The reader is forgiven for some small disappointment in learning that I am not going to definitively answer the question in the title of this piece. The scope of a blog entry simply can’t handle it. However, I will consider a number of issues that bear on the answer to that question, including the type of work action and the reasons for the work action. This is a general issue, but particularly timely as health care providers around the world are currently conducting various kinds of work actions related to the Ebola epidemic. Let us begin first with a few such examples from around the world, and then move on to a discussion of ethical issues in work actions by health care providers more generally.
IMAGE DESCRIPTION: In April of 2012, trade unions of health and social protection workers in Belgrade, Serbia, organized a one-hour “warning strike” in response to a state proposal to reduce the salaries of all healthcare employees by 10 percent. In this image, a dense crowd or professionally dressed individuals marches down a major tree-lined street. All the people who can be seen are light-skinned; both men and women are present. Street car tracks can be seen in the road surface disappearing under the feet of the crowd. Signs are not legible to this author as they are written in Cyrillic alphabet. However, the very large banners and small signs alike bear a common symbol: a blue square with rounded corners; in the middle of the right side of the square is a white circle within which is a red cross. The red cross and the color blue are traditional international symbols of modern medicine. Some signs bear the date “April 25, 2012” in European format: 25.4.12. At the bottom of this blog entry, you can find a description of more recent strikes in Serbia over similar austerity measures, as well as other examples of health care provider work actions in Asia, Europe, Africa, and North America. IMAGE CREDIT: b92.
IMAGE DESCRIPTION: A crowd of mostly women and some men wears red shirts and sweaters. Most hold picket signs (large paper bearing messages stapled to wooden pickets). The people are smiling at the camera. The line of picketers extends into the distance. Signs are read and yellow and bear messages such as “On Strike for Health and Safety”, “Kaiser open for premiums Close for safe patient care”, and “Striking for our patients and our future”. A caption provided by the image source indicates that these nurses were at Kaiser Vallejo in California, and that they are protesting lack of supplies and training as well as short staffing, issues that affect Ebola preparedness but also more common safety risks. IMAGE CREDIT: California Nurses Association
In the US, nurses have walked out to protest inadequate protections for health care workers treating patients who may have Ebola, though their employer Kaiser Permanente calls Ebola merely a “pretext for labor action.” About 19,000 nurses at Kaiser Permanente facilities in California began a two-day strike as part of a “national day of action”; protests in other parts of the U.S. as part of the day of action, including in Chicago and in Washington D.C. in front of the White House, did not involve work actions and simply had nurses protesting on their own time. The nurses’ demands include increased numbers of Hazmat suits, powered air-purifying respirators, and more training in how to properly handle patients suspect of having Ebola. Of the three people in Dallas who contracted Ebola, one was the Liberian native who was infected before he arrived in the U.S. and the other two were nurses who cared for him.
IMAGE DESCRIPTION: workers at a clinic in Sierra Leone are decontaminated after the hazardous work of treating Ebola patients. In some outbreaks where workers lacked adequate protective gear, health care provider death rates have approached 50%. IMAGE CREDIT: AFP.
In Sierra Leone, health care workers at the only Ebola clinic in southern Sierra Leone are striking. One quarter of union members are still assisting at the clinic with union permission to support patients—almost 300 new Ebola cases have been reported in Sierra Leone in the last three days—while others engage in this work action in protest that the government is not paying promised “hazard pay” as a reward, and acknowledgement, for the risks of providing Ebola care. And those risks are great. Despite the providers who remain on site, Medicine Sans Frontiers (MSF, AKA Doctors Without Borders) Sierra Leone emergency coordinator Ewald Stars told the BBC that “about 60 patients had been left unattended because of the strike at the clinic…” They threaten to resume a full-scale strike if payments do not begin.
It is a great truism of work action and labor solidarity movements that workers have the strongest bargaining position when their work is most urgently needed. If they do hard jobs which no one else wants to do but which must be done, they cannot easily be replaced by “scabs” who would be willing to do the job. Consider work actions done by coal miners and farm workers. This is also true for skilled workers, which health care providers certainly are. With respect not only to Ebola and other contagious disease, but with respect to health care generally, the need for such labor is great and the skills required to perform such labor are not easily taught. Health care providers are thus, in principle, in a very strong bargaining position. What’s more, the strongest bargaining position comes from unwavering solidarity in which no one who IS skilled and willing to do the labor in question will cross the picket line.
