11
Leadership Development and the Cultivation of Practical Wisdom
Key Questions
How can we cultivate practical wisdom in medical leaders so that they make wise decisions?
How could this help leaders in other contexts to lead more ethically?
Introduction1
Despite having professional lives that are rife with competing demands and relationships, questions have rarely been asked about what professionals need in order to be equipped morally (or otherwise) to deal with these. The most ethically challenging decisions in any organization are often cases in which there are multiple conflicting moral and functional goals that a leader feels bound to pursue. For instance, in medical settings, a consultant must weigh up the different benefits that they can pursue for their patients—should they seek to prolong life or ease pain in the palliative care setting? The good for a particular patient must also be weighed up against the good for others—for instance, who, out of a range of suitable patients, should benefit from an organ transplant when only one organ is available. Or, when five patients require emergency operations to save life or limb, who should benefit from being at the front of the queue? Even when it is clear initially what benefit or outcome to pursue, there are often multiple ways in which this outcome or an alternative can be reached—is it best, for instance, to prescribe a drug, advise on nutrition, advocate surgery or allow the patient to choose. This is often further complicated by co-morbidities such as obesity, high blood pressure, high cholesterol and so on.
When faced with such uncertainty, whether this be in a medical setting or otherwise, the response of many leaders, is to reach for the rule-book—that is, to make ever more intricate guidelines, protocols and procedures to determine what must be done in morally fraught situations. Over the last 25 years, 73 clinical guidelines could be found in PubMed in 1990 and 7.508 in 2012, indicating a significant growth in clinical practice guidelines.2 However, in the face of this tide of ever-closer codification of good medical practice, many clinicians bemoan the loss of their professional autonomy with practitioners noting the inability of these guidelines to take into account the complexity of caring for patients with multiple comorbidities. In one reported instance, practitioners resisted (and, practically speaking, sabotaged) one system3 that attempted to codify and constrain physicians’ decisions. The paradox for leaders as they govern practice today is this: while these rule-based mechanisms are supposed to bring clarity, accuracy and consistency to decision making and make it easy to know what to do, leaders themselves experience the growth of rules, guidelines and procedures as alienating, confusing and even demeaning. They also recognize the artificial work as imagined perspective of these guidelines: they tend to oversimplify the complexity of the clinical situation, making patients single-pathology entities rather than the complex multifaceted (medically and socially) humans that they are.
In medical ethics, a large body of work exists on the virtues that enable good ethical decision making. The field of medical ethics singles out a number of virtues of the good doctor for attention; amongst others, these include empathy, care, truthfulness and justice.4 According to medical ethicists like Pellegrino and Thomasma, however, practical wisdom (or what Aistotle called phronesis) “occupies a special place” among these virtues.5 For some, phronesis is regarded as being “indispensable” to good medical practice because it coordinates all the different moral virtues that the doctor must bring to ethical decisions as part of wise moral action. There is also a growing body of work in the generic leadership literature that is addressing the issue of phronesis for leaders.6 This takes us to the questions posed at the start of this chapter.
The authors are currently addressing these issues by researching doctors who take up a clinical leadership role either as consultants or General Practitioners (GPs).7 Although the focus of our research is the medical community, the issues are relevant to any leadership role in a practice-based professional community in business, education, law and so on. In this chapter we summarize the dominant theoretical discourses,8 the current challenges to those discourses and then we open new horizons for acting in this area. We explore what might be missing for this particular group of medical leaders as they navigate their way through pre-clinical education, clinical training and onto consultant or GP leadership roles. As with other professions, ethical leadership is frequently complex with the right decision for one patient not necessarily being the right decision for another.
One author9 suggests that education within the professions (or professional education) does not support either the collective or individual development of virtues, and we are beginning to see indications that this could well be the case for medical education. Certainly what we find is that doctors get very little education and training that helps them cultivate their executive virtue, phronesis. In the final “new horizons” section, we suggest what form of research and outcomes might help leaders cultivate practical wisdom in order to make ethical decisions that are not just based on rules and guidelines offered to their professions. These include resources that engage the learner-leader at a psychological, emotional and personal level beyond a formulaic set of principles or guidelines for a given profession.
Dominant Theoretical Discourses
Theoretical discourses to leadership ethics fall into three types: outcomes based (consequentialist), rule or guideline based (deontological) and the “good person” or collective (virtue ethics). For example, in medical leadership ethics as outcomes based, the doctor’s main ethical duty is to secure the best possible outcome for a patient (or a group of patients) by assessing the positive and negative consequences that result from any decision, intervention, treatment or policy. The rule-bound doctor’s essential duties are laid out in a set of principles of medical ethics that they must absolutely uphold (regardless, sometimes, of the real consequences). For the “good person”, based on Aristotle’s principles, the main concern in medical ethics is not that the good doctor must do something in a particular way, rather it is that the doctor must show good moral character (or “virtue”) in how they practice medicine. Virtue ethics holds that the right thing to do is what a leader of good character would do in that situation.
