I am a physician practicing in Wilson for 21 years. Over this time, I’ve assumed various leadership roles at the local and state level. I’ve also had to live with adverse consequences of bad decisions made by others in healthcare leadership. In observing the complex dynamics of healthcare, I’ve learned key variables leading to failure in healthcare leadership. These issues apply to other arenas such as education, media, business, sports, and politics. Existing leadership hierarchies fail the public for reasons that include a misunderstanding of the meaning of virtue (or a willful distortion of the concept), or a lack insight (or willful disregard) for how a policy is bound to lead to unintended and harmful consequences.
When a leader acts from their own sense of superior self-virtue, things are bound to go wrong. When a leader acts with an eye toward the greatest good and minimum harm for the greatest number of people, outcomes will be better. If a leader has experience in their field and an instinct for possible harms from unintended consequences of well-meaning policies, things work out better. A concern for unintended consequences acts as a restraint against excessive, impractical, or unwise policies. The goal of policy should be favorable outcomes for policy consumers, who are defined as those directly and indirectly affected by the policy.
Some leaders take actions claimed as virtuous but which in fact are designed not to help the public, but rather to enhance that leader’s stature amongst others in leadership positions, or to impress others who wield power and who could affect that leader’s future professional prospects. A decision by this sort of leader, who is not truly motivated by service to the policy customer, leads to bad outcomes. This is a narcissistic form of leadership that masquerades as virtue. These leaders never acknowledge their failed leadership because they don’t care about the harms they inflict on policy consumers. They only care about their own professional advancement.
Leaders should be judged on outcomes, not intentions. Both intended benefits and unintended harms of policy proposals should be critically analyzed and weighed. Leaders who speak of virtue but ignore or downplay possible unintended harmful consequences should be viewed with suspicion. A leader who attempts to explain in a practical, real-world sense the intended and potential unintended consequences of their proposals should be viewed more favorably. After a policy is enacted, a mechanism is needed to retroactively measure benefits and harms. This should be done by objective third parties. If unintended harms are significant, and the leader is found to have purposefully downplayed predictable downside risks, they should be held to account. Formal mechanisms for removal of failed leaders are necessary to protect the public from future harms. Many failed leaders are protected by allies within their institution whose fate may be tied to theirs, or who adhere to a similar ideology that may sound good but does not work in the real world. Some leaders rise to power through Machiavellian machinations rather than merit. Leaders should be judged solely on outcomes, not on an academic or career pedigree, or for having taken the right leadership courses.
Finally, our current problem with leadership in healthcare and other areas is linked to shifting cultural mores. Our current iteration of culture promotes decision making for instant gratification- feeling good at the point of decision- rather than viewing decisions as difficult things that might have untoward and unintended consequences. When a culture chooses a bad decision, it will reap an unpleasant harvest from the bad seeds sown, but this does not happen until the bad crop grows to maturity. If a culture makes decisions based on thoughtful analysis of long-term outcomes rather than a short term need to feel good at the point of decision, our nation could move toward a better class of leadership.
If a citizen views a complicated decision as an opportunity to feel good about themselves in the moment, with the mindset “I am a good person, so this is my preference”, poor outcomes will ensue. Making decisions from a continual need to feel good about ourselves is self-defeating and is a form of narcissism. Sometimes the better decision will make us feel bad in the moment- take for example a good mother or father who has just disciplined their child.
True virtue is judged on outcomes, not intentions. “Virtue” based on good intentions is false virtue if unintended consequences result in excessive untended harms. Failed leaders need to be held to account for bad policy decisions and removed from power. Allies of failed leaders who protect them, with an eye toward protecting their own position, also need to be held to account.
Keith Lerro, M.D.
Wilson, NC