Sunday, April 3, 2011
In the wake of the on-going strike by doctors in Pakistan, the morality of the issue has been raised and questioned. There are mixed reactions from the public, and both Doctors and Government are being held as responsible for the harm to the public. This article intends to explore the circumstances in which a strike by doctors can be justified and in what way it ought to be carried out.
The Responsibility of Health Care
Whose responsibility is it to provide health-care to the people? The traditional and usual answer to this is that it is the responsibility of the doctors, that doctors are responsible for treating those who are in need of treatment. However, this answer is utterly simplistic and ignorant of the ways in which the medical profession works in the modern world. In our current society, it is the Government, as a representative body of the people, that takes up the fundamental responsibility of ensuring availability of medical care to the public. The Government fulfils this responsibility by shifting it into the hands of people who have the necessary expertise to provide this treatment, and the Government does so by means of a Government-Doctor moral contract: Government will provide adequate facilities and working conditions for the doctors and doctors will in return provide health-care to the people on the Government’s behalf. It is only via this third party – the Government – that doctors enter into any sort of moral contract with the society in our modern world.
It is further thought that the doctors are bound by the principle of primacy of patient welfare, i.e. a doctor should always give priority to the welfare of the patient above his own personal gain. It is said that doctors take up this special obligation by their own willingness and are therefore bound to follow it. This notion too is overly-simplistic. A person who chooses to become a doctor does not avow to forge his self-interest for the rest of his life, nor does he declare that he will offer all his life to medical service without getting anything in return. What a doctor is bound to, yes, is to provide the best possible treatment for a patient he has already accepted to provide treatment for. A doctor cannot be expected to work all his life as a doctor; he doesn’t have an obligation to patients who would have become his patients in future had he continued to work.
A Justified Strike
With this sorted out, let us see when a strike by doctors can be justified. A doctor enters into a contract with the society only by virtue of his contract with the Government, therefore, if the Government refuses to honor its obligation of providing adequate facilities and working conditions for the doctors, then the doctors’ obligation to work for the Government is nullified. This includes the issue of pay, because doctors are humans, and have to support themselves and their families. If the amount of work they are expected to perform deviates significantly from the pay they are receiving, Government is violating its obligations. This can be augmented by a utilitarian justification. If the short-term harm brought about by the strike is balanced by a long-term benefit to the society in the form of an improvement in health-care, virtue of the fact that doctors can work more efficiently in better working conditions, then a strike is justified. In fact, a utilitarian might even say that the strike in such circumstances is not just justified, but it is the moral thing to do! By going on a strike, the doctors are not holding the patients as ransom, but are reminding the Government that if the Government does not fulfil its obligation to the doctors, the doctors have no obligation to the people.
Now that we have shown the moral justification of a strike by doctors, let us see what can be the moral way to go about this strike. A strike on the part of doctors can be said to be carried out in a morally justified manner, if
* the demands of the doctors are reasonable
* the doctors made their demands clear to the Government and the public, and gave them adequate time to reflect upon it
* they are flexible and are willing to negotiate in a rational manner
* they are not actively harming patients
The Current Strike
It should be clear to any observer who is aware of the conditions under which junior doctors work in Pakistan that what they are demanding is reasonable, especially when you compare it to the conditions in other countries. The current pay of House Officer is Rs 18,000 (Pakistani rupees, monthly) and that of Postgraduate Trainee is Rs 22,000. The demands are Rs 35,000 for H.O. and Rs 75,000 for P.G. Despite this, doctors were happy when the Government announced that HO pay will be raised by Rs 12,000, and PG/MO/SR pay between 20,000-30,000, to be applicable from 1st July. The Doctors, however, wanted a guarantee and written certainty from the Government that this raise will happen. The Government refused to offer any guarantee and kept offering its hollow promises, promises it has been known to break in the past, and it was in response to this that the doctors announced to carry on with the strike, also with-drawing themselves from work in the emergency.
I believe that all the conditions mentioned above for moral justification of a strike are being fulfilled by the current on-going strike of doctors in Pakistan, and therefore I judge that the strike is not only morally justified but is also being carried out in a morally justified manner. Instead of blaming the doctors, the public should understand the complexity of the issue. Any harm that has come to the public as a result of this, it is a consequence of the strike by the doctors, but it should be realized that the real blame and responsibility for this strike lies on the Government.
[For a more detailed analysis of the issue, see this article from a New Zealand medical journal.]