When the doctor cannot compromise: The deontology of conscientious objection and medical strike action
Gonzalo Herranz. departmentof Bioethics, University of Navarra.
lectureCourse on Legal Medicine and Medical Deontology, within the Programme of training. Continuing Medical Education of the Ilustre high schoolOficial de Médicos de Alicante.
Delivered on 4 June 1992.
The doctor-patient relationship as meetingbetween moral agents with convictions
I have chosen topicfor my intervention (When the doctor cannot compromise. The Deontology of Conscientious Objection and the Medical Strike) because it seems to me that doctors need, from time to time, to reflect on the state and function of their professional conscience. It is not a matter of examining his conscience in the sense of discovering what good or bad things he has done, but of checking whether his conscience is alive; that is, whether it is sensitive and delicate, and, at the same time, firm, solidly founded.
This reflection obliges us first to examine both the doctor-patient relationship and the doctor-health administrators relationship, as a meetingbetween moral agents, endowed with consciences and convictions, one of which is considered so fundamental and non-negotiable that it is not possible to compromise on it. Secondly, I believe it is appropriate to refer to the deontological significance of these two constitutional freedoms and rights to conscientious objection and to strike, in order to consider how and to what extent they apply to the practice of medicine. Thirdly, I will refer to the evolution of conscientious objection and medical strike in some of the countries around us, in order to draw some conclusions open to discussion.
The doctor-patient relationship as meetingbetween moral agents with convictions 
The doctor-patient relationship is, as a matter of principle, a friendly, peaceful relationship, based on trust and in which disagreements do not occur. This is the norm. Often, due to the simplicity of the problem presented by the patient and the brevity of the relationship, the doctor-patient meetingdoes not raise any conflicts: there is a tacit agreementabout the problem and its solution. However, in contrast to these encounters that take place on the epidermis of the conscience, there are others in which doctor and patient enter into a deeper moral dialogue and in which it is not so much a question of repairing the defects of an organism damaged by illness, but rather of respecting the moral image that doctor and patient have of themselves.
Respecting convictions
The Code of Medical Ethics and Deontology states, in its article4.1, that it is the doctor's primary duty to respect the dignity of the person; in article8.1 it states that, in the exercise of his profession, the doctor shall respect the convictions of the patient or those close to him and shall refrain from imposing his own on them; and then adds, in article8.2, that the doctor shall always act correctly, respecting his patient's privacy with sensitivity. The Code, and there is no need to go on quoting articles, presents the patient as a moral agent, endowed, regardless of the statusto which the illness has reduced him, with the supreme dignity of a human person, whose convictions must be respected, who must be treated with propriety and delicacy, precisely in what constitutes his privacy.
All this cannot be fully understood if we do not analyse, for a moment, the deontological significance of respect.
Respect entered medical ethics in 1948, when the World Medical Association ( association) offered physicians, as a substitute for the Hippocratic Oath, its Declaration of Geneva. On the surface, the change seems subtle, but it is, at heart, a Copernican shift. Subtle, because the content of the Oath and the Declaration are practically identical, since the Geneva Declaration merely seeks to translate the archaic language of the classical rules into modern language. But in substance, the mutation is radical: today, doctors no longer swear before God the clauses of the medical oath, but promise on their honour those of the modern promise. Respect, the core of modern deontology, is the secularist and universally acceptable substitute for the love of one's neighbour which was the religious core of the deontological tradition.
Without God behind it, deontological respect is always in danger of being relativised. It is, however, a very strong ethical notion. A doctor's respect for his patient is not limited to the rules of good practice Education. In medicine, such rules have a special relevance, for they are basically the cultural and social crystallisation of the basic notion that the weak are very important. But deontological respect, the respect that doctors must show towards their patients, goes far beyond the contents of politeness and good manners. Respect, as it emerges from the deontological precepts, is the centrepiece, the nervous system, of our ethical organism. It is first and foremost a sensory system. Moral life depends, to the greatest extent, on the ability to grasp moral values: only by having a great respect for each human being can the physician perceive the needs and aspirations presented to him by the humanity in crisis of the sick person. Moreover, the ability to identify the ethically relevant datarevealed to him by the patient, to order them according to their moral hierarchy, and to reach a correct judgement is not only a matter of knowledge and experience: his prudence and justice depend to a large extent on how deeply rooted the doctor's respect for the patient's person and convictions is. Even the effector arm of the moral organism, the habitual disposition to follow the dictates of conscience also depends on respect, for respect for others is an effective driving force that moves us to act, to serve the patient medically, with an intelligent and lordly subordination, not a servile or mercenary one.