As mentioned earlier, one of the dominant ethical stances for many professions including the medical profession is rule-bound or what some refer to as deontological ethics; in other words, their profession is obliged to follow guidelines or a set of principles. There are, of course, some exceptions like the obligation of confidentiality that are outcomes-based or consequentialist. Overall, all professions, including medicine (where for example the General Medical Council) have issued guidance for medical leaders), have witnessed a huge growth in the number of policy documents in recent years/This tells us that the profession recognises the need for more clarity around professional behaviors and decision making, but the less visible gray areas are still prevalent and no guidance—however good—can cover every context. So on the one hand we seem to have fewer ambiguous areas but how to apply the rules in difficult situations or where there is a conflict is as difficult as ever.
We argue that the culture of providing ever more rules has at least two unintended and unhelpful consequences. First, people switch off: there is too much to know and they are difficult to take in as they are rarely relevant at the time they are read. Second, people stop taking responsibility for what is the right thing to do—because all they have to do is follow the rules—so people lose the skill of practicing ethical judgment.10
Common Challenges to These Discourses
The main challenge to all three of the above discourses comes from MacIntyre.11 His thesis is that we are living in a time “after virtue”, that we have lost the narrative resources to make good ethical decisions in any practice community. He argues that this is due to the scientific, rationalistic neoliberalistic (market driven) influences and individualistic effectiveness and efficiency interests that have become dominant since the Enlightenment.12 For MacIntyre, the main driver of practice corruption is the prioritisation of the “external goods” of money, status and power over the “internal goods” of practice excellence, personal fulfilment and outcomes that contribute to wellbeing for all. The media is littered with national and international practice corruption scandals of this nature in all sectors, so we could argue that his thesis has some credence and has come to fruition (see Box 11.1).
Whether it is fraud or fragmented and competing moralities in these situations, the primary issue is one of ethics. To use MacIntyre’s language: although the antecedent external goods and premise ideologies are different, corruption occurs when drives towards money, status or power (external goods) rather than practice excellence, job satisfaction or patient benefit (internal goods) becomes dominant. Hence, for leaders in any professional community the cultivation of debate, reflection and discussion on ethical decision making is timely, globally significant and beneficial.
Box 11.1 Health Care Corruption in the US and the UK
In the United States, we have seen the corruption to health care on a staggering scale. The United States spends more on health care than any other industrialized country but despite the extraordinary level of spending, very little attention has been given to corruption, fraud, waste and abuse in the US health care delivery system. Sparrow13 suggests that fraud and corruption in the health care system exhibits all the standard challenges of white-collar professions, and he goes on to argue for enhanced ethical decision making on the part of professionals. The UK is apparently no better and in an attempt to stem the tide of corruption the Counter Fraud Centre and the City of London Police, Economic Crime Academy (CIPFA) launched a new professional accredited qualification to boost business and public sector defences against bribery and corruption in May 2016. The Certificate in Anti-Bribery and Corruption Studies, will equip counter-fraud, finance and regulatory compliance specialists with up-to-date knowledge of corrupt practices, legislation and investigation. This world-leading approach to professionalism came as global leaders gathered in London in May 2016 for a major summit on tackling corruption. Tiffen, Head of the CIPFA Counter Fraud Centre was quoted as saying at the summit, “Today’s summit is putting anti-corruption high on the agenda around the world. We hope it will deliver a new era of international cooperation and information sharing”.
When Aristotle first discussed phronesis, he perceived this as an individual’s virtue. More recently this idea has been challenged, particularly by MacIntyre. His main concern in any practice based community is not that an individual must do something in a particular way, it is that the community of practitioners work together to agree their practice virtues that bring “internal” goods for their practice, their own professional practice and for their patients. This also challenges the de-ontological stance of trying to define what the ethical rules are for any particular practice; this is because any such guidelines are contained in a communal narrative that engenders certain virtues and a continuous clarification of the purpose for their practices.
