- Email: [email protected]
Cultivating excellence in leadership: Wicked problems and virtues
Reflections on healthcare leadership ethics
Cultivating excellence in leadership: Wicked problems and virtues by Don Juzwishin, PhD, FCCHL; Ken Bond, BEd, MA Introduction
A challenge for leadership: Wicked problems 1,2
Previous reflections on healthcare leadership ethics have pointed to the ways in which the LEADS in a Caring Environment leadership capability framework3 reflects the Canadian College of Health Leaders (CCHL) Code of Ethics. They have also discussed the potential for this framework to provide guidance on strong ethical behaviours and professional competencies. The framework provides today’s health leaders with a tool to help them think about and act in ways that will help during turbulent times of transformation and change.1 Leaders must think issues through and be prepared to act based on their personal ethical framework; this takes courage, resolve, and commitment.1 Good governance and effective leadership also require transparency and honesty in decision making, and trustworthiness and attentiveness to the moral climate of your colleagues.2 How might leaders foster the development of these capacities personally and in their staff? How might leaders maintain and strengthen these capacities and behaviours in times of turbulence? In this article, we explore the leadership capacities and behaviours expressed in the LEADS Framework and ways a virtue approach in ethics might assist leaders striving to address the “wicked problems” encountered in complex and rapidly transforming health systems. Some concluding remarks on how to support the development of virtues in leadership are provided.
From the Institute of Health Economics, Edmonton, Alberta, Canada. Correspondence to: Don Juzwishin, PhD, FCCHL, Health Technology Assessment & Innovation, Alberta HealthServices, Suite 200, North Tower, Capital Health Centre 10030 - 107 Street Edmonton, AB T5J 3E4; Phone: (780) 735-0741; Fax: (780) 735-0765; e-mail: [email protected]. Healthcare Management Forum 2012 25:161–164 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2012.07.003
We believe that many decisions healthcare leaders face are difficult, not only because they are politically sensitive and complex, but also because they concern “wicked problems.”4 Wicked problems have the following characteristics (we have drawn partly on paraphrases by Conklin5 for ease of understanding): 1. There is no definitive statement of “The Problem.” Emphasizing different values can mean the problem is understood differently, and one cannot understand the problem without knowing about its context. 2. Wicked problems have no stopping rule. The problem-solving process ends when you run out of resources, such as time, money, or energy, not when an “optimal” solution emerges. 3. Solutions to wicked problems are not right or wrong, but are simply better or worse, or good enough or not good enough. The assessment of proposed solutions varies (sometimes widely) and depends on stakeholder values and goals. 4. There is no immediate test of solutions. Solutions to wicked problems generate waves of consequences. As a result, a solution may lead to undesirable consequences that outweigh the putative advantages of the solution. 5. Every solution to a wicked problem is a “oneshot” deal. There is no learning by trial and error or experimentation. Every implemented solution leaves “traces” that cannot be undone and alters people’s lives in irreversible ways. 6. Every wicked problem is essentially unique. The many factors and conditions that serve to define the problem and a dynamic social context mean that no two wicked problems are essentially alike. Thus, there are no principles of solution that can be applied to classes of wicked problems. In contrast, so-called tame problems have well-defined and stable problem formulation, a definite stopping point, and belong to classes of problems that are all solved in similar,
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and enumerable, ways.5 These characteristics are meant to give one a sense of what contributes to the “wickedness” of a problem, rather than to determine whether a given problem is wicked or not.5 Indeed, most problems have degrees of wickedness, lying somewhere on a continuum between tame and wicked.5,6 Leaders, especially those in times of healthcare transformation, confront both “tame” and “wicked” problems. Tame problems, such as whether or not treatment for chronic cerebro-spinal venous insufficiency is clinically effective and should be publicly funded may be addressed using a standard linear process. To be sure, such problems may be complex and difficult, but they are amenable to solution. Contrast such problems with the issue of how one ought to remedy the increasing prevalence and incidence of obesity in society. Or arrive at equitable and sustainable arrangements for the appropriate role for the national government in healthcare or the reimbursement of health service provision. Wicked problems seem to be recalcitrant. Further, the social complexity inherent in healthcare decisions and often diffuse responsibility of addressing those problems means that we can expect wickedness of problems to increase as health systems move to respond to broader issues such as the social determinants of health. Consider again the challenge of increasing obesity in Canada. Recent data from