An extended version of a presentation at the University of Oxford April 2012 outlining some of the arguments from my book "Moral Leadership in Medicine" Building Ethical Healthcare Organizations"

1. DEPARTMENT OF PRIMARY CARE HEALTH SCIENCES
Moral Leadership
in
Healthcare Organizations
Suzanne Shale
Health Experiences Research Group

2. What is this presentation about?
 Why does healthcare need moral leadership?
 What do I know about moral leadership?
 What does moral leadership mean?
 What are moral leaders in medicine concerned
with?
 How do they do moral leadership?
 Why is the practice of “propriety” important?
 Tensions between different moral behaviours
 Moral courage

3. We need moral leaders to uphold
what is acceptable in the odd moral
world of healthcare…
“In the hospital it is the good people, not the bad, who take
knives and cut people open; here the good stick others
with needles and push fingers into rectums and vaginas,
tubes in to urethras, needles into the scalp of a baby; here
the good, doing good, peel dead skin from a screaming
burn victim’s body and tell strangers to take off their
clothes…The layperson’s horrible fantasies here become
the professional’s stock in trade.”
D. Chambliss Beyond Caring Chicago UP 1996

4. What do I know about moral leadership?
 I carried out a qualitative study of
medical directors in primary and
secondary care organizations
 I asked “Looking back over recent
years, what has been the most
troubling issue you have dealt
with?”
 Then “Assume I know nothing and
tell me step by step what you did”

5. What does moral leadership mean?
 Leadership is both a role and an activity. Moral leaders are
those who ‘step up to the plate’.
 Doctors are not the only people who lead in medicine, and
demonstrating followership is an element of leadership.
 There are descriptive questions: what are the moral
concerns of leaders in medicine and how do moral leaders
behave ?
 There are normative questions: what ought to be the moral
concerns of leaders in medicine and how should they act?

6. Footnote: Is/ought & the credentials problem
 Descriptions of what the moral issues ARE and what moral
leaders DO can help us to understand the moral landscape.
 But - what can description tell us about what leadership concerns
OUGHT to be and how they SHOULD behave?
 Are & Do cannot automatically tell us about Ought & Should:
“you cannot derive ought from is”. But what respected leaders
ARE thinking & doing in a moral sense can help us to examine the
question of what moral leaders OUGHT to be thinking and doing.
 Here the credentials problem arises: were these the right people
to ask? Typically the credentials problem is described as: if we
have to ask for moral advice, how do we know who is “qualified”
to give it? Here, how are we to judge who the moral leaders are
and what moral leadership is, in order to study them?

7. The difference between
moral deciding and moral doing

8. The difference between moral deciding and
moral doing…part one
When a treatment error has necessitated additional
procedures or temporarily affected a patient’s
health, is it preferable to tell or not to tell the
patient/carer what has happened?
(A) PREFERABLE TO TELL
(B) PREFERABLE TO NOT TELL

9. The difference between moral deciding and
moral doing…part two
Watch the video* Is this a good apology or is it a poor
apology?
(A) GOOD APOLOGY
(B) POOR APOLOGY
* Video can be found at
http://www.jhsph.edu/dept/hpm/research/Wu_vide
o.html(See “Removing Insult from Injury” training video –
Pediatric surgery, an apology)

10. So what does the preceding exercise tell us?
 The moral quality of our lives is associated with the
quality of moral decisions but not decisions alone
 Our judgement of the moral quality of actions turns
significantly on how decisions are enacted in the
context of relationships with others
 Judging the moral quality of enactment is extremely
complex, and may be highly contingent on the
perspectives of the observer eg patient/nurse

11. Footnote : Nick Smith I Was Wrong: The
Meanings of Apologies (Cambridge UP 2008)
Smith identified 11 elements in a “categorical
apology”:
① Corroborated factual record
② Acceptance of blame
③ Identification of harm
④ Identification of the moral principles underlying each harm
⑤ Endorsement of the moral principles underlying each harm
⑥ Recognition of the victim as a moral interlocutor
⑦ Categorical regret
⑧ Performance of the apology
⑨ Redress
⑩ Appropriate intent
11 Appropriate emotion

12. What does moral leadership mean in the
Medical Leadership Competency Framework?

13. A helpful focus on behaviour
An unhelpful simplification of the challenge
This is what the competency framework says “Doctors show
leadership through acting with integrity: behaving in an open,
honest and ethical manner. Competent doctors:
 Uphold personal and professional ethics and values, taking into
account the values of the organisation and the culture, beliefs and
abilities of individuals
 Communicate effectively with individuals, appreciating their social,
cultural, religious and ethnic backgrounds and their age, gender and
abilities
 Value, respect and promote equality and diversity
 Take appropriate action if ethics and values are compromised.”
THE PROBLEM IS THAT ETHICS AND VALUES ARE
CONSTANTLY COMPROMISED
BECAUSE THEY ARE INHERENTLY CONFLICTING