The physician, moral agent
The Code obliges the physician to act always and in all conditions as a moral agent: both towards the individual patient and towards the institutions, public or private, that administer health care. According to article22.1: 'The physician must have professional freedom and the technical conditions that enable him to act independently and with guaranteed quality'. In medicine, as in any other human business, professional freedom is the fundamental requirement of responsibility. To a certain extent, professional freedom and independence have in the Code more the character of an ethical duty than of a fundamental right. A physician cannot renounce freedom, for to do so would make him or her irresponsible. Professional independence constitutes the moral frameworkthat the Nuremberg Declaration (article57-3 of the Treaty of Rome) requires for the doctor's workin the countries of the European Community. Paragraph I of this basic document states: 'Everyone must be assured that the doctor they consult enjoys complete independence in both moral and technical matters and is free to choose his or her treatment'.
The professional freedom of the physician is not a capricious free will: it is the duty of the physician to be able to choose, with knowledge and conscience, what, according to the medical art of the moment, is best for his patient. In all circumstances in which he works, the physician must be free to decide how much time to devote to his patient and to make the diagnosis; to apply the treatment that, in his judgement, best suits the patient's needs and interests; to determine the frequency and quality of the services to be rendered. If
I would like to recall, as it is considered by some as an obsolete rule, that it is a less serious offence not to submit contracts to the approval of the medical associations. Doctors cannot sign contracts that could seriously restrict their professional freedom.
Freedom is also a right of members recognised and enshrined in the WTO General Statutes. This freedom admits no limits other than the rules of ethics and bylaws. This is stated in article42, e): "Members have the right not to be restricted in their professional practice, unless it is not carried out in an ethical manner or due to non-compliance with the rules of this Statute that regulate it".
The physician thus has a right and duty of freedom and independence, and at the same time has an obligation to respect the patient's convictions and the reasonable demands that derive from those convictions. In the medical act, two human beings endowed with freedom and conscience meet face to face. It has been said in the past, in a lapidary phrase, that the doctor-patient relationship is the meetingof a trust with a conscience. Today it would be better to say that it is the meetingof two consciences, of two moral agents who must respect each other. This is what gives the physician's activity its human dignity and its strong ethical charge.
Respect for the patient as a moral agent
The exercise of respect is manifested in three fundamental moments of this relationship, which can be characterised as perception-knowledge, assessment-negotiation, and decision-action. The respectful doctor discovers many things about his patient right from the start, when taking the medical history and exploring the patient, data. The patient may reveal many things to him, more or less explicitly, about his attitudes to the illness, the way he demands his rights, his religious beliefs or his ethical opinions. Physicians will only invade their patients' privacy when and to the extent that it is strictly necessary. Sometimes he will respect his patient by refraining from enquiring about his convictions, because these play no part in the solution of the problem being consulted; at other times, respect requires enquiry, because only by knowing the patient's convictions will the physician be able to respect them.
If the doctor is aware of the patient's aspirations and wishes, he/she will be in a better position statusto propose the diagnostic and therapeutic measures that, in his/her opinion, should be applied. On the vast majority of occasions, there is a full coincidence of objectives, which leads to cooperation without conflict. Informed consent for diagnostic and therapeutic action comes about almost spontaneously, so there is no need for negotiation. But it sometimes happens that the views - technical, ethical, religious, professional - of doctor and patient on what to do and how to do it differ markedly. The physician must enlighten the patient, clearly and straightforwardly, without arrogance or paternalism of the wrong kind, about the medical aspects of statusand give the patient the reasons that support the plan he or she is offering. The doctor's loyalty to the patient obliges him not to omit from this information any information of moral significance to the patient. But he must always respect the patient's freedom. The patient, as a moral subject, must give thoughtful and considered consideration to the information communicated to him and act freely.
The ethics of polite disagreement
What happens when the convictions of doctor and patient do not allow them to reach an agreement agreement, and a dead-end statusoccurs? Situations of this kind abound today subject: in questions of human reproduction, in the refusal of treatment, in the face of very aggressive oncological therapies, in the face of certain psychiatric treatments, in cases of prenatal diagnosis or the suspension of terminal care, in the application of certain alternative medicines, etc.
