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Wednesday, April 30, 2014

JohnWesleyProject.com

The JohnWesleyProject.com is based on a firm belief in the relevance of John Wesley's teachings and theology for today. 
The primary goal of this project is to bring the man described as "a plain man for plain people" to as many plain people as possible, using the tools which God in His grace provides us with in the 21st century.
John Wesley,who described himself as 'a man of one book', said: "The world is my parish."  This project seeks to use high quality DVD course material, the World Wide Web, Blogging, Facebook and Twitter to reach that congregation.
For Small Group DVD material based on John Wesley's sermons on The Sermon on the Mount
Click Here

For Daily Devotions
Click Here

For John Wesley's Blog (his journal entry for this day)
Click here

To follow or become a friend of John Wesley on FaceBook
Click here to follow or click here to friend


Contact JohnWesleyProject.com
info@johnwesleyproject.com




                Visit Emmy Award winning Digistream, Producers of JohnWesleyProject.com 

High Definition DVD material
         

JohnWesleyProject.com: The Sermon on the Mount

The Sermon on the Mount
Welcome to the JohnWesleyProject.com, an attempt to bring some of John Wesley's teachings into the 21st-century via High Definition DVD, Blogging, FaceBook and Twitter.The first stage of the JohnWesleyProject.com was the production  of high quality DVD presentations of John Wesley's discourses on the Sermon on the Mount, comprising fifteen talks (recorded in High Definition DVD) by Cedric Poole in a family worship setting.

 Each of the fifteen lessons comprises a
DVD presentation of the talk itself (twenty minutes duration), discussion questions and Bible study material and daily devotional material (for personal use between the suggested weekly viewing of the course). 

For those wanting to to use the material in a young (pre-teen) setting there is a DVD presentation of each lesson with accompanying colouring-in and other activities.

 An audiovisual presentation of Chapters 5, 6 & 7 of Matthew's Gospel is also included on the DVD.

 The material is primarily designed  for small group use, but can also be used by individuals, by families in the home,and in larger church gatherings.

All media material (75 daily devotions, 15 Bible Studies and 42 children's activities and answers) is included
 on the DVD in PDF format and is accessed via personal computer and viewed on the screen or printed
 depending on personal preferences and requirements. Permission to photocopy the material is granted at the
 time of purchase when an indication is given of the number of people who will be using the material.

The Sermon on the Mount is of course universal in its appeal across denominations and John Wesley's approach to it is powerfully evangelical. The material should not be seen as only of use to members of the Methodist Church, but hopefully will appeal and be very useful to all people who desire to grow in that personal holiness, without which no one will see the Lord (Hebrews 12:14).

Next Page:    Sermon on the Mount as seen by John Wesley

Sermon on the Mount as seen by John Wesley

The Sermon on the Mount is found in chapters five six and seven of Matthew’s gospel.  Wesley regards the Sermon on the Mount as one that was preached by Christ in its entirety on one occasion to lay down at once the whole plan of His religion and to give us a full picture of what Christianity looks like.

Wesley sees the Sermon on the Mount as being neatly divided into three parts by the three chapters five, six and seven of Matthew’s gospel:  He says that in the fifth chapter our Great Teacher has laid before us those dispositions of the soul which constitute real Christianity. In the sixth chapter He has shown how all our actions may be made holy and good and acceptable to God by a pure and holy intention. In chapter seven He points out the most common and fatal hindrances to holiness and then He exhorts us to break through all such hindrances and secure that prize of our high calling.

It is Wesley's belief that faith which does not lead to the type of religion described in the Sermon on the Mount is not saving faith at all.

Wesley was once accused of being a “dry, legal preacher” as opposed to those who “preached the gospel.” His response was that he was a preacher of the law and the gospel and he writes: 

“I mean by ‘preaching the gospel’ preaching the love of God to sinners, preaching the life, death, resurrection, and the intercession of Christ, with all the blessings which in consequence thereof are freely given to true believers.  By ‘preaching the law’ I mean explaining and enforcing the commands of Christ, briefly comprised in the Sermon on the Mount.” 

(from Letter To an Evangelical Lay Man, London, December 20, 1751)

JohnWesleyProject.com: 15 Talks

Titles of the Fifteen Talks
1.  Introduction
2.  Spiritual Poverty and Holy Morning
3. Meekness, Hunger and Thirst for Righteousness, Mercy
4.  Purity of Heart, Peacemaking and Persecution
5.  Salt and Light
6.  The Law and the Gospel
7.  Giving
8.  Praying
9.  Fasting
10.  Storing up Treasure
11.  You Cannot Serve Two Masters
12.  Hindrances to Holiness
13.  Two Ways and to Gates
14.  False Prophets
15.  Rock or Sand

JohnWesleyProject.com: Discussion Questions and Bible Study Material

Discussion Questions and Bible Study Material
Bible Study material and discussion questions are provided for each of the fifteen weeks. 
The last question in each study relates very specifically to how the particular lesson from the
Sermon on the Mount relates to the four mission pillars of the Methodist Church of Southern Africa.
The following are some examples of the Discussion Questions and Bible Study material.
Week 1 Discussion Questions and Bible Study
Introduction
Study Passage Matthew 7:21–29
1
Is the Kingdom of Heaven something you enter into in this life
or do you have to wait until you die before it becomes a reality?
What are some of the different ways that people hope will “get them into Heaven”?
How do you hope to enter the Kingdom of Heaven?
2
In verses 21 & 22 Jesus mentions five different types of people. Identify them and discuss their actions
(e.g. what does it mean to say “Lord, Lord,” what is prophecy, casting out devils, etc?)
Discuss how it is possible to do these things and yet be unsaved.
3
What will cause Jesus to say: “I never knew you”?

JohnWesleyProject.com: Daily Devotions

Daily Devotions
There are five daily devotions for each of the fifteen weeks.  The devotional material is related
to the talk and is best used after viewing the relevant talk. The devotions encourage meditation on a relevant verse from the Scriptures. Many include John Wesley's comments on that particular verse and most
conclude with a relevant verse from a Wesleyan hymn to use as a prayer. 

Sometimes the specific prayers that Wesley wrote for children and for families are used.
As with the rest of the material in the JohnWesleyProject.com, the devotional material can be used by the individual but can also be used as a family devotion.

The following are some examples of a Daily Devotions:

Week 1 Day 1 Devotions
He Lives
I know that my Redeemer lives,
       and that in the end he will stand upon the earth.

