“Primum non nocere.”
(First do no harm)
“Insanity is doing the same thing over and over again, but expecting a different result.”
“Nsuo taa aponkyerεnii a, wͻ gye woͻ.”
(When water overwhelms the toad, it croaks)
History puts before us islands of events that tell us that victims created by social institutions will one day bang on the door of their perpetrators and without fear, forcefully demand what is due them (the victims). From French Revolution, through the decolonization of Africa to the Anti-apartheid in Madiba’s South Africa, history tells us a lot about the demand for what is due the victims by the victims themselves. In line with the famous quote by Victor Hugo, “No army can withstand the strength of an idea whose time has come”, victims wait for the fertile setting to “fly like a butterfly but sting like a bee” (Mohammed Ali).
These events occurring within the political arena have their lookalike (but sometimes milder and constitutional) also occurring within the employer-employee arena as well, where trade unions and associations of workers and professionals also react to their employers and other stakeholders whenever the employees think some basic but necessary responsibilities of the employer are not being performed and needs of the employees are not been provided for.
Physicians whose critical responsibility finds itself at the thin dividing line between life and death also sometimes engage in these bouts of reactions to demand what is due them. These reactions employed by employees can either be in the form of demonstration or strike. In Ghana, physicians are fond of the latter more than the former. This article focuses on physicians and strike; whether the debate surrounding physicians embarking on strike actions can actually bring out any practical and sustainable solution; and if the debate cannot open the Red Sea, what different approach can salvage the situation.
A few popular questions that find themselves at the heart of the debate are:
- Can physicians go on strike?
- Should Physicians go on strike?
- Are there any justifiable reasons for physicians to go on strike?
- Is it right for physicians to go on strike?
- Does the striking physician have any moral values?
From time immemorial, a myriad of individuals from different walks of life have contributed in their own small ways in providing arguments that sought to answer the hereinbefore questions pertaining to physicians and strike action. Primary school pupils, secondary school students, tertiary education students, medical students, physicians themselves, politicians and several other intellectuals have once in their lifetime engaged in debates (be it formal or informal) which have these questions as the hub of the discourse.
Almost each one of them has deeply held beliefs, thoughts and convictions about whether physicians could or should embark on strike actions. Some are of the view that patients who might not have died in case physicians were working die whenever physicians go on strike. And so physicians who ought to protect and sustain the lives of patients should not sacrifice human lives on the altar of their selfish financial interests. Others are also of the view that medical doctors are already well to do and so they must not grumble and complain about their share of the national cake, since there are other people in tattered penury who need augmented attention in the sharing of the national cake.
Other argument raised are that the taxpayers’ money was used to train the medical doctor, and so a physician who embarks on strike actions is not diligently performing his fair share of the social responsibility. Another commonly raised argument is that it is against the ethical texture, principles and spirit of the medical profession as inscribed in the Hippocratic Oath for physicians to embark on strike actions. In that light, the striking physician is no doctor at all and cannot be called a noble member of the noble profession.
Considering the other side of the debate, some people are of the view that physicians work and should be given what is due them, and that their families should not also be sacrificed in the abattoir of nonperforming and irresponsible institutions and structures who are supposed to make sure that they procure and appropriately respect the right of the physicians. Others are also of the view that sometimes doctors embark on strike actions for the sake of the patients. They strike to demand some necessary items that facilitate their life-saving responsibility where the institutions that ought to provide these items are just not providing them. And so, seek first the needed items, and all other life-saving functions will be possible. The arguments can go on and on like the hen and egg conundrum, but it must be appreciated and not ignored that the demands of the medical doctors are no follies and the lives of patients are no useless lives.
In fact, whichever side of the debate one tilts there are unfavourable consequences which will sprout in case that side is fully employed. If physicians should be encouraged to strike in order to demand what is due them, some patients will die any time the physicians go on strike. All lives are equal, whether they are physicians’ or the patients’; and none is useless. As strike actions continuously become the habit of the medical profession, some patients will lose confidence and no longer trust the healthcare system. They may resort to other interventions which have long term detrimental and fatal effects on their lives, even though in the orthodox medical practice there may be carefully selected treatment and curative options that could have been employed had the physicians been at post. These consequences are no beauty to be admired, but they are complete signs of failed and incompetent institutions that cannot protect the lives of the people they serve.
On the other hand, if physicians were bound by all legal and ethical instruments not to embark on strike actions to demand what is due them, it brings to bare the frank hypocrisy of our society. The physician has worked tirelessly saving the lives of other people, and so it is only fair, prudent and proper that he is paid the amount he deserves to be paid in due time. As the popular Akan adage puts it, “ͻsεnkafoͻ didi n’edwuma ho” (The preacher man makes a living from what he does daily). Also, if there is any reason to delay in paying their salaries, it is also prudent that the appropriate procedure is taken to inform them before transiently denying them of their rightfully earned money; and when the time comes to fulfil your promise, do not let become another bout of litigation.
