The bioethics literature on collective labor protest actions by health professionals is modest and recent, focusing almost exclusively on strike actions—although that is beginning to change. The essays in this special section of the Cambridge Quarterly seek to further explore many of the key ethical issues in some detail. The authors analyze existing ethical tensions and propose responses (none presume to call them solutions) to the increasingly hostile conflicts between licensed health professionals and the new corporate management of healthcare organizations.

Public opinion polls consistently reveal that U.S. society wants three basic characteristics in its healthcare system: (1) convenient access to skilled professionals and quality services for everyone, including primary care and specialty personnel and services especially for the very seriously ill; (2) personal affordability at both levels of service; and (3) happy health professionals. Meeting these three goals simultaneously has proved to be quite challenging. The goal of universal access to basic and specialty services pulls against the goal of affordability. Health professionals caught in the middle of this struggle find that their satisfaction with work conditions suffers as a result. If truth is the first casualty of war, worker and consumer happiness appears to be the first casualty of substantive healthcare reform in the United States.

Can strikes by resident doctors training to become consultants in Indian public-sector teaching hospitals be ethical? These hospitals were established for the medical care of the very poor in a country where health insurance and a national health service are nonexistent. In such a situation, the paralysis of tertiary healthcare centers by striking doctors runs contrary to the raison d'être of the profession. It also violates the first dictum of medicine: Primum, non nocere. And although there is some discussion in the Western literature on strikes by doctors, authorities in India are silent on the subject.

This paper aims to identify some of the values held by physicians in the United States that are relevant to physician strikes and other collective actions, and to articulate a position about collective actions that is consistent with medical professionalism. The concept of medical professionalism includes several elements to which physicians should aspire, but the fundamental definition of professionalism is based on just one of these elements, the virtue of altruism. As stated by a committee project paper of the American Board of Internal Medicine, “professionalism in medicine requires the physician to serve the interests of the patient above his or her self-interest.”

The term “industrial action” includes any noncooperation with management, such as strict “working to rule,” refusal of certain duties, going slow, and ultimately withdrawal of labor. The latter form of action, striking, has posed particular problems for professional ethics, especially in those professions that provide healthcare, because of the potential impact on patients' well-being. Examination of the issues, however, displays a difference in response between the healthcare professions, in particular between doctors and nurses. In considering the ethics of industrial (especially strike) action there are various aspects of professional ethics to consider: (1) whether there is a tension between industrial action and the very notion of professional ethics; (2) what specific issues arise in the case of healthcare professions; (3) what, if anything, can explain and/or justify different responses from the medical and nursing professions?

“Collective action” usually brings to mind images of picket signs held by laborers striking for better wages and benefits. Collective action, however, need not be limited to the withholding of labor. Nor need it involve only the working or middle classes, as airline pilots have recently demonstrated. Finally, collective action need not have as its only purpose the self-interest of the group. Collective action does, however, always involve a joining together of individuals united by common goals or interests in order to consolidate power for the purpose of negotiating with another group or entity. Examples of collective action obviously include striking, other withholding labor actions, and slowdowns, but can also include many other activities. “Paper strikes,” for example, have been threatened or used by house officer organizations in the past. In a paper strike, patient care continues but without documentation, and thus, the institution suffers from absent or delayed financial remuneration.

Physician strikes in the United States have been relatively rare, although this has not been the case in other countries nor with other members of the healthcare community, such as nurses. This situation, however, could change. More physicians are either joining unions or seriously discussing doing so. The National Guild for Medical Providers, for example, is actively trying to expand its membership of 11,000 doctors in Michigan, Pennsylvania, and New Hampshire into Illinois, California, New Jersey, Colorado, Texas, and South Carolina. The Federation of Physicians and Dentists, with 2,500 members in Florida and Connecticut, is trying to establish itself in Seattle, Las Vegas, Tucson, and Philadelphia. Although unions are neither necessary nor sufficient conditions for strikes, if physician unions do become more prevalent, the potential for collective work actions, including strikes, increases.

The question of whether physicians or other “essential” healthcare workers are ethically entitled to strike is troubling in that it entails a conflict in obligations. This question of a conflict of obligations (and the answer to it) has wider implications for many other workers.