Job 19:25
One need look no further than Job in the Old Testament to see someone
around whom floods rose and against whom winds raged.
The Lord himself describes Job as a perfect and upright man who

JohnWesleyProject.com: DVD Presentation

The talks have been recorded and are presented in an all-age family worship setting.
(The Children's address is optional viewing when viewing in the small group setting)

Teaching the Congregation


Teaching the Children

JohnWesleyProject.com: Resources Centre

Orders
Please note that all  the material mentioned is included on the DVD. 
The weekly children's presentation and the weekly talk can be viewed
by inserting the DVD into a DVD player.  The Children's Activities, Bible Study and Discussion Questions,
Daily Devotions and Bibliography are included on the disk in PDF format
and can be accessed on your own personal computer and printed by the
purchaser if required.  Alternatively, if you do not have access to a personal
computer, the DVD can be taken to one of the many commercial enterprises
available who, in a matter of minutes, will be able to access and print the
material for you.  Permission is granted at the time of purchase to photocopy
the material provided the number of copies to be made is stated. 
The cost of the DVD set (two DVDs), including postage and packaging to
destinations in Southern Africa, is R220 (ZAR Two Hundred and Twenty).
Orders can be placed via e-mail to orders@johnwesleyproject.com

The following information must be included:
Name and Surname
Postal Address
Number of DVD Sets  Being Ordered
Number of People Using the Material
Upon receipt of your order you will be sent a reference number which
is to be included on your bank deposit slip.  Once proof of deposit is
received and cleared by the bank your order will be mailed by registered post
and the tracking number forwarded to you.
(International orders will be dealt with on an individual basis via e-mail communication)
Banking Details for South African Orders
will be forwarded to you  upon ordering
Please allow at least two weeks for bank clearances and postal service

Home

Friday, April 25, 2014

Easter 2: The Mind-Blowing Mystery of Resurrection

Second Week of Easter

Acts 2:14a, 22–32
Psalm 16
1 Peter 1:3–9
John 20:19–31

I am on a weekend off so am not preaching on the Thomas that resides in each of us (as do each of the 12)

Thursday, April 24, 2014

From the Pastor's Desk to Amcare


24 April 2014

Dear Amcare

You may or may not know that the view from my office looks out over Amcare and I often stretch my hands in your direction and ask our Lord to bless you. I write this with love to all of you who give so selflessly in your service to Amcare and therefore to our Lord and the wider community of Alberton. I am deeply aware of the struggles Amcare is constantly dealing with and the personal struggle and difficulties that subsequently affect each of you. Please be assured of my prayers. Below is an extract from a Daily Devotional that I am currently using and I felt it might be a blessing for you today as it has been for me. 

I know how very easy it is to remind folk who are going through difficult times that Jesus is with them. I know that it is often in the difficult times that Jesus seems to us to be furthest away and difficult to reach....I have felt this way sometimes. But I have learnt that that is when He is really the closest. This devotion seems to put this idea into better words than I can, and I hope you are blessed by it.

Much love,


    Cedric

PS for my JohnWesleyProject.com congregation from the DentalMethodist: 

AMCARE was established in 2001 by the Alberton Methodist Church as a community outreach programme. It was decided to provide a Victim Empowerment Programme, comprehensive HIV and Aids services and Skills Development Services. Today, operating independently but in association with the Methodist Church of Southern Africa, AMCARE achieves the seemingly impossible with activities extending from Alberton to Thokoza, Eden Park, Phola Park and the Squatter Camps of Greenfields and Thinazonke

Please visit Amcare for more info

24 April 2014



Trust nothing, yourself least of all; but in Me have that perfect confidence that banishes fear. Remember how many storms I have quieted by a word, making a great calm to follow. Remember how I held up Peter walking on the waters. I am always as near to all people as I was then to him, and as ready to help and comfort in all that is for the good of the soul. Be confident, faithful, courageous;  have no fear for your body and soul, for I am there, loving and all-powerful. Never forget that I am there. In this life the tempest never ceases, and your boat is ever ready to sink. But I am there, and with Me it will never be wrecked.
This devotion is lifted from Celtic Daily Prayer
HarperCollins Publishers. 
Buy this excellent resource here

Saturday, April 19, 2014

Neonatal Male Circumcision and South African Health Law


A close reading of the Children's Act indicates that it does not prohibit elective neonatal medical male circumcision for medical reasons, and providing all informed consent requirements are met by obtaining consent from the parent or guardian of a newly born boy prior to performing a neonatal male circumcision, the procedure may be carried out.
Section 12 (8) of the children's act regulates circumcision of male children under 16. It states in full:

Voluntary HIV Testing in Schools: Ethical Perspective


The Minister of Health in South Africa has indicated a move in the country towards mass testing of populations as a strategy towards HIV prevention.[1] A voluntary testing programme is to be implemented, first at universities and later at schools. The next phase will be testing workers on farms and mines and in industrial areas. Expanding HCT campaigns to schools raises several ethical issues, the most important of which relate to privacy, confidentiality and voluntary participation.

Ethics and Cosmetic Surgery


Cosmetic Surgery and Body Image

Cosmetic surgery is becoming an increasingly common surgical procedure, constituting a multibillion dollar industry and is directed overwhelmingly at female clients (Morgan 1991:25-33). According to Susan Sherwin (1996:59) it is virtually unregulated, and often poses a significant risk to clients who invest years of savings for these dangerous procedures, motivated by a culture that demands female bodies and faces to conform to a limited range of stereotypes. This practice clearly poses some substantial moral questions.

Medical Research on Humans: Scandal and Protectionism


Research Ethics: ?born in scandal and reared in protectionism?
In 1988 Carol Levine, in an article which asked whether AIDS has changed the ethics of human subjects research, said the following about ethics in human research: “born in scandal and reared in protectionism” (Levine 1988:167). In this essay I will critically analyse this statement and support its veracity by showing how human research abuses continued even while codes and declarations on human research were being developed. I will argue that there has been a paternalistic protectionism on the part of scientists and researchers to protect or defend their perceived right to conduct research on human subjects and that this protectionism has to an extent been validated by Research Ethics Committees (RECs) and Institutional Review Boards (IRBs) by nature of the make up of their membership. I will argue for greater representation of participant communities in RECs and IRBs

Climate change and the problem of moral responsibility

What do we owe to future generations?
Climate change and the problem of moral responsibility.

A careful reading of the Synthesis Report of the March 2009 Copenhagen Climate Change Conference (Richardson et al: 2009) that involved 2500 professional participants, most of them climate science researchers, leads one to the conclusion that, because climate change can be prevented, inaction is inexcusable. This in fact is the title of one of the key messages to the conference and could be seen as the moral imperative of the Synthesis Report: “Inaction is inexcusable.”

