THE STEVE BIKO AFFAIR: A CASE STUDY IN MEDICAL ETHICS

Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) 

Volume 3 Number 1 2003 

THE STEVE BIKO AFFAIR: A CASE STUDY 

IN MEDICAL ETHICS 

G.R. MCLEAN AND TREFOR JENKINS 

ABSTRACT 

Steve Biko died in detention in South Africa in 1977. Critical ethical 

issues are raised both by the conduct of the doctors responsible for Biko's 

care and by the subsequent response of the medical profession as a whole. 

Because those issues are relevant to all healthcare professionals everywhere, 

the Biko affair provides a useful case study in medical ethics. We discuss 

the case in this article, describing how we use it in our teaching. 

INTRODUCTION 

On 12 September 1977, Steve Biko died while in detention in 

South Africa. This event became notorious world-wide. Biko was a 

leader of the Black Consciousness movement in South Africa, 

and an opponent of the apartheid regime. His death raised 

severe moral questions about the behaviour of the security police 

in whose custody he died, and about the nature of the society that 

employed such security apparatus. However, it also raised critical 

moral questions concerning the conduct of various medical 

practitioners who were implicated in the affair. Thus it provides 

an important case study in medical ethics. Over a number of 

years, we have discussed the Biko affair in medical ethics courses 

for students of medicine and the allied medical disciplines. We 

believe that the questions it raises, and the morals that emerge in 

the investigation of those questions, are as relevant now, 

throughout the world, as they were in South Africa in 1977. 

Hence we offer this dissection of the case to other students and 

teachers of medical ethics. 

Our discussion concerns the medical ethical aspects of the 

Biko affair, so we do not investigate the behaviour of the security 

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and 350 Main Street, Malden, MA 02148, USA.

78 G.R. MCLEAN AND TREFOR JENKINS 

police. We present an outline of the relevant parts of the history 

of the case, and we guide the students, interactively, through an 

ethical analysis of what that history reveals. For our purposes, the 

history of the affair is usefully divided into two phases: the first 

phase concerns the conduct of the individual doctors responsible 

for Biko's medical care while he was in detention; the second 

phase concerns the collective medical profession's response to 

the individual doctors' performance. We consider each phase in 

turn. 

PHASE I: THE INDIVIDUAL LEVEL 

I.1 History of Phase I 

Steve Biko was arrested on 18 August 1977, and detained by the 

security police under legislation that allowed him to be held 

indefinitely. This was not his first experience of detention: he 

had been detained on a number of previous occasions, including 

for a period of 101 days in the previous year. 

In our review of the events that followed, our focus is upon two 

district surgeons, Dr Ivor Lang and Dr Benjamin Tucker. A 

district surgeon is a general practitioner, employed by South 

Africa's Department of Health, whose responsibilities include the 

provision of medical care for prisoners and other detainees. 

On 6 September, Biko was taken from his place of close 

confinement to the Port Elizabeth security police headquarters 

for interrogation. On the morning of the following day, Colonel 

Goosen, regional head of the security police, summoned Dr Lang 

to examine Biko. Goosen had been informed by one of the 

interrogators that Biko was behaving strangely, and refusing to 

respond to questions; he asked Dr Lang to examine Biko for a 

possible stroke. However, at some stage Col. Goosen also raised 

the question of whether Biko might be feigning, or shamming, 

his symptoms. He pointed out that Biko had been a medical 

student some years previously, and he claimed that Biko had 

exhibited `similar symptoms' during a previous period of 

detention. 

In her book, Turning a Blind Eye? Medical Accountability and the 

Prevention of Torture in South Africa, Mary Rayner helpfully takes up 

the account of events from this point: 

In Goosen's presence Lang examined the detainee, who was 

lying on a mat, manacled to a metal grille in an office at 

security police headquarters. 

ß Blackwell Publishing Ltd. 2003

THE STEVE BIKO AFFAIR 79 

During his examination, which was made at floor level, Dr 

Lang found a laceration on the patient's upper lip which was 

edematous, a superficial bruise over the sternum at approximately 

the level of the second rib, a ring mark around each 

wrist, and edema of both hands, feet, and ankles. The detainee 

also walked with an ataxic gait and spoke in a slurred manner. 

When asked by Col. Goosen for a medical certificate, Dr Lang 

wrote: 

This is to certify that I have examined Steve Biko as a result 

of a request from Col. Goosen of the security police who 

complained that the above-mentioned would not speak. I 

have found no evidence of any abnormality or pathology on 

the patient. 

The next day Dr Lang was summoned again. This time he 

examined the detainee in the company of his superior, Dr 

Benjamin Tucker, the chief district surgeon for Port Elizabeth. 

The patient, still shackled to the grille, was lying on a mat now 

soaked with urine. During the examination, Dr Tucker observed 

a possible extensor plantar reflex in the patient, who also 

complained of a pain in his head. Tucker and Lang contacted 

Dr Hersch, a specialist in private practice, who agreed to 

examine Biko at Sydenham Prison Hospital. On 9 September, 

Dr Hersch performed a lumbar puncture, the results of which 

revealed bloodstaining in the cerebrospinal fluid. A neurosurgeon, 

Dr Keeley, was consulted by phone. Although Keeley 

seemed not unduly worried regarding the patient's condition, 

he advised Dr Lang to keep Biko under close observation. 

