When Doctors Hold Their Patients Hostage
On April 9, the South Korean newspaper Chosun Ilbo reported that a child fell into a one-meter-deep ditch and went into cardiac arrest when rescued by her father. After being urgently transported to a local hospital for treatment, the child’s heartbeat returned to normal. The hospital determined that it was necessary to transfer the child to a larger hospital for emergency surgery. They requested transfer to 11 hospitals in North Chungcheong Province, South Chungcheong Province, and the Seoul Capital Area. However, all of these hospitals refused to accept the critically ill child, citing reasons such as “insufficient manpower” and “lack of beds.” Shortly after, the child experienced cardiac arrest again and was pronounced dead.
The South Korean public was in an uproar, and on the same day, Prime Minister Han Duck-soo made the statement, “This incident clearly exposes the collapse of the necessary medical and local medical systems in the Republic of Korea.” But the public and opposition parties still linked the hospitals’ refusal to accept the child with the healthcare reform initiated by the Yoon Suk Yeol administration.
In February of this year, the Yoon administration decided to expand the enrollment of medical school students and announced a plan: Starting from the 2025 academic year, the enrollment capacity of medical schools in universities will be increased from the current approximately 3,000 to 5,000 students. According to reports, with the intensification of population aging, the demand for healthcare resources in South Korean society will continue to grow. If the current enrollment capacity is not expanded, by the year 2035, there will be a shortage of 15,000 doctors in South Korea.
Despite sounding like a beneficial policy, it faced strong resistance from medical associations in South Korea, who argued that it would lead to overmedicalization and strain the healthcare insurance system funds. Thousands of interns and resident doctors from the five major hospitals in the Seoul Capital Area collectively resigned in protest against the government’s policy of expanding the enrollment of medical students. Subsequently, students from 40 medical universities in South Korea announced a collective suspension of their studies.
The backlash from the medical community continues unabated, and the Yoon administration has adopted a tough stance. The South Korean Ministry of Health and Welfare personally delivered return-to-work orders to representatives of some interns and resident doctors who had resigned. They also issued a public statement demanding that resigned interns and resident doctors promptly return to work, stating that starting from March, judicial measures such as revoking medical licenses would be taken against those who fail to resume their duties. The South Korean Ministry of Education also issued a directive to universities, requiring them to discipline medical students who participated in the “collective strike” according to regulations, emphasizing that there would be no “remedial measures”.
While the South Korean government’s attitude appeared severe, the medical associations in South Korea were not buying into it. In fact, a significant number of professors from most of the 40 medical universities across the country had started submitting resignation letters or had decided to resign since the end of March. The backlash within the medical community was growing stronger.
In early April, negotiations between the government and the organizations representing the interests of doctors ended in failure, with no consensus reached. And the patients became the ones paying for the stalemate. According to a report by Yonhap News Agency on April 8, out of the seven government-designated large-scale emergency medical centers in Seoul, six had reduced or suspended certain surgeries and treatments due to insufficient manpower, and the doctors on duty were overwhelmed. Nationwide, more than nine out of 44 emergency medical centers were unable to provide emergency services normally.
What initially seemed like a beneficial policy had turned into a situation where both sides suffered. It was evidently the result of a combination of systemic flaws and the self-interest of those pulling the strings.
Let’s start with the system. After the establishment of the Sixth Republic in 1987, there was a significant shift from military authoritarian rule to a civilian government through elections. A characteristic of a civilian government is the decentralized distribution of interests and the presence of multiple interest groups. Among them, the medical associations hold a particularly unique position in Korea.
Medical school is an arduous journey. In Korea, the undergraduate medical program lasts for six years, with the first two years dedicated to pre-medical courses and the remaining four years focused on undergraduate coursework. Starting from the first year, students begin intensive studies in subjects such as anatomy, physiology, biochemistry, pathology, infectious diseases, immunology, and more. By the third year, students become even busier as they juggle attending classes, interning at hospitals, and preparing for the national medical licensing examination. Once they pass the national medical licensing examination and obtain the physician’s qualification, they can enter hospitals for one year of internship and three to four years of residency as a practicing physician. Subsequently, they need to pass relevant exams to become specialized doctors.