14. What are moral leaders in medicine thinking?
I asked what leaders were most Which was most frequently
troubled by discussed?Examples:
Resource allocation
Service reconfiguration e.g.
creating new care pathways,
clustering smaller services
into larger ones
Managing doctors suspected of
being or known to be
incompetent
Managing suspected or known
medical harm

15. The most frequent topics were…
① Managing doctors suspected of being or known to
be incompetent
② Managing suspected or known medical harm
③ Service reconfiguration
④ Allocating discretionary resources (e.g. new
drugs, plastic surgery, procedures such as IVF
with PGD)
⑤ Conflict between personal beliefs and the
demands of public service (e.g. euthanasia)
⑥ (Resource allocation in general)

16. What were moral leaders in medicine doing?
I asked what leaders did about They described five sets of
the things that troubled them moral behaviours that I call
propriety
 Fiduciary propriety
 Bureaucratic propriety
 Collegial propriety
 Inquisitorial propriety
 Restorative propriety

17. Five proprieties
& some interview data to illustrate them

18. Fiduciary propriety
“Patients first…”
Fuels noble dreams and selfless endeavour.
Motivates courageous action on behalf of patients e.g.
patients stigmatized by HIV/AIDS
Evident in a licence to speak assertively, including in ways
thought unacceptable if interests other than those of patients
at stake.
Underpins rhetorical sorties into ‘shroud waving’ or other
regions of the moral high ground.

19. Fiduciary propriety
“Patients first…”
“I probably don’t recognize the strength with which I
put over some of the arguments. I’m not by nature
a particularly forceful character. But I suppose at
times I do invest quite a lot of emotional
involvement in the way that I will put across
difficult issues at [Board] level, particularly to the
non-execs where they’re not necessarily aware
of…Well it goes back to that patient thing. You
know what the effect on individuals could be.“
(Hospital Medical Director)

20. Fiduciary propriety
“Patients first…”
“I have at board level had to hold the line…We were
proposing that we would restrict or even close
services on the basis of safety and I did have to stand
up for that. Funnily enough I didn’t find that
particularly difficult. I mean the Chief Exec did take
me to one side and say ‘Are you telling me this is
unsafe? Is there any other way?’ and I said ‘Well not
any other way you’ve come up with’… It was very
clear to me that a child had nearly died, and that’s
not hard is it?” (Primary Care Trust Medical Director)

21. Bureaucratic propriety
“Organization first”
Virtuous bureaucracy is efficient, impartial,
accountable allocation of shared (public) resources
Behaviours:
impartiality in deed and demeanour
willingness to be held to account
abnegation of personal interests and morals
support for distributive rules and protocols
conscientiousness in office.
Such practices do not come naturally. It takes self-
discipline to exercise them, especially in the face of
provocation.

22. Bureaucratic propriety
“Organization first”
“ I think doctors need to understand …that there is a
stewardship we all share…People say that money
isn’t health. It is. It’s publicly funded. We have to be
accountable. And there’s the stewardship of
quality. And the stewardship of resources. And so
on”
(Hospital Medical Director)

23. Bureaucratic propriety
“Organization first”
“I understand now what it means to be corporate and retain your
integrity; which, as a clinician, I would probably have thought was a
very long stretch! I think clinically if you work for an organization,
you have to be prepared to identify yourself as a member of that
organization; and that means espousing certain values and
plans…Through that debate and discussion you reach a point where
you can say, ‘A is to be done - I have these reservations’. Either it’s
recognized that you have those reservations and they need to be
integrated into [the solution], or you need to be having a discussion
with somebody to say, ‘I cannot go out and *implement this+’ It’s
that thing that says you are open about your problems, and you have
to resolve them…It’s that commitment to the organization that says
you'll be honest. But equally that trust, that you will work together
on it.” (Primary Care Trust Medical Director)

24. Collegial propriety
“Colleagues first…”
A ‘conspiracy against the laity’? Sustained criticism from
commentators critical of self-serving professional alliances;
dictum of Chicago School sociology to “elevate the humble and
humble the elevated”
In positive form collegial behaviours promote harmony, team
functioning, supportiveness, development of community of
practice.
Visible in fellowship, reciprocity, support and mentoring of
juniors, service to professional body such as Royal College,
deference to community determination of clinical standards

25. Collegial propriety
“Colleagues first…”
“There are issues about the history of these doctors. They
were brought here, quite deliberately, by the NHS, given the
impression that the streets were paved with gold. They
were often treated very badly. They were not promoted as
fairly. They were put into jobs that were unattractive. They
may well have been victims of discrimination years ago.
Many of them have been abused in employment
relationships in general practice, been promised things that
never happened – you know, become [an employee in the
partnership] with a view to [becoming a partner]- that never
materialized. But …” (Primary Care Trust Medical Director)

