Do no harm: should doctors strike?
Are there circumstances when doctors are justified in withdrawing their services?
On 1 December 2015, around 4000 planned outpatient appointments and medical procedures were cancelled as a result of planned strike action by junior doctors in the United Kingdom. The action was part of the ongoing dispute over the government’s attempts to change the junior doctors’ contract. Although the strike was called off at the last minute, it came too late for the patients whose care had been affected.
The action planned for 1 December affected routine work only, with juniors continuing to provide emergency cover. Two more days of action, which would have involved a complete withdrawal of labour, were also called off pending further talks with the conciliation service ACAS.
With a 98% vote for industrial action on a 75% turnout, there is no doubting the BMA’s mandate.  Junior doctors feel strongly about the government’s threat to impose a new contract, and they have serious concerns about the impact of that contract. But, given that the first duty of a doctor is supposed to be to their patients, should doctors take action that affects patient care?
Duty of care
Niall Dickson, chief executive of the General Medical Council, issued guidance to the junior doctors before the scheduled strike dates, making it clear that “any doctor contemplating industrial action must follow GMC guidance, which makes it clear that they must make the care of their patient their first concern.”
He said that doctors must “take reasonable steps to satisfy themselves that arrangements are in place to care for their patients . . . Their actions must not harm patients or put them at risk.”
Because the planned action did not involve the whole workforce (consultants are not involved in the dispute), junior doctors’ senior colleagues were expected to provide cover. Juniors had a responsibility to ensure that patients were safely transferred between teams. To free up the consultants, planned outpatient clinics and elective surgery procedures were cancelled or postponed. Patients may not have been harmed, but many will certainly have been inconvenienced.
Leaving aside the legal situation, is there a moral imperative for doctors to put their patients’ care above their right to industrial action? Should doctors be subject to different rules than other professionals?
Iain Brassington, senior lecturer in bioethics and medical law at Manchester University and a regular contributor to the Journal of Medical Ethics, thinks not.
“My general sense is that there is no deep moral difference between what a doctor does and what other professionals do. They have the same moral rights to withdraw their labour as anyone else.”
However, a junior doctor writing anonymously in the Guardian disagreed.  “The question of strike action is clear to me: doctors provide an essential and emergency service and we should never strike—organised industrial action in other forms, possibly, but strike? No.”
Yet other professionals also provide essential and emergency services. Fire fighters, ambulance drivers, paramedics, and nurses have all withdrawn or threatened to withdraw their labour in disputes in the past year. In February 2015, fire fighters walked out for 24 hours over changes to their pension scheme and retirement age. A planned 24 hour strike by the London Ambulance Service in January was called off, but emergency planning included drafting in soldiers to drive ambulances and asking hospitals to provide doctors and nurses for paramedic care. Nurses working in the NHS in England were expected to strike in January 2015 over pay, but this was also called off. The defining characteristic seems to be that strike action for emergency and care workers is usually brief—and taken reluctantly.
Although most strike action—for example, by transport workers—is planned to cause maximum disruption for the biggest impact, doctors and other healthcare workers aim to cause as little disruption as possible to their patients. This might be for moral reasons, or for the pragmatic reason that headlines about patients dying or left in pain will do their cause no good in the court of public opinion.
So what does happen when doctors strike? The BMJ published an analysis of the impact of doctors’ strikes around the world on patient mortality. The conclusion was that—perhaps surprisingly—mortality decreases or stays the same during strike action. The authors say there are a number of potential reasons why deaths don’t rise:
- Elective surgery is often cancelled to ensure sufficient cover for emergencies, so any surgical mortality is deferred until after the strike
- Senior doctors replace juniors to offer emergency care, so patients get care from more experienced staff
- Emergency cover is usually maintained, and many doctors continue to work or provide emergency cover, mitigating the impact, if required.
The finding has one exception, however. A strike in South Africa in 2010 saw all doctors in one state withdraw all care, for 20 consecutive days. Only one hospital continued to provide emergency care, and the risk of emergency patients dying in that hospital rose by an estimated 67%.
The provision of emergency medical care is usually seen as an imperative when doctors strike. Referring to the recently planned junior doctor action, Brassington said: “No-one’s suggesting closing A&E [accident and emergency] units. It’ll be scheduled care that gets postponed. In that case I don’t see any particular deep moral problem with it, as long as there are enough staff on hand to stabilise patients.”
