Self-Assessment of Leadership, Collaboration, and Ethics

Ethical decision-making in a caring

environment: The four principles and LEADS by Dan Levitt, MSc, CHE

Autonomy, beneficence, non-maleficence, and justice, often referred to as The Four Principles have canonical status within the field of medical ethics. Tom Beauchamp and James Childress originally devised the standard theo- retical framework for healthcare ethics in their definitive 1979 textbook Principles of Biomedical Ethics as a method for analyzing ethical dilemmas in clinical medicine.1 The Four Principles are defined as follows:

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Autonomy: The principle that each individual has the right to make his or her own choice, which forms the basis for the practice of informed consent in the physician-patient relationship regarding the provi- sion of healthcare.

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Beneficence: The principle of acting with the best interest of the other in mind, it is the basic premise that healthcare providers have a duty to be of a benefit to the patient as well as to take positive steps to prevent harm from the patient.

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Non-maleficence: The principle is that “above all, do no harm,” as stated in the Hippocratic Oath, the fundamental commitment on the part of healthcare professionals to protect their patients from harm.

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Justice: The principle emphasizes fairness and equal- ity among individuals as both procedural justice and distributive justice form the foundation from which scarce healthcare resources are provided in an egalitarian method.

The Four Principles provide the foundational methodology for analyzing ethical situations. When there are 2 or more

the Executive Director, Tabor Village; Adjunct Professor, Department ntology, Simon Fraser University. esponding author: Dan Levitt, MSc, CHE, Tabor Village, 31944 Sunrise t, Abbotsford, British Columbia, Canada, V2T 1N5. ail: [email protected]) are Management Forum 2014 27:105–107 04/$ - see front matter Published by Elsevier Inc. on behalf of the Canadian College of Health . x.doi.org/10.1016/j.hcmf.2014.03.013

ethical principles in conflict, the theoretical framework provides a structure to guide decision-making. For example, the principles of beneficence and justice clash where a patient medically requires treatment and the healthcare resource is not available within the clinically acceptable waiting time threshold. Since 2004, when the first ministers agreed to establish wait time indicators for priority areas related to joint replacement, sight restoration, cancer, heart, and diagnostic imaging, wait times have become viewed as widely accepted as proper goals of the healthcare system. Access to healthcare services is a factor that contributes to differences in health. Improving access to care and reducing wait times are prominent health policy issues in Canada and many other countries.2 In the case of accessibility, which is one of the 5 principles of the Canada Health Act, waitlists time thresholds are not only the goal of providing benefit to individual patients but also to the good of society as a whole. Consider the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large. The principle of beneficence is at the very heart of the health- care system, implying that a suffering patient can enter into a relationship with their physician whom society has licensed as competent to provide medical care, trusting that the physician's chief objective is to help. What happens when that physician-prescribed healthcare service is not justly available? The question of distributive justice hinges on the fact that some healthcare goods and services and are in short supply, there is not enough to go around, and thus some fair means of allocating scarce resources must be determined. The fair distribution of scarce resources is not a new concept, but a conflict, certainly one of generations where universal healthcare access has led to the entitlement to fairness in accessing limited and rationed healthcare services. Justice in healthcare is often defined as a form of fairness or as Aristotle once said, “Giving to each that which is his due.” In summary, The Four Principles establish the ethical

framework for the delivery of healthcare services that challenge an individual's personal philosophy, politics,

Levitt

religion, moral theory, or life stance. End-of-life decision- making is certainly an area of healthcare ethics that will continue to gain more front page headlines in popular culture as the baby- boomers age and expectations of patient autonomy become a wide spread accepted system of belief for the majority of the population. Consider the example of the elderly woman with advanced Alzheimer disease living long-term in a residential care facility who had previously expressed in a living will that she did not want to be kept alive when she could no longer be independent; the case of a older adult who lives at home with late-stage multiple sclerosis, who wishes to be assisted to end her life as pain management care becomes futile; and the case of the patient with chronic kidney disease who is considered by their medical care provider to be medically eligible not only for hemodialysis, but also for home-based peritoneal dialysis augmenting the growth in home dialysis through empowerment of patient choice by enhanced patient education.3

AN IMPERATIVE FOR IMPLEMENTING ETHICAL FRAMEWORKS

Based on The Four Principles, healthcare organizations have developed ethical programs with standard compo- nents: a code of ethics, ethics training initiatives, and ethics performance management. Although the 3 classic ethical components contribute to the prediction of ethical intent. Those healthcare organizations that have engaged employees in all 3 components experience significantly higher levels of ethical intent relative to those who viewed the components as either all weakly implemented or not present. This suggests that an engaged workforce will have better outcomes on quality and bottom-line profits.4

LEADS FRAMEWORK

The LEADS framework represents the key skills, abilities, and knowledge required to lead at all levels of an organization. It aligns and consolidates the competency frameworks and leadership strategies that are found in Canada's health sector and other progressive organizations.5

Embodying the collective wisdom of the current liter- ature on leadership and leadership development in the Canadian health sector, the LEADS framework is compara- ble to the top leadership competency frameworks in the private, public, and health sectors around the world and comprises the following 5 leadership principles:

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Leads Self: Leading any area of a dynamic service system begins with an understanding of one's own values, strengths, and abilities; the demonstration of exemplary character; a commitment to self-respon- sibility; and an active orientation towards learning.

