By Arjun S Byju and Kajsa A Mayo

The coronavirus pandemic in the United States has offered ample opportunity for those in medicine to reflect upon the nation’s healthcare system and its various shortcomings in delivering care during a time of crisis.

As the term “essential worker” made its way into the public lexicon, the pandemic also brought attention to the issue of workers’ rights in the field of medicine. Several prominent news stories focused on essential workers in hospitals who petitioned for more adequate PPE; at least one physician was fired for doing so. And as has been reported recently, junior doctors (variously called interns, residents, or house staff in the US) found themselves facing substantial rebuke when they asked for hazard pay during the height of the pandemic in New York City.

As medical students, the plight of these junior doctors struck particularly close to home and we found ourselves wondering about how to protect the rights of future physicians within the modern healthcare economy. One answer, posited by some, is widespread unionization of physicians in training.

Although physician unionization has not been as broadly embraced in the United States as in other countries, there exists in the US a long tradition of trade unionism in general, as well as among healthcare workers like nurses and technicians. The question remains then, what sets physicians apart? And what are the criteria, if any, that would allow physicians to unionize or take collective action?

In this paper we attempt to address the ethical and empirical criteria that would permit physician unionization, and how those criteria would align with the special professional obligation that physicians hold to their patients.

We grapple with the fact that physicians clearly enjoy a privileged position in society, both in terms of salary and esteem, and therefore may be asked to bear a significantly higher burden than other employees. Indeed, this appears to be one of the most visceral critiques of doctors’ unions, with many opponents expressing the sentiment that doctors must simply rise above and “do their job.” On this point, critics often invoke the Hippocratic and other professional oaths.

While we agree that there are many groups within our society that are significantly less fortunate than physicians, we did not find this fact a convincing argument in itself against why doctors could not also choose to unionize. And if proponents of an absolute injunction on physician unionisation were to be believed, based on the aforementioned “special status”, a doctor could be obligated to work “under any conditions, at any time, with any number of patients.” Clearly, there are limitations on what physicians can and should be expected to perform, as duty hour limits already confirm. Additionally, the objectives of a labor union need not center exclusively on salary and benefits; unions often concern themselves with topics like safety and working conditions, issues which are germane to workers regardless of their relative economic standing.

Most importantly, without union representation, the patient-centred ethic of physicians risks being manipulated by employers to increase efficiency and productivity— to the detriment of providers’ own physical and mental health, and for the financial benefit of healthcare organisations. More often than not, the principal reason that physicians desire to unionize is a concern for patient wellbeing, and a feeling that their employers are allowing too little time with patients. Insofar as this is true, doctors’ unions do not disrespect, but rather enshrine, the special relationship between physician and patient.

Simultaneously we address whether in threatening, or carrying out, collective action unionized physicians might endanger patient safety. We explore this reasonable criticism in detail, and ultimately offer several empirical rebuttals to this claim.

Finally, we end with a discussion of the Free Rider Problem. Assuming that a physicians’ union exists at a given hospital, we explore the potential ethical dilemma faced by non-member residents who benefit from union negotiations. We provide solutions to the Free Rider issue that satisfy the autonomy of those who abstain from physician unionization.

Paper title: Physician Unionization in the United States: Ethical and Empirical Considerations and the Free Rider Problem

Author(s) (do not include qualifications): Arjun S. Byju¹ and Kajsa A. Mayo²

Affiliations:

¹ Albert Einstein College of Medicine, Bronx, NY, USA

² University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

Competing interests: None