Introduction

Why do Ethics Matter in Healthcare Leadership?

Ethics matter because, in health and social care, we strive for the most human of endeavours, which is to care for other human beings. Mostly, those ‘others’ we care for are strangers, many of whom may be experiencing highly fraught, bewildering, distressing, and vulnerable times in their lives when injury, illness, or disease become an inescapable reality. Healthcare is an ‘ethically laden practice’ (Gastmans, 2001). It requires professionals to care for others and their significant others, in the physical and human sense, at times of personal fragility and disempowerment. Healthcare therefore happens within a moral relationship between the carer and the cared for. In providing care, we act to minimise harm, to bring good, to respect, to advocate, to preserve dignity, and to reassure. Care is the very heart of health and social care, and ethics can help us understand how best to care, to understand why we value the things we do, why we can sometimes disagree on fundamental questions such as whose interests will prevail when there is conflict, or what values we will prioritise if there is disagreement. We need to turn our minds to these questions if we are to achieve shared respect and understanding when decisions are to be made. While technical clinical, operational, and managerial skills are essential, leading in health and social care is an ethically laden practice – one that requires you as a leader to bring a practical and ingrained ethical way of knowing, doing, being, and becoming to every aspect of yourself. So, what does that mean in practice?

What is Ethics?

Ethics is a term that means different things to different people; yet, as a word, we often use it as though there was a clear and agreed understanding of what we collectively mean. According to Beauchamp and Childress (2001, p.1), ethics is best understood as a “generic term for various ways of understanding and examining moral life”. Within these ‘various ways’ there are many conflicting and competing accounts of ‘ethics’ based on different starting presumptions, offering differing explanations of what ethics is, how it ought to be practised, and what its purpose and potential is. Clearly, our starting presumptions, expectations, and understandings of ethics shape how we attempt to ‘do’ ethics; yet, as Isaacs notes, (Isaacs, 2003, p.3) we rarely stop to settle on a shared understanding of what ethics means – to acknowledge it is not simply categorised as one way of thinking, but rather requires us to incorporate multiple (sometimes competing) perspectives and foundational assumptions.

Within the multiple definitions of what ethics is, the understanding that most dominates the health literature is that of a theory centred, knowledge based, abstract, and generalisable application of moral principles. Such principles, or theories, are held as points of reflection and guidance when considering ‘cases’ that present an ethical dilemma or quandary (Beauchamp and Childress, 2001). Such principles and theories can be applied to reveal a consistent, considered, and rational response to the ethical question ‘What should I do’? Drawing on analysis of multiple ethical theories, Beauchamp and Childress (2001) famously developed and promoted the Four Principles approach (principlist ethics), supporting ethical decision making through consideration of four equal principles or lenses: 1) autonomy, 2) justice, 3) beneficence, and 4) non-maleficence. While this approach to ethical deliberation and decision making has gained traction in healthcare, there are significant deficits in this approach, and many critiques have been made of this model:

First, this approach implies that moral knowledge and abstract truth can be known absolutely. Critiques of principlism often centre on the need to reduce the multifaceted and complex realities of ethical situations and engagement to the sterile prescriptions of what Caplan (1982, p.8) described as “moral engineering”, further claiming that the resolution of complex moral issues “demands more than the ability to marry moral theory with the facts” (Caplan, 1982, p.2). Hence, the pitting of one principle against another or overlaying moral theories and principles onto indisputable ‘facts’ to reveal a generalisable moral truth may lead to superficial or detached analysis and prevent us from reaching the human core of our ethical decision making.

Second, the positioning of ethics as detached intellectual and scholarly inquiry may further segregate ethics as yet another expert specialty, beyond the grasp of executives, clinicians, or patients who may lack the analytical skills or philosophical language deemed necessary to contribute to such specialised discussions (Komesaroff, 1995; Pellegrino, 2003). In an era where the worth of collaborative decision making between practitioner and patient is accepted best practice and promoting ‘patient-centred’ practices permeate policy and funding models, perpetuating the separation of ethics as another ‘expert outsider’ activity is ultimately unhelpful for all stakeholders negotiating real, embedded, and emotion charged ethical decisions in health care.

Finally, this familiar approach to ethics has distracted from the ‘micro-ethical’ concerns of the everyday (Komesaroff, 1995). While big ‘headliner ethical quandaries’, complex moral dilemmas, and principled debates can hit the headlines, it is arguably the day-to-day, almost unnoticed, ‘micro-ethical’ moments and interactions that most create and reveal the true moral climate and culture of our organisations, where every action, every day, builds or undermines ethical culture (Winch, Milligan, and Rolley, 2015).