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Engages Others: Leadership is the capacity to influ- ence others to work together to achieve a common,

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constructive purpose. Healthcare leaders need to work with many others within the workplace to achieve high-quality health services.

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Achieves Results: Leaders are accountable for man- aging the resources of the organization to achieve results. This capability includes several knowledge dimensions related to the healthcare sector and management practices.

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Develops Coalitions: The healthcare system com- prises a myriad of stakeholders, from individual patients and families to communities, private sector partners, public sector governors, and non-profit organizations. Leaders must be able to build effec- tive relationships with a wide variety of internal and external stakeholders.

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Systems Transformation: New, different, and in many cases more sophisticated modes of leadership are required to address the fiscal, technological, and professional opportunities that a large, integrated health system faces in the future.

APPLICATION OF LEADS TO ETHICAL HEALTHCARE LEADERSHIP

Using the leadership framework provides a widely accepted approach to guide decision-making at the patient practice level through policy setting to determining the future prior- ities of the healthcare delivery system within a larger community. Ethical leadership is required when healthcare leaders must take a lead position providing dir- ection when competing values are in conflict—personal, organizational, professional, and societal.6 From a starting point of the LEADS framework in guiding ethical decision- making, The Four Principles can be applied providing a more robust viewpoint of both professional and clinical per- spectives in determining the best outcome for an ind- ividual and for the healthcare organization. Accessibility, affordability, cost-reduction pressures, regionalization, reve- nue generation, resource constraints and advances in med- ical technology are all major factors that have contributed to the rising tide to complicated decision-making scenarios especially at the end-of-life. Health leaders have a responsi- bility to address the increasing prevalence of complicated ethical dilemmas within a widely accepted framework that is based on leadership capabilities with a reference to clinical ethical principles.7

Within the healthcare system, ethics committees, eth- icists, policies and procedures, and decision-making frameworks assist leaders to make the best decision.8

Using them instructionally based as assets for approach- ing the most challenging situations, appropriate and thoughtful resolutions can be made where patients, families, caregivers, and the healthcare organization are in conflict.

Forum Gestion des soins de santé – Summer/Été 2014

ETHICAL DECISION-MAKING IN A CARING ENVIRONMENT: THE FOUR PRINCIPLES AND LEADS

TAKING ETHICAL STEPS

As the leaders within healthcare organizations, an active role in the development and demonstration of ethical decision-making is paramount. The following "top 10 action plan" may be used as an accountability foundation for healthcare leaders implementing ethical decision- making within healthcare organizations:

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Creating a culture of safety where both leader- ship decisions and clinical decisions are made ethically.

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Articulating the mission, vision, values and strategic priorities based on LEADS and the ethical principles.

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Modelling the highest standards of ethics personally and professionally.

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Creating a learning organization where patients, families, staff, physicians, caregivers, leaders, and boards regard ethical decision-making as the golden rule or the 10 commandments as an effectively operating healthcare organization and healthcare system.

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Providing opportunities for open dialogue on ethical issues that promote a better understanding of the principals approaches to priority setting and problem solving.

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Establishing a system for determining the way forward when clinical, organizational, business, and leadership values are in conflict and alignment is critical.

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Identifying an ethical lead as an expert resource within the healthcare organization.

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Striking an ethics committee with divergent thinking to reach the best possible solutions.

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Implementing an ethical resource team to provide consultation and point-of-care decision-making guidance.

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Evaluating the way decisions are made ensuring a balance with individual, organizational, and societal priorities.

SETTING THE ETHICAL TONE

It is the responsibility of healthcare leaders to set the ethical tone for the organization. The implementation of LEADS and the ethical principles are two integral compo- nents to a healthcare leader's life-long commitment to high ethical conduct, both personally and professionally. Ethical conflicts should be appropriately and quickly addressed by healthcare leaders at the broader organiza- tional, community, and societal level.9

REFERENCES

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. New York, NY: Oxford University Press; 1979.

2. Canadian Institute for Health Information. Access and Wait Times. Available at: ⟨http://www.cihi.ca/CIHI-ext-portal/internet/EN/Sub Theme/healthþsystemþperformance/accessþandþwaitþtimes/ cihi010647⟩.

3. Gordon M, Levitt D. Acting on a living will: a phycian's dilemma. Can Med Assoc J 1996;155:893–895.

4. Ruiz P, Martinez R, Rodrigo J, Diaz C. Level of coherence among ethics program components and its impact on ethical intent. J Bus Ethics 2013. Available at: ⟨http://link.springer.com/article/ 10.1007/s10551-014-2064-4#page-1⟩.

5. Canadian College of Health Leaders. LEADS framework. Avail- able at: ⟨http://www.leadersforlife.ca/leads-framework⟩.

6. Mendonca M. Preparing for ethical leadership in organizations. Can J Adm Sci 2001;18:266–276.

7. Davey TL. Individual and organizational ethical practices. Healthc Manage Forum 2013;26:51–53.

8. Chen YY, Chu TS, Kao YH, et al. To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization. BMC Med Ethics 2014;15:1.

9. Canadian College of Health Leaders. Code of Ethics. Available at: ⟨http://cchl-ccls.ca/assets/ethics/CodeEthics.pdf⟩.

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