Apparently because the prison hospital had no observation 

facilities, Dr Lang arranged for the patient to be transferred to 

the Walmer police station cells. As his final entry in the bed 

letter (medical record) at Sydenham Prison Hospital on 10 

September, Dr Lang wrote: `No change in condition. Have 

informed him (Biko) that Dr Hersch and myself find no 

pathology, that lumbar puncture was normal, and as a result, I 

was returning him to the police cells.' 

At the police station, the patient was left lying on a mat on the 

cement floor of the cell. Occasionally a police warden looked in 

on him. On the afternoon of 11 September, Col. Goosen again 

called Dr Tucker to the station. A police warden had found Biko 

collapsed, glassy-eyed, hyperventilating, and frothing at the 

mouth. After a five-minute examination, Dr Tucker suggested 

that the patient be transferred to a provincial hospital in Port 

Elizabeth, but Col. Goosen refused to allow it. Tucker 



acquiesced in this and gave his permission to the police for the 

patient to be transferred by motor vehicle 750 miles to Pretoria. 

On the night of 11 September, the semi-comatose patient, 

naked and handcuffed, was placed on some cell mats on the 

floor of a Land Rover and driven to Pretoria Central Prison. 

Biko was unaccompanied by any medical personnel during this 

long journey. No medical records on Biko's condition were sent 

with him. Several hours after his arrival at the prison, Biko was 

examined by district surgeon Dr A van Zyl. Without any 

information about the patient other than that he was refusing 

to eat, Dr Van Zyl administered an intravenous drip and a 

vitamin injection. During the night of 12 September 1977, Steve 

Biko died lying on a floor mat and unattended. 1 

I.2 What wrongs occurred? 

Having recounted the history of this phase of the case, we invite 

the students to evaluate the clinical performance of the doctors. 

We expect them to identify the following particular features. (In 

what follows, we list the particular acts and omissions alongside 

the general clinical rules or principles against which they are to 

be evaluated.) 

(i) Drs Lang and Tucker seemed to be unconcerned about the 

conditions under which Biko was being detained: he was 

naked, manacled, chained and, on the second day, lying on a 

urine-soaked mat. It is axiomatic that a patient should be examined 

on a couch or bed at a convenient height, under proper lighting, with 

all necessary diagnostic equipment, gloves, etc. In prison situations, 

the doctor should request that instruments of restraint be removed so 

that a full and proper examination can be performed. The doctor 

ought to explain to the prisoner that he approaches the prisoner as a 

doctor, and that he views the prisoner first and foremost as his 

patient. If necessary, the doctor ought to issue instructions that the 

patient be kept under properly hygienic conditions. 

(ii) The medical examinations were inadequate in many respects. 

Neither doctor asked Biko how he sustained his 

injuries; the security police were also not asked. In fact, the 

doctors failed to take a history. The taking of a detailed and 

accurate history is essential if a correct diagnosis is to be made. 

1 M. Rayner. 1987. Turning a Blind Eye? Medical accountability and the prevention 

of torture in South Africa. Washington, DC. American Association for the 

Advancement of Science: 23±25. 


(iii) There was no assessment of the patient's mental state; Dr 

Tucker said that he was alert. In a case of suspected head injury 

or intracranial pathology ± Col. Goosen had said that he suspected a 

stroke ± an abnormal mental state is an important differentiating 

sign. 

(iv) The doctors were subservient to the police, allowing Col. 

Goosen to be present throughout their examination of 

Biko. They were influenced by Goosen's opinion that Biko 

may be shamming. (After all, he had been a medical 

student.) If the doctor-patient relationship is to be effective, the 

doctor must ensure that his examination is independent of any 

interference and, if possible, that it is performed confidentially and 

privately. The doctor must proceed with full independence of mind if 

he is to make a properly objective, unprejudiced diagnosis. 

(v) 


On the first day that Dr Lang saw Biko he wrote a false 

medical certificate, failing to note injuries on the face and 

chest, an ataxic gait and slurred speech. When writing a 

medical certificate it is essential that all injuries and positive 

physical signs be recorded fully and accurately. A medical certificate 

has great public and legal significance. It can be the basis upon 

which the patient is awarded sick leave, or is pensioned, or receives 

compensation or exemption from military service, or is institutionalised, 

etc. It will also certify whether or not the patient has received 

injury, e.g. at the hands of the police. Hence, the doctor enjoys a 

unique privilege, but also exercises enormous power, when he issues 

a medical certificate. Given this privilege and power, it is absolutely 

essential that the doctor acts with scrupulous truthfulness and 

responsibility. 

