Healthcare leadership ethics: Time for some formal training

Introduction

In early January 2021, the CEO of Niagara Health and St. Joseph’s Healthcare Hamilton found himself in the centre of a controversy that headlined around the country; he had vacationed in the Dominican Republic over the holidays, in the midst of the COVID-19 pandemic and provincial lockdown order. ¹ Soon after came similar stories regarding the CEO of London Health Sciences Centre, ² which was still in the midst of a hospital-wide COVID-19 outbreak that virtually shut down the University Hospital campus. ³ In both cases, the public outcry was quick, loud, and decisive, demanding resignations/terminations from their CEO roles and any other related appointments.

So why would two of the most senior, and arguably highly intelligent, health leaders in the province decide to do something that was so blatantly both poor judgment and a clear breach of ethical duty?

Bioethics and the explicit consideration of clinical ethics in hospitals are well established in healthcare today. Early hospital ethical dilemmas, such as those involving allocation of scarce resources, can be traced back to first dialysis treatments of the 1960s. ⁴ Over the next 60 years, the discipline of healthcare ethics evolved to include research ethics, ⁵ withdrawal of care, ⁶ sterilization, ⁷ abortion, ⁸ advanced directives, ⁹ medical assistance in dying, ¹⁰ and many other ethical challenges in providing clinical care.

The history and expectations related to leadership ethics in healthcare are far less clear. Ethical breaches most often seem to be determined retrospectively by the public outcry after high-profile leader mistakes, rather than by clear standards, expectations, and training. Leadership ethics are rarely discussed proactively and often poorly understood by both leaders and other stakeholders in the system. Typically, leadership ethics are bundled into the broader category of hospital ethics, where leadership ethics quickly take a back seat to the more mainstream and urgent clinical ethics issues encountered in the day-to-day running of a hospital.

The ethical challenges facing hospital leaders today have never been greater. The global pandemic in 2020 brought with it new and more complex leadership decisions including, but not limited to, those around Personal Protective Equipment (PPE), vaccinations, inter-region transfers of patients, staff shortages and models of care, COVID-19 expense allocations, visitor policies, and rationing of critical care beds. These complex decision requirements have been layered on top of many continuing leadership challenges such as conflict of interest, discharge refusals, restructuring, privacy/confidentiality, program prioritization, and sustainability.

This article discusses the importance of leadership ethics in today’s healthcare environment, examines some of the complex ethical challenges created by the current healthcare context and external environment, and then presents an argument for more formal and mandatory leadership ethics education for executives and other health leaders.

The high stakes of ethical leader behaviour

Running a hospital has always been complicated; the challenges are many and the consequences of failure are high. But in 2021, the stakes are higher than ever before. Large, multi-hospital systems, horizontal and vertical integration, multiple influential stakeholders, incompatible priorities, paradoxical incentives, drug shortages, and growing social and cultural clashes—all operating under the ever-present threat of funding cuts—provide a virtual guarantee of conflict and disagreement.

Yes, there have always been many, varied stakeholders within the healthcare system, but the digital revolution and rise of social media have provided an unequaled opportunity for these many voices to be heard. The ever-watchful, 24/7 posting of unfiltered content on social media means that ethical lapses, however misunderstood or unintended, are quickly exposed, shared, and judged.

In this highly judgmental environment, ¹¹ ethical leadership behaviour is critically important. Leaders not only serve as role models to the rest of the organization but also establish the foundation of a moral organizational culture. ^{12 –14} A highly moral culture positively affects organizational reputation, brand value, favourable media presence, and political status, which, in turn, affect talent acquisition, donations, patient perspectives, and effectiveness in advocating for funding. ^{15 –18} At the frontlines, the morality of the organizational culture also affects employee behaviour around sick time and fraud, and ethical leadership is also positively correlated with perception of patient safety culture and organizational commitment. ¹⁹

When doing the “right” thing is not the obvious answer

Some have argued that simply focusing on doing the right thing should be sufficient ²⁰ ; however, the “right” thing is seldom easy to discern in these complex, multi-stakeholder situations. Consider the pandemic-related issue of PPE allocation. Early on in the pandemic, there were widespread shortages of PPE, especially face masks. ²¹ Even as the pandemic progressed and supplies stabilized, leaders still faced ongoing difficult choices related to:

The requirement for changing visitor policies in the pandemic presented a similar no-win situation.

To deal effectively with these difficult ethical choices in health leadership, executives, and managers first have to recognize that they have an ethical issue, dilemma, or conflict of interest—and then follow this with careful evaluation of alternatives and risks.

Deciding if you have an ethical conflict as a leader

In some instances, the ethical issue is easy to see and the appropriate response is obvious. Common procurement scenarios fall into this category, such as declining gifts from a supplier while in contract negotiations.

