Soobramoney v Minister of Health, KwaZulu-Natal

• Jurisdiction: South Africa
• Judge: Chaskalson P, Langa DP, Ackermann J, Didcott J, Goldstone J, Kriegler J, Madala J, Mokgoro J, O'Regan J, Sachs J
• Judgment Date: 27 November 1997
• Hearing Date: 11 November 1997
• Docket Number: CCT 32/97 G
• Citation: 1998 (1) SA 765 (CC)
• Court: Constitutional Court
• Counsel: MA Jacobs for the appellant CJ Pammenter (with him JS Moodley) for the respondent

Chaskalson P:

[1] The appellant, a 41-year-old unemployed man, is a diabetic who suffers from ischaemic heart disease and cerebro-vascular disease which caused him to have a stroke during 1996. In 1996 his kidneys also failed. Sadly his condition is irreversible and he is now in the final stages of chronic renal failure. His life could be prolonged by means of regular renal dialysis. He has sought such treatment from the renal unit of the Addington State Hospital in Durban. The hospital can, however, only provide dialysis treatment to a limited number of patients. The E renal unit has 20 dialysis machines available to it, and some of these machines are in poor condition. Each treatment takes four hours and a further two hours have to be allowed for the cleaning of a machine, before it can be used again for other treatment. Because of the limited facilities that are available for kidney dialysis the hospital has been unable to provide the appellant with the treatment he has requested. F

[2] The reasons given by the hospital for this are set out in the respondent's answering affidavit deposed to by Doctor Saraladevi Naicker, a specialist physician and nephrologist in the field of renal medicine who has worked at Addington Hospital for 18 years and who is currently the G President of the South African Renal Society. In her affidavit Dr Naicker says that Addington Hospital does not have enough resources to provide dialysis treatment for all patients suffering from chronic renal failure. Additional dialysis machines and more trained nursing staff are required to enable it to do this, but the hospital budget does not make H provision for such expenditure. The hospital would like to have its budget increased but it has been told by the provincial health department that funds are not available for this purpose.

[3] Because of the shortage of resources the hospital follows a set policy in regard to the use of the dialysis resources. Only patients who suffer from acute renal failure, which can be I treated and remedied [1] by renal dialysis are given automatic access to renal dialysis at the hospital. Those patients who, like the appellant, suffer from chronic renal failure which is irreversible are not admitted automatically to the renal programme. A

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set of guidelines has been drawn up and adopted to determine which applicants who have A chronic renal failure will be given dialysis treatment. According to the guidelines the primary requirement for admission of such persons to the dialysis programme is that the patient must be eligible for a kidney transplant. A patient who is eligible for a transplant will be provided with B dialysis treatment until an organ donor is found and a kidney transplant has been completed.

[4] The guidelines provide that an applicant is not eligible for a transplant unless he or she is '(f)ree of significant vascular or cardiac disease'. The medical criteria set out in the guidelines also provide that an applicant must be: C

'Free of significant disease elsewhere, for example ischaemic heart disease, cerebro-vascular disease, peripheral vascular disease, chronic liver disease, chronic lung disease.'

The appellant suffers from ischaemic heart disease and cerebro-vascular disease and he is therefore not eligible for a kidney transplant. D

[5] The appellant has made arrangements to receive dialysis treatment from private hospitals and doctors, but his finances have been depleted and he avers that he is no longer able to afford such treatment. In July 1997 he made an urgent application to the Durban and Coast E Local Division of the High Court for an order directing the Addington Hospital to provide him with ongoing dialysis treatment and interdicting the respondent from refusing him admission to the renal unit of the hospital. The appellant claimed that in terms of the 1996 Constitution (the Constitution of the Republic of South Africa Act 108 of 1996) the Addington Hospital is F obliged to make dialysis treatment available to him. The respondent opposed the application. The matter came before Combrinck J who dismissed the application. [2]

[6] The appellant applied to the High Court for a certificate in terms of Rule 18(e) of the Constitutional Court Rules. The certificate was granted and he applied to this Court in terms of Rule 18 for leave to appeal against the judgment of the High Court. The application for leave G to appeal was set down for hearing as a matter of urgency. The respondent did not oppose the application and correctly acknowledged that the matter raised issues of importance on which a decision on the merits of the appeal should be given by this Court. The matter was dealt with on this basis, and counsel were required to deal only with the merits of the appeal, it H being accepted by the parties and this Court that the appeal should be heard and decided.

