Introduction To Moral Leadership

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An extended version of a presentation at the University of Oxford April 2012 outlining some of the arguments from my book "Moral Leadership in Medicine" Building Ethical Healthcare Organizations"

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  • OVERVIEW OF THE TALK
  • My study of moral leadership started out as an exercise in healthcare organizational ethics. Struck by absence of organizations from medical ethics. And still didn’t know what ethics ‘looked like’. So I decided to interview NHS medical directors because they seemed to me to be people who could tell me what I wanted to know.I will say more about credentials problem but first I want to clarify what I mean by moral leadership in the context of medicine
  • Leadership is not just about people who are appointed to lead - I ended up choosing formal leaders for practical reasons but there are much leadership going on in healthcareRemember that the moral concerns I was interested in were those that arose in the course of managing healthcare provision, not giving direct patient careI wanted to understand what was going on in this environment, and what people were actually concerned about I also wanted to pose the question whether these were the proper things to be concerned aboutAs Pascal Borry has noted Ethical inquiry is an exchange between meanings embedded in empirical description, and meanings found in normative considerations. If undue priority is given to empirical description, descriptions of behaviour are raised to the status of moral norm. BUT, without “empirically saturated reflective analysis of what is going on in actual moral orders…ethics has nothing to reflect on but moral philosophers’ own assumptions and experiences”. (Walker) So the credentials problem is present in the descriptive part of the study because we need to know whether we are observing moral leadership, or the behaviour of hypocrites and charlatansAnd it is therefore inescapably present in the normative part of the study because we need an adequate account of moral leadership if we are to credibly argue that X ought to be the moral concern of a leadersInsoluble except that I asked leaders who they believed would be good people to talk to
  • Leadership is not just about people who are appointed to lead - I ended up choosing formal leaders for practical reasons but there are much leadership going on in healthcareRemember that the moral concerns I was interested in were those that arose in the course of managing healthcare provision, not giving direct patient careI wanted to understand what was going on in this environment, and what people were actually concerned about I also wanted to pose the question whether these were the proper things to be concerned aboutAs PascalBorry has noted Ethical inquiry is an exchange between meanings embedded in empirical description, and meanings found in normative considerations. If undue priority is given to empirical description, descriptions of behaviour are raised to the status of moral norm. BUT, without “empirically saturated reflective analysis of what is going on in actual moral orders…ethics has nothing to reflect on but moral philosophers’ own assumptions and experiences”. (Walker) So the credentials problem is present in the descriptive part of the study because we need to know whether we are observing moral leadership, or the behaviour of hypocrites and charlatansAnd it is therefore inescapably present in the normative part of the study because we need an adequate account of moral leadership if we are to credibly argue that X ought to be the moral concern of a leadersInsoluble except that I asked leaders who they believed would be good people to talk to
  • Answer to first question led me to revise some common assumptions about what organizational ethics should be about.Answer to second question was to make me revise what I think ethics is about. There is a common view on what both ethics and leadership is about, which is making critical decisions at a fork in the road. This is a very misleading picture of both ethics and leadership
  • This video extract is posted on the Johns Hopkins site with a warning that it is only a brief extract. But imagine that you are are busy and have time only to see your colleague present the apology as they have done – what is your intuitive judgment? Is this something to congratulate them on or worry about? CATEGORICAL APOLOGY Nick Smith “I was wrong” 11 elements – can discuss these later if they likeCorroborated factual recordAcceptance of blameIdentification of harmIdentification of the moral principles underlying each harmEndorsement of the moral principles underlying each harmRecognition of the victim as a moral interlocutorCategorical regretPerformance of the apologyRedressAppropriate intentAppropriate emotion
  • Answer to first question led me to revise some common assumptions about what organizational ethics should be about.Answer to second question was to make me revise what I think ethics is about. There is a common view on what both ethics and leadership is about, which is making critical decisions at a fork in the road. This is a very misleading picture of both ethics and leadership
  • I am going to explore these two questions in turn with some assistance from audience
  • Answer to first question led me to revise some common assumptions about what organizational ethics should be about.Answer to second question was to make me revise what I think ethics is about. There is a common view on what both ethics and leadership is about, which is making critical decisions at a fork in the road. This is a very misleading picture of both ethics and leadership
  • Fiduciary propriety fuels noble dreams and selfless endeavour.It motivatescourageous action on behalf of patients around the world: (patients stigmatized by HIV/AIDS, mutilated during war, incarcerated by state authorities, abandoned by their families.) In the normal run of things however, fiduciary propriety is most evident in how it grants a licence to speak very assertively on behalf of patients; indeed, to speak in ways that would be thought unacceptable if interests other than those of patients were at stake. It is fiduciary propriety that frequently underpins rhetorical sorties into ‘shroud waving’ or other regions of the moral high ground.
