Health care today is changing in ways that have the potential to undermine its ethical foundations. To manage these changes effectively, leaders must develop the complex skills necessary to give “voice” to the core values of health care in this evolving landscape. This entails, first, recognizing the competing ethical values underlying the challenges they face. Next, leaders must be competent in analyzing complex ethical dilemmas. Third, and perhaps most challenging, they must learn to develop and implement realistic strategies that can maintain the core values of health care in a rapidly-changing climate. To train values-driven leaders in these critical skills, we have created an ethical leadership program for health care that is based on the Giving Voice to Values (GVV) methodology. This article will make the argument for developing a version of GVV aimed at those in leadership positions in the health care field and briefly describe the program.
The major disruptive factors in health care today—the changes that are resulting in the need to transform health care organizations—are coming in the form of new perspectives on and new approaches to perennial social and economic questions such as, what should health care organizations be responsible for? What counts as high-quality care and who gets to decide? And, how should health professionals be paid or otherwise incentivized to meet these new demands? There have long been conventional answers to these questions, but as these conventional answers are being challenged, too many health care leaders have been defensive rather than proactive.1 As a result, new answers have largely been developed by people outside of medicine (such as legislators and business people) and imposed on a reluctant health care system, rather than coming from health care leaders identifying a need to resolve the pressing social and economic challenges that these questions reflect.
This article will focus on two major disruptions, one social and one economic, and how health care leaders can use the GVV framework to help their organizations address these changes. If these issues are not handled well—and by well, we mean in a manner guided by the core values of the healing professions—they have the potential of eroding the moral foundations of health care.
GVV in a Flattening Health Care Hierarchy
The first transformation is the intentional flattening of traditional health care hierarchies, and it has many roots—ranging from the increasingly free flow of information to the rise of democratic populism to declining trust in institutions including the traditional professions. We are not going to focus on why the flattening of the health care hierarchy is occurring, nor will we address in detail the benefits ascribed to this transformation in traditional power relationships. Rather, we will suffice to note that health care is, in fact, experiencing a wave of efforts to empower patients, families, and communities with regard to their health care and an equally large wave of efforts to empower nurses, pharmacists, and others who have traditionally deferred to physicians. We also should disclose our personal beliefs that the creation of collaborative care teams is largely a good thing, and we think the recognition of the critical value of patient autonomy has largely been a good thing, too. Still, both trends carry some risk if shared expectations are not established, mutual accountabilities are not clarified, communication is not improved, and outcomes are not tracked.2
Many important ethical issues are arising as this transformation in power dynamics unfolds. For instance, the U.S. National Academy of Medicine has encouraged efforts toward collaborative team care.3 Yet, along with noting benefits of team-based care with regard to patient safety, improved efficiency, and so on, Academy work groups have also acknowledged that interprofessional care teams will need to contend with a number of long-running conversations across and between health care professionals of different disciplinary backgrounds (nursing, pharmacy, public health, medicine and so on) about the fundamental goals and values that should guide care delivery.4 These working groups, and others, note that in collaborative teams, accountability is often dispersed, so explicit attention must be paid to role clarity and to ensuring effective communication and the ability of every team member to speak up. Also, organizations with empowered patients must now consider whether they will provide all aspects of patient-centered care, as defined by patients, even if that includes providing services that patients want but to which some clinicians or organizational leaders might object on grounds of religion or conscience (such as birth control prescriptions)—and if not, what rights should patients have to know about these restrictions in advance?
These are just a few of the conflicts between the “rights” of various constituencies that will inevitably arise as health care power relationships flatten. Table 1 includes several more examples of thorny questions that lie at the intersection of health policy, professional ethics, and the power structures in health care. Those hired into health care leadership roles today must be prepared to address questions like these in ways that not only respect the enduring values that the health care system embodies but that can also be realistically put into practice.
