Leadership and Ethics: Virtue Ethics as a Model for Leadership Development

Abstract

Leaders are held to the highest of standards in both performance and ethics. The same is true for leaders in medicine. Thus, medical leaders must give attention to ethical development as well as performance development. Virtue ethics provide a way for the leader to develop ethically. Virtue ethics is the oldest form of ethics. Although other ethical approaches focus on external considerations, virtue ethics focuses on the inward development of character. Following the examples of virtuous people and developing habits of virtue are critical with this approach. The cardinal virtues of prudence, courage, temperance, and justice are considered the most important. Specific virtue lists have also been developed for medical practitioners. All of these virtues can contribute to the enhancement of leadership skills. The virtue approach is especially helpful for leaders because it motivates one to excel in whatever endeavor pursued, whether medicine, leadership, relationships, or life.

To be a leader is to be held to high expectations. Leaders are expected to be effective in casting a vision and in motivating others to fulfill that vision. They are expected to overcome obstacles, stay the course, and get things done. A leader's worth is measured by her accomplishments.

To be considered a true or good leader, however, requires fulfilling these performance expectations in morally acceptable ways. In fact, in popular use, the word leader almost always includes the ethical component as well as the performance component: “The question, ‘What is a leader?’ is really the question ‘What is a good leader?’, with good including both a morally commendable, normative component as well as a pragmatic, performance-oriented component.” ¹ A worldwide survey identified desirable leaders as not only those who are able to motivate others but also those who are trustworthy, just, and honest. ^{1 (231)} Thus, to be a leader is to be held to high expectations in regard to both performance and ethical behavior. As a result, leaders must give attention to ethical development as well as performance development.

What is true for leadership in general is also true for leadership in medicine. Medical practitioners in leadership roles are held to equally high expectations in both performance and ethics. In medicine especially, the ethical expectations placed on a leader can in no way be avoided: “Leaders in health care must understand their role in creating an ethical environment that is honest and just. If you are in charge, you have an ethical responsibility to establish standards of conduct and a culture of integrity across your spheres of influence.” ² Therefore, leaders in medicine must give as much attention to ethical development as they do to performance development, if not more.

One could even make the case that all medical practitioners are leaders, at least to a point, given their task of leading their patients to act in ways that improve their health. Thus, what is said about medical leaders in this article has application to all medical practitioners. In medicine, ethical development cannot be ignored: “Doctoring is through and through an ethical enterprise.” ³

There are numerous ways of approaching ethical development in medicine. One of the most popular, and the one often used in medical schools, is the principles approach of Beauchamp and Childress. In their book, Principles of Biomedical Ethics , they discuss the bioethical principles of autonomy, beneficence, nonmaleficence, and justice and give examples of how these principles would apply in the clinical setting. ⁴ However, while principlism provides a foundation for patient-care decisions, one must turn elsewhere for help in developing ethically as a leader.

This article recommends a virtue approach for the ethical development of leaders. Although principles are external guidelines to be followed, virtues are internal dispositions to be developed. The purpose of this internal development is to produce a person who consistently responds to events in a morally praiseworthy manner. As a result, virtues are ideally suited to leadership development due to the high ethical expectations placed on leaders, especially as they work in high-pressured situations. To explain, this article will first provide a brief history of the virtues, next it will examine how virtues work generally, then it will describe the role of virtues in medical practice, and finally, it will apply virtue ethics to leadership development.

A Brief History of the Virtues

Virtue ethics began with the Greeks and especially with Aristotle (384 BCE–322 BCE) who provided the most extensive development of the virtues in antiquity. The ethical question was: How can humans be happy or flourish (eudaimonia) over the course of a lifetime. The answer was by developing virtues, the most important of which were prudence (wisdom), courage, temperance (restraint), and justice. These were called the cardinal virtues and all other virtues were organized under them. By conforming one's internal self to the virtues, one would respond to external events in a good, virtuous way, and thus achieve eudaimonia or happiness throughout one's life. This was the main way the ancient Greeks thought about ethics or morality, but there were many variations.

During the Middle Ages, Thomas Aquinas further developed Aristotle's system. Though Aquinas (1225–1274) approached Aristotle from a Christian perspective (he was a Catholic priest), his development was as much philosophical as theological. His work continues to exert much influence on virtue ethics to this day.