These CQ Sources were compiled by Bette Anton.

A few years ago a battered infant was admitted to a California hospital. After a period of observation and testing, the physicians concluded that the infant had been beaten so badly that his brain was almost completely destroyed, leaving him permanently unconscious. The hospital had just adopted a policy specifying that life-sustaining treatment for permanent unconsciousness was futile and, therefore, not indicated. According to this policy, after suitable subspecialty consultations and deliberations, including efforts to gain parental agreement and documentation of unanimous ethics committee support, the patient's physician had the authority to discontinue life-sustaining treatment. The infant's physician wished to do this. The mother, however, who was the prime battery suspect, insisted that the baby be kept alive.

Here is the doubt that triggers my inquiry: I have two beliefs that are apparently at odds. The first is that we should never kill; the second, that we should always attempt to alleviate pain. The apparent conflict between these beliefs arises from the fact that death may constitute the ultimate pain relief.

At the end of this century there are so many occasions, so many residues of the most violent of times, that challenge the very idea of forgiveness—residues personal, political, social, and cultural. The harms are vast and yet close to home: alcoholism takes its toll on relationships, divorce undermines love, parental harshness and abuse create generations of problems for offspring, addictions of every sort turn humans into caged spirits. Additional and even greater challenges include infidelity, breaking public promises, political power plays, torture, genocidal slaughtering of races and tribes, civil and cultural wars, ancient enmities—Northern Ireland, Bosnia, the Tutsis and Hutus, the Shiite and Suni Moslems, the settlers and African immigrants in South Africa, indigenous populations against the dominant culture. The open violence and rapaciousness of human enmity can be viewed now in the displacement of masses of people in Kosovo. Said the U.N. High Commissioner for Refugees, Sadako Ogata, about the Kosovo crisis: “It is frightening … that this century, as in its darkest hours, should end with the mass deportation of innocent people.”

Clinical research has become a burgeoning activity in recent years, largely stimulated by the pharmaceutical industry's interest in new drugs with high marketing profiles. Several other forces fuel this thrust: the increasing dependence of academic medical institutions on research funding from industry; the need for large, efficient multicenter trials to obtain reliable and statistically significant results in the shortest possible time for drug registration purposes; and access to research subjects in “developing” countries. The intense interest in HIV/AIDS research and recent controversies about revisions to the Helsinki Declaration, which have been seen by some to be motivated by the desire to facilitate exploitative research in “developing” countries, have stimulated renewed interest in the ethics of clinical research.

I am in the process of trying to organize an ethics committee at a large community mental health center in Central Massachusetts and am seeking advice from anyone with experience in this or a similar milieu. The agency is a large (almost 700 employees), nonprofit, community-based program that operates under the auspices of a broad, academically affiliated, behavioral health system. An independent board of trustees, responsible to the parent organization governs the agency. The agency primarily provides outpatient care and treatment to adults and children with mental health, substance abuse, developmental disabilities, and homelessness issues. It does not provide any psychiatric emergency or acute in-patient mental health services but does operate an inpatient detoxification unit for substance abuse treatment and “first offender” DUI program. Additionally, the agency has a vast network of residential programs and transitional facilities for individuals with a history of chronic mental illness and substance abuse problems. Outpatient medical care is also provided to homeless clients who reside in area shelters (including a “wet” shelter for men and women) and a large number of clients who have HIV/AIDS and/or who have been dually diagnosed (substance abuse and mental illness), and are part of a scattered-site supportive housing program.

Was this just another incendiary sound bite, headline news banner attacking the airwaves? Getting it wrong? Overstating some small technicality for the sake of getting attention? No, to all of the above: the most incendiary aspect of the blurb was that it was accurate. And it did get attention.

Ruth Macklin's new book, Against Relativism, says in its subtitle that it intends to address cultural diversity and the search for ethical universals in medicine. This it does very well. Every chapter includes some discussion of cultural relativism, cultural anthropology, or postmodernism, and her analyses are acute and scathing. Macklin is unabashed in her defense of the principles of medical ethics, and she gives a strong argument that principles are essential elements of any ethical system that is to successfully survive the skeptical doubts of relativism.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.