Leaders of academic health centers (AHCs) have what increasingly appear to be impossible jobs. They must deal with medical school and hospital administrators, faculty, employers, payers, government entities, patients and their families, research subjects, funders, donors, and other supporters, and the community. These parties often have divergent interests and conflicting demands that seem not to be reconcilable. It should come as no surprise that leaders’ levels of stress are very high and burnout common.1
The psychological and emotional dimensions of this stress and burnout are well recognized and many useful proposals have been made about how to manage them.1 What are not so well appreciated are the ethical dimensions of academic medical leadership. In particular, there has been to date no ethical framework offered that academic leaders can use to identify, prevent, and responsibly manage the ethical conflicts that are inherent, but sometimes hidden, in being an academic leader. We wrote this article to present such an ethical framework for identifying, preventing, and managing ethical conflicts confronting academic leaders and to illustrate the application of this framework using an organizational case study.
Basic Elements of the Ethical Framework
Academic health centers are not merely businesses with only contractual obligations to provide specified services covered by sources of payment.2,3 This is because AHCs have fiduciary obligations that go far beyond merely contractual ones.4
Being a fiduciary in medicine and health care has the following three components, which were first introduced into the history of medicine by two giants in the history of medical ethics, the Scottish physician–ethicist John Gregory (1724–1773)5,6 and the English physician–ethicist Thomas Percival (1740–1804)7,8:
- Health care professionals and organizations should be competent by providing patient care and conducting research to standards of scientific and moral excellence. Following the work of Francis Bacon (1561–1626),5 Gregory and Percival formulated a nascent account of evidence-based medicine as essential to achieving and maintaining competence. Today, physicians and academic health centers are the beneficiaries of a much more fully developed evidence-based medicine.
- Health care professionals and organizations should use their knowledge and skills primarily to benefit patients. The pursuit of self-interest, no matter how legitimate, should become a systematically secondary individual and organizational consideration.
- Health care professions and organizations are public trusts. They do not exist primarily for the benefit of physicians or for organizational managers and owners. Instead, health care professions and organizations exist primarily to meet the health care needs of the communities of patients they serve, and of future patients, through research and education.
With these components in mind, academic leaders should understand themselves to be cofiduciaries with their professional colleagues of present and future patients.4,9 The concept of cofiduciary responsibility provides the foundation for an ethical framework by defining the mission of AHCs: the pursuit of excellence in clinical care, education, and research in a fiscally responsible fashion. It is important to recognize that fiscal responsibility is a legitimate interest of AHCs and their leadership, because fiscal responsibility is a necessary condition for accomplishing organizational missions. However, if fiscal concerns become primary, if they are made the mission, then AHCs destroy voluntarily and from within their ethical nature as fiduciary organizations and therefore violate their responsibilities as public trusts. The central task of leaders of AHCs is to create agreement on the obligations of the AHC as the basis for decision making, especially decision making in response to ethical conflict.
Identifying Ethical Conflicts
Stakeholder theory10 explains the origins of ethical conflicts in complex organizations. When there are multiple stakeholders whose legitimate interests are not mutually compatible, ethical conflicts result. The first step in identifying ethical conflict in AHCs is to identify the multiple stakeholders and their legitimate interests. To accomplish this step, academic leaders need to distinguish reliably between legitimate and illegitimate interests of stakeholders. There are at least two criteria for an interest to be legitimate: The stakeholder provides an explanation of the stakeholder's interest (1) in terms of the stakeholder's well-recognized social role and responsibilities, especially those related to core missions, and (2) in terms of the conditions necessary for fulfilling these responsibilities. Academic leaders are completely justified in requiring such explanations from stakeholders and discounting the intellectual, and therefore the moral, authority of individual or organizational interest asserted without such explanation. False explanations, e.g., those based on cooked financial data, have no intellectual or moral authority whatsoever, even though the political authority of the stakeholder may be nontrivial.
In Table 1, we identify the major stakeholders in AHCs. We also identify nonexhaustively what we see as major examples of the legitimate interests of each of these stakeholders (listed alphabetically).
The following steps should be taken by an AHC's leader to identify potential ethical conflicts in decision-making involving stakeholders:
First, the leader should construct a table appropriate to his or her organization that lists the major stakeholders in a decision and their legitimate interests, using Table 1 as a model. This should be done in a consultative fashion. Simply representing the interests of affected stakeholders without consulting them will lack moral authority, and possibly accuracy as well. Affected stakeholders, therefore, should be asked explicitly to identify their legitimate interests.
