REVIEWManaging the Conflict between Individual Needs and GroupInterests - Ethical Leadership in Health Care Organizations
Suzanne Shale

Centre of Medical Law and Ethics, King’s College London, United Kingdom(Received for publication on June 27, 2007)(Accepted for publication on November 15, 2007)

Abstract: This paper derives from a grounded theory study of how Medical Directors working within the UK National Health Service manage the moral quandaries that they encounter as leaders of health care organizations. The reason health care organizations exist is toprovide better care for individuals through providing shared resources for groups of people.
This creates a paradox at the heart of health care organization, because serving the interests of groups sometimes runs counter to serving the needs of individuals. The paradox
presents ethical dilemmas at every level of the organization, from the boardroom to thebedside. Medical Directors experience these organizational ethical dilemmas most acutely
by virtue of their position in the organization. As doctors, their professional ethic obliges
them to put the interests of individual patients first. As executive directors, their role is tohelp secure the delivery of services that meet the needs of the whole patient population.
What should they do when the interests of groups of patients, and of individual patients, appear to conflict? The first task of an ethical healthcare organization is to secure the trustof patients, and two examples of medical ethical leadership are discussed against this background. These examples suggest that conflict between individual and population needs is
integral to health care organization, so dilemmas addressed at one level of the organization
inevitably re-emerge in altered form at other levels. Finally, analysis of the ethical activity
that Medical Directors have described affords insight into the interpersonal components of
ethical skill and knowledge. (Keio J Med 57 (1) : 37－ 44, March 2008)
Key words: organizational ethics, professional ethics, virtues, ethical issues, leadership

Introduction

turn, you have agreed to make intensive care available topatients from those other hospitals when they need it, if
you have beds available. Because your ICU is always
busy, you infrequently receive patients from your partners. So you are ‘net exporter’ of patients, and depend on
good working relationships with other organizations todeliver intensive care to your patient population.
Shortly after you arrive for work today, an eighty-three
year-old patient on one of your medical wards suffers acardiac arrest.*1 Dorothy is resuscitated, and put on aventilator in the ward. But now she needs to be admitted
to intensive care. In England, hospital specialists haveagreed national guidelines for admission to intensive
care, and the ICU team have assessed her according to
the guidance. They have come to the conclusion that her

In the situation I am about to describe, what would you
do?
Imagine that you are the Medical Director of a reasonably good general hospital in a large English city. As
Medical Director, you are the chief clinician and also an
executive member of the hospital Board. You are accountable for the quality of medical care and, along withother members of the Board, responsible for setting andmeeting the hospital’s annual budget.
Your hospital suffers a constant shortage of intensive
care beds. To provide intensive care to your patients
when there is no room for them in your own intensive
care unit (ICU) you rely on other hospitals nearby. In re-

Presented at the 1511st Meeting of the Keio Medical Society in Tokyo, March 29, 2007
Corresponding Author: Suzanne Shale B.M., M.A., 14 Waterloo Terrace, London N1 1TQ, U.K E-mail address: Suzanne Shale @ clearer-thinking.co.uk
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Shale S: Ethical leadership in health care organizations

prognosis is very poor, and that she does not satisfy thecriteria for admission. Dorothy’s family are at her bedside, very upset. Although in English law their views are
not binding on doctors, nurses have asked them what
they would wish for their mother. They said: ‘We knowthat she has Alzheimer’s disease, and that her kidneys are
failing. We realise that there is a ninety five percent
chance of her not surviving. But to us that means that
there is at least a five percent chance that she could live a
bit longer. Our mother is not ready to die yet. So we want
her to be put on a ventilator in the ICU’.
Members of the resuscitation team are angry because
the ICU team still refuses to admit the patient. Individuals in the ICU team are frustrated because they have applied the guidelines, and it is never easy to turn a patientaway even if they believe it is the right decision. In theend, a member of the resuscitation team telephones the
Medical Director’s office to request your help. She wants
you to come down to the ward and instruct the intensivists to admit Dorothy to their unit.
What would you actually do in this situation? I placeemphasis on the verb ‘do’ because the research fromwhich this example is drawn is an inquiry into the moral
action that medical leaders take when they are faced withthese and similar challenges. Much of medical ethics isconcerned with the question ‘How should doctors think
about the moral problems that arise in caring for individual patients?’ My research question differs from that in
two ways. It is, ‘What do doctors do to manage the ethical dilemmas that arise in organizing health care?’Moral beliefs and ethical actions
Thinking and doing are of course closely related but it
is a mistake to conflate the two. Moral beliefs do not automatically translate into ethical action. Many people believe that lying is wrong, but on occasion we go ahead
and do it anyway, knowing that it is wrong. There aremany reasons we do so. We tell lies with good intent,
when we think lying will bring about a more morally attractive outcome than telling the truth. Less commendably, we lie with bad intent. We are tempted by the prospect of personal advantage, and allow temptation to
overwhelm our moral beliefs. Or to avoid trouble, we decide to remain silent and allow others to believe what weknow to be an untruth. There are many reasons why beliefs, intentions, and actions may not match each other. It
is precisely because we often do not act in a way that is
consistent with what we say are our moral beliefs, that I
am interested in how people do implement their moral
values in the challenging setting of health care.
That beliefs intentions and actions may not be consistent is, to ethicists, a familiar proposition. Less familiar,
is the claim that knowing what is ethically desirable isoften only a very small part, indeed, perhaps, the least

