Title: THE ETHICS OF DOCTORS GOING ON STRIKE: A CROSSECTIONAL SURVEY OF PAKISTANI DOCTORS Muhammad Ahmed Abdullah (MBBS, MPH,

MPH, Dip. OHSE, PhD Public health fellow @ HAS Islamabad) (Senior Instructor Community Health Sciences-Shifa College of Medicine, Islamabad) drahmedabdullah83@gmail.com Nargis Yousuf Sattar (MBBS) (Instructor Basic Medical Sciences- Shifa College of Medicine, Islamabad) nargis20042003@yahoo.com Adnan Zahid (MBBS, FCPS Medicine Trainee) (Post-graduate Medical Officer - District Headquarters Hospital Rawalpindi) azuree_83@hotmail.com Correspondence to: Dr. Muhammad Ahmed Abdullah drahmedabdullah83@gmail.com House # 73/A, Affendy Colony, Sadiqabad, Rawalpindi, Pakistan Phone# 092-51-4453348 Cell # 092-333-5494758

Abstract In the wake of the recent strikes of the Young Doctors Association Punjab many ethical questions arose. This paper discusses the ethical implications of such actions. We conducted a Descriptive survey using the website surveymonkey.com and posted it on various communities for Pakistani doctors on Facebook.com. A total of 96 people responded to our 10 point questionnaire out of which 85 were eventually selected for analysis. Most (70.5%) respondents were of the opinion that doctors have a right to go on strike and around 82% claimed to be aware of the ethical implications of a doctors strike. 41.2% were directly involved in the strikes while the rest were either not a part or were not sure of it. Less than half of the respondents (47.1%) were formally trained in medical ethics The questions about the ethical implications were open ended. The main purpose of this study is to generate an academic debate for defining a clear cut line of action may, before health care providers decide to use their right of industrial action Key words: Doctors strike, medical ethics, Young Doctors Association, Pakistan.

Introduction The New Dictionary of Medical Ethics elaborates the Right to Strike of Healthcare professionals in the following text: It is generally considered in free societies that workers have the right to withdraw their labor as a last resort in resolving disputes with employers on wages or on terms and conditions of service. Many health care workers have traditionally waived this right because of their vocational approach and in order to avoid causing harm to their patients. In the more combative industrial relations setting now found in some countries, some groups (e.g., Nurses in the UK) have reserved their right, as they feel that their goodwill has been exploited.(1) The medical profession is based on the ethical principles originating from the Hippocratic Oath, which clearly elaborates four essential ethical obligations set forth for health care providers. These basic principles are (2): Respect for autonomy (the individuals right to self-determination and respect for human dignity and freedom.) Non-maleficence ( Primum non nocere first, do no harm) Beneficence (the need through ones intended actions to do good.) Justice (social and distributive justice requiring fairness in the distribution of risks and benefits, and the need for equity and impartiality across all members of the greater community.) Although each one of these issues remains highly relevant to the practice of medicine, but they are subjective in reference to each other, where in certain cases one principle needs to be sacrificed to uphold another one, in order to achieve a more significant long term goal. This can be clarified by the example that we often sacrifice the Autonomy of individuals while placing them in quarantine to contain

the spread of various infectious diseases, for greater good of the population in general. Here Autonomy is sacrificed for Beneficence of the public. (3) The Pakistan Medical and Dental Councils Code of Ethics (4) does not clearly identify any guidelines regarding the right of strike for doctors. It states the following regarding the right to refuse services to patients: A medical or dental practitioner shall not be bound to treat each and every person asking for his services, but he shall not only be ever ready to respond to the calls of the sick and the injured, if in his opinion the situation warrants it as such, but shall be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. Over the years the right of strike has been utilized and waived in many countries around the world. In May 1962, doctors from the Canadian province of Saskatchewan passed a resolution vowing that physicians would close their practices if and when Medicare came into force, and called it Socialized Medicine. As a result of the 23 day strike the government signed the "Saskatoon Agreement" with the doctors, ending the strike on July 23, 1962. As a result of the agreement, amendments to the Act were introduced allowing doctors to opt-out of Medicare and raising fee payments to doctors under the plan, as well as increasing the number of physicians sitting on the Medical Care Insurance Commission. (5) A more recent example is of the British doctors who went on strike in June 2012 for the right of better pensions. This act threatened to cause the cancellation or postponing of around 30,000, 58,000 diagnostic tests and 200,000 outpatient appointments. (6) The Young Doctors Association Punjab announced province wide strikes in 2012 in order to materialize their demand for a better Service structure for doctors in the province. A similar episode of strikes was carried out by the doctors in 2011 when they demanded a pay raise and a proper service structure. The demand for a pay raise was met by the government; ending the 37 day strike, but the issue of service structure was left unsolved. The