With the modern era, virtue ethics fell out of favor and the focus shifted to ethical systems based on duty (deontology) and consequences (consequentialism). A duty-based system recognizes external rules or obligations as ethically binding on the individual. These external obligations could take the form of the Ten Commandments, the recognition of human rights, or the bioethical principles of autonomy, beneficence, nonmaleficence, and justice. A consequences-based system attempts to determine what actions will bring the greatest good for the greatest number of people. Political decisions are often made on this basis, for example: How can we benefit the most people with the limited funds we have? It is important to note that while these approaches do not deny the value of character formation, their focus is on ethical considerations that are external to the individual, which is different from the internal focus of virtue ethics.

As is so often the case in areas of human endeavor, the pendulum has swung back to a renewed focus on virtues. To be sure, duty-based systems (e.g., Kantianism) and consequences-based systems (e.g., Utilitarianism) remain important, but the virtues-based system of Aristotle and Aquinas now commands significant attention. ⁵ This can be seen in philosophy, sociology, business, and in popular works dealing with character formation. This can also be seen in medicine, though the pendulum here is swinging rather slowly.

Virtue was once the main ethical focus in medicine, but that has changed: “In the early 20th century, the physician was viewed as a man of character, whereas in the 21st century, the physician is viewed as someone with characteristics, such as competence.” ⁶ This change in how physicians are viewed has multiple causes: the cultural ascendancy of science, the increasing technical expertise required of physicians, and high-profile cases where physicians performed poorly, to name a few. Equally to blame has been the bioethical focus on quandary ethics, that is, how to resolve perplexing medical dilemmas. ^{3 (viii)} This gave rise to approaches such as principlism, but it ignored the development of the medical practitioner's character. Recently, however, there have been calls for a restoration of virtues in medical ethics, though the success of these calls remains to be seen. ^{3 7} We will consider some of these calls later when we consider how virtues work in medicine. For now, we turn to a discussion of how virtues work in general.

How Virtues Work in General

Virtues are often equated with values or character traits, and while there are similarities, virtues are fundamentally different: “Virtues, like traits, are dispositions to behave a certain way but, unlike traits, virtues are intentionally selected, deliberately strengthened, and behaviorally predictive.” ^{1 (234)} In other words, values are what a person considers important and traits describe a person's natural nature. For example, we might say, “I think patience is important,” to share a value, or, “She is so easy-going,” to describe another's naturally patient disposition. Both values and traits will influence actions. On the contrary, virtues are consciously chosen and worked at. I decide to be a more patient person, and I work at being more patient. In this case, patience would be considered a virtue, and it will impact my behavior as much as if not more so than values or traits.

Aristotle described two ways for developing virtues. First, after determining to develop a particular virtue (or virtues), one selects an exemplar, someone who models the virtue, and then emulates that person in his demonstration of the virtue. Of course, this would need to be someone that one can observe frequently. Examples would include a mentor, close friend, work associate, or teacher. Consciously imitating others is a powerful way to change behavior.

Second (not necessarily in order), one works to make the desired virtue a habit until it becomes habitual, that is, one's consistent, unthinking response. The idea is similar to physical actions. For example, if you try to think about the mechanics of a good golf swing while swinging, your swing will not be very good. The swing occurs too rapidly for the mind to think about and direct each aspect of the swing. However, as the mechanics of a good swing become habitual, your swing will be a good one.

In a similar way, one develops virtuous behavior. Continuing with our previous example, let us say you decide to develop the virtue of patience. In addition to observing someone who models patience, you consciously work to behave in patient ways. When your assistant says an important meeting was canceled at the last minute, instead of expressing your displeasure, you mindfully respond in a calm manner. The more you behave in a calm way to unpleasant news, the more it becomes second nature or habitual, like a good golf swing. Or when you are listening to an unnecessarily long explanation from someone else, instead of looking at your phone or cutting them off, you mindfully remain attentive until they are finished. The more you behave in this way to others, the more it becomes habitual. In time, one's internal makeup becomes conformed to the virtue of patience and patience becomes one's consistent, unthinking response.

Admittedly, the Aristotelian-Thomistic virtue tradition is more complex than this. It involves the role of reason in defining what it means for humans to flourish. It includes a lengthy list of virtues, describes how they work together, and especially how they all work with prudence (wisdom). It also develops the social nature of humans in considerable detail. All this can be explored further; what we have provided here is sufficient to get someone started down the path of virtue development. At this point, we turn to the role of virtues in medical practice.

