When Healthcare Is Under Pressure, Ethics Matters Most

Beyond compliance: why trust, integrity and professional judgement matter in a changing healthcare environment

Healthcare is changing rapidly.

Artificial intelligence is entering clinical and administrative environments. Digital health is reshaping how practitioners interact with patients. Healthcare costs and affordability remain pressing concerns. Policy and regulatory reform continue to influence the sector, while questions around sustainability, access, equity and accountability are becoming increasingly urgent.

These were among the themes explored at the 2026 Board of Healthcare Funders (BHF) Conference, held in Cape Town under the theme “Facing Headwinds: Thriving in the Unknown.” The conference brought together healthcare leaders, policymakers, funders, clinicians, innovators and other stakeholders to consider how the sector can respond to a period of profound change.

In his recent SAMDP reflection on the conference, Dr Nkateko Munisi, CEO of SAMDP Group Holdings (SGH) highlighted five trends that will shape the future of healthcare: artificial intelligence, the shift from volume to value, digital transformation, collaboration and leadership.

Running through all these developments is another issue that deserves attention: ethics. Because when healthcare systems are under pressure, ethics matters most.

Ethics is bigger than compliance

Healthcare is built on trust. Every consultation, diagnosis, referral, prescription and patient interaction depends on a fundamental expectation: that the healthcare professional will act with integrity, competence and sound judgement.

Professional ethics is therefore not simply a set of rules designed to prevent misconduct. It is the foundation of the relationship between healthcare professionals and the people they serve. The HPCSA’s ethical guidance covers areas including informed consent, confidentiality, health records, social media, over-servicing, ethical billing and the ethical use of artificial intelligence.

But ethical healthcare goes beyond compliance. It is about asking a more fundamental question: What is the right thing to do — for the patient, for the profession and for the healthcare system — particularly when the answer is not always easy? That question becomes increasingly important as the environment in which healthcare is delivered becomes more complex.

Why ethics matters when the system is under pressure

Healthcare professionals operate within systems affected by rising costs, resource constraints, changing regulations, workforce pressures, technological disruption and increasing patient expectations.

Pressure can create difficult choices. A practitioner may face financial pressures within a practice. A healthcare organisation may need to balance sustainability with affordability. A funder may need to manage limited resources while protecting members. A patient may struggle to afford the care they need. These pressures do not make ethical decision-making less important. They make it more important.

Ethical practice means maintaining professional standards even when circumstances make doing so difficult. It means protecting patient dignity, maintaining confidentiality, keeping accurate records, communicating honestly, managing conflicts of interest and exercising independent professional judgement. It also means being prepared to say no when something is not clinically appropriate or professionally sound.

That is where ethical courage becomes important. Ethics is easy to discuss when there is no pressure. The real test comes when doing the right thing is difficult.

“It is not simply about knowing what is right. It is about having the integrity and courage to do what is right when the system is under pressure.”

Ethics and the South African healthcare conversation

The ethics conversation cannot be separated from the wider challenges facing South African healthcare. Questions about affordability, access, sustainability, healthcare reform and the relationship between providers, funders and patients are not only policy or financial questions. They also have an ethical dimension.

At the heart of these debates are questions of fairness.

Who gets access to care?
Who bears the cost?
How are limited resources allocated?
How should healthcare providers be treated fairly?
How do healthcare professionals protect patients while also ensuring that healthcare practices remain sustainable?

The continuing work around Section 59 illustrates the complexity of these questions. In March 2026, the Council for Medical Schemes issued directives following the Section 59 Final Investigation Report, highlighting the need for stability, fairness, proportionality and legality while the sector works towards longer-term reforms.

The lesson is important: ethical healthcare requires fairness not only in the consultation room, but also in the systems and processes surrounding healthcare delivery.

Trust, accountability and the responsible use of resources

Ethics also extends to how healthcare resources are used. Fraud, waste and abuse are often discussed as financial or regulatory issues. But they are fundamentally questions of professional and organisational integrity. When resources intended for healthcare are misused, the consequences extend beyond financial losses. Resources that are wasted or improperly claimed are resources that cannot be used to improve patient care.

Ethical billing, accurate documentation, appropriate utilisation of healthcare services and responsible financial management therefore matter not only because regulations require them, but because healthcare resources ultimately exist to serve patients.

The same principle applies across the healthcare ecosystem. Practitioners, funders, administrators, healthcare organisations and regulators all have responsibilities. Trust cannot be demanded from one part of the system while accountability is expected only from another. A culture of trust requires shared responsibility.

Technology is changing the ethical equation

Few developments illustrate this more clearly than artificial intelligence. As Dr Munisi observed in his reflection on the BHF Conference, AI has the potential to improve diagnosis, clinical decision-making, administrative efficiency and patient outcomes. But technology must not replace the judgement, compassion and ethical responsibility of healthcare professionals.

