Physicians’ strikes are not unique to Israel. The Association of American Medical Colleges, the American College of Physicians and the American Medical Association have all opposed such strikes, but they nevertheless seem to be almost a universal feature in most Western countries.In the past, disputes between individuals were settled by physical struggles, such as duels. Today such methods are considered primitive and barbaric. Most democratic societies have established courts, based on the premise that impartial, trained individuals should decide on the merits of the evidence. The use of force is considered unethical, and civilized societies reject the “might is right” behavioral pattern in interpersonal disagreements.The writer is an internist and endocrinologist, a former president of Israel Endocrine Society and professor emeritus on the Faculty of Health Sciences at Ben-Gurion University of the Negev.However, when dealing with labor disputes the public accepts strikes as the normal method of settlement.The strike is recognized as an almost inalienable human right. But is a strike a fair way of settling disputes? Who wins? Is justice decisive? “Strong” unions that can cause the most chaos and suffering by striking gain the best conditions. Electric company and dock workers have disproportionately favorable labor contracts, not because they are the most deserving, but because their strikes become unbearable for society. A labor strike represents the use of force to settle a disagreement.But strikes in modern society raise a new ethical dilemma: If Reuven has a dispute with Shimon, by what right may Reuven inflict damage on a third party, an innocent bystander, to force the bystander to pressure Shimon to grant relief to Reuven? There is a recent relevant Israeli Supreme Court decision. Israel had refused to release imprisoned Lebanese citizens who had completed their prison terms. This refusal was imposed to apply pressure for release of Israeli soldiers and to obtain information about missing soldiers. These prisoners were being held as “bargaining chips.” The court ruled it is illegal and immoral to hold innocent people hostage in order to put pressure on the kidnappers. Most strikes in the public sector present an analogous situation. By depriving citizens of services, they are being kept hostage in order to apply pressure on the employers.Historically, strikes developed in societies where power was vested largely in the hands of an upper class which controlled the media, the means of production, the courts and the government. Exploited workers had no reasonable way of getting fair compensation for their work and no realistic alternative other than to go on strike.The employer, when faced with considerable personal financial damage, often found it expedient to submit to the workers’ demands. The gains made by organized labor contributed immeasurably to raising standards of living and relieving injustices and inequalities.Compare those struggles to local or national government agencies.When employees go on strike, the public officials who are “responsible” for their alleged unfair treatment do not suffer personally. They continue to receive their salaries. But the public suffers, although they are innocent bystanders. The strike is based on the hope that these innocent bystanders will apply enough pressure on the offending management – a bizarre ethic indeed.I HAVE no realistic expectations that any democratic society is currently likely to rescind or seriously limit strikes. The concept of the right of workers to strike is so engrained in modern societies that it is unlikely to change in the near future. There are also various vested interests in preserving the present ground rules.Are strikes by physicians different than strikes by other groups? I believe that physicians are indeed different. They deal with human lives. Even when emergency services are allegedly provided during strikes it is impossible to prevent serious human suffering and unnecessary death. There are inevitably delays and cancellations of critical treatments, and the already underprivileged are those who bear the brunt of the strike.The wealthy find avenues of treatment via the private sector.Almost all of the physician strikes of which I am aware have taken place largely for the personal benefit of the physicians and not for improvement of patient care conditions.In none of the strikes were the physicians in such dire economic straits as to justify the degree of endangerment of patient lives and suffering.Physicians are professionals. The key component in medical professionalism is the primacy of the interests of the patient and the community over those of the physician. For centuries physicians have taken oaths promising to forgo personal benefit for the sake of their patients.A most damaging effect of physician strikes is the impairment of the public’s trust. Denial of treatment to patients for physicians’ benefit is perceived by many as a betrayal of an implied trust.Another negative impact of strikes is the confrontational atmosphere engendered between the physicians and their employers, as well as conflicts with patients and their families.Charges and countercharges, often exaggerated, are inevitable, leaving a significant residue. Emotionally charged disagreements between striking and non-striking doctors often occur. Quality health care requires teamwork and active cooperation between all levels of personnel, which are often damaged during strikes.THE HALACHIC (Jewish law) attitude toward physicians’ responsibilities differs fundamentally from the legal and ethical norms in the West, especially in the US. In America no physician is required to treat a patient, even in emergencies.Good Samaritan laws only provide legal protection against malpractice suits if physicians volunteer to provide emergency care, but do not mandate care.In Judaism, provision of treatment to a patient is not a matter of private contract, or discretion, but is a religious obligation, a biblical mandate.The Shulhan Arukh states, “If a physician withholds his services it is considered as shedding blood.” Even if other physicians are available, the physician approached by the patient must not refuse to treat, because “not by every person is an individual privileged to be cured” – this admonition probably results from the recognition of the importance of patient confidence in the therapeutic efficacy.The specific issue of physicians’ strikes has been discussed by a number of rabbinic authorities. None have permitted such strikes. Former Chief Rabbi Shlomo Goren said, “Even if the physicians will suffer great financial losses by breaking the strike in order to treat patients, and as a result their demands will be rejected, they cannot be freed from their obligation to come to the aid of the patients, because of the Biblical admonition ‘do not stand idly by the blood of your fellow.’” Other senior rabbinic authorities have confirmed that stance.Strikes are not acceptable in the military or the judiciary. Physicians logically belong to a group for whom binding arbitration by objective experts should be the accepted method for settling labor disputes.Even if collective actions are felt to be indicated they must not be directed at patients. It is incumbent on physicians as leaders in society to find creative and dynamic ethical ways for the settling of labor disputes.