Medical strike ethics

Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
lecture delivered in Cordoba, 1995

Today, the right to strike enjoys great prestige. It is enshrined in the Constitutions of free peoples, legitimised in papal encyclicals, recognised in social ethics as a legitimate manifestation of civil disobedience, a demand for rights and an instrument of labour justice. In medicine, however, strike action poses very serious ethical problems. The Code is very brief and only alludes to some of them. Its article6 states: "In the event of a medical strike, physicians are not relieved of their ethical obligations towards their patients, to whom they must provide urgent and urgent care that cannot be postponed. The Code is silent on what circumstances justify a strike. Making ethical recommendations for strike action can be interpreted, in principle, as a tacit acceptance that strike action can be deontologically justified, i.e., that ethically acceptable reasons for strike action can be given.

It is not difficult to imagine some of them. skillIt may happen that the conditions under which salaried doctors work, in public or private institutions, become ethically unbearable, either because they do not have the material means to carry out their work technically, or because the human relations they have with their managers or employers are degrading, or because the labour regulations to which they are subject or the salaries they receive are unfair and incompatible with professional dignity. When dialogue to seek solutions reaches an impasse and no progress is made towards understanding or reasonable negotiation, it seems that the only way to force a solution is to resort to strike action.

But the medical strike always poses a serious moral dilemma: the organized suspension of medical care always causes harm to patients, who are innocent victims of the labor conflict. Leaving aside the anecdotal data which reports a drop in hospital mortality during strike days, every physician feels uneasy that the strike contradicts the fundamental deontological principle of do no harm. It is not easy to define the boundary between urgent and unpostponable care and elective and deferrable care. Moreover, the temporary suspension of medical care always causes patients a greater or lesser degree of anxiety Degree . It is logical, therefore, that there is no unanimity among physicians as to when and under what conditions a strike is ethically justified.

Some of our colleagues deny that an ethically acceptable strike can occur in medicine, because the concerted suspension of medical care necessarily entails a deterioration, with consequences that are difficult to calculate and justify, in the care of the sick. The strike usually produces, when it hardens - and serious strikes always tend to harden - greater harm than it is intended to alleviate. For many physicians, the moral injunction to do no harm, primum non nocere, has a priority value, to be taken for what it says: first of all, do no harm. Consequently, the physician may never knowingly cause harm to the patients entrusted to his care. Other physicians maintain that only the strike that seeks to correct serious deficiencies affecting the care of the sick, the physician's diagnostic and therapeutic work , is licit, because in such a strike, the physician does not seek selfish advantages: he undertakes the strike on behalf of the patients, not against them; seeking their benefit, not their harm. Finally, there are those who think that trying to improve an objectively unjust or extremely unsatisfactory labor or remuneration status for physicians constitutes sufficient ethical reason to go on strike, since it is impossible for the salaried physician to separate his status as a physician from that of an employee status , or to sacrifice his basic human rights to abusive labor standards. If the ethical nature of the medical strike were to be denied for salary or organizational reasons, physicians would be left defenseless in the face of exploitative policies and would end up being impoverished both in their human and professional dignity, as well as in their economic status .

Whatever the opinion on the lawfulness of a medical strike, it is generally accepted that, in medicine, a strike can never be a protest action that is applied in an absolute manner and carried to its ultimate consequences. On strike days, the ethic of respect remains fully in force. The divergent opinions of colleagues must be respected: medical centers can never be places of physical or moral violence. I think that informational picketing is out of place in healthcare institutions, where it must be assumed that all those who work there have seriously formed their conscience in relation to the strike, its ends and means. Patients must also be respected: during strike days their therapeutic needs are not annulled, nor do they lose their status as human beings whose requests for care must be taken seriously.

If the medical strike is carried out in an ethic of respect, it inevitably tends to become a symbolic gesture. It can never have the character of an industrial action. And this is because, regardless of what legislation or agreements say about the minimum services that must be maintained during the strike, a total strike in medicine is ethically inadmissible. The deontological duty to ensure the care of serious and urgent patients and the unpostponable diagnostic and therapeutic attendance, on the one hand, and altruism in complying with the minimum services, on the other, tend to dilute in such a way the social discomfort created by the doctors' strike, that it becomes inoperative as a means of pressure against public administrationor against health employers: it serves, in the best of cases, as a loudspeaker that denounces to society the serious deficiencies of the system.

An eloquent demonstration of the intrinsic weakness of the doctors' strike is the text of the deontological rules that the committeeSuperior of the Belgian Order of Doctors established as obligatory in the event of a medical strike: "...It is ethically admissible to organise a collective suspension of the activity of doctors as long as it ensures:

 1. for patients already in care, the necessary treatment;

 2) to all, the attendancethat the doctor deems indispensable according to his conscience".

