Ethics of Doctors’ Strikess

Abbasi IN*

Department of Community Health Sciences, the Aga Khan University Karachi, Pakistan

*Corresponding author: Abbasi IN, Department of Community Health Sciences, the Aga Khan University Karachi, Pakistan

Received: November 01, 2016; Accepted: January 20, 2017; Published: January 24, 2017

Abstract

Doctors’ strikes present an ethical dilemma due to perceived central role of doctors in relation to human health and life. Doctors are seen and judged by higher standards than the ordinary people. Under Hippocrates oath, doctor is considered to be in a social contract and is obliged to treat patient’s health and life as a priority over everything else and going on strike is considered a breach of such contract. Though socialized medicine (being practiced in several developing countries) advocates that health care is the joint responsibility of the state, the healthcare institutions and the doctors, yet the doctors’ strikes carry greater ethical predicaments for themselves. As most societies seem to follow a Utilitarian view that pronounces strike as ethical only under the condition when such action carries greater good for the doctors and to society than the loss occurring as a result of denial of health services to the patients during the strike. However decision regarding what defines greater good is complex. There is no single best answer against or in favor of doctors’ industrial action. In a system of socialized medicine, government being in charge of resources and management decisions has to assume greater responsibility in faith of the greater good of all stakeholders including doctors and patients and working conditions of doctors in developing countries in particular demand a contextual analysis of the situation.

Keywords: Ethical dilemma; Ethics; Doctors’ strikes; Lack of security; Low wages; Socialized medicine; Utilitarian theory; Brain drain; Hippocrates oath

Background

According to the United Nations’ universal declaration on human rights articles 19 and 20, right to freedom of expression and peaceful assembly is a basic human right [1] and the governments are responsible for ensuring that everyone can exercise it without fear of intimidation or violence [2]. This right is exercised and there is varied response of state governments around the world; sometimes in favor and sometimes against it.

However, protests and strikes by doctors are viewed from a perspective known as the social contract which a doctor enters as soon as he/she swears the Hippocrates oath. He/she swears to act in the highest interest of his patient and keep the health and life of his patient a priority above everything [3]. As part of their profession doctors’ proximity to life and death situations renders strikes and protest by them as an ethical misconduct.

Discussion

Utilitarian perspective

Because of their direct link with human lives, doctors are envisioned as highly respectable in every society and the society judges them by standards higher than those of ordinary humans and they are considered as ‘the Messiahs’ (the saviors) of mankind by the society.

Under Hippocrates oath, care of the patient is a contractual obligation for the doctors, superior to everything else [3]. Though Utilitarian perspective views doctors’ strike justifiable under the circumstances where there is evidence of long term benefits to doctors, improvement in service delivery and when those in need of health care will seek the greatest benefit out of the strike [3,4]; yet the formula becomes increasingly complex when the benefits of the strike are to be weighed against the risks to the patients.

Socialized medicine

In socialized medicine, patient care is a shared responsibility of doctors, the health care institution and the government. The government provides funding, physical infrastructure and manpower to the institutions, hospitals in this case, that are responsible for ensuring operational efficiency and continuity of care. In this shared setup, if one stakeholder fails in fulfilling its commitment, the consequences are borne by all the remaining entities e.g. if the government fails in maintaining the job satisfaction of its employees or providing the required resources [5-7], then the sanctity of the other two entities may also be adversely affected.

However, even in case of government’s failure, doctors’ decision to strike could still be construed as an individual choice i.e. whether to go on strike or to obey the social contract. The question raised on the morality of the strike is: Who should be held accountable for the patients’ sufferings?

A doctor’s case of sufferings

Considering the time frame required becoming a qualified medical practitioner, a doctor’s career path is not an easy choice. Working conditions of doctors particularly in public sector hospitals of developing countries are a pity. Added misery is brought upon by low wages, extended working hours and lack of safety and security. Lack of good governance is the main hurdle due to which health is not a priority subject for policy makers and planners [8]. Yet, the question that whether such adverse working conditions of doctors justify their strike action does not have a straight yes or no answer. Suspension of care provision can be an effective way of pressurizing the government to realize the consequences of a strike on the overall health care system [6]. But whether it is the government’s fault leading to such conditions, or a way of doctors to embarrass the government, either way leads to a breach of the moral contract between doctors and patients. The ultimate result is health care denied to the patients. Viewing doctors’ protest from the perspective of socialized medicine might be perceived as a consequence of government’s negligence, but according to utilitarian theory and the Hippocrates oath it does not void the moral duty of doctors to prioritize patients’ health.

Patients’ sufferings

Historically, strikes by doctors were kept limited to nonemergency cases while keeping the emergency services functional. Such types of strikes were carried out in Israel, Australia, Tanzania and more recently in the UK and Pakistan. In Israel, an alternate system called fee for service was established to deal with outpatients and ensure continuity of care during strike [3,9,10,11]. In the UK, it was called as ‘urgent and emergency care model’ where all non-emergency surgeries, investigations, out-patient consultations and routine procedures were kept suspended [12]. Park et al. (2013) argues that doctors can protest given that any emergency care required is urgently provided. However, the emergency as defined by doctors may differ from the general perception and delaying care to non-emergency cases could ultimate turn into preventable emergency cases. Therefore, this mode of the strike also bears moral repercussions for doctors. Strikes may impact patients in the form of an increase in severity of the medical condition, prolongation of sufferings, irreversible damage to health or loss of life, delay in treatment or unwanted drug interruptions, loss of work and waste of money on transportation [13].

Suspension of public sector health care services turns the flow of the patients to the private sector. Public health services are relatively cheap compared to private sector and therefore people of low socioeconomic status may not be able to avail health care at all. Moreover, private health sector’s capacity may not be adequate to meet the requirements of the population in times of strike adding to the misery of those in most need.

Conclusion

The key areas requiring consideration are: i) responsible role of government in preventing strikes and the consequent system failure ii) role of doctors in ensuring continuity of care during strikes and minimizing its impact on those in need of health care.

First, since the social contract between doctor and patient is not considered void under any circumstances, strikes by doctors seem to raise ethical concerns about their professional conduct. Here it is vital to consider that doctors in their entirety are human beings having similar emotions, feelings and more importantly the needs as those of a common man. Bounding them with social contract does not eliminate these basic human characteristics rather it puts an added burden in the form of social responsibility tied to their profession. Therefore, while it is expected from doctors to obey the social contract, consistently ignoring their basic needs may lead to circumstances that then manifest in the form of so called undesired outcomes. Forcing doctors to work under adverse working condition can lead to demotivation and demoralization culminating in poor health care quality and brain drain. Second, enjoying an optimum level of health is the basic right of every individual and is a constitutional responsibility of the state. The state is responsible for ensuring the adequacy of resources both financial and human, and proper resource allocation. Lack of seriousness and timely interventions into the issues such as strikes ultimately ends in patients’ sufferings. Moreover, in the system of socialized medicine government is the supreme authority since it has the control of resources and important management decisions related to health (care) system.