Nile Perch into Lake Victoria: Ethical Considerations


An Ethical Perspective of some of the Economic and Environmental Issues Raised by the Introduction of Nile Perch into Lake Victoria 

Table of contents


1. Introduction

2. Economic Issues

3. Core Environmental Problem

4. Various Ethical Responses
            4.1. Anthropocentrism versus Biocentrism
            4.2. Singer’s Utilitarian Environmentalism
            4.3. Regan’s Kantian Environmentalism
            4.4 Taylor’s Kantian Environmentalism
4.5  Deep Ecology

5. Conclusion

6. Reference list

7. Declaration






1. Introduction

In the film “Darwin’s nightmare”, a number of issues were highlighted which followed the introduction of a non-indigenous species, the Nile Perch, into Lake Victoria. Robert Pringle (2005:510) quotes biologist E.O.Wilson describing this as “the most catastrophic extinction episode of recent history.” The Nile Perch prey on and devour all other fish. Algae eating cichlids have been depleted leading, in turn to a decrease in oxygen in the lake. As a result, the lake is dying. Compounding problems, the perch eat their young and year on year catches are decreasing dramatically. The situation is clearly not sustainable.

In this short essay, I will look firstly at the economic issues involved; secondly, at the core environmental problem; and thirdly, at various ethical responses to the environmental problem; and will close with some concluding remarks.

2.Economic Issues

Kayiso Fulgencio (2009:433) comments on the economic issues surrounding the Lake Victoria fisheries and points out how the positive effects of the industrial fisheries have not trickled down to the small scale fishing communities and have in fact left them marginalised and impoverished. “As a consequence, the fishery is today characterized by unemployment, malnutrition, food insecurity, environmental health hazards and criminal activities such as theft and piracy.”

3.The Core Environmental problem

The core environmental problem is that the economic boom brought about by the introduction of the Nile perch, has led to the degradation of the environment (the lake and its surrounds), the extinction of some of the species (fish) and the overgrowth of other species (algae). This has all taken place in order to satisfy the exotic desires of humans on another continent, for the meat of the Nile perch.

Rolston 3rd (2003) points out that animals are often casualties of human inabilities to manage themselves and their resources and he asks whether animals should always lose and people win. The Lake Victoria fishing industry shows that in the long term, people actually lose as well, as the actions of people cumulate and produce large scale changes.

Several nations recognise that humans have a right to an environment that is healthy. Section 24 of the Bill of Rights in the Republic of South Africa[1] is our nation’s attempt to deal with the environment. It enshrines the right to an environment which is not harmful to people’s health or well–being but in its wording seems to imply that greater importance is attached to human needs than to the needs of the environment. Rolston 3rd (1996:178) points out that while humans have a right to an environment which is healthy, when humans encounter a living organism, they become responsible for their behaviour. He thus calls for an ethical vision, where things count that are outside the human circle.

The remainder of this essay will, using the Lake Victoria fisheries example, seek to show from an ethics point of view, what, if any, duties humans have to the environment and why. It will also seek to answer whether or not the environment has or should have moral status.

4. Various Ethical responses
4.1. Anthropocentricism versus biocentrism

One’s ethical response to environmental issues is going to depend on the decision one takes regarding who or what deserves moral recognition, such that it can be meaningfully claimed that they have suffered a moral wrong. On the one side will be anthropocentrism, a human centred approach which assigns significantly greater value to human beings than to non–human entities, so that the protection or promotion of human interest or well being at the expense of non-human entities is almost always justified; on the other side is ecologism where both living beings and their environment are considered to have value.

John O Neil (2001:164) discusses the claim that to hold an environmental ethic is to hold that beings and states of affair in the non-human world have “intrinsic value”. This claim is taken to distinguish “deep” biocentric ethical theory from the more traditional “shallow” and anthropocentric counterparts. Intrinsic value implies that non human beings and entities are not simply of value as a means to human ends, but are ends in themselves, either in the sense of being valued for their own sake or more strongly of having ethical standing.

Holmes  3rd (2003:458) links the above idea to economics in claiming that developed nations are wealthy enough to be concerned about saving nature whereas “developing nations want anthropocentrism with absolutely no concern for the environment, loud and clear.” The Lake Victoria Fishing Industry shows, I believe, the results of anthropocentrism with absolutely no concern for the environment, loud and clear.

The basis for most formulations of eco–centrism is Aldo Leopold’s brief essay “The Land Ethic.” According to Fieser (1992:37), Leopold opens his essay by noting that the basis of ethics is the evolution of modes of co-operation and he argues that there are three stages in this development. The first stage involves co-operative relation between individuals; the second stage involves the relationship between individual and society. The third stage is the extension of ethics to “man’s relation to land and to the animals and plants which grow upon it”. He calls this stage the land ethic and notes that it “simply enlarges the boundaries of the community to include soils, waters, plants and animals, or collectively: the land”. He argues for the development of an ecological conscience that is not guided by economic concerns. As pointed out earlier, this is easier for developed nations than for developing nations.

The key to Leopold’s ecocentrism is his dictum that “a thing is right when it tends to conserve the integrity, stability and beauty of the biotic community; it is wrong when it tends otherwise”. [Quoted in Fieser (1992:39)]. Fieser points out that the most extreme interpretation of this principle is that the highest good is the preservation of the integrity, stability and beauty of the biotic community and all other duties stem from this, thus making Leopold’s principle a consequentialist theory of morality. Fieser then quotes William Aiken (1984:269) who argues that “the logical consequence of this view is the elimination of 90% of all human animals since such a reduction would clearly advance the integrity, stability and beauty of biotic community.”

I like Aiken’s honesty, and also Fieser’s, who goes on to say “interpreted in this way, the implications of Leopold’s principle are highly unacceptable.” I have concentrated on Leopold’s principles and these responses to it because it highlights for me a weakness in much of eco-centric ethics and that is that they are unwilling to really put the environment first and the environment’s biggest enemy, humans, lower down. (This essay does not allow for an in depth study regarding whether or not humans are generally good or generally bad for the environment but using Lake Victoria as an example, it is relatively easy to suggest that humans are generally bad for the environment, and that if Lake Victoria were left for a few million years without any human interference, it would probably recover to its former state). As will be seen in the views that follow, they all seem to want to maintain humans’ place in the environment, ignoring the fact that the environment, the whole planet, would be better off without humans.

Des Jardins (1993:241), discussing ecology and ecofeminism suggests that environmental and ecological destruction (of the type, for example, that we see in Lake Victoria) is best understood as a form of human domination of nature and that to understand this crisis more fully, we need to understand more general patterns of human domination over other humans. This calls for identifying and analysing patterns of domination and oppression within society and evaluating these in order to give rise to an ecological vision based on a model of social justice in which human beings are free from oppression and domination.

Applying this analysis to the Lake Victoria fishing industry, one sees that it is not primarily an issue of domination of one species of fish over another, but rather the domination of one group of people (i.e. first world fish eaters) over another group of people (i.e. third world lake dwellers) with one of the many casualties being the environment.

Either the environment counts and is worthy of moral recognition or it doesn’t. What follows is a summary from Sterba (2001:27-49) of various ethical approaches to the environment.