doctors initially suspended their services from the Outpatient departments of the Public sector health facilities of the province. The government eventually took strict action against the doctors which resulted in a complete closure of emergencies and indoors as well. (8) Punjab government even managed to file an FIR with the police against four doctors on account of Murder, despite The Ministry of Law passing a memorandum that professional negligence on the part of a doctor can only be prosecuted under section 318 PPC, 269 PPC or 338 PPC, and there is no need of imposing 302 PPC. (4)The conflict finally ended through negotiations on basic terms and conditions while leaving a few bullets unfired, for future rounds on both sides. In an Industrialized world most professions reserve a right to give up services, in their pursuit of better working conditions. However when the same scenario is viewed through the lens of health care providers the ethical issues involved attain greater importance than any other professional right. A few main ethical questions that need to be addressed before a decision for striking is finalized have been beautifully explained by P.S Sachdev (7): 1. Can the long-term benefits to the doctors and the public offset the short-term costs to the latter, including avoidable death? 2. Can the immediate need, be set aside in anticipation of future benefit? 3. Does the nature of the physician-patient or physician-society contract preclude strike action? 4. How would a strike affect the public image of doctors? The recent events that followed the Doctors strike called by the Young Doctors Association Punjab (YDAP) gave rise to many moral and ethical questions and initiated a debate on various forums. The electronic and print media seemed to play a biased role in this regard with most of the News covering the issue in a fashion that placed doctors at the tip of their swords.(9) The social media seemed to be one place where both sides openly displayed their opinions. The present study comprises of a survey

conducted over various community pages of Facebook.com using a survey questionnaire developed on Surveymonkey.com. This gave us an opportunity to interact with various doctors in a candid environment where they could clearly provide us with their opinions. Methods The current study is a Descriptive survey regarding perceptions of different doctors about their right to strike and based on their experiences the ethical dilemmas that arose as a consequence. We developed a ten point questionnaire using the website www.surveymonkey.com. The questionnaire was divided into two main portions. The first part gathered basic characteristics of the participants which included educational level, current posting, years of experience, departmental affiliations, type of health care facility they perform their duties in, formal training in medical ethics and their sources of information regarding medical ethics. The second part was mostly based on open ended questions which inquired about the respondents perceptions about the doctors right to strike and the probable causes which pushed the young doctors towards resorting to such drastic measures. Even though the issue teases many sensitive spots in our own thought process, we have tried to remain as non-judgmental and neutral as possible any glimpses of being opinionated demand prior apology from all readers on behalf of the authors. We posted our questionnaires on many communities on www.facebook.com ; where the issue of the doctors strike was under discussion. These community pages included, YDA Punjab, YDA Rawalpindi, Nishtar Medical College, Rawalpindi Medical College, Allama Iqbal Medical College and Quaid-E-Azam Medical College. There was no set criteria why we chose these pages , it was more of a random decision. In a period of two weeks; from the mid of June to early July 2012 we gleaned responses from around 96 respondents. Out of these 93 responses 85 were completely filled and thus became a part of our study.

