Lessons from across the North Sea

I AM NOT a woman who has her finger on the cultural pulse. So, I came to Scandinavian dramas later than most in the UK. Last night I finished watching Borgen. This morning, I am bereft. As I ponder life without Birgitte, Kasper and Katrine, I’m reflecting on what Borgen has to teach about ethics. Not convinced? Read on (it is spoiler free, I promise).

Lesson 1: Idealism and ethical erosion

Birgitte begins her term of office as Danish Prime Minister with the confidence, energy and idealism that is reminiscent of healthcare students in their early years. Over time, she is exposed to a range of political practice and demands. She meets role models and cautionary tales. Birgitte’s values and political aspirations are interrogated, mocked and forgotten. The experience of ethical erosion is well-documented in healthcare. It describes the process whereby individuals who were originally altruistic and committed become disillusioned or cynical about their work. It is closely associated with compassion fatigue and burnout.

It is, in my experience, rare that a clinician is or becomes ‘unethical’ or ‘indifferent’. Rather, ethical erosion occurs because there is a significant gap between ethics in the abstract and its enactment in the daily provision of care. Being ethical is easier in theory. Yet clinical ethics is a practical pursuit and it is the practice of ethics that is most difficult. The challenge is to continue to embody ethics, values and virtues.

What is the difference between those who are able to remain true to their ethical values and those who are silent and unable to challenge others when they are ethically discomforted? It’s a question that has long occupied bioethicists but it is the field of business (as well as fictional Danish politics) that offers a useful explanation for why putting ethics into practice can be so difficult.

Mary Gentile, a professor working in the fields of business and leadership, has developed the ‘Giving Voice to Values’ project. Drawing on research published after the Second World War that explored why some individuals acted as rescuers of those threatened by the Nazis, Gentile argues that speaking out and being loyal to ethical precepts is a skill that requires practice like any other professional skill. And that is, I would argue, as true of British healthcare professionals as it is of American business leaders and fictional Danish politicians.

Lesson 2: Compromise and ethical integrity

Birgitte learns quickly that compromise, particularly in coalition politics, is unavoidable. She negotiates the boundaries between pragmatic trade-off and effective political negotiation. She is regularly called upon to judge whether she should compromise or hold the line. We are all required to work within systems and groups that demand that we compromise. Indeed, as I wrote in a previous column, the facility to listen and to respond constructively in the face of disagreement is, in itself, an ethical imperative. Yet, knowing when and how to remain steadfast is fundamental too. What ethical principles or values are essential to you and your practice? Put another way, what moral line(s) will you not breach and why?

Your response is likely to draw on a range of sources, including professional guidance, personal reflection and clinical experience, all of which are sound bases for developing your ethical priorities. Given that, like the political machine in which Birgitte works, the NHS is a complex system that makes multiple demands on its employees, how do you determine when compromise is indicated and when you should hold your ground? Are these reactive decisions? Or are they guided by a moral framework?

Lesson 3: The public and the professional

Birgitte’s personal and professional worlds are intertwined and sometimes collide. She is constantly navigating the shifting sands of public and private. The professional healthcare bodies demand that practitioners are alert to conduct, whilst on or off duty, that may compromise trust in the profession and diminish its reputation. Yet, for most, the ethical challenges are subtler but nonetheless important. Fortunately, few people will find themselves before the regulator, but most, if not all, professionals will have times in their careers when they are less effective than they would like because of an event or stressor in their private lives.

Being alert and responsive to personal vulnerability is essential – a quiet, constant and necessary negotiation required of us all – but is too rarely considered and discussed. How do you draw boundaries between your personal and professional roles? What influences the balance? Professional boundaries are there to protect both parties in a therapeutic relationship. We are all susceptible to, if not boundary-crossing, boundary-pushing, and sometimes our boundaries will be more fragile than we would like.

See? That DVD box-set can be ethics CPD. And you thought it was just a television drama.

Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London