The second step is for the leader to ask each particular stakeholder representative to justify all claimed interests as legitimate. Each stakeholder legitimates interests when the stakeholder shows that an expressed interest satisfies the two criteria for interests to count as legitimate, as set out above.
In the third step, the leader should identify convergence of interests among stakeholders, especially common interests of which they are unaware.
In the fourth step, the leader should identify divergence of interests among stakeholders.
The fifth step is for the leader to propose a definition of the problem at hand, and develop with stakeholders a shared definition.
Sixth, the leader should identify for stakeholders problematic management strategies that may have contributed to the problem at hand. Below is a list of some of the more common of these strategies:
- Stakeholders do not admit that their resources are needed for another stakeholder to achieve its legitimate interests.
- There is failure to recognize shared problems as such.
- There is failure to acknowledge the legitimate interests of other stakeholders.
- Strategic procrastination occurs in making and implementing decisions.
- There is strategic ambiguity concerning the connection between expressed commitments and funding.
Preventing Ethical Conflicts
The most important step in preventing ethical conflict is to devise and implement an action plan, starting with identification and acknowledgment of converging interests. The leader should then identify divergent interests and acknowledge the absence of a common ground, which occurs when diverging interests cannot be mutually satisfied. Third, the leader should solicit agreement from relevant stakeholders that there is a problem of potentially mutually incompatible legitimate interests and seek agreement on the nature of the problem. Fourth, the stakeholder should be expected to understand the perspective of stakeholders with divergent interests. Fifth, the AHC leader should not accept that divergent interests must become entrenched, but should propose strategies for moving from divergent to convergent interests.11
Managing Ethical Conflicts
Successful management of ethical conflicts depends on the willingness of stakeholders to accept the concept of prima facie, fiduciary-based obligations of academic leaders in response to conflicting individual and organizational legitimate interests.12 The concept of a prima facie obligation means that it is not possible to provide in advance of actual situations or cases a rank-ordering of obligations that is indisputable, e.g., that the department or division generating the most revenue should never have to compromise its legitimate interests.9 Instead, obligations to implement the legitimate interests of all stakeholders start out as equally strong, with subsequent priorities set by AHC leaders on the basis of the strength of arguments that persuasively show the priority of one interest or groups of interests over the others. Simply asserting a set of priorities without a supporting argument will not be persuasive and will usually be counterproductive in the long run.
The first step in managing ethical conflict is for the academic leader to give clear, consistent, factually grounded reasons to set the priority of his or her prima facie obligations to stakeholders in terms of the AHC's fiduciary obligations. The tactics of strategic ambiguity and strategic procrastination should not be utilized.* Second, the academic leader should acknowledge competing action plans, present a critique of them, and explain why the proposed action plan is better in terms of both cofiduciary responsibility and, in so far as possible, why it supports the legitimate interests of stakeholders. Third, the academic leader should elicit critiques of his or her reasoning by stakeholders, requiring them to justify, in light of the AHC's fiduciary obligations, any other priority they propose. Fourth, the academic leader should present a response to such critiques, which may include revision of his or her proposed action plan, providing a final justification for the priority of obligations and an action plan that implements that priority. This action plan should be regarded as a trial of management, to be continued as long as the argument in support of it remains valid.
An Organizational Case Study
We turn now to an application of this ethical framework for identifying, preventing, and managing conflicts confronting academic leaders. This case involves a financially very successful department section proposing to become its own department.
Cardiothoracic surgery is a division of the Department of Surgery in an academic health center. For several years, the revenues generated from this single division of the Department of Surgery have provided a majority, and growing, portion of the department's revenues, and these revenues have been used by the department to cover deficits generated by less fiscally successful divisions. The hospital associated with the medical school derives considerable profit from the revenues generated from the cardiothoracic surgery services and also benefits from philanthropy generated by grateful patients. The faculty in the division are paid substantially more than their counterparts in general surgery, but less than prevailing levels of cardiothoracic surgeons in the competing community hospitals.
