Suzanne Shale Cambridge University Press, 2011, HB, 310pp, £57.79, 978-1107006157
‘It is an unoriginal (but nonetheless accurate) observation that officially designated leaders frequently fail to lead well, or indeed lead at all.’ (Quote from featured book).
It has been more than a decade since Suzanne Shale’s Moral Leadership in Medicine: Building Ethical Healthcare Organizations first saw publication, yet its relevance is undiminished.
As evidenced by the opening quotation, the work aims to unpack an enduring mystery encountered within medicine by exploring how moral challenges are (or are not) confronted by healthcare managers.
The book provides a deeper understanding of the normative (that is, action-guiding) aspects of the decisions faced by those tasked with managing health care, and the empiric work is based on qualitative interviews conducted with 24 medical directors in the UK’s NHS.
Shale’s subsequent analysis, from which she builds the book’s central argument and ethical framework, draws on a wide array of ethical influences, including philosophers such as Margaret Urban Walker and Alasdair MacIntyre.
Through analysing and theorising the interviews in light of the modern healthcare system, Shale has developed the concept of moral leadership, which she defines as being astute to the moral connotations of all that is involved in providing care, determining where action is needed, identifying situations where action is required to improve or maintain the moral quality of care, and orchestrating the activity of other people to provide a morally appropriate response when one is required.
This definition finds common ground with some conceptualisations of virtue ethics,1 particularly the notion of recognising what the right thing is to do, and then doing it. The focus on the ‘moral quality of care’ as an outcome also overlaps with the ethicist Alasdair MacIntyre’s definition of ‘internal goods’, such as health and the alleviation of suffering, which are realised when practitioners exercise virtue.
However, Moral Leadership in Medicine contains a more developed application of these ideas to health care and this deserves wider dissemination.
THE FIVE PROPRIETIES
Through analysing the moral narratives of medical directors, Shale distinguishes between ‘general practices of responsibility’ and the ‘specific practices of propriety’ through which these managers determined how to act in morally fraught situations.
Propriety, a term which is not widely used, can also be understood by considering its more familiar opposite — impropriety. I have summarised the five specific proprieties identified by Shale in Box 1.
| Propriety | Definition | ‘First priority’ to ... | Possible example |
|---|
| Fiduciary | Promoting the interests of a beneficiary | The patient | Advocating on behalf of an individual patient, perhaps for a specific treatment or access to a service |
| Bureaucratic | Prioritising the needs of the organisation and, in so doing, the needs of patients and professionals collectively | The medical corporation. In the short term this may mean the users/clients, but in the long term this means the organisation itself | Transparently following the procedures set out by the organisation in order to safeguard the collective interests of all concerned |
| Collegial | Acting in a way that promotes cooperation based on goodwill and collegiality, rather than hierarchy | Fellow professionals (the ‘collegium’) | Persuading colleagues to adopt a protocol or treatment based on the evidence rather than by command |
| Inquisitorial | Investigating ‘misconduct’, ‘misbehaviour’, and ‘mistakes’. This requires objectivity from the inquisitory, as well as ‘candour, regret and confession’ where appropriate | Justice and fair procedure | Undertaking investigations or commissions of enquiry following adverse events and allowing all sides to be heard |
| Restorative | To restore moral relations after harm | Moral relations | Transparency in the wake of events that have caused harm. Restorative gestures such as apologies or remuneration |
Box 1. The five proprieties described in Moral Leadership in Medicine. Building Ethical Healthcare Organizations
It is to be predicted that ‘moral tension’ would arise when these proprieties suggest conflicting courses of action, yet this is precisely the point at which moral leaders should recognise the need for action, decide to act, and rally others to join in the required behaviours to safeguard quality of care.
These proprieties resemble the virtues in medical practice (such as phronesis and trustworthiness), as suggested by Pellegrino and Thomasma.2 Shale notes that ‘[a]ll that is required is that propriety is sincerely performed on the appropriate occasions’, a notion that would resonate with healthcare workers who perform their work even when it is in tension with their own values.
Some may regard their stocks of ethical guidance replete with the four principles or specific General Medical Council directives; however, this would miss the opportunity to understand, as Shale puts it, ‘the behaviours through which we express our commitment to duties, responsibilities [and] obligations’.
This book provides a vital account of how the needs of patients and the aspirations of professionals are translated into actions beyond the bedside and should form part of any debate on the future of health care.
Footnotes
This book review was developed from an excerpt of the author’s doctoral thesis, which is currently unpublished.
This article was first posted on BJGP Life on 17 December 2022; https://bjgplife.com/m-leadership
- © British Journal of General Practice 2023