So rather than a rule-bound stance of defining virtues, like a set of principles to work to, we propose that each practice and context is unique and therefore only the practitioners themselves can work out what the virtues are for their professional group. MacIntyre argues this is a collective rather than individualistic process but we lack the moral debating resources14 and philosophical and theological educational underpinnings.15 This leads us to question whether this lack of moral debating resources and educational underpinnings apply in medical schools? Like other professional education faculties within some universities, have they become siloed due to market forces? For example, program affordability limitations may mean lost input from the philosophy and theological faculties as MacIntyre suggests. We argue that these “out of core” subject inputs are essential for cultivating the ethical decision-making mind and developing the executive virtue, practical wisdom. This conclusion is supported by authors from the medical ethics writing community.16
What’s Next in the Medical Profession?
In medicine, the principles of medical ethics often do not themselves settle what a person should do in a particular situation—the principles themselves need context in order to be interpreted.17 This argument again aligns with what MacIntyre puts forward around the need for practitioners themselves to define their practice virtues, rather than having them mandated. Moreover, the rules of medical ethics often make conflicting demands on the doctor and these rules need to be balanced as the situation requires. This balancing act takes the virtuous doctor out of simple rule-adherence and requires practical wisdom.
The way forward seems to be for a community of doctors to agree what they would do in that particular situation, based on their specific practice virtues. Furthermore, in defining their practice virtues there is also a need to refine them by engaging in ongoing moral debate with the other professionals who contribute to the care of patients, namely nursing, therapists, professions allied to health, social workers and the police. Each group would share the virtues for their specific disciplines and be willing to debate and refine these virtues based on a common telos (purpose) of working towards the well-being of patients and for wider society. However, MacIntyre suggests that the resources for such debate are currently lacking in our professional practices. So this is not just about the good character of individuals, as Aristotle suggests, but it is also about the facilitation by an ethical leader of moral debate with related practices.
So our preliminary conclusions are as follows:
- practical wisdom—or phronesis—can help leaders in medical and other professional contexts lead more ethically in at least here ways: An understanding that good and wise decision making for people who consider themselves ethical leaders goes beyond following a set of guidelines or rules or working out the consequences of their actions but also requires the ability to discern the relevant virtues with their colleagues.
- even when those virtues are discerned (e.g. courage, justice, prudence etc.), knowing where to act on each virtue continuum (vice to vice via a mean) requires the development of the phronesis that can be regarded as the adjudicating or executive virtue.
- phronesis needs to be cultivated over time to offer a way to balance competing demands, relationships, multiple conflicts and a range of functional goals to find an ethical decision point that will bring good outcomes for their discipline, the professionals who are part of their profession and the people they serve with their products or services.
The problem is that professional education in most universities (at whatever level) has been compartmentalized to such an extent that cross cutting subjects, like philosophy and theology, which help to develop ethical decision making, have been omitted from curricula.18 In the next section we open up new horizons to thinking about leadership development in the area of phronesis and good decision making.
New Horizons in Leadership Research and Education
In this final section, we discuss how we are working with these ideas on three levels: in our own research using a novel, narrative approach; in our leadership development, with particular reference to a particular worked example of whistleblowing; and, thirdly, on a more personal level (for the first author), as an unexpected client of healthcare!
Some Research Examples
To date little research has explored empirically the ways in which phronesis (practical wisdom) is cultivated over a period of time within one professional community.19 While a considerable scholarship has started to build around phronesis in medicine, this work has been almost entirely theoretical and while many researchers within medicine20 have made the case for a reorientation towards phronesis in medical education, little has been undertaken to explore empirically what that might look like.
It is for this reason that we are pursuing a narrative study with medical students and doctors in the United Kingdom to begin to fill some of the gaps in our understanding of phronesis in medicine. The study is currently being conducted and attempts to answer the following research questions:
- What does phronesis mean to practitioners?
- To what extent is phronesis cultivated, maintained and molded over the educational and practice life of doctors in the UK?
- To what extent can phronesis be promoted through educational and practice interventions?
As we suggested at the beginning of this chapter, questions have rarely been asked about what professionals need to be equipped morally (or otherwise) to navigate a chaotic world of practice rife with competing demands and relationships.
Existing studies have tended to capture practical wisdom within one snapshot, within one organization or by considering one practitioner.21 In our research, we are choosing to study three communities of doctors over three time periods: at the beginning of formal medical study; on placement at the end of formal study; and established medical professionals with five years plus qualified experience. This design will offer an opportunity to see if phronesis develops over time while enabling a varied discussion about moral resources and what the role of formal education is in equipping practitioners for the messy realities of practice. By asking doctors at different points in their careers about access to and use of moral resources, the study is interested to see what it means to doctors to make “good” decisions for the patient at hand; balancing care, compassion, quality, resources, capacity, medical outcomes and the wider well-being of the community.
