Human judgement must remain at the centre of healthcare accountability even as artificial intelligence and other technologies transform clinical practice, says medico-legal risk specialist Dr Hlombe Makuluma.
Technology can improve healthcare and reduce medico-legal risk, but it cannot become a convenient scapegoat when things go wrong, he adds.
“The final decision is human – you can’t blame the scribe or the technology,” Makuluma says.
Dr Makuluma is a medical doctor with a master’s degree in medical law and is currently pursuing a PhD in the field. He evaluates alleged medical errors, advises on medico-legal matters, and provides informed opinions on whether cases should be settled or defended. His assessments consider whether the issue arises from individual conduct, systemic shortcomings in healthcare delivery, or recognised medical complications.
He will join a panel titled “Beyond Technology: Preserving Humanity in Healthcare” at the South African Medico-Legal Association’s (SAMLA) annual conference at the aha Kopanong Hotel and Conference Centre in Benoni, Gauteng, from 8–10 October 2026. The conference programme places the panel on its final day, 10 October.
Makuluma’s central message is that accountability must consider the individual clinician, the system in which that clinician works and the technology available to support decision-making.
“The human factor is very important,” he says.
But that does not mean clinicians should be absolved of responsibility.
“Accountability will always lie with the individual,” he says, while cautioning that the individual cannot be judged in isolation from the environment in which the care was delivered. That environment includes staffing, equipment, workload, communication, training, and the organisational support available to healthcare professionals.
Technology is not the decisionmaker.
Makuluma says South Africa should not shy away from emerging technology.
“Technology is a friend of ours,” he says, arguing that it should be embraced where it can improve healthcare and reduce medico-legal risk.
Artificial intelligence and digital tools may increasingly assist clinicians with diagnosis and decision-making, but they cannot account for every clinical or social nuance. Technology can assist with decision-making, but the healthcare professional remains responsible for implementing the decision. A patient’s circumstances, he says, may include cultural factors and whether care is being delivered in a rural community, suburb, or informal settlement.
“These things may not appear in the technology,” he stresses.
The implication is that sophisticated technology must augment — rather than replace — clinical judgement.
Look beyond the individual.
Makuluma is equally critical of approaches that automatically locate responsibility in an individual healthcare worker when adverse events occur. He argues that South Africa’s medico-legal system tends to focus heavily on individual negligence, while hospitals and broader system failures can be more difficult to incorporate into assessments of accountability.
This is particularly important in the public sector, he says, where the quality of nursing and medical care cannot always be separated from the conditions in which healthcare workers operate. He rejects simplistic narratives that blame nurses for declining standards without considering whether they have adequate staffing, manageable nurse-to-patient ratios, functioning equipment, and appropriate working schedules.
Training is another crucial factor. Makuluma questions the impact of the closure of dedicated nursing training colleges or the decline of nursing training capacity and says nursing quality cannot be assessed independently of the environment in which nurses are educated and deployed. He also points to the loss of traditional bedside teaching.
During his own training, he says, junior doctors learned not only the science of medicine but also by observing how experienced clinicians interacted with patients. Today, he argues, some specialists move rapidly through hospital wards before returning to private practice, leaving junior doctors with less exposure to that role-modelling.
“You study the science, but the behavioural side is lacking,” he says.
R120bn contingent liability needs context.
Makuluma also cautions against portraying South Africa’s reported medical-negligence contingent liability as though billions of rands are sitting in government bank accounts waiting to be paid.
A contingent liability is not equivalent to cash already allocated for payment, he says. It represents potential future obligations arising from claims and must be distinguished from amounts being paid out. More fundamentally, he argues that government needs much better active management of medico-legal claims.
He argues there is a disconnect between provincial health departments and the State Attorney in the management of alleged medical negligence claims, with hospitals and clinicians often becoming involved principally through the provision of medical records rather than through active management of the lifecycle of the alleged claim. His proposed remedy is provincial medico-legal units that actively manage cases, bringing together health departments, clinicians, legal personnel, and relevant records rather than leaving the process to lawyers defending the state.
He cites the Western Cape as an example of a province where more active management of medico-legal matters has contributed to a comparatively lower contingent-liability figure.
Context matters in professional discipline.
Makuluma is similarly concerned that professional disciplinary processes can sometimes assess clinical conduct without adequately considering the circumstances in which healthcare was delivered.He argues that medical records, for example, need to be interpreted in context rather than simply judged against formal requirements. His concern extends to the relationship between doctors and nurses when adverse events occur. In one example he discussed, he argued that a clinical problem attributed to a doctor could involve failures elsewhere in the care team.
The wider point, he says, is that accountability should identify what happened rather than simply identify the most convenient individual to blame.
Informed consent is more than a signature.
Makuluma also challenges the notion that a signed consent form automatically establishes valid informed consent. True informed consent, he says, requires a patient to understand the proposed treatment, why it is being recommended and the available alternatives. The medical record is crucial because it should capture what the clinician observed, discussed, and advised. For him, the consultation and conversation are therefore as important as the form eventually carrying the patient’s signature.
Restoring humanity
Makuluma believes preserving humanity in healthcare begins with recognising that medicine is a relationship between people. Technology can support that relationship but cannot substitute for it – and neither can legal rules alone.
SAMLA’s value, he says, lies partly in bringing medical and legal professionals into the same room so that each can better understand the other’s world. Doctors need to understand why lawyers ask tough questions; lawyers need to understand the complexity of achieving a clinical outcome within a healthcare system.
“Take away the blame game,” he says.
For Makuluma, that may be the most important conversation surrounding healthcare’s technological future: how to make technology work better for clinicians and patients without allowing it to obscure the human judgement, responsibility, and compassion at the heart of medicine.