the Canadian Institute for Health Information found that more than one in four adults in Canada and just fewer than 1 in 11 children are considered obese. Between 1981 and 2009, obesity rates roughly doubled across all age groups and tripled for youth.7 Bringing obesity and the resulting chronic diseases under control does not have one answer. The problem is wicked ⫺ any approach to its resolution requires understanding and acting on the individual, family and community development, nutrition, exercise, education, counselling as well as metabolic disorders. And how the problem is framed, for example as an “epidemic,” radically alters support for competing policy responses.8 We think a not insignificant number of health policy problems have the shape of wicked problems. The Australian Public Service Commission recognized the challenges for policy makers and produced a report entitled “Tackling Wicked Problems: A Public Policy Perspective.”6 Addressing such problems, the report argues, requires a reassessment of some of the traditional ways of working and solving problems because these problems “challenge our governance structures, our skills base, and our organizational capacity.”6 Nevertheless, the Australian Report focused mainly on how to acquire the broad range of analytical and people skills and the organizational knowledge required to adequately address wicked problems, for example, through stakeholder engagement and by working across organizational boundaries. 162
Virtues, the LEADS Framework, and leadership Principle-based ethical frameworks, that is, those that guide action through a consideration of beneficence, nonmaleficence, respect for autonomy, and justice and that are oriented toward single actions (especially as they are applied in clinical ethics), may not be particularly helpful to leaders facing the uncertainty, intense political pressure, and the seeming intractability that comes with problem wickedness. What often counts most in the moral life in general, and in leadership in particular, is not adherence to moral rules or right action, but reliable character, good moral sense, and emotional responsiveness (though this is not meant to imply that those other things are not important to ethical leadership).9 Hence, virtue approaches to ethics, just because virtues are concerned more with attitude, enduring traits of character, and the ongoing narrative10 than the critical moment of decision, are ideally suited to providing guidance to health leaders through on-going challenges posed by wicked problems.10 A virtue approach recognizes that good leadership is a careful balance between extremes. We must hit the mean between two extremes to act rightly (Aristotle’s “golden mean”).11 Although the mean is relative, it is an objective feature of the situation in which we act and not simply a matter of personal feeling or opinion. The virtue of truthfulness, for example, requires being appropriately motivated to tell the truth about the right things, to the right people, at the right times, and in the right place. To fail in any of these will lead to an act that is either “brutally honesty,” a lie, or an act that has all the outward appearance of truthfulness, but is not a product of one’s character because it is not properly motivated. 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. One of the five domains of the LEADS Framework3 is “Lead Self” and describes four capabilities of a leader: (1) self-awareness, (2) self-management, (3) self-development, and (4) demonstration of character. By envisioning the “demonstration of character” as the “modeling of qualities such as honesty, integrity, resilience, and confidence” the framework aligns itself clearly with a virtue approach in ethics. Importantly, the LEADS Framework ties demonstrations of these qualities to “the inward motivation to do what is right,” thus connecting with philosophic conceptions of virtue. The virtues we are thinking of here derive from the role responsibilities of health leaders, and include Beauchamp and Childress’ six virtues of professional medicine and nursing: care, compassion, discernment, trustworthiness, integrity, and conscientiousness.9 Nevertheless, because health leadership encompasses roles beyond physicians and nurses, the virtues must be suitably broadened to include those working in other capacities. To these six
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
CULTIVATING EXCELLENCE IN LEADERSHIP: WICKED PROBLEMS AND VIRTUES
virtues, we would add, at the least, courage, patience, humility (or magnanimity), resilience, and confidence. We encourage leaders to identify other virtues that they believe are central to achieving excellence in leadership in their particular roles. How might thinking about virtues, such as those described, help with the “wicked problems” encountered in healthcare? We suggest that, because consequences are uncertain, the ethical behaviour and “success” of a health leader is judged not only by the consequences of their leadership, but by the virtues they display through their leadership and the environment these can help to foster. Gibson’s2 description of issues in organizational ethics supports this view. As one example, we think having humility, an awareness of the assumptions guiding one’s actions and thoughts, requires being sensitive to how problems are framed. To return to the issue of obesity, although the increase in rates of