  • Fiduciary propriety fuels noble dreams and selfless endeavour.It motivatescourageous action on behalf of patients around the world: (patients stigmatized by HIV/AIDS, mutilated during war, incarcerated by state authorities, abandoned by their families.) In the normal run of things however, fiduciary propriety is most evident in how it grants a licence to speak very assertively on behalf of patients; indeed, to speak in ways that would be thought unacceptable if interests other than those of patients were at stake. It is fiduciary propriety that frequently underpins rhetorical sorties into ‘shroud waving’ or other regions of the moral high ground.
  • Fiduciary propriety fuels noble dreams and selfless endeavour.It motivatescourageous action on behalf of patients around the world: (patients stigmatized by HIV/AIDS, mutilated during war, incarcerated by state authorities, abandoned by their families.) In the normal run of things however, fiduciary propriety is most evident in how it grants a licence to speak very assertively on behalf of patients; indeed, to speak in ways that would be thought unacceptable if interests other than those of patients were at stake. It is fiduciary propriety that frequently underpins rhetorical sorties into ‘shroud waving’ or other regions of the moral high ground.
  • Fiduciary propriety fuels noble dreams and selfless endeavour.It motivatescourageous action on behalf of patients around the world: (patients stigmatized by HIV/AIDS, mutilated during war, incarcerated by state authorities, abandoned by their families.) In the normal run of things however, fiduciary propriety is most evident in how it grants a licence to speak very assertively on behalf of patients; indeed, to speak in ways that would be thought unacceptable if interests other than those of patients were at stake. It is fiduciary propriety that frequently underpins rhetorical sorties into ‘shroud waving’ or other regions of the moral high ground.
  • The hallmarks of bureaucratic propriety are the behaviours of the good bureaucrat: impartiality in deed and in demeanour, transparency and a willingness to be held to account, abnegation of personal interests and moral predilections, support for rules and protocols as a way of distributing public goods, conscientiousness in office. These practices do not come naturally. They have to be learned, and it takes self-discipline to exercise them, especially in the face of provocation.
  • The hallmarks of bureaucratic propriety are the behaviours of the good bureaucrat: impartiality in deed and in demeanour, transparency and a willingness to be held to account, abnegation of personal interests and moral predilections, support for rules and protocols as a way of distributing public goods, conscientiousness in office. These practices do not come naturally. They have to be learned, and it takes self-discipline to exercise them, especially in the face of provocation.
  • The hallmarks of bureaucratic propriety are the behaviours of the good bureaucrat: impartiality in deed and in demeanour, transparency and a willingness to be held to account, abnegation of personal interests and moral predilections, support for rules and protocols as a way of distributing public goods, conscientiousness in office. These practices do not come naturally. They have to be learned, and it takes self-discipline to exercise them, especially in the face of provocation.