Cardiothoracic surgery is threatening to leave the academic health center and join one of the competing community hospitals as its own department unless the university will permit it to become a separate department in the medical school. The cardiothoracic surgery leadership states that its goal is to achieve greater autonomy and higher salaries and no longer be burdened with having to subsidize the rest of the Department of Surgery. The cardiothoracic surgery leadership adds that it will use part of its excess revenues to subsidize research. The Department of Surgery leadership objects to this request because the department will lose needed revenues, run a deficit, and will lack the funds to finance the recruitment of other excellent cardiothoracic surgeons.
The hospital associated with the medical school expresses support for the cardiothoracic surgeons’ request to be a separate department in the academic health center because the hospital will retain this group's patients with the associated revenues and philanthropy. The medical school is conflicted in that it wants to retain the excellent doctors, their research, and their successful practices. The medical school leadership also expresses an interest in retaining the revenues generated for the “dean's tax” and associated philanthropy, but does not want to eviscerate the Department of Surgery. The medical school leadership is also concerned about setting a precedent that could lead other successful divisions to propose establishing their own departments.
The traditional response to such a case is for the medical school leadership to recognize its vulnerability and to make a monetary calculation of the replacement costs of the cardiothoracic surgeons and a political calculation of disagreeing with the hospital leadership. This rapidly devolves into a power struggle among the medical school, Department of Surgery, the cardiothoracic surgeons, and the hospital. However, the ethical framework set out above changes the response of medical school leadership in such cases from simply negotiating a power struggle to requiring the major stakeholders to identify and evaluate their legitimate interests and fiduciary responsibilities, and to then attempt to resolve this conflict by following the preventive-ethics and management steps described earlier. A power struggle is thus transformed into a quest for an ethically justified response to a major organizational challenge.
As described earlier, the first step of this transformative process is for the medical school leadership to bring together the leadership of the major stakeholders in this case—the Department of Surgery, the cardiothoracic surgery section, and the hospital—and ask them to identify their interests and legitimate them. Each leadership group should be asked and expected to explain how claimed interests meet the two criteria, stated earlier, for interests to count as legitimate.
In this process, the medical school leadership should make it clear that the burden of proof is on the cardiothoracic surgeons to show that their proposal protects and promotes the fiduciary obligations and core mission of the medical school. The quite understandable desire to retain revenues and increase salaries does not, by itself, legitimate these interests, however strongly the desire is expressed. Threats should not count as legitimate interests.
The Department of Surgery should be pressed to identify ways in which revenues in other sections can be increased and costs rigorously controlled. The department's leadership should be asked to explain how it could preserve its core mission if cardiothoracic surgery's request is granted. A simple, unexplained assertion that the core mission of the department would be imperiled or become impossible to fulfill should not be taken at face value; an explanation should be requested and required.
The hospital leadership surely has a legitimate interest in retaining the cardiothoracic surgery group. However, this is not the end of the hospital's story. It also has a cofiduciary responsibility to protect and promote the academic and research mission of the medical school.4
The medical school leadership should identify its own legitimate interests and also provide a transparent and precise accounting of the resources available in the Department of Surgery and in the medical school to recruit new cardiothoracic surgeons, should the current group elect to leave. The medical school leadership also needs to reach a reliable assessment of the precedent-setting effect on other departmental sections of allowing the cardiothoracic surgeons to leave.
The medical school leadership should then identify convergence of and conflict among legitimate interests and fiduciary responsibility of all stakeholders, especially those related to the medical school's core mission. In doing so, the medical school leadership should stringently avoid and not accept the use of strategic ambiguity and procrastination. The medical school leadership should also be willing to challenge the major stakeholders. The cardiothoracic surgeons should be asked whether they are committed to the academic health center, a commitment that has traditionally been understood to involve reasonable financial self-sacrifice. While it may be true that they earn less than their competitors in the community (many of whom are their former residents and fellows), they are nonetheless well compensated and also have the opportunity to participate in the noneconomic advantages of being in the AHC. The claim for increased autonomy should be challenged with the question, Autonomy for what? This may just be a cover for the desire for increased earnings, which is a potentially legitimate interest and should be addressed as such. The cardiothoracic surgery group should be challenged to present a budget for how they will use their excess revenues to support research. The Department of Surgery leadership should be challenged to develop a financial plan that rigorously cuts costs and increases revenues in other sections as much as possible, to reduce the financial burden on the cardiothoracic surgery section. The department leadership should also be challenged to strengthen the academic environment of the department, to make it more attractive for faculty to come, stay, and flourish. The hospital leadership should be challenged to balance its legitimate economic interests with its fiduciary responsibility to the medical school.
