The moral foundation of medical leadership: The professional virtues of the physician as fiduciary of the patient

The moral foundation of medical leadership: The professional virtues of the physician as fiduciary of the patient Frank A. Chervenak, MD, and Laurence B. McCullough, PhD New York, New York, and Houston, Texas Leadership in medicine, as in other settings, should be based on values that provide appropriate direction for the use of institutional power and authority. Leadership also requires managerial competence. Managerial knowledge and skills can be used for worthy and unworthy goals and therefore require a moral foundation. Using the methods of ethics, we argue that the concept of the physician as the moral fiduciary of the patient should be the moral foundation of management decisions by physician-leaders. We take this concept from the history of eighteenth century medical ethics and develop it in terms of four professional virtues—selfeffacement, self-sacrifice, compassion, and integrity. We apply these four virtues to show how physicianleaders should create a moral culture of professionalism in health care organizations. We then identify four vices—unwarranted bias, primacy of self-interest, hard-heartedness, and corruption—that undermine this moral culture of professionalism. Because health care organizations now play a central role in patient care, their moral culture and therefore physician-leaders have become vital elements in physicians being able to maintain their professionalism. Physician-leaders bear major responsibility to shape organizational cultures that support the fiduciary professionalism of physicians. (Am J Obstet Gynecol 2001;184:875-80.)

Key words: Ethics, fiduciary, professionalism, virtues, physician-leaders

Leadership has always required both managerial and moral excellence. Plato teaches us in The Republic that the ideal leader is someone who commits himself and is trained for a life of service and devotion to fellow citizens.1 The power and authority that devolve upon the philosopher-king should be directed to the good of others. When directed primarily to self-interest, Plato also teaches, such power and authority corrupt and are dangerous to the good of all. In other words leadership requires competence and the direction of that competence toward human good. Plato would recognize and endorse the following description of leadership from the Drucker Foundation,2 established by Peter F. Drucker, one of the leading scholars of business management: Leadership without direction is useless. Uninformed by ideas about what is good and bad, right and wrong, worthy and unworthy, it is not only inconsistent, but dangerous. As the pace of change in our world continues to accelerate, strong basic values become increasingly necessary to guide leadership behavior.2 From the Department of Obstetrics and Gynecology, New York Presbyterian Hospital, Weill Medical College of Cornell University, and the Baylor College of Medicine, Center for Medical Ethics and Health Policy. Presented at the Nineteenth Annual Meeting of the American Gynecological and Obstetrical Society, Williamsburg, Virginia, September 7-9, 2000. Reprint requests: Frank A. Chervenak, MD, New York Presbyterian Hospital, Weill Medical College of Cornell University, Department of Obstetrics and Gynecology, 525 E 68th St-J130, New York, NY 10021. Copyright © 2001 by Mosby, Inc. 0002-9378/2001 $35.00 + 0 6/6/113854 doi:10.1067/mob.2001.113854

This view is echoed in other current texts on leadership and management.3-5 We are all familiar with the rapid pace of change in the structure and financing of medical care. Physician-leaders must provide the right direction for this change. We cannot, and therefore should not, look to insurance companies or the government to provide this needed direction. The first component of leadership that has received most of the attention is managerial—mastery of the management knowledge and skills necessary to protect the organization’s economic interests.2-5 In years past, when there were virtually unlimited sources of funding from indemnity insurers and the government, the level of management knowledge and skill required of medical leaders was low. With the advent of managed care in its many forms and the changes in Medicare and Medicaid reimbursements, the level of management skills required of physician-leaders has risen enormously. Management styles that have been successful in the past, in an era of economic abundance in health care, are at risk for becoming prescriptions for failure today in an era of quality and cost control. It should be obvious to all that mastery of the complex knowledge and skills required to manage the contemporary health care organization is essential for medical leadership. A crucial antidote to disillusionment with some physician-leaders is that they become competent managers. In the absence of such competence, creating and sustaining a culture of professionalism in health care organizations becomes impossible. In our view competent management skills are a necessary, but not sufficient, condition for medical leadership. 875

