Is it ethical for doctors to strike?BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5597 (Published 19 October 2015) Cite this as: BMJ 2015;351:h5597
- Marika Davies, freelance journalist
Marika Davies considers ethical aspects of strikes by medical professionals around the world
When junior doctors in England are balloted on industrial action next month, they will be conscious of the potential effect of any strike action on the care of patients and on doctors’ public image. The UK General Medical Council has said that doctors contemplating industrial action must follow its guidance. 1 “Doctors must make sure arrangements are in place to care for their patients,” its guidance says. “Their actions must not harm patients or put them at risk.”
There is a general consensus internationally that emergency care should always be provided during a strike, but other considerations also come into play when doctors consider the justification for a strike.
In response to strike action by doctors in 2010 the Delhi Medical Council said that it was of the view that “under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy.”2 Despite this, doctors in India have repeatedly engaged in strike action, including a nationwide strike in June 2012. Researchers at the Lokmanya Tilak Municipal Medical College in Mumbai recommend that a strike must be a last resort. “As doctors, our duties towards our patients [are] of the highest importance, but people must not forget that doctors are human beings, they have a life, a family, responsibilities and bills to pay like all of us,” they said. 3 “We must remember that human dignity and respect must be preserved from a doctor towards a patient, and the converse also holds true.”
In 1983 a strike by doctors in Israel over pay came to an end after 3000 doctors went on a hunger strike that paralysed the health system. An article about the strike in the Journal of Medical Ethics argued that strikes by doctors contradicted doctors’ responsibility to act in the best interest of patients.4 But the authors also pointed out that medicine could not function without the financial support of society and that responsibility for the patient did not rest solely on the doctor. “Depriving doctors of proper wages constitutes a breach of contract and justifies a walkout,” they said. “Therefore, society must take measures to prevent such a situation from occurring.”
National strikes in 1992 over the working conditions of junior doctors caused a raft of letters to the New Zealand Medical Journal complaining that the strike was unethical, with an equal number saying that the strike was justified. A further junior doctors’ strike in 2006 met with allegations from the public and senior doctors that the action was unethical. Frank Frizelle, editor of the New Zealand Medical Journal, said that the short term inconvenience of a strike must be balanced against an improvement in care.5 “If doctors (and others) truly believe it is important for patient care, then they must sometimes have the courage to do things that are unpopular and difficult,” he wrote. “If the conditions that doctors work under put patients at risk, then (on balance) they are morally obliged to strike.”
Doctors’ strikes have become “a part of normal existence” in Nigeria, said Olufemi Omolulu, a consultant in obstetrics and gynaecology in Lagos.6 Shima Gyoh, editor of Nigeria Africa Health, said that a strike by health workers was the worst option in the business of negotiating for higher wages.7 “The pawn is the public, with human lives and limbs as the bargaining chips,” he wrote. He warned that doctors who abandoned their patients were likely to be found guilty of misconduct if tried by the Medical and Dental Practitioners’ Disciplinary Tribunal. But he added that he had not heard of anyone reporting any striking doctor to the Medical and Dental Council on grounds that a patient suffered distress or death as a result of a strike. “Doctors must avoid the temptation of extremism by protecting the weak and the vulnerable during their quarrels with their employers,” he said.
When doctors in Pakistan went on strike in 2012 over a lack of service structure, security, and low pay the government called in law enforcement agencies to end the protests. Several doctors were physically tortured and arrested, and many were suspended from their duties. Imran Abbasi, a research fellow at Aga Khan University, said that it was important that the media were impartial when reporting on strikes.8 He said that in 2012 the media’s focus was on patients’ suffering. “People should have access to information and viewpoints of all stakeholders, which will help them in deciding the legitimacy of the situation,” he said.
The problem of striking doctors in South Africa was described as an “epidemic” in 2009 and was the subject of a symposium at the Nelson Mandela School of Medicine in Durban in 2010.9 Gboyega Ogunbanjo, professor of family medicine at the University of Limpopo, said that advocacy, dissent, and disobedience should precede strike action but that when a situation arose that was ethically catastrophic then exit from professional duties could be justified.10 “In such situations patients are likely to be harmed so the justification . . . must be made on moral grounds,” Ogunbanjo wrote. “The only moral ground is that health care will overall be substantially improved for the greater population. Can strike action by doctors ever be morally justifiable? Yes it can. But always at a cost.”
Doctors’ strikes are rare in the United States, but in January 2015 doctors across 10 campuses of the University of California staged a one day strike to protest about resourcing of students’ healthcare. David Kemp, a lawyer and columnist, said that healthcare providers might ethically leave their patients’ bedsides to go on strike only when the benefit of the patient was the ultimate goal and only after all other avenues of negotiation had been exhausted. “If we as a society allow those who care for our sick to abandon their oaths and their duties any more readily than this, then we too have abandoned our sick,” he said.11
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interest: I am employed as a medicolegal adviser by Medical Protection.