Thoughts on supporting healthcare ethics leadership, by the editors of Impact Ethics

Abstract

Impact Ethics (www.impactethics.ca) is a Canadian bioethics blog with a diversity of contributors who come from a range of backgrounds – from academics and clinicians to activists and concerned citizens. Our authors are also diverse with respect ethnicity, race, culture, and gender. We publish commentaries about ethical issues in healthcare that affect Canadians. As editors of the blog and as practicing healthcare ethicists, we make note of three crucial determinants of leadership in healthcare ethics. First, leadership in healthcare ethics requires building relationships with other leaders, including those who do not hold formal leadership roles. Second, it is essential for leaders to be open to learning new knowledge and to learning about new practices in healthcare ethics. Third, leaders must have an orientation towards the future, which means building capacity for healthcare ethics within their organizations. The Impact Ethics blog can be used to support each of these determinants of ethics leadership.

Introduction

An influential colleague was once fond of saying that while it is important to “do the right thing,” it is also important to “do the thing right.¹” What he meant was that ethics is as much about engaging in an ethical process as it is about making the right decisions. While health leaders may want to do the right thing, the right decision is not always clear. There might be a range of justifiable courses of action or disagreement about which ethical values are most important for any given issue. For example, during the COVID-19 pandemic, healthcare organizations faced ethical challenges related to mandating vaccines for workers against pandemic disease¹ and struggled with difficult decisions about critical care triage,² about fairness in public health measures,³ and about niche issues such as how to ethically manage high-risk pregnancies in the midst of the challenges of a pandemic.⁴ For these issues and others, both an ethical process and outcome matter for ethical decision-making. Deliberation about ethical issues is unavoidable in healthcare.

Discussion

While ethicists can help to support ethical decision-making, many organizations do not have access to a clinical or organizational ethicist. Decision-makers including senior leadership, directors, managers, and providers who are trying to “do the right thing” might seek input from multidisciplinary ethics committees that are not staffed with a trained ethicist, or they might rely solely on their own moral values, or look for publicly available ethics resources and tools.

We are the editors of the Canadian bioethics blog Impact Ethics (www.impactethics.ca)—a publicly available ethics resource. Impact Ethics is a forum where ethical issues in healthcare are discussed. It was established by the Novel Tech Ethics research group at Dalhousie University (Nova Scotia) in 2013. Since 2019, it has been hosted by the Memorial University Centre for Bioethics, based in St. John’s, Newfoundland and Labrador.⁵ We post well-written and well-reasoned commentaries about current and emerging issues in bioethics that affect Canadians. Our authors come from a variety of backgrounds: academics, clinicians, activists, students, and concerned citizens. They are also a diverse group with respect to ethnicity, race, culture, and gender. The commentaries are short, limited to 800 words, but they link to sources with more detail. Our contributors highlight ethically contentious issues that health leaders, as well as healthcare providers, and the public, should think about. Our hope is that these commentaries can help to encourage healthcare organizations and other public institutions to be more responsive, accountable, and just.

As the name of the blog suggests, we want our commentaries to have an impact. By disseminating ethical reasoning through this forum, we hope to spark discussion and to influence the course of ethical deliberation among members of the public, and among empowered decision-makers. As captured by our mission statement, Impact Ethics is about “using the tools of ethics to shock, press, crack, and chip society into a better place. It is about outcomes and ordering the study of ethics around changing things for the better.”⁶ People in leadership positions in healthcare can influence how ethical issues play out and affect people. Leaders (including those who are not in formal leadership positions) can influence change. In our view, there are, at minimum, three crucial determinants of leadership in healthcare ethics: building relationships with other leaders, an openness to learning new knowledge or practices, and a commitment to building ethics capacity within an organization. Impact Ethics aims to support healthcare ethics leadership in each of these ways.

First, with respect to building relationships, Impact Ethics embraces diversity, openness, and transparency in ethical reasoning. Our hope is that leaders in healthcare will find opportunities as authors or readers of the blog to identify others who are like minded or share common ethical challenges and goals. As one of the few Canada-wide forums for healthcare ethics, this blog offers a space to help leaders find one another to connect. Some Impact Ethics commentaries can also help us to think differently about the nature of healthcare ethics leadership. For example, insofar as ethical obligations can require change, some authors argue that this change happens “through relationships with people who trust each other, are open to new ideas, and are willing to think and act differently.”⁷ We know that helping people to “do the thing right” can be difficult, but also that change often happens incrementally and through the building of relationships.

One part of bringing about positive change within a healthcare organization is the discovery of new knowledge—our second determinant of healthcare ethics leadership. Such discoveries can help people to think or feel differently about an ethical issue, which can then lead them to doing things differently. Our blog supports such discoveries by making short, well-reasoned commentaries publicly accessible. Some additional examples of commentary topics include assisted reproduction; disabilities; end-of-life issues; genetics; research ethics; Indigenous health; long-term care ethics; organ donation; pediatrics; pharmaceuticals; and public health. By thinking differently and by doing things differently, healthcare leaders can help to guide change among their colleagues and communities. Those who are situated to be agents of change might also feel enriched by sharing and discussing new ethics knowledge. A typical Impact Ethics commentary is comprised of an argument that provides a perspective on a current issue in bioethics. A commentary is not a briefing note, or a summary of points for and against. Health leaders or ethics committees who read our blog might not arrive at the same conclusions as our authors, but there’s value in raising issues for critical discussion. The consideration of reasons and an openness to new knowledge are essential components of an ethical decision-making process.

In this way, “doing the thing right” requires building capacity for ethical deliberation in healthcare—our third point about leadership. In our careers, we have encountered more than one upper-level manager in healthcare who kept an eye on potential “trouble” by consistently reading ethics consultation reports, or by having regular meetings with their ethics committee. These are good practices in organizations with clinical ethicists on staff as well as in those without. For example, are health leaders able to spot emerging controversies in long-term care?⁸ Medical Assistance in Dying (MAiD) provides another example. The law on MAiD seems to be constantly changing, and new ethical controversies are always emerging, requiring updates on policy and practice.⁹

While leaders need to be competent in their ethical reasoning, healthcare organizations also benefit from leaders for whom ethics is specifically their mandate. Not every organization has access to ethicists, but every organization is required to have a framework or an approach for managing ethical challenges. Such ethics frameworks can be easier to manage when an ethicist is available. And professional ethicists themselves need support and opportunities to develop their skills. As part of professional development, ethicists need to examine and be transparent about their own goals, priorities, and funding. Healthcare ethicists should make their ethical arguments and reasoning accessible to their audience and evaluate the institutional role of bioethics “in society’s shared moral endeavor.”¹⁰ Over the years, Impact Ethics commentaries have considered the need for an explicitly Canadian form of bioethics¹¹ and have discussed how bioethics can make a positive difference in the world.¹²

Conclusion

In general, we think that effective healthcare leadership depends on relationships. Professional bioethicists, leaders, mentors, and students alike need ways to connect to build these relationships. The Impact Ethics blog is an inclusive forum for sharing ideas about ethical issues in healthcare and in the life sciences. It is a space that’s dedicated to diversity—in ideas, in authorship, and readership. It serves to help change bioethical issues for the better. Our hope is that Canadian health leaders of all kinds will see the blog as an important resource for the development of principled leadership, making connections, and as helpful for “doing the thing right.”