Several social factors favour such disagreements today, and their frequency is likely to increase in the future: the growing ethical pluralism of society; the consumerist mentality spread among more patients issue, which tends to create the notion of "à la carte" medicine; the growing role of patients in clinical decision-making, which will increase as the health culture disseminated through the media speech grows; and, finally, the denunciation of certain abuses, real or imagined, committed by doctors and which spread a diffuse prejudice against medicine and doctors.
The disagreement may arise from the patient's refusal, for cultural or religious reasons or for reasons of simple opinion, of the diagnostic or treatment plan proposed by the physician. Or it may be that the physician rejects as unacceptable, for ethical or scientific reasons, the patient's request (e.g., a complacency certificate, an unjustified work leave, or an abortion).
What does professional ethics provide for such situations of conflict? The conduct to be followed in the first case is set out in article9 of the Code, which deals with the continuity of care that physicians undertake to ensure for their patients, once their relationship has been initiated and established. Continuity of care may be suspended if the physician "becomes convinced that the necessary confidence in him does not exist. He shall then inform the patient or the patient's relatives and arrange for another physician, to whom he shall pass on the appropriate information, to take over the patient's care" ( position). Continuity is a natural element of the ordinary doctor-patient relationship and one of its most genuine manifestations. The physician responds to the patient's free choice or to the legal or regulatory requirement to treat him/her with a commitment to provide appropriate care for the necessary time. The physician cannot unilaterally abandon his patients as long as they are in need of his care. And, if he or she suspends care, he or she is obliged to ensure that another physician takes over the care of the patient and to provide the colleague chosen by the patient with the appropriate information (medical history, data, treatment given) so that his or her colleague can continue the patient's care. Continuity of care is therefore a serious obligation that a physician cannot failon his own initiative unless he has sound reasons.
The second statusis the subject of article10: "If the patient...demands from the physician a procedurewhich the physician, for scientific or ethical reasons, deems inappropriate or unacceptable, the physician is relieved of his obligation to attendance". In such situations of disagreement, the physician must inform the patient of the reasons why he or she cannot afford to accede to the patient's wishes. If, after reasonable discussion, it is not possible to reach a decision acceptable to both parties, they should proceed to failin a correct and polite manner. In contrast to articleabove, and by virtue of the special nature of the severance of the doctor-patient relationship contemplated here, the physician remains free to decide in conscience whether or not to lend financial aidto the patient in the search for a colleague who is willing to accede to his or her wishes. Obviously, he is not obliged to do so. Nor can he do so morally, if for him such a financial aidis tantamount to cooperation with evil. There is, however, a widespread view that, in the event of a disagreement on moral grounds (e.g. abortion), the physician is obliged to tell the patient which other colleague can perform the procedure. In the A.W.M. Declaration of Oslo, it is stated: "If the physician considers that his convictions do not permit him to advise or perform an abortion, he may withdraw from the case provided that he ensures that a competent colleague continues to provide attendancemedical care. This rule, which was established some time ago, for what was then called therapeutic abortion, because there was an idea, now superseded, that, in certain very serious and exceptional circumstances, it was necessary to perform an abortion to save the life of the mother. This ruleis abusive and disrespectful to the conscience of the doctor, as he cannot live a double standard and judge that what he morally forbids himself because he considers it a serious breach of ethics, can be lawfully practised by other colleagues with more relaxed morals.
It is more difficult to failthe doctor-patient relationship than to initiate it. But it can never be a violent or irreversible rupture, or have the appearance of a withdrawal. When a break is unavoidable, the physician, in order to guard against legal action, will write a letter to the patient well in advance, stating that he or she will continue to provide services until a certain date, giving the patient time to find another colleague to care for him or her. He or she will also offer to resume the relationship if the reasons for the break disappear. There are also mechanisms within public health systems that, directly or through patient care services, facilitate as far as possible the search for solutions when the relationship that existed until then breaks down, either on the doctor's or the patient's initiative.
Conscientious objection to abortion
article27.1 of the Code states that "it is in accordance with professional ethics that the physician, because of his ethical or scientific convictions, abstains from internshipabortion or in matters of human reproduction or organ transplantation. He shall promptly give reasons for his abstention and, if necessary, offer appropriate treatment for the problem for which he was consulted. He shall always respect the freedom of the persons concerned to seek the opinion of other physicians".
