Ethical and moral issues in decision-making by leaders

Accreditation Canada International’s leadership standards meet the growing international demand for clarity about the roles and responsibilities of health organizations and their managers in providing support and infrastructure necessary for excellence and quality improvement in health service delivery. Standards direct leadership functions across and through the organization, rather than individual positions or specific capabilities. They clarify the requirements for effective operational and performance management, decision-making structures, and the infrastructure needed to drive excellence and improve quality in the provision of health services.

Health leaders are increasingly being challenged by complex demands. To face these many demands, leaders must be able to make decisions based on values and ethical principles.

The problem with healthcare organizations today is that there is insufficient emphasis on the ethical culture and moral behavior of leadership. The nature of health management is such that the implications of ethical decisions are made every day for issues as diverse as access to the organization and services, employee behavior, clinical practices and resource allocation.

A major concern for health leaders is the tenuous relationship between key stakeholders in the system that includes patients, providers, payers and suppliers. The decrease in trust between stakeholders changes the very culture of interactions and communication which in turn leads to a breakdown of the relationship between the parties.

Healthcare leaders play an essential role in the success or failure of relationships between the various stakeholders. Ethics is a necessary resource for promoting positive relationships.

Health organizations have become aware that their activities suffer and generate varied impacts, therefore it is necessary to review relations with several social actors.

The question to be answered is: “do Brazilian healthcare companies adopt responsible management policies and practices, driven by ethical commitment to society?”

This problem must be dealt with clearly in the existence of two ethical universes: medical ethics and organizational ethics.

There is a need to develop an Ethics Framework for health service managers and leaders. This framework must combine these differences, placing the patient at the center of care and making the patient’s interests prevail.


The health manager is essentially a professional with management functions and not a caregiver. However, given the characteristics of the health units, the latter will necessarily have to bridge the gap between medical ethical and deontological obligations and the organization’s obligations as a company operating in a social sector, thus responding to the whole of society. This conflict represents a challenge to all stakeholders in this sector.

 It imposes the need to build an ethical structure that considers the contingencies of the role, which forces the manager to make decisions whose repercussions go beyond the doctor-patient relationship, impacting the organizational structure.

Acting as an ethical leader

Ethical training for a leader can assist in moral reasoning and in the ethical development of decision-making, however, there may be limitations influenced by the context and the organizational culture.

  1.  Be Transparent

 Leaders must be transparent and open with their teams. Sometimes it can mean being open about the fact that you don’t have all the answers. This is a much better approach to providing false information or trying to divert, or that will quickly lead to a loss of trust.

In the health sector, the contrast between social justice and individual rights is a dilemma for managers who have a duty to manage scarce resources for a growing demand.

The Ethics Framework can be a management tool in this scenario, being a guiding instrument for decision making.

Values need to be promoted and protected as a critical resource in health management activity. It must be a management tool to respond to efforts to build a climate of collaboration and trust between senior management, health professionals and other stakeholders in the health sector.

  1. Establish channels for reporting ethical violations

 Health care ethics is not just about doing the right thing. It is also talking and acting when there are violations of ethical standards.

To encourage reporting of ethical violations, managers may need to reshape employees’ minds about reporting, as crimes tend to have an unfavorable reputation. Health service managers can emphasize reporting ethical violations:

  • It is a just and principled action;
  • Protects patients’ safety, well-being and rights;
  • It promotes a better and more patient-centered hospital community.

Ethical breach reports prioritize the patient above all else and employees must perceive this activity as a beneficial action, not as a last resort.

To enable employees to report violations, managers must establish reporting procedures that protect the whistleblower from any real or perceived repercussions. In addition, ethics violation reports can lead to more than just an argument with the offender. It can also help managers to identify ethical issues that the entire hospital community can benefit from the review.

  1. Lead the system

 Act on how the system is designed, how care is organized. Most quality failures in modern health are due to the lack of organization and coordination of organizational processes. The leader must take a proactive approach to organizing assistance and process delivery.

  1. Lead at the micro level

 Leaders must exercise their ethical duty at the micro level – in monitoring individual professionals. The ethical duty of non-maleficence requires that leaders follow the results and discrepancies, through a review of clinical practice and taking corrective actions.

Leaders are ethically responsible for success or failure in learning the best practices necessary for continuous improvement.

  1. Lead the distribution of resources

 It must prioritize and determine the distribution of resources to avoid waste and inefficiency of the system.

It is a requirement that the leader take responsibility for the care that needs to be provided to all current and potential patients within the system. This requires assessing the needs of the population and proactively monitoring to ensure that these resources are used efficiently and effectively.