However, unlike coal miners and farm workers, health care providers’ very profession is laden with values which require doing that labor and most definitely require not abandoning patients. The so-called “duty to treat” comes out of this ethos, as do the ethics of emergency care regardless of ability to pay and the patient rights patients whose lifestyle one disapproves, as well as of noncompliant or even hostile patients. Widely accepted ethical principles such as non-maleficence (do no harm; strive to prevent it) and fidelity (faithfulness; non-abandonment; promise-keeping) contribute to these judgments.
Work actions and the very notion of self-oganization are thus deeply ethically problematic for health care providers, more so than for teachers, coal miners, farm workers, auto workers, or almost any other labor group. Any work action by a health care provider, whether it is a work slowdown or a strike, can harm patients by comparison with not performing that work action. It can also appear to patients already in care to be an abandonment, a lack of faithfulness on the part of providers to both the profession and the individual receiving care. It can even seem selfish.
IMAGE DESCRIPTION: On March 1 of 2012, doctors in Kenya went on strike to protest the government’s failure to increase their pay. This image shows a crowd of Kenyan physicians with stethoscopes draped around their necks, some wearing surgical masks, most wearing white coats and some with surgical gowns. They have blue ribbons pinned to the chest pockets on their white coats. Protest signs are visible behind the first rank of protesters, bearing messages such as “Doctors’ welfare to end the warfare” and “The blue revolution.” Other slogans can be seen partially but cannot be discerned in entirety, including the word “worth.” The strike lasted two weeks, during which time the Kenyan government decided to fire the 25,000 health workers who refused a return-to-work order issued after the first week of work stoppage. One condition of stopping the strike was that the government rescind this decision. Another was that workers’ “extraneous allowances” would be increased by 100 per cent (doubled); this is not the same as their salary. The strike “paralysed operations in all of Kenya’s public hospitals.” Both doctors and nurses participated. Another cause of the protest in addition to salary was a demand for improved resources and services in the country’s most ill-equipped public hospitals. IMAGE CREDIT: Reuters
And yet, health care workers also have rights and deserts of their own: a relatively safe workplace, safe from emotional assault, physical assault, a fair and livable wage, and unnecessary risks of the trade. Aristotelian virtue ethics advises us to seek moderation in all things and avoid extremes of excess and deficiency. I have long believed, though rarely put it this way in print, that constraining health care providers from taking their own wellbeing into account is vicious rather than virtuous, as is the attitude of self-sacrifice. Even the famous utilitarian John Stuart Mill argued that self-sacrifice lacks utility unless it is the only way to maximize happiness and minimize suffering for all concerned. I have argued elsewhere that any arguments about a duty to treat in pandemic conditions must take into account how the burdens of preventing epidemics from turning into pandemics are disproportionately borne by those least-equipped to handle such work. This, combined with the Aristotelian and utilitarian considerations briefly advanced here, has clear implications for considering work actions for either hazard pay or personal protective equipment (PPE): they are not so obviously impermissible.
Indeed, health care workers often bargain not only on behalf of themselves but on behalf of their patients, as now when nurses in the US bargain for better training. Even the equipment which protects health care providers can also protect other patients by preventing the spread of disease within the clinical setting. In 2011, California nurses working for Kaiser Permanente, Sutter Health, and Children’s Hospital Oakland struck after nine months of contract negotiations. California Nurses Association spokesperson Sharon Tobin said “We staunchly refuse to be silenced on patient care protections” (contract negotiations also dealt with employee pensions and health coverage). We also see self-interest and patient interest twinned in the 2012 Kenyan protests described in the image caption, above.
Writing on labor unions and healthcare in the Encyclopedia of Bioethics, which has a decent little bibliography of work before 2004 on this issue for those who are interested, Thomas F. Schindler proposes that:
While a strike can have a negative effect on patient care and the availability of medical care to the community, this result can be the consequence of employer as well as employee action. If, for example, the managers of a healthcare facility have developed policies that result in less than proper benefits, working conditions, or patient care and [then] refuse to bargain fairly with employees, their responsibility for a strike cannot be overlooked. Actions must be evaluated in light of the totality of the circumstances. In addition, during a strike, managers share with employees the responsibility for ensuring that basic healthcare resources continue to be available.
Thus, the very values that would seem to lead us to condemn work actions by health care providers—nonmaleficence, fidelity, and other related principles—also support at least some kinds of the demands health care workers make during work actions even as they undermine the ethical advisability of such work actions. And, in principle at least, bind health care management as well as health care employees who provide and support care.