Pellegrino (2003, p10) noted that, “Medicine, being simultaneously the scientific and humanistic study of man, cannot escape being based in an explicit or implicit philosophy of human nature”. Ultimately, the health condition is embedded in the human condition; hence, the human condition must be understood first, with the medical condition and the organisation and delivery of care also framing the fuller picture. Ethical conversations and deliberations must therefore begin and end, embedded in context, negotiated in relationships, and approached in a way that enables the moral perspectives of all those impacted to be an integral part of our shared considerations (Beauchamp and Childress, 1999; Pullman, Bethune, and Duke, 2005; Walker, 1993).

With these opening points in mind, this chapter takes an ontologically (being) centred approach to ethics that defines the ethical as situated within relationships and society, acknowledging the subjective and engaged nature of our lived experiences, and accepting that, while we seek shared meanings, the moral meaning and interpretation of each situation must accommodate each stakeholder’s subjectivity. Adopting this orientation to ethics will equip us to see multiple perspectives, to see the people receiving our ‘care’ through their lived experience and create strong ethical organisations and cultures that grow and lift our staff, while respecting and caring for our clients. This chapter will help leaders to develop a comprehensive, practical, and compassionate approach to leading ethically through focusing on three fundamental building blocks of practical ethics and leadership:

• care (Illness, vulnerability, and dependency),
• trust (and trustworthiness),
• power (and relationships).

Care – Illness, Vulnerability, Dependency

The term ‘care’ is ubiquitous in health, and, like the term ethics, has multiple layers of meaning. Care can describe a ‘something’, a noun – as in the activities of care; for example, clinical interventions, medications, surgeries, assistance with activities of daily living and so on. But care is also a verb – to care – to have a disposition, which Edwards (2009) explained as, “an orientation from which one is prompted to develop adequate responses to moral problems and to the moral dimension of experience”. The precursor to ‘caring’ is that we must first value, and then take responsibility for, the outcome such care seeks to promote. Within the health and social care domains, our training, resources, and organisations are all directed towards the wellbeing of those in our care. We can care for, care about, give care, receive care, and be caring or careless. When there is no cure, we can still care, and it is this disposition to care, and the small and large actions that demonstrate it, that leave the deepest impressions on those for whom we care.

Our system of organised healthcare, and the vast array of people, resources, and skills required to deliver it, is set up to attend to the needs of people at times of illness/injury/disease and vulnerability in their lives. As a foundational understanding, health and social care leaders must appreciate the lived experience of illness, injury and disease, of needing care, and how this significantly disrupts and shape one’s sense of self on multiple levels. Attention to these fundamental human realities shapes the context of the care required, and how best to deliver it.

Ill health impacts:

• Our physicality and environment. The physical impact of illness can impact our agency and autonomy. Tasks that once came easily may now require additional time and effort, or in some cases, may no longer be achievable at all, with or without assistance. Walking distances that once felt close may now feel far. For those receiving care in organisations, the loss of autonomy over simple daily tasks such as eating, showering, or having visitors can feel diminishing.
• Our notions of time. Once busy lives can become a series of ‘waitings’; waiting for results, waiting for clinicians, waiting for a bed, waiting to be discharged, waiting for the next appointment. In addition, confronting one’s own mortality, the emotional reality of time viewed through the lens of ‘life years ahead’ versus ‘life years past’ can be sobering, with deep psychological impacts.
• Our social and cultural connections. A person’s social world contracts during illness – often usurped by appointments based on others’ timetables. Once valued social activities and connections can dwindle, and the additional effort required to keep connecting can feel overwhelming, leading to social withdrawal, as Toombs (1999) noted, “When ceaseless and ongoing effort is required to perform the simplest of tasks (getting out of bed, dressing etc) there is a powerful impulse to withdraw, to cease doing what is required. The person with a disability is tempted to severely curtail involvements in the world”.
• Our language. Illness brings a whole new language to learn. The language used can be excluding through the use of jargon or it can be disrespectful (e.g., the personality disorder in bed 10). Importantly – language is not neutral – it can overtly and subtly convey what ‘really’ matters. However, language has the power to connect and mediate shared understandings; hence, must be chosen carefully.
• Our spirituality. A person’s illness experience can deeply impact their particular sense of spirituality, and space must be made for consideration of this important aspect of wellbeing, alongside clinical or scientific priorities.

