ANN ARBOR—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 medical ethicist from the University of Michigan Health System in a new paper that coincidentally parallels the current debate over collective bargaining for doctors and the American Medical Association‘s June 23 vote to form a union.
“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 Susan D. Goold, M.D., M.S.H.A., M.A., assistant professor in the UMHS Department of Internal Medicine.
“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 of Healthcare Ethics, from Cambridge University Press in England.
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, Goold writes, some argue that physicians should not strike because they are professionals. Airline pilots and teachers, she replies, 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. This must weigh heavily in any decision to act collectively.
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. 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. For instance, 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.
“Of course, the more cynical view of this example is that doctors are trying to get the same pay for less work,” she adds. “One way to make this truly ‘patient-centered’ is to use patients’ perceptions of access to doctors to set the ‘right’ number of patients per doctor in the plan.”
Similarly, doctors could and 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.
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.
She continues, “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.”

Health SystemSusan D. GooldCambridge Quarterly of Healthcare Ethics