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The notion of leadership emerged as soon as people gathered and focused on a single purpose or goal. As tribes evolved into communities and then into formal organizations, so did the notion of leadership. When a normative element was infused into leadership, ethical leadership found a signiﬁcant place in academic literature and professional practice. Yet, despite the common desire for ethical leaders, the deﬁnition and understanding of ethical leadership remains a wide diffused notion with many competing descriptions and manifestations. Many of these variant conceptions of ethical leadership are presented here. The central role of ethical leadership in bioethics, and healthcare in general, is discussed, including the impact of ethical leadership on healthcare organizations.
The practice of leadership dates as far back into the history of humankind to those that led the cave dwellers out into the wilderness to hunt and kill for sustenance. The ethics of leadership, or ethical leadership, has more recently emerged as an important concept when applied to those within organizations entrusted with or assuming the task of leading individuals, ranging across such entities as medical facilities, business organizations, nonproﬁt charitable institutions, etc. This entry provides a deﬁnition of ethical leadership and highlights some of the applications of ethical leadership to the bioethics and general healthcare ethics ﬁelds.
In a recent Harris Poll, most individuals reported a lack of perceived ethical integrity among their leaders, both within and outside of the bioethical ﬁeld. People expect leaders to be ethical, especially when the consequences of unethical leadership are high, resulting in loss of life, severe injury, or suffering or imposing signiﬁcant ﬁnancial loss on the individual. Scholars have spent many decades attempting to identify those characteristics that empower leaders to act ethically in an effort to satisfy organizational stakeholders’ demand for strong ethical leadership.
The notion of leadership, or ethical leadership, has assumed a wide variety of deﬁnitions in the bioethical and other professional literature, although there are some basic elements that have consistently emerged when attempting to describe this notion.
Ethical leadership is broadly deﬁned as the value-based process where one inﬂuences others in a way that is understood as appropriate or resulting in good. This leadership can be entrusted to an individual or assumed by the leader. Leadership may occur through formal channels such as legal authority, organizational structure, or job description or informally by leading an ad hoc team or group and could be a temporary role. Nearly every society, community, and organization has someone “in charge” or “responsible for” an informal or formal group or unit. Leadership roles are found in the military, police and ﬁre departments, religious organizations, corporations, healthcare facilities, and virtually every other type of organization. Leading can be seen as conducting, directing, escorting, guiding, inﬂuencing, inducing, commanding, and initiating, among other verbs used to reﬂect the act of leadership.
Some scholars argue that leadership is best understood as the art and science of intentionally inﬂuencing others to change behavior, beliefs, or both in some desired direction. Others add that the leadership process is relative or highly situational, dependent upon the leader, the followers, and the environment or circumstance surrounding the situation.
The notion of ethical leadership has also been understood in academic research as both a normative concept (What should ethical leaders do?) as well as a descriptive perspective (How leaders who are considered ethical behave?). In the ﬁrst case, the question is framed in an ethical context, speciﬁcally as it applies to the areas of bioethics, healthcare ethics, medical ethics, business ethics, or other professional areas of study. This normative focus has spawned important research questions: Is the leader of good, ethical character? Does the process of interaction between leaders and followers follow ethical rules?
In the second case, ethical leadership is characterized with reference to psychological notions like role models, norms, values, personal integrity, etc. This perspective would emphasize: What are the goals that the leader intends the followers to achieve? Is the intention of the leader admirable? Yet, this perspective also considers some normative elements, basic to any understanding of ethical leadership. What are the virtues of the leader – honesty, modesty, fairness? Or, what are the ethical principles used to design the leader’s strategy for the followers – respect, service, justice?
These different perspectives provide insights in the dynamics of ethical leadership. Being a leader, particularly an ethical leader, involves a complex process that plays a crucial role in mobilizing resources, motivating people, providing ethical orientation, and balancing interests. These aspects are particularly important in the bioethical ﬁeld, with their speciﬁc requirements of managing widely varying multi-stakeholders, mobilizing various professionals and volunteers, responding to different cultural contexts that inﬂuence decisions and behaviors, and balancing mission-related (often ethically laden) and economic targets.