The multiple disruptions of illness create an inevitable vulnerability; hence, an inescapable dependency on others (Dodds, 2014). Hoffmaster (2006, p43) further summed this point up, saying, “Human beings …..because they have bodies, are vulnerable……it is our very vulnerability that creates the need for morality”. Our embodied human existence inescapably creates the need for care by others, in the moral context of healthcare, the ‘ethically laden practice’. To be an effective leader, you will need a deep appreciation of the moral disruption of illness to attend to “the global sense of disorder that permeates the patient’s everyday life” (Toombs 2001). This is our leadership challenge. As discussed earlier, “human being and becoming is always at risk and our ability to deal with such misfortunes, cope with them and recover from them usually depends on the support and care provided by others” (Isaacs, 2003).

Our further challenge in health is to see beyond the disease, to consider Arthur Kleinman’s (1989, p.4-5) view, “When I use the terms illness….., I shall mean something fundamentally different from what I mean when I write disease. By invoking the term illness, I mean to conjure up the innately human experience of symptoms and suffering. Illness refers to how the sick person and the members of the family or wider social network perceive, live with and respond to symptoms and disability…..Disease is what the practitioner creates in the recasting of illness in terms of theories of disorder. Disease is what practitioners have been trained to see, through the theoretical lenses of their particular form of practice”. Our moral obligation in leading ethically is to always see the person, to be alert to the lived human experience, and to care.

Trust and Trustworthiness

“Whatever matters to human beings, trust is the atmosphere in which it thrives.”

 (Bok, 1978, cited by Baier 1986).

In the previous section, we considered the impact of illness, injury, and disease, the inescapable vulnerability and dependency this creates, and the need to rely on others to respond with care. Dependency and vulnerability inevitably then raise the issue of trust. Baier (1986, p1) explained, “to trust is to accept vulnerability to another’s will. In trusting someone you put yourself in their power to some extent, and in doing so, risk being harmed if they do not take seriously the ethical demands of having that power.” O’Neill (2018) further explained that when we trust, we become susceptible to being let down, betrayed, or dismissed. In the context of healthcare, the stakes could not be higher, as we must rely on others to access specialist knowledge and resources when our wellbeing, and ultimately, our lives, depend on others taking the gravity of this ethical obligation seriously. As O’Neill (2018) pointed out, trust is only valuable “when placed in trustworthy agents and activities, but damaging or costly when (mis)placed in untrustworthy agents and activities …….to place and refuse trust intelligently we must link trust to trustworthiness, and must focus on evidence of honesty, competence and reliability.”

By entrusting healthcare providers to care for our health and wellbeing, patients and clients must trust the providers of such care to use their expertise and discretion to make judgments that ensure the best outcomes for each individual. This dynamic, situated in the unequal relationship between those needing care and those providing it, lies at the heart of health and social care (Mackenzie., 2020).

So, what do trust and trustworthiness look like in healthcare? While there are disagreements about the exact nature or definition of trust (Khodyakov, 2016), trustworthiness generally encapsulates multiple components, including acting with honesty, competence, and reliability (O’Neill 2018). An attitude of goodwill towards the other engendering loyalty, faith, and confidence are additional elements discussed in the literature (Baghramian, 2020).

Trust is built on an individual and institutional level within relationships (Ward, 2017). As health and social care occurs in teams, interprofessional trust is critical to highly functioning teams. The positive impact on patient/client outcomes in contexts of high trust in clinicians, service providers and healthcare institutions is well documented (Birkhauer et al 2017; Ward, 2017, Sifaki-Pistolla et al., 2020). Ultimately, when distrust arises, people are less likely to engage in their healthcare or to follow advice, and therefore have worse health outcomes (Ward 2017). As a leader, your attention to nurturing the ongoing and dynamic process of building trust at individual and institutional levels, to being individually and organisationally trust-worthy, is one that delivers great dividends to all, as “without trust, relationships and the organisations that depend on them will fail. Thus, when the elements of leadership and care provision are distilled, building trust is the critical precursor to effective relationships and the benefits” this brings to care recipients” (Olley et al, 2021).

Power and Relationships

Vulnerability creates dependency, which creates the need to trust in others. Our need to trust demands those caring for us to be trustworthy, as noted. Dependency and vulnerability then inevitably create a power imbalance between carers and those being cared for. As care occurs in relationships with individuals and institutions, the final important ethical lens considered in this chapter is that of power, and the ethical use of power to promote care and trustworthiness within such relationships.