  • The bonds of collegiality have been the subject of sustained criticism from commentators critical of self-serving professional alliances and their tendency to operate, in George Bernard Shaw’s memorable phrase, as a ‘conspiracy against the laity’. In the positive form of collegial propriety, we see behaviours that help doctors to understand what they can reasonably ask of others, to express what they owe to each other, and see where they stand in relation to their professional community of practice. Collegial propriety is visible in values and practices such as fellowship, reciprocity, support for and mentoring of juniors, service to a professional body such as a Royal College, arbitration of clinical standards, and empathy with fellow professionals.
  • The bonds of collegiality have been the subject of sustained criticism from commentators critical of self-serving professional alliances and their tendency to operate, in George Bernard Shaw’s memorable phrase, as a ‘conspiracy against the laity’. In the positive form of collegial propriety, we see behaviours that help doctors to understand what they can reasonably ask of others, to express what they owe to each other, and see where they stand in relation to their professional community of practice. Collegial propriety is visible in values and practices such as fellowship, reciprocity, support for and mentoring of juniors, service to a professional body such as a Royal College, arbitration of clinical standards, and empathy with fellow professionals.
  • Inquisitorial propriety is a complex phenomenon because every party to an investigation has expectations of the other, and each is apt to judge the other as unethical if they get it wrong. For the person leading an investigation, ‘inquisitorial propriety’ suggests demeanours such as objectivity, neutrality and openness to ‘hearing the other side’. For the person under investigation, ‘inquisitorial propriety’ calls for candour, regret, and, where appropriate, frank confession. In a complainant, ‘inquisitorial propriety’ demands truthfulness and, if not forgiveness, then mercy towards the transgressor. Inquiries are capable of either rebuilding or destroying patient trust, collegial relationships, clinician self-confidence, team dynamics, and respect for medical management. The answers to apparently pragmatic questions such as who should be told about an allegation, and when, carry a significant moral load: telling the wrong people at the wrong time in the wrong way can cause real pain and injustice.
  • Inquisitorial propriety is a complex phenomenon because every party to an investigation has expectations of the other, and each is apt to judge the other as unethical if they get it wrong. For the person leading an investigation, ‘inquisitorial propriety’ suggests demeanours such as objectivity, neutrality and openness to ‘hearing the other side’. For the person under investigation, ‘inquisitorial propriety’ calls for candour, regret, and, where appropriate, frank confession. In a complainant, ‘inquisitorial propriety’ demands truthfulness and, if not forgiveness, then mercy towards the transgressor. Inquiries are capable of either rebuilding or destroying patient trust, collegial relationships, clinician self-confidence, team dynamics, and respect for medical management. The answers to apparently pragmatic questions such as who should be told about an allegation, and when, carry a significant moral load: telling the wrong people at the wrong time in the wrong way can cause real pain and injustice.
  • Inquisitorial propriety is a complex phenomenon because every party to an investigation has expectations of the other, and each is apt to judge the other as unethical if they get it wrong. For the person leading an investigation, ‘inquisitorial propriety’ suggests demeanours such as objectivity, neutrality and openness to ‘hearing the other side’. For the person under investigation, ‘inquisitorial propriety’ calls for candour, regret, and, where appropriate, frank confession. In a complainant, ‘inquisitorial propriety’ demands truthfulness and, if not forgiveness, then mercy towards the transgressor. Inquiries are capable of either rebuilding or destroying patient trust, collegial relationships, clinician self-confidence, team dynamics, and respect for medical management. The answers to apparently pragmatic questions such as who should be told about an allegation, and when, carry a significant moral load: telling the wrong people at the wrong time in the wrong way can cause real pain and injustice.