demanding part, of ethical action.
Breaking bad news to patients is an example of justsuch a task. Doctors and philosophers in the UK andNorth America generally agree that it is ethically correct
to tell a patient of their cancer diagnosis. Whether tobreak bad news is no longer, to the moral philosopher, aparticularly perplexing moral question. But it remains adifficult and sometimes perplexing moral action. A doctor planning to tell the patient his diagnosis would have amorally good intention. But it would not be a morally
praiseworthy action if he blurted the truth to the patienton the way to another task, spared no time to answer
questions, and seemed not to care about the patient’s
feelings.
Implementing moral action demands much greater carethan merely forming a moral intent. The moral action of
breaking bad news requires, first, thoughtful planning.
The doctor must find an appropriate private space, haveinformation to hand, and rehearse her statements and thepatient’s response in her own mind. Then it requires
knowledge. The doctor must marshal technical knowledge relating to the diagnosis, prognosis, management
plan, treatment choices, side effects, and the rest. And
the doctor will need to have or get personal knowledge,of the patient’s own priorities, interests, concerns, andpreferences for how information is presented. Morally
breaking bad news requires communicative skill. The
doctor has to express herself clearly, hear the questions
the patient is trying to ask, and use her mental acuity to
tailor information in response to them. Additionally, such
moral action demands emotional intelligence. The doctor
needs the ability to empathise, to manage anger or distress. And she must also possess the capacity to disengage, because the doctor who over-identifies with patients will soon ‘burn out’ emotionally. What is a simple
ethical question to the philosopher is a demanding ethicaltask in everyday clinical settings.
The very complexity of the moral task of breaking badnews tells us why doctors sometimes fail to do it as wellas they and their patients would wish. It is not because
they are simply careless, or unethical. It is because it canbe very difficult, and take considerable skill, to shape our
ethical actions to achieve our ethical intentions.
Individual and organizational ethics
Like moral belief and ethical action, providing care forindividual patients and organizing care for populations ofpatients are closely related and yet differing tasks. A doctor’s duty is to make the needs of his patient his first
concern. Similarly, ethical healthcare organizations aim
to provide the best possible care for each of their individual patients. But the reason health care organizations
exist is to provide better care for individuals through providing shared resources for groups of people. Providing