The new horizon in this project involves an artistic skyline whereby participants will be involved in creatively shaping an original “soap opera” style series of video clips that will connect to an existing virtual community of health and social care practitioners, patients and the public.22 The purpose is to engage them in providing an artistic interpretation through which they see the issues of phronesis in their practice arena. The soap opera and the way it links to the community will be debated with a broad audience of academics, practitioners, patients and policy makers and others with an interest in the field. The video series will offer an innovative, edgy resource to complement the many text based de-ontological recommendations that have emanated from scandal enquiry reports and social science based studies to date.
New understandings of the cultivation of phronesis in medical communities and its role in rebuilding public trust in the light of many scandals will be of interest to healthcare researchers, educators, practitioners and policy-makers. The project aims to impact on the medical and professional education of doctors as a community, building stronger links between the medical community and the public and rebuilding public confidence in the medical profession. The main impacts will be to increase the effectiveness of health services and enhancing health and wellbeing, all within the time-frame of the research. The lead author already has some experience of working in this way (see Box 11.2).
Box 11.2 Using Virtue Ethics and Phronesis in Research
In a prior study, I explored the ethics of leading change by using a narrative approach with practitioners.23 Stories told by practitioners to a researcher may or may not be what actually happened; however, they contribute to the “pool of meanings” and support the social construction of ethics and decision making in a given professional community. In another study, we used MacIntyre’s virtue ethics and the theory of phronesis to present a mapping what we called virtue continuums for a health and social care community.24 The virtue continuums were based on the stories told by the participants and showed where on the continuums each of their stores was located, hence the claimed phronesis. This mapping showed for each virtue narrated by the community of practitioners there is a continuum from vice to vice via a median. What we have subsequently proposed25 is that there is a median point for courage in each case, arrived at via conducting a moral debate with fellow practitioners on the corruptions observed and collectively working towards wise action.
Introducing Phronesis to Leadership Development
In a recent leadership development workshop, participants were discussing the issue of how to deal with unacceptable practice. There was general consensus that keeping schtum or rationalising corrupt acts as justified would both be at one vice pole of the virtue continuum of courage with whistle-blowing at the other vice pole (Conroy, 2015). Both are extremes that from a virtues ethics perspective are unlikely to benefit the individual, the collective or the practice. The “phronesis” or practical wisdom element was seen to be the ability to collectively find the median point on a virtue continuum—for any particular context—that will bring (internal) goods for the individual (e.g., job satisfaction), improve outcomes and experience for patients and contribute to practice excellence.
What became clear from the workshop with the community was how useful it was for medical professionals to be able to see the virtue continuums presented and where the stories indicated decision points on the continuums. Their response to seeing this depiction of phronesis was typically, “I realise now I need to move in another direction with a given virtue continuum to make a better decision”. In other words, they were using the constructed picture of virtue continuums to help them improve their decision making based on their own understanding of their practice. This is very different to giving health and social care practitioners a set of ethical guidelines or deontological principles to work to.
So using the example of whistleblowing, how do leaders find a median point on the courage continuum at which they could still find a way of resisting the corruption to practices but not risking all with an act of whistle-blowing? Anderson urges us to not to ask of a social institution: “What end or purpose does it serve?’ but rather ‘Of what conflicts is it the scene?”26 In other words, the individual and the meaning of individual action are framed by the wider culture in which the action takes place. What I do now in my work with health and social care leaders is track their practice dilemmas, rife with competing demands and relationships, back to their ideological roots and differing standpoints. Once they understand that they are wittingly or unwittingly supporting a standpoint that could lead to practice corruptions then they became angry at becoming “emplotted” in an ongoing and emergent narrative that they did not identify with. Courage to resist is found through externally facilitated peer group reflection, moral debate and collective action rather than individual whistleblowing.
This approach tallies with the recommendations made by Anand et al.27 They found that when corruptions come to light there is a tendency to “blame rogue individuals or isolated groups, arguing that they do not represent the otherwise pristine organization. In cases of collective corruption, such scapegoating misses the point that individuals and systems are mutually reinforcing” (ibid, p. 50) We see this in the Robert Francis’s Report28 into the failings at the Mid Staffordshire Foundation Trust. The Kings Fund29 say, “It is clear that the causes of the Mid Staffs scandal are deep and complex, and the solutions are equally diverse”.
In the report, a single Trust and senior individuals in the trust are heavily criticized for creating a “culture of the trust was not conducive to providing good care for patients”30 instead of looking at the ideological roots that have led to much wider system corruptions that these people were just a part of. Anand et al. (2004) suggest it is better to involve external change agents to support education and connection between staff and external networks because insiders are often part of the system and continue to be susceptible to the rationalizations associated with corrupting influences on practices. Anand et al do not elaborate on the nature of the education and connection so virtue ethics offers an option to gain clarity on the type of connection and education that would contribute to maintaining ethical practice. The seminar series suggests a reframing of leadership ethical education with its emphasis on individuals towards externally facilitated collective peer group reflection and ethical debate that develops proficiency in virtue ethics understanding and the application of phronesis.
