There are approximately 150,000 human deaths each day around the world. Most of those deaths pass without much notice, yet in the last ten days one death has received enormous, perhaps unprecedented, attention. The death and funeral of Nelson Mandela have been accompanied by countless pages of newsprint and hours of radio and television coverage. Much has been made of what was, by any account, an extraordinary life. There has been less attention, though, on Mandela’s last months and days. One uncomfortable question has not been asked. Was it ethical for this exceptional individual to receive treatment that would be denied to almost everyone else?
At the age of almost 95, and physically frail, Mandela was admitted to a South African hospital intensive care unit with pneumonia. He remained there for three months before being transferred for ongoing intensive care in a converted room in his own home. Although there are limited details available from media coverage it appears that Mandela received in his last six months a very large amount of highly expensive and invasive medical treatment. It was reported that he was receiving ventilation (breathing machine support) and renal dialysis (kidney machine). This level of treatment would be unthinkable for the vast majority of South Africans, and, indeed, the overwhelming majority of the people with similar illnesses even in developed countries. Frail elderly patients with pneumonia are not usually admitted to intensive care units. They do not have the option of prolonged support with breathing machines and dialysis at home.
There are a number of questions that might be asked about Madiba’s final medical care. We might ask whether the treatments provided for Mandela over this period did more harm than good. Were these treatments in his best interests? Intensive medical treatments may prolong life, but sometimes only at the cost of significant, pain, discomfort, confusion and agitation, indignity and distress. Equally we might ask whether such treatments were desired by Mandela, whether he wanted to receive this level of medical treatment. Patients can end up receiving intensive treatment at the end of their lives despite this being something that they would not have chosen. This can either be because they had not made their wishes known, or because their family are not willing to let them go. For the sake of argument though, let us assume that these treatments did offer some benefit to Mandela, and that he wanted them. Is it ethical for Mandela to receive treatment that would be unavailable to others?
One reason for providing Mandela with exceptional treatment is because he or his family could afford it. I have no information about the source of funding of his medical treatment. It might have been paid for from his own pocket, or from an insurer, or from the public purse. If Mandela’s treatment were privately funded, there would less ethical concern about the fairness of him receiving treatment that others could not afford. It would, though, not completely nullify any questions about equality, since we might still worry about whether it is fair for those who are economically well off to be able to access substantially more medical care, particularly when a significant number in the population fail to receive basic medical care. Nor would it resolve the potential opportunity costs of Mandela’s care. Given limited skills and physical resources in a country like South Africa it is possible that the medical attention diverted to Mandela led to treatment not being available for others.
A separate reason for providing Mandela with exceptional treatment might be out of recognition or recompense for his contribution to South Africa. Mandela was imprisoned for 27 years for his part in the political movement against apartheid. He is widely recognized for playing a key role in the peaceful transition of South Africa to democracy. Either or both of these might be thought to justify a country choosing to provide a significant additional health care benefit to Mandela. However, if that were the case there might be others who suffered in the apartheid era who would also be deserving of additional health care, or others who have contributed to the country. There would need to be some transparent means of assessing the claims of others.
Finally, there might be reason to treat Mandela differently because of his special place in the hearts of the South African people. Indeed the apparent enormous public outpouring of affection for him suggests that, if asked, the South African population would have been more than willing to spend money from their own pockets or from the public purse to support his medical care. Again, however, it would be important to know whether the funding for exceptional treatment came from existing health budgets, or was recognized as an additional expense.
Mandela might be a special case. There could be reasons to treat him differently. It may be that the costs of his exceptional treatment did not divert resources away from others with greater health need. However, in general we should be cautious about providing exceptional treatment to exceptional individuals. There are questions about who decides on exceptional status and how much additional treatment they can access. Political leaders certainly deserve appropriate compensation for their contribution to a country. But we might think that they, in particular, should not be able to access more than the best available public health care. (Such a policy would help to guarantee political support for health care for the elderly…) We might also wonder whether Mandela, with his passionate concern about poverty and inequality in the developing world, would have desired the expensive treatment that he ended up receiving.
With Mandela, end-of-life care dilemmas magnified AP June 28 2013