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Wednesday, March 8, 2006

Should doctors strike work?

Should doctors strike work? by Yash Lokhandwala at Indian Journal of Medical Ethics

Strike is a legitimate form of collective protest in a democracy. At the same time, the guiding principle of medicine is the alleviation of suffering. Thus the issue of whether doctors should ever strike work is contentious. Some have preached from an ivory tower and advocated against this form of protest (1) . Opinions have been expressed that the suffering caused by a strike of doctors violates the ‘raison d’etre’ of the medical profession.

Of course one cannot deny that patient care suffers during a strike by doctors. The scale of harm caused depends upon the role played by doctors in that particular health set- up, the type of cases under treatment, and, of course, the duration of the strike.

Issues prompting strike
It is important to analyse the issues at stake which prompt a strike if one is to make a ‘cost- benefit’ assessment. For if a strike, in the long run, is to result in better health for a large section of the people, the inconvenience caused to a few during the strike may be justifiable.

Let us consider a scenario where the medical profession is forced to become a passive or active accomplice of a tyrannical political system as when doctors are forced to participate in state torture of revolutionaries. Doctors may be made to examine the victims before torture, help decide the best means and degree of torture appropriate for each victim (2). In extreme cases, they may even be asked to participate in the torture process itself. The role played by senior German doctors in the torture and experimentation of Jews and communists in Nazi Germany is well documented. Even today, in some South American, African and Asian countries, when doctors were ordered to play such a role by the state against its political opponents, several doctors refused, at much personal risk. Individually, these doctors were hounded and persecuted

In other countries such as Pakistan the medical associations protested and even went on strike to highlight the issue. Obviously such a strike would be supported by all right- thinking people. Thus to say that it is unethical for doctors to strike work as a blanket statement is completely unrealistic.

Let us now consider a less extreme instance. In 1984, as a member of the Maharashtra Association of Resident Doctors (MARD), I was a participant in a month- long strike against the proposed setting- up of private capitation- fee medical colleges in Maharashtra. We held that these colleges would serve as a backdoor route of entry for the academically less- deserving rich into the medical profession. This would lead to rampant commercialisation of medicine by half- baked doctors sprouting forth from these colleges, out to recover their lakhs of rupees of investment at the expense of an unsuspecting public. Pleas in 1983- 84 by many, including MARD, to government and university authorities to refrain from permitting (and encouraging) private medical colleges (charging exorbitant fees) to start, fell on deaf ears. We had then pleaded that, if we really needed more doctors, more public medical colleges be started.

Each of these proposed private medical college trusts enjoyed strong political patronage. The colleges were to be used to enrich their patrons and enhance their political power. It is not surprising that MARD’s pleas were brushed aside. Left with no other option, MARD declared a strike, which unfortunately failed in preventing the setting up of these commercial colleges. The strike did succeed in getting guidelines established for maintaining academic standards in these colleges and also for reserving a portion of the seats for meritorious poor students. Over the years these guidelines were side-tracked and many more tinpot medical colleges have sprung up. Today, 12 years down the road, we are experiencing the disastrous consequences of this shameful policy. Poorly trained ‘doctors’ emerge from these colleges, their first objective being the recovery of hundreds of thousands of rupees that their parents have spent in educating them. Now these same armchair philosophers who lament the present morass, criticise efforts such as a strike (even if this is the only possibly effective means) to prevent a foreseen Greek tragedy.

MARD strike justified
Finally let us consider the most mundane, yet commonest reason for a doctors’ strike. Yes, I’m referring to strikes for economic demands, brought into focus by the recent MARD strike of resident doctors in public hospitals for pay rise and better living conditions. One need not go into the miserable conditions that resident doctors work under, since these have been repeatedly described in the lay press. Suffice it to say that their living and working conditions, coupled with a meagre salary, made it impossible for them to work efficiently and to live with dignity. Directly or indirectly, sooner or later, such oppressive working conditions are bound to result in suboptimal work quality and output. Numerous representations over the years to the authorities for provision of decent accommodation and realistic salaries have gone unheeded. Except for 1989, the state Government has never increased the salaries of resident doctors without a strike action by MARD.

If the recent predictable MARD strike had not occurred, the situation would have kept deteriorating towards a total system failure, i. e. a foreseeable breakdown of efficient patient care due to the inability of resident doctors to function properly. In fact, we frequently read about the shortage of faculty members in public hospitals due to poor salaries . It may not be alarmist to say that a breakdown of public health services is imminent. Yet our preachers from the pulpit would say, ‘Let things collapse but do not strike work. ’

1. Pandya SK: Letter from Bombay. Strikes in hospitals. British Medical Journal 1988; 297: 1278.
2. Jesani A: Supreme court judgement violates medical ethics. Medical Ethics 1995; 3: 38.
3. Amnesty International Report, 1986.
4. Jain K: Medical colleges face faculty shortage. Times of India 3 March 1996 page 7. 48

Yash Lokhandwala ,Member, Executive Committee, Maharashtra Medical Council, Member, Central Advisory Board of Education (New Delhi), Ex-member, Medical Council of India

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