GVV in an Evolving Business Climate
The second transformation encompasses the evolving financial and organizational structures of hospitals and health systems, which have increasingly adopted for-profit corporate strategies and metrics.5 Arguably, this second transformation has generated even more conflict than has the introduction of patient-centered, team-based care. While the flattening of the health care hierarchy highlights important values conflicts among and between different health professional groups and patients, this second trend brings into the health care arena an explicit set of values and goals that do not originate in the professional ethos of medicine at all.6 In fact, the values, ethics, and even the legal obligations of business ventures are sometimes at odds with traditionally enshrined health professional values.7
In some health systems, new management structures and alternative payment models have been instituted without physician buy-in.8 Other health systems and health-related industries have adopted a more explicit goal to maximize profits or shareholder interests, though other values and stakeholders can play roles in organizational decisions.9 The point is that there can be direct conflict between profit-maximization and traditional health professional values such as altruism, transparency, honesty, and selfless devotion to the needs of others.
This change in focus has not only influenced how health systems offer care, it has also influenced how emerging challenges, such as the rise of clinician burnout, should be addressed. For example, there is an emerging view that “traditional” health care ethics, with its emphasis on cultivating altruism, is unpersuasive to modern health system leaders and that a business case for addressing burnout is required.
Health professionals and the organizations in which they work have always needed to make money, and many have been very financially successful. That’s not problematic, insofar as financial success is necessary to achieve mission success. In fact, implementing more sophisticated financial tools and strategies holds the possibility of helping both for-profit and not-for-profit health care organizations achieve important goals. Problems arise, however, when introduction of financial or corporate strategies strain the core value of caring first and foremost for the protection of patients’ interests, an obligation that is ubiquitous in health professionals’ codes of ethics.10 When conflicts between profitability and patient interests arise, not all health care leaders have been trained to defend and support health professional values.11
To be clear, we are not speaking here of ethical close calls, such as whether optimal use of resources might support building a clinic in one neighborhood rather than another; nor are we referring to instances where an organization must either charge more or go bankrupt. Rather, we are referring to instances where enormous profits are being sought, often in conjunction with the explicit rejection of traditional ethical tenets of health care, examples of which we will show below.
First, recall that there is a widespread belief among the public that exorbitant profits in health care are contrary to fundamental professional values and more than 90 percent of physicians share this belief. Historically, for example, profits in health care were sought by pharmaceutical and device manufacturers, but profits tended to be reinvested into research and often they were not maximized. There are numerous examples of medical inventors essentially giving away their property interests in the hope that their inventions would help humanity. Most famously, Alexander Fleming did not patent penicillin and Jonas Salk did not patent his polio vaccine, with the latter implying that this was a moral decision. Banting, Best, and Collip did patent insulin, but then they sold the patent to the University of Toronto for $3 (Canadian) and the University allowed manufacture of the product royalty-free, in the explicit hope that all who needed it would be afforded inexpensive access to this life-saving drug.
These examples seem quaint today. In fact, in recent years insulin has become a poster child for exorbitant prices. Despite having been on the market for almost 100 years, patients with type I diabetes—for whom insulin is a requirement for life—often pay hundreds of dollars a month for the product, and stories of patients rationing insulin to save money, sometime with deadly effects, are easy to find. Moreover, insulin is hardly a solitary example of the modern approach to drug pricing decisions. In recent years, Turing Pharmaceuticals (now Vyera) acquired the American marketing rights to a 62-year-old generic drug used to treat parasitic infections and promptly raised the price of a single pill from $13.50 to $750. In 2015, Valeant pharmaceuticals raised the price of a generic diabetes drug from $572 to $5,148. After Mylan pharmaceuticals acquired rights to the EpiPen in 2007, they steadily raised its price from about $100 for a two-pack to more than $600 in 2016.
When criticized, Martin Shkreli, then the CEO of Turing Pharmaceuticals, noted that his job was to maximize profits and that criticizing him for raising prices when it was possible to do so is “like someone criticizing a basketball player for scoring too many points.” Mylan’s board chair reportedly told internal critics of EpiPen price hikes that they should, in so many words, go self-copulate, as should critics in Congress and at the Food and Drug Administration. While comments like these are remarkably blunt repudiations of health professional ethics, raising prices as high as possible is understandable if one’s goal is to maximize profits. That patients might be desperate is simply leverage to be used in price negotiations.