Keio J Med 2008; 57 (1): 37－ 44

for an entire patient population confronts health care organizations with ethical challenges different from thosethat typically confront individual doctors.
It is a paradox of health care organization that sometimes, what the ethical organization must do to secure
the interests of groups of patients, may appear to conflictwith the interests of individual patients. This paradox isevident in any controversy over allocation of health careresources. Because health care supplies are finite, andhealth care demand is infinite, all patients are effectively
in competition with one another for resources. A budgetary decision to spend more money on medical service A
almost inevitably entails there being less money available for medical service B, however needy are the individual cases receiving service B. The decision to allocate
a bed to current patient C, may mean none being available for future patient D. As Dorothy’s story suggests,
ensuring that intensive care beds will be available for thegroup of patients who can benefit from them most, may
mean turning away individual patients who benefit fromthem least.
Clinical education supplies another example of theparadox, one so familiar it often passes unnoticed. Patients attending hospital attend for the purpose of receiving treatment, and they naturally desire the most skilfultreatment from the most highly qualified doctors. But if
hospitals are to be able to treat future patients, they must
train future doctors. Doctors-in-training, of course, needpatients upon whom they can practise their undeveloped
skills; and the most highly qualified doctors, who mightotherwise use their time skilfully treating patients, must
spend time teaching those skills to others. Clearly, an
ethical organization has to balance the desires of current
patients with the needs of future patients.
Later in this paper, I take two further instances of the‘health care organization paradox’ to illustrate how ethical challenges arise out it. These examples are managing
admission to intensive care, and managing organizational
performance targets. To inform that discussion, I shallfirst of all look at the first ethical obligation of healthcare organizations, acting to secure patients’ trust. Finally, I shall return again to Dorothy’s story at the end of
the paper, to consider what moral action should be taken
in managing her case.
The foundational obligation: securing trust
Relationships of trust lie at the very heart of medicine.
One of the earliest lessons medical students learn is thata doctor’s first concern is the well being of his patient.
Taking steps to secure their trust must be among his earliest actions towards each patient. The health care organization also owes its first duty to patients, and patient
trust is as much the responsibility of the health care organization as the individual doctor.

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The trust relationship has two dimensions. There is acognitive element, where a trusting party makes a rational assessment of risk. And there is an affective element,
where emotional bonds emerge through social interaction.*2
It is extremely difficult for patients to make a rational
assessment of the risks involved in seeking medical
treatment from a particular practitioner. In medicine, as
in any profession, there is asymmetry of knowledge between professionals and the people who consult them.
The primary reason for the consultation is that the practitioner knows more than the patient, so the patient is ill
placed to judge the knowledge and competence of thepractitioner.*3 To the extent that patients do assess risk,
therefore, they rely heavily upon others to minimise hazard for them.
In the background of the doctor-patient relationship, a
multitude of organizations is responsible for assuring
standards of professional care and the education of safe
practitioners.*4 A patient submitting herself to medical
treatment implicitly assumes that these organizations
have faithfully discharged their obligations. When she
gives consent to a particular doctor or nurse she trusts
that their employer or accrediting organization is assuredof their competence. She trusts that the technical resources the hospital or clinic has made available are adequate and fit for their purpose. She trusts that medications and procedures have been properly tested, evaluated and found to be safe. She trusts there is evidence thatthe treatment she will undergo is capable of providing
some benefit. She trusts that the education of doctors intraining will be organized in a way that balances theirneed for educational experience with her need for safeand effective care. Patients place their trust as much inorganizations as they do doctors, and justifying this trust
is a significant ethical obligation for organizational leaders.
The vulnerability of those who are ill tends to heighten
the affective elements of trust. This element of trust is
elicited through such actions as demonstrating respect,
being responsive to individual patient needs, admitting
clinical uncertainty, and acting in a caring manner towards people who are feeling frail and afraid. Doctors’interpersonal skills therefore play a critical role in supporting the leap of faith that is required to procure trust.
But while doctor-patient interaction comes to the fore
to elicit the affective dimension of trust, the organizationis still at work in the background. The organization thatfails to act rapidly, impartially, and wisely when patientscomplain of poor care, courts feelings of injustice that
undermine trust. The organization that discriminates
against less favoured groups when it allocates its resources jeopardizes the trust relationship with thosegroups and probably others. Organizations must respondin an ethical and humane way to the challenges that they

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Shale S: Ethical leadership in health care organizations

