Ethics of the health strike
Gonzalo Herranz.
department Bioethics Department, University of Navarra.
Introduction
The health strike is a relatively recent phenomenon, reaching appreciable proportions only in the second half of our century31 . Only then did the necessary political conditions (recognition by democratic societies of the right to strike, development of professional trade unions) and the socio-labour circumstances (widespread introduction of salaried medicine: interns and residents, doctors contracted by public or private hospitals, and, above all, the massive development of the National Health Services, which turned the State into a quasi-monopoly of the employment health service) come together. In earlier times, medical strikes were almost unthinkable, something alien to the ethical tradition of medicine.
The same was true of the nursing profession. Although basically salaried, it was nevertheless born as an altruistic and generous vocation, inherited from its founder, Florence Nightingale, with a strong sense of hierarchy and obedient discipline , far removed from the rebellious morality of the strike demands or the feminist equalisation of women's rights.
It is not surprising that, as a result of the survival of old traditions and the introduction of new attitudes, doctors and nurses are divided in their opinions about strike action and how to deal with it2, 3, 4, 9, 19, 20, 30, 36. The disagreement concerns, first of all, the basic question of whether or not the organised withdrawal of work is ethically acceptable in outpatient clinics and hospitals. But also, among those who do not reject strike action, there are profound disagreements about some subordinate ethical issues, such as who may go on strike, what grounds and circumstances may authorise it, what its intensity and duration should be, or what role the disputing parties should play in the resolution or, preferably, in the prevention of conflicts.
In this article I intend to review the opinions that have been expressed on the ethics of health strike action, in order to conclude that, although salaried doctors and nurses, like all those in paid employment, have the right, within the framework allowed by law, to collectively exercise their right to fail work , this is a right which, for deontological reasons, they should not make use of. resource A strike by healthcare workers does not seem to be the ideal, or even effective, way of resolving conflicts, as it puts the lives and health of patients at risk and puts them at risk.
The health strike, in its extreme form of total and indefinite suspension of services, is universally considered to be irrational violence, incompatible both with the righteous conscience of doctors and nurses and with the administrative rules on minimum services7. Strike action, in its mild and moderate variants of partial and short-term suspension of work , is an ineffective instrument for forcing the concession of wage or organisational demands. If the strike hardens in its intensity or is repeated again and again, it loses popular support, as the real damage becomes much more obvious to the public than the future benefits. The health strike is destined nowadays to be a weak action, which employers, especially the powerful modern state, can resist almost without damage and for a long time. It is more a rhetorical gesture than a procedure of force.
This study concludes with proposal: that the actors concerned - employers and employees, but also and very importantly the patients' representatives, who should not stand idly by in situations that affect them so immediately - are morally obliged to design a system of preventive arbitration that, by ensuring fair and reasonable conditions for the health care work , makes the resource strike unnecessary.
The fuzzy legal framework of the healthcare strike
The resource to strike is a fundamental human right and an achievement of social justice. This is recognised by the Catechism of the Catholic Church8. In our country, it is recognised, at the highest legislative level, by the Spanish Constitution, which confers this right on all workers so that they can defend their interests. The article of our Magna Carta adds that the exercise of the right to strike will be regulated by a law that will establish the necessary guarantees to ensure the maintenance of the essential services of the community10.
Many years have passed and, after a few failed legislative attempts in the past, the strike law mandated by the Constitution has still not been enacted in Spain. A few decrees and a few court rulings, including those of the Constitutional Court, have been precariously filling this legal vacuum. As a result, the regulation of the right to strike in Spain, from which healthcare workers are not excluded, falls within a poorly defined legislative space. There are, however, a few points to be found at reference letter: a strike cannot be called without having been announced at a predefined deadline ; health activity is one of the essential services, so that it cannot legally be completely suspended, but only reduced; the level of minimum services to be provided by the striking collective is set by the governmental authority. In order for the governmental authority not to exceed its functions, the Constitutional Court has pointed out that it is obliged to act according to rational, well-founded and objective criteria, which guarantee the essential attention of the population, but which do not unduly restrict the right to strike recognised by the Constitution. Thus, the intensity and extent of the strike are not determined by the health professionals, but are imposed on them from outside by the Administration14.