obesity does have some characteristics of an epidemic,12 to see obesity as an “epidemic” is to view the problem as having particular characteristics and, therefore, as amenable to particular kinds of solution. Seeing the issue in this way is not uncontroversial,8,12 and alternative frames may, in fact, be more productive, from the view of health policy. Patience is also required to deal with wicked problems. Because wicked problems are essentially unique, part of the art of dealing with wicked problems lies in not knowing too early which type of solution to apply. Macleod and Lewis observe, “A major obstacle to progress is the failure to ask ourselves the wicked questions that will lead to a deep exploration of assumptions we make.. . . Without exploring our assumptions, we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential.”13
Support for the development of virtues of leadership Virtues are the result of sound habits of mind and heart, and a will that drives us toward excellences of character. Although leaders differ in the character traits they possess, all leaders can cultivate the traits important to ethical leadership. Similarly, Havard14 believes that leaders are not born but trained; excellence in leadership is the result of habits acquired through practice. For example, to become a courageous person, you must perform courageous acts. This requires making a conscious effort to do the courageous thing in situations in which courage is appropriate. The fact that virtues are the product of teachable habits suggests many ways that the CCHL and others might support the development of these excellences of leadership. Bashir Jiwani, director of Ethics Services at Fraser Health in British Columbia, has developed decision support tools15 that can assist leaders in a way that supports the virtues mentioned throughout this article. The support tools are
based on the idea that ethically justified decisions support not just the decision itself, but living in a desired way and being a particular kind of person. Maintaining integrity, which for Dr. Jiwani is about “having our behaviour match up with what we say,” is of utmost importance. The CCHL, at both national and regional levels, is already organizing programs to introduce healthcare leaders to the LEADS Framework. Chapters might include activities to consider the delivery of education sessions on the code of ethics, their relevance and importance of virtues, and how they can support the competency requirements of today’s healthcare leaders, particularly in effectively tackling wicked problems. Developing an ethics concentration or stream in the annual meetings of CCHL to help interrogate and address wicked problems could also be helpful. This would provide health leaders with a community or critical mass of encouragement and support toward tackling the wicked problems. The encouragement of including mentors and role models would be of enormous benefit to young and emerging leaders to help set the stage for pursuing excellence. Story telling is an effective way of communicating and learning and the CCHL might consider the development of an electronic anthology on healthcare ethics – cases, to serve as models for practice-based learning, to be available through the social media and accessible to emerging and practicing leaders. Identifying and developing case studies of the demonstration projects from across the country of courageous initiatives successful in the face of adversity could serve as beacons of hope for the direction pursue. Michael Rachlis, in his book Prescription for Excellence,16 provides numerous examples from across Canada of successful efforts to improve access to and quality of healthcare in Canada. Supporting and encouraging links between healthcare organizations and educational institutions’ teaching and research of wicked public health issues could be another supportive endeavour. Finally, CCHL could encourage CHE aspirants and those pursuing fellowship to study ethical issues and how pursuing the virtues identify challenges to be addressed and suggest paths to satisfactory results. These studies could be published and available on the CCHL web site for health leaders.
Concluding remarks We have argued that leaders ought to look to the virtues of leadership for guidance when addressing wicked problems in healthcare. Today’s call for transformative leadership relies on strengths of character that require more than just “keeping the ship afloat;” it requires our leaders to set the rudder headlong into the treacherous waters ahead. CCHL and the LEADS Framework can play an important in supporting health leaders developing the virtues of health leadership, as well as supporting a national conversation on effective approaches to virtuous leadership. CCHL must
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Juzwishin and Bond
also be prepared to step in to support a leader who has acted ethically and courageously but has encountered negative consequences. Promoting these excellences and providing leaders with the resources and support with which to develop them will be instrumental in dealing successfully with the wicked problems that lie ahead.
ACKNOWLEDGMENTS The authors would like to thank Katherine Duthie, Owen Heisler, and Eric Wasylenko for providing detailed comments on this paper. Thanks also to Christa Harstall for her discussion and feedback in the initial stages of writing this article.
