MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

CHAPTER 5
ETHICAL CONSIDERATION IN LEADERSHIP AND MANAGEMENT
Ethics is the systematic study of what a person's conduct and actions ought to be
with regard to self, other human beings, and the environment; it is the justification of what
is right or good and the study of what a person's life and relationships ought to be, not
necessarily what they are.

Applied ethics requires application of normative ethical theory to everyday

problems. The normative ethical theory for each profession arises from the purpose of the
profession. The values and norms of the nursing profession, therefore, provide the
foundation and filter from which ethical decisions are made. The nurse manager, however,
has a different ethical responsibility than the clinical nurse and does not have as clearly
defined a foundation to use as base for ethical reasoning.

Because management is a discipline and not a profession, it does not have a defined
purpose, such as medicine or the law; therefore, it lacks a specific set of norms to guide
ethical decision making. Instead, the organization reflects norms and values to the manager,
and the personal values of managers are reflected through the organization. Then
manager’s ethical obligation is tied to the organization’s purpose, and the purpose of them
organization is linked to the function it fills in society and the constraints society places on it.
Therefore, the responsibilities of the nurse manager emerge from a complex set of
interactions. Society helps define the purposes of various institutions, and the purposes, in
turn, help ensure that the institution fulfills specific functions. However, the specific values
and norms in any particular institution determine the focus of its resources and shape its
organizational life. The values of people within institutions influence actual management
practice.

The following lessons will be discussed within the

chapter: Lesson 1. Moral Decision-Making Process

Lesson 2. Meaning and Service Value of Medical Care

LESSON 1. MORAL DECION-MAKING PROCESS

Personal, organizational, subordinate, and consumer responsibilities differences,
there is great potential for nursing managers to experience intrapersonal conflict about the
appropriate course of action. Moral uncertainty occurs when one is unsure what moral
principles or values apply in an ethical conflict, or even if there is an ethical or moral
problem (Marquis & Huston, 2006). Moral distress occurs when one knows the right thing to
do, but institutional or other constraints make it difficult to pursue the desired course of
action (Marquis & Huston, 2006).

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Multiple advocacy roles and accountability to the profession further increase the
likelihood that all nurse managers will be faced with ethical dilemmas in their practice.
Nurses are often placed in situations where they are expected to be agents for patients,
physicians, and the organization simultaneously, all of which may have conflicting needs,
wants, and goals. “It is not unusual that moral uncertainty is first experienced and escalates
to moral distress as patient’s rights are not respected or as institutional constraints are
applied and nurses feel unable to act on their moral choices and judgments" (Marquis &
Huston, 2006).

Learning Outcomes:
Upon completion of this chapter and with further self-directed learning you are must
have:
1. explained comprehensively the ethical leadership;
2. enumerated the qualities of an ethical leader; and
3. applied the different frameworks and principles of theoretical problem-solving and
decision-making models in ethical-moral issues related to leadership and
management.

Warm-up Activity:
For a short period of time, take time to internalize and answer these questions:
1. What do you think is the importance of ethics in nursing leadership and
management?
2. What is the specific characteristic of an ethical-moral leader and manager?

After answering these questions, you try to discuss your insights with your
classmates for a while before starting the learning inputs.

Learning Inputs:
Ethical Leadership is a combination of being a moral person and being a moral
manager. Being a moral person rests on a combination of key traits such as integrity,
honesty, and trustworthiness. In addition to these traits, being a moral person also involves
behaviors such as doing the right thing, concern for people, being open, and standards of
personal integrity.

Moral leadership includes being a moral manager, which involves recognition that
the leader or manager serves as a role model for others in all his or her duties. It also means
providing rewards and discipline around the ethical and unethical decisions made by others,
so that a clear message is sent about what behaviors are and are not acceptable in the
organization or situation.

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A. The Qualities of an Ethical Leader

Before we go to the different principles and decision-making models, it is very
important for you to know the qualities of an ethical leader. There are specific
characteristics ethical leaders showcase. The traits you should focus on as an ethical leader
include the following:

1. Conscientious
 ethical leader’s ability to be thorough, careful and vigilant.
 Ethical leaders take their positions seriously and they want to succeed in their
role. Furthermore, they want to help empower others and ensure the
organization and subordinates they serve are succeeding. The leader focuses on
the diligence and dedication to get the job done.
 also means the leader should showcase strong moral identity. An ethical leader
wants to define and think of him- or herself as a good person. There is a concern
present for doing the right thing and perhaps more importantly, of thinking what
the right action would be.

