COVID-19: National guidelines needed to support medical profession

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The Medical Protection Society (MPS) is calling for the Health Professions Council of South Africa (HPCSA) to urgently clarify what guidelines healthcare professionals should follow when making decisions about the withholding and withdrawing of treatment during the COVID-19 pandemic.

This call follows a survey finding that many doctors in South Africa are fearful of recrimination if put in the difficult position of having to ration patient treatment. The MPS survey of doctors across South Africa found that almost one in three respondents (29%) were either concerned or extremely concerned about facing an employer, criminal or HPCSA investigation for making a decision to withhold or withdraw life prolonging treatment such as ventilation.

The findings from the survey, carried out by MPS and Research by Design, are backed up by previous larger survey results, which showed an even higher degree of concern among certain medical specialties. More than half of anaesthetists (52%) and almost half of those working in emergency medicine (45%) were concerned or extremely concerned about facing investigation in the same circumstances.

Despite being faced with this immense challenge, doctors currently have no national guidelines to refer to when making such difficult decisions.

The HPCSA’s booklet 7, entitled Guidelines for the Withholding and Withdrawing of Treatment refers to national criteria that would need to be agreed upon by the expert professional bodies in the relevant speciality, as well as the HPCSA.

However, since the publication of this booklet in 2016, MPS is not aware of any subsequent comment from HPCSA to initiate putting such guidelines in place. With the death toll from COVID-19 continuing to rise the need for national guidance is more pressing than ever and MPS has written to the HPCSA calling for guidance to support professional decision making in difficult rationing circumstances.

Dr Graham Howarth, head of Medical Services, Africa, said: “Medical professionals across South Africa are fearful that should health services be overwhelmed with COVID-19 cases, they may be forced to make difficult decisions on withholding or withdrawing patient treatment.

“That they are being asked to do so without having national guidelines on which to base such decisions only adds to the distress.

“The Critical Care Society of South Africa (CCSSA) has produced guidance to support professional decision making in difficult rationing circumstances.

“Like all ethical guidelines the CCSSA’s are open to debate but well-informed experts have deliberated over them and many will find they provide useful ethical guidance.

“However, with so many fearful of regulatory and criminal recrimination, doctors need clear guidance that is supported by their regulatory body.

“MPS has written to the HPCSA calling on the body to either study the CCSSA guidance and issue a statement in support of the document, or to issue its own guidance outlining its view as regulator.

“It is particularly important that the HPCSA makes its position clear to doctors in scenarios associated with withholding and withdrawing of treatment in respect of COVID-19 patients.

“Agreeing national guidelines will be complex and we do not presume to have all the answers. We do however know that such guidelines are needed in order to enable doctors to focus on their patients with less fear of legal recriminations.”

Survey results
The survey was conducted by the independent market research organisation, Research By Design It ran from 18 to 29 May and achieved 337 responses from Medical Protection Society members in South Africa.
The survey asked MPS members “How concerned are you about facing an employer, criminal or registration body investigation for a decision to withdraw or withhold life prolonging treatment such as ventilation?

Sample size 337
Not at all concerned 20%
Somewhat concerned 20%
Concerned 16%
Extremely concerned 13%
Total concerned (concerned and extremely concerned) 29%
Not applicable 30%


The previous survey ran from 28 April to 4 May and achieved 908 responses from MPS members in South Africa. In answer to the same question, the survey found 30% of respondents were concerned or extremely concerned.

Responses to previous survey by specialty:

Not at all concerned 17%
Somewhat concerned 22%
Concerned 24%
Extremely concerned 28%
Total concerned (concerned and extremely concerned) 52%
Not applicable 9%
Emergency Medicine
Not at all concerned 25%
Somewhat concerned 25%
Concerned 35%
Extremely concerned 10%
Total concerned (concerned and extremely concerned) 45%
Not applicable 5%


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