The preceding case study illustrates the transformative process of ethical decision-making based on the identification, prevention, and management of ethical conflicts in AHCs. This transformative process should become a major management tool in academic leaders’ toolboxes. Otherwise the academic mission becomes a function of the most powerful stakeholders, or alliances of powerful stakeholders, rather than a careful evaluation of legitimate interests disciplined by fiduciary responsibility. An AHC that simply manages power struggles without ethical tools will soon find itself at war with itself, as Thomas Hobbes predicted long ago in his discussion of power driven by self-interest alone.13 It is essential that transparency be achieved in every step we have outlined above, because transparency creates intellectual authority for a decision making process and moral authority for its results.14 Transparency also requires each party to become aware of and take seriously the cofiduciary responsibilities and legitimate interests of other stakeholders. The will of the strongest, as advocated by Thrasymachus in Plato's Republic,15 should be replaced by organizational policies and practices based on well-argued prima facie obligations of AHC leaders that implement cofiduciary responsibility.
Many conflicts center on money disputes, as the case study powerfully illustrates. This is because all stakeholders have an interest in maximizing revenue and minimizing costs (Table 1). Ethical conflicts arise when a stakeholder pursues this legitimate interest by ethically suspect means. For example, hospital administrators may strongly endorse continuous quality enhancement, from which the hospital surely benefits, but refuse to assume responsibility for a reasonable share of its cost. In addition, a chair could demand money from administration to compensate a colleague on biased grounds by exaggerating the colleague's clinical, educational, or research value to the institution.
The professional virtues become crucial management tools in this context.16 The academic leader should lead decision-making processes with integrity, especially by role-modeling the clear and well-argued articulation of legitimate interests and arguments for his or her prima facie obligations in response to conflicts among such interests based on a clear account of the AHC's fiduciary responsibilities. Self-effacement requires the academic leader to accept criticism in a thoughtful and reflective fashion, and with openness to change in reasoning. A large dose of humility in accepting well-argued criticism will create an important antidote to arrogance and other forms of power that are destructive to an organizational culture of fiduciary professionalism. Gregory's description of the “dogmatical” physician is apropos, because it describes the opposite of what the conscientious AHC leader should role-model. The term dogmatic in its original sense implied only one who endeavored to reduce his or her knowledge of diseases to certain principles. It came afterwards to be adopted by physicians, who, from weakness and vanity, pretended to practice, from knowledge of the proximate causes of all diseases, and of the mode of operation of all remedies. But now, in common language, dogmatic is generally used in an unfavorable sense, being applied to one who is conceited, dictatorial, and obstinately attached to particular opinions.11
Self-sacrifice will require the academic leader to compromise his or her legitimate interest when required to do so by better arguments for the priority of others’ interests in service of the AHC's fiduciary responsibilities. Compassion requires the academic leader to acknowledge the real and felt costs to others of having to postpone fulfillment of or compromise their legitimate interests. An important element of compassion is the promise to revisit, at regular intervals, decisions about the management of serious ethical conflict, i.e., those in which compromise of legitimate interests by some stakeholders has been required in order to fulfill the AHC's fiduciary responsibility for protecting its legitimate organizational interests.
Ethics As an Essential Tool
Ethics is an essential but still largely neglected tool in the AHC leader's “toolbox” when dealing with conflict among stakeholders and their interests. Executive fiat is at best effective only in the short-term, but in the long-term is counterproductive, because it breeds resentment and resistance. This and other inadequate responses fail to appreciate the moral and possibly financial damage to all individual parties and to the culture of the AHC as a fiduciary organization. In our view, responsibly identifying, preventing, and managing ethical conflict on the basis of careful reflection and argument conducted with transparency will strengthen AHCs as fiduciary organizations, making them worthy of the trust and also the enormous resources that society invests in them.
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Strategic ambiguity involves the deliberate promotion of uncertainty and confusion in violation of a leader's fiduciary obligation to be transparent and precise in communications. Strategic procrastination involves the deliberate delay in releasing needed information or committed resources or in announcing decisions in violation of a leader's fiduciary obligation to do so in a timely manner.4