The physician is sometimes the breadwinner of his/her nuclear family and in a typical African setting he/she may sometimes be responsible for some members in the extended family. These individuals who depend on the physician daily are no less humans than the patients of the same physician. Both the family members and patients have unique needs which must not be ignored when considering the responsibility of the physician holistically.
Also, when basic consumables that are needed for smooth and uninterrupted healthcare delivery are not being provided by the institutions responsible for their provision, will the society be suggesting that physicians sit unconcerned when their lives and that of their patients are at stake, and while the institutions responsible assume an indifferent and a blind posture to the necessities within the clinical setting? Absolutely, both sides of the coin are unfavourable in this debate.
Apart from the consequences associated with employing any of the sides of this debate, there is an inherent incompleteness and a fault in the questions (e.g. can a physician go on strike?) that have been the center of the physician-strike discourse for a very long time. It is this incompleteness and fault therein the questions that have been bringing about all these answers that rather aggravate the issue rather than solving it. So far as the questions are wrong in themselves, the answers generated will also be faulty in addressing the issue of physicians embarking on strike action. This is what I associate with GIGO (Garbage in, garbage out). You pose the wrong question to address a problem, one should not expect a right and working answer that will solve the problem. That will be insanity (“Insanity is doing the same thing over and over again, but expecting a different result.” Albert Einstein).
The stakeholders in public healthcare delivery are the employer (the government), institutions responsible for providing what is due the physicians and addressing their demands, the physicians and the patients. Any question that does not take into consideration all the stakeholders will be incomplete and faulty in addressing the issue of physicians and strike action. The questions that have been at the center of the debate from time immemorial (e.g. should physicians go on strike?) takes into consideration only two of the stakeholders – the physician and the patient. What about the other two stakeholders? It is in the exclusion of the other two stakeholders that the incompleteness of the questions lie. In this light, until the right question which is complete in incorporating all the stakeholders is asked, the GIGO rules.
In my view, the two appropriate questions to be asked are,
- Should physicians be provided with the reasons to consider strike action as an option?
- How can the society/stakeholders get rid of the reasons that physicians rely on to consider strike as an option?
These two questions are complete and have taken into consideration all the stakeholders involved in the issue of physicians and strike action. First, the reasons for physician strike actions are mostly provided by the employer (the government), the institutions responsible for meeting their demands or both of them. Their actions, inactions, comments and silence all come together to incite the whole thought process of considering strike action by the medical doctors. These two questions will call on the stakeholders implicated for generating the strike-initiation reasons to overhaul their structures and be more proactive and trustworthy in administering their duties.
The next stakeholder is the physician. The suggested questions bring to mind the idea that the group of professionals may have genuine concerns that need to be understood from different points of views and appropriate measures put in place to address them such that they are not be raised again in future. This means that new reasons are addressed with elimination in mind and not hiding the problems behind smokescreens. The questions also remind physicians of the nature of the profession they have chosen for themselves. And this can be summarized in the words of Carola Eisenberg, an American Physician, Educator and a Dean of Harvard Medical School for eight years, ‘It is still a privilege to be a doctor’. She continued, ‘But to lose sight of just how lucky we are to have a profession in which we do well for ourselves by doing well for others reflects a puzzling loss of perspective. The satisfaction of being able to relieve pain and restore function, the intellectual challenge of solving clinical problems, and the variety of human issues we confront in daily clinical practice will remain the essence of doctoring, whatever the changes in the organizational and economic structure of medicine.’
The final stakeholder, the patients, who unfortunately happen to be the victims in this misunderstanding and mistrust between the employers, institutions and the physicians will still have the detrimental effects inflicted on them by the strike actions elaborated whenever addressing the two new questions suggested. These will remind the society that the death of patients as a result of strike action is a sign of failed healthcare system.
Finally, in my view I think that the answer to the first question of the two new questions (Should physicians be provided with the reasons to consider strike action as an option?) will unanimously be “No, do not provide reasons for the physicians to embark on strike actions”. The debate will no longer be a blame game or an ejaculation of litanies of insults, but rather the debate will be on how the stakeholders can become more effective in playing their individual roles in the whole healthcare delivery process.
In conclusion, incompleteness of the old questions have created extremists (Physicians should strike versus physicians should never be allowed to strike) but no practical and sustainable solutions. The new set of questions demand as answers practical approaches to remove any reasons that make strike action an option. The new questions call on the government and other institutions with specialized interest to be more proactive and trustworthy in administering their duties; physicians to corporate with the government and never consider trading off the lives of their patients for anything; and finally patients should appraise the dealings of the government and the other institutions involved to make sure that their actions and inactions are not generating reasons that can trigger the slightest thought of physicians considering strike as an option. When adequate brainstorming is put into answering the new set of questions, even better questions can be asked to make society and the healthcare system better, and by the end of the day all stakeholders will be smiling from ear to ear.
God bless Ghana
God bless the Healthcare system
God bless the Noble profession