The University Record, July 19, 1999

Collective action OK for doctors, but only if goals help patients, too

By Kara Gavin
Health System Public Relations

Susan Goold says physicians should keep the welfare of their patients in mind if they are weighing taking collective action of some sort. Photo by Bob Kalmbach
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.

So writes a U-M medical ethicist in a paper parallelling the debate over collective bargaining for doctors and the American Medical Association’s (AMA) June 23 vote to form a union.

“Doctors already act collectively and can do so morally,” says Susan Goold, assistant professor of internal medicine. “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.

“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 each other.”

Goold’s views are in a commissioned paper to be published in a special issue of Cambridge Quarterly of Healthcare Ethics, Cambridge University Press.

In the paper, she disputes some of the most common arguments against physician collective action, unionization and strikes.

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

Collective action, Goold says, is a strategy for increasing power, and 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.

“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,” Goold 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, lobbying elected officials through professional organizations, educating the public about issues, groups of physicians in private practice joining together as a large clinic or group, and residents protesting long hours and low pay.

About 42,000 practicing physicians already are in unions. The AMA estimates that one in seven of all doctors—the approximately 100,000 now working directly for hospitals and insurance companies—would be eligible for its new union. Antitrust law prevents most of the nation’s 684,000 largely self-employed doctors from unionizing.

Goold gives examples of cases in which collective action by doctors might be morally justified.

If an HMO added patients without adding doctors to see those patients, office visit time would have to decrease or doctors would have to work longer hours. Collective action to negotiate a limit on patients per doctor would increase access to care and therefore be acceptable, she says.

Doctors have protested government “gag rules” against discussing certain procedures with patients. They would be justified in balking at limits on hospitalization that come without accompanying provisions for home care. They have mounted public relations campaigns when insurers have denied reimbursement for emergency services after-the-fact.

Issues in which doctors can act collectively with moral certainty are those in which 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.

“We must focus our collective efforts on those conditions that limit the quality of the care we give or restrict access to care. It is only this way that we will make the practice of medicine more rewarding for ourselves, more satisfying for our patients and more efficient.”