Serving two masters? Shared corporate leadership and conflict of interest

Introduction

The ethical issue of Conflict of Interest (COI) within healthcare has traditionally focused on providers. For example, the relationship between providers and the pharmaceutical industry and the subtle effect of gifts from pharmaceutical companies to providers are topics which have received considerable attention. ¹

Yet while a significant amount of literature has been written on the concept of COI among providers, the risks of COI among senior leaders who share roles within multiple organizations have largely been ignored.

In order to reduce costs and inefficiencies, break down silos, and create smoother transitions of care, health organizations are starting to experiment with sharing senior leadership roles with their regional partners. While these are laudable goals, having individuals share responsibilities among two or more organizations can pose ethical challenges. Leaders from one health organization who have been recruited to share their responsibilities with another organization can be placed in the uncomfortable position of having to choose between these organizations when there are disagreements over priority setting or resource allocation. As health leaders have an explicit ethical duty to avoid COI, ² it is important to explore how working for two different organizations could unintentionally lead to a potential COI.

Conflicts of interests and divided loyalties

The vast majority of the literature on COI within medicine focuses on financial COI and has not paid adequate attention to non-financial COI, thereby ignoring the harms that could arise from non-financial COI and the importance of mitigating these harms. ³ Non-financial COIs do not have to be based on personal interests but often stem from professional duties, personal relationships, or personal beliefs and values that involve competing ethical claims to different parties. The ethically challenging problem of COI is that many health leaders, due to their trusted leadership role, believe themselves to be immune to COI as they believe that COI is due to self-interest or poor judgment. ⁴ Yet, non-financial COIs that stem from competing loyalties and duties do not involve self-interest or moral lapses of behaviour. Instead, they can be based on a deep sense of professionalism and loyalty to one’s organization. Social reciprocity and organizational identity and loyalty can actually play an important role in justifying both ethical and unethical behaviour which benefits one’s organization. ⁵

Divided loyalties for health providers can include everything from competing duties between different patients, patients and their families, members of the care team, and between individual patients and the healthcare system or healthcare institutions. For health leaders who are employed by two or more organizations, odds are they will face divided loyalties between their perspective employers. It would be naive to think that there would be no divided loyalties, as the different organizations, even if they have similar mandates, are not identical.

Optics, identity, and trust

Even if there is not a specific COI resulting from shared loyalties to two different organizations, there is the appearance of a COI which the health leader might have to address. Colleagues and staff from both institutions might question the loyalty of the health leader and question which organization she truly represents. This might especially be the case when the leader has a history with one organization and then joins a new organization. At the new organization, she might be seen as an interloper and “not one of us,” especially if she makes comparisons to her other organization and wants to implement changes that have been successful in her other organization. On the other hand, her colleagues and staff at the organization which she has a history with might consider her new shared role with a different organization to be a betrayal as she is no longer 100% committed to her original organization. A loss of trust does not have to be based on an actual moral breach but instead on the appearance of unethical behaviour which a COI implies. ⁶

Health leaders are likely to be pressed with multiple competing demands and duties from their organizations. These competing demands and duties are bound to be more complicated if she belongs to two different organizations and must report to two different CEOs and boards of directors. Multiple and ambiguous loyalties can lead to ethical dilemmas as competing claims will require trade-offs and sacrificing one relationship for the other. Toulmin identifies the ambiguous nature of what is expected in relationships as a primary source of ethical challenges, as ambiguity muddies elements of relationships which need to be identified and clarified. ⁷ It is unrealistic to expect that ethical dilemmas from these conflicting duties will not arise or that they can be easily reconciled.

