Covid19 and clinical moral leadership

The Covid 19 crisis makes this a vital time to be thinking about moral leadership.

When I was advising The Health Foundation on their leadership programme* back in 2004, no-one was very interested in discussing the moral aspects of health care leadership. That was why I decided to pursue the research that resulted in my book Moral Leadership in Medicine (Cambridge, 2012). The challenges of moral leadership that were apparent during a time of relative calm in the NHS over a decade ago become even more stark in a time of crisis. I hope that my research into the experiences of medical leaders then can provide guidance and support for clinical leaders facing difficult decisions today.

Moral leadership means more than just having a good set of values. It means using values to make difficult decisions where there is no right answer. It means being able to explain difficult decisions, and justify them to those who disagree. It means maintaining steady purpose, but also changing your mind when the evidence changes or better arguments come along. It means putting decisions into action in a way that is kind, compassionate, and consistent. And it means being accountable, in the end, for what you decided was for the better and not the worse.

THE FIVE HORNED LEADERSHIP DILEMMA

Even at the best of times NHS medical leaders are juggling at least five morally essential, but often contradictory, goals. In my book I discuss these goals, and the leadership behaviours that serve them. I call these leadership behaviours “propriety”.

‘Fiduciary propriety’ needs least introduction. Fiduciary propriety exhibits in action the principle that a doctor’s (and any other clinician’s) first priority is to attend to their patients’ needs. In the normal run of things, fiduciary propriety is evident in how it mandates an unwavering focus on patients, needs and grants a licence to speak very assertively on their behalf. At its best fiduciary propriety is courageous action on behalf of people shunned by others – those stigmatised, infectious, unappealing, vulnerable, rejected and abandoned. At its worst, fiduciary propriety can become bullying in the name of patient care.

‘Bureaucratic propriety’ is concerned with the moral constitution of the organisation. The idea of bureaucracy has come in for quite a bit of stick, but I think it’s important to recognise its virtues. Virtuous bureaucracy is about public institutions serving the public fairly. Public organisations are the repository of the collective interests of those they serve (current patients and families, and future patients and families) and their stakeholders (for example suppliers – which may themselves be enterprises with a social mission – and staff). Of course serving the interests of patients must come before everything else, but to do this effectively means building stable, responsive, honest, accountable organisations. Good bureaucrats distribute community goods – such as healthcare –  fairly, efficiently,  predictably and transparently. Public organisations that embrace the virtues of bureaucracy serve us very much better than organisations run on nepotism, bribery, corruption or dictatorship. Good clinical leaders are (admittedly rather well-disguised) virtuous bureaucrats.

‘Collegial propriety’ is behaviour essential to an enterprise in which things get done through co-operation, collaboration and ‘discretionary effort’ (going the extra mile). Collegial propriety is a bond that sustains the medical professional community, and in doing so it also serves patients. In the positive form of collegial propriety, we see practices such as peer pressure to drive up clinical standards, reciprocal aid in caring for patients, mentoring of juniors, unpaid work for professional bodies, and recognition of exceptional service. At its best, collegial propriety is the bond that underpins patient care. At its worst, it puts loyalty to colleagues before patient safety.

‘Inquisitorial propriety’ is a set of moral practices that clinical leaders exercise when allegations of harmful treatment, poor performance, or misconduct arise. Misconduct, misbehaviour and medical mistakes present many medical leaders with their most intractable moral troubles. For the person leading an investigation into something that has gone wrong, ‘inquisitorial propriety’ suggests demeanours such as candour, objectivity, neutrality and openness to ‘hearing the other side’.

‘Restorative propriety’ is the fifth propriety. It is conduct that seeks to restore moral relations after harm and it turns on acknowledgement: acknowledging that a harm has occurred, acknowledging that certain persons or bodies are responsible, acknowledging that a complaint is legitimate, acknowledging that the person who was harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond.

DANCING ON THE FIVE-HORNED LEADERSHIP DILEMMA

Because the five proprieties come into conflict leaders find themselves being pulled in different directions by equally desirable and equally strongly argued moral claims. Here are some examples.

Rationing decisions often present clinical leaders with a choice between what is in the interests of individual patients (fiduciary propriety) and what is in the interests of patients-in-general (bureaucratic propriety). When there are poor clinical outcomes, clinical leaders may find themselves having to choose between being supportive towards a colleague (collegial propriety) and remaining strictly impartial (inquisitorial propriety). Equally, when a patient complains of injury clinical leaders can be torn between the need to ‘hear both sides’ (inquisitorial propriety) and the need to acknowledge and respect the patient’s perception of harm (restorative propriety).

CHOOSING BETWEEN GOOD AND GOOD

In my experience, it is precisely when clinical leaders have to make a choice between good and good that they are most vulnerable to criticism, sometimes being accused by those who disagree with them of ‘unethical’ or non-moral behaviour. But where there are leaderly decisions to be made, there will inevitably be choices about which good to prioritise. If there wasn’t a tricky choice to be made, we wouldn’t need leaders.

(*I’m proud that at The Health Foundation we were among the first advocates for healthcare leadership development programmes focusing on distributed and network leadership)