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As Plato and the Drucker Foundation would teach us, management skills can be used, on the one hand, in the pursuit of the goal of excellence in patient care, medical education, and clinical and basic science research, with the protection of the organization’s economic interest an important means for achieving this goal.6 On the other hand, the protection of the organization’s economic interest can become the end or overriding goal of management decisions. We should not lead our institutions toward this goal. Instead, we should lead on the basis of a core concept in the history of medical ethics, the physician as the moral fiduciary of the patient. The purpose of this paper is to argue for this core concept of medical ethics as the moral foundation of medical leadership and to argue for the role of physician-leaders in creating and sustaining a moral culture of professionalism in health care organizations. The concept of the physician as a professional (ie, as the moral fiduciary of the patient) was introduced into the English language literature of medical ethics by Dr John Gregory (1724-1773)7 and into the ethics of health care organizations by Dr Thomas Percival (1740-1803).8 Their ideas crossed the Atlantic and influenced American medical ethics, starting in the eighteenth century with Benjamin Rush, continuing in the nineteenth century with the American Medical Association’s Code of Ethics of 1847, and defining the professional nature of the doctor-patient relationship to this day.9-11 Pelligrino and Thomasma12 have emphasized the central role of the virtues of this relationship. Gregory and Percival described moral fiduciary physicians and organizations in a way that Plato would recognize and that anticipates contemporary literature on leadership and management: Individuals and institutions that act primarily to protect and promote the interests of patients, that keep self-interest in a systematically secondary position, and that have confidence that a commitment to scientific and moral excellence in patient care will result in the long run in appropriate remuneration and deserved prestige.13 On this account, making the pursuit and protection of economic interests the primary goal of patient care is unethical, because doing so undermines the physician’s ability to maintain his or her professionalism. Gregory took the maintenance of professionalism to be the task and responsibility of individual physicians. They should form their character and conduct themselves in practice by accepting the requirements of the concept of the physician as a moral fiduciary of the patient. Percival was one of the first in the history of medical ethics to begin to understand that, in the setting of the hospital and other health care organizations, successful maintenance of professionalism also vitally depended on the moral culture of the organization (ie, on the decisions of those responsible for leading and managing it). In the

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era of managed care and the consequent need to improve quality and control costs, maintenance of professionalism depends even more on the decisions of managers and the moral culture that their decisions create in a health care organization. Physicians cannot maintain their professionalism alone anymore. Creating and sustaining a moral culture of professionalism in health care organizations therefore requires moral leadership. Moral leadership means that physician-leaders should make the concept of the physician as a moral fiduciary the moral foundation of their management decisions about patient care,6, 14 medical education,6, 15 and clinical research.6 From Gregory and Percival came four professional virtues that form the moral basis of the professional, fiduciary relationship of physician to patient.13 These virtues are self-effacement, self-sacrifice, compassion, and integrity.16 In the clinical setting self-effacement means that clinical judgment should not be affected by differences between doctors and patients, such as class, gender, and race, that can introduce irrelevant and destructive bias into clinical judgment and practice.17, 18 Similarly, selfeffacement requires physician-leaders to be unbiased by factors such as one’s own specialty or subspecialty, friends and colleagues, one’s gender or ethnicity, and other factors that can result in arbitrary and unfair treatment of subordinates. In the clinical setting self-sacrifice means that the physician should be willing to take reasonable risks to health, income, and job security when required to do so to meet the needs of patients.12, 16 Similarly, the physician-leader should be willing to restrain self-interest, including organizational self-interest, as required for subordinates to sustain their primary focus on their fiduciary responsibilities to patients, trainees, or research subjects. The physicianleader should also be willing to take risks to job security, as required to create a moral culture of the organization defined by professionalism, grounded in the fiduciary obligations of physicians and health care organizations to their patients. In the clinical setting compassion means that the physician should always be aware of the patient’s pain, suffering, and distress and promptly seek to ameliorate them.12, 16 The main obligation in compassion of the physician-leader is to the physician-patient relationship and its fiduciary character. For physician-leaders, compassion therefore requires recognition of two kinds of suffering and distress on the part of their colleagues. The first kind occurs when the physician’s ability to meet fiduciary obligations to patients is adversely affected by decisions to ration resources that do not take those fiduciary obligations in account and from serious threats to legitimate self-interests of subordinates to adequate income and job security as institutions cut services and downsize. The second kind of stress occurs when the physician experiences reductions in resources that can be shown to be