26. Collegial propriety
“Colleagues first…”
“We work with virtually every other specialty in the
hospital…going round helping and advising and working in
collaboration with other consultants…We’re always having
to tread quite carefully, not offending people, or seeming to
be muscling in, or telling people how to do their job
properly…I was seen as somebody who was honest, who
didn’t tend to be judgemental, was generally supportive,
but also not afraid to tackle the difficult situations.”
(Hospital Medical Director, explaining how some draw on
their experience of having worked in ‘support’ specialties)

27. Inquisitorial propriety
“Process first”
 Reflects the prominence of troubles relating to managing
clinical performance and medical harm.
 Inquiries and investigations are capable of rebuilding or
destroying patient trust, collegial relationships, clinician self-
confidence, team dynamics, and respect for medical
management.
 Proper behaviours include:
Investigator demeanours: objectivity, neutrality, ‘hearing
the other side’.
Person under investigation: candour, regret, and, where
appropriate, frank confession.
Victim, complainant: truthfulness, mercy

28. Inquisitorial propriety
“Process first”
“To make sure that everything is done properly. That
we’re fair and equitable in our dealings with the
individual practitioner, in dealings with the legal
representatives, in dealings with the patients’
representatives. That there’s no bias…no prejudice
on my part expressed in either direction. It’s
particularly difficult when you’re face to face with
someone suffering as result of medical injury
whether it’s patient or…practitioner”
(Hospital Medical Director)

29. Inquisitorial propriety
“Process first”
“I’m a bit of a geek about regulations and powers and where
certain things have come from...I’ve a fairly encyclopaedic
knowledge, a lot of experience hands on. I wasn’t afraid of it
because I’d done it before, and I’d had experience of other
people, going down this road...And because I’d been
involved in some quite serious cases in the past…Because at
every stage you’re vulnerable to challenge, either through
the defence societies or through judicial review, or in the
High Court. So there have been time when it’s been really
quite draining…This hasn’t been done without an impact on
my personal health; it’s affected my mental and emotional
health”
(PCT Medical Director)

30. Restorative propriety
“Acknowledgement first…”
 Turns on acknowledgement: that a harm has occurred,
persons or bodies are responsible, that a complaint is
legitimate, that the person harmed has a ‘moral right’ to
define the situation in their terms, acknowledging that steps
must be taken to respond.
 Some familiar behaviours: contrition, performance of
apologies, making financial restitution.
 For organizations, raises questions such as who has standing
to ‘perform’ gestures such as apology, whether there is
sincere regret, whether and what changes to practice may
be made, and how such changes can be monitored.

31. Restorative propriety
“Acknowledgement first…”
“We’ve made a promise to this relative that we are
looking into this in order to understand it; and if
things need to be changed, to change them. Or
else, their loved one’s death becomes
meaningless…And if important lessons from this
death are not heard, or played down, then that is a
betrayal.”
(Mental Health Trust Medical Director)

32. Restorative propriety
“Acknowledgement first…”
“Sometimes it’s difficult, because sometimes patients are so
angry that it’s actually very difficult to – and they need to
get their anger out of their system; and you can’t –
whatever you say to them, they won’t – You have to accept
that you can’t always send everyone away happy I’m
afraid…Sometimes you have a discussion with patients or
relatives and, and you think at the end of it, you’ve really
moved on. But I think quite often you feel actually, they
have let out some of their anger of whatever, but they
haven’t really moved on. They’re still going away from it
angry” (Hospital Medical Director)

33. The central problem:
tensions between the proprieties
REDESIGNING SERVICES
 Bureaucratic propriety in tension with fiduciary and
collegial propriety
INVESTIGATING COLLEAGUES
 Fiduciary propriety in tension with inquisitorial propriety
& collegial propriety
ATTENDING TO PATIENT HARM
 Inquisitorial propriety in tension with restorative
propriety

34. Example: balancing collegial propriety and
inquisitorial propriety when managing performance
“I’m plagued with doubts all the time. I do worry tremendously. About,
am I being unfair? Are my standards too high? Is this…? …* In one of
the practices where I worked as a GP I witnessed the effect of] a
complaint that I thought was quite unjustified. That was a terribly
conscientious doctor. Now he killed himself. He committed suicide.
And it traumatized not only his family, the partnership, the practice
team, but the whole community. All of his patients felt guilty – that
this wonderful man had died over this wretched complaint, that was
ill founded.
That experience has really made me think. When we do discipline
somebody … we could be wrong. It’s been painted this way but
there’s another side to the story. We have to be terribly careful,
because I don’t want – I don’t want another doctor’s death on my
conscience through mishandling a disciplinary process.

35. Enacting moral decisions requires
moral determination
“I know exactly what you mean
when you say dig deep. And I
recognise that as shut your eyes,
take a deep breath and focus…
What happens in that moment of
focus? I suppose it’s almost like
checking off a rosary. It’s the right
thing. It’s correct. Its’ based on
this, that, it’s rational. It’s going to
feel unkind. You don’t have any
choice. But you can offer this, that
or the other…That’s it, and it has
to be faced. The moment’s now. “