The legal rules and regulations is here, as in many other fields of health care internship , too poor a framework to regulate the conduct of doctors and nurses in such a critical status . The ethics of the health professions offer a much more nuanced picture.
Ethical attitudes of professionals in the face of the health strike
Around the core of the unanimous agreement in rejecting a total health strike, doctors and nurses have differing attitudes about the reasons that ethically justify a limited health strike and the circumstances and ways to carry it out.
Strike action tends to be presented as a collective, gregarious phenomenon in which the dynamics of group tend to prevail over individual decision. Little research has been done on the important issue of the relative role played by personal motivations, union activism, the imposition of slogans by picket lines and employer dissuasion in initiating and maintaining health strikes: the few available programs of study suggest that the pressures of group and visceral decisions are more important than deep ethical reflection25, 35, 38.
Attitudes to strike action have been classified into certain models or categories38 , which can ultimately be reduced to three prototypical positions:
a. declaring that limited strike action is never permissible;
b. which proposes that limited strike action is not contrary to professional ethics if it is intended to dignify the working conditions or salaries of health workers;
c. which considers ethically acceptable only limited strike action in the specific interests of patients.
a. Limited strike action is never in accordance with professional ethics.
For some doctors and nurses, strike action is never morally justified, as they consider it incompatible with the obligation to serve the sick, which is an essential part of their vocation. In a survey survey of resident physicians in the United States, only 8.6 per cent felt that a strike was never justified, regardless of the circumstances38.
This view is rooted in the Hippocratic mentality, very strongly centred on the deontology of care manager to the individual and real patient, insensitive to the community commitments of the physician and blind to consequentialist considerations of possible benefits of hypothetical future patients 3, 20, 21. The fundamental commitment of the follower of Hippocrates to punctually and faithfully serve the patient before him and to protect his life and health prevails as an indeclinable obligation of conscience both in the face of demands for better material or moral conditions in which future patients are cared for, and in the face of unduly low salaries received by the physician, or the recovery of the desirable lost or usurped professional autonomy16.
The absolute rejection of strike action has, in some professional circles, attained the status of a binding statutory-ethical duty. Thus, for example, a widely circulated Ethics guide in the United States refers to the medical strike in these words: "It is unethical for physicians to suspend medical services if patients may be harmed or if the strike is for the benefit of the physicians. Individually or at group, physicians possess sufficient social standing, political awareness, and initiative to find other ways of solving the problems that justify such drastic social and political action, and are therefore obliged to exhaust all possible alternatives to strike action. "1 The Code of Professional Conduct of the Royal Nursing Council of the United Kingdom high school states that "...both the disruption of services by strike action, and the mere threat of strike action, are in direct contradiction to the professional commitment to serve patients. Strikes by nurses themselves must therefore be publicly rejected, as must strikes by other health care professions or bodies involved in health care "33. 33 In recent times, however, British nurses have been vividly debating whether this total rejection of strike action clause should be retained. There is a prevailing impression that their days are numbered12.
The defence of this attitude of total rejection of strike action, including limited strike action, is based above all on arguments that appeal to the virtues and traditions of the profession, arguments that are largely deontological.
a) The strike is unacceptable because it violates the primary professional duty not to harm, imposed both by the classical tradition of primum non nocere and by the modern principle of non-maleficence. The withdrawal of the sick, implicit in any strike, is hardly compatible with the clause of the Hippocratic Oath which obliges the doctor to work exclusively for the benefit of the patient and not to inflict any harm on him or her. The health professions will never have work-related and technical reasons to justify the unilateral withdrawal of patients and thus defraud the trust they have placed in them.
b) It is a cynical contradiction to say that strike action aimed at improving health care not only does no harm, but offers a strong favourable balance, as it exchanges a few days or weeks of minimum services for a lasting status of more satisfactory services. The doctor's first duty is to treat his real patients here and now, not to make them suffer for the sake of the welfare of hypothetical patients. Using the patient's suffering or even mere discomfort as a foothold for improving services for future patients, often for a pay raise in the process, amounts to treating these real patients as means to an end, which is abhorrent behaviour and the antithesis of treating them as people. Neither doctors nor nurses can succumb to the fallacy of doing evil to achieve good.
