Time to strike?

Authors: Camilla Boyton 

Publication date: 11 Jun 2008

Recent dissatisfaction over pay and conditions has led to a series of junior doctors’ strikes in New Zealand, raising a number of issues over the ethical acceptability of doctors going on strike. Industrial action among doctors is perceived as rare, but in reality there have been strikes by doctors in many countries in recent years. Some examples include strikes in Australia, Canada, France, Germany, India, Ireland, Israel, Italy, Malta, Spain, and the United States.[1] Historically, the most common causes of strikes have been disputes over pay and conditions.[2]

Juniors

It has been more usual for junior doctors to strike, and there are several reasons why this might be the case. Junior doctors in most countries have traditionally had the least pleasant conditions to work in and are therefore the most likely to be dissatisfied. As there is a rise in dissatisfaction at higher levels within the profession it is possible that there will a corresponding increase in the willingness to strike among senior medical staff. Doctors who are in training are also usually unable to freely take their skills elsewhere unlike many others in the workforce. Lawyers who dislike their pay and conditions may be able to find another employer where things are improved, but for doctors at a junior level in the United Kingdom and other countries such as New Zealand there is only one employer. If the doctor is dissatisfied with that employer and cannot negotiate with them then the options are limited; they can either resign or strike. Whether the doctor takes the individual or collective option in this case depends to a large extent on there being an organisation capable of leading and coordinating a strike action, and a certain amount of cohesion is essential. If there are enough people who are dissatisfied and there are leaders prepared to organise a strike then it becomes a possibility (in some cases there might be a contractual or legal obstacle to striking; this would probably not present an effective barrier to large industrial action in the future, as it has not done so in the past. Such clauses are likely to be unenforceable).

Ethics of striking

There are various ethical arguments that may be used to justify or object to a strike. One of the commonly raised concerns is that the health and welfare of patients could be compromised. Usually this is based on a utilitarian argument of “the greatest good for the greatest number” and the suggestion that greater harm will occur if there is a strike. It is possible to argue, however, that while in the shorter term this might be the case, in the longer term there could be an overall benefit. If the lives and working conditions of doctors are improved, this is obviously a benefit, but this might translate into wider gains such as better recruitment into medicine, the retention of doctors in the profession or in the public health sector, and fewer demands on a doctor’s time. Indeed it is possible to argue that patient care could be improved as a consequence. Calculations of moral good are complicated, and a utilitarian argument can be used to justify a strike in certain circumstances.

Some people argue that human life is so important that if there is even one avoidable death that occurs because of a strike, this would condemn it morally. In society, however, we do not actually see human life as a sacred absolute. The money spent on new clothes or a holiday could have been used to provide clean drinking water to people who have none and hence could have prevented deaths, but we do not usually condemn people for spending their money on such things. The proximity of the death makes a difference to our gut reaction; it seems initially worse if we fail to intervene and prevent a death in our own town than if we don’t intervene in some distant corner of the world; but is it really morally different? Death is seen as an acceptable price to pay in some circumstances, for example, in some conflicts where the loss of lives is viewed as justified by the cause, and perhaps might save others. Additionally, if a strike was carried out in a limited way, it would be very unlikely indeed that avoidable deaths would occur. So if human life is not to be treated as an absolute in society, why should doctors be held to a different set of standards?

Doctor-patient relationship

Perhaps the answer to this lies in the relationship between doctor and patient, which is seen to carry a special moral obligation. The doctor is in possession of special skills and is expected to act according to the principles of beneficence (ie doing good)[3] and non-malificence (not causing harm). It doesn’t necessarily mean, however, that a doctor is considered obliged to provide care to their patient under all circumstances and at all times.[4] A doctor does not have an obligation to continue to work forever or never to be absent from work, and it is acceptable to transfer care to another competent individual, for example at the end of working hours or when moving to another post. So these principles do not in themselves preclude a doctor being absent from work. Indeed, as Sachdev points out, when in the NHS doctors enter into this contract via a third party, the hospital.[4] It is therefore possible to view the provision of care as a triangle, and to suggest that the hospital also has an obligation to provide the doctor with the means necessary to provide care. Sachdev argues that if this is not fulfilled then the obligations of other arms of the triangle become questionable. It is also possible to strike in such a way that risk of serious harm to patients is minimised—clearly if the strike is very limited then it becomes considerably less effective,[5] but it is still arguably better to provide a good level of cover during strike periods. The recent strikes in New Zealand resulted in a loss of elective services, but inpatients and acute admissions were covered by consultants in the absence of the junior staff. The level of cover was probably better than a weekend or public holiday. The aim of this approach is to cause disruption while attempting to ensure that essential services remain covered.

Professionalism

It is sometimes said that it is not appropriate for a professional to strike, but it is not clear exactly what it means to be a professional. Perhaps the professional is seen as someone who is trustworthy, but to suggest that to go on strike would damage this view is surely incorrect. If there was a genuine grievance and a strike was executed in a responsible way, it is difficult to think that doctors might be regarded as less trustworthy as a result. Despite recent negative publicity doctors regularly top the polls of most trustworthy people.[6] Doctors often exhibit selflessness, an attribute that is generally regarded as desirable in the profession, but few would argue that this means doctors should be powerless to stand up for themselves or that they should be exploited. Another objection is that a strike would destroy the public’s impression of doctors as selfless healers, and this might depend on the powerful influence of the media on public perception. But it is questionable whether the public really do perceive doctors in this way in any case, and it is also possible for the public to support doctors who strike, as in New Zealand where the strikes were widely supported among the general public.

Too privileged to strike?

Another argument is that doctors are already viewed as overpaid and privileged and would be seen as greedy if the strike was over money. This might be a more likely response in the UK but does not necessarily present a reason not to strike—the public perception of the issues might be altered when doctors were given a forum to present their reasons for taking industrial action, especially if these also included concerns over patient safety. The argument that doctors enter willingly into their position also does not mean that they should have to suffer unreasonably or that if they believe conditions to be dangerous that they should not take action. There has been much focus recently on the importance of autonomy and respect for individuals within health care, but it is important to remember that doctors are persons with rights too, and should also be treated with respect. Many of these objections are based on striking being bad PR for doctors, rather than an ethical justification against a strike. If doctors really believed they had a genuine reason to strike and that their conditions of work could put patients at risk then they should perhaps have the courage to act on their beliefs, even at the risk of unpopularity.

Morally acceptable

Given the current climate of dissatisfaction within the profession it is possible that industrial action will be considered. It is an emotive issue, and one that is unlikely to be universally agreed upon. But it is worth noting that it is possible to be responsible about the execution of strike action and that such actions are not necessarily morally reprehensible. If the grievances of the doctors are real and the demands of the doctors are reasonable then there are good arguments that a strike can be morally acceptable.

Camilla Boyton unemployed doctor Alaska

camillaboyton@hotmail.com