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SURGICAL PERSPECTIVES

A Crucial Moment for Reflection on the Importance of Ethical Leadership in Academic Medicine

Angelos, Peter MD, PhD, FACS; Devon, Karen MDCM, MSc, FRCSC, FACS; Ferreres, Alberto R. MD, PhD, MPH, JD, FACS(Hon.)‡,§; McLeod, Robin MD, FRCSC, FACS; Ellison, Edwin Christopher MD, FACS||

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doi: 10.1097/SLA.0000000000004600
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Abstract

The emergence and surge of COVID-19 to pandemic proportions compounded by a second pandemic of widespread racial unrest affecting our communities and institutions has placed leaders in healthcare including those in academic medicine in extraordinary situations. At the center of severe institutional disruption, leaders will be compelled to take action to keep their constituents and patients safe and their hospitals and departments afloat during and after a pandemic, all while simultaneously addressing and implementing the cultural changes required to eliminate systemic racism and discrimination. The decisions made will in all probability impact patients, faculty, staff, learners, and academic communities for years to come. A leader can experience conflicting obligations to stakeholders during these emotional and complex debates and must lead with strength, compassion, fairness, and justice while eliminating implicit and explicit biases.

Organizational disruptions of this magnitude will naturally challenge one's principles, loyalties, and responsibilities while compounding the practical burdens of leadership. If the goal of responding to these challenges is to bring them to resolution and ultimately to bring about organizational change for the better, ethical leadership is critical. In this unprecedented time, it seems necessary and prudent for us to take a moment for reflection. Why is ethical leadership important? Using the guidance from ethical principles allows leaders to chart clear paths to building consensus and resolving issues and disputes both in the short and long term.

In the long term, morally upstanding leaders who believe in and promote ethics – the principles, standards, morals, values, and virtues that guide behavior – have a substantial positive impact on an organization allowing it to establish and develop an ethical culture. This is important in the day to day management and even more so in times of crisis. An ethical culture ought to be the backbone on which institutional character is built, to support the new normal that will undoubtedly occur during crisis recovery. Where does one begin to enhance or rebuild trust and respect during recovery from the coronavirus pandemic and efforts to meaningfully respond to social injustice? Rebuilding the trust of our patients, faculty, staff, residents, fellows, students, and society as a whole during and after COVID -19 and through the difficult cultural changes needed to expunge racism and discrimination will depend on leadership that is inclusive, fair, and just. That is, ethical leadership.

A logical starting point is to refresh our understanding of Ethics as it applies to leadership. Ethical leadership rests on philosophical doctrines including the concepts of moral right and wrong and moral good and bad and other systems or codes of moral rules, principles, or values. Leadership Ethics then, is determined by such pillars of moral philosophy, and moral concepts such as justice, fairness, virtue, and duty. In academic medical leadership these elements all interplay between leaders, faculty, staff, patients, and other stakeholders including learners and the communities we serve.1 Since ethics deals with the concepts of actions that are right and wrong and virtue, it follows that ethical leadership is defined as influencing and leading people by ethical principles and virtuous actions by example and instruction, with a clear framework for determining what is right and what is wrong to achieve the greatest good. Plinio and colleagues highlighted the lack of ethical leadership and poor ethical behavior as one of the more difficult challenges and threats we face in multiple organizations today.2

Different theories provide a response to the question “What is the greatest good?” Classically, moral leadership has utilized 3 separate philosophical approaches: doing the right thing and following the moral imperative, maximizing the welfare and benefit of an organization, its people, and its stakeholders (utilitarianism), and maximizing the wellbeing of an individual (libertarianism). In the modern context, just leadership often emphasizes either one of the above or a mixture of the 3. An effective leader acts and leads with trustworthiness, meaning that ethical leadership is both visible and invisible. Such a leader must behave in an unimpeachable manner guided by a fairness and justice. In the words of Brown and Treviño, “ethical leaders explicitly focus attention on ethical standards through communication and accountability processes.”3

Building trust is essential to ethical leadership. Trust is the main driver of engagement which is essential for organizational success. Leadership qualities that build trust include transparency, consistency, and equity. One key to fostering a culture of trust between leaders and their employees is transparent leadership. Faculty and staff who are kept in the loop and understand their role in the overarching purpose and goals of an organization are, understandably, more likely to put their trust in their institution and to be engaged. When a leader is consistent, they are able to inspire trust at all times, whereas a leader who is inconsistent with momentary flashes brilliance can leave their constituents confused and bewildered. Trust is further enhanced by equity. When stakeholders perceive inequitable treatment, engagement suffers and so does productivity, innovation, and the interactions of faculty and staff with patients. Keeping a focus on equity in decision making is part of ethical leadership.