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consistent with fulfilling fiduciary obligations to patients. The physician-leader, out of compassion, may be obliged to commiserate with colleagues experiencing this second kind of stress in response to change but to actively review and, if necessary, change his or her management decisions in response to the first kind of stress. In this respect the physician-leader should routinely ask subordinates, “What can I do to help?” In the clinical setting, integrity requires the physician to practice medicine according to standards of intellectual and moral excellence.12, 16 This does not mean doing the most for patients but doing what will benefit them clinically. Integrity therefore requires the physician-leader to make management decisions that are based on scientific evidence, well-documented outcomes, reliable, wellformed clinical judgments, and sound, balanced economic judgments, especially at the interface between professional colleagues and organizational resources.5 Essential to integrity is open and honest communication with subordinates and accountability for the bases of management decisions. In this way the physician-leader creates and sustains a moral culture of professionalism (ie, a clear pattern of management decisions that sustains doctor-patient relationships in the organization as moral fiduciary relationships). Part of open communication is accessibility (eg, not using subordinate administrators or staff to buffer or block access). Corresponding to these four professional virtues are vices, which physician leaders should rigorously avoid. In the clinical setting unwarranted bias, the antithesis of self-effacement, harms patients (eg, the psychologic harm done to women who have experienced romantic or sexual overtures or contact from their doctors19). For the physician-leader, negative bias that is based on race or gender can lead to unethical and even illegal forms of discrimination in hiring or promotion. The more insidious version of this vice takes the form of positive bias in hiring or promotion or the allocation of resources on the basis of gender, personal relationship, or shared specialty or subspecialty. When institutions merge, this vice can take the form of favoring departments or individuals in one’s home institution when those departments or individuals are not objectively better than their counterparts in the merger partner. Physician-leaders in managed care who preferentially contract work to friends or former associates show similar unwarranted bias. Self-effacement requires the physician-leader to be rigorously impartial in all decisions about employment, promotion, contracting for services, and allocation of resources. In the clinical setting, self-sacrifice is violated when physicians put self-interest above the health-related interests of the patient (eg, referring less frequently than warranted to maximize one’s year-end payment under a withhold compensation plan). Clinical investigators violate self-sacrifice when they use the “thumb screw of persua-

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sion”20 to put undue pressure on their own patients to enroll in their own clinical trials or when they advertise for subjects in a potentially misleading way. The academic physician-leader violates self-sacrifice when, as a chairman or division chief, he or she insists on being senior author on every paper coming from the department or division, a form of self-aggrandizement and arrogance that threatens the intellectual and moral integrity of the academic enterprise. The managed care physician-leader who inappropriately denies appeals for expensive medical care to maximize his or her year-end bonus acts on greed, which at best threatens and at worst undermines the culture of professionalism and therefore the fiduciary relationships of colleagues, contributing to a morally corrupt organizational culture. The physician-leader who claims attention, especially in the electronic media, for the clinical work or innovation of subordinates compromises the virtue of self-sacrifice. Self-sacrifice requires the physician-leader to be other-directed, not self-directed, and to display humility by focusing on the professional interests of subordinates, not on his or her own money, prestige, or power.2 For example, a physician-leader should accept and, indeed, support earnings for subordinates that are justifiably higher than the physician-leader’s own. In clinical practice, physicians violate compassion when they are indifferent to the pain, suffering, and distress of their patients. When physicians confront unavoidable pain and suffering or must cause it themselves to help patients, compassion requires them to do so reluctantly, so that they will not overlook less painful or stressful alternatives (eg, considering a lumpectomy rather than a radical mastectomy for the clinical management of breast cancer). The physician-leader who utilizes salary freezes, salary reductions, or terminations to control costs for justifiable reasons of overall organizational well-being but who does not also take serious account of the impact of such decisions on the lives of employees and their families lacks compassion. For example, rather than take the expeditious course of termination, compassion for an employee who might still be of value to the organization argues for working with that individual to be productive and contribute to the organization’s goals. When physicians lack compassion, they become hard-hearted, against which Gregory warned us.7 Hard-heartedness damages the moral sensibilities of the physician, threatening the fiduciary relationship. The physician-leader who seeks productivity improvement by demanding that everyone do more with less but without seriously considering the professional and personal impact on subordinates lacks compassion and risks creating a work environment that is exploitative and even inhumane. Such an environment is antithetical to the moral culture of a fiduciary health care organization. The physician-leader who never sees patients risks diminishment of the moral sensibilities required of physicians and thus risks indifference to or an