c) Even strikes are not admissible, which the generous minimums usually set by law reduce to a rhetorical gesture. The very fact that the minimum standards of care are somewhat less than what is normal and due makes them insufficient, since they entail for the patients whose care is postponed or reduced gratuitous suffering, less than good care, and even the occasional risk of permanent disability or avoidable death. Considering that the minimum care provided during strike days is sufficient is tantamount to implicitly confessing that the ordinary medical internship is somewhat wasteful32.
d) Moreover, work health care occupies a unique, distinct place among paid jobs. We all have to resign ourselves to the fact that other workers - railwaymen or miners, plumbers or airline pilots, bakers or petrol station attendants, even policemen and firemen - go on strike and, in order to force their employers to accede to their demands, cause us more or less serious inconvenience. It is enough for them to shrug their shoulders and say "we are really sorry and we apologise". However, those who care for the precious good of the life and health of others cannot be indifferent to the risks that their abstention from work puts that higher good at risk. A doctor can never shrug his shoulders and say to his patient "I am so sorry, I apologise for the inconvenience - the distress, the anguish, the permanent harm or the fear of dying without care - that I have caused you".15
This reluctant stance stems from a strong deontological mentality, full of altruism and dignity. Some consider it more characteristic of saintly doctors and nurses than of ordinary doctors and nurses. But this attitude is open to criticism, for while it testifies to the ethical purity of those who proclaim it, it cannot prevent the social, economic and technical degradation of the health professions. To this effect, the document prepared by a British group of work reads: "Those who maintain that it is always unethical for a professional to suspend his or her services - which, in the opinion of many, is the only effective weapon available when dialogue breaks down - are in danger of accepting that employers corner doctors into a position of servitude, a position which prevents them from maintaining their dignity. The desire not to harm their patients through strike action may result in harming them much more by preventing them from doing what is necessary for them in the future, result . It is irrational to propose that the profession stand idly by and watch as quality requirements degrades, as budgets decrease, or as the intervention of outsiders in the doctor/patient relationship increases.
The rejection of the limited strike is, at heart, a quixotic attitude, attractive and idealistic, but ineffective in the context in which labour relations tend to develop today, both in the public context of ministries or health departments dragged down by an unstoppable deficit, and in the private context of a fierce struggle for survival, through wage cuts and covert rationing.
b. Strike action for the mere benefit of the health care worker is ethically acceptable.
There are not many supporters of this attitude, at least in its hard-line version, which considers strike action justified as a means of achieving salary adjustments or the improvement of labour rights. In the above-mentioned survey 38 only 4 per cent of the resident doctors thought that strike action was justified for wage increases if, for example, the pay was moderately low or if it was adequate but lower than that offered by other hospitals, even if it was very likely that several patients would die as a result.
This position is based on a purely monetary vision of the rental of professional services, on a mercenary mentality, insensitive to the moral gratification of the service and the human value of the healing vocation. It seems to consider work as a commodity that, according to the opportunities of the moment, is exchanged for the maximum amount of money possible.
A strike based on these premises runs the risk of failing to comply with the ethical principles of a fair strike requirements , and in particular of trivialising the motives behind it. Fortunately, there are rarely real situations in which the wage claim is presented in its pure form. Low or unworthy salaries are often an additional ingredient in situations of health care shortages, so that strikers generally include in the same package of demands, along with higher salaries and dignified working conditions, the improvement of the material provision of services. It does not seem reasonable to think of hospitals where technological affluence coexists with poor salaries, or, conversely, where salaries are luxurious while facilities and services are seriously degraded.
The improbability of the pure wage strike and the minority attitude in favour of it among doctors and nurses, together with the poverty of its moral and human horizon, excuse us from analysing it in detail. Daniels has done so in his strong critique of health trade unionism13. However, there is no shortage of authors who justify purely labour demands as a humane and realistic manifestation of the economic needs and aspirations of doctors5, 30, 34, 36.
c. Only limited strike action in defence of specific patient interests is ethically acceptable.
This position is shared by the majority of doctors. In Zawacki, Kravitz and Linn's survey , 85 per cent considered a strike to be justified when the lack of equipment in health services was severe, i.e. when the necessary means to ensure the safety of patients were lacking, provided that the strike was of a limited nature and that no patient was likely to die as a result38.
