THE question is not whether or not governance in Pakistan has failed. Maybe it has. There is plenty of evidence around us to suggest that this is the case.
The health care sector, in particular, has been particularly weakened, both in terms of the provision of services and mismanagement. The rights of patients as well as doctors are violated in different ways.
But as the recent strike by the Young Doctors’ Association has illustrated, the question goes far beyond the right of doctors to protest. They may have the right to do this, but the issue hinges on whether protests such as these, which resulted in the virtual shutting down of major healthcare facilities in the city for days on end, can be defended when examined through the lens of ethics.
In a 2008 essay, ‘The Ethics of Protesting’, Dr Bruce Weinstein explained that the aim of protesting is to “make things better”. Yet this has to be balanced with ethical obligations of doing no harm, displaying respect for others and being fair. A protest that does not cause any meaningful harm or disruption in other people’s lives can generally be regarded as morally inoffensive.
Some argue that sometimes, it is only through systematic defiance of the system — for example by pressurising or embarrassing the government — that change to make things better can come. Sometimes, however, a protest may actually cause material harm, which usually comes in the form of violating other people’s rights. In this case, moral justification is required.
In order to morally be able to defend a protest that causes harm, three factors are necessary. First, the cause must be of greater concern and leaving it unresolved may cause greater harm than the damage done by the protest. Secondly, it is impossible to resolve the conflict or dispute through less harmful means, and thirdly, the harm that is being inflicted is primarily directed at the target of the protest rather than innocent and uninvolved people.
Regardless of the socio-political background of a series of protests organised by the YDA over recent months, the fact remains that the cause of each protest must be evaluated on its individual merit. The most recent dispute was about the ad hoc transfer of doctors, including some YDA officers, from teaching hospitals to district hospitals by the Punjab health department, which has to accommodate freshly appointed doctors through the Punjab Public Service Commission.
The doctors claim that the transfers were made in violation of a policy devised in 2010, and organised protests aimed at sending out a resounding message to senior officials of the health department, whom they charge of being incompetent.
As a result, however, routine services — including emergency rooms — remained suspended in hospitals for days, depriving thousands of patients access to health care and even life-saving facilities.
Let us assume here that the cause stands up to scrutiny about whether it is good and worthwhile. Let us also assume that there is no means of resolving the doctors’ grievances other than the path chosen by the YDA. Is the cause of such protest of greater moral concern than the harm it has caused in terms of the thousands of people who were affected but were uninvolved with the issue? And, subsequently, has the harm been inflicted primarily on the health department or its officials, as opposed to ordinary citizens? Clearly not.
Many feel that referring to the Hippocratic Oath would be to resort to a cliché. They argue that ‘the system’ is to blame, since it has forced members of a supposedly honourable professional group to remand ransom by holding patients hostage. But this argument reflects arrogance, manipulation and a defective emotional experience. The stance taken by the doctors that forced the closure of essential health care services can be seen as nothing other than irresponsible and above all, a display of blatant disregard for human suffering.
These are essentially the psychopathic traits originally described by Hervey Cleckley in the 1941 The Mark of Sanity that have been studied ever since. These traits vary in degree across the spectrum of protesters. Some ‘leaders’ display pronounced psychopathic traits, others constitute followers with some degree of conscience, and many are simply vulnerable people who succumb to tactics of harassment employed by the leaders.
In terms of the latest spate of doctors’ protests, another point must be made. The doctors involved do not appear to be united solely on the ideology of safeguarding health care or ensuring good governance; there is an obviously discernible clique that is defying authority at the cost of patient care.
While the causes of anti-social behaviour are not too well understood, there are biological and environmental factors that can possibly be involved. It is hard to believe that the young doctors have a neurobiological or genetic basis to their behaviour. Therefore we are left with exploring environmental factors that could have contributed to this irresponsibility.
Psycho-social theories explain that the care-giving environment can produce problematic behaviour in the vulnerable. For example, if the process of nurturing is arrested through maltreatment or neglect in childhood, personality pathology can develop. In the same way, if the social milieu is hostile, unstable or absent through neglect, people’s development processes are affected and psychological maturity is not achieved.
The increasing trend of callous behaviour on the part of doctors is frightening. If soldiers are professionally trained to fight and kill, doctors have committed their lives to saving lives. Their guiding principle should be compassion, and tolerance and empathy are required as their central traits.
The turbulent change in the temperament and behaviour of doctors, as exemplified by the protests that caused the suspension of the provision of health care, might just be the tip of the iceberg, symptomatic of the wider psychopathy that is developing unchecked within our society.
The writer is an associate professor of psychiatry at the Rawalpindi Medical College.