Every strike has as its natural end a negotiation between the parties in conflict. In medicine, there should be arbitration mechanisms not only to solve, but also to prevent the development of conflictive situations, endowed with such moral authority and technical skill that their resolutions would be imposed by the force of reason. Both medical unions or strike promoters, on the one hand, and employers (Ministry of Health, insurance companies, private hospitals), on the other, are morally obliged, albeit by different degree scroll, never to lose sight of the particular obligation they have not to harm patients. Both a national health service and a private medical service business have ethical commitments to society that cannot be systematically sacrificed to their economic interests, no matter how adverse the circumstances may be. There is no unanimity as to how and by whom the economic damages and losses caused to citizens on the occasion of strikes should be repaired. It is said that since the right to strike is a fundamental right that takes precedence over many other rights, the damages that may be caused by its exercise are not compensable. However, the right to life, at least in certain circumstances, is the fundamental right that prevails over the others. If in the course of a medical strike, due to an inappropriate calculation of the level of minimum services set by the Administration, a case of death attributable to neglect were to occur, a criminal complaint could probably prosper against those who have established that deficient rate of minimum services.

In my opinion, it is crucially important to seek effective ways of ensuring that employers comply with at least the minimum technical and moral conditions that institutions must offer physicians so that they can work with guaranteed quality. The physician is obliged in conscience to determine what these minimum requirements are: in time to be dedicated to his patients, in facilities and instruments, in auxiliary staff , etc. Freedom of prescription, we cannot forget, is an inalienable duty, since, without it, there can be no professional responsibility. Enjoying professional independence is not a whim or a demonstration of arrogance, but a serious duty imposed by the physician's loyalty to his patient. A physician who does not enjoy freedom of prescription cannot guarantee his patients professional confidentiality, quality and continuity of care.

Finally, I would like to comment on the ethical legitimacy of the strike in defense of the physician's freedom to prescribe. It is impossible for a physician to work ethically and responsibly while being deprived of a significant part of his freedom. No health institution director can ignore today that it is neither lawful nor dignified to demand blind obedience to their orders. The physician is not a robot. In a state of rights and freedoms, to bow against conscience to coercion or threat is an unworthy and immoral action. Since the Nuremberg Trial, it is no ethical or legal justification to claim that one's own unjust actions were committed "under orders".

This is why, in a time such as ours, when so much is commanded and with so much energy, it is an important duty of doctors to protect their freedom to prescribe against the many factors that tend to limit or destroy it. No physician may ethically work in the service of institutions that do not respect the rules of ethics or that prevent a competent and free workfor the benefit of the patient. internshipThe Nuremberg Declaration (article57-3 of the Treaty of Rome), which deals with the fundamental principles governing the profession within the Community, states in paragraph I: "Every person must be assured that the physician to whom he has recourse enjoys complete independence in moral and technical matters, and that he enjoys the freedom to choose his own treatment".

The scarcity or deprivation of technical resources is a factor of iatrogenic harm, which the doctor cannot tolerate. The expropriation of moral resources (freedom to prescribe, non-discrimination vis-à-vis other colleagues, guaranteed stability at work, the right to continued medical care at Education, etc.) is highly pernicious, for it dispossesses the physician of his or her conscience and turns him or her into a plaything of the employer, be it the State, the insurance company or the private clinic. Certain conditions at workdegrade the doctor, such as disproportionately low pay, deprivation of rest due to excessive on-call duty, or the denial of labour rights, which tend to induce a psychological or real "proletarianisation" of doctors.

The article 22.2 states that "individually or through professional organizations, the physician must draw the attention of the community to the deficiencies that impede the correct professional practice". According to article 3.4 of the EGOMC (General Statutes of the Collegiate Medical Organization), it is a very proper function of the Colleges to collaborate "with the public authorities in achieving ...the most efficient, fair and equitable regulation of the health attendance ...". This partnership which, ideally, should be synergetic, sometimes takes on shades of antagonism and acrimony.

It is very important for physicians at such times to always maintain equanimity and to judge responsibly whether the deficiencies are in fact a morally intolerable deterioration of medical services, or whether they are merely annoying and irritating inconveniences with which they do not agree agreement. The medical strike is a tough test of professional ethics.

Epilogue

These are the main points that the Code of Medical Ethics and Deontology devotes to this problem, so human and so complex, of tolerance and disagreement, of discrepancy taken to the limit of rupture. I believe that the solution lies in practising dialogue and negotiation, in order to clarify attitudes and iron out differences; in exercising ethical respect for people, so that everyone can act as a mature moral being and manager; in recognising that only in educated disagreement can one find a way out of conflicts of conscience.

Thank you very much.