Ethical Leadership Challenges – Death, Injury and Trauma in the UK’s Maternity Services

According to a recent study, the UK has the second highest maternal death rate amongst eight European nations, beating only Slovakia. What is more, this rate is increasing. This month a report was published by the All Parliamentary Group of MPs for Birth Trauma. The report described accounts of stillbirth, premature birth, babies born with cerebral palsy caused by oxygen deprivation, and life-changing injuries to women.

“In many of these cases, the trauma was caused by mistakes and failures made before and during labour. Frequently, these errors were covered up by hospitals who frustrated parents’ efforts to find answers.

There were also many stories of care that lacked compassion, including women not being listened to when they felt something was wrong, being mocked or shouted at and being denied basic needs such as pain relief.” APPG Report into Birth Trauma

What might these tragic circumstances have to do with ethical leadership challenges? Lots!

When we think of ethical leadership we often think of very powerful people making important decisions affecting the lives of thousands of people. We think of disasters such as the BP oil spill or the Boeing scandal or the Sackler family and the Oxycontin epidemic.

But what if ethical leadership and ethical values in the workplace comes down to moment-by-moment decisions that we hardly even notice?

Let’s look at the maternity care services case through four perspectives:

1. The Moral Compass of the Staff

The report notes that doctors and maternity staff routinely patronised mothers and refused to listen to them. Examples include one mother who was told she was over-anxious when she was bleeding internally from a complication in pregnancy; another mother whose concerns were dismissed and as a result her baby died in labour; another mother who suffered horrendous and permanent “urinary and faecal incontinence” but was told by a consultant that there was nothing physically wrong with her. The list continues. Staff often wrote in their notes, ‘anxious mother’ and in one case, the page was torn out when it was discovered that there had been a serious problem.

What is also notable is the overwhelming majority of written submissions referred to a lack of kindness or compassion from staff. Here is one example:

“I was covered in blood and my own faeces but there was no one to help me wash. A plastic sheet was put on the bed and I lay on it in my filth. Around midnight I was woken up by a woman…who reprimanded me for not feeding my baby….I didn’t know what to do and I couldn’t pick him up…but when she saw I was covered in blood and shit…she told me to get back in and said she’d hand him to me. I didn’t know how to breastfeed. She told me if I didn’t get it, she would take my son and give him a bottle. I felt like I was failing at mothering and I’d only been a mother for a few hours”

It does not take a lot of effort to be kind. But, research by Cropanzano and Walumbwa suggests that most people have a very weak moral compass. They show that only around 20% of the population make decisions based on principles and ethics. They argue that the 80% will only behave ethically if someone in leadership behaves as a role model for them to follow.

Clearly this is not happening in England’s maternity departments. We will see below that there is a lack of ethical leadership in these departments which has seeped into the culture. It seems shocking that normal staff, being paid for looking after the health of mothers and new-born babies, can mock, ignore and patronise their charges in the face of life and death situations. It is in their behaviour that we see our own shadows. We are all capable of acting cruelly and without compassion.

Question: how can we regulate our shadow sides, particularly if leaders cannot regulate their own?

2. Ethical Leadership Challenges

We know that those high in social dominance orientation (SDO) tend to make it to the top more than those low in SDO. Those high in SDO make decisions based upon self-interest rather than ethical concerns. This suggests that our leaders are more likely to come from the 80% who have a weak moral compass rather than the 20% who have strong ethical values.

This should surprise no-one.

The APPG report into maternal care, not only evidences continual cover ups by leaders of the services, they show how this is endemic in the National Health Service culture. They mention many past examples of cover ups to which I would add the tragic cases of the Bristol Royal Infirmary and the Mid Staffs Hospital. The private sector is the same. The leaders of Toyota, Boeing, BP, Volkswagen, Ford, The Post Office, Apple – all knew of the wrongdoings taking place under their watch and, regardless of who suffered, put all their energy into hiding the evidence and avoiding responsibility.

When we have leaders like this at the top, concerned only for their self-interest, expect cynicism and moral indifference throughout the organisation.

Question: how do we ensure more ethical leaders get to the tops of organisations?

3. Organizational Culture and Ethical Values in the Workplace

The Cropanzano and Walumbwa article also suggests that the morally neutral 80% are more likely to follow leaders’ unethical behaviour than their ethical behaviour! Why?

1. It is so much easier to act in our self-interest than it is to put effort into acting ethically and kindly. If we see our leaders acting in their self-interest, why shouldn’t we?
2. When a culture of self-interest sets in, social connection, mutual support and altruism drop away. These bonds are based on trust, which is hard to build and easy to destroy. As a result, people follow ethical leaders slowly to ensure they can be trusted. However, as soon as they see everyone pursuing their self-interest, they drop the ethics pretty quickly – after all, this is about survival!
3. In many organisations, there are costs to being ethical (see my last post on ‘Conviction’). You are liable to become a scapegoat for people’s feelings of guilt, anger, fear and shame. This is evidenced in the stories of many whistleblowers.
4. Compassion is a complex quality. We are much more likely to demonstrate compassion for those we know than for ‘distant others’ – even if those distant others are mothers screaming in pain in front of us, whose babies are dying. This is why continuity of care is being demanded as one of the solutions to the maternal care crisis. The midwife who ‘knows’ the mother, is much more likely to demonstrate compassion than someone who has never met her. Compassion is a sign of moral, emotional and spiritual maturity.

Question: how can we develop moral, emotional and spiritual maturity in our leaders and select out those who fail to demonstrate these qualities?

4. Why Unethical Leaders Get Away With It

The problems in the NHS of leaders intimidating, punishing and silencing staff have been known for decades (as in the Bristol Royal Infirmary Case). Little has changed and expert commenters expect little change following this report, despite the fact that compensation payments now account for fully one third of the budget for maternal care services in the UK.

The fact is that leaders at the top do not suffer any personal consequences when their organisations are sued. They belong to a leadership elite where the tacit contract is to look after each other’s interests in the face of criticisms from ‘minions’. The revolving door phenomenon is what results.

Question: how can hold leaders to account in order to align their self-interest with the needs of vulnerable stakeholders?

* * *

I am very aware that this all sounds a bit negative. As you’ll have noticed whilst reading this, the factors influencing ethical decisions are complex. I recommend learning more about behavioural ethics. The University of Texas has a fun site that is particularly good at explaining the complex dynamics in an accessible way.

What seems clear to me is that we cannot trust human beings to act in ethical ways. They have to be motivated to do so and held to account if they don’t. There must be consequences. In part, it is not our fault that we often fail to pass the ethical bar. It’s the way we are made! I don’t know why only 20% of the population progress on to Kohlberg’s higher levels of moral development, but I know from my personal experience, it’s probably true. So let’s acknowledge this and make unethical leadership hurt!