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invidious distance from the professional lives of colleagues. Such physician-leaders will be of little help, for example, to their colleagues who experience a catastrophic loss of an unexpected death caused by an unexpected fatal pulmonary embolism after a normal vaginal delivery. Compassion requires the physician-leader to evaluate consistently each physician’s behavior and contributions to the organization from the perspective of the clinician on the front line. The physician in practice violates integrity when he or she tells a hospitalized patient that Medicare requires the physician to order early discharge when the real reason is that the physician is trying to avoid becoming an outlier. This is deception in the form of a lie. Deception can take more subtle forms, such as providing incomplete information to the patient or using terms that are deliberately ambiguous (eg, quoting success rates and level of risk from the literature only but leaving out one’s own experience or by implying that medical students are doctors by introducing students as “my associates”). In addition, the physician who refuses, despite overwhelming evidence, to take responsibility for a bad outcome violates integrity. Lofty mission statements, promulgated by “leaders” whose own behavior contradicts and even undermines the values expressed in those mission statements, create a Kafkaesque organizational culture that corrupts everyone in it. Physician-leaders who, to avoid accountability for both action and inaction, say different things to different subordinates, thus creating obfuscation and stress, lack integrity. Frank deception may be less the problem than such strategic ambiguity. A medical director of a managed care plan who makes allocation decisions about medical necessity or appropriateness about nonexcluded clinical intervention that results in harm to patients and subsequently hides behind the language of ERISA (Employee Retirement Income Security Act) or claims that he or she is simply making a business, not a clinical, decision lacks integrity.6 Similarly, physician-leaders of medical schools who blame others for poor administrative decisions as a way to avoid accountability lack integrity. A physician-leader who creates or exploits levels of organizational bureaucracy to diffuse and therefore avoid accountability for decisions that he or he has made lacks integrity. In summary, such physician-leaders corrupt themselves and their organizations, by putting self-interest— in power, authority, income, or job security—ahead of their obligation to sustain a moral organizational culture of fiduciary service to patients. Integrity requires the physician-leader to be open and honest in all communications with subordinates and to be accountable to subordinates for management decisions. Fulfilling this obligation requires the physician-leader to prevent obfuscation in bureaucratic structures and not to exploit it when it emanates from such structures. Academic physi-

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cian-leaders should navigate the treacherous course between the Scylla of the medical school physician organization and the Charybdis of the hospital administration by holding both strictly accountable to the moral foundation of their respective leadership roles. As we have noted already in several places, whether the physician-leader makes virtues or vices the basis of his or her management decisions and organizational policy matters is vital to the moral life of health care organizations, because virtues are the right direction and vices the wrong direction. The tools of medical management, such as finance, communication, and strategic planning, are indifferent to whether the physician-leader uses them with virtuous or vicious foundations. The physicianleader who consistently uses institutional power and authority to advocate for the professional virtues of the physician as a moral fiduciary of the patient and physician-patient relationships that are based on these virtues will create and sustain a moral culture of professionalism in his or her organization. Doing so will crucially support physicians as the moral fiduciaries of their patients. This will be preventive ethics at its best, in the service of professionalism. To the extent that physician-leaders follow the vices described here, they will create an organizational culture of unbridled self-interest, which undermines fiduciary responsibility and therefore professionalism. Such an organizational culture is antithetical to the moral life of service that defines the physician as the moral fiduciary of the patient. This would be an organizational culture devoid of moral worth, occupied by physicians who would, in T.S. Eliot’s words, be “hollow men” and “stuffed men,”21 working in the “dead land.” This is indeed the world we will find ourselves in if too many physicianleaders lead health care organizations in the wrong direction. Ancient thinkers of both the West, such as Plato,1 and the East, such as Confucius,22 taught us that living according to the virtues we have described here sustains leaders and their subordinates in ways that money, prestige, and power cannot. Gregory echoes this thinking when he tells his reader that the trust of patients, which is earned by living according to these virtues, cannot be “purchased by the wealth of India.”7 In our view a physician-leader today is defined as the moral fiduciary of the professionalism of the doctor-patient relationship in clinical practice, medical education, and medical research.6, 14 The professional virtues of self-effacement, self-sacrifice, compassion, and integrity, rather than the vices of unwarranted bias, the primacy of self-interest, hardheartedness, and corruption, should provide the moral foundation of the physician-leader’s motivations, decisions, and actions. The physician-leader who acts on these virtues will lead institutions in the right direction, toward a moral culture of professionalism.