 Why should ethical decision-making be incorporated into crisis management?

 A crisis is an unexpected event / situation that can cause serious damage to an organization or the public.

Crisis management is designed to protect an organization and its stakeholders from threats and / or to reduce the impact of threats.

It has become imperative that modern organizations are able to recognize and deal with complex business ethics. The reason for this can be attributed to several well-documented scandals, in which the unethical behavior of leaders has shown to have serious consequences for organizations and their employees.

The consequences of these scandals have brought to light the importance of ethical decision-making before, during and after a crisis.

In times of crisis, individuals and corporations are more likely to compromise their ethical behavior and need guidance.

If ethical guidelines are designed and documented in a way that can help individuals and businesses make a decision that they consider to be an ethical obligation, this will result in long-term benefits for all stakeholders.

Leadership is a delicate work that evokes high expectations and demands high standards of moral conduct, rectitude and ethical behavior, as its actions impact millions of lives and the social and environmental well-being of the context.

  1.  Ethical leadership is doing what is right for the long-term benefit of all stakeholders;
  2. Balance the organization’s short-term goals and long-term aspirations, in order to achieve positive results for all those who could be affected by organizational decisions;
  3. Understand what impact your decisions will have on a broader group of stakeholders.

Decision making is a central function of effective leadership. Leaders often face dilemmas during crises. Perhaps now, more than ever, we are witnessing a crisis of trust in our leaders on an international scale, and the need to get it right is fundamental.

Decision-making during a crisis is affected by various sources of information and prior knowledge, such as factual information (statistics), narratives from other people and government messages in real time.

The coach and the health manager are responsible for the performance of a professional team in a championship – and the president and the board of directors are responsible for the success in the Olympics”. Anita Ho, PhD1,2,3 and Stephen Pinney, MD, MEd, FRCS(C)4

In this way, health managers must be held responsible for the quality of health care provided and the performance of the organization they are leading.


  1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: Institute of Medicine; 2001.
  2. Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 2000.
  3. Mitchell JJ. The findings of the Dartmouth Atlas Project: a challenge to clinical and ethical excellence in end-of-life care. J Clin Ethics. 2011;22(3):267-276.
  4. Reason J. Human error: models and management. BMJ. 2000;320: 768-770.
  5. Pellegrino E.Prevention of Medical Error: Where Professional and Organizational Ethics Meet. In Virginia A. Sharpe, ed. Accountability: Patient Safety and Policy Reform. Washington, DC: Georgetown University Press; 2004:83-98.
  6. Berwick DM, Hackbarth AD. Eliminating waste in US healthcare. 2012;307(14):1513-1516. doi:10.1001/jama. 2012.362
  7. Arrington, R. (1998). Western ethics: An historical introduction. Oxford, UK: Blackwell Publishers.
  8. Beauchamp, T., & Childress, J. (2001). Principles of biomedical ethics (5th ed.). Oxford, UK: Oxford University Press.
  9. Bureau of Medicine and Surgery. (2009). Bureau of Medicine and Surgery Instruction 6500.3: Research integrity, responsible conduct of research education, and research misconduct. Washington, DC: Department of the Navy.
  • Bureau of Medicine and Surgery. (2010). Bureau of Medicine and Surgery Instruction 6010.25A: Healthcare ethics committees. Washington, DC: Department of the Navy. Crawley, R. (2007). The diversity of health research ethics in Europe. Proceedings of the Institute of Clinical Research Annual Conference, 17-28.
  • Agência de Investigação de Saúde e Qualidade (2005). Padrões alterados de Cuidados em Eventos vítimas em massa. Preparado pela Health Systems Research Inc. Online em: Colégio Americano de Executivos de Saúde (2010).
  • Declaração de Política: Papel Executivos de saúde em matéria de preparação de emergência. Saúde Executivo, setembro / outubro de
  • Relatório Belmont (1979). O Relatório Belmont: Princípios éticos e diretrizes para a proteção dos seres humanos em pesquisa. Online em:
  • Canadian Standards Association (2008). Z1600-08: Gerenciamento de Emergência e Programas de Continuidade de Negócios.
  • Federico, F., Bonacum, D. (2010). Fortalecimento do Núcleo: Quadros médios desempenham um papel vital na melhoria da segurança. Saúde Executivo, Jan / Fev 2010 e on-line em: Groves, Kevin S. (2011). Práticas de gestão: como organizações de saúde criam valor em uma economia. Saúde Management Review Care. Julho/Setembro.
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