(vi) On 10 September, in spite of the slurred speech, a left sided 

positive plantar reflex (Babinski sign), left sided weakness, 

and the presence of blood in the CSF (each of which is a 

sign of brain damage), Dr Lang could write in the patient's 

notes: `No change in condition. Have informed him [Biko] 

that Hersch and myself find no pathology, that lumbar 

puncture was normal and, as a result, I was returning him to 

the police cells.' Maintaining a full and accurate record of the 

patient's condition, including its progress and physical signs and 

symptoms and investigations and treatment, is a fundamental 

requirement for proper continuing medical care. The doctor bears a 

duty of honesty to the patient. In a way that is properly balanced by 

his duty of care for the patient, he must keep the patient truthfully 

informed about his medical condition and treatment. 

(vii) Having sent Biko to the police cells, contrary to the specialist's 

instruction, Dr Lang gave no directive concerning the 



need for careful observation. One of the most important 

requirements in the care of a patient with a suspected head injury 

is the regular and frequent ± perhaps half-hourly ± monitoring of 

pulse and respiratory rates and level of consciousness, assessed by 

appropriate clinical techniques. 

(viii) Drs Lang and Tucker failed to insist on proper hospitalisation 

or to keep the specialists (Drs Hersch and Keeley) 

informed about their patient's condition. The patient must be 

nursed in a properly equipped and suitably staffed facility where the 

required observations can be made and interpreted and adequate 

ongoing care provided. 

(ix) Dr Tucker acquiesced in the plan of the police to send Biko 

to a prison hospital in Pretoria (1200km away) and did 

nothing to ensure that the transport arrangements were 

adequate; he failed to insist that an ambulance be used or 

that there must be a medical attendant; and he failed to 

provide a medical report or a referral letter to accompany 

the patient. It is the doctor's professional judgement that must 

determine the nature of the patient's care, and the doctor must not 

allow any extraneous factor to interfere with that judgement. When 

a doctor transfers a patient to another doctor, it is essential that the 

second doctor be provided with a full record of the relevant medical 

facts. 

In general, the doctors' performance displayed a profound 

failure of care. Biko received from them virtually none of the 

treatment and general care that his condition required. 

I.3 Why did these wrongs occur? 

Why did Drs Lang and Tucker behave as they did? This is the 

next question that we put to our students. How could these 

doctors, trained in the best traditions of Western medicine, have 

acted in that way? 

Our students typically propose a number of different explanations. 

However, some of the explanations that naturally come to 

mind do not, in fact, fit all the facts of the case. We list below the 

standard suggestions, and our responses to them. As will be seen, 

the first three suggestions turn out, we believe, to be incorrect. 

(i) `The doctors were plainly incompetent.' 

The standard of the physical examination and the diagnostic 

skills exhibited by Drs Lang and Tucker have been 

considered by some medical colleagues to be deplorably low 

± poorer than that of a medical student who has not yet 



received any clinical training, was the opinion of one. 

However, the wider facts of the case show that we cannot 

attribute their shocking performance merely to incompetence. 

A very famous South African-born physician, Sir 

Raymond Hoffenberg, wrote: Ì do not know what motivated 

Lang or Tucker. I do not believe they were clinically 

incompetent or ignorant . . . they may have felt their jobs 

were in jeopardy . . . Where was their professional ± or 

personal ± conscience?' 2 Hoffenberg is making the point 

that the doctors' care was so generally callous, in so many 

different respects, that it cannot be attributed merely to 

incompetence. In the sequel to these events, the doctors 

clearly demonstrated that they understood the significance 

of the ataxia and the blood in the CSF, the Babinski sign, 

and so on, and that they understood what proper care of a 

brain-damaged patient would entail. 

(ii) `The law made them do it.' 

In trying to explain the deplorable care provided by the 

doctors, many students suppose that the law governing the 

medical care of prisoners and detainees was at fault. Now it 

is true that a good deal of apartheid law was bad law. But 

that is not the explanation in this case. For in fact the 

relevant law and the regulations governing the medical care 

of prisoners and detainees was clearly intended to ensure 

care of proper quality. (District surgeons are general 

practitioners employed by the Department of Health. 

Among other responsibilities, they were required to provide 

medical care to prisoners under regulation 6 of the prison 

regulations promulgated in 1965 under Prisons Act 8 of 

1959.) The law was in effect requiring these doctors to 

provide fully competent and committed medical care to 

Steve Biko, and to any other prisoner or detainee. 

(iii) `They were intimidated by the security forces.' 

Many students imagine that the doctors were intimidated, 

perhaps even coerced, by the security police, and so had no 

real freedom to provide better care. But none of this is 

borne out by the evidence of the case. Although, as we shall 

see, the doctors adopted a subservient attitude to the 

security police when advising on the care and management 

of their patient, they were under no clear intimidatory 

pressure. Indeed, the evidence that later emerged showed 

2 R. Hoffenberg. Doctors and society ± the Biko Lecture. South African 

Medical Journal 1994; 84: 245±249 (248). 



that the security police were anxious that Biko should not be 

allowed to die while in their charge. It may have been that 

more subtle pressures were operating in the doctors' minds: 

perhaps they feared the loss of their jobs (and pension 

benefits) or ostracism by colleagues and members of their 

section of society. But even if this was the case, it was not the 

case that the doctors' freedom to provide proper care had 

been removed by the security police. 