  • Turns on acknowledgement: acknowledging that a harm has occurred, acknowledging that certain persons or bodies are responsible, acknowledging that a complaint is legitimate, acknowledging that the person who was harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond.  ‘Restorative propriety’ is a familiar element in our everyday lives, apparent in such behaviours as contrition, the performance of apologies, or making financial restitution. Restorative propriety becomes much more problematic in institutional settings. In organizations, it raises questions such as who has standing to ‘perform’ gestures such as apology, whether there is sincere regret, whether and what changes to practice may be made, and how such changes can be monitored.This slide a cautionary note –that even a perfect categorical apology may not be enough – respecting someone as a moral equal means accepting a person’s right to be angry
  • Turns on acknowledgement: acknowledging that a harm has occurred, acknowledging that certain persons or bodies are responsible, acknowledging that a complaint is legitimate, acknowledging that the person who was harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond.  ‘Restorative propriety’ is a familiar element in our everyday lives, apparent in such behaviours as contrition, the performance of apologies, or making financial restitution. Restorative propriety becomes much more problematic in institutional settings. In organizations, it raises questions such as who has standing to ‘perform’ gestures such as apology, whether there is sincere regret, whether and what changes to practice may be made, and how such changes can be monitored.This slide a cautionary note –that even a perfect categorical apology may not be enough – respecting someone as a moral equal means accepting a person’s right to be angry
  • Turns on acknowledgement: acknowledging that a harm has occurred, acknowledging that certain persons or bodies are responsible, acknowledging that a complaint is legitimate, acknowledging that the person who was harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond.  ‘Restorative propriety’ is a familiar element in our everyday lives, apparent in such behaviours as contrition, the performance of apologies, or making financial restitution. Restorative propriety becomes much more problematic in institutional settings. In organizations, it raises questions such as who has standing to ‘perform’ gestures such as apology, whether there is sincere regret, whether and what changes to practice may be made, and how such changes can be monitored.This slide a cautionary note –that even a perfect categorical apology may not be enough – respecting someone as a moral equal means accepting a person’s right to be angry
  • Introduction To Moral Leadership

    1. 1. DEPARTMENT OF PRIMARY CARE HEALTH SCIENCESMoral LeadershipinHealthcare OrganizationsSuzanne ShaleHealth Experiences Research Group
    2. 2. What is this presentation about? Why does healthcare need moral leadership? What do I know about moral leadership? What does moral leadership mean? What are moral leaders in medicine concerned with? How do they do moral leadership? Why is the practice of “propriety” important? Tensions between different moral behaviours Moral courage
    3. 3. We need moral leaders to upholdwhat is acceptable in the odd moralworld of healthcare…“In the hospital it is the good people, not the bad, who take knives and cut people open; here the good stick others with needles and push fingers into rectums and vaginas, tubes in to urethras, needles into the scalp of a baby; here the good, doing good, peel dead skin from a screaming burn victim’s body and tell strangers to take off their clothes…The layperson’s horrible fantasies here become the professional’s stock in trade.”D. Chambliss Beyond Caring Chicago UP 1996
    4. 4. What do I know about moral leadership? I carried out a qualitative study of medical directors in primary and secondary care organizations I asked “Looking back over recent years, what has been the most troubling issue you have dealt with?” Then “Assume I know nothing and tell me step by step what you did”
    5. 5. What does moral leadership mean? Leadership is both a role and an activity. Moral leaders are those who ‘step up to the plate’. Doctors are not the only people who lead in medicine, and demonstrating followership is an element of leadership. There are descriptive questions: what are the moral concerns of leaders in medicine and how do moral leaders behave ? There are normative questions: what ought to be the moral concerns of leaders in medicine and how should they act?
    6. 6. Footnote: Is/ought & the credentials problem Descriptions of what the moral issues ARE and what moral leaders DO can help us to understand the moral landscape. But - what can description tell us about what leadership concerns OUGHT to be and how they SHOULD behave? Are & Do cannot automatically tell us about Ought & Should: “you cannot derive ought from is”. But what respected leaders ARE thinking & doing in a moral sense can help us to examine the question of what moral leaders OUGHT to be thinking and doing. Here the credentials problem arises: were these the right people to ask? Typically the credentials problem is described as: if we have to ask for moral advice, how do we know who is “qualified” to give it? Here, how are we to judge who the moral leaders are and what moral leadership is, in order to study them?