The articledoes not limit itself to establishing the deontological nature of conscientious objection and scientific objection to abortion - it also admits it in relation to other issues - but also indicates the conduct that the doctor must follow when faced with persons who request information or services to which he or she objects.
instructionsand scientific objection, ethical and scientific objection
The deontology of refraining from performing abortions and counselling in matters of human reproduction is based on both ethical reasons and professional considerations. On the one hand, abortion and certain reproductive techniques violate the respect due to human life. On the other hand, abortion is not the scientific solution to any medical problem.
Of the legal indications for abortion, only those that are presented as medical indications require a medical-deontological analysis: the so-called therapeutic abortion, to save a woman who is supposedly in serious danger to her life or health, a danger that is due to the circumstance of continuing the pregnancy; and the abortion of a foetus affected by malformations or illnesses that may induce serious physical or psychological deficiencies.
The decision to treat the woman's illness without resorting to the destruction of the unborn human being stems from a profoundly professional attitude, scientifically and ethically superior to its opposite. Today, given the formidable advances in the clinical management of diseases that can seriously endanger the life of the pregnant woman, no truly competent physician considers abortion to be the treatment of choice for any illness of the mother: abortion is not such a superior and advantageous solution compared to the other treatment alternatives that it becomes ethically binding to propose or practise it. Without the need to invoke conscientious objection, the physician, based on the medical art of the moment, can refuse abortion on instructionsstrictly scientific grounds. It is not that he is refusing it on strictly moral grounds, but that he is offering valid treatment alternatives that can not only solve the medical problem of the pregnant woman, but also respect the life of the unborn child.
The doctor's refusal to abort foetuses with malformations or defects that seriously damage their further physical or mental development developmentis justified by the specifically medical respect for the deficient life. The article25.2 confers the sick unborn child the status of patient. Abortion is excluded as a treatment for the sick foetus, because the eugenicist idea of life free of imperfections, submission to the "tyranny of normality", is alien to medicine.
The conduct of the objecting doctor towards the woman requesting the abortion
The refusal of an abortion can never mean a moral insult to the person who has requested it. This article points out the deontological path that the doctor must follow: faithful to his ethical and scientific convictions, he will not limit himself to refusing the abortion, but will give the pregnant woman, calmly and clearly, the reasons for his decision. He will offer to treat her in accordance with scientific and professional criteria that respect equally the life and human dignity of the mother and the unborn child, showing the advantages and possible risks of this approach, while explaining the biological, professional and ethical basis for his refusal of the abortion requested.
The physician is repugnant to violence. If his or her offer is refused and the pregnant woman decides to seek another physician who will respond to her wishes, the objecting physician shall terminate his or her professional relationship with the patient. purposeIn respecting the woman's freedom, the criteria set out in article9 shall apply to the termination of the physician/patient relationship. The physician is not deontologically obliged to tell the woman which colleagues or which facilities would not make it difficult for her to undergo the abortion operation, for that would be to go against his own conscience and to cooperate in an action that he considers morally unacceptable. It is unacceptable, in good ethics, to act against one's own conscience; it is also unacceptable to profess the moral duplicity of considering that it is morally permissible for others to carry out actions that one considers unethical. This relativistic view, in more or less attenuated form, is widespread.
The protection of objectors
The article27.2 states that "the physician should not be conditioned by actions or omissions outside his or her own freedom to declare conscientious objection. The Medical Associations shall, in any case, provide him with the necessary advice and assistance financial aid". The protection of the freedom of those who claim conscientious objection is a matter required by the protection of professional independence. Recent history, in other countries and, episodically, also in our own, samplethat, at times, objecting physicians may be subject to discrimination by other colleagues or by those who run the health institutions in which they work.
There is no moral life without freedom, and no professional responsibility without independence. The articleencourages physicians to oppose any action that seeks to diminish their freedom or to discriminate against them because of their seriously matured and sincere ethical attitudes. It does so not only in the name of the rights to ideological freedom and non-discrimination enshrined in the Spanish Constitution (article16: "The ideological freedom of individuals and communities is guaranteed....... No one may be forced to declare their ideology, religion or beliefs"; article14: "Spaniards are equal before the law, and no discrimination may prevail on the grounds of birth, race, sex, religion, opinion or any other condition or circumstance staffor social"). It also does so in order to fulfil the statutory duty to "defend the rights... of the members... if they are subjected to vexation, undermining, disregard or disregard in professional matters" (article34, b, of the EGOMC) and to respond to the right of members "to be defended by the high schoolor by the committeeGeneral when they are vexed or persecuted because of their professional practice" (Att. 42, b of the aforementioned EGOMC).
