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Editorial AUGUST
2008
The Fiduciary Relationship Between Physician Leaders and Subordinates
Frank A. Chervenak, MD; Laurence
B. McCullough, PhD
Ethics are valuable in defining the relationship between physician leaders and
their administrative subordinates, from senior and junior colleagues to fellows,
residents, and medical students.1 A defining feature of the leader-subordinate
relationship is the obligation of the physician leader to develop the potential
of subordinates, for their own good as well as for the future of the organization.
This obligation directly parallels the core obligation of physicians in clinical
practice: primarily to protect and promote the health-related interests of
the patient, while keeping one’s own interests in a systematically secondary
place.2 The ethical relationship of physician leaders to subordinates is thus
a fiduciary relationship.
This fiduciary relationship is based on beneficence—the leader’s
obligation to protect and promote the professional interests and integrity of
subordinates. The leader’s beneficence-based obligation is to know the
subordinate’s motivating interests, clinical abilities, and goals, and
to match those maximally to the organization’s culture, taking into account
the realities of how advancement
is rewarded.
The fiduciary role of the leader is also autonomy-based. A physician leader
should elicit the subordinate’s values and preferences as to how they
want to advance their professional career and how they think they should balance
their career with other important interests and commitments in their life outside
of medicine or biomedical science, such as family or other personal interests.
Physician leaders have the power to override the subordinate’s autonomy
by controlling work assignments, space allocation, salary, and decisions about
advancement.
The fiduciary role of physician leaders is also justice-based and concerns the
responsible management of organizational resources to meet the needs of all
subordinates in order to further the mission of the organization. There must
be a fair allocation of time for research and financial support for each individual
in the organization. The leader has a justice-based obligation to protect subordinates
from exploitation, ie, situations wherein the subordinate experiences burdens
without the opportunity to experience professional, financial, and other benefits
that offset such burdens.
Subordinates who are senior clinical colleagues have the right to make decisions
that a leader may think is unwise, even if those decisions jeopardize the subordinate’s
professional development and advancement. In such cases, respect for autonomy
tends to become the controlling ethical concern. However, the more junior the
subordinate, the stronger the obligation of the physician leader to act with
authority by protecting the junior subordinate from making professionally unwise
decisions, according to the expert judgment of the leader. The burden of proof
to defeat beneficence-based judgments and recommendations of leaders increases
directly with the more junior status of the subordinate and the strength of
evidence for the leader’s expert opinion as to how to protect and promote
the subordinate’s professional interests.
The autonomous decision of a subordinate may so dislocate resources that the
leader’s ability to fulfill fiduciary obligations to other subordinates
is seriously impaired, causing harm to the leader and other subordinates, as
well as negatively affecting the mission. In these circumstances, the justice-based
and beneficence-based roles of the leader enter into synergy and become the
controlling ethical principles. This carries with it the important management
implication that exercises of autonomy by subordinates that threaten responsible
resource management (thereby threatening the organizational mission) bear a
steep, usually insurmountable burden of proof.
Physician leaders should try to prevent ethical conflict, especially by emphasizing
transparency.3 Transparency through clear communication, an accepted management
principle, has an important ethical implication. To the extent practicable,
the leader should communicate clearly when a subordinate’s autonomy will
be treated as an ethical principle secondary to beneficence or justice. The
leader should communicate as clearly as possible the justification for such
a judgment and why the subordinate should accept it.
Ethics provide powerful tools to guide physician leaders in the exercise of
the power conferred upon them by their leadership positions. These tools implement
the beneficence-based, autonomy-based, and justice-based components of the fiduciary
relationship of physician leaders to their administrative subordinates.
back to top
Frank A. Chervenak, MD, Board
Member
Laurence B. McCullough, PhD, Houston, TX
REFERENCES
- Chervenak FA, McCullough LB, Baril
TE, Sr. Ethics, a neglected dimension of power relationships
of physician leaders. Am J Obstet Gynecol. 2006;195(3):651-656.
- McCullough LB, Chervenak FA. Ethics
in Obstetrics and Gynecology. New York, NY: Oxford University
Press;1994.
- Chervenak FA, McCullough LB. An ethical
framework for identifying, preventing, and managing conflicts
confronting leaders of academic health centers. Acad Med. 2004;
79(11): 1056-1061.
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