face, if trust is to be maintained.*5
How are trustworthy health care organizations made?
It can only be through the activity of those who work in
and with them, and especially the people who lead them.
It must therefore be one of doctors’ many ethical obligations to their patients that they contribute towards building ethical organizations. This is a high expectation ofindividual doctors. For the medical leader, building an
ethical organization is an essential part of their role.
Ethical medical leadership: two examples
I argued earlier that there is a paradox at the centre ofhealth care organization. The needs of individual patients, and the needs of groups of patients, sometimes
appear to conflict. The ethical organization will seek amorally satisfactory solution to this problem. In this section I consider two examples that demonstrate how intractable a task this may prove.
The examples of the ‘health care organization paradox’
are taken from research interviews with Medical Directors working in the UK National Health Service (NHS).
At the time of writing, 20 Medical Directors of UK hospitals and Primary Care Trusts*6 have been interviewed
about the ethical dimensions of their leadership role.*7
Managing the ‘health care organization paradox’ is acommon characteristic of their ethical experience. Medical Directors experience the conflict between individualinterests, and those of populations, more acutely thanany other member of the organization. As clinicians, they
are obliged to uphold an ethic of practice that prioritises
the interests of individual patients. As organizational
leaders, they are accountable for the scope and quality ofcare provided to groups of patients.
Solving the paradox described earlier, between theneeds of individuals and the interests of patient populations, is one of the ever-present challenges of medical
leadership. The paradox is never wholly dissolved. It is
one of the striking features of the ethical life of healthcare organizations that the paradox ‘dissolved’ at one
level re-emerges in altered form elsewhere. Wherever it
re-emerges, medical leaders and their clinician colleagues are charged with re-solving it.
Dorothy’s story makes this point well. The only way torelieve resource allocation pressure in a moderately efficient health care system is to require populations to pay
for further services, either directly or indirectly throughtaxation. The UK government has concluded that this solution is neither morally nor politically acceptable. The
Medical Director’s difficulty over Dorothy arises in partout of the brute fact that he has a limited budget, and increasing the number of ICU beds would mean reducing
provision to other services. Let us assume that the Boardof his hospital has considered that solution, and concluded that it is morally undesirable. At Board level, the ethi-

cal dilemma of how to allocate health care resources has
been addressed and a moral defensible decision has beenmade. But at the bedside level, the ethical difficulties reappear. Hard choices must still be made, about which individual patients should receive the benefit of ICU resources that have been provided for the entire patient
population. As the ethical dilemma re-emerges at thebedside, so the ICU admissions protocol is introduced tore-solve it.
In keeping with our theme, the ICU admissions guidelines are intended to benefit both individual patients andgroups of patients. First, the guidelines ensure that individual patients who cannot benefit from intensive care,and who may indeed be harmed by it, are not inappropriately admitted. Second, the guidelines aim to distributeintensive care resources fairly. The guidelines allow intensive care specialists to distribute ICU care consistently, and to supply a reasoned, consensus view for theiradmission decisions. Introducing a consensus based organizational policy distributes the moral burden of difficult decisions, making them as much the responsibilityof the organization, and the clinical professional community, as of individual physicians. But, as we have seen
through Dorothy’s case, the moral pressure points remain.
Attempting to solve the ethical dilemma by using theprotocol has simply transformed the arena of ethical conflict once again. Dispute over what principles should apply has become a dispute over how guidelines do apply,in the instant case. Does this imply that moral conflicthas been transformed into mere procedural disagreement? I think not. Managing admission to ICU remains a
profoundly moral activity. Certainly, the components ofthe moral decision are altered, so that clinical judgment
comes to the fore and abstract moral principles recede to
the background. But it is a judgment with life and death
consequences for the patient. It is a judgment given
structure and shape by prior ethical commitments. And it
is a judgment that invites ethical reflection. The moral
identity of individual doctors, the ethos of the medical
profession, and the moral culture of organizations, are alla product of how these moral activities are managed.
We must remember, too, the argument that ethical decisions are only a small part of ethical action. Applying theprotocol to the instant case to make a decision is only asmall part of the ethical work that needs to be done. Attention must be given to how Dorothy’s admission or rejection is communicated, to her continuing care in lightof the decision, to the needs of her family, and to restoring organizational harmony.
When we conclude our analysis of Dorothy’s story in
the final section, we will see how ethical action is composed of clinical, interpersonal, and ethical skills as wellas ethical knowledge. Before we do so, a second example from my research supplies further evidence of how