Two ethical theories have been offered as a rationale for this subject strike31. Both encounter the difficulty of justifying the paradox that a strike intended to benefit patients must first go through the questionable process of victimising them.
a) According to the consequentialist/utilitarian view, the total damage to patients' health care during the strike matters far less than the poor care they will receive if the deficiencies the strike seeks to correct persist and the benefits patients can begin to receive from the improved status that the strike seeks to bring about. It is clear that this theory assumes that strikers will be able to obtain the improvements they seek soon and to maintain them once they have been achieved. This consequentialist view has been described as shameless because to consider present real harm tolerable by virtue of future hypothetical benefit is tantamount to playing with sick people; it is to traffic, for good ends, in the perverse means of pain and dissatisfaction inflicted on innocent third parties. Such a internship dehumanises the patient of today, turning him, in his collusion with employers, into a means to an end, a hostage to be bargained with9.
b) The deontological theory is based on the moral obligation for health care workers to actively oppose the perpetuation of such degraded conditions of patient care that, in conscience, they are incompatible with the professional duty to provide services of at least the minimum permissible standard. Professionals cannot continue to collaborate with a status that makes them accomplices of employers against patients. In such cases, strike action would not only be morally permissible; it becomes morally obligatory, as it constitutes an act of responsibility6. As Zacharias points out, to remain passive in the face of the deterioration of the system, to turn the other cheek so that ministerial officials can continue to tyrannise, is to inflict incalculable long-term damage deadline on the national health service37.
In the deontological vision, what basically counts is the ethical integrity of professionals, understood less as their virtue staff than as the moral heritage of patients: patients have the right to be cared for by independent doctors and nurses who have the minimum necessary resources for their care work .
The deontological theory is confronted with the problem of justifying, in favour of the strike, the conflict of duties which, as we have seen above, health professionals opposed to the strike, for equally deontological reasons, have resolved against it.
For a growing issue of doctors and nurses, the strike has no other way out than to dissolve the conflict of duties not in a dilemma (either care for the sick or strike), but in the joint and paradoxical option of one and the other: simultaneous suspension and continuity of care. This is what the code of ethics of Spanish nurses proposes when it says: "Even in the case of labour conflicts and organised suspension of professional services, the nurse will bear in mind that his/her first responsibility is to attend to the interests of the patients. The nurse involved in a labour conflict has the duty to coordinate and communicate the measures adopted to guarantee the continuity of care needed by his/her patients "27. The Code of Medical Ethics and Deontology of the Spanish Medical Association is more timid at proposal: "In the event of a medical strike, the doctor is not exempted from his ethical obligations towards the patients for whom he must ensure urgent and unpostponable care "28.
In fact, in many recent medical strikes, a large issue of doctors and nurses, while putting their names on the list of strikers, go to work in the hospital. They are demonstrating their support for demands that seek to improve patient care, but without abandoning their immediate duties towards patients. This is a praiseworthy attitude, but it denounces the tremendous weakness of the health strike as an instrument to impose the demands of the strikers23.
A strike based on these premises would be a just strike. Zawacki, Kravitz and Linn have applied the ethical principles of just war to the health strike and have delineated the requirements requirements for call (legitimate authority, just cause, peaceful purpose, character of last resort resource, probable success) and for carrying out (use of indispensable, proportionate, law-abiding, law-abiding means, and protective of the innocent) in order for the strike to be considered just38.
Circumstances of the health strike: intensity, duration, public image
Just as important as invoking a just cause is graduating the intensity and duration of the strike and giving the public, through the media of speech, a sincere and humane picture of its motives and circumstances.
Intensity
It is agreement unanimous that, to be ethically acceptable, strike action must be limited in its intensity. There is, however, no single criterion about the duration, indefinite or fixed deadline , of a strike.
The strike, even if it is limited and of a short, fixed duration, needs to be energetic. It requires placing employer in a status - of economic risk in the case of a private institution, of political risk in the case of the national health services - that forces the prompt convening of a negotiating table.