Key to building trust is ethical decision making. This may be one of the most important skills for the leader to master. It is an active cognitive process for the prevention and/or resolution of moral conflict. It involves logic and reason and intuition and emotion. The process of ethical decision making consists of a unique framework of moral imagination, identification, evaluation, integration, and obligation. Practical steps to this approach include problem definition, engagement, information gathering, exploration of viable options, application of ethical principles or policies to the options, resolution of discordance between ethical principles and policies or rules, and finally decision making.4 To illustrate organizational ethical decision making, we provide an example from the American College of Surgeons (ACS) early in the COVID-19 pandemic in Figure 1.

FIGURE 1
FIGURE 1:
Case example: organizational ethical decision-making

In the example in Figure 1, leadership of the ACS demonstrated many of the key attributes and steps in ethical decision making4

  • An ethical problem was identified: Acuity and severity of COVID-19, the need for hospital beds and intensive care unit beds and ventilators and the needs of the patients having non-emergency surgery.
  • Cognitive and emotional dimensions were considered as it was a dual process involving both logic and emotion: establishing a surgical review committee and displaying pragmatic optimism.
  • Moral Sensitivity to the issues was clearly expressed in the statement of the ACS Ethics Committee: Utilizing patient-centered ethics decisions evolved made to what is best for a group of patients.
  • Moral judgement and recommendations were made (what is the right or wrong thing to do in this situation: you cannot cancel all the surgeries and you cannot cancel none of them)
  • Avoidance of ethical blind spots such as group favoritism and implicit prejudice
  • Moral focus to follow through
  • Moral character as evidenced by recognition of duty

Development of specific guidelines for ethical decision making by physician leaders is an iterative process undergoing continuous reassessment and improvement. There is no absolute roadmap of how to make just decisions. Unfortunately, there is also no flow chart to clearly identify how to avoid making unjust decisions. Although many considerations of moral decision making begin with the attempt to define what the specific ethical question is, we also believe it is helpful to conceptualize ethical decision making as important for all decisions rather than only for those that narrowly fit within a specific category. If the leader thinks of making every decision in an ethical fashion, then the necessity of distinguishing which decisions involve moral dilemmas disappears. It is also important for the physician leader to realize that in his or her position as a role model, there will be many situations in which the actual decision made will be less important than the method that was used in making the decision. A thoughtful, deliberate, transparent approach that takes into consideration multiple perspectives will be far more valuable than an authoritarian jump to a position even if the same decision is ultimately made.

As evident from the case illustration and the above discussion, good leaders have learned that just as one must be prepared for negotiation, conflict resolution, personnel management, and finance, so must he or she also be prepared for ethical leadership. A monograph which examines the unique ethical challenges that leaders’ face in academic medicine and defines the constructs of ethical leadership and ethical culture was sanctioned by the American Surgical Association.9 The monograph is entitled “Ensuring Ethical Leadership in Academic Medicine” a companion piece to “Ensuring Equity, Diversity, and Inclusion in Academic Surgery.”9 It is available for download at https://americansurgical.org/ethics.10 The topics and goals are shown in Table 1. The purpose is to provide strategies that will help leaders establish and ensure an ethical culture and to address ethical concerns more effectively when they arise. There is no better time than now to embrace ethical leadership.