4.2. Singer’s Utilitarian Environmentalism

Based on the principle of equal consideration, a central principle of utilitarian ethics, Singer says it is unjustifiable to give greater weight to the human species over other species in the case of conflict and he likens this “speciesism” with biases against blacks and women. Because animals have a capacity for suffering and enjoyment, they have interests and there is no justification for regarding the pain animals feel as less important as the same amount of pain (or pleasure) humans feel. Singer suggests we give the same respect to the lives of animals as we give to the lives of humans at a similar mental level.

4.3. Regan’s Kantian Environmentalism

Regan believes that what is wrong with our treatment of non-humans is that it implies they are simply resources for our use. He feels that because they are experiencing subjects of life, they have inherent value and are thus entitled to equal respect. To those who might contend that animals have inherent value, but to a lesser degree than humans, Regan argues that this view would only be defendable if similarly deficient humans were also seen as having less inherent value.

Both Singer and Regan appear biased against certain forms of life. For Singer, it is sentient beings that count and for Regan, it is experiencing subjects of life that have inherent value. Paul Taylor takes up these issues.

4.4. Taylor’s Kantian Environmentalism

Taylor suggests that all individual living beings can be benefitted or harmed and have a good of their own and therefore qualify as moral subjects. He denies that species themselves are moral subjects with a good of their own and therefore his view has been called “biocentric individualism”

Taylor uses the following reasoning to establish that we ought to respect entities:
  1.  Humans are members of Earth’s community of life.
  2.  All living things are related to one another in an order of interdependence.
  3.  Each organism is a teleological centre of life.
  4.  The assertion of human superiority is groundless.
(From Sterba 2001:30)

Taylor’s view has two results. The first is to undermine the anthropocentric view of human superiority. The second is due to his view on entities having a good of their own, it follows that ecosystems should qualify as moral subjects since they can be benefitted and harmed and have a good of their own.

His view, as it is applied to the Lake Victoria issue, enables a viewpoint which not only considers the humans and animals but also the ecosystem of which they are a part. This brings me to the final ethical approach to the environment, namely deep ecology.

4.5. Deep Ecology

Whereas in the above mentioned approaches nature has no value apart from the needs, interests and good of human beings, and could be called “shallow ecology”, deep ecology hold that nature has value in its own right independent of the interests of humans.

Des Jardins (1993:216) refers to the work of Naess and Sessions and summarizes the deep ecology platform in the following eight points:
1. The flourishing of human and nonhuman life on earth has intrinsic value. The value of nonhuman life-forms is independent of the usefulness these may have for narrow human purposes.
2. Richness and diversity of life-forms are values in themselves and contribute to the flourishing of human and nonhuman life on earth.
3. Humans have no right to reduce this richness and diversity except to satisfy vital needs.
4. Present human interference with the nonhuman world is excessive, and the situation is rapidly worsening.
5. The flourishing of human life and cultures is compatible with a substantial decrease of the human population. The flourishing of nonhuman life requires such a decrease.
6. Significant change of life conditions for the better requires change in policies. These affect basic economic, technological, and ideological structures.
7. The ideological change is mainly that of appreciating life quality (dwelling in situations of intrinsic value) rather than adhering to a high standard of living. There will be a profound awareness of the difference between big and great.
8. Those who subscribe to the foregoing points have an obligation directly or indirectly to participate in the attempt to implement the necessary changes.


I find point 3 disturbing because of the idea that the environment is a means to an end, namely, the satisfying of humans vital needs and illustrates for me how anthropocentrism permeates even deep ecology.

5. Conclusion

Human contact with the Lake Victoria ecosystem has led to its degradation to the point where the lake itself is dying. In this essay I have looked at the economic issues involved, at the core environmental problem of non–sustainability due to the anthropocentric view of the Lake Victoria fisheries towards the environment, and discussed various ethical responses.

I have attempted to show that as long as humans exist, anthropocentrism will permeate any ethical response to environmental problems.




6. Reference list

Aiken, W.1984. Ethical Issues in Agriculture. Earthbound Ed Tom Regan. New York: Random House [In Fieser, J. 1992 below]

Constitution of the Republic of South Africa.

Des Jardins, J.1993. Environmental Ethics. Belmont: Wadsworth Publishing.

Fieser, J. 1992. Leopold and the compatibility of Eco-centric morality. In: International Journal of Applied Philosophy. Vol7:37-41. Available http://www.utm.edu/staff/jfieser/vita/research/leopold.htm[accessed 16-4-2010]

Fulgencio, K. 2009. Globalisation of the Nile perch: Assessing the sociocultural
implications of the Lake Victoria fishery in Uganda. African Journal of Political Science and International Relations Vol. 3 (10): 433-442. Available http://www.academicjournals.org/ajpsir/PDF/Pdf2009/October/Fulgencio%20pdf.pdf  [Accessed 16/4/2010]

O’Neill, J. 2001. Meta-ethics. In: A Companion to Environmental Philosophy. Dale Jamieson(Ed). Oxford: Blackwell Publishers: 163-176

Rolston 3rd, H. 1996. Earth Ethics. In: Earth Summit Ethics. J.B.Calliath and F.J.R da Rocha (Eds). NY: State University and New York Press:161-192.

Rolston 3rd, H. 2003. Feeding People versus Saving Nature.
In: Environmental Ethics. A. Light and H. Rolston 3rd (Eds)
NY: Blackwell Publishers: 451-462

Sterba, J. P. 2001.Three challenges to Ethics. New York: Oxford University Press




[1] Constitution of the Republic of South Africa No 108 of 1996

Patient Autonomy in South Africa


Autonomy and the right to self-determination in South Africa
Table of Contents
  1. Introduction.
  2. Autonomy and Self-determination.
2.1. Autonomy as a single principle.
2.2. Autonomy as a right.
2.3. Autonomy as a quality.
2.4. Health Professions Council of South Africa and Autonomy.
      3.   Medical Paternalism.
            3.1. For and Against Medical Paternalism.
                        3.1.1. For Paternalism.
                        3.1.2. Against Paternalism.
      4.   South African Law: The Constitution, legislation and case law.
            4.1. Overview.
                        4.1.1. The Constitution.
                        4.1.2. Legislation governing consent.
                        4.1.3. Case Law
            4.2. The Bill of Rights.
            4.3. Ethical guidelines regarding consent.
            4.4. Legislation governing consent.
                        4.4.1. Who may give informed consent?
                        4.4.2. Emergencies.
                        4.4.3. Statutory authority.
                        4.4.4. Court Order.
        5. Conclusion
        6. Declaration    
                       

                       

1.Introduction

In most medical ethics literature an autonomous person is said to be self-determining - to have control of his or her destiny[1]. In this essay I will define and discuss autonomy and self-determination. Having defined the terms I will then use all relevant laws and the Health Professions Council of South Africa's General Ethical Guidelines for Doctors, Dentists and Medical Scientists[2] and Seeking Patients Informed Consent: the Ethical Considerations[3]  and discuss autonomy and self-determination in health care practice in South Africa.