(iv) A wrong set of attitudes, and an absence of professional commitment. 

Given that the doctors' failures were not due to mere incompetence 

or external restraint, they need to be explained in 

terms of a set of attitudes. Clearly, the doctors did not 

conduct themselves towards Biko in the way that any ordinary 

doctor would professionally conduct himself towards any 

ordinary patient: they did not take his symptoms seriously, 

and they displayed an appalling indifference to his wellbeing. 

Why did they not regard him in the way that any 

doctor should regard any patient? And why did they allow his 

treatment to be governed, not by medical considerations, but 

by the interests of the security police? 

Derrick Silove, a South African-trained psychiatrist who 

practises in Australia, has provided a helpful analysis of the 

factors that shape the kinds of attitudes displayed by Drs 

Tucker and Lang. Writing in 1990, Silove pointed out that à 

number of powerful social and psychological influences 

undoubtedly contributed to the Biko doctors' gross lapses 

in judgment . . . the most general influence which affects all 

members of South African society is the all-pervasive ethos 

which portrays the black person as an ùntermensch', an 

inferior being, to whom one simply does not accord the same 

respect as one does to a white person.' 3 Medicine had 

become as tainted by apartheid as had any other sphere of 

interaction between people in South Africa. Furthermore, 

because Drs Lang and Tucker had for decades been working 

alongside the police, in institutions governed by the attitudes 

of the police, they could, very naturally, have assumed those 

attitudes as their own, and have become accustomed to the 

conduct within those institutions. We can readily imagine 

that they had found themselves on a `slippery slope' of 

declining standards leading to a condition of ùnethical 

compliance with acts of brutality.' They had become 

3 D. Silove. Doctors and the State: Lessons from the Biko Case. Social Science 

and Medicine 1990; 30: 417±429 (422). 



`habituated' to the methods used by the security police when 

they dealt with black people; they had ceased to see prisoners 

and detainees, particularly when they were black, as their 

patients. 4 

Confronted by a patient who was portrayed by his captors as 

a `dangerous terrorist' who, because he had been a medical 

student, would know how to feign symptoms, the doctors' 

assessment of their patient was distorted to such an extent that 

the obvious signs and symptoms of brain pathology were not 

taken seriously. Because they approached Biko with 

insufficient regard, they were not motivated by the concern 

that would have led to a proper investigation of his condition, 

and to his proper care. Because they had allied themselves 

with the security police, they allowed his treatment to be 

dictated by what the security police wanted, and not by what 

the relevant medical considerations required. 

In seeking to understand this appallingly bad care, we are 

greatly assisted by the `confession' made by Dr. Tucker himself 

in 1991, in his (successful) application to the South African 

Medical and Dental Council for reinstatement on the medical 

register. (We quote a small part of it here.): 

For a long time following the events of September 1977 . . . 

I had attempted to deny to myself the truth of my role in 

what has become known as the `Biko affair' . . . I found it 

difficult to admit to myself that my conduct with regard to 

my attendance to the late Mr Biko, and also my conduct 

subsequent to his death, fell far short of the standards 

required of a medical practitioner . . . I came to realise that 

over the period of the 30 years I had at that time been 

employed by the State as a district surgeon, I had gradually 

lost the fearless independence that is required of a 

medical practitioner when the interests of his patient are 

threatened. I had become too closely identified with the 

interest of the organs of the State, especially the police 

force, with which I dealt practically on a daily basis . . . I 

have come to realise that a medical practitioner's primary 

consideration is the well-being of his patient, and that a 

medical practitioner cannot subordinate his patient's 

interest to extraneous considerations. 5 

4 Ibid. p. 422 ff. 

5 B. Tucker. Years of sorrow, despair. The Sunday Star. Johannesburg. October 

20, 1991. 



I.4 What morals emerge? 

The case of the Biko doctors is not merely of historical interest. 

And it is neither a unique nor a particularly unusual case. It is 

one of many similar cases that have occurred in South Africa and 

in other parts of the world. The morals that emerge from the case 

are relevant for all healthcare professionals wherever they may be 

practising; and this is the most important part of our discussion 

with students. What are these morals? 

The doctors' relationship to Biko should have been primarily the 

relationship between a doctor and his patient; their commitment of 

care to Biko should have been the same commitment as is proper 

in the treatment of any patient. But as we have seen, other 

considerations ± considerations that are strictly irrelevant to the 

concern of a doctor for his patient ± were allowed to intervene. We 

have already heard Dr. Tucker stressing this fact: `. . . a medical 

practitioner's primary consideration is the well-being of his 

patient', and he `cannot subordinate his patient's interest to 

extraneous considerations.' Dr. Tucker went on to add: Ìn his 

examination, diagnosis and treatment of a patient, a medical 

practitioner should fearlessly take those steps which are required 

for the well-being of the patient.' 6 

Nor is this merely one man's understanding of the 

professional role. The world-wide medical profession, through 

its instrument, the World Medical Association, has professed the 

same understanding of professional responsibility and its 

implications. In the preamble to its Declaration of Tokyo, 7 the 

WMA affirmed that: 

. . . it is the privilege of the medical doctor to practise medicine 

in the service of humanity, to preserve and restore bodily and 

mental health without distinction as to persons, to comfort 

and to ease the suffering of his or her patients. The utmost 

respect for human life is to be maintained even under threat, 

and no use made of any medical knowledge contrary to the 

laws of humanity. 