2. Inclusive
 this means that they are open to other opinions and encourage people to voice
different ideas within the organization. But on top of this type of communicative
and collaborative inclusiveness, ethical leaders also work with people from all
sorts of backgrounds. An ethical leader understands the benefits of a diverse
work environment, and therefore, wants the organization to be more inclusive
of people from different ethnicities, races, cultures and backgrounds.

3. Accountable
 The responsibility of ethical leadership must be treated with respect and in a
serious manner. As mentioned before, by doing what you are saying, you can
show true ethical leadership and therefore build trust among the subordinates.
You must, as a leader, be responsible for the actions and decisions.

4. Considerate
 Considerate behavior is important for an ethical leader in two separate senses:
a. First, an ethical leader must consider all of his or her actions and find the
ways to minimize harm.
b. The second type of consideration requires the proper treatment of
subordinates and other stakeholders.

5. Consistent
 ethical leadership framework must be present at all times and an ethical
leader must showcase consistency in his or her approach.

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 An ethical leader can inspire the workforce by staying true to his or her own
ethical standards.
 Consistency is also required in the way you treat subordinates and
stakeholders.

6. Authoritative
 Ethical leaders must learn to be authoritative and to use his or her power.
 authoritarian models decision-making is in the hands of the leader, in ethical
leadership there must be collaboration in the process.
 The focus is to achieve the ends, not to gain personal accomplishments or to
prove you are better than others. In essence, ethical leaders use authority as
a mean to empower others and sharing responsibilities and power is seen as
a means to increase the chances of success.

B. Moral Decision-Making Process

After learning the innate characteristics of an ethical leadership, we go now to the
different principles and decision-making models that will be utilized for problem solving and
decision- making specifically when the nurse manager/leader will be faced with ethical
dilemmas.

1. The Principle of Well-Formed Conscience

It indicates that people are obligated to inform themselves about ethical norms,
incorporate that knowledge into their daily lives, act according to that knowledge, and
take responsibility for those actions.

2. Ethical Discernment
Discernment engages our spirituality, intellect, imagination, intuition, and beliefs.
It is decision making that reaches into the heart of our beliefs about ourselves, about
those with whom we live and work, about God, and about all creation. Particularly in a
situation in which a group of leaders must come together to make a collective decision, a
structured process of discernment can help discipline decision making; ensure that
relevant dimensions of a decision are considered adequately; elicit a multiplicity of
perspectives; allow decision makers to reflect on their moral intuitions; align moral
sensibilities and intuitions with the deliberative intellect; and foster an ability to
articulate and communicate the rationale for organizational decisions.

Discernment, therefore, requires structured time for reflection and prayer. Such
time may include but not be limited to considerations such as:
o What would God have me do in this situation?
o How is God speaking through events, other people, and authority?
o How would a particular decision help us to serve others better?
o How would it advance our mission?
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o How do my personal biases and preconceived plans influence my decision

making?

Framework of Ethical Discernment

A. Observe
1. Identify the Problem
- Name the problem clearly. Where is the conflict?

o What seems to create difficulty?

o Is the conflict between individuals?

2. Acknowledge Feelings
- What are the “gut” reactions? biases?, loyalties?

o What are the initial feelings about the case?

3. Gather the Facts

- Issues to consider:
a. Clinical factors: (diagnosis, prognosis, certainty?)
b. Psycho-social factors: (history, family situation?)

o What are the ethically relevant facts?

o Whose account of the “facts” counts?
o Have all relevant perspectives been obtained?

B. Deliberate
4. Consider Alternatives
- Issues to consider:
a. What are the alternative courses of action? All options should be
seriously considered before eliminating any.
b. What are the likely consequences? e.g. medical, quality of life,
relationships, legal, moral/spiritual

o What are the alternatives? Probable consequences?

5. Examine Values
- Issues to consider:
a. Preferences of the person receiving care: wishes, values, beliefs?
b. Are others’ values relevant?
c. What beliefs/values of the Christian community are relevant?

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d. Which of the values are in conflict? What is the problem? Whose

values conflict? Economics involved?

o What are the important values?

o Whose?
o What is the good we seek?

6. Evaluate
- Alternatives Issues to consider:
a. Identify the decision-maker(s). Who speaks for the
personreceiving care?
b. Rank values.
 Dignity of the person;
 Respect for life;
 Interconnectedness of every human being;
 Common good;
 Solidarity;
 Stewardship.
c. Justify ranking. By what principles?
 Totality;
 Double effect;
 Benefits/burdens;
 Legitimate cooperation;
 Subsidiarity;
 Informed choice;
 Confidentiality
d. Evaluate the consequences of alternatives in terms of principles
e. What alternatives are excluded?

o Who is the appropriate decision maker(s)?

o Rank Value

C. Act
7. Articulate the Decision
- Issues to consider:
a. Which alternative best reflects the ranking of values?
b. Which alternative best balances more of the values?
c. Have any other alternatives come to light?

o State the decision.

