 with a talk by Dr. Ellen Fox. Ellen is president and CEO of Integrated Ethics Consulting, LLC. Prior to developing Integrated Ethics, Dr. Fox was chief officer of the Veterans Health Administration's National Center for Ethics in Healthcare. In that role, Ellen and I work closely together to set up the fellowship program between the VA and the University of Chicago McLean Center. And at the earlier session, you heard Lisa Vig give a talk about consulting and Lisa was one of the trainees in that program. Ellen has over 20 years of experience working with hospitals, healthcare systems, academic institutions, professional societies, corporations, and government agencies. She's become an internationally recognized consultant, educator, researcher, and speaker. Her areas of expertise include ethics consultation, where in my view, Ellen is the leading authority in the country, ethics education, ethics evaluation, organizational ethics, and ethical issues in end of life care. As you can see behind me today, Ellen will speak on the topic of how to speak truth to power in organizations. Please join me in welcoming Ellen Fox. Good afternoon, everyone. Well, thank you so much, Mark. And it's just such a great pleasure to be back here and to be back in Chicago. I look forward to coming back every year to have the opportunity to be with friends and colleagues and enjoy this wonderful event. I am going to use my, here it is. I have my own consulting business now, as Mark mentioned. And so I have a very clear conflict of interest. If anybody would like to hire me, please come and see me after the talk. Today I'm going to share with you some reflections inspired by the job I just left as the director of the National Center for Ethics and Health Care within the Department of Veterans Affairs. And I want to start just by telling you what I'm not going to talk about. This is not going to be a tell all account of the insider workings of the federal government. I'm not here to air any dirty laundry. I spent 15 years with VA and I have no desire to say or do anything that would harm the organization. What I am going to do is to draw in my experience there to share some thoughts on a topic that I had a lot of experience with and that I think has not been adequately addressed elsewhere and that is how to be effective in speaking truth to power in organizations. So my job at VA was to advise leadership on healthcare ethics and to try to promote ethics throughout the organization. And it is a huge organization. So this was not an easy job. But then being a healthcare ethicist in any size organization I think is not an easy job. In fact, a lot of your time involves telling people things that they really don't want to hear. You don't become an ethicist because you want to be popular. You've got to have tough skin. A healthcare ethicist has to be the type of person who's satisfied with the intrinsic rewards that come with this important work. So why do we do it? Because ethicists are absolutely passionate about one thing. What do you think? Just kidding. Actually, I think being too passionate about being right can be a huge liability for an ethicist. So it's not about being right. It's about making a difference. I'm passionate about what's right because I want things to be right with the world. Right? The role of an ethicist in a healthcare organization is not to make ethical arguments for arguments' sake, but for the sake of changing the organization to make it a better place, a more ethical place for patients. So how can healthcare ethicists make a difference? Well, you may be familiar with this concept. It's from Stephen Covey's Seven Habits of Highly Effective People. You've got your circle of influence. It's much smaller than your circle of concern. And he notes that effective people focus their time and energy within their circle of influence where they can actually make a difference. By doing this, they gradually expand their circle of influence as they earn more power and respect. And within their circle of influence, healthcare ethicists really can do a lot of things to influence ethical practices. And they typically can exert their influence at multiple different levels, bedside consultation, policy, projects, communicating in the press. But one of the most important things, I think that ethicists do, is to speak truth to power. Here's as good a definition as any for that. This is how it was defined by Ansem Chan, one of Asia's most powerful women who was nicknamed Hong Kong's conscience before she resigned from Chinese government in 2001. It means giving your best advice to superiors based on the best information available and objective analysis even when you know it may not be music to their ears. So the bioethics community in Canada has written about the role of ethicists in speaking truth to power. Here they suggest that the role includes the unique obligation of speaking explicitly to moral concerns, direct responsibility for speaking to concerns regarding the moral character and behavior of the organization and to speak uncomfortable truths. Well, it can be very risky for an ethicist or for anyone else for that matter to tell those in power things that they don't wanna hear as illustrated here. Let the minutes show that Fenwick brought up the subject of corporate ethics. But all kidding aside, speaking truth to power can have serious negative consequences, as was the case in VA, where in the wake of the recent wait time scandal, dozens of employees