And one of the implications it draws from this understanding of 

its medical role is stated in Paragraph 4 of the Declaration: 

A doctor must have complete clinical independence in 

deciding upon the care of a person for whom he or she is 

6 Ibid. 

7 Included as an Appendix in Rayner, op. cit. note 1. 



medically responsible. The doctor's fundamental role is to 

alleviate the distress of his or her fellow men, and no motive 

whether personal, collective or political shall prevail against 

this higher purpose. 

Clearly, this entails that the fact that a patient belongs to a 

particular racial or ethnic group, the fact that the patient is a 

prisoner or a detainee, the fact that the patient may pose some 

threat to the state, etc, are all facts which are irrelevant to the 

doctor's commitment to the patient as patient. The fact that other 

parties may have interests that conflict with the medical interest 

of the patient is also irrelevant to the doctor's concern for the 

patient as patient. 

But there is also a second moral. Observing and maintaining 

this unqualified commitment to the medical care of the patient 

may, in certain circumstances, be difficult. Many of the cases that 

are studied in medical ethics are hard cases, insofar as it is 

difficult to ascertain what one ought to do: the situations 

described may pose a genuine ethical dilemma or at least 

represent some tension between different, countervailing 

considerations, and it may be difficult to find the right balance 

between these considerations, the right resolution of the tension. 

However, there are other kinds of hard cases that are not hard 

because it is difficult to ascertain what one ought to do. Rather, 

they are hard because it is hard to do what one ought to do. The 

Biko case falls into this latter category. It is not a case in which we 

are presented with great theoretical difficulty in ascertaining the 

doctors' professional duty. Their duty was clear; doing it was 

difficult. A clear-sighted performance of their professional duty 

required them to withstand the social, psychological and 

institutional pressures to which they had been subject for many 

years. This fact forcefully raises the question: how is one to 

ensure that when one finds oneself confronted by a hard case of 

this kind, one will do the right thing? 

The answer to this question is that one needs to have been 

personally prepared in such a way that one can be relied upon to act 

rightly when the hard case crops up, or when one finds oneself 

continually subject to more or less subtle pressures of the wrong 

kind. The Biko doctors had become habituated in wrong attitudes 

and practices. We need to develop habits of a different sort. 

Healthcare professionals need to possess a clear-sighted understanding 

of the duties of the care-giver, and they need to commit 

themselves, and repeatedly to re-commit themselves, to 

maintaining this vision throughout a lifetime of practice. Each 



individual healthcare professional needs to make this vision and 

commitment his or her own. Moreover, conduct that remains 

consistent with this vision will depend upon the healthcare 

professional's possession of a variety of personal qualities, themselves 

dependent upon habit-forming practice. These required 

character traits, or virtues, surely include the following: fidelity to 

the carer-patient relationship; benevolence, the commitment to the 

good of the patient; compassion, including sympathy and empathy; 

discernment, which enables one to identify forces at work and to 

distinguish what is relevant from what is irrelevant; truthfulness and 

trustworthiness; and, as Dr Tucker himself stressed, courage. 

We may be tempted to think that a rich list of the virtues 

displays a character of an extraordinary kind, and that because 

these are qualities required by heroes, we ordinary mortals can 

content ourselves with a lower standard. But in fact, unless these 

character traits are very firmly in place, the ordinary healthcare 

professional is very likely to fail, and to fail very badly indeed, in 

the kind of situation in which the Biko doctors found themselves. 

In other words, the virtues are what every ordinary person needs 

if he is to manage to do the right thing in each kind of case with 

which he may be confronted. 

So we need to be committed, in advance, to preparing ourselves 

for the hard cases by preparing our characters ± by training in the 

virtues. And the need for this personal preparation has wide 

implications for medical education. How can the student be 

nurtured in these commitments and habits? There is a need for 

mentoring; and the place of role models in this task is clear. 

PHASE II: THE COLLECTIVE PROFESSIONAL LEVEL 

II.1 History of Phase II 

In considering the second phase of the Biko affair, the sequel to 

his death, our concern is with the response by the medical 

profession as a whole to the performance of the Biko doctors. As 

we review the events in this phase, our focus is upon two players 

in the drama: first, and most importantly, the South African 

Medical and Dental Council; secondly, the Medical Association of 

South Africa. 

The South African Medical and Dental Council (SAMDC) was 

South Africa's principal regulatory body controlling the medical 

and dental professions during the period in which Biko died, and 

in fact until a few years ago, when it was replaced by the Health 

Professions Council of South Africa. It was a 34 member statutory 



body entrusted with the duty, under an Act of Parliament, to 

license and control the training of members of the medical and 

dental professions, and to uphold ethical and medical standards. 

