Striking, Nursing and Role Morality

Last week Dr Peter Carter (general secretary of the Royal College of Nursing) angered a large proportion of the nurses and support workers he is supposed to represent by urging them not to strike, since doing so would involve “abandoning their patients.”

One of the things he said in his speech to the RCN’s annual congress is less controversial; not giving NHS workers their 1% pay rise in line with the cost of living is obviously “insulting”, and as someone on the lowest rung of their pay scale, I can attest to the fact that what I earn is enough for a young, childless person to just about subsist on but not a lot more. And whilst striking is clearly at its most effective (and ethically defensible) when the individuals setting working conditions and wages are the ones directly harmed by the strike (i.e. corporation owners), public sector strikes  do often work, and can do so in a way which either does not harm, or only negligibly harms, the public (and may even help them.)

But if I imagine what would happen if half the nursing staff on my ward went on strike, it would be a lot more serious than people being late for work or rubbish piling up in the streets. Out of the 25 patients on the ward, 7 of them have made serious suicide attempts in the last week and are being monitored every 15 minutes to attempt to ensure that they don’t do so again (or at least to ensure they get immediate medical attention when they do). Most of them are on strong anti-psychotic medication, and not only need daily checks on their physical health, but also face potentially lethal withdrawal effects if they miss a dose. All our patients are in acute emotional distress, distress we attempt to alleviate both with medication and by supporting and talking with them when things get rough. If half the nursing staff failed to show up to work one day the best case scenario is that it would cause already very vulnerable and distressed people to become even more distressed, the worse case scenario is that it would end in deaths or serious physical injuries.

But of course it is still open for the strike-enthusiast to accept all this, and still stick to their position; of course there are costs to any strike- that’s the whole point of striking- and whilst it is unfortunate that those costs fall upon one of the most disadvantaged groups in society, that’s just tough.  The more sophisticated enthusiast could also claim that if you care about nursing, then you care about the nursing profession being the best it could be (and having the best possible people in it), and the only way to ensure that is to strike for better wages.

I still think Carter is right, though, because I think that being a nurse involves being ethically responsible for those people under your care and because of that there’s something wrong with abandoning your post, whatever good political effects you might be able to produce.

However, unless this concept of ‘responsibility’ is filled out a bit, it’s in serious danger of proving too much. Equally, one might think, you could argue that no-one should strike ever, because being a textile-worker involves a responsibility to produce textiles in accordance (perhaps) with standards laid out in your terms of employment. Going on strike involves abandoning that responsibility, which is wrong. But where does this responsibility come from? A quick answer is that they chose to be a textile worker and so to abide by those terms. Perhaps they might have even signed an employment contract to that effect. But this clearly isn’t the kind of free, autonomous choice needed to generate any substantial kind of responsibility. If the choice is between abiding by whatever terms of employment are imposed on you and being unemployed, then the situation looks ominously similar to a person held up at gunpoint being informed they freely chose to surrender all their money. Likewise with nursing; taking up a job offer in a capitalist system can’t mean that you are required to adopt whatever responsibilities associated with it.

But I think nursing (along with certain other jobs) is different. In the case of the textile worker it seems fine to say that all they are doing in obeying the stated requirements of their job in order to prevent being fired, so they are able to secure a living for themselves and their family. Of course they might take pride in their work, and might choose to adopt some kind of responsibility to carry out that job to the best of their ability, but they’re not morally required to. (And at least part of the story of workers under capitalism is that they’re “alienated from the products of their labour” to such an extent that adopting these kinds of responsibilities, or truly caring about their work, is going to be a pretty hard task.)

However if a nurse conceives of their job in the same way (as just a set of requirements they need to fulfil in order to get paid) it looks like something is going wrong somewhere. For a start, unlike in the textile or other industries, it’s unclear what those requirements actually are. I think this is my main problem with the culture of “target-setting” in the NHS, particularly in mental health. (If you’re interested, this is definitely required watching.) Of course there are some basic things  a nurse needs to do to get by (such as dispensing medication for example) but most of the tasks undertaken aren’t things which can be neatly prescribed in this way. They involve a complex and multifarious set of actions which stem from a baseline care for those patients on your ward, or under your community team. And whilst caring is a technique which you can be taught to do better, it nevertheless rests on a sense of responsibility you have for your patient, and a desire to help them recover. When a patient knocks on the ward-office door distraught and having self-harmed, yet refuses to go to A&E to be treated, I find it hard to believe that a nurse without some kind of empathy or feeling of care for them is going to do any kind of job of comforting, or persuading them to get medical help. It just isn’t the kind of thing that can be looked up in an instruction manual (in a similar way, I feel, to how it would be impossible to write an adequate instruction manual to cover all the differing actions required by friendship, even if you take out of the picture the fact that friendship requires you to have certain feelings as well.) The claim here is not that nurses who don’t care about their patients are going to be bad nurses, the claim is that it’s not obvious that what they’re doing is going to be nursing at all. Nurses are those with responsibilities of caring towards their patients, without the central concept of care it becomes very hard to put your finger on exactly what nursing as a job even is  or how it is demarcated.

