Madam Chair, I must warn that the question asked by the hon member is extremely complex, very sensitive and highly emotional, because issues of renal dialysis are more often than not linked to transplant surgery. As hon members might know, the decision to do an organ transplant of any sort - whether it is renal or whether it relates to any other organ - is always a contentious issue. Fortunately, this question has been asked by a person who, I presume, in his career as a reverend has been faced with dilemmas of human compassion, ethics and matters of life and death.
The decision whether to dialyse or not is usually made by a group of physicians; it's never left to one doctor. The group of doctors make this decision taking cognisance of the resources that any particular country is able to accumulate, and that is where the complexities and emotions come in. I want to assure you, Reverend, that I personally would not like - at any stage of my life - to be in the boots of any group of doctors who must make a decision about whether to put a person on dialysis or not, or whether to do a transplant eventually.
It is quite often the devil's alternative, if you understand what I mean. Whichever decision one takes, the devil is always there to smile, because one is always going to be found wanting. I'm not talking about a problem that's confined to South Africa; it's a universal problem. Having said that, I want to acknowledge up front that there are not enough dialysis facilities anywhere on this continent. In fact, many of our neighbours might be depending on us.
However, when the physicians sit down to decide whether or not to put an individual in dialysis, the fact that a person comes from an impoverished background is not the primary reason why he or she is excluded from accessing dialysis treatment. This group of physicians usually makes this decision based on their experience. They have to assess whether there is going to be a reasonable chance of success or that the dialysis treatment will be of benefit to that particular individual. In this process physicians don't usually allow themselves to be persuaded by the social circumstances of the particular person.
However, because everything in life is interlinked, sometimes the medical decision the group of doctors makes may actually have been socially determined for the individual involved. For instance, they might decide that if a person has an intractable infection, they might not be able to do a dialysis on that particular person because, eventually, they can't do an organ transplant on that particular person.
Also, we do have people who can't undergo this type of procedure because they suffer from tuberculosis, TB, and have only one lung. Nevertheless, one knows very well that suffering from TB might be because of social circumstances. So, life is interlinked and the physicians make a decision based on that. At no stage will they ever be allowed to look at a person and say he or she is too poor for a transplant or dialysis. They won't do that.
However, after the decision is made, it is very easy to link these factors. For instance, if physicians decide that they are going to do a peritoneal dialysis, there needs to be clean running water at the patient's home for them to do so. If the individual does not have clean running water, science should not be blamed. It is a social problem that the country is faced with.
So, when we discuss this issue, I want us to be aware of the complexities that scientists are faced with when they have to make such a decision. It's never an easy decision but they are trying their best within the available resources. Therefore, I usually accept the decision the physicians make. I never go out and question them because I understand the background to their decisions. Thank you. [Applause.]
Chairperson, I wish to thank the hon Minister for the very sensitive manner in which he phrased his response to this question. Let me quickly affirm my understanding of its sensitive and emotional nature. The reason I asked the question is because sometimes - I think this is understandable - when people come from a poor background where, perhaps, there may not be running water, exactly as in the illustration the Minister used, they are likely to understand that as having been a prejudicial decision.
What I want to ask as a follow-up is whether the Minister does not think it would be helpful if there was another process outside the hospital itself - perhaps comprising an interprofessional group - that would offer a type of counselling that would allow people to understand that they have not been prejudiced because of their poor conditions. I would also like to know the following. If, indeed, conditions of poverty, like the lack of adequate housing or water, are pertinent to providing dialysis treatment, should we not have some kind of interministerial approach - outside the hospital - that people can appeal to so that they can be satisfied that they have not been unfairly dealt with? Thank you.
I think the Reverend's proposal is a very good one. We will definitely look into it. As I've said, there is a link between medical factors and social factors. I'm sure that this will actually be considered when the Minister of Human Settlements presents his strategic plan. We no longer want a department of housing where one just puts up houses and leaves. In trying to deal with matters of this kind, one has to put up "human settlements", where there will be clean running water, electricity, tarred roads, schools, clinics, etc.
The House might be aware that a few weeks ago there was a big radio debate about somebody who was denied an organ transplant because, it was said, that particular person was poor. I phoned a professor, who said that the person involved was suffering from severe TB, had only one lung left and never came for treatment. According to the professor, that particular person was disqualified because of that.
Obviously, that individual's TB condition is because of where he or she comes from. The inability to go to the medical centres to comply with treatment is also a social problem. However, because of the fact that the lung was completely damaged, there was no way they could put this person on dialysis. It would have been like sentencing the individual to death. That is why I spoke about dilemmas and ethical dilemmas. Unfortunately, doctors are faced with these problems every day.
