The final days of former president Nelson Mandela formed part of a debate in Johannesburg on Thursday night around end-of-life decisions such as euthanasia.

Two speakers spoke about Mandela, and although both were on opposite sides of the debate, they agreed that he should not have been put on life-support machines.

Professor Willem Landman from Dignity SA told a packed lecture room at the University of Witwatersrand’s medical school that Mandela would not have been happy with his being kept artificially alive.

“I dare say that if he knew, he would call it an assault on his dignity.”
Liz Gwyther, CEO of Hospice Palliative Care Association of SA, said Mandela’s life-support did not benefit him in any way.
“He should not have had his life prolonged by artificial means, his medical team should have allowed a natural death.”

The debate followed the landmark ruling on April 30 that Cape Town advocate Robin Stransham-Ford be allowed to die with the assistance of a doctor, while the doctor would not be subject to prosecution or disciplinary proceedings.

An urgent application was heard in the High Court in Pretoria. Stransham-Ford, who was suffering from stage four cancer, died from natural causes two hours before Judge Hans Fabricius handed down his ruling.

Fabricius subsequently refused an application by the government and the Health Professions Council to rescind his order, saying it concerned a matter of public interest and could affect more people than just Stransham-Ford.

Landman said that Dignity SA was not actively involved in the cases of three people who had approached them for help in filing applications to the high court to allow doctors to assist them in ending their lives, as initially reported by the media.

“People have approached us following the ruling. We did not turn them away, but did refer them to our legal team. We are currently letting this case [Stransham-Ford’s] run its course,” he told News24 later.
“We are not actively involved in their cases at the moment. We don’t want to muddy the water. The cause of action has been established in this case. It will be tested in higher courts.”
‘Dear to my heart’
Landman told the lecture hall that the topic of euthanasia was “dear to his heart”.
“We have many differences of belief… like religion. In this debate, we must talk about law reform and policy, and the ultimate thing is the Constitution,” he said.

Landman said Health Minister Aaron Motsoaledi had failed to acknowledge the authority of the Constitution in this debate.

Law is not made on the basis of God’s will – it is based on the Constitution.

Law is not made on the basis of God’s will – it is based on the Constitution,” he said. “If playing God is determining the manner and time of death, than what about the legal ways that doctors determine death?”

He said these “legal ways” were everyday decisions taken by doctors, like withholding treatment, determining who gets a specific treatment and methods of pain management that could affect the length of a patient’s life.
He said the rules proposed for euthanasia were in fact more strict than those of the informal “legal” decisions doctors took that lead to patients’ death.

Case for euthanasia compelling

Professor Dan Ncayiyana, a former editor of the SA Medical Journal said: “There are more patients dying of doctor decisions than those who would if they if they could do active euthanasia”.

He also mentioned that the debate around euthanasia was based on the rights to life and the rights to dignity.

“They are opposite sides of the same coin. The right to life is the right to dignified life.” He said when it came to end of life decisions, there was no “one size fits all”. “On one hand, I am of the view that as a general principle, the case for euthanasia is compelling,” Ncayiyana said.
“On the other hand, euthanasia should only be implemented in a secure environment. I don’t think South Africa provides a secure environment for euthanasia.”

He said South Africa “lacked an ethos of respect for human life”.
“The argument for euthanasia is sound, and there is a place and time for it. But that time and place is not now for South Africa.”
Gwyther said suffering was subjective, and palliative care was there to provide relief from suffering. “[The] discussion is driven by our fear and imagination of how it is going to be, and in my experience, it is not as bad as our fear and imagination.”

Law professor David McQuoid-Mason from the University of KwaZulu-Natal echoed Landman by saying the Constitution was “our supreme law”.
He said Fabricius’ ruling was careful to not make itself “a general rule”.
“It is not a blanket license. My advice to doctors is not to do anything without a court order. It is a decision by one judge. Other judges are not bound to follow him.” He said the ruling would allow people to approach the courts.