Secondly, whilst someone could in theory be employed as a nurse, and yet not feel they had acquired any special responsibility towards their particular patients, what is our response to this kind of person? The kind of person who spends weeks and months looking after the same individual, and yet if they encounter them having an anxiety attack as they are just leaving the ward after their shift, don’t even pause to see if they are alright, since they’re no longer on the clock as a nurse. No-one is required to become a nurse, that much is clear. But someone who goes through the motions of being a nurse without identifying with the responsibilities involved in nursing (to care, to assist in healing, to alleviate suffering), someone who is emotionally cold enough that this is possible for them, is lacking- not just as a nurse- but as a human being.

So working as nurse does seem to require the adoption of specific responsibilities towards your patients, such that “abandoning” them, even for a good cause, means neglecting those responsibilities.

It becomes important at this point to note that “role morality” type arguments (like the above) can be just as vulnerable to the “one thought too many” objections* typically used against Utilitarianism. The objection runs roughly like this: a man who first calculates whether saving his wife (as opposed to a stranger) is ethically justified (in terms of utility maximized) before jumping in, has missed something important about what it is to love and care for someone. In much the same way if you asked someone why they put their arm around an unhappy friend, and they respond by saying “I’m merely fulfilling certain duties and responsibilities towards them, which stem from the nature of our friendship” (i.e. an answer invoking some idea of role-morality) we might think they’d missed the point of it all. Instead, the real friend would say something like “I saw they were upset”, because that is both the only explanation necessary, and the only reason a true friend should have for acting.  This is key because it means that arguments such as “You’re a nurse, you care about nursing, striking is going to improve nursing services in the long term” (like the one outlined at the beginning of this post) don’t have any bite. Undoubtedly you might become a nurse because you care about nursing as a profession, but once you are a nurse you acquire new reasons for action. You care about your patients, about helping them. You see that they are suffering in some way, and that by itself (given the nature of your relationship with them) is enough to make you attempt to help them in whatever way you can. It’s unlikely you’ll cease to care about nursing in the abstract sense, but this is distinct from the pulls you have towards looking after the particular individuals under your care, those individuals you have responsibilities towards.

This is not to say these responsibilities stemming from your role can never conflict with other responsibilities. Of course they do, and it might turn out that whatever you do you are neglecting your responsibilities towards someone or something, that there’s no blameless (or right) action available to you (I don’t have space to expand on this here, just please read Bernard Williams**.) In fact some of the more compelling arguments against role morality neglect this important point. Should the Nazi*** officer act in accordance with the responsibilities of his role? No, of course not. He should do the right thing, and clearly that massively outweighs whatever role-based responsibilities you might think he has (though I still think the right answer is to deny that he has any at all****.)

Given all this, you might in some cases think you still have an overriding responsibility to strike, but I think its wrong then to claim that you’re striking as nurses. You might be striking as people who happen to care a lot about nursing or something like that*****, but it’s not clear why this group has to be made up of actual nurses at all, though it might happen that it is. (For example, what about everyone who has ever received NHS treatment simultaneously striking?) But on top of this, as a nurse you better have a damn good reason why this more abstract responsibility outweighs your concrete responsibilities to prevent the deaths and promote the wellbeing of people in your care.

There’s one thing I disagree with Peter Carter about though, his rather pathetic idea that the only recourse we have is to lobby our MPs. I’ve recently finished watching the second series of Orange is the New Black. There’s a brilliant moment in it where the assistant-warden of the prison tries to negotiate the thoroughly sticky situation of having a group of protesting nuns showing up outside his prison. That’s what I want. I want protesting, I want riots, I want widespread destruction of property. Think about the powerful political message sent by a group of people whose profession (as we’ve established) is in the business of caring, if they descended on the houses of parliament and started wrecking things. Imagine being a police-officer trying to arrest hundreds of nurses in uniform.

I know that’s not what we’ll do, but it’s just a thought. *****



*From Bernard Williams, ‘Persons, Character and Morality”, I believe.

**Specifically, go read Shame and Necessity. For this and many other reasons.

***Sorry Bob.

****(However I think it’s fine to believe that adopting a role necessarily brings associated responsibilities, and still say that the Nazi has no responsibility to act in accordance with his. In denying this, you are essentially refusing the enter the ethical perspective of a Nazi, because that perspective is irredeemably evil. Responsibilities don’t just float around in the ether, they are attached to people, and they can only be seen through imaginative engagement with the person who has them. A denial that a Nazi has any responsibility to be a “good Nazi” is better seen as an ethical refusal to engage in any way with that perspective, a refusal which seems to me to be entirely right.)

***** Or someone trying to build class consciousness in order to bring about the revolution.

******I’m not actually a member of the RCN, since I think it’s wrong to join a union without being prepared to strike. Unions should mean something more, and bigger, than just legal support.



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