Forty years ago, in the small Western Cape town of Ceres, began a tragic story of a good man who tried his best to help in a terrible situation, who received compassion from unexpected places but yet was eventually persecuted and damaged by those who should have been protective of all involved.
Act One. Ceres Hospital.
On September 11th 1974, 87 year-old Mr Glen Frederick Hartmann died in hospital and his son, Dr Alby Desmond Hartmann, was accused of murdering him.
The old man, who had retired from mining in 1947, had developed prostate cancer and had not responded well to available treatment with chemotherapy, hormones, and radiation therapy.
He developed many highly painful secondary tumours in his bones, rendering him immobile and in severe pain. Everyone who knew him recognized that he was terminally ill. A pathological fracture of his leg, due to a tumour, simply would not heal.
He was admitted to Ceres Hospital, and placed under the care of his son, Alby, an assistant District Surgeon. After ten days, his son was urgently called to the hospital one night to find his dad unconscious and receiving oxygen. He diagnosed a pulmonary embolus and energetically treated him for that dangerous condition.
Everyone expected him to die soon, but instead he improved before beginning to deteriorate again. He had serious bed-sores and extensive tumours within his chest. He was placed on an IV drip, as he choked whenever he tried to drink, and was given increasingly large doses of painkillers.
In response to the pain relief, he improved to the point of trying to make little jokes, but his condition declined and the pain grew worse.
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Dr Hartman later told the police that he loved his father dearly and was concerned that his father kept asking for more analgesics. He wanted to keep his father alive as long as possible but, on the night of September 11th, he believed that the end had come. He felt a terrible pity for his father, and asked him if he wanted to go to sleep. The old man nodded, but could no longer speak. He felt that his father’s spirit had already left his body and so he injected the sedative/anaesthetic Sodium Pentothal into the drip.
The next day a nurse complained to the police, insisting that the death was due to a drug overdose, and a post mortem was ordered. Detectives from the Murder & Robbery Squad spent four hours taking a statement from the doctor, as he so often stopped speaking and wept. The Attorney-General decided to prosecute for murder.
So Dr. Hartmann, 51, stood trial. Under the law of that time he potentially faced the death penalty. The State Pathologist testified that the Pentothal played a part in stopping the breathing of the old man. A specialist anaesthetist told the court that the man was moribund and so very close to death that the drug could not have shortened his life by more than a few hours.
The nurse on duty that night, Sister Patricia Machill, said Dr Hartmann had phoned her and asked her to give his father some morphine but that she refused, insisting on written instructions.
He later wrote an order for a smaller dose and she administered that. Hartmann said he’d given doses of Pethidine IV, but his father still complained of severe pain. The doctor believed his father had become resistant to morphine as two earlier large doses had not given relief.
He asked the nurse to put up an IV drip bottle with Pethidine, but she refused “because I thought Pethidine on top of the Morphine was too much”, but did not explain this to the doctor. Instead, she did not add Pethidine to the drip, and slowed it down the release of the Morphine.
Later, as severe pain continued, Hartmann asked her to administer a further injection of Morphine, but she was reluctant. He asked her “If your father was screaming in agony, would you not help him?”
He said his conscience was clear and he had said goodbye to his father. She said she felt shocked and her hands were trembling as she gave the prescribed morphine.
Still later Hartmann returned, and finding the pain still unrelieved, asked her to give 100mg Pentothal. He said it was all he could think of, to perhaps induce coma so his father could sleep and be free from pain.
She was again “shocked”. She gave him the drug, and he filled the syringe. Minutes later, he came to her office weeping and said his father was dead. The next morning she reported this to the police.
The doctor confirmed this story, admitting he did not expect his father to come out of the coma induced by the drug, and made the decision knowing the consequences. He had asked his father if he was still in pain, and the man nodded. He said candidly that he was not sure if his question had been understood, or whether his father knew the further injection would cause death.
Asked “And if he had not acknowledged? If he had shaken his head? Would you have gone ahead?” he replied “If he had shaken his head I probably would not have carried on.” He said “I injected it slowly into the drip tube and saw my father sinking peacefully into sleep… My father was dead within seconds.”
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He wrote a death certificate that didn’t mention Pentothal. The pathologist said he found the cause of death to be the spread of cancer complicated by general debility and pneumonia, but the Pentothal would have played a part.
The Prosecutor insisted that even if a profoundly ill man wanted to die, anyone who ended his life would still be a murderer. He added: “Death is the best painkiller, My Lord, and Dr Hartmann intended his father’s death as a painkiller”. He accepted that the motives had been highly honourable, but that doctors were often tempted and shouldn’t be encouraged to give way to that.
His Defence advocate said any sentence would have no function. Retribution wasn’t appropriate, and deterrence insignificant.