2.Autonomy and Self-Determination

Seedhouse contends that the principle of autonomy has, as a matter of fact, always inspired health work[4]. Illness or injury, for example a broken hand, is a physical impediment to autonomy and also an obstacle to physical development. Medical interventions seek not only to restore biological development but also to allow a person to move on in life without obstacle or hindrance to the ability to act autonomously. The whole point of humane treatment is to enable full persons to flourish as much as possible. While being just, not doing harm and doing positive good are all important to health care’s primary inspiration, I would suggest that autonomy is the central healthcare notion.

Under Western law (and as will be shown later, South African law is no different), touching a competent person for the purpose of a health care intervention requires consent from the person and this consent must involve having sufficient knowledge to understand the implications of what is proposed. Seedhouse identifies three different ways of defining autonomy:

2.1. Autonomy as a Single Principle
When autonomy is seen as a single principle it is defined rather narrowly as follows:
“the wishes of individuals ought to be respected,” or “patient control of decision-making.” Seedhouse points out that practitioners who define autonomy in this way will often separate patient welfare and patient autonomy and this then allows them to ask “does autonomy apply in this case, or is it better than the doctor decides?” This gives rise to paternalism, which I will discuss later.

2.2. Autonomy as a Right
When viewed as a right, autonomy is to declare that people capable of self-determination ought not to be manipulated, even if others believe this is in their best interest. While this is a satisfactory view of autonomy it is too simple because it regards autonomy as a single type of a thing which you either have or do not have.

2.3. Autonomy as a Quality
Seedhouse sees autonomy neither as a disembodied principle or a right partially separate from human beings, but rather as an intrinsic personal quality: “to be autonomous is to be able to do - to be able to do anything rather than nothing.”[5] Thought of in this way autonomy is a matter of degree - the better the quality of autonomy the more a person is able to do. A person becomes able to move more extensively in his/her life as her/his level of autonomy rises.

This understanding of autonomy makes it possible to create a clear distinction between creating autonomy and respecting autonomy and that respecting autonomy goes much deeper than just agreeing to the wishes of others. In a medical context respecting autonomy can come to mean no more than that the practitioner is neutral and does not place undue influence on the recipient of health care. Practitioners can come to believe that the main thing is to let the patient make up her own mind and that it is not up to the practitioner to tell the patient everything about his condition, believing that if he wants to know he will ask. When autonomy is seen as a quality, a practitioner will realise that a person's autonomy may not yet be of a quality that enables her to make a reasoned choice. Seedhouse suggests that if doctors think respecting autonomy merely means saying “over to you” whenever there are hard clinical decisions to be taken, they have things badly wrong. Superficially, it may seem as if a patient's right to exercise the principle is respected if she is left alone to decide to have a treatment or not. Certainly she will not be under pressure to do what clinicians would like, but without advice, support and education - and especially if she is upset and anxious - she may have little or no autonomy to exercise.

It thus makes good sense to see autonomy as the ability to do, to see it as a quality which we all possess to some degree, and to see it as a quality which can often be enhanced in a variety of ways. This makes it possible to work for autonomy without always having to do what another person requests. Seedhouse correctly suggests that creating autonomy - enhancing the human quality of doing - is basic to health care.

2.4. Health Professions Council of S.A. and Autonomy
The Health Professions Council of South Africa (HPCSA) takes this broader view of autonomy in its Ethical Guidelines booklets. Acknowledging that the practitioner is in a position of power over a patient[6] it goes on to warn against abusing this power and encourages the following[7]:
            respect patients’ privacy and dignity;
            respect their opinion;
give them the information they ask for or need and do this in a way they can best understand;
            do not withhold information that would be in their best interest;
respect the right of patients to be fully involved in decisions about their treatment and care and respect their right to refuse treatment.

In all these it is clear that the HPCSA encourages the creation of autonomy as well as the respecting of autonomy.

A perusal of the HPCSA booklet on informed consent[8] reinforces the idea of creating autonomy by calling for effective communication and the development of relationships of mutual trust and respecting patients’ autonomy even where a refusal may result in harm to themselves or in their own death. It calls for the provision of sufficient information regarding their specific condition and a recognition that the amount of information given to each patient (even for the same condition) will be patient specific. The guidelines regarding what information patients should be given before making a decision regarding consent is extensive and concludes with a section calling on practitioners to do their best to find out about patients’ individual needs and priorities and a call to not make assumptions about patients’ views. Practitioners are expected to respond honestly to any questions and to allow sufficient time for patients to make a decision and then to abide by their decisions.

3. Medical Paternalism.
Point 7 of Seeking Patients’ Informed Consent: The Ethical Considerations states “It is for the patient, not the healthcare practitioner, to determine what is in the patient's own best interests.” The ultimate decision to undergo or refuse a medical intervention lies with the patient and not with the practitioner. This applies even if the practitioner regards a refusal by the patient’s consent to treatment as grossly unreasonable and even if the patient's death might result. The practitioner cannot violate the patient's autonomy on the basis of “the patient’s-best-interest” and “the doctor knows best.” This practice on the part of practitioners is called paternalism and is defined by Benatar[9] as “taking actions or decisions on behalf of patients, if necessary without their permission, sometimes even with coercion, and is justified by the intention of serving their welfare.” He goes on to describe how paternalism has its roots in the Hippocratic tradition and includes the implicit assumptions that the doctor is benevolent and will only undertake actions not harmful to the patient, that the doctor is qualified to act on behalf of the patient and that explicit permission is not always necessary. The patient is considered to have insufficient medical knowledge and if seriously ill could even have diminished autonomy as a consequence of the physical, emotional and social effects of disease.

3.1. For and against Medical Paternalism
As will be seen later when the relevant laws are discussed, in South Africa patient autonomy as a fundamental right has been endorsed and medical paternalism rejected. Nonetheless there is often a strong temptation for some practitioners to be paternalistic - in other words for practitioners to give their perception of the person’s welfare a higher priority than the person's choice. In Principles of Health Care Ethics[10] editor Raanan Gillon devotes a chapter to argument in favour of paternalism in the doctor patient relationship by Shinebourne and Bush[11] and another to argument against paternalism in the doctor patient relationship by Robert Veatch.[12]

3.1.1. For Paternalism
Shinebourne and Bush suggest that it may not be desirable or even possible to exclude paternalism from medicine and that their support for paternalism is for some but not all aspects of paternalism. They define paternalism as “behaving towards someone as a father would towards his children, in other words with an absolute duty to safeguard the welfare and health of his child, to act always in the best interests of the child, to use his knowledge, skill and understanding to secure those interests, to take responsibility for decisions made and to be available to the best of his ability at all times when the child needed him.” They suggest this attitude does not imply not respecting autonomy. Using this definition they go on to suggest that paternalism is inevitable in medicine because full information cannot possibly be given in every situation. They ask “Can it seriously be argued that a middle-aged man with a cough should be told that he probably has a post nasal drip but could have inoperable cancer, tuberculosis or AIDS?”[13]

In arguing for a degree of paternalism they stress that in the majority of consultations between patients and doctors there is little place for paternalism, but that when doctors have earned and gained trust (and not abused or assumed it) they have no need to apologetically defend paternalism.