The most fearsome forms of discrimination are not, however, the blatant deprivations of rights, but the techniques that are often used to subtly and finely bend the moral resistance of those who do not bow to the wishes of those in power. There are legal channels to counteract serious unjust reprisals (dismissals, transfers, opening of files). But there are none to defend against these other forms of ideological torture by which the objector can be discriminated against.
The Medical Association undertakes to provide moral support and advice to members whose professional freedom is under attack. It will be able to do so effectively in cases where the directors of institutions or groups of work, intolerant of objection, are members of the medical profession.
Hierarchical relationship, compromise and conscientious objection
I think it is worth mentioning the problems that the hierarchical organisation of hospital medicine and groupmay pose for the individual freedom of doctors and of the auxiliary staff. Doctors are obliged, by virtue of the principle of collegiality, to treat each other, says article33.2 of the Code, "with due deference, respect and loyalty, whatever the hierarchical relationship between them". The registrationat high schoolmakes physicians colleagues, confirms them in a common fellowship and vocation. The ethical respect due to nurses and auxiliaries implies respect for their freedom, their moral autonomy and their professional skill. Any interprofessional relationship must be marked by harmony. Above and beyond all legitimate differences (of professional opinion, hierarchical, generational, ideological, modalityof practice, etc.), doctors are colleagues of their colleagues, co-participants with assistants in the care of patients, who must put aside their disagreements whenever these may cause deficiencies in the care of patients.
Deontological respect for colleagues must be strong enough to overcome the difficulties that arise, for example, from the inevitable frictions of coexistence, differences of opinion on professional matters or tensions over the distribution of responsibilities and competences. It is disrespectful, for example, the conduct of those who, taking advantage of their greater age or hierarchy, burden certain colleagues with the most unpleasant part of their own work, or treat them in an unfair and discriminatory manner. The Code establishes that there is a moral duty to defend the colleague when he or she is the victim of attacks or unjust denunciations, discriminations or vexatious attention. This defence includes the speechto high schoolof "any harassment or abuse of a colleague in the exercise of their professional duties of which they are aware" (article43, c of the EGOMC). The high schoolhas as a specific skill"to defend the rights and prestige of the members they represent or of any of them, if they are the object of vexation, undermining, disregard or disrespect in professional matters" (article34, b of the same statutes). It goes without saying that the righting of such wrongs must be carried out in the strictest justice: it is unethical to repress or compensate a wrong by committing a greater one, taking revenge into one's own hands.
In order to understand the tensions that can arise between tolerance and intransigence, we are very interested in the content of article35.3: "The hierarchy within the team - it says - must be respected, but may never constitute an instrument of domination or exaltation staff. The person in charge of groupshall ensure that there is an atmosphere of ethical demands and tolerance for the diversity of professional opinions, and shall accept abstention from acting when one of its members has a reasoned scientific or conscientious objection".
It is not enough to be in charge; it is necessary to win the support of the governed day by day by means of skill, honesty and example. Assuming that the person in command has the technical ability to make decisions, his managementmust be based on moral and scientific authority, but also and above all on the ability to work, on the rationality of orders and on respect for subordinates. The articleimplies that authority should be conceived as a service to others, not as an opportunity to exercise despotic domination. Hierarchical authority among colleagues is not a awardgranted to mere seniority in the ranks or a prebend to political servility. It is a moral authority.
The director of group is manager to supervise not only the internal actions of the members of group, but also those that, as members of group, they carry out externally, such as, for example, communications to congresses or articles for scientific publications, prepared with the material and experience of group. Logically, this supervisory task should involve fair criticism, timely advice and recommendations, and respect for differences of opinion. In case of disagreement at subject scientific or professional, the group editor may require the authors to include an exclusion of liability clause on their work . This will state in the published article that the ideas expressed therein by the authors do not represent the collective opinion of the group.
Respect for colleagues manifests itself, above all, in recognising their right to hold and maintain their personal scientific and professional convictions and in creating an atmosphere of tolerance for ideological diversity, which allows for peaceful and constructive coexistence. Among the most significant phenomena of contemporary society are, on the one hand, the recognition of ethical pluralism as a reality to be lived with and, on the other hand, the acute sensitivity towards individual human rights. Both phenomena are embodied, among other things, in the need to respect the convictions of others and in the condemnation of physical or moral violence as an instrument of coercion.