from across the country came forward with claims that VA had retaliated against them for internal whistleblower. Benji Friedman in his famous article called Where Are the Heroes in Bioethics expressed concern that he did not know of any stories about heroes in bioethics, such as people who had publicly quit their jobs on principle or out of protest for bad things that were going on in the organization. But I'm not convinced that quitting your job on principle and then going public is necessarily a good thing. You know, others have expressed ideas similar to Friedman, such as Francois Bayless of this organization, Impact Ethics, this is from their website. They talk about making a difference in bioethics, but the way they talk about impact ethics is about using the tools of ethics to shock, press, crack and chip society into a better place. And you know, I find the verbs used in this definition, particularly striking, pun intended, in that they suggest physical force and maybe even violence, right? But I don't see this harsh approach as necessary or even desirable in terms of positive, promoting positive change in bioethics. You know, interestingly the origins of the phrase Speaking Truths of Power really suggests the opposite. The phrase originated in this 1955 document produced by a Quaker group. It was essentially a guide to peaceful conflict resolution. In a qualitative study of Canadian bioethicists, Frolic and Chidwick compellingly illustrate the complexity of the choices that bioethics often have to make. For example, one talked about what happened after he took a principled stance on an issue. I don't know if I accomplished anything. It's all nice to take a stand and think I'm doing the right thing, but if you undermine yourself so profoundly in an institution that you cut the institution off from your expertise, it can be a shallow victory. I was right, but so what? Was that the right fight? I don't know. I would today be more cognizant of the consequences of my choice. Well, unfortunately, there are not a lot of resources available to help ethicists make these sorts of difficult choices. As the ASPH publication on core competencies for healthcare ethics consultants points out, bioethicists have written a whole lot on everyone else's ethical dilemmas, but very little on their own dilemmas and how to solve them. So let's take a look at some relevant work from other fields. A social scientist named Alberto Hirschman was best known for this 1970 book. The basic concept is that when an organization experiences quality problems, clients or members of the organization have two avenues of recourse. They can either exit, meaning they end the relationship, usually to go to another organization they perceive to be better, or they can voice, which is the act of agitating from within to try to fix the quality problem. So when we might ask, is speaking truth to power a good idea? Well, first, I think it needs to be an act of integrity. The old professor Stephen Carter has written about this in a book called Integrity, and he outlined three steps that are essential to the exercise of integrity. First, it requires discerning right from wrong by seriously considering ethical questions, acting on your belief about what is right, and openly stating that you are acting on that belief. James O'Toole and Warren Benes, pioneers in the fields of business ethics and leadership studies, talk about the act of speaking painful truths and propose these criteria that must be met in order for this act to be virtuous. I'm not gonna read through these, but things like, it must not be self-interested, it must not be done out of spite or anger. Well, I think these criteria are thoughtful, but really not sufficient. In my work at VA, I face decisions about speaking truth to power in one form or another nearly every day. And so I think that the question for many ethicists is not so much if you should speak truth to power, but how often and how. So I'm gonna offer some practical advice for healthcare ethicists, and really for anyone who cares deeply about doing the right thing in organizations. And my number one piece of advice is pick your battles. So how? Well, first, it's important to be clear on what success would look like. I think it's a mistake to think that informing leaders about a problem is success. That's not success. The question would be things like how will patience and the organization benefit if you were successful? How likely are you to succeed? This may be determined by factors that are beyond your control, but will depend on a very significant degree on your personal effectiveness, which you can work on and improve with experience. You also wanna consider if you succeed, how much of a difference would it make? And so for example, sometimes you're aware of wrongdoing, but it's really not that big a deal. So it's better to focus your energies elsewhere. What happens if you fail and what happens if you do nothing? Sometimes things just work themselves out without your help. So it's important to weigh all these sorts of questions in picking your battles. So just a story to illustrate. One day, a proposal came across my desk for a very high profile new program affecting about a million patients and costing hundreds of millions of dollars. And this program was being heavily promoted by a very powerful leader in the organization. And I had huge ethical concerns about the project. I thought it could potentially have some very serious unintended