This way of thinking about health care is not unique to the pharmaceutical sector. Rather, it is one that all leaders of health care organizations—whether pharmaceutical companies, hospitals, clinics, or health plans—must confront. Namely, for-profit organizations have a core obligation to seek to optimize profits for shareholders or owners, within some constraints, and this obligation can be in direct conflict with the ethical commitments of health professionals to do what is best for patients and the community. Furthermore, it’s not limited to for-profit organizations; not-for-profit organizations can be caught in this dilemma too, since they must compete with for-profit peers.12
Health professionals tapped to sit at the helms of these organizations are placed in a particular bind, with conflicting obligations as health professionals and as officers of businesses. But even non-health professional leaders will need to navigate these conflicting values among their employees and contractors.
GVV at the Aspen Ethical Leadership Program
Only a proactive values-driven leader can mitigate the tensions around conflicting values that these two disruptive transformations in health care are bringing. Such a leader must understand the organizational culture of his or her hospital or health system as well as the broader social and economic environment in which that organization sits. He or she must have the knowledge and skills necessary to recognize the ethical components of these challenges, discern values-based responses, and then implement responses through effective cultural change and professional development so that the goals and values of the policies become integral within each member of the team.
To help leaders navigate the dynamic and evolving health care environment, we have developed a structured executive leadership retreat—the Aspen Ethical Leadership Program—that adapts the business ethics methodology of GVV to the tasks of cultivating ethical awareness, analysis, and action specifically for health care organizations. The program has helped health care executives practice grappling with some of the most contentious ethical issues confronting health care today (Table 1).
The overall aim of the program is to create a community of skilled and thoughtful health care professionals, capable of leading transdisciplinary teams and serving in the C-suites of health care organizations where these values tensions must be addressed. This health care-focused program was founded on GVV’s premise that ethical leadership requires both essential knowledge and practical skills and that health care executives need a welcoming environment in which to acquire and practice using the knowledge and skills of ethical leadership. While the program includes instruction on ethical awareness (learning to recognize and name common ethical issues in health care) and ethical analysis (learning to dissect complex ethical dilemmas to determine appropriate options), the main innovation of the program is its adoption of the GVV focus on providing leaders the opportunity to practice the skills needed to act strategically and successfully on their values.
Ethical awareness and the ability to carefully analyze ethical issues are critical, yet they are for naught in a leader who does not possess the knowledge and skills necessary for the final step: ethical action.13 Despite its necessity, however, rarely are health care leaders given explicit instruction in all three steps—how to recognize an ethical issue, then dissect it to determine a defensible path forward, and then how to take the practical steps involved in building that path and leading people down it.14 The last step is where the GVV methodology has offered its largest benefits to program participants. The Aspen Ethical Leadership Program’s Triple A Framework, incorporating ethical awareness, analysis, and action is summarized in Table 2.
The Aspen Ethical Leadership Program’s Triple A Framework
Awareness: recognize when you are facing an ethical issue.
- Values: why is this an ethical issue and not merely a technical problem? List the core or shared/common values that are in conflict.
- Gut reaction: how did you feel when you heard about this issue? Can you acknowledge your gut reaction to the issue and then set it aside to do the analysis? Be clear about implicit or explicit biases you and others might bring to the coming discussion and decision.
|Analysis: study the ethical issue to arrive at a decision about the right thing to do.
- Who cares? Why does this issue/decision matter to the organization? Be as specific and tangible as you can when listing organizational interests at stake. What other individuals and groups have an important stake in the decision, whether inside or outside of the organization? What values are at stake for each? Be explicit about what is at risk for each stakeholder.
- Relevant facts: what clinical, legal, economic or other facts should inform your decision? What additional information is needed to make a good decision?
- Choices: name available options and decide which represents the values-based position you should enact. Which is most consistent with the type of leader you want to be and the type of organization you want to lead? Think about both substantive (final decision) and procedural (next step) options.
|Action: develop and practice executing your plan for how to do what’s right.