Respect for ideological diversity must be present in hierarchical relations between colleagues. Whoever directs the distribution of work must accept and respect the objection to certain actions that some or all members of group may invoke because of their scientific or conscientious convictions. It is true that such objections, by breaking established routines, may cause inconveniences of a certain amount, but they do not have a negative significance: they are the price to be paid for the moral progress of society and, first and foremost, of group.
No one may invoke a scientific or conscientious objection as a ploy to get out of unattractive work. The moral integrity of the objector requires him to accept a burden from work that fairly compensates for what he has failed to do by virtue of his abstention. And whoever has the government of group must provide, without arbitrariness for or against, that this compensation is made in justice.
At times, a civil, ecumenical and peaceful ethic has been invoked as the minimum common ethical dividing line for the coexistence of all in today's pluralistic society. And since fanatics of the best ideas are never lacking, some claim that such a civil ethic must be compulsorily accepted by all, which is nothing less than a tyrannical pretension and the death of ethical pluralism. It is much more congruent with the internship of freedom, and infinitely more humane, to respect the convictions of each individual than to authoritatively force, even if only one, to violate his conscience, putting him in the alternative of abjuring his beliefs or abandoning a work that he lives vocationally and to which he has given his existence.
Medical strike ethics
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 medical strikes always pose a serious moral dilemma: the organised suspension of medical care always causes harm to patients, who are the innocent victims of labour disputes. Leaving aside the anecdotal datawhich reports a drop in hospital mortality during strike days, every doctor feels uneasy that the strike contradicts the fundamental deontological principle of "do no harm". It is not easy to define the boundary between urgent, non-urgent care and elective, 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 doctors as to when and under what conditions strike action is ethically justified.
Some of our colleagues deny that there can be an ethically acceptable strike 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. Strikes often produce, when they harden - and serious strikes always tend to harden - greater harm than the harm they are 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 and foremost, do no harm. Consequently, physicians may never knowingly cause harm to patients entrusted to their care. Other physicians argue that only a strike that seeks to correct serious deficiencies affecting the care of the sick, the physician's diagnostic and therapeutic work, is lawful, for in such a strike, the physician is not seeking selfish advantage: he is striking on behalf of the patients, not against them; he is seeking their benefit, not their harm. Finally, there are those who believe that seeking to improve an objectively unfair or grossly unsatisfactory statusemployment or remuneration of physicians is a sufficient ethical reason to go on strike, since it is impossible for a salaried physician to separate his or her status as a physician from that of an employee status, or to sacrifice basic human rights to abusive labour standards. If the ethical nature of medical strike action were to be denied on pay or organisational grounds, doctors would be powerless 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 one's opinion on the lawfulness of medical strike action, it is generally accepted that, in medicine, strike action 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 differing opinions of colleagues must be respected: medical centres can never be places of physical or moral violence. I believe that picketing is out of place in health care institutions, where it must be assumed that all those who work there have seriously formed their conscience in relation to the strike, its aims and means. Patients must also be respected: during strike days their therapeutic needs are not cancelled and they do not lose their status as human beings whose demands 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 resolve but also to prevent developmentconflict situations, endowed with such moral authority and technical skillthat their resolutions are 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. A national health service, as well as 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 damages and economic losses caused to citizens on the occasion of strikes should be compensated. 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 takes precedence over others. If in the course of a medical strike, due to 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 succeed against those who have established that deficient rate of minimum services.
In my opinion, it is crucially important to find effective ways of ensuring that employers at least meet the minimum technical and moral conditions that institutions must offer doctors so that they can work with guaranteed quality. Doctors are obliged in conscience to determine what these minimum conditions are requirements: in terms of the time they have to devote to their patients, in terms of facilities and instruments, in terms of staffauxiliary, etc. We must not forget that freedom of prescription is an inalienable duty, for 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 a doctor's loyalty to his or her patient. A physician who does not enjoy freedom of prescription cannot guarantee professional confidentiality, quality and continuity of care for his patients.
Finally, I would like to comment on the ethical legitimacy of the strike in defence of the doctor's freedom to prescribe. It is impossible for a doctor to work ethically and responsibly while being deprived of a significant part of his or her freedom. No director health institution today can ignore the fact that it is neither lawful nor dignified to demand blind obedience to their orders. The doctor 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.
According to article22.2, "individually or through professional organisations, physicians shall draw the attention of the community to deficiencies that impede proper professional practice". According to article3.4 of the EGOMC, 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 health care attendance...". This partnershipwhich, 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.