consequences for patients. And so my staff wrote up a careful critique with some very concrete recommendations on how to change the proposal. So a few weeks later, I was at a National Leadership Board meeting, which was a monthly group that I sat on that made all the big decisions for the healthcare system. And this proposal was being discussed, which was a huge surprise because it was not on the agenda. So I was not in any way ready for it. I had no notes. And I soon realized what was happening, which is that this powerful sponsor was deliberately trying to railroad it through without discussion. And during the presentation, this person actually looked me right. So this person looked me straight in the eye and during the presentation, and said with this huge smile that ethics had reviewed this proposal, clearly implying that I had also approved this proposal. And I was completely shocked and I had to decide in that moment what to do because it was about to be a vote. And since I had no time to prepare, I really wasn't confident that I would be particularly compelling or for that matter diplomatic in my approach in that moment, at least not as much as I would have liked to be. And I was pretty sure that speaking up would result in some kind of negative consequences for me. But I also thought it would potentially have a significant impact. And I thought if I did nothing, the proposal would certainly pass and veterans could potentially be harmed. So I went ahead and I spoke up. I expressed my concerns publicly. I asked people to vote no until changes could be made in the proposal and the proposal was overwhelmingly voted down. And then right after that, the powerful leader came up next to me and leaned into me in a very intimidating and actually a painful way and whispered in my ear, you have no idea who you're dealing with. Watch your back. So there can be negative consequences. I thought about reporting that up the chain of command. But in that case, I decided against it. The act, in that case, the act of speaking truth to power would have been, at least in part, motivated by self-interest. And plus, I really didn't know what difference it would make. Well, it turns out that within a year, that person was fired. And so, actually based on ethics violations, poetic justice there, but anyway. So my second piece of advice is to understand your audience. Professor Guy, don't hide behind sales figures, Bill. We both know terminating me is philosophically unsound. You know, this, I think, can be, understanding your audience can be particularly important for academics who are speaking to, say, hospital CEOs. In the 15 years I was at VA, I had something like nine different bosses I reported to and many more, probably 25 or 30 people, if you count the bosses above them. And each one was very different from the next. So one undersecretary insisted in every presentation you had exactly four sides with five bullet points on each side. Another insisted on oral presentations, but really you never made it through the second sentence without being interrupted. So you didn't really have a presentation. As a general rule, you know, when communicating with executives, I think the more quickly you get to the point, the better. But then there was a cabinet secretary who actually would ask for detailed background articles on every issue and would read every word. So you really need to carefully observe or otherwise find out what type of information a particular leader finds most compelling. And I'm on the wrong side. So what do they care about? Well, this is really negotiation one-on-one. You need to understand people's interests. And if you haven't read Getting to Yes by Roger Fisher and William Urie, you really should. That's helpful, enough said. And then what's at stake for them? Well, there's a number of possibilities here. So for many leaders, for example, it's important to save face. And it's important to think about how to help accomplish that. Maybe they are much more likely to take action if it looks like it was their idea, right? Some people are, that helps. Or at the opposite extreme, in VA, it was often important for leaders to have what was called plausible deniability, right? Because whenever something bad happened, Congress would look for somebody to be responsible and heads would roll. So sometimes a leader might go along with something as long as someone else could take the credit or the blame if something went wrong. My next piece of advice is, do your homework. If it's important, over-prepare. You know, once a leader has made a decision, they're not likely to wanna revisit it unless there's new information. So it's important to put your best foot forward the first time around. So you'll wanna be able to cite specific standards and data and cases and stakeholder perspectives and so on. And you may need support from allies. Some leaders care less about the information than they do about who agrees or who holds a particular position. So maybe they don't really rely on logic as much as on relationships. And in that case, it's a good idea to talk to a trusted advisor of theirs and get them on board before you talk to a leader. Finally, you really wanna be ready with recommended actions. Executives in general don't want you to just dump problems on them, you know? They are looking for solutions. What do you advise the leader to do? And if you don't know, do some homework and see if you can find out something that would be helpful and so you can suggest