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Opinions of Thursday, 9 May 2013

Columnist: Adobor, Henry

Some Moral Arguments against Strikes by Physicians in Ghana

Henry Adobor, PhD

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

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 labor to use any legitimate means at its disposal to gain concessions from management. 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 Ghana. 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 willful withdrawal of services from patients an immoral act.
Moral Reasoning: Simple Notions of Right and Wrong
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 to contemporary moral philosophers like Kwame Appiah. 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.
A disclaimer: I am not an expert in moral philosophy. I am merely borrowing rudimentary ideas from that field to make my points. I accept responsibility for errors of commission, omission and some amount of oversimplification because I want the article to be accessible to the average reader. That said I am confident that my basic arguments are reasonably sound. The fact that right versus wrong is the underbelly of moral reasoning makes its core principles accessible to the average person.
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, it’s 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. For example, doctors may choose to go on strike because they believe that will force the government to buy supplies for hospitals. 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 doctor’s strike is causing harm to the majority of people.
Kantian Ethics: Acting Out of Principle
The German Philosopher 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 doctor’s 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 doctor’s strikes fail on all three points. A strike by essential service personnel, especially doctors sets a bad precedence. There will be chaos each time an aggrieved group of essential services people decides to go on strike. I believe governments the world over, including Ghana, 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 abuse the dignity of patients.
Virtue Ethics: Do the Right Thing..
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. It 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.
Religion: Thou Shall Not….
No moral framework has more rules than religion. We can look at the morality of the doctor’s strike through the lens of the world’s major religions, including African religion. Clearly all religions uphold the sanctity of life. Respect for life and human dignity is a recurring theme in all religions. Our traditional religions, including Ghanaian traditions, would frown on denying help or assistance to anyone, even strangers. Morality is an integral part of our traditional religions. How then can we justify the willful denial of service to the sick? Such an act would be frowned upon in our own culture. I believe that doctors going on strike is immoral, looking at it from a purely moral and therefore human perspective. I am not saying doctors, either as individuals or as a group, are immoral people. I am only saying that the decision to strike falls flat when measured with a moral rule. Beyond the moral frameworks, there are at least two other reasons why I believe that doctors strikes are wrong in our Ghanaian context.
Two Elephants and the Game of Chicken
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.” How much more burden can we lay on the weak and vulnerable in our society?
At some level, the government and doctors are playing what is called “a game of chicken” in these kinds of situations. Simply stated, the game of chicken conceives of two drivers driving towards each other on a collision course. If none of the drivers swerve and branch off the road, there certainly will be a fatal collision and one or both drivers may die. The driver who swerves to avoid the collision, now a coward, is described as the “chicken”. The point here is that both drivers’ lives may be saved because one driver decides to “chicken” out. That is a good thing even if they lose face. I will rather live and be called a coward, than die, and be remembered as a fool. The fact is mindless power play to prove a point is, after all, not always the rational thing to do.
The Physician as a Healer
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, especially in Ghana and other developing countries, 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 absolutely 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. The oath of care to the sick is expressive of that recognition. There is something noble to be said about the profession and the nobility of a physician’s job is stepped in history. The Hippocratic Oath predates modern history. Jesus Christ himself in many ways alluded to himself as a physician, or at least many people think of him as Christ the Physician.
And Finally
I have some sympathy for the Ghana Medical Association (GMA) and its members. I too have complaints: Our governments run bloated bureaucracies that would put the old Soviet bureaucracy to shame. We elect and pay hundreds of parliamentarians three quarters of whom may not say a word in parliament their whole term. We appoint advisors, ministers and deputies of deputies when basic supplies in public hospitals are a luxury. We know you deserve to be paid a whole lot more than you are now. The cocoa farmer in Asamankese probably deserves more for his bag of cocoa too.
We value and appreciate what doctors do under difficult circumstances. They have our eternal gratitude. However, this action, holding our most vulnerable citizens hostage, hardly cuts it. It is morally wrong, and against basic sense of fairness and decency. It violates all basic moral standards and the fundamental human rights of patients. ¸There are certain things we do that leave moral stenches. I am afraid withholding medical services from patients creates a moral stench so bad that the choicest Arabian perfumes would not mask it.
Next time the GMA calls a strike; individual doctors must search their conscience, find courage, and act accordingly. Solidarity may have its virtues. To use solidarity to punish the weak makes it a vice no one individual doctor should countenance.