Keio J Med 2008; 57 (1): 37－ 44

the health care organization paradox emerges and reemerges at different levels to face medical leaders andorganizations with ethical challenge.
A little background information is required if readers
unfamiliar with the contortions of health care policy in
the UK are to grasp the nature of the problem. Since
1948, when the National Health Service was founded, it
has been a cornerstone of UK health policy that healthcare shall be free at the point of delivery to all UK citizens. The UK population pays for NHS services throughgeneral taxation, and most hospitals are in public ownership. Ever since the NHS was founded, in most geographical areas, and in most specialties, there has been
greater demand for hospital treatment than hospitals
could supply. Because there is a continuing commitment
to free care at the point of delivery, one of the few meansof rationing care has been the ‘waiting list’. Patients
form a ‘virtual’ queue for treatment. By the end of the
1990s, UK patients might wait, for example, for two or
more years for a hip replacement or knee surgery. Rather
differently, patients who attended Accident and Emergency Departments with small accidental injuries (a minor fracture or dislocation, for example) might findthemselves waiting twelve or more hours for treatment.
The time a patient waits for treatment is a moral issue.
Patients waiting for treatment are often in pain or anxious, their condition frequently deteriorates, and they
may face higher health risks when they do eventually receive treatment. It is also a political issue. Determined toreduce the amount of time that patients spend waiting,over the last ten years the Department of Health has set
stringent targets for hospitals to achieve. These havebeen accompanied by financial incentives, and also withpenalties for failure. One target is the ‘four-hour wait’ in
Accident & Emergency departments. The aim is that every patient will have been seen, treated and discharged,
or admitted to appropriate care, within four hours.
The Department of Health believed that paying organizations to meet their targets, and penalising organizations
that failed to do so, would benefit individual patients.
For the government, the moral and political problem of
waiting times was solved. But many doctors and managers feared that if their organization were penalised for
failing to meet particular targets, the penalty would diminish their capacity to provide care to all of their different patient populations. For some, implementing thegovernment’s solution to the moral problem of waiting
lists posed unanticipated ethical choices.
First, was it best to recognise the moral legitimacy of
the targets and to endeavour to meet them, even where
there was a high risk of failure? Striving to meet demanding targets could mean taking organizational resources (time and money) from other equally important
areas of health need, thus disadvantaging some groups ofpatients and distorting local health care priorities. But

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equally, failing to meet the targets could bring organizational penalties that reduced the hospital’s capacity toserve their population (as well as damaging individualcareers). Perhaps it would be better to protect the interests of the organization, and protect the interests of thewider patient population, by merely creating the impression of meeting the targets?
“A lot of people have applied technical fixes to getaround the problem. The technical fix that a lot of people
applied to the A & E wait was to just [create] an area behind the A & E department and say ‘well, that’s not an A
& E!’ At a time when we were struggling to meet that
4-hour target, our A & E [staff] were invited [to see how
other hospitals had solved the problem]. So they went toa few places and came back and said ‘There’s one place,they just painted a line across the corridor ― and thisside’s A & E, and that side’s not A & E!’ You think ‘That
doesn’t really solve the problem at all, what’s that goodfor?’ So we spent quite a lot of time arguing through themorality of this, and of the whole situation. My A & E
colleagues were absolutely adamant they were not [going to apply a technical fix]. One came to say she’dheard a rumour that something was going to happen, andsaid ‘If this happens I’m going to have to resign, I’m really sorry but I can’t work in that way’. Perhaps it went a
bit too far on the moral high ground but they certainly
were not interested in creating some technical fix to thistarget.”Second, ‘the health care organization paradox’ became
evident on those occasions when an individual patient’s
needs threatened to breach the targets. The penalties associated with failure challenged medical leaders to uphold the traditional ethic of making the patient their first
concern, when doing so could potentially work against
the interests of the organization and therefore of the patient population as a whole.
“At times [targets] begin to jeopardize patient care.
That’s where the medical manager role, particularly
Clinical Director but also the Medical Director, is absolutely essential so that you don’t have [hospital] management doing things that end up being fundamentally unethical…A very good example of that would be the fourhour A & E targets. Originally the Department of Healthsaid this target should be fulfilled 100% of the time. If
you sit there as a lay person, you say ‘Surely you shouldbe able to deal with somebody in four hours in Accident
and Emergency, and send them home or admit them tohospital’. You then immediately run into problems, people who are very unstable, very sick, very ill in the resuscitation department of casualty. You’ve got all the kit
there, you’ve got all the equipment there, you’ve got all
the staff there. If you don’t have an intensive care unit
bed to move them to, well as far as I’m concerned they
stay there until you’ve got that sorted. Which could befive hours, six hours, eight hours. That doesn’t matter.