The data collection was not random a reason for this was basically because in this particular scenario we were of the opinion that every individuals point of view counts. Results Years of service as medical practitioners Out of the 85 respondents 11.8 % had less than 1 year of service, 23.5% had 1 to 3 years of service, 29.4% had 4 to six years and 35.5% had more than 7 years of work experience as medical practitioners. Fields of specialization Most of the respondents had been trained in medicine with a percentage of 35.3%. Surgeons were next in line with 29.4% of the respondents being surgical trainees or specialists. There were 5.9% respondents from opthalmology11.8% from ENT and 17.6% practicing general practice. There were no respondents from Pediatrics and gynecology and obstetrics. Work place Around 88.2% doctors in our study worked in teaching hospitals while 5.9% each were employed in Private hospitals and GP clinics. There were no respondents from Basic health units or rural health centers. Perspectives about the Doctors right to strike When asked if doctors have a right to strike 70.6% respondents replied in affirmative while 23.5% said that doctors do not have the right to go on strikes. 5.9% of the respondents replied with the option dont know.

Knowledge about Ethical implications of a doctors strike When asked if the respondents were aware of the ethical implications of doctors going on strike 82.4% replied with Yes, 5.9% with No and 11.8% with dont know. Practices regarding the 2012 YDAP strike We asked our respondents if they were part of the 2012 YDAP strikes 41.2% said that they were, 52.9% said that they were not a part of the strikes and 5.9% werent sure if they were or were not a part of the strikes. The responses of this question have the potential to be out of context because we do not have the area of service of the respondents. This lack of information can be related to the fact that we decided to maintain respondent confidentiality and by no means collect any information that might link us to the respondents. Formal training in Medical ethics When asked if the participants had received any formal training in the field of medical ethics 47.1% said yes, 41.2% said no while 11.8% of the subjects replied with Dont know. Sources of information regarding Medical ethics Out of the total respondents 47.1% based their knowledge of ethics on the PMDCs Code of medical ethics, 52.9% on standard textbooks, 29.4% on workshops and seminars, 11.8% from seniors, 17.6% on personal moral ideas, 5.9% from the internet, 29.4% on national and international journals and 5.9% marked other means as an option. The responses to this question are not mutually exclusive and more than one response can stand true simultaneously.

How do you define Medical Ethics? This was an open ended question. It bore many interesting responses some of the more significant ones have been presented below: Do no harm Patient's safety first A code which ultimately protects the doctor-patient relationship and the dignity of this relationship. Rules which keep rights of patient and doctor preserved in medical profession. To fulfill your moral obligations as a doctor and to respect the patients physical and psychological needs. Safe guarding the best interests of patients. Serve the humanity under normal conditions.

The reasons for doctors strike When asked about the reasons which caused the young doctors of Punjab to go on strike the following key responses were gathered. Each problem of every department is not even considered by this government, but Strike. Government servants of every department have to go on strike before they listen. Punjab Government has no ears, no sight and no brain. Political Dictator is running it. Government's negligence Apathy of a government run by non-professionals. Absence of service structure. Lack of proper facilities for healthcare of patients.

Due to lack of proper service structure. However in spite of agreeing with their demand I feel that the strike went overboard and the masses were denied basic health services.

Service structure, Low salaries, long working hours, shortage of staff and medical equipment, lack of basic facilities on call.

No respect, no reward from public, no management, political interference.

The ethical implications involved in a doctors strike We asked our respondents that which ethical issues were involved when it came to the mater of health care providers refusing services to the whole community. As a response we got the following answers: No matter what the motive for strikes, in the end it is the patients that suffer the most. Doctors have a right to strike because this is being done to improve the services for the patients in the long run. We the doctors cannot work in conditions where we are not offered proper incentives and where there is lack of respect. No doubt that the rights of the patients are much more important but the doctors did not suspend emergency services until the governments brutal actions of arresting and torturing doctors started, then we had no other way but to stand back from all types of services. I think that this strike issue has greatly damaged the publics view about this noble profession, even the people who depend on us for treatment are calling us killers and butchers. Table 1: Summary of Results Discussion The medical profession since its inception in its contemporary form has been associated with characteristics of high moral standing which define a physician. In 1770 AD, during Persias Islamic era,

