By Lawrence Paul
The right of many Nigerian workers to strike as a form of objecting to unfair labour terms or conditions is one that has found both fervent support and fervent opposition. Although the Nigerian Labour Laws generally permit strikes, one industry where employee strikes are an increasing subject of controversy is the health care sector.
Health care workers—including physicians, nurses, physical therapists, nurse practitioners, mental health counsellors, lab technicians etc —are indisputably entitled to a voice in the terms of their employment, just as employees in any industry are. However, much like fire fighters and police officers, these workers provide an essential public service, which is hinged on a fundamental duty beyond self.
Without hospital staff to care for them, sick patients may languish in their pain and their suffering. Injured persons may face worsening conditions, or find their injuries becoming irreversible or vastly more complicated. Why, then, are nursing strikes, doctors’ strikes and strikes by other unionized health care workers not only legal but even commonplace in Nigeria?
Rather than delve into the nuances of labour law in this column, I instead explore the ethical dilemma presented by the decision of health care workers to go on strike. On one hand, the unjust treatment of employees is intolerable.
In the health care context, unjust treatment often means understaffing, overworking, and underpaying health staff not only to their detriment, but also to the detriment of patients who depend on the attentive care of their medical providers. On the other hand, nurses, doctors, counselors, and most other health care staff must abide by ethical guidelines imposed by state licensing boards and the law.
One ethical principle in particular is imposed universally on all health workers in all jurisdictions of the world and that is the first duty is to care for the patient.
I first will describe the normative frameworks for choosing the most ethical option from two untenable choices.
Then I will apply one framework to the context of strikes by health care workers. I conclude that the risk of harm to patients outweighs the need to use the strike as an objection to working conditions in most circumstances, and that the strike is only an ethical option in exceptional situations.
For the purpose of brevity, this column focuses on the individual as the decision maker. However, the factors surrounding the decision to strike are much more complex. The employer, as an institutional provider of health care, has ethical obligations to both its patients and its employees.
In a few circumstances, the most ethical decision depends on what approach one uses.
Virtue Ethics: “The ethical choice here is the one that develops moral virtue in our self and our community
Taking the virtue ethics approach, we would ask whether going on strike is an action that a virtuous nurse/physician/surgeon/health-care worker would take.
The medical community has widely accepted certain principles, first proposed by Thomas Beauchamp and James Childress, as the pillars of the code of the virtuous health care worker: beneficence, non-maleficence (“first, do no harm”), autonomy, and justice.
To abide by these principles, a virtuous health worker would strike only for the purpose of benefiting the patient. Assuming that a strike is based on the complaints previously described in this column—understaffing, underpay, and overwork—the goal of the strike may be aligned with keeping the patients’ best interests in focus.
There is concededly a limited circumstance in which a strike may be primarily for the purpose of something other than the benefit of the patient (such as for individual compensation) while still being ethical.
In such a circumstance, the striking individuals must have pre-emptively ensured that patient care would not be negatively impacted by the strike. If such assurances have not been made before the strike, then the decision to strike would be ethically wrong because a strike presents a risk of harm to the patient.
If the purpose of the strike satisfies the first prong of the value ethics framework—that is, if it is entirely or substantially for the benefit of patient—then the second question is whether the provider has exhausted all other avenues of negotiation before resorting to the strike.
Because of the potential harms to patients that could be caused by striking, a virtuous health worker must first exhaust all other avenues of negotiation that do not present such a risk. In the health sector, many have advocated for the continued use of the symbolic 24-hour strike, which raises public awareness of the dispute, but has arguably fewer potential negative consequences for the patients due to its short duration. Another less drastic device to raise awareness of working conditions is the picketing protest, which may last anywhere from one hour to several.
Part of the power of the worker’s strikes is based in the potent message that the system cannot function without those workers. There is thus a widespread stigma and displeasure among workers toward the replacement workers who are hired during a strike, pejoratively called “strike breakers,” as these replacements diminish the message of the strike. However, any efforts by the striking workers to impede the ability of replacement workers to care for patients effectively contravene any notions of virtue.
Thus Health-Care workers Strikes Are Ethical Only in Exceptional Circumstances! No one can reasonably argue that health care workers do not deserve fair terms of employment, nor can it reasonably be disputed that the treatment of the sick and the infirm should always be paramount for those charged with their care.
The failure of a hospital or other health-care institution to act ethically (by unfairly or inadequately providing for its employees) cannot be corrected by serving injustices to patients.
Only when the benefit of the patient is the ultimate goal, and only after all other avenues of negotiation have been exhausted, can health-care workers ethically leave their patients’ bedsides to go on strike.
If we as a society allow those who care for our sick to easily abandon their oaths and their duties any more readily than this, then we too have abandoned our sick.