Moral Courage on the Front Lines Is Lacking in the C-Suite

"Moral courage is rare and moral greatness even rarer. It requires a potent combination of deep empathy, will and conviction that social norms cannot shake."

– David Wolpe
Rabbi of Sinai Temple in Los Angeles, California

Jaya Mallidi, MD, MHS

The quote printed in bold, italic, Calibri font has been hanging on my office wall since October 15, 2018, when I read David Wolpe's account of Chiune Sugihara. Sugihara was a Japanese official who saved thousands of Jews fleeing Germany in 1939 by issuing transit visas, defying his government's orders. He did so knowing that his actions would end his career. When asked why, he said, "It was a matter of humanity. I did not care if I lost my job."

The kind of courage that Sugihara had is supposed to be rare. It is one that overcomes fear of immediate negative personal consequence because of the conviction that doing something for a noble cause benefits the rest of humanity—a moral courage.

COVID-19 and Moral Courage

Staring at the quote, I think about Li Wenliang, the Chinese physician who was admonished by government officials for his early warnings about SARS-CoV-2 and later died of COVID-19. I think about Brett E. Crozier, the captain of an aircraft carrier who sent an email via a public channel requesting assistance to save his sailors from the COVID-19 outbreak after being rebuffed by his superiors. He was subsequently fired. What about Seattle Flu Study Director, Helen Chu? She defied government orders and continued testing samples for SARS-CoV-2 to first identify community spread. I think about the nurses and physicians admonished or even fired for speaking out regarding the lack of personal protective equipment (PPE). There are stories of medical residents who voiced their concerns during this pandemic despite fear of disciplinary action. Suddenly, it feels like moral courage is no longer rare in this world.

Where did it come from? According to the Tao Te Ching, a Chinese classical text, courage is derived from love. Love for our fellow human beings, or for us physicians and nurses—our love of medicine—can inspire courage. Where there is deep love, there will be courage to protect it. Witnessing these stories, I am convinced that we are all capable of individual courage. It is as universal as the feeling of love from which it is derived—lying dormant until triggered by the prosocial milieu created by this pandemic.

Although the pandemic brought forth several examples of individual moral courage, it also lay bare the scarcity of organizational moral courage. Moral courage is traditionally seen as a valorous individual virtue. At the level of an organization, it translates into moral leadership through a top-down culture that encourages humanistic qualities such as honesty, integrity, responsibility, empathy, and forgiveness and integrates them into everyday decision-making. The leaders of such organizations create policies and practices that recognize rather than punish members whose opinions or actions are based on sound moral principles.

COVID-19 and Lack of Moral Leadership

Where are the examples of exemplary moral leadership among healthcare organizations during the COVID-19 pandemic? They are certainly not in the hospitals where healthcare workers were admonished or fired for speaking up about their lack of PPE. Decision-makers in these hospitals prioritized business or the social consequences of hospital "reputation" over people. Is it even possible to integrate morality into decision-making at an organizational level? To understand this concept, I read Moral Intelligence 2.0: Enhancing Business Performance and Leadership Success in Turbulent Times by Doug Lennick and Fred Kiel. It contrasts real-life examples of leaders of for-profit corporations who integrated morality into their decision-making with those who didn't and the subsequent repercussions for their respective organizations. For example, in the aftermath of the September 11, 2001, terrorist attacks, some CEOs of affected companies consulted public relations firms before doing anything, whereas Dick Harrington of The Thomson Corporation and Ken Chenault of American Express acted quickly and decisively to divert resources to track missing employees and contact their families even as they faced unprecedented threats to their businesses. The victims' families were given generous benefits. These CEOs prioritized people first and business second. That kind of leadership enhanced the dedication of the workforce and business success naturally followed.

The business side of healthcare has always exploited doctors and nurses in subtle ways through unpaid time spent on clinically meaningless quality measures and documentation requirements via electronic health records. This pandemic has exposed new heights of exploitation of the professional ethics of doctors and nurses who never walk away from their patients. In addition to punishing those who spoke up about a lack of PPE, pandemic pay cuts to frontline staff are reported widely as hospital revenues fall in the COVID-19 era. The executives who volunteered to take pay cuts to help with the financial fallout will be remembered for their moral leadership.

Hope From Universal Moral Courage

COVID-19 has amplified the misaligned value system of frontline healthcare staff and healthcare administrators. An aerial view of our healthcare system will show several bright sparks of individual moral courage from the front lines. However, these sparks are not enough to pierce the dark cloud of moral abdication displayed by healthcare administrators. Each such display of moral abdication would need many corresponding displays of individual moral courage to lift that cloud.

In each of our lives, there will be moments when we will have to speak up and act in accordance with our moral convictions despite the risk of disapproval and admonishment from leadership or other segments of society. When those moments come, stories like that of Li Wenliang should inspire us to find the moral courage lying dormant in each of us. I can only hope that the force of universal moral courage inspired by this pandemic will be sustained after the pandemic to rebuild our healthcare system in a way that realigns the value system of the frontline workforce and administrators and integrates morality into organizational decision-making.

Jaya Mallidi is an interventional cardiologist in Santa Rosa, California. An ardent patient advocate, she writes opinion pieces using patient stories to highlight problems in the practice of modern-day medicine. She also enjoys digital sketching and playing tennis.

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