Just War? Just Strike? Or Just Human?

Prussian military theorist and army general Carl von Clausewitz once defined war as “an act of force to compel our enemy to do our will” [1]. The same is arguably also true about doctors going on strike to seek redress from their employers or the government. Both are waged at a cost to humanity and for reasons held to be imperative and righteous by their perpetrators. The question is: are these undertakings, however fated, morally justifiable? 

Wars are not necessarily morally wrong. Under the “just war theory” and the doctrine of jus ad bellum (“right to war”) put forth by Thomas Aquinas, a war is morally permissible if it is initiated, and publicly declared, by a proper authority as a last resort for a just cause that carries a reasonable chance of success [2]. Pursuant to this loaded concept, the Allies’ declared war on Nazi Germany was just, whereas Adolf Hitler’s attempts to annex much of Europe were not—to insist on peacefulness where a grave wrong could only be ended by violence would have been a sin.

Can industrial action taken by doctors be so justified?

Doctors’ strikes are of course not exactly like wars, but that did not prevent some scholars from borrowing the forgoing framework to test their rightfulness [3,4]. The perennial criticism that these strikes violate the Hippocratic tenets and the public’s trust is compelling but not conclusive, for it has been argued that where the government had failed on its part to provide good patient care, healthcare workers may owe society the moral obligation to take action, so much so that it is ethically acceptable to risk the welfare of current patients in pursuing some long-term good for future ones [5]. Such is the position claimed by many, but it has not gone undisputed [6]. 

At the heart of the matter are the controvertible readings and pliant scope of “just cause”. While political agenda or financial self-enrichment do not by themselves normally qualify, they are often entwined and overlaid with more endearing pleadings—greater remuneration for staff retention, shorter work hours for patient safety—that tend to resist being disentangled from less altruistic motives. Granted that some doctors’ grievances are at least subjectively real, one may ask: when are doctors actually overworked and underpaid? Is that sufficient by itself to justify a strike? If not, how much agenda hijacking should we tolerate? Or does the very occurrence of a strike indicate such serious systemic failures that some kind of collective response is warranted? 

As for war where the determination of “just cause” is often an emotionally charged and politically orientated exercise, there is seldom a straightforward and universally accepted answer regarding strikes. But what about the other jus ad bellum criteria? 

A just war is distinguishable from sheer murder or terrorism in that it must be brought on and declared by a competent political authority within a legitimate political system such as the elected government of a sovereign state. The Japanese’s surprise attack on Pearl Harbor and Hitler’s dictatorship regime are, plainly, not eligible candidates. A just war must also be carried out for logically achievable objectives and only after all non-violent options have been exhausted, which probably rule out the trench warfare in WWI where callous mis-directions of blind faith and manly courage had caused the futile loss of countless lives that sound diplomacy might have averted.

By the same token a just strike ought to be organised by an authoritative professional body whose decisions represent the collective views of those whom it purports to represent; an ad hoc entity or one with a significant outsider membership would not suffice. The strikers’ requests must be realistic, which probably excludes a 35% pay rise at a time of national economic downturn, and arguably the withdrawal of governmental plans to boost medical manpower before a general election. The parties’ willingness to come to the negotiation table is a base minimum requirement although it says nothing about their will to compromise. 

There is, in addition, the doctrine of jus in bello (“justice in war”) that governs the conduct of combatants and emphasises the principle of proportionality with respect to the military objectives and the harm caused by the use of force. It underpins the spirit of the Geneva Conventions which prohibits, among other things, an attack on nurses and doctors and ambulances bearing a Red Cross. In the context of industrial action, the same utilitarian calculus can be used to weigh out the balancing between the potential benefits of a successful strike and the collateral harm done to patients—a two-day strike involving only junior doctors or non-emergency personnel would look very different in terms of acceptability from the wholesale resignation of the entire public medical workforce. Curiously, there is so far no convincing empirical evidence that patients had been unduly endangered during a strike although research biases could be at play [7].

Is the “just war” framework helpful?  

If the above sketchy analysis is anything to go by, the Aquinian doctrines when applied in the context of strikes do appear to bring clarity by particularising and re-defining the issues at hand. Yet, ensuing arguments concerning the availability of “just causes” can be so value-laden, personal, and prone to partisan ideologies that sometimes all we can hope for is a congenial agreement to disagree rather than any shared appreciation of what “justness” entails. At the end of the day perhaps the apposite question to ask is, in fact, whether our professional status and incumbent obligations should divorce us from our needs and impulses, permit no human frailties, and morally bar us from exercising a right that is otherwise lawfully available to us. Society seems to think so. Our peers are at variance. 

Are we professionals, employees, or occasionally also human? Carl von Clausewitz never finished his seminal treaties On War, nor did Aquinas his momentous Summa Theologica. Our quest for an answer is yet to conclude.