The Steve Biko affair
Trefor Jenkins, G R McLean
Steve Biko, a leader of the Black Consciousness
movement in South Africa, died in 1977 while being
detained by security police. The inquest into his death
revealed gross inadequacies in the treatment he received
from the two doctors legally responsible for his medical
care.
These doctors, Ivor Lang and Benjamin Tucker, were
called in to examine Biko after he had sustained head
injuries during interrogation by the security police. Over
Department of Human Genetics,
the five days in which they attended Biko, Lang and
National Health Laboratory Tucker failed to take his condition seriously. The doctors
Service and University of the failed to examine Biko under proper conditions despite
Witwatersrand, PO Box 1038, clear signs of possible brain damage; they failed to take
Johannesburg, 2000,
South Africa
a history, they failed to do simple tests of Biko’s mental
(G R McLean, T Jenkins) state, and allowed the police to be present during their
Correspondence to: examination and to influence their diagnosis and
Prof Trefor Jenkins management. (The police had variously suggested that
trefor.jenkins@nhls.ac.za Biko had suffered a stroke or that he was shamming.)
Lang then wrote a false medical certificate in which he
claimed to have found no evidence of abnormality or
pathology. He failed to note the injuries to Biko’s face and
chest, his ataxic gait, and his slurred speech—all of which
had been evident from the beginning. With subsequent
deterioration in Biko’s condition, further examinations
(including those performed by an independent physician
in consultation with a neurosurgeon) revealed a left-sided
positive Babinski sign, left-sided weakness, urinary
incontinence, and blood in the cerebrospinal fluid, in
addition to the earlier signs of brain damage. Nevertheless
Lang then wrote in his patient’s notes:
“No change in condition. Have informed [Biko] that [the
specialist] and myself find no pathology, that lumbar
puncture was normal, and as a result, I was returning
him to the police cells.”
Thereafter Biko was not kept under close observation
(despite the instruction of the specialist); he was not
provided with adequate nursing care; and his
deteriorating condition was not reported to the
specialists. Finally, having been called again to
examine Biko and finding him collapsed, glassy-eyed,
hyperventilating, and frothing at the mouth, Tucker
conceded to the plan of the police to send Biko
under grossly unsuitable conditions to a prison
hospital 750 miles away. Tucker failed to insist that
an ambulance be used or that a medical attendant be
present and failed to provide a medical report or a
referral letter to accompany his patient. Biko died on the
Further reading following night, having received no effective medical
McLean GR, Jenkins T. care at his destination.
The Steve Biko affair:
a case study in medical ethics.
How could these doctors, trained in the best traditions
Developing World Bioeth of western medicine, have displayed such a profound
2003; 3: 77–95. failure of care? Were they simply incompetent? Were
36
they constrained by bad apartheid law? Were they
intimidated by the security forces? Not one of these
suggestions is supported by the facts that later emerged.
Both doctors clearly demonstrated that they understood
the signs of brain damage and the required management
of a brain-damaged patient. Bad apartheid law did not
account for their behaviour, as the law regulating their
offices in fact required them to provide fully competent
medical care to prisoners in their charge. And there is no
evidence to suggest that the doctors were under any clear
intimidatory pressure from the police.
However, the doctors did adopt a subservient attitude
to the security police. It is this fact along with their
related attitudes that helps explain why they did not take
Biko’s condition seriously and why they displayed such
an appalling indifference to his wellbeing. The doctors
were members of a society riddled by racist attitudes, and
they had spent many years working alongside men who
regarded people like Biko as dangerous terrorists. They
had no doubt become habituated to the brutal methods
employed within the security institutions where they
practised medicine. A doctor’s proper professional regard
for every patient could very easily be eroded under these
conditions (if indeed it had existed in the first place).
Because these doctors approached Biko with insufficient
respect, 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 apparently
attached an undue importance to the suggestion that
Biko was shamming, and they allowed his treatment to
be dictated by what the police wanted rather than by what
the relevant medical considerations required.
This interpretation of events is supported by Tucker’s
own confession some years later when he applied
(successfully) for reinstatement to the medical roll:
“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 . . . I have come to realise that a medical
practitioner’s primary consideration is the wellbeing of
his patient, and that a medical practitioner cannot
subordinate his patient’s interest to extraneous
considerations.”
Here Tucker is spelling out the moral that emerges for
all health-care professionals everywhere. That a patient
belongs to a particular racial or ethnic group, that the
patient is a prisoner, that the patient has been detained
as a security risk, are all facts that are irrelevant to a
doctor’s commitment to the patient as patient.
The lamentable features of the Biko affair were not
confined to the conduct of Dr Tucker and Dr Lang. In
www.thelancet.com Medicine, Crime, and Punishment Vol 364 December 2004
subsequent years both the South African Medical and
Dental Council and the Medical Association of South
Africa failed to respond as they ought to have done.
Calls for a proper disciplinary inquiry into the doctors’
conduct were rejected and protests by members of the
profession were suppressed. An adequate inquiry only
eventually occurred when a small group of doctors
applied to the Supreme Court to intervene. Lang was
found guilty of improper conduct and given a caution
and reprimand. Tucker was found guilty of improper
and disgraceful conduct and given a suspended
sentence although a full Council meeting later struck
him off the roll.
How was it that the custodians of the standards of the
profession could, for nearly 8 years, steadfastly refuse to
accept that there was even prima facie evidence of
misconduct on the part of the two doctors? The answer
is that, like Lang and Tucker themselves, these
professional bodies allowed irrelevant considerations—
race, politics, state security, and so on—to cloud the
issue. They failed to concentrate upon the only question
that mattered: did Biko receive the kind of medical care
that any patient was entitled to receive as a patient?
When, directed by the court, they finally asked this
question, the answer was simple and clear.
The Biko affair is not an isolated episode of simply
historical interest. There have been numerous other
deaths in detention in South Africa, and similar abuses
occur all too commonly elsewhere in the world. Doctors
are implicated in many of these cases. And much more
frequently they are implicated in other instances of
discriminatory behaviour towards their patients. There
is no reason to suppose that the Biko doctors or the
members of the professional bodies who turned a blind
eye to their misconduct were moral monsters. They were
ordinary people who had allowed their moral sense and
their medical professionalism to be undermined by
corrupting attitudes reinforced by custom and habit. The
profession of medicine is characterised by a very specific
relationship between doctor and patient—a relationship
founded upon the doctor’s commitment to provide
uncompromised medical care. The Biko affair stands as
a reminder to all individual doctors, and to the guardians
of their profession, of how vigilant they must be if this
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commitment is to be kept intact.

www.thelancet.com Medicine, Crime, and Punishment Vol 364 December 2004 37