The Council was vested with quasi-judicial powers to regulate the 

conduct of these professions, including the power to inquire into 

the conduct of individual professionals, and to discipline any who 

may be judged to have behaved unprofessionally or disgracefully; 

such discipline may extend to striking a person off the register of 

licensed practitioners. In other words, the SAMDC was required 

by law to act as the official watchdog of the medical profession. 

The Medical Association of South Africa, or MASA, (now 

known as SAMA or the South African Medical Association) is a 

voluntary body of doctors to which 70 to 80% of the nation's 

doctors belong. It represents the interests of medical practitioners 

by conducting negotiations with government and health 

care insurance (medical aid) schemes on their behalf. Although 

it does not have the legal backing of the SAMDC to discipline 

members of the Association, it is able to investigate the alleged 

unethical conduct of members and, if it finds them guilty, it has 

the power to suspend their membership of the Association. 

After Biko's death, an official autopsy was performed. Then, in 

November 1977, as the law required, an inquest was held in order 

to establish the cause of death. In spite of what to many observers 

was compelling evidence that Biko's death was caused by head 

injuries inflicted by his interrogators, the magistrate who presided 

over the inquest concluded that the likely cause of death was: 

Head injury with associated extensive brain injury, followed by 

contusion of the blood circulation, disseminated intravascular 

coagulation as well as renal failure with uraemia. The head 

injury was probably sustained during the morning of 

Wednesday, 7 September, 1977, when the deceased was 

involved in a scuffle with members of the Security Branch . . . 

The available evidence does not prove that the death was 

brought about by any act or omission involving or amounting 

to an offence on the part of any person. 

Thus, no blame was laid at the door of the security police. 

However, the magistrate did send relevant portions of the record 

of the inquest to the SAMDC ± as he was required by law to do if he 

felt that there was prima facie evidence of improper or disgraceful 

conduct on the part of the doctors. In effect, then, he was laying a 

complaint against the Biko doctors before the SAMDC. 

A month later, another complaint was independently laid by 

the ombudsman of the South African Council of Churches. 



The SAMDC eventually held a Preliminary Inquiry to 

investigate these complaints. (For technical reasons, this inquiry 

had been delayed until April 1980.) After examining the evidence, 

the inquiry ruled that there was `no prima facie evidence' 

of misconduct by the Biko doctors. 

Many doctors were shocked by this ruling. In June 1980 some 

members of the MASA, of which Dr Tucker (but not Dr Lang) 

was also a member, called on the MASA to hold an inquiry to 

determine whether Dr Tucker `. . . is a fit and proper person to 

continue to be a member of this Association.' Two weeks later the 

MASA announced that a charge of unethical conduct against Dr 

Tucker could not be supported and that `the case is now closed.' 

The MASA also passed resolutions defending the ìntegrity and 

bona fides' of the members of the SAMDC and its committee of 

inquiry. They rejected any suggestion that there had been any 

attempt at a `cover-up' by the Council. Several of the leaders of 

the MASA were also members of the SAMDC, and, in their 

capacity as MASA members, began to attack those doctors who 

were critical of their actions. The official journal of the MASA, 

The South African Medical Journal, declined to publish letters of 

protest from leading academic doctors. A number of doctors 

resigned their membership of MASA in protest. 

A few South African doctors did pursue the issue further. First 

they laid their own complaint against the Biko doctors before the 

SAMDC. In March 1983 the SAMDC rejected this complaint, as it 

had the previous ones. This small group of doctors then took the 

matter to the Supreme Court. 8 They petitioned the Court to set 

aside the resolutions of the SAMDC and its inquiry committee, 

and to direct the Council to hold a new inquiry into the 

allegations of improper or disgraceful conduct on the part of Drs 

Lang and Tucker. 

In January 1985 the Court ruled in favour of the petitioning 

doctors. It held that there was prima facie evidence of improper or 

disgraceful conduct on the part of Drs Lang and Tucker. The 

Court repudiated the resolutions adopted by the SAMDC and 

directed the Council to set up a disciplinary committee to 

investigate the conduct of the two doctors. 

So in July 1985, nearly eight years after Biko's death, the 

SAMDC held a hearing that lasted for four days. The disciplinary 

committee found Dr Lang guilty of improper conduct on five 

8 The members of this group, who pursued the case at the risk of great cost 

to themselves, were Yosuf Veriava, Tim Wilson, Mumisame Mzamane, Frances 

Ames, Trefor Jenkins and Phillip Tobias. 



counts, in that he (1) had issued an incorrect medical certificate 

and a misleading bed letter (record of findings and care); (2) 

had failed to examine the patient properly; (3) had failed to 

inquire into and ascertain the possibilities of a head injury; (4) 

had failed to obtain a proper medical history of the patient; and 

(5) had failed to observe him and keep proper notes. Dr Lang 

was given a caution and a reprimand. Dr Tucker was found guilty 

of improper and disgraceful conduct on three counts: (1) he had 

failed to object to the patient's transport by Land Rover to 

Pretoria; (2) he should have insisted upon transportation by 

ambulance with proper medical attendants and the patient's 

medical records; and (3) he failed to make a proper medical 

check before stating that the patient's central nervous system had 

shown no changes between the examinations. The committee 

suspended Dr Tucker for three months from the medical roll, 

but recommended that this be suspended for two years, 

conditional on his not being found guilty by the SAMDC of any 

other contravention during this period. There was criticism by 

many doctors of the leniency of the sentences and a few months 

later the SAMDC decided that Dr Tucker's name should be 

immediately removed from the roll. 