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This is crucial, because institutions now play a central role in medical care. Patients are “covered lives,” the responsibility of large organizations such as managed care organizations, physician-hospital alliances, and academic practice plans. Because individual physicians discharge their fiduciary obligations in and through institutions, the moral culture of health care organizations has become a vital element in sustaining their professionalism. Physician-leaders, more than individual physicians in practice, bear the responsibility to shape organizations’ cultures that support the fiduciary professionalism of physicians with daily responsibility for patient care, medical education, and research. Moreover, subordinates should support physician-leaders who comport themselves according to these virtues and be prepared to oppose those who do not, by calling them back to the foundation of their leadership role in the professional virtues. To preserve medicine as a moral fiduciary profession, those to whom physician-leaders report should do the same. Creating and sustaining a professional culture in health care organizations is an inescapable moral responsibility of all organizational leaders, especially physicianleaders and even more so academic physician-leaders. REFERENCES

1. Plato. Republic. In: Cooper JM, Hutchinson DS, editors. Complete works. Indianapolis: Hackett; 1997. 2. Hesslebein F, Goldsmith M, Beckhard R, editors. The Drucker Foundation. The leader of the future. San Francisco: Jossey-Bass; 1996. 3. Bradford DL, Cohen AR. Managing for excellence. New York: John Wiley; 1997. 4. Kotter JP. Leading change. Boston: Harvard Business School Press; 1996. 5. Curry W, editor. New leadership in health care management: the physician executive. 2nd ed. Tampa: American College of Physician Executives; 1994. 6. McCullough LB, Chervenak FA. Ethical challenges in the managed practice of obstetrics and gynecology. Obstet Gynecol 1999;93:304-7. 7. Gregory J. Lectures on the duties and qualifications of a physician. In: McCullough LB, editor. John Gregory’s writings on medical ethics and philosophy of medicine. Dordrecht: Kluwer; 1998. 8. Percival T. Medical ethics, or a code of institutes and precepts, adopted to the professional conduct of physicians and surgeons. In: Pellegrino E, editor. The classics of medicine library. Birmingham: Gryphon Editions; 1985. 9. Baker R, Porter D, Porter R. The codification of medical morality: historical and philosophical studies of the formalization of Western medical morality in the eighteenth and nineteenth centuries. Vol. 1. Medical ethics and etiquette in the eighteenth century. Dordrecht: Kluwer; 1993. 10. Baker R. The codification of medical morality: historical and philosophical studies of the formalization of Western medical morality in the eighteenth and nineteenth centuries. Vol. 2. Anglo-American medical ethics and medical jurisprudence in the nineteenth century. Dordrecht: Kluwer; 1995. 11. Baker RB, Latham SR, Caplan AL, Emanuel LL. The American medical ethics revolution: how the AMA’s code of ethics has transformed physicians’ relationships to patients, professionals, and society. Baltimore: The Johns Hopkins University Press; 1999. 12. Pelligrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press; 1993.

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13. McCullough LB. John Gregory and the invention of professional medical ethics and the profession of medicine. Dordrecht: Kluwer; 1998. 14. Chervenak FA, McCullough LB, Chez R. Responding to the ethical challenges of managed care in the practice of obstetrics and gynecology. Am J Obstet Gynecol 1996;175:523-7. 15. Fries MH: Professionalism in obstetrics-gynecology residency education: the view of program directors. Obstet Gynecol 2000; 95:314-6. 16. McCullough LB, Chervenak FA. Ethics in obstetrics and gynecology. New York: Oxford University Press; 1994. 17. Kopelman LM, Lannin DR, Kopelman AE. Preventing and managing unwarranted biases against patients. In: McCullough LB, Jones JW, Brody BA, editors. Surgical ethics. New York: Oxford University Press; 1998. p. 242-54. 18. Kopelman L. Help from Hume reconciling professionalism and managed care. J Med Philos 1999;24:396-410. 19. McCullough LB, Chervenak FA, Coverdale JH. Ethically justified guidelines for defining sexual boundaries between obstetriciangynecologists and their patients. Am J Obstet Gynecol 1996; 175:496-500. 20. Ingelfinger FJ. Informed (but uneducated) consent. N Engl J Med 287;1972:465-6. 21. Eliot TS. The hollow men. In: Untermeyer L, editor. Modern American poetry. New York: Harcourt Brace & World; 1962. p. 395-6. 22. Leys S. The analects of Confucius. New York: WW Norton; 1997.