A competing notion of leadership focuses on three basic elements of leadership: mind, will, and emotional intelligence. These three factors emphasize strategic foresight and insight, vision or direction setting, emotional intelligence, and the ability to vary style according to the situation at hand to excel at leadership.
Others posit that there are three competing conceptions of leadership. One conception is based on trait theory. Leadership effectiveness comes from personal traits or attributes. Therefore, leaders are born, not made. The second conception looks to great events theory for support. In this view, great events call upon individuals, who may not normally be exceptional in their traits, to respond to the circumstances in some exemplary or notable way. Third, transformation leadership is touted as another perception of leadership. Here individuals are able and do learn effective skills of leadership. Leaders can be made or prepared to be leaders when given the opportunity.
Some note that ethical leadership formally emerged in the United States in the 1980s based on a century-old understanding of leadership – empowering an individual due to some delegation of hierarchical authority, such as an administrator, a doctor, or a surgical team leader, to inspire and mobilize masses of people (James 1880). Ethical leadership rose as a demand by organizational stakeholders when followers expressed a desire for or acquired power to demand this sort of leadership due to the emergence of ethical scandals that rocked society. These lapses of ethics caused a clamor for ethics to return to leadership, and organizations began to realize that ethical leadership could be associated with success or proﬁtability for the organization.
Joanna Ciulla, a leading leadership scholar, provided a chronological development of leadership by identifying how leadership changed or evolved from one decade to the next. She describes leadership by decade as (with genderspeciﬁc Bibliography : reﬂecting the business climate of the times):
1920s: ability to impress will on others inducing obedience, respect, loyalty, cooperation
1930s: organizing many to move in a speciﬁc direction
1940s: persuade or direct men, apart from prestige or power coming from your ofﬁce
1950s: authority is spontaneously accorded to him by his fellow group members
1960s: acts by a person which inﬂuence others in a shared direction
1970s: discretionary inﬂuence, leaders’ behavior which may vary person to person
1980s: to inspire others to undertake purposeful action as determined by the leader
1990s: an inﬂuence relationship between leaders and followers who intend real changes that reﬂect their mutual purposes (Ciulla 1995, pp. 11–12).
As deﬁned by Ciulla, leadership evolved from a strict command-and-control form of leadership in the 1920s and 1930s to a more collaborative and cooperative notion of leadership by the end of the twentieth century.
During the beginning of the twenty-ﬁrst century, two of the more common forms of ethical leadership discussed in academic literature are servant leadership and responsible leadership. Central to servant leadership is the leader’s desire to serve others and to satisfy their needs. In order to satisfy the needs of others, the servant leader must listen, understand, accept, and empathize with their needs. The servant leader must also communicate his/her vision concerning building a sustainable community.
Responsible leadership refers to leaders who are deemed to properly and justly meet role, normative, ethical, and moral obligations they have with respect to deﬁned stakeholders and are willing to be held accountable for the consequences of their actions and behaviors. Both of these forms of leadership can easily be applied to the bioethics ﬁeld, and leaders embracing either of these forms of leadership are generally understood to be ethical leaders.
According to leading scholars and practitioners in the healthcare ethics ﬁeld, the issue of ethical misconduct is included among the myriad of tough challenges facing healthcare leaders in today’s global and dynamic environment. And, like the many issues that keep leaders up at night, there is no magical, one-step solution to ensure that staff behave ethically, patients are treated ethically, and decisions are based on sound ethical processes. Like all vital leadership skills, understanding how to lead your organization, so that ethical decision making and behavior are the norm, requires a level of ethical leadership that is a competency that must be constantly practiced and honed.
Leading management scholar Linda Klebe Trevino and her associates have posited that for a leader to be ethical, the leader must be perceived as both an ethical person and an ethical manager (Trevino et al. 2000). An ethical person demonstrates the values of honesty, integrity, trustworthiness, caring for others, being open to others’ input, and using principles in decision making. Ethical leadership has been linked to the leaders’ cognitive moral development and is greatest when the leader demonstrates more developed moral reasoning than the followers’ moral reasoning.