The ethical questions surrounding AI are therefore becoming increasingly important.

Who is accountable when an AI-supported recommendation contributes to a clinical decision?
How should patient information be protected?
Should patients know when AI has been used in their care?
What happens when an algorithm produces an inaccurate or biased recommendation?
How do Healthcare professionals ensure that technological innovation does not deepen existing inequalities in access to quality healthcare?

The HPCSA’s ethical guidance now specifically includes guidelines on the ethical use of AI, alongside existing guidance on confidentiality, social media, health records, telehealth, over-servicing and ethical billing.

This reinforces an important principle:Technology may change how healthcare is delivered, but it does not remove professional responsibility. In fact, the more powerful technologies become, the more important human accountability becomes.

“Technology may change how healthcare is delivered, but it does not remove professional responsibility.”

What does ethical courage look like?

Ethics is sometimes presented as a list of things healthcare professionals should not do. But ethical practice is also about what professionals choose to do.
It means:

Treating every patient with dignity and respect
Communicating clearly and honestly
Protecting confidentiality
Maintaining accurate and appropriate records
Recognising and managing conflicts of interest
Being transparent about professional limitations
Using healthcare resources responsibly
Maintaining professional independence
Questioning practices that may compromise patient welfare
Remaining willing to learn and adapt as healthcare evolves.

Most importantly, ethical courage means being willing to make the right decision even when it is not the easiest decision. That may mean challenging a practice, questioning an instruction, refusing inappropriate pressure or acknowledging when something has gone wrong.

A strong professional culture should make it possible for people to raise concerns, learn from mistakes and improve systems — rather than creating a culture in which people are afraid to speak.

Building a culture of trust rather than fear

Ethics should not be reduced to punishment. A profession cannot build lasting trust simply by threatening practitioners with sanctions. Regulation and accountability are necessary, but ethical healthcare also requires education, reflection, leadership and a culture of continuous improvement.

The objective should be to create environments where doing the right thing is supported and expected. That requires leadership.

Leaders within healthcare organisations, professional associations, practices, funders and regulatory bodies have an important role to play in establishing cultures where integrity is valued and accountability is shared. This is particularly important at a time when healthcare is becoming increasingly interconnected. A decision made by one part of the healthcare ecosystem can have consequences far beyond that organisation.

Ethics in a changing healthcare system

South Africa’s healthcare system is undergoing significant change. The conversations around healthcare reform, universal health coverage, affordability, sustainability, digital transformation and the future of medical schemes will continue.

There will inevitably be differences of opinion about the best way forward. But perhaps there are principles on which the healthcare sector can agree.

Healthcare should be patient-centred.
Decisions should be transparent. Resources should be used responsibly.
Professionals should be treated fairly.
Patients should be treated with dignity.
Technology should serve people rather than replace human accountability.
Those entrusted with healthcare responsibilities should be prepared to act with integrity, even when the environment around them is uncertain.

These principles are not dependent on a particular healthcare model. They are the foundation of a healthcare system worthy of public trust.

The role of healthcare professionals

Doctors and dentists are not simply providers of clinical services. They are professionals entrusted with significant responsibility. That responsibility extends beyond technical competence. It includes judgement, communication, leadership, accountability and the ability to recognise the wider impact of professional decisions.

As healthcare becomes more digital, more interconnected and increasingly shaped by financial and technological pressures, professional responsibility becomes even more important. The future will require practitioners who are not only clinically competent, but also ethically grounded, digitally responsible, adaptable and willing to lead change.

Looking ahead

The healthcare sector will continue to face headwinds. There will be difficult policy choices, financial pressures, technological disruption and debates about how healthcare should be funded and delivered. But uncertainty does not diminish responsibility. It makes the principles that underpin ethical healthcare more important than ever.

The future of healthcare will not be determined by technology alone, nor by policy alone, nor by individual organisations working in isolation. It will be shaped by the choices made by the people who lead, fund, regulate and deliver healthcare every day.

And at the centre of those choices must remain a simple principle: Patients must be able to trust the people and systems entrusted with their care. Ethics is what makes that trust possible. It is not simply about knowing what is right. It is about having the integrity and courage to do what is right when the system is under pressure.

The challenge for SAMDP is therefore not simply to advocate for the profession, but to help shape the kind of profession that South Africa can trust. This means putting ethics firmly on the advocacy agenda — championing integrity, accountability and professional responsibility, and giving ethical leadership a stronger voice in the future of healthcare.

The question for the profession is no longer whether ethics belongs in the future of healthcare. It is whether ethical leadership will be strong enough to shape that future. SAMDP will champion that conversation — advocating for a profession in which ethical practice is not simply a requirement, but a defining characteristic of professional leadership and public trust.