Discussion DR WARREN H. PEARSE, Edgewater, Maryland. There’s an old saying: “Before you criticize someone, walk a mile in his shoes.” That way, if he gets angry, he’ll be a mile away and barefoot! My discussion is not meant to question what Dr Chervenak has eloquently presented to us. Rather I would contend that if it is possible to implement these concepts, it would be one giant step for both physicians and patients, along a very rocky road. The first challenge for a discussant is to be certain he or she clearly understands the title of the paper. I didn’t, but I was led gently out of the wilderness by Noah Webster. The word fiduciary is usually an adjective but occasionally a noun, as it is in this title, “designating a person who holds something in trust for another.” I delved more deeply. The Latin verb fidere (meaning to trust) was the base of two English words—(1) the noun faith (as in a religious belief) and (2) the adjective (rarely a noun) fiduciary meaning “to hold something in trust.” However, the Latin fidere is not a progenitor of the word fidelity, as I thought it might be. Now I understand the title. Drs Chervenak and McCullough are both thoughtful and well written in the field of medical ethics. The references for this manuscript included, after beginning powerfully with Plato’s Republic, five of their prior joint publications. I know there are many more. The manuscript sets forth four virtues and four vices for our attention. These are virtues that we understand apply to the individual physician-patient relationship. Then we are asked to help apply these virtues to a health care organization culture. This fairly large chasm can be leaped, but remember health care organizations include many leaders other than physicians.

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Two recent, yet to be published studies demonstrate that (1) it is possible to provide valid data about the quality of patient care (for example, the presence or absence of counseling about menopause) to a health care organization or a purchaser and (2) most corporate purchasers of health care for their employees—unless their workforce exceeds 1000 people—have no clue about quality and care little about anything except cost and the number of physicians signed up by the health care organization. The key questions are perhaps the following: 1. How can the four major virtues cited by the authors be implemented in a culture that says “the protection of the organization’s economic interests is our primary goal?” 2. What about the secondary virtues necessary for proper patient care—acceptance, promptness (even including prompt payment to physicians), continuity, and more. Are these a place to begin? In this realm of stem cell research and the Cochrane Collaborative, perhaps we should begin with a moral fiduciary. PRESIDENT GABBE. I wonder if you could address how the physician can avoid exercising one of the virtues, that is, self-sacrifice to the point of self-injury. How can a physician protect himself or herself in that setting? DR CHERVENAK (Closing). It would be helpful to put things in a historical perspective. If you think we have problems now with the crisis we face in medicine, these problems parallel the situation in eighteenth century Great Britain. At that time unbridled self-interest was

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rampant and the lack of professionalism was the dominant culture. Leaders of that time faced the same decisions we have to face now: Should we practice medicine as a business by which we make a living, or should we primarily practice medicine as a profession by which we serve our patients? In my presentation I argued that adherence to the core of our professional virtures, which I believe Dr Pearse and our organization would support, gives us a moral advantage as we fight battles with organizations that act on unbridled self-interest and give primacy to the bottom line. Dr Pearse, this is a battle we need to fight on many fronts. This concept of physician as fiduciary and managed care companies as cofiduciaries has been accepted in Texas, where managed care organizations can be sued for malpractice if they make decisions that injure patients. Cases in state and federal courts seek to establish the same principle. I believe this is a winnable battle. Our contribution as physician leaders is to create organizational cultures that uphold the fiduciary role of physicians. Dr Gabbe raises an excellent question. Self-sacrifice should not become self-destruction. To avoid turning a professional virtue into a vice, self-sacrifices need to be balanced against legitimate self-interest. Just as with principle-based approaches to clinical ethics, in which principles are prima facie and need to be analyzed in individual circumstances to determine their limits, so too with the professional virtues. A major challenge for our profession is to determine reliably what those limits are.