A value-based approach to leadership by physicians and other health care professionals has not been addressed systematically, although it seems to be important. This paper introduces such a principled approach, using a selective literature review and conceptual analysis, as well as illustrations from physician leadership experience. This approach prioritizes, in a context-sensitive non-formulaic way, three (sets of) values: being person-centred, being evidence-informed and being socially responsible. Research exploring and examining this approach would be helpful.
Successful health care requires effective leadership, including effective physician leadership (Taylor 2011). Various approaches to facilitate effective leadership in general and, more specifically, in health care have been described with some evidence to support them (Mintzberg 2009). However, there is a need for far more rigorous empirical research on leadership in health care, partly because counter-intuitive findings have emerged from such research. For example, senior leadership’s consultative engagement with frontline workers was found to be somewhat disruptive (Hanna 2010). Yet, health care’s prime rationale is to improve people’s lives as an end in itself. This is so even in regimes such as that of the United States where there is no universal health care. Hence, values are fundamental in health care. Top
Various approaches to health care values (and their ethical prioritization when they are in conflict) have been described and analyzed in relation to health care practice. Perhaps the most common approach in this regard is principlism (Beauchamp and Childress 2012), which upholds four general values: autonomy (respect for persons), beneficence (most benefit to persons), non-maleficence (least harm to persons) and justice (fairness to persons). A similar approach to health care leadership has not been addressed systematically, although it seems to be important. This paper introduces such an approach, using a selective literature review and a conceptual analysis, as well as illustrations from physician leadership experience.
There are different types of values. Most famously, there are moral values, such as the importance of treating others as one would treat oneself (the golden rule). There are also epistemic values, such as the importance of truth and, as a key part of that, the importance of evidence (Haddock et al. 2009). Using these two key types of values, I am introducing a value-based approach to health care leadership — including physician leadership. Note that what I refer to below as being means intending to act (in a certain way), as the ethics of acting unrelated to intention (utilitarianism and more) and as the ethics of intending unrelated to action (deontology and more) may each be inadequate.
The first value of this approach is the importance of being person-centred. This is similar to the first three values of principlism (autonomy, beneficence and non-maleficence), but can be interpreted more broadly. It can be viewed as consisting of the importance of being person-driven, which refers to the person as the decision-maker about his or her care; person-focused, which refers to the person as the intended beneficiary of care; person-sensitive, which refers to care as addressing particular needs of the person; and person-contextualized, which refers to care as considering the person’s history and current circumstances (Rudnick and Roe 2011). This multidimensional value is demonstrated in relation to health care leadership in systems planning that is based on patient inputs, on individual needs as well as population needs and on consideration of specific — hence varying — circumstances. Top
The second value is the importance of being evidence-informed. This epistemic value is not captured in principlism, which addresses only moral values. It is addressed by other approaches, such as standard hierarchies of evidence-based health care, which state that systematic reviews and randomized controlled trials (RCTs) result in the most sound health care evidence, while less well controlled studies result in less sound evidence and case reports and other anecdotal reports, such as individual or group statements that are based on opinions rather than studied facts, constitute the least sound health care evidence (Guyatt et al. 2000). It has been recognized recently that such hierarchies are problematic, because, for example, they give little or no weight to evidence from the “grey literature” and first-person accounts of patients and others involved, even though these sources of information are useful too, e.g., to evaluate feasibility and appropriateness (Evans 2003). This multilayered value is demonstrated in health care leadership in program evaluation that is informed by patient views and uncontrolled evaluations, such as plan-do-study-act (PDSA) cycles (Langley et al. 2009), in addition to RCTs when the latter are feasible.
The third value is the importance of being socially responsible. This is similar to the fourth value of principlism (justice), but can be interpreted more broadly. It can be viewed as consisting of the importance of being fair to all stakeholders, fiscally prudent, legally accountable and otherwise socially responsible. This multidimensional value is demonstrated in relation to health care leadership in policymaking that addresses all these dimensions as relevant. Top
When acceptable values conflict, decision-making must prioritize them to be ethically sound (Rudnick and Wada 2011). Principlism suggests a primarily context-sensitive, non-formulaic prioritizing of its four values. What could the principled approach to health care leadership suggest in relation to prioritizing its three values? Arguably, principlism’s suggestion would be relevant here too, as there may not be a universal way to rank being person-centred, evidence-informed and socially responsible. Indeed, the values of being person-centred and socially responsible are similar enough to the four principles of principlism that it may be self-evident that principlism’s suggestion applies to them too.
In terms of prioritizing, some situations are typically clearer than others; e.g., where many people may be harmed by one person, being socially responsible usually trumps being person-centred (hence utilitarianism’s common use in public health situations). In regard to ranking being evidence-informed against the other two values, principlism is not informative, as it does not address epistemic values. Arguably, evidence is a necessary but insufficient means to an end — delivering effective care, as evidence clarifies whether care is effective or not. Hence, the need for evidence regarding the effectiveness of health care should not be ignored, although the type of evidence needed is debatable, as argued above, and may be context-sensitive and not determinable by a formula. Thus, prioritizing the three values of this principled approach to health care leadership in a context-sensitive, non-formulaic way may be appropriate. How would such an approach manifest in a concrete situation? Top
Let’s imagine a (not uncommon) situation in which a health care intervention is deemed valuable by service users and staff, but there is no robust evidence that it is effective or even safe. This is the case for many, if not most, group counseling interventions in mental health care, such as for depression (Huntley et al. 2012). What should physician and other health care leaders do in such a situation, using the value-based approach introduced above?
I would argue that all relevant evidence should first be reviewed thoroughly. If the available evidence is promising, e.g., there are no published RCTs in this area, but less-rigorous research mainly shows positive findings, the leadership may be expected to support further empirical evaluation of — and possibly full-fledged research on — this intervention. On the other hand, if the available evidence is not promising, e.g., RCTs and one or more related systematic reviews in this area mainly show negative findings, the leadership may be expected to communicate their lack of support for this intervention and to lead a culture shift so that service users and staff endorse the need to conduct other, more effective and possibly safer interventions.
This example highlights the prioritization of person-centredness when relevant evidence is not clear and the prioritization of social responsibility when relevant evidence is clear (and shows that being person-centred would not be effective, other than perhaps for service satisfaction).
The value-based approach to physician (and other health care) leadership introduced here prioritizes, in a context-sensitive, non-formulaic way, three values: being person-centred, being evidence-informed and being socially responsible. Theoretical and empirical research is required to further explore and examine this approach, including its advantages and challenges, as well as its practical implications and its evidence base. Top
Dr. Rudnick, MD, PhD, FRCPC, CCPE is associate professor, Department of Psychiatry/Centre for Applied Ethics/Island Medical Program, University of British Columbia, and medical director/head, Mental Health and Substance Use Services/Psychiatry, Vancouver Island Health Authority.
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