Burning questions of morals, ethics as doctors strike persists

When specialist doctors in training at the University of Nairobi and the Kenyatta National Hospital went on strike a few years back, saying that their work was unpaid and therefore could best be described as slave labour, everyone was shocked.

A crisis meeting was quickly called between the university, the hospital, the Ministry of Health and representatives from the trainee specialists to lay out all the issues.

The university pointed out that they were unable to offer education for free as people teaching and in administration also needed to be paid.

Besides, the university declared that as they did not own the teaching hospital, they were not rightly situated to discuss remuneration of their students for services rendered.

The teaching hospital pointed out that they were allowing the students to learn at the hospital, a service the university should actually be paying for.

Besides that, their presence as a referral institution was endorsed by the ministry and if any policies needed to change with regard to payment of additional personnel, the ministry would have to lead in such a conversation.

The ministry pointed out that they were unable to support more doctors with scholarships from a restricted budget line, even though the need was great.

They also mentioned their reasonable expectation that the semi-autonomous relationship between the university and the referral hospital, plus their separate income generating capacities, would be enough to steer them towards good decision making in these matters.

The trainees pointed out that without them, hospital services had ground to an absolute halt and that the hospital clearly had no internal capacity to do what they claimed to be able to.

They stated that hospital work took their potentially income earning hours, and that the university strongly discouraged them from working anywhere else.

Additionally, since the ministry seemed unwilling to find the money to sponsor the doctors the country so desperately needed, where were the unsponsored ones supposed to find money to pay their living expenses on top of paying fees, if there was neither time nor permission to meaningfully earn wages? There was general agreement that the students were doing labour that deserved pay.

However, neither the ministry, the university nor the referral hospital could agree on who was supposed to pay for those services and where this money would come from. The meeting ended, as it had begun, in clouds of uncertainty.

The fundamental issues here are moral, referring to a standard of right behaviour. This goes into who bears “duty of care” and what that duty of care entails.

“Duty of care” is generally a term that has legal implications – the Collins dictionary refers to it as “the obligation to safeguard others from harm while they are in your charge”.

An easy way to understand duty of care is in considering the responsibility parents have for children, employers have for employees and vice versa, etc.

Good Samaritan

The solitary moral question that has been asked by the government, the media and the public, about the ongoing strike of allied health workers that has paralysed Kenyan public healthcare, has been to do with the duty of care that health workers have to patients. It is a legitimate question.

The parable of the Good Samaritan and other similar tales globally intimate that leaving a sick individual without the healthcare they need is a reprehensible act that is fundamentally unreasonable, regardless of circumstance.

The hyper-visibility of this one moral question is troubling. Firstly, it ignores the fact that dealings in healthcare are not just moral in isolation, but unavoidably capitalistic.

They have value, which can be acceptably represented by money, and money is exchanged for the giving of this care. It follows that the payment for the time and expertise of government caregivers is the State’s duty in the offering of healthcare to its public.

Can the government then say, with any moral authority, that they offer healthcare services, while taking the time of workers for nothing? Isn’t this, usually called theft, the original sin in this scenario?

Who is, therefore, really being cavalier about welfare of Kenyans here? Can someone who is stealing from you legitimately ask that you allow them to continue, in the name of mercy?

How can you be labelled the villain when you say no?

This unfortunate, unavoidable link between money and care raises a few more concerns. One is the selective vilification of caregivers ostensibly working because of a higher calling for “choosing to love money”.

This is particularly strange in a culture which also openly values people more the richer they are, regardless of the circumstances in which said riches were acquired.

The second is governmental priorities when spending money or accounting for loss. We are in the throes of outrage about billions that reportedly vanished from public coffers.

Kenyans cannot imagine what life would be like if a government were to spend as lavishly on them as it does on the wellbeing of holders of political office.

In 2016, some campaign promises are still about piped water, basic public sanitation and the provision of electricity. We must be honest about who gets money without question when they ask for it, and why that is not the public, or the providers of certain kinds of goods – health, education and security, etc. to this same public.

This is exactly like having a friend borrow your money (are taxes nothing but money that is supposed to come back as public goods with interest, if the State is working, in collaboration with the people, to build a better nation?) and then tell you he or she cannot pay, but then the next thing you see is their selfies splashed all over social media being frivolous about spending on a holiday or outing. Would you not have many valid questions?

Difficult time

As we hopefully move towards the end of the strike, which has been a deeply difficult time for all concerned, not in the least the people in need of healthcare, there are a few more matters to address.

There are those who have been severely disappointed in caregivers for choosing a strike as their method of engagement.

This is regardless of the fact that worldwide, strikes are the unfortunate public necessity for trade unions when all internal conflict resolution methods fail.

It is telling that those with this opinion are mostly unable to suggest any other methods for engagement.

It is also telling that other suggestions want doctors to continue to offer services, but in unorthodox ways – perhaps on the streets, in the parking lots of Afya House, etc.

However, our primary reliance on hospitals as the standard of care comes back to bite us now. Even if a doctor does a consultation at Kencom Bus Stop but a patient needs labs or images, can a lab or image technician do these tests outside of their workplace? Or how can inpatients be cared for anywhere else apart from a facility that has all the tools to treat them when issues arise?

Finally, as a country we must reflect on the spirit in which our conflict resolution is done.

Lies have been actively told about the collective bargaining agreement that doctors signed in 2013, which was first declared null and void by some government workers, then most recently declared legitimate in court. Are all the punches that have been thrown acceptable?

Can any kind of healthy relationship exist between the parties going forward? Will there be a forum for some kind of trust building and reconciliation?

Is this, furthermore, a reflection of we, the people, as the nation of unfair fighters we are – and that perhaps, the only way we know how to fight is by hurting one another and then guilting each another into uneasy ceasefires and stalemates? And if so, what are we going to do about that, when the next fight comes around?

Dr Ngumi is a former general practitioner with experience in Kenyan private and public health care sectors, and is now a maker with The Nest and HEVA. ([email protected], @njokingumi)