The judge, Justice van Winsen, convicted Hartman of murder saying he had no power to sanction euthanasia, which was the task of lawmakers. He found extenuating circumstances; the treatment he had given his father had been “close, correct and compassionate.“
He sentenced Hartmann to one year’s imprisonment, but suspended the whole sentence, except for the time until the Court adjourned, for three years. He said “This is a case which calls for a total suspension of the sentence” but explained the law didn’t allow him to order this, hence his decision. He then adjourned the Court, so Dr Hartmann was technically in custody for less than a minute, the shortest detention any convicted murderer has ever served.
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Act Two: The Public, and the Medical Council
Hartmann said “When I did what I did, I thought that everyone would accept it as an act of love, a relief from… suffering. I thought it would be understood.”
Well-wishers from all over South Africa reacted with understanding and approval, including the nurses at the hospital. Flowers, prayers and good wishes flooded to the Hartmann home. Patients flocked to make him their doctor and the practice almost doubled in size. But, wanting a fresh start, he closed that practice, and started anew in Montagu.
All convictions were automatically reported to the South African Medical and Dental Council. It took them nearly a year to decide to call a meeting of the Disciplinary Committee to consider this case. On March 3, 1976, Dr Hartmann appeared before the committee which met, as usual, in private.
The decision announced that he had been found “guilty of disgraceful conduct”, probably unavoidable in view of the facts admitted and the conviction. But this official body too, chose to be compassionate. It sentenced him to be barred from practice for a year and suspended that sentence for a year.
However, the Council leadership was not satisfied. This Council had effectively ignored the blatantly unethical nature of Apartheid medicine, found nothing at all wrong with discrimination in hospitals, clinics or private practices with separate and unequal facilities and services.
Even when grossly improper conduct of doctors was reported to it, ranging from severe alcoholism with patients falling over empty bottles to doctors condoning torture and even complaints of what may have amounted to murder, it resolutely ignored all such complaints.
If it had simply followed universal laws of medical ethics and declared discriminatory medical practice unprofessional it could at a stroke have forced radical revision of healthcare as it was provided throughout the country. It carefully and proudly chose not to do so.
But in this case the Council, under its President, Prof. H. A. Snyman, most peculiarly called a meeting of the entire Council to reconsider the Disciplinary Committee decision. After a long and secret meeting, Snyman announced that it was overthrowing the Committee’s decision and imposing a more severe penalty.
Despite a wide range of options it chose the harshest penalty it had the power to impose. Hartmann was struck off the medical register absolutely and indefinitely.
Technically, he had a right to apply every six months to be restored to the Register but it was clear this would not succeed, and indeed his first attempts at appeal were stonily refused. The Council refused to explain its decisions.
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There was a flood of petitions calling for clemency and compassion, which were treated with no respect whatsoever. The town of Montagu, where he was working, pleaded for him to be allowed to return to work. At this time of high apartheid there were petitions from white and non-white patients within the town.
The Coloured Management Committee and the Mayor of Montagu pleaded for him to be allowed to return. Petitions from groups of doctors and students from all over the country were also ignored. A survey found over 70 % of doctors thought the decision unfair.
His first application for restoration to the register lead to another four hours debate by the Council, but was thrown out. He had to give up his new practice and became penniless. There were petitions from more than 15 organisations; some pointing out that Montagu now had 15000 patients and only one doctor.
By October 1976, again rejected by the Medical Council, Hartman started in the only job he could find. Ironically, it was selling life insurance.
A little later I was in South Africa on a lecture tour, and was principle speaker at the first African conference on death and dying at Wits. One session focussed mainly on euthanasia. Other speakers included Marius Barnard (Chris Barnard’s brother and fellow transplant surgeon) and the icy Prof. Snyman from the Council.
The first question was why, when the Supreme Court and Disciplinary Committee had shown grace and compassion, the Medical Council had been so harsh? There was thunderous applause from a packed audience of health professionals.
Snyman rose, claiming pained surprise that the question could be asked. “Why”, he protested, “I almost feel as if I and the Council are being asked to defend ourselves!” “And so you should!“ cried Barnard and myself, to further fierce applause.
Snyman didn’t recognise any of us had a right to question his decisions, and uttered only a few empty platitudes describing their rightness. He sat down amid deafening silence.
As we were leaving the venue later, his cool thawed and he was very angry indeed. He muttered as he stalked off into the night: What were the young coming to if they could question the wisdom of such decisions?
If we ever form a South African medical roll of honour, I know it must contain the name of Dr. Alby Hartmann, and that it must not contain the name of Professor H.W. Snyman.
I have been unable to discover what eventually happened to Dr Hartmann, and would be grateful if any reader who knows more of his story can mail firstname.lastname@example.org
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Professor MA Simpson is Health24's CyberShrink. A South African psychiatrist, he qualified in medicine and in psychiatry in Britain. He has been a senior academic, researcher, and Professor in several countries. Read more of his columns.