Doctors, upon induction into the medical profession, take the Hippocratic Oath. It essentially entails a set of vows taken by a medical doctor. He swears to carry out his duties with the utmost sense of professionalism. This Oath has often been referred to by individuals or groups who have felt shortchanged by medical professionals. In many cases, those calls were justified but in some cases the Hippocratic Oath has been overly emphasized and often misapplied. As for the latter, a case in point was the strike of doctors in Lagos state and their sack by the state government (which was later reversed).
First and foremost, we often forget that medical doctors are human beings first and then doctors second; they are not doctors first and then human beings second. As a human being the medical doctor is first bound by the laws of the land, the laws and ethics of the medical profession come second. The Constitution of the Federal Republic of Nigeria supersedes The Code of Medical Ethics in Nigeria. The decisions of the Supreme Court of Nigeria take precedence over the decisions taken by the disciplinary tribunal of the Medical and Dental Council of Nigeria. The doctor is protected by the laws of the land which guarantees the freedom of speech, the freedom of association and his other basic human rights. He’s also protected by the Labour Laws of this country. Nigeria is a signatory to The African Charter on Human and Peoples’ Rights. Article 3 of the Charter states: ‘Every individual shall be equal before the law. Every individual shall be entitled to equal protection of the law’. Article 4 states, ‘Human beings are inviolable. Every human being shall be entitled to respect for his life and the integrity of his person. No one may be arbitrarily deprived of this right’. Article 9 and 10 states in part, ‘Every individual shall have the right to express and disseminate his opinions within the law. Every individual shall have the right to free association provided that he abides by the law’. Article 15 states, ‘Every individual shall have the right to work under equitable and satisfactory conditions, and shall receive equal pay for equal work’ (Italics mine). Every doctor who is a citizen of this country is entitled to these inalienable rights. The doctor is first a human being and taking the Hippocratic Oath does not make him less human and does not rob him of his fundamental human rights and privileges. Everyone expects the doctor to treat his patients with dignity, respect, and honour, is he less deserving of such treatment in return?
In the same vein, taking the Hippocratic Oath does not make the doctor immune to the ills, the sufferings, the injustices and the corruption that has bedeviled our country for so long. He still faces the tough economic issues and the pressure of making a living in these perilous times. He still has a family to take care of and the bills to pay. He goes to the same market and competes for basic resources like every one else. Sometimes, he pays more for goods and services because the moment the landlord or trader or businessman knows that he’s a doctor, the prices go up. The doctor even pay a higher bride-price; once the potential in-laws learn he’s a doctor, the demands automatically increases. He’s not except from taxation and he pays his dues as a citizen of this country. Taking the Hippocratic Oath does not grant him any more privileges than his neighbour; he’s not inducted into any aristocratic class with mystic powers and protection. If that was the case in the days of Hippocrates, things are a lot different now in our modern civilization. He did not swear an oath of celibacy and/or self-denial like monks/nuns living in a monastery/convent. In any case the doctor faces more pressure than most of his peers. The average citizen has high expectations from his doctor, sometimes unrealistic expectations. Thus the doctor is always under pressure to perform. In the home front, the pressure is worse. Right from the moment he starts medical school, his family and extended family expects him to be the breadwinner of the entire family. So, he graduates with a whole lot on his shoulders. We all expect the doctor to be of best behaviour and to do his job, but how is this possible when he’s poorly paid and his working conditions is a far cry from ideal! Some talk about sacrifices, that the doctor should make sacrifices for the greater good. My friend, sacrifices are over-rated! Sacrifice will not pay the bride-price or the school fees. Sacrifice will not pay the rent or buy fuel for the car or household generating set. Sacrifice will not pay the bills when his wards are sick and they need expert care. The truth is, those clamouring for sacrifices are those who, at the same, are not willing to relinquish any thing that is due them.