The challenging journey of medical education implies high expectations for returns after graduation. According to statistics, South Korea currently has an average of 2.2 doctors per thousand people, ranking last among the member countries of the Organization for Economic Cooperation and Development (OECD). While there is a severe shortage of doctors, their salaries are exceptionally high. The average annual salary for doctors nationwide reaches 180,000 USD, significantly surpassing the average doctor’s salary of 108,000 USD in OECD member countries, including the United States, which is recognized for its advanced healthcare industry. With fewer numbers and higher incomes, South Korean doctors have a sense of superiority that stems from these circumstances.
Although junior doctors, such as interns and residents, receive relatively low salaries ranging from 18,000 to 36,000 USD, on the one hand, this group is not pleased with the expansion of medical student enrollment as it may jeopardize their future high-paying prospects. On the other hand, due to the influence of the strict hierarchical culture prevalent in Korean society and workplaces, they actively participated in the strike.
Apart from the high income, an invisible factor is the establishment of influence and authority. The medical profession, known for its role in saving lives, has always enjoyed high social prestige and status in East Asian countries, including South Korea. The extensive network of connections accumulated throughout a doctor’s career can easily be transformed into political capital in a vote-driven society. In Taiwan’s political landscape, for example, both Ko Wen-je and Lai Ching-te, who come from medical backgrounds, have exerted significant influence. Similar situations are also occurring in South Korea. Currently, the conservative and progressive forces in South Korean politics are almost evenly matched. As a traditionally conservative-leaning group, the doctors’ voting intentions alone are enough to impact the overall political landscape.
With wealth, vested interests, and significant influence behind the scenes, it is only natural that the medical associations in South Korea are not yielding to the Yoon administration’s approaches.
The Yoon administration which initiated the reforms was also flanked. April 10 was the date for the 22nd National Assembly elections, and the opposition Democratic Party of Korea (DPK) and its affiliated parties had been relentlessly criticizing the government for its failures.
The Yoon administration had been repeatedly exposed for that. For instance, Yoon’s wife, Kim Keon-hee was caught accepting luxury handbags as bribes. The Minister of National Defense, Lee Jong-sup, was implicated in abuse of power and barred from leaving the country but was then appointed as an ambassador to another country – an embarrassing incident. Against this backdrop, starting the medical reforms at this particular time had made the public to perceive it as a deliberate attempt by Yoon to confront the medical associations and gain public support to salvage their declining approval ratings.
It is precisely because of the government’s heavy-handed tactics and the coincidental timing that the medical associations saw through the Yoon administration which was merely a sheep in wolf’s clothing, thus remained resolute in their stance. Instead, they continued to expand strikes, boycotts, and protests, pressuring the Yoon administration much harder. In such a system, regardless of which party is in power, all these interest groups, especially powerful ones like the medical associations, need to be appeased.
And what is the cost? The rights and interests of patients and healthcare had been neglected. The tragic example of the child mentioned at the beginning, who was shuttled between hospitals without receiving proper treatment and eventually died. It is a blatant struggle for interests, holding the entire South Korean population hostage.
More than a century ago, Abraham Lincoln’s Gettysburg Address deeply ingrained the concept of “government of the people, by the people, for the people” in the world. With the victories of World War II and the Cold War, the framework based on electoral politics, public figures, fragmented interest groups, and behind-the-scenes manipulation of capital became prevalent worldwide. It even led Francis Fukuyama to proclaim the “end of history.”
However, in the past two decades, from the early 21st century to the present, this seemingly universal Western political ideology has been facing an increasing number of challenges and problems.
Counting the votes rather than counting the individuals does seem to achieve equality in terms of votes, but the problem lies in the unequal distribution and sharing of interests. The upper and lower classes, as well as the intricate interactions between interest groups, and specific interest groups and the government, have made the game of politics increasingly challenging. This difficulty has been further amplified by the influence and instigation of social media. Politicians, driven by their own interests, take advantage of the situation and manipulate and instigate conflicts among interest groups, making it even more challenging to reach consensus and share benefits.
As a substantial member of the Western block, South Korean society has already fully embraced a Westernized logic. Even before the Yoon administration, there has been a long-standing struggle between the government and medical associations. Just three years ago, in August 2020, the Moon Jae-in administration announced a time-limited plan to expand medical school admissions, which faced strong opposition from the medical community. The Korea Medical Association organized multiple nationwide strikes. Soon, the Moon administration had to yield. The medical crisis today is merely an extension of the previous contest.