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Shale S: Ethical leadership in health care organizations

What’s important is you’re managing the patient in asafe environment.”
To avoid the ethical tensions, we could simply stop setting targets. But although the Medical Directors in mystudy supplied these examples of the difficulties that targets created, they generally supported their use. The
Medical Directors recognised that in the past, good willalone had not produced an efficient and patient-centred
health service; and that the much debated and widely
disliked ‘target culture’ had by and large improved thepatient experience. Because they accepted the benefits
that could come from working towards meeting their targets, they were also willing to accept the burden of moral
choice with which these targets sometimes confronted
them.
Some components of ethical action
We now return one last time to Dorothy’s story, to consider again what you might do if you were the Medical
Director. From the dozens of examples of moral actionthat Medical Directors in my study have narrated, fourteen dimensions of ‘doing right’ have emerged. Nine ofthem are relevant to managing Dorothy’s case.
1. Nurture moral networks. A significant part of what a
Medical Director must do, he or she must have done before this problem arises. Medical Directors who have notalready earned the moral respect of colleagues are lesslikely to be made aware of difficult issues, or to be consulted regarding their solution. To be thought a source ofmoral authority in difficult situations, they will havedemonstrated their integrity in past moral action. Probably they will have been observed prioritising patient welfare when other matters are pressing; perhaps they are
known for thoughtfully responding to patient complaints;
maybe they are seen always to act fairly in disputes between colleagues. The Medical Director sustained by astrong moral network has additional motive to ‘do theright thing’. And the Medical Director who commands
moral respect is better placed to call on others to ‘doright’ too.
2. Realize the problem. To ‘realize the problem’ maymean appreciating that it is an ethical dilemma, but thisis not always the case. Realizing the problem means understanding that a particular matter needs attention, giving it sufficient priority, and bringing moral awareness tobear upon it. When the resuscitation team telephone to
ask the Medical Director to come down to the ward, theMedical Director faces a choice. Is this a matter thatneeds his attention? Is it more important than other items
on his agenda that morning? Is it an issue that calls for
ethical leadership, so that it would be right to intervene
between the ICU and resuscitation team? Or is it a purely
clinical matter, the sole concern of the clinicians involved in the patient’s treatment? A Medical Director’s

first action therefore is noticing (or not noticing) thatsomething needs to be done.
3. Name the problem. An early step in the Medical Director’s dealing with the problem is recognising ― atleast in a preliminary way ― its components. Dorothy’s
problem obviously has to do with the needs of the patient, the wishes of her family, and the application of the
ICU protocol. For the Medical Director who described it
to me, it had other dimensions too. In part, it reflected
the junior status of the doctors in the resuscitation teamand covering the intensive care unit, who lacked the experience to resolve the conflict themselves; the temporary absence of the senior doctor caring for the patient;and failure to make difficult decisions earlier in the management of Dorothy’s case. It also concerned the Medical Director’s relationships with other hospitals thatmight be asked to ‘import’ his ICU patients. In different
circumstances, the problem could have been an expression of underlying conflict between professional groups.
Or, it could have arisen out of reluctance to implement a
protocol with which some staff disagreed. Each of thesecauses would call for a different management response
from the Medical Director. Such interpersonal issues are
rarely the stuff of philosophical analysis, but they lie at
the heart of day-to-day ethical action in health care settings.
4. Explore potential solutions. Clinical ethics protocols
urge clinicians to identify at least three possible solutionsin the course of ethical analysis. During their interviews,
Medical Directors described how they moved back andforth between the tasks of generating a range of solutions, testing them for ‘fit’, consulting colleagues, anddeepening their understanding of the situation. Some dilemmas, such as the present case, may at first seem topresent only one choice. Should the patient be admitted
to the ICU, or should the patient be cared for on theward? But there are other aspects of the problem that require solution. The Medical Director must also addressquestions around the patient’s continuing care, the needsof the patient’s family, and the restoration of organizational harmony.
5. Analyse moral considerations. Aristotle described as‘practical wisdom’ the work of understanding the moral
dimensions of specific situations, weighing moral considerations in the balance, and coming to a reasoned
moral decision. There are at least five moral considerations in Dorothy’s situation that the Medical Director
needs to weigh. The first must be the ethical obligationto act in the patient’s best interests. Dorothy should neither receive treatment that is too burdensome, nor be deprived of care from which she could benefit. A second
factor is the relationship with Dorothy’s family. Although
Dorothy’s own interests come first, and there is no legal
obligation to do what Dorothy’s family ask, her relatives
have significant moral interests that have to be taken into