To illustrate my point clearly, let me give some examples. If you own a company that provides paid services to the public, you expect to be paid for your services. Now, let’s say there is a hike in the prices of goods and in the cost of transportation of the raw materials you need to perform that paid service, won’t you increase the costs of your services to reflect the new reality? What if some customers agreed to the new price, enjoyed the service provided and refuse to pay the new fee, will you continue to provide that service and run at a loss? Is cutting off that service, no matter how vital it, not one of the strategies you would employ to enforce the new rate? A doctor who owns a private hospital with paid staff and other expenditures expects his patients to pay their hospital bill; that’s the only way he keeps the place running. What if some patients decides not pay their bills? Will he be wrong to terminate providing health-care services to those patients who continue to default on their payments in spite of incessant reminders and warnings? Doctors who work under the government are paid by the government for the health service they provide. They don’t collect money from the patients. Now, if the government promised or agreed to a better pay package for the doctors, and then later the government reneges on paying the new package, what can those doctors do to enforce the new arrangement? They can’t hold the government hostage but they can do what everybody does in situations like this, and that is the withdrawal of the services they provide after adequate warning is given. They earn that right from the point of view of the law and from the point of view of common reasoning.
Many are of the view that when doctors withdraw services, lives are endangered. That is true. That is also true when other providers of government services go on strike. When the Nigerian Labour Congress (NLC) goes on strike and commercial and economic activities are paralyzed, lives are also endangered because there are millions of ordinary Nigerian who live day–to-day from hand to mouth and they stand at grave risk when they are forced to stay at home. When the providers of water, food, electricity, security and other amenities go on strike, the lives of those who depend on those services are put at risk. Sadly, some people feel that the doctors who are on strike are effectively ‘murderers.’ Those persons forget that when an employer who fails to pay his workers as and when due, even when he’s capable of doing so, endangers the lives of those workers who desperately need that money to feed, clothe and provide shelter for himself and his family. When a politician siphons public funds like pensions, salaries, etcera, that individual puts the lives of all those who depend on that money in danger. People don’t just die because they didn’t get the services they need in hospitals. They die when they lack the education to make right choices and decisions. They die when they lack the finance to get basic needs of living: adequate nutritious food, clean water, good housing, etc. They die when they lack insurance to cover them in emergencies. They die when there are bad roads and expensive means of transportation. They die when the nearest health care facility is too far from where they live and work. They die when they go to hospitals that are poorly equipped and lack skilled manpower. Some people keep their sick relatives at home for too long and expect ‘magic’ when they get to the hospital. The whole system is at fault and doctors are not the only guilty party. Always remember that!
The question is not whether doctors are deserving of a better wage. The question is not whether doctors are in need of a better wage. The question is not whether doctors have the right to fight for a better wage or better working conditions. The question is not whether they are justified in withdrawing services as part of the overall strategy to fight for improved working conditions. The real question is, the salary scale doctors are fighting for, is it practicable or feasible? Can the employing governmental agencies afford to pay? Don’t answer that question yet. Look at the huge sums of money lost in the subsidy scams and other financial scandals. Look at the huge allowances allocated to those in the National Assembly and other political public office holders. Look at the huge resources wasted in the endemic corruption and sharp practices perpetrated by government officials and at various levels of authority. The question is not whether the government can pay. The question is do they have the will to pay? Remember, when there is a will, there is always a way. Sadly, they don’t have the will to pay. They keep talking about sacrifices while they enrich themselves and their cronies. They keep referring to the Hippocratic Oath. Those who crafted the Oath could not have anticipated a time when doctors will be poorly treated, intimidated, sacked without notice and forced out of their homes as it happened in Lagos State.
