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Should Doctors strike?
  1. John J Park,
  2. Scott A Murray
  1. Centre for Population Health Sciences, The University of Edinburgh, Medical School, Edinburgh, Scotland, UK
  1. Correspondence to John J Park, Centre for Population Health Sciences, The University of Edinburgh, Medical School, Teviot Place, Edinburgh, Scotland EH8 9AG, UK; j_park1088{at}hotmail.com

Abstract

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. Almost all doctors will agree that we should always follow the law, but often the law is unclear or does not cover a particular case. Here we must appeal to ethical discussion. The General Medical Council, in its key guidance document for practising doctors, Good Medical Practice, claims that ‘Good doctors make the care of their patients their first concern’. Is this true? And if so, how is this relevant to the issue of striking? One year on since the events, we carefully reflect and argue whether it was right for doctors to pursue strike action, and call for greater discussion of ethical issues such as the recent strikes, particularly among younger members of the profession.

  • Public Health Ethics

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Introduction

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. One year on since the events, we carefully reflect and argue whether, in this case, it was right for doctors to pursue strike action. In light of this debate, we call for greater engagement and debate, especially among students and junior doctors, on the ethical responsibilities held by doctors and the moral defensibility of strike action.

What happened?

In May 2012, the British government announced that doctors would face cuts to their National Health Service (NHS) pension scheme. It meant that every doctor, as a public sector employee, would work longer, pay more and receive less for their pensions.i The entire public sector was subject to these cuts specifically aimed to raise £3.2 billion from existing pension schemes, and others including nurses, ambulance crew, teachers and firemen had already taken action under the umbrella of the three main trade unions (Unite, Unison and GMB) several months previously.

The British Medical Association (BMA), as the largest doctors’ union, led negotiations with the government (currently, of the approximately 230 000 registered doctors, 104 544 are BMA members). However, the BMA found themselves frustrated by the lack of progress in negotiations and put forward a ballot for doctors to strike on this issue: the first strike ballots in the BMA's 180-year history. A large majority voted in favour of action, with two questions provided to strengthen the legal defensibility of strike action: one asking whether they were prepared to participate in industrial action, and the other asking if they were prepared to take action short of it. Of the 52 250 (51%) members voting, 44 023(84%) voted in favour of taking industrial action as opposed to the 8227 (16%) who voted against it. On June 6th, doctors took industrial action across the UK. The Department of Health estimated that it led to at least 2700 elective operations and 18 750 outpatient appointments being cancelled in England alone.1

Should doctors be subject to different employment rules?

In an article to the British Medical Journal (BMJ), Alan Robertson, the chairman of the BMA pensions committee, argued that he was fundamentally opposed to the notion that doctors could not strike because of moral grounds: ‘given that threats to patient safety can be addressed through thorough planning and a commitment to the continuing provision of all care urgently needed, why shouldn't doctors have the same employment rights as other workers?’2 The BMA's argument was clear: why should doctors be subject to different rules and have to suffer as a result? This is similar to arguments that doctors have made before taking industrial action all around the world, including in the UK, the USA, South Korea, Canada, New Zealand, Israel, Nicaragua, El Salvador, France, Germany, Spain, South Africa and Ghana. Reasons have included substandard service provision, unsatisfactory conditions of work or unfair malpractice payments.3 Clearly, there are no legal restrictions under the employment law that make doctors any different from other professionals.

The BMA strategy was called the ‘urgent and emergency care’ model of industrial action.2 It would aim to ensure that patients received care only if they urgently needed it. Guidance provided by the BMA stated that doctors should be at their usual place of work and patients would receive emergency care or other care urgently required that day. All other work would be postponed, including non-urgent surgery, investigations, outpatient consultations, routine appointments in general practice and paperwork. If in any doubt, it was recommended that the decision should be to provide care. Action would only take place for 24 h, and its effect on patients would be reviewed before taking any further action.2 Moreover, cooperation with managers would be needed to ensure that any decisions about care that is postponed could be achieved with careful planning, coordination and notification with other health professionals, doctors and patients. Doctors have limited strike action to non-emergency cases in the past, and several scholars have shown that such methods were used in Tanzania, Australia and Israel, where the medical association even set up an alternative ‘fee for service’ system.4–7 The idea was to maximise government embarrassment and limit harm to patients, while making sure they were safe and on the side of the law.

Reflections

Almost all doctors will agree that we should obey the law, but often the law is unclear or does not detail a particular situation. Here we must appeal to open ethical discussion. The GMC, in Good medical practice, claim that ‘Good doctors make the care of their patients their first concern’.8 Yet does this new model of industrial action reconcile with this aim? On reflection, we raise some questions concerning this action and its claims.

First, is it possible to justify strikes in any position other than in an effort to preserve the life and health of patients? To withdraw treatment not only goes against the principles of the NHS in which we practice but goes uncomfortably close to conflicting with the primary role of the doctor. Even the utilitarian argument, as proposed by Brecher, suggests that strike action is only justifiable if there is enough long-term benefit to doctors, patients and a positive improvement to healthcare delivery.6 And Veach further suggests that it may be appropriate if the concurrent increase benefits those most needing healthcare.9 Yet, this strike, with a focus on personal and financial gain of doctors at the expense of treating patients, seems difficult to justify on these grounds.

Second, in what situations can doctors strike, if any? The justification made in this occasion was that patient care would be made an ‘overriding priority’ despite a significant withdrawal of human resources and medical treatment.2 A major concern raised by such an argument is the confusion that arises over whether to treat or not treat a patient. Clarity on this issue was lacking, not least to patients who were turned away from appointments, clinics and surgeries. It is further debateable as to whether any strike action can be described to make patient care a priority.

Third, in a social health system such as the NHS, is it ethically permissible to strike when the health service's very existence is founded upon a binding, mutual responsibility of state and doctors? Of course it is not a legal agreement as such, yet Bevan would call the agreement the largest ‘social contract’ in the world.10 Julian Bion put it well in his recent article to the BMJ, ‘Failure of one monopoly does not absolve the other, and unjust treatment by the state does not entitle beneficent practitioners to become maleficent.’11 It is difficult in any health system to justify strike action in terms of retaliation to a partner. Indeed even if government may have provoked action, it was ill considered to react to such provocation when it was clear to see that it would be detrimental to patients’ wellbeing.

Finally, as was the case with many doctors’ strikes around the world, these strikes in the UK did not resolve the dispute. As Seymour Glick aptly puts it, ‘There are no victors in physicians’ strikes’.12 Worst of all, the result of this strike was that patients suffered most.

Final thoughts

This issue has no clear right or wrong answer. But there needs to be a greater and serious engagement and debate, especially with younger training students and doctors, on the vocational and ethical responsibilities held by doctors and the moral defensibility of strike action. In light of the growing power and influence of large medical organisations such as the BMA on new younger members, we call for greater discussion and debate on strikes, including other ethical issues that we will face, in informal, formal and academic circles. By engaging together, we should at least be able to build a better future as informed, involved and engaged members of the profession.

Acknowledgments

Professor Kenneth Boyd (Professor of Ethics and Medical Ethics, University of Edinburgh) for reading and advising on this article.

References

Footnotes

  • Contributors Both JP and SM contributed to conceiving the idea, writing and editing the article.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i Note: The main changes would mean doctors’ retirement age will rise from 65 to 68, contributions increase from 8.5% to 14.5% by 2014 for the highest earners, and see switch from final salary to career average earnings–based pensions; in essence, all changes aimed at raising contributions while reducing payouts.