II.2 What wrongs occurred? 

In discussing the second phase of the Biko affair, we invite the 

students to analyse the case by asking the same questions as were 

applied in analysis of the first phase. The students' task is to 

identify and explain the wrongs that occurred, and to consider 

what morals emerge. 

Our analysis of the first phase clearly showed that the Biko 

doctors' performance invited such descriptions as ìmproper' 

and `disgraceful.' Hence one would have had a right to expect 

that the body charged with the responsibility for maintaining the 

standards of the profession would have investigated the conduct 

of the doctors and disciplined them. However, over a period of 

nearly eight years the SAMDC steadfastly refused to accept that 

there was even prima facie evidence of misconduct on the part of 

Drs Lang and Tucker. This was surely a very grave wrong. The 

SAMDC signally failed to perform the role required of it both by 

the law and by its office as the principal council of the profession. 

The MASA also failed in its office as a representative of the 

profession. It refused to speak out against either the misconduct 

of the Biko doctors or the subsequent misconduct of the SAMDC. 

Instead, it sought to silence or to attack those of its members who 



called upon it to make the correct stand. (It might be pointed out 

that the MASA also failed to speak out against many other 

instances of human rights abuses in the delivery of health care to 

members of the disadvantaged South African communities.) 

II.3 Why did these wrongs occur? 

Why did the SAMDC and the MASA behave so badly? In 

considering this question, students may offer suggestions that are 

similar to those which are typically offered in explanation of the 

misconduct of the Biko doctors; and some of these are similarly 

incorrect. We can hardly suppose that the members of the 

SAMDC and of the MASA were so incompetent that they were 

unable to discern medical misconduct. Nor can we suppose that 

they were restrained by bad law. On the contrary, the MASA was 

subject to no legal restraint. And the SAMDC was positively 

required by the law to act in the way they refused to do. They did 

so act only when they were forced to do so by the Supreme Court. 

Nor is there any evidence that members of the SAMDC or of the 

MASA were under real intimidatory pressure. 

Rather, the correct explanation surely parallels the explanation 

of the individual doctors' misconduct in their care for Biko. 

The SAMDC and the MASA were failing to concentrate upon the 

only question that mattered: did Biko receive the kind of medical 

care that any patient ought to receive as a patient? The members 

of these professional bodies belonged to the same society as the 

Biko doctors themselves; they were subject to similar social and 

psychological pressures, and they could easily have adopted 

similar attitudes towards blacks and detainees. In remarks to 

South Africa's Truth and Reconciliation Commission in June 

1997, Dr Hendrik Hanekom, former Secretary General of the 

MASA, expressed the following opinion: 

MASA was so wrapped up in its white, male, eÂlitist, educated, 

professional world as individuals and as a collective 

organisation and as part of a broader society from which 

doctors were drawn, that it failed to see the need to treat all 

people as equal human beings . . . MASA allowed black and 

white people to be treated differently, and this is the form of 

human rights violations for which it stands disgraced. 9 

9 Quoted in: L. Baldwin-Ragaven, J. de Gruchy and L. London. 1999. An 

Ambulance of the Wrong Colour: Health professionals, human rights and ethics in South 

Africa. Cape Town. University of Cape Town Press: 143. 



Furthermore, many of the members of the SAMDC and of the 

MASA had formed allegiances similar to those formed by Drs 

Tucker and Lang. Indeed, a number of members of the SAMDC 

were appointed by the government; and, as we have seen, there 

was overlap between the membership of the SAMDC and the 

leadership of the MASA. And just as Dr. Tucker had allowed 

extraneous ± indeed, irrelevant ± considerations to intrude upon 

his care of Biko, so, apparently, did the professional bodies 

distract themselves from the question they had a duty to ask. 

After the June 1980 meeting of the SAMDC, which confirmed the 

rejection of the complaints against the Biko doctors, one of us 

(Trefor Jenkins) was told by a member of the Council that much 

of the discussion at this meeting had been concerned with the 

communist threat facing the country and the `total onslaught' 

which was being waged against it. The discussion, in fact, had 

little to do with the Biko doctors' performance. The question 

before the Council was a straightforward and relatively simple 

question of medical ethics; the Council had allowed irrelevant 

political and state security considerations to cloud the issue. 10 

II.4 What morals emerge? 