    7. 7. The difference betweenmoral deciding and moral doing
    8. 8. The difference between moral deciding andmoral doing…part oneWhen a treatment error has necessitated additional procedures or temporarily affected a patient’s health, is it preferable to tell or not to tell the patient/carer what has happened?(A) PREFERABLE TO TELL(B) PREFERABLE TO NOT TELL
    9. 9. The difference between moral deciding andmoral doing…part twoWatch the video* Is this a good apology or is it a poor apology?(A) GOOD APOLOGY(B) POOR APOLOGY* Video can be found at http://www.jhsph.edu/dept/hpm/research/Wu_vide o.html(See “Removing Insult from Injury” training video – Pediatric surgery, an apology)
    10. 10. So what does the preceding exercise tell us? The moral quality of our lives is associated with the quality of moral decisions but not decisions alone Our judgement of the moral quality of actions turns significantly on how decisions are enacted in the context of relationships with others Judging the moral quality of enactment is extremely complex, and may be highly contingent on the perspectives of the observer eg patient/nurse
    11. 11. Footnote : Nick Smith I Was Wrong: TheMeanings of Apologies (Cambridge UP 2008)Smith identified 11 elements in a “categorical apology”:① Corroborated factual record② Acceptance of blame③ Identification of harm④ Identification of the moral principles underlying each harm⑤ Endorsement of the moral principles underlying each harm⑥ Recognition of the victim as a moral interlocutor⑦ Categorical regret⑧ Performance of the apology⑨ Redress⑩ Appropriate intent11 Appropriate emotion
    12. 12. What does moral leadership mean in theMedical Leadership Competency Framework?
    13. 13. A helpful focus on behaviour An unhelpful simplification of the challengeThis is what the competency framework says “Doctors show leadership through acting with integrity: behaving in an open, honest and ethical manner. Competent doctors: Uphold personal and professional ethics and values, taking into account the values of the organisation and the culture, beliefs and abilities of individuals Communicate effectively with individuals, appreciating their social, cultural, religious and ethnic backgrounds and their age, gender and abilities Value, respect and promote equality and diversity Take appropriate action if ethics and values are compromised.” THE PROBLEM IS THAT ETHICS AND VALUES ARE CONSTANTLY COMPROMISED BECAUSE THEY ARE INHERENTLY CONFLICTING
    14. 14. What are moral leaders in medicine thinking?I asked what leaders were most Which was most frequently troubled by discussed?Examples: Resource allocation Service reconfiguration e.g. creating new care pathways, clustering smaller services into larger ones Managing doctors suspected of being or known to be incompetent Managing suspected or known medical harm
    15. 15. The most frequent topics were…① Managing doctors suspected of being or known to be incompetent② Managing suspected or known medical harm③ Service reconfiguration④ Allocating discretionary resources (e.g. new drugs, plastic surgery, procedures such as IVF with PGD)⑤ Conflict between personal beliefs and the demands of public service (e.g. euthanasia)⑥ (Resource allocation in general)
    16. 16. What were moral leaders in medicine doing?I asked what leaders did about They described five sets of the things that troubled them moral behaviours that I call propriety  Fiduciary propriety  Bureaucratic propriety  Collegial propriety  Inquisitorial propriety  Restorative propriety
    17. 17. Five proprieties& some interview data to illustrate them
    18. 18. Fiduciary propriety “Patients first…”Fuels noble dreams and selfless endeavour.Motivates courageous action on behalf of patients e.g.patients stigmatized by HIV/AIDSEvident in a licence to speak assertively, including in waysthought unacceptable if interests other than those of patientsat stake.Underpins rhetorical sorties into ‘shroud waving’ or otherregions of the moral high ground.