at least next steps so that you can make it easy for them to do what you want and to succeed. Next, it's important to determine the right method, location and timing. These decisions are crucial elements of strategy. Should you deliver your message face to face, email, memo, in a public meeting, behind closed doors, often timing is very important. Are they dealing with a crisis right now? Might not be the best time to go in and talk about something else. So for some people, this kind of strategic thinking comes very naturally, but if it doesn't for you, then thinking systematically through questions like this can be helpful. There are many ways to frame the conversation that you can think of as different tools you can use. So the first several items on this list, the first five, I recommend a book called Crucial Conversations by Kari Patterson at all and basically the idea is instead of starting from a position of I'm right and you're wrong and I'm kind of convinced you of something, it's often the best approach to force yourself to be open and not make assumptions and to seek out the other person's point of view in the discussion. But in some cases you just want to give advice and I actually gave specific feedback to VA leaders about how their specific words or actions were affecting the culture of the organization. And I think it made a difference at least with some leaders but there is a specific skill to this. So I wouldn't recommend doing it unless you're pretty sure you can pull it off, especially on solicited advice but there are a number of good books out there on how to give feedback and I think some of those can be really helpful for this kind of thing. Pethic's Trump card. So an example of this is I was on a conference call not that long ago where Congress had requested that VA provide certain documents and Congress has a right to do that and VA is required to comply. And in the conversation people were making all kinds of convoluted excuses for why a particular document did not need to be included in the documents that were being released to Congress because this particular document would make VA look bad. And the rationalizations were really just not defensible. There were, I was on a conference call and there were a lot of people and I really could not even get a word in edgewise. I knew I had very little opportunity to talk. So I pulled the ethics Trump card, which I very rarely do. And I said something like, as the chief ethics officer of this organization, I need to inform you that the course of action that's being proposed is not ethically defensible and cannot be allowed in this organization. So that's what I mean by pulling the ethics Trump card. And then finally the integrity statement. What I mean is you describe the specific actions you'll be forced to take in order to preserve your integrity and why. And there were a few times in my VA career where for example, I refused to do something that I was asked to do. For example, disclose confidential information to leadership. I was on occasion informed that, well on occasion informed those in power that I would have to either talk to a superior or to an oversight body of a particular situation continued. And in a couple of cases, I even had to, I did follow through and do one of those things. But I can't emphasize enough that you must use these last two strategies very sparingly. The more effective you are, I would argue, the more you should be able to get the job done without resorting to these sorts of extremely risky tactics. It's also important to keep things in perspective. Realize that there are many ways to make a difference and if you remember that series of circles, you may be better at dealing with some levels than others and good idea to go with your strengths or at least develop your weaknesses. You can't win every battle. And sometimes you win even when you don't know it. You don't necessarily see the impact that you've had. So it's good to ask for feedback and help learn about yourself and understand how you're perceived and whether you're being effective. And then know what lines you're unwilling to cross. There were probably seven or eight times during my tenure at VA that I was prepared to quit on principle if leadership did not support my position or do something that I really thought needed to be done because I would have felt it compromised my integrity to stay. On one occasion I actually drafted a letter of principle resignation that I ended up not needing but I did it as sort of part of this thought process to analyze what was going on. So important to know your own limits. My final piece of advice is to get good at speaking truth to power you really need to practice. So if there's an important conversation you have to have role play it with somebody have them critique your performance can be really, really helpful. The more you improve your skills at speaking truth to power the better strategies you will develop which will make you more effective which will expand your sphere of influence and ultimately your impact. You know being an ethicist can be a thankless job but it can also be an incredibly rewarding job. Speaking truth to power does not always make you popular but you've got to know in your heart that you're doing the right thing and you're making a difference and that's what matters, thank you. I'm Robert Sebesta from Central Texas VA. Thank you for everything that you've done in the VA for ethics and personally and publicly. I also