[7] The appellant based his claim on s 27(3) of the 1996 Constitution which provides:

'No one may be refused emergency medical treatment'

and s 11 which stipulates I

'Everyone has the right to life.'

[8] We live in a society in which there are great disparities in wealth.

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Millions of people are living in deplorable conditions and in great poverty. There is a high level A of unemployment, inadequate social security, and many do not have access to clean water or to adequate health services. These conditions already existed when the Constitution was adopted and a commitment to address them, and to transform our society into one in which B there will be human dignity, freedom and equality, lies at the heart of our new constitutional order. For as long as these conditions continue to exist that aspiration will have a hollow ring.

[9] The constitutional commitment to address these conditions is expressed in the preamble which, after giving recognition to the injustices of the past, states: C

'We therefore, through our freely elected representatives, adopt this Constitution as the supreme law of the Republic so as to -

Heal the divisions of the past and establish a society based on democratic values, social justice and fundamental human rights;

. . .

Improve the quality of life of all citizens and free the potential of each person.' D

This commitment is also reflected in various provisions of the bill of rights [3] and in particular in ss 26 and 27 which deal with housing, health care, food, water and social security.

[10] Sections 26 and 27 contain the following provisions: E

'26. Housing

(1) Everyone has the right to have access to adequate housing.

(2) The State must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of this right.

(3) . . .

27.

Health care, food, water and social security F

(1) Everyone has the right to have access to -

(a)

health care services, including reproductive health care;

(b)

sufficient food and water; and

(c)

social security, including, if they are unable to support themselves and their dependants, appropriate social assistance.

(2) The State must take reasonable legislative and other measures, within its available resources, to G achieve the progressive realisation of each of these rights.

(3) No one may be refused emergency medical treatment.'

[11] What is apparent from these provisions is that the obligations imposed on the State by ss 26 and 27 in regard to access to housing, health care, food, water and social security are dependent upon the resources available for such purposes, and that the corresponding rights H themselves are limited by reason of the lack of resources. Given this lack of resources and the significant demands on them that have already been referred to, an unqualified obligation to meet these needs would not presently be capable of being fulfilled. This is the context within which s 27(3) must be construed. I

[12] The appellant urges us to hold that patients who suffer from

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terminal illnesses and require treatment such as renal dialysis to prolong their lives are entitled A in terms of s 27(3) to be provided with such treatment by the State, and that the State is required to provide funding and resources necessary for the discharge of this obligation.

[13] The words 'emergency medical treatment' may possibly be open to a broad construction B which would include ongoing treatment of chronic illnesses for the purpose of prolonging life. But this is not their ordinary meaning, and if this had been the purpose which s 27(3) was intended to serve, one would have expected that to have been expressed in positive and specific terms.

[14] Counsel for the appellant argued that s 27(3) should be construed consistently with the C right to life entrenched in s 11 of the Constitution and that everyone requiring life-saving treatment who is unable to pay for such treatment herself or himself is entitled to have the treatment provided at a State hospital without charge.

[15] This Court has dealt with the right to life in the context of capital punishment but it has not D yet been called upon to decide upon the parameters of the right to life or its relevance to the positive obligations imposed on the State under various provisions of the bill of rights. In India the Supreme Court has developed a jurisprudence around the right to life so as to impose E positive obligations on the state in respect of the basic needs of its inhabitants. [4] Whilst the Indian jurisprudence on this subject contains valuable insights it is important to bear in mind that our Constitution is structured differently to the Indian Constitution. Unlike the Indian F Constitution ours deals specifically in the bill of rights with certain positive obligations imposed on the State and, where it does so, it is our duty to apply the...