What we have then, is an acknowledgement that some of the demands which work actions support are valid ones for health care providers to make, both on their own behalf and on behalf of their patients. Yet the means of achieving those demands put patients at risk; the more critical the care, the more at risk patients are, especially with contagious diseases. The work action in Sierra Leone has already led to patients not receiving care, and apparently to the turning away of at least one ambulance. Where did that patient go? Did the patient then bring Ebola to another clinical setting less prepared to handle it? The strategy of leaving some providers behind to do care while the rest put the pressure on seems to contradict work action notions such as solidarity. Indeed, on November 12, 2014, labor activist Duane Campbell, discussing the California Nurses Association strike, said “if union members are not organized and led to not cross picket lines than all the rest is B.S. [bullshit].”
IMAGE DESCRIPTION: A long line of men and women with various skin tones in green t-shirts walks a line chalked on a sidewalk, disappearing into the distance. Each person holds a picket sign in green and white. Signs read “Patient Care Workers Striking for: Our patients, Our family, Our future AFSCME 3299 at University of California” and “Service Workers Sympathy Striking for: Our patients, Our family, Our future AFSCME 3299 at University of California.” The latter in particular shows solidarity where non-health care providers lend their work actions to the cause of others. The image pertains to a May 21, 2013 work action in front of UC Davis Medical Center in Sacramento, CA, in the U.S. IMAGE CREDIT: AP
And yet, if union members who are health care providers do not cross picket lines, patients may die or suffer increased morbidity. This is part of why the union striking as work action at the clinic in southern Sierra Leone has permitted ¼ of their members to continue working on site. Such decisions prevent health care workers from feeling as torn by their duties since that ¼ of personnel are neither withholding essential care nor crossing picket lines. Yet such compromises limit the power of collective work action even as they allow for urgent duties to patients to be fulfilled. Here we see the difficulty of balancing duties to patients with obligations to one’s cohort and one’s self.
What to think, then, of work actions? Are the obligations of providers to their patients in conflict with obligations of solidarity during work actions all the time, or sometimes more than others? How ought we to think about work actions particularly in the context of crises such as the Ebola outbreak? How ought we to think about work actions in the context of daily care? After all, each serious illness is a crisis for the patient and her family. Is it acceptable for physicians, nurses, and other health care providers to engage in work actions not only on behalf of patient care, but also for themselves? Is it so easy to separate provider welfare from patient welfare? Are providers ever entitled to engage in work slowdowns or work stoppages only on their own behalf?
It is, as they say, “a hot mess.” I know I have not resolved the issue, nor did I set out to do so. But I hope this consideration has provided useful fodder for ethical reflection on work actions by health care providers.
As further food for thought, here is an array of health care provider work actions in support of an array of demands, in addition to those provided above:
- NHS workers across England to strike for four hours over pay (September 24, 2014): in response to UK gov’t decision to not give 60% of NHS staff a pay rise for two years. Angela, a community psychiatric nurse, said, “I feel that we’ve been taken advantage of. As nurses we’re the carers and we’re very reluctant to go on strike or work to rule because we’re looking after people. The government relies on the fact that as nurses that is our vocation and that’s what we’ll do.
- Thousands of Serbian health care workers strike against austerity (November 5, 2014): “Tens of thousands of Serbian doctors, nurses, pharmacists and medical staff launched a one-day strike on Wednesday… Medical unions representing some 80 per cent of more than 160,000 employees called the work stoppage in protest at the planned 10-per-cent cut in all wages paid from the state budget. The strike wreaked havoc in already overcrowded hospitals and overstretched ambulance services. Pediatric and emergency care as well as pre-scheduled surgeries were spared.”
- Zimbabwe: A Bitter Pill for the Sick (November 13, 2014): Junior and mid-level doctors in Zimbabwe’s major hospitals and referral centres have been striking for three weeks. These facilities “cater mainly for the vast majority poor who cannot afford private medical care.” Demands include higher salaries, higher housing allowances, and the ability to buy cars duty free, and better working conditions. Some deaths have been alleged to result. “Doctors from the uniformed forces” (armed services physicians) are attending to patients to fill the shortage of care providers. Government and the public blame the doctors for potential loss of life and health. The doctors blame the government for these same things, saying the government has not accorded the strike the urgency it deserves.
- SoBo hospital staffers demand recognition for union, go on strike (November 10, 2014): the workers at a hospital in South Mumbai, India, have attempted to form a union. After failing to be recognized by their employer, they have gone on strike until hospital management agrees to meet with union leaders. So far, the hospital has been able to cover the striking worker’s duties by having remaining staffers take over shifts; some are not allowed to leave the hospital or take food or restroom breaks. This is, the hospital says, not sustainable.
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