On a more personal note, the lead author was recently involved in a serious cycling accident and had to spend three months in hospital recovering from brain surgery, multiple head bone fractures and other post-operation complications including pneumonia. After coming round from an induced unconscious coma and then a conscious coma, what I experienced was a team of health care practitioners led by a neurological rehabilitation consultant demonstrating practical wisdom. Thankfully, I made a full recovery, and I am now back working full time and loving my work like before. The consultant concerned agreed to be interviewed as a “black-belt” in phronesis for the author’s project and spoke about his approach. His approach with the author was to listen to what I was concerned about and support me in a way that conveyed his experience with other cases like mine. He even spoke about another academic he had treated and what happened to him. The DVLA told me I would not be able to drive for 18 months. The consultant kindly wrote to them and I was back driving in six months. What the author discovered during the interview is that the consultant had recently been promoted into a significant leadership position for the hospital Trust as a whole. What he demonstrated are the internal goods and benefits of applied practical wisdom: those that are on the receiving end of their services or products feel honored and grateful and those people who are able to apply practical wisdom and develop practice excellence become sought after for leadership roles in their organization. What leader would not want to see that as an outcome from their work?
For me, the experience of the accident and recovery affected my own development as a leader. It caused me to reflect on and rethink a few things about what is important in my life and career. I would say I am less willing to spend time on things that do not contribute to internal goods and I am more courageous in proposing and taking what I think is the right course of action to bring social justice. For instance, I have recently highlighted an issue raised by participants in our recent research study about ethical purpose for the medical community. Is it to bring the best possible outcome for any individual patient or wider society?
Notes
1 This chapter gives a more detailed outline of a presentation made at the 5th ESRC seminar series (www.ethicalleadership.org.uk/news/8/15/Seminar-5-Virtue-Ethics-and-Christian-Values-in-Health-and-Education.html) on a project entitled “Phronesis and the Medical Community”.
2 Upsher (2014).
3 The UK National Health Service’s “Choose and Book” out-patient referral system. See Greenhalgh et al. (2012).
4 Carel and Kidd (2014).
5 Pellegrino and Thomasma (1993, p. 83).
6 For example Shotter and Tsoukas (2014).
7 www.birmingham.ac.uk/schools/social-policy/departments/health-services-management-centre/news/2015/03/phronesis-and-the-medical-community.aspx
8 Here and throughout, we use the word discourse to refer to the language, artifacts, thinking and assumed way of behaving in a given field. The beguiling feature of these “bubbles” is that we are often unaware of operating within them.
9 MacIntyre (2009).
10 See Derrida (1978) although he makes it fundamental—rather than a possible—outcome.
11 MacIntyre (1981).
12 The Enlightenment period stretches roughly from the mid-17th century through the 18th century and was a dramatic revolutions in science, philosophy, society and politics moving from a medieval culture of “myths” to modern Western ideas based on scientific “facts”.
13 Sparrow (2006).
14 MacIntyre (1981).
15 Macintyre (2008).
16 See Dawson (2010) and Montgomery (2006) and Kaldjian (2014).
17 Pellegrino and Thomasma (1993).
18 See, for example, Mabey and Mayrhofer (2015), Macintyre (2009).
19 Kotzee et al. (2016).
20 e.g., Kaldjian, 2014; Montgomery, 2006).
21 For example, Shotter and Tsoukas (2014).
22 This artistic element which will animate the findings of the research. The participants will be involved in creatively shaping an original “soap opera” style video series and other social media that will integrate with an existing virtual community of health and social care practitioners, patients and the public based on a fictional town (Stilwell) in England.
23 Conroy (2010).
24 Conroy et al. (2012).
25 Conroy et al. (2014).
26 Passmore (1962).
27 Anand et al. (2004).
28 Francis Report (2013) Francis’s brief was “to examine the operation of the commissioning, supervisory and regulatory organisations and other agencies, including the culture and systems of those organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009, and to examine why problems at the trust were not identified sooner and appropriate action taken”.
29 Kings Fund (2017), available from: www.kingsfund.org.uk/press/press-releases/our-response-final-report-mid-staffordshire-nhs-foundation-trust-public-inquiry
30 Guardian (2013), available from: www.theguardian.com/society/2013/jan/30/final-report-mid-staffs-scandal-devastating-nhs
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