TABLE 1 - Topics and Goals of Interest in Ensuring Ethical Leadership in Academic Medicine
Topic Goals
The Foundations and Principles of Ethics Provides the historical foundations of ethics and the evolution of bioethics, medical ethics, and surgical ethics. The foundation of ethical leadership rests on philosophical doctrines of moral right and wrong and moral good and bad.
Definition of Leaders and Followers Defines leadership as the exercise of influence and power in a group context and distinguishes between leading and following. As patient care is a moral practice, physicians have unique attributes that prepare them for ethical leadership.
The Construct of Ethical Leadership Examines the construct of ethical leadership which is defined as the application of ethical principles and guidelines to leadership. Ethical leadership is justified by its many benefits. The lack of ethical leadership and poor ethical behavior is one of the more difficult challenges and organizational threats that we face today. Seven steps to achieve ethical leadership are presented.
The Challenges of Ethical Leadership Explores the challenges of ethical leadership. These include the leader achieving balance and transparency with respect to the ethical burdens of power, privilege, and information management, and achieving consistent decision making with acknowledgment of potentially competing loyalties and responsibilities. Case examples will be used to illustrate the challenges.
Establishing an Ethical Culture: The Importance Ethical-Decision Making Defines the key strategies to develop an ethical culture in your organization. Steps to accomplishing successful management include promoting an ethical culture reinforced by a code of conduct and alignment of faculty expectations with organizational goals. The principles of ethical decision making (the foundation of an ethical culture) are discussed with case examples.
Breaches of Ethical Principles: Frequency, Examples and Management Defines the domains and frequency of individual ethical breaches and the keys to successful management. No matter what type of ethical leadership you have in any environment, not just academic medicine, there will always be breaches by single individuals who disregard those principles. They will never be fully eliminated. One of the responsibilities of the leader is to respond and manage ethical breaches when they occur. Case examples will be used to illustrate challenges and management strategies
Management of Ethical Issues in Human Subjects and Basic Science Research Focuses on the management of specific ethical issues that may arise in Human Subjects and Basic Science Research. We specify the ethical obligations of the Principal Investigator and Co-Investigators and research leaders. Leaders must establish and ensure a culture of research integrity based on published doctrine which must protect patient rights. A case example is used to illustrate the importance of patient rights.
Ethical Issues in Data Collection, Analysis and Publication Examines ethical issues in data collection, analysis, and publication. Ensuring an ethical process begins and ends with the Principle Investigator and Co-Investigators. The leader's role in ensuring integrity in this process can be circumvented by dishonest investigators that may go undetected until reported by a whistleblower. Hence, it is imperative that the leader establish a confidential system for reporting such violations and processes for managing them. Case examples is used to illustrate research fraud, how difficult it can be to detect and the subsequent negative consequences to the public. Issues in authorship and publication are discussed including the guidelines established by the Committee on Publication Ethics (COPE).
Ethical Issues Involving the Trainee: Mentoring, Resident Autonomy, and Research Explores ethical issues involving the trainee. The ethical obligations of a mentor are provided. The mentor-mentee relationship is discussed, and we consider the 6 phases of mentoring. Unique issues in mentorship in the clinical trainee are highlighted by a case involving resident autonomy. The responsibilities for mentoring a research trainee are discussed. The chapter ends with the potential ethical issues in the Mentor-Mentee relationship.
Ethical Issues Involving Faculty Discusses potential ethical issues involving faculty. We examine faculty compensation, conflict of interest with a case example and an in depth discussion of conflict of commitment with case examples. Finally, we look at the dual responsibilities of the physician leader to patients and the health system. This includes focusing on the leader's challenges to balance discord between patients and health system

Acknowledgments

The authors are grateful for the support and sponsorship by the Council of the American Surgical Association 2018–2020.

REFERENCES

1. Irwin T. The Development of Ethics: A Historical and Critical Study. Oxford, England: Oxford University Press; 2009.
2. Plinio AJ, Young JM, Lavery LM. The state of ethics in our society: a clear call for action. Int J Discl Gov 2010; 7:172–197.
3. Brown ME, Treviño LK. Ethical leadership: a review and future directions. Leadersh Q 2006; 17:595–616.
4. Johnson CE. Meeting the Ethical Challenges of Leadership. 6th edThousand Oaks: SAGE; 2018. 175–185.
5. Available at: https://www.facs.org/covid-19/clinical-guidance/elective-surgery. Accessed June 30, 2020.
    6. Available at: https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage. Accessed June 30, 2020
      7. E Mail Message from David B. Hoyt MD FACS to Fellows of the American College of Surgeons March 21, 2020.
        8. Available at: https://www.facs.org/covid-19/newsletter/032420/ethics. Accessed June 30, 2020.
          9. Available at: https://americansurgical.org/files/2018/Equity.pdf. Accessed June 30, 2020.
          10. Available at: https://americansurgical.org/ethics. Accessed October 20, 2020.
          Keywords:

          COVID-19 pandemic; discrimination; ethical leadership; racism; social injustice

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