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8. Implement the Plan

- Issues to consider:
a. How best to communicate the decision?
b. Who needs to know it?
c. How best to document the process?
d. Who needs to act?

o How should the decision be carried out?

Figure 1. Framework for Ethical Discernment in Health Care. Adapted from Health Ethics
Guide (2013).

3. Strategies of Moral Decision Making

A. Problem-Solving Process
a. The Nursing Process
1. Identify the problem.
2. Gather data to analyze the causes and consequences of the problem.
3. Explore alternative solutions.
4. Evaluate the alternatives.
5. Select the appropriate solution.
6. Implement the solution.
7. Evaluate the results.

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b. The MORAL Decision-Making Model

Crisham (1985) developed a model for ethical decision making
incorporating the nursing process and principles of biomedical ethics. This
model is especially useful in clarifying ethical problems that result from
conflicting obligations. This model is represented by the mnemonic
MORAL, representing the following:

B. Ethical Frameworks for Decision Making

Ethical leadership often takes the form of three separate approaches to
leadership. The three have historical and philosophical foundations and all three
emphasize different aspects in decision-making.

a. Utilitarianism Theory which sees the leader maximizing the welfare of the
subordinates. The focus is on ensuring the subordinates feel good and are
happy, before deciding on an action. Concern is on the proper ends of the
action, not necessarily on how you get there. The approach is closely
associated with John Stuart Mill and the ethical cost-benefit analysis.

b. Libertarianism Theory. The leader is to protect the freedom of the

individuals as the main concern. If an action or decision would restrain the
subordinate’s freedom, then the leader would not proceed with the
course of action. The concern is on the intent of individuals. The approach
follows Aristotle’s idea of virtue ethics or eudaimonism.

c. Immanuel Kant’s Ethical Theory of doing the right thing. The approach to
decision-making is therefore looking at the proper means. Moral and
ethical actions come from understanding what are the rules and customs
of the organization and following these. The idea is that by understanding
these common, agreed values, a leader can make the right decisions.

Activity: An activity will be provided after you will finish the Lesson 2 of this chapter.

Wrap-up activity: After knowing all of the essential concepts of moral decision-making
process, how do you integrate the leadership roles and management function in ethics?

Post-Assessment: Your instructor thru MVLE will give a summative test on the lessons of the
chapter. Please wait for further instructions. Good luck!

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References:

Waddock, Sandra. (2012). "Ethical Role of the Manager." Encyclopedia of Business

Ethics and Society. Ed. . Thousand Oaks, CA: SAGE, 2007. 786-91. SAGE Reference
Online.

Catholic Health Alliance of Canada (2012). Health Ethics Guide. 3rd Edition.

Marquis, B. L., & Huston, C. J. (2011). Leadership Roles and Management Functions in
Nursing: Theory and Application. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.

LESSON 2. MEANING AND SERVICE VALUE OF MEDICAL CARE

Scarce resources and soaring healthcare costs have strained all healthcare delivery
systems. There has never been a time when healthcare organizations needed to operate
more efficiently or be more aware of cost containment. Cost containment refers to effective
and efficient delivery of services while generating needed revenues for continued
organizational productivity. today depends on their ability to use their fiscal resources
wisely (Marquis, B. L., & Huston, C. J.,2011). Cost containment is the responsibility of every
healthcare provider, and the viability of most healthcare organizations.

Learning Outcomes:
Upon completion of this chapter and with further self-directed learning you are must
have:
1. defined value-based health care;
2. determined the importance and advantages of value-based health care; and
3. applied the principles of allocating health care resources.

Warm-up Activity:
“Nurses are practicing caring in environment where the economics and costs of health care
permeate discussions and impact decisions.”- Marian C. Turkel

Here is a quote from Marian C. Turkel, an author of a nursing book entitled Caring in
Nursing Classics. Try to interpret the quote and share your ideas to your classmates.

Learning Inputs:

A. Allocation of Resources

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The demand for healthcare is rising due to aging populations, rising chronic
disease prevalence, and technological innovations. There are currently more
effective and cost-effective interventions available than can be afforded within
limited budgets. A new way of thinking about the optimal use of resources is
needed. Ensuring that available resources are used for interventions that provide
outcomes that patient’s most value, rather than a focus just on effectiveness and
cost-effectiveness, may help to ensure that resources are used optimally. Value-
based healthcare puts what patients value at the center of healthcare. It helps
ensure that they receive the care that can provide them with outcomes they think
are important and that limited resources are focused on high-value interventions.