REFERENCES 1. Juzwishin DW. Ethical management in health services administration: a sequel. Healthc Manage Forum. 2011;24:31–34. 2. Gibson JL. Organizational ethics: no longer the elephant in the room. Healthc Manage Forum. 2012;25:37–39. 3. LEADS in a Caring Environment [web site]. Canadian College of Health Leaders. Available at: http://www.cchl-ccls.ca/ default_conferences.asp?active_page_id⫽6492. Accessed June 11, 2012. 4. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sci. 1973;4:155–169.
164
5. Conklin J. Wicked problems and social complexity, In: Conklin, J. Dialogue mapping: building shared understanding of wicked problems. New York: Wiley; 2005. 6. Australian Government. Tackling wicked problems: a public policy. Perspectives. 2007. 7. Canadian Institute of Health Information. Increased activity and healthier eating can improve obesity rates, but aren’t the only factors at play. Available at: http://www.cihi.ca/cihiext-portal/internet/en/document/factors⫹influencing⫹health/ environmental/release_20june11. 8. Barry CL, Brescoll VL, Brownell KD, et al. Obesity metaphors: how beliefs about the causes of obesity affect support for public policy. Milbank Q. 2009;87:7– 47. 9. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th ed. New York: Oxford University Press; 2009. 10. Campbell A. A virtue-ethics approach. In: Ashcroft R, et al, eds. Case analysis in clinical ethics. New York: Cambridge University Press; 2005:45–56. 11. Holmes RL. Basic moral philosophy, 4th ed. New York: Wadsworth Publishing; 2006. 12. Flegal KM. Commentary: the epidemic of obesity ⫺ what’s in a name? Int J Epidemiol. 2006;35:72–74. 13. Macleod H, Lewis S. Asking the unaskable – thinking the unthinkable. Health Care Q. 2012;15:6 –7. 14. Havard A. Virtuous leadership ⫺ an agenda for personal excellence. New York: Scepter; 2007. 15. Jiwani B. Incorporating ethics into daily practice. Available at: http://www.incorporatingethics.ca/. Accessed June 5, 2012. 16. Rachlis M. Prescription for excellence. Toronto: HarperCollins; 2004.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
Cultivating excellence in leadership: Wicked problems and virtues by Don Juzwishin, PhD, FCCHL; Ken Bond, BEd, MA Introduction
A challenge for leadership: Wicked problems 1,2
Previous reflections on healthcare leadership ethics have pointed to the ways in which the LEADS in a Caring Environment leadership capability framework3 reflects the Canadian College of Health Leaders (CCHL) Code of Ethics. They have also discussed the potential for this framework to provide guidance on strong ethical behaviours and professional competencies. The framework provides today’s health leaders with a tool to help them think about and act in ways that will help during turbulent times of transformation and change.1 Leaders must think issues through and be prepared to act based on their personal ethical framework; this takes courage, resolve, and commitment.1 Good governance and effective leadership also require transparency and honesty in decision making, and trustworthiness and attentiveness to the moral climate of your colleagues.2 How might leaders foster the development of these capacities personally and in their staff? How might leaders maintain and strengthen these capacities and behaviours in times of turbulence? In this article, we explore the leadership capacities and behaviours expressed in the LEADS Framework and ways a virtue approach in ethics might assist leaders striving to address the “wicked problems” encountered in complex and rapidly transforming health systems. Some concluding remarks on how to support the development of virtues in leadership are provided.
