Ethics of the on-call rota
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6866 (Published 04 January 2017) Cite this as: BMJ 2017;356:i6866
A colleague is sick. Someone is needed to cover for him tomorrow. There are no locums and no volunteers. Who should be selected?
Few issues generate more passion and cause more heartache to doctors than filling a gap in the on-call rota. Over Christmas it is likely that tears have been shed and friendships lost over who would cover the absent colleague.
So what is the fairest way to choose? There are three uncontroversial criteria.
First, the potential candidates must be available. Candidates who are abroad or too far away to make it back in time cannot be selected. As the philosopher Immanuel Kant wrote, “Ought implies can.” Someone cannot morally be required to do something that is not physically possible.
Second, the candidates must be physically able to do the shift. A candidate cannot be selected unless it is safe for the doctor and the patients. A heavily pregnant doctor, or one who has just done a 24 hour shift, or one who is too intoxicated by drink or other noxious substances cannot be eligible.
Third, it must be lawful for the candidates to cover the colleague. If doing so will result in the doctor breaching the Working Time Regulations, or some hospital policy, then that rules out the candidate.
The fourth criterion is more contentious. If a candidate has volunteered to cover a gap in the rota in the recent past, there is a strong moral argument for excluding him or her from selection. This would act as a reward for such behaviour. This policy may also increase the likelihood of finding volunteers to cover a gap in the rota. If every candidate has volunteered in the recent past, the one who did so the longest ago should be selected.
Whoever remains, I suggest, should be randomly chosen. Having young children, needing to hire a baby sitter, a spouse threatening divorce, a family reunion, an impending exam, or a longer commute to work should not exclude a doctor from the selection process. As these factors are controversial, including them in the process is likely to cause resentment and damage morale. Inclusion would also raise further difficulties. Is having two children worth more “points” than having one? Is a baby worth more or less than a 5 year old? How real should the threat of divorce be? How close does the exam have to be?
Finally, it is important to raise the issue of honesty. Some doctors will lie to avoid selection. They will claim to be at the other end of the country when they are nearby. They will say they are too drunk to work the next day. They will make up excuses. These are not “white” lies. They breach the General Medical Council’s rule that doctors shall be “honest and trustworthy.” Lying to avoid selection is unprofessional, breaches trust, and could lead to unfairness in the selection process. It represents a betrayal of your colleagues.
So here is one ethicist’s flow chart for selecting a replacement for the rota (figure), assuming that no volunteers or locums are available.
Rota problems often raise broader issues, including staffing, compliance with the Working Time Regulations, hospital trusts’ willingness to find locums and pay adequate hourly rates for covering gaps in the rota, and perhaps even the loss of the mutual loyalty that once characterised the medical profession. These matters, which underlie the very practical problem discussed in this column, are for another time.
Footnotes
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: None declared.