Keio J Med 2007; 57 (1): 37－ 44

account. A third factor is the responsibility not to waste
resources that cannot benefit Dorothy but could benefit
others. Continuing to treat Dorothy, as her family haverequested, may do her no harm. But if it does not benefit
her either, the resources could be better used for other
patients. The fourth factor is the relationship with thehospitals that the Medical Director relies upon to ‘import’his ICU patients when necessary. This reciprocal relationship may be jeopardized if he ‘exports’ patients too
frequently, particularly if his ICU admits patients outsideof the national guidelines. Finally, the Medical Director
will be aware of the organization’s need to meet the government’s target for waiting times in Accident & Emergency. If there are no beds available in the ICU, the A&E
may find itself holding patients who need critical carebeyond the four-hour time limit. ‘Practical wisdom’ requires that the Medical Director weighs all of these factors, decides which should take priority, and considers
how, if possible, any negative consequences can be minimised.
6. Coordinate group action. One of the tasks of leadership is to decide whom to involve in addressing a problem. Health care organizations are dense networks offormal and informal obligation. In this situation, there
are people (such as the senior doctor responsible for thepatient) who should be involved because of their formal
role; and there will be others affected (such as the resuscitation team) for whom the outcome is morally important. ‘Doing right’ in these circumstances entails directing the ethical activity of the group. The senior doctor
should be present to discharge her responsibility to herpatient. Someone must consult the family, and give acompassionate explanation of what is happening. The
voices of those morally interested should be heard. Thistakes us to the next dimension of moral action.
7. Hear the person. It is a profound moral act to listen
deeply to the expression of emotions such as anger, fearor grief. Giving full attention to strong negative emotion
takes courage and self-discipline, but it is an importantcomponent of moral relationships. Distress grows whenpeople feel that those who should be listening to them
are not doing so. Distress quietens when people feel they
are being listened to without being judged. The ethic oflistening allows difficult things to be said. It is throughcareful listening that both speaker and the listener cancome to understand the true moral meaning of their situation and thus engage as moral equals.
8. Give an account. Difficult ethical dilemmas arethose where we are confronted not with a choice between
right and wrong things to do, but between right and rightthings to do. In Dorothy’s case, some of those affected or
consulted will almost certainly disagree with the outcome. Medical Directors in my study emphasised theethical importance of giving an account of, and being
held to account for, their decisions. In Dorothy’s story,

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the ethical action would not be complete without athoughtful explanation to the resuscitation team, the ICU
team, and the family, about why Dorothy was or was not
admitted to the ICU. The giving of a true account is morally important because it fulfils a foundational humanneed for authentic social interaction. Just as there is an
intrinsic moral good to be found in proper listening, so
there is an intrinsic moral good to be found in giving afull explanation of one’s actions.
9. Undertake moral reflection. Learning from difficult
situations is a means of redeeming them. Medical Directors emphasised in their interviews the moral gravity ofthe dilemmas they had faced, and some treated the senseof unease that occasionally remained with them, as anintegral part of their ethical identity. Some recounted aprocess of reflection, during which they reconsidered
their ethical performance and reassessed their ethicalcompetence. The final part of ethical action, then, is considering its meaning and effects. The last of your tasks as
Medical Director will be to prompt ethical reflection inyour teams, and to consider your own conduct.
Conclusion
I started this paper arguing that moral action is as important as moral reasoning, that ethical health care organizations are as important as ethical doctors, and thatneither has received sufficient attention in medical ethics. I noted the paradox at the heart of health care organization, where serving the interests of groups seems
sometimes to cut across the interests of individuals. I argued that the paradox presents ethical dilemmas at every
level of the organization, from the boardroom to the bedside. Furthermore, because the paradox is integral tohealth care organization, I suggested there can be no lasting solution to any of these ethical dilemmas.
I suggested that the first task of the ethical health careorganization is to secure the trust of patients, and that all
further ethical action takes place in the context of thisprimary task. I then demonstrated through two examples,
ICU admission and organizational performance targets,
how problems addressed at one level of the organization
re-emerge in slightly altered form in another. Finally, I
considered how nine of the components of moral actionthat have been identified in interviews with Medical Directors were relevant to resolving a typical ethical problem arising out of managing ICU admissions.
In carrying out my research I have relied upon the generosity of the Medical Directors who agreed to be interviewed. They made time to meet me in the middle of impossibly demanding daily schedules, and gave considerable thought to the questions that I asked them. It is theirexperiences and insights that have informed this discussion. It seems fitting that this paper should conclude,
then, with the reflections of the Medical Director who