Mohamad Hosin Aghili of Shiraz wrote the work Kholasah al Hekmah. (8) The first chapter of that work contains a list of ethical duties for the physician. The Author has placed the physician is a position of highest moral standing, he suggests that : A Doctor must always be content, grateful, generous and magnanimous, and never be covetous, greedy, ravenous or jealous. Even though physicians enjoy and are burdened simultaneously with upholding the highest level of moral ethics, it is imperative to realize that they are common people like every other member of the society. Legally every individual has a right to industrial action in a free society. In Pakistan the law permits such actions as they are in accordance with the 1973 constitution of The Islamic Republic of Pakistan in particular article 15 (freedom of movement), article 16 (freedom of assembly), and article 17 (freedom of association).(9) On the other hand legality only partially satiates the moral requirements, expected of physicians. The ethical aspects are far more demanding; as industrial action by health care providers always has a direct impact on the lives of the patients. Every doctor is bound by a code of ethics which has great moral implications. According to the International Code of Medical Ethics, all doctors are expected to Maintain the utmost respect for human life from its beginning even under threat and, not to use their medical knowledge contrary to the laws of humanity. The international code of ethics further states, that; a physician shall not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patients. (10) To the doctor, the life of the patient comes first to all other things. This legality of the issue exists between the doctor and the government, while the doctor patient relationship is governed by ethics. The issues of ethics come into play when we talk of issues of good and evil, life and death, justice and crime, etc. Since the doctors primary job is to save lives and that a lost life cannot be revived, it therefore becomes delicate for the doctor when taking any action

that will obliterate these ethics. Should a patients loose his or her life as a result of doctors' strike, who would be blamed; the doctor or the government? Based on the findings of our research it became obvious that most doctors were of the opinion that doctors have a right to go on strike, most of them werent directly involved in the strikes but supported the cause. Around 47.1% said that they had formal training in medical ethics. Most said that their knowledge about medical ethics was based on the PMDC code of medical ethics. Even though most doctors supported the strikes many of them were of the opinion that when doctors utilize their right of industrial action it is the patients that suffer the most. But at this point it is essential that we understand the various contextual aspects of the situation. The doctors continued to provide emergency, in-door and OT services to the patients while they quit working in the out-patient departments of public sector health care facilities of Punjab province. They discontinued emergency services only when the government decided to use Police action to humiliate and torture them. It was then that all emergency services were shut down; which had an acute effect on the morbidity and mortality of patients. These facts make the issue of implicating a certain responsible party, subjective. The role of the electronic and print media seemed particularly biased against the doctors in this regard. The only place where doctors could express their opinions was the social media and SMSs with their personal contacts. (9) There is not much literature present on the ethical aspects regarding the right of strike for doctors, and the available material usually does not clarify many questions. One of the main purposes of this study is to generate an academic debate on the issue, particularly in our scenario so proper rules and regulations may be delineated for physicians to utilize their right of industrial action without harming the patients and their own public standing as well. According to Autumn Feister when physicians decide to go on strike the eventual purpose is to cause harm to patients which will obligate the relevant authorities to succumb to the demands, the second argument against industrial action by physicians is that it

disregards two essential principles of patient respect and non-abandonment. (11) Thus it is necessary to draw a clear line where the demands of the physicians maybe met while safeguarding patient rights. Limitations This main purpose of this study was to learn the perspectives of doctors about the ethics involved in their discontinuation of care provision to patients. Nonrandom consecutive sampling was used. As this was a blind survey conducted over the internet the validity may be questioned keeping the technical aspects in mind, but at the same time as this was meant to be an opinion poll hence most opinions that we got helped in providing a definite path to our thought process. The survey would have been more valid if face to face interviews were conducted. Keeping in mind the time and resource constraints the current methodology used seemed to be an appropriate choice. Conclusion Doctors in developing countries face tough working conditions with limited remuneration. This often leads them towards a struggle to achieve their personal rights, but in the process many aspects of patient rights are thwarted. To solve this cumbersome issue it is imperative that the regional and global authorities responsible for ascertaining the practice of biomedical ethics should come into play by clearly defining the conditions in which doctors should utilize their right of strike in a way that does not hurt patient rights. Also all physicians should be trained thoroughly in the basic principles of medical ethics starting from the time when they are medical students; so that when a situation arises where industrial action is demanded of them by their fellows each individual may be qualified enough to weigh the situation on a personal level. Conflicting Interests The authors declare that they have no conflicting interests.