3.1.2. Against Paternalism
Veatch defines paternalism as behaviour that attempts to interfere with the autonomy of an individual without his or her consent for the express purpose of benefiting that individual. His understanding of autonomy is one which extends beyond freedom of action to encompass the idea of self-determination in accordance with a plan chosen by oneself. He acknowledges that for most of the 20th century the practice of medicine was paternalistic but that two major moral changes have rendered paternalism by physicians untenable and indefensible. These changes are firstly, the development of rule consequentialism and secondly, the deontological “right-making” principle of autonomy.

All the above points to the fact that there is not uniformity of belief regarding autonomy. Benatar goes so far as to suggest that “the concept of the patient as autonomous agent is philosophically suspect.”[14] Be that as it may, Dieter Giesen[15] rightly points out that “today at least some legal systems clearly prefer the patient's autonomy to medical paternalism. This view reflects the basic human right to self-determination which, in a broader context, is acknowledged in many parts of the world.” South Africa is one of those 'parts of the world' and an examination of our laws and ethical guidelines reveals that this right cannot be denied to a person just because he or she is sick. The fundamental principle of human autonomy and self determination in South Africa primarily guarantees a person’s (and a patient's) freedom from all unauthorised infringements of physical and psychological integrity. A patient's increased vulnerability and the dependency induced by sickness should not be used as excuses for more or less eliminating his or her autonomy even if the goal is the restoration of the patient's well-being. In the next section, where the Constitution and laws of South Africa are examined, I will show that patients remain entitled to respect as persons even if, without the practitioner's knowledge and skill, they are unable to recover by themselves - the patient's consent is an essential prerequisite for any medical procedure.

4. South African Law: The Constitution, Legislation and Case Law.

4.1. Overview
Rebecca Cooke[16] points out that it is a “legal recognition of only recent evolution that treatment choices are not to be medically dictated, but are to be medically informed personal choices made by patients as acts of self-determination. Physicians are increasingly required by law to afford patients’ respect as equals - capable of and responsible for making critical life decisions - by providing them the medical information they need to fully exercise choice.”

4.1.1. The Constitution
As a constitutional democracy, residents in South Africa live in a society which places a high value on self-determination and autonomy particularly in the area of health care.

 The Constitution[17]is the supreme law of the Republic. Carstens and Pearmain[18] suggest that the Constitution in general, and the Bill of Rights in particular, embody the spirit of the law, whilst the letter of it is left to other legislation and the common law. In discussing autonomy and self-determination in healthcare practice I will look first of all at the Bill of Rights and in particular at:
  • Section 9 which protects the right to equality;
  • Section 10 which protects the right to dignity;
  • Section 11 which protects the right to life;
  • Section 12 which protects the right to bodily integrity and not to be subjected       to medical experimentation without informed consent;
  • Section 14 which protects the right to privacy;
  • Section 27 which guarantees the right to access healthcare, reproductive health and access to emergency medical treatment
  • Section 28 which guarantees all children access to basic health care services.

4.1.2. Legislation Governing Consent.
Secondly, I will look at current South African legislation governing consent, which includes:
  • the National Health Act[19];
  • the Mental Health Care Act[20];
  • the Children’s Act [21]
  • the Choice on Termination of Pregnancy Act[22];
  • and the Sterilisation Act[23];
4.1.3. Case Law
Before moving to the Bill of Rights and South African legislation, I will identify some specific case law which is important in the area of autonomy and self-determination namely:
  • Castell v De Greef[24];
  • Soobramoney v Minister of Health[25];
  • Van Biljon v Minister of Correctional Services; B & Others v Minister of Correctional Services & Others[26];
  • Ministry of Health v Treatment Action Campaign[27];

Castell v De Greef is regarded (according to Carstens and Pearmain[28]) as the locus classicus in the area of informed consent. It introduced the doctrine of informed consent into South African medical law; it ousted medical paternalism in favour of patient autonomy; it treated lack of informed consent as an issue of assault and not of negligence; and it established the yardstick of the ‘reasonable patient’ as the test for informed consent and not that of the ‘reasonable doctor.’ Carstens and Pearmain[29] submit that the “principles pertaining to the application of the doctrine of informed consent in South African medical law, as stated in Castell v De Greef are ultimately indicative of the correct approach to be followed as it conforms with the fundamental right of individual autonomy and self-determination.”

In Soobramoney a 41 year old man sought to have renal dialysis provided to him at state expense, in the absence of which he would die. He claimed that his right to life and his right to emergency medical treatment were being denied. His request was declined for the reasons that due to scarcity of resources, access to renal dialysis was rationed and he did not meet the criteria for providing dialysis at state expense. Furthermore the court gave a narrower meaning to emergency treatment in defining it as sudden catastrophe or unexpected trauma.

In Van Biljon four prisoners diagnosed as HIV positive sort orders that they had the right to the provision, at state expense, of adequate medical treatment. Two of the prisoners had already been prescribed appropriate anti-retrovirals by medical practitioners but the other two had not had any antiretroviral treatment prescribed by the state. The High Court ruled that the two who had been on antiretroviral treatment were entitled to continue at state expense, but the two who had not been on antiretroviral treatment were not entitled to treatment. The ruling established that individuals are not entitled to specific remedies unless the state has already committed itself to the provision of specific benefits.

In Treatment Action Campaign the applicants had challenged the decision of the government to confine the dispensation of Nevirapine to 18 pilot sites (only two in each of South Africa's nine provinces) for the purpose of prevention of mother to child transmission of HIV (PMTCT). According to Ngwenya and Cook, in Socio-Economic Rights in South Africa[30], although the applicants had relied on several constitutional provisions the case turned on the interpretation and application of sections 27(1) and 27(2). The trial judge, Botha J, held that the programme adopted by the government fell short of a reasonable measure to realise the right of access to health care under section 27. The court further declared that the respondents had an obligation forthwith to plan and implement a comprehensive national program to prevent mother to child transmission of HIV. Ngwena and Cook state that “the state is not at liberty to ignore the needs of those who are in a crisis and in desperate need.”[31]

4.2. The Bill of Rights

In our Constitution there is no express mention of a broad right to health. Section 27(1)(a) provides for a right to have access to health care services. In Constitutional Law of South Africa[32]  David Bilchitz points out that this right does not provide for the general resources necessary to preserve and maintain health. In Soobramoney the Constitutional Court expressly refused to adopt an understanding of the right to health care services that would require the state to provide individuals with any immediate benefits, but instead held that sometimes the larger needs of society will override the specific needs of individuals. Thus the self-determination guaranteed by the Constitution is limited by the state's ability to provide.