It is relevant here to briefly think about sources of power, particularly in the health care context. Much has been written about legitimate and illegitimate sources of power, including reward, and coercive, legitimate, expert, and referent powers. In health, perhaps the most important framing of sources of power are best described as ‘expert power’, where there is a knowledge gap between the client and the health provider, and the less knowledgeable person is in a highly dependent position; and ‘legitimate power’, where a person’s position of authority allows them control and privileged access that can support or hinder the less powerful person (Camm 2013).

In his seminal text, Power and Innocence, Rollo May (1976, p100) talked about the use of this power and defined power as “the ability to cause or prevent change” to people or situations. May defined five ways that power is exercised that can be beneficial or harmful:

• Competitive power – power against. In health, this could manifest as competing for limited resources (personnel, equipment, funding, etc) in a win-lose scenario. The more powerful actor gains the benefit, the less powerful misses out. However, May (1976) also flagged the positive use of competitive power as a way of spurring each other on to continuous improvement, where practice improvements are shared and celebrated.
• Manipulative power – power over another person. In health, this could manifest as the delaying of access to treatment by the powerful actor, until behavioural change of the patient is achieved (e.g. no operation until smoking ceases). While the reason for such a delay to ensure the best clinical outcome is based in care, the manipulative power exerted can breed resentment and disengagement.
• Exploitative power – power with force and coercion. An example of exploitative power in health could be the misuse of a position of authority/privilege to recommend interventions with limited evidence of success for the financial benefit of a service/clinician rather than the interest of the client/patient. Within healthcare teams, exploitative power could manifest as blocking a colleague’s career or withholding of development opportunities.
• Nutrient power – power for another, arising from concern and care. In health, nutrient power could include partnering with clients to support them in achieving health goals, for example, diabetes education and support programs. The client does the work, with the encouragement and sharing of expert knowledge to foster success. Organisationally, nutrient power could manifest as intentional mentoring and development of staff to reach their own career potential while contributing to the organisation’s needs.
• Integrative power – power with another. Examples in health could include multi-disciplinary teams, each bringing the best of their expertise to solve a shared problem or reach a shared goal. Multiple forms of power may be present in any given interaction, with harmful and beneficial forms of each type of power present. Your role as leader is to create positive change and prevent harmful change. Power and power imbalances are present in all aspects of life, but particularly so in healthcare. In the context of illness and vulnerability, such imbalances create strong moral obligations on those holding the power to exercise it thoughtfully, to cause or prevent change for the collective and individual good.

Poorly managed or understood power imbalances have been shown to have significant detrimental effects on patient outcomes, including discomfort in ‘speaking up’ when things seem wrong, unwillingness to ask questions, and the acceptance of a passive role even when concerns are held (Joseph-Williams et al., 2014a and b). Some research notes that when doctors become patients, they also succumb to passive compliance in face of the power imbalance they now experience as a patient, concluding that knowledge alone is not sufficient to overcome the impact of the power imbalance that exists in the clinical encounter (Tomlinson, 2014). Hence, the misuse of power in organisational settings can have a pernicious effect on culture, which ultimately erodes patient and client care, undermines staff, and destroys community trust in health and social care services we are collectively invested in and reliant upon. 

References

Baier, A. C. 1986. Trust and Antitrust. Ethics 96 (2): 231–260. doi:10.1086/292745

Baghramian, M., Petherbridge, D. and Stout, R. 2020. Vulnerability and trust: An introduction. International Journal of Philosophical Studies, 28(5), pp.575-582.

Beauchamp, D. E. and Steinbock, B. eds., 1999. New ethics for the public’s health. Oxford University Press.

Beauchamp, T. L. and Childress, J. F. 2001. Principles of biomedical ethics. Oxford University Press, USA.

Birkhäuer, J., Gaab, J., Kossowsky, J., Hasler, S., Krummenacher, P., Werner, C. and Gerger, H. 2017. Trust in the health care professional and health outcome: A meta-analysis. PloS one, 12(2), p.e0170988.

Camm T. 2013. Power and Politics in Organizations. Mining Engineering.1. https://digitalcommons.mtech.edu/mine_engr/1/

Caplan, A. 1982. Mechanics on duty: The limitations of a technical definition of moral expertise for work in Applied Ethics. Canadian Journal of Philosophy, Supplementary Volume 8, 1-18.

Caplan, A. 1999. Moral experts and moral expertise. Clinical Ethics: Theory and Practice, 59-87.

