As doctors in England prepare for strike action next month, researchers at Harvard Medical School and Brigham and Women's Hospital (Boston, USA) show that, in high-income countries, "patients do not come to serious harm during industrial action provided that provisions are made for emergency care."
In The BMJ today, David Metcalfe and colleagues report that death rates remained the same, or decreased, during all previous doctor strikes that have been studied in developed countries. They say that strikes can therefore be organised in such a way that patient safety is not compromised.
The right to strike is recognised as a fundamental human right by the United Nations, the Council of Europe, and the European Union, they explain.
However, for some doctors, industrial action is inconsistent with their over-riding duty to advocate for their patients. Some commentators, such as Health Secretary Jeremy Hunt, have claimed that doctor strikes inevitably expose patients to risk of serious harm.
So, Dr Metcalfe and colleagues examined data from previous strikes for evidence to support claims that industrial action harms patients.
Overall, they found that, within developed healthcare systems, doctor strikes have not been found to affect mortality provided that emergency care provision is made.
For instance, three studies examined the consequences of a strike by physicians in California in 1976, where care for all but emergency cases was withheld over five weeks, and all found that mortality fell during the strike period.
Similarly, an analysis of death certificates following action by 73% of doctors in Jerusalem in 1983 found no excess mortality during the strike, while research at an emergency department after a nine-day strike by junior doctors in Spain in 1999 reported no mortality difference between strike and non-strike periods.
And, in 2003, when most doctors in Croatia went on strike for four weeks, a subsequent study found no significant association between the industrial action and patient deaths.
The only report of increased mortality associated with strike action was from South Africa, where the odds of death increased at one hospital during a 20-day strike in 2010. However, this strike included both doctors and nurses who withdrew all services from patients, and left only one hospital open to serve a population of 5.5 million people.
So why don't patient deaths increase during doctor strikes, they ask?
Importantly, all strikes in developed countries guaranteed continued provision of emergency care, they explain.
Emergency care may even improve during industrial action, they add. For example, during the 1999 strike in Spain, junior doctors in the emergency department were replaced by more senior physicians.
It is likely that temporary reductions in mortality are related to the cancellation of non-urgent (elective) surgery, they say. Other possibilities are that doctors are better rested during strike periods and that the number of staff required to avert patient deaths is comparatively low.
Nevertheless, it would be naive to imagine that industrial action can be undertaken without causing any harm or inconvenience to patients, they write. For instance, no study to date has explored the effect of industrial action on patients' quality of life or confidence in the medical profession.
"Some doctors will always feel that industrial action is fundamentally inconsistent with their professional obligations because of its inevitable impact on patients," they say. "However, in balancing their competing priorities, doctors in high income countries can be reassured by the consistent evidence that patients do not come to serious harm during industrial action provided that provisions are made for emergency care."