Resource allocation
- refers to the allocation of resources to a service, department or project.
- from an ethical perspective, resource allocation is a concept that is neutral with
regard to the moral implications of the allocation decision

Value-based healthcare
- is a way of trying to ensure that limited resources are used in a way which
provides the greatest value to patient.

Three types of values:

a. Allocative value
b. Technical value
c. Personalized value

Four attributes of value-based healthcare:

 Accessibility
 Service
 Effectiveness
 Costs

Health care resources

- defined as all materials, personnel, facilities, funds, and anything else that can
be used for providing health care services.

Guiding Principles for Allocating Health Care Resources

1. Allocation of health care resources should improve people’s health.
 That is, health care resources should be used to treat disease, relieve pain
and suffering, promote public health, and/or support research with the
potential to improve health. Improvement in health is the direct result of the
application of health care resources, as opposed to the indirect effects of
education,
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regulation, and law enforcement. Agents providing these resources are

physicians and other medical providers, not teachers, politicians, or
policemen.

2. Patients and members or prospective members of health care organizations should

be informed about how health care resources are allocated and the rationale for the
allocation.
 The principle of autonomy is based on the need to respect individuals and
their need to be informed when making choices. Even in settings where
health care organizations offer a limited “menu” of services, information is
important for parents to have to be able to organize their lives and their life
plans for their children. This principle is justified by the concept of publicity.
For an action to be considered moral, it should be made public and justified
to those who are affected by it. This fosters a participatory process, allowing
people to consider the ramifications of these allocations and to have the
power to approve or disapprove of them.

3. Once provided with information, patients, members, and prospective members of a

health care organization should have the opportunity to consent to or deny that
organization’s allocation of health care resources.
 This principle promotes individuals as autonomous agents. As autonomous
agents, these individuals are stakeholders in the process of deciding how to
allocate health care resources. Being active participants in the decision-
making process allows those involved not only to consent but also to help
provide direction in making complex decisions about health care allocations
in a fair and just manner. Once again, parents serve as proxies for their
children.

4. Conflicts of interest should be minimized by individuals making decisions regarding

the allocation of health care resources. Even though the primary aim of providing
health care is to improve health, the allocation process may either benefit or
penalize individuals at the expense of others. Such opportunities have the potential
to affect the best interests of the patient. For example, there may be financial
incentives for individuals for decreased usage of resources or penalties for excessive
usage.

Activity 1: Resource Allocation and Priority Setting During the COVID-19 Pandemic

Governments, international agencies and health systems have an obligation to

ensure, to the best of their ability, adequate provision of health care for all (WHO, 2020).
However, this may not be possible during a pandemic, when health resources are likely to
be limited. Setting priorities and rationing resources in this context means making tragic
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choices, but these tragic choices can be ethically justified. This is why we have ethics. This
policy brief

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answers a number of questions about the ethics of setting priorities for the allocation of
resources during times of scarcity. Such decisions may include access to hospitals,
ventilators, vaccines and medicines. It is essential that policies and practices are ethically
justified in such contexts.

Guide Questions:
1. Imagine that you are a leader or a manager of a heath care facility, what
ethical framework or principle will you apply to guide for the resource
allocation during the pandemic (i.e. vaccines, hospital bed, ventilator)?

2. Are the ethical considerations the same for all medical countermeasures,
including therapeutics, vaccines and personal protective equipment (PPE)?

3. What is the basis for deciding who should have priority access to scarce
resources?

Table 1. Ethical considerations when deciding who to prioritize

Principle Description Practice implication

4. How should decision-makers make considered ethical judgements about

these matters, given the likelihood that there will not be enough of a
resource? Who should be involved in decision-making on scarce resources?

5. What are the key ethical considerations that governments, vaccine

manufacturers and funders should take into account to ensure a fair
distribution of vaccines globally?

Table 2. Priority populations, and rationale for prioritization

Priority population Rationale for prioritization

Wrap-up activity: After knowing all of the essential concepts of moral decision-making
process, how do you integrate the leadership roles and management function in ethics?

Post-Assessment: Your instructor thru MVLE will give a summative test on the lessons of the
chapter. Please wait for further instructions. Good luck!

References:
Defining Health in the Era of Value-based Care: Lessons from England of Relevance to
Other Health Systems

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Sarah Gentry, Padmanabhan Badrinath Cureus. 2017 Mar; 9(3): e1079. Published
online 2017 Mar 6. doi: 10.7759/cureus.1079

[Link]

Marquis, B. L., & Huston, C. J. (2011). Leadership Roles and Management Functions in
Nursing: Theory and Application. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.

[Link]
care/

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