The right to access health care services is not a direct right to healthcare services, but rather a right of access. Carstens and Pearmain point out that it is not a right to healthcare services per se[33]. It is a right to access and this distinction thus allows for the possibility of payment for health care services by those who can afford to do so. In the context of this essay, it is important to note that the right to access emphasises the responsibility of the individual for his or her own health status. A right that grants access implies that the holder of the right must also make some kind of an effort in order to obtain the services. Thus in the context of autonomy and self-determination in the area of healthcare practice, the individual’s first exercise of autonomy and self-determination is to decide to access health care services in the first place.

As mentioned above, although there is no direct right to health, there is a suite of rights which, when viewed collectively could be said to constitute a right to health. These rights are: the right to life[34]; the right to dignity[35]; the right to bodily and psychological integrity[36]; the right to privacy[37]; the right to an environment that is not harmful to health or well-being[38]; the right to emergency medical treatment and to access to health care services[39] and the right to sufficient food and water and social security[40]. The following are a few points to note regarding autonomy and self-determination in the above-mentioned rights:
  • Life: As the case of Soobramoney[41] made clear, the right to life cannot be extended to encompass the right to indefinitely evade death, no matter how self-determined we are to stay alive.
  • Dignity: When patients are so severely injured that they can no longer function as human beings, but remain biologically speaking alive, autonomy and self-determination still need to be respected.
  • Bodily and psychological integrity: The right to bodily and psychological integrity implies that the person may not be forced to receive medical treatment against his or her will. Autonomy and self-determination guarantee the right to choose and refuse treatment and this right implies a right to give or refuse informed consent.
  • Privacy: The physical examination of a person in a health care context is very much an invasion of privacy and such examination can only be lawfully conducted if that person waives the right to privacy for the purpose of the examination.

4.3. Ethical Guidelines regarding Consent

As mentioned previously, the first autonomous, self-determining decision a person makes in respect of health care is the decision to access health care services. Once within the healthcare system, it is in the area of informed consent that individuals primarily exercise autonomy and self-determination.

The HPCSA ethical guidelines[42] call on practitioners to respect a patient's privacy and dignity. Regarding informed consent they require: “give your patients the information they ask for or need about their condition, its treatment and prognosis. Give information to your patients in the way that they can best understand it. Refrain from withholding from your patients any information, investigation, treatment or procedure you know would be in their best interest. Apply the principle of informed consent as an ongoing process. Allow patients access to their medical records.” These are all essential elements in ensuring autonomy and self determination.

Furthermore the HPCSA guidelines state that “the South African courts have held that legally for a proper informed consent  the patient must have: knowledge of the nature or extent of the harm or risk; appreciated and understood the nature of the harm or risk; consented to the harm or assumed the risk; and the consent must have been comprehensive.”[43]The HPCSA further states that it is primarily the duty of the healthcare practitioner to discuss with the patient and obtain from the patient the informed consent[44]. The ethical guidelines further make clear that the healthcare practitioner must inform patients of the legislative requirement of supplying ICD-10 codes to medical aids and the inevitable loss of privacy which is a consequence of this requirement[45]. They must obtain consent to release these codes to the medical aids, preferably in writing, and this consent should constitute part of the informed consent.

4.4. Legislation Governing Consent

In discussing legislation governing consent, I am primarily following the structure and approach of Carstens and Pearmain, who in turn acknowledge that they follow the “foundational writings of Strauss and Van Oosten which undoubtedly remain the most important source references in this regard.”[46]

The purpose and function of informed consent is to ensure the patient's right to self-determination and freedom of choice and to encourage rational decision-making by enabling the patient to come to an enlightened choice either to undergo or refuse treatment. This calls for a patient centred approach which was first described in Castell v De Greef.[47] Part of this approach is to make patients aware of the diagnosis of their condition. The National Health Act[48] imposes a duty on doctors to inform patients of their health status and to then acquire consent to treatment that is freely and voluntarily given.

4.4.1.Who may give informed consent?

  • Informed consent may be given by adults provided they are sane and sober. According to the Children’s Act[49], anyone over the age of 18 years is competent to give consent. Marriage bestows majority and a woman under 18 years who is legally married can give consent.

  • Incapacitated patients, such as patients in a state of unconsciousness, intoxication, delirium, trance, shock or coma are incapable of giving consent.

  • Section 7(1) of the National Health Act[50] provides for proxy or substituted consent to medical interventions by someone else on behalf of the patient who cannot consent:
“Subject to section 8, a health service may not be provided to a user without the user’s informed consent, unless-
    (a) the user is unable to give informed consent and such consent is given by 
      A person-
(i) mandated by the user in writing to grant consent on his or her behalf; or
(ii) authorised to give such consent in terms of any law or court order;
(b)   the user is unable to give informed consent and no person is mandated or authorised to give such consent, and the consent is given by the spouse or partner of the user or, in the absence of such spouse or partner, a parent, grandparent, an adult child or a brother or a sister of the user, in the specific order as listed;
(c)    the provision of a health service without informed consent is authorised in terms of any law or court order ;
(d)  failure to treat the user, or group of people which includes the user, will result in a serious risk to public health; or
(e) any delay in the provision of the health service to the user might result in his or her death or irreversible damage to his or her health and the user has not expressly, impliedly or by conduct refused that service.”

  • The autonomy and self-determination of mentally ill patients in terms of informed consent are protected in the Mental Health Care Act[51] which makes it clear that a mentally ill person may generally be able to consent to healthcare. The mere fact that a person is mentally ill does not per se imply that the person is unable to consent. When a mentally ill patient is deemed incapable of giving consent, or is under the age of 18, proxy or substituted consent may be given. Section 17 of the Act dictates that every health care provider must, before administering treatment, inform a mental health care user in an appropriate manner of his or her rights.

  • Autonomy and self-determination are protected in marriage in that each spouse consents to their own medical interventions, including decisions regarding contraception, sterilisation and abortion.

  • Autonomy and self-determination in minors is protected in that once they have attained 14 years of age they are capable of consenting to any medical treatment. Parental consent is required for any treatment of minors under 14 years of age, and for surgical treatment under the age of 18. Carstens and Pearmain[52] discuss whether or not a minor over the age of 14 years who refuses indicated treatment can be compelled by his or her parents to undergo such treatment. They cite Van Oosten's opinion that “provided the minor has been fully informed about the consequences, risks, dangers and complications that may arise from his or her refusal, a competent minor's consent or refusal should conclude the matter.”

