Response to Carl Elliott: The Heroes that Bioethics Needs

Paula Chidwick, Jill Oliver, and Angel Petropanagos outline the qualities of adaptive leadership, an unacknowledged alternative to Carl Elliott’s false dichotomy, which depicts clinical ethicists as servants of health care organizations who are unable to make heroic choices as a way of effecting change.

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In “Why Clinical Ethicists Are Not Activists”, Carl Elliott claims that it’s not surprising we don’t see many “heroes in Bioethics” since clinical ethicists who take a moral stance through “public dissent” or “whistleblowing” would likely be fired. He suggests the choice to lose one’s job or compromise one’s moral integrity is “inevitable” given the structure of clinical ethics. He adds, “ethicists have become such institutional insiders that the very problems they should be addressing are invisible to them.” He characterizes clinical ethicists as “servants” of their organizations who “assimilate” and “go along to get along”.

Thus continues the false dichotomy: clinical ethicists will either be fired for taking a moral stance, or compromise their personal integrity. Elliott’s characterization of the clinical ethicist, as either a self-sacrificing “hero” or a submissive “servant” lacks imagination, despite the striking metaphors. He miscomprehends how and why organizational change happens. Elliott fails to recognize that clinical ethicists (like many others in healthcare) can and do create lasting, positive organizational change from within.

Hourglass (1872–1874) by Mary Vaux Walcott. Original from

Photo Credit: Mary Vaux Walcott/rawpixel.com/flickr. Image Description: Hourglass (1872–1874) by Mary Vaux Walcott.

Adaptive leaders are the “change agents” that refute Elliott’s false dichotomy. Adaptive leadership, developed by Ronald Heifetz and Marty Linsky, is a practical framework that helps people adapt and thrive in challenging environments. It embraces observation, experimentation, discovery of new knowledge, and the importance of values, motivations, and continuous improvement efforts. It’s grounded on decades of research in biology, psychology, and change management.

The task of the moral philosopher and the clinical ethicist are not the same. Moral arguments might change minds, but they are unlikely to change behaviour. Moving people in healthcare organizations towards an improved, more ethical future state also requires changes in behaviour. Through adaptive leadership, clinical ethicists can help colleagues to identify and understand ethical challenges, and co-develop (upstream) solutions that change how people think and act.

To successfully lead change, clinical ethicists must consider and anticipate the experiences of others.  Heifetz and Linsky state that “change… demands that people give up things they hold dear: daily habits, loyalties, ways of thinking.” This is especially true for ethics-related changes. Individuals will have different levels of tolerance for change. They also note “[w]hen the status quo is upset, people feel a sense of profound loss and dashed expectations … It’s no wonder they resist the change or try to eliminate its visible agent.” Clinical ethicists who take an adaptive leadership approach understand that organizational change of any type will come with a cost for everyone – not just the person leading the change. By appreciating the widespread losses change will cause, clinical ethicists can expect danger in leading change; but this is not because of their unique role in the organization, it is because change is hard.

Elliott mistakenly believes that clinical ethicists are not in the right position to make organizational change because they “have little formal power.” However, having a formally powerful position within an organization is neither sufficient nor necessary for a clinical ethicist to lead organizational change. Heifetz, Grashow and Linksy explain that power, authority and influence relate to one another in complex ways, and that authority can be both formal and informal. To lead, one need not be in a high-ranking position, as Elliott seems to assume. Clinical ethicists can make use of the power based in relationships built on trust. An adaptive leader can call colleagues in to difficult conversations without shaming or blaming them into doing the right thing. By practicing with integrity, a clinical ethicist can raise difficult issues and be a trusted colleague at the same time.

Ascribing a false dichotomy typically results in a hammer coming down on one thing or the other. In the way Elliott describes things, it seems it will come down either on the clinical ethicist, or the organization. In contrast, an adaptive leader invites colleagues to the table to work together towards various possible improvements. Adaptive leaders draw on the resources, tools, and theories of change management and quality improvement to systematically identify and drive opportunities for improvement and to align this work with how people and culture respond to change. In the world of false dichotomies, you get only one opportunity for change. In the world of adaptive leadership, you get to keep trying to make improvements.

Leaders and colleagues come and go and organizational cultures change. This doesn’t inhibit the work of adaptive leaders; in fact, it is the work. Adaptive leaders recognize that change comes through relationships with people who trust each other, are open to new ideas, and are willing to think and act differently from where they currently stand.

The work done at our Ethics Quality Improvement Lab shows that successful, sustainable change can happen from inside the organization and be led by clinical ethicists. We’ve accomplished these changes by using the principles and tools of adaptive leadership and moving beyond the false dichotomy. We influence change by working with people and helping them to think and act differently about ethical issues. For example, we’ve worked with colleagues to understand and address habits and beliefs related to discharge and co-created ethics quality improvement projects, such as ChELO (Checklist to Meet Ethical & Legal Obligations) and PoET (Prevention of Error Based Transfers) supporting changes related to consent, capacity, and substitute decision making. We support healthcare colleagues to align their habits, attitudes, beliefs, and practices with a more ethical future state.

The heroes bioethics needs don’t sink the boat, jump ship, or walk the plank – they stay on the boat and be adaptive leaders.

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Paula Chidwick is the Director of Research and Corporate Ethics at William Osler Health System. @PMCEthics

Jill Oliver is the Community Ethicist at William Osler Health System. @joethics

Angel Petropanagos is the Quality Improvement Ethicist (@EthicsQI) at William Osler Health System. @APetropanagos