Author Contribution MAA conceived the idea for the study; MAA, NYS and AZ all were involved in the questionnaire development, dissemination, data analysis and write up of the study. The final draft was proof read by all the authors. References

Boyd KM, Higgs R, Pinching AJ (editors). The new dictionary of medical ethics. London: BMJ Publishing Group;1997. 2 Soskolne CL., Last JM. Ethics and public health policy. In: Wallace RB, Kohatsu N, Last JM, editors. Public health & preventive medicine. New York: McGraw Hill Companies Inc, 2008;p.28-35. 3 Bayer R. Ethics and infectious disease control: STD, HIV, TB. In: Jennings B, Kahn J, Mastroianni A, Parker LS, editors. Ethics and public health, model curriculum. New York: The Hastings Center, 2003; p. 133-44. 4 Pakistan Medical and Dental Council. Code of Medical Ethics [accessed on 05-06-2012] available from: http://www.pmdc.org.pk/LinkClick.aspx?fileticket=v5WmQYMvhz4%3D&tabid=102&mid=554 5 The Saskatchewen Doctors Strike [accessed on 12-07-2012] available from: http://www.thecanadianencyclopedia.com/articles/saskatchewan-doctors-strike 6 The Guardian. Doctors' union calls strike on 21 June [ accessed on 12-07-2012] available from: http://www.guardian.co.uk/society/2012/may/30/public-sector-pensions-doctors 7 Sachdev PH. Ethical issues of a doctors strike. Journal of medical ethics, 1986;12: 53-54 8 Reich WT (ed.) Encyclopedia of Bioethics, revised edition Vol 5. Simon & Schuster MacMillan, New York, 1995) 9 Riaz H, Bhaumik S. Police target doctors over strike action in Pakistan. The Lancet, 2012; 380: 97-98 10 World Medical Association. International Code of Medical Ethics[accessed on 14-07-2012] availablefrom: http://www.wma.net/en/30publications/10policies/c8/ 11 Feister A. Physicians and Strikes: Can a Walkout Over the Malpractice Crisis Be Ethically Justified? The American Journal of Bioethics, 2004; 4(1):W12

Characteristics Years of service as a medical practitioner Less than 1 year 1-3 years 4-6 years More than 7 years Field of specialization Medicine Surgery Ophthalmology ENT General Practice Work place Tertiary care Private hospital GP clinic Do doctors have a right to go on strike? Yes No Dont know Awareness about Ethical implications of a doctors strike Yes No Dont know Are you a part of the current strike Yes No Dont know Formal training in medical ethics Yes No Dont know

Descriptive statistics 11.8% (n=10) 23.5% (n=20) 29.4% (n=25) 35.3% (n=30)

35.3% (n= 30) 29.4% (n= 25) 5.9% (n= 5) 11.8% (n= 10) 17.6% (15) 88.2% (n= 75) 5.9% (n= 5) 5.9% (n= 5) 70.6 (n= 60) 23.5% (n= 20) 5.9% (n= 5)

82.4% (n= 70) 5.9% (n= 5) 11.8% (n= 10) 41.2% (n= 35) 52.9% (n= 45) 5.9% (n= 5)

47.1% (n= 40) 41.2% (n= 35) 11.8% (n= 10)

Source of information about medical ethics PMDC code of ethics Standard textbooks Workshops and seminars Seniors Personal moral ideas Internet International & National journals Other Table 1: Summary of quantitative results

47.1% (n= 40) 52.9% (n= 45) 29.4% (n= 25) 11.8% (n=10) 17.6% (n= 15) 5.9% (n= 5) 29.4% (n= 25) 5.9% (n= 5)