Ethical managers use leadership tools such as rewards, discipline, communication, and decision making to emphasize the importance of ethics, to establish rules for behavior, and to hold employees accountable to those rules. Their perspective considers society as a whole and understands that the organization and individual are part of that societal focus. Perceptions of ethical leadership are strongest when linked to observations of fairness in the treatment of others. Put simply, ethical leadership is doing the right thing, even when this might require going beyond the limits of the law or some organizational rule if ethical principles or the welfare of others demands this sort of behavior (Trevino and Brown 2004).
The healthcare ethics literature identiﬁes a moral compass required or expected for all leaders (Edmonson 2013). This moral compass consists of four guiding points: integrity, responsibility, compassion, and forgiveness. Scholars argue that leaders must be ever mindful that their moral compass also serves as the moral compass for the organizations they lead. It is the synchronization of the leaders’ moral compass with an ethical organizational culture that allows ethics and ethical leadership to emerge. Without the ethical moral culture, the leader cannot act on the ethical decisions that are known to be good for the patient, medical staff, and organization. The healthcare ethics literature coined the phrase – high-reliability organizations (HRO) – to reﬂect what many hospitals and health systems seek and know they can beneﬁt from this type of ethical culture (Edmonson 2013). Embedded in HRO are the values of equity, justice, fairness, and professionalism – values that have appeared elsewhere in the literature to describe ethical leadership.
Ethics is at the core of healthcare institutions. Society and those working within these organizations perceived healthcare institutions as social enterprises with an economic dimension, not primarily economic organizations. Therefore, ethics is central to a healthcare facility, and a strong ethical presence, as found in professional codes such as the American College of Healthcare Executives’ Code of Ethics, demands ethical leadership from those in authority. In the ACHE’s Code of Ethics, professionals are expected “to maintain or enhance the overall quality of life, dignity and well-being of every individual needing healthcare service and to create a more equitable, accessible, effective and efﬁcient healthcare system” (ACHE 2011).
Ethical leadership is linked to organizational beneﬁts for healthcare institutions. Healthcare ethics scholars have shown that ethical leadership can lead to better patient care, lower employee turnover, more satisﬁed employees with stronger employee morale, more efﬁcient care delivery, and increased market share (Donnellan 2013). These beneﬁts can arise from leaders that exhibit a broad view that is reﬂected in their organizations’ ethics program and an ethical culture. Working within an ethical organization, leaders can more easily demonstrate an integrated decision process based on ethical and moral values that include all stakeholders and the effect of decisions on their livelihood, provide ongoing ethics education for all staff members to fully integrate ethics throughout the organization, and be ethically courageous when making tough decisions with signiﬁcant ethical implications.
A call for a new understanding of ethical leadership appeared in the healthcare ethics literature in 2012. Keselman calls for “a shift toward human caring values and an ethnic of authentic healing relationships” that is required for all healthcare systems and its leaders. Keselman argues for greater attention toward valuing human resources and life’s purposes, awareness of the inner meaning of life, and a sensitivity to the processes for providers and patients alike. This challenge is necessitated by the increasing societal concern that it is unacceptable for organizational leaders to be indifferent to moral responsibility, much less engage in unethical behavior. A blending of transformational and transactional leadership is important for an ethical leader. Both leadership approaches emphasize an altruistic concern for others even at a cost to the leader. By adopting this blended form of leadership, an ethical leader positions the organization to maximize the beneﬁts that materialize from enhanced patient care by respecting patients’ rights, enhanced internal organizational morale by treating employees with dignity and respecting their rights, and listening to its stakeholders to act in a transparent and moral manner.
As discussed earlier, ethical leadership is intrinsically tied to a strong ethical culture (Nelson 2014). The combination of these two elements can lead to delivering high-quality and high-valued care, positive patient outcomes, and ﬁnancial solvency. A lack of ethical leadership or a strong ethical culture or an incongruity between the leader-organization’s ethics may lead to poor quality care delivery, lower staff morale, and a weakening of the organization’s image in the community.