Compared to the COVID-19 pandemic era, where the Moon administration had to exercise restraint for the sake of the nation, the rhetoric of the Yoon administration is much more severe, and their measures appear resolute. However, the medical associations are obviously confident in their victory. Healthcare is an essential need, and as long as the government’s so-called tough measures threaten the health of the entire population, they cannot be sustained. Despite the Korean citizens’ current frustration, they will still have to seek medical treatment. Whether it’s opening military hospitals, bringing in foreign doctors, or calling back retired doctors, these are at most superficial measures and are not viable in the long run.
Those who persist the longest will have the last laugh in the game of interest. The medical associations clearly have confidence in this regard. The problem lies in the fact that the Yoon administration chose to use the healthcare system, which concerns all citizens, to garner support for themselves. However, they cannot either harness the medical associations from resisting, or guarantee that all citizens would not get sick during the healthcare political game. Their reckless and impulsive actions, the inability to reach consensus even on such matters, only tear apart Korean society and deplete the credibility of the system.
Furthermore, it is evident that neither the Yoon administration’s expansion of medical school admissions nor the demands of doctors for improved working conditions fundamentally solve the healthcare dilemma in South Korea. South Korea is a country where private hospitals account for 90% of the healthcare system. This means that even if the number of doctors doubles, the profit-oriented healthcare distribution mechanism will still allocate the most manpower to the most lucrative areas rather than the areas that need it the most. For example, certain departments and local grassroots healthcare facilities in South Korea have always been neglected by doctors due to biases. Changing the situation of doctor shortages at the local and grassroots level is also one of the reasons why the authorities are pushing for expanded admissions.
However, changing the dominance of privatized healthcare is far from simple, and it goes beyond expanding admissions or increasing salaries. Even the most staunchly leftist president in South Korean history, Moon Jae-in, was unable to make the slightest dent in this matter. When will South Korea have a more assertive leftist president than Moon?
In a healthcare system driven by maximizing profits, people’s behavior and judgment are affected. If someone goes from medical school to becoming a doctor within such an environment, their moral compass is unlikely to remain undisturbed. Moreover, in contemporary capitalist society, healthcare groups are typical vested interest groups. They easily adopt a model similar to medieval guilds, controlling the number of doctors and influencing the prices of medical services. Gradually, they develop a closed-door mentality, which is a typical behavior of industry guilds.
Karl Marx elaborated that industry guilds, while initially contributing to the development of productivity, had soon become obstacles to the production force. In the massive strike by the Korea Medical Association in August 2020, emergency doctors held their ground and did not participate in the strike due to the threat of COVID-19 outbreaks. However, this time, even the emergency doctors can no longer restrain themselves.
We can also recall that before the COVID-19 pandemic, there was already a significant influence from voices advocating for the privatization of the healthcare system in China. It was only after the outbreaks, when the public healthcare system proved to be the backbone of our society, that these voices were overwhelmed.
Those advocating for healthcare privatization did not tell the people that even in Western countries, public healthcare combined with nonprofit private hospitals often accounts for more than half of the system. They also did not tell the people about the difficulties in accessing medical care and the chaos in healthcare insurance behind the various healthcare myths they touted. They deliberately neglected that right next to us, there is a role model in South Korea where healthcare privatization dominates, and its citizens have long been subjected to exploitation by medical capital.
In modern society, social games are everywhere, but when games driven by interests such as advocating for healthcare privatization develop without limits, society will face irreversible divisions. Observing the changing logic of Western society and similar societies, which still represent the most representative economic systems of human civilization, we need to separate the wheat from the chaff.
In recent years, it has become evident that the societal production force has stagnated in Western countries and other nations under similar systems. At the same time, fragmentation of social interests has intensified. Issues related to extremism, racism, environmentalism, LGBTQ rights, and other social agendas have escalated. The reality is that the Western system has sown the seeds for this: the more “noisy” one is, the more influential they become, and the greater share they receive from the shrinking pie. And the issue of identity division is of little concern to them.
Games of interest and uplifting minority voices might be all necessary, but it will be another question when a society descends into an endless game without limits. Governments, interest groups, and the masses all need to gradually advance reforms based on social consensus. They should make adjustments to interest shares while taking care of the interests of the majority population. Engaging in a game of interests without any bottom line is unacceptable. The healthcare crisis in South Korea, which has already cost lives, serves as a reminder to the world.