The striking doctor justifies the firmness of his behaviour by the selective nature of his action: to minimise the damage, he attends to urgent patients and those with whom he has established a relationship whose continuity cannot be suspended. And he postpones what can be postponed: elective interventions, which may or may not be done, or may or may not be done now or later. It is clear that the delay of health interventions can cause patients, in addition to health losses that are difficult to calculate, discomfort, anxiety or irritation. But the striking doctor concludes that these undesirable effects have an acceptable ethical cost. In fact, many patients delay the previously agreed time of their admission to hospital on their own initiative. And, in the end, patients who require postponable care cannot morally demand that the doctor or the nurse renounce a strike that is for the benefit and safety of the patients themselves.
But there is an intermediate zone between the urgent and the postponable: a continuum of patients with an as yet undefined course, who, due to many circumstances, may turn one way or the other, and therefore need to be kept in a wait-and-see attitude.
For a health strike to be worthy of the name strike, it must necessarily cause discomfort and distress. But it is the duty of doctors and nurses to try to keep this to a minimum.
Duration
The strike must last for a limited period of time, which obliges the conveners to announce to the public, with the advance notice required by law, the time of its beginning and end. It does not seem ethically acceptable that a health strike can last indefinitely. This was pointed out in 1980 in a document issued by order of the General Assembly of the Spanish Medical Association, which stated that "a strike or stoppage by doctors cannot be of a total and/or indefinite nature, as is the case in the industrial or service sectors "29. There are at least two arguments in favour of this.
The first reasoning is as follows: call an indefinite health strike might seem, at first sight, to be a sign of the strikers' firm determination to achieve their goals at all costs, as they intend to intimidate employer, to weaken its resistance and to force it to negotiate immediately. But if the latter resists, the indefinite strike becomes a tremendous moral abdication on the part of the strikers, who, having lost all their bargaining capital at the first attempt, are at the mercy of employer. Their strong initial gamble transfers to employer the ability to decide when to end the conflict. But doctors can never abandon their non-transferable right and duty to care for their patients to third parties. The authorities, who play a very important role in setting minimum services, can today cope with a strike of indefinite or very long duration with very little loss of prestige, whereas the opposite is often the case for doctors.
Moreover, in the eyes of the community, strikes of indefinite duration carry very high risks. Given their harsh, cruel and overbearing nature, they are viewed with little public sympathy. Curiously, the initial strong impact of an indefinite strike on public opinion is dampened within a few days and replaced by a general impression that the strikers' behaviour is inflexible and unintelligent. This is helped by the media on speech , which treats the indefinite strike with disdain, as it ceases to be "news" within a few days. It is perhaps much more effective, in the eyes of the general public, the media and the health authorities, to have a well-planned succession of short periods of suspension or reduction at work.
The second argument against an indefinite health strike is of an ethical and psychological nature. The lengthy hand-to-mouth not only deadens the conscience of the striker, who loses sensitivity to the needs of patients, and encourages routine neglect, but also causes a decline in the professional skill and the habit of work, especially in the case of doctors and nurses at training. It is curious that, in Spanish, the same word, unemployment, is used to designate strike and unemployment status .
Public image
The striker's goal priority is to win the support of the public. He has to draw their attention to the dramatic circumstances that motivate and justify the strike. This requires skill to manage social opinion, because it is not easy to cause the public inconvenience, sometimes very serious, and, at the same time, to win their sympathy.
Those who call the strike, and also those who take part in it, have an obligation to give an ethical approach to their relations with the public and with patients: rather than denigrating their opponents, they should strive to justify their behaviour; they should try to feel and show sincere sorrow for the inconvenience they cause, while showing by deeds that they will not abandon the patients who need their care; they should speak of their commitment to reach a just solution as soon as possible, even at the cost of generous concessions. It is very important that their statements are sincere and rational.
Health union leaders should never present themselves to the media on speech as life savers, with haughty gestures or threatening words. Nor should striking doctors and nurses be allowed to demonstrate in or around hospitals as if they were indifferent to the problems they are creating. It is a pitiful spectacle that is sometimes presented on television and in the press, with smiling and gesticulating, even jubilant, doctors and nurses displaying banners of tacky wit. I am persuaded that this is ethically unacceptable language. Far more eloquent and more compatible with the professional dignity of health workers are silent demonstrations.
The moral duty to devise strike-prevention mechanisms
In the view of its protagonists, the health strike is a last resort resource that is used only when negotiations, usually very tense and tough, have reached an impasse. Paradoxically, however, the main purpose of strikes is to force the resumption of broken negotiations: the violent language of the strike, the social and economic pressure induced by it, is supposed to have softened the employers' positions, forcing them to return to the negotiating table and start all over again. The strike is at heart a macabre joke, a scandal, a painful round trip whose success lies in resuming the broken talks.
