Doctors' Strike and Moral Justification

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]


Blue Wit said…
Very well thought out, Awais. I know of one case where doctors from ER were protesting as well (this was a while ago) while there were children in a critical condition lying outside the hospital, and at times like that one must wonder where the line between being a professional and being a human lies, but overall what you're saying is correct. All strikes should in theory be conducted within the ambit of reason and decency... otherwise they will get the strikers nowhere.
Anonymous said…
Dear Awais, such a lovely post but I would beg to disagree on certain reasons. So far, so good on the moral ground for the young lads, but perhaps what I understand from this is that they are raising their demands, wants to revise their agreements with some extra benefits and facilities. Keeping in view their delicate nature of profession that directly deals with the human lives is what makes them part and parcel of the society, while considering the importance of their work does not make them to superior on the contractual and financial bases, but on moral grounds that you were discussing here. Also, Government has made huge investments on them in the shape of their studies and coaching, before they reach at this stage to look into the eyes of the Governing bodies and demand more benefits. This will also disrupt the balance in the society, as we all know, life is not a cake-walk for any young professional in this country, once they are developed in their professions, they will be among the highest earners through the Govt. as well as private resources.
Nouman said…
Very well written Article Awais. Hope people would stop treating Men as Gods and Messiahs. For those who are lecturing us on humanity, many of them have not even visited one Public hospital. They are ignorant people who will sit in their ACs and Judge a doctor who spends 365 days with his Poor Patients. Plus such people should muster up some courage and volunteer in the public hospitals instead of wasting time on the internet abusing Doctors.
Mazhar said…
Very well said. Perfect Illustration of current scenario. It's pitty to see such situation arising. I think state is held responsible to run system effectively. People should stop blackmailing medical professionals by calling Messiha's and not appreciating their rights, which are truly justified and reasonable.
baig said…
why is this reason given again and again that doctors have been given subsidy in their education? if you can compare the fee of govt medical college with any private medical college than you should compare the govt university fee with private engineering universities. see the comparison between lums and uet fee.
lums have also started electrical engineering 2 years ago in their school of sciences...
Anonymous said…
My dear friend, I don't think any University in Pakistan is as expensive as that of Lums, normal fee for Engg. degree from a private university is ~50K per semester.
Also, what surety does an Engineering student have of a Job? or a Govt. sector Job? At least doctors can start their careers at a reasonable amount, i.e., as per my Knowledge is 24K during House job. Now take any other young professional from any field, and see their struggling starts in their relevant fields, How much they are getting and with what certainty? A CA student after doing the CA-Inter is getting PKR 6500/- (now increased to 8000/-). Few years ago Govt. established a program for unemployed engineers, National Internship Program and they employed engineers in different Govt. sectors at the mere stipend of PKR 10,000 only.
My point of view here only is that at the start of your professional career, everyone struggles, its not just the doctors, at least they have some consumption in the Govt. sectors, but what about the other professionals? As the economic condition of the country is appalling no profession has any job security as they conclude their studies. Also, don't put the private business of doctors behind, they can easily run private clinics after their duty hours, and most of them do. Those who are young, they join established set up of seniors and famous doctors and in this way they can also earn some financial benefits but not the case for other jobians after their duty hours.
Shahida said…
an excellent post.I ,being a doctor, wish that the public in general and the silly semi educated mediamen in particular should realise that doctors also have families to feed and educate.they cannot take lavish gifts in the form of villas,plots and racy cars from property tycoons as our journalist friends do.If they demand better salaries and service structure,what s wrong with it.
Anonymous said…
Well written but more than that logical. I have read some very good articles and blogs during the past year and half but this one approaches the matter logically. A thing I regretably admit is lacking in issues concerning doctors. I have kids of my own and I know that this is very emotional when it comes to children. In country where I live these days doctors wont see a dying patient because their shif is over or the patient is not under their care for the fear of litigation. While working in Pakistan I have actually seen a dying patient in another speciality . But another fact is that I had to leave Pakistan as I could not assure a future for my kids while working in govt health sector.
ana said…
logical and unbiased. Unlike what most people are these days. after all doctors are humans. They have not become monks and devoted their lives to only serve the common man and still get only abuse in return. The majority of people these days are confused about what doctors really are. On one side they are calling the profession noble and sacred and on the other hand they are calling doctors murderers. While doctors are only men, neither killers of innocent people nor 'dervaishes' of older days who had no worldly thought in their hearts.
Anonymous said…
With reference to: 'My dear friend, I don't think any University in Pakistan is as expensive as that of Lums, normal fee for Engg. degree from a private university is ~50K per semester. Also, what surety does an Engineering student have of a Job? or a Govt. sector Job? At least doctors can start their careers at a reasonable amount, i.e., as per my Knowledge is 24K during House job.'

Sir/madam. As many as 65% house officers and 50% postgrad trainees work without a is called an honorary job. If anythimg, this is am underestimate. I wonder where the honour lies, when the public so much as fails to recognize it even. And they can't simply not do it. They gotta do their job even if they didnt get a paid seat. And thats not because he didnt study well enough or slept through classes but simply because the govt doesnt provide seats enough to cater for them all.why make medical colleges in every nook n corner then? Can you tell me of any other profession where people work without any pay? Also, govt sector employees get extramonetary benefits, at least free health care for employee amd his family, plus more as your rank.goes up. Doctors don't. They also only work a private jon after duty houra only because they cant hope to provide for a family with three children amd sometimes old parents with a meagre 40k when theyre 30. With that we shouldnt forget the doctor doesnt have a fixed 9-5 office timing, but a hectic 36 , 48 and even 72 hour calls. To clear an ambiguity, this strike is a 2nd chapter of last year's strike.not a new one.demands haven't been raised but qre exactly the same qs were last year.what is more is that the the govt had accepted them last year but failes to implement them in a whole year.even then firt reminders were sent then only OPD closed.if anything, the young doctors' perseverance is exceptional.
Anonymous said…
very well written, like always:)

i hope we succeed this time. but something that scares me is wht if we cross the line. what if all this frustration kills our conscience. i don't want to leave a person in pain when by grace o Allah i know how to relief it:(...even the thought o this kills..i pray that th right ones win and i pray that there be no mistake from our side.Allah bless our pakistan!!
Immorality: the morality of those who are having a better time.