  • Autonomy and self-determination in the area of termination of pregnancy and sterilisation are covered in the Termination of Pregnancy Act 92 of 1996 and the Sterilisation Act 44 of 1998. A woman or child of any age can consent to a termination of pregnancy. If under 18, the attending healthcare professional must advise her to consult with her parents or other confidante, but she is not obliged to follow this advice[53]. A girl under 18 may not consent to a sterilisation.

  • The individual's right to autonomy and self-determination in the area of informed consent is not absolute and is superceded in the case of emergencies, statutory authority and court orders.

4.4.2.Emergencies
When, due to unconsciousness, delirium, shock or coma arising from indulgence or accident, it is impossible to obtain the patient's consent and medical treatment is required to save life or preserve health, treatment may proceed without consent provided the treatment cannot be delayed, and provided the patient is truly incapable of consenting. The treatment must be intended to be in the patient's best interest. Even in an emergency situation, a patient is, in terms of their right to self-determination, entitled to refuse life-saving treatment.

4.4.3.Statutory authority
There are instances where a medical intervention can be carried out irrespective of whether the patient consents to it. Examples include the taking of a blood sample which may be relevant to criminal proceedings[54]; medical treatment of a non-consenting person where failure to treat him or her would result in a serious risk to public health; disclosures of suspected child abuse; notification of abuse of aged persons and compulsory medical treatment of people suspected of being carriers of communicable diseases.

4.4.4. Court order
Resorting to a court order to override a patient's autonomy and self-determination should always be seen as a last resort, but is sometimes necessary in the case of minors where there is a dispute between parents and child, or between parents and doctor or where there is an unreasonable parental refusal to a medical procedure. The High Court is the upper guardian of all minor children and its guiding principle is always what is in the best interests of the child.

5. Conclusion

In my introduction I stated that in most medical ethics literature an autonomous person is said to be self-determining. In this essay I have argued in favour of autonomy as a quality which requires creation and respect. I have shown that the ethical guidelines of the HPCSA and the laws of South Africa demand a recognition of and respect for autonomy and self-determination on the part of healthcare practitioners toward their patients which requires a move away from medical paternalism towards informed decision-making on the part of patients. I pointed out that the right of access to health care places a responsibility on the individual to access that health care and that within the health care system autonomy is not absolute but can be superceded in certain circumstances.

In South Africa, individuals accessing healthcare should be assured that their right to autonomy and self-determination is assured.




[1] D Seedhouse Ethics the Heart of Healthcare 2 (1998) 151.
[2] HPCSA General Ethical Guidelines for Doctors, Dentists and Medical Scientists (2002).
[3] HPCSA Seeking Patients’ Informed Consent: The Ethical Considerations 2 (2007).
[4] Seedhouse op cit 179.    
[5] Seedhouse op cit 182.
[6] HPCSA General Ethical Guidelines for Doctors, Dentists and Medical Scientists 2.1.3.
[7] HPCSA General Ethical Guidelines for Doctors, Dentists and Medical Scientists 2.1 – 2.5.
[8] HPCSA Seeking Patients’ Informed Consent: The Ethical Considerations 2&3.
[9] S R Benatar ‘The changing doctor-patient relationship and the new medical ethics’ (1987) 5 SA Journal of Continuing Medical Education 27 27.
[10] R Gillon (ed) Principles of Health Care Ethics (1994).
[11] E Shinebourne & A Bush For Paternalism in the Doctor Patient Relationship in R Gillon (ed) Principles of Health Care Ethics 399-419.
[12] R Veatch Against Paternalism in the Patient – Physician Relationship in R Gillon (ed) Principles of Health Care Ethics (1994) 399-408.
[13] Shinebourne & Bush op cit: 402.
[14] Benatar op cit 30.
[15] D Giesen ‘From paternalism to self-determination to shared decision making’ Law and medicine 107,116 FAMH 7013 Binder.
[16] R Cook Gender, Health and Human Rights in J Mann S Gruskin M Grodin G Annas Health and Human Rights (1991) 258.
[17] Constitution of the Republic of South Africa 108 of 1996.
[18] P Carstens and D Pearmain Fundamental Principles of South African Medical Law (2007) 22.
[19] 61 of 2003.
[20] 17 of 2002.
[21] 38 of 2005.
[22] 92 of 1996.
[23] 44 of 1998.
[24] Castell v De Greef 1993 (3) SA 501.
[25] Soobramoney v Minister of Health  Kwazulu Natal 1998 (1) SA 765 (CC).
[26] Van Biljon v Minister of Correctional Services: B & Others v Minister of Correctional Services and Others 1997 (4) SA 441 (C),1997 (6) BCLR 789 (C). 
[27] Treatment Action Campaign v Minister of Health 2002 (5) SA 721 (CC).
[28] Carstens and Pearmain op cit 891.
[29] Carstens and Pearmain op cit 893.
[30] C Ngwena & R Cook Rights Concerning Health in C Brand and C Heyns (eds) Socio-Economic Rights in South Africa (2005) 138.
[31] Ngwena and Cook op cit 141.
[32] D Bilchitz Health in S Woolman et al (eds) Constitutional Law of South Africa 2 (2005) ch 56A – 5.
[33] Carstens and Pearmain op cit 41.
[34] Section 11 of the Constitution.
[35] Section 10 of the Constitution.
[36] Section 12(2) of the Constitution.
[37] Section 14 of the Constitution.
[38] Section 24(a) of the Constitution.
[39] Section 27(1)(a) of the Constitution.
[40] Section 27(1)(b) of the Constitution.
[41] Soobramoney v Minister of Health supra.
[42] HPCSA General Ethical Guidelines for Doctors, Dentists and Medical Scientists (2002) 2.2 and 2.3.
[43] HPCSA Seeking Patients’ Informed Consent: The Ethical Considerations 2 (2007) 4.1
[44] HPCSA Seeking Patients’ Informed Consent: The Ethical Considerations 2 (2007) 5.1
[45] HPCSA Seeking Patients’ Informed Consent: The Ethical Considerations 2 (2007) 18.1.
[46] Carstens and Pearmain op cit 877-924.
[47] Castell v De Greef supra.
[48] 61 of 2003 s6(1)(a).
[49] 61 of 2003.
[50] 17 of 2002.
[51] Carstens and Pearmain op cit 903.
[52] Criminal Procedures Act 51 of 1977 ss 37(2).
[53] In terms of sections 4 and 5(3) of the Choice on Termination of Pregnancy Act No. 92 of 1996.
[54] Criminal Procedures Act 51 of 1977 ss37(2).