Preventing strike action is therefore a serious moral obligation for all involved. The need to create and maintain working conditions in the health care sector that permanently protect labour peace through a preventive, fair, effective, independent and independent arbitration system that is sensitive to the current economic and social situation, whose decisions must be accepted by all, is being spoken of with increasing force and frequency.
Among those who have reflected on the ethics of health strike action, it is common to propose the creation of such preventive arbitration committees as a solution. Fox puts it very radically, concluding that a health strike should never occur, but should always be prevented, because deciding conflicts by force rather than by reason must always be regarded, in the field of health and human life, as destructive and immoral.18 Prevention, in the opinion of Muyskens, is a permanent task, which begins with a permanent task, starting with the prevention of health strikes. Prevention, in Muyskens' view, is a permanent task, which begins with the sincere decision of the parties to avoid the causes that can lead to the emergence of conflicts: this decision necessarily includes the commitment of the conflicting parties to accept in advance the binding decision of a mutually acceptable arbitrator26. In the view of the association of American Medical Colleges, it is incumbent on society to design a clean procedure to prevent and resolve the economic and organisational problems that affect the quality of medical care and the well-being of the profession11. A British paper very representative of the dominant view among physicians concludes that the public responsibility of physicians and health authorities is unfulfilled if both are not committed to avoiding the causes of conflict and do not set in motion a rapid and effective conciliation machinery24. A Lancet publishing house commenting on this paper reinforced the idea that conflict prevention is the ideal goal 17. In Israel, after a severe and prolonged strike, there were calls for an independent body to set salaries and conditions for work, so that doctors could devote themselves fully to protecting the best interests of their patients. In that way, the need for strikes would disappear22 . And Glick proposed that physicians, as social leaders, should devise ethically acceptable procedures for resolving labour disputes in an equitable manner. Such procedures could take the form of binding arbitration, or the advice of special legislative or judicial committees, which could also serve as an example to other public employees.20
Such preventive conciliation mechanisms should not seem an unattainable desideratum. Rather, they should be the natural result of the protagonists of the conflict assuming their responsibilities with intelligence and sincerity. The responsibility of the government and administrators, doctors and nurses is clear: all of them would be publicly committed to accept the strike-preventive measures proposed by this arbitration committee , since they have all agreed to carry forward, as a banner of social progress, a truly humane national health system. The state cannot abuse its power and force health workers to work in conditions that weaken the skill or the humanity of their service to patients. It would be contradictory for the state to punish, through its judicial arm, health workers who treat their patients negligently, while at the same time imposing on its national health service conditions of work that amount to institutionalised negligence. For their part, doctors and nurses working in the national health service must be convinced that their employment cannot perform without a specific social generosity, without the pride of knowing that they give much more than they receive. They cannot have the psychology of mere employees, of mercenaries indifferent to the values of the business in which they work.
I believe that patients should also have a place on these arbitration committees. Since they suffer most in the course of a strike, they should have a vital interest in taking a leading role in preventing it. Up to now, they have been systematically reduced to the status of suffering passive subjects, stone guests at the negotiating tables. There is reason to suspect that the involvement of patients' representatives could help in the effective prevention, or speedy resolution, of conflicts. Patients and their families cannot limit their influence on health care programming to their ephemeral role as citizens voting in elections. Election campaigns are operations of collective obfuscation, where the really important issues are often not seriously addressed. There is a need to create channels through which patients can effectively intervene in health policy. One of these could be the presence of someone to represent their interests on those hopeful arbitration committees that prevent health strikes.
Bibliography
American College of Physicians. Position Paper. American College of Physicians Ethics guide. Third edition. Ann Intern Med 1992;117:947-960.
2. Baeltz P. The Right to Strike by the Caring Professions. J Med Ethics 1977;3:150.
3. Bleich D. Interns and Residents on Strike. Hastings Cent Rep 1975;5(6):8-9.
4. Brecher E. Striking Responsibilities. J Med Ethics 1985; 11:66-69.
5. Brecher E. Health Workers' Strikes. A Rejoinder Rejected. J Med Ethics 1986;12:40-42.
6. British Medical Association. The Handbook of Medical Ethics, 3rd impr. London: British Medical Association, 1986;65-66.