From the Institute of Health Economics, Edmonton, Alberta, Canada. Correspondence to: Don Juzwishin, PhD, FCCHL, Health Technology Assessment & Innovation, Alberta HealthServices, Suite 200, North Tower, Capital Health Centre 10030 - 107 Street Edmonton, AB T5J 3E4; Phone: (780) 735-0741; Fax: (780) 735-0765; e-mail: [email protected]. Healthcare Management Forum 2012 25:161–164 0840-4704/$ - see front matter © 2012 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2012.07.003
We believe that many decisions healthcare leaders face are difficult, not only because they are politically sensitive and complex, but also because they concern “wicked problems.”4 Wicked problems have the following characteristics (we have drawn partly on paraphrases by Conklin5 for ease of understanding): 1. There is no definitive statement of “The Problem.” Emphasizing different values can mean the problem is understood differently, and one cannot understand the problem without knowing about its context. 2. Wicked problems have no stopping rule. The problem-solving process ends when you run out of resources, such as time, money, or energy, not when an “optimal” solution emerges. 3. Solutions to wicked problems are not right or wrong, but are simply better or worse, or good enough or not good enough. The assessment of proposed solutions varies (sometimes widely) and depends on stakeholder values and goals. 4. There is no immediate test of solutions. Solutions to wicked problems generate waves of consequences. As a result, a solution may lead to undesirable consequences that outweigh the putative advantages of the solution. 5. Every solution to a wicked problem is a “oneshot” deal. There is no learning by trial and error or experimentation. Every implemented solution leaves “traces” that cannot be undone and alters people’s lives in irreversible ways. 6. Every wicked problem is essentially unique. The many factors and conditions that serve to define the problem and a dynamic social context mean that no two wicked problems are essentially alike. Thus, there are no principles of solution that can be applied to classes of wicked problems. In contrast, so-called tame problems have well-defined and stable problem formulation, a definite stopping point, and belong to classes of problems that are all solved in similar,
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
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Juzwishin and Bond
and enumerable, ways.5 These characteristics are meant to give one a sense of what contributes to the “wickedness” of a problem, rather than to determine whether a given problem is wicked or not.5 Indeed, most problems have degrees of wickedness, lying somewhere on a continuum between tame and wicked.5,6 Leaders, especially those in times of healthcare transformation, confront both “tame” and “wicked” problems. Tame problems, such as whether or not treatment for chronic cerebro-spinal venous insufficiency is clinically effective and should be publicly funded may be addressed using a standard linear process. To be sure, such problems may be complex and difficult, but they are amenable to solution. Contrast such problems with the issue of how one ought to remedy the increasing prevalence and incidence of obesity in society. Or arrive at equitable and sustainable arrangements for the appropriate role for the national government in healthcare or the reimbursement of health service provision. Wicked problems seem to be recalcitrant. Further, the social complexity inherent in healthcare decisions and often diffuse responsibility of addressing those problems means that we can expect wickedness of problems to increase as health systems move to respond to broader issues such as the social determinants of health. Consider again the challenge of increasing obesity in Canada. Recent data from the Canadian Institute for Health Information found that more than one in four adults in Canada and just fewer than 1 in 11 children are considered obese. Between 1981 and 2009, obesity rates roughly doubled across all age groups and tripled for youth.7 Bringing obesity and the resulting chronic diseases under control does not have one answer. The problem is wicked ⫺ any approach to its resolution requires understanding and acting on the individual, family and community development, nutrition, exercise, education, counselling as well as metabolic disorders. And how the problem is framed, for example as an “epidemic,” radically alters support for competing policy responses.8 We think a not insignificant number of health policy problems have the shape of wicked problems. The Australian Public Service Commission recognized the challenges for policy makers and produced a report entitled “Tackling Wicked Problems: A Public Policy Perspective.”6 Addressing such problems, the report argues, requires a reassessment of some of the traditional ways of working and solving problems because these problems “challenge our governance structures, our skills base, and our organizational capacity.”6 Nevertheless, the Australian Report focused mainly on how to acquire the broad range of analytical and people skills and the organizational knowledge required to adequately address wicked problems, for example, through stakeholder engagement and by working across organizational boundaries. 162
Virtues, the LEADS Framework, and leadership Principle-based ethical frameworks, that is, those that guide action through a consideration of beneficence, nonmaleficence, respect for autonomy, and justice and that are oriented toward single actions (especially as they are applied in clinical ethics), may not be particularly helpful to leaders facing the uncertainty, intense political pressure, and the seeming intractability that comes with problem wickedness. What often counts most in the moral life in general, and in leadership in particular, is not adherence to moral rules or right action, but reliable character, good moral sense, and emotional responsiveness (though this is not meant to imply that those other things are not important to ethical leadership).9 Hence, virtue approaches to ethics, just because virtues are concerned more with attitude, enduring traits of character, and the ongoing narrative10 than the critical moment of decision, are ideally suited to providing guidance to health leaders through on-going challenges posed by wicked problems.10 A virtue approach recognizes that good leadership is a careful balance between extremes. We must hit the mean between two extremes to act rightly (Aristotle’s “golden mean”).11 Although the mean is relative, it is an objective feature of the situation in which we act and not simply a matter of personal feeling or opinion. The virtue of truthfulness, for example, requires being appropriately motivated to tell the truth about the right things, to the right people, at the right times, and in the right place. To fail in any of these will lead to an act that is either “brutally honesty,” a lie, or an act that has all the outward appearance of truthfulness, but is not a product of one’s character because it is not properly motivated. 