Monday 2 July 2012
During the strike of doctors last year in Pakistan, I wrote a post as an effort to make sense of the issue of whether a strike by doctors can ever be morally justified. I am reposting it with relevant changes and refinements given that the current circumstances have made it all the more pertinent again.
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 post 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 Public 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. [I am excluding the private medical sector.]
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 under all circumstances. 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.
[Consider the hypothetical scenario to illustrate what sort of moral expectations we have from doctors: There is a small town in which there is only one doctor responsible for providing emergency care. The town is totally dependent on the doctor for his services, and in his absence there is no one else they can go to. If that doctor wishes to move to city from the town permanently to offer his family a better life, is he morally justified in doing so, given that in his absence people will die? Or is he trapped in that town forever, bound by the chains of moral obligation? Would it be reasonable to expect him to be a saint when he is in fact human, all too human?]
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 becomes questionable. This includes the issue of pay and service structure. If the amount of work and the circumstances in which they are expected to perform deviate significantly from the pay and facilities 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. But this utilitarian argument can only be an augmentation, not the crux, because we all know that human lives cannot be added and subtracted.
The moral problems associated with the strike can be minimized effectively if the emergency services continue to be offered, as that would ensure that all critically ill patients are being taken care of. Closing of emergency services is an extreme measure, as it will invariably result in loss of lives, and the responsibility of consequences will have to be borne by both doctors and Government.
Now that we have discussed the possibility of 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 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
Applying the above discussion to the current scenario is not as clear cut. Are the demands of the doctors reasonable enough to justify a strike? Did the Government make a genuine effort for a negotiation? Was closing of emergencies necessary? I cannot answer these questions objectively. But there is one observation I would like to make. The doctors had commendably restricted their strike to outpatient departments, while ensuring that patients were getting inpatient and emergency treatment. To my mind, this is a reasonable manner of protest, which any Government ought to have taken seriously. The Government however resorted to media defamation and later police arrests and brutality, effectively forcing the doctors to withdraw their services from emergency. The result is the unfortunate scenario that is in front of us.
It would be apt to end this post with this quote:
"It can be said that there is an antitrust challenge to medicine, as to other professions. But self-sacrifice is not necessarily the best method of increasing trust. It only creates unrealistic expectations, making dissatisfaction more likely. Trustworthiness will suffer if doctors make unreasonable demands, strike work without adequate notice, seem inflexible or actively undermine patient-care. But, being seen as human cannot be too detrimental! And, if physicians have special obligations, they can demand special benefits. In stressing that professionals need to look at their own interests in addition to the interests of their clients, a strike provides a good dose of realism. It shatters a somewhat antiquated myth of sainthood." [Sachdev, Doctors' Strike - An Ethical Justification]