7. British Medical Association. Philosophy & Practice of Medical Ethics. London: British Medical Association, 1988;93-94.
8. Catechism of the Catholic Church. Madrid: association de Editores del Catecismo, 1993; point 2435.
9. Colfer H. On the Physician's right to strike. In: Basson MD, ed. Ethics, Humanism, and Medicine. New York: Alan R. Liss, 1980; 303-307.
10. Spanish Constitution. bulletin Oficial del Estado, no. 311-1, 29-12-1978: article 28.2.
11. Cooper JA. The Withholding of Medical Care by Physicians. J Med Educ 1979;54:122-123.
12. Court C. Nurses to vote on no-strike rule. BMJ 1995; 310:1158.
13. Daniels N. On the Picket Line: Are Doctors' Strikes Ethical? Hastings Cent Rep 1978;8(1):24-29.
14. De Lorenzo R. The right to strike and minimum services. Noticias Médicas, 9-7-1986:6.
15. Dworkin G. Strikes and the National Health Service: Some Legal and Ethical Issues. J Med Ethics 1977;3:76-82.
16. publishing house. Strikes in the National Health Service. J Med Ethics 1977;3:55-56.
17. publishing house. The Patient Comes First. Lancet 1977;1:180-181.
18. Fox TF. Indistrial action, the National Health Service, and the Medical Profession. Lancet 1976;2:892-895.
19. Garty M. Physicians' Strikes. Second Thoughts. J Med Ethics 1986;12:104-105.
20. Glick SM. Physicians' Strikes. A Rejoinder. J Med Ethics 1985;11:196-197.
21. Glick SM. Health Workers' Strikes: A Further Rejoinder. J Med Ethics 1986;12:43-44.
22. Grosskopf I, Buckman G, Garty M. Ethical Dilemmas of the Doctors' Strike in Israel. J Med Ethics 1985;11:70-71.
23. Herranz G. La ética no hace huelga. Diario Médico, 12-5-1995:6.
24. Joint Working Party of the Conference of Medical Royal Colleges and Their Faculties in the UK and the British Medical Association. Discussion document on ethical responsibilities of doctors practising in National Health Service. BMJ 1977;1:157-159.
25. Linn R, Linn S. Notes on the Morality of Strike Within the Medical Profession. J Clin Ethics 1991;2:17-18
26. Muyskens JL. Nurses' collective responsibility and the strike weapon. J Med Phil 1982;7:101-112.
27. Nursing Collegiate Organisation. Código Deontológico de la Enfermería Española. Madrid: committee General de Colegios de Diplomados de Enfermería, 1989; Articles 78 and 79.
28. Spanish Medical Association. Código de Ética y Deontología Médica. Madrid: Organización Médica Colegial, 1990; article 6.
29. Piñal JL. Professional Ethics and Medical Strike. Informativo Médico 1981, June:4.
30. Railton P. Health Care Personnel and the Right to Strike: A Social Perspective. In: Basson MD, ed. Ethics, Humanism, and Medicine. New York: Alan R. Liss, 1980:291-302.
31. Reitemeier P.J. Strikes by health professionals. In: Reich WT, ed. Encyclopedia of Bioethics. Revised edition. New York: Simon & Schuster Macmillan, 1995:2410-2413.
32. Ribera Casado JM. Por qué no hago huelga. Noticias Médicas, 6-5-1987:7.
33. Royal College of Nursing. Rcn Code of Professional Conduct: A Discussion Document. J Med Ethics 1977;3:115-123.
34. Sachdev PS. Ethical Issues in a Doctors' Strike. J Med Ethics 1986;12:53.
35. Thomasma DC. Philosophical Methodology and Strikes. J Clin Ethics 1991;2:16-17.
36. Veatch RM. Interns and Residents on Strike. Hastings Cent Rep 1975;5(6):7-8.
37. Zacharias P. Should Doctors Strike? A staff View. J Med Ethics 1977;3:83-84.
38. Zawacki BE, Krawitz R, Linn L. Ethical Counselling for House Staff considering a Strike. J Clin Ethics 1991;2:10-15.