By Joshua Parker.
Medicine’s power to affect human well-being explains why the nature of doctors’ practice is deeply moral. With almost every medical decision having some moral component, doctors’ work carries a number of moral burdens. Aside from the decision-making itself, which of course can be very difficult and the risk of error consequential, there is the associated responsibility and psychological sequelae of making tough choices that could decide how well somebody’s life goes. Who ought to bear such moral burdens, how doctors come to shoulder moral burdens, and how they ought to be distributed is the focus of my paper. In it I argue that junior doctors are vulnerable to moral exploitation and that morally exploiting junior doctors is wrong.
Moral exploitation, like typical cases of exploitation, involves taking advantage of someone who is vulnerable to garner an unfair or excessive benefit – think migrant workers, sex trafficking and, perhaps, organ sales. However, with moral exploitation, the currency of what is transferred is moral in nature – moral burdens – rather than something physical like money, labour or the use of a person’s body. This concept was first developed in the context of soldiers. Michael Robbilard and Bradley J Strawser define it as being, ‘pressured to shoulder additional moral responsibilities, moral deliberative roles, and moral risks that they would not otherwise agree to shoulder were they not vulnerable’.
Key to the concept of exploitation is vulnerability. Yes, the idea that doctors, as a group of educated and trusted individuals with a certain socio-economic status, could have their reasonable options restricted and thereby become vulnerable appears absurd. Nevertheless, in a very limited sense, junior doctors’ moral commitments, enforced through their multiple and conflicting roles can leave them open to exploitation. Whilst they share elements of their role with other healthcare professionals, junior doctors’ position is particularly acute.
Junior doctors’ unique position and the role it entails can limit their reasonable options and leave them open to having moral burdens offloaded onto them. Broadly, there are four circumstances in which this occurs: three transactional and one structural. Transactional moral exploitation describes circumstances where junior doctors’ vulnerabilities are leveraged in such a way as to force them to take on discreet and weighty moral burdens, or simply more than their fair share. Their seniors, or at least more powerful figures around them, can leverage their position to force a junior to take on some decision and its incumbent moral burdens. More common is the second type of moral exploitation where rota gaps and staffing issues mean junior doctors take on more than their fair share of the moral burdens of practice.
The notion of structural exploitation is more slippery. Structures are the formal and informal rules that determine the environment in which healthcare is provided. As the environment provides the space in which decisions are made and care given, structures can limit the options available to healthcare professionals. When the system is unable to cope with the demands placed upon it and is in crisis, this presents healthcare professionals with new and increased moral decisions, responsibilities and stresses as they attempt to do the best for their patients. As healthcare professionals cannot avoid taking on these burdens, they become morally exploited by an unfit system that could be otherwise. Clearly this species of moral exploitation accrues not just to junior doctors.
Whilst not every case of exploitation is immoral, I argue that taking advantage of junior doctors’ vulnerability to morally exploit them is unfair and potentially harmful. Clearly this all raises the question of what can and should be done about moral exploitation in healthcare? My paper did not manage to provide anything more than a cursory answer but this important question necessitates an answer. Ultimately, the goal of my article is to begin to provide a language with which to better articulate and appreciate the moral challenges of providing modern healthcare in a system under strain.
Paper title: Junior Doctors and Moral Exploitation
Author: Dr Joshua Parker
Affiliations: Education and Research Centre, Wythenshawe Hospital, Wythenshawe, Manchester M23 9LT
Competing interests: None
Social media accounts of post author: @joshp_j