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.