Wednesday, 19 March 2014

Should Doctors go on Strike?

“I will remember that I remain a member of society with special obligations to all my fellow human beings.” — Hippocratic Oath

Dr Ashok Jahnavi Prasad

I must confess to some moral dilemmas when I commenced penning this article. Way back in 1977, I was myself spearheading a physicians’ strike in Kanpur when a morose Deputy Minister for Health by the name of Jageshwar presented himself at the Medical College Hospital along with a drunken colleague and suspended three doctors on the spot for no rhyme or reason. The Doctors’ Association in Kanpur decided to protest and I recall my own meetings with the District administration, and later the Chief Minister Ram Naresh Yadav and the Health Minister Kalyan Singh. Mr Kalyan Singh, to his credit, acted immediately before the agitation spread to the other cities — Jageshwar was sacked immediately and we resumed work.

I must confess though that after witnessing the magnification of suffering during those few days, my views underwent a radical transformation. I became convinced that come what may, there could be no justification for either the physicians or the nurses to go on strike as the worst affected were the most vulnerable sections of the society.

But having observed what had happened in Kanpur Medical College (my alma mater) recently, I am gripped by a dilemma once again — I am simply not certain whether there is any other option realistically available to the medical profession.

Strikes are very much in the news these days. Industrial action, in whatever form, is nothing new and in principle, I support the rights of organized labour to use any legitimate means at its disposal to draw attention to the egregious injustices, which can be proven and demonstrated. What I am against is the now too common practice of medical personnel, specifically doctors and pharmacists, threatening or actually engaging in work stoppage of any kind in a country like India. I say this not because I do not recognize that doctors have rights as individuals. My position here is simple: Strikes cause harm, sometimes irreparable, to patients who are in no position to influence the outcome of any conflicts between the government and doctors. More importantly, I argue that some jobs, specifically that of doctors, have what I call an implicit moral component thereby rendering the wilful withdrawal of services from patients an immoral act.

Moral theory focuses on right and wrong. Moral issues are weighty matters that have occupied philosophers throughout history: from Greek philosophers such as Aristotle and Plato. I draw on some basic moral traditions to show that in our special circumstances where the vast majority of patients who use public hospitals are the weakest members of our society, it is unethical and a violation of their fundamental human rights to deny them services to force the hands of the government to negotiate employment conditions.

Utilitarian Arguments: Acting In the Interest of the Majority

The first framework I discuss is utilitarianism. Utilitarianism suggests that moral actions are those that produce the best overall result for the majority of people. The utilitarian argues that what is important is the satisfaction of human happiness or the reduction of human suffering. For all the Hippocratic Oath is worth, its main declaration of “do no harm” is most consistent with utilitarian arguments that the best sort of decision is one that minimizes harm. The utilitarian judges actions in terms of the outcomes the action produces. In this case, motives and intentions for making a particular decision are not important; the result is what matters. Here you can say they have good intentions. This moral framework would nonetheless argue that the decision is not ideal because in the end, majority of patients would suffer. The lesson here is that we have to consider the consequences of our actions. While it is true that the doctors, as a minority, also have rights, the aspirations of the majority here trump their legitimate needs. This and other weaknesses of the framework exist. However, it still enlightens us in this case. No matter the arguments, the main issue here is that the doctors’ strike is causing harm to the majority of the most vulnerable people.

Immanuel Kant and his followers (Kantians) speak to us as reasonable individuals. Here the focus is not on the results of our actions but rather on the principles by which we act. Kant suggests that a moral person makes decisions based on what is right, regardless of the consequences. Kant adds that the best moral choices are those that you would want other people to make, even if that choice would harm you or those close to you. The idea here is that you are acting as a principled person. For example, a doctor, knowing well that their mother who lives away in their village might need emergency care at the nearest Government Hospital, nevertheless casts a vote for a doctors’ strike. Kant would say this doctor voted on principle. However, before we start celebrating, we ought to look at some additional caveats Kant raises. For lack of space, I will raise just three key questions from this view. To act, we must ask (1) does our action set a positive or negative example for others to follow in the future? (2) Is this an action that other reasonable people will believe is proper? (3) Does the action respect or at least not abuse human dignity?

I think doctors’ strikes fail on all three points. A strike by essential service personnel, especially doctors, sets a bad precedent. There will be chaos each time an aggrieved group of essential services people decides to go on strike. I believe governments the world over recognize this and that is why they pass laws that forbid essential service personnel such as doctors and police from going on strike. I am not sure that most reasonable people agree that it is appropriate to deny care to the sick. Worse yet, this sort of strike abuses the dignity of patients.

The Greek philosophers Plato and Aristotle challenge us to live our lives a certain way. Like the previous framework, this one speaks to us at a personal level. In its simplest form, their view is for us to “Do the Right Thing, Always.” They urge us to develop our character and make decisions that we believe a person who has character (a virtuous person) would make. If we reverse the roles and we find the doctors at the receiving end of the scale, would they like services to be withheld from them? I do not think so.

It is enlightening to remind readers that there are three main groups of people (stakeholders) directly associated with an industrial strike by doctors in public hospitals. They are the doctors themselves, the government and of course the patients. Clearly, the patients are in the weakest position. They are incapable of influencing the outcomes of any disputes between the other two parties. Indeed, they are not the key actors here. Ironically, they are people who stand to lose the most, at least in the short term. The government has institutional power it can draw upon to press its point. The doctor has privileged position and their knowledge and expertise confer a unique form of power on them that they can use as a bargaining chip. Now, patients have really no power here. They remain most vulnerable. As the well-known and often quoted proverb goes “when two elephants fight, it is the grass that suffers.”

Doctors, like most professionals, have years of schooling and training. Doctors acquire very important skills after their long, strenuous years of training. We, their patients, then become the beneficiaries of their effort and hard work. For the most part, people only see the physician when they are not well. The patient goes to see the physician because they want to get well. This is an important point. An ill individual is already in a vulnerable position. They need help. Sometimes, when that help is not forthcoming immediately, they may die. Therein lays the moral dimension. Morality, seem simply as right versus wrong, compels all of us to aid those who may be suffering. For the sick person, the doctor is almost playing the role of God here. The patient and doctor relationship is one of absolute trust. It at once creates a moral contract. This implicit moral contract should not be taken lightly and physicians through history seem to have recognized that.

Having made all the arguments against the idea of physicians striking work, I am still in a dilemma about the appropriateness of this position when it comes to the present strike in Kanpur and its proposed escalation. In this case, the doctors are agitated not over their stipend or conditions but the lack of the most fundamental security that is owed to them.

The medical institution was invaded by a bunch of thuggish policemen and lumpen goons who used their lathis against anyone in sight — doctors, nurses, senior medical teachers and medical students. They then went on a vandalism spree leaving behind the residential quarters in tatters. Over 20 students had been in police custody — the language used by the police, now freely evidenced on YouTube shames the entire humanity — as does the exhortation by the SSP of Kanpur on megaphone to break the bones of all the doctors. I recall how Justice A N Mulla had described our police-criminals in uniform! And they do fit the bill.

Akhilesh Yadav government has been known to patronize ‘goondas’ like no other previous regime. He is more interested in saving the skin of his MLA Irfan Solanki and the SSP who it is believed was his schoolmate. Under these conditions, I am simply unsure whether resolving not to strike is a realistic and respectable option. I am however open to suggestions as I am still wrestling with my own conscience.

My only fervent wish now is that the matter is swiftly resolved and a dispute resolution mechanism be set in place for essential services like medicine. Is anyone listening!

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