As it was for the first phase of the Biko affair, this section of the 

analysis is the most important part of the discussion with students. 

For, we believe, the morals that emerge from the second 

phase are also relevant for healthcare professionals everywhere. 

The failure of the representative professional bodies in the 

Biko case illustrates how important it is that watchdogs of the 

profession perform their duties faithfully. The profession as a 

whole bears the responsibility for maintaining its standards; and 

in the exercise of this responsibility, councils such as the SAMDC 

play a vital role. Such councils exist in the UK and in many other 

Commonwealth countries, as well as in South Africa. The judge 

of the Supreme Court described the SAMDC in words that surely 

apply to all such councils: 

They are the custodians of the honour and rectitude of the 

profession, it is left to them to say to what standard of honour 

the members of the profession should conform . . . [The 

SAMDC] is the body, par excellence, to set that standard of 

10 T. Jenkins. The MASA Letter: A Rejoinder: The Organized Medical 

Profession on Trial. South African Journal on Human Rights 1986; 2 Part 2: 236± 

241. 



honour . . . [and Council] is thus truly a statutory custos morum 

of the medical profession, the guardian of the prestige, status 

and dignity of the profession and the public interest insofar as 

the members of the public are affected by the conduct of 

members of the profession. 11 

The profession itself, through its professional bodies, should by 

its own voice emphasise this responsibility. It is sadly ironic that 

the SAMDC needed to be told its duty by a court of law. 

Moreover, the profession, in its councils, needs to recognise 

that under certain circumstances it may be hard to focus upon 

the essential ethical considerations in issues that arise. The 

profession needs to be committed, in advance, to maintaining a 

scrupulous attention to the relevant ethical questions, despite 

distractions and pressures. 

But this responsibility to uphold professional standards is not a 

responsibility borne solely by the official councils. The SAMDC 

eventually did its duty in the Biko affair only because a few 

individual doctors were brave enough to call it to account. In the 

case before the Supreme Court, the SAMDC argued that these 

doctors did not have the legal standing to challenge the SAMDC 

in court because they had no personal interest in the Biko 

matter. But the Court rejected this argument. The judge held 

that individual members of the medical profession `have a real 

and direct interest in the prestige, status and dignity of their 

profession', and so they have a right to expect of the Council that 

it should exercise its powers to protect this interest. 12 And this 

judgement surely embraces a general principle of professional 

ethics. The profession as a whole bears the responsibility to 

uphold professional standards; each individual member of the 

profession is a part of that whole; the standards actually set by the 

profession reflect upon each individual member; hence each 

individual member possesses both the right and the responsibility 

to ensure that the profession sets correct standards. 

The responsibility to uphold standards is not merely the 

responsibility to discipline wayward members of the profession; it 

is also the responsibility to support and encourage those 

members who may be under some pressure to relax standards. 

The world-wide medical profession has recognised the need to 

stand alongside doctors who are faced with situations not unlike 

11 Quoted in Baldwin-Ragaven et al, op. cit. note 9, p. 145. 

12 L. Baxter. Doctors on trial: Steve Biko, Medical Ethics, and the Courts. 

South African Journal on Human Rights. 1985; I: 137±151 (144). 


that faced by the Biko doctors. Paragraph 6 of the Declaration of 

Tokyo states: 

The World Medical Association will support, and should 

encourage the international community, the national medical 

associations and fellow doctors, to support the doctor and his 

or her family in the face of threats or reprisals resulting from a 

refusal to condone the use of torture or other forms of cruel, 

inhuman or degrading treatment. 

In all this, what is at stake is the nature and the spirit of the true 

doctor-patient relationship. This relationship depends upon 

which commitment to provide uncompromised medical care 

that stands at the heart of the profession of medicine. The 

medical ethos is the product of a particular history and tradition. 

It is a splendid thing. But it is also a fragile thing: it could easily 

be lost, and its place taken by a much less noble and much more 

self-serving set of attitudes. The profession as a whole, and each 

individual member of it, bears the responsibility to ensure that 

this ethos is preserved. 13 

G.R. McLean 

University of the Witwatersrand 

Department of Philosophy 

PO Wits 2050 

South Africa 

mcleang@social.wits.ac.za 

Trefor Jenkins 

University of the Witwatersrand 

Faculty of Health Sciences 

7 York Rd 

Parktown 2193 

Johannesburg 

South Africa 

treforj@mail.saimr.wits.ac.za 


13 For further reading, we refer the reader to the references cited in 

footnotes, and to the following: A.R. Chapman & L.S. Rubenstein, eds. 1998. 

The Legacy of Apartheid: Human Rights and Health. American Association for the 

Advancement of Science and Physicians for Human Rights; British Medical 

Association. 1992. Medicine Betrayed: The Participation of Doctors in Human Rights 

Abuses. Zed Books in association with the British Medical Association; S.A. 

Strauss. Ethics and the Law in South Africa. South African Journal of Continuing 

Medical Education 1987; 5: 21±26.

THE STEVE BIKO AFFAIR: A CASE STUDY IN MEDICAL ETHICS

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