The Hippocratic Oath not only covers the actions of a doctor at work. It also entails his relationship with his colleagues, teachers, and his conduct towards other people in general. That means that a doctor under the oath will not treat others disrespectfully, will not steal or commit an abominable act that will put his profession in disrepute, will not use his knowledge to violate the rights of others or cause harm to others. In the course of his duties, in obedience to his oath, he shows respect to his colleagues, make the wellbeing of his patients of utmost priority, will not ‘allow any considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing interfere with his duties’*. The Hippocratic Oath applies only when a doctor agrees to provide services and fails to carry out that duty with the utmost decency and sense of responsibility. When a doctor enters a contract to provide a service related to his profession, he’s under obligation, as outlined in the oath, to do so religiously. It is not in all cases that a doctor is obligated to render his services. For example, if a doctor is passing by a roadside accident, he’s not obligated to stop and render professional services. But when he does so, on his own accord, he’s bound by ethics and he’s expected to give his best under the prevailing circumstances.* Another example of when a doctor is not obligated to provide services or when he can withdraw such services is when ‘a patient insists upon an unjust or immoral course in the process of his treatment, or (the patient) deliberately disregards an agreement, or fees or expense’. He can withdraw his services ‘on due notice to the patient, allowing him time to employ another doctor’. The Code of Medical Ethics in Nigeria said and here quoted, ‘It is permissible for a doctor to withdraw his services (industrial action or strike) in pursuit of his rights under the Labour Laws of the Federal republic of Nigeria, provided that any doctor wishing to take that course of action must have satisfactory arrangements for the continuing care of his patients and must have given adequate notice of his intention to these patients and to the hospital authorities.’ Under the above circumstances, when a doctor withholds his services, it’s not a violation of the Hippocratic Oath. As I stressed earlier, many will say the withdrawal of services lead to needless loss of lives. That been true, lives are also lost on a daily basis when doctors are poorly paid and the working conditions are a far cry from basic standards. When doctors are poorly paid, many are forced to seek employment abroad with the resultant effect of ‘brain drain’. Others seek locum jobs with private hospitals so that when they close from their places of primary employment, they go to such places to make extra money. Others engage in other non-medical ventures to make ends meet. As a result, he’s often exhausted, stressed out and under such circumstances mistakes are made and patients pay the high price. Over the years, more and more doctors work in 2 or more hospitals in a month. This unpalatable situation is not necessarily a thing of choice. Many doctors would like to have some time to get sufficient rest, spend some time with his or her family and even engage in some recreational activities. Unfortunately, the unfavourable working conditions in the country have forced many doctors to look for additional source of income. So, at the end of the day, when the government chooses not to approve better wage packages, the doctors under their employ will not be able to give their utmost. A lot of economic resources are wasted when workers are fatigued and exhausted under unsavoury working conditions. Economically, the government too is losing what it claims to be saving. It is a ‘lose lose’ situation.
Finally, let us stop hiding under false pretences and vain excuses. Let’s not use sentiments to divert attention from the truth. It is said that everyone is entitled to his own opinion but not everyone is entitled to his own facts. The facts of the matter are plain and open. The Nigerian Medical Association (NMA) should do more to enlighten the public about the pertinent facts of the struggle for better salaries and welfare packages for the hard-working doctors under government employment. This fight won’t be won on the basis of strikes alone. The government at all levels has perfected a propaganda machine created to distort facts and figures and thus sway the public sympathies towards their side of the argument. The NMA must counter this war of the mind with constructive and productive enlightenment initiatives with the goal of making the public more and more aware of who is really on their side. Political leaders come and go, but the doctor is stuck with his patient year in, year out. The most important battles are not won on the battlefields; nor are they won with threats, strikes, guns, armoured tanks or angry looking security forces. The most important battles are the battles of the mind. No matter what you do, if you don’t win the mind and heart of the people you serve, ultimately you will be on the wrong side of history and the battle will be as good as lost.
(Please, note: the asterisked quotes are sourced from “The Code of Medical Ethics of Nigeria” published by The Medical and Dental Council of Nigeria.
I first wrote this article few days after the commencement of the strike and subsequent sack of doctors in Lagos State. This is an updated version of that article.)
