Supererogation in the Healthcare Setting

Is it ever justifiable to administer ARVs to a patient who refuses treatment? What if she’s pregnant?

These were the unsettling questions we tackled at the Clinical Ethics Forum in light of the case under discussion about a young pregnant woman diagnosed with a combination of illnesses, including TB, HIV and syphilis. Although not particularly co-operative (or communicative) with the hospital staff, she accepted her daily TB and syphilis treatments but vehemently refused to take her ARVs because she did not believe that she was in fact HIV positive. The treating team were deeply concerned not only about the patient’s health herself, but that of her unborn child and the discussion centred around the question of what they could – or should – do in the circumstances – specifically, whether they could administer ARVs to the patient against her will, for her own sake and particularly for that of the baby’s given that over the past decade, South Africa has successfully reduced mother-to-child transmissions of HIV from 23% (2003) to 0.7% (2019) and continuing this downward trend is a key pillar in the fight against HIV.

What struck me from the outset was the immense distress felt by the clinicians. Here was a team of people not only eager to help, but with the means to do so. The reduction of the healthcare budget in 2024/2025 means we often hear of patients who cannot access treatment despite desperately needing it: in this case we had a patient who could access treatment for her HIV but chose not to accept it.

As with many discussions around patient care, we began by considering the ethical principle of autonomy: the idea in healthcare that people – patients – have a right to decide what happens with and to their bodies. Autonomy stands in contrast to the idea of paternalism – the view that doctors ‘know best’ and can decide the appropriate course of action for their patients, as long as it is in the patient’s best interests. While questions of capacity to make autonomous decisions were raised, in the absence of clear evidence that this young woman lacked capacity, the general consensus was that she was entitled to refuse treatment for her HIV – as any autonomous patient is entitled to refuse treatment for their illness. Even if she did lack capacity, indicated by her refusal to accept her positive diagnosis, the idea of forcing her to take ARVs was rejected – not only would this involve daily assaults on the patient (to get the pills down her throat) but would cause immense distress for those who had to administer it – an outcome all considered unacceptable. That is, the patient’s right to bodily integrity and the harms that the staff would experience outweighed the benefits of the treatment to the patient and her unborn baby.

The issue of the rights of the child was raised: were the mother’s actions not transgressing the right to health (and possibly life) of her unborn child? While South Africa’s Choice on Termination of Pregnancy Act (92 of 1996) does afford increasing consideration of foetal interests as a pregnancy progresses, in the strictly legal sense, foetuses do not have rights – only once a baby has taken its first breath do such rights accrue. Despite this, the plaintive plea from the treating team came again: don’t we have a duty to prevent the transmission of HIV to the unborn child?

It was at this point that the concept of supererogation entered the discussion. The term ‘supererogation’ is used by philosophers to describe acts that are not morally required but are nevertheless morally worthy. Its roots in Latin are super – meaning ‘over and above’ – and erogare, meaning ‘to ask for or obtain for some purpose’ (Simpson 1950, p218). Strom-Gottfried’s defines supererogation as ‘the performance of more work than duty requires’ (2015, p33).

Supererogation supports the idea that we are not ethically obliged to take action that risks our life, our well-being, or our employment – that is, while onerous self-sacrifice is morally praiseworthy, it remains optional. What complicated this case was that the treating team wanted to take action that might very well put them and the hospital staff in harm’s way (physically, psychologically, and legally) for the sake of the unborn baby. It was clear that their consciences had been pricked: they felt that they ought to do more than what was morally required.

This case – and the feelings of the treating team – seemed to me to be a clear example of how deontological ethics – the idea that morality depends on duties – may not cohere with our moral intuitions. The question was less about what duties the team had and more about what kind of people the team members are – people who want always to ‘do more’.

In the end, I was reminded by Flescher’s conclusion that ‘ethics is as much about being a certain sort of person as it is about doing certain things’ (2003, p298). I left feeling immense admiration for these colleagues who were so willing to go beyond their duty for the sake of an unborn child and in a very real sense, for their patient’s sake as well. While little could ultimately be ‘done’ in this case, it revealed to me the very moral essence of who these people are.