    19. 19. Fiduciary propriety “Patients first…”“I probably don’t recognize the strength with which I put over some of the arguments. I’m not by nature a particularly forceful character. But I suppose at times I do invest quite a lot of emotional involvement in the way that I will put across difficult issues at [Board] level, particularly to the non-execs where they’re not necessarily aware of…Well it goes back to that patient thing. You know what the effect on individuals could be.“ (Hospital Medical Director)
    20. 20. Fiduciary propriety “Patients first…”“I have at board level had to hold the line…We were proposing that we would restrict or even close services on the basis of safety and I did have to stand up for that. Funnily enough I didn’t find that particularly difficult. I mean the Chief Exec did take me to one side and say ‘Are you telling me this is unsafe? Is there any other way?’ and I said ‘Well not any other way you’ve come up with’… It was very clear to me that a child had nearly died, and that’s not hard is it?” (Primary Care Trust Medical Director)
    21. 21. Bureaucratic propriety “Organization first”Virtuous bureaucracy is efficient, impartial,accountable allocation of shared (public) resourcesBehaviours: impartiality in deed and demeanour willingness to be held to account abnegation of personal interests and morals support for distributive rules and protocols conscientiousness in office.Such practices do not come naturally. It takes self-discipline to exercise them, especially in the face ofprovocation.
    22. 22. Bureaucratic propriety “Organization first”“ I think doctors need to understand …that there is a stewardship we all share…People say that money isn’t health. It is. It’s publicly funded. We have to be accountable. And there’s the stewardship of quality. And the stewardship of resources. And so on”(Hospital Medical Director)
    23. 23. Bureaucratic propriety “Organization first”“I understand now what it means to be corporate and retain your integrity; which, as a clinician, I would probably have thought was a very long stretch! I think clinically if you work for an organization, you have to be prepared to identify yourself as a member of that organization; and that means espousing certain values and plans…Through that debate and discussion you reach a point where you can say, ‘A is to be done - I have these reservations’. Either it’s recognized that you have those reservations and they need to be integrated into [the solution], or you need to be having a discussion with somebody to say, ‘I cannot go out and *implement this+’ It’s that thing that says you are open about your problems, and you have to resolve them…It’s that commitment to the organization that says youll be honest. But equally that trust, that you will work together on it.” (Primary Care Trust Medical Director)
    24. 24. Collegial propriety “Colleagues first…”A ‘conspiracy against the laity’? Sustained criticism fromcommentators critical of self-serving professional alliances;dictum of Chicago School sociology to “elevate the humble andhumble the elevated”In positive form collegial behaviours promote harmony, teamfunctioning, supportiveness, development of community ofpractice.Visible in fellowship, reciprocity, support and mentoring ofjuniors, service to professional body such as Royal College,deference to community determination of clinical standards
    25. 25. Collegial propriety “Colleagues first…”“There are issues about the history of these doctors. They were brought here, quite deliberately, by the NHS, given the impression that the streets were paved with gold. They were often treated very badly. They were not promoted as fairly. They were put into jobs that were unattractive. They may well have been victims of discrimination years ago. Many of them have been abused in employment relationships in general practice, been promised things that never happened – you know, become [an employee in the partnership] with a view to [becoming a partner]- that never materialized. But …” (Primary Care Trust Medical Director)
    26. 26. Collegial propriety “Colleagues first…”“We work with virtually every other specialty in the hospital…going round helping and advising and working in collaboration with other consultants…We’re always having to tread quite carefully, not offending people, or seeming to be muscling in, or telling people how to do their job properly…I was seen as somebody who was honest, who didn’t tend to be judgemental, was generally supportive, but also not afraid to tackle the difficult situations.” (Hospital Medical Director, explaining how some draw on their experience of having worked in ‘support’ specialties)
    27. 27. Inquisitorial propriety “Process first” Reflects the prominence of troubles relating to managing clinical performance and medical harm. Inquiries and investigations are capable of rebuilding or destroying patient trust, collegial relationships, clinician self- confidence, team dynamics, and respect for medical management. Proper behaviours include: Investigator demeanours: objectivity, neutrality, ‘hearing the other side’. Person under investigation: candour, regret, and, where appropriate, frank confession. Victim, complainant: truthfulness, mercy
