Values, principles & practices of ethical leadership

1. Values, principles & practices of ethical leadership Dr. Suzanne Shale Consultant in clinical, organizational and research ethics suzanne.shale@clearer-thinking.co.uk Tel: 020 7226 3793

2. Assumptions • Ethical considerations are embedded in the day-to-day challenges of healthcare leadership • Leadership is collaborative, so that ethical leadership entails continuous negotiation of values and principles across leadership networks • Clear choices between right and wrong are easy: what is difficult is making sense of reality and choosing between different goods • Ethics is partly, and significantly, about negotiating moral norms • Ethics is equally significantly about enacting (performing) moral behaviours

3. “Performative” ethics • Whether or not to tell bad news is rarely a contentious ethical issue in UK & US healthcare; respect for autonomy mandates it • How it is done affects our judgment of the ethical quality of the act and the actor • Managing dismissal or redundancy may be essential. • How it is done (text message?) affects the ethical quality of the act, the actor, and the organization

4. Behaving with ‘propriety’ • Fiduciary propriety • Bureaucratic propriety • Collegial propriety • Inquisitorial propriety • Restorative propriety

5. Propriety 1 • Fiduciary propriety “patients first” “There’s times – and I’d always warn my Chief Executive about this – I’ll be in a meeting or something and I’ll say ‘Now I’m going to turn rogue doctor” Because there’s a time as a medical director you have to be the conscience or the voice of the medical staff, to tell unpalatable and difficult facts to the executive. And the other way round” • 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”

6. Propriety 2 • Collegial propriety “colleagues first” “Where I’ve found it most difficult is with a small number of individuals who appear to be on board…and just never keep their end of the bargain. You realise…its extremely unlikely you’ll ever effect any lasting change by consensus. The only way you’ll get the situation fixed is by a much more aggressive…approach which isn’t my style at all and therefore I hate it” • 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”

7. Propriety 3 • 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.”

8. Choosing between goods:conflicts of propriety ‘Jacob wrestling with the Angel’ The behavioural rules, habits and values embedded in propriety provide important guidance; they are also a potent source of unexamined assumption. At their best, they are a source of moral courage…

9. A case study in ethical leadership • How would you approach the situation? • What proprieties are apparent in your own and others’ responses?

10. Responsibility in medical management Letter in HSJ 18th March 2010 “A doctor’s managerial decisions can just as easily kill or harm patients as their clinical decisions, so there is simply no tenable argument against the need for them to demonstrate appropriate competence. For similar reasons, managers must be able to demonstrate these same skills.” Professor Jenny Simpson, British Association of Medical Managers

11. Procedural justice “I have a maxim which is “if you’ve got a process, use it”. By and large most eventualities are covered by set procedures or protocols, either local to the organization or national statutory… I’m not beyond scrutiny, and certainly not above scrutiny, but if scrutinised, then what I’ve done is appropriate.”

12. ‘Speaking truth to power’ “The report that was written…hardly mentioned anything about the awful conditions that were described by the carers. And for me, this was the thing that made me feel embarrassed and terrible…It was the terrible experience that this relative had had of their loved one being in hospital. It was heartrending; it was awful. And this would not be communicated.”

13. Claiming moral high ground “What you need in systems, you do need a bit of dissent…Listen to the people who are dissenting. Sometimes [they are claiming the] high moral ground, but where it comes from is personal interest…Sometimes there is real proper, it’s not personal interest, it’s actual proper dissent “This is wrong, be careful”…It’s very easy to lose all the dissent because everyone feels frightened or threatened, jobs and everything else but I sense that doctors will always dissent…and they know how to dissent in the highest possible places…”

14. Questions of equity “There were 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 assistant with a view to partnership that never materialized - - - But you can’t excuse unacceptable patient care, even taking all of those things into account.”

15. Organizational responsibility “Sometimes you feel, “We’ve really let down a patient…you know as a doctor not everything always goes well. You get lots of thank you letters but occasionally you just know that this is not what you wanted to happen…Seeing that in complaints, I understand that things don’t always go well. But equally you feel that you have let patients down, and sometimes we as an organization should have done better, even if individuals have done their best.”

16. Corporate responsibility 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…I don’t think I appreciated how those values and plans are hammered out…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. But you cannot keep them until you’re on the [public] stage [representing the organization]. It’s that commitment to the organization that says you'll be honest. But equally that trust, that you will work together on it.

17. 7 aspects of moral repair • acknowledging an injured party as a moral interlocutor; • acknowledging the authority of shared norms; • acknowledging injury; • acknowledging responsibility; • acknowledging that remedy is due, and that the injured party may define what is owed; • acknowledging righteous anger, or other negative feelings, in those who have been injured; and • acknowledging that in injuring another, we should experience sorrow and regret.

18. Individual responsibility “The bits which I suppose are most difficult, are the bits which leave you feeling most alone…”

19. Digging deep “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. “