STRIKES-International experience

Journal of the New Zealand Medical Association, 23-June-2006, Vol 119 No 1236



Is it ethical for doctors to strike?

Frank Frizelle
A strike by doctors meets with a great deal of resistance not only by the public but from within the medical profession. The recent resident medical officers’ (RMOs—also known as junior doctors) strike in New Zealand has again created a discussion about the ethics of doctors striking. Previous national strikes in 1992 caused a raft of letters to the NZMJ complaining that the strike was unethical, with an equal number saying that junior doctors needed an improvement in conditions and that the strike was justified.1–6
The present junior doctors’ strike has lead to local newspapers publishing letters from senior doctors and members of the public saying that this action (of striking) is unethical and “has broken the 2000-year-old Hippocratic oath.”
The press has reported the present RMO strike as unprecedented. But anyone who has been an RMO or senior medical officer (SMO—also known as specialist or consultant) since 1985 will know that this is rubbish. RMOs have been on strike before—locally, nationally, and internationally. Not only RMOs have been on strike, but SMOs as well.
The usual claims are pay, conditions, or contractual relationships—as with any occupational group. (The specific details of the claims that form the basis of the latest New Zealand junior doctors’ strike are not the basis for discussion here.)
Apart from New Zealand, in the past 20 years there has been strikes by medical doctors in Australia, Belgium, Canada, Chile, Finland, France, Germany, Ghana, India, Ireland, Israel, Italy, Korea, Malta, Peru, Serbia, Spain, Sri Lanka, Romania, USA, UK, Zambia, and Zimbabwe to name but a few.
Many of these strikes have caused lasting damage from which health systems have struggled to get over; have been very costly (both in the short and long term); and have not achieved what the management appear to have wanted.
Many strikes around the World have been about similar issues. One of the most famous strikes was in the Mediterranean island state of Malta, which lasted for 10 years.7 The origin of this strike lay with low pay for RMOs, leading to problems with recruitment (as new medical graduates left the country as soon as possible after graduation).
A new role was subsequently established called temporary medical offices (TMOs). These TMOs were required to work long hours for low pay. To correct this chronic shortage of junior doctors, the Maltese Government made it compulsory for all graduating doctors to serve as housemen in public hospitals for 2 years. The senior doctors protested and, as a result, the Government brought in overseas doctors from Libya, Algeria, Cyprus, Czechoslovakia, and Egypt at three times the rate the local doctors were being paid. Many of the Maltese doctors left for the UK and other countries, no doubt to large pay increases themselves.
Amongst those who left were the teaching staff from the medical school, leading to the Malta Medical School losing the General Medical Council (GMC) and international recognition of the Maltese medical degree. The Maltese Labour Party in power at the time lost the next election. The National Government which replaced the Labour Government attempted to reappoint doctors at higher pay rates than those who had lost their jobs, however by them many were well-established elsewhere in other countries—in fact, some of the most famous British surgeons over the past 20 years have come from Malta.
Strikes in New Zealand have also caused considerable and at times lasting dysfunction in certain hospitals. The SMO Timaru strike of 2003 was over the usual issues of pay and working conditions. Eventually, after a 5-week strike by SMOs, it was settled, however several consultant staff left Timaru Hospital for other centres or full-time private practices. The strike is reported as creating an “overwhelming feeling of a complete lack of confidence and trust in the hospital management team.”8
A similar situation occurred with the prolonged strike in Invercargill where RMO staff were on strike for about 2 months in 1992. The strike was over individual contracts versus collective contracts. The strike was near the end of the year, and when the RMOs finished their year, the new RMOs took up the individual contacts, however within 2 years almost all were back in the collective contract. The results of the strike meant that the general manager left, a large number of SMOs felt disillusioned by the pathway the management had taken with dealing with the RMOs, and the hospital struggled to obtain and retain New Zealand RMOs for years afterwards, instead relying heavily on overseas RMOs. This required special packages and extensive (and expensive) advertising to facilitate recruitment.
Reasons given by those against strikes were published in 1986 and are the same as those reiterated by many today.

These include:9
1.It could result in avoidable suffering and death;
2.It would be a breach of the implicit contract doctors have entered into with their patients;
3.It would be against the code of ethics doctors may have sworn to;
4.It would amount to “holding to ransom” a weak and vulnerable segment of the population for material gain;
5.It would shatter the image of doctors as selfless healers; and
6.Doctors are already overpaid—strike action is greed.
(While there are shades of truth in each of these points they are all debatable.)
A detailed ethical justification for doctors striking was put forward and published 20 years ago in the NZMJ.9 It is worth re-reading for those interested. The main point is that despite doctors having a special contract with society, a utilitarian case can be made for a strike. What this means in simple terms is “what is right should result in the greatest good for the greatest number of people.” The short-term inconvenience such as a strike must be balanced against an improvement in care—as a result of allowing doctors to have better living conditions and being better rested, and so then being able to do their job better.
If doctors (and others) truly believe it is important for patient care, then they must sometimes have the courage to do things that are unpopular and difficult. If the conditions that doctors work under put patients at risk, then (on balance) they are morally obliged to strike.
Author information: Frank A Frizelle, NZMJ Editor and Professor of Colorectal Surgery, Colorectal Unit, Department of Surgery, Christchurch Hospital, Christchurch
Correspondence: Professor Frank Frizelle, Colorectal Unit, Department of Surgery, Christchurch Hospital, PO Box 4345, Christchurch. Fax: (03) 364 0352; email: FrankF@cdhb.govt.nz
References:
Malloch JA. Resident hospital doctors strike. N Z Med J. 1992;105:135.
Hunter P. Resident hospital doctors’ strike. N Z Med J. 1992;105:44.
Ackland RH, Becroft DM, Fraser AR, et al. Resident hospital doctors’ strike. N Z Med J. 1992;105:43.
de Geus JJ. Resident hospital doctors’ strike. N Z Med J. 1992;105:43.
Dunn HP. Resident hospital doctors’ strike. N Z Med J. 1992;105:20.
Culpan S. Resident hospital doctors’ strike. N Z Med J. 1992;105:20.
Scott A. A lesion from Malta. New Zealand Medical Association Newsletter. 22 January 1992, page 11.
Rietveld J. Strike action by senior medical staff in Timaru – how did this come about? N Z Med J. 2003;116(1170). URL: http://www.nzma.org.nz/journal/116-1170/352
Sachdev PS. Doctors’ strike—an ethical justification. N Z Med J. 1986;99:412–4. URL: http://www.nzma.org.nz/journal/119-1236/2037/Drsstrike.pdf

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Remember,low salaries of doctors,poor working conditions,political interference to professional matters,and many more gives the doctors the moral right to strike!