Reflections on Ethical Leadership: Organizational Ethics and Moral Injury

Abstract

Starting with the question of “why would anyone choose to become a health leader?”, this column shares reflections on the nature of ethical leadership. Different features of health leaders and their practice that support engaging in organizational (systems-level) ethics issues in accordance with relevant values are discussed. The possibility of experiencing moral injury as a leader is highlighted as an important aspect of preparing health leaders for this role. Related reflections on moral resilience and moral integrity further support the need to ensure that training for health leaders captures the complexity of organizational ethics work and navigating fundamental challenges to one’s sense of self as a leader.

Introduction

“Why would anyone choose to become a health leader?” is a question that is sometimes heard in discussions about difficult ethics issues that seem intractable, involve conflict, and will face much scrutiny, internally and externally, whatever path forward is chosen. This question is ethically, arguably equally, intriguing and dismaying, as it is often an expression of the emotional turmoil and deeply values-laden nature of the issue(s) under discussion. It’s also a recognition of the ethical complexities and uncertainties that accompany this role. Given the focus of this special issue on preparing to lead in healthcare, this question takes on a particularly significant resonance for me as a Practicing Healthcare Ethicist (PHE) and as someone who has held/holds different leadership roles.

I am keenly interested in the ways in which we design and deliver healthcare from a values-based perspective. This area of ethics support is often referred to as organizational (or systems-level) ethics and is involved with examining how these broader types of decisions, policies, and processes contribute to or detract from our ability to live up to and enact the values that are espoused by the healthcare system and, in this instance, by leaders who work within this system. Engaging in organizational ethics work with health leaders has provided opportunities, for example, to imagine how a new policy may provide better guidance for healthcare providers in making difficult decisions with patients and families about their treatment and care. This work has also created space within which to explore the development of a more equitable approach to resource allocation, which in turn then opened up possibilities for reorganizing care in ways that are better aligned with this commitment to fairness and improving access.

Organizational ethics work takes time and commitment. It needs health leaders who are willing to question assumptions that seem “sacred” in healthcare. It also needs leaders who are willing to feel uncomfortable, and even vulnerable, with respect to the uncertainties that accompany the process of “doing the thing right” ¹ or as right as possible all things considered. Appreciating the multiple, inter-connecting layers that inform and underlie many organizational ethics issues, engaging in this work may seem fundamentally at odds with the pressure, implicit and/or explicit, that health leaders feel to “just deal with it,” “make a decision now,” and to “demonstrate (immediate) success”—even while there may be less-than-needed clarity about timelines and what success is or ought to look like.

I feel privileged to work with health leaders who are committed to engaging in organizational ethics work. They see the possibilities and practicalities of making changes within the health system. They also see the hard work involved in trying to ensure that the relevant ethical values are reflected in these changes, especially when these values may be in tension with each other. They recognize the importance of thoughtfulness and curiosity about how to weigh these values in relation to possible options, as well as the importance of being able to explain how the relevant values inform the decisions that are made. These leaders are invested in the process of how decisions are arrived at, not just what the decision or outcome is.

Yet I have also witnessed and had the “heartbreak” shared with me by health leaders when conditions change such that a well-designed, justifiable, ethical approach to a health system issue is not implemented (or only implemented part-way or abandoned at a later point in time). The reasons for this may include shifts in organizational priorities, changes in more senior leadership, political aspects, and so on. Some of, or even all of, these factors may be anticipated or acknowledged as possibilities by health leaders in relation to a project or policy change; still the underlying challenge to the values that a leader is endeavouring to uphold is real. In providing ethics support, we (PHEs) sometimes are the “safer” space within which health leaders can share their sense of loss, and the ways in which experiences like this, among others, can undermine their sense of moral integrity and their confidence in their ability to be a good, in all the meanings of this word, leader.

It is from these experiences that I think it is imperative to continue to expand the discussion about what ethical leadership is and means, including what one may be exposed to or have occur as part of aspiring to be a good health leader. This preparation should include, for example, the possibility of experiencing moral injury caused by the very system that you are there to support and represent. This may be particularly important for preparing future, emerging and early career leaders in order to lessen the possibility of experiencing moral injury, increase their ability to name and navigate this should it occur, and to be better prepared to support those they work with (as noted below).