    28. 28. Inquisitorial propriety “Process first”“To make sure that everything is done properly. That we’re fair and equitable in our dealings with the individual practitioner, in dealings with the legal representatives, in dealings with the patients’ representatives. That there’s no bias…no prejudice on my part expressed in either direction. It’s particularly difficult when you’re face to face with someone suffering as result of medical injury whether it’s patient or…practitioner”(Hospital Medical Director)
    29. 29. Inquisitorial propriety “Process first”“I’m a bit of a geek about regulations and powers and where certain things have come from...I’ve a fairly encyclopaedic knowledge, a lot of experience hands on. I wasn’t afraid of it because I’d done it before, and I’d had experience of other people, going down this road...And because I’d been involved in some quite serious cases in the past…Because at every stage you’re vulnerable to challenge, either through the defence societies or through judicial review, or in the High Court. So there have been time when it’s been really quite draining…This hasn’t been done without an impact on my personal health; it’s affected my mental and emotional health”(PCT Medical Director)
    30. 30. Restorative propriety “Acknowledgement first…” Turns on acknowledgement: that a harm has occurred, persons or bodies are responsible, that a complaint is legitimate, that the person harmed has a ‘moral right’ to define the situation in their terms, acknowledging that steps must be taken to respond. Some familiar behaviours: contrition, performance of apologies, making financial restitution. For organizations, raises questions such as who has standing to ‘perform’ gestures such as apology, whether there is sincere regret, whether and what changes to practice may be made, and how such changes can be monitored.
    31. 31. Restorative propriety “Acknowledgement first…”“We’ve made a promise to this relative that we are looking into this in order to understand it; and if things need to be changed, to change them. Or else, their loved one’s death becomes meaningless…And if important lessons from this death are not heard, or played down, then that is a betrayal.”(Mental Health Trust Medical Director)
    32. 32. Restorative propriety “Acknowledgement first…”“Sometimes it’s difficult, because sometimes patients are so angry that it’s actually very difficult to – and they need to get their anger out of their system; and you can’t – whatever you say to them, they won’t – You have to accept that you can’t always send everyone away happy I’m afraid…Sometimes you have a discussion with patients or relatives and, and you think at the end of it, you’ve really moved on. But I think quite often you feel actually, they have let out some of their anger of whatever, but they haven’t really moved on. They’re still going away from it angry” (Hospital Medical Director)
    33. 33. The central problem: tensions between the proprietiesREDESIGNING SERVICES  Bureaucratic propriety in tension with fiduciary and collegial proprietyINVESTIGATING COLLEAGUES  Fiduciary propriety in tension with inquisitorial propriety & collegial proprietyATTENDING TO PATIENT HARM  Inquisitorial propriety in tension with restorative propriety
    34. 34. Example: balancing collegial propriety andinquisitorial propriety when managing performance“I’m plagued with doubts all the time. I do worry tremendously. About, am I being unfair? Are my standards too high? Is this…? …* In one of the practices where I worked as a GP I witnessed the effect of] a complaint that I thought was quite unjustified. That was a terribly conscientious doctor. Now he killed himself. He committed suicide. And it traumatized not only his family, the partnership, the practice team, but the whole community. All of his patients felt guilty – that this wonderful man had died over this wretched complaint, that was ill founded.That experience has really made me think. When we do discipline somebody … we could be wrong. It’s been painted this way but there’s another side to the story. We have to be terribly careful, because I don’t want – I don’t want another doctor’s death on my conscience through mishandling a disciplinary process.
    35. 35. Enacting moral decisions requiresmoral determination“I know exactly what you mean when you say dig deep. And I recognise that as shut your eyes, take a deep breath and focus…What happens in that moment of focus? I suppose it’s almost like checking off a rosary. It’s the right thing. It’s correct. Its’ based on this, that, it’s rational. It’s going to feel unkind. You don’t have any choice. But you can offer this, that or the other…That’s it, and it has to be faced. The moment’s now. “

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