- Reasons and rationalizations: build your action plan using data from above and considerations about what each impacted stakeholder (including yourself) is concerned about, motivated by, and what each has at risk. Who might be allies in acting on your choice and who might raise objections? What objections are you most likely to face, and how will you answer these objections?
- Script and rehearse: create an action plan and test it. Answer relevant logistical questions such as: Whom do I need to influence? What personal strengths can I rely on? Will I do this alone or should I build a set of allies? What is a reasonable timeline? Should I seek out a one-on-one conversation or a group discussion? When have I seen my target audience change his/her/their minds before and what helped that to happen? Whom do they listen to? How do they like to receive information (in writing, orally, data-driven, anecdotes)? Think of your script and action plan as a decision tree; how might you proceed given different initial responses? This is not a short, pretty speech—it should be a practical roadmap for a series of actions and a multi-branched set of conversations.
- Prevention: leaders don’t just solve problems, they help organizations avoid them. What could you have done (if anything) to prevent the original dilemma from arising? What should you do now to help avoid similar dilemmas arising in future?
GVV methods can be useful for people at all levels of an organization in addressing the transformative changes we described above. For instance, GVV training would help every member of a collaborative care team communicate honestly and effectively with patients and with each other around adverse events or mistakes. Studies regularly show that members of care teams too often fail to speak up when they see inadequate communication, even when patient safety might be at stake.15 The GVV method encourages members of the collaborative care team to ask themselves, in advance, “What would be your best strategy for speaking up and giving voice to your values in that moment—right when you notice that the patient seems not to understand? What exactly would you say and do? And what support will you need to make sure you are able to do the right thing, at the right time, and in an effective way?” The GVV approach creates the opportunity for anyone to imagine how they might act in ways that align with their values.
Still, the Aspen program’s focus has been on using the GVV approach to help create values-driven leaders in health care. Our exercises (Table 1) illustrate that we often work on issues where a leader must address a business-critical issue while recognizing a risk that health professionals in the organization will resist any policy solution that they perceive to clash with core professional values. Leaders in the program first seek to develop a policy that is coherent with professional values, and then they practice how they would communicate and launch it in the most effective way. For example, if a policy is interpreted as a means to alleviate financial pressures at the expense of quality, or if standardization is seen to be emphasized at the expense of clinical expertise, then physicians and other providers should be expected to comply haphazardly or even to directly undermine the change, because doing so is a means of protecting their professional integrity. Such challenges must be addressed, not avoided, which means learning how to give voice effectively to important managerial and professional values so that each member of the health care team has the potential to act with integrity. When health systems must confront a direct conflict of values, such as reducing charitable services to stay in business, simply creating a policy will not be enough to engender changes in behavior. Just as clinical teams must learn to communicate and confront conflicts productively, so must leadership teams develop processes to discuss and integrate values that are in tension with each other to implement sound decisions.
In health care organizations, the flattening of hierarchies and adoption of for-profit structures and strategies each have the potential to support as well as test values-driven leadership. Flattened hierarchies can allow more voices to be heard and more opportunities for collaboration to be realized. Similarly, for-profit structures and strategies can be utilized to decrease wasteful spending and optimize efficient care. Yet these ongoing transformations also pose profound challenges to focusing leadership decision-making and practice on the ethical values underpinning the healing professions. The flattening hierarchy raises possibilities of role ambiguity, communication challenges, and goal conflicts. For-profit structures and strategies can introduce corporate values that are foreign to the medical profession’s historical ethos. The GVV paradigm, as we are using it at the Aspen Ethical Leadership Program, offers health care leaders the opportunity to practice navigating these tensions and leveraging these disruptions for the improvement of health care delivery. Recognizing these transformations and addressing them in ways that put health care ethics in the forefront will be a key to success for 21st century health care leaders.
Matthew Wynia, M.D., MPH, is Director of the University of Colorado Center for Bioethics and Humanities and a Professor at the University of Colorado School of Medicine and the Colorado School of Public Health. He can be reached at email@example.com.
Ira Bedzow, Ph.D., is the Director of the Biomedical Ethics and Humanities Program at New York Medical College and Senior Scholar of the Aspen Center for Social Values. He can be reached at firstname.lastname@example.org.