Bruce Keogh, the medical director of NHS England, was criticised by doctors after writing to the BMA asking for assurances that striking junior doctors would provide emergency cover in the event of a terrorist attack, such as happened in Paris earlier in November. The BMA said that doctors would “of course” respond to a major incident and pointed out that many members of the association were first on the scene when one of the 7/7 London bombs exploded outside the BMA’s headquarters in 2005.
A just cause?
The final consideration when doctors contemplate strike action is the justice of the cause. Given the reluctance to harm patients, an all out strike over pay is unusual. Doctors tend not to strike for purely financial reasons, although in June 2012 some doctors voted to withdraw non-urgent cover for 24 hours over changes to pensions. The danger of this was immediately apparent in newspaper headlines like: “£110 000 a year doctors to strike over pay,” in the Daily Express.
Writing in the Journal of Medical Ethics about the 2012 action, John Park and Scott Murray asked: “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 practise but goes uncomfortably close to conflicting with the primary role of the doctor.”
They accepted that there may be a “just cause” argument for some industrial disputes, but added: “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.”
“If you were going on strike about the quality of the coffee in the staffroom, people might say you’re taking yourself too seriously,” says Brassington. “When it’s about hours or a safety issue, they might have more justice on their side. The justice of the cause is going to make a difference.”
Although pay is a factor in the current junior doctors’ contract dispute, the BMA said that the removal of safeguards on doctors working excessive hours, and the potential impact on patient safety, was the “over-riding concern.” The BMA also claimed that: “the offer removes financial penalties for employers who overwork doctors, replacing it with a system of work schedule reviews.” This, they say, meant employers were more likely to ignore the European Working Time Directive and require juniors to work dangerously long hours.
Whether or not the proposed contract risks patient safety is not the remit of this article; however, the fact that the doctors cite patient safety as a reason for their action might make an important difference for many to the justification of their ethical position. Some might also argue that the junior doctor contract being put forward will threaten patient safety in the long term and that taking a stand against it now could reduce harm in the future.
The junior doctors’ dispute has a just cause dimension, whether or not you agree with the BMA’s assessment. The doctors had planned to cause disruption to employers, rather than patients, and to avoid putting lives at risk. They had confirmed that they would assist in the case of a major incident.
However, the action clearly caused inconvenience and possibly harm for many patients who had been expecting to have treatment on 1 December, and the BMA has made it clear that the threat of full strike action is suspended, not withdrawn, pending further negotiations.
For those who think that doctors should always put their patients’ interests above their own, the question of whether doctors should ever strike remains a difficult one.Anna Sayburn, freelance journalist
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Refs not tagged
- Triggle N. Disruption expected as junior doctors’ strike called off. BBC News 2015. www.bbc.co.uk/news/health-34965603.
- BMA. Industrial action: juniors vote in favour. November 2015; http://bma.org.uk/news-views-analysis/news/2015/november/juniors-vote-in-favour-of-industrial-action.
- General Medical Council. GMC advice for doctors in England considering industrial action. November 2015. www.gmc-uk.org/news/28249.asp.
- Anonymous. I’m a junior doctor and I will not strike. Guardian 2015 www.theguardian.com/healthcare-network/2015/nov/19/junior-doctors-contract-strike.
- Metcalfe D, Chowdhury R, Salim A. What are the consequences when doctors strike? BMJ 2015;351:h6231.
- Rimmer A. BMA rebuts concern that junior doctors on strike wouldn’t attend major incident. BMJ 2015;351:h6322.
- Little A. £110 000 a year doctors to strike over pay. Express 2012. www.express.co.uk/news/uk/323531/110-000-a-year-doctors-to-strike-over-pay.
- Park JJ, Murray SA. Should doctors strike. J Med Ethic 2013. http://jme.bmj.com/content/early/2013/06/19/medethics-2013-101397.full.pdf.
- BMA. BMA Response to NHS Employers offer. November 2015; http://bma.org.uk/working-for-change/in-depth-junior-and-consultant-contract/junior-doctor-contract-negotiations-home.
Cite this as: Student BMJ 2015;23:h6668