Chair, I wonder if the Minister would mind very much if I broadened the question a little. I understand that this is a sensitive issue and people have to make very difficult decisions. I think we all understand as a starting point that there are limits in what the state can spend on medical treatment. The question I would like to put to the Minister is whether there are specified limits to the amount of money to be spent on a particular procedure for a given patient. I presume that there are certain procedures that are simply too expensive to be considered. Certainly, that is the case in private medical aids, and they have been challenged in court. However, I don't know whether that is the case in the state system.
Secondly, I would like to know whether criteria other than success, which the Minister mentioned, are used, because presumably factors like age and life expectancy would have a bearing as well.
Thirdly, I would like to know whether the procedure that is used to make these decisions - as the Minister explained to us - is applied uniformly throughout the country. In other words, if one is a patient in hospital A in province B, and is in dire need of some assistance, would he or she perhaps get a different answer if he or she was in another province?
Madam Chair, in response to the issue of rand limits - that is to say, whether there is a limit to the money that can be spent on treating a human being or not - I say that is obviously never done in the public sector. It is definitely done in the private sector.
However, I can give this House an example of a case that arose when we were debating the issue of the national health insurance, NHI. This is a highly contentious matter. A doctor prescribed a drug that would have cost R400 000 per annum. The medical aid refused and said it can't afford that. The concerned patient went to court and, of course, won the case because it's his or her life and right.
In the public sector we don't make such decisions, unless we don't have the services. We can't offer people what we don't have. However, if we do have the services, we do give them to the people. For example, if the child who was born with her heart on the outside of the chest - unfortunately she passed away last week - had gone to a private hospital, it would have charged that poor family more than R1 million. However, because it was a public hospital, we were able to do it. We don't put rand limits, unless, as I've said, we simply don't have resources.
Regarding the issue of success and pertinent criteria, I agree that if, for instance, a patient is quite advanced in age and suffers from uncontrollable diabetes, he or she won't get a transplant because the new organ would be damaged as well. So, physicians will make such a decision and that is where issues and dilemmas of ethics come in. For example, one cannot tell a person that he or she is too old and he or she must go and die but, unfortunately, it's a reality.
With regard to the issue of uniformity, the House knows that our country, unfortunately, is not uniform in terms of riches. For example, one cannot offer the people in Limpopo the same thing that is being offered people here in the Western Cape. This does not only apply to health but to education as well. I'm sure the Minister here next to me will agree with me that what kids get in education in Limpopo is not the same as what kids get here in the Western Cape. I remember, for instance ... [Time expired.]
Chairperson, given the chronic lack of staff at state hospitals and the fact that dialysis machines are not being used optimally, could the hon Minister tell us whether the government has approached the private sector to assist in the operation of these machines?
Chairperson, my response to the question by the hon member is that I'm not aware of us not being able to optimally use dialysis machines when they are available. The biggest problem we face is the space for dialysis itself. If there could be space and machines, I don't think the skill to dialyse is so difficult that we actually need the private sector to help. The manner in which the private sector can help is to offer their facilities at a reasonable price to help the public. At the prices they are charging now, it might not be very easy to do dialysis for a large number of people.
House Chairperson, I would like to thank the hon Minister for explaining the issues which relate to "prognosis versus dialysis" to us. We have the Minister's response, but could the hon Minister indicate whether the Soobramoney judgment in the Constitutional Court has informed policies around the exclusion of certain people from receiving renal dialysis. If so, in what way? If not, what implications will this judgment have in future? I thank you.
Chairperson, I think this is the point I've been making. Yes, there is a Constitutional Court judgment regarding the Soobramoney case. The Constitutional Court did rule that indeed, given certain criteria, a person can be excluded from dialysis. The court ruled that it's within the right of medical doctors to exclude a person. In support of this, the court quoted the issue of expenses and whether a successful outcome is guaranteed - issues that I alluded to earlier on. The court also quoted the issue of whether the country can actually afford a particular hospital.
However, when we make our protocols we try our best to base the protocol on medical conditions as reasonably as we can. Nevertheless, the Constitutional Court did make a ruling that it is constitutional to be excluded. I believe it is unfortunate when one looks at it from the point of view of human compassion, but such a ruling does exist.
Steps taken by department to deal with alleged corruption by contractors and to ensure proper management of human settlement development
59. Ms B N Dambuza (ANC) asked the Minister of Human Settlements:
What is his department doing to (a) deal with the problem of alleged manipulation and corruption by contractors who are assigned to co- ordinate housing beneficiary lists, especially in Matatiele and (b) to ensure that municipalities take responsibility in co-ordinating and managing human settlement development in their areas?