Others are far less obvious. Consider the opening example of the two CEOs deciding to take a winter vacation in the middle of a lockdown order. One obvious possibility is that they knew it was wrong and did it anyway for personal gain, as is often the case in fallen leaders ²² ; or, more likely, they felt there was no real conflict of interest, illegality, or even risk to their employees if they observed the quarantine periods.

However, as with most conflict of interest situations, leaders also need to consider perceptions; here any reasonable observer might conclude they were behaving in a way that would not be seen positively by their employees or the general public, especially in an environment where most organizations were actively discouraging any kind of employee travel.

Situations where competing values make it difficult to choose the best path are far more challenging. How do you balance the needs to your employees against the needs of the patients or community? How do you weight short-term impact over long-term effects, or the possible against the probable?

In such a challenging environment, as leaders we need to be able to count on our colleagues and employees to point out and challenge decisions they feel are unethical or are ethically grey. However, research has shown that most people uncomfortable with calling out behaviour they think is morally wrong and unwilling to demand moral behaviour from others. ^23,24 During the COVID-19 pandemic, there have been widespread examples of behaviours that are contrary to the common good and prevailing morality, but a marked reluctance to challenge these behaviours, ²⁵ except of course after the fact and through the anonymity provided by social media.

Addressing leader ethical challenges in healthcare organizations

So where should leaders turn to assistance in making ethical decisions? Structurally, hospitals are not well set up to support ethical leader decision-making. Most organizations approach leadership ethics through a compliance model. Leaders are required to sign off on conflict of interest declarations, employment contracts, and privacy/confidentiality agreements, and then the system relies on reporting of breaches through whistle blower hotlines and other failure-based systems. Few organizations have regular discussions around the ethical appropriateness of their key decisions. Larger projects, such as Hospital Information Systems (HIS) or redevelopments, may have a compliance officer appointed to monitor ethical issues; however, basic ethical review of leadership decisions is not typical, even around big decisions such as restructuring and program closures.

In the common bioethics context, there are multiple supports available for clinicians, beginning with early education. Most healthcare professionals have received foundational training in clinical ethics and understand the principles of autonomy, beneficence, non-maleficence, and justice that form the basis of clinical ethics. When clinicians encounter ethical conflicts, they also can usually turn to the hospital’s ethical framework—a process that is supported by hospital accreditation standards in both United States and Canadian hospital accreditation. But these foundational principles are not particularly helpful in many leadership ethics contexts.

Clinicians can also turn to hospital ethics committees (if present). Hospital ethics committees have existed since the 1980s ⁴ ; however, their primary goal is typically to help clinicians deal with ethical challenges in clinical practice, including the most common issues such as end-of-life care, power of attorney challenges, withdrawal-of-care, research ethics and also supporting clinicians through difficult situations. ^{26 –28} Providing consultation on leadership ethics is rarely, if ever, in their mandate or their comfort level.

Healthcare leadership professional associations in both the United States and Canada do provide detailed guidance on ethical behaviour for health leaders ^29,30 ; however, the guidance is not always helpful in the multifaceted choices facing leaders. Many executives and other leaders also are not members and/or are not familiar with all of these resources.

Some of the most well-established ethical frameworks, such as Daniels and Sabin. ³¹ “Accounting for Reasonableness” actually provides a useful structure for many of the pandemic-related decisions that faced health leaders—if leaders are familiar with the work.

A need for leadership ethics support and training

Although the lack of emphasis and support for ethical leadership has been an ongoing risk for decades, as evidenced by the many examples of ethical lapses and charges, ^{1,2,32 –34} the COVID-19 pandemic brought the issue to the forefront. Most healthcare organizations found themselves unprepared to deal with the complex ethical issues related to pandemic in general and PPE and vaccinations in particular. A few hospitals quickly established Incident Management Systems (IMS) committees, facilitating broad input from a diverse stakeholder group; with these committees they quickly positioned themselves well for informed decision-making and clear communication within a situation that brought many ethically grey choices. Some of these hospitals also quickly moved to embed ethicists in their IMS committees and some working groups.

Although most hospitals (and governments) eventually adopted these kinds of approaches, the lack of consistent and proactive action suggests an overall lack of leadership preparation around ethical decision-making. In the rapidly evolving healthcare environment, leaders can expect to find themselves in more and more situations that required deliberate reflection and informed approaches to ethical decision-making.

In the post pandemic world, as the government drives to recover from the tremendous financial burden of COVID-19, there will be enormous pressure to optimize costs and utilization of healthcare resources. Leaders need to be ready to deal with challenging and multi-faceted situations. Today, leaders are also increasingly expected to respond publically to current sociopolitical issues such as the Black Lives Matter movement. ³⁵ Foundational training in leadership ethics, along with specific scenario planning and simulations, is essential.