 be dictated by need, and not on a first come, first=20 serve basis, or by ability to pay.
The Department of Health official co-ordinating the=20 issue, Dr Lennox Matthews, said donor organs covered by=20 such a policy would include hearts, livers, kidneys and=20 corneas. But he preferred not to be drawn further on=20 detail until the minister had decided on policy.
The guidelines were discussed at a meeting of=20 department officials and private health care interests=20 in April.=20
The policy would also regulate some difficult areas,=20 like excluding certain people who because of a poor=20 prognosis, or being too old, would not be seen as=20 suitable recipients.
The present confusion, exacerbated by accusations that=20 surgeons are looking at their career paths rather than=20 broader health care needs, is pushing all involved to=20 make an enforceable, binding policy decision soon.
This week, Fanus Serfontein, the controversial Pretoria=20 surgeon at the heart of the storm, performed a second=20 (and unsuccessful) heart/lung transplant, this time in=20 a private hospital not covered by the Gauteng=20 moratorium on transplants in the province.=20
This followed Serfontein’s action the week before when=20 he broke the moratorium agreed to by the Gauteng=20 Department of Health, academic health professionals,=20 and hospitals. The reason for the moratorium had been=20 to formulate a policy for the region, which suffered=20 severe budget cuts in health, and has no reliable=20 figures on what transplants actually cost.
No adequate costing of such procedures has been carried=20 out in the past in the state health sector.
Several thorny issues have been raised by the row –=20 which is likely to rage on beyond any policy decisions=20 — as it does in several other countries.
Among them are political issues as well as legal issues=20 such as medical malpractice, and the right of a=20 consumer to have a transplant vs the authority’s right=20 to cut back on those facilities it offers (see box).
In New Zealand, according to Dr Alan Rothberg, director=20 of policy at RAMS (the representative body of medical=20 aids schemes) , when the government wished to revise=20 its national health policies and priorities, it did not=20 as a first move, stop transplants or other expensive=20 high-tech procedures.=20
The government decided instead to educate the public=20 about the costs involved in such procedures, so that a=20 prospective patient would know that one transplant’s=20 costs were the equivalent of several dialysis machines=20 and the same cost as a facility to treat hundreds of=20 people at some other level of care.
Politically, a sophisticated lobby has managed to=20 portray the ANC-dominated health administrators as=20 heartless, willing to sacrifice lives on the altar of=20 new political imperatives.
Zuma’s hand has been forced and she was compelled late=20 last week to pronounce that Groote Schuur is to be the=20 only facility for heart transplants for the time being.
In the Western Cape, Gauteng’s heart transplant issue=20 has resonated in a debate between the ANC’s health=20 ministry, the National Party-dominated administration=20 and the doctors at Tygerberg and Groote Schuur.
The plan drawn up by the department of health in the=20 Western Cape would have Groote Schuur performing all=20 transplants and “super specialties” while Tygerberg=20 would relinquish its liver and other transplant=20 functions in favour of a different, more community- oriented service.
Ebrahim Rasool, the province’s ANC MEC for health, said=20 the Gauteng row showed the effective lobbying of the=20 medical establishment which did not want to face=20 changed health care needs and priorities.
Referring to the lack of good health information=20 systems, Rasool says while the transplant moguls manage=20 to get much vociferous publicity, nobody manages to=20 quantify the effect that living for five months a year=20 in a water-logged squatter camp has on a community.=20 Hundreds of those types of deaths are being put down to=20 natural causes, he says. They should be preventable, if=20 enough resources could get to those people.
Zuma, in her statement last week, noted that heart=20 transplants had not been undertaken in Gauteng’s public=20 hospitals before this year.
Statistically, the longer a transplant facility does a=20 particular transplant, the longer the recipients=20 survive — causing eyebrows to be raised at the actions=20 of Serfontein and the teams of doctors at HF Verwoerd.
Meanwhile, legally speaking, the family in Pretoria who=20 lost a member this week under the knife of Serfontein,=20 may have a malpractice suit against the doctors=20 involved and possibly the hospital.
The question that would have to be asked legally, says=20 law Professor Dennis Davis, is whether any reasonable=20 doctor would have performed this operation under these=20
Was the patient offered the opportunity of going to=20 Groote Schuur? Was there a need to take his healthy=20 heart out? Was the hospital in which he had the=20 operation, the correct place to be? Davis believed=20 these and other questions raised the possibility of a=20 successful malpractice claim. “It was “high time”, he=20 said, that legal principles were adopted which would=20 render doctors more accountable to the public.