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. One of the five domains of the LEADS Framework3 is “Lead Self” and describes four capabilities of a leader: (1) self-awareness, (2) self-management, (3) self-development, and (4) demonstration of character. By envisioning the “demonstration of character” as the “modeling of qualities such as honesty, integrity, resilience, and confidence” the framework aligns itself clearly with a virtue approach in ethics. Importantly, the LEADS Framework ties demonstrations of these qualities to “the inward motivation to do what is right,” thus connecting with philosophic conceptions of virtue. The virtues we are thinking of here derive from the role responsibilities of health leaders, and include Beauchamp and Childress’ six virtues of professional medicine and nursing: care, compassion, discernment, trustworthiness, integrity, and conscientiousness.9 Nevertheless, because health leadership encompasses roles beyond physicians and nurses, the virtues must be suitably broadened to include those working in other capacities. To these six
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
CULTIVATING EXCELLENCE IN LEADERSHIP: WICKED PROBLEMS AND VIRTUES
virtues, we would add, at the least, courage, patience, humility (or magnanimity), resilience, and confidence. We encourage leaders to identify other virtues that they believe are central to achieving excellence in leadership in their particular roles. How might thinking about virtues, such as those described, help with the “wicked problems” encountered in healthcare? We suggest that, because consequences are uncertain, the ethical behaviour and “success” of a health leader is judged not only by the consequences of their leadership, but by the virtues they display through their leadership and the environment these can help to foster. Gibson’s2 description of issues in organizational ethics supports this view. As one example, we think having humility, an awareness of the assumptions guiding one’s actions and thoughts, requires being sensitive to how problems are framed. To return to the issue of obesity, although the increase in rates of obesity does have some characteristics of an epidemic,12 to see obesity as an “epidemic” is to view the problem as having particular characteristics and, therefore, as amenable to particular kinds of solution. Seeing the issue in this way is not uncontroversial,8,12 and alternative frames may, in fact, be more productive, from the view of health policy. Patience is also required to deal with wicked problems. Because wicked problems are essentially unique, part of the art of dealing with wicked problems lies in not knowing too early which type of solution to apply. Macleod and Lewis observe, “A major obstacle to progress is the failure to ask ourselves the wicked questions that will lead to a deep exploration of assumptions we make.. . . Without exploring our assumptions, we will continue to be hostage to our indifference to failure and be unable to reach our improvement potential.”13
Support for the development of virtues of leadership Virtues are the result of sound habits of mind and heart, and a will that drives us toward excellences of character. Although leaders differ in the character traits they possess, all leaders can cultivate the traits important to ethical leadership. Similarly, Havard14 believes that leaders are not born but trained; excellence in leadership is the result of habits acquired through practice. For example, to become a courageous person, you must perform courageous acts. This requires making a conscious effort to do the courageous thing in situations in which courage is appropriate. The fact that virtues are the product of teachable habits suggests many ways that the CCHL and others might support the development of these excellences of leadership. Bashir Jiwani, director of Ethics Services at Fraser Health in British Columbia, has developed decision support tools15 that can assist leaders in a way that supports the virtues mentioned throughout this article. The support tools are
based on the idea that ethically justified decisions support not just the decision itself, but living in a desired way and being a particular kind of person. Maintaining integrity, which for Dr. Jiwani is about “having our behaviour match up with what we say,” is of utmost importance. The CCHL, at both national and regional levels, is already organizing programs to introduce healthcare leaders to the LEADS Framework. Chapters might include activities to consider the delivery of education sessions on the code of ethics, their relevance and importance of virtues, and how they can support the competency requirements of today’s healthcare leaders, particularly in effectively tackling wicked problems. Developing an ethics concentration or stream in the annual meetings of CCHL to help interrogate and address wicked problems could also be helpful. This would provide health leaders with a community or critical mass of encouragement and support toward tackling the wicked problems. The encouragement of including mentors and role models would be of enormous benefit to young and emerging leaders to help set the stage for pursuing excellence. Story telling is an effective way of communicating and learning and the CCHL might consider the development of an electronic anthology on healthcare ethics – cases, to serve as models for practice-based learning, to be available through the social media and accessible to emerging and practicing leaders. Identifying and developing case studies of the demonstration projects from across the country of courageous initiatives successful in the face of adversity could serve as beacons of hope for the direction pursue. Michael Rachlis, in his book Prescription for Excellence,16 provides numerous examples from across Canada of successful efforts to improve access to and quality of healthcare in Canada. Supporting and encouraging links between healthcare organizations and educational institutions’ teaching and research of wicked public health issues could be another supportive endeavour. Finally, CCHL could encourage CHE aspirants and those pursuing fellowship to study ethical issues and how pursuing the virtues identify challenges to be addressed and suggest paths to satisfactory results. These studies could be published and available on the CCHL web site for health leaders.