Discussion

There is increasing discussion about moral injury within healthcare, understood as “the psychological, social and spiritual impact of events involving betrayal or transgression of one’s own deeply held moral beliefs and values…” ² Research has focused on healthcare providers and how exposure to potentially moral injurious events may occur and what the repercussions of experiencing such an event may be. ³ The important role of leaders in supporting healthcare providers who experience moral injury is also (naturally) identified and discussed. ⁴

However, arguably, there is relatively less discussion about what happens when the leaders themselves experience moral injury (although this can be found in the literature). ⁵ Are the same types of supports available for health leaders? Should the supports be the same for healthcare providers as for leaders or might being in a leadership role create some differences that may be important to attend to with respect to addressing moral injury? For example, as one works through the shame, guilt, anger, questioning, that may arise in connection with moral injury, how might this influence one’s sense of self as a leader or leadership style? And potentially shape one’s ability to lead over the short and long(er) term? When would it be appropriate (or not) for a health leader to share with their team that they (the leader) has experienced moral injury? These questions open up a range of considerations with respect to supporting health leaders who experience moral injury, as well as what it may mean to prepare future leaders for this possibility.

Further, when moral injury is discussed, there are often corresponding discussions about moral resiliency and/or moral integrity. While I do not have the space here for an in-depth analysis of these concepts, there are a couple of reflections that I would like to offer:

First, built into the word resiliency itself is the notion of “recoil” or “rebound” (from the Latin verb resilire), or, perhaps more colloquially, that resiliency is about being able to “bounce back.” For health leaders, my worry is that there is an underlying expectation that they should be able to “bounce back” from whatever happens—as is sometimes said, “they are the leader, after all.” Uncritical acceptance of this understanding of resiliency can create barriers for health leaders to acknowledge and admit to themselves and others that they have experienced moral injury and to ask for assistance and support. It may also potentially limit opportunities to reflect on what one, as a leader, has learned from the experience of moral injury (or leading through other difficult ethics issues, even if this did not result in moral injury). The “bounce back” image of leadership is not one that easily embraces growth and change as a leader—the latter being something I believe is a valuable contributor to being, and becoming, a good leader.

Second, moral integrity, as part of ethical leadership, is sometimes described as “walking the talk,” that is, putting the values that one holds as a leader into practice in visible or tangible ways. While I agree that “walking the talk” is important and is likely one possible marker of whether someone is demonstrating ethical leadership, I also invite further reflection on how we picture or tend to frame what this looks like. For example, what image comes to mind? It might be one where the leader is portrayed as a solitary figure who is walking on a relatively straight, even if uphill, path. What does this type of image convey or suggest about what good leadership is, especially in the context of engaging with organizational ethics issues and the possibility of experiencing moral injury? For me, there are at least two things to notice about this type of image:

(1) The leader is alone. Yet we know that it is easier to “walk the talk” if one has others around you who are trying to do the same thing. And that these persons will support you in “stepping out” and taking a risk to do something different, especially when you are trying to put values into practice by making changes within the healthcare system. While all leaders can likely benefit from being part of a community of support, especially for navigating experiences of moral injury, for future, emerging, and/or early career leaders, knowing they are not alone and that it is safe, and even encouraged, to wrestle with the ethical issues that arise is vital. In other words, as leaders face ethical hurdles and will sometimes stumble and fall, knowing someone will be there to pick you up and support you can make all the difference. Indeed, walking, ethically speaking, is harder than it seems in the face of various organizational ethics issues and the demands on health leaders.

(2) Why is the path that the leader needs to walk often portrayed as straight or clear, even if uphill? Or that the choices for going forward are well-identified (choose option 1, 2, or 3)? Where are the potholes? The dead-ends? Or the need to find a way through a tangled ethical jungle of vines with lurking dangers? Sometimes the hardest part of trying to act with integrity as a leader seems to be in identifying and framing, or reframing, what the actual ethics issue is. The path is often not obvious. And finding the path, the most ethically defensible way forward, can be particularly challenging amid all the “noise” telling a leader that it is something else or to not even to go down that path or to even ignore finding a path forward.

Conclusion

Expanding and adding complexity to our expectations and images of what it means to be an ethical leader is required. I am heartened by the calls, and development of programs, for additional training for leaders about ethics and about ethical leadership.^6-8 This includes the role of adaptive leadership and how this may assist leaders with engaging in different ways with organizational ethics issues in the healthcare system. ⁹ As Kaposy and Petropanagos put it, “By thinking differently and by doing things differently, health leaders can help to guide change among their colleagues and communities.” ¹ Overall, it is through these types of supports and approaches that we can—with more transparency, respect, and empathy—better prepare people to choose this career path and to become, and be, ethical health leaders.