For a health leader sharing her role with two organizations, conflicts could involve divulging information, maintaining confidentiality, fundraising, staffing, and lobbying the ministry of health for funding. Perhaps the most challenging conflict for a health leader is in fairly distributing her time and energy between two organizations. Even if the leader has very explicit expectations about how many days or hours should be allocated to each organization, it would be unrealistic to think that this would be possible in reality as the different needs and cultures of each organization would require a different amount of support. In an attempt to treat each organization equally, the leader might alienate colleagues and staff for not responding to certain issues as she has met her “time and energy quota” for one of her organizations. This approach rarely works within organizations where health leaders have multiple obligations and priorities, let alone two organizations, and would only cause increased workload, anxiety, and moral distress as the health leader would be constantly trying to fulfill unrealistic expectations.

Different organizations have different cultures, histories, mission statements, and priorities, so there are bound to be tensions between how a senior leader at two different organizations can navigate between them. This can be especially true in the case of a health leader who works for both a secular and faith-based healthcare organization. For a leader immersed in a Roman Catholic moral framework, for example, it might be difficult to simply turn this off when she is performing her duties at the secular institution. ⁸ Even if she could simply “change hats” when performing duties at her secular institution, she might be seen as being biased and of trying to subtly push Catholic perspectives on her colleagues and staff at the secular organization. For example, if she is fully immersed in the moral language of Catholic healthcare, she might make references to human dignity, which is a commonly accepted concept within Catholic moral teaching ⁹ but is a highly controversial concept within secular ethics. ¹⁰ Her position on ethically controversial issues such as medical assistance in dying or gender reassignment surgery could also be suspect at her secular organization even if she personally supports or is neutral on these issues.

Bias and disclosure

To help address the problem of possible COI, health leaders must acknowledge the role of bias in decision-making. They should not think of themselves as being immune to bias and COI due to their positions. They are in good company as even health ethicists report of COI resulting from competing duties and professional responsibilities. ¹¹ We should remember that we are all subject to biases and that biases are not intentional or sign of moral indiscretion but a basic fact of human psychology. ⁴ It is therefore important for health leaders to be aware of bias and acknowledge possible bias. Self-awareness of potential bias and sharing this with colleagues can help create a culture where other health leaders become more comfortable discussing their personal values and perspectives which could bias their decision-making. ¹²

Perhaps the best way to respond to possible or perceived COI is to acknowledge this concern in a form of full disclosure. In a health setting, disclosure is a commonly accepted means of informing patients or the public of possible bias or COI. Disclosure supports the ethical principles of transparency, honesty and informed decision-making, and trust. ¹³ Disclosure also supports a sense of self-awareness and reflection which is essential to provide effective leadership. ¹⁴ As critical self-awareness and acknowledging bias is an essential foundation of ethical behaviour and leadership, the practice of disclosure is one that should be adopted by health leaders.

Unfortunately, studies have indicated that COI disclosure does not necessarily mitigate against COI as it can lead to unintended results. An admission of possible COI could lead to a form of “moral licensing” where disclosure merely helps alleviate the individual’s moral guilt of being in a COI without actually resolving the COI. Disclosure can let individuals feel they have done their due diligence and are now no longer ethically responsible for the COI. Disclosures of COI can also unintentionally make others feel inclined to trust the individual who acknowledges a COI, thereby increasing instead of decreasing the risk of bias. ¹⁵

While disclosure of COI has its limits and should not be seen as a cure all for possible COIs, acknowledging the possibility of bias is a healthy practice for any health leader. If a health leader who shares responsibilities with two different organizations can be open and honest about her ethical struggles of avoiding bias and trying to treat both organizations fairly, it can help create a more transparent environment in both organizations where health leaders are more open about discussing their ethical challenges of trying to respond to competing demands and priorities.

Conclusion

While there is no easy way to respond to potential COI due to divided loyalties, it is important to ask whether COI is avoidable. As health leaders, we must ask ourselves whether increased efficiency is worth the risk of possible COI and question the practice of shared leadership roles among different organizations. Leaders have a hard enough time responding to multiple competing demands from one organization. It is not fair to place leaders in situations of having divided loyalties and placing them in possible COI.