Collective Action, Unions and Even Strikes May be Moral for MDs: Ethicist Susan Dorr Goold, M.D.

Before they strike, negotiate with insurance companies or lobby Congress, physicians should make sure they are acting with their patients—not just themselves— in mind, according to Susan Dorr Goold, M.D., assistant professor of internal medicine and a medical ethicist.

“Doctors already act collectively and can do so morally. But the goal of collective action must be completely consistent with their commitment to the patient and respectful of the trust patients place in them,” says Goold. “Even a strike could be morally justified if circumstances were bad enough,” Goold continues, “but there are many other collective action options available short of striking. And doctors must also remember that morality and legality are not always in line with one another.”

Goold presents her views in a commissioned paper to be published in a special issue of the Cambridge Quarterly o Healthcare Ethics, from Cambridge University Press in England to be published next year. In the paper, she disputes some of the most common arguments against physician collective action, unionization and strikes, but puts forth other reasons why such actions might not stand on solid moral ground.

For example, some argue that physicians should not strike because they are professionals. Airline pilots and teachers, Goold points out, are professionals, too, yet they are organized and routinely strike. Others say striking doctors would deprive the public of essential services and cause hardship or even death. But, she answers, most health-care services are non-essential, and physicians could strike without withholding emergency care.

It is the moral argument for or against striking—or any collective action—that counts, she concludes. Doctors take on a moral responsibility for their patients when they enter medicine because of the trust patients must place in their doctors’ knowledge, experience and good faith. Due to this power imbalance, she says, physicians bear a moral burden to act in ways that strengthen, not dilute, that trust.

Collective action, says Goold, is a strategy for increasing power, so it is no surprise that doctors feel it is necessary as they perceive their professional autonomy diminishing. However, given the trust and power already placed in physicians’ hands, it is imperative that it be used for the welfare of patients, and not just to serve physicians’ own (often financial) interests. “There is some merit to the old saying ‘A happy physician makes a happy patient,’ but patient and doctor interests don’t always automatically overlap,” Goold comments.

“The more the process or outcome of collective action will harm patients, or undermine patient trust, the more difficult it becomes to morally justify it,” she writes. “This is why it is so difficult to morally justify a strike: withholding care from patients ostensibly to benefit them rarely adds up.”

In fact, she says, doctors already act collectively, whether through professional organizations lobbying elected officials or educating the public about issues, groups of physicians in private practice joining together as a large clinic or group, or residents protesting long hours or low pay. About 42,000 practicing physicians are already in unions, including the house officers at the University of Michigan.

In general, she concludes, issues where doctors can act collectively with moral certainty are those where they can join their interests with those of patients and curb the power of corporations that have a financial stake in the health care field. “If enough physicians refused a company’s contract clauses because they undermined the doctor-patient relationship and professional values, the companies might eliminate such clauses,” Goold states.

Goold can be reached at sgoold@umich.edu