Dodds, S. 2014. Dependence, Care and Vulnerability. P181-201. In Mackenzie C, Rogers W and Dodds S. 2014 The importance of relational autonomy and capabilities for an ethics of vulnerability C Mackenzie – Vulnerability: New essays in ethics and feminist philosophy. Oxford University Press.

Edwards, S. 2009. Three versions of an ethics of care. https://doi.org/10.1111/j.1466-769X.2009.00415.x Volume10, Issue4. October 2009. Pages 231-240

Gastmans, C. A. 2002. Fundamental ethical approach to nursing: some proposals for ethics education. Nursing Ethics 2002;9(5):494–507.

Hawley, K. 2014. Trust, Distrust and Commitment. Noûs 48 (1): 1–20. doi:10.1111/ nous.12000.

Holton, R. 1994. Deciding to Trust, Coming to Believe. Australasian Journal of Philosophy 72 (1): 63–76. doi:10.1080/00048409412345881

Isaacs, P. 2003. Doing ethics – An action based approach. Paper presented at the Peninsula Behavioural Health Conference, Gatlinburg, Tennessee.

Joseph-Williams, N., Elwyn, G. and Edwards, A. 2014a. Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient education and counseling, 94(3), pp.291-309.

Joseph-Williams, N., Edwards, A. and Elwyn, G. 2014b. Power imbalance prevents shared decision making. Bmj, 348.

Khodyakov, D. 2016. Trust as a Process. Sociology, 41(1), 115-132. https://doi.org/10.1177/0038038507072285

Kleinman, A. 1989. The Illness Narratives: Suffering, Healing and the Human Condition.

Komesaroff, P. 1995. From bioethics to microethics: Ethical debate and clinical medicine. In P.

Komesaroff, P. A. (Ed.), Troubled bodies. Critical perspectives on postmodernism, medical ethics and the body: Melbourne University Press

Layland, A. 2018. Why is trust important for effective healthcare teams? British Journal of Healthcare Management. Vol 24. Issue 2. https://doi.org/10.12968/bjhc.2018.24.2.61

Mackenzie, C. 2020. Vulnerability, Insecurity and the Pathologies of Trust and Distrust. Pages 624-643 | Published online: 14 Dec 2020 International Journal of Philosophical Studies Volume 28, 2020 – Issue 5: Vulnerability and Trust.

May, R. 1976. Power and Innocence: A search for the sources of violence. Fontana. London.

Olley, R., Broadley, S., Rogers, G., Milligan, E. and Lee, C. 2021. It’s a matter of trust: The impact of leadership style on organisational identification and job satisfaction of aged care employees. Griffith University Higher Degree Research Collection. DOI: https://doi.org/10.25904/1912/4351.

O’Neill O. 2018. Linking Trust to Trustworthiness. International Journal of Philosophical Studies Vol 26. Issue 2 Trust. 293-300.

Pellegrino, E. D. 2003. From medical ethics to a moral philosophy of the professions. In J. K. Walter & E. P. Klein (Eds.), The story of bioethics. Washington: Georgetown University Press.

Pullman, D., Bethune, C., and Duke, P. 2005. Narrative means to humanistic ends. Teaching and Learning in Medicine, 17(3), 279-284.

Sifaki-Pistolla, D., Melidoniotis, E., Dey, N. and Chatzea, V. E. 2020. How trust affects performance of interprofessional health-care teams. Journal of interprofessional care, 34(2), pp.218-224.https://doi.org/10.1080/13561820.2019.1631763

Tomlinson, J. 2014. When doctors become patients. A better NHS: exploring the relationships between doctors and patients and health policy. http://abetternhs.wordpress.com/2014/01/27/dr-patients/.

Toombs, S. K. (Ed.). 2001. Reflections on Bodily Change: The Lived Experience of Disability. Handbook of Phenomenology and Medicine. Dordrecht: Kluwer, pp. 247 -261.

Walker, M. U. 1993. Keeping moral space open: New images of ethics consulting. The Hastings Centre Report, 23(2), 33-40.

Ward, P. 2017. Improving Access to, Use of, and Outcomes from Public Health Programs: The Importance of Building and Maintaining Trust with Patients/Clients. Frontiers in Public Health. Vol 5. https://doi.org/10.3389/fpubh.2017.00022

Winch, S., Milligan, E. and Rolley, A. 2015. Clinical ethics for emergency healthcare. In Curtis, K & Ramsden, C (Eds.) Emergency and trauma care for nurses and paramedics [2nd Edition, Australia and New Zealand]. Mosby Elsevier Australia, Australia.