Ethical leadership, particularly in the bioethics ﬁeld, is central to safeguarding medicine’s ethical foundation. Souba proposes four pillars of ethical leadership – awareness, commitment, integrity, and authenticity. This leadership framework is based on ethical principles, a rule-based approach, rather than a more common approach of seeking to maximize the consequences or outcomes of actions, a result-oriented approach. Awareness requires the ethical leader to be watchful, vigilant, and prudent. The commitment focus requires the ethical leader to unite, connect, and bring together all those affected by the decision or action. Situations are bigger than the leader and emphasize a caring for others. Integrity comes from the notion of integrate and means that the ethical leader must consider the whole condition of an object, person, or organization. This means that the bioethics system must be seen as an integrated whole and a leader cannot impair any of its functions through the leader’s decisions or action. Finally, authenticity focuses on being accountable for one’s own actions. This ethical leadership value tempers the nature desire for approval or to look good to others. Rather, an ethical leader must take responsibility for the action taken regardless of the possible negative implications for the leader.
Examples of the challenges welcomed by various leaders who sought to be an ethical leader are accounted in Squazzo’s Healthcare Executive article from 2012. Two examples are provided next.
John J. Donnellan, Jr., adjunct professor of health policy and management at New York University, spoke of the “personal revolution” he experienced as a leader when he developed the US Department of Veterans Affairs’ Integrated Ethics program. He learned that rules alone do not stop unethical behavior nor do they encourage ethical behavior. Rather he found that an ethical leader must spend quality time and the organization’s money to train staff and support staff at all levels in the healthcare system to demonstrate how important the organization values ethical behavior.
Nancy G. Levitt-Rosenthal, senior vice president of health systems development at Greenwich Hospital in Connecticut, recognized the importance of the CEO’s ethical leadership in creating an ethical culture in her organization. “Our CEO practices good behavior every day and is a good role model for inﬂuencing behavior.” Included in this good behavior are open communication and transparency with the staff, especially during tough times, and ensuring that the staff are in tune with the organization’s values, including its commitment to ethics, found in the mission and vision statements.
Despite the lack of a consensus on the deﬁnition or characteristics of ethical leadership, there is general agreement in the academic literature and among healthcare professionals that staff, patients, and other individuals and organizations in the bioethics ﬁeld beneﬁt from the presence of ethical leaders and there is great urgency that ethics in leadership be the norm in bioethics.
- American College of Healthcare Executives (ACHE). (2011). Code of ethics. www.ache.org/abt_ache/code. cfm. Accessed 27 July 2014.
- Ciulla, J. B. (1995). Leadership ethics: Mapping the territory. Business Ethics Quarterly, 5, 5–28.
- Donnellan, J. J., Jr. (2013). A moral compass for management decision making: A healthcare CEO’s reﬂections. Frontiers of Health Services Management, 30(1), 14–26.
- Edmonson, C. (2013). Wanted: Morally courageous leaders. Frontiers of Health Services Management, 30(1), 33–38.
- James, W. (1880). Great men, great thoughts, and the environment. Atlantic Monthly, 46, 441–459.
- Keselman, D. (2012). Ethical leadership. Holistic Nursing Practice, 26, 259–261.
- Nelson, W. A., Taylor, E., & Walsh, T. (2014). Building an ethical organizational culture. The Health Care Manager, 33, 158–164.
- Squazzo, J. D. (2012). Ethical challenges and responsibilities of leaders. Healthcare Executive, 27, 32–38.
- Trevino, L. K., & Brown, M. (2004). Managing to be ethical: Debunking ﬁve business ethics myths. Academy of Management Executive, 18(4), 69–81.
- Trevino, L. K., Hartman, L. P., & Brown, M. (2000). Moral person and moral managers: How executives develop a reputation for ethical leadership. California Management Review, 42(4), 128–142.
- Burns, J. M. (1978). Leadership. New York: Harper & Row.
- Flight, C.A. (2013). Code of ethics: Principles for ethical leadership. Perspectives in Health Information Management, 1–11.
- Storch, J., Makaroff, K. S., Pauly, B., & Newton, L. (2013). Take me to my leader: The importance of ethical leadership among formal nurse leaders. Nursing Ethics, 20, 150–157.
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