wanted to say thank you for introducing me to these amazing people. Actually I thought this was different from what you were gonna be talking about so I was excited about the topic. I'm gonna use some of these things back with the local leadership. A question along these lines and hopefully I can get another practical answer. With VA leadership at local hospitals for directors being involved with ethical leadership projects is tied to how they're measured and rated and of course VA has had problems with how incentives are enacted. We've even talked today about how do you incent and do you look at skills versus building character. Is there a way to measure aside from bonuses and pay that will inspire leaders beyond just saying gosh I hope you're of good character and we're taking the other extreme of we'll pay you big bucks if you try to change the culture of your facility. I wish I had a short answer to that. I don't think I do. Certainly I agree with you that performance incentives can create perverse incentives but they're also a useful tool if done well. So I wouldn't throw the baby out with the bath water. I think for those of you that don't know the most recent scandal in VA had to do with wait times and gaming of numbers and it was largely understood that this related to some very powerful performance incentives that is clean incentivized people to cheat. So I would say I think actually performance incentives are good if used well but I think there are lots of other ways to motivate people to change their behaviors. I see four other people are waiting to question short questions and we're gonna ask Ellen for short answers. Ron Miller University of California, Irvine. Ellen your courage is most remarkable and appreciated. I wonder what effect you think the 60 minutes exposé may have. I didn't see the 60 minutes exposé probably happened after I left I don't know. I'm not sure what you're referring to sorry. I'm sorry my hearing is sufficiently impaired I can't. Oh I was just saying Ron I'm not sure what the topic was of the 60 minutes exposé I'm not familiar with it. Right too little too late perhaps. Yeah okay. Eugene Perez from McGill thanks Ellen that was great. My question is sometimes you're listening to those kind of situations where the consequences may be to the ethicist but there might be other situations where the negative consequences of less than strategic intervention might be to the whole ethics enterprise. My question is I've thankfully rarely but been in situations where in order to resolve that and make the ethics enterprise not only survive but grow required an exit strategy and a face saving strategy for the power structure which required confidentiality and not disclosing how we got there which can put then the ethicist in the light of you crossed over to the dark side and sold out. Have you ever had that experience or any advice on how to handle that? No. That was a short answer. So Ellen I want to thank you and I want to thank you for your courage I do want to point out that in response to Benjamin Freedman's where are the heroes I would like to call out two other ethicists who were former McLean fellows who really have in a sense taken some risks in their ethics job. One is Carl Elliott and the work he's done at the University of Minnesota and the other is Steve Miles also in Minnesota. Yep. And you know my people keep saying I'm courageous. I mean you know my departure had nothing to do with anything I'm talking about here. So just in case anybody was wondering. Thanks Katie Watson Northwestern University. Absolutely loved your talk. I want to ask you to push further on the definition of truth. That's right. So when we say we speak truth to power it assumes that I am the person who has the truth. And the next layer for me is as financial pressures on hospitals certainly reach in deep in academic medical centers where maybe in a previous era we thought that we had shared values of academics and some are transitioning to where finances are raining and branding is starting to creep ahead of academic values. Some of us might find us in environments where if there's an organization where there's a shared set of values and assumptions we might be on a shared truth terrain. But when there's competing values or powerful assertions of values where there's a performance of one set of values but that we all understand there's a subterranean driver that's different than that. Can you speak to how when the contest is not so specific on each outcome or this case or this policy but it's sort of a broader organizational drift that one is witnessing and accidentally participating in perhaps. What does that mean to speak truth to power about those larger issues of organizational values for patients and for academic freedom? Another big question. Could you solve that for us? Well, I mean a couple of thoughts come to mind. One is that if your personal values are not sufficiently aligned with the values of the organization you're in trouble. If you are working for an organization where you really can't get behind their priorities you're in trouble, right? I mean, you may be in the wrong organization. On the other hand, some people would say that's precisely the situation where you can be most effective to get the organization back on track. So I think there's not a simple solution there. I just stick to what can you change? How can you make a difference? How can you be effective? And if you can't, then you're not gonna be happy.