Concluding remarks We have argued that leaders ought to look to the virtues of leadership for guidance when addressing wicked problems in healthcare. Today’s call for transformative leadership relies on strengths of character that require more than just “keeping the ship afloat;” it requires our leaders to set the rudder headlong into the treacherous waters ahead. CCHL and the LEADS Framework can play an important in supporting health leaders developing the virtues of health leadership, as well as supporting a national conversation on effective approaches to virtuous leadership. CCHL must
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012
163
Juzwishin and Bond
also be prepared to step in to support a leader who has acted ethically and courageously but has encountered negative consequences. Promoting these excellences and providing leaders with the resources and support with which to develop them will be instrumental in dealing successfully with the wicked problems that lie ahead.
ACKNOWLEDGMENTS The authors would like to thank Katherine Duthie, Owen Heisler, and Eric Wasylenko for providing detailed comments on this paper. Thanks also to Christa Harstall for her discussion and feedback in the initial stages of writing this article.
REFERENCES 1. Juzwishin DW. Ethical management in health services administration: a sequel. Healthc Manage Forum. 2011;24:31–34. 2. Gibson JL. Organizational ethics: no longer the elephant in the room. Healthc Manage Forum. 2012;25:37–39. 3. LEADS in a Caring Environment [web site]. Canadian College of Health Leaders. Available at: http://www.cchl-ccls.ca/ default_conferences.asp?active_page_id⫽6492. Accessed June 11, 2012. 4. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. Policy Sci. 1973;4:155–169.
164
5. Conklin J. Wicked problems and social complexity, In: Conklin, J. Dialogue mapping: building shared understanding of wicked problems. New York: Wiley; 2005. 6. Australian Government. Tackling wicked problems: a public policy. Perspectives. 2007. 7. Canadian Institute of Health Information. Increased activity and healthier eating can improve obesity rates, but aren’t the only factors at play. Available at: http://www.cihi.ca/cihiext-portal/internet/en/document/factors⫹influencing⫹health/ environmental/release_20june11. 8. Barry CL, Brescoll VL, Brownell KD, et al. Obesity metaphors: how beliefs about the causes of obesity affect support for public policy. Milbank Q. 2009;87:7– 47. 9. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th ed. New York: Oxford University Press; 2009. 10. Campbell A. A virtue-ethics approach. In: Ashcroft R, et al, eds. Case analysis in clinical ethics. New York: Cambridge University Press; 2005:45–56. 11. Holmes RL. Basic moral philosophy, 4th ed. New York: Wadsworth Publishing; 2006. 12. Flegal KM. Commentary: the epidemic of obesity ⫺ what’s in a name? Int J Epidemiol. 2006;35:72–74. 13. Macleod H, Lewis S. Asking the unaskable – thinking the unthinkable. Health Care Q. 2012;15:6 –7. 14. Havard A. Virtuous leadership ⫺ an agenda for personal excellence. New York: Scepter; 2007. 15. Jiwani B. Incorporating ethics into daily practice. Available at: http://www.incorporatingethics.ca/. Accessed June 5, 2012. 16. Rachlis M. Prescription for excellence. Toronto: HarperCollins; 2004.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2012