The Role of Virtues in Medical Practice

Two concerns form the basis for the role of virtues in medical practice. The first is the need for virtues in providing a complete ethical approach for the medical practitioner. Pellegrino and Thomasma write:

While incomplete, a principle-based ethic nonetheless has much to offer, not the least of which is its freedom from the slavery of the moment in favor of a more universalizable view. Standards and guidelines against which individuals, institutions, and society can measure their actions are necessary. But they must be linked to a virtue-based ethic if a more complete picture of the moral life is to be obtained. ^{7 (xi)}

In other words, while the principles approach provides a needed foundation for making ethical decisions in medicine, principles by themselves are not enough. Virtues are also needed to provide the comprehensive ethical approach needed by the medical practitioner. This is especially seen in the clinical setting: “In that setting it is obvious that the way principles are selected, interpreted, ordered in relation to each other, and applied, is dependent on the character of each participant in a clinical activity.” ^{7 (xi)} Thus, virtues enable the physician to select which principles apply in various situations, supply insight for understanding the principles, and give appropriate weight to the most important principle when principles conflict. This provides a complete ethical approach for the medical practitioner.

The second concern providing the basis for the role of virtues comes from reflection on the doctor–patient relationship. Drane writes that this relationship is “a form of human encounter characterized by help” which involves “a certain closeness or relationship.” ^{3 (21)} From the time of Hippocrates through the Christian era and into the modern period, this relationship has been examined. Drawing on this foundation, Drane concludes that certain virtues are necessary for a good doctor–patient relationship and defines them as benevolence, truthfulness, respect, friendship, justice, and religion. The two that stand out in this list, no doubt, are friendship and religion. The virtue of friendship calls for doctors to have a genuine affection for their patients, and the virtue of religion calls on doctors to be prepared to talk with their patients about spiritual issues. This last virtue is needed (1) because when faced with death, patients will often look to their doctors for help, and (2) because of the priestly status of doctors in contemporary culture. Drane is not saying that doctors should be religious themselves (although it helps) but that they should be prepared to have such discussions and, at the least, point their patients to those who can help when death is looming. ^{3 (119)}

Pellegrino and Thomasma also examine the doctor–patient relationship and define the virtues needed as fidelity to trust, compassion, phronesis (wisdom), justice, fortitude (courage), temperance (restraint), integrity, and self-effacement (humility). While these lists are different, they are not as different as they may at first seem. What is important is their agreement that virtues are needed for a good doctor–patient relationship. For these two reasons, then, virtues play a critical role in medical practice. As Pellegrino and Thomasma observe:

Principles and duties are the letter of medical ethics. It remains to virtue to live according to the spirit of medical ethics, which has been and should remain focused on the good of the sick person. Principles and duties enable physicians to do good, but virtues enable them to be good, to make the difference that can make a competent professional a noble one. ^{7 (173)}

Appling Virtue Ethics to Leadership Development

As the previous section makes clear, this author advocates virtues for the ethical development of all medical practitioners. In this way, as Pellegrino and Thomasma contend, physicians can both “do good” and “be good,” which leads to a professionalism described as “noble.” Thus, the application of virtue ethics to the development of medical leaders simply takes what has been previously said to a higher level.

Given the expectations mentioned earlier that a leader must be professionally as well as ethically competent, virtue ethics provide a way for a leader to grow ethically much like she grows professionally. For example, finding an exemplar to imitate ethically is much like finding a mentor to imitate professionally, and working to develop a habit of virtue is much like working to develop a habit of a good leadership trait. So, the development of virtues fits well with the development of leadership skills.

An additional reason for motivating a leader to incorporate virtue ethics are the research indicating that virtues can contribute to effective leadership overall. In their book, Character Strengths and Virtues , Peterson and Seligman make the case that virtues such as wisdom, courage, temperance, and justice go hand-in-hand with effective leadership. ⁸ All the more reason, then, that leaders should adopt virtue ethics.

Yet, another reason for leaders (and others) to incorporate virtues is because virtue ethics motivate one to be the best person he/she can be. The Greek word for virtue (arête) can also be translated “excellence.” Thus, Aristotle considered the virtues to be the excellence of character, and thus, a virtuous person is one who seeks excellence. Pellegrino and Thomasma explain:

In this view, virtuous persons are distinguished as agents, and their acts as well, by a capacity to be disposed habitually not only to do what is required as duty but to seek the perfection—the excellence, the arête of a particular virtue. Virtuous persons … see themselves as bound to act as excellently as possible in achieving their ends …. The virtuous person is impelled by his virtues to strive for perfection—not because it is a duty, but because he seeks perfection in pursuit of the telos of whatever it is he is engaged in. He cannot act otherwise. It is part of his character. ^{7 (166)}

Being a medical leader means being called to a higher standard, if not perfection then close to it. Virtue ethics enable one to rise to that standard, both ethically and professionally. Thus, it is hoped that more leaders will embrace the virtues as a means to achieving excellence in leadership.