Are doctors justified in taking industrial action in defence of their pensions? No

In liberal democracies, the legal right to take collective industrial action is denied only to members of the armed forces who are required to defend the state. There is therefore no reason in law why doctors should not behave in the same way as other workers with an unresolved grievance. Indeed, doctors’ strikes have occurred in the United States, the UK, Canada, New Zealand, Israel, El Salvador, Nicaragua, Spain, South Korea, Germany, France, Ghana, and South Africa. Causes include unsatisfactory working conditions, changes to terms and conditions of service, or burdensome malpractice premiums. The outcomes have not usually been positive for the profession.1

However, we are not concerned here solely with legality but with ethics and the nature of the relationship between doctor and patient, both now and for the future. If there is nothing special about this relationship then we can terminate the discussion at this point: might is right, and the patient is a mere fulcrum on which doctors and employers leverage their collective power. Few doctors would adopt this view, recognising that professional status brings particular responsibilities as well as privileges. Therefore when the strike weapon is exhibited, various arguments and strategies are deployed as balm to the professional conscience:

• Targeted action—The BMA’s stance is that industrial action can be fine tuned to maximise institutional inconvenience and political embarrassment while minimising patient harm.2 The difficulty with this approach is finding activities that do not at some point affect patient care. Cancelling an outpatient clinic or refusing to see patients with non-urgent conditions in the surgery (using which criteria?) will delay treatment and may result in chronic conditions becoming urgent and life threatening. Perhaps non-attendance at administrative meetings would not affect patients, but this raises the question of whether the meeting, or doctor’s involvement, was necessary in the first place

• Displacement of moral responsibility—Employers (government and hospitals) are primarily responsible for workforce satisfaction and patient safety. This approach diminishes the profession as leaders, and fails to recognise that the NHS is still largely a duopoly of state and profession, with shared responsibility to the public (that pays our salaries) in the middle. Failure of one monopoly does not absolve the other, and unjust treatment by the state does not entitle beneficent practitioners to become maleficent. Those who wish to follow this pathway should reflect on whether the decision by general practitioners to withdraw from out of hours care has enhanced the image of family practice

• Special cause—Doctors should be treated as privileged individuals because of our skills and lifelong commitment. We are indeed privileged, with better job security and pay and greater clinical freedom than our colleagues in most European countries, working in a healthcare system that has been better protected from the financial crisis than many other state and private enterprises.

• Collective amnesia—The public will forgive us after a few months, and anyway doctors are consistently at the top of public “trust” ratings, with politicians at the bottom. This conflates public appreciation for individual doctors, providing a service free at the point of delivery, with respect for the profession as a whole. The fact that 88% of the public believes that doctors will tell them the truth does not mean that people have complete confidence in them. When asked to what extent they would trust doctors to act in the best interests of their patients, 42% of respondents selected the lower rating of “a fair amount” and 9% “not very much” or “not at all”3—hardly a complete vote of confidence.

It is difficult to find an argument that would justify industrial action in any circumstance other than to preserve services to patients. But striking over pensions seems particularly hard to justify. Pensioners, unemployed people, and taxpayers—as ultimate underwriters—will not understand why well paid doctors should be protected in current economic conditions.

A common response from colleagues to the view that strike action over pensions is wrong is: “If not industrial action, then what?” I fully understand the anger that pensions reforms have caused, since I too have seen my expected pension diminished without my consent and have a personal interest in protecting the terms and conditions offered to the next generation of young doctors. If there were a more effective weapon at our disposal it would already have been deployed. But industrial action may result in collateral damage that outweighs the immediate benefit of hitting the target, and in political terms the consequences may be slow to emerge.

Industrial action is likely to diminish the authority of doctors and enhance political arguments for creating a devolved and fragmented healthcare system in which collaboration is replaced by competition, and commitment by contracts. The casualty in this slow process of attrition is trust, manifest by progressive erosion of what it means to be a professional. We see some of this effect in growing litigation, and in evidence to the Mid Staffordshire inquiry into serious lapses of care and compassion.4 Mid Staffs is not unique: little long remembered acts of unkindness, of not caring, of not taking responsibility, occur every day in the NHS. Industrial action is both a symptom and a facilitator of this sort of behaviour.

Neither the 1975 strike by junior doctors protesting against poor working conditions and pay nor the “work to rule” by consultants opposed to reductions in private beds in the NHS5 improved anything.6 What made the difference for junior doctors was persistent negotiation over many years within and outside the profession, and public support. Taking industrial action now will not solve the pensions problem. It will tarnish our reputation, diminish us as professionals, and compromise patient care.