44

Shale S: Ethical leadership in health care organizations

supplied the example that I have written up as Dorothy’s
story.
“The trouble is, that when you’re implementing healthpolicy, you’re playing the percentage game. You think
about how difficult that is, from time to time.
If someone is going to go into intensive care, andthere’s a ninety to ninety five percent chance they’re going to die, the intensivists will feel that’s inappropriate.
And that’s supported by the national frameworks. If I
now said to you, ‘I’ve got your nearest and dearest here,
and there’s a ninety to ninety five percent chance they’regoing to die’ you’ll turn round to me and say, ‘But thatmeans there’s a one in ten, one in twenty chance that if
you take them to intensive care they’ll survive’.

EndnotesThat’s the problem isn’t it? It’s those individual things.”

*5

*1
*2
*3

*4

Acknowledgements
This research has been made possible through the generous funding of the Wellcome Trust, London. I am also
grateful to the Daiwa Anglo-Japanese Foundation forsupporting the visit to Keio Medical School throughaward of a Small Grant. The study received ethical approval from a National Health Service Research Ethics
Committee in September 2006 Reference No. 06/Q
1606/105.

*6References
1.
2.
3.
4.

Calnan M, Rowe R: Trust relations in health care - the new agenda. Eur J Public Health 2006; 16: 4－6.
Report of a Working Party - Doctors in Society: Medical Professionalism in a Changing World, Royal College of Physicians,
2005, p 66.
Rubin HJ, Rubin IS: Qualitative Interviewing. Thousand Oaks,
California, Sage, 1995.
Strauss A, Corbin J: Basics of Qualitative Research: Techniques
and Procedures for Developing Grounded Theory. Thousand
Oaks, CA, Sage, 1998.

*7

This story is derived from an example provided by a research participant. The patient’s name is fictional.
Calnan M, Rowe R: Trust relations in health care - the new agenda. Eur J Public Health 2006; 16: 4－6.
This is not invariably true. In the case of chronic conditions, forexample, the primary purpose for the consultation may be to gain
access to medical technologies or medication. The patient often
knows more than the practitioner about their condition, how it affects them, and how it is best alleviated.
In the UK these include the medical Royal Colleges, the General
Medical Council, the Postgraduate Medical Education and Training Board, the Healthcare Commission, the National Clinical Assessment Authority, the National Patient Safety Agency, the National Institute for Health and Clinical Excellence, Local Research
Ethics Committees, and of course health care providers themselves through clinical audit.
The UK Royal College of Physicians argues that just as trust operates at the level of both the individual doctor and the institution,
so does professionalism. The individual professionalism of individual doctors depends upon the institutional professionalism of
the organization and vice versa. Report of a Working Party - Doctors in Society: Medical Professionalism in a Changing World,Royal College of Physicians, 2005, p 66.p15
Primary Care Trusts (PCTs) in effect direct the budget for healthcare services for a defined geographical population. They contract
for primary care from General Practitioners and commission secondary care from hospitals, and hold a budget for prescribing.
General Practitioners run their practice as a private business partnership, and are paid for the services they provide according totheir contract with the PCT. Hospitals are paid for the treatment
they carry out, reimbursed at a national tariff and according to
numbers agreed with the PCT. It is the role of the PCT to ensurethat adequate services are available to the population, to enforce
standards in GP practices, and to co-ordinate public health activities.
Each has participated in a single conversational-style, semi-structured interview lasting between 90 minutes and 2 hours. Interviews have been recorded and transcribed verbatim, and then analysed using the software package Atlas ti. In accordance with theprinciples of grounded theory, analysis is taking place concurrently with data collection. Emergent themes and concepts are being
elaborated and clarified through subsequent research activity. As
the data set expands, findings are being comparatively analysed
for internal consistency through the processes of coding and thematic categorization. Rubin HJ, Rubin IS: Qualitative Interviewing. Thousand Oaks, California, Sage, 1995. Strauss A, Corbin J:
Basics of Qualitative Research: Techniques and Procedures forDeveloping Grounded Theory. Thousand Oaks, CA, Sage, 1998.