By Philip Berry.
As the impact of strikes begins to be felt, political messaging becomes stronger and, inevitably, more vitriolic. Edwina Currie (a former Conservative Parliamentary Under-Secretary of State for Health) Tweeted that every doctor on the picket line has left a patient in pain on the wards. This comment encapsulates the ethical argument against striking – that it causes harm. The uninformed, who believe that every doctor stands in a large hall and recites the Hippocratic Oath after receiving their medical degree, opine that doctors must never cause harm, and therefore cannot strike. Yet, healthcare workers (HCW) around the world strike due to pay and conditions, and there is no generalisable ethical argument to support the exclusion of HCW from historically hard fought labour rights.
Harm resulting from absence
Although emergency pathways are largely protected by redeployment of colleagues, other activities cannot be done. These are elective investigations, procedures and operations, some of which are clinically urgent. Patients are left on waiting lists, and a small proportion of those will deteriorate. The most at risk groups are those with cardiovascular disorders that can destabilise at any moment (coronary artery or valvular disease), and those with cancer whose tumours might advance or metastasise over several weeks of delay. Given that there are tens of thousands of patients with these conditions, it is likely that some will suffer complications, and some may even die. We can choose to call that outcome ‘harm’.
Healthcare related harm usually occurs through error (i.e., inadvertent omission or commission) done by people working within systems who are there, not by those who are not there. We would struggle to find a root cause analysis that draws a solid line between an individual HCW’s absence and a patient’s harm or death. Consider sickness. When HCW are ill they do not attend work. If cover cannot be arranged (a common situation) we do not presume that harm ensues. However, if we add up all the sick days taken in a typical year (bearing mind that sickness among nurses runs between 3% and 5%) it is reasonable to infer that sickness is associated with harm. If this is so, the harm ‘belongs’ to the organisation, not the absent HCWs. We would not direct accusations of harm to HCW in this scenario. Of course, the important difference here is that sickness is not a choice. Yet, the principle may still apply – absence and harm cannot easily be associated with one another.
The price to pay for a better future
The BMA and RCN will point out that we are living in an era of excess avoidable harm through inadequate staffing, and that IA is the only tool available to shake the government out of its refusal to address the issue. The BMA/RCN say that restoring pay in line with relative falls against inflation will attract more young people to careers in healthcare, resulting in hospitals working at establishment, correct ratios of patients, improved quality of care and better outcomes. If they are right, they have the moral high ground. If a safer future is the destination, the harm experienced by patients who come to harm now are can be considered the cost. This is an essentially utilitarian ‘greater good’ argument, however it can be criticised as classical utilitarianism require an impartial concern for society’s welfare. The primary end-point of IA is better pay and conditions for HCW, with societal benefit being the secondary benefit. Additionally, short term ‘sacrifice’ does not sit comfortably with the personal and professional desire and duty of HCWs to promote and improve the health of patients at all times.
The duty to escalate safety concerns
HCW are duty-bound to escalate concerns about patient safety, and to do something about it. A few months ago Dr Rita Issa (UCL Institute for Global Health) was featured on BBC Radio 4’s Moral Maze where she explained that IA was an available tool to observe this duty. You are a doctor or a nurse routinely observing what you perceive as unsafe conditions due, for instance, to under-staffing. What do you do? There are local actions, such as reporting to line managers and submitting incident forms. The reports may result in some internal strengthening of certain areas or departments, but this usually means moving resource away from other areas (unless extra funds are made available to employ bank staff or locums). Your complaints are ignored, or, if acknowledged at least, no meaningful actions have been taken. There was no money, and only the government can fix that. If your trade union now organises a ballot for IA, you are bound to vote in favour.
Impact versus safety
For the second doctors’ strike, the BMA chose four straight days after the long Easter break, a time when hospitals ae usually full and many consultants plan to be on leave. This looked like a conscious decision to hurt the NHS in a vulnerable place. Was this an ethical decision? IA must be impactful, otherwise employers will carry on providing a tolerable service without too much inconvenience and striking workers are likely to lose heart. In healthcare, impact means reduced quality of patient care and longer waiting lists. If we believe and accept that this is a form of harm (let’s not worry too much about who ‘owns’ it) then high impact = more harm. The question must be asked: if healthcare is an exceptional ‘industry’ (due to its product, which is better health), does an ethical union need to be mindful of impact? Should the ethical union compromise? One can argue that higher impact is justified if it result is a swifter resolution (pay restoration), with a rapid arrival at the rosier future where employees are happier and more numerous, and patients are cared for better. This journey, comprised of bumps, swerves and sudden stops, may lead to people getting hurt… and not only patients, as I will now explain.
Moral injury
If you are a junior doctor or nurse, you might agree with the argument in favour of IA, but feel unable to strike for personal reasons, in which case you are not contributing to the collective action. If IA is successful, you will benefit without having ‘stood up to be counted’. Alternatively, you might be lukewarm about the argument, but feel compelled to strike through trade union membership (what’s the point of belonging otherwise?) and the principle solidarity. These overlapping grey zones illustrate how difficult it must be for HCWs involved in IA. We talk about moral injury in healthcare, where staff are unable to provide the care they feel that patients need and deserve; I think the current IA is causing a whole new level of moral injury. People want to work, and to look after patients, but cannot, for the reasons given above. Those who do not come to work are vulnerable to personal accusations of harm (as in Edwina Currie’s Tweet), and these arrows travel deep into a HCW’s moral core. This all comes in the wake of a pandemic that was itself a hugely potent source of moral injury. Let us be in no doubt; harm is being done to HCW, and it may play out it various ways during the remainder of their careers.
Communication
Given the uncertainties and shades described above, parties involved in IA (HCW, their union representatives and government) should articulate the justification for their decisions to the populations affected. In the author’s view, this applies to decisions around timing and scale of IA, including derogations, not just the overall principle of taking IA. As waiting lists grow and morbidity becomes visible, this need will become more apparent.
Author: Philip Berry
Affiliations: Guy’s and St Thomas’s NHS Foundation Trust
Competing interests: None declared.
Social media accounts of post author: @philaberry